ANTIBIOTIC
POLICY
Sassoon General
Hospital & BJGMC,
Pune
1
ANTIBIOTIC
POLICY
Sassoon Hospital
&
BJGMC
Pune
2014-15
2
FOREWORD
It gives me immense pleasure to present this handbook on Antimicrobial Policy for Sassoon
Hospital, Pune. I sincerely appreciate the efforts of team who have worked to make this policy
a reality.
It is less than a century since antibiotic therapy became available to humanity. However,
widespread and indiscriminate use of antibiotics has resulted in microorganisms developing
resistance to them, so much so, that now the antibiotic resistance has reached alarming
proportion. This antibiotic policy will ensure rational use of antibiotics in Sassoon Hospital
and help us contribute to minimizing the menace of antibiotic resistance.
Dr A.S. Chandanwale
Dean
B.J. Govt. Medical College &
Sassoon Hospital, Pune
3
Index
Foreword
3
Introduction
5
General Guidelines
6
MEDICINE
7-9
SURGERY
10-15
PEDIATRICS
16-17
ENT
18
NEONATAL INFECTIONS
19-20
OBST. & GYNAEC.
21-22
ORTHOPEDICS
23-24
DERMATOLOGY
25-26
CVTS
27
OPHTHALMOLOGY
28-30
Contributors
31
Steps of Hand-washing
32
4
INTRODUCTION
The emergence and spread of antibiotic resistance is becoming a global public health
concern. The widespread use of antibiotics both inside and outside of medicine has
contributed largely to this phenomenon. The large volume of antibiotics prescribed in health
care settings is a major cause of concern and bacteria once exposed to antibiotics have the
capacity to adapt and develop resistance by various mechanisms. All newly introduced
antimicrobial agents have only a limited ‘virginity’ before the specter of resistance emerges.
The current situation is that there are very few newer antibiotics in the pipeline as it is no
longer cost effective for the pharmaceutical industry to develop newer antimicrobials.
Antimicrobial resistance in hospitals hampers the control of infectious diseases and threatens
a return to the pre-antibiotic era. It also increases the costs of health care and jeopardizes
health-care gains to society
Thus, this antibiotic policy was developed by the staff of B.J. Government Medical College
& Sassoon general Hospitals, Pune as an effort to rationalize the use of antibiotics in the
hospital keeping in mind the current sensitivity patterns of hospital bacteria and availability
in our drug store. It is planned that the policy will be renewed regularly based on the
feedback of the clinicians, the availability of drugs in the hospital and the drug sensitivity
pattern of the hospital pathogens. I would like to reiterate that these are guidelines only and the
interpretation and application of these guidelines is the responsibility of the clinician. A review of
the current guidelines will be planned based on the experiences of the clinicians and the problems
faced by them.
Formulation & implementation of an antibiotic policy is a first step in implementing the rationale use
of antibiotics. It is also a step towards controlling the spread of antimicrobial resistance in our
hospital. However it cannot be a short cut to appropriate infection control practices especially hand
washing.
An antibiotic policy can only succeed if there is willingness and ownership of every single doctor in
the hospital. Please ensure that samples for culture and sensitivity are sent before onset of therapy, so
that data regarding antimicrobial spectrum of pathogens from various sites stays updated and is
available to you so you can plan therapy better
5
GENERAL GUIDELINES
1. Clinical samples for microbiologic culture and sensitivity must ALWAYS be
sent, before starting empiric therapy.
2. Empiric treatment can be started as per policy guidelines and clinical judgment
3. Step down or step up of treatment can be done based on the antibiotic
sensitivity report. In case of no clinical response, consult microbiologist and
pharmacologist.
4. Various factors associated with drug metabolism must be taken into account
while prescribing treatment
 Hypersensitivity(Patient MUST be questioned about drug allergies in
past)
 Renal function
 Drug interactions
5. Irrational drug combinations must be avoided.
6. Colistin, Carbapenems and linezolid are reserve drugs only and should be
prescribed only after culture sensitivity report demonstrating sensitivity
exclusively to these drugs.
7. Therapy monitoring: Need of antibiotic must be reviewed on daily basis. Most
common infections usually need antibiotics for not more than 7 days. IV
antibiotics should be switched to oral within 24-48 hours, based on clinical
improvement and microbiology antibiotic sensitivity pattern.
8. Antibiotics should not be used as a substitute for appropriate infection control
procedures.
