Sandbox ID Lower Respiratory Tract: Difference between revisions

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::::* Preferred regimen: [[Clindamycin]] 450–900 mg IV q8h {{and}} [[Ceftriaxone]] 1.5 g IV/IM q24h
::::* Preferred regimen: [[Clindamycin]] 450–900 mg IV q8h {{and}} [[Ceftriaxone]] 1.5 g IV/IM q24h
::::* Alternative regimen: [[Imipenem]] 500 mg IV q6h {{or}} [[Piperacillin-Tazobactam]] 3.375 g IV q4h {{or}} [[Ticarcillin-clavulanate]] 3.1 g IV q4h {{or}} [[Ampicillin-Sulbactam]] 2/1 g IV q6h
::::* Alternative regimen: [[Imipenem]] 500 mg IV q6h {{or}} [[Piperacillin-Tazobactam]] 3.375 g IV q4h {{or}} [[Ticarcillin-clavulanate]] 3.1 g IV q4h {{or}} [[Ampicillin-Sulbactam]] 2/1 g IV q6h
===Pneumonia, Actinomycosis===
:* Preferred regimen (1): [[Penicillin]] V 1 g po qid 2-6 wk.<ref name="pmid20582172">{{cite journal| author=Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ| title=Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients. | journal=Ann Thorac Med | year= 2010 | volume= 5 | issue= 2 | pages= 80-5 | pmid=20582172 | doi=10.4103/1817-1737.62470 | pmc=PMC2883202 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20582172  }} </ref><ref name="pmidPMID: 14727221">{{cite journal| author=Sudhakar SS, Ross JJ| title=Short-term treatment of actinomycosis: two cases and a review. | journal=Clin Infect Dis | year= 2004 | volume= 38 | issue= 3 | pages= 444-7 | pmid=PMID: 14727221 | doi=10.1086/381099 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14727221  }} </ref>
:* Alternative regimen: [[Tetracycline]] 500 mg po q 6 h {{or}} [[Doxycycline]] 100 mg q 12 h may be given instead of [[Penicillin]].
:: Note: [[Minocycline]], [[Clindamycin]], and [[Erythromycin]] have also been successful.
===Pneumonia, Anaerobes===
: Anaerobe (aspiration) pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
::* Preferred Regimen: [[Piperacillin-Tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin-Clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-Sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
::* Alternate Regimen: [[Carbapenem]]-([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])
===Pneumonia, Aspiration pneumonia===
:* Aspiration (anaerobe) pneumonia <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
::* Preferred Regimen: [[Piperacillin-Tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin -Clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-Sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-Clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
::* Alternate Regimen: [[Carbapenem]]-([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])


===Pneumonia===
===Pneumonia===
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:::* 1.1.1 '''Outpatient treatment'''
:::* 1.1.1 '''Outpatient treatment'''
::::* 1.1.1.1 '''Previously healthy and no use of antimicrobials within the previous 3 months'''
::::* 1.1.1.1 '''Previously healthy and no use of antimicrobials within the previous 3 months'''
:::::* Preferred regimen: [[Azithromycin]] 500 mg PO single dose {{then}} [[Azithromycin]] 250 mg PO qd for 2 days (or [[Azithromycin]] 500 mg IV single dose) {{or}} [[Clarithromycin]] 250 mg PO bid for 7-14 days (or [[Clarithromycin]] 1000 mg PO qd for 7 days) {{or}} [[Erythromycin]] 250-500 mg PO bid or tid (max: 4 g/day)
:::::* Preferred regimen (1): ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days) {{or}} [[Azithromycin]] 500 mg IV single dose
:::::* Alternative regimen: [[Doxycycline]] 100 mg PO/IV q12h (Weak recommendation).
:::::* Preferred regimen (2): [[Clarithromycin]] 250 mg PO bid for 7-14 days {{or}} [[Clarithromycin]] 1000 mg PO qd for 7 days
:::::* Preferred regimen (3): [[Erythromycin]] 250-500 mg PO bid or tid (maximum daily dose 4 g)
:::::* Alternative regimen: [[Doxycycline]] 100 mg PO/IV q12h
::::* 1.1.1.2 '''Presence of comorbidities, use of immunosuppressing drugs, or use of antimicrobials within the previous 3 months'''
::::* 1.1.1.2 '''Presence of comorbidities, use of immunosuppressing drugs, or use of antimicrobials within the previous 3 months'''
:::::* Preferred regimen (1): [[Levofloxacin]] 500 mg PO qd for 7-14 days (or [[Levofloxacin]] 750 mg PO qd for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}}  [[Gemifloxacin]] 320 mg PO qd for 5 or 7 days)
:::::* Preferred regimen (1): [[Levofloxacin]] 500 mg PO qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg PO qd for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}}  [[Gemifloxacin]] 320 mg PO qd for 5 or 7 days
:::::* Preferred Regimen (2): [[Amoxicillin]] 875 mg PO bid or [[Amoxicillin]] 500 mg PO tid
:::::* Preferred regimen (2): ([[Amoxicillin]] 1 g PO q8h {{or}} [[Amoxicillin-clavulanate]] 1-2 g PO bid {{or}} [[Ceftriaxone]] 1-2 g IV q24h {{or}} [[Cefpodoxime]] 200 mg PO bid for 14 days {{or}} [[Cefuroxime]] 750 mg IM/IV q8h) {{and}} either ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days) {{or}} ([[Clarithromycin]] 250 mg PO bid for 7-14 days {{or}} [[Clarithromycin]] 1000 mg PO qd for 7 days) {{or}} [[Erythromycin]] 250-500 mg PO bid or tid (maximum daily dose 4 g)
:::::* Preferred Regimen (3): [[Amoxicillin-clavulanate]] 2 g PO bid
:::::* Preferred regimen (4): [[Ceftriaxone]] 1 g IV q24h (or [[Ceftriaxone]] 2 g IV q24h for patients at risk {{or}} [[Cefpodoxime]] 200 mg PO bid for 14 days {{or}} [[Cefuroxime]] 750 mg IM/IV q8h) {{and}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg PO qd on days 2-5
:::::* Preferred regimen (5): [[Doxycycline]] 100 mg PO/IV q12h
:::::*Note: In the case of recent (past 3 months) antimicrobial therapy, an alternative from a different class should be selected.
:::::*Note: In the case of recent (past 3 months) antimicrobial therapy, an alternative from a different class should be selected.
:::* 1.1.2 '''Inpatient treatment'''
:::* 1.1.2 '''Inpatient treatment'''
::::* 1.1.2.1 '''Non-ICU treatment'''
::::* 1.1.2.1 '''Non-ICU treatment'''
:::::* Preferred regimen (1): [[Levofloxacin]] 500 mg PO qd for 7-14 days or [[Levofloxacin]] 750 mg PO qd for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO qd for 5 or 7 days  
:::::* Preferred regimen (1): [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days {{or}} [[Moxifloxacin]] 400 mg IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO qd for 5-7 days  
:::::* Preferred regimen (2): [[Amoxicillin ]] 1 g PO q8h
:::::* Preferred regimen (2): ([[Amoxicillin]] 1 g PO q8h {{or}} [[Amoxicillin-clavulanate]] 1-2 g PO bid {{or}} [[Ceftriaxone]] 1-2 g IV q24h {{or}} [[Cefpodoxime]] 200 mg PO bid for 14 days {{or}} [[Cefuroxime]] 750 mg IM/IV q8h) {{and}} either ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days) {{or}} ([[Clarithromycin]] 250 mg PO bid for 7-14 days {{or}} [[Clarithromycin]] 1000 mg PO qd for 7 days) {{or}} [[Erythromycin]] 250-500 mg PO bid or tid (maximum daily dose 4 g)
:::::* Preferred regimen (3): [[Amoxicillin-clavulanate]] 2 g PO bid
:::::* Alternative regimen: [[Ceftriaxone]] 1 g IV q24h (or [[Ceftriaxone]] 2 g IV q24h for patients at risk {{or}} [[Cefpodoxime]] 200 mg PO bid for 14 days {{or}} [[Cefuroxime]] 750 mg IM/IV q8h)
::::* 1.1.2.2 '''ICU treatment'''
::::* 1.1.2.2 '''ICU treatment'''
:::::* Preferred regimen (1): [[Cefotaxime]] 1 g IM/IV q12h (or [[Ceftriaxone]] 1 g IV q24h, 2 g/day for patients at risk) 
:::::* Preferred regimen (1): ([[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1-2 g IV q24h {{or}} [[Ampicillin-sulbactam]] 1.5-3 g IV q6h) {{and}} ([[Levofloxacin ]] 500 mg IV q24h for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO q24h for 5-7 days)
:::::* Preferred regimen (2): [[Ampicillin-sulbactam]] 1.5-3 g IV q6h) {{and}} [[Azithromycin]] 500 mg/day PO once, followed by 250 mg q24h for 4 days  
:::::* Alternative regimen (1): ([[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1-2 g IV q24h {{or}} [[Ampicillin-sulbactam]] 1.5-3 g IV q6h) {{and}} ([[Azithromycin]] 500 mg IV qd for 2 days (PO for a total of 7-10 days)
:::::* Preferred regimen (3): [[Ciprofloxacin]] 500-750 mg q12h for 7-14 days (or [[Levofloxacin ]] 500 mg q24h for 7-14 days or [[Levofloxacin ]] 750 mg q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Gemifloxacin]] Oral: 320 mg q24h for 5 or 7 days)
:::::* Alternative regimen (2): [[Aztreonam]] 2 g IV q6-8h (maximum daily dose 8 g) {{and}} ([[Levofloxacin ]] 500 mg IV q24h for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV q24h for 5 days {{or}} [[Moxifloxacin]] 400 mg IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO q24h for 5-7 days)
:::::* Alternative regimen (For penicillin allergy): [[Levofloxacin]] 500 mg PO qd for 7-14 days (or [[Levofloxacin]] 750 mg PO q24h for 5 day {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Gemifloxacin]] 320 mg PO q24h for 5 or 7 days) {{and}} [[Aztreonam]] 2 g IV q6-8h (max: 8 g/day)
:::* 1.1.3 '''Special considerations'''
:::* 1.1.3 '''Special considerations'''
::::* 1.1.3.1 '''Suspected Pseudomonas'''
::::* 1.1.3.1 '''Suspected Pseudomonas'''
:::::* Preferred regimen (1): [[Piperacillin-Tazobactam]] {{and}} ([[Ciprofloxacin]] {{or}} [[Levofloxacin]] 750 mg q24h
:::::* Preferred regimen (1): [[Piperacillin-Tazobactam]] 3.375-4.5 g IV q6h for 7-14 days {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
:::::* Preferred regimen (2):[[Cefepime]] {{and}} ([[Ciprofloxacin]] {{or}} [[Levofloxacin]] 750 mg q24h
:::::* Preferred regimen (2): [[Cefepime]] 1-2 g IV q8-12h for 7-10 days {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
:::::* Preferred regimen (3):([[Imipenem]] {{or}} [[Meropenem]]) {{and}} [[Ciprofloxacin]] {{or}} [[Levofloxacin]] 750 mg q24h
:::::* Preferred regimen (3): ([[Imipenem]] 500 mg IV q6h for ≤5 days {{or}} [[Meropenem]] 500 mg IV q8hr for ≤5 days) {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
:::::* Alternative regimen (1): [[Piperacillin-Tazobactam]] {{and}} [[Aminoglycosides]] {{and}} [[Azithromycin]]
:::::* Preferred regimen (4): [[Piperacillin-Tazobactam]] 3.375-4.5 g IV q6h for 7-14 days {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days)
:::::* Alternative regimen (2): [[Cefepime]] {{and}} [[Aminoglycosides]] {{and}} [[Azithromycin]]
:::::* Preferred regimen (5): [[Cefepime]] {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days)
:::::* Alternative regimen (3): ([[Imipenem]] {{or}} [[Meropenem]]) {{and}} [[Aminoglycosides]] {{and}} [[Azithromycin]] {{or}} [[Levofloxacin]] 750 mg PO q24h {{or}} [[Moxifloxacin]] {{or}} [[Gemifloxacin]]
:::::* Preferred regimen (6): ([[Imipenem]] 500 mg IV q6h for ≤5 days {{or}} [[Meropenem]] 500 mg IV q8hr for ≤5 days) {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Azithromycin]] 500 mg PO single dose for 1 day {{then}} 250 mg PO qd for 4 days)
:::::* Alternative regimen (4): [[Piperacillin-Tazobactam]] {{and}} [[Levofloxacin]] 750 mg PO q24h {{or}} [[Moxifloxacin]] {{or}} [[Gemifloxacin]]
:::::* Preferred regimen (7): ([[Imipenem]] 500 mg IV q6h for ≤5 days {{or}} [[Meropenem]] 500 mg IV q8hr for ≤5 days) {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg PO qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg PO qd for 5 days)
:::::* Alternative regimen (5): [[Cefepime]] {{and}} [[Aminoglycosides]] {{and}} [[Levofloxacin]] 750 mg PO q24h {{or}} [[Moxifloxacin]] {{or}} [[Gemifloxacin]]
:::::* Preferred regimen (8): [[Piperacillin-Tazobactam]] 3.375-4.5 g IV q6h for 7-14 days {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
:::::* Alternative regimen (6): ([[Imipenem]] {{or}} [[Meropenem]]) {{and}} [[Levofloxacin]] 750 mg PO q24h {{or}} [[Moxifloxacin]] {{or}} [[Gemifloxacin]]
:::::* Preferred regimen (9): [[Cefepime]] 1-2 g IV q8-12h for 7-10 days {{and}} ([[Amikacin]] 20 mg/kg/day IV q8-12h {{or}} [[Gentamicin]] 3-5 mg/kg/day IV/IM q8h {{or}} [[Tobramycin]] 3-6 mg/kg/day IV/IM q8h) {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg IV qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg IV qd for 5 days)
:::::* Note: For penicillin-allergic patients, substitute the beta-lactam for [[Aztreonam]]
:::::* Preferred regimen (10): ([[Imipenem]] 500 mg IV q6h for ≤5 days {{or}} [[Meropenem]] 500 mg IV q8hr for ≤5 days) {{and}} ([[Ciprofloxacin]] 400 mg IV q8h for 7-14 days {{or}} [[Levofloxacin]] 500 mg PO qd for 7-14 days {{or}} [[Levofloxacin]] 750 mg PO qd for 5 days)
:::::* Note: For penicillin-allergic patients, substitute the beta-lactam for [[Aztreonam]] 1-2 g IV q6-8h.
::::* 1.1.3.2 '''Suspected methicillin resistant Staphylococcus aureus (add the following)'''
::::* 1.1.3.2 '''Suspected methicillin resistant Staphylococcus aureus (add the following)'''
:::::* Preferred regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days.
:::::* Preferred regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days
::*1.2 '''Empiric therapy in neonates''' (Age < 28 days)
::::* 1.1.3.3 '''Neutropenic patient''' <ref name="pmid15699079">{{cite journal| author=American Thoracic Society. Infectious Diseases Society of America| title=Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 171 | issue= 4 | pages= 388-416 | pmid=15699079 | doi=10.1164/rccm.200405-644ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15699079  }} </ref>
:::* Preferred regimen: [[Ampicillin]] 500 mg/day for 7-14 days {{or}} 750 mg/day for 5 days {{or}} ([[Gentamicin]] 400 mg/day PO/IV for 7-14 days '''±''' [[Cefotaxime]] 320 mg PO q24h for 5 or 7 days)
:::::* 1.1.3.3.1 '''No risk for multi-drug resistance'''
:::* 1.2.1 '''Special considerations'''
::::::* Preferred regimen: [[Ceftriaxone]] 1-2 g q24h IV or IM (max: 4 g/day) {{or}} [[Levofloxacin]] 750 mg q24h for 7-14 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Ciprofloxacin]] 400 mg PO q8h for 10-14 days {{or}} [[Ampicillin sulbactam]] 1-2 g q6-8h IV/IM (maximum: 8 g/day) {{or}} [[Ertapenem]] 1 g IM/IV q24h for 10-14 days.
::::* 1.2.1.1 '''Suspected methicillin resistant Staphylococcus aureus (add the following)'''
:::::* 1.1.3.3.2 '''Risk for multi drug resistance'''
:::::*Preferred regimen: [[Vancomycin]] 10 mg/kg IV q8h {{or}} [[Linezolid]] 10 mg/kg IV q8h
::::::* Preferred Regimen: ([[Cefepime]] 1-2 g q8-12h {{or}} [[Ceftazidime]] 2 g q8h {{or}} [[Imipenem]] 500 mg q6h or 1g q8h {{or}} [[Meropenem]] 1 g q8h {{or}} [[Piperacillin-tazobactam]] 4.5 g q6h) {{and}} ([[Ciprofloxacin]] 400 mg q8h {{or}} [[Levofloxacin]] 750 mg q24h {{or}} [[Amikacin]] 20 mg/kg per day {{or}} [[Gentamycin]] 7 mg/kg per day {{or}} [[Tobramycin]] 7 mg/kg per day) {{and}} ([[Linezolid]] 600 mg q12h {{or}} [[Vancomycin]] 15 mg/kg q12h).
 
