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WikiDoc Infectious Disease Project — Pathogen-Based Infections

Pathogens of Public Health Significance

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Pathogens of Clinical Significance

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Bacteria – Gram-Positive Cocci

  • 1. Bacteremia[1]
  • 1.1 Ampicillin or Penicillin susceptible
  • 1.2 Ampicillin resistant and vancomycin susceptible or Penicillin allergy
  • 1.3 Ampicillin and Vancomycin resistant
  • 2.1 Endocarditis in Adults
  • 2.1.1 Strains Susceptible to Penicillin, Gentamicin, and Vancomycin
  • Preferred regimen: (Ampicillin 12 g/day IV for 4–6weeks OR Aqueous crystalline penicillin G sodium 18–30 MU/day IV for 4–6weeks) AND Gentamicin sulfate 3 mg/kg/day IV/IM for 4–6 weeks
  • Note : In case of native valve endocarditis, 4-wk therapy recommended for patients with symptoms of illness ≤3 months and 6-wk therapy recommended for patients with symptoms >3 months and prosthetic valve or other prosthetic cardiac material a minimum of 6 wk of therapy recommended
  • Alternate regimen: Vancomycin hydrochloride 30 mg/kg/day IV for 6 weeks AND Gentamicin sulfate 3 mg/kg/day IV/IM for 6weeks
  • 2.1.2 Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin
  • 2.1.3 Strains Resistant to Penicillin and Susceptible to Aminoglycoside and Vancomycin
  • 2.1.3.1 β Lactamase–producing strain
  • 2.1.3.2 Intrinsic penicillin resistance
  • 2.1.4 Strains Resistant to Penicillin, Aminoglycoside, and Vancomycin
  • 2.2 Endocarditis in Pediatrics
  • 2.2.1 Strains Susceptible to Penicillin, Gentamicin, and Vancomycin
  • Preferred regimen: (Ampicillin 300 mg/kg/day IV for 4–6weeks OR Penicillin 300,000 U/kg/day IV for 4–6 weeks) AND Gentamicin 3 mg/kg q24h IV/IM 4–6weeks
  • Note : In case of native valve endocarditis, 4-wk therapy recommended for patients with symptoms of illness ≤3 months and 6-wk therapy recommended for patients with symptoms >3 months and prosthetic valve or other prosthetic cardiac material a minimum of 6 wk of therapy recommended
  • Alternate regimen : Vancomycin 40 mg/kg/day IV for 6weeks AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • 2.2.2 Strains Susceptible to Penicillin, Streptomycin, and Vancomycin and Resistant to Gentamicin
  • 2.2.3 Strains Resistant to Penicillin and Susceptible to Aminoglycoside and Vancomycin
  • 2.2.3.1 β Lactamase–producing strain
  • 2.2.3.2 Intrinsic penicillin resistance
  • 2.2.4 Strains Resistant to Penicillin, Aminoglycoside, and Vancomycin
  • 3. Meningitis[4]
  • 3.1 Ampicillin susceptible
  • 3.2 Ampicillin resistant
  • 3.3 Ampicillin and vancomycin resistant
  • 4. Urinary tract infections [5]
  • Preferred regimen (2): Fosfomycin 3 g PO single dose
  • Preferred regimen (3): Amoxicillin 875 mg to 1 g PO q12h for 5 days
  • 5. Intra abdominal or Wound infections [6]
  • Preferred regimen(1): Penicillin
  • Preferred regimen(2): Ampicillin
  • Alternative regimen(Penicillin allergy or high-level Penicillin resistance): Vancomycin
  • Alternative regimen(For complicated skin-skin structure and intra-abdominal infection): Tigecycline 100 mg IV single dose and 50 mg IV q12h
  • 1.Bacteremia[7]
  • 2.Endocarditis
  • 2.1.Endocarditis in Adults [2]
  • Preferred regimen : (Ampicillin 12 g/day IV for 4–6weeks ORAqueous crystalline penicillin G sodium 18–30 MU/day IV for 4–6weeks) ANDGentamicin sulfate 3 mg/kg/day IV/IM for 4–6 weeks
  • Note : In case of native valve endocarditis, 4-wk therapy recommended for patients with symptoms of illness ≤3 months and 6-wk therapy recommended for patients with symptoms >3 months and prosthetic valve or other prosthetic cardiac material a minimum of 6 wk of therapy recommended
  • Alternate regimen : Vancomycin hydrochloride 30 mg/kg/day IV for 6 weeks ANDGentamicin sulfate 3 mg/kg/day IV/IM for 6weeks
  • 2.2.Endocarditis in Pediatrics
  • Preferred regimen : (Ampicillin 300 mg/kg/day IV for 4–6 weeks ORPenicillin 300,000U/kg/day IV for 4–6 weeks) ANDGentamicin 3 mg/kg per 24 h IV/IM 4–6 weeks
  • Note : In case of native valve endocarditis, 4-wk therapy recommended for patients with symptoms of illness ≤3 months and 6-wk therapy recommended for patients with symptoms >3 months and prosthetic valve or other prosthetic cardiac material a minimum of 6 wk of therapy recommended
  • Alternate regimen : Vancomycin 40 mg/kg/day IV for 6weeks ANDGentamicin 3 mg/kg/day IV/IM for 6weeks
  • β Lactamase–producing strain
  • Preferred regimen : Ampicillin-sulbactam 300 mg/kg/day IV for 6weeks ANDGentamicin 3 mg/kg/day IV/IM for 6weeks
  • Alternate regimen : Vancomycin 40 mg/kg/day IV for 6weeks ANDGentamicin 3 mg/kg/day IV/IM for 6weeks
  • Intrinsic penicillin resistance : Vancomycin 40 mg/kg/day IV ANDGentamicin 3 mg/kg/day IV/IM for 6weeks
  • 3.Meningitis[4]
  • 4.Urinary tract infections [8]
  • 5.Intra abdominal or Wound infections [9]
  • 1. Infectious endocarditis
  • 1.1 In adults
  • Preferred regimen (1): Vancomycin 15-20 mg/kg IV q8-12h
  • Preferred regimen (2): Daptomycin 6mg/kg/dose IV qd
  • 2. Intravascular catheter-related infections[10]
  • 2.1 Methicillin susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q6h
  • Preferred regimen (2): Oxacillin 2 g IV q6h
  • Alternative regimen (1): Cefazolin 2 g IV q8h
  • Alternative regimen (2): Vancomycin 15 mg/kg IV q12h
  • 2.1.1 Pediatric dose
  • 2.1.1.1.1 Neonates
  • 0–4 weeks of age and 1200 g- 50 mg/kg/day q12h
  • ≤7 days and 1200–2000 g- 50 mg/kg/day q12h
  • >7 days of age and <2000g- 75 mg/kg/day q8h
  • >7 days of age and >1200 g - 100 mg/kg/day q6h
  • 2.1.1.1.2 Infants and children is Nafcillin 100–200 mg/kg/day q4–6h
  • 2.1.1.2.1 Neonates
  • 0–4 weeks of age and 1200 g is 50 mg/kg/day q12h
  • Postnatal age <7 days and 1200–2000 g is 50–100 mg/kg/day q12h
  • Postnatal age <7 days and >2000 g is 75–150 mg/kg/day q8h
  • Postnatal age ≥7 days and 1200–2000 g is 75–150 mg/kg/day q8h
  • Postnatal age ≥7 days and >2000 g is 100–200 mg/kg/day q6h
  • 2.1.1.3.1 Neonates
  • Postnatal age ≤7 days is 40 mg/kg/day q12h
  • Postnatal age >7 days and 2000 g is 40 mg/kg/day q12h
  • Postnatal age >7 days and 12000 g is 60 mg/kg/day q8h
  • 2.1.1.3.2 Infants and children is 50 mg/kg/day q8h
  • 2.1.1.4.1 Neonates
  • Postnatal age ≤7 days and <1200 g is 15 mg/kg/day q24h
  • Postnatal age ≤7 days and 1200–2000 g is 10–15 mg/kg q12–18h
  • Postnatal age ≤7 days and >2000 g is 10–15 mg/kg q8–12h
  • Postnatal age >7 days and <1200 g is 15 mg/kg/day q24h
  • Postnatal age >7 days and 1200–2000 g is 10–15 mg/kg q8–12h
  • Postnatal age >7 days and >2000 g is 15–20 mg/kg q8h
  • 2.1.1.4.2 Infants and children is 40 mg/kg/day q6–8h
  • 2.2 Methicillin resistant Staphylococcus aureus (MRSA)
  • 2.2.1 Pediatric dose
  • 2.2.1.1.1 Neonates
  • 0–4 weeks of age and birthweight <1200 g is 10 mg/kg q8–12h (note: q12h in patients <34 weeks gestation and <1 week of age)
  • <7 days of age and birthweight >1200 g is 10 mg/kg q8–12h (note: q12h in patients <34 weeks gestation and <1 week of age)
  • 7 days and birthweight >1200 g is 10 mg/kg q8h
  • 2.2.1.1.2 Infants and children <12 years of age is 10 mg/kg q8h Children 12 years of age and adolescents is 10 mg/kg q12h
  • 2.2.1.2.1 Neonates
  • Premature neonates and <1000 g is 3.5 mg/kg q24h; 0–4 weeks and <1200 g is 2.5 mg/kg q18-24h
  • Postnatal age 7 days is 2.5 mg/kg q12h
  • Postnatal age 17 days and 1200–2000 g is 2.5 mg/kg q8-12h
  • Postnatal age 17 days and 12000 g is 2.5 mg/kg q8h
  • Premature neonates with normal renal function is 3.5–4 mg/kg q24h
  • Term neonates with normal renal function is 3.5–5 mg/kg q24h
  • 2.2.1.2.2 Infants and children <5 years of age is 2.5 mg/kg q8h; qd dosing in patients with normal renal function, 5–7.5 mg/kg q24h
  • 2.2.1.2.3 Children >5 years of age is 2–2.5 mg/kg q8h; qd with normal renal function, 5–7.5 mg/kg q24h
  • 2.2.1.3.1 Infants 12 months of age and children of mild-to-moderate infections is 6–12 mg TMP/kg/day q12h; serious infection, 15–20 mg TMP/kg/day q6-8h
  • 3. Cellulitis
3.1 Purulent cellulitis (defined as cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess)
  • 3.1.1 In adults
  • 3.1.2 In children
  • Preferred regimen (1): Clindamycin 10–13 mg/kg PO q6–8h, not to exceed 40 mg/kg/day
  • Preferred regimen (2): Trimethoprim 4–6 mg/kg, Sulfamethoxazole 20–30 mg/kg PO q12h
  • Preferred regimen (3)
  • 3.1 If patient body weight <45kg then Doxycycline 2 mg/kg PO q12h
  • 3.2 If patient body weight 45kg then Doxycycline adult dose
  • Preferred regimen (4): Minocycline 4 mg/kg PO 200 mg as a single dose, then 2 mg/kg PO q12h
  • Preferred regimen (5): Linezolid 10 mg/kg PO q8h, not to exceed 600 mg
  • 3.2 Nonpurulent cellulitis (defined as cellulitis with no purulent drainage or exudate and no associated abscess)
  • 3.2.1 In adults
Note (1): Empirical therapy for beta-hemolytic streptococci is recommended. Empirical coverage for CA-MRSA is recommended in patients who do not respond to beta-lactam therapy and may be considered in those with systemic toxicity
Note (2): Provide coverage for both beta-hemolytic streptococci and CA-MRSA beta-lactam (eg, Amoxicillin) with or without Trimethoprim-Sulfamethoxazole or a Tetracycline
  • 3.2.2 In children
  • Preferred regimen (1): Clindamycin 10–13 mg/kg PO q6–8h, not to exceed 40 mg/kg/day
  • Preferred regimen (2): Trimethoprim 4–6 mg/kg, Sulfamethoxazole 20–30 mg/kg PO q12h
  • Preferred regimen (3): Linezolid 10 mg/kg PO q8h, not to exceed 600 mg
Note (1): Clindamycin causes Clostridium difficile–associated disease may occur more frequently, compared with other oral agents
Note (2): Trimethoprim-Sulfamethoxazole not recommended for women in the third trimester of pregnancy and for children ,2 months of age
Note (3): Tetracyclines are not recommended for children under 8 years of age and are pregnancy category D
  • 4.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 4.1.1 In adults
  • 4.1.2 In children
  • Preferred regimen (1): Vancomycin15 mg/kg/dose IV q6h
  • Preferred regimen (2): Linezolid 10 mg/kg/dose PO/IV q8h
Note: Consider the addition of Rifampin 600 mg qd OR 300–450 mg bid to Vancomycin.
  • 4.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4h
  • Preferred regimen (2): Oxacillin 2 g IV q4h
  • Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h
  • 5. Cerebrospinal fluid shunt infection [14][15]
  • 5.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h with or without Rifampin 600 mg IV or PO q24h
Note: Shunt removal is recommended, and it should not be replaced until cerebrospinal fluid cultures are repeatedly negative.
  • 5.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4h with or without Rifampin 600 mg IV/PO q24h
  • Preferred regimen (2): Oxacillin 2 g IV q4h
  • 6.1 Penicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen: Penicillin G 4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • 6.2 Methicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen (1): Cefazolin 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks
  • Preferred regimen (2): Nafcillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • Preferred regimen (3): Oxacillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • Alternative regimen: Clindamycin 600 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks
  • 6.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 6.3.1 In adults
  • Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks
  • 6.3.2 Pediatric dose
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
  • Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin in adult patients.
  • 7. Bacterial meningitis
  • 7.1 Methicillin susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 9–12 g/day IV q4h
  • Preferred regimen (2): Oxacillin 9–12 g/day IV q4h
  • Alternative regimen (1): Vancomycin 30–45 mg/kg/day IV q8–12h
  • Alternative regimen (2): Meropenem 6 g/day IV q8h
  • 7.2 Methicillin resistant Staphylococcus aureus (MRSA)
Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin in adult patients.
  • 8. Septic thrombosis of cavernous or dural venous sinus[20]
  • 8.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 8.1.1 In adults
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h for 4–6 weeks
  • Alternative regimen (1): Linezolid 600 mg PO or IV q12h for 4–6 weeks
  • Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg/dose PO or IV q8–12h for 4–6 weeks
  • 8.1.2 Pediatric dose
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
  • Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible.
Note (2): Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin.
  • 9. Subdural empyema
  • 9.1 Methicillin-resistant Staphylococcus aureus (MRSA)[21]
  • 9.1.1 In adults
  • Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
  • Alternative regimen (1): Linezolid 600 mg PO or IV q12h for 4–6 weeks
  • Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO or IV q8–12h for 4–6 weeks
  • 9.1.2 In children
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
  • Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin.
  • 10. Acute conjunctivitis [22]
  • 10.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 11. Appendicitis
11.1 Health Care–Associated Complicated Intra-abdominal Infection [23]
11.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • 12. Diverticulitis
12.1 Health Care–Associated Complicated Intra-abdominal Infection [23]
12.1.1Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h.
  • 13. Peritonitis secondary to bowel perforation, peritonitis secondary to ruptured appendix, peritonitis secondary to ruptured appendix, typhlitis
13.1 Health Care–Associated Complicated Intra-abdominal Infection [23]
  • 13.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • 14. Cystic fibrosis [24]
  • 14.1 Adults
  • 14.1.1 If methicillin sensitive staphylococcus aureus
  • 14.1.2 If methicillin resistant staphylococcus aureus
  • Preferred Regimen (1): Vancomycin 15-20 mg/kg IV q8-12h
  • Preferred Regimen (2): Linezolid 600 mg PO or IV q12h
  • 14.2 Pediatric
  • 14.2.1 If methicillin sensitive staphylococcus aureus
  • Preferred Regimen (1): Nafcillin 5 mg/kg q6h (Age >28 days)
  • Preferred Regimen (2): Oxacillin 75 mg/kg q6h (Age >28 days)
  • 14.2.2 If methicillin resistant staphylococcus aureus
  • Preferred Regimen (1): Vancomycin 40 mg/kg q6-8h (Age >28 days)
  • Preferred Regimen (2): Linezolid 10 mg/kg PO or IV q8h (up to age 12)
  • 15. Bronchiectasis [25]
  • 15.1 In adults
  • 15.1.1 Recommended first-line treatment and length of treatment
15.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.1.1.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 15.1.1.2.1 Patient's body weight is <50 kg
  • 15.1.1.2.2 Patient's body weight is >50 kg
  • 15.1.1.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen (1): Vancomycin 1 g IV bd (monitor serum levels and adjust dose accordingly)
  • Preferred regimen (2): Teicoplanin 400 mg qd for 14 days
  • 15.1.2 Recommended second-line treatment and length of treatment
  • 15.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.1.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 15.1.2.2.1 Patient's body weight is <50 kg
  • 15.1.2.2.2 Patient's body weight is >50 kg
  • 15.1.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Linezolid 600 mg IV bd 14 days
  • 15.2 In children
  • 15.2.1 Recommended first-line treatment and length of treatment
  • 15.2.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.2.1.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 15.2.1.2.1 Children (< 12 yr)
  • Preferred regimen: Trimethoprim 4-6 mg/kg/day divided q12h PO
  • 15.2.1.2.2 Children (> 12 yr)
  • 15.2.1.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 15.2.2 Recommended second-line treatment and length of treatment
  • 15.2.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
15.2.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen (1): Rifampicin AND Doxycycline 2-5 mg/kg/day divided q12-24h PO or IV (max dose: 200 mg/24 hr)
  • Preferred regimen (2): Rifampicin AND Doxycycline 2-5 mg/kg/day divided q12-24h PO or IV (max dose: 200 mg/24 hr)
  • Third-line: Linezolid 10 mg/kg q12h IV or PO
  • 15.2.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Linezolid 10 mg/kg q12h IV or PO
  • 15.3 Long-term oral antibiotic treatment
  • 15.3.1 In adults
  • 15.3.1.1 Recommended first-line treatment and length of treatment
  • 15.3.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.3.1.2 Recommended second-line treatment and length of treatment
  • 15.3.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 17. Community-acquired pneumonia[27]
  • 17.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 17.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred Regimen (1): Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days
  • Preferred Regimen (2): Linezolid 600 mg PO/IV q12h for 10-14 days
  • Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h
  • 18. Olecranon bursitis or prepatellar bursitis
  • 18.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 18.2 Methicillin-resistant Staphylococcus aureus (MRSA)
Note: Initially aspirate q24h and treat for a minimum of 2–3 weeks.
  • 19. Septic arthritis
  • 19.1 In adults
  • 19.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • Alternative regimen (1): Daptomycin 6 mg/kg IV q24h in adults
  • Alternative regimen (2): Linezolid 600 mg PO or IV q12h
  • Alternative regimen (3): Clindamycin 600 mg PO or IV q8h
  • Alternative regimen (4): TMP-SMX 3.5–4.0 mg/kg PO or IV q8–12h
  • 19.2 In childern
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
  • Preferred regimen (2): Daptomycin 6–10 mg/kg IV q24h
  • Preferred regimen (3): Linezolid 10 mg/kg PO or IV q8h
  • Preferred regimen (4): Clindamycin 10–13 mg/kg PO or IV q6–8h
  • 19.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q6h
  • Preferred regimen (2): Clindamycin 900 mg IV q8h
  • Alternative regimen (1): Cefazolin 0.25–1 g IV/IM q6–8h
  • Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h
  • 20. Septic arthritis, prosthetic joint infection (device-related osteoarticular infections)
  • 20.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4–6h
  • Preferred regimen (2): Oxacillin 2 g IV q4–6h
  • Alternative regimen (1): Cefazolin 1–2 g IV q8h
  • Alternative regimen (2): Ceftriaxone 2 g IV q24h
  • Alternative regimen (if allergic to penicillins) (3): Clindamycin 900 mg IV q8h
  • Alternative regimen (if allergic to penicillins) (4): Vancomycin 15–20 mg/kg IV q8–12h, not to exceed 2 g per dose
  • 20.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Early-onset (2 months after surgery) or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)
  • Preferred regimen: Vancomycin AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
  • Alternative regimen (1): Daptomycin 6 mg/kg IV q24h AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
  • Alternative regimen (2): Linezolid 600 IV q8h AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
Note: The above regimen should be followed by Rifampin and Fluoroquinolone, Trimethoprim/Sulfamethoxazole, a Tetracycline or Clindamycin for 3 or 6 months for hips and knees, respectively.
  • 21. Hematogenous osteomyelitis
  • 21.1 Adult (>21 yrs)
  • 21.1.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • Preferred regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
  • 21.1.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • 21.2 Children (>4 months)-Adult
  • 21.2.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • 21.2.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • Preferred regimen (1): Nafcillin
  • Preferred regimen (2): Oxacillin q6h (to max. 8–12 gm per day)
Note: Add Ceftazidime 50 mg q8h or Cefepime 150 mg q8h if gram negative bacilli on Gram stain
  • 21.3 Newborn (<4 months.)
  • 21.3.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • 21.3.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • 21.4 Specific therapy
  • 21.4.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin
  • Preferred regimen (2): Oxacillin 2 gm IV q4h
  • Preferred regimen (3): Cefazolin 2 gm IV q8h
  • Alternative regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
  • 21.4.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 1 gm IV q12h
  • Alternative regimen: Linezolid 600 mg q12h IV or PO with or without Rifampin 300 mg PO or IV bid
  • 22. Diabetic foot osteomyelitis
  • High risk for MRSA
  • Preferred regimen (1): Linezolid 600 mg IV or PO q12h
  • Preferred regimen (2): Daptomycin 4 mg/kg IV q24h
  • Preferred regimen (3): Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
  • 23. Necrotizing fasciitis[28]
  • 23.1 In adult
  • 23.2 In childern
  • 24. Staphylococcal toxic shock syndrome [29]
  • 24.1 Methicillin sensitive Staphylococcus aureus
  • Preferred regimen (1): Cloxacillin 250-500 mg PO q6h (max dose: 4 g/24 hr)
  • Preferred regimen (2): Nafcillin 4-12 g/24 hr divided IV q4-6hr (max dose: 12 g/24 hr)
  • Preferred regimen (3): Cefazolin 0.5-2g IV or IM q8h (max dose: 12 g/24 hr), AND Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
  • Alternative regimen (1): Clarithromycin 250-500 mg PO q12h (max dose: 1 g/24 hr) AND Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
  • Alternative regimen (2): Rifampicin, AND Linezolid 600 mg IV or PO q12h
  • Alternative regimen (3): Daptomycin ::::* Alternative regimen (4): Tigecycline 100 mg loading dose followed by 50 mg IV q12h
  • 24.2 Methicillin resistant Staphylococcus aureus
  • Preferred regimen (1): Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
  • Preferred regimen (2): Linezolid 600 mg IV or PO q12h AND Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per dose
  • Preferred regimen (3): Teicoplanin
  • Alternative regimen (1): Rifampicin, AND Linezolid 600 mg q12h IV or PO
  • Alternative regimen (2): Daptomycin
  • Alternative regimen (3): Tigecycline 100 mg loading dose followed by 50 mg q12h IV
  • 24.3 Glycopeptide resistant or intermediate Staphylococcus aureus
  • Preferred regimen: Linezolid 600 mg IV or PO q12h AND Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO) (if sensitive)
  • Alternative regimen (1): Daptomycin
  • Alternative regimen (2): Tigecycline 100 mg loading dose followed by 50 mg IV q12h
Note: Incidence increasing. Geographical patterns highly variable.
  • Staphylococcus aureus ,prophylaxis
  • 1. Prophylaxis for coronary artery bypass graft-associated acute mediastinitis[30]
  • 1.1 Methicillin susceptible staphylococcus aureus (MSSA)
  • Preferred regimen: A first- or second-generation Cephalosporin is recommended for prophylaxis in patients without methicillin-resistant Staphylococcus aureus colonization.
  • 1.2 Methicillin resistant staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin alone or in combination with other antibiotics to achieve broader coverage is recommended for prophylaxis in patients with proven or suspected methicillin-resistant S. aureus colonization
Note (1): Preoperative antibiotics should be administered to all patients to reduce the risk of mediastinitis in cardiac surgery.
Note (2): The use of intranasal Mupirocin is reasonable in nasal carriers of Staphylococcus aureus.
  • 1. Bacteremia: most often due to IV lines, vascular grafts, cardiac valves (30-40% of all coagulase-negative staphylococcus infections)
Note: Site sepcific recommendation for peripheral line is to remove line, antibiotics for 5-7 days and for central line may often keep line and systemic antibiotics for 2 wks with antibiotics lock.
  • 2. CSF shunt: meningitis
Note: Shunt removal usually recommended but variable. Vancomycin 22.5 mg/kg IV q12h and rifampin PO/IV and possible intraventricular antibiotics: Vancomycin 20 mg/day with or without Gentamicin 4-8 mg/day is recommended.
  • 3. Peritoneal dialysis catheter: peritonitis
Note: Site sepcific recommendation is to keep dialysis catheter (at least for first effort) and IV Vancomycin (usually 2 g IV/wk and redose when level <15 mcg/mL) with antibiotics lock for 10-14 days.
  • 4. Prosthetic joint: septic arthritis
Note: Site sepcific recommendation is typically remove joint (two stage more common than single stage replacement), antibiotics for 6 wks. If very early infection (less than 3 wks post-op, debridement and retention an option).
  • 5. Prosthetic or natural cardiac valve: endocarditis
Note: Site sepcific recommendation is consider valve replacement and antibiotics for 6 wks.
  • 6. Post-sternotomy: osteomyelitis
  • 7. Implants (breast, penile, pacemaker) and other prosthetic devices: local infection
Note: Site sepcific recommendation for vascular graft is to remove graft, antibiotics for 6 wks.
  • 8. Post-ocular surgery: endophthalmitis
  • 9. Surgical site infections
Note: only assume Methicillin susceptible if multiple isolates are so identified.
Note (1): Mastitis with no abscess- increase frequency of nursing may hasten response.
Note (2): Mastitis with abscess- needle aspiration reported successful. Resume breast feeding from affected breast as soon as pain allows.
  • 2. Non-puerperal mastitis with abscess
Note (1): If subareolar & odoriferous, most likely anaerobes; need to add Metronidazole 500 mg IV/po tid.
Note (2): If not subareolar, staph. Need pretreatment aerobic/anaerobic cultures. Surgical drainage for abscess.
Note (3):Staphylococcus lugdunensis usually susceptible to gentamicin. 75% are penicillin-susceptible.
  • 1.1 Acute uncomplicated urinary tract infection (cystitis-urethritis) in females
Note (1): Pyridium non-prescription—may relieve dysuria. Hemolysis if G6PD deficient.
Note (2): >7-day treatment recommended in pregnancy [discontinue or do not use sulfonamides (Trimethoprim-Sulfamethoxazole) near term (2 weeks before EDC) because of potential increase in kernicterus]. If failure on 3-day course, culture and treat for 2 weeks.
  • 1.2 Recurrent urinary tract infection in postmenopausal women
Note (1): Recurrent urinary tract infection definition is ≥3 culture and symptomatic urinary tract infection in 1 year or 2 urinary tract infection in 6 months. Evaluate for potentially correctable urologic factors like (1) cystocele (2) incontinence (3) increased residual urine volume (≥50 mL).
Note (2): Nitrofurantoin more effective than vaginal cream in decreasing frequency, but adverse effect is pulmonary fibrosis with long-term Nitrofurantoin treatment.
  • Streptococcus moniliformis treatment[33]
  • 1. Migratory arthropathy and arthritis
  • Preferred regimen (uncomplicated disease): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 wk, switch to oral Amoxicillin OR Penicillin Vk complete 14 days.
  • 2. Diarrhea, (especially kids) liver or spleen abscess
  • Preferred regimen (uncomplicated disease): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 wk, switch to oral Amoxicillin OR Penicillin Vk complete 14 days.
  • 3. Undifferentiated fever
  • Preferred regimen (uncomplicated disease): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 wk, switch to oral Amoxicillin OR Penicillin Vk complete 14 days.
  • 4. Endocarditis, myocarditis, pericarditis (cardiac)
  • 5. Meningitis, brain abscess
  • 6. Anemia
  • Preferred regimen (uncomplicated disease): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 wk, switch to oral Amoxicillin OR Penicillin Vk complete 14 days.
  • 7. Pneumonia
  • Preferred regimen (uncomplicated disease): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 wk, switch to oral Amoxicillin OR Penicillin Vk complete 14 days.
  • 8. Amnionitis (pregnancy)
  • Preferred regimen (uncomplicated disease): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 wk, switch to oral Amoxicillin OR Penicillin Vk complete 14 days.
  • 9. Renal abscess
  • Preferred regimen (uncomplicated disease): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 wk, switch to oral Amoxicillin OR Penicillin Vk complete 14 days.
  • Streptococcus anginosus treatment[34]
Note (1): Endocarditis caused by Steptococcus anginosus module for management is follow viridans Streptococci recommendations.
Note (2): Dental abscesses,sinusitis,fasciitis of head and neck caused by Steptococcus anginosus can be life threatening and require aggressive surgical management and appropriate HEENT module for specific management.
Note (3): Bacteremia caused by Steptococcus anginosus often associated with deep-seated abscess—most often intraabdominal investigation for abscess is required.Drainage is usually recommended.
Note (4): Brain abscesses caused by Steptococcus anginosus is often polymicrobial,but S.intermedius found in 50-80%.
Note (5): Infection caused by Steptococcus anginosus is implicated in aspiration pneumonia,lung abscess and empyema.


