Antibiotic Guidelines 2012

Guide to Antimicrobial Therapy in the Adult ICU 2012
Dose schedules are being continually revised and new

side effects recognised. The Writing Committee has
endeavoured to ensure drug dosages are current and
accurate. However the reader is strongly encouraged
to always keep abreast with developments in drug
information and clinical application.
Published by
Malaysian Society of Intensive Care (MSIC)
c/o MSIC Secretariat
Medical Academies of Malaysia
210 Jalan Tun Razak
50400 Kuala Lumpur
Copyright 2012 Malaysian Society of Intensive Care
All rights reserved. No part of this book may be reproduced in any form or by
any means without prior permission from the Publisher.
Pusat Kebangsaan ISBN Malaysia
ISBN 978 967 11415 2
Guide to Antimicrobial
Therapy in the Adult ICU
2012
By Malaysian Society of Intensive Care
This guide can be downloaded from the Malaysian Society

of Intensive Care website: www.msic.org.my
i
FOREWORD
Sepsis still remains one of the commonest cause of intensive care
admission here in Malaysia. In the last six years following the first
edition, there has been burgeoning increase in knowledge and
usage of antimicrobials. However the pressing issues of growing
antimicrobial resistance, inappropriate therapy and escalating cost
compel for a more responsible prescriber.
In order to keep pace with important advances, most chapters
have been revised and others eliminated. The objective of this book
has not strayed from its original purpose that is to provide a quick
and comprehensive guide for the Malaysian doctors caring for the
critically ill. The structure has been kept to facilitate easy bedside
referencing. The notations have expanded to explain the rationale
behind antibiotic choices. Hence we hope this handbook will add
to the armamentarium of those who work in intensive care units.
The first revision of the The MSA Guide to Antimicrobial Therapy
in the Adult ICU has been assumed by the Malaysian Society of
Intensive Care. This guide has been a culmination of many hours
of evidence review and exchange of opinions. Putting it together
to cater to our local needs have been a challenge for us. We would
like to thank our external reviewers for their invaluable input and
also acknowledge the contribution of the working committee of the
first edition: it is on the foundation of their work that the present,
Second edition has been developed.
Dr Louisa Chan
Chairperson and Editor, Writing Committee for

ii
WRITING COMMITTEE
Dr Louisa Chan (Chairperson & Editor)
Consultant Intensivist
Dept. of Anaesthesia and Intensive Care
Hospital Kuala Lumpur
Associate Professor Dr Mohd Basri Mat Nor
Dept. of Anesthesiology and Intensive Care
Kulliyyah of Medicine
International Islamic University Malaysia
Dr Noor Airini Ibrahim
Senior Lecturer and Consultant Intensivist
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
Dr Shanti Rudra Deva
Dr Tai Li Ling
iii
EXTERNAL EXPERT REVIEWERS

(in alphabetical order)
Dato Dr Hj Abdul Razak Muttalif
Dr Norazim bin Mohd Yunos
Director
Institute of Respiratory Medicine
Kuala Lumpur
Senior Lecturer and

Clinical School of Johor Bahru
Jeffrey Cheah School of Medicine and
Health Sciences
Monash University Sunway Campus
Dr Claudia Cheng Ai Yu
Consultant Intensivist and
Anaesthesiologist
Loh Guan Lye Specialists Centre, Penang
Prof Dr Rohaizak Muhammad

Breast and Endocrine Surgeon
Department of Surgery
University Kebangsaan Malaysia
Medical Centre
Datuk Dr Christopher K.C Lee

Head of Department
Consultant Infectious Diseases Physician
Department of Medicine
Hospital Sungai Buloh
Dr Shanthi Ratnam
Consultant Physician and Intensivist
Hospital Sungai Buloh
Dr Liew Ngoh Chin

Professor of Surgery
Department of Surgery
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
Dr Tan Jit Ern Jonathan

Consultant Anaesthesiologist and
Intensivist
Director
Surgical Intensive Care Unit
Tan Tock Seng Hospital
Prof Dr Victor Lim

Vice President (Education)
International Medical University
iv
TABLE OF CONTENTS
Contents
Foreword
Working Committee
External Expert Reviewers
Page
ii
iii
iv
Introduction
Principles of Empirical Antimicrobial Therapy
Microbiological Investigations
Community-Acquired Pneumonia
Aspiration Pneumonia
Lung Abscess
Healthcare-Associated Pneumonia
Genitourinary Tract Infection
Acute Infective Diarrhoea
Acute Infective Pancreatitis
Biliary Sepsis
Liver Abscess
Peritonitis
Catheter-Related Bloodstream Infection
Infective Endocarditis
Central Nervous System Infection
Skin and Soft Tissue Infections
Diabetic Foot Infection
Melioidosis
Tuberculosis
Leptospirosis
Severe Malaria
Candidiasis in the non-Neutropenic ICU patient
1
3
9
22
27
28
30
35
39
42
44
45
47
50
56
60
66
71
72
74
77
78
79
Appendix A Dose Adjustment for Renal Impairment

