MEDICAL SPECIALITIES A.CARDIOVASCULAR INFECTIONS

MEDICAL SPECIALITIES A.CARDIOVASCULAR INFECTIONS Infection/Condition/lik ely organism Infective endocarditis native valve/due to Penicillin- Susceptible Streptococcus Viridans/S.bovis Suggested treatment Preferred Inj. Aqueous Crystalline penicillin 12-18 million units/24 hr i.v continuously or in 4 or 6 divided doses * Gentamicin 3 mg/kg dose (2weeks) Alternative Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose Gentamicin 3 IV/IM in 1 dose(2 weeks) OR Vancomycin 30 IV in 2 equally divided doses not exceed 2 g/24 h unless concentrations in serum are inappropriately low Comment *Preferred in most patients >65 y or patients with impairment of 8th cranial nerve function or renal or function #2-wk regimen not intended for patients with known cardiac or extracardiac abscess or for those with creatinine clearance of >20 ml/min, impaired 8th cranial nerve function, or Abiotrophia, Granulicatella, or Gemella spp infection; gentamicin dosage should be adjusted to achieve peak serum concentration of 3 4 µg/ml and trough serum concentration of < 1µg /ml when 3 divided doses are used; nomogram used for single daily dosing

Native Valve Endocarditis Caused by Strains of Viridans Group Streptococci and Streptococcus bovis Relatively Resistant to Penicillin [Minimum inhibitory concentration (MIC) >0.12 µg/ml 0.5 µg/ml] Inj. Aqueous Crystalline penicillin 24 million units/24 hr i.v continuously or in 4 or 6 divided doses Gentamicin 3 mg/kg dose (2 weeks) Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose Gentamicin 3 IV/IM in 1 dose (2 weeks) @ Vancomycin therapy recommended only for patients unable to tolerate penicillin or ceftriaxone; vancomycin dosage should be adjusted to obtain peak (1 h after infusion completed) serum concentration of 30 45 µg /ml and a trough concentration range of 10 15 µg /ml Patients with endocarditis caused by penicillin-resistant (MIC >0.5 µg/ml) strains should be treated with regimen recommended for enterococcal endocarditis OR Vancomycin 30 IV in 2 equally divided doses not exceed 2 g/24 h unless concentrations in serum are inappropriately low Vancomycin therapy recommended only for patients unable to tolerate penicillin or ceftriaxone therapy

Endocarditis of prosthetic valve or other prosthetic material Caused by Viridans Group Streptococci and Streptococcus bovis Penicillin-susceptible strain (minimum inhibitory concentration <0.12 µg/ml) Inj. Aqueous Crystalline penicillin 24 million units/24 hr i.v continuously or in 4 or 6 divided doses 6weeks) With/without Gentamicin 3 mg/kg dose (2 weeks) Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose With/without Gentamicin 3 IV/IM in 1 dose (2 weeks) OR Vancomycin 30 IV in 2 equally divided doses not exceed 2 g/24 h unless concentrations in serum are inappropriately low Penicillin or ceftriaxone together with gentamicin has not demonstrated superior cure rates compared with monotherapy with penicillin or ceftriaxone for patients with highly susceptible strain; gentamicin therapy should not be administered to patients with creatinine clearance of <30 ml/min Vancomycin therapy recommended only for patients unable to tolerate penicillin or ceftriaxone therapy Penicillin relatively or fully resistant strain (minimum inhibitory concentration >0.12 µg/ml) Inj. Aqueous Crystalline penicillin 24 million units/24 hr i.v continuously or in 4 or 6 divided doses 6weeks) Ceftriaxone sodium 2 g/24 h IV/IM in 1 dose

Gentamicin 3 mg/kg dose (2weeks) Gentamicin 3 IV/IM in 1 dose(2 weeks) OR Vancomycin 30 IV in 2 equally divided doses not exceed 2 g/24 h unless concentrations in serum are inappropriately low Endocarditis Caused by Staphylococci in the Absence of Prosthetic Materials For Oxacillin resistant strains Nafcillin or oxacillin* 12 g/24 h IV in 4 6 equally divided doses 6weeks) With/optional Gentamicin 3 mg/kg dose (3-5d) Vancomycin 30 IV in 2 equally divided For penicillin allergic,nonanaphylactoid: Cefazolin 6 g/24 h IV/IM in 3 divided dose Gentamicin 3 IV/IM in 1 dose(2 weeks) * Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (minimum inhibitory concentration <0.1 µg/ml) and does not produce β- lactamase -For complicated right-sided IE and for left-sided IE; for uncomplicated right-sided IE, 2 wk therapy -Adjust vancomycin dosage to achieve

