17
ment
Comments
Alternative
thromycin 500mg PO stat *Azithromycin: Recommended for pregnant woman
ot responding to Azithromycin: *Recommend for early IV to oral switch once symptoms
mpicin 600mg PO q24h for 5 days improve or stable.
ycycline 100mg PO q12h for 6 weeks Longer duration (up to 12 weeks) is required in complicated
S cases i.e. spondylitis, neurobrucellosis, IE, localized
tamicin 5mg/kg/24h IV for 7 days suppurated lesions.
ycycline 100mg PO q12h for 6 weeks
S
mpicin 600-900mg (15mg/kg) PO
h for 6 weeks
ommended alternative for pregnant
man:
mpicin 600-900mg (15 mg/kg) PO
h for 6 weeks
S
methoprim/ Sulphamethoxazole
/800mg PO q12h for 6 weeks.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
5. LEPTOSPIROSIS (Leptospira sp.)
Mild to Moderate disease Doxycycline 100mg PO q12h for 5-7 days Azith
Severe disease Ceftriaxone 2gm IV q24h for 7 days
(Leptospiral pulmonary syndrome, multiorgan (to deescalate to Benzylpenicillin once
involvement, sepsis) symptoms improve/stable)
OR
Benzylpenicillin 1.5MU IV q6h for 7 days
6. TETANUS
Clostridium tetani Metronidazole 500mg IV q6-8h for Benz
7-10 days kg/2
PLUS PLUS
Human Tetanus Immunoglobulin Hum
3000-6000IU IM stat 3000
PLUS PLUS
Anti-tetanus toxoid vaccine IM (initiate Anti-
age appropriate active immunization at a age a
different site) diffe
7. MELIOIDOSIS (Burkholderia pseudomallei)
Intensive Therapy (Uncomplicated) Ceftazidime 100-120mg/kg/24h IV q6-8h
(usual dose: 2gm IV q6h)
PLUS/MINUS
*Trimethoprim/ Sulphamethoxazole
• < 40 kg: 160/800mg PO q12h
• 40-60kg: 240/1200mg PO q12h
• >60kg: 320/1600 mg PO q12h
Intensive Therapy (Complicated) Meropenem 75mg/kg/24h IV q8h (usual
(Severe melioidosis or neuromelioidosis) dose: 1gm IV q8h; if neurologic, 2gm IV q8h)
17
ment
Comments
Alternative
hromycin 500mg PO q24h for 3 days
May consider Methylprednisolone 500-1000 mg IV for 3
days if pulmonary haemorrhage present. However, there is
insufficient evidence to support the routine use
corticosteroid.
zylpenicillin 100,000-200,000 unit/ Human Tetanus Immunoglobulin 500IU might be as
24h IV q6h for 7-10 days effective as higher doses of 3,000 to 6,000IU and causes
S less discomfort.
man Tetanus Immunoglobulin
0-6000IU IM stat All patients with tetanus should undergo wound
S debridement to eradicate spores and necrotic tissue.
-tetanus toxoid vaccine IM (initiate
appropriate active immunization at a
erent site)
*Add on Trimethoprim/ Sulphamethoxazole in eye,
neurologic, testicular, prostatic, pericardium, bone and joint
melioidosis.
Dose as per eradication therapy.
Drainage of abscesses should be attempted where ever
appropriate such as prostatic, empyema and pericardium.
Duration of intensive therapy:
• Skin, bacteraemia with no foci, mild pneumonia: 2
weeks
Suggested Treatm
Infection/ Condition & Likely Organism Preferred
Eradication/Maintenance Therapy
OR
Imipenem 50mg/kg/24h IV q6h (usual
dose: 500-1000mg q6h)
PLUS/MINUS
*Trimethoprim/ Sulphamethoxazole
(to deescalate to Ceftazidime once
symptoms improve/stable)
Trimethoprim/ Sulphamethoxazole Amo
•
• < 40 kg: 160/800mg PO q12h
• 40-60kg: 240/1200mg PO q12h •
• >60kg: 320/1600 mg PO q12h
8. MALARIA
Refer to the Ministry of Health’s latest guideline on management of malaria.
References:
1. WHO. The diagnosis, treatment and prevention of typhoid fever. 2003
2. CDC. Antibiotic Treatment in Cholera. 2015.
3. JKN Sabah. Garis panduan pengurusan dan pengendalian penyakit Kolera. 2012.
4. PAHO. Recommendations for clinical management of cholera. November 2010.
5. Rahi M, etal.DHR-ICMR Guidelines for Diagnosis & Management of Rickettsial Diseases in India. Indian J
Med Res. 2015;141(4):417-22.
6. Kim YS et al. A comparative trial of single dose azithromycin vs doxycycline for treatment old mild scrub
typhus. CID. 2004; 39(9):1329-35
7. MOH Malaysia. CPG Brucellosis. 2012
8. WHO. Brucellosis in humans and animals. 2006
9. WHO. Leptospirosis. 2013.
10. Phimda K, et al. Doxycycline vs azithromycin for treatment of leptospirosis and scrub typhus. Antimicrob
Agents Chemother. 2007;51(9):3259-63
11. Panaphut, T et al. Ceftriaxone compared with s.penicillin G for treatment of severe leptospirosis. CID.
2003;36(12), 1507-13
ment 17
Alternative Comments
• Complicated pneumonia, prostatic, deep-seated foci,
septic arthritis: 4 weeks
• Osteomyelitis: 6 weeks
• Neurologic/CNS: 8 weeks
To use clinical judgement to guide prolongation of intensive
phase if improvement is slow/persistent bacteraemia.
