Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Acute Peritonsillar Abscess Ampicillin/sulbactam 3gm IV q6h Amo
Common organisms: OR OR
Group A Streptococcus Amoxicillin/clavulanate 1.2gm IV q8h
Staphylococcus aureus OR Phen
Haemophilus influenza PO q
Fusobacterium necrophorum Benzylpenicillin 2MU IV q6h PLUS
PLUS Metr
Diphteria Metronidazole 500mg IV q6-8h for
Corynebacterium diphtheriae 10-14 days OR
Clind
Antib
Clind
*Antitoxin
PLUS
Erythromycin Lactobionate 500mg IV q6h
followed by Erythromycin Ethylsuccinate
800 mg PO q12h for total of 14 days
OR
Benzylpenicillin 50,000 units/kg to a
maximum of 1.2 MU IV q12h
followed by Phenoxymethylpenicillin
(Pen V) 250mg PO q6h for total of 14 days
Acute Epiglottitis Ceftriaxone 2gm IV q24h Antib
Common organisms: OR Clind
Haemophilus influenzae Type B virus Ampicillin/sulbactam 3gm IV q6h PLUS
Streptococcus pneumonia Cipro
12
ment
Comments
Alternative
oxicillin/clavulanate 625mg PO q8h Abscess to be drained
Antibiotic allergy refer to Appendix 8
noxymethylpenicillin (Pen V) 500mg
q6h
S
ronidazole 500mg PO q6h
damycin 300-450mg PO q6h *Diphtheria Antitoxin:
biotic allergy:
damycin 600mg IV q8h Pharyngeal/ laryngeal 20,000 - 40,000 units
disease of 2 days
biotic allergy: duration
damycin 600-900mg IV q8h
S Nasopharyngeal disease 40,000 – 60,000 units
ofloxacin 400mg IV q12h
Systemic disease of ≥3 80,000 – 120,000 units
days or any patient with
diffuse neck swelling
Administer over 60 mins to inactivate toxin rapidly
Urgent hospitalisation. May present with life threatening
upper airway obstruction, especially in paediatrics.
Antibiotic allergy refer to Appendix 8
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Deep Neck Space Abscess Oral step down therapy:
Common organisms: Amoxicillin/clavulanate 625mg PO q8h
Streptococcus pyogenes for 7–14 days
Staphylococcus aureus
Fusobacterium necrophorum Ampicillin/sulbactam 3gm IV q6h
3. Rhinology OR
Acute Bacterial Rhinosinusitis (ABRS)
Common organisms: Ceftriaxone 2gm IV q24h
Streptococcus pneumoniae, Haemophilus PLUS
influenzae, Moraxella catarrhalis Metronidazole 500mg IV q6h
Amoxicillin 500mg PO q8h for 5-10 days Antib
OR Doxy
Amoxicillin/clavulanate 625mg PO q8h for
5-7 days Preg
*If no improvement after 3 days of oral woul
antibiotic, refer ENT. Azith
4. Otology *For non-severe AOM: Antib
Acute otitis media (AOM) Amoxicillin 500mg PO q8h for 5days Azith
Common organisms:
Streptococcus pneumoniae, Haemophilus follo
influenza, Moraxella catarrhalis
If symptoms not improved in 48-72 hours,
treat as severe AOM.
ment 12
Alternative Comments
Consider adding Vancomycin for patients with moderate to
severe sepsis, meningitis or previously colonized with
MRSA.
Duration: 10-14 days
biotic allergy: Consider antibiotic if present at least 3 of below:4
ycycline 100 mg q12h for 5-7 days • Purulent/ greenish nasal discharge
• Severe local pain (VAS 8-10)
gnant patients with Antibiotic allergy • Fever
ld need to be treated with • Elevated ESR/ CRP
hromycin 500mg PO q24hr for 3 days • Double sickening (becoming worse after initial recovery)
VAS: Visual Analogue Score.
The patient is asked:
“How troublesome are your symptoms?”
Not troublesome (0) to Worst thinkable troublesome (10)
Antibiotic allergy refer to Appendix 8
biotic allergy: *Non-severe AOM:
hromycin 500mg PO on day 1, • Mild otalgia
owed by 250mg PO q24h until day 5 • Temp <39°C
May consider 48-72hours of observation with symptomatic
therapy before prescribing antibiotic.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
**For severe AOM or perforated
tympanic membrane:
Amoxicillin/clavulanate 625mg PO q8h
for 5 days.
Malignant Otitis Externa/ Necrotizing Otitis Ciprofloxacin 400mg IV q8h
Externa OR
Common organism: Ceftazidime 2gm IV q8h
Pseudomonas aeruginosa followed by
Once showing clinical response, consider
switching to oral therapy:
Ciprofloxacin 750mg PO q12h to complete
6 weeks
Acute Diffuse Otitis Externa Ofloxacin 0.3% otic solution
Common organisms: Instill 10 drops into affected ear(s) q24h
Pseudomonas aeruginosa for 7 days
Staphylococcus aureus
Chronic Suppurative Otitis Media Ofloxacin 0.3% otic solution
Pseudomonas aeruginosa Instill 10 drops into affected ear(s) q12h
Staphylococcus aureus for 10-14 days
Otomycosis Clotrimazole 1% ear solution, applied
Common organism: q12h for 10 to 14 days
Aspergillus sp.
