Sandbox ID Lower Respiratory Tract

Pneumonia, community-acquired

• Community acquired pneumonia

• Empiric therapy in adults

• (A) Outpatient treatment

• (1) Previously healthy and no use of antimicrobials within the previous 3 months.

• Preferred regimen : Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Azithromycin 500 mg IV as a single dose OR Clarithromycin 250 mg q12h for 7-14 days OR 1000 mg q24h for 7 days OR Erythromycin 250-500 mg q6-12h (max: 4 g/day)
• Alternative regimen : Doxycycline 100 mg PO/IV q12h (Weak recommendation).

• (2) Presence of comorbidities such as chronic heart, lung, liver or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; or use of antimicrobials within the previous 3 months (in this case an alternative from a different class should be selected)

• Preferred regimen (1) : Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Gemifloxacin 320 mg PO q24h for 5 or 7 days
• Preferred Regimen (2) : (Amoxicillin 875 mg PO q12h or 500 mg q8h OR Amoxicillin-clavulanate 2 g q12h OR Ceftriaxone 1 g IV q24h, (2 g q24h for patients at risk) OR Cefpodoxime 200 mg PO q12h for 14 days OR Cefuroxime 750 mg IM/IV q8h) AND ( Macrolide Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Doxycycline 100 mg PO/IV q12h)

• (B) Inpatient Therapy (in regions with a high rate (125%) of infection with high-level (minimum inhibitory concentration 16 mg/mL) macrolide-resistant Streptococcus pneumoniae)

• (1) Non-ICU treatment

• Preferred Regimen : Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Gemifloxacin 320 mg PO q24h for 5 or 7 days OR Amoxicillin 1 g q8h OR Amoxicillin-clavulanate 2 g q12h
• Alternative Regimen : Ceftriaxone 1 g IV q24h, (2 g q24h for patients at risk) OR Cefpodoxime 200 mg PO q12h for 14 days OR Cefuroxime 750 mg IM/IV q8h

• (2) ICU treatment

• Preferred Regimen : (Cefotaxime I.M., I.V.: 1 g q12h OR Ceftriaxone 1 g IV q24h, 2 g/day for patients at risk OR Ampicillin-sulbactam 1.5-3 g IV q6h) AND (Azithromycin 500 mg/day PO once, followed by 250 mg q24h for 4 days OR Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Gemifloxacin Oral: 320 mg q24h for 5 or 7 days)
• Alternative Regimen (For penicillin allergy): (Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 day OR Moxifloxacin 400 mg q24h PO/IV for 7-14 days OR Gemifloxacin 320 mg PO q24h for 5 or 7 days) AND Aztreonam I.V.: 2 g q6-8h (max: 8 g/day)

• (C) Special Concerns

• (1) Pseudomonas

• Preferred Regimen (1): (Piperacillin-tazobactam 3.375 g IV q6h for 7-10 days OR Cefepime 1-2 g q12h for 10 days OR Imipenem 500 mg IV q6h OR Meropenem 500 mg IV q8h) AND (Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 day)
• Preferred Regimen (2): (Piperacillin-tazobactam 3.375 g IV q6h for 7-10 days OR Cefepime 1-2 g q12h for 10 days OR Imipenem 500 mg IV q6h OR Meropenem 500 mg IV q8h) AND Aminoglycoside AND (Azithromycin Oral: 500 mg on day 1 followed by 250 mg q24h on days 2-5 OR Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR Moxifloxacin 400 mg PO/IV q24h for 7-14 days OR Gemifloxacin 320 mg PO q24h for 5 or 7 days)

Note : For penicillin-allergic patients, substitute the B-lactam for Aztreonam 2 g IV q6-8h (maximum 8 g/day)

• (2) Methicillin resistant staphylococcus aureus ,Add the following to the selected regimen

• Preferred regimen: Vancomycin 45-60 mg/kg/day divided q8-12h OR Linezolid 600 mg PO/IV q12h for 10-14 days.

• Empiric therapy in neonates ( Age < 1 month)

• Preferred regimen: Ampicillin 500 mg/day for 7-14 days or 750 mg/day for 5 days OR Gentamicin 400 mg/day PO/IV for 7-14 days With or without Cefotaxime 320 mg PO q24h for 5 or 7 days

Note (1) : If methicillin resistant staphylococcus aureus is suspected, add the following Vancomycin 10 mg/kg q8h

Note (2) : If Chlamydia trachomatis is suspected, add the following Erythromycin 12.5 mg/kg PO or IV qid for 14 days OR Azithromycin 10 mg/kg PO/IV on day one then 5 mg/kg PO/IV q24h for 4 days.

