Updated Final HAP

NIMS ANTIMICROBIAL
Empowering Medical Professionals in Rational Prescribing of Antimicrobials
Rational prescribing
prevents development
of Antimicrobial
Resistance
Localize organ of
infection and
identify type of
infection
De-escalate Review
after Culture reports Send Culture
or 72 hours of before starting
therapy
antimicrobials
Hospital
antimicrobial
policy
Use Rapid
Optimize PK-PD Diagnostics
of
Antimicrobials
Choose Empiric
from Access
group of WHO
AWaRe
Compiled by
Department of Clinical Pharmacology & Therapeutics
Nizam’s Institute of Medical Sciences, Hyderabad, India
TABLE OF CONTENTS
CONTENTS Page No
Message from the Secretary to Govt, Health, Medical & Family welfare Dept. iv
Government of Telangana
Foreword by the Director, NIMS v
Foreword by the Dean, NIMS vi
Foreword by the Medical Superintendent, NIMS vii
Preface by Head of Department of Clinical Pharmacology & Therapeutics, viii
NIMS
Acknowledgements ix
List of Contributors x
Instructions to users of the antimicrobial policy xi
Abbreviations and Acronyms xii
Chapter 1 Introduction 1-2
Chapter 2 Principles of Rational Antibiotic Prescribing 3-12
Chapter 3 Case Definitions and Diagnosis for Common Infections 13-25
A. Acute Undifferentiated Fever
B. Sepsis syndromes
C. Acute Bacterial Meningitis
D. Infective Endocarditis
E. Pneumonia
F. Urinary Tract Infection
G. Surgical Site Infections
Chapter 4 Syndromic approach for empirical therapy of common
infections
A. Acute undifferentiated Fever 27-28
B. Sepsis 29-30
C. Central Nervous system infections 31-33
D. Cardiovascular infections (Vascular + IE) 34-40
E. Gastrointestinal and intra-abdominal infections 41-44
F. Respiratory Tract infections 45-48
G. Genito Urinary Tract infections 49-50
H. Skin and Soft tissue infections 51-52
I. Bones and joint infections 53-55
J. Infections in Plastic surgery 56
K. Gynecological infections 57-59
L. Hospital Acquired Infections 60-61
M. Other infections 62-63
N. Peritoneal Dialysis related peritonitis 64-66
O. Infections in Immunocompromised host (Post solid organ 67-72
transplant)
P. Trauma 73
NIMS ANTIMICROBIAL POLICY- 2023
Q. Fungal infections 74-76

Chapter 5 Surgical Antimicrobial Prophylaxis 77-82
Chapter 6 Treatment of Multi-Drug Resistant Bacterial pathogens
A. Carbapenem Resistant Organism (CRO) 83-88
B. Methicillin Resistant Staph Aureus (MRSA) 90-91
C. Vancomycin Resistant Enterococcus (VRE) 92-93
Chapter 7 Dosage Guide for commonly used antimicrobial agents 93-112
List of references 113-114
iii
iv
v
Dr. Liza Rajasekhar

DEAN
Sr. Professor of Rheumatology
Nizam’s Institute of Medical Sciences
Punjagutta, Hyderabad.
FOREWORD
Dear Colleagues,
It is with great pleasure to note the introduction of the new hospital antibiotic policy. It is
crucial for us to ensure the highest standards of patient care and safety, and a well-defined
antibiotic policy plays a pivotal role in achieving these goals.
Antibiotics are powerful agents that have revolutionized modern medicine. However their
indiscriminate use has led to emergence of Antimicrobial resistance (AMR), a grave threat to
public health. Recognizing the urgent need to address AMR, our hospital has developed a
comprehensive antibiotic policy that encompasses various key aspects. Firstly, the policy
emphasizes the need for appropriate prescribing of antimicrobials. We must remember that
antibiotics are not a panacea for all health care situations. For eg each one of us has a role in
differentiating between bacterial and viral infections and prescribing antibiotics only when they
are truly necessary. Secondly, the policy outlines evidence-based recommendations for
antibiotic selection, dosing, and duration and encouraging choosing narrow spectrum
antimicrobial wherever possible. In addition, this policy recognizes the importance of infection
prevention and control strategies. Preventing infections through good hygiene practices,
vaccination, and a clean healthcare environment is essential in reducing the need for antibiotics.
Implementing this antibiotic policy requires the commitment and active participation of every
healthcare professional in our hospital. I urge you all to familiarize yourselves with the policy,
adhere to its principles, and actively engage in antimicrobial stewardship activities. Together,
we can make a significant impact in combating antimicrobial resistance and protecting the
health of our patients.
Lastly, there is a need for continuous surveillance and monitoring of antibiotic usage and
resistance patterns to evaluate effectiveness of our interventions, and adapting our policy
accordingly.
I thank the Department of Clinical Pharmacology & Therapeutics for their dedication who in
collaboration with all departments have brought this policy to the table and all those who will
give it the importance it deserves.
Dr. Liza Rajasekhar

DEAN, NIMS
vi
Dr N. Satyanarayana
Medical Superintendent
Prof & HOD Hospital Administration
NIMS
FOREWORD
Antimicrobial resistance (AMR) is a fundamental threat to global health and safety. Tackling
antimicrobial resistance is a collective responsibility of all stakeholders especially the
healthcare professionals. We the health-care professionals have a responsibility to judiciously
use the existing antimicrobials to mitigate the problem of AMR.
The major drivers of AMR are irrational use of antibiotics in humans and animals, unregulated
over the counter sale of antibiotics and lack of guidance and awareness on antibiotic use. To
aid healthcare professionals in tackling AMR, by promoting prudent use of antimicrobials the
department of Clinical Pharmacology & Therapeutics have come up with the NIMS-
Antimicrobial policy. This policy has been drafted after extensive review of antimicrobial
surveillance studies conducted in major ICU’s and Wards of our hospital. Additionally, the
choice of empiric antimicrobials is based on our hospital antibiogram. Furthermore, an
exhaustive list of antimicrobials with details of dosage schedule, reconstitution, administration
and infusion time, dosing of drugs in renal and hepatic impairment and alternatives drugs for
patients with beta-lactam and vancomycin allergy has been furnished to ease the effective use
of antimicrobials.
I hope this policy will aid us in making optimum use of the resources available to us, and
therefore potentiate transformational change in prescribing practices and leading to eventual
improvements in clinical outcomes.
Medical Superintendent, NIMS
vii
Dr. P. Usha Rani

Senior Professor & Head
Nizams Institute of Medical Sciences, Hyderabad
PREFACE
Antimicrobial resistance (AMR) is one of the most serious global public health threats in this
century and has emerged as one of the principal public health problems that threatens the
effective prevention and treatment of an ever-increasing range of infections caused by bacteria,
parasites, viruses and fungi no longer susceptible to the common medicines used to treat them.
Faced with this reality, the need for action to avert a developing global crisis in health care is
imperative. Increased resistance leads to elevated costs associated with more expensive
antibiotics. In the hospital setting, the intensive and prolonged use of antimicrobial drugs is
probably the main contributor to the emergence and spread of highly antibiotic-resistant
nosocomial infections.
There is a shortage of new antibiotics in the pipeline and few incentives for industry to invest
in research and development in this field. There are very few effective drugs to treat multidrug-
resistant infections due to Gram-negative bacteria that represent the main threat at
present. Without an effective antibiotic policy, the success of treating severe life-threatening
medical conditions, major surgery and cancer chemotherapy would be compromised. Further,
lack of proper monitoring, misuse and overuse of antimicrobials are the main drivers in the
development of drug-resistant pathogens.
It is my privilege to present NIMS Antimicrobial Policy prepared by the Department of Clinical
Pharmacology and Therapeutics. We hope this document serves as a practical guide to all health
care providers in effectively prescribing and dispensing antimicrobial agents. Proper
implementation and practise of these guidelines is a highly effective strategy in improving
quality of patient care and lowering health care associated infections, morbidity and mortality
and thus reducing antibiotic resistance.
Dr. P Usha Rani

Chairman- NIMS AMSP Committee
viii
ACKNOWLEDGEMENTS
We acknowledge with gratitude the inspiration and patronage of Dr. N Bheerappa, Director,
NIMS, to draft the Hospital Antimicrobial policy for NIMS. The base pillars of this policy are
the microbiological data and antimicrobial surveillance data collected from the microbiology
department and case-sheets from the wards and ICU’s respectively at NIMS. We whole-
heartedly thank the Microbiology Dept, NIMS for sharing the culture data and NIMS
antibiogram. Sincere thanks to all the Heads and Unit-heads of all Clinical departments at
NIMS for letting us collect the antimicrobial surveillance data and graciously hosting us for
the feedback programme conducted based on the survey. The drafting of this policy involved a
very large number of deliberations with Medical and Surgical departments who provided
comments during face to face as well as online meetings. We gratefully acknowledge the
support of all the stake-holders- Heads of departments, unit-heads, faculty ,residents and the
Nursing staff from all the Medical and Surgical departments of NIMS for sparing their time
and providing their valuable comments and suggestions. We appreciate and acknowledge the
support of Dr. Radhika S, during her tenure as Additional professor in NIMS towards her
support and guidance in conducting the antimicrobial surveillance studies. We also appreciate
the support extended to us by Dr. Subbalaxmi M and Dr. Padmaja D and the AMSP team during
the conduct of the antimicrobial surveillance and feedback session in various clinical
departments. The administrative support from all the departments of NIMS is duly
acknowledged. It is hoped that this document will aid the residents and faculty in addressing
the challenge of antimicrobial resistance by rational prescribing of antimicrobials especially to
critically ill patients.
Dr. P Usha Rani

ix

Chairman- NIMS AMSP Committee
LIST OF CONTRIBUTORS
Prepared by
Dr. P Usha Rani,
Senior Professor & Head,
Dept of Clinical Pharmacology & Therapeutics,
Nizam’s Institute of Medical Sciences, Hyderabad
Contributors
1. Dr. C Prabhakar Reddy 2. Dr. M Padmaja
Additional Professor, Associate Professor,
Dept of CP&T Dept of CP&T
Nizam’s Institute of Medical Sciences, Nizam’s Institute of Medical Sciences,
Hyderabad Hyderabad
Assistant Professors Senior Residents

Dr Vuppalanchi Bhavani Dr Imran khan
Dr K Sireesha Dr Vandana Godella
Dr Ankita Sharma Dr P Sravanasandya
Dr Roopali Somani Dr Ankita Panigrahy
Dr Ruby Raphael Dr Mohd Shahabuddin Adil
Dr Md Abid Ali Dr Saheli
Dr Sailajapriyadarsini.P
x
Instructions to Users of Antimicrobial Guidelines

The “NIMS Antimicrobial policy- 2023” aims to promote rational use of
antimicrobials on National List of Essential Medicines (NLEM) and WHO
AWaRe criteria and to establish consistency in the treatment of various
infectious conditions.
The Department of Clinical Pharmacology has conducted antimicrobial
surveillance studies across various departments of NIMS. The surveillance
data along with Antibiogram has been used to guide the treatment of various
syndromes across various disciplines. All recommendations are either
evidence-based or as per universally accepted standards. The
recommendations have been provided as first line agents to be preferred and
second line agents to be chosen when the first line drug is intolerable or
contraindicated or not available. Alternative agents in patients with beta-
lactam and vancomycin allergy have been recommended.
In the drug appendix along with adult and paediatric doses, the reconstitution
details and dosage adjustment details in renal and hepatic failure has also been
provided.
xi
ABBREVIATIONS
AMR Antimicrobial resistance
AMA Antimicrobial Agent
Tmax Time at which maximum concentration achieved
AUC Area Under the serum concentration time Curve
Cmax maximum concentration
Cmin Minimum or trough concentration
LD Loading Dose
MD Maintenance Dose
MIC Minimum Inhibitory Concentration
PAE Post-antibiotic effect
HAP Hospital acquired pneumonia
SSI Surgical site infection
SSSI Skin and skin structure infection
cIAI Complicated intra-abdominal infection
AUF Acute Undifferentiated febrile
qSOFA quick Sepsis Related Organ Failure Assessment
MAP Mean Arterial Pressure
ABM Acute Bacterial Meningitis
CRP C Reactive Protein
PCT Procalcitonin
IE Infective endocarditis
HACEK group Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, & Kingella
TEE TransEsophageal Echocardiography
TTE TransThoracic Echocardiography
IDU Injection Drug Use
CAP Community acquired pneumonia
VAP Ventilator Associated Pneumonia
UTI Urinary tract infections
ASB Asymptomatic Bacteriuria
CAUTI Catheter associated urinary tract infection
VGS Viridans group streptococcal (VGS) bacteremia
CONS Coagulase-negative staphylococci
NVS Nutrionally variant streptococci
HLAR High level aminoglycoside resistant Enterococci
NVE Native Valve Endocarditis
PVE Prosthetic Valve Endocarditis
CRBSI Catheter-related bloodstream infection
CLABSI Central Line-associated Bloodstream Infection
MRSA Methicillin resistant staphylococcus aureus
MSSA Methicillin sensitive staphylococcus aureus
VRE Vancomycin resistant Enterococci
CRO Carbapenem resistant organism
CRE Carbapenem resistant Enterobacteriaceae
xii
CRAB Carbapenem resistant Acinetobacter baumanii

CRPA Carbapenem resistant Pseudomonas aeruginosa
ESBL Extended Spectrum Beta-Lactamase
xiii
INTRODUCTION
The burden of anti-microbial resistance (AMR), in addition to being a major public health
concern, threatens to take us back to the pre-antibiotic era. It also intimidates the scientific and
technological advancements of modern medicine. It is predicted that by 2050, highly resistant
infections will be the leading cause of mortality surpassing cancer. Human antimicrobial
misuse and overuse is the leading cause of anti-microbial resistance. To counter this threat,
various governmental agencies have launched the anti-microbial stewardship initiatives.
Stewardship means to “protect”, it is imperative to preserve the efficacy of the few
antimicrobials that we currently have and protect the ones in drug development. Rational
prescribing of antimicrobials and compliance to infection control practices have emerged as
the most promising methods to attain the objectives of antimicrobial stewardship.
To combat AMR, a “three-pillar” approach is recommended:

1. Optimize the use of antimicrobials by rational prescribing
2. Prevent the transmission of drug-resistant organisms
3. Improve environmental decontamination
Rational prescribing aims to optimise treatment of individual patients to achieve good clinical
outcome for prevention or cure of infection with minimal toxicity to the patient and minimal
impact on subsequent resistance. It involves prescribing an antibiotic only when it is needed
and selecting an appropriate and effective agent at the recommended dose, with the narrowest
spectrum of antimicrobial activity, fewest adverse effects and lowest cost.
Rational antimicrobial prescribing encompasses the 6D’s and includes
✓ Right Diagnosis
✓ Right Drug,
✓ Right Dose, Dosage Schedule
✓ Right Duration
✓ Debridement/Drainage.
This document was prepared with the objective to guide in the selection of initial empirical
antimicrobial agent in patients with infections commonly seen in clinical practice.
The recommendations in this guideline are based on current scientific knowledge, the
antimicrobial sensitivity pattern as per NIMS antibiogram (released twice a year), audit and
feedback sessions conducted in many of the departments. The recommendations provided in
this document serve to guide and are not binding in nature.
1
To further improve the empiric antimicrobial recommendations, it is crucial to have robust data
on local resistance pattern which can be obtained only when cultures are sent before initiating
empirical antimicrobials. Thus it is, imperative to ensure that cultures are sent before starting
empirical antimicrobials even in life threatening infections, however the treatment should not
be delayed while waiting for diagnostic tests to be performed or awaiting results.
2
PRINCIPLES OF RATIONAL ANTIMICROBIAL PRESCRIBING
Rational prescribing of antimicrobials can be divided into 3 zones
1. Pre-Initiation zone: before starting antimicrobials.

2. Optimization zone: during anti-microbial therapy
3. Discontinuation zone
Table 1: Rational Prescribing Zones
Pre-Initiation Zone - Optimisation zone - Antimicrobials-

Before starting During Anti-microbial therapy discontinuation zone
antimicrobials
1. Arrive at a DIAGNOSIS 1. Review after 72-96 hours 1. Switch from IV to
2. Localize the source of /after culture report for oral
infection appropriateness of therapy 2. Stop antimicrobials
3. Assess if the patient 2. De-escalate the antimicrobial- following the
really needs from broad spectrum to timelines for
antimicrobials? narrow spectrum (With the various infections
4. Send for appropriate lowest MIC) as per this
cultures before starting 3. Monitor for toxicity guideline
AMA 4. Monitor response to therapy
5. Adequate source control 5. Monitor drug levels in
is essential appropriate fluid
6. Depending upon the (Vancomycin, voriconazole)
patient’s condition, 6. Discontinue antibiotic if
choose from the drugs infection is not confirmed
given in this guideline
I. Pre-Initiation zone:
Step 1: Arrive at a diagnosis: “A correct diagnosis is three fourths of the remedy”
a) Consider if it is an infection.
a) Localize the source and organ of infection- Empirical antimicrobial of choice will vary
based on the location of infection.
b) Try to identify the type of infection- Bacterial, viral, parasitic, fungal?
c) What are the possible non-infectious mimics?
Step 2: Microbiological sample collection
a) Collect appropriate sample from the suspected site of infection using aseptic
precautions (Blood, Urine, CSF, Pus etc) before starting empirical antimicrobials
b) Avoid the practice of obtaining “pan cultures” unless clinically indicated.
c) Avoid sending cultures from superficial wounds, decubitus ulcers, and chronic
wounds and draining sinuses. Surface swab cultures are either inadequate or provide
misleading information regarding diagnosis (as they cannot differentiate infection from
colonization / contamination).
3
• Blood culture: at least 2 different sets (2 bottles per set- with at least 10 ml of blood/set)
from different Venipuncture sites for each septic episode.
• Preferably transport the sample within 2 hours of collection to the microbiology lab.
Step 3: Empiric antimicrobial treatment should be limited to conditions where immediate

/ early initiation of antimicrobials has been shown to be beneficial. Some examples are:
I. Severe sepsis and septic shock
II. Acute bacterial meningitis
III. Community acquired pneumonia.
IV. Ventilator associated pneumonia
V. Necrotizing fasciitis
VI. Febrile neutropenia
VII. Infective endocarditis
Step 4: Choosing an empirical antimicrobial in sepsis and septic shock

• Choose from ACCESS group of WHO AWaRe classification
• Based on the spectrum of the antibiotic taking into account possible resistant
patterns –
• Use the correct dose, route and duration
• Ensure chosen antibiotic has adequate tissue penetration at the site of infection –
• Optimize PK-PD parameters according to co-morbidities
WHO AWaRe Classification:

The WHO AWaRe classification divides antimicrobials into 3 groups based on their potential
of development of resistance and antimicrobial spectrum into ACCESS, WATCH and
RESERVE group.
Fig 1: WHO AWaRe Classification
Table 2: Antibiotic Classification as per WHO AWaRe
4
* Meropenem is in Watch only for CNS indications. For other indications it is considered as
Reserve antibiotic and should not be preferred empirically.
Pharmacokinetic and Pharmacodynamic properties of antimicrobials
Pharmacokinetics (PK) is concerned with the time course of antimicrobial concentrations in

the body, while Pharmacodyamics (PD) is concerned with the relationship between those
concentrations and the antimicrobial effect.
The primary measure of antibiotic activity is the minimum inhibitory concentration (MIC).
The MIC is the lowest concentration of an antibiotic that completely inhibits the growth of
a microorganism in vitro. While the MIC is a good indicator of the potency of an antibiotic,
it indicates nothing about the time course of antimicrobial activity.
PK parameters quantify the serum level time course of an antibiotic. The three
pharmacokinetic parameters that are most important for evaluating antibiotic efficacy are the
peak serum level (Cmax), the trough level (Cmin), and the Area Under the serum
5
concentration time Curve (AUC). While these parameters quantify the serum level time
course, they do not describe the killing activity of an antibiotic.
Integrating the PK parameters with the MIC gives us three PK/PD parameters which quantify
the activity of an antibiotic: the Peak/MIC ratio, the T>MIC (time above MIC), and the 24h-
AUC/MIC ratio. The Peak/MIC ratio is simply the Cmax divided by the MIC. The T>MIC
is the percentage of a dosage interval in which the serum level exceeds the MIC. The 24h-
AUC/MIC ratio is determined by dividing the 24-hour-AUC by the MIC .
Fig 2: PK-PD of Antibiotics
Optimize dosing of antimicrobials based on their PK-PD:
The three pharmacodynamic properties of antibiotics that best describe killing activity are time-
dependence, concentration-dependence, and persistent effects. The rate of killing is determined
by either the length of time necessary to kill (time-dependent), or the effect of increasing
concentrations (concentration-dependent). Persistent effects include the Post-Antibiotic Effect
(PAE). PAE is the persistent suppression of bacterial growth following antibiotic exposure.
For Type I antibiotics (aminoglycosides, fluoroquinolones, daptomycin and the ketolides),

the ideal dosing regimen would maximize concentration, because the higher the
concentration, the more extensive and the faster is the degree of killing. Therefore, the
Peak/MIC ratio is the important predictors of antibiotic efficacy.
6
eg: For aminoglycosides, a Peak/MIC ratio of at least 8-10 maximises efficacy while
minimizing resistance potential. This can be achieved with once-a-day dosing of
aminoglycosides which has the added advantage of less nephrotoxicity.
Type II antibiotics (beta-lactams, clindamycin, erythromcyin, and linezolid) demonstrate

the complete opposite properties. The ideal dosing regimen for these antibiotics maximizes
the duration of exposure. The T>MIC which means the Time duration during which the
unbound concentration remains above the MIC is the parameter that best correlates with
efficacy. For beta-lactams and erythromycin, maximum killing is seen when the time above
MIC is at least 70% of the dosing interval. This can be achieved by giving these drugs as
extended infusions over 2-3 hours or continuous infusions throughout the dosing interval.
Type III antibiotics (vancomycin, tetracyclines, azithromycin, and the dalfopristin-

quinupristin combination) have mixed properties, they have time-dependent killing and
moderate persistent effects. The ideal dosing regimen for these antibiotics maximizes
the amount of drug received. Therefore, the 24h-AUC/MIC ratio is the parameter that
correlates with efficacy. For vancomycin, a 24h-AUC/MIC ratio of at least 400 is necessary
for MRSA. This can be achieved by optimising the amount of total daily dose depending
upon the MIC to achieve the 24h- AUC/MIC ratio.
Other strategies to optimize the PK-PD of antimicrobials:
1) Choosing right drug to target the site of infection

eg: Tigecycline is ineffective in Blood stream infection, as tigecycline has high volume
of distribution (Vd) and is lipophilic - meaning it accumulates in tissues. Hence
tigecycline is preferred for Intra-abdominal and Skin and soft tissue infections.
2) Use of loading dose when needed – Eg: Colistin
3) Monitoring Plasma concentration for efficacy and toxicity (Vancomycin: AUC/MIC ratio
of 400, corresponds to trough conc of 15-20ng/ml)
7
Table 3: PK-PD of Antibiotics:
Pattern of PK-PD Antibiotics Goal of therapy Post

activity parameter antibiotic
effect
Type I Cmax/MIC Aminoglycosides Efficacy is Prolonged
Concentration- Daptomycin optimized by persistent
dependent killing Fluoroquinolones achieving high peak effects
Ketolides concentration by
giving high dose
once daily
Type II T>MIC Carbapenems Maximize the time Minimal
Time-dependent (70% dosing Cephalosporins period where drug persistent
killing interval> Erythromycin concentration is effects
MIC) Linezolid above the MIC by
Penicillin giving the drugs as
infusions over
prolonged periods
Type III 24h- Azithromycin Efficacy is Moderate to
Time-dependent AUC/MIC Clindamycin optimized by prolonged
killing Tetracyclines increasing total drug persistent
Vancomycin exposure in 24hr effects.
period
Table 4 : PK- PD of Antifungals
Pattern of PK-PD Explanation Example Post antifungal

activity INDEX Effect
Time T >MIC Efficacy is related to Flucytosine No
Dependent 40% maintaining the
concentration MIC for
certain period of time
Concentratio Cmax /MIC Efficacy is optimized by Amphotericin B Yes (prolonged)
n Dependent 0-40 achieving high peak Echinocandins
concentration by giving
high dose once daily
Concentratio AUC0- Efficacy is optimized by Triazoles Yes (prolonged)
n 24/MIC increasing total drug (Fluconazole,Itr
Independent exposure aconazole,
Voriconazole)
Fig 3: Predictors of bacterial eradication – PK-PD profiles of antibiotics
8
Right Dose and Dosage Schedule:
Optimise the dose of drug as per MIC of the organism and site of infection:
Eg :
1) If meropenem MIC is 8ug/ml, then dose of Meropenem can be increased to 2gm IV

every 8th hourly given as extended infusion over 3 hours.
2) For CNS infections, the dose of Meropenem is 2g IV every 8th hourly given as infusion
over 30 min-1 hour.
3) As per Fig 5: Increase in the MIC of Vancomycin, increases the treatment failure, hence
if vancomycin MIC> 1ug/ml, either choose a different drug or increase the dose of the
drug.
Fig 4: Triad of Host, drug and bug interaction
9
Fig 5: Relationship of MIC to Vancomycin treatment failure in patients with MRSA

infections
Adequate source control:
• If catheter/implant associated infection is suspected, then it is essential to change
the catheter/implant
• If any pus/collection present anywhere in the body, then along with anti-microbial
essential to drain/remove the collection wherever feasible.
II. Optimization zone -During Anti-microbial therapy

