3A. Antibiotic Policy

Name of Organisation: Document Code: Date of Issue:
Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

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CONTROL BOX
Document Name: Antibiotic Policy
Date of Creation: 15-03-2021
Date of Approval: 24-03-2021
Date of Review: NA
Date of Expiry: 31-03-2022
Approved By: Name: Dr. Daljit Singh

Designation: Managing Director
Signature:
Created By: Name:

Designation: Infection Control Officer
Signature:
NABH Reference: 5th Edition – HIC 3. a
Authorized By: Dr. Amandeep Kaur Issue No./Version No. Issued By: Mr. Tushar Singh
Medical Director Quality Manager
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This document is the property of Chauhan Multispeciality & Trauma Centre, Pathankot, Punjab. Any copying,
reproduction or use in any manner/from, either in part of full, is to be done only with express, written permission.

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TABLE OF CONTENTS
Amendment Sheet...................................................................................................................................
1 Introduction................................................................................................................................... 4
1.1 Purpose of This Policy................................................................................................................. 4
1.2 Responsibility............................................................................................................................... 4
1.3 An Antibiotic policy to guide in empiric therapy has been prepared based on the local
antibiogram of the hospital................................................................................................................... 5
1.4 Antibiotic Prophylaxis to prevent surgical site infections in adults.........................................9
1.5 Fundamental principles of surgical prophylaxis........................................................................9
1.6 Antibiotics Prophylaxis.............................................................................................................. 10
2 ANTIBIOTIC POLICIES OF VARIOUS DEPARTMENTS............................................................16
2.1 CLINICAL HEMATOLOGY & BONE MARROW TRANSPLANTATION......................................16
2.2 CRITICAL CARE AND RESPIRATORY MEDICINE:...................................................................16
3 Antibiotic lock therapy............................................................................................................... 20
4 ENT............................................................................................................................................... 23
5 ENDOCRINOLOGY:..................................................................................................................... 24
6 EYE:.............................................................................................................................................. 25
7 GASTROENTEROLOGY & HEPATOLOGY:...............................................................................25
8 Prophylaxis for Endoscopy........................................................................................................ 28
9 OBSTETRICS AND GYNAECOLOGY......................................................................................... 30
10 Genital Tract Infections.............................................................................................................. 31
11 GYNAE-ONCOLOGY................................................................................................................... 31
12 INTERVENTIONAL RADIOLOGY................................................................................................ 32
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13 INTERAL MEDICINE…………………………………………………………….……………………….…
14 DIALYSIS & NEPHROLOGY PATIENTS:....................................................................................44
15 NEUROSCIENCES DEPARTMENT:............................................................................................45
16 ORTHOPAEDICS DEPARTMENT............................................................................................... 46
17 PAEDIATRICS AND ADOLESCENT MEDICINE:........................................................................48
18 NEONATOLOGY.......................................................................................................................... 50
19 RHEUMATOLOGY:...................................................................................................................... 52
20 Appendix 1: Treatment regimens for Tuberculosis (RNTCP)..................................................53
21 Appendix 2: Antibiotics to be modified in liver disease..........................................................55
22 Appendix 3: Antibacterial agents in Pregnancy: Risk Categories..........................................57
Pregnancy risk category..................................................................................................................... 59
Category A........................................................................................................................................... 59
Category B........................................................................................................................................... 59
Category C........................................................................................................................................... 59
Category D............................................................................................................................................ 60
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Hospital Antibiotic Policy
1 Introduction
The majority of hospitalized patients receive antibiotics for therapy or prophylaxis during their inpatient stay. Majority
receive inappropriate antibiotics. Reasons include continuation of empiric therapy despite negative cultures in a
stable patient, and a lack of awareness of susceptibility patterns of common pathogen. Over prescribing not only
increases the costs of healthcare, but may result in super-infection due to antibiotic-resistant bacteria, as well as
opportunistic fungi and may increase the likelihood of an adverse drug reaction. On the other hand, not prescribing
(when there is an urgent need at the bedside) may also lead to serious consequences
A guideline for empirical therapy based on the local antibiogram has been prepared. The materials in this document
constitute guidelines / recommendations only and are subject to change pursuant to medical judgement relative to
individual patient needs.
1.1 Purpose of This Policy
The aim of implementing this policy throughout the hospital is to ensure that antibiotics are used appropriately. This
should result in more effective treatment of infections so that patient outcomes are optimized.
1.2 Responsibilities
Responsibilities of the Antibiotic Working Group

The terms of reference of the Antibiotic Working Group will be as follows:
 The group shall be known as the Antimicrobial Stewardship group. (Under Infection Control Committee)
 The aims of the group are to ensure that antibiotics are utilized across the Hospital in a way which results in
optimal treatment of infections with minimal risk of healthcare-associated infections.
 The Antibiotic Working Group will report to the Hospital Infection Committee
The group’s specific objectives are as follows: -
 To formulate and agree an annual action plan for monitoring the use of antibiotics across the hospital
 To ensure that the Drug Formulary Antibiotic Guidelines are reviewed annually and kept up-to-date.
 To monitor antibiotic usage and compliance to the laid policy.
The antibiotic working group will meet on a regular basis at least once every three months. The minutes of each
meeting will be recorded permanently as soon as possible following each meeting. The working quorum will be 4
members. The core membership of the group will be as follows:
 Intensivist
 An infection prevention and control nurse (Audit on antibiotic usage and compliance will be done by ICN)
 Infection Control Officer.
Additional clinical staff may be requested to join the group when needed to help develop targeted action plans to
influence antibiotic prescribing in specific clinical areas.
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1.3 An Antibiotic policy to guide in empiric therapy has been prepared based on the local antibiogram of
the hospital.
A. Urinary tract infections
OPD IPD ICU

No contact with health care Contact with health care system Long hospitalization/ invasive No
history of antibiotics Recent antibiotic history therapy
Recent and multiple antibiotic
therapy
Co-morbid factors present
A. Haemodynamically stable
B. Haemodynamically unstable
Send sample for cultures

Presumptive therapy Presumptive therapy Presumptive therapy
Piperacillin/ Tazobactum Amikacin or A. Piperacillin/ Tazobactum or

Nitrofurantoin Ertapenem B. Imipenem/Meropenem
After Culture Report – 48 to 72 hours

If organism is:
1. Sensitive to the prescribed antibiotics: Continue same
2. Sensitive to lower group of antibiotics: De-escalate as per susceptibility report
3. Resistant to prescribed antibiotics: Escalate
Consider Escalation
ESBL +: Escalate and treat Pseudomonas/ Resistant bug MDR Pseudo/ E. coli
as IPD patients Escalate and treat as per report Add Colistin
Enterococcus: Add Vanco/
Linezolid
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B. BLOOD STREAM INFECTIONS

OPD IPD ICU
No contact with health care Contact with health care system Long hospitalization/ invasive therapy
No history of antibiotics Recent and multiple antibiotic Co-morbid factors present
therapy Severe sepsis/ Septic shock

Ceftriaxone and Azithromycin Imipenem/Meropenem or A. Imipenem/Meropenem
/ Fluoroquinoles Amikacin and Vancomycin
Consider Caspofungin
 if line associated
 neutropenic
If organism is:
Consider Escalation
ESBL + Enterobactericae: MDR bug: Add Colistin MDR bug: Add Colistin
Meropenem Imipenem/
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C. PUS AND SOFT TISSUE INFECTIONS

OPD IPD ICU
No contact with health care Contact with health care system Long hospitalization/ invasive
therapy
No history of antibiotics Recent antibiotic history Recent and multiple antibiotic

therapy Co-morbid factors present
Amoxyclav or Cefuroxime Amikacin and Clindamycin Amikacin and Vancomycin /

Tecioplanin

If organism is:
.
Consider Escalation
MRSA: Add Linezolide MRSA: Continue Vanco/ Tecioplanin ESBL+: Imipenem/ Meropenem
ESBL+: Consider Ertapenem ESBL+: Consider Ertapenem Acinetobacter: Add Colistin and
Pseudomonas/ Acinetobacter: Meropenem
Consider Imipenem/ Meropenem/
Colistin
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D.RESPIRATORY TRACT INFECTIONS
A. Community acquired pneumoniae:
Non-ICU: Amoxy-Clav plus Clarithromycin/Azithromycin or Levofloxacin

ICU: Ceftriaxone plus Clarithromycin/Azithromycin or Levofloxacin
B. Aspiration pneumoniae: Clindamycin / Metronidazole
c. Hospital acquired pneumoniae D.Ventilator acquired pneumoniae
Imipenem/ Meropenem Imipenem/ Meropenem and Linezolide

Or Piperacillin/ Tazobactam

If organism is:
Consider Escalation
MRD +: Add Colistin
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1.4 Antibiotic Prophylaxis to prevent surgical site infections in adults
Antibiotic prophylaxis is defined as the use of antibiotics for the prevention of infection in the absence of
current signs or symptoms of infection.
Infections in surgical patients arise as a result of exogenous or endogenous bacterial contamination,
either in the operating theatre or in the wards.
FACTORS ASSOCIATED WITH INCREASED RISK OF SURGICAL INFECTION

1. Host factors
Old age (>60yrs), Obesity (>70kg), Malnutrition, Diabetis mellitus, Immunocompromising diseases or
therapies, presence of other infections and skin diseases
2. Preoperative factors
Prolonged preoperative stay, shaving of skin, inadequate antibiotic prophylaxis
3. Surgical factors
Inadequate skin antiseptics, Emergency procedures, prosthetic implants, Prolonged surgeries, use of
Drains, Poor techniques, unexpected contamination, Blood loss >1500ml
4. Environmental factors
Staphylococcal or Streptococcal carrier, excessive activity in operation room, contaminated antiseptics,
inadequate ventilation, inadequately sterilized equipment
1.5 FUNDAMENTAL PRINCIPLES OF SURGICAL PROPHYLAXIS
1. The antibiotic must be in the tissue before the bacteria are introduced, i.e., Antibiotic must be given
intravenously within one hour of the incision...
2. There is no data to support more than a single dose. Further doses generally constitute treatment.
3. The chosen antibiotics must be active against the most common expected pathogens.
4. Deviations from these guidelines may be warranted in certain situations, like MRSA outbreak in the
hospital.
5. High risk patients or pts with co-morbidities generally warrant antibiotic prophylaxis.
Timing of administration
Prophylaxis should be started preoperatively, ideally within 30 minutes of the induction of anaesthesia
During caesarean section prophylaxis should be delayed until the cord is clamped to prevent the drug
reaching the neonate
Dose and duration of prophylaxis
1. Single dose only
2. Second dose to be given peri-operatively if surgery lasts for more than 3 hrs.
3. Additional dose of antibiotics to be given in case of blood loss > 1500 ml after fluid replacement.
4. Prophylaxis should be confined to perioperative period only.
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5. Prophylaxis may be continued up to 24 hrs in cases of high risk of surgical infection, as noted above.
6. There is no data to support more than a single dose.
Further doses generally constitute treatment. Further doses are waste of resources, increased risk of
complication, and the fact that multiple doses are not associated with increased efficiency
 Antibiotics must be started within 1 hour before incision.

