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  • Cytomegalovirus treatment
  • 1. Retinitis
  • In HIV-infected adults

Ganciclovir IV, Valganciclovir PO, Foscarnet IV, Cidofovir IV AND Ganciclovir intraocular implant coupled with Valganciclovir.

  • In HIV-infected infants and children

initial treatment (induction therapy): Ganciclovir IV for acquired CMV disease, including CMV retinitis and other end-organ disseminated CMV disease (e.g., colitis, esophagitis, CNS disease).

Note (1): Oral Valganciclovir, a prodrug of Ganciclovir, is one of the first-line treatments for HIV infected adults with CMV retinitis and is an option in older children who weigh enough to receive the adult dose and tablet formulation of Valganciclovir. The drug is well absorbed from the GI tract and rapidly metabolized to Ganciclovir in the intestine and liver.
Note (2): Valganciclovir oral solution has not been studied in pediatric patients for treatment of CMV retinitis, but consideration can be given to its use for transitioning from Ganciclovir IV to Valganciclovir oral to complete treatment and or for secondary prophylaxis once improvement in retinitis is noted.
  • An alternative drug for treating CMV disease or for use in Ganciclovir-resistant CMV infections in HIV infected children : Foscarnet.
Note (1): Foscarnet used as suppressive therapy has been associated with increased length of survival relative to Ganciclovir in HIV-infected adults. Doses should be modified in patients with renal insufficiency.
Note (2): Cidofovir is effective in treating CMV retinitis in adults who are intolerant of other therapies.
Note (3): Combination therapy with Ganciclovir and Foscarnet delays progression of retinitis in certain patients in whom monotherapy fails and can be used as initial therapy in children with sight-threatening disease.
Note (4): Combination therapy also has been used for adults with retinitis that has relapsed on single-agent therapy.
  • 2. In Transplant patients
Note (1): Use of Valganciclovir to prevent infections in CMV seronegative recipients who receive organs from a seropositive donor and in seropositive receivers has been highly effective.
Note (2): Others suggest preemptive treatment when pt develops CMV antigenemia or positive PCR post-transplant.
  • 3. Colitis, Esophagitis
  • Preferred regimen (1): Valganciclovir 900 mg PO q24h.
  • Preferred regimen (2): Valganciclovir 900 mg PO q12h for 14–21 days, then 900 mg PO q24h for maintenance therapy
  • Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days ,Ganciclovir as with retinitis except induction period extended for 3–6 wks (No agreement on use of maintenance; may not be necessary except after relapse. Responses less predictable than for retinitis.), then Valganciclovir 900 mg PO q24h OR Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV for 2wks, then 5 mg/kg every other wk; each dose should be administered with IV saline hydration AND oral probenecid OR repeated intravitreal injections with Fomivirsen (for relapses only, not as initial therapy)
Note (1): Diagnosis by biopsy of ulcer base or edge with demonstration of CMV inclusions and other pathogen.
Note (2): Switch to oral Valganciclovir when PO tolerated & when symptoms not severe enough to interfere with absorption.
Note (3): Antiretroviral therapy is essential in long term suppression.
  • 4. Pneumonia
  • Preferred regimen: : Valganciclovir 900 mg PO q12h for 14–21 days, then 900 mg PO q24h for maintenance therapy
  • Alternative regimen for retinitis: Ganciclovir 5 mg/kg IV q12h for 14–21 days, then Valganciclovir 900 mg PO q24h OR Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h OR Cidofovir 5 mg/kg IV for 2wks, then 5 mg/kg every other wk; each dose should be administered with IV saline hydration AND oral probenecid.
Note (1): CMV pneumonia seen predominantly in transplants (esp. bone marrow), rare in HIV.
Note (2): Treat only when histological evidence resent in IDS patients and other pathogens not identified.
Note (3): High rate of CMV reactivation in immunocompetent ICU patients; prolonged hospitalizations and increased mortality.
Note (4): In bone marrow transplant patients, combination therapy with CMV immune globulin. In bone marrow transplant patients, serial measure of pp65 antigen was useful in establishing early diagnosis of CMV interstitial pneumonia with good results if Ganciclovir was initiated within 6 days of antigen positivity.
  • 5. Encephalitis, Ventriculitis
Note: Treatment not defined, but should be considered the same as retinitis. Disease may develop while taking Ganciclovir as suppressive therapy.
  • 6. Lumbosacral polyradiculopathy
Note (1): Diagnosis by CMV DNA in CSF.
Note (2): Suppression continued until CD4 remains >100/mm3 for 6 months.
Note (3): About 50% will respond; survival increases (5.4wks to 14.6wks).
  • 7. Mononeuritis multiplex
Note (1): Due to vasculitis and may not be responsive to antiviral therapy
Note (2): Marked decrease in HIV associated CMV infections & death with Highly Active Antiretroviral Therapy. Initial treatment should optimize HAART.
Note (3): Primary prophylaxis not generally recommended. Preemptive therapy in patients with increased in CMV DNA titers in plasma and CD4 <100/mm3. Recommended by some is Valganciclovir 900 mg PO q24h.
Note (4): Risk for developing CMV disease correlates with quantity of CMV DNA in plasma is each log 10. increase associated with 3.1-fold increase in disease.
  • 8. Specific considerations
Note (1): Currently, no therapies are available for the treatment of maternal or fetal CMV infection.
Note (2): Antiviral medications such as Ganciclovir, Valganciclovir and Foscarnet are approved by the U.S. Food and Drug Administration (FDA) only for treatment of patients with acquired immunodeficiency syndrome (AIDS) or organ transplants.
  • Prevention
  • 1. Prevention of opportunistic infections in human stem cell transplantation (HSCT) by CMV (Recipient with CMV positive or Donor with CMV positive /Recipient with negative CMV)
  • Preemptive therapy: Monitor ≥1 wk (days 10-100) CMV viremia by PCR or CMV-antigenemia and start treatment if positive. Traditional approach was to use Ganciclovir 5 mg/kg IV q12h for 7-14 days, then 5 mg/kg IV q24h 5 days/wk to the longer of: d 100 or ≥3 wks.
Note (1): More recently, Valganciclovir used more often in those who can take oral medications. Continue therapy until viral load negative (preferably twice).
Note (2): One study found Valganciclovir 900 mg po bid comparable to Ganciclovir 5 mg/kg iv bid in preemptive regimen
Note (3): Valganciclovir 900 mg po bid for 2 wks, then 900 mg PO q24h for ≥7 days after negative viral assay, was effective
Note (4): Preemptive regimen of Valganciclovir 900 mg po bid×2 wks, then 450 mg po bid, was effective OR
  • Alternatively Prophylaxis approach (for high-risk pts or when CMV detection tests not rapidly available): From engraftment to day 100, ganciclovir 5 mg/kg IV q12h for 7 days, then 5 mg/kg IV q24h 5 to 6 days per week.
  • 2. Prevention of opportunistic infections in Solid organ transplant (SOT) by CMV (Recipient with CMV positive or Donor with CMV positive /Recipient with negative CMV)
  • 2.1 Kidney, Kidney/Pancreas, Heart
  • Preferred regimen: Valganciclovir 900 mg PO q24h; start by day 10 and continue to at least day 100.
  • 2.2 Liver
  • 2.3 Lung
  • Preferred regimen: Ganciclovir 5 mg/kg iv q12h for 5-7 days, then Valganciclovir 900 mg po q24h for 6 mos (or at least 3 months).
Note (1): With antiviral prophylaxis, onset of CMV is appearing later; optimal duration of prophylaxis under study.
Note (2): Valganciclovir does not have FDA indication for CMV prevention in liver or lung transplantation, but commonly used.
Note (3): In selected cases, some institutions add CMV immune globulin to antiviral drug in high risk cases. Regimen for lung, heart, liver, pancreas: 150 mg/kg within 72h of transplant and at 2, 4, 6 & 8 weeks post-transplant; then 100 mg/kg at weeks 12 & 16.
  • 3. Post treatment suppression for retinitis (prophylactic) if CD4 count <100/mm3
Note (1): Discontinue if CD4 >100/mm3 for 6 months on ART.
Note (2): Patients who discontinue suppression therapy should undergo regular eye examination for early detection of relapses.
  • Severe acute respiratory distress syndrome- coronavirus
  • Supportive therapy
Ribavirin—ineffective.
Interferon alfa with or without steroids—small case series.
Pegylated IFN-α effective in monkeys.
Low dose steroids alone successful in one Beijing hospital.
High dose steroids increases serious fungal infections.
Inhaled nitric oxide improved oxygenation and improved chest x-ray.
Note (1): Therapy remains predominantly supportive care.Therapy tried or under evaluation
Note (2):Transmission by close contact: effective infection control practices (mask [changed frequently], eye protection, gown, gloves) key to stopping transmission.
Note (3):Other coronaviruses implicated as cause of croup, asthma exacerbations and other RTIs in children.May be associated with Kawasaki disease.
  • Enterovirus treatment
  • Aseptic Meningitis
  • Preferred regimen: Immunoglobulins IV typical dose is 2 g/kg IV infused over 24hrs.
  • Alternative regimen: Pleconaril
Note (1): Pleocytosis of 100s of cells, CSF glucose normal, negative culture for bacteria
Note (2): Enterovirus is the most common cause of aseptic meningitis.
Note (3): Rapid CSF PCR test is accurate; reduces costs and hospital stay for infants.
Note (4): No treatment currently recommended; however, still under investigation.
Note (5): Hot tender parotid swelling and vesicular,ulcerative pharyingitis
  • Parvovirus B19
  • 1. Erythema infectiosum
  • Supportive therapy: Symptomatic treatment only
  • 2. Arthritis/arthalgia
  • Preferred regimen: Nonsteroidal anti-inflammatory drugs (NSAID)
  • 3.Transient aplastic crisis
  • Supportive therapy: Transfusions and oxygen
  • 4. Fetal hydrope
  • Supportive therapy: Intrauterine blood transfusion
  • 5. Chronic infection with anemia
  • Preferred regimen: IVIG and transfusion
  • 6.Chronic infection without anemia
  • Preferred regimen: IVIG
Note (1): Diagnostic tools are IgM and Igb antibody titers.Perhaps better is blood parvovirus PCR.
Note (2): Dose of IVIG not standardized; suggest 400 mg/kg IV of commercial IVIG for 5 or 10 days or 1000 mg/kg IV for 3 days.
Note (3): Most dramatic anemias in pts with pre-existing hemolytic anemia.
Note (4): Bone marrow shown erythrocyte maturation arrest with giant pronormoblasts.
  • Ebola virus treatment[1]
  • Supportive therapy
Providing intravenous fluids (IV) and balancing electrolytes (body salts).
Maintaining oxygen status and blood pressure.
Treating other infections if they occur.
Note (1): Recovery from Ebola depends on good supportive care and the patient’s immune response.
Note (2): People who recover from Ebola infection develop antibodies that last for at least 10 years, possibly longer. It is not known if people who recover are immune for life or if they can become infected with a different species of Ebola.
Note (3): Some people who have recovered from Ebola have developed long-term complications, such as joint and vision problems.
  • Hanta virus treatment[2]
  • Supportive therapy
  • ICU management should include careful assessment, monitoring and adjustment of volume status and cardiac function, including inotropic and vasopressor support if needed.
  • Fluids should be administered carefully due to the potential for capillary leakage.
  • Supplemental oxygen should be administered if patients become hypoxic.
  • Equipment and materials for intubation and mechanical ventilation should be readily available since onset of respiratory failure may be precipitous.
  • Note (1): There is no specific treatment or cure for hantavirus infection.
  • Note (2): Treatment of patients with HPS remains supportive in nature.
  • Note (3): Patients should receive appropriate, broad-spectrum antibiotic therapy while awaiting confirmation of a diagnosis of HPS. Care during the initial stages of the disease should include antipyretics and analgesia as needed.
  • Note (4): If there is a high degree of suspicion of Hantavirus pulmonary syndrome, patients should be immediately transferred to an emergency department or intensive care unit (ICU) for close monitoring and care.
  • Note (5): if the individual is experiencing fever and fatigue and has a history of potential rural rodent exposure, together with shortness of breath, would be strongly suggestive of Hantavirus pulmonary syndrome.
  • Supportive therapy
  • Hepatitis E is usually self-limiting, hospitalization is generally not required.
  • Hospitalization is required for people with fulminant hepatitis and should also be considered for symptomatic pregnant women.
Note (1): There is no available treatment capable of altering the course of acute hepatitis.
Note (2): Prevention is the most effective approach against the disease.
  • Prevention
  • The risk of infection and transmission can be reduced by
  • (1) Maintaining quality standards for public water supplies;
  • (2) Establishing proper disposal systems to eliminate sanitary waste.
  • On an individual level, infection risk can be reduced by
  • (1) Maintaining hygienic practices such as hand washing with safe water, particularly before handling food;
  • (2) Avoiding drinking water and/or ice of unknown purity;
  • (3) Adhering to WHO safe food practices-determining the mode of transmission; identifying the population specifically exposed to increased risk of infection;

eliminating a common source of infection; improving sanitary and hygienic practices to eliminate faecal contamination of food and water raising awareness, promoting partnerships and mobilizing resources;formulating evidence-based policy and data for action;preventing transmission; andexecuting screening, care and treatment.

