BYRAMJEE JEEJEEBHOY MEDICAL COLLEGE AND SASSOON …



|ANTIBIOTIC POLICY |

|Sassoon General Hospital & BJGMC, Pune |

ANTIBIOTIC POLICY

Sassoon Hospital

&

BJGMC

Pune

2014-15

FOREWORD

It gives me immense pleasure to present this handbook on Antimicrobial Policy for Sassoon Hospital, Pune. I sincerely appreciate the efforts of team who have worked to make this policy a reality.

It is less than a century since antibiotic therapy became available to humanity. However, widespread and indiscriminate use of antibiotics has resulted in microorganisms developing resistance to them, so much so, that now the antibiotic resistance has reached alarming proportion. This antibiotic policy will ensure rational use of antibiotics in Sassoon Hospital and help us contribute to minimizing the menace of antibiotic resistance.

Dr A.S. Chandanwale

Dean

B.J. Govt. Medical College &

Sassoon Hospital, Pune

Index

Foreword 3

Introduction 5

General Guidelines 6

MEDICINE 7-9

SURGERY 10-15

PEDIATRICS 16-17

ENT 18

NEONATAL INFECTIONS 19-20

OBST. & GYNAEC. 21-22

ORTHOPEDICS 23-24

DERMATOLOGY 25-26

CVTS 27

OPHTHALMOLOGY 28-30

Contributors 31

Steps of Hand-washing 32

INTRODUCTION

The emergence and spread of antibiotic resistance is becoming a global public health concern. The widespread use of antibiotics both inside and outside of medicine has contributed largely to this phenomenon. The large volume of antibiotics prescribed in health care settings is a major cause of concern and bacteria once exposed to antibiotics have the capacity to adapt and develop resistance by various mechanisms. All newly introduced antimicrobial agents have only a limited ‘virginity’ before the specter of resistance emerges. The current situation is that there are very few newer antibiotics in the pipeline as it is no longer cost effective for the pharmaceutical industry to develop newer antimicrobials.

Antimicrobial resistance in hospitals hampers the control of infectious diseases and threatens a return to the pre-antibiotic era. It also increases the costs of health care and jeopardizes health-care gains to society

Thus, this antibiotic policy was developed by the staff of B.J. Government Medical College & Sassoon general Hospitals, Pune as an effort to rationalize the use of antibiotics in the hospital keeping in mind the current sensitivity patterns of hospital bacteria and availability in our drug store. It is planned that the policy will be renewed regularly based on the feedback of the clinicians, the availability of drugs in the hospital and the drug sensitivity pattern of the hospital pathogens. I would like to reiterate that these are guidelines only and the interpretation and application of these guidelines is the responsibility of the clinician. A review of the current guidelines will be planned based on the experiences of the clinicians and the problems faced by them.

Formulation & implementation of an antibiotic policy is a first step in implementing the rationale use of antibiotics. It is also a step towards controlling the spread of antimicrobial resistance in our hospital. However it cannot be a short cut to appropriate infection control practices especially hand washing.

An antibiotic policy can only succeed if there is willingness and ownership of every single doctor in the hospital. Please ensure that samples for culture and sensitivity are sent before onset of therapy, so that data regarding antimicrobial spectrum of pathogens from various sites stays updated and is available to you so you can plan therapy better

GENERAL GUIDELINES

1. Clinical samples for microbiologic culture and sensitivity must ALWAYS be sent, before starting empiric therapy.

2. Empiric treatment can be started as per policy guidelines and clinical judgment

3. Step down or step up of treatment can be done based on the antibiotic sensitivity report. In case of no clinical response, consult microbiologist and pharmacologist.

4. Various factors associated with drug metabolism must be taken into account while prescribing treatment

• Hypersensitivity(Patient MUST be questioned about drug allergies in past)

• Renal function

• Drug interactions

5. Irrational drug combinations must be avoided.

6. Colistin, Carbapenems and linezolid are reserve drugs only and should be prescribed only after culture sensitivity report demonstrating sensitivity exclusively to these drugs.

7. Therapy monitoring: Need of antibiotic must be reviewed on daily basis. Most common infections usually need antibiotics for not more than 7 days. IV antibiotics should be switched to oral within 24-48 hours, based on clinical improvement and microbiology antibiotic sensitivity pattern.

8. Antibiotics should not be used as a substitute for appropriate infection control procedures.

ANTIBIOTIC POLICY

MEDICINE DEPARTMENT

|Clinical condition |Empirical therapy |Remarks |

|Community acquired Pneumonia | | |

|Mild(Not hospitalized) |Oral Doxycycline100 mg 12 hourly X 7days /Oral |Use oral drugs |

| |Azithromycin 500 mg OD 3 days | |

|Moderate(Hospitalised, Not in ICU) |Inj Levofloxacin |Use injectables. Switch to oral as early as |

| |750 mg IV 6 hourly X 7-10days/ |possible |

| |Oral Azithromycin 500 mg OD 3 days | |

|Severe (ICU) |Levofloxacin 750 mg IV 6 hourly X 7-10 days |-Use injectables. Switch to oral as early as |

| |OR |possible |

| |Moxifloxacin 400 mg IV 24 hourly | |

|Hospital Acquired Pneumonia |Amikacin15mg/kg 6 hourly +IIIrd generation |-Escalate/descalte after culture sensitivity |

| |cephalosporins Cefotaxime 1–2 g IV|report |

| |8 hourly , Ceftriaxone 2 g IV qd) |-Stop antibiotics after 5 days of clinical |

| | |response |

|VAP |Vancomycin 15 mg/kg, up to 1 g IV, 12 hourly + |-Escalate/deescalate after culture sensitivity |