 All patients scheduled for elective surgery should be advised chlorhexidine bath, the night
previous to surgery and morning of surgery.
 Hair removal, if necessary, should be done with clippers, preferably before sending the patient to
the operation theatre.
 All patients who were referred from other healthcare facilities should be preferably screened for
MRSA, ESBL, MDR Acinetobacter baumanii & colonization.
1.6 Antibiotics Prophylaxis

 Most of the clean & elective surgeries require a single preoperative dose.
 2nd dose to be administered if surgery continues beyond 3 hours
 Antimicrobials used for prophylaxis should not be used for empiric therapy.
 The recommendations are only valid for clean, clean-contaminated surgeries.
The Surgical prophylaxis stated below has been formulated in consensus with the surgical team
and the Infection control Team, with inputs on the local antibiogram of common pathogens from the
department of Microbiology.
TYPE OF SURGERY PROPHYLAXIS COMMENTS

Bariatric Surgery Inj. Cefuroxime 3 gm as a Single infusion just before
Single dose followed by surgery is effective, In high
repeat dose if surgery risk patients Inj. Cefuroxime 3
continues beyond 3 hours. gm is continued 12 hrly for
next 48 hours
Breast Surgery Inj. Cefazolin 1-2 gm iv at Single infusion just before
induction. surgery is effective, In high
risk patients Inj. Cefuroxime
1.5 gm is continued 12 hrly for
next 48 hours
Cardiovascular Surgery Inj. Cefuroxime 1.5 gm as a Single infusion just before
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repeat dose if surgery risk patients Inj. Cefuroxime

continues beyond 3 hours. 1.5 gm is continued 12 hrly for
next 48 hours. These patients
will be continued on oral
Amoxycillin-clavulanic acid for
5-7 days post discharged.
Gastric, biliary & colonic Inj. Cefazolin 1gm /

surgery Cefuroxime 1.5 gm as a
Gastro-duodenal, includes Single dose followed by
percutaneous endoscopic repeat dose if surgery
Gastrostomy continues beyond 3 hours.
(Additional doses q12h for 2-3
days may be given if the
Biliary includes laparoscopic
surgeon considers necessary)
cholecystectomy
General surgery
Colorectal – anal surgery Inj. Cefazolin 1gm /
ceftriaxone 1gm +
Metronidazole 0.5gm IV
Head & Neck Surgery
(Otorhinolaryngology)
CSOM/ Otitis External Amoxicillin + Clavulanic Acid
1.2 gm IV Bd or 625 mg TDS
for 5 days.
Alternatives- Inj Cefuroxime
500mg BD For 5 days.
Acute Sinusitis / Rhinitis Levofloxacin 500mg OD for
5days
Clindamycin 600mg BD for 5
Acute Parotitis
days
Inj. Ceftriaxone 1 gm IV +
Cochlear Implant
Inj. Amikacin 500mg IV BD for
5 days
Neurosurgical procedures Cefuroxime 1.5 gm as a Oral Cefuroxime axetil will be
Clean Surgery Single dose followed by continued post discharge / till
repeat dose if surgery stitches are removed.
continues beyond 3 hours. In case of suspected MRSA
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Cefuroxime 1.5 gm is vancomycin will be the drug of

continued 12 hrly for next 48 choice for surgical prophylaxis
hrs days + (Ceftriaxone +
Netilmicin) if required will be
continued
Clean-contaminated Surgery In case of cross sinuses or
naso/Oropharynx Clindamycin
Cefuroxime 1.5 gm/Amoxy- 900mg IV (single dose)
clav 1.2gm IV as a single maybe used
dose followed by repeat dose
if surgery continues beyond 3
Cefuroxime 1.5 gm is
continued 12 hrly for next 48
hrs days + (Ceftriaxone +
Netilmicin) if required will be
continued
Obstetrics & Gynaecologic
surgery
Normal delivery None
Normal delivery with Cefazolin 1-2 gm I/V prior to

episiotomy skin incision
Cefazolin 1-2gm I/V prior to

Assisted vaginal delivery skin incision

3rd degree perineal tear skin incision
Abdominal Hysterectomy/TLH skin incision / cefuroxime 1.5
gm + Augmentin 1.2gm an
acceptable alternative
Metronidazole 500mg
all IV 30 min before surgery

Vaginal Hysterectomy/LAVH
skin incision or cefuroxime 1.5
gm ; +
Metronidazole 500mg
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Cystectomy/Myomectomy Cefazolin 1-2gm I/V prior to

skin incision or
cefuroxime 1.5 gm ;
D&C/MTP procedure or
cefuroxime 1.5 gm ;

procedure or
Diagnostic
Laparoscopy/hysteroscopy cefuroxime 1.5 gm ;
Inj Cefazolin 1-2 gm I/V

Pre incision cefazolin may be
Exploratory laparotomy +Inj Gentamicin 4mg/Kg superior to post clamp dosing
+Metronidazole 500mg-1 gm
Cefazolin 1-2gm I/V 30 min

prior to skin incision
Caesarean section
OR
Augmentin 1.2 gm I/V 30 min
prior to skin incision +
Metronidazole 500mg
Erythromycin 500mg TDS x 5
Days
PPROM
Oncology-Surgery Inj. Cefuroxime 1.5 gm as a Single infusion just before
repeat dose if surgery risk patients or if some tubes
continues beyond 3 hours. & drains are in place than
these patients will be
+ Metronidazole 500mg continued on oral Amoxycillin-
Abdominal/Pelvic clavulanic acid for 5-7 days
post discharged.
Ophthalmology Post – operatively

Tab. Ciprofloxacin 500mg BD
Cataract surgery Moxifloxacin Eye drops every for 5 days
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2 hourly 48 hours prior to + Moxifloxacin Eye drops &

surgery. Eye ointment
Orthopaedics-surgery Inj. Cefuroxime 1.5 gm as a Single infusion just before
next 24 hours. These patients
will be continued on Amikacin
for 3 days post surgery.
Pediatric Surgery
Laprotomy/Colostomy Inj. Ceftriaxone +
Metronidazole for 48 hours.
Hepatobiliary surgery Inj. Cefuroxime 1.5 gm as a Single infusion just before

next 48 hours
Plastic Surgery
Oromaxillofacial Surgery Cefazolin 1-2gm IV 30 min
prior to skin incision / Inj.
Cefuroxime 1.5 gm
Genitourinary surgery Inj. Cefuroxime 1.5 gm/Inj.
Ciprofloxacin 500mg i.v/PO
Hand Surgery Cefazolin 1-2gm IV 30 min

prior to skin incision / Inj.
Cefuroxime 1.5 gm
Cefazolin 1-2gm IV 30 min
Implant insertion prior to skin incision / Inj.
Cefuroxime 1.5 gm +
(discretion of the surgeon)
Ceftriaxone 2gms IV
Urology Surgery
Cystoscopy Cefuroxime 1.5gm IV 30min
Cystoscopy with manipulation prior to surgery. 1 dose peri-
TURP / TURBT operatively if surgery is
prolonged and 2 doses post-
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OIU operatively
Ciprofloxacin 500mg +
Trans-rectal prostrate biopsy Metronidazole 500mg PO,
one dose night before
surgery, repeat dose 30min
before procedure, + 1gm
Amikacin (high risk patients)
Cefuroxime 1.5gm IV 30min

Ureteroscopy / PCNL / Any prior to surgery. 1 dose peri-
other open surgery operatively if surgery is
prolonged and 2 doses post- If bowel is manipulated
operatively Amikacin 1gm + 0.5g
Metronidazole IV is added
Renal transplants: prior to surgery. 1 dose peri-
Donor operatively if surgery is
prolonged and 2 doses of
750mg PO post-operatively

prior to surgery. 1 dose peri-
operatively if surgery is
Recipient prolonged and 2 doses of 1.5g 1.5g IV cefuroxime 1 dose
IV post-operatively given at the time of catheter
removal
2 ANTIBIOTIC POLICIES OF VARIOUS DEPARTMENTS
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2.1 CLINICAL HEMATOLOGY & BONE MARROW TRANSPLANTATION
Condition First line Therapy Alternatives Comments

Low risk febrile Cefoperazone – Levofloxacin Escalation and De
neutropenia Sulbactum and escalation of
Amikacin antibiotics according
to Culture Sensitivity
Reports
High risk febrile Meropenem and Second line Add Antifungal if fever
neutropenia Vancomycin Meropenem+ persist even after 72
Colistin+ Linezolid hrs of antibiotics in
high-risk febrile
neutropenia
(Amphotericin B or
Voriconazole)
2.2 CRITICAL CARE AND RESPIRATORY MEDICINE:

a. Central Line Associated Blood Stream Infections (CLA-BSI)
Condition First Line Alternatives Comments

Therapy
Start Empiric antibiotic therapy. Once
Patients suspected but not proven to have culture report is available, targeted therapy
CRBSI should be used.
Suspected Vancomycin Linezolid & Teicoplanin should not be used
MRSA for empirical therapy.
BL-BLI Carbapenem Empiric antibiotic therapy will be based on
Suspected combination   Amino- CMTC antimicrobial susceptibility data and
GNB Aminoglycoside glycoside the severity of disease. Therapy should
(if incidence cover for ESBL’s.
of ESBL is
high)
Neutropenic, severely ill with sepsis & septic Give cover for Pseudomonas aeruginosa
shock patients suspected but not proven to
have CRBSI.
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Empiric therapy should cover for gram-

