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 2

Rub palms together. Rub the back of both hands.

3 4

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

5 6

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

Rub both wrists in a rotating manner.

Rinse and dry thoroughly.
Contents
Contents
DESCRIPTION
Editorial Note
Page
5
Message from Director 6
Message from Medical Superintendent 7
Message from HOD - Microbiology 8
Message from HOD - Medicine 9
Antimicrobial Prescribing : Good Practices 10
Monitoring Treatment 11
The Importance of Infection Control (IC) to
Control Antimicrobial Resistance 11
Hypersensitivity 12
Patient Risk Stratification 13
How to use Pocket Guide? 14
Antibiogram : Blood Stream Infection - ICU 15
Antibiogram : Blood Stream Infection - IPD 15
Antibiogram : Blood Stream Infection - OPD 16
Antibiogram : Urinary Tract infections - ICU 16
Antibiogram : Urinary Tract infections - IPD 17
Antibiogram : Urinary Tract infections - OPD 17
Antibiogram : Respiratory / Skin Soft Tissue infections - ICU 18
Antibiogram : Respiratory / Skin Soft Tissue infections - IPD 18
Antibiogram : Respiratory / Skin Soft Tissue infections - OPD 19
Antibiotic Protocol : Blood Stream Infection - ICU 20
Antibiotic Protocol : Blood Stream Infection - IPD 22
Antibiotic Protocol : Blood Stream Infection - OPD 24
 Contents
Contents
DESCRIPTION
Antibiotic Protocol : Urinary Tract infections - ICU
Page
26
Antibiotic Protocol : Urinary Tract infections - IPD 28
Antibiotic Protocol : Urinary Tract infections - OPD 30
Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - ICU 32
Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - IPD 34
Antibiotic Protocol : Respiratory / Skin Soft Tissue infections - OPD 36
Notes 38
Standard dosages of commonly used drugs 39
Maximum daily dose of antibiotics 41
Safe injection practices 42
Antibiotic Summary Chart 44
Irrational/Less evidence based antibiotics 46
Categorization of Antibiotics 47
Restricted use antibiotics : What and Why? 48
Limited access antibiotics : What and Why? 49
Under surveillance antibiotics : What and Why? 49
Notes 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

