zubnํ strแnky - antibiotika - p๘evzato z Froedtert Hospital,Medical College of Wisconsin

This guide is intended to serve as an educational tool for antibiotic use at Froedtert Hospital, the major teaching affiliate of the Medical College of Wisconsin. It is intended to promote selective, cost effective use of antimicrobials, and to serve as Drug Use Evaluation criteria for antibiotic audits.

This guide is not intended to be a definitive treatise. Not every patient will fit these guidelines. When faced with a therapeutic dilemma, an Infectious Disease specialist should be consulted.

There exists a wide spectrum of antimicrobial agents available for therapy. One must consider not only likely microbiologic causes, but toxicity and cost as well. This guide offers therapeutic options based on likely pathogens and local sensitivity patterns.

MCW & FMLH Antibiotic Guide

(Your web browser must support tables to view this information!)
1. Antimicrobial Agents, Costs, and Indications
2. Treatment Recommendations for Common Infections
3. Recommendations for Surgical Prophylaxis
4. AHA Endocarditis Prophylaxis Guidelines



Antimicrobial Agents, Costs, and Indications

Drug (Brand) Name/ Dose Hospital Acquisition Cost/24 hr Indication(s)/(Infection) Comments


Acyclovir* (Zovirax)


200 mg po 5 times qd


• Therapy of acute genital herpes simplex

• Does not prevent post-herpetic neuralgia, but may decrease length of acute episode

800 mg po 5 times qd


• Therapy of Herpes zoster (varicella) or primary varicella (chicken pox) or CMV prophylaxis in renal transplant patients

• Prophylaxis for BMT/lung/heart transplant

• (Most benefit if started within 72h of onset of symptoms)

400 mg po bid


• Suppression of chronic genital herpes

• May use for up to one year, then re-evaluate

5 mg/kg IV q8h


• Prophylaxis or treatment of mucosal or cutaneous HSV 1 & 2 in immunocompromised patients who are unable to take po drug

• Severe first episodes of genital herpes in immunocompetent patients unable to take po

• May require dosage adjustment if CrCl<50 mL/min

• Infuse IV dose 500 mg or less slowly over 60 min

• Infuse IV doses >500 mg over 120 min to prevent crystal precipitation in renal tubules and subsequent renal dysfunction

10 mg/kg IV q8h


• Disseminated Herpes zoster or severe localized HZ infection, especially facial lesions near the eye in patients unable
to take po

• HSV encephalitis

2. Amantadine (Symmetrel)


100 mg po qd or bid

$0.13 (qd)
$0.26 (bid)

• Treatment of influenza A

• Prophylaxis of influenza A

• Decrease dose to once a day in elderly

• Prophylaxis should be considered for patients who cannot be immunized or for 7-10 days after recent immunization

• Best results are seen if treatment is begun within 48 hours of onset of infection

3. Aminoglycosides*



• Serious aerobic gram-negative bacilli infections

• Aminoglycosides should not be used alone to treat gram-negative pneumonia

• No effective CNS penetration

• Nephro/ototoxic, especially associated with prolonged therapy

• Suggest pharmacokinetics for initial and follow up individualization of dosage regimen

• Once daily dosing–see Appendix A

Amikacin* (generic)
500 mg qd



• Amikacin is 20X should be reserved for gram-negative infections resistant to gentamicin and tobramycin

Gentamicin* (generic)
200 mg qd


• Gentamicin activity is comparable to tobramycin against Serratia marcescens

• Gentamicin or tobramycin via HHN in cystic fibrosis patients

• When synergy for gram-positive coverage (Staph, S. viridans, and Enterococcus) is desired, gentamicin is aminoglycoside of choice at 1 mg/kg q8h (assuming CrCl >50), max of 80 mg q8h

• For use in the treatment of VRE if strain is sensitive to aminoglycosides

Tobramycin* (generic)
200 mg qd


• Tobramycin has better activity against Pseudomonas aeruginosa

4. Amoxicillin (generic)


250-500 mg po q8h


• Treatment of acute otitis media, sinusitis and acute bronchitis

• Bacterial endocarditis prophylaxis in patients undergoing dental, oral or upper respiratory tract procedures

• Susceptible enterococcal, E. coli, or Proteus UTI

• Caution: Some H. flu and most Moraxella catarrhalis produce beta-lactamase (therefore resistant to amoxicillin)

5. Amoxicillin/Clavulanate (Augmentin)


250 mg po q8h

500 mg po q8h

875 mg po q12h




• Respiratory tract infections where beta-lactamase producing organisms and/or anaerobes are suspected; higher doses for lower respiratory tract infections

• Human and animal bite wounds, closed fist trauma; higher doses for severe infections

• Incidence of diarrhea with oral drug may be decreased if drug is taken with food

• Logical choice for oral therapy after ampicillin/sulbactam parenteral therapy

6. Amphotericin B, nonlipid (Fungizone)


0.5-1.5 mg/kg IV q24h


• Life threatening Candida, Histoplasma capsulatum, Blastomyces dermatitidis, Coccidioides immitis, Aspergillus, Mucormycosis and Cryptococcus infections

• See Section 8, Appendix C for Amphotericin B Lipid Complex indications

• Full dose may be given in first 24 h of therapy; give first 1 mg slowly, watching for anaphylaxis

• Premedication (acetaminophen and diphenhydramine) may limit infusion-related side effects such as fevers, chills, and nausea

• Dilute 1 mg to 10 mL D5W (not saline) for peripheral lines

• Infuse over 1-4 h

• Monitor serum Na+, K+, Mg+, HCO3-, and SCr; amphotericin B may cause hypokalemia, hypomagnesemia, RTA and azotemia

• Saline loading with 0.9% NaCl reduces azotemia (500 mL)

• Does not cover Pseudallescheria boydii (Scedosoprium apiospermum)

• Although the drug is not renally excreted, the incidence of nephrotoxicity is about 80%

• Efficacy of bladder irrigation is unclear (dose range is
5-50 mg/L of H

Amphotericin B, oral solution
100 mg po qid


Oral, pharyngeal or esophageal Candidiasis


Amphotericin B, liposomal
3 mg/kg/d IV


7. Ampicillin* (generic)


1-2 g IV q4-6h

$7.44-$8.80 (q6h)

$11.16-$13.20 (q4h)

• Susceptible Enterococcus, E. coli, or Proteus UTI

• Listeria infections including meningitis

• H. flu (non-beta-lactamase-producing) infections

• Listeria meningitis requires 2 g IV q4h

• 1 g IV q6h for other infections

8. Ampicillin/sulbactam* (Unasyn)


1.5-3 g IV q6-8h

$21.51-$36.66 (q8h)

$28.68-$48.88 (q6h)

• Mixed gram-positive and anaerobic infections such as community acquired aspiration pneumonia, diabetic foot infections, decubitus infections or mild/moderate intra-abdominal infections

• IV drug of choice for empiric treatment of animal bites

• Sulbactam is a beta-lactamase inhibitor that enhances ampicillin's spectrum to include penicillinase producing Staphylococcus aureus, (MSSA), ampicillin resistant H. flu, Moraxella catarrhalis, ampicillin resistant anaerobes. NOTE: Amp/sulbactam does not cover hospital acquired gram-negative aerobes or MRSA

• Anaerobic activity is similar to metronidazole, imipenem/cilastatin and clindamycin

• Sulbactam does not improve enterococcal activity of ampicillin (use either ampicillin or vancomycin with gentamicin for serious enterococcal infection)

9. Atovaquone (Mepron)


750 mg po q8h
(3 x 250 mg tabs/dose)


• Treatment of mild to moderate Pneumocystis carinii pneumonia in AIDS patients who are intolerant of trimethoprim/sulfamethoxazole and able to take po medication

• Take with food

• Clinical failures have been associated with decreased bioavailability particularly in patients with diarrhea

750 mg/mL bid


• PCP prophylaxis

10. Azithromycin (Zithromaxฎ)


500 mg po qd then
250 mg po X 4 d


• Mild to moderate upper and lower respiratory tract infections due to mycoplasma, S. pneumoniae, Moraxella catarrhalis, H. influenza or Chlamydia

• Treatment of mild to moderate skin and soft tissue infection due to Staph and Strep


1 g po x 1 single dose


• Alternative to doxycycline for Chlamydia urethritis


500 mg IV qd



• Should only be used as an alternative to erythromycin when patients do not tolerate erythromycin

• To be used in fluid restricted patients who need macrolide therapy

• When macrolide monotherapy is needed to have active coverage against H. flu

• When switching from IV to po dose, follow-up doses are 500 mg qd x 5 d

1200 mg po 1X/wk


• MAC prophylaxis for AIDS pts.

