Sandbox ID Lower Respiratory Tract: Difference between revisions

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Latest revision as of 17:27, 6 August 2015

Acute exacerbations of chronic bronchitis

Acute exacerbation of chronic bronchitis^[1]

1. Outpatient management

Patients with only 1 of the 3 cardinal symptoms of COPD (↑ dyspnea, ↑ sputum volume, ↑ sputum purulence) may not benefit from antibiotics
Preferred regimen (1): Doxycycline 100 mg PO bid for 7-10 days
Preferred regimen (2): Amoxicillin 875 mg PO bid
Preferred regimen (3): Amoxicillin 500 mg PO tid
Preferred regimen (4): Trimethoprim-sulfamethoxazole DS 800/160 mg PO bid for 10-14 days
Alternative regimen (1): Amoxicillin-clavulanate 875/125 mg PO bid for 10-14 days
Alternative regimen (2): Levofloxacin 500 mg PO qd for 7-10 days
Alternative regimen (3): Azithromycin 500 mg PO single dose THEN 250 mg PO qd for 4 days
Alternative regimen (4): Cefpodoxime 200 mg PO bid for 10 days
Alternative regimen (5): Amoxicillin-clavulanate 500/125 mg PO tid for 10-14 days
Alternative regimen (6): Moxifloxacin 400 mg PO qd for 5 days
Alternative regimen (7): Gemifloxacin 320 mg PO qd for 5 days
Alternative regimen (8): Clarithromycin 250-500 mg PO bid for 7-14 days
Alternative regimen (9): Clarithromycin ER 1000 mg PO qd for 14 days
Alternative regimen (10): Cefprozil 250-500 mg PO bid for 10 days
Alternative regimen (11): Cefixime 400 mg PO qd for 10 days

2. Inpatient management

Indications for hospital admission:

Intense symptoms (e.g.: sudden development of resting dyspnea)
Old age
Severe underlying COPD
Cyanosis
Peripheral edema
Serious comorbidities (e.g.: HF, Afib, renal failure)
Failure of outpatient treatment
Frequent exacerbations
Insufficient home support

2.1 Treatment of acute exacerbation of chronic bronchitis, when pseudomonas infection not suspected

Preferred regimen (1): Moxifloxacin 400 mg IV q24h for 5 days
Preferred regimen (2): Levofloxacin 500 mg IV q24h for 7-10 days

2.2 Treatment of acute exacerbation of chronic bronchitis, when pseudomonas infection is suspected

Preferred regimen (1): Ceftazidime 30-50 mg/kg IV q8hr (maximum dose 6 g/day)
Preferred regimen (2): Piperacillin-Tazobactam 3.375 g IV q6h for 7-10 days
Preferred regimen (3): Cefepime 1-2 g IV q8-12hr for 7-10 days (extend to 21 days if culture positive for Pseudomonas)
Alternative regimen (1): Ceftriaxone 1-2 g IV/IM q12-24h for 4-14 days
Alternative regimen (2): Ceftriaxone 1-2 g IV/IM q8h for 4-14 days

Bronchiectasis

Bronchiectasis^[2]

1. Acute exacerbations of bronchiectasis

1.1 Empiric antimicrobial therapy

Preferred regimen: Amoxicillin 0.5-1 g PO/IV q8h for 14 days
Alternative regimen (1): Ciprofloxacin 500-750 mg PO bid for 14 days
Alternative regimen (2): Clarithromycin 500 mg PO bid for 14 days

1.2 Pathogen-directed antimicrobial therapy

1.2.1 Streptococcus pneumoniae

Preferred regimen: Amoxicillin 500 mg PO tid for 14 days
Alternative regimen: Clarithromycin 500 mg PO bid for 14 days

1.2.2 Haemophilus influenzae (b-lactamase negative)

Preferred regimen (1): Amoxicillin 0.5-1 g PO tid for 14 days
Preferred regimen (2): Amoxicillin 3 g PO bid for 14 days
Alternative regimen (1): Clarithromycin 500 mg PO bid for 14 days
Alternative regimen (2): Ciprofloxacin 500 mg PO bid for 14 days
Alternative regimen (3): Ceftriaxone 2 g IV q24h for 14 days

1.2.3 Haemophilus influenzae (b-lactamase positive)

Preferred regimen: Amoxicillin-Clavulanate 625 mg PO tid for 14 days
Alternative regimen (1): Clarithromycin 500 mg PO bid for 14 days
Alternative regimen (2): Ciprofloxacin 500 mg PO bid for 14 days
Alternative regimen (3): Ceftriaxone 2 g IV q24h for 14 days

1.2.4 Moraxella catarrhalis

Preferred regimen: Amoxicillin-Clavulanate 625 mg PO tid for 14 days
Alternative regimen: Ciprofloxacin 500 mg PO bid for 14 days

1.2.5 Staphylococcus aureus (MSSA)

Preferred regimen: Flucloxacillin 500 mg PO qid for 14 days
Alternative regimen: Clarithromycin 500 mg PO bid 14 days

1.2.6 Staphylococcus aureus (MRSA) (mild-to-moderate)

Preferred regimen (weight < 50 kg): Rifampicin 450 mg PO qd AND Trimethoprim 200 mg PO bid for 14 days
Preferred regimen (weight > 50 kg): Rifampicin 600 mg PO qd AND Trimethoprim 200 mg PO bid for 14 days
Alternative regimen (weight < 50 kg): Rifampicin 450 mg PO qd AND Doxycycline 200 mg PO qd for 14 days
Alternative regimen (weight > 50 kg): Rifampicin 600 mg PO qd AND Doxycycline 200 mg PO qd for 14 days
Alternative regimen: Linezolid 600 mg PO bid for 14 days (third-line therapy)

1.2.7 Staphylococcus aureus (MRSA) (severe)

Preferred regimen (1): Vancomycin 1 g IV q12h (trough levels of 10-20 ng/mL)
Preferred regimen (2): Teicoplanin 400 mg IV q24h for 14 days
Alternative regimen: Linezolid 600 mg IV q12h for 14 days

1.2.8 Coliforms (eg, Klebsiella, enterobacter)

Preferred regimen: Ciprofloxacin 500 mg PO bid for 14 days
Alternative regimen: Ceftriaxone 2 g IV od 14 days

1.2.9 Pseudomonas aeruginosa

Preferred regimen: Ciprofloxacin 500-750 mg PO bid for 14 days
Alternative regimen (1): Ceftazidime 2 g PO tid for 14 days
Alternative regimen (2): Piperacillin-Tazobactam 4.5 g PO tid for 14 days
Alternative regimen (3): Aztreonam 2 g PO tid for 14 days
Alternative regimen (4): Meropenem 2 g PO tid for 14 days

1.2.10 Pediatric Dosing

Amoxicillin 20-50 mg/kg/day PO bid or tid
Co-amoxiclav 20-45 mg/kg/day PO bid or tid
Trimethoprim 4-6 mg/kg/day PO bid (Children < 12 yr)
Trimethoprim 100-200 mg PO bid (Children > 12 yr)
Rifampicin 450 mg PO qd (weight < 50 kg)
Rifampicin 600 mg PO qd (weight > 50 kg)
Vancomycin 45-60 mg/kg/day IV q8-12h
Ciprofloxacin 15-30 mg/kg/day PO/IV q12h
Doxycycline 2-5 mg/kg/day PO/IV q12-24h (maximum daily dose: 200 mg)
Linezolid 10 mg/kg IV/PO q12h
Ceftriaxone 50-75 mg/kg IV/IM q24h
Ceftazidime 150 mg/kg/day IV/IM q8h

2. Long-term antibiotic prophylaxis
Patients with ≥3 exacerbations/year requiring antibiotic therapy or patients with fewer exacerbations that are causing significant morbidity should be considered for long-term antibiotic prophylaxis

2.1 Pathogen-directed antimicrobial therapy

2.1.1 Streptococcus pneumoniae

Preferred regimen: Amoxicillin 500 mg PO bid
Alternative regimen: Clarithromycin 250 mg PO bid

2.1.2 Haemophilus influenzae (b-lactamase negative)

Preferred regimen: Amoxicillin 500 mg PO bid
Alternative regimen: Clarithromycin 250 mg PO bid

2.1.3 Haemophilus influenzae (b-lactamase positive)

Preferred regimen: Amoxicillin-Clavulanate 375 mg PO tid
Alternative regimen: Clarithromycin 250 mg PO bid

2.1.4 Moraxella catarrhalis

Preferred regimen: Amoxicillin-Clavulanate 375 mg PO tid
Alternative regimen: Clarithromycin 250 mg PO bid

2.1.5 Staphylococcus aureus (MSSA)

Preferred regimen: Flucloxacillin 500 mg PO bid
Alternative regimen: Clarithromycin 250 mg PO bid

3. Pseudomonas eradication (colonization)

3.1 Initial therapy

Preferred regimen: Ciprofloxacin 750 mg PO bid for 14 days

3.2 Secondary therapy in case of treatment failure

Preferred regimen (1): Piperacillin-tazobactam 4.5 g PO tid for 14 days
Preferred regimen (2): Cefepime 1-2 g IV q8-12h
Preferred regimen (3): Ciprofloxacin 750 mg PO bid for 4 weeks AND Colistin (Nebulized) 2 MU NEB bid for 3 months
Preferred regimen (3): Colistin (Nebulized) 2 MU NEB bid for 3 months

Bronchiolitis

Bronchiolitis^[3]

1. Treatment

Preferred regimen: Supportive care. No antimicrobial therapy recommended.

2. Prophylaxis

Indications for prophylaxis:

First year of life during RSV season in infants with hemodynamically significant heart disease
First year of life during RSV season in preterm infants < 32 weeks 0 days’ gestation who require > 21% oxygen for at least the first 28 days of life

Preferred regimen: Palivizumab 15 mg/kg IM monthly for 5 months

Bronchitis

Acute bronchitis^[4]

1.Treatment of acute bronchitis with no suspicion of pertussis

Preferred regimen: Supportive care. Antimicrobial therapy not recommended.

2.Treatment of acute bronchitis with suspected or confirmed pertussis

Preferred regimen (1): Erythromycin 15 mg/kg PO tid for 5-14 days
Preferred regimen (2): Azithromycin 500 mg PO single dose THEN Azithromycin 250 mg PO qd for 4 days

Cystic fibrosis

Cystic Fibrosis

1.Pathogen-directed antimicrobial therapy ^[5]

1.1 Pseudomonas aeruginosa

1.1.1 Adults

Preferred regimen (1): Tobramycin 3.3 mg/kg PO tid OR Tobramycin 12 mg/kg IV q24h AND (Piperacillin 100 mg/kg PO qid
Preferred regimen (2): Ticarcillin 100 mg/kg PO qid
Preferred regimen (3): Ceftazidime 50 mg/kg IV q8h (to maximum of 6 g/day)
Alternative regimen (1): (Tobramycin 3.3 mg/kg PO tid OR Tobramycin 12 mg/kg IV q24h) AND Aztreonam 50 mg/kg IV q8h
Alternative regimen (2): (Tobramycin 3.3 mg/kg PO tid OR Tobramycin 12 mg/kg IV q24h) AND Imipenem 15-25 mg/kg IV q6h
Note: If Tobramycin resistant add Ciprofloxacin 500-750 mg PO bid for 7-14 days OR Ciprofloxacin 400 mg IV q12h for 7-14 days OR Levofloxacin 750 mg PO qd for 7-14 days

1.1.2 Children

Preferred regimen: (Ciprofloxacin 500-750 mg PO bid for 7-14 days OR Ciprofloxacin 400 mg IV q12h for 7-14 days) AND Ceftazidime 0.5-1 g IV q8h

1.2 Staphylococcus aureus

1.2.1 Adults

1.2.1.1 Methicillin sensitive staphylococcus aureus

Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h

1.2.1.2 Methicillin resistant staphylococcus aureus

Preferred regimen: Vancomycin 15-20 mg/kg IV q8-12h OR Linezolid 600 mg PO/IV q12h

1.2.2 Children

1.2.2.1 Methicillin sensitive staphylococcus aureus

Preferred regimen: Nafcillin 5 mg/kg IV q6h (age > 28 days) OR Oxacillin 75 mg/kg IV q6h (age > 28 days)

1.2.2.2 Methicillin resistant staphylococcus aureus

Preferred regimen: Vancomycin 40 mg/kg IV divided q6-8h (age >28 days) OR Linezolid 10 mg/kg PO/IV q8h (up to age 12)

1.3 Burkholderia cepacia

Preferred regimen: Trimethoprim-sulfamethoxazole 5/25 mg/kg IV q6h
Alternative regimen: Chloramphenicol 15–20 mg/kg PO/IV q6h

Empyema

Empyema^[6]

1. Empiric antimicrobial therapy or culture negative therapy

Causative pathogens:

Streptococcus milleri
Streptococcus pneumoniae
Streptococcus intermedius
Staphylococcus aureus
Enterobacteriaceae
Escherichia coli
Fusobacterium spp.
Bacteroides spp.
Peptostreptococcus spp.

Preferred regimen (1): Cefuroxime 1.5 g IV q8h AND Metronidazole 500 mg IV q8h
Preferred regimen (2): Ceftriaxone 1.5 g IV q8h AND Metronidazole 500 mg IV q8h
Preferred regimen (3): Piperacillin-Tazobactam 3.375 g IV q4h OR Ticarcillin-clavulanate 3.1 g IV q4h OR Ampicillin-Sulbactam 2/1 g IV q6h
Preferred regimen (4): Meropenem 1 g IV q8h OR Imipenem 500 mg IV q6h
Note: Consider coverage for MRSA if high suspicion exists.

2. Pathogen-based therapy

2.1 Acute empyema

2.1.1 Streptococcus pneumoniae, Group A streptrococcus

Preferred regimen: Ceftriaxone 1.5 g IV/IM q24h

2.1.2 Staphylococcus aureus

2.1.2.1 MSSA

Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h

2.1.2.2 MRSA

Preferred regimen: Vancomycin 1 g IV q12h OR Linezolid 600 mg PO/IV q12h

2.1.3 Hemophilus influenzae

Preferred regimen: Ceftriaxone 1.5 g IV/IM q24h
Alternative regimen: Trimethoprim-Sulfamethoxazole 8-20 mg TMP/kg/day IV q6-12h or Ampicillin-Sulbactam 2/1 g IV q6h

2.2 Subacute/chronic empyema

2.2.1 Anaerobic streptococcus, Streptococcus milleri, Bacteroides species, Enterobacteriaceae, Mycobacterium tuberculosis

Preferred regimen: Clindamycin 450–900 mg IV q8h AND Ceftriaxone 1.5 g IV/IM q24h
Alternative regimen: Imipenem 500 mg IV q6h OR Piperacillin-Tazobactam 3.375 g IV q4h OR Ticarcillin-clavulanate 3.1 g IV q4h OR Ampicillin-Sulbactam 2/1 g IV q6h

Pneumonia

Pneumonia

1. Community-acquired pneumonia

1.1 Empiric therapy in adults ^[7]

1.1.1 Outpatient treatment

1.1.1.1 Previously healthy and no use of antimicrobials within the previous 3 months

Preferred regimen (1): (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days) OR Azithromycin 500 mg IV single dose
Preferred regimen (2): Clarithromycin 250 mg PO bid for 7-14 days OR Clarithromycin 1000 mg PO qd for 7 days
Preferred regimen (3): Erythromycin 250-500 mg PO bid or tid (maximum daily dose 4 g)
Alternative regimen: Doxycycline 100 mg PO/IV q12h

1.1.1.2 Presence of comorbidities, use of immunosuppressing drugs, or use of antimicrobials within the previous 3 months

Preferred regimen (1): Levofloxacin 500 mg PO qd for 7-14 days OR Levofloxacin 750 mg PO qd for 5 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Gemifloxacin 320 mg PO qd for 5 or 7 days
Preferred regimen (2): (Amoxicillin 1 g PO q8h OR Amoxicillin-clavulanate 1-2 g PO bid OR Ceftriaxone 1-2 g IV q24h OR Cefpodoxime 200 mg PO bid for 14 days OR Cefuroxime 750 mg IM/IV q8h) AND either (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days) OR (Clarithromycin 250 mg PO bid for 7-14 days OR Clarithromycin 1000 mg PO qd for 7 days) OR Erythromycin 250-500 mg PO bid or tid (maximum daily dose 4 g)
Note: In the case of recent (past 3 months) antimicrobial therapy, an alternative from a different class should be selected.