1) Modify empiric broad spectrum antibiotics to targeted narrow spectrum ones
depending on culture and susceptibility reports and patient status.
2) Discontinue antibiotics if a non-infectious mimic identified
3) De-escalate combination therapy to a single agent
4) Change IV to oral antibiotics
5) Discontinue MRSA coverage when cultures don’t retrieve MRSA and patient is
unlikely to have MRSA.
Change from IV to oral- antibiotic of choice
• Deescalate to oral antibiotics either from the culture and sensitivity report OR choose
from the same class of antimicrobials
• Do not change from Carbapenems to Faropenem. Faropenem is not an alternative to
MEROPENEM. Additionally, Misuse of Faropenem can cause cross-resistance to
Carbapenems
• In case of confirmed infection with ESBL or Highly Resistant organism-
➢ Complete the entire course of antibiotic
➢ Do not Switch from Cefoperazone+Sulbactam to Cefuroxime after 3-4 days of
therapy
10
Fig 6: Antimicrobials Switch Criteria (Adapted from ICMR)
Stop antibiotics in the following clinical situations:

• Asymptomatic bacteriuria and pyuria including in catheterized patients
• Microbial colonization and culture contamination
Eg: If candida grows in tracheal aspirate and patient is asymptomatic then consider it
as colonizer
• Low grade fever
11
Fig 7: Guidance for Antimicrobial Stewardship
12
CASE DEFINITIONS AND DIAGNOSIS FOR COMMON INFECTIONS
A. ACUTE UNDIFFERENTIATED FEVER (AUF):

● Previously healthy (non-immunosuppressed) community (urban or rural) dwelling
adult (ages 19-64 yrs.) reporting no previous medical illness or recent hospitalization
(in the preceding 30 days) presenting with acute onset of fever > 38.3° C (101.0° F) for
>2 days and lasting up to 14 days and having received no specific treatment for this
current illness with antimalarials or antibiotics.
● With history of no localizing symptoms (except accompaniments of fever such as –
chills, headaches, retro-orbital pain, myalgia, malaise, nausea or vomiting). On
examination found to have normal vital signs (excepting fever) and lacking organ or
system specific physical signs.
Diagnostic Workflow:
• History and clinical examination to assess for localization of fever and try to arrive at
a provisional diagnosis using the flow chart Fig 8
• Regional epidemiology and host factors (immunosuppression, pregnancy) should be
taken into consideration while arriving at a provisional diagnosis.
o AUF can be seasonal; e.g; malaria, arboviral infection, scrub typhus,
leptospirosis.
o H/o potential exposure to animals, vectors (mosquitos and mites).
• Recognize Sepsis &if the patient is in septic shock, send relevant culture(s) and
initiate empiric antimicrobials as early as possible.
• Utilize the Rapid Diagnostic Tests to rule out Malaria, Dengue, Typhoid, Leptospira,
Scrub Typhus as per clinical scenario
• Based on Provisional Diagnosis, initiate empirical therapy as given in the guideline
for management of acute undifferentiated fever.
• Reassess the situation within 48 hours based on test results and patient status.
13
Acute febrile illness

Fever > 100o F , < 14 days
Acute localised Acute Undifferentiated febrile

infection , illness (without septic shock)
respiratory,
urinary tract, Malaria(by smear microscopy &
gastrointestinal Nonmalaria rapid diagnostic tests)
or patient in
septic shock
Refer the Viral (r/o using Bacterial Parasitic
specific section rapid diagnostic
in the guideline tests)
Hepatic
Zoonotic amoebiasis
Influenza (Rule Arboviral Bacteraemia infections
out influenza if (Enteric fever
(dengue) (Spirochetal
currently active & Other , Rickettsial)
in the region) Bacteria)
Fig 8: Diagnostic Workflow for AUF
B. SEPSIS SYNDROMES
• Sepsis is defined as a life-threatening organ dysfunction caused by a dysregulated host
response to infection
• Septic shock is defined by the need for a vasopressor to maintain a patient’s mean
arterial pressure (MAP) ≥ 65 mmHg and serum lactate level ≥ 2 mmol/L
Suspect sepsis when the following are present:

Adult patients with suspected infection can be quickly screened for likelihood of having poor
outcomes typical of sepsis if they have at least 2 of the following 3 clinical criteria: (qSOFA)
1. Respiratory rate of 22/minute or greater
2. Altered mentation
3. Systolic blood pressure of 100 mmHg or less.
Other signs or symptoms that may be present:
a) General: fever (>38°C), hypothermia (< 36°C), tachycardia (HR>90)
14
b) Inflammatory: leukocytosis, leukopenia, >10% band forms, thrombocytopenia,

elevated plasma C- reactive protein, elevated Procalcitonin.
c) Hemodynamic: arterial hypotension (MAP< 70 mm Hg, or SBP decrease >40mm Hg)
d) Organ dysfunction: arterial hypoxemia, acute oliguria, creatinine increase >0.5 mg/dL,
coagulation abnormalities (INR >1.5 or aPTT>60 sec), ileus, platelets <1 lakh,
hyperbilirubinemia (bilirubin >4 mg/dL)
e) Decreased tissue perfusion: elevated lactate >1 mmol/L, decreased capillary refill or
mottling
f) Look for source of sepsis: urinary tract infections, intra-abdominal sources, pneumonia,
skin and soft tissue infection and vascular line; hospital acquired infections.
Obtain cultures:
a) Blood cultures (10ml) x 2 sets before initiating antibiotics (one drawn percutaneously
and the other through central line if present)
b) Other relevant cultures and Imaging to determine the need for source control.
C. ACUTE BACTERIAL MENINGITIS (ABM):
Acute meningitis is characterized by the classic triad of fever, neck stiffness and alteration of
sensorium.
a) Clinically suspected meningitis is defined as a child/adult presenting with fever (either
by historyor clinical presentation ) for less than seven days along with one of the following
signs-
• neck stiffness,
• bulging fontanelle (only in children)
• altered or reduced level of consciousness,
• prostration or lethargy,
• convulsions without documented seizure disorder.
b) Clinically probable meningitis is defined as a child/adult presenting with suspected

meningitis and CSF examination showing turbid appearance, leukocytosis >100
cells/mm3or leukocytosis 10–100 cells/mm3 with either decreased glucose (<40 mg/dl) or
elevated protein (>100 mg/dl) levels.
15
c) Confirmed meningitis is defined as a patient with a positive CSF latex/ culture/ PCR and
or positive blood culture with clinical syndrome consistent with meningitis.
Investigations and Diagnosis – Initial evaluation with complete blood count, two sets of blood
cultures and if available CRP and PCT. CSF for cell count, sugar and protein, gram stain and
culture. When a lumbar puncture cannot be done immediately, blood cultures should be drawn
and empiric antibiotics administered.
Health care associated meningitis/ ventriculitis:
Health care associated meningitis/ ventriculitis is seen in patients undergoing neurosurgeries,

head trauma, external ventricular drainage, lumbar punctures etc.
The etiology depends on local epidemiology but commonly includes multi drug / extremely
drug resistant gram-negative pathogens including Acinetobacter, Pseudomonas, Klebsiella and
Staphylococcus aureus/ epidermidis
Diagnosis is a challenge since sensorial obtundation (a cardinal symptom of meningitis) may
be due to the underlying disease/ surgery. The CSF may be abnormal due to pre existing bleed/
surgery induced chemical meningitis. The patients are frequently on antibiotics and hence
microbial isolation rates are low.
CSF should be sampled and sent for cell count, biochemistry and aerobic cultures. Elevated
CSF lactate (> 4 mmol/l) and procalcitonin help in differentiating between infective and
chemical meningitis. If suspecting shunt related infection, CSF collected from the shunt
chamber should be sent for aerobic culture. Contrast MRI is recommended to pick up
meningitis, ventricular enhancement, abscesses, cerebritis, and empyemas.
BRAIN ABSCESS:
A brain abscess is a focal, suppurative infection within the brain parenchyma, typically
surrounded by a vascularized capsule. The etiology of brain abscess is based on the underlying
predisposing factors like immunocompromised state, ear or dental infections, trauma or
surgical procedures, hematogenous spread, etc.
Diagnosis is by neuroimaging. An attempt should be made to establish the etiology by blood

cultures and aspiration. Aerobic and anaerobic bacterial cultures, mycobacterial and fungal
16
cultures should be obtained. This is especially required if the host is immunocompromised.

Imaging of the chest and abdomen should be done to see if an extra-CNS site can be sampled.
D. INFECTIVE ENDOCARDITIS:
Infective endocarditis (IE) is the infection of endothelial surfaces of the heart or iatrogenic
foreign bodies like prosthetic valves and other intracardiac devices. Streptococci (VGS) and
Enterococci are the most common organisms isolated.
Diagnosis:
Clinical suspicion, blood culture and echocardiography remain the cornerstone of diagnosis of
IE.
Definition of IE According to the Modified DukeCriteria
Definite IE
a) Pathological criteria:- Microorganisms demonstrated by culture or histological
examination of a vegetation that has embolized, or an intracardiac abscess specimen;
or pathological lesions; vegetation or intracardiac abscess confirmed by histological
examination showing active endocarditis
b) Clinical criteria:-
Definite IE:
2 Major criteria, 1 major criterion and 3 minor criteria, or 5 minor criteria
Possible IE:
1 Major criterion and 1 minor criterion, or 3 minor criteria
Rejected IE:
Firm alternative diagnosis explaining evidence of IE; or resolution of IE
syndrome with antibiotic therapy for ≤4 d; or no pathological evidence of
IE at surgery or autopsy with antibiotic therapy for ≤4 d; or does not meet
criteria for possible IE as above
St Thomas modification of Dukes criteria:

Inclusion of elevated ESR or CRP, the presence of newly diagnosed clubbing, splenomegaly
and microscopic hematuria as minor criteria (St. Thomas modifications) have been shown to
increase the sensitivity by 10%, without significant loss of specificity of the western setting.
17
Table 5: Modified Duke’s Criteria for the Diagnosis of IE
Criteria Features
Major 1. Blood culture positive for IE

Criteria
Typical microorganisms consistent with IE from 2 separate blood
cultures: Viridans streptococci, Streptococcus bovis, HACEK group,
Staphylococcus aureus; or community-acquired enterococci in the
absence of a primary focus, or microorganisms consistent with IE from
persistently positive blood cultures defined as follows: at least 2 positive
cultures of blood samples drawn >12 h apart or all 3 or a majority of ≥4
separate cultures of blood (with first and last sample drawn at least 1 h
apart) Single positive blood culture for Coxiella burnetii or anti–phase 1
IgG antibody titer ≥1:800
2. Evidence of endocardial involvement
Echocardiogram positive for IE (TEE recommended for patients with

prosthetic valves, rated at least possible IE by clinical criteria, or
complicated IE [paravalvular abscess]; TTE as first test in other patients)
defined as follows: oscillating intracardiac mass on valve or supporting
structures, in the path of regurgitant jets, or on implanted material in the
absence of an alternative anatomic explanation; abscess; or new partial
dehiscence of prosthetic valve or new valvular regurgitation (worsening
or changing or pre-existing murmur not sufficient)
Minor 1. Predisposition, predisposing heart condition, or IDU

Criteria 2. Fever, temperature >38°C
3. Vascular phenomena, major arterial emboli, septic pulmonary infarcts,
mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages,
and Janeway lesions
4. Immunological phenomena glomerulonephritis, Osler nodes, Roth spots,
and rheumatoid factor
5. Microbiological evidence: positive blood culture but does not meet a
major criterion as noted above (excludes single positive cultures for
coagulase negative staphylococci and organisms that do not cause
endocarditis) or serological evidence of active infection with organism
consistent with IE
HACEK indicates Haemophilus species, Aggregatibacter species, cardiobacterium hominis,

Eikenella corrodens, and Kingella species; IDU, injection drug use; IE, infective endocarditis;
IgG, immunoglobulin G; TEE transesophageal echocardiography; and TTE, transthoracic
echocardiography.
18
E. PNEUMONIA:
Pneumonia is an infection of the pulmonary parenchyma. Usually classified as community-

acquired, hospital-acquired or ventilator-associated pneumonia.
Community Acquired Pneumonia (CAP)
CAP is characterized by symptoms of an acute lower respiratory tract illness (cough with or
without expectoration, shortness of breath, pleuritic chest pain) for less than 1 week.
S.pneumoniae is the commonest organism causing CAP followed by H. influenza,
Mycoplasma pneumoniae, espiratory viruses and scrub typhus, leptospirosis, melioidosis.
Diagnosis: Symptoms of an acute lower respiratory tract illness (cough with or without
expectoration, shortness of breath, pleuritic chest pain) for less than 1 week.
At least, one systemic feature (temperature >37.7°C, chills, and rigors, and/or severe malaise).
New focal chest signs on examination (bronchial breath sounds and/or crackles); with no other
explanation for the illness. When a chest X-Ray is available, CAP is defined as the above with
new shadows on the X-Ray with no other defined cause.
Routine Laboratory investigations, with ABG, Blood and Sputum Culture with Gram stain to
be done.
Severity assessment based on CURB 65 score: one point each, range 0-5
i. Confusion (new onset disorientation in person, place, or time)
ii. Urea >126 mg/dL
iii. Respiratory rate > 30/min
iv. Low Blood pressure (SBP < 90 mm Hg or DBP < 60 mm Hg)
v. Age >65 years
Interpretation:
i. CURB-65 score 0 or 1: low risk of death; setting of care – out-patient
ii. CURB-65 score 2: moderate risk of death; setting of care – in-patient (ward)
iii. CURB-65 score >3: high risk of death; setting of care – in-patient (ICU)
Hospital Acquired Pneumonia

Hospital Acquired Pneumonia (HAP) is pneumonia that develops 48 hours or more after
admission and did not appear to be incubating at the time of admission.
19
Ventilator Associated Pneumonia (VAP) is pneumonia that develops after more than 48 hours
of mechanical ventilation.
When to suspect
When a patient who is hospitalized/on mechanical ventilation for > 48 hours develops new or
progressive infiltrates on chest radiography and has at least 2 of the following features:
1. Fever> 100.4o F.
2. Leucocytosis (> 12000/µl) or leucopenia (< 4000/ µl).
3. Altered mental status with no other recognizable cause in the elderly.
4. New onset purulent sputum or change in sputum character.
5. Worsening gas exchange (i.e. increased FiO2 requirement).
6. New onset or worsening cough or dyspnea.
7. Rales or bronchial breathing.
Diagnosis: Based on history and clinical characteristics as stated above.

*No gold standard for diagnosis of VAP; combination of above findings increases probability
of VAP. Obtain ET aspirate for Gram stain, culture and virology; Negative ET aspirate
culture rules out VAP (very high negative predictive value)
F. URINARY TRACT INFECTIONS (UTI):

It is important to distinguish lower tract (e.g. cystitis) from upper tract (e.g. pyelonephritis)
• Symptoms of a lower tract UTI or cystitis may include urinary frequency, urgency
and dysuria
• Symptoms of an upper tract UTI or pyelonephritis may include fever, chills, flank
pain, costovertebral angle tenderness, and nausea/vomiting
Table 6: 1. Definition(s) of UTI Syndromes

TYPE DEFINITION
(i) In Women: Two consecutive voided urine specimens with
isolation of the same bacteria at ≥ 105 CFU/mL (preferably
in 2 weeks).
Asymptomatic Bacteriuria
(ASB) (ii) In Men: (a) A single, clean-catch, voided urine specimen
with 1 bacteria isolated 105 CFU/mL (b) A single
catheterized urine specimen with 1 bacteria isolated ≥ 102
CFU/mL
20
(i) Positive urine culture
(ii) Infection associated with a condition, such as structural

Complicated UTI or functional abnormalities of the genitourinary tract or the
presence of an underlying disease, which increases the risks
of acquiring an infection or of failing therapy.
(i) Indwelling urethral, indwelling suprapubic, or
intermittent catheterization
(ii) Presence of symptoms or signs compatible with UTI with

CAUTI no other identified source of infection along with
⩾103 colony-forming units (cfu)/mL of ⩾1 bacterial species
in a single catheter urine specimen or in a midstream voided
urine specimen from a patient whose urethral, suprapubic, or
condom catheter has been removed within the previous 48 h.
2. Urine Culture:
2.1 The sample is to be collected in a sterile screw-capped container and up to a minimum
volume of 10-20 ml. The sample must be collected by either of the following:
• Midstream clean catch.
• Supra-pubic aspiration especially in infants or aseptic single catheterization for sample
collection.
• Collection procedure in a catheterized patient:
o If the catheter is in place <14 days, urine must be collected using a syringe and
needle from the foley`s catheter after disinfecting the rubber surface with 70%
ethyl alcohol.
o If the catheter is > 14 days, replace the old catheter before collection of urine
for culture.
2.2 Transport of the specimen and plating should be done within 1 hour. If delay, the urine
sample must be refrigerated at 4ºC for a maximum of 6-8 hours.
3. Urine Microscopy:
3.1 Clinically suspected UTI: The presence of 10 leukocytes/mm3 of uncentrifuged urine or
10 leukocytes/hpf of the centrifuged sample, in a clinically suspected UTI
3.2 Bacteriuria of >105cfu/ml is associated with UTI. However, any colony count is significant
in symptomatic young women and men with pyuria. Any colony count of bacteria grown from
a suprapubic aspirate is significant.
3.3 Blood cultures (two sets) – Should be sent before the first dose of antibiotics if the patient
is febrile, has suspected acute pyelonephritis or complicated UTI
21
SUSPECTED UTI
Assymptomatic Symptomatic
Bacteriuria
(No antimicrobial needed Uncomplicated Complicated
unless risk factors
present) Cystitis Pyelonephritis
If risk factors present :
Pregancy Pyelonephritis Cystitis
Renal Transpant
prostatitis
(< 1month)
Endourological procedures
Treat as per guidance given for approach to

Genitourinary tract infections
Fig 9: Classification of UTI Syndromes
PERITONEAL DIALYSIS RELATED PERITONITIS:

Peritoneal dialysis related peritonitis is suspected when
1. clinical features consistent with peritonitis, that is, abdominal pain and/or cloudy
dialysis effluent
2. dialysis effluent white cell count > 100/μL or > 0.1 x 109/L (after a dwell time of at
least 2 h), with > 50% polymorphonuclear leukocytes (PMN)
3. positive dialysis effluent culture
Catheter-related peritonitis is defined as peritonitis that occurs in temporal conjunction (within
3 months) with a catheter infection (either exit-site or tunnel) with the same organism at the
exit-site or from a tunnel collection and in the effluent or one site sterile in the context of
antibiotic exposure.
Microbiological sample collection:
• It is recommended to send the entire effluent bag to the microbiology laboratory for
analysis.
22
G. SURGICAL SITE INFECTION (SSI):

Any surgical wound with local signs and symptoms of infection, for example, heat, redness,
pain and swelling, and (in more serious cases) with systemic signs of fever or a raised white
blood cell count. Infection in the surgical wound may prevent healing, causing the wound edges
to separate, or it may cause an abscess to form in the deeper tissues.
Criteria for defining a Surgical Site Infection
Superficial incisional SSI
Infection occurs within 30 days after the operation and infection involves only skin or
subcutaneous tissue of the incision and at least one of the following:
a. Purulent drainage, with or without laboratory confirmation, from the superficial incision.
b. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial
incision.
c At least one of the following signs or symptoms of infection: pain or tenderness, localized
swelling, redness, or heat and the superficial incision are deliberately opened by the surgeon
unless incision is culture-negative.
d. Diagnosis of superficial incisional SSI by the surgeon or attending physician.
Deep incisional SSI
Infection occurs within 30 days after the operation if no implant is left in place or within 1 year
if the implant is in place and the infection appears to be related to the operation and infection
involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the
following:
a. Purulent drainage from the deep incision but not from the organ/space component of the
surgical site.
b. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the
patient has at least one of the following signs or symptoms: fever (>38 ºC), localized pain or
tenderness unless the site is culture-negative.
c. An abscess or other evidence of infection involving the deep incision is found on direct
examination, during reoperation, or by histopathologic or radiologic examination.
d. Diagnosis of a deep incisional SSI by a surgeon or attending physician
Notes:
∙ Report infection that involves both superficial and deep incision sites as deep incisional SSI.
∙ Report an organ/space SSI that drains through the incision as a deep incisional SSI.
23
Organ/space SSI:
Organ / Space SSI is defined as Infection occurs within 30 days after the operation if no implant
is left in place or within 1 year if implant is in place and the infection appears to be related to
the operation and infection involves any part of the anatomy (e.g., organs or spaces), other than
the incision, which was opened or manipulated during an operation and at least one of the
following:
a. Purulent drainage from a drain that is placed through a stab wound into the organ/space.
b. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space.
c. An abscess or other evidence of infection involving the organ/space that is found on direct
examination, during reoperation, or by histopathologic or radiologic examination.
d. Diagnosis of an organ/space SSI by a surgeon or attending physician.
Do not report the following conditions as SSI

i. Stitch abscess (minimal inflammation and discharge confined to the points of suture
penetration).
ii. Infection of an episiotomy or newborn circumcision site.
iii. Infected burn wound.
iv. SSI that extends into the fascial and muscle layers.
Common pathogens
a. Staphylococcus aureus
b. E. coli
c. Pseudomonas aeruginosa
d. Klebsiella pneumonia
e. Proteus sp.
f. Coagulase negative Staphylococcus
g. Enterococcus sp.
24
Table 7: Surgical Wound Classification

SURGICAL
WOUND
DEFINITION Likely organism
CLASSIFIC
ATION
An incision in which no inflammation is
encountered in a surgical procedure,
Class 1/
without a break in sterile technique, and
Staphylococcusaureus, CONS
during which the respiratory, alimentary
Clean
or genitourinary tracts are not entered.
Class II/ An operative wound in which the

respiratory, alimentary, genital or urinary
Clean- tracts are entered under controlled Staphylococcus aureus, CONS,
Contaminate conditions and without unusual Anaerobes, gram-ve bacilli
d contamination.
An incision undertaken during an
operation in which there is a major break
in sterile technique (eg: open cardiac
ClassIII/ massage) or gross spillage from the
Contaminate gastrointestinal tract, or an incision in Gram negative bacilli, anaerobes,
d which acute, non-purulent inflammation Staphylococcus aureus, CONS
is encountered. Open traumatic wounds
that are more than 12 to 24 hours old also
fall into this category.
Class IV/ Antibiotics are not