| |Imipenem/Meropenem 500 mg IV 6 hourly or 1 g IV |report |

| |8 hourly |-Stop antibiotics after 5 days of clinical |

| | |response |

|Clinical condition |Empirical therapy |Remarks |

|Acute meningitis | Vancomycin 15 mg/kg IV 8hourly+ Ceftriaxone 2 gIV | |

| |12hourly/Cefotaxime 2 g IV 6hourlyfor 10-14 days+ Dexamethasone | |

| |0.15mg/kg X 4 days | |

|Chronic meningitis |Culture is mandatory prior to starting therapy | |

|Clinical condition |Empirical therapy | |

|Gastroenteritis | | |

|Mild diarrhoea < 3 unformed stools with min |Ciprofloxacin 500 mg/ Norfloxacin 400mg orally 12 hourly) + | |

|symptoms |Metronidazole 250 mg 8 hourly for 3 days | |

|Moderate diarrhoea > 4 < 6 |Ciprofloxacin 500 mg/ Norfloxacin 400mg orally 12 hourly) for 3 -5 | |

| |days + Metronidazole 250 mg 8 hourly for 5 days | |

|Severe diarrhoea > 6 with > temp. tenesmus |Ciprofloxacin500 mg/ / Norfloxacin 400mg orally 12 hourly for 3 -5 | |

| |days + Metronidazole 250 mg 8 hourly for 5 days | |

|Cholera like watery diarrhoea |Doxycycline 300 mg orally x 1 day | |

|Clostridium difficile associated diarrhoea |Oral Metronidazole 400 mg orally tds X 10-14 days OR | |

| |Oral Vancomycin (125mg 6 hourly ) X 10-14 days | |

|Clinical condition |Empirical therapy |Remarks |

|Oesophagitis |Fluconazole 200 -400 mg daily/ |Use fluconazole only if candidial |

| |Injection Amphotericin B |oesophagitis is suspected |

|Duodenal/gastric ulcer |Omeprazole(20 mg 12 hourly) + Clarithromycin(250 or | |

| |500 mg 12 hourly)+Metronidazole(500 mg 12 hourly) for| |

| |14 days | |

|Clinical condition |Empirical therapy |Remarks |

|Blood stream infections | | |

|1) CRBSI |Vancomycin(15mg/kg IV 12 hourly)+ Third generation | |

| |cephalosporins (Ceftazidime 2 gm IV 8 | |

| |hourly,Cefoperazone) for 4-6 weeks | |

|2) Native valve endocarditis |Vancomycin(15mg/kg IV 12 hourly) + Gentamicin( 1mg /kg | |

| |IM or IV 8 hourly) for 4-6 week | |

|3) Prosthetic valve endocarditis |Vancomycin (15mg/kg IV 12 hourly)+ Gentamicin( 1mg /kg IM|Cardiothoracic surgery consultation |

| |or IV 8 hourly) for 4-6 weeks | |

|Clinical condition |Empirical therapy |Remarks |

|Urinary tract infection | | |

|Community acquired |Cotimoxazole DS 12 hourly for 3 days /Nitrofurantoin | |

| |100 mg orally 12 hourly for 5 days | |

|Catheter associated |Gentamicin( 1mg /kg IM or IV 8 hourly) | |

| |+ | |

| |Imipenem(500 mg IV 6 hourly) x 7-14 days | |

|Pyelonephritis |Uncomplicated: Oral Ciprofloxacin 500 mg BD | |

| |Complicated: Piperacillin with Tazobactam 3.375 IV 6 | |

| |hourly/ Imipenem 500 mg IV 6 hourly or 1 g IV 8 hourly| |

|Clinical condition |Empirical therapy |Remarks |

|Fever of unknown origin(PUO) |Cefotaxime (2g IV every 4-6 hourly) | |

|Clinical condition |Empirical therapy |Remarks |

|Diabetic foot Mild (No systemic symptoms, Localised |1. Cloxacillin 500 - 1000 | |

|cellulitis |mild (localized mg orally6 hourly × 7-10 days | |

| |2.Cefazolin 1 gm i.v. 8 hourly | |

| |symptoms) /Cephalexin 500 mg | |

| |orally6 hourly × 7-10 day | |

| |+ Metronidazole IV500 mg 8 hourly | |

|Diabetic foot –moderate to severe (Limb |Cefazolin 1 gm i.v. 8 hourly+ Gentamicin 5mg/kg |Surgery consultation if |

|threatening-severe cellulits/gangrene/SIRS) |i.v once daily |intervention needed |

| |OR | |

| |Ciprofloxacin 400 mg IV 12 hourly+ Metronidazole | |

| |IV500 mg 8 hourly | |

SURGERY DEPARTMENT

|Clinical condition |Empirical therapy |Remarks |

|Ulcer without inflammation |No antibacterial therapy | |

|Ulcer with 2 cm of inflammation |Oral Cotrimoxazole DS 12 hourly | |

| |Gentamicin Gentamicin 5mg/kg i.v once daily / Piperacillin with Tazobactam | |

| |3.375 IV 6 hourly +Metronidazole IV500 mg 8 hourly | |

| | | |

|GIT | | |

|Cholecystitis | Ciprofloxacin 400 mg IV 12 hourly / Gentamicin 5mg/kg i.v once daily + | |

| |Metronidazole IV 500 mg 8 hourly | |

| |If severe, Piperacillin with Tazobactam 3.375 IV 6 hourly /Imipenem 500 mg IV| |

| |6 hourly /Doripenem 500 mg 8 hourly /Meropenem 1 g IV 24 hourly + | |

| |Metronidazole IV500 mg 8 hourly | |

|Cholangitis |Same as above | |

|Biliary sepsis |Same as above | |

|Oesophagitis |Fluconazole 200 -400 mg daily or Amphotercin B 0.5 mg/kg daily) | |

|Duodenal/Gastric ulcer |Omeprazole(20 mg 12 hourly) +Clarithromycin (250 or 500 mg 12 | |