• Pregnancy category B

Azithromycin oral soln
200 mg/5 mL


11. Cefazolin* (generic)


1-2 g IV q8h


• Perioperative surgical prophylaxis, agent of choice for most elective operations with the exception of colorectal and gynecological

• Intraperitoneally for CAPD patients with peritonitis

• Skin and soft tissue infections, osteomyelitis

• UTI's - with susceptible organisms (E. coli, (Klebsiella pneumonia, Proteus mirabilis)

• Does not cross the blood brain barrier

• Nafcillin is agent of choice for life-threatening Staphylococcal infection

• For cephalosporinase-producing organisms, cefuroxime is agent of choice

12. Cefepime* (Maxipime)


1-2 g IV q12h


• Treatment of severe community- or hospital-acquired infections that are documented or suspected to involve resistant aerobic gram-negative bacteria, including Enterobacteriaceae (Serratia, Enterobacter, Citrobacter, Morganella), and Pseudomonas

• Ceftazidime is equally active against Pseudomonas

• Cefepime exhibits good activity in vitro against Pseudomonas (as does ceftazidime) as well as against gram-positive bacteria such as streptococci (as for ceftriaxone)

• Cefepime may also be more active than either ceftriaxone or ceftazidime against gram-negative bacteria with inducible ง-lactamases (Enterobacter, Citrobacter, Serratia, Acinetobacter), although additional data are necessary

2 g IV q8h


• Empiric therapy for febrile neutropenia

• Neutropenia: <500 neutrophils

• IM injection available

13. Cefotaxime* (Claforan)


1 g IV q12h to
2 g IV q8h


• Empiric therapy of community acquired pneumonia, urosepsis, meningitis, or intraabdominal infection with aerobic organisms

• Uncomplicated gonorrhea as 1 g IM single dose

• Osteomyelitis or skin and soft tissue infection with susceptible organisms

• Lyme disease, especially with rheumatologic, neurologic, or cardiac involvement

• Nonformulary; can be used as third-generation cephalosporin for nonpseudomonal infections

• Cefotaxime 1 g q8h is equal to ceftriaxone 1 g/d and cefotaxime 2 g q8h is equal to ceftriaxone 2 g/day

• For meningitis, 200 mg/kg/day q6h (not to exceed 12 g/d)

• For Lyme disease, especially with rheumatologic, neurologic, or cardiac involvement, dose is 2 g IV q8h

14. Cefotetan* (Cefotan)


1-2 g IV q12h


• Surgical prophylaxis where anaerobic coverage needed (colorectal, gynecologic )

• Treatment of mild-moderate mixed anaerobic infections (i.e., PID, mild diverticulitis)

• Interchangeable with cefoxitin

• Disulfuram-like reactions possible. Patients should be advised to avoid alcohol for 72h after last dose. Vitamin K dependent increases in PT and bleeding possible with chronic therapy in malnourished/debilitated patients

15. Cefpodoxime (Vantin)


100 mg-200 mg po q12h


• Upper and lower RTI due to Strep, H. flu, or Moraxella catarrhalis


• Skin & soft tissue infections

• Take with food for absorption

• 400 mg bid for skin & soft tissue infections

16. Ceftazidime* (generic)


1-2 g IV q8h


• Known or suspected nosocomial aerobic gram-negative bacilli infection (including meningitis), with concurrent aminoglycoside if Pseudomonas is suspected

• If aspiration has occurred, clindamycin may be added for gram-positive and anaerobic activity

• Empiric treatment of febrile neutropenic patients

• Most active antipseudomonal third-generation cephalosporin

• Inappropriate for community acquired infections

• Poor Staph / Strep and anaerobic coverage

• Recent antibiogram patterns show decreasing activity against Enterobacter and Citrobacter species

• Not recommended for serious Enterobacter infection, regardless of sensitivity

17. Ceftizoxime* (Cefizox)


1-2 g IV 12h

1-2 g IV q8h



• Mild to moderate mixed aerobic/anaerobic infections

• Not indicated for life-threatening infections

• Spectrum of activity similar to other third generation cephalosporins (no Pseudomonas activity)

• More severe infections require q8h dosing

18. Ceftriaxone (Rocephin)


1-2 g IV q24h


• Empiric therapy of community acquired pneumonia, urosepsis, meningitis, or intraabdominal infection with anaerobic agent

• Gonorrhea, dose 125 mg IM x 1 for urogenital, rectal or pharyngeal infections

• Dose 1 g IV q24 hours (for 7-10 days) for disseminated gonorrhea

• Osteomyelitis or skin and soft tissue infection with susceptible organisms (often given as IV therapy at home)

• Lyme disease, especially with rheumatologic, neurologic or cardiac involvement

• Considered the primary non-pseudomonal third generation cephalosporin

• Empiric drug of choice for community acquired meningitis in an immunocompetent host

• Not active against Listeria monocytogenes, Pseudomonas aeruginosa, Enterococcus or MRSA

• May administer q12h for meningitis, otherwise use q24h interval

• Once-a-day dosing is advantageous for outpatient use for susceptible osteomyelitis or skin and soft tissue infections

• 2 g dose for meningitis

19. Cefuroxime* (Zinacef)


0.75-1.50 g IV q8h


• Lower respiratory tract infections where beta-lactamase producing organisms are suspected (H. flu, Moraxella cat.)

• Use 1.5 g IV q8h for Klebsiella

• Use of 750 mg IV q8h for Strep pneumo., Moraxella, H. flu is adequate

250-500 mg po bid


• Intermediate Strep infection

• Switch to po as soon as possible

1.5 g IV q12h


• Cardiothoracic surgery prophylaxis

20. Cephalexin (generic)


250-500 mg po qid


• Treatment of mild to moderate community acquired infections of the skin or urinary tract (susceptible organisms)

• First-generation cephalosporin with good in vitro activity against Staph and non-enterococcal Strep

21. Chloramphenicol* (generic)


1 g IV q6h


• Treatment of bacterial meningitis in penicillin and cephalosporin allergic patients

• Option for treatment of Salmonella typhi (typhoid fever)

• Toxicities include dose-related bone marrow suppression when drug levels >25 mcg/mL

• Idiosyncratic aplastic anemia 1 in 20,000 to 40,000

• Multiple drug interactions (Appendix H)

22. Clotrimazole (Mycelex)


10 mg troche
5 times qd


• Oropharyngeal and mild esophageal candidiasis

• Severe esophagitis should be treated with oral ketoconazole, fluconazole, or amphotericin B oral suspension

23. Ciprofloxacin* + (Cipro)


250 mg po bid

500 mg po bid



• Cystitis caused by susceptible organisms

• Therapy of bacterial gastrointestinal infection (including Shigella, Salmonella, enterotoxigenic E. coli and Enterobacter)

• Pyelonephritis, prostatitis or serious UTI, esp. when organisms are known or suspected to be resistant to TMP/SMX

• Selected soft tissue or respiratory tract infections with susceptible gram-negative organisms

• Poor gram-positive drug, no anaerobic coverage

• Consider amoxicillin, TMP/SMX for UTI

• May be combined with other agents (clindamycin) for infections that may include gram-positive organisms or anaerobes

• Ciprofloxacin should not be used for: methicillin-resistant Staph aureus or epidermidis; urinary tract infections unless due to multiresistant gram-negatives, CNS infections, serious Pseudomonas infection unless known sensitive, respiratory infections

• Ciprofloxacin should not be used in pregnant women and patients <17 y/o


• Decreased po absorption with antacids, sucralfate, didanosine tablets, iron

• IV Cipro should be used only when absorption from the oral route is questionable or impossible

• Decreases metabolism of theophylline, caffeine, cyclosporine, warfarin

• 400 mg IV = 500 mg po (oral is about 80% bioavailable)

• Higher IV dose may be needed for critically ill patient because of larger volume of distribution