  • Treatment of diarrhoea caused by rotavirus
* Rehydration with oral rehydration salts (ORS) solution. oral rehydration salts (ORS) solution is a mixture of clean water, salt and sugar. It costs a few cents per treatment. oral rehydration salts (ORS) solution is absorbed in the small intestine and replaces the water and electrolytes lost in the faeces.
  • Zinc supplements-with zinc supplements reduce the duration of a diarrhoea episode by 25% and are associated with a 30% reduction in stool volume.
  • Rehydration with intravenous fluids in case of severe dehydration or shock.
  • Nutrient-rich foods the vicious circle of malnutrition and diarrhoea can be broken by continuing to give nutrient-rich foods including breast milk during an episode, and by giving a nutritious diet including exclusive breastfeeding for the first six months of life to children when they are well.
  • Consulting a health professional , in particular for management of persistent diarrhoea or when there is blood in stool or if there are signs of dehydration.
Note (1): Rotavirus and Escherichia coli are the two most common etiological agents of diarrhoea in developing countries.
Note (2): There is no antiviral drug to treat rotavirus infection. Antibiotic drugs will not help because antibiotics fight against bacteria not viruses.
Note (3): Rotavirus infection can cause severe vomiting and diarrhea. This can lead to dehydration (loss of body fluids). During rotavirus infection, infants and young children, older adults, and people with other illnesses are most at risk becoming dehydrated.
Note (4): Symptoms of dehydration include decrease in urination, dry mouth and throat, feeling dizzy when standing up. A dehydrated child may also cry with few or no tears and be unusually sleepy or fussy.
  • Prevention
  • Access to safe drinking-water
  • Use of improved sanitation
  • Hand washing with soap
  • Exclusive breastfeeding for the first six months of life
  • Good personal and food hygiene
  • Health education about how infections spread; and Rotavirus vaccination.
  • Supportive therapy
  • Symptomatic treatment-Ipratropium bromide intranasal (2 sprays tid) AND Clemastine 1.34 mg 1–2 tab PO bid–tid (over the counter)
  • Symptomatic relief by Ipratropium nasal spray decreases rhinorrhea and sneezing vs placebo.[6] Clemastine (an antihistamine) decreases sneezing, rhinorrhea but associated with dry nose, mouth & throat in 6–19%.[7]Oral pleconaril given within 24 hrs of onset reduced duration (1 day) & severity of “cold symptoms” in DBPCT (p < .001).[8]:::* Note (1): No antiviral rx indicated . [9]:::* Note (2) Found in 1/2 of children with community-acquired pneumonia; role in pathogenesis unclear (CID 39:681, 2004). [10]:::* Note (3) High rate of rhinovirus identified in children with significant lower resp tract infections [11]