| |hourly)+Metronidazole(500 mg 12 hourly) for 14 days | |

|Diverticulitis |OPD: MILD /DRAINED PERIRECTAL ABCESS: Cotimoxazole bid/Levo 750 mg 24hourly+ | |

|Perirectal abscess |Metro 500 mg 6hourly: All orally FOR 7-10 DAYS | |

|Peritonitis |IPD:MILD –MODERATE: Piperacillin-Tazobactam 3.375.g IV 6hourly/4.5 g IV | |

| |8hourly/Ticarcillin-Clavulinic acid 3.1 g IV 6 hourly/Ertapenem 1 g IV 24 | |

| |hourly/Moxi 400 mg IV 24 hourly | |

| |SEVERE LIFE THREATENING: Imipenem 500 mg IV 6 hourly/Meropenem 1 g IV 8 | |

| |hourly/Doripenem 500 mg 8 hourly | |

|UTI | | |

|Catheter associated |Mild: Nitrofurantoin 100 mg 12 hourly/Cotrimoxazole DS 12 hourly | |

| |Severe: Amikacin 15mg/kg 6 hourly /Gentamicin 5mg/kg i.v once daily / | |

| |Ciprofloxacin 400 mg IV 12 hourly / IIIrd generation cephalosporin/ | |

| |Piperacillin- Tazobactam 3.375 IV 6 hourly | |

|Perinephric abscess |Vancomycin 15mg/kg IV 12 hourly + IIIrd generation cephalosporin/ | |

| |Piperacillin with Tazobactam 3.375 IV 6 hourly | |

| |Start with Vancomycin 15mg/kg IV 12 hourly. Descalate to Cloxacillin 250 mg | |

| |oral 6 hourly | |

|Prostatitis |Cotrimoxazole DS 12 hourly / Ciprofloxacin IV: 400 mg IV every 12 hours | |

| |Oral: 500 mg oral 12 hourly / Ofloxacin 300 mg orally 12 hourly | |

|Clinical condition |Empirical therapy |Remarks |

|Skin and soft tissue infections | | |

|Cellulitis |Oral regimens: | |

| |Cotimoxazole 1-2 DS tablets orally 12 hourly + Amoxycillin 500| |

| |mg orally 8 hourly | |

| |Doxycycline 100 mg orally 12 hourly | |

| | | |

| |Parenteral regimens | |

| |Clindamycin 600 mg IV 8 hourly | |

| |If spreading, Vancomycin 15mg/kg IV 12 hourly. | |

|Cutaneous abscess |Oral regimens: | |

| |Cotimoxazole 1-2 DS tablets orally 12 hourly + Cloxacillin 500| |

| |mg orally 6 hourly | |

| |Doxycycline 100 mg orally 12 hourly | |

| | | |

| |Parenteral regimens | |

| |Clindamycin 600 mg IV 8 hourly | |

| |If spreading, Vancomycin 15mg/kg IV 12 hourly. | |

|Diabetic foot with extensive inflammation and |Vancomycin 15mg/kg IV 12 hourly. + Piperacillin with Tazobactam| |

|systemic toxicity |3.375 IV 6 hourly + Metronidazole IV500 mg 8 hourly | |

| |Descalate | |

|Clinical condition |Empirical therapy | |

|SSI | | |

|For clean procedures(Orthopaedic joint replacements, |Cloxacillin 1-2g IV 4 hourly | |

|open reduction of closed fractures, Vascular |PCN allergy: Clindamycin 600 mg IV 8 hourly | |

|procedures, craniotomy, breast & hernia surgery) | | |

|For clean contaminated procedures(GI/GU procedures, |Piperacillin with Tazobactam 3.375 IV 6 hourly | |

|oropharyngesl & OBGY ) |/Gentamicin 5mg/kg i.v once daily +Metronidazole IV500 | |

| |mg 8 hourly | |

|In deep fascia involvement |Clindamycin 600 mg IV 8 hourly +Metronidazole IV500 mg 8| |

| |hourly | |

|Necrotising fascitis |Clindamycin 600 mg IV 8 hourly +Metronidazole IV500 mg 8| |

| |hourly | |

| | | |

|Clinical condition |Empirical therapy |Remarks |

|CNS | | |

|Brain abscess | | |

|Primary |Meropenem 1 g IV 8 hourly +Metronidazole IV500 mg 8 | |

| |hourly | |

|Postsurgical |Vancomycin 15mg/kg IV 12 hourly.+Meropenem 1 g IV 8 | |

| |hourly +Metronidazole IV 500 mg 8 hourly/ | |

Preop prophylaxis (Recommended)

|Urologic surgery | |

|Transrectal prostate biopsy |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV500 mg|

| |8 hourly with or without Gentamicin 5mg/kg i.v once daily |

|Transurethral surgery(eg. TURP, TURBT, ureteroscopy, cystouretoscopy, |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM |

|lithotripsy) | |

|Nephrectomy or radial prostectomy |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM |

|Radial cystectomy, Cystoprostectomy or Anterior exenteration |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV500 mg|

| |8 hourly with or without Gentamicin 5mg/kg i.v once daily |

| | |

|Head and Neck Surgery | |

|Major procedure with incision of oral or pharyngeal or sinus mucosa |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg |

| |IV 8 hourly |

|Major Neck dissection or Parotid dissection |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg |

| |IV 8 hourly |

|Thyroid/Parathyroid surgery | Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Amikacin15mg/kg 6 |

| |hourly |

|Tonsillectomy | Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Amikacin15mg/kg 6 |

| |hourly |

|Neurosurgery | |

|Craniotomy (including shunt placement) |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM |

|Spinal fusion |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM |

|Laminectomy |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM |

|General surgery | |

|Inguinal hernia repair |Uncomplicated with mesh: Ceftriaxone/Cefotaxime 1 to 2 g/day IV or |