Endocarditis Caused by Staphylococci in Prosthetic valve doses Nafcillin or oxacillin* 12 g/24 h IV in 4 6 equally divided doses 6weeks) Rifampin 900 mg per 24 h IV/PO in 3 equally divided doses 6weeks) Gentamicin 3 mg/kg dose (2 weeks) 1-h serum concentration of 30 45 µg/ml and trough concentration of 10 15 µg/ml * Penicillin G 24 million U/24 h IV in 4 to 6 equally divided doses may be used in place of nafcillin or oxacillin if strain is penicillin susceptible (minimum inhibitory concentration <0.1 µg/ml) and does not produce β- lactamase) Oxacillin resistant Staphylococci Vancomycin 30 IV in 2 equally divided Doses 6weeks) Rifampin 900 mg per 24 h IV/PO in 3 equally divided doses 6weeks) Adjust vancomycin dosage to achieve 1-h serum concentration of 30 45 µg/ml and trough concentration of 10 15 µg/ml Gentamicin 3 mg/kg dose (2 weeks) Endocarditis Caused by Enterococci (native and prosthetic) Ampicillin sodium 12 g/24 h IV in 6 equally divided doses (4-6 weeks)# OR Aqueous crystalline penicillin G sodium Vancomycin* 30 mg/kg per 24 h IV in 2 equally divided Doses 6weeks) # Native valve: 4- wk therapy recommended for patients with symptoms of illness 3

18 30 million U/24 h IV either continuously or in 6 equally divided doses (4-6Weeks)# Gentamicin$ 3 mg/kg dose (4-6 weeks)# Gentamicin 3 IV/IM in 1 dose (6 weeks) mo; 6-wk therapy recommended for patients with symptoms 3 mo * Vancomycin therapy recommended only for patients unable to tolerate penicillin or ampicillin $ If gentamicin resistant strain, Streptomycin 15 IV/IM in 2 equally divided Doses for 6weeks given Acute Rheumatic Fever (Secondary prophylaxis) Benzathine Penicillin IM 1.2 mega units (>30kg); 0.6 mega units (<30 kg) every 3-4 weeks Duration With carditis: 10 years or until 25 years of age Without carditis: 5 years or until 18 years of age OR Cephalexin 250mg bd orally 1 hour prior to procedure Penicillin V potassium 250 mg orally twice daily Penicillin allergy Erythromycin 250mg bd Secondary Prophylaxis should only be ceased following: No ARF signs/symptoms for at least 5 years, and Medical Specialist review (Paediatrician / Physician / Cardiologist) and Echocardiogram to establish presence & severity of RHD (if available) Treatment of Pacemaker infections Antibiotic Duration Comment While awaiting Complete removal

microbiological diagnosis provide empirical cover for MRSA with: Vancomycin 15mg/kg IV q12h not to exceed 2g/24h (unless serum levels are monitored) Infection of pulse generator pocket with blood stream infection Lead associated endocarditis Change antibiotics according to culture results 10-14 days 6 weeks of the entire implanted system including the cardiac leads is recommended even in patients with clinical infection of the pocket only The new implant can be placed on the contra lateral side 10 to 14 days after the removal of the implanted system in patients with infection of the pulse generator pocket and as late as 6 weeks in those with endocarditis Reference: American Heart Association Guideline 2005 B. CENTRAL NERVOUS SYSTEM INFECTIONS Infection/Conditi on/likely organism Acute bacterial meningitis Common organisms: Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae Other organisms: Gram negative rods Leptospirosis Scrub typhus Suggested treatment Preferred Cefotaxime 200mg/kg/24h IV in 3 divided doses (max: 12g/day). Usual dose is 2g q8h+ Inj Vancomycin 500mg I.V Q6h for 10-14 days Alternative Inj Ceftriaxone 2gm Q12h I.V. for 10-14 days + Inj Vancomycin 500mg I.V Q6h for 10-14 days Comment

Melioidosis Mycoplasma pneumoniae Viral encephalitis Herpes simplex Acyclovir 5mg/kg IV q8h for 10-14 days Herpes zoster Brain Abscess Acyclovir 10mg/kg IV q8h for 10-14 days Inj Ceftriaxone 2gm I.V. Q12h +Inj Amikacin 500mg IV Q8h + Inj Metronidazole I.V500mg I.V Q8h x 14 days Add vancomycin 30 45 mg/kg IV if secondary to trauma Duration of antibiotic would depends on response by neuroimaging; 4-8 weeks may be needed) C.GASTROINTESTINAL INFECTIONS Infection/Conditi Suggested treatment on/likely organism Preferred Alternative Acute Antibiotics not gastroenteritis recommended (Usually viral, Enteropathogenic or Enterotoxigenic E.coli) Comment Oral rehydration is the cornerstone of treatment Bacillary dysentery ( Shigella spp) Cholera Tab Ciprofloxacin 500 mg bd X 5 days Cap Doxycycline 300 mg, single dose (6mg/ Tab Cefixime 200mg bd X 5 days (8mg/kg/day) Tab Ciprofloxacin 1gm single dose Most mild infections resolved spontaneously without antibiotics Ciprofloxacin to be avoided if isolates are nalidixic acid resistant Prompt rehydration essential, antibiotic