• Alternate Regimen (If methicillin resistant staphylococcus aureus is suspected): Vancomycin 10 mg/kg q8h OR Linezolid 10 mg/kg q8h

• Empiric therapy,Children (> 3 months) Outpatient Therapy

• Preferred Regimen: Amoxicillin 90 mg/kg/day q12h for 5 days OR Azithromycin 10 mg/kg PO 1 dose (max 500 mg), then 5 mg/kg (max 250 mg) PO for 4 days
• Alternate Regimen: Amoxicillin-clavulanate 90 mg/kg/day OR Clarithromycin 15 mg/kg/day q12h for 7-14 days

• pathogen directed antimicrobial therapy
• Bacterial

• (A) Streptococcus pneumoniae

• (1) Penicillin nonresistant; minimum inhibitory concentration < 2 mg / mL

• Preferred Regimen : Penicillin G 2-3 million units IV q4h OR Amoxicillin 875 mg PO q12h or 500 mg q8h
• Alternative Regimen : Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Cefpodoxime 200 mg PO q12h for 14 days OR Cefprozil 500 mg PO q12h for 10 days OR Cefuroxime 750 mg PO/IV q8h OR Cefdinir 300 mg PO q12h for 10 days OR Cefditoren 400 mg PO q12h for 14 day OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR Cefotaxime 1 g IM/IV q12h OR Clindamycin 150-450 mg PO q6-8h (maximum: 1800 mg/day) OR Clindamycin 1.2-2.7 g/day IM/IV in 2-4 divided doses (maximum:4800 mg/day) OR Doxycycline 100 mg PI/IV q12h OR Respiratory levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h.

• (2) Penicillin resistant; minimum inhibitory concentration > 2 mg / mL

• Preferred Regimen (Agents chosen on the basis of susceptibililty) : Cefotaxime 1 g IM/IV q12h OR Ceftriaxone 1 g IV q24h, 2 g daily for patients at risk OR levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h
• Alternative Regimen: Vancomycin 45-60 mg/kg/day divided q8-12h (maximum: 2000 mg/dose) for 7-21 days depending on severity OR Linezolid 600 mg PO/IV q12h for 10-14 days OR Amoxicillin 875 mg PO q12h or 500 mg q8 ( 3 g/day with penicillin ,minimum inhibitory concentration 4 ≤ microgram / mL)

• (B)Haemophilus influenzae

• (1) Non–B-lactamase producing

• Preferred Regimen: Amoxicillin 875 mg PO q12h or 500 mg q8h
• Alternative Regimen : levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h OR Doxycycline 100 mg PO/IV q12h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days

• (2) B-lactamase producing

• Preferred Regimen: 2nd or 3rd Generation Cephalosporin OR Amoxicillin-clavulanate 2 g q12h
• Alternative Regimen: levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h OR Doxycycline 100 mg PO/IV q12h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h on days 2-5 OR Clarithromycin 250 mg q12h for 7-14 days or 1000 mg q24h for 7 days

• (C) Bacillus anthracis (inhalation)

• Preferred Regimen  :Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 500 mg q24h for 7-14 days or 750 mg q24h for 5 days OR Doxycycline 100 mg PO/IV q12h
• Alternate Regimen : Other fluoroquinolones OR B-lactam (if susceptible) OR Rifampin 600 mg PO/IV q24h for 4 days OR Clindamycin 150-450 mg PO q6-8h OR Chloramphenicol 50-100 mg/kg/day IV in divided q6h

• (D) Enterobacteriaceae

• Preferred Regimen: 3rd generation cephalosporin OR Carbapenem- (Imipenem-cilastatin, OR meropenem, OR ertapenem) (drug of choice if extended-spectrum b-lactamase producer)
• Alternate Regimen : b-Lactam / b-lactamase inhibitor- (Piperacillin-tazobactam for gram-negative bacilli, OR ticarcillin-clavulanate OR ampicillin-sulbactam OR amoxicillin-clavulanate) OR (levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h)

• (E)Pseudomonas aeruginosa

• Preferred Regimen: (Ticarcillin 200-300 mg/kg/day in divided doses q4-6h (max: 18 g/day) OR Piperacillin 6-8 g/day IM/IV (100-125 mg/kg daily) divided q6-12h OR Ceftazidime 500 mg to 1 g q8h OR Cefepime 1-2 g q12h for 10 days OR Aztreonam 2 g IV q6-8h (max: 8 g/day) ORImipenem 500 mg IV q6h OR Meropenem 500 mg IV q8h) AND (Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 750 mg daily OR Aminoglycoside)
• Alternate Regimen: Aminoglycoside AND (Ciprofloxacin 500-750 mg q12h for 7-14 days OR Levofloxacin 750 mg daily)

• (F)Staphylococcus aureus

• (1) Methicillin susceptible

• Preferred Regimen : Nafcillin 1000-2000 mg q4h OR Oxacillin 2 g IV q4h OR Flucloxacillin 250 mg IM/IV q6h
• Alternative Regimen : Cefazolin 500 mg IV q12h OR Clindamycin 150-450 mg PO q6-8h

• (2) Methicillin resistant

• Preferred Regimen : Vancomycin 45-60 mg/kg/day divided q8-12h (max: 2000 mg/dose) for 7-21 days OR Linezolid 600 mg PO/IV q12h for 10-14 days
• Alternative Regimen: Trimethoprim-sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

• (G)Bordetella pertussis

• Preferred Regimen:Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
• Alternate Regimen: Trimethoprim-sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

• (H) Anaerobe (aspiration)

• Preferred Regimen: Piperacillin-tazobactam 3.375 g IV q6h for 7-10 days (For gram-negative bacilli) OR Ticarcillin clavulanate 200-300 mg/kg/day IV divided q4-6h (max: 18 g/day) OR Ampicillin-sulbactam 1500-3000 mg IV q6h OR Amoxicillin-clavulanate 250-500 mg PO q8h or 875 mg q12h OR Clindamycin 150-450 mg PO q6-8h (max: 1800 mg/day)
• Alternate Regimen: Carbapenem

• (I) Mycobacterium tuberculosis

• Preferred Regimen:

• Intensive phase: Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
• Continuation phase: Isoniazid 300 mg/day PO daily for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO daily for 4 months (10 mg/kg/day).

