1 In patients requiring antibiotic therapy, make rational choices (i.e., first-line therapies, knowledge of local resistance patterns, patient’s medical and drug history, patient’s context).
H Pylori Infection – 1st line Tx:
- Amoxicillin 1g bid + Clarithromycin 500mg bid + Pantoprazole 40mg bid x 7 days
- Alt: Metronidazole 500mg bid + Clarithromycin 500mg bid + Pantoprazole 40mg bid x 7 days
C. Difficile infection
- Mild to Moderate (WBC<15, SCr
- Metronidazole 500mg tid x 10-14 days
- Severe (WBC >15, SCr >1.5x baseline)
- Vancomycin (40mg/kg/d div 3 or 4) 125mg qid x 10-14days
Traveller’s Diarrhea
- Avoid anti-motility (loperamide) if F/C, bloody diarrhea
- Avoid quinolones in <16yo
- Prevention:
- Pepto 2 tabs or 30 mL qid with meals and in evening
- Cirpofloxacin 500mg daily
- Mild to Moderate (<3BM/d, no blood, no f/c)
- Loperamide 4mg x 1 then 2mg after each BM (max 8/d)
- Pepto 2tabs or 30mL, repeat q30min (max 8/d)
- Severe (>3BM/d or blood or f/c)
- Ciprofloxacin 750mg daily x 1-3d
Endocarditis prophylaxis
- Pt with prosthetic valve, previous bacterial endocarditis, unrepaired cyanotic congenital heart valve, cardiac transplant recipient
- Procedure: dental req gingival manipulation, derm procedure, cystoscopy, tonsillectomy, adenoidectomy, bronchoscopy
- Amoxicillin 2g po x 1 – 1hr before the procedure
Epididymitis – Tx 10-14 days
- >35yo: Ciprofloxacin 500mg bid or extended release 1g daily
Prostatis – Tx 2-4 wk after symptoms have resolved
- Ciprofoxacin 500mg bid or extended release 1g
Trichomoniasis – Tx all cases and sexual partners
- Metronidazole 2g daily or 500mg bid x 7 days
BV (bacterial vaginosis)
- Metronidazole 500mg bid x 7 days (10-14 days if recurrent)
Genital Herpes
- Valacyclovir 500mg bid (5-7 days if acute & prophylaxis at 36 wk & 3 days if acute recurrent)
- Valacyclovir 500mg daily for chronic suppressive (>6/yr)
External Genital Warts
- Cryotherapy q1-2wk
- Podophyllin 10-25% applied weekly, wash off after 1-4 hr
- TriChloroAcetic acid 80-90% in 70% ethyl alcohol weekly prn
- Imiquimod 5% crm qhs 3/wk x 16 wk, wash off after 6-10hr
- Podofilox 0.5% bid x 3 d, repeat x 4 prn
- Laser
- Surgical
Cervicitis
- Cefixime 800mg + Azithromycin 1g x1
PID
- Cefixime 800mg x 1 or ceftriaxone 500mg IM x 1 AND Doxycycline 100mg bid x 14 days
- Add Metronidazole 500mg bid x 14 d
- if adnexal mass, abscess, peritonitis or BV
Urethritis
- Cefixime 400mg x 1 or Ceftriaxone 250mg IM x 1 AND Azithromycin 1g x 1 or Doxycycline 100mg bid x 7 days
Vulvovaginal Candidiasis – use topical in pregnancy
- Acute:
- Clotrimazole 500mg PV x 1 or 200mg PV x 3 days
- Fluconazole 150mg po x 1
- Recurrent (>=4/yr)
- Fluconazole 150mg po q3d x 3 doses then Fluconazole 150mg po q1week x 3-6mo
COPD exacerbation
- Simple (FEV1>50, mild-mod, =
- Clarithromycin 500mg bid or 1000mg extended daily x 5 days
- Complicated (FEV1<50, >=4/yr, cardiac dz)
- Levofloxacin 750mg daily x 5 days
- Amoxicillin/Vlavulanate 875mg bid x 7-10 days
- Pseudomonas (FEV1<35, chronic steroids, constant purulent sputum)
- Ciprofloxacin 500-750mg bid x 7-10 days
Otitis Externa
- No perforation
- Buro-sol Otic solution 2-3 drops qid x 5 days
- Perforation
- Cirpdex otic suspension 4 drops bid x 5 d
- Fungal
- Clotrimazole 1% crm apply bid x 5 d
Otitis media – 10 d if 2yo
- Amoxicilin 80mg/kg/d div 2-3 (max 3g/d)
- Chronic perforation
