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OUT Patient

Dysenteric Diarrhea

Frequent, sometimes bloody, small-volume diarrhea associated with abdominal pain and cramping.

Patient may be febrile and toxic.

Shigella

Salmonella

Campylobacter

Yersinia

E. coli 0157:H7

'C.difficile' 

Ciprofloxacin 500 mg PO BID

OR

Ciprofloxacin 750 mg daily x 3 days

(avoid in cases of E. coli O157:H7 as it may increase the risk of hemolytic-uremic syndrome)

Recent antibiotic exposure: consider C. difficile

Antimotility drugs should not be used in C.difficile.

C. difficile - Metronidazole 500 mg PO TID x 10-14 days. If no response at 5 days, switch to Vancomycin 125mg PO QID x10-14 days. See inpatient guidelines for severe or recurrent C. difficile infection and/or policy on C. difficile management.

  • Empiric therapy is generally indicated if patient is toxic appearing, elderly or immunocompromised.  If empiric therapy is given, obtain culture and give fluoroquinolone x 3 days while awaiting cultures
  • Azithromycin should be used for pregnancy and suspected quinolone resistant Campylobacter.
  • Antimotility drugs improve symptoms and can be used if patient is not toxic.  
  • Antimicrobial treatment may worsen outcomes in patients with E. coli0157:H7
  • E. histolytica - Metronidazole 750 mg PO TID x 7-10 days then Iodoquinol 650 mg PO TID x 20 days or Paromomycin5 25-35 mg/kg/day in 3 divided doses x 7 days
Nondysenteric Diarrhea

Large volume, nonbloody, watery diarrhea.

Patient may have nausea, vomiting, and abdominal cramping but fever often absent.

Viruses

Giardia

Enterotoxigenic E. coli

Enterotoxin-producing bacteria

General Care: Observation

Oral rehydration

Antimotility agents

Giardia – especially if patient describes recent history of travel and/or ingestion of unfiltered water (e.g., camping), consider – Metronidazole 250 mg PO TID x 5 days.

  • Generally, empiric therapy and stool cultures are not indicated. Most disease is self-limiting and can be treated with antimotility agents
  • If patient fails to improve, cultures (-), and symptoms persist, consider stool for O & P.
  • Metronidazole resistance seen in 20% giardia cases. Check C. difficile toxin if recent history of antibiotic use or hospitalization.
Traveler’s diarrhea

Empiric treatment while abroad

Toxigenic E. coli

Salmonella

Shigella

Campylobacter

Amebiasis

Ciprofloxacin 500 mg PO BID x 1-3 days

Pregnancy or fluoroquinolone-resistant campylobacter:

Azithromycin 1 g x 1 dose

EITHER WITH or WITHOUT:

Loperamide 4 mg PO x 1; then 2 mg after each loose stool,

MAX 16 mg/day

Mild, self-limited cases can be treated with fluid and electrolyte repletion and bismuth subsalicylate.

Prophylaxis generally not recommended.

Diverticulitis Enterobacteriaceae

Bacteroides fragilis

'Enterococcus' 

Amoxicillin/clavulanate 

875 mg/125 mg PO BID

OR

MoxifloxacinID-R: SFGH 400 mg PO daily

OR the combination of:

Metronidazole 500 mg PO TID

PLUS ONE OF:

Ciprofloxacin 500 mg PO BID

OR

LevofloxacinID-R: VASF  500 mg PO daily

Duration of treatment should be until patient is afebrile for 3-5 days.

Surgical evaluation and follow up is advised.

'Acute Bronchitis'  Viral No drug therapy required 
Acute bacterial exacerbation of chronic bronchitis (COPD) S. pneumoniae

H. influenzae 

Moraxellacatarrhalis

Doxycycline 100 mg PO BID X 10 days Azithromycin 500 mg PO daily X 1 day; then 250 mg PO daily X 4 days
Community-acquired Pneumonia (CAP)  S. pneumoniae

M. pneumoniae

C. pneumoniae

Respiratory viruses

Legionella spp.

