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OUT Patient

Dysenteric Diarrhea

Frequent, sometimes bloody, small-volume diarrhea associated with abdominal pain and cramping.

Patient may be febrile and toxic.

Shigella

Salmonella

Campylobacter

Yersinia

E. coli 0157:H7

'C.difficile' 

Ciprofloxacin 500 mg PO BID

OR

Ciprofloxacin 750 mg daily x 3 days

(avoid in cases of E. coli O157:H7 as it may increase the risk of hemolytic-uremic syndrome)

Recent antibiotic exposure: consider C. difficile

Antimotility drugs should not be used in C.difficile.

C. difficile - Metronidazole 500 mg PO TID x 10-14 days. If no response at 5 days, switch to Vancomycin 125mg PO QID x10-14 days. See inpatient guidelines for severe or recurrent C. difficile infection and/or policy on C. difficile management.

  • Empiric therapy is generally indicated if patient is toxic appearing, elderly or immunocompromised.  If empiric therapy is given, obtain culture and give fluoroquinolone x 3 days while awaiting cultures
  • Azithromycin should be used for pregnancy and suspected quinolone resistant Campylobacter.
  • Antimotility drugs improve symptoms and can be used if patient is not toxic.  
  • Antimicrobial treatment may worsen outcomes in patients with E. coli0157:H7
  • E. histolytica - Metronidazole 750 mg PO TID x 7-10 days then Iodoquinol 650 mg PO TID x 20 days or Paromomycin5 25-35 mg/kg/day in 3 divided doses x 7 days
Nondysenteric Diarrhea

Large volume, nonbloody, watery diarrhea.

Patient may have nausea, vomiting, and abdominal cramping but fever often absent.

Viruses

Giardia

Enterotoxigenic E. coli

Enterotoxin-producing bacteria

General Care: Observation

Oral rehydration

Antimotility agents

Giardia – especially if patient describes recent history of travel and/or ingestion of unfiltered water (e.g., camping), consider – Metronidazole 250 mg PO TID x 5 days.

  • Generally, empiric therapy and stool cultures are not indicated. Most disease is self-limiting and can be treated with antimotility agents
  • If patient fails to improve, cultures (-), and symptoms persist, consider stool for O & P.
  • Metronidazole resistance seen in 20% giardia cases. Check C. difficile toxin if recent history of antibiotic use or hospitalization.
Traveler’s diarrhea

Empiric treatment while abroad

Toxigenic E. coli

Salmonella

Shigella

Campylobacter

Amebiasis

Ciprofloxacin 500 mg PO BID x 1-3 days

Pregnancy or fluoroquinolone-resistant campylobacter:

Azithromycin 1 g x 1 dose

EITHER WITH or WITHOUT:

Loperamide 4 mg PO x 1; then 2 mg after each loose stool,

MAX 16 mg/day

Mild, self-limited cases can be treated with fluid and electrolyte repletion and bismuth subsalicylate.

Prophylaxis generally not recommended.

Diverticulitis Enterobacteriaceae

Bacteroides fragilis

'Enterococcus' 

Amoxicillin/clavulanate 

875 mg/125 mg PO BID

OR

MoxifloxacinID-R: SFGH 400 mg PO daily

OR the combination of:

Metronidazole 500 mg PO TID

PLUS ONE OF:

Ciprofloxacin 500 mg PO BID

OR

LevofloxacinID-R: VASF  500 mg PO daily

Duration of treatment should be until patient is afebrile for 3-5 days.

Surgical evaluation and follow up is advised.

'Acute Bronchitis'  Viral No drug therapy required 
Acute bacterial exacerbation of chronic bronchitis (COPD) S. pneumoniae

H. influenzae 

Moraxellacatarrhalis

Doxycycline 100 mg PO BID X 10 days Azithromycin 500 mg PO daily X 1 day; then 250 mg PO daily X 4 days
Community-acquired Pneumonia (CAP)  S. pneumoniae

M. pneumoniae

C. pneumoniae

Respiratory viruses

Legionella spp.