750 mg po q12h


• Gram-negative osteomyelitis


200-400 mg IV q12h


• For UTI, dose dependent on severity:
200 mg q12h for mild-moderate infection;
400 mg q12 for severe-complicated (pyelonephritis)


400 mg IV q12h


• For LRTI, skin and skin structure or bone and joint infection with susceptible gram-negative organisms

24. Clarithromycin + (Biaxin)


500 mg-1 g po bid


• Legionella, Strep pneumonia, H. influenza, or upper/lower RTI, if intolerant of erythromycin

• For MAI as part of combination therapy for active infection and prophylaxis

• Drug interactions include: cyclosporine, theophylline (monitor blood concentration of each)


• Gram-positive anaerobic bacteria
(e.g., Peptococcus)

25. Clindamycin*+ (Cleocin)


600-900 mg IV q8h
or 1200 mg IV q12h

300-450 mg po tid
or 300 mg po qid

or 23.76

or $10.40

• Community acquired aspiration pneumonia and lung abscess

• Recurrent group A beta-streptococcal pharyngitis

• Toxoplasmosis in patients allergic to sulfonamides (combined with pyrimethamine)

• May be drug of choice for life-threatening group A Strep infections

• For therapy of PCP combined with primaquine if intolerant or allergic to trimethoprim-sulfamethoxazole

• Adjust dosage interval in severe renal or hepatic failure

• Relatively high incidence of pseudomembranous colitis

• Not drug of choice for clostridial sepsis due to possible resistance

26. Dapsone


50-100 mg/d po qd

Initial 50 mg/d
Increase to max 300 mg/d

1 mg/kg/d to max 100 mg/d
Adults: 100 mg/d
in combination with TMX 20 mg/kg/d for 21 d

$0.30/100 mg


• Leprosy and dermatitis herpetiforms (infections caused by Mycobacterium leprae

• Prophylaxis & treatment for Pneumocystis carinii pneumonia


• Monitor pts. for signs of jaundice and hemolysis

• CBC weekly for first month; monthly for 6 months

• Use with caution in pts. allergic to sulfonamides

• Check G6PD deficiency

27. Dicloxacillin (generic)


250-500 mg po qid


• Known or suspected infection caused by penicillin-resistant, methicillin-susceptible Staphylococci

• Should not be used for initial treatment of severe, life-threatening infections, but can be used as follow-up to parenteral therapy, e.g., in chronic osteomyelitis

• High dose (500 mg qid) may cause diarrhea

• Take on empty stomach

28. Doxycycline (generic)


100 mg po bid


• Non-gonococcal or post gonococcal urethritis, cervicitis

• Chlamydia

• Trichomonas

• Less costly alternative to azithromycin

• Can be used in patients with renal failure without dosage adjustments

• Do not use in pregnant women or in children <8 yo

29. Erythromycin lactobionate* + (generic)


500 mg-1 g IV q6h


250-500 mg po q6h




Drug of choice for:
• Legionella pneumonia
• Mycoplasma pneumonia
• Campylobacter jejuni enteritis
• H. ducreyi (chancroid)

May also be used for:
• Strep pharyngitis in penicillin allergic
• Mild skin and soft tissue infections
• Preop orally (as base), with neomycin
prior to colorectal surgery

• For patients <50 kg use 500 mg IV dose q6h as maximum

• High doses (4 g/day), diminished CrCl's and hepatic dysfunction puts patients at increased risk for ototoxicity

• Peripheral IV administration requires substantial dilution to avoid phlebitis/pain

• Significant drug interaction may occur with concurrent use of astemizole antihistamines, theophylline

• High incidence of GI symptoms

30. Fluconazole* + (Diflucan)



• Oropharyngeal candidiasis in dose of 200 mg IV or po x 1, then 100 mg q24h when topical antifungal (nystatin, clotrimazole) or oral ketoconazole is ineffective

• Oral drug serum concentration and IV are similar

• Reserve IV therapy for patients who cannot absorb oral drug

400 mg x 1, then
200 mg q24h po or IV

$98.30 (IV)

• Candida esophagitis 200 mg/d
(400 mg x 1 load)

• Fluconazole may inhibit drug metabolism because of inhibition of the P-450 isoenzyme (e.g., cyclosporine)

200-400 mg po q24h


• Coccidioides immitis meningitis (400/d)

• Chronic use may result in colonization with resistant species

100 mg po M, W, F, daily


• Chronic suppressive therapy of cryptococcal meningitis in patients with HIV

• Prophylaxis in short term neutropenia (BMT, chemotherapy reaction)

• Fluconazole may not be active against Torulopsis glabrata or Candida krusei

400 mg po or IV q24h

$18.20 (po)
$96.02 (IV)

• Disseminated non-life-threatening Candida albicans (400 mg/d)

• Treatment of urinary colonization may not be effective (need removal of Foley catheter, avoidance of antibiotics, treatment of diabetes, etc.)

• Fluconazole should replace ketoconazole if (1) absorption is a problem (ileus, achlorhydria), (2) pt. is taking H2 blockers which cannot be discontinued, (3) Candidal UTI is present, (4) pt. has AIDS and requires indefinite suppressive therapy for Cryptococcus neoformans

31. Foscarnet * (Foscavir)


60 mg/kg q8h IV x 14 d

90-120 mg/kg IV q24h (maintenance)



• CMV retinitis

• Acyclovir resistant HSV 1 and 2

• CMV pneumonitis, enterocolitis or esophagitis when ganciclovir cannot be used, or resistance suspected

• May cause nephrotoxicity; prehydration with NS may decrease insult to kidneys (500-1000 mL)

• HHV-6 therapy (BMT patients)

• Monitor SCr, serum calcium, phosphorus, potassium, & magnesium


Ganciclovir* (Cytovene DHPG)


5 mg/kg IV q12h x 2-3 wk

5 mg/kg IV q24h (maintenance)

(See Section 8, Appendix F for po dosing)



$3.28/250 mg capsule
$6.56/500 mg capsule

• CMV retinitis, pneumonitis, enterocolitis, or esophagitis

• Prophylaxis for CMV in seronegative transplant recipients of graft from a seropositive donor

• High incidence of complicating neutropenia (30-40%) and thrombocytopenia (20%)

• Concomitant use of other bone marrow suppressive agents (zidovudine) may need to be discontinued while on ganciclovir

• Neutropenia may be treated with G or GM-CSF

• Consult Section 7 to adjust dose for patients with CrCl < 80 mL/min

• Do not use if patient is allergic to acyclovir

33. Gatifloxacin* (Tequin)


400 mg IV or po qd

$4.86 (po)

$20.00 (IV)

• May be used as an alternative to macrolides in the treatment of documented or suspected community-acquired pneumonia (CAP)

• May be considered as alternative to cephalosporins and/or macrolides for patients requiring empiric therapy

• Has in vitro activity against typical respiratory pathogens (S. pneumoniae, H. influenzae, S. aureus, Moraxella catarrhalis) and atypical pathogens (C. pneumoniae, M. pneumoniae, L. pneumoniae)

• Penicillin-resistant Pneumococcus

• May be used for acute bronchitis exacerbation or acute sinusitis

• IV gatifloxacin should be used only when absorption from oral route is questionable or impossible

• Iron, zinc, and magnesium should be taken 4 h before or after gatifloxacin administration

• May prolong QT interval

• The manufacturer recommends careful serum monitoring of digoxin levels

• Careful blood glucose monitoring is recommended in diabetic patients receiving oral hypoglycemics or insulin

34. Imipenem/Cilastatin* (Primaxin)


500 mg-750 mg IV q6-8h

$64.11-$93.96 (500-750 mg q8h)

$85.48-$125.28 (500-750 mg q6h)

• Hospital acquired infection

• Mixed intra-abdominal infection

• Resistant nosocomial gram-negatives, e.g., Enterobacter

• Hospital acquired infections after previous exposure to broad spectrum agents

• Resistance seen when used alone for Pseudomonas aeruginosa

• Seizures have been reported in patients on imipenem/cilastatin therapy, esp. in patients with renal insufficiency, elderly patients, those with CNS abnormalities and/or patients receiving high doses

• Usual recommended daily dose is 25 mg/kg in divided doses (see Section 7 for dosage adjustment in renal failure)

1 g IV q8h



• 1 g q8h reserved for moderately sensitive organisms

35. Isoniazid* (generic)


300 mg po qd


• Treatment of infections due to Mycobacterium tuberculosis, either as a single agent (prophylaxis) or in combination with other antitubercular agents

• Atypical mycobacteria, when sensitive

• Hepatotoxicity more common in elderly and patients with underlying liver disease

• Peripheral neuropathy (B6 deficiency- more common in malnourished). Give B6 (pyridoxine) 10-50 mg qd

36. Itraconazole + (Sporanox)


200 mg capsules po bid x 3d then

200 mg po daily

$80.08 days 1,2,3, then


$11.68/day oral soln

• Blastomycosis, pulmonary and extrapulmonary (non-meningeal, non-life threatening)

• Histoplasmosis; including chronic cavitary pulmonary disease and disseminated (non-meningeal, non-life threatening)

• For serious infections, start with 200 mg capsules po bid. CNS penetration is unreliable. Food increases absorption of itraconazole capsules but H2 blockers and antacids decrease absorption. Monitor therapy for other significant drug-drug interactions (see ketoconazole)

• Studies on use for prophylactic or therapeutic treatment of Aspergillosis is limited

• May increase cyclosporine serum concentrations; combine cautiously!