| |IM |

| |Complicated, recurrent, remergent: Metronidazole IV 500 mg 8 hourly |

| |+ (Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM) |

|PEG |Ampicillin +Gentamicin +Metronidazole ORPCN allergy: Clindamycin |

| |±Gentamicin |

|Gastrectomy/Hepatectomy/cholecystectomy | Metronidazole IV 500 mg 8 hourly +(Ceftriaxone/Cefotaxime 1 to 2 |

| |g/day IV or IM |

|Small bowel or colon surgery |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 |

| |mg 8 hourly |

|Whipple procedure or pancreatectomy |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 |

| |mg 8 hourly |

|Appendectomy(uncomplicated),if complicated and perforated treated as |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 |

|secondary peritonitis |mg 8 hourly |

|Penetrating abdominal trauma |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 |

| |mg 8 hourly |

|Mastectomy |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 |

| |mg 8 hourly |

|Mastectomy with lymph node dissection | Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500|

| |mg 8 hourly |

Post op prophylaxis

|Condition |Antibiotic |

|General Surgery | |

|Appendicitis | Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + |

| |Amikacin15mg/kg 6 hourly |

| |+IV Metronidazole IV500 mg 8 hourly |

|Enterocolitis |Mild- Tab.Ciprofloxacin 500 mg orally 12 hourly |

| |Tab. Metronidazole 500 mg 12 hourly |

| |Severe- IV Ciprofloxacin |

| |IV Metronidazole IV500 mg 8 hourly/ |

|Liver abscess |IV Ciprofloxacin400 mg IV every 12 hours double dose |

| |IV Metronidazole double dose IV500 mg 8 hourly/ |

|Acute Pancreatitis |IV Piperacillin with Tazobactam3.375 IV 6 hourly |

| |IV Metronidazole 500 mg 8 hourly/ |

|Severe acute pancreatits |IV Piperacillin –Tazobactam3.375 IV 6 hourly |

| |IV Metronidazole IV500 mg 8 hourly/ |

|Urology | |

|Epididymo orchitis |Mild- Oral. Amoxicillin-Clavulinic acid 500/125 mg BD |

| |Severe- IV Piperacillin with Tazobactam3.375 IV 6 hourly |

| |IV Metronidazole IV500 mg 8 hourly/ |

|Testicular torsion/ infarct/ gangrene |IV Piperacillin with Tazobactam 3.375 IV 6 hourly |

