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Bacteria – Gram-Positive Cocci

  • Endocarditis in Adults [2]
  • 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
  • Endocarditis in Pediatrics
  • Preferred regimen : (Ampicillin 300 mg/kg/day IV for 4–6 weeks OR Penicillin 300,000U/kg/day IV for 4–6 weeks) AND Gentamicin 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 AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • β Lactamase–producing strain
  • Preferred regimen : Ampicillin-sulbactam 300 mg/kg/day IV for 6weeks AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • Alternate regimen : Vancomycin 40 mg/kg/day IV for 6weeks AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • Intrinsic penicillin resistance : Vancomycin 40 mg/kg/day IV AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • Urinary tract infections [4]
  • Intra abdominal or Wound infections [5]
  • Endocarditis in Adults [2]
  • 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
  • Endocarditis in Pediatrics
  • Preferred regimen : (Ampicillin 300 mg/kg/day IV for 4–6 weeks OR Penicillin 300,000U/kg/day IV for 4–6 weeks) AND Gentamicin 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 AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • β Lactamase–producing strain
  • Preferred regimen : Ampicillin-sulbactam 300 mg/kg/day IV for 6weeks AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • Alternate regimen : Vancomycin 40 mg/kg/day IV for 6weeks AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • Intrinsic penicillin resistance : Vancomycin 40 mg/kg/day IV AND Gentamicin 3 mg/kg/day IV/IM for 6weeks
  • Urinary tract infections [7]
  • Intra abdominal or Wound infections [8]
  • In adults
  • (2) Intravascular catheter-related infections[9]
  • Methicillin susceptible Staphylococcus aureus (MSSA)
  • 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.
  • Neonates
  • 0–4 weeks of age and 1200 g - 50 mg/kg/day q12h.
  • Postnatal age <7 days and 1200–2000 g- 50–100 mg/kg/day q12h.
  • Postnatal age <7 days and >2000 g, 75–150 mg/kg/day q8h.
  • Postnatal age ≥7 days and 1200–2000 g- 75–150 mg/kg/day q8h.
  • Postnatal age ≥7 days and >2000 g, 100–200 mg/kg/day q6h.
  • Infants and children Nafcillin 100–200 mg/kg/day q4–6h.
  • Neonates
  • Postnatal age ≤7 days: 40 mg/kg/day q12h.
  • Postnatal age >7 days and 2000 g: 40 mg/kg/day q12h.
  • Postnatal age >7 days and 12000 g: 60 mg/kg/day q8h.
  • Infants and children: 50 mg/kg/day q8h.
  • Neonates
  • Postnatal age ≤7 days and <1200 g, 15 mg/kg/day q24h.
  • Postnatal age ≤7 days and 1200–2000 g, 10–15 mg/kg q12–18h.
  • Postnatal age ≤7 days and >2000 g, 10–15 mg/kg q8–12h.
  • Postnatal age >7 days and <1200 g, 15 mg/kg/day q24h.
  • Postnatal age >7 days and 1200–2000 g, 10–15 mg/kg q8–12h.
  • Postnatal age >7 days and >2000 g, 15–20 mg/kg q8h.
  • Infants and children: 40 mg/kg/day q6–8h.
  • Methicillin resistant Staphylococcus aureus (MRSA)
  • Neonates
  • 0–4 weeks of age and birthweight <1200 g: 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, 10 mg/kg q8–12h (note: q12h in patients <34 weeks gestation and <1 week of age).
  • 7 days and birthweight >1200 g, 10 mg/kg q8h.
  • Infants and children <12 years of age: 10 mg/kg q8h Children 12 years of age and adolescents: 10 mg/kg q12h.
  • Neonates
  • Premature neonates and <1000 g, 3.5 mg/kg q24h; 0–4 weeks and <1200 g, 2.5 mg/kg q18-24h.
  • Postnatal age 7 days: 2.5 mg/kg q12h.
  • Postnatal age 17 days and 1200–2000 g, 2.5 mg/kg q8-12h.
  • Postnatal age 17 days and 12000 g, 2.5 mg/kg q8h.
  • Once daily dosing for premature neonates with normal renal function, 3.5–4 mg/kg q24h.
  • Once daily dosing for term neonates with normal renal function, 3.5–5 mg/kg q24h.
  • Infants and children <5 years of age: 2.5 mg/kg q8h; qd dosing in patients with normal renal function, 5–7.5 mg/kg q24h.
  • Children >5 years of age: 2–2.5 mg/kg q8h; qd s with normal renal function, 5–7.5 mg/kg every 24 h.
  • Infants 12 months of age and children: mild-to-moderate infections, 6–12 mg TMP/kg/day q12h; serious infection, 15–20 mg TMP/kg/day q6-8h.
  • (3) Purulent cellulitis (defined as cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess)
  • In adults
  • In childern
Doxycycline If patient body weight 45kg: adult dose OR Minocycline 4 mg/kg PO 200 mg as a single dose, then 2 mg/kg/dose PO q12h OR Linezolid 10 mg/kg PO q8h, not to exceed 600 mg/dose
  • Nonpurulent cellulitis (defined as cellulitis with no purulent drainage or exudate and no associated abscess)
  • In adults
Note: Empirical therapy for b-hemolytic streptococci is recommended. Empirical coverage for CA-MRSA is recommended in patients who do not respond to b-lactam therapy and may be considered in those with systemic toxicity.
Note: Provide coverage for both b-hemolytic streptococci and CA-MRSA b-lactam (eg, amoxicillin) and/or TMP-SMX or a tetracycline
  • In childern
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.
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • In adults
  • In childern
Note: Consider the addition of Rifampin 600 mg qd OR 300–450 mg bid to Vancomycin.
  • Methicillin-susceptible Staphylococcus aureus (MSSA)
  • (5) Cerebrospinal fluid shunt infection [13][14]
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND/OR 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.
  • Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 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
  • Methicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen: Cefazolin 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks OR Nafcillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR 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
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • 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
  • Alternative regimen: Linezolid 600 mg PO or IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg PO or IV q8–12h for 4–6 weeks
  • Pediatric dose: Vancomycin 15 mg/kg IV q6h OR 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
  • Methicillin susceptible Staphylococcus aureus (MSSA)
  • 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[19]
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h for 4–6 weeks
  • Alternative regimen: Linezolid 600 mg PO IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
  • Pediatric dose: Vancomycin 15 mg/kg IV q6h OR 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
  • Methicillin-resistant Staphylococcus aureus (MRSA)[20]
  • In adults
  • Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
  • Alternative regimen: Linezolid 600 mg PO or IV q12h for 4–6 weeks OR TMP-SMX 5 mg/kg/dose PO/IV q8–12h for 4–6 weeks