  • 1.1 In adults
  • Preferred regimen (1): Vancomycin 15-20 mg/kg IV q8-12h
  • Preferred regimen (2): Daptomycin 6mg/kg/dose IV qd
  • 2. Intravascular catheter-related infections[12]
  • 2.1 Methicillin susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q6h
  • Preferred regimen (2): Oxacillin 2 g IV q6h
  • Alternative regimen (1): Cefazolin 2 g IV q8h
  • Alternative regimen (2): Vancomycin 15 mg/kg IV q12h
  • 2.1.1 Pediatric dose of Nafcillin
  • 2.1.1.1 Neonates (< 4 weeks)
  • For < 1200 g: Nafcillin 50 mg/kg/day q12h
  • For ≤ 7 days of age and 1200–2000 g: Nafcillin 50 mg/kg/day q12h
  • For ≤ 7 days of age and > 2000 g: Nafcillin 75 mg/kg/day q8h
  • For > 7 days of age and 1200–2000 g: Nafcillin 75 mg/kg/day q8h
  • For > 7 days of age and > 2000 g: Nafcillin 100 mg/kg/day q6h
  • 2.1.1.2 Infants and children (> 4 weeks)
  • 2.1.2 Pediatric dose of Oxacillin
  • 2.1.2.1 Neonates (< 4 weeks)
  • For < 1200 g: Oxacillin 50 mg/kg/day q12h
  • For Postnatal age < 7 days and 1200–2000 g: Oxacillin 50–100 mg/kg/day q12h
  • For Postnatal age < 7 days and > 2000 g: Oxacillin 75–150 mg/kg/day q8h
  • For Postnatal age ≥ 7 days and 1200–2000 g: Oxacillin 75–150 mg/kg/day q8h
  • For Postnatal age ≥ 7 days and > 2000 g: Oxacillin 100–200 mg/kg/day q6h
  • 2.1.2.2 Infants and children(> 4weeks)
  • 2.1.3 Pediatric dose of Cefazolin
  • 2.1.3.1 Neonates (< 4 weeks)
  • Postnatal age ≤ 7 days: Cefazolin 40 mg/kg/day q12h
  • Postnatal age > 7 days and ≤ 2000 g: Cefazolin 40 mg/kg/day q12h
  • Postnatal age > 7 days and > 2000 g: Cefazolin 60 mg/kg/day q8h
  • 2.1.3.2 Infants and children (> 4 weeks)
  • 2.1.4 Pediatric dose of Vancomycin
  • 2.1.4.1 Neonates (< 4 weeks)
  • Postnatal age ≤ 7 days and < 1200 g: Vancomycin 15 mg/kg/day q24h.
  • Postnatal age ≤ 7 days and 1200–2000 g: Vancomycin 10–15 mg/kg q12–18h.
  • Postnatal age ≤ 7 days and > 2000 g: Vancomycin 10–15 mg/kg q8–12h.
  • Postnatal age > 7 days and < 1200 g: Vancomycin 15 mg/kg/day q24h.
  • Postnatal age > 7 days and 1200–2000 g: Vancomycin 10–15 mg/kg q8–12h.
  • Postnatal age > 7 days and > 2000 g: Vancomycin 15–20 mg/kg q8h.
  • 2.1.4.2 Infants and children (> 4 weeks)
  • 2.2 Methicillin resistant Staphylococcus aureus (MRSA)
  • 2.2.1 Pediatric dose of Linezolid
  • 2.2.1.1 Neonates (< 4 weeks)
  • For < 1200 g: Linezolid 10 mg/kg q8–12h (note: q12h in patients < 34 weeks gestation and < 1 week of age).
  • For < 7 days of age and ≥ 1200 g: Linezolid 10 mg/kg q8–12h (note: q12h in patients < 34 weeks gestation and < 1 week of age).
  • For ≥ 7 days and ≥ 1200 g: Linezolid 10 mg/kg q8h
  • 2.2.1.2 Infants and children < 12 years (> 4 weeks)
  • 2.2.1.3 Children ≥ 12 years and adolescents
  • 2.2.2 Pediatric dose of Gentamycin
  • 2.2.2.1 Neonates (< 4 weeks)
  • Premature neonates and < 1000 g: Gentamycin 3.5 mg/kg q24h
  • < 1200 g: Gentamycin 2.5 mg/kg q18-24h.
  • Postnatal age ≤ 7 days: Gentamycin 2.5 mg/kg q12h.
  • Postnatal age > 7 days and 1200–2000 g: Gentamycin 2.5 mg/kg q8-12h.
  • Postnatal age > 7 days and > 1200 g: Gentamycin 2.5 mg/kg q8h.
  • Premature neonates with normal renal function: Gentamycin 3.5–4 mg/kg q24h.
  • Term neonates with normal renal function: Gentamycin 3.5–5 mg/kg q24h.
  • 2.2.2.2 Infants and children < 5 years (> 4 weeks)
  • Gentamycin 2.5 mg/kg q8h; qd dosing in patients with normal renal function, Gentamycin 5–7.5 mg/kg q24h.
  • 2.2.2.3 Children ≥ 5 years
  • 2.2.3 Pediatric dose of Trimethoprim-Sulfamethoxazole
  • 2.2.3.1 Infants > 2 months of age and children of mild-to-moderate infections
3.1 Purulent cellulitis (defined as cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess)
  • 3.1.1 In adults
  • 3.1.2 In children
  • Preferred regimen (1): Clindamycin 10–13 mg/kg PO q6–8h, not to exceed 40 mg/kg/day
  • Preferred regimen (2): Trimethoprim 4–6 mg/kg, Sulfamethoxazole 20–30 mg/kg PO q12h
  • Preferred regimen (3)
  • 3.1 If patient body weight < 45kg then Doxycycline 2 mg/kg PO q12h
  • 3.2 If patient body weight 45kg then Doxycycline adult dose
  • Preferred regimen (4): Minocycline 4 mg/kg PO 200 mg as a single dose, THEN Minocycline 2 mg/kg PO q12h
  • Preferred regimen (5): Linezolid 10 mg/kg PO q8h, (max: 600 mg)
  • 3.2 Nonpurulent cellulitis (defined as cellulitis with no purulent drainage or exudate and no associated abscess)
  • 3.2.1 In adults
  • Preferred regimen (1): Beta-lactam (eg, Cephalexin and Dicloxacillin) 500 mg PO qid
  • Preferred regimen (2): Clindamycin 300–450 mg PO tid
  • Preferred regimen (3): Amoxicillin 500 PO mg tid
  • Preferred regimen (4): Linezolid 600 mg PO bid
  • Note (1): Empirical therapy for beta-hemolytic streptococci is recommended. Empirical coverage for CA-MRSA is recommended in patients who do not respond to beta-lactam therapy and may be considered in those with systemic toxicity.
  • Note (2): Provide coverage for both beta-hemolytic streptococci and CA-MRSA beta-lactam (eg, Amoxicillin) with or without Trimethoprim-Sulfamethoxazole or a Tetracycline
  • 3.2.2 In children
  • Preferred regimen (1): Clindamycin 10–13 mg/kg PO q6–8h, not to exceed 40 mg/kg/day
  • Preferred regimen (2): Trimethoprim 4–6 mg/kg, Sulfamethoxazole 20–30 mg/kg PO q12h
  • Preferred regimen (3): Linezolid 10 mg/kg PO q8h, not to exceed 600 mg
  • Note (1): Clindamycin causes Clostridium difficile–associated disease may occur more frequently, compared with other oral agents.
  • Note (2): Trimethoprim-Sulfamethoxazole not recommended for women in the third trimester of pregnancy and for children ,2 months of age.
  • Note (3): Tetracyclines are not recommended for children under 8 years of age and are pregnancy category D.
  • 4.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 4.1.1 In adults
  • 4.1.2 In children
  • Preferred regimen (1): Vancomycin15 mg/kg/dose IV q6h
  • Preferred regimen (2): Linezolid 10 mg/kg/dose PO/IV q8h
  • Note: Consider the addition of Rifampin 600 mg qd OR 300–450 mg bid to Vancomycin.
  • 4.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4h
  • Preferred regimen (2): Oxacillin 2 g IV q4h
  • Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h
  • 5. Cerebrospinal fluid shunt infection[17][18]
  • 5.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h with or without Rifampin 600 mg IV or PO q24h
  • Note: Shunt removal is recommended, and it should not be replaced until cerebrospinal fluid cultures are repeatedly negative.
  • 5.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4h with or without Rifampin 600 mg IV/PO q24h
  • Preferred regimen (2): Oxacillin 2 g IV q4h
  • 6.1 Penicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen: Penicillin G 4 MU IV q4h for 2–4 weeks, THEN PO to complete 6–8 weeks
  • 6.2 Methicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen (1): Cefazolin 2 g IV q8h for 2–4 weeks, THEN PO to complete 6–8 weeks
  • Preferred regimen (2): Nafcillin 2 g IV q4h for 2–4 weeks, THEN PO to complete 6–8 weeks
  • Preferred regimen (3): Oxacillin 2 g IV q4h for 2–4 weeks, THEN PO to complete 6–8 weeks
  • Alternative regimen: Clindamycin 600 mg IV q6h for 2–4 weeks, THEN PO to complete 6–8 weeks
  • 6.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 6.3.1 In adults
  • Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV THEN Vancomycin 15–20 mg/kg IV q8–12h for 2–4 weeks, THEN PO to complete 6–8 weeks
  • Alternative regimen (1): Linezolid 600 mg PO/IV q12h for 4–6 weeks
  • Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO/IV q8–12h for 4–6 weeks
  • 6.3.2 Pediatric dose
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
  • Preferred regimen (2): Linezolid 10 mg/kg PO/IV q8h
  • Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin in adult patients.
  • 7. Bacterial meningitis
  • 7.1 Methicillin susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 9–12 g/day IV q4h
  • Preferred regimen (2): Oxacillin 9–12 g/day IV q4h
  • Alternative regimen (1): Vancomycin 30–45 mg/kg/day IV q8–12h
  • Alternative regimen (2): Meropenem 6 g/day IV q8h
  • 7.2 Methicillin resistant Staphylococcus aureus (MRSA)
  • 8. Septic thrombosis of cavernous or dural venous sinus[23]
  • 8.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 8.1.1 In adults
  • 8.1.2 Pediatric dose
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
  • Preferred regimen (2): Linezolid 10 mg/kg PO/IV q8h
  • Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible.
  • Note (2): Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin.
  • 9. Subdural empyema
  • 9.1 Methicillin-resistant Staphylococcus aureus (MRSA)[24]
  • 9.1.1 In adults
  • 9.1.2 In children
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
  • Preferred regimen (2): Linezolid 10 mg/kg PO/IV q8h
  • Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin.
  • 10. Acute conjunctivitis[25]
  • 10.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 11. Appendicitis
  • 11.1 Health care–associated complicated intra-abdominal infection[26]
  • 11.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • 12. Diverticulitis
  • 12.1 Health care–associated complicated intra-abdominal infection[26]
  • 12.1.1 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
  • 13.1 Health care–associated complicated intra-abdominal infection[26]
  • 13.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • 14. Cystic fibrosis[27]
  • 14.1 Adults
  • 14.1.1 If methicillin sensitive staphylococcus aureus
  • 14.1.2 If methicillin resistant staphylococcus aureus
  • Preferred Regimen (1): Vancomycin 15-20 mg/kg IV q8-12h
  • Preferred Regimen (2): Linezolid 600 mg PO/IV q12h
  • 14.2 Pediatric
  • 14.2.1 If methicillin sensitive staphylococcus aureus
  • Preferred Regimen (1): Nafcillin 5 mg/kg q6h (Age >28 days)
  • Preferred Regimen (2): Oxacillin 75 mg/kg q6h (Age >28 days)
  • 14.2.2 If methicillin resistant staphylococcus aureus
  • Preferred Regimen (1): Vancomycin 40 mg/kg q6-8h (Age >28 days)
  • Preferred Regimen (2): Linezolid 10 mg/kg PO/IV q8h (up to age 12)
  • 15. Bronchiectasis[28]
  • 15.1 In adults
  • 15.1.1 Recommended first-line treatment and length of treatment
  • 15.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.1.1.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Patient's body weight is < 50 kg
  • Patient's body weight is > 50 kg
  • 15.1.1.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen (1): Vancomycin 1 g IV bd (monitor serum levels and adjust dose accordingly)
  • Preferred regimen (2): Teicoplanin 400 mg qd for 14 days
  • 15.1.2 Recommended second-line treatment and length of treatment
  • 15.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.1.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Patient's body weight is < 50 kg
  • Patient's body weight is > 50 kg
  • 15.1.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Linezolid 600 mg IV bd for 14 days
  • 15.2 In children
  • 15.2.1 Recommended first-line treatment and length of treatment
  • 15.2.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.2.1.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 15.2.1.2.1 Children (< 12 yr)
  • 15.2.1.2.2 Children (> 12 yr)
  • 15.2.1.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen (1): Vancomycin 45-60 mg/kg/day IV q8-12h
  • Preferred regimen (2): Teicoplanin 400 mg qd for 14 days
  • 15.2.2 Recommended second-line treatment and length of treatment
  • 15.2.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.2.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 15.2.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Linezolid 10 mg/kg PO/IV q12h
  • 15.3 Long-term oral antibiotic treatment
  • 15.3.1 In adults
  • 15.3.1.1 Recommended first-line treatment and length of treatment
  • 15.3.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 15.3.1.2 Recommended second-line treatment and length of treatment
  • 15.3.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 gm IV q4h
  • Preferred regimen (2): oxacillin 2 gm IV q4h (if MSSA)
  • Alternative regimen (1): Vancomycin 1 gm IV q12h
  • Alternative regimen (2): Linezolid 600 mg PO bid (if MRSA)
  • 17. Community-acquired pneumonia[30]
  • 17.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 17.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred Regimen (1): Vancomycin 45-60 mg/kg/day q8-12h (max: 2000 mg/dose) for 7-21 days
  • Preferred Regimen (2): Linezolid 600 mg PO/IV q12h for 10-14 days
  • Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h
  • 18. Olecranon bursitis or prepatellar bursitis
  • 18.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 18.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen (1): Vancomycin 1 g IV q12h
  • Preferred regimen (2): Linezolid 600 mg PO qd
  • Note: Initially aspirate q24h and treat for a minimum of 2–3 weeks.
  • 19. Septic arthritis
  • 19.1 In adults
  • 19.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • Alternative regimen (1): Daptomycin 6 mg/kg IV q24h in adults
  • Alternative regimen (2): Linezolid 600 mg PO/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
  • 19.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q6h
  • Preferred regimen (2): Clindamycin 900 mg IV q8h
  • Alternative regimen (1): Cefazolin 0.25–1 g IV/IM q6–8h
  • Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h
  • 19.2 In childern
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h
  • Preferred regimen (2): Daptomycin 6–10 mg/kg IV q24h
  • Preferred regimen (3): Linezolid 10 mg/kg PO/IV q8h
  • Preferred regimen (4): Clindamycin 10–13 mg/kg PO/IV q6–8h
  • 20. Septic arthritis, prosthetic joint infection (device-related osteoarticular infections)
  • 20.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4–6h
  • Preferred regimen (2): Oxacillin 2 g IV q4–6h
  • Alternative regimen (1): Cefazolin 1–2 g IV q8h
  • Alternative regimen (2): Ceftriaxone 2 g IV q24h
  • Alternative regimen (if allergic to penicillins) (3): Clindamycin 900 mg IV q8h
  • Alternative regimen (if allergic to penicillins) (4): Vancomycin 15–20 mg/kg IV q8–12h, (max: 2 g per dose)
  • 20.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Early-onset (2 months after surgery) or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)
  • Preferred regimen: Vancomycin AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
  • Alternative regimen (1): Daptomycin 6 mg/kg IV q24h AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
  • Alternative regimen (2): Linezolid 600 IV q8h AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
  • Note: The above regimen should be followed by Rifampin and a Fluoroquinolone, TMP/SMX, a Tetracycline or Clindamycin for 3-6 months for hips and knees, respectively.
  • 21. Hematogenous osteomyelitis
  • 21.1 Adult (> 21 yrs)
  • 21.1.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • Preferred regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
  • 21.1.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • 21.2 Children (> 4 months)-Adult
  • 21.2.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • 21.2.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • Preferred regimen (1): Nafcillin
  • Preferred regimen (2): Oxacillin q6h (max. 8–12 gm per day)
  • Note: Add Ceftazidime 50 mg q8h or Cefepime 150 mg q8h if Gram negative bacilli on Gram stain
  • 21.3 Newborn (< 4 months.)
  • 21.3.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • 21.3.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • 21.4 Specific therapy
  • 21.4.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin
  • Preferred regimen (2): Oxacillin 2 gm IV q4h
  • Preferred regimen (3): Cefazolin 2 gm IV q8h
  • Alternative regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
  • 21.4.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 22. Diabetic foot osteomyelitis
  • High risk for MRSA
  • Preferred regimen (1): Linezolid 600 mg IV or PO q12h
  • Preferred regimen (2): Daptomycin 4 mg/kg IV q24h
  • Preferred regimen (3): Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
  • 23. Necrotizing fasciitis[31]
  • 23.1 In adult
  • 23.2 In childern
  • 24. Staphylococcal toxic shock syndrome[32]
  • 24.1 Methicillin sensitive Staphylococcus aureus
  • Preferred regimen (1): Cloxacillin 250-500 mg PO q6h (max dose: 4 g/24 hr)
  • Preferred regimen (2): Nafcillin 4-12 g/24 hr IV q4-6hr (max dose: 12 g/24 hr)
  • Preferred regimen (3): Cefazolin 0.5-2g IV/IM q8h (max dose: 12 g/24 hr) AND Clindamycin 150-600 mg IV, IM/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/PO q6-8h (max dose: 5 g/24 hr IV/IM or 2 g/24h PO)
  • Alternative regimen (2): Rifampicin AND Linezolid 600 mg IV/PO q12h
  • Alternative regimen (3): Daptomycin
  • Alternative regimen (4): Tigecycline 100 mg loading dose THEN 50 mg IV q12h
  • 24.2 Methicillin resistant Staphylococcus aureus
  • Preferred regimen (1): Clindamycin 150-600 mg IV, IM/PO q6-8h (max dose: 5 g/24h IV/IM or 2 g/24h PO)
  • Preferred regimen (2): Linezolid 600 mg IV/PO q12h AND Vancomycin 15-20 mg/kg IV q8-12h, (max: 2 g per dose)
  • Preferred regimen (3): Teicoplanin
  • Alternative regimen (1): Rifampicin AND Linezolid 600 mg IV/PO q12h
  • Alternative regimen (2): Daptomycin
  • Alternative regimen (3): Tigecycline 100 mg loading dose THEN 50 mg IV q12h
  • 24.3 Glycopeptide resistant or intermediate Staphylococcus aureus
  • Preferred regimen: Linezolid 600 mg IV/PO q12h AND Clindamycin 150-600 mg IV, IM/PO q6-8h (max dose: 5 g/24 hr IV/IM or 2 g/24h PO) (if sensitive)
  • Alternative regimen (1): Daptomycin
  • Alternative regimen (2): Tigecycline 100 mg loading dose THEN 50 mg IV q12h
  • Staphylococcus aureus ,prophylaxis
  • 1. Prophylaxis for coronary artery bypass graft-associated acute mediastinitis[33]
  • 1.1 Methicillin susceptible staphylococcus aureus (MSSA)
  • Preferred regimen: A first- or second-generation Cephalosporin is recommended for prophylaxis in patients without MRSA colonization.
  • 1.2 Methicillin resistant staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin alone or in combination with other antibiotics to achieve broader coverage is recommended for prophylaxis in patients with proven or suspected MRSA 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. Infectious endocarditis
  • 1.1 In adults
  • Preferred regimen (1): Vancomycin 15-20 mg/kg IV q8-12h
  • Preferred regimen (2): Daptomycin 6mg/kg/dose IV qd
  • 2. Intravascular catheter-related infections[12]
  • 2.1 Methicillin susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q6h ::::* Preferred regimen (2): Oxacillin 2 g IV q6h.
  • Alternative regimen (1): Cefazolin 2 g IV q8h ::::* Alternative regimen (2): Vancomycin 15 mg/kg IV q12h.
  • 2.1.1 Pediatric dose
  • 2.1.1.1.1 Neonates
  • 0–4 weeks of age and 1200 g- 50 mg/kg/day q12h.
  • ≤7 days and 1200–2000 g- 50 mg/kg/day q12h.
  • >7 days of age and <2000g- 75 mg/kg/day q8h.
  • >7 days of age and >1200 g - 100 mg/kg/day q6h.
  • 2.1.1.1.2 Infants and children is Nafcillin 100–200 mg/kg/day q4–6h.
  • 2.1.1.2.1 Neonates
  • 0–4 weeks of age and 1200 g is 50 mg/kg/day q12h.
  • Postnatal age <7 days and 1200–2000 g is 50–100 mg/kg/day q12h.
  • Postnatal age <7 days and >2000 g is 75–150 mg/kg/day q8h.
  • Postnatal age ≥7 days and 1200–2000 g is 75–150 mg/kg/day q8h.
  • Postnatal age ≥7 days and >2000 g is 100–200 mg/kg/day q6h.
  • 2.1.1.3.1 Neonates
  • Postnatal age ≤7 days is 40 mg/kg/day q12h.
  • Postnatal age >7 days and 2000 g is 40 mg/kg/day q12h.
  • Postnatal age >7 days and 12000 g is 60 mg/kg/day q8h.
  • 2.1.1.3.2 Infants and children is 50 mg/kg/day q8h.
