Antibiotic Guidelines for Adults 2022

Christian Medical College, Vellore

Prepared by
Hospital Infection Control Committee
Dr Rajiv Karthik
Dr. O.C. Abraham
Dr. V. Balaji
Dr. Joy S. Michael
Dr. Hema Paul
Dr. Priscilla Rupali

Acknowledgments for contributors:

Dr. Anand Zachariah
Dr. Abi Manesh
Dr. Rini Bandyopadhyay
Dr. Selwyn Selvakumar
Dr. Bhanu Prasad
Dr. Prasanna Kumar
Dr. KPP Abhilash
Ms. Catherine Truman
Dr. Hanna Alexander
Dr. Jisha Sara John

Approved by:

Dr. Prasad Mathews (Medical Superintendent)

Doc. No: MAN/HICC/001/P/10/2022 Version: 14

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 Contents

Chapter Content Page No

1 Introduction ... 3
2 Principles of rational antibiotic ... 5
prescribing
3 Initial Empiric Antibiotics for Common ... 7
Infections
A1. GI and intra-abdominal infections ... 7
A2.CNS infections ... 10
A3. Skin and soft tissue infections ... 14
A4. Bone and joint infections ... 19
A5. Respiratory tract infections ... 21
A6. Genitourinary infections ... 31
A7. Sepsis ... 34
4 Targeted (Definitive) Therapy of 37
Common Infections ...
1. Infective endocarditis ... 37
2. Bloodstream infections ... 39
3. Other infections ... 42
5 Infective Endocarditis Prophylaxis ... 48
6 Surgical prophylaxis guidelines ... 49
7 Prophylactic Antibiotic Protocol For ... 55
Trauma Patients In The Adult Emergency
Department
8 Covid-19 Treatment Guidelines ... 60
9 Dosing of antimicrobial agents in renal ... 69
insufficiency
10 Hospital Antibiogram ... 83
11 Drug, dosage and dilution ... 88
12 Hand Hygiene Technique ... 100

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 Chapter 1: Introduction

Increasing antimicrobial resistance today poses a significant threat to

public health in India. This threat is compounded by the lack of
development of new antibiotics. Prudent antimicrobial utilization and
a stringent adherence to infection control practices therefore remain
the major strategies to counter this threat. A safe and effective
strategy for antibiotic use involves prescribing an antibiotic only
when it is needed and selecting an appropriate and effective agent at
the recommended dose, with the narrowest spectrum of
antimicrobial activity, fewest adverse effects and lowest cost.

Good antibiotic prescription practices include:

1. Prescribing empiric antibiotics for suspected bacterial infections
only if:
• Symptoms are significant or severe
• There is a high risk of complications
• The infection is not resolving or is unlikely to resolve

2. Using first-line antibiotics first

3. Reserving broad spectrum antibiotics for specifically indicated
conditions

The following information is intended to serve as a guide, to aid in the

selection of an appropriate antimicrobial for patients with infections
commonly seen in clinical practice. Individual patient circumstances
and resistance patterns may alter treatment choices. The hospital
antibiogram with susceptibility pattern of various organisms is
reviewed every year and antibiotic recommendations are modified
accordingly. These recommendations are based not only on current
scientific knowledge but also take the local resistance patterns, our
collective clinical experience and cost into consideration. The
recommendations relate to empirical, targeted or definitive therapy
for a clinical infection and prophylaxis in beneficial situations. If
empiric therapy is initiated, the treatment should be reviewed once

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the culture and susceptibility results are ready (usually within 72
hours) and targeted therapy should be done whenever possible to
give the narrowest spectrum antibiotic based on culture and
susceptibility data, the site of infection and the clinical status of the
patient. The doses mentioned in these guidelines are for patients with
normal renal function. The doses have to be modified for those with
renal insufficiency.

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 Chapter 2: Principles of rational antibiotic
Prescribing

1. Empiric antimicrobial treatment should be limited to

conditions where immediate/early initiation of
antimicrobials has been shown to be beneficial. Some
examples are:
• Severe sepsis (sepsis-induced tissue hypo perfusion or
organ dysfunction) and septic shock
• Acute bacterial meningitis
• Community acquired pneumonia
• Ventilator associated pneumonia
• Necrotizing fasciitis
• Febrile neutropenia

2. Fever, leukocytosis or elevated c-reactive protein (CRP)

levels by themselves should not be considered indications
for starting empiric antimicrobials, as these have been shown
to have very poor specificity to diagnose bacterial sepsis. Always
consider multiple data points (history, physical findings and
investigation reports) together to make an accurate diagnosis.

3. Incomplete or inaccurate diagnosis is the most important

reason for inappropriate use of antimicrobials.

4. Always obtain cultures (two sets of blood cultures and other

appropriate samples as clinically indicated – e.g. normally
sterile body fluids, deep pus etc.) before starting empiric
antimicrobial treatment. Avoid the practice of obtaining “pan
cultures” unless clinically indicated.

5. Avoid sending cultures from superficial wounds, decubitus

ulcers, and chronic wounds and draining sinuses. Surface
swab cultures are either inadequate or provide misleading
5
 information regarding diagnosis (as they cannot differentiate
infection from colonization / contamination).

6. When starting antimicrobials, use full therapeutic doses,

paying close attention to dose, frequency, and route of
administration and duration of treatment.

7. Review all antimicrobial prescriptions after 48 to 72 hours

(“antimicrobial timeout”) with a view to modify or stop the
initial empiric therapy.

8. De-escalate (targeted or pathogen-specific therapy) the

antimicrobial regimen once culture and susceptibility reports
are available, and the patient is showing signs of improvement
with the initial empiric broad-spectrum antimicrobial.

· Examples of optimization include switch

i. To a narrow-spectrum antimicrobial,
ii. From combination to single agent,
iii. To less toxic drug, or
iv. From IV. to an oral formulation.

9. Stop antimicrobials if the cause of initial symptoms is found to

be non-infectious

10. When antibiotics are required to treat an infection, it is

important to consider the right choice, right dose, right route,
right duration, and right frequency to ensure adequate target
site concentration and therapeutic efficacy.

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 Chapter 3: Initial Empiric Antibiotics for
Common Infections

A1. GI and Intra-abdominal infections

Condition Most likely First choice Alternatives Comment

microbial etiology s
1. Acute ● Viral (calici- None indicated • Rehydration
Gastroenteritis viruses, rotavirus) • Symptomatic
(acute onset entero toxigenic treatment
nausea, and entero
vomiting, watery pathogenic
diarrhoea) E Coli
● Salmonella Spp
2. Acute Watery ● Vibrio Cholera Doxycycline 300 mg • Azithromycin Prompt
Diarrhoea, P.O ×1 dose 1g P.O× 1 Dose rehydration
Cholera • Ciprofloxacin essential
500mg PO BID x
Suspected
3 Days
3. Bacillary ● Campylobacter ● None needed for • Ciprofloxacin Prompt
Spp. previously healthy 500mg PO bid rehydration
Dysentery (acute
onset fever and ● Shigella Spp. patient with mild x 3 days
symptoms • Azithromycin
bloody
● Treat patients with 500mg PO
diarrhoea) - severe od x 3 days
symptoms
- Immuno-
compromised
status

4. Enteric Fever ● Salmonella Emperic therapy not Antibiotic

suspect if acute Typhi recommended treatment should
febrile illness × ● Salmonella be based on
Paratyphi A culture and
several days –
susceptibility (see
and other enteric fever in
etiologies ruled section on
out definitive therapy)

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 Most Likely
Condition Microbial First Choice Alternatives Comments
Etiology
5.Cholangitis ● Enterobact- ● Ertapenem 1g IV ● Cefoperazone – • Duration 7 days
eriaceae OD (for severely ill Sulbactam 3 g •Biliary drainage
Anaerobes patients-sepsis or IV BID In case of ESBL-
septic shock) E.coli, / Klebsiella
● Piperacillin- bacteremia,
Tazobactam 4.5g piperacillin-
IV.Q6H tazobactam is not a
suitable choice.

Consult ID in case
of hospital
acquired or high
risk for MDRO
infection
6.Acute ● Enterobact- ● Ertapenem 1g IV ● Cefoperazone – Patients
cholecystitis eriaceae OD (for severely ill sulbactam 3 g undergoing
patients-sepsis or IV BID cholecystectomy
septic shock) should have
● Piperacillin- antimicrobials
Tazobactam 4.5g discontinued within
IV Q6H 24h unless there is
evidence of
infection outside the
wall of the
gallbladder
7.Spontaneous E. coli ● Piperacillin- ● Cefoperazone – Duration 7 days
bacterial Tazobactam 4.5g Sulbactam 3 g
peritonitis IV Q6H IV BID
● Ertapenem 1g IV
OD (for severely ill
patients-sepsis or
septic shock
8.Secondary • Enterobact - ● Ertapenem 1g IV ● Cefoperazone ● Emergency
peritonitis (bowel eriaceae OD –Sulbactam 3 surgery and
• Anaerobes g IV BID adequate
perforation)
(bacteroides source control.
species) ● Duration- 5 days
if source control
is adequate

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 Most Likely
Condition Microbial First Choice Alternatives Comments
Etiology
9.Intra - ● Enterobact -eri • Ertapenem 1g IV • Cefoperazone • Emergencydrainage
abdominal aceae OD –Sulbactam Duration -5 days if
abscess ● Anaerobes 3g IV BID source controlis
(bacteroides • Tigecycline adequate
species) 100 mg IV
×1dose
followedby
50 mg IV
BID
10.Pyogenic Escherichia coli, Piperacillin Duration of treatment
liver abscess K. pneumoniae, Tazobactam 4.5g IV - 5-10days.
Anaerobes, Q 6H Therapy should
Streptococcus depend on clinical
millerigroup, response and
polymicrobial adequate drainage.
11.Acute Routine use of ● Infected
pancreatitis prophylactic pancreatic necrosis
antibiotics NOT should be considered in
recommended patients who deteriorate
or fail to improve after
7-10 days of
hospitalization or CT
scan
with gas in the
pancreas

12.Infective Entero Meropenem 1 g ● Image- guided

Post bacteriaceae, IV. TID aspiration for gram
necrotizing Enterococcus sp., stain and culture to
Pancreatitis / guide use of
S.aureus, CoNS,
abscess appropriate
Anaerobes antibiotic

*When using carbapenems (eg. Ertapenem, meropenem) or beta-lactam + beta lactamase inhibitor combination
(eg.piperacillin –tazobactam) for intra -abdominal infections there is NO NEED to add metronidazole. Carbapenems
and BI+BLI combinations have excellent activity against anaerobes

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A2. CNS infections

I. Management protocol for acute meningitis (community

acquired)

1. Suspect if patient (no neurosurgical procedure in the previous

two weeks; not immuno-compromised) has any combination of the
following:
a. Symptoms: fever, headache, altered mental status (new
onset confusion, disorientation, drowsiness, coma)
b. Signs: Temp >38 °C, neck stiffness, other signs of meningeal
irritation.

2. Confirm by a lumbar puncture (to be done as soon as possible)

a. CSF findings highly suggestive of bacterial meningitis
i. Gross appearance turbid
ii. Total WBC count >1000 cells/mm3
iii. Neutrophilic pleocytosis
iv. Low CSF glucose (<50% of concomitant blood glucose)

3. CT scan brain

a. Should NOT be ordered as a routine test before LP in all

cases of suspected acute meningitis
b. Indications for CT scan brain before LP
i. Papilledema
ii. New onset seizures
iii. Focal neurological deficits (e.g., hemiparesis)
iv. Decreased level of consciousness (GCS <10)
v. Immunocompromised patients (e.g., HIV infection)

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4. Lab tests
a. CSF analysis
i. WBC count (total and differential)
ii. Glucose
iii. Protein
iv. Gram stain and culture
v. Virology panel (PCR)
vi. Additional investigations if duration of symptoms >5
days
1. Xpert MTB/RIF
2. Mycobacterial (MGIT) culture
3. India ink preparation
4. Cryptococcal antigen
5. Fungal culture
6. VDRL
b. Blood culture
c. CBC
d. Urea, creatinine, electrolytes

5. Antimicrobial management:

a. All patients should receive the first dose of antimicrobials

as soon as the diagnosis of acute bacterial meningitis is
suspected.

b. DO NOT delay antimicrobials if there is a delay in obtaining

a CSF sample.
• Prior administration of antimicrobials tends to have
minimal effects on the chemistry and cytology findings,
but can reduce the yield of Gram stain and culture
c. Modify antimicrobial regimen based on the results of
culture & susceptibility reports

a. Adjunctive steroid therapy (to be started for patients with

strong clinical suspicion of acute bacterial meningitis or CSF
results as described below):

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 a. Indications:
i. Cloudy CSF
ii. CSF WBC count >1000/ml, or
iii. Bacteria in CSF on Gram’s staining

b. Contra-indications
i. Septic shock
ii. Patients who have already received antimicrobials

II. Other CNS infections

Most Likely
Condition Microbial First Choice Alternative Comments
Agent
Pyogenic meningitis Strep.pneumoniae, Ceftriaxone 2 Monitor Vancomycin
Meningococci, g IV. BD + AUC/MIC levels (Normal
H.influenzae, Listeria Vancomycin range 400-600).
monocytogenes 15–20 mg/kg Dexamethasone 0.15
q8 - 12h (after mg/kg Q6H x4 days; first
Loading dose dose 15 min before or
20-35mg/kg, along with first dose of
max 1.5gm) x antimicrobial
10 to 14 days.
Discontinue if culture
If Listeria is grows organisms other
suspected than Strep pneumoniae
to add
Ampicillin In Acute encephalitis
2gm iv syndrome to consider Inj.
q4h. Acyclovir 10mg/kg IV q8h
only if there is a strong
clinical suspicion
of HSV encephalitis.
Tuberculous M.tuberculosis Susceptible or Steroids
meningitis not suspected For MRC grade 1
to be drug

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 resistant -Weight Dexamethasone
based ATT, IP for 2 0.3mg/kg/day iv – 1st week
months (HRZE)+ CP
0.2mg/kg/day iv – 2nd week
for minimum 10
months (HRE) 0.1mg/kg/day oral – 3rd
week
3mg /day oral – 4th week,
then tapering by reducing by
1 mg each week over 2
weeks
For MRC grade II and III
0.4mg /kg/day iv – 1st
week
0.3mg/kg/day iv – 2nd week
0.2mg/kg/day iv – 3rd week
0.1mg/kg/day iv – 4th week
4mg/day oral – 5th week,
then reducing by 1 mg
each week over 3 weeks
Brain abscess ● Streptococci ● Empiric therapy Neurosurgery referral for
(aerobic & should be avoided aspiration or excision of
anaerobic) if the patient is abscess.
● Enterobact- stable and there is Duration: until it is resolved
eriaceae no sign of sepsis.
● Anaerobes ● Treat as per
culture and
sensitivity reports
Post-surgical brain CoNS, Vancomycin 15- Duration depends on
abscess S.aureus 20mg/kg q8-12h + clinical response.
Enterobacteria ceae Meropenem 2g IV
Pseudomonas q8h
Ventriculo- Acinetobacter Shunt removal with Consult ID team for
peritoneal shunt baumanii, CSF culture +IV the medical
Klebsiella
infections (VPSI) pneumonia, antibiotics +/- management.
Pseudomonas, Intraventricular or
S.aureus Intrathecal
antibiotics.
Consider staged
shunt replacement,
if the patient is
shunt dependent

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A3. Skin and soft tissue infections (SSTI)

I. Management protocol for necrotizing fasciitis (NF)

1.Suspect NF in any patient presenting with SSTI who has severe

pain, sepsis (organ dysfunction) or septic shock. 2. Symptoms
and signs:
a. Pain (out of proportion to physical findings), swelling,
redness and warmth of affected area;
b. Changes in skin colour from red-purple to patches of blue-
gray;
c. Bullae containing thick pink or purple fluid; crepitus;
d. Cutaneous gangrene;
e. Compartment syndrome;
f. MOSF;
g. Hypotension

2. Obtain urgent surgical consultation. Surgical exploration is the

only way to definitively establish the diagnosis of necrotizing
infection.

