Antimicrobial Prescribing Guidelines Government Health Services

ANTIMICROBIAL PRESCRIBING GUIDELINES
GOVERNMENT HEALTH SERVICES
Published by
Antibiotic Team
St. Lukes Hospital
GMangia MSD08
Malta
Health Division, Malta
email: michael.a.borg@gov.mt
Reproduction is authorised, provided the source is acknowledged, save if otherwise stated.
ISBN: 99932-0-277-0
This edition 2004
Printed by Bonavia Offset Printers, Sliema
ii
ANTIMICROBIAL PRESCRIBING GUIDELINES

GOVERNMENT HEALTH SERVICES
Prepared by the Antibiotic Team St. Luke's Hospital

on behalf of the Drugs and Therapeutics Committee
Dr. M. A. Borg
Consultant Hospital Infection Control (Chair)
Dr. P. Cuschieri
Consultant Microbiologist
Dr. C. Mallia Azzopardi
Consultant Infectious Disease Physician
Mr. P. Zarb
Antibiotic Pharmacist
Table of Contents
iii
ACKNOWLEDGEMENTS
We thank our colleagues who have contributed feedback to this booklet and the Health Division for
sponsorsing the printing costs involved.
PHARMACEUTICAL CARE
This terminology was succinctly defined as, "The responsible provision of drug therapy for the purpose
of achieving definite outcomes that improve a patient's quality of life." (Hepler & Strand 1990 )
The three key phrases in Pharmaceutical Care are;
The responsible provision of drug therapy
Definite patient outcomes
Improved Quality of life
The time has come for the medical profession to moderate its insistence on clinical freedom to
prescribe what it likes when it likes
Gould I: J. Ant. Chemother 1988:22:395-401
There is a need for uniform policies for compromised patients reviewed prospectively to deal with
excessive antibiotic use
OHanley et al: Am J Med 1989:87:605-613
Table of Contents
iv
CONTENTS
INTRODUCTION............................................................................................... IX
1
RESPIRATORY INFECTIONS.................................................................. 1
1.1
1.2
UPPER RESPIRATORY TRACT INFECTIONS ................................................... 1

PNEUMONIA ................................................................................................ 2
ORAL AND DENTAL INFECTIONS........................................................ 4
GASTRO-INTESTINAL TRACT INFECTIONS ..................................... 4

3.1 ACUTE ENTERIC INFECTIONS ...................................................................... 5
3.1.1
Intestinal Parasites........................................................................... 5
INFECTIONS OF THE CARDIOVASCULAR SYSTEM ....................... 6

4.1
4.2
INFECTIONS OF THE CENTRAL NERVOUS SYSTEM ..................... 9

5.1
5.2
EAR INFECTIONS ....................................................................................... 10

THROAT .................................................................................................... 11
NOSE AND SINUSES ................................................................................... 11
INFECTIONS OF THE EYE AND ADNEXA......................................... 12

7.1
7.2
7.3
7.4
7.5
MENINGITIS ................................................................................................ 9
OTHER BRAIN INFECTIONS ......................................................................... 9
COMMON INFECTIONS IN E.N.T......................................................... 10

6.1
6.2
6.3
ENDOCARDITIS ........................................................................................... 6
IV LINE INFECTIONS .................................................................................... 8
INFECTIONS OF THE EYELIDS .................................................................... 12

INFECTIONS OF THE CONJUNCTIVA ........................................................... 12
INFECTIONS OF THE CORNEA .................................................................... 12
PERI-ORBITAL INFECTIONS ....................................................................... 13
INTRA-OCULAR INFECTIONS ..................................................................... 13
INFECTIONS OF SKIN, MUSCLE, BONE AND JOINTS ................... 13

8.1 SKIN.......................................................................................................... 13
8.1.1
Wounds ........................................................................................... 14
1.1.2
Diabetic Foot.................................................................................. 15
1.1.3
Bites ................................................................................................ 16
1.2 MUSCLE .................................................................................................... 16
1.3 BONE ........................................................................................................ 17
1.4 JOINTS ...................................................................................................... 18
Table of Contents
URINARY TRACT INFECTIONS........................................................... 19

9.1
9.2
10
ACUTE (UNCOMPLICATED) URINARY TRACT INFECTIONS ........................ 19

COMPLICATED URINARY TRACT INFECTIONS ........................................... 20
INFECTIONS OF THE GENITAL TRACT ........................................... 20

10.1
10.2
10.3
10.4
10.5
10.6
URETHRITIS.......................................................................................... 20
SYPHILIS .............................................................................................. 20
VAGINITIS ............................................................................................ 21
HERPES SIMPLEX GENITAL INFECTIONS ................................................ 21
CONDYLOMATA ACUMINATA (GENITAL WARTS) ................................. 22
PELVIC INFECTIONS ............................................................................. 22
11
INFECTIOUS DISEASES ......................................................................... 22
12
SEPTICAEMIA .......................................................................................... 23
12.1
12.2
13
NEUTROPENIC ...................................................................................... 23
NON-NEUTROPENIC .............................................................................. 24
NON-SURGICAL ANTIBIOTIC PROPHYLAXIS ................................ 25

13.1
PREVENTION OF ENDOCARDITIS OR INFECTION OF PROSTHETIC
IMPLANTS ........................................................................................................... 25
13.2
PATIENTS WITHOUT A FUNCTIONING SPLEEN........................................ 26
14
SURGICAL PROPHYLAXIS ................................................................... 26

14.1
CARDIOTHORACIC SURGERY ................................................................ 26
14.1.1 Prosthetic Valve Insertion:............................................................. 26
14.1.2 Arterial Reconstructive Surgery:.................................................... 27
14.2
ORTHOPAEDIC SURGERY...................................................................... 27
14.2.1 Joint replacement, internal fixation of selected fracture ................ 27
14.2.2 Muscular, skeletal and soft tissue trauma ...................................... 27
14.3
LOWER LIMB AMPUTATION ................................................................. 28
14.4
NEUROSURGERY .................................................................................. 28
14.4.1 CSF leakage ................................................................................... 28
14.4.2 Craniotomy involving prosthetic implants...................................... 28
14.5
HEAD, NECK & THORACIC SURGERY (INCLUDING ENT PROCEDURES)28
14.5.1 Involving oral, pharyngeal or oesophageal mucosa ...................... 28
14.5.2 Extensive procedures particularly for carcinoma .......................... 28
14.6
ABDOMINAL SURGERY......................................................................... 29
14.6.1 Endoscopic Procedures .................................................................. 29
14.6.2 Gastroduodenal Surgery ................................................................ 29
14.6.3 Biliary Tract Surgery...................................................................... 29
14.6.4 Colorectal Surgery ......................................................................... 29
Table of Contents
vi
14.6.5 Laparotomy .................................................................................... 30

14.7
TRANSPLANT SURGERY ....................................................................... 31
14.7.1 Kidney Transplantation .................................................................. 31
14.8
OBSTETRIC AND GYNAECOLOGICAL SURGERY .................................... 31
14.8.1 Hysterectomy .................................................................................. 31
14.8.2 Caesarian section - high risk only .................................................. 31
14.9
UROLOGICAL SURGERY ....................................................................... 31
14.10 OPHTHALMIC SURGERY ....................................................................... 32
14.11 DENTAL PROCEDURES ......................................................................... 32
14.11.1
Under local or no anaesthesia................................................... 32
14.11.2
Under general anaesthesia ........................................................ 32
15
METHODS OF ADMINISTRATION OF INTRAVENOUS AGENTS 33
16
ANTIBIOTIC THERAPY IN RENAL FAILURE .................................. 37

16.1
ANTIBACTERIAL ................................................................................... 37
1.2 ANTIFUNGAL ............................................................................................ 40
1.3 ANTIVIRAL................................................................................................ 40
17 ANTIMICROBIAL THERAPY DURING PREGNANCY AND

LACTATION........................................................................................................ 41
17.1
18
FDA CATEGORY INTERPRETATION ...................................................... 41
FOOD ANTIBIOTIC INTERACTIONS.................................................. 45

18.1
ANTIBIOTICS TO TAKE WITH FOOD ....................................................... 45
18.1.1 Food may reduce gastrointestinal upset......................................... 45
18.1.2 Food increases absorption or bioavailability................................. 45
18.2
ANTIBIOTICS TO TAKE ON AN EMPTY STOMACH ................................... 45
18.2.1 Food decreases or delays absorption ............................................. 45
19 GUIDELINES FOR THERAPEUTIC DRUG MONITORING IN

ADULTS................................................................................................................ 46
20
GUIDELINES FOR IV TO ORAL CONVERSIONS ............................. 46
21
GENTAMICIN / TOBRAMYCIN DOSING GUIDELINES.................. 47

21.1
ONCE DAILY DOSING [ODD] GUIDELINE FOR GENTAMICIN. ................. 48
Monitoring gentamicin levels: The Hartford nomogram.............................. 49
1.2 TWICE DAILY DOSING GUIDELINE FOR GENTAMICIN.................................. 50
22
VANCOMYCIN DOSING GUIDELINES ............................................... 51
23
METHODS FOR PENICILLIN DESENSITISATION........................... 51
Table of Contents
vii
24 NOTES ON THE COLLECTION AND TRANSMISSION OF

SAMPLES (TO THE MICROBIOLOGY LABORATORY)........................... 52
25
COSTINGS OF ANTIMICROBIALS ...................................................... 56
BIBLIOGRAPHY ................................................................................................ 62
Table of Contents
viii
Introduction
Antibiotic resistance is a serious and growing health problem, gaining national attention as resistance
increases at an alarming rate, particularly in hospital settings. To help curb resistance, there is an
urgency to improve both physician prescribing practices and diagnosis of those conditions for which an
antibiotic is indicated.
Selective pressure exerted by widespread antimicrobial use is a driving force in the development of
antibiotic resistance. Improving the use of antibiotics, together with better infection control and
prevention management, have been recognised as the key interventions that can control the continuing
emergence of antibiotic resistance.
Antibiotic policies and guidelines have been shown to:
improve patient care by prudent use of antibiotics for prophylaxis and therapy,
make better use of finance
retard the emergence of multiple antibiotic-resistant bacteria.
advance the education of junior doctors by providing templates for appropriate therapy.
To this end, the Antibiotic Team of St. Luke's Hospital has updated the Antibiotic Prescribing
Guidelines and shall be continually reviewing them according to changes in local resistance
epidemiology and evidence based literature. The formulation of these guidelines has been preceded by a
wide consultation exercise; similarly any further feedback or proposals of amendments are more than
welcome.
The Guidelines are in the main intended for the treatment of adult patients in the hospital setting,
especially in St. Luke's Hospital. It cannot be emphasised sufficiently that they are only intended as a
source of assistance to the clinician and cannot be regarded as a replacement for professional expertise
and acumen as well as proper history taking and examination. Furthermore, if an infection is complex,
expert advice should always be sought.
It is additionally important to emphasise a number of basic antibiotic prescribing principles:
Topical antibiotics
Topical use of systemic agents should be avoided in order to decrease the spread of resistance that is
well associated with such practices.
Parenteral therapy
Antibiotic therapy should always be stepped down to a narrower spectrum and/or safer antimicrobial
that is active against the isolated pathogen deemed to be causing the infection. If more than one
antibiotic qualifies for these criteria, the cheaper one should be preferred. Additionally parenteral
therapy should be switched to oral as soon as this is indicated.
Specimen Collection
The accuracy of the laboratory culture and sensitivity result depends significantly on the quality of the
specimen submitted. Guidelines on the proper collection and submission of specimens to the
Microbiology Laboratory are included in these Guidelines. It is important that the laboratory sheet
accompanying the specimen includes clearly stated information of any antibiotic treatment that the
patient was already on or that would have been started after collection of the specimen.
Introduction
ix
Sensible antibiotic prescribing

Before putting pen to paper, and writing out a prescription, please look at the checklist below
Is there a strict indication for using an antibiotic?
Is the condition serious or complicated enough to warrant consultation with a colleague?
Have I decided on a short, sharp course?
Have I chosen the right antibiotic with minimal side effects, maximal efficacy and the narrowest
spectrum possible?
Do I need bacteriological control?
Am I familiar with the pharmacology of the antibiotic(s) I intend prescribing?
Are there cheaper and acceptable alternatives?
Have I taken into account any relevant host factors?
Have I taken into consideration local resistance patterns?
Am I unwittingly contributing to the further development of antibiotic resistance at national and
even global levels?
Do I need to review the case? If so, when and how often?
Are there any infection control measures that should have been taken, which I have missed?
Is vaccination indicated / available?
Has the patient understood my instructions? Do I need to explain them to a relative or write them
out for the patient?
Where do I stand as a prescriber: Fossilised? Precipitous? Overcautious? Prudent?
Do I often consider seriously that the widespread use, misuse, abuse and overuse of antibiotics, for
both treatment and prophylaxis, leads to the emergence of multi-drug resistance in
microorganisms by a natural process of selection?
Does my diagnosis impose upon me an obligation to notify Infection Control and/or the Public
Health Authorities?
It is hoped that these Antibiotic Guidelines will prove a useful tool in continuing efforts to avoid
unnecessary and inappropriate antibiotic therapy and the repercussions of costs and resistance that
invariably result from such .
Further assistance on these guidelines or any aspect of antibiotic therapy can be addressed to the
Antibiotic Team on (2595) 1659 or pager 4512.
Introduction
x
Infection
Most likely
organism/s
Recommendations
(Oral unless otherwise
indicated)
Length
of
Course
Comments/Notes
Respiratory Infections
In hospitalised patients with a resiratory tract infection, physiotherapy is very important. Also one has to
collect blood cultures, sputum and other appropriate specimen for culture and sensitivity.
1.1
Upper Respiratory Tract Infections
Acute sore
throat
(bacterial)
Strep. pyogenes
Acute
bacterial otitis
media and
sinusitis
Strep. pneumoniae,
H. influenzae,
Moraxella catharralis,
Staph. aureus,
Strep. pyogenes,
Chlamydia
pneumoniae,
Viruses & others
H. influenzae,
Strep. pyogenes,
Strep. pneumoniae.
Acute
epiglottitis
Acute
bronchitis
Strep. pneumoniae,
H. influenzae,
viruses
Acute
bacterial
exacerbations
of Chronic
Bronchitis
Influenza
Strep. pneumoniae,
H. influenzae,
Moraxella catharralis.
Note:
Penicillin V 500mg 8hourly

OR
Erythromycin 500mg
6-hourly
Co-amoxiclav 375mg
8-hourly
OR
Clarithromycin 250mg
12-hourly
7-10
days
10 days
Cefotaxime 10010 days

150mg/kg/day
OR
Chloramphenicol
500mg 6-hourly
Co-amoxiclav 375mg
8-hourly
5 days
OR
12-hourly
Co-amoxiclav 375mg
8-hourly
5 days
OR
12-hourly
Antibiotics are not
indicated in a previously
healthy person
If patient fails to respond

within 48 hours, expert
advice should be sought.
Hospitalise immediately and

seek expert advice.
If Strep. pneumoniae is
resistant to penicillin seek
expert advice.
expert advice.
In those at special risk (e.g.
chronic heart or lung
disease, the elderly or in
pregnant women), secondary
bacterial infection may
require treatment.
All regimens are oral unless otherwise stated.

Regimens in green are oriented for patients with a reliable history of penicillin allergy
1.2
Pneumonia
VentilatorAssociated
Pneumonia
VAP diagnostic aid

Temperature
(C)
Blood
leucocytosis
(mm-3)
Tracheal
secretions
Oxygenation
(PaO2/FiO2
mmHg)
Pulmonary
radiography
Leucocytes per
HPF
36.5C < < 38.4C
0 points
38.5C < < 38.9C
1 point
> 39C or < 36C
2 points
4,000 < < 11,000
0 points
> 11,000 or < 4,000
1 point
< 14 aspirations / day
0 points
> 14 aspirations / day
1 point
Purulent sputum
+ 1 point
> 240 or ARDS
0 points
< 240 and no ARDS
2 points
No infiltrate
0 points
Diffused or patchy infiltrate
1 point
Localised infiltrate
2 points
< 10
0 points
> 10
1 point
A total score of 7 is highly suggestive of VAP

Ventilated for
< 7 days &
no previous
antibiotic
therapy given
Staph. aureus,
H. influenzae,
Str. pneumoniae,
Enterobacteriaceae
Piperacillin-tazobactam
IV 4.5g 8-hourly
Ventilated for
< 7 days and
previous
antibiotic
therapy given
Ps. aeruginosa,
H. influenzae,
Enterobacteriaceae
Gentamicin 80mg +
IV 4.5g 8-hourly
Ventilated for
> 7 days &
no previous
antibiotic
therapy given
Ps. aeruginosa,
Acinetobacter,
Enterobacteriaceae
Amikacin 500 mg +
+ Meropenem 1g 8hourly IV
8-hourly
Ventilated for
> 7 days and
previous
antibiotic
therapy given
Ps. aeruginosa,
Acinetobacter,
MRSA
Amikacin 500 mg IV +
Meropenem 1gr IV 814 - 21
hourly
days
Teicoplanin 400mg IV
st
12-hourly for 1 3 doses
and daily subsequently
Note:
7 -14
days
14 - 21
days
14 - 21
days
Take endotracheal aspirates

and blood cultures before
starting antibiotics.
Consider a change to the
empiric therapy according
to antimicrobial sensitivity
results should endotracheal
cultures yield more than
106cfu/ml or blood culture
is positive.
Seek expert
necessary

advice
if
Anaerobes,
Co-amoxiclav 1.2g 8Aerobic Gram-negative hourly
bacilli,
OR
Staph. aureus
Clindamycin 600mg IV
8-hourly +
ciprofloxacin 200mg IV
12-hourly.
Staph. aureus (possibly Amikacin 500 mg
HospitalMRSA), Ps.
+ Piperacillinacquired
aeruginosa,
tazobactam 4.5g every 8
Pneumonia
Acinetobacter,
hours
Enterobacteriaceae,
(excluding
OR
others
Amikacin 500 mg +
ventilatorTeicoplanin 400mg IV
associated)
12-hourly for 1st 3 doses
and daily subsequently,
according to severity.
Strep. pneumoniae,
Cefuroxime 750mg IV
Communityatypical organisms,
8-hourly +
Acquired
others.
clarithromycin 500mg
Pneumonia
IV 12-hourly
OR
Levofloxacin 500mg IV
12-24 hourly
Cefuroxime 750mg IV
Post-Influenza As in communityacquired pneumonia,
8-hourly +
Staph. aureus.
clarithromycin 500mg
IV 12-hourly +
Flucloxacillin 2 gr 6hourly
OR
12-24 hourly +
12-hourly for 1st 3
doses, and daily
subsequently, according
to severity.
Legionella
Legionella
IV 12-hourly
Aspiration
pneumonia or
lung abscess
Fungal
pneumonia
Pneumocystis
carinii
pneumonia
Tuberculous
pneumonia
Note:
Candida albicans,
Aspergillus fumigatus,
Pneumocystis carinii
Pneumocystis carinii
10-14
days
10 days
7-10
days
10 days
If post-pneumonia, seek
laboratory guidance.
Aspiration pneumonia is
often polymicrobial.
Seek expert advice.