1.1.2 Inpatient treatment

1.1.2.1 Non-ICU treatment

Preferred regimen (1): Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days OR Moxifloxacin 400 mg IV q24h for 7-14 days OR Gemifloxacin 320 mg PO qd for 5-7 days
Preferred regimen (2): (Amoxicillin 1 g PO q8h OR Amoxicillin-clavulanate 1-2 g PO bid OR Ceftriaxone 1-2 g IV q24h OR Cefpodoxime 200 mg PO bid for 14 days OR Cefuroxime 750 mg IM/IV q8h) AND either (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days) OR (Clarithromycin 250 mg PO bid for 7-14 days OR Clarithromycin 1000 mg PO qd for 7 days) OR Erythromycin 250-500 mg PO bid or tid (maximum daily dose 4 g)

1.1.2.2 ICU treatment

Preferred regimen (1): (Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1-2 g IV q24h OR Ampicillin-sulbactam 1.5-3 g IV q6h) AND (Levofloxacin 500 mg IV q24h for 7-14 days OR Levofloxacin 750 mg IV q24h for 5 days OR Moxifloxacin 400 mg IV q24h for 7-14 days OR Gemifloxacin 320 mg PO q24h for 5-7 days)
Alternative regimen (1): (Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1-2 g IV q24h OR Ampicillin-sulbactam 1.5-3 g IV q6h) AND (Azithromycin 500 mg IV qd for 2 days (PO for a total of 7-10 days)
Alternative regimen (2): Aztreonam 2 g IV q6-8h (maximum daily dose 8 g) AND (Levofloxacin 500 mg IV q24h for 7-14 days OR Levofloxacin 750 mg IV q24h for 5 days OR Moxifloxacin 400 mg IV q24h for 7-14 days OR Gemifloxacin 320 mg PO q24h for 5-7 days)

1.1.3 Special considerations

1.1.3.1 Suspected Pseudomonas

Preferred regimen (1): Piperacillin-Tazobactam 3.375-4.5 g IV q6h for 7-14 days AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (2): Cefepime 1-2 g IV q8-12h for 7-10 days AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (3): (Imipenem 500 mg IV q6h for ≤5 days OR Meropenem 500 mg IV q8hr for ≤5 days) AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (4): Piperacillin-Tazobactam 3.375-4.5 g IV q6h for 7-14 days AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days)
Preferred regimen (5): Cefepime AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days)
Preferred regimen (6): (Imipenem 500 mg IV q6h for ≤5 days OR Meropenem 500 mg IV q8hr for ≤5 days) AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days)
Preferred regimen (7): (Imipenem 500 mg IV q6h for ≤5 days OR Meropenem 500 mg IV q8hr for ≤5 days) AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg PO qd for 7-14 days OR Levofloxacin 750 mg PO qd for 5 days)
Preferred regimen (8): Piperacillin-Tazobactam 3.375-4.5 g IV q6h for 7-14 days AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (9): Cefepime 1-2 g IV q8-12h for 7-10 days AND (Amikacin 20 mg/kg/day IV q8-12h OR Gentamicin 3-5 mg/kg/day IV/IM q8h OR Tobramycin 3-6 mg/kg/day IV/IM q8h) AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg IV qd for 7-14 days OR Levofloxacin 750 mg IV qd for 5 days)
Preferred regimen (10): (Imipenem 500 mg IV q6h for ≤5 days OR Meropenem 500 mg IV q8hr for ≤5 days) AND (Ciprofloxacin 400 mg IV q8h for 7-14 days OR Levofloxacin 500 mg PO qd for 7-14 days OR Levofloxacin 750 mg PO qd for 5 days)
Note: For penicillin-allergic patients, substitute the beta-lactam for Aztreonam 1-2 g IV q6-8h.

1.1.3.2 Suspected methicillin resistant Staphylococcus aureus (add the following)

Preferred regimen: Vancomycin 45-60 mg/kg/day divided q8-12h OR Linezolid 600 mg PO/IV q12h for 10-14 days

1.1.3.3 Neutropenic patient ^[8]

1.1.3.3.1 No risk for multi-drug resistance

Preferred regimen: Ceftriaxone 1-2 g q24h IV or IM (max: 4 g/day) OR Levofloxacin 750 mg q24h for 7-14 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Ciprofloxacin 400 mg PO q8h for 10-14 days OR Ampicillin sulbactam 1-2 g q6-8h IV/IM (maximum: 8 g/day) OR Ertapenem 1 g IM/IV q24h for 10-14 days.

1.1.3.3.2 Risk for multi drug resistance

Preferred Regimen: (Cefepime 1-2 g q8-12h OR Ceftazidime 2 g q8h OR Imipenem 500 mg q6h or 1g q8h OR Meropenem 1 g q8h OR Piperacillin-tazobactam 4.5 g q6h) AND (Ciprofloxacin 400 mg q8h OR Levofloxacin 750 mg q24h OR Amikacin 20 mg/kg per day OR Gentamycin 7 mg/kg per day OR Tobramycin 7 mg/kg per day) AND (Linezolid 600 mg q12h OR Vancomycin 15 mg/kg q12h).
Note (1) : Trough levels for Gentamycin and Tobramycin should be less than 1 g/ml, and for Amikacin they should be less than 4-5 g/ml.
Note (2) : Trough levels for Vancomycin should be 15-20 g/ml
Note (3) : Hospital or community acquired, neutropenic patient (<500 neutrophils per mm3) Vancomycin not included in initial therapy unless high suspicion of infected intravenous access or drug-resistant Streptococcus pneumonia. Amphotericin not used unless still febrile after 3 days or high clinical likelihood.

1.2 Pathogen-directed antimicrobial therapy

1.2.1 Bacterial pathogens

1.2.1.1 Streptococcus pneumoniae

1.2.1.1.1 Penicillin sensitive (minimum inhibitory concentration < 2 mg/mL)

Preferred regimen : Penicillin G 2-3 million units IV q4h OR Amoxicillin 875 mg PO q12h or 500 mg q8h
Alternative regimen : Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Cefpodoxime 200 mg PO q12h for 14 days OR Cefprozil 500 mg PO q12h for 10 days OR Cefuroxime 750 mg PO/IV q8h OR Cefdinir 300 mg PO q12h for 10 days OR Cefditoren 400 mg PO q12h for 14 day OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR Cefotaxime 1 g IM/IV q12h OR Clindamycin 150-450 mg PO q6-8h (maximum: 1800 mg/day) OR Clindamycin 1.2-2.7 g/day IM/IV in 2-4 divided doses (maximum:4800 mg/day) OR Doxycycline 100 mg PI/IV q12h ORLevofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

1.2.1.1.2 Penicillin resistant (minimum inhibitory concentration > 2 mg/mL)

Preferred regimen (Agents chosen on the basis of susceptibililty) : Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h
Alternative regimen: Vancomycin 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity OR Linezolid 600 mg PO/IV q12h for 10-14 days OR Amoxicillin 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)

1.2.1.2 Haemophilus influenzae

1.2.1.2.1 Non-beta lactamase producing

Preferred regimen: Amoxicillin 875 mg PO q12h or 500 mg q8h
Alternative regimen : Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Doxycycline 100 mg PO/IV q12h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days

1.2.1.2.2 Beta lactamase producing

Preferred regimen: 2nd or 3rd Generation Cephalosporin OR Amoxicillin-clavulanate 2 g q12h
Alternative regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Doxycycline 100 mg PO/IV q12h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days

1.2.1.2 Bacillus anthracis (inhalational)

Preferred Regimen :Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR Doxycycline 100 mg PO/IV q12h
Alternate Regimen : Other Fluoroquinolones OR B-lactam (if susceptible) OR Rifampin 600 mg PO/IV q24h for 4 days OR Clindamycin 150-450 mg PO q6-8h OR Chloramphenicol 50-100 mg/kg/day IV in divided q6h

1.2.1.3 Enterobacteriaceae

Preferred Regimen: 3rd generation cephalosporin OR Carbapenem- (Imipenem-Cilastatin, OR Meropenem, OR Ertapenem) (drug of choice if extended-spectrum b-lactamase producer)
Alternate Regimen : b-Lactam / b-lactamase inhibitor- (Piperacillin-Tazobactam for gram-negative bacilli, OR Ticarcillin-Clavulanate OR Ampicillin-Sulbactam OR Amoxicillin-Clavulanate) OR (Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h)

1.2.1.4 Pseudomonas aeruginosa

Preferred Regimen: (Ticarcillin 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) OR Piperacillin 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h OR Ceftazidime 500 mg to 1 g q8h OR Cefepime 1-2 g q12h for 10 days OR Aztreonam 2 g IV q6-8h (maximum: 8 g/day) OR Imipenem 500 mg IV q6h OR Meropenem 500 mg IV q8h) AND (Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 750 mg daily OR Aminoglycoside)
Alternative Regimen: Aminoglycoside AND (Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 750 mg daily)

1.2.1.5 Staphylococcus aureus

1.2.1.5.1 Methicillin sensitive

Preferred Regimen : Nafcillin 1000-2000 mg q4h OR Oxacillin 2 g IV q4h OR Flucloxacillin 250 mg IM/IV q6h
Alternative Regimen : Cefazolin 500 mg IV q12h OR Clindamycin 150-450 mg PO q6-8h

1.2.1.5.2 Methicillin resistant

Preferred Regimen : Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR Linezolid 600 mg PO/IV q12h for 10-14 days
Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

1.2.1.6 Klebsiella pneumonia^[9]

1.2.1.6.1 Resistant to third generation cephalosporins and aztreonam

Preferred regimen (1): Imipenem 0.5 g IV q6h OR Meropenem 0.5–1 g IV q8h

1.2.1.6.2 Klebsiella pneumoniae Carbapenemase producers

Preferred regimen (1): Colistin (=Polymyxin E).In USA : Colymycin-M 2.5-5 mg/kg per day of base divided into 2-4 doses 6.7-13.3 mg/kg per day of colistimethate sodium (max 800 mg/day). Elsewhere: Colomycin and Promixin ≤60 kg, 50,000-75,000 IU/kg per day IV in 3 divided doses (=4-6 mg/kg per day of colistimethate sodium). >60 kg, 1-2 mill IU IV tid (= 80-160 mg IV tid) OR Polymyxin B (Poly-Rx) 15,000–25,000 units/kg/day divided q12h
Note (1): some strains which hyperproduce extended spectrum beta-lactamase are primarily resistant to Ticarcillin-Clavulanate, Piperacillin-Tazobactam
Note (2): Extended spectrum beta-lactamases inactivates all Cephalosporins, beta-lactam/beta-lactamase inhibitor drug activation not predictable; co-resistance to all Fluoroquinolones & often Aminoglycosides.
Note (3): Can give IM, but need to combine with “caine” anesthetic due to pain.

1.2.1.7 Moraxella catarrhalis

Preferred regimen: Amoxicillin-Clavulanate (Augmentin) 2 tablets po bid ( (or)500/125 mg 1 tablet po tid (or) 875/125 mg 1 tablet po bid) OR Cephalosporins- Cefdinir 300 mg po q12h (or) 600 mg q24h, OR (Cefditoren pivoxil 200–400 mg, 2 tabs po bid,OR Cefpodoxime proxetil 0.1–0.2 g po q12h, OR Cefprozil 500 mg po q12h), OR Cefoxitin 1 g q8h–2 g IV/IM q4h, OR (Cefuroxime 0.75–1.5 g IV/IM q8h,ORCefotaxime 1 g q8–12h to 2 g IV q4h, OR Ceftazidime 1–2 g IV/IM q8–12h) OR Trimethoprim-Sulfamethoxazole Single-strength (SS) is Trimethoprim 80 mg / Sulfamethoxazole 400 mg ,OR (double-strength (DS) Trimethoprim 160 mg /Sulfamethoxazole 800 mg)
Alternative regimen: Azithromycin 500 mg IV q24h ,OR Clarithromycin 0.5 g po q12h, OR Telithromycin 800 mg po q24h (two 400 mg tabs po q24h).

1.2.1.8 Stenotrophomonas maltophilia

Preferred regimen: Trimethoprim-Sulfamethoxazole Single-strength (SS) tablet is Trimethoprim 80 mg / Sulfamethoxazole 400 mg, double-strength (DS) tablet is Trimethoprim 160 mg / Sulfamethoxazole 800 mg OR IV treatment (base on TMP component): standard 8–10 mg per kg per day divided q6h, q8h, or q12h.
Alternative regimen: Ticarcillin-Clavulanate 3.1 g IV q4–6h (Ticarcillin 3 g, Clavulanate 0.1 g per vial) AND Aztreonam 1 g IV q6h (or) 2 g IV q8h
Note (1): Potential synergy with Trimethoprim-Sulfamethoxazole AND Ticarcillin-Clavulanate.
Note (2): Stenotrophomonas is one of the microorganisms causing hospital-acquired pneumonia usually with mechanical ventilation.

1.2.1.9 Bordetella pertussis

Preferred Regimen:Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

1.2.1.10 Anaerobes (aspiration pneumonia)

Preferred Regimen: Piperacillin-Tazobactam 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) OR Ticarcillin Clavulanate 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) OR Ampicillin-Sulbactam 1500-3000 mg IV q6h OR Amoxicillin-Clavulanate 250-500 mg PO q8h or 875 mg q12h OR Clindamycin 150-450 mg PO q6-8h (max: 1800 mg/day)
Alternative Regimen: Carbapenem -(Imipenem-Cilastatin, OR Meropenem, OR Ertapenem)

1.2.1.11 Mycobacterium tuberculosis

1.2.1.11.1 Intensive phase

Preferred Regimen: Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
Alternative regimen (1): Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
Alternative regimen (2): Isoniazid 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s AND Ethambutol 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months AND Pyrazinamide 1000 - 2000 mg / day 3 times per week for 2 months.

1.2.1.11.2 Continuation phase

Preferred Regimen:Isoniazid 300 mg/day PO daily for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO daily for 4 months (10 mg/kg/day)
Alternative regimen (1): Isoniazid 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day)

1.2.1.12 Yersinisa pestis

Preferred Regimen: Streptomycin 15 mg/kg/day (max 1 g/day) OR Gentamicin 7 mg/kg/day
Alternate Regimen: Doxycycline 100 mg PO/IV q12h OR Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

1.2.1.13 Atypical bacteria

1.2.1.13.1 Mycoplasma pneumoniae

Preferred Regimen:Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Tetracycline Oral: 250-500 mg q6h
Alternate Regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

1.2.1.13.2 Chlamydophila pneumoniae

Preferred Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Tetracycline 250-500 mg PO q6h
Alternate Regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h

1.2.1.13.3 Legionella spp.

Preferred Regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
Alternate Regimen: Doxycycline 100 mg PO/IV q12h

1.2.1.13.4 Chlamydophila psittaci

Preferred Regimen: Tetracycline 250-500 mg PO q6h
Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h

1.2.1.13.5 Coxiella burnetii

Preferred Regimen: Tetracycline 250-500 mg PO q6h
Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h

1.2.1.13.6 Francisella tularensis

Preferred Regimen: Doxycycline 100 mg PO/IV q12h
Alternate Regimen: Gentamicin 7 mg/kg/day OR Streptomycin 15 mg/kg/day (maximum: 1 g)

1.2.1.13.7 Burkholderia pseudomallei

Preferred Regimen : Carbapenem -(Imipenem-Cilastatin, OR Meropenem, OR Ertapenem) OR Ceftazidime 0.5-1 g q8h
Alternate Regimen: Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h OR Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

1.2.1.13.8 Acinetobacter species

Preferred Regimen : Carbapenem-(Imipenem-Cilastatin, OR Meropenem, OR Ertapenem)
Alternate Regimen: Cephalosporin-Aminoglycoside OR Ampicillin-Sulbactam OR Colistin 2.5-5 mg/kg/day IM/IV divided q6-12h (maximum: 5 mg/kg/day)

1.2.1.14 Gram-positive filamentous bacteria

1.2.1.14.1 Actinomyces spp.^[10]^[11]

Preferred regimen: Penicillin V 1 g po qid 2-6 wk
Alternative regimen: Tetracycline 500 mg po q 6 h OR Doxycycline 100 mg q 12 h
Note: Minocycline, Clindamycin, and Erythromycin have also been successful.

1.2.1.14.2 Nocardia spp.^[12], ^[13], ^[14]

1.2.1.14.2.1 Initial intravenous therapy (induction therapy)

Preferred regimen: Trimethoprim-Sulfamethoxazole (15 mg/kg/day IV of the trimethoprim component in 2 to 4 divided doses) for at least three to six weeks AND Amikacin (7.5 mg/kg IV q12h) for at least three to six weeks
Alternative regimen: Imipenem (500 mg IV q6h) AND Amikacin (7.5 mg/kg IV q12h)
Note (1): If the patient is allergic to Sulfonamides, desensitization should be performed when possible.
Note (2): If the isolate is susceptible to the third-generation cephalosporins (Ceftriaxone, Cefotaxime), Imipenem can be switched to one of these agents.
Note (3): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.

1.2.1.14.2.2 Oral maintenence therapy

Preferred regimen: A sulfonamide (eg,Trimethoprim-Sulfamethoxazole 10 mg/kg/day of the trimethoprim component in 2 or 3 divided doses) AND / OR Minocycline (100 mg bd) AND / OR Amoxicillin-Clavulanate (875 mg bd)
Note (1): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
Note (2): The duration of intravenous therapy varies with the patient's immune status. In immunocompromised patients, maximal tolerated doses should be given intravenously for at least six weeks and until clinical improvement has occurred; in contrast, immunocompetent patients may be successfully treated with a shorter duration of intravenous therapy. Following the intravenous induction phase, patients may be stepped down to oral antibiotics based upon susceptibility studies
Note (3): Serious pulmonary infection is treated for 6 to 12 months or longer.

1.2.2 Viral pathogens

1.2.2.1 Influenza virus

Preferred Regimen: Oseltamivir 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) OR Zanamivir Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)

1.2.2.2 Cytomegalovirus^[15]

Preferred regimen (1): Ganciclovir Induction therapy 5 mg/ kg IV every 12 h for normal GFR; maintenance therapy 5 mg/kg IV daily; 1 g orally every 8 h with food.
Preferred regimen (2): Valganciclovir Induction therapy 900 mg orally every 12 h; maintenance therapy 900 mg daily.
Alternative regimen (1): Foscarnet Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
Alternative regimen (2): Cidofovir Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.