  • 2.1.1.4.1 Neonates
  • Postnatal age ≤7 days and <1200 g is 15 mg/kg/day q24h.
  • Postnatal age ≤7 days and 1200–2000 g is 10–15 mg/kg q12–18h.
  • Postnatal age ≤7 days and >2000 g is 10–15 mg/kg q8–12h.
  • Postnatal age >7 days and <1200 g is 15 mg/kg/day q24h.
  • Postnatal age >7 days and 1200–2000 g is 10–15 mg/kg q8–12h.
  • Postnatal age >7 days and >2000 g is 15–20 mg/kg q8h.
  • 2.1.1.4.2 Infants and children is 40 mg/kg/day q6–8h.
  • 2.2 Methicillin resistant Staphylococcus aureus (MRSA)
  • 2.2.1 Pediatric dose
  • 2.2.1.1.1 Neonates
  • 0–4 weeks of age and birthweight <1200 g is 10 mg/kg q8–12h (note: q12h in patients <34 weeks gestation and <1 week of age).
  • <7 days of age and birthweight >1200 g is 10 mg/kg q8–12h (note: q12h in patients <34 weeks gestation and <1 week of age).
  • 7 days and birthweight >1200 g is 10 mg/kg q8h.
  • 2.2.1.1.2 Infants and children <12 years of age is 10 mg/kg q8h Children 12 years of age and adolescents: 10 mg/kg q12h.
  • 2.2.1.2.1 Neonates
  • Premature neonates and <1000 g is 3.5 mg/kg q24h; 0–4 weeks and <1200 g is 2.5 mg/kg q18-24h.
  • Postnatal age 7 days is 2.5 mg/kg q12h.
  • Postnatal age 17 days and 1200–2000 g is 2.5 mg/kg q8-12h.
  • Postnatal age 17 days and 12000 g is 2.5 mg/kg q8h.
  • Premature neonates with normal renal function is 3.5–4 mg/kg q24h.::::::::* Term neonates with normal renal function is 3.5–5 mg/kg q24h.
  • 2.2.1.2.2 Infants and children <5 years of age is 2.5 mg/kg q8h; qd dosing in patients with normal renal function, 5–7.5 mg/kg q24h.
  • 2.2.1.2.3 Children >5 years of age is 2–2.5 mg/kg q8h; qd with normal renal function, 5–7.5 mg/kg q24h.
  • 2.2.1.3.1 Infants 12 months of age and children of mild-to-moderate infections is 6–12 mg TMP/kg/day q12h; serious infection, 15–20 mg TMP/kg/day q6-8h.
  • 3. Cellulitis
3.1 Purulent cellulitis (defined as cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess)
  • 3.1.1 In adults
  • 3.1.2 In children
  • Preferred regimen (1): Clindamycin 10–13 mg/kg PO q6–8h, not to exceed 40 mg/kg/day ::::* Preferred regimen (2): Trimethoprim 4–6 mg/kg, Sulfamethoxazole 20–30 mg/kg PO q12h  ::::* Preferred regimen (3):::::* 3.1 If patient body weight <45kg then Doxycycline 2 mg/kg PO q12h:::::* 3.2 If patient body weight 45kg then Doxycycline adult dose  ::::* Preferred regimen (4): Minocycline 4 mg/kg PO 200 mg as a single dose, then 2 mg/kg PO q12h  ::::* Preferred regimen (5): Linezolid 10 mg/kg PO q8h, not to exceed 600 mg
  • 3.2 Nonpurulent cellulitis (defined as cellulitis with no purulent drainage or exudate and no associated abscess)
  • 3.2.1 In adults
Note (1): Empirical therapy for beta-hemolytic streptococci is recommended. Empirical coverage for CA-MRSA is recommended in patients who do not respond to beta-lactam therapy and may be considered in those with systemic toxicity.
Note (2): Provide coverage for both beta-hemolytic streptococci and CA-MRSA beta-lactam (eg, Amoxicillin) with or without Trimethoprim-Sulfamethoxazole or a Tetracycline
  • 3.2.2 In children
  • Preferred regimen (1): Clindamycin 10–13 mg/kg PO q6–8h, not to exceed 40 mg/kg/day  ::::* Preferred regimen (2): Trimethoprim 4–6 mg/kg, Sulfamethoxazole 20–30 mg/kg PO q12h  ::::* Preferred regimen (3): Linezolid 10 mg/kg PO q8h, not to exceed 600 mg
Note (1): Clindamycin causes Clostridium difficile–associated disease may occur more frequently, compared with other oral agents.
Note (2): Trimethoprim-Sulfamethoxazole not recommended for women in the third trimester of pregnancy and for children ,2 months of age.
Note (3): Tetracyclines are not recommended for children under 8 years of age and are pregnancy category D.
  • 4.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 4.1.1 In adults:::::* Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
  • 4.1.2 In children
  • Preferred regimen (1): Vancomycin15 mg/kg/dose IV q6h :::::* Preferred regimen (2): Linezolid 10 mg/kg/dose PO/IV q8h
Note: Consider the addition of Rifampin 600 mg qd OR 300–450 mg bid to Vancomycin.
  • 4.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4h  ::::* Preferred regimen (2): Oxacillin 2 g IV q4h
  • Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h
  • 5. Cerebrospinal fluid shunt infection [37][38]
  • 5.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h with or without Rifampin 600 mg IV or PO q24h
Note: Shunt removal is recommended, and it should not be replaced until cerebrospinal fluid cultures are repeatedly negative.
  • 5.2 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4h with or without Rifampin 600 mg IV/PO q24h:::* Preferred regimen (2): Oxacillin 2 g IV q4h
  • 6.1 Penicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen: Penicillin G 4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • 6.2 Methicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen (1): Cefazolin 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks  ::::* Preferred regimen (2): Nafcillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks ::::* Preferred regimen (3): Oxacillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • Alternative regimen: Clindamycin 600 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks
  • 6.3 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 6.3.1 In adults
  • Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks
  • 6.3.2 Pediatric dose
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h ::::* Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin in adult patients.
  • 7. Bacterial meningitis
  • 7.1 Methicillin susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 9–12 g/day IV q4h :::* Preferred regimen (2): Oxacillin 9–12 g/day IV q4h
  • Alternative regimen (1): Vancomycin 30–45 mg/kg/day IV q8–12h:::* Alternative regimen (2): Meropenem 6 g/day IV q8h
  • 7.2 Methicillin resistant Staphylococcus aureus (MRSA)
Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin in adult patients.
  • 8. Septic thrombosis of cavernous or dural venous sinus[43]
  • 8.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 8.1.1 In adults
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h for 4–6 weeks
  • Alternative regimen (1): Linezolid 600 mg PO or IV q12h for 4–6 weeks  :::::* Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg/dose PO or IV q8–12h for 4–6 weeks
  • 8.1.2 Pediatric dose
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h ::::* Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
Note (1): Surgical evaluation for incision and drainage of contiguous sites of infection or abscess is recommended whenever possible.
Note (2): Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin.
  • 9. Subdural empyema
  • 9.1 Methicillin-resistant Staphylococcus aureus (MRSA)[44]
  • 9.1.1 In adults
  • Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h for 4–6 weeks
  • Alternative regimen (1): Linezolid 600 mg PO or IV q12h for 4–6 weeks ::::* Alternative regimen (2): Trimethoprim-Sulfamethoxazole 5 mg/kg PO or IV q8–12h for 4–6 weeks
  • 9.1.2 In children
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h ::::* Preferred regimen (2): Linezolid 10 mg/kg PO or IV q8h
Note: Consider the addition of Rifampin 600 mg qd or 300–450 mg bid to Vancomycin.
  • 10. Acute conjunctivitis [45]
  • 10.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • 11. Appendicitis
11.1 Health Care–Associated Complicated Intra-abdominal Infection [26]
11.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • 12. Diverticulitis
12.1 Health Care–Associated Complicated Intra-abdominal Infection [26]
12.1.1Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h.
  • 13. Peritonitis secondary to bowel perforation, peritonitis secondary to ruptured appendix, peritonitis secondary to ruptured appendix, typhlitis
13.1 Health Care–Associated Complicated Intra-abdominal Infection [26]
  • 13.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • 14. Cystic fibrosis [27]
  • 14.1 Adults
  • 14.1.1 If methicillin sensitive staphylococcus aureus:::::* Preferred Regimen (1): Nafcillin 2 gm IV q4h:::::* Preferred Regimen (2): Oxacillin 2 gm IV q4h
  • 14.1.2 If methicillin resistant staphylococcus aureus:::::* Preferred Regimen (1): Vancomycin 15-20 mg/kg IV q8-12h  :::::* Preferred Regimen (2): Linezolid 600 mg PO or IV q12h
  • 14.2 Pediatric
  • 14.2.1 If methicillin sensitive staphylococcus aureus:::::* Preferred Regimen (1): Nafcillin 5 mg/kg q6h (Age >28 days) :::::* Preferred Regimen (2): Oxacillin 75 mg/kg q6h (Age >28 days)
  • 14.2.2 If methicillin resistant staphylococcus aureus:::::* Preferred Regimen (1): Vancomycin 40 mg/kg q6-8h (Age >28 days) :::::* Preferred Regimen (2): Linezolid 10 mg/kg PO or IV q8h (up to age 12)
  • 15. Bronchiectasis [28]
  • 15.1 In adults
  • 15.1.1 Recommended first-line treatment and length of treatment
15.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)::::::* Preferred regimen: Flucloxacillin 500 mg oral qds for 14 days
  • 15.1.1.2 Methicillin-resistant Staphylococcus aureus (MRSA):::::* Patient's body weight is <50 kg::::::* Preferred regimen: Rifampicin 450 mg PO qd AND Trimethoprim 200 mg PO bd for 14 days :::::* Patient's body weight is >50 kg::::::* Preferred regimen: Rifampicin 600 mg PO qdAND Trimethoprim 200 mg PO bd for 14 days
  • 15.1.1.3 Methicillin-resistant Staphylococcus aureus (MRSA):::::* Preferred regimen (1): Vancomycin 1 g IV bd (monitor serum levels and adjust dose accordingly) :::::* Preferred regimen (2): Teicoplanin 400 mg qd for 14 days
  • 15.1.2 Recommended second-line treatment and length of treatment
  • 15.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)::::::* Preferred regimen: Clarithromycin 500 mg oral bd 14 days
  • 15.1.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)::::::* Patient's body weight is <50 kg: :::::::* Preferred regimen: Rifampicin 450 mg PO qd AND Doxycycline 200 mg PO qd 14 days, ::::::* Patient's body weight is >50 kg: :::::::* Preferred regimen: Rifampicin 600 mg PO AND Doxycycline 200 mg PO qd 14 days. ::::::* Third-line is Linezolid 600 mg bd 14 days:::::* 15.1.2.3 Methicillin-resistant Staphylococcus aureus (MRSA): Linezolid 600 mg IV bd 14 days
  • 15.2 In children
  • 15.2.1 Recommended first-line treatment and length of treatment
  • 15.2.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA)::::::* Preferred regimen: Flucloxacillin
  • 15.2.1.2 Methicillin-resistant Staphylococcus aureus (MRSA)::::::* 15.2.1.2.1 Children (< 12 yr):::::::* Preferred regimen: Trimethoprim 4-6 mg/kg/day divided q12h PO ::::::* 15.2.1.2.2 Children (> 12 yr) : :::::::* Preferred regimen (1): Trimethoprim 100-200 mg q12hr PO. :::::::* Preferred regimen (2): Rifampicin 450 mg PO od  : Rifampicin 600 mg PO od AND :::::* 15.2.1.3 Methicillin-resistant Staphylococcus aureus (MRSA) ::::::* Preferred regimen (1): Vancomycin 45-60 mg/kg/day divided q8-12h IV  ::::::* Preferred regimen (2): Teicoplanin
  • 15.2.2 Recommended second-line treatment and length of treatment
  • 15.2.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)::::::* Preferred regimen: Clarithromycin 15 mg/kg/24 hr divided q12h PO
15.2.2.2 Methicillin-resistant Staphylococcus aureus (MRSA)::::::* Preferred regimen (1): Rifampicin AND Doxycycline 2-5 mg/kg/day divided q12-24h PO or IV (max dose: 200 mg/24 hr) ;  ::::::* Preferred regimen (2): Rifampicin AND Doxycycline 2-5 mg/kg/day divided q12-24h PO or IV (max dose: 200 mg/24 hr) . ::::::* Third-line: Linezolid 10 mg/kg q12h IV or PO
  • 15.2.2.3 Methicillin-resistant Staphylococcus aureus (MRSA)::::::* Preferred regimen: Linezolid 10 mg/kg q12h IV or PO
  • 15.3 Long-term oral antibiotic treatment
  • 15.3.1 In adults
  • 15.3.1.1 Recommended first-line treatment and length of treatment
  • 15.3.1.1.1 Methicillin-susceptible Staphylococcus aureus (MSSA):::::::* Preferred regimen: Flucloxacillin 500 mg PO bd
  • 15.3.1.2 Recommended second-line treatment and length of treatment
  • 15.3.1.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA):::::::* Preferred regimen: Clarithromycin 250 mg PO bd
  • 17. Community-acquired pneumonia[30]
  • 17.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred Regimen (1): Nafcillin 1000-2000 mg q4h  ::::* Preferred Regimen (2): Oxacillin 2 g IV q4h  ::::* Preferred Regimen (3): Flucloxacillin 250 mg IM/IV q6h
  • Alternative Regimen (1): Cefazolin 500 mg IV q12h  ::::* Alternative Regimen (2): Clindamycin 150-450 mg PO q6-8h
  • 17.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred Regimen (1): Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR ::::* Preferred Regimen (2): Linezolid 600 mg PO/IV q12h for 10-14 days::::* Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h
  • 18. Olecranon bursitis or prepatellar bursitis
  • 18.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • 18.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen (1): Vancomycin 1 g IV q12h ::::* Preferred regimen (2): Linezolid 600 mg PO qd
Note: Initially aspirate q24h and treat for a minimum of 2–3 weeks.
  • 19. Septic arthritis
  • 19.1 In adults
  • 19.1.1 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h
  • Alternative regimen (1): Daptomycin 6 mg/kg IV q24h in adults
  • Alternative regimen (2): Linezolid 600 mg PO or IV q12h
  • Alternative regimen (3): Clindamycin 600 mg PO or IV q8h
  • Alternative regimen (4): TMP-SMX 3.5–4.0 mg/kg PO or IV q8–12h
  • 19.2 In childern
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q6h ::::* Preferred regimen (2): Daptomycin 6–10 mg/kg IV q24h ::::* Preferred regimen (3): Linezolid 10 mg/kg PO or IV q8h ::::* Preferred regimen (4): Clindamycin 10–13 mg/kg PO or IV q6–8h
  • 19.2.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q6h ::::* Preferred regimen (2): Clindamycin 900 mg IV q8h
  • Alternative regimen (1): Cefazolin 0.25–1 g IV/IM q6–8h ::::* Alternative regimen (2): Vancomycin 500 mg IV q6h or 1 g IV q12h
  • 20. Septic arthritis, prosthetic joint infection (device-related osteoarticular infections)
  • 20.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin 2 g IV q4–6h ::::* Preferred regimen (2): Oxacillin 2 g IV q4–6h
  • Alternative regimen (1): Cefazolin 1–2 g IV q8h  ::::* Alternative regimen (2): Ceftriaxone 2 g IV q24h
  • Alternative regimen (if allergic to penicillins) (3): Clindamycin 900 mg IV q8h ::::* Alternative regimen (if allergic to penicillins) (4): Vancomycin 15–20 mg/kg IV q8–12h, not to exceed 2 g per dose
  • 20.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Early-onset (2 months after surgery) or acute hematogenous prosthetic joint infections involving a stable implant with short duration (< 3 weeks) of symptoms and debridement (but device retention)
  • Preferred regimen: Vancomycin AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
  • Alternative regimen (1): Daptomycin 6 mg/kg IV q24h AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks ::::* Alternative regimen (2): Linezolid 600 IV q8h AND Rifampin 600 mg PO qd or 300–450 mg PO bid for 2 weeks
Note: The above regimen should be followed by Rifampin plus a fluoroquinolone, TMP/SMX, a tetracycline or Clindamycin for 3 or 6 months for hips and knees, respectively.
  • 21. Hematogenous osteomyelitis
  • 21.1 Adult (>21 yrs)
  • 21.1.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • Preferred regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
  • 21.1.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • 21.2 Children (>4 months)-Adult
  • 21.2.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • 21.2.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • Preferred regimen (1): Nafcillin ::::* Preferred regimen (2): Oxacillin 37 q6h (to max. 8–12 gm per day)
Note: Add Ceftazidime 50 q8h or Cefepime 150 div q8h if Gm-neg. bacilli on Gram stain
  • 21.3 Newborn (<4 months.)
  • 21.3.1 Methicillin-resistant Staphylococcus aureus (MRSA) possible
  • 21.3.2 Methicillin-resistant Staphylococcus aureus (MRSA) unlikely
  • 21.4 Specific therapy
  • 21.4.1 Methicillin-susceptible Staphylococcus aureus (MSSA)
  • Preferred regimen (1): Nafcillin ::::* Preferred regimen (2): Oxacillin 2 gm IV q4h ::::* Preferred regimen (3): Cefazolin 2 gm IV q8h
  • Alternative regimen: Vancomycin 1 gm IV q12h (if over 100 kg, 1.5 gm IV q12h)
  • 21.4.2 Methicillin-resistant Staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin 1 gm IV q12h
  • Alternative regimen: Linezolid 600 mg q12h IV or PO with or without Rifampin 300 mg PO or IV bid
  • 22. Diabetic foot osteomyelitis
  • High risk for MRSA
  • Preferred regimen (1): Linezolid 600 mg IV or PO q12h ::::* Preferred regimen (2): Daptomycin 4 mg/kg IV q24h ::::* Preferred regimen (3): Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
  • 23. Necrotizing fasciitis[31]
  • 23.1 In adult
  • Preferred regimen (2): Oxacillin 1–2 g IV q4h
  • Preferred regimen (3): Cefazolin 1 g IV q8h
  • Preferred regimen (4): Vancomycin 15 mg/kg IV bid
  • Preferred regimen (5): Clindamycin 600–900 mg IV q8h
  • 23.2 In childern
  • 24. Staphylococcal toxic shock syndrome [32]
  • 24.1 Methicillin sensitive Staphylococcus aureus
  • Preferred regimen (1): Cloxacillin 250-500 mg PO q6h (max dose: 4 g/24 hr) ::::* Preferred regimen (2): Nafcillin 4-12 g/24 hr divided IV q4-6hr (max dose: 12 g/24 hr) ::::* Preferred regimen (3): Cefazolin 0.5-2g IV or IM q8h (max dose: 12 g/24 hr), AND Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
  • Alternative regimen (1): Clarithromycin 250-500 mg PO q12h (max dose: 1 g/24 hr) AND Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
  • Alternative regimen (2): Rifampicin, AND Linezolid 600 mg IV or PO q12h ::::* Alternative regimen (3): Daptomycin ::::* Alternative regimen (4): Tigecycline 100 mg loading dose followed by 50 mg IV q12h
  • 24.2 Methicillin resistant Staphylococcus aureus
  • Preferred regimen (1): Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO) ::::* Preferred regimen (2): Linezolid 600 mg IV or PO q12h AND Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per dose ::::* Preferred regimen (3): Teicoplanin
  • Alternative regimen (1): Rifampicin, AND Linezolid 600 mg q12h IV or PO ::::* Alternative regimen (2): Daptomycin ::::* Alternative regimen (3): Tigecycline 100 mg loading dose followed by 50 mg q12h IV
  • 24.3 Glycopeptide resistant or intermediate Staphylococcus aureus
  • Preferred regimen: Linezolid 600 mg IV or PO q12h AND Clindamycin 150-600 mg IV, IM, or PO q6-8h (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO) (if sensitive)
  • Alternative regimen (1): Daptomycin ::::* Alternative regimen (2): Tigecycline 100 mg loading dose followed by 50 mg IV q12h
Note: Incidence increasing. Geographical patterns highly variable.
  • Staphylococcus aureus ,prophylaxis
  • 1. Prophylaxis for coronary artery bypass graft-associated acute mediastinitis[33]
  • 1.1 Methicillin susceptible staphylococcus aureus (MSSA)
  • Preferred regimen: A first- or second-generation Cephalosporin is recommended for prophylaxis in patients without methicillin-resistant Staphylococcus aureus colonization.
  • 1.2 Methicillin resistant staphylococcus aureus (MRSA)
  • Preferred regimen: Vancomycin alone or in combination with other antibiotics to achieve broader coverage is recommended for prophylaxis in patients with proven or suspected methicillin-resistant S. aureus colonization
Note (1): Preoperative antibiotics should be administered to all patients to reduce the risk of mediastinitis in cardiac surgery.
Note (2): The use of intranasal Mupirocin is reasonable in nasal carriers of Staphylococcus aureus.