Maximum cumulative dose
for amikacin is 15grams for
whole duration of threrapy
In severe, potentially lifethreatening situations,
consider substituting
piperacillin/tazobactam with
meropenem and seek expert
advice.
expert advice.
Switch to oral formulations
when patients condition
improves.
expert advice.
Switch to oral formulations
when patients condition
improves.
10 days
Confirm by urinary antigen

test.
Add rifampicin if severe.
Seek expert advice
Mycobacterium
tuberculosis

Oral and Dental Infections
Gingival
infections
Oral aerobes &

anaerobes
Metronidazole 200400mg 8-hourly
5 days
Pericoronitis
or
Tooth abscess
with cellulitis
Oral aerobes &

anaerobes
5 days
Oral
Candidosis
Candida albicans
Co-amoxiclav 1.2g IV
8-hourly
OR
Clindamycin 150mg
6-hourly
Amphotericin 10mg
lozenge or nystatin oral
suspension 6-hourly
Only if symptoms present.

Seek expert advice from
dental surgeon.
In the case of a tooth
abscess, removal of the
infected pulp tissue, with
drainage, is usually required
7-14
days
Consider
immunosuppression in
severe cases.
Nystatin suspension should
be swallowed after adequate
gargling.
7-10
days
Seek expert advice if

ascending cholangitis is
suspected.
Gastro-Intestinal Tract Infections
Acute
cholecystitis
Klebsiella spp., E.coli,

Enterobacteriaceae,
Enterococcus faecalis,
anaerobes
Primary acute Diverse aetiology

peritonitis
Aerobic and anaerobic
Secondary
bowel flora
peritonitis
(following GIT
surgery or
pathology)
CAPD
Peritonitis
Acute
pancreatitis
Note:
Aerobic and anaerobic

bowel flora,
staphylococci.
8-hourly
OR
Gentamicin 80mg IV +
clindamycin 300mg IV
8-hourly
Seek expert advice
If patient is septic and
4.5g every 8 hours
condition is life-threatening
consider the use of
OR
meropenem.
8-hourly +
Gentamicin 1.5mg/kg
IV
OR
8-hourly
Seek expert advice from nephrologist
4.5g every 8 hours
OR
8-hourly +
Gentamicin 1.5mg/kg
IV
OR
8-hourly
Antibiotics are not

recommended unless
bacterial infection is thought
to have supervened.

Clostridium difficile
Pseudomembranous colitis
3.1
A yeast probiotic should be

given in conjunction with
therapy
Antibiotics are not usually necessary unless

there is evidence of
septicaemia or colitis
(i.e. fever, bloody
diarrhoea +/- high
WBC).
If antibiotic treatment is
deemed necessary consider
ciprofloxacin in adults. In
children use co-trimoxazole
or ceftriaxone.
Acute Enteric Infections
Gastroenteritis
3.1.1
If mild or moderate:
7-14
metronidazole 400mg 8- days
hourly orally.
If severe or relapsing:
vancomycin 125mg
orally 6-hourly.
Intestinal Parasites
Amoebiasis
Enterobiasis
Tapeworm
infections
Entamoeba histolytica
Enterobius
vermicularis
Diphyllobothrium
latum [fish]
Dipylidium caninum
[dog]
Taenia saginata [beef]
Taenia solium [pork]
Echinococcus
granulosus, [hydatid
disease]
Asymptomatic:
Paromomycin 500mg 8hourly
OR
Diloxanide furoate
500mg 8-hourly
Symptomatic:
Metronidazole 600mg
8-hourly, followed by
paromomycin 500mg 8hourly.
Mebendazole 100mg
12-hourly
OR
pyrantel pamoate
11mg/kg (max 1.0g)
Praziquantel, 5-10
mg/kg
OR
niclosamide 4 tablets
(500 mg each)
7 days.
10 days.
10 days.
7 days
3 days
Single
dose
Albendazole 400 mg 12- 28 days,

hourly, (15 mg/kg/day
then 14
in children)
days rest
period;
Echinococcus
Albendazole 400 mg 12- repeat
multilocularis [alveolar hourly, in conjunction
for 3
cyst disease
with surgery
consecutive
cycles.
Note:
If very severe, extraintestinal disease is present,

metronidazole IV is needed.
Repeat twice at 2-weekintervals.
Simultaneously treat all
members of the family, even
if asymptomatic.
If untreated may cause
vitamin B12 deficiency and
megaloblastic anaemia
Surgery is the treatment of

choice.
Concomitant -interferon
may enhance the efficacy of
these drugs.

Trichomoniasis
Trichomonas vaginalis
Metronidazole 2.0g
Single
dose
Ascariasis
Ascaris lumbricoides
Mebendazole 100mg
12-hourly
OR
albendazole 400mg
OR
pyrantel pamoate
11mg/kg (max 1.0g)
Metronidazole 400mg
8-hourly
OR
Albendazole 400mg
daily
3 days
Giardiases
Giardia lamblia
If pregnant, postpone
prescription till after first
trimester.
Treat the male partner in the
same way.
If refractory to treatment
seek expert advice..
.
single
dose
single
dose
If refractory to treatment
seek expert advice.
5 days
Infections of the Cardiovascular System
4.1
Endocarditis
Four to six weeks of antimicrobial therapy are required. The initial treatment should be given intravenously.
Common:
Penicillin G 12 to 18
Three sets of blood cultures
Empiric
Viridans streptococci,
MU daily IV in 4
or other appropriate
therapy
coagulase-negative
divided doses
microbiological specimens,
staphylococci,
+
must be obtained before
Staph. aureus
gentamicin 1 mg/kg IV 4-6
therapy is commenced.
(up to 80 mg) 8-hourly weeks
Rare:
OR
Enterobacteriaceae,
Vancomycin 15 mg/kg
diphtheroids, others.
IV (up to 1 g) 12-hourly
+ gentamicin 1 mg/kg
IV (up to 80 mg) 8hourly
Note:

Streptococcal
endocarditis
Penicillin-sensitive
streptococci:
Viridans streptococci,
microaerophilic and
anaerobic streptococci,
and non-enterococcal
group D streptococci,
including Strep. bovis.
Penicillin G 12 to 18
MU daily IV in 4
divided doses
gentamicin 1 mg/kg
Penicillin-resistant
streptococci (or
penicillin-allergic
patients)
4 weeks
Vancomycin 15 mg/kg
IV (up to 1 g) 12-hourly
Staphylococcal Absence of prosthetic

material:
endocarditis
Methicillin-sensitive
staphylococci
Presence of prosthetic
material:
Methicillin-sensitive
staphylococci
Methicillin-resistant
staphylococci (or
penicillin-allergic
patients)
Gramnegative
bacterial
endocarditis
Note:
Enterobacteriaceae
Ps. aeruginosa
4 weeks
Strep. bovis suggests occult

bowel pathology.
If gentamicin is added use
both for 2 weeks only
Regimen must be guided by

in vitro antibiotic sensitivity
tests.
Seek expert advice

Flucloxacillin 2g 4hourly +
Gentamicin 1 mg/kg IV
(up to 80 mg) 8-hourly
for the first 5 days.
OR
Vancomycin 30 mg/kg
per 24 h IV not to
exceed 2 g/24 h
Flucloxacillin 2g 6hourly IV +
Rifampicin PO 300mg
8-hourly +
Gentamicin 1mg/kg IV
8-hourly for the first
two weeks
Vancomycin 30 mg/kg
(up to 2g/day) IV +
Rifampicin PO 300mg
8-hourly +
Gentamicin 1mg/kg IV
8-hourly for the first
two weeks
Seek expert advice
4-6
weeks
4-6
weeks
6 weeks
Benefit of aminoglycosides
has not been established
after the fifth day.
For penicillin-allergic
patients or methicillinresistant staphylococci.
Benefit of gentamicin has

not been established after
the second week.
Rifampicin increases the
requirement of warfarin for
antithrombotic therapy.
Regimen must be guided by
in vitro antibiotic sensitivity
tests.
6 weeks

CultureNegativeEndocarditis
Prosthetic
valve
endocarditis
Fungal
endocarditis
4.2
Seek expert advice
Early consultation with a cardiovascular surgeon, infectious

disease physician or microbiologist is recommended
Early consultation with a cardiovascular surgeon, infectious
disease physician or microbiologist is recommended
IV line infections
Heparin lock,
midline
catheter, nontunneled
central venous
catheter,
peripherally
inserted
central
catheter
Tunnel type
catheter [e.g.,
Hickman line]
Impaired host
Hyperaliment
ation
IV lipid
emulsion
Note:
may be attributed to
fastidious organisms,
prior institution of
antibiotic treatment, or
both.
Staph. epidermidis,
Corynebacterium spp.,
Enterobacteriaceae, Ps.
aeruginosa and fungi
Candida spp.
Staph epidermidis,
Staph aureus.
Regimen must be guided by in vitro antibiotic sensitivity tests.
Staph epidermidis,
Staph aureus
[+Candida spp]
Staph epidermidis,
Staph aureus, Candida
spp.,
Enterobacteriaciae,
Corynebacterium,
Aspergillus, Rhizopus
Staph epidermidis,
Staph aureus, Candida
spp
Staph epidermidis,
Malassezia furfur



Infections of the Central Nervous System
5.1
Meningitis
Empiric therapy N. meningitidis,

Strep. pneumoniae,
Adults < 50
H. influenzae
years
Adults > 50
years,
Alcoholism,
Immunocompromised
Pneumococcal
Meningococcal
Strep. pneumoniae
L. monocytogenes
Gram-negative
bacilli
Strep.pneumoniae
Neisseria
meningitidis
H. influenzae type b
Listeriosis
5.2
10-14
days
Ceftriaxone 4g loading 10-14

dose followed by 2g IV days
12-hourly +
Amoxicillin 2g 4-hourly
Ceftriaxone 4g loading
dose, followed by 2g
IV 12-hourly
OR
Chloramphenicol
50mg/kg (up to 1 gm)
IV 6-hourly
Amoxicillin 2g 4-hrly
IV loading dose, then
1.7mg/kg 8-hourly
OR
Co-trimoxazole 960mg
IV 12-hourly
If bacterial meningitis is
suspected, take blood and
CSF cultures before
initiating antibiotic
therapy.
If N. meningitidis is likely,
petechial cultures and throat
swabs can be taken up to 2
hours after starting
treatment.
Consider results of Gramstain (on CSF and petechial
material) and other
laboratory investigations.
If necessary seek expert
advice.
If penicillin-allergic seek
specialist advice.
10-14
days
10-14
days
Gentamicin blood levels

must be monitored
14-28
days
Aciclovir should be given

over 1 hour to decrease risk
of nephrotoxicity
Other Brain Infections
Herpes
simplex
encephalitis
Note:
L. monocytogenes
Ceftriaxone 4g loading
dose, followed by 2g
IV 12-hourly
OR
Chloramphenicol
50mg/kg (up to 1 gm)
IV 6-hourly
Aciclovir 10mg/kg IV
8-hourly

Brain abscess
(primary /
haematogeous)
Streptococci,
anaerobes,
Enterobacteriaceae,
staphylococci.
Ceftriaxone 2g IV 12hourly + metronidazole

500mg IV 6-hourly
OR
Chloramphenicol 50
mg/kg (up to 1 gm) IV
6-hourly +
metronidazole 500mg
IV 6-hourly
Brain abscess
(post-surgical,
posttraumatic)
Staph. aureus,
Enterobacteriaceae
Ceftriaxone 2g IV 12hourly + flucloxacillin

2g IV 4-hourly
OR
Chloramphenicol 50
mg/kg (up to 1 gm) IV 6
hourly + teicoplanin
400mg IV 12-hourly for
1st 3 doses and daily
subsequently
Ceftriaxone 2g IV 12hourly + metronidazole
500mg IV 6-hourly
OR
Chloramphenicol 50
mg/kg (up to 1 gm) IV
6-hourly +
Metronidazole 500mg
IV 6-hourly
Streptococci,
anaerobes,
Enterobacteriaceae,
staphylococci.
Subdural
empyema
In conjunction with
aspiration and drainage.
6-8
weeks
Seek expert advice
In conjunction with
aspiration and drainage
6-8
weeks
If nosocomial consider
MRSA.
Seek expert advice
6-8
weeks
In conjunction with
aspiration and drainage
Seek expert advice
Common Infections in E.N.T.
6.1
Ear Infections
Otitis externa
- localised
(furuncle)
Staph. aureus
Otitis externa
diffuse
Ps. aeruginosa,
coliforms, others
Malignant
Otitis Externa
in diabetics
and immunosuppressed
Ps. aeruginosa
Note:
Flucloxacillin 500mg
6-hourly
OR
Erythromycin 500mg
6-hourly
Ciprofloxacin 500mg
12-hourly
7 days
7 days
Ciprofloxacin 400mg IV 6-8

12-hourly, for the first 2 weeks
weeks, followed by
ciprofloxacin 750mg
12-hourly PO.
Furuncles should be allowed

to drain spontaneously
If fungal overgrowth is
suspected an antifungal
agent should be added.
Therapy includes control of
blood glucose, local
debridement of devitalised
tissue and possibly
hyperbaric oxygen.
Antibiotic sensitivity testing
is a must.

10
Perichondritis Gram-negative rods

of the Pinna
Otitis Media
Acute Otitis
Media
Benign
Chronic
Suppurative
Otitis Media
Serous Otitis
Media
6.2
Strep. pneumoniae,
Haemophilus spp.,
viruses, others
(including atypicals)
Multiple aetiology
Strep. pyogenes
(consider possibility of
EB virus)
Peritonsillar
Abscess
Strep. pyogenes and

oral flora (including
anaerobes)
Oral and
Perioral
Fungal
Infection
Candida spp.
Incision and suctiondrainage are used to

approximate the blood
supply of the perichondrium
to the cartilage. Adjust
treatment according to
culture and sensitivity
results.
Co-amoxiclav 375mg 8hourly

10 days
OR
12-hourly, according to
age / body weight
Hydrocortisone 1%,
neomycin sulphate
0.4%, polymyxin B
sulphate 0.1% drops
OR
12-hourly.
Route usually oral; other

routes may need to be
considered
Cefalexin 500mg 6hourly

OR
Erythromycin 500mg
6-hourly
Co-amoxiclav 1.2g 8hourly IV
OR
Clindamycin 600mg 8hourly IV
Nystatin 500,000IU 6hourly oral suspension
OR
Amphotericin 10mg
lozenge
If unable to swallow, or
hospitalised, consider other
pathogens and/or IV
therapy
Therapy often depends on

culture & sensitivity results
10 days
Depend- Drain abscess

ing on
clinical
response
10-14
days
Consider oral (systemic)

fluconazole in the
immunosuppressed
Nose and Sinuses
Sinusitis
Acute rhinosinusitis
Note:
Depending on
clinical
result
Throat
Acute
Tonsillitis
6.3
Gentamicin 80mg IV
12-hourly
Piperacillin/tazobactam
4.5g 8-hourly
OR
Gentamicin 80mg IV
12-hourly
Ciprofloxacin 200mg IV
12-hourly.
Pneumococci,
H. influenzae, others
Cefuroxime 500mg 8hourly

OR
12-hourly
7-10
days

11
Polymicrobial,
including anaerobes
Chronic
sinusitis
Antibiotics usually not

effective
ENT consultation
recommended
Infections of the Eye and Adnexa
7.1
Infections of the Eyelids
Blepharitis
Infected
Chalazion
Styes
Infections of
the Lacrimal
ducts and sac
(Canaliculitis
and
Dacryocystitis)
7.2
Flucloxacillin 500mg 6hourly

OR
Clindamycin 150mg 8hourly
Various aetiological
Cefalexin 500mg 6agents especially Staph. hourly
aureus
OR
Staph. aureus, Strep.

pneumoniae, and H.
influenzae
Drainage needed if abscess

has formed
7-10
days
Gentamicin 0.3% eye

drops and eye ointment
OR
framycetin 0.5% eye
drops and eye ointment
7-10
days
Conjunctivitis in the neonate

requires microbiological
guidance.
Topical chloramphenicol
and tetracycline should be
used in chlamydial
infections.
Infections of the Cornea
Staph aureus, Ps
Corneal
Infiltrate and aeruginosa, or Strep
pneumoniae
Ulcer
Herpetic infections Herpes simplex
of the Cornea,
Disciform Dendritic
Keratitis and
Herpetic Ulcers
Note:
7-10
days
Infections of the Conjunctiva
Bacterial
Conjunctivitis
7.3
Staph. aureus
Suspect Pseudomonas when associated with contact lens wear

and Acanthamoeba if a previous history of swimming is present.
Seek expert advice immediately.
Aciclovir eye ointment
Seek expert advice
5 times daily
immediately.
Aciclovir 200mg orally 10 days
5 times daily can be
added in very severe
infections

12
7.4
Peri-orbital Infections
Peri-orbital
cellulitis
7.5
8-hourly,
followed by
Co-amoxiclav 375mg 8hourly orally
OR
12-hourly, followed by
Ciprofloxacin 750mg
12-hourly orally.
7 days
Seek expert advice
IV
followed
by
7 days
orally
Intra-Ocular Infections
Endophthalmitis
Staph. aureus, Strep.

pneumoniae and H.
influenzae type b
Ps aeruginosa, others
Seek expert advice immediately.
Infections of Skin, Muscle, Bone and Joints
8.1
Skin
Impetigo Contagiosa
(including secondary
bacterial infection of
viral or pruritic skin
lesions)
Staph.
aureus,and haemolytic
streptococci
especially
Strep pyogenes

OR
Clindamycin 150mg 8- 7 days
hourly
Aciclovir 200mg
(400mg in immunocompromised)
5 times daily
Herpes simplex
5-10
days
Boils,
Carbuncles
and Bullous
Impetigo
Staph. aureus, occasionally in association

with Strep pyogenes

OR
Clindamycin 150mg 8- 10 days
hourly
Cellulitis and
Erysipelas
Strep pyogenes (Staph.

aureus uncommon but
difficult to exclude)
Benzylpenicillin 2-4MU
IV 6-hourly +
Flucloxacillin 1g
7 days
IV 6-hourly
OR
Clindamycin 300mg 6hourly IV
Note:
In localised cases, topical

mupirocin ointment for a
duration of 5 days can be
used instead. Triclosan daily
baths may be useful as an
adjunct.
HSV-1 commonly causes
herpes labialis, herpetic
stomatitis, and keratitis;
HSV-2 usually causes
genital herpes
Boils should be drained;
antibiotic treatment is
reserved for spreading
cellulitis.
Seek expert advice for
recurrent furunculosis.
Seek expert advice in
neutropenic patients.

13
8.1.1
Wounds
Infected Wound
- Post traumatic
Mild/moderate
Infected Wound
- Post traumatic
Febrile with sepsis
Infected Wound
Post-Op
Not following
gastrointestinal
or female genital
tract surgery
Without sepsis
Not involving GI
or fe male genital
tract
With sepsis
Following
gastrointestinal
or female genital
tract surgery
Without sepsis
Following
gastrointestinal
or female genital
tract surgery
Polymicrobial,
staphylococci,
streptococci,
coliforms,
anaerobes.