  • Streptococcus pneumonia treatment
  • 1. Lung (pneumonia)
  • Community-acquired pneumonia [27]
  • 1.1 Penicillin sensitive (minimum inhibitory concentration ≤ 2)
  • Preferred regimen (1): Aqueous crystalline Penicillin-G 6 MU q4-6h IV for 4 weeks
  • Preferred regimen (2) (who are unable to tolerate beta lactams therapy): Vancomycin 15 mg/kg/day IV q12h
  • Preferred regimen (3) (If the isolate is resistant (MIC 2 g/mL) to cefotaxime): Cefotaxime 1-2 g q8-12h IV or IM (max dose: 12 g/24 hr) AND Vancomycin 15 mg/kg/day IV q12h AND Rifampin
  • Alternative regimen: Cefazolin 0.5-2 g q8h IV or IM (max dose: 12 g/24 hr) OR Ceftriaxone 2 g IV q12h
Note : S pneumoniae with intermediate doses Minimum inhibitory concentration (MIC) 0.12 g/mL–0.5 g/mL penicillin resistance (MIC 0.1 to 1.0 g/mL) or high penicillin resistance (MIC 2.0 g/mL) is being recovered from patients with bacteremia.
  • 3. Sinuses (sinusitis)[36]
  • Sinusitis (empiric therapy)
  • 4. Bronchi (acute exacerbation of chronic bronchitis)[37]
  • 5. CNS (meningitis)[4]
  • Empiric therapy
Note: Middle ear infections (otitis media), peritoneum infections (spontaneous bacterial peritonitis), pericardium infections (purulent pericarditis), skin infections (cellulitis) and eye infections (conjunctivitis) caused by Streptococcus pneumonia.
  • Prevention
  • 1. Pneumovax (23-valent) prevents bacteremia; impact on rates of CAP are modest or nil.
  • 2. Prevnar vaccine for children <2 yrs age prevents invasive pneumococcal infection in adults by herd effect. Impact is impressive with rates of invasive pneumococcal infection down 80% in peds and 20-40% in adults.
  • 3. Risk for bacteremia in splenectomy, HIV, smokers, black race, multiple myeloma, asthma.
  • 1. Pharynx
  • 1.1 Pharyngitis
  • Preferred regimen: Penicillin-benzathine]] Penicillin 1.2 mU IM once OR Penicillin VK 500 mg PO bd or tid for 10 days.
  • Alternative regimen (1): Amoxicillin 750 PO bd or tid for 10 days.
  • Alternative regimen (Penicillin allergy) (2): Erythromycin 500 mg PO bd or tid for 10 days OR (Azithromycin 500 mg, then 250 mg for 5 days, Clarithromycin (Biaxin) 1 g XR/day or 500 mg bd for 10 days. Note: 5-10% isolates are macrolide resistant) OR Cefpodoxime proxetil (Vantin) 200 mg bd for 5 days OR Cefdinir 300 mg bd PO for 5 days OR Cefadroxil 500 mg bd PO for 5 days OR Loracarbef 200 mg PO bd for 5 days.
  • 1.2 Epiglottitis in childern
Note: Have tracheostomy set “at bedside.” Chloro is effective, but potentially less toxic alternative agents available.
  • 2. Skin
  • 2.1 Erysipelas, lymphangitis, cellulitis
  • Preferred regimen (1): Clindamycin 600 mg IV q8h AND Penicillin G G 4 mU IV q4h. (clindamycin to stop toxin production).
  • Preferred regimen (2) topical antimicrobials: Retapamulin (Altabax) 1% ointment 5, 10 & 15 gm bid tubes.
Note: Microbiologic success with Retapamulin (Altabax) 1% ointment in 90% S. aureus infections and 97% of S. pyogenes infections(do not use for MRSA)
  • 2.2 Burn wound sepsis
Note: Erythema multiformedue to Herpes simplex type 1, mycoplasma, Streptococcus pyogenes, drugs (sulfonamides, phenytoin, penicillins)
  • 3. Soft tissue
Note: For necrotizing fasciitis, surgical consultation for emergent fasciotomy and debridement; repeat debridements usually necessary.
  • 4. Muscle
Note: For myositis-debirdement is recommended.
  • 5. Toxin mediated
  • 5.1 Toxic shock syndrome
  • Preferred regimen (1): Penicillin G 24 MU qd IV AND Clindamycin 900 mg IV q8h
  • Preferred regimen (2): Immunoglobulin-G IV 1 gm/kg day 1, then 0.5 gm/kg days 2 & 3.,massive IV fluids (10-20 L/day), Albumin if <2 g/dL, debridement of necrotic tissue
  • Alternative regimen: Ceftriaxone 2 gm IV q24h AND Clindamycin 900 mg IV q8h
Note (1): Surgery usually required.
Note (2): Mortality with fasciitis 30–50%, myositis 80% even with early treatment.
Note (3): Clindamycin decreases toxin production.
Note (4): Use of NSAID may predispose to TSS.
Note (5): For reasons Penicillin G may fail in fulminant Streptococcus pyogenes infections
Note (6):Immunoglobulin-G IV associated with decreased in sepsis-related organ failure. IVIG preparations vary in neutralizing antibody content.
  • 6. Breast implant infection
  • Preferred regimen for acute infection: Vancomycin 1 gm IV q12h; if over 100 kg, 1.5 gm q12h.
Note: Acute infection caused by Staphylococcus aureus, Sreptococcus pyogenes. Toxic shock syndrome reported.
  • Preferred regimen for chronic infection:
Note (1): For chronic infections look for rapidly growing Mycobacteria
Note (2): For chronic infections wait for culture results.
  • 7. Acute mastoiditis
  • 7.1 Outpatient treatment
  • 7.1.1 Adult doses for sinusitis
  • 7.1.2 Pediatric doses for sinusitis
Note: need Vancomycin OR Nafcillin/Oxacillin if culture positive for Staphylococcus aureus.
  • 7.2 Hospitalized treatment
  • 8. Eye
  • 8.1 Keratitis
  • 8.1.1 Acute bacterial keratitis
  • Preferred regimen: Moxifloxacin eye gtts. 1 gtt tid for 7 days
  • Alternative therapy: Gatifloxacin eye gtts. 1-2 gtts q2h while awake for 2 days, then q4h for 3-7 days.
Note: Prefer Moxifloxacin due to enhanced lipophilicity and penetration into aqueous humor (1 gtt = 1 drop).
  • 8.1.2 Keratitis due to dry cornea, diabetes, immunosuppression
  • Preferred regimen: Cefazolin (50 mg/mL) AND (Gentamicin OR Tobramycin (14 mg/mL) q15–60 min around clock for 24–72 hrs, then slow reduction)
  • Alternative therapy: Vancomycin (50 mg/mL) AND Ceftazidime (50 mg/mL) q15–60 min around clock for 24–72 hrs, then slow reduction.
Note: Specific therapy guided by results of alginate swab culture and sensitivity. Ciprofloxacin 0.3% found clinically equivalent to CefazolinAND Tobramycin; only concern was efficacy of Ciprofloxacin vs S. pneumoniae
  • 8.2 Dacryocystitis (lacrimal sac)
  • 9. Suppurative phlebitis
  • Preferred regimen: Vancomycin 15 mg/kg IV q12h (normal weight):::* Alternative regimen: Daptomycin 6 mg/kg IV q12h:::: Note: Retrospective study for suppurative phlebitis recommends 2-3 weeks IV therapy and 2 weeks PO therapy.
  • 10. Infected prosthetic joint
Note: Debridement & prosthesis retention with intravenous antibiotics.
  • 11. “Hot” tender parotid swelling
Note: Predisposing factors are stone(s) in Stensen’s duct, dehydration. Therapy depends on ID of specific etiologic organism.
  • 12. Diabetic foot ulcer (ulcer with <2 cm of superficial inflammation)
  • Preferred regimen: (Trimethoprim-Sulfamethoxazole-DS 1-2 tabs PO bid OR Minocycline 100 mg PO bid) AND ([[Penicillin VK 500 mg PO qidOR selected Cephalosporins 2, 3 generation - cefprozil 500 mg PO q12h OR cefuroxime axetil 500 mg PO q12h OR cefdinir 300 mg PO q12h or 600 mg PO q24h OR cefpodoxime 200 mgPO q12h OR Fluoroquinolones Levo 750 mg po q24h).
Note (1): Common infections are bacterial pharyngitis and cellulitis. Rare but devastating are toxic shock syndrome, necrotizing fasciitis.
Note (2): Diagnosis recovery from normally sterile site, ASO antibody response (rheumatic fever),anti-DNAase B (pyoderma). Supportive are positive throat culture or rapid strep antigen test.
Note (3): Cellulitis is very hard to detect Group A streptococcus by culture (needle aspiration or blood culture).
Note (4): Ecologic niche is pharynx. 2-3% of adults colonized, 15-20% school children. Virulence depends on proteins that represent toxins, mimic host macromolecules and after immune responses.
Note (5): Predisposing factors: soft tissue (IDU, diabetes, surgery, trauma, varicella, vein donor, lymphedema); pneumonia (influenza), contacts w/ gas (pharyngitis and fasciitis).
Note (6): Mastoiditis has become a rare entity, presumably as result of the aggressive treatment of acute otitis media.
  • 1. Acute rheumatic fever prophylaxis
  • 2. Recurrent cellulitis, chronic lymphedema prophylaxis


  • Streptococcus agalactiae treatment [39]
  • 1. Bacteremia, soft tissue infections
  • Preferred regimen: Penicillin G 10-12 MU/day for 10 days [e.g., give 2 MU q4h or six divided doses/day].
  • 2. Meningitis (Adult)
  • Preferred regimen: Penicillin G 20-24 MU/day for 14-21 days.
  • 3. Osteomyelitis
  • 4. Endocarditis
Note (1):Gentamicin 1 mg/kg q8h IV additionally for any serious group B Streptococcus infection.
Note (2): Penicillin allergic may substitute Vancomycin 15 mg/kg IV q12h for Penicillin.
Note (3): Clindamycin can be considered, but rates of resistance vary. Consider confirming absence of inducible Clindamycin resistance (typically associated with macrolide resistance) before using as monotherapy.
Note (4): Streptococcus agalactiae causes neonatal sepsis or meningitis, puerperal sepsis, chorioamnionitis; also bacteremia (often without clear source), skin and soft-tissue infections, septic arthritis. Found in gastrointestinal,genitourinary tracts. More common in adults >65 years and those with comorbidities.

Bacteria – Gram-Positive Bacilli

  • Actinomyces israelii treatment[40]
  • Arcanobacterium haemolyticum treatment
Note: Arcanobacterium haemolyticum is sensitivity to most drugs but resistent to Trimethoprim-Sulfamethoxazole
  • 1. Treatment for cutaneous anthrax, without systemic involvement[41]
Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
  • 2. Treatment for systemic anthrax including anthrax meningitis, inhalational anthrax, injectional anthrax, and gastrointestinal anthrax; and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck[41]
  • 2.1 Systemic anthrax with possible/confirmed meningitis
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): 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 (4): Increased risk for seizures associated with Imipenem/Cilastatin treatment.
Note (5): 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 (6): 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 (7): Chloramphenicol should only be used if other options are not available because of toxicity concerns.
  • 2.2 Systemic anthrax when meningitis has been excluded
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): 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 (4): Increased risk for seizures associated with Imipenem/Cilastatin treatment.
Note (5): 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 (6): 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 (7): A single 10-14 days course of Doxycycline is not routinely associated with tooth staining.
  • 3. Specific considerations
  • 3.1 Treatment of anthrax for pregnant Women
  • 3.1.1 Intravenous antimicrobial treatment for systemic anthrax with possible/confirmed meningitis [42]
  • 3.1.1.1 A Bactericidal Agent (Fluoroquinolone): Ciprofloxacin 400 mg IV q8h is preferred, OR Levofloxacin 750 mg IV q24h, OR
  • 3.1.1.2 A Bactericidal Agent (ß-lactam)
  • 3.1.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Meropenem 2 g q8h,OR
  • 3.1.1.2.2 Alternatives for penicillin-susceptible strains: Ampicillin 3 g IV q6h,OR Penicillin G 4 million units IV q4h, OR
Note (1): At least one antibiotic with transplacental passage is recommended.
Note (2): Duration of treatment is for =2–3 weeks until clinical criteria for stability are met. Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
  • 3.1.2 Intravenous antimicrobial treatment for systemic anthrax when meningitis has been excluded
  • 3.1.2.1 A Bactericidal Antimicrobial: Ciprofloxacin 400 mg IV q8h is preferred, OR Levofloxacin 750 mg IV q24h, OR
  • 3.1.2.2 A Bactericidal Agent (ß-lactam)
  • 3.1.2.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Meropenem 2 g q8h,OR
  • 3.1.2.2.2 Alternatives for penicillin-susceptible strains:Ampicillin 3 g IV q6h,OR Penicillin G 4 million units IV q4h, OR
Note (1): At least one antibiotic with transplacental passage is recommended.
Note (2):Duration of treatment: for =2 weeks until clinical criteria for stability are met. Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness
  • 3.1.3 Oral antimicrobial treatment for cutaneous anthrax without systemic involvement
  • 3.1.3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Ciprofloxacin 400 mg IV q8h is preferred.
Note (1): duration of treatment is 60 days
Note (2): Recommendations are specific to cutaneous anthrax in the setting of bioterrorism.
  • 3.2 Treatment for anthrax in childern [43]
  • 3.2.1 Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)
  • 3.2.1.1 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
  • 3.2.1.2 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.
  • 3.2.2 Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older)
  • 3.2.2.1 A bactericidal antimicrobial
  • 3.2.2.1.1 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)
  • 3.2.2.1.2 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
  • 3.2.2.2 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
  • 3.2.3 Triple therapy for systemic anthrax (anthrax meningitis or disseminated infection and meningitis cannot be ruled out) for Children 1 Month of Age and Older
  • 3.2.3.1 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
  • 3.2.3.2 A bactericidal antimicrobial (ß-lactam or glycopeptide)
  • 3.2.3.2.1 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
  • 3.2.3.2.2 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
  • 3.2.3.3 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.
  • 3.2.4 Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older)
  • 3.2.4.1 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 q12h (not to exceed 500 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-q8h AND
  • 3.2.4.2 A protein synthesis inhibitor: Clindamycin 30 mg/kg/day, PO, divided q8h (not to exceed 600 mg/dose) OR Doxycycline <45 kg: 4.4 mg/kg/day, PO, divided q12h (not exceed 100 mg/dose) =45 kg: 100 mg, PO, given q12h OR Linezolid (non-CNS infection dose):
<12 y old: 30 mg/kg/day, PO, divided q8h
=12 years old: 30 mg/kg/day, PO, divided q12h (not to exceed 600 mg/dose)
Note (1): 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.
Note (2): Severe anthrax includes inhalation anthrax; injection, gastrointestinal, or cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck.
Note (3): Bold font for preferred antimicrobial agent.
Note (4): Normal font for 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 (5): Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
Note (6): A single 14-day course of doxycycline is not routinely associated with tooth staining.
Note (7): Linezolid should be used with caution in patients with thrombocytopenia, as it may exacerbate it. Linezolid use for >14 days carries additional hematopoietic toxicity.
  • 3.2.5 Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)
  • 3.2.5.1 Triple therapy for severe anthrax(anthrax meningitis or disseminated infection and meningitis cannot be ruled out)
  • 3.2.5.1.1 Bactericidal antimicrobial (fluoroquinolone) therapy
  • 3.2.5.1.1.1 For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin IV 20 mg/kg/day, divided q12h OR Moxifloxacin IV 5 mg/kg/day, q24h
For 1–4 weeks of Age : Ciprofloxacin IV 20 mg/kg/day, divided q12h OR Moxifloxacin IV 5 mg/kg/day, q24h
  • 3.2.5.1.1.2 For 34–37 week gestational age
For 0–1 wk of Age : Ciprofloxacin IV 20 mg/kg/day, divided q12h OR Moxifloxacin IV 5 mg/kg/day, q24h
For 1–4 wk of Age : Ciprofloxacin IV 20 mg/kg/day, divided q12h OR Moxifloxacin IV 5 mg/kg/day, q24h
  • 3.2.5.1.1.3 Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin IV 30 mg/kg/day, divided q12h OR Moxifloxacin IV 10 mg/kg/day, q24h
For 1–4 weeks of Age : Ciprofloxacin IV 30 mg/kg/day, divided q12h OR Moxifloxacin IV 10 mg/kg/day, q24h AND
  • 3.2.5.1.2 A bactericidal antimicrobial (ß-lactam)
  • 3.2.5.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown:
  • 3.2.5.1.2.1.1 For 32–34 weeks gestational age
For 0–1 week of Age : Meropenem IV 60 mg/kg/day, divided q8h OR Imipenem IV 50 mg/kg/day, divided q12h OR Doripenem IV 20 mg/kg/day, divided q12h
For 1–4 wk of Age : Meropenem IV 90 mg/kg/day, divided q8h OR Imipenem IV 75 mg/kg/day, divided q8h OR Doripenem IV 30 mg/kg/day,divided q8h
  • 3.2.5.1.2.1.2 For 34–37 week gestational age
For 0–1 week of Age : Meropenem IV 60 mg/kg/day, divided q8h OR Imipenem IV 50 mg/kg/day, divided q12h OR Doripenem IV 20 mg/kg/day, divided q12h
For 1–4 week of Age : Meropenem IV 90 mg/kg/day, divided q8h OR Imipenem IV 75 mg/kg/day, divided q8h OR Doripenem IV 30 mg/kg/day,divided q8h
  • 3.2.5.1.2.1.3 Term Newborn Infant
For 0–1 week of Age : Meropenem IV 60 mg/kg/day, divided q8h OR Imipenem IV 50 mg/kg/day, divided q12h OR Doripenem IV 20 mg/kg/day, divided q12h
For 1–4 week of Age : Meropenem IV 90 mg/kg/day, divided q8h OR Imipenem IV 75 mg/kg/day, divided q8h OR Doripenem IV 30 mg/kg/day,divided q8h OR
  • 3.2.5.1.2.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.1.2.2.1 For 32–34 weeks gestational age
For 0–1 week of Age : Penicillin G 200000 Units/kg/day divided q12h,OR Ampicillin 100 mg/kg/day divided q12h,
For 1–4 week of Age : Penicillin G 300000 Units/kg/day divided q12h,OR Ampicillin 150 mg/kg/day divided q12h,
  • 3.2.5.1.2.2.2 For 34–37 week gestational age
For 0–1 week of Age : Penicillin G 300000 Units/kg/day divided q12h,OR Ampicillin 150 mg/kg/day divided q12h,
For 1–4 week of Age : Penicillin G 400000 Units/kg/day divided q12h,OR Ampicillin 200 mg/kg/day divided q12h,
  • 3.2.5.1.2.2.3 Term Newborn Infant
For 0–1 week of Age : Penicillin G 300000 Units/kg/day divided q12h,OR Ampicillin 150 mg/kg/day divided q12h,
For 1–4 week of Age : Penicillin G 400000 Units/kg/day divided q12h,OR Ampicillin 200 mg/kg/day divided q12h, AND
  • 3.2.5.1.3 A protein synthesis inhibitor
  • 3.2.5.1.3.1 For 32–34 weeks gestational age
For 0–1 week of Age : Linezolid 20 mg/kg/day,divided q12h, OR Clindamycin 10 mg/kg/day,divided q12h OR Rifampin 10 mg/kg/day,divided q12h , OR Chloramphenicol 25 mg/kg/day,q24h
For 1–4 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 15 mg/kg/day,divided q8h OR Rifampin 10 mg/kg/day,divided q12h, OR Chloramphenicol 50 mg/kg/day,q12h
  • 3.2.5.1.3.2 For 34–37 week gestational age
For 0–1 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 15 mg/kg/day,divided q8h OR Rifampin 10 mg/kg/day,divided q12h, OR Chloramphenicol 25 mg/kg/day,q24h
For 1–4 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 20 mg/kg/day,divided q6h OR Rifampin 10 mg/kg/day,divided q12h, OR Chloramphenicol 50 mg/kg/day,q12h
  • 3.2.5.1.3.3 Term Newborn Infant
For 0–1 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 15 mg/kg/day,divided q8h OR Rifampin 10 mg/kg/day,divided q12h, OR Chloramphenicol 25 mg/kg/day,q24h
For 1–4 week of Age : Linezolid 30 mg/kg/day,divided q8h, OR Clindamycin 20 mg/kg/day,divided q6h OR {[Rifampin]] 20 mg/kg/day,divided q12h, OR Chloramphenicol 50 mg/kg/day,q12h
Note :Duration of therapy For =2–3 week, until clinical criteria for stability are met. Will require prophylaxis to complete an antibiotic course of upto 60 days from onset of illness.
  • 3.2.5.2 Therapy for severe anthrax when meningitis can be ruled out
  • 3.2.5.2.1 A bactericidal antimicrobial
  • 3.2.5.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.2.1.1.1 For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin IV 20 mg/kg/day,divided q12h OR Meropenem IV 40 mg/kg/day,divided q8h OR Imipenem IV 40 mg/kg/day,divided q12h
For 1–4 week of Age : Ciprofloxacin IV 20 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 50 mg/kg/day,divided q12h
  • 3.2.5.2.1.1.2 For 34–37 week gestational age
For 0–1 week of Age : Ciprofloxacin IV 20 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 50 mg/kg/day,divided q12h
For 1–4 week of Age : Ciprofloxacin IV 20 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 75 mg/kg/day,divided q8h
  • 3.2.5.2.1.1.3 Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin IV 30 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 50 mg/kg/day,divided q12h
For 1–4 week of Age : Ciprofloxacin IV 30 mg/kg/day,divided q12h OR Meropenem IV 60 mg/kg/day,divided q8h OR Imipenem 75 mg/kg/day,divided q8h OR
Vancomycin IV (dosing based on serum creatinine for infants =32 wk gestational age). Follow vancomycin serum concentrations to modify dose.
If Serum creatinine <0.7 then Vancomycin IV 15 mg/kg/dose q12h
If Serum creatinine 0.7 -0.9 then Vancomycin IV 20 mg/kg/dose q24h
If Serum creatinine 1–1.2 then Vancomycin IV 15 mg/kg/dose q24h
If Serum creatinine 1.3–1.6 then Vancomycin IV 10 mg/kg/dose q24h
If Serum creatinine >1.6 15 then Vancomycin IV mg/kg/dose q48h
Note : Begin treatment with a 20-mg/kg loading dose OR
  • 3.2.5.2.1.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.2.1.2.1 For 32–34 weeks gestational age
For 0–1 week of Age : Penicillin G IV 200000 U/kg/day,divided q12h, OR Ampicillin IV 100 mg/kg/day,divided q12h
For 1–4 week of Age : Penicillin G IV 300000 U/kg/day,divided q8h, OR Ampicillin IV 150 mg/kg/day,divided q8h
  • 3.2.5.2.1.2.2 For 34–37 week gestational age
For 0–1 week of Age : Penicillin G IV 300000 U/kg/day,divided q8h, OR Ampicillin IV 150 mg/kg/day,divided q8h
For 1–4 week of Age : Penicillin G IV 400000 U/kg/day,divided q6h, OR Ampicillin IV 200 mg/kg/day,divided q6h
  • 3.2.5.2.1.2.3 Term Newborn Infant
For 0–1 week of Age : Penicillin G IV 300000 U/kg/day,divided q8h, OR Ampicillin IV 150 mg/kg/day,divided q8h
For 1–4 week of Age : Penicillin G IV 400000 U/kg/day,divided q6h, OR Ampicillin IV 200 mg/kg/day,divided q6h AND
  • 3.2.5.2.2 A protein synthesis inhibitor
  • 3.2.5.2.2.1 For 32–34 weeks gestational age
For 0–1 week of Age : Clindamycin IV 10 mg/kg/day, divided q12h, OR Linezolid IV 20 mg/kg/day, divided q12h, OR Rifampin IV 10 mg/kg/day, q24h
For 1–4 week of Age : Clindamycin IV 15 mg/kg/day, divided q8h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Rifampin IV 10 mg/kg/day, q24h
  • 3.2.5.2.2.2 For 34–37 week gestational age
For 0–1 week of Age : Clindamycin IV 15 mg/kg/day, divided q8h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Rifampin IV 10 mg/kg/day, q24h
For 1–4 week of Age : Clindamycin IV 20 mg/kg/day, divided q6h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Rifampin IV 10 mg/kg/day, q24h
  • 3.2.5.2.2.3 Term Newborn Infant
For 0–1 week of Age : Clindamycin IV 15 mg/kg/day, divided q8h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Doxycycline IV 4.4 mg/kg/day, divided q12h, (loading dose 4.4 mg/kg) OR Rifampin IV 10 mg/kg/day, q24h
For 1–4 week of Age : Clindamycin IV 20 mg/kg/day, divided q6h, OR Linezolid IV 30 mg/kg/day, divided q8h, OR Doxycycline IV 4.4 mg/kg/day, divided q12h, (loading dose 4.4 mg/kg) OR Rifampin IV 10 mg/kg/day, q24h
Note: Duration of therapy: For =2–3 wk, until clinical criteria for stability are met (see text). Will require prophylaxis to complete an antimicrobial course of upto 60 days from onset of illness
  • 3.2.5.3 Oral follow-up combination therapy for severe anthrax
  • 3.2.5.3.1 A bactericidal antimicrobial
  • 3.2.5.3.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.3.1.1.1 For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h
  • 3.2.5.3.1.1.2 For 34–37 week gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h
  • 3.2.5.3.1.1.3 Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR
  • 3.2.5.3.1.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.3.1.2.1 For 32–34 weeks gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h, OR Penicillin VK PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin VK PO 75 mg/kg/day, divided q8h
  • 3.2.5.3.1.2.2 For 34–37 week gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin VK PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin VK PO 75 mg/kg/day, divided q8h
  • 3.2.5.3.1.2.3 Term Newborn Infant
For 0–1 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin VK PO 75 mg/kg/day, divided q8h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin VK PO 75 mg/kg/day, divided q6–8h AND
  • 3.2.5.3.2 A protein synthesis inhibitor
  • 3.2.5.3.2.1 For 32–34 weeks gestational age
For 0–1 week of Age : Clindamycin PO 10 mg/kg/day, divided q12h OR Linezolid PO 20 mg/kg/day, divided q12h
For 1–4 week of Age : Clindamycin PO 15 mg/kg/day, divided q8h OR Linezolid PO 30 mg/kg/day, divided q8h
  • 3.2.5.3.2.2 For 34–37 week gestational age
For 0–1 week of Age : Clindamycin PO 15 mg/kg/day, divided q8h OR Linezolid PO 30 mg/kg/day, divided q8h
For 1–4 week of Age : Clindamycin PO 20 mg/kg/day, divided q6h OR Linezolid PO 30 mg/kg/day, divided q8h
  • 3.2.5.3.2.3 Term Newborn Infant
For 0–1 week of Age : Clindamycin PO 15 mg/kg/day, divided q8h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (loading dose 4.4 mg/kg) OR Linezolid PO 30 mg/kg/day, divided q8h
For 1–4 week of Age :Clindamycin PO 20 mg/kg/day, divided q6h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (loading dose 4.4 mg/kg) OR Linezolid PO 30 mg/kg/day, divided q8h OR
Note: Duration of therapy: to complete a treatment course of 10–14 days or greater. May require prophylaxis to complete an antimicrobial course of upto 60 days from onset of illness.
  • 3.2.5.4 Treatment of cutaneous anthrax without systemic involvement
  • 3.2.5.4.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.4.1.1 For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 10 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 15 mg/kg/day, divided q8h
  • 3.2.5.4.1.2 For 34–37 week gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 15 mg/kg/day, divided q8h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 20 mg/kg/day, divided q6h
  • 3.2.5.4.1.3 Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) OR Clindamycin PO 15 mg/kg/day, divided q8h
For 1–4 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) OR Clindamycin PO 20 mg/kg/day, divided q6h
  • 3.2.5.4.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.4.2.1 For 32–34 weeks gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin Vk PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
  • 3.2.5.4.2.2 For 34–37 week gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin Vk PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
  • 3.2.5.4.2.3 Term Newborn Infant
For 0–1 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q6–8h
Note : Duration of therapy for naturally acquired infection is 7–10 days and for a biological weapon–related event,may require additional prophylaxis for inhaled spores to complete an antimicrobial course of up to 60 days from onset of illness.
  • 1.1 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
  • 1.2 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.
  • 2. For children = 1 month[43]
  • 2.1 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
  • 2.2 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.
  • 3. For children < 1 month
  • 3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.1.1 For 32–34 weeks gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 10 mg/kg/day, divided q12h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 15 mg/kg/day, divided q8h
  • 3.1.2 For 34–37 week gestational age
For 0–1 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 15 mg/kg/day, divided q8h
For 1–4 week of Age : Ciprofloxacin PO 20 mg/kg/day, divided q12h OR Clindamycin PO 20 mg/kg/day, divided q6h
  • 3.1.3 Term Newborn Infant
For 0–1 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) OR Clindamycin PO 15 mg/kg/day, divided q8h
For 1–4 week of Age : Ciprofloxacin PO 30 mg/kg/day, divided q12h OR Doxycycline PO 4.4 mg/kg/day, divided q12h (Loading dose 4.4 mg/kg) OR Clindamycin PO 20 mg/kg/day, divided q6h OR
  • 3.2 Alternatives for penicillin-susceptible strains
  • 3.2.1 For 32–34 weeks gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin Vk PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
  • 3.2.2 For 34–37 week gestational age
For 0–1 week of Age : Amoxicillin PO 50 mg/kg/day, divided q12h OR Penicillin Vk PO 50 mg/kg/day, divided q12h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
  • 3.2.3 Term Newborn Infant
For 0–1 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q8h
For 1–4 week of Age : Amoxicillin PO 75 mg/kg/day, divided q8h OR Penicillin Vk PO 75 mg/kg/day, divided q6–8h
Note: Duration of therapy is 60 days from exposure
  • Bacillus cereus treatment[44]
  • 1. Food poisoning
  • Preferred treatment: Food poisoning is self-limited, no antibiotics necessary. Treatment is Supportive therapy, hydration, and anti-emetics. Prevention is by fried/boiled rice should be maintained >60° C or rapidly cooled <8 ° C to avoid room temperature germination of spores and toxin.
Note (1): Bacillus cereus with two forms.(a) Emetic phase: 1-6 hrs after ingestion contaminated usually starchy food, e.g., fried rice. (b) Diarrheal phase: 10-12 hrs after eating e.g. tainted meats, milk, vegetables, etc. with watery diarrhea, tenesmus lasting <2-10 days.
  • 2. Bacteremia
Note (1): Bacillus cereus often resistant to beta-lactams.
Note (2): Uncommon, may complicate mixed infections including surgical wounds or infected necrotic tumors.
Note (3): Source of pseudobacteremia is contaminated blood cultures, gloves, syringes, etc. Often transient bacteremia of no significance in intravenous drug user population.
  • 3. Meningitis, brain abscess
Note (1): Blood culture isolates are mostly contaminates until proven otherwise, especially in intravenous drug user population.
Note(2): Uncommon presentations, may complicate otitis, mastoiditis, neurosurgical procedures, and shunts.
  • 4. Endophthalmitis
Note (1): Prognosis for sight retention poor.
Note (2): Rapid, massive destruction of vitreous/retina in intravenous drug user or posttraumatic with ringabscess within 48 hrs. Pathognomic Bacillus cereus panophthalmitis.
Note (3): Early ophthalmological consultation, culture ocular fluids. Early vitrectomy and intravitreal antibiotics is advocated.
Note (4): Ocular infections devastating and require quick intervention.
Note (5): primary pathogen of post-traumatic , risk factor also intravenous drug use. May also cause keratitis, orbital abscess, conjunctivitis, dacryocystitis.
  • 5. Endocarditis
Note (1): Well-described but rare complication seen in intravenous drug user . Most blood cultures in intravenous drug user positive for bacillus are contaminates or represent transient bacteremia.
Note (2): Evidence of valvular involvement should be sought by echocardiography to prove endocarditis. Tricuspid valve involvement most common. Course indolent.
Note (3): Tricuspid valve endocarditis mostly indolent in nature.
  • 6. Soft tissue
note: rare reports of fasciitis.
  • 7. Pneumonia
Note: rare pathogen of compromised host. May mimic Bacillus anthracis-type presentation.
  • 1. Food poisoning
  • Preferred regimen: supportive treatment
  • 2. Other infections
  • Preferred regimen: Trivalent antitoxin (A 7,500 IU, B 5,000 IU, and E 5,000 IU) 1 vial diluted 1:10, IV infusion over 30 min
  • Alternative regimen: Equine antitoxin
  • 2.General Therapy
  • Preferred regimen: Mechanical ventilation; IV hydration; tube feedings
  • Clostridium perfringens [49]
  • 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
  • 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
  • 1.Diphtheria treatment[50]
  • 1.1 Antitoxin
  • Preferred regimen: 20,000-40,000 U pharyngeal disease <48 hrs; 40-60,000 U nasopharyngeal; 80-120,000 U for extensive disease, brawny neck or sx >72 hrs; Adiminister IV (severe disease) or IM
  • 1.2 Antibiotics:
  • Preferred regimen: Procaine Penicillin G (<20 lbs: 300,000 U; >20 lbs: 600,000 U) IM q12h until patient can swallow then Penicillin VK 125-250 mg PO QID OR Erythromycin 125-500 mg PO QID for 14 days total.
  • Alternative regimen (1): Erythromycin 20-25mg/kg IV q6h (max 4g/day; β-lactam allergic patients)
  • Alternative regimen (2): Clindamycin 600 mg IV q8h
  • 2.C. diphtheriae carrier
  • 3.Endocarditis treatment
  • Corynebacterium jeikeium[51]
  • Corynebacterium urealyticum[52]
  • 1.Acute Q fever
  • 1.1 Adults
  • Preferred Regimen: Doxycycline 100 mg PO bid for 14 days
  • 1.2 Children
  • 1.2.1 Children with age ≥8 years:
  • Preferred regimen: Doxycycline 2.2 mg/kg PO bid for 14 days (maximum 100 mg per dose)
  • 1.2.2 Children with age <8 years with high risk criteria
  • Preferred regimen: Doxycycline 2.2 mg/kg PO bid for 14 days (maximum: 100 mg per dose)
  • 1.2.3 Children with age <8 years with mild or uncomplicated illness
  • Preferred regimen: Doxycycline 2.2 mg/kg PO bid for 5 days (maximum 100 mg per dose). If patient remains febrile past 5 days of treatment: Trimethoprim/Sulfamethoxazole 4-20 mg/kg bid for 14 days (maximum: 800 mg per dose)
  • 1.3 Pregnant women
  • 2. Chronic Q fever
  • 2.1 Endocarditis or vascular infection
  • Preferred regimen: Doxycycline 100 mg PO bid AND Hydroxychloroquine 200 mg PO tid for ≥18 months
  • Note: childern and pregnant women- consultation Recommended
  • 2.2 Noncardiac organ disease
  • 2.3 Postpartumwith serologic profile for chronic Q fever
  • Preferred regimen: Doxycycline 100 mg PO bid AND Hydroxychloroquine 200 mg PO tid for 12 months
  • Note: Women should only be treated postpartum if serologic titers remain elevated >12 months after delivery (immunoglobulin G phase I titer ≥1:1024). Women treated during pregnancy for acute Q fever should be monitored similarly to other patients who are at high risk for progression to chronic disease (e.g., serologic monitoring at 3, 6, 12, 18, and 24 months after delivery)
  • Note:Post-Q fever fatigue syndrome- no current recommendation
  • Preferred regimen: Doxycycline 100 mg PO/IV q12h for 7-14 days
  • NOTE: Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement
  • Alternative regimen: Chloramphenicol 500mg QID OR Rifampin 600 mg PO/IV daily for 7-10 days
  • 2.1 ≥8 years old
  • Preferred regimen: Doxycycline 2 mg/kg IV/PO q12h (max 200 mg/day) for 10 days
  • 2.2 <8 years old without Lyme disease
  • Preferred regimen: Doxycycline 2 mg/kg IV/PO q12h (max 200 mg/day) for 4-5 days (or 3 days after resolution of fever)
  • 2.3 co-infected with Lyme disease
  • Preferred regimen: At the conclusion of Doxycycline then give Amoxicillin 50 mg/kg in 3 divided doses (max 500 mg/dose) OR Cefuroxime 30 mg/kg in 2 divided doses (max 500 mg/dose) for 14 days
  • 1. Erysipeloid of Rosenbach (localized cutaneous infection)[55]
  • 2. Diffuse cutaneous infection
  • Preferred regimen: As for localized infection
Note: Assess for endocarditis
  • 3. Bacteremia or endocarditis
  • Preferred regimen: Penicillin G benzathine 2-4 MU IV q4h for 4-6 weeks
  • Alternative regimen (1): Ceftriaxone 2 g IV q24h for 4-6 weeks
  • Alternative regimen (2): Imipenem 500 mg IV q6h for 4-6 weeks
  • Alternative regimen (3): Ciprofloxacin 400 mg IV q12h for 4-6 weeks
  • Alternative regimen (4): Daptomycin 6 mg/kg IV q24h for 4-6 weeks
Note: Recommended duration of therapy for endocarditis is 4 to 6 weeks, although shorter courses consisting of 2 weeks of intravenous therapy followed by 2 to 4 weeks of oral therapy have been successful.
  • Preferred regimen: Ampicillin 2g IV q4-6h ± Gentamicin 1.7 mg/kg IV q8h for more than 3 weeks
  • Alternative regimen: TMP-SMX 3-5 mg/kg (trimethoprim) q6h IV for more than 3 weeks
  • 2. Bacteremia
  • Preferred regimen: Ampicillin 2g IV q4-6h ± Gentamicin 1.7 mg/kg IV q8h for 2 weeks
  • Alternative regimen: TMP-SMX 3-5 mg/kg (trimethoprim) q6h IV for 2 weeks
  • 3. Brain abscess or rhomboencephalitis
  • Preferred regimen: Ampicillin 2g IV q4-6h ± Gentamicin 1.7 mg/kg IV q8h for 4-6 weeks
  • Alternative regimen: TMP-SMX 3-5 mg/kg (trimethoprim) q6h IV for 4-6 weeks
  • 4. Gastroenteritis
  • 1. Endovascular Infection [57]
  • 2. Odontogenic Infection
  • 3. Intrabdominal Abscess
  • 1. Sulfonamide-based therapies [58]
  • 1.1 Pulmonary
  • Preferred regimen: TMP-SMX 10 mg/kg/day (TMP) in 2-4 doses IV for 3-6 weeks, then PO (2 DS BID) for >5 months
  • 1.2 Pulmonary alternatives
  • 1.3 CNS (AIDS, severe or disseminated disease)
  • Preferred regimen: TMP-SMX 15 mg/kg/day (TMP) IV for 3-6 weeks, then PO (3 DS BID) for 6-12 months
  • 1.4 CNS alternatives
  • 1.5 Severe disease, compromised host, multiple sites
  • 1.6 Sporotrichoid (cutaneous)
  • Preferred regimen: TMP-SMX 1 DS BID for 4-6 months
  • NOTE(1): Immunocompetent medicine use for 6 months; Immunosuppressed medicine for 12 months
  • NOTE(2): Treat based on host, site of disease and in vitro activity; Sulfonamide usually preferred, must treat for 6-12 months; Preferred drugs for resistant strains are Amikacin and/or Imipenem
  • NOTE(3): Seriously ill usually treated with IV Imipenem or Sulfonamide or Cefotaxime all potentially combined with Amikacin; less seriously ill treated with oral agents— especially TMP-SMX or Minocycline
  • 2. Sulfonamide alternatives
  • 2.1 Severe
  • 2.2 Mild
  • 1. Systemic infection[59]
  • 2. Shoulder prosthesis infection
  • 3. Acne vulgaris
  • Rhodococcus equi [60]
  • 1. Preferred regimen:
  • 1.1 First line: vancomycin 1 g IV q12h (15 mg/kg q12 for >70 kg) OR Imipenem 500 mg IV q6h AND Rifampin 600 mg PO once daily OR Ciprofloxacin 750 mg PO twice daily OR Erythromycin 500 mg PO four times a day for at least 4 weeks or until infiltrate disappears (at least 8 weeks in immunocompromised patients)
  • 1.2 Oral/maintenance therapy (after infiltrate clears): Ciprofloxacin 750 mg PO twice daily OR Erythromycin 500 mg PO four times a day
  • Rickettsia rickettsii [61]
  • Preferred regimen: Doxycycline 200 mg load (severe disease) and then 100 mg PO/IV BID for 3-7 days after defervescence
  • Alternative regimen: Chloramphenicol 500 mg PO QID for 3-7 days after defervescence
  • Pediatric regimen: Doxycycline 2-4 mg/kg/day (up to 200 mg/day) q12h OR Tetracycline 25-50 mg/kg/day PO in 4 divided doses OR Chloramphenicol 50-75 mg/kg/day PO in 4 divided doses

