Disease / Etiology
|
Preferred
|
Alternative
|
Comments
|
Purulent SSTI
|
Impetigo
|
Staphylococcus aereus
&
Streptococcus pyogens
Localized/mild
|
Topical Mupirocin 2% *q12H 5 - 7 days
OR
Cloxacillin 500mg PO q6H, 5-7 days
(if topical options are not available)
|
Topical Fusidic Acid 2% *q8 - 12H 5 - 7 days
Cephalexin 500 mg PO q6H, 5-7 days (if topical options are not available)
|
Incision and drainage indicated.
Send pus / exudate for C&S.
De-escalate/ streamline once C&S result is available.
If penicillin allergic:
Erythromycin Ethylsuccinate 400 mg PO q6H
OR
Clindamycin 300 mg PO q6H
OR
Co-trimoxazole 480 mg 2 - 4 tablets
PO q12H
If MRSA suspected,
Clindamycin 300 mg PO q6H
OR
Co-trimoxazole 480 mg 2 - 4 tablets q12H
*
Topical Mupirocin 2% and Topical
Fusidic Acid 2% are not available in UMMC formulary
**Note: Co-trimoxazole may not cover streptococci |
Generalized/moderate |
Cloxacillin 500mg PO q6H, 5-7 days |
Cephalexin 500 mg PO q6H, 5-7
days (if topical options are not available)
OR
Co-amoxiclav 625 mg PO q8H
Duration 5 - 7 days |
|
Abscess, Carbuncles & Furuncles
|
Staphylococcus aureus
Streptococcus pyogens
Polymicrobial (regional skin flora)
Mild
|
Cloxacillin 500 mg PO q6H, 5 days
|
Cephalexin 500 mg PO q6H, 5 days |
Incision and drainage indicated.
Send pus / exudate for C&S.
De-escalate/streamline
once C&S result is available.
IV antibiotics should be de-escalated
to oral once clinical improvement occurs
Total duration 5 - 7 days
Duration is suggested and can be adjusted depending on
clinical progress.
** Consider in diabetes mellitus or
immunocompromised/ in shock / not responding to Co-amoxiclav or
Ampicillin/Sulbactam
*** Risk for ESBL or failed Piperacillin/Tazobactam or penicillin allergy
If penicillin allergic:
Clindamycin 300 mg PO /IV q6H
OR
Co-trimoxazole 480 mg PO 3 - 4
tablets q12H
If MRSA suspected:
Clindamycin 300 mg PO q6H
OR
Co-trimoxazole 480 mg PO 3 - 4
tablets q12H
OR
Vancomycin 25 - 30 mg/kg (max. 2gm)
IV loading dose, followed by 15 - 20 mg/kg IV q8 - 12H.
Optimise Vancomycin dose by doing therapeutic drug monitoring.
Note: Co-trimoxazole may not cover streptococci
|
Moderate |
Cloxacillin 2g IV q6H |
Cefazolin 2 gm IV q8H
|
Severe |
Co-amoxiclav 1.2g IV q8H
OR
Ampicillin/Sulbactam 1.5g IV q8H
|
Piperacillin / Tazobactam 4.5 gm IV
q6H **
OR
Meropenem 1 gm IV q8H***
|
Non Purulent SSTI
|
Erysipelas
|
Streptococcus pyogenes
Staphylococcus aureus
Localized/ mild
|
Cloxacillin 500mg PO q6H, 5 days
OR
Phenoxymethylpenicillin 500 mg PO q6H, 5 days
OR
Amoxicillin 500 mg PO q6H, 5 days*
|
Cephalexin 500 mg PO q6H, 5 days
|
Total duration:
Duration is suggested and can be
adjusted depending on clinical progress.
IV antibiotics should be de-escalated
to oral once clinical improvement occurs
|
Systemic |
Cloxacillin 2 gm IV q6H |
Cefazolin 1 gm IV q8H |
If Penicillin allergy:
Erythromycin
Ethylsuccinate 400 mg PO q6H
Clindamycin 300 mg PO q6H
OR
Clindamycin 600mg IV q8H (for severe
infection)
OR
Co-trimoxazole 480 mg 3 - 4 tablets
PO q12H
OR
Co-trimoxazole 15mg/kg/day IV
(trimethoprim component) divided into BD (for severe infection)
*If only S. pyogenes is strongly
suspected or cultured
Note: Co-trimoxazole may not cover streptococci
|
Cellulitis
|
Streptococcus pyogenes
Staphylococcus aureus
Mild
|
Cloxacillin 500mg PO q6H, 5-7 day
OR
Phenoxymethylpenicillin 500mg PO q6H, 5-7 days*
OR
Amoxicillin 500 mg PO q6H, 5-7 days*
|
Cephalexin 500 mg PO q6H, 5-7 days
|
Total duration: 5 - 7
days
Duration is suggested and can be adjusted
depending on clinical progress.
Blood C&S if moderate to severe infection.