- Ciprodex otic suspension 4 drops bid x 5 days
Pertussis
- Clarithromycin 500mg bid x 5-7 days
Pharyngitis (majority viral)
- Amoxicillin 40mg/kg/d div 2-3 x 10 days
Sinusitis
- Amoxicillin 500mg tid x 5-10d
- Peds: Amoxicillin 800mg/kd/d div 2-3 (max 3g/d)
Pneumonia
- Clarithromycin 500mg bid or 1g-extended daily x 7-14 days
- Amoxicillin 1g tid, Erythromycin 500mg qid, Azithromycin 500mg x 1 hen 250mg x 4 days)
- Corbidities or Long term care
- Moxifloxacin 400mg daily x 7-14 days
- Levofloxacin 750mg daily x 5 days
- Suspected aspiration
- Amoxicillin/Clavulanate 875mg bid x 7-14 days
Influenza
- post-exposure prophylaxis within 36hr: Oseltamivir 75mg x 10 d
- Tx within 36hr: Oseltamivir 75mg bid x 5d
Cellulitis – Tx 7-14 days
- Mild and uncomplicated: Keflex 500mg qid
- Severe and uncomplicated: Clindamycin 450mg qid
- Face and complicated: ceftriaxone 1g IV/IM daily (75mg/kd/d – peds)
- Diabetic foot (not limb threatening): Keflex 500mg qid + metronidazole 500mg bid
- Diabetic foot (limb threatening): ceftriaxone 2g IV/IM + Metronidaole 500mg bid x 14-28 days or 4-12 weeks if osteomyelitis
Bites
- Amoxicillin/Clavulanate 875mg bid x 7-14days
Cutaneous infections
- Folliculitis + furuncle (boil): Hot compresses and anti-septic
- Carbuncles (mod to severe): keflex 500mg qid
- Complicated (peri-rectal abscess): Ciprofloxacin 750mg bid
- consider adding metronidazole 500mg bid
Impetigo
- Mupirocin 2% apply tid x 7 days
- Fusidic acid 2% tid-qid x 7 days
- Keflex 500mg qid x 7-10days
Lyme dz
- Amoxicillin 500mg tid x 14-21 days
- Doxycycline 100mg bid x 14-21 days
MRSA
- Moderate:
- Clindamycin 400mg qid
- Doxycycline 100mg bid (not for children <8)
- Severe
- Vancomycin 1g bid IV
- Linezolid 600mg bid
Onychomycosis 12-16 wk for toe and 6 wk for finger
- Terbinafine 250mg daily
- Penlac daily x 48wk
Shingles (Varicella Zoster) – initiate within 72hr of onset of rash
- Valacyclovir 1g tid x 7-14 days
Cystitis or Asymptomatic bacteuria in Pregnancy
- Macrobid 100mg bid x 5 days (7-14 days if recurrent <1mo)
Pyelonephritis / Complicated UTI
- Ciprofloxacin 500mg bid or 1g -extended x 7-14 days
Malaria Prophylaxis (certain regions are resistant to Mefloquine or Chloroquine)
- Malarone (Atovaquone-Proguanil) 1 d before till 1 wk after
- Doxycycline 1 d before till 4 wk after
- Mefloquine 1wk before till 4 wk after
- Chloroquine 1 wk before till 4 wk after
2 In patients with a clinical presentation suggestive of a viral infection, avoid prescribing antibiotics.
Viral features include conjunctivitis, cough, hoarseness, coryza, anterior stomatitis
3 In a patient with a purported antibiotic allergy, rule out other causes (e.g., intolerance to side effects, non-allergic rash) before accepting the diagnosis.
4 Use a selective approach in ordering cultures before initiating antibiotic therapy (usually not in uncomplicated cellulitis, pneumonia, urinary tract infections, and abscesses; usually for assessing community resistance patterns, in patients with systemic symptoms, and in immunocompromised patients).
5 In urgent situations (e.g., cases of meningitis, septic shock, febrile neutropenia), do not delay administration of antibiotic therapy (i.e., do not wait for confirmation of the diagnosis).
Reference:
- 2013 Anti-infective guidelines for community acquired infections
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