oxicillin/clavulanate Duration of eradication therapy:
<60kg: 1250mg (2 tabs of 625 mg)
PO q8h • Osteomyelitis, Neurologic/CNS: 24 weeks
>60kg: 1875mg (3 tabs of 625 mg) • Others: minimum 12 weeks
PO q8h
12. Suputtamongkol Y, et al. An open, RCT comparing penicillin, doxycycline and cefotaxime for patients with
severe leptospirosis. CID 2004:39(10):1417-24
13. Shenoy VV et al. Pulmonary leptospirosis: an excellent response to bolus methylprednisolone. Postgrad
Med J. 2006; 82(971): 602–6
14. Rodrigo C et al. High dose corticosteroids in severe leptospirosis: a systematic review. Trans R Soc Trop
Med Hyg. 2014;108(12):743-50
15. WHO. Current recommendations for treatment of tetanus. 2010.
16. CDC. Tetanus, Clinical information for clinicians. 2017
17. Currie B. Melioidosis: The 2014 Revised RDH Guideline. The Northern Territory Disease Control Bulletin.
2014;21(2): 4-8.
18. Dance D. Treatment and prophylaxis of melioidosis. Int J Antimicrob Agents 2014; 43: 310-8.
19. White NJ, et al. Halving of mortality of severe melioidosis by ceftazidime. Lancet. 1989;2: 697–701
20. Simpson AJ, et al. Comparison of imipenem and ceftazidime as therapy for severe melioidosis. CID.
1999;29:381–7
18
SECTION A
ADULT
A15 Urinary Tract Infections
National Antimicrobial Guideline 2019 181
A15 Urinary Tract Infections Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
1. CYSTITIS
Uncomplicated Cystitis *Nitrofurantoin 50-100mg PO q6h Cefu
Common organisms: (macrocrystals) or 100mg PO q12h OR
Escherichia coli (monohydrate/ macrocrystals) Amo
Staphylococcus saprophyticus OR OR
Enterobacteriaceae: Klebsiella, Proteus Cephalexin 500mg PO q12h Amp
OR
In non-pregnant, pre-menopausal women with **Fo
structurally and functionally normal urinary tract.
Cystitis in Pregnancy *Nitrofurantoin 50-100mg PO q6h Cefu
(macrocrystals) or 100mg PO q12h OR
(monohydrate/macrocrystals) #Am
OR OR
Cephalexin 500mg PO q12h Amp
OR
**Fo
18
ment
Comments
Alternative
uroxime 250mg PO q12h Urine culture is indicated only if symptoms unresolved or
recur.
oxicillin/clavulanate 625mg PO q8h *Avoid Nitrofurantoin if GFR < 30ml/min.
Ciprofloxacin and other quinolones are not recommended as
picillin/sulbactam 375-750mg PO q12h empirical treatment in UTIs due to ;
• selection of resistance, and
osfomycin 3gm PO x 1 dose • potential serious adverse events i.e. aortic aneurysm or
dissection, tendinopathy or tendon rupture and
peripheral neuropathy
Consider use of quinolones only in patient with history of
anaphylactic reaction to ß-lactam antibiotics.
**Consider Fosfomycin for patients suspected to have MDR
Gram Negative Infection.
Duration: 5-7 days
uroxime 250mg PO q12h Obtain urine culture before starting treatment and repeat 1-2
weeks after completion of antibiotics to ensure eradication.
moxicillin/clavulanate 625mg PO q8h Duration: 5-7 days
Treat for 7 days if recurrent.
picillin/sulbactam 375-750mg PO q12h *Avoid Nitrofurantoin at third trimester if another option
available due to small risk of haemolyticanaemia in
osfomycin 3gm PO x 1 dose newborn.
#Amoxicillin/clavulanate is generally safe in pregnancy
(Category B), but there may be an increased risk of
necrotising enterocolitis associated with use in preterm,
premature rupture of membranes.
**Consider Fosfomycin for patients suspected to have MDR
Gram-negative Infection.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
2. PYELONEPHRITIS
Uncomplicated Pyelonephritis Outpatient treatment:
Amoxicillin/clavulanate 625mg PO q8h for
Common organisms: 14 days
Enterobacteriaceae OR
Enterococci Ampicillin/sulbactam 375-750mg PO q12h
for 14 days
In non-pregnant, pre-menopausal women
without urological abnormalities or comorbidities. Inpatient treatment:
Amoxicillin/clavulanate 1.2gm IV q8h Ceftr
OR
Cefuroxime 750mg IV q8h
OR
Ampicillin/sulbactam 1.5-3gm IV q8h
Pyelonephritis in other categories (eg: Pregnancy) Treat as In-patient treatment for Uncomplicated P
3. OTHER URINARY TRACT INFECTIONS (UTI)
Complicated UTIs Oral Therapy:
Amoxicillin/clavulanate 625mg PO q8h for
Common organisms: 7 days
Enterobacteriaceae OR
Enterococci Cephalexin 500mg PO q6h for 7 days
Pseudomonas sp.
UTI symptoms in men OR presence of a structural Parenteral Therapy: Ceftr
PLUS
or functional abnormality: Amoxicillin/clavulanate 1.2gm IV q8h Amin
• Urinary tract obstruction OR
• Chronic kidney disease Ampicillin/sulbactam 1.5-3gm IV q8h
• Poorly-controlled type 2 diabetes OR
• Immunosuppression Cefuroxime 750mg IV q8h
• Urinary catheter in situ
18
ment
Comments
Alternative
Obtain urine culture before starting treatment.
Perform ultrasound of the upper urinary tract to exclude
obstructive pyelonephritis.
May step down to oral antibiotic guided by culture and
sensitivity result once can tolerate orally and afebrile > 48
hours.
riaxone 1gm IV q24h Obtain urine culture before starting treatment.
