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Antibioitcs Guide 2013
Antibioitcs Guide 2013
Eyes
E.N.T.
ANTIBIOTICS
CNS
Skin
Gastrointestinal
16
bpac nz
better medicine
2013 EDITION
Genito-urinary
20
www.bpac.org.nz/antibiotics
The information in this guide is correct as at the time of publication. Reviewed July, 2013. Updated October, 2015.
Respiratory
Respiratory
COPD acute exacerbations
Management
Common pathogens
Antibiotic treatment
First choice
Alternatives
Amoxicillin
Adult: 500 mg, three times daily, for five days
Doxycycline
Adult: 200 mg, on day one (loading dose), followed by 100 mg,
once daily, on days two to five
Common pathogens
Bordetella pertussis
continued over page
Respiratory
Respiratory (continued)
Antibiotic treatment
First choice
Alternatives
None
Pneumonia adult
Management
Common pathogens
First choice
Respiratory
Antibiotic treatment
Pneumonia adult
Amoxicillin
Adult: 500 mg 1 g, three times daily, for five to seven days
If M. pneumoniae, C. pneumoniae or L. pneumophila are suspected
or if the patient has not improved after 48 hours, add either
roxithromycin 300 mg, once daily, for seven days or doxycycline
200 mg, twice daily*, on day one, followed by 100 mg, twice daily,
from days two to seven
* Increased dose as recommended by ADHB pneumonia guidelines
Alternatives
Pneumonia child
Management
Common pathogens
Antibiotic treatment
Pneumonia child
First choice
Alternatives
Amoxicillin
Child: 25 30 mg/kg/dose, three times daily, for five to seven days
(maximum 500 mg/dose age three months to five years, 1000 mg/
dose age > five years)
Erythromycin
Child: 10 12.5 mg/kg/dose, four times daily, for seven days
N.B. Can be first-line in school-aged children where the likelihood of
atypical pathogens is higher.
Roxithromycin
Child: 4 mg/kg/dose, twice daily, for seven to ten days
N.B. Only available in tablet form, therefore only if the child can swallow
tablets; whole or half tablets may be crushed.
E.N.T.
Antibiotic treatment
First choice
Alternatives
Otitis media
Management
Common pathogens
4
First choice
Otitis media
Amoxicillin
Child: 15 mg/kg/dose, three times daily, for five days (seven to
ten days if age < two years, underlying medical condition or
perforated ear drum)
E.N.T.
Antibiotic treatment
Co-trimoxazole
Child > 6 weeks: 0.5 mL/kg/dose oral liquid (40+200 mg/5 mL),
twice daily, for five to seven days (maximum 20 mL/dose)
If a child can swallow tablets, co-trimoxazole 80+400 mg tablets
can be used (one tablet is equivalent to 10 mL of co-trimoxazole
oral liquid)
N.B. Co-trimoxazole should be avoided in infants aged under six weeks,
due to the risk of hyperbilirubinaemia.
Common pathogens
E.N.T.
First choice
Alternatives
Pharyngitis
Phenoxymethylpenicillin (Penicillin V)
Child < 20 kg: 250 mg, two or three times daily, for ten days
Child 20 kg and Adults: 500 mg, two or three times daily, for ten
days
OR
Amoxicillin
Child < 30 kg: 750 mg, once daily, OR 25 mg/kg, twice daily
(maximum 1000 mg/day), for ten days
Child 30 kg and Adults: 1000 mg, once daily, for ten days
OR
IM benzathine penicillin (stat)
Child < 30 kg: 450 mg (600 000 U)
Child 30 kg and Adults: 900 mg (1 200 000 U)
Erythromycin
Child: 20 mg/kg/dose, twice daily or 10 mg/kg/dose, four times
daily, for ten days (maximum 1 g/day)
Adult: 400 mg, twice daily, for ten days
N.B. Co-trimoxazole does not have reliable activity against S. pyogenes or
eradicate pharyngeal carriage and should not be used.