  • In childern
Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin.
  • (10) Acute conjunctivitis [21]
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • (11) Appendicitis
Health Care–Associated Complicated Intra-abdominal Infection [22]
Methicillin-resistant Staphylococcus aureus (MRSA):
Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • (12) Diverticulitis
Health Care–Associated Complicated Intra-abdominal Infection [22]
Methicillin-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
Health Care–Associated Complicated Intra-abdominal Infection [22]
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • (14) Cystic fibrosis [23]
  • Preferred Regimen (Adult)
  • If methicillin sensitive staphylococcus aureus: Nafcillin 2 gm IV q4hs OR Oxacillin 2 gm IV q4hs
  • If methicillin resistant staphylococcus aureus: Vancomycin 15-20 mg/kg IV q8-12h OR Linezolid 600 mg po/IV q12h
  • Preferred regimen (Pediatric)
  • If methicillin sensitive staphylococcus aureus: Nafcillin 5 mg/kg q6h (Age >28 days) OR Oxacillin 75 mg/kg q6h (Age >28 days)]]
  • If methicillin resistant staphylococcus aureus: Vancomycin 40 mg/kg q6-8h (Age >28 days) OR Linezolid 10 mg/kg po or IV q8h (up to age 12)
  • (15) Bronchiectasis [24]
  • (a) Preferred Regimen in adults
  • Recommended first-line treatment and length of treatment
Methicillin-susceptible Staphylococcus aureus (MSSA): Flucloxacillin 500 mg oral qds for 14 days
Methicillin-resistant Staphylococcus aureus (MRSA): Patient's body weight is <50 kg: Rifampicin 450 mg oral od AND Trimethoprim 200 mg oral bd for 14 days ; Patient's body weight is >50 kg: Rifampicin 600 mg oral od AND Trimethoprim 200 mg oral bd for 14 days
Methicillin-resistant Staphylococcus aureus (MRSA): Vancomycin 1 g IV bd (monitor serum levels and adjust dose accordingly) OR Teicoplanin 400 mg od for 14 days
  • Recommended second-line treatment and length of treatment
Methicillin-susceptible Staphylococcus aureus (MSSA): Clarithromycin 500 mg oral bd 14 days
Methicillin-resistant Staphylococcus aureus (MRSA): Patient's body weight is <50 kg: Rifampicin 450 mg oral od AND Doxycycline 200 mg oral od 14 days, Patient's body weight is >50 kg: Rifampicin 600 mg oral AND Doxycycline 200 mg oral od 14 days. Third-line: Linezolid 600 mg bd 14 days
Methicillin-resistant Staphylococcus aureus (MRSA): Linezolid 600 mg IV bd 14 days
  • (b) Preferred Regimen in children
  • Recommended first-line treatment and length of treatment
Methicillin-susceptible Staphylococcus aureus (MSSA): Flucloxacillin
Methicillin-resistant Staphylococcus aureus (MRSA): Children (< 12 yr): Trimethoprim 4-6 mg/kg/24 hr divided q 12 hr PO Children (> 12 yr) : Trimethoprim 100-200 mg q 12 hr PO. Rifampicin 450 mg oral od  : Rifampicin 600 mg oral od AND
Methicillin-resistant Staphylococcus aureus (MRSA): Vancomycin 45-60 mg/kg/24 hr divided q 8-12 hr IV OR Teicoplanin
  • Recommended second-line treatment and length of treatment
Methicillin-susceptible Staphylococcus aureus (MSSA): Clarithromycin 15 mg/kg/24 hr divided q 12 hr PO
Methicillin-resistant Staphylococcus aureus (MRSA): Rifampicin AND Doxycycline 2-5 mg/kg/24 hr divided q 12-24 hr PO or IV (max dose: 200 mg/24 hr) ; Rifampicin AND Doxycycline 2-5 mg/kg/24 hr divided q 12-24 hr PO or IV (max dose: 200 mg/24 hr) . Third-line: Linezolid 10 mg/kg q 12 hr IV or PO
Methicillin-resistant Staphylococcus aureus (MRSA): Linezolid 10 mg/kg q 12 hr IV or PO
  • (B)Long-term oral antibiotic treatment
  • (a) Preferred Regimen in adults
  • Recommended first-line treatment and length of treatment
Methicillin-susceptible Staphylococcus aureus (MSSA): Flucloxacillin 500 mg oral bd
  • Recommended second-line treatment and length of treatment
Methicillin-susceptible Staphylococcus aureus (MSSA): Clarithromycin 250 mg oral bd
  • (16) Empyema
  • (17) Community-acquired pneumonia
  • Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred Regimen : Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR Linezolid 600 mg PO/IV q12h for 10-14 days
  • Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h
  • (18) Olecranon bursitis or prepatellar bursitis
  • Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Methicillin-resistant Staphylococcus aureus (MRSA)
Note: Initially aspirate q24h and treat for a minimum of 2–3 weeks.
  • (19) Septic arthritis
  • In adults
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regime: 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/IV q12h
  • Alternative regimen (3): Clindamycin 600 mg PO/IV q8h
  • Alternative regimen (4): TMP-SMX 3.5–4.0 mg/kg PO/IV q8–12h
  • In childern
  • Methicillin-susceptible Staphylococcus aureus (MSSA)
  • (20) Septic arthritis, prosthetic joint infection (device-related osteoarticular infections)
  • Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 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: (Daptomycin 6 mg/kg IV q24h OR 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 plus a fluoroquinolone, TMP/SMX, a tetracycline or Clindamycin for 3 or 6 months for hips and knees, respectively.
  • (21) Hematogenous osteomyelitis
  • Adult (>21 yrs)
  • Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • Preferred regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
  • Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • Children (>4 mos.)-Adult
  • Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
Note: Add Ceftazidime 50 q8h or Cefepime 150 div q8h if Gm-neg. bacilli on Gram stain
  • Newborn (<4 mos.)
  • Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • Specific therapy
  • Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • (22) Diabetic foot osteomyelitis
  • High Risk for MRSA
  • (23) Necrotizing fasciitis[25]
  • In adult
  • In childern
  • (24) Staphylococcal toxic shock syndrome [26]
  • Methicillin sensitive Staphylococcus aureus
  • Preferred regimen: Cloxacillin 250-500 mg PO q6h (max dose: 4 g/24 hr) OR Nafcillin 4-12 g/24 hr divided IV q4-6hr (max dose: 12 g/24 hr) OR 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 (1):Rifampicin, AND Linezolid 600 mg IV or PO q12h OR Daptomycin OR Tigecycline 100 mg loading dose followed by 50 mg IV q12h
  • Methicillin resistant Staphylococcus aureus
  • 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 OR Tigecycline 100 mg loading dose followed by 50 mg IV q12h
Note: Incidence increasing. Geographical patterns highly variable.
  • Prophylaxis for coronary artery bypass graft-associated acute mediastinitis[27]
  • 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.
  • 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.
  • 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.