3. Lab investigations
a. CBC
b. Urea, creatinine, electrolytes
c. CPK
d. Blood culture
e. Gram stain and culture of tissue and pus sample obtained at
surgery

4. Imaging (plain x-rays, CT scan, MRI scan) to look for presence of

gas. The presence of gas in the fascial planes is a highly specific
finding, but not very sensitive. DO NOT delay surgical
intervention.

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5. Management
a. Surgery: Aggressive debridement of all necrotic tissue
b. Antimicrobials:
 Initial empiric treatment: Meropenem 1 g IV. TID +
Clindamycin 900 mg IV. TID
 Modify antimicrobials according to culture and
sensitivity report
 For confirmed group A streptococcus infection:
Penicillin G 2 million units IV. Q4H + Clindamycin 900
mg IV. TID

Most Likely
Condition Microbial First Choice Alternative Comments
Agent
Early
Necrotizingfasciitis Group A streptococcus, Meropenem 1 g IV. TID Pipericillin
surgical
anaerobes, + Clindamycin900 mg Tazobactam 4.5gm
debridement
Staphylococcus aureus, IV. TID+/- IV q8h+ as mentioned
Clostridium spp Vancomycin if there is a Clindamycin900 above
risk factor for MRSA mg IV. TID +/-
Vancomycin if there
is a risk factor for
MRSA
Group A streptococcus Penicillin G 2 million
units IV. Q4H +
Clindamycin 900 mg IV.
TID
Clindamycin or Early
Synergistic Mixture of aerobic and Meropenem 1gm ivTID
metronidazole exploratory
Necrotizing anaerobic bacteria OR
with a fluoro surgery to
fasciitis- poly /PiperacillinTazobactam
quinolone establish
microbial cellulitis 4.5gm iv
(Patients With diagnosis and
spreading in a TID+Vancomycin if there Severe resect
fascial plane is a risk factorfor MRSA Penicillin necrotic
Hyper tissue
sensitivity)

15
6. Features that warrant empiric MRSA cover

 Systemic signs of toxicity (e.g. fever >100.5°F/38°C, hypotension,

or sustained tachycardia.
 Prior episode of MRSA infection or known MRSA colonization
 Lack of clinical response to antibiotic regimen that does not
include activity against MRSA
 Presence of risk factor(s) for MRSA infection (including recent
hospitalization, residence in a long-term care facility, recent
surgery, haemodialysis, and HIV infection)
 Proximity of the lesion to an indwelling medical device (e.g.
prosthetic joint or vascular graft)

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II. Other SSTI
Most Likely
Condition Microbial First Choice Alternative Comments
Agent
1.Skin infections
Cellulitis (no purulent ● Strep Cefuroxime 1.5gm q8h(for Cloxacillin 500 • Oral therapy
drainage) pyogenes hospitalized patients with mg p.o. QID x for mild
● Staph aureus moderate illness) 7-10 days illness and
step-down
Cloxacillin 1 g IV Q6H Cephalexin following
500mg p.o improvement
Cefazolin 1g IV Q8H QID x 7-10 with IV
days therapy
• Duration: until
Amoxicillin- clinical cure
Clavulanate • MRSA cover
1gm p,o. to be added if
BID for 7- there is risk.
10 days

Carbuncles, cutaneous Staph aureus Cloxacillin 500 mg IV Cloxacillin 500 Incision and
abscesses Q6H×7-10 days mg drainage
p.o. Q6H x 7-
10 days
Tinea versicolor Malassezia furfur Topical clotrimazole 1% Topical duration 1-2
OD miconazole weeks
2% OD
Tinea Corporis T.rubrum Topical clotrimazole 1% topical duration 2-4
OD miconazole weeks
2% OD
Scabies Sarcoptes Permethrin cream 5% to Ivermectin • Wash off
scabiei be applied all over the 12mg stat after 8-14
body from the neck hours
downwards overnight and (Treat all • Clothing
washed off in the family should be
morning members as washed in
well) hot water
and dried
before
reuse

17
 Most Likely
Condition Microbial First Choice Alternative Comments
Agent
2.Diabetic foot ulcer
Mild (local infection ● Staph aureus Cefuroxime 1.5gm iv Q8h Cloxacillin 500 - Cultures should
involving only skin and ● Strep Cefazolin 1gm IV Q8H 1000 mg P.O not be taken from
subcutaneous tissue, pyogenes clinically non-
erythema <2 cm, no Q6H×7-10 infected wounds
systemic signs days

Moderate (local Polymicrobial Piperacillin- Surgical

infection with Staph aureus, Tazobactam 4.5 gIV consultationfor
erythema > 2 cm ,or Q8H+Vancomycin drainageor
involving structures Group A strep, 15mg/kg IV Q12H debridement
deeper than skin and Aerobic Gram-
subcutaneous tissues negative bacilli, Add MRSA
eg.abscess anaerobes cover only if
.osteomyelitis, septic there is a risk
arthritis,fasciitis) factor.
Severe(limb Polymicrobial Meropenem 1 g IVTID + Surgical
threatening-severe Staph aureus, either consultationfor
cellulitis/gangrene, Group A strep, Vancomycin15mg – 20 drainageor
severe sepsis/septic aerobic Gram- mg/kg IV Q12H debridement
shock negative bacilli, or
anaerobes Daptomycin 4mg/kg IV Add MRSA
OD or cover only if
Linezolid 600mg IV/p.o there is a risk
BD factor.
3. Bites (cat,dog,human, ● Pasteurella Amoxicillin ● Duration 3-7
rat,pig) multocida Clavulanate625 mg days
● Capnocytoph P.O.TID ● Administer rabies
aga vaccinations as
● Eikenella appropriate
● Strep viridans ● Administer
● Spirillum minus Tetanus Toxoid
● Streptobacillus vaccine as
moniliformis appropriate

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 A4. Bone and joint infections
Condition Most likely First Alternative Comments
microbial etiology choice
Acute Osteomyelitis Staph aureus Cloxacillin 2 g For patients at ●For optimal treatment,
IV Q4H risk for microbial etiology should
methicillin- be confirmed
Cefuroxime resistant S. ●Orthopedic referral for
1.5gm IV Q6H aureus bone biopsy and
(MRSA), debridement of necrotic
Cefazolin 2 g vancomycin15 material
IV Q8H mg/kg ●Modify initial empiric
IV[maximum 2g] regimen based on culture
report
● Duration: 6 weeks from
last debridement
Consider switching
to appropriate oral
antibiotics at the
earliest
Chronic Osteomyelitis
▪ Secondary to a
contiguous focus of Staphylococci Avoid empiric ● For optimal treatment,
infection (e.g., treatment microbial etiology should
decubitus ulcer). Aerobic GNB be confirmed
Streptococci ● Orthopaedic referral for
▪ Osteomyelitis that Anaerobes bone biopsy and
develops as a result of
debridement of necrotic
contaminated open
material
fractures or surgical
● Obtain cultures (bone
treatment or closed
and blood) before
fractures
antimicrobial so avoid
sending swab cultures
from chronic discharging
sinuses and ulcers
● Duration: 6 weeks from
last debridement
● Consider switching to oral
antibiotics at the earliest

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Chronic Osteomyelitis Avoid empiric ● For optimal treatment,
with orthopaedic implants antimicrobials microbial etiology should
unless patient
seriously ill be confirmed
● Orthopedic opinion with
regard to implant removal
● Obtain cultures (bone and
blood) before initiating
antimicrobials
● Modify initial empiric
regimen based on
culture report

Osteomyelitis associated See section on diabetic foot infections

with diabetic footinfection

Septic arthritis Staph aureus Cloxacillin 2g IV. Cefuroxime ● Orthopedic referral

Q4H 1.5gm IV ● Obtain Blood cultures and
Q6H joint fluid for culture
before starting
antimicrobials
● Modify initial empiric
regimen based on culture
report
● Duration: 4 weeks;
change to appropriate
oral therapy after 10-14
days of IV. therapy
Open fracture repair Inj.Augmentin Type 3 fractures, antibiotic
1.2gm iv BD should be continued for 72
hrs after injury or not more
than 24hrs after soft tissue
coverage has been
achieved.

20
Prosthetic joint infections CoNS, In stable patients Teicoplanin Duration: Depends on
S.aureus, antibiotics may be 12mg/kg clinical response.
Streptococci, withheld pending q12h for 3
Enterococci, establishment of to 5 doses
cutibacterium, microbiological followed by
Enterobact- result. 12mg/kg
eriaceae od.
If the patient is
unstable,
Vancomycin 20
mg/kg q12h then
15mg/kg q12h.
A5. Respiratory tract infections
I. Community acquired pneumonia (CAP) management protocol
1. Suspect if patient (not been hospitalized in the previous 90
days; not immuno-compromised; no structural lung disease
like bronchiectasis) has any combination of the following:
a. Symptoms: fever, cough (with or without expectoration),
shortness of breath, chest pain

b. Signs: Temp >38 °C, tachypnea, tachycardia, impaired

percussion notes, bronchial breath sounds, crackles, altered
VF/VR.
*In a patient presenting with cough, normal vital signs and
physical examination findings rule out a diagnosis of pneumonia

2. Confirm with chest x-ray (to be done as soon as possible).

Inpatients with a clinical suspicion of CAP, but no abnormalities
on chest x-ray, repeat the x-ray within 48 hours.

3. Severity assessment based on CURB 65 score:

a. 6 point score (range 0 - 5)

b. Gives one point each for:
i. Confusion (new onset disorientation in person,
place,or time)

21
 ii. Urea >126 mg/dL
iii. Respiratory rate > 30/min
iv. Low Blood pressure (SBP < 90 mm Hg or DBP < 60
mm Hg)
v. Age >65 years

c. Interpretation
i. CURB-65 score 0 or 1: low risk of death
ii. CURB-65 score 2: moderate risk of death
iii. CURB-65 score >3: high risk of death

22
 CURB 65 score is NOT a replacement for
good clinical judgment
4. Lab Test
a. CBC
b. Urea, creatinine, electrolytes
c. For patients with CURB 65 score >2
i. ABG
ii. Blood culture
iii. Sputum Gram stain & culture
*Sputum sample should be transported promptly to the lab Respiratory sample (NP
swab, throat swab, nasal swab, ET aspirate or BAL) for respiratory viral panel (includes
influenza testing by RT-PCR)
• In patients with pneumonia, BAL or ET aspirate should be
collected for influenza testing if NP swab is negative

5. Setting of care
a. CURB-65 score 0 or 1: out-patient
b. CURB-65 score 2: in-patient (ward)
c. CURB-65 score 3: in-patient (ICU)

6. Antimicrobial management:
a. All patients should receive the first dose of antimicrobials as
soon as the diagnosis of CAP is confirmed
b. Change to an oral regimen as soon as clinical
improvement occurs and the temperature has been
normal for 24 h, and there is no contraindication to the
oral route.
c. Modify antimicrobial regimen based on the results of culture
& susceptibility reports
d. Consider unusual microbial etiology (e.g., Burkholderia
pseudomallei in poorly controlled diabetes and Staph aureus
(MSSA & MRSA) in post-influenza bacterial pneumonia

23
 CURB – Most likely microbial
65 Score etiology Preferred Alternate Comments
0 or 1 Respiratory viruses; Amoxicillin 500mg 1. Azithromycin See section on “influenza”
Strep pneumoniae; p.o. TID x 5days 500mg p.o. OD x for indications for
Mycoplasma 5days oseltamivir
pneumoniae; 2..Doxycycline
Chlamydophila 100
pneumoniae mg p.o. BID x 5
days

2 ● Respiratory ● Penicillin G20 L Piperacillin – Antiviral treatment might

viruses; IV. Q4H Tazobactam 4.5g still be beneficial in
● Strep- OR IV Q8H patients with severe,
pneumoniae; +
Ceftriaxone 2 gm complicated, or
● Mycoplasma Azithromycin
IV OD progressive illness and in
pneumoniae; 500 mg IV. OD
+ x5–7 hospitalized patients
● Chlamydophila ● Azithromycin days when started after 48
pneumoniae; 500mg IV. OD x + hours of illness onset, as
● Legionella 5-7days Oseltamivir 75mg
p.o. BID x 5 days indicated by
+
observational studies
Oseltamivir 75mg
(CDC, 2013)
p.o. BID x 5 days
● Discontinue oseltamivirif
PCR negative
● Continue if clinical
suspicion of influenza
high
● No virological or clinical
advantages with double
dose oseltamivir
compared with standard
dose in patients with
severe influenza admitted
to hospital
● (BMJ, 2013)

24
≥3 ● Strep pneumoniae; Meropenam Consider adding
● Legionella 1gm IV. Q8H Vancomycin if there are
● Klebsiella + risk factors for MRSA or
pneumoniae; Azithromycin if Community Acquired
● H influenza; 500mg IV. OD x MRSA is suspected
● Respiratory viruses, 5-7 days
+
primarily influenza
Oseltamivir
75mg
p.o. BID x 5 days

II. Ventilator associated pneumonia management protocol

1. Diagnosis
a. Develops 48 – 72 hours after endotracheal intubation
b. Clinical features: fever, alteration in sputum characteristics
(increased purulence and /or volume), worsening
oxygenation (increasing FiO2& PEEP requirement,
worsening PF ratio) Labs: leukocytosis (WBC >11000),
leukopenia (WBC <4000)or band forms >10%, elevated PCT
/ CRP
c. Chest x-ray: new or worsening infiltrates
*No gold standard for diagnosis of VAP; combination
of above findings increases probability of VAP
d. Obtain ET aspirate for Gram stain, culture and virology (No
advantage of BAL over ETA)
e. Negative ET aspirate culture rules out VAP (very high
negative predictive value)

25
26
2. Antimicrobials (to be started after obtaining cultures)
(65% ofVAP in CMC MICU caused by A. baumannii)

Condition Etiology First choice Alternatechoice Comment

Ventilator Polymyxin 15 lakh units If high Modify once culture

associated loading dose followed by suspicision of and sensitivity
pneumonia 7.5 lakh twice daily till MRSA consider reports are available.
culture susceptibility adding
reports are available Vancomycin Duration of
appropriate
antimicrobial therapy:
8-10 days– may
extend to 14 days in
specific
circumstances

27
III. Influenza-like illness (ILI) management protocol

*Patients at higher risk of influenza complications

• Children <2 years
• Adults >65 years
• Pregnant women
• Persons with following co morbidities
● Morbid obesity
● COPD, bronchial asthma
● CAD, heart failure
● CKD
● CLD
● Hematological conditions (including sickle cell disease)
● DM
● Neurological & neuromuscular disorders
● Immunosuppression (HIV infection,
immunosuppressive treatment)

28
IV. Other respiratory infections
S. No Condition Most likely Preferred Alternative Comments
microbial etiology antimicrobial
1. Acute ● Respiratory viruses Amoxicillin 1. Azithromycin Self-limited viral
pharyngitis ● Group A 500mg PO 500mg PO illness, for which
Streptococcus (GAS) TID × 10 days OD × 5 days supportive care is
needed
2. Penicillin GAS infection –
250mgPO fever, no cough,
QID × 10 days tonsillar exudates &
tender anterior
cervical
lymphadenopathy
2. Acute epiglottitis Haemophilus Ceftriaxone Levofloxacin -Airway
influenzae 1-2g IV 750mg IV OD management
OD × 7 days + /-
Clindamycin -Consider addition
600mg IV q8h of Vancomycin if
there is a risk for
MRSA
3. Deep neck ● Polymicrobial (Oral Mild : Clindamycin Airway
space infection anaerobes) Amoxicillin – 600mgIV management
including ● Streptococcus spp clavulanate Q8H × 14 days Consider
Ludwig's angina ● Peptostreptococcus 1.2gm IV Surgery;
● Bacteroides spp BD × 14 days Continue
● Fusobacteria spp antibiotics till clear
evidence of clinical
improvement -
Consider addition
of Vancomycin if
there is a risk for
MRSA.
4. Acute bronchitis Viral None needed Symptomatic
treatment only
5. Acute bacterial Streptococcus Amoxicillin – Antimicrobials
rhino sinusitis pneumoniae; clavulanate 1gm needed only if
Haemophilus influenzae; PO fever, Facial pain
Moraxella catarrhalis; BID × 7 days and purulent
nasal discharge
for >7days