“prophylactic” here. Choice of
Old traumatic wounds with retained
Dirty- antibiotics will depend on
devitalized tissue and those that involve
Infected whether organ dysfunction is
existing clinical infection or perforated
present or not. Specimens for
viscera. This definition suggests that the
culture and sensitivity should be
organisms causing postoperative
taken at operation. If organ
infection were present in the operative
dysfunction is present broad-
field before the operation.
spectrum antibiotics will be
chosen initially and de-escalate
once culture / sensitivity results
are available.
25
SYNDROMIC APPROACH FOR

EMPIRICAL THERAPY OF COMMON
INFECTIONS
26
A. MANAGEMENT OF ACUTE UNDIFFERENTIATED FEVER
➢ For severely ill patients with non-malarial, non-arboviral AUF use a

combination (3rd generation cephalosporin + doxycycline) as empirical therapy
to cover rickettsioses, leptospirosis, and enteric fever.
Indication Likely Empiric agents Alternative agents Comments

causative (presumptive agents)
organisms
Inj Ceftriaxone 1 g IV Tab Treatment
q12h Cotrimoxazole* duration 10-14
(160:800 mg) DS days.
OR q12h * Consider
adding Tab
Inj Ciprofloxacin 750 OR Cotrimoxazole
S Typhi mg IV q12h OR
Typhoid
S.Paratyphi Tab Cefixime 10 Tab
fever
A mg/kg q12h (upto Azithromycin
max 400mg) if not
responding to
OR Inj Ceftriaxone
Tab Azithromycin* in proven
500 mg q24h infection of
Typhoid
Tab Azithromycin Treatment
Inj Doxycycline 100 500 mg q24h duration- 7
mg IV q12h days
Orientia
Rickettsial OR
tsutsugamus
infections
hi
Tab
Clarithromycin
500 mg q12h
Inj Doxycycline 100 Treatment
mg IV q12h duration-7-21
Leptospiro Leptospira Tab Azithromycin
OR days
sis sp 500 mg q24h
Inj Ceftriaxone 1g IV
q12h
*-Influenza
Cap Oseltamivir* 75 mg (suspected or
Influenza A PO q12h for 5 days confirmed)
Influenza and B who require
viruses hospitalization
or patients at
high risk of
complications
Brucella Uncomplicated
Cap Doxycycline
Brucellosis abortus brucellosis:
100 mg PO q12h
+
B.melitensis
27
Cap Doxycycline 100 Cap Rifampicin

mg PO q12h for 6 600 mg PO q24h
weeks for
+ 6 weeks
Inj Gentamicin 5 mg/kg
IV q24h for1 week
ORAL
{Tab Artesunate 4
mg/kg PO for 3 days Patient weight ≥
+ 35kg:
Tab Sulfadoxine 25
Treatment
mg/kg PO on Day 1 {Tab Artemether
duration- 14
+ 80 mg PO q12h for
days
Tab Pyrimethamine 3 days
1.25 mg/kg PO Day 1 +
Switch over to
Falciparu + Tab Lumefantrine
P. falciparum oral therapy as
m malaria Tab Primaquine 0.75 480 mg PO q12h
soon as
mg/kg PO single dose} for 3 days
possible.
+
PARENTERAL Tab Primaquine
{Inj Artesunate 2.4 mg 0.75 mg/kg PO
/kg IV at 0h, 12h f/b single dose}
q24h for 3 days
+
Tab Primaquine 0.75
mg/kg PO single dose}
{Tab Chloroquine
10 mg/kg PO on Day
1& 2 f/b 5 mg/kg on
Day 3
+
Tab Primaquine 0.25
mg/kg PO q24h for 14
{Tab Artemether +
days}
Tab Lumefantrine
(80+480 mg) q12h
If Chloroquine Treatment
for 3 days
Resistant: duration- 14
Vivax
P. vivax {Tab Artesunate 4 days
malaria +
mg/kg PO for 3 days
+
Tab Primaquine
Tab Sulfadoxine 25
0.25 mg/kg daily
mg/kg PO on day 1
for 14 days}
+
Tab Pyrimethamine
1.25 mg/kg PO on day
1
+
Tab Primaquine 0.25
mg/kg PO q24h for 14
days}
28
B. MANAGEMENT OF SUSPECTED SEPSIS SYNDROMES

PREFFERED ALTERNATIVE Comments
AGENTS AGENTS
*
Inj Meropenem 1-2 g In case of ß -lactam allergy Send appropriate culture
IV q8h consider starting before starting empirical
+/- combination of antimicrobials.
Patient with Inj Doxycycline 100 {Inj Levofloxacin# 500 mg
Severe sepsis mg IV q12h (if IV q12h $- consider adding
(Focus Rickettsia/brucella/Lep OR MRSA cover, if
unclear) tospira suspected) Inj Amikacin 15 mg/kg IV severe skin and soft
+/- q24 h} tissue infections, severe
$
(except in Inj Vancomycin + pneumonia, prosthetic
Dengue LD 20 - 35 mg/kg IV material / recent central
Septic f/b MD 15 mg/kg IV Inj Metronidazole 500 mg line placement.
Shock) q12h IV q8h
+/- +/- *- For CNS infection
If risk factors for If MRSA is suspected add give Meropenem 2g IV
invasive candidiasis are Inj Vancomycin and q8h.
present, consider if risk factors for invasive
Inj Caspofungin 70 mg candidiasis are present, #- In patients with CKD
LD f/b MD 50 mg add Caspofungin/ and severe AKI and CNS
q24h/ Micafungin 100 Micafungin/ infections choose
mg q24h / Anidulafungin Levofloxacin
Anidulafungin 200mg
LD, MD: 100mg Q24h Modify antimicrobial
{Inj Meropenem 2 g IV {Inj Levofloxacin 500 mg regimen in 48-72 hours
q8h IV q12h based on the results of
+ + culture & susceptibility
Inj Amikacin 15 mg/kg Inj Amikacin 15 mg/kg IV reports, the site of
IV q24 h} q24 h infection and the clinical
+/- + status of the patient
• Add Inj Inj Metronidazole 500 mg
Clindamycin 800 IV q8h}
mg IV Q 6-8h if +/-
Septic shock toxic shock is • Add Clindamycin
suspected when toxic shock is
• Inj Vancomycin LD suspected
20-35mg/kg IV, • Vancomycin if MRSA$
MD: 15mg/kg q12h is likely
$
if MRSA is likely • Echinocandins if risk
• Echinocandins if factors for invasive
risk factors for candidiasis are present
invasive candidiasis
are present
➢ If Septic shock is due to carbapenem resistant organism:
➢ Suspect CRO if
o h/o treatment with Carbapenems in the previous 90 days,
o h/o previous CRO infection in the past 6 months
29
o Hospital acquired infection

➢ As polymyxin B achieves reliable concentration and is less nephrotoxic ,prefer
polymyxin B over colistin for all infections expect for cystitis and urinary tract
infections
➢ In septic shock due to cystitis and urinary tract infections, prefer colistin over
polymyxin B
PREFFERED ALTERNATIVE Comments

AGENTS AGENTS
{Inj Polymyxin* B LD {Inj Colistin LD - # In patients with
25000 units/kg IV f/b 9 MU IV f/b MD CKD and severe AKI
MD 15000 units/kg q12h 3 MU q8h and CNS infections
(single dose not to + choose Levofloxacin
exceed 20,00,000 units) Inj Levofloxacin instead of amikacin.
+ 500-750 mg IV
Inj Amikacin# 20 mg/kg q24h} For Intra-abdominal
IV q24 h} +/- infections, Tigecycline
+/- • Add can be chosen instead
If toxic shock is Clindamycin of amikacin
Suspected suspected - Inj when toxic
septic shock Clindamycin 600-900 mg shock is If CNS infection is
due to IV q8h suspected suspected Consider
Carbapenem +/- • Vancomycin starting Intrathecal/
resistant If MRSA is likely- Inj if MRSA is Intraventricular
organism Vancomycin LD 20 – 35 likely antibiotics if patient not
(CRO) mg/kg f/b MD 15 mg/kg • Echinocandins responding with IV
q12h if risk factors antibiotics (Dosage
+/- for invasive given in management
Inj candidiasis are of CNS infections)
Caspofungin 70 mg LD present
f/b MD 50 mg IV q24h/
/inj Micafungin 100mg
IV q24h/
Inj Anidulafungin 200mg
LD f/b MD 100mg IV
q24h
(If risk factors for
invasive candidiasis are
present)
• Adequate source control should be done.

• Review after culture report or 48 -72 hours (after starting empiric antimicrobial
therapy) for appropriateness of therapy.
• Discontinue antimicrobial if non-infectious source is confirmed
• De-escalate the antibiotic- from broad spectrum to narrow spectrum as appropriate
depending on culture& sensitivity report
• Duration of antimicrobial treatment recommended for 10-14 days or till clinical cure.
30
C. MANAGEMENT OF CENTRAL NERVOUS SYSTEM INFECTIONS
Condition Likely Empiric AlAlternative Comments

Causative Antibiotics antibiotics
Organisms (presumptive
antibiotics)
Community S.pneumoniae Inj Ceftriaxone 2 g Inj Cefotaxime 2 Antibiotics should be
acquired H.influenzae
Acute bacterial Neisseria IV q12h g IV q6h started as soon as the
Meningitis meningitides possibility of bacterial
If Listeria is meningitis becomes
suspected evident, ideally within
If Age >50 years 30 minutes.
Suspect Listeria Add Inj Ampicillin In ß-lactam
2 g IV q4h allergy Rule out Tubercular
Tab Co- meningitis
trimoxazole DS
960 mg q12h Do not wait for CT
scan or LP results.
No need to add
Vancomycin as
primary agent, since
Ceftriaxone resistant
Pneumococcus is not
common in India.
L
Infant <1 month Gram negative( {Inj Meropenem 40 {Inj Cefotaxime
Klebsiella, E coli, mg/kg IV q8h 50 mg/kg q6h
 Acute
Pseudomonas,
bacterial + +
Acinetobacter),
meningitis
(Community Staphylococcus, Inj Vancomycin 15 Inj Gentamicin
acquired) Enterococcus, mg/kg IV q6h} 2.5 mg/kg q8h}
 Post surgical Pneumococcus,
brain abscess Candida
Acute Febrile Leptospira, Inj Ceftriaxone 2 g Inj Cefotaxime 2

Encephalopathy Enteric fever, IV q12h g q6h
Rickettsia, + +
Cerebral malaria
Inj Artesunate 2.4 Inj Artesunate 2.4
Sporadic viral mg/kg IV 0,12 and mg/kg IV 0,12
encephalopathy 24 hours f/b MD and 24 hours f/b
and Gram q24h MD q24h
negative bacilli + +
encephalopathy
Inj Doxycycline Inj Doxycyline
100 mg IV q12h 100 mg IV q12h
+ +
31
Inj Acyclovir 10 Inj Acyclovir 10

mg/kg IV q8h (if mg/kg IV q8h (if
viral encephalitis viral encephalitis
suspected) suspected)
Meningitis Post- Staph.epidermidis {Inj Meropenem 2 In ß-lactam May need

neurosurgery Staph.aureus, g IV q8h allergy Intraventricular
therapy in severe cases
or
shunt infections Propionibacteriu + Inj Levofloxacin
or m acnes, 750 mg IV q24h Before starting
Inj Vancomycin
Penetrating head Pseudomonas Levofloxacin/
LD 20-30 mg/kg IV +
trauma aeruginosa, f/b MD 15 mg/kg Linezolid
Klebsiella q12h} In Vancomycin investigation for TB
pneumoniae allergy needs to be sent.
Acinetobacter
baumanii Inj Linezolid 600 Consider adding
mg IV q12 h Voriconazole- if no
response after 72 hrs
of appropriate
antibiotic therapy and
h/o of antibiotic intake
for past 7-10 days
Meningitis withS S.pneumoniae, Inj Ceftriaxone 2 Inj Co- Dexamethasone 0.15

basilar skull H.influenzae gm IV q12h for 14 trimoxazole 960 mg/kg IV q6h for 2-4
days (before first
fractures days mg q12h antibiotic dose).
Consider TB,
Brain abscess, Streptococci, {Inj Ceftriaxone 2 Inj Meropenem 2 Nocardia, Aspergillus,
Bacteroides gm IV q12h gm IV q8h and Mucormycosis as
OR differentials
Subdural Enterobacteriaceae Inj Cefotaxime 2 In ß-lactam
empyema gm IV q6-8h} allergy If abscess < 2.5cm and
S.aureus + patient neurologically
\ Inj Metronidazole 1 InjLevofloxacin stable, await response
gm IV q12h 750mg IV q24h to antibiotics.
Duration of Otherwise, consider
treatment to be aspiration/surgical
drainage and modify
decided by clinical antibiotics as per
& radiological sensitivity of aspirated
response, minimum /drained secretions.
two months
required.
32
Intraventricular dose of antimicrobials
Drug Intraventricular dose

Vancomycin 5-20 mg (adjust as per table below)
Teicoplanin 5-40 mg q24h
Amikacin 5-50 mg q24h
Gentamicin 1-8 mg (adjust as per table below)
Colistin (colistemethate sodium) 10-20 mg q24h
Polymyxin B 50,000 units q24h
Tobramycin 5-20 mg q24h
Daptomycin 2-5 mg q24h
Amphotericin B deoxycholate 0.01–0.5 mg in 2 mL of 5% dextrose
in water q24h *
*- only if patients do not respond to systemic antifungal therapy
Dose and frequency based on ventricular size and external ventricular drain output
Vancomycin dose Gentamicin dose

Ventricular size
Slit ventricles 5 mg 2 mg
Normal Size 10 mg 3 mg
Enlarged ventricles 15-20 mg 4-5 mg
Based on External ventricular drain output
< 50 mL/24h Every 3rd day Every 3rd day
50-100 mL/24h Every 2nd day Every 2nd day
100-150 mL/24h Once daily Once daily
150–200 mL/24h Once daily and increase Once daily and increase
dose by 5mg dose by 5mg
33
D. MANAGEMENT OF CARDIOVASCULAR INFECTIONS

Antimicrobial therapy for Infective Endocarditis: Treatment of IE should be started
promptly only in patients who are in frank sepsis or who are hemodynamically unstable.
Indication Likely Empiric agents Alternative agents Comments

causative
Organism
Infective Viridians Inj Ampicillin- Inj Vancomycin 15 If patient is stable,
Endocarditis Streptococ Sulbactam 3g IV mg/kg IV q12h ideally wait for blood
Native valve ci, q6h (Ampicillin- (maximum 1g q12h) cultures.
(Awaiting other 150 mg/kg/day, OR
cultures) Streptococ Sulbactam 50 {Inj Teicoplanin 12 Gentamicin used for
ci, mg/kg/day) in 4 mg/kg IV q12h for 3 synergy, peak levels
Indolent Enterococc divided doses doses f/b 6-12 mg IV need not exceed 4
i, OR q24h depending upon mcg/mL.
Enterococcal VGS, Inj Ampicillin 2 g severity
IE common NVS, IV q4h or 200 + Advantage of
in elderly Streptococ mg/kg/day in 6 Inj Gentamicin 3 Ampicillin/sulbactam
patients, cus divided doses mg/kg IM/ IV q24h} (AS) over crystalline
patients with gallolyticu OR penicillin (CP)
CLD or in s Inj Penicillin G Duration: 4-6 weeks /Ampicillin:
patients with 20 MU IV in 4 AS Covers β-lactamase
UTI. divided doses OR producing Enterococci
OR Inj Daptomycin 6 &HACEK Group of
{Inj Ceftriaxone 2 mg/kg IV q24h Organisms.
g IV q24h
+ Duration: 4-6 weeks
Inj Gentamicin 3
mg/kg IV q24h}
Duration: 4-6
weeks
Infective S. aureus Inj Vancomycin {Inj Daptomycin 6 Recommended
Endocarditis: (MSSA or 25 mg/kg IV LD mg/kg IV q24h for Vancomycin trough
Native valve MRSA) f/b 30 mg/kg IV Right-sided IE or 8-10 levels in serious MRSA
(Awaiting Risk for in 2-3 equally mg/kg IV q24h for infections- 15-20
cultures) gram divided doses left- sided IE μg/mL.
negative OR +
In Severe bacilli {Inj Teicoplanin Inj Meropenem 1gm Nephrotoxicity (0-12%)
Sepsis 12 mg/kg IV q12h IV q8h} is associated with
for 3 doses f/b 6- Vancomycin trough
12 mg/kg IV q24h Duration:4-6wks levels greater than or
depending upon equal to 15 μg/mL, in
severity those receiving high
+ dose Vancomycin
Inj Meropenem 1 (greater or equal to 4
gm IV q8h} g/day) and concomitant
use of nephrotoxic
34
Duration:4-6wks agents, and long

duration of vancomycin
MSSA: Inj therapy
Flucloxacillin
200-300
mg/kg/day IV in
4-6 equally
divided doses
OR
Inj Cefazolin 60
mg/kg/day IV in 3
divided doses.
Infective {Inj Ceftriaxone 2 In patients Use lower dose of
Endocarditis: g IV q24h in 2 unresponsive to or rifampicin in severe
divided doses intolerant of renal impairment.
Prosthetic + Vancomycin /
Valve Inj Vancomycin Teicoplanin or with Start Rifampicin 3-5
awaiting 25 mg/kg IV LD Vancomycin / days after Vancomycin
Cultures f/b MD 30-60 Glycopeptide resistant and Gentamicin
mg/kg IV q24h isolates, consider -
+ Request
Inj Gentamicin 3 Inj Daptomycin 12 Vancomycin MIC;
mg/kg IV q24h mg/kg IV q12h for 3 If Vancomycin MIC >1
+ doses f/b 6-12 mg/kg μg/mL consider use of
Cap/Inj IV q24h depending alternative agent
Rifampicin 300- upon severity.
600 mg PO/IV . Duration: 2 weeks
q12h} Parenteral and 6 weeks
Oral therapy
35
DEFINITIVE ANTIMICROBIAL TREATMENT FOR INFECTIVE ENDOCARDITIS
Etiologies Definitive Regimens Alternative antibiotics Duration of therapy

Highly Inj Aqueous Crystalline Inj Ampicillin 200
Penicillin penicillin G (CP) mg/kg/day IV in six 4 weeks
Susceptible Sodium 20-40 lac divided doses (Max dose: 2
VGS Units/kg/day IV q4h or g IV q4h)
and S 12–18 million Units IV OR
gallolyticus q24h in 4-6 divided Inj Ceftriaxone 50-100 mg
(bovis) (MIC ≤ doses or continuously if (60 mg/kg/day) IV in 2
0.12 μg/mL) possible divided doses (Max dose: 2
g IV q24h)
Add Gentamicin 5-7

Relatively Add Inj Gentamicin 5-7 mg/kg/day IV β-lactam with
resistant VGS mg/kg/day IV gentamicin for 2
(MIC > 0.12 - weeks
0.5 μg/mL)
VGS isolates
with a penicillin Add Inj Gentamicin 5-7
MIC ≥ 0.5 Add InjGentamicin 5- mg/kg/day IV β-lactam with
μg/mL & 7mg/kg/day IV Gentamicin for 6
Abiotrophia and weeks
Granulicatella
spp.
(nutritionally
variant
Streptococci)
Native valve Inj Cloxacillin 12 Inj Flucloxacillin 200-300 Gentamicin - 2 weeks
MSSA IE gm/day IV in 3 divided mg/kg/day IV in 4-6 Cloxacillin,
doses equally divided doses Flucloxacillin and
OR Rifampicin - 6 weeks
Inj Cefazolin 30-100 mg
(60 mg/kg/day) IV in 3
divided doses
Prosthetic Add Inj Rifampicin max Add Inj Rifampicin 15 Start Rifampicin 3-5
valve dose 900 mg IV mg/kg/day IV in 3 divided days after Cloxacillin
MSSA IE + doses (Max dose 900 mg) & Gentamicin
Inj Gentamicin 1mg/kg +
IV q8h Inj Gentamicin 1 mg/kg IV
q8h
Native valve Inj Vancomycin 25 Inj Daptomycin Gentamicin-2weeks
MRSA IE mg/kg IV f/b MD 30 Right-sided IE: 6 mg/kg/ Vancomycin,
mg/kg IV in 2-3 equally dose IV Daptomycin and
divided doses Rifampicin - 6 weeks
Left-sided IE/complicated
IE: 8-10 mg/kg/dose IV
36
Prosthetic {Inj Vancomycin15-30 {Inj Vancomycin 15-30 Start Rifampicin 3-5

valve mg/kg IV q12h mg/kg IV q12h days after
MRSA IE + + Vancomycin and
Inj Rifampicin IV 900 Inj Rifampicin 15 Gentamicin
mg in 3 divided doses mg/kg/day IV in 3 divided
+ doses Vancomycin
Inj Gentamicin 1mg/kg + alternative-
IV q8h} Inj Gentamicin 1mg/kg IV Teicoplanin (12mg/kg
q8h} q12h for 3 days, f/b 12
mg/kg/day)
Native valve Inj Vancomycin 30 Gentamicin-2 weeks
MR CoNS IE mg/kg/day IV in 2 Vancomycin-6 weeks
divided doses
Prosthetic Add Inj Rifampicin IV

valve 900 mg in 3 divided
MR CoNS IE doses
+
Inj Gentamicin 1 mg/kg
IV q8h
Ampicillin {Inj Ampicillin 200 Recommended for patients 4-weeks: Native valve
Sensitive (MIC mg/kg/day IV in 6 with Creatinine Clearance patients with
≤4 mg/L) and divided doses (Max >50 mL/min. symptoms of illness
non-HLAR dose: 2 g IV q4h) <3 months
(MIC ≤128 + 6-weeks: Symptoms
mg/L) Inj Gentamicin 5-7 >3 months for native
Enterococcus mg/kg IV/IM in 3 valve and for patients
equally divided doses} with prosthetic valve
or material
Ampicillin {Inj Ampicillin- 4-6 weeks
Resistant (β Sulbactam (Ampicillin-
lactamase 150 mg/kg/day and
producing) and Sulbactam 50
non-HLAR mg/kg/day) IV in 4
Enterococcus divided doses
+
InjGentamicin 5-7
mg/kg IV/IM in 3
equally divided doses}
Ampicillin {Inj Ampicillin- 6 weeks
Resistant (β- Sulbactam (Ampicillin-
lactamase 150 mg/kg/day with
producing) and Sulbactam 50
HLAR/Risk of mg/kg/day) IV in 4
nephrotoxicity divided doses
Enterococcus +
Inj Ceftriaxone 2 g IV
q12h}
37
Ampicillin Inj Vancomycin 30 Inj Daptomycin 8-10 6 weeks

Resistant mg/kg IV in 2 equally mg/kg/day IV High risk of
(aPBP) and divided doses nephrotoxicity
HLAR +
Inj Gentamicin 5-7
mg/kg IV/IM q24h
HACEK Inj Ceftriaxone 2 g IV Inj Ampicillin 2 g IVq4h NVE should receive 4
q24h weeks and PVE 6
week of treatment
For patients with beta lactam allergy use Inj Vancomycin 15-30 mg/kg IV q12h
NVE- Native Valve Endocarditis : PVE- Prosthetic Valve Endocarditis. HLAR- High level
aminoglycoside resistant Enterococci
Antibiotic prophylaxis for IE prior to invasive procedures:

The following antibiotic regime is recommended for standard prophylaxis:
Tab/Inj Amoxicillin or Ampicillin 50 mg/kg PO/IV (2 g orally) 1 hr before procedure OR Inj
Cefuroxime 1.5 g IV/IM 30-60 min before the procedure
For patients allergic to penicillin: Tab Clindamycin 600 mg (20 mg/kg) PO 1 hr before or IV
just before (dental and respiratory) procedure
POST-CARDIOVASCULAR SURGERY INFECTIONS
Empirical Treatment after appropriate specimen for stain & cultures have been
collected
Antibiotic Prophylaxis Comments

