Ulcerative colitis medical therapy: Difference between revisions

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{{Ulcerative colitis}}
{{Ulcerative colitis}}
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{{CMG}}; {{AE}}{{TarekNafee}}


==Overview==
==Overview==
The first step in the management of an acute ulcerative colitis attack involves determining the anatomical extent of the disease [[endosccope|endoscopically]], and the severity of the disease, clinically. This [[Ulcerative colitis classification|classification]] is important to determine the necessity for topical (in distal disease) or systemic (in extensive disease) pharmacotherapy. Additionally, the severity of the disease may help determine the prognosis and the requirement for more aggressive intervention. Once the disease goes into remission, the goal of maintenance therapy is to prevent any subsequent acute exacerbations.
The first step in the management of an acute ulcerative colitis attack involves determining the anatomical extent of the disease [[endosccope|endoscopically]], and the severity of the disease, clinically. This [[Ulcerative colitis classification|classification]] is important to determine the necessity for topical (in distal disease) or systemic (in extensive disease) pharmacotherapy. Additionally, the severity of the disease may help determine the prognosis and the requirement for more aggressive intervention. Once the disease goes into remission, the goal of maintenance therapy is to prevent any subsequent acute exacerbations.
==Medical Therapy==
==Medical Therapy==
{{main|Treatment of ulcerative colitis}}
The goal of medical therapy is to induce [[Remission (medicine)|remission]] initially with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The concept of induction of remission and maintenance of remission is very important. The medications used to induce and maintain a remission somewhat overlap, but the treatments are different. Physicians first direct treatment to inducing a remission which involves relief of symptoms and mucosal healing of the lining of the colon and then longer term treatment to maintain the remission.


{{main|Biological therapy for inflammatory bowel disease}}
Standard treatment for ulcerative colitis depends on extent of involvement (proximal vs. distal) and disease severity (e.g. mild, moderate, severe and fulminant) as follows: <ref name="pmid20068560">{{cite journal| author=Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology| title=Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee. | journal=Am J Gastroenterol | year= 2010 | volume= 105 | issue= 3 | pages= 501-23; quiz 524 | pmid=20068560 | doi=10.1038/ajg.2009.727 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20068560  }} </ref>