29
Sl.No Condition Most likely microbial Preferred Alternative Comments
etiology antimicrobial
6. Acute bacterial Streptococcus Amoxicillin – 1.Azithromycin Start Oseltamivirif
exacerbation of pneumoniae; clavulanate 1gm 500mg PO clinical suspicion
COPD Haemophilus PO OD × 3 days of influenza is high;
(Presence of any influenzae; BID × 7 days
2 of the Moraxella catarrhalis; 2.Doxycycline Antimicrobials
following) Respiratory viruses 100mg PO BID needed for all
a.Increased ×7days patients who
dyspnea require
b. Increased mechanical
sputum volume ventilation;
c. Increased
sputum
purulence
7. Bronchiectasis Haemophilus Initial empiric Adjunct therapy - Duration needed is
– acute influenzae; therapy based on chest 5 to 7 days
exacerbation Streptococcus previous sputum physiotherapy, depending on
(Increased pneumoniae; culture reports postural drainage, clinical response
cough, Sputum Pseudomonas when available; If steam inhalation and culture report.
volume and aeruginosa NA then oral
purulence) therapy:
Amoxicillin
clavulanate OR
Levofloxacin
8. Lung abscess Oral anaerobes Amoxicillin – Clindamycin 600mg Duration: Till
(Peptostreptococcus, clavulanate 1.2gm TID clinical and
Prevotella, IV radiological
Bacteroides spp TID till clinical resolution;
{usually not response and step Usually 3 to 4
B.fragilis}, down to oral weeks.
Fusobacterium spp.,) therapy
9. Empyema Streptococcus As per culture 1.Penicillin G 20LIV Modify antibiotics
thoracis pneumoniae; reports Q4H once the culture
anaerobes 2. Amoxicillin – reports available;
Streptococcus milleri clavulanate Intercostal
1.2gm IV drainage needed
TID when pleural fluid
3. Piperacillin – has pH<7.2;
Tazobactam 4.5g frankly purulent;
IV. Q8H shows bacteria on
3. 4.Clindamycin Gram stain or
600mg IV TID culture.
30
A6. Genitourinary infections

I. UTI management protocol

1. Symptoms and signs
a. Young women: dysuria, frequency of urination, and negative
history of vaginal discharge (post-test probability 90%); fever;
costo-vertebral angle tenderness

b. Older patients may have these additional symptoms

i. Cloudy, malodorous or bloody urine
ii. Worsening incontinence
iii. Systemic symptoms (altered mental status, MOSF,
hypotension)

c. Symptoms of urinary catheter associated UTI (CAUTI): new

onset or worsening of fever, rigors, altered mental status,
malaise, or lethargy with no other identified cause; flank pain;
costo-vertebral angle tenderness; acute hematuria; pelvic
discomfort

2. Lab tests
a. Urinalysis (leukocyte esterase and nitrite by dipstick). Absence
of pyuria and bacteriuria rules out UTI (high negative
predictive value)
b. CBC
c. U&E
d. Urine culture
e. Blood culture
f. Imaging (ultrasound or CT KUB) indicated for
i. Severe sepsis or septic shock
ii. Palpable kidneys
iii. Persistent symptoms after 72 hrs appropriate treatment
iv. DM
v. Immune suppression
vi. Recurrent UTI

31
3. Antimicrobial management
Most likely
Preferred
S.No Condition microbial Alternative Comments#
etiology antimicrobial
1. Asymptomatic bacteriuria E.coli No Screening for and
(positive urine culture from an antimicrobial treatment of
individual without symptoms or needed asymptomatic
signs of UTI) bacteriuria is
indicated:
1.Pregnancy
2.Patients
undergoing
urological
procedures in
which mucosal
bleeding is
anticipated
2. Acute uncomplicated cystitisin E.coli Nitrofurantoin Co-
women – dysuria and 100mg PO trimoxazole
frequency in healthy, adult, non BID × 7 days 1DS BD X3-5
pregnant women with normal days
urinary tract (no
structural or functional
abnormalities)
3. Pyelonephritis – E.coli Mild to Definitive therapy
uncomplicated (no underlying moderate based on culture
genitourinary disease) illness: and susceptibility
Piperacillin – report.
Tazobactam
4.5gm IV TID Duration:
Mild to moderate
Severe illness cases – 7 days
– sepsis or Severe cases –
shock: 14days
Ertapenem1gm
IV OD
4. Complicated UTI (underlying E. coli, Meropenem1g Definitive therapy
GU disease Eg: neurogenic Proteus, IV TID based on culture
bladder, renal stones, Pseudomonas and susceptibility
hydronephrosis etc.,) aeruginosa report;
Duration 10-14
days
32
 Most likely Preferred
S.No Condition microbial antimicrobial Alternative Comments#
etiology
5. Foley catheter associated UTI E. coli, No empiric
Proteus, treatment
Pseudomonas
aeruginosa,
Acinetobacter
spp
* Do not send urine culture from an asymptomatic patient with an
indwelling urinary catheter

● Urinalysis for pyuria NOT useful in diagnosing CAUTI

● Treat only when patient has symptoms attributable to UTI
● Urine sample for culture should be obtained either through
- A new catheter (after removing the indwelling catheter), or
- Through sample port near junction of drainage tubing and
Foley catheter
- Do not send samples from the drainage bag· Remove urinary
catheter if possible
● Replace urinary catheter only if essential; consider alternatives
(e.g., condom catheter, intermittent catheterization etc.)
● Duration of antimicrobials: 7 – 14 days

33
 A7. Sepsis

1. Sepsis is a life-threatening organ dysfunction caused by host

response to infection. Septic shock is a subset of sepsis with
shock, cellular, and metabolic abnormalities which is associated
with an increased risk of mortality.

2. Suspect sepsis when some of the following are present:

a. General: fever (>38°C), hypothermia (< 36°C), tachycardia
(HR>90), tachypnea (RR>20), altered mental status.

b. Inflammatory: leukocytosis, leukopenia, >10% band forms,

thrombocytopenia (consumption), elevated plasma C-
reactive protein, elevated Procalcitonin.

c. Hemodynamic: arterial hypotension (SBP< 90 mm Hg, MAP<

70 mm Hg, or SBP decrease >40mm Hg)
d. Organ dysfunction: arterial hypoxemia, acute oliguria,
creatinine increase >0.5 mg/dL, coagulation abnormalities
(INR >1.5 or aPTT>60 sec), ileus, platelets <1 lakh,
hyperbilirubinemia (bilirubin >4 mg/dL)

e. Decreased tissue perfusion: elevated lactate >1 mmol/L,

decreased capillary refill or mottling

3. Prompt management of hypotension and hypoxia as per the

emergency and critical care management protocol

4. Look for common source of sepsis: urinary tract infections,

intra-abdominal sources, pneumonia, skin and soft tissue
infection and vascular line.

5. Assess possibility of hospital acquired infection

34
6. Obtain cultures:

a. Blood cultures (10ml) x 2 sets before initiating antibiotics

(one drawn percutaneously and the other through central
line if present)

b. Other relevant cultures based on the suspected source (eg.

urine, sputum, pus etc.)
c. Imaging studies to evaluate the source and to determine the
need for source control.

7. Common pathogens causing sepsis:

a. Gram-negative bacteria: E. coli, Klebsiella,

Enterobacter, Pseudomonas, Acinetobacter
b. Gram-positive bacteria: Staphylococcus aureus,
S.pneumoniae, Streptococcus spp.
c. Toxin mediated: Streptococcal or Staphylococcal toxic shock
syndrome

8. Antimicrobial management:

a. All patients should receive the first dose of antimicrobials as

soon as possible, preferably within 1 hour of presentation.
b. Empiric antibiotic selection should be based on the source of
infection and the local susceptibility profile of the suspected
organism causing the infection.
c. Initial empiric antimicrobials for sepsis when the
source is unclear:

35
 Condition Communityorganisms First choice Alternative Comments
Consider MRSA
Community Gram-negative Meropenem Add clindamycin when
cover in patients
acquired bacteria: E. coli, 1-2g IV. TID toxic shock is
with severe skin
Klebsiella, suspected and
and soft tissue
Enterobacter, vancomycin when
infections,
Pseudomonas, MRSA is likely
Hospital acquired severe
Acinetobacter
pneumonia,
Meropenem 2 g prosthetic Modify antimicrobial
Gram-positive IV TID + material / recent regimen in 48-72
bacteria: Polymyxin 15 central line hours based on the
Staphylococcus lakhs loading placement results of culture &
aureus, dose followed susceptibility reports,
S. pneumoniae, by7.5 lakhs the site of infection
Streptococcus twicedaily and the clinical status
spp of the patient

36
 Chapter 4: Targeted (Definitive) Therapy of
Common Infections
1. Infective endocarditis
Common
Condition organisms First choice Alternative Comments
Infective Penicillin Penicillin G 2-3 million Penicillin G2 million units 2 weeks regimen only
endocarditis susceptible Strep units IV Q4H x 4weeks IV Q4H + Gentamicin for uncomplicated
(native valve) viridans 3mg/kg IVOD x 2 weeks cases (no cardiac/
(MIC <0.12ug/ml) Ceftriaxone 2 g IV ODx 4 extra-cardiac
weeks Ceftriaxone 2g IV OD + abscess,
Gentamicin 3mg/kg IV. eGFR>50ml/min and
OD x 2 weeks age <65 years) of
Use if Ceftriaxone MIC native valve IE due to
<0.5 highly penicillin
susceptible Strep
viridans (MIC<0.12
ug/ml). For patients
with beta-lactam
allergy,use Vancomycin
15mg/kg IV BID
Strep viridans with Penicillin G 4 millionunits Ceftriaxone 2 g IV. OD For patients with beta-
penicillin MIC IV. Q4H x 4 weeks + + Gentamicin 3mg/kg lactam allergy.Use
>0.12 and Gentamicin3mg/kg IV. IV. OD x 2 weeks (if Vancomycin 15mg/kg
<0.5ug/ml OD x 2weeks isolate susceptible to IV. BID
ceftriaxone)
Enterococcus and Penicillin G 4 million units Ampicillin 2g IV. Q4H + Increase the treatment
Streptococci with IV. Q4H + Gentamicin Ceftriaxone 2g IV. Q12H to 6 weeksif symptom
penicillin MIC 3mg/kg IV.OD x 4weeks x 4 weeks duration is >3 months
>0.5ug/ml VRE: request for ID
consultation
MSSA Cloxacillin 2g IV. Q4Hx 6 Cefazolin 2 gm IV q8h For patients with beta-
weeks x 6 weeks lactam allergy.
Use Vancomycin 15-
30mg/kg IV. BID
MRSA Vancomycin 15- 30mg/kg Daptomycin 8-12mg
IV. Q12H x 6weeks /Kg IV Q24h
(Adjust dose toobtain
vancomycin trough level
15-20ug/ml)
HACEK Ceftriaxone 2 g IV. ODx Ampicillin 2 g IV. Q4Hx 4
4 weeks weeks

37
 Common
Condition organisms First choice Alternative Comments
Infective MSSA Cloxacillin 2 g IV. Q4H x6 ▪ Start rifampicin
endocarditis weeks + Rifampicin 3-5days after
(prosthetic 600mg p.o. BID x 6 cloxacillin and
valve) weeks + Gentamicin 1 gentamicin
mg/kg IV. Q8H x 2 ▪ Cardiothoracic
weeks surgery
consultation
MRSA Vancomycin 15mg/kg IV. ▪ Start rifampicin
Q12H x 6weeks + 3-5days after
Rifampicin 600mg p.o. BID vancomycin and
x 6 weeks + Gentamicin gentamicin
1mg/kg IV. Q8H x 2 ▪ Teicoplanin may
weeks be used instead
of vancomycin
(12mg/kg12h x
3days, followed
by 12
mg/kg/day).
▪ Request
vancomycin
MIC; if vanco
mic>1
▪ ID consult
should be
obtained

38
2. Bloodstream infections

a. Candidemia (Candida isolated from a single peripheral

or central-line blood culture):
Common
Condition First choice Alternative Comments
organisms

Candidemia C.albicans, Inj Anidulafungin Inj.Liposomal Candida krusei:

200mg loading Amphotericin B Echinocandinsor
C. glabrata
followed by 100mg 5mg/kg od Amphotericin B only
C.tropicalis, once daily Inj.Fluconazole
800mg stat f/b Duration:For 2weeks
C.krusei, OR
400mg od after documented
C.parapsilo Inj Caspofungin clearance from blood
sis 70mg loading without metastatic foci
followed by 50mg
once daily
Staphylococcus MSSA Cloxacillin 2 g IV.
aureus bacteremia Q4H
Duration: 14 days from
OR end of bacteremia for
Inj Cefazolin uncomplicated illness;
2gm IV Q8h longer duration for IE,
metastatic infections,
MRSA Vancomycin 15 delayed clearance of
mg/kg IV. BID bacteremia
OR
Teicoplanin
Daptomycin 6mg/Kg IV q12h
6mg/KG IV od . for 3 doses
Higher doses followed by
upto 10-12mg 6mg/Kg IV od
/Kg for
endocarditis
and serious
MRSA
infections

39
 i. Obtain blood cultures on alternate days until negative to
document clearance of candidemia

ii. Ophthalmology evaluation (fundoscopic examination) to r/o

retinal involvement

iii. Echocardiography for patients with persistently positive

(>96 hours after antifungal therapy) or clinical features
suggestive of IE
iv. Central venous catheters should be removed as early as
possible when presumed to be the source and the catheter
can be removed safely; decision should be individualized for
each patient

v. Duration of treatment: 14 days from end of candidemia (for

patients without obvious metastatic complications); change
to Fluconazole 400 mg p.o. OD after 5 to 7 days if isolate
susceptible and patient clinically stable
b. Staphylococcus aureus bacteremia (SAB)

i. Detailed history and physical examination to:

1. Determine source of bacteremia

2. Ascertain presence of prosthetic devices

3. Evidence of metastatic infection (e.g., endocarditis, bone and

joint infection, splenic abscess, renal abscess etc.)

ii. Echocardiography required for all patients with SAB to

r/o endocarditis. TTE may be adequate for patients
without identified risk factors for IE

40
 ● Indications for TEE: persistently positive (>96 hours
after appropriate antimicrobials) blood cultures,
presence of prosthetic heart valve, peripheral
stigmataof IE, cardiac valvular abnormalities,
metastatic infections.

iii. Obtain blood cultures on alternate days to document

clearance of bacteremia

iv. Antimicrobials:
1. MRSA: Vancomycin 15 mg/kg IV. BID

2. MSSA: Cloxacillin 2 g IV. Q4H (Alternative Cefazolin

2gm IV Q8h)

v. Duration: 14 days from end of bacteremia for uncomplicated

illness; longer duration for IE, metastatic infections, delayed
clearance of bacteremia

41
3. Other infections
Condition Etiology Preferred Alternative Comments
3.1 Bacterial infections
1.Enteric fever S.typhi 1. Azithromycin 20 Ceftriaxone 2 g IV OD
S.paratyphi A mg/kg/day×7 ×14 days
days(for MDR &cipro
resistant isolates
2. Co-trimoxazole 1
double –strength
tablet p.o BID ×14
days (if susceptible)