Surgery 1st line 2nd line Special
Antibiotic/
Combination
Pneumonia Inj Carbapenems:
and Piperacillin-
UTI tazobactam
4.5 g IV Inj De-escalation as
q6h Meropenem/ per the isolate,
OR Imipenem 1 g susceptibility,
Inj IV q8h MICs, adverse
Cefoperazo +/- effects, drug
ne- Inj Amikacin allergy
Sulbactam 3 15 mg/kg/day
g IV q12h IV
+/-
Inj
Amikacin
15
mg/kg/day
IV
38
Sternotomy Add Add Removal of the

site infection Vancomycin Daptomycin/ foreign body (steel
/Teicoplanin Linezolid wires) should be
considered
Infection of Add Empirical anti-
vascular Vancomycin MRSA drug if
catheters /Teicoplanin incidence of
MRSA CRBSI
is high
Mediastinitis Add Carbapenem
Vancomycin with or without
/Teicoplanin amikacin
Definitive Treatment after appropriate specimen for stain & cultures have been
collected
Likely Antibiotic Prophylaxis Comments
Infection/ Causative
syndrome organism
1st line 2nd line Special
Antibiotic/Com
bination
Coagulase Vancomycin, Daptomycin De-escalation to Consider
Negative Teicoplanin Linezolid Cotrimoxazole MICs, risk of
Staphylococ or Cloxacillin or nephrotoxicit
ci, MRSA, Cefazolin y, bone
Enterococc (CoNS)/ penetration
us doxy/ for choosing
Sternotom minocycline the antibiotic
y site (MRSA)
infection Ampicillin/
Ampi-sulbactam
(Enterococcus)
Removal of
the Foreign
GNB Inj Inj De-escalation body (steel
(Enterobact Piperacillin- Meropenem to oral agent if wires)
eriacae, tazobactam / Imipenem possible after 2- should be
Pseudomon 4.5 g IV q6h 1 g IV q8h 6 weeks of considered
as, OR antibiotic
Acinetobact Inj therapy
er) Cefoperazon-
sulbactam 3 g
IV q12h
+/-
Inj Amikacin
15 mg/kg/day
IV
39
Candida Inj
Liposomal- De-escalation to For Candida
Amphotericin Tab Fluconazole osteomyelitis
B 3-5 800 mg PO LD , 12 months
mg/kg/day IV f/b MD 200 mg treatment is
OR q12h recommende
Inj d
Amphotericin
B-
deoxycholate
0.5-1.5
mg/kg/day in
5% Dextrose
over
24 hours
for 3 weeks
40
E. RECOMMENDATIONS FOR USE OF ANTIMICROBIALS IN

GASTROINTESTINAL AND INTRAABDOMINAL INFECTIONS
Likely
Recommended Alternative
Indication Causative Comments
Agents Agents
Organisms
Viral,
Entero toxigenic
Acute
and Entero Rehydration and
Gastroenterit
pathogenic Symptomatic
is Prebiotics and
E.coli treatment
probiotics for post-
Salmonellasp Antimicrobials -
antiobtic associated
indicated for
illness
conditions listed
Food
S.aureus below
poisoning
B.cereus
C.botulinum
Azithromycin 1g Doxycycline is
Doxycycline
Acute watery P.O× 1 Dose NOT recommended
300 mg P.O ×1
Diarrhoea, Vibrio cholera Or in children and
dose
Cholera Ciprofloxacin pregnant women
suspected 500mg PO q12h x Prompt rehydration
3 Days is essential
Ceftriaxone 2g Ciprofloxacin 500
Shigella sp IV as single mg bd for 3days
dose Or
Bacillary Azithromycin 500
Dysentery mg OD for 3days
Azithromycin
Campylobacter 500 mg for -
3days
Outpatients: Empiric therapy
Azithromycin NOT
500 mg OD for recommended
7 days(for MDR
& Cipro Antibiotic
Salmonella typhi
resistant Cefixime 20 treatment should be
isolates) mg/kg/day for 14 based on culture
Enteric fever Salmonella
Or days and susceptibility
paratyphi A
Co-trimoxazole
960 mg BD ×14
days (if
susceptible)
Inpatients:
41
Ceftriaxone 2 g
IV OD for 14
days
Azithromycin 1g Doxycycline is
Doxycycline
Acute watery P.O× 1 Dose NOT recommended
300 mg P.O ×1
Diarrhoea, Vibrio cholera Or in children and
dose
Cholera Ciprofloxacin pregnant women
suspected 500mg PO q12h x Prompt rehydration
3 Days is essential
Ceftriaxone 2g Ciprofloxacin 500
Shigella sp IV as single mg bd for 3days
dose Or
Bacillary Azithromycin 500
Dysentery mg OD for 3days
Azithromycin
Campylobacter 500 mg for -
3days
Outpatients: Empiric therapy
Azithromycin NOT
500 mg OD for recommended
7 days(for MDR
& Cipro Antibiotic
resistant treatment should be
isolates) based on culture
Salmonella typhi
Or Cefixime 20 and susceptibility
Co-trimoxazole mg/kg/day for 14
Enteric fever Salmonella
960 mg BD ×14 days
paratyphi A
days (if
susceptible)
Inpatients:
Ceftriaxone 2 g
IV OD for 14
days
Metronidazole
Amoebiasis Entamoeba Tinidazole 2 g PO
500 mg t.i.d for
histolytica OD for 3 days
5 days
Metronidazole
Giardiasis Giardia lamblia Tinidazole 2 g PO
250 mg t.i.d for
one dose
5 days
Severe disease: Avoid antimotility
Metronidazole
Vancomycin 125 drugs and stop
Hospital 400 mg P.O TID
Clostridiumdiffic to 250 mg P.O QID proton-pump
acquired ×10 days
le +/- Metronidazole inhibitors
diarrheoa
500 mg IV tid ×10
days
42
Mild to High Severity: Biliary drainage in

Enterobacteriace moderate Inj Meropenem 1 g case of
ae (E.coli, severity: IV.Q8H for 7-10 ESBLE.coli, /
Klebsiella sp) InjCefoperazone days Klebsiella
Cholangitis
Anaerobes – Sulbactam 3 g bacteremia,
IVQ12H for 7- piperacillintazobact
Acute
10 days am is not a
cholecystitis
OR suitable choice.
InjPiperacillinTa
zobactam 4.5g
IV.Q6H for 7-10
days
Enterobacteriace InjCefoperazone Inj Meropenem 1 g Image-guided
ae, Enterococcus – Sulbactam 3 g IV.Q8H aspiration for gram
Acute
sp., S.aureus, IVQ12H stain and culture to
necrotising
CoNS, OR guide choice of
pancreatitis
Anaerobes InjPiperacillinTa antibiotic
zobactam 4.5g
IV.Q6H
Acute Source control if
InjCefoperazone InjPiperacillinTazo
Appendicitis Enterobacteriace possible
– Sulbactam 3 g bactam 4.5g
ae,
IVQ12H IV.Q6H
Mesenteric Anaerobes
ischaemia
Enterobacteriace Mild: Mild: Duration of
ae, Amoxycillin- Ciprofloxacin 500 treatment based on
Anaerobes Clavulanate 652 mg BD + improvement (7-14
mg TID for 7 Metronidazole 400 days)
days mg TID for 7 days
Moderate: Moderate:
Diverticulitis Inj Ceftriaxone InjCefoperazone –
2 g IV OD + Inj Sulbactam 3 g
Metronidazole IVQ12H
500 mg IV TID OR
Inj Piperacillin -
Severe: Tazobactam 4.5g
Inj Meropenem IV.Q6H
1 g IV.Q8H
Add diloxanide
furoate 500mg q 8h
Inj Piperacillin- for 7-10 days to
InjCefoperazone Tazobactam 4.5g Metronidazole 500
E.coli, – Sulbactam 3 g IV.Q6H mg IV /800mg PO
Liver abscess
Klebsiella, IV Q12H TID for Amoebic
Anaerobes, ±Inj Metronidazole liver abscess
Streptococcus 500 mg IV Q8H
gp, Ultrasound guided
drainage indicated
Polymicrobial in large abscesses,
43
signs of imminent
rupture and no
response to medical
treatment
Enterobacteriace InjCefoperazone Emergency
ae, – Sulbactam 3 g drainage,
Intra- Inj Tigecycline 100
Anaerobes IV Q12H duration of
abdominal mg stat f/b 50 mg
treatment 5 days –
abscess IV BD
if adequate source
control is achieved
Enterobacteriace InjCefoperazone Source control is

ae, – Sulbactam 3 g important to reduce
Spontaneous Anaerobes IV Q12H bacterial load
Bacterial (Bacteroides- OR
Peritonitis colonic Inj Piperacillin- Inj Meropenem 1 g
perforation), Tazobactam IV.Q8H
Hollow 4.5g IV.Q6H
viscous
perforation ±Inj
Metronidazole
500 mg IV Q8H
44
F. Respiratory tract infections
Indication Likely Empiric Antimicrobial Alternative Comments

causativ agents antimicrobial agents
e
organis
m
Mild : (CURB-65 <2) Tab Azithromycin @-
Cap Amoxycillin Macrolide
500mg PO q24h
Clavulanic 625mg PO should be
(OR)
q8h administered first
Tab Doxycycline
followed by beta-
100mg PO q12h
lactam
Moderate: (CURB-65- {Tab Azithromycin * If pseudomonas
2/3)@# 500mg PO q24h (OR) is suspected start
{Tab Azithromycin Tab Doxycycline inj Piperacillin+
Streptoc 500mg PO q24h (OR) 100mg PO q12h} Tazobactam
Communit occus Tab Doxycycline +
y Acquired pneumon 100mg PO q12h} {Inj Piperacillin+ #- Consider
Pneumonia iae, + Tazobactam 4.5g IV adding Inj
(CAP) Haemop {Inj Amoxycillin q6-8h (OR) Inj Vancomycin 1g
hilus Clavulanic acid* 1.2g Ceftriaxone*1g IV IV q12h there are
influenza IV q8h} q12h} risk factors for
e MRSA
Severe (CURB-65
≥4)@: Tab Azithromycin $ start inj
Azithromycin 500mg 500mg IV/PO q24h Meropenem if
IV/PO q24h + there is previous
+ Inj Ceftriaxone + history of
Inj Piperacillin+ Sulbactam $ 1.5g IV antibiotic use or
Tazobactam$ 4.5g IV q12h hospitalization in
q6-8h the last 90days
CAP Mycopla Tab Doxycycline # If secondary

Atypical sma, 100mg PO q12h bacterial infection
agents Chlamyd + is suspected then
ia, Tab Azithromycin choose antibiotic
Legionel 500mg PO q24h prophylaxis from
la, Moderate
respirato (CURB-65- 2/3)
ry - Consider
viruses adding
Oseltamivir if
there is
influenza
outbreak.
45
Oseltamivir* 75 mg PO *-Influenza
BID×5 DAYS (suspected or
confirmed) who
Influenza require
Influenza A and B hospitalization or
viruses patients at high
risk of
complications
S. Inj Cefoperazone + In case of b-lactam #- prefer

penumon Sulbactam 3g IV q12h allergy consider carbapenem if
ae, OR Inj Amikacin 15- patient is in septic
Hospital
P. 20mg/Kg IV q24h shock.
Acquired
aerugino Inj Meropenem# 1g IV OR
Pneumonia
sa, q8h Inj Levofloxacin* *- Rule out
(HAP)
S + 750mg IV Q24h pulmonary
Ventilator
aureus, + tuberculosis
Associated
anaerobe Inj Vancomycin LD 20- Inj Vancomycin LD before starting
Pneumonia
s, 35mg/kg f/b 15mg/kg 20-35mg/kg f/b Levofloxacin
(VAP)
A.bauma IV q12h 15mg/kg IV q12h
nii,
Enteroba
ctericeae
Inj Piperacillin+ *if MRSA : Inj
S. Tazobactam$ 4.5g IV Vancomycin
In case of b-lactam
pneumon q6-8h (OR)
Lung allergy consider
iae, E. OR Inj Linezolid
Abscess/ Inj Amikacin 15-
coli, InjCefoperazone + (In case of
Empyema 20mg/Kg IV q24h
Klebsiell Sulbactam 3g IV q12h vancomycin
OR
a sp., + allergy)
Inj Levofloxacin*
P.aerugi Inj Clindamycin*600- *- Rule out
750mg IV Q24h
nosa, 900mg q8h pulmonary
+
S.aureus, tuberculosis
Inj Clindamycin*600-
anaerobe before starting
900mg q8h
s Levofloxacin
Acute Mild: Cap Amoxicillin

COPD + Clavulanic acid Mild: Tab
S.pneum
exacerbatio 625mg PO q8h Azithromycin 500mg
oniaeH.i
n PO q24h
nfluenza
Bronchiect Mod to Severe: Inj Mod to Severe:
eM.catar
asis – acute Amoxycillin + Inj Ceftriaxone 1g IV
rhalis
exacerbatio Clavulanic acid 1.2g IV q12h
n q8h
Pneumocys Pneumoc Cotrimoxazole (p.o. or Duration: 21 days
tis ystis IV.) Dose:
pneumonia jiroveci Trimethoprim 15
46
mg/kg/day given in 3 or
4 divided doses
Melioidosis B.Pseudo Intensive phase: Intensive phase: prolonged IV

mallei ● Ceftazidime 2 g IV ● meropenem 1 g IV therapy (4-8
q6h ×14 daysfollowed q8h ×14 days weeks or
by (forpatients in ICU) longer )for
Eradication phase: ● meropenem 2 g IV Complicated
● Co-trimoxazole 2 q8h ×14 pneumonia
double-strength days(forneurological infection
tablets bd ×3 months melioidosis) including
prostatic
abscesses,
Neurological
melioidosis
Osteomyelitis
Septic
ArthritisAbscess
drainage
Acute Viral Antibiotics not required
bronchitis
Coronaviru
Refer NIMS guideline for covid-19 management
s
Respiratory infections in Immunocompromised patients:

Empiric agents Alternative agents Comments
Nocardia Tab Trimethoprim- {Inj Imipenem# #- Inj Meropenem
Pulmonary stable sulfamethoxazole- 500mg q6h may be used
(15mg/kg/day of + alternatively to
trimethoprim Inj Amikacin 10- Inj Imipenem
component- 2-4 equally 15mg/kg IVq24h} Duration: for 6-
divided doses) PO OR 12 months
Inj ceftriaxone 2g IV
OR
Inj linezolid 600mg
IV/PO q12h
Nocardia {Inj Imipenem# 500mg Inj Linezolid 600mg Duration for

Pulmonary- q6h IV/PO q12h pulmonary- 6-12
critically ill + For months.
Cerebral Inj Amikacin 10- Cerebral/disseminated For cerebral: 3
Disseminated (>1 15mg/kg IVq24h} Nocardiosis weeks of
organ ± cerebral OR Inj Linezolid parenteral f/b 12
disease) Tab Trimethoprim- OR months of oral
sulfamethoxazole- Inj Ceftriaxone 2g IV therapy.
(15mg/kg/day of q12h
47
trimethoprim OR For
component- 2-4 equally Inj Cefotaxime 2g IV disseminated:
divided doses) q6-8h 9-12 months
For critically ill
patients – triple
combination of
Imipenem+ Amikacin
+ TMP-SMX may be
considered
Respiratory Tab Ribavirin 20mg/kg q12h to be taken with Duration: 7
syncytial virus- food days.
(RSV) LRTI in Ribavirin – use
immuno- In HSCT treat if cautiously in
compromised : • pre-engraftment patients with
Hematologic • ≤ 1 month post-transplant severe baseline
malignancy • Absolute Lymphocyte Count < 0.3 anemia or where
hematopoietic • active GVHD anemia would
stem cell • on immunosuppression exacerbate an
transplant In hematologic malignancy treat if underlying
(HSCT) and lung • 3+ lines of therapy condition (e.g:
transplant • Bispecific, on treatment or within 6 unstable ischemic
months of stopping cardiac disease)
• Pancytopenia on treatment
In Lung transplant treat if LRTI is present
48
G. GENITO-URINARY TRACT INFECTIONS

• Asymptomatic bacteriuria NOT to be treated except in pregnant women and
immunocompromised patients. All cases of dysuria may not be UTI.
• Isolation of candida in urine cultures usually suggest a colonization, always rule out
obstructive uropathy with imaging if symptomatic candida urinary infection is
suspected.
• In CA-UTI, replace the catheter if in place for >7 days before initiating therapy.
Condition Likely Causative Empirical Alternative Comments
Organisms antimicrobials antimicrobial
Treatment Not Required
Asymptomatic
Bacteriuria (ASB) *Screening for and treatment of asymptomatic bacteriuria is
/ Catheter indicated:
Associated (CA) - 1.Pregnancy (Refer to Gynaecological infection management)
ASB with risk 2. Patients undergoing urological procedures in which mucosal
factors* bleeding is anticipated, Renal transplant patients(<1month)-
Treat as per acute uncomplicated cystitis
Acute E.coli, Tab Nitrofurantoin Tab Ciprofloxacin 500- Send urine
uncomplicated Staphylococcus (E.coli) 100mg PO 750mg q12h for 3- 5days cultures
Cystitis saphrophyticus(in q12h for 7 days before
(OR)
sexually active antibiotics &
(OR)
young women), Inj Amikacin 15mg/kg modify
Klebsiella Tab Cotrimoxazole IV or IM Single dose therapy
pneumoniae 960 mg q12h for 3- based on
5days culture &
sensitivity.
For E.coli:
Tab Fosfomycin 3g
single dose
Acute E.coli, Inj Piperacillin- Inj Amikacin 15mg/kg Send urine
uncomplicated Staphylococcus Tazobactam 4.5g q24h IM/ IV cultures
Pyelonephritis saphrophyticus(in IV q6h before
(OR)
sexually active you antibiotics &
(OR)
ng women), Inj Levofloxacin 750mg modify
InjCefoperazone- IV q24h therapy
Klebsiella
Sulbactam 3g IV based on
pneumoniae,
q12h culture &
Proteus mirabilis
sensitivity.
Duration: 14
days
Complicated Escherichia coli Inj Meropenem 1g Inj Amikacin 15mg/kg Send urine
Pyelonephritis Klebsiella IV q8h IV q24h cultures
pneumonia, (OR) before
49
Proteus mirabilis, (OR) antibiotics &

Pseudomonas InjCefoperazone- switch to
aeruginosa Sulbactam 3gm IV narrow
Inj Piperacillin-
q12h spectrum
Enterococcus sp. Tazobactam 4.5g IV q6h
based on
culture &
sensitivity
Tab Levofloxacin In severe cases, Get urine and
500mg q 24h Inj Piperacillin- prostatic
Acute prostatitis Enterobacteriaceae
Tazobactam 4.5 gm IVmassage
(E.coli, Klebsiella
q6h cultures &
sp.)
switch to
OR
narrow
InjCefoperazone - spectrum
sulbactam 3g IV q12h agent based
OR on
sensitivities
Inj Meropenem 1gm IV and then treat
q8h total for3-
4weeks.
Epididymo-orchitis N.Gonorrhoeae, If high risk of Tab Ofloxacin 200mg Total
C.trachomatis and sexually q12h x 14 days duration of
M.genitalium, transmitted treatment is
OR 14
Inj Ceftriaxone
Tab levofloxacin 500mg days (except
500mg IV q 12h for
q24 h x10 days
x14 days Levofloxacin
+ where it is 10
Tab Doxycycline days)
100mg q12h x14
days
If Low risk of
sexually
transmitted
Tab Ofloxacin or
Tab levofloxacin
50
H. Skin and soft tissue
Condition Likely Empirical Alternative Comments

Causative antimicrobial antimicrobial
Organisms
Cellulitis Streptococcus Tab Amoxicillin- Inj Clindamycin Treat for5-7 days.
pyogenes Clavulanate PO 600- 900mg IV
,S.aureus 625mg q 8h q8h
(OR)
Tab Cephalexin
500mg POq6h
(OR)
Inj Ceftriaxone 1g
IV q12h
S. pyogenes Inj Meropenem
Necrotizing S.aureus, Inj Piperacillin 1g IV q8h Early exploratory
Fasciitis anaerobes, Tazobactam 4.5g + surgery to
Gram IV q8h Inj Clindamycin establish
negative + Inj Clindamycin 600- 900mg IV diagnosis and
organisms 600- 900mg IV q8h resect necrotic
(polymicrobial) q8h tissue.
If MRSA is Send intra-
suspected operative
If MRSA is Add Inj specimen for
suspected Vancomycin 25 C&S.
Add Inj mg/kg loading Treat for 14 days
Vancomycin 25 dose followed if adequate source
mg/kg loading by 15mg /kg control.
dose followed by q12h Consider use of
15mg /kg q12h IVIG
for streptococcal
NF/TSS
Necrotizing Aeromonas/ Ciprofloxacin + Generally,

fasciitis V.vulnificus Doxycycline 14 days if
(suspect when adequate
history of source
exposure control
to fresh water or achieved
salt water
respectively)
Carbuncles, S. pyogenes, Tab Cloxacillin Tab Incision and
cutaneous Oral anaerobes, 500 mg p.o. q6h clindamycin drainage.
abscesses facultative gram for 7-10 days 300mg p.o q8h
negative for 7-10days If possible get pus
anaerobes C&S done
Tinea Malassezia Topical Topical duration 1-2

versicolor furfur clotrimazole 1% miconazole weeks
51
once a day 2% once a day
application application
Tinea T. rubrum Topical topical duration 2-4
Corporis clotrimazole 1% miconazole weeks
once a day 2% once a day
application application
Scabies Sarcoptesscabiei Permethrin cream Ivermectin •Wash off after 8-
5% to be applied 12mg stat 14 hours
all over the body (Treat all family •Clothing/bedding
from the neck members as should be
downwards well) washed in hot
overnight and water and dried
washed off in the before reuse
morning
Recommendations for treatment of Leprosy:
Type of Drugs Frequency of Dosage Dosage Dosage Criteria
Leprosy administration – – – for
– Adults ≥ 15 yrs Children Children Release
(Children in 10-14 <10 yrs from
bracket) yrs# treatment
PB Rifampicin Once Monthly 600 mg 450 mg 300 mg Completion
Leprosy Dapsone Once Daily 100 mg 50 mg 25 mg of 6
daily or monthly
50 mg pulses in 9
alternate consecutive
days months
MB Rifampicin Once Monthly 600 mg 450 mg 300 mg Completion
Leprosy Clofazimine Once Monthly 300 mg 150 mg 100 mg of 12
Dapsone Once Daily 100 mg 50 mg 25 mg monthly
Clofazimine Once Daily for 50 mg 50 mg 50 mg pulses in
adults (once (alternate (twice 18
every other day days) weekly) consecutive
for children) months
52
I . Bone and Joint infections
Indication Likely Empiric agents Alternative Comments

causative (presumptive agents agents
organism )
Acute Staph Inj Cloxacillin 2 g IV Inj Cefuroxime *- Bone biopsy and
Osteomyelitis* / aureus, S. Q4H 1.5gm IV Q6H debridement of
septic arthritis pyogenes (OR) necrotic tissue
Enterobact Inj Cefazolin 2 g IV In case of b- ➢ Obtain Blood
eriaceae Q8H lactam allergy cultures and
Inj Clindamycin joint fluid for
600-900mg IVq culture before
8h starting
or antimicrobials
Tab ➢ Duration for
Cotrimoxazole septic arthritis-
960mg PO q12h 4 weeks;
➢ For Acute
osteomyelitis-6
weeks from last
debridement.
➢ change to
appropriate oral
therapy after
10-14 days of
IV. Therapy
Chronic Staphyloc Avoid Empiric treatment ➢ For optimal
Osteomyelitis occi treatment,
Aerobic microbial
Secondary to a GNB aetiology should
contiguous Streptococ be confirmed
focus of ci ➢ Bone
infection Anaerobes biopsy and
(e.g., decubitus debridement of
ulcer). necrotic tissue
➢ Obtain
Osteomyelitis Blood cultures
that develops as and joint fluid for
a result of culture before
contaminated starting
open fractures antimicrobials
or surgical ➢ Avoid
treatment or sending swab
closed fractures cultures from
chronic
Chronic discharging
Osteomyelitis sinuses and
with orthopaedic ulcers.
implants
53
➢ Duration: 6
weeks from last
debridement
➢ Consider
switching to oral
antibiotics at the
earliest.
Mild infection Mild infection ➢ Cultures