100-200 mg oral solution swish & swallow 1X daily

1500 mg bottle

• Oropharyngeal Candidiasis

• Esophageal Candidiasis

• Aspergillosis

• Dose oropharyngeal Candidiasis 200 mg swish & swallow daily for 1-2 weeks

• Dose esophageal Candidiasis 100 mg swish & swallow daily for a minimum of 3 weeks. Treatment should continue for 2 weeks following resolution of symptoms

• Bioavailability of oral solution increases in the fasting patient

• Doses may be increased to 200 mg oral solution based on medical judgment & patient’s response to therapy

• Itraconazole remains secondary/refractory therapy in patients with Aspergillus infection if they cannot tolerate Amphotericin B due to poor renal function

37. Ketoconazole + (generic)


200-400 mg po qd


• Mucocutaneous or oropharyngeal candidiasis

• Antacids, H2 receptor antagonists interfere with absorption

• For long term use, monitor LFT's (may cause hepatitis)

• Do not use when meningitis suspected due to poor CNS penetration

38. Metronidazole* +


500 mg IV q8h

or 750 mg IV q12h

500-750 mg po tid

250 mg po qid (colitis)





• Anaerobic infections where Bacteroides fragilis is a likely pathogen

• Brain abscess (if anaerobes suspected)

• Bacterial vaginosis (Gardnerella vaginalis)

• Giardiasis

• Drug of choice for Clostridium difficile colitis (oral or IV)

• Amoebic dysentery and other Entamoeba histolytica infections (esp. liver abscesses - may require increased dose)

• Disulfuram-like reactions have been reported. Counsel patients regarding abstinence from alcohol while on metronidazole therapy and for 72 hours after last dose of drug

• Take po drug with food

• Due to long half-life of drug, dosage regimen may be every 12 h (increased dose)

• Metronidazole has limited activity against gram-positive anaerobes and no activity against gram-positive anaerobic cocci involving respiratory tract


• Prophylaxis for colorectal surgery

• Helicobacter pylori gastritis/ulcers in combination with bismuth subsalicylate and amoxicillin or tetracycline with or without ranitidine (Section 8, Appendix E)


2 g po X 1


• Trichomoniasis vaginitis

39. Nafcillin*


1-2 g IV q4-6h

(1 g q6h)

(2 g q4h)

• Penicillin-resistant Staphylococcus aureus infection (methicillin sensitive)

• Also has activity against pneumococci and Streptococcus pyogenes

• CAUTION: Not effective against enterococci, MRSA, gram-negative bacilli or Bacteroides fragilis

• Anaerobic Strep coverage is marginal

• Drug of choice for serious methicillin-sensitive Staph. aureus infection

40. Nitrofurantoin


50-100 mg bid


• Prophylaxis or treatment of UTI caused by enteric gram-negative bacteria or Enterococcus

• Do not use if CrCl <40 (unable to achieve adequate tubular levels)

• Chronic use associated with pulmonary fibrosis

• Use may cause hemolysis in pts. with G6PD deficiency

41. Nystatin (generic)


500,000 units/5 mL qid
swish & swallow


• Mild oropharyngeal and esophageal candidiasis

• Severe refractory esophagitis requires treatment with ketoconazole, fluconazole, or amphotericin

42. Penicillin G* (generic)


(Na or K salt)
600,000 units q6h to
2-4 MU q3-4h

Pen VK (generic)
250-500 mg po qid

$10.50-$28.90 (Pen GK)
$0.75-$1.50 (PenGNa)


• All Strep infections (Groups A, B, C, Dviridans , Pneumococcus, and Enterococcus)

• Actinomycosis

• Pasteurella multocida

• Syphilis

• Drug carries 1.7 mEq K+/MU drug. Potassium salt is commonly used, sodium salt may be used upon request (2 MU q4h PenGK provides over 20 mEq K+/day)

• Pneumococcal resistance may require alternate therapy, especially for CNS infection

43. Pentamidine* (generic)


300 mg-aerosolized once a month

4 mg/kg/d IV (usually 300 mg dose)



• Prophylaxis for Pneumocystis carinii

• Treatment of Pneumocystis carinii

• Usually 300 mg dose

• TMP/SMX is initial drug of choice for PCP

• TMP/SMX or dapsone are preferred for prophylaxis

• Side effects include pancreatitis, hypoglycemia, renal insufficiency

• Sudden death can occur with rapid infusion

44. Piperacillin/Tazobactam* (Zosyn)


3.375 g IV q6h


• Treatment of moderate to severe community- or hospital-acquired infections involving mixed bacteria (respiratory, skin/soft tissue, intraabdominal bacteremia) such as staphylococci, streptococci, anaerobic bacteria including Bacteroides

• Against Pseudomonas, combination therapy with an aminoglycoside is recommended

• Zosyn will not be any more active against Pseudomonas than piperacillin because ง-lactamases of Pseudomonas are not inhibited by tazobactam

• When compared with clavulanic acid and sulbactam, tazobactam is apparently less likely to induce (derepress) production of type I ง-lactamases by bacteria such as Pseudomonas, Enterobacter, Citrobacter, and Serratia which may lead to failure of therapy. However, if these ง-lactamases are already present, tazobactam is no more active in inhibiting these enzymes than sulbactam or clavulanic acid

45. Rifampin + (Rifadin)


600-900 mg qd for MTB

300 mg bid-tid for S. aureus infection

$1.04-$1.56 (po)

$62.20-$93.30 (IV)

• Part of multi-drug regimen for MTB

• Part of multi-drug regimen for atypical mycobacterium

• Part of multi-drug regimen for Staph infection of joints, osteomyelitis

• Serious MRSA infections with vancomycin

• Prophylaxis of Neisseria meningitidis exposure

• Not to be used for endocarditis

• Discolors tears, urine, saliva (body fluids)

• Potent hepatic enzyme inducer (may increase drug metabolism)

• Infrequently causes cholestatic hepatitis

46. Quinupristin-Dalfopristin (Synercid)


525 mg IV q8h


• Treatment of vancomycin-resistant (MIC>16 mcg/mL) Enterococcus faecium

• Treatment of MRSA or MRSE infections that have failed to respond to vancomycin or for patients intolerant of vancomycin

• Treatment of multi-drug-resistant Streptococcus pneumoniae infections for which PCN, erythromycin, or a fluoroquinolone have been determined ineffective or intolerable.

• Treatment of severe gram-positive infections in patients who are unable to tolerate therapy with active beta-lactams, cephalosporins, glycopeptides, or quinolones.