Bacteria – Gram-Negative Cocci and Coccobacilli

  • 2.Complications of brucellosis
  • 2.1Spondylitis
  • 2.2 Neurobrucellosis
  • Preferred regimen: Ceftriaxone 2 mg IV bid for 1 month AND Doxycycline 100 mg PO bid for 4-5 month AND Rifampicin 600–900 mg/day PO for 4-5 month
  • 2.3 Brucella endocarditis
  • 3. Pregnancy
  • Preferred regimen:Rifampin 900 mg PO qd for 6 weeks
  • NOTE: Adding Trimethoprim-sulfamethoxazole can be considered, but this option should probably be avoided preceding the 13th week and after the 36th week of gestation because of concern about teratogenicity and kernicterus.
  • 4.For children < 8 yrs of age
  • 1. Human bite/soft tissue infections [64]
  • 1.1 Severe
  • 1.2 Mild
  • 2. Head and neck infections
  • 2.1 Severe
  • 2.2 Mild
  • 3. Endocarditis
  • Preferred Regimen(1): Azithromycin 1 g PO in a single dose
  • Preferred Regimen(2): Ceftriaxone 250 mg IM in a single dose
  • Preferred Regimen(3): Ciprofloxacin 500 mg PO bid for 3 days
  • Preferred Regimen(4): Erythromycin base 500 mg PO tid for 7 days
  • Note: Patients should be tested for HIV infection at the time chancroid is diagnosed. If the initial test results were negative, a serologic test for syphilis and HIV infection should be performed 3 months after the diagnosis of chancroid.
  • 1.1 Follow-up
  • Patients should be re-examined 3–7 days after initiation of therapy. If treatment is successful, ulcers usually improve symptomatically within 3 days and objectively within 7 days after therapy. If no clinical improvement is evident, the clinician must consider whether 1) the diagnosis is correct, 2) the patient is coinfected with another STD, 3) the patient is infected with HIV, 4) the treatment was not used as instructed, or 5) the H. ducreyi strain causing the infection is resistant to the prescribed antimicrobial.
  • Clinical resolution of fluctuant lymphadenopathy is slower than that of ulcers and might require needle aspiration or incision and drainage, despite otherwise successful therapy. Although needle aspiration of buboes is a simpler procedure, incision and drainage might be preferred because of reduced need for subsequent drainage procedures.
  • 1.2 Management of sex partners
  • Regardless of whether symptoms of the disease are present, sex partners of patients who have chancroid should be examined and treated if they had sexual contact with the patient during the 10 days preceding the patient’s onset of symptoms.
  • 1.3 Pregnancy
  • Ciprofloxacin presents a low risk to the fetus during pregnancy, with a potential for toxicity during breastfeeding. Alternative drugs should be used during pregnancy and lactation
  • 1.4 HIV Infection
  • Persons with HIV infection who have chancroid should be monitored closely because they are more likely to experience treatment failure and to have ulcers that heal slowly. Persons with HIV infection might require repeated or longer courses of therapy, and treatment failures can occur with any regimen.
  • 1.Non-threatening infections[67]
1.1.Adults
  • Preferred regimen (1) : Amoxicillin-clavulanate 500mg PO tid or 875mg PO bid.
  • Preferred regimen (2) : Amoxicillin 500mg PO tid.
  • Preferred regimen (3) : TMP-SMX DS PO bid.
  • Preferred regimen (4) : Cefuroxime 250-500mg PO bid.
  • Preferred regimen (5) : Moxifloxacin 400mg PO OD,
  • Preferred regimen (6) : Levofloxacin 500mg PO daily
  • Preferred regimen (7) : Azithromycin 500mg PO single dose then 250mg for 4days OR Clarithromycin 500mg bid or XL 500mg/day.
  • Note: Treatment duration of Otitis media is 10-14days, Acute exacerbation of Chronic Bronchitis is (5days[quinolone]-14days), Sinusitis is 10-14days.
  • Preferred regimen : Dexamethasone (0.15mg/kg)15-20min before first dose of abx and then q6h for 4days.
  • 2.1.Adults
  • Preferred regimen (1) : Ceftriaxone 2g IV q12h(4gmax).
  • Preferred regimen (2) : Cefotaxime 2g IV q4-6h(12gmax).
  • Preferred regimen (3) :Ampicillin 2g IV q4h if sensitive.
  • Beta-lactamalternative : Ciprofloxacin 400mg IV q8h OR other Fluoroquinolones.
  • 2.2.Pediatric
  • 2.2.1.Neonates <7days
  • 2.2.2.Neonates >7days
  • 2.3.Post-meningitis exposure prophylaxis : Rifampin 600mg PO OD for 4days [69]
  • 3.Severe infections[70]
  • 3.1.Adults
  • Neisseria gonorrhoeae, treatment[71]
  • 1. Gonococcal infections in adolescents and adults
  • 1.1 Uncomplicated gonococcal infections of the cervix, urethra, and rectum
  • Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
  • Alternative regimen: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose (if ceftriaxone is not available)
  • 1.2 Uncomplicated gonococcal infections of the pharynx
  • 1.2.1 Management of sex partners
  • Expedited partner therapy: Cefixime 400 mg PO in a single dose AND Azithromycin 1 g PO in a single dose
Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or gonorrhea diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present.
  • 1.2.2 Allergy, intolerance, and adverse reactions
Note: Use of ceftriaxone or cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy (e.g., anaphylaxis, Stevens Johnson syndrome, and toxic epidermal necrolysis).
  • 1.2.3 Pregnancy
  • 1.2.4 Suspected cephalosporin treatment failure
  • Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1 g PO in a single dose
  • Alternative regimen (1): Gemifloxacin 320 mg PO single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
  • Alternative regimen (2): Gentamicin 240 mg IM single dose AND Azithromycin 2 g PO single dose (when isolates have elevated cephalosporin MICs)
  • Alternative regimen (3): Ceftriaxone 250 mg IM as a single dose AND Azithromycin 2 g PO as a single dose (failure after treatment with cefixime and azithromycin)
Note: Treatment failure should be considered in: (1) persons whose symptoms do not resolve within 3–5 days after appropriate treatment and report no sexual contact during the post-treatment follow-up period; (2) persons with a positive test-of-cure (i.e., positive culture ≥ 72 hours or positive NAAT ≥ 7 days after receiving recommended treatment) when no sexual contact is reported during the post-treatment follow-up period; (3) persons who have a positive culture on test-of-cure (if obtained) if there is evidence of decreased susceptibility to cephalosporins on antimicrobial susceptibility testing, regardless of whether sexual contact is reported during the post-treatment follow-up period.
  • 1.3 Gonococcal conjunctivitis
Note: Consider one-time lavage of the infected eye with saline solution.
  • 1.3.1 Management of sex partners
  • Patients should be instructed to refer their sex partners for evaluation and treatment.
  • 1.4 Disseminated gonococcal infection
  • 1.4.1 Arthritis and arthritis-dermatitis syndrome
  • 1.4.2 Gonococcal meningitis and endocarditis
  • 2. Gonococcal infections among neonates
  • 2.1 Ophthalmia neonatorum caused by N. gonorrhoeae
  • Preferred regimen: Ceftriaxone 25-50 mg/kg IV or IM in a single dose, not to exceed 125 mg
  • 2.1.1 Management of mothers and their sex partners
  • Mothers of infants with ophthalmia neonatorum caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
  • 2.2 Disseminated gonococcal infection and gonococcal scalp abscesses in neonates
  • Preferred regimen: Ceftriaxone 25-50 mg/kg/day IM/IV qd for 7 days OR Cefotaxime 25 mg/kg IV /IM q12h for 7 days.
Note (1): The duration of treatment is 10-14 days if meningitis is documented.
Note (2): Ceftriaxone should be administered cautiously to hyperbilirubinemic infants, especially those born prematurely.
  • 2.2.1 Management of mothers and their sex partners
  • Mothers of infants who have DGI or scalp abscesses caused by N. gonorrhoeae should be evaluated, tested, and presumptively treated for gonorrhea, along with their sex partner(s).
  • 2.3 Neonates born to mothers who have gonococcal infection
  • Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
  • 2.3.1 Management of mothers and their sex partners
  • Mothers who have gonorrhea and their sex partners should be evaluated, tested, and presumptively treated for gonorrhea.
  • 3. Gonococcal infections among infants and children
  • 3.1 Infants and children who weigh ≤ 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • Preferred regimen: Ceftriaxone 25-50 mg/kg IM/IV in a single dose, not to exceed 125 mg
  • 3.2 Children who weigh > 45 kg and who have uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis
  • Preferred regimen: Ceftriaxone 250 mg IM in a single dose AND Azithromycin 1g PO in a single dose
  • Alternative regimen: Cefixime 400 mg PO single dose AND Azithromycin 1 g PO single dose.(If ceftriaxone is not available)
  • 3.3 Children who weigh ≤ 45 kg and who have bacteremia or arthritis
  • Preferred regimen: Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM/IV q24h for 7 days
  • 3.4 Children who weigh > 45 kg and who have bacteremia or arthritis
  • Preferred regimen: Ceftriaxone 1 g IM/IV q24h for 7 days
  • Meningococcal Meningitis or Bacteremia [72]
  • Preferred regimen (1): Ceftriaxone 2 g IV q24h for 7-10 days.
  • Preferred regimen (2): Cefotaxime 2 g IV q4-6h for 7-10 days.
  • Alternatives regimen (1): Chloramphenicol 4-6 g/day for 7-10 days
  • Alternatives regimen (2): Penicillin 18-24 MU/day IV
  • Alternatives regimen (3): Ampicillin 12 g/day IV
  • Alternatives regimen (4): Aztreonam 6-8 g/day IV
  • Alternatives regimen (5): Moxifloxacin 400 mg/day IV.
  • Steroids: Dexamethasone 10 mg IV q6h for 2-4 days starting before or with first dose.
  • Preferred regimen (1): Amoxicillin/clavulanate 500 mg PO TID or 875 mg PO BID with food (also preferred empirical coverage of animal bite wounds)
  • Preferred regimen (2): Ampicillin/sulbactam 3g IV q6h
  • Preferred regimen (3): Ciprofloxacin 500 mg PO BID or 400 mg IV q12h OR Levofloxacin 500 mg PO qd or IV q24h
  • Alternative regimen (1): Doxycycline 100 mg PO BID OR TMP-SMX DS PO BID (for beta-lactam allergic patients )
  • Alternative regimen (2): Penicillin 500 mg PO QID or 4 million units IV q4h (use only if isolate known to be susceptible)

Bacteria – Spirochetes

  • Lyme disease
  • 1. Early Lyme Disease
  • 1.1 Erythema migrans
  • Preferred regimen: Doxycycline 100 mg twice per day for 10-21 days OR Amoxicillin 500 mg 3 times per day for 14-21 days OR Cefuroxime axetil 500 mg twice per day for 14-21 days
  • Alternatie regimen: : Azithromycin 500 mg PO per day for 7–10 days OR Clarithromycin 500 mg PO twice per day for 14–21 days (if the patient is not pregnant) OR Erythromycin 500 mg PO 4 times per day for 14–21 days
  • Pediatric regimen (1): (children <8 years of age) Amoxicillin 50 mg/kg per day in 3 divided doses [maximum of 500 mg per dose] OR Cefuroxime axetil 30 mg/kg per day in 2 divided doses （maximum of 500 mg per dose)
  • Pediatric regimen (2):（children ≥8 years of age）Doxycycline 4 mg/kg per day in 2 divided doses（maximum of 100 mg per dose）
  • Pediatric regimen (3): Azithromycin 10 mg/kg per day (maximum of 500 mg per day) OR Clarithromycin 7.5 mg/kg twice per day (maximum of 500 mg per dose) OR Erythromycin 12.5 mg/kg 4 times per day (maximum of 500 mg per dose)
  • 1.2 When erythema migrans cannot be reliably distinguished from community-acquired bacterial cellulitis
  • Preferred regimen: Amoxicillin–clavulanic acid 500 mg 3 times per day;
  • Pediatric regimen；Amoxicillin–clavulanic acid 50 mg/kg per day in 3 divided doses (maximum of 500 mg per dose)
  • 1.3 Lyme meningitis and other manifestations of early neurologic Lyme disease
  • Preferred regimen: Ceftriaxone 2g once per day IV for 10–28 days
  • Alternative regimen (1): Cefotaxime 2 g IV q8h OR Penicillin G 18–24 million U q4h per day for patients with normal renal function
  • Alternative regimen (2): Doxycycline 200–400 mg per day in 2 divided doses PO for 10–28 days
  • Pediatric regimen (1): Ceftriaxone 50–75 mg/kg per day in a single daily intravenous dose (maximum, 2g)
  • Pediatric regimen (2): Cefotaxime 150–200 mg/kg per day divided into 3 or 4 intravenous doses per day (maximum, 6 g per day)
  • Pediatric regimen (3): Penicillin G 200,000–400,000 units/kg per day (maximum, 18–24 million U per day) divided into doses given intravenously q4h for those with normal renal function
  • Pediatric regimen (4): (≥8 years old) Doxycycline 4–8 mg/kg PO per day in 2 divided doses (maximum, 100–200 mg per dose)
  • 1.4 Lyme carditis
  • Preferred regimen: Ceftriaxone 2g once per day IV for 10–28 days
  • NOTE: patients with advanced heart block, a temporary pacemaker may be required; expert consultation with a cardiologist is recommended; Use of the pacemaker may be discontinued when the advanced heart block has resolved; An oral antibiotic treatment regimen should be used for completion of therapy and for outpatients, as is used for patients with erythema migrans without carditis (see above)
  • 1.5 Borrelial lymphocytoma
  • Preferred regimen: The same regimens used to treat patients with erythema migrans (see above)
  • Late Lyme Disease
  • 1.6 Lyme arthritis
  • Preferred regimen: Doxycycline 100 mg twice per day OR Amoxicillin 500 mg 3 times per day
  • Alternative regimen: Cefuroxime axetil 500 mg twice per day for 28 days
  • Pediatric regimen: Amoxicillin 50 mg/kg per day in 3 divided doses (maximum of 500 mg per dose) OR Cefuroxime axetil 30 mg/kg per day in 2 divided doses (maximum of 500 mg per dose) OR (≥8 years of age) Doxycycline 4 mg/ kg per day in 2 divided doses (maximum of 100 mg per dose)
  • NOTE: For patients who have persistent or recurrent joint swelling after a recommended course of oral antibiotic therapy, we recommend re-treatment with another 4-week course of oral antibiotics or with a 2–4-week course of Ceftriaxone IV
  • 1.7 patients with arthritis and objective evidence of neurologic disease
  • 1.8 Late neurologic Lyme disease
  • 1.9 Acrodermatitis chronica atrophicans
  • 2. Post–Lyme Disease Syndromes
  • Preferred regimen: Further antibiotic therapy for Lyme disease should not be given unless there are objective findings of active disease (including physical findings, abnormalities on cerebrospinal or synovial fluid analysis, or changes on formal neuropsychologic testing)
  • 1. Tick-Borne Relapsing Fever [74]
  • Preferred regimen: Doxycycline 100 mg PO twice daily for 5-10 days
  • Alternative regimen: Erythromycin 500 mg PO four times a day for 5-10 days
  • NOTE: If meningitis/encephalitis present, use Ceftriaxone 2 g IV q12h for 14 days
  • 2. Louse-Borne Relapsing Fever
  • 1. Treatment
  • Preferred regimen: Penicillin 1.5 million units IV q6hr for 5-7 days
  • 1.2 Less severe
  • 2. Prophylaxis
  • Leptospira interrogans [77]
  • 1. Syphilis Among non-HIV-Infected Persons[78]
  • 1.1 Primary and Secondary Syphilis
  • Preferred regimen (adult): Benzathine penicillin G 2.4 million units IM in a single dose
  • Preferred regimen (pediatric): Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose
  • 1.2 Latent Syphilis
  • 1.2.1 Early Latent Syphilis
  • Preferred regimen: Benzathine penicillin G 2.4 million units IM in a single dose
  • Pediatric regimen: Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units in a single dose
  • 1.2.2 Late Latent Syphilis or Latent Syphilis of Unknown Duration
  • Preferred regimen: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervalspediatric
  • Pediatric regimen: Benzathine penicillin G 50,000 units/kg IM, up to the adult dose of 2.4 million units, administered as 3 doses at 1-week intervals (total 150,000 units/kg up to the adult total dose of 7.2 million units)
  • 1.3 Tertiary Syphilis
  • Preferred regimen: Benzathine penicillin G 7.2 million units total, administered as 3 doses of 2.4 million units IM each at 1-week intervals
  • 1.4 Neurosyphilis and ocular syphilis
  • Preferred regimen: Aqueous crystalline penicillin G 18--24 million units per day, administered as 3--4 million units IV every 4 hours or continuous infusion, for 10--14 days
  • Alternative regimen: Procaine penicillin 2.4 million units IM once daily AND Probenecid 500 mg orally four times a day, both for 10--14 days
  • 2. Syphilis Among HIV-Infected Persons
  • 2.1 Primary and Secondary Syphilis Among HIV-Infected Persons
  • Preferred regimen: Benzathine penicillin G 2.4 million units IM in a single dose.
  • 2.2 Latent Syphilis Among HIV-Infected Persons
  • 2.2.1 early latent
  • Preferred regimen: Benzathine penicillin G 2.4 million units IM in a single dose.
  • 2.2.2 late latent
  • Preferred regimen: Benzathine penicillin G at weekly doses of 2.4 million units for 3 weeks.
  • 2.3 Neurosyphilis Among HIV-Infected Persons
  • Preferred regimen: Aqueous crystalline penicillin G 18--24 million units per day, administered as 3--4 million units IV every 4 hours or continuous infusion, for 10--14 days
  • Alternative regimen: Procaine penicillin 2.4 million units IM once daily AND Probenecid 500 mg orally four times a day, both for 10--14 days
  • 3. Syphilis During Pregnancy
  • Preferred regimen: Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection
  • 4. Congenital Syphilis in neonates
  • 4.1 condition 1 : Infants with proven or highly probable disease and (1)an abnormal physical examination that is consistent with congenital syphilis;（2）a serum quantitative nontreponemal serologic titer that is fourfold higher than the mother's titer;¶ or（3）a positive darkfield test of body fluid(s).
  • Preferred regimen: Aqueous crystalline penicillin G 100,000--150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days OR Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days
  • NOTE: If more than 1 day of therapy is missed, the entire course should be restarted. Data are insufficient regarding the use of other antimicrobial agents (e.g., ampicillin). When possible, a full 10-day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis. The use of agents other than penicillin requires close serologic follow-up to assess adequacy of therapy. In all other situations, the maternal history of infection with T. pallidum and treatment for syphilis must be considered when evaluating and treating the infant.
  • 4.2 condition 2: Infants who have a normal physical examination and a serum quantitive nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1)mother was not treated, inadequately treated, or has no documentation of having received treatment; (2)mother was treated with erythromycin or another nonpenicillin regimen;†† or (3)mother received treatment < 4 weeks before delivery.
  • Preferred regimen: Aqueous crystalline penicillin G 100,000--150,000 units/kg/day, administered as 50,000 units/kg/dose IV every 12 hours during the first 7 days of life and every 8 hours thereafter for a total of 10 days OR Procaine penicillin G 50,000 units/kg/dose IM in a single daily dose for 10 days OR Benzathine penicillin G 50,000 units/kg/dose IM in a single dose
  • NOTE:If the mother has untreated early syphilis at delivery, 10 days of parenteral therapy can be considered.
  • 4.3 condition 3:Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1)mother was treated during pregnancy, treatment was appropriate for the stage of infection, and treatment was administered >4 weeks before delivery and (2)mother has no evidence of reinfection or relapse.
  • Preferred regimen: Benzathine penicillin G 50,000 units/kg/dose IM in a single dose
  • 4.4 condition 4: Infants who have a normal physical examination and a serum quantitative nontreponemal serologic titer the same or less than fourfold the maternal titer and the (1)mother's treatment was adequate before pregnancy and (2)mother's nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2; RPR <1:4).
  • Preferred regimen: No treatment is required; however, benzathine penicillin G 50,000 units/kg as a single IM injection might be considered, particularly if follow-up is uncertain.
  • 5. Congenital Syphilis in infants and children
  • Preferred regimen: Aqueous crystalline penicillin G 50,000 U/kg q4–6h for 10 days

Bacteria – Gram-Negative Bacilli

  • Aeromonas hydrophila[79]
  • 1.Diarrhea
  • Preferred regimen: (consider if not self-limiting, or if severe), Ciprofloxacin 500 mg PO bid.
  • Alternate regimen: TMP-SMX single dose PO bid
Note: High resistance to sulfa agents described in Taiwan and Spain
  • 2.Skin and soft tissue infection
  • 2.1.Mild infection
  • 1.Cat scratch disease
  • 1.1.If extensive adenopathy
  • 2.Retinitis
  • 3.Bacillary angiomatosis
  • 4.Peliosis hepatitis
  • 5.Oroya fever
  • 6.Endocarditis
  • Bordetella pertussis[81]
  • 1.Whooping cough
  • 1.1.Adults
  • 1.2.Infants <6 months of age
  • 1.2.1.Infants <1 month
  • 1.2.2.Infants of 1-5 months of age
  • 1.3.Infants >6 months of age-children
  • Preferred regimen: Azithromycin 10 mg/kg (500 mg max) daily for 5 days OR Clarithromycin 15 mg/kg (1 g daily max)bid for 7 days OR Erythromycin 10mg/kg PO (2g daily max) qid for 14 days OR TMP-SMX 4 mg/40 mg/kg bid for 14 days.
  • Note(1): TMP-SMX should only be used in patients ≥2 mos of age who are allergic or intolerant of macrolides or who have a macrolide-resistant strain.
  • Note(2): Although fluoroquinolones have excellent in vitro sensitivity profiles, clinical experience for B. pertussis is limited.
  • Burkholderia cepacia[82]
  • Burkholderia pseudomallei
  • 1.1.Intial intensive therapy (Minimum of 10-14 days)
  • Preferred regimen : Ceftazidime 50 mg/kg upto 2 g q6h OR Meropenem 25mg/kg upto 1g q8h OR Imipenem 25 mg/kg upto 1g
  • Note : Any one of the three may be combined with TMP-SMX6/30 mg/kg upto 320/1600 mg/kg q12h (recommended for neurologic, bone, joint, cutaneous and prostatic melioidosis)
  • 1.2.Eradication therapy (Minimum of 3months)
  • Preferred regimen : TMP-SMX6/30 mg/kg upto 320/1600 mg/kg q12h
  • Campylobacter fetus[84]
  • Serious infections
  • Endovascular infections
  • CNS
  • Capnocytophaga canimorsus[85]
  • 1.Severe Cellulitis/Sepsis or Endocarditis
  • Preferred regimen
  • 2.Complicated infections or Immunocompromise
  • Preferred regimen : Clindamycin 600 mg IV q8h may be combined with above agents
  • Note (1): Resistance to aztreonam described, and variable susceptibility reported to TMP-SMX and aminoglycosides.
  • Note (2): For endocarditis, alternatives to penicillins not well established, treated for duration of 6 weeks. For non-endocarditis infections, duration not well established, but most authorities recommend at least 14-21 days of therapy.
  • 3.Mild Cellulitis/Dog or Cat Bites
  • 4.Meningitis or brain abscess
  • 5.Prevention
  • Although no firm data supports this recommendation, many clinicians do give prophylaxis for dog and cat bites in asplenic patients with amoxicillin/clavulanate for 7-10 days.
  • Citrobacter freundii[86]
  • Citrobacter koseri[87]
  • Escherichia coli[90]
  • 1.Meningitits
  • 2.Uncomplicated urinary tract infection
Note: For older patients, those with comorbidities (e.g., diabetes mellitus) use 7-10 days course.
  • 3.Pyelonephritis
  • 3.1.Acute uncomplicated pyelonephritis
  • 3.1.Acute pyelonephritis (Hospitalized)
  • 4.Traveler’s diarrhea
  • Preferred regimen : Ciprofloxacin 750 mg PO OD for 1-3 days or other Fluoroquinolones
  • Pediatrics & pregnancy: Azithromycin 10 mg/kg/day single dose OR Ceftriaxone 50 mg/kg/day IV OD for 3 days.
Avoid Fluoroquinolones in Pediatrics and pregnancy.
  • 5.Malacoplakia
  • 6.Bacteremia/Pneumonia
  • Francisella tularensis[91]
  • 1.Tularemia
  • Helicobacter pylori[92]
  • 1.Peptic ulcer disease
  • 1.1.Regimens for Initial Treatment
  • 1.1.1.Triple therapy : PPI(standard dose twice daily) AND Amoxicillin 1 g bid AND Clarithromycin 500 mg bid for 7-14 days
  • 1.1.2.Quadruple therapy: PPI (standard dose twice daily) AND Metronidazole 250 mg q6h AND Tetracycline 500 mg q6h AND Bismuth (dose depends on preparation) for 10-14 days
  • 1.1.3.Sequential therapy: PPI (standard dose twice daily)AND Amoxicillin 1 g bid for 1-5 days followed by PPI (standard dose twice daily)AND Clarithromycin 500 mg bid AND Tinidazole 500 mg bid for 6-10 days
  • 1.2. Second-Line Therapies
  • 1.2.1.Triple therapy: PPI (standard dose twice daily) AND Amoxicillin 1 g bid AND Metronidazole 500 mg bid
  • 1.2.2.Quadruple therapy: PPI (standard dose twice daily)AND Metronidazole 250 mg q6h AND Tetracycline 500 mg q6h AND Bismuth (dose depends on preparation) for 10-14 days
  • 1.2.3.Levofloxacin triple therapy: PPI (standard dose twice daily) AND Amoxicillin 1 g bid AND Levofloxacin 500 mg bid for 10 days
  • 1.2.4.Rifabutin triple therapy: PPI (standard dose twice daily) and Amoxicillin 1 g bid AND Rifabutin 150-300 mg/day for 10 days
  • Klebsiella granulomatis (formly known as Calymmatobacterium granulomatis)
  • 1. Granuloma inguinale (donovanosis)[93]
  • Preferred regimen: Azithromycin 1 g PO once a week or 500 mg qd for 3 weeks and until all lesions have completely healed
  • Alternative regimen (1): Doxycycline 100 mg PO bid for 3 weeks and until all lesions have completely healed
  • Alternative regimen (2): Ciprofloxacin 750 mg PO bid for at least 3 weeks and until all lesions have completely healed
  • Alternative regimen (3): Erythromycin base 500 mg PO qid for at least 3 weeks and until all lesions have completely healed
  • Alternative regimen (4): Trimethoprim-sulfamethoxazole one double-strength (160 mg/800 mg) tablet PO bid for at least 3 weeks and until all lesions have completely healed
  • Klebsiella pneumoniae[94]
  • 1.Severe,nosocomial infection
  • Preferred regimen: Levofloxacin 750mg PO/IV OD for 7-10days OR Moxifloxacin 400mg PO/IV OD for 7-10 days OR Azithromycin 500mg PO/IV OD for 7-10days OR Rifampin 300mg PO/IV bid(optional) AND any other agent listed.
  • Alternative regimen: Erythromycin 1g IV q6h and then 500mg PO q6h for 7-10days OR Ciprofloxacin400mg IV q12h then 750mg PO bid 7-10days
  • Pneumonia
  • Preferred regimen : Imipenem 500mg IV q6h OR Meropenem 1.0g IV q8h (adjustdose if necessary for renalfunction).
  • Note (1): Carbapenems are considered first line therapy due to inducible cephalosporinases, and presence of extended-spectrum beta-lactamases in some isolates.
  • Note (2): Duration of treatment for UTI(generallycomplicated) is 7days and Duration of treatment for bacteremia is 14days.
  • Note (3): Tigecycline is not reliably effective
  • Alternative Regimen (1) : Cefepime 2.0 g IV q8-12h OR Ciprofloxacin 500 mg PO/400mg IV q12h OR Piperacillin 3g IV q6h OR Ticarcillin 3g IV q4h
  • Alternative Regimen (2) : Aminoglycosides can be used alone for treatment of UTI,Gentamicin OR Tobramycin 1mg/kg/day IV OR Amikacin 3mg/kg/day
  • Plesiomonas shigelloides[101]
  • 1.Immunocompetent Hosts or Severe Infection
  • Preferred regimen : Ciprofloxacin 500mg PO bid or 400mg IV q12h.
  • Alternative regimen (1): Ofloxacin 300mg PO bid OR Norfloxacin 400mg PO bid OR TMP-SMX DS PO bid for 3days.
  • Alternative regimen (2): Ceftriaxone 1-2g IV OD used successfully in severe cases.
  • 2.Immunocompromised Hosts
  • Preferred regimen (1): Ampicillin 500 mg PO q6h or 2 g IV q6h.
  • Preferred regimen (2): Cefuroxime 250 mg PO bid or 750 mg IV q8h.
  • Preferred regimen (3): Ciprofloxacin 250-500 mg PO bid or 400 mg IV q12h.
  • Preferred regimen (4): Levofloxacin 500 mg PO OD or 500 mg IV q24h.
  • Note: Uncomplicated UTI 3 days, pyelonephritis 7-14 days, complicated UTI 10-21 days and bacteremia 7-14 days.
  • Indole positive Proteus species[103]
  • Preferred regimen (1): Ceftriaxone 1 g IV q24h.
  • Preferred regimen (2): Imipenem 500 mg IV q6h.
  • Preferred regimen (3): Ciprofloxacin 400 mg IV q12h or 250-500 mg PO bid.
  • Preferred regimen (4): Levofloxacin 500 mg IV/PO q24h.
  • Complicated UTI/Bacteremia/Acute prostatitis
  • Preferred regimen : Ciprofloxacin 500-750mg PO q12h or 400 mg IV q8-12h OR Levofloxacin 500mg IV/PO q24h OR Piperacillin-Tazobactam 3.375 mg IV q6h ORCeftriaxone 1-2g IV q24h (donot use if ESBL suspected or critically ill)OR Meropenem 1g IV q8h (consider if critically ill or ESBL suspected)ORAmikacin 7.5mg/kg IV q12h OR Gentamicin OR Tobramycin acceptable if susceptible but many species are resistant.
  • Note (1) : Duration of treatment for (UTI)is 7days common or 3-5days after defervescence or control/elimination of complicating factors (e.g.,removal of foreign material catheter).
  • Note (2) : Duration of treatment for (bacteremia)is 10-14days or 3-5days after defervescence or control/elimination of complicatingfactors.
  • Note (3) : Duration for acute prostatitis(2weeks), shorter than chronic prostatitis(4-6wks)
  • Alternative regimen : TMP-SMX(Bactrim)DS1 PO q12h for 10-14days OR TMP 5-10 mg/kg/day IV q6h.
  • Pseudomonas aeruginosa[105]
  • 1.Gastroenteritis
  • Preferred treatment
  • 2.Typhoidfever
  • 3.Non-typhoid(seriousinfection)
  • 4.Bacteremia
  • 5.Vascular prosthesis infection
  • 6.Osteomyelitis
  • 7.Arthritis
  • 8.Endocarditis
  • 9.UTI
  • 10.HIV and salmonellosis
  • Preferred regimen : IV Cephalosporin OR IV Fluoroquinolone, then oral Flouroquinolones(Ciprofloxacin 500-750mg PO bid for 4weeks).
  • Note : If relapse occurs within 6weeks give life-long abx or until immune recovery post-ART
  • 1.Bacteremia,Pneumonia or SeriousInfections
  • 2.Endocarditis
  • Preferred regimen : Choice dictated by sensitivities. 4to6 week duration of parenteral therapy.
  • 3.Osteomyelitis
  • Preferred regimen : Choice dictated by sensitivity profile. Treat for 6-12weeks depending upon response. Use IV treatment until stable/clinically improved(10-14days min)then may convert to PO therapy if appropriate
  • 4.UTI
  • Preferred regimen
  • If known sulfa sensitive : TMP(160mg)/SMX(800mg) PO q12h for 3-5days.
  • Pediatric dose : TMP5mg/SMX 25mg/kg PO bid.
  • If TMP/SMX resistant or unknown susceptibility : Ciprofloxacin 500mg OR Norfloxacin 400mg OR Ofloxacin 200mg PO bid for 3-5days.
  • Alternative regimen : Ceftriaxone 1g IV q24h OR} Azithromycin 500mg PO single dose, then 250mg PO for 4days OR Nalidixicacid 250mg PO q6h or pediatric dose 55kg/day) OR Ampicillin(500mg PO q6h depending on susceptibility patterns.
  • Note : In southeast Asia, growing resistance seen to fluoroquinolones, azithromycin maybe preferred.
  • Stenotrophomonas maltophilia[109]
  • Preferred treatment : TMP-SMX 15-20(TMP component)mg/kg/day IV/PO q8h.
  • Alternative treatment (1) : Ceftazidime 2g IV q8h OR Ticarcillin/clavulanate 3.1g IV q4h OR Tigecycline 100mg IV Single dose,then 50mg IV q12h.
  • Alternative treatment (2) : Ciprofloxacin 500-750mg PO /400mg IV q12h OR Moxifloxacin 400mg PO/IV OR Levofloxacin 750mg PO/IV .
  • Alternative treatment (3) : Multiply-resistantance Colistin 2.5mg/kg q12h IV.
  • Note : Treatment duration uncertain,but usually ≥14days