Appendix B Therapeutic Drug Dosing and Monitoring
Appendix C Extended Infusions of -lactams
84
87
91
INTRODUCTION
Antimicrobials are commonly administered in the intensive
care unit (ICU). This is in association with the high incidence of
admissions with severe sepsis to ICUs and the increased risk of
acquiring infections in ICU. In the Extended Prevalence of Infection
in Intensive Care (EPIC II) study, an international study on the
prevalence and outcomes of infections in ICUs, 51% of patients
were infected while 71% were receiving antibiotics on the day of
the study. Of the infected patients, 16% were being treated with
antifungal agents. In Malaysia, 18.7% of patients had severe sepsis
on admission to ICU in 2011.
In the EPIC II study, 75% of infected patients had positive microbial
isolates; 62% of the positive isolates were Gram-negative,
47% Gram-positive, and 19% fungal. However, there was
considerable variation in the types of organisms isolated among
the different geographical regions. The proportion of Gram-negative
organisms was more common in Asia, Western Europe and Latin
America. Based on the Malaysian Registry of Intensive Care
Report 2011, Gram-negative organisms accounted for 83.7% of
the organisms causing ventilator-associated pneumonia (VAP);
the most common organisms being Acinetobacter spp, Klebsiella
spp and Pseudomonas aeruginosa. 61.9% of the causative
organisms in VAP were of multi-drug resistant strains. In another
study on catheter-related bloodstream infection in a Malaysian
ICU, 38.9% of the isolates were Klebsiella pneumoniae, of which
half of them were extended spectrum beta-lactamase (ESBL)
producing strains.
Overall mortality from severe sepsis or septic shock ranges
from 30% to 60%. The Surviving Sepsis Campaign (SCC) is a
global effort to improve the care of patients with severe sepsis and
septic shock. The SCC guidelines recommend starting intravenous
1
antibiotic therapy as early as possible once severe sepsis is

diagnosed. In a recent retrospective cohort study in patients with
septic shock, delay in the initiation of appropriate antimicrobial
therapy after the onset of hypotension was associated with a
significant increased risk of death. A study on compliance of SCC
targets in the management of severe sepsis in ICUs in Asia, one of
the three variables independently associated with hospital mortality
was the delay in administration of antibiotics.
Antimicrobial use contributes to the emergence of resistant
strains, which has become a major problem in ICUs worldwide.
Antimicrobial stewardship and infection control are key
components of a multifaceted approach to preventing emergence
of antimicrobial resistance. Good antimicrobial stewardship involves
selecting an appropriate drug, optimising its dose and duration
to treat an infection while minimising toxicity and conditions for
selection of resistant strains.
Bibliography:
1.
2.
3.
4.
5.
BMJ 2011 Jun 13; 342: d3245. Epub 2011 Jun 13.
Malaysian Registry of Intensive Care Report 2011
JAMA 2009; 302(21): 2323-9
Med J Malaysia 2007; 62(5): 370-4
Crit Care Med 2006; 34(6): 1589-96
PRINCIPLES OF EMPIRICAL
ANTIMICROBIAL THERAPY
Severe sepsis presents a diagnostic and management challenge to
those who care for the critically ill patients. Besides adequate fluid
resuscitation, vasopressor therapy and support of the failing organ
systems, the use of appropriate antimicrobial therapy and adequate
source control is equally important.
Empirical antimicrobial therapy should be guided by the
knowledge of the most likely site of infection and likely organisms.
All appropriate microbiological specimens including blood cultures
should be obtained before commencing therapy whenever possible.
Inappropriate antimicrobial therapy is associated with poor
outcomes. Moreover this can lead to the emergence of resistant
organisms, antimicrobial-related adverse events and increase in
healthcare costs.
The urgency to start antibiotics can be broadly classified as follows:
Category
1. Emergency
Interval between diagnosis

of suspected infection
and administration of
antibiotics
Within 1 hour
Examples
Severe sepsis or septic shock

Infections known to have
a fulminant course e.g.
meningococcaemia
Bacterial meningitis
Sepsis in splenectomised
patients
Clinical evidence of infection
in neutropenic patients
Category
2. Urgent
Interval between diagnosis

of suspected infection
and administration of
antibiotics
Examples
Suspected infection in
stable patients pending
investigations e.g. suspected
VAP, awaiting chest X-ray
> 1 hour
When initiating appropriate empirical antimicrobials in patients with

severe sepsis, consider the likely causative organisms, patient
factors and properties of antimicrobials.
1. Likely causative organism
Decide if community or healthcare-acquired infection
Identify the most likely source of infection
Take appropriate specimens for microscopy, culture and
sensitivity testing. Imaging modalities may be necessary to
locate the source of infection.
Consider local epidemiological data
Empiric antimicrobial choice depends on local susceptibility
patterns. Knowing the resistance profiles in the community,
hospital or unit helps in choosing antimicrobials appropriately.
2. Patient factors
Severity of illness
Patients in severe sepsis or septic shock require emergent and
broad spectrum antimicrobial therapy.
Prior antimicrobial use or prolonged hospitalisation
Both are risk factors for the presence of resistant organisms.
Immunosuppressive states
Patients with underlying malignancy, malnutrition, on steroids
or immunosuppressive drugs may require broad-spectrum
therapy including antifungal.
4
Presence of renal or hepatic dysfunction

The risk-benefit of the antimicrobial must be determined on
a case-to-case basis. Maintenance doses are adjusted in line
with the severity of organ dysfunction.
Others
Pregnancy, drug allergy
3. Antimicrobial profile
Route of administration
The intravenous route should always be used in severe sepsis
as oral absorption is unpredictable even in drugs with good oral
bioavailability.
Dose and interval
Pathophysiological changes in critically ill patients alter the
pharmacokinetic (PK) and pharmacodynamic (PD) profile of
the antimicrobials. Antibiotics can be categorised into three
different classes depending on the PK/PD indices associated
with their optimal killing activity.
Classification
PK/PD index
Goals of Therapy
Examples
Timedependent
T>MIC
Percentage of
time where drug
concentration
remains above MIC
during a dosing
interval
Maximise duration
of exposure
(Refer to
Appendix C for
extended infusion
of -lactams)
Penicillins
Cephalosporins
Carbapenems
Clindamycin
Maximise
concentration of
drug
Aminoglycosides
Polymyxin
Concentration- Cmax /MIC

dependent
Ratio of peak
concentration to
MIC
Classification
PK/PD index
Goals of Therapy
Examples
Concentrationdependent
with time
dependence
AUC0-24 /MIC
Ratio of area under
concentration-time
curve (AUC) during
a 24-h period to
MIC
Maximise amount
of drug
Fluoroquinolones
Vancomycin
Azithromycin
Linezolid
Tetracyclines
MIC: Minimum Inhibitory Concentration
Achievable antimicrobial concentrations in tissue

