Antibiotics by diagnosis

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Antibiotics by diagnosis

For antibiotics by organism see Microbiology (Main)

Bone and Joint

Diabetic foot infection

Associated organisms include Staphylococcus, Streptococcus, Enterococcus, Enterobacteriaceae, Proteus, Bacteroides, and Pseudomonas, and Klebsiella

Superficial Mild Infections

Prior antibiotic treatment or moderate infections

Inpatient Treatment


Diskitis or Osteomyelitis

Inpatient Therapy

Use cefepime or ciprofloxacin if targeting Pseudomonas spp

Felon

Definitive treatment is drainage but antibiotic coverage for S. aureus and Strep with caution to identify Herpetic whitlow

Infectious Tenosynovitis

Treatment should cover S. aureus, Streptococcus, and MRSA

Animal Bites

Ampicillin/Sulbactam 3g (50mg/kg) IV four times daily

Pediatrics

Mycobacteria related

Treatment should include usual therapy listed above in addition to:

AND consult infectious disease

Open fracture

Prophylactic Antibiotics for Open fractures

Initiate as soon as possible; increased infection rate when delayed[1]

Grade I & II Fractures Options

  • Cefazolin (Ancef) 2 g IV (immediately and q8 hours x 3 total doses)[2]
  • Cephalosporin allergy: clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)[2]

Grade III Fracture Options

  • Ceftriaxone 2 g IV (immediately x 1 total dose) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]
  • Cephalosporin allergy: aztreonam 2 g IV (immediately and q8 hours x 3) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]

Special Considerations

Osteomyelitis

Risk Factor Likely Organism Initial Empiric Antibiotic Therapy'
Elderly, hematogenous spread MRSA, MSSA, gram neg Vancomycin 1gm + (Piperacillin/Tazobactam 3.375 grams OR imipenem 500mg)
Sickle Cell Disease Salmonella, gram-negative bacteria Ceftriaxone 50mg/kg IV once daily OR Cefotaxime 50mg/kg IV three times daily, PLUS
  • Vancomycin 15mg/kg IV four times daily OR
  • Clindamycin 10mg/kg IV PO four times daily OR
  • Nafcillin 50 mg/kg IV four times daily to cover K. Kingae (common in daycare population)
DM or vascular insufficiency Polymicrobial: Staph, strep, coliforms, anaerobes Vancomycin 1gm + (Piperacillin/Tazobactam 3.375 grams OR imipenem 500mg)
IV drug user MRSA, MSSA, pseudomonas Vancomycin 1gm 
Newborn MRSA, MSSA, GBS, Gram Negative Vancomycin 15mg/kg load, then reduce dose, AND ceftazidime 30mg/kg IV q12 h
Children MRSA, MSSA Vancomycin 10mg/kg q6 h AND ceftazidime 50mg/kg q8hr
Postoperative (ortho) MRSA, MSSA Vancomycin 1gm
Human bite Strep, anaerobes, HACEK organism Piperacillin/Tazobactam 3.375gm OR imipenem 500mg
Animal bites Pasteurella, Eikenella, HACEK organism Piperacillin/Tazobactam 3.375gm OR imipenem 500mg
Foot puncture wound Pseudomonas Anti-pseudomonal, staph coverage

Septic Arthritis

For adults treatment should be divided into Gonococcal and Non-Gonococcal

Gonococcal

Non-Gonococcal

Pediatrics

Sickle Cell

Coverage for Salmonella and Staphylococcus spp

  • Vancomycin 20mg/kg IV twice daily PLUS
    • Ciprofloxacin 400mg IV three times daily OR
    • Imipenem/cilastatin 1g IV three times daily

Septic Bursitis

Cover Staphylococcus aureus (80-90%) and Streptococcus

Outpatient Options

Treatment followup with primary physician is important since the regimen may need extension to 3 weeks.

Inpatient Options

  • Vancomycin 25-30 mg/kg IV loading then 15-20 mg/kg IV OR
  • Clindamycin 600 mg (10/mg/kg) IV three times daily
  • Linezolid 600 mg IV BID (10mg/kg Q8hrs for pediatrics)

Cardiovascular

Endocarditis

Native Valves

Options:[4]

Suspected MRSA:[4]

Prosthetic Valves (Early)

Early prosthetic valve endocarditis defined as < 12 months post surgery[4]

IV Drug User without Prosthetic Valve

Prosthetic Valve (Late)

Late prosthetic valve endocarditis defined as ≥ 12 months post surgery[4]
  • Same as native valve endocarditis empiric therapy

Dental Procedure Prophylaxis

All antibiotics options are given as a single dose 1 hour prior to the dental procedure

Options:[5]

ENT

Conjunctivitis

Newborn

Chlamydial

  • Doxycycline 100mg PO BID for 7 days OR
  • Azithromycin 1g (20mg/kg) PO one time dose
  • Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days
    • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

  • Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
  • Ceftriaxone 250mg IM one dose PLUS
  • Azithromycin 1g PO one dose
  • Newborn Treatment:
    • Prophylaxis: Erythromycin ophthalmic 0.5% x1
    • Disease manifests 1st 5 days post delivery (early onset)
    • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg

Bacterial Conjunctivitis

  • Counsel patient/family on importance of hand hygiene/avoiding touching face to prevent spread!
  • Apply warm or cool compresses (for comfort and cleansing) every 4 hours, followed by instillation of ophthalmic antibiotic solutions

These options do not cover gonococcal or chlamydial infections

  • Polymyxin B/Trimethoprim (Polytrim) 2 drops every 6 hours for 7 days OR
  • Erythromycin applied to the conjunctiva q6hrs for 7 days OR
  • Levofloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
  • Moxifloxacin 0.5% ophthalmic 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
  • Gatifloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN 1 drop every 6 hours for 5 days OR
  • Azithromycin 1% ophthalmic solution 1 drop BID for 2 days THEN 1 drop daily for 5 days
  • Chloramphenicol 0.5% ophthalmic solution 1 drop QID for 7 days

NB: levofloxacin is preferred for contact lens wearers for coverage of pseudomonas. Advise not to wear contacts for duration of treatment

Epiglottitis

Coverage targets Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae, and H. parainfluenzae

Immunocompetent

Immunocompromised

Coverage should extend to all of the typical organisms above as well as Pseudomonas, M. tuberculosis, and C. albicans

Dental Abscess

Treatment is broad and focused on polymicrobial infection

Ludwig's Angina

  • Must cover typical polymicrobial oral flora and tailored based on patient's immune status
  • Most commonly a 3rd generation cehpalosporin + (clindamycin or metronidazole)
  • If the patient is immuncompromised, the antibiotics need to also cover MRSA and gram-negative rods[7]

Immunocompetent Host[8]

Immunocompromised[9]

Mastoiditis

Coverage against S. pneumoniae, S. pyogenes, S. aureus, H. influenzae

Trench Mouth (Acute Necrotizing Ulcerative Gingivitis)

Options

also nystatin oral rinses of 5ml q6 hrs daily for 14 days will help with concominent fungal infection

HIV positive

in addition to antibiotic regimen consider an oral anti-fungal or nystatin

  • Fluconazole 200mg PO daily for 14 days

Otitis Media

Initial Treatment

  1. Amoxicillin 80-90mg/kg/day divided into 2 daily doses 7-10 days

Treatment during prior Month

  1. If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea
  2. Cefdinir 14mg/kg/day BID x7-10 days
  3. Cefpodoxime 10mg/kg PO daily x7-10 days
  4. Cefuroxime 15mg/kg PO BID x7-10 days
  5. Cefprozil 15mg/kg PO BID x7-10 days

Otitis/Conjunctivitis

  • Suggestive of non-typeable H.flu
  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea

Treatment Failure

defined as treatment during the prior 7-10 days

  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
  2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
    • Use if cannot tolerate PO

Penicillin Allergy

  1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
  2. Clarithromycin 7.5mg/kg PO BID x 10 days
  3. Clindamycin 10mg/kg PO three times daily

Otitis Externa

  1. Ofloxacin (Floxin otic): 5 drops in affected ear BID x 7 days[10]
    • Safe with perforations
  2. Ciprofloxacin-hydrocortisone (Cipro HC): 3 drops in affected ear BID x 7 days
    • Contains hydrocortisone to promote faster healing
    • Not recommended for perforation since non-sterile preparation
  3. Ciprofloxacin-dexamthasone (Ciprodex): 4 drops in affected ear BID x 7 days
    • Similar to Cipro HC but safe for perforations
    • Often more expensive
  4. Cortisporin otic (neomycin/polymixin B/hydrocortisone): 4 drops in ear TID-QID x 7days
    • Use suspension (NOT solution) if possibility of perforation
    • Animal studies suggest possible toxicity from the neomycin although rigorous data is lacking[11]

Streptococcal Pharyngitis

Treatment can be delayed for up to 9 days and still prevent major sequelae

Penicillin Options:[12]

  • Penicillin V 250mg PO BID x 10d (child) or 500mg BID x 10d (adolescent or adult)
  • Bicillin L-A <27 kg: 0.6 million units; ≥27 kg: 1.2 million units IM x 1
  • Amoxicillin 500-875 mg PO q12h or 250-500 PO q8h for 10d[13]

Penicillin allergic (mild):[12]

  • Cefuroxime 10mg/kg PO QID x 10d (child) or 250mg PO BID x 4d

Penicillin allergic (anaphylaxis):[12]

  • Clindamycin 7.5mg/kg PO QID x 10d (child) or 450mg PO TID x 10d OR
  • Azithromycin 12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5

Periorbital Cellulitis

Antibiotics

Outpatient

Treatment recommended for 5-7 days. If signs of cellulitis persist at the end of this period, treatment should be continued until the eyelid erythema and swelling have resolved or nearly resolved.