Sinusitis acute
Management
Common pathogens
Antibiotic treatment
Sinusitis (acute)
First choice
Amoxicillin
Child: 15 mg/kg/dose, three times daily, for seven days
Use 30 mg/kg/dose, three times daily, for seven days in severe or
recurrent infection (maximum 500 mg/dose age three months to
five years, 1000 mg/dose age > five years)
Antibiotic treatment
Alternatives
Eyes
Eyes
Conjunctivitis
Management
Common pathogens
Antibiotic treatment
First choice
Alternatives
Conjunctivitis
Chloramphenicol 0.5% eye drops
Adult and child > 2 years: 1 2 drops, every two hours for the
first 24 hours, then every four hours +/ chloramphenicol eye
ointment at night until 48 hours after symptoms have cleared
Fusidic acid eye gel
Adult and child: 1 drop, twice daily until 48 hours after symptoms
have cleared
CNS
Bacterial meningitis and suspected meningococcal sepsis
Management
Common pathogens
Antibiotic treatment
First choice
CNS
Alternatives
Skin
Bites human and animal (Includes injury to fist from contact with teeth)
Management
Clean and debride wound thoroughly and assess the need for
tetanus immunisation.
All infected bites should be treated with antibiotics. Prophylactic
antibiotic treatment is appropriate for human and cat bites, or dog
bites if severe or deep, and any bites that occur to the hand, foot,
face, tendon or ligament, or in immunocompromised people.
Consider referral to hospital if there is bone or joint involvement.
Common pathogens
Antibiotic treatment
First choice
Amoxicillin clavulanate
Child: 10 mg/kg/dose (amoxicillin component), three times daily,
for seven days (maximum 500 mg/dose, amoxicillin component)
Adult: 500+125 mg, three times daily, for seven days
Adult and child > 12 years: Metronidazole 400 mg, three times
daily, + doxycycline 200 mg on day one, followed by 100 mg, once
daily, on days two to seven
Metronidazole + co-trimoxazole is an alternative for children
aged under 12 years (doxycycline contraindicated)
Skin
Alternatives
Skin (continued)
Boils
Management
Common pathogens
Staphylococcus aureus
Consider MRSA if there is a lack of response to flucloxacillin.
Antibiotic treatment
First choice
Boils
Flucloxacillin
Child: 12.5 mg/kg/dose, three to four times daily, for seven days
Adult: 500 mg, four times daily, for five to seven days
OR (if flucloxacillin not tolerated in children)
Cephalexin
Child: 12.5 25 mg/kg/dose, twice daily, for five to seven days
Alternatives
Cephalexin
Adult: 500 mg, four times daily, for five to seven days
Skin
Erythromycin
Child aged < 12 years: 20 mg/kg/dose, twice daily, or 10 mg/kg/
dose, four times daily, for five to seven days (maximum 1 g/day)
Adult: 800 mg, twice daily, or 400 mg, four times daily, for five to
seven days
Co-trimoxazole (if MRSA present):
Child > 6 weeks: 0.5 mL/kg oral liquid (40+200 mg/ 5 mL), twice
daily, for five to seven days (maximum 20 mL/dose)
N.B. Co-trimoxazole should be avoided in infants aged under six weeks, due to
the risk of hyperbilirubinaemia.
Adult and child >12 years: 160+800 mg (two tablets), twice daily,
for five to seven days
10
Cellulitis
Management
Common pathogens
Antibiotic treatment
Cellulitis
First choice
Flucloxacillin
Child: 12.5 mg/kg/dose, four times daily, for seven days
Adult: 500 mg, four times daily, for five to seven days
OR (if flucloxacillin not tolerated)
Cephalexin
Child: 12.5 mg/kg/dose, four times daily, for seven to ten days
(maximum 500 mg/dose)
Adult: 500 mg, four times daily, for seven days
Cephalexin
Adult: 500 mg, four times daily, for seven days
Erythromycin
Child < 12 years: 20 mg/kg/dose, twice daily, or 10 mg/kg/dose,
four times daily, for seven to ten days (maximum 1 g/day)
Adult: 800 mg, twice daily, or 400 mg, four times daily, for seven
days
Skin
Alternatives
11
Skin (continued)
Diabetic foot infections
Management
Antibiotics (and culture) are not necessary unless there are signs
of infection in the wound. However, in people with diabetes
and other conditions where perfusion and immune response
are diminished, classical clinical signs of infection are not always
present, so the threshold for suspecting infection and testing a
wound should be lower.
Referral to hospital should be considered if it is suspected that
the infection involves the bones of the feet, if there is no sign of
healing after four weeks of treatment, or if other complications
develop.