Pyelonephritis. Treat for 10-14 days in patients with upper tract symptoms,
delayed response or sepsis.
riaxone 1gm IV q24h
S/MINUS May step down to oral antibiotic guided by culture and
noglycoside sensitivity result once can tolerate orally and afebrile > 48
hours.
Suggested Treatm
Infection/ Condition & Likely Organism
Preferred
• Neurogenic bladder PLUS/MINUS
• Post-menopausal women Aminoglycoside
• History of recurrent UTIs
• Nephrolithiasis
Asymptomatic Bacteriuria (ABU) Screening for, and treating asymptomatic bacteriu
Urine bacterial growth ≥ 105cfu/mL in 2 serial • in pregnant women,
samples in women or a single sample in men
OR
without UTI symptoms. • prior to transurethral resection of prostate (T
breaching the mucosa (refer “surgical prophy
Whenever indicated, treatment should be gui
result.
Catheter-associated UTIs (CA-UTI) Refer to “Complicated UTIs”
Urine colony count ≥ 103cfu/mL with at least
one sign or symptom compatible with UTI, with
no other identifiable source of infection.
Prophylaxis for Recurrent Urinary Tract Nitrofurantoin 50-100mg PO ON Trim
Infections (rUTIs) (macrocrystals) or 100mg PO ON 80/4
2 episodes/6 months OR >3 episodes/year (monohydrate/macrocrystals) OR
OR Trim
Cephalexin 250mg PO ON
#The ORACLE trials demonstrated an increased risk of necrotising enterocolitis in women with preter
received Amoxicillin/clavulanate compared to those who did not13. A much smaller study also reporte
study of Ampicillin/sulbactam+Amoxicillin/clavulanate compared with Cefazolin/Cephalexin/Erythrom
suggest avoiding Amoxicillin/clavulanate in pregnancy16-20.
18
ment
Comments
Alternative
uria is not recommended, except; Duration of treatment for pregnant women: 5-7 days
TURP) or urological procedures
ylaxis” for treatment)
ided by urine culture and sensitivity
Routine screening and treating asymptomatic catheterized
patients is not recommended.
Pyuria alone in the absence of other symptoms is not
diagnostic of CA-UTI.
Remove unnecessary catheters.
Whenever indicated, change catheter prior to starting
treatment.
Treat for 10-14 days in patients with delayed response or
sepsis.
methoprim/sulfamethoxazole Antimicrobial prophylaxis is indicated if non-antimicrobial
400mg PO ON measures fail.
Post-coital prophylaxis may be appropriate for sexually
methoprim 100mg PO ON related rUTIs.
Duration: 3-6 months
rm, premature rupture of membranes (and to a lesser extent for those with preterm labour) who
ed an increased risk of necrotizing enterocolitis with Amoxicillin/clavulanate14, but a retrospective
mycin demonstrated no difference in rates of necrotising enterocolitis15. Many expert sources do not
References:
1. Urological Infections - European Association of Urology Guidelines March 2017
2. SA Health UTI Treatment Clinical Guidelines 2017
3. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and
Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the
European Society for Microbiology and Infectious Diseases
4. The Sanford Guide to Antimicrobial Therapy 2017 (47th edition)
5. IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults 2005
6. Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults:
2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America
7. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and
Pyelonephritis in Women: A 2010 Update by the IDSA and European Society for Microbiology
and Infectious Diseases 2011.
8. Australian Clinical Practice Guidelines : Therapeutic Guidelines Antibiotic Version 15
9. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults:
2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America,
Clinical Infectious Diseases, Volume 50, Issue 5, 1 March 2010
10. AntimicrobChemother 2013; Duration of antibiotic treatment for acute pyelonephritis and septic
urinary tract infection— 7 days or less versus longer treatment: systematic review and meta-
analysis of randomized controlled trial
11. J antimicrobial therapy 2015; Huttner A et al; Nitrofurantoin revisited : a systematic review and
meta-analysis of controlled trials
12. Antibiotic Treatment for Urinary tract infection, Clinical Guidelines Obstetrics and Gynaecology,
King Edward Memorial Hospital,Perth Western Australia
13. Kenyon SL, Taylor DJ, Tarnow-Mordi W; ORACLE Collaborative Group. Broad-spectrum
antibiotics for preterm, prelabour rupture of fetal membranes: the ORACLE I randomised trial.
ORACLE Collaborative Group. Lancet. 2001 Mar 31
14. S.M. Cox, K.J. Leveno, M.L. Sherman, L. Travis, R. DePalma. Ruptured membranes at 24 to 29
weeks: a randomized double blind trial of antimicrobials versus placebo. Am J ObstetGynecol
1995 1
18
15. Ehsanipoor RM1, Chung JH, Clock CA, McNulty JA, Wing DA. A retrospective review of
ampicillin-sulbactam and amoxicillin + clavulanate vs cefazolin/cephalexin and erythromycin in
the setting of preterm premature rupture of membranes: maternal and neonatal outcomes. Am
J Obstet Gynecol. 2008 May;198(5):e54-6.
16. eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2013. Acute Cystitis in
Adults. 2013.
17. eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2013. Acute
Pyelonephritis in Adults.
18. Hooton TM. Urinary tract infections and asymptomatic bacteriuria in pregnancy. In: UpToDate,
Post TW (Ed), UpToDate, Waltham, MA
19. Scottish Intercollegiate Guidelines Network (SIGN). Management of suspected bacterial urinary
tract infection in adults. Edinburgh: SIGN; 2012
20. National Institute for health and care excellence. cks.nice.org.uk/urinary-tract-infection-lower-
women (accessed 15th September 2014)
21. American Geriatric Society’s (AGS) Beers Criteria of Potentially Inappropriate Drugs, 2012 and
recently revised and updated in 2015
22. J.Obs gynecology Canada 2009; Yudin MH et al ; Antibiotic therapy in preterm premature
rupture of the membranes.