Group comprises 3-15% of streptococcal isolates of endocarditis. See Diagnosis section for Endocarditis module for management, follow viridans Streptococci recommendations. Dental abscesses, sinusitis, fasciitis of head and neck: can be life threatening and require aggressive surgical management. See appropriate HEENT module for specific management. Bacteremia often associated with deep-seated abscess. Investigate for abscess—most often intraabdominal. Drainage is usually recommended. Brain abscesses often polymicrobial, but S. intermedius found in 50-80%. See Brain abscess module for management. Implicated in aspiration pneumonia, lung abscess and empyema.



  • 1. Lung (pneumonia)
  • Community-acquired pneumonia
  • Penicillin sensitive (minimum inhibitory concentration ≤ 2)
Oral agents: Penicillin V 500 mg PO qid, Amoxicillin 500-1000 mg PO tid, Cefpodoxime 200 mg PO bd, Cefprozil 500 mg PO bd, Cefditoren 400 mg PO bd, Cefdinir 300 mg PO bd, OR Doxycycline 100 mg PO bd.
  • 2. Sinuses (sinusitis)
  • Sinusitis (empiric therapy)
Note (1): For patients with pen/cephalosporin allergy, especially severe IgE-mediatedallergy, e.g., hives, anaphylaxis, then the treatment options are Clarithromycin 250 mg bid 10 days, Azithromycin 500 mg qd and then 250 mg q24h for 4 days or 500 mg q24h for 3 days., Trimethoprim-Sulfamethoxazole 8–10 mg/kg qd (based on TMP component) div q6h, q8h, or q12h., Doxycycline or Flouroquinolones. Avoid Flouroquinolones if under age 18.
Note (2): Treatment goals: 2.1 Resolve infection, 2.2 Prevent bacterial complications, e.g., subdural empyema, epidural abscess, brain abscess, meningitis and cavernous sinus thrombosis ,2.3 Avoid chronic sinus disease, 2.4 Avoid unnecessary antibiotic treatment. High rate of spontaneous resolution.
Note (3): Reserve antibiotic therapy for patients given decongestants or analgesics for 10 days who have maxillary/facial pain and purulent nasal discharge; if severe illness (pain, fever), treat sooner—usually requires hospitalization. Viral infections should resolve within 10 days.For mild or moderate disease, ask if recent antibiotic use (recent = in last month)
  • 3. Middle ear (otitis media)
  • (4)Bronchi (acute exacerbation of chronic bronchitis)
  • (5)CNS (meningitis)
  • Empiric therapy
  • In age group of 1 months– 50 years

Adult dosage: (Cefotaxime 2 gm IV q4–6h OR Ceftriaxone 2 gm IV q12h) AND Dexamethasone AND Vancomycin 15 mg/kg/day IV q12h

  • Penicillin sensitive (minimum inhibitory concentration ≤ 0.06)
  • Penicillin resistant (minimum inhibitory concentration ≥ 0.12) or beta-lactam hypersensitivity
Dexamethasone 0.15 mg/kg IV q6h for 2-4 days starting 10-20 min before antibiotic.
  • (6)Peritoneum (spontaneous bacterial peritonitis)
  • (7)Pericardium (purulent pericarditis)
  • (8)Skin (cellulitis)
  • (9)Eye (conjunctivitis)
  • (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): 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.
  • (2) Skin: erysipelas, lymphangitis, cellulitis
  • (3) Soft tissue
  • Necrotizing fasciitis: surgical consultation for emergent fasciotomy and debridement; repeat debridements usually necessary.
  • (4) Muscle
  • Myositis: debirdement
  • (5) Endometrium
  • (6) Puerperal sepsis
  • (7) Lung
  • pneumonia with or without early bloody effusion Bacteremia
  • (8) Cardiac are endocarditis (very rare in antibiotic era)
  • (9) Toxin mediated
  • Scarlet fever
  • Toxic shock syndrome
  • Preferred regimen: Immunoglobulin-G 2 or more doses IV , massive IV fluids (10-20 L/day), Albumin if <2 g/dL, debridement of necrotic tissue.
  • (10)Non-suppurative complications are rheumatic fever and glomerulonephritis


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).
  • Prophylaxis
  • Acute rheumatic fever prophylaxis
  • Recurrent cellulitis, chronic lymphedema prophylaxis