  • 1. Bacteremia: most often due to IV lines, vascular grafts, cardiac valves (30-40% of all coagulase-negative staphylococcus infections)
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
Note: Site specific 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
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h added to Vancomycin AND Rifampin 300 mg IV or PO q8h for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg IV/PO q8h.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): (Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
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
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV or PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h added to Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
Note: Site specific 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
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
Note: Site specific 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
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole. ::::: Note: Site specific recommendation is consider valve replacement and antibiotics for 6 wks.
  • 6. Post-sternotomy: osteomyelitis
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
  • 7. Implants (breast, penile, pacemaker) and other prosthetic devices: local infection
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
Note: Site sepcific recommendation for vascular graft is to remove graft, antibiotics for 6 wks.
  • 8. Post-ocular surgery: endophthalmitis
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
  • 9. Surgical site infections
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h with or without Rifampin 300 mg q8h IV/PO
  • Preferred regimen (2): Gentamicin 3 mg/kg/day IV q8h AND Vancomycin AND Rifampin 300 mg q8h IV/PO for prosthetic valve infective endocarditis.
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (1): Linezolid 600 mg IV/PO bd
  • Alternative regimen (methicillin resistent Staphylococcus epidermidis) (2): Daptomycin IV 6 mg/kg/day with or without Rifampin 300 mg q8h IV/PO.
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (2): Oxacillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (3): Nafcillin 1.5-3 g IV q6h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (4): Cefazolin 1-2 g IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (5): Ciprofloxacin 400 mg IV q12h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (6): Clindamycin 600 mg IV q8h
  • Alternative regimen (methicillin-sensitive Staphylococcus epidermidis) (7): Trimethoprim-Sulfamethoxazole.
  • 1. Urinary tract infection [47]
  • 1.1 Acute uncomplicated urinary tract infection (cystitis-urethritis) in females
  • Alternative regimen (in sulfa allergy) (4): Nitrofurantoin 100 mg PO bid for 7 days
  • Note (1): Pyridium non-prescription drug 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
  • Preferred regimen (1): Trimethoprim-Sulfamethoxazole-DS (double strength) 160 mg/800 mg PO bid for 3 days
  • Preferred regimen (in sulfa allergy) (2): Nitrofurantoin 100 mg PO bid for 7 days
  • Preferred regimen (in sulfa allergy) (3): Fosfomycin single 3 gm dose PO AND Phenazopyridine Pyridium 200 mg PO tid for 2 days
  • Alternative regimen (in sulfa allergy) (1): Ciprofloxacin 250 mg PO bid for 3 days
  • Alternative regimen (in sulfa allergy) (2): Ciprofloxacin 250 mg PO bid for 7-14 days -Erythromycin 500 mg PO q24h for 7 days
  • Alternative regimen (in sulfa allergy) (3): Levofloxacin 250 mg PO q24h for 5 days (or Moxifloxacin 400 mg PO q24h for 7 days)
  • Alternative regimen (in sulfa allergy) (4): Nitrofurantoin 100 mg PO bid for 7 days
  • Alternative regimen (in sulfa allergy) (5): Fosfomycin single 3 gm dose PO AND Phenazopyridine Pyridium 200 mg PO tid for 2 days
  • Note (1): Recurrent urinary tract infection definition is ≥3 culture and symptomatic urinary tract infection in 1 year or 2 urinary tract infection in 6 months. Evaluate for potentially correctable urologic factors like (1) cystocele (2) incontinence (3) increased residual urine volume (≥50 mL).
  • Note (2): Nitrofurantoin more effective than vaginal cream in decreasing frequency, but adverse effect is pulmonary fibrosis with long-term Nitrofurantoin treatment.