| |IV Metronidazole IV500 mg 8 hourly/ |

|Neurosurgery | |

|Meningitis |IV Ceftriaxone 1 to 2 g/day IV or IM |

| |IV Gentamicin/Amikacin 15mg/kg 6 hourly |

| |IV Vancomycin 15mg/kg IV 12 hourly. |

|Paediatric surgery | |

|MeningoMyelocoele |IV Vancomycin 15mg/kg IV 12 hourly. |

| |IV Amikacin 15mg/kg 6 hourly |

|Rectovaginal fistula |IV Amikacin 15mg/kg 6 hourly |

| |IV Metronidazole IV500 mg 8 hourly/ |

|Tracheo oesophageal |IV Piperacillin with Tazobactam 3.375 IV 6 hourly |

|fistula |IV Metronidazole IV500 mg 8 hourly/ |

|Splenectomy |IV Piperacillin with Tazobactam 3.375 IV 6 hourly |

|Hirschsprung |IV Piperacillin with Tazobactam3.375 IV 6 hourly |

|Disease |IV Metronidazole IV500 mg 8 hourly/ |

|Decortication |IV Piperacillin with Tazobactam3.375 IV 6 hourly |

| |IV Vancomycin 15mg/kg IV 12 hourly. |

|Intestinal atresia |IV Piperacillin with Tazobactam 3.375 IV 6 hourly |

| |IV Metronidazole IV500 mg 8 hourly |

|Biliary atresia |IV Piperacillin with Tazobactam 3.375 IV 6 hourly |

| |IV Metronidazole IV500 mg 8 hourly |

|Hypospadias |IV Piperacillin with Tazobactam 3.375 IV 6 hourly |

|Hernia |IV Piperacillin with Tazobactam 3.375 IV 6 hourly |

|Hydrocele |IV Piperacillin with Tazobactam 3.375 IV 6 hourly |

PEDIATRICS

CNS

|Disease |Treatment |Remarks |

|Meningitis |IIIrd generation cephalosporin Ceftriaxone(100 | |

| |mg/kg/day) +Vancomycin 60 m/k/d q 8 hr) | |

| |Descalation after culture sensitivity report | |

|Encephalitis |21 day course of acyclovir(60 m/k/d q 8hr) | |

|Brain abscess |Meropenem 120 mkd 8 hourly+ Metronidazole 30 | |

| |mkd q 8 hr | |

|Shunt infection |Vancomycin( 60 mkd q 8 hr) and Gentamicin(5 | |

| |mkd) X 10-14 days | |

|Transverse myelitis |Antibiotics are not routinely used | |

| |High dose steroids (Methyl prednisolone) | |

Respiratory system

|Disease |Treatment |Remarks |

|Mild pneumonia |Oral Azithromycin (10 mg/kg/day OD) for 5 days | |

|Moderate pneumonia |Oral azithromycin (10mg/kg/day OD) | |

| |+ Augumentin 50 mg/kg/day 12 hourly | |

| |/Cefotaxime50-75 mg/kg/day 12 hourly | |

| |If pseudomonas suspected , Piperacillin with | |

| |Tazobactam (300 mg/kg/day 8 hourly)+ Amikacin | |

| |(15 mg/kg/day) for 7-10 days | |

|Severe pneumonia | IV cefotaxime (50-75mg/kg/day 12 hourly) or IV| |

| |ceftriaxone (50-75 mg/kg/day 12 hourly) plus | |

| |IV Vancomycin (40 mg/kg/day 12 hourly) for | |

| |10-14 days | |

| |If pseudomonas suspected , Piperacillin with | |

| |Tazobactam (300 mg/kg/day 8 hourly)+ Amikacin | |

| |(15 mg/kg/day) for 7-10 days | |

|Hospital acquired pneumonia | Vancomycin (40 mg/kg/day 8 hourly)+ | |

| |Piperacillin with Tazobactam (300 mg/kg/day 8 | |

| |hourly) | |

| |Deescalate according to sensitivity | |

|Ventilator associated pneumonia |Meropenem (40-60 mg/kg/day 8 hourly) + | |

| |Vancomycin (40-60mg/kg/day 8 hourly) | |

|Pulmonary abscess | IV ceftriaxone (50-75 mg/k/day 12 hourly / | |

| |Piperacillin with Tazobactam (300 mg/kg/day 8 | |

| |hourly)+Vancomycin(40 mg/kg/day 8 hourly) | |

| |If serious, Ceftriaxone((50-75 mg/k/day 12 | |

| |hourly )/ Piperacillin with Tazobactam (300 | |

| |mg/kg/day ) +Amikacin(15 mg/kg/day) | |

| |Add Metronidazole( 30 mkg/kg 8 hourly) if | |

| |anaerobic infection is suspected | |

|Empyema |IV ceftriaxone (50-75 mg/k/day 12 hourly / | |

| |Piperacillin with Tazobactam (300 mg/kg/day ) | |

| |+Vancomycin(40 mg/kg/day 8 hourly) | |

| |If serious, , Ceftriaxone((50-75 mg/k/day 12 | |

| |hourly )/ Piperacillin with Tazobactam (300 | |

| |mg/kg/day ) +Amikacin(15 mg/kg/day) | |

| |Add Metronidazole if anaerobic infection is | |

| |suspected | |

|Bronchiectasis |Ceftriaxone/Piperacillin with Tazobactam | |

| |+Vancomycin | |

| |If serious, Ceftriaxone/Piperacillin with | |

| |Tazobactam +Amikacin | |

| |Add Metronidazole if anaerobic infection is | |

| |suspected | |

Renal system

|Urinary tract infection |Cotrimoxazole (8mg/kg/day 12 hourly) / | |

| |Nitrofurantoin(5-7mg/kg/day) | |

|Pyelonephritis |Piperacillin with Tazobactam (300 mg/kg/day 8 | |

| |hourly +Gentamicin(3-5mg/kg/day) X 3 days | |

| |Deescalate after culture sensitivity | |

|Dialysis |Treat according to culture/sensitivity | |

ENT

|Otitis media | | |

|Acute |Cotimoxazole (8mg/kg/day 12 hourly) | |

| |/Azithromycin(10 mg/kg/day OD) | |

|Chronic |Refer to ENT | |

Infective endocarditis

|Initial Empirical |Cefotaxime 50-200 mg/kg/day IV/IM divided | |

| |q6-8hr +Gentamicin 2.5 mg/kg IV or IM every 18| |

| |to 24 hours | |

|Severe |Vancomycin 15 mg/kg IV every 24 hours + | |

| |gentamicin 2.5 mg/kg IV or IM every 18 to 24 | |

| |hours | |

| |Deescalate after culture sensitivity | |

|Febrile neutropenia |IV Ceftazidime 50mg/kg every 8 hours (max 2 |IV Ceftazidime 50mg/kg every 8 hours (max 2 |

| |grams tds)/Piperacillin with Tazobactam (300 |grams tds)and Gentamicin 6-7.5mg/kg/day IV/IM |

| |mg/kg/day ) + Amikacin(15 mg/kg/day) + Oral |Oral fluconazole prophylaxis 3mg/kg once daily |

| |fluconazole prophylaxis 3mg/kg once daily | |

|Severe |Vancomycin 15 mg/kg IV every 24 hours + | |

| |Meropenem 20 mg/kg IV every 8 hours + | |

| |Amphotericin B IV 0.6-1mg/kg/day | |

NEONATAL INFECTIONS

|Chorioamnionitis |1st line-amoxicillin + clavulunate 30 mg/kg/day in| |

| |2 doses | |

| |2nd line-Piperacillin with Tazobactam 75 mg/kg IV | |

| |Q8h + piperacillin and gentamicin for 3 days( if | |

| |CBC is non septic) | |

|Neonatal sepsis (Early onset) |1st line – Ampicillin IV or IM 100mg/kg/day 12 | |

| |hourly / | |

| |Gentamicin | |

| |2nd line – Piperacillin with Tazobactam 75 mg/kg | |

| |IV Q8h | |

| |3rd line-Vancomycin 15 mg/kg IV q24h;  with or | |

| |without antifungal | |

| |4th line- Meropenem 20 mg/kg/day | |

|Neonatal sepsis (Late onset) |1st line-Piperacillin with Tazobactam 75 mg/kg IV | |