1.2.3 Fungal pathogens

1.2.3.1 Coccidioides species

Preferred Regimen: Itraconazole 200 mg q12h OR Fluconazole 200-400 mg daily for 3-6 month
Alternative Regimen: Amphotericin B 0.5-0.7 mg/kg/day
Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection

1.2.3.2 Histoplasmosis

Preferred Regimen: Itraconazole 200 mg q12h
Alternative Regimen: Amphotericin B 0.5-0.7 mg/kg/day

1.2.3.3 Blastomycosis

Preferred Regimen: Itraconazole 200 mg q12h
Alternate Regimen: Amphotericin B 0.5-0.7 mg/kg/day

2. Health care-associated pneumonia^[8]

2.1 Empiric antimicrobial therapy

2.1.1 No risk factors for multi drug resistance

Preferred Regimen : Ceftriaxone 1-2 g q24h IV or IM (max: 4 g/day) OR Levofloxacin 750 mg q24h for 7-14 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Ciprofloxacin 400 mg PO q8h for 10-14 days OR Ampicillin sulbactam 1-2 g q6-8h IV/IM (maximum: 8 g/day) OR Ertapenem 1 g IM/IV q24h for 10-14 days.

2.1.2 Risk factors for multi drug resistance

Preferred Regimen: (Cefepime 1-2 g q8-12h OR Ceftazidime 2 g q8h OR Imipenem 500 mg q6h or 1g q8h OR Meropenem 1 g q8h OR Piperacillin-tazobactam 4.5 g q6h) AND (Ciprofloxacin 400 mg q8h OR Levofloxacin 750 mg q24h OR Amikacin 20 mg/kg per day OR Gentamycin 7 mg/kg per day OR Tobramycin 7 mg/kg per day) AND (Linezolid 600 mg q12h OR Vancomycin 15 mg/kg q12h).
Note (1): Health care-associated pneumonia used to designate large diverse population of patients with many co-morbidities who reside in nursing homes, other long-term care facilities, require home intravenous therapy (or) are dialysis patients. Pneumonia in these patients frequently resembles hospital-acquired pneumonia.
Note (2): Trough levels for Gentamycin and Tobramycin should be less than 1 g/ml, and for Amikacin they should be less than 4-5 g/ml.
Note (3): Trough levels for Vancomycin should be 15-20 g/ml.

References

↑ Sethi S, Murphy TF (2004). "Acute exacerbations of chronic bronchitis: new developments concerning microbiology and pathophysiology--impact on approaches to risk stratification and therapy". Infect Dis Clin North Am. 18 (4): 861–82, ix. doi:10.1016/j.idc.2004.07.006. PMID 15555829.
↑ Pasteur MC, Bilton D, Hill AT, British Thoracic Society Bronchiectasis non-CF Guideline Group (2010). "British Thoracic Society guideline for non-CF bronchiectasis". Thorax. 65 Suppl 1: i1–58. doi:10.1136/thx.2010.136119. PMID 20627931.
↑ Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM; et al. (2014). "Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis". Pediatrics. 134 (5): e1474–502. doi:10.1542/peds.2014-2742. PMID 25349312.
↑ Braman SS (2006). "Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 95S–103S. doi:10.1378/chest.129.1_suppl.95S. PMID 16428698.
↑ Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB; et al. (2013). "Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health". Am J Respir Crit Care Med. 187 (7): 680–9. PMID 23540878.
↑ LastName, FirstName (2007). Sanford guide to antimicrobial therapy. Place of publication not identified: Antimicrobial Therapy. ISBN 9781930808386.
↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC; et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin Infect Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
↑ ^8.0 ^8.1 American Thoracic Society. Infectious Diseases Society of America (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am J Respir Crit Care Med. 171 (4): 388–416. doi:10.1164/rccm.200405-644ST. PMID 15699079.
↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
↑ Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ (2010). "Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients". Ann Thorac Med. 5 (2): 80–5. doi:10.4103/1817-1737.62470. PMC 2883202. PMID 20582172.
↑ Sudhakar SS, Ross JJ (2004). "Short-term treatment of actinomycosis: two cases and a review". Clin Infect Dis. 38 (3): 444–7. doi:10.1086/381099. PMID 14727221 PMID: 14727221 Check |pmid= value (help).
↑ Lerner PI (1996). "Nocardiosis". Clin Infect Dis. 22 (6): 891–903, quiz 904-5. PMID 8783685.
↑ Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ (2006). "Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy". Clin Microbiol Rev. 19 (2): 259–82. doi:10.1128/CMR.19.2.259-282.2006. PMC 1471991. PMID 16614249.
↑ Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D; et al. (2012). "Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey". J Clin Microbiol. 50 (3): 670–2. doi:10.1128/JCM.06243-11. PMC 3295118. PMID 22170936.
↑ Torres-Madriz G, Boucher HW (2008). "Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients". Clin Infect Dis. 47 (5): 702–11. doi:10.1086/590934. PMID 18652557.

[pmid15555829-1] Sethi S, Murphy TF (2004). "Acute exacerbations of chronic bronchitis: new developments concerning microbiology and pathophysiology--impact on approaches to risk stratification and therapy". Infect Dis Clin North Am. 18 (4): 861–82, ix. doi:10.1016/j.idc.2004.07.006. PMID 15555829.

[pmid20627931-2] Pasteur MC, Bilton D, Hill AT, British Thoracic Society Bronchiectasis non-CF Guideline Group (2010). "British Thoracic Society guideline for non-CF bronchiectasis". Thorax. 65 Suppl 1: i1–58. doi:10.1136/thx.2010.136119. PMID 20627931.

[pmid25349312-3] Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM; et al. (2014). "Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis". Pediatrics. 134 (5): e1474–502. doi:10.1542/peds.2014-2742. PMID 25349312.

[pmid16428698-4] Braman SS (2006). "Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 95S–103S. doi:10.1378/chest.129.1_suppl.95S. PMID 16428698.

[pmid23540878-5] Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB; et al. (2013). "Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health". Am J Respir Crit Care Med. 187 (7): 680–9. PMID 23540878.

[6] LastName, FirstName (2007). Sanford guide to antimicrobial therapy. Place of publication not identified: Antimicrobial Therapy. ISBN 9781930808386.

[pmid17278083-7] Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC; et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin Infect Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.

[pmid15699079-8] 8.0 ^8.1 American Thoracic Society. Infectious Diseases Society of America (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am J Respir Crit Care Med. 171 (4): 388–416. doi:10.1164/rccm.200405-644ST. PMID 15699079.

[9] Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

[pmid20582172-10] Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ (2010). "Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients". Ann Thorac Med. 5 (2): 80–5. doi:10.4103/1817-1737.62470. PMC 2883202. PMID 20582172.

[pmidPMID:_14727221-11] Sudhakar SS, Ross JJ (2004). "Short-term treatment of actinomycosis: two cases and a review". Clin Infect Dis. 38 (3): 444–7. doi:10.1086/381099. PMID 14727221 PMID: 14727221 Check |pmid= value (help).

[pmid8783685-12] Lerner PI (1996). "Nocardiosis". Clin Infect Dis. 22 (6): 891–903, quiz 904-5. PMID 8783685.

[pmid16614249-13] Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ (2006). "Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy". Clin Microbiol Rev. 19 (2): 259–82. doi:10.1128/CMR.19.2.259-282.2006. PMC 1471991. PMID 16614249.

[pmid22170936-14] Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D; et al. (2012). "Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey". J Clin Microbiol. 50 (3): 670–2. doi:10.1128/JCM.06243-11. PMC 3295118. PMID 22170936.

[pmid18652557-15] Torres-Madriz G, Boucher HW (2008). "Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients". Clin Infect Dis. 47 (5): 702–11. doi:10.1086/590934. PMID 18652557.

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Sandbox ID Lower Respiratory Tract: Difference between revisions

