Sandbox ID Lower Respiratory Tract

Acute bacterial exacerbations of chronic bronchitis

• Chronic bronchitis with Acute bacterial Exacerbation

• Preferred Regimen

• For mild or moderate disease: Amoxicillin 500 mg po tid OR Doxycycline 100 mg po bid OR Trimethoprim-sulfamethoxazole 1 DS tab po bid
• 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

Bronchiectasis

• Bronchiectasis

• Preferred Regimen : Levofloxacin 500 mg po q24h for 14 days OR Moxifloxacin 400 mg po q24h for 14 days

Cystic fibrosis

• Pathogen directed antimicrobial therapy
• Bacterial

• 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))
• 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
• 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.

• Staphylococcus aureus

• Preferred Regimen (Adult)

• IF methicillin sensitive staphylococcus aureus: Nafcillin 2 gm IV q4hs OR Oxacillin 2 gm IV q4hs
• If methicillin resistant staphylococcus aureus: Vancomycin 15-20 mg/kg IV q8-12h OR Linezolid 600 mg po/IV q12h

• Preferred regimen (Pediatric)

• IF methicillin sensitive staphylococcus aureus: Nafcillin 5 mg/kg q6h (Age >28 days) OR Oxacillin 75 mg/kg q6h (Age >28 days)]]
• 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)

• Burkholderia cepacia

• Preferred Regimen: Trimethoprim-sulfamethoxazole 5 mg/kg (TMP component) IV q6h
• Alternate Regimen : Chloramphenicol 15–20 mg/kg IV/po q6h

Inhalational anthrax, Prophylaxis

• Oral postexposure prophylaxis for infection with Bacillus anthracis (for adults)

• (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 strain Amoxicillin, 1 g q8h OR Penicillin VK, 500 mg q6h

Note (1): Preferred drugs are indicated in boldface.

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.

• Postexposure Prophylaxis for Bacillus anthracis (for Children 1 Month of Age and Older)

• (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

• (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 (1) : Duration of Therapy is 60 days after exposure

Note (2) : Bold font are preferred antimicrobial agent (when 2 bolded antimicrobial agents are present, both are considered equivalent in overall safety and efficacy).

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.

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 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.

Note (7) : Safety data for Levofloxacin in the pediatric population are limited to 14 days for duration therapy.

Note (8) : Be aware of the possibility of emergence of penicillin-resistance during monotherapy with Amoxicillin or Penicillin.

Inhalational anthrax, Treatment

• Treatment for anthrax in adults

• Pathogen-directed antimicrobial therapy
• Intravenous therapy for systemic anthrax with possible/confirmed meningitis

• Preferred regimen

• (1) Bactericidal agent (fluoroquinolone): Ciprofloxacin, 400 mg IV q8h (OR Levofloxacin, 750 mg IV q24h OR Moxifloxacin, 400 mg IV q24h) AND
• (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
• (3) Alternatives for penicillin-susceptible strains : Penicillin G, 4 million units q4h OR Ampicillin, 3 g q6h AND
• (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.

Note (1): Duration of treatment: ≥2-3 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. Preferred drugs are indicated in boldface.

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 days has additional hematopoietic toxicity.

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.

Note (8): ChloramphenicolShould only be used if other options are not available because of toxicity concerns.

• Intravenous therapy for systemic anthrax when meningitis has been excluded

• Preferred regimen:

• Bactericidal drug

• (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
• (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.

• 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

• 2. Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)

3. Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older) 4. Triple therapy for systemic anthrax (anthrax meningitis or disseminated infection and meningitis cannot be ruled out) for Children 1 Month of Age and Older 5. Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older) 6. 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)

• 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, Anaerobes

Anaerobe (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)
• 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)

• 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 ORlevofloxacin 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

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

• (F) 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)

• (G) 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

• (H) 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)

• Viral

• 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)

• Fungal

• (A) Coccidioides species

• Preferred Regimen: Itraconazole 200 mg q12h OR Fluconazole 200-400 mg daily for 3-6 month
• Alternate Regimen: Amphotericin B 0.5-0.7 mg/kg/day

Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection

• (B) Histoplasmosis

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

• (C) Blastomycosis

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

Pneumonia, concomitant influenza

• Influenza virus pneumonia

• 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)

Pneumonia, Cytomegalovirus

• Treatment

• 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

• 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.

Pneumonia, Haemophilus Influenza

• Haemophilus influenzae pneumonia

• (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

Pneumonia, hospital-acquired

• 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.

• Presence of 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) : 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.

Note (2) : Trough levels for vancomycin should be 15-20 g/ml

Pneumonia, Legionella

• Legionella pneumonia (atypical bacterial pneumonia)

• 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, Mycoplasma

• Mycoplasma pneumoniae (atypical bacterial pneumonia)

• 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

Pneumonia, Pseuodomonas

• Pseudomonas aeruginosa pneumonia

• 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)

Pneumonia, Staphylococcus aureus

• Staphylococcus aureus pneumonia

• (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

Pneumonia, Streptococcus pneumoniae

• 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)

Pneumonia, Tularemia

• Francisella tularensis pneumonia

• 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, Yersinia pestis

• Yersinisa pestis pneumonia

• 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