Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Isospora Belli Infection
Initial Therapy Trimethoprim/ sulfamethoxazole *Pyr
(160/800mg) IV/PO q6h PLUS
Cryptosporidiosis Folin
Cryptosporidium sp. OR
Cipro
Symptomatic treatment of diarrhoea
Microsporidiosis
Microsporidium sp. Albendazole 400mg PO q12h for 2-4 weeks
PLUS
Symptomatic treatment of diarrhoea
(The best treatment option is ART and
fluid support)
Syphilis (Treponema pallidum Infection)
Refer to section (Sexually Transmitted Disease)
9
ment
Comments
Alternative
rimethamine 50-75mg PO q24h Duration: 10 days
S *Requires DG's Approval
nic acid 10-25mg PO q24h
ofloxacin 500mg PO q12h
Effective ART (to increase CD4 >100 cells/µL) can result in
complete, sustained clinical, microbiological and histologic
resolution.
Effective ART (to increase CD4 >100 cells/µL) can result in
complete, sustained clinical, microbiological and histologic
resolution.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Bartonellosis
For Bacillary Angiomatosis, Peliosis Hepatis, Doxycycline 100mg PO q12h Azith
Bacteraemia, and Osteomyelitis OR OR
Erythromycin 500mg PO/IV q6h Clari
Other Severe Infections (or CNS involvement) Doxycycline 100mg PO/IV q12h
PLUS/MINUS
Rifampicin 300mg PO/IV q12h
OR
Erythromycin 500mg PO/IV q6h
PLUS/MINUS
Rifampicin 300mg PO/IV q12h
Confirmed Bartonella Endocarditis Refer to section (Cardiovascular infections)
References:
1. Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and
and Prevention (CDC) and HIV Medicine Association of the Infectious Disease Society of America
2. The BMJ Best Practices: HIV-related opportunistic infections
3. The Sanford Guide to Antimicrobial Therapy (updated 16/02/2018)
4. The John Hopkins POC-IT ABX Guide 2000-2017
5. European AIDS Clinical Society Guidelines
9
ment
Comments
Alternative
hromycin 500mg PO q24h Duration: At least 3 months
ithromycin 500mg PO q12h If relapse occurs after initial (>3 month) course of therapy,
long-term suppression with doxycycline or a macrolide is
recommended as long as CD4 <200 cells/µL.
d Adolescents by panel members of National Institutes of Health (NIH), the Centers for Disease Control
a (HIVMA/IDSA) 2017.
10
SECTION A
ADULT
A6 Obstetrics &
Gyneacological Infections
National Antimicrobial Guideline 2019 101
A6. Obstetrics & Gyneacological Infections Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Septic Abortion Ampicillin 2gm IV q4-6h Amp
Common organisms: PLUS PLUS
Bacteroides sp (especially Prevotella bivia) Gentamicin 5mg/kg IV q24h Doxy
Streptococcus sp (Grp A, Grp B) PLUS
Enterobacteriaceae Metronidazole 500mg IV q8h OR
Chlamydia trachomatis
Ureaplasma urealyticum Clind
PLUS
Intra-partum antibiotic prophylaxis (IAP) for Benzylpenicillin 5MU IV initial dose, Gent
Group B Streptococcus (GBS) positive mothers then 2.5–3MU IV q4h until delivery Amp
IV q4
Indications of IAP:
• Previous infant with invasive GBS disease Mild
• Preterm labour Cefa
• GBS carriage in previous pregnancy q8h
• PPROM with known GBS carrier OR
• GBS carriage in current pregnancy Cefu
q8h
Seve
Vanc
deliv
OR
Clind
Preterm Premature Rupture of Membranes If non-GBS carrier:
(PPROM) Erythromycin Ethylsuccinate 400mg
PO q6h for 7-10 days
If GBS carrier:
Ampicillin 2gm IV q6h for 48 hours
10
ment
Alternative Comments
picillin/sulbactam 3gm IV q6h Intravenous antibiotics are administered until the patient has
S improved and afebrile for 48 hours, then are typically
ycycline 100mg PO q12h followed by oral antibiotics
damycin 900mg IV q8h To complete a 10-14 days course.
S
tamicin 5mg/kg IV q24h
picillin 2 gm IV initial dose, then 1 gm Prophylaxis begins at hospital admission for labour or
4h until delivery. rupture of membrane and continued every four hours until
the infant is delivered.
d Antibiotic allergy
azolin 2 gm IV initial dose, then 1 gm Antibiotic allergy refer to Appendix 8
until delivery
Treatment is NOT INDICATED if
uroxime 1.5 gm IV stat and 750mg IV C-section performed before onset of labour with intact
until delivery membrane (please use standard surgical prophylaxis)
ere Antibiotic allergy Antenatal treatment is NOT RECOMMENDED for GBS
comycin 15-20 mg/kg IV q8-12h until cultured from a vaginal or rectal swab.
very
damycin 900mg IV q8h until delivery.
