CMC Hospital Antibiotic Policy2012 PDF

Christian Medical College & Hospital
Ludhiana, Punjab (INDIA)
GUIDELINES FOR
ANTIMICROBIAL THERAPY
(VALID TILL OCTOBER 2013)
FOR INTERNAL USE ONLY
WHO - Seven steps of Handwashing

1
Rub palms together.
Rub the back of both hands.
Interface fingers and rub hands together.
Interlock fingers and rub the back of fingers

of both hands.
Rub thumb in a rotating manner followed

by the area between index finger and thumb
for both hands.
Rub fingertips on palm for both hands.
Rub both wrists in a rotating manner.

Rinse and dry thoroughly.
Contents
Contents
DESCRIPTION
Page
Editorial Note
Message from Director

Message from Medical Superintendent
Message from HOD - Microbiology
Message from HOD - Medicine
Antimicrobial Prescribing : Good Practices
Monitoring Treatment
The Importance of Infection Control (IC) to
Control Antimicrobial Resistance
Hypersensitivity
Patient Risk Stratification
How to use Pocket Guide?
Antibiogram : Blood Stream Infection - ICU
Antibiogram : Blood Stream Infection - IPD
Antibiogram : Blood Stream Infection - OPD
Antibiogram : Urinary Tract infections - ICU
Antibiogram : Urinary Tract infections - IPD
Antibiogram : Urinary Tract infections - OPD
Antibiogram : Respiratory / Skin Soft Tissue infections - ICU
Antibiogram : Respiratory / Skin Soft Tissue infections - IPD
Antibiogram : Respiratory / Skin Soft Tissue infections - OPD
Antibiotic Protocol : Blood Stream Infection - ICU
Antibiotic Protocol : Blood Stream Infection - IPD
Antibiotic Protocol : Blood Stream Infection - OPD
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Contents
Contents
DESCRIPTION
Page
Antibiotic Protocol : Urinary Tract infections - ICU
26
Antibiotic Protocol : Urinary Tract infections - IPD

Antibiotic Protocol : Urinary Tract infections - OPD
Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - ICU
Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - IPD
Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - OPD
Notes
Standard dosages of commonly used drugs
Maximum daily dose of antibiotics
Safe injection practices
Antibiotic Summary Chart
Irrational/Less evidence based antibiotics
Categorization of Antibiotics
Restricted use antibiotics : What and Why?
Limited access antibiotics : What and Why?
Under surveillance antibiotics : What and Why?
Notes
28
30
32
34
36
38
39
41
42
44
46
47
48
49
49
50
EDITORIAL NOTE
These guidelines were developed by a multi-disciplinary working group to ensure
balanced input. It has considered the antimicrobial choice for specific conditions, and the
existing policies for specific agents. The latest available evidence backed guidelines and
recommendations were followed with due modification to the antibiotic choices where
it was warranted by local antibiogram. We believe that by following the guidelines it will
be possible to maintain a high standard of patient care, delivered in a consistent way
across the Hospital. We recommend it to our colleagues.
This manual will be revised as and when new recommendations come or with the change
in the local antibiogram.
This general guidance is not applicable to all patients. The choice of antimicrobial may
need to be modified in the following situations:
Hypersensitivity to first choice antimicrobial (see guidance on hypersensitivity)
Recent antimicrobial therapy or preceding cultures indicating presence of resistant
organisms
In pregnant or lactating patients
In renal or hepatic failure (see data for individual antimicrobials)
Where significant drug interactions may occur.
Though the manual only provides a general guideline in choosing the antibiotic, it
incorporates the best in antimicrobial therapy and hence any deviation must be justified
in documentation in the case records. The compliance to general principles (as
mentioned in the section GOOD PRACTICE) is especially subjected to clinical audit as
deviation in these aspects with out an evidence backed and peer approved reason will be
considered as endangering the patient safety.
We welcome suggestions from our colleagues/readers.
Best Wishes
MESSAGE FROM DIRECTOR

I am glad the Department of Medicine and particularly Infectious Diseases unit in
collaboration with the Department of Microbiology, has taken the issue of antibiotic
stewardship, a venture which was long overdue.
Antibiotics are blessing to human beings since its first discovery in the 1940's, to fight
bacteria. Since then, further discoveries have taken place, following painstaking research
and clinical trials. But we are still far away from major breakthrough in viral diseases and
fungal ailments. The need of the hour is a guarded approach to use of antibiotics to
prevent resistance, till new molecules could be evolved. Let us also not forget, no
antibiotic is without side effects.
I would wholeheartedly support this venture of antibiotic stewardship in our
multispecialty college and hospital.
With best wishes,

Yours sincerely
Dr. Abraham G. Thomas

Director
MESSAGE FROM MEDICAL SUPERINTENDENT

CMC Ludhiana, A premier Medical Institute takes privilege in announcing and printing its
ANTIMICROBIAL POLICY based on principles of evidence based medicine.
The discovery of antibiotics in the 20th century marked a watershed in the treatment of
infections. However, the organisms countered this change effectively by becoming
resistant. The hand book will be a significant step in the expansion of our knowledge in
this direction and achieving better clinical outcome and rational use of antibiotics.
With best regards
Dr. Kanwal Masih

Medical Superintendent
CMC & Hospital
Ludhiana
MESSAGE FROM HOD-Microbiology

At the outset we wish to thank our Director Dr. A.G. Thomas, for his leadership and able
guidance for achievement of this goal. Being Microbiologists, we come across multi-drug
resistant pathogens on a daily basis. The extent of antimicrobial resistance has reached
alarming proportions and poses a serious threat not only to the future of antimicrobials
but also the patient's clinical outcome.
A robust infection control policy coupled with antimicrobial stewardship based on local
microbiology data is the most suitable remedy to delay the menace of resistance from
spreading fast. We are glad that finally we have such an antibiotic policy in place. We must
thank the hospital management specially Dr. Kanwal Masih, our Medical Superintendent
and all the senior clinicians mainly Dr. Mary John, Professor and Head, Medicine
Department for providing their input in making this policy booklet. My sincere thanks
owe to Dr. Sangeetha Mohan, Mrs. Shereen Rachel Varghese, Dr. Serene Varghese, Mr.
Alvin and all Microbiology colleagues. We are sure to take necessary steps to ensure a
strict and mandatory implementation of this antimicrobial policy booklet across the
hospital.
With regards
Dr. Aroma Oberoi, MD

Professor & Head
Microbiology Department
CMC and Hospital
Ludhiana
MESSAGE FROM HOD-Medicine

Christian Medical College & Hospital, Ludhiana has always followed the highest
standards of Medical Practices and Professional ethics. We are committed to provide
quality health care to the community and maintain our status as a centre for medical
excellence
It has been my long standing wish to see the evolution of antimicrobial policy for the
hospital. We are glad that finally we have such an antibiotic policy in place. The addition of
a qualified ID Physician to the Department of Medicine will help in the practical
implementation of this policy.
It is essential that every department in the hospital should have a well structured and
evidence based guidelines for the use of antimicrobials.
To highlight the importance of rational use of antibiotics, Antibiotic Stewardship
workshop was organized in the hospital last year. As a logical outcome of the workshop, a
consensual and comprehensive antibiotic policy for the hospital has been framed which
is based on the following principles of Antibiotic Care:
a. Empirical antibiotics to be given based on site of infection and considering the
possible pathogens causing such infections
b. The risk stratification for the presence of multi-drug resistant bugs should be done for
every patient
c. Empirical antibiotics for Nosocomial infections to be prescribed based on the local
microbiology data of the hospital
d. The practice of De-escalation to be encouraged based on the culture and sensitivity
results and the patient's clinical condition
The antibiotic policy booklet will be available both at the outpatient and inpatient
stations. I expect your full cooperation and compliance in following the antibiotic policy.
The current antibiotic policy is applicable for the year 2012-2013 and will be updated on
an annual basis.
I seek your full support and cooperation in making this initiative a huge success
Best Regards,
Dr. Mary John
HOD, Medicine
CMC, Ludhiana
ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES

1.
Send for the appropriate investigations in all these infections as recommended. These are
the minimum required for diagnosis, prognosis and follow up of these infections.
2.
All antibiotic initiations would be done after sending appropriate cultures
3.
Change in antibiotic would be done after sending fresh cultures
4.
Follow the Hospital policy when choosing antimicrobial therapy whenever possible. If
alternatives as chosen, document the reason in the case records.
5.
Check for factors which will affect drug choice & dose, eg, renal function, interactions,
allergy.
6.
Check that the appropriate dose is prescribed. If uncertain, contact Infectious disease
physician, Pharmacy, or check in the formulary.
7.
The need for antimicrobial therapy should be reviewed on a daily basis. For most
infections 5 7 days of antimicrobial therapy is sufficient (simple UTIs can be adequately
treated with 3 days of antibiotic).
8.
All IV antibiotics may only be given for 48 72 hours without review and consideration of
oral alternatives. New microbiological or other information (eg fever defervescence for at
least 24h, marked clinical improvement; low CRP) should at this stage often permit a
switch to oral antibiotic(s), or switch to an IV narrow spectrum alternative, or cessation of
antibiotics (no infection present).
9.
Once culture reports are available, the physician shall step down to the narrowest
spectrum, most efficacious and most cost effective option. If there is no step down
availed, the reason shall be documented and is subjected to clinical audit.
10.
Empiric Therapy - Where delay in initiating therapy to await microbiological results would
be life threatening or risk serious morbidity, antimicrobial therapy based on a clinically
defined infection is justified. Where empiric therapy is used the accuracy of diagnosis
should be reviewed regularly and treatment altered/stopped when microbiological
results become available.
11.
Microbiological samples must always be sent prior to initiating antimicrobial therapy.

Rapid tests, such as Gram smears, can help determine therapeutic choices when empiric
therapy is required.
12.
Prescribing antibiotics just in case an infection is present is rarely justified. Where patients
are in hospital close observation is usually a better option.
10
MONITORING TREATMENT
The continued need for antimicrobial therapy should be reviewed at least daily. For most types
of infection treatment should continue until the clinical signs and symptoms of infection have
resolved exceptions to this are indicated in the relevant sections. Parenteral therapy is
normally used in seriously ill patients and those with gastrointestinal upset. Oral therapy can
often be substituted as the patient improves.
Where treatment is apparently failing, advise from the microbiologist and ID Physician should
normally be sought rather than blindly changing to an alternative choice of antimicrobial
agent.
THE IMPORTANCE OF INFECTION CONTROL (IC)

TO CONTROL ANTIMICROBIAL RESISTANCE
The use of antimicrobial agents inevitably leads to the emergence of resistant micro-organisms.
It also destroys the normal flora of the body and renders patients far more susceptible to
colonisation with micro-organisms introduced from elsewhere in the hospital through the
process of cross infection.
Hospitals may be considered as reservoirs and breeding grounds within the world of
antibiotic resistance.
Prevention of cross infection and good quality antimicrobial prescribing contribute
to the prevention of antimicrobial resistance. Infection Control and Clinical
Microbiology are inextricably linked.
The importance of hand washing in preventing hospital acquired infection and the
spread of antibiotic resistant micro-organisms is clear.
High standards of hospital cleanliness may be important in controlling the spread of
resistant organism in the environment e.g. MRSA, Acinetobacter baumannii
Surveillance is a crucial part of the control of antimicrobial resistance.
11
HYPERSENSITIVITY
All patients should be asked about drug allergies. This is the responsibility of the doctor
examining the patient. If a patient reports a drug allergy clarify whether this is an allergy or
drug intolerance. In some cases there will be an overlap between drug allergy and drug
intolerance.
Clinical features suggestive of drug allergy:
One or more symptoms developed during or following drug administration including
difficulty in breathing, swelling, itching, rash, anaphylaxis, swelling of the lips, loss of
consciousness, seizures or congestion involving mucous membranes of eyes, nose and
mouth.
Clinical features suggestive of drug intolerance:
One or more symptoms developed during or following drug administration including
gastrointestinal symptoms eg. nausea, vomiting, diarrhoea, abdominal pain and giddiness.
If patients are unable to give an allergy history, the doctor clerking in the patient should take
reasonable steps to contact someone who can provide a reliable allergy history.
It is the prime responsibility of the prescribing doctor to ensure that;
i.
The allergy box on the patients drug chart is completed when a new prescription chart
is written or transcribed. If no allergy - specify "No known allergy or NKA". The box
should be signed and dated. If allergy history cannot be obtained, then specify
"history not available." Under no circumstances should the allergy box be left blank.
A pharmacist or nurse may complete the allergy box if the allergy status is documented
in the clerking in notes.
ii.
The allergy box is completed before prescribing a new drug, except in exceptional
circumstances.
If patients have a suspected drug allergy then the drug and suspected reaction should
be documented in the clerking-in notes and the drug chart.
12
PATIENT RISK STRATIFICATION

Patient Type 3
Patient Type 4
No contact with health

care system
Patient Type 1
Contact with health care

system (e.g. recent hospital
admission, nursing home,
CAPD) without/minimal
invasive procedures
Hospitalization >5 days

and or infections following
invasive procedures
Type 3 patient with fever despite

antibiotic therapy (>5days) with no
obvious source / after appropriate
source control
No prior antibiotic
treatment in last 90 days
Antibiotic therapy in last 90

days
Recent & multiple

antibiotic therapies
severe sepsis/septic shock PLUS
Patient young with no

co-morbid conditions
Patient old ( > 65years) with

few co-morbidities
Patient with multiple

Co-morbidities eg: cystic
fibrosis, structural lung
disease, advanced AIDS,
neutropenia, other severe
immunodeficiency
Has 1 or more than 1 of the following

factors. (but not limited to) for
invasive fungal infections: TPN,
Hemodialysis, Immunodeficiency of
variable origin, Major Abdominal
s u rg e r y, M u l t i - fo c a l c a n d i d a
colonization, Diabetes
Risk of Bacterial
infections with
pathogens like ESBL
producing
Enterobacteriacae and
MRSA.
Risk of Bacterial infections

with Pan-drug resistant
Pseudomonas and
Acinetobacter
High Risk of Invasive fungal

infections
Minimal risk of
Nonfermentors like
Pseudomonas and
Acinetobacter
Bacterial infections to be
treated with novel
combination of antibacterials
suggested for Pan resistant
bacteria using alternate drug
delivery systems/PK-PD
parameters.
Empiric treatment of fungal

infections for both stable and
unstable patients as per IDSA
guidelines.
Bacterial infections
with minimal risk of
Multidrug resistant
pathogens like ESBL
producing
Enterobacteriacae,
MRSA or Non
fermentors like
Pseudomonas and
Acinetobacter
Patient Type 2
High risk of Bacterial

infections with any of
Multi drug resistant
pathogens like ESBL
producing
Enterobacteriacae,
MRSA and nonfermentors like
Pseudomonas and
Acinetobacter
Invasive Fungal
Infections are
unlikely
Minimal risk of Invasive

Fungal infections .
Risk of invasive fungal

infections in special
cases like patients
undergoing Allogenic
BMT, Liver transplant or
chemotherapy induced
neutropenic patients.
Limited use of broad

spectrum
antibacterials
No role of
Antifungal agents
ESBL infections to be
treated with NonPseudomonal antibiotics
like Group 1
Carbapenem
BL+BLIs can also be

preferred for mild ESBL
infections.
Vancomycin/Tiecoplanin
to be used for MRSA
Bacterial infections to
be treated with broad
spectrum antibiotics
like Group 2.
Carbapenem or AntiPseudomonal BL-BLIs
in combination with
Fluoroquinolones/ami
noglycosides/Glycope
ptides.
No role of Antifungal
agents
Prophylaxis for fungal

infections in select
cases as per IDSA
guidelines
6
5
4
13
HOW TO USE THE POCKET GUIDE?
This pocket guide is divided into 3 sections: the first part contains a drug dose ready
reckoner, the second part has the antibiotic protocols for each infection type and the
third part has footnotes along with space for personal notes.
To use these protocols follow these steps:

Identify the type of infection Respiratory, intra-abdominal, pneumonia, blood
stream, urinary tract and skin and soft tissue.
Define the location ICU or ward patient
Accordingly refer to the respective chart.
Identify the patient type based on described parameters Type 1, 2, 3, or 4
Refer to the empiric/presumptive therapy column for that patient type.
This will give you the protocol drug to start.
If a column has more than one drug option
- Choose the drug showing better susceptibility data in the left hand side table OR
- Doctor's discretion advised
Send respective cultures before starting antibiotic therapy
Once culture / sensitivity report available:
- Presumptive therapy antibiotic may require to be changed
- Consult Microbiologist / ID physician to decide the choice of antibiotic (based on
narrowest spectrum antibiotic which covers the pathogen isolated)
In all cases physician's discretion is advised based on patient condition
14
Blood Stream Infections (BSI) - ICU Antibiogram

