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Table 304.

Drugs of choice for suspected or proved microbial pathogens,

Suspected or Proved Etiologic Agent Moraxella catarrhalis

Drug(s) of First Choice

Alternative Drug(s)

Gram-negative cocci Cefuroxime, a fluoroquinolone2 Cefotaxime, ceftriaxone, cefuroxime axetil, an erythromycin,3 a tetracycline,4 azithromycin, amoxicillinclavulanic acid, clarithromycin, TMPSMZ5 Cefpodoxime proxetil

Neisseria gonorrhoeae (gonococcus)

Cefixime, ceftriaxone

Neisseria Penicillin6 meningitidis (meningococcu s) Gram-positive cocci Streptococcus Penicillin6 pneumoniae7 (pneumococcu s)

Cefotaxime, ceftriaxone, ampicillin

An erythromycin,3 a cephalosporin,8 vancomycin, TMPSMZ,5 clindamycin, azithromycin, clarithromycin, a tetracycline,4 certain fluoroquinolones2 An erythromycin,3 a cephalosporin,8 vancomycin, clindamycin, azithromycin, clarithromycin Cephalosporin,8 vancomycin

Streptococcus, Penicillin6 hemolytic, groups A, B, C, G Viridans streptococci Penicillin6 gentamicin

Staphylococcu Vancomycin gentamicin rifam TMP-SMZ,5 doxycycline, minocycline, a s, methicillin- pin or Linezolid (MRSA) fluoroquinolone,2 daptomycin, resistant quinupristin-dalfopristin, tigecycline Staphylococcu Penicillin6 s, nonpenicillinaseproducing A cephalosporin,8 clindamycin

Staphylococcu Penicillinase-resistant penicillin9 s, penicillinaseproducing Enterococcus faecalis Enterococcus faecium Ampicillin gentamicin10 Vancomycin gentamicin10

Vancomycin, a cephalosporin,8 clindamycin, amoxicillinclavulanic acid, ampicillin-sulbactam, piperacillin-tazobactam, TMP-SMZ5 Vancomycin gentamicin Linezolid,11 quinupristindalfopristin,11 daptomycin11 tigecycline11

Gram-negative rods Acinetobacter Imipenem, meropenem Tigecycline, ertapenem, minocycline, doxycycline, aminoglycosides,12 colistin Metronidazole

Prevotella, Clindamycin oropharyngeal strains Bacteroides, Metronidazole gastrointestinal strains Brucella Doxycycline + rifampin4

Ticarcillin-clavulanate, ampicillinsulbactam, piperacillin-tazobactam, carbapenem TMP-SMZ5 gentamicin; ciprofloxacin + rifampin Tetracycline,f a fluoroquinolone2 Aminoglycoside, a fluoroquinolone,2 TMPSMZ5 Imipenem13 or meropenem,13 aminoglycosides,12 a fluoroquinolone,2 aztreonam, ticarcillin-clavulanate, ampicillin-sulbactam, piperacillintazobactam TMP-SMZ,5 oral cephalosporin

Campylobacter Erythromycin3 or azithromycin jejuni Enterobacter Ertapenem, imipenem, meropenem, cefepime Cefotaxime, ceftriaxone,

Escherichia coli (sepsis)13

Escherichia Fluoroquinolones,2 nitrofurantoin coli (uncomplicate d outpatient urinary infection) Haemophilus (meningitis Cefotaxime, ceftriaxone

Aztreonam

and other serious infections) Haemophilus (respiratory infections, otitis) Helicobacter pylori Klebsiella13 TMP-SMZ5 Ampicillin, amoxicillin, doxycycline, azithromycin, clarithromycin, cefotaxime, ceftriaxone, cefuroxime, cefuroxime axetil, ampicillin-clavulanate Bismuth subsalicylate + tetracycline + metronidazol e + PPI TMP-SMZ,5 aminoglycoside,12 imipenem13 or meropenem,13 a fluoroquinolone,2 aztreonam, ticarcillinclavulanate, ampicillin-sulbactam, piperacillin-tazobactam Doxycycline rifampin

