Updated May 2007
Empiric
Antibiotic Selection for Adults with Suspected Infections
This guideline is intended to assist in antibiotic selection
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Head and Neck (including CNS) | Bone and Joint | |
Thorax | Urinary tract | |
Abdomen/GI | Obstetric-Gyn | |
Miscellaneous |
Location |
Syndrome |
First Choice |
Alternative |
Comment |
(including CNS) |
Community-Acquired Brain Abscess/Subdural empyema
|
Ceftriaxone High Dose + Metronidazole |
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Postoperative brain abscess/Subdural empyema |
Ceftazidime + Vancomycin |
Aztreonam + Ciprofloxacin + Vancomcyin (Severe beta-lactam allergy). |
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Encephalitis |
Acyclovir IV |
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Meningitis, Community-Acquired |
Ceftriaxone HD + Vancomycin |
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Add Ampicillin (or Bactrim in Pen allergic patients) if Immunocompromissed or older than 50.
Consider starting Dexamethasome before or at the same time of first dose of antibiotics.
Consider ID consultation |
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Meningitis, Community-Acquired in HIV patient with CD4 below 100 |
Ceftriaxone High Dose + Vancomycin + Ampicillin + Amphotericin B if opening pressure > 20 cm H2O and AMS |
Ceftriaxone High Dose + Vancomycin + Ampicillin |
Awaiting India ink report, Crypto Ag and gram-stain and culture. Once results available, optimize therapy. |
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Meningitis, Postoperative |
Ceftazidime + Vancomycin |
Aztreonam + Ciprofloxacin + Vancomcyin (Severe beta-lactam allergy). |
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Acute otitis, NO history of Beta-lactam treatment within 30 days |
Amoxicillin |
Azithromcycin or Clarithromycin |
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Acute otitis media, history of Beta-lactam treatment within 30 days |
Levofloxacin |
Amoxicillin High Dose |
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Acute Sinusitis |
See Otitis Media |
See Otitis Media |
Only treat if symptoms > 7 days or if pt has both facial pain and purulent discharge. |
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Pharyngitis |
Benzathine PCN or PenVK or Amoxicillin |
Erythromycin (Penicillin allergy) |
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Mild odontogenic infections |
Amoxicillin |
Clindamycin |
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Moderate to severe odontogenic, ENT/neck infections |
Ampicillin/Sulbactam |
Clindamycin + Levofloxacin |
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Endocarditis, native valve |
Vancomycin + Ceftriaxone +/- Gentamicin |
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Make sure 2-3 blood cultures are taken before starting empiric antibiotics. Consider ID consultation |
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Endocarditis, prosthetic valve |
Vancomycin + rifampin + gentamicin |
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Outpatient CAP, no comorbidities, no antibiotics last 3 months |
Doxycycline or Azithromycin |
Clarithromycin or Levofloxacin |
Comorbidities: renal disease, liver disease, heart failure, immunosuppression, diabetes, malignancies, asplenia, alcoholism.