Latest revision as of 17:27, 6 August 2015

Contents

Acute exacerbations of chronic bronchitis

Bronchiectasis

Bronchiolitis

Bronchitis

Cystic fibrosis

Empyema

Pneumonia

References

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@@ Line 1: / Line 1: @@
-===Acute bacterial  exacerbations of chronic bronchitis===
-:* Chronic bronchitis with Acute bacterial Exacerbation <ref name="pmid20965408">{{cite journal| author=Rabbat A, Guetta A, Lorut C, Lefebvre A, Roche N, Huchon G| title=[Management of acute exacerbations of COPD]. | journal=Rev Mal Respir | year= 2010 | volume= 27 | issue= 8 | pages= 939-53 | pmid=20965408 | doi=10.1016/j.rmr.2010.08.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20965408  }} </ref>
+===Acute exacerbations of chronic bronchitis===
-::* Preferred Regimen
+:* '''Acute exacerbation of chronic bronchitis'''<ref name="pmid15555829">{{cite journal| author=Sethi S, Murphy TF| title=Acute exacerbations of chronic bronchitis: new developments concerning microbiology and pathophysiology--impact on approaches to risk stratification and therapy. | journal=Infect Dis Clin North Am | year= 2004 | volume= 18 | issue= 4 | pages= 861-82, ix | pmid=15555829 | doi=10.1016/j.idc.2004.07.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15555829  }} </ref>
-:::* For mild or moderate disease: [[Amoxicillin]] 500 mg po tid {{or}} [[Doxycycline]] 100 mg po bid {{or}} [[Trimethoprim-sulfamethoxazole]] 1 DS tab po bid
+::* '''1. Outpatient management'''
-:::* For severe disease: [[Amoxicillin clavulanate]] 875/125 mg po bid (or) 500/125 mg po q8hv (or) 2000/125 mg po bid {{or}}  Azithromycin 500 mg po for 1 dose, then 250 mg q24h for 4 days,500 mg po q24h for 3 days {{or}} [[Clarithromycin]] extended release 1000 mg po q24h {{or}} [[Cefaclor]] 500 mg po q8h or 500 mg extended release q12h {{or}} [[Cefdinir]] 300 mg po q12h or 600 mg po q24h {{or}}  [[Cefditoren]] 200 mg tabs—2 tabs bid {{or}} [[Cefpodoxime proxetil]] 200 mg po q12h {{or}}  [[Cefprozil]] 500 mg po q12h {{or}}  [[Ceftibuten]] 400 mg po q24h {{or}} [[Cefuroxime axetil]] 250 or 500 mg q12h {{or}} [[Levofloxacin]] 500 mg po q24h {{or}} [[Moxifloxacin]] 400 mg po q24h
+:::* Patients with only 1 of the 3 cardinal symptoms of COPD (↑ dyspnea, ↑ sputum volume, ↑ sputum purulence) may not benefit from antibiotics
+:::* Preferred regimen (1): [[Doxycycline]] 100 mg PO bid for 7-10 days
+:::* Preferred regimen (2): [[Amoxicillin]] 875 mg PO bid
+:::* Preferred regimen (3): [[Amoxicillin]] 500 mg PO tid
+:::* Preferred regimen (4): [[Trimethoprim-sulfamethoxazole]] DS 800/160 mg PO bid for 10-14 days
+:::* Alternative regimen (1): [[Amoxicillin-clavulanate]] 875/125 mg PO bid for 10-14 days
+:::* Alternative regimen (2): [[Levofloxacin]] 500 mg PO qd for 7-10 days
+:::* Alternative regimen (3): [[Azithromycin]] 500 mg PO single dose {{then}} 250 mg PO qd for 4 days
+:::* Alternative regimen (4): [[Cefpodoxime]] 200 mg PO bid for 10 days
+:::* Alternative regimen (5): [[Amoxicillin-clavulanate]] 500/125 mg PO tid for 10-14 days
+:::* Alternative regimen (6): [[Moxifloxacin]] 400 mg PO qd for 5 days
+:::* Alternative regimen (7): [[Gemifloxacin]] 320 mg PO qd for 5 days
+:::* Alternative regimen (8): [[Clarithromycin]] 250-500 mg PO bid for 7-14 days
+:::* Alternative regimen (9): [[Clarithromycin]] ER 1000 mg PO qd for 14 days
+:::* Alternative regimen (10): [[Cefprozil]] 250-500 mg PO bid for 10 days
+:::* Alternative regimen (11): [[Cefixime]] 400 mg PO qd for 10 days
+::* '''2. Inpatient management'''
+:::* Indications for hospital admission:
+::::* Intense symptoms (e.g.: sudden development of resting dyspnea)
+::::* Old age
+::::* Severe underlying COPD
+::::* Cyanosis
+::::* Peripheral edema
+::::* Serious comorbidities (e.g.: HF, Afib, renal failure)
+::::* Failure of outpatient treatment
+::::* Frequent exacerbations
+::::* Insufficient home support
+:::* 2.1 '''Treatment of acute exacerbation of chronic bronchitis, when pseudomonas infection not suspected'''
+::::* Preferred regimen (1): [[Moxifloxacin]] 400 mg IV q24h for 5 days
+::::* Preferred regimen (2): [[Levofloxacin]] 500 mg IV q24h for 7-10 days
+:::* 2.2 '''Treatment of acute exacerbation of chronic bronchitis, when pseudomonas infection is suspected'''
+::::* Preferred regimen (1): [[Ceftazidime]] 30-50 mg/kg IV q8hr (maximum dose 6 g/day)
+::::* Preferred regimen (2): [[Piperacillin-Tazobactam]] 3.375 g IV q6h for 7-10 days
+::::* Preferred regimen (3): [[Cefepime]] 1-2 g IV q8-12hr for 7-10 days (extend to 21 days if culture positive for Pseudomonas)
+::::* Alternative regimen (1): [[Ceftriaxone]] 1-2 g IV/IM q12-24h for 4-14 days
+::::* Alternative regimen (2): [[Ceftriaxone]] 1-2 g IV/IM q8h for 4-14 days
 ===Bronchiectasis===
-:*Bronchiectasis
+*'''Bronchiectasis'''<ref name="pmid20627931">{{cite journal| author=Pasteur MC, Bilton D, Hill AT, British Thoracic Society Bronchiectasis non-CF Guideline Group| title=British Thoracic Society guideline for non-CF bronchiectasis. | journal=Thorax | year= 2010 | volume= 65 Suppl 1 | issue=  | pages= i1-58 | pmid=20627931 | doi=10.1136/thx.2010.136119 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20627931  }} </ref>
-::*Preferred Regimen : [[Levofloxacin]] 500 mg po q24h for 14 days {{or}} [[Moxifloxacin]] 400 mg po q24h for 14 days
+:* 1. '''Acute exacerbations of bronchiectasis'''
+::* 1.1 '''Empiric antimicrobial therapy'''
+:::* Preferred regimen: [[Amoxicillin]] 0.5-1 g PO/IV q8h for 14 days
+:::* Alternative regimen (1): [[Ciprofloxacin]] 500-750 mg PO bid for 14 days
+:::* Alternative regimen (2): [[Clarithromycin]] 500 mg PO bid for 14 days
+::* 1.2 '''Pathogen-directed antimicrobial therapy'''
+:::* 1.2.1 '''Streptococcus pneumoniae'''
+::::* Preferred regimen: [[Amoxicillin]] 500 mg PO tid for 14 days
+::::* Alternative regimen: [[Clarithromycin]] 500 mg PO bid for 14 days
+:::* 1.2.2 '''Haemophilus influenzae (b-lactamase negative)'''
+::::* Preferred regimen (1): [[Amoxicillin]] 0.5-1 g PO tid for 14 days
+::::* Preferred regimen (2): [[Amoxicillin]] 3 g PO bid for 14 days
+::::* Alternative regimen (1): [[Clarithromycin]] 500 mg PO bid for 14 days
+::::* Alternative regimen (2): [[Ciprofloxacin]] 500 mg PO bid for 14 days
+::::* Alternative regimen (3): [[Ceftriaxone]] 2 g IV q24h for 14 days
+:::* 1.2.3 '''Haemophilus influenzae (b-lactamase positive)'''
+::::* Preferred regimen: [[Amoxicillin-Clavulanate]] 625 mg PO tid for 14 days
+::::* Alternative regimen (1): [[Clarithromycin]] 500 mg PO bid for 14 days
+::::* Alternative regimen (2): [[Ciprofloxacin]] 500 mg PO bid for 14 days
+::::* Alternative regimen (3): [[Ceftriaxone]] 2 g IV q24h for 14 days
+:::* 1.2.4 '''Moraxella catarrhalis'''
+::::* Preferred regimen: [[Amoxicillin-Clavulanate]] 625 mg PO tid for 14 days
+::::* Alternative regimen: [[Ciprofloxacin]] 500 mg PO bid for 14 days
+:::* 1.2.5 '''Staphylococcus aureus (MSSA)'''
+::::* Preferred regimen: [[Flucloxacillin]] 500 mg PO qid for 14 days
+::::* Alternative regimen: [[Clarithromycin]] 500 mg PO bid 14 days
+:::* 1.2.6 '''Staphylococcus aureus (MRSA) (mild-to-moderate)'''
+::::* Preferred regimen (weight < 50 kg): [[Rifampicin]] 450 mg PO qd {{and}} [[Trimethoprim]] 200 mg PO bid for 14 days
+::::* Preferred regimen (weight > 50 kg): [[Rifampicin]] 600 mg PO qd {{and}} [[Trimethoprim]] 200 mg PO bid for 14 days
+::::* Alternative regimen (weight < 50 kg): [[Rifampicin]] 450 mg PO qd {{and}} [[Doxycycline]] 200 mg PO qd for 14 days
+::::* Alternative regimen (weight > 50 kg): [[Rifampicin]] 600 mg PO qd {{and}} [[Doxycycline]] 200 mg PO qd for 14 days
+::::* Alternative regimen: [[Linezolid]] 600 mg PO bid for 14 days (third-line therapy)
+:::* 1.2.7 '''Staphylococcus aureus (MRSA) (severe)'''
+::::* Preferred regimen (1): [[Vancomycin]] 1 g IV q12h (trough levels of 10-20 ng/mL)
+::::* Preferred regimen (2): [[Teicoplanin]] 400 mg IV q24h for 14 days
+::::* Alternative regimen: [[Linezolid]] 600 mg IV q12h for 14 days
+:::* 1.2.8 '''Coliforms (eg, Klebsiella, enterobacter)'''
+::::* Preferred regimen: [[Ciprofloxacin]] 500 mg PO bid for 14 days
+::::* Alternative regimen: [[Ceftriaxone]] 2 g IV od 14 days
+:::* 1.2.9 '''Pseudomonas aeruginosa'''
+::::* Preferred regimen: [[Ciprofloxacin]] 500-750 mg PO bid for 14 days
+::::* Alternative regimen (1): [[Ceftazidime]] 2 g PO tid for 14 days
+::::* Alternative regimen (2): [[Piperacillin-Tazobactam]] 4.5 g PO tid for 14 days
+::::* Alternative regimen (3): [[Aztreonam]] 2 g PO tid for 14 days
+::::* Alternative regimen (4): [[Meropenem]] 2 g PO tid for 14 days
+:::* 1.2.10 '''Pediatric Dosing'''
+::::* [[Amoxicillin]] 20-50 mg/kg/day PO bid or tid
+::::* [[Co-amoxiclav]] 20-45 mg/kg/day PO bid or tid
+::::* [[Trimethoprim]] 4-6 mg/kg/day PO bid (Children < 12 yr)
+::::* [[Trimethoprim]] 100-200 mg PO bid (Children > 12 yr)
+::::* [[Rifampicin]] 450 mg PO qd (weight < 50 kg)
+::::* [[Rifampicin]] 600 mg PO qd (weight > 50 kg)
+::::* [[Vancomycin]] 45-60 mg/kg/day IV q8-12h
+::::* [[Ciprofloxacin]] 15-30 mg/kg/day PO/IV q12h
+::::* [[Doxycycline]] 2-5 mg/kg/day PO/IV q12-24h (maximum daily dose: 200 mg)
+::::* [[Linezolid]] 10 mg/kg IV/PO q12h
+::::* [[Ceftriaxone]] 50-75 mg/kg IV/IM q24h
+::::* [[Ceftazidime]] 150 mg/kg/day IV/IM q8h
+:* 2. '''Long-term antibiotic prophylaxis'''
+:* Patients with ≥3 exacerbations/year requiring antibiotic therapy or patients with fewer exacerbations that are causing significant morbidity should be considered for long-term antibiotic prophylaxis
+::* 2.1 '''Pathogen-directed antimicrobial therapy'''
+:::* 2.1.1 '''Streptococcus pneumoniae'''
+::::* Preferred regimen: [[Amoxicillin]] 500 mg PO bid
+::::* Alternative regimen: [[Clarithromycin]] 250 mg PO bid
+:::* 2.1.2 '''Haemophilus influenzae (b-lactamase negative)'''
+::::* Preferred regimen: [[Amoxicillin]] 500 mg PO bid
+::::* Alternative regimen: [[Clarithromycin]] 250 mg PO bid
+:::* 2.1.3 '''Haemophilus influenzae (b-lactamase positive)'''
+::::* Preferred regimen: [[Amoxicillin-Clavulanate]] 375 mg PO tid
+::::* Alternative regimen: [[Clarithromycin]] 250 mg PO bid
+:::* 2.1.4 '''Moraxella catarrhalis'''
+::::* Preferred regimen: [[Amoxicillin-Clavulanate]] 375 mg PO tid
+::::* Alternative regimen: [[Clarithromycin]] 250 mg PO bid
+:::* 2.1.5 '''Staphylococcus aureus (MSSA)'''
+::::* Preferred regimen: [[Flucloxacillin]] 500 mg PO bid
+::::* Alternative regimen: [[Clarithromycin]] 250 mg PO bid
+:* 3. '''Pseudomonas eradication (colonization)'''
+::* 3.1 '''Initial therapy'''
+:::* Preferred regimen: [[Ciprofloxacin]] 750 mg PO bid for 14 days
+::* 3.2 '''Secondary therapy in case of treatment failure'''
+:::* Preferred regimen (1): [[Piperacillin-tazobactam]] 4.5 g PO tid for 14 days
+:::* Preferred regimen (2): [[Cefepime]] 1-2 g IV q8-12h
+:::* Preferred regimen (3): [[Ciprofloxacin]] 750 mg PO bid for 4 weeks {{and}} [[Colistin]] (Nebulized) 2 MU NEB bid for 3 months
+:::* Preferred regimen (3): [[Colistin]] (Nebulized) 2 MU NEB bid for 3 months
 ===Bronchiolitis===
+*'''Bronchiolitis'''<ref name="pmid25349312">{{cite journal| author=Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM et al.| title=Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. | journal=Pediatrics | year= 2014 | volume= 134 | issue= 5 | pages= e1474-502 | pmid=25349312 | doi=10.1542/peds.2014-2742 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25349312  }} </ref>
+:* 1. '''Treatment'''
+::* Preferred regimen: Supportive care. No antimicrobial therapy recommended.
+:* 2. '''Prophylaxis'''
+::*Indications for prophylaxis:
+:::*First year of life during RSV season in infants with hemodynamically significant heart disease
+:::*First year of life during RSV season in preterm infants < 32 weeks 0 days’ gestation who require > 21% oxygen for at least the first 28 days of life
+::* Preferred regimen: [[Palivizumab]] 15 mg/kg IM monthly for 5 months
 ===Bronchitis===
+* '''Acute bronchitis'''<ref name="pmid16428698">{{cite journal| author=Braman SS| title=Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines. | journal=Chest | year= 2006 | volume= 129 | issue= 1 Suppl | pages= 95S-103S | pmid=16428698 | doi=10.1378/chest.129.1_suppl.95S | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16428698  }} </ref>
+:* 1.'''Treatment of acute bronchitis with no suspicion of pertussis'''
+::* Preferred regimen: Supportive care. Antimicrobial therapy not recommended.
+:* 2.'''Treatment of acute bronchitis with suspected or confirmed pertussis'''
+::* Preferred regimen (1): [[Erythromycin]] 15 mg/kg PO tid for 5-14 days
+::* Preferred regimen (2): [[Azithromycin]] 500 mg PO single dose {{then}} [[Azithromycin]] 250 mg PO qd for 4 days
 ===Cystic fibrosis===
-:* Pathogen directed antimicrobial therapy <ref name="pmid23540878">{{cite journal| author=Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB et al.| title=Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health. | journal=Am J Respir Crit Care Med | year= 2013 | volume= 187 | issue= 7 | pages= 680-9 | pmid=23540878 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23540878  }} </ref>
+* '''Cystic Fibrosis'''
-:* Bacterial
+:* 1.'''Pathogen-directed antimicrobial therapy''' <ref name="pmid23540878">{{cite journal| author=Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB et al.| title=Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health. | journal=Am J Respir Crit Care Med | year= 2013 | volume= 187 | issue= 7 | pages= 680-9 | pmid=23540878 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23540878  }} </ref>
-::* Pseudomonas aeruginosa
+::* 1.1 '''Pseudomonas aeruginosa'''
-:::* Preferred Regimen: [[Tobramycin]] 3.3 mg/kg q8h or 12 mg/kg IV q24h {{and}} ([[Piperacillin]] 100 mg/kg q6h {{or}} [[Ticarcillin]] 100 mg/kg q6h {{or}} [[Ceftazidime]] 50 mg/kg IV q8h (to maximum of 6 gm/day))
+:::* 1.1.1 '''Adults'''
-:::* Alternative Regimen: [[Tobramycin]] (3.3 mg/kg q8h or 12 mg/kg IV q24h) {{and}} ([[Aztreonam]] 50 mg/kg IV q8h {{or}} [[Tobramycin]] 3.3 mg/kg q8h or 12 mg/kg IV q24h) {{and}} Imipenem 15-25 mg/kg IV q6. If Tobramycin resistant add [[Ciprofloxacin]] Oral : 500-750 mg twice daily for 7-14 days-IV 400 mg every 12 hours for 7-14 days {{or}} [[Levofloxacin]] 750 mg every 24 hours for 7-14 days
+::::* Preferred regimen (1): [[Tobramycin]] 3.3 mg/kg PO tid {{or}} [[Tobramycin]] 12 mg/kg IV q24h {{and}} ([[Piperacillin]] 100 mg/kg PO qid
-:::* Only in children: [[Ciprofloxacin ]]Oral :500-750 mg twice daily for 7-14 days-IV 400 mg every 12 hours for 7-14 days {{and}} [[Ceftazidime]] IV 500 mg to 1 g every 8 hours.
+::::* Preferred regimen (2): [[Ticarcillin]] 100 mg/kg PO qid
+::::* Preferred regimen (3): [[Ceftazidime]] 50 mg/kg IV q8h (to maximum of 6 g/day)
-::*Staphylococcus aureus
+::::* Alternative regimen (1): ([[Tobramycin]] 3.3 mg/kg PO tid {{or}} [[Tobramycin]] 12 mg/kg IV q24h) {{and}} [[Aztreonam]] 50 mg/kg IV q8h
-:::* Preferred Regimen (Adult)
+::::* Alternative regimen (2): ([[Tobramycin]] 3.3 mg/kg PO tid {{or}} [[Tobramycin]] 12 mg/kg IV q24h) {{and}} [[Imipenem]] 15-25 mg/kg IV q6h
-::::* IF methicillin sensitive staphylococcus aureus: [[Nafcillin]] 2 gm IV q4hs {{or}} [[Oxacillin]] 2 gm IV q4hs
+::::* Note: If [[Tobramycin]] resistant add [[Ciprofloxacin]] 500-750 mg PO bid for 7-14 days {{or}} [[Ciprofloxacin]] 400 mg IV q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg PO qd for 7-14 days
-::::* If methicillin resistant staphylococcus aureus: [[Vancomycin]] 15-20 mg/kg IV q8-12h {{or}} [[Linezolid]] 600 mg po/IV q12h
+:::* 1.1.2 '''Children'''
-:::* Preferred regimen (Pediatric)
+::::* Preferred regimen: ([[Ciprofloxacin ]] 500-750 mg PO bid for 7-14 days {{or}} [[Ciprofloxacin ]] 400 mg IV q12h for 7-14 days) {{and}} [[Ceftazidime]] 0.5-1 g IV q8h
-::::* IF methicillin sensitive staphylococcus aureus: [[Nafcillin]] 5 mg/kg q6h (Age >28 days) {{or}} [[Oxacillin]] 75 mg/kg q6h (Age >28 days)]]
+::* 1.2 '''Staphylococcus aureus'''
-::::* If methicillin resistant staphylococcus aureus: [[Vancomycin]] 40 mg/kg divided q6-8h (Age >28 days) {{or}} [[Linezolid]] 10 mg/kg po/IV q8h (up to age 12)
+:::* 1.2.1 '''Adults'''
+::::* 1.2.1.1 '''Methicillin sensitive staphylococcus aureus'''
-::* Burkholderia cepacia
+:::::* Preferred regimen: [[Nafcillin]] 2 g IV q4h {{or}} [[Oxacillin]] 2 g IV q4h
-:::* Preferred Regimen: [[Trimethoprim-sulfamethoxazole]] 5 mg/kg (TMP component) IV q6h
+::::* 1.2.1.2 '''Methicillin resistant staphylococcus aureus'''
-:::* Alternate Regimen : [[Chloramphenicol]] 15–20 mg/kg IV/po q6h
+:::::* Preferred regimen: [[Vancomycin]] 15-20 mg/kg IV q8-12h {{or}} [[Linezolid]] 600 mg PO/IV q12h
+:::* 1.2.2 '''Children'''
+::::* 1.2.2.1 '''Methicillin sensitive staphylococcus aureus'''
+:::::* Preferred regimen: [[Nafcillin]] 5 mg/kg IV q6h (age > 28 days) {{or}} [[Oxacillin]] 75 mg/kg IV q6h (age > 28 days)
+::::* 1.2.2.2 '''Methicillin resistant staphylococcus aureus'''
+:::::* Preferred regimen: [[Vancomycin]] 40 mg/kg IV divided q6-8h (age >28 days) {{or}} [[Linezolid]] 10 mg/kg PO/IV q8h (up to age 12)
+::* 1.3 '''Burkholderia cepacia'''
+:::* Preferred regimen: [[Trimethoprim-sulfamethoxazole]] 5/25 mg/kg IV q6h
+:::* Alternative regimen: [[Chloramphenicol]] 15–20 mg/kg PO/IV q6h