MICROBIOLOGY DATA (n=36)
Most Common Pathogens
Prevalance %
Antibiotic Sensitivity (%)
Staph aureus (n=20)
55%
Linezolid/Vancomycin (100%), Erythromycin (65%),

Cefoxitin (30%), Cotrimoxazole (45%), AmoxicillinClavulanate (11%)
Pseudomonas (n=8)
22%
Polymyxin B/Amikacin (88%),

Imipenem/Piperacillin-Tazobactam/CefoperazoneSulbactam/Ciprofloxacin (75%), Aztreonam (63%),
Ceftazidime (38%)
E. coli (n=6)
17%
Imipenem/Cefoperazone-Sulbactam (100%),
Piperacillin-Tazobactam (83%), Amikacin (67%),
Cefotaxime/Ceftriaxone (50%), Ceftazidime/
Ciprofloxacin (33%)
Salmonella paratyphi A (n=1)
3%
Azithromycin/Chloramphinecol/Ceftriaxone (100%)
Acinetobacter (n=1)
3%
Polymyxin B/Cefoperazone-Sulbactam (100%)
Blood Stream Infections (BSI) - IPD Antibiogram

Prevalance %
Staph aureus (n=115)
31%
Vancomycin (96%), Linezolid (92%), Cefoxitin (80%)

Erythromycin (65%), Amoxicillin-Clavulanate (56%),
Cotrimoxazole (49%)
E. coli (n=90)
24%
Imipenem (93%), Piperacillin-Tazobactam (86%),

Cefoperazone-Sulbactam (85%), Amikacin (82%),
Ceftriaxone /Cefotaxime/Ciprofloxacin (37%),
Ceftazidime (26%)
Pseudomonas (n=82)
22%
Piperacillin-Tazobactam (98%), Polymyxin (96%),

Imipenem /Cefoperazone-Sulbactam (95%), Amikacin
(89%), Ciprofloxacin (65%), Aztreonam (57%),
Ceftazidime (45%)
Salmonella typhi &

paratyphi A (n=51)
14%
Azithromycin/Chloramphenicol (100%),
Ceftriaxone (96%)
Acinetobacter (n=34)
9%
Polymyxin B (100%), Cefoperazone-Sulbactam (90%),

Imipenem (85%), Amikacin (74%), PiperacillinTazobactam (70%), Ciprofloxacin (65%), Ceftazidime
(29%)
15
Blood Stream Infections (BSI) - OPD Antibiogram

Prevalance %
Salmonella typhi &

paratyphi A (n=26)
53%
Azithromycin/Ceftriaxone (100%),
Chloramphenicol (88%)
Staph aureus (n=8)
16%
Vancomycin (88%), Cefoxitin (75%), Cotrimoxazole

(71%), Augmentin (50%), Erythromycin (38%)
Pseudomonas (n=7)
14%
Polymyxin B/Cefoperazone-Sulbactam (100%),

Imipenem/Piperacillin-Tazobactam/Amikacin
(86%), Ciprofloxacin (80%), Aztreonam (75%),
Ceftazidime (57%)
E. coli (n=6)
12%
Imipenem/Piperacillin-Tazobactam/CefoperazoneSulbactam (100%), Amikacin (83%), Ceftriaxone

/Cefotaxime/Ciprofloxacin (50%)
Acinetobacter (n=2)
4%
Polymyxin B (100%), Imipenem/PiperacillinTazobactam/Cefoperazone-Sulbactam/

Amikacin/Ciprofloxacin (50%)
Urinary Tract Infections (UTI) - ICU Antibiogram

Prevalance %
E.coli (n=22)
49%
Imipenem (100%), Amikacin/Nitrofurantoin (60%),

Piperacillin-Tazobactam/Cefoperazone-Sulbactam
(40%), Cefotaxime/Ciprofloxacin (20%)
Pseudomonas (n=13)
29%
Polymyxin B (100%), Imipenem/PiperacillinTazobactam/Amikacin (67%), Ciprofloxacin (33%)
Enterococcus (n=7)
16%
Vancomycin/Nitrofurantoin (50%)
16
Urinary Tract Infections (UTI) - IPD Antibiogram

Prevalance %
E.coli (n=228)
54%
Imipenem (97%), Nitrofurantoin (87%), PipercillinTazobactam (84%), Amikacin (83%), CefoperazoneSulbactam (80%), Cefotaxime (42%)
Enterococcus (n=52)
12%
Vancomycin (86%), Nitrofurantoin (84%), Ampicillin

(54%), Gentamicin (27%)
Pseudomonas (n=35)
8%
Polymyxin B (94%), Imipenem (73%), Amikacin (65%),

Piperacillin-Tazobactam (62%), CefoperazoneSulbactam (52%), Aztreonam (38%), Ciprofloxacin
(36%), Cefoperazone (34%)
Staph aureus (n=13)
3%
Linezolid/Vancomycin (100%), Augmentin (63%),

Cefoxitin (62%), Erythromycin (50%),
Cotrimoxazole (33%)
Proteus (n=12)
3%
Imipenem/Piperacillin-Tazobactam (100%),
Cefoperazone-Sulbactam/Cefotaxime (83%),
Amikacin (82%), Nitrofurantoin (70%),
Ceftazidime/Ciprofloxacin (50%)
Urinary Tract Infections (UTI) - OPD Antibiogram

Prevalance %
E.coli (n=171)
57%
Imipenem (99%), Nitrofurantoin (95%), PiperacillinTazobactam (93%), Amikacin (89%), CefoperazoneSulbactam (87%), Cefotaxime (55%),
Ceftazidime (44%), Ciprofloxacin (37%)
Enterococcus (n=20)
7%
Vancomycin (85%), Nitrofurantoin (69%),

Ampicillin (63%), Gentamicin (35%)
Pseudomonas (n=16)
5%
Polymyxin B (100%), Imipenem (81%), PiperacillinTazobactam (63%), Amikacin (50%), Ciprofloxacin

(44%), Cefoperazone-Sulbactam/
Cefoperazone (38%), Ceftazidime (25%)
Staph aureus (n=13)
4%
Linezolid/Vancomycin (100%), Erythromycin (92%),

Amoxicillin-clavulanate (75%), Cefoxitin (69%),
Cotrimoxazole (45%)
Proteus (n=5)
2%
Imipenem/Piperacillin-Tazobactam/CefoperazoneSulbactam/Cefotaxime (100%), Amikacin/

Ceftazidime (80%), Ciprofloxacin (60%),
Nitrofurantoin (20%)
17
Respiratory / Skin Soft Tissue infections - ICU Antibiogram

Prevalance %
37%
Polymyxin B (100%), Imipenem (76%), CefoperazoneSulbactam (45%), Piperacillin-Tazobactam (38%),

Amikacin (24%)
Pseudomonas (n=32)
19%
Polymyxin B (100%), Piperacillin-Tazobactam/

Amikacin (88%), Imipenem (75%), CefoperazoneSulbactam (63%), Ciprofloxacin (47%),
Aztreonam (42%), Cefoperazone (40%)
E. coli (n=28)
17%

Cefotaxime/Ceftazidime (35%), Ciprofloxacin (31%)
Klebsiella (n=23)
14%
Imipenem (100%), Piperacillin-Tazobactam/

Cefoperazone-Sulbactam/Amikacin (65%),
Ciprofloxacin (48%), Cefotaxime (44%),
Ceftazidime (35%)
Staph aureus (n=18)
10%
Linezolid/Vancomycin (100%), Cefoxitin (61%),

Cotrimoxazole (56%), Augmentin/Erythromycin (50%)
Enterococcus (n=5)
3%
Linezolid/Vancomycin (100%), Ampicillin (60%),

Gentamicin/Erythromycin (40%)
Respiratory / Skin Soft Tissue infections - IPD Antibiogram

Prevalance %
Pseudomonas (n=209)
24%
Polymyxin B (100%), Piperacillin-Tazobactam (88%),

