Sandbox jyostna
- Cytomegalovirus treatment
- 1. Retinitis
- In HIV-infected adults
Ganciclovir IV, Valganciclovir PO, Foscarnet IV, Cidofovir IV AND Ganciclovir intraocular implant coupled with Valganciclovir.
- In HIV-infected infants and children
initial treatment (induction therapy): Ganciclovir IV  for acquired CMV disease, including CMV retinitis and other end-organ disseminated CMV disease (e.g., colitis, esophagitis, CNS disease).
- An alternative drug for treating CMV disease or for use in Ganciclovir-resistant CMV infections in HIV infected children : Foscarnet.
- 2. In Transplant patients
- Preferred regimen: Valganciclovir
- 3. Colitis, Esophagitis
- Preferred regimen (1): Valganciclovir 900 mg PO q24h.
- Preferred regimen (2): Valganciclovir 900 mg PO q12h for 1421 days, then 900 mg PO q24h for maintenance therapy
- Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 1421 days ,Ganciclovir as with retinitis except induction period extended for 36 wks (No agreement on use of maintenance; may not be necessary except after relapse. Responses less predictable than for retinitis.), then Valganciclovir 900 mg PO q24h OR Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 1421 days, then 90120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV for 2wks, then 5 mg/kg every other wk; each dose should be administered with IV saline hydration AND oral probenecid OR repeated intravitreal injections with Fomivirsen (for relapses only, not as initial therapy)
- 4. Pneumonia
- Preferred regimen: : Valganciclovir 900 mg PO q12h for 1421 days, then 900 mg PO q24h for maintenance therapy
- Alternative regimen for retinitis: Ganciclovir 5 mg/kg IV q12h for 1421 days, then Valganciclovir 900 mg PO q24h OR Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 1421 days, then 90120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV for 2wks, then 5 mg/kg every other wk; each dose should be administered with IV saline hydration AND oral probenecid.
- 5. Encephalitis, Ventriculitis
- 6. Lumbosacral polyradiculopathy
- Preferred regimen: Ganciclovir, as with retinitis. Foscarnet 40 mg/kg IV q12h another option.Switch to Valganciclovir when possible.
- 7. Mononeuritis multiplex
- 8. Specific considerations
- Prevention
- 1. Prevention of opportunistic infections in human stem cell transplantation (HSCT) by CMV (Recipient with CMV positive or Donor with CMV  positive /Recipient with negative CMV)
- Preemptive therapy: Monitor 1  wk (days 10-100) CMV viremia by PCR or CMV-antigenemia and start treatment if positive. Traditional approach was to use Ganciclovir 5 mg/kg IV q12h for 7-14 days, then 5 mg/kg IV q24h 5 days/wk to the longer of: d 100 or 3 wks.
- Alternatively Prophylaxis approach (for high-risk pts or when CMV detection tests not rapidly available): From engraftment to day 100, ganciclovir 5 mg/kg IV q12h for 7 days, then 5 mg/kg IV q24h 5 to 6 days per week.
- 2. Prevention of opportunistic infections in Solid organ transplant (SOT) by CMV (Recipient with CMV positive or Donor with CMV  positive /Recipient with negative CMV)
- 2.1 Kidney, Kidney/Pancreas, Heart
- Preferred regimen: Valganciclovir 900 mg PO q24h; start by day 10 and continue to at least day 100.
- 2.2 Liver
- Preferred regimen: Ganciclovir 5 mg/kg IV qd or Ganciclovir 1 gm PO tid; start by day 10 and continue to at least day 100. Or, with caution, Valganciclovir.
- 2.3 Lung
- Preferred regimen: Ganciclovir 5 mg/kg iv q12h for 5-7 days, then Valganciclovir 900 mg po q24h for 6 mos (or at least 3 months).
- 3. Post treatment suppression for retinitis (prophylactic) if CD4 count <100/mm3
- Preferred regimen: Valganciclovir 900 mg PO q24h.
- Severe acute respiratory distress syndrome- coronavirus
- Supportive therapy
- Enterovirus treatment
- Aseptic Meningitis
- Preferred regimen: Immunoglobulins IV typical dose is 2 g/kg IV infused over 24hrs.
- Alternative regimen: Pleconaril
- Parvovirus B19
- 1. Erythema infectiosum
- Supportive therapy: Symptomatic treatment only
- 2. Arthritis/arthalgia
- Preferred regimen: Nonsteroidal anti-inflammatory drugs (NSAID)
- 3.Transient aplastic crisis
- Supportive therapy: Transfusions and oxygen
- 4. Fetal hydrope
- Supportive therapy: Intrauterine blood transfusion
- 5. Chronic infection with anemia
- Preferred regimen: IVIG and transfusion
- 6.Chronic infection without anemia
- Preferred regimen: IVIG
- Ebola virus treatment
- Supportive therapy
- Hantavirus Return to Top
- Hanta virus treatment
- Supportive therapy
- ICU management should include careful assessment, monitoring and adjustment of volume status and cardiac function, including inotropic and vasopressor support if needed.
- Fluids should be administered carefully due to the potential for capillary leakage.
- Supplemental oxygen should be administered if patients become hypoxic.
- Equipment and materials for intubation and mechanical ventilation should be readily available since onset of respiratory failure may be precipitous.
- Note (1): There is no specific treatment or cure for hantavirus infection.
- Note (2): Treatment of patients with HPS remains supportive in nature.
- Note (3): Patients should receive appropriate, broad-spectrum antibiotic therapy while awaiting confirmation of a diagnosis of HPS. Care during the initial stages of the disease should include antipyretics and analgesia as needed.
- Note (4): If there is a high degree of suspicion of Hantavirus pulmonary syndrome, patients should be immediately transferred to an emergency department or intensive care unit (ICU) for close monitoring and care.
- Note (5):  if the individual is experiencing fever and fatigue and has a history of potential rural rodent exposure, together with shortness of breath, would be strongly suggestive of Hantavirus pulmonary syndrome.
- Hepatitis E virus Return to Top - Hepatitis E treatment
- Supportive therapy
- Hepatitis E is usually self-limiting, hospitalization is generally not required.
- Hospitalization is required for people with fulminant hepatitis and should also be considered for symptomatic pregnant women.
- Prevention
- The risk of infection and transmission can be reduced by
- (1) Maintaining quality standards for public water supplies;
- (2) Establishing proper disposal systems to eliminate sanitary waste.
- On an individual level, infection risk can be reduced by
- (1) Maintaining hygienic practices such as hand washing with safe water, particularly before handling food;
- (2) Avoiding drinking water and/or ice of unknown purity;
- (3) Adhering to WHO safe food practices-determining the mode of transmission; identifying the population specifically exposed to increased risk of infection;
eliminating a common source of infection; improving sanitary and hygienic practices to eliminate faecal contamination of food and water raising awareness, promoting partnerships and mobilizing resources;formulating evidence-based policy and data for action;preventing transmission; andexecuting screening, care and treatment.
- Rotavirus Return to Top
- Rotavirus treatment,
- Treatment of diarrhoea caused by rotavirus
- Zinc supplements-with zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume.
- Rehydration with intravenous fluids in case of severe dehydration or shock.
- Nutrient-rich foods the vicious circle of malnutrition and diarrhoea can be broken by continuing to give nutrient-rich foods  including breast milk during an episode, and by giving a nutritious diet  including exclusive breastfeeding for the first six months of life  to children when they are well.
- Consulting a health professional , in particular for management of persistent diarrhoea or when there is blood in stool or if there are signs of dehydration.
- Prevention
- Access to safe drinking-water
- Use of improved sanitation
- Hand washing with soap
- Exclusive breastfeeding for the first six months of life
- Good personal and food hygiene
- Health education about how infections spread; and Rotavirus vaccination.
- Rhinovirus Return to Top
- Rhinovirus treatment
- Supportive therapy
- Symptomatic treatment-Ipratropium bromide intranasal (2 sprays tid) AND Clemastine 1.34 mg 12 tab PO bidtid (over the counter)
- Symptomatic relief by Ipratropium nasal spray decreases rhinorrhea and sneezing vs placebo. Clemastine (an antihistamine) decreases sneezing, rhinorrhea but associated with dry nose, mouth & throat in 619%.Oral pleconaril given within 24 hrs of onset reduced duration (1 day) & severity of cold symptoms in DBPCT (p < .001).:::- Note (1): No antiviral rx indicated . :::- Note (2) Found in 1/2 of children with community-acquired pneumonia; role in pathogenesis unclear (CID 39:681, 2004). :::- Note (3) High rate of rhinovirus identified in children with significant lower resp tract infections 
- 1.1 In adults
- Preferred regimen (1): Vancomycin 15-20 mg/kg IV q8-12h
- Preferred regimen (2): Daptomycin 6mg/kg/dose IV qd
- 2. Intravascular catheter-related infections
- 2.1 Methicillin susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q6h
- Preferred regimen (2): Oxacillin 2 g IV q6h
- Alternative regimen (1): Cefazolin 2 g IV q8h
- Alternative regimen (2): Vancomycin 15 mg/kg IV q12h
- 2.1.1 Pediatric dose of Nafcillin
- 2.1.1.1 Neonates (< 4 weeks)
- For < 1200 g: Nafcillin 50 mg/kg/day q12h
- For  7 days of age and 12002000 g: Nafcillin 50 mg/kg/day q12h
- For  7 days of age and > 2000 g: Nafcillin 75 mg/kg/day q8h
- For > 7 days of age and 12002000 g: Nafcillin 75 mg/kg/day q8h
- For > 7 days of age and > 2000 g: Nafcillin 100 mg/kg/day q6h
- 2.1.1.2 Infants and children (> 4 weeks)
- Nafcillin 100200 mg/kg/day q46h
- 2.1.2 Pediatric dose of Oxacillin
- 2.1.2.1 Neonates (< 4 weeks)
- For < 1200 g: Oxacillin 50 mg/kg/day q12h
- For Postnatal age < 7 days and 12002000 g: Oxacillin 50100 mg/kg/day q12h
- For Postnatal age  2000 g: Oxacillin 75150 mg/kg/day q8h
- For Postnatal age  7 days and 12002000 g: Oxacillin 75150 mg/kg/day q8h
- For Postnatal age  7 days and > 2000 g: Oxacillin 100200 mg/kg/day q6h
- 2.1.2.2 Infants and children(> 4weeks)
- Oxacillin 150200 mg/kg/day q46h
- 2.1.3 Pediatric dose of Cefazolin
- 2.1.3.1 Neonates (< 4 weeks)
- Postnatal age  7 days: Cefazolin 40 mg/kg/day q12h
- Postnatal age > 7 days and  2000 g: Cefazolin 40 mg/kg/day q12h
- Postnatal age > 7 days and > 2000 g: Cefazolin 60 mg/kg/day q8h
- 2.1.3.2 Infants and children (> 4 weeks)
- Cefazolin 50 mg/kg/day q8h.
- 2.1.4 Pediatric dose of Vancomycin
- 2.1.4.1 Neonates (< 4 weeks)
- Postnatal age  7 days and < 1200 g: Vancomycin 15 mg/kg/day q24h.
- Postnatal age  7 days and 12002000 g: Vancomycin 1015 mg/kg q1218h.
- Postnatal age  7 days and > 2000 g: Vancomycin 1015 mg/kg q812h.
- Postnatal age > 7 days and < 1200 g: Vancomycin 15 mg/kg/day q24h.
- Postnatal age > 7 days and 12002000 g: Vancomycin 1015 mg/kg q812h.
- Postnatal age > 7 days and > 2000 g: Vancomycin 1520 mg/kg q8h.
- 2.1.4.2 Infants and children (> 4 weeks)
- Vancomycin 40 mg/kg/day q68h.
- 2.2 Methicillin resistant Staphylococcus aureus (MRSA)
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h
- Preferred regimen (2): Daptomycin 68 mg/kg/day IV
- Preferred regimen (3): Linezolid 10 mg/kg IV/PO q12h
- Preferred regimen (4): Vancomycin 15 mg/kg IV q12h AND (Rifampicin IV or Gentamycin IV)
- Preferred regimen (5): Trimethoprim-Sulfamethoxazole 612 mg TMP/kg/day q12h alone (if susceptible)
- 2.2.1 Pediatric dose of Linezolid
- 2.2.1.1 Neonates (< 4 weeks)
- For < 1200 g: Linezolid 10 mg/kg q812h (note: q12h in patients < 34 weeks gestation and < 1 week of age).
- For < 7 days of age and  1200 g: Linezolid 10 mg/kg q812h (note: q12h in patients < 34 weeks gestation and < 1 week of age).
- For  7 days and  1200 g: Linezolid 10 mg/kg q8h
- 2.2.1.2 Infants and children  4 weeks)
- Linezolid 10 mg/kg q8h
- 2.2.1.3 Children  12 years and adolescents
- Linezolid 10 mg/kg q12h
- 2.2.2 Pediatric dose of Gentamycin
- 2.2.2.1 Neonates (< 4 weeks)
- Premature neonates and < 1000 g: Gentamycin 3.5 mg/kg q24h
- < 1200 g: Gentamycin 2.5 mg/kg q18-24h.
- Postnatal age  7 days: Gentamycin 2.5 mg/kg q12h.
- Postnatal age > 7 days and 12002000 g: Gentamycin 2.5 mg/kg q8-12h.
- Postnatal age > 7 days and > 1200 g: Gentamycin 2.5 mg/kg q8h.
- Premature neonates with normal renal function: Gentamycin 3.54 mg/kg q24h.
- Term neonates with normal renal function: Gentamycin 3.55 mg/kg q24h.
- 2.2.2.2 Infants and children  4 weeks)
- Gentamycin 2.5 mg/kg q8h; qd dosing in patients with normal renal function, Gentamycin 57.5 mg/kg q24h.
- 2.2.2.3 Children  5 years
- Gentamycin 22.5 mg/kg q8h; qd with normal renal function, Gentamycin 57.5 mg/kg q24h.
- 2.2.3 Pediatric dose of Trimethoprim-Sulfamethoxazole
- 2.2.3.1 Infants > 2 months of age and children of mild-to-moderate infections
- Trimethoprim-Sulfamethoxazole 612 mg TMP/kg/day q12h; serious infection- Trimethoprim-Sulfamethoxazole 1520 mg TMP/kg/day  q6-8h.
- 3. Cellulitis
- 3.1.1 In adults
- Preferred regimen (1): Clindamycin 300450 mg PO tid
- Preferred regimen (2): Trimethoprim-Sulfamethoxazole 12 DS (double strength) tab PO bid
- Preferred regimen (3): Doxycycline 100 mg PO bid
- Preferred regimen (4): Minocycline 200 mg as a single dose THEN 100 mg PO bid
- Preferred regimen (5): Linezolid 600 mg PO bid
- 3.1.2 In children
- Preferred regimen (1): Clindamycin 1013 mg/kg PO q68h, not to exceed 40 mg/kg/day
- Preferred regimen (2): Trimethoprim 46 mg/kg, Sulfamethoxazole 2030 mg/kg PO q12h
- Preferred regimen (3)
- 3.1 If patient body weight < 45kg then Doxycycline 2 mg/kg PO q12h
- 3.2 If patient body weight 45kg then Doxycycline adult dose
- Preferred regimen (4): Minocycline 4 mg/kg PO 200 mg as a single dose, THEN Minocycline 2 mg/kg PO q12h
- Preferred regimen (5): Linezolid 10 mg/kg PO q8h, (max: 600 mg)
- 3.2 Nonpurulent cellulitis (defined as cellulitis with no purulent drainage or exudate and no associated abscess)
- 3.2.1 In adults
- Preferred regimen (1): Beta-lactam (eg, Cephalexin and Dicloxacillin) 500 mg PO qid
- Preferred regimen (2): Clindamycin 300450 mg PO tid
- Preferred regimen (3): Amoxicillin 500 PO mg tid
- Preferred regimen (4): Linezolid 600 mg PO bid
- Note (1): Empirical therapy for beta-hemolytic streptococci is recommended. Empirical coverage for CA-MRSA is recommended in patients who do not respond to beta-lactam therapy and may be considered in those with systemic toxicity.