Femoral catheter with suspicion of CLA-BSI positive pathogens as well as gram-
negative bacilli and Candida species
Suspected Fluconazole in Echinocandin Empirical therapy for suspected catheter-
catheter- patients related Candidemia should be used for
related without azole septic patients with any of the following risk
Candidemia exposure in the factors:
previous 3  Total parenteral nutrition
months and  Prolonged use of broad-spectrum
where risk of antibiotics
C. krusei or C.  Hematologic malignancy
glabrata  Receipt of bone marrow or solid-organ
infection is transplant
very low.  Femoral catheterization
 Colonization due to Candida species at
multiple sites.
Duration of therapy
 Four to 6 weeks antibiotic treatment

 for persistent fungemia or bacteremia after central line removal (i.e., occurring
>72 h after line removal)
 Patients who have infective endocarditis or suppurative Thrombophlebitis
 Pediatric patients with osteomyelitis
 6–8 weeks of therapy should be used for the treatment of osteomyelitis in adults.
Removal of central line
Long-term catheters should be removed from patients with CLA-BSI associated with any of the
following conditions:
i. Severe sepsis
ii. Suppurative thrombophlebitis
iii. Endocarditis
iv. Bloodstream infection that continues despite >72 h of antimicrobial therapy to susceptible
infecting organisms.
v. Or infections due to S. aureus, P. aeruginosa, fungi, or mycobacteria.
Short-term catheters should be removed from patients with CRBSI due to gram-negative bacilli,
S. aureus, enterococci, fungi, and mycobacteria.
Specific pathogen specific therapy:

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1. Coagulase negative Staphylococcus spp

a. For uncomplicated CRBSI, treat with antibiotics for 5–7 days if the catheter is
removed. Treat for 10–14 days, in combination with antibiotic lock therapy, if the
catheter is retained.
b. Alternatively, these patients can be observed without antibiotics if they have
i. No intravascular or orthopaedic hardware
ii. The catheter is removed
iii. And additional blood cultures are obtained after catheter withdrawal to
confirm the absence of bacteremia.
2. S. aureus
a. Patients with S. aureus CLA-BSI should have the infected catheter removed, and
receive 4–6 weeks of antimicrobial therapy.
b. Patients can be considered for a shorter duration of antimicrobial therapy (i.e., a
minimum of 14 days of therapy) if:
 The patient is not diabetic
 The patient is not immunosuppressed (i.e., not receiving systemic steroids or
other immunosuppressive drugs, such as those used for transplantation, and
is nonneutropenic)
 The infected catheter is removed
 The patient has no prosthetic intravascular device (e.g., pacemaker or
recently placed vascular graft)
 There is no evidence of endocarditis or suppurative thrombophlebitis on TEE
and ultrasound.
 Fever and bacteremia resolve within 72 h after initiation of appropriate
antimicrobial therapy.
 There is no evidence of metastatic infection on physical examination and
sign- or symptom-directed diagnostic tests.
c. Patients who are being considered for a shorter duration of therapy should have a
transesophageal echocardiograph obtained.
 If a TEE is performed, it should be done at least 5–7 days after onset of
bacteremia to minimize the possibility of false-negative results.
 Short-term catheters should be removed immediately for patients with S.
aureus CLA-BSI.
 For S. aureus CLA-BSI involving long-term catheters, the catheters should be
removed unless there are major contraindications
i. there is no alternative venous access
ii. the patient has significant bleeding diathesis
iii. or quality of life issues take priority over the need for reinsertion of a new
catheter at another site.
iv. In the rare circumstance that the catheter is retained for a patient with S.
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aureus CLA-BSI involving a long-term catheter, the patient should receive

systemic and antibiotic lock therapy for 4 weeks.
1. Catheter guide wire exchange should be done, if possible, and if it is
done, an antimicrobial-impregnated catheter with an anti-infective
intraluminal surface should be considered for catheter exchange.
v. Patients whose catheter tip grows S. aureus but whose initial peripheral
blood cultures have negative results should receive a 5–7-day course of
antibiotics and close monitoring for signs and symptoms of ongoing
infection, including additional blood cultures, as indicated.
3. Enterococcus species
a. Removal of infected short-term intravascular catheters is recommended.

b. Removal of infected long-term catheters should be done in cases of insertion site or
pocket infection, suppurative thrombophlebitis, sepsis, endocarditis, persistent
bacteremia, or metastatic infection.
c. Ampicillin is the drug of choice for ampicillin-susceptible enterococci; vancomycin should
be used if the pathogen is resistant to ampicillin.
d. A 7–14-day course of therapy is recommended for uncomplicated enterococcal CRBSI in
which the long-term catheter is retained and antibiotic lock is used or when the short-term
catheter is removed.
e. In cases of CLA-BSI due to ampicillin- and vancomycin resistant enterococci, linezolid or
daptomycin may be used, based on antibiotic susceptibility results.
f. The recommendation for TEE and antibiotic lock therapy are same as for other infections.
4. Gram Negative Bacilli
a. Patients with possible CLA-BSI should receive empirical antibiotic therapy to cover gram-
negative bacilli if they are critically ill, if they have sepsis, if they are neutropenic, if they
have a femoral catheter in place, or if they have a known focus of gram-negative bacillary
infection.
b. Patients who are critically ill with suspected CLA-BSI and who have recent colonization or
infection with an MDR gram negative pathogen should receive 2 antimicrobial agents of
different classes as initial therapy. De-escalation of the initial regimen to a single
appropriate antibiotic is recommended once culture and susceptibility results are
available.
c. In patients with GNB- CLA-BSI involving a long-term catheter and persistent bacteremia
or severe sepsis despite systemic and antibiotic lock therapy, the device should be
removed, an evaluation for endovascular infection and metastatic infection should be
pursued, and the duration of antibiotic therapy should be extended beyond 7–14 days
5. Candida spp
a. Catheters should be removed in cases of CLA-BSI due to Candida species.
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b. For patients with candidemia and a short-term CVC for whom no source of candidemia is
obvious, the catheter should be removed and the catheter tip sent for culture.
Alternatively, for patients with limited venous access, exchange the catheter over a guide
wire and perform catheter cultures. If the catheter is colonized with the same species of
Candida as found in a percutaneous blood culture, the CVC should be removed.
c. Antifungal therapy is recommended for all cases of CLBSI due to Candida species,
including cases in which clinical manifestations of infection and/or candidemia resolve
after catheter withdrawal and before initiation of antifungal therapy.
3 Antibiotic lock therapy
Antibiotic lock therapy should be used for catheter salvage; however, if antibiotic lock therapy
cannot be used in this situation, systemic antibiotics should be administered through the
colonized catheter.
 Installing high concentration of antibiotic (AB) to which causative organism is susceptible
in the catheter lumen.
 AB lock solutions contain the desired antimicrobial concentrations mixed with 50-100ml
units of heparin or NS in sufficient volume to fill the catheter lumen (usually 2-5ml).
 Dwell time for lock solution not more than 48 hrs, preferably reinstall every 24hrs.
 Duration of lock varied but usually it is 2 weeks.
 AB lock therapy unlikely to have any impact on extra luminal infections.
Final concentrations of antibiotic lock solutions used for the treatment of catheter-related
bloodstream infection.
DRUGS DOSAGE HEPARIN OR SALINE, IU/ML

Vancomycin 5.0 ml/ml 5000
Ceftazidime 0.5mg/ml 100
Cefazolin 5.0mg/ml 2500 or 5000
Gentamicin 1.0mg/ml 2500
Ampicillin 10.0mg/ml 10 or 5000
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Condition First Line Therapy Alternatives Comments
VAP: (Suspected Piperacillin-tazobactum Ertapenem

VAP without risk or Cefoperazone-
factors for MDR sulbactum, or
pathogens) Cefepime-Tazobactam
Resistance to 3/4GC and BL-
VAP: Patients Carbapenems for BLI combinations is high.
with suspicion of GNBs and Vancomycin
MDR pathogens for MRSA. Linezolid would be reserved
for VRE
2 anti-pseudomonal Ceftazidime should only be
VAP: agents of different used for Pseudomonas.
Pseudomonas class will be used
- - Discontinue antibiotic therapy

VAP: Tracheal
aspirate or BAL
culture results
are negative at 3
days and who are
clinically
improving
- - Evaluate for non-infectious
VAP: In Non- mimics of pneumonia, MDR
ARDS patients, if organisms, extrapulmonary
there is no infection, and the
clinical response complications of pneumonia
by day 3
b) Ventilator Associated Pneumonia (VAP)
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 Once a suspicion or diagnosis of VAP has been made, antibiotic therapy should be initiated
promptly.
 The selection of antibiotic therapy will be based on patient risk factors, recent exposure to
specific antibiotic classes, and the CMTC antibiogram.
 The therapy for VAP would be limited 8 days unless the organism isolated is Acinetobacter or
Pseudomonas, where the therapy will be given for 15 days.
 The empiric therapy should be changed to specific antimicrobial therapy after the culture &
sensitivity report is available. It should then be reviewed everyday
 The resistance to Flouroquinolones is high and their empiric use in VAP is not recommended.
Aminoglycosides carry high nephrotoxicity. They don’t delay development of resistance and have
no synergistic effects.
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 Since clinical improvement usually takes 48 to 72 h, do not change/modify the antibiotics unless
the patient is declining clinically or unless it is dictated by the results of microbiologic sensitivity
data.
 The use of inhaled antibiotics would be after mutual discussion between treating units and the
department of Clinical microbiology.
 Antibiotic dosing may need to be adjusted in patients with impaired renal or hepatic function. The
dose may have to be adjusted daily and, in some instances, re-dosed after procedures such as
dialysis.
The recommended IV doses of antibiotics are:
a. Cephalosporins
i. Ceftriaxone 1-2 g every 24 h
ii. Cefepime 1-2 g every 8-12 h
iii. Ceftazidime 2g every 8 h
b. Carbapenems
i. Ertapenem 1 g every 24 h
ii. Imipenem 500 mg every 6 h or 1 g every 8 h
iii. Meropenem 1 g every 8 h
c. Beta-lactamase/Beta-lactamase Inhibitors
i. Ampicillin-sulbactum 3 g every 6 h
ii. Piperacillin-tazobactum 4.5 g every 6 h
d. Aminoglycosides
i. Gentamicin 7 mg/kg every 24 h (trough levels <1ug/ml)
ii. Tobramycin 7 mg/kg every 24 h (trough levels <1ug/ml)
iii. Amikacin 20 mg/kg every 24 h (trough levels <4-
5ug/ml)
e. Antipseudomonal Flouroquinolones
i. Moxifloxacin 400 mg every 24 h
ii. Ciprofloxacin 400 mg every 8 h
iii. Levofloxacin 750 mg every 24 h
f. Drugs effective against MRSA
i. Vancomycin 15 mg/kg every 12 h (trough levels 15-
20ug/ml)
ii. Linezolid 600 mg every 12 h
g. Miscellaneous
i. Azithromycin 500 mg every 24 h
ii. Minocycline 100 mg every 12 h
iii. Colistin 2.5-5 mg/kg/d in divided doses
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h.
4 ENT:
S. No. Conditions First line Therapy Alternatives