• Poor activity against Enterococcus faecalis - should not be used to treat vancomycin-resistant E. faecalis infections

• Should not be used to treat infections due to gram-negative or anaerobic pathogens

• Dose should be reduced to 7.5 mg/kg q12h in patients with markedly decreased liver function

• Synercid is a strong inhibitor of the cytochrome P450 3A4 enzyme – carefully monitor cyclosporine and tacrolimus

• For peripheral administration, administer the drug in a minimum of 250 mL D5W to avoid irritation

• Volume of 100 mL may be used if infused via central line only

• Synercid can cause elevations of liver enzymes (usually reversible); liver enzymes and bilirubin should be checked at least twice during the first week of therapy and once per week thereafter

• Infuse over 30 min

47. Ticarcillin/clavulanate* (Timentin)


3.1 g IV q4-6h


• Therapy for polymicrobial infection (includes anaerobes) such as intra-abdominal sepsis

• Polymicrobial skin and soft tissue infection (diabetic foot)

• Polymicrobial coverage with an aminoglycoside for nosocomial pneumonia

• For serious community-acquired pneumonia when aspiration is suspected

• Ticarcillin/Clavulanate provides broad spectrum coverage for Staph, Strep, anaerobes, and gram-negatives when used with aminoglycosides

• Activity against E. coli and Klebsiella may be variable

• Good anaerobic activity for intra-abdominal infections

• May produce platelet dysfunction

• 3.1 g Timentin = 3 g Ticarcillin + 100 mg Clavulanate

• Provides 5.2 mEq/g Na+ (can add up to 80-100 mEq Na/day)

• Based on FMLH guidelines, ticarcillin/clavulanate is indicated for Bactrim-resistant Stenotrophomonas maltophilia and must be special-ordered

48. Trimethoprim sulfamethoxazole* (generic)


10-20 mg TMP/kg/d IV or
po in 2-3 doses

1 DS Tab po bid

$5.88-$17.64 (IV)

$0.12 (po)

• Pneumocystis carinii pneumonia (15-20 mg/kg/day)

• UTI's

• Bacterial bronchitis, otitis media, sinusitis

• Enteric bowel infections including shigellosis, typhoid fever, E. coli, Salmonella

• Double Strength (DS): 160 mg TMP/800 mg SMX

• Single Strength (SS): 80 mg TMP/400 mg SMX

• May cause photosensitivity

• Side effects:
Nausea, vomiting, hepatitis, leukopenia, thrombocytopenia, renal failure, hyperkalemia

1 SS Tab po q24-48h


• Prophylaxis for recurrent UTI’s in patients with normal urinary tract


2 DS Tabs po qid


• PCP therapy


1 DS Tab po qd 3x/wk


• Sensitive infections with Stenotrophomonas and Pseudomonas cepacia, and non TB mycobacterial sp.

• Pneumocystis carinii prophylaxis

49. Valacyclovir (Valtrex)*


1 g po tid x 7 d

500 mg po bid

500-1000 mg po qd




• Primary treatment for Herpes 1 and 2

• Herpes zoster

• Episodic genital Herpes

• Prophylaxis for genital Herpes

• 500 mg qd for chronic suppression

• See Section 8, Appendix F

• Same levels as IV acyclovir

• Switch to po as soon as possible

50. Vancomycin* (generic)


500 mg-1 g IV q12h


• Agent of choice for MRSA and MRSE

• Treatment of Enterococcus for penicillin-allergic patients

• Alternative agent for gram-positive infections/prophylaxis in patients with life-threatening beta-lactam allergy

• See Vancomycin Guidelines (Appendix B, Section A)

• Vancomycin is the only reliable antibiotic for MRSA or methicillin-resistant coagulase-negative Staph

• Vancomycin is not absorbed orally

• Monitor blood levels so trough <10 mg/mL (IV drug) to reduce nephrotoxicity

• Nephrotoxicity increased when used in combination with aminoglycoside, cyclosporine, Amphotericin B

• Combined with aminoglycoside for life threatening enterococcal infection (endocarditis, sepsis)

Vancomycin* oral solution

125 mg po q6h


• C. difficile resistant to metronidazole


*Requires dosage adjustment in renal failure.
+Possible drug interactions.

Return to table of contens





Treatment Recommendations for Common Infections



Likely Microbiology

Therapy (IV unless noted otherwise)





Community acquired


a. Non-ICU patient Unknown

Mycoplasma or Chlamydia


Beta-lactam +/- Macrolide 



Beta-lactam = Ceftriaxone, Cefuroxime

Macrolide = Erythromycin, Clarithromycin, or Azithromycin

Quinolone = Gatifloxacin or Trovafloxacin

b. ICU patient   Ceftriaxone + (Macrolide or quinolone)


Beta-lactam/Beta-lactamase inhibitor + (Macrolide or quinolone)

Beta-lactam/Beta-lactamase inhibitor = Ampicillin/sulbactam or Pipercillin/tazobactam
c. Suspected aspiration Anaerobes, gram-positive organisms Quinolone + (clindamycin or metronidazole)


Beta-lactam/Beta-lactamase inhibitor

d. Bronchiectasis   (Pipercillin/tazobactam or imipenem or cefipine) + (macrolide or quinolone) + aminoglycoside  


Hospital acquired (including aspiration)

Gram-negatives: E. coli, Enterobacter, Pseudomonas, Klebsiella

Piperacillin/tazobactam + tobramycin 


Clindamycin + ciprofloxacin or
Ceftazidime or Imipenem +/- aminoglycoside

60% of nosocomial pneumonias are gram-negative in origin, 15% staph


Staphylococcus aureus


If MRSA suspected, treat with vancomycin

2. Fungal Infections


Itraconazole (non-life threatening, non-meningeal)

Amphotericin B

Itraconazole requires acid pH for absorption. Avoid antacids, H2 blockers

Amphotericin should be reserved for life threatening or CNS disease



Itraconazole (non-life-threatening, non-meningeal)

Amphotericin B

Amphotericin B is indicated for meningeal infections



Amphotericin B ฑ 5-Flucytosine

Amphotericin is the agent of choice for rapidly progressing life-threatening disease

Fluconazole is used for chronic suppression in HIV related disease


Candida albicans

Fluconazole (po)


Miconazole (topical)

Clotrimazole (topical)

Ketoconazole (topical or IV)

For Candida esophagitis, fluconazole is preferred agent

Flucytosine should not be used alone to treat Candida infections


Candida albicans
Deep seated, disseminated

Amphotericin B


Amphotericin is the agent of choice for rapidly progressing life-threatening disease

Prophylaxis with fluconazole in high risk populations is experimental, and should be limited to short courses


Deep seated, disseminated non-albicans candidiasis, (Torulopsis glabrata, Candida krusei)

Amphotericin B

Fluconazole has relatively poor activity against these species


Candida lusetaniae


Resistant to Amphotericin





Coliforms and enterococci


Piperacillin/tazobactam (or ampicillin/sulbactam) + Gentamicin

Cefotetan should be reserved for mild to moderate infections






Piperacillin/tazobactam (or ampicillin/sulbactam) + Gentamicin








Clindamycin + Ciprofloxacin

Piperacillin/tazobactam (or ampicillin/sulbactam) + Gentamicin

Cefotetan should be reserved for mild to moderate infections


Intra-abdominal peritonitis or abscess




Piperacillin/tazobactam (or ampicillin/sulbactam) + Gentamicin




Clindamycin + Ciprofloxacin

The gram-negative activity of ampicillin/sulbactam and gentamicin may be less than that of the other combinations listed

Cefotetan should be reserved for mild to moderate infections





E. coli

Staphylococcus saprophyticus




Three day course; may resolve spontaneously without therapy.




Oral therapy for mild disease is appropriate


(no underlying GU disease)

E. coli, Proteus




Ciprofloxacin (oral)

Enterococcus is an uncommon pathogen and can be identified on gram stain


(underlying GU disease)

Other gram-negatives including

E. coli



Ampicillin + gentamicin or tobramycin

Piperacillin/tazobactam + tobramycin

Ciprofloxacin ฑ ampicillin

These drug combinations are for empiric coverage for Pseudomonas and Enterococcus

Patients who are septic require double gram-negative coverage







Age<35 y/o

Neisseria gonorrhoeae


Ceftriaxone 125 mg IM in a single dose
Ciprofloxacin 500 mg po in a single dose
Doxycycline 100 mg po bid X 7 days


Age>35 y/o


TMP/SMX or ciprofloxacin






TMP/SMX X 3 mos or
ciprofloxacin X 4 wks

If treatment failure, rule out prostatic calculi


Skin/Soft tissue


Cellulitis (non-diabetic)



Nafcillin (oral dicloxacillin)

Clindamycin or cefazolin in non-anaphylactic penicillin allergy

For known Streptococcal infection, penicillin G is drug of choice


Decubitus ulcer / Diabetic ulcer





Amoxicillin/clavulanate (po) or ampicillin/sulbactam (IV)

