Professional Documents
Culture Documents
Antibiotic Guidelines (2005)
Antibiotic Guidelines (2005)
Dhaka, Bangladesh
October 2005
Antibiotic Guidelines
BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSIT
Dhaka, Bangladesh
October 2005
ISBN : 984-32-2715-8
Published by :
Bangabandhu Sheikh Mujib Medical University
Shahbag, Dhaka, Bangladesh
All rights reserved by the BSMMU
First Edition: October, 2005
Price: Tk. 50.00
Printed by:
Asian Colour Printing
130, DIT Extension Road
Fakirerpool, Dhaka-1000
Tel: 9357726, 8362258
,
Acknowledgement
All teachers of BSMMU who actively participate in preparing this guidelines.
Committee to prepare the manual
I. Prof. M. A. Mannan
Pro-Vice Chancellor (Hospital)
2. Prof. Md. Salehuddin
Department of Ophthalmology
3. Prof. Md. Ruhul Amin Miah
Department of Microbiology
4. Prof. M. Jalilur Rahman
Department of Hematology
5. Prof. M. Anwar Hussain
Department of Obstetrics & Gynecology
6. Prof. Motiur Rahman Molla
Department of Maxillofacial Surgery
7. Prof. Zahidul Haq
Department of Surgery
8. Prof. N asim Akhter Chowdhury
Department of Medicine
9. Dr. Hossain Imam Al Hadi
Department of Otolaryngology
10. Prof. Mir Misbahuddin
Department of Pharmacology
Chairman
Member
Member
Member
Member
Member
Member
Member
Member
Member Secretary
PREFACE
Antibiotics are an expensive sector of modem medicine. In
Bangladesh, we spend about forty percent of our pharmacy budget
of more than Taka four thousand crores on antibiotics alone. No
doubt antibiotics are essential medicines. They selectively kill
organisms that are sensitive to them. As a result, if used for
prolonged periods, not only such use is uneconomic, but they also
produce unwanted side efects and may encourage the overgrowth of
resistant organisms. As antibiotic resistance is increasing, antibiotic
abuse carries collective penalties for the individual patient and for
the community. Therefore, antibiotics should be used careflly.
Owing to geographical diferences in bacterial sensitivity, each
hospital has its own antibiotic guideline. Therefore, this booklet is
published on treatment guideline that may help our doctors
overcome the above mentioned problems and thereby improve the
quality of teatment.
Our antibiotic guideline is mainly based on empirical treatment that
we are using in BSMMU Hospital. This guideline will be reviewed
and updated periodically because of continuing changes in the patter
of bacterial resistance to antibiotic. In this booklet common diseases
are highlighted and their appropriate therapeutic recommendations are
mentioned. Microbiological statistics of our hospital is presented,
though inadequate, may be helpfl for our doctors for proper selection
of the antibiotic.
Constructive criticism and usefl suggestions for improving the
quality and contents of this booklet are welcomed from its users.
I thank the chairman and members of the committee and contributing
faculty members for their active support and help without which this
publication on the safe use of antibiotics would not have been seen
the light of the day.