References:
1. Sore Throat (Acute): Antimicrobial Prescribing (NG84), NICE 2018
2. Stanford T. Shulman, Alan L. Bisno, Herbett W. Clegg, Michael A. Gerber, Edward L. Kaplan, Grace Lee. et al. Clinical Practice Guidelines fo
Dis 2012:55:86-102
3. Use of Diphtheria Antitoxin (DAT) for Suspected Diphtheria Cases, CDC 2016
4. Fokkens WJ, Lund VJ, Mullol J et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhin
5. American Academy of Paediatrics and American Academy of Family Physicians; Subcommittee on Management of Acute Otitis Media. Diag
ment 12
Alternative Comments
**Severe AOM:
• Moderate to severe otalgia
• Temperature >39°C
If symptoms not resolving after 48-72hours, refer ENT.
Antibiotic allergy refer to Appendix 8
Aural toileting required in discharging ears
Aural toileting required in discharging ears
Aural toileting required.
or the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America, Clin Infect
nolaryngologists. Rhinology 2012 Mar; 50(1):1-12
gnosis and management of acute otitis media. Paediatrics 2004; 113: 1451-65
12
SECTION A
ADULT
A10 Respiratory Infections
National Antimicrobial Guideline 2019 129
A10. Respiratory Infections Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
LOWER RESPIRATORY TRACT INFECTIONS
1. COMMUNITY ACQUIRED PNEUMONIA (CAP)
• The diagnosis of CAP generally requires the demonstration of an infiltrate on chest radiograp
production)
• CURB-65 is a clinical prediction rule that has been validated for predicting mortality in CAP.
i. Confusion
ii. BUN > 7 mmol/l
iii. Respiratory rate of ≥ 30 BPM
iv. Blood pressure ≤ 90/60 mmHg
v. Age ≥ 65
Score 0-1: Manage Outpatient (unless patient has co-morbidity or has difficult social circumstanc
Score 2 and above: Consider Admission
• Physicians should use CURB-65 prediction tools to support, not replace clinical judgments.
Outpatient Amoxicillin 500mg PO q8h for 5-7 days Amo
for 5
OR
Doxy
Inpatient (CURB ≥2) Amoxicillin/clavulanate 1.2gm IV q8h for Ceftr
5-7 days PLUS
PLUS Azith
Azithromycin 500mg IV/PO q24h for 3-5 d
3-5 days
Antib
*Lev
for 5
13
ment
Comments
Alternative
ph in a patient with a clinically compatible syndrome (e.g; fever, dyspnoea, cough and sputum
ces)
oxicillin/clavulanate 625mg PO q8h
5-7 days
ycycline 100mg PO q12h for 7 days
riaxone 2gm IV q24h for 5-7 days Antibiotic allergy refer to Appendix 8
S *Levofloxacin should be strictly reserved for Antibiotic
hromycin 500mg IV/PO q24h for allergy due to higher risk of adverse events.
days
To switch to oral therapy when clinical condition improves
biotic allergy and patient is able to tolerate orally.
vofloxacin 500-750mg IV/PO q24h
5-7 days If suspected melioidosis infection, please refer to the
section on tropical infections.
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
2. VIRAL PNEUMONIA Oseltamivir 75mg PO q12h for 5 days
Influenza Acyclovir 10mg/kg IV q8h for 7 days
Varicella zoster
3. LUNG ABSCESS AND EMPYEMA Amoxicillin/clavulanate 1.2gm IV q6-8h Ceftr
Empirical PLUS
*Me
Antib
Clind
Staphylococcus aureus Cloxacillin 2gm IV q4-6h Cefa
13
ment
Comments
Alternative
riaxone 2gm IV q24h Duration of treatment:
S • Drained abscess / empyema may require 2-4 weeks of
etronidazole 500mg IV q8h
biotic allergy antibiotics
damycin 600mg IV/PO q6h • Undrained abscess/ Empyema may require 4-6 weeks
azolin 2gm IV q8h of antibiotics
Lung empyema: Attempts should be made to drain the
collection.
May change to oral regime once clinical improvement seen
*Metronidazole: in cases of lung abscess when aspiration is
suspected
If melioidosis is suspected, please refer to the section on
tropical infections.
Antibiotic allergy refer to Appendix 8
Duration: 4-6 weeks, depending on clinical response. In rare
cases (slow response to antibiotics) may need prolonged
therapy.