6
ANTIBIOTIC POLICY
MEDICINE DEPARTMENT
Clinical condition
Community acquired
Pneumonia
Mild(Not hospitalized)
Empirical therapy
Remarks
Oral Doxycycline100 mg 12
hourly X 7days /Oral
Azithromycin 500 mg OD 3 days
Use oral drugs
Moderate(Hospitalised, Not in
ICU)
Inj Levofloxacin
750 mg IV 6 hourly X 7-10days/
Oral Azithromycin 500 mg OD 3
days
Levofloxacin 750 mg IV 6 hourly
X 7-10 days
OR
Moxifloxacin 400 mg IV 24
hourly
Amikacin15mg/kg 6 hourly +IIIrd
generation cephalosporins
Cefotaxime 1–2 g IV 8 hourly ,
Ceftriaxone 2 g IV qd)
Vancomycin 15 mg/kg, up to 1 g
IV, 12 hourly +
Imipenem/Meropenem 500 mg IV
6 hourly or 1 g IV 8 hourly
Use injectables. Switch to oral as
early as possible
Severe (ICU)
Hospital Acquired Pneumonia
VAP
Clinical condition
Acute meningitis
Chronic meningitis
-Use injectables. Switch to oral as
early as possible
-Escalate/descalte after culture
sensitivity report
-Stop antibiotics after 5 days of
clinical response
-Escalate/deescalate after culture
sensitivity report
-Stop antibiotics after 5 days of
clinical response
Empirical therapy
Vancomycin 15 mg/kg IV 8hourly+ Ceftriaxone
2 gIV 12hourly/Cefotaxime 2 g IV 6hourlyfor 1014 days+ Dexamethasone 0.15mg/kg X 4 days
Culture is mandatory prior to starting therapy
Clinical condition
Gastroenteritis
Empirical therapy
Mild diarrhoea < 3 unformed
stools with min symptoms
Ciprofloxacin 500 mg/ Norfloxacin 400mg
orally 12 hourly) + Metronidazole 250 mg 8
hourly for 3 days
Ciprofloxacin 500 mg/ Norfloxacin 400mg
orally 12 hourly) for 3 -5 days + Metronidazole
250 mg 8 hourly for 5 days
Ciprofloxacin500 mg/ / Norfloxacin 400mg
orally 12 hourly for 3 -5 days + Metronidazole
250 mg 8 hourly for 5 days
Doxycycline 300 mg orally x 1 day
Oral Metronidazole 400 mg orally tds X 107
Moderate diarrhoea > 4 < 6
Severe diarrhoea > 6 with > temp.
tenesmus
Cholera like watery diarrhoea
Clostridium difficile associated
Remarks
diarrhoea
14 days OR
Oral Vancomycin (125mg 6 hourly ) X 1014 days
Clinical condition
Oesophagitis
Empirical therapy
Fluconazole 200 -400 mg daily/
Injection Amphotericin B
Duodenal/gastric ulcer
Omeprazole(20 mg 12 hourly) +
Clarithromycin(250 or 500 mg 12
hourly)+Metronidazole(500 mg 12
hourly) for 14 days
Clinical condition
Blood stream infections
1) CRBSI
2) Native valve endocarditis
3) Prosthetic valve endocarditis
Clinical condition
Urinary tract infection
Community acquired
Catheter associated
Pyelonephritis
Clinical condition
Fever of unknown origin(PUO)
Empirical therapy
Vancomycin(15mg/kg IV 12 hourly)+
Third generation cephalosporins
(Ceftazidime 2 gm IV 8
hourly,Cefoperazone) for 4-6 weeks
Vancomycin(15mg/kg IV 12 hourly) +
Gentamicin( 1mg /kg IM or IV 8 hourly)
for 4-6 week
Vancomycin (15mg/kg IV 12 hourly)+
Gentamicin( 1mg /kg IM or IV 8 hourly)
for 4-6 weeks
Empirical therapy
Remarks
Use fluconazole only if
candidial oesophagitis is
suspected
Remarks
Cardiothoracic surgery
consultation
Remarks
Cotimoxazole DS 12 hourly for 3 days
/Nitrofurantoin 100 mg orally 12
hourly for 5 days
Gentamicin( 1mg /kg IM or IV 8
hourly)
+
Imipenem(500 mg IV 6 hourly) x 7-14
days
Uncomplicated: Oral Ciprofloxacin
500 mg BD
Complicated: Piperacillin with
Tazobactam 3.375 IV 6 hourly/
Imipenem 500 mg IV 6 hourly or 1 g
IV 8 hourly
Empirical therapy
Cefotaxime (2g IV every 4-6 hourly)
8
Remarks
Clinical condition
Diabetic foot Mild (No systemic
symptoms, Localised cellulitis
Diabetic foot –moderate to severe
(Limb threatening-severe
cellulits/gangrene/SIRS)
Empirical therapy
1. Cloxacillin 500 - 1000
mild (localized mg orally6 hourly ×
7-10 days
2.Cefazolin 1 gm i.v. 8 hourly
symptoms) /Cephalexin 500 mg
orally6 hourly × 7-10 day
+ Metronidazole IV500 mg 8
hourly
Cefazolin 1 gm i.v. 8 hourly+
Gentamicin 5mg/kg i.v once daily
OR
Ciprofloxacin 400 mg IV 12
hourly+ Metronidazole IV500 mg 8
hourly
9
Remarks
Surgery consultation if
intervention needed
SURGERY DEPARTMENT
Clinical condition
Ulcer without
inflammation
Ulcer with<2 cm of
sup inflamation
Ulcer with > 2 cm of
inflammation
GIT