• Alternate regimen (1):

• Intensive phase: Isoniazid 5 mg/kg/day q24h daily for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day daily for 2 months (maximum: 600 mg / day) AND Ethambutol 5-25 mg/kg daily for 2 months (maximum dose: 1.6 g) AND Pyrazinamide 1000 - 2000 mg / day daily for 2 months.
• Continuation phase: Isoniazid 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day).

Note : Acceptable alternative for any new TB patient receiving directly observed therapy

• Alternate regimen (2)

• Intensive phase:Isoniazid 5 mg/kg/day q24h 3 times per week for 2 months (usual dose: 300 mg/day) AND Rifampin 10 mg/kg/day 3 times per week for 2 months (maximum: 600 mg / day) s AND Ethambutol 5-25 mg/kg (maximum dose: 1.6 g) 3 times per week for 2 months AND Pyrazinamide 1000 - 2000 mg / day 3 times per week for 2 months.
• Continuation phase: Isoniazid 300 mg/day PO 3 times per week for 4 months (5 mg/kg/day) AND Rifampicin 600 mg/day PO 3 times per week for 4 months (10 mg/kg/day).

Note : Acceptable alternative provided that the patient is receiving directly observed therapy and is not living with HIV or living in an HIV prevalent setting.

• (J) Yersinisa pestis

• Preferred Regimen: Streptomycin 15 mg/kg/day (max 1 g/day) OR Gentamicin 7 mg/kg/day
• Alternate Regimen: Doxycycline 100 mg PO/IV q12h OR levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h

• pathogen directed antimicrobial therapy
• Atypical bacteria

• (A) Mycoplasma pneumoniae

• Preferred Regimen:Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Tetracycline Oral: 250-500 mg q6h
• Alternate Regimen: levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h

• (B) Chlamydophila pneumoniae

• Preferred Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h OR Tetracycline 250-500 mg PO q6h
• Alternate Regimen: levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h

• (C) Legionella species

• Preferred Regimen: levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h OR Azithromycin 500 mg PO on day 1 followed by 250 mg q24h
• Alternate Regimen: Doxycycline 100 mg PO/IV q12h

• (D)Chlamydophila psittaci

• Preferred Regimen: Tetracycline 250-500 mg PO q6h
• Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h

• (E) Coxiella burnetii

• Preferred Regimen: Tetracycline 250-500 mg PO q6h
• Alternate Regimen: Azithromycin 500 mg PO on day 1 followed by 250 mg q24h

• (F) Francisella tularensis

• Preferred Regimen: Doxycycline
• Alternate Regimen: Gentamicin 7 mg/kg/day OR Streptomycin 15 mg/kg/day (maximum: 1 g)

• (G) Burkholderia pseudomallei

• Preferred Regimen : Carbapenem OR Ceftazidime 0.5-1 g q8h
• Alternate Regimen: levofloxacin 750 mg IV q24h OR moxifloxacin 400 mg IV q24h OR Trimethoprim-sulfamethoxazole 1-2 double-strength tablets (800/160 mg) q12-24h

• (H) Acinetobacter species

• Preferred Regimen : Carbapenem
• Alternate Regimen: Cephalosporin-aminoglycoside OR Ampicillin-sulbactam OR Colistin 2.5-5 mg/kg/day IM/IV divided q6-12h (max: 5 mg/kg/day)

• pathogen directed antimicrobial therapy
• Viral

• Influenza virus

• Preferred Regimen: Oseltamivir 75 mg PO q12h for 5 days (initiated within 48 hours of onset of symptoms) OR Zanamivir Two inhalations (10 mg total) q12h for 5 days (Doses on first day should be separated by at least 2 hours; on subsequent days, doses should be spaced by ~12 hours)

• pathogen directed antimicrobial therapy
• Fungal

• (A) Coccidioides species

• Preferred Regimen: Itraconazole 200 mg q12h OR Fluconazole 200-400 mg daily for 3-6 month
• Alternate Regimen: Amphotericin B 0.5-0.7 mg/kg/day

Note: No therapy is indicated for uncomplicated infection, treat only if complicated infection

• (B) Histoplasmosis

• Preferred Regimen: Itraconazole 200 mg q12h
• Alternate Regimen: Amphotericin B 0.5-0.7 mg/kg/day

• (C) Blastomycosis

• Preferred Regimen: Itraconazole 200 mg q12h
• Alternate Regimen: Amphotericin B 0.5-0.7 mg/kg/day