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<table class="wikitable">
{|
<tr class="v-firstrow"><th>Scenario </th><th> Recommendation</th></tr>
|colspan=2|Outpatient
<tr><td>Outpatient: Previously healthy and no use of antibiotics within the last 3 months </td><td> A [[macrolide]], '''''OR''''' <br> [[Doxycyline]]</td></tr>
|-
<tr><td>Outpatient: Presence of comorbidities ([[diabetes mellitus]]; chronic heart, lung, liver or renal disease; alcoholism; malignancies; asplenia; immunosuppression)</td><td>A [[fluoroquinolone]] ([[moxifloxacin]], [[gemifloxacin]], or [[levofloxacin]] [750 mg]), '''''OR'''''<br>
|Previously healthy and no use of antimicrobials within the previous 3 months || A macrolide <br> Doxycyline
A [[b-lactam]] plus a [[macrolide]]</td></tr>
|-
<tr><td>Outpatient: Use of antibiotics within the last 3 months</td><td> An alternative from a different class should be selected:<br>
|Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs||A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])<br>
A [[fluoroquinolone]] ([[moxifloxacin]], [[gemifloxacin]], or [[levofloxacin]] [750 mg]), '''''OR'''''<br>
A b-lactam plus a macrolide
A [[b-lactam]] plus a [[macrolide]]</td></tr>
|-
<tr><td>Outpatient: In regions with a high rate (125%) of infection with high-level (MIC 16 mg/mL) [[macrolide]]-resistant Streptococcus pneumoniae</td><td>A [[fluoroquinolone]] ([[moxifloxacin]], [[gemifloxacin]], or [[levofloxacin]] [750 mg]), '''''OR'''''<br>
|Use of antimicrobials within the last 3 months|| An alternative from a different class should be selected:<br>
A [[b-lactam]] plus a [[macrolide]]</td></tr>
A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) (strong recommendation; level I evidence)<br>
<tr><td>Inpatient general medical ward </td><td> A [[fluoroquinolone]], '''''OR'''''<br>A [[b-lactam]] plus a [[macrolide]]</td></tr>
A b-lactam plus a macrolide (strong recommendation; level I evidence)
<tr><td>Inpatient ICU </td><td> A [[b-lactam]] ([[cefotaxime]], [[ceftriaxone]], or [[ampicillin]]-[[sulbactam]]) plus [[azithromycin]], '''''OR'''''<br> A [[b-lactam]] ([[cefotaxime]], [[ceftriaxone]], or [[ampicillin]]-[[sulbactam]]) plus a [[fluoroquinolone]], '''''OR'''''<br> For [[penicillin-allergic]] patients: a [[fluoroquinolone]] plus [[aztreonam]]</td></tr>
|-
<tr><td>Outpatient: Concern about [[pseudomona]]s</td><td>An antipneumococcal, antipseudomonal b-lactam ([[piperacillintazobactam]], [[cefepime]], [[imipenem]], or [[meropenem]]) plus either [[ciprofloxacin]] or [[levofloxacin]] (750 mg), '''''OR'''''<br> [[B-lactam]] plus an [[aminoglycoside]] and [[azithromycin]], '''''OR'''''<br>[[B-lactam]] plus an [[aminoglycoside]] and an antipneumococcal [[fluoroquinolone]], '''''OR'''''<br>
|In regions with a high rate (125%) of infection with high-level (MIC 16 mg/mL) macrolide-resistant Streptococcus pneumoniae||A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])<br>
For [[penicillin]]-allergic patients, substitute [[aztreonam]] for above [[b-lactam]]</td></tr>
A b-lactam plus a macrolide
<tr><td>Concern about community acquired [[MRSA]] </td><td> Add [[vancomycin]] or [[linezolid]]</td></tr>
|-
</table>
|Inpatient general medical ward || A respiratory fluoroquinolone<br>A b-lactam plus a macrolide
|
|-
| Inpatient ICU || A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus azithromycin<br> A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus a fluoroquinolone
<br> For penicillin-allergic patients: a respiratory fluoroquinolone and aztreonam
|-
|Concern about pseudomonas||An antipneumococcal, antipseudomonal b-lactam (piperacillintazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750 mg)
<br> B-lactam plus an aminoglycoside and azithromycin
<br>B-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone<br>
For penicillin-allergic patients, substitute aztreonam for above b-lactam
|-
|Concern about community acquired MRSA || Add vancomycin or linezolid
|}

Revision as of 18:10, 20 February 2015

Outpatient
Previously healthy and no use of antimicrobials within the previous 3 months A macrolide
Doxycyline
Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

A b-lactam plus a macrolide

Use of antimicrobials within the last 3 months An alternative from a different class should be selected:

A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg]) (strong recommendation; level I evidence)
A b-lactam plus a macrolide (strong recommendation; level I evidence)

In regions with a high rate (125%) of infection with high-level (MIC 16 mg/mL) macrolide-resistant Streptococcus pneumoniae A fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

A b-lactam plus a macrolide

Inpatient general medical ward A respiratory fluoroquinolone
A b-lactam plus a macrolide
Inpatient ICU A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus azithromycin
A b-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam) plus a fluoroquinolone


For penicillin-allergic patients: a respiratory fluoroquinolone and aztreonam

Concern about pseudomonas An antipneumococcal, antipseudomonal b-lactam (piperacillintazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750 mg)


B-lactam plus an aminoglycoside and azithromycin
B-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone
For penicillin-allergic patients, substitute aztreonam for above b-lactam

Concern about community acquired MRSA Add vancomycin or linezolid
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