- In children: 8 to 12 mg/kg QD of the TMP component divided every 12 hours

- In children: 30 to 40 mg/kg per day in three to four equally divided doses, maximum 1.8 grams per day

PLUS one of the following agents:

- In children: usual dosing is 45 mg/kg per day divided every 12 hours; dosing for severe infections or when penicillin-resistant S. pneumoniae is a concern (using the 600 mg/5 mL suspension) is 90 mg/kg per day divided every 12 hours

- In children <12 years of age: 10 mg/kg per day divided every 12 hours, usual maximum dose 200 mg; in children ≥12 years and adolescents: 400 mg every 12 hours

- In children: 14 mg/kg per day, divided every 12 hours, maximum daily dose 600 mg

Inpatient

Vancomycin 15-20mg/kg IV BID + (one of the following)

Peritonsillar Abscess

Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus

Outpatient Options

Inpatient Options

Pertussis

  • Antibiotics do not help with severity or duration but may decrease infectivity.
  • A reasonable guideline is to treat persons aged >1 year within 3 weeks of cough onset and infants aged <1 year and pregnant women (especially near term) within 6 weeks of cough onset. [14]
  • TMP--SMZ should not be administered to pregnant women, nursing mothers, or infants aged <2 months.[15]
  • The following regemins are for active disease or postexposure prophylaxis. If a patient is has confirmed disease and is likely to be in contact with infants or pregnant women then the patient should be treated as up to 6-8 weeks after the onset of their illness.

< 1 month old

Same antibiotics for active disease and postexposure prophylaxis

>1 month old

  • Azithromycin 10mg/kg (max 500mg/day) daily x 5 days
    • if > 6 months old then day 2-5 of treatment should be reduced to 5mg/kg (250mg/day max)
  • TMP/SMX 4mg/kg PO BID daily for 14 days (if > 2 months old)

Adults

any of the following antibiotics are acceptable although azithromycin is most commonly prescribed

Suppurative Parotitis

Treatment targeted at S. aureus, gram negative bacilli, mumps, enteroviruses, and influenza virus

Thrush

  • Nystatin oral suspension 400,000-600,000 units (swish and swallow) Q6H until 48 hours after symptoms disappear OR
  • Clotrimazole 10 mg troches 5 times/day for 14 consecutive days OR
  • Fluconazole 200 mg (Peds: 6 mg/kg) PO on day one, followed by 100 mg (Peds: 3 mg/kg_ daily for two weeks.
    • Fluconazole is reserved for moderate to severe disease

Pediatric Dosing

If the patient is breast feeding it is important for the mother to treat her nipples before and after feeding

  • Nystatin Oral Suspension
    • 100,000 units/ml for 14 days for all ages
    • Premature infants should only have 0.5 - 1 mL given to each side of the mouth every 6 hours
  • Clotrimazole 10mg PO five times daily for 14 days
    • reserved for patients > 3 years old

Eye

Corneal Abrasion

Does Not Wear Contact Lens

Wears Contact Lens

Antibiotics should cover pseudomonas and favor 3rd or 4th generation fluoroquinolones

  • Levofloxacin 0.5% solution 2 drops ever 2 hours for 2 days THEN q6hrs for 5 days OR
  • Moxifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
  • Tobramycin 0.3% solution 2 drops q6hrs for 5 days OR
  • Gatifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
  • Gentamicin 0.3% solution 2 drops six times for 5 days

Orbital Cellulitis

Vancomycin 15-20mg/kg IV BID + (one of the following)

GI

Appendicitis

Coverage should extend to E. coli, Klebsiella, Proteus, and Bacteroides (an anaerobe)

Adult Simple Appendicitis

Antibiotic prophylaxis should be coordinated with surgical consult

Options:

Pediatric Simple Appendicitis

Options:

Complicated Appendicitis

Defined as perforation, abscess, or phlegmon

Options:

Cautious use should be applied to use of fluoroquinolones in complicated pediatric appendicitis due to the risk of tendon injury

Cholecystitis

Most often isolated organisms are Escherichia coli, Klebsiella pneumonia, and anaerobes, especially Bacteroides fragilis

Uncomplicated

Pathogenicity of Enterococci remains unclear and specific coverage is not routinely suggested for community-acquired infections[16]

Complicated or Healthcare Associated

Examples of complication include severe sepsis or hemodynamic instability

  • Vancomycin 15-20mg/kg PLUS any of the following options

Options:

Clostridium Difficile

Moderate Infection

  • Vancomycin 125 mg PO four times daily for 10 days
  • Fidaxomicin 200 mg PO two times daily for 10 days
  • Metronidazole 500mg PO or IV four times daily for 10 days (third line therapy)

Serous Infection

Diverticulitis

Uncomplicated

Options:

Complicated

Options:

Peritonitis

Intra-Abdominal Sepsis/Peritonitis

Harbor-UCLA Santa Monica-UCLA Other
Primary
Allergy or prior exposure

Infectious Diarrhea

Campylobacter jejuni

Entamoeba Histolytica

Giardia lamblia

Microsporidium

Cryptosporidium

Salmonella (non typhoid)

  • Treatment is not recommended routinely but should be considered if:
  • Immunocompromised
  • Age<6 mo or >50yo
  • Has any prostheses
  • Valvular heart disease
  • Severe Atherosclerosis
  • Active Malignancy
  • Uremic

Options: Immunocompromised patients should have 14 days of therapy

Shigella

Treatment extended for 10 days if immunocompromised'