- Note (2): Provide coverage for both beta-hemolytic streptococci and CA-MRSA beta-lactam (eg, Amoxicillin) with or without Trimethoprim-Sulfamethoxazole or a Tetracycline
- 3.2.2 In children
- Preferred regimen (1): Clindamycin 1013 mg/kg PO q68h, not to exceed 40 mg/kg/day
- Preferred regimen (2): Trimethoprim 46 mg/kg, Sulfamethoxazole 2030 mg/kg PO q12h
- Preferred regimen (3): Linezolid 10 mg/kg PO q8h, not to exceed 600 mg
- Note (1): Clindamycin causes Clostridium difficileassociated disease may occur more frequently, compared with other oral agents.
- Note (2): Trimethoprim-Sulfamethoxazole not recommended for women in the third trimester of pregnancy and for children ,2 months of age.
- Note (3): Tetracyclines are not recommended for children under 8 years of age and are pregnancy category D.
- 4. Brain abscess
- 4.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- 4.1.1 In adults
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h for 46 weeks
- Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 46 weeks
- Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO/IV q812h for 46 weeks
- 4.1.2 In children
- Preferred regimen (1): Vancomycin15 mg/kg/dose IV q6h
- Preferred regimen (2): Linezolid 10 mg/kg/dose PO/IV q8h
- Note: Consider the addition of Rifampin 600 mg qd OR 300450 mg bid to Vancomycin.
- 4.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q4h
- Preferred regimen (2): Oxacillin 2 g IV q4h
- Alternative regimen: Vancomycin 3045 mg/kg/day IV q812h
- 5. Cerebrospinal fluid shunt infection
- 5.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h with or without Rifampin 600 mg IV or PO q24h
- Note: Shunt removal is recommended, and it should not be replaced until cerebrospinal fluid cultures are repeatedly negative.
- 5.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q4h with or without Rifampin 600 mg IV/PO q24h
- Preferred regimen (2): Oxacillin 2 g IV q4h
- 6. Spinal epidural abscess
- 6.1 Penicillin-susceptible Staphylococcus aureus or Streptococcus
- Preferred regimen: Penicillin G 4 MU IV q4h for 24 weeks, THEN PO to complete 68 weeks
- 6.2 Methicillin-susceptible Staphylococcus aureus or Streptococcus
- Preferred regimen (1): Cefazolin 2 g IV q8h for 24 weeks, THEN PO to complete 68 weeks
- Preferred regimen (2): Nafcillin 2 g IV q4h for 24 weeks, THEN PO to complete 68 weeks
- Preferred regimen (3): Oxacillin 2 g IV q4h for 24 weeks, THEN PO to complete 68 weeks
- Alternative regimen: Clindamycin 600 mg IV q6h for 24 weeks, THEN PO to complete 68 weeks
- 6.3 Methicillin-resistant Staphylococcus aureus (MRSA)
- 6.3.1 In adults
- Preferred regimen: Vancomycin loading dose 2530 mg/kg IV THEN Vancomycin 1520 mg/kg IV q812h for 24 weeks, THEN PO to complete 68 weeks
- Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 46 weeks
- Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO/IV q812h for 46 weeks
- 6.3.2 Pediatric dose
- Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
- Preferred regimen (2): Linezolid 10 mg/kg PO/IV q8h
- Note: Consider the addition of Rifampin 600 mg qd or 300450 mg bid to Vancomycin in adult patients.
- 7.  Bacterial meningitis
- 7.1 Methicillin susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 912 g/day IV q4h
- Preferred regimen (2): Oxacillin 912 g/day IV q4h
- Alternative regimen (1): Vancomycin 3045 mg/kg/day IV q812h
- Alternative regimen (2): Meropenem 6 g/day IV q8h
- 7.2 Methicillin resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h
- Alternative regimen (1): Trimethoprim-Sulfamethoxazole 1020 mg/kg/day q612h
- Alternative regimen (2): Linezolid 600 mg IV q12h
- Note: Consider the addition of Rifampin 600 mg qd or 300450 mg bid to Vancomycin in adult patients.
- 8. Septic thrombosis of cavernous or dural venous sinus
- 8.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- 8.1.1 In adults
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h for 46 weeks
- Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 46 weeks
- Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg/dose PO/IV q812h for 46 weeks
- 8.1.2 Pediatric dose
- Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
- Preferred regimen (2): Linezolid 10 mg/kg PO/IV q8h
- Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible.
- Note (2): Consider the addition of Rifampin 600 mg qd or 300450 mg bid to Vancomycin.
- 9. Subdural empyema
- 9.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- 9.1.1 In adults
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h for 46 weeks
- Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 46 weeks
- Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO/IV q812h for 46 weeks
- 9.1.2 In children
- Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
- Preferred regimen (2): Linezolid 10 mg/kg PO/IV q8h
- Note: Consider the addition of Rifampin 600 mg qd or 300450 mg bid to Vancomycin.
- 10.  Acute conjunctivitis
- 10.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin ointment 1% qid
- 11. Appendicitis
- 11.1 Health careassociated complicated intra-abdominal infection
- 11.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h
- 12. Diverticulitis
- 12.1 Health careassociated complicated intra-abdominal infection
- 12.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h.
- 13. Peritonitis secondary to bowel perforation, peritonitis secondary to ruptured appendix, peritonitis secondary to ruptured  appendix, typhlitis
- 13.1 Health careassociated complicated intra-abdominal infection
- 13.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h
- 14. Cystic fibrosis
- 14.1 Adults
- 14.1.1 If methicillin sensitive staphylococcus aureus
- Preferred Regimen (1): Nafcillin 2 gm IV q4h
- Preferred Regimen (2): Oxacillin 2 gm IV q4h
- 14.1.2 If methicillin resistant staphylococcus aureus
- Preferred Regimen (1): Vancomycin 15-20 mg/kg IV q8-12h
- Preferred Regimen (2): Linezolid 600 mg PO/IV q12h
- 14.2 Pediatric
- 14.2.1 If methicillin sensitive staphylococcus aureus
- Preferred Regimen (1): Nafcillin 5 mg/kg q6h (Age >28 days)
- Preferred Regimen (2): Oxacillin 75 mg/kg q6h (Age >28 days)
- 14.2.2 If methicillin resistant staphylococcus aureus
- Preferred Regimen (1): Vancomycin 40 mg/kg  q6-8h (Age >28 days)
- Preferred Regimen (2): Linezolid 10 mg/kg PO/IV q8h (up to age 12)
- 15. Bronchiectasis
- 15.1 In adults
- 15.1.1 Recommended first-line treatment and length of treatment
- 15.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen: Flucloxacillin 500 mg PO qds for 14 days
- 15.1.1.2  Methicillin-resistant Staphylococcus aureus (MRSA)
- Patient's body weight is < 50 kg
- Preferred regimen: Rifampicin 450 mg PO qd AND Trimethoprim 200 mg PO bd for 14 days
- Patient's body weight is > 50 kg
- Preferred regimen: Rifampicin 600 mg PO qd AND Trimethoprim 200 mg PO bd for 14 days
- 15.1.1.3 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen (1): Vancomycin 1 g IV bd (monitor serum levels and adjust dose accordingly)
- Preferred regimen (2): Teicoplanin 400 mg qd for 14 days
- 15.1.2 Recommended second-line treatment and length of treatment
- 15.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen: Clarithromycin 500 mg PO bd 14 days
- 15.1.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Patient's body weight is < 50 kg
- Preferred regimen: Rifampicin 450 mg PO qd AND Doxycycline 200 mg PO qd for 14 days
- Patient's body weight is > 50 kg
- Preferred regimen: Rifampicin 600 mg PO qd AND Doxycycline 200 mg PO qd for 14 days
- Third-line: Linezolid 600 mg bd for 14 days
- 15.1.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Linezolid 600 mg IV bd for 14 days
- 15.2 In children
- 15.2.1 Recommended first-line treatment and length of treatment
- 15.2.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen: Flucloxacillin
- 15.2.1.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- 15.2.1.2.1 Children (< 12 yr)
- Preferred regimen: Trimethoprim 4-6 mg/kg/day PO q12h
- 15.2.1.2.2 Children (> 12 yr)
- Preferred regimen (1): Trimethoprim 100-200 mg PO q12h
- Preferred regimen (2): Rifampicin 450 mg PO od (or Rifampicin 600 mg PO od)
- 15.2.1.3 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen (1): Vancomycin 45-60 mg/kg/day IV q8-12h
- Preferred regimen (2): Teicoplanin 400 mg qd for 14 days
- 15.2.2 Recommended second-line treatment and length of treatment
- 15.2.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen: Clarithromycin 15 mg/kg/day PO q12h
- 15.2.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen (1): Rifampicin AND Doxycycline 2-5 mg/kg/day PO/IV q12-24h  (max dose: 200 mg/24 hr)
- Preferred regimen (2): Rifampicin AND Doxycycline 2-5 mg/kg/day PO/IV q12-24h  (max dose: 200 mg/24 hr)
- Third-line: Linezolid 10 mg/kg PO/IV q12h
- 15.2.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Linezolid 10 mg/kg PO/IV q12h
- 15.3 Long-term oral antibiotic treatment
- 15.3.1 In adults
- 15.3.1.1 Recommended first-line treatment and length of treatment
- 15.3.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen: Flucloxacillin 500 mg PO bd
- 15.3.1.2 Recommended second-line treatment and length of treatment
- 15.3.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen: Clarithromycin 250 mg PO bd
- 16. Empyema
- Preferred regimen (1): Nafcillin  2 gm IV q4h
- Preferred regimen (2): oxacillin  2 gm IV q4h (if MSSA)
- Alternative regimen (1): Vancomycin  1 gm IV q12h
- Alternative regimen (2): Linezolid  600 mg PO bid (if MRSA)
- 17. Community-acquired pneumonia
- 17.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred Regimen (1): Nafcillin 1000-2000 mg q4h
- Preferred Regimen (2): Oxacillin 2 g IV q4h
- Preferred Regimen (3): Flucloxacillin 250 mg IM/IV q6h
- Alternative Regimen (1): Cefazolin 500 mg IV q12h
- Alternative Regimen (2): Clindamycin 150-450 mg PO q6-8h
- 17.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred Regimen (1): Vancomycin 45-60 mg/kg/day q8-12h (max: 2000 mg/dose) for 7-21 days
- Preferred Regimen (2): Linezolid 600 mg PO/IV q12h for 10-14 days
- Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h
- 18. Olecranon bursitis or prepatellar bursitis
- 18.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q4h
- Preferred regimen (2): Oxacillin 2 g IV q4h
- Preferred regimen (3): Dicloxacillin 500 mg PO qid
- 18.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen (1): Vancomycin 1 g IV q12h
- Preferred regimen (2): Linezolid 600 mg PO qd
- Note: Initially aspirate q24h and treat for a minimum of 23 weeks.
- 19. Septic arthritis
- 19.1 In adults
- 19.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h
- Alternative regimen (1): Daptomycin 6 mg/kg IV q24h in adults
- Alternative regimen (2): Linezolid 600 mg PO/IV q12h
- Alternative regimen (3): Clindamycin 600 mg PO/IV q8h
- Alternative regimen (4): TMP-SMX 3.54.0 mg/kg PO/IV q812h
- 19.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q6h
- Preferred regimen (2): Clindamycin 900 mg IV q8h
- Alternative regimen (1): Cefazolin 0.251 g IV/IM q68h
- Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h
- 19.2 In childern
- Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
- Preferred regimen (2): Daptomycin 610 mg/kg IV q24h
- Preferred regimen (3): Linezolid 10 mg/kg PO/IV q8h
- Preferred regimen (4): Clindamycin 1013 mg/kg PO/IV q68h
- 20. Septic arthritis, prosthetic joint infection (device-related osteoarticular infections)
- 20.1  Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q46h
- Preferred regimen (2): Oxacillin 2 g IV q46h
- Alternative regimen (1): Cefazolin 12 g IV q8h
- Alternative regimen (2): Ceftriaxone 2 g IV q24h
- Alternative regimen (if allergic to penicillins) (3): Clindamycin 900 mg IV q8h
- Alternative regimen (if allergic to penicillins) (4): Vancomycin 1520 mg/kg IV q812h, (max: 2 g per dose)
- 20.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Early-onset (2 months after surgery) or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)
- Preferred regimen: Vancomycin AND Rifampin 600 mg PO qd or 300450 mg PO bid for 2 weeks
- Alternative regimen (1): Daptomycin 6 mg/kg IV q24h AND Rifampin 600 mg PO qd or 300450 mg PO bid for 2 weeks
- Alternative regimen (2): Linezolid 600 IV q8h AND Rifampin 600 mg PO qd or 300450 mg PO bid for 2 weeks
- Note: The above regimen should be followed by Rifampin and a Fluoroquinolone, TMP/SMX, a Tetracycline or Clindamycin for 3-6 months for hips and knees, respectively.
- 21. Hematogenous osteomyelitis
- 21.1 Adult (> 21 yrs)
- 21.1.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
- Preferred regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
- 21.1.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
- Preferred regimen (1): Nafcillin
- Preferred regimen (2): Oxacillin 2 gm IV q4h
- 21.2 Children (> 4 months)-Adult
- 21.2.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
- Preferred regimen: Vancomycin 40 mg IV q68h
- 21.2.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
- Preferred regimen (1): Nafcillin
- Preferred regimen (2): Oxacillin q6h (max. 812 gm per day)
- Note: Add Ceftazidime 50 mg q8h or Cefepime 150 mg q8h if Gram negative bacilli on Gram stain
- 21.3 Newborn (< 4 months.)