Tab Cloxacillin In case of b- should not be
500-1g PO q6h lactam allergy taken from
S. aureus
T. Cotrimoxazole clinically non-
Strept.
Parenteral: DS 960mg PO infected wounds
Pyogenes.
Inj Cefuroxime q12h ➢ Drainage/de
1.5g IV q8h bridement to be
done
Polymicro Moderate Moderate ➢ Add MRSA
bial Infection Infection cover only if
S.aureus, In case of b-lactam there is a risk
Group A Inj Piperacillin- allergy factor.
strep, Tazobactam 4.5g Inj Amikacin ➢ Rule out
Aerobic IV q8h 15mg/kg IV q24h tuberculosis
Gram- +/- (OR) before starting
Osteomyelitis negative If Risk factor for Inj Levofloxacin Levofloxacin
associated with bacilli, MRSA 750mg IV Q24h ➢ In case of
diabetic foot anaerobes Inj vancomycin LD +/- Vancomycin
infection 20-35mg/kg f/b If risk factor for allergy/intolerabl
15mg/kg IV q12h MRSA add e, consider Inj
vancomycin Linezolid 600mg
Severe infection Severe infection IV q12h
Inj Meropenem 1g In case of b-lactam
Polymicro
IVq8h allergy
bial,
(OR) Inj Amikacin
S.aureus,
InjCefoperazone+ 15mg/kg IV q24h
Group A
Sulbactam 3g IV (OR)
strep,
12h Inj Levofloxacin
aerobic
+/- 750mg IV Q24h
Gram-
If Risk factor for +/-
negative
MRSA If risk factor for
bacilli,
Inj vancomycin LD MRSA add
anaerobes
20-35mg/kg f/b vancomycin
15mg/kg IV q12h
Open fracture S.aureus, InjAugmentin In case of b-lactam Type 3 fractures,
repair Streptococ 1.2gm IV q12h allergy antibiotic should be
ci Tab Co- continued for 72
trimoxazole 960mg hrs after injury or
PO q12h not more than
24hrs after soft
tissue coverage has
been achieved.
54
Prosthetic joint CoNS, In stable patients If the patient is *- If pseudomonas
infections S.aureus, antibiotics may be unstable is suspected
Streptococ withheld pending Inj Ceftriaxone+ consider starting
ci, establishment of Sulbactam 1.5gm Inj
Enterococ microbiological Q12h Piperacillin/tazobac
ci, result. (OR) tam 4.5gm IV q8h.
cutibacteri InjCefoperazone+S If vancomycin
um, If the patient is ulbactam 3g IV allergy/intolerable
Enterobact unstable, Q12h consider Inj
- Inj Ceftriaxone* + Linezolid 600mg
eriaceae 1gm IV q12h Vancomycin IV q12h
+ LD:20-35 mg/kg
Vancomycin f/b15mg/kg IV
LD:20-35 mg/kg q12h
f/b 15mg/kg IV
q12h
55
J . Recommendations for Plastic surgery
Likely Alternative
Indication Recommended agents Comments
pathogens agents
Trauma (Prophylaxis)  For Freshwater

Degloving Staphylococ Inj. Cefazolin 1 g IV contamination
injury ci, CoNS, stat and q8h consider Inj
antibiotic anaerobes OR Piperacillin +
treatment Inj. Cefuroxime 1.5 g Tazobactam 4.5
naïve stat and q8h gm q8h
Inj
+/-  If fungal
clindamycin
Inj. Metronidazole 500 Contamination is
600mg IV q8h
mg IV stat and Q8h (if suspected consider
+
contaminated wound) Inj Fluconazole
Inj Amikacin
Crush Injury Staphylococ Inj. Cefazolin 1 g IV 12mg/kg loading
15mg/kg q24h
antibiotic ci, CoNS, stat and q8h dose f/b 6mg/kg
treatment anaerobes OR q24h
naïve Inj. Cefuroxime 1.5 g
stat and q8h
+
Inj. Metronidazole 500
mg IV stat and Q8h
Indications and Choice of Empiric Antimicrobials
Degloving, Gram  If MRSA is
crush injury ( negative Inj Piperacillin- suspected,
> 48 hours, bacilli, Tazobactam 4.5g IV consider Inj
febrile with Staphylococ q8h Inj Amikacin Vancomycin 20-
infected ci, CoNS, 15mg/kg q24h 35 mg LD f/b
wound) anaerobes + 15mg/kg q12h
Gram Inj  If fungal infection
negative Clindamycin is suspected
bacilli, 600mg q8h consider Inj
Post surgical InjCefoperazone-
Staphylococ Fluconazole
site infection sulbactam 3g q12h
ci, CoNS, 12mg/kg loading
anaerobes dose f/b 6mg/kg
q24h
“q” – every , “h” – hours
56
K. OBSTETRICS AND GYNAECOLOGY INFECTIONS: -
• Fluoroquinolones are contraindicated in 1st trimester.
• Cotrimoxazole is contraindicated in 1st trimester.
• Doxycycline is not recommended in nursing mothers. If need to administer
doxycycline discontinuation of nursing may be contemplated.

Causative antibiotics antibiotics
antibiotics)
Asymptomatic E.coli Tab Treat as per
Bacteriuria in Nitrofurantoin sensitivity
pregnant 100mg oral result for 7
women q12h days.
>1,00,000cfu/ml OR
of bacteria of Tab Amoxicillin
same species in 500mg oral
2 urine cultures q12h
obtained 2-7 x 7-10 days.
days apart.
Pelvic N. gonorrhoeae, Tab Cefixime Tab Ofloxacin
Inflammatory C. trachomatis (400 mg orally (400mg q24h X 7
disease and anaerobes. STAT) + Tab days) with Tab
(Mild to E. coli, Metronidazole Metronidazole
moderate) Bacteroides (400 mg q12h X (400 mg q8h X
GBS, GAS, 14 days) + 14 Days)
S.aureus Tab
Doxycycline (OR)
(100 mg q12h X Inj Ceftriaxone
14 days) (250 mg IM
single dose) +
Tab Doxycycline
(orally 100 mg
q12h X
14 days)
with/without T.
Metronidazole
(500 mg q12h X
14 days)
Pelvic C. trachomatis, N. Inj Cefotetan (2 Inj Clindamycin An attempt
Inflammatory gonorrhoea, gm IV q12h ) 900 mg IV q8h + should be
disease Bacteroides, (+) Inj Gentamycin made to
(Severe) peptostreptococci, Doxycycline 4-5mg/kg q 24h obtain
Eg:-tubo- mycoplasma, (100 mg orally cultures and
ovarian Gardnerella or IV q12h) deescalate
abscess, pelvic vaginalis, based on
abscess that.
57
Haemophilus Duration is
influenzae, enteric two
Gram-negative weeks but can
rods, Streptococcus be
agalactiae, S extended
aureus depending
anaerobes upon the
clinical
situation.
Vaginal C. albicans, Tab Fluconazole Miconazole, Treat for 7
candidiasis C. glabrata, 150 mg PO Nystatin days in
C. tropicalis single dose Vaginal pregnancy,
OR tablets/creams diabetes.
Clotrimazole Recurrent
500 mg vaginal infections:
tablet Single Fluconazole
dose 150 mg
on day 1,4,7
then
weekly for 6
months
Vaginal T. vaginalis Tab. Tab. Tinidazole Avoid
trichomoniasis Secnidazole 500 mg PO q12 h Alcohol -24
2 gm PO, single X 5days hours after
dose metronidazole
(OR) or 72
Tab. hours after
Metronidazole completion of
400 mg PO, secnidazole.
q12h X7 days Partner
treatment also
essential.
Cervicitis Polymicrobial Inj Ceftriaxone Tab Doxycycline
/Urethritis 500mg IM 100mg PO x
(Mucopurulent Single dose + 7days
gonococcal) Tab
Azithromycin
1gm PO single
dose
Bacterial Overgrowth of T. T. Secnidazole Refrain from
vaginosis anaerobes Metronidazole 2 g orally q24h sexual
(Gardnerella 400 mg q12h PO X 1 day activity or use
vaginalis) PO X 7 days (OR) condoms
(OR) Tinidazole 2 g during the
Metronidazole q24 PO X 2 days/ treatment.
gel 1 g orally q24h X Treat the
0.75%, one 5 days partner.
applicator (5 g) (OR)
intravaginal x 5
days
58
(OR) Clindamycin
orally 300 mg
clindamycin q12h X 7 days
Cream (OR)
2%, one Clindamycin
applicator (5 g) ovules 100 mg
intravaginal x 7 intravaginally q
days 24h HS for 3
days*
Puerperal sepsis Gram positive: Inj. Inj Clindamycin
/ Streptococci (A, B, Piperacillin 600-900mg IV q
Septic abortion / D), Tazobactam 8h
chorioamnionitis S.aureus. 4.5gm IV q6h +
Gram negative: Inj Gentamycin
Enterobacteriaceae 5mg/kg IV q 24h
P.aeruginosa,
P.mirabilis, If MRSA is
G. vaginalis, suspected
Bacteroides sp consider adding
C.perfringens. Inj Vancomycin
25-30mg/Kg LD
f/b 15mg/kg 12h
59
L.Hospital acquired infection:

Likely agent Empiric agents Alternative Comments
(presumptive agents
agents)
Catheter Gram-negative Inj Inj Teicoplanin Remove catheter
related blood (Klebsiella Vancomycin 400mg IV every a) Septic shock
stream pneumoniae> loading dose 12h for 3 doses b)Hemodynamic
infections Acinetobacter 20-35mg/kg IV f/b 400mg IV instability
spp.) more f/b 15mg/kg q24h) c) Suppurative
common than q8-12h + thrombophlebitis
Gram positive + Inj d) Endocarditis
(Staphylococc Inj Meropenem Cefoperazone/ or evidence of
us spp., 1-2g IV q8h Sulbactam 3g metastatic
Enterococcus + IV q12h infection
spp.) Inj Amikacin + e) Persistent
20mg/kg IV Inj Gentamycin bacteraemia
q24h 5-7mg/kg q24h after 72 hours of
appropriate
therapy
CLABSI Carbapenem Refer to Carbapenem resistant organism/

resistant MRSA/VRE guideline (pg- 73-81)
organism
MRSA Refer guideline for fungal infections (pg-64-66)
VRE
Fungal
CLABSI due Ampicillin Ampicillin 200 Inj Vancomycin
to sensitive (MIC mg/kg/day in LD: 20-
enterococcus ≤4 mg/L) and six divided 35mg/kg f/b
non-HLAR (MIC doses (Max 15mg/kg IV 8-
≤128 mg/L) dose - 2 g IV in 12h
enterococcus q4h). +/-
+/- Inj Gentamicin
Inj gentamicin 5-7mg/kg q24h
5-7mg/kg q24h
Ampicillin Inj Ampicillin- Inj Vancomycin

Resistant (β sulbactam : LD: 20-
lactamase (Ampicillin- 35mg/kg f/b
producing) and 150mg /kg/day 15mg/kg IV 8-
non-HLAR in four divided 12h
enterococcus doses (Max 2g +/-
IV 4h) Inj Gentamicin
Sulbactam 50 5-7mg/kg q24h
mg/kg/day in
3-4 divided
doses)
60
PLUS
Inj Ceftriaxone
2g IV q12h
For hospital Refer to Management of respiratory tract infections
associated
pneumonia
Clostridium Initial episode Tab vancomycin Only is .
difficle non severe 125 mg PO q 6h vancomycin not
infection available
Tab
metronidazole
400mg PO q8h
Initial episode Tab vancomycin
fulminant : 500 mg PO q 6h
Hypotension or If ileus present,
shock, ileus, consider
megacolon retention enema
Tab of Vancomycin
vancomycin 500mg in 100ml
125 mg PO q 6h saline per
for 10 days rectum q6h
+
Inj
Metronidazole
500mg IV q8h
First recurrence Tab vancomycin Prolonged and
125 mg PO q 6h tapered regimen
(if Tab
metronidazole Vancomycin
was used for 125 mg PO q6h
initial episode x10 days f/b
125mg PO q12h
x1 week f/b
125mg PO q24h
X 1 week f/b
every 2-3 days
for 8 weeks
Second or VAN in a Faecal
subsequent tapered and microbiota
recurrence pulsed transplantation
regimen
Tab vancomycin
125mg q6h x10
days f/b Tab
rifaximin 400
mg q8h x 20
days
61
M. OTHER INFECTIONS
Causative antibiotics antibiotics
antibiotics)
Toxoplasmosis Toxoplasma Tab Tab Trimethoprim Leucovorin
Encephalitis gondii Pyrimethamine* 5mg/kg*/ should be
(TE) – 200mg PO LD Sulfamethoxazole administered to
treatment f/b 50 mg PO q 25mg/kg PO q12h prevent
(Adult) 24h in pts < 60 + pyrimethamine
kg or 75 mg daily Tab Folinic acid induced
in pts > 60 kg (Leucovorin) 10 -50 hematologic
+ mg q24 toxicity.
Tab Sulfadiazine
1000 mg q6h in In case of sulfa Therapy should
pts < 60 kg or drugs allergy be given for 4 to
1500 mg PO q6h 6 weeks or
a day in pts > 60 Tab Atavoquone depending on
kg If patient 1500mg PO q12h ± clinical and
cannot tolerate Tab Tab radiological
*
Sulfadiazine then Pyrimethamine response
Tab Clindamycin 200mg PO LD
600 mg PO q6h followed by 50 mg
PO q 24h in pts <
+ 60 kg or 75 mg
Tab Folinic acid daily in pts > 60 kg
(Leucovorin) 10 - +
50 mg q24h Tab Folinic acid 10
-50 mg q24h
* *
Toxoplasmosis Toxoplasmosis Tab Spiramycin 1g PO q8h To prevent
in Pregnancy Gondii vertical
(suspected or After 18 weeks of gestation transmission.
confirmed of If fetal infection has been confirmed by
having either by positive amniotic fluid PCR or #-
acquired their highly suspected (positive fetal pyrimethamine
primary is teratogenic-
ultrasound suggestive of congenital
infection < 18 to be used after
weeks of toxoplasmosis) then 18 weeks.
gestation) Tab Pyrimethamine# 50 mg PO q12h Sulfadiazine not
+ be used alone.
Tab Sulfadiazine: 75 mg/kg (first dose)
followed by 50 mg/kg PO q12h (max
4g/day)
+
Tab Folinic acid(Leucovorin) 10-25 mg
q24h (till 1 week after stopping
pyrimethamine)
62
Visceral Leishmania Liposomal Amphotericin B
leishmaniasis donovani Amphotericin deoxycholate
B10 mg/kg IV 1 mg/kg iv on
for 1DOSE alternate days for 15
Liposomal days
Amphotericin B
3 mg/kg on D1 to
D5, D14, D21
Chickenpox Varicella zoster Valacyclovir Acyclovir 800 mg To be started
virus 1000 mg P.O TID P.O. five times within 24h of
for 7 days /day for 7 days onset of rash
Herpes zoster Varicella zoster Valacyclovir Acyclovir 800 mg Begin within
virus 1000 mg P.O TID P.O. five times/day 72hours of onset
for 7 days for 7 days of rash.
Immuno-compr
Omised
patients:
Acyclovir 10
mg/kg IV TID
Change to
Valacyclovir
100 mg P.O.TID
Total duration
7-10 days
63
N. PERITONIAL DIALYSIS RELATED PERITONITIS
Likely Comments
Recommended Alternative
Indication Causative
Agents Agents
Organisms
PD- S. Aureus, Inj vancomycin Inj Cefepime 1g In severe
Peritonitis Streptococcal intra-peritoneal 15– q24h intra- systemic
spp,CoNS, 30 mg/kg q5–7days peritoneal with sepsis
Enterococcus, for CAPD dwell time of at consider IV
S.maltophilia, 15 mg/kg q4days least 6 hours antimicrobial
Enterobacteriac for APD with dwell + therapy.
eae, time for at least 6h Tab/cap Nystatin
P.Aeruginosa, + 5,00,000 units The Whole
A.baumanii, Inj PO q6h PD effluent
Candida spp Piperacillin/Tazoba bag should be
ctam, intra- sent for
peritoneal LD 4.5g, culture
MD 1.125 g in all
exchanges Deescalate
+ after C&S
Tab/cap Nystatin report and
5,00,000 units PO continue
Q6h treatment as
per C&S
If Pseudomonas is report for 2-3
suspected then a weeks
combination of
Inj
Piperacillin/Tazoba
ctam, intra-
peritoneal LD 4.5g,
MD 1.125 g in all
exchanges
+
Inj Gentamycin 0.6
mg/kg q24h with
dwell time of at
least 6h
Refractory peritonitis, is defined as failure of the PD effluent to clear up after 5 days of

appropriate antibiotics
PD catheter should be removed for
• Refractory peritonitis
• relapsing peritonitis
• fungal peritonitis,
• non-tuberculous mycobacterial infections
64
and individualized for tuberculous peritonitisRe-insertion of catheter can be considered after
2-4 weeks of bacterial and 4-6 weeks of fungal peritonitis along with complete resolution of
peritoneal symptoms.
IP antibiotic dosing recommendations for treatment of peritonitis

Antibiotic Intermittent (1 exchange Continuous (all
daily for at least 6 h) exchanges)
Aminoglycosides
Amikacin 2 mg/kg daily Not advised
Gentamicin 0.6 mg/kg daily Not advised
Netilmicin 0.6 mg/kg daily Not advised
Tobramycin 0.6 mg/kg daily Not advised
Cephalosporins
Cefazolin# 15 mg/kg daily (for long dwell) LD 500 mg/L, MD 125mg/L
Cefepime# 20 mg/kg daily (for short

dwell) LD 500 mg/L, MD
125mg/L
Cefoperazone 1000 mg daily LD 500 mg/L, MD 62.5-125
Cefotaxime No data mg/L
Ceftazidime# 500–1000 mg daily No data
1000–1500 mg daily (for long LD 500 mg/L, MD 125
Ceftriaxone dwell) mg/L
20 mg/kg daily (for short
dwell) No data
1000 mg daily
Penicillins
Penicillin G No data LD 50,000 U/L, MD 25,000
Amoxicillin No data U/L
Ampicillin 4 gm daily MD 150 mg/L
Ampicillin/ No data MD 125 mg/L
Sulbactam LD 1000 mg/500 mg, MD
Piperacillin/ No data 133.3 mg/66.7mg
Tazobactam LD 4 gm/0.5 gm, MD 1
gm/0.125 gm
Ticarcillin/ No data
Clavulanic acid LD 3 gm/0.2 gm, MD 300
mg/20 mg/L
Aztreonam 2 gm daily LD 500 mg/L, MD 250
mg/L
Ciprofloxacin No data MD 50 mg/L
Clindamycin No data MD 600 mg/bag
Daptomycin 300 mg daily LD 100 mg/L MD 20 mg/L
Imipenem/cilastatin 500 mg in alternate exchange LD 250 mg/L, MD 50 mg/L
Ofloxacin No data LD 200 mg, MD 25 mg/L
Polymyxin B No data MD 300,000 unit (30
mg)/bag
Meropenem 500 mg daily (for long dwell) MD 125 mg/L
65
1000 mg daily (for short dwell)
Teicoplanin 15 mg/kg every 5 days LD 400 mg/bag, MD 20
mg/L
Vancomycin 15–30 mg/kg every 5–7 days LD 20–25 mg/kg, MD 25
for CAPD mg/L of peritoneal dialysate
15 mg/kg every 4 days for fluid
APD
Antifungal
Fluconazole 150–200 mg every 24 to 48 h No data
(oral route is preferred)
Voriconazole 2.5 mg/kg daily No data
(oral route is preferred)
#- Increase in doses by 25% may be needed for patients with significant residual kidney
function.
IP antibiotics stability
Antibiotics PD solution Stability Storage
Dextrose Icodextrin Room temp underrefrigeration
Gentamicin  14days  
 14days  
Cefazolin  8days 
 14days 
 7days 
 14days 
Ceftazidime  4days 
 7days 
 2days 
 14days 
Cefepime  14days 
Vancomycin  28days 
 14days  
Piperacillin   7days 
tazobactam
Stable for X days’ indicates that the antibiotic concentration retained at least 90% of its initial
concentration up to day X
66
RECOMMENDATIONS OF ANTIMICROBIALS FOR INFECTIONS IN
IMMUNOCOMPROMISED PATIENTS
Prophylaxis and treatment in Hematopoietic Stem Cell Transplantation (HSCT)
Source: Tomblyn M et al. Guidelines for preventing infectious complications among hematopoietic cell
transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009 Oct;15(10):1143-238.
BMT PRE ENGRAFTMENT

BMT pre Drug Comments
engraftment
Antibiotic No prophylaxis Stool surveillance culture for multidrug
prophylaxis resistant bacteria in stool and throat swab
samples may be done to detect colonization
with MDR bacteria.Stool and throat swab
samples from patients may be screened for
the presence of genes indicating
colonization with MDR bacteria
Antifungal Posaconazole oral Blood levels may be monitored if TDM
prophylaxis syrup: 600-800 mg/ day (Therapeutic Drug Level) monitoring
(200 mg q 6-8h); facilities are present. If posaconazole is
IV/oral : Loading dose contraindicated then alternative agents
of 300 mg q12h for 1 include liposomal Amphotericin or an
day f/b 300mg q24h echinocandin
(e.g.Micafungin/Anidulafungin)
Antiviral Tab Acyclovir 400 – Continued in the post transplant period
prophylaxis 800 mg PO q12h for 6 months for autologous and 1 year
for allogeneic BMT.
67
Influenza vaccination Yearly vaccination preferably at the
beginning of flu season (AprilSeptember)
and at least 2 weeks before starting
chemotherapy
Ganciclovir (Induction Consider pre-emptive therapy if 2
5 mg/kg IV q12h for 7- consecutive viral loads (CMV viral load
CMV 14 days, f/b MD 1000-10,000 copies/mL) are showing an
prophylaxis 5 mg/kg IV q24h for 7 upward trend suggesting possibility of
days per week progression to CMV disease OR
OR Start pre-emptive anti-CMV therapy if
6mg/kg IV q24h for 5 CMV viral load is high (>10,000
days per week until copies/mL).
100-120 days post
transplantation.
OR
Valganciclovir 900 mg
PO Q24h within 10
days of transplantation
until 100 days post
transplantation
BMT POST ENGRAFTMENT