The goal is to induce [[Remission (medicine)|remission]] initially with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The concept of induction of remission and maintenance of remission is very important. The medications used to induce and maintain a remission somewhat overlap, but the treatments are different. Physicians first direct treatment to inducing a remission which involves relief of symptoms and mucosal healing of the lining of the colon and then longer term treatment to maintain the remission.
Standard treatment for ulcerative colitis depends on extent of involvement (proximal vs. distal) and disease severity (e.g. mild, moderate, severe and fulminant).
===Pharmacotherapy===
:* 1. '''Mild to Moderate Distal Colitis'''
:* 1. '''Mild to Moderate Distal Colitis'''
:** '''Acute Management'''
:** '''Acute Management'''
:*** Preferred regimen (1): Topical [[Mesalamine]]
:*** Preferred regimen (1): Topical [[Mesalamine]]
:*** Preferred regimen (2): Topical [[corticosteroids]]
:*** Preferred regimen (2): Topical [[corticosteroids]]
::** Preferred regimen (3):Oral aminosalicylates
:*** Preferred regimen (3):Oral aminosalicylates
::** Alternative regimen (1): [[Mesalamine]] enemas or suppositories (in patients refractory to topical [[corticosteroid]]<nowiki/>s or oral aminosalicylates.
:*** Alternative regimen (1): [[Mesalamine]] enemas or suppositories (in patients refractory to topical [[corticosteroid]]<nowiki/>s or oral aminosalicylates.
::** Alternate regimen (2): Oral [[prednisone]] up to 40-60 mg/day '''AND''' infliximab 5mg/kg at weeks 0, 2, 6 of treatment
:*** Alternate regimen (2): Oral [[prednisone]] up to 40-60 mg/day '''AND''' infliximab 5mg/kg at weeks 0, 2, 6 of treatment
::*** Note: Effective dose of [[Sulfasalazine]] is 4-6g/day in 4 doses; [[mesalamine]] is 2-4.6g/day in 3 doses; [[Balsalazide|balasalazine]] 6.75g/day in 3 doses; [[mesalamine]] multimatrix formulation is 2.4 to 4.8 g/day. These drugs are effective within 2.4 weeks.
:**** Note: Effective dose of [[Sulfasalazine]] is 4-6g/day in 4 doses; [[mesalamine]] is 2-4.6g/day in 3 doses; [[Balsalazide|balasalazine]] 6.75g/day in 3 doses; [[mesalamine]] multimatrix formulation is 2.4 to 4.8 g/day. These drugs are effective within 2.4 weeks.
::**'''Maintenance of Remission'''
:::*'''Maintenance of Remission'''
::***Preferred regimen (1): [[Mesalamine|mesalamin]]<nowiki/>e suppository 500 mg qd or bid
:::**Preferred regimen (1): [[Mesalamine|mesalamin]]<nowiki/>e suppository 500 mg qd or bid
::*** Preferred regimen (2):[[Mesalamine (rectal)|mesalamin]]<nowiki/>e enema 2-4 g  q1-3 days
:::** Preferred regimen (2):[[Mesalamine (rectal)|mesalamin]]<nowiki/>e enema 2-4 g  q1-3 days
::*** Preferred regimen (3):[[sulfasalazine]] 2g/day '''OR''' [[Mesalamine (oral)|mesalamine compounds]] 1.6g/day '''OR''' [[balsalazide]] 3-6g/day
:::** Preferred regimen (3):[[sulfasalazine]] 2g/day '''OR''' [[Mesalamine (oral)|mesalamine compounds]] 1.6g/day '''OR''' [[balsalazide]] 3-6g/day
::*** Alternative regimen (1): [[6-mercaptopurine]] '''OR''' [[azathioprine]] '''AND''' [[infliximab]]
:::** Alternative regimen (1): [[6-mercaptopurine]] '''OR''' [[azathioprine]] '''AND''' [[infliximab]]
::**** Note: A combination of oral [[Mesalamine (oral)|mesalamine]] 1.6g/day and [[Mesalamine (rectal)|mesalamine enema]] 4g twice weekly is more effective than oral treatment alone.
:::*** Note: A combination of oral [[Mesalamine (oral)|mesalamine]] 1.6g/day and [[Mesalamine (rectal)|mesalamine enema]] 4g twice weekly is more effective than oral treatment alone.
::**'''2. Mild to Moderate Extensive Colitis'''
 