- 21.3.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
- Preferred regimen (1): Vancomycin AND Ceftazidime 2 gm IV q8h
- Preferred regimen (2): Vancomycin AND Cefepime 2 gm IV q12h
- 21.3.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
- Preferred regimen (1): Nafcillin  AND Ceftazidime
- Preferred regimen (2): Oxacillin AND Cefepime
- 21.4 Specific therapy
- 21.4.1  Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin
- Preferred regimen (2): Oxacillin 2 gm IV q4h
- Preferred regimen (3): Cefazolin 2 gm IV q8h
- Alternative regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
- 21.4.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 1 gm IV q12h
- Alternative regimen: Linezolid 600 mg q12h PO/IV with or without Rifampin 300 mg PO/IV bid
- 22. Diabetic foot osteomyelitis
- High risk for MRSA
- Preferred regimen (1): Linezolid 600 mg IV or PO q12h
- Preferred regimen (2): Daptomycin 4 mg/kg IV q24h
- Preferred regimen (3): Vancomycin 1520 mg/kg IV q812h (trough: 1020 mg/L)
- 23.  Necrotizing fasciitis
- 23.1 In adult
- Preferred regimen (1): Nafcillin 12 g IV  q4h (severe Pencillin allergy: Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin)
- Preferred regimen (2): Oxacillin 12 g IV  q4h
- Preferred regimen (3): Cefazolin 1 g IV  q8h
- Preferred regimen (4): Vancomycin 15 mg/kg IV bid
- Preferred regimen (5): Clindamycin 600900 mg IV  q8h
- 23.2 In childern
- Preferred regimen (1): Nafcillin 50 mg/kg/dose IV  q6h  (severe Pencillin allergy: Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin)
- Preferred regimen (2): Oxacillin 50 mg/kg/dose IV q6h
- Preferred regimen (3): Cefazolin 33 mg/kg/dose IV q8h
- Preferred regimen (4): Vancomycin 15 mg/kg/dose IV q6h
- Preferred regimen (5): Clindamycin 1013 mg/kg/dose IV q8h  (Bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in methicillin resistent staphylococcus aureus)
- 24. Staphylococcal toxic shock syndrome
- 24.1 Methicillin sensitive Staphylococcus aureus
- Preferred regimen (1): Cloxacillin  250-500 mg PO q6h (max dose: 4 g/24 hr)
- Preferred regimen (2): Nafcillin  4-12 g/24 hr IV q4-6hr (max dose: 12 g/24 hr)
- Preferred regimen (3): Cefazolin 0.5-2g IV/IM q8h (max dose: 12 g/24 hr) AND Clindamycin 150-600 mg IV, IM/PO q6-8h  (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
- Alternative regimen (1): Clarithromycin 250-500 mg PO q12h (max dose: 1 g/24 hr) AND Clindamycin 150-600 mg IV, IM/PO q6-8h  (max dose: 5 g/24 hr IV/IM or 2 g/24h PO)
- Alternative regimen (2): Rifampicin AND Linezolid 600 mg IV/PO q12h
- Alternative regimen (3): Daptomycin
- Alternative regimen (4): Tigecycline 100 mg loading dose THEN 50 mg IV q12h
- 24.2 Methicillin resistant Staphylococcus  aureus
- Preferred regimen (1): Clindamycin 150-600 mg IV, IM/PO q6-8h (max dose: 5 g/24h IV/IM or 2 g/24h PO)
- Preferred regimen (2): Linezolid 600 mg IV/PO q12h AND Vancomycin 15-20 mg/kg IV q8-12h, (max: 2 g per dose)
- Preferred regimen (3): Teicoplanin
- Alternative regimen (1): Rifampicin AND Linezolid 600 mg IV/PO q12h
- Alternative regimen (2): Daptomycin
- Alternative regimen (3): Tigecycline 100 mg loading dose THEN 50 mg IV q12h
- 24.3 Glycopeptide resistant or intermediate Staphylococcus aureus
- Preferred regimen: Linezolid 600 mg IV/PO q12h AND Clindamycin 150-600 mg IV, IM/PO q6-8h (max dose: 5 g/24 hr IV/IM or 2 g/24h PO) (if sensitive)
- Alternative regimen (1): Daptomycin
- Alternative regimen (2): Tigecycline 100 mg loading dose THEN 50 mg IV q12h
- Staphylococcus aureus ,prophylaxis
- 1. Prophylaxis for coronary artery bypass graft-associated acute mediastinitis
- 1.1 Methicillin susceptible staphylococcus aureus (MSSA)
- Preferred regimen: A first- or second-generation Cephalosporin is recommended for prophylaxis in patients without MRSA colonization.
- 1.2 Methicillin resistant staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin alone or in combination with other antibiotics to achieve broader coverage is recommended for prophylaxis in patients with proven or suspected MRSA colonization
- Note (1): Preoperative antibiotics should be administered to all patients to reduce the risk of mediastinitis in cardiac surgery.
- Note (2): The use of intranasal Mupirocin is reasonable in nasal carriers of Staphylococcus aureus.
- Staphylococcus aureus treatment
- 1. Infectious endocarditis
- 1.1 In adults
- Preferred regimen (1): Vancomycin 15-20 mg/kg IV q8-12h
- Preferred regimen (2): Daptomycin 6mg/kg/dose IV qd
- 2. Intravascular catheter-related infections
- 2.1 Methicillin susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin  2 g IV q6h ::::- Preferred regimen (2): Oxacillin 2 g IV q6h.
- Alternative regimen (1): Cefazolin 2 g IV q8h ::::- Alternative regimen (2): Vancomycin 15 mg/kg IV q12h.
- 2.1.1 Pediatric dose
- 2.1.1.1 Nafcillin
- 2.1.1.1.1 Neonates
- 04 weeks of age and 1200 g- 50 mg/kg/day  q12h.
- 7 days and 12002000 g- 50 mg/kg/day  q12h.
- >7 days of age and <2000g- 75 mg/kg/day  q8h.
- >7 days of age and >1200 g - 100 mg/kg/day  q6h.
- 2.1.1.1.2 Infants and children is Nafcillin 100200 mg/kg/day q46h.
- 2.1.1.2 Oxacillin
- 2.1.1.2.1 Neonates
- 04 weeks of age and 1200 g is 50 mg/kg/day q12h.
- Postnatal age <7 days and 12002000 g is 50100 mg/kg/day q12h.
- Postnatal age 2000 g is 75150 mg/kg/day q8h.
- Postnatal age 7 days and 12002000 g is 75150 mg/kg/day q8h.
- Postnatal age 7 days and >2000 g is 100200 mg/kg/day q6h.
- 2.1.1.3 Cefazolin
- 2.1.1.3.1 Neonates
- Postnatal age 7 days is 40 mg/kg/day q12h.
- Postnatal age >7 days and 2000 g is 40 mg/kg/day q12h.
- Postnatal age >7 days and 12000 g is 60 mg/kg/day q8h.
- 2.1.1.3.2 Infants and children is 50 mg/kg/day q8h.
- 2.1.1.4 Vancomycin
- 2.1.1.4.1 Neonates
- Postnatal age 7 days and <1200 g is 15 mg/kg/day q24h.
- Postnatal age 7 days and 12002000 g is 1015 mg/kg q1218h.
- Postnatal age 7 days and >2000 g is 1015 mg/kg q812h.
- Postnatal age >7 days and <1200 g is 15 mg/kg/day q24h.
- Postnatal age >7 days and 12002000 g is 1015 mg/kg q812h.
- Postnatal age >7 days and >2000 g is 1520 mg/kg q8h.
- 2.1.1.4.2 Infants and children is 40 mg/kg/day q68h.
- 2.2 Methicillin resistant Staphylococcus aureus (MRSA)
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h  ::::- Preferred regimen (2):Daptomycin 68 mg/kg/day IV::::- Preferred regimen (3):Linezolid 10 mg/kg q12h IV or PO ::::- Preferred regimen (4):Vancomycin 15 mg/kg IV q12h AND (Rifampicin IV or Gentamycin IV) ::::- Preferred regimen (5):Trimethoprim-Sulfamethoxazole 612 mg TMP/kg/day in divided doses q12h alone (if susceptible).
- 2.2.1 Pediatric dose
- 2.2.1.1 Linezolid 10 mg/kg IV or PO q12h
- 2.2.1.1.1 Neonates
- 04 weeks of age and birthweight <1200 g is 10 mg/kg q812h (note: q12h in patients <34 weeks gestation and <1 week of age).
- 1200 g is 10 mg/kg q812h (note: q12h in patients <34 weeks gestation and <1 week of age).
- 7 days and birthweight >1200 g is 10 mg/kg q8h.
- 2.2.1.1.2 Infants and children <12 years of age is 10 mg/kg q8h Children 12 years of age and adolescents: 10 mg/kg q12h.
- 2.2.1.2 Gentamycin
- 2.2.1.2.1 Neonates
- Premature neonates and <1000 g is 3.5 mg/kg q24h; 04 weeks and <1200 g is 2.5 mg/kg q18-24h.
- Postnatal age 7 days is 2.5 mg/kg q12h.
- Postnatal age 17 days and 12002000 g is 2.5 mg/kg q8-12h.
- Postnatal age 17 days and 12000 g is 2.5 mg/kg q8h.
- Premature neonates with normal renal function is 3.54 mg/kg q24h.::::::::- Term neonates with normal renal function is 3.55 mg/kg q24h.
- 2.2.1.2.2 Infants and children <5 years of age is 2.5 mg/kg q8h; qd dosing in patients with normal renal function, 57.5 mg/kg q24h.
- 2.2.1.2.3 Children >5 years of age is 22.5 mg/kg q8h; qd with normal renal function, 57.5 mg/kg q24h.
- 2.2.1.3 Trimethoprim-Sulfamethoxazole
- 2.2.1.3.1 Infants 12 months of age and children of mild-to-moderate infections is 612 mg TMP/kg/day  q12h; serious infection, 1520 mg TMP/kg/day  q6-8h.
- 3. Cellulitis
- 3.1.1 In adults
- Preferred regimen (1): Clindamycin 300450 mg PO tid :::::- Preferred regimen (2): Trimethoprim-Sulfamethoxazole 12 DS tab PO bid :::::- Preferred regimen (3): Doxycycline 100 mg PO bid :::::- Preferred regimen (4): Minocycline 200 mg as a single dose, then 100 mg PO bid :::::- Preferred regimen (5): Linezolid 600 mg PO bid
- 3.1.2 In children
- Preferred regimen (1): Clindamycin 1013 mg/kg PO q68h, not to exceed 40 mg/kg/day ::::- Preferred regimen (2): Trimethoprim 46 mg/kg, Sulfamethoxazole 2030 mg/kg PO q12h  ::::- Preferred regimen (3):::::- 3.1 If patient body weight <45kg then Doxycycline 2 mg/kg PO q12h:::::- 3.2 If patient body weight 45kg then Doxycycline adult dose  ::::- Preferred regimen (4): Minocycline 4 mg/kg PO 200 mg as a single dose, then 2 mg/kg PO q12h   ::::- Preferred regimen (5): Linezolid 10 mg/kg PO q8h, not to exceed 600 mg
- 3.2 Nonpurulent cellulitis (defined as cellulitis with no purulent drainage or exudate and no associated abscess)
- 3.2.1 In adults
- Preferred regimen (1): Beta-lactam (eg, Cephalexin and Dicloxacillin) 500 mg PO qid::::- Preferred regimen (2): Clindamycin 300450 mg PO tid ::::- Preferred regimen (3): Amoxicillin 500 PO mg tid ::::- Preferred regimen (4): Linezolid 600 mg PO bid
- 3.2.2 In children
- Preferred regimen (1): Clindamycin 1013 mg/kg PO q68h, not to exceed 40 mg/kg/day   ::::- Preferred regimen (2): Trimethoprim 46 mg/kg, Sulfamethoxazole 2030 mg/kg PO q12h  ::::- Preferred regimen (3): Linezolid 10 mg/kg PO q8h, not to exceed 600 mg
- 4. Brain abscess
- 4.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- 4.1.1 In adults:::::- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h for 46 weeks
- Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 46 weeks  :::::- Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO/IV q812h for 46 weeks
- 4.1.2 In children
- Preferred regimen (1): Vancomycin15 mg/kg/dose IV q6h :::::- Preferred regimen (2): Linezolid 10 mg/kg/dose PO/IV q8h
- 4.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q4h  ::::- Preferred regimen (2): Oxacillin 2 g IV q4h
- Alternative regimen: Vancomycin 3045 mg/kg/day IV q812h
- 5. Cerebrospinal fluid shunt infection 
- 5.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h with or without Rifampin 600 mg IV or PO q24h
- 5.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q4h with or without Rifampin 600 mg IV/PO q24h:::- Preferred regimen (2): Oxacillin 2 g IV q4h
- 6. Spinal epidural abscess 
- 6.1 Penicillin-susceptible Staphylococcus aureus or Streptococcus
- Preferred regimen: Penicillin G 4 MU IV q4h for 24 weeks, then PO to complete 68 weeks
- 6.2 Methicillin-susceptible Staphylococcus aureus or Streptococcus
- Preferred regimen (1): Cefazolin 2 g IV q8h for 24 weeks, then PO to complete 68 weeks  ::::- Preferred regimen (2): Nafcillin 2 g IV q4h for 24 weeks, then PO to complete 68 weeks ::::- Preferred regimen (3): Oxacillin 2 g IV q4h for 24 weeks, then PO to complete 68 weeks
- Alternative regimen: Clindamycin 600 mg IV q6h for 24 weeks, then PO to complete 68 weeks
- 6.3 Methicillin-resistant Staphylococcus aureus (MRSA)
- 6.3.1 In adults
- Preferred regimen: Vancomycin loading dose 2530 mg/kg IV followed by 1520 mg/kg IV q812h for 24 weeks, then PO to complete 68 weeks
- Alternative regimen (1): Linezolid 600 mg PO or IV q12h for 46 weeks ::::- Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO or IV q812h for 46 weeks
- 6.3.2 Pediatric dose
- Preferred regimen (1): Vancomycin 15 mg/kg IV q6h ::::- Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
- 7.  Bacterial meningitis
- 7.1 Methicillin susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 912 g/day IV q4h :::- Preferred regimen (2): Oxacillin 912 g/day IV q4h
- Alternative regimen (1): Vancomycin 3045 mg/kg/day IV q812h:::- Alternative regimen (2): Meropenem 6 g/day IV q8h
- 7.2 Methicillin resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h
- Alternative regimen (1): Trimethoprim-Sulfamethoxazole 1020 mg/kg/day q612h  :::- Alternative regimen (2): Linezolid 600 mg IV q12h
- 8. Septic thrombosis of cavernous or dural venous sinus
- 8.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- 8.1.1 In adults
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h for 46 weeks
- Alternative regimen (1): Linezolid 600 mg PO or IV q12h for 46 weeks  :::::- Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg/dose PO or IV q812h for 46 weeks
- 8.1.2 Pediatric dose
- Preferred regimen (1): Vancomycin 15 mg/kg IV q6h ::::- Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
- 9. Subdural empyema
- 9.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- 9.1.1 In adults
- Preferred regimen: Vancomycin 3045 mg/kg/day IV q812h for 46 weeks
- Alternative regimen (1): Linezolid 600 mg PO or IV q12h for 46 weeks ::::- Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO or IV q812h for 46 weeks
- 9.1.2 In children
- Preferred regimen (1): Vancomycin 15 mg/kg IV q6h ::::- Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
- 10.  Acute conjunctivitis 
- 10.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin ointment 1% qid
- 11. Appendicitis
- 12. Diverticulitis
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h.