1 Acute Tonsillitis / Amoxicillin + Clavulanic Cefuroxime
Pharyngitis Acid 500 mg BD for 7 days.
1.2 gm i/v BD or 625 mg
TDS for 7 days
2 CSOM/ Otitis Externa Amoxicillin + Clavulanic Cefuroxime

Acid 500 mg BD for 7 days.
TDS for 7 days
3 Acute Sinusitis / Rhinitis Amoxicillin + Clavulanic Levofloxacin

Acid 500 mg OD for 10 days
TDS for 7 days
4 Acute Parotitis Clindamycin -

600 mg TDS for 5 days
5 Malignant Otitis Externa Cefoperazone + Sulbactum Ciprofloxacin

2 gm i/v BD for 7 days 500 mg BD for 10-14
followed by oral days
Ciprofloxacin 500 mg BD for
7 days
The treatment is modified after the Microbiology report becomes available.
5 ENDOCRINOLOGY:
Condition Common pathogens First Line Therapy Alternatives Therapy
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Diabetic foot Staphylococcus aureus Cloxacillin 250mg Clindamycin 300mg qid or

(mild, po q6h Amoxicillin/clavulanate 875/125mg
outpatient Group A Streptococcus or PO q12 x 14 days
therapy) Cefazolin 1-2g IV
q8h
Diabetic foot Staphylococcus aureus Clindamycin 300mg Ciprofloxacin 750mg po bid +
ulcer: Mild Pseudomonas po qid). (Metronidazole 500mg po q6-8h or
Complicated aeruginosa
(Hospitalized Anaerobes e.g.
patient) Bacteroides
Diabetic foot Piperacillin- Ceftazidime 2 grams IV q8h or
ulcer: Tazobactam Cefepime 2 grams IV q12h PLUS
Severe 3.375g IV q4h + Metronidazole 500mg PO or IV q6h
Complicated Metronidazole or Clindamycin 600mg IV q6h
(Hospitalized 500mg IV q6h
patient)
Diabetic foot Staphylococcus aureus Vancomycin 1g IV - Clindamycin 900mg IV q8h +
(limb Pseudomonas q12h + Cefepime 2 grams IV q12h or
threatening) aeruginosa Meropenem 1g IV Piperacillin- Tazobactam 3.375g
Anaerobes e.g., q8h IV q4h
Bacteroides - Vancomycin 1g IV q12h +
Aztreonam 2g IV q8h +
Metronidazole 500mg IV q6h
- Imipenem 500mg IV q6h or
Meropenem 1g IV q8h
6 EYE:
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Clinical conditions Antibiotic(s) Pathogens
Conjunctivitis (adults) Usually self-limiting or else use Viral

Topical Chloramphenicol Strep. pneumoniae
Staph. aureus
Peri-orbital cellulitis High dose Flucloxacillin Streptococcus spp

+ IV high dose Ceftriaxone Staph. aureus
Haemophilus
7 GASTROENTEROLOGY & HEPATOLOGY:
A. Chronic Liver Disease
S. Clinical condition Antibiotic 1st choice Alternatives Remarks

No
1. Upper Gastrointestinal Inj Ciprofloxacin Has been shown to
bleed, no other 200mg IV twice daily. be useful in
complication patients with
Switch to 500 mg cirrhosis with or
twice daily orally once without ascites by
clinical situation reducing bacterial
allows. infections, reducing
re-bleeding rate
Duration of use 5 to 7 and improving
days. survival.
(AASLD
guidelines 2007)
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2. Spontaneous Bacterial
Peritonitis (SBP).
First presentation with no

Inj
other complication Inj Cefotaxime 2 G IV Add IV Albumin, if
Ceftazidime 2
tid for 5 days. gm iv bid if patient can afford.
First presentation with there is
high risk features: Inj Cefoperazone + significant
TLC > 16,000 Sulbactam (dose hepatic
Ascitic TLC > 5000/cmm modified for renal dysfunction.
Hypotension / inotropic function ),
support Prophylaxis for
Renal dysfunction Or SBP (indicated if
Second or later ascitic fluid albumin
presentation, is <1G/dl or there is
regardless of cell count past history of
or complication SBP)
Use oral Quinolones Rotate antibiotic

once daily. (Quinolones /
Ampicillin / Co-
trimoxazole) every
3 months.
3. Hepatic Inj Cefotaxime 2 gm iv Inj

encephalopathy and no bid + Tab Rifaximin Meropenem
other complication 200 mg tid 1gm iv 8-12
tid
In ICU with multiple
complications / Inj Piperacillin +
ventilatory support Tazobactam 4.5 gm iv
tid
4. IV Cefotaxime 2G 8
Secondary peritonitis hourly +
(Clinical / Radiological /
any 2 of the following in IV Metronidazole 500
ascitic fluid: protein > 1 mg 8 hourly
G/dl; glucose < 50mg/dl;
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LDH > ULN)
B. Fulminant Hepatic Failure / Acute on Chronic Liver failure / Sub acute Hepatic failure
Sepsis has been demonstrated in up to 100% patients with prospective cultures. Although not shown to
improve survival, prophylactic antibiotics may be considered for grade III or IV hepatic encephalopathy,
especially on ventilator.
Conditions First Line Therapy Alternatives Remarks
Fulminant Hepatic Inj Piperacillin + Tazobactam
Failure / Acute on 4.5 gm iv tid + Inj Teicoplanin
Chronic Liver failure / 400 mg bid on Day-1 and then
Sub acute Hepatic OD
failure
+ Inj Metronidazole 500 mg IV
tid +Inj Fluconazole 200 mg
IV OD
C. Liver Abscess
Clinical condition Antibiotic 1st Alternatives Remarks

choice
Liver abscess Inj Ceftazidime 2G Once there is
IV bid defervescence of Consider
All patients with liver fever, once should antibiotics for 4-6
abscess should receive + Inj Metronidazole switch to oral weeks if multiple
antibiotics. 500 mg IV tid second generation liver abscess / pus
cephalosporin (like culture positive /
Cefuroxime) for 5-7 amebic serology
days and oral negative.
Metronidazole for a
total of 10 days.
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8 Prophylaxis for Endoscopy
This is indicated in the following two clinical settings:-
1. Those undergoing a High Risk Endoscopic Procedure such as

 Polypectomy
 Biliary sphincterotomy
 Pneumatic or bougie dilation
 Percutaneous Endoscopic Gastrostomy (PEG)
 Endoscopic US guided FNA
AND have any of the following High Risk Cardiac Conditions
 Prosthetic cardiac valve

 History of previous IE
 Cardiac transplant recipients who develop cardiac valvulopathy
 Patients with Congenital heart disease (CHD) including
 Those with unrepaired cyanotic CHD (including palliative shunts and conduits)
 Those with completely repaired CHD with prosthetic material or device, placed
surgically or by catheter, for the first 6 months after the procedure and
 Those with repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or device
2. High Risk Endoscopic Procedures without associated high risk cardiac condition:-
 Biliary sphincterotomy
 EUS-guided FNA
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 PEG
SNo Clinical condition Antibiotic 1st choice Alternatives Remarks

1.
Polypectomy/Biliary Inj Ciprofloxacin 200
sphincterotomy/Pneumatic mg iv prior to
or bougie dilation/ EUS- procedure
guided FNA
2. PEG
Inj Amoxycillin-
clavulanic acid 1.2 gm
iv prior to procedure
3. Uncomplicated ERCP
Inj Ciprofloxacin 200
mg iv prior to
procedure
4. ERCP in patient with
Cholangitis / hypotension Inj Cefoperazone +
Sulbactam (dose
modified for renal
function )
5. Endoscopic drainage of Inj Ciprofloxacin 200
pseudocyst of pancreas mg iv prior to
procedure and 500 mg
BID orally 3 days or
AND
Inj Metronidazole 500

mg iv TID
A. Antibiotic prophylaxis Acute Pancreatitis
SNo Clinical condition Antibiotic 1st Alternatives Remarks

choice
1. No antibiotic
Mild pancreatitis: prophylaxis.
2. Severe pancreatitis with > Inj Imipenem 1 Antibiotics to be
30 % pancreatic necrosis gm TID X 14 Inj Ciprofloxacin started and after
days. 200 mg BID + Inj cultures sent.
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Inj Fluconazole Metronidazole Antifungals to be

200 mg OD 500 mg TID X 14 added after 7 days
days. (If not of antibiotics
affording)
Emergency surgery- Open surgery

Contamination Inj Cefazolin 1 gm or
unlikely (e.g. breast, Inj Cefuroxime 1.5 gm
thyroid)
Where Inj Ceftriaxone 1 gm Consider Gut contamination
contamination is + Inj Metronidazole Likely.
likely (e.g. GI, biliary 500 mg Once contamination has
etc) occurred, the antibiotics may
be continued for 24h
If gross contamination, the
antibiotics may be continued
for 72h
Presumptive therapy Empirical antibiotics started but changes
made as per antibiotic sensitivity based on
Microbiology lab reports
Superficial Cloxacillin / If gram positive cocci
infections (Cellulitis Amoxycillin- suspected
etc) Clavulanic acid
Aminoglycoside /Inj If gram negative bacilli
Ceftriaxone 1 gm suspected
Cloxacillin+ If mixed/ unknown organisms
Aminoglycoside/ suspected
Ceftriaxone 1 gm
Cloxacillin+ If mixed aerobes/ anaerobes
Aminoglycoside/ suspected e.g. perianal
Ceftriaxone 1 gm + Inj abscess
Metronidazole
Deep seated Inj Cefoperazone+
infections (e.g. Sulbactam +/-
abdominal sepsis) Metronidazole
Life threatening Combination of Deescalate when response is
sepsis carbapenems + good or change antibiotics
Teicoplanin when response is poor or
microbiology report suggests
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different sensitivity pattern

Therapeutic antibiotics Based on microbiology reports as far as
possible.
It is imperative, in situations where gross contamination has occurred, a sample is taken
intraoperatively or as and when detected so that culture-based therapy can be started as soon
as possible.
9 OBSTETRICS AND GYNAECOLOGY
1 Diagnostic Cefazolin 1-2gm I/V prior to