Antibiotic prophylaxis Stable and engrafted • Penicillin prophylaxis in those
patient: with splenectomy or those with
• Tab Cotrimoxazole sickle cell anemia to be continued
960mg PO q12h for twice till 14 years.
weekly for 1 year, • Penicillin prophylaxis in those
and patients who have not taken
• Tab Penicillin V 400 mg Pneumococcus, Haemophilus and
PO q12h for 1 year. Meningococcal vaccination
Vaccination following PNEUMOCOCCAL VACCINES should be taken
splenectomy or CONJUGATE (Pneumococcal +
functional asplenia VACCINE (13-valent) Hib+Influenza+meningococcus) at
followed by (at least 8 least 14 days prior to the
weeks later by splenectomy or 14 days after
PNEMOCOCCAL splenectomy. All could be
POLYSACCHARIDE administered simultaneously into
VACCINE (23 different limbs.
valent) 0.5ML
VACCINE) (0.5 ML Individuals with a bleeding disorder
intramuscular upper arm) should be given vaccine by
X 1 stat. deepsubcutaneous injection to
reduce the risk of bleeding.
Haemophilus influenzae
vaccine 0.5ML INJ. (0.5 Re-vaccination with
ML intra-muscular upper pneumonococcal vaccine may be
arm) X considered 5 years after
primary vaccination.
68
1 stat: to be
givenintramuscularly into
theupper arm or antero-
lateral thigh. A
reinforcing (booster) dose
of Hib vaccine is
recommended at 12
months.
Influenza vaccine
0.5MLvaccine: (0.5 mL)
X 1 stat. To be
administered yearly at the
beginning of the
Influenza season every
year; given by
intramuscular injection
should be given
preferably into the upper
arm.
Meningococcal vaccine
ACWY 0.5mL vaccine
(0.5 mL) X 1 stat; All
meningococcal-
containing vaccines are
given intramuscularly
into the upper arm or
anterolateral thigh.
Antifungal prophylaxis Posaconazole oral syrup: Posaconazole/ liposomal
600-800 mg/ day (200 mg amphotericin B or echinocandin
q 6-8h); IV/oral : Loading (Micafungin/Anidulafungin) based
dose of 300 mg q12h for on oral medication tolerability,
1 day f/b 300mg q24h requirement of mold active
prophylaxis,
OR intolerance to azoles (liver function
Inj Liposomal derangement, hallucination, drug
amphotericin B interaction, etc), and presence of
1 mg/kg/day IV or GVHD.
3 mg/kg IV twice weekly.
Antiviral prophylaxis Yearly Influenza Yearly vaccination preferably at the
vaccination beginning of flu season (April
Tab Acyclovir 400 mg – September) and at least 2 weeks
800 mg PO q12h before starting chemotherapy. Please
note the recommended vaccine
composition(northern/southern
hemispheric vaccine) from the
WHO website Updated twice yearly
Acyclovir 6 months forautologous
and 1 year for allogeneic BMT.
69
Antimicrobial therapy in Febrile neutropenia patients in BMT/Solid organ Transplant
Condition Likely Empiric Alternative Comments
antibiotics)
Febrile Escherichia Inj Piperacillin- Inj Meropenem Continue
Neutropenia coli, tazobactam 4.5g 2g IV q8h broad-
(FN)/ sepsis Klebsiella q6-8h spectrum
pneumoniae, + If patient is in antibiotics
Pseudomonas Inj Amikacin Septic Shock until the
aeruginosa, 15 mg/kg q24h start patient is
Acinetobacter Inj Polymyxin B afebrile for at
species, If MRSA is 25000 U/Kg LD least 2 days
Staphylococcus suspected f/b 10000-12500 and the
aureus, Inj Teicoplanin U/kg q12h neutrophil
Coagulase LD-400 mg IV + count is >500
q12h for 3 doses Inj Meropenem cells/mm3 on
f/b 400 mg IV 2 g IV q8h at least one
q24h ± occasion. If
OR If MRSA is blood cultures
Inj Vancomycin suspected are negative
LD 20-35 mg/kg Inj Teicoplanin at 3 days
f/b 15 mg/kg in or Inj following
q12h Vancomycin initiation of
antibiotic the
Teicoplanin
/Vancomycin
may be
discontinued.
Antimicrobial therapy in the immunocompromised patients for various indications is
discussed in respective chapters. Kindly refer the relevant chapter for detailed guidance.
70
Toxoplasmosis treatment in Immunocompromised:
Condition Likely Empiric Alternative Comments
antibiotics)
*
Toxoplasmosis Toxoplasma Tab Tab Trimethoprim Leucovorin
Encephalitis gondii Pyrimethamine* 5mg/kg*/ should be
(TE) – 200mg PO LD Sulfamethoxazole administered
treatment followed by 50 25mg/kg PO q12h to prevent
(Adult) mg PO q 24h in + pyrimethamine
pts < 60 kg or Tab Folinic acid induced
75 mg daily in (Leucovorin) 10 - hematologic
pts > 60 kg 50 mg q24 toxicity.
+
Tab In case of sulfa Therapy
Sulfadiazine drugs allergy should be
1000 mg q6h in Tab Atavoquone given for 4 to
pts < 60 kg or 1500mg PO q12h 6 weeks or
1500mg PO q6h ± depending on
a day in pts > 60 Tab clinical and
kg If patient Pyrimethamine* radiological
cannot tolerate 200mg PO LD response
Sulfadiazine followed by 50
then mg PO q 24h in
Tab pts < 60 kg or 75
Clindamycin mg daily in pts >
600 mg PO q6h 60 kg
+
+ Tab Folinic acid
Tab Folinic acid 10 -50 mg q24h
(Leucovorin)
10 -50 mg q24h
Toxoplasmosis To be given until Tab Tab Discontinue
Chronic immune pyrimethamine Trimethoprim*/ therapy if after
Maintenance reconstitution 25-50mg PO Sulfamethoxazole completion of
therapy occurs after anti- q24h 960(160+800)mg initial therapy
retro viral + q12h there is no
therapy Tab OR signs and
Sulfadiazine Tab symptoms of
2000-4000mg Trimethoprim*/ TE and CD4
PO in 2-4 Sulfamethoxazole count >200
divided doses 960(160+800)mg cells/mm3 for
daily q24h >6 months in
+ OR response to
Tab Folinic acid Tab Atovaquone ART
(Leucovorin) 10 750–1500 mg PO
-50 mg PO q24h q12h
71
Herpes Herpes Simplex Tab Acyclovir Inj Foscarnet Dose and
simplex Virus Type 1 and 800mg PO five 35mg/kg IV q 8- Duration of
Type 2 (HSV1, times/day 12h infusion over therapy
HSV2) OR 1 hr. depends on
Tab (Foscarnet in organ
Valacyclovir acyclovir resistant involvement.
1000mg PO q8h infections)
X 7 days
CMV Cytomegalovirus Inj GanciclovirInj Foscarnet Treat till
reactivation 5 mg/kg IV 60mg/kg IV q8h clinical
or disease q24h infused or 90mg/kg IV improvement
(colitis, over 1 hr q12h or resolution
pneumonitis, OR of
hepatitis, OR Inj Cidofovir viremia (2
retinitis, Tab 5mg/kg IV as negative viral
encephalitis) Valgancyclovir infusion over 1 hr load reports).
900mg PO q12h once weekly for 2 In case of
or weeks f/b 5mg/kg treatment
once every 2 failure with
weeks Ganciclovir,
foscarnet is
the drug of
choice
Pneumocystis Pneumocystis Tab Co- Inj/tab Duration of
jirovecii jirovecii trimoxazole (10- Clindamycin therapy: 21
pneumonia 15 mg/kg of 600mg PO q8h or days
TMP 600-900mg IV Corticosteroids
component in 2 - q8h to be
3 divided doses + considered as
Tab Primaquine an adjunctive
30mg PO q24h therapy along
with
Option2: antimicrobial
Tab Dapsone therapy against
100mg PO q24h PCP.
+ Tab
Trimethoprim
oral 20mg/kg/day
in 3 divided
doses.
Option3:
Tab Atovaquone
1500mg q12h
with food
(preferably high
fat) Duration: 21
days
72
P. ANTIMICROBIAL PROPHYLAXIS IN TRAUMA PATIENTS
Trauma Site First choice Alternate choice Comments
Abrasion Scalp, Face, Local application
Thorax, of Fusidic acid
Abdomen, /Neosporin
Back & Pelvis)
Scalp, Face, Cap. Cloxacillin Tab Clindamycin Add T.
Thorax, 500mg q6h x3 300mg q8h Metronidazole
abdomen, days or if severely
back & pelvis or Tab contaminated &
Involving Cap. Cephalexin Cotrimoxazole intra oral
epidermis, 500mg q6h x DS 960mg PO extension
Superficial
dermis 3days q12h
laceration
& fascia, + /-
involving Add T.
dangerous area Metronidazole
of face +/- 400mg q8h if
intraoral severely
Laceration contaminated
Scalp, Face, Inj. Cloxacillin 1g Inj Clindamycin If discharged
Thorax, IV q6h 600-900mg IV from
abdomen, or q8h emergency
back & pelvis Inj. Cefuroxime department :
involving 1.5g IV q8h Cap.
epidermis, + /- Cloxacillin
Deep dermis, Inj. Metronidazole (OR)
laceration fascial & 500mg IV q8h Cap.
muscle, (only if severely Cephalexin
with bone contaminated) +
fractures Tab.
+/- intraoral Metronidazole-
extension if severely
contaminated
Penetrating Inj. Piperacillin- Inj Amikacin
injuries tazobactam4.5g IV 15mg/kg IV q
q8h 24h +
(OR) Inj Clindamycin
InjCefoperazone+ 600-900mg IV
Sulbactam 3g IV q q8h
12h
Human bite/ Cap Amoxicillin/ Tab.
Dog/cat/rat bite clavulanate 625mg Clindamycin 300
PO q8h mg PO q8h for
Animal/ x 3-5 days 3-5 days
human bites (OR)
Tab
Co-trimoxazole
960mg PO q12h
73
Q. MANAGEMENT OF FUNGAL INFECTIONS
• All Non-neutropenic patients who develop invasive candidiasis should undergo dilated
ophthalmic examination within the first week of diagnosis.
• For C.Glabrata, C. Krusei, C. Parapsilosis and C.Auris- Echinocandins are the drug of
choice as per NIMS Antibiogram.
Empiric antifungal therapy Duration Comments

Suspected /
First choice Alternative
confirmed
Choice
Uncomplicated C. Auris –
Low Risk patients with candidiasis- 2 Echinocandins
no prior exposure to Inj Liposomal weeks from the are the drug of
Fluconazole amphotericin B 3- last negative choice as per
5mg/kg q 24h blood culture. NIMS
Inj Fluconazole LD antibiogram.
12mg/kg f/b MD (OR) Complicated
Candidiasis 6mg/kg q24h candidiasis- Step down to
• C. albicans (OR) Inj Amphotericin 3 to 12 months fluconazole/v
Inj Voriconazole LD B deoxylate 0.5- depending on oriconazole
• C.glabrata 6mg/kg IV q12h for 1.5 mg/kg q24h clinical after 1st week
• C.tropicalis first 24 hours f/b MD improvement or of
4mg/kg q12h radiological echinocandins
• C.parapsilosi images or fundus / in clinically
s Mod- Severe Risk (for examination or stable patients
C.krusei and C.Auris)- CSF fluid with Azole
• C. krusei patients with prior susceptible
• C. Auris# exposure to Azoles and isolates
in Neutropenic patients
*-
Echinocandins* Anidulafungin
Inj Anidulafungin is the least
200 mg on day 1, f/b hepatoxic
MD 100 mg q24h drug among
(OR) the
Inj Micafungin 100mg echinocandins
q24h
(OR)
Inj Caspofungin LD
70mg f/b MD 50mg
q24h
(OR)
74
Low Risk patients In Mod-Severe risk 3 to 12 months
with no prior (for non albicans depending on
exposure to spp) clinical
Fluconazole improvement or
Inj Liposomal radiological
Inj Fluconazole LD amphotericin B images or fundus
CNS
12 mg/kg followed 3-5 mg/kg q 24h examination or
Candidiasis by 6 mg/kg q24h with or without oral CSF fluid
(OR) flucytosine,
Inj Voriconazole LD 25 mg/kg q6h
6 mg/kg IV q12h for
first 24 h f/b
4 mg/kg q12h
• Remove the indwelling bladder catheter, if feasible.
• Treatment with antifungal agents is NOT recommended
unless the patient belong to a group at high risk for
dissemination like
Asymptomati
c Candiduria o neutropenic patients (Treat as per candidiasis)
o patients who will undergo urologic manipulation-
Oral Fluconazole, 400 mg (6 mg/kg) q 24h, OR Amp
B deoxycholate, 0.3–0.6 mg/kg q24h, for several
days before and after the procedure.
• Removal of an indwelling bladder catheter, if feasible. Bladder
irrigation
• For fluconazole-susceptible organisms, oral fluconazole, with Amp B
200 mg (3 mg/kg) daily for 2 weeks is recommended. deoxycholate5
0 mg/L sterile
• For fluconazole-resistant C. glabrata, water q24 for
Symptomatic o Amp B deoxycholate, 0.3–0.6 mg/kg q24h for 7d 5d – For
candida fluconazole
(OR) resistant
cystitis
o oral flucytosine, 25 mg/kg q6hfor 7–10 d cystitis.
• For C. krusei,
o Amp B deoxycholate, 0.3–0.6 mg/kg q24h , for 1-
7d
Inj Voriconazole Inj For pulmonary
6mg/kg q12h day 1 Isuvaconazole aspergillosis treat
followed by 4mg/kg 200 mg q8h for for 6 to 12 weeks
q12h six doses f/b depending on
Invasive
200 mg q24h clinical and
Aspergillosis (OR) (OR) radiological
Oral : Voriconazole improvement.
200 mg q12h
75
Inj Liposomal For disseminated
amphotericin B aspergillosis -up
3-5 mg/kg q24h to 12 weeks
(OR) depending on
Posaconazole localization and
300 mg IV q12h surgical removal
f/b 300 mg q24h
(IV OR ORAL)
Option 1: 2 weeks on Complete
Inj Liposomal Inj Liposomal Amp surgical
amphotericin B Isuvaconazole B f/b debridement is
3-5 mg/kg q24h 200 mg q8h for Posaconazole or necessary
six doses f/b isuvaconazole
Invasive OR 200 mg q24h
Mucor- Inj Amphotericin B Option 2:
mycosis deoxylate 0.5-1.5 Posaconazole 300
mg/kg q24h mg IV q12h
followed by 300
mg q24h (IV OR
ORAL)
Antifungal Tissue Distribution-PK Measurement

Spleen Kidney Liver/Biliary Lung/ELF Brain/CSF Eye
LAMB + + + + - -
DAMB + + + ± ± ±
5 FC + ± + + ± +
FLU + + + + + +
ITR + + + ± ± -
VOR ± + + ± + ±
POS ND + + + ± -
ISAV + + + + + ND
Echino ± + + ± - -
+ >0.5 times of serum concentrations

- <0.5 times of serum concentrations
REF: Fellon T, et al. Clin Microbiol Rev 2014; 68-88; Slover & Cleary Curr Fungal Infect
rep 2020; 14:279-288
76
CHAPTER 5 SURGICAL ANTIMICROBIAL PROPHYLAXIS
Principles of surgical prophylaxis
• A single preoperative dose of antibiotic is sufficient; there is no evidence for post-
operative prophylactic antibiotics.
• Dose: Full therapeutic dose of the antibiotic should be given
• Timing of administration -Prophylactic antibiotics should be administered within 1
hour prior to incision.
• Route -Prophylactic antibiotics for surgical procedures should be administered
intravenously.
• Antibiotics are repeated, if surgery extends beyond two half-lives of an antibiotic or if
blood loss is > 1.5 liter or hemodilution of upto 15 ml/kg (except vancomycin,
aminoglycoside, fluoroquinolone).
• Peri-operative antibiotic prophylaxis should be limited to 12 hours post-operatively
except for cardiothoracic surgery for upto 48 hours.
• Prophylactic antibiotics should not be used in perianal procedures (lay open fistula,
hemorrhoidectomy, lateral anal sphincterotomy (unless active infection is suspected)
• Vancomycin and fluoroquinolones should be administered 120 min before surgery as
they require prolonged infusion times
• Dosing is based on the patient's actual body weight. If the patient's actual weight is
more than 20% above ideal body weight (IBW), the dosing weight (DW) can be
determined using the formula DW = IBW + 0.4 (actual weight — IBW)
Table 1: Surgical site infection classification, likely pathogen and prophylactic

antibiotics.
Surgical wound Definition Likely Surgical

classification organism antimicrobial
prophylaxis
Class 1/ Clean An uninfected operative wound in None or single
which no inflammation is Staphylococc perioperative
encountered and the respiratory, us. Aureus, dose of
alimentary, genital, or uninfected CONS
urinary tract is not entered. In cefuroxime/
addition, clean wounds are cefazolin
primarily closed and, if necessary,
drained with closed drainage.
Operative incisional wounds that
follow non-penetrating (blunt)
77
trauma should be included in this
category if they meet the criteria.
Class II/ Clean- An operative wound in which the Staphylococc Single peri-
Contaminated respiratory, alimentary, genital or us. Aureus, operative dose of
urinary tracts are entered under CONS, Cefazolin/Cefur
controlled conditions and without Anaerobes, oxime/
unusual contamination. gram-ve Ceftriaxone +
bacilli Metronidazole
In case of b-
lactam allergy
Clindamycin
+Amikacin
Class III/ Open, fresh, accidental wounds. In Gram Cefazolin/Cefur
Contaminated addition, operations with major negative oxime/
breaks in sterile technique (e.g., bacilli, Ceftriaxone +
open cardiac massage) or gross anaerobes, Metronidazole
spillage from the gastrointestinal Staphylococc
tract, and incisions in which acute, us. Aureus,
nonpurulent inflammation is CONS
encountered are included in this •In case of b-
category. lactam allergy
Clindamycin
+Amikacin/
Levofloxacin
Class IV/Dirty- Old traumatic wounds with retained Antibiotics are not “prophylactic”
Infected: devitalized tissue and those that here. Choice of antibiotics will
involve existing clinical infection or depend on whether organ
perforated viscera. This definition dysfunction is present or not.
suggests that the organisms causing Specimens for culture and
postoperative infection were present sensitivity should be taken at
in the operative field before the operation. If organ dysfunction is
operation. present broad-spectrum
antibiotics will be chosen initially
and de-escalate once culture /
sensitivity results are available.
78
Table 2: Operations, likely Surgical Site Infection (SSI) pathogens and
prophylactic antibiotics
Nature of Likely Pathogen Recommended Alternative

operation antimicrobials antimicrobials
Placement of all Staphylococcus Cefazolin (OR) Clindamycin (OR)
grafts, prostheses, aureus; CoNS Cefuroxime Vancomycin
or implants
Cardiac Staphylococcus Cefazolin Clindamycin (OR)
aureus; CoNS (OR)Cefuroxime Vancomycin
Neurosurgery Staphylococcus Cefazolin (OR) Clindamycin (OR)
aureus; CoNS, Cefuroxime Vancomycin
If Trans-nasal/trans-oral
procedures
Anaerobes Add metronidazole with
Cefazolin (OR)
Cefuroxime
Breast Staphylococcus Cefazolin (OR) Clindamycin (OR)
aureus; CoNS Cefuroxime vancomycin
Orthopedic Total Staphylococcus Inj Cefazolin (OR) Clindamycin (OR)
joint replacement, aureus; CoNS; Cefuroxime vancomycin
closed
fractures/use of For “Below-the-belt For “Below-the-belt
nails, bone plates, surgeries” surgeries”
other internal Gram-negative
fixation devices, bacilli Piperacillin+Tazobactam Inj Amikacin
functional repair + (OR)
without Clindamycin Inj Levofloxacin
implant/device, +
trauma Inj Metronidazole
Cardiac Staphylococcus Cefazolin (OR) Clindamycin (OR)
Coronary artery aureus; CoNS; Cefuroxime Vancomycin
bypass(CABG).
Cardiac device
insertion
procedure (eg:
pacemaker
implantation)
Ventricular assist
devices
Non-cardiac Staphylococcus Cefazolin (OR) Inj Amikacin
thoracic surgery aureus; CoNS; Cefuroxime (OR) (OR)
Streptococcus Inj Levofloxacin
Thoracic pneumonia; Ampicillin-sulbactam +
(lobectomy,
pneumonectomy
79
wedge resection, Clindamycin (OR)
other non-cardiac vancomycin
mediastinal gram-negative
procedures),closed bacilli
tube thoracostomy
Vascular Staphylococcus Cefazolin Clindamycin (OR)
aureus; CoNS (OR)Cefuroxime Vancomycin
Appendectomy Gram-negative Piperacillin-Tazobactam Amikacin + Metronidazole
bacilli; anaerobes (OR) Cefoperazone+
sulbactam
Biliary tract Gram-negative Piperacillin-Tazobactam Amikacin + Metronidazole
sulbactam
Colorectal Gram-negative Piperacillin-Tazobactam Amikacin + Metronidazole
sulbactam
Gastroduodenal Gram-negative Piperacillin-Tazobactam Amikacin + Metronidazole
bacilli; (OR) Cefoperazone+
Streptococci; sulbactam
oropharyngeal
anaerobes (e.g.,
peptostreptococci)
Head and neck Staphylococcus Cefazolin + Clindamycin OR
(major procedures aureus; metronidazole Vancomycin
with an incision streptococci; (OR)
through oropharyngeal Cefuroxime +
oropharyngeal anaerobes (e.g., metronidazole
mucosa peptostreptococci)
(OR) ampicillin–
sulbactam
Peritoneal dialysis Staphylococcus Cefazolin (OR) Clindamycin (OR)
catheter insertion aureus; Cefuroxime Vancomycin
Plastic surgery Cefazolin (OR) Clindamycin (OR)
Cefuroxime Vancomycin
Clean with risk
factors or clean-
contaminated
Urology Gram-negative Ampicillin +sulbactam Amikacin+ Clindamycin
bacilli (OR) (OR)
Clean Cefoperazone+ Vancomycin + Amikacin
with/without entry Sulbactam
into urinary tract
involving
implanted
prosthesis (eg
Penile prosthesis)
Clean
contaminated
80
Trans-rectal Gram-negative Cefoperazone+ Amikacin+ Metronidazole
prostatic surgery
bacilli, Anaerobes Sulbactam
Gynaecological Polymicrobial: Cefazolin (OR) Clindamycin
oncology (for
Gram-positive: Inj cefuroxime
uterine and
Staphylococci,
ovarian cancers)Gram Negative: +/-
Enterococci,
Cervical cancer aerobic Inj Metronidazole# (for
gramnegative, cervical and perineal
Cancers of the Anaerobes procedures)
perineum region Bacteroides spp,
Solid organ Transplants
Liver Staphylococcus Piperacillin-Tazobactam Inj Amikacin + Inj

transplantation aureus; CoNS; (OR) Metronidazole + Inj
Gram-negative Cefoperazone-sulbactam Fluconazole
bacilli, Fungus +
Inj Fluconazole
Kidney Staphylococcus Cefazolin (OR) Clindamycin (OR)
transplantation aureus; CoNS; Cefuroxime Vancomycin
Heart, heart-lung Staphylococcus Cefazolin (OR) Cefazolin (OR)
transplantation aureus; CoNS; Cefuroxime Cefuroxime
#- if Bacterial Vaginosis is suspected, oral metronidazole 500 mg BD for 7 days is given,
beginning at least 4 days pre-op.
Table 3: Recommended Doses and Redosing Intervals for Antimicrobials for surgical
prophylaxis
Antimicrobial Adult dose Paediatric dose Infusion Intraoperative

time Redosing
Interval,
(hours)
Cefazolin 2 g, 3 g for pts 30 mg/kg 10 min 4
weighing ≥120
kg
Cefuroxime 1.5 g 50 mg/kg 15-30 min 4
infusion
Ceftriaxone 2g 50-75 mg/kg 30min NA
Sulbactam(SBT)- 3g 40-80 mg/kg 15-20 min 4
Cefoperazone(CPZ)- (1SBT:2CPZ) (1SBT:2CPZ)
60-120 mg/kg
(1SBT:2CPZ)
Piperacillin (PPZ)- 4.5 g For > 9months of 30 min 2
Tazobactam(TZB) age-
112.5 mg/kg
(100 mg of PPZ+
12.5 mg of TZB)
81
Metronidazole 500 mg 15 mg/kg. 15-30 min NA
Neonates
weighing <1200
g should receive
a single dose
7.5 mg/kg
Clindamycin 900 mg 10 mg/kg 20 min 6
Amikacin 15 mg/kg 15-20 mg/kg 60 min NA
Vancomycin 15 mg/kg 15 mg/kg 60 min NA
Fluconazole 400 mg 6 mg/kg 20 min NA
Ampicillin+ 3g 15-30min 4
Sulbactam
82
CHAPTER 6: Treatment of Multi-Drug Resistant Bacterial pathogens
A. Gram Negative Infections: Culture showing Carbapenem Resistant organisms