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Chorioamnionitis followed by Amoxicillin 500mg PO q8h for
an additional 5-7 days or until delivery
Pelvic Inflammatory Disease whichever comes first
Common organisms: PLUS
Neisseria gonorrhoeae One dose of Azithromycin 1gm PO upon
Chlamydia trachomatis admission
Bacteroides sp (to cover for Ureaplasmas – important
Enterobactericiae cause of chorioamnionitis & Chlamydia)
Haemophilus influenza
Streptococcus sp especially Streptococcus Ampicillin 2gm IV q6h Amp
agalactiae (GBS) PLUS
Gardnerella vaginalis Gentamicin 5mg/kg IV q24h Mild
Ureaplasma urealyticum Cefa
Mycoplasma hominis If the patient is undergoing a cesarean PLUS
delivery: Gent
PLUS
Metronidazole 500mg IV q8h Seve
Clind
Outpatient regimen (Mild-moderate):
Ceftriaxone 500mg IM in a single dose
OR
Cefotaxime 1gm IM in a single dose
PLUS
Metronidazole 400mg PO q12h for 14 days
PLUS
Doxycycline 100mg PO q12h for 14 days
OR
Azithromycin 1gm PO once per week for
2 weeks
10
ment
Comments
Alternative
picillin/ sulbactam 3gm IV q6h Antibiotic regimen is continued postpartum until patient is
d Antibiotic allergy: afebrile and asymptomatic for AT LEAST 48 HOURS
azolin 2gm IV q8h
S There is NO evidence that continuation with oral antibiotic
tamicin 5mg/kg IV q24h are beneficial after discontinuation of parenteral therapy
ere Antibiotic allergy: Antibiotic allergy refer to Appendix 8
damycin 900mg IV q8h
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Endometritis Inpatient regimen (Moderate-severe): Amp
Cefuroxime 1.5gm IV q8h PLUS
Vaginitis OR Doxy
Bacterial vaginosis Ceftriaxone 2gm IV q24h
Vaginal Candidiasis Amo
Candida albicans PLUS OR
Uncomplicated infection Doxycycline 100mg PO q12h Amp
PLUS
Metronidazole 500mg IV/PO q8h Clind
Fluco
Duration of treatment: 14 days
Non-pregnancy:
Follow antibiotic guide for severe PID
Post-partum endometritis:
Clindamycin 900mg IV q8h
PLUS
*Gentamicin 5mg/kg q24h
OR
Cefotaxime 1gm IV q8h
PLUS
Metronidazole 500mg IV q8h
PLUS
*Gentamicin 5mg/kg IV x 1 dose
Metronidazole 400mg PO q12h for
5-7 days
Clotrimazole 500mg as a single vaginal
pessary (Stat dose)
OR
ment 10
Alternative Comments
picillin/sulbactam 3gm IV q6h Tubo ovarian abscess:
S Surgical intervention for source control may be required.
ycycline 100mg PO q12h May need to consider tuberculosis if not responding to
standard treatment
oxicillin/clavulanate 1.2gm IV q8h Duration of treatment: 10-14 days
picillin/sulbactam 3gm IV q6h *TDM for gentamicin is required
damycin 300mg PO q12h for 7 days Metronidazole can be use in any stage of pregnancy
onazole 150-200mg PO for one dose Pregnancy:
If indicated, treat with topical therapy as oral therapy is
CONTRAINDICATED.
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Vaginal Candidiasis Clotrimazole 200mg as vaginal pessary
Candida albicans for 3 nights
Complicated infections:
Severe vaginitis symptoms:
Trichomoniasis Fluconazole 150-200mg PO q72h for 2 or
Trichomonas vaginalis 3 doses
Recurrent vulvovaginal candidiasis: Clotr
Fluconazole 150-200mg PO q72h for 3 once
doses then weekly for 6 months
Metronidazole 400mg PO q8h for 7 days
OR
Metronidazole 2gm PO as single dose
Cervicitis Azithromycin 1gm single dose Doxy
Cefa
Postpartum mastitis Outpatient
Common organisms: Cephalexin 500mg PO q6h for 5-7 days
Staphylococcus aureus (MSSA)
Streptococcus pyogenes (Grp A, B) Inpatient
Escherichia coli Cloxacillin 2gm IV q6h
Bacteroides sp
Corynebacterium sp 1st and 2nd degree tear:
CoNS Antibiotics not required
Post episiotomy tear 3rd and 4th degree tear:
Cefuroxime 1.5gm IV as single dose
Antib
Clind
10
ment
Comments
Alternative
rimazole 500mg vaginal suppository
e weekly for 6 months
Metronidazole can be use in any stage of pregnancy
(reference)
If post-partum and breastfeeding, not advisable to
breastfeed during treatment. May resume breastfeeding
after 24 hrs of the last dose.
ycycline 100mg PO q12h for 7 days
Duration of therapy for 5-7 days may be adequate but if
poor response consider extending to 10-14days.
azolin 1-2gm IV q8h Milk culture for less severe infection
If severe infection (hemodynamic instability) blood culture
required
Antibiotic allergy refer to Appendix 8
biotic allergy:
damycin 600mg IV as single dose
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Manual removal of placenta Ampicillin 2gm IV as single dose Cefa
Post Lower Segment Caesarean Section
(LSCS) infection In mild Surgical Site Infections (SSI), antibiotic is
dressing is the primary treatment.