23. Archives of Medical Science_: AMS. 2015;11(1):67-77.Matuszkiewicz-Rowi_ska J, Ma_yszko J,
Wieliczko M. Urinary tract infections in pregnancy: old and new unresolved diagnostic and
therapeutic problems.
24. BMJ 2018 Mar 8. Pasternak B et al. Fluoroquinolone use and risk of aortic aneurysm and
dissection: Nationwide cohort study.
25. The Journal of clinical and aesthetic dermatology. 2010;3(4):49-54. Kim GK. The Risk of
Fluoroquinolone-induced Tendinopathy and Tendon Rupture: What Does the Clinician Need to
Know? Del Rosso JQ, ed..
26. ISPD Peritonitis Recommendations: 2016 Update On Prevention And Treatment
27. Beerepoot, M., &Geerlings, S. (2016). Non-Antibiotic Prophylaxis for Urinary Tract Infections.
Pathogens, 5(2), 36.
18
SECTION B
PEADIATRICS
B1 Cardiovascular Infections
National Antimicrobial Guideline 2019 187
B1. Cardiovascular Infections Suggested Treatm
Infection/ Condition & Preferred
Likely Organism
Treatment mainly supportive
Acute Myocarditis
Treatment mainly supportive.
Viral (commonest cause)
Empiric for purulent pericarditis: Antib
Enteroviruses Cloxacillin 200mg/kg/day IV in 4-6 divided Cefa
Adenovirus doses dose
Influenza PLUS
HIV etc. Cefotaxime 200-300mg/kg/day IV in 4
divided doses.
Acute pericarditis
Viral (commonest cause)
Bacterial:
Staphylococcus aureus
Haemophilus influenza
Salmonella spp.
M. tuberculosis
Infective Endocarditis Ampicillin 200-300mg/kg/day in 4-6 PLUS
divided doses *Clo
Empirical therapy for infective endocarditis PLUS 4-6 d
Gentamicin 1mg/kg/dose IV q8h
Community-acquired organisms:
Streptococcus, Enterococcus
HACEK Gram-negative organisms
18
ment
Comments
Alternative
Among the viruses implicated are enteroviruses including
Coxsackie & EV71. For severe HFMD with
cardiopulmonary failure stage, use of IVIG may be
considered if not used during CNS involvement or
autonomic nervous system dysregulation stage.
biotic allergy: Need pericardial fluid to differentiate between different
azolin 100mg/kg/day IV in 3 divided
es (max. 6gm/day) etiologic agent & C&S to adjust antibiotic. Consider
surgical drainage for tamponade, pre-tamponade &
ineffective conservative management.
Duration of therapy: 4 weeks.
Antibiotic allergy refer to Appendix 8.
S/MINUS *For acute presentation, need to cover for MSSA since
oxacillin 200 mg/kg/day IV in Streptococcus & Enterococcus HACEK presentations are
divided doses usually sub-acute.
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Healthcare-associated organisms:
MRSA Vancomycin 60mg/kg/day IV in
Non-HACEK Gram-negative organisms 2- 3 divided doses (max. 2gm/day if
Enterococcus sp. unable to achieve therapeutic level)
PLUS
Gentamicin 1mg/kg/dose IV q8h
PLUS/MINUS
*Rifampicin 20mg/kg/day in 3 divided
doses (max. 900mg/day)
Specific Organisms:
Infective Endocarditis (Streptococcus viridans)
Strains fully susceptible to penicillin Benzylpenicillin 200,000-300,00 Amp
(MIC<0.125 mg/l) units/kg/day IV in 4-6 divided doses dose
(up to 12-18MU/day) OR
Ceftr
1-2 d
OR
Antib
*Van
2-3 d
Strains with MIC>0.125 to 2 µg/ml PLUS
Gentamicin 1mg/kg/dose IV q8h for
2 weeks (add to first line regimen of
penicillin/ceftriaxone)
Do not use ampicillin.
ment 18
Alternative Comments
*Rifampicin IS ONLY for prosthetic valve AND added after
3-5 days later than vancomycin & gentamicin.
If non-HACEK Gram-negative organism like pseudomonas
is suspected epidemiologically, add cefepime
50mg/kg/dose IV q8h until cultures are known.
Once cultures are available, adjust accordingly.
picillin 300mg/kg/day IV in 4-6 divided Duration:
es (max. 12gm/day) • 4 weeks for native valve
• 6 weeks for prosthetic valve
riaxone 100mg/kg/day IV in
divided doses (max. 4gm/day) Vancomycin dose adjusted for trough concentration of 10 -
15 mg/ml.
biotic allergy
ncomycin 40mg/kg/day IV in Antibiotic allergy refer to Appendix 8
divided doses (max. 2gm/ day)
*Vancomycin therapy is recommended only for patients
with immediate type penicillin hypersensitivity.
For this strain (MIC>0.125):
Antibiotic of choice is either penicillin with gentamicin or
ceftriaxone with gentamicin.
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Infective Endocarditis (Enterococcus sp.)
Penicillin-sensitive (MIC≤ 8 mg/l) Ampicillin 200-300mg/kg/day IV in 4-6 Amp
divided doses for *4-6 weeks equa
Sensitive to penicillin & vancomycin but high- PLUS PLUS
level resistance to gentamicin Gentamicin 1mg/kg/dose IV q8h for Ceftr
(MIC>500 mg/l) *2-6 weeks 1-2 d
Resistant to penicillin but susceptible to Ampicillin 300mg/kg/day IV in 4-6 divided
vancomycin & gentamicin doses
PLUS
Ceftriaxone 100mg/kg/day IV in
1-2 divided doses (max. 4gm/day)
Duration: 6 weeks.