Bacteria – Gram-Positive Bacilli

  • (A) Treatment for cutaneous anthrax, without systemic involvement[33]
Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
  • (B) 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[33]
  • (B-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.
  • (B-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.
  • Specific considerations
  • Treatment of anthrax for pregnant Women
  • (A) Intravenous antimicrobial treatment for systemic anthrax with possible/confirmed meningitis [34]
  • (1) A Bactericidal Agent (Fluoroquinolone): Ciprofloxacin 400 mg IV q8h is preferred, OR Levofloxacin 750 mg IV q24h, OR
  • (2). A Bactericidal Agent (β-lactam)
  • (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : Meropenem 2 g q8h,OR
  • (b). 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.
  • (B) Intravenous antimicrobial treatment for systemic anthrax when meningitis has been excluded
  • (1). A Bactericidal Antimicrobial: Ciprofloxacin 400 mg IV q8h is preferred, OR Levofloxacin 750 mg IV q24h, OR
  • (2). A Bactericidal Agent (β-lactam)
  • (a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown : Meropenem 2 g q8h,OR
  • (b). 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
  • (C) Oral antimicrobial treatment for cutaneous anthrax without systemic involvement
  • (a).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.
  • Treatment for anthrax in children [35]
  • (1). Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)
  • (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 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
  • (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 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.
  • (2). Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older)
  • (A). A bactericidal antimicrobial
  • (a). 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)
  • (b). 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
  • (B). 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).Triple therapy for systemic anthrax (anthrax meningitis or disseminated infection and meningitis cannot be ruled out) for Children 1 Month of Age and Older
  • (A). 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
  • (B). A bactericidal antimicrobial (β-lactam or glycopeptide)
  • (a). 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
  • (b). 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
  • (C). 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.
  • (4).Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older)
  • (A). 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
  • (B). 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.
  • (5). Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)
  • (A). Triple therapy for severe anthrax(anthrax meningitis or disseminated infection and meningitis cannot be ruled out)
  • (1). Bactericidal antimicrobial (fluoroquinolone) therapy
  • (a) 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
  • (b) 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
  • (c) 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
  • (2). A bactericidal antimicrobial (β-lactam)
  • a. For all strains, regardless of penicillin susceptibility or if susceptibility is unknown :
  • (a) 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
  • (b) 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
  • (c) 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
  • b. Alternatives for penicillin-susceptible strains
  • (a) 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,
  • (b) 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,
  • (c) 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).A protein synthesis inhibitor
  • (a) 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
  • (b) 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
  • (c) 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.
  • (B). Therapy for severe anthrax when meningitis can be ruled out
  • (1).A bactericidal antimicrobial
(a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • (a) 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
  • (b) 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
  • (c) 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
(b). Alternatives for penicillin-susceptible strains
  • (a) 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
  • (b) 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
  • (c) 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
  • (2).A protein synthesis inhibitor
  • (a) 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
  • (b) 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
  • (c) 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
  • (C). Oral follow-up combination therapy for severe anthrax
(1).A bactericidal antimicrobial
(a). For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • (a) 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
  • (b) 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
  • (c) 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
(b). Alternatives for penicillin-susceptible strains
  • (a) 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
  • (b) 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
  • (c) 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
(2).A protein synthesis inhibitor
  • (a) 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
  • (b) 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
  • (c) 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.
  • (D).Treatment of cutaneous anthrax without systemic involvement
  • (1).For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • (a) 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
  • (b) 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
  • (c) 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
  • (2).Alternatives for penicillin-susceptible strains
  • (a) 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
  • (b) 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
  • (c) 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) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown: Ciprofloxacin, 500 mg q12h OR Doxycycline, 100 mg q12h OR Levofloxacin, 750 mg q24h OR Moxifloxacin, 400 mg q24h OR Clindamycin, 600 mg q8h OR
  • (2) Alternatives for penicillin-susceptible strain Amoxicillin, 1 g q8h OR Penicillin VK, 500 mg q6h
Note (1): Preferred drugs are indicated in boldface.
Note (2): Alternative drugs are listed in order of preference for treatment for patients who cannot take first-line treatment or if first-line treatment is unavailable.
  • For children ≥ 1 month[35]
  • (1) For penicillin-resistant strains or prior to susceptibility testing: Ciprofloxacin, 30 mg/kg/day, by mouth (PO), divided q12h (not to exceed 500 mg/dose) OR Doxycycline, <45 kg: 4.4 mg/kg/day, PO, divided q12h (not to exceed 100 mg/dose) >45 kg: 100 mg/dose, PO, given q12h OR Clindamycin, 30 mg/kg/day, PO, divided q8h (not to exceed 900 mg/dose) OR Levofloxacin, <50 kg: 16 mg/kg/day, PO, divided q12h (not to exceed 250 mg/dose) >50 kg: 500 mg, PO, given q24h OR
  • (2) For penicillin-susceptible strains: Amoxicillin, 75 mg/kg/day, PO, divided every q8h (not to exceed 1 g/dose) OR Penicillin VK, 50-75 mg/kg/day, PO, divided q6h to q8h
Note (1) : Duration of Therapy is 60 days after exposure
Note (2) : Bold font are preferred antimicrobial agent (when 2 bolded antimicrobial agents are present, both are considered equivalent in overall safety and efficacy).
Note (3) : Normal font are alternative selections are listed in order of preference for therapy for patients who cannot take first-line therapy or if first-line therapy is unavailable.
Note (4) : Doses are provided for children with normal renal and hepatic function. Doses may vary for those with some degree of organ failure.
Note (5) : Italicized font: indicates FDA approval for the indication in the pediatric population.
Note (6) : A single 14-day course of doxycycline is not routinely associated with tooth staining, but some degree of staining is likely for a prolonged treatment course of up to 60 days.
Note (7) : Safety data for Levofloxacin in the pediatric population are limited to 14 days for duration therapy.
Note (8) : Be aware of the possibility of emergence of penicillin-resistance during monotherapy with Amoxicillin or Penicillin.
  • For children < 1 month
  • (1) For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • (a) 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
  • (b) 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
  • (c) 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
  • (2) Alternatives for penicillin-susceptible strains
  • (a) 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
  • (b) 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
  • (c) 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 [36]
  • (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
Note: Distinguish clinically significant infection from contamination before administering antibiotics.
  • Diphtheria treatment
  • 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
  • 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
  • C. diphtheriae carrier
  • Endocarditis treatment
* Acute Q fever [40]
  • Adults:
  • Preferred Regimen: DoxycyclinePO 100 mg bid for 14 days
  • Children
  • Children with age ≥8 years:
  • Preferred regimen:Doxycycline PO 2.2 mg/kg per dose bid for 14 days (maximum 100 mg per dose)
  • 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 per dose)
  • 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 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)
  • Pregnant women
* Chronic Q fever
  • 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
  • Noncardiac organ disease
  • Postpartumwith serologic profile for chronic Q fever
  • Preferred regimen:Doxycycline PO 100 mg bid and hydroxychloroquine PO 200 mg 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
  • ≥8 years old
  • Preferred regimen: Doxycycline 2 mg/kg IV/PO q12h (max 200 mg/day) for 10 days
  • <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)
  • 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
  • Erysipeloid of Rosenbach (localized cutaneous infection)[42]
  • Diffuse cutaneous infection
  • Preferred regimen: As for localized infection
Note: Assess for endocarditis
  • 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
  • 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
  • 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
  • Gastroenteritis
  • Endovascular Infection [44]
  • Odontogenic Infection
  • Intrabdominal Abscess