::***'''Acute Management'''
:*'''2. Mild to Moderate Extensive Colitis'''
::****Preferred regimen (1):  oral [[Sulfasalazine|sulfasalazin]]<nowiki/>e titrated up to 4-6g/day '''OR''' oral aminosalicylate in doses of up to 4.8g/day of active 5-ASA moiety
:**'''Acute Management'''
::**** Alternate regimen (1): Oral [[steroids]] (in patients refractory to aminosalicylates in combination with topical therapy)
:***Preferred regimen (1):  oral [[Sulfasalazine|sulfasalazin]]<nowiki/>e titrated up to 4-6g/day '''OR''' oral aminosalicylate in doses of up to 4.8g/day of active 5-ASA moiety
::**** Alternate regimen (2): 6-[[mercaptopurine]] AND [[azathioprine]] (in patients refractory to oral steroids)
:*** Alternate regimen (1): Oral [[steroids]] (in patients refractory to aminosalicylates in combination with topical therapy)
::**** Alternative regimen (3):  [[infliximab]] 5mg/kg I.V. at weeks 0,2, and 6 (steroid refractory or [[steroid]] dependent despite adequate [[Mercaptopurine|6-MP]] dosing or intolerant to other regimens)
:*** Alternate regimen (2): 6-[[mercaptopurine]] AND [[azathioprine]] (in patients refractory to oral steroids)
::***** Note (1): [[Infliximab]] is contraindicated in patients with untreated latent [[Tuberculosis|TB]], pre-existing demyelinating disorder, [[optic neuritis]], moderate to severe [[Congestive heart failure|CHF]], current or recent [[malignancy]]
:*** Alternative regimen (3):  [[infliximab]] 5mg/kg I.V. at weeks 0,2, and 6 (steroid refractory or [[steroid]] dependent despite adequate [[Mercaptopurine|6-MP]] dosing or intolerant to other regimens)
::***** Note (2): Transdermal [[Nicotine (transdermal)|nicotine]] is effective in achieving remission.
:**** Note (1): [[Infliximab]] is contraindicated in patients with untreated latent [[Tuberculosis|TB]], pre-existing demyelinating disorder, [[optic neuritis]], moderate to severe [[Congestive heart failure|CHF]], current or recent [[malignancy]]
::***'''Maintenance of Remission'''
:**** Note (2): Transdermal [[Nicotine (transdermal)|nicotine]] is effective in achieving remission.
::****Preferred regimen (1):  [[Sulfasalazine]], [[olsalazine]], [[mesalamine]], and [[balsalazide]]
::* '''Maintenance of Remission'''
::**** Alternative regimen (1): [[6-mercaptopurine]] '''OR''' [[azathioprine]]  
::**Preferred regimen (1):  [[Sulfasalazine]], [[olsalazine]], [[mesalamine]], and [[balsalazide]]
::**** Alternate regimen (2): [[infliximab]] (in patients with successful induction with [[infliximab]])
::**Alternative regimen (1): [[6-mercaptopurine]] '''OR''' [[azathioprine]]  
::***** Note: [[Corticosteroids]] are not recommended for long-term maintenance therapy
::**Alternate regimen (2): [[infliximab]] (in patients with successful induction with [[infliximab]])
::::* 1.1.1.2 '''Presence of comorbidities, use of immunosuppressing drugs, or use of antimicrobials within the previous 3 months'''
::***Note: [[Corticosteroids]] are not recommended for long-term maintenance therapy
:::::* 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)
:* '''3.Severe Colitis'''
:::::*Note: In the case of recent (past 3 months) antimicrobial therapy, an alternative from a different class should be selected.
::**'''Acute Management'''
:::* 1.1.2 '''Inpatient treatment'''
::***Preferred Regimen (1): Maximal oral treatment with [[prednisone]] '''AND''' oral aminosalicylate drugs '''AND''' topical [[mesalamine]]
::::* 1.1.2.1 '''Non-ICU treatment'''
::***Alternate regimen (2): Infliximab 5mg/kg (if refractory and urgent hospitalization is not necessary)
:::::* 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
::***Alternate regimen (3): Intravenous [[corticosteroids]] (if patient presents with toxicity)
:::::* 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: Failure to show significant improvement within 3-5 days is an indication for [[colectomy]]. [[Infliximab]] may be effective in avoiding [[colectomy]] in patients failing to respond to [[corticosteroids]].
::::* 1.1.2.2 '''ICU treatment'''
::::**'''Maintenance of Remission'''
:::::* 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)
::::***Preferred Regimen (1): 6 [[mercaptopurine]]
:::::* 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)
::*'''4.Management of Pouchitis (complication of [[Ulcerative colitis surgery|IPAA surgery]])'''
:::* 1.1.3 '''Special considerations'''
 
::::* 1.1.3.1 '''Suspected Pseudomonas'''
::**Preferred Regimen (1): [[Metronidazole]] 400mg q8h '''OR''' 20mg/kg daily
:::::* 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): [[Ciprofloxacin]] 500mg bid
:::::* 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)
::***Note: Other etiologies mimicking pouchitis include irritable pouch syndrome, cuffitis, CD of the pouch, and postoperative complications such as anastomotic leak or stricture.
:::::* 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)
===Pharmacotherapy===
:::::* 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''' <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>
:::::* 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 {{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)
::::* 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'''<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>
:::::* 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,{{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)
:::::*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.'''<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: [[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.'''<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.
:::* 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'''<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.
:::::* 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
===Pharmacotherapies===


==== Aminosalicylates ====
==== Aminosalicylates ====
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== References ==
== References ==
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[[Category:Autoimmune diseases]]
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[[Category:Abdominal pain]]
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Latest revision as of 00:33, 30 July 2020

Ulcerative colitis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]

Overview

The first step in the management of an acute ulcerative colitis attack involves determining the anatomical extent of the disease endoscopically, and the severity of the disease, clinically. This classification is important to determine the necessity for topical (in distal disease) or systemic (in extensive disease) pharmacotherapy. Additionally, the severity of the disease may help determine the prognosis and the requirement for more aggressive intervention. Once the disease goes into remission, the goal of maintenance therapy is to prevent any subsequent acute exacerbations.