**Vancomycin 40mg/kg/day IV in 3
divided doses
PLUS
Gentamicin 1mg/kg/dose IV q8h
Duration: 6 weeks
Infective Endocarditis (Staphylococcus aureus)
Methicillin-sensitive (left-sided) Cloxacillin 200-300mg/kg/day IV in 4-6 Antib
divided doses for 4-6 weeks Cefa
dose
Methicillin-sensitive (right-sided) Cloxacillin 200-300mg/kg/day IV in OR
4-6 divided doses for 4 weeks Vanc
2-3 d
19
ment
Comments
Alternative
picillin 200-300mg/kg/day IV in 4-6 *Duration:
ally-divided doses • If symptoms less than 3 months & native valve:
S
riaxone 100mg/kg/day IV in ampicillin for 4 weeks & gentamicin for 2 weeks.
divided doses. • If symptoms more than 3 months: ampicillin &
gentamicin for 6 weeks.
Ampicillin plus ceftriaxone is preferred for individuals with
renal impairment (CrCl ≤50ml/min) ONLY.
Can not use ceftriaxone alone since enterococcus is
intrinsically resistant to this drug.
This combination is NOT ACTIVE against E. faecium.
**Maximum dose of vancomycin: 2gm/day unless not able
to achieve therapeutic range. Aim for serum trough of 10-
20mg/l.
biotic allergy If allergy to penicillin but not immediate type
azolin 100mg/kg/day IV in 3 divided hypersensitivity, use cefazolin.
es for 4-6 weeks Antibiotic allergy refer to Appendix 8
Methicillin-sensitive (right sided): Can shorten duration to
comycin 60mg/kg/day IV in 2 weeks if good response, no metastatic sites, no cardiac
divided doses for 4-6 weeks. or extracardiac complications with size of vegetation less
than 20mm.
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Methicillin-resistant (left & right)
Methicillin-sensitive (prosthetic valve) Vancomycin 60mg/kg/day IV in 2-3 Dapt
divided doses (max. 2gm/day) for week
Methicillin-resistant (prosthetic valve) 4-6 weeks
Culture-negative endocarditis Cloxacillin 200-300mg/kg/day in 4-6
divided doses for ≥6 weeks
PLUS
Gentamicin 1mg/kg/dose IV q8h for 2 weeks
PLUS
*Rifampicin 20mg/kg/day PO in 3 divided
doses for ≥6 weeks
Vancomycin 60mg/kg/day in 2-3 divided
doses for ≥ 6 weeks
PLUS
Gentamicin 1mg/kg/dose IV q8h for 2 weeks
PLUS
*Rifampicin 20mg/kg/day PO in 3 divided
doses ≥6 weeks
Ampicillin/sulbactam 300mg/kg/day IV in
4-6 divided doses for 4-6 weeks
PLUS
Gentamicin 1mg/kg/dose IV q8h for
4-6 weeks
References :
1. American Academy of Paediatrics. Committee on Infectious Diseases. Red Book: Report of the Co
2. Malaysian Clinical Practise Guideline for the Prevention, Diagnosis and Management of Infective E
19
ment
Alternative Comments
tomycin 10 mg/kg IV daily for 4-6 Daptomycin is superior to vancomycin for MRSA
ks. bacteremia with MIC >1 mg/l.
*Rifampicin has better penetration but to protect against
development of resistance, use only after 3-5 days of
cloxacillin &/or bacteremia has been cleared.
MRSA (prosthetic valve): Vancomycin & rifampicin for 6
weeks or more.
Culture-negative endocarditis (CNE) is diagnosed when a
child has clinical & echocardiogram evidence of IE but
persistent negative cultures.
This is in individuals with no prior antimicrobial use.
If fungi or fastidious organism is suspected, need to ask
microbiologist to prolong incubation.
Patients with culture-negative endocarditis should be
treated in consultation with an ID specialist.
ommittee on Infectious Diseases (2018).
Endocarditis 2017.
19
SECTION B
PEADIATRICS
B2 Central Nervous Infections
National Antimicrobial Guideline 2019 193
B2. Central Nervous Infections Suggested Treatm
Infection/ Condition &
Likely Organism Preferred
Meningitis empirical treatment Cefotaxime 200-300mg/kg/day IV in 4
Age groups: divided doses
1-3 months: (max. 2gm/dose)
Group B streptococcus (GBS), E. coli, OR
S. pneumoniae & N. meningitidis Ceftriaxone 100mg/kg/day IV in
>3 months: 1-2 divided doses
S. pneumoniae, Hib, E. coli, Salmonellosis & (max. 2gm/dose; 4gm/day)
N. meningitidis
PLUS
Specific Organisms Benzylpenicillin 300,000-400,000
Haemophilus influenza (HI) units/kg/day IV in 4-6 divided doses
(max. 24MU/day)
Neisseria meningitidis
Cefotaxime 200-300mg/kg/day IV in 4 Amp
Strepcoccus pneumonia (SP) divided doses (max. 2gm/dose) (if M
Penicillin-susceptible (MIC≤0.06 mcg/ml) OR
Ceftriaxone 100mg/kg/day IV in 1 or 2
divided doses (max. 2gm/dose; 4gm/day)
Benzylpenicillin 300,000-400,000 Cefo
units/kg/day; max. 12MU/day) IV in 4-6 divid
divided doses for 7 days OR
Ceftr
1-2 d
4gm
Benzylpenicillin 300,00-400,000
units/kg/day in 4-6 divided doses
(max. 24MU/day)
ment 19
Alternative Comments
For children below 3 months of age:
Cefotaxime is the preferred third generation cephalosporin
since less drug-drug interactions (in terms of interaction
with calcium-containing infusion & bilirubin
displacement).