Clindamycin + ciprofloxacin (or ceftazidime)


Piperacillin/tazobactam ฑ tobramycin

Amoxicillin/clavulanate or ampicillin/sulbactam does not cover Pseudomonas

Surgical consultation should be part of routine management


Necrotizing fasciitis



Gram-negative aerobes


Penicillin + clindamycin + aminoglycoside (or ciprofloxacin)

Ampicillin/sulbactam + aminoglycoside (or ciprofloxacin)


Necrotizing fasciitis may be due to mixed flora, including anaerobes (Clostridia perfringens). Broad spectrum coverage may be required. Primary emphasis is on surgical treatment


Human/animal bites

Pasteurella multocida



Ampicillin/sulbactam IV or amoxicillin/clavulanate po

Spectrum includes Pasteurella multocida, especially in cat bites

Do not use oral first-generation cephalosporins for Pasteurella


Bone & Joint





Acute (hematogenous)

Staphylococcus aureus

Gram-negatives (less frequent)

Nafcillin + rifampin

Nafcillin ฑ aminoglycoside

Establish bacteriology with appropriate cultures whenever possible

Gram-negative osteomyelitis may occur in the setting of underlying gastrointestinal or genito-urinary tract infection

Ceftriaxone therapy may allow outpatient parenteral therapy

Cefazolin or clindamycin may be options for penicillin allergic patients


Diabetic foot or contiguous ulcer




Piperacillin/tazobactam or
Ampicillin/sulbactam + aminoglycoside

Establish bacteriology with appropriate deep cultures (not superficial swabs) whenever possible

Adequate surgical debridement is critical to overall success


Chronic osteomyelitis


See comments

Establishing microbiology is primary


Septic Arthritis



Sexually active
young adult

Neisseria gonorrhoeae


Ceftriaxone 1 gm IV q24h (single dose)
Ciprofloxacin 500 mg IV q12h (single doses)
Doxycycline 100 mg po bid X 7 days

Continue IV therapy for 24 h after improvement
Change to ciprofloxacin 400 mg po bid
doxycycline 100 mg po bid X 7 d



Staphylococcus aureus

Group A Streptococcus

Gram-negative aerobes

Nafcillin + gentamicin or
Nafcillin + po ciprofloxacin

Microbiology needed

Orthopedic consultation required


With prosthesis

Staphylococcus epidermidis

Staphylococcus aureus


Vancomycin + 3rd generation cephalosporin
(+ rifampin if S. aureus)

Orthopedic consultation required


CNS Infections




3rd generation cephalosporins are empiric drug of choice due to concerns of moderately nonsusceptible Pneumococcus

(Penicillin may be used if organism is penicillin-susceptible)


Age 18-50

Streptococcus pneumoniae

N. meningitis

Haemophilus influenza (1-3%)


Antimicrobial therapy should be initiated within
30-60 min of presentation

Penicillin-allergic patients should receive chloramphenicol


Age >50 or
Alcoholic or
Debilitated medical condition

Gram-negative aerobes

Strep. pneumoniae


Ampicillin + ceftriaxone



Post neurosurgery

Staphylococcus epidermidis


Gram-negative aerobes

Vancomycin & ceftazidime

Infection related to catheters may require removal



Community acquired pathogens

Listeria monocytogenes



Ampicillin + ceftriaxone

Initial gram stain may provide clues for likely microbiology

Need to rule out Cryptococcus or other opportunistic infections




Viral encephalitis/ Meningioencephalitis

Viral encephalitis

Herpes simplex




No therapy

No therapy

Early initiation of acyclovir is important for all patients suspected to have viral encephalitis

Bacterial cerebritis expected if contiguous focus, i.e., mastoiditis, sinusitis, otitis media

Legionella or mycoplasma may present with encephalopathy


Encephalitis in immunosuppressed host

Herpes simplex







No therapy

No therapy

Amphotericin B

Pyrimethamine + sulfadiazine


Need to make specific diagnosis to rule out Cryptococcus or toxoplasmosis before empiric therapy


Brain Abscess




Otogenic(temporal, parietal, cerebellar)

Paranasal (frontal)

Strep. species



Ceftriaxone & metronidazole +/– Penicillin G

If endocarditis suspected, nafcillin should be added instead of Pen G for Staph. aureus


Head and Neck





Strep. pneumoniae

H. influenzae

Moraxella catarrhalis


Cefuroxime po

Amoxicillin/clavulanate po

Need to consider fungal etiology in neutropenic, transplant, or IDDM patients



Above plus anaerobes plus staph

Amoxicillin/clavulanate po

Chronic sinusitis requires surgical drainage



Gram-negative aerobes

Staph. aureus


See pneumonia treatment

Nasotracheal intubation and nasogastric tubes may increase risk of hospital-acquired sinusitis





Group A Strep.

Penicillin po

Mononucleosis may present with exudative pharyngitis



Herpes simplex virus

Acyclovir (herpes simplex only)





No treatment


Endotracheal intubation for maintenance of airway

Steroids for impending airway obstruction



Group A Strep. or H. flu

Cefuroxime or ceftriaxone

Early elective endotracheal intubation


Periorbital/Orbital Cellulitis

Streptococcus species


Haemophilus influenza (adults)

Anaerobes (if related to dental procedures)





R/O dental or sinus focus

If immunosuppressed, fungal etiology must be considered


Otitis media

See acute sinusitis

See acute sinusitis

Consider ENT pathology in adults with recurrent otitis media





Strep. pneumoniae

Strep. pyrogenes

Staph. aureus



Surgery for abscess or osteomyelitis



Polymicrobial, including Pseudomonas

Staph. aureus and anaerobes

Tobramycin + Piperacillin/tazobactam

Surgery is required


Sexually Transmitted Diseases (STD )





N. gonorrhoeae


Ceftriaxone 125 mg IM in a single dose

Ciprofloxacin 500 mg po in a single dose
Doxycycline 100 mg po bid X 7 days

OR (another alternative is)
Ciprofloxacin 500 mg po in a single dose
Azithromycin 1 g po in a single dose


Disseminated N. gonorrhoeae

Ceftriaxone 1 gm route X 24-48h then switch to ciprofloxacin dose freq route for 7 days




N. gonorrhoeae



Enteric gram-negatives

Outpatient - Ceftriaxone 250 mg IM + doxycycline dose po bid X 14 days

Inpatient - Cefotetan 2 gm IV q12h + doxycycline dose po bid X 14 days

Candidates for outpatient–temp <38กC, WBC <11,000, no indication of peritonitis


Genital lesions



Herpes Simplex


Acyclovir, Valacyclovir




Haemophilus ducreyi

Ceftriaxone 250 mg IM single dose
Erythromycin 500 mg po qd X 7 days
Azithromycin 1 gm po X 1 single dose



Lymphogranula-matous virus


Doxycycline 100 mg po bid X 21 days

Rare disease in USA



Treponema pallidum  

HIV patients and pregnant patients with syphilis should have infectious disease consult


Latent <1 yr


Benzathine PCN 2.4 mu IM single dose


Latent >1 yr or unknown duration


Benzathine PCN 2.4 mu IM X 3 doses





Penicillin G - 12 mu-24 mu IM qd X 10-14 days (2-4 mu q4 hr)


Return to table of contens



Suggested Recommendations and Guidelines for Surgical Prophylaxis


Postoperative wound infections are the major source of infectious morbidity in the surgical patient. The use of perioperative antibiotics has become an essential component of the standard of care in virtually all surgical procedures and has resulted in a reduced risk of postoperative infection when sound and appropriate principles of prophylaxis are applied.

  1. There is probable risk of infection in the absence of a prophylactic agent.

  2. There is a knowledge of the probable contaminating flora associated with the operative wound or organ site.

  3. The activity of the chosen prophylactic agent should encompass the majority of pathogens likely to contaminate the wound or operative site.

  4. When more than one choice is given as a prophylactic agent, the agents or agents selected should be based on the most likely contaminating organisms.

  5. The prophylactic agent must be administered in a dose which provides an effective tissue concentration prior to intraoperative bacterial contamination. Administration must occur 30-45 minutes prior to incision (usually with the induction of anesthesia).

  6. The effective dose should be governed by the patient's weight. For cephalosporins, patients weighing >70 kg, dosage should be doubled (i.e., 70 kg: cefazolin 1 g IV, >70 kg: cefazolin 2 g IV).