Bacteria – Atypical Organisms

  • 1. Atypical pneumonia caused by Chlamydophila pneumoniae [110]
  • 1.1 Adult
  • Preferred regimen (1): Doxycycline 100 mg PO bid for 14-21 days
  • Preferred regimen (2): Tetracycline 250 mg PO qid for 14-21 days
  • Preferred regimen (3): Azithromycin 500 mg PO as a single dose, followed by 250 mg PO qd for 4 days
  • Preferred regimen (4): Clarithromycin 500 mg PO bid for 10 days
  • Preferred regimen (5): Levofloxacin 500 mg IV or PO qd for 7 to 14 days
  • Preferred regimen (6): Moxifloxacin 400 mg PO qd for 10 days.
  • 1.2 Pediatric
  • Preferred regimen (1): Erythromycin suspension,PO 50 mg/kg/day for 10 to 14 days
  • Preferred regimen (2): Clarithromycin suspension, 15 mg/kg/day for 10 days
  • Preferred regimen (3): Azithromycin suspension, PO 10 mg/kg once on the first day, followed by 5 mg/kg qd daily for 4 days
  • 2.Upper respiratory tract infection[111]
  • Bronchitis
  • Antibiotic therapy for C. pneumoniae is not required.
  • Pharyngitis
  • Antibiotic therapy for C. pneumoniae is not required.
  • Sinusitis
  • Antibiotic therapy is advisable if symptoms remain beyond 7-10 days.
  • 1.1 Chlamydial Infections in Adolescents and Adults
  • Preferred regimen(1): Doxycycline 100 mg PO bid for 7 days
  • Preferred regimen(2): Azithromycin 1 g PO in a single dose
  • Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days
  • Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
  • Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
  • Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days.
  • Note: Patients should be instructed to refer their sex partners for evaluation, testing, and treatment if they had sexual contact with the patient during the 60 days preceding onset of the patient's symptoms or chlamydia diagnosis.
  • 1.2 Chlamydial Infections in patients with HIV Infection
  • Alternative regimen (2): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
  • Alternative regimen (3): Levofloxacin 500 mg PO qd for 7 days
  • Alternative regimen (4): Ofloxacin 300 mg PO bid for 7 days.
  • 1.3 Pregancy
  • Preferred regimen: Azithromycin 1 g PO in a single dose
  • Alternative regimen (1): Amoxicillin 500 mg PO tid for 7 days
  • Alternative regimen (2): Erythromycin base 500 mg PO qid for 7 days
  • Alternative regimen (3): Erythromycin base 250 mg PO qid for 14 days
  • Alternative regimen (4): Erythromycin ethylsuccinate 800 mg PO qid for 7 days
  • 1.4 Management of sex partners
Note (1): Recent sex partners (i.e., persons having sexual contact with the infected patient within the 60 days preceding onset of symptoms or Chlamydia diagnosis) should be referred for evaluation, testing, and presumptive dual treatment.
Note (2): If the patient’s last potential sexual exposure was >60 days before onset of symptoms or diagnosis, the most recent sex partner should be treated.
Note (3): To avoid reinfection, sex partners should be instructed to abstain from unprotected sexual intercourse for 7 days after they and their sexual partner(s) have completed treatment and after resolution of symptoms, if present
  • 2 Chlamydial infection among neonates
  • 2.1 Ophthalmia Neonatorumcaused by C. trachomatis
  • Preferred regimen :Erythromycin base or ethylsuccinate ,PO 50 mg/kg/ day divided into 4 doses daily for 14 days
  • Alternative regimen : Azithromycin suspension, PO 20 mg/kg /day qd for 3 days
  • Note: The mothers of infants who have chlamydial infection and the sex partners of these women should be evaluated and treated.
  • 2.2Infant Pneumonia
  • Preferred regimen :Erythromycin base or ethylsuccinate PO 50 mg/kg/ day divided into 4 doses daily for 14 days
  • Alternative regimen : Azithromycin suspension, PO 20 mg/kg /day qd for 3 days
  • 3.Chlamydial infection among infants and childern
  • 3.1 Infants and childern who weigh < 45 kg
  • Preferred regimen :Erythromycin base or ethylsuccinate PO 50 mg/kg/ day divided into 4 doses daily for 14 days
  • 3.2 Infants and childern who weigh ≥45 kg but who are aged <8 years
  • 3.3 Infants and childern aged ≥8 years
  • 3. Lymphogranuloma venereum (LGV)
  • Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3 '[113]
  • Preferred regimen : Doxycycline 100 mg PO bid for 21 days
  • Alternative regimen: Erythromycin base 500 mg PO qid for 21 days
Note (1): azithromycin 1 g orally once weekly for 3 weeks is probably effective based on its chlamydial antimicrobial activity. Fluoroquinolone-based treatments might also be effective, but extended treatment intervals are likely required.
Note (2): Pregnant and lactating women should be treated with erythromycin. Azithromycin might prove useful for treatment of LGV in pregnancy, but no published data are available regarding its safety and efficacy. Doxycycline is contraindicated in pregnant women.
Note (3): Persons with both LGV and HIV infection should receive the same regimens as those who are HIV negative. Prolonged therapy might be required, and delay in resolution of symptoms might occur.
Note(4): Persons who have had sexual contact with a patient who has LGV within the 60 days before onset of the patient’s symptoms should be examined and tested for urethral, cervical, or rectal chlamydial infection depending on anatomic site of exposure. They should be presumptively treated with a chlamydia regimen ( Azithromycin 1 g PO single dose OR Doxycycline 100 mg PO bid for 7 days).
  • 1.1 Adult
  • 1.2 Pediatric
  • Preferred regimen: Azithromycin
  • Alternative regimen: fluoroquinolones
  • 1.3 Pregnant Patients
  • Preferred regimen : Azithromycin
  • Alternative regimen: fluoroquinolones
  • 2.Endocarditis in valve replacement patients
  • Preferred regimen : Doxycycline
  • Alternative regimen : fluoroquinolones.
  • 1.1 Adults:
  • Preferred Regimen: Doxycycline PO 100 mg bid for 14 days
  • 1.2 Children
  • 1.2.1 Children with age ≥8 years:
  • Preferred regimen:Doxycycline PO 2.2 mg/kg per dose bid for 14 days (maximum 100 mg/dose)
  • 1.2.2 Children with age <8 years with high risk criteria
  • Preferred regimen:Doxycycline PO 2.2 mg/kg per dose bid for 14 days (maximum: 100 mg/dose)
  • 1.2.3 Children with age < 8 years with mild or uncomplicated illness:
  • Preferred regimen:Doxycycline PO 2.2 mg/kg per dose bid for 5 days (maximum 100 mg/dose). If patient remains febrile past 5 days of treatment: Trimethoprim/Sulfamethoxazole 4-20 mg/kg bid for 14 days (maximum: 800 mg/dose)
  • 1.3 Pregnant women
  • 2. Chronic Q fever
  • 2.1 Endocarditis or vascular infection
  • Preferred regimen:Doxycycline PO 100 mg bid and hydroxychloroquine PO 200 mg tid for ≥18 months
  • Note: childern and pregnant women- consultation Recommended
  • 2.2 Noncardiac organ disease
  • 2.3 Postpartumwith serologic profile for chronic Q fever
  • Preferred regimen:Doxycycline PO 100 mg bid and hydroxychloroquine PO 200 mg tid for 12 months
  • Note(1): Women should only be treated postpartum if serologic titers remain elevated >12 months after delivery (immunoglobulin G phase I titer ≥1:1024). Women treated during pregnancy for acute Q fever should be monitored similarly to other patients who are at high risk for progression to chronic disease (e.g., serologic monitoring at 3, 6, 12, 18, and 24 months after delivery)
  • Note(2):Post-Q fever fatigue syndrome- no current recommendation
  • Atypical bacterial pneumonia caused by Legionella [27]
  • Atypical pneumonia caused by Mycoplasma pneumoniae[116]
  • Preferred regimen (1): Azithromycin 500 mg PO day 1 and 250 mg day 2 to 5
  • Preferred regimen (2): Doxycycline 100 mg PO bid for 14 days
  • Preferred regimen (3): Moxifloxacin 400 mg PO qd for 14 days
  • 1. Urethritis and cervicitis[117]
  • Preferred regimen (macrolide-susceptible strains): Azithromycin 1 g PO as a single dose OR Azithromycin 500 mg PO as a dose followed by 250 mg PO qd for 4 days
  • Preferred regimen (for patients with previous treatment failures): Moxifloxacin 400 mg PO qd for 7–14 days
  • 2. Pelvic inflammatory disease (PID)[118]
  • 3. Specific considerations[119]
  • 3.1 Management of sex partners
  • Sex partners should be managed according to guidelines for patients with nongonococcal urethritis, cervicitis, and pelvic inflammatory disease.
  • 3.2 HIV infection
  • Persons who have an M. genitalium infection and HIV infection should receive the same treatment regimen as those who are HIV negative.

Bacteria – Miscellaneous

  • 1.Bacterial Vaginosis'[120]
  • Gardnerella vaginalis is one of the anaerobic bacteria causing Bacterial Vaginosis,which is a polymicrobial clinical syndrome
  • Preferred regimen: Metronidazole 500 mg PO bid for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days OR Clindamycincream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days
  • Alternative regimen: Tinidazole 2 g PO qd for 2 days OR Tinidazole 1 g PO qd for 5 days OR Clindamycin 300 mg PO bid for 7 days OR Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days
  • Note:Clindamycin ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.
  • 2.Management of Sex Partners
  • Routine treatment of sex partners is not recommended.
  • 3.Special Considerations
  • 3.1 Allergy, Intolerance, or Adverse Reactions
  • Intravaginal clindamycin cream is preferred in case of allergy or intolerance to metronidazole or tinidazole. Intravaginal metronidazole gel can be considered for women who are not allergic to metronidazole but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.
  • 3.2 Pregnancy
  • Preferred regimen: Metronidazole 500 mg PO bid for 7 days OR Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days
  • Note: Tinidazole should be avoided during pregnancy
  • 3.3 HIV Infection
  • Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

Bacteria – Anaerobic Gram-Negative Bacilli

  • 2. Combination therapy

Fungi

  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal Amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • 2. Invasive sinus aspergillosis
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal Amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • 3. Tracheobronchial aspergillosis
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal Amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • 4. Chronic necrotizing pulmonary aspergillosis
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal Amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • 5. Aspergillosis of the CNS
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal Amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • Note (1): There are drug interactions with anticonvulsant therapy.
  • 6. Aspergillus infections of the heart (endocarditis, pericarditis, and myocarditis)
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • Note (1): endocardial lesions generally require surgical treatment. Aspergillus pericarditis usually requires pericardiectomy.
  • 7. Aspergillus osteomyelitis and septic arthritis
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • Note (1): Surgical resection of devitalized bone and cartilage is important for curative intent.
  • 8. Aspergillus infections of the eye (endophthalmitis and keratitis)
  • Preferred regimen: Intraocular Amphotericin B indicated with partial vitrectomy
  • Alternative regimen (1): Liposomal amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • Alternative regimen (7): Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Note: Topical therapy is indicated for keratitis, ophthalmologic intervention and management is recommended for all forms of ocular infection. Systemic therapy may be beneficial when treating aspergillus endophthalmitis.
  • 9. Cutaneous aspergillosis
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • Note: Surgical resection is indicated when feasible.
  • 10. Aspergillus peritonitis
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • 11. Prophylaxis against invasive aspergillosis
  • 12. Aspergilloma
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen: Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • 13.Chronic cavitary pulmonary aspergillosis
  • Preferred regimen: Voriconazole (6 mg/kg IV every 12 h for 1 day, followed by 4 mg/kg IV every 12 h; oral dosage is 200 mg every 12 h)
  • Alternative regimen (1): Liposomal amphotericin B (L-AMB) 3–5 mg/kg/day IV
  • Alternative regimen (2): Amphotericin B lipid complex (ABLC) 5 mg/ kg/day IV
  • Alternative regimen (3): Caspofungin (70 mg day 1 IV and 50 mg/day IV thereafter)
  • Alternative regimen (4): Micafungin (IV 100–150 mg/day; dose not established )
  • Alternative regimen (5): Posaconazole (200 mg QID initially, then 400 mg BID PO after stabilization of disease )
  • Alternative regimen (6): Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • Note: long-term therapy might be needed.
  • 14.Allergic bronchopulmonary Itraconazole aspergillosis
  • Preferred regimen: Itraconazole (dosage depends upon formulation - The dosage for tablets is 600 mg/day for 3 days, followed by 400 mg/day while the dosage for parenteral used in studies is 200 mg every 12h IV for 2 days, followed by 200 mg daily thereafter).
  • Alternative regimen (1): Voriconazole PO 200 mg bid.
  • Alternative regimen (2): Posaconazole PO 400 mg bid.
  • Note: Corticosteroids are a cornerstone of the therapy.
  • Allergic aspergillus sinusitis
  • Preferred regimen: None or Itraconazole
  • Note: Few data available for other agents.
  • Relative indications for surgical treatment of invasive aspergillosis
  • Pulmonary lesion in proximity to great vessels or pericardium;
  • Pericardial infection;
  • Invasion of chest wall from contiguous pulmonary lesion;
  • Aspergillus empyema;
  • Persistent hemoptysis from a single cavitary lesion;
  • Infection of skin and soft tissues;
  • Infected vascular catheters and prosthetic devices;
  • Endocarditis;
  • Osteomyelitis;
  • Sinusitis;
  • Cerebral lesions.


  • 1. Mild to moderate pulmonary blastomycosis
  • Preferred regimen: Itraconazole 200 mg PO once or twice per day for 6–12 months
  • Note: Oral Itraconazole, 200 mg 3 times per day for 3 days and then once or twice per day for 6–12 months, is recommended
  • 2. Moderately severe to severe pulmonary blastomycosis
  • Preferred regimen (1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day for 1–2 weeks AND Itraconazole 200 mg PO bid for 6–12 months
  • Preferred regimen (2): Amphotericin B deoxycholate 0.7–1 mg/kg per day for 1–2 weeks AND Itraconazole 200 mg PO bid for 6–12 months
  • Note: Oral Itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended
  • 3. Mild to moderate disseminated blastomycosis
  • Preferred regimen: Itraconazole 200 mg PO once or twice per day for 6–12 months
  • Note (1): Treat osteoarticular disease for 12 months
  • Note (2): Oral Itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended
  • 4. Moderately severe to severe disseminated blastomycosis
  • Preferred regimen (1): Lipid amphotericin B(Lipid AmB) 3–5 mg/kg per day, for 1–2 weeks AND Itraconazole 200 mg PO bid for 6–12 months
  • Preferred regimen (2): Amphotericin B deoxycholate 0.7–1 mg/kg per day, for 1–2 weeks AND Itraconazole 200 mg PO bid for 6–12 months
  • Note: oral Itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 6–12 months, is recommended
  • 5. CNS disease
  • Preferred regimen: Lipid amphotericin B (Lipid AmB) 5 mg/kg per day for 4–6 weeks AND an oral azole for at least 1 year
  • Note (1): Step-down therapy can be with Fluconazole, 800 mg per day OR Itraconazole, 200 mg 2–3 times per day OR voriconazole, 200–400 mg twice per day.
  • Note (2): Longer treatment may be required for immunosuppressed patients.
  • 6. Immunosuppressed patients
  • Preferred regimen (1): Lipid amphotericin B (Lipid AmB), 3–5 mg/kg per day, for 1–2 weeks, AND Itraconazole, 200 mg PO bid for 12 months
  • Preferred regimen (2): Amphotericin B deoxycholate, 0.7–1 mg/kg per day, for 1–2 weeks, AND Itraconazole, 200 mg PO bid for 12 months
  • Note (1): Oral Itraconazole, 200 mg 3 times per day for 3 days and then 200 mg twice per day, for a total of 12 months, is recommended
  • Note (2): Life-long suppressive treatment may be required if immunosuppression cannot be reversed.
  • 7. Pregnant women
  • Preferred regimen: Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day
  • Note (1): Azoles should be avoided because of possible teratogenicity
  • Note (2): If the newborn shows evidence of infection, treatment is recommended with Amphotericin B deoxycholate, 1.0 mg/kg per day
  • 8. Children with mild to moderate disease
  • Preferred regimen: Itraconazole 10 mg/kg PO per day for 6–12 months
  • Note: Maximum dose 400 mg per day
  • 9. Children with moderately severe to severe disease
  • Preferred regimen (1): Amphotericin B deoxycholate 0.7–1 mg/kg per day for 1–2 weeks AND Itraconazole 10 mg/kg PO per day to a maximum of 400 mg per day for 6–12 months
  • Preferred regimen (2): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg per day for 1–2 weeks AND Itraconazole 10 mg/kg PO per day to a maximum of 400 mg per day for 6–12 months
  • Note: Children tolerate Amphotericin B deoxycholate better than adults do.
  • Preferred regimen (1): [124]
  • Adults: Itraconazole 200 mg/day PO.
  • Children: Itraconazole (<30/kg and >5 yr) 5-10 mg/kg/day PO.
  • Note: Treatment duration based on organ involvement:
  • Mild involvement: 6-9 months.
  • Moderate involvement: 12-18 months.
  • Preferred regimen (2): [124]
  • Adults Trimethoprim/sulfamethoxazole (TMP/SMX) TMP: 160-240 mg/day PO/IV, SMX: 800-1200 mg/day PO/IV divided into two doses per day.
  • Children Trimethoprim/sulfamethoxazole (TMP/SMX) TMP: 8-10 mg/kg PO/IV, SMX: 40-50 mg/kg PO/IV, divided into two doses per day.
  • Note (1): Treatment duration based on organ involvement:
  • Minor involvement: 12 months.
  • Moderate involvement: 18-24 months.
  • Note (2): Preferred treatment in children due to larger experience.
  • Note (3): Preferred in IV formulation in severe forms of the disease - 2 ampules IV tid until patient condition improves so that oral medication can be given.
  • Preferred regimen (3): Amphotericin B deoxycholate mg/kg/day IV until patient improves and can be treated by the oral route.[124]
  • Note: Preferred in severe forms of the disease.[124]
  • Alternative regimen (5): Voriconazole initial dose 400 mg PO/IV each 12 hr for one day, then 200 mg each 12 hr for 6 months.[126]
  • Note: Diminish the dose to 50% if weight is <40 kg.


  • 1. If lesions small and few[127]
  • surgical excision or cryosurgery with liquid nitrogen.
  • 2. If lesions chronic, extensive, burrowing[128]
  • Preferred regimen: Itraconazole 200-400 mg PO q24h OR 400 mg pulse therapy once daily for 1 week monthly for 6-12 months
  • 1. Cryptococcus neoformans
  • 1.1 Cryptococcus neoformans meningitis in HIV infected patients[129]
  • Preferred regimen for induction and consolidation: Amphotericin B deoxycholate 0.7-1.0 mg/kg per day IV (consider using lipid formulations for patients with renal dysfunction OR Liposomal AmB 3-4mg/kg per day IV OR Amphotericin B lipid complex (ABLC) 5mg/kg IV per day) PLUS Flucytosine 100mg/kg PO or IV divided in 4 doses for at least 2 weeks followed by fluconazole 400mg (6mg/kg) per day PO for at least 8 weeks.
  • Alternative regimen for induction and consolidation (1): Amphotericin B deoxycholate 0.7-1.0 mg/kg per day IV OR Liposomal AmB 3-4 mg/kg per day IV OR AmB lipid complex 5mg/kg IV per day for 4-6 weeks.
  • Alternative regimen for induction and consolidation (2): Amphotericin B deoxycholate 0.7 mg/kg IV per day PLUS fluconazole PO 800mg q.d. for 2 weeks, followed by fluconazole 800mg PO q.d. for at least 8 weeks.
  • Alternative regimen for induction and consolidation (3): Fluconazole (>800 mg per day PO, 1200mg daily is favored) PLUS flucytosine (100mg/kg PO per day, divided in 4 doses) for 6 weeks.
  • Alternative regimen for induction and consolidation (4): Fluconazole PO 800-2000mg per day for 10-12 weeks.
  • Preferred regimen for maintenance and prophylactic therapy: Initiate HAART 2-10 weeks after commencing initial antifungal therapy AND Fluconazole PO 200mg q.d..
  • Alternative regimen for maintenance and prophylactic therapy: Itraconazole PO 200mg b.i.d. - monitor drug-level OR Amphotericin B deoxycholate (1 mg/kg) per week IV (should be used in azole-intolerant patients).
  • Note (1): Consider discontinuing supressive therapy if CD4 count is higher than 100 cells/uL AND undetectable OR very low HIV RNA level for more than 3 months. Consider reinstitution of maintenance therapy if CD4 count <100 cels/uL.
  • Note (2): Do not use Acetazolamide OR mannitol OR corticosteroids to treat increased intracranial pressure, instead it should be used lombar puncture in the absence of focal neurologic signs or impaired mentation (which, if present, patient must be submitted to CT or MRI scan first).
1.2. Cerebral cryptococcomas
  • Preferred regimen for induction and consolidation: Amphotericin B deoxycholate 0.7-1.0 mg/kg per day IV (consider using lipid formulations for patients with renal dysfunction - Liposomal AmB 3-4mg/kg per day IV OR AmB lipid complex (ABLC) 5mg/kg IV per day) PLUS Flucytosine 100mg/kg PO OR IV divides in 4 doses for at least 6 weeks followed by fluconazole 400-800mg per day PO for 6-18 months; corticosteroids might be useful for surrounding edema and mass effect.
  • Note (1): Consider surgery if lesions are larger than 3cm, accessible lesions with mass effect or lesions that are enlarging and not explained by IRIS.
1.3. Cryptococcus neoformans meningitis in HIV negative patients
  • Preferred regimen: Amphotericin B deoxycholate 0.7-1.0 mg/kg per day IV PLUS Flucytosine 100mg/kg PO OR IV divides in 4 doses for at least 4 weeks (which may be extended to 6 weeks if there is any neurological complications) followed by fluconazole 400mg per day PO for 8 weeks. If there's toxicity to AmBd, consider changing to LFAmB in the second 2 weeks.
  • Note (1): After induction and consolidation therapy, start fluconazole 200mg (3mg/kg) per day, PO for 6-12 months.
  • Note (2): If flucytosine is not given, consider lengthening the induction therapy for at least 2 weeks.
1.4. Cryptococcus neoformans pulmonary disease - immunosupressed
  • Mild-moderate symptoms, without severe immunosupression and absence of diffuse pulmonary infiltrates:
  • Preferred regimen: Fluconazole 400mg per day orally for 6-12 months.
  • Severe pneumonia or disseminated disease or CNS infection:
  • Preferred regimen: treat like CNS cryptococcosis.
  • Note (1): In HIV- infected patients, treatment should be stopped after 1 year if CD4 count is >100 and a cryptococcal antigen titer is <1:512 and not increasing.
  • Note (2): Consider corticosteroid if ARDS is present in a context which it might be attributed to IRIS.
1.5 Cryptococcus neoformans pulmonary disease - non-immunosupressed
  • Mild-moderate symptoms, without severe immunosupression and absence of diffuse pulmonary infiltrates:
  • Preferred regimen: Fluconazole 400mg per day orally for 6-12 months.
  • Alternative regimen: if fluconazole is unavailable or contraindicated, Itraconazole PO 200 mg twice per day, voriconazole PO 200 mg twice per day, and posaconazole PO 400 mg twice per day.
  • If there's severe pneumonia, disseminated disease or CNS infection:
  • Preferred regimen: treat like CNS cryptococcosis for 6-12 months.
1.6 Cryptococcus neoformans non-lung, non-CNS infection
  • Cryptococcemia or disseminated cryptococcic disease (involvement of at least 2 noncontiguous sites or cryptococcal antigen titer >1:512):
  • Preferred regimen: treat like CNS infection.
  • If infection occurs at a single site and no immunosupressive risk factors
  • Preferred regimen: fluconazole 400mg PO per day for 6-12 months.
1.7. Cryptococcosis in Children
  • Preferred regimen for induction and consolidation: Amphotericin B deoxycholate 1.0 mg/kg per day IV plus Flucytosine 100mg/kg PO or IV divided in 4 doses for 2 weeks followed by fluconazole 10-12mg/kg per day PO for 8 weeks.
  • Alternative regimen: patients with renal dysfunction: change Amphotericin B deoxycholate by Liposomal AmB 5mg/kg per day IV or Amphotericin B lipid complex (ABLC) 5mg/kg IV per day).
  • Preferred regimen for maintenance: fluconazole 6mg/kg PO per day
  • Cryptococcal pneumonia:
  • Preferred regimen fluconazole 6-12mg/kg PO per day for 6-12 months.
1.8. Cryptococcosis in Pregnant Women
  • Preferred regimen for induction and consolidation: Amphotericin B deoxycholate 0.7-1.0 mg/kg per day IV (consider using lipid formulations for patients with renal dysfunction - Liposomal AmB 3-4mg/kg per day IV OR Amphotericin B lipid complex (ABLC) 5mg/kg IV per day). Consider using flucytosine in relationship to benefit risk basis, since it is a Category C drug for pregnancy. Start fluconazole after delivery. Avoid use during first trimester and consider use in the last 2 trimesters with the need for continuous antifungal therapy during pregnancy.
  • Note (1): If pulmonary cryptococcosis: perform close follow-up and administer fluconazole after delivery.
2. Cryptococcus gatti
  • Disseminated cryptococcosis or CNS disease:
  • Preferred regimen: treatment is the same as C. neoformans.
  • Pulmonary disease: single and small cryptococcoma:
  • Preferred regimen: fluconazole 400mg per day PO
  • Pulmonary disease: Very large or multiple cryptococcomas:
  • Preferred regimen: administer flucytosine AND AmB deocycholate for 4-6 weeks, followed by fluconazole for 6-18 months.
  • Note (1): Surgery should be considered if there is compression of vital structures OR failure to reduce the size of the cryptococcoma after 4 weeks of therapy.
  • Tinea Corporis
  • 2.1 Small, well-defined lesions:
  • 2.2 Larger lesions:
  • 1. Tinea Pedis
  • Tinea Capitis
  • Preferred regimen: Griseofulvin PO 10-20mg/kg/day for at least 6 weeks (Preferred for children).
  • Alternative regimens: Terbinafine PO 62.5mg/day if <20kg; 125 mg/day if 20-40kg; 250mg/day if >40kg OR Itraconazole PO 4-6mg/kg pulsed dose weekly.
  • Note: Nistatin is not effective in the treatment of dermatophytosis.
  • Tinea Barbae
  • Preferred regimen: Terbinafine PO 250mg/day for 4 weeks.
  • Alternative regimen: Itraconazole PO 200mg/day for 2 weeks.
  • Tinea Incognito
  • Preferred regimen: Stop topical steroids and treat with topical 1% terbinafine cream for 6 weeks.
  • Tinea Manuum
  • Preferred regimen: topical or systemic terbinafine PO 250 mg/day por 2-4 weeks.
  • Tinea Versicolor
  • Majocchi's Granuloma
  • Preferred regimen: Terbinafine PO 250mg/day for 2-4 weeks.
  • Alternative regimen: Itraconazole 200mg PO bid for 1 week, per month for 2 months.
  • 10.1 Fingernails
  • Preferred regimen: Terbinafine PO 250mg/day for 6 weeks OR Itraconazole PO 200mg twice a day for a week a month for 2 months (European guidelines).
  • 10.2 Toenails
  • Preferred regimen: Toenails Terbinafine PO 250mg/day for 12 weeks OR Itraconazole PO 200mg/day for 12 weeks (U.S. guidelines) OR Itraconazole PO 200mg twice a day for a week a month for 3 months (European guidelines).
  • Note (1): There is no evidence that combining systemic and topic treatments has any benefit to the patient.
  • 1. Preventing First Episode of PCP (Primary Prophylaxis)[132]
  • Preferred regimen: TMP-SMX 1 Double-Strength(DS) PO daily OR TMP-SMX 1 Single-Strength(SS) PO daily
  • Alternative regimen (1): TMP-SMX 1 Double-Strength(DS) tid weekly OR Dapsone 100 mg PO daily or 50 mg PO BID
  • Alternative regimen (2): Dapsone 50 mg PO daily AND (Pyrimethamine 50 mg + Leucovorin 25 mg) PO weekly
  • Alternative regimen (3): Dapsone 200 mg AND Pyrimethamine 75 mg AND Leucovorin 25 mg PO weekly
  • Alternative regimen (4): Aerosolized Pentamidinec 300 mg via Respigard II™ nebulizer every month
  • Alternative regimen (5): Atovaquone 1500 mg PO daily with food
  • Alternative regimen (6): Atovaquone 1500 mg AND Pyrimethamine 25 mg AND Leucovorin 10 mg PO daily with food
  • 2. Treatment of Pneumocystis Pneumonia[133]
  • 2.1. Moderate to Severe PCP
  • Preferred regimen: TMP-SMX (TMP 15–20 mg and SMX 75–100 mg)/kg/day IV given q6h or q8h
  • Note: May switch to PO after clinical improvement
  • Alternative regimen (1): Pentamidine 4 mg/kg IV once daily infused over at least 60 minutes
  • Note: May reduce the dose to 3 mg/kg IV once daily because of toxicities.
  • Alternative regimen (2): Primaquine 30 mg (base) PO once daily AND (Clindamycin [IV 600 mg q6h or 900 mg q8h] or [PO 450 mg q6h or 600 mg q8h])
  • Note (1): Duration of PCP treatment is 21 days
  • Note (2): Adjunctive corticosteroid may be indicated in some moderate to severe cases.Prednisone doses (beginning as early as possible and within 72 hours of PCP therapy) (AI):
  • Note (3): Prednisone doses (beginning as early as possible and within 72 hours of PCP therapy)
  • Days 1–5 40 mg PO BID
  • Days 6–10 40 mg PO daily
  • Days 11–21 20 mg PO daily
  • 2.2. Mild to Moderate PCP
  • Preferred regimen: TMP-SMX (TMP 15–20 mg/kg/day and SMX 75–100 mg/kg/day), given PO in 3 divided doses OR TMP-SMX Double-Strength(DS) - 2 tablets tid
  • Alternative regimen (1): Dapsone 100 mg PO daily AND TMP 15 mg/kg/day PO (3 divided doses)
  • Alternative regimen (2): Primaquine 30 mg (base) PO daily AND Clindamycin PO (450 mg q6h or 600 mg q8h)
  • Alternative regimen (3): Atovaquone 750 mg PO BID with food
  • Note: Duration of PCP treatment is 21 days
  • 3. Preventing Subsequent Episode of PCP (Secondary Prophylaxis)[134]
  • Preferred regimen: TMP-SMX 1 Double-Strength(DS) PO daily OR TMP-SMX 1 Single-Strength(SS) PO daily
  • Alternative regimen (1): TMP-SMX 1 Double-Strength(DS) tid weekly OR Dapsone 100 mg PO daily or 50 mg PO BID
  • Alternative regimen (2): Dapsone 50 mg PO daily AND (Pyrimethamine 50 mg + Leucovorin 25 mg) PO weekly
  • Alternative regimen (3): Dapsone 200 mg AND Pyrimethamine 75 mg AND Leucovorin 25 mg PO weekly
  • Alternative regimen (4): Aerosolized Pentamidinec 300 mg via Respigard II™ nebulizer every month
  • Alternative regimen (5): Atovaquone 1500 mg PO daily with food
  • Alternative regimen (6): Atovaquone 1500 mg AND Pyrimethamine 25 mg AND Leucovorin 10 mg PO daily with food