5
 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

6
 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

7
 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

8
 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

9
 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 1 Patient Type 2
No contact with health Contact with health care
care system system (e.g. recent hospital
admission, nursing home,
CAPD) without/minimal
invasive procedures
No prior antibiotic Antibiotic therapy in last 90
treatment in last 90 days days
Patient young with no Patient old ( > 65years) with
co-morbid conditions few co-morbidities
• Bacterial infections • Risk of Bacterial
with minimal risk of infections with
Multidrug resistant pathogens like ESBL
pathogens like ESBL producing
producing Enterobacteriacae and
Enterobacteriacae, MRSA.
MRSA or Non • Minimal risk of
fermentors like Nonfermentors like
Pseudomonas and Pseudomonas and
Acinetobacter Acinetobacter
• Invasive Fungal • Minimal risk of Invasive
Infections are Fungal infections .
unlikely
• Limited use of broad • ESBL infections to be
spectrum treated with Non-
antibacterials Pseudomonal antibiotics
• No role of like Group 1
Antifungal agents Carbapenem
• BL+BLI’s can also be
preferred for mild ESBL
infections.
• Vancomycin/Tiecoplanin
to be used for MRSA
• No role of Antifungal
agents
Patient Type 3 Patient Type 4
Hospitalization >5 days Type 3 patient with fever despite
and or infections following antibiotic therapy (>5days) with no
invasive procedures obvious source / after appropriate
source control
Recent & multiple ± severe sepsis/septic shock PLUS
antibiotic therapies
Patient with multiple Has 1 or more than 1 of the following
Co-morbidities eg: cystic factors. (but not limited to) for
fibrosis, structural lung invasive fungal infections: TPN,
disease, advanced AIDS, Hemodialysis, Immunodeficiency of
neutropenia, other severe variable origin, Major Abdominal
immunodeficiency s u rg e r y, M u l t i - fo c a l c a n d i d a
colonization, Diabetes
• High risk of Bacterial • Risk of Bacterial infections
infections with any of with Pan-drug resistant
Multi drug resistant Pseudomonas and
pathogens like ESBL Acinetobacter
producing • High Risk of Invasive fungal
Enterobacteriacae, infections
MRSA and non-
fermentors like
Pseudomonas and
Acinetobacter
• Risk of invasive fungal
infections in special
cases like patients
undergoing Allogenic
BMT, Liver transplant or
chemotherapy induced
neutropenic patients.
• Bacterial infections to • Bacterial infections to be
be treated with broad treated with novel
spectrum antibiotics combination of antibacterials
like Group 2. suggested for Pan resistant
Carbapenem or Anti- bacteria using alternate drug
Pseudomonal BL-BLI’s delivery systems/PK-PD
in combination with parameters.
Fluoroquinolones/ami • Empiric treatment of fungal
noglycosides/Glycope infections for both stable and
ptides.
unstable patients as per IDSA
• Prophylaxis for fungal guidelines.
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
Most Common Pathogens
Staph aureus (n=20)
Pseudomonas (n=8)
E. coli (n=6)
Salmonella paratyphi A (n=1)
Acinetobacter (n=1)
Blood Stream Infections (BSI) - IPD Antibiogram
Most Common Pathogens
Staph aureus (n=115)
E. coli (n=90)
Pseudomonas (n=82)
Salmonella typhi &
paratyphi A (n=51)
Acinetobacter (n=34)
MICROBIOLOGY DATA (n=36)
Prevalance % Antibiotic Sensitivity (%)
55% Linezolid/Vancomycin (100%), Erythromycin (65%),
Cefoxitin (30%), Cotrimoxazole (45%), Amoxicillin-
Clavulanate (11%)
22% Polymyxin B/Amikacin (88%),
Imipenem/Piperacillin-Tazobactam/Cefoperazone-
Sulbactam/Ciprofloxacin (75%), Aztreonam (63%),
Ceftazidime (38%)
17% Imipenem/Cefoperazone-Sulbactam (100%),
Piperacillin-Tazobactam (83%), Amikacin (67%),
Cefotaxime/Ceftriaxone (50%), Ceftazidime/
Ciprofloxacin (33%)
3% Azithromycin/Chloramphinecol/Ceftriaxone (100%)
3% Polymyxin B/Cefoperazone-Sulbactam (100%)
MICROBIOLOGY DATA (n=372)
Prevalance % Antibiotic Sensitivity (%)
31% Vancomycin (96%), Linezolid (92%), Cefoxitin (80%)
Erythromycin (65%), Amoxicillin-Clavulanate (56%),
Cotrimoxazole (49%)
24% Imipenem (93%), Piperacillin-Tazobactam (86%),
Cefoperazone-Sulbactam (85%), Amikacin (82%),
Ceftriaxone /Cefotaxime/Ciprofloxacin (37%),
Ceftazidime (26%)
22% Piperacillin-Tazobactam (98%), Polymyxin (96%),
Imipenem /Cefoperazone-Sulbactam (95%), Amikacin
(89%), Ciprofloxacin (65%), Aztreonam (57%),
Ceftazidime (45%)
14% Azithromycin/Chloramphenicol (100%),
Ceftriaxone (96%)
9% Polymyxin B (100%), Cefoperazone-Sulbactam (90%),
Imipenem (85%), Amikacin (74%), Piperacillin-
Tazobactam (70%), Ciprofloxacin (65%), Ceftazidime
(29%)
15
 Blood Stream Infections (BSI) - OPD Antibiogram
MICROBIOLOGY DATA (n=49)
Most Common Pathogens Prevalance % Antibiotic Sensitivity (%)
Salmonella typhi & 53% Azithromycin/Ceftriaxone (100%),
paratyphi A (n=26) 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/Cefoperazone-
Sulbactam (100%), Amikacin (83%), Ceftriaxone
/Cefotaxime/Ciprofloxacin (50%)
Acinetobacter (n=2) 4% Polymyxin B (100%), Imipenem/Piperacillin-
Tazobactam/Cefoperazone-Sulbactam/
Amikacin/Ciprofloxacin (50%)

Urinary Tract Infections (UTI) - ICU Antibiogram

MICROBIOLOGY DATA (n=45)
Most Common Pathogens Prevalance % Antibiotic Sensitivity (%)
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/Piperacillin-
Tazobactam/Amikacin (67%), Ciprofloxacin (33%)
Enterococcus (n=7) 16% Vancomycin/Nitrofurantoin (50%)

16
 Urinary Tract Infections (UTI) - IPD Antibiogram
MICROBIOLOGY DATA (n=425)
Most Common Pathogens Prevalance % Antibiotic Sensitivity (%)
E.coli (n=228) 54% Imipenem (97%), Nitrofurantoin (87%), Pipercillin-
Tazobactam (84%), Amikacin (83%), Cefoperazone-
Sulbactam (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%), Cefoperazone-
Sulbactam (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

MICROBIOLOGY DATA (n=301)
Most Common Pathogens Prevalance % Antibiotic Sensitivity (%)
E.coli (n=171) 57% Imipenem (99%), Nitrofurantoin (95%), Piperacillin-
Tazobactam (93%), Amikacin (89%), Cefoperazone-
Sulbactam (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%), Piperacillin-
Tazobactam (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/Cefoperazone-
Sulbactam/Cefotaxime (100%), Amikacin/
Ceftazidime (80%), Ciprofloxacin (60%),
Nitrofurantoin (20%)

17
Respiratory / Skin Soft Tissue infections - ICU Antibiogram

MICROBIOLOGY DATA (n=169)

