Antibiotics by diagnosis: Difference between revisions
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===[[Diverticulitis]]=== | ===[[Diverticulitis]]=== | ||
====Uncomplicated==== | |||
{{Uncomplicated Diverticulitis Antibiotics}} | |||
====Complicated==== | |||
{{Complicated Diverticulitis Antibiotics}} | |||
===Infectious [[Diarrhea]]=== | ===Infectious [[Diarrhea]]=== | ||
Revision as of 03:04, 30 June 2014
Bone and Joint
Open Fracture
Cefazolin (Ancef) 2g IV[1][2]
AND
Gentamicin 300 mg (1-1.7mg/kg) IV (especially if wound is dirty)
Cardiovascular
CNS
Meningitis
Neonates (up to 1 month of age)[3]
MRSA is uncommon in the neonate
- Ampicillin 75mg/kg IV q6hrs PLUS
- Cefotaxime 50mg/kg IV q6hrs OR 2.5mg/kg IV q8hrs
- Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups[4]
- If suspecting S. pneumoniae or MRSA, add standard neonatal dosing
- Consider acyclovir for HSV
> 1 month old[5]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily
- Vancomycin is for resistant Pneumococcus
Alternatives (e.g. penicillin/cephalosporin allergy):
- Meropenem 40mg/kg IV q8hrs (max 2g/dose)
- Chloramphenicol 75-100mg/kg/day IV divided q6h (max 4g/day)
Adult < 50 yr[6]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily
- Vancomycin is for resistant Pneumococcus
Adult > 50 yr and Immunocompromised[7]
- Ceftriaxone 2gm (50mg/kg) IV BID daily PLUS
- Vancomycin 15-20 mg/kg IV BID daily PLUS
- Ampicillin 2gm IV q4h (hourly if listeria suspected)[8]
Post Procedural (or penetrating trauma)[9]
- Vancomycin 15-20mg/kg IV BID daily PLUS
- Cefepime 2g (50mg/kg) IV q8 hours daily OR Ceftazidime 2g (50mg/kg) IV q8 hours daily OR Meropenem 2gm (40mg/kg) IV q8 hours daily
Cryptococcosis Meningitis
Options
- Amphotericin B 1mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
- Amphotericin B 5mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
Meningitis with severe PCN allergy
- Chloramphenicol 1g IV q6h + 15mg/kg q8-12hr
Meningitis with VP shunt
- Coverage for skin contaminants (S. epidermis, S. aureus)
- Vancomycin plus ceftriaxone plus shunt removal
Neisseria meningitidis Prophylaxis
- Ceftriaxone 250mg IM once
- Ceftriaxone 125mg IM once (if <=15yr)
- Ciprofloxacin 500mg PO once
- Rifampin 600 mg PO BID x 2 days
- Rifampin <1mo: 5mg/kg PO BID x 2 days; >=1mo: 10mg/kg PO BID x 2 days
- Ampicillin/Sulbactam 400mg ampicillin/kg/day IM/IV divided q6 hours; First Dose: 100mg ampicillin/kg IM/IV x 1 (150mg Unasyn/kg IM/IV x 1); Max: 2000mg ampicillin (3000mg Unasyn) per DOSE
- Meropenem 2g IV every 8 hours.