Cloxacillin 2gm q6h Risk
OR infec
Cefazolin 1-2gm IV q8h Amp
References:
1. Savaris RF, de Moraes GS, Cristovam RA, Braun RD. Are antibiotics necessary after 48hours of im
J ObstetGynecol.2011;204(4):301.e1.Epub 2010 Dec31
2. Mackeen A, Packard RE, Ota E, Speer L. Antibiotic Regimens for postpartum endometritis. Cochr
3. Prevention of early-onset Group B Streptococcal Disease in newborns. Committee Opinion No. 48
4. Hughes RG, Brocklehurst P, Steer PJ, Heath P, Stenson BM on behalf of the Royal College of Obs
5. early-onset neonatal group B streptococcal disease. Green-top Guideline No. 36. BJOG 2017;124
6. NICE Guideline.Pretermlabor and birth.https://www.nice.org.uk/guidance/ng25/resources/preterm
7. Hemsell DL, Little BB, Faro S et al. Comparison of three regimens recommended by the Centers f
inflammatory disease. Clin Infect Dis 1994;19(4):720-727
8. UK National Guideline for Management of Pelvic Inflammatory Disease 2011. Clinical Effectivenes
9. World Health Organization; Mastitis: causes and management; Geneva, Switzerland; accessed21/
10. Workowski KA, Bolan GA, Centers for Disease Control and Prevention: Sexually transmitted disea
11. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized
12. WHO guidelines for the management of postpartum hemorrhage and retained placenta, 2009
10
ment
Comments
Alternative
azolin 2gm IV as single dose
s generally not indicated. Appropriate
k of Gram negative or anaerobic
ction (eg: Diabetes):
picillin/sulbactam 3gm IV q6-8h
mprovement in infected/septic abortions? A randomized controlled trial followed by cohort study. Am
rane Database Syst Rev 2:2015
85.American College of Obstetricians and Gynecologists. ObstetGynecol 2011;117:1019-27
stetricians and Gynaecologists. Prevention of
4:e280–e305.
m-labour-and-birth
for Disease Control and Prevention for the treatment of women hospitalized with acute pelvic
ss Group British Association for Sexual Health and HIV. 2011
/3/2018
ases treatment guidelines, 2015. MMWR Recomm Rep 64:1, 2015
controlled trial, 2008
SECTION A
ADULT
A7 Ocular Infections
National Antimicrobial Guideline 2019 107
A7. Ocular Infections Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Dosage alterations in Ophthalmology NAG:
Dose alteration may be needed for systemic and intravitreal antibiotics in paediatric patients.
Blepharitis Eyelid hygiene/ scrubs is the mainstay of Oxyt
Common organisms: therapy ointm
Staphylococcus aureus OR
Staphylooccus epidermidis Topical antibiotics are not indicated as an Fusid
initial therapy q12h
Meibomian Gland Dysfunction Warm compresses and massage In re
Systemic therapy is not indicated as an *Dox
initial therapy. 4-6 w
OR
Azith
Internal Hordeolum with Secondary Infection Warm compresses Amo
Staphylococcus aureus Cloxacillin 500mg PO q6h
Systemic antibiotics are indicated in the presence
of superficial cellulitis or abscess.
External Hordeolum (Stye) Epilation of affected eye lash and warm
Staphylococcus aureus compresses
In the presence of superficial cellulitis or abscess.
Cloxacillin 500mg PO q6h Amo
Bacterial Conjunctivitis Chloramphenicol 0.5% eye drop q6h Mox
Common organisms: OR
Staphylococcus aureus Cipro
Streptococcus pneumonia OR
Haemophilus influenzae Levo
10
ment
Comments
Alternative
tetracycline with Polymyxin B eye
ment applied q12h to the lid margin
dic Acid 1% eye ointment applied
h to the lid margin
esistant cases: *Tetracyclines are contraindicated in children <8 years.