Mycobacteria

  • 1.Limited, localized extrapulmonary disease [135]
  • 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
  • Preferred regimen: Clarithromycin 500 mg PO twice daily AND Amikacin 15 mg/kg/day IV AND Cefoxitin 2g q4h IV OR Imipenem 1g q6h IV for at least 2-4 months, if limited by adverse effects, then switch toClarithromycin 500 mg PO BID or 1000 mg XR OD OR Azithromycin 250 mg PO OD
  • Alternative regimen(1): Tigecycline 100 mg IV load then 50 mg IV q12h could be substituted as one of the injectables
  • Alternative regimen(2): Linezolid 600 mg PO q12h or 600 mg PO OD AND Clarithromycin could replace parental tx if not tolerated or feasible
  • 2. Disseminated or extensive disease
  • 2.1 monotherapy
  • 2.2 multidrug therapy
  • NOTE: Total treatment duration is 6 months
  • 3. Keratitis (LASIK-related)


Parasites – Intestinal Protozoa

  • Preferred regimen: No clear benefit
  • 3. HIV and Immunodeficiency[139]
  • Preferred regimen: Effective antiretroviral therapy
  • Note: Nitazoxanide is not licensed for immunodeficient patients
  • Preferred regimen: No clear benefit
  • 3. HIV and Immunodeficiency[142]
  • Preferred regimen: Effective antiretroviral therapy
  • Note: Nitazoxanide is not licensed for immunodeficient patients
  • Preferred regimen: Trimethoprim-sulfamethoxazole one double-strength tablet PO bid for 7-10 days[143]
  • Alternative regimen(1): Ciprofloxacin 500 mg PO bid for 7 days[144]
  • Alternative regimen(2): Nitazoxanide 500 mg PO bid for 7 days[145]
  • Note(1): One double-strength tablet (160 mg TMP/800 mg SMX) .
  • Note(2): Treatment is continued for 7 days in immunocompetent hosts and for 7 to 10 days in patients with HIV infection.
  • 1. Amebic Liver Abscess[146]
  • 3. Asymptomatic Intestinal Colonization[148]
  • 2. Intestinal (diarrhea)[150]
  • Preferred regimen:
  • Adult: Albendazole 400 mg PO bid for 3 weeks for E. intestinalis
  • Pediatric: Albendazole 15 mg/kg per day divided into 2 daily doses for 7 days for E. intestinalis
  • Note: Fumagillin 20 mg PO tid reported effective for E. bieneusi
  • Preferred regimen: Albendazole 400 mg po bid for 3 weeks

Parasites – Extraintestinal Protozoa

  • 2. Acanthamoeba Granulomatous Amebic Encephalitis and Disseminated Disease
  • Chronic granulomatous meningitis[153]
  • Preferred regimen: Amphotericin B 1.5 mg/kg /day bid for 3 days; then 1 mg/kg/day for 6 days AND1.5 mg/day intrathecal x 2 days; then 1 mg/day intrathecal qd for 8 days.
  • Note: Investigational drug called miltefosine also available for treatment.
  • 1. Mild/moderate disease.[156]
  • 2.Severe babesiosis:
  • Preferred regimen: Clindamycin 600 mg po tid AND Quinine 650 mg po tid for 7–10 days OR Clindamycin 1.2 gm IV bid.
  • Note(1) For overwhelming infection in asplenic patients and immunocompromised patients, treat for 6 or more weeks
  • Note(2)Consider transfusion if 􀂕10% parasitemia
  • 1.Cutaneous Leishmaniasis[157]
  • 1.1Systemic Therapy (Parenteral)
  • Preferred Regimen: Sodium stibogluconate 20 mg/kg IV/IM once qd for 10-20 days OR Meglumine antimoniate 20 mg/kg IV/IM once qd for 10-20 days
  • Alternative Regimen: Liposomal amphotericin B 3 mg/kg/day IV infusion for 6-10 days OR Pentamidine 2-3 mg/kg/day IV/IM for 4-7 days
  • Note: Data supporting the use of amphotericin B for treatment of cutaneous (and mucosal) leishmaniasis are anecdotal; standard dosage regimens have not been established. In the United States, pentamidine isethionate is uncommonly used for treatment of cutaneous leishmaniasis. Its limitations include the potential for irreversible toxicity and variable effectiveness.
  • 1.2 Systemic Therapy (Oral)
  • Preferred Regimen: In adults and adolescents at least 12 years of age who weigh from 33-44 kg:-Miltefosine 50 mg PO q12h for 28 days
  • Patients who weigh >45 kg:-Miltefosine 50 mg PO q8h for 28 days
  • Alternative Regimen:Ketoconazole 600 mg qd for 28 days OR Fluconazole 200 mg qd for 6 weeks
  • Note:The FDA-approved indications are limited to infection caused by three particular species, all three of which are New World species in the Viannia subgenus—namely, Leishmania (V.) braziliensis, L. (V.) panamensis, and L. (V.) guyanensis. The "azoles" showed modest activity against some Leishmania species in some cases, but are not FDA approved
  • 1.3Local Therapy
  • List of possible local therapies
  • Cryotherapy (with liquid nitrogen OR Thermotherapy (use of localized current field radiofrequency heat) OR Intralesional administration of SbV OR Topical application of paromomycin (such as an ointment containing 15% paromomycin/12% methylbenzethonium chloride in soft white paraffin)
  • 2.Visceral Leishmaniasis
  • 2.1Systemic Therapy (Parenteral)
  • Preferred Regimen: Liposomal amphotericin B 3 mg/kg/day IV for 5 days, then once on day 14 and once on day 21 (Total dose: 21 mg/kg) ORSodium stibogluconate 20 mg/kg IV/IM once daily for 28 days OR Meglumine antimoniate 20 mg/kg IV/IM once daily for 28 days'
  • Alternative Regimen:Amphotericin B deoxycholate 0.5-1 mg/kg IV once daily (Total dose: 15-20 mg/kg)
  • Note: In immunosuppressed patients, dose is 4 mg/kg/day for 5 days, then once on day 10, 17, 24, 31, and 38 (Total dose: 40 mg/kg)
  • 2.2 Systemic Therapy (Oral)
  • Preferred Regimen:In adults and adolescents at least 12 years of age, who weigh from 33-44 kg:-Miltefosine 50 mg PO q12h for 28 days Patients who weigh >45 kg:-Miltefosine 50 mg PO q8h for 28 days

===

  • 1.1 Treatment of uncomplicated P. falciparum malaria
  • 1.1.1 Treat children and adults with uncomplicated P. falciparum malaria (except pregnant women in their first trimester) with one of the following recommended ACT (artemisinin-based combination therapy)
  • Preferred regimen (1): Artemether 5–24 mg/kg bw PO AND Lumefantrine 29–144 mg/ kg bw PO, Both are given bid for 3 days (total, six doses). The first two doses should, ideally, be given 8 h apart.
  • Preferred regimen (2): Artesunate (2–10) mg/kg bw per day AND Amodiaquine(7.5–15) mg/kg bw per day ,both are given once a day for 3 days. A total therapeutic dose range of 6–30 mg/kg bw per day artesunate and 22.5–45 mg/kg bw per dose amodiaquine is recommended
  • Preferred regimen (3): Artesunate (2–10) mg/kg bw per dayAND Mefloquine (2–10) mg/kg bw per day both are given once a day for 3 days
  • Dosage regimen based on Body weight (kg)
  • Body weight (kg)-5 to < 9- Artesunate 25 (mg) AND Mefloquine 55 (mg) given bid for 3 days;
  • Body weight (kg)-9to < 18- Artesunate 50 (mg) AND Mefloquine 110 (mg) given bid for 3 days;
  • Body weight (kg)-18 to < 36- Artesunate 100 (mg) AND Mefloquine 220 (mg) given bid for 3 days;
  • Body weight (kg)- ≥ 36 - Artesunate 200 (mg) AND Mefloquine 440 (mg) given bid for 3 days;
  • Preferred regimen (4): Artesunate (2–10) mg/kg bw per day given once a day for 3 days AND Sulfadoxine-Pyrimethamine 1.25 (25–70 / 1.25–3.5) mg/kg bw given as a single dose on day 1
  • 1.1.2 Reducing the transmissibility of treated P. falciparum infections In low-transmission areas in patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months)
  • Preferred regimen: single dose of 0.25 mg/kg bw Primaquine with ACT
  • 1.2 Recurrent Falciparum Malaria
  • 1.2.1 Failure within 28 days
  • Note:The recommended second-line treatment is an alternative ACT known to be effective in the region. Adherence to 7-day treatment regimens (with artesunate or quinine both of which should be co-administered with + tetracycline, or doxycycline or clindamycin) is likely to be poor if treatment is not directly observed; these regimens are no longer generally recommended.
  • 1.2.2 Failure after 28 days
  • Note: all presumed treatment failures after 4 weeks of initial treatment should, from an operational standpoint, be considered new infections and be treated with the first-line ACT. However, reuse of mefloquine within 60 days of first treatment is associated with an increased risk for neuropsychiatric reactions, and an alternative ACT should be used
  • 1.3 Reducing the transmissibility of treated P. falciparum infections In low-transmission areas in patients with P. falciparum malaria (except pregnant women, infants aged < 6 months and women breastfeeding infants aged < 6 months)
  • Note: a single dose of 0.25 mg/kg bw Primaquine with ACT
  • 1.4 Treating uncomplicated P. falciparum malaria in special risk groups
  • 1.4.1 Pregnancy
  • First trimester of pregnancy :Quinine AND Clindamycin PO 10mg/kg bw bid for 7 days
  • Second and third trimesters : Mefloquine is considered safe for the treatment of malaria during the second and third trimesters; however, it should be given only in combination with an artemisinin derivative.
  • Note: Quinine is associated with an increased risk for hypoglycaemia in late pregnancy, and it should be used (with clindamycin) only if effective alternatives are not available.
  • Note: Primaquine and tetracyclines should not be used in pregnancy.
  • 1.4.2 Infants less than 5kg body weight : with an ACT at the same mg/kg bw target dose as for children weighing 5 kg.
  • 1.4.3 Patients co-infected with HIV: should avoid Artesunate + SP if they are also receiving Co-trimoxazole, and avoid artesunate + amodiaquine if they are also receiving efavirenz or zidovudine.
  • 1.4.4 Large and Obese adults: For obese patients, less drug is often distributed to fat than to other tissues; therefore, they should be dosed on the basis of an estimate of lean body weight, ideal body weight. Patients who are heavy but not obese require the same mg/kg bw doses as lighter patients.
  • 1.4.5 Patients co-infected with TB: Rifamycins, in particular rifampicin, are potent CYP3A4 inducers with weak antimalarial activity. Concomitant administration of rifampicin during quinine treatment of adults with malaria was associated with a significant decrease in exposure to quinine and a five-fold higher recrudescence rate
  • 1.4.6 Non-immune travellers : Treat travellers with uncomplicated P. falciparum malaria returning to nonendemic settings with an ACT.
  • 1.4.7 Uncomplicated hyperparasitaemia: People with P. falciparum hyperparasitaemia are at increased risk of treatment failure, severe malaria and death so should be closely monitored, in addition to receiving an ACT
  • 2. Treatment of uncomplicated malaria caused by P. vivax, P. ovale, P. malariae or P. knowlesi
  • 2.1 Blood Stage infection
  • 2.1.1. Uncomplicated malaria caused by P. vivax
  • 2.1.1.1 In areas with chloroquine-sensitive P. vivax
  • Preferred regimen: Chloroquine PO total dose of 25 mg base/kg bw. Chloroquine is given at an initial dose of 10 mg base/kg bw, followed by 10 mg/kg bw on the second day and 5 mg/kg bw on the third day.
  • 2.1.1.2 In areas with chloroquine-resistant P. vivax
  • 2.1.2 Uncomplicated malaria caused by P. ovale, P. malariae or P. knowlesi malaria
  • Note: Resistance of P. ovale, P. malariae and P. knowlesi to antimalarial drugs is not well characterized, and infections caused by these three species are generally considered to be sensitive to chloroquine. In only one study, conducted in Indonesia, was resistance to chloroquine reported in P. malariae. The blood stages of P. ovale, P. malariae and P. knowlesi should therefore be treated with the standard regimen of ACT or chloroquine, as for vivax malaria.
  • 2.1.3 Mixed malaria infections
  • Note: ACTs are effective against all malaria species and so are the treatment of choice for mixed infections.
  • 2.2 Liver stages (hypnozoites) of P. vivax and P. ovale
  • Note: To prevent relapse, treat P. vivax or P. ovale malaria in children and adults (except pregnant women, infants aged < 6 months, women breastfeeding infants < 6 months, women breastfeeding older infants unless they are known not to be G6PD deficient and people with G6PD deficiency) with a 14-day course of primaquine in all transmission settings. Strong recommendation, high-quality evidence In people with G6PD deficiency, consider preventing relapse by giving primaquine base at 0.75 mg base/kg bw once a week for 8 weeks, with close medical supervision for potential primaquine-induced adverse haematological effects.]
  • 2.2.1 Primaquine for preventive relapse
  • Preferred regimen: Primaquine PO 0.25–0.5 mg/kg bw per day qd for 14 days
  • 2.2.2 Primaquine and glucose-6-phosphate dehydrogenase deficiency
  • Preferred regimen:Primaquine PO 0.75 mg base/kg bw once a week for 8 weeks.
  • Note: The decision to give or withhold Primaquine should depend on the possibility of giving the treatment under close medical supervision, with ready access to health facilities with blood transfusion services.
  • 2.2.3 Prevention of relapse in pregnant or lacating women and infants
  • Note: Primaquine is contraindicated in pregnant women, infants < 6months of age and in lactating women (unless the infant is known not to be G6PD deficient).
  • 3.Treatment of severe malaria
  • 3.1 Treatment of severe falciparum infection with Artesunate
  • 3.1.1 Adults and children with severe malaria (including infants, pregnant women in all trimesters and lactating women):-
  • Preferred regimen: Artesunate IV/IM for at least 24 h and until they can tolerate oral medication. Once a patient has received at least 24 h of parenteral therapy and can tolerate oraltherapy, complete treatment with 3 days of an ACT (add single dose Primaquine in areas of low transmission).
  • 3.1.2 Young children weighing < 20 kg
  • Preferred regimen:Artesunate (3 mg/kg bw per dose)
  • Alternatives regimen: use Artemether in preference to quinine for treating children and adults with severe malaria
  • 3.2.Treating cases of suspected severe malaria pending transfer to a higher-level facility (pre-referral treatment)
  • 3.2.1 Adults and children
  • 3.2.2 Children < 6 years
  • Preferred regimen: Where intramuscular injections of artesunate are not available , treat with a single rectal dose (10 mg/kg bw) of Artesunate, and refer immediately to an appropriate facility for further care.
  • Note: Do not use rectal artesunate in older children and adults.
  • 3.3 Pregancy
  • Note: Parenteral artesunate is the treatment of choice in all trimesters. Treatment must not be delayed
  • 3.4 Treatment of severe P.Vivax infection
  • Note: parenteral artesunate, treatment can be completed with a full treatment course of oral ACT or chloroquine (in countries where chloroquine is the treatment of choice). A full course of radical treatment with primaquine should be given after recovery
  • 3.5 Additional aspects of management in severe malaria
  • Fluid therapy: It is not possible to give general recommendations on fluid replacement; each patient must be assessed individually and fluid resuscitation based on the estimated deficit
  • Blood Transfusion :In high-transmission settings, blood transfusion is generally recommended for children with a haemoglobin level of < 5 g/100 mL(haematocrit < 15%). In low-transmission settings, a threshold of 20% (haemoglobin,7 g/100 mL) is recommended
  • Exchange blood transfusion: Exchange blood transfusion requires intensive nursing care and a relatively large volume of blood, and it carries significant risks. There is no consensus on the indications, benefits and dangers involved or on practical details such as the volume of blood that should be exchanged. It is, therefore, not possible to make any recommendation regarding the use of exchange blood transfusion.
1.T. vaginalis infection [159]
2.T. vaginalis infection in Pregnant and Lactating Women
  • 2.1 Pregnant women
  • Preferred regimen:Metronidazole 2 g PO in a single dose.
  • 2.2 Post-partum and Breastfeeding
  • Preferred regimen:Metronidazole 2 g PO in a single dose.OR Tinidazole 2 g PO in a single dose
  • Note(1): do not breastfeed for 12-24 hrs following Metronidazole and 72 hrs following Tinidazole
  • Note(2)Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment. Pregnant women should be advised of the risk and benefits to treatment as infection (definitely) and treatment (possibly)
  • Note(3): Pregnant women with HIV who are treated for T. vaginalis infection should be retested 3 months after treatment.
3.T. vaginalis infection in patients with HIV
4. Persistent or Recurrent Trichomoniasis
  • Treatment Failure
  • Preferred regimen:Metronidazole 500 mg PO bid for 7 days
  • Treatment failure again
  • Preferred regimen:Metronidazole 2 g PO for 7 days OR Tinidazole 2 g PO for 7 days
  • Nitroimidazole-resistant cases
  • Preferred regimen: Tinidazole 2-3 g PO for 14 days
  • 1. East African trypanosomiasis
  • 1.1T. b. rhodesiense, hemolymphatic stage
  • Adult
  • Preferred regimen: Suramin 1 gm IV on days 1,3,5,14, and 21
  • Pediatric
  • Preferred regimen: Suramin 20 mg/kg IV on days 1, 3, 5, 14, and 21
  • 1.2 T. b. rhodesiense, CNS involvement
  • Adult
  • Preferred regimen: Melarsoprol 2-3.6 mg/kg/day IV for 3 days.After 7 days, 3.6 mg/kg/day for 3 days. Give a 3rd series of 3.6 mg/kg/d after 7 days.
  • Pediatric
  • Preferred regimen: Melarsoprol 2-3.6 mg/kg/day IV for 3 days.After 7 days, 3.6 mg/kg/day for 3 days. Give a 3rd series of 3.6 mg/kg/d after 7 days
  • 2. West African trypanosomiasis
  • 2.1 T. b. gambiense, Hemolymphatic stage
  • Adult
  • Preferred regimen: Pentamidine 4 mg/kg/day IM or IV for 7-10 days
  • Pediatric
  • Preferred regimen: Pentamidine 4 mg/kg/day IM or IV for 7-10 days
  • Note(1): Pentamidine should be used during pregnancy and lacation only if the potential benefit justifies the potential risk
  • Note(2): IM/IV Pentamidine have a similar safety profile in children age 4 months and older as in adults. Pentamidine is listed as a medicine for the treatment of 1st stage African trypanosomiasis infection (Trypanosoma brucei gambiense) on the WHO Model List of Essential Medicines for Children, intended for the use of children up to 12 years of age.
  • 2.2 T. b. gambiense, CNS involvement
  • Adult
  • Preferred regimen: Eflornithine 400 mg/kg/day in 4 doses for 14 days
  • Pediatric
  • Preferred regimen: Eflornithine 400 mg/kg/day in 4 doses for 14 days
  • Note (1): Eflornithine should be used during pregnancy and lactation, only if the potential benefit justifies the potential risk
  • Note (2): The safety of Eflornithine in children has not been established. Eflornithine is not approved by the Food and Drug Administration (FDA) for use in pediatric patients. Eflornithine is listed for the treatment of 1st stage African trypanosomiasis inTrypanosoma brucei gambiense infection on the WHO Model List of Essential Medicines for Children, intended for the use of children up to 12 years of age.
  • 1.Preferred regimen(1):Benznidazole < 12 years5-7.5 mg/kg per day orally in 2 divided doses for 60 days

12 years or older5-7 mg/kg per day orally in 2 divided doses for 60 days

  • 2.Preferred regimen(2): Nifurtimox ≤ 10 years15-20 mg/kg per day orally in 3 or 4 divided doses for 90 days

11-16 years12.5-15 mg/kg per day orally in 3 or 4 divided doses for 90 days 17 years or older8-10 mg/kg per day orally in 3 or 4 divided doses for 90 days

  • Note: In the United States, nifurtimox and benznidazole are not FDA approved and are available only from CDC under investigational protocols.


Parasites – Intestinal Nematodes (Roundworms)

  • Preferred regimen: Albendazole 400 mg/day PO for 10 days
  • Alternative regimen: Mebendazole 200 mg PO bid for 20 days

Parasites – Extraintestinal Nematodes (Roundworms)

  • Adult: Albendazole 400 mg per day PO for 3 to 7 days
  • Pediatric: Albendazole > 2 years 400 mg per day PO for 3 days
  • Note: This drug is contraindicated in children younger than 2 years age.
  • Adult: Ivermectin 200 mcg/kg PO single dose
  • Pediatric: Ivermectin >15 kg give 200 mcg/kg single dose
  • Preferred: Symptomatic therapy, serial lumber puncture and analgesics[173]
  • Alternative regimen: Albendazole 400 mg PO (once daily or bid) for 21 days[174]
  • Filariasis
  • 1. Lymphatic filariasis- Wuchereria bancrofti, Brugia malayi Brugia timori
  • 2. Cutaneous filariasis- Onchocercia volvulus, Loa loa


  • Onchoceria volvulus cutaneous filariasis (river blindness) treatment[175]
  • Preferred regimen: Ivermectin Single dose of 150mcg/kg po; repeat every 6-12 months until asymptomatic.
  • Alternative regimen: If Ivermectin fails, consider Suramin.
Note (1): Onchocercia and Loa loa may both be present. Check peripheral smear; if Loa loa microfilaria present, treat onchocercia first with Ivermectin before Diethylcarbamazine (DEC) for Loa loa.
Note (2): Retreatment for microfilaremia often necessary q6-12 months as demonstrated by repeat blood smear or antigen testing.
Note (3): Do not use Diethylcarbamazine (DEC) in Onchocerca volvulus due to increased risks of precipitating blindness.
  • Treatment of endosymbiont Wolbachia (bacteria) may help clear infection
  • Preferred regimen: Doxycycline 100 mg qd or bid for 6-8 wks in lymphatic filariasis although effect may be more important for co-infecting pathogens such as Wuchereria or Onchocerca than loaloa.
  • Loa loa cutaneous filariasis (eyeworm disease) treatment[176]
  • Preferred regimen: Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days 4-21, 8-10mg/kg/day in 3 divided dose
  • Alternative regimen: Albendazole 200mg po bid for 21 days
Note: If concomitant onchocercia Loa loa, treat oncho first. Ifover 5,000 microfilaria/mL of blood, Diethylcarbamazine (DEC) can cause encephalopathy. Might start with albendazole for few days with or without steroids, then Diethylcarbamazine (DEC).


  • Wuchereria bancrofti lymphatic filariasis (elephantiasis) treatment[177]
  • Preferred regimen (1): Scaled dose Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days 4-14, 2 mg/kg q8h for total of 72 mg over 14 days. (Diethylcarbamazine(DEC) 2 mg/kg PO tid for 12 days (may be accompanied by systemic reaction to dying worms,local reactions include lymphadenitis, transient lymphedema)).
Note: Corticosteroids or antihistamines may be needed to treat allergic reactions that develop as a consequence of dying microfilariae.
  • Preferred regimen (2): Albendazole 400 mg PO single dose regimen AND (Ivermectin 200 mcg/kg PO OR Diethylcarbamazine 6mg/kg) may reduce or suppress microfilariae; however, this will not affect adultworms.
Note (1): Most symptoms with Wuchereria bancrofti are due to the adultworm.
Note (2): Retreatment for microfilaremia often necessary q6-12 months as demonstrated by repeat blood smear or antigen testing.
Note (3): Do not use Diethylcarbamazine (DEC) in Onchocerca volvulus due to increased risks of precipitating blindness.
Note (4): Skin snip technique is skin snips can be obtained using a corneal scleral punch, or more simply a scalpel and needle. The sample must be allowed to incubate for 30 minutes to 2 hrs in saline or culture medium, and then examined for microfilariae that would have migrated from the tissue to the liquid phase of the specimen.
Note (5): Site of infection
5.1 General: filarial fever includes fever, chills, malaise during acute or recurrent episode.
5.2 Lymph:localized lymphadenitis, may be painful(red,warm) or painless, unilateral or bilateral groin swelling. May be due to adult worm or complicating bacterial infection.
5.3 Derm:pruritus,dermatitis,subcutaneous nodules.
5.4 Genital:scrotal or vulvar swelling/ hydrocele; may be able to visualize adult W.bancrofti worm by ultrasound.
5.5 Extremities:unilateral or bilateral swelling, acute or chronic. May be extreme (classic elephantiasis) or mild. May be associated with recurrent bacterial cellulitis (abrupt onset of redness ,fever).
5.6 Lungs:tropical pulmonary eosinophilia (miliary pattern on CXR, nocturnal paroxysmal cough, wheezing, accompanied by marked eosinophilia, responds to DEC, usually amicrofilaremic).
5.7 Renal: chyluria, hematuria (rupture of dilated lymphatics into urinary excretory system). May see weightloss, hypoproteinemia, lymphopenia, anemia.
5.8 Musculoskeletal:acute monoarthritis (knee>ankle) which responds to DEC, tenosynovitis (rare), thrombophlebitis (rare).
Note (6)
Diagnosis 1.serological-antigen detection by commercially available card test ; IgG4 antibody (not filaria species specific and may cross react with other helminths);
Diagnosis 2.special maneuvers DEC provocative days test (induce microfilaremia with dose of DEC); polymerase chain reaction.
Diagnosis 3.skin snips (detect Onchocerca volvulus, Mansonella streptocerca). Ultrasonography can detect adult W.bancrofti worms in scrotal lymphatics.
  • Treatment of endosymbiont Wolbachia (bacteria) may help clear infection
  • Preferred regimen: Doxycycline 100 mg qd or bid for 6-8 wks in lymphatic filariasis although effect may be more important for co-infecting pathogens such as Wuchereria or Onchocerca than loaloa.
  • Brugia malayi, Brugia timori lymphatic filariasis (elephantiasis) treatment[178]
  • Preferred regimen (1): Scaled dose Diethylcarbamazine (DEC) escalation recommended to reduce reactions on day 1-50 mg, day 2-50 mg tid, day 3-100 mg tid, Days 4-14, 2 mg/kg q8h for total of 72 mg over 14 days. (Diethylcarbamazine(DEC) 2 mg/kg PO tid for 12 days (may be accompanied by systemic reaction to dying worms,local reactions include lymphadenitis, transient lymphedema)).
Note: Corticosteroids or antihistamines may be needed to treat allergic reactions that develop as a consequence of dying microfilariae.
  • Preferred regimen (2): Albendazole 400 mg PO single dose regimen AND (Ivermectin 200 mcg/kg PO OR Diethylcarbamazine 6mg/kg) may reduce or suppress microfilariae; however, this will not affect adultworms.
Note
Diagnosis 1.serological-antigen detection by commercially available card test ; IgG4 antibody (not filaria species specific and may cross react with other helminths);
Diagnosis 2.special maneuvers DEC provocative days test (induce microfilaremia with dose of DEC); polymerase chain reaction.
Diagnosis 3.skin snips (detect Onchocerca volvulus, Mansonella streptocerca). Ultrasonography can detect adult W.bancrofti worms in scrotal lymphatics.
  • 1.1.Visceral toxocariasis[181]
  • Preferred regimen: Albendazole 400 mg PO bid for five days (both adult and pediatric dosage)
  • Alternative regimen: Mebendazole 100-200 mg PO bid for five days (both adult and pediatric dosage)
  • 1.2.Ocular toxocariasis[182]
  • Preferred regimen: First 4 weeks of illness (Prednisone 30-60mg PO q24h AND subtenon triamcinolone 40mg/week) for 2 weeks
  • Preferred regimen: Albendazole 400 mg PO bid for 8 to 14 days OR Mebendazole 200 to 400 mg PO tid for 3 days, then 400 to 500 mg PO tid for 10 days[183]
  • Note(1): Albendazole and Mebendazole are contraindicated during pregnancy and not recommended in children aged 2 years.
  • Note(2): Prednisone administered at a dose of 30 mg/day to 60 mg/day for 10 to 15 days for severe symptoms

Parasites – Trematodes (Flukes)

  • Preferred regimen: Triclabendazole 10 mg/kg PO one dose[188]
  • Note: Two-dose (double-dose) triclabendazole therapy can be given to patients who have severe or heavy Fasciola infections (many parasites) or who did not respond to single-dose therapy.
  • 1. Schistosoma mansoni, S. haematobium, S. intercalatum
  • Preferred regimen: Praziquantel 40 mg/kg per day PO in two divided doses for one day[190]
  • 2. S. japonicum, S. mekongi
  • Preferred regimen: Praziquantel 60 mg/kg per day PO in three divided doses for one day[191]

Parasites – Cestodes (Tapeworms)

  • 1.1 Echinococcus granulosus (hydatid disease) treatment[192]
  • Preferred regimen: Percutaneous aspiration-injection-reaspiration (PAIR) and Albendazole.Before & after drainage:Albendazole ≥60 kg, 400 mg PO bid or <60 kg, 15 mg/kg per day divided bid, with meals. Then: Puncture (P) & needle aspirate (A) cyst content. Instill (I) hypertonic saline (15–30%) or absolute alcohol, wait 20–30 min, then re-aspirate (R) with final irrigation.
Note: Continue Albendazole for 28 days Cure in 96% as comp to 90% patients with surgical resection
  • 1.2 Echinococcus multilocularis (alveolar cyst disease) treatment[193]
  • Preferred regimen: Albendazole ≥60 kg, 400 mg PO bid or <60 kg, 15 mg/kg per day divided bid, with meals.
Note (1): Albendazole efficacy not clearly demonstrated, can try in dosages used for hydatid disease.
Note (2): Wide surgical resection only reliable treatment; technique evolving.