2. Scrub typhus O.tsutsugamushi 1.Doxycycline 100mg Azithromycin 500mg PO x

p.o/IV BID x 7days 5 days
3. Melioidosis ● B.Pseudomallei Intensive phase: Intensive phase: ● prolonged IV
● Ceftazidime 2 g IV ● meropenem 1 g IV therapy (4-8
Q6H ×14 days TID×14 days (for weeks or
followed by patients in ICU) longer )for
Eradication phase: ● meropenem 2 g IV Complicated
● Co-trimoxazole 2 TID×14 days(for pneumonia
double-strength neurological infection
tablets BID×3 months melioidosis) including
prostatic
abscesses,
o Neurological
melioidosis
o Osteomyelitis
o Septic
arthritis
• Abscess
drainage
4. Brucellosis Brucella abortus ● 1.uncomplicatrd Doxycycline 100 mg p.o Obtain ID consult
B.melitensis brucellosis: BID+ Rifampicin 600mg for patients with
Doxycycline 100 mg p.o OD×6 weeks complicated
focal disease
p.o BID×6 weeks+
(spondylitis,
Gentamicin 5mg/kg IV endocarditis,
OD x1 week neurobrucellosis)

42
 Most Likely
Condition Microbial First Choice Alternative Comments
Agent
5. C.difficile C.difficile ● Non severe disease ● testing for
colitis Metronidazole 500 C.difficile or its
mg P.O TID ×10 toxin should be
days performed only
● severe disease - when there is
Vancomycin 125 to diarrhoea(unformed
250 mg P.O QID stool) or ileus or
+/- Metronidazole toxic megacolon
500 mg IV tid ×10 due to C.difficile
days ● discontinue
unnecessary
antibiotic
● fluid and
electrolyte
replacement
● avoid antimotility
drugs and
● Stop proton
pump inhibitor
use
● surgery for
1. colonic
perforation
2. severe disease
not respondingto
antimicrobials

43
 Condition Etiology Preferred Alternative Comments
3.2 Parasitic infections
6.Malaria Plasmodiumvivax Chloroquine phosphate Primaquine
Day 1000 mg (600 mg base = 4 contraindicated for
tablets)P.O ×1 dose patients with
Day 2: 4 tablets P.O×1 dose G6PD
Day 3: 2 tablets P.O ×1 dose + deficiency
Primaquine 15 mg P.O OD ×14
days
Plasmodium Artemether20/Lumefantrine Primaquine
falciparum 120) 4 tabs twice daily for 3days 45mg P.O×1dose
after completion of
Artesunate
treatment
Severe Malaria Artesunate 2.4 mg/kg body weight
IV at admission ,then at 12and24
h, then once a day forat least 24
hours or clinically stable followed
by full course of oral ACT
7.Visceral Leishmania Liposomal Amphotericin B10 Amphotericin B
leishmaniasis donovani mg/kg IV ×1 DOSE deoxycholate 1
Liposomal Amphotericin B 3mg/kg mg/kg iv on
on D1 to D5, D14, D21 alternate days×15
days
8.Amoebic Liver Entamoeba Metronidazole 500 mg IV /800mg T Tinidazole 2gm Ultrasound
Abscess histolytica PO TID ,followed by: Diloxanide once daily for 5 d guided drainage
(suspect in furoate 500 mg PO TID 10 days indicated in:
patient with ● Large
single abscess abscesses(diameter
in the right lobe >10 cm
● Left lobeabscess
of the liverwith
● Signs of
no IHBRD and imminentrupture
no primary ● No responseto
intra- medical treatment
abdominal ● cannot
source) differentiatefrom
pyogenic liver
abscess

44
 Condition Etiology Preferred Alternative Comments
3.3 viral infections
9. Influenza Influenza A and B Oseltamivir 75 mg POBID×5 Indications for antiviral
viruses DAYS treatment
● Patients with suspected
or confirmed influenza
who are at high risk for
influenza complications
● Severe influenza
(suspected or confirmed
influenza who require
hospitalization)
3.4 Mycobacterial infections
10. Pulmonary Mycobacterium Rifampicin 10 mg/kg/day p.o If GeneXepert shows
Tuberculosis tuberculosis (max 600 mg OD)+Isoniazid 5 rifampicin resistance,
mg/kg/day p.o (max 300 mg obtain ID consultant
OD)+Pyridoxine 10 mg
p.o OD + Ethambutol
20mg/kg/day p.o. (max. 1600
mg OD) + Pyrazinamide
25mg/kg/day p.o. (max. 2000
mg OD) X 2months, followed
by Rifampicin + Isoniazid +
Pyridoxine + Ethambutol x 4
months (total duration: 6
months)
11. Surgical site M. cheloniei Clarithromycin 500 mg p.o. BID Surgical debridement
infection caused M. abscessus + Levofloxacin 750 mg OD + Duration of therapy depends
by rapidly M. fortuitum Amikacin 750 mg IV. OD x 3 - 6 on clinical response
growing months
mycobacteria
3.5 Fungal infections
12. Pneumocystis Cotrimoxazole (p.o. or IV.) Adjunctive therapy for severe
Pneumocystis jiroveci Dose: Trimethoprim 15 PCP (Pa <70 mmHg on room
pneumonia mg/kg/day given in 3 or 4 air)
divided doses ▪ Day 1 to 5: Prednisolone40
Duration: 21 days mg p.o. BID
▪ Day 6 to 10: Prednisolone
40 mg p.o.OD
▪ Day 11 to 21:
Prednisolone 20 mg p.o.OD

45
 Condition Etiology Preferred Alternative Comments

13. Invasive Aspergillus fumigat Voriconazole 6 mg/kg IV.or

aspergillosis us p.o. x 2 days, followedby 4
mg/kg BID till resolution of
symptoms, signs -
resolution or stabilization
of radiographic
abnormalities
14. Invasive Mucorales Liposomal AmphotericinB Amphotericin B ▪ Surgical
mucormycosis 5 mg/kg/day IV. till deoxycholate 1 debridement.
resolution of symptoms, mg/kg/day until Consider
signs -resolution or resolution of changing to T.
stabilization of symptoms, Posaconazole
radiographic signs resolution 300 mg p.o. bid
abnormalities or stabilization for 2 doses and
radiographic then 200mg od,
abnormalities after 2 weeks of
Amphotericin in
patients with
good clinical
response
▪ TDM for
Posaconazole
should be
checked after 1
week and aim to
achieve trough
concentration of
1ug/ml
15. Candiduria: Candida spp. ▪ Most patients
Treatment is need no
required only in antifungals
specific situations ▪ Remove urinary
such as catheter
▪ Neutropenic or Neutropenic
▪ Undergoing patients treated
urologic when indicated
manipulation ▪ T.Fluconazole
400mg OD

46
 Condition Etiology Preferred Alternative Comments

16. Chickenpox Varicella zoster Valacyclovir 1000 Acyclovir 800 mg To be started

virus mg P.O TID ×7 P.O. five times within 24 hours
days /day×7 days of onsetof rash

17. Herpes zoster Varicella zoster Valacyclovir 1000 Acyclovir 800 mg Begin within 72
virus mg P.O TID ×7 P.O. five times hours of onset
days /day×7 days of rash.
Immuno-compr
omised
patients:
Acyclovir 10
mg/kg IV TID

Change to
Valacyclovir
100 mg
P.O.TID once
infection is
controlled

Total duration
7-10 days

47
 Chapter 5: Infective Endocarditis Prophylaxis

High risk conditions requiring IE prophylaxis:

1. Prosthetic heart valves and prosthetic material used for cardiac

valve repair, such as annuloplasty rings and chords
2. Prior history of IE
3. Unrepaired cyanotic congenital heart disease
4. Repaired congenital heart disease with residual shunts or
valvular regurgitation at the site or adjacent to the site of the
prosthetic patch or prosthetic device
5. Repaired congenital heart defects with catheter-based
intervention involving an occlusion device or stent during the
first six months after the procedure
6. Valve regurgitation due to a structurally abnormal valve in a
transplanted heart

Procedures requiring IE prophylaxis:

a. Dental or oral procedures that involve manipulation of gingival

tissue or the periapical region of teeth or perforation of the oral
mucosa.
b. Invasive respiratory tract procedures that involve incision or
biopsy of the respiratory mucosa (eg, tonsillectomy,
adenoidectomy, bronchoscopy with biopsy).

The following antibiotic regime is recommended for standard

prophylaxis:
• Amoxicillin 2g orally 1 hr before procedure OR
• Cefuroxime 1.5gm IV/IM 30-60 min before the procedure

For patients allergic to penicillin:

• Clindamycin 600mg orally 1 hr or IV just before (dental and
respiratory) procedure

48
 Chapter 6 : Surgical prophylaxis

1. A single preoperative dose of antibiotic is sufficient; there is no

evidence for post-operative prophylactic antibiotics.
2. Antibiotics are repeated if the duration of operation is > 4 hours
or if blood loss is > 1 liter (except vancomycin, aminoglycoside,
fluoroquinolone).
3. Prophylactic antibiotics should be administered within 1 hour
prior to incision.
4. Prophylactic antibiotics should not be used in perianal
procedures (lay open fistula, hemorrhoidectomy, lateral anal
sphincterotomy)
5. Avoid hypothermia as it increases incidence of surgical site
infection.
6. No role for prophylactic antibiotics in prosthetic implant,
thyroglossal cyst excision, thyroidectomy and in routine
catheterization.
7. No role of prophylactic antibiotics in Laparoscopy, diagnostic
hysteroscopies and cervical encerclage procedure.
1a. Clean operation without use of prosthetic implant:
(parotidectomy, radical neck dissection, mastectomy,
adrenalectomy, hepatectomy, hydatid cyst liver without biliary
communication, splenectomy, porto- systemic shunt operation)
The evidence for the use of antibiotic is thin. However, if an
antibiotic is deemed necessary:
Recommendation: Inj Cefuroxime 1.5 gm IV

1b. Clean operation with use of prosthetic

implant (inguinal hernioplasty, incisional hernia mesh repair,
aortic aneurysm repair, aorto femoral bypass).
Recommendation: Inj Cefuroxime 1.5 gm IV

49
2a. Clean contaminated operation (cholecystectomy
laparoscopic and open, gastrojejunostomy, gastrectomy, jejunal
resection anastomosis, distal pancreatectomy, pseudocyst
gastrostomy, pseudocyst jejunostomy, low risk perforated peptic
ulcer)

Recommendation: Inj Cefuroxime 1.5 gm IV (evidence for

prophylactic antibiotics in low risk laparoscopic cholecystectomy is
thin)

2b. Clean contaminated operation (head & neck operation where

oral cavity / upper aerodigestive tract is open, including
esophageal operations). Recommendation: Inj Cefuroxime 1.5 gm
IV + Inj Metronidazole 500 mg IV (alternative: clindamycin)

3. Contaminated operation (colectomy, obstructed biliary tract,

choledocholithiasis). Recommendation: Inj Cefuroxime 1.5 gm IV
+ Inj Metronidazole 500 mg IV (alternative: clindamycin +
metronidazole). Surgeries on obstructed Biliary system should
also add Inj. Amikacin 15mg /Kg.

4. Dirty (fecal peritonitis, anastomotic leakage)

Antibiotics are not “prophylactic” here. Choice of antibiotics will

depend on whether organ dysfunction is present or not. Specimens
for culture and sensitivity should be taken at operation. If organ
dysfunction is present broad-spectrum antibiotics will be chosen
initially and de-escalate once culture / sensitivity results are
available.

50
 Esophago-gastro duodenal surgery

Recommended Usual
Nature of operation Etiology RedoseInterval
antimicrobials adult dose
Procedure involving entry Enteric gram Cefuroxime 1.5 g IV 4 hours
into lumen of gastrointestinal negative bacilli,
tract gram- positive
cocci.
Procedure not involvingentry Enteric gram- *High risk only: 1.5g IV 4 hours
into lumen of gastrointestinal negative bacilli, Cefuroxime
tract (selective vagotomy. gram- positive
antireflux) cocci
*HIGH RISK – Morbid obesity, gastrointestinal obstruction, decreased gastric acidity or GI
motility, gastric bleeding, malignancy or perforation, or immunosuppression.

Biliary tract surgery (including pancreatic)

Nature of operation Recommended sual adult dose Redose Interval

Etiology antimicrobials
Laparoscopic - NA NA NA
procedure (lowrisk)

Open procedure or Enteric gram- Cefuroxime 1.5g IV 4 hours

laparoscopic negative bacilli,
procedure (high enterococci,
risk) clostridia
Obstructed biliary Enteric gram- Cefuroxime 1.5g IV 4 hours
system negative bacteria
PLUS NA
Amikacin 15mg/kg
High risk laparoscopic – age >70 years, acute cholecystitis, non-functioning gallbladder, or
common bile duct stones

51
 Small intestine surgery
Nature ofoperation Recommended Usual adultdose Redose Interval
Etiology antimicrobials
Non obstructed Enteric gram- Cefuroxime 1.5g IV 4 hours
negative bacilli,
gram-positivecocci
Obstructed Enteric gram- Cefuroxime 1.5g IV 4 hours
negative bacilli,
anaerobes,
enterococci PLUS 500 mg IV NA
Metronidazole

Colorectal surgery
Nature of Recommended Usual adult Redose
operation Etiology antimicrobials dose Interval
Colorectal surgery Enteric gram- Cefuroxime 1.5g IV 4 hours
negative bacilli,
anaerobes,
PLUS
enterococci Metronidazole 500 mg IV NA

Hernia Surgery
Nature of Recommended Usual adult Redose
operation Etiology antimicrobials dose Interval
Hernia Aerobic gram- Cefuroxime 1.5g IV 4 hours
positive
organisms

52
 Head & Neck Surgery
Recommended Usual adult Redose
Nature of operation Etiology antimicrobials dose Interval
Clean including - None N/A N/A
thyroidectomy
Clean contaminated Anaerobes, Cefuroxime 1.5g IV 4 hours
enteric gram-
negative PLUS
bacilli, 500 mg IV
S.aureus Metronidazole NA

Vascular Surgery
Recommended Usual adult Redose
Nature of operation Etiology antimicrobials dose Interval
Arterial surgery S.aureus Cefuroxime 1.5g IV 4 hours
involving prosthesis, S. epidermidis
abdominal aorta or
groin incision
Superficial venous S.aureus NA NA NA
system surgery S. epidermidis

Mastectomy
Recommended Usual adult Redose
Nature of operation Etiology antimicrobials dose Interval
Clean Aerobic gram- Cefuroxime 1.5g IV 4 hours
positive organisms

Orthopedic Surgery
Nature of operation Etiology Recommended Usual adult dose Redose
antimicrobials Interval
Clean surgeries Aerobic Cefuroxime 1.5g IV 4 hours
including fracture gram-positive
repair, implantation organisms
of fixation devices
and joint replacement

53
 Obstetrics and Gynecology
Recommended Redose
Nature of operation Etiology antimicrobials Usual adult dose Interval
Caesarean delivery Aerobic Cefuroxime 1.5g IV 4 hours
(Elective and gram-positive
emergency) organism
Hysterectomy Aerobic Cefuroxime 1.5g IV 4 hours
(Abdominal and gram-positive
Vaginal) organism
Please Note: Inj Cefazolin 1gm IV can be used in place of Inj Cefuroxime 1.5gm IV

Reproductive Medicine
Recommended Redose
Nature of operation Etiology antimicrobials Usual adult Interval
dose
Operative Laparoscopy, Aerobic Cefuroxime 1.5g IV 4 hours
Operative Hysteroscopy, gram-positive
Major Operative organism Metronidazole 500mg 4 hours
Laparoscopy
Myomectomy
Cystectomy
Hysterolaparoscopy
Salpingectomy
Septal resection

54
 Chapter 7: Prophylactic Antibiotic Protocol For
Trauma Patients In The Adult Emergency Department

Trauma sites Antibiotics

1. Scalp 1a. Abrasion Neosporin/ Fusidic acid L/A

1b. Laceration (clean) Daily cleaning and dressing if

needed

1c. Laceration Cap. Cloxacillin 500 mg q6h x3

(contaminated) days or
Cap. Cephalexin 500 mg q6h x3
days
+
Tab. Metronidazole 400 mg
TID x3 days
(only if severely
contaminated)
1d. Laceration with Inj. Cloxacillin 1 g IV stat and
underlying fracture of q6h
skull bones or
Inj. Cefazolin 1 g IV stat and
q8h
or
Inj. Cefuroxime 1.5 g stat and
q8h
+
Inj. Metronidazole 500 mg IV
stat and Q8h (only if severely
contaminated)
If discharged from ED:
Cap. Cloxacillin 500 mg q6h x3
days or

