Treatment

Guide
TREATMENT GUIDE
Fifteenth Edition 2020
A Book for Practicing Physicians

Muhammad Inayatullah
FRCP
Professor of Medicine
Multan Medical and Dental College,
Multan

Shabbir Ahmad Nasir

FRCPE
Principal/Dean
Multan Medical & Dental College,
Multan

Karachi | Lahore | Islamabad | Hyderabad | Faisalabad | Peshawar | Abbottabad

 Paramount Books (Pvt.) Ltd.

Treatment Guide
by
Muhammad Inayatullah/Shabbir Ahmad Nasir

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Copyright © 2020
All Rights Reserved

First edition.................................. 1997 Eighth edition............................... 2011

Second edition.............................. 1999
Third edition................................. 2002
Fourth edition.............................. 2003
Fifth edition.................................. 2007
Sixth edition................................. 2008
Seventh edition............................. 2010
Ninth edition................................ 2014
Tenth edition................................ 2015
Eleventh edition........................... 2016
Twelfth edition............................. 2017
Thirteenth edition........................ 2018
Fourteenth edition....................... 2019

Fifteenth edition........................... 2020

152/O, Block-2, P.E.C.H.S., Karachi-75400.

Tel: +92-21-34310030, info@paramountbooks.com.pk
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ISBN: 978-969-637-780-1
Printed in Pakistan
 CONTENTS
1. Principles of
Antimicrobial
Therapy........................ 1
Choice of Initial
Antimicrobial Therapy... 1
Antibacterial Agents............ 2
Beta-Lactam
Antimicrobials.................. 2
Penicillin........................... 2
Beta Lactamase Inhibitors....3
Cephalosporins................ 4
Cephamycins.................... 6
Monobactam.................... 7
Carbapenems.................... 7
Tigecycline........................ 7
Macrolide and Azalide
Antimicrobials.................. 7
Lincosamides.................... 8
Other Anti-
Staphylococcal Agents...... 8
Tetracyclines..................... 9
Chloramphenicol............. 10
Aminoglycosides.............. 10
Sulfonamides and
Trimethoprim................... 11
Quinolones....................... 11
New Antibiotics............... 12
Antibiotics used for UTI. 12
Antituberculous Agents... 13
Second Line Agents.......... 14
Antileprotic Drugs........... 14
Antiviral Agents................ 15
Antifungal Agents............. 19
Antiprotozoal Agents....... 20
Antimalarials..................... 20
Amebicides....................... 22
Anthelmintics................... 23
Groups, Trade Names,
Strength & Preparations
and Dosage of
Antimicrobials.................. 24
Groups, Trade Names,
Strength & Preparations
and Dosage of Vaccines,
Immune Globulins and
Antisera............................. 45
2. Treatment of
Infections..................... 48
Principles of Therapy.......... 48
Respiratory System.......... 50
Pharyngitis/Tonsillitis......... 50
Acute Sinusitis..................... 50
Influenza.............................. 50
Dengue Fever...................... 51
Pneumonia.......................... 52
Community Acquired
Pneumonia....................... 52
Nosocomial Pneumonia.... 53
Pneumonia due to Specific
Organisms........................... 53
Streptococci Pneumoniae
(Pneumococcus).............. 53
Staphylococcus Aureus.... 54
Klebsiella Pneumoniae.... 54
Haemophilus Influenzae. 54
Pseudomonas Aeruginosa....54
Mycoplasma Pneumoniae...55
Legionnaire’s Disease....... 55
Pneumocystis Carinii....... 55
Mixed Flora...................... 55
 Complications of
Pneumonia....................... 55
Tuberculosis........................ 57
Aspergillosis......................... 60
Sample Prescriptions
of Respiratory System
Infections.......................... 60
Urinary Tract Infection.... 66
UTI in Women................... 66
UTI in Men........................ 68
Sample Prescriptions of
Urinary Tract Infections.. 69
Central Nervous System.71
Acute Bacterial Meningitis. 71
Viral Meningitis.................. 73
Brain Abscess....................... 73
Herpes Encephalitis......... 73
Herpes Zoster................... 74
Sample Prescriptions of
Central Nervous System
Infections.......................... 74
Cardiovascular System... 75
Rheumatic Fever................. 78
Sample Prescriptions of
Cardiovascular System
Infections.......................... 78
Infective Endocarditis......... 79
Gastrointestinal Tract..... 80
Candidiasis.......................... 80
Acute Diarrhea.................... 80
Dysentery............................ 81
Amebiasis (Amebic
Dysentery)........................... 81
Cholera................................ 82
Giardia Lamblia................... 83
Pseudomembranous
Enterocolitis........................ 83
Diarrhea and Fluid
Management........................ 84
Enteric Fever (Typhoid
Fever)................................... 85
Intraabdominal Infections..... 86
Peritonitis.......................... 86
Sample Prescriptions of
Gastrointestinal Tract
Infections.......................... 87
Miscellaneous Infections.... 89
Brucellosis........................... 89
Sample Prescriptions of
Miscellaneous Infections.... 89
Osteomyelitis...................... 90
Cellulitis.............................. 90
Sepsis of Unknown Origin.90
Septicemia........................... 91
Tetanus................................. 91
Rabies.................................. 92
Leptospirosis........................ 93
Malaria............................... 93
Diseases of Helminths.... 96
Sexually Transmitted
Diseases.............................. 101
Syphilis................................ 101
Gonorrhea........................... 102
Non-Gonococcal
Urethritis (NGU)............... 102
Lymphogranuloma
Venereum (LGV)................ 102
Chancroid............................ 103
Sample Prescriptions
of Sexually Transmitted
Diseases............................... 103
3. Heat Illness.................. 105
Near-Drowning................ 106
High Altitude Illness....... 106
4. Shock............................ 108
Addisonian Crisis................ 112
Groups, Trade Names,
Strength & Preparations
and Dosage of Drugs
Used as Plasma
 Expanders......................... 112
Sample Prescriptions of
Shock................................ 113
5. Overdosage/
Poisoning..................... 114
Caustic Ingestion.............. 114
Acid Ingestion.................. 115
Hydrocarbon Ingestion
(Petroleum Products,
Kerosene).......................... 115
Organophosphates........... 115
Opioids............................. 116
Phenothiazines................. 116
Salicylates.......................... 117
Sedatives, Hypnotics........ 118
Barbiturates...................... 118
Benzodiazepines............... 118
Cyclic Antidepressants..... 118
Digoxin............................. 119
Snake Bite............................ 119
Hair Dye (Black Stone Or
Kala Pather)......................... 121
Wheat Pill............................ 121
Groups, Trade Names,
Strength & Preparations
and Dosage of Drugs
Used in Overdosage/
Poisoning.......................... 123
Sample Prescriptions of
Poisoning.......................... 124
6. Hypertension.............. 127
General Management......... 128
Nonpharmacological
Measures.............................. 129
Antihypertensive Drugs...... 130
Diuretics........................... 130
Beta-Blockers................... 132
Alpha and Beta Blockers.. 132
Calcium Antagonists........ 133
Angiotensin-Converting
Enzyme Inhibitors........... 133
Angiotensin ii Receptor
Antagonists....................... 134
Renin Inhibitors............... 134
Centrally Acting
Antihypertensives............. 134
Alpha-Adrenoceptor
Blocking Drugs................ 135
Vasodilators....................... 135
General Guidelines for
Antihypertensive Drugs
Therapy............................... 135
First-Choice Drugs.......... 137
Drugs for Additional
Therapy............................. 137
Preferences in Different
Patients.............................. 138
Secondary Hypertension.... 140
Hypertensive Crisis............ 141
Parenteral
Antihypertensive Agents.. 141
Groups, Trade Names,
Strength & Preparations
and Dosage of
Antihypertensive Drugs... 143
Sample Prescriptions of
Hypertension.................... 152
7. Ischemic Heart
Disease.......................... 155
Angina Pectoris................ 155
Drugs................................... 156
Aspirin.............................. 156
Beta-Blockers................... 156
Calcium Antagonists........ 157
Nitrates............................. 157
Other Therapies............... 158
Coronary
 Revascularization............. 159
Preparations of Nitrates/
Potassium Channel
Activator............................ 160
Acute Coronary Syndrome.162
Unstable Angina, Non-
ST-Elevation Myocardial
Infarction............................. 162
Variant Angina
(Prinzmetal’s Angina)......... 165
Silent (Asymptomatic)
Ischemia............................... 166
Unconventional
Treatments for Ihd.............. 166
Myocardial Infarction..... 166
Complications of
Infarction.......................... 174
Secondary Prevention......... 184
Summary of Approach
to a Patient Presenting
with Chest Pain Likely
to be due to Myocardial
Infarction.......................... 185
Sample Prescriptions of
Angina and Myocardial
Infarction Prescriptions... 188
8. Heart Failure............... 195
New York Heart
Association Functional
Classification.................... 195
General Measures............ 196
Pharmacologic Agents...... 198
Refractory Heart Failure.... 203
Device Therapy................ 204
Cardiogenic Pulmonary
Edema............................... 205
Valvular Heart Diseases.... 207
Mitral Stenosis.................... 208
Aortic Stenosis..................... 208
Mitral Regurgitation........... 209
Mitral Valve Prolapse.......... 209
Aortic Regurgitation........... 209
Cardiomyopathy.............. 210
Dilated Cardiomyopathy.... 210
Hypertrophic
Cardiomyopathy................. 210
Restrictive
Cardiomyopathy................. 211