- Nafcillin 100-200mg/kg/day IV divided q4-6h; Max: 12 g/day
Tetanus
- Metronidazole 500 mg IV every 6 hours
(<1200g)
- 7.5 mg/kg PO/IV q48h
- First Dose: 7.5 mg/kg PO/IV x 1
(>1200g AND <1 Month Old)
- <7 days old
- 7.5-15 mg/kg/day PO/IV q12-24h
- First Dose: 7.5-15 mg/kg PO/IV x 1
- >7 days old
- 15-30 mg/kg/day PO/IV q12h
- First Dose: 7.5-15 mg/kg PO/IV x 1
(>1 Month Old)
- 30 mg/kg/day PO/IV q6h
- First Dose: 7.5 mg/kg PO/IV x 1
- Max: 4 g/day
ENT
Otitis Media
Initial Treatment
High Dose Amoxicillin
- <2 months
- Amoxicillin 30mg/kg/day PO divided q12h x 10 days
- First Dose: 15mg/kg PO x 1
- 2 months - 5 years
- Amoxicillin 80-90mg/kg/day PO divided q12h x 10 days
- First Dose: 40-45mg/kg PO x 1
- Max: 1000mg/dose
- 6-12 years
- Amoxicillin 80-90mg/kg/day PO divided q12h x 5-10 days
- First Dose: 40-45mg/kg/day PO x 1
- Max: 1000mg/dose
Treatment during prior Month
- If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
- 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
- Clavulanate increases vomiting/diarrhea
- Cefdinir 14mg/kg/day BID x7-10 days
- Cefpodoxime 10mg/kg PO daily x7-10 days
- Cefuroxime 15mg/kg PO BID x7-10 days
- Cefprozil 15mg/kg PO BID x7-10 days
Otitis/Conjunctivitis
- Suggestive of non-typeable H.flu
- Amoxicillin/Clavulanate
- 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
- Clavulanate increases vomiting/diarrhea
Treatment Failure
defined as treatment during the prior 7-10 days
- Amoxicillin/Clavulanate 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
- Ceftriaxone 50mg/kg IM once as single injection x 3 days
- Use if cannot tolerate PO
Penicillin Allergy
- Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
- Clarithromycin 7.5mg/kg PO BID x 10 days
- Clindamycin 10mg/kg PO three times daily
- Clindamycin does not cover H. influenza and M. catarrhalis and treatment should favor Azithromycin use
- Cephalexin 75-100mg/kg/day PO divided q12h x 10 days; Max: 4,000mg/24h
Otitis Externa
- Ofloxacin 5 drops in affected ear BID x 7 days (Floxin otic)[10]
- Safe with perforations
- Ciprofloxacin-hydrocortisone 3 drops in affected ear BID x 7 days
- Contains hydrocortisone to promote faster healing
- Not recommended for perforation since non-sterile preparation
- Ciprofloxacin-dexamethasone 4 drops in affected ear BID x 7 days
- Similar to Cipro HC but safe for perforations
- Often more expensive
- Cortisporin otic 4 drops in ear TID-QID x 7days (neomycin/polymixin B/hydrocortisone)
- Use suspension (NOT solution) if possibility of perforation
- Animal studies suggest possible toxicity from the neomycin although rigorous data is lacking[11]
Pediatric: Same topical regimens apply to children
- Ofloxacin 5 drops (>12yr) or 3 drops (<12yr) in affected ear BID x 7 days
- Ciprofloxacin 3-4 drops in affected ear BID x 7 days (with dexamethasone or hydrocortisone)
Streptococcal Pharyngitis
Treatment can be delayed for up to 9 days and still prevent major sequelae
Penicillin Options:
- Penicillin V 250mg PO BID x 10d (child) or 500mg BID x 10d (adolescent or adult)[12][13]
- Bicillin L-A <27 kg: 0.6 million units; ≥27 kg: 1.2 million units IM x 1[12][14]
- Amoxicillin 50 mg/kg once daily (maximum = 1000 mg) for 10 days[15]
Penicillin allergic (mild):
- Cephalexin 20 mg per kg PO BID (maximum 500 mg per dose) x 10 days[16]