Avoid using Levofloxacin if TB is suspected or/and consider r/o TB. |
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Outpatient CAP, comorbidities, no antibiotics last 3 months |
Levofloxacin |
[Azithromycin or Clarithromycin] + Amoxicillin HD |
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Outpatient CAP, use of beta-lactam antibiotic during the last 3 months |
Levofloxacin |
[Azithromycin or Clarithromycin] + Amoxicillin HD |
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Outpatient CAP, use of quinolone antibiotic during the last 3 months |
[Azithromycin or Clarithromycin] + Amoxicillin HD |
Levofloxacin |
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Inpatient CAP, no risk factors for resistant organisms** |
Ceftriaxone + Azithromycin |
Levofloxacin |
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Inpatient CAP, no risk factors for resistant organisms**, patient admitted to the ICU |
Ceftriaxone + Azithromycin |
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Use Levofloxacin and Clindamycin if patient has severe allergy to beta-lactam. |
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Healthcare Associated Pneumonia, no recent quinolone use |
Vancomcyin + Piperacillin-tazobactam + Levofloxacin |
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Use Aztreonam instead of Piperacillin-tazobactam if severe allergy to beta-lactam |
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Healthcare Associated Pneumonia, recent quinolone use, non-ICU admission, CURB-65 score < 2 and PSI score class < 4. |
Vancomcyin + Piperacillin-tazobactam + Tobramycin |
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Use Aztreonam instead of Piperacillin-tazobactam if severe allergy to beta-lactam |
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Healthcare Associated Pneumonia, recent quinolone use + [ICU admission or PSI score class ≥ 4 or CURB-65 score ≥ 2]. |
Vancomcyin + Piperacillin-tazobactam + Tobramycin + Azithromycin |
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Use Aztreonam instead of Piperacillin-tazobactam if severe allergy to beta-lactam |
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Hospital Acquired Pneumonia and Ventilator Associated Pneumonia without risk factors for multi-resistant organisms*** |
Vancomcyin + Piperacillin-tazobactam + Levofloxacin |
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Use Aztreonam instead of Piperacillin-tazobactam if severe allergy to beta-lactam |
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Hospital Acquired Pneumonia and Ventilator Associated Pneumonia with risk factors for multi-resistant organisms*** |
Vancomcyin + Imipenem + Levofloxacin or Amikacin |
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Use Aztreonam instead of Imipenem if severe allergy to beta-lactam |
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Pneumonia in HIV infected patient, mild or moderate, PCP very likely^^ |
Bactrim Pneumocystis Dose |
Clindamycin + Primaquine (for allergy to sulfas)
or
Atovaquone (mainly for patients with G6PD Deficiency) |
Add steroids if A-a∆ > 35 or PaO2 > 70. Consider early bronchoscopy for etiologic diagnosis in patients with moderate severity if patient intubated or if patient not intubated and O2 sat > 90% on supplemental O2. |
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Pneumonia in HIV infected patient, severe (RR>30, or intubated or FiO2 ³50% to keep Sat >90), and PCP very likely^^ |
Batrim Pneumocystis Dose, consider adding antibiotics for bacterial pneumonia |
Pentamidine IV (for allergy to sulfas)
Consider rapid Bactrim desensitization protocol |
Add steroids Consider early bronchoscopy for etiologic diagnosis if patient intubated or if patient not intubated and O2 sat > 90% on supplemental O2. |
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Pneumonia in HIV infected patient, mild or moderate, and bacterial pneumonia very likely^^^ |
Same as CAP or HCAP |
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Pneumonia in HIV infected patient, severe (RR>30, or intubated, or FiO2 ³50% to keep Sat >90), and bacterial pneumonia very likely^^^ |
Same as CAP or HCAP, consider adding PCP therapy as above |
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Consider early bronchoscopy for etiologic diagnosis if patient intubated or if patient not intubated and O2 sat > 90% on supplemental O2. |
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Pneumonia in HIV infected patient, mixed picture |
Treat for PCP and for CAP/HCAP |
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Empyema, Comm.-Acquired |
Same as CAP |
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Empyema, Hospital-Acquired |
Same as Hospital Acquired Pneumonia |
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Acute exacerbations of chronic bronchitis |
Amoxicillin |
Doxycycline or Bactrim |
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Community-Acquired intrabdominal infection, mild to moderate |
Ceftriaxone + Metronidazole
or Ampicillin-sulbactam
or Cefoxitin.
