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Disease / Etiology
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Preferred
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Alternative
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Comments
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Biliary tract infection:
Cholecytits, cholangitis, biliary sepsis or common duct obstruction
Microorganisms:
Gram negative aeroebs:
E coli
Klebsiella sp,
Enterococcus faecalis (less common)
Anaerobe rare unless there is biliary obstruction: Bacteroides (rarely- perforation, serious illness and bowel manipulation)
Yeast (rarely) |
Co-amoxiclav 1.2 gm IV q8H
In septic shock or needing ICU management or patient with risk of Pseudomonas:
Piperacillin / Tazobactam 4.5 gm IV q8H
Clinical improvement:
Co-amoxiclav 625 mg PO q12H
OR
Cefuroxime 500 mg PO q12H
+
Metronidazole 400 mg PO q8H
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Cefoperazone 1 - 2 gm IV q12H OR Ceftriaxone 2 gm IV q24H
+
Metronidazole 500 mg IV q8H
±
Gentamicin 3 - 5 mg/kg IV q24H if risk of Pseudomonas present |
Duration: 7 days.
To consider laparocsopic cystectomy during presentation.
Blood cultures should be taken BEFORE antibiotics.
Use susceptible testing to guide ongoing therapy.
*Fluoroquinolones cause collateral damage, should be used only when the other drugs are contraindicated.
Biliary drainage should be performed for moderate to severe cholangitis.
Empirical agents should be changed according to bile C&S. |
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Infectious Diarrhea
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Acute mild to moderate diarrhea
Virus: norovirus (usually)
Bacteria
Parasite (rarely)
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To replace fluids.
No antibiotics required. |
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Mild: ≤ 3 unformed stools, minimal symptoms
Moderate: ≥ 3 unformed stools and/or symptomatic
Severe: fever (> 38.5oC), ≥ 6 unformed stool. Severe diarrhea in the elderly, fecal leucocytes ± bloody stools.
Ciprofloxacin resistance increasing for salmonella and campylobacter.
TMP-SMX resistant and Campylobacter resistance common in Asia. |
Acute severe diarrhoea
Campylobacter
Yersinia
Salmonella
Aeromonas
Plesiomonas spshigella
C difficile |
Ciprofloxacin 500 - 750 mg PO q12H for 3 - 5 days.
If C diff suspected, to add Metronidazole 400 - 800 mg PO q8H for 10 - 14 days
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Trimethoprim -Sulfamethoxazole (TMP-SMX) (TMP 80 mg/SMX 400 mg) 2 tablet PO q12H for 3 - 5 days
OR
Azithromycin 500 mg PO q24H for 3 days
Alternative,
Vancomycin 125 - 500mg PO q6H for 14 days
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Hepatic Abscess
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Pyogenic abscess:
Enterobacteriaceae
Strep anginosus/milleri (occasionally)
Enterococci
Bacteroides
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Co-amoxiclav 1.2 gm IV q8H
If septic shock:
Piperacillin / Tazobactam 4.5 gm IV q8H |
Cefoperazone 2 gm IV q24H
OR Ceftriaxone 2 gm IV q24H
+
Metronidazole 500 mg IV q8H
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Duration: 4 - 6 weeks.
Modify antibiotics according to culture.
Convert to oral once clinically improved.
If no culture available, oral Augmentin can be used.
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Amoebic abscess:
Entamoeba histolytica |
Metronidazole 500 mg IV q8H
Switch to Metronidazole 400 mg PO q8H for 10 days when clinical improvement occurs.
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Tinidazole 2 gm PO q24H for 3 - 5 days |
Tinidazole not available in UMMC. |
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Acute Pancreatitis
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Mild to moderate pancreatitis including alcoholic pancreatitis |
Antibiotics not required |
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Severe non necrotizing pancreatitis |
Antibiotics not required |
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Perform an image guided percutaneous aspiration before antibiotics.
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Severe non infected necrotizing pancreatitis
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Antibiotics not required |
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Prophylaxis antibiotics to prevent pancreatic infection are no longer recommended because of lack of benefit and possibly of harm.
Surgical debridement is the treatment of choice.
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Severe infected necrotizing pancreatitis: infected pseudo cyst, pancreatic abscess
Enterobacteriaceae
Enterococci
Staph aureus
Streptococcus
Staph Epidemidis
Anaerobes
Candida spp (Rarely)
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Imipenem* 500 mg IV q6H |
Cefoperazone 1 - 2 gm IV q24H OR Ceftriaxone 2 gm IV q24H
+
Metronidazole 500 mg IV q8H or 400 mg PO q8H |
* Deescalate antibiotic once culture and sensitivity result is available. |
Prophylaxis antibiotics if > 30% of pancreas necrotic on CT scan
(CONTROVERSIAL)
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Imipenem 500 mg IV q6H OR
Meropenem 1 gm IV q8H |
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Duration: if cultures are negative, stop antibiotics by Day 3.
Perform an image guided percutaneous aspiration before antibiotics.
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Diverticular Disease
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Diverticulitis, appendicitis, Peri-diverticular abscess, Peri-appendiceal abscess, Peritonitis due to Perforated viscus, Perirectal abscess:
Enterobacteriaceae
Enterococci (in perforation of large bowel)
Anaerobes
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Co-amoxiclav 1.2 gm IV q8H
If patient is at risk of Pseudomonas infection:
Piperacillin / Tazobactam 4.5 gm IV q8H
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Ceftriaxone 1 gm IV q24H
+
Metronidazole 500 mg IV q8H |
Duration: 5 - 10 days
*Fluoroquinolone causes collateral damage.
Should be used only when the other drugs are contraindicated.
Add Metronidazole if peritonitis, perforation or abscess present. |
Spontaneous Bacterial Peritonitis (SBP)‡
Entereobacteriaceae (63%)
S. pneumoniae (15%)
Enterococci (6-10%)
Anaerobes (uncommon)
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Co-amoxiclav 1.2 gm IV q8H
If patient is at risk of Pseudomonas infection: Piperacillin / Tazobactam 4.5 gm IV q8H
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Ceftriaxone 1 gm IV q24H
+
Metronidazole 500 mg IV q8H |
Duration: 5 - 7 days
* Add Ampicillin 1 gm IV q6H if on TMP / SMX or Norfloxacin prophylaxis because in these cases, Streptococcus and Enterococci are more common |
Esophageal Gastric Infection
Esophageal Perforation
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Piperacillin / Tazobactam 4.5 gm IV q8H
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Cefoperazone 1 - 2 gm IV q24H
OR Ceftriaxone 1 - 2 gm IV q24H
+
Metronidazole 500 mg IV q8H
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Perforated Gastric / Duodenal Ulcers |
Co-amoxiclav 1.2 gm IV q8H
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