  • Sulfonamide-based therapies [45]
  • 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
  • Pulmonary alternatives
  • 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
  • CNS alternatives
  • Severe disease, compromised host, multiple sites
  • 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
  • Sulfonamide alternatives
  • Severe
  • Mild
  • Systemic infection[46]
  • Shoulder prosthesis infection
  • Acne vulgaris
  • Rhodococcus equi [47]
  • Preferred regimen:
  • 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)
  • Oral/maintenance therapy (after infiltrate clears): Ciprofloxacin 750 mg PO twice daily OR Erythromycin 500 mg PO four times a day
  • Alternative regimen: Azithromycin OR TMP-SMX OR Chloramphenicol OR Clindamycin
  • NOTE: Avoid Penicillins/Cephalosporins due to development of resistance; Linezolid effective in vitro, but no clinical reports of use
  • Rickettsia rickettsii [48]
  • 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

  • Preferred Regimen: Azithromycin 1 g PO in a single dose OR Ceftriaxone 250 mg IM in a single dose OR Ciprofloxacin 500 mg PO bid for 3 days OR Erythromycin base 500 mg PO three tid for 7 days
  • Note(1): 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.
  • Note(2):Persons with HIV infection might require repeated or longer courses of therapy, and treatment failures can occur with any regimen.


  • Neisseria gonorrhoeae, treatment[50]
  • 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
  • Neisseria gonorrhoeae, prophylaxis[51]
  • 1. Ophthalmia neonatorum
  • Preferred regimen: Erythromycin 0.5% ophthalmic ointment in each eye in a single application at birth
  • Alternative regimen: Ceftriaxone 25–50 mg/kg IV/IM in a single dose, not to exceed 125 mg (if erythromycin ointment is not available)
  • Antimicrobials:
  • Preferred regimen : Ceftriaxone 2 g IV q24h OR 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 OR moxifloxacin 400 mg/day IV.
  • Steroids: Dexamethasone 10 mg IV q6h for 2-4 days starting before or with first dose.

Bacteria – Spirochetes

  • Lyme disease
  • Early Lyme Disease
  • 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)
  • 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)
  • 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)
  • 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)
  • Borrelial lymphocytoma
  • Preferred regimen: The same regimens used to treat patients with erythema migrans (see above)
  • Late Lyme Disease
  • 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
  • patients with arthritis and objective evidence of neurologic disease
  • Late neurologic Lyme disease
  • Acrodermatitis chronica atrophicans
  • 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)
  • 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
  • Louse-Borne Relapsing Fever
  • Treatment
  • Preferred regimen: Penicillin 1.5 million units IV q6hr for 5-7 days
  • Less severe
  • Prophylaxis
  • Leptospira interrogans [56]
  • Syphilis Among non-HIV-Infected Persons[57]
  • 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
  • Latent Syphilis
  • 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
  • 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)
  • 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
  • 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
  • Syphilis Among HIV-Infected Persons
  • Primary and Secondary Syphilis Among HIV-Infected Persons
  • Preferred regimen: Benzathine penicillin G 2.4 million units IM in a single dose.
  • Latent Syphilis Among HIV-Infected Persons
  • early latent
  • Preferred regimen: Benzathine penicillin G 2.4 million units IM in a single dose.
  • late latent
  • Preferred regimen: Benzathine penicillin G at weekly doses of 2.4 million units for 3 weeks.
  • 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
  • Syphilis During Pregnancy
  • Preferred regimen: Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection
  • Congenital Syphilis in neonates
  • 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.
  • 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.
  • 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
  • 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.
  • 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

  • Enteric flora
  • Aeromonas hydrophila
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
Alternatives to fluoroquinolones for Aeromonas coverage include carbapenems (ertapenem, doripenem, imipenem or meropenem),ceftriaxone, cefepime and aztreonam.
Note: Usually Ampicillin resistant, but may be sensitive to first generation cephalosporins
  • UTI
  • UTI
  • Escherichia coli
  • 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
  • 3.1.1.Acute uncomplicated pyelonephritis
  • 3.1.2.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
  • Preferred regimen : Ceftriaxone 1-2g IV q24h OR other third or fourth generation cephalosporin OR Ciprofloxacin 400mg IV q12h or 500mg PO q12h OR Levofloxacin 500mg PO/IV q24h OR Moxifloxacin 400mg IV/PO q24h OR Ampicillin(if sensitive) 2g IV q6h OR TMP-SMX(if sensitive) 5-10mg/kg/day for q6-8hIV
  • Alternative regimen : Imipenem, Meropenem, Ertapenem, Doripenem, Ceftazidime, Cefepime, Cefazolin or Cefuroxime(ifsensitive), Aztreonam, Ticarcillin, Piperacillin, Piperacillin-Tazobactam, Aminoglycosides, Tigecycline(intra-abdorskin/softtissue).
Monotherapy generally not recommended for bacteremia/pneumonia
  • Aspiration Pneumonia
  • Non-fermenters