::::::* Note (1) : Trough levels for [[Gentamycin]] and [[Tobramycin]] should be less than 1 g/ml, and for [[Amikacin]] they should be less than 4-5 g/ml.
::::* 1.2.1.2 '''Suspected Chlamydia trachomatis (add the following)'''
::::::* Note (2) : Trough levels for [[Vancomycin]] should be 15-20 g/ml
:::::*Preferred regimen: [[Erythromycin]] 12.5 mg/kg PO/IV q6h for 14 days {{or}} ([[Azithromycin]] 10 mg/kg PO/IV single dose for 1 day {{then}} 5 mg/kg PO/IV q24h for 4 days)
::::::* Note (3) : Hospital or community acquired, neutropenic patient (<500 neutrophils per mm3) [[Vancomycin]] not included in initial therapy unless high suspicion of infected intravenous access or drug-resistant Streptococcus pneumonia. Amphotericin not used unless still febrile after 3 days or high clinical likelihood.
:* '''pathogen directed antimicrobial therapy'''
:* Bacterial
::* (A) '''Streptococcus pneumoniae'''
:::* (1) Penicillin nonresistant; minimum inhibitory concentration < 2 mg / mL
::::* Preferred Regimen : [[Penicillin G]] 2-3 million units IV q4h {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
::::* Alternative Regimen : [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Cefpodoxime]] 200 mg PO q12h for 14 days {{or}} [[Cefprozil]] 500 mg PO q12h for 10 days {{or}} [[Cefuroxime]] 750 mg PO/IV q8h {{or}} [[Cefdinir]] 300 mg PO q12h for 10 days {{or}} [[Cefditoren]] 400 mg PO q12h for 14 day {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (maximum: 1800 mg/day) {{or}} [[Clindamycin]] 1.2-2.7 g/day IM/IV in 2-4 divided doses (maximum:4800 mg/day) {{or}} [[Doxycycline]] 100 mg PI/IV q12h {{or}}[[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h.
:::* (2) Penicillin resistant;  minimum inhibitory concentration > 2 mg / mL
::::* Preferred Regimen (Agents chosen on the basis of susceptibililty) : [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
::::* Alternative Regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)
 
::* (B)'''Haemophilus influenzae'''
:::* (1) Non-beta lactamase producing
::::* Preferred Regimen: [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
::::* Alternative Regimen : [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
:::* (2) Beta lactamase producing
::::* Preferred Regimen: 2nd or 3rd Generation [[Cephalosporin]] {{or}} [[Amoxicillin-clavulanate]] 2 g q12h
::::* Alternative Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
 
::* (C) '''Bacillus anthracis''' (inhalation)
:::* Preferred Regimen  :[[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Doxycycline]] 100 mg PO/IV q12h
:::* Alternate Regimen : Other [[Fluoroquinolones]] {{or}} B-lactam (if susceptible) {{or}} [[Rifampin]] 600 mg PO/IV q24h for 4 days {{or}} [[Clindamycin]] 150-450 mg PO q6-8h {{or}} [[Chloramphenicol]] 50-100 mg/kg/day IV in divided q6h
 
::* (D) '''Enterobacteriaceae'''
:::* Preferred Regimen: 3rd generation cephalosporin {{or}} Carbapenem- ([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) (drug of choice if extended-spectrum b-lactamase producer)
:::* Alternate Regimen : b-Lactam / b-lactamase inhibitor- ([[Piperacillin-Tazobactam]] for gram-negative bacilli, {{or}} [[Ticarcillin-Clavulanate]] {{or}} [[Ampicillin-Sulbactam]] {{or}} [[Amoxicillin-Clavulanate]]) {{or}} ([[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h) 
 
::* (E)'''Pseudomonas aeruginosa'''
:::* Preferred Regimen: ([[Ticarcillin]] 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) {{or}} [[Piperacillin]] 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h {{or}} [[Ceftazidime]] 500 mg to 1 g q8h {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Aztreonam]] 2 g IV q6-8h (maximum: 8 g/day) {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily {{or}} [[Aminoglycoside]])
:::* Alternate Regimen: [[Aminoglycoside]] {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily)
 
::* (F)'''Staphylococcus aureus'''
:::* (1) Methicillin susceptible
::::* Preferred Regimen : [[Nafcillin]] 1000-2000 mg q4h {{or}} [[Oxacillin]] 2 g IV q4h {{or}} [[Flucloxacillin]] 250 mg IM/IV q6h
::::* Alternative Regimen : [[Cefazolin]] 500 mg IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h
:::* (2) Methicillin resistant
::::* Preferred Regimen : [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days
::::* Alternative Regimen: [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
 
::* (G)'''Bordetella pertussis'''
:::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
:::* Alternate Regimen: [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
 
::* (H) Anaerobe (aspiration)
:::* Preferred Regimen: [[Piperacillin-Tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin Clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-Sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-Clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
:::* Alternate Regimen: [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])
 
::* (I) '''Mycobacterium tuberculosis'''
:::* Preferred Regimen:
::::* Intensive phase: [[Isoniazid]] 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) {{and}} [[Rifampin]] 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) {{and}} [[Ethambutol]] 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day daily for 2 months.
::::* Continuation phase: [[Isoniazid]] 300 mg/day PO daily for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO daily for 4 months (10 mg/kg/day).
 