May change to oral therapy (e.g. Amoxicillin/clavulanate
625mg PO q8h) to complete the duration once patient
stabilized and improved.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
4. INFECTIVE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Antibiotics only considered if there is:
Increased purulence in sputum AND one of the following:
• Increased sputum volume
• Increased dyspnoea
OR
Patient intubated (GOLD 2019)
Outpatient Amoxicillin/clavulanate 625mg PO q8h Cefu
for 5-7 days OR
Doxy
Inpatient Amoxycillin/clavulanate 1.2gm IV q8h for Ceftr
5-7days PLUS
PLUS/MINUS Azith
Azithromycin 500mg IV/PO for 3-5 days
*If suspect Pseudomonas infection **Piperacillin/tazobactam 4.5gm IV q6-8h Cefta
OR PLUS
Cefepime 2gm IV q8h Azith
PLUS/MINUS
Azithromycin 500mg IV/PO for 3-5 days
Reference:
COPD (GOLD) 2019 Guideline
5. HOSPITAL ACQUIRED PNEUMONIA (HAP/VAP)
Risk factors for multi-drug resistance (MDR) organisms:
1. Prior intravenous antibiotic use within 90 days
2. More than 5 days of hospitalization in high risk ward (ICU, HDU)
3. Previous colonization with MDR pathogens
Risk of MDR organisms is lower with early onset HAP/VAP.
13
ment
Comments
Alternative
uroxime 500mg PO q12h for 5-7 days
ycycline 100mg PO q12h for 5-7 days
riaxone 2gm IV q24h for 5-7 days
S/MINUS
hromycin 500mg IV/PO for 3-5 days
azidime 2gm IV q8h *Pseudomonas sp risk factors:
S/MINUS 1. Frequent exacerbation
hromycin 500mg IV/PO for 3-5 days 2. Severe airflow limitation
3. Exacerbation requiring mechanical ventilation
**Piperacillin/tazobactam: If given as q8h, to be given as
extended infusion (over 3-4 hours).
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Early Onset HAP/VAP Amoxicillin/clavulanate 1.2gm IV q8h for Ceftr
(2-4 days of admission/intubation) 5-7 days
Late Onset HAP/VAP *Piperacillin/tazobactam 4.5gm IV q6-8h Imip
(5 days or more of admission/intubation) for 7 days 7 day
Causative organism is determined by local OR OR
prevalence. Cefepime 2gm IV q8h for 7 days Mero
6. ASPIRATION PNEUMONIA
Amoxicillin/clavulanate 1.2gm IV q8h Ceftr
PLUS
Metr
References:
1. Malaysian Society of Intensive Care. Guide to antimicrobial therapy in the adult ICU 2017.
Available from: http://www.msic.org.my
2. British Thoracic Society. Guideline for the management of community acquired pneumonia in
adult. Thorax 2009;64(3):1-55.
3. NICE guideline for Pneumonia in adults: diagnosis and management Clinical guideline
Published: 3 December 2s014
4. Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Management
of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice
guidelines by the infectious diseases society of America and the American thoracic society.
Clinical Infectious Diseases 2016; 63(5):e61-111.
13
ment
Alternative Comments
Need to adjust to local antibiogram/ prevalent organisms
riaxone 2gm IV q24h for 5-7 days
penem/cilastatin 500mg IV q6h for Ideal empirical antibiotic coverage depends on local
ys prevalence of organisms.
Duration of antibiotics could be shortened to 7 days even
openem 1gm IV q8h for 7 days for MDR Pseudomonas aeruginosa and Acinetobacter
baumanii infections. Longer duration may be indicated
depending upon clinical, radiological and laboratory parameters.
To de-escalate antibiotics according to culture and
sensitivity results.
*Piperacillin/tazobactam: If given as q8h, to be given as
extended infusion (over 3-4 hours).
riaxone 2gm IV q24h Duration: 7- 10 days
S To switch to oral therapy when clinical condition improves
ronidazole 500mg IV q8h and patient is able to tolerate orally.
Antibiotics are not indicated for aspiration (chemical)
pneumonitis.
5. Balter MS, LA Forge L, Low DE, Mandell L, Grossman RF, Canadian Thoracic Society, et al.
Canadian Guidelines for the management of acute exacerbation of chronic bronchitis. Can
Respir J 2003;10(Suppl B): 3B-32B.
6. Australian Clinical Practice Guidelines – Therapeutic guidelines antibiotic version 15
7. Global Initiative for Chronic Obstructive Lung Disease – Pocket Guide to COPD Diagnosis,
Management and Prevention 2017 Report
8. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American
Thoracic Society consensus guidelines on the management of community-acquired pneumonia
in adults. Clin Infect Dis 2007;44(Suppl 2):S27
9. Murtaza Mustafa, HM Iftikhar, RK Muniandy et al. Lung Abscess: Diagnosis, Treatment and
Mortality. International Journal of Pharmaceutical Science Invention 2015;4 (2):37- 41
13
SECTION A
ADULT
A11 Sexually Transmitted
Infections
National Antimicrobial Guideline 2019 135
A11. Sexually Transmitted Infections Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
SEXUALLY TRANSMITTED INFECTIONS (STIs)
• Ideally diagnosis of STI (apart from syphilis) should be Nucleic Acid Amplification Test (NAAT) ba
• Contact tracing/ partner notification is important in all STIs.