Myocarditis.......................... 212
Groups, Trade Names,
Strength & Preparations
and Dosage of Drugs
Used In Heart Failure...... 212
Sample Prescriptions of
Heart Failure.................... 212
Infusion Tables.................... 214
Dopamine......................... 214
Dobutamine..................... 215
Noradrenaline.................. 215
Sodium Nitroprusside..... 216
Nitroglycerin.................... 217
Isosorbide Dinitrate......... 218
Lignocaine........................ 218
Aminophylline................. 219
Atropine............................ 219
Diazepam.......................... 220
Pericardial Disease.......... 220
Acute Pericarditis................ 220
Chronic Pericardial
Effusion............................... 221
Cardiac Tamponade............ 221
Constrictive Pericarditis..... 221
9. Arrhythmias................ 222
Sinus Tachycardia................ 222
Sinus Bradycardia................ 222
Atrial Ectopics..................... 222
Ventricular Ectopics............ 222
Paroxysmal
Supraventricular
Tachycardia (SVT).............. 223
Atrial Fibrillation................. 224
Atrial Flutter........................ 227
Multifocal Atrial
Tachycardia.......................... 227
Ventricular Tachycardia....... 227
Torsades De Pointes............ 228
Stokes-Adams Attacks......... 229
Sick Sinus Syndrome.......... 229
Carotid Sinus
Hypersensitivity.................. 230
Wolff-Parkinson-White
Syndrome............................ 230
Conduction Defects............ 231
Antiarrhythmic Agents....... 232
Groups, Trade Names,
Strength & Preparations
and Dosage of
Antiarrhythmic Agents..... 235
Sample Prescriptions of
Arrhythmias...................... 239
10. Cardiac Arrest............. 244
Basic Life Support............ 245
Advanced Life Support.... 245
Pulseless Ventricular
Tachycardia Or
Ventricular Fibrillation..... 246
Asystole............................. 246
Ventricular Fibrillation
and Pulseless Ventricular
Tachycardia....................... 247
Airways Management..... 248
Tracheostomy................... 248
Cricothyroid Needle
Cannulation...................... 248
Oxygen Therapy............... 249
11. Respiratory Tract
Diseases........................ 250
Cough.................................. 250
Hemoptysis......................... 250
Allergic Rhinitis.................. 250
Bronchial Asthma............... 251
Drugs Used In the
Treatment of Bronchial
Asthma................................. 251
Acute Severe Attack of
Bronchial Asthma............. 255
Management..................... 255
Long Term Management. 257
A New Patient.................. 260
Refractory Asthma........... 260
Chronic Obstructive
Pulmonary Disease............. 261
Acute Exacerbations of
Chronic Bronchitis.......... 261
Long Term Management. 262
Emphysema...................... 264
Bronchiectasis..................... 265
Pulmonary Embolism......... 265
Pulmonary Hypertension... 267
Cor Pulmonale................. 268
Sleep Apnea......................... 269
Aspiration of Gastric
Contents.............................. 270
Lung Abscess....................... 270
Interstitial Lung Disease
(Ild)...................................... 271
Extrinsic Allergic Alveolitis.271
Sarcoidosis........................... 272
Acute Respiratory Distress
Syndrome............................ 272
Respiratory Failure.............. 273
Management of Type I
Respiratory Failure........... 273
Management of Type II
Respiratory Failure........... 273
Pleural Effusion.................. 274
Pneumothorax..................... 276
Groups, Trade Names,
 Strength & Preparations
and Dosage of Drugs
Used in Respiratory Tract
Diseases............................. 277
Sample Prescriptions
of Respiratory Tract
Diseases............................. 283
12. Gastrointestinal
Tract.............................. 290
Nausea and Vomiting.......... 290
Diarrhea............................... 291
Constipation........................ 291
Esophageal Diseases........ 293
Reflux Esophagitis
(Gastroesophageal Reflux
Disease)............................... 293
Infectious Esophagitis......... 295
Candida Esophagitis......... 296
Normal or Minimally
Immunocompromized
Patient............................... 296
Immunocompromized
Patient or Severe
Infection........................... 296
Herpes Simplex/Zoster
Esophagitis........................ 296
Corrosive Intake............... 296
Esophageal Motility
Disorders............................. 296
Achalasia........................... 296
Diffuse Esophageal
Spasm and Other Related
Disorders.......................... 297
Carcinoma Esophagus........ 297
Gastritis................................ 298
Acute Gastritis.................. 298
Chronic Gastritis due to
H. Pylori........................... 298
Autoimmune Chronic
Gastritis............................. 298
Peptic Ulcer...................... 298
Ulcer Healing Drugs.......... 298
Zollinger Ellison
Syndrome......................... 304
Stress Ulcers and
Erosions............................ 304
Nonulcer Dyspepsia........ 304
Gastroparesis....................... 305
Gastric Carcinoma.............. 305
Gastrointestinal Bleeding... 305
Upper Gi Bleeding........... 307
Bleeding Peptic Ulcer...... 308
Esophageal Variceal
Bleeding............................ 309
Fundal Varices.................. 313
Mallory-Weiss Tears......... 313
Stress Ulceration.............. 314
Lower GI Bleeding........... 314
Malabsorption.................. 314
Celiac Disease..................... 314
Tropical Sprue..................... 315
Lactose Intolerance............. 315
Bacterial Overgrowth of
Small Intestine.................... 315
Ileal Resection..................... 315
Giardiasis............................. 316
Inflammatory Bowel
Disease................................. 316
Ulcerative Colitis............. 316
Crohn’s Disease............... 322
Microscopic Colitis.......... 325
Radiation Enteritis........... 325
Gut Ischemia..................... 325
Diverticulosis.................... 326
Hemorrhoids and Anal
Fissure................................. 326
Irritable Bowel
Syndrome........................... 327
Groups, Trade Names,
 Strength & Preparations
and Dosage of Drugs
Used in GIT Diseases...... 328
Sample Prescriptions of
GIT Diseases.................... 337
13. Liver Diseases............. 344
Acute Viral Hepatitis........... 344
Acute Fulminant Hepatic
Failure............................... 345
Chronic Viral Hepatitis...... 346
Chronic Hepatitis B......... 347
Hepatitis B Vaccination.... 362
Chronic Hepatitis C........ 364
Drug Induced Hepatitis... 371
Alcoholic Liver Disease.... 371
Non-Alcoholic Fatty
Liver Disease.................... 372
Autoimmune Chronic
Active Hepatitis................ 372
Cholestatic Liver Disease... 372
Primary Biliary Cirrhosis.373
Primary Sclerosing
Cholangitis....................... 373
Inherited Liver Diseases..... 374
Wilson’s Disease............... 374
Hemochromatosis............ 374
Alpha1 Antitrypsin
Deficiency......................... 375
Budd-Chiari Syndrome... 375
Liver Abscess....................... 375
Pyogenic Liver Abscess.... 376
Amebic Liver Abscess...... 376
Hepatocellular Carcinoma. 376
Cirrhosis of Liver................ 377
Portal Hypertension......... 377
Portal Vein Thrombosis... 378
Ascites and Edema............ 378
Refractory Ascites............. 379
Spontaneous Bacterial
Peritonitis.......................... 380
Portosystemic (Or
Hepatic) Encephalopathy.381
Hepatorenal Syndrome.... 382
Coagulopathy................... 382
Pregnancy Associated
Liver Disease.................... 383
Acute Cholestasis of
Pregnancy......................... 383
Acute Fatty Liver of
Pregnancy......................... 383
Toxemia of Pregnancy
and Hellp Syndrome........ 383
Hepatic Transplantation... 383
Drugs Used in Liver
Disorders............................. 384
Groups, Trade Names,
Strength & Preparations
and Dosage of Drugs
Used In Liver Disorders.. 384
Sample Prescriptions of
Liver Disorders................. 386
Gallstones.......................... 390
Biliary Tree Infections...... 390
Pancreatitis....................... 390
Acute Pancreatitis................ 390
Chronic Pancreatitis........... 392
Carcinoma Pancreas............ 392
Gastroenteropancreatic
Neuro-Endocrine Tumors. 392
Sample Prescriptions
of Cholecystitis and
Pancreatitis........................ 393
14. Electrolyte
Imbalance.................... 394
Hyponatremia..................... 394
Hypernatremia.................... 395
Hypokalemia....................... 395
Hyperkalemia...................... 396
 Sample Prescriptions of
Electrolyte Imbalance...... 397
15. Renal Diseases............ 399
Acute Kidney Injury........ 399
Pre-Renal Failure................ 399
Obstructive Nephropathy.. 400
Renal Failure....................... 400
Acute Tubular Necrosis... 400
Glomerulonephritis............ 402
Minimal Change Disease.402
Focal Segmental
Glomerulosclerosis.......... 403
Membranous
Glomerulonephritis......... 404
Iga Nephropathy.............. 404
Membranoproliferative
Glomerulonephritis......... 404
Anti-Gbm Antibody
Disease.............................. 404
Systemic Lupus
Erythematosis (Sle).......... 405
Post-Streptococcal
Glomerulonephritis......... 405
Nephrotic Syndrome....... 406
Tubulo-Interstitial Diseases_407
Acute Interstitial
Nephritis.......................... 407
Chronic Interstitial
Nephritis.......................... 407
Chronic Kidney Disease.407
Conservative Management.408
Renal Replacement
Therapy............................... 411
Dialysis.............................. 411
Renal Transplantation...... 414
Urinary Tract Infection....... 414
Urethritis and Cystitis..... 414
Acute Pyelonephritis........ 414
Sample Prescriptions of
Renal Diseases.................. 415
16. Hematology................. 418
Anemia................................. 418
Iron Deficiency
Anemia......................... 418
Parenteral Iron Therapy... 419
Megaloblastic Anemia.... 419
Aplastic Anemia................... 420
Pure Red Cell Aplasia......... 420
Anemia of Chronic Renal
Failure.................................. 421