| |Q8h + Gentamicin | |

| |2nd line-Vancomycin 15 mg/kg IV q24h with or | |

| |without antifungal | |

| |3rd line- Meropenem 20 mg/kg/day | |

Focal bacterial infections

|Cellulitis |Cloxacillin IV 10 mg/kg BD+ Vancomycin 15 mg/kg IV| |

| |q24h | |

|Pustulosis |Betadine application /Chlorhexidine | |

| |Amoxiclav /Diclox/Cephalexin | |

|SSSS |Nafcillin IV 10 mg/kg BD /Oxacillin 50 mg/kg/day | |

| |IM/IV divided q12h. | |

|Omphalitis |Oxacillin 50 mg/kg/day IM/IV divided q12h. | |

| |/Nafcillin IV 10 mg/kg BD +Gentamicin | |

|Pneumonia |Ist line: Piperacillin with Tazobactam 75 mg/kg IV | |

| |Q8h + Gentamicin | |

| |2nd line: Meropenem 20 mg/kg/day | |

| |3rd line –Antifungal | |

|Necrotizing enterocolitis |Piperacillin with Tazobactam 75 mg/kg IV Q8h | |

| |+Vancomycin 15 mg/kg IV q24h +Metronidazole | |

|Meconium aspiration syndrome: |Ampicillin IV or IM 100mg/kg/day 12 hourly + | |

| |gentamicin 5mg/kg/dose | |

Gastrointestinal Infection

| |Antibiotic used | |

|Mild Diarrhoea |Syrup septran 2.5 ml every 12 hours | |

|Moderate diarrhoea |Syrup septran 2.5 ml every 12 hours or IV cefotaxime| |

| |100-150 mg/kg/day IM/IV divided q8-12hourly | |

|Severe diarrhoea |IV cefotaxime 100-150 mg/kg/day IM/IV divided | |

| |q8-12hourly | |

| |IV Metronidazole 100-150 mg/kg/day IM/IV divided | |

| |q8-12hourly | |

OBSTETRICS AND GYNAECOLOGY

|Clinical condition |Empirical therapy |Remarks |

|PID |Ciprofloxacin 500 mg BD for 7 days | |

| |Metronidazole 400 mg PO TDS 14 days | |

|Trichomonas Vaginitis |-Metronidazole 400 mg TDS for 7 days | |

| |-Treat sexual partner | |

|Bacterial vaginosis |Metronidazole 400 mg PO TDS for 7 days with or | |

| |without Metronidazole gel 0.75%,5g | |

| |intravaginally daily | |

|Vulvovaginal candidiasis |Clotrimazole 1% cream,5 g intravaginally for 7 | |

| |days | |

|Endocervicits | | |

|N.gonorrhoea |Ceftriaxone ,250 mg IM single dose | |

|C.trachomatis |Azithromycin 500 mg OD for 3 days or | |

| |Doxycycline,100 mg twice daily for 7 days | |

| | | |

|Asymptomatic bacteriuria in pregnant women |Nitrofurantoin 50-100 mg x 4 times | |

|Cystitis |Nitrofurantoin 50-100 mg x 4 times | |

| |Ciprofloxacin 500 mg BID for 14 days or | |

| |Norfloxcin 400 mg BD for 14 days | |

|Pyelonephritis |Augumentin1.2 gm BD / Piperacillin with | |

| |Tazobactam 3.375 IV 6 hourly | |

| | | |

|Puerperal sepsis |Mild : Oral cefixime on discharge | |

| |Severe: Gentamicin 5mg/kg i.v once daily | |

| |/Amikacin 15mg/kg 6 hourly | |

| |/Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM | |

| |+Metronidazole IV500 mg 8 hourly + Augumentin | |

| |1.2 gm BD | |

| |If no response, wait for culture sensitivity | |

| |report or start Imipenem | |

|Preoperative prophylaxis | | |

|Surgical procedures | | |

|Elective LSCS |Augumentin 1.2 gm BD + Metronidazole 500 mg TDS| |

|hysterosalpingogram |Doxyxycline 100 mg twice for 5 days | |

|Manual removal of placenta |Augumentin 1.2 gm BD + Metronidazole 500 mg TDS| |

|Post partum D & C |Augumentin 1.2 gm BD + Metronidazole 500 mg TDS| |

|Elective minor procedures(MTP ,D&C ) |Augumentin 1.2 gm BD + Metronidazole 500 mg TDS| |

|Hysterectomy(abdominal or vaginal) |Augumentin 1.2 gm BD + Metronidazole 500 mg TDS| |

|Repair of cystocoele or rectocoele |Augumentin 1.2 gm BD + Metronidazole 500 mg TDS| |

| | | |

|Postoperative treatment | | |

|Surgical site infections | | |

|Gynaecology |Augumentin 1.2 gm BD + Metronidazole 500 mg TDS| |

| | | |

|Obstetrics |Gentamicin 5mg/kg i.v once daily | |

| |+Metronidazole IV500 mg 8 hourly | |

| |Augumentin 1.2 gm BD + Metronidazole IV500 mg 8| |

| |hourly (In renal impairment) | |

| | | |

ORTHOPEDICS

|Clinical condition |Empirical therapy |Remarks |

|Osteomyelitis |Pediatric: IIIrd gen cephalosporins/ Cefoperazone) |Pediatric reference for pediatric |

| |If no response, send sample for culture. Vancomycin|osteomyelitis if surgical intervention |

| |recommended. |like drainage of abscess required, ortho |

| |Adults: |surgeon will drain and retransfer. |

| |-Uncomplicated: Augumentin I.V | |

| |-Complicated(MRSA suspected) Vancomycin , | |

| |Vancomycin 15mg/kg IV 12 hourly.I.V | |

|Osteomyelitis with comorbidities like |Ciprofloxacin IV 400 mg IV every 12 hours + | |

|Diabetes mellitus |Gentamicin 5mg/kg i.v once daily | |

| |/Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM | |

| |+Metronidazole IV500 mg 8 hourly | |

|Clinical condition |Empirical therapy |Remarks |

|Prophylaxis for closed fractures after |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM x 5 | |

|surgery |days + 5mg/kg i.v once daily for 3 days | |

|Infected compound fractures |Debride within 24 hours followed by the following| |

| |treatment | |

|Grade 1 |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM | |

| |x5days + Gentamicin 5mg/kg i.v once daily for 3| |

| |days | |

|Grade 2 |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + | |

| |Gentamicin x5mg/kg i.v once daily 7 days-10days | |

|Grade3 |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + |If wound deteriorating, treatment according|

| |Gentamicin 5mg/kg i.v once daily +Metronidazole|to culture report or Pip -taz |