OR
Clarithromycin 500 mg
12-hourly
5-10 days,
depending
on severity
Clindamycin 600mg 8hourly + ciprofloxacin
200mg IV 12-hourly
Consider early surgical

intervention and tetanus
prophylaxis
Take pus specimen in
transport medium
(preferable to swab) for
culture prior to initiating
antibiotic therapy.
If not on ciprofloxacin,
consider Pseudomonas
aetiology, if patient fails to
respond
Cefuroxime 500mg 12Wound cleansing and

hourly
debridement are
essential. Gram-stain
OR
might guide treatment.
12-hourly
Staph. aureus,
Until afebrile
Strep. pyogenes,
and wound
If MRSA is suspected a
Enterobacteriaceae Piperacillin/tazobactam granulating
glycopeptide should be
added.
4.5g IV 8-hourly
OR
Clindamycin 600mg 8hourly + ciprofloxacin
200mg IV 12-hourly
Co-amoxiclav 375mg 8Ciprofloxacin +
hourly + ciprofloxacin
metronidazole does not
200mg IV 12-hourly
cover Enterococcus spp.
Staph. aureus,
Depends Cultures should be taken
OR
Ciprofloxacin 200mg IV on
Strep. pyogenes,
before treatment and advice
Enterobacteriaceae, 12-hourly +
response sought if patient does not
Bacteroides other metronidazole 400mg 8respond.
hourly
anaerobes,
Enterococcus spp.
Carbapenems are -lactams
4.5g IV 8-hourly
and should not be used in
severe penicillin allergy.
OR
Meropenem 1g 8-hourly
With sepsis
Note:

14
Varicose or
decubitus
ulcers with
surrounding
cellulitis
8.1.2
Usually polymicrobial
including; Strep
pyogenes,
staphylococci,
anaerobes,
Enterobacteriaceae.
Consider possibility of
Pseudomonas in nonresolving cases.
8-hourly
OR
12-hourly +
metronidazole 400mg 8hourly
Culture is generally not

helpful in choosing an
Duration antibiotic. Lab reaults may
depends be misleading due to surface
on
growth (colonisation), which
clinical is often polymicrobial.
response
Diabetic Foot
Diabetic foot can be divided in 2 major sub-divisions:

Abscess: which requires surgical drainage and
Ulcer. An ulcer is infected if there is pus and/or redness and/or pain and/or tenderness. Ulcers can be
further subdivided into;
Neuropathic which requires removal of callus and maybe antibiotics and,
Gangrenous ulcers which in turn are also subdivided into;
Wet gangrenous ulcers which need debridement possibly after a few days of antibiotic therapy and
Dry gangrenous ulcers where one aims to improve vascular status.
General Points
Cure with antibiotics alone should not be attempted. Early surgical intervention can reduce the duration of
antimicrobial therapy and restore full ambulation faster while reducing the risk for future above-ankle
amputations, which is always the last resort. Correction of documented atherosclerotic, large-vessel
occlusive disease is also needed to maximise healing and save the limb.
Culture of material, carefully collected from abscess cavities, or by surgical biopsy of deep soft tissue or
bone provides the most useful guide to treatment and minimises the potential for contamination. Routine
swab cultures of an ulcerative lesion are often difficult to interpret because of the number of pathogens
found on the wound's surface. Even a non-infected, chronic pedal ulcer is likely to yield several organisms
on culture, but the findings are of little clinical significance. Culture of material from sinus tracts is also
unreliable.
Before an infected wound is cultured, care should be taken to remove any overlying necrotic debris from
the site. Vigorously scrubbing the wound with saline-moistened sterile gauze often can accomplish this.
Culture of the wound base, preferably from expressed pus, can then be attempted. Specimens obtained
from curettage of the base of the ulcer correlate best with results from deep-tissue culture
Gram's stain is often helpful for interpreting culture results and should always be requested from the
microbiology laboratory, especially if there is an abscess. An abscess has always to be drained before
antibiotic therapy is started and a sample from drain fluid should be sent for direct Gram-stain.
Foul-smelling drainage and the presence of gas in the tissues, detected by clinical or radiographic
evaluation, often predict a mixed polymicrobial infection. Pseudomonas aeruginosa, for example, is an
organism associated with moisture and is often recovered from surface cultures of chronic ulcers,
especially in patients previously treated with antibiotics. This usually represents colonisation only; specific
therapy for P aeruginosa is rarely indicated.
Anaerobic isolates are often found when collection techniques are appropriate. Adequate coverage for
these organisms is important when initial empirical therapy is started.
Another important factor in hospitalised patients is the control of blood glucose levels which should be
targeted at 8-12mol/mL
Note:

15
Localised cellulitis
Superficial
ulceration
Minimal purulence
No systemic signs or
symptoms
Cellulitis of foot or
ankle
Deep or penetrating
ulceration
Plantar abscess
Acute osteomyelitis
Systemic signs or
symptoms
Mild infection
Moderate
infection
Staph. aureus
and streptococci
Flucloxacillin
500mg 6-hourly
OR
Clindamycin 300mg
6-hourly
Staph. aureus
and
streptococci,
Gram-negative
bacilli and
anaerobes
Co-amoxiclav 1.2g
IV 8-hourly
OR
Clindamycin 600mg
IV 8-hourly +
ciprofloxacin 200400mg IV 12-hourly
Switch over to oral
therapy once patient
is better.
Proximal cellulitis,
lymphangitis
Gangrene,
necrotizing fasciitis
Clinical septicaemia
Severe
infection
8.1.3
8.2
Pasteurella multocida,
oral streptococci &
anaerobes,
Staphylococcus
intermedius,
Capnocytophaga
canimorsus,
Polymicrobial
including: oral flora,
and Staph. aureus
Piperacillin/tazobact
am 4.5g IV 8-hourly
OR
Ciprofloxacin
400mg IV 12-hourly
+ clindamycin
900mg IV 8-hourly

OR
Ciprofloxacin 500mg
12-hourly +
clindamycin 300mg 67 days
hourly
OR
If treatment is started late

the duration would have to
be prolonged. Wound
cleansing and elevation of
the affected part are vital.
Consider tetanus
immunisation
Muscle
Gas Gangrene Clostridia

(with
confirmatory
Gram-stain)
Note:
Treatment is
usually prolonged.
Duration is
determined by
outcome and
presence/absence
of osteomyelitis
Bites
Animal (dog
and cat)
Human
Anaerobes,
Staph. aureus,
streptococci and
Gram-negative
bacilli
Treated as outpatients. One can

refer to Diabetic
Clinic - Foot
Screening Clinic.
8-hourly +
Benzylpenicillin 6MU
IV 6-hourly
OR
8-hourly +
metronidazole 500mg
IV 8-hourly
Antibiotics and hyperbaric

oxygen are indicated but
are not substitutes for
surgical debridement.

16
Necrotising
fasciitis
8.3
Polymicrobial
including -haemolytic
streptococc, and
Clostridia,.
Meropenem 1g IV 8hourly.
If culture indicates
streptococci switch to
Benzylpenicillin 6MU
IV 6-hourly
OR
8-hourly + gentamicin
IV 80mg 8-hourly
Bacteriological
investigations are
mandatory.
Bone
Regardless of the type of osteomyelitis a specific microbiologic diagnosis is essential. Ideally empirical
therapy is initiated after collection of blood, infected bone (and pus if any) for culture.
Mixed cultures
Co-amoxiclav 1.2g IV +
If infection is established,
Following
gentamicin 80mg 8treat as per osteomyelitis
compound
hourly
fracture
13 days
(prophylaxis
OR
for
osteomyelitis)
IV 80mg 8-hourly
If condition improves,
Osteomyelitis Usually Staph. aureus Flucloxacillin 1g IV 6hourly + ciprofloxacin
consider switching over to
without
200mg IV 12-hourly
46
oral therapy after 7 days.
predisposing
weeks
factors
OR
6-hourly + ciprofloxacin
200mg IV 12-hourly
Ciprofloxacin 400mg IV 4 6
Osteomyelitis Salmonelli
12-hourly
weeks
in sickle cell
oral therapy.
anaemia
Flucloxacillin 1g IV 6If condition improves,
IV drug abuse Staph. aureus, Ps.
aeruginosa, Candida
hourly + ciprofloxacin
or
200mg IV 12-hourly
46
oral therapy after 7 days
haemodialysis spp.
weeks
Consider fungal aetiology
OR
if patient does not respond.
200mg IV 12-hourly
Note:

17
Contiguous
Osteomyelitis
Post reduction &

internal fixation:
Coliforms, Staph.
aureus Ps. aeruginosa
Flucloxacillin 1g IV 6hourly + ciprofloxacin

750mg 12-hourly
OR
200mg IV 12-hourly
Post-op sternotomy:
Staph aureus
Vancomycin 1g IV 12- 4 6
hourly + rifampicin 600- weeks
900mg daily
If MRSA is suspected a
glycopeptide should be
added.
Post nail puncture of

foot (through tennis
shoe or slippers):
Ps. aeruginosa
Chronic
Osteomyelitis
8.4
Ceftazidime 2g IV 8hourly
OR
Ciprofloxacin 750mg
12-hourly
Staph. aureus,
Empiric treatment not recommended. Therapy should be based
Enterobacteriaceae, Ps. on culture and sensitivity.
aeruginosa
Joints
Treatment requires both adequate drainage of purulent joint fluid and adequate systemic (not intra-articular)
antibiotic treatment, which should be started after collection of blood culture specimens. Joint fluid should
also be sent for Gram-stain, culture and crystal analysis.
Staph. aureus, Strep. According to GramAll empiric choices guided
Acute
stain:
by Gram-stain.
Monoarticular pyogenes, GramSeptic Arthritis negative bacilli
Inconclusive:
including
Modify treatment
Flucloxacillin 1g IV 6Pseudomonas spp.,
according to identification
hourly + Ciprofloxacin
N. gonorrhoeae
and sensitivity results.
200mg IV 12-hourly.
OR
Clindamycin 300mg IV 3 weeks consider switching over to
oral therapy after 7 days.
200mg IV 12-hourly.
Gram-positive cocci:
200mg IV 12-hourly.
Gram-negative
organisms:
Ceftriaxone 1g IV daily
+ ciprofloxacin 200mg
IV 12-hourly
OR
Gentamicin IV 80mg 8hourly + ciprofloxacin
200mg IV 12-hourly.
Note:

18
Brucella, Nocardia,
Chronic
monoarticular mycobateria, fungi
Polyarticular Gonococcus, Borrelia
burgdorferi, others
including viruses
Staph epidemidis,
Prosthetic
Staph. aureus
joint
Enterobacteriaceae,
Pseudomonas spp.
Septic Bursitis Staph. aureus
Seek expert advice

Seek expert advice
12-hourly for 1st 3
doses, and daily
subsequently, +
ciprofloxacin 200mg IV 3 weeks
12-hourly.
Flucloxacillin 1g IV 6hourly
OR
6-hourly
3 weeks
Most strains are hospitalacquired. Methicillinresistance is often present.

Specific treatment will
depend on culture and
sensitivity results. Expert
advice should be sought
Specific treatment will
depend on culture and
sensitivity results.
Urinary Tract Infections
It is important to stress the importance of fluid replacement in UTIs. In catheterised patients antibiotics
should be avoided, if possible, and antibiotic treatment only stsrted following a Gram-stain and specimen
collection for Culture and Sensitivity.
9.1
Acute (uncomplicated) Urinary Tract Infections
Lower urinary E. coli

tract infection Staphylococcus
saprophyticus
(Cystitis)
Upper
Urinary Tract
Infection
Involving
kidneys and
ureter
(Pyelonephritis)
Recurrent
Urinary Tract
Infection
Community acquired:
E. coli, Klebsiella spp.,
Proteus spp.
Nosocomial:
E. coli, Klebsiella spp.,
Proteus spp..,
Pseudomonas spp.,
Enterococcus spp.
E. coli,
Staphylococcus
saprophyticus, Proteus
mirabilis
Nitrofurantoin 100mg 8hourly

OR
co-trimoxazole 960mg
12-hourly
Norfloxacin 400mg 12hourly
Increased water intake and

acidifying urine are
recommended
14 days
In pyelonephritis blood
culture is recommeded.
Avoid nitrofurantoin and
nalidixic acid.
If afebrile for >48 hours
switch to oral ciprofloxacin
500mg 12-hourly
12-hourly
14 days
Urine pH < 7
Nitrofurantoin 100mg
8-hourly
Urine pH > 7
Norfloxacin 400mg 12hourly
Note:
Male 10 days
female 3 days
3 days
Investigate for structural

urinary abnormalities. If
intercourse related a single
post-coital dose may be
considered.

19
9.2
Complicated Urinary Tract Infections
Catheterassociated
Obstructive
uropathy
Urinary tract
infection with
sepsis
syndrome
10
Enterobacteriaceae,
Ps. aeruginosa.
Ciprofloxacin 200mg
IV 12-hourly
14
Change of catheter is often
days indicated. A fresh urine specimen
taken during change of catheter
should be sent for culture.
If culture yields Enterococcus,
consider appropriate therapy.
Antibiotic treatment is not
indicated in asymptomatic
bacteruria and/or afebrile patients.
E. coli and other
Piperacillin/tazobactam 4.5g May occur in patients with severe
coliforms,
8-hourly
underlying renal disease, urinary
Pseudomonas spp.,
tract abnormalities, or where there
OR
Enterococcus faecalis Ciprofloxacin 200mg IV 12- has been instrumentation of the
and related organisms. hourly + clindamycin 900mg urinary tract
IV 8-hourly + gentamicin
2mg/kg/day IV.
Infections of the Genital Tract
10.1
Urethritis
Neisseria gonorrhoeae
Non-specific
urethritis
Chlamydia trachomatis Doxycycline 100mg 12- 7 days

hourly
10.2
Expert advice should be

sought in cases of
disseminated gonococcal
infection, meningitis,
endocarditis and
complicated disease.
Concomitant infection with
chlamydia is common.
The female partner must
also be treated even if
asymptomatic
Syphilis
Primary,
Secondary or
latent <1 year
> 1 year
duration
Note:
Ciprofloxacin 500mg
OR
ceftriaxone 500mg IM
single
dose
Gonorrhoea
Treponema
pallidum
Benzathine penicillin G 2.4MU Single

dose
OR
Doxycycline 100mg 12-hourly 14 days
1/week
Benzathine penicillin G 2.4MU x 3
weeks
OR
Doxycycline 100mg 12-hourly 28 days
Benzathine penicillin can

only be prescribed by GU
specialist.
Seek expert advice in cases
of congential or
neurosyphilis. In pregnancy
only penicillin is
recommended.
Allergic persons should be
desensitised and treated
with penicillin

20
10.3
Vaginitis
Candida
vaginitis
(acute)
Candida albicans
Clotrimazole 500 mg 6 days

pessary nocte and 1%
cream externally.
Recurrent
Candidosis
Candida albicans,
Candida glabrata
Bacterial
vaginosis
Anaerobes,
Gardnerella vaginalis
Fluconazole 150 mgs

Up to 6
stat repeated weekly
months
OR
Itraconazole
400mg
monthly
Metronidazole 400 mg
7 days
12-hourly
OR
Trichomonas
vaginitis
Trichomonas vaginalis
Metronidazole 500mg
12-hourly
Actinomycosis
Actinomyces spp.
Amoxicillin 1 gram
8-hourly I.V. for 4 - 6
weeks
followed by amoxicillin
500mg 8-hourly oral
therapy for a further 5
months.
OR
3 days
Doxycycline 100mg 12hourly

I.V for 4 6 weeks
followed by orally for a
further 5 months
10.4
Herpes simplex genital infections
Primary
infections
Recurrent
infections
Note:
Vaginal discharge is
usually white and cheesy,
has a pH less than 5,
nonodorous, and is
adherent to the vaginal
walls. Yeast hyphae on
direct microscopy are seen
Culture should be sent for
identification of
aetiological agent and
antifungal sensitivity
testing before treament.
Characterised by a thin,
clear vaginal discharge
with a characteristic fishlike odour and presence of
clue-cells in direct Gramstain.
pH usually 5.5-6.0
Characterised by a greenish
frothy discharge and
presence of motile pearshaped cells with flagella
on direct microscopy. If
unresponsive to therapy,
seek expert advice.
Characterised by a thick,
yellow, foul-smelling,
vaginal discharge from
cervix, with intermittent
blood-streaking; often
present for months. Gramstain - sulphur granules on
microscopy. Frequently
IUD-associated; IUD
removal is mandatory
HSV
HSV
Aciclovir 200mg 5
times daily
Aciclovir 200mg tds
10 days
For symptom relief
3
months
Reassess after treatment

21
10.5
Condylomata acuminata (Genital warts)

Human papillomavirus
types 6 & 11 most
common
10.6
Inpatient
management
Pelvic sepsis in
females
(following
operation or
trauma )
N. gonorrhoeae,
Bacteroides spp.,
Enterobacteriaceae,
Chlamydia,
Streptococcus spp
Ciprofloxacin 500mg
12-hourly +
clindamycin 300mg
6-hourly + doxycycline
100mg 12-hourly
N. gonorrhoeae,
Bacteroides spp.,
Enterobacteriaceae,
Chlamydia,
Streptococcus spp
2mg/kg/day IV.
Anaerobes,
haemolytic
streptococci,
enterococci, aerobic
gram-negative bacilli
*Podophyllin preparations
are reserved for GU
specialist. Keratinised
warts and warts which do
not respond well to
podophyllin are best treated
with cryotherapy.
On discharge, follow
with doxycycline
100mg 12-hourly
(orally) for a further 14
days.
Co-amoxiclav 1.2 g IV
IV 80 mg IV 8-hourly
OR
200mg IV 12-hourly
Evaluate and treat sexual

partner
14 days Hospitalise when:
1. Fever > 38oC
2. WBC > 11,000
3. Evidence of peritonitis
14 days
14 days
Infectious Diseases
Typhoid Fever Salmonella typhi,

Salmonella paratyphi
Typhus
Note:
Once or
twice
weekly
Pelvic Infections
Pelvic
Inflammatory
Disease (PID),
Salpingitis,
Tubo-ovarian
Abscess
Outpatient
management
Pelvic
Inflammatory
Disease (PID),
Salpingitis,
Tubo-ovarian
Abscess
11
*Podophyllin 25%
(topical)
Rickettsia typhi
Rickettsia conori
Ciprofloxacin 500mg
12-hourly
Ceftriaxone 2g IVonce
daily
14 days
Doxycycline 100mg 12hourly

10 days
If associated with shock,

dexamethasone 3 mg/kg IV
initially, followed by 1
mg/kg 6-hourly for 48
hours total is
recommended.
Chloramphenicol,
flouroquinolones or
macrolides may be
indicated in special
circumstances

22
Brucellosis
Whooping
Cough
Brucella melitensis
Bordetella pertussis
Legionnaires
Disease
Legionella
pneumophila
Salmonella
Enteritis
Salmonelli
Campylobacter Enteritis
Campylobacter spp.
Leptospirosis
Leptospira interrogans
Pneumocystis
carinii
infection
Pnemocystis carinii
12
Doxycycline 100mg 12hourly + rifampicin

600mg - 900mg daily
Erythromycin 500mg 6hourly
OR
12-hourly
IV 12-hourly
(+ Rifampicin 300mg
IV 12-hourly in
seriously ill)
Antibiotic treatment is
not generally
advisable.
6 weeks
Gentamicin may be
indicated in special
circumstances.
14 days
Approx.
3 weeks
Ciprofloxacin 500mg
5 days
12-hourly
OR
Erythromycin 500mg 6hourly
Penicillin G 6 MU IV 6hourly
7 days
OR
Doxycycline 100mg IV
12-hourly
Co-trimoxazole
120mg/kg/day IV 8hourly
21 days
Diagnosis should be
confirmed by sending urine
specimen for Legionella
antigen.
Ciprofloxacin 500mg 12hourly for 5 days may be
necessary for bacteraemia,
severe disease or systemic
involvement.
Consider pentamidine if
patient is non-responsive or
intolerant. Prednisone may
be indicated in severe
hypoxic states.
Septicaemia
The best choice of antibiotic for the treatment of bacteraemia should always be based on the source of
infection.
12.1
Neutropenic
Adults
Febrile
> 38.3oC
Note:
Aaerobic Gramnegative rods,

streptococci,
staphylococci,
4.5g IV 8-hourly
OR
Meropenem 1g IV 8hourly
OR
80mg IV 8-hourly
Appropriate body fluids,

especially blood, should be
taken for culture before
starting antibiotic treatment