(Prof. M.A. Hadi)
Vice Chancellor
Contents
Principles of antimicrobial therapy in infectious disease
Collection of sample for culture
Microbiological statistics
Desirable serum antibiotic levels
Treatment of specifc diseases
Acne vulgaris
Alveolar abscess
Alveolar osteitis (dry socket)
Amoebiasis
Bite wounds
Breast abscess/mastitis
Bronchiectasis
Bronchitis
Chancroid
Cellulitis
Cerebral abscess
Cholecystitis (acute)
Cholera
Conjunctivitis
Coreal ulcer
Cystitis (acute uncomplicated)
Dysentery (bacillary)
Eczema (infected)
Enteric fever
Febrile neutropenia
Genital herpes
Giardiasis
Gingivitis
Pyogenic liver abscess
Mastoiditis
4
10
24
25
26
27
27
28
29
30
31
32
33
34
35
36
36
37
38
39
39
40
40
41
42
43
4
4
44
Meningitis
Neonatal sepsis
Otitis exter a
Otitis media (acute suppurative)
Oral thrush (candidiasis)
Peptic ulcer (due to helicobacter pylori)
Pericoronitis
Periodontal abscess
Spontaneous bacterial peritonitis
Pharyngitis
Pneumonia
Prostatitis
Pyelonephritis (acute)
Sepsis in neuropathic foot in diabetes mellitus
Sinusitis
Syphilis
Tonsillitis
Tuberculosis
Urethritis (acute, for males)
Urinary tract infections
Vaginal candidiasis
Vaginal trichomoniasis
Vaginosis (bacterial)
Wounds (infected)
Guideline for use of antibiotics in renal failure
Use of antibiotics in liver disease
Antibiotics in pregnancy
Drug present in breast milk
Management of anaphylactic shock
Antibiotic prophylaxis in surgery
Antibiotic prophylaxis for nonsurgical conditions
Antimicrobial agents associated with photosensitivity
Hospital infection control team
Index
45
47
47
48
49
49
50
50
51
51
52
55
55
56
56
57
58
58
62
62
63
6
6
65
66
67
78
70
71
72
80
84
85
89
ANTIBIOTIC GUIDELINE
PRINCIPLES OF ANTIMICROBIAL THERAPY IN
INFECTIOUS DISEASE
Selection of antimicrobial agent depends on the following factors:
Agent:
identification of possible agent- identify/suspect
knowledge on possible organism in particular situation
aware about situation
possible load and virulence
sampling to identify agent
Host and environment:
identification of host and environmental factors
site of infection
immunological status
nutritional status
precondition affecting susceptibility- congenital heart disease,
presence of foreign body, steroid, susceptible disease, liver/renal
impairment, heart/respiratory failure
Choice of antibiotic:
empiric and specific
which drug to choose- pharmacokinetic properties
choosing combination preparation
Monitoring response:
clinical
estimation of drug level
development of resistance/ superinfection
Representative specimen collection before starting therapy
It is important to obtain adequate and representative specimens from
all potentially infected sites prior to the initiation of antimicrobial
therapy. Appropriate antimicrobial therapy is based on definitive
identification of pathogenic organisms, which usually requires
culture. Once antimicrobial therapy has been started, cultures often
are rendered sterile, even though viable organisms may remain in the
host. It is also important to avoid or minimize contamination by
surface contaminants and commensals when collecting specimens.
ANTIBIOTIC GUIDELINE
Initial empirical choice based on the most likely pathogens and
susceptibilities
In most cases, it may be impossible to determine the exact nature of
the infecting organisms before institution of antimicrobial therapy.
Initial therapy must therefore be empirical - to make a rational choice
from the many currently available antimicrobial agents, the clinician
must be able to predict or "guess" infecting microorganism(s) and the
antimicrobial susceptibility thereof. In these cases, the use of
"bacteriological statistics" i.e. an awareness of those microorganisms
most likely to cause infection in a given clinical setting, in
conjunction with the local antibiotic resistance patters, may be
particularly helpful in choosing an empiric antimicrobial agent.
Subsequent need to adjust antimicrobial therapy in light of the
sensitivity results
Since different organisms vary in their susceptibility to antimicrobial
agents, it is imperative that we have some means for determining the
antimicrobial susceptibility of the infecting organism(s). Once the
pathogen has been isolated, susceptibility testing to be done.
Monitoring therapeutic response
In many patients, it is possible to monitor the therapeutic response on
clinical grounds alone. Thus the subsidence of fever, the retur of
well-being, and the disappearance of both local and systemic signs of
infection in the patient, all signify an appropriate response. No further
formal monitoring is necessary in most cases.