- 13. Peritonitis secondary to bowel  perforation, peritonitis secondary to ruptured  appendix, peritonitis secondary to ruptured  appendix, typhlitis
- 13.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h
- 14. Cystic fibrosis 
- 14.1 Adults
- 14.1.1 If methicillin sensitive staphylococcus aureus:::::- Preferred Regimen (1): Nafcillin 2 gm IV q4h:::::- Preferred Regimen (2): Oxacillin 2 gm IV q4h
- 14.1.2 If methicillin resistant staphylococcus aureus:::::- Preferred Regimen (1): Vancomycin 15-20 mg/kg IV q8-12h  :::::- Preferred Regimen (2): Linezolid 600 mg PO or IV q12h
- 14.2 Pediatric
- 14.2.1 If methicillin sensitive staphylococcus aureus:::::- Preferred Regimen (1): Nafcillin 5 mg/kg q6h (Age >28 days) :::::- Preferred Regimen (2): Oxacillin 75 mg/kg q6h (Age >28 days)
- 14.2.2 If methicillin resistant staphylococcus aureus:::::- Preferred Regimen (1): Vancomycin 40 mg/kg  q6-8h (Age >28 days) :::::- Preferred Regimen (2): Linezolid 10 mg/kg PO or IV q8h (up to age 12)
- 15. Bronchiectasis 
- 15.1 In adults
- 15.1.1 Recommended first-line treatment and length of treatment
- 15.1.1.2  Methicillin-resistant Staphylococcus aureus (MRSA):::::- Patient's body weight is 50 kg::::::- Preferred regimen: Rifampicin 600 mg PO qdAND Trimethoprim 200 mg PO bd for 14 days
- 15.1.1.3 Methicillin-resistant Staphylococcus aureus (MRSA):::::- Preferred regimen (1): Vancomycin 1 g IV bd (monitor serum levels and adjust dose accordingly) :::::- Preferred regimen (2): Teicoplanin 400 mg qd for 14 days
- 15.1.2 Recommended second-line treatment and length of treatment
- 15.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)::::::- Preferred regimen: Clarithromycin 500 mg oral bd 14 days
- 15.1.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)::::::- Patient's body weight is 50 kg: :::::::- Preferred regimen: Rifampicin 600 mg PO AND Doxycycline 200 mg PO qd 14 days. ::::::- Third-line is Linezolid 600 mg bd 14 days:::::- 15.1.2.3 Methicillin-resistant Staphylococcus aureus (MRSA): Linezolid 600 mg IV bd 14 days
- 15.2 In children
- 15.2.1 Recommended first-line treatment and length of treatment
- 15.2.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)::::::- Preferred regimen: Flucloxacillin
- 15.2.1.2 Methicillin-resistant Staphylococcus aureus (MRSA)::::::- 15.2.1.2.1 Children ( 12 yr) : :::::::- Preferred regimen (1): Trimethoprim 100-200 mg q12hr PO. :::::::- Preferred regimen (2): Rifampicin 450 mg PO od  : Rifampicin 600 mg PO od AND :::::- 15.2.1.3 Methicillin-resistant Staphylococcus aureus (MRSA) ::::::- Preferred regimen (1): Vancomycin 45-60 mg/kg/day divided q8-12h IV  ::::::- Preferred regimen (2): Teicoplanin
- 15.2.2 Recommended second-line treatment and length of treatment
- 15.2.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)::::::- Preferred regimen: Clarithromycin 15 mg/kg/24 hr divided q12h PO
- 15.2.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)::::::- Preferred regimen: Linezolid 10 mg/kg q12h IV or PO
- 15.3 Long-term oral antibiotic treatment
- 15.3.1 In adults
- 15.3.1.1  Recommended first-line treatment and length of treatment
- 15.3.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA):::::::- Preferred regimen: Flucloxacillin 500 mg PO bd
- 15.3.1.2  Recommended second-line treatment and length of treatment
- 15.3.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA):::::::- Preferred regimen: Clarithromycin 250 mg PO bd
- 16. Empyema
- Preferred regimen: Nafcillin  2 gm IV q4h OR oxacillin  2 gm IV q4h if MSSA
- Alternate regimen: Vancomycin  1 gm IV q12h OR Linezolid  600 mg PO bid if MRSA
- 17. Community-acquired pneumonia
- 17.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred Regimen (1): Nafcillin 1000-2000 mg q4h  ::::- Preferred Regimen (2): Oxacillin 2 g IV q4h  ::::- Preferred Regimen (3): Flucloxacillin 250 mg IM/IV q6h
- Alternative Regimen (1): Cefazolin 500 mg IV q12h  ::::- Alternative Regimen (2): Clindamycin 150-450 mg PO q6-8h
- 17.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred Regimen (1): Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR ::::- Preferred Regimen (2): Linezolid 600 mg PO/IV q12h for 10-14 days::::- Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h
- 18. Olecranon bursitis or prepatellar bursitis
- 18.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q4h  ::::- Preferred regimen (2): Oxacillin 2 g IV q4h ::::- Preferred regimen (3): Dicloxacillin 500 mg PO qid
- 18.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen (1): Vancomycin 1 g IV q12h ::::- Preferred regimen (2): Linezolid 600 mg PO qd
- 19. Septic arthritis
- 19.1 In adults
- 19.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 1520 mg/kg IV q812h
- Alternative regimen (1): Daptomycin 6 mg/kg IV q24h in adults
- Alternative regimen (2): Linezolid 600 mg PO or IV q12h
- Alternative regimen (3): Clindamycin 600 mg PO or IV q8h
- Alternative regimen (4): TMP-SMX 3.54.0 mg/kg PO or IV q812h
- 19.2 In childern
- Preferred regimen (1): Vancomycin 15 mg/kg IV q6h ::::- Preferred regimen (2): Daptomycin 610 mg/kg IV q24h ::::- Preferred regimen (3): Linezolid 10 mg/kg PO or IV q8h ::::- Preferred regimen (4): Clindamycin 1013 mg/kg PO or IV q68h
- 19.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q6h ::::- Preferred regimen (2): Clindamycin 900 mg IV q8h
- Alternative regimen (1): Cefazolin 0.251 g IV/IM q68h ::::- Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h
- 20. Septic arthritis, prosthetic joint infection (device-related osteoarticular infections)
- 20.1  Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin 2 g IV q46h ::::- Preferred regimen (2): Oxacillin 2 g IV q46h
- Alternative regimen (1): Cefazolin 12 g IV q8h  ::::- Alternative regimen (2): Ceftriaxone 2 g IV q24h
- Alternative regimen (if allergic to penicillins) (3): Clindamycin 900 mg IV q8h ::::- Alternative regimen (if allergic to penicillins) (4): Vancomycin 1520 mg/kg IV q812h, not to exceed 2 g per dose
- 20.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Early-onset (2 months after surgery) or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)
- Preferred regimen: Vancomycin AND Rifampin 600 mg PO qd or 300450 mg PO bid for 2 weeks
- Alternative regimen (1): Daptomycin 6 mg/kg IV q24h AND Rifampin 600 mg PO qd or 300450 mg PO bid for 2 weeks ::::- Alternative regimen (2): Linezolid 600 IV q8h AND Rifampin 600 mg PO qd or 300450 mg PO bid for 2 weeks
- 21. Hematogenous osteomyelitis
- 21.1 Adult (>21 yrs)
- 21.1.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
- Preferred regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
- 21.1.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
- Preferred regimen (1): Nafcillin  ::::- Preferred regimen (2): Oxacillin 2 gm IV q4h
- 21.2 Children (>4 months)-Adult
- 21.2.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
- Preferred regimen: Vancomycin 40 div q68h
- 21.2.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
- Preferred regimen (1): Nafcillin ::::- Preferred regimen (2): Oxacillin 37 q6h (to max. 812 gm per day)
- 21.3 Newborn (<4 months.)
- 21.3.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
- Preferred regimen (1): Vancomycin AND Ceftazidime 2 gm IV q8h ::::- Preferred regimen (2): Vancomycin AND Cefepime 2 gm IV q12h
- 21.3.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
- Preferred regimen (1): Nafcillin  AND Ceftazidime ::::- Preferred regimen (2): Oxacillin AND Cefepime
- 21.4 Specific therapy
- 21.4.1  Methicillin-susceptible Staphylococcus aureus (MSSA)
- Preferred regimen (1): Nafcillin ::::- Preferred regimen (2): Oxacillin 2 gm IV q4h ::::- Preferred regimen (3): Cefazolin 2 gm IV q8h
- Alternative regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
- 21.4.2 Methicillin-resistant Staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin 1 gm IV q12h
- Alternative regimen: Linezolid 600 mg q12h IV or PO with or without Rifampin 300 mg PO or IV bid
- 22. Diabetic foot osteomyelitis
- High risk for MRSA
- Preferred regimen (1): Linezolid 600 mg IV or PO q12h ::::- Preferred regimen (2): Daptomycin 4 mg/kg IV q24h ::::- Preferred regimen (3): Vancomycin 1520 mg/kg IV q812h (trough: 1020 mg/L)
- 23.  Necrotizing fasciitis
- 23.1 In adult
- Preferred regimen (1): Nafcillin 12 g IV  q4h (Severe Pencillin allergy: Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin)
- Preferred regimen (2): Oxacillin 12 g IV  q4h
- Preferred regimen (3): Cefazolin 1 g IV  q8h
- Preferred regimen (4): Vancomycin 15 mg/kg IV bid
- Preferred regimen (5): Clindamycin 600900 mg IV  q8h
- 23.2 In childern
- Preferred regimen (1): Nafcillin 50 mg/kg/dose IV  q6h  (Severe Pencillin allergy: Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin)
- Preferred regimen (2): Oxacillin 50 mg/kg/dose IV q6h
- Preferred regimen (3): Cefazolin 33 mg/kg/dose IV q8h
- Preferred regimen (4): Vancomycin 15 mg/kg/dose IV q6h
- Preferred regimen (5): Clindamycin 1013 mg/kg/dose IV q8h  (Bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in methicillin resistent staphylococcus aureus)
- 24. Staphylococcal toxic shock syndrome 
- 24.1 Methicillin sensitive Staphylococcus aureus
- Preferred regimen (1): Cloxacillin  250-500 mg PO q6h (max dose: 4 g/24 hr) ::::- Preferred regimen (2): Nafcillin  4-12 g/24 hr divided IV q4-6hr (max dose: 12 g/24 hr) ::::- Preferred regimen (3): Cefazolin 0.5-2g  IV or IM q8h (max dose: 12 g/24 hr), AND Clindamycin 150-600 mg IV, IM, or PO q6-8h  (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
- Alternative regimen (1): Clarithromycin 250-500 mg PO q12h (max dose: 1 g/24 hr) AND Clindamycin 150-600 mg IV, IM, or PO q6-8h  (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
- Alternative regimen (2): Rifampicin, AND Linezolid 600 mg IV or PO q12h ::::- Alternative regimen (3): Daptomycin ::::- Alternative regimen (4): Tigecycline 100 mg loading dose followed by 50 mg  IV q12h
- 24.2 Methicillin resistant Staphylococcus  aureus
- Preferred regimen (1): Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO) ::::- Preferred regimen (2): Linezolid 600 mg IV or PO q12h AND Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per dose ::::- Preferred regimen (3): Teicoplanin
- Alternative regimen (1): Rifampicin, AND Linezolid 600 mg q12h IV or PO ::::- Alternative regimen (2): Daptomycin ::::- Alternative regimen (3): Tigecycline 100 mg loading dose followed by 50 mg q12h IV
- 24.3 Glycopeptide resistant or intermediate Staphylococcus aureus
- Preferred regimen: Linezolid 600 mg IV or PO q12h AND Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO) (if sensitive)
- Alternative regimen (1): Daptomycin ::::- Alternative regimen (2): Tigecycline 100 mg loading dose followed by 50 mg IV q12h
- Staphylococcus aureus ,prophylaxis
- 1. Prophylaxis for coronary artery bypass graft-associated acute mediastinitis
- 1.1 Methicillin susceptible staphylococcus aureus (MSSA)
- Preferred regimen: A first- or second-generation Cephalosporin is recommended for prophylaxis in patients without methicillin-resistant Staphylococcus aureus colonization.
- 1.2 Methicillin resistant staphylococcus aureus (MRSA)
- Preferred regimen: Vancomycin alone or in combination with other antibiotics to achieve broader coverage is recommended for prophylaxis in patients with proven or suspected methicillin-resistant S. aureus colonization
- Staphylococcus, coagulase-negative species (CoNS)
- Staphylococcus epidermidis group (Staphylococcus epidermidis, Staphylococcus haemolyticus)
- 1. Bacteremia: most often due to IV lines, vascular grafts, cardiac valves (30-40% of all coagulase-negative staphylococcus infections)
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
- 2. CSF shunt: meningitis
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h added to Vancomycin AND Rifampin 300 mg IV or PO q8h for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd  Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg IV/PO q8h.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): (Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
- 3. Peritoneal dialysis catheter: peritonitis
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV or PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h added to Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
- 4. Prosthetic joint: septic arthritis
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
- 5. Prosthetic or natural cardiac valve: endocarditis
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole. ::::: Note: Site specific recommendation is consider valve replacement and antibiotics for 6 wks.
- 6. Post-sternotomy: osteomyelitis
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
- 7. Implants (breast, penile, pacemaker) and other prosthetic devices: local infection
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
- 8. Post-ocular surgery: endophthalmitis
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
- 9. Surgical site infections
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
- Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
- Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
- Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
- Staphylococcus saprophyticus treatment
- 1. Urinary tract infection 
- 1.1 Acute uncomplicated urinary tract infection (cystitis-urethritis) in females
- Preferred regimen (1): Cephalosporin-Cefdinir 600 mg PO q24h for 10 days
- Preferred regimen (2): Amoxicillin-Clavulanate 625 mg PO (Amoxicillin trihydrate equivalent to Amoxicillin 500 mg and Potassium clavulanate equivalent to Clavulanic acid 125 mg) q12h for 3-7 days
- Preferred regimen (3): Trimethoprim-Sulfamethoxazole-DS (double strength) 160 mg/800 mg PO bid for 3 days
- Preferred regimen (if sulfa allergy) (4): Nitrofurantoin 100 mg PO bid for 5 days
- Preferred regimen (if sulfa allergy) (5): Fosfomycin 3 gm PO as a single dose AND Pyridium 200 mg PO tid for 2 days
- Alternative regimen (in sulfa allergy) (1): Ciprofloxacin 250 mg PO bid for 3 days
- Alternative regimen (in sulfa allergy) (2): Ciprofloxacin 250 mg PO bid for 7-14 days -Erythromycin 500 mg PO q24h for 7 days
- Alternative regimen (in sulfa allergy) (3): Levofloxacin 250 mg PO q24h for 5 days (or Moxifloxacin 400 mg PO q24h for 7 days)
- Alternative regimen (in sulfa allergy) (4): Nitrofurantoin 100 mg PO bid for 7 days
- Alternative regimen (in sulfa allergy) (5): Fosfomycin single 3 gm dose PO AND Phenazopyridine Pyridium 200 mg PO tid for 2 days
- Note (1): Pyridium non-prescription drug may relieve dysuria. Hemolysis if G6PD deficient.
- Note (2): >7-day treatment recommended in pregnancy . If failure on 3-day course, culture and treat for 2 weeks.
- 1.2 Recurrent urinary tract infection in postmenopausal women
- Preferred regimen (1): Trimethoprim-Sulfamethoxazole-DS (double strength) 160 mg/800 mg PO bid for 3 days
- Preferred regimen (in sulfa allergy) (2): Nitrofurantoin 100 mg PO bid for 7 days
- Preferred regimen (in sulfa allergy) (3): Fosfomycin single 3 gm dose PO AND Phenazopyridine Pyridium 200 mg PO tid for 2 days
- Alternative regimen (in sulfa allergy) (1): Ciprofloxacin 250 mg PO bid for 3 days
- Alternative regimen (in sulfa allergy) (2): Ciprofloxacin 250 mg PO bid for 7-14 days -Erythromycin 500 mg PO q24h for 7 days
- Alternative regimen (in sulfa allergy) (3): Levofloxacin 250 mg PO q24h for 5 days (or Moxifloxacin 400 mg PO q24h for 7 days)
- Alternative regimen (in sulfa allergy) (4): Nitrofurantoin 100 mg PO bid for 7 days
- Alternative regimen (in sulfa allergy) (5): Fosfomycin single 3 gm dose PO AND Phenazopyridine Pyridium 200 mg PO tid for 2 days
- Note (1): Recurrent urinary tract infection definition is 3 culture and symptomatic urinary tract infection in 1 year or 2 urinary tract infection in 6 months. Evaluate for potentially correctable urologic factors like (1) cystocele (2) incontinence (3) increased residual urine volume (50 mL).