kg, maximum 300 mg Giardiasis Metronidazole 200 mg PO tds for 5-7 days Amoebic dysentery Metronidazole 400mg tds for 7 days Typhoid fever Outpatients- Ciprofloxacin* 750mg p.o bd x 14days If no clinical response then switch to Inj Ceftriaxone 1gm I.V. BD for 14 days Acute cholecystitis Ceftriaxone 1-2 gm every 12hourly x 7 days with Metronidazole 500mg 8th - 12th hourly x 5-7 Acute cholangitis (Gram negative, anaerobes, gram positive) Spontaneous Bacterial Peritonitis Secondary peritonitis (bowel perforation), Intra abdominal abscess Ticarcillin/clavul anic acid 3.1gm IV 4-6hrly X 10-14 days plus Metronidazole 500 mgi.v. tds x 5-7 days Cefotaxime 2g IV q8h for 7-10 days Ceftriaxone IV 2gm 12 hourly x 14 days with Metronidazole 500mg 8hrly Tinidazole 2gm 1 dose Outpatients- Tab. Cefixime (20mg/kg/day)max.400mg/da y for 10-14 days Cefepime 2 gm every 8-12 hours in combination with Metronidazole 500mg 8th - 12th hourly x 5-7 Piperacillin -Tazobactam 4.5 gm 6hrly i.v. plus Metronidazole 500 mg I.V. tds x 5-7 days Ceftriaxone IV 2gm 12 hourly x 7-10 days therapy is only adjunct to rehydration Treatment with Ciprofloxacin is discouraged due to high clinical failure seen in disease with isolates having intermediate MIC Antibiotics to be continued until resolution of clinical signs of infection,

H. pylori associated disease, gastric MALT1 lymphomas Amoebic liver abscess x 7 days Omeprazole 20mg bd + Clarithromycin 500mg p. o bd +Amoxicillin 1gm bd p.o x 14 days Metronidazole 500mg IV tdsx 10days Bismuth subsalicylate 2tab qid+ Tetracycline 500mg qid+metronidazole 500mgtid+Omeprazole 20mg bd D. SKIN & SOFT TISSUE INFECTIONS Infection/Conditi Suggested treatment on/likely organism Preferred Alternative Cellulitis Cloxacillin 500- Cephalexin 500mg 1000mg P.O. 6th P.O Q 6 h for 7-10 days hourly for 7-10 days including normalization of temperature and WBC count & return of GI function USG guided drainage indicated in large abscesses, signs of imminent rupture, and no response to medical treatment Comment Furunculosis Diabetic foot mild(localized cellulites,no systemic symptoms) Cloxacillin 500mg P.O Q 6 h for 7-10 days Cloxacillin 500mg P.O Q 6 h for 7-10 days Cephalexin 500mg P.O Q 6 h for 7-10 days Cephalexin 500mg P.O Q 6 h for 7-10 days

Diabetic footmoderate to severe (limb threatening) Acute adenolymphangitis CP 20lakh units I.V. Q4h + Clindamycin 600mg I.V. Q6h x 14 days+ Gentamicin 5mg/kg I.V. Q 24h Outpatient: Cap Amoxycillin 500mg 8 th hrly x 5days Inpatient: CP 15 lakh units I.V. Q4hx 7days Cefazolin 1gm IV 8hourly + Gentamicin 5mg/Kg IV /day Cap Cloxacillin 500mg 6hrly Inj Cefotaxime 1gm 8hrlyx 5days E. RESPIRATORY TRACT INFECTIONS UPPER RESPIRATORY TRACT INFECTIONS Infection/Condition/likely organism Suggested treatment Preferred Alternative Acute tonsillo-pharyngitis Amoxicillin 500mg P.O. Q8h for 10 days Group A β hemolytic streptococci Acute sinusitis Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Amoxicillin- Clavulanate 500/125mg p.o bd x10 days LOWER RESPIRATORY TRACT INFECTIONS Penicillin VK 500 mg P.O. Q8h for 10 days OR In Penicillin allergic patients, Azithromycin 500 mg od for 5days Azithromycin 500 mg od for 5days Comment * If S.pneumoniae prevalence >10%,start high dose amoxicillin 80-90 mg/kg/day in 2 diviided doses Community acquired pneumonia (Outpatient) Azithromycin 500mg P.O. od for 5 days or Doxycycline 100mg P.O. bd for 7 days Tab Amoxyclav 1gm BD +Azithromycin 500mg od for 7 days