Aminoglycosides and glycopeptides penetrate tissues poorly.
Aminoglycosides should not be used as monotherapy while
a higher plasma level of glycopeptides is recommended to
ensure adequate tissue penetration. Both -lactams and
quinolones have good tissue penetration.
Post antibiotic effect (PAE)
This is defined as persistent suppression of bacterial growth
even after the serum antibiotic concentration falls below
the MIC of the target organism. Aminoglycosides and
fluoroquinolones have post antibiotic effect against gram
negative bacteria.
Adverse events
Risk-benefit of antimicrobials with potential serious adverse
events should be considered on a case-to-case basis. If
unavoidable, serum levels should be monitored for toxicity
(e.g. aminoglycosides).
Ecological profile
Limit the use of antimicrobials with known potential for
selecting resistant organisms and associated risks of
superinfection e.g. third generation cephalosporins (selection
pressure for ESBL producing Enterobacteriaceae).
Empirical therapy should be re-evaluated after 48-72 hours or

when culture results become available. Once a causative pathogen
is identified, narrow the spectrum of antimicrobial therapy
(de-escalation). Sensitivity tests should be interpreted carefully.
In vitro sensitivity does not equate with clinical effectiveness
(e.g. ESCAPPM organisms: Enterobacter spp, Serratia spp,
Citrobacter freundii, Aeromonas spp, Proteus vulgaris, Providencia
spp, Morganella morganii).
If the patient is improving, the recommended duration of
antimicrobial therapy is 5 to 7 days. There is increased risk of
resistance with prolonged use of antimicrobials. Certain conditions
may require prolonged therapy e.g. P. aeruginosa sepsis, complicated
S. aureus infections and infective endocarditis. Consider switching
to the oral route whenever possible.
If there is no clinical response within 48-72 hours, consider:
The possibility of a secondary infection
The presence of resistant organisms
Abscesses that are not drained or infected foreign bodies that
are not removed
Inadequate penetration of antimicrobial to the site of infection
Inadequate spectrum of antimicrobial coverage
Inadequate dose/interval
Non-infectious causes e.g. deep vein thrombosis, acute
myocardial or pulmonary infarctions, acute pancreatitis,
hyperthyroidism, Addisonian crisis, malignancies and central
nervous system hemorrhages.
Pathway in choosing the empirical antimicrobial
Decide if community or healthcare-acquired infection
Identify site of infection
Know local susceptibility patterns
Consider patient factors
Know the antimicrobial profiles
Choose antimicrobial:
Decide dose, route, interval and duration
MICROBIOLOGICAL INVESTIGATIONS
Identification of causative organisms is central to effective
antimicrobial therapy. Whenever possible, appropriate cultures
should always be obtained before commencing antimicrobials.
Below are some common microbiological investigations that are
relevant to the intensive care practice.
Blood specimen
All septic patients (irrespective of source) should have blood
cultures taken prior to commencement of antimicrobials.
The volume of blood determines the yield of positive result in
blood culture. A minimum of 20 ml of blood should be drawn;
10 ml for each aerobic and anaerobic bottle. Increasing the volume
to 40-60 ml from different venepuncture sites (obtaining 2-3 pairs
of blood cultures) has been shown to increase the yield further.
In endocarditis, 3 pairs of blood cultures taken at least an
hour apart is required to confirm constant bacteraemia but
administration of antimicrobials should not be delayed in severely
ill patients. If catheter-related blood stream infection is suspected
simultaneous blood sampling from the peripheral blood and
catheter hub needs to be taken.
When disseminated tuberculosis (TB) or fungaemia is suspected,
BACTEC Myco/F Lytic culture bottles should be used to improve
yield of these suspected organisms.
Blood can be taken for serological testing to diagnose atypical
pneumonias, leptospirosis, melioidosis, toxoplasmosis, rickettsial
and typhoid infections.
Blood tests for viral infections include serology for herpes simplex
type 1 and 2, cytomegalovirus (CMV), dengue, viral hepatitis and
respiratory viruses. Consider Human Immunodeficiency Virus
(HIV) serology in patients at risk. Viral cultures are not routinely
performed.
The diagnosis of malaria requires 3 sets of thick and thin blood
smear preparations taken over a 48 hour period (at 6, 12 and 48
hour). In smear negative patients, in which malaria is stll strongly
suspected blood for malarial polymerase chain reaction (PCR) can
be sent.
Respiratory specimen
A good specimen of sputum or tracheal aspirate for Gram stain and
cultures should have less than 10 epithelial cells per low power
field reflecting a lower respiratory tract sample. Special stains can
be requested to diagnose Pneumocystis jiroveci or Mycobacterium
tuberculosis.
Most laboratories report the results of sputum and tracheal
aspirate cultures semi-quantitatively; either as light, moderate
or heavy growth. A positive culture does not differentiate true
pathogens from colonisers. Results must be interpreted in the
context of the clinical condition to prevent unnecessary
antimicrobial use. If quantitative test is available, the threshold for
diagnosing ventilator-associated pneumonia (VAP) with tracheal
aspirate is 105 or 106 cfu/ml.
Respiratory specimens can also be obtained invasively by
performing bronchoalveolar lavage (BAL) or protected specimen
brushing (PSB). Both specimens need to be analysed quantitatively
based on the number of colony forming units (cfu). The threshold
for diagnosing VAP with BAL is 104 or 105 cfu/ml and with PSB is
103 cfu/ml. Indications for BAL include non-resolving pneumonia,
10
diffuse lung infiltrates in the immunocompromised host or