An apparent failure to respond clinically may be due to either
inefectiveness of antimicrobial agent(s) (due to resistance or
inappropriate route of administration) or to other reasons e.g. a
localised infection that requires surgical drainage, or a superinfection
etc. Careful reassessment is recommended when considering changes
of antimicrobial therapy.
In certain situations, measurement of antimicrobial activity may be
useful in predicting clinical response, e.g. determination of serum
bactericidal activity (Schlichter test) in cases of infective
endocarditis.
2
ANTIBIOTIC GUIDELINE
Assays for drugs with narrow therapeutic:toxic ratio
For antibiotics such as the aminoglycosides and vancomycin, the
measurement of their concentrations in serum/plasma or other body
fluids is often useful to avoid excessive levels which are associated
with toxicity, yet ensure that adequate (therapeutic) levels ae
achieved.
Pharmacokinetic properties of antibiotics
Knowledge of the pharmacodynamic and kinetic properties of
antibiotics is imperative in choosing the correct antibiotic and correct
dose.
Time dependant killing: (penicillins, cephalosporins, macrolides).
The time that the antibiotic exceeds the mimi mal inhibitory
concentration (MIC) is crucial in predicting clinical outcome and
cure. Concentrations of members of this group of antibiotics are
required to be above the MIC for at least 50% of the dosing interval.
If the bacterium is more resistant, the MIC is higher with subsequent
reduction in time that the antibiotic concentration exceeds the MIC
and therefore higher dosages of the drug may be required.
Concentration dependant antibiotics: (quinolones, aminoglyco
sides). The more the antibiotic concentration exceeds the MIC, the
more killing will take place (irrespective and independent of the time
the concentration exceeds the MIC). For this group of antibiotics a
ratio of concentration: MIC 10 is required. This implies that a dose
regimen should be chosen which results in a serum or tissue
concentration of at least 10 times the MIC. Failure to achieve this
concentration at the site of infection will lead to clinical and
bacteriological failure, and is likely to induce resistance to the entire
class of antibiotic.
3
ANTIBIOTIC GUIDELINE
COLLECTION OF SAMPLE FOR CULTURE
URNE SAMPLE
Collection:
1. Male: Cleaning the urethral meatus with plain tap water (free skin
retracted), allow to dry and at least 30 ml of mid stream urine
(MSU) should be collected in sterile container. It is better to
collect the first MSU passed at the beginning of the day.
2. Female: The vulva is cleaned by cotton plug soaked with water
Labia is separated and moring mid stream urine (MSU)
should be collected in a wide mouth sterile container.
3. Children:
(a) Sterile adhesive bag:
(b) Suprapubic tap: Tap by fngers on the suprapubic region
1
hour after feed (one tap per second) for 10 seconds; 1 minute
interval repeat the procedre.
4. Suprapubic aspiration: Occasionally necessary in acute
retention of urine or unconscious patient.
5. Urethral catheterization: Rarely used in children or unconscious
patients. Fresh sterile catheter should be used. Urine sample
should be collected directly from the catheter, never from
collecting bag.
6. Ureteric cathelerization: In operation theatre during urological
surgery/ examination, when necessary.
7. Genitourinary tuberculosis : 3 consecutive early moring
urine specimen (EMU) or 24 hours urine in a container containing
1 % boric acid.
4
ANTIBIOTIC GUIDELINE
Tansport:
All specimens should be processed in the laboratory within 2 hours of
collection; if delay is unavoidable more than 2 hours use one of the
following.