De-escalate/ streamline once C&S result is available.
IV antibiotics should be de-escalated to
oral once clinical improvement occurs
Elevation of
the leg is important to aid healing
*If only S. pyogenes is strongly suspected or
** if not responded to
Cefazolin or Cloxacillin
***Consider if diabetes mellitus or
immunocompromised/ in shock / not responding to Co-amoxiclav or
Ampicillin/Sulbactam.
****Risk for ESBL
^To cover for MRSA if:
- Had previous MRSA infection / colonization
- History of recent hospitalization
- Recent surgical procedure (especially surgical
implant related surgery)
- Illicit drug user
- Athlete
- MSM (consider)
- Penetration injury (consider)
- Severe sepsis / shock
- Failed initial antibiotic
- Impaired host defences
Optimise Vancomycin dose by doing
therapeutic drug monitoring.
Refer to ID if
allergy to vancomycin
Note: Co-trimoxazole does not cover streptococci.
Penicillin allergy:
Clindamycin 300 mg POq6H
OR
Clindamycin 600mg IV q8H (for severe
infection)
OR
Co-trimoxazole 480 mg 2 - 4 tablets PO
q12H
OR
Vancomycin 25 - 30 mg/kg (max 2gm)
IV loading dose, followed by 15 - 20 mg/kg IV q8 - 12H
|
Moderate
|
Cloxacillin 2 gm IV q6H
|
Cefazolin 2 gm IV q8H |
|
Severe
^If MRSA suspected in severe
infection
If community
acquired MRSA suspected or MRSA
suspected in mild infection
|
Cloxacillin 2 gm IV q6H
Vancomycin 25 - 30 mg/kg (max 2gm) IV loading dose, followed by 15 - 20
mg/kg IV q8 - 12H
Clindamycin 300 mg PO q6H, 5-7 days
|
Cefazolin 2 gm IV q8H
OR
Co-amoxiclav 1.2g IV
q8H**
OR
Ampicillin/ Sulbactam 1.5g IV q8H**
OR
Piperacillin / Tazobactam 4.5 gm IV q6H***
OR
Meropenem 1 gm IV q8H****
Co-trimoxazole 480 mg 2 - 4 tablets PO q12H, 5-7 days
|
|
Diabetic Foot Infection
|
Staphylococcus aureus
Streptococcus spp
Gram negatives
Anaerobes
Mild
|
Co-amoxiclav 625 mg PO q8H
OR
Ampicillin / Sulbactam 375 mg PO q12H
|
Cephalexin 500 mg PO q6 H
+
Metronidazole 400 mg PO q8H
|
Send
tissue/deep swabs for C&S
Total duration: 5 - 7 days
Duration is
suggested and can be adjusted depending on clinical progress.
IV antibiotics
should be de-escalated to oral once clinical improvement occurs
De-escalate/streamline
once C&S result is available.
If penicillin
immediate hypersensitivity, call ID
|
Moderate infection |
Co-amoxiclav 1.2 gm IV q8H
OR
Ampicillin / Sulbactam 1.5 gm IV q8H |
Cefazolin 2g
IV q8H
+
Metronidazole 500mg IV q12H |
Duration: 7 - 14 days (subjected to clinical assessment)
With toxin production: Clindamycin 7 days
Surgical debridement URGENT.
Based on intraoperative culture and sensitivity, antibiotic should be streamlined.
|
Severe infection
|
Piperacillin / Tazobactam
4.5 gm IV q6H
+
* ADD Clindamycin 900 mg IV q8H if
necrotizing fasciitis suspected/ confirmed |
Meropenem 1g IV q8H
+
* Clindamycin 900 mg IV q8H |
URGENT Surgical debridement.
Antibiotics should be streamlined
based on intraoperative culture results
Total duration:
7 - 10 days Duration is suggested and can be adjusted depending on clinical progress
IV antibiotics should be de-escalated
to oral once clinical improvement occurs
*Clindamycin is used to stop toxin production in infections due to Staphylococcus aureus,
Streptococcus pyogenes and some anaerobic gram positive organisms
Clindamycin should be stopped once clinical improvement occurs
If penicillin allergy:
Meropenem 1g IV q8H
+
*Clindamycin - 900 mg IV q8H
|
Chronic, recurrent diabetic
foot ulcer, no evidence of infection
|
No antibiotics, daily dressing, wound care |
|
|
Necrotising Fasciitis
|
Monomicrobial
Streptococcus pyogenes
Streptococcus spp
Staphylococcus aureus
Clostridium spp
Vibrio spp
Aeromonas hydrophila
Polymicrobial
In diabetes / perianal abscess, post op wound infection (esp. abdominal
wound)
Mixed aerobes-anaerobes
|
Piperacillin / Tazobactam
4.5 gm IV q6H
+
*Clindamycin 900 mg IV q8H |
Meropenem
1g IV q8H
+
* Clindamycin 900 mg IV q8H
|
URGENT Surgical debridement.