Vibrio Cholerae

Yersinia enterocolitica

Antibiotics are not required unless patient is immunocompromised or systemically ill


Traveler's Diarrhea

Options for Adults:

Typhoid Fever

Oral therapy with Quinolone Susceptibility

Parenteral Therapy with Quinolone Susceptibility

Parenteral Therapy with Quinolone Resistance

if nalidixic acid resistant, assume fluoroquinolone resistant
OR
  • Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

Oral Therapy with Quinolone Resistance

GU

Candida vaginitis

Intravaginal Therapy

  • Clotrimazole 1 % cream applied vaginally for 7 days OR
  • Clotrimazole 2% applied vaginally for 3 days
  • Miconazole 2% cream applied vaginally for 7 days OR 4% cream x 3 days
  • Butoconazole 2% applied vaginally x 3 days
  • Tioconazole 6.5% applied vaginally x 1

Oral Therapy

  • Fluconazole 150mg PO once
    • a second dose at 72hrs can be given if patient is still symptomatic

Pregnant Patients

  • Intravaginal Clotrimazole or Miconazole are the only recommended treatments
  • Duration is 7 days
  • PO fluconazole associated with congenital malformations and spontaneous abortions[26]

Balanoposthitis

Common organisms are Candida, anaerobes, and Group B Streptococcus

Antifungal

  • Clotrimazole 1% applied topically to glans q12hrs until resolution
  • Nystatin cream 100,000 units/gm if infection is recurrent after clotrimazole therapy

Antibacterial

  • Topical triple antibiotic ointment QID or mupirocin cream BID

Epididymitis/Epididymorchitis

  • For acute epididymitis likely caused by STI [27]
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.

Cervicitis/Urethritis

Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[28]

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard

  • Gonorrhea
    • Ceftriaxone IM x 1
      • 500 mg, if weight <150 kg
      • 1 g, if weight ≥150 kg
  • Chlamydia


Ceftriaxone contraindicated

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

Pregnant

Only treat if the patient is symptomatic and avoid breast feeding until 24-hrs after last dose

Sexual Partner Treatment

Men

Acute cystitis

Outpatient

Women, Uncomplicated

  • Nitrofurantoin ER 100mg BID x 5d, OR
  • TMP/SMX DS (160/800mg) 1 tab BID x 3d, OR
  • Cephalexin 250mg QID x 5d, OR
  • Ciprofloxacin 250mg BID x3d
    • Avoid using fluoroquinolone for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.[32]
  • Fosfomycin 3 g PO once
    • Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [33]

Women, Complicated

Women, Concern for Urethritis

Men

Inpatient Options

Bacterial Vaginosis

First Line Therapy[34]

  • Metronidazole 500 mg PO BID for 7 days OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, qd for 5 days OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally qHS for 7 days

Alternative Regimin

  • Tinidazole 2 g PO qd for 2 days OR
  • Tinidazole 1 g PO qd for 5 days OR
  • Clindamycin 300 mg PO BID for 7 days OR
  • Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hrs)

Pregnant

Prophylaxis (Sexual Assault)

Prostatitis

Associated with STD

Target organisms are E. coli, and STDs (GC)

No Associated STD and Chronic Bacterial Prostatitis

Aimed at Enterobacteriaceae, enterococci, Pseudomonas

  • Ciprofloxacin 500mg PO q12hrs x 28 days OR
  • Levofloxacin 500mg PO daily x 28 days OR
  • TMP/SMX 1 DS tablet PO q12hrs x 28 days
  • Consider extension to 6 wks of empiric therapy

Septic

Pyelonephritis

Treatment is targeted at E. coli, Enterococcus, Klebsiella, Proteus mirabilis, S. saprophyticus.

Outpatient

Consider one dose of Ceftriaxone 1g IV or Gentamycin 7mg/kg IV if the regional susceptibility of TMP/SMX or Fluoroquinolones is <80%

Adult Inpatient Options

Pediatric Inpatient Options

Lymphogranuloma venereum

  • Doxycycline 100mg PO BID x 21 days (first choice) OR
  • Erythromycin 500mg PO QID x 21 days OR
    • Preferred for pregnant and lactating females
  • Azithromycin 1g PO weekly for 3 weeks OR
    • Alternative for pregnant women - poor evidence for this treatment currently
  • Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
  • Treat sexual partner

Herpes

Initial Episode[40][41]

Recurrence[40]

  • Acyclovir OR
    • 400mg PO q8hrs x 5 days
    • or 800mg PO q12hrs x 5 days
    • or 800mg PO q8hrs x 2 days
  • Valacyclovir OR
    • 500mg PO q12hrs x 3 days
    • or 1g PO qd x 5 days
  • Famciclovir
    • 125mg PO q12hrs for 5 days
    • or 1g PO q12hrs for 1 day
    • or 500mg PO once, followed by 250mg PO q12hrs for 2 days

Suppressive Therapy[40]

Syphilis

Early Stage

This is classified as primary, secondary, and early latent syphilis less than one year.