  • Neurocysticercosis treatment (NCC)[194]
  • 1. Larval form of Taenia solium
  • Preferred regimen: Treat Taenia solium intestinal tapeworms, if present, with Praziquante l5-10 mg/kg PO for 1 dose for children & adults.
  • 2. Parenchymal neurocysticercosis
  • Preferred regimen: Patients body weight of ≥60 kg,Albendazole 400mg bid with meals or Patients body weight of 60 kg, Albendazole 15 mg/kg per day in 2 divided doses (max. 800 mg/day) AND Dexamethasone 0.1 mg/kg per day with or without anti-seizure medication] all for 8-30 days
Note : “Viable” cysts by CT/MRI Meta-analysis: treatment associated with cyst resolution, decreased seizures, and decreased seizure recurrence.
  • Alternative regimen: (Praziquantel 100 mg/kg per day in 3 div. doses PO for 1 day, then 50 mg/kg/d in 3 doses and [[Dexamethasone]} ANDDexamethasone 0.1mg/kg per day with or without anti-seizure medication) all for 29 days.
Note (1): Albendazole associated with 46% decrease in seizures.
Note (2): Praziquantel less cysticidal activity.
Note (3): Steroids decrease serum levels of [[Praziquantel].
Note (4): NIH reports Methotrexate at ”20 mg/wk allows a reduction in steroid use.
  • 3. Degenerating cysts
  • Preferred regimen: Patients body weight of ≥60 kg,Albendazole 400mg bid with meals or Patients body weight of 60 kg, Albendazole 15 mg/kg per day in 2 divided doses (max. 800 mg/day) AND Dexamethasone 0.1 mg/kg per day with or without anti-seizure medication] all for 8-30 days
Note (1): Treatment improves prognosis of associated seizures.
Note (2): For dead calcified cysts, no treatment indicated
  • 4. Subarachnoid neurocysticercosis
  • Preferred regimen: (Patients body weight of ≥60 kg,Albendazole 400mg bid with meals or Patients body weight of 60 kg, Albendazole 15 mg/kg per day in 2 divided doses (max. 800 mg/day) AND Dexamethasone 0.1 mg/kg per day with or without anti-seizure medication] all for 8-30 days) AND shunting for hydrocephalus.
Note: Without shunt, 50% died within 9 years.
  • 5. Intraventricular neurocysticercosis
  • Preferred regimen: (Patients body weight of ≥60 kg,Albendazole 400mg bid with meals or Patients body weight of 60 kg, Albendazole 15 mg/kg per day in 2 divided doses (max. 800 mg/day) AND Dexamethasone 0.1 mg/kg per day with or without anti-seizure medication] all for 8-30 days) AND perhaps neuroendoscopic removal if obstruction of CSF circulation.
  • Sparganosis (Spirometra mansonoides) treatment [195]
  • Preferred treatment: Surgical resection or ethanol injection of subcutaneous masses
Note: Source for Spirometra mansonoides larval cysts is frogs or snakes

Parasites – Ectoparasites

  • Body lice
  • Pediculus humanus, corporis treatment[196]
  • Preferred regimen (1): Success with Ivermectin in home shelter with 12 mg PO on days 0, 7, & 14
Note (1): No drugs for the patient.
Note (2): Organism lives in and deposits eggs in seams of clothing. Discard clothing; if not possible treat clothes with 1% Malathion powder OR 0.5% Permethrin powder.
  • Head lice
  • Pediculus humanus, capitis treatment[197]
  • Preferred regimen: Permethrin 1% lotion apply to shampooed dried hair for 10 min.; repeat in 9-10 days OR Malathion 0.5% lotion (Ovide) apply to dry hair for 8–12hrs, then shampoo. 2 doses 7-9 days apart.
  • Alternative regimen: Ivermectin 200 μg/kg PO once; 3 doses at 7 day intervals reported effective. Malathion 0.5% lotion report that 1–2 20-minutes applications 98% effective.
Note (1):Malathion in alcohol is potentially flammable.
Note (2): Permethrin success in 78%.
Note (3): Extra combing of no benefit.
Note (4): Resistance increasing.No advantage to 5% permethrin.
  • Pubic lice
  • Phthirus pubis treatment[198]
  • Preferred regimen: Pubic hair with Permethrin 1% lotion OR Malathion 0.5% lotion as for head lice
  • Alternative regimen: For eyelids apply Petroleum jelly qid for 10 days OR Yellow oxide of mercury 1% qid for 14 days.
  • Preferred regimen: No medications approved by the FDA are available for treatment[199]
  • Note: Fly larvae need to be surgically removed.
  • Fly larvae treatment [200]
  • Preferred treatment (1): Occlude punctum to prevent gas exchange with petrolatum, fingernail polish, makeup cream or bacon.
  • Preferred treatment (2): When larva migrates, manually remove.
Note (1): Myiasis is due to larvae of flies
Note (2): Usually cutaneous/subcutaneous nodule with central punctum.
  • Scabies
  • Sarcoptes scabiei treatment [201]
  • 1. Immunocompetent patisent
  • Preferred regimen: (Primary) Permethrin 5% cream (ELIMITE).
Note (1): Apply entire skin from chin down to and including toes with Permethrin 5% cream. Leave on 8–14hours. Repeat if itching persists for >2-4 wks after treatment or new pustules occur.
Note (2): Safe for children >2 months old.
  • Alternative regimen: Ivermectin 200 μg/kg PO once. As above, second dose if persistent symptoms.
Note (1): Trim fingernails.
Note (2): Reapply to hands after hand washing.
Note (3): Pruritus may persist times 2 weeks after mites gone.
  • Alternative regimen (2): Less effective is Crotamiton 10% cream, apply for 24 hours, rinse off, then reapply for 24 hours.
  • 2. AIDS patients (CD4 <150 per mm3), debilitated or developmentally disabled patients
* preferred regimen (for Norwegian scabies) : Permethrin 5% cream-2 or more applications a week apart may be needed. After each Permethrin dose (days 2-7) apply 6% Sulfur in petrolatum.
Note: Apply entire skin from chin down to and including toes with Permethrin 5% cream. Leave on 8–14hours. Repeat if itching persists for >2-4 wks after treatment or new pustules occur.
  • Alternative regimen: Ivermectin 200 mcg/kg PO once is reported effective; may need 2 or more doses separated by 14 days.
Note: Norwegian scabies in AIDS patients is extensive, crusted. Can mimic psoriasis and not pruritic but highly contagious—isolate.

Viruses

  • 1. In severe cases of pneumonia or post hematopoietic stem cell transplantation
  • Preferred regimen (1): Cidofovir 5 mg/kg/week IV for 2 weeks, then q 2 weeks AND Probenecid 1.25 g/M2 PO given 3 hours before Cidofovir and 3 & 9 hours after each infusion
  • Preferred regimen (2): Cidofovir 1 mg/kg IV 3 times per week
  • 2. For hemorrhagic cystitis
  • Preferred regimen: Cidofovir (5 mg/kg in 100 mL saline instilled into bladder) intravesical.
Note (1): Adenovirus is the cause of respiratory tract infections including fatal pneumonia in children and young adults and 60% mortality in transplant patients.
Note (2): Adenovirus is frequent cause of cystitis in transplant patients.
Note (3): Adenovirus 14 associated with severe pneumonia in otherwise healthy young adults .Findings include fever, decreases liver enzymes, leukopenia, thrombocytopenia, diarrhea, pneumonia, or hemorrhagic cystitis.
note (4): Cidofovir is successful in 3/8 immunosuppressed children and 8 of 10 children with post Hematopoietic stem cell transplantation. Decrease in virus load predicted response to Cidofovir.
  • 3. Pink eye (viral conjunctivitis)
Note (1): Usually unilateral Adenovirus (types 3 & 7 in children, 8, 11 & 19 in adults)
Note (2): No treatment.
Note (3): If symptomatic, cold artificial tears may help.
Note (4): Highly contagious.
Note (5): Onset of ocular pain and photophobia in an adult suggests associated keratitis—rare.
  • 4.Bronchitis
Infants/children (≤ age 5)
< Age 2: Adenovirus;
Note:Antibiotics indicated only with associated sinusitis or heavy growth on throat culture for S. pneumo., Group A strep, H. influenzae or no improvement in 1 week. Otherwise treatment is symptomatic.


  • Severe acute respiratory distress syndrome- coronavirus[203]
  • Supportive therapy
  • Ribavirin—ineffective.
  • Interferon alfa with or without steroids—small case series.
  • Pegylated IFN-α effective in monkeys.
  • Low dose steroids alone successful.
  • High dose steroids increases serious fungal infections.
  • Inhaled Nitric oxide improved oxygenation and improved chest x-ray.
Note (1): Therapy remains predominantly supportive care.Therapy tried or under evaluation
Note (2):Transmission by close contact: effective infection control practices (mask [changed frequently], eye protection, gown, gloves) key to stopping transmission.
Note (3):Other coronaviruses implicated as cause of croup, asthma exacerbations and other RTIs in children.May be associated with Kawasaki disease.
  • Cytomegalovirus treatment[204]
  • 1.Retinitis
  • 1.1 In HIV-infected adults
  • 1.2 In HIV-infected infants and children
  • Initial treatment (induction therapy): Ganciclovir IV for acquired CMV disease, including CMV retinitis and other end-organ disseminated CMV disease (e.g., colitis, esophagitis, CNS disease).
Note (1): Oral Valganciclovir, a prodrug of Ganciclovir, is one of the first-line treatments for HIV infected adults with CMV retinitis and is an option in older children who weigh enough to receive the adult dose and tablet formulation of Valganciclovir. The drug is well absorbed from the GI tract and rapidly metabolized to Ganciclovir in the intestine and liver.
Note (2): Valganciclovir oral solution has not been studied in pediatric patients for treatment of CMV retinitis, but consideration can be given to its use for transitioning from Ganciclovir IV to Valganciclovir oral to complete treatment and or for secondary prophylaxis once improvement in retinitis is noted.
  • 1.3 An alternative drug for treating CMV disease or for use in Ganciclovir-resistant CMV infections in HIV infected children : Foscarnet.
Note (1): Foscarnet used as suppressive therapy has been associated with increased length of survival relative to Ganciclovir in HIV-infected adults. Doses should be modified in patients with renal insufficiency.
Note (2): Cidofovir is effective in treating CMV retinitis in adults who are intolerant of other therapies.
Note (3): Combination therapy with Ganciclovir and Foscarnet delays progression of retinitis in certain patients in whom monotherapy fails and can be used as initial therapy in children with sight-threatening disease.
Note (4): Combination therapy also has been used for adults with retinitis that has relapsed on single-agent therapy.
  • 2. In Transplant patients
Note (1): Use of Valganciclovir to prevent infections in CMV seronegative recipients who receive organs from a seropositive donor and in seropositive receivers has been highly effective.
Note (2): Others suggest preemptive treatment when pt develops CMV antigenemia or positive PCR post-transplant.
  • 3. Colitis, Esophagitis
  • Preferred regimen (1): Valganciclovir 900 mg PO q24h.
  • Preferred regimen (2): Valganciclovir 900 mg PO q12h for 14–21 days, then 900 mg PO q24h for maintenance therapy
  • Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days ,Ganciclovir as with retinitis except induction period extended for 3–6 wks (No agreement on use of maintenance; may not be necessary except after relapse. Responses less predictable than for retinitis.), then Valganciclovir 900 mg PO q24h OR Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV for 2wks, then 5 mg/kg every other wk; each dose should be administered with IV saline hydration AND oral probenecid OR repeated intravitreal injections with Fomivirsen (for relapses only, not as initial therapy)
Note (1): Diagnosis by biopsy of ulcer base or edge with demonstration of CMV inclusions and other pathogen.
Note (2): Switch to oral Valganciclovir when PO tolerated & when symptoms not severe enough to interfere with absorption.
Note (3): Antiretroviral therapy is essential in long term suppression.
  • 4. Pneumonia
  • Preferred regimen: : Valganciclovir 900 mg PO q12h for 14–21 days, then 900 mg PO q24h for maintenance therapy
  • Alternative regimen for retinitis: Ganciclovir 5 mg/kg IV q12h for 14–21 days, then Valganciclovir 900 mg PO q24h OR Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV for 2wks, then 5 mg/kg every other wk; each dose should be administered with IV saline hydration AND oral probenecid.
Note (1): CMV pneumonia seen predominantly in transplants (esp. bone marrow), rare in HIV.
Note (2): Treat only when histological evidence resent in IDS patients and other pathogens not identified.
Note (3): High rate of CMV reactivation in immunocompetent ICU patients; prolonged hospitalizations and increased mortality.
Note (4): In bone marrow transplant patients, combination therapy with CMV immune globulin. In bone marrow transplant patients, serial measure of pp65 antigen was useful in establishing early diagnosis of CMV interstitial pneumonia with good results if Ganciclovir was initiated within 6 days of antigen positivity.
  • 5. Encephalitis, Ventriculitis
Note: Treatment not defined, but should be considered the same as retinitis. Disease may develop while taking Ganciclovir as suppressive therapy.
  • 6. Lumbosacral polyradiculopathy
Note (1): Diagnosis by CMV DNA in CSF.
Note (2): Suppression continued until CD4 remains >100/mm3 for 6 months.
Note (3): About 50% will respond; survival increases (5.4wks to 14.6wks).
  • 7. Mononeuritis multiplex
Note (1): Due to vasculitis and may not be responsive to antiviral therapy
Note (2): Marked decrease in HIV associated CMV infections & death with Highly Active Antiretroviral Therapy. Initial treatment should optimize HAART.
Note (3): Primary prophylaxis not generally recommended. Preemptive therapy in patients with increased in CMV DNA titers in plasma and CD4 <100/mm3. Recommended by some is Valganciclovir 900 mg PO q24h.
Note (4): Risk for developing CMV disease correlates with quantity of CMV DNA in plasma is each log 10. increase associated with 3.1-fold increase in disease.
  • 8. Specific considerations
Note (1): Currently, no therapies are available for the treatment of maternal or fetal CMV infection.
Note (2): Antiviral medications such as Ganciclovir, Valganciclovir and Foscarnet are approved by the U.S. Food and Drug Administration (FDA) only for treatment of patients with acquired immunodeficiency syndrome (AIDS) or organ transplants.
  • Prevention
  • 1. Prevention of opportunistic infections in human stem cell transplantation (HSCT) by CMV (Recipient with CMV positive or Donor with CMV positive /Recipient with negative CMV)
  • Preemptive therapy: Monitor ≥1 wk (days 10-100) CMV viremia by PCR or CMV-antigenemia and start treatment if positive. Traditional approach was to use Ganciclovir 5 mg/kg IV q12h for 7-14 days, then 5 mg/kg IV q24h 5 days/wk to the longer of: d 100 or ≥3 wks.
Note (1): More recently, Valganciclovir used more often in those who can take oral medications. Continue therapy until viral load negative (preferably twice).
Note (2): One study found Valganciclovir 900 mg po bid comparable to Ganciclovir 5 mg/kg iv bid in preemptive regimen
Note (3): Valganciclovir 900 mg po bid for 2 wks, then 900 mg PO q24h for ≥7 days after negative viral assay, was effective
Note (4): Preemptive regimen of Valganciclovir 900 mg po bid×2 wks, then 450 mg po bid, was effective OR
  • Alternatively Prophylaxis approach (for high-risk pts or when CMV detection tests not rapidly available): From engraftment to day 100, ganciclovir 5 mg/kg IV q12h for 7 days, then 5 mg/kg IV q24h 5 to 6 days per week.
  • 2. Prevention of opportunistic infections in Solid organ transplant (SOT) by CMV (Recipient with CMV positive or Donor with CMV positive /Recipient with negative CMV)
  • 2.1 Kidney, Kidney/Pancreas, Heart
  • Preferred regimen: Valganciclovir 900 mg PO q24h; start by day 10 and continue to at least day 100.
  • 2.2 Liver
  • 2.3 Lung
  • Preferred regimen: Ganciclovir 5 mg/kg iv q12h for 5-7 days, then Valganciclovir 900 mg po q24h for 6 mos (or at least 3 months).
Note (1): With antiviral prophylaxis, onset of CMV is appearing later; optimal duration of prophylaxis under study.
Note (2): Valganciclovir does not have FDA indication for CMV prevention in liver or lung transplantation, but commonly used.
Note (3): In selected cases, some institutions add CMV immune globulin to antiviral drug in high risk cases. Regimen for lung, heart, liver, pancreas: 150 mg/kg within 72h of transplant and at 2, 4, 6 & 8 weeks post-transplant; then 100 mg/kg at weeks 12 & 16.
  • 3. Post treatment suppression for retinitis (prophylactic) if CD4 count <100/mm3
Note (1): Discontinue if CD4 >100/mm3 for 6 months on ART.
Note (2): Patients who discontinue suppression therapy should undergo regular eye examination for early detection of relapses.
  • Enterovirus treatment
  • Preferred regimen: Immunoglobulins IV typical dose is 2 g/kg IV infused over 24hrs.
  • Alternative regimen: Pleconaril
Note (1): Pleocytosis of 100s of cells, CSF glucose normal, negative culture for bacteria
Note (2): Enterovirus is the most common cause of aseptic meningitis.
Note (3): Rapid CSF PCR test is accurate; reduces costs and hospital stay for infants.
Note (4): No treatment currently recommended; however, still under investigation.
Note (5): Hot tender parotid swelling and vesicular,ulcerative pharyingitis are also caused by Enterovirus.
  • Ebola virus treatment[206]
  • Supportive therapy
Providing intravenous fluids (IV) and balancing electrolytes (body salts).
Maintaining oxygen status and blood pressure
Treating other infections if they occur.
Note (1): No FDA-approved vaccine or medicine (e.g., antiviral drug) is available for Ebola.
Note (2): Recovery from Ebola depends on good supportive care and the patient’s immune response.
Note (3): People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer. It is not known if people who recover are immune for life or if they can become infected with a different species of Ebola.
Note (4): Some people who have recovered from Ebola have developed long-term complications, such as joint and vision problems.


  • Hanta virus treatment[207]
  • Supportive therapy
  • ICU management should include careful assessment, monitoring and adjustment of volume status and cardiac function, including inotropic and vasopressor support if needed.
  • Fluids should be administered carefully due to the potential for capillary leakage.
  • Supplemental oxygen should be administered if patients become hypoxic.
  • Equipment and materials for intubation and mechanical ventilation should be readily available since onset of respiratory failure may be precipitous.
Note (1): There is no specific treatment or cure for hantavirus infection.
Note (2):if the individual is experiencing fever and fatigue and has a history of potential rural rodent exposure, together with shortness of breath, would be strongly suggestive of Hantavirus pulmonary syndrome.
Note (3): Treatment of patients with Hantavirus pulmonary syndrome remains supportive in nature.
Note (4): If there is a high degree of suspicion of Hantavirus pulmonary syndrome, patients should be immediately transferred to an emergency department or intensive care unit (ICU) for close monitoring and care.
Note (5): Patients should receive appropriate, broad-spectrum antibiotic therapy while awaiting confirmation of a diagnosis of Hantavirus pulmonary syndrome. Care during the initial stages of the disease should include antipyretics and analgesia as needed.


  • 1. Patients who may be sent home
  • These are patients who are able to tolerate adequate volumes of oral fluids and pass urine at least once every six hours, and do not have any of the warning signs, particularly when fever subsides
  • Patients who are sent home should be monitored daily by health care providers for temperature pattern, volume of fluid intake and losses, urine output (volume and frequency), warning signs, signs of plasma leakage and bleeding, haematocrit, and white blood cell and platelet counts
  • 2. Ambulatory patients with stable haematocrit can be sent home
  • Encourage oral intake of oral rehydration solution (ORS), fruit juice and other fluids containing electrolytes and sugar to replace losses from fever and vomiting
  • Give Paracetamol for high fever if the patient is uncomfortable. The interval of paracetamol dosing should not be less than six hours. Tepid sponge if the patient still has high fever
  • Should be brought to hospital immediately if any of the following occur: no clinical improvement, deterioration around the time of defervescence, severe abdominal pain, persistent vomiting, cold and clammy extremities, lethargy or irritability/restlessness, bleeding (e.g. black stools or coffee-ground vomiting), not passing urine for more than 4–6 hours
  • 3. Patients who should be referred for in-hospital management
  • Patients may need to be admitted to a secondary health care centre for close observation, particularly as they approach the critical phase. These include patients with warning signs (Abdominal pain or tenderness, Persistent vomiting, Clinical fluid accumulation, Mucosal bleed, Lethargy, restlessness, Liver enlargment >2cm, Laboratory:increase in HCT concurrent with rapid decrease in platelet count), those with co-existing conditions that may make dengue or its management more complicated (such as pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, chronic haemolytic diseases), and those with certain social circumstances (such as living alone, or living far from a health facility without reliable means of transport)
  • 3.1 With warning signs
  • Obtain a reference haematocrit before fluid therapy. Give only isotonic solutions such as 0.9% saline, Ringer’s lactate, or Hartmann’s solution. Start with 5–7 ml/ kg/hour for 1–2 hours, then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response
  • Reassess the clinical status and repeat the haematocrit. If the haematocrit remains the same or rises only minimally, continue with the same rate (2–3 ml/kg/hr) for another 2–4 hours. If the vital signs are worsening and haematocrit is rising rapidly, increase the rate to 5–10 ml/kg/hour for 1–2 hours. Reassess the clinical status, repeat the haematocrit and review fluid infusion rates accordingly
  • Give the minimum intravenous fluid volume required to maintain good perfusion and urine output of about 0.5 ml/kg/hr. Intravenous fluids are usually needed for only 24–48 hours. Reduce intravenous fluids gradually when the rate of plasma leakage decreases towards the end of the critical phase. This is indicated by urine output and/or oral fluid intake that is/are adequate, or haematocrit decreasing below the baseline value in a stable patient
  • Patients with warning signs should be monitored by health care providers until the period of risk is over. A detailed fluid balance should be maintained. Parameters that should be monitored include vital signs and peripheral perfusion (1–4 hourly until the patient is out of the critical phase), urine output (4–6 hourly), haematocrit (before and after fluid replacement, then 6–12 hourly), blood glucose, and other organ functions (such as renal profile, liver profile, coagulation profile, as indicated)
  • 3.2 Without warning signs
  • Encourage oral fluids. If not tolerated, start intravenous fluid therapy of 0.9% saline or Ringer’s lactate with or without dextrose at maintenance rate. For obese and overweight patients, use the ideal body weight for calculation of fluid infusion. Patients may be able to take oral fluids after a few hours of intravenous fluid therapy. Thus, it is necessary to revise the fluid infusion frequently. Give the minimum volume required to maintain good perfusion and urine output. Intravenous fluids are usually needed only for 24–48 hours
  • Patients should be monitored by health care providers for temperature pattern, volume of fluid intake and losses, urine output (volume and frequency), warning signs, haematocrit, and white blood cell and platelet counts. Other laboratory tests (such as liver and renal functions tests) can be done, depending on the clinical picture and the facilities of the hospital or health centre
  • 4. Severe dengue
  • Severe dengue: Severe plasma leakage leading to dengue shock and/or fluid accumulation with respiratory distress; severe haemorrhages; severe organ impairment (hepatic damage, renal impairment, cardiomyopathy, encephalopathy or encephalitis)
  • 4.1 Treatment of shock
  • 4.1.1 Compensated shock
  • Start intravenous fluid resuscitation with isotonic crystalloid solutions at 5–10 ml/kg/hour over one hour. Then reassess the patient’s condition (vital signs, capillary refill time, haematocrit, urine output). The next steps depend on the situation
  • If the patient’s condition improves, intravenous fluids should be gradually reduced to 5–7 ml/kg/hr for 1–2 hours, then to 3–5 ml/kg/hr for 2–4 hours, then to 2–3 ml/kg/hr, and then further depending on haemodynamic status, which can be maintained for up to 24–48 hours
  • If vital signs are still unstable (i.e. shock persists), check the haematocrit after the first bolus. If the haematocrit increases or is still high (>50%), repeat a second bolus of crystalloid solution at 10–20 ml/kg/hr for one hour. After this second bolus, if there is improvement, reduce the rate to 7–10 ml/ kg/hr for 1–2 hours, and then continue to reduce as above. If haematocrit decreases compared to the initial reference haematocrit (<40% in children and adult females, <45% in adult males), this indicates bleeding and the need to cross-match and transfuse blood as soon as possible
  • Further boluses of crystalloid or colloidal solutions may need to be given during the next 24–48 hours
  • 4.1.2 Hypotensive shock
  • Initiate intravenous fluid resuscitation with crystalloid or colloid solution (if available) at 20 ml/kg as a bolus given over 15 minutes to bring the patient out of shock as quickly as possible
  • If the patient’s condition improves, give a crystalloid/colloid infusion of 10 ml/kg/hr for one hour. Then continue with crystalloid infusion and gradually reduce to 5–7 ml/kg/hr for 1–2 hours, then to 3–5 ml/kg/hr for 2–4 hours, and then to 2–3 ml/kg/hr or less, which can be maintained for up to 24–48 hours
  • If vital signs are still unstable (i.e. shock persists), review the haematocrit obtained before the first bolus. If the haematocrit was low (<40% in children and adult females, <45% in adult males), this indicates bleeding and the need to cross- match and transfuse blood as soon as possible (see treatment for haemorrhagic complications)
  • If the haematocrit was high compared to the baseline value (if not available, use population baseline), change intravenous fluids to colloid solutions at 10–20 ml/kg as a second bolus over 30 minutes to one hour. After the second bolus, reassess the patient. If the condition improves, reduce the rate to 7–10 ml/kg/hr for 1–2 hours, then change back to crystalloid solution and reduce the rate of infusion as mentioned above. If the condition is still unstable, repeat the haematocrit after the second bolus
  • If the haematocrit decreases compared to the previous value (<40% in children and adult females, less than 45% in adult males), this indicates bleeding and the need to cross-match and transfuse blood as soon as possible (see treatment for haemorrhagic complications). If the haematocrit increases compared to the previous value or remains very high ( more than 50%), continue colloid solutions at 10–20 ml/kg as a third bolus over one hour. After this dose, reduce the rate to 7–10 ml/kg/hr for 1–2 hours, then change back to crystalloid solution and reduce the rate of infusion as mentioned above when the patient’s condition improves
  • Further boluses of fluids may need to be given during the next 24 hours. The rate and volume of each bolus infusion should be titrated to the clinical response. Patients with severe dengue should be admitted to the high-dependency or intensive care area
  • 4.2 Treatment of haemorrhagic complications
  • Blood transfusion required
  • Give 5–10ml/kg of fresh-packed red cells or 10–20 ml/kg of fresh whole blood at an appropriate rate and observe the clinical response. It is important that fresh whole blood or fresh red cells are given. Oxygen delivery at tissue level is optimal with high levels of 2,3 di-phosphoglycerate (2,3 DPG). Stored blood loses 2,3 DPG, low levels of which impede the oxygen-releasing capacity of haemoglobin, resulting in functional tissue hypoxia. A good clinical response includes improving haemodynamic status and acid-base balance
  • Consider repeating the blood transfusion if there is further blood loss or no appropriate rise in haematocrit after blood transfusion. There is little evidence to support the practice of transfusing platelet concentrates and/or fresh-frozen plasma for severe bleeding. It is being practised when massive bleeding can not be managed with just fresh whole blood/fresh-packed cells, but it may exacerbate the fluid overload
  • Great care should be taken when inserting a naso-gastric tube which may cause severe haemorrhage and may block the airway. A lubricated oro-gastric tube may minimize the trauma during insertion. Insertion of central venous catheters should be done with ultra-sound guidance or by a very experienced person
  • 5. Treatment of complications and other areas of treatment
  • 5.1 Fluid overload
  • Oxygen therapy should be given immediately
  • When the following signs are present, intravenous fluids should be discontinued or reduced to the minimum rate necessary to maintain euglycaemia
  • signs of cessation of plasma leakage; stable blood pressure, pulse and peripheral perfusion; haematocrit decreases in the presence of a good pulse volume; afebrile for more than 24–48 days (without the use of antipyretics); resolving bowel/abdominal symptoms; improving urine output
  • The management of fluid overload varies according to the phase of the disease and the patient’s haemodynamic status. If the patient has stable haemodynamic status and is out of the critical phase (more than 24–48 hours of defervescence), stop intravenous fluids but continue close monitoring. If necessary, give oral or intravenous furosemide 0.1–0.5 mg/kg/dose once or twice daily, or a continuous infusion of furosemide 0.1 mg/kg/hour. Monitor serum potassium and correct the ensuing hypokalaemia
  • If the patient has stable haemodynamic status but is still within the critical phase, reduce the intravenous fluid accordingly. Avoid diuretics during the plasma leakage phase because they may lead to intravascular volume depletion
  • Patients who remain in shock with low or normal haematocrit levels but show signs of fluid overload may have occult haemorrhage. Further infusion of large volumes of intravenous fluids will lead only to a poor outcome. Careful fresh whole blood transfusion should be initiated as soon as possible. If the patient remains in shock and the haematocrit is elevated, repeated small boluses of a colloid solution may help
  • 5.2 Other complications of dengue
  • Both hyperglycaemia and hypoglycaemia may occur, even in the absence of diabetes mellitus and/or hypoglycaemic agents. Electrolyte and acid-base imbalances are also common observations in severe dengue and are probably related to gastrointestinal losses through vomiting and diarrhoea or to the use of hypotonic solutions for resuscitation and correction of dehydration. Hyponatraemia, hypokalaemia, hyperkalaemia, serum calcium imbalances and metabolic acidosis (sodium bicarbonate for metabolic acidosis is not recommended for pH ≥ 7.15) can occur. One should also be alert for co-infections and nosocomial infections.
  • 5.3 Supportive care and adjuvant therapy
  • renal replacement therapy, with a preference to continuous veno-venous haemodialysis (CWH), since peritoneal dialysis has a risk of bleeding;
  • vasopressor and inotropic therapies as temporary measures to prevent life- threatening hypotension in dengue shock and during induction for intubation, while correction of intravascular volume is being vigorously carried out;
  • further treatment of organ impairment, such as severe hepatic involvement or encephalopathy or encephalitis;
  • further treatment of cardiac abnormalities, such as conduction abnormalities, may occur (the latter usually not requiring interventions)
  • Preferred regimen: No specific treatment is available for yellow fever. In the toxic phase, supportive treatment includes therapies for treating dehydration and fever. Ribavirin has failed in several studies in the monkey model.
  • Note: An international seminar held by WHO in 1984 recommended maintenance of nutrition, prevention of hypoglycemia, maintenance of the blood pressure with fluids and vasoactive drugs, prevention of bleeding with fresh-frozen plasma, dialysis if renal failure, correction of metabolic acidosis, administration of cimetidine IV to avoid gastric bleeding and oxygen if needed.
Chikungunya Fever [211]
  • Preferred regimen: no specific therapeutics agents are available and there are no licensed vaccines to prevent Chikungunya Fever.
  • Note: Anti inflammatory drugs can be used to control joint swelling and arthritis.
  • Preferred regimen: No therapy recommended. If within 2 wks of exposure, IVIG 0.02 mL per kg IM times 1 protective.
  • Chronic Hepatitis B
  • 1. Patients with HBeAg-positive chronic hepatitis B [212]
  • 1.1. HBV DNA >20,000, ALT <2 times upper limit normal (ULN) [212]
  • Observe; consider treatment when ALT becomes elevated.
  • Consider biopsy in persons 40 years, ALT persistently high normal >2 times upper limit normal (ULN), or with family history of HCC.
  • Consider treatment if HBV DNA >20,000 IU/mL and biopsy shows moderate/severe inflammation or significant fibrosis.
  • 1.2. HBV DNA >20,000, ALT >2 times upper limit normal (ULN) [212]
  • Preferred regimen(1): Pegylated IFN-alpha 180 mcg weekly SC for 48 weeks
  • Preferred regimen(2): Tenofovir(TDF) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 300 mg q24 hrs
  • If creatinine clearance 30–49 give 300 mg q48 hrs
  • If creatinine clearance 10–29 give 300 mg q72-96 hrs
  • If creatinine clearance <10 with dialysis give 300 mg once a week or after a total of approximately 12 hours of dialysis
  • If creatinine clearance <10 without dialysis there is no recommendation
  • Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion
  • Preferred regimen(3): Entecavir(ETV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 give 0.5 mg PO daily for patients with no prior Lamivudine treatment, and 1 mg PO daily for patients who are refractory/resistant to lamivudine for minimum 1 year, continue for at least 6 months after HBeAg seroconversion.
  • If creatinine clearance 30–49 give 0.25 mg PO qd OR 0.5 mg PO q48 hr for patients with no prior Lamivudine treatment, and 0.5 mg PO qd OR 1 mg PO q 48 hr for patients who are refractory/resistant to lamivudine for minimum 1 year, continue for at least 6 months after HBeAg seroconversion.
  • If creatinine clearance 10–29 give 0.15 mg PO qd OR 0.5 mg PO q 72 hr for patients with no prior Lamivudine treatment, and 0.3 mg PO qd OR 1 mg PO q 72 hr for patients who are refractory/resistant to lamivudine for minimum 1 year, continue for at least 6 months after HBeAg seroconversion.
  • If creatinine clearance <10 or hemodialysis or continuous ambulatory peritoneal dialysis give 0.05 mg PO qd OR 0.5 mg PO q7 days for patients with no prior Lamivudine treatment, and 0.1 mg PO qd OR 1 mg PO q 7 days for patients who are refractory/resistant to lamivudine for minimum 1 year, continue for at least 6 months after HBeAg seroconversion.
  • Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion
  • Alternative regimen(1): Interferon alpha(IFNα) 5 MU daily or 10 MU thrice weekly SC for 16 weeks
  • Alternative regimen(2): Lamivudine(LAM) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 100 mg PO qd
  • If creatinine clearance 30–49 give 100 mg PO first dose, then 50 mg PO qd
  • If creatinine clearance 15–29 give 100 mg PO first dose, then 25 mg PO qd
  • If creatinine clearance 5-14 give 35 mg PO first dose, then 15 mg PO qd
  • If creatinine clearance <5 give 35 mg PO first dose, then 10 mg PO qd
  • The recommended dose of lamivudine for persons coinfected with HIV is 150mg PO twice daily.
  • Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion
  • Alternative regimen(3): Adefovir(ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 10 mg PO daily
  • If creatinine clearance 30–49 give 10 mg PO every other day
  • If creatinine clearance 10–19 10 mg PO every third day
  • If hemodialysis patients give 10 mg PO every week following dialysis
  • Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion
  • Alternative regimen(4): Telbivudine(LdT)Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 600 mg PO once daily
  • If creatinine clearance 30–49 600 give mg PO once every 48 hours
  • If creatinine clearance <30 (not requiring dialysis) give 600 mg PO once every 72 hours
  • If End-stage renal disease give 600 mg PO once every 96 hours after hemodialysis
  • Note: duration of treatment is minimum 1 year, continue for at least 6 months after HBeAg seroconversion
  • Notes:
  • Observe for 3-6 months and treat if no spontaneous HBeAg loss.
  • Consider liver biopsy prior to treatment if compensated.
  • Immediate treatment if icteric or clinical decompensation.
  • Interferon alpha(IFNα)/ pegylated interferon-alpha(peg-IFNα), Lamivudine(LAM), Adefovir(ADV), Entecavir(ETV), tenofovir disoproxil fumarate(TDF) or telbivudine(LdT) may be used as initial therapy.
  • Adefovir(ADV) not preferred due to weak antiviral activity and high rate of resistance after 1st year.
  • Lamivudine(LAM) and Telbivudine(LdT) not preferred due to high rate of drug resistance.
  • End-point of treatment – Seroconversion from HBeAg to anti-HBe.
  • Interferon alpha(IFNα) non-responders / contraindications to IFNα change to Tenofovir(TDF)/Entecavir(ETV).
  • 1.3. Children with elevated ALT greater than 2 times normal [212]
  • Preferred regimen(1): Interferon alpha(IFNα) 6 MU/m2 SC thrice weekly with a maximum of 10 MU
  • Preferred regimen(2): Lamivudine(LAM) 3 mg/kg/d PO with a maximum of 100 mg/d.
  • 2. Patients with HBeAg-negative chronic hepatitis B [212]
  • 2.1. HBV DNA >20,000 IU/mL and elevated ALT >2 times normal
  • Preferred regimen(1): Pegylated IFN-alpha 180 mcg weekly SC for 1 year
  • Preferred regimen(2): Tenofovir(TDF) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 300 mg q24 hrs
  • If creatinine clearance 30–49 give 300 mg q48 hrs
  • If creatinine clearance 10–29 give 300 mg q72-96 hrs
  • If creatinine clearance <10 with dialysis give 300 mg once a week or after a total of approximately 12 hours of dialysis
  • If creatinine clearance <10 without dialysis there is no recommendation
  • Note: duration of treatment is more than 1 year
  • Preferred regimen(3): Entecavir(ETV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 give 0.5 mg PO daily for patients with no prior Lamivudine treatment, and 1 mg PO daily for patients who are refractory/resistant to lamivudine.
  • If creatinine clearance 30–49 give 0.25 mg PO qd OR 0.5 mg PO q48 hr for patients with no prior Lamivudine treatment, and 0.5 mg PO qd OR 1 mg PO q 48 hr for patients who are refractory/resistant to lamivudine.
  • If creatinine clearance 10–29 give 0.15 mg PO qd OR 0.5 mg PO q 72 hr for patients with no prior Lamivudine treatment, and 0.3 mg PO qd OR 1 mg PO q 72 hr for patients who are refractory/resistant to lamivudine
  • If creatinine clearance <10 or hemodialysis or continuous ambulatory peritoneal dialysis give 0.05 mg PO qd OR 0.5 mg PO q7 days for patients with no prior Lamivudine treatment, and 0.1 mg PO qd OR 1 mg PO q 7 days for patients who are refractory/resistant to lamivudine.
  • Note: duration of treatment is more than 1 year
  • Alternative regimen(1): Interferon alpha(IFNα) 5 MU daily or 10 MU thrice weekly SC for 1 year
  • Alternative regimen(2): Lamivudine(LAM) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 100 mg PO qd
  • If creatinine clearance 30–49 give 100 mg PO first dose, then 50 mg PO qd
  • If creatinine clearance 15–29 give 100 mg PO first dose, then 25 mg PO qd
  • If creatinine clearance 5-14 give 35 mg PO first dose, then 15 mg PO qd
  • If creatinine clearance <5 give 35 mg PO first dose, then 10 mg PO qd
  • The recommended dose of lamivudine for persons coinfected with HIV is 150mg PO twice daily.
  • Note: duration of treatment is more than 1 year
  • Alternative regimen(3): Adefovir(ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 10 mg PO daily
  • If creatinine clearance 30–49 give 10 mg PO every other day
  • If creatinine clearance 10–19 10 mg PO every third day
  • If hemodialysis patients give 10 mg PO every week following dialysis
  • Note: duration of treatment is more than 1 year
  • Alternative regimen(4): Telbivudine(LdT)Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 600 mg PO once daily
  • If creatinine clearance 30–49 600 give mg PO once every 48 hours
  • If creatinine clearance <30 (not requiring dialysis) give 600 mg PO once every 72 hours
  • If End-stage renal disease give 600 mg PO once every 96 hours after hemodialysis
  • Note: duration of treatment is more than 1 year
  • Notes:


  • 3. HBV DNA >2,000 IU/mL and elevated ALT >1-2 times normal [212]
  • Consider liver biopsy and treat if liver biopsy shows moderate/severe necroinflammation or significant fibrosis.
  • 4. HBV DNA <2,000 IU/mL and ALT < upper limit normal (ULN) [212]
  • Observe, treat if HBV DNA or ALT becomes higher.
  • 5. +/- HBeAg and detectable HBV DNA with Cirrhosis [212]
  • 5.1. Compensated Cirrhosis and HBV DNA >2,000
  • Preferred regimen(1): Lamivudine(LAM) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 100 mg PO qd
  • If creatinine clearance 30–49 give 100 mg PO first dose, then 50 mg PO qd
  • If creatinine clearance 15–29 give 100 mg PO first dose, then 25 mg PO qd
  • If creatinine clearance 5-14 give 35 mg PO first dose, then 15 mg PO qd
  • If creatinine clearance <5 give 35 mg PO first dose, then 10 mg PO qd
  • The recommended dose of lamivudine for persons coinfected with HIV is 150mg PO twice daily.
  • Preferred regimen(2): Adefovir(ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 10 mg PO daily
  • If creatinine clearance 30–49 give 10 mg PO every other day
  • If creatinine clearance 10–19 give 10 mg PO every third day
  • If hemodialysis patients give 10 mg PO every week following dialysis
  • Preferred regimen(3): Entecavir(ETV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 give 0.5 mg PO daily for patients with no prior Lamivudine treatment, and 1 mg PO daily for patients who are refractory/resistant to lamivudine.
  • If creatinine clearance 30–49 give 0.25 mg PO qd OR 0.5 mg PO q48 hr for patients with no prior Lamivudine treatment, and 0.5 mg PO qd OR 1 mg PO q 48 hr for patients who are refractory/resistant to lamivudine.
  • If creatinine clearance 10–29 give 0.15 mg PO qd OR 0.5 mg PO q 72 hr for patients with no prior Lamivudine treatment, and 0.3 mg PO qd OR 1 mg PO q 72 hr for patients who are refractory/resistant to lamivudine.
  • If creatinine clearance <10 or hemodialysis or continuous ambulatory peritoneal dialysis give 0.05 mg PO qd OR 0.5 mg PO q7 days for patients with no prior Lamivudine treatment, and 0.1 mg PO qd OR 1 mg PO q 7 days for patients who are refractory/resistant to lamivudine.
  • Preferred regimen(4): Telbivudine(LdT) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 600 mg PO once daily
  • If creatinine clearance 30–49 600 give mg PO once every 48 hours
  • If creatinine clearance <30 (not requiring dialysis) give 600 mg PO once every 72 hours
  • If End-stage renal disease give 600 mg PO once every 96 hours after hemodialysis
  • Preferred regimen(5): Tenofovir(TDF) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 300 mg q24 hrs
  • If creatinine clearance 30–49 give 300 mg q48 hrs
  • If creatinine clearance 10–29 give 300 mg q72-96 hrs
  • If creatinine clearance <10 with dialysis give 300 mg once a week or after a total of approximately 12 hours of dialysis
  • If creatinine clearance <10 without dialysis there is no recommendation
  • Notes:
  • LAM and LdT not preferred due to high rate of drug resistance.
  • ADV not preferred due to weak antiviral activity and high risk of resistance after 1st year.
  • These patients should receive long-term treatment. However, treatment may be stopped in HBeAg-positive patients if they have confirmed HBeAg seroconversion and have completed at least 6 months of consolidation therapy and in HBeAg-negative patients if they have confirmed HBsAg clearance.
  • 5.2. Compensated Cirrhosis and HBV DNA <2,000
  • Consider treatment if ALT elevated.
  • 5.3. Decompensated Cirrhosis
  • Preferred regimen(1): Tenofovir(TDF) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 300 mg q24 hrs
  • If creatinine clearance 30–49 give 300 mg q48 hrs
  • If creatinine clearance 10–29 give 300 mg q72-96 hrs
  • If creatinine clearance <10 with dialysis give 300 mg once a week or after a total of approximately 12 hours of dialysis
  • If creatinine clearance <10 without dialysis there is no recommendation
  • Preferred regimen(2): Entecavir(ETV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 give 0.5 mg PO daily for patients with no prior Lamivudine treatment, and 1 mg PO daily for patients who are refractory/resistant to lamivudine.
  • If creatinine clearance 30–49 give 0.25 mg PO qd OR 0.5 mg PO q48 hr for patients with no prior Lamivudine treatment, and 0.5 mg PO qd OR 1 mg PO q 48 hr for patients who are refractory/resistant to lamivudine.
  • If creatinine clearance 10–29 give 0.15 mg PO qd OR 0.5 mg PO q 72 hr for patients with no prior Lamivudine treatment, and 0.3 mg PO qd OR 1 mg PO q 72 hr for patients who are refractory/resistant to lamivudine.
  • If creatinine clearance <10 or hemodialysis or continuous ambulatory peritoneal dialysis give 0.05 mg PO qd OR 0.5 mg PO q7 days for patients with no prior Lamivudine treatment, and 0.1 mg PO qd OR 1 mg PO q 7 days for patients who are refractory/resistant to lamivudine.
  • Lamivudine(LAM) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 100 mg PO qd
  • If creatinine clearance 30–49 give 100 mg PO first dose, then 50 mg PO qd
  • If creatinine clearance 15–29 give 100 mg PO first dose, then 25 mg PO qd
  • If creatinine clearance 5-14 give 35 mg PO first dose, then 15 mg PO qd
  • If creatinine clearance <5 give 35 mg PO first dose, then 10 mg PO qd
  • The recommended dose of lamivudine for persons coinfected with HIV is 150mg PO twice daily.
  • Adefovir(ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 10 mg PO daily
  • If creatinine clearance 30–49 give 10 mg PO every other day
  • If creatinine clearance 10–19 give 10 mg PO every third day
  • If hemodialysis patients give 10 mg PO every week following dialysis
  • Telbivudine(LdT) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 600 mg PO once daily
  • If creatinine clearance 30–49 600 give mg PO once every 48 hours
  • If creatinine clearance <30 (not requiring dialysis) give 600 mg PO once every 72 hours
  • If End-stage renal disease give 600 mg PO once every 96 hours after hemodialysis
  • Adefovir(ADV) Adjustment of Adult Dosage in Accordance with Creatinine Clearance:
  • If creatinine clearance >50 or normal renal function give 10 mg PO daily
  • If creatinine clearance 30–49 give 10 mg PO every other day
  • If creatinine clearance 10–19 give 10 mg PO every third day
  • If hemodialysis patients give 10 mg PO every week following dialysis
  • Notes:
  • Coordinate treatment with transplant center.
  • Refer for liver transplant.
  • Life-long treatment is recommended.
  • 6. +/- HBeAg and undetectable HBV DNA with Cirrhosis [212]
  • Compensated Cirrhosis: Observe
  • Uncompensated Cirrhosis: Refer for liver transplant

Chronic Hepatitis C

  • 1. Treatment regimens for chronic hepatitis C virus genotype 1 [213]
  • 1.1. Treatment regimens for genotype 1a:
  • Preferred regimen(1): Daily fixed-dose combination of Ledipasvir 90 mg AND Sofosbuvir 400 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 1a infection
  • Preferred regimen(2): Daily fixed-dose combination of Paritaprevir 150 mg AND Ritonavir 100 mg AND Ombitasvir 25 mg plus twice-daily dosed Dasabuvir 250 mg AND weight-based Ribavirin(RBV) ([1000 mg <75 kg] to [1200 mg >75 kg]) for 12 weeks (no cirrhosis) OR 24 weeks (cirrhosis) is recommended for treatment-naive patients with HCV genotype 1a infection.
  • Preferred regimen(3): Daily Sofosbuvir 400 mg plus Simeprevir 150 mg ± weight-based Ribavirin(RBV) ([1000 mg <75 kg] to [1200 mg >75 kg]) for 12 weeks (no cirrhosis) or 24 weeks (cirrhosis) is recommended for treatment-naive patients with HCV genotype 1a infection.
  • 1.2. Treatment regimens for genotype 1b:
  • Preferred regimen(1): Daily fixed-dose combination of Ledipasvir 90 mg AND Sofosbuvir 400 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 1b infection.
  • Preferred regimen(2): Daily fixed-dose combination of Paritaprevir 150 mg AND Ritonavir 100 mg AND Ombitasvir 25 mg plus twice-daily dosed Dasabuvir 250 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 1b infection. The addition of weight-based RBV (1000 mg [<75kg] to 1200 mg [>75 kg]) is recommended in patients with cirrhosis.
  • Preferred regimen(3): Daily Sofosbuvir 400 mg plus Simeprevir 150 mg for 12 weeks (no cirrhosis) or 24 weeks (cirrhosis) is recommended for treatment-naive patients with HCV genotype 1b infection.
  • 2. Treatment regimens for chronic hepatitis C virus genotype 2 [214]
  • Preferred regimen: Daily sofosbuvir 400 mg AND weight-based RBV (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 12 weeks is recommended for treatment-naive patients with HCV genotype 2 infection. Extending treatment to 16 weeks is recommended in patients with cirrhosis.
  • 3. Treatment regimens for chronic hepatitis C virus genotype 3 [215]
  • Preferred regimen: Daily sofosbuvir (400 mg) and weight-based RBV (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 24 weeks is recommended for treatment-naive patients with HCV genotype 3 infection.
  • Alternative regimen: Daily sofosbuvir 400 mg and weight-based RBV (1000 mg [<75 kg] to 1200 mg [>75 kg]) plus weekly PEG-IFN for 12 weeks is an acceptable regimen for IFN-eligible, treatment-naive patients with HCV genotype 3 infection.
  • 4. Treatment regimens for chronic hepatitis C virus genotype 4
  • Preferred regimen(1): Daily fixed-dose combination of Ledipasvir 90 mg AND Sofosbuvir 400 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 4 infection.
  • Preferred regimen(2): Daily fixed-dose combination of Paritaprevir 150 mg AND Ritonavir 100 mg AND Ombitasvir 25 mg AND weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 12 weeks is recommended for treatment-naive patients with HCV genotype 4 infection.
  • Preferred regimen(3): Daily Sofosbuvir 400 mg AND weight-based RibavirinRBV (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 24 weeks is recommended for treatment-naive patients with HCV genotype 4 infection.
  • Alternative regimen(1): Daily Sofosbuvir 400 mg AND weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) plus weekly PEG-IFN for 12 weeks is an acceptable regimen for treatment-naive patients with HCV genotype 4 infection.
  • Alternative regimen(2): Daily Sofosbuvir 400 mg plus Simeprevir 150 mg ± weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 12 weeks is an acceptable regimen for treatment-naive patients with HCV genotype 4 infection.
  • 5. Treatment regimens for chronic hepatitis C virus genotype 5 [216]
  • Preferred regimen: Daily Sofosbuvir 400 mg AND weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) plus weekly PEG-IFN for 12 weeks is recommended for treatment-naive patients with HCV genotype 5 infection.
  • Alternative regimen: Weekly PEG-IFN plus weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) for 48 weeks is an alternative regimen for IFN-eligible, treatment-naive patients with HCV genotype 5 infection.
  • 6. Treatment regimens for chronic hepatitis C virus genotype 6 [217]
  • Preferred regimen: Daily fixed-dose combination of Ledipasvir 90 mg AND Sofosbuvir 400 mg for 12 weeks is recommended for treatment-naive patients with HCV genotype 6 infection.
  • Alternative regimen: Daily Sofosbuvir 400 mg AND weight-based Ribavirin(RBV) (1000 mg [<75 kg] to 1200 mg [>75 kg]) plus weekly PEG-IFN for 12 weeks is an alternative regimen for IFN-eligible, treatment-naive patients with HCV genotype 6 infection.
  • Supportive therapy
  • Hepatitis E is usually self-limiting, hospitalization is generally not required.
  • Hospitalization is required for people with fulminant hepatitis and should also be considered for symptomatic pregnant women.
Note (1): There is no available treatment capable of altering the course of acute hepatitis.
Note (2): Prevention is the most effective approach against the disease.
  • Prevention
  • The risk of infection and transmission can be reduced by
  • (1) Maintaining quality standards for public water supplies;
  • (2) Establishing proper disposal systems to eliminate sanitary waste.
  • On an individual level, infection risk can be reduced by
  • (1) Maintaining hygienic practices such as hand washing with safe water, particularly before handling food;
  • (2) Avoiding drinking water and/or ice of unknown purity;
  • (3) Adhering to WHO safe food practices-determining the mode of transmission; identifying the population specifically exposed to increased risk of infection; eliminating a common source of infection; improving sanitary and hygienic practices to eliminate faecal contamination of food and water raising awareness, promoting partnerships and mobilizing resources;formulating evidence-based policy and data for action;preventing transmission; and executing screening, care and treatment.
  • There is no vaccine to protect against EBV infection. You can help protect yourself by not kissing or sharing drinks, food, or personal items, like toothbrushes, with people who have EBV infection.
  • There is no specific treatment for EBV. However, some things can be done to help relieve symptoms, including
  • drinking fluids to stay hydrated
  • getting plenty of rest
  • taking over-the-counter medications for pain and fever
  • Human herpesvirus 6 treatment[220]
  • Preferred regimen: Ganciclovir decreased viral copies in response to treatment and Foscarnet therapy improved thrombotic microangiopathy.
Note (1): Human herpesvirus 6 (HHV-6) infects lymphocytes. It is typically acquired in early infancy and causes exanthem subitum (roseola infantum) and other febrile diseases of childhood.
Note (2): Fever & rash documented in transplant patients .
Note (3): Reactivation in hematopoietic stem cell transplant patients associated with delayed monocytes & platelet engraftment.
Note (4): Recognized in assocation with meningoencephalitis in immunocompetent adults.
Note (5): Diagnosis made by positive PCR in CSF.


  • Human herpesvirus 7 (roseola virus) treatment
  • Supportive therapy
  • Most patients with infection with HHV-7 will be asymptomatic. It is unknown whether treatment in asymptomatic patients will lead to a reduction in subsequent infection.[221]
  • Immunocompetent hosts with uncomplicated skin manifestations associated with HHV-7, particularly roseola infantum and pityriasis rosea, need only symptomatic management.[222]
  • For HIV-positive patients, antiretroviral therapy may be advisable.[223]
  • There are no defined circumstances that warrant specific antiviral therapy for HHV-7.[224]
  • The most active antiviral compounds against HHV-7 are Cidofovir and Foscarnet.[225]
  • Note (1) Ubiquitous virus (>90% of the population is infected by age 3 yrs).
  • Note (2) Infects CD4 lymphocytes via CD4 receptor; transmitted via saliva.
  • 1. Mild to moderate Kaposi sarcoma[226]
  • Preferred regimen: initiate or optimize ART
  • 2. Advanced Kaposi sarcoma (ACTG Stage T1, including disseminated cutaneous or visceral Kaposi sarcoma)
  • Preferred regimen: chemotherapy (per oncology consult) AND ART
  • 3. Primary effusion lymphoma
  • Preferred regimen: chemotherapy (per oncology consult) AND ART
  • Note: Valganciclovir PO or Ganciclovir IV can be used as adjunctive therapy.
  • 4. Multicentric Castleman's disease
  • Preferred regimen (1): Valganciclovir 900 mg PO bid for 3 weeks
  • Preferred regimen (2): Ganciclovir 5 mg/kg IV q12h for 3 weeks
  • Preferred regimen (3): Valganciclovir 900 mg PO BID AND Zidovudine 600 mg PO q6h for 7–21 days
  • Alternative regimen: Rituximab 375 mg/m2 given weekly for 4–8 weeks (may be an alternative to or used adjunctively with antiviral therapy)
  • 1.First Clinical Episode of Genital Herpes[227]
  • Preferred Regimens: Acyclovir 400 mg PO tid for 7–10 days OR Acyclovir 200 mg PO five times a day for 7–10 daysOR Valacyclovir 1 g PO bid for 7–10 daysORFamciclovir 250 mg PO tid for 7–10 days
  • Note:Treatment can be extended if healing is incomplete after 10 days of therapy.
  • 2.Established HSV-2 Infection
  • 3. Severe Disease (disseminated infection, pneumonitis, or hepatitis) or CNS complications (e.g., meningoencephalitis).
  • Preferred Regimens: Acyclovir 5–10 mg/kg IV q8h for 2–7 days or until clinical improvement is observed, followed by oral antiviral therapy to complete at least 10 days of total therapy. HSV encephalitis requires 21 days of intravenous therapy. Impaired renal function warrants an adjustment in acyclovir dosage.
  • 4. Special Considerations
  • 4.1HIV Infection
  • 4.1.1 Daily Suppressive Therapy in Persons with HIV
  • Preferred Regimens: Acyclovir 400–800 mg PO bid /tid ORValacyclovir 500 mg PO bid ORFamciclovir 500 mg PO bid
  • 4.1.2 Episodic Infection in Persons with HIV
  • Preferred Regimens: Acyclovir 400 mg PO tid for 5–10 days OR Valacyclovir 1 g PO bid for 5–10 days OR Famciclovir 500 mg PO bid for 5–10 days
  • Note:For severe HSV disease, initiating therapy with Acyclovir 5–10 mg/kg IV every 8 hours might be necessary.
  • 4.2.Genital Herpes in Pregnancy
  • suppressive therapy of pregnant women with recurrent genital herpes *
  • Preferred Regimens: Acyclovir 400–800 mg PO bid /tid ORValacyclovir 500 mg PO bid
  • Note:Treatment recommended starting at 36 weeks of gestation.
  • 4.3Neonatal Herpes
  • known or suspected neonatal herpes: Acyclovir 20 mg/kg IV q 8 h
  • Note(1):treatment for 14 days if disease is limited to the skin and mucous membranes, or
  • Note(2):treatment for 21 days for disseminated disease and that involving the central nervous system.
  • 4.4 Acyclovir-resistant genital herpes
  • Preferred Regimens:Foscarnet 40–80 mg/kg IV q8 h until clinical resolution is attained
  • Alternative Regimens: Cidofovir 5 mg/kg IV once weekly might also be effective.
  • Alternative Regimens:Imiquimod topical preparations should be applied to the lesions qd for 5 consecutive days.
  • 4.5Management of Sex Partners
  • Preferred Regimens: Acyclovir 400 mg PO tid for 7–10 days OR Acyclovir 200 mg PO five times a day for 7–10 daysOR Valacyclovir 1 g PO bid for 7–10 daysOR Famciclovir 250 mg PO tid for 7–10 days
  • Note:The sex partners of persons who have genital herpes can benefit from evaluation and counseling. Symptomatic sex partners should be evaluated and treated
  • 4.6 Allergy, Intolerance, and Adverse Reactions
  • Allergic and other adverse reactions to oral acyclovir, valacyclovir, and famciclovir are rare. Desensitization to acyclovir has been described.
  • 1.Preferred regimen for External Anogenital Warts (i.e., penis, groin, scrotum, vulva, perineum, external anus, and perianus)
  • 1.1 Patient-Applied::Imiquimod 3.75% or 5% cream ORPodofilox 0.5% solution or gel OR Sinecatechins 15% ointment
  • 1.2 Provider-Administered:Cryotherapy with liquid nitrogen or cryoprobe OR Surgical removal either by tangential scissor excision, tangential shave excision, curettage, laser,or electrosurgery OR Trichloroacetic acid (TCA) or Bichloroacetic acid (BCA) 80%-90% solution
  • Note(1):Many persons with external anal warts also have intra-anal warts. Thus, persons with external anal warts might benefit from an inspection of the anal canal by digital examination, standard anoscopy, or high-resolution anoscopy.
  • Note(2):Might weaken condoms and vaginal diaphragms.
  • 2.Alternative Regimens for External Genital Warts
  • 2.1 Urethral Meatus Warts
  • Regimens :Cryotherapy with liquid nitrogen OR Surgical removal
  • 2.2Vaginal Warts
  • Regimens:Cryotherapy with liquid nitrogen. OR Surgical removal OR TCA or BCA 80%–90% solution
  • Note: The use of a cryoprobe in the vagina is not recommended because of the risk for vaginal perforation and fistula formation
  • 2.3 Cervical Warts
  • Regimen: Cryotherapy with liquid nitrogen OR Surgical removal OR TCA or BCA 80%–90% solution
  • Note: Management of cervical warts should include consultation with a specialist.For women who have exophytic cervical warts, a biopsy evaluation to exclude high-grade SIL must be performed before treatment is initiated.
  • 2.4 Intra-anal Warts
  • Regimens :Cryotherapy with liquid nitrogen OR Surgical removalOR TCA or BCA 80%–90% solution
  • Note:Management of intra-anal warts should include consultation with a specialist.
  • 3. Specific considerations
  • 3.1. Follow-up
  • Most anogenital warts respond within 3 months of therapy. Factors that might affect response to therapy include immunosuppression and treatment compliance. In general, warts located on moist surfaces or in intertriginous areas respond best to topical treatment. A new treatment modality should be selected when no substantial improvement is observed after a complete course of treatment or in the event of severe side effects; treatment response and therapy-associated side effects should be evaluated throughout the course of therapy.
  • 3.2 Management of sex partners
  • Persons should inform current partner(s) about having genital warts because the types of HPV that cause warts can be passed on to partners. Partners should receive counseling messages that partners might already have HPV despite no visible signs of warts, so HPV testing of sex partners of persons with genital warts is not recommended.
  • 3.3 Pregnancy
  • Podofilox (podophyllotoxin), podophyllin, and sinecatechins should not be used during pregnancy. Imiquimod appears to pose low risk but should be avoided until more data are available.
  • Cesarean delivery is indicated for women with anogenital warts if the pelvic outlet is obstructed or if vaginal delivery would result in excessive bleeding.
  • Pregnant women with anogenital warts should be counseled concerning the low risk for warts on the larynx of their infants or children (recurrent respiratory papillomatosis).
  • 3.4 HIV infection
  • Data do not support altered approaches to treatment for persons with HIV infection.
  • Squamous cell carcinomas arising in or resembling anogenital warts might occur more frequently among immunosuppressed persons, therefore requiring biopsy for confirmation of diagnosis for suspicious cases
  • 3.5 High-grade squamous intraepithelial lesions
  • Biopsy of an atypical wart might reveal HSIL or cancer of the anogenital tract. In this instance, referral to a specialist for treatment is recommended.
  • Note:Patients with severe disease may have diarrhea and may not absorb oseltamivir efficiently
  • 2 Patients with Avian Influenza who have diarrhea and malabsorption
  • Preferred regimen:Zanamivir10 mg inhaled bid for minimum 5 days OR Peramivir600 mg IV as a single dose for1 day
  • Note(1)Preliminary evidence demonstrates that neuraminidase inhibitor can reduce the duration of viral replication and improve survival among patients with avian influenza. In cases of suspected avian influenza, one of the following 3 neuraminidase inhibitors should be administered as soon possible, preferably within 48 hours of symptom onset.
  • Note(2)The use of corticosteroids is not recommended.
  • Note(3): Physicians may consider increasing either the recommended daily dose and/or the duration of treatment in cases of severe disease.
  • Note(4):The use of amantadine is not recommended as most H5N1 and H7N9 avian influenza viruses are resistant to it.[230]
  • Note(5):Supportive care is also an important cornerstone of the care of patients with avian influenza. Considering the severity of the illness and the possible complications, patients may require fluid resuscitation, vasopressors, intubation and ventilation, paracentesis, hemodialysis or hemofiltration, and parentral nutrition.
  • 1. Condition1: Patients who have severe or progressive clinical illness
  • Preferred regimen: Oseltamivir 150 mg PO BID, treatment duration depends on clinical response
  • NOTE(1): Where the clinical course remains severe or progressive, despite 5 or more days of antiviral treatment, monitoring of virus replication and shedding, and antiviral drug susceptibility testing is desirable
  • NOTE(2): Antiviral treatment should be maintained without a break until virus infection is resolved or there is satisfactory clinical improvement
  • NOTE(3): Patients who have severe or progressive clinical illness, but who are unable to take oral medication may be treated with oseltamivir administered by nasogastric or orogastric tube
  • 2. Condition2: In situations where oseltamivir is not available, or not possible to use, patients who have severe or progressive clinical illness
  • Preferred regimen: Zanamivir inhaled
  • NOTE: Intravenous Zanamivir should be considered where available and is recommended for those with serious or progressive illness. If not available, intravenous Peramivir may be considered
  • 3. Condition3: Severely immunosuppressed patients
  • 1.Adults
  • Preferred regimen : Ribavirin PO/IV 10 mg/kg q8h
  • Day 1: Start with 600 mg loading dose,then 200 mg q8h
  • Day 2: 400 mg q8h
  • Day 3: Increase the dose to a maximum of 10 mg/kg q8h
  • 2.In case of adverse events: Decrease dose or Discontinue Ribavirin
  • 3.Creatinine clearance
  • 30–50 mL/min : Ribavirin PO/IV Maximal 200 mg q8h
  • 10–30 mL/ min : No recommendation can be given