| |IV500 mg 8 hourly x 2 weeks | |

|Surgical site infections |Vancomycin |Apart wound infections Vancomycin and |

| |plus |tobramycin powder will be needed for making|

| |Piperacillin with Tazobactam 3.375 IV 6 hourly |the beads for bone cement. |

| |/Amikacin | |

|4)Infected joint replacements | | |

| - Spine or hip |Piperacillin with Tazobactam 3.375 IV 6 hourly |Apart wound infections Vancomycin and |

| |+Vancomycin , Vancomycin 15mg/kg IV 12 hourly. |tobramycin powder will be needed for making|

| | |the beads for bone cement. |

|-Hemiarthroplasty |Vancomycin 15mg/kg IV 12 hourly + Amikacin15mg/kg| |

| |6 hourly | |

|-THR/TKR |-Wound wash +Culture | |

| |-Antibiotics: Vancomycin 15mg/kg IV 12 hourly. | |

| |Plus | |

| |Imipenem/Piperacillin with Tazobactam 3.375 IV 6 | |

| |hourly | |

| |Plus | |

| |Metronidazole IV500 mg 8 hourly | |

|Preop prophylaxis | | |

|Joint replacements |Vancomycin 15mg/kg IV 12 hourly+ | |

|THR/TKR |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM | |

| |+Gentamicin for 3 days | |

| | | |

|Spinal fusion |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +| |

| |Gentamicin5mg/kg i.v once daily X 3 days | |

|Laminectomy |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM | |

| |GM tds)+Gentamicin 5mg/kg i.v once daily X 3 | |

| |days | |

DERMATOLOGY

|Clinical Condition |Treatment |Remarks |

|Furuncles and carbuncles |Cloxacillin 500 - 1000 | |

| |mg orally6 hourly × 7-10 | |

| |days | |

| |severe: Vancomycin 1 g IV Q12h | |

| |step down to cloxacillin | |

| | | |

|Cellulitis |Cloxacillin2 g IV q4–6h | |

|Necrotizing fasciitis(Group A streptococcal |-Surgical debridement, gram staining & | |

|infections) |culture | |

| |-Clindamycin, 600–900 mg IV q6–8h, plus | |

| |Penicillin G, 4 million units IV q4h | |

|Necrotizing fasciitis(mixed aerobes and |Surgical debridement, gram staining & culture| |

|anaerobes) |-Ampicillin, 2 g IV q4h, plus Clindamycin, | |

| |600–900 mg IV q6–8h, plus Ciprofloxacin, 400 | |

| |mg IV q6–8h + Metronidazole IV500 mg 8 hourly| |

| | | |

| |+ | |

| |Antigas gangrene serum | |

|Scabies |Topical treatment : | |

| |Permethrin 5% cream | |

| |(apply to entire skin | |

| |below neck & leave | |

| |for 8 hours) | |

| |Systemic treatment:· | |

| |Ivermectin 200 mgm/kg | |

| |orally× 1 dose | |

|Herpes simplex |Acyclovir 400 mg PO 8 Hourly for 10 days | |

|Herpes zoster(immunocompetent host >50 years |Acyclovir 400 mg PO 8 Hourly for 10 days | |

|of age) | | |

|Dermatophytosis | | |

|Tinea pedis |Oral: Itraconazole ,200 mg/day for 1 week per| |

| |month; fluconazole ,250 mg weekly for 4-8 | |

| |weeks | |

|Tinea Corporis |Oral: Itraconazole ,200 mg/day for 1 week; | |

| |fluconazole ,250 mg weekly for 2-4 weeks | |

|Tinea capitis |Oral: Itraconazole ,200 mg/day for 1 week; | |

|Onychomychosis | | |

|Fingernails |Itraconazole ,400 mg /day for 1 week each | |

| |month ,repeated for 2-3 months | |

|Toenails |Itraconazole ,400 mg /day for 1 week each | |

| |month ,repeated for 2-4 months | |

| |or | |

| |Fluconazole,200 mg weekly for 12-24 weeks | |

|Mycetoma: Actinomycotic |Streptomycin 15 mg/kg/ day i.m. + | |

| |CotimoxazoleazoleDS 1 tab orally12 hourly | |

| |Amikacin 15 mg/kg/day with Co-trimoxazole DS | |

| |tab orally12 hourly | |

|Eumycotic |Itraconazole 200 mg /day | |

CVTS

|Cardiac Surgery/Procedure | |

|Median sternotomy/ Uncomplicated heart transplant |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg IV 8 |

| |hourly) |

| |PCN allergy: Vancomycin + Gentamicin |

|Median sternotomy/ Heart transplant- previous VAD or MRSA |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg IV 8 |

|colonization/ infection |hourly) |

| |PCN allergy: Vancomycin + Gentamicin |

|Pacemaker/ICD placement |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg IV 8 |

| |hourly) |

| |PCN allergy: Vancomycin or Clindamycin |

|Pacemaker/ICD placement and MRSA colonization /Infection |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg IV 8 |

| |hourly)+ Vancomycin |

| |PCN allergy: Vancomycin |

|Lung Transplant |PIP-TZ 4.5 g IV 6 hourly |

| |PCN allergy: Vancomycin + Ciprofloxacin |

| |If CF patient please confirm with transplant ID |

|LVAD / BIVAD placement |Vancomycin + Ciprofloxacin + Fluconazole for 48 hrs |

|Vascular surgery | |

|All the procedures |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg IV 8 |

| |hourly) |

| |PCN allergy: Vancomycin |

| |Prophylaxis not recommended for carotid surgery unless risk of |

| |infection thought to be high |

| | |

|Thoracic surgery | |

|All cases except oesophageal |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg IV 8 |

| |hourly) |

|Oesophageal cases |Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV500 mg 8 hourly|