quantitative cultures for VAP.
Nasopharyngeal swabs and the above respiratory specimens can
be sent using appropriate viral transport media for viral serology and
PCR tests. Viral cultures are not routinely performed. The viruses
commonly investigated are influenza, parainfluenza, respiratory
syncytial virus (RSV), adenovirus and CMV. Viral detection does not
preclude concurrent bacterial infection.
Pleural fluid specimen
Normal pleural fluid has the following characteristics:
clear ultrafiltrate of plasma
pH 7.60-7.64
protein content less than 20 g/L
less than 1000 leucocytes/mm3
glucose concentration similar to that of plasma
lactate dehydrogenase (LDH) level less than 50% of plasma
In diseased conditions, pleural fluid can be classified into exudative
or transudative. Infective causes of exudative pleural effusion are
bacterial, tuberculous or viral pneumonias. According to Lights
criteria, a pleural effusion is likely exudative if at least one of the
following exists:
Pleural fluid/serum protein > 0.5 or absolute pleural protein
> 30 g/L
Pleural fluid/serum LDH > 0.6
Pleural fluid LDH level > 2/3 upper limit of normal serum value
An exudative pleural fluid needs to be correlated with the other
analysis below to determine if it is of an infective cause.
1. Microscopic examination
Pleural fluid for leucocytes and differential cell count
should be sent in an anticoagulated tube. Leucocyte count
11
> 10,000 /mm3 strongly suggests infection while counts

> 50,000 /mm3 is usually seen in empyema. Predominance
of polymorphs is suggestive of bacterial infection while
lymphocytic predominance is suggestive of TB, resolving
pneumonia or fungal infections. Gram stain is done to
enable direct observation of bacteria or fungi under
microscopic examination.
2. Smear for acid-fast bacilli
Pleural fluid smears are rarely positive for acid-fast bacilli
(< 10% of proven PTB).
3. Glucose
Pleural fluid glucose levels < 3.3 mmol/L is suggestive of
infection. Levels of 1.7 2.8 mmol/L suggests tuberculous
infection while levels < 1.7 mmol/L suggests bacterial
empyema.
4. pH
Pleural fluid pH < 7.2 is suggestive of infection. Pleural fluid
pH < 7.1-7.2 is more predictive of complicated effusions
and indicates the need for urgent drainage of the effusion,
while pleural fluid pH > 7.3 suggests that the effusion may be
managed with systemic antibiotics alone.
5. Lactate dehydrogenase
Pleural fluid LDH levels > 1000 IU/L suggest complicated
parapneumonic effusions.
6. Culture and susceptibility testing
Culture of infected pleural fluid yields positive results in
approximately 40% - 60% of cases. Diagnostic yields,
particularly for anaerobic pathogens, may be increased by
directly culturing pleural fluid into blood culture bottles.
12
For Mycobacterium tuberculosis, the use of broth medium

(e.g. BACTEC) provides higher yields and faster results
(1-2 weeks) than conventional methods.
7. Polymerase chain reaction (PCR) for tuberculous DNA
PCR findings are positive in almost all of culture-positive TB
pleural fluids but in only 30 - 60% of culture-negative pleural
fluids.
8. Pleural adenosine deaminase (ADA)
If lymphocyte predominant in exudate, ADA of > 40 U/L has a
90-100% sensitive and 85-95% specific for TB pleuritis.
Cerebrospinal fluid specimen
Lumbar puncture should only be performed after a neurological
examination but should never delay the administration of
antimicrobials. A CT scan to rule out raised intracranial pressure
prior to lumbar puncture is indicated in patients with the following:
age > 60 years, history of central nervous system (CNS) lesion,
seizure within 1 week of presentation, focal neurological signs,
altered conscious level, papilloedema and immunodeficiency.
Cerebrospinal fluid (CSF) should be analysed within an hour of
collection. If there is a delay, it should be stored between 4 - 8oC.
CSF analysis
Minimum
Volume
Microscopy and stain (Indian ink and Ziehl Neelsen)
1ml
Biochemistry
1ml
Culture and sensitivity (aerobic and anaerobic)
2ml
Latex agglutination test:

S. pneumoniae, group B streptococcus, H. influenzae type B,
N. meningitidis group A, B, C, Y and W135, E.Coli K1
1ml
13
CSF analysis
Minimum
Volume
Viral: PCR and /or serology

Herpes simplex type 1 & 2, varicella zoster virus, Japanese B
encephalitis virus, Nipah virus, Enterovirus
3ml
Parasite PCR
Toxoplasma gondii
3mls
Mycobacterium PCR and culture
10mls
Fungal antigen and culture