Most Common Pathogens Prevalance % Antibiotic Sensitivity (%)
Acinetobacter (n=63) 37% Polymyxin B (100%), Imipenem (76%), Cefoperazone-
Sulbactam (45%), Piperacillin-Tazobactam (38%),
Amikacin (24%)
Pseudomonas (n=32) 19% Polymyxin B (100%), Piperacillin-Tazobactam/
Amikacin (88%), Imipenem (75%), Cefoperazone-
Sulbactam (63%), Ciprofloxacin (47%),
Aztreonam (42%), Cefoperazone (40%)
E. coli (n=28) 17% Imipenem (100%), Piperacillin-Tazobactam (86%),
Cefoperazone-Sulbactam (79%), Amikacin (78%),
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

MICROBIOLOGY DATA (n=853)
Most Common Pathogens Prevalance % Antibiotic Sensitivity (%)
Pseudomonas (n=209) 24% Polymyxin B (100%), Piperacillin-Tazobactam (88%),
Imipenem (83%), Amikacin (73%), Cefoperazone-
Sulbactam (48%), Ciprofloxacin (47%), Cefoperazone(33%)
Staph aureus (n=197) 23% Linezolid/Vancomycin (100%), Cefoxitin (69%),
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%)
Acinetobacter (n=138) 16% Polymyxin B (99%), Imipenem (87%), Piperacillin-
Tazobactam (57%), Cefoperazone-Sulbactam (47%),
Amikacin (29%)
Klebsiella (n=82) 10% Imipenem (99%), Piperacillin-Tazobactam (85%),
Cefoperazone-Sulbactam (80%), Amikacin (74%),
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
MICROBIOLOGY DATA (n=191)
Most Common Pathogens Prevalance % Antibiotic Sensitivity (%)
Staph aureus (n=77) 40% Linezolid/Vancomycin (100%), Cefoxitin (91%),
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%)
Acinetobacter (n=16) 8% Polymyxin B (100%), Imipenem (94%), Piperacillin-
Tazobactam (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) Antibiotic Protocol: ICU
Patient Risk Stratification
Patient Type 1 (CAI) Patient Type 2 (HCAI) Patient Type 3 (NI) Patient Type 4 (NI)

No contact with health care system in last 90
days
No prior antibiotic treatment in last 90 days
Patient young with no or few co-morbid
conditions
Recent contact with health care system(hospital / nursing
home admission, CAPD) without major invasive procedure
Antibiotic therapy in last 90 days
Patient old (> 65 years) with few co-morbidities.
Hospitalization >5 days ± infections following major
invasive procedures
Recent & multiple antibiotic therapies
Patient old (> 65 years) + multiple co-morbidities
(eg. structural lung disease, immunodeficiency)
Type 3 patient with fever despite antibiotic therapy
(>5days) with no obvious source / after appropriate
source control
± severe sepsis/septic shock
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 Send Samples For Culture Send Samples For Culture Send Samples For Culture
Presumptive Therapy Presumptive Therapy Presumptive Therapy Presumptive Therapy
Ceftriaxone OR Amoxicillin-Clavulanate OR Ertapenem OR Piperacillin-Tazobactam +/-Amikacin Imipenem / Cefoperazone-Sulbactam + Amikacin Hemodynamically stable and no prior exposure to Azoles
Ciprofloxacin* / Ofloxacin Note: Vancomycin / Teicoplanin to be used only in MRSA incidence is +/- Vancomycin - Fluconazole
*Avoid ciprofloxacin in Patient type 1 since it has potent high Note: Colistin can be used empirically on Physician's discretion Hemodynamically Stable + Prior exposure to Azoles -
antipseudomonal activity in very sick patients 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 After Culture Report After Culture Report After Culture Report
Continue Treatment Continue Treatment Continue Treatment Continue Treatment
If the pathogen is sensitive to the drug used 1. If the pathogen is susceptible to the drug used 1. If the culture is negative & patient responds to If Candida Albicans and patient stable : Continue
empirically or culture is negative & patient empirically or culture is negative & patient responds to clinical treatment Fluconazole
responds to clinical treatment clinical treatment 2. If sensitive Pseudomonas / Acinetobacter - If Candida Non-Albicans OR Patient unstable : Continue
2. If ESBL +ve Enterobacteriaceae: Continue treatment Preferably a combination of Antipseudomonal Echinocandin / Lip Amp B
with monotherapy as per sensitivity report (Avoid using beta-lactam + Aminoglycoside /
broad spectrum anti-Pseudomonal drugs) Antipseudomonal FQ for 3-5 days followed by
3. If MRSA/Enterococcus: Use Vancomycin or Teicoplanin beta lactam monotherapy for another 5-7 days
Monotherapy 3. If MRSA- Shift to Vancomycin / Teicoplanin
monotherapy.