Anemia of Chronic
Disease................................. 421
Autoimmune Hemolytic
Anemia................................. 421
Warm Antibody
Autoimmune Hemolytic
Anemia.............................. 421
Cold Antibody
Autoimmune Hemolytic
Anemia.............................. 422
Thalassemias....................... 423
Sickle Cell Disease.............. 425
Glucose-6-Phosphate-
Dehydrogenase Deficiency.428
Hereditary Spherocytosis... 428
Myelodysplastic
Syndromes........................... 429
Sideroblastic Anemia....... 429
Thrombocytopenia.......... 430
Thrombocytosis.................. 433
Hemophilia......................... 434
Von Willebrand Disease
(Vwd)................................... 435
Vitamin K Deficiency......... 436
Coagulopathy in Liver
Disease.............................. 436
Disseminated Intravascular
Coagulation (Dic)............... 436
Thromboembolic
Disorders............................. 436
Acute Arterial Occlusion. 436
Venous Thrombosis......... 438
Deep Venous Thrombosis
(Dvt)................................. 438
Antithrombotic Therapy.. 439
Anticoagulants.................. 439
Anticoagulation Therapy. 439
Antiplatelet Drug
Therapy............................. 445
Thrombolytic Therapy.... 446
Groups, Trade Names,
Strength & Preparations
and Dosage of
Hematinics and Drugs..... 447
Used In Hemorrhage and
Thromboembolism.......... 449
Sample Prescriptions of
Hematological Disorders.453
Transfusion Therapy....... 456
17. Diabetes Mellitus....... 461
Patient Education............. 466
Diet................................... 466
Exercise............................. 467
Ramadan........................... 469
Drugs Used For Diabetes
Mellitus............................. 469
Oral Antidiabetic Drugs.. 469
Insulin Secretagogues...... 470
Biguanides........................ 471
Alpha Glucosidase
Inhibitors.......................... 471
Thiazolidinediones
(Glitazones)...................... 471
Dipeptidylpeptidase-4
Inhibitors and Glucagon-
Like Peptide 1 Receptor
Agonists............................ 472
Insulin............................... 473
Type 1 (Insulin Dependent
Diabetes Mellitus)............... 477
Diabetic Ketoacidosis....... 481
Type 2 (Non-Insulin
Dependent Diabetes
Mellitus).............................. 485
Diabetes Mellitus In
Pregnancy......................... 490
Gestational Diabetes........ 492
Hyperglycemia In Acute
Medical Illness.................. 493
Diabetes Mellitus and
Surgery.............................. 493
Chronic Complications
of Diabetes Mellitus......... 495
Hypoglycemia..................... 501
Groups, Trade Names,
Strength & Preparations
and Dosage of Drugs
Used In Diabetes
Mellitus............................. 503
Sample Prescriptions of
Diabetes Mellitus............. 508
Nonketotic
Hyperosmolar Syndrome.510
18. Endocrine.................... 513
Thyroid.............................. 513
Hypothyroidism.................. 513
Hyperthyroidism................. 515
Thyroid Crisis.................. 522
Hyperthyroidism in
Pregnancy......................... 522
Euthyroid Goiter................. 524
Thyroiditis........................... 525
Adrenal Gland.................. 525
Adrenal Failure.................... 525
Cushing’s Syndrome.......... 527
Adrenal Neoplasm.............. 528
Primary
Hyperaldosteronism........... 528
Pheochromocytoma............ 528
Anterior Pituitary
Gland.................................. 529
Hypopituitarism.................. 529
Acromegaly.......................... 529
Hyperprolactinemia............ 529
Lipid Disorders................ 531
Mineral and Metabolic
Bone Disease..................... 535
Hypercalcemia..................... 535
Hypocalcemia...................... 539
Osteoporosis........................ 539
Osteomalacia....................... 542
Groups, Trade Names,
Strength & Preparations
and Dosage of Hormones,
Drugs Used In Endocrine
System, Lipid Lowering
Drugs, Vitamins,
Minerals and Drugs Used
In Bone Diseases.............. 543
Sample Prescriptions
of Bone and Endocrine
Disorders.......................... 551
19. Rheumatology............. 556
Chronic Pain....................... 556
Infectious Arthritis (Septic
Arthritis))............................. 557
Lyme Disease.................... 559
Crystal Induced Arthritis.... 559
Primary Gout...................... 559
Secondary Gout.................. 561
Pseudogout.......................... 561
Rheumatoid Arthritis.......... 561
Osteoarthritis...................... 569
Carpal Tunnel Syndrome... 570
Fibrositis.............................. 570
Tendinitis, Tenosynovitis
and Bursitis.......................... 570
Spondyloarthritis................. 571
Ankylosing Spondylitis.... 571
Arthritis Due To
Inflammatory Bowel
Disease.............................. 572
Reiter’s Syndrome and
Reactive Arthritis.............. 572
Behcet’s Syndrome.......... 572
Psoriatic Arthritis............. 573
Systemic Lupus
Erythematosis...................... 573
Systemic Sclerosis
(Scleroderma)...................... 576
Polymyalgia Rheumatica
and Temporal Arteritis........ 577
Polymyositis and
Dermatomyositis................. 578
Mixed Connective Tissue
Disease................................. 579
Groups, Trade Names,
Strength & Preparations
and Dosage of Drugs
Used In Arthritis,
Immunosuppressants and
Steroids ............................ 580
Sample Prescriptions
of Rheumatological
Disorders.......................... 589
20. Central Nervous
System........................... 597
General Management of
Coma................................... 597
Cerebrovascular
Diseases.............................. 598
Cerebral Ischemia............... 598
Intracranial Hemorrhage.... 603
Intracerebral
Hemorrhage..................... 603
Subarachnoid
 Hemorrhage..................... 603 Bell’s Palsy........................... 627
Headache........................... 628
Syncope, Postural
Hypotension and Migraine.............................. 628
Vertigo................................ 605 Cluster Headache................ 630
Epilepsy.............................. 606 Tension Headache............... 630
Antiepileptic Drugs............. 606 Depression......................... 630
Generalized Tonic Clonic .. 608 Anxiety Disorders............ 632
Focal Onset Seizures/ Insomnia.............................. 633
Secondary Generalization... 608 Groups, Trade Names,
Absence Seizures................. 608 Strength & Preparations
Myoclonic Epilepsy............ 609 and Dosage of Drugs
Used In Central Nervous
Single Seizure...................... 609
System Disorders............. 634
Epilepsy and Pregnancy/
Contraception.................. 612 Sample Prescriptions of
Central Nervous System
Eclampsia.......................... 612 Disorders.......................... 648
Status Epilepticus............. 612 Index................................... 656
Parkinson’s Disease......... 614
Torsion Dystonia
(Torsion Spasm; Dystonia
Musculorum Deformans).. 617
Tardive Dystonia Or
Dyskinesia........................... 618
Restless Legs Syndrome..... 618
Multiple Sclerosis............ 618
Transverse Myelitis............. 620
Neuromyelitis Optica......... 620
Alzheimer’s Disease............ 621
Periodic Paralysis................. 621
Guillain Barré
Syndrome........................... 622
Botulism.............................. 624
Myasthenia Gravis........... 624
Myasthenia Crisis............. 626
Lambert-Eaton
Myasthenic Syndrome..... 626
Myotonic Dystrophy.......... 626
Subacute Combined
Degeneration of the Spinal
Cord..................................... 627
Trigeminal Neuralgia.......... 627
 PREFACE TO FIRST EDITION
One of the most important milestones in a doctor’s life
is achieved when he makes the transition from learned
pharmacology to applied medicine. This transition, despite
its importance, often needs to be made alone if he goes
directly into practice after graduation. If he is fortunate to get
a residency he is aided by the resident staff and consultants;
but not all residencies are alike and the guidance available
is varied and in some cases even inadequate. There exists
a gap between the contents of therapeutic pharmacology
and textbook medicine, between principles of treatment
and the problems of drug administration, between theory
and practice. This book aims to bridge this gap by providing
guidelines for treatment but the most important aspect is
the inclusion of sample prescriptions that include drug
combinations, dosages and duration of treatment.
Medicine is a huge subject, made even more daunting by
the huge number of drugs in the market. It is difficult, or
even impossible, to remember and use available therapeutic
options rationally. Often inappropriate drug combinations
or dosages are put to use. This book aims to help this
situation by providing a core of sample prescriptions that
can be used as such in treatments and as the physician gets
more experience, he can adapt or even change these to suit
his local requirements.
Trade names are more familiar and are used in prescriptions
so these have been used in the samples; only one trade
name of a generic substance is used to avoid confusion, this
does not mean any endorsement of a particular brand over
another; but the physician is cautioned against the veritable
explosion of dubious pharmaceuticals preparations and
advises to choose good quality preparations.
The prescriptions include, established medical practices,
the combinations and doses represent accepted regimens
and appropriate therapy in the stated conditions.
We realize the rapidity with which new therapeutic options
become available and hope to publish an addendum to this
book every year and a new edition every two years to ensure
that the information contained is always updated.
This book should be of equal use to the practicing physician,
in both the hospital and general practice environment; we
hope this book will be used as a frequent reference and be
kept within easy reach on the desks of doctors.
We would appreciate feedback from our readers and hope to
incorporate reader suggestions in the next editions.

