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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Disclaimer:
The recommendations expressed in these guidelines reflect the existing available evidence from the current
literature and are subject to change over time. The recommendations described here are general and may
not apply to a specific patient. Application of these guidelines to a particular situation remains the
professional responsibility of the caring physician and/or the prescriber.
1
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Antimicrobial Subcommittee
Dr. Amina Al Jardani, MD
Dr. Amal Al Maani, MD
Dr. Mubarak Al Yaqubi, MD
Dr. Khalid Al Hinai, MD
Dr. Nada Al Siyabi, MD
Ph. Zaher Al Salmi, Msc
Ph. Huda Al Harthi, Msc
Dr. Khalid Al Harthi, MD
Contributors
Dr.Faryal Al Lawati, MD
Dr. Seif Al Abri, MD
Dr. Saleh Al Azri, MD
Dr. Fatma Al Yaqubi, MD
Dr. Azza Al Rashdi, MD
Dr. Amal Al Tai, MD
Dr. Hana Al-Areimi, MD
Dr. Nashat Al Sukaiti
Ph. Umkulthoum Al Barwani, MSc
Ph. Wijdan Hashmani, MSc
Ph. Fatma Al Raisi, MSc
Ph. Mardheya Abdulla Al Kharusi
Dr. Hanan Al Kindi, MD
Dr.George Paul, MD
Acknowledgments
We thank all those who contributed to the review of this guideline:
Departments of ENT & Ophthalmology at AlNahadhah Hospital
Dr. Abraham Ooriapadickal ,MD(SQUH)
Dr.Mohammed ALMukhaini,MD
Dr. Issa Al Jahdhami ,MD(AFH)
Dr.Fatma AlYaqoubi,MD
Dr. Badria Al Adawi ,MD (SQUH)
Dr. Said Abdul Rahman,MD
Dr. Jalila Al-Lawatia,MD
Dr. Nawal AlMaskri,MD
Ms Zavila Shakeel
Ms.Nazira Begum Abubakar
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Table of Contents
Preface
Abbreviations
Antimicrobials Prescribing Policy
Table 1: Guidelines for Treatment of Respiratory Infections in Adults
Table 2: Guidelines for Treatment of Ear, Nose and Throat Infections
Table 3: Guidelines for Treatment of Eye Infection
Table 4: Guidelines for Treatment of Infective Endocarditis and Related
Infections
Table 5-A: Prophylaxis of Infective Endocarditis
Table 5-B: Antibiotic prophylactic regimens for dental procedures
Table 6: Guidelines for Treatment of Central Nervous System Infections in
Adults
Table 7: Guidelines for Treatment of Bone and Joint Infections in Adults
Table 8: Guidelines for Treatment of Abdominal Infections in Adults
Table 9: Guidelines for Treatment of Skin and Soft Tissue Infections
Table 10: Guidelines for Treatment of Urinary Tract Infections and Sexually
Transmitted Diseases in Adults
Table 11: Guidelines for Treatment of Systemic Infections
Table 12: Guidelines for Treatment of Common Viral Infections
Table 13-A: Guidelines for Emperical Treatment of Paediatric Infections
Table 13-B: Paediatric antibiotics dosage guideline
Table 14: Guidelines for Therapeutic Drug Monitoring
Table 15: Guidelines for Surgical Antimicrobial Prophylaxis
Table 16: Antimicrobial in Pregnancy and Lactation
Penicillin Allergy
Table 17: Suggested Duration of Antibiotic Therapy in Common Infections
Guidelines for Antimicrobial Prophylaxis in Haematology/Oncology in Adults
Table 18/A: Antibacterial prophylaxis for Haematology/Oncology patients
Table 18/B: Primary Antifungal prophylaxis for Haematology/Oncology
patients
Table 18/C: Antiviral prophylaxis for Haematology/Oncology patients
Table 18/D: Anti-PCP prophylaxis for Haematology/Oncology patients
3
4
5-6
7 - 20
21 - 25
26 - 29
30 - 33
34 - 40
41
42
43 - 47
48 - 50
51 – 56
57 – 62
63 – 65
66 – 70
71 – 72
73 – 87
88 – 93
94 – 97
98 - 104
105 - 110
111 - 114
115 - 116
117
118 – 119
119 – 120
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Preface
The emergence and the spread of antimicrobial resistance is a challenging epidemic with great impact on
the global health economy. Antimicrobial resistance adversely affects patients’ outcomes with increasing
mortality and morbidity. Inappropriate use of antibiotics in hospitals and the community is playing a major
role in the increase of antimicrobial resistance. Many studies have shown that over 50% of antimicrobial
use is inappropriate. Importance of prudent antimicrobial use (i.e. appropriate choice, dose and duration)
has been shown to reduce the emergence of resistance and improves patient outcome.
The aim of these national antimicrobial guidelines is to provide guidance for clinicians in the
Ministry of Health and other healthcare settings for the empirical and targeted antimicrobial
therapy of various infectious syndromes. Treatment guidelines for paediatric and adult patients are
included. In addition, guidance on antibiotic prophylaxis is covered. The users of these guidelines
should seek experts in antimicrobials such as infectious disease physicians, medical microbiologists
and clinical pharmacists in order to optimize antimicrobial use in various healthcare settings.
Empirical broad-spectrum antibiotic drugs are often prescribed. However, once culture and
susceptibilities are known, therapy should be reviewed and adjusted accordingly.
This guide does not address treatment of HIV, tuberculosis or malaria. Users are advised to consult the
Ministry of Health’s specific guidelines for these conditions.
This guideline is produced by the national antimicrobial subcommittee. While every attempt has been
made to ensure the accuracy of the content, physicians and prescribers should ensure the correct drug and
dose is prescribed as appropriate for each individual patient. The interpretation and implementation
remains the responsibility of the treating physician.
___________________________
Dr.Ahmed Al Saidi
Minister of Health
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Abbreviations
ABECB
FEVI
Forced expiratory volume in 1 second
AHA
ALL
AM-CL
AML
Amoxi
AMP
AM-SB
Azithro
B. abortus
B. cepacia
Acute bacterial exacerbation of chronic
bronchitis
American Heart Association
Acute lymphoblastic leukaemia
Amoxicillin-clavulanate
acute myelogenous leukaemia
Amoxicillin
Ampicillin
Ampicillin-sulbactam
Azithromycin
Brucella abortus
Burkholderia cepacia
FQ
g6PD
GAS
gent
GI
GP
GU
GVHD
Hr
HAART
Fluoroquinolone
Glucose-6-phosphate dehydrogenase
Group A Streptococcus
Gentamycin
Gastrointestinal
General practitioner
Genitourinary
Graft-versus-host disease
Hour
Highly active antiretroviral therapy
B. henselae
Bartonella henselae
HACEK
A group of Gram-negative bacteria that
includes Haemophilus spp.
B-Lactam
B. melitensis
B. quintana
B. suis
BID
C. pneumoniae
CA-MRSA
H. influenzae
HSCT
HSV
ICU
IM
INH
IV
Haemophilus influenzae
Hematopoietic stem cell
Herpes simplex virus
Intensive care unit
Intramuscular
Isoniazid
Intravenous
Caz
CAP
CAPD
Beta-lactam
Brucella melitensis
Bartonella quintana
Brucella suis
Twice a day
Chlamydophila pneumoniae
Community-associated methicillinresistant S. aureus
Ceftazidime
Community-acquired pneumonia
Chronic Ambulatory Peritoneal Dialysis
IVDU
IVIG
K. pneumoniae
Intravenous drug user
Intravenous immunoglobulin
Klebsiella pneumonia
CBC
CBT
Ceph
Cip
Complete blood count
Cord blood test
Cephalosporin
Ciprofloxacin
Levo
M. catarrhalis
M. pneumoniae
MDR-GNB
Levofloxacin
Moraxella catarrhalis
Mycoplasma pneumoniae
Multidrug-resistant Gram-negative bacilli
Clarith
CML
Clarithromycin
Chronic myelogenous leukaemia
MDR
MDRSP
CNS
CoNS
CRBSI
CrCl
Central nervous system
Coagulase-negative staphylococci
Catheter-related bloodstream infection
Creatinine clearance
MDS
MIC
Moxi
MRI
Multidrug-resistant
multidrug-resistant Streptococcus
pneumoniae
Myelodysplastic syndrome
Minimum inhibitory concentration
Moxifloxacin
CRE
MRSA
Methicillin-resistant S. aureus
CSF
Carbapenem-resistant Enterobacteriaceae
Cerebrospinal fluid
MSSA
CT
CVP line
Computed tomography
central venous pressure line
N. farcinica
NG
Methicillin-sensitive S. aureus
Nocardia farcinica
Nasogastric
CXR
Dapto
DM
doxy
DRSP
DS
E. faecium
ENT
ESBL
ESR
FAMCO
FDA
PO
q1h
Chest X-ray
Daptomycin
Diabetes mellitus
Doxycycline
Drug-resistant S. pneumoniae
Double strength
Enterococcus faecium
Ear, nose and throat
Extended spectrum beta-lactamases
Erythrocyte sedimentation rate
Family and community medicine
Food and Drug Administration (USA)
Per OS (by mouth)
Every hour
NTD
OD
P. aeruginosa
PCP
PCR
PD
Pen
Pen-G
Pen-V
Pip
q4h
PJP
Vanco
VRE
Neglected Tropical diseases
Once daily
Pseudomonas aeruginosa
Pneumocystis pneumonia
Polymerase chain reaction
Peritoneal dialysis
Penicillin
Penicillin G
Penicillin V
Piperacillin
Every 4 hours
Pneumocystis jiroveci pneumonia
Vancomycin
Vancomycin-resistant Enterococci
5
Magnetic resonance imaging
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
q8h
QID
R
R/O
Every 8 hours
Four times a day
Resistant
Rule out
RFT
Rif
RR
RT
rt
Rx
S. aureus
S. bovis
S. milleri
S. pneumoniae
Renal function test
Rifampicin
Respiratory rate
Radiation therapy
Right
Treatment
Staphylococcus aureus
Streptococcus bovis
Streptococcus milleri
Streptococcus pneumoniae
SBP
Staph
Strept
Taz
TB
TDM
TID
TMP-SMX
Tobra
Spontaneous bacterial peritonitis
Staphylococcus
Streptococcus
Tazobactam
Tuberculosis
Therapeutic drug monitoring
Three times a day
Trimethoprim/sulfamethoxazole
Tobramycin
UTI
Urinary tract infection
VZV
WBC
β-lactam
6
Varicella zoster virus
White blood cell
beta-lactam
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Antimicrobials Prescribing Policy
1. Introduction
The emergence of antimicrobial resistance is becoming a major public health issue. Infections caused by
multidrug-resistant (MDR) organisms are associated with increased morbidity, increased length of hospital
stay and increased mortality.
An effective strategy to limit the effect of multidrug resistance must be multifaceted and must include the
education of patients and physicians about appropriate drug, dose and duration, establishment of national
antimicrobial guidelines, use of effective infection control practices to prevent transmission from infected
to uninfected patients, surveillance of antimicrobial resistance and antimicrobial use, and improved use of
immunization.
The combat of antimicrobial resistance is one of the important priorities of the Ministry of Health in Oman.
Establishing a national antimicrobial policy and guidelines is one facet of many measures that will be
undertaken to improve the prudent use of antibiotics and reduce antimicrobial resistance in the country.
2. Scope
This policy applies to all healthcare settings in the Sultanate of Oman and to all employees who are involved
in prescribing, administering and monitoring antimicrobials use.
3. Aim
To ensure the appropriate use of antimicrobials to optimize the patient's outcome, minimize the risk of
adverse reactions and reduce the emergence of antibiotic resistance.
4. Policy principles
This guidance is based on the best available evidence; however, professional judgment based on patient
clinical presentation should be used. Patients should be involved or informed on the decision of initiation of
antibiotics.
Antimicrobial prescriptions in all health care facilities in Oman are expected to adhere to the following
principles:
1. Treat infections and not colonization. Prescribe antibiotics when there is evidence of a bacterial infection
and there is likely to be a clear clinical benefit. In severe infections, initiate antibiotics as early as possible.
2. Specify clearly the indications, dose and duration in all the antibiotic prescription.
3. Always conduct appropriate microbiological investigations prior to antimicrobial therapy. Antimicrobial
therapy should be reviewed in 24–48 hours upon the availability of microbiological investigations. De-
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
escalation of empirical therapy should be adjusted to target the causative organism based on patient’s
susceptibility testing. (Fig.1).
4. When deciding on the most appropriate antibiotic to prescribe, the following factors should be
considered:







History of drug allergy and document the type of allergy: minor (rash only) or major (anaphylaxis,
angioedema)
Recent cultures (review previous culture, e.g. if the patient grew or colonized with multiple –
resistant organisms
Recent antibiotic therapy
Potential drug interactions
Potential adverse effects
Some antibiotics are considered unsafe in pregnancy, infants or young children
Dose adjustment may be required for renal or hepatic dysfunctions
5. Consider removal of any foreign body/indwelling devices, drainage of pus or any surgical interventions to
control the infection source.
6. For advice on appropriate investigations and management of infections, consult your local infection
specialists (infectious disease physician, medical microbiologists and/or clinical pharmacist).
7. The use of 2 agents with anaerobic activity to treat infections with potential anaerobic bacteria
involvement.
7.1. Double anaerobic coverage is unnecessary and puts the patient at risk of drug toxicity. No data or
guidelines support the use of double anaerobic coverage in clinical practice.
Example: the use of piperacillin/tazobactam and metronidazole or meropenem and metronidazole is not
recommended.
7.2. Two clinical exceptions:


Addition of metronidazole to another agent with anaerobic activity to treat C. difficile
Clindamycin added to another agent with anaerobic activity when treating necrotizing fasciitis
8. The use of “double coverage" for Gram-negative bacteria.
8.1. Double coverage of suspected Gram-negative infections serves the purpose of providing broadspectrum initial empiric coverage until susceptibility data are known.
8.2. No evidence exists to support the superiority of combination therapy over monotherapy for Gramnegative infections once susceptibilities are known.
8.3. Once culture identification and susceptibilities have been reported, de-escalation to a single agent is
strongly recommended.
9. Avoid routine prescription of intravenous forms of highly bioavailable antimicrobials agents for patients
who can reliably take and absorb oral medications.
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Antibiotics such as fluoroquinolone, trimethoprim/sulfamethoxazole (TMP-SMX), clindamycin, linezolid,
metronidazole and fluconazole have excellent bioavailability and only rarely need to be administered
intravenously. Use of oral forms will reduce the need for IV access and their associated complications.
FIG.1
4. Selected formulary antimicrobial and restriction status
Group I
Antibiotics for general use and primary health care
This policy limits the general practitioner’s (GP) choice of antibiotics to a few drugs only. With these drugs,
he/she should be able to treat most community-acquired infections successfully. Some antibiotics in this
group are restricted to specialist in family and community medicine (FAMCO) or other physicians (e.g.
dermatologist or, ear, nose and throat [ENT] specialist). However, some infections, such as pneumonia and
otitis media caused by penicillin-resistant S. pneumoniae and M. catarrhalis and ampicillin (AMP)-resistant
H. influenzae may not respond to treatment with any of the antibiotics available to the GP. Ideally, such
infections are treated with ceftriaxone, co-amoxiclav or other ß-lactamase-resistant drugs. However, in
order to rationalize antibiotic usage, it is not possible; to avail such drugs for general use. Nevertheless,
doctors in general practice must be aware of the possibilities of infections by resistant organisms. They
should, therefore refer all patients with pneumonia and children suffering from acute otitis media to the
nearest specialist for further evaluation and management.
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Table (a)-List of Group I Antimicrobials
Antimicrobial
Benzylpenicillin (penicillin G)
Penicillin V
Procaine penicillin
Benzathine benzylpenicillin
Amoxicillin
Amoxicillin + Clavulanate
Cloxacillin
Cephalexin
Cefuroxime
Erythromycin
Azithromycin
Trimethoprim/sulfamethoxazole
Doxycycline
Ciprofloxacin
Nalidixic acid
Nitrofurantoin
Metronidazole
Acyclovir
Valacyclovir
Nystatin
Ketoconazole
Fluconazole
Itraconazole
Terbinafine
Albendazole
Comments
Restricted
Restricted
Restricted
Restricted
Restricted
Restricted
Restricted
Restricted
Restricted
Restricted
Group II
These antimicrobials are to be used by consultants (exceptions are prescribers in intensive care unit [ICU],
ER, OR hematology oncology wards) in emergency and according to the prescribing criteria for a period not
exceeding more than 3 days until microbiological investigations are through. All antimicrobials need review
and approval after 72 hours in consultation with the infectious diseases unit, medical microbiologist or the
antimicrobial stewardship team.
Or
In accordance with antibiotic susceptibility results, i.e. if the microorganism is sensitive only to the
antibiotics in this group.
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Or
By the recommendation of the infectious disease physician, the medical microbiologist or the antimicrobial
stewardship team in view of the prevalent antibiotic susceptibility pattern in the hospital concerned.
Table (b)-List of Group II Antimicrobials
Restricted Antibiotics
Amikacin
Meropenem
imipenem
Piperacillin/tazobactam
Cefepime
Ceftazidime
Vancomycin
Ertapenem
Linezolid
Tigecycline
Colistin
Fosfomycin
Daptomycin
Ambisome
Anidulafungin
Voriconazole
Caspofungin
Route
IV
IV
IV
IV
IV
IV
IV
IV
IV & PO
IV
IV
PO
IV
IV
IV
IV & PO
IV
Comments
**Antibiotics not listed under group 1 or 2 should be prescribed or used for inpatients or outpatients with
approval of specialist and above, and in accordance to the prescribing indications outlined in this guideline.
5. Prescribing criteria for restricted anti-infective agents
Meropenem


Suspected or proven polymicrobial infection when combination therapy with other antibiotics or
piperacillin-tazobactam monotherapy is not desirable because:
o The organism is documented or likely resistant to all alternatives, risk of toxicity with
aminoglycosides or clinical failure.
Infection with an organism proven or likely resistant to all alternatives.
Vancomycin


Serious infections due to beta (β)-lactam-resistant Gram-positive organisms.
Infections due to Gram-positive organisms in patients with serious allergy to β-lactam antibiotics.
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016





Empiric treatment pending susceptibility for S. aureus identified from a sterile site when there is a
strong suspicion of methicillin-resistant S. aureus (MRSA), e.g. in hospitalized patients, patients with
known MRSA colonization.
Surgical prophylaxis in patients with life-threatening allergy to β-lactam antibiotics.
Prophylaxis for endocarditis in patients with life-threatening β-lactam allergy.
Empiric treatment of febrile neutropenic patients with suspected Gram-positive infections (e.g.
inflamed IV site).
C. difficile-associated colitis unresponsive to metronidazole. (Oral vancomycin).
Piperacillin-tazobactam



Suspected or proven polymicrobial infection when combination therapy with other antibiotics is
not desirable because organisms are documented or likely to be resistant to narrower spectrum
antibiotics or risk of toxicity with aminoglycosides.
Empiric therapy of febrile neutropenia.
Suspected or proven nosocomial pneumonia where the organisms are documented or likely
resistant to narrower spectrum antibiotics.
Moxifloxacin

Moxifloxacin is a quinolone antibiotic. It has activity against Gram-positive cocci, Gram-negative
cocci (except N. gonorrhoeae due to high prevalence of resistance), Gram-negative bacilli (including
extended spectrum β-lactamases [ESBL] organisms, Legionella spp.), Chlamydophila and M.
pneumoniae, and activity against anaerobes except C. difficle.
Indications:






Mild to moderate community-acquired pneumonia (CAP), including MDR S. pneumoniae.
Acute bacterial exacerbation of chronic bronchitis.
Acute bacterial sinusitis.
Uncomplicated skin and soft tissue infections.
Intra-abdominal infections.
Bacterial conjunctivitis.
Acceptable off-label use:

Treatment of infections caused by Legionella spp.
Unacceptable uses:

Avoid in use in CAP if tuberculosis (TB) suspected.
Linezolid

Treatment of vancomycin-resistant E. faecium infections.
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016




Proven glycopeptide intermediate S. aureus infection.
One of the following infections that is vancomycin-resistant or methicillin-resistant when
vancomycin (or other sensitive antimicrobial) is contraindicated, has failed or is not tolerated:
i. Nosocomial pneumonia
ii. Skin and skin structure infections including diabetic foot infections
iii. Community-acquired necrotizing pneumonia
Oral switch from IV glycopeptide where oral Rifampicin and trimethoprim are not appropriate.
Poor IV access and glycopeptide is indicated.
Tigecycline
 Complicated polymicrobial intra-abdominal infections.
 Complicated skin and soft tissue infections.
If the patients cannot receive other combination or the organism is resistant to other first line
treatment.
Note: Not active against P. aeruginosa.
Colistin

Treatment of MDR Gram-negative bacteria such as A. baumannii, P. aeruginosa and no other
treatment options are available.
Ertapenem



Ertapenem is a carbapenem antibiotic.
It has in vitro activity against many Gram-negative organisms including those that produce ESBL,
but it does not have activity against Pseudomonas spp. or Acinetobacter spp.
Its anaerobic and Gram-positive activity is similar to that of other carbapenem, except it does not
have activity against Enterococcus spp.
Indications:





Mild to moderate intra-abdominal infections (biliary tract infections, diverticulitis, secondary
peritonitis/gastrointestinal-intestinal [GI] perforation).
Moderate diabetic foot infections without osteomyelitis.
Moderate surgical site infections following contaminated procedures.
Pelvic Inflammatory disease.
Urinary tract infections due to ESBL producing organisms (not severe infections).
Note: Ertapenem is not recommended for severe infections in which Pseudomonas spp. are suspected.
Daptomycin

Daptomycin is a lipopeptide antibiotic.
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016


It has activity against most strains of staphylococci and streptococci (including MRSA and
Vancomycin-Resistant Enterococci [VRE].
Daptomycin does NOT have activity against Gram-negative organisms.
Indications:
All cases need to be discussed and approved by the infectious diseases and/or antimicrobial stewardship
team



Bacteraemia or endocarditis due to MRSA or coagulase-negative staphylococci (CoNS) in a patient
with serious allergy to vancomycin.
Bacteraemia or endocarditis due to MRSA in a patient failing vancomycin therapy as defined by:
o Clinical decompensation after 3–4 days.
o Failure to clear blood culture after 7 days despite maintaining vancomycin level at 15–20
mcg/ml.
o Vancomycin minimum inhibitory concentration (MIC) is 2 mcg/ml.
Treatment of VRE infections.
Daptomycin is NOT indicated for:



Pneumonia as it is inactivated by the pulmonary surfactant.
Initial therapy of Gram-positive infections.
VRE colonization of the urine, drains, wounds or sputum.
Fosfomycin


Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in vitro activity against large
number of Gram-negative and Gram-positive organisms including E. coli, Klebsiella spp., Proteus
spp., Pseudomonas spp., and VRE.
It does not have activity against Acinetobacter spp.
Indications:



Management of uncomplicated UTI in patients with history of antibiotic allergies and/or when no
other oral therapy options are available.
Uncomplicated UTI due to VRE.
Salvage therapy of UTI due to MDR Gram-negative organisms.
Susceptibility to fosfomycin should be confirmed prior to initiation of therapy
Antifungals
Liposomal amphotericin B
Indications:
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016


Cryptococcal meningitis in HIV-infected patients: treatment of cryptococcal meningitis in HIVinfected patients.
Fungal infections, empiric therapy: empiric treatment in febrile neutropenic patients with
presumed fungal infection.

Fungal infections, systemic therapy: treatment of systemic infections caused by Aspergillus spp.,
Candida spp., and/or Cryptococcus spp. in patients refractory to conventional amphotericin B
deoxycholate therapy or when renal impairment or unacceptable toxicity precludes the use of the
deoxycholate formulation.