 ===Empyema===
+*'''Empyema'''<ref>{{cite book | last = LastName | first = FirstName | title = Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Place of publication not identified | year = 2007 | isbn = 9781930808386 }}</ref>
+:* 1. '''Empiric antimicrobial therapy or culture negative therapy'''
+:::*Causative pathogens:
+::::*Streptococcus milleri
+::::*Streptococcus pneumoniae
+::::*Streptococcus intermedius
+::::*Staphylococcus aureus
+::::*Enterobacteriaceae
+::::*Escherichia coli
+::::*Fusobacterium spp.
+::::*Bacteroides spp.
+::::*Peptostreptococcus spp.
+:::* Preferred regimen (1): [[Cefuroxime]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8h
+:::* Preferred regimen (2): [[Ceftriaxone]] 1.5 g IV q8h {{and}} [[Metronidazole]] 500 mg IV q8h
+:::* Preferred regimen (3): [[Piperacillin-Tazobactam]] 3.375 g IV q4h {{or}} [[Ticarcillin-clavulanate]] 3.1 g IV q4h {{or}} [[Ampicillin-Sulbactam]] 2/1 g IV q6h
+:::* Preferred regimen (4): [[Meropenem]] 1 g IV q8h {{or}} [[Imipenem]] 500 mg IV q6h
+:::* Note: Consider coverage for MRSA if high suspicion exists.
+:* 2. '''Pathogen-based therapy'''
+::* 2.1 '''Acute empyema'''
+:::* 2.1.1 '''Streptococcus pneumoniae, Group A streptrococcus  '''
+::::* Preferred regimen: [[Ceftriaxone]] 1.5 g IV/IM q24h
+:::* 2.1.2 '''Staphylococcus aureus'''
+::::* 2.1.2.1 '''MSSA'''
+:::::* Preferred regimen: [[Nafcillin]] 2 g IV q4h {{or}} [[Oxacillin]] 2 g IV q4h
+::::* 2.1.2.2 '''MRSA'''
+:::::* Preferred regimen: [[Vancomycin]] 1 g IV q12h {{or}} [[Linezolid]] 600 mg PO/IV q12h
+:::* 2.1.3 '''Hemophilus influenzae'''
+::::* Preferred regimen: [[Ceftriaxone]] 1.5 g IV/IM q24h
+::::* Alternative regimen: [[Trimethoprim-Sulfamethoxazole]] 8-20 mg TMP/kg/day IV q6-12h or [[Ampicillin-Sulbactam]] 2/1 g IV q6h
+::* 2.2 '''Subacute/chronic empyema'''
+:::* 2.2.1 '''Anaerobic streptococcus, Streptococcus milleri, Bacteroides species, Enterobacteriaceae, Mycobacterium tuberculosis'''
+::::* Preferred regimen: [[Clindamycin]] 450–900 mg IV q8h {{and}} [[Ceftriaxone]] 1.5 g IV/IM q24h
+::::* Alternative regimen: [[Imipenem]] 500 mg IV q6h {{or}} [[Piperacillin-Tazobactam]] 3.375 g IV q4h {{or}} [[Ticarcillin-clavulanate]] 3.1 g IV q4h {{or}} [[Ampicillin-Sulbactam]] 2/1 g IV q6h
-===Influenza===
+===Pneumonia===
+*'''Pneumonia'''
-===Inhalational anthrax, Prophylaxis===
+:* 1. '''Community-acquired pneumonia'''
-*''' Oral postexposure prophylaxis for infection with Bacillus anthracis (for adults)'''<ref name="pmid24447897">{{cite journal| author=Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT et al.| title=Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. | journal=Emerg Infect Dis | year= 2014 | volume= 20 | issue= 2 | pages=  | pmid=24447897 | doi=10.3201/eid2002.130687 | pmc=PMC3901462 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24447897  }} </ref>
+::* 1.1 '''Empiric therapy in adults''' <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
-:* (1) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: '''[[Ciprofloxacin]], 500 mg q12h''' {{or}} '''Doxycycline, 100 mg q12h''' {{or}} Levofloxacin, 750 mg q24h {{or}} Moxifloxacin, 400 mg q24h {{or}} Clindamycin, 600 mg q8h {{or}}
+:::* 1.1.1 '''Outpatient treatment'''
+::::* 1.1.1.1 '''Previously healthy and no use of antimicrobials within the previous 3 months'''
-:* (2) Alternatives for penicillin-susceptible strain Amoxicillin, 1 g q8h {{or}} Penicillin VK, 500 mg q6h
+:::::* Preferred regimen (1): ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days) {{or}} [[Azithromycin]] 500 mg IV single dose
-:: Note (1): Preferred drugs are indicated in boldface.
+:::::* Preferred regimen (2): [[Clarithromycin]] 250 mg PO bid for 7-14 days {{or}} [[Clarithromycin]] 1000 mg PO qd for 7 days
-:: Note (2): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment or if first-line treatment is unavailable.
+:::::* Preferred regimen (3): [[Erythromycin]] 250-500 mg PO bid or tid (maximum daily dose 4 g)
+:::::* Alternative regimen: [[Doxycycline]] 100 mg PO/IV q12h
-*'''Postexposure Prophylaxis for Bacillus anthracis (for Children 1 Month of Age and Older)'''<ref name="pmid24777226">{{cite journal| author=Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D et al.| title=Pediatric anthrax clinical management. | journal=Pediatrics | year= 2014 | volume= 133 | issue= 5 | pages= e1411-36 | pmid=24777226 | doi=10.1542/peds.2014-0563 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24777226  }} </ref>
+::::* 1.1.1.2 '''Presence of comorbidities, use of immunosuppressing drugs, or use of antimicrobials within the previous 3 months'''
-:* (1). For penicillin-resistant strains or prior to susceptibility testing: '''[[Ciprofloxacin]], 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose)''' {{or}} '''[[Doxycycline]], <45 kg: 4.4 mg/kg/day, PO, divided q12h (not to exceed 100 mg/dose)''' >45 kg: 100 mg/dose, PO, given q12h {{or}} [[Clindamycin]], 30 mg/kg/day, PO, divided q8h (not to exceed 900 mg/dose) {{or}} [[Levofloxacin]], <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) >50 kg: 500 mg, PO, given q24h {{or}}
+:::::* Preferred regimen (1): [[Levofloxacin]] 500 mg PO qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg PO qd for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}}  [[Gemifloxacin]] 320 mg PO qd for 5 or 7 days
+:::::* Preferred regimen (2): ([[Amoxicillin]] 1 g PO q8h {{or}} [[Amoxicillin-clavulanate]] 1-2 g PO bid {{or}} [[Ceftriaxone]] 1-2 g IV q24h {{or}} [[Cefpodoxime]] 200 mg PO bid for 14 days {{or}} [[Cefuroxime]] 750 mg IM/IV q8h) {{and}} either ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days) {{or}} ([[Clarithromycin]] 250 mg PO bid for 7-14 days {{or}} [[Clarithromycin]] 1000 mg PO qd for 7 days) {{or}} [[Erythromycin]] 250-500 mg PO bid or tid (maximum daily dose 4 g)
-:* (2). For penicillin-susceptible strains: '''[[Amoxicillin]], 75 mg/kg/day, PO, divided every q8h (not to exceed 1 g/dose)''' {{or}} [[Penicillin VK]], 50-75 mg/kg/day, PO, divided q6h to q8h
+:::::*Note: In the case of recent (past 3 months) antimicrobial therapy, an alternative from a different class should be selected.
-:: Note (1) : '''Duration of Therapy is 60 days after exposure'''
+:::* 1.1.2 '''Inpatient treatment'''
-:: Note (2) : Bold font are  preferred antimicrobial agent (when 2 bolded antimicrobial agents are present, both are considered equivalent in overall safety and efficacy).
+::::* 1.1.2.1 '''Non-ICU treatment'''
-:: Note (3) : Normal font are alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.
+:::::* Preferred regimen (1): [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days {{or}} [[Moxifloxacin]] 400 mg IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO qd for 5-7 days
-:: Note (4) : Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
+:::::* Preferred regimen (2): ([[Amoxicillin]] 1 g PO q8h {{or}} [[Amoxicillin-clavulanate]] 1-2 g PO bid {{or}} [[Ceftriaxone]] 1-2 g IV q24h {{or}} [[Cefpodoxime]] 200 mg PO bid for 14 days {{or}} [[Cefuroxime]] 750 mg IM/IV q8h) {{and}} either ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days) {{or}} ([[Clarithromycin]] 250 mg PO bid for 7-14 days {{or}} [[Clarithromycin]] 1000 mg PO qd for 7 days) {{or}} [[Erythromycin]] 250-500 mg PO bid or tid (maximum daily dose 4 g)
-:: Note (5) : Italicized font: indicates FDA approval for the indication in the pediatric population.
+::::* 1.1.2.2 '''ICU treatment'''
-:: Note (6) : A single 14-day course of doxycycline is not routinely associated with tooth staining, but some degree of staining is likely for a prolonged treatment course of up to 60 days.
+:::::* Preferred regimen (1): ([[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1-2 g IV q24h {{or}} [[Ampicillin-sulbactam]] 1.5-3 g IV q6h) {{and}} ([[Levofloxacin ]] 500 mg IV q24h for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO q24h for 5-7 days)
-:: Note (7) : Safety data for [[Levofloxacin]] in the pediatric population are limited to 14 days for duration therapy.
+:::::* Alternative regimen (1): ([[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1-2 g IV q24h {{or}} [[Ampicillin-sulbactam]] 1.5-3 g IV q6h) {{and}} ([[Azithromycin]] 500 mg IV qd for 2 days (PO for a total of 7-10 days)
-:: Note (8) : Be aware of the possibility of emergence of penicillin-resistance during monotherapy with [[Amoxicillin]] or [[Penicillin]].
+:::::* Alternative regimen (2): [[Aztreonam]] 2 g IV q6-8h (maximum daily dose 8 g) {{and}} ([[Levofloxacin ]] 500 mg IV q24h for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO q24h for 5-7 days)
+:::* 1.1.3 '''Special considerations'''
-===Inhalational anthrax, Treatment===
+::::* 1.1.3.1 '''Suspected Pseudomonas'''
-* '''Treatment for anthrax in adults''' <ref name="pmid24447897">{{cite journal| author=Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT et al.| title=Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults. | journal=Emerg Infect Dis | year= 2014 | volume= 20 | issue= 2 | pages=  | pmid=24447897 | doi=10.3201/eid2002.130687 | pmc=PMC3901462 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24447897  }} </ref>
+:::::* Preferred regimen (1): [[Piperacillin-Tazobactam]] 3.375-4.5 g IV q6h for 7-14 days {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
-:* Pathogen-directed antimicrobial therapy
+:::::* Preferred regimen (2): [[Cefepime]] 1-2 g IV q8-12h for 7-10 days {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
-:* '''(1) Intravenous therapy for systemic anthrax with possible/confirmed meningitis'''
+:::::* Preferred regimen (3): ([[Imipenem]] 500 mg IV q6h for ≤5 days {{or}} [[Meropenem]] 500 mg IV q8hr for ≤5 days) {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
-::* Preferred regimen
+:::::* Preferred regimen (4): [[Piperacillin-Tazobactam]] 3.375-4.5 g IV q6h for 7-14 days {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days)
-:::* (1) Bactericidal agent (fluoroquinolone): '''[[Ciprofloxacin]], 400 mg IV q8h''' ({{or}} [[Levofloxacin]], 750 mg IV q24h {{or}} [[Moxifloxacin]], 400 mg IV q24h) {{and}}
+:::::* Preferred regimen (5): [[Cefepime]] {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days)
-:::* (2) Bactericidal agent (β-lactam) for all strains, regardless of penicillin susceptibility or if susceptibility is unknown: '''[[Meropenem]], 2 g IV q8h''' {{or}} [[Imipenem]], 1 g IV q6h {{or}} [[Doripenem]], 500 mg IV q8h {{or}}
+:::::* Preferred regimen (6): ([[Imipenem]] 500 mg IV q6h for ≤5 days {{or}} [[Meropenem]] 500 mg IV q8hr for ≤5 days) {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days)
-:::* (3) Alternatives for penicillin-susceptible strains : [[Penicillin G]], 4 million units q4h {{or}} [[Ampicillin]], 3 g q6h {{and}}
+:::::* Preferred regimen (7): ([[Imipenem]] 500 mg IV q6h for ≤5 days {{or}} [[Meropenem]] 500 mg IV q8hr for ≤5 days) {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg PO qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg PO qd for 5 days)
-:::* (4) Protein synthesis inhibitor : '''[[Linezolid]], 600 mg q12h''' {{or}} [[Clindamycin]], 900 mg q8h {{or}} [[Rifampin]], 600 mg q12h {{or}} [[Chloramphenicol]], 1 g q6h or q8h.
+:::::* Preferred regimen (8): [[Piperacillin-Tazobactam]] 3.375-4.5 g IV q6h for 7-14 days {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
-::: Note (1): Duration of treatment: ≥2-3 weeks until clinical criteria for stability are met.(Preferred drugs are indicated in boldface)
+:::::* Preferred regimen (9): [[Cefepime]] 1-2 g IV q8-12h for 7-10 days {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
-::: Note (2): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
+:::::* Preferred regimen (10): ([[Imipenem]] 500 mg IV q6h for ≤5 days {{or}} [[Meropenem]] 500 mg IV q8hr for ≤5 days) {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg PO qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg PO qd for 5 days)
-::: Note (3): Systemic anthrax includes anthrax meningitis; inhalation, injection, and gastrointestinal anthrax; and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck. Preferred drugs are indicated in boldface.
+:::::* Note: For penicillin-allergic patients, substitute the beta-lactam for [[Aztreonam]] 1-2 g IV q6-8h.
-::: Note (4): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable.
+::::* 1.1.3.2 '''Suspected methicillin resistant Staphylococcus aureus (add the following)'''
-::: Note (5):Increased risk for seizures associated with [[Imipenem]]/[[Cilastatin]] treatment.
+:::::* Preferred regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days
-::: Note (6): [[Linezolid]] should be used with caution in patients with thrombocytopenia because it might exacerbate it. [[Linezolid]] use for >14 days has additional hematopoietic toxicity.
+::::* 1.1.3.3 '''Neutropenic patient''' <ref name="pmid15699079">{{cite journal| author=American Thoracic Society. Infectious Diseases Society of America| title=Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 171 | issue= 4 | pages= 388-416 | pmid=15699079 | doi=10.1164/rccm.200405-644ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15699079  }} </ref>
-::: Note (7): [[Rifampin]] is not a protein synthesis inhibitor. However, it may be used in combination with other antimicrobial drugs on the basis of its in vitro synergy.
+:::::* 1.1.3.3.1 '''No risk for multi-drug resistance'''
-::: Note (8): [[Chloramphenicol]]Should only be used if other options are not available because of toxicity concerns.
+::::::* Preferred regimen: [[Ceftriaxone]] 1-2 g q24h IV or IM (max: 4 g/day) {{or}} [[Levofloxacin]] 750 mg q24h for 7-14 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Ciprofloxacin]] 400 mg PO q8h for 10-14 days {{or}} [[Ampicillin sulbactam]] 1-2 g q6-8h IV/IM (maximum: 8 g/day) {{or}} [[Ertapenem]] 1 g IM/IV q24h for 10-14 days.
+:::::* 1.1.3.3.2 '''Risk for multi drug resistance'''
-:*'''(2) Intravenous therapy for systemic anthrax when meningitis has been excluded'''
+::::::* Preferred Regimen: ([[Cefepime]] 1-2 g q8-12h {{or}} [[Ceftazidime]] 2 g q8h {{or}} [[Imipenem]] 500 mg q6h or 1g q8h {{or}} [[Meropenem]] 1 g q8h {{or}} [[Piperacillin-tazobactam]] 4.5 g q6h) {{and}} ([[Ciprofloxacin]] 400 mg q8h {{or}} [[Levofloxacin]] 750 mg q24h {{or}} [[Amikacin]] 20 mg/kg per day {{or}} [[Gentamycin]] 7 mg/kg per day {{or}} [[Tobramycin]] 7 mg/kg per day) {{and}} ([[Linezolid]] 600 mg q12h {{or}} [[Vancomycin]] 15 mg/kg q12h).
-::* Preferred regimen:
+::::::* Note (1) : Trough levels for [[Gentamycin]] and [[Tobramycin]] should be less than 1 g/ml, and for [[Amikacin]] they should be less than 4-5 g/ml.
-:::* Bactericidal drug
+::::::* Note (2) : Trough levels for [[Vancomycin]] should be 15-20 g/ml
-::::* (1) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : '''[[Ciprofloxacin]], 400 mg q8h''' ({{or}} [[Levofloxacin]], 750 mg q24h {{or}} [[Moxifloxacin]], 400 mg q24h) {{or}} [[Meropenem]], 2 g q8h {{or}} [[Imipenem]], 1 g q6h† {{or}} [[Doripenem]], 500 mg q8h {{or}} [[Vancomycin]], 60 mg/kg/d IV divided q8h (maintain serum trough concentrations of 15-20 µg/mL) {{or}}
+::::::* Note (3) : Hospital or community acquired, neutropenic patient (<500 neutrophils per mm3) [[Vancomycin]] not included in initial therapy unless high suspicion of infected intravenous access or drug-resistant Streptococcus pneumonia. Amphotericin not used unless still febrile after 3 days or high clinical likelihood.
-::::*(2) Alternatives for penicillin-susceptible strains: [[Penicillin G]], 4 million units q4h {{or}} [[Ampicillin]], 3 g q6h {{and}}
-::::* (3) Protein synthesis inhibitor: '''[[Clindamycin]], 900 mg q8h''' {{or}} '''[[Linezolid]], 600 mg q12h''' {{or}} [[Doxycycline]], 200 mg initially, then 100 mg q12 h§ {{or}} [[Rifampin]], 600 mg q12h¶
-:::: Note (1): Duration of treatment: for 2 weeks until clinical criteria for stability are met. (Preferred drugs are indicated in boldface).
-:::: Note (2):Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
-:::: Note (3):Systemic anthrax includes anthrax meningitis; inhalation, injection, and gastrointestinal anthrax and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
-:::: Note (4):Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable.
-:::: Note (5):Increased risk for seizures associated with imipenem/cilastatin treatment.
-:::: Note (6):Linezolid should be used with caution in patients with thrombocytopenia because it might exacerbate it.Linezolid use for >14 d has additional hematopoietic toxicity.
-:::: Note (7):A single 10-14 days course of [[Doxycycline]] is not routinely associated with tooth staining.
-:::: Note (8):[[Rifampin]] is not a protein synthesis inhibitor. However, it may be used in combination with other antimicrobials drugs on the basis of its in vitro synergy.
-:* '''(3) Oral treatment for cutaneous anthrax without systemic involvement'''
-::* (1) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : '''[[Ciprofloxacin]], 500 mg q12h''' {{or}} '''[[Doxycycline]], 100 mg q12h''' {{or}} '''[[Levofloxacin]], 750 mg q24h''' {{or}} '''[[Moxifloxacin]], 400 mg q24h''' {{or}} [[Clindamycin]], 600 mg q8h {{or}}
-::* (2) Alternatives for penicillin-susceptible strains: [[Amoxicillin]], 1 g q8h {{or}} [[Penicillin VK]], 500 mg q6h