Cholecystitis
Cholangitis
Biliary sepsis
Oesophagitis
Duodenal/Gastric ulcer
Diverticulitis
Perirectal abscess
Peritonitis
UTI
Catheter associated
Perinephric abscess
Empirical therapy
No antibacterial therapy
Oral Cotrimoxazole DS 12 hourly /Tetracycline 500
mg 12 hourly
 Oral Cotrimoxazole DS 12 hourly
 Gentamicin Gentamicin 5mg/kg i.v once
daily / Piperacillin with Tazobactam 3.375 IV
6 hourly +Metronidazole IV500 mg 8 hourly
Ciprofloxacin 400 mg IV 12 hourly / Gentamicin
5mg/kg i.v once daily + Metronidazole IV 500
mg 8 hourly
If severe, Piperacillin with Tazobactam 3.375 IV 6
hourly /Imipenem 500 mg IV 6 hourly /Doripenem
500 mg 8 hourly /Meropenem 1 g IV 24 hourly +
Metronidazole IV500 mg 8 hourly
Same as above
Same as above
Fluconazole 200 -400 mg daily or Amphotercin B 0.5
mg/kg daily)
Omeprazole(20 mg 12 hourly) +Clarithromycin (250 or
500 mg 12 hourly)+Metronidazole(500 mg 12 hourly)
for 14 days
OPD: MILD /DRAINED PERIRECTAL ABCESS:
Cotimoxazole bid/Levo 750 mg 24hourly+ Metro 500
mg 6hourly: All orally FOR 7-10 DAYS
IPD:MILD –MODERATE: Piperacillin-Tazobactam
3.375.g IV 6hourly/4.5 g IV 8hourly/TicarcillinClavulinic acid 3.1 g IV 6 hourly/Ertapenem 1 g IV 24
hourly/Moxi 400 mg IV 24 hourly
SEVERE LIFE THREATENING: Imipenem 500 mg
IV 6 hourly/Meropenem 1 g IV 8 hourly/Doripenem
500 mg 8 hourly
Mild: Nitrofurantoin 100 mg 12 hourly/Cotrimoxazole
DS 12 hourly
Severe: Amikacin 15mg/kg 6 hourly /Gentamicin
5mg/kg i.v once daily / Ciprofloxacin 400 mg IV 12
hourly / IIIrd generation cephalosporin/ PiperacillinTazobactam 3.375 IV 6 hourly
Vancomycin 15mg/kg IV 12 hourly + IIIrd generation
cephalosporin/ Piperacillin with Tazobactam 3.375 IV 6
hourly
Start with Vancomycin 15mg/kg IV 12 hourly.
10
Remarks
Descalate to Cloxacillin 250 mg oral 6 hourly
Prostatitis
Cotrimoxazole DS 12 hourly / Ciprofloxacin IV: 400 mg
IV every 12 hours
Oral: 500 mg oral 12 hourly / Ofloxacin 300 mg orally
12 hourly
Clinical condition
Skin and soft tissue infections
Cellulitis
Empirical therapy
Oral regimens:
Cotimoxazole 1-2 DS tablets orally 12 hourly
+ Amoxycillin 500 mg orally 8 hourly
Doxycycline 100 mg orally 12 hourly
Parenteral regimens
Clindamycin 600 mg IV 8 hourly
If spreading, Vancomycin 15mg/kg IV 12
hourly.
Cutaneous abscess
Diabetic foot with extensive
inflammation and systemic
toxicity
Oral regimens:
Cotimoxazole 1-2 DS tablets orally 12 hourly
+ Cloxacillin 500 mg orally 6 hourly
Doxycycline 100 mg orally 12 hourly
Parenteral regimens
Clindamycin 600 mg IV 8 hourly
If spreading, Vancomycin 15mg/kg IV 12
hourly.
Vancomycin 15mg/kg IV 12 hourly. +
Piperacillin with Tazobactam 3.375 IV 6
hourly + Metronidazole IV500 mg 8 hourly
Descalate
11
Remarks
Clinical condition
SSI
For clean procedures(Orthopaedic
joint replacements, open reduction of
closed fractures, Vascular procedures,
craniotomy, breast & hernia surgery)
Empirical therapy
For clean contaminated
procedures(GI/GU procedures,
oropharyngesl & OBGY )
Piperacillin with Tazobactam 3.375 IV 6
hourly /Gentamicin 5mg/kg i.v once
daily +Metronidazole IV500 mg 8 hourly
In deep fascia involvement
Clindamycin 600 mg IV 8 hourly
+Metronidazole IV500 mg 8 hourly
Clindamycin 600 mg IV 8 hourly
+Metronidazole IV500 mg 8 hourly
Necrotising fascitis
Cloxacillin 1-2g IV 4 hourly
PCN allergy: Clindamycin 600 mg IV 8
hourly
12
Clinical condition
CNS
Brain abscess
Primary
Empirical therapy
Postsurgical
Vancomycin 15mg/kg IV 12
hourly.+Meropenem 1 g IV 8 hourly
+Metronidazole IV 500 mg 8 hourly/
Remarks
Meropenem 1 g IV 8 hourly
+Metronidazole IV500 mg 8 hourly
Preop prophylaxis (Recommended)
Urologic surgery
Transrectal prostate biopsy
Transurethral surgery(eg. TURP, TURBT,
ureteroscopy, cystouretoscopy, lithotripsy)
Nephrectomy or radial prostectomy
Radial cystectomy, Cystoprostectomy or Anterior
exenteration
Head and Neck Surgery
Major procedure with incision of oral or pharyngeal
or sinus mucosa
Major Neck dissection or Parotid dissection
Thyroid/Parathyroid surgery
Tonsillectomy
Neurosurgery
Craniotomy (including shunt placement)