• Most Carbapenem resistant organisms are extremely resistant to β-lactam antibiotics,
aminoglycosides, Fluoroquinolones, tetracyclines and β- lactam–βlactamase inhibitor
combinations.
• Isolate the patient.
• Follow contact precautions as per WHO guidelines.
• Adequate source control.
• Check the culture and sensitivity report, If Ceftazidime-avibactam sensitive start
Inj Ceftazidime-avibactam irrespective of the site of infection.
• If Culture & Sensitivity of CAZ-AVI is not reported, immediately consult with
Microbiologist.
• If a sample is sent for rapid diagnostic test, based on the type of carbapenemase detected
first choice of antimicrobials can be prescribed from below Table
• For E.coli- Because of PBP-3, Ceftazadime-avibactam+ aztreonam resistance is
documented. Avoid empirical use of Ceftazadime-avibactam+ Aztreonam for E.coli,
unless synergy is proven.
• Prefer a combination of Polymyxins+ tetracyclines/ aminoglycosides over
monotherapy.
• Polymyxin B has reliable pharmacokinetics as compared to colistin and as per anecdotal
reports considered less nephrotoxic as compared to colistin. Hence prefer Polymyxin B
over colistin except for urinary tract infections.
• High dose Meropenem can be considered if Meropenem MIC is < 16 mcg/ml
Table: Choice of antimicrobials in CR Enterobacteriaceae isolates
Isolate characteristics:
1st choice Antimicrobials
Inj Ceftazidime-avibactam 2.5 g IV q8h,
a) NDM (Except for E.coli NDM) infused over 3h PLUS Inj Aztreonam 2 g IV
q8h, infused over 3h along with a invitro
active agent
a) KPC
b) OXA-48 like Inj Ceftazidime-avibactam 2.5 g IV q8h,
c) CRE susceptible to Ceftazidime- infused over 3h
avibactam
83
Table 2: Alternative Agents for treatment of infections with Carbapenem
Resistant Enterobacteriaceae (CRE) pathogens based on culture sensitivity
reports:
• Based on the C&S report a combination of two invitro active agents (belonging to two
different antimicrobial classes like Polymyxins, tigecycline, aminoglycosides and
fluoroquinolones) may be considered
• For Intra-abdominal infections prefer a combination based on High dose tigecycline as
it has excellent penetration in the abdominal cavity
• Avoid using aminoglycosides for lung and intraabdominal infection (use if other
options are not available)
Comments
Alternative agents (If invitro
susceptible)
Inj Tigecycline (high dose) Tigecycline has excellent
based combinations with either penetration in the abdominal
cavity hence prefer High dose
Inj Polymyxin B/ Inj Colistin Tigecycline based combination
Intra-
(OR) for Intra-Abdominal infections
abdominal
Inj Amikacin
infections
(OR)
Inj High dose Meropenem
(OR)
any other invitro active drug
Inj Polymyxin B/ Colistin combination If Tobramycin is active, choose
with either inhalational tobramycin along
Hospital
Inj Tigecycline (high dose) with IV antimicrobials
Associated
(OR)
Pneumonia/
Inj Amikacin
Ventilator
(OR)
Associated
Inj high dose Meropenem
pneumonia
(OR)
Inj Polymyxin B/Colistin Intravenous Polymyxins, Tigecycline and
+IVT/intrathecal aminoglycosides do not achieve
combination with either therapeutic concentration in
Inj Tigecycline (high dose) CNS. Hence prefer Intra-
Intravenous +IVT/intrathecal ventricular/Intra-thecal route
Central
(OR) along with Intra-venous route for
Nervous system
Inj Amikacin Intravenous +IVT/intrathecal this groups of drugs.
(OR)
High dose Meropenem
(OR)
84
Colistin is preferred as it
Inj Colistin based combination with a converts into its active form in
CAUTI
second invitro active agent the urinary tract and achieves
high concentration
Inj Polymyxin B/ Colistin combination Avoid tigecycline for blood
with either stream infections as it doesn’t
(OR) achieve therapeutic
Inj Amikacin concentration in blood
CLABSI
(OR)
(OR)
Complicated
Inj Tigecycline (if sensitive) based
Skin and Skin
combination along with second in-vitro
structure
active agent
infections
(3) Infections with Carbapenem Resistant Acinetobacter Baumannii

(CRAB) pathogens:
• Combination therapy with at least two active agents (one agent preferably high dose
sulbactam even if non-susceptible). Sulbactam has intrinsic whole-cell activity against
Acinetobacter baumannii
Resistant A. baumanii (CRAB) pathogens based on culture sensitivity
reports:
Alternative agents (If invitro Comments
susceptible)
Inj Sulbactam (even if non susceptible) Tigecycline has excellent
based combinations with either penetration in the abdominal
cavity hence prefer High dose
Inj Tigecycline (high dose) Tigecycline based combination for
(OR) Intra-Abdominal infections
Intra- Inj Polymyxin B/ Inj Colistin
abdominal (OR)
infections Inj Amikacin
(OR)
Inj High dose Meropenem (if MIC <16)
(OR)
85
Inj Sulbactam (even if non susceptible) If Tobramycin is active, choose
based combinations with either inhalational tobramycin along
(OR) with IV antimicrobials
Inj Polymyxin B/ Colistin
Hospital
Associated
Inj Tigecycline (high dose)
Pneumonia/
(OR)
Ventilator
Inj Amikacin
Associated
(OR)
pneumonia
Inj high dose Meropenem (if MIC <16)
(OR)
Inj Sulbactam (even if non susceptible) • Polymyxins, Tigecycline and

based combinations with either aminoglycosides do not
achieve therapeutic
Inj Polymyxin B/Colistin Intravenous concentration in CNS. Hence
+IVT/intrathecal prefer Intra-ventricular/Intra-
(OR) thecal route along with Intra-
Inj Tigecycline (high dose) venous route for this groups of
Central Intravenous +IVT/intrathecal drugs.
Nervous system (OR) • If Levofloxacin/moxifloxacin
Inj Amikacin Intravenous is active in-vitro then they can
+IVT/intrathecal be preferred in CNS infections
(OR) as they achieve good
High dose Meropenem (if MIC <16) concentration
(OR)
Inj Sulbactam (even if non susceptible) + Colistin is preferred as it converts

Inj Colistin based combination into its active form in the urinary
CAUTI tract and achieves high
concentration
Inj Sulbactam (even if non susceptible) Avoid tigecycline for blood stream
based combination with either infections as it doesn’t achieve
Inj Polymyxin B/ Colistin therapeutic concentration in blood
(OR)
CLABSI Inj Amikacin
(OR)
Inj high dose Meropenem (if MIC <16)
(OR)
Inj Sulbactam (even if non susceptible)
Complicated +
Skin and Skin Inj Tigecycline (if sensitive)
structure (OR)
infections combination with second in-vitro active
agent
86
Resistant Pseudomonas Aeruginosa (CRPA) pathogens based on culture
sensitivity reports:
Alternative agents (If invitro Comments

susceptible)
Inj Cefepime 2 g IV q8h, infused over 3 hours
(OR)
Inj Polymyxin B/ Inj Colistin based
combination therapy with
Intra-
abdominal
Inj Amikacin
infections
(OR)
Inj High dose Meropenem (If MIC < 16)
(OR)
Inj Polymyxin B/ Inj Colistin based If Tobramycin is active,
Hospital combination therapy with choose inhalational
Associated tobramycin along with IV
Pneumonia/ Inj Amikacin antimicrobials
Ventilator (OR)
Associated Inj High dose Meropenem (If MIC < 16)
pneumonia (OR)
Inj Polymyxin B/Colistin Intravenous Polymyxins,
+IVT/intrathecal based combination with either aminoglycosides do not
achieve therapeutic
Inj Amikacin Intravenous +IVT/intrathecal concentration in CNS.
Central
(OR) Hence prefer Intra-
Nervous system
High dose Meropenem (If MIC < 16) ventricular/Intra-thecal route
(OR) along with Intra-venous
any other invitro active drug route for this groups of
drugs.
Colistin is preferred as it
Inj Colistin based combination with second converts into its active form
CAUTI
invitro agent in the urinary tract and
achieves high concentration
Inj Polymyxin B/ Colistin based combination
with second in vitro agent
(OR)
Inj Amikacin
CLABSI
(OR)
(OR)
87
Complicated
Inj Polymyxin B/ Colistin based combination
Skin and Skin
with second invitro agent
structure
infections
Dosing of antimicrobials for Carbapenem resistant organisms

Ceftazidime -avibactam 2.5g IV q 8h as infusion over 3 hours Intraventricular
/intrathecal dose
Ceftazidime -avibactam CZA-2.5g IV q 8h as infusion over 3 hours Not required
(CZA) + + AZT-2g IV q 8h as infusion over 3 hours
Aztreonam(AZT) both administered at the same time.
Meropenem 2g IV q8h as infusion over 2-3 hours Not required
Colistin LD: 9MU IV f/b 9MU-10.9 MU IV 10-20mg q 24h
divided in 2-3 doses
Polymyxin B LD: 20,000-25000 IU/kg over 1h f/b 50,000 units q 24h
12500-15000 IU/kg every 12h infused
over 1h
High dose Tigecycline LD-200mg IV f/b MD 100mg IV q12h 5mg q24h
Amikacin 20mg/kg IV q 24h, subsequent dosing 5-50 mg q 24h
based on Therapeutic monitoring of serum
levels of amikacin
Gentamycin 7mg/kg IV q24h subsequent dosing based 1-8mg adjust as
on Therapeutic monitoring of serum levels per table2)
of Gentamycin
Cefepime 2 g IV q8h, infused over 3 hours Not required
Sulbactam 2g IV q6-8h Not required
Minocycline 200mg IV q12h Not required
IV Fosfomycin 4-6g IV q6h Not required
High dose ampicillin- 9g IV q8h over 4 hours Not required
sulbactam (2g of
ampicillin and 1 gm of
sulbactam)
Cefoperazone- 4g IV q6-8h NA
sulbactam (1g/1g)
88
Gram Positive Infections
B. Antibiotics of choice for MRSA infections:
• Isolate the patient and follow hand-hygiene practices to prevent spread.
• Choice of antibiotic will depend on the invitro susceptibility profile and source of infection
along with patient specific factors. Depending upon these, the drugs from the below table
can be used.
• Tab Linezolid can be substituted for intravenous linezolid wherever long duration of
therapy required.
• Vancomycin and teicoplanin belong to the same group and cross-reactivity can occur in
patients with history of hypersensitivity to Vancomycin. However teicoplanin has lesser
incidence of nephrotoxicity and thrombocytopenia.
Alternative Agents Comments
Recommended
Indications
Antibiotics:
Hospital Inj Linezolid 600 mg IV Inj Vancomycin LD Choice between
associated q12h 20-35 mg/kg f/b MD Vancomycin
pneumonia 15-20 mg/kg IV q8- and Linezolid to
12h be guided by
OR patient-specific
Inj Teicoplanin factors (renal
12 mg/kg q12h x 3 functions,
doses; f/b MD 10 concomitant
mg/kg q24h bacteraemia )
Bone and Joint Inj Vancomycin LD 20- Daptomycin 8-10 Choice of oral
Infections 35 mg/kg f/b MD 15-20 mg/kg q 24h depending on
mg/kg IV q8-12h OR sensitivity:
OR Inj/Tab Linezolid Linezolid 600
Inj Teicoplanin 12 mg/kg 600mg IV/PO q12h mg q12h
q12h x 3 doses f/b 10 OR
mg/kg q24h TMP-SMX
800/160 mg
OR
Doxycycline 100
mg q12h
Central nervous Inj Linezolid 600 mg IV Inj Vancomycin LD *For
system q12h 20-35 mg/kg f/b MD intraventricular
15-20 mg/kg IV q8- dose refer to
12h + Intraventricular chapter 2
Vancomycin 5-20 mg
q24h*
89
Bloodstream Inj Vancomycin LD 20- Inj Linezolid 600mg
infections 35mg/kg f/b MD 15-20 IV q12h
mg/kg IV q8-12h
(OR)
Inj Teicoplanin 12 mg/kg
q12h x 3 doses f/b 10
mg/kg q24h)
Skin and soft Inj Vancomycin LD 20- Inj Clindamycin 600-
tissue infection 35mg/kg f/b MD 15-20 900mg IV q8h
mg/kg IV q8-12h
(OR)
Inj Teicoplanin 12 mg/kg
q12h x 3 doses f/b 10
mg/kg q24h)
Native Valve Inj Vancomycin 25 Inj Daptomycin 6 Vancomycin
Infective mg/kg loading dose f/b mg/kg q24h (for trough levels to
Endocarditis 30 mg/kg/day in 2-3 Right-sided IE) for 6 be monitored – 1
equally divided doses weeks hour before the
given intravenously for 6 OR 4th dose
weeks Inj Daptomycin 8-10
mg/kg q24h (for Left-
sided IE) for 6 weeks
Prosthetic Valve Inj Vancomycin 25 Inj Daptomycin 6

Infective mg/kg LD f/b MD 10 mg/kg q24h (for
Endocarditis mg/kg q8h IV for 6 Right-sided IE) for 6
weeks weeks
+ OR
Cap Rifampicin in three 8-10 mg/kg q24h (for
divided doses, max dose Left-sided IE) for 6
900 mg/day for 6 weeks weeks
+ +
Inj Gentamicin 3- Cap Rifampicin in
5mg/Kg q24 h three divided doses,
max dose 900 mg/day
for 6 weeks
(Paediatric 15
mg/kg/day)
+
Inj Gentamicin 3-
5mg/kg q24 h
90
C.Infections with Vancomycin Resistant Enterococci (VRE) pathogens:
• Adequate source control should be done before initiating antibiotics.
• Choice of linezolid or daptomycin is based on patient specific factors (tolerability, drug
interactions, need for gram-positive treatment for pneumonia, other infections, etc.)
• VRE endocarditis or other high-burden infections in which source control is not achievable:
Daptomycin 12 mg/kg IV daily -Consider combination therapy with a B-lactam -Choice of
B-lactam to depend on patient specific factors.
• Combination Therapy: -
o B-lactams reduce the net positive bacterial surface charge of VRE, and thereby
enhance the bactericidal effect of daptomycin.
o In vitro data shows synergy between daptomycin and various B-lactams (ampicillin,
ceftaroline, ertapenem, ceftriaxone, and cefepime)
Indications Recommended Antimicrobials: Duration
Inj Linezolid 600 mg iv q12h 7 to 14 days
IAI
Inj Daptomycin 4 mg/kg IV q24 h 7 to 14 days
OR
cSSI
Inj Linezolid 600 mg iv q12h
Inj Linezolid 600 mg iv q12h 10-14 days

OR
Complicated Inj Daptomycin 6-12 mg/kg IV q24 h
Inj Ampicillin 1-2g iv q6h 7 days
OR
UTI Fosfomycin 3g single dose, PO
OR
Tetracycline 100mg BD, PO
Uncomplicated
OR
Doxycyline 100mg BD, PO
OR
Nitrofurantoin 100mg PO q6h
Inj Linezolid 600 mg iv q12h 7 to 14 days
Blood OR
Inj Daptomycin 8-12 mg/kg IV q24 h
7 to 14 days
Infective Inj Daptomycin 8-12 mg/kg IV q24 h
endocarditis
Hospital associated 7 to 14 days
Inj Linezolid 600 mg iv q12h
pneumonia
Inj Linezolid 600 mg iv q12h 10-14 days
Meningitis
OR
91
Inj Daptomycin 8-12 mg/kg IV q24 h along with
Intraventricular 2-5mg q24 h
Bone and Joint Inj/Tab Linezolid 600 mg iv q 12 h 4-6 weeks
OR
Inj Daptomycin 6mg/kg IV q 24 h
92
Sl. Reconstitute Renally Hepatic Storage &
Antimicrobial Infusion
NO Adult dose Paediatric dose & Dilution adjusted doses impairment Stability
time
(CrCl ml/min) dose
1 Low Dose: 1,200,000units(>30Kg) 3 ml of WFI - CrCl 10-50 Refrigerate
0.6-1.2 MU IM 100 ml decrease dose by solutions at 2
30 min
q4h 600,000units(<30Kg) of N.S 25%, to 8°C and
High Dose: administer
20 - 40 lac Units CrCl<10 within 7 days
IV q4h decrease dose by
Inj. Benzyl Not
(For meningo - 50%
penicillin Available
coccal meningitis,
the administration
should be done
q2h)
Max Daily Dose:
24 MU
2 Mild-mod 50-100mg/kg/day in 500 mg in 10 No Dosage
infections: 1 g IV 3- 4 divided doses. ml of NS or Adjustment
Inject
q4h (6 g) 5% dextrose needed
Inj Cloxacillin slowly over Not
Serious infection: 100-200mg/kg/day in
3-4 minutes Available
2 g IV q4h (12 g) 3- 4 divided doses.
Max Daily Dose:
12 g
3 5 ml of WFI CrCl 10-20: After
100 ml of 0.5-1 g q8h reconstitution,
2 g IVq4h
Inj. Ampicillin 400mg/ kg/ day IV/IM 30-60 min N.S. Not solution is
Max Daily Dose:
q6h HD: 1 g q12h, Available stable at
12 g
1 g post HD room temp. for
up to 1 hour,
93
time
(CrCl ml/min) dose
and 48hours if
refrigerated
4 40 mg/kg/day CrCl 10-30: 1.2 Store at a

(amoxicillin) IV in 2 5 ml of WFI g IV stat f/b MD controlled
divided doses per 300 mg 600 mg IV q12h room
Inj Amoxicillin
- None temperature,
sodium & 4 min
90mg/kg/day if CrCl<10: 1.2 g between 20
clavulanate (BOLUS)
1.2 g IV q8h penicillin Resistant IV stat f/b MD and 25°C
potassium
S.pneumoniae 5 ml of WFI 600 mg IV q24h Not
(each 30 mg 30 – 40 min
Severe infections: suspected in otitis per 300 mg- Available
contains 25 mg (INFUSIO
1.2 g IV q6h media 100mg/kg/day 50 – 100
Amoxicillin & N)
ml of NS ( 50
5 mg clavulanate )
ml of NS
per 600 mg
Amoxiclav)
5 CrCl< 30: 1.5-3 Contraindic

g IV q12h ated in
patients with
5 min 5 ml WFI
1.5- 3 g IV q6h CrCl < 15: 1.5- a previous
(BOLUS) None 3 g IV q24h history of
Inj. Ampicillin &
For cholestatic
Sulbactam 15-30 min 5 ml WFI 2ml
Acinetobacter: 3g jaundice/hep
(INFUSIO of WFI per
IV q4h atic
N) 0.75 g – 25ml dysfunction
of NS/0.75 g ass with
Ampicillin -
Sulbactam
94
time
(CrCl ml/min) dose
6 5 ml of WFI CrCl 20-40: Reconstituted
4.5 g IV q8h per gm of 3.375g IVq6h solutions will
Severe infections Piperacillin CrCL <20- maintain
Inj Piperacillin (20ml for 2.25g IV q6h potency for
No Dosage
sodium & and 200-400 mg/kg/day in 3- 4.5g of HD: 2.25g IV 24h at room
30 min adjustment
Tazobactam antipseudomonal 4 divided doses piperacillin q8h LD temperatures
needed
coverage: 4.5 g tazobactam)- Additional dose
IV q6h 100 ml of NS of 0.75g
following each
HD sesssion
7 13 ml of WFI CrCl 30- 60: 2 g
IV q4h
50 ml of N.S CrCl 10 – 30: 2
g IV q8h
50 mg/kg/day
CrCl< 10: 2 g
Usual dose: 3.1 g
IV q12h
IV q6h
CrCl < 10 with CrCl < 10
> 3 months <60 kg:
hepatic with
Inj Ticarcillin & Severe infections: 200-300mg/kg/day IV
dysfunction: 2 hepatic
Clavulanic acid 3.1 g IV q4h divided q4-6h 30 min
g IV q24h dysfunction
Patients on : 2 g IV
3 g ticarcillin, + >
peritoneal q24h
100mg clavulanic
dialysis: 3.1 g
acid
Ivq12h
Patients on
HD: 2 g IV
q12h with 3.1 g
IV post HD
95
time
(CrCl ml/min) dose
8 50 mg/kg/day IV 10 ml of After
CrCl 35-54:
in 3 divided doses WFI reconstitution,
Full dose IV q8h
Usual dose: 1 g 30 ml of stable for 24 h
CrCl 11-34:
Inj Cefazolin IV q8h NS at 2–8°C
100 mg/kg/day IV in 3- 50% of the usual Not
Sodium For severe 10 min
4 divided doses dose IV q12h, Available
infections: 2 g IV
CrCl<10: 50%
q6- 8h
of the usual dose
Max Daily Dose :
IV q24h
8g
9 30-100 (60 50 to 100 mg/kg/day IV CrCl 10-20:
mg/kg/day) IV in q6-8h 2/6/15 ml 750mg IV q12h
three divided Bone and joint 5 min of WFI CrCl <10:
doses infection: 150 (BOLUS) 750mg IV q24h
Mild-mod mg/kg/day IV q8h Not
Inj Cefuroxime
infections: 750 Bacterial Meningitis- 15-30 min 50-100 Available
mg IV q8h 200 to 240 mg/kg/day (INFUSIO ml of NS
Serious IV q6-8h N)
infections: 1.5 g
Ivq8h
10 100mg/kg/day IV in 3- 2/6/15 ml CrCl <50-10: After
4 divided doses of WFI 2g IV q12h reconstitution,
50-100 CrCl <10: 2 g if not used
Inj Cefotaxime 10 min Not
1-2 g IV q6-8h Meningitis: ml of NS IV q24h immediately,
Sodium Available
200mg/kg/day IV in 4 stable for
divided doses 7days at 2–
8°C
11 50-100 mg/kg/day IV in 5 ml of No Dosage No dosage After
Inj Ceftriaxone 2 divided doses WFI reconstitution,
1-2 g IV q12-24h 30 min adjustment adjustment
Meningitis: 20 ml of needed needed if not used
96
time
(CrCl ml/min) dose
100 mg/kg/day IV in 2 NS immediately
divided doses stable for 24 h
at 2–8°C
12 o mCrCl 50 -30: 1g Stable at room
5 l IV q12h temp. or
min(BOLU o CrCl 30-10: refrigeration
Inj. Ceftazidime 100 mg/kg/day in 3 S) f 1g IV q24h for 3 days.
divided doses No dosage
1-2g IV q8-12h WFI / CrCl<10:
adjustment
15 – 30 250 mg – 500 mg IV q24h
100 mg/kg/day in needed
min None
Meningitis
(INFUSIO 2.5 ml of
N) WFI /250 mg
– 50 ml of NS
13 2 yrs to < 18yrs - 10ml of CrCl 31-50 -
62.5 mg/kg to a WFI/NS /5% 1.25g q8h (CAZ
maximum of 2.5 g(CAZ dextrose 1g and AVI 0.25
50 mg/kg and AVI g)
12.5 mg/kg) to a CrCl 16-30 –
maximum dose of CAZ 0.94g q12h
2 g and AVI 0.5 g (CAZ 0.75g and Avibactam
Inj Ceftazidime 2.5g q8h
6months to <2yrs - AVI 0.19 g) dosage
(CAZ) and (CAZ 2 g and 2hrs
62.5mg/kg (CAZ 50 CrCl 6-15- adjustment
avibactam (AVI) AVI 0.5g)
mg/kg and AVI 12.5 0.94g q24h not available
mg/kg) (CAZ 0.75g and
AVI 0.19 g)
3months to < 6months CrCl < or <5 –
-50 mg/kg (CAZ 40 0.94g q48h
mg/kg and AVI 10 (CAZ 0.75 g
mg/kg) and AVI 0.19 g)
97
time
(CrCl ml/min) dose
14 30mg/kg IV q6-8h 3-5 CrCl10 -30 Room