C. psittaci

'H. influenzae (if patient has co-morbidity)

No recent antibiotic therapy:

Doxycycline 100 mg PO BID X 7 days

OR

Azithromycin 500 mg PO daily X 1 day; then 250 mg PO daily X 4 days

Recent antibiotic therapy or patients with co-morbidities:

Levofloxacin 750 mg PO daily X 5 days

OR

MoxifloxacinID-R: SFGH 400 mg PO daily X 7 days

Previous antibiotic therapy within last 3 month should be elicited from patient. A course of antibiotics is a risk factor for drug resistance. Recent use of a fluoroquinolone should dictate selection of a non-fluoroquinolone regimen, and vice versa.

Careful follow-up highly recommended.

Anerobic infection Amoxicillin/clavulanate 875 mg/125 mg PO BID

OR

Clindamycin 300 mg PO TID

Acute otitis media

OR

'Otitis media with effusion' (OME) with signs or symptoms of acute infection 

S. pneumoniae

H. influenzae

M. catarrhalis

Group A Strep.

Amoxicillin

1 g PO BID x 5-7 days

OR

500 mg PO TID x 5-7 days

For severe PCN allergy:

Azithromycin 500 mg PO daily x 1 day; then 250 mg PO daily x 4 days

OR

Doxycycline 100 mg PO BID for 5-7 days

  • Amoxicillin/clavulanic acid not indicated as initial therapy of acute otitis.
  • High dose amoxicillin 1 g PO TID should be used over low dose in the treatment of patients at risk for drug resistant S. pneumoniae.
  • OME in the absence of acute signs and symptom of infection does not require antibiotics.
  • For recurrent prolonged otitis consider ENT referral.
Pharyngitis Viral (EBV, rhinovirus, coronavirus, adenovirus etc)

Group A Streptococcus

(5-20%)

Penicillin VK 250 mg PO TID-QID x 10 days For severe PCN allergy:

Clindamycin300 mg PO TID x 7-10 days

  • Most pharyngitis is viral thus antibiotics should not be used.
  • Treatment with PCN prevents rheumatic fever.
  • Treat documented Group A streptococcal infection confirmed by rapid strep. antigen test or culture or if 3 out 4 clinical criteria present.
  • Clinical Criteria: history of fever, tender anterior cervical adenopathy, absence of cough, tonsillar exudates.
Acute Sinusitis Viruses

S. pneumoniae

H. influenzae

M. catarrhalis

Amoxicillin 500 mg PO TID X 5-7 days For severe PCN allergy:

Doxycycline 100 mg PO BID X 5-7 days

Consider treatment only in presence of fever, purulence or bloody discharge following an upper respiratory infection if symptoms persist for 7-10 days suggesting bacterial etiology.

Chronic Sinusitis Viruses

S. pneumoniae

H. influenzae

M. catarrhalis

Anaerobes

Staph. aureus

Enterobacteriacae 

Amoxicillin/clavulanate

875 mg/125 mg PO BID X 10-14 days

OR

Amoxicillin/clavulanate CR 2 g BID X 10-14 days if drug-resistant Streptococcus pneumonia 

For severe PCN allergy:

Ciprofloxacin 500 mg PO BID

OR

Levofloxacin 500 mg PO daily x 10-14 days

EITHER OF ABOVE WITH OR WITHOUT*:

Clindamycin 300 mg PO TID

  • Consider otolaryngology consult to rule out anatomic abnormality.
  • If acute exacerbation, treat as acute sinusitis.
  • HIV positive patients may need a 2-3 week course.
Treatment of active tuberculosis Isoniazid 300 mg PO daily x 6 months

PLUS

Rifampin 600 mg PO daily x 6 months

PLUS

Pyrazinamide 25 mg/kg PO daily x 2 months

PLUS

Ethambutol 15 mg/kg PO daily until Isoniazid or Rifampin sensitivity established

PLUS:

Pyridoxine (Vitamin B-6) 50 mg PO daily for 6 months

Latent TB 'Isoniazid' 300 mg PO daily x 9 months Rifampin 600 mg PO daily x 4 months 
Abscess 'S. aureus'
  • Uncomplicated: Incision and drainage, no antibiotics needed
  • Complicated: Incision and drainage PLUS TMP/SMX 1-2 DS tablets PO BID OR Doxycycline 100 mg PO BID
Give antibiotics for complicated abscess
  • Abscess is large (> 5 cm) or incompletely drained
  • There is significant surrounding cellulitis
  • Systemic signs and symptoms of infection are present
  • Patient is immunocompromised

7-10 days of therapy is generally adequate

Bites

Dog and Cat

Streptococci

Pasteurella spp.*

Staphylococci

Oral anaerobes 

Amoxicillin/clavulanate

875 mg/125 mg PO BID

Prophylaxis – x 5 days

Treatment – x 10 days  

For severe PCN allergy

Clindamycin 300 mg PO TID

PLUS ONE OF:

Ciprofloxacin 500 mg PO BID

OR

Levofloxacin 500 mg PO daily

  • Only 5% of dog bites become infected, whereas 30-50% of cat bites become infected.
  • Prophylaxis in high risk patients or in high risk bite only:
  • High risk patient = post splenectomy, immunocompromised
  •  High risk bite = hand or foot
  • P.multocida is resistant to cephalexin & clindamycin; many strains are resistant to erythromycin but sensitive to fluoroquinolones, doxycycline and penicillin
Bites

Human

Viridans streptococci

Eikenella*

Oral anaerobes

Amoxicillin/clavulanate 875 mg/125 mg PO BID

Prophylaxis – x 5 days

Treatment – x 10 days

For severe PCN allergy:

Clindamycin 300 mg PO TID

PLUS ONE OF:

Ciprofloxacin 500 mg PO BID

OR

Levofloxacin500 mg PO daily

OR

TMP/SMX One DS tablet PO BID

Cellulitis β-hemolytic streptococci (most common)

 S. aureus (less common)

Cephalexin500 mg PO QID

OR

Amoxicillin500 mg PO TID

OR

Clindamycin300 mg PO TID

  • If the patient does not respond to beta-lactam-based therapy consider adding TMP/SMX or doxycycline for MRSA coverage.
  • Clindamycin monotherapy provides reasonable coverage for both Group A strep and community-acquired MRSA however some isolates may be resistant. Please refer to hospital-specific antibiogram.
  • For cellulitis associated with an abscess treat for complicated abscess (see below).
  • 7-10 days of therapy is generally adequate
Diabetic Foot Ulcer

Localized cellulitis without systemic signs or symptoms, no osteomyelitis

S. aureus

Streptococci

Enterobacteriaceae

Clindamycin 300 mg PO TID

If patient has been treated with antibiotics within the past month ADD:

LevofloxacinID-R: VASF 750 mg PO daily

OR

Ciprofloxacin 500 mg PO BID   

  • While infections may be polymicrobial, they frequently respond to Gram-positive coverage alone.
  • Increasing rates of MRSA in the community may be a cause for failure to respond to initial therapy.
  • Consider osteomyelitis especially if there is a failure to respond to therapy.
  • 7-14 days of treatment is generally sufficient, duration should be based on clinical response.
Herpes Zoster Immunocompetent

(Shingles/Zoster)

Immunocompromised

(Lymphoma, HIV infection, etc) and not severe (one dermatome)

Acyclovir 800 mg PO 5x/day x 7-10 days

OR

Valacyclovir 1 g PO TID x 7 days

  • Treatment effective only if initiated within 48-72 hours of onset of lesions. May shorten duration of illness in immunocompetent patients.
  • In patients > 65 years old administration of concomitant corticosteroids may improve quality of life.
Primary Infection in Adults (Chicken Pox) Acyclovir 800 mg PO 5x/day x 5 days