Aspergillus fumigatus, Cryptococcus neoformans
3mls
The results of the bacterial antigen testing should be interpreted

with respect to the microscopy and culture results. A diagnosis
of bacterial infection based on antigen testing alone is not
recommended.
Abnormalities of CSF in various CNS infections:
Normal
Pressure
(cmH2O)
Appearance
Bacterial
Viral
TB
Meningitis Meningitis/ Meningitis
Encephalitis
Fungal
Meningitis
10 - 20
N or
Clear
Turbid
Clear
Fibrin web
Clear or
Turbid
< 0.45
N or
Glucose
(mmol/L)
2.5 - 3.5
N or
CSF:serum
glucose ratio
0.4 - 0.5
< 0.4
< 0.6
< 0.5
< 0.5
< 2.9
Protein (g/L)
Lactate
(mmols/L)
Cell
10 - 1000
0-5
> 1000
10 - 1000
10 - 500
count/mm3 lymphocytes polymorphs polymorphs lymphocytes lymphocytes
&
(predominant
&
mononuclear
cell type)
monocytes
cells
14
Non-infective causes may have similar biochemical findings

as infective causes. Partial treatment with antibiotics may alter
CSF parameters.
The diagnosis of CNS infection in the presence of CNS shunts and
drains is largely clinical. Analysis of CSF taken may be suggestive
of infection if the cell count > 15/mm3, CSF:serum glucose < 0.5
or WBC:RBC ratio is less than 1:100. Cell count index (ratio of
WBC:RBC in CSF to WBC:RBC in blood) > 1 has also been used
as an indicator of infection. A positive CSF culture may represent
contaminant and clinical correlation is needed.
Urine specimen
Urine collection must be taken under aseptic technique to minimise
the degree of bacterial contamination. The sample should be
sent within 2 hours of collection since bacteria will continue to
proliferate. Urine samples not sent immediately should be stored
at 4oC.
If the patient needs catheterisation, discard the first few mls of
urine and collect the rest in the sterile container. If the patient is
already catheterised, clamp the catheter and clean the sampling
port with 70% alcohol and collect 10 ml sample of urine. Do not
take urine samples from the drainage bag due to high risk of
bacterial overgrowth leading to false positive results. In and out
catheterisation for urine samples in an uncatheterised patient can
be done.
Most cases of urinary tract infection (UTI) can be diagnosed using
the criteria below. Pyuria in the absence of signs and symptoms in
a person with bacteriuria should not be interpreted as symptomatic
infection or as an indication for antimicrobial therapy.
15
16
Pyuria
WBC/mm3
No. of
species
Nitirite
>10
Do not treat
bacteriuria except in
- Pregnancy
- Prior to genitourinary
manipulation
Replace catheter if in
place for > 7 days.
Treat as UTI.
Comments
Do not treat
bacteriuria except in
- Pregnancy
- Prior to genitourinary
manipulation
detected
Treat as UTI
(Only positive in
nitrite producing
bacteria e.g. E.
coli, Serratia spp,
Klebsiella spp and
Proteus spp)
Significant asymptomatic bacteriuria if 2 consecutive MSU grows 105 cfu/ml of

the same bacterial species in women and 103 cfu/ml in men.
105 in complicated UTI in women
104 in complicated UTI in men
104 in acute uncomplicated

pyelonephritis in women.
103 in pregnant women and acute

uncomplicated cystitis in women
Significant asymptomatic bacteriuria:

- a single specimen 105 cfu/ml
- specimen collected by in and out catheter 102 cfu/ml.
Pyuria is common
2
not detected
in patients with
10 in complicated UTI
catheter. Its level
has no predictive
103 in pregnant women
value.
Routine urine culture in asymptomatic catheterised patients is not recommended.
105 in uncomplicated UTI
Bacteriuria
cfu/ml
For definition of complicated and uncomplicated UTI refer to the chapter on genitourinary tract infection.
Absent
Without Present
catheter
Absent
With
Present
catheter
Symptom
Peritoneal fluid specimen

Analysis of peritoneal fluid obtained through paracentesis should
be carried out to determine if there is presence of ascitic fluid
infection in a patient with ascites and in whom intra-abdominal
sepsis is suspected. The fluid should be evaluated for glucose,
protein, lactate dehydrogenase (LDH), cell count, Gram stain,
and aerobic and anaerobic cultures. Routine intraoperative
peritoneal fluid culture in acute abdomen e.g. perforated viscus
is controversial.
Classification of ascitic fluid infection in relation to polymorphs cell
count and bacterial culture
Polymorphs
count (/mm3)
Bacterial
culture
Treatment Note
250
Spontaneous
bacterial
peritonitis (SBP)
Need
Positive
In advanced cirrhosis
(usually 1 type antibiotics of liver
of organism)
Culture negative 250

neutrocytic
ascites
Negative
Treat as
SBP
Causes include:
prior antibiotics,
peritoneal carcinomatosis,
pancreatitis, tuberculous
peritonitis
Monomicrobial
non-neutrocytic
bacteriascites
250
Positive
(1 type of
organism)
Polymicrobial
bacteriascites
< 250
Positive
Usually as a result of
No
(polymicrobial) antibiotics inadvertent puncture
of the intestines during
paracentesis.
Secondary
bacterial
peritonitis
250
Positive
Need
(polymicrobial) antibiotics
If asymptomatic, do not
treat with antibiotics.
Repeat paracentesis.
Treat as SBP in presence
of sepsis.
For definition of peritonitis, refer to the chapter on peritonitis.