Bacteria – Atypical Organisms

  • 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[59]
  • 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.
  • Chlaymydial infections [60]
  • 1. Chlamydial Infections in Adolescents and Adults
  • Preferred regimen : Doxycycline 100 mg PO bid for 7 days OR Azithromycin 1 g PO in a single dose
  • Alternative regimen (1): Erythromycin base 500 mg PO qid for 7 days OR Erythromycin ethylsuccinate 800 mg PO qid for 7 days
  • Alternative regimen (2): Levofloxacin 500 mg PO qd for 7 days OR 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.
  • 1.1 Chlamydial Infections in patients with HIV Infection
  • 1.2Pregancy
  • 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
  • Lymphogranuloma venereum (LGV)
  • Lymphogranuloma venereum (LGV) is caused by C. trachomatis serovars L1, L2, or L3[61]
  • 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): Patients should be followed clinically until signs and symptoms have resolved.
  • 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.
  • Q fever [63]
  • 1.Acute Q fever
  • 1.1 Adults:
  • Preferred Regimen: DoxycyclinePO 100 mg bid for 14 days
  • 1.2 Children
  • 1.2.1Children with age ≥8 years:
  • Preferred regimen:Doxycycline PO 2.2 mg/kg per dose bid for 14 days (maximum 100 mg per 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 per 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 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 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: 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
  • Legionella pneumonia (atypical bacterial pneumonia) [64]
  • Atypical pneumonia caused by Mycoplasma pneumoniae[65]
  • 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 caused due to Mycoplasma Genitalium[66]
  • Preferred regimen: Azithromycin 1 g PO single dose
  • Note(1): Resistant strains -Azithromycin PO in 500 mg single dose followed by 250 mg qd for 4 days
  • Note(2): previous treatment failures- Moxifloxacin PO 400 mg qd for 7, 10 or 14 days) has been successfully used to treat both men and women
  • 2. PID caused due to Mycoplasma Genitalium

Bacteria – Miscellaneous

  • Human bite/soft tissue infections [67]
  • Severe
  • Mild
  • Head and neck infections
  • Severe
  • Mild
  • Endocarditis