Once organism is known, please refer below to adjust
antibiotics.
picillin 300mg/kg/day q6h Duration: 10 days (HI)
MIC <1mcg/ml)
otaxime 200-300mg/kg/day IV in 4 Prophylaxis for all household contacts & health care
ded doses (max. 2gm/dose) for 7 days workers involved in unprotected contact during intubation
& suctioning of airway/mouth-to-mouth resuscitation.
riaxone 100mg/kg/day IV in
divided doses (max. 2gm/dose;
m/day) for 7 days
Duration: 14 days (SP)
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Penicillin-resistant (MIC≥0.12 mcg/ml) &
cefotaxime/ ceftriaxone- sensitive Cefotaxime 200-300mg/kg/day IV in 4
(MIC ≤0.5 mcg/ml) divided doses
(max. 2gm/dose)
Penicillin & cefotaxime/ceftriazone-resistant OR
(MIC ≥2.0 mcg/ml) (drug-resistant Ceftriaxone 100mg/kg/day IV in 1 or 2
Streptococcus pneumoniae, DRSP) divided doses (max. 2gm/dose; 4gm/day)
Cryptococcal meningitis
Cryptococcus neoformans High dose cefotaxime or ceftriaxone
PLUS
Herpes simplex encephalitis Vancomycin 60mg/kg/day in 4 divided doses
Brain abscess Induction Therapy:
Amphotericin B 1.0mg/kg/day IV q24h
PLUS/MINUS
5-flucytosine 25mg/kg/dose
(max. 2gm/dose) PO q6h for 2-4 weeks
Consolidation Therapy:
Fluconazole 6mg/kg/dose
(max. 400mg/dose) IV/PO q12h for 8 weeks
4 months to 12 years old:
Acyclovir 30-45mg/kg/day IV in 3
divided doses
Cefotaxime 200-300mg/kg/day IV in 4 If sec
divided doses (max. 2gm/dose) PLUS
OR Clox
Ceftriaxone 100mg/kg/day IV in divid
1-2 divided doses (max. 2gm/dose; ceph
4gm/day)
PLUS
Metronidazole 15mg/kg IV stat then
7.5mg/kg IV q8h
19
ment
Comments
Alternative
Treat in consultation with ID specialist.
Duration of induction with 5-flucytosine (5-FU) is at least 2
weeks & until CSF repeat culture is NEGATIVE.
condary to trauma: Duration: 14-21 days.
S Doses of 60mg/kg/day OR dosing exceeding 15mg/kg or
xacillin 200-300mg/kg/day in 4-6 500mg/m2 is associated with acute kidney injury.
ded doses (add to third generation
halosporin) Surgical drainage may be indicated if appropriate.
Duration: 6-8 weeks, depending on response based on
neuroimaging & clinical presentations.
References:
1. American Academy of Paediatrics. Committee on Infectious Diseases. Red Book: Report of the Co
2. Sanford Guide to antimicrobial therapy.
19
ommittee on Infectious Diseases (2018).
SECTION B
PEADIATRICS
B3 Chemoprophylaxis
National Antimicrobial Guideline 2019 197
B3. i SURGICAL
Guidelines for prevention of surgical site infections (SSIs) have been published. General principles:
1. Agent used for antimicrobial prophylaxis should prevent SSIs and related morbidity and mortality
2. Reduce duration and cost of care
Timing:
Effective chemoprophylaxis occurs only when the appropriate antimicrobial drug is present in tissues
at sufficient local concentration at the time of intra-operative bacterial contamination. Administration
of antimicrobial agent is recommended within 60 minutes before surgical incision to ensure adequate
tissue concentration at the start of the procedure. Agents that require longer administration time such
as vancomycin should begin within 120 minutes before surgery begins. Adequate antimicrobial
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Cardiac surgery
S. epidermidis, S. aureus, Corynebacterium sp., Cefazolin 30 mg/kg IV; max. 2gm If kn
Enteric Gram-negative bacilli Recommended re-dosing interval from colon
initiation of pre -operative dose: every
4 hours
Thoracic surgery
Non-cardiac including lobectomy, Cefazolin 30mg/kg IV; max. 2gm Amp
pneumonectomy, lung resection & thoracotomy Recommended re-dosing interval from amp
initiation of pre -operative dose:every 4
hours Reco
initia
2 ho
19
3. Produce no adverse effect
4. Minimize adverse consequences to the microbial flora
concentration should be maintained throughout the surgical procedure and in most instances, single
dose of antimicrobial agent is sufficient and the duration of prophylaxis after any procedure should
not exceed 24 hours. Intra-operative dosing is required if the duration of the procedure is greater
than two times the half-life of the antimicrobial agent or if there is excessive blood loss.