Step down "De-Escalate" Step down "De-Escalate" Step down "De-Escalate" Step down "De-Escalate"
If Non ESBL enterobacteriacae / MSSA: Shift to If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat 1. If ESBL +ve Enterobacteriaceae- Deescalate and Empirically started on Echinocandin / Lip Amp B and
monotherapy if combination used empirically as as Patient type 1 treat as patient Type 2 Culture shows Candida albicans plus patient is stable -
per the sensitivity report. 2. If Non ESBL/MSSA - De-escalate and Treat as De-escalate to Azoles #
Patient Type 1

Consider Escalation Consider Escalation Consider Escalation 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
1. If culture negative & no clinical response within 48 hours
of treatment.
2. If culture shows Pseudomonas/Acinetobacter - Treat as
Patient type 3
1. MDR Pseudomonas / Klebsiella: Colistin + Anti-
pseudomonal 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
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

20 21
 Blood Stream Infections (BSIs) Antibiotic Protocol: IPD
Patient Risk Stratification
Patient Type 1 (CAI) Patient Type 2 (HCAI) Patient Type 3 (NI)

No contact with health care system in last 90 Recent contact with health care system(hospital / nursing Hospitalization >5 days ± infections following major invasive procedures
days home admission, CAPD) without major invasive procedure

No prior antibiotic treatment in last 90 days Antibiotic therapy in last 90 days Recent & multiple antibiotic therapies
Patient young with no or few co-morbid Patient old (> 65 years) with few co-morbidities. Patient old (> 65 years) + multiple co-morbidities (eg. structural lung disease, immunodeficiency)
conditions

Send Samples For Culture Send Samples For Culture Send Samples For Culture
Presumptive Therapy Presumptive Therapy Presumptive Therapy
Oral: Cefixime OR Ofloxacin OR Amoxicillin- Ertapenem OR Piperacillin-Tazobactam Imipenem / Piperacillin-Tazobactam / Cefoperazone-Sulbactam +/- Vancomycin
Clavulanate Note: Vancomycin / Teicoplanin to be used only in MRSA incidence is
high
IV/IM: Ceftriaxone OR Amoxicillin-Clavulanate
OR Ciprofloxacin* / Ofloxacin
*Avoid ciprofloxacin in Patient type 1 since it has potent
antipseudomonal activity

After Culture Report After Culture Report After Culture Report

Continue Treatment
If the pathogen is sensitive to the drug used
empirically or culture is negative & patient
responds to clinical treatment
Continue 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
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.

Step down "De-Escalate" Step down "De-Escalate" Step down "De-Escalate"

If Non ESBL enterobacteriacae / MSSA: Shift to If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat 1. If ESBL +ve Enterobacteriaceae- Deescalate and treat as patient Type 2
monotherapy if combination used empirically as as Patient type 1 2. If Non ESBL/MSSA - De-escalate and Treat as Patient Type 1
per the sensitivity report.

Consider Escalation Consider Escalation Consider Escalation

1. If culture negative & no clinical response 1. If culture negative & no clinical response within 48 hours 1. MDR Pseudomonas / Klebsiella: Colistin + Antipseudomonal Beta lactam (pref Carbapenem in Extended
within 48 hours of treatment. of treatment Infusion) with maximum sensitivity
2. If culture is ESBL positive, treat as Patient 2. If culture shows Pseudomonas/Acinetobacter - Treat as 2. MDR Acinetobacter: Colistin + High dose Sulbactam +/- Carbapenem in Extended Infusion
type 2 Patient type 3 3. VRSA / VRE : Escalate to Linezolid or Daptomycin

22 23
 Blood Stream Infections (BSIs) Antibiotic Protocol: OPD
Patient Risk Stratification
Patient Type 1 (CAI) Patient Type 2 (HCAI)

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

No prior antibiotic treatment in last 90 days Antibiotic therapy in last 90 days

Patient young with no or few co-morbid conditions Patient old (> 65 years) with few co-morbidities.

Send Samples For Culture Send Samples For Culture

Presumptive Therapy Presumptive Therapy

Oral: Cefixime OR Ofloxacin OR Amoxicillin-Clavulanate 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)

After Culture Report After Culture Report

Continue Treatment Continue Treatment

If the pathogen is sensitive to the drug used empirically or culture is negative & patient responds to clinical 1. If the pathogen is susceptible to the drug used empirically or culture is negative & patient responds to
treatment clinical treatment
2. If ESBL +ve Enterobacteriaceae: Continue treatment with monotherapy as per sensitivity rep

Step down "De-Escalate" Step down "De-Escalate"

If Non ESBL enterobacteriacae / MSSA: Shift to monotherapy if combination used empirically as per the If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat as Patient type 1
sensitivity report.