55
 Cap. Cephalexin 500 mg q6h x3
days
+
Tab. Metronidazole 400 mg
TID x3 days
(only if severely
contaminated)
2. Face 2a. Abrasion Neosporin/ Fusidic acid L/A

2b. Superficial laceration Cap. Cloxacillin 500 mg q6h x3

(involves epidermis, dermis days or
& fascia) Cap. Cephalexin 500 mg q6h x
3 days
2c. Superficial laceration Cap. Cloxacillin 500 mg QID x3
involving dangerous area days
of face
2d. Superficial laceration Cap. Cloxacillin 500mg QID x3
involving dangerous area days
of face + intraoral +
laceration Tab. Metronidazole 400 mg
TID x3 days
2e. Deep laceration Inj. Cloxacillin 1 g IV stat and
(involves epidermis, dermis q6h
fascial & muscle) or
Inj. Cefazolin 1g IV stat and
q8h
or
Inj. Cefuroxime 1.5 g stat and
q8h
+
Inj. Metronidazole 500 mg IV
stat and Q8h (only if severely
contaminated)
2f. Deep laceration with Inj. Cloxacillin 1 g IV stat and
facial bone fractures q6h
or
Inj. Cefazolin 1 g IV stat and
q6h
or
Inj. Cefuroxime 1.5 g stat and q8h

56
 +
Inj. Metronidazole 500 mg IV
stat and Q8h (only if severely
contaminated)

If discharged from ED:

Cap. Cloxacillin 500 mg q6h x3
days or
Cap. Cephalexin 500 mg q6h x3
days
+
Tab. Metronidazole 400 mg
TID x3 days
(only if severely
contaminated)

2g. Deep laceration + facial Inj. Cloxacillin 500 mg IV stat

bone fractures +intraoral and q6h
extension or
Inj. Cefazolin 1 g IV stat and
q6h
or
Inj. Cefuroxime 1.5 g stat and
q8h
+
Inj. Metronidazole 500 mg IV
stat and Q8h

If discharged from ED:

Cap. Cloxacillin 500 mg q6h x3
days or
Cap. Cephalexin 500 mg q6h x3
days
+
Tab. Metronidazole 400 mg
TID x3 days
3. Thorax, 3a. Abrasion Neosporin/ Fusidic acid L/A
abdomen, back& 3b. Superficial laceration Cap. Cloxacillin 500 mg q6h x3
pelvis (involves epidermis, dermis days or
& fascia) Cap. Cephalexin 500 mg q6h x 3
days

57
 3c. Deep laceration Inj. Cloxacillin 1 g IV stat and
(involves epidermis, dermis, q6h
fascia & muscle) or
Inj. Cefazolin 1 g IV stat and
q6h
or
Inj. Cefuroxime 1.5 g stat and
q8h
+
Inj. Metronidazole 500 mg IV
stat and Q8h (only if severely
contaminated)

If discharged from ED:

Cap. Cloxacillin 500 mg q6h x3
days or
Cap. Cephalexin 500 mg q6h x3
days
+
Tab. Metronidazole 400 mg
TID x3 days
(only if severely
contaminated)
3d. Penetrating injuries Inj. Piperacillin-tazobactam 4.5g
(Stab entering parietal IV stat and Q8h
pleura or peritoneum)
4. Animal/ 4a. Human bite Tab. Augmentin 625 mg TID x
human bites 3-5 days

4b. Dog/cat/rat bite Tab. Augmentin 625 mg TID x

3-5 days

4c. Bull gore injury Inj. Piperacillin-tazobactam 4.5g

(penetrating) IV stat and Q8h

5. Appendicular 5a. Abrasion Neosporin/ Fusidic acid L/A

injuries

58
Without 5b. Superficial laceration Cap. Cloxacillin 500 mg q6h x3
fractures (involves epidermis, dermis days or
and fascia) Cap. Cephalexin 500 mg q6h x
3 days
5c. Deep laceration Inj. Cloxacillin 500 mg IV stat
(involves epidermis, dermis, and q6h
fascia, muscle and tendon) or
Inj. Cefazolin 1g IV stat and
q8h
or
Inj. Cefuroxime 1.5 g stat and
q8h
+
Inj. Metronidazole 500 mg IV
stat and Q8h (only if severely
contaminated)
If discharged from ED:
Cap. Cloxacillin 500 mg q6h x3
days or
Cap. Cephalexin 500 mg q6h x3
days
+
Tab. Metronidazole 400 mg
TID x3 days
(only if severely
contaminated)
Appendicular 5d. No or minimal Inj. Cloxacillin 500 mg IV stat
injuries with contamination and q6h
fracture Or Inj. Cefazolin 1 g IV stat
and q8h or Inj. Cefuroxime 1.5g
stat and q8h
5e. Heavily contaminated Inj. Cloxacillin 1 g IV stat and
wound q6h or Inj. Cefazolin 1 g IV stat
and q8h or Inj. Cefuroxime 1.5 g
stat and q8h
+
Inj. Metronidazole 500 mg IV
stat and Q8h

59
 Chapter 8: Covid-19 Treatment Guidelines

This is a dynamic protocol which will change according to the available

evidences. Please see the latest guidelines in intranet.
Please note that all recommendations apply to non-pregnant adults
with PCR-confirmed COVID-19 only. These are dynamic guidelines,
which are updated regularly.

WHO definitions of disease severity for COVID-19

• Critical COVID-19 – Defined by the criteria for acute respiratory
distress syndrome (ARDS), sepsis, septic shock, or other conditions
that would normally require the provision of life-sustaining
therapies such as mechanical ventilation (invasive or non-invasive)
or vasopressor therapy.

• Severe COVID-19 – Defined by any of: ◦ oxyg

on room air; ◦ sign
distress (in adults, accessory muscle use, inability to complete full
sentences, respiratory rate > 30 breaths per minute; and, in
children, very severe chest wall in-drawing, grunting, central
cyanosis, or presence of any other general danger signs including
inability to breastfeed or drink, lethargy, convulsions or reduced
level of consciousness).
• Non-severe COVID-19 – Defined as the absence of any criteria for
severe or critical COVID-19.

Amended guidance for Remdesivir: Benefit for remdesivir use has

been downgraded as per latest evidence available. Please note the
changes in mild, moderate, severe and critical categories
All recommended doses assume weight ≥50kg, eGFR
≥30ml/min and normal liver function: outside of these, please
apply clinical judgment, consult product literature, and/or
seek specialist input.

60
CONSIDER ENROLMENT OF ALL ELIGIBLE PATIENTS INTO A
CLINICAL TRIAL

Table 1: Treatment options according to clinical severity (adapted from WHO

treatment guidelines (14th July 2022)
Non – Severe COVID -19 For ALL patients on the home isolation
program:
• Pulse oximetry and temperature twice
daily; 40-step test OR 1-minute sit and
stand OR 6-minute walk test for
exertional desaturation once daily(if
able)
• Symptom management withParacetamol
Triggers for admission into hospital are:
o Fever >101⁰F for > 7 days
o SpO2 < 92% on room air

In those with high risk for disease

progression or hospitalization or
death

1. If available, consider Nirmatrelvir

and ritonavir * 14
300 mg (two 150 mg tablets) of
nirmatrelvir and 100 mg of ritonavir
every 12 hours daily for 5 days.
[Strong recommendation]
OR
2.Inj. Remdesivir D1: 200mg, D2 and
3 100mg once daily for 3 days6
[Weak/ Conditional
recommendation]
OR
3. Consider Casirivimab/Imdevimab
combination13 (If viral genotyping is available
and for those with Seronegative status for
SARS -CoV 2 antibodies). Evidence of limited
efficacy against Omicron variant. [Conditional
recommendation]

61
Severe or Critical COVID -19 For ALL:
• Pulse oximetry continuously
• Give Dexamethasone5 [Strong
recommendation]
• Give prophylactic dose
thromboprophylaxis 4 AND ensure no
contra- indications3
• Give therapeutic anticoagulation if
thromboembolism strongly suspected (for
example, PE may be suggested by sudden
respiratory or haemodynamic deterioration,
or if oxygen requirements are
disproportionate to the severity of
pneumonia on chest imaging) if no contra-
indications
If requiring vasopressor OR respiratory
support (NIV/IMV/ECMO) for < 24 hours,
AND CRP >100mg/ml
• Careful consideration of adding
Tocilizumab (single dose of 8mg/kg-
maximum 800mg) in consultation with a
senior member of the treating team10
Second dose of Tocilizumab NOT
recommended routinely unless there are
extenuating circumstances
• Consider Baricitinib 4mg once daily for 14
days if Tocilizumab cannot be given and
patient requires progressively increasing
oxygen flows (FiO2 >40%) with evidence of
systemic inflammation12. AVOID Baricitinib
and Tocilizumab combination as it can
predispose to a higher risk of infection)
Adjunctive therapies
• Consider Casirivimab/Imdevimab
combination13 (If viral genotyping is
available and for those with Seronegative
status for SARS -CoV 2 antibodies). Evidence
of limited efficacy against Omicron variant.
[Conditional recommendation]
62
 •Proning, if no contra-indications8
Post discharge thromboprophylaxis
• As dictated by confirmed thrombotic
manifestation
• May be considered if patients considered
high risk for VTE and low risk for bleeding
as determined by HASBLED score
Pulmonary Rehabilitation
•Breathing and other exercises as per
booklet available on intranet
Visit Post SARI clinic for intensive
pulmonary rehabilitation

All recommended doses assume weight ≥50kg, eGFR ≥30ml/min and normal
liver function. Risk factors for disease progression include age >50 years,
obesity, defined as body mass index >30, cardiovascular disease including
hypertension, chronic lung disease including asthma, chronic metabolic
disease including diabetes, chronic kidney disease including those on
dialysis, chronic liver disease, immunosuppressed (cancer treatment, bone
marrow or organ transplantation, immune deficiencies, poorly controlled
human immunodeficiency virus [HIV] or acquired immunodeficiency
syndrome [AIDS], prolonged use of immune suppressants.

Modified VTE score:

VTE risk factor VTE risk Score

Previous VTE 3
Known Thrombophilia 2
Current lower limb paralysis or paresis 2
History of cancer 2
ICU/CCU stay 1
Complete immobilization ≥ 1day 1
Age ≥ 60 years 1

63
THROMBOPROPHYLAXIS (ANTICOAGULANT) DOSING TABLE

Product Thromboprophylaxis dose Therapeuticdose

Low dose Intermediatedose

40 mg q24h
Low Molecular
Weight [BMI>40/Weight >120Kg – 1 mg/kg q24h 1mg/kg q12h
Heparin(LMWH) dose increase to40 mg
– Enoxaparin q12h]

Unfractionated 5000U q12h 5000 U q8hOR 80 U/kg bolus

Heparin(UFH) 7500 U q12h followed by 18
U/kg/hour
infusion
Targeting APTT
of 55-
75 seconds

HASBLED SCORE

Risk factor Score

Hypertension (>160mmHg systolic) 1
Abnormal liver or renal function 1 or 2
Stroke 1
Bleeding tendency 1
Labile INR 1
Age >65 1
Drugs (concomitant aspirin, NSAIDs and 1 or 2
alcohol)
MAXIMUM SCORE 9
A score 0-2 indicates a low risk of
bleeding; a score of ≥ 3 indicates a high
risk of bleeding.

64
Kindly consider the following points prior to prescription

1. Prophylactic dose anticoagulation: First option: Enoxaparin or

Dalteparin, as per table below; Second option: Fondaparinux 2.5mg
OD SC; Third option: Unfractionated heparin 5000 units BD SC.
Consider dose adjustment in renal failure (refer to product
literature for further details).
2. Risk factors for thrombotic disease: Symptomatic for COVID-19 (not
incidentally detected), Age ≥60 years; dehydration; active cancer;
BMI>30; previous thrombotic disease; oestrogen use; recent surgery
(<28 days); significantly reduced mobility from baseline likely to
persist for ≥3 days. The list is not exhaustive; clinician judgement
may identify other less common risk factors.
3. Contra-indications to anticoagulation:

-ALL: Absolute: Platelets <20,000/mm3. Relative: platelets <50,000/mm3;

Brain metastases; Recent major trauma; Major abdominal surgery within
the past 2 days; Gastrointestinal or genitourinary bleeding within the past 14
days; Endocarditis; Severe hypertension (systolic BP >200 or diastolic BP
>120 mm Hg).

[Modified from: Bates N Engl J Med 2004;351:268-77 &Kearon Chest

2016; 149(2):315-352 DOI 10.1016/j.chest.2015.11.026]

-AND for Enoxaparin (taken from literature for Clexane®): Known

hypersensitivity to enoxaparin, heparin or other LMWHs; History of
immune mediated heparin-induced thrombocytopenia (HIT) within the
past 100 days or in the presence of circulating antibodies; Active major
bleeding and conditions with a high risk of uncontrolled haemorrhage
including recent haemorrhagic stroke. (Refer to product literature for
further details, including dosing for renal failure.)

-AND for Dalteparin (taken from literature for Fragmin®): Acute

gastroduodenal ulcer; cerebral haemorrhage; known haemorrhagic diathesis
or other active haemorrhage; serious coagulation disorders; acute or sub-
acute septic endocarditis; injuries to and operations on the central nervous
system, eyes and ears.

AND for Fondaparinux (Arixtra®): Known hypersensitivity to Arixtra or

any of the excipients; Active clinically significant bleeding; Acute
65
 bacterial endocarditis. (Refer to product literature for further details,
including dosing for renal failure.) 4: Intermediate dose anticoagulation:
Enoxaparin or Dalteparin, as per table above. Consider dose adjustment in
renal failure (see product literature for full details). For alternative drugs,
consult productliterature.

4. Intermediate dose of anticoagulation (1mg/kg once daily);Therapeutic

dose anticoagulation 1mg/kg twice daily. Enoxaparin or Dalteparin, as
per table above. Consider dose adjustment in renal failure (see product
literature for full details). For alternative drugs, consult product
literature.

5. Dexamethasone: 6mg OD IV/PO for 7-10 days or until discharge (if

earlier), if no contra indications, with PPI gastroprotection and blood
glucose monitoring. If pregnant orbreastfeeding, use prednisolone 40 mg OD
PO or methylprednisolone 32mg OD IV instead. If already receiving
hydrocortisone for shock or ARDS (or steroids for other indications)
clinicians should consider whether to switch to dexamethasone, and its
dose/duration.

6. Remdesivir: Evidence synthesis from the India covid guidelines group

reveals that Remdesivir confers no mortality benefit. In addition there is
no evidence that it prevents progression to oxygen or respiratory
support. There is a signal to a reduced time to clinical improvement,
however whether Remdesivir adds to the mortality benefit of steroids is
uncertain. Considering the cost and availability issues it seems
appropriate, that it should be used only in patients in the moderate
category. Also note practical considerations: cost, and requirement for 5
days’ intravenous course. Dosing: 200mg once IV on day 1, then 100mg
OD for 4 days (total 5 days). Check FDA factsheet for cautions, contra-
indications and special considerations. Note interaction with CQ/HCQ.

7. Significant requirements: oxygen ≥40% FiO2 or ≥5L via simple mask or

NIV/CPAP/high-flow nasal oxygen or ARDS.

8. Proning: see awake self-proning protocol for patients on wards, and ICU
protocol for patients on MICU.
9. Recent data from mPRCT (ATTACC, ACTIV-4, REMAP-CAP) indicates that while
therapeutic anticoagulation does not reduce mortality may have a role in
preventing thrombotic events RR=0.58(0.37-0.89) leading to an absolute risk
reduction of 4 per 100 with a NNT of 20, with no higher risk of bleeding
noted in present evidence synthesis. This data had moderate certainty of
evidence.
66
10. Tocilizumab: There is considerable heterogeneity in stratification of
severity among the various trials. The relative benefit of reducing
mortality is 11% could vary from 2% to 19% and this will need to be
taken into context of cost. This should be given in addition to
Dexamethasone. Dose modification not required in renal impairment
with CrCl >30ml/min. Initiation not recommended in the presence of
active non-COVID infection or significant hepatic impairment. Common
adverse effects include increased risk of GI perforation, neutropenia,
thrombocytopenia, liver injury, herpes zoster reactivation. Increased
vigilance recommended for bacterial, viral, protozoal and fungal
opportunistic infections.