Antibiotics should be streamlined
based on intraoperative culture results
Total duration: 7 -10 days Duration is suggested and can be
adjusted depending on clinical progress.
IV antibiotics should be de-escalated
to oral once clinical improvement occurs
*Clindamycin is used to stop toxin production in infections due to Staphylococcus aureus,
Streptococcus pyogenes and some anaerobic gram positive organisms
Clindamycin should be stopped once clinical improvement occurs
(max duration 7 days)
Add Vancomycin if MRSA suspected.
If penicillin allergy:
Meropenem 1gm IV q8H
+
*Clindamycin 900mg IV q8H
|
Animal / Human Bites
|
Purulent:
Polymicrobial, mixed aerobes and anaerobes
Non Purulent Wounds:
Staphylococci spp
Streptococci spp
Mild
Moderate
Severe Sepsis
|
Co-amoxiclav 625 mg PO q8H,
5 days
OR
Ampicillin / Sulbactam 375 mg PO q12H, 5 days
Co-amoxiclav 1.2g IV q8H
OR
Ampicillin/ Sulbactam 3g IV q8H
Piperacillin / Tazobactam 4.5 gm IV q6H
|
Cefuroxime 500 mg PO q12H, 5 days
+
or Metronidazole 400 mg PO q8H, 5
days
OR
Clindamycin 300 mg PO q6 H, 5 days
+
Ciprofloxacin 500mg PO q12H, 5 days
OR
Metronidazole 400mg PO q8H, 5 days
+
Co-trimoxazole (480 mg) 2 tablets PO q12H
Cefuroxime 750 mg IV q8H
+
Metronidazole 500 mg IV q8H
OR
Co-trimoxazole (Trimethoprim component) 5 - 10 mg/kg/day in
divided dose
+
Metronidazole 500 mg IV q8H
Meropenem 1g IV q8H
|
Surgical debridement usually
required.
Antibiotics should be streamlined based on intraoperative
culture results.
Total duration for mild infection: 5 days
Duration is suggested and can be
adjusted depending on clinical progress.
Total duration for moderate to severe
infection: 10-14 days. Duration is suggested and can be adjusted depending on
clinical progress.
For wounds that do not have established infection, antibiotics
may be considered if:
*delayed presentation (>8 hours)
*wound cannot be debrided adequately
*involving deeper tissues
*immunocompromised
Use Co-amoxiclav 625 mg PO q8H 3-5 days
If penicillin allergy:
Use one of the established infection regimens.
For cat bites,
Clindamycin has no Pasturella multocida cover.
Consider adding rabies post exposure prophylaxis if fulfil criteria.
Tetanus vaccination should be considered for high risk
bites eg. Contaminated with soil
Valacyclovir is not available in UMMC
|
For monkey bite (only macaque family) Herpes
simiae
Herpes B virus
Monkey B virus
Herpesvirus B
|
As above
+
Post-exposure prophylaxis Valacyclovir** 1 gm PO q8H or Acyclovir 800 mg PO
5x/day should be given for 14 days
|
|
Surgical Site Infections
|
No systemic symptoms:
WBC not raised
Erythema < 5 cm around incision
Systemic symptoms:
WBC raised
Erythema > 5 cm around incision
Induration / necrosis
Mild
Moderate
|
No antibiotics
Change dressing
Clean wound, wound on trunk,
head, neck, extremities:
Cephalexin 500 mg PO q6H, 5
days
Wound of perineum, GIT, female genital
tract:
Co-amoxiclav 625 mg PO q8H, 5
days
Clean wound
Wound on trunk, head, neck, extremities:
IV Cloxacillin 2gm IV q6H
Wound of perineum, GIT, female genital tract:
Co-amoxiclav 1.2gm IV q8H
|
Clindamycin 300mg PO q6H, 5 days
OR
Co-trimoxazole 2-3 tablets PO q12H, 5 days
Cefuroxime 500mg PO q12H, 5 days
+
Metronidazole 400mg PO q8H, 5 days
Cefazolin 2 gm IV q8H
Cefuroxime 1.5 gm IV q8H
+
Metronidazole 500 mg IV q8H
|
Collect deep samples for C&S
Antibiotics should be streamlined
based on intraoperative culture results
Total duration for mild infection: 5
days
Duration is suggested and can be
adjusted depending on clinical progress.
Total duration for moderate to severe
infection:5-7 days, depending on response
If MRSA is suspected, in mild infection:
Clindamycin 300mg PO q6H
OR
Co-trimoxazole 2-3 tablets
PO q12H
If MRSA is suspected in moderate to severe infection: add Vancomycin 25 - 30 mg/kg (max 2 gm)
IV loading dose, then 15 - 20 mg/kg q8 - 12H.
Optimise vancomycin dosing by doing drug monitoring
|
Severe
|
Piperacillin / Tazobactam 4.5 gm IV q6H
|
Meropenem 1g IV q8H
|