Spinal fusion
Laminectomy
General surgery
Inguinal hernia repair
PEG
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV500 mg 8 hourly with or without
Gentamicin 5mg/kg i.v once daily
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV500 mg 8 hourly with or without
Gentamicin 5mg/kg i.v once daily
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or
Clindamycin 600 mg IV 8 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or
Clindamycin 600 mg IV 8 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Amikacin15mg/kg 6 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Amikacin15mg/kg 6 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Uncomplicated with mesh:
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Complicated, recurrent, remergent: Metronidazole
IV 500 mg 8 hourly + (Ceftriaxone/Cefotaxime
1 to 2 g/day IV or IM)
Ampicillin +Gentamicin +Metronidazole ORPCN
allergy: Clindamycin ±Gentamicin
13
Gastrectomy/Hepatectomy/cholecystectomy
Small bowel or colon surgery
Whipple procedure or pancreatectomy
Appendectomy(uncomplicated),if complicated and
perforated treated as secondary peritonitis
Penetrating abdominal trauma
Mastectomy
Mastectomy with lymph node dissection
Metronidazole IV 500 mg 8 hourly
+(Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV 500 mg 8 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV 500 mg 8 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV 500 mg 8 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV 500 mg 8 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV 500 mg 8 hourly
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV 500 mg 8 hourly
Post op prophylaxis
Condition
Antibiotic
General Surgery
Appendicitis
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Amikacin15mg/kg 6 hourly
+IV Metronidazole IV500 mg 8 hourly
Enterocolitis
Mild- Tab.Ciprofloxacin 500 mg orally 12 hourly
Tab. Metronidazole 500 mg 12 hourly
Severe- IV Ciprofloxacin
IV Metronidazole IV500 mg 8 hourly/
IV Ciprofloxacin400 mg IV every 12 hours double dose
IV Metronidazole double dose IV500 mg 8 hourly/
IV Piperacillin with Tazobactam3.375 IV 6 hourly
IV Metronidazole 500 mg 8 hourly/
IV Piperacillin –Tazobactam3.375 IV 6 hourly
IV Metronidazole IV500 mg 8 hourly/
Liver abscess
Acute Pancreatitis
Severe acute pancreatits
Urology
Epididymo orchitis
Testicular torsion/ infarct/
gangrene
Mild- Oral. Amoxicillin-Clavulinic acid 500/125 mg BD
Severe- IV Piperacillin with Tazobactam3.375 IV 6 hourly
IV Metronidazole IV500 mg 8 hourly/
IV Piperacillin with Tazobactam 3.375 IV 6 hourly
IV Metronidazole IV500 mg 8 hourly/
14
Neurosurgery
Meningitis
IV Ceftriaxone 1 to 2 g/day IV or IM
IV Gentamicin/Amikacin 15mg/kg 6 hourly
IV Vancomycin 15mg/kg IV 12 hourly.
Paediatric surgery
MeningoMyelocoele
IV Vancomycin 15mg/kg IV 12 hourly.
IV Amikacin 15mg/kg 6 hourly
Rectovaginal fistula
IV Amikacin 15mg/kg 6 hourly
IV Metronidazole IV500 mg 8 hourly/
Tracheo oesophageal
fistula
Splenectomy
Hirschsprung
Disease
Decortication
IV Piperacillin with Tazobactam 3.375 IV 6 hourly
IV Metronidazole IV500 mg 8 hourly/
IV Piperacillin with Tazobactam 3.375 IV 6 hourly
IV Piperacillin with Tazobactam3.375 IV 6 hourly
IV Metronidazole IV500 mg 8 hourly/
IV Piperacillin with Tazobactam3.375 IV 6 hourly
IV Vancomycin 15mg/kg IV 12 hourly.
Intestinal atresia
IV Piperacillin with Tazobactam 3.375 IV 6 hourly
IV Metronidazole IV500 mg 8 hourly
IV Piperacillin with Tazobactam 3.375 IV 6 hourly
IV Metronidazole IV500 mg 8 hourly
IV Piperacillin with Tazobactam 3.375 IV 6 hourly
IV Piperacillin with Tazobactam 3.375 IV 6 hourly
IV Piperacillin with Tazobactam 3.375 IV 6 hourly
Biliary atresia
Hypospadias
Hernia
Hydrocele
15
PEDIATRICS
CNS
Disease
Meningitis
Encephalitis
Brain abscess
Shunt infection
Transverse myelitis
Treatment
IIIrd generation cephalosporin
Ceftriaxone(100 mg/kg/day)
+Vancomycin 60 m/k/d q 8 hr)
Descalation after culture
sensitivity report
21 day course of acyclovir(60
m/k/d q 8hr)
Meropenem 120 mkd 8 hourly+