• Duration of contact tracing/partner notification depends on the type of STIs
Syphilis (Treponema pallidum Infection)
Primary Syphilis Benzathine Penicillin 2.4MU IM STAT Antib
OR Doxy
Secondary Syphilis Procaine Penicillin 600,000units IM q24h
for 10 days
Early Latent Syphilis
(History of syphilis infection within the last 2
years).
13
ment
Comments
Alternative
ased testing.
biotic allergy If drug administration is interrupted for ≥ 1 day at any point
ycycline 100mg PO q12h for 14 days during the treatment course, it is recommended that the
entire course is restarted.
Patients should be warned of possible reactions to
treatment:
• Jarisch-Herxheimer reaction
• Anaphylaxis/Allergy
Abstain from sex for 2 weeks after they and their partner(s)
have completed treatment.
Screen for HIV.
All sexual partners should be examined, investigated and
treated epidemiologically.
Partner notification: Primary syphilis (3 months), Others (6
months – 12 months).
Antibiotic allergy refer to Appendix 8
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Late Latent Syphilis Benzathine Penicillin 2.4MU IM weekly Antib
Gummatous Syphilis for 3 weeks (Day 1, 8, & 15) Doxy
Cardiovascular Syphilis OR
Procaine Penicillin 600,000units IM
q24h for 14 days
Neurosyphilis Benzylpenicillin 4MU q4h IV for 14 days Antib
OR Ceftr
for 1
Procaine Penicillin 2.4MU IM q24h OR
PLUS Doxy
Probenecid 500mg PO q6h, both for
14 days.
Syphilis in HIV Treatment as appropriate for stage of Treat
Primary, secondary, early and late latent and infection infec
neurosyphilis
13
ment
Comments
Alternative
biotic allergy For cardiovascular syphilis:
ycycline 100mg PO q12h for 28 days Consider Prednisolone 40-60 mg OD for 3 days starting 24
hours before the antibiotics.
If a patient defaults Benzathine Penicillin treatment by ≥ two
weeks in between the weekly doses, the whole regime needs
to be restarted.
Contact tracing and partner notification as above.
Antibiotic allergy refer to Appendix 8
biotic allergy Consider Prednisolone 40-60 mg OD for 3 days starting 24
hours before the antibiotics.
riaxone 2gm IM or IV q24h
14 days (if no anaphylaxis to penicillin) CSF examination should be done in:
ycycline 200mg PO q12h for 28 days 1. Patients with neurological and/or ocular symptoms or
signs.
2. Nontreponemal test titres do not decrease by fourfold
within 12 months of therapy.
Contact tracing and partner notification as above.
** IM Ceftriaxone – dilute with Lidocaine
Antibiotic allergy refer to Appendix 8
tment as appropriate for stage of Perform full neurological examination
ction Contact tracing and partner notification as above.
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Syphilis in Pregnancy
Primary, secondary, early latent 1st & 2nd Trimesters Antib
(up to and including 27 weeks): (All t
Late latent, gummatous, cardiovascular Benzathine penicillin 2.4MU IM single Ceftr
Neurosyphilis dose OR
3rd Trimester Azith
(from week 28 to term): OR
Benzathine penicillin 2.4MU IM weekly Eryth
for 2 weeks (Day 1 & 8) q6h
OR
(All three trimesters)
Procaine penicillin 600,000unit IM q24h
for 10 days
Treat as for non-pregnant patients
(DO NOT USE DOXYCYCLINE in pregnancy)
Treat as for non-pregnant patients with Neurosyp
(DO NOT USE DOXYCYCLINE in pregnancy)
Gonorrhoea (Neisseria Gonorrhoeae Infection)
Uncomplicated (Urogenital, Anorectal, Ceftriaxone 500mg IM as a single dose Antib
Pharyngeal) PLUS Gent
*Azithromycin 1gm PO as a single dose PLUS
*Azit
Preg
Ceftr
PLUS
*Azit
13
ment
Comments
Alternative
biotic allergy Tetracycline and Doxycycline are contraindicated in
three trimesters) pregnancy.
riaxone 500mg IM q24h for 10 days
Antibiotic allergy refer to Appendix 8
hromycin 500mg PO q24h for 10 days
If Macrolide therapy:
hromycin Ethylsuccinate 800mg PO Neonate require assessment and treatment at birth
for 14 days
philis
biotic allergy *Azithromycin: Dual therapy to treat for coexisting
tamicin 240mg IM as a single dose Chlamydia trachomatis infection (35-40%), synergistic
S effect & reduce cephalosporin resistance
thromycin 2gm PO as a single dose
Avoid unprotected sexual intercourse for 1 week following
gnancy and breastfeeding: treatment (partner(s) need to be treated as well)
riaxone 500mg I.M. as a single dose
S Test of cure in 2 weeks post treatment with NAAT is
thromycin 1gm P.O as a single dose advisable
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Gonococcal Conjunctivitis Ceftriaxone 500mg IM q24h for 3 days Antib
Epididymitis/ Epididymo-orchitis Azith
PLUS
Disseminated Gonorrhoea Doxy
PLUS
Cipro
Caused by gonorrhoea and chlamydia:
Ceftriaxone 500mg IM STAT
PLUS
Azithromycin 1gm PO STAT
PLUS
Doxycycline 100mg PO q12h
for 14 days
STI related but unlikely gonorrhoea:
Doxycycline 100mg PO q12h for 14 days
Non-STI related (Enteric organisms):
Ciprofloxacin 500mg PO q12h for 10 days
Ceftriaxone 1-2gm IV q24h for 7 days Cefo
13
ment
Comments
Alternative
Partner notification:
Symptomatic partners in last 2 weeks. Asymptomatic
partners in last 3 months
Sexual partners should be treated for gonorrhoea even
though they are asymptomatic.