OR

'Valacyclovir' 1 g PO TID x 5 days

  • Initiate therapy within 24 hours of onset of rash.
  • Vaccination of non-immune close contacts recommended. Acyclovir treatment may also be effective for prophylaxis of at-risk individuals.
Mastitis

Postpartum

S. aureus

Including MRSA becoming more frequent

Dicloxacillin 500 mg PO QID x 10-14 days

OR

Cephalexin 500 mg PO QID x 10 -14 days

If patient with risk factors for MRSA:

TMP/SMX One DS tablet PO BID x 10-14 days

OR

Clindamycin 300mg PO TID x 10-14 days

For mild PCN allergy:

Cephalexin 500 mg PO QID x 10-14 days

For severe PCN allergy:

Clindamycin 300 mg PO TID x 10-14 days

  • If no abscess, increased frequency of nursing may hasten response.
  • If abscess, I & D required; discontinue nursing.
  • Doxycycline is active against MRSA but should not be used if patient is breastfeeding.
Uncomplicated Cystitis

Women

Enterobacteriaceae (E. coli)

S. saprophyticus (Coagulase negative staphylococcus) (4%)

Nitrofurantoin 100 mg PO BID x 5-7 days – contraindicated in renal insufficiency (CrCl < 60 ml/min)

OR

TMP/SMX 1 DS tablet PO BID x 3 days (if no previous antibiotic therapy)

OR

Fosfomycin 3 g PO x1 dose

Reserve for patients at highest risk of failure (selection for resistant isolates):

Ciprofloxacin 500 mg PO BID x 3 days

OR

Levofloxacin 500 mg PO daily x 3 days

Reserve for patients with history of resistant organisms or therapeutic failure (less effective):

Cephalexin 500 mg PO QID x 7 days

OR

Cefpodoxime 200 mg PO BID x 7 days

  • IDSA guidelines state Trimethoprim/ Sulfamethoxazole is appropriate if resistance rates do not exceed 20%.
  • Nitrofurantoin is contraindicated in renal insufficiency (CrCl <60 ml/min).
Recurrent Cystitis Enterobacteriaceae (E. coli)

S. saprophyticus(Coagulase negative staphylococcus) (4%)

Prophylaxis:

Either self administration if symptoms occur or prophylactic post-coital antibiotics

Post menopausal: topical estrogen

Asymptomatic bacteriuria E.coli

Klebsiella

Enterococcus

No treatment required
Pyelonephritis Enterobacteriaceae (E. coli)

Enterococci

Ciprofloxacin 500 mg PO BID X 7-14 days

OR

LevofloxacinID-R: VASF 500 mg PO daily X 7-14 days

OR

Trimethoprim/ Sulfamethoxazole 1 DS tablet PO BID X 14 days

PLUS

Ceftriaxone 1 g IV X 1 dose

Cephalexin 500 mg PO QID X 10-14 days

OR

Cefpodoxime200 mg PO BID X 10-14 days

EITHER OF ABOVE PLUS:

Ceftriaxone 1 g IV X 1 dose

  • Urine analysis and urine culture should be performed and therapy adjusted based on culture and sensitivity.
  • Trimethoprim-sulfamethoxazole is preferred if organism is susceptible.
  • Consider a single intravenous dose of ceftriaxone prior to fluoroquinolone therapy if patient is at high risk for fluoroquinolone-resistant organisms.
Prostatitis

Acute

Enterobacteriaceae(E. coli) Cephalexin 500 mg PO QID x 21 days

OR

Ciprofloxacin 500 mg PO BIDX 2-4 weeks*

OR

LevofloxacinID-R: VASF 500 mg PO daily x 2-4 weeks*

Trimethoprim/ Sulfamethoxazole 1 DS tablet PO BID
  • Antibiotic penetration in the acute inflammatory state is adequate for most antibiotics.
  • Consider sexually transmitted disease treatment (Gonococcus or C. trachomatis) for appropriate patient populations.
  • Cultures should be obtained and definitive therapy should be based on sensitivities.
Prostatitis