xycycline 100mg PO q12h for
weeks
hromycin 500mg PO q24h for 3 days
Duration: 5 days
oxicillin/clavulanate 625mg PO q8h
Duration: 5 days
oxicillin/clavulanate 625mg PO q8h
xifloxacin 0.5% eye drop q6h
ofloxacin 0.3% eye drop q6h
ofloxacin 0.5% eye drop q6h
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Gonococcal Conjunctivitis (including neonates) Requires systemic therapy. Refer to Sexually Tran
Neisseria Gonorrhoea Infection Sections
Chlamydial Conjunctivitis (including neonates) Requires systemic therapy. Refer to Sexually Tran
Chlamydial Trachomatis Infection Sections
Bacterial Keratitis Ciprofloxacin 0.3% eye drop q1-2h *Cef
No Growth OR PLUS
Moxifloxacin 0 .5% eye drop q1-2h *Gen
OR
Levofloxacin 0.5% eye drop q1-2h
Contact Lens Related Bacterial Keratitis Ciprofloxacin 0.3% eye drop q1-2h *Gen
No Growth OR PLUS
Levofloxacin 0.5% eye drop q1-2h *Cef
Bacterial Keratitis Moxifloxacin 0 .5% eye drop q1-2h *Cef
Gram-positive cocci For M
* Va
Bacterial Keratitis Ciprofloxacin 0.3% eye drop q1-2h *Gen
Gram-negative rods OR PLUS
Levofloxacin 0.5% eye drop q1-2h *Cef
Acanthamoeba Keratitis *Chlorhexidine 0.02% eye drop q1-2h
Acanthamoeba sp. PLUS
**Propamidine isethionate 0.1% eye
drop q1-2h
Fungal Keratitis **Natamycin 5% eye drop q1-2h */**
OR OR
10
ment
Alternative Comments
nsmitted Infections & Neonatal Copious irrigation with topical saline drops or artificial tears
every 30-60 minutes.
Topical antibiotics may be considered as ancillary therapy.
nsmitted Infections & Neonatal
furoxime 5% eye drop q1-2h *Prepared extemporaneously using injectable forms
S
ntamicin 0.9% or 1.4% eye drop q1-2h
ntamicin 0.9% or 1.4% eye drop q1-2h *Prepared extemporaneously using injectable forms
S
ftazidime 5% eye drop q1-2h
furoxime 5% eye drop q1-2h *Prepared extemporaneously using injectable forms
MRSA:
ancomycin 5% eye drop q1-2h
ntamicin 0.9% or 1.4% eye drop q1-2h *Prepared extemporaneously using injectable forms
S
ftazidime 5% eye drop q1-2h
*Prepared extemporaneously using injectable forms
**Requires DG’s Approval
*Voriconazole 1% eye drop q1-2h Natamycin is the choice therapy for fusariam
Amphotericin B is the choice therapy for candida
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Herpes Simplex Keratitis *Amphotericin B 0.15%-0.2% eye drop *Fluc
Herpes Simplex Type 1 & 2 q1-2h
Oral
Herpes Zoster Ophthalmicus May
Herpes Zoster Virus cont
Ocular Toxoplasmosis Fluco
Toxoplasma gondii OR
Keto
Acyclovir 3% eye ointment 5 times/day
In presence of stromal or endothelial
disease:
Acyclovir 400mg PO 5 times/day for
7-14 days
Prophylaxis for recurrent cases:
Acyclovir 400mg PO q12h for 12 months
Needs systemic therapy. Refer to Skin & Soft Tiss
Trimethoprim/sulfamethoxazole *Pyr
160/800mg PO q12h for at least 6 weeks PLUS
Folin
PLUS
*Sul
OR
Azitr
OR
Clind
then
11
ment
Alternative Comments
conozole 0.2% eye drop q1-2h In severe fungal keratitis – combination therapy may be
used
l Therapy: *Prepared extemporaneously using injectable forms
be considered in the absence of **Requires DG’s Approval
traindications.
onozole 200mg PO q24h
oconazole 200mg PO q24h
sue Infections Section
rimethamine 25-50mg PO q24H Pregnancy : May consider Intravitreal Clindamycin
S 1.0mg/0.1ml
nic acid 10-25mg PO q24H
S Systemic steroids are usually indicated in
immunocompetent patients.
lfadiazine 1gm PO q6H
*Requires DG's Approval
romycin 500mg PO q24h
damycin 300mg PO q6h for 3-4 weeks,
n 150mg q6h PO for 3-4 weeks
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Acute Retinal Necrosis Prophylaxis for recurrent lesions:
Herpes Simplex Trimethoprim/sulfamethoxazole 80/400mg
q12h PO for 3 times a week
CMV Retinitis
Cytomegalovirus Acyclovir 10mg/kg/dose IV q8h (not more * Va
than 800mg) for 10-14 days
FOLLOWED BY
Acyclovir 800mg PO 5 times/day for 6 weeks
Systemic therapy: Syst
Ganciclovir 5mg/kg IV q12h for 2-3 weeks * Va
3 we
PO q
Intravitreal therapy: Intra
Intravitreal Ganciclovir 2mg/0.1ml biweekly *Intr
(1-2w
Ocular Syphilis Ocular Syphilis (syphilitic uveitis) should be treate
Treponema Pallidum Refer to Sexually Transmitted Infections Section
Ocular Tuberculosis Needs systemic therapy.
Mycobacterium Tuberculosis Refer to Ministry of Health’s CPG on
Management of Tuberculosis (Extra
pulmonary TB)
*Ethambutol may cause optic neuropathy
and should be avoided depending on the
case.