Antibiotic allergy refer to Appendix 8
biotic allergy Antibiotic allergy refer to Appendix 8
hromycin 2gm PO single dose
S
ycycline 100mg PO q12h for 7 days
S
ofloxacin 250mg PO q24h for 3 days
otaxime 1gm IV q8h for 7 days May be switched to Ciprofloxacin 500mg PO q12h 24-48hrs
after symptoms improve.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Chlamydia Infections (Chlamydia trachomatis)
Uncomplicated (urogenital, pharyngeal and Doxycycline 100mg PO q12h for 7 days Azith
rectal infection) PO q
Chlamydia in pregnancy Azithromycin 1gm PO stat, then 500mg Amo
PO q24h for 2 days OR
Eryth
PO q
Non-Gonococcal Urethritis (NGU) Doxycycline 100mg PO q12h for 7 days Azith
250m
First episode of Non-gonococcal urethritis
(NGU)
14
ment
Comments
Alternative
hromycin 1gm PO stat, then 500mg Avoid unprotected sexual intercourse for 1 week following
q24h for 2 days treatment (partner(s) need to be treated as well)
oxicillin 500mg PO q8h for 7 days Test of cure (TOC) is not routinely recommended. Only
hromycin Ethylsuccinate 800mg consider TOC in pregnancy, poor compliance, and persistent
q6h for 7 days symptoms. TOC ideally between 4-6 weeks post treatment
with NAAT test
Partner notification:
Symptomatic partners in last 6 weeks. Asymptomatic
partners in last 6 months
Sexual partners should be treated for chlamydia even
though they are asymptomatic
Doxycycline is contraindicated in pregnancy
hromycin 500mg PO STAT then
mg q24h for 4 days
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Recurrent and persistent Non-gonococcal If treated with Doxycycline first line:
urethritis (NGU) Azithromycin 500mg PO stat then 250mg
PO q24h for the next 4 days
PLUS
Metronidazole 400mg PO q12h for 5 days
If treated with Azithromycin first line:
Moxifloxacin 400mg PO q24h for 10-14 days
PLUS
Metronidazole 400mg PO q24h for 5 days
Herpes Simplex Virus Type-1 and 2 (HSV-1 & 2) Infections
Herpes Genitalis First episode:
Acyclovir 400mg PO q8h for 5 days
*Val
Recurrent episode: *Val
Short-course
Acyclovir 800mg PO q8h for 2 days
5-day regimens
Acyclovir 400mg PO q8h
ment 14
Alternative Comments
Most common cause of recurrent or persistent NGU is
Mycoplasma genitalium.
Also consider infection with Trichomonas vaginalis
Partner notification: preceding 6 months from diagnosis
Abstain from sexual intercourse until has completed therapy
and his partner(s) have been treated – at least 1 week
Follow-up is recommended after 2-3 weeks
TOC in asymptomatic patient not recommended
For confirmed Mycoplasma genitalium infection, TOC in 3
weeks post treatment is recommended using PCR
Physical supportive measures: saline bathing, analgesia,
lacyclovir 500mg PO q12h for 5 days local anaesthetics and psychological support.
Oral antiviral drugs indicated within 5 days of the start of the
episode and while new lesions are still forming.
lacyclovir 500mg PO q12h for 3-5 days
Topical antivirals are less effective than oral agents and not
recommended, due to the association with acyclovir
resistant strain.
Addition of topical antivirals to oral treatment is of no
benefit.