17
Secondary bacterial peritonitis should be considered in patients

diagnosed with SBP who display persistent symptoms, increasing
polymorphs, or a persistently positive ascitic fluid culture despite
appropriate antibiotic therapy for 48 hours.
Other characteristics of peritoneal fluid in ascitic fluid infection:
1. Cell count:
Leucocytes > 500/ml or absolute neutrophils > 250/ml
suggests infection. Polymorphonuclear cells and lymphocytes
are predominantly seen in bacterial and tuberculous peritonitis
respectively. Secondary peritonitis should be suspected if
leucocytes are > 10,000/ml
2. Protein level
Protein levels < 1 g/dL is usually seen in spontaneous
peritonitis while levels > 1 g/dL in secondary peritonitis. In
tuberculous peritonitis, protein level is typically > 2.5 g/dL.
3. Serum albumin-ascitic fluid albumin gradient
In tuberculous peritonitis, the gradient is usually < 1.1 g/dL.
4. Glucose levels < 2.7 mmol/L is suggestive of secondary
peritonitis.
5. Increased LDH > 225 IU/ml (> upper limit of normal serum) is
suggestive of secondary peritonitis. In tuberculous peritonitis,
LDH level is usually > 90 IU/ml.
6. Gram stain, culture and sensitivity
The yield for Gram stain and acid-fast stain is relatively poor in
peritoneal fluid. Inoculating peritoneal fluid into blood culture
bottles at bedside has been shown to improve sensitivity.
18
Stool specimen
At least 5 ml of diarrheal stool per rectal or per stoma is collected in
a clean leak proof container. The specimen should be transported
to the laboratory and processed within 2 hours after collection.
Culture of a single stool specimen has a sensitivity of > 95% for
detection of the enteric bacterial pathogen.
Acute infectious diarrhea is most often a foodborne or waterborne
disease. The causes include viral, bacterial and parasitic pathogens.
Bacteria

Salmonella, Campylobacter, Shigella, Vibrio cholera, Yersinia,

Listeria, enterotoxigenic E. coli, Aeromonas
C. difficile if recent antibiotic therapy
Protozoal Cryptosporidium, Giardia lambia, Cyclospora,

Entamoeba histolytica
Virus
Novovirus, rotavirus, enteric adenovirus, astrovirus
Stool culture is not routine in all patients presenting with diarrhea

unless immunocompromised, elderly, those with underlying
inflammatory bowel disease and with severe or bloody diarrhea.
A negative culture for Salmonella, Campylobacter and Shigella
usually rules out infection by these organisms as excretion of these
pathogens are continuous and repeat specimens are not required.
Stool cultures should not be performed for patients who develop
new onset of diarrhea while in hospital as it is likely to be due
to antimicrobial therapy. In such cases stools should be sent for
C. difficile toxin assay instead.
Stool samples for ova and parasites are only recommended
in patients with persistent or bloody diarrhea or during waterborne
outbreaks. Three specimens should be sent on consecutive
days since parasite excretion may be intermittent in contrast to
bacterial pathogens.
19
Clostridium difficile toxin detection falls into two categories

of laboratory tests: organism detection assay and toxin assay
[enterotoxin (toxin A) and cytotoxin (toxin B)]. Toxin assays available
are cytotoxicity assay, enzyme immunoassay (EIA) and PCR. EIA is
the preferred diagnostic assay in most clinical laboratories because
the technique is relatively simple, inexpensive with results available
within 24 hours. However, because of high false negative rates,
three consecutive samples are recommended. Positive organism
detection without toxin detection does not require treatment
because this represents colonisation.
Wound swabs
Wound infections should be diagnosed clinically. Routine cultures
of wounds are not indicated unless there are clinical signs of
infection. Culturing uninfected wounds may only be used as part of
an infection control surveillance protocol.
Tissue specimens obtained from biopsy, ulcer curettage or
aspiration are preferable to wound swabs. Wound swabs should
be obtained only from viable infected tissue and not from necrotic
tissue, eschar or wound debris.
To obtain wound swabs, clean the wound with sterile saline to
irrigate purulent debris. Moisten the swab with sterile saline to
increase the adherence of bacteria. Rotate the swab while moving
it across the entire wound in a zigzag manner. Alternatively
Levines technique can be used where one rotates the swab over
1cm2 of the cleansed wound exerting enough pressure to express
exudates from within the tissue. Promptly send the swabs obtained
to the lab in an appropriate transport media for both aerobic and
anaerobic culture.
20
Bibliography:
1.

2.

3.

4.
5.

6.
7.
European Handbook of neurological management

2nd Edition 2011
Guidelines on urological infections by European Association
of Urology 2011
World Diabetes: New insights in diabetic foot
infections 2011; 2(2): 24-32
Clinical Microbiology Procedures Handbook 3rd Edition 2010
Wound watch: Three techniques for collecting wound specimen.
Jan/Feb 2008 Vol 4 No.1
N Engl J Med 2002; 346: 1971-7
Hepatology 1984; 4: 447-450
21
COMMUNITY-ACQUIRED PNEUMONIA
Community-acquired pneumonia (CAP) is associated with
significant morbidity and mortality, particularly in the elderly.
10% of patients who are admitted to the hospital with a diagnosis
of CAP will require management in the ICU. The mortality for severe
CAP is between 20% to 50%.
Aetiologic pathogens remain unidentified in up to 50% of cases.
Empirical therapy should be started after considering patients risk
factors for certain organisms e.g. patients with chronic lung disease
are at higher risk of Pseudomonas aeruginosa pneumonia.
Common
Organisms
S. pneumoniae
H. influenzae
K. pneumoniae
M. pneumoniae
L. pneumophilia
C. pneumoniae
Antimicrobials
Preferred
Alternative
IV Amoxicillin/
Clavulanate
1.2g q8h
X 5-7 days
PLUS
IV Azithromycin
500mg q24h
X 3-5 days
IV Ceftriaxone
2g q24h
X 5-7 days
PLUS
IV Azithromycin
500mg q24h
X 3-5 days
OR
IV Levofloxacin
750 mg q24h
X 5-7 days
Notes
The indiscriminate
use of 3rd generation
cephalosporins may
promote the emergence
of ESBL producers.
Duration of treatment
for confirmed atypical
infection:
1. Mycoplasma:
Azithromycin 5 days
Levofloxacin 7 days
2. Chlamydia:
Azithromycin 7-10 days.
Consider doxycycline if
not responding.
3. Legionella:
Azithromycin:
immunocompetent 7-10
days, immunocompromised
up to 3 weeks
22
Common
Organisms
Antimicrobials
Preferred
Alternative
PLUS OPTIONAL
S. aureus
(MSSA)
Notes
Risk factors (MSSA):
1. ESRF
2. IVDUs
3. Prior antibiotics use
especially quinolones
4. Prior influenza
IV Cloxacillin
2g q4-6h
X 10-14 days
Suspect MSSA pneumonia