ment
Comments
Alternative
nown to have MRSA/MRSE Antibiotic allergy:
nisation, use Vancomycin 15mg/kg IV Clindamycin 10mg/kg IV; max 900mg
Recommended re-dosing interval from initiation of pre-
operative dose: every 6 hours
Antibiotic allergy refer to Appendix 8
picillin/sulbactam 50mg/kg (of Antibiotic allergy:
picillin component) IV Clindamycin 10mg/kg IV; max 900mg
Recommended re-dosing interval from initiation of pre-
ommended re-dosing interval from operative dose: every 6 hours
ation of pre -operative dose: every
ours Antibiotic allergy refer to Appendix 8
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Abdominal Surgery
Gastroduodenale Cefazolin 30mg/kg IV; max. 2gm Amp
Recommended re-dosing interval from amp
initiation of pre -operative dose: every Reco
4 hours initia
2 ho
Biliary tract Cefazolin 30mg/kg IV; max. 2gm Ceftr
(Open procedure/Laparoscopic procedure/ Recommended re-dosing interval from OR
Appendectomy/Small intestine/Hernia repair initiation of pre -operative dose: every Cefo
(hernioplasty & herniorrhaphy) /Colorectal) 4 hours Reco
OR initia
Head & neck Ampicillin/sulbactam 50mg/kg (of every
Clean (tonsillectomy, adenoidectomy, ampicillin component) IV PLUS
tracheostomy, thyroglossal cyst excision, Recommended re-dosing interval from Metr
precauricular sinus, dermoid cyst, brachial initiation of pre -operative dose: (For
anomaly, thyroidectomy, paroidectoy, lymph every 2 hours to gi
node biopsy etc.)
Clean with placement of prosthesis No antibiotic routinely No a
(excludes tympanostomy tubes)
Cefazolin 30mg/kg IV; max. 2gm Amp
Recommended re-dosing interval from amp
initiation of pre -operative dose: Reco
every 4 hours initia
every
19
ment
Comments
Alternative
picillin/sulbactam 50mg/kg (of Antibiotic allergy:
picillin component) IV Clindamycin 10mg/kg IV; max 900mg
ommended re-dosing interval from Recommended re-dosing interval from initiation of pre -
ation of pre -operative dose: every operative dose: every 6 hours
ours AND
Gentamicin 2.5 mg/kg IV
riaxone 50-75mg/kg IV; max. 2gm
Antibiotic allergy refer to Appendix 8
otaxime 50mg/kg; max. 1gm
ommended re-dosing interval from Antibiotic allergy:
ation of pre -operative dose: Clindamycin 10mg/kg IV; max 900mg
y 3 hours Recommended re-dosing interval from initiation of pre -
S operative dose: every 6 hours
ronidazole 15 mg/kg IV PLUS
neonates less than 1200gm, Gentamicin 2.5 mg/kg IV
ive 7.5 mg/kg)
Antibiotic allergy refer to Appendix 8
antibiotic routinely
picillin/sulbactam 50mg/kg (of Antibiotic allergy:
picillin component) IV Clindamycin 10mg/kg IV; max 900mg
ommended re-dosing interval from Recommended re-dosing interval from initiation of pre-
ation of pre-operative dose: operative dose: every 6 hours
y 2 hours Antibiotic allergy refer to Appendix 8
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Clean-contaminated procedures with the
exception of tonsillectomy & functional OR
endoscopic sinus procedure Cefu
Reco
Clean-contaminated cancer surgery initia
every
Cefazolin 30mg/kg IV; max. 2gm Amp
Recommended re-dosing interval from amp
initiation of pre -operative dose: Reco
every 4 hours initia
PLUS every
Metronidazole 15mg/kg IV OR
Cefu
Reco
initia
every
PLUS
Metr
Cefazolin 30mg/kg IV; max. 2gm Amp
Recommended re-dosing interval from amp
initiation of pre -operative dose: Reco
every 4 hours initia
PLUS every
Metronidazole 15mg/kg IV OR
Cefu
max.
Reco
initia
every
PLUS
Metr
20
ment
Comments
Alternative
uroxime 50mg/kg IV; max. 1.5gm Antibiotic allergy:
ommended re-dosing interval from Clindamycin 10mg/kg IV; max 900mg
ation of pre -operative dose: Recommended re-dosing interval from initiation of pre-
y 4 hours operative dose: every 6 hours
Antibiotic allergy refer to Appendix 8
picillin/sulbactam 50mg/kg (of
picillin component) IV Antibiotic allergy:
ommended re-dosing interval from Clindamycin 10mg/kg IV; max. 900mg
ation of pre -operative dose: Recommended re-dosing interval from initiation of pre-
y 2 hours operative dose: every 6 hours
Antibiotic allergy refer to Appendix 8
uroxime 50mg/kg IV; max. 1.5gm
ommended re-dosing interval from
ation of pre -operative dose:
y 4 hours
S
ronidazole 15mg/kg IV
picillin/sulbactam 50mg/kg (of
picillin component) IV
ommended re-dosing interval from
ation of pre -operative dose:
y 2 hours
uroxime 50mg/kg IV;
. 1.5gm
ommended re-dosing interval from
ation of pre -operative dose:
y 4 hours
S
ronidazole 15mg/kg IV
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Neurosurgery
Cefazolin 30mg/kg IV; max. 2gm If kn
Elective craniotomy & cerebrospinal fluid- Recommended re-dosing interval from colon
shunting procedures initiation of pre -operative dose:
every 4 hours
Orthopaedics
Clean operations involving hand, knee, or foot None None
& not involving implantation of foreign materials
Spinal procedure with or without Cefazolin 30mg/kg IV; max. 2gm
instrumentation/hip surgery/ Implantation of Recommended re-dosing interval from
internal fixation devices (e.g. nails, screws, initiation of pre -operative dose:
plates, wires) every 4 hours
Urology Cefa
Reco
Low tract instrumentation with risk factors for Trimethoprim 2mg/kg PO; max. 150mg initia
infections every
Clean without entry into urinary tract/clean Cefazolin 30mg/kg IV; max. 2gm Amo
with entry into urinary tract (e.g. hypospadia Recommended re-dosing interval from 30m
surgery) initiation of pre-operative dose: Reco
every 4 hours initia
every
20
ment
Comments
Alternative
nown to have MRSA/MRSE Antibiotic allergy:
nisation, use Vancomycin 15mg/kg IV Clindamycin 10mg/kg; max. 900 mg
Recommended re-dosing interval from initiation of pre-
operative dose: every 6 hours
Antibiotic allergy refer to Appendix 8
e
Antibiotic allergy:
Clindamycin 10mg/kg; max. 900 mg
Recommended re-dosing interval from initiation of pre -
operative dose: every 6 hours
Antibiotic allergy refer to Appendix 8
azolin 30mg/kg IV; max. 2gm Antibiotic allergy:
ommended re-dosing interval from Gentamicin 2.5mg/kg IV
ation of pre -operative dose: Antibiotic allergy refer to Appendix 8
y 4 hours
UTI should be treated before procedure when possible.