- Note (2): Nitrofurantoin more effective than vaginal cream in decreasing frequency, but adverse effect is pulmonary fibrosis with long-term Nitrofurantoin treatment.
- Streptobacillus moniliformis Return to Top
- Streptococcus moniliformis treatment
- 1. Migratory arthropathy and arthritis
- Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
- Preferred regimen (2):  Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h  complete 14 days.
- 2. Diarrhea, (especially kids) liver or spleen abscess
- Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
- Preferred regimen (2):  Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h  complete 14 days.
- 3. Undifferentiated fever
- Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
- Preferred regimen (2):  Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h  complete 14 days.
- 4. Endocarditis, myocarditis, pericarditis (cardiac)
- Preferred regimen: Penicillin 20 MU/day IV divided q4h for 4 weeks (optimal duration recommendation for infective endocarditis is 4 weeks.)
- Alternative regimen (1): Cephalosporins-Cefdinir 600 mg PO q24h for 10 days -Ceftriaxone 2 g IV/IM q24h for 6 weeks with or without Gentamicin sulfate 3 mg/kg IM or IV  in 1 dose (preferred) or in 3 equally divided doses for 2 weeks
- Alternative regimen (2): Clindamycin 6001200 mg/day IM or IV in 2, 3 or 4 equal doses
- Alternative regimen (3): Erythromycin
- Alternative regimen (4): Chloramphenicol 100 mg/kg/day AND Streptomycin
- Streptomycin may be used for 2-week treatment concomitantly with Penicillin.
- The Streptomycin regimen is 1 g bid for the first week, and 500 mg bid for the second week.
- If the patient is over 60 years of age, the dosage should be 500 mg bid for the entire 2- week period.
- 5. Meningitis, brain abscess
- Preferred regimen: Penicillin 10 MU/day IV divided q4h.
- Alternative regimen (1): Cephalosporins-Cefdinir 600 mg PO q24h for 10 days -Ceftriaxone 2 g IV/IM q24h for 6 weeks with or without Gentamicin sulfate 3 mg/kg IM or IV  in 1 dose (preferred) or in 3 equally divided doses for 2 weeks
- Alternative regimen (2): Clindamycin 6001200 mg/day IM or IV in 2, 3 or 4 equal doses
- Alternative regimen (3): Erythromycin
- Alternative regimen (4): Chloramphenicol 100 mg/kg/day
- 6.  Pneumonia
- Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
- Preferred regimen (2):  Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h  complete 14 days.
- 7. Amnionitis (pregnancy)
- Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days :::- Preferred regimen (2):  Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h  complete 14 days.
- 8. Renal abscess
- Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
- Preferred regimen (2):  Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h  complete 14 days.
- Staphylococcus lugdunensis Return to Top
- Staphylococcus lugdunensis treatment
- 1. Skin and soft tissue infections
- Preferred regimen: Oxacillin 1-2 g IV q4h for 1-2 weeks
- Note:  Abscesses should be drained if possible.
- 2.  Endocarditis
- 2.1 Native valve infectious endocarditis
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL)
- Preferred regimen (for most patients with normal renal function) (2): Vancomycin 15-20 mg/kg (actual body weight) IV q8-12h -for trough concentration of 15-20 mcg/mL (minimum inhibitory concentration, 1 mcg/mL or less)
- Note: should consist of 6 weeks of parenteral beta-lactam therapy or Vancomycin (depending on susceptibility testing and beta-lactam hypersensitivity).
- 2.2 Prosthetic valve infective endocarditis
- Preferred regimen: Combination therapy including a beta-lactam (or Vancomycin) with an Aminoglycoside- Gentamicin 3 mg/kg/day in 1-3 divided doses and Rifampin 300 mg PO/IV q8h for at least 6 weeks
- Note (1): Combine with Vancomycin for the entire duration of therapy and Gentamicin for the first 2 weeks.
- Note (2): The Gentamicin should be administered for the first 2 weeks of therapy; the beta-lactam (or Vancomycin) and Rifampin should be continued for 6 weeks.
- Note (3): Surgery must be considered given the frequency of valvular compromise in the setting of Staphylococcus lugdunensis infective endocarditis.
- Note (4): The treatment of Staphylococcus lugdunensis pacemaker endocarditis includes antibiotic therapy as well as removal of the pacer system
- 3. Bacteremia
- Preferred regimen: Oxacillin 1-2 g IV q4h for 1-2 weeks
- Note (1): Bacteremia without endocarditis (often related to an intravascular catheter) appears to have a good prognosis.
- Note (2): For intravascular catheter-related Staphylococcus lugdunensis bacteremia, the catheter should be removed, followed by 14 days of antibiotics, provided that all of the following are applicable
- 4. Prosthetic devices,
- Preferred regimen (1): Vancomycin 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL)
- Preferred regimen (for most patients with normal renal function) (2): Vancomycin 15-20 mg/kg (actual body weight) IV q8-12h -for trough concentration of 15-20 mcg/mL (minimum inhibitory concentration, 1 mcg/mL or less)
- Preferred regimen (3): Daptomycin 6 mg/kg IV qd for 3-4 weeks
- Preferred regimen (4): Linezolid 600 mg IV q12h
- 5. Vertebral osteomyelitis, discitis
- Preferred regimen: Vancomycin 15-20 mg/kg IV q8-12h, (maximum dose: 2 g per dose)
- 6. Septic arthritis in adults
- Preferred regimen: Vancomycin 15 mg/kg IV bd, (maximum dose: 2 g q24h) (unless cncentrations in serum are inappropriately low) for 4 weeks
- Streptococcus pneumoniae Return to Top
- Streptococcus pneumonia treatment
- 1. Lung (Community-acquired pneumonia)
- 1.1 Penicillin sensitive (minimum inhibitory concentration < 2 mcg/ml)
- Preferred regimen: Penicillin G 5-24 MU IV in equally divided doses q4-6h, Amoxicillin 1 g PO tid (+/- macrolide)
- Alternative regimen:  Macrolides (Azithromycin (IV) 500 mg IV qd for at least 2 days followed by 500 mg PO qd 7-10 days or Clarithromycin extended-release tablets 1000 mg PO qd for 7 days) and oral Cephalosporins-Cefpodoxime 200 mg PO bd, (Cefprozil 500 mg PO bd, Cefditoren 400 mg PO bd, Cefdinir 300 mg PO bd), OR parenteral Cephalosporins-Ceftriaxone 2 g IV q24h (or Cefotaxime 1-2 g IV q6-8h), Clindamycin 600-1200 mg IV/IM q6-12h, do not give single IM doses > 600 mg; IV infusion rates should not exceed 30 mg/min , Doxycycline 100 mg PO bd, respiratory flouroquniolones.
- 1.2 Penicillin-resistant (Penicillin minimum inhibitory concentration  2 mcg/ml)
- Preferred regimen: Ceftriaxone 2 g IV q24h (or Cefotaxime 1-2 g IV q6-8h), respiratory Flouroquniolones Levofloxacin (Levaquin) 500 mg IV/PO q24h for 7-14 days or 750 mg IV/PO q24h for 5 days  (or Moxifloxacin (Avelox) 400 mg PO/IV over 60 minutes q24h for 7-14 days)
- Alternative regimen: Vancomycin 2 g/day IV q6-12h over at least 60 minutes, Linezolid  600 mg IV/PO q12h for 7-21 days , high-dose Amoxicillin (3 g qd with Penicillin minimum concentration of inhibitory <4 mcg/mL).
- 2.Endocarditis
- Preferred regimen (1):  Aqueous crystalline Penicillin-G  6 MU q4-6h IV  for 4 weeks
- Preferred regimen (2) (who are unable to tolerate beta lactams therapy): Vancomycin 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL); for troughs of 15-20 mcg/mL (MIC, 1 mcg/mL or less), 15-20 mg/kg (actual body weight) IV q8-12h for most patients with normal renal function
- Preferred regimen (3) (If the isolate is resistant (MIC 2 g/mL) to cefotaxime): Cefotaxime 1-2 g q8-12h IV/IM (max dose: 12 g/24 hr) AND Vancomycin 15 mg/kg/day IV q12h AND Rifampin 300 mg IV/PO q8h for 6 weeks, in combination with appropriate antimicrobial therapy
- Alternative regimen (1): Cefazolin  0.5-2 g q8h IV/IM (max dose: 12 g/24 hr)
- Alternative regimen (2): Ceftriaxone 2 g IV q12h
- Note : Streptococcus pneumoniae with intermediate doses minimum inhibitory concentration (MIC) 0.12 g/mL0.5 g/mL Penicillin resistance (MIC 0.1 to 1.0 g/mL) or high Penicillin resistance (MIC 2.0 g/mL) is being recovered from patients with bacteremia.
- 3. Sinuses (sinusitis)
- Empiric therapy
- 3.1 For initial empiric treatment of acute bacterial rhinosinusitis in adults
- Preferred regimen: Amoxicillin 500 mg/Clavulanate 125 mg PO tid or Amoxicillin 875 mg/Clavulanate 125 mg PO bid for 5 to 7 days recommended by the Infectious Disease Society of America (IDSA)
- Alternative regimen (1): Doxycycline 100 mg PO q12h
- Note: Doxycycline can be used in patients with Penicillin allergy.
- Alternative regimen (2): A respiratory Fluoroquinolone (Levofloxacin or Moxifloxacin) is another recommended drug for Penicillin-allergic patients.
- 3.2 For second-line high-dose therapy for acute bacterial rhinosinusitis in adults
- Preferred regimen: Amoxicillin 2 g/Clavulanate 125 mg PO bid recommended by the Infectious Disease Society of America (IDSA).
- Note: The second line high dose therapy  is recommended in adults who have failed initial therapy, in regions of high endemic rates (10% or greater) of invasive Penicillin-nonsusceptible Streptococcus pneumoniae, severe infection.
- 4. Bronchi (acute exacerbation of chronic bronchitis)
- Preferred regimen (1): Amoxicillin 875 mg PO q12h or 500 mg PO q8h
- Preferred regimen (2): Doxycycline 100 mg PO q12h
- 5. CNS (meningitis)
- Empiric therapy
- Preferred regimen: Vancomycin 15 mg/kg/day IV q12h AND a third-generation cephalosporin (Ceftriaxone 2 g IV q12h OR Cefotaxime 2 g IV q4h or 3 g q6h) AND Rifampin 600 mg IV qd in combination with Vancomycin
- Alternative regimen: Meropenem, fluoroquinolones
- Prevention
- 1. Pneumovax (23-valent) prevents bacteremia; impact on rates of CAP are modest or nil.
- 2. Prevnar vaccine for children <2 yrs age  prevents invasive pneumococcal infection in adults by herd effect. Impact is impressive with rates of invasive pneumococcal infection down 80% in peds and 20-40% in adults.
- 3. Risk for bacteremia in splenectomy, HIV, smokers, black race, multiple myeloma, asthma.
- Streptococcus agalactiae Return to Top
- Streptococcus agalactiae treatment (GBS-group B Streptococcus)
- 1. Early onset group B streptococcal infections
- 1.1 Bacteremia or sepsis or pneumonia
- 1.1.1 Empiric therapy
- Preferred regimen: Ampicillin 150 mg/kg IV q12h for 10 days AND Gentamicin 4 mg/kg IV q12h for 10 days-for infants born at  35 weeks gestation; Gentamicin 3 mg/kg IV q24h for 10 days-for infants born at < 35 weeks gestation
- 1.1.2 Definitive therapy
- Preferred regimen: Penicillin G 50,000-100,000 units/kg per day IV divided q12h for 10 days
- 1.2 Meningitis
- 1.2.1 Empiric therapy
- Preferred regimen: Ampicillin 100-150 mg/kg IV q8h for 14-21 days AND Gentamicin 4 mg/kg IV q24h for 14-21 days-for infants born at  35 weeks gestation; Gentamicin 3 mg/kg IV q24h for 14-21 days-for infants born at < 35 weeks gestation
- 1.2.2 Definitive therapy
- Preferred regimen: Penicillin G 250,000-450,000 units/kg per day IV divided q8h for 14-21 days
- Note: Cellulitis is the most frequent clinical manifestation of GBS-associated skin and soft tissue infections.
- 2. Late onset group b streptococcus infections in neonates and young infants (age > 1 week and body weight  1 kg with normal renal function)
- 2.1 Bacteremia without a focus
- 2.1.1 Empiric therapy
- Preferred regimen: Ampicillin IV for 10 days, Nafcillin IV for 10 days, (OR Vancomycin IV for 10 days) AND Gentamicin IV for 10 days (OR Cefotaxime IV for 10 days)
- 2.1.2 Definitive therapy
- Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 10 days
- 2.2 Meningitis
- 2.2.1 Empiric therapy
- Preferred regimen: Ampicillin IV for 14-21 days with or without Vancomycin IV for 14-21 day AND Gentamicin IV for 14-21 days OR Cefotaxime IV for 14-21 day
- 2.2.2 Definitive therapy
- Preferred regimen: Penicillin-G 450,000-500,000 units/kg per day IV divided q6h for 14-21 days
- 2.3 Cellulitis or adenitis
- 2.3.1 Empiric therapy
- Preferred regimen: Nafcillin IV for 10-14 days (OR [[Vancomycin IV for 10-14 days) AND Gentamicin IV for 10-14 days (OR Cefotaxime IV for 10-14 days)
- 2.3.2 Definitive therapy
- Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 10-14 days
- 2.4 Septic arthritis
- 2.4.1 Empiric therapy
- Preferred regimen: Nafcillin IV for 14-21 days OR Vancomycin IV for 14-21 days AND Cefotaxime IV for 14-21 days
- 2.4.2 Definitive therapy
- Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 14-21 days
- 2.5 Osteomyelitis
- 2.5.1 Empiric therapy
- Preferred regimen: Nafcillin IV for 21-28 days OR Vancomycin IV for 21-28 days AND Cefotaxime IV for 21-28 days
- 2.5.2 Definitive therapy
- Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 21-28 days
- 2.6 Urinary tract infection
- 2.6.1 Empiric therapy
- Preferred regimen: Ampicillin IV for 10 days, Nafcillin IV for 10 days, (OR Vancomycin IV for 10 days) AND Gentamicin IV for 10 days (OR Cefotaxime IV for 10 days)
- 2.6.2 Definitive therapy
- Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 10 days
- Neonatal prophylaxis
- Group B streptococcus infection (maternal dose for neonatal prophylaxis)
- Preferred regimen: Penicillin-G, Ampicillin 2 g IV initial dose, THEN 1 g q4h until delivery, Cefazolin  4h prior to delivery.