Bacteria – Anaerobic Gram-Negative Bacilli

  • Combination therapy

Fungi

  • 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):
  • 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: Treatment duration based on organ involvement:
  • Minor involvement: 12 months
  • Moderate involvement: 18-24 months
  • Preferred regimen(2): Ketoconazole 200-400 mg/day PO for 9-12 months
  • Preferred regimen(3):
  • Adults: Itraconazole 600 mg/day PO for 3 days; continue 200 mg/day PO for 6-9 months
  • Children: Itraconazole (<30/kg and >5 yr) 5-10 mg/kg/day PO for 6-9 months
  • Preferred regimen(4): Voriconazole initial dose 400 mg PO/IV each 12 hr for one day, then 200 mg each 12 hr for 6 months
  • Note: Diminish the dose to 50% if weight is <40 kg
  • Preferred regimen(5): Amphotericin B deoxycholate mg/kg/day IV until patient improves and can be treated by the oral route
  • Fingernail Treatment Options
  • Preferred regimen: Terbinafine 250 mg PO q24h (children <20 kg: 67.5 mg/day, 20–40 kg: 125 mg/day, >40 kg: 250 mg/day) for 6 weeks OR Itraconazole 200 mg PO q24h for 3 months OR Itraconazole 200 mg PO bid for 1 week/month for 2 months OR Fluconazole 150–300 mg PO q week for 3–6 months
  • Toenail Treatment Options
  • Preferred regimen: Terbinafine 250 mg PO q24h (children <20 kg: 67.5 mg/day, 20–40 kg:125 mg/day, >40 kg: 250 mg/day) for 12 weeks OR Itraconazole 200 mg PO q24h for 3 months OR Itraconazole 200 mg bid for 1 week/month for 3–4 months OR Fluconazole 150–300 mg PO q week for 6–12 months
  • Preferred regimen(1): Griseofulvin 10-20 mg/kg/day for minimum 6 weeks
  • Preferred regimen(2): Itraconazole 4-6 mg/kg pulsed dose weekly
  • Preferred regimen(3): Terbinafine if <20 kg: 62.5 mg/day, if 20-40 kg: 125 mg/day, if >40 kg: 250 mg/day
  • Small, well-defined lesions
  • Larger lesionss
  • Athlete's foot
  • Interdigital
  • “Dry type”
  • Preferred regimen: Terbinafine 250 mg/day PO for 2-4 weeks OR Itraconazole 400 mg/day PO for 1 week per month (repeated if necessary) OR Fluconazole 200 mg PO weekly for 4-8 weeks
  • Preferred regimen: Ketoconazole 400 mg PO single dose OR 200 mg q24h for 7 days OR 2% cream once q24h for 2 weeks
  • Alternative regimen: Fluconazole 400 mg PO single dose OR Itraconazole 400 mg PO q24h for 3–7 days
  • Acute pulmonary histoplasmosis
  • Moderately severe or severe
  • Preferred regimen: Lipid amphotericin B (Lipid AmB) 3.0–5.0 mg/kg daily for 1–2 weeks OR Amphotericin B deoxycholate 0.7–1.0 mg/kg daily for 1–2 weeks, followed by Itraconazole 200 mg 3 times daily for 3 days and then 200 mg twice daily, for a total of 12 weeks
  • Note: Methylprednisolone 0.5–1.0 mg/kg daily IV during the first 1–2 weeks of antifungal therapy is recommended for patients who develop respiratory complications, including hypoxemia or significant respiratory distress.
  • Mild to moderate
  • Preferred regimen:
  • For symptoms of <4 weeks, none
  • For symptoms of >4 weeks, Itraconazole 200 mg PO 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks
  • Chronic cavitary pulmonary histoplasmosis
  • Preferred regimen: Itraconazole 200 mg PO 3 times daily for 3 days and then once or twice daily for at least 1 year
  • Pericarditis
  • Moderately severe to severe
  • Preferred regimen(1): Prednisone 0.5–1.0 mg/kg daily (maximum, 80 mg daily) in tapering doses over 1–2 weeks
  • Note(1): Itraconazole 200 mg PO 3 times daily for 3 days and then once or twice daily for 6–12 weeks is recommended if corticosteroids are administered
  • Note(2): Tamponade requires drainage of pericardial fluid
  • Note(3): Antifungal therapy is given to reduce possible dissemination caused by prednisone induced immunosuppression
  • Mild
  • Preferred regimen: Nonsteroidal anti-inflammatory agents
  • Rheumatologic histoplasmosis
  • severe
  • Preferred regimen: Prednisone 0.5–1.0 mg/kg daily (maximum, 80 mg daily) in tapering doses over 1–2 weeks is recommended in severe cases
  • Note: Itraconazole 200 mg 3 times daily for 3 days and then once or twice daily for 6–12 weeks is recommended if corticosteroids are administered
  • Mild
  • Preferred regimen: Nonsteroidal anti-inflammatory agents
  • Note: Corticosteroids are rarely needed
  • Mediastinal lymphadenitis
  • Mild symptoms of <4 weeks
  • Preferred regimen: None
  • Symptoms of >4 weeks
  • Preferred regimen: Itraconazole 200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks
  • Symptoms warranting treatment
  • Preferred regimen: Prednisone 0.5–1.0 mg/kg daily in tapering doses over 1–2 weeks AND Itraconazole 200 mg 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks
  • Mediastinal granuloma
  • Asymptomatic
  • Preferred regimen: None
  • Symptomatic
  • Preferred regimen: Itraconazole 200 mg PO 3 times daily for 3 days and then 200 mg once or twice daily for 6–12 weeks
  • Mediastinal fibrosis
  • Preferred regimen: The placement of intravascular stents is recommended for selected patients with pulmonary vessel obstruction
  • Note(1): Antifungal treatment is not recommended
  • Note(2): Itraconazole 200 mg PO once or twice daily for 12 weeks is recommended if clinical findings cannot differentiate mediastinal fibrosis from mediastinal granuloma
  • Broncholithiasis
  • Preferred regimen: Antifungal treatment is not recommended
  • Bronchoscopic or surgical removal of the broncholith is recommended
  • Pulmonary Nodules (Histoplasmomas)
  • Preferred regimen: Antifungal treatment is not recommended
  • Note: Must be differentiated from malignancy
  • Progressive disseminated histoplasmosis
  • Moderately severe to severe
  • Preferred regimen: Liposomal amphotericin B 3.0 mg/kg daily for 1–2 weeks, followed by Itraconazole 200 mg PO 3 times daily for 3 days and then 200 mg twice daily for a total of at least 12 months
  • Alternative regimen: Amphotericin B deoxycholate 0.7–1.0 mg/kg daily for 1–2 weeks, followed by Itraconazole 200 mg PO 3 times daily for 3 days and then 200 mg twice daily for a total of at least 12 months
  • Note: Longer treatment may be required in patients with persistent immunodeficiency
  • Mild to moderate
  • Preferred regimen: Itraconazole 200 mg PO 3 times daily for 3 days and then twice daily for at least 12 months.
  • Note: Longer treatment may be required in patients with persistent immunodeficiency.
  • CNS histoplasmosis
  • Preferred regimen: Liposomal amphotericin B 5.0 mg/kg daily for a total of 175 mg/kg given over 4–6 weeks followed by Itraconazole 200 mg PO 2 or 3 times daily for at least 12 months and until resolution of CSF abnormalities, including Histoplasma antigen levels.
  • Note: Blood levels of itraconazole should be obtained to ensure adequate drug exposure
  • Lymphocutaneous/cutaneous
  • Preferred regimen: Itraconazole 200mg PO/day
  • Alternative regimen: Itraconazole 200 mg PO bid OR Terbinafine 500 mg bid OR Saturated solution potassium iodide(SSKI) with increasing doses OR Fluconazole 400–800 mg/day OR local hyperthermia
  • Note(1): Treat for 2–4 weeks after lesions resolved
  • Note(2): SSKI initiated at a dosage of 5 drops (using a standard eyedropper) 3 times daily, increasing as tolerated to 40–50 drops 3 times daily
  • Osteoarticular
  • Preferred regimen: Itraconazole 200mg PO bid for 12 months
  • Alternative regimen: Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day OR Amphotericin B deoxycholate 0.7–1 mg/kg/day
  • Note(1): Switch to Itraconazole after favorable response if AmB used
  • Note(2): Treat for a total of at least 12 months
  • Pulmonary
  • Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day for severe or life-threatening pulmonary sporotrichosis, then Itraconazole 200 mg PO bid
  • Preferred regimen(2): Itraconazole 200 mg PO bid for 12 months for less severe disease
  • Alternative regimen: Amphotericin B deoxycholate 0.7–1 mg/kg/d, then Itraconazole 200 mg PO bid OR surgical removal
  • Note(1): Treat severe disease with an AmB formulation followed by Itraconazole
  • Note(2): Treat less severe disease with Itraconazole
  • Note(3): Treat for a total of at least 12 monthsSurgery combined with amphotericin B therapy is rec- ommended for localized pulmonary disease
  • Meningitis
  • Preferred regimen: Lipid amphotericin B (Lipid AmB) 5 mg/kg daily for 4–6 weeks, then Itraconazole 200 mg PO bid
  • Alternative regimen: Amphotericin B deoxycholate 0.7–1 mg/kg/d, then Itraconazole 200 mg PO bid
  • Note(1): Length of therapy with AmB not established, but therapy for at least 4–6 weeks is recommended.
  • Note(2): Treat for a total of at least 12 months.
  • Note(3): May require long-term suppression with Itraconazole.
  • Disseminated
  • Preferred regimen: Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day, then Itraconazole 200 mg PO bid
  • Alternative regimen: Amphotericin B deoxycholate 0.7–1 mg/kg/day, then Itraconazole 200 mg PO bid
  • Note(1): Therapy with AmB should be continued until the patient shows objective evidence of improvement.
  • Note(2): Treat for a total of at least 12 months.
  • Note(3): May require long-term suppression with Itraconazole.
  • Pregnant women
  • Preferred regimen(1): Lipid amphotericin B (Lipid AmB) 3–5 mg/kg/day OR Amphotericin B deoxycholate 0.7–1 mg/kg/day for severe sporotrichosis
  • Preferred regimen(2): Local hyperthermia for cutaneous disease.
  • Note(1): It is preferable to wait until after delivery to treat non–life-threatening forms of sporotrichosis.
  • Note(2): Azoles should be avoided.
  • Children
  • Preferred regimen:
  • Mild disease: Itraconazole 6–10 mg/kg/day (400 mg/day maximum)
  • Severe disease: Amphotericin B deoxycholate 0.7 mg/kg/day followed by Itraconazole 6–10 mg/kg up to a maximum of 400 mg PO daily, as step-down therapy
  • Alternative regimen: Saturated solution potassium iodide(SSKI) with increasing doses for mild disease initiated at a dosage of 1 drop (using a standard eyedropper) 3 times daily and increased as tolerated up to a maximum of 1 drop/kg or 40–50 drops 3 times daily, whichever is lowest