Amoxicillin + clarithromycin + proton pump inhibitor (PPI) A cephalosporin

Legionella species (pneumonia) Proteus mirabilis Proteus vulgaris and other species (Morganella, Providencia) Pseudomonas aeruginosa

Azithromycin, or fluoroquinolones2 rifampin Ampicillin

An aminoglycoside,12 TMP-SMZ,5 a fluoroquinolone,2 a cephalosporin8 Aminoglycoside,12 imipenem, TMP-SMZ,5 a fluoroquinolone2

Cefotaxime, ceftriaxone

Piperacillin-tazobactam or ceftazidime or cefepime, or imipenem or meropenem aminoglycoside12 Ceftazidime

Ciprofloxacin (or levofloxacin) piperacillin-tazobactam; ciprofloxacin (or levofloxacin) ceftazidime; ciprofloxacin (or levofloxacin) cefepime Tetracycline,4 TMP-SMZ,5 amoxicillinclavulanic acid, imipenem or meropenem Chloramphenicol + streptomycin

Burkholderia pseudomallei (melioidosis) Burkholderia mallei (glanders) Salmonella (bacteremia) Serratia

Streptomycin + tetracycline4

Ceftriaxone Carbapenem

A fluoroquinolone2 TMP-SMZ,5 aminoglycosides,12 a fluoroquinolone,2 cefotaxime, ceftriaxone

Shigella

A fluoroquinolone2

Azithromycin, ampicillin, TMPSMZ,5 ceftriaxone TMP-SMZ,5 a fluoroquinolone2

Vibrio (cholera, sepsis)

A tetracycline4

Yersinia pestis Streptomycin a tetracycline4 (plague, tularemia) Gram-positive rods Actinomyces anthrax Penicillin6 ciprofloxacin or doxycycline for anthrax Penicillin6

Chloramphenicol, TMP-SMZ5

Tetracycline,4 clindamycin Penicillin Erythromycin,3 a fluoroquinolone2 Metronidazole, clindamycin, imipenem or meropenem

Clostridium (eg, gas gangrene, tetanus)

Corynebacteri Erythromycin3 um diphtheriae Corynebacteri Vancomycin um jeikeium Listeria Acid-fast rods Mycobacteriu m tuberculosis14 Mycobacteriu m leprae Mycobacteriu m kansasii Mycobacteriu m avium complex Mycobacteriu Isoniazid (INH) + rifampin + pyrazinamide etha mbutol (or streptomycin) Ampicillin aminoglycoside12

Penicillin6

A fluoroquinolone TMP-SMZ5

Other antituberculous drugs (see Tables 9 12 and 913)

Dapsone + rifampin clofazimine Minocycline, ofloxacin, clarithromycin INH + rifampin ethambutol Clarithromycin or azithromycin + ethambutol, rifabutin Amikacin + clarithromycin Clarithromycin, azithromycin, ethionamide, cycloserine Amikacin, ciprofloxacin

Cefoxitin, rifampin, sulfonamide,

m fortuitumchelonei Nocardia Spirochetes Borrelia burgdorferi (Lyme disease) Borrelia recurrentis (relapsing fever) Leptospira Treponema pallidum (syphilis) Treponema pertenue (yaws) Doxycycline, amoxicillin, cefuroxime axetil TMP-SMZ5

doxycycline, linezolid Minocycline, imipenem or meropenem, linezolid Ceftriaxone, cefotaxime, penicillin, azithromycin, clarithromycin

Doxycycline4

Penicillin6

Penicillin6 Penicillin6

Doxycycline, 4 ceftriaxone Doxycycline, ceftriaxone

Penicillin6

Doxycycline

Mycoplasmas Clarithromycin or azithromycin or A fluoroquinolone,2 erythromycin3 doxycycline Chlamydiae C psittaci Doxycycline Chloramphenicol Ofloxacin C trachomatis Doxycycline or azithromycin (urethritis or pelvic inflammatory disease) C pneumoniae Doxycycline4