Laparoscopy/hysteroscop procedure or Cefuroxime 1.5 gm
y
2 Exploratory laparotomy Inj Cefazolin 1-2 gm I/V
+ Inj Gentamicin 4mg/Kg
+Metronidazole 500mg-1 gm
3 PPROM Erythromycin 500mg TDS x 5
Days
10 Genital Tract Infections
Clinical conditions Antibiotic(s) Pathogen(s)
Vaginal thrush Clotrimazole pessary or Candida albicans

if systemic treatment if
planned, use oral
fluconazole
Bacterial vaginosis* Metronidazole Gardnerella vaginalis

Trichomoniasis* Metronidazole Trichomonas vaginalis
11 GYNAE-ONCOLOGY
A. THERAPEUTIC
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CATEGORY FIRST LINE ALTERNATIVE
1 PID Amoxycillin – Clavulanic acid (Oral) (7 III generation

days) Cephalosporin/
Doxycycline/Aminoglyc
osides
(Oral- Injectable)
2 Lower urogenital Ciprofloxacin + (Injectable) (7 days) -
Tract infection Ornidazole (Oral) (3 days)
3 Surgical Site III gen Cephalosporin (Injectable) + Depending on culture/

Infections Aminoglycoside (Injectable) + sensitivity report
Metronidazole (Injectable) – all for (7
days)
12 INTERVENTIONAL RADIOLOGY
Recommendations Regarding Pre-Procedure (Prophylactic) Antibiotics
Vascular Procedures Recommendations
Vascular Diagnostic Arteriogram uncomplicated No Antibiotics (Ab)

Arteriogram with graft puncture Ab
Arteriogram with acute thromboembolic disease No Ab
Arteriogram in patients with heart valve No Ab
Synthetic bypass graft Ab
IVC filter No Ab
Joint replacement No Ab
transplant organ No Ab
vascular stent No Ab
TIPS diagnostic only No Ab
Dialysis conduit fistulogram No Ab
Vascular Interventional Procedures
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TIPS Ab
PTA No Ab
Vascular Stent placement
artery No Ab except after lysis
vein No Ab
Vascular Stent revision
artery No Ab except after lysis
vein No Ab
TIPS No Ab
Covered Stent/Stent Graft
artery Ab
vein Ab
TIPS Ab
Atherectomy No Ab
Thrombolysis (pharmacologic) No Ab
Mechanical Thrombectomy
Device or thromboaspiration Ab
possible graft infection contraindication to declot
Transjugular Liver Biopsy No Ab

Foreign Body Retrieval No Ab
Embolization
particulate yes if of solid organ
coil yes if of solid organ
glue yes if of solid organ
detachable balloon yes if of solid organ
sclerosant (ie. alcohol) yes if of solid organ
Chemoembolization Ab
Non vascular Procedures
PTC Ab
PTBD Ab
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Perc Cholecystectomy Ab
Ante grade Pyelogram Ab
PCN or ureteral stent Ab
GJ tube No Ab
Abscess catheter placement Ab
Tube change
biliary Ab
GU Ab
abscess Ab
Thoracocentesis No Ab
Paracentesis No Ab
Biopsy fluoro guided No Ab
Fallopian tube recanalization Ab
Antibiotic Prophylaxis Guidelines

Conditions First Line Alternatives Comments
Vascular Procedures
Vascular interventional Inj Cefazolin 1 gm Inj Ciprofloxacin 400mg antibiotic to
procedures (other than I.V. one dose I.V. one dose (If allergic to be
embolization) cephalosporin or administered
penicillin) OR one hour prior
Inj Vancomycin 1 gm I.V. to the
one dose (If allergic to procedure
cephalosporin, penicillin
or Quinolones)
Embolization Inj Ceftazidime 1 gm antibiotic to
procedure (other than I.V. one dose be
chemoembolization) administered
where particulate, coil, one hour prior
glue, balloon or to the
sclerosant is used as procedure
embolic agent
Chemoembolization Inj Ceftazidime 1 Administer one
such as for HCC, gram + Inj Amikacin hour before the
Splenic embolization 500 mg followed by procedure
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etc Inj Ceftazidime 1 gm

tds and Inj Amikacin
500 mg bd I.V. to be
continued for 72
hours
Non-Vascular Procedures
Interventional biliary Inj. Ceftriaxone 1 gm Administer one
procedures (PTC, I.V. one dose + Inj hour before the
PTBD, Percutaneous Amikacin 500 mg I.V, procedure
Cholecystectomy) Inj Ceftriaxone 1 gm
I.VO.D. + Inj Amikacin
1 gm O.D. I.V. to be
continued for three
days
Interventional urinary Inj. Ceftriaxone 1 gm Inj Ceftriaxone 1 gm Administer one
procedures (PCN, I.V. one dose + Inj I.VO.D. + Inj Amikacin 1 hour before the
Ureteric Stenting) Amikacin 500 mg I.V. gm O.D. I.V) may be procedure
continued for three days
Fallopian tube Inj Cefazolin 1 gm I.V.
recanalization one dose before and
one dose after 12
hours
13 INTERNAL MEDICINE
General Guidelines for use of antimicrobials:

1. Drugs will be used on basis of organ system involvement, suspected organism causing infection and
empiric regimen as per international guidelines and standard text book recommendations.
2. Empiric treatment expected to have maximum efficacy will be initiated as early as possible after
sensitivity testing.
3. Specimen for laboratory testing will obtained to determine susceptibility.
4. On basis of clinical response, laboratory evaluation and other co associated morbidities the drugs will
re evaluated.
5. Isolation of organisms (Mixed flora) will be evaluated for colonization, contamination and
pathogenecity before abandoning drug already being used as empirical therapy.
6. Knowledge regarding local resistance patterns will be put to appropriate use.
7. Appropriate course and duration will be decided as per guidelines or clinical improvement and switch
over to oral therapy will be done as per clinical improvement.
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8. Agents requiring therapeutic monitoring or laboratory safety screening will be used only if strongly
indicated.
9. Selection of drugs will, after therapeutic indication, will be based upon adverse effects Availability
and cost effectiveness.
A) Anti- bacterial Therapy
Disease Antibacterial Therapy Special
Considerations
Meningitis community Ceftriaxone 2 gram 12 hrly + -
acquired Vancomycin 10mg /kg 8 hrly
Meningitis Ceftazidime 3 gram 8 hrly + -

(Post Op /Post traumatic) Vancomycin 10 mg /kg IV 8 hrly
Brain Abscess Cefotaxime 2-3 gram IV 6 hrly or

Ceftriaxone 2 gram 12 hrly +
Metronidazole 500 mg IV 8 hrly
Outpatient treatment Macrolide
Previously healthy and no risk Azithromycin or Clarithromycin, or
factors for drug-resistant S. Erythromycin
pneumoniae (DRSP) infection:
Presence of co - morbidities, Flouroquinolone
 chronic Moxifloxacin / Gemifloxacin / Levofloxacin
 Heart Or
 Lung A Beta-lactam plus a Macrolide
 Liver High-dose amoxicillin [e.g., 1 g 3 times
 Renal disease daily] Or
 Diabetes Mellitus Amoxicillin-clavulanate [2 g 2 times daily]
 Alcoholism
Or
 Malignancies
Ceftriaxone / Cefpodoxime / Cefuroxime
 Asplenia
500 mg 12 hrly
 Immunosuppressant
conditions or Or
Immunosuppressant Doxycycline (alternative to the Macrolide.)
drugs
 Antimicrobials within
the previous 3
months (in which
case an alternative
from a different class
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Trauma Centre
should be selected)
 DRSP infection.
Community Acquired Flouroquinolone Or A respiratory
Inpatient Beta-lactam plus a Macrolide flouroquinolone for
Non-ICU treatment (Beta-lactam agents include Cefotaxime, penicillin-allergic
Ceftriaxone, and ampicillin; Ertapenem for patients
selected patients)
ICU treatment Cefotaxime 2 gram IV 8hrly Or For penicillin-allergic

Ceftriaxone 1 gram IV 12 hrly patients, a respiratory
+ Azithromycin Or flouroquinolone and
Flouroquinolone Aztreonam are
recommended.
For Pseudomonas infection Use an Antipseudomonal beta-lactam

(Piperacillin-Tazobactam, Cefepime,
Imipenem, or Meropenem)
plus
Ciprofloxacin / Levofloxacin or
Beta-lactam plus an aminoglycoside and
Azithromycin or
The above beta - lactam plus an
aminoglycoside and an antipneumococcal
flouroquinolone
Community-acquired MRSA Add Vancomycin or Linezolid

(Methicillin-resistant
Staphylococcus aureus
infection)
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Pneumonia Cefepime 2 gram IV 8 hrly Or

(Post Op / Nosocomial) Ceftazidime 2grm 8 hrly Or
Piperacillin + Tazobactum 4.5 gram IV 6
hrly Or Imipenem 500 mg IV 6 hrly Or
Meropenem 1 gram IV 8 hrly +
Aminoglycoside 1 gram / day Or
Levofloxacin 750 mg IV 24 hrly +
Vancomycin 15 mg /kg IV 12 hrly
Pneumonia Aspiration Clindamycin 600 mg IV 8 hrly

Or Amoxicillin Clavulanate 1.2 gram IV 12
hrly
Endocarditis Vancomycin 15 mg /kg IV 12 hrly
+ Aminoglycoside 1 gram /day IV
Intra abdominal Sepsis Piperacillin + Tazobactum 4.5 gram IV 6
Post op /Peritonitis hrly or Ticarcillin-Clavulanate 3.1 gram IV
6 hrly or Ertapenem 1 gram IV 24 hrly
Pyelonephritis Ceftriaxone 1 gram IV every 24 hrly
Or Ciprofloxacin 400 mg IV 12 hrly
Or Levofloxacin 500 mg IV 24 hrly
UTI (Recurrent) Ceftriaxone 1 gram every 24 hrly
Or Ciprofloxacin 400 mg IV 12 hrly
Or Levofloxacin 500 mg 24 hrly
Septic Thrombophlebitis Vancomycin15 mg /Kg IV 12 hrly +
Ceftriaxone 1 gram IV every 24 hrly
Osteomyelitis Cefazolin 2 gram IV 8 hrly
Neutropenic Fever Ceftazidime 2 gram IV 8 hrly
(on Chemotherapy) Or Cefepime 2 gram IV 8 hrly
B) Anti Fungal
Fungus Antifungal Special Consideration
Candidiasis
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1 Non-Neutropenic IV Am B 0.6 – 1.0 mg /kg / day Or x 14 days from last