Mycobacteria

Parasites – Intestinal Protozoa

  • Preferred regimen: Metronidazole 750 mg PO tid or 1.5 g daily, for 10 days OR Trimethoprim-sulfamethoxazole One double strength tablet bid or two double strength tablets daily for 7 days OR Iodoquinol 650 mg PO tid for 20 days OR Nitazoxanide 500 mg bid for 3 days OR Paromomycin 25-35 mg/kg divided tid for 7 days
  • Note(1): Treatment of asymptomatic infections is unnecessary
  • Note(2): One double strength tablet contains 160 mg trimethoprim/800 mg sulfamethoxazole
  • Preferred regimen(1):
  • Preferred regimen(2):
  • Preferred regimen(3):
  • Adult: Nitazoxanide 500 mg bid for 3 days
  • Pediatric: Nitazoxanide Age 12-47 months: 100 mg bid for 3 days and for Age 4-11 years: 200 mg bid for 3 days
  • Preferred regimen(4):
  • Adult: Albendazole 400 mg qd for 5 days
  • Pediatric: Albendazole 15 mg/kg/day for 5-7 days (maximum, 400 mg)
  • Preferred regimen(5):
  • Preferred regimen(6):
  • Preferred regimen(7):

Parasites – Extraintestinal Protozoa

Parasites – Intestinal Nematodes (Roundworms)

Parasites – Extraintestinal Nematodes (Roundworms)

Parasites – Trematodes (Flukes)

Parasites – Cestodes (Tapeworms)

Parasites – Ectoparasites

Viruses

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. ↑ 3.0 3.1 Lua error: expandTemplate: template "citation error" does not exist.
  4. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  5. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  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. ↑ 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.
  10. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  11. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  12. ↑ 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.
  13. ↑ 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.
  14. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  15. ↑ Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.
  16. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  17. ↑ 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.
  18. ↑ 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.
  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. ↑ 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.
  22. ↑ 22.0 22.1 22.2 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.
  23. ↑ 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.
  24. ↑ Pasteur MC, Bilton D, Hill AT, British Thoracic Society Bronchiectasis non-CF Guideline Group (2010). "British Thoracic Society guideline for non-CF bronchiectasis". Thorax. 65 Suppl 1: i1–58. doi:10.1136/thx.2010.136119. PMID 20627931.
  25. ↑ 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.
  26. ↑ Lappin E, Ferguson AJ (2009). "Gram-positive toxic shock syndromes". Lancet Infect Dis. 9 (5): 281–90. doi:10.1016/S1473-3099(09)70066-0. PMID 19393958.
  27. ↑ Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG; et al. (2011). "2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons". J Am Coll Cardiol. 58 (24): e123–210. doi:10.1016/j.jacc.2011.08.009. PMID 22070836.
  28. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  29. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  30. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  31. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  32. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  33. ↑ 33.0 33.1 33.2 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.
  34. ↑ 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.
  35. ↑ 35.0 35.1 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.
  36. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  37. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  38. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  39. ↑ 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)
  40. ↑ "q fever".
  41. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  42. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  43. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  44. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  45. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  46. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  47. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  48. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  49. ↑ 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.
  50. ↑ 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.
  51. ↑ 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.
  52. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  53. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  54. ↑ LastName, FirstName (2003). Human leptospirosis guidance for diagnosis, surveillance and control. Geneva: World Health Organization. ISBN 9241545895.
  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. ↑ 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.
  58. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  59. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  60. ↑ "Chlamydial Infections".
  61. ↑ "LGV".
  62. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  63. ↑ "q fever".
  64. ↑ 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.
  65. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  66. ↑ "mycoplasma genitalium".
  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. ↑ Chapman SW, Dismukes WE, Proia LA, Bradsher RW, Pappas PG, Threlkeld MG; et al. (2008). "Clinical practice guidelines for the management of blastomycosis: 2008 update by the Infectious Diseases Society of America". Clin Infect Dis. 46 (12): 1801–12. doi:10.1086/588300. PMID 18462107.
  70. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  71. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  72. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  73. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  74. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  75. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  76. ↑ Parry WH, Martorano F, Cotton EK, Parry WH, Martorano F, Cotton EK (1976). "Management of life-threatening asthma with intravenous isoproterenol infusions". Am. J. Dis. Child. 130 (1): 39–42. PMID 2007.
  77. ↑ Kauffman, C. A.; Bustamante, B.; Chapman, S. W.; Pappas, P. G. (2007). "Clinical Practice Guidelines for the Management of Sporotrichosis: 2007 Update by the Infectious Diseases Society of America". Clinical Infectious Diseases. 45 (10): 1255–1265. doi:10.1086/522765. ISSN 1058-4838.
  78. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  79. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
  80. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  81. ↑ 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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