Medical Therapy

The goal of medical therapy is to induce remission initially with medications, followed by the administration of maintenance medications to prevent a relapse of the disease. The concept of induction of remission and maintenance of remission is very important. The medications used to induce and maintain a remission somewhat overlap, but the treatments are different. Physicians first direct treatment to inducing a remission which involves relief of symptoms and mucosal healing of the lining of the colon and then longer term treatment to maintain the remission.

Standard treatment for ulcerative colitis depends on extent of involvement (proximal vs. distal) and disease severity (e.g. mild, moderate, severe and fulminant) as follows: [1]

  • 1. Mild to Moderate Distal Colitis
    • Acute Management
      • Preferred regimen (1): Topical Mesalamine
      • Preferred regimen (2): Topical corticosteroids
      • Preferred regimen (3):Oral aminosalicylates
      • Alternative regimen (1): Mesalamine enemas or suppositories (in patients refractory to topical corticosteroids or oral aminosalicylates.
      • Alternate regimen (2): Oral prednisone up to 40-60 mg/day AND infliximab 5mg/kg at weeks 0, 2, 6 of treatment
        • Note: Effective dose of Sulfasalazine is 4-6g/day in 4 doses; mesalamine is 2-4.6g/day in 3 doses; balasalazine 6.75g/day in 3 doses; mesalamine multimatrix formulation is 2.4 to 4.8 g/day. These drugs are effective within 2.4 weeks.
  • 2. Mild to Moderate Extensive Colitis
    • Acute Management
      • Preferred regimen (1): oral sulfasalazine titrated up to 4-6g/day OR oral aminosalicylate in doses of up to 4.8g/day of active 5-ASA moiety
      • Alternate regimen (1): Oral steroids (in patients refractory to aminosalicylates in combination with topical therapy)
      • Alternate regimen (2): 6-mercaptopurine AND azathioprine (in patients refractory to oral steroids)
      • Alternative regimen (3): infliximab 5mg/kg I.V. at weeks 0,2, and 6 (steroid refractory or steroid dependent despite adequate 6-MP dosing or intolerant to other regimens)
        • Note (1): Infliximab is contraindicated in patients with untreated latent TB, pre-existing demyelinating disorder, optic neuritis, moderate to severe CHF, current or recent malignancy
        • Note (2): Transdermal nicotine is effective in achieving remission.
  • 3.Severe Colitis
    • Acute Management
      • Preferred Regimen (1): Maximal oral treatment with prednisone AND oral aminosalicylate drugs AND topical mesalamine
      • Alternate regimen (2): Infliximab 5mg/kg (if refractory and urgent hospitalization is not necessary)
      • Alternate regimen (3): Intravenous corticosteroids (if patient presents with toxicity)
    • Preferred Regimen (1): Metronidazole 400mg q8h OR 20mg/kg daily
    • Preferred Regimen (2): Ciprofloxacin 500mg bid
      • Note: Other etiologies mimicking pouchitis include irritable pouch syndrome, cuffitis, CD of the pouch, and postoperative complications such as anastomotic leak or stricture.

Pharmacotherapy

Aminosalicylates

Sulfasalazine has been a major agent in the therapy of mild to moderate UC for over 50 years. In 1977 Mastan S.Kalsi et al determined that 5-aminosalicyclic acid (5-ASA and mesalazine) was the therapeutically active compound in sulfasalazine. Since then many 5-ASA compounds have been developed with the aim of maintaining efficacy but reducing the common side effects associated with the sulfapyridine moiety in sulfasalazine.[2]

Corticosteroids

Immunosuppressive drugs

Biological treatment

Contraindicated medications

Ulcerative colitis is considered an absolute contraindication to the use of the following medications:

References

  1. ↑ Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology (2010). "Ulcerative colitis practice guidelines in adults: American College Of Gastroenterology, Practice Parameters Committee". Am J Gastroenterol. 105 (3): 501–23, quiz 524. doi:10.1038/ajg.2009.727. PMID 20068560.
  2. ↑ S. Kane (2006). "Asacol - A Review Focusing on Ulcerative Colitis".

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