Chronic

Enterobacteriaceae(E. coli) Ciprofloxacin x 2 months*

OR

LevofloxacinID-R: VASF x 2 months*

Trimethoprim/ Sulfamethoxazole 1 DS tablet PO BID
  • Few drugs penetrate non-inflamed prostate. Fluoroquinolones and trimethoprim/sulfamethoxazole adequately penetrate in non-inflamed state.
  • Consider sexually transmitted disease treatment (Gonococcus or C. trachomatis) for appropriate patient populations.
Chlamydia 

Genital/Rectal

'Pharyngeal' 

'Chlamydia trachomatis' Azithromycin 1 g PO once

OR

'Doxycycline' 100 mg PO BID X 7 days

First Clinical Episode or Anogenital Herpes HSV 2 = 70-90%

HSV 1 = 10-30% 

Acyclovir 400 mg PO TID x 7-10 days Valacyclovir 1 g PO BID x 7-10 days

In HIV patients with documented acyclovir resistance, use foscarnet.

Episodic Therapy for Recurrent Episodes Acyclovir 400 mg PO  TID x 5 days

OR

Acyclovir 800 mg PO BID x 5 days

OR

Acyclovir 800 mg PO TID x 2 days

Valacyclovir 1 g PO daily x 5 days 
  • HIV patients:

Acyclovir 400 mg PO TID x 5-10 days

OR

Valacyclovir 1 g PO BID x 5-10 days

Suppression for Frequent Recurrence HSV 2 = 70-90%

HSV 1 = 10-30%

Acyclovir 400 mg PO BID

HIV patients:

Acyclovir 400-800 mg BID or TID

OR

Valacyclovir 500 mg PO BID

Valacyclovir 500-1000 mg PO daily

Consider suppressive therapy for patients experiencing greater than 3-4 episodes in 12 months. 

Pelvic inflammatory diseases (PID N.gonorrhoeae 

C.trachomatis anaerobes

Gram-negative facultative bacteria streptococci

Ceftriaxone 250 mg IM X 1

PLUS

Doxycycline 100 mg PO BID X 14 days

PLUS

Metronidazole 500 mg PO BID x 14 days if BV is present or cannot be ruled out

  • Follow-up examination should be performed within 72 hours when PID is treated with these regimens.
  • Fluoroquinolones should not be used due to increasing resistance and treatment failures.
Syphilis

Primary, Secondary, Early Latent

'T. pallidum'  Benzathine penicillin G2.4 MU IM X 1 dose Doxycycline100 mg PO BID X 2 weeks
Syphilis

Late Latent and Latent of Unknown Duration

'T. pallidum'  Benzathine penicillin G2.4 MU IM Q week X 3 doses  Doxycycline100 mg PO BID X 4 weeks  

Sexual partners must be treated.

  • Alternatives should only be used for penicillin-allergic patients because efficacy of these therapies has not been established.  Compliance with some of these regimens is difficult, and close follow-up is essential.
Candidal Vaginitis 'Fluconazole' 150 mg PO x 1 dose Miconazole 2% cream 5 g intravaginally x 3 days

OR

Miconazole 100 mg suppository, one suppository daily x 7 days

OR

Clotrimazole 1% cream 5 g intravaginally x 7-14 days

Protazoan Vaginitis Metronidazole 2 g PO x 1 dose  Metronidazole 500 mg PO BID x 7 days 

In treatment failures to metronidazole, retreat with metronidazole 500 mg PO BID x 7 days.

Bacterial Vaginitis Metronidazole 500 mg BID PO x 7 days

OR

Metronidazole vaginal gel 0.75%, 5 g intravaginally daily x 5 days

OR

Clindamycin vaginal cream 2%, 5 g intravaginally daily x 7 days

Clindamycin 300 mg PO BID X 7 days

OR

Clindamycin ovules 100 mg intravaginally daily x 3 days