Consider Escalation 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

Patient Type 1 (CAI)
No contact with health care system in last 90
days
No prior antibiotic treatment in last 90 days
Patient young with no or few co-morbid
conditions
Send Samples For Culture
Presumptive Therapy
Ceftriaxone / Ofloxacin OR Amikacin /
Ertapenem ( If community acquired ESBL
producing pathogen)
After Culture Report
Continue Treatment
If the pathogen is sensitive to the drug used
empirically or culture is negative & patient
responds to clinical treatment
Step down "De-Escalate"
If Non ESBL enterobacteriacae / MSSA: Shift to
monotherapy if combination used empirically as
per the sensitivity report.
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 Patient type 3
Urinary Tract Infections (UTI)
Patient Risk
Patient Type 2 (HCAI)
Recent contact with health care system(hospital / nursing
home admission, CAPD) without major invasive procedure
Antibiotic therapy in last 90 days
Patient old (> 65 years) with few co-morbidities.
Send Samples For Culture
Presumptive Therapy
Ertapenem / Piperacillin-Tazobactam +/- Amikacin
After Culture Report
Continue 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"
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
1. If culture negative & no clinical response within 48 hours
of treatment .
2. If culture shows Pseudomonas/Acinetobacter - Treat as
26
Antibiotic Protocol: ICU
Stratification
Patient Type 3 (NI)
Hospitalization >5 days ± infections following major
invasive procedures
Recent & multiple antibiotic therapies
Patient old (> 65 years) + multiple co-morbidities
(eg. structural lung disease, immunodeficiency)
Send Samples For Culture
Presumptive Therapy
Imipenem / Piperacillin-Tazobactam / Cefoperazone
-Sulbactam + Amikacin
Note: Colistin can be used empirically on Physician's discretion
in very sick patients
After Culture Report
Continue Treatment
1. If the culture is negative & patient responds to
clinical treatment
2. If sensitive Pseudomonas / Acinetobacter - Use
Antipseudomonal beta-lactam as per sensitivity
either alone or in combination with flouroquino-
lone or aminoglycoside
Step down "De-Escalate"
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
3. If sensitive Enterococcus- A combination of
Ampicillin + Gentamicin ( look for synergy test) OR
Vancomycin alone
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
Patient Type 4 (NI)
Type 3 patient with fever despite antibiotic therapy
(>5days) with no obvious source / after appropriate
source control
± severe sepsis/septic shock
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
Hemodynamically stable and no prior exposure to Azoles
- 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
After Culture Report
Continue Treatment
If Candida Albicans and patient stable: Continue
Fluconazole
If Candida Non-Albicans OR Patient unstable : Continue
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 )
Step down "De-Escalate"
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
Empirically started on Azole but culture shows Candida
species resistant to azoles OR the patient condition
deterioates : Escalate to Lip Amp B / Amp B or
Echinocandin based on C/S report and patient
condition
27

Patient Type 1 (CAI)
No contact with health care system in last 90
days
No prior antibiotic treatment in last 90 days
Patient young with no or few co-morbid
conditions
Send Samples For Culture
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)
After Culture Report
Continue Treatment
If the pathogen is sensitive to the drug used
empirically or culture is negative & patient
responds to clinical treatment
Step down "De-Escalate"
If Non ESBL enterobacteriacae / MSSA: Shift to
monotherapy if combination used empirically as
per the sensitivity report.
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
Urinary Tract Infections (UTI)
Patient Risk
Patient Type 2 (HCAI)
Recent contact with health care system(hospital / nursing
home admission, CAPD) without major invasive procedure
Antibiotic therapy in last 90 days
Patient old (> 65 years) with few co-morbidities.
Send Samples For Culture
Presumptive Therapy
Ertapenem / Piperacillin-Tazobactam
After Culture Report
Continue 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"
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
1. If culture negative & no clinical response within 48 hours
of treatment .
2. If culture shows Pseudomonas/Acinetobacter - Treat as
Patient type 3
28
Antibiotic Protocol: IPD
Stratification
Patient Type 3 (NI)
Hospitalization >5 days ± infections following major invasive procedures
Recent & multiple antibiotic therapies
Patient old (> 65 years) + multiple co-morbidities (eg. structural lung disease, immunodeficiency)
Send Samples For Culture
Presumptive Therapy
Imipenem / Piperacillin-Tazobactam +/- Amikacin
Note: Colistin can be used empirically on Physician's discretion in very sick patients
After Culture Report
Continue Treatment
1. If the culture is negative & patient responds to clinical treatment
2. If sensitive Pseudomonas / Acinetobacter - Use Antipseudomonal beta-lactam as per sensitivity either alone
or in combination with flouroquinolone or aminoglycoside
Step down "De-Escalate"
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
3. If sensitive Enterococcus- A combination of Ampicillin + Gentamicin ( look for synergy test) OR Vancomycin
alone
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
29
 Urinary Tract Infections (UTI) Antibiotic Protocol : OPD
Patient Risk Stratification
Patient Type 1 (CAI) Patient Type 2 (HCAI)

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

No prior antibiotic treatment in last 90 days Antibiotic therapy in last 90 days

Patient young with no or few co-morbid conditions Patient old (> 65 years) with few co-morbidities.