Treatment Options:

  • Penicillin G Benzathine 2.4 million units IM x 1
    • Repeat dose after 7 days for pregnant patients and HIV infection
  • Doxycycline 100mg oral twice daily for 14 days as alternative

Late Stage

Late stage is greater than one year duration, presence of gummas, or cardiovascular disease

Treatment Options:

Neurosyphilis

There are 3 Major options with none showing greater efficacy than others:

  • Penicillin G 3-4 million units IV every 4 hours x 10-14 days
  • Penicillin G 24 million units continuous IV infusion x 10-14 days
  • Penicillin G Procaine2.4 million units IM daily + probenecid 500mg oral every 6 hours for 10-14 days.
  • Alternative:
  • Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)

Pregnancy

  • Penicillin, dosage depends on stage [42]

Neuro

Bell's Palsy

Eye Protection

  • Cornea eye protection (Level X)[43]
    • Artificial tears qhr while patient is awake
    • Ophthalmic ointment at night
    • Eye should be taped shut at night
    • Protective glasses or goggles

Steroids

Should be started within 72hrs of symptom onset[44]

Antivirals

Most likely no added benefit when combined with steroids.[47] However also little harm associated with antivirals especially in patients with normal renal function[46]

Antibiotics

  • Consider empiric doxycycline if high index of suspicion for Lyme based on clinical presentation or lab data

Encephalitis

Often it is unclear which type of encephalitis is present and starting Acyclovir empirically is appropriate. In addition to the pathogens below, possible causes can include West Nile Virus, EBV, HIV, toxoplasmosis, or rabies.

HSV encephalitis

  • Acyclovir 10mg/kg (10-15mg/kg for pediatrics) every 8hrs

HZV encephalitis

CMV encephalitis

Tick Associated (Borrelia burgdorferi, Ehrlichiosis or Rickettsia)

  • Doxycycline 200 mg IV once followed by 100 mg IV twice daily

Epidural Abscess

Treat for 6-8 weeks

Meningitis

Neonates (up to 1 month of age)[49]

MRSA is uncommon in the neonate

> 1 month old[51]

Adult < 50 yr[52]

Adult > 50 yr and Immunocompromised[53]

Post Procedural (or penetrating trauma)[55]

Cryptococcosis Meningitis

Options

  • Amphotericin B 1mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
  • Amphotericin B 5mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily

Meningitis with severe PCN allergy

Meningitis with VP shunt

Neisseria meningitidis Prophylaxis

  • Ceftriaxone 250mg IM once (if less than 15yr then 125mg IM)
  • Ciprofloxacin 500mg PO once
  • Rifampin 600 mg PO BID x 2 days
    • if < 1 month old then 5mg/kg PO BID x 2 days
    • if ≥ 1 month old then 10mg/kg (max at 600mg) PO BID x 2 days

Tetanus

Metronidazole:

  • 500 mg IV every 6 hours

(<1200g)

  • 7.5 mg/kg PO/IV q48h
  • First Dose: 7.5 mg/kg PO/IV x 1

(>1200g AND <1 Month Old)

  • <7 days old
    • 7.5-15 mg/kg/day PO/IV q12-24h
    • First Dose: 7.5-15 mg/kg PO/IV x 1
  • >7 days old
    • 15-30 mg/kg/day PO/IV q12h
    • First Dose: 7.5-15 mg/kg PO/IV x 1

(>1 Month Old)

  • 30 mg/kg/day PO/IV q6h
  • First Dose: 7.5 mg/kg PO/IV x 1
  • Max: 4 g/day


OBGYN

Mastitis

  • No need to routinely interrupt breastfeeding with puerperal mastitis.
  • For mild symptoms <24 hours, supportive care may be sufficient[56]
    • Effective milk removal (frequent breast feeding - use pumping to augment milk removal)
    • Analgesia (NSAIDs)

Treatment directed at S. aureus and Strep and E. coli

Endometritis

<48hrs Post Partum

Treatment is targeted against polymicrobial infections, most often 2-3 organisms of normal vaginal flora

>48hrs Post Partum

  • Doxycycline 100mg IV or PO q12hrs + Metronidazole 500mg IV or PO q8hrs daily
    • Use Metronidazole with caution in breastfeeding mothers its active is present in breast milk at concentrations similar to maternal plasma concentrations

PID

Antibiotics

  • No sexual activity for 2 weeks;
  • Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Antibiotic Options

Inpatient Antibiotic Options

Pulmonary

Pneumonia

Outpatient

Coverage targeted at S. pneumoniae, H. influenzae. M. pneumoniae, C. pneumoniae, and Legionella

Healthy[67]

No comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) and no or risk factors for MRSA or Pseudomonas aeruginosa (include prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics (in the last 90 d))

  • Amoxicillin 1 g three times daily (strong recommendation, moderate quality of evidence), OR
  • Doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence), OR
  • Macrolide in areas with pneumococcal resistance to macrolides <25% (conditional recommendation, moderate quality of evidence).
  • Duration of therapy 5 days minimum

Unhealthy[68]