  • Streptococcus moniliformis treatment[48]
  • 1. Migratory arthropathy and arthritis
  • Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
  • Preferred regimen (2): Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h complete 14 days.
  • 2. Diarrhea, (especially kids) liver or spleen abscess
  • Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
  • Preferred regimen (2): Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h complete 14 days.
  • 3. Undifferentiated fever
  • Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
  • Preferred regimen (2): Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h complete 14 days.
  • 4. Endocarditis, myocarditis, pericarditis (cardiac)
  • Preferred regimen: Penicillin 20 MU/day IV divided q4h for 4 weeks (optimal duration recommendation for infective endocarditis is 4 weeks.)
  • Alternative regimen (1): Cephalosporins-Cefdinir 600 mg PO q24h for 10 days -Ceftriaxone 2 g IV/IM q24h for 6 weeks with or without Gentamicin sulfate 3 mg/kg IM or IV in 1 dose (preferred) or in 3 equally divided doses for 2 weeks
  • Alternative regimen (2): Clindamycin 600–1200 mg/day IM or IV in 2, 3 or 4 equal doses
  • Alternative regimen (3): Erythromycin
  • Alternative regimen (4): Chloramphenicol 100 mg/kg/day AND Streptomycin
Note: In Penicillin-sensitive alpha and non-hemolytic streptococcal endocarditis (Penicillin minimum concentration inhibitory <0.1 mcg/mL)
  • Streptomycin may be used for 2-week treatment concomitantly with Penicillin.
  • The Streptomycin regimen is 1 g bid for the first week, and 500 mg bid for the second week.
  • If the patient is over 60 years of age, the dosage should be 500 mg bid for the entire 2- week period.
  • 5. Meningitis, brain abscess
  • 6. Pneumonia
  • Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
  • Preferred regimen (2): Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h complete 14 days.
  • 7. Amnionitis (pregnancy)
  • Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days :::* Preferred regimen (2): Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h complete 14 days.
  • 8. Renal abscess
  • Preferred regimen (1): Penicillin G 2.4-4.8 MU/day IV divided q6h. If better after 1 week, switch to Amoxicillin 1 g q12h PO for 14 days
  • Preferred regimen (2): Penicillin Vk 125 to 250 mg (200,000 to 400,000 units) PO q6-8h complete 14 days.
Note: Streptococcus moniliformis also causes anemia.
  • Staphylococcus lugdunensis treatment
  • 1. Skin and soft tissue infections[49]
  • Preferred regimen: Oxacillin 1-2 g IV q4h for 1-2 weeks
  • Note: Abscesses should be drained if possible.
  • 2.1 Native valve infectious endocarditis
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL)
  • Preferred regimen (for most patients with normal renal function) (2): Vancomycin 15-20 mg/kg (actual body weight) IV q8-12h -for trough concentration of 15-20 mcg/mL (minimum inhibitory concentration, 1 mcg/mL or less)
  • Note: should consist of 6 weeks of parenteral beta-lactam therapy or Vancomycin (depending on susceptibility testing and beta-lactam hypersensitivity).
  • 2.2 Prosthetic valve infective endocarditis
  • Note (1): Combine with Vancomycin for the entire duration of therapy and Gentamicin for the first 2 weeks.
  • Note (2): The Gentamicin should be administered for the first 2 weeks of therapy; the beta-lactam (or Vancomycin) and Rifampin should be continued for 6 weeks.
  • Note (3): Surgery must be considered given the frequency of valvular compromise in the setting of Staphylococcus lugdunensis infective endocarditis.
  • Note (4): The treatment of Staphylococcus lugdunensis pacemaker endocarditis includes antibiotic therapy as well as removal of the pacer system
  • Preferred regimen: Oxacillin 1-2 g IV q4h for 1-2 weeks
  • Note (1): Bacteremia without endocarditis (often related to an intravascular catheter) appears to have a good prognosis.
  • Note (2): For intravascular catheter-related Staphylococcus lugdunensis bacteremia, the catheter should be removed, followed by 14 days of antibiotics, provided that all of the following are applicable
2.1 The patient is not diabetic or immunosuppressed.
2.2 There is no prosthetic material, thrombophlebitis, infective endocarditis, evidence of metastatic infection.
2.3 The patient’s fever and bacteremia resolve within 72 hours after initiation of appropriate antibiotic therapy.
  • Preferred regimen (1): Vancomycin 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL)
  • Preferred regimen (for most patients with normal renal function) (2): Vancomycin 15-20 mg/kg (actual body weight) IV q8-12h -for trough concentration of 15-20 mcg/mL (minimum inhibitory concentration, 1 mcg/mL or less)
  • Preferred regimen (3): Daptomycin 6 mg/kg IV qd for 3-4 weeks
  • Preferred regimen (4): Linezolid 600 mg IV q12h
  • 5. Vertebral osteomyelitis, discitis
  • Preferred regimen: Vancomycin 15-20 mg/kg IV q8-12h, (maximum dose: 2 g per dose)
  • 6. Septic arthritis in adults
  • Preferred regimen: Vancomycin 15 mg/kg IV bd, (maximum dose: 2 g q24h) (unless cncentrations in serum are inappropriately low) for 4 weeks
  • Streptococcus pneumonia treatment
  • 1. Lung (Community-acquired pneumonia)[30]
  • 1.1 Penicillin sensitive (minimum inhibitory concentration < 2 mcg/ml)
  • Preferred regimen: Penicillin G 5-24 MU IV in equally divided doses q4-6h, Amoxicillin 1 g PO tid (+/- macrolide)
  • Alternative regimen: Macrolides (Azithromycin (IV) 500 mg IV qd for at least 2 days followed by 500 mg PO qd 7-10 days or Clarithromycin extended-release tablets 1000 mg PO qd for 7 days) and oral Cephalosporins-Cefpodoxime 200 mg PO bd, (Cefprozil 500 mg PO bd, Cefditoren 400 mg PO bd, Cefdinir 300 mg PO bd), OR parenteral Cephalosporins-Ceftriaxone 2 g IV q24h (or Cefotaxime 1-2 g IV q6-8h), Clindamycin 600-1200 mg IV/IM q6-12h, do not give single IM doses > 600 mg; IV infusion rates should not exceed 30 mg/min , Doxycycline 100 mg PO bd, respiratory flouroquniolones.
  • Preferred regimen (1): Aqueous crystalline Penicillin-G 6 MU q4-6h IV for 4 weeks
  • Preferred regimen (2) (who are unable to tolerate beta lactams therapy): Vancomycin 15 mg/kg IV q12h (target trough concentration, 10-15 mcg/mL); for troughs of 15-20 mcg/mL (MIC, 1 mcg/mL or less), 15-20 mg/kg (actual body weight) IV q8-12h for most patients with normal renal function
  • Preferred regimen (3) (If the isolate is resistant (MIC 2 g/mL) to cefotaxime): Cefotaxime 1-2 g q8-12h IV/IM (max dose: 12 g/24 hr) AND Vancomycin 15 mg/kg/day IV q12h AND Rifampin 300 mg IV/PO q8h for 6 weeks, in combination with appropriate antimicrobial therapy
  • Alternative regimen (1): Cefazolin 0.5-2 g q8h IV/IM (max dose: 12 g/24 hr)
  • Alternative regimen (2): Ceftriaxone 2 g IV q12h
  • Note : Streptococcus pneumoniae with intermediate doses minimum inhibitory concentration (MIC) 0.12 g/mL–0.5 g/mL Penicillin resistance (MIC 0.1 to 1.0 g/mL) or high Penicillin resistance (MIC 2.0 g/mL) is being recovered from patients with bacteremia.
  • 3. Sinuses (sinusitis)[53]
  • Empiric therapy
  • 3.1 For initial empiric treatment of acute bacterial rhinosinusitis in adults
  • 3.2 For second-line high-dose therapy for acute bacterial rhinosinusitis in adults
  • Preferred regimen: Amoxicillin 2 g/Clavulanate 125 mg PO bid recommended by the Infectious Disease Society of America (IDSA).
  • Note: The second line high dose therapy is recommended in adults who have failed initial therapy, in regions of high endemic rates (10% or greater) of invasive Penicillin-nonsusceptible Streptococcus pneumoniae, severe infection.
  • 4. Bronchi (acute exacerbation of chronic bronchitis)[54]
  • Preferred regimen (1): Amoxicillin 875 mg PO q12h or 500 mg PO q8h
  • Preferred regimen (2): Doxycycline 100 mg PO q12h
  • 5. CNS (meningitis)[55]
  • Empiric therapy
Note: Middle ear infections (otitis media), peritoneum infections (spontaneous bacterial peritonitis), pericardium infections (purulent pericarditis), skin infections (cellulitis) and eye infections (conjunctivitis) caused by Streptococcus pneumonia.
  • Prevention
  • 1. Pneumovax (23-valent) prevents bacteremia; impact on rates of CAP are modest or nil.
  • 2. Prevnar vaccine for children <2 yrs age prevents invasive pneumococcal infection in adults by herd effect. Impact is impressive with rates of invasive pneumococcal infection down 80% in peds and 20-40% in adults.
  • 3. Risk for bacteremia in splenectomy, HIV, smokers, black race, multiple myeloma, asthma.
  • Streptococcus agalactiae treatment (GBS-group B Streptococcus)
  • 1. Early onset group B streptococcal infections[56]
  • 1.1 Bacteremia or sepsis or pneumonia
  • 1.1.1 Empiric therapy
  • Preferred regimen: Ampicillin 150 mg/kg IV q12h for 10 days AND Gentamicin 4 mg/kg IV q12h for 10 days-for infants born at ≥ 35 weeks gestation; Gentamicin 3 mg/kg IV q24h for 10 days-for infants born at < 35 weeks gestation
  • 1.1.2 Definitive therapy
  • Preferred regimen: Penicillin G 50,000-100,000 units/kg per day IV divided q12h for 10 days
  • 1.2 Meningitis
  • 1.2.1 Empiric therapy
  • Preferred regimen: Ampicillin 100-150 mg/kg IV q8h for 14-21 days AND Gentamicin 4 mg/kg IV q24h for 14-21 days-for infants born at ≥ 35 weeks gestation; Gentamicin 3 mg/kg IV q24h for 14-21 days-for infants born at < 35 weeks gestation
  • 1.2.2 Definitive therapy
  • Preferred regimen: Penicillin G 250,000-450,000 units/kg per day IV divided q8h for 14-21 days
  • Note: Cellulitis is the most frequent clinical manifestation of GBS-associated skin and soft tissue infections.
  • 2. Late onset group b streptococcus infections in neonates and young infants (age > 1 week and body weight ≥ 1 kg with normal renal function)[57]
  • 2.1 Bacteremia without a focus
  • 2.1.1 Empiric therapy
  • 2.1.2 Definitive therapy
  • Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 10 days
  • 2.2 Meningitis
  • 2.2.1 Empiric therapy
  • 2.2.2 Definitive therapy
  • Preferred regimen: Penicillin-G 450,000-500,000 units/kg per day IV divided q6h for 14-21 days
  • 2.3 Cellulitis or adenitis
  • 2.3.1 Empiric therapy
  • Preferred regimen: Nafcillin IV for 10-14 days (OR [[Vancomycin IV for 10-14 days) AND Gentamicin IV for 10-14 days (OR Cefotaxime IV for 10-14 days)
  • 2.3.2 Definitive therapy
  • Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 10-14 days
  • 2.4 Septic arthritis
  • 2.4.1 Empiric therapy
  • 2.4.2 Definitive therapy
  • Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 14-21 days
  • 2.5 Osteomyelitis
  • 2.5.1 Empiric therapy
  • 2.5.2 Definitive therapy
  • Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 21-28 days
  • 2.6 Urinary tract infection
  • 2.6.1 Empiric therapy
  • 2.6.2 Definitive therapy
  • Preferred regimen: Penicillin-G 75,000-150,000 units/kg per day IV divided q8h for 10 days
  • Neonatal prophylaxis[58]
  • Group B streptococcus infection (maternal dose for neonatal prophylaxis)