:::* Alternate regimen (1):
::::* Intensive phase: [[Isoniazid]] 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day)  {{and}} [[Rifampin]] 10 mg/kg/day daily for 2 months (maximum: 600 mg / day)  {{and}} [[Ethambutol]] 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g)  {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day daily for 2 months.
::::* Continuation phase: [[Isoniazid]] 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day).
:::: Note : Acceptable alternative for any new TB patient receiving directly observed therapy
 
:::* Alternate regimen (2)
::::* Intensive phase:[[Isoniazid]] 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day)  {{and}} [[Rifampin]] 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s {{and}} [[Ethambutol]] 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months  {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day 3 times per week for 2 months.
::::*Continuation phase: [[Isoniazid]] 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day).
:::: Note : Acceptable alternative provided that the patient is receiving directly observed therapy and is not living with HIV or living in an HIV prevalent setting.


::* (J) '''Yersinisa pestis'''
::* 1.2 '''Pathogen-directed antimicrobial therapy'''
:::* Preferred Regimen: [[Streptomycin]] 15 mg/kg/day (max 1 g/day) {{or}} [[Gentamicin]] 7 mg/kg/day
:::* 1.2.1 '''Bacterial pathogens'''
:::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
::::* 1.2.1.1 '''Streptococcus pneumoniae'''
:::::* 1.2.1.1.1 '''Penicillin sensitive (minimum inhibitory concentration < 2 mg/mL)'''
::::::* Preferred regimen : [[Penicillin G]] 2-3 million units IV q4h {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
::::::* Alternative regimen : [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Cefpodoxime]] 200 mg PO q12h for 14 days {{or}} [[Cefprozil]] 500 mg PO q12h for 10 days {{or}} [[Cefuroxime]] 750 mg PO/IV q8h {{or}} [[Cefdinir]] 300 mg PO q12h for 10 days {{or}} [[Cefditoren]] 400 mg PO q12h for 14 day {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (maximum: 1800 mg/day) {{or}} [[Clindamycin]] 1.2-2.7 g/day IM/IV in 2-4 divided doses (maximum:4800 mg/day) {{or}} [[Doxycycline]] 100 mg PI/IV q12h {{or}}[[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
:::::* 1.2.1.1.2 '''Penicillin resistant (minimum inhibitory concentration > 2 mg/mL)'''
::::::* Preferred regimen (Agents chosen on the basis of susceptibililty) : [[Cefotaxime]] 1 g IM/IV q12h {{or}} [[Ceftriaxone]] 1 g IV q24h, 2 g daily for patients at risk {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
::::::* Alternative regimen: [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days {{or}} [[Amoxicillin]] 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)


:* Atypical bacteria
::::* 1.2.1.2 '''Haemophilus influenzae'''
::* (A) '''Mycoplasma pneumoniae'''
:::::* 1.2.1.2.1 '''Non-beta lactamase producing'''
:::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] Oral: 250-500 mg q6h
::::::* Preferred regimen: [[Amoxicillin]] 875 mg PO q12h or 500 mg q8h
:::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
::::::* Alternative regimen : [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days
:::::* 1.2.1.2.2 '''Beta lactamase producing'''
::::::* Preferred regimen: 2nd or 3rd Generation [[Cephalosporin]] {{or}} [[Amoxicillin-clavulanate]] 2 g q12h
::::::* Alternative regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 {{or}} [[Clarithromycin]] 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days


::* (B) '''Chlamydophila pneumoniae'''
::::* 1.2.1.2 '''Bacillus anthracis (inhalational)'''
:::* Preferred Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] 250-500 mg PO q6h
:::::* Preferred Regimen :[[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 500 mg q24h for 7-14 days or 750 mg q24h for 5 days {{or}} [[Doxycycline]] 100 mg PO/IV q12h
:::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
:::::* Alternate Regimen : Other [[Fluoroquinolones]] {{or}} B-lactam (if susceptible) {{or}} [[Rifampin]] 600 mg PO/IV q24h for 4 days {{or}} [[Clindamycin]] 150-450 mg PO q6-8h {{or}} [[Chloramphenicol]] 50-100 mg/kg/day IV in divided q6h


::* (C) '''Legionella species'''
::::* 1.2.1.3 '''Enterobacteriaceae'''
:::* Preferred Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
:::::* Preferred Regimen: 3rd generation cephalosporin {{or}} Carbapenem- ([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) (drug of choice if extended-spectrum b-lactamase producer)
:::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h
:::::* Alternate Regimen : b-Lactam / b-lactamase inhibitor- ([[Piperacillin-Tazobactam]] for gram-negative bacilli, {{or}} [[Ticarcillin-Clavulanate]] {{or}} [[Ampicillin-Sulbactam]] {{or}} [[Amoxicillin-Clavulanate]]) {{or}} ([[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h) 


::* (D)'''Chlamydophila psittaci'''
::::* 1.2.1.4 '''Pseudomonas aeruginosa'''
:::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
:::::* Preferred Regimen: ([[Ticarcillin]] 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) {{or}} [[Piperacillin]] 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h {{or}} [[Ceftazidime]] 500 mg to 1 g q8h {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Aztreonam]] 2 g IV q6-8h (maximum: 8 g/day) {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily {{or}} [[Aminoglycoside]])
:::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
:::::* Alternative Regimen: [[Aminoglycoside]] {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily)


::* (E)''' Coxiella burnetii'''
::::* 1.2.1.5 '''Staphylococcus aureus'''
:::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
:::::* 1.2.1.5.1 '''Methicillin sensitive'''
:::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
::::::* Preferred Regimen : [[Nafcillin]] 1000-2000 mg q4h {{or}} [[Oxacillin]] 2 g IV q4h {{or}} [[Flucloxacillin]] 250 mg IM/IV q6h
::::::* Alternative Regimen : [[Cefazolin]] 500 mg IV q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h
:::::* 1.2.1.5.2 '''Methicillin resistant'''
::::::* Preferred Regimen : [[Vancomycin]] 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days {{or}} [[Linezolid]] 600 mg PO/IV q12h for 10-14 days
::::::* Alternative Regimen: [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h


::* (F) '''Francisella tularensis'''
:::* Preferred Regimen: [[Doxycycline]]  100 mg PO/IV q12h
:::* Alternate Regimen: [[Gentamicin]] 7 mg/kg/day {{or}} [[Streptomycin]] 15 mg/kg/day (maximum: 1 g)


::* (G) '''Burkholderia pseudomallei'''
::::* 1.2.1.6 '''Klebsiella pneumonia'''<ref> {{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:::* Preferred Regimen : [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) {{or}} [[Ceftazidime]] 0.5-1 g q8h
:::::* 1.2.1.6.1 '''Resistant to third generation cephalosporins and aztreonam'''
:::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
::::::* Preferred regimen (1): [[Imipenem]] 0.5 g IV q6h {{or}} [[Meropenem]]  0.5–1 g IV q8h
:::::* 1.2.1.6.2 '''Klebsiella pneumoniae Carbapenemase producers'''
::::::* Preferred regimen (1): [[Colistin]] (='''Polymyxin E''').In USA : '''Colymycin-M '''2.5-5 mg/kg per day of base divided into 2-4 doses 6.7-13.3 mg/kg per day of [[colistimethate sodium]] (max 800 mg/day). Elsewhere: '''Colomycin''' and '''Promixin''' ≤60 kg, 50,000-75,000 IU/kg per day IV in 3 divided doses (=4-6 mg/kg per day of [[colistimethate sodium]]). >60 kg, 1-2 mill IU IV tid (= 80-160 mg IV tid) {{or}} [[Polymyxin B]] (Poly-Rx) 15,000–25,000 units/kg/day divided q12h
::::::* Note (1): some strains which hyperproduce extended spectrum beta-lactamase are primarily resistant to [[Ticarcillin-Clavulanate]], [[Piperacillin]]-[[Tazobactam]]
::::::* Note (2): Extended spectrum beta-lactamases inactivates all [[Cephalosporins]], beta-lactam/beta-lactamase inhibitor drug activation not predictable; co-resistance to all [[Fluoroquinolones]] & often [[Aminoglycosides]].
::::::* Note (3): Can give IM, but need to combine with “caine” anesthetic due to pain.


::* (H) '''Acinetobacter species'''
::::* 1.2.1.7 '''Moraxella catarrhalis'''
:::* Preferred Regimen : [[Carbapenem]]-([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])
:::::* Preferred regimen: [[Amoxicillin-Clavulanate]] (Augmentin) 2 tablets po bid ( (or)500/125 mg 1 tablet po tid (or) 875/125 mg 1 tablet po bid) {{or}} [[Cephalosporins]]- [[Cefdinir]] 300 mg po q12h (or) 600 mg q24h, {{or}} ([[Cefditoren pivoxil]] 200–400 mg, 2 tabs po bid,{{or}} [[Cefpodoxime proxetil]] 0.1–0.2 g po q12h, {{or}} [[Cefprozil]] 500 mg po q12h), {{or}} [[Cefoxitin]] 1 g q8h–2 g IV/IM q4h, {{or}} ([[Cefuroxime]] 0.75–1.5 g IV/IM q8h,{{or}}[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h, {{or}} [[Ceftazidime]] 1–2 g IV/IM q8–12h) {{or}} [[Trimethoprim-Sulfamethoxazole]] Single-strength (SS) is [[Trimethoprim]] 80 mg / [[Sulfamethoxazole]] 400 mg ,{{or}} (double-strength (DS) [[Trimethoprim]] 160 mg /[[Sulfamethoxazole]] 800 mg)
:::* Alternate Regimen: [[Cephalosporin]]-[[Aminoglycoside]] {{or}} [[Ampicillin-Sulbactam]] {{or}} [[Colistin]] 2.5-5 mg/kg/day IM/IV divided q6-12h (maximum: 5 mg/kg/day)
:::::*Alternative regimen:  [[Azithromycin]] 500 mg IV q24h ,{{or}} [[Clarithromycin]] 0.5 g po q12h, {{or}} [[Telithromycin]] 800 mg po q24h (two 400 mg tabs po q24h).