Muhammad Inayatullah
SA. Nasir
Multan, 1997
 PREFACE TO FIFTEENTH EDITION
The fifteenth edition of the book contains addition of
recent knowledge so that the contents remain as updated
as possible. Changes have been made throughout the
book; chapters most affected are principles of antimicrobial
therapy, treatment of infections, cardiovascular system,
respiratory system and liver diseases.
We reiterate the policy of keeping abreast of developments
by publishing annual editions of the book. This way the
readers are assured that the contents of a recent copy of this
book will always reflect accepted practice and not contain
obsolete material.
We would also request our readers to continue giving their
feedback and suggestions for further improvement.

Muhammad Inayatullah
SA. Nasir
Multan, 2020
 DISCLAIMER
This book contains drug names, dosages, indications and
duration of their use in various diseases. All efforts have
been made to ensure that the information contained is
correct and reflects accepted practice standards. However,
no warranty is made, expressed or implied, and the reader
should consult standard texts of medicine and pharmacology
and also the package inserts about the effects, reactions,
interactions, precautions, indications, contra-indications
and dosages of the drugs that are being used in any patient.
No legal responsibility or financial liability would be
acceptable for any error or omission, or for any eventuality
arising from the use of any drug, drug combination, dosage
or duration, any recommendation, treatment strategy or
information contained in this book.
Only one trade name of a particular drug has been used to
avoid confusion; although this choice has been based on the
efficacy and quality of the drug, this does not in any way
endorse one brand name over another.
 ACKNOWLEDGMENT
Acknowledging friends and colleagues who have contributed
to writing this book is certainly the most pleasurable part of
the whole process. It might not be possible to acknowledge
all to whom we owe gratitude for support, ideas, help and
assistance but a few of them are:
Dr. Durr-e-Sabih who has been persistent critic, proof
reader and editor of sorts, whose ideas sometimes even
make sense.
Dr. Zahida Sabih who has always kept us on toes. An
excellent though reluctant cook whose dining table has
been the field where seeds of many wild and some practical
projects have been sown.
Dr. Zahra Nazish and Salim Akhtar who helped by
suggesting required changes wherever they were overlooked
by the authors.
Our families who put up with us in normal times, and more
so when we have the writing bug.
 Chapter 1
Principles of Antimicrobial
Therapy

Antimicrobials are the drugs used to treat infections.

Decision to use them should be made carefully as they are
expensive, have side effects and there is risk of development
of resistance.

CHOICE OF INITIAL ANTIMICROBIAL

THERAPY
Empirical antimicrobials therapy can be started against most
likely organism after specimen for culture and sensitivity
(C/S) have been sent. They can be modified when laboratory
results are available or according to the patient’s response.
Specimen for C/S should be collected and sent to the
laboratory according to the instructions of the laboratory.
Patient should not be taking antibiotics for 48 hours.
IV route is used for serious infections and in patients who
cannot take orally while oral route is used for routine
infections.
Patient’s age, weight, renal and hepatic status also should be
considered. Patient with disturbed renal/hepatic function
should be given antimicrobials which are safe and are not
excreted through affected organ; otherwise dose should be
adjusted. Measurement of serum levels is helpful in these
situations.
Pregnancy and lactation should be considered and drugs
which are not harmful to the fetus or baby should be used.
Drug interaction is another issue; check for the table of
drug interactions if patient is on other medications at the
same time.
Antimicrobials combination to provide broader coverage
is justified in seriously ill patients when the organism and
2 Treatment Guide 2020

its susceptibility is not known. It is also used for synergism

(endocarditis), to treat polymicrobial infections (ruptured
abdominal viscus) and to prevent resistance (tuberculosis).
Indiscriminate use of antimicrobial combinations should be
avoided.
In uncomplicated patients antimicrobials should be con-
tinued till patient has been afebrile for at least 72 hours.
Deep infections (arthritis, osteomyelitis) require therapy
for longer duration.

ANTIBACTERIAL AGENTS
BETA-LACTAM ANTIMICROBIALS
These include Penicillin, cephalosporins, cephamycins,
carbapenems and monobactams.