23
12.2
Non-neutropenic
2 or more of the following: Fever >38oC or <36oC; heart rate >90 beats/min; respiratory rate >20 br/min;
WBC >12,000/l.
Appropriate body fluids, especially blood, should taken for culture before starting antibiotic treatment
Various
Unknown
4.5g IV 8-hourly +
aetiology
gentamicin 80mg IV 8BUT
hourly
Likely biliary
or gastroOR
Meropenem 1g IV 8intestinal tract
hourly + gentamicin
focus
80mg IV 8-hourly
OR
200mg IV 12-hourly +
gentamicin 80mg IV 8hourly
Strep. pneumoniae, H. Ceftriaxone 2g IV 12
Asplenic
influenzae, N.
hourly
individual
meningitidis
OR
12-24 hourly
Flucloxacillin 2g IV 6Consider fungal aetiology
Illicit IV drug- Staph. aureus
hourly
use
OR
12-hourly for the first 3
doses, then 400mg daily
Streptococci
Ceftriaxone 2g IV 12
Blood cultures should be
Primary
hourly + gentamicin
taken prior to initiation of
Bacterial
80mg IV 8-hourly
treatment. Peritoneal fluids
Peritonitis
should be sent for Gramin adolescents
OR
stain and culture if a
laparatomy is performed
2mg/kg/day IV
(prior to peritoneal lavage)
and, as far as possible,
before starting treatment.
Refer to Section 1.1 Hospital-Acquired Pneumonia
Pneumonia
Urinary tract Refer to Section 9.2 Urinary Tract Infection with Sepsis Syndrome
infection
Staph. aureus,
Flucloxacillin 2g IV 6Carbuncle,
hourly + gentamicin
Strep. pyogenes
Furunculosis
80mg IV 8-hourly
with Cellulitis
OR
80mg IV 8-hourly
Note:

24
13
Non-Surgical Antibiotic Prophylaxis
Prevention of
Recurrence of
Rheumatic
Fever
Strep. pyogenes
Prevention of
Meningococcal
Disease
N. meningitidis,
Prevention of
H. infulenzae
type b
Meningitis
Prevention and
chemoprophylaxis of
Tuberculosis
13.1
Phenoxymethylpenicillin 250mg 12hourly

OR
sulfadiazine 1g daily
OR
Erythromycin 250mg
12-hourly
Ciprofloxacin 500mg
stat dose.
OR
Rifampicin 600mg 12hourly
10 years
or until
25 years
of age
Single
dose
2 days
H. influenzae type b
Rifampicin 600mg daily 4 days
Mycobacterium
tuberculosis
Seek expert advice
If pregnant ceftriaxone
250mg IM is indicated
unless penicillin-allergic,
where spiramycin 500mg
6-hourly for 5 days is
recommended . See
infections of the CNS
(Section 5)
For non-immunised
children under 5 years
Prevention of Endocarditis or Infection of Prosthetic Implants
Dental
Extractions,
Scaling, or
Periodontal
Surgery
Local anaesthesia;
Amoxicillin 3g
OR
Clindamycin 600mg
1 hour before procedure
General Anaesthesia [no special risk];
Amoxicillin 1g IV at induction + 500mg orally 6 hours later
OR
Clindamycin 600mg 4 hours before incision + 600mg ASAP after prcocedure
Special Risk Patients;

Amoxicillin 1g IV + gentamicin 120mg IV at induction and
amoxicillin 500mg orally 6 hours later
OR
Vancomycin 1g IV [over 100 minutes] followed by gentamicin 120mg IV at induction.
Instrumentation of Upper Respiratory As for Dental Procedures above but post-operative dose can be
given IV since swallowing might be painful.
Tract
As for Special Risk Patients undergoing dental procedures under
Genito-Urinary Instrumentation
general anaesthesia
Note:

25
Obstetric and Gynaecological

Procedures
Gastrointestinal Procedures
Cardiac catheterisation, pacemaker
insertion

general anaesthesia. Prophylaxis required only for patients with
prosthetic valve or history of endocarditis.
general anaesthesia
American Heart Association does not recommend antibiotic
prophylaxis
Patients without a functioning spleen
13.2
For patients who are to undergo

splenectomy or who have just been
splenctomised:
Pneumococcal vaccination
H influenzae type b vaccination
N meningitidis groups A & C vaccination
Vaccination:
Repeat pneumococcal vaccine at 5 yearly interval. Do not repeat

Hib if immunisation was given in childhood.
Antibiotic Prophylaxis:
Penicillin V 500mg 12-hourly

OR
Erythromycin 250mg once daily
Prophylaxis should be considered for children < 5 years of age
and in older children and adolescents for 3 years post-splenectomy.Seek expert advice if patients do not tolerate either
of these antibacterials.
14
Surgical Prophylaxis
Surgical Prophylaxis
It should always be of a short duration giving perioperative cover
The antibiotic used for prophylaxis should be different from the one that would be used if a postoperative
infection develops.
It is worth noting that if prophylaxis is prolonged or used outside the indication this would increase the risk
of resistance and increase the cost of stay.
14.1
Cardiothoracic Surgery
14.1.1
Prosthetic Valve Insertion:
Conclusive evidence, based on controlled trials, for the effectiveness of prophylactic antibiotics in this area
is lacking. However, prophylaxis is commonly given when prosthetic heart valves are inserted. The
usefulness of routine prophylactic antibiotics in coronary artery bypass surgery has not been established.
Rationale: Staphylococci most likely pathogens
Antibiotic
At induction
Further doses (if any)
Cefuroxime
1.5g IV
750mg at 8 & 16 hours
Co-amoxiclav
Note:
1.2g IV
1.2g at 8 & 16 hours

26
Vancomycin
14.1.2
500mg over 100 min
Arterial Reconstructive Surgery:
Surgery involving the abdominal aorta and/or the lower limb, particularly if a groin incision is involved,
may benefit from the administration of prophylactic antibiotics. Patients undergoing any vascular procedure
involving prosthesis should probably also receive prophylaxis. The incidence of infection after operations on
the brachial and carotid arteries, not involving prosthetic materials, is too low to justify the use of
prophylactic antibiotics.
Rationale: Staphylococci major aetiological agents associated with vascular graft infection; mixed flora
(anaerobes + aerobes) in abdominal aorta and diabetic foot patients.
Cefuroxime
1.5g IV
Co-amoxiclav
1.2g IV
1.2g at 8 & 16 hours
Vancomycin
500mg over 100 min
14.2
Orthopaedic Surgery
There is some evidence that an antibiotic with proven activity against local strains of staphylococci, as
advised by the microbiologist, can decrease the incidence of infection of prosthetic joints following total hip
replacement. Similarly, a decrease in the infection rate has been demonstrated for proximal femoral fractures
treated with internal fixation by nail or plate under appropriate anti-staphylococcal antibiotic cover. It may
also be appropriate to use prophylactic antibiotics for other orthopaedic procedures involving insertion of
prosthetic material, but this remains unproven.
The value of incorporating antibiotics into cement for primary or non-infected joint insertion is
unproven but it has been used successfully in the replacement of infected joint prostheses.
It is recommended that antibiotic prophylaxis be given in situations involving severe musculoskeletal
and soft tissue trauma, including compound fractures. In this situation, an increased duration of
therapy (early treatment) may be appropriate.
14.2.1
Joint replacement, internal fixation of selected fracture
Rationale: Staphylococci are the major infecting organisms in joint replacement surgery.
Cefuroxime
1.5g IV
up to 2 days
Co-amoxiclav
1.2g IV
up to 2 days
Vancomycin
1g over 100 min
up to 2 days
14.2.2
Muscular, skeletal and soft tissue trauma
Particularly if severe, and/or with compound fractures

Rationale: The more frequently encountered pathogens are staphylococcal skin flora in grade I & II
fractures whereas coliforms often infect grade III fractures.
Grade I and II fractures
Co-amoxiclav
1.2g IV
Single dose
Clindamycin
Grade III fractures
Ceftriaxone
Note:
600mg IV
Single dose
2g IV
Single dose

27
Ciprofloxacin
14.3
200mg IV
Single dose
Lower Limb Amputation
Amputation, particularly of an ischaemic leg carries a small but important risk of clostridial infection.
Appropriate antibiotic prophylaxis must be given.
Rationale: Clostridia are the major infecting organisms in lower limb amputation.
Metronidazole
500mg IV or 1g rectally
14.4
Neurosurgery
With the exception of cerebrospinal fluid leakage following trauma, and craniotomy involving the
implantation of prosthetic material, e.g. shunts, prophylactic antibiotic use remains unproven.
Rationale: Isolates from neurosurgical wound infections are predominantly staphylococci.
14.4.1
CSF leakage
Ceftriaxone
2g IV
Co-amoxiclav
1.2g IV
2nd dose if procedure > 3 hours
Clindamycin
900mg IV
14.4.2
Craniotomy involving prosthetic implants
Flucloxacillin
2g IV
Clindamycin
900mg IV
14.5
Head, Neck & Thoracic Surgery (including ENT procedures)
Prophylaxis should in general be considered for procedures that involve an incision through oral, nasal,
pharyngeal or oesophageal mucosa, stapedectomy or similar operation, or the insertion of prosthetic
material. The benefits of antibiotic prophylaxis for tonsillectomy and adenoidectomy are unproven. Where
an established focus of infection is suspected or shown to be present, e.g. chronic mastoiditis, an early
treatment regimen may be appropriate.
14.5.1
Involving oral, pharyngeal or oesophageal mucosa
Rationale: Coverage against skin staphylococci plus oral anaerobic bacteria.

Co-amoxiclav
1.2g IV
Clindamycin
600-900mg IV
14.5.2
Extensive procedures particularly for carcinoma
Rationale: Coverage against skin staphylococci, oral anaerobic bacteria and Gram negative rods.
Cefuroxime +
1.5g IV +
metronidazole
500mg IV
Co-amoxiclav
1.2g IV
Clindamycin
gentamicin
Note:
600-900mg IV
1.5mg/kg IV

28
14.6
Abdominal Surgery
14.6.1
Endoscopic Procedures
Endoscopic
Retrograde
Cholagiopancreatography
[ERCP]
14.6.2
If Bile Duct
Obstruction
Suspected
If patient has
abnormal [or
prosthetic] heart
valve
Gram-negative
bacteria
Alphahaemolytic
streptococci
Ciprofloxacin
750mg Orally
STAT DOSE
Cefuroxime
750mg IV
2 hours prior to
procedure
30 minutes before
surgery
Gastroduodenal Surgery
When the stomach or duodenum is to be opened, prophylaxis should be considered if the mechanisms that
normally inhibit bacterial growth in the stomach and duodenum, namely, gastric acidity and gastrointestinal
motility are diminished by conditions such as obstruction, haemorrhage, gastric ulceration, gastric
malignancy, previous gastric surgery. (e.g., vagotomy, gastrectomy, or drugs reducing gastric acidity such as
ranitidine.)
Rationale: Likely flora includes coliforms, Bacteroides, peptostreptococci and clostridia.
Cefuroxime +
1.5g IV +
metronidazole
500mg IV
Co-amoxiclav
Ciprofloxacin +
metronidazole
14.6.3
1.2g IV
200mg IV +
500mg IV

Biliary Tract Surgery
Prophylaxis should generally be considered only for patients at increased risk of acquiring infection. These
include those:
older than 70 years;
with acute cholecystitis;
in whom complicated surgery or re-operation is to be undertaken;
having surgery involving the common bile duct, particularly in the presence of obstruction, (when
anaerobic organisms are more likely to be present).
Rationale: Likely flora include coliforms. Bacteroides, peptostreptococci and clostridia which are more
likely in common bile duct surgery
At risk patients:
Ceftriaxone
1g IV
Common bile duct surgery:
Co-amoxiclav
1.2g IV
Ciprofloxacin +
metronidazole
14.6.4
200mg IV +
500mg IV
Colorectal Surgery
The measures that can be taken to reduce the high risk of infection associated with colorectal surgery are not
equally applicable to both elective and emergency procedures.
Elective procedures
Note: All regimens are oral unless otherwise stated.
29
Pre-operative mechanical bowel preparation with appropriate peri-operative antibiotic(s) (administered parenterally, rectally or orally) substantially reduce infective complications. Marked improvement accompanies
the use of drugs against Bacteroides fragilis. However, additional protection results if an aminoglycoside or
-lactam is added to provide aerobic Gram-negative cover.
Metronidazole +
500mg IV +
ceftriaxone
1g1V
Metronidazole +
1g rectal / 500mg IV +
Gentamicin
1.5mg/kg IV
*Evacuate the bowel by 4L polyethylene glycol in electrolyte solution orally
(b) Emergency procedures
Mechanical bowel preparation is not possible and parenterally administered antibiotics are recommended. If
obvious peritonitis is detected at the time of surgery or if major peritoneal soiling occurs then an early
treatment regimen should be adopted.
Cefotaxime +
2g IV +
Continue 8-hourly for 24 hours
Metronidazole
500mg IV
Gentamicin +
1.5mg/kg IV +
clindamycin
600mg IV
Appendicectomy
Metronidazole
500mg rectally
If gangrenous, perforated or severely inflamed appendix seen during operation
Co-amoxiclav
1.2g IV
8-hourly for 2 days
Cefuroxime +
1500mg IV +
8-hourly for 2 days
Metronidazole
500mg IV
Gentamicin +
1.5mg/kg IV +
8-hourly x 2 days
Clindamycin
600mg IV
Ruptured, perforated or gangrenous viscus (e.g. perforated colon or appendix) suspected before
procedure
Rationale: Coliforms and anaerobic bacteria likely infecting organisms.
Co-amoxiclav +
1.2g IV +
8-hourly for 2 days
Gentamicin
1.5mg/kg IV
Gentamicin +
1.5mg/kg IV +
8-hourly for2 days
Clindamycin
600mg IV
14.6.5
Laparotomy
Rationale: Coliform , Gram-positive & Gram-negative anaerobic bacteria and enterococci likely to be
involved.
Co-amoxiclav +
1.2g IV +
gentamicin
1.5mg/kg IV
Cefuroxime +
1.5g IV +
metronidazole
500mg IV
Gentamicin +
1.5mg/kg IV +
Clindamycin
600mg IV
Gentamicin +
1.5mg/kg IV +
Metronidazole
500mg IV
Note:

30
14.7
14.7.1
Transplant Surgery
Kidney Transplantation
Rationale: Staphylococci are the predominant organisms involved.

Ceftriaxone
1g IV
Teicoplanin
400mg IV
14.8
Single dose
Single dose
Obstetric and Gynaecological Surgery
Antibiotic prophylaxis has been shown to decrease the incidence of septic complications following
Caesarean section in high-risk patients, esp. those in labour or with ruptured membranes. To avoid exposing
the infant to the drug, administration can be delayed until after the cord is clamped. Infective complications
following hysterectomy, particularly if performed by the vaginal route, can also be reduced by appropriate
prophylaxis. An infected abortion requires appropriate early treatment.
14.8.1
Hysterectomy
Rationale: Coliforms, Enterococcus, Streptococcus, clostridia and Bacteroides are potential infecting
organisms.
Cefuroxime +
1.5g IV +
Single Dose
Metronidazole
1g rectal (500mg IV)
Co-amoxiclav
1.2g IV
Single Dose
Gentamicin +
Clindamycin
14.8.2
6mg/kg IV +
600mg IV
Single Dose
Caesarian section - high risk only
Rationale: Coliforms, Enterococcus, Streptococcus spp., clostridia and Bacteroides potential aetiological
agents.
Co-amoxiclav
1.2g IV
Single Dose
Clindamycin
600 mg IV
Single Dose
Bowel Injury: add gentamicin
14.9
Urological Surgery
Prophylaxis is usually necessary for prolonged or difficult endoscopic procedures (e.g. urethral dilatation or
percutaneous nephrolithotripsy). Prophylaxis is not usually recommended for simple procedures (e.g.
cystoscopy) in patients with sterile urine at the time of urological surgery. Patients suspected of having
urinary tract infection should be treated pre-operatively to prevent postoperative sepsis and ideally this
should be on the basis of prior urine culture, with therapy being guided by sensitivity results. Strict maintenance of closed-catheter drainage can prevent urinary tract infection in patients who temporarily require an
indwelling catheter. The use of bladder irrigants does not provide any additional benefit and may select out
resistant organisms. Equally, administration of oral antibiotics to cover the period of catheterisation is not
recommended.
For proven or suspected urinary infection, according to urine culture and sensitivity.
If data unavailable,
Rationale: Coliforms and staphylococci (community strains) are the major infecting organisms,
pseudomonads are also occasionally involved.
Note:

31
Cefuroxime
1.5g IV
14.10 Ophthalmic Surgery

Topical antibiotics are recommended for prophylaxis. The more frequently encountered bacteria are Staph.
aureus, streptococci and Staphylococcus epidermidis.
Chloramphenicol eye drops or ointment
1-2 days only
14.11 Dental Procedures

Prevention of endocarditis in patients with heart-valve lesions, septal defects, patent ductus or prosthetic
valve. It is important to use chlorhexidine gluconate 0.2% mouthwash 5 minutes prior to the procedure.
14.11.1 Under local or no anaesthesia

Normal Risk
Patients who are not allergic to penicillin and who have not received more than a single dose of penicillin in
the previous month.
Antibiotic
1 hour before surgery
Amoxicillin
3g [sachet] orally
Stat Dose
Penicillin-allergic patients or who have received more than a single dose of penicillin in the previous month.
Clindamycin
300mg PO or IV (over at least 10 min.)
Special Risk
the previous month.
Antibiotic
1 hour before surgery
Amoxicillin +
1g IV +
amoxicillin 500mg PO after 6 hours
Gentamicin
120mg IV
Clindamycin
150mg PO or IV 6 hours later
300mg IV over 10min
14.11.2 Under general anaesthesia

the previous month.
Normal Risk
Antibiotic
At induction
1g IV
500mg IV after 6 hours [for nil by mouth]
Amoxicillin
or
or
3g [sachet] 4 hours
3g sachet orally (ASAP after surgery)
before induction orally
Special Risk
Amoxicillin +
1g IV +
amoxicillin 500mg PO after 6 hours
gentamicin
120mg IV
(Normal/Special Risk)
Clindamycin
300mg IV
150mg PO or IV 6 hours later
(over at least 10 min.)
Teicoplanin +
Gentamicin
Note:
400mg IV +
120mg IV
Stat dose of each