Common pathogens
Antibiotic treatment
First choice
Alternatives
Amoxicillin clavulanate
Adult: 500+125 mg, three times daily, for five to seven days
Cephalexin 500 mg, four times daily, + metronidazole 400 mg,
twice to three times daily, for five to seven days
OR (for patients with penicillin hypersensitivity)
Co-trimoxazole 160+800 mg (two tablets), twice daily, +
clindamycin* 300 mg, three times daily, for five to seven days
Skin
Skin
Impetigo
Management
12
Common pathogens
Antibiotic treatment
Impetigo
First choice
Alternatives
Skin
Adult and child > 12 years: 160+800 mg (two tablets), twice daily,
for five to seven days
Mastitis
Management
Common pathogens
Antibiotic treatment
Mastitis
First choice
Flucloxacillin
Adult: 500 mg, four times daily, for seven days
13
Skin (continued)
Antibiotic treatment
Alternatives
Mastitis continued
Cephalexin
Adult: 500 mg, four times daily, for seven days
Erythromycin
Adult: 400 mg, four times daily, for seven days
Treat mastitis in males or non-lactating females with amoxicillin
clavulanate 500+125 mg, three times daily, for seven days
Skin
Skin
Nil
Skin
Alternatives
15
Gastrointestinal
Campylobacter enterocolitis
Management
Common pathogens
Campylobacter jejuni
Antibiotic treatment
Campylobacter enterocolitis
First choice
Erythromycin
Child: 10 mg/kg/dose, four times daily, for five days
Adult: 400 mg, four times daily, for five days
Gastrointestinal
Alternatives
16
Ciprofloxacin
Adult: 500 mg, twice daily, for five days (not recommended for
children)
Common pathogens
Clostridium difficile
Antibiotic treatment
Alternatives
Metronidazole
Adult: 400 mg, three times daily, for 10 days
Vancomycin
If patient has not responded to two courses of metronidazole;
discuss with an infectious diseases physician or clinical
microbiologist. Oral vancomycin (using the injection product)
may be required.
Gastrointestinal
First choice
17
Gastrointestinal (continued)
Giardiasis
Management
Common pathogens
Giardia lamblia
Antibiotic treatment
Giardiasis
First choice
Ornidazole
Child < 35 kg: 125 mg/3 kg/dose,* once daily, for one to two days
Adult and child > 35 kg: 1.5 g, once daily, for one to two days
* N.B. Dose is per 3 kg bodyweight; ornidazole is only available in tablet form,
tablets may be crushed, child dosing equates to one quarter of a tablet per 3 kg.
OR
Metronidazole
Child: 30 mg/kg/dose, once daily, for three days (maximum
2 g/dose)
Adult: 2 g, once daily, for three days
Alternatives
Gastrointestinal
18
Salmonella enterocolitis
Management
Common pathogens
Antibiotic treatment
Salmonella enterocolitis
Alternatives
Ciprofloxacin
Adult: 500 mg, twice daily, for three days
Co-trimoxazole
Adult: 160+800 mg (two tablets), twice daily, for three days
Gastrointestinal
First choice
19
Genito-urinary
Bacterial vaginosis
Management
Common pathogens
Antibiotic treatment
Bacterial vaginosis
Alternatives
Genito-urinary
Metronidazole
Adult: 400 mg, twice daily, for seven days, or 2 g, stat, if adherence
to treatment is a concern, however, this is associated with a higher
relapse rate
Ornidazole 500 mg, twice daily, for five days or 1.5 g, stat may
be used instead of metronidazole, but is not recommended in
women who are pregnant as no study data is available
Chlamydia
Management
Gastrointestinal
Gastrointestinal
First choice
Common pathogens
Chlamydia trachomatis
Antibiotic treatment
Chlamydia
First choice
Azithromycin
Adult: 1 g, stat
OR
Doxycycline
Adult: 100 mg, twice daily, for seven days. Do not use in
pregnancy or breast feeding.