PENICILLIN
These are effective and safe. These are mostly excreted by
the kidney and dose reduction is required in renal failure.
Hypersensitivity is common and skin testing should be
performed to avoid anaphylaxis.

Natural penicillin
Benzyl penicillin (penicillin G) is used to treat infections
with aerobic cocci (e.g. Streptococcus viridans). Resistance
is increasing and should be kept in mind. Dose varies with
the disease. Aqueous penicillin is used IM or IV. Both
sodium and potassium salts are available. Potassium salt
should not be given IV in high doses. It is given in 6 hourly
doses.
Procaine penicillin is given IM and 12 hourly. It causes less
pain.
Benzathine penicillin is slow release form. It is given deep
IM at 2-4 weeks interval mainly as prophylaxis against
rheumatic fever.
Phenoxymethylpenicillin (Penicillin V) (250-500 mg PO 6
hourly) is used orally for treatment of Gram +ve cocci.

Penicillinase resistant semisynthetic penicillin

Cloxacillin and flucloxacillin (250 - 500 mg PO 6 hourly)
are used to treat penicillinase producing staphylococci.
Chapter 1 Principles of Antimicrobial Therapy 3

Pivmecillinam is used for treating urinary tract infections.

It is effective against gram negative bacteria except
Pseudomonas.

Aminopenicillin
These are also semisynthetic penicillin but have enhanced
activity against Gram negative bacilli.
Ampicillin (500 mg PO 6 hourly for routine infections,
1-2 g IV 4-6 hourly for serious infections) is used against
both cocci and Gram -ive bacilli. Staphylococci, E. coli and
H. influenzae resistance is frequent and it should not be
used for hospital infections without C/S. Its absorption is
decreased by food. Rash is a common side effect.
Amoxycillin (250-500 mg PO/IV 8 hourly) is similar to
ampicillin. Its oral bioavailability is superior.

Carboxypenicillin
Ticarcillin is used in combination with beta lactamase
inhibitor, has extended spectrum including Pseudomonas
aeruginosa and other Gram -ive bacilli.
Temocillin is derived from ticarcillin. Temocillin (1-2 g IV
or IM BID) is active against gram negative bacteria except
Pseudomonas and Acinetobacter and stable against beta
lactamases. It is used in urinary and lower respiratory tract
infections. It is less likely to trigger C. difficile infection.

Ureidopenicillin
Piperacillin in combination with beta lactamase inhibitor
is more active than ticarcillin against Pseudomonas
aeruginosa. CNS penetration is poor, hence should not be
used for meningitis.

Beta lactamase inhibitors

These include clavulanic acid, sulbactam and tazobactam.
These have minimal antibacterial activity but are potent
inhibitors of many beta lactamases. These are used in
combination with penicillin. These combinations are useful
in the treatment of methicillin resistant staphylococci and
beta lactamase resistant pseudomonas and enterobacter.
Their CSF penetration is unreliable.
4 Treatment Guide 2020

Amoxicillin with clavulanic acid (250 + 125 mg, 500 + 125

mg PO 8 hourly; 875 + 125 mg BID) is useful for UTI
and respiratory tract infections. Injection (500 + 100 mg,
1000+200 mg IV 8 hourly) is used for severe infections.
It should never be given IM. It is also used as prophylaxis
after animal bite.
Ampicillin with sulbactam (500 + 250 mg, 1-2 vials IV, IM 6
hourly) has similar indications. Combination of ampicillin
and cloxacillin is also available.
Piperacillin with tazobactam (2 g + 250 mg, 3 g + 375
mg, 4 g + 500 mg, 1 vial IV slowly 8 hourly) is useful for
lower respiratory tract infections, UTI, abdominal sepsis,
septicemia and polymicrobic infections.
Ticarcillin with clavulanic acid (3 g + 200 mg, IV infusion
6-8 hourly) have indications similar to piperacillin with
tazobactam.

CEPHALOSPORINS
These are classified by generations. Newer generation tends
to have increased activity against Gram -ive bacilli usually
at the expense of activity against Gram +ive cocci. Use of
new drugs has led to the development of resistant bacteria.
Cross-resistance with other beta lactam antimicrobials
also occurs. Hypersensitivity reaction may occur. Some
penicillin allergic patients are also allergic to cephalosporins.
Most cephalosporins are excreted through kidneys and dose
should be reduced in renal failure.

First Generation Cephalosporins

These are active against Gram +ive cocci (including beta
lactamase producing strains), and some Gram -ive bacilli
causing common infection (i.e. E. coli, Klebsiella). They
don’t cross meninges.
Cefradine (250 - 500 mg PO 6 hourly, 500-1000 mg PO 12
hourly or 0.5 - 2.0 g IV, IM 4-6 hourly in serious infections).
Cefazolin (0.5-1 g IV, IM 8 hourly) produces more sustained
serum levels. Cefalexin (250 - 500 mg PO 6-8 hourly) and
cefadroxil (0.5-1 g/day PO bid) are primarily used for the
treatment of UTI.
Chapter 1 Principles of Antimicrobial Therapy 5

Second Generation Cephalosporins

These retain Gram +ive activity and have wider
coverage against Gram -ive bacilli. Their major role is in
cephalothin-resistant Gram -ive bacilli. They are not active
against P. aeruginosa. They don’t penetrate meninges except
cefuroxime.
Cefuroxime axetil (125-250 mg PO 12 hourly) is oral
preparation with activity against beta lactamases producing
H. influenzae and Gram +ive cocci and is used for lower
respiratory tract infection and UTI.
Cefuroxime (0.75 - 1.5 g IV IM 8 hourly) is more resistant
to beta-lactamases. It enters CSF in sufficient concentration
to be useful in the treatment of meningitis in doses of 3 g
IV 8 hourly.
Cefaclor (250-500 mg PO 8 hourly) is similar to cephalexin
but is more active against H. influenza.

Third Generation Cephalosporins

These are more active against Gram -ive bacilli and less
active against Gram +ive cocci than 1st and 2nd generation
cephalosporins. These are not effective against Pseudomonas
and enterococcal infections except ceftazidime. These are
the drugs of choice for Gram -ive bacterial meningitis. For
other infections, these should be discriminately used and
are not indicated for routine surgical prophylaxis.
Cefotaxime (1-2 g IV 8-12 hourly, max 12 g daily) and
ceftriaxone (oxidil)(1-4 g IV OD) have similar spectrum.
Dosage of cefotaxime should be adjusted in renal failure
while that of ceftriaxone only in combined renal and hepatic
dysfunction.
Ceftazidime (1-2 g IV, IM 8-12 hourly) is the most active
cephalosporins against P. aeruginosa. It is less active than
other 3rd generation cephalosporins against Gram +ive
cocci.
Cefoperazone (1-4 g IV 6-12 hourly) is less active than other
3rd generation cephalosporins against Gram -ive bacilli. It is
not recommended for the treatment of meningitis.
6 Treatment Guide 2020

Cefixime (mixel) (200-400 mg PO in one or two doses),

cefpodoxime proxetil (100-400 mg PO 12 hourly) and cefdinir
(100 mg PO tid) are oral 3rd generation cephalosporins
active against streptococci but have poor activity against
pseudomonas and enterobacter. These are used for upper
respiratory tract infections but have no clear advantage over
cheaper agents.

Fourth Generation Cephalosporins

These have excellent aerobic gram negative rod coverage
including P. aeruginosa. Their gram positive and
anaerobic coverage is similar to those of third generation
cephalosporins.
Cefepime (500 mg - 2 g IV, IM 2-3 times daily) can be used
as empiric therapy in febrile neutropenic patients. It can
also be used in treating antibiotic resistant gram negative
bacteria and polymicrobial infections in any site except
CNS. Metronidazole should be given with cefepime for
intraabdominal infections.
Cefpirome (1-2 g IV bid bolus or infusion) has indications
similar to those of cefepime.

Fifth Generation Cephalosporins

These have extended spectrum against gram positive
bacteria including methicillin resistant Staph. aureus and
multi drug resistant Strept. pneumoniae and retain activity
against Gram –ve bacilli. Ceftobiprole is active against
Pseudomonas. Ceftaroline fosamil (600 mg IV 12 hourly)
is another example.
NOTE: Spectrum of cephalosporins has also been extended
by adding beta lactamase inhibitors.