*Requires DG's Approval
Infection/ Condition & Likely Organism Preferred Suggested Treatm
Acyclovir 400mg PO q12h *Val
Herpes Genitalis
Suppressive therapy:
(Indicated if > 6 recurrences per year, severe,
prolonged, or with psychosocial problems)
Herpes Genitalis in pregnancy First or second trimester acquisition *Val
First episode (until 27+6 weeks): *Val
Acyclovir 400mg PO q8h for 5 days
Third trimester acquisition (from 28
weeks):
Acyclovir 400mg PO q8h for 5 days
Suppressive therapy for recurrent Herpes Acyclovir 400mg PO q8h
Genitalis in pregnancy Treatment recommended starting at 36
weeks of gestation until delivery
Other Sexually Transmitted Infections
Azithromycin 1gm PO in a single dose
Chancroid OR
Haemophilus ducreyi Ceftriaxone 250mg IM in a single dose
OR
*Ciprofloxacin 500mg PO q12h for 3 days
*preferred in HIV +ve patients
14
ment
Comments
Alternative
lacyclovir 500mg PO q24h Duration: All for up to 1 year, then reassess
If breakthrough recurrences occur,
dosage should be increased (refer: Recurrent episode dose)
*Requires DG's Approval
lacyclovir 500mg PO q12h for 5 days Do not delay treatment whilst awaiting results (HSV PCR
recommended)
lacyclovir 500mg PO q12h for 5 days Third trimester acquisition:
No additional monitoring of the pregnancy is required
Continue daily suppressive Acyclovir 400 mg PO q8h until
delivery
*Requires DG's Approval
Avoid unprotected sexual intercourse until they and their
partner(s) have completed treatment and follow-up.
Sexual contacts within 10 days before onset of the patient’s
symptoms should be examined and treated even in the
absence of symptoms.
Patients should be re-examined 3-7 days after initiation of
therapy. Successful treatment; ulcers improve
symptomatically within 3 days and substantial re-
epithelisation occurs within 7 days after onset of therapy.
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Lymphogranuloma Venereum Doxycycline 100mg PO q12h for 21 days Azith
Chlamydia trachomatis
Serovars L1,2,3
Granuloma Inguinale (Donovanosis) Azithromycin 1gm PO weekly or 500mg Doxy
Klebsiella granulomatis q24h OR
PLUS/MINUS Trim
Trichomoniasis Gentamicin 1mg/kg IM/IV q8h 160/
Trichomonas vaginalis (in patients whose lesions do not respond OR
Treatment failure (Second regimen) in the first few days to other agents) Cipro
PLUS
Gent
(in p
in th
Metronidazole 2gm PO in a single dose
OR 400mg PO q12h for 5 days
Metronidazole 400mg PO q12h for 7 days
14
ment
Comments
Alternative
hromycin 1gm PO weekly for 3 weeks Fluctuant buboes: Should be aspirated through healthy
adjacent skin. Surgical incision contraindicated.
Sexual contacts within 1 month prior to patient’s symptoms,
or the last 3 months of detected asymptomatic LGV, should
be examined and tested for chlamydial infection and treated
with the same regimen.
Should be followed up until symptoms resolve.
Routine TOC not necessary if recommended regimen is
used and completed.
If TOC is required (tetracycline allergy or pregnant), should
be performed 2 weeks post completion of treatment.
ycycline 100mg PO q12h Treatment duration:
for at least 3 weeks or until all lesions completely heal
methoprim/Sulfamethoxazole
/800mg PO q12h In the absence of any reliable screening test and the long
incubation period, all sexual contacts in the last 6 months
ofloxacin 750mg PO q12h should be examined for possible lesions by clinical
examination.
S/MINUS
tamicin 1mg/kg IM/IV q8h Patients should be followed up until lesions have healed
patients whose lesions do not respond completely.
he first few days to other agents)
Screen other STIs
Sexual contact(s) should be treated simultaneously and
patients should be advised to abstain for at least one week
until they and their partner(s) have completed treatment and
follow-up.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Bacterial vaginosis Metronidazole 400mg PO q12h for 5-7 days Clind
Common organisms: OR 2gm PO as single dose
Anaerobic bacteria (e.g., Prevotella sp.,
Mobiluncus sp., Gardnerella vaginalis, and
Mycoplasma hominis)
References:
1. Malaysian Guideline in the Management of Sexually Transmitted Infections 2015
2. UK National Guidelines on the Management of Syphilis 2015
3. UK National Guideline for the Management of Gonorrhoea in Adults. 2011
4. Kirkcaldy RD, Weinstock HS, Moore PC, et al. The efficacy and safety of gentamicin plus azithrom
2014:598 1083-91.
5. 2010 UK National Guideline for the Management of Epididymo-Orchitis
6. 2015 UK National Guideline for the Management of Infection With Chlamydia trachomatis
7. BASHH Update on the Treatment of Chlamydia Trachomatis (CT) Infection. Sept 2018
8. Update to the 2015 BASHH UK National Guideline on the Management of Non-Gonococcal Urethr
9. UK National Guideline for the Management of Chancroid 2014
10. 2013 UK National Guideline for the Management of Lymphogranuloma venereum. CEG/BASHH
11. Centre Of Disease Control, USA 2015
12. UK National Guideline for the Management of Donovanosis 2018
13. UK National Guideline on the Management of Trichomonas vaginalis 2014, CEG BASHH
14. UK National Guideline for the Management of Bacterial Vaginosis 2012, CEG BASHH
15. 2014 UK National Guideline for the Management of Anogenital Herpes
16. Management of Genital Herpes in Pregnancy. BASHH and RCOG (UK). October 2014
17. Sanford Guide Antimicrobial Therapy, 2018
14
ment
Comments
Alternative
Any partners within the 4 weeks prior to presentation should
be screened for the full range of STIs and treated for TV.