min(bolus) decrease dose by temperature,
20-60 50% after an avoid
min(infusio initial loading excessive heat
500 mg-1g IM/IV n) dose of 1 or 2 g. used within 48
q8h(UTI), 1g-2g h following
Inj Aztreonam IM/IV q8h (mod- <10 decrease to Not constitution if
severe systemic 25% after the Available kept at
infections) Max initial dose controlled
Daily Dose: 8 gm room
temperature or
within 7 days
if refrigerated.
98
time
(CrCl ml/min) dose
15 Sulbactam After
o mrequires renal reconstitution
l dose ifnot used
Inj Sulbactam 3g (1SBT:2CPZ) o modification immediately
(SBT)- 40-80mg/kg f < 30-15: 1 g chemically
Cefoperazone WFI per q12h ( max stable for7
(CPZ) (1SBT:2CPZ) 1 g vial 2g/day) days at 2-8 °C
Sulbactam (SBT) 60-120mg/kg < 15 : 500 mg Max and24h at 9-
& Cefoperazone 40-80mg/kg q12h (max 99ecommen 25°C
(CPZ) sodium Inj.( (1SBT:2CPZ) (1SBT:2CPZ) o m1g/day) der dose of
1:1) Usual dose : 3 g 30 min l <30-15:Inj Cefoperazon ( At least total
12 hourly 60-120mg/kg o cefoperazone/sul e is 4g/day daily dose of
(1SBT:2CPZ) f bactam (1:2) 1.5 in hepatic cefoperazone
WFI per g q8h or 3 g impairment – 3 g/
Sulbactam (SBT)& Serious infections 1 g vial q12h day)
Cefoperazone :6g < 15: Inj
(CPZ) sodium Inj. 12 hourly cefoperazone/sul
( 1:2) : bactam (1:1) 1
g q12h plus
Inj cefoperazone
1 g q12h
16 o m< 50-10: 1 g OD reconstituted
l < 10: 0.5-1 g Solutions
o OD stable
1-4gm/day f Hemodialysis for 18 h at
Inj Cefepime 50mg/kg q12 hr 30 min
2-3 doses WFI / patients: 1 g on room temp(15-
250 mg – 2.5 day 25°C) and for
ml of 1 then 500 mg 2 daysif kept
WFI / everyday
99
time
(CrCl ml/min) dose
250 mg in arefrigerator
(2 -8°C)
17 10 ml of 2 g LD f/b The Room
WFI – None CrCl < 50-20 : pharmacoki temperature
1 g q12h netics of upto 6h and 2-
50 mg/kg/day in
cefepime 8°C for 24h
two divided 4 min
10 ml of CrCl 20-5 : 1 g were
doses (BOLUS)
>2 months: 50mg/kg iv WFI – 100 ml q24h unaltered in
Inj.Cefpirome Usual dose: 1 g 20 – 30
q8 – 12h not to exceed of NS per g patients with
sulphate q12 h min
2 g/dose hepatic
Severe (INFUSIO
impairment
infections: 2 g N)
who
q12 h
received a
single 1 g
dose
18 10 ml of LD f/b
WFI per < 60-30:
50/12.5 Vial – 500 ml 500/62.5 mg
mg/kg/day in two of NS q24h
divided doses
<10: 250 /31.25
Inj.Cefepime Usual dose: mg
30 min
tazobactam 1.125gm IV q12h q24h
Severe HD: 1000/125

infections: 2.25g mg
IV q8-12h on day 1, then
500/62.5 mg
q24h
100
time
(CrCl ml/min) dose
Should be given
Post HD
19 20 ml of If initial dose is
WFI 500
100 ml mg 6h, then
of N.S. LD of
per 500 500 mg IV f/b
mg < 70-41: 500 mg
q8h
For most <40-21: 500 mg
infections : 500 q12h
Inj Imipenem & mg q6h < 20 or HD :
Cilastatin 30 min 250 mg q24h
Sodium Severe <5: do not give
infections : 1 g until HD is
q8h initiated
within 48 hrs
Patients on
hemodialysis
should receive
imipenem after
dialysis
5 ml of If CrCl 26- Reconstituted

Usual dose: 1 g 30 min
WFI per 50ml/min-1gm solutions are
q8h Over 3
20 20mg/kg q8h 250 mg q8h No dosage stablefor up to
Inj.Meropenem hours for
(Max upto 1g q8h) - adjustment 2 h atroom
Meningitis or severe
50 ml of If CrCl 10-25- temperature,
treatment of infections
N.S. 500mg q12h 15 to 25 °C ,
101
time
(CrCl ml/min) dose
resistant gram - or for up to12
negatives : 120 If CrCl-<10 - hours at 4 °C
mg/kg/day in 500mg q24h
3 divided
doses (2 g q8h)
21 3 months-12 yr: CrCl <30- The
15mg/kg q12h not to 500mg q24h reconstituted
exceed 1 g/day solution,
immediately
diluted in
0.9% Sodium
Chloride
Injection
may be stored
at room
No dosage temperature
Inj Ertapenem 1gm IV/IM q24h 30 min
adjustment (25°C)
and used
within 6h or
stored for 24h
under
refrigeration
(5°C) and used
within 4h
after removal
from
refrigeration.
102
time
(CrCl ml/min) dose
22 Infusion 10 ml of Dose mg/day: reconstituted
LD 25-30 mg/kg rate not WFI per 15.4 mg X CrCL solution may
f/b MD 15 exceeding 500 mg be stored in
mg/kg q8-12h 15 mg/min 100 ml HD: 1 g q48h refrigerator for
Usual of 0.9 (after HD) up to 96 h
Meningitis: 15 infusion % N.S. without
mg/kg q8-12h rate: or 5% significant loss
Inj. Vancomycin 40mg/kg/d Not
1 g in 200 dextrose of potency
hydrochloride Divided q6-8 h Available
Adults (60 kgs ml 0.9% per 500
with normal NS over mg
CrCL): 1.5 g 60 min &
(loading dose) 500 mg in
f/b MD 1g q12h 100 ml
0.9% NS
over 30min
23 LD 6 mg/kg 12h 1.5 ml of CrCl< 60-40 or The
for first 3 doses WFI per on HD the dose reconstituted
Inj Teicoplanin f/b MD 6 mg/kg 200 mg – (6 or 12 mg/kg) and diluted
Bolus and q24h Not to be given in None should be solutions
Infusion Usual dose : 400 children less than 30 1 min For infusion administered should be used
mg IV 12h for 3 days of age (Bolus) 1.5ml of q48h and 72h immediately
doses f/b 400 mg From 1 month-18 years WFI per or stored
q24h LD: 10mg/kg q12h for X` 200 mg – Maximum dose between 2 –
For serious first 3 doses 30 min 100 ml in 8°C
infections MD: 6-10mg/kg( max: (Infusion)3 of NS patients on HD: for up to 24h
12 mg/kg q12h 400mg) q24h 10 mg/kg q48 -
for 3 doses 72h
followed by 12
mg/kg q24h
103
time
(CrCl ml/min) dose
24 SSTI : 350 mg CrCl < 30: reconstituted
6 mg/kg/day in 100 ml solution- 12
of NS q48h hat room
Inj.Daptomycin for severe 30 min temp. or
infections and up to 48 h
endocarditis: when
10-12 mg/kg/day refrigerated
25 10mg/kg IV/oral q8h No dosage Store at 25°C
adjustment (77°F). Protect
from light.
Keep bottles
tightly closed
to protect from
600mg IV/oral No dosage
Linezolid 30-120 min moisture. It is
q12h adjustment
recommended
that the
infusion bags
be kept in the
overwrap until
ready to use.
26 To be avoided in 50 mg in No dose Do not
LD: 100mg IV, children less than 8 100 ml of NS. adjustment Child Pugh administer
f/b MD 50mg years of age Class C- through the
q12h 8-11 years: LD: 100mg same line -
Inj Tigecycline 1.2 mg/kg IV q12hr, 60 min IV f/b MD AmB-d,
For CRE/CRAB: Max upto 50 mg q12 h. 25 mg ABLC,
LD: 200mg, f/b q12h diazepam,
MD 100mg q12h 12-17 years: esmoprazole,
50 mg IV q12 h. omeprazole
104
time
(CrCl ml/min) dose
27 <7 days and <2kg or 20ml in WFI, No dose Once diluted
>7days and < 1.2kg- f/b 20 ml of adjustment preparations
5mg/kg IV/IM q12 h; NS may bestored
up to 24 hat
<7 days and >2kg
600-900 mg IV q room
or>7 days and 1.2-2kg
8h temperature
5mg/kg IV/IM q8 h No dose
Clindamycin 20 min
adjustment
Oral dose: 300mg >7 days and >2kg-
q 6-8 h 5mg/kg q 6 h
> 1month-16 yr-
20-40mg/kg/day
divided in 3-4 equal
doses.
28 1 ml of CrCl 59-40 : diluted
WFI / 500 mg 15 mg/kg q36h solution is
f/b 100ml of CrCl 39-30: stable 60 days
NS 15mg/kg q48h refrigerated,
New born:LD 10mg/kg
CrCl <30: Not then 24h at
15 mg/kg IV IM f/b MD 7.5mg/kg
Recommended. No dose room temp.
Inj Amikacin q24 h IM or IV infusion over 60 min
Patient on adjustment or stable 30
max dose: 1.5g 2 hours q12 h
intermittent days frozen,
dialysis, the then 24 hours
dose thawed and
should be given stored at
after dialysis room temp.
29 4-5 mg/kg q24h To be avoided in 2 ml of Cr Cl 40-60: controlled
neonates unless for life WFI, f/b 5 mg/kg q36hr No dose room
Inj Gentamycin 20 min
In critically ill: threatening infections. 50ml adjustment temperature,
5- 7 mg/kg q24h
105
time
(CrCl ml/min) dose
In infants and neonates Cr Cl <40: between 20
upto 1 week: 6 mg/kg 4 mg/kg, next and 25°C
/day in divided doses dose should
q 12 h. preferably be on
the basis of
In children : 3mg/kg concentration
q24h
30 2 ml of Cr Cl 40-60:
WFI, f/b 5mg/kg q36h
4-5mg/kg q24h. 50ml
Cr Cl<40_ 4
Inj Tobramycin mg/kg, next No dose
20 min
In critically ill: dose should adjustment
7mg/kg q24h preferably be on
the basis of
concentration
31 4.8 ml of No dose Reconstituted
WFI f/d 250- adjustment stablefor 24 h
For most
500 at orbelow
infections:
ml of NS room
500 mg OD No dose
Tab Azithromycin 20 min temperature,
adjustment
30°Cor for 7
Enteric fever:
days ifstored
mg/kg/day)
underrefrigerat
ion 5 °C
32 400 mg 8-12h 100 ml CrCl< 50 : Controlled
Ciprofloxacin
60 min of N.S. 50% of dose room
Oral 500-750mg Q24h
106
time
(CrCl ml/min) dose
q12h Solutions temperature
Solutions between15 and
containing 30 °C. Do not
multivalent refrigerate
cations
such as
magnesium
33 100ml of NS CrCl 50-10 : Reconstituted
50% of dose OD solutions are
stablefor 14
500-750 mg OD CrCl< 10 : days when
Levofloxacin 25 % of dose stored in
60-90 min
Oral 250-750mg q24h or 50% plastic
q12h dose q48 h Ivcontainers at
5°C or
for 72 hat or
below 25 °C
34 400 mg q12h IV 100 ml of NS CrCl <10 :
60 min
Avoid with 50 % of dose
Ofloxacin (slow
200-400mg q12h heparin q24h
infusion)
solutions
35 100 ml of NS CrCl < 10: 50% End stage
of dose q12 h liver
LD 15 mg/kg, f/b
Metronidazole disease:
MD 7.5 mg/kg 8h 30 min
50% of
or 15 mg/kg q12h
usual dose
12 h
107
time
(CrCl ml/min) dose
36 Colistimethate 40 ml of Cr Cl 79-50: Controlled
(CMS) 0.9 % NS. CBA 2.5- 3.8 room Temp
LD 9-12 MU f/b
Colistin Base mg/kg/day between
MD 4.5 MU q12h
(CBA) in 2 divided 20 – 25 °C
1mg=30,000 U of doses once diluted
Nebulized 30 min for
CMS Mixing with SWFI,
Colistin: 4.5 MU each 1 CrCl 30-49:
Erythromycin Store solution
q12 h million 2.5 mg/kg/day
tetracycline, up to 7 days,
unit
cephalothin Cr Cl:10 -29: between 20
Intrathecal/ventr
may 1.5 mg /kg q36h and 25 °C or
icular colistin:
lead to refrigerated
125,000 IU/day
precipitation between
2 and 8 °C
37 LD: 25000 IU/Kg 300- 500ml No dose
f/b MD 10000- of 5% adjustment
12500 IU/Kg Dextrose for
q12h. IV
Intrathecal/Intra
Polymyxin B
ventricular- Intrathecal
50,000 U once administer-
daily for 3 to 4 ation dissolve
days, then every in NS
alternate day
38 Inj Amphotericin 0.5-1.5 LD: 0.25 mg/kg/dose 4 hours 5 ml of WFI CrCl<10: 0.5-
B –deoxycholate mg/kg/day in IV f/b and 0.7 mg/kg IV No data
(AmB-d) D-5% over MD: Increase by 0.25 500 ml of q24-48hr available
24 h mg/kg increments as 5% Dextrose Intermittent
tolerated to 1-1.5 hemodialysis:
mg/kg/day 0.5-1 mg/kg IV
108
time
(CrCl ml/min) dose
q24hr after
dialysis session
Continuous
renal
replacement
therapy: 0.5-1
mg/kg IV q24hr
39 Inj Liposomal 3-5mg/kg/day, 3-5 mg/kg/day OD 120 mints 12 ml of No data No data
Amphotericin B once a day sterile WFI available available
and 5%
Dextrose to
give a final
conc of 1-2
mg/ml
40 Fluconazole LD 12 mg/kg LD 6 mg/kg orally on 20 min Crcl<50: 50% No data
IV stat f/b MD day 1 f/b MD 3 mg/kg of dose should available
6 mg/kg /day /day be given
41 Voriconazole LD 6 mg/kg Below 12yrs safety not 60 min 19 ml of no adjustment is Mild to
12 h f/b MD established WFI for each necessary for moderate
4 mg/kg 12 h 20 mg of oral dosing in hepatic
voriconazole mild to severe cirrhosis
and 180 ml of renal (Child-Pugh
0.9% NS impairment Class A and
for each 20 B)
mg of moderate or 109ecomme
voriconazole severe renal nder loading
impairment dose
(creatinine regimens be
clearance <50 used, but
109
time
(CrCl ml/min) dose
mL/min) Oral that the
voriconazole maintenance
should be dose be
administered halved in
adult
patients
42 Inj Caspofungin LD 70 mg f/b MD LD 70mg/m2 f/b 60 min 10.5 ml of No data mild
50 mg OD MD 50 mg/m2 once 0.9 % NS or available hepatic
daily WFI and impairment
0.9% NS (Child-Pugh
( 250 ml score 5 to 6)
for 70 mg) do not need
& a dosage
100 ml for adjustment
50 mg moderate
hepatic
impairment
(Child-Pugh
score 7 to
9), 70 mg
loading dose
administere
d on Day 1 ,
followed by
35 mg once
daily
43 Anidulafungin LD 200 mg LD 3 mg/kg (not to 60 min 10.5 ml of Data not Data not
f/b MD exceed 200 mg/dose) 0.9 % NS or available available
100 mg OD IV infusion, f/b MD WFI and
110
time
(CrCl ml/min) dose
1.5 mg/kg (not to 0.9% NS(
exceed 100 mg/dose) 250 ml for 70
IV mg)
& 100 ml for
50 mg
44 Inj Micafungin 100 mg IV q24h 60 min No dose No dose
(No loading adjustment adjustment
dose) required required
45 5 mg/kg to 7 mg/kg PO Store at
in four divided doses controlled
Tab/cap 50mg-100 mg PO
(contraindicated under room
Nitrofurantoin q6-12h
one month of temperature
age).
46 800 mg 40 mg/kg/day PO CrCl 15-30: Store at 20° to
sulfamethoxazole sulfamethoxazole and 50%of usual 25°C
and 160 mg 8 mg/kg/day PO dose
Trimethoprim PO trimethoprim given in CrCl <15: not
q24h two divided doses recommended Dispense in
PCP pneumonia- tight, light
Tab
75 to 100 mg/kg resistant
Trimethoprim/Sul
/day PO container.
famethoxazole DS
sulfamethoxazole
and 15 to 20
mg/kg/day PO
trimethoprim in
equally divided
doses q6h
47 20 mg/kg PO 15 mg/kg/day PO in 2 CrCl 30-49: C/I in
Tab Ribavarin -
q12h equally divided doses 200mg PO q12h hepatic
111
time
(CrCl ml/min) dose
for <60kg: If decompensa
- >60 kg- 200mg tion with
PO q8h child pugh
CrCl 10-29: score >6
200mg PO q24h
CrCl <10: not
Recommended
112
References:
1. Indian council of medical research. Treatment Guidelines For Antimicrobial Use in
Common Syndromes 2022 Available from
:https://main.icmr.nic.in/sites/default/files/upload_documents/treatment_amr_2022.pd
f
2. Jarrell AS, Kruer RM, Johnson D, Lipsett PA. Antimicrobial Pharmacokinetics and
Pharmacodynamics. Surg Infect (Larchmt). 2015 Aug;16(4):375-9. doi:
10.1089/sur.2014.180
3. Christian Medical College, Vellore. India. Antibiotic Guidelines 2022 for adults; 2022.
Available from
4. Ambrose PG, Bhavnani SM, Rubino CM, Louie A, Gumbo T, Forrest A et al.
Pharmacokinetics-Pharmacodynamics of Antimicrobial Therapy: It's Not Just for Mice
Anymore, Clinical Infectious Diseases, Volume 44, Issue 1, 1 January 2007, Pages 79–
86, https://doi.org/10.1086/510079
5. Bratzler WD, Dellinger EP, Olsen MK, Perl TM, Auwaerter PG, Bolon MK et al. Clinical
practice guidelines for antimicrobial prophylaxis in surgery, American Journal of Health-
System Pharmacy, Volume 70, Issue 3, 1 February 2013, Pages 195–
283, https://doi.org/10.2146/ajhp120568
6. Tunkel AR, Hasbun R, Bhimraj A, Byers K, Kaplan LS, Scheld WM et al. 2017
Infectious Diseases Society of America’s Clinical Practice Guidelines for Healthcare-
Associated Ventriculitis and Meningitis, Clinical Infectious Diseases, Volume 64,
Issue 6, 15 March 2017, Pages e34–e65, https://doi.org/10.1093/cid/ciw861
7. Pappas GP, Kauffman AC, Andes RD, Clancy JC, Marr AK, Zeichner OL et al.
Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the
Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 62, Issue
4, 15 February 2016, Pages e1–e50, https://doi.org/10.1093/cid/civ933
8. Delgado V, Marsan NA, Waha SD, Bonaros N, Brida M, Burri H et al. ESC Scientific
Document Group , 2023 ESC Guidelines for the management of endocarditis: Developed
by the task force on the management of endocarditis of the European Society of Cardiology
(ESC) Endorsed by the European Association for Cardio-Thoracic Surgery (EACTS) and
the European Association of Nuclear Medicine (EANM), European Heart Journal, 2023;,
ehad193, https://doi.org/10.1093/eurheartj/ehad193
9. Patterson TF, Thompson GR 3rd, Denning DW, Fishman JA, Hadley S, Herbrecht R,
Kontoyiannis DP, Marr KA, Morrison VA, Nguyen MH, Segal BH, Steinbach WJ,
Stevens DA, Walsh TJ, Wingard JR, Young JA, Bennett JE. Practice Guidelines for the
Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases
Society of America. Clin Infect Dis. 2016 Aug 15;63(4):e1-e60. doi:
10.1093/cid/ciw326.
10. National Institute for Health and Care Excellence (2019) Surgical site infections:
prevention and treatment. NICE guideline Available from:
https://www.nice.org.uk/guidance/ng125/chapter/recommendations#preoperative-
phase
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11. Rybak MJ, Le J, Lodise TP, Levine DP, Bradley JS, Liu C et al. Therapeutic monitoring
of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: A
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Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious
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12. Peyrani P, Wiemken TL, Metersky ML, Arnold FW, Mattingly WA, Feldman C et al.
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114
NIZAM’S INSTITUTE OF MEDICAL SCIENCES

HOSPITAL ANTIMICORBIAL POLICY -2023
Compiled by
Nizam’s Institute of Medical Sciences,
Punjagutta, Hyderabad. India 115

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NIMS ANTIMICROBIAL

Empowering Medical Professionals in Rational Prescribing of Antimicrobials

Q. Fungal infections 74-76

Dr. Liza Rajasekhar

Dr. Liza Rajasekhar

Medical Superintendent, NIMS

Dr. P. Usha Rani

Dr. P Usha Rani

Dr. P Usha Rani

Department of Clinical Pharmacology & Therapeutics

Assistant Professors Senior Residents

Instructions to Users of Antimicrobial Guidelines

CRAB Carbapenem resistant Acinetobacter baumanii

To combat AMR, a “three-pillar” approach is recommended:

PRINCIPLES OF RATIONAL ANTIMICROBIAL PRESCRIBING

Rational prescribing of antimicrobials can be divided into 3 zones

1. Pre-Initiation zone: before starting antimicrobials.

Pre-Initiation Zone - Optimisation zone - Antimicrobials-

Step 3: Empiric antimicrobial treatment should be limited to conditions where immediate

Step 4: Choosing an empirical antimicrobial in sepsis and septic shock

WHO AWaRe Classification:

Table 2: Antibiotic Classification as per WHO AWaRe

Pharmacokinetics (PK) is concerned with the time course of antimicrobial concentrations in

Fig 2: PK-PD of Antibiotics

Optimize dosing of antimicrobials based on their PK-PD:

For Type I antibiotics (aminoglycosides, fluoroquinolones, daptomycin and the ketolides),

Type II antibiotics (beta-lactams, clindamycin, erythromcyin, and linezolid) demonstrate

Type III antibiotics (vancomycin, tetracyclines, azithromycin, and the dalfopristin-

Other strategies to optimize the PK-PD of antimicrobials:

1) Choosing right drug to target the site of infection

Table 3: PK-PD of Antibiotics:

Pattern of PK-PD Antibiotics Goal of therapy Post

Table 4 : PK- PD of Antifungals

Pattern of PK-PD Explanation Example Post antifungal

Fig 3: Predictors of bacterial eradication – PK-PD profiles of antibiotics

Right Dose and Dosage Schedule:

1) If meropenem MIC is 8ug/ml, then dose of Meropenem can be increased to 2gm IV

Fig 4: Triad of Host, drug and bug interaction

Fig 5: Relationship of MIC to Vancomycin treatment failure in patients with MRSA

II. Optimization zone -During Anti-microbial therapy

Fig 6: Antimicrobials Switch Criteria (Adapted from ICMR)

Stop antibiotics in the following clinical situations:

Fig 7: Guidance for Antimicrobial Stewardship

CASE DEFINITIONS AND DIAGNOSIS FOR COMMON INFECTIONS

A. ACUTE UNDIFFERENTIATED FEVER (AUF):

Acute febrile illness

Acute localised Acute Undifferentiated febrile

Fig 8: Diagnostic Workflow for AUF

Suspect sepsis when the following are present:

b) Inflammatory: leukocytosis, leukopenia, >10% band forms, thrombocytopenia,

C. ACUTE BACTERIAL MENINGITIS (ABM):

b) Clinically probable meningitis is defined as a child/adult presenting with suspected

Health care associated meningitis/ ventriculitis:

Health care associated meningitis/ ventriculitis is seen in patients undergoing neurosurgeries,

Diagnosis is by neuroimaging. An attempt should be made to establish the etiology by blood

cultures should be obtained. This is especially required if the host is immunocompromised.

St Thomas modification of Dukes criteria:

Table 5: Modified Duke’s Criteria for the Diagnosis of IE

Major 1. Blood culture positive for IE

2. Evidence of endocardial involvement

Echocardiogram positive for IE (TEE recommended for patients with

Minor 1. Predisposition, predisposing heart condition, or IDU

HACEK indicates Haemophilus species, Aggregatibacter species, cardiobacterium hominis,