- Cefadroxil 30 mg per kg PO QD (maximum 1 g daily) x 10 days[17]
Penicillin allergic (anaphylaxis):[12]
- Clindamycin 7 mg/kg/dose TID (maximum = 300 mg/dose) x 10 days[18]
- Azithromycin 12 mg/kg PO once (maximum = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days[19]
- Clarithromycin 7.5 mg/kg/dose PO BID (maximum = 250 mg/dose) x 10 days[20]
Pediatric Dosing:
- Amoxicillin 50mg/kg PO once daily x 10 days (max 1000mg)
- Penicillin V <27kg: 250mg PO BID-TID x 10 days; >27kg: 500mg PO BID-TID x 10 days
- Penicillin G Benzathine <27kg: 600,000 units IM x 1; >27kg: 1.2 million units IM x 1
- PCN allergy (mild): Cephalexin 20mg/kg PO BID x 10 days (max 500mg/dose)
- PCN allergy (mild): Cefadroxil 30mg/kg PO daily x 10 days (max 1g)
- PCN allergy (severe): Azithromycin 12mg/kg PO day 1 (max 500mg), then 6mg/kg daily x 4 days (max 250mg)
- PCN allergy (severe): Clindamycin 7mg/kg/dose PO TID x 10 days (max 300mg/dose)
- PCN allergy (severe): Clarithromycin 7.5mg/kg PO BID x 10 days (max 250mg/dose)
- Clindamycin 7mg/kg/dose PO q8h x 10 days[21]; Max: 300mg/dose
- Azithromycin Children ≥2 years and Adolescents: Oral: 12mg/kg/dose once daily for 5 days (maximum: 500mg daily)
- Amoxicillin 50mg/kg PO q24h x 10 days[22]; Max: 1000mg/day
- Clarithromycin >6mo: 15mg/kg/day PO divided q12h x 7-10d
- Cephalexin 40mg/kg/day PO divided q12h x 10 days; Max: 500mg/dose
- Cefpodoxime 100mg q 12 h for 5-10 days
- Cefuroxime 250mg PO bid x10 days
- Cefuroxime 250mg PO bid x10 days
Eye
Corneal Abrasion
Does Not Wear Contact Lens
- Erythromycin ointment qid x 3-5d OR
- Ciprofloxacin 0.3% ophthalmic solution 2 drops q6 hours OR
- Ofloxacin 0.3% solution 2 drops q6 hours OR
- Sulfacetamide 10% ophthalmic ointment q6 hours
Wears Contact Lens
Antibiotics should cover pseudomonas and favor 3rd or 4th generation fluoroquinolones
- Levofloxacin 0.5% solution 2 drops ever 2 hours for 2 days THEN q6hrs for 5 days OR
- Moxifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
- Tobramycin 0.3% solution 2 drops q6hrs for 5 days OR
- Gatifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
- Gentamicin 0.3% solution 2 drops six times for 5 days
Pediatric
Same topical regimens as adults
- Erythromycin 0.5% ointment applied QID x 3-5 days (preferred in young children)
- Moxifloxacin 0.5% ophthalmic solution 1-2 drops QID x 5 days
Orbital Cellulitis
- Vancomycin 15-20mg/kg IV BID + (one of the following)
- Ampicillin/Sulbactam 3 g IV q6hr OR
- Ticarcillin/Clavulanate 3.1 g IV q4h OR
- Piperacillin/Tazobactam 4.5 g IV q6h OR
- Ceftriaxone 2 g IV q12hr OR
- Cefotaxime 2 g IV q4h
Pediatric:
- Vancomycin 15mg/kg IV q6hrs + (one of the following)
- Ampicillin/Sulbactam 50mg/kg IV q6hrs (max 3g/dose) OR
- Piperacillin/Tazobactam 100mg/kg IV q8hrs (max 4.5g) OR
- Ceftriaxone 50mg/kg IV q12hrs (max 2g/dose) OR
- Cefotaxime 50mg/kg IV q6hrs (max 2g/dose)
GI
Appendicitis
Zosyn 4.5g (100 mg/kg) IV Q6
OR
Flagyl 500mg (7.5mg/kg) IV Q6
PLUS
Ciprofloxacin 400mg IV Q12
Cholecystitis
Augmentin 3g IV Q6
OR
Imipenem/Cilastin 500mg IV Q6
Diverticulitis
Uncomplicated
First, consider whether antibiotics are needed:
- In immunocompetent patients with mild uncomplicated diverticulitis (no systemic signs, able to tolerate PO, reliable follow-up), a trial of supportive care alone (bowel rest, hydration, pain control) without antibiotics is reasonable[23][24]