32
15
METHODS OF ADMINISTRATION OF INTRAVENOUS AGENTS
The slow intravenous injection of antibiotics (over 1-2 minutes at a minimum) is an acceptable
method of administration of most antibiotics (Method 1). However, this method may produce
transiently high blood levels of antibiotics that could possibly be toxic and may also predispose to
thrombophlebitis. In these situations, a slow infusion via a burette or piggyback container is preferred
(Method 2), remembering that this method involves greater expense and may be complicated by
factors such as stability and fluid restriction. When in doubt as to the best method of administration,
slow infusion offers greater safeguards.
The compatibility with both intravenous fluids and other drugs should always be checked, as should
the stability of the antibiotic. Product literature should also be consulted.
Method 1 Reconstitute with or dilute to 10-20ml of water for injection, which might be supplied with
the powder for reconstitution.. Inject slowly over 1-2 minutes (at a minimum).
Method 2 Reconstitute with water for injection and dilute in 50-100ml of compatible infusion fluid in
a burette or by piggyback container and infuse over 30 minutes.
Antibiotic
Recommended Method
Diluents
Comments
of Administration
Aciclovir
Infuse over one hour.
5% Dextrose,
Do not refrigerate; stable 24
The concentration of the
Normal Saline
hours (RT)
solution must not exceed
5mg/mL
(e.g.500mg/100mL)
Amikacin
Method 2
5% Dextrose,
Stability: 1 day (RT) 7 days
Normal Saline
(REF).
Amoxicillin
Method 1
Normal Saline,
Limited stability, especially in
Method 2 for doses 2g or 5% Dextrose
dextrose solution. Use within 2
greater
hours
Amphotericin B
Powder to be
5% Dextrose
Infusion fluid needs to be
reconstituted only with
buffered at pH 4.2 or higher.
water for injection.
(pH of commercially available
Infuse over 6 hours
dextrose 5% is usually 4.2).
Solution concentration not to
exceed 0.1mg/mL
(50mg/500ml)
Amphotericin B Reconstitute each vial
5% Dextrose
(initial test dose 1 mg over 10
Liposomal
with 12 mL water for
minutes); incompatible with
injection; shake
sodium chloride solutions,
vigorously. Preparation
flush existing intravenous line
contains 4 mg/mL;
with glucose 5% or use
withdraw required dose
separate line
and introduce into
infusion fluid through
the 5 micron filter
provided. Final
concentration of 0.22
mg/mL; infuse over 30
60 minutes.
Azithromycin
500 mg/250mL [60 min]
5% Dextrose,
Stability: 24hrs (RT); 7 Days
Normal Saline
(REF). Label: refrigerate
Appendices - Methods of Administration of Intravenous Agents

33
Aztreonam
Benzylpenicillin
Caspofungin
Method 2, solution not

exceeding a concentration of 2% (1g/50mL
[30 min], >1g/100mL
[60min])
Method 2
Cefepime
Initially reconstitute
each vial with 10.5mL
water for injections,
mixing gently to dissolve
then dilute requisite dose
in 250mL (35- 50mg
doses may be diluted in
100mL if necessary);
give over 60 minutes.
Method 2
Cefotaxime
Method 2
Cefoxitin
Method 2
Ceftazidime
Method 2
Ceftriaxone
Method 2
Cefalotin
Method 1
Method 2 for doses 2g or
greater
Method 2
Cefuroxime
sodium
Chloramphenicol
Ciprofloxacin
Clarithromycin
Method 2
(1g/50mL [30 min],
>1g/100mL [60min])
Ready-made solution
Dissolve initially in
water for injections
(500 mg in 10 mL)
then dilute to a
concentration of
2mg/mL; give over
60 minutes
5% Dextrose,
Normal Saline
Stability: 1 Day (RT); 7 Days

(REF).
5% Dextrose,
Normal Saline
Stability is 8 hours in normal

saline, 4 hours in dextrose.
Normal Saline
Allow vial to reach room

temperature; incompatible with
glucose solutions
5% Dextrose,
Normal Saline
5% Dextrose,
Normal Saline
5% Dextrose,
Normal Saline
5% Dextrose,
Normal Saline
Stability: 24 hr (RT)/ 7 Days

(REF). Label: Refrigerate
Stability: 1 day (RT) / 5 days
Stability: 1 Day (RT)/ 7 Days
Care needed: see product
literature; carbon dioxide release produces positive
pressure in vial
Stability: 1 Day (RT) / 10
Days (REF). Label:
Refrigerate
Dilute with l0ml water for
Injection for each gram
5% Dextrose,
Normal Saline
5% Dextrose,
Normal Saline
5% Dextrose,
Normal Saline

Stability: 1 Day (RT)
5% Dextrose,
Normal Saline

34
Clindamycin
Co-amoxiclav
Method 2
(600mg/50mL [30
min],
>600mg/100mL
[60min])
Method 2
Colistin
Method 2
Co-trimoxazole
Method 2
Dose volume
5mL
10mL
15mL
5% Dextrose,
Normal Saline
Stability: 2 Days (RT) / 10 Days

(REF). Label: Refrigerate.
5% Dextrose,
Normal Saline
Finish within 4 hours of

reconstitution
Normal Saline
(Also known as colistimethate

sodium)
5% Dextrose
Ertapenem
Method 2
Normal Saline
Erythromycin
lactobionate
Method 2
(500mg/100mL
[60 min],
>500g/250mL
[120min])
Method 1
Method 2 for doses
greater than 2g
Ready-made solution
(see Sodium Fusidate)
Method 2
100mL over 60min
Method 2
(40mg/50mL [30
min], >40g/100mL
[30min])
Method 2
(500mg/100mL
[30 min],
>500g/250mL
[60min])
Ready-made solution
600 mg/ 300 ml
400 mg/ 200 ml
(Pre-made) 60
minutes
Method 2
Normal Saline
Flucloxacillin
Fluconazole
Fusidic acid
Ganciclovir
Gentamicin
Imipenem/
Cilastatin
Levofloxacin
Linezolid
Meropenem
Metronidazole
Netilmicin
Dilution Volume
100mL
250mL
500mL
Stability: 6 hours (RT)/ 2hrs
(minimum dilution). Label: Do
not Refrigerate.
Incompatible with glucose
solutions
Stability: 1 Day (RT/REF).
Label: Refrigerate.
Normal Saline,
5% Dextrose
5% Dextrose,
Normal Saline
5% Dextrose,
Normal Saline
Stability: 1 Day (REF). Label:

Refrigerate
Stability: 1 Day (RT) ; 4 Days
Normal Saline
Stability: 4 HRS (RT) / 24 HRS

(REF) Label: Refrigerate.
Isotonic D5W
(Pre-made)
(range: 30 to 120 minutes)
5% Dextrose,
Normal Saline
Supplied as 500mg/l00mL IV solution. Infuse over a minimum of 30 minutes
Method 2
50200mL over 30120 minutes

35
Penicillin G
Synercid
(quinupristin/dalfo
pristin)
Method 2
(4MU/50mL [30
min], >4MU/100mL
[60min])
350mg/250mL
[60min]
Method 2
(2.25g/50mL [30
min], >2.25g/100mL
[30min])
Dissolve in solvent
supplied and further
dilute to 500mL.
Infuse over 2-3
hours
Reconstitute with
the buffer solution
provided and dilute
to 500 mL of normal
saline and infuse
over 2-4 hours
Prescribed
dose/250mL
[60min]
Teicoplanin
Method 2
Pentamidine
Piperacillintazobactam
Rifampicin
Sodium Fusidate
Tobramycin
Trimethoprim
Vancomycin
Voriconazole
Zidovudine
5% Dextrose,
Normal Saline
Stability: 1 Day (RT) / 3 Days

5% Dextrose
Stability: 1 DAY (RT) . Label:

Protect from light.
Stability: 1 Day(RT) / 7 Days
Cannot be given IM
5% Dextrose,
Normal Saline
5% Dextrose,
Normal Saline
Use within 6 hours
Normal Saline
Give through central venous line

over 2 hours (or over 6 hours if
superficial vein used);
incompatible in solution of pH
less than 7.4
5% Dextrose
If patient complains of pain at

site of injection dilute prescribed
dose to 500mL.
Stability: (RT) 5 hours; (REF)
54 hours. Label: refrigerate
Reconstitute initially with water
for injections provided
Stability: 1 Day (RT) / 3 Days
5% Dextrose,
Normal Saline
Method 2
5% Dextrose,
Normal Saline
Method 2
5% Dextrose,
Normal Saline
500 mg/100mL [30 min]
5% Dextrose,
501-1250mg/250mL [1 hour]
Normal Saline
1251-1750mg/250mL [1.5
hours]
1751-2250mg/250mL
[2 hours]
Reconstitute each 200mg
5% Dextrose,
with 19 mL water for
Normal Saline
injection to produce a 10
mg/mL solution; dilute to a
concentration of 25 mg/mL.
Dilute to a concentration of
5% Dextrose
2-4mg/mL, infuse over 60
min.
Stability: 2 Days(RT) / 7 Days

(REF).
Give at a rate not exceeding 3

mg/kg/hour

36
16
Antibiotic Therapy in Renal Failure
Most antimicrobials are excreted primarily by the kidneys, so downward adjustments in dosage must be
made when there is significant renal functional impairment and the intervals between doses can be
lengthened. Exceptions are drugs such as chloramphenicol, which are metabolized to inactive
conjugates, and those excreted primarily by the liver, such as sodium fusidate. Rules of thumb for
drug dosage based on blood urea nitrogen and creatinine clearance developed for adults can be used for
older children, but they are not useful for infants.
Major adjustments in dosage and dosing intervals are necessary for treating renal failure patients with
aminoglycosides, flucytosine and vancomycin. No adjustments in dosage are necessary in the use of
amphotericin B, cefoperazone, chloramphenicol, cloxacillin, dicloxacillin, doxycycline, erythromycin,
isoniazid, metronidazole, minocycline, nafcillin and rifampicin. For other antibiotics minor to moderate
adjustments are necessary.
The most satisfactory way to use drugs in children with decreased renal function is by monitoring the
antibiotic concentrations in serum. The customary initial loading dose is given. Initially, until antibiotic
assay results are available, one makes estimates of appropriate dosage based on past experience of rates
of excretion related to the degree of renal failure. Three or four serum specimens are collected at
intervals over a 12-48 hour period (depending on the drug and the degree of renal failure). The serum
half-life is estimated. The interval dosing is every three half-lives for patients with moderate renal
dysfunction and every two half-lives for those with severe renal failure; subsequent dosages are twothirds or one-half respectively of the initial loading dose.
Patients undergoing dialysis need additional doses after the procedure if a substantial amount of drug is
removed by dialysis.
With peritoneal dialysis <10% of drug is removed in the case of most antibiotics. The exceptions are
aminoglycosides (20-25%), cefuroxime (20%), vancomycin (15-20%).
Clinically significant amounts of most drugs are removed by haemodialysis.
Removed by
Beta-lactams
Other drugs
haemodialysis
> 50%
Most cephalosporins (only 20- 30%
Aciclovir, aminoglycosides,
with cefaclor, moxalactam) imipenem
flucytosine, isoniazid,
spectinomycin, sulfonamides,
trimethoprim
20 50%
Most penicillins (see exceptions
Ethambutol, metronidazole,
below), aztreonam
vancomycin
<10%
Cloxacillin, dicloxacillin, methicillin,
Amphotericin B, fluoroquinolones,
nafcillin, oxacillin
macrolides, miconazole,
polymyxins, tetracyclines
16.1
Antibacterial
Amoxicillin (PO)
Co-amoxiclav
Azithromycin (PO)
Aztreonam
Renal Dosing
>30: no change
10-30: q8-12h
<10: q24h
>30/ no change || 10-30/ 250-500mg q12h ||
<10/ 250-500mg po q24h
No adjustment in renal failure
>30/ no change || 10-30/ 50% of usual dose

q6-8h || <10/ 25% of usual dose q6-8h ||
HD/PD: see <10 guidelines. (HD: 500mg
AD) Give loading dose of 1-2g before
Appendices - Antibiotic Therapy in Renal Failure
Haemodialysis
Dose as for CrCl<10, on
dialysis days dose AD
250/125- 500/125mg
q24h, on dialysis days
dose AD
No adjustment
1-2g x 1, then 25% of
usual dose at same
interval (e.g. , 0.5 q612h)
37
starting regimens above.

Co-trimoxazole
>30/ no change || 15-30/ 50% of usual dose
q12h-alternatively: 8-10mg/kg/day divided
q12h x 1-2 days, then 4-6mg/kg q24h. || <15/
not recommended .Alternatively: 810mg/kg/dose q48h or 4-6 mg/kg/day.
Cefepime
Cefoxitin
Cefotaxime
Cefuroxime sodium
Cefuroxime axetil
Ceftriaxone IV
Ceftazidime
Cefalexin
Chloramphenicol
(IV or PO)
Ciprofloxacin
Clarithromycin
Clindamycin (IV/PO)
Doxycycline
>60/ 0.5-2g q12h || 30-60/ 0.5g-2g q24h || 1129/ 0.5g-1g q24h || <10/ 250-500mg q24h or
0.5-2g q48h. || HD: 1g AD || PD: 1-2 grams
q48h
10-50/ q8-12h || <10/ q24-48h || HD: give 1g
after Dialysis: e.g. Give Cefoxitin 1g ivpb
M-W-F after dialysis + a supplemental dose
on Sunday.
>50/ Usual dose || 10-50/ q8-12h || <10/ q24h
|| HD: 0.5 to 2g ivpb q24h AD. || PD: 1g ivpb
q24h.
>20/q8h || 10-20/ q12h || <10/ 750mg q24h. ||
Hemodialysis: Give single dose after dialysis
or give 750mg q12h. || PD: 750mg-1.5g q24h
>30: no change
10-29: 250-500mg q12-24h
<10: 250mg q24h
No dosage adjustments req'd in renal failure.
PD: 750mg ivpb q12h
for serious infxn: may

supplement 250 mg AD)
PO: Avoid if possible.
If unavoidable, give
480mg q24h.
On dialysis days dose AD
IV: Avoid if possible.
If unavoidable, give
5mg/kg q24h.
On dialysis days dose AD
Dose as for CrCl<10
q24h, on dialysis day
dose AD
Dose as for CrCl<10,
supplement 1g AD
Dose as for CrCl <10,
supplement 1g AD
Dose as for CrCl<10,
supplement 750mg AD
No adjustment, on
No adjustment, on
dialysis days give AD
Crcl 30-50/ q12h || 10-30/ q24h || <10/ q48h dialysis days supplement
1g AD
Keflex: 10-50/ q6-12h || <10/ q12-24h .
Velosef: >20/ no change || 5-20/ 250mg q6h || dialysis days dose AD
< 5/ 250mg q12h
No dosage adjustment in renal failure
No adjustment
(If both hepatic dysfx and significant renal
disease, limit dose to 2g/day)
>50/ no change || 10-50/ 50-75% of usual
- 200mg q12h OR
dose q12h || <10/50% of usual dose q12.
- 200-400mg q24h
Alternatives: [200mg ivpb or 250mg po
(on dialysis days dose
q12h] or [400 mg ivpb or 500mg po q24h]. || AD)
HD/PD: 250-500mg po or 200-400mg ivpb
q24h AD or 200mg ivpb or 250mg po q12h.
Severe renal dysfunction: decrease dose or
increase interval. [crcl < 30 ml/min: 500mg
loading dose, then 250 mg once or twice
daily.]
No dosage adjustments required for renal
No adjustment
failure
No dosage adjustments required for renal
No adjustment
failure

38
Erythromycin
Imipenem/cilastatin
Levofloxacin
Meropenem
>10/ No change || <10/ 50-75% of usual

dose. Max 2 grams/day. || Hemo: no
supplement.
31-70/ 500mg q6-8h || 21-30/ 500mg q8-12h
max || 0-20/ 250-500mg q12h max. || HD:
250 mg AD + q12h. || PD: max dose=
1gram/day i.e. 500mg ivpb q12h.
>50/ no change || 20-49/ 500mg x 1 then
250mg q24h || <19/HD/PD: 500mg x 1 then
250mg q48h
>50: no change
26-50: 1g q12h
10-25: 500mg q12h
<10: 500mg q24h
Metronidazole
> 10/ no change || <10/ 500mg ivpb q12h.
Nitrofurantoin
Norfloxacin
Penicillin G
Penicillin V
Rifampicin
Tetracycline
Trimethoprim
Dose as for CrCl

<10ml/min
125 250mg q12h, on
500mg x1, then 250mg
q48h, on dialysis days
dose AD
0.5g q24h, on dialysis
days dose AD
Dose as for CrCl
<10ml/min, on dialysis
days dose AD
Insufficient data
50: usual dose

<50: avoid usage
50: no change
No adjustment
10-50: q 12-24h
<10: q24h
>50/ Usual dose || 10-50/ 75% of usual dose || Dose as for
<10/ 20-50% of usual dose. || Hemo/PD: 20- CrCl<10ml/min
50% of dose usually q6h. Max dose in
ESRD: 6 mu/day.
Dose as for CrCl <10
>10/ No Changes || <10/ 250-500mg po q8h ml/min, on dialysis days
dose AD
>40/ 3.375g q6h || 20-40/ 2.25g q6h || <20/
3 to 4 g q8-12h, on
2.25g q8h || HD: Max 2.25g q8h. 0.75g AD. dialysis days dose AD
|| PD: 2.25g q8h
10: no change
No data
<10: May give 1/2 usual dose
Same as for Crcl <10
50-90/ q8-12h || 10-50/ q12-24h || <10/ q24h ml/min
(use not recommended)
** Avoid if possible due to risk of liver
** Avoid if possible due
toxicity- use doxycyline instead at usual
to risk of liver toxicitydoses
use doxycyline instead at
usual doses
30: no change
100mg q24h, on dialysis
days dose AD
<30: 100mg q24h

39
16.2
Antifungal
Amphotericin B
Fluconazole
Itraconazole
16.3
Renal Dosing
Haemodialysis
MD: Initially give 0.25-0.3 mg/kg/day. Increase as tolerated by an
equivalent amount qd. Usual daily dose: 0.5-1 mg/kg/day or up to 1.5
mg/kg qd. For life-threatening infection may give full dose the first day
(usually 0.6-0.7 mg/kg IBW on Day # 1). During therapy if the BUN
increases above 40 mg/dl or the serum creatinine exceeds 2.5-3 mg/dl,
Hold Ampho B until renal function improves, then restart at a reduced
dose or change to QOD dosing until Serum creatinine/BUN improve.
Bladder irrigation: Add 30-50mg Ampho B to 1000ml (or less) sterile
water administered intermittently or continuously for 2 to 14 days.
>50/ no change || <50 / 50% of usual dose. || Same as for Crcl=10
Alternatively: 20 to 50/ give normal dose
ml/min, on dialysis days
q48h. || <20 / 50% of usual dose q48h. ||
give dose AD
Hemodialysis: give 100-200mg after each
dialysis. || CAPD: give 50% of usual dose at
usual interval.
No adjustments necessary in renal
Insufficient data
insufficiency. Duration of therapy: Oral
candidosis, Tinea Corporis, and Tinea Cruris:
15 days. Tinea Pedis: 30 days. Tinea Capitis:
4-8 weeks.[100mg CAPSULESule; 10
mg/mL oral soln]
Antiviral
Renal Dosing
Haemodialysis
50 - 90/ 5 to 12.4 mg/kg q8h || 10-50 / 5-12.4 Dose as for
mg/kg q12-24h || <10 / 2.5 to 6 mg/kg q24h. CrCl<10ml/min, on
Alternatively: (Oral): 10-25 / dose q8h || <10 dialysis days dose AD
/ dose q12h. IV: 25-50/ 5-10mg/kg q12h ||
10-25/ 5-10mg/kg q24h || <10/ 2.5 to 5mg/kg
IV q24h. || HD: dose after dialysis || CAPD:
see < 10.
Amantadine
50-60/ 200mg alternating c 100mg po qd ||
200mg q7 days
30-50/ 100mg qd || 20-30/ 200mg twice
weekly || 10-20/ 100mg 3x/week || <10/ 200
mg alternating c 100mg q7 days. || HD/PD:
No supplemental dose req'd.
*AD= after dialysis,, CrCl= creatinine clearance, Fx= function, HD= hemodialysis, MD= maintenance
dose, Tx= treatment
Aciclovir