:* Viral
::* '''Influenza virus'''
:::* Preferred Regimen: [[Oseltamivir]] 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) {{or}} [[Zanamivir]] Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)


:* Fungal
::::* 1.2.1.8 '''Stenotrophomonas maltophilia'''
::* (A) '''Coccidioides species'''
:::::* Preferred regimen: [[Trimethoprim-Sulfamethoxazole]] Single-strength (SS) tablet is [[Trimethoprim]] 80 mg / [[Sulfamethoxazole]]  400 mg, double-strength (DS) tablet is [[Trimethoprim]] 160 mg / [[Sulfamethoxazole]] 800 mg {{or}} IV treatment (base on TMP component): standard 8–10 mg per kg per day divided q6h, q8h, or q12h.
:::* Preferred Regimen: [[Itraconazole]] 200 mg q12h {{or}} [[Fluconazole]] 200-400 mg daily for 3-6 month
:::::* Alternative regimen: [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h ([[Ticarcillin]] 3 g, [[Clavulanate]] 0.1 g per vial) {{and}} [[Aztreonam]] 1 g IV q6h (or) 2 g IV q8h
:::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
:::::* Note (1): Potential synergy with [[Trimethoprim-Sulfamethoxazole]] {{and}} [[Ticarcillin-Clavulanate]].
::::Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection
:::::* Note (2): Stenotrophomonas is one of the microorganisms causing hospital-acquired pneumonia usually with mechanical ventilation.


::* (B) '''Histoplasmosis'''
::::* 1.2.1.9 '''Bordetella pertussis'''
:::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
:::::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
:::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
:::::* Alternative Regimen: [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h


::* (C) '''Blastomycosis'''
::::* 1.2.1.10 '''Anaerobes (aspiration pneumonia)'''
:::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
:::::* Preferred Regimen: [[Piperacillin-Tazobactam]] 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) {{or}} [[Ticarcillin Clavulanate]] 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) {{or}} [[Ampicillin-Sulbactam]] 1500-3000 mg IV q6h {{or}} [[Amoxicillin-Clavulanate]] 250-500 mg PO q8h or 875 mg q12h {{or}} [[Clindamycin]] 150-450 mg PO q6-8h (max: 1800 mg/day)
:::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
:::::* Alternative Regimen: [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])


:*2. '''Health care-associated pneumonia'''<ref name="pmid15699079">{{cite journal| author=American Thoracic Society. Infectious Diseases Society of America| title=Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 171 | issue= 4 | pages= 388-416 | pmid=15699079 | doi=10.1164/rccm.200405-644ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15699079  }} </ref>
::::* 1.2.1.11 '''Mycobacterium tuberculosis'''
:*  '''Empiric therapy'''
:::::* 1.2.1.11.1 '''Intensive phase'''
::*  '''No Risk Factors for multi drug resistance'''
::::::* Preferred Regimen: [[Isoniazid]] 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) {{and}} [[Rifampin]] 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) {{and}} [[Ethambutol]] 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day daily for 2 months.
:::* Preferred Regimen : [[Ceftriaxone]] 1-2 g q24h IV or IM (max: 4 g/day) {{or}} [[Levofloxacin]] 750 mg q24h for 7-14 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Ciprofloxacin]] 400 mg PO q8h for 10-14 days {{or}} [[Ampicillin sulbactam]] 1-2 g q6-8h IV/IM (maximum: 8 g/day) {{or}} [[Ertapenem]] 1 g IM/IV q24h for 10-14 days.
::::::*Alternative regimen (1): [[Isoniazid]] 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day)  {{and}} [[Rifampin]] 10 mg/kg/day daily for 2 months (maximum: 600 mg / day)  {{and}} [[Ethambutol]] 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day daily for 2 months.
::*'''Presence of Risk Factors for multi drug resistance'''
::::::*Alternative regimen (2): [[Isoniazid]] 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day)  {{and}} [[Rifampin]] 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s {{and}} [[Ethambutol]] 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months  {{and}} [[Pyrazinamide]] 1000 - 2000 mg / day 3 times per week for 2 months.
:::* Preferred Regimen: ([[Cefepime]] 1-2 g q8-12h {{or}} [[Ceftazidime]] 2 g q8h {{or}} [[Imipenem]] 500 mg q6h or 1g q8h {{or}} [[Meropenem]] 1 g q8h {{or}} [[Piperacillin-tazobactam]] 4.5 g q6h) {{and}} ([[Ciprofloxacin]] 400 mg q8h {{or}} [[Levofloxacin]] 750 mg q24h {{or}} [[Amikacin]] 20 mg/kg per day {{or}} [[Gentamycin]] 7 mg/kg per day {{or}} [[Tobramycin]] 7 mg/kg per day) {{and}} ([[Linezolid]] 600 mg q12h {{or}} [[Vancomycin]] 15 mg/kg q12h).
:::::* 1.2.1.11.2 '''Continuation phase'''
:::* Note (1): Health care-associated pneumonia used to designate large diverse population of patients with many co-morbidities who reside in nursing homes, other long-term care facilities, require home intravenous therapy (or) are dialysis patients. Pneumonia in these patients frequently resembles hospital-acquired pneumonia.
::::::* Preferred Regimen:[[Isoniazid]] 300 mg/day PO daily for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO daily for 4 months (10 mg/kg/day)
:::* Note (2): Trough levels for [[Gentamycin]] and [[Tobramycin]] should be less than 1 g/ml, and for [[Amikacin]] they should be less than 4-5 g/ml.
::::::* Alternative regimen (1): [[Isoniazid]] 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) {{and}} [[Rifampicin]] 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day)
:::* Note (3): Trough levels for [[Vancomycin]] should be 15-20 g/ml.


===Pneumonia, concomitant influenza===
::::* 1.2.1.12 '''Yersinisa pestis'''
:* '''Influenza virus pneumonia''' <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
:::::* Preferred Regimen: [[Streptomycin]] 15 mg/kg/day (max 1 g/day) {{or}} [[Gentamicin]] 7 mg/kg/day
::* Preferred Regimen: [[Oseltamivir]] 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) {{or}} [[Zanamivir]] Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)
:::::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h {{or}} [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h


===Pneumonia, Cytomegalovirus===
::::* 1.2.1.13 '''Atypical bacteria'''
* '''Cytomegalovirus pneumonia''' <ref name="pmid18652557">{{cite journal| author=Torres-Madriz G, Boucher HW| title=Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients. | journal=Clin Infect Dis | year= 2008 | volume= 47 | issue= 5 | pages= 702-11 | pmid=18652557 | doi=10.1086/590934 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18652557  }} </ref>
:::::* 1.2.1.13.1 '''Mycoplasma pneumoniae'''
:* Preferred regimen (1): [[Ganciclovir]] Induction therapy 5 mg/ kg IV every 12 h for normal GFR; maintenance therapy 5 mg/kg IV daily; 1 g orally every 8 h with food.
::::::* Preferred Regimen:[[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] Oral: 250-500 mg q6h
:* Preferred regimen (2): [[Valganciclovir]] Induction therapy 900 mg orally every 12 h; maintenance therapy 900 mg daily.
::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h
:* Alternate regimen (1): [[Foscarnet]] Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
:* Alternate regimen (2): [[Cidofovir]] Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.


* '''Prophylaxis'''
:::::* 1.2.1.13.2 '''Chlamydophila pneumoniae'''
:* Preferred regimen (1): [[Cytomegalovirus]] [[immunoglobulin]] 150 mg/kg within 72 h; then at 2, 4, 6, and 8 weeks; 100 mg/kg at 12 and 16 weeks after [[transplantation]].
::::::* Preferred Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h {{or}} [[Tetracycline]] 250-500 mg PO q6h
::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h


===Pneumonia, Klebsiella===
:::::* 1.2.1.13.3 '''Legionella spp.'''
* '''Klebsiella pneumonia''' <ref> {{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
::::::* Preferred Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
::* '''Pathogen directed antimicrobial therapy'''
::::::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h
::* (A) Resistant to [[Ceftazidime]] and other 3rd generation [[Cephalosporins]], [[Aztreonam]]
:::* Preferred regimen (1): [[Imipenem]] 0.5 g IV q6h {{or}} [[Meropenem]]  0.5–1 g IV q8h
::* (B) Resistant to [[Carbapenems]], 2nd and  3rd generation [[Cephalosporins]] due to KPC enzymes
:::* Preferred regimen (2): [[Colistin]] (='''Polymyxin E''').In USA : '''Colymycin-M '''2.5-5 mg/kg per day of base divided into 2-4 doses 6.7-13.3 mg/kg per day of [[colistimethate sodium]] (max 800 mg/day). Elsewhere: '''Colomycin''' and '''Promixin''' ≤60 kg, 50,000-75,000 IU/kg per day IV in 3 divided doses (=4-6 mg/kg per day of [[colistimethate sodium]]). >60 kg, 1-2 mill IU IV tid (= 80-160 mg IV tid) {{or}} [[Polymyxin B]] (Poly-Rx) 15,000–25,000 units/kg/day divided q12h
:::: Note (1): some strains which hyperproduce extended spectrum beta-lactamase are primarily resistant to [[Ticarcillin-Clavulanate]], [[Piperacillin]]-[[Tazobactam]]
:::: Note (2): Extended spectrum beta-lactamases inactivates all [[Cephalosporins]], beta-lactam/beta-lactamase inhibitor drug activation not predictable; co-resistance to all [[Fluoroquinolones]] & often [[Aminoglycosides]].
:::: Note (3): Can give IM, but need to combine with “caine” anesthetic due to pain.


===Pneumonia, Legionella===
:::::* 1.2.1.13.4 '''Chlamydophila psittaci'''
:* '''Legionella pneumonia''' (atypical bacterial pneumonia) <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
::::::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
::* Preferred Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
::::::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
::* Alternate Regimen: [[Doxycycline]] 100 mg PO/IV q12h


===Pneumonia, Lung abscess===
:::::* 1.2.1.13.5 ''' Coxiella burnetii'''
* '''Aspiration pneumonia and lung abscess'''
::::::* Preferred Regimen: [[Tetracycline]] 250-500 mg PO q6h
:*  '''Empiric therapy'''<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
::::::* Alternate Regimen: [[Azithromycin]] 500 mg PO on day 1 followed by 250 mg q24h
::* Preferred regimen: [[Piperacillin]]-[[Tazobactam]] 3.375 g IV q6h or 4-hr infusion of 3.375 g q8h .
::* Alternative regimen: [[Ceftriaxone]] 1 g IV q24h {{and}} [[Metronidazole]] 500 mg IV q6h or 1 g IV q12h
::* Adjunctive therapy : [[Moxifloxacin]] 400 mg IV/po q24h another option
::* Note : Transthoracic culture  of total isolates is anaerobes 34%, gram positive cocci 26%, St milleri 16%, Klebsiella pneumoniae 25%, Nocardia 3%.