11
ment
Comments
Alternative
alacyclovir 1gm PO q8H for 6 weeks *Requires DG’s Approval
Systemic steroid is indicated depending on location or
severity of the infection.
temic therapy: Systemic therapy is indicated in all cases.
alganciclovir: 900mg PO q12h for
eeks (induction) followed by 900mg Maintenance may need to continue until CD4 count is >150
q24h (maintenance) cells/mm3 for 3 consecutive months.
avitreal therapy:
ravitreal Foscarnet 2.4mg/0.1ml Intravitreal therapy is indicated in zone 1 and 2 lesions.
weekly)
Intravitreal to be tapered according to clinical response.
ed as Neurosyphilis.
Ganciclovir implant: 4.5gm an option for prolonged usage of
intravitreal Ganciclovir.
*Requires DG’s Approval
Referral to Dermatologist/ ID Physician
Ocular TB: presents as a unilateral/ bilateral infective uveitis
characterized by multifocal choroiditis/ granuloma and there
may be supportive FFA findings of occlusive vasculitis. The
diagnosis maybe clinical as vitreous sampling for AFB or
TB PCR may not be very sensitive due to small sample
size and sensitivity of the tests. Clinical response to anti-
TB is often diagnostic.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Post Operative Bacterial Endophthalmitis Intravitreal antibiotic injections: Intra
Common organisms: Vancomycin 1-2mg/0.1ml Vanc
Staphylococcus epidermidis Staphylococcus PLUS PLUS
aureus Pseudomonas aeruginosa Ceftazidime 2mg/0.1ml Amik
Bacteroids species
Streptococcus pneumoniae If suspicious of fungal endophthalmitis:
Alpha-haemolytic streptococcus ADD
Intravitreal Amphotericin B 0.005mg/0.1ml
Topical treatment-options:
• *Ceftazidime 5% eye drop
• *Vancomycin 5% eye drop
• *Gentamicin 1.4% eye drop
• Moxifloxacin 0.5% eye drop
• Levofloxacin 0.5% eye drop
(monotherapy or combination)
ment 11
Alternative Comments
avitreal antibiotic injections: Uveitis secondary to TB Hypersensitivity is an immune
comycin 1-2mg/0.1ml response to acid fast bacilli in the eye and manifests
S predominantly as an inflammatory uveitis. Treatment
kacin 0.4mg/0.1ml includes anti-TB in combination with an
immunosuppressive dose of systemic steroids for at least 6-
9 months.
Systemic steroids maybe indicated but is only for
• non-active systemic TB
• immunocompetent patients
• severe ocular inflammation developing after starting
anti-TB treatment and
• vision threatening condition
Systemic steroids should not be started ALONE without
anti-TB treatment.
Systemic antibiotics are indicated in severe, virulent
endophthalmitis.
Repeat intravitreal antibiotics after 48 to 72 hours if
indicated.
*Prepared extemporaneously using injectable forms
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Post Operative Fungal Systemic treatment: Syst
Endophthalmitis Ciprofloxacin 750mg PO q12h for 10 days Vanc
For culture negative cases: not t
Endogenous Endophthalmitis ADD PLUS
Systemic treatment Clarithromycin 250-500mg PO q12h for Cefta
7-14 days
Intravitreal therapy: Intra
Intravitreal Amphotericin B 0.005mg/0.1ml *Intr
OR
*Intr
50ug
Systemic therapy: Syst
Fluconazole 200mg PO q24h for 6 weeks * Vo
(minimum)
Systemic therapy: Syst
Ciprofloxacin 750mg PO q12h for 10 days Vanc
to ex
For culture negative cases:
ADD PLUS
Clarithromycin 250-500mg PO q12h Cefta
for 7-14 days
Topical treatment-options:
• *Ceftazidime 5% eye drop
• *Vancomycin 5% eye drop
• *Gentamicin 0.3% eye drop
• Moxifloxacin 0.5% eye drop
• Levofloxacin 0.5% eye drop
(monotherapy or combination)
11
ment
Comments
Alternative
temic treatment:
comycin 15-20mg/kg IV q8-12h;
to exceed 2gm/dose
S
azidime 1-2gm IV q8h
avitreal therapy: Intravitreal and Systemic therapy are indicated in all cases.
ravitreal Miconazole 0.01mg/0.1ml *Requires DG’s Approval
ravitreal Voriconazole
g-100ug/0.1ml
temic therapy:
oriconazole 200mg PO q12h
temic therapy: Treatment is based on primary infection (bacterial/fungal
comycin 15-20mg/kg IV q8-12h; not etc) and culture and sensitivity results.
xceed 2gm/dose
All cases require systemic therapy. Intravitreal injection is
S indicated in cases with vitreous involvement and sight
azidime 1-2gm IV q8h threatening choroidal lesions.
Topical therapy may supplement therapy. Not to use
systemic steroids in these cases.
Review antibiotic regimen after microbiology results. Repeat
intravitreal antibiotics after 48 to 72 hours if indicated.