CEPHAMYCINS
Cefoxitin (1-2 g IM, IV 4-8 hourly) and cefmetazole (2 g
IV 6-12 hourly) are cephamycins that are resistant to beta
lactamases and are active against Gram +ive and Gram -ive
aerobes and anaerobes including B. fragilis. These are not
active against P. aeruginosa.
Chapter 1 Principles of Antimicrobial Therapy 7

MONOBACTAM
Aztreonam (0.5 - 2 g IV 6-8 hourly) is a monobactam,
which is active against Gram -ive bacilli only. It is useful in
patients allergic to penicillin.

CARBAPENEMS
These have the broadest antibacterial activity against most
clinically significant bacteria including anaerobes.
Imipenem (0.5 – 1.0 g IV 6-8 hourly) is a carbapenem
antimicrobial. It is partially inactivated in the kidney
by enzymatic activity. It is, therefore, given in a fixed
combination with cilastatin, a specific enzyme inhibitor,
which blocks its renal metabolism. It is active against most
Gram +ive cocci anaerobes (except methicillin resistant
Staph aureus) & Gram -ive bacilli including Pseudomonas.
Dosage should be adjusted in some less severe infections.
It is useful for treatment of resistant organisms and mixed
infections. Toxicity is similar to penicillin.
Meropenem (0.5-1 g IV 8 hourly) is similar to imipenem
but is stable to the renal enzyme which inactivates
imipenem and can be given without cilastatin. It is preferred
carbapenem for CNS infections.
Doripenem (0.5-1 g IV 8 hourly) is similar to meropenem
Ertapenem (1 g IV daily) is licensed for abdominal and
gynaecological infections, community acquired pneumonia
and skin soft tissue infections in diabetics. It is not active
against Pseudomonas.

TIGECYCLINE
Tigecycline (50 mg IV 12 hourly) is similar to tetracycline,
is effective against gram positive (including methicillin
resistant Staph aureus) and gram negative bacteria
(excluding Pseudomonas). It should be exclusively used in
complicated skin, soft tissue and abdominal infections as
there is increased risk of mortality.

MACROLIDE AND AZALIDE ANTIMICROBIALS

These have good tissue penetration except CSF.
Erythromycin has hepatic excretion while clarithromycin
8 Treatment Guide 2020

is excreted through kidneys. These drugs increase levels of

theophylline, carbamazepine, digoxin and warfarin. When
given in combination with terfenadine (an antihistamine),
there is risk of arrhythmias. These are used for Mycoplasma,
Legionella, Chlamydia and Bordetella infections.
Erythromycin (250-500 mg PO 6 hourly or 500-1000 mg
IV 6 hourly) is also used as an alternative to penicillin in
penicillin allergic patients for treatment of infections caused
by streptococci or staphylococci.
Clarithromycin (250-500 mg PO 12 hourly) has a spectrum
similar to that of erythromycin but has improved activity
against H. influenzae. It is contraindicated in pregnancy.
Doses should be reduced in renal failure.
Azithromycin (500 mg once daily for 3 days) has spectrum
similar to that of clarithromycin but has no drug interactions
seen with it. It is effective in enteric fever. Roxithromycin
and spiramycin are recommended for respiratory tract
infection.
Telithromycin (800 mg daily) has spectrum similar to that
of clarithromycin but is also effective against erythromycin
resistant Strept pneumoniae.

LINCOSAMIDES
Clindamycin (150-450 mg PO 6 hourly or 600-900 mg IV
8 hourly) and lincomycin (500 mg PO 8 hourly or 600-1000
mg IV 8 hourly) have Gram +ive spectrum similar to that
of erythromycin. These are also effective against anaerobes
including B. fragilis. Pseudomembranous colitis occurs in
significant number of patients treated with these agents.

Other anti-staphylococcal agents

Vancomycin is a tricyclic glycopeptide that is bactericidal
against most Gram +ive cocci and bacteriostatic against
enterococci. Its use by IV route (1 g IV 12 hourly) is restricted
for prophylaxis and treatment of Enterococcal endocarditis,
infections due to methicillin resistant staphylococci
and infection due to penicillin resistant Pneumococci if
patient is seriously ill. It is given orally (125-500 mg PO
6 hourly for 10 days) in Clostridium difficile diarrhea
Chapter 1 Principles of Antimicrobial Therapy 9

(pseudomembranous colitis). It is both nephrotoxic and

ototoxic. Its dose is reduced in renal failure.
Teicoplanin (200-400 mg IV OD or BID) is similar to
vancomycin but has longer half-life so that single daily dose
is sufficient. Unlike vancomycin it can be give both IV and
IM.
Fusidic acid (500-750 mg PO IV infusion 8 hourly) has a
very narrow spectrum and its only indication is infection
caused by penicillin-resistant staphylococci, especially
osteomyelitis as it is well concentrated in bone. It is also
used for staphylococcal endocarditis.
Daptomycin (4 mg/kg once daily IV infusion) has spectrum
similar to vancomycin. It has restricted use for complicated
infections caused by resistant gram positive bacteria.
Linezolid (600 mg PO 12 hourly) has spectrum similar to
vancomycin but is effective against vancomycin resistant
enterococci.

TETRACYCLINES
These are bacteriostatic agents with a broad spectrum of
activity against variety of organisms including Rickettsia,
Chlamydia, Mycoplasma, Nocardia and Actinomyces.
There is widespread resistance to Staph, Strept and Gram
-ive bacilli.
These are used for non-gonococcal urethritis, rickettsial
disease, exacerbations of chronic bronchitis, brucellosis,
leptospirosis, early Lyme disease and acne. These are also
used in malaria prevention.
These are better absorbed on an empty stomach. Tetracycline
hydrochloride (250-500 mg PO 6 hourly) and minocycline
(200 mg stat, then 100 mg 12 hourly PO IV) are excreted
by the kidney. Doxycycline (100 mg PO IV 12 hourly) is
excreted by the liver.
These can cause photosensitivity and elevation of urea.
These are contraindicated in pregnancy and children
younger than 10 years because of effects on developing
teeth and bones.
10 Treatment Guide 2020

CHLORAMPHENICOL
Chloramphenicol (500-750 mg PO 6 hourly or 50-100
mg/kg/day IV in divided doses 6 hourly) is a bacteriostatic
agent and is active against a number of Gram -ive and Gram
+ive organisms. It is generally recommended for treatment
of bacterial meningitis (due to H. influenzae) and typhoid
fever. Reversible bone marrow suppression when high dose
is used and idiosyncratic irreversible aplasia are main side
effects. ‘Grey baby’ syndrome in infants is another side
effect.

AMINOGLYCOSIDES
Aminoglycoside antimicrobials are bactericidal for mainly
Gram -ive bacilli. CSF penetration is poor. These are
mainly excreted through kidneys and dose is to be reduced
in renal failure. These are contraindicated in pregnancy.
These are used for treatment of infection due to Gram -ive
bacilli including Pseudomonas where these are combined
with beta lactamase antibiotics. These are also used for
streptococcal endocarditis (especially enterococcal) in
combination with penicillin. Streptomycin is used for
brucellosis and tuberculosis. These are given IV or IM.
Gentamicin and tobramycin (1.5 - 2.0 mg/kg loading dose
and 3-5 mg Kg/day in 3 doses maintenance dose), amikacin
and kanamycin (5.0 - 7.5 mg/kg loading dose and 15 mg/
kg/day in 2-3 doses maintenance dose) are the examples.
Amikacin is an important second line antituberculous.
Nephrotoxicity and ototoxicity are the major side effects.
These can be avoided by monitoring renal function and
drugs levels and by use of short course regimens.
Dibekacin (100 mg per day in 2 doses IM or IV infusion)
is a broad spectrum aminoglycoside effective in UTI and
respiratory tract infection.
Spectinomycin (2 g deep IM as a single dose) is used for
gonorrhea in pregnancy or in patients allergic to beta lactam
antibiotics.
Neomycin (500-1000 mg 3-4 times daily) is used for gut
sterilization and in hepatic encephalopathy. It has been
replaced by new agents.
Chapter 1 Principles of Antimicrobial Therapy 11

SULFONAMIDES AND TRIMETHOPRIM

Sulfonamides are useful for treatment of uncomplicated
UTI and topical therapy of burns. CSF penetration is
good. Hypersensitivity reactions are common. Crystalluria,
erythema multiform and Stevens-Johnson syndrome
may occur. Hemolysis can occur in patients with G6PD
deficiency. These are contraindicated in last months of
pregnancy.
Trimethoprim can be used for prophylaxis and therapy of
UTI. Side effects are marrow suppression and megaloblastic
anemia.
Trimethoprim/sulfamethoxazole (Cotrimoxazole) is a fixed
combination in a ratio of 1:5, this is effective against most
of Gram -ive and Gram +ive pathogens. Dosage needs to
be adjusted in renal failure. Indications are UTI, prostatitis,
bronchitis, Shigellosis and Salmonellosis. It is the treatment
of choice for Pneumocystis carinii infection. Dose is 1
double strength tablet (160 mg/800 mg) 12 hourly for
moderate infection and 8 hourly for severe infection.