- Antibiotics ARE indicated if: immunocompromised, significant comorbidities/frailty, CRP >140 mg/L, WBC >15 × 10⁹/L, refractory symptoms, vomiting, or CT showing fluid collection or longer segment of inflammation[23]
If antibiotics are prescribed (4-7 day course preferred):[23]
Preferred:
- Amoxicillin/Clavulanate 875/125mg PO Q8hrs x 5 days (or Augmentin XR 2 tablets BID [each tablet 1gm amoxicillin 62.5mg clavulanate])[25][26]
- Equally effective as fluoroquinolone + metronidazole with lower C. difficile risk (especially in patients ≥65 years)[26]
- Avoids FDA black box fluoroquinolone risks (tendinopathy, neuropathy, aortic dissection, CNS effects)[27]
Alternatives (penicillin allergy or intolerance):
- Trimethoprim/Sulfamethoxazole one double-strength tablet BID PLUS Metronidazole 500mg PO Q8h x 5 days
- Metronidazole 500mg PO Q8hrs PLUS Ciprofloxacin 500mg PO BID x 5 days (reserve for patients without non-fluoroquinolone options)[27]
- Moxifloxacin 400mg PO QDaily (same fluoroquinolone cautions apply)[28]
Complicated
Options:
- Ticarcillin/Clavulanate 3.1 g IV Q6h or
- Piperacillin/Tazobactam 3.375 g IV q6 hours x 7-10 days
- Ciprofloxacin 400 mg IV q12h and Metronidazole 1 g IV Q12h
- Ampicillin 2 g IV Q6h and Metronidazole 500 mg IV q6h Plus (Gentamicin 7 mg/kg Q24h or Ciprofloxacin 400 mg IV Q12h)
- Imipenem/Cilastatin 500 mg IV Q6h
Infectious Diarrhea
Empiric: Cipro 500mg PO Q12 x3d
Giardia: Flagyl 500mg PO Q8 x5d
C. diff: Flagyl 500mg PO Q8 x14d
GU
Epididymitis
Age <35 (gonorrhea suspected)
Doxycycline 100mg PO Q12 x14d
PLUS
Cefixime 400mg PO once
Age >35 (gonorrhea not suspected)
Ciprofloxacin 500mg PO Q12 x14d
Cervicitis/Urethritis
Cefixime 400mg PO once
OR
Azithromycin 1g PO once
ADD
Flagyl 2g PO once if concern for trichomoniasis
PID
Ceftriaxone 250mg 1M once
PLUS
Doxycycline 100 mg PO Q12 x14d
UTI
===Outpatient=== Women, Uncomplicated
- Nitrofurantoin ER 100mg BID x 5d, OR
- TMP/SMX DS (160/800mg) 1 tab BID x 3d (Females) x7days (Males), OR
- Cephalexin 250mg QID x 5d, OR
- Ciprofloxacin 250mg BID x3d
- Avoid using fluoroquinolone for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.[29]
- Fosfomycin 3 g PO once
- Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [30]
Women, Complicated
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
Women, Concern for Urethritis
- Ceftriaxone 250mg IM x1 AND azithromycin 1gm PO x1 AND nitrofurantoin ER 100mg BID x5d, OR
- Levofloxacin 500mg QD x 14d (covers urinary pathogens, GC, and chlamydia)
- GC resistance to fluoroquinolones is increasing
Men
- Ciprofloxacin 500mg BID x10-14d, OR
- Cefpodoxime 200 mg BID x10-14d
===Inpatient Options=== *Ciprofloxacin 400mg IV q12hr, OR
- Ceftriaxone 1gm IV QD, OR
- Cefotaxime 1-2gm IV q8hr, OR
- Gentamicin 3mg/kg/day divided q8hr +/- ampicillin 1–2 gm q4hr, OR
- Piperacillin/Tazobactam 3.375 gm IV q6hr, OR
- Cefepime 2gm IV q8hr, OR
- Imipenem/Cilastatin 500mg IV q8hr
- Cefotetan 500 mg IM/IV q12h
Pediatric
- TMP/SMX 6-12mg/kg/day (TMP) PO divided BID x 7-10 days
- Cephalexin 25-50mg/kg/day PO divided q6-8h x 7-10 days (max 500mg/dose)
- Nitrofurantoin 5-7mg/kg/day PO divided q6h x 7-10 days; avoid in infants <1 month
- Cefpodoxime 10mg/kg/day PO divided BID (max 200mg/dose)