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Levofloxacin+ Metronidazole |
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Community-Acquired intrabdominal infection, severe, non-ICU. |
Ceftriaxone + Metronidazole
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Levofloxacin + Metronidazole
or
Ertapenem (restricted to surgical service) |
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Community-Acquired intrabdominal infection, severe, patient in the ICU |
Piperacillin-tazobactam |
Ceftriaxone + Metronidazole
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Use Levofloxacin + Metronidazole if severe allergy to beta-lactams |
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Hospital acquired intra-abdominal infection, no risk factors for multi-resistant organisms*** |
Piperacillin-Tazobactam +/- Vancomycin |
Aztreonam + Metronidazole +/- Vancomycin (severe Beta-lactam allergy only). |
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Hospital acquired intra-abdominal infection, risk factors for multi-resistant organisms*** |
Imipenem +/- Vancomycin +/- Amikacin or Levofloxacin |
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Acute spontaneous bacterial peritonitis (SBP) |
Levofloxacin |
Ceftriaxone (consider if total bilirrubin less than 2 mg/dl). |
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SBP prophylaxis in patients with acute variceal bleed |
Levofloxacin |
Ceftriaxone (consider if total bilirrubin less than 2 mg/dl). |
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Chronic SBP prophylalxis (for patients with ascitic fluid protein concentration of less than 15g/L) |
Bactrim DS 1 tab 5 days/week |
Levofloxacin q week. |
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Non-infected pancreatic necrosis |
Antibiotics controversial |
Antibiotics controversial |
May consider imipenem only if pancreatic necrosis documented by CT and after needle aspirate has been taken from necrotic area for gram stain and culture. |
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Infected pancreatic necrosis *Surgery required* |
Imipenem |
Ceftriaxone + Metronidazole, or Levofloxacin + Metronidazole |
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Severe diarrhea with fever, community-acquired |
Levofloxacin + Metronidazole |
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Order CDiff toxin in stool, order stool cultures, other stool studies. |
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Severe diarrhea with fever, hospital acquired |
Consider Metronidazole |
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Order CDiff toxin in stool. |
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Outpatient cellulitis without abscess (including diabetic foot infections NOT associated with ulcers).
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Cephalexin or Dicloxacillin. |
Clindamycin |
Add TMP-SMX or Doxycycline to above regimens if Clindamycin not selected and high suspicion of CA-MRSA. |
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Outpatient community acquired skin and soft tissue abscess (with or without cellulitis) |
Bactrim, use MRSA dose |
Doxycycline |
Incision and drainage is the main therapy, and oral antibiotics may be added based on clinician judgment. If regional adenopathy rapid onset, or lymphangitic streaking use above regimens in combination with Clindamycin or a Beta-lactam (cephalexin, amoxicillin). |
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Inpatient community acquired cellulitis without abscess (including diabetic foot infections NOT associated with ulcers).
|
Cefazolin or Nafcillin |
Clindamycin IV, or Vancomycin |
Add TMP-SMX or Doxycycline to regimen if Clindamycin or Vancomycin not selected and high suspicion of CA-MRSA |
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Inpatient community acquired skin and soft tissue abscess (with or without cellulitis) |
Vancomycin |
Bactrim MRSA dose + Clindamycin IV |
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Severe community acquired soft-tissue infection (including possible necrotizing fasciitis), non-diabetic |
Vancomycin + Penicillin G + Clindamycin + Gentamicin |
Vancomycin + Cefazolin + Clindamycin + Gentamicin |
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Severe hospital-acquired or healthcare associated soft-tissue infection (including possible necrotizing fasciitis) |
Piperacillin-Tazobactam + Vancomycin + /-Clindamycin |
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For patients with severe allergy to beta-lactams, use Aztreonam instead of Piperacillin-tazobactam. |
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Mild diabetic foot infection with ulcer (cellulitis/erythema extends ≤2 cm around the ulcer, and infection is limited to the skin or superficial subcutaneous tissues; no other local complications or systemic illness) |