Send Samples For Culture Send Samples For Culture

Presumptive Therapy Presumptive Therapy

Oral: Cefixime OR Ofloxacin OR Amoxicillin-Clavulanate Oral: Cefixime OR Ofloxacin OR Amoxicillin-Clavulanate

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

After Culture Report After Culture Report

Continue Treatment Continue Treatment

If the pathogen is sensitive to the drug used empirically or culture is negative & patient responds to clinical 1. If the pathogen is susceptible to the drug used empirically or culture is negative & patient responds to
treatment clinical treatment
2. If ESBL +ve Enterobacteriaceae: Continue treatment with monotherapy as per sensitivity rep

Step down "De-Escalate" Step down "De-Escalate"

If Non ESBL enterobacteriacae / MSSA: Shift to monotherapy if combination used empirically as per the If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat as Patient type 1
sensitivity report.

Consider Escalation 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

30 31
 Respiratory / Skin Soft Tissue infections
Patient Type 1 (CAI)
No contact with health care system in last 90
days
No prior antibiotic treatment in last 90 days
Patient young with no or few co-morbid
conditions
Send Samples For Culture
Presumptive Therapy
SSTI: Cefazolin/Cefuroxime/Cloxacillin/
Ciprofloxacin* + Metronidazole OR Clindamycin/
Amoxicillin-Clavulanate alone
*Avoid ciprofloxacin in Patient type 1 since it has potent anti-
pseudomonal activity Note: Source control is must in SSTIs
RTI: Ceftriaxone / Amoxicillin-Clavulanate +/-
Macrolide OR Respiratory Flouroquinolone (eg
Gemifloxacin, Moxifloxacin)
After Culture Report
Continue Treatment
If the pathogen is sensitive to the drug used
empirically or culture is negative & patient
responds to clinical treatment
Step down "De-Escalate"
If Non ESBL enterobacteriacae / MSSA: Shift to
monotherapy if combination used empirically as
per the sensitivity report.
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
Antibiotic Protocol: ICU
Patient Risk Stratification
Patient Type 2 (HCAI) Patient Type 3 (NI) Patient Type 4 (NI)
Recent contact with health care system(hospital / nursing Hospitalization >5 days ± infections following major Type 3 patient with fever despite antibiotic therapy
home admission, CAPD) without major invasive procedure invasive procedures (>5days) with no obvious source / after appropriate
source control
Antibiotic therapy in last 90 days Recent & multiple antibiotic therapies ± severe sepsis/septic shock
Patient old (> 65 years) with few co-morbidities. Patient old (> 65 years) + multiple co-morbidities Plus >1 of the following (but not limited to) risk factors for
(eg. structural lung disease, immunodeficiency) invasive fungal infections: • TPN • Hemodialysis
• Immunodeficiency of variable origin • Major abdominal
surgery • Multi-focal candida colonization • Diabetes
Send Samples For Culture Send Samples For Culture Send Samples For Culture
Presumptive Therapy Presumptive Therapy Presumptive Therapy
SSTI : SSTI and RTI: Hemodynamically stable and no prior exposure to Azoles
Ertapenem / Piperacillin-Tazobactam + Amikacin Imipenem / Piperacillin-Tazobactam / - Fluconazole
Note: Vancomycin / Teicoplanin to be used only in MRSA incidence is Cefoperazone- Sulbactam + Amikacin/Levofloxacin Hemodynamically Stable + prior exposure to Azoles -
high Note: Colistin can be used empirically on Physician's discretion Echinocandins (Caspofungin)/ Lip Amp B / Conv. Amp B
RTI: in very sick patients (Use Conv Amp B if intolerance or limited availability of other
antifungals, with proper administration guidelines/precautions )
Piperacillin-Tazobactam / Cefoperazone-Sulbactam +/-
Hemodynamically Unstable - Echinocandins
Ciprofloxacin / Amikacin
(Caspofungin) / Lip Amp B
After Culture Report After Culture Report After Culture Report
Continue Treatment Continue Treatment Continue Treatment
1. If the pathogen is susceptible to the drug used 1. If the culture is negative & patient responds to If Candida Albicans and patient stable : Continue
empirically or culture is negative & patient responds to clinical treatment Fluconazole
clinical treatment 2. If sensitive Pseudomonas/Acinetobacter- If Candida Non-Albicans OR Patient unstable : Continue
2. If ESBL +ve Enterobacteriaceae: Continue treatment with Preferably a combination of Antipseudomonal Echinocandin / Lip Amp B
monotherapy as per sensitivity report (Avoid using broad beta-lactam + Aminoglycoside / Antipseudo-
spectrum anti-Pseudomonal drugs) monal FQ for 3-5 days followed by beta lactam
3. If MRSA/Enterococcus: Use Vancomycin or Teicoplanin monotherapy for another 5-7 days
Monotherapy 3. If MRSA-Shift to Vancomycin/Teicoplanin
monotherapy.
Step down "De-Escalate" Step down "De-Escalate" Step down "De-Escalate"
If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat 1. If ESBL +ve Enterobacteriaceae- Deescalate and Empirically started on Echinocandin / Lip Amp B and
as Patient type 1 treat as patient Type 2 Culture shows Candida albicans plus patient is stable -
#
2. If Non ESBL/MSSA - De-escalate and Treat as De-escalate to Azoles
Patient Type 1
Consider Escalation Consider Escalation Consider Escalation
1. If culture negative & no clinical response within 48 hours 1. MDR Pseudomonas / Klebsiella: Colistin + Empirically started on Azole but culture shows Candida
of treatment . Antipseudomonal Beta lactam (pref Carbapenem species resistant to azoles OR the patient condition
2. If culture shows Pseudomonas/Acinetobacter - Treat as in Extended Infusion) with maximum sensitivity deterioates : Escalate to Echinocandin / Lip Amp B / Conv.
Patient type 3 2. MDR Acinetobacter: Colistin+High dose Amp B based on C/S report and patient condition
Sulbactam +/- Carbapenem in Extended Infusion
OR Tigecycline (only in SSTI)
3. VRSA / VRE : Escalate to Linezolid / Daptomycin
(only in SSTI)
32 33
 Respiratory / Skin Soft Tissue infections Antibiotic Protocol: IPD
Patient Risk Stratification
Patient Type 1 (CAI) Patient Type 2 (HCAI) Patient Type 3 (NI)