Leishmaniasis (visceral): treatment of visceral leishmaniasis.
Note: Lipid-based amphotericin formulations (AmBisome) may be confused with conventional formulations
(desoxycholate [Amphocin, Fungizone]) or with other lipid-based amphotericin formulations (amphotericin
B lipid complex [Abelcet], amph. Lipid-based and conventional formulations are not interchangeable and
have different dosing recommendations. Overdoses have occurred when conventional formulations were
dispensed inadvertently for lipid-based products.
Usual (Adult) dosage range: IV: 3 to 6 mg/kg/day.
Note: Premedication: For patients, who experience non-anaphylactic immediate infusion-related reactions,
pre-medicate with the following drugs 30 to 60 minutes prior to drug administration:

A nonsteroidal anti-inflammatory agent ± diphenhydramine; OR

acetaminophen with diphenhydramine; OR hydrocortisone.
Caspofungin
Indications:



Treatment of invasive Aspergillus infections in patients who are refractory or intolerant of other
therapies.
Treatment of Candidaemia and other Candida infections (intra-abdominal abscesses, peritonitis,
pleural space).
Empirical treatment for presumed fungal infections in febrile neutropenic patients.
Voriconazole

Oral voriconazole is approximately 96% bioavailable. For this reason, it is recommended that oral
voriconazole be used whenever possible.
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NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
Indications:
 Primary treatment of pulmonary Aspergillus.
 Primary treatment of amphotericin B and fluconazole resistant fungal infections (including
Fusarium spp. and Scedosporium apiospermum - asexual form of Pseudoallescheria boydii).
 Treatment of invasive fungal infections in patients who are intolerant of, or refractory to, other
antifungal therapy.
Posaconazole
Restricted to ID consultant only.
Indications:

Prophylaxis of invasive Aspergillus and Candida infections in patients who are at high risk of
developing these infections due to being severely immunocompromised (e.g., hematopoietic stem
cell transplant [HSCT] recipients with graft-versus-host disease [GVHD] or those with prolonged
neutropenia secondary to chemotherapy for haematologic malignancies).
Off-label indications:



Treatment of invasive aspergillosis (refractory to or intolerant of conventional therapy).
Mucormycosis.
Refractory or relapsed invasive fungal infections (salvage therapy).
6. Intravenous (IV) to oral (PO) antibiotic conversion
This describes the practice of converting intravenous antimicrobial therapies to effective alternative oral
formulation. Several clinical trials have been conducted that demonstrate the efficacy and safety of IV to PO
antimicrobial conversion, and several studies have also addressed the economic impact of this conversion.
Cost savings are achieved through lowering direct acquisition costs, eliminating the need for ancillary
supplies, reducing pharmacy and nursing time, and shortening the length of hospital stay. Intravenous to
oral antimicrobials conversion also benefits the patient by eliminating adverse events associated with IV
therapy, increasing patient comfort and mobility, and increasing the possibility of earlier discharge.
Conversion to oral therapy also reduces the risk of adverse effects associated with intravascular lines like
catheter‐related bloodstream infection (CRBSI) and thrombophlebitis.
For examples of antimicrobials that can be included in IV to PO therapy conversion and bioavailability of
selected antimicrobials available in both IV and PO formulations, please refer to Table (c).
16
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
Table : Bioavailability of selected antibiotics available in both IV and PO formulations
80% to 100%
Ciprofloxacin
Clindamycin
Doxycycline
Fluconazole
Linezolid
Metronidazole
Moxifloxacin
Sulfamethoxazole/trimethoprim
Azithromycin (<50%: although azithromycin has a low bioavailability, it is well‐distributed into
tissues)
Table (c)
Criteria used to determine patients for IV to PO therapy conversion:
1. Intact and functioning gastrointestinal (GI) tract as evidenced by:
 Patient is tolerating food, fluids or enteral feeds
 Patient is receiving other oral medications
 No nausea, emesis or diarrhoea in the past 24 hours
2. Criteria indicating absorption of oral medications may be compromised:
 Nil by mouth status (and no medications are being administered orally)
 Nasogastric (NG) tube with continuous suction
 Severe/persistent nausea or vomiting
 Gastrointestinal transit time too short for absorption such as malabsorption syndromes, partial
or total removal of the stomach, short bowel syndrome
 Active upper gastrointestinal bleeding
 High doses of vasopressor medications (typically in persistent hypotension despite high dose of
vasopressor)
 Difficulty swallowing or loss of consciousness and no NG access available
 Documented ileus or gastrointestinal obstruction
 Continuous tube feedings that cannot be interrupted and patient requires a medication known to
bind to enteral nutrition formulas
3. Improving clinical status:
 The patient should be clinically stable and deterioration should not be expected
 Should be afebrile or have had a maximum temperature of less than 38°C in the previous 24 hours
 White blood cell (WBC) count should be trending downward. It is important to examine the
patient’s medication therapy for other medications that can cause an increase or sustained high
WBC count such as steroids
 It is also important to review the cultured pathogen (bacteria, fungus, etc.) and ensure that it is
susceptible to the oral medication
17
NATIONAL ANTIMICROBIAL GUIDELINES
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4. Does not meet any of the following exclusion criteria:
 Endocarditis
 Central nervous system infections (e.g. meningitis, brain abscess, etc.)
 Orbital cellulitis
 Osteomyelitis
 Endophthalmitis
 Melioidosis (at least 10 to 14 days of IV therapy)
 Abscesses
 Patients who are neutropenic are typically excluded from IV to PO therapy conversion
Table(d): Antimicrobials IV-PO conversion equivalent doses
Antimicrobials
Parenteral IV dose
PO equivalent
dose
Comments
Azithromycin
500 mg IV daily
500 mg daily
With and without
food for the tab
suspension: take 1 hr before or 2 hrs
after food
Cefuroxime
* 750–1500 mg IV Q8hrs
500 mg PO
Q12 hrs
Ciprofloxacin *
400 mg IV q8hrs
400 mg IV q12 hrs
400 mg IV q24 hrs
750 mg PO q12hrs
500 mg PO q12
hrs
500 mg PO q24
hrs
Moxifloxacin
400 mg IV daily
400 mg PO daily
Clindamycin
600 mg IV q8 hrs
300 mg PO q6 hrs
OR 600 mg q8 hrs for
severe skin
infections
Doxycycline
100 mg IV q12 hrs
With or without
100 mg PO q 12
hrs
18
Give 2 hrs
before calcium,
iron or dairy
products
-Not for patients with
continuous enteral
feeding or
jejunostomy tube
-stop tube feeding
2 hrs before
and 2 hrs after
administration**
With or without
food
Take 1 hour (hr) before
or 2 hrs after
meals
NATIONAL ANTIMICROBIAL GUIDELINES
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Linezolid
600 mg IV q12 hrs
600 mg PO q12
hrs
Metronidazole*
500 mg IV q 8-12
hrs
500 mg PO q 8-12
hrs
Fluconazole
IV dose daily
Same dose PO daily
Avoid tyramine rich
Foods e.g chocolate, cheese,
yoghurt, shrimp
* Not affected by
food
(1:1 conversion)
(patients with
Candidaemia or
disseminated
candidiasis, keep
IV)
Note:
*Consider renal dosing for patients with renal impairment
** Patients with feeding tubes: tubes should be flushed with water both before and after Medication administration
7. Performance measures:
The compliance with this guide and policy will be monitored by specific activities such as audit and
feedback.
Antimicrobials bundle of care audit tool:
1. Life-threatening conditions
1.1 Median time from first clinical contact to the first dose of antibiotics for patients with suspected
bacterial meningitis or for patients with suspected sepsis.
2. Use of antimicrobial guidelines and clinical conditions
2.1 Proportion of antibiotic prescriptions that are in accordance with guidelines.
3. Documentation
3.1 Rate of documentation of clinical indications (reason) for prescribing antibiotics.
4. Use of broad-spectrum antibiotics
19
NATIONAL ANTIMICROBIAL GUIDELINES
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4.1 Proportion of patient prescriptions of broad-spectrum antibiotics for which a medical review is
documented within 72 hours from first prescription.
5. Surgical prophylaxis
5.1 Proportion of patients for whom surgical prophylactic antibiotics were prescribed in accordance with
guideline.
5.2 Proportion of patients who are administered indicated prophylactic antibiotics within 30–60 minutes
prior to surgical procedure.
5.3 Proportion of patients whose prophylactic antibiotics were discontinued within 24 hours after surgery
or 48 hours after cardiac surgery.
20
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
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TABLE 1: GUIDELINES FOR TREATMENT OF RESPIRATORY INFECTIONS IN ADULTS
ANATOMIC
SITE/
DIAGNOSIS
ETIOLOGIES
RESPIRATORY SYSTEM
Acute
Usually viral
bronchitis
M. pneumoniae
5%,
C. pneumoniae 5%
Pertussis
B. pertussis,
B. parapertussis
SUGGESTED REGIMENS
FIRST LINE
COMMENTS
SECOND LINE
Supportive care
No antibiotics are indicated
If persistent fever and
cough do chest x-ray
(CXR)
Azithromycin 500 mg
day 1 then 250 mg
q24 hr days 2-5
Erythromycin 500 mg
4 times a day (QID) x
14 days OR
Clarithromycin twice a
day (BID) X 7 days OR
Prophylaxis of
household or close
contacts is indicated as
per treatment
regimens
TMP-SMX (1 DS tab
q12h for 14 days) is an
alternative if
macrolides resistance
is expected
(Persistent cough >14
days, afebrile
10–20% of adults will
have pertussis)
21
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 1: GUIDELINES FOR TREATMENT OF RESPIRATORY INFECTIONS IN ADULTS
ANATOMIC SITE/
DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
RESPIRATORY SYSTEM
Acute Bacterial
Viruses causes 20–
Exacerbation of
50%,
Chronic Bronchitis C. pneumoniae ,
(ABECB)
M. pneumonia,
H. influenzae,
S. pneumoniae,
M. catarrhalis,
Gram-negative
enteric organisms
Risk factors for
Pseudomonas:
Recent
hospitalization
(within 3 months),
frequent
administration of
antibiotics (≥4
courses in past
year), isolation of
Pseudomonas in
previous
exacerbation,
systemic steroids
use, colonization
with Pseudomonas
during stable
disease,
FEV1<50%.
SECOND LINE
Role of antibiotics is debated. However
recent evidence showed benefit in
patients hospitalized with severe
disease.
-Mild disease:
Amoxicillin 500 mg PO 3 times daily
(TID) OR Cotrimoxazole 1 DS tab BID,
OR Doxycycline100 mg BID, OR
Cefuroxime 500 mg PO BID.
- Moderate or severe disease
And no risk of Pseudomonas
amoxicillin-clavulanate plus
azithromycin OR clarithromycin OR
fluoroquinolone (FQ) with enhanced
activity against pneumococci
(moxifloxacin, levofloxacin [levo])
-if Risk for Pseudomonas :
IV FQ (levo) OR tazocin.
22
COMMENTS
Severe: increased
dyspnea, sputum
viscosity and volume,
FEV1 <50%, >4
exacerbations in the
last 12 months, Home
O2, Coronary artery
disease or heart failure,
chronic steroid use,
antibiotics in the last 3
months
Consider:
1) CXR esp. if febrile or
has low O2 sat
2) inhaled
bronchodilators
3) corticosteroids taper
over 2 weeks
4) stop smoking
5) non-invasive positive
pressure ventilation
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 1: GUIDELINES FOR TREATMENT OF RESPIRATORY INFECTIONS IN ADULTS
ANATOMIC SITE/
DIAGNOSIS
Bronchiectasis
ETIOLOGIES
H. influenzae,
P. aeruginosa,
S. pneumoniae
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
COMMENTS
Levo 500 q24h, OR moxifloxacin 400
mg q24h
Prevention: consult respiratory/chest
physician
Community-acquired pneumonia
prognosis prediction using
CURB65 criteria(C=confusion, U=urea >7.5 mmol/L, R=RR ≥30,B=SBp <90 or DBp ≤60,Age ≥65.)
Score:
- 0–1 (mortality 1.5%)  treat as outpatient.
- 2 (mortality 9.2%)  admit to medical ward.
- 3 or more (mortality 22%)  consider admission to ICU.
NB: clinical judgment should be used for all patients.
-Obtain appropriate cultures
-Start empirical influenza treatment during flu season and look for S. aureus
CAP, Outpatient
Outpatient :
Previously healthy and no use of antimicrobials within the
S. pneumoniae,
previous 3 months:
M. pneumoniae,
Amoxicillin 1 gm TID PLUS clarithromycin 500 mg BID PO
H. influenzae,
OR
C. pneumoniae,
respiratory FQ (levo OR moxifloxacin)
Respiratory viruses OR
Doxycycline 200 mg PO stat then 100 mg BID for 7 days.
Presence of comorbidities such as chronic heart, lung, liver
or renal disease; diabetes mellitus; alcoholism;
malignancies; asplenia; immunosuppressing conditions or
drugs; OR use of antimicrobials within the previous 3
months (in which case an alternative from a different class
should be selected):
Amoxicillin high dose (1 g q8h) (OR amoxicillinclavulanate) PLUS a macrolide (clarithromycin
/azithromycin).
OR a respiratory FQ (Moxifloxacin 400 mg q24h OR
levo (750 mg) q24h.
23
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 1: GUIDELINES FOR TREATMENT OF RESPIRATORY INFECTIONS IN ADULTS
ANATOMIC SITE/
DIAGNOSIS
CAP, In-patient (nonICU):
CAP In-patient (ICU):
Aspiration pneumonia
+/-lung abscess
Empyema
ETIOLOGIES
S. pneumoniae,
M. pneumoniae,
C. pneumoniae,
H. influenzae,
Legionella spp.,
Respiratory viruses
SUGGESTED REGIMENS
COMMENTS
FIRST LINE
SECOND LINE
IV AMP (OR amoxicillin-clavulanate) PLUS IV azithromycin OR
clarithromycin
OR
Respiratory fluoroquinolone (levo 750 mg IV q24h OR
moxifloxacin 400 mg IV q24h.
S. pneumoniae,
S. aureus,
Legionella spp.,
Gram-negative
bacilli
H. influenzae
Ceftriaxone plus either macrolide OR a respiratory
fluoroquinolone
(for penicillin [pen]-allergic patients, a respiratory
fluoroquinolone is recommended).
Special concerns
-If pseudomonas is a consideration (see above):
piperacillin-tazobactam OR cefepime plus
levo (750 mg once daily )
-If community-associated methicillin-resistant S. aureus (CAMRSA) is a consideration, add vancomycin (vanco) OR
linezolid
Anaerobes 34%,
Clindamycin 600
Ceftriaxone 1g IV
Gram-positive
mg IV q8h
q24h plus metro
cocci 26%, S. milleri
500 mg IV q6hOR
16%, K.
Piperacillinpneumoniae 25%,
Tazobactam 4.5 g
Nocardia spp.3%
IV q8h
S. pneumoniae.
Clindamycin 600
Ceftriaxone 1 g IV Diagnostic
Group A Strept,
mg IV q8h PLUS
q24h plus metro
thoracentesis and
S. aureus,
(Ceftriaxone 1 g IV 500 mg IV q6h OR chest tube for
H. influenzae,
q24h OR cefepime 1 g IV q12h
drainage
coliforms,
IV 2 g q12h)
anaerobes
OR
PIP-TAZ 4.5 g IV
q8h
24
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 1: GUIDELINES FOR TREATMENT OF RESPIRATORY INFECTIONS IN ADULTS
ANATOMIC SITE/
DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
Pneumonia with fever,
night sweats and
weight loss
Cystic fibrosis,
pulmonary
exacerbation
To rule out
pulmonary TB
Refer to national
TB guidelines
S. aureus and
H. influenzae early
in disease
P. aeruginosa later
in disease
B. cepacia
Non-tuberculous
mycobacteria is
emerging
important
pathogen
Tobramycin +
piperacillin/
tazobactam .
for methicillinsensitive S. aureus
(MSSA) use
cloxacillin.
For MRSA use
vanco.
For B. cepacia:
TMP-SMX (Septrin)
FIRST LINE
COMMENTS
SECOND LINE
Tobramycin +
Ceftazidime
If P.aeruginosa
resistant then
Ciprofloxacin
OR levo can be
used if
P.aeruginosa is
susceptible.
Consult ID/Chest
Physician to
streamline
therapy.
References:
1. Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. IDSA/ATS guidelines for CAP in
adults. CID 2007;44(Suppl 2):S27–S72.
2. Rothberg MB, Pekow PS, Lahti M, Brody O, Skiest DJ, Lindenauer PK. Antibiotic therapy and treatment failure in
patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease. JAMA 2010;303(20):2035–
42.
25
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 2: GUIDELINES FOR TREATMENT OF EAR, NOSE AND THROAT INFECTIONS
The microbial flora of the external canal is similar to the flora of skin elsewhere. There is predominance of
S. epidermidis, S. Aureus, Corynebacterium, and, to a lesser extent, anaerobic bacteria such as P. acnes.
Pathogens responsible for infection of the middle ear (S. pneumoniae, H. influenzae, or M. catarrhalis) are
uncommonly found in cultures of the external auditory canal when the tympanic membrane is intact).
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
COMMENTS
SECOND LINE
Chronic Otitis
Externa
Usually due to
seborrhoea
Eardrops
(polymyxin B+
neomycin+
hydrocortisone
QID) + selenium
sulphide
shampoo
Otitis Externa
Fungal
Candida spp.
Clotrimazole ear
drops BID for
10–14 days then
reassess
Fluconazole 200
mg PO one dose &
then 100 mg PO
once daily for 3–5
days
Oral therapy is given in
refractory cases were no
response to topical antifungals
Otitis Externa
Malignant
P. aeruginosa
>95%
early in the
disease:
S. aureus
Cip 750 mg PO
q8–12 h
Piperacillintazobactam 4.5 g
IV q8h OR
Meropenem 1 g IV
q8h OR any other
antipseudomonal
± aminoglycoside
R/O osteomyelitis by computed
tomography (CT) or MRI scans.
If bone involved treat for 6– 8
weeksConsult ENT specialist
26
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 2: GUIDELINES FOR TREATMENT OF EAR, NOSE AND THROAT INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
Acute Otitis
Media
ETIOLOGIES
Commonly caused
by viral infection
(70%)
Bacterial:
S. pneumoniae
H. influenzae ,
M. Cattarhalis,
rarely S. aureus,
S. pyogenes
Acute
mastoiditis
Require inpatient therapy
Chronic
mastoiditis
First episode:
S. pneumoniae,
H. influenzae,
M. cattarhalis
Secondary to
chronic otitis
media: S. aureus,
P. aeruginosa,
S. pneumoniae
Often
polymicrobial
(Gram-positive,
enterobacteriaceae and
Pseudomonas)
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Mild to moderate
disease :
amoxicillin PO 500
mg every 12 hrs,
OR 250 mg every 8
hrs
Cefuroxime 500 mg
q12 hrs
OR clarithromycin
500 mg BID x 10
days
Severe disease:
amoxicillinclavulanate 875
mg every 12 hrs
IV ceftriaxone 2
gm IV once daily
Levo 750 mg IV
once daily
ENT consultation. Obtain cultures, treat
for acute exacerbations or
preoperatively
27
COMMENTS
Duration of treatment:
<2 yrs: 10 days
>2 yrs: 5–7 days
Antibiotics to be modified
by availability of cultures
and susceptibility
CT or MRI for diagnosis.
ENT consultation for surgical
intervention and
management of
complications
Diagnosis: CT or MRI
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 2: GUIDELINES FOR TREATMENT OF EAR, NOSE AND THROAT INFECTIONS
Acute Sinusitis: It is generally not possible to distinguish acute viral from bacterial rhinosinusitis in first 10 days,
based on history, examination or radiologic study. Since acute viral rhinosinusitis is expected to resolve within 10
days, and acute bacterial rhinosinusitis may also resolve spontaneously within the first 10 days, patients who
present with fewer than 10 days of symptoms in general should be managed with supportive care. Exceptions
would be patients who experience clinical worsening after initial improvement, patients with severe symptoms
and clearly worsening clinical course, and immunocompromised patients.
ANATOMIC
SITE/DIAGNOSIS
Acute Sinusitis
ETIOLOGIES
S. pneumonia,
H. influenzae,
Viral,
M. catarrhalis,
S. aureus,
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Amoxicillin 1 g
q8 hrs.
Amoxicillinclavulanate
(extended
release)
1000/62.5 Mg
BID
Anaerobes:
S. pyogenes
OR
Levo 750 mg
PO q24h x 5
days
28
COMMENTS
Pen allergy:
Alternative first line therapy, narrow
spectrum antibiotics include:
trimethoprim/ sulfamethoxazole OR
erythromycin OR azithromycin OR
doxycycline.
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 2: GUIDELINES FOR TREATMENT OF EAR, NOSE AND THROAT INFECTIONS
Chronic sinusitis: there is limited evidence that antibiotics, as a single therapy, are beneficial in the treatment of
chronic sinusitis. Instead, a comprehensive approach to medical management, which includes antimicrobials
combined with topical or systemic glucocorticoids, and sometimes other agents, is now encouraged.
ANATOMIC
SITE/DIAGNOSIS
Chronic sinusitis
Allergic
Infective
Dental
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
Anaerobes:
Prevotella spp.,
Streptococcus spp.,
Fusobacterium spp.
Aerobes:
Streptococcus spp.
ENT consultation,
If antibiotics needed:
amoxicillinclavulanate 875 mg
PO BID
COMMENTS
SECOND LINE
Clindamycin 300 mg
QID
Treatment should
be continued for at
least 3 weeks
Clindamycin 300–450
mg PO q6–8h x 5days
OR erythromycin 500
mg QID x 10 days
If pen-allergic:
clindamycin OR
erythromycin
Idiopathic
H. influenzae,
P. aeruginosa,
Enterobacteriaceae:
S. aureus,
M. catarrhalis
Pharyngitis /
tonsillitis
Avoid antibiotics
as 90% resolve in
7 days without
antibiotics
Commonly viral EBV
(Infectious
mononucleosis)
Pen V 500 mg PO BID
OR 250 mg PO QID x
10 days
Streptococcus spp.
(group A,C,G)
If compliance is
unlikely give
benzathine pen
intramuscular (IM) x
1.2 million unit once
only
Other causes:
Primary HIV
C. diphtheria,
A. hemolyticum,
(rare)M.pneumoniae,
F. Necrophorum.
29
OR cefuroxime 250
mg BID x 5 days
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 3: GUIDELINES FOR TREATMENT OF EYE INFECTION
CONDITION
External
hordeolum/
Chalazion
SUSPECTED
ORGANISM
Non (common)
Staphylococcus
(if associated
preseptal
cellulitis)
TREATMENT
Frequent hot
compresses
topical
antibiotic/corticesteroid ointment
combination (may
benefit)
ALTERNATIVE
TREATMENT
Referred to an
ophthalmologist for
incision and
curettage OR direct
glucocorticoid
injection
COMMENTS
If there is concurrent
preseptal cellulitis,
oral antibiotics with
Staphylococcal
coverage are
appropriate
Blepharitis
Aetiology
unclear. Factors
include
Staphylococcus,
seborrhoea,
rosacea & dry
eye.
Lid margin care with
baby shampoo &
warm compresses
q24h.
Artificial tears if dry
eye.
Erythromycin
ointment.
Tetracycline
ointment.
Fucithalmic eye drops
for 5–7 days
If associated in chronic
or refractory cases or
rosacea, add
doxycycline 100 mg PO
bid for 2 weeks.
Consult
ophthalmologist
Acute bacterial
conjunctivitis
S. epidermidis,
S. aureus,
S. pneumoniae,
H. influenzae .
Ofloxacin eye drops
Gentamicin ointment
for 5–7 days
Eye washes with warm
water (saline).
Add systemic
antibiotics.
If extraocular
involvement refer to
ophthalmologist
Viral conjunctivitis
(pink eye)
Adenovirus
No treatment. If symptomatic, cold artificial
tears may help.
If membrane or pseudo membrane is present
add mild steroid
Viral
keratoconjunctivitis
herpes simplex
TRifluridine
virus (HSV), types ophthalmic solution,
1&2
one drop q2h up to 9
drops/day until reepithelialized, then 1
drop q4h up to 5 x
days for total not to
exceed 21 days
Tetracycline ointment
30
Acyclovir ointment
(30 mg)
Five times a day at
approximately 4
hourly intervals.
Treatment should be
continued for 14 days
Highly contagious.
Onset of ocular pain
and photophobia in an
adult suggests
associated keratitis
Consult
ophthalmologist
Topical Antibiotics to
prevent infection can
be considered.
Alternate mild steroid
&
Artificial tears can be
added
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 3: GUIDELINES FOR TREATMENT OF EYE INFECTION
CONDITION
SUSPECTED
ORGANISM
TREATMENT
ALTERNATIVE
TREATMENT
COMMENTS
Varicella zoster
ophthalmicus
VZV
Valacyclovir 1 g PO
q8h for 10 days
Acyclovir 800 mg PO
5 x day for 10 days
Inclusion
Chlamydial
conjunctivitis
C. trachomatis
Azithromycin 1 gm
once
Doxycycline once
daily (OD) capsule
100 mg for 7 days
Gonococcal
conjunctivitis
N. gonorrhoeae
Ceftriaxone 1 g IM OR
IV one dose
AND azithromycin 1
gm once to cover for
presumptive
chlamydial coinfection.
Trachoma
C. trachomatis
Azithromycin 1 g PO
single dose
Doxycycline caps 100
mg BID x 21 days.
Tetracycline 250 mg
PO QID for 14 days
Topical therapy is of
marginal benefit
Fungal keratitis
Aspergillus spp.,
fusarium spp.,
Candida spp. and
others
Amphotericin B 1
drop every 1–2 hrs
for several days
Consult
ophthalmologist,
obtain appropriate
cultures,
practice good hygiene
and cleaning
Bacterial keratitis
S. aureus,
S. pneumoniae,
S. pyogenes,
Haemophilus
Natamycin 1 drop
every 1–2 hrs for
several days, then q3–
4h for several days
-Voriconazole 1% eye
solution hourly taper
to 4 hourly for 4–6
weeks
Moxifloxacin
ophthalmic 0.5% 1
drop q1h for the first
48 hrs and then taper
according to
response.
Fortified gentamicin /
cefuroxime OR vanco
eye drops hourly
with tapering
according to clinical
response
Consult
Ophthalmologist,
obtain appropriate
cultures, practice
good hygiene and
cleaning
Pseudomonas
aeruginosa
(contact lens
wearer)
Cip 0.3% ophthalmic
drops
31
Consult
ophthalmologist
NATIONAL ANTIMICROBIAL GUIDELINES
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TABLE 3: GUIDELINES FOR TREATMENT OF EYE INFECTION
CONDITION
SUSPECTED
ORGANISM
TREATMENT
ALTERNATIVE
TREATMENT
Orbital cellulitis
S. pneumoniae,
H. influenzae,
M. catarrhalis,
S. aureus,
anaerobes,
group A Strept,
occasionally Gramnegative
organisms.
Ceftriaxone 2 g IV OD
in adults q24h
PLUS metronidazole
adult 500 mg IV q6–
8h
Topical erythromycin
eye ointment.
If allergic to pen:
levo 750 mg IV OD
and Metronidazole
500 mg IV q6–8h
if MRSA DD vanco IV
1.5 mg/kg q12h
Necrotizing
herpetic
retinopathy
(ARN/PORN)
Varicella zoster
virus
HSV type 2
Acyclovir IV 10–12
mg/kg q8h for 1–2
weeks then
famciclovir 500 mg PO
TID
OR valacyclovir 1000
mg PO q8h OR
acyclovir 800 Mg PO
q8h
ganciclovir/
valganciclovir
Consult
ophthalmologist
and infectious disease
physician
intravitreal vanco 1
mg/0.1 ml and either,
ceftazidime 2 mg/0.1
ml OR Amikacin 0.4
mg/0.1 ml
Then topical third or
fourth generation of
fluoroquinolones
PLUS oral cip 750 mg
BID
or IV injection
Ceftriaxone 1 g BID
Immediate ophthalmic
consults
Rarely CMV
Postoperative
endophthalmitis
Most common:
S. epidermidis,
S. aureus,
Streptococcal spp.
less common
Gram-negative
bacteria:
Pseudomonas,
Haemophilus,
Klebsiella, E. coli
32
COMMENTS
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 3: GUIDELINES FOR TREATMENT OF EYE INFECTION
CONDITION
Traumatic
endophthalmitis
Endogenous
Bacterial
Endophthalmitis
SUSPECTED
ORGANISM
Bacillus spp. ,
S. epidermidis
Gram-negative
B. cereus (especially
in IV drug abuse),
streptococci,
N. meningitidis,
S. aureus,
H. influenzae
TREATMENT
Topical fortified
tobramycin q1h with
fortified cefazolin OR
fortified vanco.
Systemic antibiotic cip
400 mg IV q12h and
clindamycin 600 mg IV
q8h.
Intravitreal ceftazidime
2 mg/0.1 ml OR
amikacin 0.4 mg/0.1 ml
and vanco 1 mg/0.1 ml
OR clindamycin 1
mg/0.1 may be
repeated every 48–72
hrs
Intravitreal amikacin
0.4 mg/0.1 ml
OR
Ceftriaxone 2 mg/0.1
ml
and vanco 1 mg/0.1 ml
OR
Clindamycin 1 mg/0.1
ml
33
ALTERNATIVE
TREATMENT
Systemic antibiotic is
recommended and
should be given at least
for 2 weeks depending
on blood culture
COMMENTS
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 4: GUIDELINES FOR TREATMENT OF INFECTIVE ENDOCARDITIS AND RELATED INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
Infective endocarditis:
native valve-empirical
Rx awaiting cultures-No
IV illicit drugs, valvular
or congenital heart
disease but no
modifying
circumstances
Infective endocarditis:
Native valve- IV illicit
drug use +/- evidence
right-sided
endocarditis-empirical
therapy
ETIOLOGIES
Viridans
streptococci 30–
40%,
Other Strep. 15–
25%,
enterococci 5–
18%,
staphylococci 20–
35% including
CoNS
S. aureus (MSSA &
MRSA). All others
rare
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Pen G 20 million Vanco 15-20
units IV divided mg/kg IV q12h,
q4h OR AMP 12 not to exceed 2
gm IV /day
g q24h unless
divided q4h +
serum level
Fucloxacillin2 g
monitored. Aim
IV q4–6h (use
for vanco target
q4h regimen if
trough level 15–
weight >85 kg) + 20 mcg/ml +
gentamicin 1
gentamicin 1
mg/kg IV q8h
mg/kg IV q8h
Vanco 15–20
mg/kg q 12 hrs
IV divided in 2–3
doses to
achieve target
trough
concentration
of 15–20
mcg/ml,
recommended
for serious
infections
34
Dapto 6 mg/kg
IV q24h,
approved for
right-sided
endocarditis
COMMENTS
If patient not acutely
ill and not in heart
failure, we prefer to
wait for blood culture
results. If initial 3
blood cultures
negative after 24–48
hrs, obtain 2–3 more
blood cultures before
empiric therapy
started.
If acutely ill and high
risk for MRSA, add
vanco to first line till
cultures are available
or patient cannot
tolerate pen
-Consult ID
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 4: GUIDELINES FOR TREATMENT OF INFECTIVE ENDOCARDITIS AND RELATED INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
Infective
endocarditis:
Native valve-culture
positive
viridians streptococci,
S. bovis (S.
gallolyticus) with pen
G MIC <0.1 mcg/ml
Viridans
streptococci,
S. bovis
Infective
endocarditis-Native
valve-culture positive
viridians streptococci,
S. bovis
(S. gallolyticus) with
pen G MIC >0.1 to
<0.5 mcg/ml
SUGGESTED REGIMENS
COMMENTS
FIRST LINE
Pen G 12–18 million
units/day IV divided
q4h x 2 weeks +
gentamicin 1 mg/kg
q8h IV x 2 weeks OR
pen G12–18 million
units/day IV divided
q4h x 4 weeks
SECOND LINE
Ceftriaxone 2g IV
q24h x 4 weeks.
Viridians
streptococci,
S. bovis,
nutritionally
variant
streptococci,
(e.g. S.
abiotrophia)
tolerant
streptococci.
Pen G 18–24 million
units/day IV divided
q4h x 4 weeks) +
(gentamicin 1 mg/kg
IV q8h x 2 weeks)
Note: low dose of
gentamicin
Vanco 15 mg/kg IV
q12h to 2 g/day max
unless serum levels
measured x 4 weeks
For viridians
streptococci, S. bovis
with pen G MIC >0.5
and enterococci
susceptible to
AMP/pen G, vanco,
gentamicin
Note: ID consultation
suggested
“Susceptible”
enterococci,
viridians
streptococci,
S. bovis,
nutritionally
variant
streptococci
Pen G 18–30 million
units/24h IV, divided
q4h x 4–6 weeks +
gentamicin 1–1.5
mg/kg IV q8 hr IV x
4–6 weeks OR AMP
12g/day IV, divided
q4h +gentamicin (as
above)for 4–6 weeks
Vanco 15 mg/kg IV
q12h to 2 g/day max
unless serum levels
measured plus
gentamicin 1–1.5
mg/kg q8h IV for
4–6 weeks
Note: low dose of
gentamicin
Vanco for penallergic patients. Do
not use
cephalosporin.
Enterococci:
MIC streptomycin
>2000 mcg/ml; MIC
gentamicin >500–
2000 mcg/ml; no
resistance to pen
Enterococci,
high-level
aminoglycosi
de resistance
AMP 12g/day IV
divided q4h PLUS
ceftriaxone 2 g IV
q12h for 8 weeks
Prolonged pen G OR
AMP for 8–12 weeks
OR AMP plus dapto
If prolonged Rx fails
consider surgical
removal of the valve
35
OR
Ceftriaxone2 g IV q24h
+ gentamicin IV 1
mg/kg q8h IV x 2
weeks
Always ensure that
MICs are provided by
the microbiology lab.
Target gent levels
peak 3 mcg/ml,
trough gent level
<1mcg/ml). If allergy
with pen: use vanco
15 mg/kg IV q12h to
2 g/day max unless
serum levels
measured x 4 weeks
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 4: GUIDELINES FOR TREATMENT OF INFECTIVE ENDOCARDITIS AND RELATED INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
Enterococci:
pen G MIC >16
mcg/ml; no
gentamicin resistance
Enterococci,
intrinsic pen
G /AMP
resistance
Vanco 15 mg/kg IV
q12h (check levels if >2
g) PLUS gentamicin 1–
1.5 mg/kg q8h for 6
weeks. See comment.
Desired vanco serum
levels trough 10–15
mcg/ml. Gent used for
synergy; peak levels
need not exceed 4
mcg/ml.
Enterococci:
Pen/AMP resistance +
high-level
gent/Strept.
resistance + vanco
resistance, usually
VRE
ID consultation
required
Enterococci,
vancoresistant,
usually
E. faecium
No reliable
effective therapy:
linezolid 600 mg IV
OR PO q12h OR
dapto-see
comment
Quinupristin/dalfopristi
n activity limited to E.
faecium and is usually
bacteriostatic,
therefore expect high
relapse rate. Dose: 7.5
mg/kg IV (via central
line) q8h. Linezolid
active against most
enterococci, but
bacteriostatic. Dose:
600 mg IV OR PO q12h.
Linezolid failed in
patients with
E. faecalis endocarditis.
Dapto is bactericidal in
vitro; clinical experience
in CID 41:1134, 2005.
Native valve
staphylococcal
endocarditis
MSSA
S. aureus,
methicillinsensitive
Flucloxacillin 2 g IV
q4–6h (Use q4h
regimen if weight
>85 kg) x 4–6
weeks
FIRST LINE
36
COMMENTS
SECOND LINE
Teicoplanin active
against a subset of
vanco-resistant
enterococci: 6
mg/kg (~400 mg) I.V.
on the first day,
followed by 6 mg/kg
I.V. OD thereafter.
For more severe
infections: 6 mg/kg
(~400 mg) I.V. given
every 12 hrs for 3
doses, followed by 6
mg/kg/day; doses
up to 12mg/kg/day
may be used
OR dapto: I.V.: 6
mg/kg OD for 2–6
weeks
Cefazolin 2 g IV q8h
x 4–6 weeks
If pen allergy : vanco 15
mg/kg IV q12h. Check
level if >2 g/day x 4–6
weeks.
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 4: GUIDELINES FOR TREATMENT OF INFECTIVE ENDOCARDITIS AND RELATED INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
Native valve
staphylococcal
endocarditis
MRSA,
ID consultation
required
S. aureus,
methicillinresistant
Slow-growing
fastidious Gramnegative bacilli in
any valve
A group of Gramnegative bacteria
that includes
Haemophilus spp.
(HACEK) group
(see comments).
SUGGESTED REGIMENS
FIRST LINE
Vanco 30–60 mg/kg
per day divided into
2–3 doses to
achieve target
trough
concentration 15–
20 mcg/ml
recommended for
serious infections
For 6 weeks
SECOND LINE
Dapto 6–10 mg/kg
OD
Ceftriaxone 2 g IV
q24h x 4 weeks
If penicillinasenegative,
cip 1000 mg/24h
PO OR 800 mg/24 h
IV in 2 equally
divided doses.
Fluoroquinolone
therapy
recommended only
for patients unable
to tolerate
cephalosporin and
AMP therapy
37
COMMENTS
Note: dapto is not
Food and Drug
Administration (FDA)
approved for left sided
endocarditis,
can cause muscle
toxicity. Need to
monitor creatinine
kinase regularly
Penicillinase
positive HACEK should
be susceptible to AMSB plus gentamicin
HACEK (acronym for H.
parainfluenza, H.
aphrophilus
(Aggregatiba-cter,
Actinobacillus),
Cardiobact-erium,
Eikenella, Kingella).
AM-SB plus
gentamicin.
Patients with
endocarditis involving
prosthetic cardiac
valve or other
prosthetic cardiac
material should be
treated for 6 weeks
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 4: GUIDELINES FOR TREATMENT OF INFECTIVE ENDOCARDITIS AND RELATED INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
COMMENTS
SECOND LINE
Bartonella species-any
valve
B. henselae,
B. quintana
Ceftriaxone 2 g IV q24h x 6 weeks +
gentamicin 1 mg/kg q8h x 14 days +
doxy 100 mg IV PO bid x 6 weeks
Patients with
Bartonella endocarditis
should be treated in
consultation with an ID
specialist
If gentamicin is not
tolerated, Rifampicin
(Rif) 300 mg IV PO bid
for 14 days can be
used.
If doxy is not tolerated,
azithromycin 250 mg
PO OD can be used
Infective endocarditis:
Prosthetic valve
empiric therapy
(culture pending):
-Early (<2 months postop)
-Late (>2 months postop)
S. aureus,
S. epidermidis,
Rarely,
Enterobacteriaceae
,
diphtheroids, fungi
S. epidermidis,
viridians
streptococci,
enterococci,
S. aureus.
Vanco 15–20 mg/kg IV q12h +
gentamicin 1 mg/kg IV q8h + Rif 600
mg IV/PO q24h
Surgical and ID
consultations
38
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 4: GUIDELINES FOR TREATMENT OF INFECTIVE ENDOCARDITIS AND RELATED INFECTIONS
ANATOMIC
SITE/DIAGNOSI
S
Infective
endocarditis:
Prosthetic
valve-positive
blood culture:
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
S. epidermidis,
Vanco 15–20 mg/kg IV q12h + Rif 300 mg
PO q8h X 6 weeks + gentamicin 1 mg/kg IV
q8h X 14 days.
S. aureus,
Methicillin-sensitive (flucloxacillin 2 g IV
q4h + Rif 300 mg PO q8h X 6weeks +
gentamicin 1 mg/kg IV q8h X 14 days.
Methicillin-resistant (vanco 1g IV q12h+ Rif
300 mg PO q8h X 6weeks +gentamicin 1
mg/kg IV q8h X 14 days
viridians
streptococci,
enterococci
Enterobacteriacea
e OR P.
aeruginosa
See infective endocarditis, native valve,
and positive culture.
Candida,
aspergillus
Aminoglycoside (tobramycin if P.
aeruginosa) + β-lactam (e.g. Tazo or
Cefeor Ceftazidime or Meropenem).
Caspofungin 50–150 mg /day OR
Anidulafungin 100–200 mg/day OR Lipidbase amphotericin B 3–5 mg/kg/day plus
flucytosine 25 mg/kg QID
Doxy 100 mg PO BID + hydroxychloroquine
600 mg/day for at least 18 months.
Pregnancy: Need long term TMP-SMX
Infective
endocarditis-Q
fever
Coxiella burnetii
Pacemaker/
defibrillator
infections
S. aureus (40%),
S. epidermidis
(40%), Gramnegative bacilli
(5%), and fungi
(5%)
Device removal +
vanco 15–20 mg/kg
IV q8–12h + Rif 300
mg PO BID.
Ventricular
assist devicerelated
infection
S. aureus,
S. epidermidis,
Aerobic Gramnegative bacilli,
candida spp.
After culture of blood, wounds, drive line,
device pocket & maybe pump: Empiric
vanco 15–20 mg/kg IV q8–12h + (cip 400
mg IV q24h OR levo 750 IV q24h) +
fluconazole 800 mg IV q24h.
39
COMMENTS
Device removal +
Dapto 6–10 mg/kg
IV q24h + Rif 300 mg
PO BID
ID and surgical
consultation required.
Indications for surgery:
severe heart failure, S.
aureus infection,
prosthetic dehiscence,
resistant organism,
emboli due to large
vegetation.
High mortality.
Valve replacement plus
antifungal therapy is
recommended.
ID consultation is
required
ID consultation is
required
Dapto is not FDA
approved for this
indication.
ID consultation is
required.
Duration is 4–6 weeks
after device removal
ID consultation is
required
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 4: GUIDELINES FOR TREATMENT OF INFECTIVE ENDOCARDITIS AND RELATED INFECTIONS
ANATOMIC
SITE/DIAGNOSI
S
Pericarditis,
purulent
Empirical
therapy
Rheumatic
fever
prophylaxis
ETIOLOGIES
S. aureus,
S. pneumoniae,
GAS , Gramnegative
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
COMMENTS
Vanco + cip
OR vanco + cefepime
ID consultation is
required
Benzathine pen G 1.2 million units IM Q 3–
4 weeks
OR pen V 250 mg PO BID
Duration: for 5 years
after acute rheumatic
fever or until age 21,
whichever is longer.
If carditis present
continue prophylaxis for
10 years
40
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 5-A: PROPHYLAXIS OF INFECTIVE ENDOCARDITIS
ANTIMICROBIAL PROPHYLAXIS FOR THE PREVENTION OF BACTERIAL ENDOCARDITIS IN PATIENTS WITH
UNDERLYING CARDIAC CONDITIONS
Antibiotic prophylaxis for dental procedures is now directed at individuals who are likely to suffer the most
devastating consequences should they develop endocarditis. Prophylaxis to prevent endocarditis is no
longer specified for gastrointestinal or GU procedures. The following is adapted from and reflects the new
American Heart Association (AHA) recommendations (2007).
For patients with
any of these highrisk cardiac
conditions
associated with
endocarditis
Prosthetic heart
valves
Previous infective
endocarditis
Congenital heart
disease with any of
the following:
Completely
Repaired cardiac
defect using
prosthetic material
(only for first 6
months), partially
corrected but with
residual defect
near prosthetic
material,
uncorrected
cyanotic
congenital heart
disease, surgically
constructed shunts
and conduits,
valvulopathy
following heart
transplant.
SELECTION OF PATIENTS FOR ENDOCARDITIS PROPHYLAXIS
Patients undergoing
Patients
Patients undergoing
dental procedures
undergoing invasive invasive procedures of
involving…
respiratory
the GI or GU tracts
procedures
involving…
Any manipulation of
gingival tissue, dental
periapical regions or
perforating the oral
mucosa.
Prophylaxis
recommended++
(See Table 5-B.
Antibiotic
Prophylactic
Regimens for Dental
Procedures).
Prophylaxis is not
recommended for
routine anaesthetic
injections (unless
through infected
area), dental x-rays,
shedding of primary
teeth, adjustment of
orthodontic
appliances or
placement of
orthodontic brackets
or removable
appliances.
Incision of
respiratory tract
mucosa consider
prophylaxis
(See Table 5-B.
Antibiotic
Prophylactic
Regimens for Dental
Procedures)
OR for treatment of
established
infection.
Prophylaxis
recommended (see
Table 5-B. Antibiotic
Prophylactic
Regimens for Dental
Procedures) for oral
flora, but include
anti-staphylococcal
coverage when S.
aureus is of
concern).
Prophylaxis is no longer
recommended solely to
prevent endocarditis, but
the following approach is
reasonable:
for patients with
enterococcal UTIs,
treat before elective GU
procedures.
Include
enterococcal* coverage in
perioperative regimen for
non-elective procedures +
for patients with existing
GU or GI infections or
those who receive
perioperative antibiotics
to prevent surgical site
infections or sepsis.
It is reasonable to include
agents with antienterococcal activity in
perioperative coverage.
Patients
undergoing
procedures
involving
infected skin
and soft tissues
Include
coverage
against
staphylococci
and Betahaemolytic
staphylococci in
treatment
regimens.
*Agents with anti-enterococcal activity include penicillin, amoxicillin, piperacillin, vancomycin and others.
++ 2008 AHA/ACC focused update of guidelines on valvular heart disease use term “is reasonable” to reflect level of
evidence (Circulation 118:887, 2008).
41
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 5-B. ANTIBIOTIC PROPHYLACTIC REGIMENS FOR DENTAL PROCEDURES
SITUATION
AGENT
Oral
Unable to take oral medication
Amoxicillin
AMP OR
2g
2 g IM OR IV*
Cefazolin OR
ceftriaxone
Cephalexin**†
OR
Clindamycin
OR
Azithromycin OR clarithromycin
Cefazolin OR
ceftriaxone †
OR
clindamycin
1 g IM OR IV
Allergic to pen or AMP-oral
regimen
Allergic to pen or AMP and
unable to take oral medication
**
REGIMEN-SINGLE DOSE
30–60 MINUTES
BEFORE PROCEDURE
ADULTS CHILDREN
2g
50 mg/kg
50 mg/kg IM
OR IV
50 mg/kg IM
OR IV
50 mg/kg
600 mg
20 mg/kg
500 mg
1 g IM OR IV
15 mg/kg
50 mg/kg IM
OR IV
20 mg/kg IM OR IV
600 mg IM OR
IV
Or other first or second generation oral cephalosporin in equivalent adult or paediatric dosage.
†Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema or urticarial with
penicillin or AMP.
42
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 6: GUIDELINES FOR TREATMENT OF CENTRAL NERVOUS SYSTEM INFECTIONS IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
Brain abscess
(empirical
treatment is
guided by
suspected
source and
underlying
condition. While
therapy should
be adjusted
based on culture
results,
anaerobic
coverage should
always continue
even if none are
grown
Central nervous
system (CNS)
shunt infections
ETIOLOGIES
Primary (oral,
otogenic, or sinus
source)
S. milleri,
Bacteroides,
Enterobacteriaceae
S. aureus
Rare: Nocardia,
Listeria
SUGGESTED REGIMENS
PRIMARY
ALTERNATIVE
Ceftriaxone 2 g IV Cefotaxime 2 g
q12h +
IV q4h +
metronidazole 7.5 metronidazole 7.5
mg/kg IV q8h
mg/kg IV q8h
Vanco (1 g IV
q12h)to be used if
MRSA is suspected
COMMENTS
Consult ID &
neurosurgeon at the
time of diagnosis.
Obtain appropriate
cultures.
Duration should be
guided by clinical
response and
radiological findings
Post-surgery or
post-traumatic
Cloxacillin 2 g IV
q4h + cefepime 2
g IV q8h
Vanco 15–20
Adjust vanco
mg/kg/day IV q12h + according to renal
ceftazidime
function and trough
level
If ESBL,
Pseudomonas spp.
or MDR organisms
are suspected,
consider using a
carbapenem
Nocardia
(N.asteroids,
N. farcinica,
N. brasiliensis)
TMP-SMX 15/75
mg/kg/day IV /PO
divided into 2–4
doses +
imipenem 500 mg
IV q6h
Linezolid 600 mg IV
OR PO q12h +
meropenem 2g IV
q8h
May add amikacin if
multi-organ
involvement after
consulting with ID.
CoNS ,
S. aureus, and other
skin flora
Vanco 15–20
mg/kg/dose IV
q8h (not to
exceed 2 g per
dose) + cefepime
OR ceftazidime 2 g
IV q8h
Vanco 15–20
mg/kg/dose IV q8h
(not to exceed 2g
per dose) +
meropenem 2g IV
q8h
Successful
management
includes shunt
removal and IV
antibiotic therapy.
Consult
neurosurgeon and
ID
43
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 6: GUIDELINES FOR TREATMENT OF CENTRAL NERVOUS SYSTEM INFECTIONS IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
PRIMARY
ALTERNATIVE
Acyclovir 10
mg/kg IV q8h
COMMENTS
Encephalitis
Herpes simplex,
VZV, arboviruses or
flaviviruses
Epidural abscess
S. aureus and Gramnegative bacilli
Cloxacillin 2 g IV
q4h + ceftriaxone
2 g IV q12h +
metronidazole 15
mg/kg IV q12h
Vanco
15–20
mg/kg/dose IV
q8h (not to
exceed 2 g per
dose) + cefepime
2 g IV q8h +
Metronidazole 15
mg/kg IV q12h
Consult ID &
neurosurgeon for
surgical drainage
Meningitis,
acute bacterial
Age <1 month
S. agalactiae, E. coli,
L. monocytogenes,
Klebsiella species
AMP plus
cefotaxime
AMP plus an
aminoglycoside
See paediatric infection
guide for dosage
44
Empiric therapy while
awaiting for
cerebrospinal fluid
(CSF), herpes viruses,
polymerase chain
reaction (PCR), culture
results, etc. Consult ID
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 6: GUIDELINES FOR TREATMENT OF CENTRAL NERVOUS SYSTEM INFECTIONS IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
PRIMARY
ALTERNATIVE
Meningitis,
acute bacterial
Age 1 month-50
years.
Empirical
therapy
S. pneumoniae,
N. meningitidis,
and H. influenza
(rare).
Vanco
15–20
mg/kg/dose IV
q8h (not to
exceed 2 g per
dose) +
ceftriaxone 2 g IV
q12h +
dexamethasone
0.15 mg/kg IV q6h
Vanco 15–20
mg/kg/dose IV q8h
(not to exceed 2 g
per dose) +
Meropenem 2 g IV
q8h +
Dexamethasone
Give dexamethasone
before the first dose of
antibiotic for 2–4 days.
Discontinue if CSF Gram
stain or culture is not
suggestive of S.
pneumoniae
Meningitis,
acute bacterial
Age: >50 years
or alcoholism or
other
debilitating
associated
illnesses or
impaired
immunity.
Empirical
therapy
S. pneumoniae,
N. meningitis,
L.monocytogenes
,
aerobic Gramnegative bacilli
AMP 2 g IV q4h +
vanco 15–20
mg/kg dose IV q8h
(not to exceed 2g
per dose) +
ceftriaxone 2 g IV
q12h
Vanco 15–20
mg/kg/dose IV q8h
(not to exceed 2 g
per dose) +
Meropenem 2 g IV
q8h
Give dexamethasone
before the first dose of
antibiotic for 2–4 days. For
patients with severe pen
allergy, TMP-SMX + vanco
can be used pending
culture results
Postneurosurgery or
penetrating
head
trauma
S. pneumoniae
(if CSF leak),
H. influenzae,
staphylococci
(MRSA, CoNS),
Gram-negative
Vanco
15–20
mg/kg/dose IV
q8h (not to
exceed 2 g per
dose) PLUS
ceftriaxone
Vanco
15–20 mg/kg/dose
IV q8h (not to
exceed 2g per
dose) PLUS
meropenem 2 g IV
q8h
Give dexamethasone
before the first dose of
antibiotic for 2–4 days
45
COMMENTS
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 6: GUIDELINES FOR TREATMENT OF CENTRAL NERVOUS SYSTEM INFECTIONS IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
Acute bacterial
meningitis
Specific therapy:
ETIOLOGIES
S. pneumoniae
SUGGESTED REGIMENS
PRIMARY
Check culture and
sensitivity report.
Pen G 4 million unit
IV q4h
COMMENTS
ALTERNATIVE
Ceftriaxone 2 g IV
q12h
Treat for 10–14 days.
dexamethasone prior
to first dose of
antibiotics and
continue for 4 days
E. coli
Ceftriaxone 2 g IV
q12h OR
cefotaxime ±
gentamicin IV
Cefepime 2 g IV q8h
Meropenem 2 g IV
q8h
H. influenzae
Ceftriaxone 2 g IV
q12h OR
cefotaxime
Cefepime 2 g IV q8h
Meropenem 2 g IV
q8h
N. meningitidis
Ceftriaxone 2 g IV
q12h OR
cefotaxime
Pen 4 million units
IV q4h (24 million
units per day OR
AMP 2 g IV q4h
Prophylaxis
L. monocytogenes
AMP 2 g IV q4h +
gentamicin IV
TMP/SMX
meropenem 2 g IV
q8h
Addition of an
aminoglycoside
should be considered
S. agalactiae
Pen: 4 million units
IV q4h (24 million
units per day OR
AMP: 2 g IV q4h
plus IV gentamicin
Ceftriaxone 2 g IV
q12h OR cefotaxime
Addition of an
aminoglycoside
should be considered
46
Consult ID.
Treat for 21 days
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 6: GUIDELINES FOR TREATMENT OF CENTRAL NERVOUS SYSTEM INFECTIONS IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
PRIMARY
ALTERNATIVE
Isoniazid 300 mg OD
+ Rif 600 mg OD +
Ethambutol 15–25
mg/kg/day +
Pyrazinamide 15 to
30 mg/kg/day
(maximum 2 g dose),
x 2 months followed
by isoniazid (INH)
and Rif for 7–10
months.
Meningitis, TB*
Isoniazid 300 mg OD
+ Rif 600 mg OD +
streptomycin 1g IM
q24h + Pyrazinamide
15 to 30 mg/kg/day
(maximum 2 g dose),
x 2 months followed
by INH and Rif for 7–
10 months
Dexamethasone 0.3 to
0.4 mg/kg/day for 2
weeks, then 0.2
mg/kg/day week 3, then
0.1 mg/kg/day week 4,
then 4 mg per day and
taper 1 mg off the daily
dose each week; total
duration approximately
8 weeks. Consulting
with ID is advisable
especially if MRD-TB is
suspected or confirmed
Albendazole 400 mg
PO BID +
Dexamethasone 0.1
mg/kg/day + Antiseizure medications
Viable cysts by MRI. Eye
exam is needed for
evidence of
involvement. Duration
of therapy depends on
extent and severity of
disease, please consult
ID physician
Plus steroids as
adjucant
thearapy.see
comments for dose.
Neurocysticercosis
Taenia solium
Albendazole 400 mg
PO BID +
Praziquantel 50
mg/kg/day
Dexamethasone 0.1
mg/kg/day + antiseizure medications
COMMENTS
*REFRENCES:
1. American Thoracic Society, Center for Disease Control and Prevention, and Infectious Diseases Society
of America. 2003. Treatment of tuberculosis. MMWR Recomm. Rep. 52:1–7.
2. NICE Guideline .2016.Tuberculosis.nice.org.uk/guidance/ng33
3. World Health organization. Treatment of tuberculosis Guidelines.Fourth edition.
47
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 7: GUIDELINES FOR TREATMENT OF BONE AND JOINT INFECTIONS IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
COMMENTS
SECOND LINE
BONE: Osteomyelitis:
Important: Essential to obtain specimens (blood, bone) before starting antibiotic treatment. Total duration of
treatment differs from patient to patient but 4–6 weeks of antibiotic therapy is recommended as a minimum.
Clinical, radiological and laboratory, erythrocyte sedimentation rate (ESR) should be used to monitor
response to therapy. Other modalities of treatment such as surgical debridement of necrotic bone and
removal of hardware are frequently needed. In selected cases, hyperbaric Oxygen therapy may be
recommended. Team management including surgeons, microbiologist/ID physicians and pharmacists
increases chance of successful treatment.
Hematogenous
(vertebral &
non-vertebral)
S. aureus (MSSA)
Cloxacillin IV 2 g
q4–6h OR Cefazolin
2 gm IV q8h.
Vanco 1 g q12h
MRSA
Vanco 1 g q12h
Teicoplanin IV 6–
12 mg/Kg q12h for
3–5 doses) then
6–12 mg/kg q24h
OR linezolid 600
mg PO/IV q12h ±
Rif 300 mg PO BID
With SCD
Enterobacteriaceae
Cip PO 750 mg
q12h
Ceftriaxone 1–2 IV
gm q24h
Salmonella
Cip 750 mg q12h
orally OR IV 400 mg
q12h
Ceftriaxone 1–2 g
q24h
48
OR levo 750 mg
IV/PO q24h
Empiric antibiotic
treatment (after
obtaining specimens)
may include
combination therapy
to cover different
potential pathogens
Combination of
quinolone and third
generation cephalosporin can be considered
if quinolone resistance
is uncertain
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 7: GUIDELINES FOR TREATMENT OF BONE AND JOINT INFECTIONS IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
Intravenous drug
user (IVDU)
Contiguous
without
vasculopathy,
e.g. trauma
Contiguous
without
vasculopathy,
e.g. trauma
(targeted
therapy)
With
orthopaedic
implant
ETIOLOGIES
Pseudomonas
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Piperacillin/tazob
Cip IV 400 mg q12h
actam 4.5g q8h
Empiric therapy
Pseudomonas (nail
penetrating trauma
to foot). Long bone
post internal
fixation: (MSSA,
MRSA, Gramnegative or
Pseudomonas)
Cip 750 mg PO BID
S. aureus
Cloxacillin IV 2g q4–6h
+ Rif oral 900 mg daily
Vanco 1 g q12h +
Rif oral 900 mg
daily
Enterococcus
AMP 1g IV q6h
Vanco 1 g q12h
Enterobacteriaceae
Cip 750 mg PO BID OR
IV 400 q12h
Ceftriaxone 1–2 g
q12h
Pseudomonas
Cip 750 mg PO BID OR
IV 400 q12h
Piperacillintazobactam 4.5 g
q8h
S. aureus
Cloxacillin IV 2g q4–6h
+ Rif oral 600–900 mg
daily
Vanco 1g q12h +
Rif oral 600–900
mg daily
CoNS
Vanco 1 gm q12h + Rif
oral 600 mg daily
Teicoplanin 400–
600 mg q12h +
Rif oral 600 mg
daily
COMMENTS
Oral Cip dose is
750 mg q12h
Levo 750 mg PO
once a day
OR vanco plus
cefepime
OR
Linezolid plus
ceftazidime OR
cefepime
49
Linezolid plus Rif is
another alternative
combination
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 7: GUIDELINES FOR TREATMENT OF BONE AND JOINT INFECTIONS IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
Contiguous with
Vasculopathy e.g.
DM
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Enterococci
AMP 1 g IV q6h
Vanco 1 g q12h
Enterobacteriaceae
Cip 750 mg PO BID
OR 400 q12h
Ceftriaxone 2 g
q12h
Pseudomonas
Cip 750 mg PO BID
OR IV 400 q12h
PiperacillinTazobactam 4.5 g
q8h
S. aureus
Cloxacillin IV 2 g
q4–6h
Vanco 1 g q12h
Polymicrobial: Gramnegative bacilli,
Anaerobic organisms
Cip 750 mg PO
q12h +
Metronidazole 500
mg IV q8h
Amoxicillinclavulanate, 875
mg and 125 mg,
respectively, orally
every 12 hrs
Any MDR organisms
According to
identity and
antibiotic
susceptibility of the
organism, please
consult
microbiologist /ID
physician
50
COMMENTS
Debridement of
ulcers and obtain
bone biopsy for
culture and
histology.
Therapy should
be guided by
cultures
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 8: GUIDELINES FOR TREATMENT OF ABDOMINAL INFECTIONS IN ADULTS
ANATOMIC SITE/
DIAGNOSIS
ETIOLOGIES
Esophagitis
Candida albican,
(mainly in HIV pts)
HSV,CMV
Duodenal/ Gastric
Ulcer
H.pylori
Biliary infections
(cholecystitis
cholangitis, biliary
sepsis, CBD
obstruction)
Enterobacteriacae
Enterococci,
anaerobes, Candida
Diverticulitis
Almost all infections
are polymicrobial.
(Most commonly
Enterobacteriacae
Bacteroides spp and
enterococcus spp,
Occasionally P.
aeruginosa)
SUGGESTED REGIMENS
FIRST LINE
Fluconazole 200400mg IV/PO q24h
14-21 days
SECOND LINE
Voriconazole
200 q12h
14-21 days
Omeprazole 20 mg
q12h +
Amoxicillin 1g
Q12H +
Clarithromycin
500mg q12h
Empiric treatment
:Mild
Ciprofloxacin or
Moxifloxacin, plus
Metronidazole
Omeprazole 20mg
q12h +
Clarithromycin
500mg q12h +
Metronidazole 500
mg PO TID
Hospital or severe
piperacillin/tazoba
ctam 4.5 gm IV TID
Cefepime 2 gm TID
plus Metronidazole
500 mg IV TID
Or
Meropenem
Mild to moderate
Out- patient Rx
AmoxicillinClavulanate
875/125 mg PO
q12h
Ciprofloxacin
plus metronidazole
OR
TMP-SMX-SD plus
metronidazole
Moderate to
Severe infection
Piperacillin –
Tazobactam
ampicillin +
aminoglycoside +
metronidazole OR
Meropenem
OR Tigecycline
51
Ceftriaxone plus
Metronidazole
COMMENTS
Amphotericin and
echinocandins used
for patient with
fluconazole
refractory infection
Duration: 10-14
days
In severely ill pts
with cholangitis or
complicated
cholecystitis,
adequate biliary
drainage is crucial
CT scan is important
in assessing the
need for drainage in
severe disease.
Duration: 7-10 days
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 8: GUIDELINES FOR TREATMENT OF ABDOMINAL INFECTIONS IN ADULTS
Pancreatitis
Acute alcoholic pancreatitis without necrosis does not require antibiotic therapy or prophylaxis as studies
have shown no advantage. Observe for abscess formation or necrosis which will require therapy.
ANATOMIC
ETIOLOGIES
SUGGESTED REGIMENS
COMMENTS
SITE/
DIAGNOSIS
FIRST LINE
SECOND LINE
Pancreatitis,
post necrotizing
Infected
pseudocyst,
pancreatic
abscess
Enterobacteriaceae
enterococci,
S aureus,
anaerobes, candida
Piperacillintazobactam 4.5 gm
q8h
52
Meropenem 1 gm
IV q8h
OR
Cip OR levo,+
metronidazole
Infected pancreatic
necrosis is defined as
one or both of the
following :
1- CT scan with gas
2- Percutaneous
aspirate or surgical
specimen with
organism evident
on Gram stain or
culture
Pen and cephalosporin
poorly penetrate into
the pancreas,
peak incidence of
infection in the 3rd
week
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 8: GUIDELINES FOR TREATMENT OF ABDOMINAL INFECTIONS IN ADULTS
ANATOMIC
SITE/
DIAGNOSIS
Peritonitis
Primary
(spontaneous
bacterial
peritonitis
(SBP)
ETIOLOGIES
FIRST LINE
Enterobacteriaceae
S. pneumoniae,
Enterococci,
anaerobes
Primary: cefotaxime 2g
IV TID
If infection life
threatening: piperacillin
/tazobactam
COMMENTS
SECOND LINE
Cip OR levo, +
metronidazole
Duration: Uncomplicated
5–7 days. Complicated or
positive culture: 10 days,
may be longer if patient is
bacteremic
Carbapenem
Secondary
Peritonitis
secondary to
GI perforation
Prevention of
SBP
Chronic
ambulatory
peritoneal
dialysis
(CAPD)
peritonitis
SUGGESTED REGIMENS
Mild to moderate:
Cefepime
PLUS Metronidazole
Ciprofloxacin OR
levo, PLUS
metronidazole
Severe (ICU):
Piperacillin/ Tazobactam
OR
carbapenem
AMP plus
ciprofloxacin +
metronidazole
OR AMP +
aminoglycoside +
metronidazole
Cip 500 mg PO
once a week
TMP-SMX DS 1 tab PO 5
days per week
Most common:
Gram-positive cocci:
s. aureus,
coagulase-negative,
enterococci
Less common:
Gram-negative and
yeast
Mild to moderate:
Intraperitoneal therapy
is preferred
Cefazolin and
gentamicin
Severe:
Vanco + (ceftazidime OR
meropenem OR
cefepime OR gentamicin
OR ciprofloxacin)
(Intraperitoneal therapy
unless bacteraemia for
which IV therapy is
used)
Fluconazole to be added
if yeast is seen in Gram
stain.
Duration: 10–14 days
53
Most infections
caused by
contamination of
the catheter.
Diagnosis of CAPD
catheter infection
if peritoneal
dialysis fluid WBC
>100/mm3 with
>50%
polymorphonuclear leukocytes +
clinical signs and
symptoms
Empirical antifungal
generally not indicated
unless the patient has
risk factors.
Surgical source control is
essential
1 year risk of SBP in
patients with ascites and
cirrhosis as high as 29%.
TMP-SMX reduce SBP
bacteraemia from 27% to
3%
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 8: GUIDELINES FOR TREATMENT OF ABDOMINAL INFECTIONS IN ADULTS
ANATOMIC
SITE/
DIAGNOSIS
Infectious
diarrhoea
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
COMMENTS
SECOND LINE
Campylobacter
jejuni/coli
(self-limited in
normal host)
Erythromycin
500 mg PO QID 5
days
Cip 500 mg PO BID,
azithromycin 500 PO
OD x 3 days
Duration: 3–5 days
Campylobacter
foetus
gentamicin IV
AMP OR imipenem IV
Diarrhoea uncommon,
more systemic disease
in debilitated host
Shiga toxinproducing E. coli
Avoid antibiotics
Salmonella spp.
(non-typhi)
Cip 500 mg/12 hrs
for 7–10 days
Azithromycin 500 mg
q24H for 7 days
(14 days if
immunocompromised)
Cipro 500 mg q12h
for 3 days
Azithromycin
OR STM-SMZ
No indicated treatment
if asymptomatic or mild
disease. Treat only if
severe illness, ˂1 year,
>50 yrs., prosthesis,
vascular graft, valvular
heart disease, severe
atherosclerosis &
immunocompro-mised
patients. Treatment
should be guided by
antimicrobial sensitivity
result
Duration: 3 days. If
severe infection,
ceftriaxone 1–2 gm
Q24H should be used.
Longer (7–10 days)
duration for immunocompromised
Typhoid fever:
refer to
systemic
infection guide
Shigella
54
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 8: GUIDELINES FOR TREATMENT OF ABDOMINAL INFECTIONS IN ADULTS
ANATOMIC
SITE/
DIAGNOSIS
ETIOLOGIES
FIRST LINE
Doxycycline 300 mg
PO single dose.
Y. enterocolitica
Treatment
recommended for:
immunocompromised,
bacteraemia,
pseudoappendicitis
syndrome
Aeromonas/
plesiomonas
E. histolytica
Severe: doxycycline
+ gentamicin
Giardia
Metronidazole 250 mg PO TID for 5 days
Albendazole 400 PO q24h with food for 5
days
Cryptosporidium
Nitazoxanide 500 mg PO q12h x 3days
If AIDS: HAART and nitazoxanide for 14
days
TMP-SMZ 1DS PO
q12h for 7–10 days
Initial episode, mild or
moderate: Leucocytosis
with a WBC
count of 15,000 cells/ml
or lower and no increase
in serum creatinine
Initial episode, severe:
Leucocytosis with a WBC
count of 15,000 cells/ml
or higher or a serum
creatinine level greater
than or
equal to 1.5 times the
premorbid level
Erythromycin 500
QID for 3 days OR
Azithromycin 1 gm
PO single dose
TMP-SMX OR
fluoroquinolone
Cip 750 PO OD/BID
Azithromycin 500
PO OD
Metronidazole 500–750 MG Q8H for 10
days followed by intraluminal agent
paromomycin 500 mg q8h for 7 days
Metronidazole, 500
mg q8h by
mouth for 10-14
days
Vanco, 125 mg q6h
by
mouth for 10–14
days
55
COMMENTS
SECOND LINE
Vibrio cholera:
Cyclospora
C. difficile
Infection (CDI)
SUGGESTED REGIMENS
Vanco 12 5 mg PO
q6h for 10–14 days
Duration: 3 days
Discontinue
offending
antibiotics
Consult ID & GI
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 8: GUIDELINES FOR TREATMENT OF ABDOMINAL INFECTIONS IN ADULTS
ANATOMIC
SITE/
DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
COMMENTS
SECOND LINE
Initial episode, severe:
Hypotension or shock,
ileus, megacolon
Vanco, 500 mg 4 times per day by
mouth or by nasogastric tube, PLUS
metronidazole, 500 mg every 8 hrs
intravenously. If complete ileus,
consider adding
rectal instillation of vanco
First recurrence
second recurrence
Same as for initial episode
Vanco 125 mg PO q6 hs 10–14 days
then start tapering.
Tapered and/or pulsed
Regimen. Consult ID and GI physicians
Referral of severe
cases to abdominal
surgeon is
recommended.
Rectal installation of
vanco
into bowel, consult
GI, ID team and
clinical pharmacy
References:
1.
2.
3.
Guerrant, RL, Van Gilder T, Steiner TS, Thielman NM, Slutsker L, Tauxe RV, et al. Practice guidelines for the
management of infectious diarrhea. Clin Infect Dis 2001;32:331–50.
Cheng AC, McDonald JR, Thielman NM. Infectious diarrhea in developed and developing countries. J Clin
Gastroenterol 2005;39:757–773.
Gilbert DN, Chambers HF, Eliopoulos GM, Saag MS, Black D, Freedman DO, et al. The Sanford Guide to
Antimicrobial Therapy 2015. 45th ed. Sperryville,VA: Sanford; 2015.
56
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 9: GUIDELINES FOR TREATMENT OF SKIN AND SOFT TISSUE INFECTIONS
DIAGNOSIS/
ETIOLOGIES
SUGGESTED REGIMENS
ANATOMIC
(USUAL)
PRIMARY
SITE
Bites : Remember tetanus prophylaxis
Cat bite:
complicated by
infection in
80%. Patient
should be
cultured and
treat
empirically
Pasteurella
multocida,
S. aureus
SUGGESTED
REGIMENS
ALTERNATIVE
COMMENTS
Amoxicillinclavulanate 875/125
mg PO BID
OR 500/125 mg PO
TID
Cefuroxime 500 mg
PO BID OR doxy 100
mg PO BID
P. multocida resistant to
cloxacillin, cephalexin,
clindamycin, many
strains resistant to
erythromycin. If the
culture is positive for
P. multocida, can switch
to pen
Dog bite:
complicated by
infection in
5%.Treat if bite
is severe or
with comorbidity (e.g.
diabetes)
Pasteurella canis,
S. aureus,
Bacteroides spp.,
Fusobacterium,
Capnocytophaga
Amoxicillinclavulanate 875/125
mg PO q12h OR
500/125 PO q8h
Clindamycin 300 mg
PO QID +
fluoroquinolone
(adults) OR
clindamycin + TMPSMX (children)
Consider anti-rabies
prophylaxis (rabies
immunoglobulin and
vaccine)
Human bite
Viridians
streptococci,
S. epidermidis,
S. aureus,
Eikenella,
Bacteroides,
Peptostreptococcus
Early (not infected)
amoxicillinclavulanate 875/125
mg PO q12h for 5
days
Later: signs of
infection (usually in
3–24 h) PIP-TAZ 4.5
gm q8h
If pen allergy:
Clindamycin + (either
cip OR TMP-SMX)
Cleaning, irrigation and
debridement most
important for clenched
fist injuries x-rays should
be obtained. Bites
inflicted by hospitalized
patients, consider
aerobic Gram-negative
bacteria. Eikenella
resistant to Clindamycin,
nafcillin/oxacillin, metro,
first gen cephalosporin,
and erythromycin,
susceptible to FQs, and
TMP-SMX
57
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 9: GUIDELINES FOR TREATMENT OF SKIN AND SOFT TISSUE INFECTIONS
DIAGNOSIS/
ANATOMIC
SITE
Snake bite
Boils,
furunculosis
carbuncles
afebrile
Boils,
subcutaneous
abscesses,
furunculosis,
carbuncles
(connecting
abscesses)
febrile
Recurrent
boils,
subcutaneous
abscesses,
furunculosis
ETIOLOGIES
(USUAL)
SUGGESTED REGIMENS
PRIMARY
Enterobacteriaceae,
Pseudomonas,
Staphylococcus,
Clostridium spp.
Primary therapy is antivenom,
ceftriaxone AND
tetanus prophylaxis
S. aureus both MSSA
& MRSA-increase
incidence of
communityassociated MRSA
Incision & drainage is
indicated.
If abscess <5 cm in
diameter: culture
abscess, hot packs, NO
drugs.
If abscess >5 cm in
diameter: TMP/SMX 1
DS tab q12h
S. aureus both MSSA Incision & drainage is
& MRSA-increase
the mainstay of
incidence of
treatment
communityassociated MRSA
Outpatient:
TMP/SMX 1 DS tab
q12h for 5–10days
MSSA, MRSA
Consult ID if
decolonization is
considered. mupirocin
2% ointment to
anterior nares twice a
day for 7 days and daily
chlorohexidine 2% bath
for 7 days.
Decontamination of
personal items such as
towels, linen, etc.
58
SUGGESTED
REGIMENS
ALTERNATIVE
COMMENTS
Antibiotic treatment
indicated if signs of
infections. Should be
guided by culture
report
Clindamycin PO 300–
600 mg q6–8h for 5–
10 days
Clindamycin PO 300–
600 mg q6–8h
In-patient:
vanco 15 mg/kg
q12htill culture results
are available
Consult ID or
microbiologist if oral
antibiotics needed for
decolonization
Needle aspiration is
inadequate.
Consider imaging if
not sure of extent or
the diagnosis.
Therapy should be
given before incision
and drainage in
patients with
prosthetic heart
valves or other
conditions placing
them at high risk
for endocarditis
Adult patients should
be evaluated for
neutrophil disorder if
recurrent abscesses
started in early
childhood
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 9: GUIDELINES FOR TREATMENT OF SKIN AND SOFT TISSUE INFECTIONS
DIAGNOSIS/
ANATOMIC
SITE
Impetigo
ETIOLOGIES
(USUAL)
Group A Strept
(rare group B, C
& G)
S. aureus (MSSA,
MRSA)
Burns
Non-infected
Burns
Wound
sepsis
Cellulitis,
Erysipelas
Extremities,
non-diabetic
S. pyogenes
S. aureus,
Enterobacterspp.,
P. aeruginosa,
E. coli,
Fungi,
HSV (Rare)
Strept spp.
(group A,B,C,G)
S. aureus
SUGGESTED
REGIMENS
PRIMARY
No oral antibiotics
unless severe,
extensive or bullous
or in outbreak
setting: cloxacillin
500 mg PO QID OR
cephalexin 250 mg
PO QID for 5–7 days
based on clinical
response
SUGGESTED
REGIMENS
ALTERNATIVE
For MRSA :
doxycycline,
TMP-SXT,OR
clindamycin can
be used
Early excision, wound
closure, skin graft.
Role of topical
antibiotic unclear
Cefepime 2 gm
q8–12h OR tazocin
4.5 gm q8h ±
amikacin 10 mg/kg
loading dose then 7.5
mg/kg IV q12h
(therapeutic drug
monitoring)
Cefazolin IV 1 gm q8h
OR cloxacillin 2 gm IV
QID
Silver
sulfadiazine
Anti-tetanus is indicated
Meropenem
PLUS vanco
Consider adding vanco if patient is
known or suspected MRSA.
Monitor serum levels of vanco and
amikacin as serum half-life of most
antibiotics is decreased in burns
patients.
Candida usually colonizes wounds
but rarely invades
Always elevate the affected
extremity.
Cultures should be obtained for
patients on chemotherapy,
neutropenia, animal bites or
immuno- compromised or
immersion injuries.
Pen G 1–2 million units IV q6h if
streptococci
When afebrile can
step to oral therapy
59
Amoxicillinclavulanate OR
clindamycin OR
clarithromycin
COMMENTS
Reserve topical antibiotics for
localized lesions : topical fusidic
acid 2% TID for 5 days can be used
Do not use mupirocin (Reserved
for MRSA)
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 9: GUIDELINES FOR TREATMENT OF SKIN AND SOFT TISSUE INFECTIONS
DIAGNOSIS/
ANATOMIC SITE
ETIOLOGIES
(USUAL)
SUGGESTED
REGIMENS
PRIMARY
Ceftriaxone 1 gm IV q
24 hrs
SUGGESTED
REGIMENS
ALTERNATIVE
Vanco 1 gm IV
q12h if MRSA
suspected
Facial, adult
(erysipelas)
Strept (group A,B,C
& G)
S. aureus (MRSA),
S. pneumoniae
Erysipelas and
Diabetes mellitus
Strept (group A, B,
C& G)
S. aureus,
Enterobacteriaceae
Clostridia(rare)
Early mild:
TMP-SMX-DS 1–2
tabs PO q12h PLUS
cephalexin PO 500
mg q6h
Severe:
Meropenem +
(vanco OR
linezolid)
Diabetic foot
Mild: presence of
purulence & >1 sign
of inflammation and
cellulitis (if present)
<2 cm around the
ulcer limited to skin
and superficial
subcutaneous tissue
S. aureus,
Streptococci Group
A,B
Cephalexin PO 500
mg QID
OR Clindamycin
600 mg PO TID
Amoxicillin/
clavulanate 875
mg PO BID
Diabetic foot:
Moderate: same as
mild PLUS >2 cm of
cellulitis,
lymphangitis
streaking, spread
beneath superficial
fascia, deep tissue
abscess, gangrene,
involvement of
muscle, tendon, joint
or bone.
As above
+ coliforms
If IV needed :
IV clindamycin 600
mg q8h
OR IV cefazolin 1 gm
q8h
Ciprofloxacin 500 mg
PO BID OR 400 mg IV
BID plus either
clindamycin 600 mg
IV/PO TID OR
metronidazole 500
mg IV/PO TID
60
Ertapenem 1 gm
IV q24h OR
piperacillintazobactam 4.5
gm q8h
COMMENTS
Obtain cultures
Surgical consultation
to rollout necrotizing
fasciitis and for
debridement to
obtain cultures.
If septic consider
x-rays to assess the
presence of gas
If MRSA risk or
positive infection or
colonization add
vanco OR linezolid to
regimens not
containing
clindamycin or
microbiology reports
indicates clindamycin
resistance
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 9: GUIDELINES FOR TREATMENT OF SKIN AND SOFT TISSUE INFECTIONS
DIAGNOSIS/
ANATOMIC SITE
Diabetic foot
Severe: same as
above in addition
to systemic
toxicity or
metabolic
instability
Necrotizing
fasciitis
ETIOLOGIES
(USUAL)
Streptococcal
(A,C,G)
All types require
prompt surgical
debridement.
Pen G 2–4 million unit
IV q4–6 h +
clindamycin 600 mg IV
q8h
Polymicrobial
Meropenem 1 gm IV
TID, add vanco if
MRSA suspected
Pen G 2–4 million unit
IV q4–6 h +
clindamycin 600 mg IV
q8h
Clostridia spp.
Staphylococcal
scalded skin
syndrome
SUGGESTED
REGIMENS
PRIMARY
piperacillintazobactam 4.5 gm
q8h + vanco 15 mg/kg
q12h
Toxinproducing
S. aureus
MSSA: cloxacillin 2 gm
IV q4h for 5–7 days
MRSA: vanco 15
mg/kg q12h
61
SUGGESTED REGIMENS
ALTERNATIVE
COMMENTS
Cip 400 mg IV q12h
plus IV metronidazole
500 gm q8h plus IV
vanco 15 mg/kg q12h
OR Meropenem 1 gm
q8h + vanco
Toxin causes intraepidermal split and
positive Nikolsky sign.
Biopsy can
differentiate drug
cause such as toxin
epidermal necrolysis
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 9: GUIDELINES FOR TREATMENT OF SKIN AND SOFT TISSUE INFECTIONS
DIAGNOSIS/
ANATOMIC SITE
Infected wound
extremities posttrauma
Infected wound
Postoperative, not
involving
intestinal or
genital surgeries
Infected wound
postoperative,
involving
intestinal or
genital surgeries
Scabies
ETIOLOGIES
(USUAL)
Polymicrobial
S. aureus,
Streptococcus
spp., Coliform,
Clostridium spp.,
Water exposure:
Pseudomonas
spp., Aeromonas
spp.
S. aureus,
Strept. A, B, C, G
MSSA, MRSA
Coliforms,
Bacteroides,
anaerobes
SUGGESTED REGIMENS
PRIMARY
Mild:
TMP/SMX DS PO 1 tab
BID
OR
clindamycin
Febrile with sepsis:
piperacillin-tazobactam
+ vanco
Mild:
TMP/SMX 1 tab PO BID
+ cephalexin 500 mg
q8h
Severe:
vanco 15 mg/kg q12h
Mild: amoxicillinclavulanate 875/125 mg
PO BID
+ TMP/SMX 1–2tab PO
BID (if Gram-positives
seen on Gram stain)
Severe:
piperacillin-tazobactam
4.5 gm q8h + vanco 15
mg/kg q12h
OR meropenem + vanco
15 mg/kg q12h
Permethrin 5% cream
62
SUGGESTED
REGIMENS
ALTERNATIVE
Doxycycline PO 100
mg q12h
OR amoxicillinclavulanate PO
OR vanco + (cip OR
levo)
COMMENTS
Debride the wound
if necessary
Culture and
sensitivity is
indicated
Tetanus toxoid
Mild:
clindamycin 300–450
mg PO q8h
Severe:
Linezolid
Drain wound and get
cultures. Can
substitute linezolid for
vanco. Can substitute
cip OR levo for betalactam antibiotics
Treat all household
and sexual contacts
Check Gram stain
of exudate
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 10: GUIDELINES FOR TREATMENT OF URINARY TRACT INFECTIONS AND SEXUALLY
TRANSMITTED DISEASES IN ADULTS
ANATOMIC
ETIOLOGIES
SUGGESTED REGIMENS
COMMENTS
SITE/DIAGNOSIS
FIRST LINE
SECOND LINE
Urinary
A complicated UTI, whether localized to the lower or upper tract, is associated with an underlying condition that
increases the risk of failing therapy, including the following:
 Diabetes
 Pregnancy
 Symptoms for 7 or more days before seeking care
 Hospital-acquired infection
 Renal failure
 Urinary tract obstruction
 Presence of an indwelling urethral catheter, stent, nephrostomy tube or urinary diversion
 Recent urinary tract instrumentation
 Functional or anatomic abnormality of the urinary tract
 History of UTI in childhood
 Renal transplantation
 Immunosuppression
Infection with an uropathogen with broad-spectrum antimicrobial resistance is also considered complicated
although there are no data to suggest that such infections are more likely to fail if an antimicrobial to which the
infecting pathogen is susceptible is used.
Uncomplicated
Cystitis
E. coli,
Klebsiella,
Proteus,
S. saprophyticus
Nitrofurantoin
100 mg q12h x
5 days
63
Trimethoprim/
sulfamethoxazole
960 mg q12h x 3
days
OR fosfomycin 3
gm PO single
dose
OR
if G6PD deficient
amoxicillinclavulanate
875/125 mg x
7–10 days
Routine urine culture is not
recommended. Obtaining a
urine culture prior to initiation
of therapy is warranted if
symptoms are not
characteristic of UTI, if
symptoms persist, recurring
within 3 months following prior
antimicrobial therapy, or if a
complicated infection is
suspected
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 10: GUIDELINES FOR TREATMENT OF URINARY TRACT INFECTIONS AND SEXUALLY
TRANSMITTED DISEASES IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
UTI (pregnancy)
Candiduria
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Nitrofurantoin
Amoxicillin100 mg q12h x 7
Clavulanate
days
875/125 mg x 10–
14 days
COMMENTS
Contraindicated in
pregnancy: cip,
tetracycline.
Avoid during 1st trimester:
Trimethoprim,
nitrofurantoin. Avoid near
term: nitrofurantoin,
sulphonamides.
Avoid the day before
delivery: Ceftriaxone. A
follow up culture (test of
cure) should be obtained a
week after completion of
therapy. Consult ID/micro if
bacteriuria persists
Candida species
Asymptomatic,
Candiduria
No treatment
required except if
undergoing
urologic
procedure, in the
setting of
neutropenia or in
low birth weight
neonates
Symptomatic
cystitis (or
asymptomatic but
undergoing
urologic procedure
or high risk for
disseminated
infection)
Fluconazole 200
mg (3 mg/kg) daily
for 14 days
64
If possible, remove the
urinary catheter or stent
Amphotericin B
0.3–0.6 mg/kg daily
(for
fluconazole
resistant
organisms) for
1–7 days.
Bladder irrigation
with amphotericin B is NOT
recommended for cystitis
or pyelonephritis
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 10: GUIDELINES FOR TREATMENT OF URINARY TRACT INFECTIONS AND SEXUALLY
TRANSMITTED DISEASES IN ADULTS
ANATOMIC
SITE/DIAGNOSIS
Pyelonephritis,
Candiduria
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
Fluconazole
oral/IV 200–
400 mg (3–6
mg/kg) daily 14
days
65
COMMENTS
SECOND LINE
Amphotericin B
0.5–0.7 mg/kg
daily (for
fluconazole
resistant
organisms) for
1–7 days.
Lipid formulations of
amphotericin B should not be
used to treat UTIs because they
do not penetrate into the
kidney or achieve adequate
concentrations in the urine
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 11: GUIDELINES FOR TREATMENT OF SYSTEMIC INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Important: Obtain careful epidemiologic history
Brucellosis
B. abortus (cattle),
B. suis (swine),
B. melitensis,
(goats),
B. canis (dogs)
No focal disease:
doxycycline 100 mg PO
BID for 6 weeks +
gentamicin 5 mg/kg OD
for the first 7 days
Doxycycline 100 mg
PO BID PLUS Rif 600–
900 PO OD for 6
weeks
Spondylitis, sacroiliitis:
Cip 750 mg PO BID +
gentamicin (7 days as
Rif 600–900 PO OD for
above) PLUS doxycycline a minimum of 3
and Rif for minimum of
months
3 months
Neuro-brucellosis:
doxycycline and Rif (as above) + ceftriaxone 2 gm
q12h until CSF parameters return to normal
Endocarditis:
Surgery + combination of (doxycycline + Rif +
cotrimoxazole for 6 weeks-6months) PLUS
gentamicin for 2–4weeks
Pregnancy:
Rif 900 mg PO OD for 6
weeks
Leptospirosis
Leptospira: urine of
domestic livestock,
dogs and small
rodents
Severe illness:
pen G 1.5mU IV q6h
OR ceftriaxone 1 gm
q24h
Duration: 7 days
66
Rif 600–900 mg PO
OD + cotrimoxazole 5
mg/kg PO BID for 4
weeks.
(Cotrimoxazole may
cause kernicterus if
given during the last
week of pregnancy)
Mild illness:
doxycycline 100 mg
IV/PO q12h OR
AMP
0.5–1 gm IV q6h for 7
days
COMMENTS
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 11: GUIDELINES FOR TREATMENT OF SYSTEMIC INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
Typhoid fever
ETIOLOGIES
Salmonella
Typhi
Salmonella
Paratyphi
A,B,C
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Ceftriaxone 2g IV Cip 750 mg PO
q24h x 10–14
bid OR 400 mg
days
IV q12h 7–10
days
OR
Azithromycin 1
g PO x one
dose, then 500
mg OD x 5–7
days
Salmonella
bacteraemia
(Non-typhoidal)
Salmonella
enteritidis or
other
serotypes
from animal
sources
Ceftriaxone 2 g IV
q24h for 2 weeks
Q Fever, acute
C. burnetii
Doxycycline 100
mg q12h + Rif
600 mg OD
67
COMMENTS
Susceptibility test results are
essential to guide therapy as
resistance to cip is increasing.
Dexamethasone is used in severe
infections, first dose should be
prior to antibiotics 3 mg/kg IV,
then 1 mg /kg IV q6h x 8 doses
Cip 400 IV q12h Do not use quinolones until
OR Levo 750 PO susceptibility determined.
for 14 days
Bacteraemia can infect any organ
or tissue: look for endovascular
infection, osteomyelitis in sickle
cell disease patients. Treatment
duration ranges from 14 days
(immunocompetent) to ≥6 weeks
(if mycotic aneurysm or
endocarditis).
Azithromycin 1 gm for the first
days then, 500 mg PO OD for 5–7
days is another alternative
treatment.
Test for HIV status
Cip 500 mg
h/o animal contact
q12h + Rif 600
mg OD
Consult ID
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 11: GUIDELINES FOR TREATMENT OF SYSTEMIC INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
Sepsis
(suggested
empiric therapy
assumes patient
is bacteremic)
Not neutropenic
No clear source
Life-threatening
Refer to specific
sections of this
guide for the
empiric
recommendatio
n therapy for
specific source
of infection
Shock
syndromes
ETIOLOGIES
Aerobic Gramnegative
S. aureus,
streptococci
See specific
syndromes
Proven therapies:
replete
intravascular
volume with IV
saline, goal is CVP
>8 cm within 6 hrs
of admission
Attempt to correct
the source of
bacteraemia.
Obtain cultures
then start
appropriate
antibiotics, time of
first dose is crucial
Appropriate
pressors if still
hypotensive and
elevated lactate
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Piperacillin/
Meropenem +
tazobactam
vanco
4.5 gm IV q6h OR cefepime
+ vanco
plus vanco
Piperacillin/
tazobactam
4.5 gm IV q6h
+ vanco
68
If high
prevalence of
MDR Gramnegative Gram
(such as
carbapenemresistant
Enterobacteriac
eae [CRE] or
MDR-GNB)
consider adding
IV colistin
Meropenem +
vanco
If high
prevalence of
MDR Gramnegative (such
as CRE or MDRGNB), consider
adding IV
colistin
COMMENTS
Sepsis : (SIRS + a documented
infection )
Severe sepsis: sepsis + organ
dysfunction.
Obtain appropriate cultures
prior to antimicrobial therapy
Check patient. old cultures and
their antibiograms
Could substitute linezolid for
vanco, however linezolid is
bacteriostatic against S.
aureus.
Stop vanco and colistin if no
resistant organisms are
isolated from cultures
Hydrocortisone in stress dose
100 mg IV q8h if BP persistent
after fluids and one pressor.
Benefit in patients with severe
sepsis (systolic pressure <90
mmHg)
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 11: GUIDELINES FOR TREATMENT OF SYSTEMIC INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
Toxic shock
syndrome due to
Clostridium sordellii
present as shock,
capillary leak,
hemoconcentration, very high
WBCs, afebrile
ETIOLOGIES
Clostridium
sordellii
(haemorrhagi
c and lethal
toxins)
Staphylococcal
toxic shock
syndrome-
S. aureus
(toxic shocktoxin
mediated)
Streptococcal
toxic shock
syndrome
associated with
invasive disease
like necrotizing
fasciitis or
chickenpox
Febrile
neutropenia
Low risk
(ANC >100, normal
CXR, normal liver
function tests and
creatinine, no
clinical IV
site/tunnel
infection, tem <39,
no abdominal pain,
no comorbidities.
Neutropenia <7
days)
Group A, B, C,
G
streptococci
Aerobic
Gramnegative
bacilli,
viridians
streptococci
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
See above shock
syndrome pen G
18–20 million
units divided q4h
+ clindamycin
600 mg q6–8h
surgical
debridement is a
key
Cloxacillin 2 gm
If MRSA vanco
IV q4h plus
1 g IV q12h) +
clindamycin 600
clindamycin 600
mg IV q6–8h +
mg IV q6–8h +
intravenous
IVIG
immunoglobulin
(IVIG) (see
comment for
dose)
Pen G 24 million
Ceftriaxone 2
units per day in
gm IV q24h +
divided doses +
clindamycin
clindamycin 600– 600–900 mg IV
900 mg IV q8h
q8h
Low risk:
cip 500–750 mg
PO q12h daily +
amoxicillinclavulanate 500
mg PO q8h
69
COMMENTS
Occurs in variety of settings
that produce anaerobic tissue,
e.g. IVDU, post-partum, use of
mifepristone & misoprostol for
abortion
IVIG dose 1 gm per kg on day 1
then 0.5 gm per kg days 2 & 3
IVIG associated with reduction
in sepsis related organ failure
IVIG dose 1 gm per kg on day 1
then 0.5 gm per kg days 2 & 3.
Consider household contacts
prophylaxis
Fever defined as a single oral
temperature of >38.3°C or a
temperature of >38.0°C
sustained for >1 hr.
Neutropenia defined as ANC
<500/mm3.
Obtain appropriate cultures
and radiological investigations
to identify the focus of
infection.
Adjust antibiotics according to
susceptibility profiles
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 11: GUIDELINES FOR TREATMENT OF SYSTEMIC INFECTIONS
ANATOMIC
SITE/DIAGNOSIS
Febrile neutropenia
High Risk:
(anticipate >7 days,
profound
neutropenia &
active
comorbidities).
Initial fever
Persistent fever or
new fever after 4–7
days in clinically
stable patient
without established
bacterial infection
Clinically unstable
patient despite
appropriate
antibiotic and
antifungal coverage
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Aerobic
Monotherapy with:
(Cefepime OR
Grampiperacillin/tazobact piperacillin/tazo
negative
am 4.5 gm TID.
-bactam) +
bacilli,
Consider vanco if
aminoglycoside
P. aeruginosa, indicated (see
OR
viridians
comments)
(cefepime +
streptococci,
cip).
MRSA
Consider vanco
if indicated (see
comments)
Candida spp.,
Aspergillus,
VRE Gramnegative
bacilli
Continue antibiotics
as above and add
antifungal coverage:
-if receiving
fluconazole or no
fungal prophylaxis,
start
voriconazole or
caspofungin
-if receiving
voriconazole or
posaconazole as
prophylaxis then
start amphotericin
B liposomal .
Meropenem + vanco
+ an aminoglycoside
70
COMMENTS
-Indications for vanco:
history of MRSA infection
OR colonization
OR suspected CRBSI, skin
and soft tissue infection or
pneumonia or severe
pharyngitis or mucositis or
positive blood culture with
Gram-positive organisms.
-If suspected multidrug
Gram-negative consider
meropenem
Prior to antifungal:
obtain cultures,
biopsy suspected skin
lesions,
CT chest/abdomen/sinuses,
galactomannan assay,
consult ID
Obtain cultures and
radiological workup.
Consult ID
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 12: GUIDELINES FOR TREATMENT OF COMMON VIRAL INFECTIONS
DISEASE
Chickenpox
DRUG
Valacyclovir 1 g TID
PO for 5–7 days
ALTERNATIVE
Oral acyclovir 800
mg 5 x a day for 7
days
IV acyclovir 10
mg/kg every 8 hrs
Shingles
Valacyclovir 1 g TID
for 7 days
Acyclovir 800 mg 5 x
a day
71
COMMENTS
Clinical value of antiviral is minimal
(especially if treatment started more than 24
hrs from onset of rash)
Exceptions in the following situations:
Case is immunocompromised
Case is on steroid.
Severe pain. Presence of secondary
household case. If case is pregnant seek
advice. Treatment can be given as outpatient
basis.
If admission is required, infection control
team should be notified. Immediate
hospitalization and IV treatment should be
offered if the patient develops lifethreatening complications such as
encephalitis, pneumonitis or CNS
deterioration.
Immunocompromised patients with severe
chickenpox must always be given IV acyclovir
If case is pregnant seek expert advice.
Treatment should be offered in the following
situation:
case is presenting for the first time up to 72
hrs after onset of rash AND there are
ophthalmic signs or age is more than 50
years (strong predictor predictors of postherpetic neuralgia).
Severe pain or severe skin rash
prolonged prodromal pain
Case is immunosuppressed.
Consider HIV testing
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 12: GUIDELINES FOR TREATMENT OF COMMON VIRAL INFECTIONS
DISEASE
Oral herpes
simplex
DRUG
Acyclovir 5% topical
cream 5 times a day
for 5 days
ALTERNATIVE
Genital herpes
simplex infection
(first episode)
Valacyclovir 1 g TID
for 5 days or Oral
acyclovir 200 mg 5 x
a day for 5 days
(review and
continue for further
5 days if new lesions
continue to appear)
Valacyclovir 1 g TID
for 5 days Oral
acyclovir 200 mg 5
times a day for 5
days
Oseltamivir 75 mg
every 12 hrs orally
for 5 days (for ICU
admission, 75 to
150 mg 12 hourly)
For children less
than 13 years of
age, dose should be
adjusted
accordingly
IV acyclovir (5 mg/kg
every 8 hrs)
Recurrent genital
herpes simplex
infection
Influenza
COMMENTS
Counsel patient that treatment needs to be
initiated at the onset of symptoms before
vesicles appear and that topical antivirals only
affect the course of the current episode, they
do not cure the individual or prevent further
recurrence
Treatment is effective if started within 5 days of
onset of first lesion and while new lesions are
appearing. In severe cases consult a specialist
and consider IV treatment. If case is pregnant,
consult ID
Only supportive measures are required for the
majority of cases. If greater than 6 episodes per
year suppressive therapy should be considered
and refer the patient to a specialist
Please note that annual influenza vaccination is
essential for all those at risk of influenza
infection. Antiviral drugs are not in a substitute
for vaccination, which remain the most
effective way of preventing illness from
influenza. This is particularly important in
pregnant women
72
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
CENTRAL NERVOUS SYSTEM
SYSTEM
AGE
GROUP
Brain
abscess
Primary or
contiguous
source
PostSurgical ,
Post
traumatic
Meningitis
Neonate
Meningitis
1-3 months
SUSPECTED
MICROBIAL AGENT
INITIAL
THERAPY
ALTERNATIVE THERAPY OR COMMENTS
Streptococcus spp.
Bacteroides,
Enterobacteriaceae,
S. milleri,
S. aureus,
Rare: Nocardia,
Listeria,
Consider
Toxoplasma gondii
in HIV patient
S. aureus,
Enterobacteriaceae
Group B
Streptococcus, gram
negative enteric
bacilli (e.g E. Coli,
Listeria)
Ceftriaxone+
Vancomycin
+Metronidazole
Consult
infectious
diseases
specialist
Use initially Vancomycin to cover MRSA
or beta lactam resistant S.pneumoniae
then adjust according to culture results.
Use Ceftazidime instead of Ceftriaxone if
secondary to chronic otitis externa.
Meropenem may be used in situation of
antibiotic resistant(ESBL)
S. aureus more likely if endocarditis +ve
blood culture.
Need neurosurgical consult for potential
drainage
Ampicillin +
Cefotaxime
Add Vancomycin if pneumococcus
suspected on gram stain pending culture
results.
If patient diagnosed with meningitis after
prolonged hospitalization and /or after
neurosurgical procedure consider
coverage for resistant gram negative,
enterococci and candida
Includes organisms
usually seen in
neonates or older
children
Ampicillin +
Cefotaxime
+ Vancomycin
listeria should be considered as a cause
of meningitis in infants < 2months of age)
Treatment durations (S. pneumonia 1014 days, N. Meningitides 5-7 days, H.
influenza 10 days, Group B streptococci,
Listeria 2-3 weeks, and E. coli ≥ 3weeks)
73
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SUSPECTED
MICROBIAL AGENT
INITIAL THERAPY
ALTERNATIVE THERAPY OR
COMMENTS
S. pneumonia,
N. meningitides,
H. Influenzae
Ceftriaxone or
Cefotaxime +
Vancomycin
Shunt
infection
Coagulase-negative,
Staphylococcus,
coliform
bacilli
Vancomycin+
Ceftriaxone
Or
Vancomycin +
Meropenem
Subdural
empyema
Most of
the time its
extension
of sinusitis
or otitis
media
Encephalitis/ Neonate
meningo
encephalitis
Same as for primary
brain abscess
If allergic to cephalosporin: Consult
ID .Consider Chloramphenicol to
cover N.meningitidis,
Co trimoxazole to cover Listeria in
addition to the Vancomycin.
Prophylaxis of close contact
recommended for N. meningitidis
and H. influenzae meningitis
Use Ceftazidime if concerned about
pseudomonas or Meropenem if
ESBL suspected guided by institute
antibiogram.
Consult neurosurgery for shunt
Taping and need for shunt removal
Surgical emergency and must be
drained.
Herpes simplex
IV: Acyclovir
20mg/kg/dose
every 8 hrs and for
21 days
Add Cefotaxime and Vancomycin to
cover for meningitis till results of
CSF culture and viral PCR available.
Encephalitis
Herpes simplex
Others :
Enteroviruses,
Arboviruses, EBV
Influenza, Varicella,
Mycoplasma,
Bartonella henselae,
TB, Malaria and
Listeria in
immunocompromised
IV Acyclovir
20mg/kg/dose every
8hrs for 21 days
Ampicillin +
Gentamicin if
suspected Listerial
rhomboencephalitis
Herpes simplex is the most common
and treatable cause.
Add ceftriaxone and Vancomycin to
cover for meningitis till results of
CSF culture and viral PCR available.
CSF should be sent for HSV PCR
SYSTEM
Meningitis
AGE
GROUP
Older
children
Older
children
74
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
SUSPECTED
MICROBIAL AGENT
ANTIMICROBIAL
OF CHOICE
ALTERNATIVE THERAPY OR
COMMENTS
RESPIRATORY SYSTEM
Epiglottitis
H. influenza,
S. aureus, S. pyogenes,
S. pneumoniae,
Group A Streptococcus
in immunized children
(Ceftriaxone /
cefotaxime ) +
(clindamycin OR
vanco)
If suspected call paediatric ICU.
Administer anaesthesia and ENT
without distressing the child.
Do not attempt IV for antibiotics
or throat examination before
securing airway.
Keep in position of comfort
(usually sitting)
Peritonsillar
cellulitis or
retropharyngea
l abscess
Group A Streptococcus,
S. aureus,
Haemophilus spp.,
oral microflora /
anaerobes
Group A Streptococcus,
group C and G
streptococci,
mycoplasma.
Majority of cases
(>70%) viral etiology
and do not require
antimicrobial therapy
Clindamycin+
cefuroxime
alternative
amoxicillin/clavulanate
Pen V OR
Amoxicillin
Urgent ENT consult and
consider drainage.
Close observation of airway as
artificial airway may be required
Dental abscess
Oral aerobic &
anaerobic flora
Bacterial
tracheitis
S. aureus,
S. Pneumonia,
Group A streptococci,
H. influenzae
(Pen +
metronidazole)
OR
clindamycin
Cefuroxime OR
clindamycin
Alternative Amoxicillin Clavulanate
Tooth extraction may be
necessary
Bacterial tracheitis can present
as a croup but will have more
rapid onset and higher
temperature.
In patient with tracheostomy,
consider Pseudomonas or other
Gram-negative organisms.
If C-MRSA suspected use vanco
until sensitivity available
Oropharyngeal
infection
Pharyngitis
75
For patients with pen allergy
clindamycin, erythromycin can
be an alternative.
For uncommon failure or
frequent relapses amoxicillinclavulanate OR clindamycin will
be more effective
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SUSPECTED
MICROBIAL AGENT
SYSTEM
Bacterial
Neonate
pneumonia
Immunocompromised
Aspiration Neonates
pneumonia
ANTIMICROBIAL
OF CHOICE
ALTERNATIVE THERAPY OR
COMMENTS
Group B streptococci,
Listeria, Coliforms,
S. aureus,
P. aeruginosa
Others: C.
trachomatis, syphilis
AMP +
gentamicin
OR
cefotaxime +
gentamicin
Add erythromycin if
Chlamydia suspected in late
onset pneumonia.
If baby behaves septic,
obtain blood culture and
send CSF for culture
Any organisms but
particularly
pneumocystis,
P. aeruginosa,
Gram-negative
enteric bacilli (e.g. E.
coli), S. aureus
Piperacillin/
tazobactam +
gentamicin ±
cotrimoxazole
(for Pneumocystis
pneumonia
[PCP]) ±
clindamycin OR
vanco (for MRSA)
Meropenem + gentamicin +/cotrimoxazole is an
alternative.
An early bronco alveolar
lavage may be needed to
prove or exclude PCP and
look for other rare
aetiologies (e.g. Aspergillus)
Please consult infectious
disease unit and
pulmonologist
Oral anaerobes,
Streptococcus spp.,
S. aureus
Gram-negative
enteric bacilli
Empiric antibiotic
not
recommended
Mild-moderate:
none
Moderately
severe:
amoxicillin clavulanate
Hospital-acquired
infection:
amoxicillinclavulanate +
gentamicin
If infection suspected, start
AMP + gentamicin. Use
Clindamycin + gentamicin if
severe case OR if AMP
therapy within last 5 days.
Use clindamycin OR
piperacillin + tazobactam if
pen-resistant organisms
suspected
Older children
76
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
EMPIRIC TREATMENT OF COMMUNITY- ACQUIRED BACTERIAL PNEUMONIA IN CHILDREN#
AGE GROUPS
1–3 months
ORGANISMS
S. pneumoniae,
C. trachomatis, B. pertusis,
S. aureus, H. influenzae
AGENTS OF CHOICE
Cefuroxime (IV) +/clarithromycin (if PO)
For ICU patients:
cefotaxime +
erythromycin
/clarithromycin ±
cloxacillin*
ALTERNATIVE AGENTS
AMP (IV) +/- erythromycin or
clarithromycin
cefotaxime +/ - vanco **
3 months – 5 years
S. pneumoniae, S. aureus
(MSSA/MRSA),
H. influenzae,
M. pneumoniae,GAS
AMP (IV) amoxcillin OR
amoxicillin-clavulanate
if PO
± clarithromycin
For ICU patients:
Cefuroxime + either
Erythromycin OR
Clarithromycin
Cefuroxime OR amoxicillinclavulanate
± clarithromycin
AMP (IV), Amoxicillin if
PO + either
erythromycin OR
clarithromycin
For ICU patients:
cefuroxime + either
erythromycin OR
clarithromycin
Cefuroxime OR amoxicillinclavulanate + either erythromycin
OR clarithromycin
>5 years
S. pneumoniae, S. aureus,
H. influenzae,
M. pneumoniae
Ceftriaxone +vanco**
Cefotaxime OR ceftriaxone +
vanco**
# Consider viral etiologies in differential diagnosis and start empirically oseltamivir until influenza diagnosis
is excluded
*Use Cloxacillin if one suspected S. aureus pneumonia/sepsis in critically ill infants
** use vancomycin if resistant S. pneumoniae or CA-MRSA suspected
Beta-lactam allergic patients:
For patients with significant β-lactam allergy, macrolides or clindamycin are alternatives to the β-lactams
77
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
Hospitalacquired
pneumonia
SUSPECTED MICROBIAL
AGENT
ANTIMICROBIAL OF CHOICE
ALTERNATIVE THERAPY OR
COMMENTS
P. aeruginosa, S. aureus,
Gram-negative enteric
bacilli (Enterobacter,
Klebsiella, Serratia, E. coli)
Stenotrophomonas and
Gram-positive organisms –
enterococci including VRE,
MRSA
Piperacillin/tazobactam OR
meropenem, OR cefepime with
or without gentamicin and
vanco
Empirical therapy based on prior
colonization and hospital
epidemiology
Add vanco if MRSA suspected
Meconium
aspiration
syndrome,
neonates
AMP + gentamicin
recommended if there is a
septic set-up and/or a clinical
suspicion of sepsis
Pertussis
B. pertussis
Pneumonia in
Sickle cell
disease
S. pneumoniae, M.
pneumoniae, H. influenzae
Acute
pulmonary
exacerbations
of cystic
fibrosis
Lung
Empyema
1 month - 5
years
P. aeruginosa, S. aureus,
B. cepacia, H. influenzae
>5 years
S. pneumoniae, group A
streptococci
S. aureus, S. pneumoniae
H. influenzae,
K. pneumoniae
Erythromycin IV OR PO X 14
days OR clarithromycin X 7 days
OR azithromycin X 5 days
Ceftriaxone/cefotaxime ±
erythromycin/ clarithromycin
(PO) ± vanco
Piperacillin + tazobactam +
gentamicin. Where possible
base antibiotic selection on
patients most recent culture &
sensitivity reports
Ceftriaxone OR cefotaxime +
vanco
78
Isolate for first 5 days of therapy.
Report the case to communicable
diseases. Family prophylaxis
In presence of significant Blactam allergy: use clindamycin.
Add erythromycin OR
clarithromycin if required for
coverage against chlamydia,
mycoplasma
