Appendicitis, Bites, Bowel perforation, Breast Abscess, Bronchitis, Cellulitis, Cholecystitis, Conjunctivitis, Cystitis, Dental infections, Diverticulitis, Epidydimitis, Gastroenteritis, Mastitis, Meningitis, NeutropenicFever, Open Frx, Otitis externa, Otitis media, Pharyngitis, Pneumonia, Pyelonephritis,
Sexual assault prophylaxis,Sinusitis
Must know Christ Medical Center Protocols well (ie sepsis protocol antibiotic regimen; pneumonia protocol)
Do NOT use in pregnancy:
Erythromycin estolate, lindane (Kwell), Flagyl (safe for use in 2nd and 3rd trimesters), Macrodantin (contraindicated in 3rd trimester), quinolones, sulfonamides (safe in 1st and 2nd trimesters, avoid in 3rd trimester due to possible kernicterus), tetracycline, doxycycline, Bactrim/Septra (kernicterus in 3rd trimester, category C in 1st and 2nd trimester due to interference with folic acid metabolism)
Appendicitis: Back to Top
Cefoxitin 1-2 g IV q 6 hours (peds: 25mg/kg/dose q 6 hours) (give in consultation with surgeon).
Bites (outpatient tx): Back to Top
-Cat: Augmentin 875mg bid x 7-10d
-PCN allergic: Ceftin 500mg q12h OR Doxy 100mg bid
-Dog: Augmentin 875mg bid x 7-10d
-PCN allergic: Clinda PLUS [FQ (adults)/Bactrim (peds)]
-Human: Augmentin 875mg bid x 7-10d
-PCN allergic: Clinda 300mg qid PLUS Bactrim DS bid
Bites (inpatient tx-- includes cat/dog/human): Back to Top
-Unasyn 1.5g IV OR Zosyn 3.375g IV
-PCN allergy: Clinda 900mg IV PLUS [Cipro 400mg OR Bactrim 5mg/kg IV]Bowel perforation/Peritonitis: Back to Top
Breast Abscess: Back to Top
: I and D (probably should be done by surgery) and:
-Keflex OR Dicloxacillin 500mg qid x 10-14d for mild cases
-Ancef 1g IV OR Nafcillin 2g IV OR Vanco 15mg/kg IV (max 1g)
Bronchitis (smoker or chronic bronchitis/COPD exacerbation) (outpt): Back to Top
-Bactrim DS 1 tab bid OR Doxy 100mg bid OR Azithro OR Levaquin 500mg qd x 10d
Bronchitis (acute episode in nonsmoker or young smoker without chronic bronchitis):
-No antibiotics. Usually viral. Treat symptoms with Albuterol inhaler
Cellulitis: Back to Top
-Duration: until 3 days after inflammation disappears
-TMP-SMX DS 2 PO bid OR Clinda 300-450mg PO tid
-Diabetic foot
-Unasyn 1.5g IV (3g if >80kg)
-If PCN allergic (Clinda 600mg IV PLUS Cipro 400mg)
Cholecystitis/Cholangitis: Back to Top
Conjunctivitis: Back to Top
-Most cases are viral, but treat all in the ED as if bacterial
-Bacterial will resolve without abx, but resolves quicker with abx
-May use E-mycin/sulfacetamide/ophthalmic bacitracin (gtts q2hrs, ointment qid) x 7d
-Avoid neomycin as causes allergic rxns frequently
-Avoid gent/tobra as toxic to the eye and add little to the treatment coverage
-Cipro 2 gtts q2h while awake x 2d then q4h x 5d
-Covers pseudomonas
Cystitis (<10yo): Back to Top
-Amoxicillin 10mg/kg/dose tid x 10d
-Augmentin 10mg/kg/dose tid x 10d
-Omnicef 14mg/kg/day up to 600mg/day PO divided qd or bid
-In < 1yo there is no literature to support initial parenteral dose of abx if tolerating PO
Cystitis (adult):
-3 days of: Bactrim DS bid OR Levaquin 250mg qd OR Cipro XR 500mg PO qd for non-complicated cystitis
*FQ probably best choice now due to high resistance to Bactrim
-10 days of: Bactrim DS, Levaquin, Ciprofloxacin, Augmentin, Keflex for complicated cystitis