No contact with health care system in last 90 Recent contact with health care system(hospital / nursing Hospitalization >5 days ± infections following major invasive procedures
days home admission, CAPD) without major invasive procedure

No prior antibiotic treatment in last 90 days Antibiotic therapy in last 90 days Recent & multiple antibiotic therapies
Patient young with no or few co-morbid Patient old (> 65 years) with few co-morbidities. Patient old (> 65 years) + multiple co-morbidities (eg. structural lung disease, immunodeficiency)
conditions

Send Samples For Culture Send Samples For Culture Send Samples For Culture
Presumptive Therapy Presumptive Therapy Presumptive Therapy
SSTI: Oral: Amoxycillin- Clavulanate OR SSTI and RTI: SSTI and RTI:
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 + / - Ertapenem / Piperacillin-Tazobactam +/- Amikacin Imipenem / Piperacillin-Tazobactam / Cefoperazone- Sulbactam + Vancomycin +/- Amikacin/Levofloxacin
Metronidazole /Ciprofloxacin
IV/IM: Cefazolin / Cefuroxime / Oxacillin / Note: Vancomycin / Teicoplanin to be used only if MRSA incidence is
Ciprofloxacin* +/- Metronidazole OR Amoxicillin- very high
Clavulanate / Clindamycin Macrolide can be added in RTI
*Avoid ciprofloxacin in Patient type 1 since it has potent
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

After Culture Report After Culture Report After Culture Report

Continue Treatment
If the pathogen is sensitive to the drug used
empirically or culture is negative & patient
responds to clinical treatment
Continue 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
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.

Step down "De-Escalate" Step down "De-Escalate" Step down "De-Escalate"

If Non ESBL enterobacteriacae / MSSA: Shift to If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat 1. If ESBL +ve Enterobacteriaceae- Deescalate and treat as patient Type 2
monotherapy if combination used empirically as as Patient type 1 2. If Non ESBL/MSSA - De-escalate and Treat as Patient Type 1
per the sensitivity report.

Consider Escalation Consider Escalation 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
1. If culture negative & no clinical response within 48 hours
of treatment .
2. If culture shows Pseudomonas/Acinetobacter - Treat as
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 OR Tigecycline
(only in SSTI)
3. VRSA / VRE : Escalate to Linezolid / Daptomycin (only in SSTI)

34 35
 Respiratory / Skin Soft Tissue infections Antibiotic Protocol: OPD
Patient Risk Stratification
Patient Type 1 (CAI) Patient Type 2 (HCAI)

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

No prior antibiotic treatment in last 90 days Antibiotic therapy in last 90 days

Patient young with no or few co-morbid conditions Patient old (> 65 years) with few co-morbidities.

Send Samples For Culture Send Samples For Culture

Presumptive Therapy Presumptive Therapy

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

After Culture Report After Culture Report

Continue Treatment Continue Treatment

If the pathogen is sensitive to the drug used empirically or culture is negative & patient responds to clinical 1. If the pathogen is susceptible to the drug used empirically or culture is negative & patient responds to
treatment clinical treatment
2. If ESBL +ve Enterobacteriaceae: Continue treatment with monotherapy as per sensitivity rep

Step down "De-Escalate" Step down "De-Escalate"

If Non ESBL enterobacteriacae / MSSA: Shift to monotherapy if combination used empirically as per the If Non ESBL Enterobacteriaceae / MSSA: De-Escalate & treat as Patient type 1
sensitivity report.