If patient has comorbidities or risk factors for MRSA or Pseudomonas aeruginosa

  • Combination therapy:
    • Amoxicillin/Clavulanate
      • 500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued[69]
    • OR cephalosporin
    • AND macrolide
      • Azithromycin 500 mg on first day then 250 mg daily
      • OR clarithromycin 500 mg BID OR clarithromycin ER 1,000 mg daily]) (strong recommendation, moderate quality of evidence for combination therapy)
    • OR doxycycline 100 mg BID (conditional recommendation, low quality of evidence for combination therapy)
  • Monotherapy: respiratory fluoroquinolone (strong recommendation, moderate quality of evidence):

Inpatient

  • Monotherapy or combination therapy is acceptable
  • Combination therapy includes a cephalosporin and macrolide targeting atypicals and Strep Pneumonia [70]
  • The use of adjunctive corticosteroids (methylprednisolone 0.5 mg/kg IV BID x 5d) in CAP of moderate-high severity (PSI Score IV or V; CURB-65 ≥ 2) is associated with:[71]
    • ↓ mortality (3%)
    • ↓ need for mechanical ventilation (5%)
    • ↓ length of hospital stay (1d)

Community Acquired (Non-ICU)

Coverage against community acquired organisms plus M. catarrhalis, Klebsiella, S. aureus

Hospital Acquired or Ventilator Associated Pneumonia

Ventilator Associated Pneumnoia

  • High Risk of MRSA: Use 3-Drug Regimen. Several options are available, but recommendation is to include an antibiotic from each of these categories:[73]

ICU, low risk of pseudomonas

ICU, risk of pseudomonas

Skin and Soft Tissue

Erysipelas

Coverage for S. pyogenes

  • Penicillin G 300K U/d IM for <30 kg, 600K to 1 million U/d IM for >30 kg (first line therapy[74]) OR
  • Clindamycin 450mg (5mg/kg) PO q8hrs x 10 days (if PCN allergic) OR
  • Cephalexin 500mg (6.25mg/kg) PO q6hrs x 10 days OR
  • Ceftriaxone 1g (50mg/kg) IV once daily x 10 days OR
  • Levofloxacin 500mg PO/IV daily x 10 days OR
  • Augmentin 500mg PO BID x 10 days (generally reserved for failure of first line therapy)

Bullous Erysipela or MRSA suspected: trimethoprim-sulfamethoxazole, clindamycin, doxycycline, or minocycline

Cellulitis/Superficial Abscess with Cellulitis

Tailor antibiotics by regional antibiogram[75]

Outpatient

Coverage primarily for Strep

MRSA coverage only necessary if cellulitis associated with: purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS[76]

  • 5 day treatment duration, unless symptoms do not improve within that timeframe[76]
    • Cephalexin 500mg PO q6hrs OR
      • Add TMP/SMX DS 1 tab PO BID[77] if MRSA is suspected
      • Most cases of non-purulent cellulitis are caused by Strep. In these cases, the addition of TMP/SMX has been demonstrated to offer no clinical benefit over cephalexin alone.[78]
    • Clindamycin 450mg PO TID covers both Strep and Staph
    • Tetracyclines (like Doxycycline) should be avoided in non-purulent cellulitis due to high rates of Strep resistance[79]

Inpatient

Saltwater related cellulitis

coverage extended for Vibrio vulnificus

Freshwater related cellulitis

coverage extended for Aeromonas sp

Impetigo

Coverage for MSSA, MRSA, Group A Strep

Topical therapy

  • Mupirocin (Bactroban) 2% ointment q8hrs x 5 days
    • For nonbullous impetigo, topic antibiotics are as effective as oral antibiotics

Oral Therapy

Bioterrorism

Anthrax

Postexposure Prophylaxis

Patient should be vaccinated at day #0, #14, #28

Cutaneous Anthrax (not systemically ill)

  • Ciprofloxacin 500mg PO q12hrs x 60 days
  • Doxycycline 100mg PO q12hrs x 60 days

Inhalation or Cutaneous with systemic illness

Pediatric Postexpsoure Prophylaxis

Pediatric Cutaneous Anthrax (not ill)

  • Same as post exposure dosing and duration

Pediatric Inhalational or Cutaneous (systemically ill

Botulism

Supportive Care

  • Early ventilatory support
    • Consider intubation when vital capacity <30% predicted or <12cc/kg
  • Wound Managment
    • Early wound debreedment with surgical consult.
    • Also exclude Necrotizing fasciitis and coverage with same broad antibiotic coverage

Foodborne Botulism

  • Equine Serum Botulism Antitoxin
    • only for patients > 1yo
  • Antitoxin obtained through CDC or local Department of Health.