a) Refrigerate the urine at 4
^
Susceptibil ity of some bacteria to certain antibiotics
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Staph au reus (penicillin-resistant) R 1 R R 2 2 2 0 2 2R 2 2R 2R 0 2R 2 R
Strep (group A) 1 0 2 0 2 2 0 0 2 2R 2 R 2R 0 R 2 R
Strep pneumoniae 1 0 1 0 2 2 2 0 2 2R R 2R 2R R R 2 R
Enterococcus faecalis R R 1 2 R R R R 2 0 R R R 0 R 2 R
N meningitides 1 0 2 0 2 0 2 0 2 0 0 R 2 R R R R
Listeria monocytogenes 0 0 1 0 R R R R 2 R R 0 0 0 2 0 R
H influenzae R R 1 R 0 2 1 R 1 0 2 R R 2R 0 2 0 R R
Ecoli R R 2R 2 2 1 R 2R R 2 R R R R 1 R 1 R* R R
Klebsiella species R R R 2R 2 1 R 2R 2R 2 R R R R 1 R 1 R* R R
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Pseudomonas aeruginosa R R R 1 R R R R 1 R 2 R R R R R 1 R* R R
Bacteroides frogilis R R R R R R R R 2 R 2 0 2R R R R 1
Other Bacteroides species 2 R R R R R R R 2 R 2 0 2R R R R 1
Clostridium difficule 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 1
1= susceptible, first choice. 2 = 2nd choice, R = Resistance likely. = Usually inappropriate. R' = resistance is rare in most areas.
N . This table is a guide only, and different populations will exhibit their own (changing) patterns of resistance.
. In practice, the best thing is ofen to talk to a microbiologist
Classifcation of medically important bacteria
Characteristics Genus Representative Diseases
I. Rigid, thick-walled cells
A. Free-living (extracellular bacteria)
1 . Gram-positive
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(2) Filamentous
2. Gram-negative
a. Cocci
b. Rods
( 1 ) Facultative
(a) Straight
(i) Respi ratory organisms
(ii) Zoonotic organisms
Staphylococcus
Anthrax
Clostridium
Corynebacterium
Listeria
Actinomyces
Nocardia
Neisseria
Haemophilus
Bordetella
Legionella
Brucella
Francisella
Yersinia
Abscess of skin and other organs
Tetanus, gas gangrene, botulism
Diphtheria
Meningitis
ActinomYCOSis
Nocardiosis
Gonorrhea, meningitis
Meningitis
Whooping cough
Pneumonia
Brucellosis
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I NDEX
A
Abdominal trauma 76
Abscess
alveolar 27
breast 30
cerebral 35
liver (pyogenic) 44
periodontal 50
Acne vulgaris 26
Acyclovir 42, 43
Alveolar osteitis 27
Ami kacin 47
Amoebiasis 28
Amoxyci l l i n 27, 31 , 32, 33,
39, 44, 49, 50
Ampicillin 31 , 46, 47, 52
Amputation
lower l i mb 75
Antibiotic
liver disease 67
pregnancy 68
renal fai l ure 66
Antimicrobial therapy 1
Antiserum 30
Aortic resection 74
Appendicectomy 76
Azelaic acid 26
Azithromycin 26, 40, 62
B
Bacitracin 38, 65
Bacterial endocarditis 80
Benzylpenicillin 35,52,54, 57,58
Benzathine 51 , 57
Procaine 57, 58
Benzoyl peroxide 27
Betamethasone 40
Biopsy
trans rectal prostate 77
Bronchiectasis 31
Bronchitis 32
c
Cefalaxin 58
Cefixime 33, 35
Cefotaxime 32, 44, 46, 51 , 53
Cefradine 27, 30, 31 , 50
Ceftazi di me 41 , 46, 47
Cefti pi me 51
Cefuroxime 52, 53, 56
Cel l ul itis 34
Cesarean section 78
Ceftriaxone 34, 35, 36, 38,
40, 44, 45, 46, 49, 51 , 55
Chicken pox 82
Chancroid 33
Chloramphenicol 37
Chol ecystitis
acute 36
Cholera 36
89
ANTIBIOTIC GUI DELI NE
Ci profloxacin 28, 32, 36, 37,
39, 40, 44, 45, 47, 48, 49, 51 ,
52, 53, 54, 55, 56, 62, 63
Clarithromycin 50, 51 , 52, 53
Cl eft lip 79
Cl i ndamycin 53, 54, 64
Clotrimazole 63, 64
Cloxacillin 30, 31
Co-amoxiclav 29, 34, 35, 49,
52, 53, 56, 58
Conjunctivitis 37
Co-trimoxazole 31 , 32, 33,
39, 40, 55, 62, 63
Cystitis
acute uncomplicated 39
Cystoscopy 76
o
Dexamethasone 41
Doxycycline 27, 36, 44, 54, 57
Drugs i n
breast mi l k 70
Dysentery
amoebic 28
bacillary 39
E
Econazole 47
Eczema (i nfected) 40
Endocarditis
bacterial 80
Enteric fever 40
Erythromycin 26, 27, 33, 36,
38, 51 , 54, 58 .