-:: Note (1): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment, or if first-line treatment is unavailable. (Preferred drugs are indicated in boldface).
-:: Note (2): Duration of treatment is 60 days  for bioterrorism-related cases and 7-10 days for naturally acquired cases.
-* '''Treatment for anthrax in childern''' <ref name="pmid24777226">{{cite journal| author=Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D et al.| title=Pediatric anthrax clinical management. | journal=Pediatrics | year= 2014 | volume= 133 | issue= 5 | pages= e1411-36 | pmid=24777226 | doi=10.1542/peds.2014-0563 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24777226  }} </ref>
-:* '''(1). Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)'''
-::* (A). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : '''[[Ciprofloxacin]], 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose)''' {{or}} [[Doxycycline]], <45 kg: 4.4 mg/kg/day, PO, divided q12h (not to exceed 100 mg/dose) ≥45 kg: 100 mg/dose, PO, given q12h {{or}} [[Clindamycin]], 30 mg/kg/day, PO, divided q8h (not to exceed 600 mg/dose) {{or}} [[Levofloxacin]] <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) >50 kg: 500 mg, PO, given q24h {{or}}
-::* (B). Alternatives for penicillin-susceptible strains: '''[[Amoxicillin]], 75 mg/kg/day, PO, divided q8h (not to exceed 1 g/dose)''' {{or}} [[Penicillin VK]], 50-75 mg/kg/day, PO, divided q6h to q8h
-::: Note (1): Duration of therapy for naturally acquired infection: 7-10 days and for a biological weapon-related event: will require additional prophylaxis for inhaled spores, to complete an antimicrobial course of up to 60 days from onset of illness.
-::: Note (2): Bold font for preferred antimicrobial agent.
-::: Note (3): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or first-line therapy is unavailable.
-::: Note (4): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
-::: Note (5): Italicized font indicates FDA approval for the indication in the pediatric population.
-::: Note (6): A single 10- to 14-day course of doxycycline is not routinely associated with tooth staining.
-::: Note (7): Be aware of the possibility of emergence of penicillin-resistance during monotherapy with amoxicillin or penicillin.
-:* '''(2). Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older)'''
-::* (A). A bactericidal antimicrobial
-:::* (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: '''[[Ciprofloxacin]], 30 mg/kg/day, intravenously (IV), divided q8h (not to exceed 400 mg/dose)''' {{or}} [[Meropenem]], 60 mg/kg/day, IV, divided q8h (not to exceed 2 g/dose) {{or}} [[Levofloxacin]] <50 kg: 20 mg/kg/day, IV, divided q12h (not to exceed 250 mg/dose >50 kg: 500 mg, IV, q24h {{or}} [[Imipenem]]/[[Cilastatin]],a 100 mg/kg/day, IV, divided q6h (not to exceed 1 g/dose) {{or}} [[Vancomycin]], 60 mg/kg/day, IV, divided q8h (follow serum concentrations)
-:::* (b). Alternatives for penicillin-susceptible strains: '''[[Penicillin G]], 400 000 U/kg/day, IV, divided q4h (not to exceed 4 MU/dose)''' {{or}} [[Ampicillin]], 200 mg/kg/day, IV, divided q6h (not to exceed 3 g/dose) {{and}}
-::* (B). A Protein Synthesis Inhibitor: '''[[Clindamycin]], 40 mg/kg/day, IV, divided q8h (not to exceed 900 mg/dose)''' {{or}} [[Linezolid]] (non-CNS infection dose): <12 y old: 30 mg/kg/day, IV, divided q8h ≥12 y old: 30 mg/kg/day, IV, divided q12h (not to exceed 600 mg/dose) {{or}} [[Doxycycline]] <45 kg: 4.4 mg/kg/day, IV, loading dose (not to exceed 200 mg); ≥45 kg: 200 mg, IV, loading dose then <45 kg: 4.4 mg/kg/day, IV, divided q12h   (not to exceed 100 mg/dose); ≥45 kg: 100 mg, IV, given q12h {{or}} Rifampin,d 20 mg/kg/day, IV, divided q12h (not to exceed 300 mg/dose)
-::: Note (1): Duration of therapy for 14 days or longer until clinical criteria for stability are met.Will require prophylaxis to complete an antimicrobial course of up to 60 days from onset of illness.
-::: Note (2): Systemic anthrax includes inhalation anthrax; injection, gastrointestinal, or cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
-::: Note (3): Children with altered mental status, signs of meningeal inflammation, or focal neurologic deficits should be considered to have CNS infection if CSF examination is not possible. A normal CSF may not completely exclude deep brain hemorrhage/abscess.
-::: Note (4): Bold font for preferred antimicrobial agent.
-::: Note (5): Normal font for  alternative selections are listed in order of preference for therapy for patients who cannot tolerate first-line therapy or if first-line therapy is unavailable.
-::: Note (6): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
-::: Note (7): Increased risk of seizures associated with [[Imipenem]]/[[Cilastatin]] therapy.
-::: Note (8): [[Linezolid]] should be used with caution in patients with thrombocytopenia, as it may exacerbate it.[[Linezolid]] use for >14 days carries additional hematopoietic toxicity.
-::: Note (9): A single 14-day course of [[Doxycycline]] is not routinely associated with tooth staining.
-::: Note (10): [[Rifampin]] is not a protein synthesis inhibitor; it may also be used in combination therapy based on in vitro synergy
-:* '''(3).Triple therapy for systemic anthrax (anthrax meningitis or disseminated infection and meningitis cannot be ruled out) for Children 1 Month of Age and Older'''
-::* (A). A bactericidal antimicrobial (fluoroquinolone): [[Ciprofloxacin]], 30 mg/kg/day, intravenously (IV), divided q8h (not to exceed 400 mg/dose){{or}} [[Levofloxacin]] <50 kg: 16 mg/kg/day, IV, divided q12h (not to exceed 250 mg/dose); >50 kg: 500 mg, IV, q24h {{or}}[[Moxifloxacin]] 3 months to <2 years: 12 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
-::::2-5 years: 10 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
-::::6–11 years: 8 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose)
-::::12–17 years, ≥45 kg body weight: 400 mg, IV, once daily
-::::12–17 years, <45 kg body weight: 8 mg/kg/day, IV, divided q12h (not to exceed 200 mg/dose) {{and}}
-::* (B). A bactericidal antimicrobial (β-lactam or glycopeptide)
-:::* (a). For all strains, regardless of penicillin susceptibility testing or if susceptibility is unknown : [[Meropenem]], 120 mg/kg/day, IV, divided q8h (not to exceed 2 g/dose) {{or}} [[Imipenem]]/[[Cilastatin]], 100 mg/kg/day, IV, divided q6h (not to exceed 1 g/dose) {{or}} [[Doripenem]], 120 mg/kg/day, IV, divided q8h (not to exceed 1 g/dose) {{or}} [[Vancomycin]], 60 mg/kg/day, IV, divided q8h
-:::* (b). Alternatives for penicillin-susceptible strains: [[Penicillin G]], 400 000 U/kg/day, IV, divided q4h (not to exceed 4 MU/dose) {{or}} [[Ampicillin]], 400 mg/kg/day, IV, divided q6h (not to exceed 3 g/dose) {{and}}
-::* (C). A Protein Synthesis Inhibitor: [[Linezolid]] <12 y old: 30 mg/kg/day, IV, divided every 8 h≥12 y old: 30 mg/kg/day, IV, divided q12h (not to exceed 600 mg/dose) {{or}} [[Clindamycin]], 40 mg/kg/day, IV, divided q8h (not to exceed 900 mg/dose)  {{or}} [[Rifampin]], 20 mg/kg/day, IV, divided q12h (not to exceed 300 mg/dose)  {{or}} [[Chloramphenicol]], 100 mg/kg/day, IV, divided q6h
-::: Note (1): Duration of therapy for 2–3 wk or greater, until clinical criteria for stability are met.Will require prophylaxis to complete an antimicrobial course of up to 60 days from onset of illness.
-::: Note (2): Systemic anthrax includes anthrax meningitis; inhalation anthrax; or injection, gastrointestinal, and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
-::: Note (3): Children with altered mental status, signs of meningeal inflammation, or focal neurologic deficits should be considered to have CNS infection if CSF examination is not possible. Normal CSF may not completely exclude deep brain hemorrhage/abscess.
-::: Note (4): Bold font for preferred antimicrobial agent.
-::: Note (5): Normal font for alternative selections are listed in order of preference for therapy for patients who cannot tolerate first-line therapy or if first-line therapy is unavailable.
-::: Note (6): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
-::: Note (7):  A 400-mg dose of [[Ciprofloxacin]], IV, provides an equivalent exposure to that of a 500-mg ciprofloxacin oral tablet.
-::: Note (8): Increased risk of seizures associated with [[Imipenem]]/[[Cilastatin]] therapy.
-::: Note (9): [[Doripenem]] is approved in Japan at this dose for the treatment of community-acquired bacterial meningitis.
-::: Note (10): [[Linezolid]] should be used with caution in patients with thrombocytopenia, as it may exacerbate it. Linezolid use for >14 days carries additional hematopoietic toxicity.
-::: Note (11): [[Rifampin]] is not a protein synthesis inhibitor; it may also be used in combination therapy based on in vitro synergy for some strains of staphylococci. Not evaluated for Bacillus anthracis.
-::: Note (12) : [[Chloramphenicol]] Should be used only if other options are not available, because of toxicity concerns.
-. Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older)
-ewline"> Oral Follow-up Combination Therapy for Severe Anthrax (for Children 1 Month of Age and Older)
-. A bactericidal antimicrobial
-a. For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
-Ciprofloxacin, 30 mg/kg/day, by mouth (PO), divided every 12 h (not to exceed 500 mg/dose)
-OR
-Levofloxacin <50 kg: 16 mg/kg/day, PO, divided every 12 h (not to exceed 250 mg/dose) ≥50 kg: 500 mg, PO, given every 24 h
-OR
-b. Alternatives for penicillin-susceptible strains
-Amoxicillin, 75 mg/kg/day, PO, divided every 8 h (not to exceed 1 g/dose)
-OR
-Penicillin VK, 50–75 mg/kg/day, PO, divided every 6 to 8 h
-PLUS
-. A protein synthesis inhibitor
-Clindamycina 30 mg/kg/day, PO, divided every 8 h (not to exceed 600 mg/dose)
-OR
-Doxycyclineb <45 kg: 4.4 mg/kg/day, PO, divided every 12 h (not exceed 100 mg/dose) ≥45 kg: 100 mg, PO, given every 12 h
-OR
-Linezolidc (non-CNS infection dose):
-<12 y old: 30 mg/kg/day, PO, divided every 8 h
-≥12 y old: 30 mg/kg/day, PO, divided every 12 h
-(not to exceed 600 mg/dose)
-Duration of therapy: to complete a treatment course of 14 days or greater. May require prophylaxis to complete an antimicrobial course of up to 60
-days from onset of illness (see Appendix 1).
-Severe anthrax includes inhalation anthrax; injection, gastrointestinal, or cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
-Bold font: preferred antimicrobial agent.
-Normal font: alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.
-Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
-a Based on in vitro susceptibility data rather than studies of clinical efficacy.
-b
-A single 14-day course of doxycycline is not routinely associated with tooth staining.
-c Linezolid should be used with caution in patients with thrombocytopenia, as it may exacerbate it. Linezolid use for >14 days carries additional hematopoietic toxicity.
-. Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)
-===Pertussis===
-:*Pertussis (whooping cough)
-::* Preferred Regimen
-:::* Infant (age < 1 month): [[Azithromycin]] 10 mg/kg/d for 5 days  {{or}} [[Trimethoprim-sulfamethoxazole]] (8/40 mg/kg/day) in two divided doses x 14 days
-:::* Infant 1-5 months of age: [[Azithromycin]] 10 mg/kg/d for 5 days {{or}} [[Trimethoprim-sulfamethoxazole]] 40 mg/kg/d in 4 divided doses for 14 days
-:::* Infant (age > 6 months): [[Azithromycin]] children: 10 mg/kg on day 1, then 5 mg/kg/d for days 2-5 (max dose 500 mg {{or}} [[Erythromycin]] children: 40 mg/kg/d in 4 divided doses for 14 days (max dose 2000 mg/day)
-:::* Adult: [[Azithromycin]] 500 mg day 1, then 250 mg days 2-5 {{or}} [[Erythromycin]] 500 mg 4 times daily for 14 days
-::* Alternate Regimen
-:::* Infant 1-5 mo of age: [[Clarithromycin]] 15 mg/kg/d in two divided doses for 7 days {{or}} [[Trimethoprim-Sulfamethoxazole]] contraindicated for age < 2 months (8/40 mg/kg/day) in two divided doses for 14 days
-:::* Infant (age > 6 months): [[Clarithromycin]] 15 mg/kg/d in two divided doses (maximum dose 1 gm/day) for 7 days {{or}} [[Trimethoprim-Sulfamethoxazole]] 8/40 mg/kg/day in two divided doses for 14 days)
-:::* Adult: [[Clarithromycin]] 500 mg 2 times/day for 7 days {{or}} [[Trimethoprim-Sulfamethoxazole]] 320/1600 mg/day in two divided doses for 14 days
-:::: Note: Clarithromycin and Trimethoprim-Sulfamethoxazole are contraindicated in children below 6 mths and 2 mths respectively
-===Pneumonia, Acinetobacter===
-:* Acinetobacter species (atypical bacterial pneumonia) <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
-:::* Preferred Regimen : [[Carbapenem]] ([[Imipenem]]-[[cilastatin]], {{or}} [[meropenem]], {{or}} [[ertapenem]])
-:::* Alternate Regimen: [[Cephalosporin]]-[[aminoglycoside]]  {{or}} [[Ampicillin-sulbactam]] {{or}} [[Colistin]] 2.5-5 mg/kg/day IM/IV divided q6-12h (maximum: 5 mg/kg/day)
-===Pneumonia, Actinomycosis===
-===Pneumonia, Anaerobes===
-: Anaerobe (aspiration) pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
-::* Preferred Regimen: [[Piperacillin-tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
-::* Alternate Regimen: [[Carbapenem]]-([[Imipenem]]-[[cilastatin]], {{or}} [[meropenem]], {{or}} [[ertapenem]])
-===Pneumonia, Aspiration pneumonia===
-:* Aspiration (anaerobe) pneumonia
-::* Preferred Regimen: [[Piperacillin-tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
-::* Alternate Regimen: [[Carbapenem]]-([[Imipenem]]-[[cilastatin]], {{or}} [[meropenem]], {{or}} [[ertapenem]])
-===Pneumonia, Chlamydophila===
-:* Chlamydophila pneumoniae (atypical bacterial pneumonia) <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
-::* Preferred Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] 250-500 mg PO q6h
-::* Alternate Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h
-===Pneumonia, community-acquired===
-* '''Community acquired pneumonia'''
-:*''' Empiric therapy in adults'''
-::* (A) Outpatient treatment
-:::*(1) Previously healthy and no use of antimicrobials within the previous 3 months.
-::::* Preferred regimen : [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Azithromycin]] 500 mg IV as a single dose {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days {{or}} 1000 mg q24h for 7 days {{or}} [[Erythromycin]] 250-500 mg q6-12h (max: 4 g/day)
-::::* Alternative regimen : [[Doxycycline]] 100 mg PO/IV q12h (Weak recommendation).
-:::*(2) Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in this case an alternative from a different class should be selected)
-::::* Preferred regimen (1) :  [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}}  [[Gemifloxacin]] 320 mg PO q24h for 5 or 7 days
-::::* Preferred Regimen (2) : ([[Amoxicillin]] 875 mg PO q12h or 500 mg q8h {{or}} [[Amoxicillin-clavulanate]] 2 g q12h {{or}} [[Ceftriaxone]] 1 g IV q24h, (2 g q24h for patients at risk) {{or}} [[Cefpodoxime]] 200 mg PO q12h for 14 days {{or}} [[Cefuroxime]] 750 mg IM/IV q8h) {{and}} ( Macrolide [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Doxycycline]] 100 mg PO/IV q12h)
-::* (B) Inpatient Therapy (in regions with a high rate (125%) of infection with high-level (minimum inhibitory concentration 16 mg/mL) macrolide-resistant Streptococcus pneumoniae)
-:::* (1) Non-ICU treatment
-::::* Preferred Regimen : [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO q24h for 5 or 7 days {{or}} [[Amoxicillin ]]1 g q8h {{or}} [[Amoxicillin-clavulanate]] 2 g q12h
-::::* Alternative Regimen : [[Ceftriaxone]] 1 g IV q24h, (2 g q24h for patients at risk) {{or}} [[Cefpodoxime]] 200 mg PO q12h for 14 days {{or}} [[Cefuroxime]] 750 mg IM/IV q8h
-:::* (2) ICU treatment
-::::* Preferred Regimen : ([[Cefotaxime]] I.M., I.V.: 1 g q12h {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g/day for patients at risk {{or}} [[Ampicillin-sulbactam]] 1.5-3 g IV q6h) {{and}} ([[Azithromycin]] 500 mg/day PO once, followed by 250 mg q24h for 4 days {{or}} [[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}}  [[Levofloxacin ]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Gemifloxacin]] Oral: 320 mg q24h for 5 or 7 days)
-::::* Alternative Regimen (For penicillin allergy): ([[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 day {{or}} [[Moxifloxacin]] 400 mg q24h PO/IV for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO q24h for 5 or 7 days) {{and}} [[Aztreonam]] I.V.: 2 g q6-8h (max: 8 g/day)
-::* (C) Special Concerns
-:::* (1) Pseudomonas
-::::* Preferred Regimen (1): ([[Piperacillin-tazobactam]] 3.375 g IV q6h for 7-10 days {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 day)
-::::* Preferred Regimen (2): ([[Piperacillin-tazobactam]] 3.375 g IV q6h for 7-10 days {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} Aminoglycoside {{and}} ([[Azithromycin]] Oral: 500 mg on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO q24h for 5 or 7 days)
-:::: Note : For penicillin-allergic patients, substitute the B-lactam for Aztreonam 2 g IV q6-8h (maximum 8 g/day)
-:::* (2) Methicillin resistant staphylococcus aureus ,Add the following to the selected regimen
-::::* Preferred regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days.
-:*''' Empiric therapy in neonates''' ( Age < 1 month)