- Bacillus anthracis Return to Top
- Bacillus anthracis treatment
- 1. Treatment for cutaneous anthrax, without systemic involvement
- Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (1): Ciprofloxacin 500 mg PO bid for 7-10 days
- Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (2): Doxycycline 100 mg PO bid for 7-10 days
- Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (3): Levofloxacin 750 mg PO qd for 7-10 days
- Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (4): Moxifloxacin 400 mg PO qd for 7-10 days
- Alternative regimen (1): Clindamycin 600 mg PO tid for 7-10 days
- Alternative regimen (2): Amoxicillin 1 g PO tid (for penicillin-susceptible strains) for 7-10 days
- Alternative regimen (3): Penicillin VK 500 mg PO qid (for penicillin-susceptible strains) for 7-10 days
- Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
- 2. Treatment for systemic anthrax including anthrax meningitis, inhalational anthrax, injectional anthrax, and gastrointestinal anthrax; and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck
- 2.1 Systemic anthrax with possible/confirmed meningitis
- 2.1.1 Bactericidal agent (fluoroquinolone)
- Preferred regimen (1): Ciprofloxacin 400 mg IV q8h for 2-3 weeks
- Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2-3 weeks
- Preferred regimen (3): Moxifloxacin 400 mg IV q24h for 2-3 weeks AND
- 2.1.2 Bactericidal agent (-lactam) for all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- Preferred regimen (1): Meropenem 2 g IV q8h for 2-3 weeks
- Preferred regimen (2): Imipenem 1 g IV q6h for 2-3 weeks
- Preferred regimen (3): Doripenem 500 mg IV q8h for 2-3 weeks
- Preferred regimen (4): Penicillin G 4 MU IV q4h (for penicillin-susceptible strains) for 2-3 weeks
- Preferred regimen (5): Ampicillin 3 g IV q6h (for penicillin-susceptible strains) for 2-3 weeks AND
- 2.1.3 Protein synthesis inhibitor
- Preferred regimen (1): Linezolid 600 mg IV q12h for 2-3 weeks
- Preferred regimen (2): Clindamycin 900 mg IV q8h for 2-3 weeks
- Preferred regimen (3): Rifampin 600 mg IV q12h for 2-3 weeks
- Preferred regimen (4): Chloramphenicol 1 g IV q6-8h for 2-3 weeks
- Note (1): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
- Note (2): Increased risk for seizures associated with Imipenem/Cilastatin treatment.
- Note (3): Linezolid should be used with caution in patients with thrombocytopenia because it might exacerbate it. Linezolid use for > 14 days has additional hematopoietic toxicity.
- Note (4): Rifampin is not a protein synthesis inhibitor. However, it may be used in combination with other antimicrobial drugs on the basis of its in vitro synergy.
- 2.2 Systemic anthrax when meningitis has been excluded
- 2.2.1 Bactericidal agent
- Preferred regimen (1): Ciprofloxacin 400 mg IV q8hfor 2 weeks
- Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2 weeks
- Preferred regimen (3): Moxifloxacin 400 mg q24h for 2 weeks
- Preferred regimen (4): Meropenem 2 g IV q8h for 2 weeks
- Preferred regimen (5): Imipenem 1 g IV q6h for 2 weeks
- Preferred regimen (6): Doripenem 500 mg IV q8h for 2 weeks
- Preferred regimen (7): Vancomycin 20 mg/kg IV q8h (maintain serum trough concentrations of 15-20 g/mL) for 2 weeks
- Preferred regimen (8): Penicillin G 4 MU IV q4h (penicillin-susceptible strains) for 2 weeks
- Preferred regimen (9): Ampicillin 3 g IV q6h (penicillin-susceptible strains) for 2 weeks AND
- 2.2.2 Protein synthesis inhibitor
- Preferred regimen (1): Clindamycin 900 mg IV q8h for 2 weeks
- Preferred regimen (2): Linezolid 600 mg IV q12h for 2 weeks
- Preferred regimen (3): Doxycycline 200 mg IV initially, then 100 mg IV q12h for 2 weeks
- Preferred regimen (4): Rifampin 600 mg IV q12h for 2 weeks
- Note: Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
- 3. Specific considerations
- 3.1 Treatment of anthrax for pregnant Women
- 3.1.1 Intravenous antimicrobial treatment for systemic anthrax with possible/confirmed meningitis 
- 3.1.1.1  A Bactericidal Agent (Fluoroquinolone)
- Preferred regimen (1): Ciprofloxacin 400 mg IV q8h for 23 weeks OR
- Preferred regimen (2): Levofloxacin 750 mg IV q24h for 23 weeksOR
- 3.1.1.2  A Bactericidal Agent (-lactam)
- 3.1.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- Preferred regimen: Meropenem 2 g q8h for 23 weeks
- 3.1.1.2.2 Alternatives for penicillin-susceptible strains
- Alternative regimen (1): Ampicillin 3 g IV q6h for 23 weeks
- Alternative regimen (2): Penicillin G 4 MU IV q4h for 23 weeks OR
- 3.1.1.3  A Protein Synthesis Inhibitor
- Preferred regimen (1): Clindamycin 900 IV mg q8h for 23 weeks
- Preferred regimen (2): Rifampin 600 IV mg q12h for 23 weeks
- Note: At least one antibiotic with transplacental passage is recommended.
- 3.1.2 Intravenous antimicrobial treatment for systemic anthrax when meningitis has been excluded
- 3.1.2.1  A Bactericidal Antimicrobial
- Preferred regimen (1): Ciprofloxacin 400 mg IV q8h for 2 weeks
- Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2 weeks OR
- 3.1.2.2  A Bactericidal Agent (-lactam)
- 3.1.2.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- Preferred regimen: Meropenem 2 g q8h for 2 weeks  OR
- 3.1.2.2.2 Alternatives for penicillin-susceptible strains
- Alternative regimen (1): Ampicillin 3 g IV q6h for 2 weeks
- Alternative regimen (2): Penicillin G 4 MU IV q4h for 2 weeks OR
- 3.1.2.3  A Protein Synthesis Inhibitor
- Preferred regimen (1): Clindamycin 900 IV mg q8h for 2 weeks
- Preferred regimen (2): Rifampin 600 IV mg q12h for 2 weeks
- 3.1.3 Oral antimicrobial treatment for cutaneous anthrax without systemic involvement
- 3.1.3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- Preferred regimen: Ciprofloxacin 400 mg IV q8h
- Note: Duration of treatment is 60 days
- 3.2 Treatment for anthrax in childern 
- 3.2.1 Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)
- 3.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day PO bid (not to exceed 500 mg/dose) for 7-10 days
- Preferred regimen (2):
- If patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day PO bid (not to exceed  100 mg/dose) for 7-10 days
- If patients body weight is = 45 kg: Doxycycline  100 mg/dose PO bid for 7-10 days
- Preferred regimen (3): Clindamycin 30 mg/kg/day PO tid (not to exceed  600 mg/dose) for 7-10 days
- Preferred regimen (4):
- If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day PO bid (not to exceed  250 mg/dose) for 7-10 days
- If patients body weight is > 50 kg: Levofloxacin 500 mg PO qd for 7-10 days
- 3.2.1.2 Alternatives for penicillin-susceptible strains
- Alternative regimen (1):Amoxicillin 75 mg/kg/day PO tid (not to exceed 1 g/dose) for 7-10 days
- Alternative regimen (2): Penicillin VK 50-75 mg/kg/day PO tid or qid for 7-10 days
- 3.2.2  Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older)
- 3.2.2.1 A bactericidal antimicrobial
- 3.2.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q8h (not to exceed 400 mg/dose) for 14 days
- Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h (not to exceed 2 g/dose) for 14 days
- Preferred regimen (3):
- If patients body weight is < 50 kg: Levofloxacin 20 mg/kg/day IV divided q12h (not to exceed 250 mg/dose) for 14 days
- If patients body weight is > 50 kg: Levofloxacin 500 mg IV q24h for 14 days
- Preferred regimen (4): Imipenem/Cilastatin 100 mg/kg/day IV divided q6h (not to exceed 1 g/dose) for 14 days
- Preferred regimen (5): Vancomycin 60 mg/kg/day IV divided q8h (follow serum concentrations) for 14 days
- 3.2.2.1.2 Alternatives for penicillin-susceptible strains
- Alternative regimen (1): Penicillin G 400 000 U/kg/day IV divided q4h (not to exceed 4 MU/dose) for 14 days
- Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q6h (not to exceed 3 g/dose) for 14 days AND
- 3.2.2.2 A Protein Synthesis Inhibitor
- Preferred regimen (1): Clindamycin, 40 mg/kg/day IV divided q8h (not to exceed 900 mg/dose) for 14 days
- Preferred regimen (2):  (non-CNS infection dose)
- If patient is < 12 y old: Linezolid 30 mg/kg/day IV divided q8h for 14 days
- If patient is = 12 y old: Linezolid 30 mg/kg/day IV divided q12h (not to exceed 600 mg/dose) for 14 days
- Preferred regimen (3):
- If patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day IV loading dose (not to exceed 200 mg) THEN Doxycycline 4.4 mg/kg/day IV divided q12h   (not to exceed 100 mg/dose) for 14 days
- If patients body weight is =45 kg: Doxycycline 200 mg IV loading dose THEN Doxycycline 100 mg IV given q12h for 14 days
- Preferred regimen (4): Rifampin 20 mg/kg/day IV divided q12h (not to exceed 300 mg/dose) for 14 days
- Note: Duration of therapy for 14 days or longer until clinical criteria for stability are met.Will require prophylaxis to complete an antimicrobial course of up to 60 days from onset of illness.
- 3.2.3 Triple therapy for systemic anthrax (anthrax meningitis or disseminated infection and meningitis cannot be ruled out) for Children 1 Month of Age and Older
- 3.2.3.1 A bactericidal antimicrobial (fluoroquinolone)
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q8h (not to exceed 400 mg/dose) for 23 wks
- Preferred regimen (2):
- If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day IV divided q12h (not to exceed 250 mg/dose) for 23 wks
- If patients body weight is > 50 kg: Levofloxacin 500 mg IV q24h for 23 wks
- Preferred regimen (3):
- If patients age is 3 months to < 2 years: Moxifloxacin  12 mg/kg/day IV, divided q12h (not to exceed 200 mg/dose) for 23 wks
- If patients age is 2-5 years: Moxifloxacin 10 mg/kg/day IV divided q1h (not to exceed 200 mg/dose) for 23 wks
- If patients age is 611 years: Moxifloxacin 8 mg/kg/day IV divided q12h (not to exceed 200 mg/dose) for 23 wks
- If patients age is 1217 years, = 45 kg body weight: Moxifloxacin 400 mg IV q24h for 23 wks
- If patients age is 1217 years, < 45 kg body weight: Moxifloxacin 8 mg/kg/day IV divided q12h (not to exceed 200 mg/dose) for 23 wks AND
- 3.2.3.2 A bactericidal antimicrobial (-lactam or glycopeptide)
- 3.2.3.2.1 For all strains, regardless of penicillin susceptibility testing or if susceptibility is unknown:
- Preferred regimen (1): Meropenem 120 mg/kg/day IV divided q8h (not to exceed 2 g/dose) for 23 wks
- Preferred regimen (2): Imipenem/Cilastatin 100 mg/kg/day IV divided q6h (not to exceed 1 g/dose) for 23 wks
- Preferred regimen (3): Doripenem 120 mg/kg/day IV divided q8h (not to exceed 1 g/dose) for 23 wks
- Preferred regimen (4): Vancomycin 60 mg/kg/day IV divided q8h for 23 wks
- 3.2.3.2.2 Alternatives for penicillin-susceptible strains
- Alternative regimen (1): Penicillin G 400 000 U/kg/day IV divided q4h (not to exceed 4 MU/dose) for 23 wks
- Alternative regimen (2): Ampicillin 400 mg/kg/day IV divided q6h (not to exceed 3 g/dose) for 23 wks AND
- 3.2.3.3 A Protein Synthesis Inhibitor
- Preferred regimen (1):
- If patients age is < 12 y old: Linezolid 30 mg/kg/day IV divided q8h for 23 wk
- If patients age is = 12 y old: Linezolid 30 mg/kg/day,IV divided q12h (not to exceed 600 mg/dose) for 23 wk
- Preferred regimen (2): Clindamycin 40 mg/kg/day IV divided q8h (not to exceed 900 mg/dose)  for 23 wk
- Preferred regimen (3): Rifampin 20 mg/kg/day IV divided q12h (not to exceed 300 mg/dose) for 23 wk
- Preferred regimen (4): Chloramphenicol 100 mg/kg/day IV divided q6h for 23 wk
- 3.2.4 Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older)
- 3.2.4.1 A bactericidal antimicrobial
- 3.2.4.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day PO bid (not to exceed 500 mg/dose)
- Preferred regimen (2):
- If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day PO bid (not to exceed 250 mg/dose)
- If patients body weight is = 50 kg: Levofloxacin 500 mg PO qd
- 3.2.4.1.2 Alternatives for penicillin-susceptible strains
- Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid (not to exceed 1 g/dose)
- Alternative regimen (2): Penicillin VK 5075 mg/kg/day PO tid or qds AND
- 3.2.4.2 A protein synthesis inhibitor:
- Preferred regimen (1):Clindamycin 30 mg/kg/day PO tid (not to exceed 600 mg/dose)
- Preferred regimen (2):
- If the patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day PO bid (not exceed 100 mg/dose)
- If the patients body weight is = 45 kg: Doxycycline 100 mg PO bid
- Preferred regimen (3): (non-CNS infection dose):
- If the patients age is < 12 yrs old: Linezolid 30 mg/kg/day PO tid
- If the patients age is = 12 yrs old: Linezolid 30 mg/kg/day PO bid (not to exceed 600 mg/dose)
- Note: Duration of therapy to complete a treatment course of 14 days or greater. May require prophylaxis to complete an antimicrobial course of up to 60 days from onset of illness.
- 3.2.5  Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)
- 3.2.5.1 Triple therapy for severe anthrax(anthrax meningitis or disseminated infection and meningitis cannot be ruled out)
- 3.2.5.1.1 Bactericidal antimicrobial (fluoroquinolone) therapy
- 3.2.5.1.1.1 For 3234 weeks gestational age
- For 01 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 23 weeks
- For 14 weeks of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 23 weeks
- 3.2.5.1.1.2 For 3437 week gestational age
- For 01 wk of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (2):Moxifloxacin 5 mg/kg/day IV q24h for 23 weeks
- For 14 wk of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 23 weeks
- 3.2.5.1.1.3 Term newborn infant
- For 01 week of age
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (2): Moxifloxacin 10 mg/kg/day IV q24h for 23 weeks
- For 14 weeks of age
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (2): Moxifloxacin 10 mg/kg/day IV q24h for 23 weeks AND
- 3.2.5.1.2 A bactericidal antimicrobial (-lactam)
- 3.2.5.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown:
- 3.2.5.1.2.1.1 For 3234 weeks gestational age
- For 01 week of Age :
- Preferred regimen (1): Meropenem 60 mg/kg/day  IV divided q8h for 23 weeks
- Preferred regimen (2): Imipenem 50 mg/kg/day  IV divided q12h for 23 weeks
- Preferred regimen (3): Doripenem 20 mg/kg/day  IV divided q12h for 23 weeks
- For 14 wk of Age :
- Preferred regimen (1): Meropenem 90 mg/kg/day  IV divided q8h for 23 weeks
- Preferred regimen (2): Imipenem 75 mg/kg/day  IV divided q8h for 23 weeks
- Preferred regimen (3): Doripenem 30 mg/kg/day  IV divided q8h for 23 weeks
- 3.2.5.1.2.1.2 For 3437 week gestational age
- For 01 week of Age :
- Preferred regimen (1): Meropenem 60 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Imipenem 50 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (3): Doripenem  20 mg/kg/day IV divided q12h for 23 weeks
- For 14 week of Age :
- Preferred regimen (1): Meropenem 90 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Imipenem 75 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (3): Doripenem 30 mg/kg/day IV divided q8h for 23 weeks
- 3.2.5.1.2.1.3 Term newborn infant
- For < 1 week of age
- Preferred regimen (1):Meropenem 60 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Imipenem 50 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (3): Doripenem 20 mg/kg/day IV divided q12h for 23 weeks
- For 14 week of age
- Preferred regimen (1):Meropenem 90 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Imipenem 75 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (3): Doripenem 30 mg/kg/day IV divided q8h for 23 weeks
- 3.2.5.1.2.2  Alternatives for penicillin-susceptible strains
- 3.2.5.1.2.2.1 For 3234 weeks gestational age
- For 01 week of age
- Alternative regimen (1):Penicillin G 200000 Units/kg/day IV divided q12h for 23 weeks
- Alternative regimen (2): Ampicillin 100 mg/kg/day IV divided q12h for 23 weeks
- For 14 week of age :
- Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 23 weeks
- Alternative regimen (2): Ampicillin 150 mg/kg/day divided IV q12h for 23 weeks
- 3.2.5.1.2.2.2 For 3437 week gestational age
- For < 1 week of age
- Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 23 weeks
- Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q12h for 23 weeks
- For 14 week of age
- Alternative regimen (1): Penicillin G 400000 Units/kg/day IV divided q12h for 23 weeks
- Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q12h for 23 weeks
- 3.2.5.1.2.2.3 Term newborn infant
- For 01 week of age
- Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 23 weeks
- Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q12h for 23 weeks
- For 14 week of age
- Alternative regimen (1): Penicillin G 400000 Units/kg/day IV divided q12h for 23 weeks
- Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q12h for 23 weeks AND
- 3.2.5.1.3 A protein synthesis inhibitor
- 3.2.5.1.3.1 For 3234 weeks gestational age
- For < 1 week of age
- Preferred regimen (1): Linezolid 20 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (2): Clindamycin 10 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 23 weeks
- For 14 week of age
- Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 23 weeks
- 3.2.5.1.3.2 For 3437 week gestational age
- For < 1 week of age
- Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 23 weeks
- For 14 week of age
- Preferred regimen (1):Linezolid 30 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Clindamycin 20 mg/kg/day IV divided q6h for 23 weeks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 23 weeks
- 3.2.5.1.3.3 Term newborn infant
- For < 1 week of age
- Preferred regimen (1):Linezolid 30 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 23 weeks
- For 14 week of age
- Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 23 weeks
- Preferred regimen (2): Clindamycin 20 mg/kg/day IV divided q6h for 23 weeks
- Preferred regimen (3): Rifampin 20 mg/kg/day IV divided q12h for 23 weeks
- Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 23 weeks
- Note :Duration of therapy for 23 weeks, until clinical criteria for stability are met. Will require prophylaxis to complete an antibiotic course of upto 60 days from onset of illness.