11. Risk factors for severe disease include older age group (>60), presence
of comorbidities, elevated inflammatory parameters like CRP, D-dimer,
lymphopenia, thrombocytopenia and a transamnitis. Lancet.
2020;395(10229):1054. Epub 2020 Mar 11. References: Lancet.
2020;395(10229):1054. Epub 2020 Mar 11, JAMA Intern Med.
2020;180(7):934.

12. Baricitinib is an orally administered selective inhibitor of Janus kinase

(JAK) 1 and 2 inhibitor and is believed to inhibit the intracellular
signaling pathway of cytokines known to be elevated in COVID19
including IL-2, IL_6, IL-10,IFN-and GM-CSF. It acts against SARS CoV-2
through impairment of AP2-associated protein kinase 1 and and
prevents SARS CoV-2 entry and infectivity and improves lymphocyte
counts in patients with COVID-19. It is given orally 4mg daily for 14 days
or until hospital discharge. In patients who were given Baricitinib was
found to have a mortality in a pooled estimate of 2 trials RR=0.63 (0.48-
0.81).

13. Casirivimab Imdevimab or REGN-COVTM is a cocktail made up of two

noncompeting, neutralizing human IgG1 antibodies that target the
receptor binding domain of the SARS-CoV-2 spike protein, thereby
preventing viral entry into human cells through the angiotensin-
converting enzyme 2 (ACE2) receptor. At a dose of 1.2g there is
moderate certainty evidence that it reduces hospital admission RR=0.27
(95% CI 0.11-0.65) but does not reduce mortality, progression to
invasive mechanical ventilation or admission to critical care. Risk factors
for disease progression include age >50 years, obesity, defined as body
mass index >30, cardiovascular disease including hypertension, chronic
lung disease including asthma, chronic metabolic disease including
diabetes, chronic kidney disease including those on dialysis, chronic

67
 liver disease, immunosuppressed (cancer treatment, bone marrow or
organ transplantation, immune deficiencies, poorly controlled human
immunodeficiency virus [HIV] or acquired immunodeficiency syndrome
[AIDS], and prolonged use of immune-weakening medications).
Intravenous total dose of the monoclonal antibody combination differed
in the non-severe trials, ranging from total dose 1200 mg–8000 mg (600
mg–4000 mg each antibody), demonstrating efficacy at all doses,
including the lowest tested, 1200 mg total dose (600 mg of each
antibody). Should be given early in the illness (less than 7 days of
symptoms)

14. Nirmatrelvir inhibits the SARS-CoV-2 protease (3CLpro), thereby

preventing cleavage of the viral polyprotein which is needed for viral
proteins to become functional (32). Inhibition of the protease renders
the virus unable to replicate. Nirmatrelvir is coadministered with
ritonavir, a HIV protease inhibitor, used in this context to boost the
pharmacokinetics of nirmatrelvir but without exerting any direct
antiviral activity itself. In renal insufficiency (GFR 30–59 mL/min) the
dose reduction is 150 mg of nirmatrelvir and 100 mg of ritonavir every
12 hours daily for 5 days. The GDG concluded that nirmatrelvir-ritonavir
represents a superior choice because it may have greater efficacy in
preventing hospitalization than the alternatives, has fewer concerns
with respect to harms than does molnupiravir; and is easier to
administer than intravenous remdesivir and the antibodies. The strong
recommendation in favour does not apply to pregnant or breastfeeding
women, children, or those with possible dangerous drug interactions
(many drugs interact with nirmatrelvir-ritonavir, see mechanism of
action). It should be administered as soon as possible after onset of
symptoms, ideally within 5 days

68
 Chapter 9: Dosing of antimicrobial agents in
renal insufficiency
Cockcroft-Gault equation to calculate creatinine clearance (CrCl) for
drug dosing in renal impairment CrCl (ml / min) = (140-age) x
weight(kg) (x0.85if female)
72 x serum creatinine (mg / dl)
NB If anuric, morbidly obese or in acute renal failure, this equation
will NOT give a true reflection of the creatinine clearance. Anuric
and oliguric(<500ml / day) patients assumed to have CrCl<10ml /
min.

If morbidly obese, use ideal bosy weight (IBM):

IBM (in kg) for males = 50kg + 2.3kg for every inch over 5 feet
(Devineformula – Average BMI of 23.0)
IBM (in kg) for women = 49kg + 1.7kg for each inch over 5
feet(Robinson formula – average BMI of 21.1)

Antimicrobial agent Normal dose Mild 20-50

Aciclovir IV 10 mg/kg q8h 10 mg/kg q12h
Aciclovirpo Simplex: 200-400 mg q6h Normal dose
Zoster: 800 mg 5 times a day
Amikacin IV 15 mg/kg q24h 7.5 mg/kg q24h
Amoxicillin po 500 mg – 1g q8h Normal
Amphotericin IV 1 mg/kg q24h Normal
Liposomal Amphotericin IV 3-5mg/kg q24h Normal
Ampicillin IV 2gm q4-6h Normal
Anidulafungin IV 200 mg for 1 day then 100 mg Normal
q24h
Artemether with 20 mg / 120 mg tabs: 4 tabs Normal
lumefantrinepo q12h for 3 days
Artesunate IV 2.4 mg/kg at 0, 12 and 24 h Normal
then q24h
Azithromycin IV + po IV: 500 mg q24h Normal
Po: 500mg – 1g q24h
Benzylpenicillin (CP) IV 20-40L units q4h Normal

69
Caspofungin IV 70 mg for 1 day then 50 mg Normal
q24h [if >80 kg 70mg q24h]
Cefazolin IV 1-2g q8h Normal
Cefoperazone + sulbactam IV 3g q12h but severe / less Normal
(1.5g = 1g + 500 mg, 3g = 2g + sensitive / neutropenia 3g q8h
1g) tomax6g q12h

Comments
CrCl (ml/min)
Severe <10 AD = After
Moderate 10-20
haemodialysis
10 mg/kg q24h 5 mg/kg q24h AD
Simplex: 200 – 400mg q6h Simplex: 200 – 400mg AD
Zoster: 800mg q8h q12h
Zoster: 800mg q12h
7.5mg/kg q24-48h 7.5mg/kg q48-72h Supplement
HD: 7.5 mg/kg AD
500mg – 1g q12h 500mg – 1g q24h AD
Consider liquid Consider liquid No supplementation after
formulations formulations HD
Amphotericin is highly NEPHROTOXIC. Consider using Liposomal Amphotericin.
Monitor CrCl daily
Normal Normal
2gm q6-8h 2gm q8-12h AD
Normal Normal
Normal Normal <10 Monitor ECG &
potassium
Normal Normal
Normal Normal
10-20L q4h 5-10L q4h AD
Normal Normal
1-2g q12h 1g q24h AD
3g q12h plus if severe extra 1.5g q12h plus extra AD
cefoperazone 2g q24h to cefoperazone 1g q12h; if
max 2g q12h severe 2g q12h tomax 3g
q12h

70
 ANTIBIOTICS,
ANTIFUNGALS, Normal dose Mild 20-50
ANTIVIRALS
Ceftazidime IV 1-2 g q8h CrCl 31-50: 1-2g 12h
Ceftriaxone IV 1-2g q12 – 24h Normal
Ciprofloxacin IV + po IV 400mg q8h Normal
PO 750mg q12h
Clarithromycin IV + po IV 500mg q12h Normal
PO 750mg q12h
Clindamycin IV + po IV 600mg q6-8h Normal
PO 300-450mg q6h
IV 1-2g q4-6h
Cloxacillin IV + po Normal
PO 500mg -1g q6h
Co-amoxiclav IV + po IV-1.2gm q8h Normal
(Agugmentin ® etc) PO 1000 mg q12h
9MU Loading dose (LD) CrCl-60-80: Normal
Colistimethate sodium IV
[If <60kg 0.15MU/kg] CrCl-50-59: Normal
LD then
THEN after 12 hours 4MU q12h [if <60kg
0.044MU/kg q8h]
3MH q8h
CrCl-20-49: Normal
[If <60kg 0.05MU/kg q8h]
LD then 2MU q8h (if
>60kg) [If <60kg
0.038Mu/kg q8h]
Colistimethate sodium NEB 1-2MU q12h 1 MU q12h
PCP: (TMP 15mh/kg/day) or 1
DS (960mg) tab per 10 kg/day
in 2-4 divided doses.
Co-trimoxazole IV + po [DS Melioidosis: 1920mg (2 DS
= 960 mg = 800mg (960mg) tabs) q12h
Nocardiosis: (TMP 10-15 CrCl-30-50: Normal
sulfamethoxazole and 160
mg/kg/day) in 2-4 divided
mg trimethoprim]
dosesToxoplasmosis: (TMP
5mg/kg) q12h
Prophylaxis: 960mg q24h or
960mg q12-24h 3 days a week

71
 Comments
CrCl (ml/min) Moderate 10-20 AD = After
Severe <10
haemodialysis

CrCl-10-30: 1-2g q24h 500mg – 1g q24h AD

Normal Normal
IV 200-400 IV 200-400 mg q12h PO 250-
mg q12h PO 500mg q12h
250-500mg
q12h
250-500 mg q12h 250-500mg q24h AD

Normal Normal
Normal (Max 6g/day)
Normal IV 1.2g q24h AD
PO 625mg q8-12h
IV 1.2g q12h Normal LD then1.5MU q12h 2MU q12h on
PO 625 mg [If <60kg 0.023MU/kg dialysis days[If
q8-12h <60kg
Normal LD
then
2MU q12h q12h] 0.038MU/kg
[If <60kg .038MU/kg q12h] q12h] NB if <
60kg round to
nearest 0.5g
1 MU q24h AD
1MU q12h CrCl<15 AD
CrCl-15-30 All infections: 50% of
PCP: Normal for first 3days followed usual doses
by
50% of usual dose Prophylaxis: Normal

72
ANTIBIOTICS, ANTIFUNGALS,
Normal dose Mild 20-50
ANTIVIRALS
Daptomycin IV Soft tissue infections 4- Normal
5mg/kg q24h Bacteremia
and Endocarditis 8-
10mg/kg q24h
Dicoloxacillin IV + po IV 1-2g q4-6h Normal
PO 500 mg-1g q6h
Doxycycline IV + po 100 mg q12h Normal
Ertapenem IV 1g q24h Normal
Ethambutolpo 20mg/kg q24h Normal
Fluconazole IV + po 50-800 mg daily Start normal dose
then 50%
Ganciclovir (induction) 5 mg/kg q12h CrCl-50-69 2.5mg/kg
q12h
CrCl-25-49 2.5mg/kg
q24h
Gentamicin IV Once daily: 5-7 mg/kg Once daily: 60-79
q24h 4mg/kg q24h
Infective endocarditis: 40-59 3.5mg/kgq24h
3mg/kg q24h 30-39 2.5mg/kg q24h
IE: 2mg/kg q24h
Imipenem IV 500 mg – 1g q6h CrCl-41-70500-
750mg q8h
CrCl-21-40 250-
500mg q6h
Isoniazid po 1 mg/kg q24h Normal
Itraconazole po 200mg q12h Normal

73
 Comments
CrCl Moderate
Severe <10 AD = After
(ml/min) 10-20
haemodialysis
Soft tissue infections 4-6mg/kg q48h Bacteremia AD monitor creatine
and Endocarditis: 8-10mg/kg q48h kinase initially and at
least weekly
Normal Normal (Max 6g/day)
Normal 500 mg q24h AD
20mg/kg q24-36h 20mg/kg q48h AD
Start normal dose then 50% Start normal dose then 50% AD
HD: 100% after each dialysis
[on non-dialysis Single dose: Normal
days dose according to CRRT: Normal
CrCl]
CrCl-10-24 1.25mg/kg q24h 1.25 mg/kg 3 times a week AD
‘Once daily’: 3mg/kg q48hIE: ‘Once daily’: 2mg/kg q48-75h AD
1mg/kg q24h IE: 1mg/kg q48h

250-500 mg q12h Risk of seizures – use AD

Meropenem
Normal 150-300 mg q24h AD
Normal 100 mg q12h

74
ANTIBIOTICS, ANTIFUNGALS,
ANTIVIRALS Normal dose Mild 20-50

Levofloxacin IV + po 750 mg q24h 750 mg q48h

Linezolid IV + po 600 mg q12h Normal
Meropenem IV 1-2g q8h 1-2g q12h
Metronidazole IV 500mg q8h Normal
PO 400-800mg q8h
Moxifloxacinpo 400-600mg q24h Normal
Nitrofurantoinpo 50-100mg q6h >45 Normal 30-45
Prophylaxis: 50-1400mg at Normal – ONLY if
night no option, 3-7days
ONLY
Oseltamivirpo (Treatment 75mg q12h 30-60 30mg q12h
dose)
Piperacillin / Tazobactam IV 4.5g q6-6h 4.5g q8h
Posaconazolepo Treatment: 400mg q12h, with Normal
(Suspension) food, or 200mg q8h
Prophylaxis: 200mg q8h
Pyrazinamide po 25 mg/kg q24h Normal
Rifabutinpo 300mg q24h Normal
Rifampicin po 10 mg/kg q24h Normal
Streptomycin IM 15 mg/kg q24h 30-50 15mg/kg q48
<30 12-15 mg/kg
q48-75h
Teicoplanin IV Loading dose (LD) 6mg/kg CrCl-30-50 Loading
q12h for 3 doses then 6mg/kg dose: Normal day 3
q24h. and 4 Normal after
Bone and joint infection / day 4-400mg q48h
endocarditis: LD 12mg/kg
q12h for 3 doses then 12 mg/kg
(max. 800mg) q24h
Tigecycline IV Loading dose (LD) 100mg then Normal
50 mg q12h

75
 CommentsAD =
CrCl (ml/min)
Severe <10 After
Moderate 10-20
haemodialysis
200mg q48h 250-500mg q24-48h
Normal Normal AD
<10 Monitor platelets
500-1g q12h 500mg – 1g q24h AD
CRO: Infuse each dose
over 3 hours
Normal Normal AD
CrCl (ml/min)
Normal Normal 600mg q24h for MDR TB
<30 Contraindicated as ineffective due to inadequate urine Unsuitable for
concentrations pyelonephritis of urinary
sepsis
10-30 30mg q24h 30 mg start then every 5 AD
days if required 30mg after each dialysis
4.5g q12h or 2.25mg q6h 4.5g q12h or 2.25mg q8h AD
Normal Normal
Normal 15 mg/kg q24h AD
<30 15-300 mg q24h AD
Normal Normal
12-15mg/kg q72h 12-15mg/kg q72-96h AD (+extra 7.5mg/kg AD)
CrCl<30 Loading dose: CrCl<30 Loading dose:
Normal day 3 and 4 Normal day 3 and 4 Normal
Normal after day 4- after day 4-400mg q72h
400mg q72h
Normal Normal For CRO use 200mg as
loading dose followed by
100mg q12h

76
 ANTIBIOTICS,
ANTIFUNGALS, Normal dose Mild 20-50
ANTIVIRALS
Valganciclovir IV Induction 900mg q12h CrCl-40-59
Maintenance 900mg q24h I-450mg q12h
M 450 mg 24h 25-
39
I 450 mg q24h
M 450mg q48h
Vancomycin IV 20-30 mg/kg loading (Max 1.5gm) 15 mg/kg q24h
followed by 15mg/kg q12h
Voriconazole IV and po IV 6 mg/kg q12h X 2 doses, then
4mg/kg q12h PO 400mg q12h X 2
doses then 200-300mg q12h
Comments
CrCl (ml/min)
Severe <10 AD = After
Moderate 10-20
haemodialysis
CrCl-10-24 I 450mg q48h M 450mg Not recommended AD
twice weekly Limited data: I 450mg
2-3 times a week M
450 mg 1-2 times a
week
15mg/kg q48h 15mg/kg once Monitor trough levels
followed by redosing before 5th dose to
based on trough levels achieve 15-
20mcg/ml
Normal but PO preferred, ideally AVOID IV as solubilizing agentmay AD
lead to renal damage. If IV essential monitor creatinine