Alternatives
20
Amoxicillin 500 mg, three times daily, for seven days (only in
women who are pregnant who are unable to take azithromycin)
Epididymo-orchitis
Management
Common pathogens
Antibiotic treatment
Epididymo-orchitis
First choice
21
Genito-urinary
Alternatives
Genito-urinary (continued)
Gonorrhoea
Management
Common pathogens
Neisseria gonorrhoeae
Antibiotic treatment
Gonorrhoea
First choice
Ceftriaxone
Adult: 500 mg IM, stat (make up with 2 mL of 1% lignocaine or
according to data sheet)
AND
Azithromycin
Adult: 1 g, stat (including in pregnancy and breastfeeding)
Alternatives
Genito-urinary
22
Antibiotic treatment
First choice
Alternatives
Common pathogens
Antibiotic treatment
Acute pyelonephritis
Alternatives
Co-trimoxazole
Adult: 160+800 mg (two tablets), twice daily, for 10 days
Amoxicillin clavulanate
Adult: 500+125 mg, three times daily, for 10 days
Ciprofloxacin 500 mg, twice daily, for seven days but should
be reserved for isolates resistant to initial empiric choices and
avoided during pregnancy
23
Genito-urinary
First choice
Genito-urinary (continued)
Trichomoniasis
Management
Common pathogens
Trichomonas vaginalis
Antibiotic treatment
Trichomoniasis
First choice
Metronidazole
Adult: 2 g, stat
Can be used in women who are pregnant or breast feeding, but
advise to avoid breastfeeding for 1224 hours after dose
Alternatives
For those intolerant of the stat dose, use metronidazole 400 mg,
twice daily, for seven days
Ornidazole 1.5 g, stat or 500 mg, twice daily, for five days may be
used instead of metronidazole, but is not recommended in women
who are pregnant as no study data is available
Genito-urinary
24
Antibiotic treatment
First choice
Alternatives
Nil
Common pathogens
Antibiotic treatment
First choice
Trimethoprim
Adult: 300 mg, once daily, for three days (avoid during the first
trimester of pregnancy)
OR
Nitrofurantoin
Adult: 50 mg, four times daily, for five days (avoid at 36+ weeks in
pregnancy, and in patients with creatinine clearance < 60 mL/min)
Alternatives Norfloxacin
Adult: 400 mg, twice daily for three days but should be reserved
for isolates resistant to initial empiric choices and avoided during
pregnancy
25
Genito-urinary
Genito-urinary (continued)
Urinary tract infection (UTI) child
Management
Refer children aged under three months, those with severe illness,
or those with recurrent infection, to hospital. Also consider referral
of children aged under six months.
Children aged over six months, without renal tract abnormalities,
and who do not have acute pyelonephritis, may be treated with a
short course (three days) of antibiotics.
All children with suspected UTI should have a urine culture
collected as a clean specimen (clean catch, catheter, midstream
urine) as it may be a marker for previously undetected renal
malformations, particularly in younger children. In older children
it can be a marker for bladder and/or bowel dysfunction.
For information on collecting a urine specimen in children,
see: Managing urinary tract infections in children, BPJ 44 (May,
2012).
Common pathogens
Antibiotic treatment
First choice
Co-trimoxazole
Child: 0.5 mL/kg/dose oral liquid (40+200 mg/ 5 mL), twice daily,
for three days (maximum 20 mL/dose)
If a child can swallow tablets, co-trimoxazole 80+400 mg tablets
can be used (one tablet is equivalent to 10 mL of co-trimoxazole
oral liquid)
Alternatives
Cefaclor
Child: 8 10 mg/kg/dose, three times daily, for three days
(maximum 500 mg/dose)
Genito-urinary
Amoxicillin clavulanate
Child: 10 mg/kg/dose (amoxicillin component), three times daily,
for three days (maximum 500 mg/dose,amoxicillin component)
26
The information in this publication is specifically designed to address conditions and requirements in
New Zealand and no other country. BPAC NZ Limited assumes no responsibility for action or inaction
by any other party based on the information found in this publication and readers are urged to seek
appropriate professional advice before taking any steps in reliance on this information.
27
Respiratory
E.N.T.
Eyes
CNS
Skin
Eyes
Conjunctivitis
CNS
Bacterial meningitis and suspected meningococcal sepsis
Skin
Bites human and animal (includes
injury to fist from contact with teeth)
Boils
Cellulitis
Gastrointestinal
Gastrointestinal
Campylobacter enterocolitis
Clostridium difficile colitis
Giardiasis
Salmonella enterocolitis
20
Genito-urinary
Genito-urinary
16
Respiratory
Bacterial vaginosis
Chlamydia
Epididymo-orchitis
Gonorrhoea
Pelvic inflammatory disease
Pyelonephritis acute
Trichomoniasis
Urethritis acute non-specific
Urinary tract infection adult
Urinary tract infection child