- 3.2.5.2 Therapy for severe anthrax when meningitis can be ruled out
- 3.2.5.2.1 A bactericidal antimicrobial
- 3.2.5.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- 3.2.5.2.1.1.1 For 3234 weeks gestational age
- For < 1 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
- Preferred regimen (2): Meropenem 40 mg/kg/day IV divided q8h for 2-3 weeks
- Preferred regimen (3): Imipenem 40 mg/kg/day IV divided q12h for 2-3 weeks
- For 14 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
- Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
- Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
- 3.2.5.2.1.1.2 For 3437 week gestational age
- For < 1 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
- Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
- Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
- For 14 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
- Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
- Preferred regimen (3): Imipenem 75 mg/kg/day IV divided q8h for 2-3 weeks
- 3.2.5.2.1.1.3 Term Newborn Infant
- For < 1 week of age
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 2-3 weeks
- Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
- Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
- For 14 week of age
- Preferred regimen (1):Ciprofloxacin 30 mg/kg/day IV divided q12h for 2-3 weeks
- Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
- Preferred regimen (3): Imipenem 75 mg/kg/day IV divided q8h for 2-3 weeks
- Vancomycin IV (dosing based on serum creatinine for infants of 32 wk gestational age). Follow vancomycin serum concentrations to modify dose.
- If  Serum creatinine < 0.7 then Vancomycin 15 mg/kg/dose IV q12h for 2-3 weeks
- If Serum creatinine 0.7 -0.9 then Vancomycin 20 mg/kg/dose IV q24h for 2-3 weeks
- If Serum creatinine 11.2 then Vancomycin 15 mg/kg/dose IV q24h for 2-3 weeks
- If Serum creatinine 1.31.6 then Vancomycin 10 mg/kg/dose IV q24h for 2-3 weeks
- If Serum creatinine > 1.6 then Vancomycin mg/kg/dose IV q48h for 2-3 weeks
- Note: Begin treatment with a 20 mg/kg loading dose OR
- 3.2.5.2.1.2 Alternatives for penicillin-susceptible strains
- 3.2.5.2.1.2.1 For 3234 weeks gestational age
- For < 1 week of age
- Alternative regimen (1): Penicillin G 200000 U/kg/day IV divided q12h for 2-3 weeks
- Alternative regimen (2): Ampicillin 100 mg/kg/day IV divided q12h for 2-3 weeks
- For 14 week of age
- Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
- Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
- 3.2.5.2.1.2.2 For 3437 week gestational age
- For < 1 week of age
- Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
- Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
- For 14 week of age
- Alternative regimen (1): Penicillin G 400000 U/kg/day IV divided q6h for 2-3 weeks
- Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q6h for 2-3 weeks
- 3.2.5.2.1.2.3 Term newborn infant
- For < 1 week of age
- Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
- Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
- For 14 week of age
- Alternative regimen (1): Penicillin G 400000 U/kg/day IV divided q6h for 2-3 weeks
- Alternative regimen (2):Ampicillin 200 mg/kg/day IV divided q6h for 2-3 weeks
- 3.2.5.2.2 A protein synthesis inhibitor
- 3.2.5.2.2.1 For 3234 weeks gestational age
- For < 1 week of age
- Preferred regimen (1): Clindamycin 10 mg/kg/day IV divided q12h for 23 wks
- Preferred regimen (2): Linezolid 20 mg/kg/day IV divided q12h for 23 wks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 23 wks
- For 14 week of age
- Preferred regimen (1): Clindamycin 15 mg/kg/day IV divided q8h for 23 wks
- Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 23 wks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 23 wks
- 3.2.5.2.2.2 For 3437 week gestational age
- For < 1 week of age
- Preferred regimen (1): Clindamycin  15 mg/kg/day IV divided q8h for 23 wks
- Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 23 wks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 23 wks
- For 14 week of age
- Preferred regimen (1): Clindamycin 20 mg/kg/day IV divided q6h for 23 wks
- Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 23 wks
- Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 23 wks
- 3.2.5.2.2.3 Term newborn infant
- For 01 week of age :
- Preferred regimen (1): Clindamycin 15 mg/kg/day  IV divided q8h for 23 wks
- Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 23 wks
- Preferred regimen (3): Doxycycline 4.4 mg/kg/day IV divided q12h, (loading dose 4.4 mg/kg) for 23 wks
- Preferred regimen (4): Rifampin 10 mg/kg/day IV q24h for 23 wks
- For 14 week of age :
- Preferred regimen (1): Clindamycin 20 mg/kg/day IV divided q6h for 23 wks
- Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 23 wks
- Preferred regimen (3): Doxycycline 4.4 mg/kg/day IV divided q12h, (loading dose 4.4 mg/kg) for 23 wks
- Preferred regimen (4): Rifampin 10 mg/kg/day IV q24h for 23 wks
- Note: Duration of therapy for 23 wks, until clinical criteria for stability are met (see text). Will require prophylaxis to complete an antimicrobial course of upto 60 days from onset of illness
- 3.2.5.3 Oral follow-up combination therapy for severe anthrax
- 3.2.5.3.1 A bactericidal antimicrobial
- 3.2.5.3.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- 3.2.5.3.1.1.1 For 3234 weeks gestational age
- For < 1 week of age
- Preferred regimen: Ciprofloxacin 20 mg/kg/day PO bid
- For 14 week of age
- Preferred regimen: Ciprofloxacin 20 mg/kg/day PO bid
- 3.2.5.3.1.1.2 For 3437 week gestational age
- For < 1 week of age
- Preferred regimen: Ciprofloxacin 20 mg/kg/day PO bid
- For 14 week of age
- Preferred regimen: Ciprofloxacin 20 mg/kg/day PO bid
- 3.2.5.3.1.1.3 Term newborn infant
- For < 1 week of age
- Preferred regimen: Ciprofloxacin 30 mg/kg/day PO bid
- For 14 week of age
- Preferred regimen: Ciprofloxacin 30 mg/kg/day PO bid OR
- 3.2.5.3.1.2 Alternatives for penicillin-susceptible strains
- 3.2.5.3.1.2.1 For 3234 weeks gestational age
- For < 1 week of age
- Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
- Alternative regimen (2): Penicillin VK  50 mg/kg/day PO bid
- For 14 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day PO bid
- Alternative  regimen (2): Penicillin VK 75 mg/kg/day PO bid
- 3.2.5.3.1.2.2 For 3437 week gestational age
- For < 1 week of age
- Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
- Alternative regimen (2): Penicillin VK 50 mg/kg/day PO bid
- For 14 week of age
- Alternative regimen (1):Amoxicillin 75 mg/kg/day PO bid
- Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid
- 3.2.5.3.1.2.3 Term newborn infant
- For < 1 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
- Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid
- For 14 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
- Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid or qid
- 3.2.5.3.2 A protein synthesis inhibitor
- 3.2.5.3.2.1 For 3234 weeks gestational age
- For < 1 week of age
- Preferred regimen (1): Clindamycin 10 mg/kg/day PO bid
- Preferred regimen (2): Linezolid 20 mg/kg/day PO bid
- For 14 week of age
- Preferred regimen (1):Clindamycin 15 mg/kg/day PO bid
- Preferred regimen (2):Linezolid 30 mg/kg/day PO bid
- 3.2.5.3.2.2 For 3437 week gestational age
- For < 1 week of age
- Preferred regimen (1): Clindamycin 15 mg/kg/day PO tid
- Preferred regimen (2): Linezolid 30 mg/kg/day PO tid
- For 14 week of age
- Preferred regimen (1): Clindamycin 20 mg/kg/day PO qid
- Preferred regimen (2): Linezolid 30 mg/kg/day PO tid
- 3.2.5.3.2.3 Term newborn infant
- For < 1 week of age
- Preferred regimen (1): Clindamycin 15 mg/kg/day PO tid
- Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (loading dose 4.4 mg/kg)
- Preferred regimen (3): Linezolid 30 mg/kg/day PO tid
- For 14 week of age
- Preferred regimen (1): Clindamycin 20 mg/kg/day PO qid
- Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (loading dose 4.4 mg/kg)
- Preferred regimen (3): Linezolid 30 mg/kg/day PO tid
- Note: Duration of therapy to complete a treatment course of 1014 days or greater. May require prophylaxis to complete an antimicrobial course of upto 60 days from onset of illness.
- 3.2.5.4 Treatment of cutaneous anthrax without systemic involvement
- 3.2.5.4.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- 3.2.5.4.1.1 For 3234 weeks gestational age
- For < 1 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day PO bid
- Preferred regimen (2): Clindamycin 10 mg/kg/day PO bid
- For 14 week of age
- Preferred regimen (1):Ciprofloxacin 20 mg/kg/day PO bid
- Preferred regimen (2):Clindamycin 15 mg/kg/day PO tid
- 3.2.5.4.1.2 For 3437 week gestational age
- For < 1 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day PO bid
- Preferred regimen (2): Clindamycin 15 mg/kg/day PO tid
- For 14 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day PO bid
- Preferred regimen (2): Clindamycin 20 mg/kg/day PO qid
- 3.2.5.4.1.3 Term newborn infant
- For < 1 week of age
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day PO bid
- Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (Loading dose 4.4 mg/kg)
- Preferred regimen (3): Clindamycin 15 mg/kg/day PO tid
- For 14 week of age
- Preferred regimen (1):Ciprofloxacin 30 mg/kg/day PO bid
- Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (Loading dose 4.4 mg/kg)
- Preferred regimen (3): Clindamycin 20 mg/kg/day PO qid
- 3.2.5.4.2 Alternatives for penicillin-susceptible strains
- 3.2.5.4.2.1 For 3234 weeks gestational age
- For < 1 week of age
- Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
- Alternative regimen (2): Penicillin Vk 50 mg/kg/day PO bid
- For 14 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
- Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid
- 3.2.5.4.2.2 For 3437 week gestational age
- For < 1 week of age
- Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
- Alternative regimen (2): Penicillin Vk 50 mg/kg/day PO bid
- For 14 week of age
- Alternative regimen (1):' Amoxicillin' 75 mg/kg/day PO bid
- Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO bid
- 3.2.5.4.2.3 Term newborn infant
- For < 1 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
- Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid
- For 14 week of age
- Alternative regimen (1): Amoxicillin  75 mg/kg/day PO tid
- Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid or qid
- Note : Duration of therapy for naturally acquired infection is 710 days and for a biological weaponrelated event,may require additional prophylaxis for inhaled spores to complete an antimicrobial course of up to 60 days from onset of illness.
- Bacillus anthracis, postexposure prophylaxis
- 1. For adults
- 1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- Preferred regimen (1): Ciprofloxacin 500 mg IV q12h
- Preferred regimen (2): Doxycycline 100 mg IV q12h
- Preferred regimen (3): Levofloxacin 750 mg IV q24h
- Preferred regimen (4): Moxifloxacin 400 mg IV q24h
- Preferred regimen (5): Clindamycin 600 mg IV q8h
- 1.2 Alternatives for penicillin-susceptible strain
- Preferred regimen (1): Amoxicillin 1 g IV q8h
- Preferred regimen (2): Penicillin VK 500 mg IV q6h
- 2. For children = 1 month
- 2.1 For penicillin-resistant strains or prior to susceptibility testing
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day, PO, bid (not to exceed 500 mg/dose)
- Preferred regimen (2):
- If patients body weight < 45 kg: Doxycycline 4.4 mg/kg/day, PO, bid (not to exceed 100 mg/dose)
- If patients body weight > 45 kg: Doxycycline 100 mg/dose, PO, bid
- Preferred regimen (3): Clindamycin 30 mg/kg/day, PO, tid (not to exceed 900 mg/dose)
- Preferred regimen (4):
- If patients body weight < 50 kg: Levofloxacin 16 mg/kg/day, PO, bid (not to exceed 250 mg/dose)
- If patients body weight > 50 kg: Levofloxacin 500 mg, PO, qd
- 2.2 For penicillin-susceptible strains
- Preferred regimen (1): Amoxicillin 75 mg/kg/day, PO, tid (not to exceed 1 g/dose)
- Preferred regimen (2): Penicillin VK 50-75 mg/kg/day, PO, id or tid
- Note: Duration of Therapy is 60 days after exposure
- 3. For children < 1 month
- 3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
- 3.1.1 For 3234 weeks gestational age
- 3.1.1.1 For < 1 week of Age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day, PO, bid
- Preferred regimen (2): Clindamycin 10 mg/kg/day, PO, bid
- 3.1.1.2 For 14 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day, PO,bid
- Preferred regimen (2): Clindamycin 15 mg/kg/day, PO, tid
- 3.1.2 For 3437 week gestational age
- 3.1.2.1 For < 1 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day, PO, bid
- Preferred regimen (2): Clindamycin 15 mg/kg/day, PO, tid
- 3.1.2.2 For 14 week of age
- Preferred regimen (1): Ciprofloxacin 20 mg/kg/day, PO, bid
- Preferred regimen (2): Clindamycin 20 mg/kg/day, PO, id
- 3.1.3 Term newborn infant
- 3.1.3.1 For < 1 week of age
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day, PO, bid
- Preferred regimen (2): Doxycycline 4.4 mg/kg/day, PO, bid (Loading dose 4.4 mg/kg)
- Preferred regimen (3): Clindamycin 15 mg/kg/day, PO, tid
- 3.1.3.2 For 14 week of Age
- Preferred regimen (1): Ciprofloxacin 30 mg/kg/day, PO, bid
- Preferred regimen (2): Doxycycline 4.4 mg/kg/day, PO, bid (Loading dose 4.4 mg/kg)
- Preferred regimen (3): Clindamycin 20 mg/kg/day, PO, qid
- 3.2 Alternatives for penicillin-susceptible strains
- 3.2.1 For 3234 weeks gestational age
- 3.2.1.1 For < 1 week of age
- Alternative regimen (1): Amoxicillin 50 mg/kg/day, PO, bid
- Alternative regimen (2): Penicillin Vk  50 mg/kg/day, PO, bid
- 3.2.1.2 For 14 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
- Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid
- 3.2.2 For 3437 week gestational age
- 3.2.2.1 For < 1 week of age
- Alternative regimen (1): Amoxicillin 50 mg/kg/day, PO, bid
- Alternative regimen (2): Penicillin Vk 50 mg/kg/day, PO, bid
- 3.2.2.2 For 14 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
- Alternative regimen (2): Penicillin Vk  75 mg/kg/day, PO, tid
- 3.2.3 Term newborn infant
- 3.2.3.1 For < 1 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
- Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid
- 3.2.3.2 For 14 week of age
- Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
- Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, id or tid
- Note: Duration of therapy is  60 days from exposure.