Candidemia IV Fluconazole 200 – 400 mg / day blood culture positive +
Or Remove all
IV Caspofungin 70 mg Stat; 50 mg Intravascular catheters,
24 hrly if possible
2 Neutropenic IV Am B 0.6 – 1.0 mg /kg / day Or x 14 days from last

Candidemia IV Caspofungin 70 mg Stat; 50 mg blood culture positive
24 hrly and resolution of
neutropenia +
Removal of
Intravascular catheters
is controversial
3 Urinary IV Fluconazole 200 mg/ day for 7–14 1 ) Removal of catheter
days Or or change will help
IV AmpB 0.3–1.0 mg/kg / day for 1–7 2 ) Bladder irrigation
days or with amphotericin B
Oral Flucytosine 25 mg/kg hrly for deoxycholate (50–200
eradicating candiduria due to non- mg/ mL.) may
albicans species of Candida transiently clear
funguria
1) Pulmonary & IV Amphotericin B 0.7–1.0 mg/kg / Firm diagnosis is
Laryngeal day elusive and requires
histopathologic
confirmation.
1) Intra abdominal IV Am B 0.6 – 1.0 mg /kg / day Mechanical restoration
a) Catheter assoc. Or of functional drainage,
b) Surg./Traumatic IV Fluconazole 200 – 400 mg / day Combined catheter
injury removal ;
After removal of the
peritoneal dialysis
catheter and a delay of
at least 2 weeks, a new
catheter may be placed
Intraperitoneal
amphotericin B has
been associated with
painful chemical
peritonitis and should, in
general, be avoided.
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2) Esophageal IV Fluconazole 100-200 mg /day Duration of therapy is

or not well defined and is
Oral Itraconazole 200mg /day guided by the patient’s
response; usually 2–3
Or
weeks.
IV Voriconazole 4 mg /kg 12 hrly
Therapy for 14 – 21
days
IV for severe and
refractory esophagitis
Aspergillosis
 Invasive Pulmonary IV Voriconazole 6mg /kg 12 hrly for
 Tracheobronchial 2 doses;
 Chr. Necrotizing Followed by 4mg /kg IV every 12 hrly
pulmonary
 Invasive Sinus
 CNS
 Endocarditis
 Pericarditis
 Myocarditis
 Endophthalmitis &
Keratitis
Chronic Cavitary PO Voriconazole / Itraconazole 200
Pulmonary mg 12 hrly
ABPA PO Itraconazole 200 mg 12 hrly Long Term
Histoplasmosis
1) Acute Pulmonary IV AmpB 3.0-5.0 mg /Kg /day for 7-
14 days; followed by Itraconazole
200 mg 12 hrly for 12 weeks
+Methyprednisolone 0.5 -1.0
mg/kg /day x 7-14 days
2) Chr. Cavitary PO Itraconazole 200 mg 12 hrly x

12 mths
3) Disseminated IV AmpB 3.0-5.0 mg /Kg /day for 7-

14 days; followed by Itraconazole
200 mg 12 hrly for 12 mths
Cryptococcal
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HIV Negative
Pulmonary Fluconazole / Itraconazole 200mg -
400 mg /day x 6 -12 mths
 Mild – Moderate Treat Like CNS
 Severe
IV Amphotericin B 0.7 1.0 mg /kg If Intracranial pressure

CNS /day elevated identify for
+ Flucytosine 100mg/kg/d x 14 days mass lesions, radio
Followed by Fluconazole 400mg /day graphically. If no SOL
minimum 10 weeks present treat with
medical management
followed by Lumbar
puncture at 2 weeks
HIV Positive
Pulmonary Fluconazole / Itraconazole 200mg -
 Mild – Moderate 400 mg /day x Life long
Treat Like CNS
 Severe
CNS IV Amphotericin B 0.7 - 1.0 mg Repeat LP drainage

/kg /day + Flucytosine 100mg/kg/d daily till opening
x 14 days Followed by Fluconazole pressure stable
/Itraconazole 400mg /day minimum If pressure persists VP
Life Long shunt/lumbar drain
Cortico steroids not
recommended
C) Anti Viral
Conditions Antiviral Comments
Herpes simplex
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Trauma Centre
 Genital
 Recurrent Genital
 Encephalitis
 Disseminated disease
Immuno competent Acyclovir 200mg 4 hrly or 400mg Cidofovir if resistant to

8hrly Or Valacyclovir 1 gram 12 both Acyclovir and
hrly Or Famciclovir 250 mg 8 hrly Foscarnet
X 7- 10 days
Immuno compromised IV Acyclovir 10 mg /kg 8 hrly x 10

days IV High Dose Acyclovir 30
mg /kg 8 hrly
Acyclovir Resistant IV Foscarnet 40 – 60 mg /kg 8 hrly
x 10 days
Respiratory Viral Infections

A) Paramyxovirus Ribavarin 200 mg 6 hrly X 5 days
RSV
Metapneumovirus
Para influenza
Oseltamivir 75mg !2 hrly X 5 days

B) Orthomyxovirus Or Ribavarin 200 mg 6 hrly X 5
Influenza Type A & B days Or
Inhaled Zanmivir 5mg Inhalation
12 hrly X 5 days
C) Avian Influenza Oseltamivir 75mg 12 hrly X 5 days

Influenza A subtype H5N1 Or Ribavarin 200 mg 6 hrly X 5
days Or Inhaled Zanmivir 5mg
Inhalation 12 hrly X 5 days
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D) Severe Acute Ribavarin 400-600mg /day Or

Respiratory Syndrome Lopinavir 400mg /day Or
(SARS): Coronavirus Ritonavir 100mg /day Or
Interferon Type I.
Steroids Can be used
Varicella Zoster
Immuno competent PO Acyclovir 20 mg /kg / day (up to

i) Mild 800mg per dose ) 4 hrly x 5 days
ii) Severe IV Ganciclovir 5 mg / kg / 12 hrly
14 – 21 days
Immuno deficient /Pregnant IV Acyclovir Corticosteroids If

women/ /Extra cutaneous 30 mg /kg /day in three divided Pneumonia present
lesions doses x 7 days Especially AIDS patients
(Encephalitis/Pneumonia)
Extra dermatomal Complication IV Acyclovir 30 mg/kg/day x 7 days
Acyclovir Resistant Disease IV Foscarnet 20 mg /kg bolus ;

followed by
IV 120 mg / kg 8 hrly
x 14 days
Cytomegalovirus
i) Retinitis IV Ganciclovir 5 mg /kg 12 hrly X
 Ganciclovir 14 – 21 days ;
sensitive Maintenance dose :IV 5 mg /Kg
12 hrly
 Ganciclovir IV Foscarnet 20 mg /kg bolus ;
Resistant Disease followed by IV 120 mg / kg 8 hrly
x 14 days., Maintenance 60 mg /kg
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/day IV 5 days each week

ii) Resistant retinitis Ganciclovir + Foscarnet
iii) Post Transplant IV Ganciclovir
5 mg /kg 12 hrly 14 – 21 days
followed by
Maintenance dose IV
3.75 mg / Kg / Day for 5 days each
week
Epstein Barr & Infectious No Treatment ; Symptomatic only Corticosteroids if

Mononucleosis  Impending
respiratory distress
 Splenic rupture
pericarditis
Myocarditis
 CNS involvement
 Hemolytic anemia
 Severe
Thrombocytopenia
Acyclovir not
recommended
Influenza Virus Oseltamivir 75 mg 12 hrly X 5 days
Measles Ribavarin
Intrathecal Ribavarin in SSPE
Note: Department of Internal Medicine, Chauhan Hospital has based these General consensus
guidelines on the basis of various International guidelines with no Conflict of Interest.
These guidelines will be appropriately updated as per international recommendations and local guiding
principles.
14 DIALYSIS & NEPHROLOGY PATIENTS:

1. Prophylactic antibiotic therapy is avoided.
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2. For those running fever, Urine/C/S & Blood C/S are advised before giving empirical therapy.
3. Those patients who have suspected subclavian or IJ catheter infection; Blood C/S, swab C/S
taken and empirically start:
 IV Vancomycin 1 gm for those whose weight is more than 60 Kg
 IV Vancomycin 500 mg for those whose weight is less than 60 Kg
 Vancomycin levels recommended.
 In case of repeated infection, consider removing Central Line.
 To avoid VRE we take care and not to use Vancomycin very often.
4. Other commonest infections in CRF & Kidney transplant patients are UTI. Considering the
preponderance of ESBLs in our setting the first line in serious patients is a Carbapenem –
Imipenem, Meropenem, and Ertapenem.
5. Kidney transplant patients are given prophylaxis of Co-trimoxazole for 6 months for UTI & PCP.
6. For CAPD patients with Peritonitis, we follow Baxter guideline for IP antibiotics. Initially PD fluid is
examined for bacterial count, Gram staining, and C/S. Also swab C/S taken from exit sites. For
severe infections, blood culture is also being taken.
15 NEUROSCIENCES DEPARTMENT:
Conditions First line Alternatives Comments

Meningitis
In Adults Injectable Ceftriaxone Crystalline Penicillin +

and Amikacin Metronidazole +
Garamicin/Amikacin
Children below 2 Injectable Ceftriaxone Amoxycillin added to
years and adults and Amikacin + cover Listeria
above 60 years of age Amoxycillin monocytogenes
Meningococcal Injectable Penicillin
meningitis after standard test
dose
Encephalitis Acyclovir
Cerebral Malaria Injectable Artesunate
to be given for 5 days
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16 ORTHOPAEDICS DEPARTMENT
 ARTHROPLASTY Inj. Cefuroxime 1.5 First dose of Antibiotics to

gm IV as first dose be administered the night
followed by 1.5 gm IV before and repeated 60
12 hrly Inj. Amikacin minutes before inflation of
500mg IV as first dose tourniquet/incision.
followed by 500mg IV Duration of IV antibiotics 3-5
12 hrly (if Sr. days (till drains/catheters
creatinine is normal) are removed)
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 ORIF FOR Inj. Cefuroxime 1.5 Once IV antibiotics are