Dental infections and intraoral lacs: Back to Top
Clindamycin 300mg qid OR PCN 500mg qid x 10d
Diverticulitis: Back to Top
--[Bactrim DS 1 tab PO bid OR Levaquin 750mg qd OR Cipro 750mg PO bid] PLUS Flagyl 500mg qid x 7-10d
-May treat as an outpatient if nontoxic and can tolerate PO and no perf/abscess on CT
Epidydimitis/Orchitis/Prostatitis: Back to Top
-- <35 yo (tx as GC/C): Should now treat the same as PID in a female
-Rocephin 250mg IM PLUS Doxycycline 100mg PO bid x 10d
- >35yo (coliforms): Bactrim DS 1 tab bid OR Levo 250mg qd x 10-14d
Gastroenteritis (suspected bacterial in adults): Back to Top
-Cipro 500mg bid 3-5 days OR Bactrim DS 1 tab bid x 5d
-Dysentery symptoms, recent travel to 3rd world (o/w probably viral and no abx needed)
Mastitis: Back to Top
-Keflex 500mg qid OR Dicloxacillin 500mg qid OR Clinda 300mg qid x 10-14d
-MRSA Possible: TMP-SMX DS 1 PO bid or Vanco 1gm IV q12h (if MRSA)
Meningitis: Back to Top
- Dexamethasone 0.15mg/kg q 6h (10 mg max) for 2-4 days – give prior to or at time of initial abx to prevent bacterial lysis. Give for suspected pneumococcal meningitis and continue only in proven cases
- < 8 weeks: Claforan IV (100mg/kg q 8h) PLUS Ampicillin IV (50-100mg/kg q 6h +/- Vanc 15mg/kg IV q 12h– pharmacy to dose after first dose)
-8wks to 18yrs: Rocephin IV (100mg/kg max 2g q12h) PLUS Vancomycin IV (15mg/kg to max 1.5g q 12h – pharmacy to dose after first dose)
-18yrs to 50yrs: Rocephin IV (2g q 12h) PLUS Vanc IV (15mg/kg max 1.5 g q 12h- pharmacy to dose after first dose)
- > 50yrs: Rocephin IV (2g q12h) PLUS Ampicillin IV (2g q4h) PLUS Vanc IV (15mg/kg max 1.5g q 12h- pharmacy to dose after first dose)
- PCN allergy: Rocephin IV (2g q12h) PLUS Vanc IV (15mg/kg max - pharmacy to dose after first dose)
Neutropenic Fever with Septic Shock:
-Imipenem/Cilastin IV (500mg q 8h - need creatinine clearance calculated after first dose) OR Cefipime IV (2g q8h) PLUS Vancomycin IV (15 mg/kg IV max 1g - pharmacy to dose after first dose)
-PCN allergy: Amikacin IV (20mg/kg max 1.5g q 24h - pharmacy to dose subsequent doses) PLUS Aztreonam IV (2g q 8h PLUS Vancomycin IV (15mg/kg max 1g q 12h - pharmacy to dose subsequent doses)
Open Frx: Back to Top
Ancef 1-2g OR Vanc 15mg/kg OR Clinda 600mg
-If severe: PLUS Gent 2mg/kg
Otitis externa: Back to Top
: Cortisporin Otic 4gtt qid OR Floxin 5-10gtt bid x 10d
-If refractory: Cipro HC 3gtt bid x 7d OR Dicloxacillin 500mg PO qid x 7d
Otitis media: Back to Top
-Amoxicillin is first-line tx
-Low-risk (> 2yrs old/no daycare/no abx for 2 months) gets 40mg/kg/day x 5d
-High-risk (<2 yrs old/daycare/abx in past 2 months) gets 80-90mg/kg/day x 10d
-Zithromax 10mg/kg on first day then 5mg/kg for 4 days is first-line tx for PCN allergic
-Do NOT use for amoxicillin failures
-Bactrim 1mL/kg/day divided bid x 10d
-Rocephin 50mg/kg IM x 1 dose
Otitis media (refractory):
-Augmentin 80-90mg/kg/day divided bid or tid x 10d is first-line tx
-Ceftin 10mg/kg/dose bid x 10d
-Rocephin 50mg/kg IM or IV qd for 3 days
-One-time dose of Rocephin ONLY good for NON-treatment failures
Pharyngitis: Back to Top
--PCN 500mg bid x 10d for adults (15mg/kg/dose tid for children)
-Z pack (Azithromycin)