QUINOLONES
Quinolones have good oral absorption and are well
tolerated. These should be avoided in pregnancy and
children. Nalidixic acid (1 g PO 6 hourly) is the prototype
of this family. It is effective against Gram -ive bacilli;
widespread resistance has developed to this drug.
Fluoroquinolones are effective against most Gram -ive
cocci and bacilli including P. aeruginosa and Salmonella,
and also many Gram +ive cocci. Ciprofloxacin, ofloxacin,
levofloxacin and moxifloxacin are also effective against
Mycobacterium tuberculosis. The dosage of these drugs
should be reduced in renal failure. They should be avoided
in epilepsy.
Norfloxacin (400 mg PO 12 hourly) enoxacin (200-400 mg
PO 12 hourly) are mainly used in UTI due to Gram-ive
organisms and typhoid fever.
Ofloxacin (200-400 mg PO 12 hourly) is used for urethritis
(gonococcal and chlamydial), UTI, prostatitis, respiratory
infections, soft tissue infections and typhoid fever.
12 Treatment Guide 2020

Ciprofloxacin (250-750 mg PO 12 hourly or 200-400 mg IV

12 hourly) is used for treatment of UTI, typhoid fever and
infective diarrhea. It is the most effective quinolone against
P. aeruginosa. Its activity against gram +ve cocci is poor;
it should not be used as monotherapy against community
acquired pneumonia and skin and soft tissue infections.
Oral absorption is very good and is as effective as IV.
Levofloxacin (500-750 mg PO/IV once daily), Moxifloxacin
(400 mg PO/IV daily) and Gemifloxacin (320 mg PO
OD) have improved coverage against gram +ve cocci and
atypical respiratory pathogens (Chlamydia, Mycoplasma
and Legionella) but less activity against gram -ve bacilli like
P. aeruginosa than ciprofloxacin. These can be used for skin,
respiratory and urinary tract infections (except moxifloxacin
which is minimally excreted in the urine). These are also
called respiratory quinolones.
Lomefloxacin (400 mg PO daily) may be useful for bronchitis
and UTI. It should not be used for Strep pneumonia.
Rufloxacin (400 mg PO first day, 200 mg PO daily) is useful
for UTI and acute respiratory tract infections.
Sparfloxacin (100-300 mg PO daily) is useful for urinary
tract, respiratory tract, biliary tract, eye, skin, bone and
intraabdominal infections.

New Antibiotics
Streptogramins; it is effective against drug resistant gram-
positive organisms. Example; quinupristin.
Colistimethate sodium (1-2 million units IV 8 hourly)
is a polymyxin and is active against gram negative bacteria
including Pseudomonas and should be used for bacteria
resistant to other drugs.
Rifaximin (200-550 mg 8 hourly) is poorly absorbed
from gut. It is mainly used in hepatic encephalopathy
and sometimes in irritable bowel syndrome and
pseudomembranous colitis.
Fidaxomicin (200 mg 12 hourly) is similar to rifaximin.

ANTIBIOTICS USED FOR UTI

Fosfomycin (500 mg PO IV IM 6 hourly) is used for the
Chapter 1 Principles of Antimicrobial Therapy 13

treatment of urinary tract infection. It is also effective for

respiratory tract infection.
Nitrofurantoin (50-100 mg 2-4 times daily) is used for the
treatment of urinary tract infection. It is safe in pregnancy
and childhood. Prolonged use can cause serious side effects.

ANTITUBERCULOUS AGENTS
Combination chemotherapy is essential to prevent the
development of resistance.
Isoniazid (INH) (300 mg PO OD) is bactericidal for M.
tuberculosis. Larger doses are used in severe disease (risk of
toxicity is increased). Asymptomatic rise in transaminases
occurs in 20% cases during first few months of therapy and
resolve without discontinuation of treatment. Hepatitis is
an idiosyncratic reaction and occurs in up to 3% cases. It
resolves on discontinuation of drug. Peripheral neuropathy
is a dose-related complication. It is more likely to occur in
patients with diabetes mellitus, pregnancy, chronic renal
failure or malnutrition. Giving 50 mg of pyridoxine PO
daily can prevent it.
Rifampicin (450 - 600 mg daily) is bactericidal. It is also
effective against Gram -ive cocci and Gram -ive bacilli in
addition to M. tuberculosis. It should be taken half an hour
before breakfast. Harmless orange-red discoloration of
urine and other secretions occurs. Vomiting and hepatitis
may occur.
Rifabutin (150-450 mg daily) is a new rifamycin
recommended for non-tuberculous mycobacterial disease
and pulmonary tuberculosis.
Rifapentin is another rifamycin used for tuberculous but
risk of relapse is high.
Pyrazinamide (PZA) 30-35 mg/kg/day) is bactericidal
for intracellular Mycobacteria. Major side effect is
hepatotoxicity.
Ethambutol is used in a dose of 25 mg/kg/day and then
reduced to 15 mg/kg/day if required for more than 2
months. It is bacteriostatic at usual concentration and
bactericidal in higher concentration. It is excreted through
14 Treatment Guide 2020

kidneys; dose should be reduced and drug levels monitored

in renal failure. Optic neuritis is the major side effect. It is
dose related. Decreased visual acuity and color perception
are early manifestations. Routine eye examination is
suggested in patients taking doses more than 15 mg/kg and
for more than 2 months. Drug should be discontinued if
patient develops optic neuritis.
Streptomycin (15 mg/kg/day IM) is bactericidal. It is ototoxic.

Second line agents

Second line therapy should be used by an experienced
physician only.
Ethionamide (0.5 - 1.0 mg/day PO in 2 doses) has wide
distribution including CSF. Gastric irritation, hepatotoxicity
and neuropathy are the side effects.
Cycloserine (250 mg bid for 2 weeks then increased to 500 mg
bid) has distribution similar to ethionamide. It is excreted
through kidney and serum levels should be measured in
renal failure. Side effects are behavior disturbances and fits.
Capreomycin (1 g daily deep IM for 2-4 months, then 1 g
2-3 times per week) is used in patients with drug resistant
tuberculosis.
Other aminoglycosides like amikacin (250 mg BID) and
kanamycin can also be used.
Quinolones (ciprofloxacin 750 mg BID, ofloxacin 400
mg BID, levofloxacin 750 mg OD, moxifloxacin 400
mg OD) and new macrolides (clarithromycin 500 mg
BID, azithromycin 500 mg daily) are being used for drug
resistant cases. Linezolid is also used and has good CSF
penetration.
Rifabutin (150 mg per day) is a semisynthetic rifamycin. It
is more effective than rifampicin. It is being used in drug
resistant tuberculosis.
Rifapentine (600 mg once or twice weekly) is new
antituberculous drug. Its main advantage over rifampicin is
that it is longer acting and has fewer side effects.

ANTILEPROTIC DRUGS
Rifampicin (discussed under anti-tuberculous drugs)
Chapter 1 Principles of Antimicrobial Therapy 15

dapsone and clozamine are drugs used for leprosy.