  • Bacillus anthracis treatment
  • 1. Treatment for cutaneous anthrax, without systemic involvement[59]
  • Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (1): Ciprofloxacin 500 mg PO bid for 7-10 days
  • Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (2): Doxycycline 100 mg PO bid for 7-10 days
  • Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (3): Levofloxacin 750 mg PO qd for 7-10 days
  • Preferred regimen (regardless of penicillin susceptibility or if susceptibility is unknown) (4): Moxifloxacin 400 mg PO qd for 7-10 days
  • Alternative regimen (1): Clindamycin 600 mg PO tid for 7-10 days
  • Alternative regimen (2): Amoxicillin 1 g PO tid (for penicillin-susceptible strains) for 7-10 days
  • Alternative regimen (3): Penicillin VK 500 mg PO qid (for penicillin-susceptible strains) for 7-10 days
  • Note: Duration of treatment is 60 days for bioterrorism-related cases and 7-10 days for naturally acquired cases.
  • 2. Treatment for systemic anthrax including anthrax meningitis, inhalational anthrax, injectional anthrax, and gastrointestinal anthrax; and cutaneous anthrax with systemic involvement, extensive edema, or lesions of the head or neck[59]
  • 2.1 Systemic anthrax with possible/confirmed meningitis
  • 2.1.1 Bactericidal agent (fluoroquinolone)
  • Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2-3 weeks
  • Preferred regimen (3): Moxifloxacin 400 mg IV q24h for 2-3 weeks AND
  • 2.1.2 Bactericidal agent (ß-lactam) for all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen (1): Meropenem 2 g IV q8h for 2-3 weeks
  • Preferred regimen (2): Imipenem 1 g IV q6h for 2-3 weeks
  • Preferred regimen (3): Doripenem 500 mg IV q8h for 2-3 weeks
  • Preferred regimen (4): Penicillin G 4 MU IV q4h (for penicillin-susceptible strains) for 2-3 weeks
  • Preferred regimen (5): Ampicillin 3 g IV q6h (for penicillin-susceptible strains) for 2-3 weeks AND
  • 2.1.3 Protein synthesis inhibitor
  • Preferred regimen (1): Linezolid 600 mg IV q12h for 2-3 weeks
  • Preferred regimen (2): Clindamycin 900 mg IV q8h for 2-3 weeks
  • Preferred regimen (3): Rifampin 600 mg IV q12h for 2-3 weeks
  • Note (1): Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
  • Note (3): 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 (4): 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.
  • 2.2 Systemic anthrax when meningitis has been excluded
  • 2.2.1 Bactericidal agent
  • Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2 weeks
  • Preferred regimen (4): Meropenem 2 g IV q8h for 2 weeks
  • Preferred regimen (5): Imipenem 1 g IV q6h for 2 weeks
  • Preferred regimen (6): Doripenem 500 mg IV q8h for 2 weeks
  • Preferred regimen (7): Vancomycin 20 mg/kg IV q8h (maintain serum trough concentrations of 15-20 µg/mL) for 2 weeks
  • Preferred regimen (8): Penicillin G 4 MU IV q4h (penicillin-susceptible strains) for 2 weeks
  • Preferred regimen (9): Ampicillin 3 g IV q6h (penicillin-susceptible strains) for 2 weeks AND
  • 2.2.2 Protein synthesis inhibitor
  • Preferred regimen (1): Clindamycin 900 mg IV q8h for 2 weeks
  • Preferred regimen (2): Linezolid 600 mg IV q12h for 2 weeks
  • Preferred regimen (3): Doxycycline 200 mg IV initially, then 100 mg IV q12h for 2 weeks
  • Preferred regimen (4): Rifampin 600 mg IV q12h for 2 weeks
  • Note: Patients exposed to aerosolized spores will require prophylaxis to complete an antimicrobial drug course of 60 days from onset of illness.
  • 3. Specific considerations
  • 3.1 Treatment of anthrax for pregnant Women
  • 3.1.1 Intravenous antimicrobial treatment for systemic anthrax with possible/confirmed meningitis [60]
  • 3.1.1.1 A Bactericidal Agent (Fluoroquinolone)
  • Preferred regimen (1): Ciprofloxacin 400 mg IV q8h for 2–3 weeks OR
  • Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2–3 weeksOR
  • 3.1.1.2 A Bactericidal Agent (ß-lactam)
  • 3.1.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen: Meropenem 2 g q8h for 2–3 weeks
  • 3.1.1.2.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Ampicillin 3 g IV q6h for 2–3 weeks
  • Alternative regimen (2): Penicillin G 4 MU IV q4h for 2–3 weeks OR
  • 3.1.1.3 A Protein Synthesis Inhibitor
  • Preferred regimen (1): Clindamycin 900 IV mg q8h for 2–3 weeks
  • Preferred regimen (2): Rifampin 600 IV mg q12h for 2–3 weeks
  • Note: At least one antibiotic with transplacental passage is recommended.
  • 3.1.2 Intravenous antimicrobial treatment for systemic anthrax when meningitis has been excluded
  • 3.1.2.1 A Bactericidal Antimicrobial
  • Preferred regimen (2): Levofloxacin 750 mg IV q24h for 2 weeks OR
  • 3.1.2.2 A Bactericidal Agent (ß-lactam)
  • 3.1.2.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen: Meropenem 2 g q8h for 2 weeks OR
  • 3.1.2.2.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Ampicillin 3 g IV q6h for 2 weeks
  • Alternative regimen (2): Penicillin G 4 MU IV q4h for 2 weeks OR
  • 3.1.2.3 A Protein Synthesis Inhibitor
  • Preferred regimen (1): Clindamycin 900 IV mg q8h for 2 weeks
  • Preferred regimen (2): Rifampin 600 IV mg q12h for 2 weeks
  • 3.1.3 Oral antimicrobial treatment for cutaneous anthrax without systemic involvement
  • 3.1.3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Note: Duration of treatment is 60 days
  • 3.2 Treatment for anthrax in childern [61]
  • 3.2.1 Treatment of cutaneous anthrax without systemic involvement (for children 1 month of age and older)
  • 3.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day PO bid (not to exceed 500 mg/dose) for 7-10 days
  • Preferred regimen (2):
  • If patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day PO bid (not to exceed 100 mg/dose) for 7-10 days
  • If patients body weight is = 45 kg: Doxycycline 100 mg/dose PO bid for 7-10 days
  • Preferred regimen (3): Clindamycin 30 mg/kg/day PO tid (not to exceed 600 mg/dose) for 7-10 days
  • Preferred regimen (4):
  • If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day PO bid (not to exceed 250 mg/dose) for 7-10 days
  • If patients body weight is > 50 kg: Levofloxacin 500 mg PO qd for 7-10 days
  • 3.2.1.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1):Amoxicillin 75 mg/kg/day PO tid (not to exceed 1 g/dose) for 7-10 days
  • Alternative regimen (2): Penicillin VK 50-75 mg/kg/day PO tid or qid for 7-10 days
  • 3.2.2 Combination therapy for systemic anthrax when meningitis can be ruled out (for children 1 month of age and older)
  • 3.2.2.1 A bactericidal antimicrobial
  • 3.2.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q8h (not to exceed 400 mg/dose) for 14 days
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h (not to exceed 2 g/dose) for 14 days
  • Preferred regimen (3):
  • If patients body weight is < 50 kg: Levofloxacin 20 mg/kg/day IV divided q12h (not to exceed 250 mg/dose) for 14 days
  • If patients body weight is > 50 kg: Levofloxacin 500 mg IV q24h for 14 days
  • Preferred regimen (4): Imipenem/Cilastatin 100 mg/kg/day IV divided q6h (not to exceed 1 g/dose) for 14 days
  • Preferred regimen (5): Vancomycin 60 mg/kg/day IV divided q8h (follow serum concentrations) for 14 days
  • 3.2.2.1.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Penicillin G 400 000 U/kg/day IV divided q4h (not to exceed 4 MU/dose) for 14 days
  • Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q6h (not to exceed 3 g/dose) for 14 days AND
  • 3.2.2.2 A Protein Synthesis Inhibitor
  • Preferred regimen (1): Clindamycin, 40 mg/kg/day IV divided q8h (not to exceed 900 mg/dose) for 14 days
  • Preferred regimen (2): (non-CNS infection dose)
  • If patient is < 12 y old: Linezolid 30 mg/kg/day IV divided q8h for 14 days
  • If patient is = 12 y old: Linezolid 30 mg/kg/day IV divided q12h (not to exceed 600 mg/dose) for 14 days
  • Preferred regimen (3):
  • If patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day IV loading dose (not to exceed 200 mg) THEN Doxycycline 4.4 mg/kg/day IV divided q12h (not to exceed 100 mg/dose) for 14 days
  • If patients body weight is =45 kg: Doxycycline 200 mg IV loading dose THEN Doxycycline 100 mg IV given q12h for 14 days
  • Preferred regimen (4): Rifampin 20 mg/kg/day IV divided q12h (not to exceed 300 mg/dose) for 14 days
  • Note: 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.
  • 3.2.3 Triple therapy for systemic anthrax (anthrax meningitis or disseminated infection and meningitis cannot be ruled out) for Children 1 Month of Age and Older
  • 3.2.3.1 A bactericidal antimicrobial (fluoroquinolone)
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q8h (not to exceed 400 mg/dose) for 2–3 wks
  • Preferred regimen (2):
  • If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day IV divided q12h (not to exceed 250 mg/dose) for 2–3 wks
  • If patients body weight is > 50 kg: Levofloxacin 500 mg IV q24h for 2–3 wks
  • Preferred regimen (3):
  • If patients age is 3 months to < 2 years: Moxifloxacin 12 mg/kg/day IV, divided q12h (not to exceed 200 mg/dose) for 2–3 wks
  • If patients age is 2-5 years: Moxifloxacin 10 mg/kg/day IV divided q1h (not to exceed 200 mg/dose) for 2–3 wks
  • If patients age is 6–11 years: Moxifloxacin 8 mg/kg/day IV divided q12h (not to exceed 200 mg/dose) for 2–3 wks
  • If patients age is 12–17 years, = 45 kg body weight: Moxifloxacin 400 mg IV q24h for 2–3 wks
  • If patients age is 12–17 years, < 45 kg body weight: Moxifloxacin 8 mg/kg/day IV divided q12h (not to exceed 200 mg/dose) for 2–3 wks AND
  • 3.2.3.2 A bactericidal antimicrobial (ß-lactam or glycopeptide)
  • 3.2.3.2.1 For all strains, regardless of penicillin susceptibility testing or if susceptibility is unknown:
  • Preferred regimen (1): Meropenem 120 mg/kg/day IV divided q8h (not to exceed 2 g/dose) for 2–3 wks
  • Preferred regimen (2): Imipenem/Cilastatin 100 mg/kg/day IV divided q6h (not to exceed 1 g/dose) for 2–3 wks
  • Preferred regimen (3): Doripenem 120 mg/kg/day IV divided q8h (not to exceed 1 g/dose) for 2–3 wks
  • Preferred regimen (4): Vancomycin 60 mg/kg/day IV divided q8h for 2–3 wks
  • 3.2.3.2.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Penicillin G 400 000 U/kg/day IV divided q4h (not to exceed 4 MU/dose) for 2–3 wks
  • Alternative regimen (2): Ampicillin 400 mg/kg/day IV divided q6h (not to exceed 3 g/dose) for 2–3 wks AND
  • 3.2.3.3 A Protein Synthesis Inhibitor
  • Preferred regimen (1):
  • If patients age is < 12 y old: Linezolid 30 mg/kg/day IV divided q8h for 2–3 wk
  • If patients age is = 12 y old: Linezolid 30 mg/kg/day,IV divided q12h (not to exceed 600 mg/dose) for 2–3 wk
  • Preferred regimen (2): Clindamycin 40 mg/kg/day IV divided q8h (not to exceed 900 mg/dose) for 2–3 wk
  • Preferred regimen (3): Rifampin 20 mg/kg/day IV divided q12h (not to exceed 300 mg/dose) for 2–3 wk
  • Preferred regimen (4): Chloramphenicol 100 mg/kg/day IV divided q6h for 2–3 wk
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): A 400-mg dose of Ciprofloxacin IV, provides an equivalent exposure to that of a 500-mg ciprofloxacin oral tablet.
  • 3.2.4 Oral follow-up combination therapy for severe anthrax (for Children 1 Month of Age and Older)
  • 3.2.4.1 A bactericidal antimicrobial
  • 3.2.4.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day PO bid (not to exceed 500 mg/dose)
  • Preferred regimen (2):
  • If patients body weight is < 50 kg: Levofloxacin 16 mg/kg/day PO bid (not to exceed 250 mg/dose)
  • If patients body weight is = 50 kg: Levofloxacin 500 mg PO qd
  • 3.2.4.1.2 Alternatives for penicillin-susceptible strains
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid (not to exceed 1 g/dose)
  • Alternative regimen (2): Penicillin VK 50–75 mg/kg/day PO tid or qds AND
  • 3.2.4.2 A protein synthesis inhibitor:
  • Preferred regimen (1):Clindamycin 30 mg/kg/day PO tid (not to exceed 600 mg/dose)
  • Preferred regimen (2):
  • If the patients body weight is < 45 kg: Doxycycline 4.4 mg/kg/day PO bid (not exceed 100 mg/dose)
  • If the patients body weight is = 45 kg: Doxycycline 100 mg PO bid
  • Preferred regimen (3): (non-CNS infection dose):
  • If the patients age is < 12 yrs old: Linezolid 30 mg/kg/day PO tid
  • If the patients age is = 12 yrs old: Linezolid 30 mg/kg/day PO bid (not to exceed 600 mg/dose)
  • Note: 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.
  • 3.2.5 Dosing in preterm and term neonates 32 to 44 Weeks postmenstrual Age (Gestational Age Plus Chronologic Age)
  • 3.2.5.1 Triple therapy for severe anthrax(anthrax meningitis or disseminated infection and meningitis cannot be ruled out)
  • 3.2.5.1.1 Bactericidal antimicrobial (fluoroquinolone) therapy
  • 3.2.5.1.1.1 For 32–34 weeks gestational age
  • For 0–1 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 weeks of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 2–3 weeks
  • 3.2.5.1.1.2 For 34–37 week gestational age
  • For 0–1 wk of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2):Moxifloxacin 5 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 wk of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 5 mg/kg/day IV q24h for 2–3 weeks
  • 3.2.5.1.1.3 Term newborn infant
  • For 0–1 week of age
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 10 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 weeks of age
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Moxifloxacin 10 mg/kg/day IV q24h for 2–3 weeks AND
  • 3.2.5.1.2 A bactericidal antimicrobial (ß-lactam)
  • 3.2.5.1.2.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown:
  • 3.2.5.1.2.1.1 For 32–34 weeks gestational age
  • For 0–1 week of Age :
  • Preferred regimen (1): Meropenem 60 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 50 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (3): Doripenem 20 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 wk of Age :
  • Preferred regimen (1): Meropenem 90 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 75 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Doripenem 30 mg/kg/day IV divided q8h for 2–3 weeks
  • 3.2.5.1.2.1.2 For 34–37 week gestational age
  • For 0–1 week of Age :
  • Preferred regimen (1): Meropenem 60 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 50 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (3): Doripenem 20 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of Age :
  • Preferred regimen (1): Meropenem 90 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 75 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Doripenem 30 mg/kg/day IV divided q8h for 2–3 weeks
  • 3.2.5.1.2.1.3 Term newborn infant
  • For < 1 week of age
  • Preferred regimen (1):Meropenem 60 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 50 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (3): Doripenem 20 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of age
  • Preferred regimen (1):Meropenem 90 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Imipenem 75 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Doripenem 30 mg/kg/day IV divided q8h for 2–3 weeks
  • 3.2.5.1.2.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.1.2.2.1 For 32–34 weeks gestational age
  • For 0–1 week of age
  • Alternative regimen (1):Penicillin G 200000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 100 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of age :
  • Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day divided IV q12h for 2–3 weeks
  • 3.2.5.1.2.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 400000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q12h for 2–3 weeks
  • 3.2.5.1.2.2.3 Term newborn infant
  • For 0–1 week of age
  • Alternative regimen (1): Penicillin G 300000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q12h for 2–3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 400000 Units/kg/day IV divided q12h for 2–3 weeks
  • Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q12h for 2–3 weeks AND
  • 3.2.5.1.3 A protein synthesis inhibitor
  • 3.2.5.1.3.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Preferred regimen (1): Linezolid 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 2–3 weeks
  • 3.2.5.1.3.2 For 34–37 week gestational age
  • For < 1 week of age
  • Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 week of age
  • Preferred regimen (1):Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 20 mg/kg/day IV divided q6h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 2–3 weeks
  • 3.2.5.1.3.3 Term newborn infant
  • For < 1 week of age
  • Preferred regimen (1):Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 25 mg/kg/day IV q24h for 2–3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Linezolid 30 mg/kg/day IV divided q8h for 2–3 weeks
  • Preferred regimen (2): Clindamycin 20 mg/kg/day IV divided q6h for 2–3 weeks
  • Preferred regimen (3): Rifampin 20 mg/kg/day IV divided q12h for 2–3 weeks
  • Preferred regimen (4): Chloramphenicol 50 mg/kg/day IV q12h for 2–3 weeks
  • Note :Duration of therapy for 2–3 weeks, until clinical criteria for stability are met. Will require prophylaxis to complete an antibiotic course of upto 60 days from onset of illness.
  • 3.2.5.2 Therapy for severe anthrax when meningitis can be ruled out
  • 3.2.5.2.1 A bactericidal antimicrobial
  • 3.2.5.2.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.2.1.1.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 40 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 40 mg/kg/day IV divided q12h for 2-3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
  • 3.2.5.2.1.1.2 For 34–37 week gestational age
  • For < 1 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
  • For 1–4 week of age
  • Preferred regimen (1): Ciprofloxacin 20 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 75 mg/kg/day IV divided q8h for 2-3 weeks
  • 3.2.5.2.1.1.3 Term Newborn Infant
  • For < 1 week of age
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 50 mg/kg/day IV divided q12h for 2-3 weeks
  • For 1–4 week of age
  • Preferred regimen (1):Ciprofloxacin 30 mg/kg/day IV divided q12h for 2-3 weeks
  • Preferred regimen (2): Meropenem 60 mg/kg/day IV divided q8h for 2-3 weeks
  • Preferred regimen (3): Imipenem 75 mg/kg/day IV divided q8h for 2-3 weeks
  • Vancomycin IV (dosing based on serum creatinine for infants of 32 wk gestational age). Follow vancomycin serum concentrations to modify dose.
  • If Serum creatinine < 0.7 then Vancomycin 15 mg/kg/dose IV q12h for 2-3 weeks
  • If Serum creatinine 0.7 -0.9 then Vancomycin 20 mg/kg/dose IV q24h for 2-3 weeks
  • If Serum creatinine 1–1.2 then Vancomycin 15 mg/kg/dose IV q24h for 2-3 weeks
  • If Serum creatinine 1.3–1.6 then Vancomycin 10 mg/kg/dose IV q24h for 2-3 weeks
  • If Serum creatinine > 1.6 then Vancomycin mg/kg/dose IV q48h for 2-3 weeks
  • Note: Begin treatment with a 20 mg/kg loading dose OR
  • 3.2.5.2.1.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.2.1.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Alternative regimen (1): Penicillin G 200000 U/kg/day IV divided q12h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 100 mg/kg/day IV divided q12h for 2-3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
  • 3.2.5.2.1.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 400000 U/kg/day IV divided q6h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 200 mg/kg/day IV divided q6h for 2-3 weeks
  • 3.2.5.2.1.2.3 Term newborn infant
  • For < 1 week of age
  • Alternative regimen (1): Penicillin G 300000 U/kg/day IV divided q8h for 2-3 weeks
  • Alternative regimen (2): Ampicillin 150 mg/kg/day IV divided q8h for 2-3 weeks
  • For 1–4 week of age
  • Alternative regimen (1): Penicillin G 400000 U/kg/day IV divided q6h for 2-3 weeks
  • Alternative regimen (2):Ampicillin 200 mg/kg/day IV divided q6h for 2-3 weeks
  • 3.2.5.2.2 A protein synthesis inhibitor
  • 3.2.5.2.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Preferred regimen (1): Clindamycin 10 mg/kg/day IV divided q12h for 2–3 wks
  • Preferred regimen (2): Linezolid 20 mg/kg/day IV divided q12h for 2–3 wks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • For 1–4 week of age
  • Preferred regimen (1): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • 3.2.5.2.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Preferred regimen (1): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • For 1–4 week of age
  • Preferred regimen (1): Clindamycin 20 mg/kg/day IV divided q6h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • 3.2.5.2.2.3 Term newborn infant
  • For 0–1 week of age :
  • Preferred regimen (1): Clindamycin 15 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Doxycycline 4.4 mg/kg/day IV divided q12h, (loading dose 4.4 mg/kg) for 2–3 wks
  • Preferred regimen (4): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • For 1–4 week of age :
  • Preferred regimen (1): Clindamycin 20 mg/kg/day IV divided q6h for 2–3 wks
  • Preferred regimen (2): Linezolid 30 mg/kg/day IV divided q8h for 2–3 wks
  • Preferred regimen (3): Doxycycline 4.4 mg/kg/day IV divided q12h, (loading dose 4.4 mg/kg) for 2–3 wks
  • Preferred regimen (4): Rifampin 10 mg/kg/day IV q24h for 2–3 wks
  • Note: Duration of therapy for 2–3 wks, until clinical criteria for stability are met (see text). Will require prophylaxis to complete an antimicrobial course of upto 60 days from onset of illness
  • 3.2.5.3 Oral follow-up combination therapy for severe anthrax
  • 3.2.5.3.1 A bactericidal antimicrobial
  • 3.2.5.3.1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.3.1.1.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.3.1.1.2 For 34–37 week gestational age
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.3.1.1.3 Term newborn infant
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.3.1.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.3.1.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin VK 50 mg/kg/day PO bid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin VK 75 mg/kg/day PO bid
  • 3.2.5.3.1.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin VK 50 mg/kg/day PO bid
  • For 1–4 week of age
  • Alternative regimen (1):Amoxicillin 75 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid
  • 3.2.5.3.1.2.3 Term newborn infant
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin VK 75 mg/kg/day PO tid or qid
  • 3.2.5.3.2 A protein synthesis inhibitor
  • 3.2.5.3.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Preferred regimen (2): Linezolid 20 mg/kg/day PO bid
  • For 1–4 week of age
  • Preferred regimen (2):Linezolid 30 mg/kg/day PO bid
  • 3.2.5.3.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Preferred regimen (2): Linezolid 30 mg/kg/day PO tid
  • For 1–4 week of age
  • Preferred regimen (2): Linezolid 30 mg/kg/day PO tid
  • 3.2.5.3.2.3 Term newborn infant
  • For < 1 week of age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (loading dose 4.4 mg/kg)
  • Preferred regimen (3): Linezolid 30 mg/kg/day PO tid
  • For 1–4 week of age
  • Preferred regimen (1): Clindamycin 20 mg/kg/day PO qid
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (loading dose 4.4 mg/kg)
  • Preferred regimen (3): Linezolid 30 mg/kg/day PO tid
  • Note: Duration of therapy to complete a treatment course of 10–14 days or greater. May require prophylaxis to complete an antimicrobial course of upto 60 days from onset of illness.
  • 3.2.5.4 Treatment of cutaneous anthrax without systemic involvement
  • 3.2.5.4.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.2.5.4.1.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.4.1.2 For 34–37 week gestational age
  • For < 1 week of age
  • For 1–4 week of age
  • 3.2.5.4.1.3 Term newborn infant
  • For < 1 week of age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (Loading dose 4.4 mg/kg)
  • For 1–4 week of age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day PO bid (Loading dose 4.4 mg/kg)
  • 3.2.5.4.2 Alternatives for penicillin-susceptible strains
  • 3.2.5.4.2.1 For 32–34 weeks gestational age
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin Vk 50 mg/kg/day PO bid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid
  • 3.2.5.4.2.2 For 34–37 week gestational age
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin Vk 50 mg/kg/day PO bid
  • For 1–4 week of age
  • Alternative regimen (1):' Amoxicillin' 75 mg/kg/day PO bid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO bid
  • 3.2.5.4.2.3 Term newborn infant
  • For < 1 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid
  • For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day PO tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day PO tid or qid
  • 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.
  • Bacillus anthracis, postexposure prophylaxis
  • 1.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 1.2 Alternatives for penicillin-susceptible strain
  • Preferred regimen (2): Penicillin VK 500 mg IV q6h
  • 2. For children = 1 month[61]
  • 2.1 For penicillin-resistant strains or prior to susceptibility testing
  • Preferred regimen (1): Ciprofloxacin 30 mg/kg/day, PO, bid (not to exceed 500 mg/dose)
  • Preferred regimen (2):
  • If patients body weight < 45 kg: Doxycycline 4.4 mg/kg/day, PO, bid (not to exceed 100 mg/dose)
  • If patients body weight > 45 kg: Doxycycline 100 mg/dose, PO, bid
  • Preferred regimen (3): Clindamycin 30 mg/kg/day, PO, tid (not to exceed 900 mg/dose)
  • Preferred regimen (4):
  • If patients body weight < 50 kg: Levofloxacin 16 mg/kg/day, PO, bid (not to exceed 250 mg/dose)
  • If patients body weight > 50 kg: Levofloxacin 500 mg, PO, qd
  • 2.2 For penicillin-susceptible strains
  • Preferred regimen (1): Amoxicillin 75 mg/kg/day, PO, tid (not to exceed 1 g/dose)
  • Preferred regimen (2): Penicillin VK 50-75 mg/kg/day, PO, id or tid
  • Note: Duration of Therapy is 60 days after exposure
  • 3. For children < 1 month
  • 3.1 For all strains, regardless of penicillin susceptibility or if susceptibility is unknown
  • 3.1.1 For 32–34 weeks gestational age
  • 3.1.1.1 For < 1 week of Age
  • Preferred regimen (2): Clindamycin 10 mg/kg/day, PO, bid
  • 3.1.1.2 For 1–4 week of age
  • Preferred regimen (2): Clindamycin 15 mg/kg/day, PO, tid
  • 3.1.2 For 34–37 week gestational age
  • 3.1.2.1 For < 1 week of age
  • Preferred regimen (2): Clindamycin 15 mg/kg/day, PO, tid
  • 3.1.2.2 For 1–4 week of age
  • Preferred regimen (2): Clindamycin 20 mg/kg/day, PO, id
  • 3.1.3 Term newborn infant
  • 3.1.3.1 For < 1 week of age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day, PO, bid (Loading dose 4.4 mg/kg)
  • Preferred regimen (3): Clindamycin 15 mg/kg/day, PO, tid
  • 3.1.3.2 For 1–4 week of Age
  • Preferred regimen (2): Doxycycline 4.4 mg/kg/day, PO, bid (Loading dose 4.4 mg/kg)
  • Preferred regimen (3): Clindamycin 20 mg/kg/day, PO, qid
  • 3.2 Alternatives for penicillin-susceptible strains
  • 3.2.1 For 32–34 weeks gestational age
  • 3.2.1.1 For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day, PO, bid
  • Alternative regimen (2): Penicillin Vk 50 mg/kg/day, PO, bid
  • 3.2.1.2 For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid
  • 3.2.2 For 34–37 week gestational age
  • 3.2.2.1 For < 1 week of age
  • Alternative regimen (1): Amoxicillin 50 mg/kg/day, PO, bid
  • Alternative regimen (2): Penicillin Vk 50 mg/kg/day, PO, bid
  • 3.2.2.2 For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid
  • 3.2.3 Term newborn infant
  • 3.2.3.1 For < 1 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, tid
  • 3.2.3.2 For 1–4 week of age
  • Alternative regimen (1): Amoxicillin 75 mg/kg/day, PO, tid
  • Alternative regimen (2): Penicillin Vk 75 mg/kg/day, PO, id or tid
  • Note: Duration of therapy is 60 days from exposure.
  • Human herpesvirus 6 treatment[62]
  • Preferred regimen: Ganciclovir, Foscarnet OR Cidofovir
  • Note (1): Fever & rash documented in transplant patients .
  • Note (2): Reactivation in hematopoietic stem cell transplant patients associated with delayed monocytes & platelet engraftment.
  • Preferred regimen: most active agents are Piperacillin-Tazobactam, Meropenem AND Trimethoprim–Sulfamethoxazole whereas Ceftazidime is more active than Cefepime
  • Alternative regimen: Colistin inhaled, could also be considered
  • Note : Achromobacter (formerly Alcaligenes) xylosoxidans is a newly emerging microorganism isolated with increased frequency from the lungs of patients with cystic fibrosis. Combination therapy has been recommended for the treatment of Achromobacter xylosoxidans pulmonary exacerbations in cystic fibrosis