*Prepared extemporaneously using injectable forms
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Ocular Melioidosis Intravitreal antibiotic injections: Intra
Ocular Bartonellosis Vancomycin 1-2mg/0.1ml Vanc
Ocular Leptospirosis PLUS PLUS
Dacryocystitis Ceftazidime 2mg/0.1ml Amik
Common organisms:
Streptococcus pneumonia If suspicious of fungal endophthalmitis: ADD
Staphylococcus aureus Intravitreal Amphotericin B 0.005mg/0.1ml
Gram-negative anaerobes
Preseptal Cellulitis For ocular manifestations of Melioidosis, refer to
Common organisms:
Streptococcus pneumoniae For ocular manifestations of Bartonella, refer to tr
Staphylococcus aureus Streptococcus sp.
Orbital Cellulitis/abscess For ocular manifestations of Leptospira, refer to t
Common organisms:
Streptococcus pneumoniae Cefuroxime 250mg PO q12h Amo
Staphylococcus aureus Streptococcus sp.
Gram-negative anaerobes Cloxacillin 500-1000mg PO q6h for 5 days Amo
for 7
OR
Ceftr
Amoxicillin/clavulanate 1.2gm IV q8h Ceftr
If An
ADD
Metr
11
ment
Comments
Alternative
avitreal antibiotic injections:
comycin 1-2mg/0.1ml
S
kacin 0.4mg/0.1ml
treatment of Melioidosis infection. Consider intravenous antibiotics in severe infections.
reatment of Bartonella infection. Duration: 7 days
treatment of Leptospira infection.
oxicillin/clavulanate 625mg PO q8h
oxicillin/clavulanate 625mg PO q8h Consider intravenous antibiotics in severe infections.
7 days Duration: 7-10 days
riaxone 1-2gm IV q24h
riaxone 1-2gm IV q24h
naerobes suspected:
D
ronidazole 500mg IV q8h
References:
1. Sobrin L, Kump L, Foster CS. Intravitreal clindamycin for toxoplasmicretinochoroiditisRetina 200
2. Patrick MKT, Claire Y H, Susan L. Antiviral selection in the management of acute retinal necrosis.
3. Peter R, Jost H, Livia G, et al. Virus Diagnostics and Antiviral Therapy in Acute Retinal Necrosis (A
4. MN Muthiah, M Michaelides, CS Child, et al. Acute retinal necrosis: a national population-based s
J Ophthalmol2007;91:1452–1455
5. Simon RJT, Robin H, Claire YH, Sue Lightman. Valacyclovir in the treatment of acute retinal necro
6. Robert WW, Emmett TC et al. Diagnosing and Managing Acute Retinal Necrosis. Retinal Physician
7. Helm CJ, Holland GN. Ocular tuberculosis.SurvOphthalmol. 1993 Nov-Dec;38(3):229-56
8. Bodaghi B1, LeHoang P. Ocular tuberculosis. CurrOpinOphthalmol. 2000 Dec;11(6):443-8
9. CPG for Management of Post- Operative Endophthalmitis, Ministry of Health Malaysia, August 20
10. Periorbital and orbital cellulitis : A 10 year review of Hospitalized children. Eur J Ophthalmol 2010
11. Microbiology and Antibiotic Management of Orbital Cellulitis Pediatrics 2011;127;e566
11
07. Sep;27(7): 952-7.
Clinical Ophthalmology 2010:4 11–20
ARN). Antiviral Drugs – Aspects of Clinical Use and Recent Advances. Intechopen.
study to assess the incidence, methods of diagnosis, treatment strategies and outcomes in the UK. Br
osis. BMC Ophthalmology 2012, 12:48.
n.
006
0;20(6): 1066-1072
11
SECTION A
ADULT
A8 Oral/Dental Infections
National Antimicrobial Guideline 2019 117
A8. Oral/Dental Infections Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
A. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS
INFECTIONS OF THE TEETH AND SUPPORTING STRUCTURES
Reversible/ Irreversible Pulpitis Systemic antibiotic use not recommended Syst
Localised Dentoalveolar Abscess Superficial
Systemic antibiotic use not recommended Syst
(unless medically compromised) (unle
Deep Infection/ Medically Compromised Antib
Amoxicillin 500mg PO q8h Clind
PLUS
Metronidazole 400mg PO q8h
OR
Amoxicillin/clavulanate 625mg PO q8h
Dry Socket Systemic antibiotic use not recommended Syst
Localised Pericoronitis Systemic antibiotic use not recommended Syst
Chronic Gingivitis
in absence of regional or systemic signs in ab
and symptoms. and s
Systemic antibiotic use not recommended Syst
11
ment
Comments
Alternative
temic antibiotic use not recommended
Antibiotic allergy refer to Appendix 8
temic antibiotic use not recommended
ess medically compromised)
biotic allergy
damycin 300mg PO q6h
temic antibiotic use not recommended Local treatment with saline irrigation and antiseptic/
analgesic dressings and symptomatic relief of pain
temic antibiotic use not recommended Local treatment with antiseptic irrigation and mouthwash
bsence of regional or systemic signs and symptomatic relief of pain
symptoms.
temic antibiotic use not recommended 1st line treatment-Mechanical and chemical plaque control.
