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Clostridium difficile

• 1. Initial episode

• 1.1 Mild to moderate

• Preferred regimen: Metronidazole 500 mg orally q8h
• Alternative regimen(If no improvement in 5-7 days): Vancomycin 125 mg orally q6h

• 1.2 Severe

• Preferred regimen: Vancomycin 125 mg orally q6h

• 1.3 Severe complicated

• Preferred regimen: Vancomycin 500 mg orally q6h AND Metronidazole 500 mg IV q8h
• NOTE: If ileus present, add Vancomycin 500 mg in 100 mL normal saline per rectum q6h as retention enema

• 2.Recurrence

• 2.1 First recurrence

• preferred regimen: Same as first episode but stratified by severity

• 2.2 Second recurrence

• preferred regimen: Vancomycin 125 mg 4 times daily for 14 days or 125 mg 2 times daily for 7 days or 125 mg once daily for 7 days or 125 mg once every 2 days for 8 days (4 doses) or 125 mg once every 3 days for 15 days (5 doses)

Clostridium tetani

• 1. General measures

• Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated

• 2. Immunotherapy

• Preferred regimen: Human TIG 500 units by intramuscular injection or intravenously as soon as possible AND Age-appropriate TT-containing vaccine, 0.5 cc by intramuscular injection at a separate site

• NOTE: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later

• 3. Antibiotic treatment

• Preferred regimen: Metronidazole 500 mg intravenously or orally every six hours OR Penicillin G 100,000–200,000 IU/kg/day intravenously, given in 2–4 divided doses

• Alternative regimen: Tetracyclines OR Macrolides OR Clindamycin OR Cephalosporins OR Chloramphenicol

• 4. Muscle spasm control

• Preferred regimen: Diazepam 5 mg intravenous OR Lorazepam 2 mg titrating to achieve spasm control without excessive sedation and hypoventilation

• Alternative regimen (1): Magnesium sulphate 5 gm (or 75mg/kg) intravenous loading dose, then 2–3 grams per hour until spasm control is achieved ± Benzodiazepines

• NOTE: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased

• Alternative regimen (2): Baclofen OR Dantrolene 1–2 mg/kg intravenous/orally every 4 hours

• Alternative regimen (3): Barbiturates 100–150 mg every 1–4 hours by any route

• Alternative regimen (4): Chlorpromazine 50–150 mg by intramuscular injection every 4–8 hours

• Pediatric regimen: Lorazepam 0.1–0.2 mg/kg every 2–6 hours, titrating upward as needed; Barbiturates 6–10 mg/kg in children by any route; Chlorpromazine 4–12 mg every by intramuscular injection every 4–8 hours

• NOTE: As for Benzodiazepines, large amounts may be required (up to 600 mg/day); Oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest

• 5. Autonomic dysfunction control

• Preferred regimen: Magnesium sulphate OR Morphine OR Esmolol

Mycobacterium abscessus

• 1.Limited, localized extrapulmonary disease

• Preferred regimen: Clarithromycin 500 mg PO twice daily ± Amikacin 10-15 mg/kg/day IV or 25 mg/kg three times weekly for 4 months

• Alternative regimen (1): Amikacin AND Cefoxitin 12 g/day typically for two weeks until clinical improvement in severe cases

• Alternative regimen (2): Amikacin AND Imipenem 500 mg IV q6-8h for two weeks until clinical improvement in severe cases
• NOTE: Osteomyelitis should be treated for as least 6 months; Infected foreign bodies should be removed

• 2.Pulmonary or serious extrapulmonary disease