Imipenem (83%), Amikacin (73%), CefoperazoneSulbactam (48%), Ciprofloxacin (47%), Cefoperazone(33%)
Staph aureus (n=197)
23%

Erythromycin (63%), Augmentin (57%),
Cotrimoxazole (52%)
E. coli (n=176)
21%
Imipenem (99%), Piperacillin-Tazobactam (82%), Amikacin

(77%), Cefoperazone-Sulbactam (75%), Cefotaxime (41%),
Ciprofloxacin (28%),Ceftazidime (25%)
16%
Polymyxin B (99%), Imipenem (87%), PiperacillinTazobactam (57%), Cefoperazone-Sulbactam (47%),

Amikacin (29%)
Klebsiella (n=82)
10%

Ciprofloxacin (57%), Cefotaxime (49%), Ceftazidime (26%)
Enterococcus (n=51)
6%
Linezolid (100%), Vancomycin (98%), Ampicillin (65%),

Gentamicin (49%), Erythromycin (38%)
18
Respiratory / Skin Soft Tissue infections - OPD Antibiogram

Prevalance %
Staph aureus (n=77)
40%

Erythromycin (72%), Amoxicillin-Clavulanate (70%),
Cotrimoxazole (35%)
Pseudomonas (n=42)
22%
Polymyxin B (100%), Piperacillin-Tazobactam (95%),

Imipenem (88%), Cefoperazone-Sulbactam/Amikacin
(83%), Cefoperazone (70%), Ciprofloxacin (61%),
Aztreonam (46%), Ceftazidime (29%)
E. coli (n=26)
14%
Imipenem (100%), Piperacillin-Tazobactam

/Cefoperazone-Sulbactam/Amikacin (85%),
Cefotaxime (54%), Ceftazidime/Ciprofloxacin (31%)
Klebsiella (n=17)
9%
Imipenem (100%), Piperacillin-Tazobactam/

Cefoperazone-Sulbactam (82%) Amikacin (76%),
Ciprofloxacin (71%), Cefotaxime (65%),
Ceftazidime (47%)
8%
Polymyxin B (100%), Imipenem (94%), PiperacillinTazobactam (88%), Cefoperazone-Sulbactam (56%),

Ciprofloxacin (38%), Amikacin (25%)
Enterococcus (n=13)
7%
Vancomycin (100%), Ampicillin (92%), Gentamicin

(85%), Erythromycin (46%)
19
Blood Stream Infections (BSIs)

Patient Risk
Patient Type 1 (CAI)
No contact with health care system in last 90
days
Patient Type 2 (HCAI)
Antibiotic Protocol: ICU

Stratification
Patient Type 3 (NI)
Patient Type 4 (NI)
Recent contact with health care system(hospital / nursing

home admission, CAPD) without major invasive procedure
Hospitalization >5 days infections following major

invasive procedures
Type 3 patient with fever despite antibiotic therapy

(>5days) with no obvious source / after appropriate
source control
No prior antibiotic treatment in last 90 days
Antibiotic therapy in last 90 days
Recent & multiple antibiotic therapies
severe sepsis/septic shock
Patient young with no or few co-morbid

conditions
Patient old (> 65 years) with few co-morbidities.
Patient old (> 65 years) + multiple co-morbidities

(eg. structural lung disease, immunodeficiency)
Plus >1 of the following (but not limited to) risk factors for
invasive fungal infections: TPN Hemodialysis
Immunodeficiency of variable origin Major abdominal
surgery Multi-focal candida colonization Diabetes
Send Samples For Culture
Presumptive Therapy
Presumptive Therapy
Presumptive Therapy
Ceftriaxone OR Amoxicillin-Clavulanate OR
Ciprofloxacin* / Ofloxacin
*Avoid ciprofloxacin in Patient type 1 since it has potent
antipseudomonal activity
Ertapenem OR Piperacillin-Tazobactam +/-Amikacin

Note: Vancomycin / Teicoplanin to be used only in MRSA incidence is
high
Imipenem / Cefoperazone-Sulbactam + Amikacin

+/- Vancomycin
Note: Colistin can be used empirically on Physician's discretion
in very sick patients

Presumptive Therapy
Hemodynamically stable and no prior exposure to Azoles
- Fluconazole
Hemodynamically Stable + Prior exposure to Azoles Echinocandins (Caspofungin)/ Lip Amp B / Conv. Amp B
(Use Conv Amp B if intolerance or limited availability of other
antifungals, with proper administration guidelines/precautions )
H e m o d y n a m i c a l l y U n s t a b l e - Ec h i n o c an d i n s
(Caspofungin) / Lip Amp B
After Culture Report
Continue Treatment
Continue Treatment
Continue Treatment
If the pathogen is sensitive to the drug used

empirically or culture is negative & patient
responds to clinical treatment
1. If the pathogen is susceptible to the drug used

empirically or culture is negative & patient responds to
clinical treatment
2. If ESBL +ve Enterobacteriaceae: Continue treatment
with monotherapy as per sensitivity report (Avoid using
broad spectrum anti-Pseudomonal drugs)
3. If MRSA/Enterococcus: Use Vancomycin or Teicoplanin
Monotherapy
Step down "De-Escalate"

If Non ESBL enterobacteriacae / MSSA: Shift to
monotherapy if combination used empirically as
per the sensitivity report.

If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat
as Patient type 1
Consider Escalation
1. If culture negative & no clinical response
within 48 hours of treatment.
2. If culture is ESBL positive, treat as Patient
type 2
Consider Escalation
1. If culture negative & no clinical response within 48 hours
of treatment.
2. If culture shows Pseudomonas/Acinetobacter - Treat as
Patient type 3
20
1. If the culture is negative & patient responds to

clinical treatment
2. If sensitive Pseudomonas / Acinetobacter Preferably a combination of Antipseudomonal
beta-lactam + Aminoglycoside /
Antipseudomonal FQ for 3-5 days followed by
beta lactam monotherapy for another 5-7 days
3. If MRSA- Shift to Vancomycin / Teicoplanin
monotherapy.

Continue Treatment
If Candida Albicans and patient stable : Continue
Fluconazole
If Candida Non-Albicans OR Patient unstable : Continue
Echinocandin / Lip Amp B

1. If ESBL +ve Enterobacteriaceae- Deescalate and
treat as patient Type 2
2. If Non ESBL/MSSA - De-escalate and Treat as
Patient Type 1

Empirically started on Echinocandin / Lip Amp B and
Culture shows Candida albicans plus patient is stable De-escalate to Azoles #
Consider Escalation
1. MDR Pseudomonas / Klebsiella: Colistin + Antipseudomonal Beta lactam (pref. Carbapenem) in
Extended Infusion) with maximum sensitivity
2. MDR Acinetobacter: Colistin+High dose
Sulbactam +/- Carbapenem in Extended Infusion
3. VRSA / VRE : Escalate to Linezolid or Daptomycin
Consider Escalation
Empirically started on Azole but culture shows Candida
species resistant to azoles OR the patient condition
deterioates : Escalate to Echinocandin / Lip Amp B /
Conv. Amp B based on C/S report and patient condition
21

Patient Risk
days
Antibiotic Protocol: IPD

Stratification
Patient Type 3 (NI)

Hospitalization >5 days infections following major invasive procedures

conditions
Patient old (> 65 years) + multiple co-morbidities (eg. structural lung disease, immunodeficiency)
Presumptive Therapy
Presumptive Therapy
Oral: Cefixime OR Ofloxacin OR AmoxicillinClavulanate

IV/IM: Ceftriaxone OR Amoxicillin-Clavulanate
OR Ciprofloxacin* / Ofloxacin
Ertapenem OR Piperacillin-Tazobactam

Presumptive Therapy
Imipenem / Piperacillin-Tazobactam / Cefoperazone-Sulbactam +/- Vancomycin

high

antipseudomonal activity
Continue Treatment
Continue Treatment


clinical treatment
2. If ESBL +ve Enterobacteriaceae: Continue treatment with
monotherapy as per sensitivity report (Avoid using broad
spectrum anti-Pseudomonal drugs)
Monotherapy


as Patient type 1
Consider Escalation
type 2

Continue Treatment
1. If the culture is negative & patient responds to clinical treatment
2. If sensitive Pseudomonas / Acinetobacter - Preferably a combination of Antipseudomonal beta-lactam +
Aminoglycoside / Antipseudomonal FQ for 3-5 days followed by beta lactam monotherapy for another 5-7
days
3. If MRSA- Shift to Vancomycin / Teicoplanin monotherapy.