-Erythromycin 500mg bid x 10d (10mg/kg/dose qid)
Pharyngitis (refractory cases):
-Clindamycin 300mg qid x 10d (5mg/kg/dose qid)
-Augmentin 875mg bid x 10d (10mg/kg/dose tid)
Pneumonia: Back to Top
- <6 months: Ampicillin 50mg/kg IV PLUS [Gent 2mg/kg OR Cefotaxime 50mg/kg IV]
-Patients < 6 months of age should be admitted
-6 months to 5yrs: Amoxicillin OR Augmentin 80-90mg/kg/day
-PCN allergic: Pediazole 50mg/kg/day divided tid
-5 to 18yrs: Azithromycin x 5d OR E-mycin x 10-14d
-Adult:
-Outpatient: Z-pack OR E-mycin 500mg OR Clarithromycin 500mg PO bid OR Levo 500mg OR Doxy 100mg x 10d
-Inpatient:
Individual hospitals are graded and ranked on the following:
Blood culture before antibiotics given
Timeliness of abx: within 4 hours from triage: if close to 4 hours, consider giving before xray result. This is required of all patients with pneumonia whether they’re a special case or not
Use doxycycline instead of erythromycin if a patient has a prolonged QT
Floor: Ceftriaxone IV (1 gm q 24h) + Biaxin po (500 mg q 12h)
OR: Ceftriaxone IV (1 gm q 24h) + Erythromycin IV (500 mg q6h [if NPO]
-Pen allergy: Avelox (moxifloxacin) IV (400 mg q 24h) [single antibiotic]
-Macrolide allergy: Doxycyline IV/PO (100 mg q 12 h) [for Biaxin or erythro]
ICU: Ceftriaxone IV (1 gm q 24h) + Erythro IV (500 mg q 6h)
-Pen allergy: Avelox (moxifloxacin) IV (400 mg q 24h)
NURSING HOME: Zosyn (piperacillin/tazobactam) IV (3.375 gm q 6h) + Erythromycin IV (500 mg q 6h)] [or if pen allergic: Clindamycin IV (600 mg q 8h) + Cipro (400 mg q 12h)]
-Be sure to make a specific notation if during the last 3 months the patient either
If documented resistance to zosyn on nursing home sheet: Imipenem 500mg IV
Pyelonephritis: Back to Top
-Outpatient: Ciprofloxacin 1000mg PO qd OR Cipro XR 500mg PO OR Levaquin 250mg qd OR Augmentin 875mg bid x 14d
-Do NOT use Bactrim for pyelonephritis (high resistance)
-Pediatric Outpatient (FQ contraindicated): Omnicef 14mg/kg PO qd x 10 days (refer <2yo to PMD for imaging)
-Inpatient: Cipro 400mg IV q8-12h OR Rocephin 2g IV q 24h OR Unasyn 3g IV q6h OR Zosyn 3.375g IV q 6h
-Urosepsis: Zosyn 3.375g IV q6h OR Gentamycin 7mg/kg IV x 1 (if not on dialysis), then pharmacy to dose
-STD (GC/C): Azithromycin 2g PO alone
-Trichomonas: Flagyl 2g PO
-Pregnancy: Ovral 2 tabs now then 2 in 12h OR Lo/Ovral 4 tabs now then 4 in 12h
-Must have negative urine hcg first (no pre-existing pregnancy)
-Phenergan 25mg PO for home (high-dose birth control will cause nausea)
Sinusitis,Backtotop
-Sudafed 60mg PO q 4-6h
-Afrin 2-3 drops/sprays/nostril BID for 3 days (>3 days use results in rebound symptoms)
-Antibiotics indicated if:
->7 days symptoms with maxillary/facial pain and purulent nasal discharge
-<7 days if severe illness (pain/fever)
-No prior antibiotics in the prior month:
-Amoxicillin 500 mg PO tid for 10 days (peds 90mg/kg/day divided bid for 10 days)
- Antibiotics in the prior month:
-Augmentin 500-875mg PO bid for 10 days (peds 90mg amoxicillin component/kg/day divided bid)
-PCN allergy:
-TMP/SMX (Bactrim) 1 double strength tablet PO bid for 10 days (peds 8-10 mg/kg/d divided bid). One study shows 3 days treatment equal to 10 days
-Doxycycline 100mg PO bid for 10 days