40
17
Antimicrobial Therapy During Pregnancy and Lactation
A number of factors determine the degree of transfer of antibiotics across the placenta: lipid solubility,
degree of ionization, molecular weight, protein binding, placental maturation, and placental and foetal
blood flow. During the latter part of pregnancy maternal serum concentrations of most antibiotics
decrease because of the increased volume of distribution. Foetal serum concentration of the following
drugs are equal to, or only slightly less than, those in the mother: penicillin G, amoxicillin, cotrimoxazole, tetracyclines, nitrofurantoin and chloramphenicol. The aminoglycoside concentrations in
foetal serum are from 20% to 50% of those in maternal serum. Cephalosporins, clindamycin and
colistimethate penetrate poorly (10-15%) and foetal concentrations of erythromycin and flucloxacillin
are less than 10% of those in the mother.
Some drugs can cause harm to the pregnant woman or foetus. Drugs that are contraindicated are:
ribavirin, amantadine, ciprofloxacin, norfloxacin, erythromycin estolate, griseofulvin, nalidixic acid,
tetracyclines, and primaquine. Drugs that are considered safe are: penicillins, aztreonam,
cephalosporins, erythromycin base, nystatin, chloroquine, niclosamide, paromomycin, permethrin,
praziquantel, pyrantel pamoate and pyrethrins. Drugs not listed should be used with caution for firm
clinical indications.
Concentrations of antibiotics in human breast milk are not well studied. Isoniazid, metronidazole, and
co-trimoxazole occur in equal concentrations in maternal serum and milk. Tetracyclines,
chloramphenicol and erythromycin are found in breast milk in concentrations 50% to 75% of those in
serum. Breast milk concentrations of penicillin G and V, aminoglycosides, nalidixic acid, various
cephalosporins, and nitrofurantoin have been reported to be less than 25% of the maternal serum
concentrations. Because these are microgram amounts they would not be ingested by the infant in
therapeutic amounts.
For example, if an infant took 110cc/kg body weight of breast milk containing 10 mcg/mL isoniazid in a
day, this would amount to a dose of 1.1 mg/kg/day. The same infant ingesting milk containing 10
mg/dl of sulfonamide would receive 11 mg/kg/day. Similarly, with a penicillin V concentration of 0.1
mcg/mL in breast milk the amount of penicillin taken by the infant would be only 0.011 mg/kg/day.
The American Association of Pediatrics Committee on Drugs recommends that breast-feeding be
discontinued 12-24 hours before treating a nursing mother with metronidazole. Other antibiotics are
usually compatible with breast-feeding but the Committee warns about the possibility of inducing
haemolysis in babies with G-6-PD deficiency by nalidixic acid, nitrofurantoin or sulfa drugs. Urinary
retention, vomiting and rash have been attributed to amantadine in breast milk.
17.1
FDA Category Interpretation
A CONTROLLED STUDIES SHOW NO RISK. Adequate, well-controlled studies in pregnant

women have failed to demonstrate a risk to the foetus in any trimester of pregnancy.
B NO EVIDENCE OF RISK IN HUMANS. Adequate, well-controlled studies in pregnant women
have not shown increased risk of foetal abnormalities despite adverse findings in animals, or, in the
absence of adequate human studies, animal studies show no foetal risk. The chance of foetal harm is
remote, but remains a possibility.
C RISK CANNOT BE RULED OUT. Adequate, well-controlled human studies are lacking, and
animal studies have shown a risk to the foetus or are lacking as well. There is a chance of foetal harm
if the drug is administered during pregnancy, but the potential benefits may outweigh the potential
risks.
D POSITIVE EVIDENCE OF RISK. Studies in humans, or investigational or post-marketing data,
have demonstrated foetal risk. Nevertheless, potential benefits from the use of the drug may outweigh
the potential risk. For example, the drug may be acceptable, if needed in a life-threatening situation or
serious disease, for which safer drugs cannot be used or are ineffective.
X CONTRAINDICATED IN PREGNANCY. Studies in animals or humans, or investigational or
post-marketing reports, have demonstrated positive evidence of foetal abnormalities or risks which
clearly outweighs any possible benefit to the patient.
Appendices - Antibiotic Therapy During Pregnancy and Lactation
41
Drug
Aciclovir
Category
B
Amantadine
Amikacin
Aminoglycosides
Amoxicillin
Amphotericin B
Azithromycin
Aztreonam
Cefalexin
B
B
B
B
B
Cefuroxime
Cephalosporins
Chloramphenicol
B
C
Ciprofloxacin
Clarithromycin
C
C
Clindamycin
Clotrimazole
Co-amoxiclav
Co-trimoxazole
Didanosine
B
B
C
B
Doxycycline
Efavirenz
Erythromycin
Ethambutol
Flucloxacillin
B
B
B
Breast Feeding
Compatible. Concentrated in
human milk
The manufacturer reports
amantadine is excreted in
human
milk,
and
recommends the drug not be
used in nursing mothers
Compatible. Excretion into
milk
negligible.
Oral
absorption is poor.
Compatible.
Compatible.
No data
Compatible.
Compatible.
Excreted
into
milk.
Compatible.
Excreted
into
milk.
Compatible.
Compatible.
The American Academy of
Pediatrics has classified
chloramphenicol as a drug
"for which the effect on
nursing infants is unknown
but may be of concern"
Compatible
Excreted into human breast
milk
Compatible
Compatible.
Compatible
Breast
feeding
contraindicated
in
infection
Compatible
Breast
feeding
contraindicated
in
infection
Compatible
Compatible
Excreted
Compatible.
into
Neonatal side-effects
None Reported
Potential release of levodopa,
urinary retention, vomiting,
and rash after breast-feeding.
Potentiation of MgSO4induced
neuromuscular
blockade
postpartum.
Diarrhoea
after
breast
feeding.
Possible diarrhoea
No data
No data
No data
Potential for diarrhoea
Diarrhoea
Gray
Syndrome,
marrow suppression
bone
None Reported
One case of GI bleeding
reported
Diarrhoea
is
HIV
Manufacturer advises use

only if potential benefit
outweighs risk no
information available
is
HIV
Toxicity in animal studies;

manufacturer advises use
outweighs risk and no
alternative options available
Possible diarrhoea
milk.

42
Fluconazole
Gentamicin
C
C
Compatible
Compatible
Imipenem/
cilastatin
Excreted in milk. Manufacturer

recommends
avoidance
Indinavir
Isoniazid
Breast
feeding
contraindicated
in
infection
Lamivudine
Levofloxacin
Mebendazole
Meropenem
C
C
Metronidazole
Miconazole
Nalidixic acid
B
B
Nevirapine
Compatible. Mother should

be on pyridoxine.
Breast
feeding
is
contraindicated
in
HIV
infection
Based upon data from
ofloxacin, it can be presumed
that levofloxacin will be
excreted in human milk.
Compatible
The American Academy of

Pediatrics has classified
metronidazole as a drug "for
which the effect on nursing
infants is unknown but may
be of concern". Discontinue
breast feeding for 12-24 h to
allow excretion of drug.
Compatible
Breast
feeding
contraindicated
in
infection
Nitrofurantoin
Nystatin
Paromomycin
C
C
Pyrantel pamoate
Rifampicin
C
C
is
HIV
is
HIV
Excreted into breast milk.

Compatible
Compatible
Compatible
with
breast
feeding. Because this drug is
poorly absorbed orally high
concentrations in breast milk
would not be expected
None reported
Diarrhoea, bloody stools
reported
Manufacturer advises to
avoid unless potential benefit
outweighs risk (toxicity in
animal studies)
Toxicity in animal studies;
manufacturer advises use
outweighs risk; theoretical
risk of hyperbilirubinaemia
and renal stones in neonate if
used at term
Rash, diarrhoea, constipation
Manufacturer advises avoid
during first trimester no
Contraindicated
Potential for arthropathy

outweighs risk no
Diarrhoea
Haemolysis
in
G6PDdeficiency
Although
manufacturers
advise to avoid, may be
appropriate to use if clearly
indicated
Haemolysis
in
G6PDdeficiency
None reported
None reported
Compatible

43
Ritonavir
Breast
feeding
contraindicated
in
infection
Saquinavir
Breast
feeding
is
contraindicated
in
HIV
infection
Breast
feeding
is
contraindicated
in
HIV
infection
Compatible
outweighs risk
Negligible absorption by
infant. Compatible
Stavudine
Sulbactam
Teicoplanin
Tetracyclines
Tobramycin
Trimethoprim
Vancomycin
Zidovudine
C
C
is
HIV

outweighs risk no
outweighs risk
outweighs risk
Diarrhoea
Teratogenic risk (folate
antagonist); manufacturers
advise to avoid
Poor absorption from GIT
Breast
feeding
is
contraindicated
in
HIV
infection

44
18
Food Antibiotic Interactions
18.1 Antibiotics to take with food

18.1.1 Food may reduce gastrointestinal upset
Co-amoxiclav
Chloroquine
Erythromycin
Ethambutol
Ethionamide
Hydroxychloroquine
Ketoconazole
Metronidazole
Nalidixic Acid
Niclosamide
Praziquantel
Primaquine
Pyrimethamine
Quinine
Sulfasalazine
18.1.2 Food increases absorption or bioavailability

Atovaquone
Cefuroxime axetil
Clofazimine
Griseofulvin (take with fatty meal)
Itraconazole
Mebendazole (Chew or crush tablet)
Mefloquine (with food and a full glass of water)
Nitrofurantoin
18.2 Antibiotics to take on an empty stomach

18.2.1 Food decreases or delays absorption
Azithromycin
Chloramphenicol
Ciprofloxacin
Flucloxacillin
Didanosine
Isoniazid (may take with food if GI upset occurs)
Norfloxacin
Penicillin G
Piperazine
Rifampin (may require Vitamin D Supplementation)
Sulfonamides (with a full glass of water)
Tetracycline (no food or milk within 3 hours)
Zidovudine (may take with food other than fatty meal)
Appendices - Food-Antibiotic Interactions
45
19
Guidelines for Therapeutic Drug Monitoring in adults
Drug
Gentamicin
Vancomycin IV
Time to Sampling Time

Steady
State
1 day
Twice daily regimen:- Sample
after 3rd dose then every 5 days
if renal function stable. Sample
48 hours after a change in dose.
Trough- Immediately pre-dose
Peak- 1 hour after end of
administration
Once daily regimen:- sample
after 6-14 hours then after every
third dose.
1 day
Sample after 24 hours of
therapy or any change in dose
Target
range
Comments
Trough<2mg/L
Peak- 510mg/L
Check more frequently in

impaired renal function.
Daily monitoring indicated if
blood urea >6mmol/L or
Creatinine > 100mol/L
Refer to Hartford Nomogram

Check more frequently in
Trough<5-10mg/L impaired renal function.
Peak- 5-2030mg/L (not
routinely
measured)
20
Guidelines for IV to Oral Conversions
Indications in which a change in route of administration is appropriate include:

Urinary Tract Infections
Hospital-Acquired Pneumonia
Intra-Abdominal Infections
Gram-Negative Septicaemia
Sepsis of Unknown Aetiology
Consider IV to oral switch when patient satisfies the following criteria:
Temperature < 38oC for 48 hours
Clinically improved and there are no longer indications for IV therapy
Oral fluids/food tolerated and oral absorption of antibiotics is not poor
Suitable oral alternative available
Drug
IV
Oral
Comments
Aciclovir
Depends on indication
Amoxicillin
500mg 3 x daily
250-500500mg 3 x daily
Benzylpenicillin
1g 3 x daily
300-600mg 4 x daily
1.2g 4-6 x daily
Ceftriaxone
Ceftazidime
Cefotaxime
500mg 3 x daily
Penicillin V 500mg 4 x
daily
Not applicable in
severe infections,
meningococcal or
gonococcal infections.
Penicillin V 750mg 4 x
daily
1g daily
Ciprofloxacin 250mg twice However, check
daily
sensitivities first as
ciprofloxacin might
2g daily
Ciprofloxacin 250mg twice not be the most
daily
suitable agent.
Check sensitivities for alternative agent
As for ceftriaxone
Appendices - Therapeutic Drug Monitoring, IV to Oral Conversions and Aminoglycoside Dosing

46
Cefuroxime
Ciprofloxacin
750mg 3-4 x daily
250mg twice daily
1.5g 3-4 x daily
500mg twice daily
100-200mg twice daily 250mg twice daily

400mg twice daily
500mg twice daily
Clarithromycin
Clindamycin
Co-amoxiclav
Flucloxacillin
500mg twice daily

600mg 4 x daily
600mg 3 x daily
250mg twice daily

300-450mg 4 x daily
375mg 3 x daily
1.2g 3 x daily
625mg 3 x daily
Fluconazole
Metronidazole
1g 4 x daily
500mg 4 x daily
2g 4 x daily
1g 4 x daily
Use same dose for either route
500mg 3 x daily
400mg 3 x daily
Teicoplanin

21
IV formulation is the
sodium salt whereas
the oral formulation is
the axetil salt.
In the absence of any
problems with
absorption, the oral
route can be started,
even if patient is still
pyrexial.
Co-amoxiclav 625mg
is not available on the
formulary. Dose can
be achieved by
combining 1 tab/cap:
co-amoxiclav 375mg +
amoxicillin 250mg.
The oral dose can also

substitute 1g pr 3 x
daily.
Gentamicin / Tobramycin Dosing Guidelines
Aminoglycosides (Ags) are characterised by their rapid bactericidal action, clinical efficacy, and
generally low resistance rates; thus, they serve as an essential class of antimicrobial agents for the
treatment of serious systemic infections. These agents also exhibit synergistic effects when used with
beta-lactams (penicillins, cephalosporins). However, toxicity remains a limiting factor to using Ags;
nephrotoxicity and ototoxicity are the most common adverse reactions.

47
Over the past two decades, research has focused on maximising the efficacy of Ags while minimising
toxicity. Key areas of research salient to less frequent Ag dosing have included:
1) Mechanism of Nephrotoxicity:
Renal cortical uptake of Ags is saturable. Once daily dosing (ODD) is thought to reduce uptake,
and thus decrease toxicity. As a result, in vivo animal-model studies have been conducted using
single daily doses of Ags to assess the nephrotoxicity of this dosing regimen.
2) Concentration-Dependent Bactericidal Activity:
Ags possess a concentration-dependent killing action; the higher the concentration above the
minimum inhibitory concentration (MIC) of the organism, the better the killing or bactericidal rate.
Several studies have been conducted that have established that once daily administration of Ags
can be as effective as twice or three-times daily dosage regimens.
3) Post-antibiotic Effect of Ags:
These drugs maintain a post-antibiotic effect after the drug concentration falls below the MIC. This
effect has been tested both in vitro and in vivo, where it has been observed to last two to three
hours and two to eight hours, respectively. The post-antibiotic effect varies with the organism and
the peak concentrations achieved.
4) Adaptive Resistance of Ags:
In vitro studies have also demonstrated that some microorganisms can develop an adaptive
resistance to Ags when these drugs are present for sustained intervals. The mechanism of resistance
is thought to be due to down regulation of bacterial Ags uptake. This potential resistance problem
is thought to be reversed by allowing several hours for the organism to grow in a drug-free
environment; however, this phenomenon has not yet been tested in vivo.
When administered once daily, Ags will reduce renal cortical accumulation, which results in reduction in
tissue-concentration-dependent-nephrotoxicity. Higher peak levels obtained with the ODD regimen will
also ensure maximal bactericidal activity. ODD of Ags will produce lower trough concentrations which
might limit adaptive resistance. Since Ags exert a long post-antibiotic effect (2 or more hours), lower
troughs should not jeopardise their clinical efficacy.
21.1
Once daily dosing [ODD] guideline for gentamicin.
Initial dose
5 - 7 mg/kg gentamicin in 100mL glucose 5% or sodium chloride 0.9% administered by IV infusion over
1 hour. (Record time infusion was started)
Subsequent dose-plan
Repeat at 24 hour intervals unless the patient has impaired renal function (CrCl < 40mL/min) in which
case the dosing interval will vary according to the calculated CrCl.
Calculating Creatinine Clearance from serum creatinine (at stable serum creatinine)
(140-age) x wt(kg)
CrCl (ml/min) = -------------------------- x 1.23 (males) or 1.04 (females)
serum creatinine (mol/L)
Creatinine clearance (mL/min)

Dosing interval (hours)
60
24
40-59
36
20-39
48
<20
seek expert advice
48
Monitoring.
Take a single blood sample at any time 6 to 12 hours after the start of an IV infusion. Interpret as per the
nomogram below.
Where appropriate monitor the level twice weekly. NB It is essential that the time between
administration and taking the sample is recorded accurately and documented on the request form.
Monitoring gentamicin levels: The Hartford nomogram.
1.
If the level falls in the area designated Q24h, Q36h or Q48h, the dose interval should be 24, 36 or
48 hours respectively. If the result is on the line, choose the longer interval.
2.
If the result is off the nomogram, stop the scheduled therapy and obtain serial levels to determine
the appropriate time of the next dose (result < 2.0 mg/L).
Patient Selection Criteria

The use of ODD of aminoglycoside therapy is safe in patients with urinary tract, intra-abdominal,
pulmonary, or pelvic infections because of the availability of sufficient clinical data to demonstrate the
efficacy and safety of this dosing regimen.
Conditions in which the volume of distribution is altered significantly may not be optimal for the use of
ODD of AG. Such conditions include: ascites, cystic fibrosis, burns of greater than 20% of total body
surface area, pregnancy, and end stage renal disease.
Other conditions in which ODD is not recommended include:
Endocarditis and Paediatrics.