TOC only recommended if the patient remains symptomatic
following treatment, or if symptoms recur.
**Higher-dose of metronidazole is required if failing second
regimen.
damycin 300mg PO q12h for 7 days Not an STI but frequently detected during STI screening
mycin and Gemifloxacin plus azithromycin as treatment of uncomplicated gonorrhea. Clin Infect Dis.
ritis. May 2017
SECTION A
ADULT
A12 Skin & Soft Tissue Infections
National Antimicrobial Guideline 2019 145
A12. Skin & Soft Tissue Infections Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
1. PURULENT SKIN & SOFT TISSUE INFECTION
Localised Impetigo *Topical 2% Fusidic acid q8-12h for 5 days
Common Organisms: (Outpatient use only)
Staphylococcus aureus OR
Streptococcus pyogenes Cloxacillin 500-1000mg PO q6h for 5-7 days
OR
Cephalexin 250-500mg PO q6h for 5-7 days
Generalised Impetigo/Ecthyma Cephalexin 250-500mg PO q6h Amo
Antibiotic allergy: Othe
Erythromycin Ethylsuccinate 800mg PO q12h Clind
OR
Trim
160/
Ecthyma gangrenosum Ciprofloxacin 500mg PO q12h Cefta
Most common causative organism is OR OR
Pseudomonas sp. however antibiotics need to *Piperacillin/tazobactam 4.5gm IV q6-8h Cefe
be tailored according to culture result.
2. NON-PURULENT SKIN & SOFT TISSUE INFECTION
Furuncles Cloxacillin 500mg PO q6h for 5-7days Amo
for 5
14
ment
Alternative Comments
*Only can be used by Dermatologist
oxicillin/clavulanate 625mg PO q8h Duration : 5-7 days
er alternative/ in case of CA-MRSA: Antibiotic allergy refer to Appendix 8
damycin 600mg PO q8h
methoprim/sulfamethoxazole
/800mg PO q12h
azidime 2gm IV q8h Consider adding aminoglycoside in selected cases such as
epime 2gm IV q8h in immunocompromised/neutropenic and septic shock
patients. Use synergistic combination therapy with
aminoglycosides until susceptibilities are known.
*Piperacillin/tazobactam: If given as q8h, to be given as
extended infusion (over 3-4 hours).
oxicillin/clavulanate 625mg PO q8h
5-7days
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Carbuncles Cloxacillin 1-2gm IV q6h Amo
Common organism: OR
Staphylococcus aureus Cefa
Erysipelas
Common organism: Phenoxymethylpenicillin 500mg PO q6h Ceph
Streptococcus pyogenes OR
Amoxicillin 500mg PO q8h
Diabetic Foot Infections
Gas Gangrene/ Myonecrosis/ Necrotizing If severe: If se
Fasciitis Benzylpenicillin 2-4MU IV q4-6h Cefa
Yaws OR
Treponema pertenue Cefu
MRSA:
*Vancomycin 15-20mg/kg q8-12h; not to
exceed 2gm/dose
Refer to section Surgical Infection - Bone and Joi
Refer to section Surgical Infection - Bone and Joi
Benzathine Penicillin 1.2MU IM single dose Doxy
OR
Azith
dose
Antib
Tetra
OR
Eryth
PO q
14
ment
Alternative Comments
oxicillin/clavulanate 1.2gm IV q8h Surgical drainage is the mainstay of treatment.
Duration : 7-10 days
azolin 1gm IV q8h
Duration : 7-10 days
halexin 500mg PO q6h
evere:
azolin 1gm IV q8h
uroxime 750mg IV q8h
*Vancomycin loading dose refer to Appendix 1
int Infections
int Infections
ycycline 100mg PO q12h for 15 days Antibiotic allergy refer to Appendix 8
hromycin 30mg/kg (max 2gm) single
e
biotic allergy:
acycline 500mg PO q6h for 15 days
hromycin Ethylsuccinate 800mg
q12h for 15 days
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
CELLULITIS Cephalexin 500mg PO q6h Cefu
Cloxacillin 1-2gm IV q6h OR
Mild: Amo
Common organisms:
Staphylococcus aureus & Cefa
Streptococcus pyogenes
Ampicillin/sulbactam 3gm IV q6-8h *Pip
Moderate: PLUS/MINUS PLUS
Common organisms: Clindamycin 600mg IV q6h Clind
Staphylococcus aureus & Streptococcus (Deescalate once cultures are available/ (Dee
pyogenes Necrotizing fasciitis ruled out) Necr
Severe:
Common organisms:
Staphylococcus aureus & Streptococcus
pyogenes
**Consider alternative organisms in the following circumstances:
Dog/cat bite: Amoxicillin/clavulanate 625mg PO q8h
Common organisms:
Pasteurella multocida, Capnocytophaga
canimorsus
Cat scratch disease Azithromycin 500mg PO on Day 1,
Bartonella henselae then 250mg PO q24h for 4 days
Human bite: Amoxicillin/Clavulanate 625mg PO q8h
Common organisms:
Eikenella corrodens, anaerobes, Staphylococcus
aureus
14
ment
Comments
Alternative
uroxime 250-500mg PO q12h Duration : 5-10 days according to clinical response
oxicillin/clavulanate 625mg PO q8h Change to oral once condition improves.