Community acquired pneumonia (Inpatient) (hospitalized but not in ICU, NOT CRITICALLY ILL) Inj Amoxyclav 1.2 gm Q8h for 5-7 days + Inj Azithromycin 500 mg od for 5-7 days Switch to oral when clinically appropriate Inj Cefotaxime 1gm Q8h or Inj Ceftriaxone 2gm od + inj Azithromycin 500mg od for 5-7 days *Add Vancomycin or clindamycin for suspected CA- MRSA Lung abscess or aspiration pneumonia Inj Ceftriaxone 2gm BD plus inj Clindamycin 600mg Q8h switch to oral when clinically stable treat for 4-6 weeks Inj Ceftriaxone 2gm BD PLUS inj Metronidazole 500mg Q8h Or Inj Crystalline Penicillin 2 million units Q4h G. GENITOURINARY INFECTIONS Infection/Condition/likely Suggested treatment organism Preferred Acute Nitrofurantoin 100mg uncomplicated P.O. BD for 7 days cystitis in Non pregnant women Acute pyelonephritis (no underlying GU disease) Complicated UTI (underlying GU disease) Catheter Amikacin 15mg/kg I.V Q24H for 7 days (mild illness) or 14 days(severe illness) Cefoperazone sulbactam Or Piperacillintazobactam x 10-14 days Treat only when Alternative Ciprofloxacin 500mg BD P.O for 5 days Comment

associated UTI patient has systemic symptoms H. TROPICAL INFECTIONS Infection/Conditi on/likely organism Scrub Typhus(Adults) Uncomplicated Scrub Typhus(Adults) complicated Leptospirosis Malaria P.vivax Suggested treatment Preferred Doxycycline 200 mg/day in two divided doses for individuals above 45 kg for duration of 7 days Intravenous doxycycline (wherever available) 100mg twice daily in 100 ml normal saline to be administered as infusion over half an hour initially followed by oral therapy to complete 7-15 days of therapy. Tab.Doxycycline 100mg x7days Chloroquine 25mg/Kg *x 3days + Primaquine 0.25mg/kg x 14 days Artesunate 4 mg/kg body weight daily for 3 Alternative Azithromycin 500 mg in a single oral dose for 5 days Intravenous Azithromycin in the dose of 500mg IV in 250 ml normal saline over 1 hour once daily for 1-2 days followed by oral therapy to complete 5 days of therapy Pregnancy/lactation: Capsule Ampicillin 500mg 6hrly Comment In children Doxycycline 4.5mg/Kg body weight/day in 2 divided doses Or Single dose Azithromycin 10mg/Kg body wt for 5 days Children(<8yrs) : Amoxycillin/A mpicillin 30-50mg/Kg/day in divided doses for 7 days Chloroquine: 25 mg/kg body weight divided over three days i.e. 10 mg/kg on day 1, 10 mg/kg on day 2 and

P.falciparum days Sulfadoxine (25 mg/kg body weight) Pyrimethamine (1.25 mg/kg body weight) on first day+primaquine 0.25mg/kg single dose on second day 5 mg/kg on day 3. All mixed infections should be treated with full course of ACT and Primaquine 0.25 mg per kg body weight daily for 14 days Melioidosis Burkholderia Pseudomallei Initial parentral( Intensive phase): Ceftazidime 1gm iv every 6 hrs for 10 days /Minus Trimethoprim/Sulpham ethoxazole 8/40mg/kg/24h IV for 2-3 weeks Inj Meropenem 1gm# iv 8hrly for 10days # If malaria is acquired in North-eastern states ; treatment strategy for P.f and mixed infections will include Artemether and Lumifantrine # Refer NVBDCP 2013 Diagnosis and Treatment Guidelines #2gm for CNS Infections Maintenance Therapy: Trimethoprim/Sulpham ethoxazole 10/50mg/kg/24h PO β-lactam/β-lactamase inhibitors, e.g. Amoxycillin/Clavulana te 1250mg

PLUS Doxycycline 100mg PO q12h Duration minimum 20 weeks (2 tablets of 625mg) PO q8h OR Trimethoprim/Sulpham ethoxazole 8/40mg/kg/24h Duration minimum 20 weeks