Erythromycin,3 clarithromycin, azithromycin, a fluoroquinolone2,15


Chloramphenicol, a fluoroquinolone2

Rickettsiae Toxoplasmosis

Doxycycline4 PYRIMETHAMINE +SULFONAMIDE with folinic acid (If sulfadiazine toxicity develops replace it with clindamycin) spiramycin

Primary prophylaxis: is trimethoprimsulfamethoxazole.

pregnancy

pneumocystis jirovecii

Combo of TRIMETHOPRIM and SULFAMETHOXAZOLE (both folate inhibitors) for 21 days

African trypanosomiasis early Pentamidine, suramin CNS involvement

Eflornithine

Melarsoprol

Nifurtimox

American Trypanosomiasi s (Chagas nifurtimox Disease) visceral leishmaniasis Cutaneous leishmaniasis liposomal amphotericin B or sodium stibogluconate

Benznidazole

sodium stibogluconate

Trichomona Giardia

Metronidazole

schistosomiasis Praziquantel Liver and lung flukes noninvasive tapeworm infections Praziquantel

Praziquantel

Niclosamide

neurocysticerco Albendazole sis primary hydatid cyst Albendazole (Echinococcus granulosus) Nematodes (round worms, etc) Albendazole or pyrantal palmoate

Praziquantel

Mebendazole, Praziquantel

Mebendazole

Strongyloides sterocoralis Filariasis

ivermectin

Thiabendazole/albendazole

Diethyl caramazine (DEC) (kills microfilaria and adults forms)

Ivermectin or albendazole (only microfilaria)

Onchocerciasis Ivermectin Antibioticassociated C. difficile disease

DEC

Metrodinazole or Vancomycin

Adapted, with permission, from Treat Guide Med Lett. 2007 May;5(57):3350.

Fluoroquinolones include ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin, and others (see text). Gemifloxacin, levofloxacin, and moxifloxacin have the best activity against gram-positive organisms, including penicillin-resistant S pneumoniae and methicillin-sensitive S aureus. Activity against enterococci and S epidermidis is variable. Erythromycin estolate is best absorbed orally but carries the highest risk of hepatitis; erythromycin stearate and erythromycin ethylsuccinate are also available. All tetracyclines have similar activity against most microorganisms. Minocycline and doxycycline have increased activity against S aureus.
5 4 3

TMP-SMZ is a mixture of 1 part trimethoprim and 5 parts sulfamethoxazole.

Penicillin G is preferred for parenteral injection; penicillin V for oral administrationto be used only in treating infections due to highly sensitive organisms. Infections caused by isolates with intermediate resistance may respond to high doses of penicillin, cefotaxime, or ceftriaxone. Infections caused by highly resistant strains should be treated with vancomycin. Many strains of penicillin-resistant pneumococci are resistant to macrolides, cephalosporins, tetracyclines, and TMP-SMZ. Most intravenous cephalosporins (with the exception of ceftazidime) have good activity against gram-positive cocci.
9 8 7

Parenteral nafcillin or oxacillin; oral dicloxacillin, cloxacillin, or oxacillin.

Addition of gentamicin indicated only for severe enterococcal infections (eg, endocarditis, meningitis). Linezolid, daptomycin, tigecycline, quinupristin-dalfopristin should be reserved for the treatment of vancomycin resistant isolates or in patients intolerant of vancomycin. Aminoglycosidesgentamicin, tobramycin, amikacin, netilmicinshould be chosen on the basis of local patterns of susceptibility.
13 12 11

10

Extended beta-lactamaseproducing isolates should be treated with a carbapenem. Resistance is common and susceptibility testing should be done. Ciprofloxacin has inferior antichlamydial activity compared with newer fluoroquinolones.

14

15

Key: , alone or combined with.