  7. In procedures lasting 3 hour or less, a single prophylactic dose is usually sufficient. Procedures lasting greater than three hours require an additional effective dose. Procedures in which there is rapid blood loss and/or fluid administration will dictate more frequent prophylactic dosing. Under no circumstance should any prophylactic agent be given on-call because it often results in less than effective tissue levels at the time of incision. Postoperative prophylaxis is strongly discouraged except in the scenario of a bioprosthetic insertion in which case 2 or 3 additional prophylactic doses may be deemed sufficient (Warning: there are no standard rules on prophylaxis following prosthetic insertion and clinical experience strongly dictates practice).

  8. Vancomycin may be used for patients with severe penicillin/cephalosporin allergy.

  9. An effective and thoughtful prophylactic regimen is no substitute for exquisite surgical technique and competent postsurgical management.

I. General Surgery

a. Clean Procedures

Under most circumstances antimicrobial prophylaxis is not required when performing a clean surgical procedure. However, prophylaxis should be employed under those conditions where there is a potential intrinsic risk of infections such as in:

  1. Insertion of a synthetic biomaterial device or prosthesis

  2. Clean operations performed in a patients with impaired host defenses

Agents: Cefazolin or cefuroxime.

Route/Dosage/Timing: 1 gram cefazolin IV or 750 mg cefuroxime IV 30-45 minutes before skin incision; second dose if procedure >3 hours.

Rationale: Likely infecting organism are gram-positive cocci (S. aureus or S. epidermidis) and aerobic coliforms (E. coli).

b. Upper GI & Elective Small Bowel (Stomach, Small Bowel, Pancreas, Hepatobiliary)

Agents: Ciprofloxacin
               Ceftizoxime OR ceftizoxime + metronidazole if anarobes suspected.

Route/Dosage/Timing: 400mg IV ciprofloxacin OR 1 gram ceftizoxime (500 mg metronidazole) IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Common infecting organisms: Coliforms > Enterococcus > streptococci > anaerobic clostridia, peptostreptococci, Bacteroides, Prevotella or Porphyromonous (formerly oral Bacteroides).

c. Large Bowel Resections

Agents: Oral mechanical prep (Neomycin/Erythromycin) and parenteral cephalosporin (ceftizoxime or cefotetan).

Route/Dosage/Timing: 1 gram ceftizoxime or cefotetan IV 30-45 minutes prior to incision; second dose if procedure lasts > 3 hours. No additional doses required.

Rationale: Likely flora includes coliforms, Enterococcus, Bacteroides, peptostreptococci and clostridia.

d. Acute Appendectomy (Non-perforated)

Agents: Single agent: Ceftizoxime or cefotetan.
Combination therapy: Ceftizoxime plus metronidazole.

Route/Dosage/Timing: Single agent: 1 gram ceftizoxime or cefotetan IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.
Combination therapy: 1 gram ceftizoxime IV plus 500 mg metronidazole IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Coliforms and anaerobic bacteria likely infecting organisms.

II. Trauma Surgery

a. Penetrating Abdominal Trauma

Agents: Single agent: Ampicillin/sulbactam.
Combination therapy: Ceftizoxime plus metronidazole.

Route/Dosage/Timing: 3 grams ampicillin/sulbactam IV or 2 grams ceftizoxime plus 500 mg metronidazole IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Coliform and anaerobic bacteria (gram-positive & gram-negative) present in peritoneal cavity follow bowel injury.

III. Obstetrics and Gynecology

a. Vaginal or Abdominal Hysterectomy (Including Radical)

Agents: Ceftizoxime or cefotetan.

Route/Dosage/Timing: 1 gram ceftizoxime, or cefotetan IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Coliforms, Enterococcus, Streptococcus, Clostridia and Bacteroides are potential infecting organisms.

b. Cesarean Section/Hysterectomy

Agents: Cefazolin or ceftizoxime.

Route/Dosage/Timing: 1 gram cefazolin or ceftizoxime IV 30-45 minutes before skin incision; in high risk patients, may use 2 grams cefazolin or ceftizoxime IV after clamping and cutting of umbilical cord.

Rationale: Coliforms, Enterococcus, Streptococcus, Clostridia and Bacteroides potential contaminants.

IV. Urology

a. Prostatectomy

Agents: Cefazolin or ciprofloxacin.

Route/Dosage/Timing: 1 gram cefazolin IV OR 400 mg ciprofloxacin IV 30-45 minutes before skin incision; second dose of either cefazolin or ciprofloxacin after procedure.

Rationale: Coliforms and staphylococci (community strains) are major infecting organism, pseudomonads occasional pathogen.

V. Transplant Surgery

a. Kidney Transplantation

Agents: Cefazolin

Route/Dosage/Timing: 1 gram cefazolin IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Staphylococci are the predominant contaminants, gram-negative enterococci are occasionally encountered.

b. Liver Transplantation

Agents: Ampicillin/sulbactam.

Route/Dosage/Timing: 3 grams ampicillin/sulbactam IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Coliforms, enterococci and staphylococci are potential contaminating organisms.

c. Pancreas or Kidney/Pancreas

Agents: Vancomycin, imipenem/cilastatin, and fluconazole.

Route/Dosage/Timing: 1 gram vancomycin IV, 500 mg  imipenem/cilastatin IV, and 400 mg fluconazole IV 30-45 minutes before skin incision.

Rationale: Donor duodenum is often colonized with gram positive organisms such as Staphylococcus epidermis, Enterococcus, and yeast.

VI. Head and Neck Surgery

a. Clean Procedures (skin excision, neck dissections)

Agents: Cefazolin or penicillin G.

Route/Dosage/Timing: 1 gram cefazolin IV or 2-4 MU penicillin G IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Coverage against staphylococcal flora.

b. Laryngectomy & Other Head and Neck Cancer Operations

Agents: Cefazolin or ceftizoxime plus metronidazole.

Route/Dosage/Timing: 1 gram cefazolin or ceftizoxime IV and 500 mg metronidazole IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.
or 400 mg ciprofloxacin IV plus 500 mg metronidazole IV 30-45 minutes before skin incision.

Rationale: Coverage against skin staphylococci plus oral anaerobic bacteria.

c. Mandibular Fractures

Agents: Penicillin.

Route/Dosage/Timing: 2 MU penicillin (>60 kg use 4 MU) IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Coverage for oral flora.

VII. Orthopaedic Surgery

a. Total Joint Replacement

Agents: Cefazolin or cefuroxime.

Route/Dosage/Timing: 1 gram cefazolin or 750 mg cefuroxime IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Staphylococci are major infecting organism in joint replacement surgery.

b. Traumatic Open Fractures

Agents: Cefazolin (grade I & II fractures); ceftizoxime (grade III fractures).

Route/Dosage/Timing: 2 gram cefazolin or ceftizoxime IV 30-45 minutes before incision; second dose if procedure > 3 hours.

Rationale: Staphylococcal skin flora common contaminant in grade I and II fractures, coliforms often infect the serious grade III fractures.

VIII. Vascular Surgery

a. Peripheral Vascular Procedures

Agents: Cefazolin or
              Ciprofloxacin plus metronidazole.

Route/Dosage/Timing: 1 gram cefazolin IV 30-45 minutes before skin incision; second dose if procedure > 3 hours or 400 mg ciprofloxacin IV plus 500 mg metronidazole IV 30-45 minutes before skin incision.

Rationale: Staphylococci major contaminants associated with vascular graft infection; mixed microbial flora (anaerobes and aerobes) associated with abdominal aorta and diabetic foot patients.

IX. Cardiothoracic Surgery, Coronary Bypass Surgery, and Pulmonary Resection

Agents: Cefazolin or cefuroxime.

Route/Dosage/Timing: 1 gram cefazolin or 750 mg cefuroxime IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Staphylococci most common infecting organism.

X. Neurosurgery

Agents: Cefazolin.

Route/Dosage/Timing: 1 gram cefazolin IV 30-45 minutes before skin incision; second dose if procedure > 3 hours.

Rationale: Staphylococci are the predominant isolates from neurosurgical wound infections.



Nichols RL. Postoperative wound infection. N Engl J Med 307:1701, 1982.