Ceftazidime + gentamicin.
Consider vanco if MRSA
suspected. Consult respiratory
medicine
Clindamycin is an option for
sensitive CA-MRSA and in
patients with beta-lactam allergy.
Consult pulmonologist and
infectious diseases regarding
drainage and further
management.
NATIONAL ANTIMICROBIAL GUIDELINES
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
SUSPECTED MICROBIAL
AGENT
ANTIMICROBIAL OF
CHOICE
ALTERNATIVE THERAPY OR
COMMENTS
Heart Infection
Infective
endocarditis
Native valve (including
congenital heart disease):
viridians streptococci,
Enterococcus,
staphylococci including
CoNS, Pneumococcus
Empirical therapy:
Penicillin + gentamicin OR
ceftriaxone + gentamicin
Group A streptococci
Prosthetic valve: including
above and gGramnegative bacilli,
diphtheroids
Vancomycin+ Gentamicin+
Rifampin
79
If patient not acutely ill or in heart
failure, wait for blood culture results.
If initial 3 blood cultures negative
after 24–48 hrs incubation obtain
another 2–3 more blood cultures
before starting empiric therapy.
If MRSA suspected Add Vancomycin.
Gentamicin is synergistic dosage for
gram positive organisms.
Definitive therapy should be guided
by results of blood culture
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
SUSPECTED MICROBIAL
AGENT
ANTIMICROBIAL OF CHOICE
Gr B streptococci, Gramnegative enteric bacilli (e.g.
E. coli, Enterococcus,
listeria).
AMP + aminoglycosides
Includes organisms usually
seen in neonates or older
children
Cloxacillin + cefotaxime ± AMP
OR vanco + cefotaxime
ALTERNATIVE THERAPY OR COMENTS
SEPSIS
New
admission
neonate
1–3 months
AMP + cefotaxime
Consider AMP if listeria
suspected
>3 months
S. pneumoniae,
meningococcus,S. aureus,
H. influenzae
Ceftriaxone/cefotaxime +
vanco
Sickle cell
disease with
fever
S. pneumonia, H. influenza,
Salmonella species
Ceftriaxone/cefotaxime ±
vanco
Piperacillin + tazobactam
CVL-tunnel
infection
Coagulase-negative
Staphylococcus, S. aureus,
less likely Gram-negative
organisms and Candida
spp.
Vanco
Consider removing the central
lines. Modify therapy with
culture reports.
S. typhi, S. paratyphi
Cefotaxime/ceftriaxone
Narrow therapy once sensitivity
available
Enteric fever
80
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SUSPECTED
MICROBIAL
AGENT
SYSTEM
ANTIMICROBIAL OF
CHOICE
ALTERNATIVE THERAPY OR COMMENTS
SKIN AND SOFT TISSUE
Cellulitis neonates
Gram-negative
enteric bacilli,
S. aureus
IV cloxacillin +
aminoglycoside
Infants & children
S. aureus, group A
streptococci
Cephalexin oral OR IV
cephazolin OR Cloxacillin
Impetigo
S. aureus, group A
streptococci
Mild: mupirocin (topical)
Moderate-severe:
Cloxacillin OR cephazolin
Clindamycin (oral) OR cephalexin (oral)
Necrotizing
fasciitis**
** For suspected
cases consult ID
and surgeons
Group A
streptococci,
S. aureus
IV clindamycin+ cloxacillin
OR IV cephazolin +
clindamycin. Use vanco if
MRSA suspected
Invasive group A streptococci disease.
Suspected (chickenpox,
immunocompromised, trauma). Consider
also IVIG
Myositis,
supportive
(tropical myositis,
pyomyositis)
Cervical adenitis
S. aureus
Cloxacillin
Vanco for CA-MRSA, clindamycin OR
linezolid.
Surgical drainage/excision when needed
S. aureus, group A
streptococci
S. pneumoniae,
Group A
streptococci,
S.aureus,
H. influenzae,
M. catarrhalis,
anaerobes
Cloxacillin PO/IV
Clindamycin , cephalexin or cefazolin
IV cloxacillin +
ceftriaxone/cefotaxime ±
metronidazole
Ceftriaxone /cefotaxime + clindamycin
Orbital cellulitis
81
Drain any abscess first. If Late onset group
B streptococci suspected add IV AMP.
If Invasive group A streptococci suspected
(chickenpox, immunocompromised,
trauma) IV pen +clindamycin to be
started.
Use vanco if MRSA suspected.
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
Periorbital cellulitis
Traumatic
Non-traumatic
Dog bite/cat bite
Human bite
Soil contamination
injuries
SUSPECTED
MICROBIAL
AGENT
S. aureus, group
A streptococci
ANTIMICROBIAL OF
CHOICE
ALTERNATIVE THERAPY OR COMMENTS
IV cloxacillin
Vanco OR clindamycin
S. pneumoniae,
group A
streptococci,
S. aureus,
H. influenzae,
M. catarrhalis
IV cefotaxime OR
ceftriaxone + Cloxacillin
OR vanco if MRSA
suspected
If no associated bacteraemia and mild
disease step down to oral therapy is
appropriate with cefuroxime OR
amoxicillin-clavulanate
P. multocida,
Streptococcus
spp., S. aureus,
anaerobes and
many other
organisms
Streptococcus
spp., S. aureus,
anaerobes
Oral: amoxicillinclavulanate OR (if severe)
IV amoxicillinclavulanate
Pen-allergic patients:
>8 yrs: doxycycline + clindamycin
≤8 yrs: cotrimoxazole + clindamycin OR
cotrimoxazole + metronidazole. Assess
need for tetanus, rabies prophylaxis
Oral: Amoxicillin/
clavulanate OR (if severe)
IV: amoxicillinclavulanate
Pen-allergic patients:
>8 yrs: doxycycline + clindamycin
≤8 yrs: cotrimoxazole + clindamycin OR
cotrimoxazole + metronidazole. Assess
need for tetanus, rabies prophylaxis
Mixed flora,
including
Clostridium,
S. aureus, Gramnegative enteric
bacilli
IV: Amoxicillinclavulanate + gentamicin
Assess need for tetanus vaccine ± immune
globulin
82
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
SUSPECTED MICROBIAL
AGENT
SKELETAL INFECTIONS
Septic arthritis
Neonates
Group B streptococci,
S. aureus, Gramnegative enteric bacilli
(e.g., E. coli).
Infants 1–3
months
H. influenzae,
Streptococcus spp.,
Staphylococcus spp. Also
pathogens as of
neonates.
Children
Group A streptococci,
S. aureus,
S.pneumoniae,
K. kingae, H. influenzae
Osteomyelitis
(acute)
Neonate
S. aureus, Group B
streptococci, Gramnegative enteric bacilli
(e.g., E. coli)
Infants 1–3
H. influenzae,
months
Streptococcus spp.,
Staphylococcus spp. Also
pathogens as of
neonates
Children
S. aureus, S.pneumoniae
Group A Streptococci,
rarely Kingella
Sickle cell disease
S. aureus, Salmonella
with
spp., S. pneumoniae
osteomyelitis/
septic arthritis
Puncture wound
P. aeruginosa
of foot
Sneakers
No sneakers
S. aureus
ANTIMICROBIAL OF
CHOICE
Cloxacillin + cefotaxime
OR gentamicin
Cefotaxime + cloxacillin
ALTERNATIVE THERAPY OR
COMMENTS
Drain any abscess first, consider late
onset group B streptococci
If MRSA suspected OR cultured use
vanco OR clindamycin as per
sensitivity report.
Can step down to oral option once
patient afebrile, mobilizing joint and
inflammatory markers coming down
Cefazolin OR cloxacillin
Vanco + cefotaxime.
Cloxacillin + cefotaxime
Cefotaxime + cloxacillin
Cefazolin
Cefotaxime/ceftriaxone
+ cloxacillin
Drain any abscess first
consider late onset Group B
streptococci
If MRSA suspected or cultured use
vanco OR clindamycin as per
sensitivity report
Can step down to oral option once
patient afebrile, mobilizing joint and
inflammatory markers coming down
Vanco + ceftriaxone/cefotaxime
Cloxacillin + cip
Significant B-lactam allergy;
Cip + gentamicin
Oral/IV: cloxacillin
Culture and sensitivity desirable
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TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
SUSPECTED MICROBIAL AGENT
ANTIMICROBIAL
OF CHOICE
ALTERNATIVE THERAPY OR
COMMENTS
Add metronidazole for perforation,
peritonitis and rapidly advancing
sepsis.
Add antifungal if infection
suggested by Gram stain or culture
Gastrointestinal Infections
Necrotizing
enterocolitis
neonate
Enteric Gram-negative bacilli,
Enterococcus, anaerobes,
Pseudomonas in hospitalized
patient
AMP +
aminoglycoside
± metronidazole
OR piperacillintazobactam
Colitis –antibiotic
associated
C. difficile
Stop implicated
antibiotics, start
metronidazole
OR, if failed, oral
vanco
Cholera
V. cholerae
Doxycycline for
age >8 yrs.
Azithromycin OR cip as alternative
to doxycycline
Gastritis, peptic
ulcer disease
H. pylori
Triple therapy :
(clarithromycin
amoxicillin,
omeprazole)
Most data are from adult.
Treat for 10 days
Perforated
appendix
Enteric Gram-negative bacilli,
Enterococcus, anaerobes
AMP +
gentamicin +
Metronidazole
Piperacillin + tazobactam
Bloody diarrhoea
Salmonella spp., Shigella spp.,
C. jejuni, verotoxin-producing
E. coli (including 0157:H7),
Y. enterocolitica, toxin-producing
C. difficile, E. histolytica
Empiric therapy
is generally not
indicated,
except for
certain
pathogens and
selected
situations where
the child is very
sick or toxic. Use
empirically cip
and adjust
according to
pathogen
isolated
Based on culture results .
Antibiotic is indicated for: all
Shigella and E. histolytica
infections; Salmonella in severe
infections or at-risk patients
including immunocompromised or
<3months old; Yersinia infections in
presence of terminal ileitis or
mesenteric adenitis; toxinproducing C. difficile; enteric
infection with sepsis.
Antibiotics NOT indicated for:
Verotoxin-producing E. coli
infections, uncomplicated Yersinia,
Salmonella, Campylobacter
infection
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TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
Peritonitis
Primary
Secondary to
bowel
perforation
Secondary to
peritoneal
dialysis
SUSPECTED MICROBIAL AGENT
Pneumococcus, S. aureus, enteric
Gram-negative organism,
Streptococcus spp.
Enteric Gram-negative bacilli
Bacteroides, Enterococcus,
Pseudomonas in hospitalized patient
Coagulase-negative staph., S. aureus,
Gram-negative organism, candida
85
ANTIMICROBIAL
OF CHOICE
Ceftriaxone
If pen
susceptible, pen
AMP
+gentamycin +
metronidazole
Ceftriaxone+
vanco.
Antibiotic added
to the dialysate
in concentration
approximating
those attained
in serum for
systemic
disease.
ALTERNATIVE THERAPY OR
COMMENTS
Other antibiotics according to
culture and sensitivity
Piperacillin-tazobactam
Surgical management is essential
Selection of antibiotics based on
organism isolated from peritoneal
fluid. Systemic antibiotics if there is
bacteraemia.
Catheter removal especially with
fungal infection and in recurrent
episodes of bacterial infection.
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
SUSPECTED MICROBIAL
AGENT
EYE, EAR AND SINUS INFECTIONS
Conjunctivitis
N. gonorrhoeae,
neonates
C. trachomatis,
herpes simplex,
Pseudomonas aeruginosa,
Older infants &
children
Mastoiditis
(acute)
Sinusitis (acute
& subacute)
Non-typeable H. influenzae,
S. pneumoniae,
N. gonorrhoea
S. pneumoniae, S. aureus,
H. influenzae, M. catarrhalis,
Group A streptococci
S. pneumoniae, H.influenzae,
M. catarrhalis, Group A
streptococci
ANTIMICROBIAL OF CHOICE
Cefotaxime
erythromycin PO.
Acyclovir topical and IV
piperacillin + gentamicin
gentamicin ophthalmic
solution
Topical ofloxacin. Consult
ophthalmologist.
IV ceftriaxone
IV: ceftriaxone/cefotaxime +
cloxacillin OR vanco if MRSA
suspected
Amoxicillin (high dose)
ALTERNATIVE THERAPY OR
COMMENTS
Consider switch to oral therapy
when clinically improved.
Definitive therapy depends on
cultures result and sensitivity
Amoxicillin-clavulanate
May need 14–21 days
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ANTIBIOTICS TREATMENT OF OTITIS MEDIA
S. pneumoniae, M. catarrhalis,
H. influenzae non-type B
ANTIBIOTICS IN MONTH PRIOR TO DIAGNOSIS
NO
YES
Initial
Usual dose of amoxicillin
High dose amoxicillin OR high dose
amoxicillin-clavulanate OR cefuroxime
Failure day 3
High dose
amoxicillin-clavulanate OR
cefuroxime OR ceftriaxone/IM
given OD x 3 days
Tympanocentesis and culture
should be considered.
Antibiotic therapy is same as
day 3
Ceftriaxone IM/IV given OD x 3 days and/or
culture-guided therapy
Failure day 10–28
Tympanocentesis and culture should be
considered.
High dose amoxicillin-clavulanate
or ceftriaxone IM/IV given OD x 3 days
TABLE 13-A: GUIDELINES FOR EMPERICAL TREATMENT OF PEDIATRIC INFECTIONS
SYSTEM
SUSPECTED
MICROBIAL AGENT
ANTIMICROBIAL OF
CHOICE
ALTERNATIVE THERAPY OR
COMMENTS
GENITOURINARY
UTI:
Neonate
Infants & children
E. coli, P. mirabilis,
klebsiella,
Enterococcus spp.,
P. aeruginosa
IV: AMP + gentamicin
Cath or suprapubic urine sample for
culture and adjust antibiotics
according to sensitivity.
E. coli, P. mirabilis,
klebsiella,
Enterococcus spp, p.
aeruginosa,group B
Streptococcus
Oral: amoxicillinclavulanate
Consider step down to oral sequential
therapy when clinically improved.
IV: AMP + gentamicin
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Effective Date:09/05/2016
TABLE 13-B: PAEDIATRIC ANTIBIOTICS DOSAGE GUIDELINE
ANTIMICROBIAL
RECOMMENDED DOSAGE
PENICILLIN
Amoxicillin
50 mg/kg/day PO divided every 8 or 12 hrs
80–90 mg/kg/day PO divided every 8 or 12 hrs (high dose)
Amoxicillin-clavulanate
45–50 mg/kg/day PO (amoxicillin) divided every 8 hrs (4:1)
formulation
80–90 mg/kg/day PO (amoxicillin) divided every 12 hrs (7:1)
formulation (high dose)
Ampicillin
100–200 mg/kg/day IV divided every 6 hrs
300–400 mg/kg/day IV divided every 6 hrs for severe infection
Penicillin V
25–50 mg/kg/day PO divided every 6 hrs or every 12 hrs
Penicillin G
100,000–250,000 units/kg/day IV divided every 4–6 hrs
250,000–400,000 units/kg/d IV day IV divided every 4–6 hrs for
severe infections
Cloxacillin
50–100 mg/kg/day PO/IV/IM divided every 6 hrs for mild to
moderate infections
150–200 mg/kg/day IV/IM divided every 6 hrs for severe
infections
Piperacillin-Tazobactam
240–300 mg piperacillin/kg/day IV divided every 6–8 hrs
All doses based on piperacillin component:
Infant <6 mos.: 150- 300 mg/kg/d IV div q6–8h
Infant >6 mos.: 300- 400 mg/kg/d IV div q6–8h
Cystic fibrosis: 350–600 mg/kg/d IV div q4–6h
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TABLE 13-B: PAEDIATRIC ANTIBIOTICS DOSAGE GUIDELINE
ANTIMICROBIAL
RECOMMENDED DOSAGE
Imipenem
CARBAPENEMS
60–100 mg/kg/day IV div q6h
Meropenem
60–120 mg/kg/day IV div q8h
CEPHALOSPORINS
Cephalexin
25-50 mg/kg/d PO div q6–8h
50–100 mg/kg/d PO div q6–8h in severe infections
Cefazolin
25–50 mg/kg/d IV div q6-8h
100–150 mg/kg/d IV div q6-8h in severe infections
Cefuroxime axetil
20–30 mg/kg/d PO div q12h
75-150 mg/kg/day IV div Q8H for severe infections.
Cefixime
8 mg/kg/d PO div q12–24h
Cefotaxime
100–200 mg/kg/d IV div q6–8h
200–225 mg/kg/d IV div q4–6h in severe infections; up to 300
mg/kg/d div q6h has been used for meningitis, pneumococcal
meningitis
Ceftriaxone
50–100 mg/kg/d IV div q12–24h
Ceftazidime
100–150 mg/kg/d IV div q8h
200–300 mg/kg/d IV div q8h in severe infections
100–150 mg/kg/d IV div q8h
Cefepime
Amikacin
AMINOGLYCOSIDES
15–30 mg/kg/day IV/IM div q8h
20 mg/kg/dose IV q24h for febrile neutropenia
30 mg/kg/dose IV q24h in cystic fibrosis
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TABLE 13-B: PAEDIATRIC ANTIBIOTICS DOSAGE GUIDELINE
ANTIMICROBIAL
Gentamicin
RECOMMENDED DOSAGE
7.5 mg/kg/day IV/IM div q8h
Febrile neutropenia patients:
1 month- <9 yrs. initial dose 10 mg/kg/dose IV/IM q24h
9–12 yrs. initial dose 8 mg/kg/dose IV/IM q24h
>12 yrs. initial dose 6 mg/kg/dose IV/IM q24h
Synergy with β-lactams for Gram-positive infections : 3
mg/kg/day IV/IM div q8h
For cystic fibrosis: 7.5- 10.5 mg/kg/d IV div q8h
Tobramycin
7.5 mg/kg/d IV div q8h
10–12 mg/kg/dose q24q in cystic fibrosis.
MACROLIDES
Erythromycin
20-50 mg/kg/d PO/IV div q6h
Azithromycin
Serious infection: 10 mg/kg IV OD
Cystic fibrosis:
18–35.9 kg: 250 mg PO 3 times weekly
≥36 kg: 500 mg 3 times weekly
Other infections oral therapy:
5-day regimen: 10 mg/kg once on day 1 followed by 5 mg/kg OD
on days 2–5
3-day regimen: 10 mg/kg OD for 3 days
1-day regimen: 30 mg/kg as a single dose
Clarithromycin
15-30 mg/kg/day PO div q12h
OTHERS
Clindamycin
Mild to moderate infections : 20–30 mg/kg/d PO/IV div q6–8h
Severe infections: 30–40 mg/kg/day IV div q6–8h
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TABLE 13-B: PAEDIATRIC ANTIBIOTICS DOSAGE GUIDELINE
ANTIMICROBIAL
RECOMMENDED DOSAGE
Metronidazole
15–30 mg/kg/d PO div q8-12h
30 mg/kg/d IV div q6–8h
Cotrimoxazole
6–12 mg TMP/kg/d PO div BID
15–20 mg TMP/kg/d IV div q6–8h for severe infections
20 mg TMP/Kg/d IV/PO div q6h for treatment of Pneumocystis
jiroveci pneumonia
5mg TMP/kg/d PO OR IV div q12h in pneumocystis prophylaxis
2–4 mg TMP/kg/d PO q6h in UTI prophylaxis
Trimethoprim
4–6 mg/kg/d PO div q12h
For UTI prophylaxis: 2–3 mg/kg/day PO qhs
Doxycycline
For children >8 yrs. of age: 2–4 mg/kg/d PO div q12–24h
Nitrofurantoin
For treatment: 5–7 mg/kg/d PO div QID
UTI prophylaxis: 1–2 mg/kg/day PO qhs
Vancomycin
40–60 mg/kg/d IV div q6–8h
Linezolid
<12 yrs. old: 30 mg/kg/d IV/PO div q8h
≥12 yrs. old: 600 mg IV/PO q12h
ANTIVIRAL
Acyclovir
HSV: 40–60 mg/kg/d PO div q6–12h
HSV encephalitis : 60 mg/kg/d IV div q8h for 21 days
VZV: 80 mg/kg/d PO div q8h
VZV immunocompromised: 30 mg/kg/d IV div q8h
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Effective Date:09/05/2016
TABLE 13-B: PAEDIATRIC ANTIBIOTICS DOSAGE GUIDELINE
ANTIMICROBIAL
Amantadine
Oseltamivir
RECOMMENDED DOSAGE
Treatment & prophylaxis of influenza A ONLY
1–9 yrs. and/or <40 kg: 5 mg/kg/d PO div q12h (max 150 mg/day)
≥ 10 yrs. & ≥40 kg: 100 mg PO q12h
Treatment of Influenza A & B
1–3 mos.: 2.5 mg/kg PO q12h x 5 days
3 mos-1 yr.: 3 mg/kg PO q12h x 5 days
>1 yr.:
10–15 kg: 30 mg PO q12h x 5 days
15–23 kg: 45 mg PO q12h x 5 days
23–40 kg: 60 mg PO q12h x 5 days
>40 kg: 75 mg PO q12h x 5 days
13 yrs.: 75 mg PO BID
Prophylaxis Of Influenza A&B
>1 yr.:
10–15 kg : 30 mg PO daily x10 days
15–23 kg: 45 mg PO daily x 10 days
23–40 kg: 60 mg PO daily x 10 days
40 kg: 75 mg PO daily x 10 days
ANTIFUNGAL
Amphotericin B
0.25–1.5 mg/kg/d IV daily
Amphotericin B Lipid Complexed (Abelcet)
5 mg/kg/IV OD
Amphotericin B Liposomal (AmBisome)
3–5 mg/kg IV OD
Caspofungin
ketoconazole
For age ≥3 mos. : 70 mg/m²/day IV (max 70 mg) day 1, then 50
mg/m²/day IV (Max50 mg in patients <12 yrs., max 70 mg in
patients ≥12 yrs.)
5–10 mg/kg/d PO div q12–24h
fluconazole
3–12 mg/kg/d IV/PO div q24h
Itraconazole
5–10 mg/kg/d PO div q12–24h
2.5- 5 mg/kg/d PO div q8–12h for prophylaxis OR oropharyngeal
candidiasis treatment
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TABLE 13-B: PAEDIATRIC ANTIBIOTICS DOSAGE GUIDELINE
ANTIMICROBIAL
RECOMMENDED DOSAGE
Nystatin
400,000–2,400,000 units/day PO div q6–8h
Voriconazole PO
18mg/kg/day PO div q12h
Voriconazole IV
2-12y: 18mg/kg/day div q12h x 2doses, then 16mg/kg/day div
q12h.
>12 years: 12 mg/kg/d IV div q12h x 2 doses, then 8 mg/kg/d IV
div q12h,
may be increased to 5 mg/kg/dose q12h if needed or reducedto
3 mg/kg/dose q12h if patient is unable to tolerate.
mg/kg/d=milligram per kilogram per day. Usual doses for paediatric patients with normal renal and
hepatic function. Paediatric dose should not exceed recommended adult dose (except for cefuroxime
where maximum is 1.5g IV q8h).
1. These doses do not apply to neonates, except where noted.
2. For completion of therapy of bone and joint infections.
3. For meningitis and other CNS infections, higher end of the dosage listed should be used
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TABLE 14: GUIDELINES FOR THERAPEUTIC DRUG MONITORING (TDM):
CLINICAL GUIDE FOR ADULTS
Therapeutic drug monitoring is required for patients on aminoglycoside (e.g. gentamicin, amikacin)
and glycopeptides (e.g. vancomycin). Serum concentration monitoring aims to avoid both excessive
and sub-therapeutic concentration thereby preventing toxicity and ensuring efficacy.
DRUG
Gentamicin
TROUGH AND PEAK
RANGE (mg/l)
Trough: <2 mg/l
(<1 mg/l for
Endocarditis)
Peak: 5–10 mg/l
(3–5 mg/l for
endocarditis)
SAMPLING TIME
REMARKS
Multiple daily regimen:
initial trough sampling: take
sample just before 3rd or 4th
dose.
Trough: should be taken 8–12
hrs after the previous dose for
TID and BID regimen
respectively
Peak: 30 min after 30 minutes
infusion
Once daily regimen:
Obtain a single serum level
after 1st dose, 8 hrs after start
of infusion. Evaluate on the
nomogram (SEE THE FORM
ATTACHED). If the level falls in
area q24h, q36h or q48h, the
interval should be every 24,
36 or 48 hrs respectively. If
the point is on a slanting line,
choose longer interval. If the
point is above the nomoGram,
stop schedule treatment. Do
serial levels to determine time
of next dose (2 mg/l).
Fresh sample must be used if
pen group is also prescribed.
Aminoglycoside adverse drug
reactions (ADRs):
nephrotoxicity, autotoxicity
(especially when combined with
other
aminoglycoside/diuretics).
Subsequent levels should be
measured every 2–3 days until
the dose is stabilized, then
weekly.
More frequent monitoring may
be required if renal impairment
is present, or if other
nephrotoxic drugs are being
administered concomitantly.
Interpretation: If trough
concentration is >2 mg/l,
withhold until it falls >2 mg/l
(check serum level daily if
necessary) and seek pharmacist
advice
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TABLE 14: GUIDELINES FOR THERAPEUTIC DRUG MONITORING (TDM):
TROUGH AND PEAK
RANGE (mg/l)
SAMPLING TIME
REMARKS
Amikacin
Trough:
<10 mg/l
Peak:
20–30 mg/l
(25–30 for CNS,
pulmonary, bone,
serious infections, and
patients with febrile
neutropenia)
Initial trough sampling: take
sample 15 hrs after the start
of the first dose infusion
Trough: within 30 minutes of
next due dose
Peak: 30 minutes after end of
infusion.
1 hr following IM injection
Vancomycin
Trough:
once or twice daily
regimen: 10–15 mg/l
(15–20 mg/l for
serious infections due
to MRSA including
bacteraemia, infective
endocarditis,
osteomyelitis,
meningitis)
pneumonia and severe
SSTI)
Initial trough sampling: take
sample just before the fourth
dose.
Trough: For once or twice
daily regimen collect within
30 minutes of next due dose
Peak: not required
Fresh sample must be used if
pen group is also prescribed.
Subsequent levels should be
measured every 2–3 days until
the dose is stabilized, then
weekly.
More frequent monitoring may
be required if renal impairment
is present, or if other
nephrotoxic drugs are being
administered concomitantly
If trough concentration is higher
than target level, withhold until
it falls (check serum level daily if
necessary) and seek advice
Subsequent levels should be
measured every 2–3 days until
the dose is stabilized, then
weekly.
Nephrotoxicity: 2–3 consecutive
documented increase by 50% in
serum creatinine from baseline.
More frequent monitoring may
be required if patient
haemodynamically unstable or
renal impairment is present, or
if other nephrotoxic drugs are
being administered
concomitantly.
If trough level is higher than 25
mg/l, withhold until it falls
(check serum level daily if
necessary) and seek pharmacist
advice
DRUG
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Please consider the following :
-
These are guidelines only; if you need more advice on the appropriateness of the sampling time, and
the interpretation of the levels, contact the clinical pharmacist.
TDM results must be interpreted in conjunction with the clinical status of the patient.
Always use actual body weight for dose calculations.
Recording the sampling time (e.g. sample was taken at 6.30 am) is a MUST in order to interpret the
results and modify the dose accordingly.
Tips assist in interpreting TDM results
- Was the sample taken at steady state?
- Was the sample taken at the right time?
- Was the drug administered at the right time?
- Was the sample taken is peak or trough?
- Are there any interacting drugs/foods?
- Drug compliance?
- Is the result what you would expect?
- If any of the following clinical conditions is present:
Ascites, burns, CHF, Gram-negative sepsis, hepatic/renal failure, neonate.
References:
1. Surrey and Sussex Healthcare NHS trust. Therapeutic Drug Monitoring (TDM). Gentamicin
prescribing guidelines –updated 27th Mar 2014, AL.
2. BNF, 2010.
3. Rybak M, Lomaestro B, Rotschafer JC, Moellering R Jr, Craig W, Billeter M, et al. Therapeutic
monitoring of vancomycin in adult patients: a consensus review of the American Society of HealthSystem Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious
Diseases Pharmacists. Am J Health Syst Pharm 2009;66:82–98.
4. Pharmacy Bulletin. SQUH. Vol.4, No 1.
5. Therapeutics: A Handbook for prescribers. NHS Greater Glasgow and Clyde, UK. August 2010.
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HARTFORD HOSPITAL ONCE DAILY GENTAMICIN NOMOGRAM
FIG 2
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GUIDELINES FOR SURGICAL ANTIMICROBIAL PROPHYLAXIS
Rationale
Antibiotics are administered prior to surgical procedures to prevent surgical site infections.
Aims
1. To provide antimicrobial recommendations for surgical prophylaxis in adult and children undergoing
surgical procedures taking into consideration the type of surgery, most common organisms involved,
international guidelines, expert opinion and cost.
2. To optimize antimicrobial use and patient outcome in prevention of surgical site infections in a rational
way to prevent the emergence of resistance among bacteria.
Antimicrobial surgical prophylaxis is generally indicated for the following type of surgery:
1. Clean wounds are uninfected operative wounds in which no inflammation is encountered and the
wound is closed primarily. By definition, a viscus (respiratory, alimentary, genital or urinary tract) is not
entered during a clean procedure.
2. Clean-contaminated wounds are operative wounds in which a viscus is entered under controlled
conditions and without unusual contamination.
Antimicrobial prophylaxis is not indicated for an operation classified as dirty or contaminated as treatment
is required.
General considerations
When prescribing an antimicrobial surgical prophylaxis, the following points should be considered:
1. Selection of an appropriate agent for specific patients should take into account not only comparative
efficacy but also adverse-effect profiles and patient drug allergies.
2. For most procedures, cefazolin 1 g or cefuroxime should be the agent of choice because of their
relatively long duration of action, their effectiveness against the organisms most commonly
encountered in surgery and their relatively low cost.
3. Clindamycin or vancomycin should be used in penicillin-allergic patients.
4. Clindamycin may be preferable for patients not at risk for infections due to resistant Gram-positive
organisms secondary to its narrower spectrum and a more rapid infusion time.
5. Routine vancomycin use is discouraged.
6. Modification of a surgical prophylaxis regimen may be necessary in patients with pre-existing infections
prior to surgery, significant length of hospital stay prior to surgery and previous positive
cultures/colonization. Consult infectious diseases unit for specific recommendations.
7. The recommendations in this guideline are provided for adult and paediatric (1–12 years) patients.
They do not specifically address infants.
8. Decolonization therapy for MRSA is recommended prior to surgery and antibiotic prophylaxis should
include cover for MRSA. Please refer to infection prevention protocol for decolonization.
9. Hospital-based guidelines should be developed in accordance to surgical site surveillance, the most
frequently isolated pathogens implicated and their local antibiogram.
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Timing
1. Administration of antibiotics for surgical prophylaxis should be as near to the incision time as possible.
Infusion of antibiotics for surgical prophylaxis should begin within 1 hour prior to skin incision (i.e. at
induction of anaesthesia in case of general anaesthesia).
2. Vancomycin may begin within 2 hours prior to incision due to the longer infusion time and to ensure
adequate tissue levels at the time of incision.
3. All antibiotic infusions should be completed prior to incision.
Duration
1. The optimal duration of perioperative prophylaxis is unknown. It is unlikely that further benefit is
attained by the administration of additional doses beyond wound closure and postoperative
prophylaxis is not recommended.
2. Single prophylactic doses +/- additional intraoperative doses in prolonged procedures are strongly
recommended. If prophylaxis is extended beyond the operative period, antibiotics should be
discontinued within 24 hours unless otherwise specified.
3. Additional intraoperative doses are strongly recommended in prolonged procedures at intervals
approximately 2 times the half-life of the drug. This roughly corresponds with redosing antimicrobials at
a frequency of one interval shorter than usual (see Table 1). Additional intraoperative doses may not be
warranted in patients for whom the half-life of the antimicrobial is prolonged, such as those patients
with renal insufficiency.
4. The continuation of prophylaxis until all catheters and drains have been removed is not appropriate
and not recommended.
Responsibility for application
The attending surgeon should ensure that the appropriate dose, timing and duration are followed.
References:
1. Bratzler DW, Dellinger EF, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice
guidelines for antimicrobial prophylaxis in surgery. Am J health Syst Pharm 2013;70:195–283
2. Gulf Cooperation Council. Infection prevention and control manual. 2nd edition. Riyadh, KSA: National
Guard Health Affairs; 2013.
3. Garey KW, Dao T, Chen H, Amrutkar P, Kumar N, Reiter M, et al. Timing of vancomycin prophylaxis for
cardiac surgery patients and the risk of surgical site infections. J Antimicrobial Chemotherapy
2006;58:645–650.
4. Weber WP, Marti WR, Zwahlen, Misteli H, Rosenthal R, Reck S, et al. Annals of Surgery 2008;247: 918–
926.
5. Stuart Wolf, Jr., Chairman; Carol J. Bennett; Roger R. Dmochowski,; Brent K. Hollenbeck; Margaret
S. Pearle,; Anthony J. Schaeffer, American Urological Association Best Practice Policy on
Antibiotic prophylaxis for Urological Procedures (2008).
99
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Recommended redosing intervals at which a supplemental dose is required if surgery is prolonged.
ANTIBIOTICS
ADULT DOSE
PAEDIATRIC
DOSE
HALF-LIFE
(H)
2 g, 3 g for patients
weighing >120 kg
30 mg/kg
1.2–2.2
RECOMMENDED REDOSING
INTERVAL (FROM INITIATION OF
THE FIRST PREOPERATIVE DOSE)
(H)
4
Cefuroxime
1.5 gm
50 mg/kg
1–2
4
Clindamycin
900 mg
10 mg /kg IV
2–4
6
Vancomycin
15 mg/kg
15 mg/kg/dose
IV
6.0
6–12
Gentamicin
1.5 mg/kg
2.5 mg/kg
2.0
NA
500 mg
15 mg/kg
8.0
8
Cefazolin
Metronidazole
100
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TABLE 15: SURGICAL PROCEDURES AND THE RECOMMENDED DRUGS
SURGICAL PROCEDURE
Cardiac:
-Median sternotomy
-pacemaker & implant
-prosthetic valve
-coronary artery bypass
LIKELY
PATHOGEN
Coagulasenegative
Staphylococcus,
S. aureus,
enteric Gramnegative bacilli
RECOMMENDED
DRUG AND DOSAGE
Adult: cefazolin 2 gm IV pre-op
dose (then q8h x 24 hrs postop)
Paediatric: cefazolin 30
mg/kg/dose IV pre-op and q8h
x 24 hrs post-op.
(Consider use of intranasal
mupirocin evening before, day
of surgery & bid for 5 days,
post-op in patients who are
colonized with MRSA
preoperatively)
Adult: cefazolin
2 g pre-op
Paediatric: cefazolin 30
mg/kg/dose IV pre-op
-Thoracic non-cardiac
-lung resections
-Thoracoscopy
-Thoracotomy
S. aureus,
coagulasenegative
Staphylococcus,
Enteric Gramnegative bacilli
Vascular:
-Arterial surgery abdominal
aorta
-Any vascular procedure
that inserts prosthesis, or
foreign body
-Procedures on the leg that
involve a groin incision
-Lower extremity
amputation for ischemia
S. aureus,
Coagulasenegative
Staphylococcus,
Enteric Gramnegative bacilli
Adult: cefazolin 2 g IV pre-op
and q8h x 1 days
Paediatric: cefazolin 30
mg/kg/dose IV q8h x 1 days
(Intranasal mupirocin as per
cardiac surgery)
S. aureus,
Coagulasenegative
Staphylococcus
Adult: cefazolin 2 g IV pre-op
Paediatrics:
Cefazolin 30 mg/kg pre-op
ALTERNATE DRUG AND
DOSAGE
Adult: cefuroxime 1.5
g pre-op
Paediatric: cefuroxime 50
mg/kg pre-op
Adult: vanco 1 g pre-op and
continued q12h x 1 days
Paediatric: vanco 15
mg/kg/dose IV pre-op and
continued q12h 1 days
Adult: vanco 1 g IV pre-op
OR clindamycin 900 mg IV
pre-op
Paediatric: vanco 15
mg/kg/dose IV pre-op
OR clindamycin
10 mg/kg IV pre-op
Adult: vanco
1 IV g q12h x 1 d
OR Clindamycin 900 mg IV
pre-op
Paediatric: vanco 15
mg/kg/dose IV continued
q12h x1d
OR clindamycin 10 mg /kg IV
pre-op
Prophylaxis is not indicated
for carotid endarterectomy
or brachial artery repair
without prosthetic material
Neurosurgery:
-Craniotomy
-Skull fracture
-CSF leak
-Penetrating trauma
-Spine
-CSF shunt
101
Adult: vanco
1 g IV pre-op
Paediatrics: vanco 15 mg/kg
pre-op
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Effective Date:09/05/2016
TABLE 15: SURGICAL PROCEDURES AND THE RECOMMENDED DRUGS
SURGICAL PROCEDURE
-Orthopaedic
-Hip arthroplasty
-Hip fracture repair
-Implantation of internal
fixation devices (e.g. nails,
screws, plates, wires)
-Total joints replacement
-Spinal fusion
-Spinal procedures with and
without instrumentation
-Open fractures (considered
contaminated, treatment is
indicated rather than
prophylaxis)
Ophthalmic
Head/neck:
-Incision through oral, sinus
or pharyngeal mucosa
-Major neck dissection
-Parotid surgery
Note that prophylaxis is not
recommended for
tonsillectomy or functional
endoscopic sinus procedure
or tympanostomy tube
insertion
Gastrointestinal
oesophageal, gastroduodenal
(high risk only: morbid
obesity, oesophageal
obstruction, decreased
gastric acidity or motility
LIKELY
PATHOGEN
S. aureus,
Coagulasenegative
Staphylococcus
RECOMMENDED
DRUG AND DOSAGE
Adult: cefazolin 2 gm IV
pre-op (for 24 hrs post-op
)
Paediatric:
cefazolin 30 mg/kg/IV
pre-op plus q8h for 2
doses post-op
S. aureus,
Staphylococcus
epIdemidis.
Streptococci,
Enteric, Gramnegative bacilli,
Pseudomonas
spp.
S. aureus,
Streptococci,
oral anaerobes,
enteric Gramnegative bacilli
Topical :
gentamicin, OR
tobramycin OR cip,
ofloxacin OR Gramicidinpolymyxin GramB
ophthalmic multiple
drops topically over
2–24 hrs
Adult: cefazolin
2 g IV plus metronidazole
500 mg IV pre-op
Paediatric : cefazolin 30
mg/kg/dose IV pre-op IV
single dose plus IV
metronidazole 15 mg/kg
pre-op
Addition of cefazolin 100 mg by
subconjunctival injection OR
intracameral cefazolin 1–2.5 mg
OR cefuroxime 1 mg at the end of
the procedure is optional
Enteric Gramnegative bacilli,
Gram-positive
cocci
Adult: cefazolin 1–2 g IV
pre-op
Paediatric: cefazolin 30
mg/kg/dose IV pre-op
single dose
Adult: gentamicin
1.5 mg/Kg/ IV plus clindamycin
900 mg IV pre-op
Paediatric: gentamicin 2.5
mg/kg/dose plus clindamycin 10
mg/kg/dose IV pre-op
TABLE 15: SURGICAL PROCEDURES AND THE RECOMMENDED DRUGS
102
ALTERNATE DRUG AND DOSAGE
Adult: vanco 1 g IV q12h for 1 day
Paediatric: vanco 15 mg/kg pre-op
plus q12h x 2 doses post-op
Adult : clindamycin 600 mg IV preop
Paediatric: clindamycin 10
mg/kg/dose IV
*addition of gentamicin to
clindamycin is recommended if
Gram-negative contamination of
procedure is likely
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
SURGICAL PROCEDURE
Biliary tract:
In high-risk patients:
-Age over 70 yrs
-Common duct stones
-Obstructive jaundice
-Acute cholecystitis
-Non-functioning gall
bladder
-ERCP
Inguinal hernia
complicated or recurrent,
mesh placement
LIKELY
PATHOGEN
Enteric Gramnegative bacilli,
Clostridia,
Enterococcus
RECOMMENDED
DRUG AND DOSAGE
Adult: cefazolin 1–2 g IV
pre-op x 1 dose
Paediatric: cefazolin
30 mg/kg/dose IV pre-op
single dose
Gram-positive
cocci, Gramnegative bacilli
Adult: cefazolin
2g IV pre-op x 1 dose
Paediatric: cefazolin
30 mg/kg pre-op x 1 dose
Appendectomy,
Non-perforated
Enteric Gramnegative bacilli,
anaerobes,
enterococci
Adult: cefazolin
2 g IV plus metronidazole
500 mg IV pre-op single
dose
Enteric Gramnegative bacilli,
anaerobes,
enterococci
Paediatric: cefazolin
30 mg/kg pre-op plus
metronidazole
15 mg/kg/dose IV pre-op
single dose
Adult: cefazolin
2 g IV plus metronidazole
500 mg IV pre-op single
dose
Mastectomy
S. aureus,
Paediatric: cefazolin
30 mg/kg/IV pre-op plus
metronidazole
15 mg/kg/dose IV pre-op
single dose
Adult: cefazolin,
Involving placement of
prosthetic materials, saline
implant, tissue expander
Coagulasenegative Staph.
Colorectal:
-Whipple procedure
-Pancreatectomy
-Small bowel
2 g IV Pre-op x 1 dose
ALTERNATE DRUG AND DOSAGE
Adult: gentamicin
1.5 mg/kg IV plus clindamycin 900
mg IV pre-op x 1 dose
Paediatric: gentamicin 2.5
mg/kg/dose plus clindamycin
10 mg/kg/dose IV pre-op
Adult: gentamicin
1.5 mg/kg/IV plus clindamycin 900
mg IV pre-op x 1 dose
Paediatric: gentamicin 2.5
mg/kg/dose IV plus clindamycin
10 mg/kg dose IV
pre-op
Adult: gentamicin
1.5 mg/kg IV plus clindamycin 900
mg IV pre-op
Paediatric: gentamicin 2.5
mg/kg/dose IV plus clindamycin
10 mg/kg/dose/IV
pre-op
Adult:
gentamycin
1.5 mg/kg/IV plus clindamycin 900
mg IV Pre-op
Paediatric: gentamicin 2.5
mg/kg/dose IV plus clindamycin
10 mg/kg dose IV pre-op
Adult: vanco
1 g IV pre-op x 1 dose
OR clindamycin 900 mg IV pre-op
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Effective Date:09/05/2016
TABLE 15: SURGICAL PROCEDURES AND THE RECOMMENDED DRUGS
SURGICAL PROCEDURE
Gynaecologic
vaginal, abdominal or
laparoscopic
hysterectomy
Caesarean Section
Urology:
-Genitourinary
preoperative catheter
-Transrectal prostaticbiopsy
-Placement of prosthetic
material
(Patients with
preoperative bacteria
should be treated to
sterilize the urine before
surgery or receive
antibiotic active against
the bacteria pre-op and
continued until catheter
removal or for 10 days)
TURP, TURBT
-Ureteroscopy
-Rigid cystoscopy
-Visual Internal
urethrotomy
-Lithotripsy
-Nephrectomy
-Pyeloplasty
-Adrenalectomy
Ileal conduit
Renal transplantation
LIKELY PATHOGEN
Enteric Gram-negative
anaerobes, group B
Strept., Enterococcus
RECOMMENDED
DRUG AND DOSAGE
Adult: cefazolin
2 g pre-op
ALTERNATE DRUG AND DOSAGE
Adult: gentamicin
1.5 mg/kg IV plus clindamycin
600 mg IV pre-op
Enteric Gram-negative
anaerobes, group B
Strept., Enterococcus
Enteric Gram-negative
bacilli, enterococci
Adult: cefazolin 2 g IV
pre-op
Enteric Gram-negative
bacilli, enterococci
Cefazolin 2 g
pre-op
Cip 500 mg PO OR 400 mg IV Preop
OR gentamicin 1.5 mg/kg IV preop
Enterobacteriaceae,
anaerobes
Adult : cefazolin 2 g IV
pre-op PLUS
metronidazole 500 mg
IV pre-op
Adult: cefazolin
2 g Iv pre-op
Paediatric: cefazolin 30
mg/kg IV pre-op
Adult: clindamycin 900 mg IV preop
PLUS gentamicin 1.5 mg/kg IV
pre-op
Adult : clindamycin 900 mg IV
pre-op plus cip 400 mg IV pre-op
Paediatrics: clindamycin 10
mg/kg IV plus gentamicin 2
mg/kg IV pre-op
S. aureus,
coagulase-negative
Staph,
Streptococci,
Enterobacteriaceae
Adult : cip 500 mg PO 2
hrs pre-op
OR
400 mg IV pre-op 1–2
hrs pre-op
Paediatric :
trimethoprim/sulfamethoxazole 6 mg/kg 2
hrs pre-op PO
OR cefazolin 30 mg/kg
IV pre-op
OR, gentamicin 1.5 mg
kg x 1 dose
104
Adult: gentamicin 1.5mg/kg IV
plus clindamycin 600 mg IV both
as pre-op
Gentamicin 1.5 mg/kg IV pre-op
+/- clindamycin 600 mg IV pre-op
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Effective Date:09/05/2016
TABLE 16: ANTIMICROBIAL IN PREGNANCY AND LACTATION: Safe use of anti-infective agents
Antibacterial agents
NAME OF THE AGENT
Amikacin
Gentamycin
PREGNANCY
BREASTFEEDING
AMINOGLYCOSIDES
Avoid unless potential
benefit outweighs risk.
Risk of auditory or vestibular
nerve damage in the infant
when used in the second and
third trimesters of pregnancy
Safe during
breastfeeding
FDA PREGNANCY CATEGORY
Category D
PENICILLIN
AMP
Cloxacillin
Pen G
Amoxicillin-clavulanic
acid
Piperacillin/tazobacta
m
Safe during pregnancy
Safe during
amoxicillin-clavulanic acid
breastfeeding
should be avoided in women
at risk of preterm delivery
due to increased risk of
neonatal necrotizing
enterocolitis.
Risk-pen allergy categories.
CEPHALOSPORINS
Category B
Cefazolin
Ceftazidime
Ceftriaxone
Cefuroxime
Cephalexin
Cefepime
Safe during pregnancy
Category B
Ertapenem
Meropenem
Azithromycin
Clarithromycin
Erythromycin
Safe during
breastfeeding
CARBAPENEMS
Use only if potential benefit
Not safe during
outweighs risk
breastfeeding
MACROLIDES
Safe during pregnancy
Safe during
breastfeeding
105
Category B
Category B
Category C
Category B
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TABLE 16: ANTIMICROBIAL IN PREGNANCY AND LACTATION: Safe use of anti-infective agents
Antibacterial agents
NAME OF THE
AGENT
PREGNANCY
BREASTFEEDING
FDA PREGNANCY CATEGORY
QUINOLONES
Ciprofloxacin
Levofloxacin
Moxifloxacin
Use only if potential benefit
outweighs risk.
Avoid G6PD deficiency cases.
Safe during
breastfeeding.
Avoid breastfeeding an
infant with G6PD
deficiency.
Select other than
moxifloxacin during
breastfeeding.
Category C
SULFONAMIDES
Cotrimoxazole—
TMP-SMX
Case studies:
Avoid during 1st trimester
may cauase neural tube
defects (NTDs),
cardiovascular &
malformation.
Add folic acid 4.5 mg/day to
minimize the risk of NTDs.
Sulfamethoxazole should be
avoided near term due to
potential toxicity to the
newborn haemolytic
anaemia and kernicterus.
Avoid G6PD deficiency cases.
Avoid sulfonamides allergy
Safe during breastfeeding
for healthy and full term
infants.
Sulfamethoxazole used
with caution while
breastfeeding to
premature infants or
neonates with
hyperbilirubinemia.
Sulfamethoxazole should
be avoided while
breastfeeding an infants
with G6PD deficiency
Category D
TETRACYCLINES
Doxycycline
Minocycline
Tetracycline
Should be avoided after 15
week of gestation due to
reports of possible
discoloration of the
deciduous teeth
Short term therapy
during breastfeeding is
safe.
Prolonged treatment
courses during nursing
should be avoided.
Black discoloration of
breast milk has been
reported with
minocycline
106
Category D
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TABLE 16: ANTIMICROBIAL IN PREGNANCY AND LACTATION: Safe use of anti-infective agents
NAME OF THE
AGENT
Clindamycin
Daptomycin
Linezolid
Nitrofurantoin
Rifampin
Tigecycline
Vancomycin
Amphotericin B
PREGNANCY
BREASTFEEDING
MISCELLANEOUS ANTIBACTERIAL AGENTS
Safe during pregnancy
To be monitored during
breastfeeding to infants.
Chance of diarrhoea,
candidiasis (oral thrush) and
for blood in the stool,
antibiotic-associated colitis
st
Avoid during 1 trimester.
Safe during breastfeeding
Use only if potential benefit
outweighs risk
Use only if potential benefit
Not safe during breastfeeding
outweighs risk.
An alternate agent would be
preferred
Safe during pregnancy.
Not safe infant under 1
Avoid- g6PD deficiency cases. month and those with G6PD
An alternate agent should be deficiency
used after 37 weeks of
Safe infants above 1 month
gestation
Prenatal exposure to Rif has
Safe during breastfeeding
been connected to
haemorrhagic disease of the
newborn.
Prophylactic administration
of vitamin K is recommended
to prevent this complication
Should be avoided after 15
Not safe during
weeks of gestation.
breastfeeding.
Use an alternative agent with Use an alternative agent with
known safety profile is
known safety profile is
recommended
recommended during
breastfeeding.
Avoid unless potential
Safe during breastfeeding
benefit outweighs risk.
ANTIFUNGAL AGENTS
Not safe during pregnancy.
Not safe during breastfeeding
Should be used only when
benefit outweighs unknown
risk to the foetus
107
FDA PREGNANCY
CATEGORY
Category B
Category B
Category C
Category B
Category C
Category D
Category B
Category B
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TABLE 16: ANTIMICROBIAL IN PREGNANCY AND LACTATION: Safe use of anti-infective agents
NAME OF THE
AGENT
Caspofungin
Fluconazole
Itraconazole
Pentamidine
Posaconazole
Voriconazole
Acyclovir/valacy
clovir
Famciclovir
Foscarnet
PREGNANCY
BREASTFEEDING
FDA PREGNANCY
CATEGORY
Category C
Not safe during pregnancy.
Should be used only when benefit
outweighs unknown risk to the
foetus. Should be avoided in 1st
trimester whenever possible
Not safe during
breastfeeding
Not safe during pregnancy.
Should be used (in low dose, 150 mg)
only when benefit outweighs
unknown risk to the foetus. for
vaginal candidiasis
Not safe during pregnancy.
Should be used only when benefit
outweighs unknown risk to the
foetus. Ensure effective
contraception during treatment and
until the next menstrual period
following end the treatment
Not safe during pregnancy
Safe during
breastfeeding
Category C
Safe during
breastfeeding
Category C
Not safe during
breastfeeding
Not safe during pregnancy. Should
Not safe during
be used only when benefit outweighs breastfeeding
unknown risk to the foetus
Not safe during pregnancy
Not safe during
Should be avoided during pregnancy breastfeeding
at least for the 1 trimester unless
other treatments have failed and the
benefit outweighs the unknown risk
to the foetus
ANTIVIRAL AGENTS
Safe during pregnancy
Safe during
breastfeeding
Avoid unless potential benefit
Not safe during
outweighs risk
breastfeeding
Avoid unless potential benefit
Not safe during
outweighs risk (in 2nd and 3nd
breastfeeding
trimester)
108
Category C
Category D
Category B
Category B
Category C
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TABLE 16: ANTIMICROBIAL IN PREGNANCY AND LACTATION: Safe use of anti-infective agents
NAME OF THE
PREGNANCY
AGENT
Ganciclovir/
Avoid unless potential benefit
valganciclovir
outweighs risk-teratogenic risk,
ensure effective contraception
during and barrier contraception for
men during and for at least 90days
after treatment
Oseltamivir
Chloroquine
Avoid unless potential benefit
outweighs risk (during a pandemic)
BREASTFEEDING
Not safe during
breastfeeding
Safe during
breastfeeding
ANTIMALARIAL AGENTS
Benefit of prophylaxis and treatment Safe during
in malaria outweighs risk
breastfeeding
FDA PREGNANCY
CATEGORY
Category C
Category C
Category C
Primaquine
Risk of neonatal haemolysis and
methemoglobinemia in 3rd trimester
Not safe during
breastfeeding
Category X
Quinine
High doses are teratogenic in first
trimester, but in malaria, benefit of
treatment outweighs risk
safe during
breastfeeding
Category C
Artemether with
lumefantrine
Avoid unless potential benefit
outweighs risk
Avoid breastfeeding for
at least 1 week after last
dose
Category C
Appendix A - Dose adjustment in pregnancy: general considerations.
Some of the physiological changes occurring in pregnancy may affect the pharmacokinetics of drugs taken
during the gestational period and post-partum. Depending on the clinical significance of these changes,
adjustment of the doses and/or dosing interval may warrant consideration. Below are some examples of
altered drug distribution and elimination in pregnancy.