1. If ESBL +ve Enterobacteriaceae- Deescalate and treat as patient Type 2
2. If Non ESBL/MSSA - De-escalate and Treat as Patient Type 1
Consider Escalation
Consider Escalation

of treatment
Patient type 3
1. MDR Pseudomonas / Klebsiella: Colistin + Antipseudomonal Beta lactam (pref Carbapenem in Extended
Infusion) with maximum sensitivity
2. MDR Acinetobacter: Colistin + High dose Sulbactam +/- Carbapenem in Extended Infusion
3. VRSA / VRE : Escalate to Linezolid or Daptomycin
22
23

Patient Risk
Antibiotic Protocol: OPD

Stratification
No contact with health care system in last 90 days
Recent contact with health care system(hospital / nursing home admission, CAPD)
without major invasive procedure
Patient young with no or few co-morbid conditions
Presumptive Therapy
Presumptive Therapy
Oral: Cefixime OR Ofloxacin OR Amoxicillin-Clavulanate

IV/IM(as OPAT*): Ceftriaxone OR Ofloxacin OR Amoxicillin-Clavulanate

IV/IM(as OPAT*): Ceftriaxone OR Ertapenem (If ESBLs suspected strongly)
Continue Treatment
Continue Treatment
If the pathogen is sensitive to the drug used empirically or culture is negative & patient responds to clinical
treatment

If Non ESBL enterobacteriacae / MSSA: Shift to monotherapy if combination used empirically as per the
sensitivity report.
Consider Escalation
1. If the pathogen is susceptible to the drug used empirically or culture is negative & patient responds to
clinical treatment
2. If ESBL +ve Enterobacteriaceae: Continue treatment with monotherapy as per sensitivity rep

If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat as Patient type 1
Consider Escalation
1. If culture negative & no clinical response within 48 hours of treatment.
1. If culture negative & no clinical response within 48 hours of treatment .
2. If culture is ESBL positive, treat as Patient type 2
2. If culture shows Pseudomonas/Acinetobacter - Treat as Patient type 3 in IPD protocol
24
25
Urinary Tract Infections (UTI)

Patient Risk
days

Stratification
Patient Type 3 (NI)
Patient Type 4 (NI)


invasive procedures

source control

conditions

Presumptive Therapy
Presumptive Therapy
Presumptive Therapy
Ceftriaxone / Ofloxacin OR Amikacin /

Ertapenem ( If community acquired ESBL
producing pathogen)
Ertapenem / Piperacillin-Tazobactam +/- Amikacin
Imipenem / Piperacillin-Tazobactam / Cefoperazone

-Sulbactam + Amikacin

Presumptive Therapy
- Fluconazole
Hemodynamically Stable + prior exposure to Azoles Conv. Amp B / Lip Amp B
Hemodynamically Unstable - Lip Amp B / Conv Amp B /
Echinocandins ** (Can use Azoles like Voriconazole as alternative
if No prior exposure to azoles)
**The urine concentration of Echinocandin is low, therefore they are
not preferred therapy for UTI, use only if UTI leads to Candidemia
Continue Treatment
Continue Treatment
Continue Treatment


clinical treatment
Monotherapy


1. If Non ESBL Enterobacteriaceae / MSSA: De-Escalate &
treat as Patient type 1
2. If sensitive Enterococcus- A combination of Ampicillin +
Gentamicin ( look for synergy test) OR Vancomycin alone
Consider Escalation
2. If culture is ESBL positive, treat as Patient type
2
Consider Escalation
of treatment .
Patient type 3
26

clinical treatment
2. If sensitive Pseudomonas / Acinetobacter - Use
Antipseudomonal beta-lactam as per sensitivity
either alone or in combination with flouroquinolone or aminoglycoside

Continue Treatment
If Candida Albicans and patient stable: Continue
Fluconazole
Lip Amp B / Amp B or Echinocandin **
(**The urine concentration of Echinocandin is low, therefore they are
not preferred therapy for UTI, use only if UTI leads to Candidemia )

Patient Type 1
3. If sensitive Enterococcus- A combination of
Ampicillin + Gentamicin ( look for synergy test) OR
Vancomycin alone

Empirically started on Lip Amp B / Amp B or
echinocandin and Culture shows Candida albicans plus
#
patient is stable - De-escalate to Azoles
Consider Escalation
1. MDR Pseudomonas / Klebsiella: Colistin +
Antipseudomonal Beta lactam (pref Carbapenem
in Extended Infusion) with maximum sensitivity
2. MDR Acinetobacter: Colistin +High dose
Consider Escalation
deterioates : Escalate to Lip Amp B / Amp B or
Echinocandin based on C/S report and patient
condition
27

Patient Risk
days

Stratification
Patient Type 3 (NI)


conditions
Presumptive Therapy
Presumptive Therapy
Oral: Norfloxacin OR Cefuroxime / Cefixime OR

Amoxicillin-clavulanate OR Nitrofurantoin (If
community acquired ESBL Cystitis)
IV/IM: Ceftriaxone / Ofloxacin OR Amikacin /
Ertapenem ( If community acquired ESBL UTI)
Ertapenem / Piperacillin-Tazobactam

Presumptive Therapy
Imipenem / Piperacillin-Tazobactam +/- Amikacin
Note: Colistin can be used empirically on Physician's discretion in very sick patients
Continue Treatment
Continue Treatment
Continue Treatment

clinical treatment
Monotherapy

2. If sensitive Pseudomonas / Acinetobacter - Use Antipseudomonal beta-lactam as per sensitivity either alone
or in combination with flouroquinolone or aminoglycoside


1. If Non ESBL Enterobacteriaceae / MSSA: De-Escalate &

treat as Patient type 1
2. If sensitive Enterococcus- A combination of Ampicillin +
Gentamicin ( look for synergy test) OR Vancomycin alone

3. If sensitive Enterococcus- A combination of Ampicillin + Gentamicin ( look for synergy test) OR Vancomycin
alone
Consider Escalation
type 2
Consider Escalation
Consider Escalation

of treatment .
Patient type 3
2. MDR Acinetobacter: Colistin + High dose Sulbactam +/- Carbapenem in Extended Infusion
28
29

Patient Risk
Antibiotic Protocol : OPD

Stratification
Presumptive Therapy
Presumptive Therapy

Note: Can use Nitrofurantoin for ESBL Cystitis
IV/IM (as OPAT): Ceftriaxone OR Ofloxacin OR Ertapenem (if ESBL suspected strongly)

Note: Can use Nitrofurantoin for ESBL Cystitis
IV/IM (as OPAT): Ceftriaxone OR Ertapenem (if ESBL suspected strongly)
Continue Treatment
Continue Treatment
treatment

sensitivity report.
Consider Escalation
clinical treatment

Consider Escalation
1. If culture negative & no clinical response within 48 hours of treatment .
2. If culture shows Pseudomonas/Acinetobacter - Treat as Patient type 3 in IPD protocol
30
31
Respiratory / Skin Soft Tissue infections

Patient Risk
days

Stratification
Patient Type 3 (NI)
Patient Type 4 (NI)


invasive procedures

source control

conditions

Presumptive Therapy
Presumptive Therapy
Presumptive Therapy
SSTI: Cefazolin/Cefuroxime/Cloxacillin/
Ciprofloxacin* + Metronidazole OR Clindamycin/
Amoxicillin-Clavulanate alone
*Avoid ciprofloxacin in Patient type 1 since it has potent antipseudomonal activity Note: Source control is must in SSTIs
RTI: Ceftriaxone / Amoxicillin-Clavulanate +/Macrolide OR Respiratory Flouroquinolone (eg

Gemifloxacin, Moxifloxacin)
SSTI :
Ertapenem / Piperacillin-Tazobactam + Amikacin
high
RTI:
Piperacillin-Tazobactam / Cefoperazone-Sulbactam +/Ciprofloxacin / Amikacin
SSTI and RTI:

Imipenem / Piperacillin-Tazobactam /
Cefoperazone- Sulbactam + Amikacin/Levofloxacin
Continue Treatment
Continue Treatment
Continue Treatment

clinical treatment
Monotherapy


as Patient type 1
Consider Escalation
type 2
Consider Escalation
of treatment .
Patient type 3
32
Presumptive Therapy
- Fluconazole
Hemodynamically Stable + prior exposure to Azoles Echinocandins (Caspofungin)/ Lip Amp B / Conv. Amp B
(Use Conv Amp B if intolerance or limited availability of other
antifungals, with proper administration guidelines/precautions )
Hemodynamically Unstable - Echinocandins

(Caspofungin) / Lip Amp B


clinical treatment
2. If sensitive Pseudomonas/AcinetobacterPreferably a combination of Antipseudomonal
beta-lactam + Aminoglycoside / Antipseudomonal FQ for 3-5 days followed by beta lactam
monotherapy for another 5-7 days
3. If MRSA-Shift to Vancomycin/Teicoplanin
monotherapy.