Metronidazole 30 mkd q 8 hr
Vancomycin( 60 mkd q 8 hr) and
Gentamicin(5 mkd) X 10-14 days
Antibiotics are not routinely used
High dose steroids (Methyl
prednisolone)
Remarks
Treatment
Oral Azithromycin (10
mg/kg/day OD) for 5 days
Oral azithromycin (10mg/kg/day
OD)
+ Augumentin 50 mg/kg/day 12
hourly /Cefotaxime50-75
mg/kg/day 12 hourly
If pseudomonas suspected ,
Piperacillin with Tazobactam
(300 mg/kg/day 8 hourly)+
Amikacin (15 mg/kg/day) for 710 days
IV cefotaxime (50-75mg/kg/day
12 hourly) or IV ceftriaxone (5075 mg/kg/day 12 hourly) plus
IV Vancomycin (40 mg/kg/day
12 hourly) for 10-14 days
If pseudomonas suspected ,
Piperacillin with Tazobactam
(300 mg/kg/day 8 hourly)+
Amikacin (15 mg/kg/day) for 710 days
Vancomycin (40 mg/kg/day 8
hourly)+ Piperacillin with
Tazobactam (300 mg/kg/day 8
hourly)
Deescalate according to
16
Remarks
Respiratory system
Disease
Mild pneumonia
Moderate pneumonia
Severe pneumonia
Hospital acquired pneumonia
sensitivity
Ventilator associated pneumonia
Pulmonary abscess
Empyema
Bronchiectasis
Meropenem (40-60 mg/kg/day 8
hourly) + Vancomycin (4060mg/kg/day 8 hourly)
IV ceftriaxone (50-75 mg/k/day
12 hourly / Piperacillin with
Tazobactam (300 mg/kg/day 8
hourly)+Vancomycin(40
mg/kg/day 8 hourly)
If serious, Ceftriaxone((50-75
mg/k/day 12 hourly )/
Piperacillin with Tazobactam
(300 mg/kg/day ) +Amikacin(15
mg/kg/day)
Add Metronidazole( 30 mkg/kg 8
hourly) if anaerobic infection is
suspected
IV ceftriaxone (50-75 mg/k/day
12 hourly / Piperacillin with
Tazobactam (300 mg/kg/day )
+Vancomycin(40 mg/kg/day 8
hourly)
If serious, , Ceftriaxone((50-75
mg/k/day 12 hourly )/
Piperacillin with Tazobactam
(300 mg/kg/day ) +Amikacin(15
mg/kg/day)
Add Metronidazole if anaerobic
infection is suspected
Ceftriaxone/Piperacillin with
Tazobactam +Vancomycin
If serious,
Ceftriaxone/Piperacillin with
Tazobactam +Amikacin
Add Metronidazole if anaerobic
infection is suspected
Renal system
Urinary tract infection
Pyelonephritis
Dialysis
Cotrimoxazole (8mg/kg/day 12
hourly) / Nitrofurantoin(57mg/kg/day)
Piperacillin with Tazobactam
(300 mg/kg/day 8 hourly
+Gentamicin(3-5mg/kg/day) X 3
days
Deescalate after culture
sensitivity
Treat according to
culture/sensitivity
17
ENT
Otitis media
Acute
Chronic
Cotimoxazole (8mg/kg/day 12
hourly)
/Azithromycin(10 mg/kg/day
OD)
Refer to ENT
Infective endocarditis
Initial Empirical
Severe
Cefotaxime 50-200 mg/kg/day
IV/IM divided q6-8hr
+Gentamicin 2.5 mg/kg IV or
IM every 18 to 24 hours
Vancomycin 15 mg/kg IV every
24 hours + gentamicin 2.5 mg/kg
IV or IM every 18 to 24 hours
Deescalate after culture
sensitivity
Febrile neutropenia
IV Ceftazidime 50mg/kg every 8
hours (max 2 grams
tds)/Piperacillin with
Tazobactam (300 mg/kg/day ) +
Amikacin(15 mg/kg/day) + Oral
fluconazole prophylaxis 3mg/kg
once daily
Severe
Vancomycin 15 mg/kg IV every
24 hours + Meropenem 20 mg/kg
IV every 8 hours + Amphotericin
B IV 0.6-1mg/kg/day
18
IV Ceftazidime 50mg/kg every 8
hours (max 2 grams tds)and
Gentamicin 6-7.5mg/kg/day
IV/IM
Oral fluconazole prophylaxis
3mg/kg once daily
NEONATAL INFECTIONS
Chorioamnionitis
Neonatal sepsis (Early onset)
Neonatal sepsis (Late onset)
1st line-amoxicillin + clavulunate
30 mg/kg/day in 2 doses
2nd line-Piperacillin with
Tazobactam 75 mg/kg IV Q8h +
piperacillin and gentamicin for 3
days( if CBC is non septic)
1st line – Ampicillin IV or IM
100mg/kg/day 12 hourly /
Gentamicin
2nd line – Piperacillin with
Tazobactam 75 mg/kg IV Q8h
3rd line-Vancomycin 15 mg/kg IV
q24h; with or without antifungal
4th line- Meropenem 20 mg/kg/day
1st line-Piperacillin with
Tazobactam 75 mg/kg IV Q8h +
Gentamicin
2nd line-Vancomycin 15 mg/kg IV
q24h with or without antifungal
3rd line- Meropenem 20 mg/kg/day
Focal bacterial infections
Cellulitis
Pustulosis
SSSS
Omphalitis
Pneumonia
Necrotizing enterocolitis
Meconium aspiration
syndrome:
Cloxacillin IV 10 mg/kg BD+
Vancomycin 15 mg/kg IV q24h
Betadine application /Chlorhexidine
Amoxiclav /Diclox/Cephalexin
Nafcillin IV 10 mg/kg BD
/Oxacillin 50 mg/kg/day IM/IV
divided q12h.