Consider Escalation 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 as in IPD protocol

36 37
 NOTES
Antibiotic Protocol: ICU
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.
2. 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
3. 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.
4. 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)
5. 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)
6. # 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

Antibiotic Protocol: IPD

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.
2. 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
3. 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.
4. 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)
5. 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)

Antibiotic Protocol: OPD

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
2. 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
3. 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.
4. *OPAT - Out Patient parenteral antibiotic therapy

Important Points
1. The marker used in our laboratory to assess potential ESBL production among enterobacteriacae is resistance to
Cefotaxime and Ceftazidime.
2. 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 Maximum Daily Dose

COLISTIN 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 / The usual total daily dose of Piperacillin and Tazobactam for injection for adults is 3.375 g
TAZOBACTAM 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/ In severe or refractory infections the daily dosage of sulbactam/cefoperazone may be

SULBACTAM 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.
Ÿ Use aseptic technique to avoid contamination of sterile injection equipment.
Ÿ 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.
Ÿ 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 patient’s intravenous infusion bag or administration set.
Ÿ Use single-dose vials for parenteral medications whenever possible.
Ÿ 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 manufacturer’s 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
 Antibiotic Summary Chart

Antibiotics Major Spectrum Bactericidal or Mechanism Major Adverse

of Acitivity Bacteriostatic of Action Reactions

Penicillin Gram+cocci bactericidal Inhibits cell wall Allergy

Penicillin G and Some anaerobes synthesis
Penicillin V
Penicillin Staphylococci bactericidal Inhibits cell wall Allergy
Penicillinase
Resistant
Penicillins
Penicillin Gram+cocci bactericidal Inhibits cell wall Allergy
Aminopenicillins Some Gram - bacilli synthesis
Penicillin Gram + cocci bactericidal Inhibits cell wall Allergy
Antipseudomonal gram+bacilli synthesis
and Extended- Pseudomonas sp.
Spectrum
Penicillins
Carbapenem Gram+species bactericidal Inhibits cell wall Allergy
Imipenem Gram+species synthesis
Ertapenem Anaerobes
Monobactam Gram-bacilli bactericidal Inhibits cell wall NA
Aztreonam synthesis
Cephalosporin First Gram+cocci bactericidal Inhibits cell wall Allergy
Generation- eg.: Some Gram-bacilli synthesis
cefazolin, cephalexin
Cephalosporin Gram+cocci bactericidal Inhibits cell wall Allergy
Second-Generation Gram+bacilli synthesis
eg: Cefuroxime Some anaerobes
Cephalosporin Many Gram-bacilli bactericidal Inhibits cell wall Allergy
Third-Generation Pseudomonas sp. synthesis
eg: ceftriaxone,
ceftazidime
Fourth-Generation-
eg: cefepime
Aminoglycosides Gram-bacilli bactericidal Inhibits bacerial • Nephrotoxicity
oprotein synthesis • Ototoxicity
Quinolones Gram-bacilli bactericidal Inhibits DNA • CNS reactions
Second- Staphylococcus sp. gyrase • Photosensitivity
Generation Atypical organisms • Developmental
bone/joint
lesions

44
 Antibiotic Summary Chart

Antibiotics Major Spectrum Bactericidal or Mechanism Major Adverse

of Acitivity Bacteriostatic of Action Reactions

Quinolones Gram-bacilli bactericidal Inhibits DNA • CNS reactions

Second- Staphylococcus sp. gyrase • Photosensitivity
Generation Streptococcus sp. • Developmental
Atypical organisms bone/joint
lesions
Macrolides Gram+/Gram-cocci bacteriostatic Inhibits bacterial • well tolerate
eg: azithromycin Some Haemophllus sp. protein synthesis • Some GI
Atypical organisms intolerance
Tetracyclines Gram+/Gram- bacteriostatic Inhibits bacterial • GI intolerance
aerobes & anaerobes protein synthesis • Photosensitivity
Atypical organisms • Developmental
tooth staining
Co-trimoxazole Gram+/ Gram- bactericidal Inhibits Formation • GI intolerance
organisms of vital metabolic • CNS effects
compound • Skin rash
• Hematologic
reactions
Glycopeptides Staphylococcus sp. bactericidal Inhibits cell wall • Skin rash
eg: Vancomycin Streptococcus sp. bacteriostatic synthesis • nephrotoxicity
Enterococci vs. enterococci • 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
 CMC’s Motto:

“My Work is for a King”

Dr. Edith Mary Brown
Founder of CMC Ludhiana

CMC Ludhiana exists to:

Ÿ Provide Excellence in medical care
Ÿ Serve the health needs of the community including the
underprivileged.
Ÿ Train health professionals for India
Ÿ 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