Increased maternal plasma volume may increase the volume of distribution of the same drug, which
may require a dose increase.
 Decreased plasma protein concentration, specifically albumin, may increase the free fraction of
highly protein-bound drugs, which may require a dose reduction.
 Increased renal blood flow and glomerular filtration rate may increase the elimination of drugs that
are excreted primarily in the urine. This may require use of an increased dose and/or a shorter
dosing interval.
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
Alteration in the activity of hepatic drug metabolizing enzymes may require dosage adjustment as
follows:
o Decreased activity (e.g., CYP1A2 and CYP2C19). For drugs that are dependent on these enzymes
for elimination, a dose reduction may be required. For drugs that require these enzymes for
conversion to their active form, a dose increase may be appropriate.
o Increased activity (e.g., CYP3A, CYP2D6 and CYP2CP). For drugs that are dependent on these
enzymes for elimination, a dose increase may be required. For drug that requires these
enzymes for conversion to their active form, a dose reduction may be required.
Appendix B - Pregnancy category chart
Pregnancy category A
Pregnancy category B
Pregnancy category C
Pregnancy category D
Pregnancy category X
Adequate research has been done with the conclusion that drugs in this
category are not likely to cause any harm to the foetus in the first
trimester as well as later in pregnancy.
Studies carried out on animals have shown no adverse effects on the
foetus; however, there is a lack of controlled studies on human
pregnancy.
Animal studies have shown evidence of harmful effects on the foetus;
however, no controlled study has been done on a human pregnancy.
The medicines may be prescribed in cases where the potential benefits
outweigh the possible adverse effects.
Studies done on human pregnancy have shown positive risks to the
foetus. However, doctors might prescribe them in certain cases where
the potential benefits outweigh the risks.
Both human and animal studies have shown positive risks to the foetus,
with the adverse effects extending to serious birth defects, miscarriage
and foetal death. The possible risks of using these medicines outweigh
any potential benefits.
110
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PENICILLIN ALLERGY
Adverse drug reactions are defined as any noxious, unintended, undesired effect of a drug that occurs at
doses used for prevention, diagnosis or treatment.
Type of ADR
Type of ADR
A
Predictable
A
Predictable
Side Effect
B
Unpredictable
Idiosyncratic
Reaction
Overdose
Drug Allergy
FIG-3
Drug Allergy is immunologically mediated reactions either antibody mediated or cell mediated.
Penicillin:
 Belongs to ß-lactam antibiotics.
 Generally effective at eradicating common bacterial infections such as skin, ear, sinus and upper
respiratory tract infections.
Allergy to penicillin is the most commonly-reported medication allergy but true penicillin allergy is rare.
 Estimated frequency of anaphylaxis 1–5 per 10,000 cases of penicillin therapy.
Allergic reactions to penicillin categorized based on time of onset of symptoms:


Immediate reactions:
o Begin within an hour of the first administered dose.
o Reactions are usually type I (IgE-mediated) reactions.
o May escalate to life-threatening anaphylaxis.
Anaphylaxis symptoms and signs include: pruritus, flushing, urticaria, angioedema, and wheezing,
laryngeal enema, abdominal distress with emesis or diarrhoea, and hypotension.
The diagnosis of immediate allergic reactions to penicillin is based on clinical history, skin testing
when available, and sometimes graded challenge
111
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
Delayed reactions:
o Begin after multiple doses, typically after days or weeks of treatment.
o Maculopapular exanthemas and less commonly urticarial eruptions are the most common
form.
Usually mild and often related to a concomitant viral infection, especially in children.
o
o
Rare delayed systemic reactions also exist and can be severe.
Patients with past delayed systemic reactions, such as Stevens-Johnson syndrome, toxic
epidermal necrolysis, hypersensitivity syndrome, or other exfoliating dermatoses should
not receive penicillin again under any circumstances.
Risk of recurrent reactions depends on the time elapsed since the patient’s last reaction.


~ 50% lost sensitivity after 5 years.
~ 80% lost sensitivity after 10 years.
Thorough history is an essential component in the evaluation of patients with suspected drug allergy:










Why was the medication prescribed?
How long ago did the reaction occur?
Which systems (e.g. cutaneous, respiratory, GI) were involved in the reaction and what were
the characteristics?
Characterization of the cutaneous lesions important in determining the cause, further
diagnostic tests and management decisions
When during the course did the reaction occur?
Was the patient taking concurrent medications at the time of the reaction?
What was the therapeutic management required secondary to the reaction?
Had the patient taken the same or cross reacting medication before the reaction?
Has the patient been exposed to the same or similar medication since the reaction?
Does the patient have an underlying condition that favours reactions to certain medications?
Cross reactivity among B-lactams i.e. “penicillin, cephalosporins, carbapenems and monobactams”.