Lepromatous (3 drugs) for at least 2 years
Rifampicin 600 mg once monthly
Dapsone100 mg daily
Clozamine 300 mg once monthly
Tuberculoid (2 drugs) for 6 months
Rifampicin 600 mg once monthly
Dapsone 100 mg daily

ANTIVIRAL AGENTS
Most important viral diseases requiring antiviral therapy
are HIV infection, herpesvirus including cytomegalovirus
infections, viral hepatitis B and C, influenza and respiratory
syncytial virus infection.
Abacavir, didanosine, emtricitabine, lamivudine, stavudine,
tenofovir disoproxil and zidovudine are nucleoside reverse
transcriptase inhibitors (nucleoside analogue) used for
the treatment of HIV infection in combination with other
antiretroviral drugs. There is risk of lactic acidosis and they
should be used with caution in patients who are obese or
have liver disease.
Aciclovir is most active against Herpes simplex virus and
Varicella zoster virus. It is used for recurrent genital herpes,
severe herpes stomatitis and herpes simplex encephalitis.
It is also indicated for Varicella pneumonitis, disseminated
zoster and Herpes zoster ophthalmicus. It is excreted by the
kidneys and dose should be reduced in renal impairment.
Herpes simplex infection: 200 mg PO 5 times/day for 5
days; for severe infection 5 mg/kg IV 8 hourly for 7 days;
herpes simplex encephalitis 10 mg/kg IV 8 hourly for 10
days. Herpes zoster infection: 800 mg PO 5 times/day for 7
days for local infections and 10 mg/kg IV 8 hourly for 7 days
for more disseminated infections. Injection should be given
over an hour to reduce risk of crystalline nephropathy.
Adefovir dipivoxil is a nucleoside analogue used for
treatment of chronic hepatitis B. It is less effective than
lamivudine but risk of resistance strain development is low
and is effective against lamivudine resistance strains. Dose
16 Treatment Guide 2020

is 10 mg per day orally for 1-3 years. Overall response rate

is about 25%. Its main indication is add-on therapy for
lamivudine resistance strains.
Amantadine (Dose is 100 mg PO 12 hourly. It should be
reduced in renal failure) and rimantadine are no more
recommended for prophylaxis during epidemic of influenza
as resistance is very common. These are still indicated for
treatment of oseltamivir resistant influenza A infection in
patients who can’t take zanamivir (e.g. ventilated patients).
Atazanavir, darunavir, fosamprenavir, indinavir, lopinavir
with rotinavir, nelfinavir, ritonavir, saquinavir and
tipranavir are protease inhibitors used for the treatment
of HIV infection in combination with other antiretroviral
drugs. They are associated with hyperglycemia and diabetic
patients should be closely monitored. Caution is required
in patients with hemophilia and acute porphyria.
Cidofovir, ganciclovir, foscarnet and valganciclovir (a
pro-drug of ganciclovir) are used for the treatment of
cytomegalovirus (CMV) infections. Cidofovir is used for
CMV retinitis in AIDS. It is nephrotoxic. Ganciclovir causes
myelosuppression. Valganciclovir is used for treatment of
CMV retinitis in AIDS and prevention of CMV infection
following solid organ transplantation if donor is CMV
positive.
Daclatasvir (deklinza) is an NS5A inhibitor. Tablet 30 mg
or 60 mg is used in combination with sofosbuvir for the
treatment of all types of hepatitis C.
Dolutegravir, enfuvirtide, maraviroc and raltegravir are also
antiretroviral drugs used in combination with other drugs
for treatment of HIV infection.
Efavirenz, etavirine, nevirapine and rilpivirine are non-
nucleoside reverse transcriptase inhibitors (nucleoside
analogue) used for the treatment of HIV infection in
combination with other antiretroviral drugs.
Elbasvir (50 mg once daily), NS5A inhibitor is used in
fixed combination with grazoprevir (100 mg once daily)
NS3/4A inhibitor (zepatier) for treatment of hepatitis C
genotype 1, 4 and 6. This combination is contraindicated in
decompensated cirrhosis.
Chapter 1 Principles of Antimicrobial Therapy 17

Entecavir (0.5-1.0 mg daily) is recommended for treatment

of chronic hepatitis B; it is more effective than lamivudine
with very low risk of resistance. It is one of the drugs of
choice in treatment naïve patients.
Famciclovir is effective orally. Doses are as follow: 500
mg PO 8 hourly for herpes zoster and 125 – 250 mg 12-8
hourly for genital herpes.
Inosine pranobex is used for mucocutaneous herpes simplex,
genital warts and subacute sclerosing panencephalitis.
Peginterferon is a preparation of interferon alpha with
longer half-life, so that once weekly dose is sufficient. It is
recommended for hepatitis B and D. Duration of treatment
is 48 weeks (hepatitis B) and 48-96 weeks (hepatitis D).
Interferon is also being used in certain lymphomas and
solid tumors. Side effects include nausea, influenza like
syndrome, depression and myelosuppression.
Lamivudine is nucleoside analogue initially used in AIDS,
is also effective in chronic liver disease due to hepatitis B
virus even with decompensation in a dose of 100 mg PO
daily.
Ledipasvir is an NS5A inhibitor. A combination tablet
containing 90 mg of ledipasvir and 400 mg of sofosbuvir
(harvoni) is used once daily in the morning for the
treatment of hepatitis C type 1, 4, 5 and 6.
Oseltamivir (75 mg BD for 5 days for treatment, 75 mg
OD for 10 days for prophylaxis) and zanamivir are most
effective in influenza if started within 48 hours of onset
of symptoms. They are also used for post-exposure
prophylaxis. Peramivir is effective in oseltamivir/zanamivir
resistant seriously ill patients.
Palivizumab is a monoclonal antibody used for prevention
of respiratory syncytial virus infection in children.
Paritaprevir is an NS3/4A protease inhibitor. Ombitasvir
is an NS5A inhibitor. Ritonavir is a CYP3A inhibitor;
it is given to increase half-life of paritaprevir. Two fixed
combination tablets containing paritaprevir 75 mg
ombitasvir 12.5 mg and ritonavir 50 mg (Viekira Pak) are
given in the morning with food for treatment of hepatitis
18 Treatment Guide 2020

C type 1 and 4. For type 1 dasabuvir (a non-nucleoside

inhibitor) 250 mg tablet twice daily is also given in addition
to above mentioned 3 drugs.
Ribavirin is used for treatment of chronic liver disease due
to hepatitis C virus before decompensation in combination
with directly acting antivirals in a dose of 800-1200 mg in
divided doses according to patient’s weight. Hemolytic
anemia and hyperuricemia are main side effects.
Simeprevir is an NS3/4A protease inhibitor. Cap 150 mg
once daily in the morning is combined with pegylated
interferon plus ribavirin or sofosbuvir for the treatment of
hepatitis C genotype 1 and 4 only.
Sofosbuvir (sovaldi) is a nucleotide analog NS5B polymerase
inhibitor. Its 400 mg tablet is taken once daily with or
without food. It is used in various combinations with other
antivirals for treatment of hepatitis C. Regimen, duration
of treatment and response rate are discussed on page 365.
Telbivudine is a nucleoside analog with strong antiviral
activity against hepatitis B and mild rate of induction of
resistant mutant. It is not recommended in new patients.
Tenofovir disoproxil (300 mg daily), nucleoside analogue is
one of the drugs of choice for treatment of chronic hepatitis
B. It is similar to entecavir in efficacy and risk of resistance
development. It is potentially nephrotoxic; renal function
and serum phosphates should be checked before treatment
and then monthly for one year and then every 3 month. If
renal function deteriorates or serum phosphate decreases,
drug should be discontinued.
Valaciclovir is pro drug for aciclovir and has similar
indications. It is excreted by the kidneys and dose should
be reduced in renal impairment. Herpes simplex infection:
first episode, 500 mg bid for 5-10 days; recurrent infection,
500 mg bid for 5 days; suppression of recurrence, 500 mg
daily. Herpes zoster infection: 1 g 3 times daily for 7 days. It
is also indicated for prevention of cytomegalovirus infection
following renal transplantation.
Velpatasvir is HCV NSA5 inhibitor. Its dose is 100 mg
in fixed combination with sofosbuvir (400 mg) (epclusa)
once daily for treatment nearly all types of hepatitis C virus.