azolin 1-2gm IV q8h Gram negative coverage may be necessary in the following
circumstances:
peracillin/tazobactam 4.5gm IV q6-8h 1. Potential relation of the cellulitis to a decubitus ulcer
S/MINUS 2. Crepitant cellulitis
damycin 600mg IV q6h 3. Prominent skin necrosis/ gangrene
escalate once cultures are available/ 4. Location:
rotizing fasciitis ruled out)
a. Perioral
b. Perirectal cellulitis
5. Clinical condition:
a. Septicaemic shock
b. Suspecting necrotizing fasciitis
6. Immunocompromised patients.
7. Specific exposures**
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Salt water exposure: Doxycycline 200mg stat then 100mg
Common organism: PO q12h
Vibrio sp. PLUS/MINUS
***Ceftriaxone 2gm IV q24h
Fresh or brackish water exposure: Ciprofloxacin 400mg IV q12h
Common organisms: OR
Aeromonas sp., Plesiomonas Ciprofloxacin 750mg PO q12h
Neutropenic patients: *Piperacillin/tazobactam 4.5gm IV q6-8h Cefta
OR
Common organisms: Cefe
Pseudomonas aeruginosa, other Gram negatives
MRSA Vancomycin 15-20mg/kg IV q8-12h Linez
In severe infections:
To load with Vancomycin 25-30mg/kg IV,
followed by 15-20mg/kg (actual body
weight) IV q8-12h; not exceeding 2gm/dose
****If CA-MRSA suspected Clindamycin 300-450mg IV/PO q8h
OR
Doxycyline 100mg PO q12h
OR
Trimethoprim/sulfamethoxazole
160/800mg PO q12h
3. PERIPHERAL PHLEBITIS/THROMBOPHLEBITIS
Common organisms: Early stage phlebitis:
Staphylococcus aureus, Coagulase negative Remove the intravenous cannula
Staphylococcus,
Gram negative rods Medium and advanced stage phlebitis or
thrombophlebitis:
ment 14
Alternative Comments
***Consider adding 3rd Generation Cephalosporin in severe
infection
azidime 2gm IV q8h *Piperacillin/tazobactam: If given as q8h, to be given as
epime 2gm IV q8h extended infusion (over 3-4 hours).
zolid 600mg IV/PO q12h
Vancomycin loading dose refer to Appendix 1
****Consider CA-MRSA if :
1. Outbreaks of known CA-MRSA
2. If non-resolving cellulitis
Peripheral intravenous catheters with associated pain,
induration, erythema, or exudate should be removed.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
Remove the intravenous cannula and take
blood culture
Can consider empirical treatment if
persistent fever:
Cephalexin 500mg PO q6h
OR
Cloxacillin 1-2gm IV q6h
4. BED SORE/PRESSURE SORE/DECUBITUS ULCER
Local treatment is preferred.
If there is surrounding cellulitis/signs of
bacteremia/ fasciitis/ surrounding
intramuscular abscess/ OM changes:
Ampicillin/Sulbactam 3gm IV q6-8h
5. MYCOBACTERIAL INFECTIONS
Hansen’s Disease (Leprosy) Paucibacillary *Bac
Mycobacterium Leprae Rifampicin 600mg PO monthly to fir
(supervised) Can
PLUS follo
Dapsone 100mg PO q24h Oflox
OR
Duration: 6 months Mino
(Completion of 6 doses within 9 months) OR
Surveillance: 5 years. Clari
OR
Ethio
Multibacillary
Rifampicin 600mg PO monthly
15
ment
Comments
Alternative
cterial resistance or hypersensitivity *Second line can only be initiated by a dermatologist.
rst line
be substituted with one of the
owing:
xacin 400mg PO q24h
ocycline 100mg PO q24h
ithromycin 500mg PO q24h
onamide 250mg PO q24h
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
PLUS
Clofazimine 300mg PO monthly and
50-100mg PO q24h
PLUS
Dapsone 100mg PO q24h
Duration: 1 year (if initial BI<4) or 2 years
(if BI≥4)
Completion of 12 doses within 18 months
(BI<4)
Completion of 18 doses within 36 months
(BI≥4)
Surveillance: 15 years
Hansen’s Disease (Leprosy) in HIV Same as non HIV patients
NON-TUBERCULOUS MYCOBACTERIAL INFECTIONS
Mycobacterium marinum Clarithromycin 500mg PO q12h Rifam
PLUS PLUS
Minocycline/Doxycycline 100mg PO q12h Etha
mon
Duration: At least 2 months of treatment after
until clearance.
OR
Mon
for 1
(3-4
Mycobacterium kansasii Isoniazid 300mg PO q24h
PLUS
Rifampicin 600mg PO q24h
PLUS
Ethambutol 15mg/kg PO q24h for 18
months