Antibiotics

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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Posted in 99 Priority Topics, antibiotics, FM 99 priority topics

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