Continue Treatment
If Candida Albicans and patient stable : Continue
Fluconazole
Echinocandin / Lip Amp B

Patient Type 1

Empirically started on Echinocandin / Lip Amp B and
Culture shows Candida albicans plus patient is stable #
De-escalate to Azoles
Consider Escalation
1. MDR Pseudomonas / Klebsiella: Colistin +
Antipseudomonal Beta lactam (pref Carbapenem
in Extended Infusion) with maximum sensitivity
2. MDR Acinetobacter: Colistin+High dose
OR Tigecycline (only in SSTI)
3. VRSA / VRE : Escalate to Linezolid / Daptomycin
(only in SSTI)
Consider Escalation
deterioates : Escalate to Echinocandin / Lip Amp B / Conv.
Amp B based on C/S report and patient condition
33

Patient Risk
days

Stratification
Patient Type 3 (NI)


conditions
Presumptive Therapy
Presumptive Therapy
SSTI: Oral: Amoxycillin- Clavulanate OR

C e f u r ox i m e / C e p h a l e x i n / C e f a d r ox y l + / Metronidazole
IV/IM: Cefazolin / Cefuroxime / Oxacillin /
Ciprofloxacin* +/- Metronidazole OR AmoxicillinClavulanate / Clindamycin
SSTI and RTI:

Ertapenem / Piperacillin-Tazobactam +/- Amikacin
/Ciprofloxacin

Presumptive Therapy
SSTI and RTI:
Imipenem / Piperacillin-Tazobactam / Cefoperazone- Sulbactam + Vancomycin +/- Amikacin/Levofloxacin
Note: Vancomycin / Teicoplanin to be used only if MRSA incidence is

very high
Macrolide can be added in RTI

antipseudomonal activity Note: Source control is must in SSTIs
R T I : O r a l : A m ox i c i l l i n - C l a v u l a n a t e O R
Cefpodoxime / Cefdinir +/- Macrolide (
Erythromycin/ Azithromycin) OR Respiratory
Flouroquinolone (eg Gemifloxacin, Moxifloxacin)
IV/IM: Ceftriaxone OR Amoxicillin-Clavulanate +/Macrolide
Continue Treatment
Continue Treatment
Continue Treatment

clinical treatment
Monotherapy

2. If sensitive Pseudomonas / Acinetobacter - Preferably a combination of Antipseudomonal beta-lactam +
Aminoglycoside / Antipseudomonal FQ for 3-5 days followed by beta lactam monotherapy for another 5-7
days
3. If MRSA- Shift to Vancomycin / Teicoplanin monotherapy.



as Patient type 1
Consider Escalation
type 2

Consider Escalation
Consider Escalation

of treatment .
Patient type 3
2. MDR Acinetobacter: Colistin + High dose Sulbactam +/- Carbapenem in Extended Infusion OR Tigecycline
(only in SSTI)
3. VRSA / VRE : Escalate to Linezolid / Daptomycin (only in SSTI)
34
35

Patient Risk

Stratification
Presumptive Therapy
Presumptive Therapy
SSTI:
Oral: Amoxycillin- Clavulanate OR Cefuroxime/ Cephalexin/ Cefadroxyl +/- Metronidazole
IV/IM (as OPAT): Cefazolin / Cefuroxime / Oxacillin +/- Metronidazole OR Amoxicillin-Clavulanate / Clindamycin
Note: Source control is must in SSTIs
RTI:
Oral: Amoxicillin-Clavulanate OR Cefpodoxime / Cefdinir +/- Macrolide ( Erythromycin/ Azithromycin) OR
Respiratory Flouroquinolone (eg Levofloxacin, Gemifloxacin, Moxifloxacin)
IV/IM (as OPAT) : Ceftriaxone OR Amoxicillin-Clavulanate +/- Macrolide
SSTI:
Oral: Amoxycillin- Clavulanate OR Ciprofloxacin +/- Metronidazole
IV/IM (as OPAT): Levofloxacin OR Ertapenem
RTI:
Oral: Amoxicillin-Clavulanate +/- Macrolide ( Erythromycin/ Azithromycin) OR Respiratory Flouroquinolone
(eg Gemifloxacin, Moxifloxacin)
IV/IM (as OPAT) : Levofloxacin OR Ertapenem
Continue Treatment
Continue Treatment
treatment

sensitivity report.
Consider Escalation
36
clinical treatment

Consider Escalation
2. If culture shows Pseudomonas/Acinetobacter - Treat as Patient type 3 as in IPD protocol
37
NOTES
1.
For treating the Indoor patients, the Microbiology data should be considered mainly for patients belonging to Patient Types 2, 3
and 4. Patient type 1 refers to the patients reporting with Community acquired infections, and for them the treatment options
are based on the guidelines.
Avoid Antipseudomonal Fluoroquinolones (e.g.Ciprofloxacin and Levofloxacin) and Antipseudomonal 3rd generation
Cephalosporins (e.g. Ceftazidime and Cefoperazone) in Patients Type 1 and 2 since they have potent antipseudomonal activity
Treatment of serious infections caused by ESBL +ve pathogens with BL-BLI combinations (eg Piperacillin-Tazobactam,
Cefepime-Tazobactam and Cefoperazone-Sulbactam) should be avoided as there is limited clinical data and evidence available
for the use of these drugs in such infections.
In infections with MDR Pseudomonas/ Acinetobacter, Carbapenems should be used as Extended Infusions e.g. Imipenem (2 -3
hrs infusion), Meropenem (3hrs infusion), Doripenem (4hrs infusion)
Linezolid and Daptomycin are reserved drugs for inpatients and should be used only in cases of Vancomycin Resistant Staph
Aureus (VRSA) or Vancomycin Resistant Enterococci (VRE)
# De-escalation to Fluconazole if: Isolates susceptible to Fluconazoie (eg: Candida Albicans) + Patient clinically stable.
Deescalation to Voriconazole if : C. Krusei or Voriconazole susceptible C.Glabrata + Patient clinically stable. De-escalation to
fluconazole or voriconazole not recommended without confirmation of isolate susceptibility
2.
3.
4.
5.
6.

1.
For treating the Indoor patients, the Microbiology data should be considered mainly for patients belonging to Patient Types 2
and 3. Patient type 1 refers to the patients reporting with Community acquired infections, and for them the treatment options
are based on the guidelines.
In infections with MDR Pseudomonas/ Acinetobacter, Carbapenems should be used as Extended Infusions e.g. Imipenem (2 -3
hrs infusion), Meropenem (3hrs infusion), Doripenem (4hrs infusion)
Linezolid and Daptomycin are reserved drugs for inpatients and should be used only in cases of Vancomycin Resistant Staph
Aureus (VRSA) or Vancomycin Resistant Enterococci (VRE)
2.
3.
4.
5.