49
21.2
Twice daily dosing guideline for gentamicin.
Recommended initial dose:

1. determine CrCl either by urine collection for 24 hours or
using the equation (provided serum creatinine stable)
(140-age) x wt(kg)
CrCl (mL/min) = -------------------------- x 1.23 (males) or 1.04 (females)
- if creatinine is <60mol/L use 60mol/L

- if patient is obese use Ideal Body Weight:
IBW (kg): Males 50kg + 2.3kg for every inch over 5 feet
Females 45.5kg + 2.3kg for every inch over 5 feet
2. Determine initial dose from table below
3. If CrCl<20mL/min give 2.5mg/kg then take a sample after 24 hours.
Dosing Recommendations mg(interval in hours)
CrCl (mL/min)
Wieght (kg)
40-49
50-59
60-69
70-79
20-29
100(24)
100(24)
100(24)
160(48)
30-39
120(24)
120(24)
140(24)
140(24)
40-49
120(24)
140(24)
140(24)
160(24)
50-59
100(12)
140(24)
160(24)
180(24)
60-69
120(12)
140(12)
140(12)
180(24)
70-79
140(12)
140(12)
160(12)
180(24)
80-89
140(12)
160(12)
160(12)
160(12)
90-99
160(12)
160(12)
180(12)
180(12)
>100
160(12)
180(12)
200(12)
200(12)
These recommended initial doses are designed to achieve:
Peak concentrations of 7-10mg/L
Trough concentrations of <2mg/L
(Not for Endocarditis - Seek Expert Advice)
Sampling Guidelines
Check Peak (1 hour post dose) and trough (immediately pre-dose)
Record EXACT times of all doses and samples.
>79
180(48)
160(24)
180(24)
180(24)
180(24)
200(24)
180(12)
180(12)
200(12)

50
22
Vancomycin Dosing Guidelines
Recommended initial dose:

1. determine CrCl either by urine collection for 24 hours or
using the equation (provided serum creatinine stable)
(140-age) x wt(kg)
CrCl (ml/min) = -------------------------- x 1.23 (males) or 1.04 (females)
- if creatinine is <60mol/L use 60mol/L

- if patient is obese use Ideal Body Weight:
IBW (kg): Males 50kg + 2.3kg for every inch over 5 feet
Females 45.5kg + 2.3kg for every inch over 5 feet
2. Determine initial dose from table below
3. If CrCl <20mL/min give 20mg/kg then take a sample after 24 hours.
4. Vancomycin must be administered by infusion at a concentration <5mg/mL. The rate of infusion must
NOT be >10mg/min. (1g over 100-120 minutes).
Vancomycin Dosing Guidelines dose in mg[interval in hours]
CrCl (mL/min)
<60kg
>60kg
20-29
1000[48]
1000[48]
30-49
750[24]
750[24]
50-59
1000[24]
1000[24]
60-69
500[12]
1000[24]
70-79
750[12]
750[12]
80-100
750[12]
1000[12]
>100
1250[12]
1250[12]
These recommendations for initial doses are designed to achieve through levels of 5-10mg/L
Sampling Guidelines
Check trough (immediately pre-dose) after 24-72 hours of therapy
Record EXACT times of all doses and samples.
Peak concentrations are not routinely measured.
23
Methods for Penicillin Desensitisation
Perform in ITU setting. Dtop all -adrenergic agents. Have IV lineECG and spirometer. Once
desensitised prescription must not lapse as risk of allregic reactions increases. A history of StevensJohnson syndrome, exfoliative dermatitis, erythroderma are nearly absolute contra-indications to
desensitisation.
Oral Route: If oral route available and patient has functional GIT this route is preferred. 1/3 patients
will develop a transient reaction during desensitisation or treatment. This is usually mild.
Step
1
2
3
4
5
6
7
8
9
10 11 12 13 14
Drug (mg/mL)
0.5 0.5 0.5 0.5 0.5 0.5 0.5 5.0 5.0 5.0 50 50 50 50
Amount (mL)
0.1 0.2 0.4 0.8 1.6 3.2 6.4 1.2 2.4 4.8 1.0 2.0 4.0 8.0
Interval between doses 15 minutes. After step 14 observe 30 minutes then 1g IV.
IV Route:
Step
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17
Drug (mg/mL)
0.1 0.1 0.1 0.1 1.0 1.0 1.0 10 10 10 100 100 100 100 1000 1000 1000
Amount (mL)
0.1 0.2 0.4 0.8 0.16 0.32 0.64 0.12 0.24 0.48 0.1 0.2 0.4 0.8 0.16 0.32 0.64
Interval between doses 15 minutes. After step 17 observe 30 minutes then 1g IV.
Appendices - Vancomycin Dosing & Penicillin Desensitisation

51
24
NOTES ON THE COLLECTION AND TRANSMISSION OF

SAMPLES (TO THE MICROBIOLOGY LABORATORY)
Please feel free to contact the laboratory and ask for advice in case of doubt or when dealing with
unusual samples or infections. Please make sure that specimens are correctly labelled and the
appropriate request forms are filled in completely and legibly. Avoid using in-house abbreviations.
Always make a note of any antibiotic that the patient would have been on or is due to be started
at the time of specimen collection.
BLOOD CULTURES:
Cultures should be taken prior to starting antibiotic therapy. Strict aseptic precautions should be
adopted. The following technique is recommended:
1.
Swab the rubber liners with an alcoholic tincture of iodine.
2.
Clean the antecubital fossa with chlorhexidine in alcohol. Prior to venepuncture, apply a 30
second 70% (isopropyl) alcohol scrub to the skin surface.
3.
Dry the skin with sterile gauze.
4.
Apply tincture of iodine to the part by means of sterile swabs. Start centrally over the planned site
of venepuncture and, exerting moderate pressure, move outwards in concentric circles. One can use
either 1% to 2% tincture of inorganic iodine in alcohol for 30 seconds or 10% povidone iodine in
alcohol for 60 seconds. Please note that these time periods are essential, both for mechanical
cleansing and the contact time required for the disinfectant to inactivate the skin flora.
5.
Allow to dry, waiting for at least one minute.
6.
Scrub hands well. Wearing cap, mask, sterile gown and gloves, withdraw 10 to 20ml of blood
aseptically using a disposable syringe (children 1 to 5 ml).
7.
Change the needle and inoculate the appropriate volume of blood in each bottle. This should
include at least one aerobic and one anaerobic bottle, respectively.
8.
Holding the bottles upright, submit immediately to the laboratory.
CATHETERS:
Central catheters: Culture of venous or arterial catheters (CVC) should be done only when catheterrelated blood stream infection is suspected. Quantitative or semi-quantitative cultures of catheters are
recommended. When culturing a CVC segment, either the catheter tip or a subcutaneous segment
should be submitted for culture. For suspected pulmonary artery infection, culture of the introducer tip
should be done because it provides a higher yield, in comparison with the pulmonary artery catheter tip.
Two sets of blood samples for culture, with at least 1 drawn percutaneously, should be obtained from all
patients with a new episode of suspected CVC-related blood stream infection. Paired quantitative blood
cultures with a continuously monitored differential time to positivity are recommended for the diagnosis
of catheter-related infection, especially when the long-term catheter cannot be removed.
Peripheral venous catheters: If there is suspicion of short-term peripheral catheter infection, the
catheter should be removed; the tip should be cultured by using a semi-quantitative method, and 2
separate blood samples should be obtained for culture before starting antibiotic therapy.
If there are signs of local infection, any exudates at the exit site should be submitted for Gram-stain and
culture.
Appendices - Specimen Collection
52
CEREBROSPINAL FLUID:
Collect CSF in a sterile disposable screw-capped universal container or in a sterile disposable MSU
bottle. Cotton-wool plugged test-tubes are unsatisfactory and should be avoided. Bloodstained
specimens are unsuitable for microscopy.
Since low temperatures are lethal to such important pathogens as the meningococcus and Haemophilus,
submit immediately to the laboratory. If delay is unavoidable, such samples should be sent to the
Emergency Laboratory for storage at 37C. Never store a CSF sample in a refrigerator.
FAECES SAMPLES:
Culture: Specimens of faeces should be collected in a disposable universal container with a fitted
spoon; if delay is unavoidable store the sample in a fridge. Rectal swabs should be moist and visibly
soiled with faeces. They should arrive at the laboratory within a few hours of their being taken. If delay
is unavoidable, use Cary Blair transport medium. Remember that Shigella species are rapidly
overgrown and killed by acid-forming commensal bacteria. When cholera is suspected, this should be
clearly stated on the forms accompanying the specimen.
Parasites: If the patient is thought to be in the diarrhoeic stage of amoebic dysentery, the sample must
be sent to the laboratory as soon as the faeces have been passed; delay will seriously affect the
possibility of finding this important pathogen. For this purpose, rectal swabs are unsatisfactory;
specimens should be taken in clear wide-mouthed stool containers.
For ova and cyst analysis about 10g of faeces should be sent. Use clean, wide-mouthed containers with
a securely fitting lid. Duodenal aspirates for Giardia trophozoites must be collected in sterile,
disposable, screw-capped containers. These should be sent immediately to the laboratory after having
informed the staff about the request for this investigation.
Clostridium difficile colitis: A fresh stool specimen is needed. If delay is unavoidable the stool
specimen should be stored in a freezer (ideally at 20C).
GASTRIC JUICE FOR TUBERCLE BACILLI:
A nasogastric aspirate should be should be taken in a sterile universal container and sent to the
laboratory immediately it is taken. It is imperative that the date and time be written on these containers.
The laboratory should be informed the day before. The procedure must be carried out first thing in the
morning on a fasting patient.
PETECHIAL SCRAPINGS:
These are indicated in the laboratory diagnosis of meningococcal infection. Contact the laboratory for
information on the procedure that should be adopted to take the appropriate specimens for direct Gramstain and culture.
PLEURAL, ASCITIC AND SYNOVIAL FLUIDS:
20ml of the fluid should be collected in a McCartney bottle containing sterile sodium citrate as anticoagulant. The laboratory supplies these containers on request. Clotted specimens are unsuitable.
In case of requests for cultures for tubercle bacilli please use a heparin-containing sterile tube.
53
PUS:
The submission of actual pus in a sterile container is preferable especially for samples taken during
surgery. Swabs are, nevertheless, satisfactory if moist and visibly soiled with pus. Submit immediately
to the laboratory; if delay is inevitable, use charcoal transport medium. When microscopy or special
investigations (e.g. culture for tubercle bacillus) are required, 2ml or more of the pus should be sent in a
sterile disposable MSU bottle. When anaerobic infections are suspected, inform the laboratory prior to
taking specimens.
SCOTCH-TAPE PREPARATIONS:
For the diagnosis of threadworm infestation a scotch tape preparation should be submitted. Make sure
that the slides are clean, the tape is properly applied to the slide, that there are no creases in the tape, and
that no air bubbles are trapped between tape and slide. Faecal material on the tape interferes with the
visualisation of the ova.
SEROLOGY:
Blood Specimens for agglutinin titrations such as Brucella, VDRL, TPHA, etc should be sent in plain
blood-collecting tubes. Adopt a correct technique to avoid lysing the blood. Keep the bottles upright at
all times, otherwise leakage will occur or the blood clot will adhere to the cap.
Every effort should be made to avoid soiling the rim and the outside of the container with blood. Ensure
that the cap is secure and the specimen is fully and correctly labelled. As a general rule, 5ml of blood
are required for any of the above serological tests.
SPUTUM:
Sputum and not saliva should be sent. If the patient does not bring up sputum, the clinician who ordered
the test should be informed. Use clean, wide-mouthed containers of a pattern known not to leak. First
morning specimens should be collected and submitted immediately to the laboratory.
URINE:
Mid-stream specimens of urine should be passed directly in either disposable universal bottles or in
special wide-mouthed containers. In the case of women, the patient should be instructed to divaricate
the labia; cleaning of the ano-genital region before taking the specimen should be carried out using
water and bland soap (not disinfectant). Dabbing of the genital area with a freshly laundered towel
should follow. The residual moisture should be absorbed with clean tissue paper.
The procedure in males is similar. It is of utmost importance to retract the prepuce, whenever this is
possible.
In patients with chronic indwelling urethral catheters attached to closed drainage, urine is collected
for culture by disinfecting, with a suitable agent, the wall of the catheter at its junction with the drainage
tube, and puncturing it with a 21 gauge needle attached to a syringe, into which the urine is aspirated.
Specimens must be transported to the laboratory without delay. If a delay of more than half an hour is
unavoidable, keep at 4oC in a domestic type refrigerator.

54
Bag urines in infants are generally notoriously unreliable. However, appropriate sampling and
transportation can minimize contamination. Please contact the laboratory for further information.
Cultures of suprapubic aspirates of urine should be done by appointment and prior notification.
For the investigation of urinary tuberculosis three consecutive early-morning, mid-stream specimens
should be submitted in sterile, universal containers. Boric acid bottles are unsuitable for this purpose.
Each specimen should be stored at 4C prior to submission.
A fresh urine specimen should be sent for the detection of Legionella urinary antigen.
URETHRAL DISCHARGE:
Smears for microscopy should be thin and allowed to dry at room temperature and submitted in a
disposable Petri dish. If specimens are being sent for culture, use in addition Stuarts or Amies transport
medium and the special swabs supplied by the laboratory.
UTERINE CURETTINGS:
These should be sent in a sterile universal bottle containing 10ml of physiological saline.
VAGINAL DISCHARGES:
It is important that the samples should reach the laboratory as soon as possible after sampling. If for
some reason this is not practicable, the laboratory should be asked to provide Stuarts or Amies
transport medium.
For the collection of vaginal discharge a disposable Pasteur pipette fitted with a teat, a small amount of
sterile saline and a sterile universal container are issued. The fluid should be taken with the pipette from
the posterior fornix and placed in a universal container.
The pipette should be safely discarded after use. If the discharge is so thick that it cannot be drawn up
into the pipette, the sterile saline supplied should be used to make it less viscous. Avoid over-diluting
the specimen with saline.
For gonorrhoea investigations a cervical swab should be submitted. Use the special swabs supplied by
the laboratory and submit immediately or culture on site, in the case of the GUM clinic.
WHOOPING COUGH:
The classical cough plate is now considered to be unsatisfactory for the diagnosis of pertussis. The
specimen of choice is mucus from the posterior wall of the nasopharynx. This may be conveniently
collected by the pernasal route using special swabs supplied by the laboratory. Insert the pernasal swab
gently through the nose into the nasopharynx. Keep close to the septum and floor of the nose. Remove it
fairly quickly and insert it once more. Rotate and remove. The first swabbing stimulates local
secretions, which are then picked up when the swab is reinserted. Specimens must be submitted
immediately to the laboratory.

55
25
Costings of Antimicrobials
Item Description
Package
quantity
ACICLOVIR 200mg TABLETS
5
25
1000
ACICLOVIR 200mg/5mL SUSPENSION
1
ACICLOVIR 250mg INJECTIONS
1
5
10
35
500
ALBENDAZOLE 100mg SUSPENSION
20ml
ALBENDAZOLE 400mg TABLET
1
AMANTADINE 100mg CAPSULES OR TABLETS
14
20
56
AMIKACIN 500mg INJECTIONS
1
5
100
AMOXICILLIN 125mg/5mL SUSPENSION
100ml
AMOXICILLIN 250mg CAPSULES
500
AMOXICILLIN 250mg CAPSULES
1000
AMOXICILLIN 250mg INJECTION
10
AMOXICILLIN 3g SACHETS
2
AMOXICILLIN 3g SACHETS
14
AMOXICILLIN 500mg INJECTIONS
10
1
100
AMPHOTERICIN 100mg/mL SUSPENSION
12mL
AMPHOTERICIN 50mg INJECTIONS
1
AMPHOTERICIN LOZENGES 10mg
60
AZITHROMYCIN DIHYDRATE 200mg/5mL SUSPENSION
4
AZITHROMYCIN DIHYDRATE 250mg CAPSULES
4
AZITHROMYCIN DIHYDRATE 250mg CAPSULES
6
AZTREONAM 1g INJECTIONS
1
AZTREONAM 2g INJECTIONS
1
BENZATHINE PENICILLIN 1.2MU INJECTIONS
10
BENZATHINE PENICILLIN 1.2MU INJECTIONS
100
BENZYLPENCILLIN 600mg INJECTIONS
25
BENZYLPENCILLIN 600mg INJECTIONS
50
CEFALEXIN 125mg/5mL SUSPENSION
100ml
CEFALEXIN 125mg/5mL SUSPENSION
60ml
CEFALEXIN 250mg CAPSULES
100
1000
500
CEFEPIME DIHYDROCHLORIDE MONOHYDRATE 1G INJECTION 1
CEFOTAXIME SODIUM 1g INJECTIONS
50
CEFTAZIDIME 1g INJECTIONS
1
Unit Dose Price

Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
0.35
0.35
0.06
11.73
0.98
7.57
0.95
1.49
0.09
1.05
0.79
0.28
0.12
0.20
0.56
8.16
1.28
0.04
0.02
0.01
0.45
0.93
0.83
0.46
0.35
0.26
2.45
3.46
0.05
1.20
1.10
1.09
6.76
13.63
1.35
0.19
0.33
0.33
0.69
0.34
0.05
0.03
0.02
7.64
0.77
0.41
Appendices - Costings of Antimicrobials

56
CEFTRIAXONE 1g IM INJECTIONS
CEFTRIAXONE 1g IV INJECTIONS
CEFTRIAXONE 500mg IM INJECTIONS
CEFTRIAXONE 500mg IM INJECTIONS
CEFTRIAXONE 500mg IV INJECTIONS
CEFTRIAXONE 500mg IV INJECTIONS
CEFUROXIME AXETIL 250mg TABLETS
CEFUROXIME AXETIL SUSPENSION
CEFUROXIME SODIUM 250mg INJECTIONS
CEPHALOTINE SODIUM 1g INJECTION
CHLORAMPHENICOL 1g VIAL
CHLORAMPHENICOL 250mg TABLETS/CAPSULES
CHLORAMPHENICOL 250mg TABLETS/CAPSULES
CHLORAMPHENICOL SUSPENSION 125mg/5mL
CHLOROQUINE 40mg/mL INJECTIONS
CHLOROQUINE PHOSPHATE 250mg TABLETS
CHLOROQUINE PHOSPHATE 250mg TABLETS
CHLOROQUINE SULPHATE SUSPENSION50mg/5mL
CIPROFLOXACIN 100mg/50mL IV INJECTIONS
CIPROFLOXACIN 200mg/100mL IV INJECTIONS
CIPROFLOXACIN 250mg TABLETS
CIPROFLOXACIN 250mg TABLETS
CIPROFLOXACIN 250mg/5mL ORAL SUSPENSION
CLARITHROMYCIN 125mg/5mL SUSPENSION
CLARITHROMYCIN 250mg TABLETS
CLINDAMYCIN 150mg CAPSULES
CLINDAMYCIN 150mg CAPSULES
CLINDAMYCIN PHOSPHATE 150mg/mL INJECTIONS
CLINDAMYCIN PHOSPHATE 150mg/mL INJECTIONS
CLOFAZIMINE 100mg TABLETS
CO-AMOXICLAV 1.2g INJECTIONS
CO-AMOXICLAV 1.2g INJECTIONS
CO-AMOXICLAV 375mg TABLETS
CO-AMOXICLAV 600mg INJECTIONS
CO-AMOXICLAV SUSPENSION 156mg/5mL
COLISTIN SULPHATE 1.5MU TABLETS
COLISTIN SULPHOMETHATE SODIUM 0.5MU INJECTIONS
CO-TRIMOXAZOLE 480mg TABLETS
CO-TRIMOXAZOLE ADULT SUSPENSION
1
5
1
1
10
1
10
1
6
10
100mL
14
50
5
100
1
50
100
1
1
1
25
10
60
100
100ml
10
20
100
100ml
1
1
100
500
1
60mL
10
24
100
1
5
100
5
10
20
10
100mL
50
10
1000
100ml
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
1.39
8.98
1.59
14.03
1.29
4.29
1.30
1.44
0.32
0.42
3.14
0.54
0.48
0.79
0.63
0.60
0.67
0.58
22.74
1.66
1.05
1.16
0.48
0.30
0.03
5.28
2.72
0.51
0.03
2.79
3.57
0.58
0.04
0.08
16.62
4.26
0.39
0.10
0.07
1.84
3.76
0.52
1.21
1.09
0.09
0.82
0.82
1.16
0.98
0.01
2.14