CLOSED gm IV as first dose discontinued oral
FRACTURES followed by 750mg IV Cefuroxime axetil 500mg
 SPINAL 8 hrly twice daily till sutures are
SURGERY WITH Inj. Amikacin 500mg removed
IMPLANTS IV as first dose
 SPINAL followed by 500mg IV
SURGERY 12 hrly (if Sr.
WITHOUT creatinine is normal)
IMPLANTS
 COMPOUND Inj. Cefuroxime 1.5 Duration of
FRACTURES gm IV as first dose parenteral antibiotics
followed by 750mg IV to be decided on
8 hrly case to basis. (to be
Inj. Amikacin dictated by state of
500mg IV as first dose the wound)
followed by 500mg IV
12 hrly (if Sr.
creatinine is normal)
Inj. Metrogyl 100mg
IV infusion 8 hrly for
72 hrs.
 ARTHROSCOPY Inj. Cefuroxime 1.5 If implants are used eg.
Diagnostic/Therap gm IV as first dose Interference
eutic procedures followed by 750mg IV screws/washers in ACL/PCL
8 hrly for 24 hrs reconstruction, oral
antibiotic Cefuroxime axetil
500mg twice daily till 1 week
from the day of surgery.
PRESUMPTIVE ANTIBIOTIC THERAPY
SUPERFICIAL Amoxicillin plus

INFECTION clavulanic acid 1.2 gm
Cellulitis/lymphangitis iv 8 hrly
DEEP INFECTION Inj. Cefuroxime 1.5
gm IV as first dose
8 hrly
Inj. Amikacin 500 mg
IV as first dose
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12 hrly (if Sr.
creatinine is normal)
THERAPEUTIC ANTIBIOTICS Should be based on microbiology reports as

far as possible. When prophylactic or
presumptive therapy is continued because of
clinical condition they should be changed to a
appropriate evidence based antibiotic at the
earliest.
17 PAEDIATRICS AND ADOLESCENT MEDICINE:
Conditions Ist Line IInd Line Comments

Severe Amoycillin-clavulanate / Add Cloxacillin, if To give antibiotics for 7-10
Pneumonias Cefuroxime / Ceftriaxone suspecting MSSA or days
(Community + vancomycin if In cases of Necrotizing
acquired Macrolide (Azithro / suspecting MRSA Pneumonia (Staphylococcus)
pneumonia) Clarithro) the duration can be extended
to 4 weeks
Ventilator Piperacillin-tazobactum/ Duration of antibiotic for 7

associated Cefepime/Meropenem days
Pneumonias +
(Depends on the Flouroquinolones or
Hospital aminoglycoside
antibiogram) +/-
Linezolid or Vancomycin if
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suspecting
Staphylococcus also
Severe Sepsis: Third generation Piperacillin- Duration of antibiotic 7-14
Broad spectrum cephalosporin tazobactum/ days
coverage + Cefepime/Meropenem Aminoglycosides should be
Aminoglycoside + added for initial 3-5 days
Aminoglycoside
Acute Piperacillin-tazobactum + Ciprofloxacin + Duration of antibiotic 7 days

Cholangitis Cloxacillin Metronidazole
Acute Oral antibiotics (Cefixime, If IV therapy is chosen, To give IV antibiotic till the
Pyelonephritis ceftibuten and give Ceftriaxone child is afebrile then can be
(Community- Amoxycillin/clavulanic (100mg/kg) or an discharged home on oral
acquired acid) aminoglycoside antibiotics for total duration of
infections is 7-14 days.
usually E coli or
other
Enterobacteriace
ae)
Meningitis: 0- 3months: Duration of antibiotic 14 days
Cefotaxime
> 3months – 15 years :
Cefotaxime or Ceftriaxone
Any age: Vancomycin to
be added if penicillin
resistant S. pneumoniae
meningitis
Shunt Vancomycin / Teicoplanin Vancomycin / Duration of antibiotic 14 days
Infections: + Teicoplanin
Ceftriaxone +
Ceftazidime/ Cefepime
Brain Abscesses Third generation Piperacillin + Treatment is with systemic
cephalosporin tazobactum / antibiotics as per the
(Cefotaxime/Ceftriaxone) Meropenem predisposing factors and
+ + abscesses which are larger
Metronidazole Metronidazole than 2 cm in diameter have to
be drained surgically.
+ +
Duration of antibiotic 14 days
Vancomycin Vancomycin
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/Teicoplanin (post-
surgical cases)
Acute Cloxacillin Clindamycin To add Ceftriaxone if child
Osteomyelitis: not immunized for H.
influenzae
Duration of antibiotics 4 – 6
weeks
Facial / Cloxacillin + Ceftriaxone + Clindamycin + Duration of antibiotic 14 days
Periorbital Metronidazole Ceftriaxone
cellulitis: (Broad
spectrum
coverage)
Toxic Shock Cloxacillin Clindamycin Vancomycin or linezolid
Syndrome (MRSA)
(Antibiotics
effective against Duration of antibiotic 14 days
S aureus and S
pyogenes)
Retropharyngeal Clindamycin Piperacillin + Drainage of abscess
abscess/peri +/- Tazobactam
tonsillar Ampicillin-sulbactum
abscess: usually
polymicrobial:
Infective Penicillin + Gentamicin Cloxacillin + Vancomycin/teicoplanin +
Endocarditis Gentamicin gentamicin (MRSA
(Bacterial suspected)
endocarditis) Duration of antibiotic 4 weeks
Enteric Fever IV Ceftriaxone Flouroquinolones (if Duration of antibiotic 14 days

or Nalidixic acid
Oral Cefixime sensitive)
(20mg/kg/day)
Enteric Relapse IV Ceftriaxone Flouroquinolones (if Duration of antibiotic 14 days,
or Nalidixic acid Azithromycin x 10 days
Oral sensitive)
Cefixime(20mg/kg/day)
+
Azithromycin(20mg/kg/
day)
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Liver Abscess 3rd Generation Duration of antibiotic 4- 6

Cephalosporin weeks
+
Cloxacillin
+
Metronidazole
18 NEONATOLOGY
GUIDELINES REGARDING USE OF ANTIBIOTICS IN NEONATES

• Antibiotic Usage will be evidence based and restrictive.
• Empirical usage of Antibiotics will be discouraged and if based on risk of sepsis will be stopped
once evidence to contrary has been established.
• A different approach of antibiotics shall be used for those babies born in-utero and those
transferred from outside hospital
Starting of Antibiotics:
• When to start and type of antibiotic will decide by the consultant on call after reviewing all the
available reports.
• This will be a consultant decision not a reflex decision of junior medical staff.
• Time to time internal audit will be performed to ascertain the judicious use of antibiotics.
• In all patients who need to be on antibiotics for more than 48 hours and consultation will be sort
from clinical microbiologist and further course will be decided after a combined census.
Choice of antibiotics for starting empirical therapy:
First line: Amoxycillin 50 mg/kg/day + Gentamicin 3 mg/kg/day
Second Line: Meropenem IV 20 mg/kg every 8 h + Vancomycin 20

mg/kg/day
Suspected IV catheter Vancomycin 20 mg/kg/day
related infection
Policy for stopping antibiotics

• In asymptomatic neonate: stop the empirical antibiotics, if blood culture report is negative by 48
hrs and clinical suspicion of sepsis abates.
• In a symptomatic neonate: if culture is sterile and there is no further suspicion of sepsis (acute
phase reactant are negative and there is alternative explanation of symptoms): stop antibiotics.
• In a symptomatic neonate: if culture is sterile but acute phase reactant are positive and/or clinical
suspicion of sepsis remains: continue antibiotics for 10 days.
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• In a symptomatic baby: if culture is positive, give antibiotics for minimum 14 days, repeat culture
after 7 days of therapy.
Duration of Antibiotics:
Type of Infection DURATION
Gram Negative Septicemia 2 weeks (at least 1 week after culture sterility)
Gram Negative Meningitis 3 weeks (at least 2 week after culture sterility)
Gram negative Ventriculitis/ 4-6 weeks

Arthritis/Endocarditis
Gram Positive septicemia 7- 10 days
Gram positive meningitis 2 weeks for GBS, 4 weeks for S. aureus
Gram Positive 4-6 weeks
Ventriculitis/Arthritis
Fungal Septicemia 3 weeks (at least 2 week after culture sterility)
Fungal Meningitis 3 weeks (at least 2 week after culture sterility)
Fungal ventriculitis 4-6 weeks
Fungal UTI 2 weeks
Fungal balls in kidneys 12 weeks or till resolution of the ball, followed
by prophylaxis for 1 year
Additional considerations
• In case of persistent sepsis (culture positive even after 7 days of starting antibiotics), screen for
the focus of infection: plan USG abdomen, Echo, eye checkup, neuroimaging; try to remove
central line.
• In case of meningitis, repeat CSF after 72 hours to document sterility and cytological
improvement.
• In CONS and Candida sepsis, remove central line, if it is not the life line. Send the line tip for
culture.
19 RHEUMATOLOGY:
Presumptive therapy Changes to be made as per antibiotic

sensitivity based on microbiology reports
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when available
Superficial Cloxacillin If considered to be due to Gram positive
infections Cocci
(cellulitis etc) Aminoglycosides/ If considered to be due to Gram Negative
2nd generation organisms
cephalosporins, Inj
Cefuroxime/
Cloxacillin +
Aminoglycoside or
3rd generation
cephalosporins
Inj Metronidazole If anaerobes are likely to be involved
added to the above
regimen
Deep seated infections
Pyogenic arthritis Combination of third

generation
cephalosporins+ Sulbactum
+/- Metronidazole
Life threatening Combination of De-escalate when response is good or
sepsis Carbapenems + teicoplanin change antibiotics when response is poor
or microbiology report suggests different
sensitivity pattern
2. Therapeutic antibiotics
These should be based on microbiology report as far as possible. When prophylaxis or presumptive
therapy is continued because of clinical condition, they should be changed to appropriate evidence based
antibiotics as soon as possible.
20 Appendix 1: Treatment regimens for Tuberculosis (RNTCP)
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* The number before the letters refers to the number of months of treatment. The subscript after the
letters refers to the number of doses per week. The dosage strengths are as follows: H: Isoniazid (600
mg), R: Rifampicin (450 mg), Z: Pyrazinamide (1500 mg), E: Ethambutol (1200 mg), S: Streptomycin
(750 mg). Patients who weigh 60 kg or more receive additional Rifampicin 150 mg. Patients who are
more than 50 years old receive Streptomycin 500 mg. Patients who weigh less than 30 kg receive drugs
as per body weight. Patients in Categories I and II who have a positive sputum smear at the end of the
initial intensive phase receive an additional month of intensive phase treatment.
** Seriously ill also includes any patient, pulmonary or extra-pulmonary, who is HIV-positive and declares
his sero-status to the categorizing/ treating medical officer (MO). For the purpose of categorization, HIV
testing should not be done.
*** In rare and exceptional cases, patients who are sputum smear-negative or who have extrapulmonary
disease can have Relapse or Failure. This diagnosis in all such cases should always be made by an MO
and should be supported by culture or histological evidence of current, active TB. In these cases, the
patient should be categorized as ‘Others’ and given Category II treatment.
 Patients with extra-pulmonary TB should receive Category III treatment unless they are seriously
ill, in which case they should receive Category I treatment.
Examples of seriously ill patients are those suffering from meningitis, disseminated TB,
tuberculous pericarditis, peritonitis, bilateral or extensive pleurisy, spinal TB with neurological
complications, smear-negative pulmonary TB with extensive parenchymal involvement, intestinal
and genitourinary TB and co-infection with HIV. All forms of pediatric smear negative TB except
primary complex and pediatric extrapulmonary TB except lymph node TB and unilateral pleural
effusion.
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21 Appendix 2: Antibiotics to be modified in liver disease
S.No. Antibiotics Description