Cephalosporins: cross reactivity occurs because of the B-lactams ring and also the R chain side
group.
o Cross reactivity can be as high as 10%.
o Avoid only drugs with similar R side chain.
Carbapenems:
o >99% of penicillin-allergic patients tolerate carbapenems e.g. meropenem.
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
Monobactams:
o No immune cross reactivity, therefore penicillin-allergic patients may receive aztreonam
normally.

Diagnostic tests in drug allergy:
o Testing for immediate reactions:
 Markers of anaphylaxis: tryptase, histamine.
 Skin testing for drug-specific IgE.
 In vitro tests.
o Drug Provocative graded challenge:
 Purpose: VeRify that the patient will not experience an immediate adverse reaction
to a given drug.
 Administration of progressively increasing doses of a medication until a full dose is
reached.
 Medication is introduced in a controlled manner to a patient who has a low
likelihood of reacting to it.

Drug desensitization:
o Procedure that modifies a patient’s immune response to a drug allowing him/her to take
the drug temporarily in a safe manner.
o Done only in case of:
 IgE-mediated drug allergy.
 When no other alternative exists.
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Issued by: National Antimicrobial Sub Committee
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Effective Date:09/05/2016
APPROACHING THE PATIENT WITH PENICILLIN ALLERGY
Clinical History
Late or less common
allergic reaction
Immediate Reaction
1-discontinue penicillin drug
2-Use alternative eg erythromicin,
clindamycin,azithromax..etc
Refer to an allergist for assessment,
testing and possible graded challenge
If skin test is positive
consider desensitization if
no other alternative
Mild reaction eg maculopapular
rash
Serious reaction or other
systematic reactions eg
SJS,TEN,DRESS
Discontinue penicillin and use
alternative antibiotic
Strictly avoid penicillin ,use
alternative antibiotic
If skin test is negative
can use penicillin after a
trial of a test dose
Refer to an allergist for
assessment
Refer to an allergist for
assessment
FIG 4
References:
1. Khan DA, Solensky R. Drug allergy. J Allergy Clin Immunol 2010; 125(2 Suppl 2):S126–137.
2. Daulat S, Solensky R, Earl HS, Casey W, Gruchalla RS. Safety of cephalosporin administration to patients
with histories of penicillin allergy. J Allergy Clin Immunol 2004;113:1220–1222.
3. Kula B, Djordjevic G, Robinson JL. A systematic review: can one prescribe Carbapenems to patients with
IgE-mediated allergy to penicillins or cephalosporins? Clin Infect Dis 2014;59:1113–1122.
4. Caubet JC, Eigenmann PA. Managing possible antibiotic allergy in children. Curr Opin Infect Dis
2012;25:279–285.
5. Blanca M, Romano A, Torres MJ, Férnandez J, Mayorga C, Rodriguez J, et al. Update on the evaluation
of hypersensitivity reactions to betalactams. Allergy 2009;64:183–193.
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Effective Date:09/05/2016
TABLE 17: SUGGESTED DURATION OF ANTIBIOTIC THERAPY IN COMMON INFECTIONS
Early change from IV to oral regimens is cost effective in many infections. The recommended duration is a
minimum or average time and should not be considered as absolute.
CLINICAL DIAGNOSIS
DURATION OF THERAPY (DAYS)
COMMENTS
Bacteraemia with removable focus (no
10–14 (1)
endocarditis)
Osteomyelitis Adult; acute
42
Adult; chronic
Until ESR normal (often >3
months)
Child; acute; Staph. and
21
Duration to be guided by
Enterobacteriaceae
clinical response and
normalization of
Child; acute; Strept.
14
inflammatory markers
meningococci, Haemophilus
Infective
Enterococci
28 or 42
endocarditis,
S. aureus
14 (R-sided only) or 28
native valve
Viridians streptococci
14 or 28
Bacillary dysentery (Shigellosis)/traveller’s
3
diarrhoea
Typhoid fever Ceftriaxone
10–14
(Typhi):
Cip
7–10
Azithro
Chloramphenicol
5- 7 (children/
adolescents)
14
H. pylori
10–14. For triple-drug regimes
Pseudomembranous enterocolitis (C. difficile)
10
Genital
disease
Non-gonococcal urethritis or
mucopurulent cervicitis
Pelvic inflammatory disease
Adult
Infant/child
7 days doxy or single dose
Azithromycin
14
14–28
Rx as osteomyelitis above.
Cotrimoxazole
Nitrofurantoin
Pneumonia, pneumococcal
3
5
14 (7 days if cip used, 5 days if
levo 750 mg)
Until afebrile, minimum 5 days
CAP
Minimum 5 days & afebrile for
2–3 days.
Septic arthritis
(nongonococcal)
Cystitis
(bladder
Bacteriuria)
Pyelonephritis
115
Duration to be guided by
clinical response and
normalization of
inflammatory markers
NATIONAL ANTIMICROBIAL GUIDELINES
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Effective Date:09/05/2016
TABLE 17: SUGGESTED DURATION OF ANTIBIOTIC THERAPY IN COMMON INFECTIONS
CLINICAL DIAGNOSIS
Pneumonia, Enterobacteriaceae or
pseudomonal
Pneumonia, staphylococcal
DURATION OF THERAPY
(DAYS)
21, often up to 42
21–28
Legionella, mycoplasma, chlamydia
7–14
Lung abscess
Usually 28–42
Meningitis
N. meningitidis
H. influenzae
S. pneumoniae
7
7
10–14
Listeria
21(longer in
immunocompromised)
21(longer in
immunocompromised)
10 (azithromycin
effective at 5 days)
meningoencephalitis, group
B Strept, coliform
Group A Strept. pharyngitis
Also see pharyngitis
Acute sinusitis
5–7 (mild to moderate)
14 or longer therapy if βlactam or for severe
infection
Cellulitis
Until 3 days after acute
inflammation disappears
References:
1.(CID 14:75,1992)
2. J.D Nelson, APID 6:59, 1991
3. Ln351:197,1998
4. CID 44:S55,2007:AJM 120:783,2007
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COMMENTS
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Effective Date:09/05/2016
GUIDELINES FOR ANTIMICROBIAL PROPHYLAXIS IN HAEMATOLOGY/ONCOLOGY
IN ADULTS
ANTI-INFECTIVE PROPHYLAXIS FOR ADULT HAEMATOLOGY/ONCOLOGY PATIENTS
TABLE (18/A): ANTIBACTERIAL PROPHYLAXIS FOR HAEMATOLOGY/ONCOLOGY PATIENTS (ADULT)
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
COMMENTS
SECOND LINE
Autologous HSCT:
 Myeloma patients
receiving
melphalan
Allogeneic HSCT
Cip: start at time of stem cell
infusion until resolution of
neutropenia OR initiation
antibacterial therapy for febrile
neutropenia.
Prophylactic dose: 500 mg PO q12h
Prophylaxis may increase
risk of bacterial resistance
and super infection,
Separate administration
from antacids,
multivitamins, and other
products containing
aluminium, magnesium,
iron, or zinc by 2 hrs.
Renal dose adjustment
required
Chronic GVHD
Pen VK: 500 mg PO q12h
Until discontinuation of
Immunosuppression
renal adjustment required
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Effective Date:09/05/2016
TABLE (18/B): PRIMARY ANTIFUNGAL PROPHYLAXIS FOR HAEMATOLOGY/ONCOLOGY
PATIENTS(ADULT)
ANATOMIC
ETIOLOGIES
SITE/DIAGNOSIS
ALL
CML lymphoid
blast crisis
-Acute
myelogenous
leukaemia
(AML)
-Myelodysplastic
syndrome (MDS)
-CML myeloid
blast crisis
Autologous
HSCT
Allogeneic HSCT
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Initial prophylaxis for most patients: fluconazole
during neutropenia with induction and
intensification/ consolidation chemotherapy cycles
Fluconazole OR posaconazole (if high rate of
zygomycetes):
-Initial prophylaxis for most patients during
chemotherapy induction
-Fluconazole for consolidation chemotherapy
Voriconazole OR posaconazole (if high rate of
zygomycetes):
To be used when >1 chemotherapy treatment
course to achieve
complete remission OR chemotherapy for relapsed
or refractory disease.
Micafungin:alternative to
voriconazole/posaconazole AND any one of the
following:
 Chemotherapy treatment with CYP3A4
substrate
 Inability to tolerate PO
 Ongoing diarrhoea precluding oral therapy
 Intolerability to voriconazole/posaconazole
-No prophylaxis in low probability of developing
mucositis
-High probability of developing mucositis
-Fluconazole in high probability of developing
mucositis
Fluconazole: initial prophylaxis for most patients
COMMENTS
Start 24 hrs after last
anthracycline dose or
on first day of
chemotherapy
inpatients not receiving
anthracycline-based
treatment.
Until resolution of
neutropenia AND
achievement of
complete remission.
Re-start with each
consolidation
chemotherapy
treatment and
continue until
resolution of
neutropenia
Until resolution of
neutropenia
Start fluconazole with
conditioning regimen
and continue until day
75 post-transplant
Posaconazole: CBT ORT-cell depleted HLAStart posaconazole on
haploidentical transplant OR unrelated donor with
day of transplant and
bone marrow stem cell source
continue until
Micafungin: alternative to posaconazole and any one discontinuation of
of the following
immunosuppression
 Inability to tolerate PO
Intolerability to posaconazole
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ANATOMIC
SITE/DIAGNOSIS
Severe GVHD
requiring treatment
Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Posaconazole : Initial prophylaxis for most
patients
Micafungin for intestinal GVHD OR
diarrhoea
COMMENTS
Severe GVHD
requiring treatment
TABLE (18/C): ANTIVIRAL PROPHYLAXIS FOR HAEMATOLOGY/ONCOLOGY PATIENTS
(ADULT)
ANATOMIC
SITE/DIAGNOSIS
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
SECOND
LINE
None unless prior HSV episode (during
neutropenia)
Standard
chemotherapy
regimens for solid
tumours
Autologous HSCT
Lymphoma
Purine analogue
therapy (i.e.,
fludarabine,
clofarabine,
nelarabine,
cladribine)
HSV
HSV
VZV
Acyclovir: 800 mg PO q12h
OR
Valacyclovir: 500 mg PO q12h
OR
Famciclovir: 250 mg PO q12h
Renal dose adjustment required
ALL
AML
MDS
CML blast crisis
Bortezomib
(multiple
myeloma patients
only)
Alemtuzumab
HSV
VZV
During neutropenia:
Acyclovir: 800 mg PO q12h OR
Valacyclovir : 500 mg PO q12h OR
Famciclovir: 250 mg PO q12h
Until discontinuation of bortezomib:
Acyclovir: 800 mg PO q12h OR
Valacyclovir: 500 mg PO q12h OR
Famciclovir: 250 mg PO q12H
Acyclovir OR valacyclovir OR famciclovir
VZV
HSV
VZV
Allogeneic HSCT
119
COMMENTS
Until 30 days after
autologous HSCT During
neutropenia with
aggressive lymphoma
regimens (e.g., hyperCVAD, CODOXM/ IVAC)
Until 3 months after
discontinuation of purine
analogue therapy
Renal dose adjustment
required
Renal dose adjustment
required
Until at least 2 months
after discontinuation of
alemtuzumab AND CD4
≥200 cells/mm3
Start with conditioning
regimen for allogeneic
HSCT AND continue for 1
year
NATIONAL ANTIMICROBIAL GUIDELINES
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Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE (18/C): ANTIVIRAL PROPHYLAXIS FOR HAEMATOLOGY/ONCOLOGY PATIENTS
(ADULT)
ANATOMIC
SITE/DIAGNOSIS
Severe GVHD
requiring
treatment
ETIOLOGIES
CMV
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
No prophylaxis
120
COMMENTS
Until resolution of severe
GVHD AND presumed
recovery of immune status.
Monitor CMV PCR weekly.
Perform surveillance until
the respective time points
listed
above with HSV/VZV
NATIONAL ANTIMICROBIAL GUIDELINES
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Issued by: National Antimicrobial Sub Committee
Applies to: All Healthcare Facilities in Oman
Effective Date:09/05/2016
TABLE (18/D): ANTI-PCP PROPHYLAXIS FOR HAEMATOLOGY/ONCOLOGY PATIENTS (ADULT)
ANATOMIC
SITE/DIAGNOSIS
ALL
CML lymphoid
blast
crisis
Allogeneic HSCT
+/- GVHD
Alemtuzumab
ETIOLOGIES
SUGGESTED REGIMENS
FIRST LINE
SECOND LINE
Trimethoprim/s Dapsone1st-line
ulfamethoxalternative to TMP-SMX:
azole:
100 mg PO q24h.
1 DS tablet
Atovaquone 2nd line
(160/800 mg)
alternative:
PO
1500 mg PO q24h
q24h(CrCl>50
ml/min)
OR
1 SS tablet
(80/400 mg) PO
q24h(CrCl30–50
ml/min)
OR
1 DS tablet
(160/800 mg)
PO TIW (CrCl<30
ml/min)
Trimethoprim
Dapsone 1st-line
sulfamethoxalternative to
azole
trimethoprim
sulfamethox-azole
Atovaquone 2nd line
alternative to
trimethoprim
sulfamethox-azole
Initial
Dapsone 1st line
prophylaxis for
alternative to TMP-SMX
most patients:
Atovaquone 2nd line
TMP-SMX
alternative to TMP-SMX
Purine analogue
therapy
(i.e., fludarabine,
clofarabine,
nelarabine,
cladribine)
Temozolomide +
RT
COMMENTS
Initial prophylaxis for most
patients
Until completion of antileukemic therapy
G6PD required prior to
initiating Dapsone therapy
Administer atovaquone with
meals to reduce diarrhoea
and GI adverse effects
Initial prophylaxis for most
patients.
Start with engraftment
until discontinuation of
immunosuppression with
allogeneic HSCT
Until at least 2 months after
discontinuation of
alemtuzumab AND CD4 ≥200
cells/mm3
Until 3–6 months after
discontinuation of purine
analogue therapy
Until recovery of
lymphopenia after
temozolomide + R
121
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