Ethambutol 59
90
F
Famciciovir 42, 43
Fever
enteric 40
rheumatic 82
Febrile neutropenia 41
Fl ucloxacil li n 27, 30, 31 , 34,
48, 56
Fl uconazole 49, 63
Fracture
open reduction 75
Fusidic acid 65
G
Gatifloxacin 34
Gentamicin 28, 35, 36, 40,
44, 46, 47, 48, 53, 54, 65
Giardiasis 43
Gi ngivitis 44
H
Helicobacter pylori 49
Herpes genital 42
Hydrocortisone 40, 47, 48
Hysterectomy 78
I mepenum 53, 55
Infection
uri nary tract 62
I nguinal hernia repair 76
I soni azid 59, 60, 61
Itraconazole 49
J
Joi nts
L
arthroplasty 75
replacement 75
Lansoprazole 50
Levofloxacin 56
Liver abscess (pyogenic) 44
M
Mastitis 30
Mastoiditis 44
Measles 82
Meningitis 45
Meni ngococcus contact 81
Metronidazole 27, 28, 31 , 35,
36, 43, 44, 49, 50, 54, 56, 64
Miconazole 64
Mupirocin 65
N
Neomycin 40, 65
Nitrofurantoin 62, 63
Nystatin 49
ANTIBIOTIC GUI DELI NE
o
Ofloxacin 37, 41 , 63
Omeprazole 49
Oral thrush (candidiasis) 49
Otitis
externa 47
media (acute suppurative) 48
p
Pacemaker implant 74
Peptic ulcer 49
Pericoronitis 50
Peritonitis 51
Pertussis 82
P-floxaci llin 40
Pharyngitis 51
Phenoxymethyl penicillin 34, 51
Photosensitivity 84
Polymyxin B 32
Pneumoni a 52
Prostate biopsy
trans rectal 77
Prostatectomy 77
Prostatitis 55
Prosthetic valve i nseri on 74
Pyelonephritis (acute) 55
Pyrazi nami de 59, 60, 61
91
R
Rabies
i mmune gl obul i n 29
vaccine 29
Rheumatic fever 82
Rifampicin 59, 60, 61 T
Tetanus i mmunogi obul i n 30
Tetracycline 32, 33, 36, 38,
44, 54, 57
Tinidazole 28, 43, 64
Tobramycin 37
Tonsillitis 58
Tooth extraction 80
Transplantation
Kidney 77
Treti noi n 26
Triamcinolone 47
Tuberculosis 58
s
Secnidazole 28, 43, 64
Sepsis
bil iary 28
neonatal 47
neuropathi c foot in
ANTIBI OTIC GUI DELI NE
Surgery
bi l i ary tract 75
cardi ovascul ar 74
gastroduodenal 75
open heart 74
orhopaedic 75
urological 76
Syphilis 57
u
Ulcer
corneal 38
Urethritis (acute, for males) 62
Urinary tract i nfection 62
v
Vaccine
rabies 29
Vagi nal
candidiasis 63
trichomoniasis 64
Vaginosis (bacterial) 64
Valacyclovir 42, 43
Vancomycin 46,52
Vitamin A 40
diabetes mell itus 56
W
Shock
anaphylactic 71
Sinusitis 56
Streptomycin 60
Wounds
bite 29
i nfected 65