77
Antimicrobial susceptibility profile of Blood stream
infections: January to December, 2021
AST Profile of BSI organisms - Susceptible percentage
*Escherichia coli *Klebsiella spp.
(n=676) (n=591)
Gentamicin 70% 48.05%
Amikacin 86% 52.62%
Netilmicin Not done Not done
Ciprofloxacin 22% 31.13%
Piperacillin / Tazobactam 57.05% 40%
Cefoperazone / Sulbactam 75% 46.61%
Ertapenem 83% 51.77%
Meropenem 83% 51.86%
Cefepime 30% 35.76%
Tigecycline Not done Not done
Minocycline 79% 68.59%
Tetracycline Not done Not done
#Cefotaxime 23% 30.79%
#Ceftazidime 23% 32.14%
Chloramphenicol 76% 51.76%
*Colistin** 100% (n=80) 80% (n= 187)

#Surrogate marker of ESBL production

*Adult and child data are merged together
** Colistin intermediate susceptibility among carbapenem resistant
organisms

78
 AST Profile of BSI organisms - Susceptible percentage

*Enterobacter spp. (n=99)

Gentamicin 82%
Amikacin 89%
Netilmicin Not done
Ciprofloxacin 79%
Piperacillin / Tazobactam 76%
Cefoperazone / Sulbactam 78%
Imipenem 0%
Meropenem 88%
Ceftazidime 18%
Cefepime 76%
Cefotaxime 27%
Chloramphenicol 74%
Tetracycline Not done
Minocycline 85%
Tigecycline 76%
*Adult and child data are merged together
AST Profile of BSI organisms- Susceptible percentage

*Salmonella Salmonella *Non Typhoidal

Typhi (n=39) Paratyphi A Salmonella
(adult)
(n=15)
(n=8)
Ampicillin 92.30% 100% 86.6%
Chloramphenicol 92.30% 100% 100%
Co-trimoxazole 92.30% 100% 100%
Ceftriaxone 100% 100% 100%
Ciprofloxacin 0% 0% 100%
Azithromycin 100% 100% 100%
Pefloxacin 0% 0% 100%
Adult and child data are merged

79
AST Profile of BSI organisms- Susceptible percentage
*Streptococcus pneumoniae *Streptococcus pneumoniae
Meningeal isolates Non-meningeal isolates (n=29)
(n=9)
Penicillin 55% 100
%
Cefotaxime 100% 100
%
Erythromycin 11% 22%
Vancomycin 100% 100
%
Levofloxacin 100% 93%
*Adult and child data are merged together

AST Profile of BSI organisms- Susceptible percentage

*Pseudomonas *ABC complex(n=240)
aeruginosa
(n=314)
Ceftazidime 71.01% 13.75%
Cefepime 70.38% 13.75%
Amikacin 7.70% 15.83%
Tobramycin 70.06% 16.25%
Gentamicin Not done 15.38%
Netilmicin 78% Not done
Piperacillin / Tazobactam 69.42% 13.33%
Cefoperazone / Sulbactam Not done 15.41%
Imipenem Not done 14.15%
Meropenem 69.42% 13.33%
Colistin** 92% (n=61) 95% (n=93)
Tigecycline Not done Not done
Aztreonam 61.14% Not done
Co-trimoxazole Not done Not done
Levofloxacin 67.19% 15%
Tetracycline Not done Not done
Minocycline Not done 45.72%
Chloramphenicol Not done Not done

Adult and child data are merged together

** Colistin intermediate susceptibility among carbapenem resistant organisms

80
 AST Profile of BSI organisms - Susceptible percentage

*Staphylococcus aureus *Staphylococcus aureus

(MRSA) (n=69) (MSSA) (n=156)
Cefoxitin 0% 100%
Clindamycin 46.39% 76.28%
Erythromycin 31.88% 51.92%
Co-trimoxazole 92.75% 94.23%
Gentamicin 65.21% 89.74%
Netilmicin Not done Not done
Rifampicin 100% 98.71%
Vancomycin 100% Not done
Linezolid 100% 100%
Chloramphenicol 97.10% 99.35%
Minocycline Not done Not done

*Adult and child data merged together

AST Profile of BSI organisms - Susceptible percentage

*Enterococcus faecium *Enterococcus faecalis

(n=96) (n = 62)
Ampicillin 10.52% 96.77%
HLG 32.29% 75.80%
Levofloxacin 9.37% 41.66%
Vancomycin 64.58% 96.77%
Linezolid 95.83% 100%
Tigecycline - 100%
Chloramphenicol 90.62% 74.19%
Teicoplanin 70.83% 96.77%
Tetracycline - -

*Adult and child data merged together

81
 AST profile of Stenotrophomonas maltophilia from
BSI and Respiratory Samples - Susceptible percentage
* Stenotrophomonas maltophilia (n=22)
Co- trimoxazole 86%
Minocycline 100%
Levofloxacin 91%
Tetracycline Not
done
*Adult and child data merged together

AST profile of Shigella species isolated from faeces

sample - Susceptible percentage

*Shigella flexneri (n=22) *Shigella sonnei (n=32)

Ampicillin 18% 69%
Co- trimoxazole 23% 9%
Ciprofloxacin Not done 0%
Azithromycin 85% 91%
Cefotaxime 82% 81%
Cefixime 82% 77%
*Adult and child data merged together

AST profile of Aeromonas species isolated from faeces

sample - Susceptible percentage

* Aeromonas spp (n=192)

Co- trimoxazole 86%
Ciprofloxacin 92%
Tetracycline 83%
Ofloxacin 100%
Cefotaxime Not done
Meropenem 86%
Imipenem 64%
*Adult and child data merged together

82
 TABLE 1
COMPARISON OF ANTIMICROBIAL SPECTRA FOR DIFFERENT
ORGANISMS
Organisms

Cloxacillin / Dicloxacillin
Penicillin

Pefloxacin NUS
Penicillin

Ciprofloxacin

Moxifloxacin
Amp / Amox

Meropenem

Levofloxacin
Amox / Clav

Gatifloxacin
Imipenem
Pip / Tazo
Amp / Sulb

Piperacillin
Ertapenem

Aztreonam
Methicilli

Ofloxacin
n

GRAM
POSITIVE
Strep, Group A,B, + + + + + + + + + + + + 0 + + 0 + + +
C, G
Strep + + + + + + + + + + + + 0 + + 0 + + +
pneumoniae
Enterococcus + + 0 0 + + + + + + + + 0 ** ** 0 + + +
faecalis
Enterococcis + + 0 0 + + + + + 0 + 0 0 0 0 0 0 + +
faecium
Staph aureus 0 0 + + 0 + + + 0 + + + 0 + + + + + +
(MSSA)
Staph. aureus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 + +
(MRSA)
GRAM
NEGATIVE
N. gonorrhoeae 0 0 0 0 0 + + + + + + + + + + + + + +
N. meningitidis + 0 0 0 + + + + + + + + + + + + + + +
M. catarrhalis 0 0 0 0 0 + + + + + + + + + + + + + +
H. Influenzae 0 0 0 0 + + + + + + + + + + + + + + +
E.Coli 0 0 0 0 + + + + + + + + + + + + + + +
Klebsiella sp. 0 0 0 0 0 + + + + + + + + + + + + + +

83
Enterobacter 0 0 0 0 0 0 0 + + + + + + + + + + + +
sp.
Serratia sp. 0 0 0 0 0 0 0 + 0 + + + + + + + + + +
Salmonella sp. 0 0 0 0 + + + + + + + + + + + + +
Shigella sp. 0 0 0 0 + + + + + + + + + + + + + +
Proteus 0 0 0 0 + + + + + + + + + + + + + + +
mirabilis
Proteus 0 0 0 0 0 + + + + + + + + + + + + + +
vulgaris
Providencia sp. 0 0 0 0 0 + + + + + + + + + + + + + +
Morganella sp. 0 0 0 0 0 + + + + + + + + + + + + + +
Citrobacter sp. 0 0 0 0 0 0 0 + + + + + + + + + + + +
Aeromonas sp. 0 0 0 0 0 + + + + + + + + + + + + +
Acinetobacter 0 0 0 0 0 0 + + 0 + + + 0 + + + + +
sp.
Ps. 0 0 0 0 0 0 0 + + + + + + + + + + +
aeruginosa
B. (Ps.) Cepacia 0 0 0 0 0 0 0 0 0 + 0 0 0 0 0
5

S. (X.) 0 0 0 0 0 0 0 + + 0 0 0 0 0 0 0 + +
maltophilla5
Y. 0 0 0 0 0 + + + + + + + + + + +
enterocolitica
ANAEROBES
Actinomyces + + 0 0 + + + + + + 0 0 + + +
Bacteroides 0 + 0 0 0 + + + 0 + + + 0 0 0 0 0 + +
fragilis
Pepto- + + + + + + + + + + + + 0 + + + + +
streptococcus
sp.

84
 TABLE 1 (2)

Cefaclor / Loracarbef*
Cefuroxime axetil
Cefixime NUS
Ceftazidime
Cefuroxime

Ceftriaxone
Cefotaxime

Cephalexin
Cefadroxil
Cefotetan

Cefoxitin

Cefepime
Cefazolin
Organisms

Gram – Positive:
Strep, Group A, B, C, G + + + + + + + + + + + + +
Strep pneumoniae + + + + + + + + + + + + +
Viridans strep + + + + + + + + + + + + +
Enterococcus faecalis 0 0 0 0 0 0 0 0 0 0 0 0 0
Staph. aureus (MSSA) + + + + + + + + + + + + 0
Staph. aureus (MRSA) 0 0 0 0 0 0 0 0 0 0 0 0 0
Staph. epidermidis + + + + + + + + + + + + 0
Gram – Negative:
N. gonorrhoeae + + + + + + + + 0 0 + + +
N. meningitidis 0 + + + + + + + 0 0 + + +
H. Influenzae + + + + + + + + 0 + + +
E.coli + + + + + + + + + + + +
Klebsiella sp. + + + + + + + + + + + + +
Enterobacter sp. 0 + 0 + + + + + 0 0 0 0 0
Serratia sp. 0 + 0 0 + + + + 0 0 0 0 +
Salmonella sp. + + 0
Shigella sp. 0
Proteus mirabilis + + + + + + + + + + + + +
Proteus vulgaris 0 + + + + + + + 0 0 0 0 +
C. freundii 0 0 0 0 0 0 0 + 0 0 0 0 0
C. diversus 0 + + + + + + + 0 0 0
Citrobacter sp. 0 + + + + + + + 0 + + +
Aeromonas sp. 0 + + + + + + + +
Acinetobacter sp. 0 0 0 0 + + + + 0 0 0 0 0
Ps. aeruginosa 0 0 0 0 + + + + 0 0 0 0 0
B. (Ps.) Cepacia 5 0 0 0 0 + + + + 0 0 0 0 0
S. (X.) maltophilla5 0 0 0 0 0 0 + 0 0 0 0 0 0
Anaerobes:
Actinomyces +
Bacteroides fragilis 0 + + 0 0 0 0 0 0 0 0 0

85
 TABLE 1 (3)
Organisms Aminoglycosides Macrolides Tetracy Glycop Urinary Miscellaneous
clines eptides tract
AGTS

Gentamicin

Tobramycin
Amikacin
Netilmicin
Chloramphenicol
Clindamycin

Erthyromycin
Azithromycin
Clarithromycin
Doxycycline
Minocycline
Vancomycin
Teicoplanin
Fusidic Acid NUS

TMP / SMX
Nitrofurantoin
Fosfomycin
Rifampin

Metronidazole
Dalfopristin
Quinupristin /
LInezolid
Daptomycin
(Colistin)
Colistimethate
Gram – Positive:
Strep, Group A, B, C, G 0 0 0 0 + + + + + + + + + + + + + 0 + + + 0
Strep pneumoniae 0 0 0 0 + + + + + + + + + + + + + 0 + + + 0
Enterococcus faecalis S S S S + 0 0 0 0 0 0 + + + + + + + 0 0 + + 0
Enterococcus faecium S 0 0 0 + 0 0 0 0 0 0 + + 0 + + 0 0 + + + 0
Staph. Aureus (MSSA) + + + + + + + + + + + + + + + + + 0 + + + 0
Staph. Aureus (MRSA) 0 0 0 0 0 0 0 0 0 + + + + + + 0 + 0 + + + 0
Staph. epidermidis + + + + 0 0 + 0 0 0 0 + + + + + 0 + + + 0
Gram – Negative:
N. gonorrhoeae 0 0 0 0 + 0 + + + + + 0 + + + + + 0 + 0
N. meningitidis 0 0 0 0 + 0 + + + + 0 0 + + + 0 0 0 0
H. Influenzae + + + + + 0 + + + + + + + 0 + +
Aeromonas 0 + + + 0 + 0 0
E.Coli + + + + + 0 0 0 0 + 0 0 0 + + + 0 0 0 0 0 +

86
Klebsiella sp. + + + + + 0 0 0 0 + + 0 0 0 + + + 0 0 0 0 0 +
Enterobacter sp. + + + + 0 0 0 0 0 0 0 0 0 0 + + 0 0 0 0 0 +
Salmonella sp. + 0 0 + 0 + + 0 0 0 + + 0 0 0 0 0
Shigella sp. + + + + + 0 0 + 0 + + 0 0 0 + + 0 0 0 0 0
Serratia marcescens + + + + 0 0 0 0 0 0 0 0 0 0 + 0 + 0 0 0 0
Proteus vulgaris + + + + + 0 0 0 0 0 0 0 0 0 0 0 + 0 0 0 0 0
Acinetobacter sp. 0 + 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 +
Ps. Aeruginosa + + + + 0 0 0 0 0 0 + 0 0 0 0 0 0 0 0 0 0 +
B. (Ps.) Cepacia 5 0 0 0 0 + 0 0 0 0 0 + 0 0 0 + 0 0 0 0 0 0
S. (X.) maltophilla5 0 0 0 0 + 0 0 0 0 0 0 0 0 0 + 0 0 0 0
Brucella sp. + + 0 0 0 0 + + 0 0 + + 0 0
Anaerobes:
Actinomyces 0 0 0 0 + + + + + + + + + 0
Bacteroides fragilis 0 0 0 0 + + 0 0 0 + + 0 0 + +

87
 DRUG, DOSAGE AND DILUTION
DRUG DOSAGE FORMS DILUENTS ADMINISTRATION STORAGE AND
STABILITY
1. PENICILLINS
a. Benzyl penicillin

Benzyl penicillin Intravenous Solution:1 WFI, NS, D5 IV infusion only Dissolve in small amounts refrigerate solutions
Million U/50 ML, 2 of diluent and administer peripherally as a at 2 to 8 degrees C
Million U/50 ML, 3 0.5–1L unit/mL solution.If fluid-restricted, (36 to 46 degrees F)
Million U/50 ML 1.46L units/mL in WFI-15to 30min or and administer within
in 100 ml of diluent-30to 60 mins 7 days
Intravenous Powder
for Solution: 5 Million
U, 20 Million U
b. Penicillinase-Resistant Penicillins
Dicloxacillin Powder for injection- NS,D5W IV bolus: 500 mg (9.6 mL WFI) slowly over Reconstituted
500mg,1 g 3–5 mins and at least 5min for 1gm dose. solution : 2–8degree
IV infusion: Dissolve in WFI (as above) C for up to 24 hours
then add (100–250 mL) of NS or D5W - or not more than 4
infuse for at least 60 mins hours at room
temperature