Ulualp, K., and Condon, R.E.: Antibiotic prophylaxis for scheduled operative procedures. In Dellinger E (ed): Surgical Infections. Infectious Disease Clinics of North America, Philadelphia, PA, W.B. Saunders Company, 1992.

Wittman DH, Condon RE. Prophylaxis of postoperative infections. Infection 19:S337-S344, 1991.

General Surgery

Bauer T. Vennits BO, Holm B. et al. Antibiotic prophylaxis in acute non-perforated appendicitis. Ann Surg 209:307, 1989.

Browder W. Smith JW, Vivoda L, et al. Nonperforative appendicitis: a continuing surgical dilemma. J Infect Dis 159:1088,1989.

Condon RE, Bartlett JG, Greenlee H, et al. Efficacy of oral and systemic antibiotic prophylaxis in colorectal operations. Arch Surg 118:496, 1983.

Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound class, operative procedure and patient risk index. Am J Med 91 (Suppl 3B):152S­157S.

Jagelman PG, Fabian TC, Nichols RL, et al. Single dose cefotetan versus multiple­dose cefoxitin as prophylaxis in colorectal surgery. Am J Surg 155 (5A):71, 1988.

Nichols RL, Webb WR, Jones JW, et al. Efficacy of antibiotic prophylaxis in high risk gastroduodenal operations. Am J Surg 143:94, 1982.

Platt R. Zaleznik DF, Hopkins CC, et al. Perioperative antibiotic prophylaxis for herniorrhaphy and breast surgery. N Engl J Med 322:153, 1990.

Ulualp K, and Condon RE. Antibiotic prophylaxis for scheduled operative procedures. In Dellinger E (ed): Surgical Infection. Infectious Disease Clinics of North America, Philadelphia, PA, WB Saunders Company, 1992.

Weigelt JA, Easley SM, Thel ER, et al. Abdominal surgical wound infection is lower with improved perioperative Enterococcus and Bacteroides therapy. J Trauma 34:579, 1993.

Trauma Surgery

Dellinger EP, Wertz MJ, Lennard ES, et al. Efficacy of short course antibiotic prophylaxis after penetrating intestinal trauma. Arch Surg 121:23, 1986.

Dellinger EP. Antibiotic prophylaxis in trauma: penetrating abdominal injuries and open fractures. Rev Infect Dis 13 (Suppl):S847, 1991.

Nichols RL, Smith JW, Robertson GD, Muzik AC, Pearce P. Ozmen V, McSwain NE, Flint LM. Prospective alterations in therapy for penetrating abdominal trauma. Arch Surg 128:55, 1993.

Page CP, Bohnen JMA, Fletcher JR, McManus AT, Solomkin JS, Wittmann DH. Antimicrobial prophylaxis for surgical wounds: Guidelines for critical. Arch Surg 128:79, 1993.

Obstetrics and Gynecology

Antimicrobial Prophylaxis in Surgery, Med Lett 31:105, 1989.

Gorbach SL. The role of cephalosporins in surgical prophylaxis. J Antimicrob Chemother 23 (Suppl D): 61, 1989.

Hemsell DL. Prophylactic antibiotics in gynecologic and obstetric surgery. Rev Infect Dis 13 (Suppl 10):S821, 1991.

McGregor JA, Phillips LE, Dunne JT, et al. Results of double-blind, placebo-controlled clinical trial of si.ngle dose ceftizoxime vs. multiple dose cefotetan as prophylaxis for patients undergoing vaginal and abdominal hysterectomy. J Am Coll Surg 175;123-131, 1994.

Weigelt JA, Faro S. Antimicrobial therapy for surgical prophylaxis and for intraabdominal and gynecologic infections. Am J Surg 176:1S, 1998.


Hofer DR, Schaeffer AJ. Use of antimicrobials for patients undergoing prostatectomy. Uron Clin North Am 17:595, 1990.

Head and Neck Surgery

Becker GD, Parell GJ, Busch DF, et al. Anaerobic and aerobic bacteriology in head and neck surgery. Arch Otolaryngol 104:591, 1978.

Byers RM, Fainstein V, Schantz SP, et al. Wound prophylaxis with metronidazole in head and neck surgical oncology. Laryngoscope 98: 803, 1988.

Orthopaedic Surgery

Benson DR, Riggin RS, Lawrence RM, et al. Treatment of open fractures: a prospective study. J Trauma 23:25, 1983.

Dellinger EP. Antibiotic prophylaxis in trauma: penetrating abdominal injuries and open fractures. Rev Infect Dis 13(Suppl):S847, l991.

Gorbach SL, Condon RE, Conte JE, et al. Evaluation of new anti­infective drugs for surgical prophylaxis. Clin Infect Dis 15(Suppl):S313, 1992.

Norden CW, Antibiotic prophylaxis in orthopaedic surgery. Rev Infect Dis 13 (Suppl):S842, 1991.

Vascular Surgery

Hopkins CC. Antibiotic prophylaxis in clean surgery: peripheral vascular surgery, noncardiovascular thoracic surgery, herniorrhaphy and mastectomy. Rev Infect Dis 13(Suppl):S869, 1991.

Kaiser AB, Roach AC, Mulherin J, et al. The costeffectiveness of antimicrobial prophylaxis in clean vascular surgery. J Infect Dis 147:1103, 1983.

Cardiothoracic Surgery

Ariano RE, Zhanel GG. Antimicrobial prophylaxis on coronary bypass surgery: a critical appraisal. DICP Ann Pharmacother 25:478, 1991.

Ilves R. Cooper JD, Todd TRJ, et al. Prospective, randomized, double­blind study using prophylactic cephalothin for major, elective general thoracic surgery. J Thorac Cardiovasc Surg 81:813, 1981.

Slama TG, Sklar SJ, Misinski J. et al. Randomized comparison of cefamandole, cefazolin and cefuroxime prophylaxis in open heart surgery. Antimicrob Agents Chemother 29:744, 1989.


Dempsey R. Rapp RP, Young B. Prophylactic parenteral antibiotics in clean neurosurgical procedures: a review. J Neurosurg 69:52, 1988.

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AHA Prophylaxis Guidelines for Prevention Of Bacterial Endocardiditis

Recommended Prophylactic Regimen For Dental, Oral, Or Upper Respiratory Procedures In Patients Who Are At Risk

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Condition Drug Adult Dose
Standard regimen
  • Amoxicillin
  • 2 g po 1 h before procedure
    Amoxicillin/penicillin allergic patients
  • Clindamycin or

  • Cephalexin or cefadroxil or

  • Azithromycin or clarithromycin
  • 600 mg po 1 h before procedure

    2 g po 1 h before proceedue

    500 mg po 1 h before procedure
    Patients unable to take oral medication
  • Ampicillin
  • 2 g IV/IM 30 min before procedure
    Patients unable to take oral medications and are ampicillin/amoxicillin/penicillin allergic
  • Clindamycin or

  • Cefazolin
  • 600 mg IV 30 min before procedure

    1 g 30 min before procedure

    Regimens For Genitourinary/Gastrointestinal (excluding esophageal) Procedures

    Condition Drug Adult Dose
    Standard regimen
  • Ampicillin




    Amoxicillin or Ampicillin

  • 2 g IV/IM 30 min before procedure.
    1.5 mg/kg IV/IM (maximum 80 mg) 30 min before procedure.

    1 g po 6 h after initial dose or
    1 g IV/IM 6 h after initial dose
    Ampicillin/amoxicillin/penicillin allergic patients
  • Vancomycin


  • Gentamicin
  • 1 g IV over 1-2 h completing within 30 min of starting procedure
    1.5 mg/kg IV/IM (maximum 120 mg) completing within 30 min of starting procedure
    Alternate regimen for low-risk patients
  • Amoxicillin or

  • Ampicillin
  • 2 g po 1 h before procedure

    2 g IM/IV within 30 min of starting procedure

    Return to table of contens

    This guide was prepared by members of the Antibiotic Subcommittee of the Pharmacy and Therapeutics Committee and has been approved for use at Froedtert Hospital

    9200 W. Wisconsin Ave.
    Milwaukee, WI. 53226

    last update 5/16/2000
    WWW version maintained for the hospital P&T committee by:
    Gary P. Barnas, M.D., Office of Clinical Informatics
    send comments to: Cindy Hennen, R.Ph.

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