Oxacillin 50 mg/kg/day IM/IV
divided q12h. /Nafcillin IV 10
mg/kg BD +Gentamicin
Ist line: Piperacillin with Tazobactam
75 mg/kg IV Q8h + Gentamicin
2nd line: Meropenem 20 mg/kg/day
3rd line –Antifungal
Piperacillin with Tazobactam 75
mg/kg IV Q8h +Vancomycin 15
mg/kg IV q24h +Metronidazole
Ampicillin IV or IM 100mg/kg/day
12 hourly + gentamicin 5mg/kg/dose
19
Gastrointestinal Infection
Mild Diarrhoea
Moderate diarrhoea
Severe diarrhoea
Antibiotic used
Syrup septran 2.5 ml every 12 hours
Syrup septran 2.5 ml every 12 hours
or IV cefotaxime 100-150 mg/kg/day
IM/IV divided q8-12hourly
IV cefotaxime 100-150 mg/kg/day
IM/IV divided q8-12hourly
IV Metronidazole 100-150 mg/kg/day
IM/IV divided q8-12hourly
20
OBSTETRICS AND GYNAECOLOGY
Clinical condition
PID
Trichomonas Vaginitis
Bacterial vaginosis
Vulvovaginal candidiasis
Endocervicits
 N.gonorrhoea

C.trachomatis
Empirical therapy
Ciprofloxacin 500 mg BD for 7
days
Metronidazole 400 mg PO TDS
14 days
-Metronidazole 400 mg TDS
for 7 days
-Treat sexual partner
Metronidazole 400 mg PO
TDS for 7 days with or
without Metronidazole gel
0.75%,5g intravaginally daily
Clotrimazole 1% cream,5 g
intravaginally for 7 days
Ceftriaxone ,250 mg IM single
dose
Azithromycin 500 mg OD for
3 days or
Doxycycline,100 mg twice
daily for 7 days
Asymptomatic bacteriuria in Nitrofurantoin 50-100 mg x 4
times
pregnant women
Cystitis
 Nitrofurantoin 50-100
mg x 4 times
 Ciprofloxacin 500 mg
BID for 14 days or
Norfloxcin 400 mg BD
for 14 days
Augumentin1.2 gm BD /
Pyelonephritis
Piperacillin with Tazobactam
3.375 IV 6 hourly
Puerperal sepsis
Mild : Oral cefixime on
discharge
Severe: Gentamicin 5mg/kg i.v
once daily /Amikacin 15mg/kg 6
hourly /Ceftriaxone/Cefotaxime
1 to 2 g/day IV or IM
+Metronidazole IV500 mg 8
hourly + Augumentin 1.2 gm
BD
21
Remarks
If no response, wait for culture
sensitivity report or start
Imipenem
Preoperative prophylaxis
Surgical procedures
Elective LSCS
Augumentin 1.2 gm BD +
Metronidazole 500 mg TDS
hysterosalpingogram
Doxyxycline 100 mg twice for
5 days
Manual removal of placenta
Augumentin 1.2 gm BD +
Metronidazole 500 mg TDS
Augumentin 1.2 gm BD +
Metronidazole 500 mg TDS
Augumentin 1.2 gm BD +
Metronidazole 500 mg TDS
Augumentin 1.2 gm BD +
Metronidazole 500 mg TDS
Augumentin 1.2 gm BD +
Metronidazole 500 mg TDS
Post partum D & C
Elective minor
procedures(MTP ,D&C )
Hysterectomy(abdominal or
vaginal)
Repair of cystocoele or
rectocoele
Postoperative treatment
Surgical site infections
Gynaecology
Obstetrics
Augumentin 1.2 gm BD +
Metronidazole 500 mg TDS


Gentamicin 5mg/kg i.v
once daily
+Metronidazole IV500
mg 8 hourly
Augumentin 1.2 gm
BD + Metronidazole
IV500 mg 8 hourly (In
renal impairment)
22
ORTHOPEDICS
Clinical condition
Osteomyelitis
Osteomyelitis with
comorbidities like Diabetes
mellitus
Clinical condition
1) Prophylaxis for closed
fractures after surgery
2) Infected compound
fractures
Grade 1
Grade 2
Grade3
3) Surgical site infections
4)Infected joint replacements
- Spine or hip
Empirical therapy
1. Pediatric: IIIrd gen
cephalosporins/ Cefoperazone)
If no response, send sample for
culture. Vancomycin
recommended.
2. Adults:
-Uncomplicated: Augumentin
I.V
-Complicated(MRSA suspected)
Vancomycin , Vancomycin
15mg/kg IV 12 hourly.I.V

Remarks
Pediatric reference for
pediatric osteomyelitis if
surgical intervention like
drainage of abscess required,
ortho surgeon will drain and
retransfer.
Ciprofloxacin IV 400 mg
IV every 12 hours +
Gentamicin 5mg/kg i.v
once daily
/Ceftriaxone/Cefotaxime
1 to 2 g/day IV or IM
+Metronidazole IV500
mg 8 hourly
Empirical therapy
Ceftriaxone/Cefotaxime 1 to 2
g/day IV or IM x 5 days + 5mg/kg
i.v once daily for 3 days
Debride within 24 hours followed
by the following treatment
Ceftriaxone/Cefotaxime 1 to 2
g/day IV or IM x5days +
Gentamicin 5mg/kg i.v once
daily for 3 days
Ceftriaxone/Cefotaxime 1 to 2
g/day IV or IM + Gentamicin
x5mg/kg i.v once daily 7 days10days
Ceftriaxone/Cefotaxime 1 to 2
g/day IV or IM + Gentamicin
5mg/kg i.v once daily
+Metronidazole IV500 mg 8
hourly x 2 weeks
Vancomycin
plus
Piperacillin with Tazobactam
3.375 IV 6 hourly /Amikacin
Remarks
Piperacillin with Tazobactam
23
Apart wound infections
If wound deteriorating,
treatment according to culture
report or Pip -taz
Apart wound infections
Vancomycin and tobramycin
powder will be needed for
making the beads for bone
cement.