===Pneumonia, Meliodosis===
:::::* 1.2.1.13.6 '''Francisella tularensis'''
:*'''Burkholderia pseudomallei (meliodosis) pneumonia'''<ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
::::::* Preferred Regimen: [[Doxycycline]] 100 mg PO/IV q12h
::* Pathogen directed antimicrobial activity
::::::* Alternate Regimen: [[Gentamicin]] 7 mg/kg/day {{or}} [[Streptomycin]] 15 mg/kg/day (maximum: 1 g)
:::* Preferred Regimen : [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) {{or}} [[Ceftazidime]] 0.5-1 g q8h
:::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h


===Pneumonia, Moraxella catarrhalis===
:::::* 1.2.1.13.7 '''Burkholderia pseudomallei'''
* '''Moraxella catarrhalis (branhamella) pneumonia'''<ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
::::::* Preferred Regimen : [[Carbapenem]] -([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]]) {{or}} [[Ceftazidime]] 0.5-1 g q8h
:*  '''Pathogen-directed antimicrobial therapy'''
::::::* Alternate Regimen: [[Levofloxacin]] 750 mg IV q24h {{or}} [[Moxifloxacin]] 400 mg IV q24h {{or}} [[Trimethoprim-Sulfamethoxazole]] 1-2 double-strength tablets (800/160 mg) q12-24h
::* Preferred regimen: [[Amoxicillin-Clavulanate]] (Augmentin) 2 tablets po bid ( (or)500/125 mg 1 tablet po tid (or) 875/125 mg 1 tablet po bid) {{or}} [[Cephalosporins]]- [[Cefdinir]] 300 mg po q12h (or) 600 mg q24h, {{or}} ([[Cefditoren pivoxil]] 200–400 mg, 2 tabs po bid,{{or}} [[Cefpodoxime proxetil]] 0.1–0.2 g po q12h, {{or}} [[Cefprozil]] 500 mg po q12h), {{or}} [[Cefoxitin]] 1 g q8h–2 g IV/IM q4h, {{or}} ([[Cefuroxime]] 0.75–1.5 g IV/IM q8h,{{or}}[[Cefotaxime]] 1 g q8–12h to 2 g IV q4h, {{or}} [[Ceftazidime]] 1–2 g IV/IM q8–12h) {{or}} [[Trimethoprim-Sulfamethoxazole]] Single-strength (SS) is [[Trimethoprim]] 80 mg / [[Sulfamethoxazole]] 400 mg ,{{or}} (double-strength (DS) [[Trimethoprim]] 160 mg /[[Sulfamethoxazole]] 800 mg)
::*Alternative regimen:  [[Azithromycin]] 500 mg IV q24h ,{{or}} [[Clarithromycin]] 0.5 g po q12h, {{or}} [[Telithromycin]] 800 mg po q24h (two 400 mg tabs po q24h).


===Pneumonia, neutropenic patient===
:::::* 1.2.1.13.8 '''Acinetobacter species'''
* '''Pneumonia in neutropenic patients''' <ref name="pmid15699079">{{cite journal| author=American Thoracic Society. Infectious Diseases Society of America| title=Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 171 | issue= 4 | pages= 388-416 | pmid=15699079 | doi=10.1164/rccm.200405-644ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15699079  }} </ref>
::::::* Preferred Regimen : [[Carbapenem]]-([[Imipenem]]-[[Cilastatin]], {{or}} [[Meropenem]], {{or}} [[Ertapenem]])
:* Empiric therapy
::::::* Alternate Regimen: [[Cephalosporin]]-[[Aminoglycoside]] {{or}} [[Ampicillin-Sulbactam]] {{or}} [[Colistin]] 2.5-5 mg/kg/day IM/IV divided q6-12h (maximum: 5 mg/kg/day)
::* No Risk Factors for multi drug resistance
:::* Preferred Regimen : [[Ceftriaxone]] 1-2 g q24h IV or IM (max: 4 g/day) {{or}} [[Levofloxacin]] 750 mg q24h for 7-14 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Ciprofloxacin]] 400 mg PO q8h for 10-14 days {{or}} [[Ampicillin sulbactam]] 1-2 g q6-8h IV/IM (maximum: 8 g/day) {{or}} [[Ertapenem]] 1 g IM/IV q24h for 10-14 days.
::*Presence of Risk Factors for multi drug resistance
:::* Preferred Regimen: ([[Cefepime]] 1-2 g q8-12h {{or}} [[Ceftazidime]] 2 g q8h {{or}} [[Imipenem]] 500 mg q6h or 1g q8h {{or}} [[Meropenem]] 1 g q8h {{or}} [[Piperacillin-tazobactam]] 4.5 g q6h) {{and}} ([[Ciprofloxacin]] 400 mg q8h {{or}} [[Levofloxacin]] 750 mg q24h {{or}} [[Amikacin]] 20 mg/kg per day {{or}} [[Gentamycin]] 7 mg/kg per day {{or}} [[Tobramycin]] 7 mg/kg per day) {{and}} ([[Linezolid]] 600 mg q12h {{or}} [[Vancomycin]] 15 mg/kg q12h).
:::* Note (1) : Trough levels for [[Gentamycin]] and [[Tobramycin]] should be less than 1 g/ml, and for [[Amikacin]] they should be less than 4-5 g/ml.
:::* Note (2) : Trough levels for [[Vancomycin]] should be 15-20 g/ml
:::* Note (3) : Hospital or community acquired, neutropenic patient (<500 neutrophils per mm3) [[Vancomycin]] not included in initial therapy unless high suspicion of infected intravenous access or drug-resistant Streptococcus pneumonia. Amphotericin not used unless still febrile after 3 days or high clinical likelihood.


===Pneumonia, Nocardia===
::::* 1.2.1.14 '''Gram-positive filamentous bacteria'''
*'''Nocardia pneumonia'''
:::::* 1.2.1.14.1 '''Actinomyces spp.'''<ref name="pmid20582172">{{cite journal| author=Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ| title=Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients. | journal=Ann Thorac Med | year= 2010 | volume= 5 | issue= 2 | pages= 80-5 | pmid=20582172 | doi=10.4103/1817-1737.62470 | pmc=PMC2883202 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20582172  }} </ref><ref name="pmidPMID: 14727221">{{cite journal| author=Sudhakar SS, Ross JJ| title=Short-term treatment of actinomycosis: two cases and a review. | journal=Clin Infect Dis | year= 2004 | volume= 38 | issue= 3 | pages= 444-7 | pmid=PMID: 14727221 | doi=10.1086/381099 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14727221  }} </ref>
:* '''Pathogen directed antimicrobial therapy'''<ref name="pmid8783685">{{cite journal| author=Lerner PI| title=Nocardiosis. | journal=Clin Infect Dis | year= 1996 | volume= 22 | issue= 6 | pages= 891-903; quiz 904-5 | pmid=8783685 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8783685  }} </ref>, <ref name="pmid16614249">{{cite journal| author=Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ| title=Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. | journal=Clin Microbiol Rev | year= 2006 | volume= 19 | issue= 2 | pages= 259-82 | pmid=16614249 | doi=10.1128/CMR.19.2.259-282.2006 | pmc=PMC1471991 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16614249  }} </ref>, <ref name="pmid22170936">{{cite journal| author=Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D et al.| title=Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey. | journal=J Clin Microbiol | year= 2012 | volume= 50 | issue= 3 | pages= 670-2 | pmid=22170936 | doi=10.1128/JCM.06243-11 | pmc=PMC3295118 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22170936  }} </ref>,
::::::* Preferred regimen: [[Penicillin]] V 1 g po qid 2-6 wk
::*'''Initial intravenous therapy''' (inductinal therapy)
::::::* Alternative regimen: [[Tetracycline]] 500 mg po q 6 h {{or}} [[Doxycycline]] 100 mg q 12 h
:::* Preferred regimen: [[Trimethoprim]]-[[Sulfamethoxazole]] (15 mg/kg/day IV of the trimethoprim component in 2 to 4 divided doses) for at least three to six weeks  {{and}} [[Amikacin]] (7.5 mg/kg IV  q12h) for at least three to six weeks
::::::* Note: [[Minocycline]], [[Clindamycin]], and [[Erythromycin]] have also been successful.
:::* Alternative regimen: [[Imipenem]] (500 mg IV q6h) {{and}} [[Amikacin]] (7.5 mg/kg IV  q12h)
:::::* 1.2.1.14.2 '''Nocardia spp.'''<ref name="pmid8783685">{{cite journal| author=Lerner PI| title=Nocardiosis. | journal=Clin Infect Dis | year= 1996 | volume= 22 | issue= 6 | pages= 891-903; quiz 904-5 | pmid=8783685 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8783685  }} </ref>, <ref name="pmid16614249">{{cite journal| author=Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ| title=Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy. | journal=Clin Microbiol Rev | year= 2006 | volume= 19 | issue= 2 | pages= 259-82 | pmid=16614249 | doi=10.1128/CMR.19.2.259-282.2006 | pmc=PMC1471991 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16614249  }} </ref>, <ref name="pmid22170936">{{cite journal| author=Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D et al.| title=Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey. | journal=J Clin Microbiol | year= 2012 | volume= 50 | issue= 3 | pages= 670-2 | pmid=22170936 | doi=10.1128/JCM.06243-11 | pmc=PMC3295118 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22170936  }} </ref>
:::* Note (1): If the patient is allergic to [[Sulfonamides]], desensitization should be performed when possible.
::::::* 1.2.1.14.2.1 '''Initial intravenous therapy''' (induction therapy)
:::* Note (2): If the isolate is susceptible to the third-generation cephalosporins ([[Ceftriaxone]], [[Cefotaxime]]), [[Imipenem]] can be switched to one of these agents.
:::::::* Preferred regimen: [[Trimethoprim]]-[[Sulfamethoxazole]] (15 mg/kg/day IV of the trimethoprim component in 2 to 4 divided doses) for at least three to six weeks  {{and}} [[Amikacin]] (7.5 mg/kg IV  q12h) for at least three to six weeks
:::* Note (3): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
:::::::* Alternative regimen: [[Imipenem]] (500 mg IV q6h) {{and}} [[Amikacin]] (7.5 mg/kg IV  q12h)
::* '''Switch to oral therapy''': A sulfonamide (eg,[[Trimethoprim]]-[[Sulfamethoxazole]]  10 mg/kg/day of the trimethoprim component in 2 or 3 divided doses) {{and}} / {{or}} [[Minocycline]] (100 mg bd) {{and}} / {{or}} [[Amoxicillin]]-[[Clavulanate]] (875 mg bd)
:::::::* Note (1): If the patient is allergic to [[Sulfonamides]], desensitization should be performed when possible.
:::* Note (1): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
:::::::* Note (2): If the isolate is susceptible to the third-generation cephalosporins ([[Ceftriaxone]], [[Cefotaxime]]), [[Imipenem]] can be switched to one of these agents.
:::* Note (2): The duration of intravenous therapy varies with the patient's immune status. In immunocompromised patients, maximal tolerated doses should be given intravenously for at least six weeks and until clinical improvement has occurred; in contrast, immunocompetent patients may be successfully treated with a shorter duration of intravenous therapy. Following the intravenous induction phase, patients may be stepped down to oral antibiotics based upon susceptibility studies
:::::::* Note (3): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
:::* Note (3): Serious pulmonary infection is treated for 6 to 12 months or longer.
::::::* 1.2.1.14.2.2 '''Oral maintenence therapy'''
:::::::*Preferred regimen: A sulfonamide (eg,[[Trimethoprim]]-[[Sulfamethoxazole]]  10 mg/kg/day of the trimethoprim component in 2 or 3 divided doses) {{and}} / {{or}} [[Minocycline]] (100 mg bd) {{and}} / {{or}} [[Amoxicillin]]-[[Clavulanate]] (875 mg bd)
:::::::* Note (1): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
:::::::* Note (2): The duration of intravenous therapy varies with the patient's immune status. In immunocompromised patients, maximal tolerated doses should be given intravenously for at least six weeks and until clinical improvement has occurred; in contrast, immunocompetent patients may be successfully treated with a shorter duration of intravenous therapy. Following the intravenous induction phase, patients may be stepped down to oral antibiotics based upon susceptibility studies
:::::::* Note (3): Serious pulmonary infection is treated for 6 to 12 months or longer.