0.2% Aqueous Chlorhexidine Gluconate not be used alone
but as an adjunct to mechanical debridement
2nd line treatment-Antimicrobial mouth rinse
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Chronic Periodontitis Systemic antibiotic use generally not Syst
Antibiotic use can be considered in cases of: recommended. reco
1. Unresponsive to conventional mechanical Amoxicillin 500mg PO q8h Antib
PLUS Clind
therapy. Metronidazole 400mg PO q8h
2. Acute infection associated with systemic Antib
OR Clind
manifestation Amoxicillin/clavulanate 625mg PO q8h
3. Medically compromised
Amoxicillin 500mg PO q8h
Aggressive Periodontitis PLUS
Common organisms: Metronidazole 400mg PO q8h
Aggregatibacter actinomycetemcomitans
Porphyromonas gingivalis Systemic antibiotic use not recommended Syst
Tannerellafor sythensis
Prevotella intermedia
Spirochaetes
Local missed Periodontal Abscess
INFECTIONS OF THE JAWS For acute cases, start with: Antib
Amoxicillin 500mg PO q8h Clind
Osteomyelitis of the jaws of dental origin PLUS
Different organisms maybe involved. Metronidazole 400mg PO q8h
OR
Amoxicillin/clavulanate 625mg PO q8h
11
ment
Alternative Comments
temic antibiotic use generally not 1st line treatment-Mechanical plaque control
ommended. Antibiotic allergy refer to Appendix 8
biotic allergy
damycin 300mg PO q6h
biotic allergy Antibiotics are not used alone but are used as an adjunct to
damycin 300mg PO q6h scaling and root debridement.
Antibiotic allergy refer to Appendix 8
temic antibiotic use not recommended Incision and drainage
Management of cause of abscess and symptomatic relief of
pain
biotic allergy Culture and sensitivity is necessary to guide the antibiotic.
damycin 300-450mg PO/IV q6h
For chronic cases, start with surgical treatment first.
Antibiotics only when causative organisms are identified
Duration of antibiotic therapy:
can be 4-6 weeks depending on patient response /
microbiological clearance of the pathogen.
Antibiotic allergy refer to Appendix 8
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
SPREADING INFECTIONS AND INFECTIONS OF FASCIAL SPACES (WITH/WITHOUT SYSTEMIC SI
Cellulitis ±Abscess of dental origin Benzylpenicillin 2-4MU IV q4-6h Antib
Common organisms: PLUS Clind
Viridans Streptococci Metronidazole 500mg IV q8h
Staphylococci
Prevotella OR
Peptostreptococcus Amoxicillin/Clavulanate 1.2gm IV q6-8h
Fusobacterium nucleatum (not more than1.2gm in a single dose-
Clostridium sp max 7.2gm daily)
OR
Cefuroxime 750mg-1.5gm IV q8h
Surgical site infection &Traumatic wound PLUS Antib
infection Metronidazole 500mg IV q8h Clind
Infection is usually by endogenous organisms
rather than exogenous OR
Common organisms: If not responding to above antibiotics:
Viridans Streptococci Ceftriaxone 1-2gm IV q24h
Staphylococci PLUS
Prevotella intermedia Metronidazole 500mg IV q8h
Peptostreptococcus
Eubacterium Step Down/Oral Therapy:
Fusobacterium nucleatum Amoxicillin 250-750mg PO q8h
PLUS
Metronidazole 400mg PO q8-12h
OR
Amoxicillin/Clavulanate 625mg PO q8h
OR
Cefuroxime 250-500mg PO q12h
PLUS
Metronidazole 400mg PO q8-12h
12
ment
Alternative Comments
IGNS) Empirical antibiotics are started
Incision and drainage is advised and antibiotic is changed in
biotic allergy: accordance with result of culture and sensitivity.
damycin 300-450mg IV/PO q6h Antibiotic allergy refer to Appendix 8
biotic allergy:
damycin 300-450mg PO q6h
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Traumatic wound involving skin / Infection of Cloxacillin 500-1000mg IV q6h
skin origin (in skin involvement- if Staphylococcus
expected)
OR
Clindamycin 300-450mg IV/PO q6h
OR
Amoxicillin 250-750mg PO q8h
PLUS
Metronidazole 400mg PO q8-12h
POST IMPLANT INFECTIONS (“PERIIMPLANTITIS”)
Causative organisms: Amoxicillin/clavulanate 625mg PO q8h Antib
Actinomyces sp. OR Doxy
Eubacterium sp. Amoxicillin 500mg PO q8h OR
Propionibacterium sp. PLUS Clind
Lactobacillus sp. Metronidazole 400mg PO q8h
Veillonella sp.
