Sandbox Rim

Scenario	Recommendation
Outpatient: Previously healthy and no use of antimicrobials within the previous 3 months	A macrolide, OR Doxycyline
Outpatient: Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs	A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) A b-lactam plus a macrolide
Outpatient: Use of antimicrobials within the last 3 months	An alternative from a different class should be selected: A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]), OR A b-lactam plus a macrolide
Outpatient: In regions with a high rate (125%) of infection with high-level (MIC 16 mg/mL) macrolide-resistant Streptococcus pneumoniae	A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]), OR A b-lactam plus a macrolide
Inpatient general medical ward	A respiratory fluoroquinolone, OR A b-lactam plus a macrolide
Inpatient ICU	A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus azithromycin, OR A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus a fluoroquinolone, OR For penicillin-allergic patients: a respiratory fluoroquinolone and aztreonam
Outpatient: Concern about pseudomonas	An antipneumococcal, antipseudomonal b-lactam (piperacillintazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750 mg), OR B-lactam plus an aminoglycoside and azithromycin, OR B-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone, OR For penicillin-allergic patients, substitute aztreonam for above b-lactam
Concern about community acquired MRSA	Add vancomycin or linezolid