| |with or without Gentamicin 5mg/kg i.v once daily |

OPHTHALMOLOGY

|Disease |Treatment |Remarks |

|Eye lid | | |

|Blepharitis |Lid margin care with warm compresses/lid massage /lid scrubs | |

| |Topical antibiotics: 0.3%Gentamicin/0.5% Tobramycin | |

| |Tear substitutes: 4-6 times a day | |

| |Refractory cases: a)+c) +Oral doxycycline 100 mg 12 hourly x 1 | |

| |week,then, 100 mg OD X6 weeks/oral erythromycin in children & | |

| |pregnant women/ Oral azithromycin 500mg/day for 5 days in acute| |

| |exacerbations | |

|Stye |Hot fomentation | |

| |Systemic antibiotics | |

| |Levofloxacin 500 mg/day x5days | |

| |Amoxicillin 250 mg 8 hourly x 5 days | |

| |Pulling out cilium with underlying pus evacuation | |

|Conjunctivitis | | |

|Bacterial |Opthalmic solution: topical | |

| |Gentamicin , 0.3% 6 times per day for 10-15 days | |

| |Moxifloxacin 0.5% 6 times per day for 10-15 days | |

| |Refractory cases: Polymyxin B 6 hourly 7-10 days | |

| |Bacitracin 6 hourly 7-10 days | |

|Viral |Cold compresses + tear substitutes 4-6 times /day+ weak steoid | |

| |antibiotic combinations in severe inflammation | |

|Neonatal conjunctivitis |Within 4-6 weeks of life | |

| |Chlamydia – Oral Erythromycin 50 mg/kg/day in 4 divided doses | |

| |Gram positive bacteria- 0.5% erythromycin ointment Qid x2 Weeks| |

| |Gram negative bacteria –Gentamicin (0.5%) | |

|Keratitis | | |

| Viral |Acyclovir 3% eye ointment 5 times a day | |

| |Severe: Systemic treatment -Oral acyclovir (400 mg) 5 times | |

| |/day x10 days | |

| | | |

| Bacterial |Topical antibiotic drops – Gentamicin(1.5%) | |

| Fungal |Topical treatment for 6 weeks |Corneal scraping with blade size 15 must |

| |-Natamycin 5% every 3 -4 hours with slow reduction |be done first and inoculated onto SDA |

| | |plate before antibiotics are started. |

|Lacrimal apparatus | | |

| Canaliculitis |-Topical Ciprofloxacin(0.3%) 4 times a day for atleast 10 days | |

| |-Transconjunctival canaliculotomy with curettage | |

| Dacryocystitis |-Local warm compresses | |

| |-Systemic antibiotics-Tab.Amoxiclav 500 mg 12 hourly X5 days | |

| |-NSAID: Tab combiflam 12 hourly x 5 days | |

|Endophthalmitis | | |

| |-Intravitreal Vancomycin(1mg in 0.1 ml NS) + Ceftazidime (2-25 |Vitrectomy done when: |

| |mg in 0.1 ml NS) + Dexamethasone 400 µg in 0.1 ml |Lack of improvement or worsening after 48 |

| |-Topical fortified eyedrops Vancomycin 50 µg /ml + Amikacin |hours |

| |20µg/ml + 1% atropine sulphate +1% prednisolone acetate |Absence of red glow at initial |

| |-Systemic antibiotics : |presentation |

| |Ceftazidime 2g IV every 8 hourly x 5 days |Suspected fungal etiology or bleb |

| |Amikacin 7.5 mg/kg IV 12 hourly x 5 days |Endophthalmitis with intraocular foreign |

| |Tab Ciprofloxain 750 mg 12 hourly x5 days |body |

|Retinitis | | |

| |CMV retinitis | |

| |- Ganciclovir ( IV)5mg/kg 12 hourly x2-3 weeks | |

| |5mg/kg /day – maintenance | |

|Orbital cellulitis |Ceftazidime 1gm 8 hourly x1 week IM + Oral Metronidazole (500 | |

| |mg) 8 hourly X1week | |

|Antibiotic prophylaxis for | | |

|surgeries | | |

|AIOS |Broad spectrum antibiotic drops eg:Ed Ciplox ..one day rpior to| |

| |surgery | |

| |No contact procedures (eg: Tonometry ,Biometry)- one day prior | |

| |to surgery | |

| |Preop : Povidone iodine 5% for 3 min on skin and periorbital | |

| |area | |

| |Povidone iodine %% for 1 min in conjuctival cul de sac | |

| |Post Surgery : Patch for atleast 6 hours | |

| |Topical antibiotics + steroids for 1 min 4 weeks post surgery | |

| |Tab.Ciplox ( 500 mg 12 hourly x 3 days ) high risk cases | |

|AAO |Hand disinfection with povidone iodine(10%) | |

| |Instillation of povidone iodine (5%) in cul de sac | |

| |Draping of eyelashes and lid margins | |

| |Pre operative 3 days use of 4th generation cephalosporin and | |

| |continue post operative for 4 weeks | |

Contributors

|Microbiology |Dr. K.Madhuri |

| |Dr. Swati Mudshingkar |

|Pharmacology |Dr. Bharti Daswani |

| |Dr.BB Ghongane |

|ENT |Dr. Samir Joshi |

|Medicine |Dr. HB Prasad |

|Obstetrics & Gynaecology |Dr. Bhosale RA |

|Opthalmology |Dr. Sanjeevani Ambekar |

| |Dr. Meghana Panse |

|Orthopedics |Dr. Vishal Patil |

|Pediatrics |Dr. Chhaya Valvi |

| |Dr.Khadse SS |

|Skin |Dr.Vasudha M Belgaomkar |

| |Dr CB Mhaske |

|Surgery |Dr. (Mrs). Vandana Dubey |

|CVTS |Dr.N.Thakur |

STEPS OF HANDWASHING

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