88
Flucloxacillin Powder for injection D5,NS IV bolus: 1 g (15-20ml)WFI[3-4min] After reconstitution, if
1g DOSE ABOVE 1g BY IV INFUSION ONLY. not used
IV infusion: dissolve in WFI (as immediately, stable
above)[100mlD5/NS]-30-60 mins for 24h at 2–8°C

c. Broad-Spectrum Penicillins
Ampicillin Injection Powder for NS,D5W,RL Reconstitute 125 mg,250mg After reconstitution,
Solution: 1 GM, 2 GM, 500MG,(5ml),1 g(7.4ml)2g(14.8 ml)in solution is stable at
10 GM, 125 MG, 250 SWFI room temperature for
MG, 500 MG IV bolus: after reconstitution, dose of up to 1 hour, and 48
125mg,250mg,500mg-directly inject over hours if refrigerated
3-5 min
IV infusion: after reconstitution-1g, 2g-
administer over10 to 15 min[up to
30mg/ml]in diluent
Co-amoxiclav Powder for injection NS IV bolus- 300 mg (5ml,)600 mg ( 10 controlled room
300mg,600mg,1.2g mL),1.2 g (20 mL )WFI over 3–4 mins IV temperature,
Infusion Reconstitute as above then between 20 and 25
dilute 300 mg (25mL); 600 mg ( 50 mL); degrees C (68 and 77
1.2 g( 100 ml)NS - over 30–40 mins degrees F)

89
d. Antipseudomonal Penicillins
Piperacillintazobactam Powder for solution: NS, D5W, WFI reconstitute (2.25 g in 10 mL, 4.5 g in 20 Reconstituted
2 gm-0.25 gm, 3 gm- mL) with WFI solutions will
0.375 gm, 4 gm-0.5 IV Infusion- after reconstitution -dilute to a maintain potency for
gm concentration of 15–90 mg/ml(50-100 ml)- 24 hours at room
temperatures
over 30 min
Extended infusion [off-label]-:over 3–4
hours.
2.CEPHALOSPORINS
FIRST GENERATION Powder for injection NS, D5W, D10W, Reconstitution: After reconstitution,
Cefazolin 500 mg,1g D5LR, D5NS, D5- 500mg(2mlSWFI)[225mg/ml],1g(2.5mlSW if not used
(not available in CMC) 0.45%NaCl, D5- FI)[330mg/ml] immediately stable
0.2%NaCl, LR IV bolus: dilute the reconstituted vial to5ml- for 24 h at 2–8°C
3 to 5 min
IV infusion: reconstitution ,then dilute to
50-100ml diluent-30 min
SECOND GENERATION Injection Powder for D5W, 0.9% NS or IV bolus-reconstitute 750 mg in 8.3 mL or Solution for IV
Solution: 750 MG,1.5G 0.45% NS the 1.5 g vin 16 ml SWFI at a concentration administration are
of 90 mg/ml- inject directly orinto a running stable for up to 24
Cefuroxime IV line over 3 to 5 minutes hours (room tem) 7
IV Infusion- after dilution in 50 ml or 100 days (5 0 C)
ml compatible fluid –over 15-30 min
THIRD GENERATION Injection Powder for SWFI,D5W.O.9% Reconstitute the 500 (mg), 1 (g), and 2 g After reconstitution, if
Solution: 1 GM, 500 NS vials with 10 (ml) of SWFI for not used
Cefotaxime MG concentrations of 50, 95, and 180 mg/ml, immediately, stable
respectively for 7days at 2–8°C

90
 IV bolus: after reconstitution ,1-2g in 10 ml- or stable in plastic
over 3-5min syringe for 5 days
IV Infusion: reconstituted solution of 1 g in Store premixed
50ml D5W over 30 minutes; > 1 g in 100 solution in freezer at
ml of D5W over 30 minutes or below -20 0C
Ceftazidime Injection Powder for D5W, NS, D5NS, reconstitution:500 mg (5.3 ml), 1 g(10 ml), dry state(15 and
Solution: 1 GM, 2 D10W, LR, or 2 g (10 ml) sterile water for injection. 30 0 C )
GM, 500 MG Reconstituted
IV bolus: reconstituted solution- 3 to 5
solutions- 12 hours at
minutes or give through existing tubing
room temperature, or
containing compatible solution.
under refrigeration
IV Infusion: reconstituted solution in 50 to for3 days.
100ml compatible fluid(15-30 min)
Ceftriaxone Injection Powder for Sterile Water for do not reconstitute vials or administer After reconstitution, if
Solution: 1 GM, 2 Injection (SWFI), simultaneously with calcium-containing not used immediately
GM, 250 MG, 500MG NS, D5W, and solutions stable for 24 h at 2–
D10W reconstitution - 250mg(2.4 ml), 500mg(4.8 8°C
ml), 1g(9.6 ml) and 2g( 19.2 ml)
IV bolus: in 10 ml-over 2 to 4 min
IV Infusion: 30 min-40 to 60 mg/ml
Cefoperazone Powder for injection- D5W, D5NS, D5 1g in 20-100 ml diluent[15-60 min][2- at or below 25 0C
1g SWFI 50mg/ml] protected from light
prior to reconstitution
Light protection is not
required after
reconstitution

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FOURTH GENERATION Injection Powder for NS, D5W or D10W IV bolus: 1g(10 ml),2g(10 or 20 ml) reconstituted
Solution: 1 GM, 2 GM SWFI,NS- over 2 to 5 minutes solutions physically
Cefepime IV infusion: Reconstitute 500 mg(5 and chemically stable
Intravenous Solution:1
ml)[100mg/ml]1g (10 ml) for 18 hours at room
GM/50 ML, 2
2g[approximately 160mg/ml]- temperature (15-
GM/100 ML
SWFI,NS,D5W 25°C) and for 2 days
Further dilution to 50-100ml diluent-30 min if kept in a
refrigerator (2 -8°C).
Cefoperazone + Powder for injection D5W,NS IV bolus: Reconstitute 1.5g(5ml)3g(10 After reconstitution if
sulbactam 1.5g,3 g ml)NS,D5W,WFI- atleast 3 min not used immediately
IV infusion: after reconstitution-further chemically stable for
dilution to 20—100 ml diluents-over 15 7 days at 2-8 c and24
to60 min hrs at 9-250C
3.CARBAPENEMS
Intravenous Powder D5W, 0.9% NS Reconstitution-500 mg&1g(10 ml,20ml Reconstituted
Meropenem for Solution: 1 GM, SWFI)-50 mg/ml solutions are stable
IV bolus– reconstituted solution for up to 2 hours at
500 MG
administered over 3 to 5 min room temperature, 15
IV infusion :after reconstitution-further to 25 0C , or for up to
dilution to 1-20 mg/ml, over 15-30 min 12 hours at 4 0C
Extended infusion: 3 hrs
Ertapenem Injection Powder for NS IV bolus: 1 g(10 ml NS)-5 min (rate of 2 Store un
Solution: 1 GM ml/min) reconstituted powder
IV infusion : 1 g(10 ml NS,SWFI)[50 ml]-30 at or below 25 0 C.
min Reconstituted
solution may be
stored at room temp.

92
 of 25 0 C or
refrigerated for 24
hours at 5 0 C
Do not freeze
Imipenem and cilastatin Intravenous Powder NS, D5W, D10W, DO NOT ADMINISTER IV PUSH Reconstituted
for Solution: 250 D5W and NS, Reconstitute with 10 ml diluent then to solution is stable for
mg+250 mg, 500 D5W with 0.225% 100 ml 4 hours at room
mg+500 mg or 0.45% sodium doses ≤500 mg -20 to 30 minutes doses temperature or 24
chloride, >500 mg over 40 to 60 minutes hours under
refrigeration
Aztreonam Injection Powder for NS,D5W IV bolus: reconstitute with 6-10 ml SWFI- up to 48 hours at
Solution: 1 GM, 2 GM infuse over 3-5 min controlled room
IV infusion: reconstitute with SWFI(1g/3 temperature, 15 to 30
ml) then dilute to < 20 mg/ml with diluents - 0C or up to 7 days if
20to 60 min refrigerated between
2 and 8 0C
4.TETRACYCLINES
Doxycycline intravenous Powder NS; D5W; Ringer 100mg- dilute in 10 ml SWFI to a 48 hours at 25 0C
for Solution: 100 MG injection concentration of 10 mg/ml then dilute with fluorescent
to 100 to 1000ml lighting. Protect from
200mg- dilute in 20 ml SWFI to a direct sunlight during
concentration of 10 mg/ml then dilute to storage and infusion.
200 to 2000ml Solutions may be
refrigerated for up to
Final concentration-1 mg/ml to 0.1 mg/ml 72 hrs
Infuse over 1-4 hrs

93
 Tigecycline Intravenous Powder NS, D5W, LR IV infusion 50 mg(5.3ml)-10 mg/ml [100 reconstituted, the
for Solution: 50 MG ml]-1 mg/ml solution is stable at
Over 30-60 min room temperature up
to 25 degrees C for up
to 24 hours (up to 6
hours in the vial
and remaining time in
the IV bag)
5.AMINOGLYCOSIDES
Amikacin Injection Solution: NS, D5W, LR, D5- IV infusion: diluted solution is
250 MG/1 ML 0.45%NS, 500MG(100-200 ml diluent)-30to 60 min stable 60 days
Infants-1to 2 hrs refrigerated, then 24
hours at room temp.
or stable 30 days
frozen, then 24 hours
thawed and stored at
room temp.
Gentamicin Injection Solution: 10 NS,D5W Intermittent infusion controlled room
MG/1 ML, 40 MG/1 M in 50 to 200 mL of sterile isotonic saline temperature,
solution or in a sterile solution of D5W.-30 between 20 and 250C
min to 2 hrs
IV bolus
Dose< 800mg – 20 ml NS-3 to 5 min

Kanamycin Injection(s NS,D5W IV Infusion Store at controlled

odium 500 mg (200ml),1g(400ml)-30 to 60 room temperature of
salt)500mg,750mg,1g minutes 20 to 25 0 C

94
Netilmicin Injection as sulphate- NS,D5W IV Infusion Store at 2 to 30°C.
200mg/2ml,400mg/ 50 to 200 ml-30 min Protect from freezing
2ml,10 mg/ml IV bolus:
injected directly into vein or IV tubing over
3 to 5 minutes
6.MACROLIDES
Azithromycin Intravenous Powder NS, ½ NS, D5W,LR INFUSION ONLY Reconstituted stable
for Solution: 500 MG 500mg(4.8 ml SWFI) for 24 hours at or
Reconstituted Solution-500 ml diluents-1 below room
mg/ml-3 hr temperature, 30 0
250 ml-2mg/ml-1 hr C,or for 7 days if
stored under
refrigeration 5 0 C
Clindamycin Intravenous Solution: D5W,NS Dilute with D5W or NS to <18 mg/ml Once diluted
300 MG/50 ML, 600 preparations may be
MG/50 ML, 900 Never administer undiluted as bolus; IV stored up to 24 hours
MG/50 ML, 150 MG/1 intermittent infusion -10 to 60 min at room temperature
ML Maximum rate of 30 mg/minute (do not
exceed 1,200 mg/hour).
7.GLYCOPEPTIDES
Teicoplanin Powder for injection NS, ringer IV bolus: Reconstitute 200-mg or 400-mg The reconstituted
200 mg,400mg solution, RL, D5W, 3.14 ml SWFI; rotate until all powder is and diluted solutions
D10W, clear or yellowish-3 to 5 min should be used
IV Infusion: reconstitution-30 min immediately or stored
between 2 and 8
degrees C for up to 24
hours

95
Vancomycin powder for solution: 1 5W, D5NS, LR, reconstituted solution
gm, 1.25 gm, 1.5 gm, D5LR, NS; Before use, may be stored in the
250 mg, 500 mg, 750 Reconstitute the vial 500mg in 10ml WFI & refrigerator for up to
mg 1gm in 20ml WFI. 96 hours without
solution: 1.5 gm/300 Further reconstituted with D5W or NS. significant loss of
ml, 1 gm/200 ml 500mg (100ml) (30min) potency
1gm (200ml)(60min)

Maximum concentration-5mg/ml and

maximum rate 10mg/min.

Linezolid 600 mg/300 ml, 2 D5W,NS,LR Administer over 30 to 120 minutes Store infusion bags
mg/1 ml at controlled room
temperature 250 C.Do
not freeze
8.SULPHONAMIDES
Co trimoxazole Injected solution D5W Do not use NS as diluent at controlled room
(16mg/80mg)/mL temperature, 25
dilute each 5 mL in 125 mL of D5W and degrees Celsius. Do
infuse over 60 to 90 minutes not refrigerate.
(fluid restriction) dilute each 5 mL in 75 mL
of D5W

RAPID INFUSION OR BOLUS INJECTION

MUST BE AVOIDED.

96
9.ANTI TUBERCULOUS DRUGS
Capreomycin Powder NS,SWFI Reconstituted
fo IV Infusion Reconstitute 1 g in 2 ml solutions stored
rSolution: 1 GM compatible fluid-100 ml NS - over 60 min under refrigeration
must be administered
within 24 hours
10.METRONIDAZOLE
Metronidazole 500 mg/100 ml premixed solution IV Infusion Slow IV drip infusion at controlled room
only(continuous or intermittent)for 60min temperature, 250C.Do
discontinue the primary solution during not refrigerate.
infusion

11.QUINOLONES
Ciprofloxacin Intravenous NS, D5W, SWFI, D10W IV Infusion The final concentration should Controlled room
solution: 200 5%, D5-1/2 NS,LR. be 1 to 2 mg/ml temperature between
mg/100 ml, 400 -over 60 min 15 and 30 0C. Do not
mg/200 ml, 10 refrigerate
mg/1 ml

Levofloxacin Intravenous D5W,D5NS,NS IV Infusion Final concentration of 5 mg/ml Reconstituted

Solution: 25 250 mg (50 ml)-, infuse over 60 min; solutions are stable
MG/1 ML 500 mg (100 ml)- infuse over 60 min; for 14 days when
750 mg(150 ml),-infuse over 90 min stored in plastic IV
containers at 5 0 C or
for 72 hours at or
below 25 0 C

97
12.CHLORAMPHENICOL
Chloramphenicol Intravenous sterile water for Reconstitute to a final concentration of10% Dry form-stable at
Powder for injection or D5W (100 mg/ml) - at least 1 minute room temp.
Solution: 1 GM Reconstituted
Paediatric- IVP (1 min)or intermittent
solutions are stable
infusion:15-30min
at room temperature
for 30 days
13.OTHER ANTIBACTERIALS
Colistimethate sodium Injection Powder NS, D5NS, D5W, Reconstitute 150 mg vial with 2ml SWFI- controlled room
for Solution: 150 75 mg/ml temperature between
MG Continuous Administration 20 and 25 0 C
one-half of the total daily dose is
administered by direct IV injection over 3 to once diluted with
5 minutes followed 1 to 2 hours later by the SWFI, store solution
remaining one-half of the total daily dose up to 7 days, between
diluted in a compatible IV solution infused 20 and 25 0 C or
over 22 to 23 hours refrigerated between
2 and 8 0 C
Direct Intermittent administration
Inject one-half of the total daily dose-
slowly over 3 to 5 minutes every 12 hours
Daptomycin Intravenous NS,RL reconstitution:500mg(10 ml NS )-at a reconstituted
Powder for concentration of 50mg/ml solution- 12 hours at
Solution: 350 IV Infusion room temperature or
MG, 500 MG after reconstitution ,dilute to up to 48 hours when
50 ml NS (adult)-infuse over 30 min refrigerated
25 ml(1-6 yrs)-infuse over 60 min

98
 50 ml (7-17 yrs)-infuse over 30 min The diluted solution-
IV bolus: 2 min (adult) in infusion bag for 12
do not administer as IV injection in children hours at room
do not mix with dextrose-containing temperature or 48
diluents hours when
refrigerated

Abbreviations:
NS Normal saline
SWFI Sterile water for injection
D5W 5% dextrose in water
D5NS 5% dextrose in normal saline
D10NS 10% dextrose in normal saline
LR Lactated ringers

99
 Hand Hygiene Technique

5 Moments of Hand Hygiene