Balantidium coli

  • Balantidium coli treatment[69]
  • Adult dosage:
  • Pediatric dosage:
  • Preferred regimen: Metronidazole 35-50 mg/kg/day PO in three doses (maximum dosage: 2 g) for 5 days, Tetracycline 40 mg/kg/dose PO in four doses for 10 days.
  • Alternative regimen: Iodoquinol 40 mg/kg/dose PO in three doses for 20 days AND Doxycycline.
  • Note: Nitazoxanide, a broad-spectrum antiparasitic and antihelminthic drug, may be another treatment for balantidiosis.
  • BK virus treatment[70]
  • 1. Immunosuppression should be reduced in kidney transplant patients with definitive polyomavirus associated nephropathy.
  • Immunosuppressant drugs
  • Preferred regimen (1): Tacrolimus trough levels are commonly targeted to < 6 ng/mL,
  • Preferred regimen (2): Cyclosporine trough levels to < 150 ng/mL ,
  • Preferred regimen (3): Sirolimus trough levels of < 6 ng/mL, and
  • Preferred regimen (4): Mycophenolate mofetil daily dose equivalents of ≤ 1000 mg.
  • Note (1): Lower calcineurin inhibitor levels, that is targeting trough levels for Tacrolimus of 3 ng/mL and Cyclosporine of 100 ng/mL may be considered as a first step.
  • Note (2): Additional strategies have been switching from Tacrolimus to low-dose Cyclosporine or switching from Mycophenolic acid to Leflunomide, to low-dose Sirolimus, or from calcineurin inhibitor to low-dose Sirolimus.
  • Note (3): Immunosuppression is further adapted according to the course of serum creatinine concentration and the plasma viral loads, but responses may require several weeks.
  • 2. In patients with sustained high-level plasma BK virus load despite adequately reduced immunosuppression, the adjunctive use of agents with antiviral activity may be considered
  • Preferred regimen (1): Cidofovir 0.25 mg/kg-1.0 mg/kg IV at 1–3 weekly intervals, without Probenecid 1 mg/kg, administered weekly as a slow IV infusion after hydration, for up to 10 weeks.
  • Preferred regimen (2): Loading dose of Leflunomide 100 mg PO for 5 days, followed by an initial maintenance dose of Leflunomide 40 mg PO.
  • Note: Leflunomide is orally administered as a replacement for discontinued Mycophenolic acid.
  • Preferred regimen (3): Intravenous immunoglobulins (IVIG) 0.2 g/kg-2.0 g/kg in conjunction with reduced immunosuppression.
  • Preferred regimen (4): Fluoroquinolones may inhibit BKV replication.
  • Note (1): Acute rejection following reduced immunosuppression for presumptive or definitive polyomavirus associated nephropathy should be treated according to standard protocols.
  • Note (2): Anti-rejection treatment administered in patients with a history of BK virus replication with or without polyomavirus associated nephropathy should be accompanied by at least bi-weekly monitoring of the urine and plasma viral load.
  • Prevention and prophylaxis
  • Note (1): Kidney transplant recipients should be screened for BKV replication to identify patients at increased risk of polyomavirus associated nephropathy.
  • Note (2): Retransplantation can be considered for patients after loss of a first kidney allograft due to polyomavirus associated nephropathy, but frequent screening for BK virus replication is recommended.
  • Fusobacterium necrophorum treatment[71]
  • 1. In adults
  • 2. In children


  • Alternative regimen (1): Imipenem
  • Alternative regimen (2): Ampicillin-Sulbactam
  • Alternative regimen (3): antipseudomonal penicillins
  • Alternative regimen (4): Clindamycin
  • Note: More frequent dosing of ceftriaxone is needed in cases of CNS infection.

Endophthalmitis

  • 1. Bacterial endogenous endophthalmitis[72]
  • Preferred regimen (1): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal
  • Preferred regimen (2): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Amikacin 0.4 mg/0.1 mL intravitreal (antibiotic active against underlying source of bacteremia)
  • Note (1): In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary in nearly all cases.
  • Note (2): Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.
  • Note (3): Endogenous bacterial endophthalmitis arises from bacteremic seeding associated with endocarditis, urinary tract infections, indwelling central venous catheters, illicit injection drug use, procedures (e.g., endoscopy), or liver abscess. Common pathogens include Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus milleri group, group A and B streptococci, and gram-negative bacilli (e.g., Escherichia coli, Klebsiella pneumoniae).
  • 2. Bleb-related endophthalmitis[72]
  • Preferred regimen: Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal
  • Note (1): In conjunction with intravitreal antibiotic therapy, a vitrectomy is necessary in most cases.
  • Note (2): Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.
  • Note (3): It is reasonable to give an oral quinolone, such as Moxifloxacin, that achieves good vitreous levels and treats the major pathogens.
  • 3. Candidal endophthalmitis
  • 3.1 Endogenous candida endophthalmitis[72]
  • Preferred regimen (1): Amphotericin intravitreal
  • Preferred regimen (2): Voriconazole intravitreal.
  • Preferred regimen (3): Fluconazole IV
  • Preferred regimen (4): Voriconazole IV
  • Preferred regimen (5): Amphotericin IV
  • Note (1): In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary if viritis (endophthalmitis) is present.
  • Note (2): often there is a need to remove artificial intra-ocular lense.
  • Note (3): Systemic antibiotics alone are not effective in treating endophthalmitis, except for most cases of Candida chorioretinitis without vitritis. They are indicated in endogenous endophthalmitis and fungal endophthalmitis. Whether they are beneficial as adjunctive therapy in exogenous bacterial endophthalmitis is unknown.
  • 3.2 Exogenous candida endophthalmitis
  • Preferred regimen (1): Amphotericin is 5-10 mcg in 0.1 mL of sterile water intravitreal
  • Preferred regimen (2): Voriconazole is usually 100 mcg in 0.1 mL of sterile water intravitreal.
  • Preferred regimen (3): High-dose Fluconazole (400-800 mg IV qd assuming the normal kidney function) is also indicated for susceptible strains, OR::* Preferred regimen (4): Voriconazole IV for Fluconazole-resistant butVoriconazole-susceptible strains.
  • Note (1): Candida parapsilosis is the most common species, especially in postsurgical outbreaks.
  • Note (2): if infection follows cataract surgery, it is often necessary to remove the intra ocular lense as well.
  • 4. Chronic endophthalmitis:* Chronic endophthalmitis [73]
  • Preferred regimen (intial therapy): Clarithromycin 500 mg PO bid for 2-4 weeks AND Moxifloxacin 400 mg PO qd for a week as it also has good intraocular penetration and a broad spectrum of antimicrobial activity.
  • 5. Mold endophthalmitis:*5.1 Exogenous mold endophthalmitis[72]
  • Preferred regimen (1): Amphotericin intravitreal and intracameral injections::* Preferred regimen (2): Voriconazole intravitreal and intracameral injections
  • Preferred regimen (3): Voriconazole IV
  • Note (1): Unless the fungus is known, the initial intra-ocular injection should be Amphotericin; subsequent injections may be Voriconazole for sensitive fungi. Repeated intra-ocular injections of Voriconazole (if the organism is susceptible) or Amphotericin can be given, at least 48 hours apart.
  • Note (2): In conjunction with intravitreal and systemic antibiotic therapy, a vitrectomy is necessary in nearly all cases.
  • Note (3): Artificial intra-ocular lense needed to be removed.
  • 5.2 Endogenous mold endophthalmitis
  • Preferred therapy (1): Amphotericin intravitreal or voriconazole intravitreal
  • Note (1): In immunocompromised patients, treatment must include systemic antifungal therapy
  • Note (1): if the patient is able to tolerate surgery , vitrectomy and removal of any IOL, followed by Amphotericin intravitreal or Voriconazole intravitreal should be performed.::* Note (2): If too ill for surgery, the patient should have Amphotericin intravitreal injection or Voriconazole intravitreal injection , with repeated injections as needed.::* Note (3): In injection drug users with no evidence of ongoing fungaemia, vitrectomy, intravitreal anti-fungal injection and systemic therapy should be given.
  • 6. Post-cataract surgery endophthalmitis:*6.1 Acute endophthalmitis post-cataract surgery[72]::* Preferred regimen (intravitreal): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal
  • Note (1): In conjunction with intravitreal antibiotic therapy, a vitrectomy is necessary if severe infection or fungal etiology
  • Note (2): If there is no improvement in 48 h, a repeat intravitreal injection may be given with either Vancomycin or Ceftazidime, depending on culture results.
  • Note (3): Repeated injections of Amikacin are avoided, owing to concerns about retinal toxicity.
  • Note (4): No need to remove intra-ocular lense, unless fungal etiology.
  • 6.2 Chronic endophthalmitis post-cataract surgery[72]::* Preferred regimen: Vancomycin 1 mg/0.1 mL normal saline intravitreal
  • Note (1): Artificial intra-ocular lense needed to be removed.
  • Note (2): Most common pathogen causing post-cataract endophthalmitis is Propionibacterium acnes.
  • Note (3): Necessity for vitrectomy is varied.
  • 7. Post-tramatic endophthalmitis[72]:* Preferred regimen (1): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Ceftazidime 2.25 mg/0.1 mL intravitreal :* Preferred regimen (2): Vancomycin 1 mg/0.1 mL normal saline intravitreal AND Amphotericin intravitreal if fungi suspected:* Note: Intravitreal antibiotics are given at the end of a vitrectomy case in the operating room, or as an office procedure without a vitrectomy.
  • Preferred regimen (intravenous): Intravenous Vancomycin AND (Ceftazidime OR Ciprofloxacin)
  • Note (1): Systemic antibiotics alone are not effective in treating endophthalmitis, except for most cases of Candida chorioretinitis without vitritis. They are indicated in endogenous endophthalmitis and fungal endophthalmitis. Whether they are beneficial as adjunctive therapy in exogenous bacterial endophthalmitis is unknown.
  • Note (2): In conjunction with intravitreal antibiotic therapy and intravenous antibiotic therapy , a vitrectomy is necessary in most cases.
  • Note (3): Need to remove artificial intra-ocular lens varies (always if fungal).
  • Note (4): Treatment should be aggressive, with vitrectomy, intravitreal antibiotics (e.g. Vancomycin AND Ceftazidime), and systemic therapy.
  • Note (5): Most common pathogens are Bacillus cereus, coagulase-negative staphylococci (fungi in some cases).

Wound infection

  • 1. Mild to moderate
  • Preferred regimen (1): TMP-SMX-DS double strength 1-2 tabs PO bid
  • Preferred regimen (2): Clindamycin 300-450 mg PO tid
  • Alternative regimen (1): Minocycline 100 mg PO bid
  • Alternative regimen (2): Linezolid 600 mg PO bid
  • 2. Febrile with sepsis

Yaws

  • Preferred regimen (1): Phenoxymethylpenicillin 12.5 mg/kg q6h 7-10days (maximum dose, 300 mg q6h)
  • Preferred regimen (2): Tetracyclines 500 mg q6h 15 days or doxycycline 100 mg q12h (alternative agents for the treatment of yaws in nonpregnant adults)
  • Preferred regimen (3): Erythromycin 8–10 mg/kg 15 days q6h
  • Preferred regimen (4): Azithromycin 30 mg/kg single-dose (maximum dose 2 g)


  • STREPTOCOCCUS PNEUMONIA MEDICAL THERAPY INTRODUCTION:-

Historically, treatment relied primarily on β-lactam antibiotics. In the 1960s, nearly all strains of S. pneumoniae were susceptible to penicillin, but since that time, there has been an increasing prevalence of penicillin resistance, especially in areas of high antibiotic use. A varying proportion of strains may also be resistant to cephalosporins, macrolides (such as erythromycin), tetracycline, clindamycin and the quinolones. Penicillin-resistant strains are more likely to be resistant to other antibiotics. Most isolates remain susceptible to vancomycin, though its use in a β-lactam-susceptible isolate is less desirable because of tissue distribution of the drug and concerns of development of vancomycin resistance. More advanced beta-lactam antibiotics (cephalosporins) are commonly used in combination with other drugs to treat meningitis and community-acquired pneumonia. In adults, recently developed fluoroquinolones such as levofloxacin and moxifloxacin are often used to provide empiric coverage for patients with pneumonia. Susceptibility testing should be routine, with empiric antibiotic treatment guided by resistance patterns in the community in which the organism was acquired, pending the results. There is currently debate as to how relevant the results of susceptibility testing are to clinical outcome.[75][76] There is slight clinical evidence that penicillins may act synergistically with macrolides to improve outcomes.[77]


References

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  16. ↑ 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.
  17. ↑ 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.
  18. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  19. ↑ Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.
  20. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  21. ↑ 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.
  22. ↑ 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.
  23. ↑ 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.
  24. ↑ 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.
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  39. ↑ Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.
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  57. ↑ "group B Streptococcus infections".
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  72. ↑ 72.0 72.1 72.2 72.3 72.4 72.5 72.6 Durand ML (2013). "Endophthalmitis". Clin Microbiol Infect. 19 (3): 227–34. doi:10.1111/1469-0691.12118. PMC 3638360. PMID 23438028.
  73. ↑ [www.escrs.org/downloads/endophthalmitis-guidelines.pdf "Endophthalmitis"] Check |url= value (help) (PDF).
  74. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  75. ↑ Peterson LR (2006). "Penicillins for treatment of pneumococcal pneumonia: does in vitro resistance really matter?". Clin Infect Dis. 42 (2): 224–33. PMID 16355333.
  76. ↑ Tleyjeh IM, Tlaygeh HM, Hejal R, Montori VM, Baddour LM (2006). "The impact of penicillin resistance on short-term mortality in hospitalized adults with pneumococcal pneumonia: a systematic review and meta-analysis". Clin Infect Dis. 42 (6): 788–97. PMID 16477555.
  77. ↑ Martínez JA, Horcajada JP, Almela M; et al. (2003). "Addition of a Macrolide to a β-Lactam based empirical antibiotic regimen is associated with lower in-hospital mortality for patients with bacteremic pneumococcal pneumonia". Clin Infect Dis. 36: 389–395. doi:10.1086/367541. PMID 12567294.
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