1.
For treating the Indoor patients, the Microbiology data should be considered mainly for patients belonging to Patient Types 2
and 3. Patient type 1 refers to the patients reporting with Community acquired infections, and for them the treatment options ar
*OPAT - Out Patient parenteral antibiotic therapy
2.
3.
4.
Important Points
1.
2.
The marker used in our laboratory to assess potential ESBL production among enterobacteriacae is resistance to
Cefotaxime and Ceftazidime.
The marker used in our laboratory to assess potential MRSA production is the resistance of S. aureus to cefoxitin.
38
39
40
Maximum Daily Dose of Antibiotics

Antibiotic
COLISTIN
Maximum Daily Dose

The recommended maximum daily dose of colistin is 10 million IU, or 800 mg of
colistimethate sodium, from the manufacturer of Coly-Mycin M, which is approximately
double the recommended daily dose from the manufacturer of ColomycinColy-Mycin M
Parenteral should be given in 2 to 4 divided doses at dose levels of 2.5 to 5 mg/kg per day
for patients with normal renal function, depending on the severity of the infection.
IMIPENEM/CILASTATIN
Maximum dose is 50mg/kg/day or 4 grams/day, whichever is lowest . Give in divided doses
MEROPENEM
2 g every 8 h.
ERTAPENEM
1gm/day
PIPERACILLIN /
TAZOBACTAM
The usual total daily dose of Piperacillin and Tazobactam for injection for adults is 3.375 g
every six hours totaling 13.5 g (12 g piperacillin/1.5 g tazobactam). presumptive treatment
of patients with nosocomial pneumonia should start with Piperacillin and Tazobactam for
injection at a dosage of 4.5 g every six hours plus an aminoglycoside, totaling 18 g (16 g
piperacillin/2 g tazobactam). For patients on hemodialysis, the maximum dose is 2.25 g
every twelve hours for all indications other than nosocomial pneumonia and 2.25 g every
eight hours for nosocomial pneumonia. max dose 4.5 gm tds Paediatric (Intravenous)
Dose:300 mg/kg/day in 3-4 divided doses, max: 4g tds.
AMPICILLIN/SULBACTAM
The recommended adult dosage of ampicillin and sulbactam for injection is 1.5 g (1 g
ampicillin as the sodium salt plus 0.5 g sulbactam as the sodium salt) to 3 g (2 g ampicillin as
the sodium salt plus 1 g sulbactam as the sodium salt) every six hours. This 1.5 to 3 g range
represents the total of ampicillin content plus the sulbactam content of ampicillin and
sulbactam for injection, and corresponds to a range of 1 g ampicillin/0.5 g sulbactam to 2 g
ampicillin/1 g sulbactam. The total dose of sulbactam should not exceed 4 grams per day.
CEFOPERAZONE/
SULBACTAM
In severe or refractory infections the daily dosage of sulbactam/cefoperazone may be

increased up to 8 g of the 1:1 ratio (i.e., 4 g cefoperazone activity maximum dosage is
4g/day.). Patients receiving the 1:1 ratio may require additional cefoperazone
administered separately. Doses should be administered every 12 hours in equally divided
doses. The recommended maximum daily dosage of sulbactam is 4 g.
TIGECYCLINE
Adults IV Maximum 100 mg daily.
CEFTRIAXONE
The total daily dose should not exceed 4 g.
CEFUROXIME
1.5 g tds
CIPROFLOXACIN
IV maximum total daily dose 1200 mg
MOXIFLOXACIN
400 mg orally or IV q24h
LINEZOLID
Maximum adult dose: 600 mg IV or orally every 12 hours
VANCOMYCIN
maximum: 2gm/dose Higher total daily doses of vancomycin have been associated with
nephrotoxicity
METRONIDAZOLE
IV max: 500 mg tds
AMIKACIN
The total daily dose by all routes of administration should not exceed 15 mg/kg/day.
CEFTAZIDIME
Maximum dose 12 g/day
CEFIXIME
The recommended dose of cefixime is 400 mg once daily
AZTREONAM
8 grams/day.
41
Safe Injection Practices

From the CDC Healthcare Infection Control Practices Advisory Committee
Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings, 2007
The following recommendations apply to the use of needles, cannulas that replace
needles, and, where applicable, intravenous delivery systems.
Use aseptic technique to avoid contamination of sterile injection equipment.
Do not administer medications from a syringe to multiple patients, even if the

needle or cannula on the syringe is changed. Needles, cannulae and syringes are
sterile, single-use items; they should not be reused for another patient or to access
a medication or solution that might be used for a subsequent patient.
Use fluid infusion and administration sets (i.e. intravenous bags, tubing and
connectors) for one patient only and dispose appropriately after use. Consider a
syringe or needle/cannula contaminated once it has been used to enter or
connect to a patients intravenous infusion bag or administration set.
Use single-dose vials for parenteral medications whenever possible.
Do not administer medications from single-dose vials or ampoules to multiple

patients or combine leftover contents for later use.
If multi-dose vials must be used, both the needle or cannula and syringe used to
access the multi-dose vial must be sterile.
Do not keep multi-dose vials in the immediate patient treatment area. Store in
accordance with the manufacturers recommendations and discard if sterility is
compromised or questionable.
Do not use bags or bottles of intravenous solution as a common source of supply

for multiple patients.
Infection control practices for special lumbar puncture procedures: Wear a surgical
mask when placing a catheter or injecting material into the spinal canal or
subdural space (i.e., during myelograms, lumbar puncture, and spinal or epidural
anesthesia.
Worker safety: Adhere to federal and state requirements for protection of

healthcare personnel from exposure to bloodborne pathogens (see OSHA
Bloodborne Pathogens Standard CFR 1910.1030 and Needlestick Safety and
Prevention Act on the OSHA website at
http://www.osha.gov/SLTC/bloodbornepathogens/index.htm
42
REMEMBER
Improper use of syringes, needles,
and medication vials can result in
transmission of life-threatening infections to patients
notification of patients of possible exposure to bloodborne pathogens
and recommendations that they be tested for hepatitis B virus,
hepatitis C virus, and human immunodeficiency virus
referral of providers to licensing boards for disciplinary action
malpractice suits filed by patients
43

Antibiotics
Major Spectrum
of Acitivity
Bactericidal or
Bacteriostatic
Mechanism
of Action
Major Adverse
Reactions
Penicillin
Penicillin G and
Penicillin V
Gram+cocci
Some anaerobes
bactericidal
Inhibits cell wall

synthesis
Allergy
Penicillin
Penicillinase
Resistant
Penicillins
Staphylococci
bactericidal
Inhibits cell wall
Allergy
Penicillin
Aminopenicillins
Gram+cocci
Some Gram - bacilli
bactericidal
Inhibits cell wall

synthesis
Allergy
Penicillin
Antipseudomonal
and ExtendedSpectrum
Penicillins
Gram + cocci
gram+bacilli
Pseudomonas sp.
bactericidal
Inhibits cell wall

synthesis
Allergy
Carbapenem
Imipenem
Ertapenem
Gram+species
Gram+species
Anaerobes
bactericidal
Inhibits cell wall

synthesis
Allergy
Monobactam
Aztreonam
Gram-bacilli
bactericidal
Inhibits cell wall

synthesis
NA
Cephalosporin First
Generation- eg.:
cefazolin, cephalexin
Gram+cocci
Some Gram-bacilli
bactericidal
Inhibits cell wall

synthesis
Allergy
Cephalosporin
Second-Generation
eg: Cefuroxime
Gram+cocci
Gram+bacilli
Some anaerobes
bactericidal
Inhibits cell wall

synthesis
Allergy
Cephalosporin
Third-Generation
eg: ceftriaxone,
ceftazidime
Fourth-Generationeg: cefepime
Many Gram-bacilli
Pseudomonas sp.
bactericidal
Inhibits cell wall

synthesis
Allergy
Aminoglycosides
Gram-bacilli
bactericidal
Inhibits bacerial
oprotein synthesis
Nephrotoxicity
Ototoxicity
Quinolones
SecondGeneration
Gram-bacilli
Staphylococcus sp.
Atypical organisms
bactericidal
Inhibits DNA
gyrase
CNS reactions
Photosensitivity
Developmental
bone/joint
lesions
44

Antibiotics
Major Spectrum
of Acitivity
Quinolones
SecondGeneration
Gram-bacilli
Staphylococcus sp.
Streptococcus sp.
Atypical organisms
Macrolides
eg: azithromycin
Bactericidal or
Bacteriostatic
bactericidal
Mechanism
of Action
Major Adverse
Reactions
Inhibits DNA
gyrase
CNS reactions
Photosensitivity
Developmental
bone/joint
lesions
Gram+/Gram-cocci
bacteriostatic
Some Haemophllus sp.
Atypical organisms
Inhibits bacterial
protein synthesis
well tolerate
Some GI
intolerance
Tetracyclines
Gram+/Gramaerobes & anaerobes