Infant Botulism (<1yo)

  • Human-based Botulism IG 100mg/kg IV x 1 dose (BabyBIG)
    • infusion divided into 25mg/kg/hr IV x 15 min followed by 50mg/kg/hr if no allergic reactions
    • Stop infusion after total of 100mg/kg infused
  • BabyBIG obtained through CDC or local Department of Health

Inhalational Botulism

  • Equine Serum Botulism Antitoxin
    • only for patients > 1yo
  • Antitoxin obtained through CDC or local Department of Health

Wound Botulism

  • Individualize therapy with ID consultant
  • Broad antibiotic coverage same as for Necrotizing fasciitis while awaiting wound cultures

Smallpox

  • IMMEDIATE NOTIFICATION OF PUBLIC HEALTH AUTHORITIES
  • Vaccine administered up to 3 days post-exposure was effective in preventing infection as well as lessening the severity of the disease if infection occurred [80]

Post-Exposure Prophylaxis

  • Vaccinia Vaccine (administer within 72hrs of exposure)

Active Disease

  • Supportive care and wound care for open lesions
  • Vaccinia Vaccine within the first 72hrs can decrease total disease severity and within 7 days may decrease symptoms
    • Vaccination is not efficacious once the patient has developed rash[81]

Tularemia

Postexposure Prophylaxis

Active Disease

Yersinia

Postexposure Prophylaxis

Active Disease

Environmental Exposure

Mammalian bites

Cat and Dog Bites

Coverage for Pasteurella, Strep, and Staph

  • Consider for high-risk wounds
    • wounds reaching the level of the muscle/tendon, wounds to the hand[82], violation of bone or joint capsule, immunocompromised hosts, wounds associated with significant local edema
  • Amoxicilin-clavulanate 875mg PO BID x 5-7 days OR[83]
  • Doxycycline 100mg PO BID x 14 days if penicillin allergic [84]
  • Clindamycin 450mg (5mg/kg) PO q8hrs daily x7 days PLUS

Human Bites

All human bites should be strongly considered for antibiotic therapy.[85]

Requires polymicrobial coverage for: S. aureus, Strep Viridans, Bacteroides, Coagulase-neg Staph, Eikenella, Fusobacterium, Cornebacterium, peptostreptococus

Mammalian Bites Severe Infections

Tetanus (Acute)

Penicillin

  • Although once the drug of choice it is now no longer recommended since it may potentiate the effect of tetanus toxin by inhibiting the GABA receptors[86]

Immunocompromised

CMV Retinitis

Severe Vision Threatening

  • Ganciclovir intraocular implant for 8 months AND
    • Valganciclovir 900mg PO q12hrs x 14 days FOLLOWED BY 900mg PO q24hrs x 7 days

Peripheral lesions

  • Valganciclovir 900mg PO q12hrs x 21 days FOLLOWED BY 900mg PO q24hrs x 7 days

CMV esophagitis

  • Ganciclovir 5mg/kg IV q12hrs daily x 21 days (or until symptom resolution)
  • Foscarnet 90mg/kg IV q12 hrs daily x 21 days (or until symptom resolution)

CMV colitis

  • Ganciclovir 5mg/kg IV q12hrs x 21 days (or until resolution of symptoms)
  • Foscarnet 90mg/kg IV q12hrs daily x 21 days (or until resolution of symptoms)

CMV neurologic disease

  • Ganciclovir 5mg/kg IV q12hrs daily x 21 days FOLLOWED BY 5mg/kg IV q24hrs +
    • Foscarnet 90mg/kg IV q12hrs x 21 days THEN 90-120mg/kg IV q24hrs

CMV pneumonia


Neutropenic Fever

Therapy is aimed at treating multiple flora that include Gram Negatives, Gram Positive Bacteria, Pseudomonas and if there is an indwelling catheter or high risk, then MRSA.

Inpatient

Outpatient

Post Exposure Prophylaxis

Pediatric

See Antibiotics By Diagnosis (Peds)