:::* 1.2.2 '''Viral pathogens'''
::::* 1.2.2.1 '''Influenza virus'''
:::::* Preferred Regimen: [[Oseltamivir]] 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) {{or}} [[Zanamivir]] Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)
::::* 1.2.2.2 '''Cytomegalovirus'''<ref name="pmid18652557">{{cite journal| author=Torres-Madriz G, Boucher HW| title=Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients. | journal=Clin Infect Dis | year= 2008 | volume= 47 | issue= 5 | pages= 702-11 | pmid=18652557 | doi=10.1086/590934 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18652557  }} </ref>
:::::* Preferred regimen (1): [[Ganciclovir]] Induction therapy 5 mg/ kg IV every 12 h for normal GFR; maintenance therapy 5 mg/kg IV daily; 1 g orally every 8 h with food.
:::::* Preferred regimen (2): [[Valganciclovir]] Induction therapy 900 mg orally every 12 h; maintenance therapy 900 mg daily.
:::::* Alternative regimen (1): [[Foscarnet]] Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
:::::* Alternative regimen (2): [[Cidofovir]] Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.


===Pneumonia, Pseuodomonas===
:::* 1.2.3 '''Fungal pathogens'''
:* '''Pseudomonas aeruginosa pneumonia''' <ref name="pmid17278083">{{cite journal| author=Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC et al.| title=Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. | journal=Clin Infect Dis | year= 2007 | volume= 44 Suppl 2 | issue=  | pages= S27-72 | pmid=17278083 | doi=10.1086/511159 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17278083  }} </ref>
::::* 1.2.3.1 '''Coccidioides species'''
::* Preferred Regimen: ([[Ticarcillin]] 200-300 mg/kg/day in divided doses q4-6h (maximum: 18 g/day) {{or}} [[Piperacillin]] 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h {{or}} [[Ceftazidime]] 500 mg to 1 g q8h {{or}} [[Cefepime]] 1-2 g q12h for 10 days {{or}} [[Aztreonam]] 2 g IV q6-8h (maximum: 8 g/day) {{or}} [[Imipenem]] 500 mg IV q6h {{or}} [[Meropenem]] 500 mg IV q8h) {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily {{or}} [[Aminoglycoside]])
:::::* Preferred Regimen: [[Itraconazole]] 200 mg q12h {{or}} [[Fluconazole]] 200-400 mg daily for 3-6 month
::* Alternate Regimen: [[Aminoglycoside]] {{and}} ([[Ciprofloxacin]] 500-750 mg q12h for 7-14 days {{or}} [[Levofloxacin]] 750 mg daily)
:::::* Alternative Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
:::::* Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection


::::* 1.2.3.2  '''Histoplasmosis'''
:::::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
:::::* Alternative Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day


===Pneumonia, Stenotrophomonas===
::::* 1.2.3.3  '''Blastomycosis'''
* '''Stenotrophomonas (maltophilia) pneumonia''' <ref>{{cite book | last = Gilbert | first = David | title = The Sanford guide to antimicrobial therapy | publisher = Antimicrobial Therapy | location = Sperryville, Va | year = 2015 | isbn = 978-1930808843 }}</ref>
:::::* Preferred Regimen: [[Itraconazole]] 200 mg q12h
:* '''Pathogen directed antimicrobial activity'''
:::::* Alternate Regimen: [[Amphotericin]] B 0.5-0.7 mg/kg/day
::* Preferred regimen: [[Trimethoprim-Sulfamethoxazole]] Single-strength (SS) tablet is [[Trimethoprim]] 80 mg / [[Sulfamethoxazole]]  400 mg, double-strength (DS) tablet is [[Trimethoprim]] 160 mg / [[Sulfamethoxazole]] 800 mg {{or}} IV treatment (base on TMP component): standard 8–10 mg per kg per day divided q6h, q8h, or q12h.
::* Alternative regimen: [[Ticarcillin-Clavulanate]] 3.1 g IV q4–6h ([[Ticarcillin]] 3 g, [[Clavulanate]] 0.1 g per vial) {{and}} [[Aztreonam]] 1 g IV q6h (or) 2 g IV q8h
::* Note (1): Potential synergy with [[Trimethoprim-Sulfamethoxazole]] {{and}} [[Ticarcillin-Clavulanate]].
::* Note (2): Stenotrophomonas is one of the microorganisms causing hospital-acquired pneumonia usually with mechanical ventilation.


:* 2. '''Health care-associated pneumonia'''<ref name="pmid15699079">{{cite journal| author=American Thoracic Society. Infectious Diseases Society of America| title=Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. | journal=Am J Respir Crit Care Med | year= 2005 | volume= 171 | issue= 4 | pages= 388-416 | pmid=15699079 | doi=10.1164/rccm.200405-644ST | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15699079  }} </ref>
::* 2.1  '''Empiric antimicrobial therapy'''
:::* 2.1.1 '''No risk factors for multi drug resistance'''
::::* Preferred Regimen : [[Ceftriaxone]] 1-2 g q24h IV or IM (max: 4 g/day) {{or}} [[Levofloxacin]] 750 mg q24h for 7-14 days {{or}} [[Moxifloxacin]] 400 mg PO/IV q24h for 7-14 days {{or}} [[Ciprofloxacin]] 400 mg PO q8h for 10-14 days {{or}} [[Ampicillin sulbactam]] 1-2 g q6-8h IV/IM (maximum: 8 g/day) {{or}} [[Ertapenem]] 1 g IM/IV q24h for 10-14 days.
:::* 2.1.2 '''Risk factors for multi drug resistance'''
::::* Preferred Regimen: ([[Cefepime]] 1-2 g q8-12h {{or}} [[Ceftazidime]] 2 g q8h {{or}} [[Imipenem]] 500 mg q6h or 1g q8h {{or}} [[Meropenem]] 1 g q8h {{or}} [[Piperacillin-tazobactam]] 4.5 g q6h) {{and}} ([[Ciprofloxacin]] 400 mg q8h {{or}} [[Levofloxacin]] 750 mg q24h {{or}} [[Amikacin]] 20 mg/kg per day {{or}} [[Gentamycin]] 7 mg/kg per day {{or}} [[Tobramycin]] 7 mg/kg per day) {{and}} ([[Linezolid]] 600 mg q12h {{or}} [[Vancomycin]] 15 mg/kg q12h).
::::* Note (1): Health care-associated pneumonia used to designate large diverse population of patients with many co-morbidities who reside in nursing homes, other long-term care facilities, require home intravenous therapy (or) are dialysis patients. Pneumonia in these patients frequently resembles hospital-acquired pneumonia.
::::* Note (2): Trough levels for [[Gentamycin]] and [[Tobramycin]] should be less than 1 g/ml, and for [[Amikacin]] they should be less than 4-5 g/ml.
::::* Note (3): Trough levels for [[Vancomycin]] should be 15-20 g/ml.


==References==
==References==
{{reflist}}
{{reflist}}

Latest revision as of 17:27, 6 August 2015

Acute exacerbations of chronic bronchitis

  • Acute exacerbation of chronic bronchitis[1]
  • 1. Outpatient management
  • Patients with only 1 of the 3 cardinal symptoms of COPD (↑ dyspnea, ↑ sputum volume, ↑ sputum purulence) may not benefit from antibiotics
  • Preferred regimen (1): Doxycycline 100 mg PO bid for 7-10 days
  • Preferred regimen (2): Amoxicillin 875 mg PO bid
  • Preferred regimen (3): Amoxicillin 500 mg PO tid
  • Preferred regimen (4): Trimethoprim-sulfamethoxazole DS 800/160 mg PO bid for 10-14 days
  • Alternative regimen (1): Amoxicillin-clavulanate 875/125 mg PO bid for 10-14 days
  • Alternative regimen (2): Levofloxacin 500 mg PO qd for 7-10 days
  • Alternative regimen (3): Azithromycin 500 mg PO single dose THEN 250 mg PO qd for 4 days
  • Alternative regimen (4): Cefpodoxime 200 mg PO bid for 10 days
  • Alternative regimen (5): Amoxicillin-clavulanate 500/125 mg PO tid for 10-14 days
  • Alternative regimen (6): Moxifloxacin 400 mg PO qd for 5 days
  • Alternative regimen (7): Gemifloxacin 320 mg PO qd for 5 days
  • Alternative regimen (8): Clarithromycin 250-500 mg PO bid for 7-14 days
  • Alternative regimen (9): Clarithromycin ER 1000 mg PO qd for 14 days
  • Alternative regimen (10): Cefprozil 250-500 mg PO bid for 10 days
  • Alternative regimen (11): Cefixime 400 mg PO qd for 10 days
  • 2. Inpatient management
  • Indications for hospital admission:
  • Intense symptoms (e.g.: sudden development of resting dyspnea)
  • Old age
  • Severe underlying COPD
  • Cyanosis
  • Peripheral edema
  • Serious comorbidities (e.g.: HF, Afib, renal failure)
  • Failure of outpatient treatment
  • Frequent exacerbations
  • Insufficient home support
  • 2.1 Treatment of acute exacerbation of chronic bronchitis, when pseudomonas infection not suspected
  • Preferred regimen (1): Moxifloxacin 400 mg IV q24h for 5 days
  • Preferred regimen (2): Levofloxacin 500 mg IV q24h for 7-10 days
  • 2.2 Treatment of acute exacerbation of chronic bronchitis, when pseudomonas infection is suspected
  • Preferred regimen (1): Ceftazidime 30-50 mg/kg IV q8hr (maximum dose 6 g/day)
  • Preferred regimen (2): Piperacillin-Tazobactam 3.375 g IV q6h for 7-10 days
  • Preferred regimen (3): Cefepime 1-2 g IV q8-12hr for 7-10 days (extend to 21 days if culture positive for Pseudomonas)
  • Alternative regimen (1): Ceftriaxone 1-2 g IV/IM q12-24h for 4-14 days
  • Alternative regimen (2): Ceftriaxone 1-2 g IV/IM q8h for 4-14 days