3.375 IV 6 hourly +Vancomycin ,
Vancomycin 15mg/kg IV 12
hourly.
-Hemiarthroplasty
-THR/TKR
Preop prophylaxis
Joint replacements
THR/TKR
Spinal fusion
Laminectomy
Vancomycin 15mg/kg IV 12
hourly + Amikacin15mg/kg 6
hourly
-Wound wash +Culture
-Antibiotics: Vancomycin
15mg/kg IV 12 hourly.
Plus
Imipenem/Piperacillin with
Tazobactam 3.375 IV 6 hourly
Plus
Metronidazole IV500 mg 8 hourly
Vancomycin 15mg/kg IV 12
hourly+
Ceftriaxone/Cefotaxime 1 to 2
g/day IV or IM +Gentamicin for
3 days
Ceftriaxone/Cefotaxime 1 to 2
g/day IV or IM +
Gentamicin5mg/kg i.v once daily
X 3 days
Ceftriaxone/Cefotaxime 1 to 2
g/day IV or IM GM
tds)+Gentamicin 5mg/kg i.v
once daily X 3 days
24
Vancomycin and tobramycin
powder will be needed for
making the beads for bone
cement.
DERMATOLOGY
Clinical Condition
Furuncles and carbuncles
Treatment
Cloxacillin 500 - 1000
mg orally6 hourly × 7-10
days
severe: Vancomycin 1 g IV
Q12h
step down to cloxacillin
Cellulitis
Necrotizing fasciitis(Group A
streptococcal infections)
Cloxacillin2 g IV q4–6h
-Surgical debridement, gram
staining & culture
-Clindamycin, 600–900 mg IV
q6–8h, plus
Penicillin G, 4 million units
IV q4h
Surgical debridement, gram
staining & culture
-Ampicillin, 2 g IV q4h, plus
Clindamycin, 600–900 mg IV
q6–8h, plus Ciprofloxacin,
400 mg IV q6–8h +
Metronidazole IV500 mg 8
hourly
+
Antigas gangrene serum
Topical treatment :
Permethrin 5% cream
(apply to entire skin
below neck & leave
for 8 hours)
Systemic treatment:·
Ivermectin 200
mgm/kg
orally× 1 dose
Acyclovir 400 mg PO 8
Hourly for 10 days
Acyclovir 400 mg PO 8
Hourly for 10 days
Necrotizing fasciitis(mixed
aerobes and anaerobes)
Scabies
Herpes simplex
Herpes
zoster(immunocompetent host
>50 years of age)
Dermatophytosis
Tinea pedis
Tinea Corporis
Oral: Itraconazole ,200
mg/day for 1 week per month;
fluconazole ,250 mg weekly
for 4-8 weeks
Oral: Itraconazole ,200
25
Remarks
Tinea capitis
Onychomychosis
Fingernails
Toenails
Mycetoma: Actinomycotic
Eumycotic
mg/day for 1 week;
fluconazole ,250 mg weekly
for 2-4 weeks
Oral: Itraconazole ,200
mg/day for 1 week;
Itraconazole ,400 mg /day for
1 week each month ,repeated
for 2-3 months
Itraconazole ,400 mg /day for
1 week each month ,repeated
for 2-4 months
or
Fluconazole,200 mg weekly
for 12-24 weeks
Streptomycin 15 mg/kg/ day
i.m. + CotimoxazoleazoleDS 1
tab orally12 hourly
Amikacin 15 mg/kg/day with
Co-trimoxazole DS
tab orally12 hourly
Itraconazole 200 mg /day
26
CVTS
Cardiac Surgery/Procedure
Median sternotomy/ Uncomplicated heart
transplant
Median sternotomy/ Heart transplantprevious VAD or MRSA colonization/
infection
Pacemaker/ICD placement
Pacemaker/ICD placement and MRSA
colonization /Infection
Lung Transplant
LVAD / BIVAD placement
Vascular surgery
All the procedures
Thoracic surgery
All cases except oesophageal
Oesophageal cases
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or
Clindamycin 600 mg IV 8 hourly)
PCN allergy: Vancomycin + Gentamicin
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or
Clindamycin 600 mg IV 8 hourly)
PCN allergy: Vancomycin + Gentamicin
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or
Clindamycin 600 mg IV 8 hourly)
PCN allergy: Vancomycin or Clindamycin
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or
Clindamycin 600 mg IV 8 hourly)+ Vancomycin
PCN allergy: Vancomycin
PIP-TZ 4.5 g IV 6 hourly
PCN allergy: Vancomycin + Ciprofloxacin
If CF patient please confirm with transplant ID
Vancomycin + Ciprofloxacin + Fluconazole for 48 hrs
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or
Clindamycin 600 mg IV 8 hourly)
PCN allergy: Vancomycin
Prophylaxis not recommended for carotid surgery
unless risk of infection thought to be high
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or
Clindamycin 600 mg IV 8 hourly)
Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM +
Metronidazole IV500 mg 8 hourly with or without
Gentamicin 5mg/kg i.v once daily
27
OPHTHALMOLOGY
Disease
Eye lid
Blepharitis
Stye
Conjunctivitis
Bacterial
Viral
Neonatal
conjunctivitis
Keratitis
Viral
Bacterial
Fungal
Treatment
Remarks
a) Lid margin care with warm
compresses/lid massage /lid scrubs
b) Topical antibiotics:
0.3%Gentamicin/0.5% Tobramycin
c) Tear substitutes: 4-6 times a day
 Refractory cases: a)+c) +Oral
doxycycline 100 mg 12 hourly x 1
week,then, 100 mg OD X6
weeks/oral erythromycin in children
& pregnant women/ Oral
azithromycin 500mg/day for 5 days
in acute exacerbations
 Hot fomentation
 Systemic antibiotics
a) Levofloxacin 500 mg/day x5days
b) Amoxicillin 250 mg 8 hourly x 5
days
 Pulling out cilium with underlying
pus evacuation
Opthalmic solution: topical
Gentamicin , 0.3% 6 times per day for 10-15
days
Moxifloxacin 0.5% 6 times per day for 10-15
days
Refractory cases: Polymyxin B 6 hourly 7-10
days
Bacitracin 6 hourly 7-10 days
Cold compresses + tear substitutes 4-6 times
/day+ weak steoid antibiotic combinations in
severe inflammation
Within 4-6 weeks of life
Chlamydia – Oral Erythromycin 50
mg/kg/day in 4 divided doses
Gram positive bacteria- 0.5% erythromycin
ointment Qid x2 Weeks
Gram negative bacteria –Gentamicin (0.5%)
Acyclovir 3% eye ointment 5 times a day
Severe: Systemic treatment -Oral acyclovir
(400 mg) 5 times /day x10 days
Topical antibiotic drops – Gentamicin(1.5%)
Topical treatment for 6 weeks
-Natamycin 5% every 3 -4 hours with slow
reduction
28
Corneal scraping with blade
size 15 must be done first and
inoculated onto SDA plate
before antibiotics are started.
Lacrimal
apparatus
Canaliculitis
Dacryocystitis
-Topical Ciprofloxacin(0.3%) 4 times a day
for atleast 10 days
-Transconjunctival canaliculotomy with
curettage
-Local warm compresses
-Systemic antibiotics-Tab.Amoxiclav 500 mg
12 hourly X5 days
-NSAID: Tab combiflam 12 hourly x 5 days
Endophthalmitis
-Intravitreal Vancomycin(1mg in 0.1 ml NS)
+ Ceftazidime (2-25 mg in 0.1 ml NS) +
Dexamethasone 400 µg in 0.1 ml
-Topical fortified eyedrops Vancomycin 50
µg /ml + Amikacin 20µg/ml + 1% atropine
sulphate +1% prednisolone acetate
-Systemic antibiotics :
Ceftazidime 2g IV every 8 hourly x 5 days
Amikacin 7.5 mg/kg IV 12 hourly x 5 days
Tab Ciprofloxain 750 mg 12 hourly x5 days
Retinitis
Orbital cellulitis
Antibiotic
prophylaxis for
surgeries
AIOS
CMV retinitis
- Ganciclovir ( IV)5mg/kg 12 hourly x2-3
weeks
5mg/kg /day – maintenance
Ceftazidime 1gm 8 hourly x1 week IM + Oral
Metronidazole (500 mg) 8 hourly X1week
1. Broad spectrum antibiotic drops
eg:Ed Ciplox ..one day rpior to
surgery
2. No contact procedures (eg:
Tonometry ,Biometry)- one day prior
to surgery
3. Preop : Povidone iodine 5% for 3 min
on skin and periorbital area
4. Povidone iodine %% for 1 min in
conjuctival cul de sac
5. Post Surgery : Patch for atleast 6
hours
6. Topical antibiotics + steroids for 1
min 4 weeks post surgery
7. Tab.Ciplox ( 500 mg 12 hourly x 3
days ) high risk cases
29
Vitrectomy done when:
1. Lack of improvement
or worsening after 48
hours
2. Absence of red glow
at initial presentation
3. Suspected fungal
etiology or bleb
4. Endophthalmitis with
intraocular foreign
body
AAO
Hand disinfection with povidone iodine(10%)
Instillation of povidone iodine (5%) in cul de
sac
Draping of eyelashes and lid margins
Pre operative 3 days use of 4th generation
cephalosporin and continue post operative for
4 weeks
30
Contributors
Microbiology
Dr. K.Madhuri
Dr. Swati Mudshingkar
Pharmacology
ENT
Dr. Bharti Daswani
Dr.BB Ghongane
Dr. Samir Joshi
Medicine
Dr. HB Prasad
Obstetrics & Gynaecology
Dr. Bhosale RA
Opthalmology
Dr. Sanjeevani Ambekar
Dr. Meghana Panse
Orthopedics
Dr. Vishal Patil
Pediatrics
Surgery
Dr. Chhaya Valvi
Dr.Khadse SS
Dr.Vasudha M Belgaomkar
Dr CB Mhaske
Dr. (Mrs). Vandana Dubey
CVTS
Dr.N.Thakur
Skin
31
STEPS OF HANDWASHING
32