  • 1. Erythema infectiosum
  • Supportive therapy: Symptomatic treatment only
  • 2. Arthritis/arthalgia
  • Preferred regimen: Nonsteroidal anti-inflammatory drugs (NSAID)
  • 3.Transient aplastic crisis
  • Supportive therapy: Transfusions and oxygen
  • 4. Fetal hydrops
  • Supportive therapy: Intrauterine blood transfusion
  • 5. Chronic infection with anemia
  • Preferred regimen: IVIG and transfusion
  • 6.Chronic infection without anemia
  • Preferred regimen: IVIG
Note (1): Diagnostic tools are IgM and Igb antibody titers.Perhaps better is blood Parvovirus PCR.
Note (2): Dose of IVIG not standardized; suggest 400 mg/kg IV of commercial IVIG for 5 or 10 days or 1000 mg/kg IV for 3 days.
Note (3): Most dramatic anemias in pts with pre-existing hemolytic anemia.
Note (4): Bone marrow shown erythrocyte maturation arrest with giant pronormoblasts.
  • Human polyomavirus (BK virus) treatment
  • Note (1): For those who are hypogammaglobulinemic, we administer intravenous immunoglobulins (IV IG) in replacement doses of 500 mg/kg. Quantitative immunoglobulins should be checked two to three months later to determine whether hypogammaglobulinemia has recurred. Intravenous immunoglobulins (IV IG) is also an option in certain settings, based upon polymerase chain reaction (PCR) and kidney biopsy results. IVIG may contain antibodies against BK and JC virus since these viruses are ubiquitous in the general population.
  • Note (2): The goals of decreased immunosuppressive therapy are to restrain viral replication without triggering rejection.
  • Note (3): Reduced immunosuppression (defined as lowering mean doses of Mycophenolate and Tacrolimus) resulted in the successful elimination of viremia (mean period of six months) and allograft survival.
  • Note (4): Alternative approaches to reducing immunosuppression have also been effective
  • 4.1 Changing from Tacrolimus to low-dose Cyclosporine not only reduces the effect of the Calcineurin inhibitor, but also reduces Mycophenolate concentrations.
  • 4.2 Replacing the Calcineurin inhibitor with Sirolimus, with or without discontinuation of the antimetabolite, has the advantage of avoiding the long-term Calcineurin inhibitor-related nephrotoxic effects.
  • 4.3 Lowering the dose of Calcineurin inhibitors may slow the loss of renal function.
  • Primary Regimens
  • Decrease immunosuppression if possible. (Cornerstone of Treatment)
  • Suggested antiviral therapy is based on anecdotal data. If progressive renal dysfunction:
  • Fluoroquinolone AND IVIG 500 mg/kg IV AND Leflunomide 100 mg for daily for 3 days, then 10-20 mg PO daily
  • If refractory to all of the above, add Cidofovir 5 mg/kg once per week for 2 weeks, then once every other week if refractory to all of the above
  • Ancillary Therapies in BK Virus Nephropathy
  • Cidofovir 0.25-1.0 mg/kg IV biweekly for 8 wk without Probenecid, prehydration recommended
  • Leflunomide 100 mg loading dose for 3 days, 20-60 mg/day, goal Leflunomide trough 50-100 ng/mL (consider lower trough goals of 20-40 ng/mL given hemolysis risk)
  • IV Ig 1-2 g/kg IV for 1-2 doses or 150 mg/kg IV biweekly for 8 wk
  • Fluoroquinolones-Ciproflaxacin 500 mg/day, duration dependent on virological response.
  • Progressive Multifocal Leukoencephalopathy (PML) caused by JC Virus ( John Cunningham virus) infections[234]
  • There is no specific antiviral therapy for JC virus infection.
  • The main treatment approach is to reverse the immunosuppression caused by HIV.
  • Initiate anti retroviral therapy (ART) immediately in ART-naive patients .
  • Optimize ART in patients who develop Progressive Multifocal Leukoencephalopathy in phase of HIV viremia on ART .
  • Corticosteroids may be used for Progressive Multifocal Leukoencephalopathy- immune reconstitution inflammatory syndrome (IRIS) characterized by contrast enhancement, edema or mass effect, and with clinical deterioration
  • Preferred regimen: no specific therapeutics agents are available once the disease is established.
  • Note: There are vaccines and immune globulins available for postexposure prophylaxis:
  • Postexposure Prophylaxis for non immunized individuals: Wound cleansing, human rabies immune globulin - administer full dose infiltrated around any wound. Administer any remaining volume IM at other site anatomically distant from the wound. Administer vaccine 1,0ml, IM at deltoid area one each on days 0, 3, 7 and 14.
  • Postexposure Prophylaxis for immunized individuals: Wound cleansing, do not administer human rabies immune globulin. Administer vaccine 1,0ml, IM at deltoid area one each on days 0 and 3.
  • Respiratory Syncytial Virus Return to Top
  • Respiratory syncytial virus treatment
  • Supportive therapy
  • Hydration and supplemental oxygen.
  • Routine use of Ribavirin not recommended. Ribavirin therapy associated with small increases in O2 saturation.
  • No consistent decrease in need for mechanical ventilation or ICU stays. High cost, aerosol administration and potential toxicity[235]
Note (1) In adults, Respiratory syncytial virus accounted for 10.6% of hospitalizations for pneumonia, 11.4% for COPD, 7.2% for asthma & 5.4% for CHF in pts >65 yrs of age [236]. Respiratory syncytial virus caused 11% of clinically important respiratory illnesses in military recruits[237]
Note (2) Respiratory Syncytial Virus major cause of morbidity in neonates/infants.
Note (3) Nucleic acid test now approved to detect 12 respiratory viruses (xTAG Respiratory Viral Panel, Luminex Molecular Diagnostics).
  • Prevention of Respiratory syncytial virus
  • 1. In children <24 months old with chronic lung disease of prematurity (formerly broncho-pulmonary dysplasia) requiring supplemental oxygen or
  • 2. In premature infants (<32 wks gestation) and <6 months old at start of Respiratory syncytial virus season or
  • 3. In children with selected congenital heart diseases.
  • Preferred regimen for prevention of Respiratory syncytial virus: Palivizumab (Synagis) 15 mg per kg IM q month Nov.-April[235]
Note : Significant reduction in Respiratory syncytial virus hospitalization among children with congenital heart disease[238]
  • Supportive therapy
  • Symptomatic treatment-Ipratropium bromide intranasal (2 sprays tid) AND Clemastine 1.34 mg 1–2 tab PO bid–tid (over the counter)
  • Symptomatic relief by Ipratropium nasal spray decreases rhinorrhea and sneezing vs placebo.[239] AND Clemastine (an antihistamine) decreases sneezing, rhinorrhea but associated with dry nose, mouth & throat in 6–19%.[240]OR Oral pleconaril given within 24 hrs of onset reduced duration (1 day) & severity of “cold symptoms” in DBPCT (p < .001).[241]
  • Note (1)No antiviral rx indicated . [242]
  • Note (2) Found in 1/2 of children with community-acquired pneumonia; role in pathogenesis unclear (CID 39:681, 2004). [243]
  • Note (3) High rate of rhinovirus identified in children with significant lower resp tract infections [244]
  • Treatment of diarrhoea caused by rotavirus
  • Rehydration with oral rehydration salts (ORS) solution. oral rehydration salts (ORS) solution is a mixture of clean water, salt and sugar. It costs a few cents per treatment. oral rehydration salts (ORS) solution is absorbed in the small intestine and replaces the water and electrolytes lost in the faeces.
  • Zinc supplements-with zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume.
  • Rehydration with intravenous fluids in case of severe dehydration or shock.
  • Nutrient-rich foods the vicious circle of malnutrition and diarrhoea can be broken by continuing to give nutrient-rich foods including breast milk during an episode, and by giving a nutritious diet including exclusive breastfeeding for the first six months of life to children when they are well.
  • Consulting a health professional , in particular for management of persistent diarrhoea or when there is blood in stool or if there are signs of dehydration.
Note (1): Rotavirus and Escherichia coli are the two most common etiological agents of diarrhoea in developing countries.
Note (2): There is no antiviral drug to treat rotavirus infection. Antibiotic drugs will not help because antibiotics fight against bacteria not viruses.
Note (3): Rotavirus infection can cause severe vomiting and diarrhea. This can lead to dehydration (loss of body fluids). During rotavirus infection, infants and young children, older adults, and people with other illnesses are most at risk becoming dehydrated.
Note (4): Symptoms of dehydration include decrease in urination, dry mouth and throat, feeling dizzy when standing up. A dehydrated child may also cry with few or no tears and be unusually sleepy or fussy.
  • Prevention
  • Access to safe drinking-water
  • Use of improved sanitation
  • Hand washing with soap
  • Exclusive breastfeeding for the first six months of life
  • Good personal and food hygiene
  • Health education about how infections spread; and Rotavirus vaccination.
  • Supportive care is the mainstay of therapy.
  • Currently, there are no anti-viral drugs of proven efficacy.
  • Recently, animal studies suggest that cidofovir and its cyclic analogues, given at the time of or immediately after exposure, have promise for the prevention of cowpox, vaccinia, and monkeypox.
  • Patients need adequate hydration and nutrition, because substantial amounts of fluid and protein can be lost by febrile persons with dense, often weeping lesions.
  • Secondary baceterial infection
  • Penicillinase-resistant antimicrobial agents should be used if smallpox lesions are secondarily infected, if bacterial infection endangers the eyes, or if the eruption is very dense and widespread.
  • Daily eye rinsing is required in severe cases. Topical idoxuridine (Dendrid, Herplex, or Stoxil) should be considered for the treatment of corneal lesions, although its efficacy is unproved for smallpox.
  • 1.1 A Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) Based Regimen:
  • 1.2 Integrase Strand Transfer Inhibitor-Based Regimens
  • Preferred regimen:
  • Alternative Regimen
  • 1.3 Protease Inhibitor-Based Regimen
  • Alternative Regimen(2)
  • Alternative Regimen(3)
  • Alternative Regimen(4)
  • Alternate Regimen(5)
  • Atazanavir 300 mg-Ritonavir 100 mg once-daily AND Abacavir 600 mg-Lamivudine 300 mg once-daily in patients who are HLA-B*5701-negative and with pre-treatment HIV RNA <100,000 copies/mL.
  • Alternate Regimen(6)
  • Alternate Regimen(7)
  • 1.4 Other Regimen Options
  • 1.4.1 NNRTI-Based Regimen
  • Preferred regimen: Efavirenz 600mg AND Abacavir 600 mg/Lamivudine—only for patients who are HLA-B*5701 negative and with pre-treatment HIV RNA <100,000 copies/mL.
  • 1.4.2 Other Regimens When Tenofovir or Abacavir Cannot be Used
Pediatric dose: Abacavir 300 mg po BID, Didanosine 20 to < 25 kg: 200 mg po once daily 25 to < 60 kg: 250 mg po once daily ≥60 kg: 400 mg po once daily; Lamivudine 4 mg/kg/dose po BID; maximum 150 mg po BID; Stavudine 1 mg/kg/dose po q12h, Tenofovir Recommended oral dose is 8 mg/kg; Zidovudine 180 - 240 mg/m2/dose po q12h or 160 mg/m2/dose po q8h (range 90-180); Efavirenz 10 to < 15 kg: 200 mg, 15 to <20 kg: 250 mg, 20 to < 25 kg: 300 mg, 25 to < 32.5 kg: 350 mg, 32.5 to <40 kg: 400 mg, ≥ 40 kg: 600 mg; Nevirapine maximum 200 mg per dose; Lopinavir 400mg; Nelfinavir 50 mg/kg/dose po BID; Raltegravir 300mg
  • 2. Pre-Exposure Prophylaxis(PrEP)
  • Preferred regimen- Daily, continuing, oral doses of Tenofovir disoproxil fumarate 300mg-Emtricitabine 200 mg, ≤90-day supply.
Note(1): People with high risk behaviour such as men who have sex with men, intravenous drug abusers, HIV-positive sexual partner, recent bacterial STI, high number of sex partners, history of inconsistent or no condom use, commercial sex work, people in high-prevalence area or network are advised to take pre-exposure prophylaxis of drugs.
Note(2): Follow-up visits at least every 3 months to provide the following: HIV test, medication adherence counseling, behavioral risk reduction support, side effect assessment, STI symptom assessment, pregnancy testing.
Note(3): At 3 months and every 6 months thereafter, assess renal function.
Note(4): Every 6 months, test for bacterial STIs.
  • 3. Post- Exposure Prophylaxis
  • 4. Perinatal Antiretroviral Regimen
  • 4.1 Antepartum
  • 4.1.1 Protease Inhibitor-Based Regimen
  • 4.1.2 A non-nucleoside reverse transcriptase inhibitor (NNRTI) based regimen:
  • 4.2 Intrapartum
  • HIV RNA <1000 copies/mL and good afherance-Continue the regimen during delivery or cessarean section.
  • HIV RNA >1000 copies/mL near delivery, possible poor adherence, or unknown HIV RNA levels- Intravenous Zidovudine 2 mg/kg IV over 1 hr should be given three hours before cesarean section or delivery and then 1 mg/kg/hr IV continuous infusion until umbilical cord clamping.
  • 4.3 Postpartum
Initiate ART and continue after delivery and cessation of breastfeeding
  • 5.Infant Antiretroviral Prophylaxis for Prevention of Mother-To-Child Transmission of HIV
  • 5.1 Preferred regimen: Zidovudine (ZDV) 100mg given at birth and continued till six weeks.
Note(1): Dose based on gestational age at birth and weight, initiated as soon after birth as possible and preferably within 6 to 12 hours of delivery.
Note(2): ≥35 weeks gestation at birth: 4 mg/kg/dose orally (or, if unable to tolerate oral agents, 3 mg/kg/dose IV) every 12 hours.
Note(3): ≥30 to <35 weeks gestation at birth: 2 mg/kg/dose orally (or 1.5 mg/kg/dose IV) every 12 hours, advanced to 3 mg/kg/dose orally (or 2.3 mg/kg/dose IV) every 12 hours at age 15 days.
  • <30 weeks gestation at birth: 2 mg/kg/dose orally (or 1.5 mg/kg/dose IV) every 12 hours, advanced to 3 mg/kg/dose orally (or 2.3 mg/kg/dose IV) every 12 hours after age four weeks.
  • 5.2 Prophylaxis for HIV-exposed infants of women who received no antepartum antiretroviral prophylaxis
  • Dose based on birth weight, initiated as soon after birth as possible.
  • Birth weight 1.5 to 2 kg: 8 mg/dose orally.
  • Birth weight >2 kg: 12 mg/dose orally.
AND
Zidovudine (ZDV)
  • Dose based on gestational age at birth and weight, initiated as soon after birth as possible and preferably within 6 to 12 hours of delivery.
  • ≥35 weeks gestation at birth: 4 mg/kg/dose orally (or, if unable to tolerate oral agents, 3 mg/kg/dose IV) every 12 hours.
  • ≥30 to <35 weeks gestation at birth: 2 mg/kg/dose orally (or 1.5 mg/kg/dose IV) every 12 hours, advanced to 3 mg/kg/dose orally (or 2.3 mg/kg/dose IV) every 12 hours at age 15 days.
  • <30 weeks gestation at birth: 2 mg/kg/dose orally (or 1.5 mg/kg/dose IV) every 12 hours, advanced to 3 mg/kg/dose orally (or 2.3 mg/kg/dose IV) every 12 hours after age four weeks.
Note(1): Three doses in the first week of life
Note(2): First dose within 48 hours of birth (birth to 48 hrs)
Note(3): Second dose 48 hours after first
Note(4): Third dose 96 hours after second

References

  1. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  2. ↑ 2.0 2.1 Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)
  3. ↑ "Infective Endocarditis Diagnosis, Antimicrobial Therapy, and Management of Complications A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association".
  4. ↑ 4.0 4.1 4.2 Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM; et al. (2004). "Practice guidelines for the management of bacterial meningitis". Clin Infect Dis. 39 (9): 1267–84. doi:10.1086/425368. PMID 15494903.
  5. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  6. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  7. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  8. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  9. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  10. ↑ Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP; et al. (2009). "Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America". Clin Infect Dis. 49 (1): 1–45. doi:10.1086/599376. PMC 4039170. PMID 19489710.
  11. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  12. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  13. ↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.
  14. ↑ Tunkel, Allan R.; Hartman, Barry J.; Kaplan, Sheldon L.; Kaufman, Bruce A.; Roos, Karen L.; Scheld, W. Michael; Whitley, Richard J. (2004-11-01). "Practice guidelines for the management of bacterial meningitis". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 39 (9): 1267–1284. doi:10.1086/425368. ISSN 1537-6591. PMID 15494903.
  15. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  16. ↑ Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.
  17. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  18. ↑ Darouiche, Rabih O. (2006-11-09). "Spinal epidural abscess". The New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 1533-4406. PMID 17093252.
  19. ↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.
  20. ↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.
  21. ↑ Liu, Catherine; Bayer, Arnold; Cosgrove, Sara E.; Daum, Robert S.; Fridkin, Scott K.; Gorwitz, Rachel J.; Kaplan, Sheldon L.; Karchmer, Adolf W.; Levine, Donald P.; Murray, Barbara E.; J Rybak, Michael; Talan, David A.; Chambers, Henry F.; Infectious Diseases Society of America (2011-02-01). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 52 (3): –18-55. doi:10.1093/cid/ciq146. ISSN 1537-6591. PMID 21208910.
  22. ↑ Azari, Amir A.; Barney, Neal P. (2013-10-23). "Conjunctivitis: a systematic review of diagnosis and treatment". JAMA. 310 (16): 1721–1729. doi:10.1001/jama.2013.280318. ISSN 1538-3598. PMC 4049531. PMID 24150468.
  23. ↑ 23.0 23.1 23.2 Solomkin JS, Mazuski JE, Bradley JS, Rodvold KA, Goldstein EJ, Baron EJ; et al. (2010). "Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America". Clin Infect Dis. 50 (2): 133–64. doi:10.1086/649554. PMID 20034345.
  24. ↑ 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.
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  26. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  27. ↑ 27.0 27.1 27.2 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.
  28. ↑ Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
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  31. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  32. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  33. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  34. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  35. ↑ Baddour LM, Wilson WR, Bayer AS, Fowler VG, Bolger AF, Levison ME; et al. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145.
  36. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  37. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  38. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  39. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  40. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  41. ↑ 41.0 41.1 41.2 Hendricks KA, Wright ME, Shadomy SV, Bradley JS, Morrow MG, Pavia AT; et al. (2014). "Centers for disease control and prevention expert panel meetings on prevention and treatment of anthrax in adults". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130687. PMC 3901462. PMID 24447897.
  42. ↑ Meaney-Delman D, Zotti ME, Creanga AA, Misegades LK, Wako E, Treadwell TA; et al. (2014). "Special considerations for prophylaxis for and treatment of anthrax in pregnant and postpartum women". Emerg Infect Dis. 20 (2). doi:10.3201/eid2002.130611. PMC 3901460. PMID 24457117.
  43. ↑ 43.0 43.1 Bradley JS, Peacock G, Krug SE, Bower WA, Cohn AC, Meaney-Delman D; et al. (2014). "Pediatric anthrax clinical management". Pediatrics. 133 (5): e1411–36. doi:10.1542/peds.2014-0563. PMID 24777226.
  44. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  45. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  46. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  47. ↑ Andrews, J. M.; Wise, R. (2002-06). "Susceptibility testing of Bacillus species". The Journal of Antimicrobial Chemotherapy. 49 (6): 1040–1042. ISSN 0305-7453. PMID 12039902. Check date values in: |date= (help)
  48. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  49. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  50. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  51. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  52. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  53. ↑ "q fever".
  54. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  55. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  56. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  57. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  58. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  59. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  60. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  61. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  62. ↑ Corbel, Michael (2006). Brucellosis in humans and animals. Geneva: World Health Organization. ISBN 9241547138.
  63. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  64. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  65. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  66. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  67. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  68. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  69. ↑ Centers for Disease Control (CDC) (1982). "Prevention of secondary cases of Haemophilus influenzae type b disease". MMWR Morb Mortal Wkly Rep. 31 (50): 672–4, 679–80. PMID 6819447.
  70. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  71. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  72. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  73. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  74. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  75. ↑ LastName, FirstName (2003). Human leptospirosis guidance for diagnosis, surveillance and control. Geneva: World Health Organization. ISBN 9241545895.
  76. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  77. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  78. ↑ Workowski KA, Bolan GA (2015). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and Reports : Morbidity and Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control. 64 (RR-03): 1–137. PMID 26042815.
  79. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  80. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  81. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  82. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  83. ↑ Wiersinga WJ, Currie BJ, Peacock SJ (2012). "Melioidosis". N. Engl. J. Med. 367 (11): 1035–44. doi:10.1056/NEJMra1204699. PMID 22970946.
  84. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  85. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  86. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  87. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  88. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  89. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  90. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  91. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  92. ↑ Lua error: expandTemplate: template "citation error" does not exist.
  93. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  94. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  95. ↑ Mukara, B. K.; Munyarugamba, P.; Dazert, S.; Löhler, J. (2014-07). "Rhinoscleroma: a case series report and review of the literature". European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 271 (7): 1851–1856. doi:10.1007/s00405-013-2649-z. ISSN 1434-4726. PMID 23904142. Check date values in: |date= (help)
  96. ↑ de Pontual, Loïc; Ovetchkine, Philippe; Rodriguez, Diana; Grant, Audrey; Puel, Anne; Bustamante, Jacinta; Plancoulaine, Sabine; Yona, Laurent; Lienhart, Pierre-Yves; Dehesdin, Danièle; Huerre, Michel; Tournebize, Régis; Sansonetti, Philippe; Abel, Laurent; Casanova, Jean Laurent (2008-12-01). "Rhinoscleroma: a French national retrospective study of epidemiological and clinical features". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 47 (11): 1396–1402. doi:10.1086/592966. ISSN 1537-6591. PMID 18947330.
  97. ↑ Gaafar, Hazem A.; Gaafar, Alaa H.; Nour, Yasser A. (2011-04). "Rhinoscleroma: an updated experience through the last 10 years". Acta Oto-Laryngologica. 131 (4): 440–446. doi:10.3109/00016489.2010.539264. ISSN 1651-2251. PMID 21198342. Check date values in: |date= (help)
  98. ↑ Mukara, B. K.; Munyarugamba, P.; Dazert, S.; Löhler, J. (2014-07). "Rhinoscleroma: a case series report and review of the literature". European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 271 (7): 1851–1856. doi:10.1007/s00405-013-2649-z. ISSN 1434-4726. PMID 23904142. Check date values in: |date= (help)
  99. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  100. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  101. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  102. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  103. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  104. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  105. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  106. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  107. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  108. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  109. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  110. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  111. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  112. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  113. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  114. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  115. ↑ "q fever".
  116. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  117. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  118. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  119. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  120. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  121. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  122. ↑ Walsh TJ, Anaissie EJ, Denning DW, Herbrecht R, Kontoyiannis DP, Marr KA; et al. (2008). "Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America". Clin Infect Dis. 46 (3): 327–60. doi:10.1086/525258. PMID 18177225.
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  126. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
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  128. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
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  164. ↑ Attia, Rasha A. H.; Tolba, Mohammed E. M.; Yones, Doaa A.; Bakir, Hanaa Y.; Eldeek, Hanan E. M.; Kamel, Shereef (2012-01). "Capillaria philippinensis in Upper Egypt: has it become endemic?". The American Journal of Tropical Medicine and Hygiene. 86 (1): 126–133. doi:10.4269/ajtmh.2012.11-0321. ISSN 1476-1645. PMC 3247121. PMID 22232463. Check date values in: |date= (help)
  165. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  166. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  167. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  168. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  169. ↑ "WGO Practice Guideline Management of Strongyloidiasis" (PDF).
  170. ↑ "Parasites - Trichuriasis".
  171. ↑ "Parasites - Zoonotic Hookworm".
  172. ↑ "Parasites - Zoonotic Hookworm".
  173. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  174. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  175. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  176. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  177. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  178. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  179. ↑ "Gnathostomiasis".
  180. ↑ "Gnathostomiasis".
  181. ↑ "Parasites - Toxocariasis".
  182. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  183. ↑ Gottstein B, Pozio E, Nöckler K (2009). "Epidemiology, diagnosis, treatment, and control of trichinellosis". Clin Microbiol Rev. 22 (1): 127–45, Table of Contents. doi:10.1128/CMR.00026-08. PMC 2620635. PMID 19136437.
  184. ↑ "Clonorchis".
  185. ↑ "Clonorchis".
  186. ↑ "Dicrocoeliasis".
  187. ↑ "Dicrocoeliasis".
  188. ↑ "Parasites - Fascioliasis".
  189. ↑ "Parasites - Paragonimiasis".
  190. ↑ "Parasites - Schistosomiasis".
  191. ↑ "Parasites - Schistosomiasis".
  192. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  193. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  194. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  195. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  196. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  197. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  198. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  199. ↑ "Parasites - Myiasis".
  200. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  201. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  202. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  203. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  204. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  205. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  206. ↑ "Ebola virus treatment".
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  209. ↑ "District guidelines for yellow fever surveillance" (PDF).
  210. ↑ name="pmid3547569">Monath TP (1987). "Yellow fever: a medically neglected disease. Report on a seminar". Rev Infect Dis. 9 (1): 165–75. PMID 3547569.
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  212. ↑ 212.0 212.1 212.2 212.3 212.4 212.5 212.6 212.7 212.8 Lok AS, McMahon BJ (2009). "Chronic hepatitis B: update 2009". Hepatology. 50 (3): 661–2. doi:10.1002/hep.23190. PMID 19714720.
  213. ↑ "INITIAL TREATMENT OF HCV INFECTION".
  214. ↑ "INITIAL TREATMENT OF HCV INFECTION".
  215. ↑ "INITIAL TREATMENT OF HCV INFECTION".
  216. ↑ "INITIAL TREATMENT OF HCV INFECTION".
  217. ↑ "INITIAL TREATMENT OF HCV INFECTION".
  218. ↑ Template:Citeweb
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  220. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
  221. ↑ "Other herpesviruses: HHV-6, HHV-7, HHV-8, HSV-1 and -2, VZV". Am J Transplant. 4 Suppl 10: 66–71. 2004. doi:10.1111/j.1600-6135.2004.00697.x. PMID 15504215.
  222. ↑ Wolz MM, Sciallis GF, Pittelkow MR (2012). "Human herpesviruses 6, 7, and 8 from a dermatologic perspective". Mayo Clin Proc. 87 (10): 1004–14. doi:10.1016/j.mayocp.2012.04.010. PMC 3538396. PMID 22819486.
  223. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  224. ↑ Black JB, Pellett PE (1999). "Human herpesvirus 7". Rev Med Virol. 9 (4): 245–62. PMID 10578120.
  225. ↑ De Clercq E, Naesens L, De Bolle L, Schols D, Zhang Y, Neyts J (2001). "Antiviral agents active against human herpesviruses HHV-6, HHV-7 and HHV-8". Rev Med Virol. 11 (6): 381–95. PMID 11747000.
  226. ↑ "Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents" (PDF).
  227. ↑ Workowski, Kimberly A.; Bolan, Gail A. (2015-06-05). "Sexually transmitted diseases treatment guidelines, 2015". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 64 (RR-03): 1–137. ISSN 1545-8601. PMID 26042815.
  228. ↑ Avian Influenza Factsheet. World Health Organization. http://www.who.int/mediacentre/factsheets/avian_influenza/en/ Accessed on April 22, 2015
  229. ↑ "avian influenza".
  230. ↑ WHO guidelines for pharmacological management of pandemic (H1N1) 2009 influenza and other influenza viruses. http://www.who.int/csr/resources/publications/swineflu/h1n1_use_antivirals_20090820/en/ Accessed on April 22, 2015
  231. ↑ WHO Guidelines for Pharmacological Management of Pandemic Influenza A(H1N1) 2009 and Other Influenza Viruses. WHO Guidelines Approved by the Guidelines Review Committee. Geneva: World Health Organization. 2010. PMID 23741777. Retrieved 2015-07-14.
  232. ↑ Hirsch HH, Martino R, Ward KN, Boeckh M, Einsele H, Ljungman P (2013). "Fourth European Conference on Infections in Leukaemia (ECIL-4): guidelines for diagnosis and treatment of human respiratory syncytial virus, parainfluenza virus, metapneumovirus, rhinovirus, and coronavirus". Clin Infect Dis. 56 (2): 258–66. doi:10.1093/cid/cis844. PMC 3526251. PMID 23024295.
  233. ↑ Gilbert, David (2014). The Sanford guide to antimicrobial therapy 2014. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808782.
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  236. ↑ Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE (2005). "Respiratory syncytial virus infection in elderly and high-risk adults". N Engl J Med. 352 (17): 1749–59. doi:10.1056/NEJMoa043951. PMID 15858184.
  237. ↑ O'Shea MK, Ryan MA, Hawksworth AW, Alsip BJ, Gray GC (2005). "Symptomatic respiratory syncytial virus infection in previously healthy young adults living in a crowded military environment". Clin Infect Dis. 41 (3): 311–7. doi:10.1086/431591. PMID 16007526.
  238. ↑ Feltes TF, Sondheimer HM (2007). "Palivizumab and the prevention of respiratory syncytial virus illness in pediatric patients with congenital heart disease". Expert Opin Biol Ther. 7 (9): 1471–80. doi:10.1517/14712598.7.9.1471. PMID 17727335.
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  240. ↑ Gwaltney JM, Park J, Paul RA, Edelman DA, O'Connor RR, Turner RB (1996). "Randomized controlled trial of clemastine fumarate for treatment of experimental rhinovirus colds". Clin Infect Dis. 22 (4): 656–62. PMC url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8729205 Check |pmc= value (help). PMID 8729205.
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  242. ↑ Turner RB (2005). "New considerations in the treatment and prevention of rhinovirus infections". Pediatr Ann. 34 (1): 53–7. PMID 15693216.
  243. ↑ Heikkinen T, Järvinen A (2003). "The common cold". Lancet. 361 (9351): 51–9. doi:10.1016/S0140-6736(03)12162-9. PMID 12517470.
  244. ↑ Louie JK, Roy-Burman A, Guardia-Labar L, Boston EJ, Kiang D, Padilla T; et al. (2009). "Rhinovirus associated with severe lower respiratory tract infections in children". Pediatr Infect Dis J. 28 (4): 337–9. doi:10.1097/INF.0b013e31818ffc1b. PMID 19258921.
  245. ↑ Template:Citeweb
  246. ↑ Template:Citeweb
  247. ↑ "DIAGNOSIS AND MANAGEMENT OF SMALLPOX".
  248. ↑ "AIDSinfoNIH".
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