Bronchiectasis

  • Bronchiectasis[2]
  • 1. Acute exacerbations of bronchiectasis
  • 1.1 Empiric antimicrobial therapy
  • Preferred regimen: Amoxicillin 0.5-1 g PO/IV q8h for 14 days
  • Alternative regimen (1): Ciprofloxacin 500-750 mg PO bid for 14 days
  • Alternative regimen (2): Clarithromycin 500 mg PO bid for 14 days
  • 1.2 Pathogen-directed antimicrobial therapy
  • 1.2.1 Streptococcus pneumoniae
  • 1.2.2 Haemophilus influenzae (b-lactamase negative)
  • Preferred regimen (1): Amoxicillin 0.5-1 g PO tid for 14 days
  • Preferred regimen (2): Amoxicillin 3 g PO bid for 14 days
  • Alternative regimen (1): Clarithromycin 500 mg PO bid for 14 days
  • Alternative regimen (2): Ciprofloxacin 500 mg PO bid for 14 days
  • Alternative regimen (3): Ceftriaxone 2 g IV q24h for 14 days
  • 1.2.3 Haemophilus influenzae (b-lactamase positive)
  • 1.2.4 Moraxella catarrhalis
  • 1.2.5 Staphylococcus aureus (MSSA)
  • 1.2.6 Staphylococcus aureus (MRSA) (mild-to-moderate)
  • Preferred regimen (weight < 50 kg): Rifampicin 450 mg PO qd AND Trimethoprim 200 mg PO bid for 14 days
  • Preferred regimen (weight > 50 kg): Rifampicin 600 mg PO qd AND Trimethoprim 200 mg PO bid for 14 days
  • Alternative regimen (weight < 50 kg): Rifampicin 450 mg PO qd AND Doxycycline 200 mg PO qd for 14 days
  • Alternative regimen (weight > 50 kg): Rifampicin 600 mg PO qd AND Doxycycline 200 mg PO qd for 14 days
  • Alternative regimen: Linezolid 600 mg PO bid for 14 days (third-line therapy)
  • 1.2.7 Staphylococcus aureus (MRSA) (severe)
  • Preferred regimen (1): Vancomycin 1 g IV q12h (trough levels of 10-20 ng/mL)
  • Preferred regimen (2): Teicoplanin 400 mg IV q24h for 14 days
  • Alternative regimen: Linezolid 600 mg IV q12h for 14 days
  • 1.2.8 Coliforms (eg, Klebsiella, enterobacter)
  • 1.2.9 Pseudomonas aeruginosa
  • 1.2.10 Pediatric Dosing
  • 2. Long-term antibiotic prophylaxis
  • Patients with ≥3 exacerbations/year requiring antibiotic therapy or patients with fewer exacerbations that are causing significant morbidity should be considered for long-term antibiotic prophylaxis
  • 2.1 Pathogen-directed antimicrobial therapy
  • 2.1.1 Streptococcus pneumoniae
  • 2.1.2 Haemophilus influenzae (b-lactamase negative)
  • 2.1.3 Haemophilus influenzae (b-lactamase positive)
  • 2.1.4 Moraxella catarrhalis
  • 2.1.5 Staphylococcus aureus (MSSA)
  • 3. Pseudomonas eradication (colonization)
  • 3.1 Initial therapy
  • 3.2 Secondary therapy in case of treatment failure
  • Preferred regimen (1): Piperacillin-tazobactam 4.5 g PO tid for 14 days
  • Preferred regimen (2): Cefepime 1-2 g IV q8-12h
  • Preferred regimen (3): Ciprofloxacin 750 mg PO bid for 4 weeks AND Colistin (Nebulized) 2 MU NEB bid for 3 months
  • Preferred regimen (3): Colistin (Nebulized) 2 MU NEB bid for 3 months

Bronchiolitis

  • Bronchiolitis[3]
  • 1. Treatment
  • Preferred regimen: Supportive care. No antimicrobial therapy recommended.
  • 2. Prophylaxis
  • Indications for prophylaxis:
  • First year of life during RSV season in infants with hemodynamically significant heart disease
  • First year of life during RSV season in preterm infants < 32 weeks 0 days’ gestation who require > 21% oxygen for at least the first 28 days of life
  • Preferred regimen: Palivizumab 15 mg/kg IM monthly for 5 months

Bronchitis

  • Acute bronchitis[4]
  • 1.Treatment of acute bronchitis with no suspicion of pertussis
  • Preferred regimen: Supportive care. Antimicrobial therapy not recommended.
  • 2.Treatment of acute bronchitis with suspected or confirmed pertussis

Cystic fibrosis

  • Cystic Fibrosis
  • 1.Pathogen-directed antimicrobial therapy [5]
  • 1.1 Pseudomonas aeruginosa
  • 1.1.1 Adults
  • 1.1.2 Children
  • 1.2 Staphylococcus aureus
  • 1.2.1 Adults
  • 1.2.1.1 Methicillin sensitive staphylococcus aureus
  • 1.2.1.2 Methicillin resistant staphylococcus aureus
  • 1.2.2 Children
  • 1.2.2.1 Methicillin sensitive staphylococcus aureus
  • Preferred regimen: Nafcillin 5 mg/kg IV q6h (age > 28 days) OR Oxacillin 75 mg/kg IV q6h (age > 28 days)
  • 1.2.2.2 Methicillin resistant staphylococcus aureus
  • Preferred regimen: Vancomycin 40 mg/kg IV divided q6-8h (age >28 days) OR Linezolid 10 mg/kg PO/IV q8h (up to age 12)
  • 1.3 Burkholderia cepacia

Empyema

  • 1. Empiric antimicrobial therapy or culture negative therapy
  • Causative pathogens:
  • Streptococcus milleri
  • Streptococcus pneumoniae
  • Streptococcus intermedius
  • Staphylococcus aureus
  • Enterobacteriaceae
  • Escherichia coli
  • Fusobacterium spp.
  • Bacteroides spp.
  • Peptostreptococcus spp.
  • 2. Pathogen-based therapy
  • 2.1 Acute empyema
  • 2.1.1 Streptococcus pneumoniae, Group A streptrococcus
  • 2.1.2 Staphylococcus aureus
  • 2.1.2.1 MSSA
  • 2.1.2.2 MRSA
  • 2.1.3 Hemophilus influenzae
  • 2.2 Subacute/chronic empyema
  • 2.2.1 Anaerobic streptococcus, Streptococcus milleri, Bacteroides species, Enterobacteriaceae, Mycobacterium tuberculosis

Pneumonia

  • Pneumonia
  • 1. Community-acquired pneumonia
  • 1.1 Empiric therapy in adults [7]
  • 1.1.1 Outpatient treatment
  • 1.1.1.1 Previously healthy and no use of antimicrobials within the previous 3 months
  • Preferred regimen (1): (Azithromycin 500 mg PO single dose for 1 day THEN 250 mg PO qd for 4 days) OR Azithromycin 500 mg IV single dose
  • Preferred regimen (2): Clarithromycin 250 mg PO bid for 7-14 days OR Clarithromycin 1000 mg PO qd for 7 days
  • Preferred regimen (3): Erythromycin 250-500 mg PO bid or tid (maximum daily dose 4 g)
  • Alternative regimen: Doxycycline 100 mg PO/IV q12h
  • 1.1.1.2 Presence of comorbidities, use of immunosuppressing drugs, or use of antimicrobials within the previous 3 months
  • 1.1.2 Inpatient treatment
  • 1.1.2.1 Non-ICU treatment
  • 1.1.2.2 ICU treatment
  • 1.1.3 Special considerations
  • 1.1.3.1 Suspected Pseudomonas
  • 1.1.3.2 Suspected methicillin resistant Staphylococcus aureus (add the following)
  • Preferred regimen: Vancomycin 45-60 mg/kg/day divided q8-12h OR Linezolid 600 mg PO/IV q12h for 10-14 days
  • 1.1.3.3 Neutropenic patient [8]
  • 1.1.3.3.1 No risk for multi-drug resistance
  • 1.1.3.3.2 Risk for multi drug resistance
  • 1.2 Pathogen-directed antimicrobial therapy
  • 1.2.1 Bacterial pathogens
  • 1.2.1.1 Streptococcus pneumoniae
  • 1.2.1.1.1 Penicillin sensitive (minimum inhibitory concentration < 2 mg/mL)
  • 1.2.1.1.2 Penicillin resistant (minimum inhibitory concentration > 2 mg/mL)
  • Preferred regimen (Agents chosen on the basis of susceptibililty) : Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h
  • Alternative regimen: Vancomycin 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity OR Linezolid 600 mg PO/IV q12h for 10-14 days OR Amoxicillin 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)
  • 1.2.1.2 Haemophilus influenzae
  • 1.2.1.2.1 Non-beta lactamase producing
  • 1.2.1.2.2 Beta lactamase producing
  • 1.2.1.2 Bacillus anthracis (inhalational)
  • 1.2.1.3 Enterobacteriaceae
  • 1.2.1.4 Pseudomonas aeruginosa
  • 1.2.1.5 Staphylococcus aureus
  • 1.2.1.5.1 Methicillin sensitive
  • 1.2.1.5.2 Methicillin resistant
  • Preferred Regimen : Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR Linezolid 600 mg PO/IV q12h for 10-14 days
  • Alternative Regimen: Trimethoprim-Sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h