- Human herpesvirus 6 Return to Top
- Human herpesvirus 6 treatment
- Preferred regimen: Ganciclovir, Foscarnet OR Cidofovir
- Note (1): Fever & rash documented in transplant patients .
- Note (2): Reactivation in hematopoietic stem cell transplant patients associated with delayed monocytes & platelet engraftment.
- Achromobacter xylosoxidans Return to Top
- Achromobacter xylosoxidans treatment,,,,,
- Preferred regimen: most active agents are Piperacillin-Tazobactam, Meropenem AND TrimethoprimSulfamethoxazole whereas Ceftazidime is more active than Cefepime
- Alternative regimen: Colistin inhaled, could also be considered
- Note : Achromobacter (formerly Alcaligenes) xylosoxidans is a newly emerging microorganism isolated with increased frequency from the lungs of patients with cystic fibrosis. Combination therapy has been recommended for the treatment of Achromobacter xylosoxidans pulmonary exacerbations in cystic fibrosis

# Balantidium coli
- Balantidium coli treatment
- Adult dosage:
- Preferred regimen: Metronidazole 750 mg PO tid for 5 days, Tetracycline 500 mg PO qid for 10 days
- Alternative regimen: Iodoquinol 650 mg PO tid for a 20-days
- Pediatric dosage:
- Preferred regimen: Metronidazole 35-50 mg/kg/day PO in three doses (maximum dosage: 2 g) for 5 days, Tetracycline 40 mg/kg/dose PO in four doses for 10 days.
- Alternative regimen: Iodoquinol 40 mg/kg/dose PO in three doses for 20 days AND Doxycycline.
- Note: Nitazoxanide, a broad-spectrum antiparasitic and antihelminthic drug, may be another treatment for balantidiosis.
- BK virus Return to Top
- BK virus treatment
- 1. Immunosuppression should be reduced in kidney transplant patients with definitive polyomavirus associated nephropathy.
- Immunosuppressant drugs
- Preferred regimen (1): Tacrolimus trough levels are commonly targeted to < 6 ng/mL,
- Preferred regimen (2): Cyclosporine trough levels to < 150 ng/mL ,
- Preferred regimen (3): Sirolimus trough levels of < 6 ng/mL, and
- Preferred regimen (4): Mycophenolate mofetil daily dose equivalents of  1000 mg.
- Note (1): Lower calcineurin inhibitor levels, that is targeting trough levels for Tacrolimus of 3 ng/mL and Cyclosporine of 100 ng/mL may be considered as a first step.
- Note (2): Additional strategies have been switching from Tacrolimus to low-dose Cyclosporine or switching from Mycophenolic acid to Leflunomide, to low-dose Sirolimus, or from calcineurin inhibitor to low-dose Sirolimus.
- Note (3): Immunosuppression is further adapted according to the course of serum creatinine concentration and the plasma viral loads, but responses may require several weeks.
- 2. In patients with sustained high-level plasma BK virus load despite adequately reduced immunosuppression, the adjunctive use of agents with antiviral activity may be considered
- Preferred regimen (1): Cidofovir 0.25 mg/kg-1.0 mg/kg IV at 13 weekly intervals, without Probenecid 1 mg/kg, administered weekly as a slow IV infusion after hydration, for up to 10 weeks.
- Preferred regimen (2): Loading dose of Leflunomide 100 mg PO for 5 days, followed by an initial maintenance dose of Leflunomide 40 mg PO.
- Note: Leflunomide is orally administered as a replacement for discontinued Mycophenolic acid.
- Preferred regimen (3): Intravenous immunoglobulins (IVIG) 0.2 g/kg-2.0 g/kg in conjunction with reduced immunosuppression.
- Preferred regimen (4): Fluoroquinolones may inhibit BKV replication.
- Note (1): Acute rejection following reduced immunosuppression for presumptive or definitive polyomavirus associated nephropathy should be treated according to standard protocols.
- Note (2): Anti-rejection treatment administered in patients with a history of BK virus replication with or without polyomavirus associated nephropathy should be accompanied by at least bi-weekly monitoring of the urine and plasma viral load.
- Prevention and prophylaxis
- Note (1): Kidney transplant recipients should be screened for BKV replication to identify patients at increased risk of polyomavirus associated nephropathy.
- Note (2): Retransplantation can be considered for patients after loss of a first kidney allograft due to polyomavirus associated nephropathy, but frequent screening for BK virus replication is recommended.
- Fusobacterium necrophorum Return to Top
- Fusobacterium necrophorum treatment
- 1. In adults
- Preferred regimen: Combination therapy of Metronidazole 500 mg IV q8h AND Ceftriaxone 2 gm IV q24h
- 2. In children
- Preferred regimen: Combination therapy of Metronidazole 1015 mg/kg tid AND Ceftriaxone 80100 mg/kg q12h
- Alternative regimen (1): Imipenem
- Alternative regimen (2): Ampicillin-Sulbactam
- Alternative regimen (3): antipseudomonal penicillins
- Alternative regimen (4): Clindamycin
- Note: More frequent dosing of ceftriaxone is needed in cases of CNS infection.

# Endophthalmitis
- 1. Bacterial endogenous endophthalmitis
- Preferred regimen (1): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal
- Preferred regimen (2): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Amikacin 0.4 mg/0.1 mL intravitreal (antibiotic active against underlying source of bacteremia)
- Note (1): In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary in nearly all cases.
- Note (2): Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.
- Note (3): Endogenous bacterial endophthalmitis arises from bacteremic seeding associated with endocarditis, urinary tract infections, indwelling central venous catheters, illicit injection drug use, procedures (e.g., endoscopy), or liver abscess. Common pathogens include Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus milleri group, group A and B streptococci, and gram-negative bacilli (e.g., Escherichia coli, Klebsiella pneumoniae).
- 2. Bleb-related endophthalmitis
- Preferred regimen: Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal
- Note (1): In conjunction with intravitreal antibiotic therapy, a vitrectomy is necessary in most cases.
- Note (2): Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.
- Note (3): It is reasonable to give an oral quinolone, such as Moxifloxacin, that achieves good vitreous levels and treats the major pathogens.
- 3. Candidal endophthalmitis
- 3.1  Endogenous candida endophthalmitis
- Preferred regimen (1): Amphotericin intravitreal
- Preferred regimen (2): Voriconazole intravitreal.
- Preferred regimen (3): Fluconazole IV
- Preferred regimen (4): Voriconazole IV
- Preferred regimen (5): Amphotericin IV
- Note (1): In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary if viritis (endophthalmitis) is present.
- Note (2): often there is a need to remove artificial intra-ocular lense.
- Note (3): Systemic antibiotics alone are not effective in treating endophthalmitis, except for most cases of Candida chorioretinitis without vitritis. They are indicated in endogenous endophthalmitis and fungal endophthalmitis. Whether they are beneficial as adjunctive therapy in exogenous bacterial endophthalmitis is unknown.
- 3.2  Exogenous candida endophthalmitis
- Preferred regimen (1): Amphotericin is 5-10 mcg in 0.1 mL of sterile water intravitreal
- Preferred regimen (2): Voriconazole  is usually 100 mcg in 0.1 mL of sterile water intravitreal.
- Preferred regimen (3): High-dose Fluconazole (400-800 mg IV qd assuming the normal kidney function)  is also indicated for susceptible strains, OR::- Preferred regimen (4): Voriconazole IV for  Fluconazole-resistant butVoriconazole-susceptible strains.
- Note (1): Candida parapsilosis is the most common species, especially in postsurgical outbreaks.
- Note (2): if infection follows cataract surgery,  it is often necessary to remove the intra ocular lense as well.
- 4. Chronic endophthalmitis:- Chronic endophthalmitis 
- Preferred regimen (intial therapy): Clarithromycin 500 mg PO bid for 2-4 weeks AND Moxifloxacin 400 mg PO qd for a week as it also has good intraocular penetration and a broad spectrum of antimicrobial activity.
- 5.  Mold endophthalmitis:*5.1  Exogenous mold endophthalmitis
- Preferred regimen (1): Amphotericin intravitreal and intracameral injections::- Preferred regimen (2): Voriconazole intravitreal and intracameral injections
- Preferred regimen (3): Voriconazole IV
- Note (1):  Unless the fungus is known, the initial intra-ocular injection should be Amphotericin; subsequent injections may be Voriconazole for sensitive fungi. Repeated intra-ocular injections of Voriconazole (if the organism is susceptible) or Amphotericin can be given, at least 48 hours apart.
- Note (2): In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary in nearly all cases.
- Note (3): Artificial intra-ocular lense needed to be removed.
- 5.2  Endogenous mold endophthalmitis
- Preferred therapy (1): Amphotericin intravitreal or voriconazole intravitreal
- Note (1): In immunocompromised patients, treatment must include systemic antifungal therapy
- Note (1): if the patient is able to tolerate surgery , vitrectomy and removal of any IOL, followed by Amphotericin intravitreal or Voriconazole intravitreal should be performed.::- Note (2): If too ill for surgery, the patient should have Amphotericin intravitreal injection  or Voriconazole intravitreal injection , with repeated injections as needed.::- Note (3): In injection drug users with no evidence of ongoing fungaemia, vitrectomy, intravitreal anti-fungal injection and systemic therapy should be given.
- 6. Post-cataract  surgery endophthalmitis:*6.1  Acute endophthalmitis post-cataract  surgery::- Preferred regimen (intravitreal): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal
- Note (1): In conjunction with intravitreal antibiotic therapy, a vitrectomy is necessary  if severe infection or fungal etiology
- Note (2): If there is no improvement in 48 h, a repeat intravitreal injection may be given with either Vancomycin or Ceftazidime, depending on culture   results.
- Note (3): Repeated injections of Amikacin are avoided, owing to concerns about retinal toxicity.
- Note (4): No need to remove intra-ocular lense, unless fungal etiology.
- 6.2 Chronic endophthalmitis post-cataract  surgery::- Preferred regimen: Vancomycin 1 mg/0.1 mL normal saline intravitreal
- Note (1): Artificial intra-ocular lense needed to be removed.
- Note (2): Most common pathogen causing post-cataract endophthalmitis is  Propionibacterium acnes.
- Note (3): Necessity for vitrectomy is varied.
- 7. Post-tramatic endophthalmitis:- Preferred regimen (1): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal :- Preferred regimen (2): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Amphotericin intravitreal if fungi suspected:- Note: Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.
- Preferred regimen (intravenous): Intravenous Vancomycin AND (Ceftazidime OR Ciprofloxacin)
- Note (1): Systemic antibiotics alone are not effective in treating endophthalmitis, except for most cases of Candida chorioretinitis without vitritis. They are indicated in endogenous endophthalmitis and fungal endophthalmitis. Whether they are beneficial as adjunctive therapy in exogenous bacterial endophthalmitis is unknown.
- Note (2): In conjunction with intravitreal antibiotic therapy and intravenous antibiotic therapy , a vitrectomy is necessary in most cases.
- Note (3): Need to remove artificial intra-ocular lens varies (always if fungal).
- Note (4): Treatment should be aggressive, with vitrectomy, intravitreal antibiotics (e.g. Vancomycin AND Ceftazidime), and systemic therapy.
- Note (5): Most common pathogens are Bacillus cereus, coagulase-negative staphylococci (fungi in some cases).

# Wound infection
- Wound infection
- 1. Mild to moderate
- Preferred regimen (1): TMP-SMX-DS double strength 1-2 tabs PO bid
- Preferred regimen (2): Clindamycin 300-450 mg PO tid
- Alternative regimen (1): Minocycline 100 mg PO bid
- Alternative regimen (2): Linezolid 600 mg PO bid
- 2. Febrile with sepsis
- Preferred regimen (1): Ticarcillin-clavulanate 3.1 gm IV q4-6h (OR Piperacillin-Tazobactam 3.375 gm q6h) AND Vancomycin 1gm IV q12h
- Preferred regimen (2): Doripenem 500 mg IV q 8hr (OR Imipenem OR Meropenem OR Ertapenem 1gm IV q24h) AND Vancomycin 1gm IV q12h
- Alternative regimen (1): Vancomycin 1 gm IV q12h (OR Daptomycin 6 mg/kg IV q24h) AND Ciprofloxacin 750 mg IV q24h (OR Levofloxacin 750 mg IV q24h)
- Alternative regimen (2): Ceftaroline 600 mg IV q12h  AND Ciprofloxacin 750 mg IV q24h (OR Levofloxacin 750 mg IV q24h)
- Alternative regimen (3): Telavancin 10 mg/kg IV q24h AND Ciprofloxacin 750 mg IV q24h (OR Levofloxacin 750 mg IV q24h)

# Yaws
- Yaws
- Preferred regimen (1): Phenoxymethylpenicillin 12.5 mg/kg q6h 7-10days (maximum dose, 300 mg q6h)
- Preferred regimen (2): Tetracyclines 500 mg q6h 15 days or doxycycline 100 mg q12h (alternative agents for the treatment of yaws in nonpregnant adults)
- Preferred regimen (3): Erythromycin 810 mg/kg 15 days q6h
- Preferred regimen (4): Azithromycin 30 mg/kg single-dose (maximum dose 2 g)
- STREPTOCOCCUS PNEUMONIA MEDICAL THERAPY INTRODUCTION:-
Historically, treatment relied primarily on -lactam antibiotics.  In the 1960s, nearly all strains of S. pneumoniae were susceptible to penicillin, but since that time, there has been an increasing prevalence of penicillin resistance, especially in areas of high antibiotic use. A varying proportion of strains may also be resistant to cephalosporins, macrolides (such as erythromycin), tetracycline, clindamycin and the quinolones.  Penicillin-resistant strains are more likely to be resistant to other antibiotics. Most isolates remain susceptible to vancomycin, though its use in a -lactam-susceptible isolate is less desirable because of tissue distribution of the drug and concerns of development of vancomycin resistance. More advanced beta-lactam antibiotics (cephalosporins) are commonly used in combination with other drugs to treat meningitis and community-acquired pneumonia. In adults, recently developed fluoroquinolones such as levofloxacin and moxifloxacin are often used to provide empiric coverage for patients with pneumonia. Susceptibility testing should be routine, with empiric antibiotic treatment guided by resistance patterns in the community in which the organism was acquired, pending the results.  There is currently debate as to how relevant the results of susceptibility testing are to clinical outcome.  There is slight clinical evidence that penicillins may act synergistically with macrolides to improve outcomes.