-::* Preferred regimen: [[Ampicillin]] 500 mg/day for 7-14 days or 750 mg/day for 5 days {{or}} [[Gentamicin]] 400 mg/day PO/IV for 7-14 days With or without [[Cefotaxime]] 320 mg PO q24h for 5 or 7 days
-::: Note (1) : If methicillin resistant staphylococcus aureus  is suspected, add the following [[Vancomycin]] 10 mg/kg q8h
-::: Note (2) : If Chlamydia trachomatis is suspected, add the following [[Erythromycin]] 12.5 mg/kg PO or IV qid for 14 days {{or}} [[Azithromycin]] 10 mg/kg PO/IV on day one then 5 mg/kg PO/IV q24h for 4 days.
-::* Alternate Regimen (If methicillin resistant staphylococcus aureus  is suspected): [[Vancomycin]] 10 mg/kg q8h {{or}} [[Linezolid]] 10 mg/kg q8h
-:*'''Empiric therapy,Children (> 3 months) Outpatient Therapy'''
-::* Preferred Regimen: [[Amoxicillin]] 90 mg/kg/day q12h for 5 days {{or}} [[Azithromycin]] 10 mg/kg PO 1 dose (max 500 mg), then 5 mg/kg (max 250 mg) PO for 4 days
-::* Alternate Regimen: [[Amoxicillin-clavulanate]] 90 mg/kg/day {{or}} [[Clarithromycin]] 15 mg/kg/day q12h for 7-14 days
-:*'''pathogen directed antimicrobial therapy'''
-:* Bacterial
-::* (A) Streptococcus pneumoniae
-:::* (1) Penicillin nonresistant; minimum inhibitory concentration < 2 mg / mL
-::::* Preferred Regimen : [[Penicillin G]] 2-3 million units IV q4h {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
-::::* Alternative Regimen : [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Cefpodoxime]] 200 mg PO q12h for 14 days {{or}} [[Cefprozil]] 500 mg PO q12h for 10 days {{or}} [[Cefuroxime]] 750 mg PO/IV q8h {{or}} [[Cefdinir]] 300 mg PO q12h for 10 days {{or}} [[Cefditoren]] 400 mg PO q12h for 14 day {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (maximum: 1800 mg/day) {{or}} [[Clindamycin]] 1.2-2.7 g/day IM/IV in 2-4 divided doses (maximum:4800 mg/day) {{or}} [[Doxycycline]] 100 mg PI/IV q12h {{or}}[[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h.
-:::* (2) Penicillin resistant;  minimum inhibitory concentration > 2 mg / mL
-::::* Preferred Regimen (Agents chosen on the basis of susceptibililty) : [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h
-::::* Alternative Regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)
-::* (B)Haemophilus influenzae
-:::* (1) Non-beta lactamase producing
-::::* Preferred Regimen: [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
-::::* Alternative Regimen : [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
-:::* (2) Beta lactamase producing
-::::* Preferred Regimen: 2nd or 3rd Generation [[Cephalosporin]] {{or}} [[Amoxicillin-clavulanate]] 2 g q12h
-::::* Alternative Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
-::* (C) Bacillus anthracis (inhalation)
-:::* Preferred Regimen  :[[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Doxycycline]] 100 mg PO/IV q12h
-:::* Alternate Regimen : Other [[fluoroquinolones]] {{or}} B-lactam (if susceptible) {{or}} [[Rifampin]] 600 mg PO/IV q24h for 4 days {{or}} [[Clindamycin]] 150-450 mg PO q6-8h {{or}} [[Chloramphenicol]] 50-100 mg/kg/day IV in divided q6h
-::* (D) Enterobacteriaceae
-:::* Preferred Regimen: 3rd generation cephalosporin {{or}} Carbapenem- ([[Imipenem]]-[[cilastatin]], {{or}} [[meropenem]], {{or}} [[ertapenem]]) (drug of choice if extended-spectrum b-lactamase producer)
-:::* Alternate Regimen : b-Lactam / b-lactamase inhibitor- ([[Piperacillin-tazobactam]] for gram-negative bacilli, {{or}} [[ticarcillin-clavulanate]] {{or}} [[ampicillin-sulbactam]] {{or}} [[amoxicillin-clavulanate]]) {{or}} ([[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h)
-::* (E)Pseudomonas aeruginosa
-:::* Preferred Regimen: ([[Ticarcillin]] 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) {{or}} [[Piperacillin]] 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h {{or}} [[Ceftazidime]] 500 mg to 1 g q8h {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Aztreonam]] 2 g IV q6-8h (maximum: 8 g/day) {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily {{or}} [[Aminoglycoside]])
-:::* Alternate Regimen: [[Aminoglycoside]] {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily)
-::* (F)Staphylococcus aureus
-:::* (1) Methicillin susceptible
-::::* Preferred Regimen : [[Nafcillin]] 1000-2000 mg q4h {{or}} [[Oxacillin]] 2 g IV q4h {{or}} [[Flucloxacillin]] 250 mg IM/IV q6h
-::::* Alternative Regimen : [[Cefazolin]] 500 mg IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h
-:::* (2) Methicillin resistant
-::::* Preferred Regimen : [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days
-::::* Alternative Regimen: [[Trimethoprim-sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
-::* (G)Bordetella pertussis
-:::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
-:::* Alternate Regimen: [[Trimethoprim-sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
-::* (H) Anaerobe (aspiration)
-:::* Preferred Regimen: [[Piperacillin-tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
-:::* Alternate Regimen: [[Carbapenem]] -([[Imipenem]]-[[cilastatin]], {{or}} [[meropenem]], {{or}} [[ertapenem]])
-::* (I) Mycobacterium tuberculosis
-:::* Preferred Regimen:
-::::* Intensive phase: [[Isoniazid]] 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) {{and}} [[Rifampin]] 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) {{and}} [[Ethambutol]] 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day daily for 2 months.
-::::* Continuation phase: [[Isoniazid]] 300 mg/day PO daily for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO daily for 4 months (10 mg/kg/day).
-:::* Alternate regimen (1):
-::::* Intensive phase: [[Isoniazid]] 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day)  {{and}} [[Rifampin]] 10 mg/kg/day daily for 2 months (maximum: 600 mg / day)  {{and}} [[Ethambutol]] 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g)  {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day daily for 2 months.
-::::* Continuation phase: [[Isoniazid]] 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day).
-:::: Note : Acceptable alternative for any new TB patient receiving directly observed therapy
-:::* Alternate regimen (2)
-::::* Intensive phase:[[Isoniazid]] 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day)  {{and}} [[Rifampin]] 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s {{and}} [[Ethambutol]] 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months  {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day 3 times per week for 2 months.
-::::*Continuation phase: [[Isoniazid]] 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day).
-:::: Note : Acceptable alternative provided that the patient is receiving directly observed therapy and is not living with HIV or living in an HIV prevalent setting.
-::* (J) Yersinisa pestis
-:::* Preferred Regimen: [[Streptomycin]] 15 mg/kg/day (max 1 g/day) {{or}} [[Gentamicin]] 7 mg/kg/day
-:::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h
-:* Atypical bacteria
-::* (A) Mycoplasma pneumoniae
-:::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] Oral: 250-500 mg q6h
-:::* Alternate Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h
-::* (B) Chlamydophila pneumoniae
-:::* Preferred Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] 250-500 mg PO q6h
-:::* Alternate Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h
-::* (C) Legionella species
-:::* Preferred Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
-:::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h
-::* (D)Chlamydophila psittaci
-:::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
-:::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
-::* (E) Coxiella burnetii
+::* 1.2 '''Pathogen-directed antimicrobial therapy'''
-:::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
+:::* 1.2.1 '''Bacterial pathogens'''
-:::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
+::::* 1.2.1.1 '''Streptococcus pneumoniae'''
+:::::* 1.2.1.1.1 '''Penicillin sensitive (minimum inhibitory concentration < 2 mg/mL)'''
+::::::* Preferred regimen : [[Penicillin G]] 2-3 million units IV q4h {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
+::::::* Alternative regimen : [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Cefpodoxime]] 200 mg PO q12h for 14 days {{or}} [[Cefprozil]] 500 mg PO q12h for 10 days {{or}} [[Cefuroxime]] 750 mg PO/IV q8h {{or}} [[Cefdinir]] 300 mg PO q12h for 10 days {{or}} [[Cefditoren]] 400 mg PO q12h for 14 day {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (maximum: 1800 mg/day) {{or}} [[Clindamycin]] 1.2-2.7 g/day IM/IV in 2-4 divided doses (maximum:4800 mg/day) {{or}} [[Doxycycline]] 100 mg PI/IV q12h {{or}}[[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
+:::::* 1.2.1.1.2 '''Penicillin resistant (minimum inhibitory concentration > 2 mg/mL)'''
+::::::* Preferred regimen (Agents chosen on the basis of susceptibililty) : [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
+::::::* Alternative regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)
-::* (F) Francisella tularensis
+::::* 1.2.1.2 '''Haemophilus influenzae'''
-:::* Preferred Regimen: [[Doxycycline]]  100 mg PO/IV q12h
+:::::* 1.2.1.2.1 '''Non-beta lactamase producing'''
-:::* Alternate Regimen: [[Gentamicin]] 7 mg/kg/day {{or}} [[Streptomycin]] 15 mg/kg/day (maximum: 1 g)
+::::::* Preferred regimen: [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
+::::::* Alternative regimen : [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
+:::::* 1.2.1.2.2 '''Beta lactamase producing'''
+::::::* Preferred regimen: 2nd or 3rd Generation [[Cephalosporin]] {{or}} [[Amoxicillin-clavulanate]] 2 g q12h
+::::::* Alternative regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
-::* (G) Burkholderia pseudomallei
+::::* 1.2.1.2 '''Bacillus anthracis (inhalational)'''
-:::* Preferred Regimen : [[Carbapenem]] -([[Imipenem]]-[[cilastatin]], {{or}} [[meropenem]], {{or}} [[ertapenem]]) {{or}} [[Ceftazidime]] 0.5-1 g q8h
+:::::* Preferred Regimen :[[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Doxycycline]] 100 mg PO/IV q12h
-:::* Alternate Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h {{or}} [[Trimethoprim-sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
+:::::* Alternate Regimen : Other [[Fluoroquinolones]] {{or}} B-lactam (if susceptible) {{or}} [[Rifampin]] 600 mg PO/IV q24h for 4 days {{or}} [[Clindamycin]] 150-450 mg PO q6-8h {{or}} [[Chloramphenicol]] 50-100 mg/kg/day IV in divided q6h
-::* (H) Acinetobacter species
+::::* 1.2.1.3 '''Enterobacteriaceae'''
-:::* Preferred Regimen : [[Carbapenem]]-([[Imipenem]]-[[cilastatin]], {{or}} [[meropenem]], {{or}} [[ertapenem]])
+:::::* Preferred Regimen: 3rd generation cephalosporin {{or}} Carbapenem- ([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) (drug of choice if extended-spectrum b-lactamase producer)
-:::* Alternate Regimen: [[Cephalosporin]]-[[aminoglycoside]]  {{or}} [[Ampicillin-sulbactam]] {{or}} [[Colistin]] 2.5-5 mg/kg/day IM/IV divided q6-12h (maximum: 5 mg/kg/day)
+:::::* Alternate Regimen : b-Lactam / b-lactamase inhibitor- ([[Piperacillin-Tazobactam]] for gram-negative bacilli, {{or}} [[Ticarcillin-Clavulanate]] {{or}} [[Ampicillin-Sulbactam]] {{or}} [[Amoxicillin-Clavulanate]]) {{or}} ([[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h)
-:* Viral
+::::* 1.2.1.4 '''Pseudomonas aeruginosa'''
-::* Influenza virus
+:::::* Preferred Regimen: ([[Ticarcillin]] 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) {{or}} [[Piperacillin]] 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h {{or}} [[Ceftazidime]] 500 mg to 1 g q8h {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Aztreonam]] 2 g IV q6-8h (maximum: 8 g/day) {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily {{or}} [[Aminoglycoside]])
-:::* Preferred Regimen: [[Oseltamivir]] 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) {{or}} [[Zanamivir]] Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)
+:::::* Alternative Regimen: [[Aminoglycoside]] {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily)
-:* Fungal
+::::* 1.2.1.5 '''Staphylococcus aureus'''
-::* (A) Coccidioides species
+:::::* 1.2.1.5.1 '''Methicillin sensitive'''
-:::* Preferred Regimen: [[Itraconazole]] 200 mg q12h {{or}} [[Fluconazole]] 200-400 mg daily for 3-6 month
+::::::* Preferred Regimen : [[Nafcillin]] 1000-2000 mg q4h {{or}} [[Oxacillin]] 2 g IV q4h {{or}} [[Flucloxacillin]] 250 mg IM/IV q6h
-:::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
+::::::* Alternative Regimen : [[Cefazolin]] 500 mg IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h
-::::Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection
+:::::* 1.2.1.5.2 '''Methicillin resistant'''
+::::::* Preferred Regimen : [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days
+::::::* Alternative Regimen: [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
-::* (B) Histoplasmosis
-:::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
-:::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
-::* (C) Blastomycosis
+::::* 1.2.1.6 '''Klebsiella pneumonia'''<ref> {{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
-:::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
+:::::* 1.2.1.6.1 '''Resistant to third generation cephalosporins and aztreonam'''
-:::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
+::::::* Preferred regimen (1): [[Imipenem]] 0.5 g IV q6h {{or}} [[Meropenem]]  0.5–1 g IV q8h
+:::::* 1.2.1.6.2 '''Klebsiella pneumoniae Carbapenemase producers'''
+::::::* Preferred regimen (1): [[Colistin]] (='''Polymyxin E''').In USA : '''Colymycin-M '''2.5-5 mg/kg per day of base divided into 2-4 doses 6.7-13.3 mg/kg per day of [[colistimethate sodium]] (max 800 mg/day). Elsewhere: '''Colomycin''' and '''Promixin''' ≤60 kg, 50,000-75,000 IU/kg per day IV in 3 divided doses (=4-6 mg/kg per day of [[colistimethate sodium]]). >60 kg, 1-2 mill IU IV tid (= 80-160 mg IV tid) {{or}} [[Polymyxin B]] (Poly-Rx) 15,000–25,000 units/kg/day divided q12h
+::::::* Note (1): some strains which hyperproduce extended spectrum beta-lactamase are primarily resistant to [[Ticarcillin-Clavulanate]], [[Piperacillin]]-[[Tazobactam]]
+::::::* Note (2): Extended spectrum beta-lactamases inactivates all [[Cephalosporins]], beta-lactam/beta-lactamase inhibitor drug activation not predictable; co-resistance to all [[Fluoroquinolones]] & often [[Aminoglycosides]].
+::::::* Note (3): Can give IM, but need to combine with “caine” anesthetic due to pain.
-===Pneumonia, concomitant influenza===
+::::* 1.2.1.7 '''Moraxella catarrhalis'''
-:* Influenza virus pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+:::::* Preferred regimen: [[Amoxicillin-Clavulanate]] (Augmentin) 2 tablets po bid ( (or)500/125 mg 1 tablet po tid (or) 875/125 mg 1 tablet po bid) {{or}} [[Cephalosporins]]- [[Cefdinir]] 300 mg po q12h (or) 600 mg q24h, {{or}} ([[Cefditoren pivoxil]] 200–400 mg, 2 tabs po bid,{{or}} [[Cefpodoxime proxetil]] 0.1–0.2 g po q12h, {{or}} [[Cefprozil]] 500 mg po q12h), {{or}} [[Cefoxitin]] 1 g q8h–2 g IV/IM q4h, {{or}} ([[Cefuroxime]] 0.75–1.5 g IV/IM q8h,{{or}}[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h, {{or}} [[Ceftazidime]] 1–2 g IV/IM q8–12h) {{or}} [[Trimethoprim-Sulfamethoxazole]] Single-strength (SS) is [[Trimethoprim]] 80 mg / [[Sulfamethoxazole]] 400 mg ,{{or}} (double-strength (DS) [[Trimethoprim]] 160 mg /[[Sulfamethoxazole]] 800 mg)
-::* Preferred Regimen: [[Oseltamivir]] 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) {{or}} [[Zanamivir]] Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)
+:::::*Alternative regimen:  [[Azithromycin]] 500 mg IV q24h ,{{or}} [[Clarithromycin]] 0.5 g po q12h, {{or}} [[Telithromycin]] 800 mg po q24h (two 400 mg tabs po q24h).
-===Pneumonia, Cytomegalovirus===
-* Treatment<ref name="pmid18652557">{{cite journal| author=Torres-Madriz G, Boucher HW| title=Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients. | journal=Clin Infect Dis | year= 2008 | volume= 47 | issue= 5 | pages= 702-11 | pmid=18652557 | doi=10.1086/590934 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18652557  }} </ref>
-:* Preferred regimen (1): [[Ganciclovir]] Induction therapy 5 mg/ kg IV every 12 h for normal GFR; maintenance therapy 5 mg/kg IV daily; 1 g orally every 8 h with food.
-:* Preferred regimen (2): [[Valganciclovir]] Induction therapy 900 mg orally every 12 h; maintenance therapy 900 mg daily.
-:* Alternate regimen (1): [[Foscarnet]] Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
-:* Alternate regimen (2): [[Cidofovir]] Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.
-* Prophylaxis
+::::* 1.2.1.8 '''Stenotrophomonas maltophilia'''
-:* Preferred regimen (1): [[Cytomegalovirus]] [[immunoglobulin]] 150 mg/kg within 72 h; then at 2, 4, 6, and 8 weeks; 100 mg/kg at 12 and 16 weeks after [[transplantation]].
+:::::* Preferred regimen: [[Trimethoprim-Sulfamethoxazole]] Single-strength (SS) tablet is [[Trimethoprim]] 80 mg / [[Sulfamethoxazole]]  400 mg, double-strength (DS) tablet is [[Trimethoprim]] 160 mg / [[Sulfamethoxazole]] 800 mg {{or}} IV treatment (base on TMP component): standard 8–10 mg per kg per day divided q6h, q8h, or q12h.
+:::::* Alternative regimen: [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h ([[Ticarcillin]] 3 g, [[Clavulanate]] 0.1 g per vial) {{and}} [[Aztreonam]] 1 g IV q6h (or) 2 g IV q8h