in the presence of cavitary
infiltrates without risk
factors for anaerobic
aspiration.
CommunityIV Vancomycin
IV Linezolid
acquired MRSA 15-20mg/kg q12h 600mg q12h
(CA-MRSA)
X 10-14 days
X 10-14 days
Colonisation with
CA-MRSA predisposes to
pneumonia. Risk Factors
for colonisation:
1. Contact sports
2. IVDUs and homosexuals
3. Living in crowded
unsanitary conditions eg
prison, military barracks
4. Post influenza
For loading dose and
monitoring of vancomycin
refer to Appendix B.
23
Common
Organisms
P. aeruginosa
Antimicrobials
Preferred
Alternative
IV Piperacillin/
Tazobactam
4.5g q6h
OR
IV Cefepime
2g q8-12h
IV Imipenem
500mg q6h
OR
IV Meropenem
1g q8h
OR
IV Doripenem
500mg q8h
PLUS
OPTIONAL
PLUS
OPTIONAL
IV Amikacin
15mg/kg/day
X 3-5 days
OR
IV Ciprofloxacin
400mg q8h
X 7 days
IV Amikacin
15mg/kg/day
X 3-5 days
OR
IV Ciprofloxacin
400mg q8h
X 7 days
Notes
Risk factors are severe
structural lung disease
(e.g. bronchiectasis),
COPD, recent antibiotic
therapy or hospitalisation.
Ceftazidime is not
recommended for
empirical use because it
is the main offender in
promoting rapid selection
of resistant organism.
However if P. aeruginosa
is sensitive to ceftazidime,
consider de-escalation.
Dual therapy may be
considered in :
1. neutropenic patients
2. CAP with bacteraemia
3. septic shock
In confirmed P. aeruginosa
pneumonia, treat for 10-14
days.
Burkholderia
pseudomallei
Risks factors: diabetes

mellitus, chronic renal
failure, chronic lung
disease.
Refer to chapter
on Melioidosis
24
Common
Organisms
Pneumocystis
carinii
(Pneumocystis
jiroveci)
Antimicrobials
Preferred
Alternative
IV Trimethoprim/ IV Pentamidine
Sulfamethoxazole 4mg/kg/day
5mg/kg (TMP
component) q8h x 21 days
Notes
Prednisolone should be
given 15-30 min before
antimicrobials.
PO Prednisolone 40mg
q12h x 5days, then 40mg
q24h x 5days, then 20mg
q24h x 11days
x 21 days
Patients at risk :
1. HIV infection with CD4+
cells < 200/L
2. HIV infection with other
opportunistic infections e.g.
oral thrush
3. Long term
immunosuppressive
or chemotherapy
4. Primary immunodeficiencies
Viral pneumonias
Influenza A
T. Oseltamivir
(pandemic
75mg q12h
H1N1, seasonal
H3N2, avian
x 5 days
influenza)
Influenza B
Oseltamivir 150mg q12h for

10 days should be considered
in the critically ill.
Varicella zoster IV Acyclovir

Herpes simplex 500mg q8h
x 7 days
No antiviral of
Parainfluenza,
RSV, adenovirus, proven value
SARS, hantavirus
25
Patients with CAP should be treated for a minimum of 5 days, be

afebrile for 48 - 72 hours, and have no more than 1 CAP associated
sign of clinical instability (temperature > 37.8C, heart rate > 100,
respiratory rate > 24, systolic pressure < 90mmHg, SaO2 < 90%,
or PaO2 < 60mmHg) before discontinuation of therapy.
A longer duration of therapy may be needed if initial therapy is
not active against the identified pathogen or if complicated by
extrapulmonary infection, such as meningitis or endocarditis.
If there is no response, consider other possible diagnosis e.g.
congestive heart failure, pulmonary embolism, neoplasm,
sarcoidosis, drug reaction, pulmonary haemorrhage and empyema.
Also consider other causative micro-organisms e.g. mycobacteria,
fungi and viruses.
Bibliography:
1.