Atypical organisms
bacteriostatic
Inhibits bacterial
protein synthesis
GI intolerance
Photosensitivity
Developmental
tooth staining
Co-trimoxazole
Gram+/ Gramorganisms
bactericidal
Inhibits Formation
of vital metabolic
compound
GI intolerance
CNS effects
Skin rash
Hematologic
reactions
Glycopeptides
eg: Vancomycin
Staphylococcus sp.
Streptococcus sp.
Enterococci
bactericidal
bacteriostatic
vs. enterococci
Inhibits cell wall

synthesis
Skin rash
nephrotoxicity
Otoloxicity
45
IRRATIONAL/LESS EVIDENCE BASED ANTIBIOTICS

1.
Amoxicllin - tazobactam
2.
Cefadroxil-clavulanic acid
3.
Cefepime + Amikacin
4.
Cefepime-sulbactam
5.
Cefepime-tazobactam
6.
Cefixime + Ofloxacin
7.
Cefixime + Ornidazole
8.
Cefixime-clavulanic acid
9.
Cefotaxime-sulbactam
10.
Cefpodoxime-clavulanic
11.
Ceftazidime-tazobactam
12.
Ceftriaxone-sulbactam
13.
Ceftriaxone-tazobactam
14.
Cefuroxime-clavulanic acid
15.
Cefuroxime-sulbactam
16.
Meropenem-sulbactam
17.
Vancomycin + Ceftriaxone
18.
Cefoperazone Tazobactam
19.
Ampicilin-Amoxicilin-Cloxacillin
20.
Ceftazidime-Sulbactam
21.
Ofloxacin- Ornidazole/Tinidazole
22.
Gatifloxacin-Ornidazole
23.
Fluconazole-Tinidazole
24.
Doxycycline-Tinidazole
25.
Tetracycline-Metronidazole
26.
Cefixime/Cefadroxil + Ambroxol + Lactobacillus
27.
Ciprofloxacin/Gatifloxacin + Ambroxol
28.
Roxithromycin + Ambroxol
46
CATEGORIZATION OF ANTIBIOTICS
Restricted use
A pre use authorisation from an ID Physician / Clinical Microbiologist needs to be taken
before prescribing these antibiotics. A written documentation to be maintained which
captures the request along with justification for use by the clinician and also captures
the approval for use by the authority in charge
Limited access
Unrestricted use of these antibiotics may be allowed for empirical use for first 48-72hrs
but after that a clinical justification by clinician and approval from authority in charge
needs to be documented that why these antibiotics cannot be de-escalated and need
to be continued further
Under Surveillance
A close monitoring to check their usage (indication, quantity and pattern) in OPD /
Type 1 Patients/ Surgical prophylaxis. Audits to be done at regular intervals to assess
their consumption
47
RESTRICTED USE ANTIBIOTICS: WHAT AND WHY ?

Colistin: It is the last resort for managing gram negative MDRs and its use, dose and
duration needs to be rationalised. Liberal use should be restricted
Doripenem: It is the last carbapenem (at least in near future). If Imipenem and
Meropenem are working, we need to conserve the use of Doripenem
Rifampicin: (For Non-TB use) This is a valuable drug for TB. The use of rifampicin in MDR
Pseudomonas, Acinetobacter or MRSA should be restricted
Linezolid: Alternatives available eg. Vancomycin/Teicoplanin. Linezolid is
bacteriostatic and available as oral - more prone for misuse VRSA / VRE rare
Daptomycin: Alternatives are available for MRSA eg. Vancomycin and Teicoplanin.
Moreover VRSA and VRE are still not a major cause of concern
Tigecycline: Bacteriostatic, one of the most Broad spectrum drugs, has limited role in
MDR infections like SSTI, IAI where ESBL/MRSA and or Acinetobacter are feared.
Sulbactam: Recently introduced in market. Reserved for PDR Acinetobacter. Dose has
to be correct (4-12gm/day for PDR Acinetobacter)
48
LIMITED ACCESS ANTIBIOTICS: WHAT AND WHY?

Imipenem/Meropenem : Use as empirical in sick patients is allowed looking at the
antibiograms in most hospitals showing better sensitivity of these antibiotics over
other classes, however after culture and sensitivity report is available, if it shows a
susceptible pathogen to other classes of ABs plus if patient condition improves - then
de-escalation should be advised.
Piperacillin-Tazobactam/Cefoperazone-Sulbactam: These are as broad spectrum
as carbapenems (this fact is not appreciated generally). Use as empirical in sick patients
is allowed looking at the antibiograms in most hospitals showing decent sensitivity of
these antibiotics over other classes, however after culture and sensitivity report is
available, if it shows a susceptible pathogen to other classes of antibiotics plus if
patient condition improves - then de-escalation should be advised.
Vancomycin/Teicoplanin: Use as empirical in sick patients may be allowed specially
in BSI, SSTI where MRSA is suspected but if after 48-72hrs culture and sensitivity
report shows no staph aureus or MSSA then Vanco/Teico have absolutely no role and
should be discontinued.
UNDER SURVEILLANCE ANTIBIOTICS: WHAT AND WHY?

3rd generation cephalosporins (both oral and IV) and Flouroquinolones:
One of the main reasons for widespread ESBLs in India in the community is due to
overuse of 3rd gen ceph and flouroquinolones at OPD level-Type 1 patients , pediatric
patients and Surgical prophylaxis.
It is must to educate the clinicians about these antibiotics and the collateral damage
they cause. Also it is imperative to exercise control on liberal usage of these antibiotics
in a phased manner and perform regular audits on the rate of consumption of these
antibiotics. This could be the single most valuable intervention to curb resistance in
India in community
49
NOTES
50
CMCs Motto:
My Work is for a King

Dr. Edith Mary Brown
Founder of CMC Ludhiana
CMC Ludhiana exists to:

Provide Excellence in medical care
Serve the health needs of the community including the
underprivileged.
Train health professionals for India
Provide wholistic healing (body, spirit and soul) in the
spirit of Jesus Christ.
Christian Medical College

Ludhiana, Punjab (INDIA)
Tel:+91-161-5026999; 5010925; 5010924
Fax:+91-161-2228416; 5010815
Web: www.cmcludhiana.org

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Christian Medical College & Hospital

Ludhiana, Punjab (INDIA)

WHO - Seven steps of Handwashing

Rub palms together.

Rub the back of both hands.

Interface fingers and rub hands together.

Interlock fingers and rub the back of fingers

Rub thumb in a rotating manner followed

Rub fingertips on palm for both hands.

Rub both wrists in a rotating manner.

Message from Director

Antibiotic Protocol : Urinary Tract infections - ICU

Antibiotic Protocol : Urinary Tract infections - IPD

MESSAGE FROM DIRECTOR

With best wishes,

Dr. Abraham G. Thomas

MESSAGE FROM MEDICAL SUPERINTENDENT

With best regards

Dr. Kanwal Masih

MESSAGE FROM HOD-Microbiology

Dr. Aroma Oberoi, MD

MESSAGE FROM HOD-Medicine

ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES

All antibiotic initiations would be done after sending appropriate cultures

Change in antibiotic would be done after sending fresh cultures

Microbiological samples must always be sent prior to initiating antimicrobial therapy.

THE IMPORTANCE OF INFECTION CONTROL (IC)

PATIENT RISK STRATIFICATION

No contact with health

Contact with health care

Hospitalization >5 days

Type 3 patient with fever despite

Antibiotic therapy in last 90

Recent & multiple

severe sepsis/septic shock PLUS

Patient young with no

Patient old ( > 65years) with

Patient with multiple

Has 1 or more than 1 of the following

Risk of Bacterial infections

High Risk of Invasive fungal

Empiric treatment of fungal

High risk of Bacterial

Minimal risk of Invasive

Risk of invasive fungal

Limited use of broad

BL+BLIs can also be

Prophylaxis for fungal

HOW TO USE THE POCKET GUIDE?

To use these protocols follow these steps:

Blood Stream Infections (BSI) - ICU Antibiogram

Antibiotic Sensitivity (%)

Staph aureus (n=20)

Linezolid/Vancomycin (100%), Erythromycin (65%),

Polymyxin B/Amikacin (88%),

Salmonella paratyphi A (n=1)

Polymyxin B/Cefoperazone-Sulbactam (100%)

Blood Stream Infections (BSI) - IPD Antibiogram

Antibiotic Sensitivity (%)

Staph aureus (n=115)

Vancomycin (96%), Linezolid (92%), Cefoxitin (80%)

Imipenem (93%), Piperacillin-Tazobactam (86%),

Piperacillin-Tazobactam (98%), Polymyxin (96%),