Sepsis

Arthropod and Parasitic Infections

See Also

References

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  2. ↑ 2.0 2.1 2.2 2.3 2.4 Garner MR, et al. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. Journal of the American Academy of Orthopaedic Surgeons. April 15, 2020. 28(8):309-315
  3. ↑ HoffWS, Bonadies JA, Cachecho R, Dorlac WC: East practice management guidelines work group: Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011;70:751-754.
  4. ↑ 4.0 4.1 4.2 4.3 ESC Task Force Guidelines on the prevention, diagnosis, and treatment of infective endocarditis. European Heart Journal (2009) 30, 2369–2413 doi:10.1093/eurheartj/ehp285 PDF
  5. ↑ AHA Pocket Card Dental Prophylaxis Endocarditis
  6. ↑ Young LS, Price CS. Complicated adult epiglottitis due to methicillin-resistant Staphylococcus aureus. Am J Otolaryngol. Nov-Dec 2007;28(6):441-3.
  7. ↑ Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
  8. ↑ Barton E, Blair A. Ludwig’s Angina. J Emerg Med. 2008. 34(2): 163-169.
  9. ↑ Spitalnic SJ, Sucov A. Ludwig's angina: case report and review. J Emerg Med. 1995;13:499-503
  10. ↑ Clinical Practice Guideline: Acute Otitis Externa Executive Summary. Otolaryngology -- Head and Neck Surgery 2014 150: 161 DOI: 10.1177/0194599813517659 PDF
  11. ↑ Wright, C. et al. Ototoxicity of neomycin and polymyxin B following middle ear application in the chinchilla and baboon. Am J Otol. 1987 Nov;8(6):495-9.
  12. ↑ 12.0 12.1 12.2 Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82
  13. ↑ Shah, U. K., MD. (2020, October 14). Tonsillitis and Pharyngitis Organism-Specific Therapy: Specific Organisms and Therapeutic Regimens. Emedicine. https://emedicine.medscape.com/article/2011872-overview
  14. ↑ CDC - Pertussis http://www.cdc.gov/pertussis/clinical/treatment.html
  15. ↑ CDC MMWR Pertusis http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5414a1.htm
  16. ↑ Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5
  17. ↑ Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.
  18. ↑ The STAND trial: Jaung R, Nisbet S, Gosselink MP, Di Re A, Keane C, Lin A, Milne T, Su’a B, Rajaratnam S, Ctercteko G, Hsee L, Rowbotham D, Hill A, Bissett I. Antibiotics Do Not Reduce Length of Hospital Stay for Uncomplicated Diverticulitis in a Pragmatic Double-Blind Randomized Trial. Clin Gastroenterol Hepatol. 2020 Mar 30:S1542-3565(20)30426-2. doi: 10.1016/j.cgh.2020.03.049. PMID: 32240832
  19. ↑ Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.
  20. ↑ Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
  21. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  22. ↑ Sanders JW. et al. An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection. Am J Trop Med Hyg. 2002;67:533–8
  23. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  24. ↑ Steffen R, et al. Traveler’s Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
  25. ↑ DuPont HL. et al. Rifaximin versus ciprofloxacin for the treatment of traveler’s diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis. 2001;33:1807–15
  26. ↑ Molgaard-Nielsen D et al. Association Between Use of Oral Fluconazole During Pregnancy and Risk of Spontaneous Abortion and Stillbirth. JAMA. 2016;315(1):58-67.
  27. ↑ https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
  28. ↑ Cyr SS et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
  29. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  30. ↑ CDC Trichomoniasis 2015. https://www.cdc.gov/std/tg2015/trichomoniasis.htm
  31. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  32. ↑ Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
  33. ↑ Huttner, A., Kowalczyk, A., Turjeman, A., Babich, T., Brossier, C., Eliakim-Raz, N., … Harbarth, S. (2018). Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(17), 1781–1789.
  34. ↑ Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  35. ↑ 35.0 35.1 35.2 CDC Pregnancy BV Treatment Guidelines.cdc.gov
  36. ↑ Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women. Clinical Infectious Diseases. 2011;52(5):e103-e120. doi:10.1093/cid/ciq257
  37. ↑ Colgan R, Williams M. Diagnosis and treatment of acute uncomplicated cystitis. Am Fam Physician. 2011 Oct 1;84(7):771-6.
  38. ↑ Acute Pyelonephritis in Adults. Johnson, JR and Russo, TA. New England Journal of Medicine 2018; 378:48-59.
  39. ↑ Sandberg T. et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012 Aug 4;380(9840):484-90.
  40. ↑ 40.0 40.1 40.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  41. ↑ https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf
  42. ↑ Mackay G. Chapter 43. Sexually Transmitted Diseases & Pelvic Infections. In:DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e. New York, NY: McGraw-Hill; 2013
  43. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named bells guidelines
  44. ↑ Vargish L. For Bell’s palsy, start steroids early; no need for an antiviral. J Fam Pract. Jan 2008; 57(1): 22–25http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183838/pdf/JFP-57-22.pdf
  45. ↑ 45.0 45.1 UpToDate. Bell's Palsy Prognosis and Treatment. March, 2014
  46. ↑ 46.0 46.1 Gronseth GS, Paduga R. Evidence-based guideline update: Steroids and antivirals for Bell palsy: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2012Full Text
  47. ↑ Lockhart et al. Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869.
  48. ↑ Rigamonti D. et al. Spinal epidural abscess: contemporary trends in etiology, evaluation, and management. Surg Neurol 1999; 52:189-96
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  50. ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1
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  55. ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
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  60. ↑ Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020 https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm
  61. ↑ Ness RB et al. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002;186:929–37
  62. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  63. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  64. ↑ Ross J, Guaschino S, Cusini M, Jensen J, 2017 European guideline for the management of pelvic inflammatory disease. Int J STD AIDS. 2018 Feb;29(2):108-114. doi: 10.1177/0956462417744099. Epub 2017 Dec 4.
  65. ↑ CDC PID Treatment http://www.cdc.gov/std/treatment/2010/pid.htm
  66. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  67. ↑ Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
  68. ↑ Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67
  69. ↑ IDSA. Mandell 2007
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  72. ↑ Luther MK, Timbrook TT, Caffrey AR, Dosa D, Lodise TP, LaPlante KL. Vancomycin Plus Piperacillin-Tazobactam and Acute Kidney Injury in Adults: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(1):12-20.
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  82. ↑ EBQ:Antibiotic prophylaxis for mammalian bites
  83. ↑ Griego RD, Rosen T, Orengo IF, Wolf JE. Dog, cat, and human bites: a review. J Am Acad Dermatol. 1995;33:1019–29.
  84. ↑ Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999;340:85–92.
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  86. ↑ Ganesh Kumar AV. Benzathine penicillin, metronidazole and benzyl penicillin in the treatment of tetanus: a randomized, controlled trial .Ann Trop Med Parasitol. 2004 Jan;98(1):59-63 PMID 15000732
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  88. ↑ Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clinical Infectious Disease 2002; 34:730-751
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