Porphyromonas gingivalis
Prevotella intermedia
Fusobacterium nucleatum
B. ANTIMICROBIAL USE FOR FUNGAL INFECTIONS
Oral Candidiasis Refer to section [Infections in Immunicompromis
12
ment
Comments
Alternative
biotic allergy: Bacteria associated with periimplantitis are extremely
ycycline 100mg PO q12h resistant to antibiotics.
damycin 300mg PO q6h
Antibiotics are not used alone but are used as an adjunct to
sed patients – HIV] local mechanical and chemical debridement.
Also irrigation with Chlorhexidine and optimal oral hygiene
by patient.
Locally delivered antibiotics is preferred compared to
systemic administration.
Currently there is no reliable study to suggest most effective
antibiotic therapy.
Antibiotic allergy refer to Appendix 8
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
C. ANTIMICROBIAL USE FOR VIRAL INFECTIONS
Common oral viral infections: Symptomatic treatment in most cases.
Can also consider:
Herpes simplex virus type 1 (HSV-1) 1) Topical Acyclovir 5% cream q4h for
Primary herpetic gingivostomatitis
Herpes labialis 5-10 days in prodromal phase for
recurrent herpes labialis
Herpes simplex virus type 2 (HSV-2) 2) Systemic antiviral
Epstein-Barr virus Acyclovir 400-800mg PO 5 times
Infectious mononucleosis, oral hairy leukoplakia daily for 7-14 days
Varicella-zoster virus
Coxsackie virus
Herpangina
Hand, foot and mouth disease
Severe Varicella/Herpes infections or in Refer to section [Skin & Soft Tissue Infections – V
immunocompromised patients
Viral encephalitis Refer to section [Central Nervous System (CNS)In
References:
1. Antibiotics and The Treatment of Endodontic Infections, Endodontics colleagues for Excellence 2006; American
Association of Endodontics
2. Incision and Drainage and Management of Cause of Abscess and Symptomatic Relief of Pain: JCan Dent Assoc2003
Nov 69 (10):660 &Clin.Microbiol.Rev.2013,26(2):255
3. CPG 2016 Management of periodontal abscess
4. Med Oral Patol Oral Cir Bucal2005; 10:77-85
5. JClinMicrobiol.2003;41(12):5794-7
6. Journal of the Irish Dental Association 2009; 55 (4): 190 – 192
7. Clinical Periodontology-12thed.2014
8. Clinical Periodontology-9thed.2002
9. Periodontology 2000, Vol. 62, 2013, 218-231
10. CPG Management of chronic periodontitis Nov 2012 MOH,Malaysia
12
ment
Comments
Alternative
Viral Infections]
nfections – Viral Encephalitis]
11. JClin Periodontol.2012;39:284-294
12. JClin Periodontol.2011;38:43-49
13. J ClinPeriodontol 2008; 35: 696–704
14. J Periodont Res 2012; 47: 137–148
15. Periodontology 2000. Jun2014, Vol. 65 Issue 1, p149-177. 29p.
16. Malaysian Dental Journal (2008) 29(2) 154-157
17. CPG=Management of periodontal abscess-MOH,Malaysia 2003
18. Eur J Oral Implantol 2012; 5 (Suppl): S21-S41
19. Clin Oral Impl Res 2012 (23): 205-210
20. Int.J Oral Maxillofac Implants 2014 (29): 325-345
21. Clin Oral Impl Res 2000:11(suppl): 146-155
22. Aust Dent J 2005;50 Suppl 2: S31-S35
SECTION A
ADULT
A9 Otorhinolaryngology
Infections
National Antimicrobial Guideline 2019 123
A9. Otorhinolaryngology Infections Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
1. Sore Throat
The modified Centor Score can be used to help physicians decide which patients need no testing, thro
The cumulative score determines the likeli-hood of streptococcal pharyngitis and the need for antibiot
CRITERIA SCORE
Absence of cough 1
Swollen and tender anterior cervical lymph nodes 1
Temperature > 100.4° F (38° C) 1
Tonsillar exudates or swelling 1
Cumulative score:
TOTAL SCORE RISK
<3 Low ri
≥ 3 High r
References:
A clinical score to reduce unnecessary antibiotic use in patients with sore throat. Can Med Assoc J, Ja
2. Throat and Upper Respiratory Tract
Tonsillitis/Pharyngitis Phenoxymethylpenicillin (Pen V) 500mg Amo
Common organism: PO q6h or 1gm PO q12h for 5-10 days
Group A Streptococcus OR Antib
Benzathine Penicillin 1.2MU IM, one Eryth
single dose. for 5
12
ment
Comments
Alternative
oat culture/rapid antigen detection testing, or empiric antibiotic therapy.
tics:
AGE SCORE
3 to 14 years 1
15 to 44 years 0
45 years and older -1
K COMMENT
isk Do not require antibiotic therapy
risk Treat with antibiotic therapy
an. 13, 1998
oxicillin 500mg PO q8h for 5-10 days Antibiotics should be prescribed in suspected (Modified
Centor Score ≥3)/proven bacterial infections, as sore throats
biotic allergy: are commonly viral in origin.
hromycin Ethylsuccinate 800mg q12h
5-10 days Antibiotic allergy refer to Appendix 8