  • 1.2.1.6 Klebsiella pneumonia[9]
  • 1.2.1.6.1 Resistant to third generation cephalosporins and aztreonam
  • 1.2.1.6.2 Klebsiella pneumoniae Carbapenemase producers
  • Preferred regimen (1): Colistin (=Polymyxin E).In USA : Colymycin-M 2.5-5 mg/kg per day of base divided into 2-4 doses 6.7-13.3 mg/kg per day of colistimethate sodium (max 800 mg/day). Elsewhere: Colomycin and Promixin ≤60 kg, 50,000-75,000 IU/kg per day IV in 3 divided doses (=4-6 mg/kg per day of colistimethate sodium). >60 kg, 1-2 mill IU IV tid (= 80-160 mg IV tid) OR Polymyxin B (Poly-Rx) 15,000–25,000 units/kg/day divided q12h
  • Note (1): some strains which hyperproduce extended spectrum beta-lactamase are primarily resistant to Ticarcillin-Clavulanate, Piperacillin-Tazobactam
  • Note (2): Extended spectrum beta-lactamases inactivates all Cephalosporins, beta-lactam/beta-lactamase inhibitor drug activation not predictable; co-resistance to all Fluoroquinolones & often Aminoglycosides.
  • Note (3): Can give IM, but need to combine with “caine” anesthetic due to pain.
  • 1.2.1.7 Moraxella catarrhalis


  • 1.2.1.8 Stenotrophomonas maltophilia
  • 1.2.1.9 Bordetella pertussis
  • 1.2.1.10 Anaerobes (aspiration pneumonia)
  • 1.2.1.11 Mycobacterium tuberculosis
  • 1.2.1.11.1 Intensive phase
  • Preferred Regimen: Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
  • Alternative regimen (1): Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
  • Alternative regimen (2): Isoniazid 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s AND Ethambutol 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months AND Pyrazinamide 1000 - 2000 mg / day 3 times per week for 2 months.
  • 1.2.1.11.2 Continuation phase
  • Preferred Regimen:Isoniazid 300 mg/day PO daily for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO daily for 4 months (10 mg/kg/day)
  • Alternative regimen (1): Isoniazid 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day)
  • 1.2.1.12 Yersinisa pestis
  • 1.2.1.13 Atypical bacteria
  • 1.2.1.13.1 Mycoplasma pneumoniae
  • 1.2.1.13.2 Chlamydophila pneumoniae
  • 1.2.1.13.3 Legionella spp.
  • 1.2.1.13.4 Chlamydophila psittaci
  • Preferred Regimen: Tetracycline 250-500 mg PO q6h
  • Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
  • 1.2.1.13.5 Coxiella burnetii
  • Preferred Regimen: Tetracycline 250-500 mg PO q6h
  • Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
  • 1.2.1.13.6 Francisella tularensis
  • 1.2.1.13.7 Burkholderia pseudomallei
  • 1.2.1.13.8 Acinetobacter species
  • 1.2.1.14 Gram-positive filamentous bacteria
  • 1.2.1.14.2.1 Initial intravenous therapy (induction therapy)
  • Preferred regimen: Trimethoprim-Sulfamethoxazole (15 mg/kg/day IV of the trimethoprim component in 2 to 4 divided doses) for at least three to six weeks AND Amikacin (7.5 mg/kg IV q12h) for at least three to six weeks
  • Alternative regimen: Imipenem (500 mg IV q6h) AND Amikacin (7.5 mg/kg IV q12h)
  • Note (1): If the patient is allergic to Sulfonamides, desensitization should be performed when possible.
  • Note (2): If the isolate is susceptible to the third-generation cephalosporins (Ceftriaxone, Cefotaxime), Imipenem can be switched to one of these agents.
  • Note (3): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
  • 1.2.1.14.2.2 Oral maintenence therapy
  • Preferred regimen: A sulfonamide (eg,Trimethoprim-Sulfamethoxazole 10 mg/kg/day of the trimethoprim component in 2 or 3 divided doses) AND / OR Minocycline (100 mg bd) AND / OR Amoxicillin-Clavulanate (875 mg bd)
  • Note (1): Selected patients who clinically improve with induction intravenous therapy and do not have CNS disease may be switched to oral monotherapy (usually after three to six weeks) based upon susceptibility results.
  • Note (2): The duration of intravenous therapy varies with the patient's immune status. In immunocompromised patients, maximal tolerated doses should be given intravenously for at least six weeks and until clinical improvement has occurred; in contrast, immunocompetent patients may be successfully treated with a shorter duration of intravenous therapy. Following the intravenous induction phase, patients may be stepped down to oral antibiotics based upon susceptibility studies
  • Note (3): Serious pulmonary infection is treated for 6 to 12 months or longer.
  • 1.2.2 Viral pathogens
  • 1.2.2.1 Influenza virus
  • Preferred Regimen: Oseltamivir 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) OR Zanamivir Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)
  • 1.2.2.2 Cytomegalovirus[15]
  • Preferred regimen (1): Ganciclovir Induction therapy 5 mg/ kg IV every 12 h for normal GFR; maintenance therapy 5 mg/kg IV daily; 1 g orally every 8 h with food.
  • Preferred regimen (2): Valganciclovir Induction therapy 900 mg orally every 12 h; maintenance therapy 900 mg daily.
  • Alternative regimen (1): Foscarnet Induction therapy 60 mg/ kg every 8 h for 14–21 days or 90 mg/kg every 12 h for 14–21 days; maintenance therapy 90–120 mg/kg per day as a single infusion.
  • Alternative regimen (2): Cidofovir Induction therapy 5 mg/ kg per week for 2 weeks, followed by maintenance therapy every 2 weeks.
  • 1.2.3 Fungal pathogens
  • 1.2.3.1 Coccidioides species
  • Preferred Regimen: Itraconazole 200 mg q12h OR Fluconazole 200-400 mg daily for 3-6 month
  • Alternative Regimen: Amphotericin B 0.5-0.7 mg/kg/day
  • Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection
  • 1.2.3.2 Histoplasmosis
  • 1.2.3.3 Blastomycosis
  • 2. Health care-associated pneumonia[8]
  • 2.1 Empiric antimicrobial therapy
  • 2.1.1 No risk factors for multi drug resistance
  • 2.1.2 Risk factors for multi drug resistance
  • Preferred Regimen: (Cefepime 1-2 g q8-12h OR Ceftazidime 2 g q8h OR Imipenem 500 mg q6h or 1g q8h OR Meropenem 1 g q8h OR Piperacillin-tazobactam 4.5 g q6h) AND (Ciprofloxacin 400 mg q8h OR Levofloxacin 750 mg q24h OR Amikacin 20 mg/kg per day OR Gentamycin 7 mg/kg per day OR Tobramycin 7 mg/kg per day) AND (Linezolid 600 mg q12h OR Vancomycin 15 mg/kg q12h).
  • Note (1): Health care-associated pneumonia used to designate large diverse population of patients with many co-morbidities who reside in nursing homes, other long-term care facilities, require home intravenous therapy (or) are dialysis patients. Pneumonia in these patients frequently resembles hospital-acquired pneumonia.
  • Note (2): Trough levels for Gentamycin and Tobramycin should be less than 1 g/ml, and for Amikacin they should be less than 4-5 g/ml.
  • Note (3): Trough levels for Vancomycin should be 15-20 g/ml.

References

  1. ↑ Sethi S, Murphy TF (2004). "Acute exacerbations of chronic bronchitis: new developments concerning microbiology and pathophysiology--impact on approaches to risk stratification and therapy". Infect Dis Clin North Am. 18 (4): 861–82, ix. doi:10.1016/j.idc.2004.07.006. PMID 15555829.
  2. ↑ Pasteur MC, Bilton D, Hill AT, British Thoracic Society Bronchiectasis non-CF Guideline Group (2010). "British Thoracic Society guideline for non-CF bronchiectasis". Thorax. 65 Suppl 1: i1–58. doi:10.1136/thx.2010.136119. PMID 20627931.
  3. ↑ Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM; et al. (2014). "Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis". Pediatrics. 134 (5): e1474–502. doi:10.1542/peds.2014-2742. PMID 25349312.
  4. ↑ Braman SS (2006). "Chronic cough due to acute bronchitis: ACCP evidence-based clinical practice guidelines". Chest. 129 (1 Suppl): 95S–103S. doi:10.1378/chest.129.1_suppl.95S. PMID 16428698.
  5. ↑ Mogayzel PJ, Naureckas ET, Robinson KA, Mueller G, Hadjiliadis D, Hoag JB; et al. (2013). "Cystic fibrosis pulmonary guidelines. Chronic medications for maintenance of lung health". Am J Respir Crit Care Med. 187 (7): 680–9. PMID 23540878.
  6. ↑ LastName, FirstName (2007). Sanford guide to antimicrobial therapy. Place of publication not identified: Antimicrobial Therapy. ISBN 9781930808386.
  7. ↑ Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC; et al. (2007). "Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults". Clin Infect Dis. 44 Suppl 2: S27–72. doi:10.1086/511159. PMID 17278083.
  8. ↑ 8.0 8.1 American Thoracic Society. Infectious Diseases Society of America (2005). "Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia". Am J Respir Crit Care Med. 171 (4): 388–416. doi:10.1164/rccm.200405-644ST. PMID 15699079.
  9. ↑ Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  10. ↑ Song JU, Park HY, Jeon K, Um SW, Kwon OJ, Koh WJ (2010). "Treatment of thoracic actinomycosis: A retrospective analysis of 40 patients". Ann Thorac Med. 5 (2): 80–5. doi:10.4103/1817-1737.62470. PMC 2883202. PMID 20582172.
  11. ↑ Sudhakar SS, Ross JJ (2004). "Short-term treatment of actinomycosis: two cases and a review". Clin Infect Dis. 38 (3): 444–7. doi:10.1086/381099. PMID 14727221 PMID: 14727221 Check |pmid= value (help).
  12. ↑ Lerner PI (1996). "Nocardiosis". Clin Infect Dis. 22 (6): 891–903, quiz 904-5. PMID 8783685.
  13. ↑ Brown-Elliott BA, Brown JM, Conville PS, Wallace RJ (2006). "Clinical and laboratory features of the Nocardia spp. based on current molecular taxonomy". Clin Microbiol Rev. 19 (2): 259–82. doi:10.1128/CMR.19.2.259-282.2006. PMC 1471991. PMID 16614249.
  14. ↑ Brown-Elliott BA, Biehle J, Conville PS, Cohen S, Saubolle M, Sussland D; et al. (2012). "Sulfonamide resistance in isolates of Nocardia spp. from a US multicenter survey". J Clin Microbiol. 50 (3): 670–2. doi:10.1128/JCM.06243-11. PMC 3295118. PMID 22170936.
  15. ↑ Torres-Madriz G, Boucher HW (2008). "Immunocompromised hosts: perspectives in the treatment and prophylaxis of cytomegalovirus disease in solid-organ transplant recipients". Clin Infect Dis. 47 (5): 702–11. doi:10.1086/590934. PMID 18652557.
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