+:::::* Note (1): Potential synergy with [[Trimethoprim-Sulfamethoxazole]] {{and}} [[Ticarcillin-Clavulanate]].
+:::::* Note (2): Stenotrophomonas is one of the microorganisms causing hospital-acquired pneumonia usually with mechanical ventilation.
-===Pneumonia, Haemophilus Influenza===
+::::* 1.2.1.9 '''Bordetella pertussis'''
-:* Haemophilus influenzae pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+:::::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
-::* (1) Non-beta lactamase producing
+:::::* Alternative Regimen: [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
-:::* Preferred Regimen: [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
-:::* Alternative Regimen : [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
-::* (2) Beta lactamase producing
-:::* Preferred Regimen: 2nd or 3rd Generation [[Cephalosporin]] {{or}} [[Amoxicillin-clavulanate]] 2 g q12h
-:::* Alternative Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
-===Pneumonia, health care-associated===
+::::* 1.2.1.10 '''Anaerobes (aspiration pneumonia)'''
+:::::* Preferred Regimen: [[Piperacillin-Tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin Clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-Sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-Clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
+:::::* Alternative Regimen: [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])
-===Pneumonia, hospital-acquired===
+::::* 1.2.1.11 '''Mycobacterium tuberculosis'''
-:* No Risk Factors for multi drug resistance
+:::::* 1.2.1.11.1 '''Intensive phase'''
-::* Preferred Regimen : [[Ceftriaxone]] 1-2 g q24h IV or IM (max: 4 g/day) {{or}} [[Levofloxacin]] 750 mg q24h for 7-14 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Ciprofloxacin]] 400 mg PO q8h for 10-14 days {{or}} [[Ampicillin sulbactam]] 1-2 g q6-8h IV/IM (maximum: 8 g/day) {{or}} [[Ertapenem]] 1 g IM/IV q24h for 10-14 days.
+::::::* Preferred Regimen: [[Isoniazid]] 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) {{and}} [[Rifampin]] 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) {{and}} [[Ethambutol]] 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day daily for 2 months.
-:*Presence of Risk Factors for multi drug resistance
+::::::*Alternative regimen (1): [[Isoniazid]] 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day)  {{and}} [[Rifampin]] 10 mg/kg/day daily for 2 months (maximum: 600 mg / day)  {{and}} [[Ethambutol]] 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g)  {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day daily for 2 months.
-::* Preferred Regimen: ([[Cefepime]] 1-2 g q8-12h {{or}} [[Ceftazidime]] 2 g q8h {{or}} [[Imipenem]] 500 mg q6h or 1g q8h {{or}} [[Meropenem]] 1 g q8h {{or}} [[Piperacillin-tazobactam]] 4.5 g q6h) {{and}} ([[Ciprofloxacin]] 400 mg q8h {{or}} [[Levofloxacin]] 750 mg q24h {{or}} [[Amikacin]] 20 mg/kg per day {{or}} [[Gentamycin]] 7 mg/kg per day {{or}} [[Tobramycin]] 7 mg/kg per day) {{and}} ([[Linezolid]] 600 mg q12h {{or}} [[Vancomycin]] 15 mg/kg q12h).
+::::::*Alternative regimen (2): [[Isoniazid]] 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day)  {{and}} [[Rifampin]] 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s {{and}} [[Ethambutol]] 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months  {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day 3 times per week for 2 months.
-::: Note (1) : Trough levels for gentamicin and tobramycin should be less than 1 g/ml, and for amikacin they should be less than 4-5 g/ml.
+:::::* 1.2.1.11.2 '''Continuation phase'''
-::: Note (2) : Trough levels for vancomycin should be 15-20 g/ml
+::::::* Preferred Regimen:[[Isoniazid]] 300 mg/day PO daily for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO daily for 4 months (10 mg/kg/day)
+::::::* Alternative regimen (1): [[Isoniazid]] 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day)
-===Pneumonia, Klebsiella===
+::::* 1.2.1.12 '''Yersinisa pestis'''
+:::::* Preferred Regimen: [[Streptomycin]] 15 mg/kg/day (max 1 g/day) {{or}} [[Gentamicin]] 7 mg/kg/day
+:::::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
-===Pneumonia, Legionella===
+::::* 1.2.1.13 '''Atypical bacteria'''
-:* Legionella pneumonia (atypical bacterial pneumonia) <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+:::::* 1.2.1.13.1 '''Mycoplasma pneumoniae'''
-::* Preferred Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
+::::::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] Oral: 250-500 mg q6h
-::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h
+::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
-===Pneumonia, Lung abscess===
+:::::* 1.2.1.13.2 '''Chlamydophila pneumoniae'''
+::::::* Preferred Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] 250-500 mg PO q6h
+::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
-===Pneumonia, Meliodosis===
+:::::* 1.2.1.13.3 '''Legionella spp.'''
+::::::* Preferred Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
+::::::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h
-===Pneumonia, Moraxella catarrhalis===
+:::::* 1.2.1.13.4 '''Chlamydophila psittaci'''
+::::::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
+::::::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
-===Pneumonia, Mycoplasma===
+:::::* 1.2.1.13.5 ''' Coxiella burnetii'''
-:* Mycoplasma pneumoniae (atypical bacterial pneumonia) <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+::::::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
-::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] Oral: 250-500 mg q6h
+::::::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
-::* Alternate Regimen: [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h
-===Pneumonia, neutropenic patient===
+:::::* 1.2.1.13.6 '''Francisella tularensis'''
+::::::* Preferred Regimen: [[Doxycycline]]  100 mg PO/IV q12h
+::::::* Alternate Regimen: [[Gentamicin]] 7 mg/kg/day {{or}} [[Streptomycin]] 15 mg/kg/day (maximum: 1 g)
-===Pneumonia, Nocardia===
+:::::* 1.2.1.13.7 '''Burkholderia pseudomallei'''
+::::::* Preferred Regimen : [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) {{or}} [[Ceftazidime]] 0.5-1 g q8h
+::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
-===Pneumonia, post-influenza===
+:::::* 1.2.1.13.8 '''Acinetobacter species'''
+::::::* Preferred Regimen : [[Carbapenem]]-([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])
+::::::* Alternate Regimen: [[Cephalosporin]]-[[Aminoglycoside]]  {{or}} [[Ampicillin-Sulbactam]] {{or}} [[Colistin]] 2.5-5 mg/kg/day IM/IV divided q6-12h (maximum: 5 mg/kg/day)
-===Pneumonia, Pseuodomonas===
+::::* 1.2.1.14 '''Gram-positive filamentous bacteria'''
-:* Pseudomonas aeruginosa pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+:::::* 1.2.1.14.1 '''Actinomyces spp.'''<ref name="pmid20582172">{{cite journal| author=Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ| title=Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients. | journal=Ann Thorac Med | year= 2010 | volume= 5 | issue= 2 | pages= 80-5 | pmid=20582172 | doi=10.4103/1817-1737.62470 | pmc=PMC2883202 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20582172  }} </ref><ref name="pmidPMID: 14727221">{{cite journal| author=Sudhakar SS, Ross JJ| title=Short-term treatment of actinomycosis: two cases and a review. | journal=Clin Infect Dis | year= 2004 | volume= 38 | issue= 3 | pages= 444-7 | pmid=PMID: 14727221 | doi=10.1086/381099 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14727221  }} </ref>
-::* Preferred Regimen: ([[Ticarcillin]] 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) {{or}} [[Piperacillin]] 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h {{or}} [[Ceftazidime]] 500 mg to 1 g q8h {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Aztreonam]] 2 g IV q6-8h (maximum: 8 g/day) {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily {{or}} [[Aminoglycoside]])
+::::::* Preferred regimen: [[Penicillin]] V 1 g po qid 2-6 wk
-::* Alternate Regimen: [[Aminoglycoside]] {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily)
+::::::* Alternative regimen: [[Tetracycline]] 500 mg po q 6 h {{or}} [[Doxycycline]] 100 mg q 12 h
+::::::* Note: [[Minocycline]], [[Clindamycin]], and [[Erythromycin]] have also been successful.
+:::::* 1.2.1.14.2 '''Nocardia spp.'''<ref name="pmid8783685">{{cite journal| author=Lerner PI| title=Nocardiosis. | journal=Clin Infect Dis | year= 1996 | volume= 22 | issue= 6 | pages= 891-903; quiz 904-5 | pmid=8783685 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8783685  }} </ref>, <ref name="pmid16614249">{{cite journal| author=Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ| title=Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. | journal=Clin Microbiol Rev | year= 2006 | volume= 19 | issue= 2 | pages= 259-82 | pmid=16614249 | doi=10.1128/CMR.19.2.259-282.2006 | pmc=PMC1471991 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16614249  }} </ref>, <ref name="pmid22170936">{{cite journal| author=Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D et al.| title=Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey. | journal=J Clin Microbiol | year= 2012 | volume= 50 | issue= 3 | pages= 670-2 | pmid=22170936 | doi=10.1128/JCM.06243-11 | pmc=PMC3295118 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22170936  }} </ref>
+::::::* 1.2.1.14.2.1 '''Initial intravenous therapy''' (induction therapy)
+:::::::* Preferred regimen: [[Trimethoprim]]-[[Sulfamethoxazole]] (15 mg/kg/day IV of the trimethoprim component in 2 to 4 divided doses) for at least three to six weeks  {{and}} [[Amikacin]] (7.5 mg/kg IV  q12h) for at least three to six weeks
+:::::::* Alternative regimen: [[Imipenem]] (500 mg IV q6h) {{and}} [[Amikacin]] (7.5 mg/kg IV  q12h)
+:::::::* Note (1): If the patient is allergic to [[Sulfonamides]], desensitization should be performed when possible.
+:::::::* Note (2): If the isolate is susceptible to the third-generation cephalosporins ([[Ceftriaxone]], [[Cefotaxime]]), [[Imipenem]] can be switched to one of these agents.
+:::::::* Note (3): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
+::::::* 1.2.1.14.2.2 '''Oral maintenence therapy'''
+:::::::*Preferred regimen: A sulfonamide (eg,[[Trimethoprim]]-[[Sulfamethoxazole]]  10 mg/kg/day of the trimethoprim component in 2 or 3 divided doses) {{and}} / {{or}} [[Minocycline]] (100 mg bd) {{and}} / {{or}} [[Amoxicillin]]-[[Clavulanate]] (875 mg bd)
+:::::::* Note (1): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
+:::::::* Note (2): The duration of intravenous therapy varies with the patient's immune status. In immunocompromised patients, maximal tolerated doses should be given intravenously for at least six weeks and until clinical improvement has occurred; in contrast, immunocompetent patients may be successfully treated with a shorter duration of intravenous therapy. Following the intravenous induction phase, patients may be stepped down to oral antibiotics based upon susceptibility studies
+:::::::* Note (3): Serious pulmonary infection is treated for 6 to 12 months or longer.
-===Pneumonia, Staphylococcus aureus===
+:::* 1.2.2 '''Viral pathogens'''
-:* Staphylococcus aureus pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+::::* 1.2.2.1 '''Influenza virus'''
-::* (1) Methicillin susceptible
+:::::* Preferred Regimen: [[Oseltamivir]] 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) {{or}} [[Zanamivir]] Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)
-:::* Preferred Regimen : [[Nafcillin]] 1000-2000 mg q4h {{or}} [[Oxacillin]] 2 g IV q4h {{or}} [[Flucloxacillin]] 250 mg IM/IV q6h
+::::* 1.2.2.2 '''Cytomegalovirus'''<ref name="pmid18652557">{{cite journal| author=Torres-Madriz G, Boucher HW| title=Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients. | journal=Clin Infect Dis | year= 2008 | volume= 47 | issue= 5 | pages= 702-11 | pmid=18652557 | doi=10.1086/590934 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18652557  }} </ref>
-:::* Alternative Regimen : [[Cefazolin]] 500 mg IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h
+:::::* Preferred regimen (1): [[Ganciclovir]] Induction therapy 5 mg/ kg IV every 12 h for normal GFR; maintenance therapy 5 mg/kg IV daily; 1 g orally every 8 h with food.
-::* (2) Methicillin resistant
+:::::* Preferred regimen (2): [[Valganciclovir]] Induction therapy 900 mg orally every 12 h; maintenance therapy 900 mg daily.
-:::* Preferred Regimen : [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days
+:::::* Alternative regimen (1): [[Foscarnet]] Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
-:::* Alternative Regimen: [[Trimethoprim-sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
+:::::* Alternative regimen (2): [[Cidofovir]] Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.
-===Pneumonia, Stenotrophomonas===
+:::* 1.2.3 '''Fungal pathogens'''
+::::* 1.2.3.1 '''Coccidioides species'''
+:::::* Preferred Regimen: [[Itraconazole]] 200 mg q12h {{or}} [[Fluconazole]] 200-400 mg daily for 3-6 month
+:::::* Alternative Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
+:::::* Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection
-===Pneumonia, Streptococcus pneumoniae===
+::::* 1.2.3.2  '''Histoplasmosis'''
-:* Streptococcus pneumoniae <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+:::::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
-::* (1) Penicillin nonresistant; minimum inhibitory concentration < 2 mg / mL
+:::::* Alternative Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
-:::* Preferred Regimen : [[Penicillin G]] 2-3 million units IV q4h {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
-:::* Alternative Regimen : [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Cefpodoxime]] 200 mg PO q12h for 14 days {{or}} [[Cefprozil]] 500 mg PO q12h for 10 days {{or}} [[Cefuroxime]] 750 mg PO/IV q8h {{or}} [[Cefdinir]] 300 mg PO q12h for 10 days {{or}} [[Cefditoren]] 400 mg PO q12h for 14 day {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (maximum: 1800 mg/day) {{or}} [[Clindamycin]] 1.2-2.7 g/day IM/IV in 2-4 divided doses (maximum:4800 mg/day) {{or}} [[Doxycycline]] 100 mg PI/IV q12h {{or}} [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h.
-::* (2) Penicillin resistant;  minimum inhibitory concentration > 2 mg / mL
-:::* Preferred Regimen (Agents chosen on the basis of susceptibililty) : [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h
-:::* Alternative Regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)
-===Pneumonia, Tularemia===
+::::* 1.2.3.3  '''Blastomycosis'''
-:* Francisella tularensis pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+:::::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
-::* Preferred Regimen: [[Doxycycline]] 100 mg PO/IV q12h
+:::::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
-::* Alternate Regimen: [[Gentamicin]] 7 mg/kg/day {{or}} [[Streptomycin]] 15 mg/kg/day (maximum: 1 g)
-===Pneumonia, Yersinia pestis===
+:* 2. '''Health care-associated pneumonia'''<ref name="pmid15699079">{{cite journal| author=American Thoracic Society. Infectious Diseases Society of America| title=Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 171 | issue= 4 | pages= 388-416 | pmid=15699079 | doi=10.1164/rccm.200405-644ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15699079  }} </ref>
-:* Yersinisa pestis pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
+::* 2.1  '''Empiric antimicrobial therapy'''
-::* Preferred Regimen: [[Streptomycin]] 15 mg/kg/day (max 1 g/day) {{or}} [[Gentamicin]] 7 mg/kg/day
+:::* 2.1.1 '''No risk factors for multi drug resistance'''
-::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[levofloxacin]] 750 mg IV q24h {{or}} [[moxifloxacin]] 400 mg IV q24h
+::::* Preferred Regimen : [[Ceftriaxone]] 1-2 g q24h IV or IM (max: 4 g/day) {{or}} [[Levofloxacin]] 750 mg q24h for 7-14 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Ciprofloxacin]] 400 mg PO q8h for 10-14 days {{or}} [[Ampicillin sulbactam]] 1-2 g q6-8h IV/IM (maximum: 8 g/day) {{or}} [[Ertapenem]] 1 g IM/IV q24h for 10-14 days.
+:::* 2.1.2 '''Risk factors for multi drug resistance'''
+::::* Preferred Regimen: ([[Cefepime]] 1-2 g q8-12h {{or}} [[Ceftazidime]] 2 g q8h {{or}} [[Imipenem]] 500 mg q6h or 1g q8h {{or}} [[Meropenem]] 1 g q8h {{or}} [[Piperacillin-tazobactam]] 4.5 g q6h) {{and}} ([[Ciprofloxacin]] 400 mg q8h {{or}} [[Levofloxacin]] 750 mg q24h {{or}} [[Amikacin]] 20 mg/kg per day {{or}} [[Gentamycin]] 7 mg/kg per day {{or}} [[Tobramycin]] 7 mg/kg per day) {{and}} ([[Linezolid]] 600 mg q12h {{or}} [[Vancomycin]] 15 mg/kg q12h).
+::::* Note (1): Health care-associated pneumonia used to designate large diverse population of patients with many co-morbidities who reside in nursing homes, other long-term care facilities, require home intravenous therapy (or) are dialysis patients. Pneumonia in these patients frequently resembles hospital-acquired pneumonia.
+::::* Note (2): Trough levels for [[Gentamycin]] and [[Tobramycin]] should be less than 1 g/ml, and for [[Amikacin]] they should be less than 4-5 g/ml.
+::::* Note (3): Trough levels for [[Vancomycin]] should be 15-20 g/ml.
 ==References==
 {{reflist}}