C. psittaci

'H. influenzae (if patient has co-morbidity)

No recent antibiotic therapy:

Doxycycline 100 mg PO BID X 7 days

OR

Azithromycin 500 mg PO daily X 1 day; then 250 mg PO daily X 4 days

Recent antibiotic therapy or patients with co-morbidities:

Levofloxacin 750 mg PO daily X 5 days

OR

MoxifloxacinID-R: SFGH 400 mg PO daily X 7 days

Previous antibiotic therapy within last 3 month should be elicited from patient. A course of antibiotics is a risk factor for drug resistance. Recent use of a fluoroquinolone should dictate selection of a non-fluoroquinolone regimen, and vice versa.

Careful follow-up highly recommended.

Anerobic infection Amoxicillin/clavulanate 875 mg/125 mg PO BID

OR

Clindamycin 300 mg PO TID

Acute otitis media

OR

'Otitis media with effusion' (OME) with signs or symptoms of acute infection 

S. pneumoniae

H. influenzae

M. catarrhalis

Group A Strep.

Amoxicillin

1 g PO BID x 5-7 days

OR

500 mg PO TID x 5-7 days

For severe PCN allergy:

Azithromycin 500 mg PO daily x 1 day; then 250 mg PO daily x 4 days

OR

Doxycycline 100 mg PO BID for 5-7 days

  • Amoxicillin/clavulanic acid not indicated as initial therapy of acute otitis.
  • High dose amoxicillin 1 g PO TID should be used over low dose in the treatment of patients at risk for drug resistant S. pneumoniae.
  • OME in the absence of acute signs and symptom of infection does not require antibiotics.
  • For recurrent prolonged otitis consider ENT referral.
Pharyngitis Viral (EBV, rhinovirus, coronavirus, adenovirus etc)

Group A Streptococcus

(5-20%)

Penicillin VK 250 mg PO TID-QID x 10 days For severe PCN allergy:

Clindamycin300 mg PO TID x 7-10 days

  • Most pharyngitis is viral thus antibiotics should not be used.
  • Treatment with PCN prevents rheumatic fever.
  • Treat documented Group A streptococcal infection confirmed by rapid strep. antigen test or culture or if 3 out 4 clinical criteria present.
  • Clinical Criteria: history of fever, tender anterior cervical adenopathy, absence of cough, tonsillar exudates.
Acute Sinusitis Viruses

S. pneumoniae

H. influenzae

M. catarrhalis

Amoxicillin 500 mg PO TID X 5-7 days For severe PCN allergy:

Doxycycline 100 mg PO BID X 5-7 days

Consider treatment only in presence of fever, purulence or bloody discharge following an upper respiratory infection if symptoms persist for 7-10 days suggesting bacterial etiology.

Chronic Sinusitis Viruses

S. pneumoniae

H. influenzae

M. catarrhalis

Anaerobes

Staph. aureus

Enterobacteriacae 

Amoxicillin/clavulanate

875 mg/125 mg PO BID X 10-14 days

OR

Amoxicillin/clavulanate CR 2 g BID X 10-14 days if drug-resistant Streptococcus pneumonia 

For severe PCN allergy:

Ciprofloxacin 500 mg PO BID

OR

Levofloxacin 500 mg PO daily x 10-14 days

EITHER OF ABOVE WITH OR WITHOUT*:

Clindamycin 300 mg PO TID

  • Consider otolaryngology consult to rule out anatomic abnormality.
  • If acute exacerbation, treat as acute sinusitis.
  • HIV positive patients may need a 2-3 week course.
Treatment of active tuberculosis Isoniazid 300 mg PO daily x 6 months

PLUS

Rifampin 600 mg PO daily x 6 months

PLUS

Pyrazinamide 25 mg/kg PO daily x 2 months

PLUS

Ethambutol 15 mg/kg PO daily until Isoniazid or Rifampin sensitivity established

PLUS:

Pyridoxine (Vitamin B-6) 50 mg PO daily for 6 months

Latent TB 'Isoniazid' 300 mg PO daily x 9 months Rifampin 600 mg PO daily x 4 months