1 Atazanvir Manufacturer advises caution in mild hepatic impairment; avoid in
moderate to severe hepatic impairment
2 Azathioprine May need to close reduction
3 Azithromycin Avoid; jaundice reported
4 Caspofungin 70mg on first day then 35mg once daily in moderate hepatic impairment;
no information available for severe hepatic impairment
5 Chloramphenicol Avoid if possible-increased risk of bone-marrow depression; reduce dose
and monitor plasma chloramphenicol concentration
6 Cyclosporine May need dose adjustment
7 Clarithromycin Hepatic dysfunction including jaundice reported
8 Clavulanic acid Monitor liver function in liver disease. Avoid in cholestatic jaundice
9 Co-amoxiclav Monitor liver function in liver disease. Avoid in cholestatic jaundice
10 Co-trimoxazole Manufacturer advises avoid in severe liver disease
11 Doxycycline Avoid (or use with caution);
12 Erythromycin May cause idiosyncratic hepatotoxicity
13 Famciclovir Usual dose in well compensated liver disease (information not available on
decompensated)
14 Flucloxacillin Caution in hepatic impairment, risk of cholestatic jaundice and hepatitis.
15 Fluconazole Toxicity with related drugs
16 Griseofulvin Avoid in severe liver disease
17 Ketoconazole Avoid
18 Lymecycline Avoid (or use with caution);
19 Mefloquine Avoid for prophylaxis in severe liver disease
20 Meropenem Monitor transaminase and bilirubin concentrations
21 Metronidazole In severe liver disease reduce total daily dose to one-third, and give once
daily
22 Miconazole Avoid
23 Moxifloxacin Manufacturer advises avoid in severe hepatic impairment
24 Nalidixic Acid Manufacturer advises caution in liver disease
25 Neomycin Absorbed from gastro-intestinal tract in liver disease-increased risk of
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ototoxicity
26 Nitrofurantion Cholestatic jaundice and chronic active hepatitis reported
27 Ofloxacin Elimination may be reduced in severe hepatic impairment
28 Pantoprazole Max. 20mg daily in severe hepatic impairment and cirrhosis-monitor liver
function (discontinue if deterioration)
29 Ribavirin No dosage adjustment required; avoid oral administration in severe hepatic
dysfunction or decompensated cirrhosis
30 Rifabutin Reduce dose in severe hepatic impairment
31 Rifampicin Impaired elimination; monitor liver function; avoid or do not exceed 8mg/kg
daily.
32 Saquinavir Manufacturer advises caution in moderate hepatic impairment ; avoid
severe impairment
33 Tetracyclines Avoid (or use with caution); max, 1 g daily in divided doses
34 Ticarcillin Cholestatic jaundice, Monitor liver functions in liver disease. Avoid in
cholestatic jaundice
35 Timentin Cholestatic jaundice, Monitor liver functions in liver disease. Avoid in
cholestatic jaundice
36 Valaciclovar Manufacturer advises caution with high doses used for preventing
cytomegalovirus disease-no information available
37 Voriconazole In mild to moderate hepatic cirrhosis use normal loading dose then halve
normal maintenance dose; no information available for severe hepatic
cirrhosis - manufacturer advises use only if potential benefit outweighs risk
38 Zidovudine Accumulation may occur
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22 Appendix 3: Antibacterial agents in Pregnancy: Risk Categories
AGENTS PREGNANCY RISK CATEGORY
Natural penicillins
Penicillins G B
Penicillins V B
Antistaphylococcal penicillins
Nafcillin B
Oxacillin B
Aminopenicillins
Ampicillin B
Amoxicillin B
Aminopenicillins + β- lactamase inhibitors
Amipicillin-sulbactam B
Amoxicillin-clavulanate B
Extended-spectrum penicillins + β – lactamase inhibitors
Piperacillin-Tazobactam B
Ticarcillin-clavulanate B
First-generation cephalosporins
Cefazolin B
Cefadroxil B
Cephalexin B
Second-generation cephalosporins
Cefotetan B
Cefoxitin B
Cefuroxime B
Cefuroxime axetil B
Cefprozil B
Cefaclor B
Loracarbef B
Third-generation cephalosporins
Cefotaxime B
Ceftazidime B
Ceftizoxime B
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Ceftriaxone B
Cefdinir B
Cefditoren B
Cefditoren B
Cefpodoxime B
Cefixime B
Fourth-generation cephalosporins
Cefepime B
Carbapenems
Imipenem/cilastatin C
Meropenem B
Ertapenem B
Monobactams
Aztreonam B
Vancomycin C
Rifamycins
Rifampin C
Rifaximin C
Rifabutin B
Aminoglycosides
Streptomycin D
Gentamicin D
Tobramycin D
Amikacin D
Macrolides and ketolides
Erythromycin B
Azithromycin B
Clarithromycin C
Telithromycin C
Tetracyclines and glycylcyclines
Tetracycline D
Doxycycline D
Minocycline D
Tigecycline D
Chloramphenicol C
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Clindamycin B
Linezolid C
Trimethoprim-sulfamethoxazole C
Quinolones
Ofloxacin C
Ciprofloxacin C
Levofloxacin C
Moxifloxacin C
Gemifloxacin C
Metronidazole B
Antimycobacterial agents
Isoniazid C
Rifampin C
Pyrazinamide C
Ethambutol B
Pregnancy risk category
Category A
Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of
pregnancy (and there is no evidence of risk in later trimesters).
Category B
Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-
controlled studies in pregnant women.
Category C
Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-
controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite
potential risks.
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Category D
There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing
experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women
despite potential risks.
Adapted from Gilbert DN, Moellering RC Jr, Eliopoulos GM, et al. The Sanford Guide to Antimicrobial
th
Therapy. 36 Ed. Sperryville, VA: Antimicrobial Therapy, Inc., 2006; Briggs GG, Freeman RK, Yaffe SJ. Drugs
in Lactation and Pregnancy. 7th Ed. Philadelphia: Lippincott Williams & Wilkins, 2005
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3A. Antibiotic Policy

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Name of Organisation: Document Code: Date of Issue:

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

Date of Creation: 15-03-2021

Date of Approval: 24-03-2021

Date of Expiry: 31-03-2022

Approved By: Name: Dr. Daljit Singh

Created By: Name:

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

1.1 Purpose of This Policy................................................................................................................. 4

1.4 Antibiotic Prophylaxis to prevent surgical site infections in adults.........................................9

1.5 Fundamental principles of surgical prophylaxis........................................................................9

1.6 Antibiotics Prophylaxis.............................................................................................................. 10

2 ANTIBIOTIC POLICIES OF VARIOUS DEPARTMENTS............................................................16

2.1 CLINICAL HEMATOLOGY & BONE MARROW TRANSPLANTATION......................................16

2.2 CRITICAL CARE AND RESPIRATORY MEDICINE:...................................................................16

3 Antibiotic lock therapy............................................................................................................... 20

7 GASTROENTEROLOGY & HEPATOLOGY:...............................................................................25

8 Prophylaxis for Endoscopy........................................................................................................ 28

9 OBSTETRICS AND GYNAECOLOGY......................................................................................... 30

10 Genital Tract Infections.............................................................................................................. 31

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

14 DIALYSIS & NEPHROLOGY PATIENTS:....................................................................................44

17 PAEDIATRICS AND ADOLESCENT MEDICINE:........................................................................48

20 Appendix 1: Treatment regimens for Tuberculosis (RNTCP)..................................................53

21 Appendix 2: Antibiotics to be modified in liver disease..........................................................55

22 Appendix 3: Antibacterial agents in Pregnancy: Risk Categories..........................................57

Pregnancy risk category..................................................................................................................... 59

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

Hospital Antibiotic Policy

1.1 Purpose of This Policy

Responsibilities of the Antibiotic Working Group

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

A. Urinary tract infections

OPD IPD ICU

Send sample for cultures

Piperacillin/ Tazobactum Amikacin or A. Piperacillin/ Tazobactum or

After Culture Report – 48 to 72 hours

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

B. BLOOD STREAM INFECTIONS

Send sample for cultures

After Culture Report – 48 to 72 hours

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

C. PUS AND SOFT TISSUE INFECTIONS

No history of antibiotics Recent antibiotic history Recent and multiple antibiotic

Send sample for cultures

Presumptive therapy Presumptive therapy Presumptive therapy

Amoxyclav or Cefuroxime Amikacin and Clindamycin Amikacin and Vancomycin /

After Culture Report – 48 to 72 hours

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

D.RESPIRATORY TRACT INFECTIONS

Send sample for cultures

A. Community acquired pneumoniae:

Non-ICU: Amoxy-Clav plus Clarithromycin/Azithromycin or Levofloxacin

B. Aspiration pneumoniae: Clindamycin / Metronidazole

c. Hospital acquired pneumoniae D.Ventilator acquired pneumoniae

Imipenem/ Meropenem Imipenem/ Meropenem and Linezolide

After Culture Report – 48 to 72 hours

MRD +: Add Colistin

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

1.4 Antibiotic Prophylaxis to prevent surgical site infections in adults

FACTORS ASSOCIATED WITH INCREASED RISK OF SURGICAL INFECTION

1.5 FUNDAMENTAL PRINCIPLES OF SURGICAL PROPHYLAXIS

Chauhan Multispeciality & CMTC/HIC/AP/05 01-04-2021

 Antibiotics must be started within 1 hour before incision.