oxicillin/clavulanate Medical literature does not support continuing
mg/kg IV; max 1.2gm antimicrobial prophylaxis until urinary catheter have been
removed.
ommended re-dosing interval from
ation of pre -operative dose:
y 4 hours
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Clean-contaminated (entering gastrointestinal Cefazolin 30mg/kg IV; max. 2gm Amo
tract) Recommended re-dosing interval from 30m
initiation of pre -operative dose: Reco
every 4 hours initia
PLUS every
Metronidazole 15 mg/kg IV
Plastic Surgery
Elective soft tissue surgery No prophylaxis unless complex
prolonged procedure
If complex, Cloxacillin 25mg/kg IV; max 1gm
Recommended re-dosing interval from
initiation of pre -operative dose:
every 4 hours
Elective hand or foot surgery involving bone Cloxacillin 25mg/kg IV; max 1gm
Recommended re-dosing interval from
initiation of pre -operative dose:
every 4 hours
Cleft lip & palate surgery Amoxicillin/clavulanate 30mg/kg;
Excision & grafting surgery max. 1.2gm
Recommended re-dosing interval from
initiation of pre -operative dose:
every 4 hours
Amoxicillin/clavulanate 30mg/kg;
max. 1.2gm
Recommended re-dosing interval from
initiation of pre -operative dose:
every 4 hours
20
ment
Alternative Comments
oxicillin/clavulanate Antibiotic allergy:
mg/kg IV; max 1.2gm Gentamicin 2.5mg/kg IV
Antibiotic allergy refer to Appendix 8
ommended re-dosing interval from
ation of pre -operative dose:
y 4 hours
Antibiotic allergy:
Clindamycin 10mg/kg IV; max. 900mg
Recommended re-dosing interval from initiation of pre -
operative dose: every 6 hours
Antibiotic allergy refer to Appendix 8
Antibiotic allergy:
Clindamycin 10mg/kg; max. 900mg
Recommended re-dosing interval from initiation of pre -
operative dose: every 6 hours
Antibiotic allergy refer to Appendix 8
Antibiotic allergy:
Clindamycin 10mg/kg; max. 900mg
Recommended re-dosing interval from initiation of pre -
operative dose: every 6 hours
Antibiotic allergy refer to Appendix 8
Infection/ Condition & Suggested Treatm
Likely Organism
Preferred
Interventional radiology
Percutaneous endoscpic gastrostomy (PEG) or Cefazolin 30mg/kg IV; max. 2gm Amo
jejunostomy (PEJ) or nephrostomy tube Recommended re-dosing interval from 30m
placement initiation of pre -operative dose: Reco
every 4 hours initia
every
Micturating cystourethrogram (MCUG) Trimethoprim 2mg/kg PO; max. 150 mg
(if patient is already on existing antibiotic
UTI prophylaxis, increase antibiotic to
therapeutic dose for a single dose prior
procedure)
Tenckhoff peritoneal dialysis cathether insertion Cefazolin 30mg/kg IV; max. 2gm Amo
Recommended re-dosing interval from 30 m
initiation of pre -operative dose: Reco
every 4 hours initia
every
Burns No prophylaxis required
References:
1. Clinical Practical Guideline for Antimicrobial Prophylaxis for Surgery 2013. American Society of H
Healthcare Epidemiology of America (SHEA). Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwa
American Journal of Health-system Pharmacy 2013. 70(3):195-283.
2. Antibiotic Prophylaxis for Paediatric Surgery. Royal Hospital for Children Glasgow. 2018.
20
ment
Comments
Alternative
oxicillin/clavulanate
mg/kg IV; max. 1.2gm
ommended re-dosing interval from
ation of pre -operative dose:
y 4 hours
oxicillin/clavulanate
mg/kg IV; max. 1.2gm
ommended re-dosing interval from
ation of pre -operative dose:
y 4 hours
Hospital Pharmacists (ASHP) guideline, IDSA, Surgical Infection Society (SIS) and Society of
aerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA.
B3.ii Non-Surgical Suggested Treatm
Infection/ Condition &
Likely Organism Preferred
Rheumatic fever Benzathine penicillin Phen
(Secondary prevention)
1.2MU (>27kg); Duration 250
0.6MU (£ 27 kg)
IM every 3-4 weeks 1. With carditis & residual heart disease
Infective Endocarditis (IE) (persistent valvular disease): 10 Antib
years since the last episode of ARF or Eryth
40 years of age whichever is longer. mg/k
Consider lifelong prophylaxis.
2. With carditis but no residual heart
disease (no valvular disease): 10
years since the last episode of ARF or
21 years of age whichever is longer.
3. Without carditis: 5 years since last
ARF or until 21 years of age whichever
is longer.
Amoxicillin 50mg/kg PO 30-60 minutes Antib
before procedure Clind
OR minu
Ampicillin 50mg/kg IV 30-60 minutes
before procedure Othe
Cefa
shou
anap