Nosocomial infections due to gram(-) bacilli that is resistant to ALL other chemotherapy and involving Pseudomonas aeruginosa Polymixin E (colistin) Nosocomial infections due to gram(-) bacilli that is resistant to ALL other chemotherapy and involving Acinetobacter Polymixin E (colistin)

Table 355. Drugs for the prevention of malaria in travelers.1 Drug Use2 Adult Dosage (All Oral)3 500 mg weekly 1 tablet (250 mg atovaquone/100 mg proguanil) daily 250 mg weekly 100 mg daily 30 mg base daily for 14 days after travel

Chloroquine Areas without resistant Plasmodium falciparum Malarone Areas with multidrug-resistant P falciparum

Mefloquine Areas with chloroquine-resistant P falciparum Doxycycline Areas with multidrug-resistant P falciparum Primaquine Terminal prophylaxis of Plasmodium vivax and Plasmodium ovale infections; alternative for P falciparum prophylaxis
4

Malaria-Clinical Setting
Chloroquine-sensitive Plasmodium falciparum and Plasmodium malariae infections Plasmodium vivax and Plasmodium ovale infections

Drug Therapy1
Chloroquine phosphate, 1 g, followed by 500 mg at 6, 24, and 48 hoursorChloroquine phosphate, 1 g at 0 and 24 hours, then 0.5 g at 48 hours Chloroquine (as above), then (if G6PD normal) primaquine, 30 mg base daily for 14 days

Alternative Drugs

For infections from Indonesia and Papua New Guinea: therapies listed for uncomplicated chloroquine-resistant P falciparum plus primaquine Mefloquine, 15 mg /kg once or 750 mg, then 500 mg in 68 hours or ASAQ2 (artesunate 100 mg, amodiaquine 270 mg), two tablets daily for 3 days

Uncomplicated infections Coartem (artemether 20 mg, with chloroquine-resistant lumefantrine 120 mg), four tablets P falciparum twice daily for 3 days Malarone, four tablets (total of 1 g atovaquone, 400 mg proguanil) daily for 3 days Quinine sulfate, 650 mg three times daily for 37 days Plus one of the following (when quinine given for < 7 days) Doxycycline, 100 mg twice daily for 7 days or Clindamycin, 600 mg twice daily for 7 days Severe or complicated infections with P falciparum3 Artesunate 2.4 mg/kg IV every 12 hours for 1 day, then daily3,6

Quinidine gluconate,46 10 mg/kg IV over 12 hours, then 0.02 mg/kg IV/min or Quinine dihydrochloride,2,46 20 mg/kg IV over 4 hours, then 10 mg/kg IV every 8 hours or Artemether,2,6 3.2 mg/kg IM, then 1.6 mg/kg/d IM

Amebiasis Asymptomatic intestinal infection

Drugs of Choice and Adult Dosage Luminal agent: Diloxanide furoate,2 500 mg orally three times daily for 10 days or Iodoquinol, 650 mg orally three times daily for 21 days or Paromomycin, 10 mg/kg orally three times daily for 7 days

Alternative Drugs and Adult Dosage

Mild to moderate intestinal infection

Metronidazole, 750 mg orally Luminal agent (see above)plus either three times daily (or 500 mg IV every 6 hours) for 10 days plus Luminal agent (see above) Tetracycline, 250 mg orally three times daily for 10 days or Erythromycin, 500 mg orally four times daily for 10 days

Severe intestinal infection

Metronidazole, 750 mg orally Luminal agent (see above) three times daily (or 500 mg IV every 6 hours) for 10 days or plus either

Tinidazole, 2 g orally daily for Tetracycline, 250 mg orally three times daily for 3 days 10 days plus Luminal agent (see above) Hepatic abscess, ameboma, and other extraintestinal disease or Dehydroemetine 3 or emetine,2 1 mg/kg SC or IM for 35 days

Metronidazole, 750 mg orally Dehydroemetine 3 or emetine,2 1 mg/kg SC or three times daily (or 500 mg IM for 810 days, followed by (liver abscess IV every 6 hours) for 10 days only) chloroquine, 500 mg orally twice daily for 2 days, then 500 mg daily for 21 days or Tinidazole, 2 g orally daily for plus 3 days plus Luminal agent (see above) Luminal agent (see above)

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