- Cefixime 8mg/kg/day PO daily (max 400mg)
Pediatric Inpatient
- Ceftriaxone 50-75mg/kg IV daily (max 2g)
- Cefotaxime 50mg/kg IV q8hrs (max 2g/dose)
- Gentamicin 2.5mg/kg IV q8hrs +/- Ampicillin 50mg/kg IV q6hrs
Pulmonary
Pneumonia
Outpatient
Azithromycin 500mg PO, 250mg PO x3d
OR
Doxycycline 100mg PO Q12 x7d
Inpatient, Community Acquired
Ceftriaxone 1g IV
PLUS
Azithromycin 500mg IV
Inpatient, Health Care Acquired
Vancomycin 1g IV (MRSA)
PLUS
Cefepime 2g IV (Pseudomonas)
PLUS
Tobramycin 4mg/kg IV (Pseudomonas)
Skin and Soft Tissue
Cellulitis/Superficial Abscess
Bactrim DS 2tab PO Q12 x5-10d
PLUS
Cephalexin 500mg PO Q6 x5-10
OR
Clindamycin 450mg PO Q8 x5-10d
Diabetic with systemic toxicity
Vancomycin 1g IV
PLUS
Unasyn 3g IV
OR
Zosyn 3.375g IV
Bioterrorism
Environmental Exposure
Immunocompromised
Neutropenic Fever
Zosyn 4.5g IV
OR
Meropenem 1g IV
PLUS/MINUS
Gentamicin 2mg/kg IV
ADD
Vancomycin 1g IV for catheter related infection, colonization with MRSA, gram-positive culture unknown susceptibility, suspected sepsis
Post Exposure Prophylaxis
Pediatric
See Antibiotics By Diagnosis (Peds)
Sepsis
Arthropod and Parasitic Infections
See Also
Source
- University of Cincinnati Department of Emergency Medicine "Handbook of EM Fundamentals"
- ↑ Gosselin RA, Roberts I, Gillespie WJ. Antibioticsfor preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;1:CD003764
- ↑ The NNT Review http://www.thennt.com/nnt/antibiotics-for-open-fractures/
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ https://www.aappublications.org/content/early/2015/02/25/aapnews.20150225-1
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ [Guideline] Chaudhuri A, Martinez-Martin P, Kennedy PG, et al. EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Eur J Neurol. 2008 Jul. 15(7):649-59.
- ↑ van de Beek D. et al. Advances in treatment of bacterial meningitis. Lancet. Nov 10 2012;380(9854):1693-702
- ↑ Clinical Practice Guideline: Acute Otitis Externa Executive Summary. Otolaryngology -- Head and Neck Surgery 2014 150: 161 DOI: 10.1177/0194599813517659 PDF
- ↑ Wright, C. et al. Ototoxicity of neomycin and polymyxin B following middle ear application in the chinchilla and baboon. Am J Otol. 1987 Nov;8(6):495-9.
- ↑ 12.0 12.1 12.2 Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
- ↑ 23.0 23.1 23.2 Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021;160(3):906-911.e1. doi:10.1053/j.gastro.2020.09.059
- ↑ Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.
- ↑ Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.
- ↑ 26.0 26.1 Gaber CE, Kinlaw AC, Edwards JK, et al. Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies. Ann Intern Med. 2021;174(6):737-746. doi:10.7326/M20-6315
- ↑ 27.0 27.1 FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. July 26, 2016.
- ↑ Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.
- ↑ Choosing Wisely. American Urogynecologic Society. http://www.choosingwisely.org/societies/american-urogynecologic-society
- ↑ Huttner, A., Kowalczyk, A., Turjeman, A., Babich, T., Brossier, C., Eliakim-Raz, N., … Harbarth, S. (2018). Effect of 5-Day Nitrofurantoin vs Single-Dose Fosfomycin on Clinical Resolution of Uncomplicated Lower Urinary Tract Infection in Women: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(17), 1781–1789.