Amoxicillin/clavulanate + Bactrim MRSA dose |
Clindamycin + Levofloxacin |
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Moderate diabetic foot infection (patient is systemically well and metabolically stable but has ≥1 of the following characteristics: cellulitis extending >2 cm around the ulcer, lymphangitic streaking, spread beneath the superficial fascia, deep-tissue abscess, gangrene, and involvement of muscle, tendon, joint or bone) |
Ampicillin/Sulbactam + Vancomycin |
Clindamycin + Levofloxacin |
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Severe diabetic foot infection (Infection in a patient with systemic toxicity or metabolic instability [e.g., fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycemia, or azotemia]). |
Piperacillin-Tazobactam + Vancomycin |
Clindamycin + Levofloxacin or Ticarcillin/Clavulanate + Vancomycin |
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Human and Animal bites, outpatient |
Amoxicillin/clavulanate |
Levofloxacin + clindamycin, Doxycycline |
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Human and Animal bites, inpatient |
Ampicillin-sulbactam |
Levofloxacin + clindamycin |
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Mild surgical site infection (SSI) |
Bactrim MRSA dose + Clindamycin |
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Use Clindamycin + Levofloxacin IV or Ciprofloxacin PO if sulfa allergy |
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Moderate SSI, no abdominal/pelvic surgery |
Vancomycin + [Levofloxacin or Tobramycin] |
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Moderate SSI, abdominal/pelvis surgery |
Vancomycin + [Levofloxacin or Tobramycin] + Metronidazole |
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Severe SSI (severe sepsis, septic shock, or patient in the ICU), no risk factors for multi-resistant organisms |
Vancomycin + Piperacillin-tazobactam + [Levofloxacin or Tobramycin] |
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Use Aztreonam + (with Metronidazole if abdominal/pelvic surgery) instead of Piperacillin-tazobactam in patients with severe Beta-lactam allergy. |
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Severe SSI, abdominal/pelvic surgery (severe sepsis, septic shock, or patient in the ICU), risk factors for multi-resistant organisms |
Vancomycin + Imipenem + [Levofloxacin or Tobramycin] |
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Septic arthritis |
Vancomycin + Ceftriaxone |
Vancomycin + levofloxacin |
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Acute osteomyelitis – long bones or vertebral |
Vancomycin + Ceftriaxone |
Vancomycin + levofloxacin |
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Acute (or acute on chronic) osteomyelitis – Contiguous to soft tissue ulcer or infection. |
Same as diabetic foot infection.
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Same as diabetic foot infection.
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If possible delay antibiotic administration until bone cultures taken.
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Chronic osteomyelitis
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No empiric antibiotics recommended |
No empiric antibiotics recommended |
Needs surgery with bone debridement and culture |
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Infected prosthetic joint and infected ORIF |
Vancomyin + Levofloxacin |
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Ideally obtain cultures before starting antibiotics |
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Uncomplicated UTI (needs to meet all the following criteria: women, no functional or structural abnormality of the urinary tract). |
Nitrofurantoin |
Levofloxacin or Bactrim |
Avoid nitrofurantoin if CrCl<60 ml/min |
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Community-acquired, complicated UTI and Pyelonephritis (UTIs not meeting the uncomplicated UTI criteria) |
Levofloxacin |
Ceftriaxone |
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Hospital acquired or healthcare related UTI, patient not severely ill |
Levofloxacin |
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Hospital acquired or healthcare related UTI, patient severely ill (severe sepsis, septic shock, or patient in the ICU) |
Piperacillin-tazobactam +/- [Tobramycin or Levofloxacin] |
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Use Aztreonam if severe allergy to beta-lactams. |
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Hospital acquired or healthcare related UTI, patient severely ill (severe sepsis, septic shock, or patient in the ICU) and risk factors for multi-resistant organisms |