57
CO-TRIMOXAZOLE INTRAVENEOUS INFUSION

CO-TRIMOXAZOLE INTRAVENEOUS INFUSION
CO-TRIMOXAZOLE PAEDIATRIC SUSPENSION
CYCLOSERINE 250mg TABLETS
DAPSONE 100mg TABLETS
DEMECLOCYCLINE HCL 150mg CAPSULES
DIDANOSINE 100mg TABLETS
DILOXANIDE FUROATE TABLETS
DILOXANIDE FUROATE TABLETS
DOXYCYCLINE 100mg CAPSULES
ERYTHROMYCIN 250mg TABLETS
ERYTHROMYCIN LACTOBIONATE 1g INJECTIONS
ERYTHROMYCIN LACTOBIONATE 1g INJECTIONS
ERYTHROMYCIN SUSPENSION 125mg/5mL
ERYTHROMYCIN SUSPENSION 125mg/5mL
ETHAMBUTOL 400mg TABLETS
ETHAMBUTOL 400mg TABLETS
ETHAMBUTOL HCl 100mg TABLETS
ETHAMBUTOL HCl 100mg TABLETS
FLUCLOXACILLIN 250mg INJECTIONS
FLUCLOXACILLIN 250mg CAPSULES
FLUCLOXACILLIN 250mg TABLETS
FLUCLOXACILLIN SUSPENSION 125mg/5mL
FLUCONAZOLE 150mg CAPSULES
FLUCONAZOLE 2mg/mL IN 100mL INJECTIONS
FLUCONAZOLE 2mg/mL - 25mL INJECTIONS
FLUCONAZOLE 50mg /5mL SUSPENSION
FLUCYTOSINE 2.5g INFUSION
FLUCYTOSINE 500mg TABLETS
FUSIDATE SODIUM 250mg TABLETS
FUSIDIC ACID ORAL SUSPENSION 250mg/5mL
GANCICLOVIR 500mg INJECTIONS
GENTAMICIN 80mg INJECTIONS
GRISEOFULVIN 125mg TABLETS
GRISEOFULVIN 125mg TABLETS
IMIPENEM 500mg + CILASTATIN INJECTIONS
INDINAVIR 400mg CAPSULES
ISONIAZID 100mg TABLETS
5
10
100ml
100
28
100
28
100
28
60
15
30
10
50
100
28
1000
1
10
100ml
140ml
56
1000
56
100
10
500
1000
100ml
1
200
500
1000
1
1
500
1000
1
1
100
100
90ml
1
5
25
100
100
1000
1
180
100
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
0.80
1.47
1.16
2.15
0.09
0.02
0.08
0.02
0.20
1.22
0.18
1.81
0.01
0.02
0.03
0.06
0.02
5.11
2.62
0.77
0.83
0.60
0.01
0.36
0.20
0.49
0.03
0.03
1.13
0.17
0.18
0.15
0.19
11.91
3.53
0.12
0.07
13.13
4.91
1.35
0.37
8.65
23.00
26.41
22.73
0.07
0.02
0.01
8.11
0.87
0.02

58
ISONIAZID 100mg TABLETS

ISONIAZID 50mg/2mL - 2mL AMPOULE I.M
ISONIAZID. RIFAMPICIN, PROTHIONAMIDE, DAPSONE
TABLETS
ITRACONAZOLE 100mg CAPSULES
ITRACONAZOLE 100mg CAPSULES
ITRACONAZOLE LIQUID
KETOCONAZOLE 200mg TABLETS
LAMIVUDINE 150mg TABLETS
LEVAMISOLE 59MG TABLETS
LEVAMISOLE 8mg/mL SUSPENSION
LEVAMISOLE HCL 40mg TABLETS
LINEZOLID 600mg TABLETS
LIPOSOMAL AMPHOTERICIN INFUSION 50mg
LIPOSOMAL AMPHOTERICIN INFUSION 50mg
MEBENDAZOLE 100mg TABLETS
MEBENDAZOLE 2% SUSPENSION
MEFLOQUINE 250mg TABLETS
MEPACRINE HCL 100mg TABLETS
MEROPENEM POWDER 1g INJECTIONS
MEROPENEM POWDER 500mg INJECTIONS
MEROPENEM POWDER 500mg INJECTIONS
METRONIDAZOLE 200mg TABLETS
METRONIDAZOLE 200mg TABLETS
METRONIDAZOLE 200mg/5mL SUSPENSION
METRONIDAZOLE 500mg INFUSION
METRONIDAZOLE 500mg, SUSPENSION
METRONIDAZOLE TABLETS 200mg
NALIDIXIC ACID 300mg/5mL SUSPENSION
NALIDIXIC ACID 300mg/5mL SUSPENSION
NALIDIXIC ACID 500mg TABLETS
NALIDIXIC ACID 500mg TABLETS
NEOMYCIN SULPHATE 500mg TABLETS
NETILMICIN 150mg/1.5mL INJECTIONS
NETILMICIN 50mg/mL INJECTIONS
NEVIRAPINE 200mg TABLETS
NEVIRAPINE 200mg TABLETS
NICLOSAMIDE 0.5g TABLETS
NITROFURANTOIN 25mg/5mL SUSPENSION
NITROFURANTOIN 25mg/5mL SUSPENSION - 300mL
NITROFURANTOIN 50mg TABLETS
NITROFURANTOIN 50mg TABLETS
NORFLOXACIIN 400mg TABLETS
NOXYTHIOLIN INJECTIONS
NYSTATIN 500,000IU TABLETS
1000
10
1000
Lm 0.02
Lm 2.65
Lm 0.06
15
60
1
10
30
100
60
20
15mL
3
10
1
10
6
30ml
6
100
10
10
1
100
1000
100ml
1
10
250
150ml
120ml
56
500
100
10
1
10
10
60
100
4
60ml
1
25
1000
14
100
500
10
50
Lm 0.72
Lm 1.06
Lm 41.61
Lm 0.93
Lm 0.43
Lm 0.10
Lm 1.43
Lm 0.58
Lm 0.79
Lm 0.24
Lm 287.60
Lm142.45
Lm 91.03
Lm 0.16
Lm 1.08
Lm 0.49
Lm 0.27
Lm 14.96
Lm 7.29
Lm 10.03
Lm 0.004
Lm 0.003
Lm 4.47
Lm 0.39
Lm 1.19
Lm 0.01
Lm 10.73
Lm 8.89
Lm 0.03
Lm 0.04
Lm 0.13
Lm 0.27
Lm 2.14
Lm 0.87
Lm 1.41
Lm 1.60
Lm 1.67
Lm 3.73
Lm 3.65
Lm 35.91
Lm 0.02
Lm 0.01
Lm 0.06
Lm 0.04
Lm 0.06
Lm 5.79
Lm 0.08

59
NYSTATIN SUSPENSION 100,000 IU/mL

NYSTATIN TABLETS 500,000 IU.
PAROMOMYCIN 250mg TABLETS
PENTAMIDINE ISETHIONATE 300mg INJECTIONS
PENTAMIDINE ISETHIONATE 300mg NEBULISER SOLUTION
PENTAMIDINE ISETHIONATE BP 300mg/5mL INJECTIONS
PHENOXYMETHYLPENCILLIN 250mg TABLETS
PHENOXYMETHYLPENCILLIN SUSPENSION 125mg/5mL
PIPERACILLIN/TAZOBACTAM 2.25g INJECTIONS
PIPERACILLIN/TAZOBACTAM 4.5g INJECTIONS
PIPERAZINE ELIXIR 750mg/5mL
PIPERAZINE ELIXIR 750mg/5mL
PRAZIQUANTEL 500mg TABLETS
PRIMAQUINE 7.5mg TABLETS
PROGUANIL HCL 100mg TABLETS
PROGUANIL HCL 100mg TABLETS
PROGUANIL HCL 100mg, ATOVAQUONE 250mg TABLETS
PROTHIONAMIDE 250mg TABLETS
PYRAZINAMIDE 500mg TABLETS
PYRIMETHAMINE 12.5mg & DAPSONE 100mg TABLETS
PYRIMETHAMINE 25mg TABLETS
PYRIMETHAMINE 25mg, SULPHADOXINE 500mg TABLETS
PYRIMETHAMINE 25mg, SULPHADOXINE 500mg TABLETS
QUININE DIHYDROCHLORIDE 300mg INJECTIONS
QUININE SULPHATE 300mg TABLETS
QUININE SULPHATE 300mg TABLETS
RIFAMPICIN 150mg TABLETS
RIFAMPICIN 150mg, ISONIAZID 100mg TABLETS
RIFAMPICIN 150mg, ISONIAZIDE 100mg TABLETS
RIFAMPICIN 300mg CAPSULES
RIFAMPICIN 300mg CAPSULES
RIFAMPICIN 600mg/10mL INJECTION
RIFAMPICIN SUSPENSION 100mg/5mL
RIFAMPICIN SUSPENSION 100mg/5mL
RIFAMPICIN, ISONIAZID, PYRAZINAMIDE TABLETS
RIFAMPICIN, ISONIAZID, PYRAZINAMIDE TABLETS
RITONAVIR 100mg CAPSULES
RITONAVIR 80mg/mL ORAL SOLUTION 90mL
ROXITHROMYCIN 150mg TABLETS
SAQUINAVIR 150mg CAPSULES
SAQUINAVIR 200mg CAPSULES
SODIUM FUSIDATE 500mg INJECTIONS
SODIUM FUSIDATE 500mg INJECTIONS
SODIUM STIBOGLUCONATE 10G INJECTIONS
30ml
56
12
5
1
1
1000
100ml
1
1
140ml
28ml
90
100
98
100
12
100
1000
60
100
30
1
10
3
10
500
1000
60
100
84
100
8
100
500
1000
30
100
1
120ml
60ml
60
100
84
1
10
270
180
1
10
1
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
1.13
0.07
0.30
24.71
26.74
26.74
0.01
0.79
4.31
8.48
2.40
0.30
3.61
0.85
0.06
0.04
1.83
1.28
0.03
0.06
0.06
0.17
19.31
0.40
0.52
2.18
0.04
0.03
0.10
0.10
0.11
0.15
0.44
0.06
0.06
0.01
0.26
0.29
4.68
3.44
1.08
0.11
0.30
0.77
55.27
0.32
0.99
0.79
5.44
0.37
33.32

60
SPECTINOMYCIN INJECTIONS
SPIRAMYCIN 0.75 MU - 6g SACHET
SPIRAMYCIN 3000000 I.U TABLETS
STAVUDINE 30mg CAPSULES
STREPTOMYCIN 1g INJECTION
STREPTOMYCIN SULPHATE 1g INJECTIONS
SULPHADIAZINE 250mg INJECTIONS
SULPHADIAZINE 500mg TABLETS
SULPHADIAZINE 500mg TABLETS
TEICOPLANIN 200mg INJECTIONS
TETRACYCLINE 250mg INJECTIONS
TETRACYCLINE 250mg CAPSULES
TETRACYCLINE 250mg TABLETS
TETRACYCLINE HCL 500mg INJECTIONS
THIABENDAZOLE 500mg TABLETS
TOBRAMYCIN 40mg/mL - 2ML INJECTIONS
TRIMETHOPRIM 100mg TABLETS
TRIMETHOPRIM 100mg TABLETS
TRIMETHOPRIM 100mg/5mL SUSPENSION
TRIMETHOPRIM 50mg IN 5mL SUSPENSION
VANCOMYCIN 125mg CAPSULES
VANCOMYCIN 500mg INJECTIONS
ZIDOVUDINE 100mg CAPSULES
ZIDOVUDINE 10mg/mL SUSPENSION
ZIDOVUDINE 200mg/20mL INJECTIONS
1
10
10
56
60
56
1
10
10
56
100
1
6
28
1000
6
6
1
5
5
28
100
5
100 mL
20
1
100
200ml
5
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
Lm
3.09
0.18
0.52
2.34
1.82
3.39
2.45
6.37
4.16
0.28
0.02
16.25
0.89
0.04
0.01
1.92
0.09
3.07
3.26
1.09
0.02
0.01
0.94
1.62
2.24
2.35
0.26
32.20
11.50

61
Bibliography
American Academy of Orthopaedic Surgeons and American Association of Orthopaedic

Surgeons, Antibiotic prophylaxis for urological patients with total joint replacements, December
2002; Document number; 1023.
American Heart Association, Prevention of bacterial endocarditis, Circulation 1997; 96: 358366, and JAMA 1997; 277: 1794-1801.
Antimicrobial prophylaxis in neurosurgery and after head injury. Infection in Neurosurgery
Working Party of the British Society for Antimicrobial Chemotherapy. Lancet 1994; 344: 1547-1551
Bartlett JG, Editor; The Johns Hopkins Antibiotic Guide The Johns Hopkins University
Division of Infectious Diseases http://hopkins-abxguide.org/ : 2003
Bartlett JG, et al, Practice Guidelines for the Management of Community-Acquired Pneumonia
in Adults CID 2000;31 (August). 347-82.
Beers MH, Berkow R, Editors; The Merck Manual of Diagnosis and Therapy, Edition 17,
(http://www.merck.com/mrkshared/mmanual/), Copyright 1999 Merck & Co., Inc., Whitehouse Station,
NJ.
Blasi F, et al, Treating hospital-acquired pneumonia, Hosp Pharm Europe [Winter] 2002: 31-33
Cavill I, Guidelines for the prevention and treatemnt of infection in patients with an absent or
dysfunctional spleen, BMJ (17 February) 1996;312:430-434.
Centers for Disease Control and Prevention - National Center for Infectious Diseases - Travellers
Health. Http://www.cdc.gov/travel/diseases.htm
Davies CWH, et al, BTS guidelines for the management of pleural infection, Thorax 2003; 58
(Suppl II) ii18-ii28.
Gilbert DN,. et al, editors, The Sanford guide to antimicrobial therapy 33rd Ed., 2003;
Antimicrobial Therapy Inc. USA.
Hanon FX, et al, Survival of patients with bacteraemia in relation to intial empirical
antimicrobial treatment, Scand J Infect Dis 2002; 34: 520-8.
Heikkinen T, Saeed KA, McCormick DP, Baldwin C, Reisner BS, Chonmaitree T. A single
intramuscular dose of ceftriaxone changes nasopharyngeal bacterial flora in children with acute otitis
media. Acta Paediatr 2000; 89: 1316-1321.
Horsburgh et al, Practice Guidelines for the Treatment of Tuberculosis CID 2000;31
(September). 633-9
Hughes WT, et al,. Guidelines for Febrile Neutropenic Patients CID 2002:34 (15 March). 73051
Hughes WT, et al,. Neutropenic Patients with Unexplained Fever CID 1997;25 (September).
551-73
Mandell LA, et al, Guidelines for CAP in Adults CID 2003:37 (1 December).1405-33
Mazuski JE, et al, The Surgical Infection Society Guidelines on Antimicrobial Therapy for IntraAbdominal Infections: An Executive Summary, Surg Inf 2002; 3(3): 161-173.
Mermel LA et al, Guidelines for Catheter Infections; CID 2001:32 (1 May). 1249-72
Nichols RL, Preventing Surgical Site Infections: A Surgeons Perspective Emerging Infectious
Diseases Vol. 7, No. 2, MarchApril 2001. 220-224.
Rey JF, Budzynska A, Axon A, Kruse A, Nowak A, [Working Group] Guidelines of the Society
of Gastrointestinal Endoscopy (ESGE); Antibiotic Prophylaxis for Gastrointestinal Endoscopy,
http://www.esge.com/guidelines/antibiotic_prolax.php
Sanchez Manuel FJ, Seco Gil JL, Antibiotic Prophylaxis for Hernia Repair. (Cochrane Review),
Bibiliography
62
2003; Issue 2:The Cochrane Review. Oxford.

Scott M, Strategies for better quality antibiotic prescribing, Hosp Pharm Europe [Winter] 2002:
60-62.
Subhani JM, et al, Antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography
(ERCP), Aliment Pharmacol Ther 1999 February; 13(2): 103-16.
Vrijland WW, Jeekel J, Prosthetic Mesh Repair Should Be Used for any Defect in the Abdominal
Wall, Curr Med Res Opin 2003; 19(1):1-3.
Wong-Beringer A, Nguyen KH, Razeghi J, Implementing a Program for Switching From I.V. to Oral
Antimicrobial Therapy;Am J Health-Syst Pharm 58(12):1139-1142
Bibiliography
63

Antimicrobial Prescribing Guidelines Government Health Services

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Antimicrobial Prescribing Guidelines Government Health Services

Uploaded by

Copyright:

Available Formats

ANTIMICROBIAL PRESCRIBING GUIDELINES

GOVERNMENT HEALTH SERVICES

Reproduction is authorised, provided the source is acknowledged, save if otherwise stated.

ANTIMICROBIAL PRESCRIBING GUIDELINES

Prepared by the Antibiotic Team St. Luke's Hospital

UPPER RESPIRATORY TRACT INFECTIONS ................................................... 1

ORAL AND DENTAL INFECTIONS........................................................ 4

GASTRO-INTESTINAL TRACT INFECTIONS ..................................... 4

INFECTIONS OF THE CARDIOVASCULAR SYSTEM ....................... 6

INFECTIONS OF THE CENTRAL NERVOUS SYSTEM ..................... 9

EAR INFECTIONS ....................................................................................... 10

INFECTIONS OF THE EYE AND ADNEXA......................................... 12

COMMON INFECTIONS IN E.N.T......................................................... 10

INFECTIONS OF THE EYELIDS .................................................................... 12

INFECTIONS OF SKIN, MUSCLE, BONE AND JOINTS ................... 13

URINARY TRACT INFECTIONS........................................................... 19

ACUTE (UNCOMPLICATED) URINARY TRACT INFECTIONS ........................ 19

INFECTIONS OF THE GENITAL TRACT ........................................... 20

INFECTIOUS DISEASES ......................................................................... 22

NON-SURGICAL ANTIBIOTIC PROPHYLAXIS ................................ 25

SURGICAL PROPHYLAXIS ................................................................... 26

14.6.5 Laparotomy .................................................................................... 30

METHODS OF ADMINISTRATION OF INTRAVENOUS AGENTS 33

ANTIBIOTIC THERAPY IN RENAL FAILURE .................................. 37

17 ANTIMICROBIAL THERAPY DURING PREGNANCY AND

FDA CATEGORY INTERPRETATION ...................................................... 41

FOOD ANTIBIOTIC INTERACTIONS.................................................. 45

19 GUIDELINES FOR THERAPEUTIC DRUG MONITORING IN

GUIDELINES FOR IV TO ORAL CONVERSIONS ............................. 46

GENTAMICIN / TOBRAMYCIN DOSING GUIDELINES.................. 47

VANCOMYCIN DOSING GUIDELINES ............................................... 51

METHODS FOR PENICILLIN DESENSITISATION........................... 51

24 NOTES ON THE COLLECTION AND TRANSMISSION OF

COSTINGS OF ANTIMICROBIALS ...................................................... 56

Sensible antibiotic prescribing

Upper Respiratory Tract Infections

Penicillin V 500mg 8hourly

Cefotaxime 10010 days

If patient fails to respond

Hospitalise immediately and

All regimens are oral unless otherwise stated.

VAP diagnostic aid

36.5C < < 38.4C

38.5C < < 38.9C

> 39C or < 36C

4,000 < < 11,000

> 11,000 or < 4,000

< 14 aspirations / day

> 14 aspirations / day

> 240 or ARDS

< 240 and no ARDS

Diffused or patchy infiltrate

A total score of 7 is highly suggestive of VAP

Take endotracheal aspirates

All regimens are oral unless otherwise stated.

Seek expert advice.

Confirm by urinary antigen

Seek expert advice

All regimens are oral unless otherwise stated.

Oral and Dental Infections

Oral aerobes &

Metronidazole 200400mg 8-hourly

Oral aerobes &

Only if symptoms present.