Imipenem + [Tobramycin or Levofloxacin] |
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Acute Prostatitis in patients younger than 35 |
Ceftriaxone 250 mg IM x1 dose + Doxycycline |
Ciprofloxacin PO or Levofloxacin IV |
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Acute Prostatitis in patients older than 35 |
Ciprofloxacin |
Bactrim |
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Chronic Prostatitis |
Ciprofloxacin |
Bactrim |
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Asymptomatic bacteriuria in pregnant women |
Nitrofurantoin |
Amoxicillin/clavulanate |
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Asymptomatic bacteriuria in patients undergoing urologic procedures |
Ciprofloxacin PO or Levofloxacin IV |
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Asymptomatic bacteriuria in other patients (including nursing home, diabetic patients) |
Do not treat |
Do not treat |
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Mastitis, outpatient |
Cephalexin + Bactrim MRSA dose. |
Clindamycin + Bactrim MRSA dose. |
Consider incision and drainage. |
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Mastitis, inpatient |
Vancomycin |
Bactrim MRSA dose + Clindamycin IV |
Consider incision and drainage. |
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Postpartum Endometritis |
Gentamicin + Clindamycin |
Ampicillin-Sulbactam or Cefoxitin |
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Prolonged Ruptured of Membranes with fever |
Ampicillin + Gentamicin |
Clindamycin + Gentamicin |
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Premature rupture of Membranes without fever |
Ampicillin + Erythromycin |
Clindamycin + Erythromycin |
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Pelvic inflammatory disease, outpatient |
Ceftriaxone 250mg IM x1 + Doxycycline +/- Metronidazole |
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Pelvic inflammatory disease, inpatient |
Clindamycin + Gentamicin + Doxycycline |
Cefoxitin + Doxycycline Or Ampicillin/Sulbactam + Doxycycline |
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Febrile neutropenia |
Ceftazidime +/- Amikacin +/- Vancomcyin
or
Piperacillin/Tazobactam +/- Amikacin +/- Vancomcyin |
Aztreonam +/- Amikacin +/- Vancomcyin (ONLY FOR SEVERE BETA-LACTAM ALLERGY) |
Use Vancomycin if suspected catheter-related infection, suspected soft-tissue infection, severe mucositis, quinolone prophylaxis or history of colonization with MRSA or Penicillin-Resistant Streptococcus pneumoniae. |
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Community-acquired, sepsis of unknown source |
Ceftriaxone +/- Vancomcyin |
Vancomcyin + Levofloxacin |
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Hospital-acquired or healthcare associated, sepsis of unknown source, no risk for multi-resistant organisms |
Vancomcyin + Piperacillin/Tazobactam + [Levofloxacin or Tobramycin] |
Vancomcyin + Aztreonam + [Levofloxacin or Tobramycin] (ONLY FOR SEVERE BETA-LACTAM ALLERGY) |
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Hospital-acquired or healthcare associated, sepsis of unknown source, risk for multi-resistant organisms |
Vancomcyin + Imipenem + [Levofloxacin or Tobramycin] |
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** Risk factors for Resistant organisms: 1) Hospitalization for more than 4 days in the last 90 days; 2) Residence in a nursing home for more than 4 days in the last 90 days; 3) Received 3 or more days of antibiotics in the last 90 days; 4) Neutropenia (Absolute Granulocyte count less than 500 or between 500 and 1000 and decreasing). 5) Home infusion therapy, home wound care, hemodialysis in the last 30 days.
*** Risk factors for Multi-resistant organisms: meets one of the following criteria: 1) [ICU stay more than 3 days within last 30 days] AND/OR [has received more than 3 days of Ceftriaxone, Ceftazidime, Levofloxacin, Ciprofloxacin, or Piperacillin/Tazobactam within the last 30 days] AND [requires pressors or has an APACHE II score less above 15]; 2) Has received more than 3 days of Ceftriaxone, Ceftazidime, Levofloxacin, Ciprofloxacin, or Piperacillin/Tazobactam within the last 10 days.
^^ PCP very likely: most meet all the following criteria: 1) Not receiving or non-compliant with Bactrim prophylaxis; 2) CD4 < 200, CD4 % < 14%, or oral thrush; 3) Dyspnea of more than 7 days duration; 4) CXRay showing non-segmental infiltrates, with no pleural effusion and no adenopathy; 5) Hypoxemia or O2 desaturation with ambulation; 6) LDH > 220.
^^^ Bacterial pneumonia very likely: most meet all of the following criteria: 1) Fever and non-productive cough of less than 7 days duration; 2) Chest XRay showing focal infiltrate.