2.
3.
4.
WHO Guidelines for Pharmacological Management of Pandemic

Influnza A (H1N1) 2009 and other Influenza Viruses.
Revised February 2010
Thorax 2009; 64 Suppl 3: iii
Clin Infect Dis 2007; 44 Suppl 2: S27
Clin Infect Dis 2005; 41(Supplement 4): S269-S272
26
ASPIRATION PNEUMONIA
The usual causative organisms in aspiration pneumonia are those that
colonise the oropharynx. Risk factors for aspiration are conditions that
suppress cough and mucociliary clearance. In community-acquired
cases, oral anaerobes are the predominant organisms related to
poor dentition or oral care and periodontal disease. Hospitalised
and institutionalised patients are more likely to have oropharyngeal
colonisation with Gram-negative enteric bacilli and Staphylococcus
aureus. Antimicrobials are not indicated in aspiration without evidence
of infection.
Common
Antimicrobials
Organisms
Preferred
Alternative
Community-acquired
Oral anaerobes
IV Amoxicillin/ IV Ceftriaxone
S. pneumoniae
Clavulanate
2g q24h
H. influenzae
1.2g q8h
S. aureus
Enterobacteriaceae
M. catarrhalis
Healthcare-associated
Gram-negative
IV Piperacillin/
bacilli
Tazobactam
P. aeruginosa
4.5g q6h
S. aureus
OR
Anaerobes
IV Cefepime
2g q8-12h
PLUS
IV Metronidazole
500 mg q8h
IV Imipenem
500mg q6h
OR
IV Meropenem
1g q8h
Bibliography:
1. Clin Infect Dis 2007; 44 Suppl 2: S27
27
Notes
Oral anaerobes are sensitive to
all -lactams. Additional enteric
anaerobic (Bacteroides fragilis)
coverage is not needed.
Treat for 7-10 days in patients
who respond promptly or
longer if complicated with lung
abscess or empyema.
Treat for 7-14 days or longer
if complicated with lung
abscess or empyema.
LUNG ABSCESS
Lung abscess is defined as necrosis of the pulmonary parenchyma
caused by microbial infection. Common causes include:
i. aspiration pneumonia
ii. severe necrotising pneumonia due to S. aureus or
K. pneumoniae
iii. septic emboli from right sided endocarditis
(tricuspid valve endocarditis)
iv. septic thrombophlebitis of internal jugular veins
(Lemierre syndrome)
Attempts should be made to identify the causal organism.
Bronchoscopy or fine needle aspiration may be required. Drainage
of the abscess via a percutaneous catheter is recommended.
Antibiotic therapy is generally continued for 4 to 6 weeks.
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Secondary to aspiration pneumonia / Lemierre syndrome
Anaerobes:
IV Clindamycin IV Piperacillin/
Use preferred therapy
Peptostreptococi
600mg q8h
Tazobactam
in community-acquired
Fusobacterium spp PLUS
4.5g q6h
or Lemierre syndrome
Prevotella
IV Ceftriaxone
and alternative therapy
Bacteroides
2g q24h
OR
in healthcare-associated
(usually not
infection.
Bacteroides
OR
IV Meropenem
fragilis)
1g q8h
IV Ampicillin/
S. aureus
Sulbactam
OR
E. coli
3g 6qh
K. pneumoniae
IV Imipenem
P. aeruginosa
500mg 6qh
S. milleri
S. pneumoniae
H. Influenzae
28
Common
Antimicrobials
Organisms
Preferred
Alternative
Secondary to tricuspid valve endocarditis
MethicillinRefer to chapter
sensitive
on Infective
S. aureus
Endocarditis
Methicillinresistant
S. aureus
Others
Burkholderia
pseudomallei
Refer to chapter
on Melioidosis
Bibliography:
1. Thorax 2010; 65 Suppl 2
29
Notes
HEALTHCARE-ASSOCIATED PNEUMONIA
Healthcare-associated pneumonia (HCAP) is defined as pneumonia
in any patient who has been admitted to an acute care hospital
for 2 days of the preceding 90 days; resided in a nursing home
or long-term care facility; received recent intravenous antibiotic
therapy, chemotherapy within the past 30 days; or attended a
hospital or haemodialysis clinic. Hospital-acquired pneumonia
(HAP) is defined as pneumonia that occurs 48 hours or more after
hospitalisation while ventilator-associated pneumonia (VAP) is
pneumonia that occurs after 48 hours following intubation.
The timing of HCAP is an important risk factor for pathogens and
outcomes in patients with HAP and VAP. Early-onset pneumonia
(< 5 days) have a better prognosis as the infecting micro-organisms
are more likely to be antibiotic-sensitive than late onset pneumonia
( 5 days).
Risk factors for multidrug-resistant (MDR) infections are:
1. Prolonged hospital stay ( 5 days)
2. Previous hospitalisation of > 2 days within past 90 days
3. Was on antibiotics within past 90 days,
especially broad-spectrum antibiotics
4. Antibiotic resistance in the healthcare setting
5. Admission from long-term care institution
6. Chronic renal dialysis within past 30 days
7. Poor underlying condition
8. Presence of chronic wounds
9. Immunocompromised or neutropenic patient
10. Presence of invasive catheters e.g. central venous catheters
30
It is now recognised that MDR organisms are increasing in

frequency. The prevalence of these organisms varies from
unit to unit hence guidelines will not replace auditing of local
microbiological data. Occasionally the causative organisms in
pneumonia may be polymicrobial.
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Empirical treatment in patients without risk factors for MDR pathogens
S. pneumoniae
IV Amoxicillin/
IV Ceftriaxone S. aureus is more
H. influenzae
Clavulanate
2g q24h
common in diabetes
S. aureus
1.2g q8h
mellitus, head trauma.
E. coli
X 5-7days
K. pneumoniae
OR
IV Cefuroxime
1.5g q8h
X 5-7 days
P. aeruginosa
IV Piperacillin/
Tazobactam
4.5g q6h
IV Cefepime
2g q8-12h
X 10-14 days
X 10-14 days
31
Consider in patients with

chronic lung disease.
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Empirical treatment in patients with risk factors for MDR pathogens
P. aeruginosa
IV Imipenem
Consider the alternative
IV Piperacillin/
K. pneumoniae
500mg q6h
regime if patient is
Tazobactam
haemodynamically
4.5g q6h
unstable.
OR
OR
Acinetobacter
spp
IV Cefepime
2g q8-12h
IV Meropenem
1g q8h
PLUS
OPTIONAL
PLUS
OPTIONAL
IV
Cefoperazone/
Sulbactam
4g q6h
IV Polymyxin E
3 million units
q8h
Sulbactam component of
8g/day is required.
OR
IV Ampicillin/
Sulbactam
3g q3h
S. aureus
PLUS
OPTIONAL
PLUS
OPTIONAL
IV Vancomycin
15-20mg/kg
q12h
IV Linezolid
600mg q12h
32

Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific
P. aeruginosa
IV Ceftazidime IV Imipenem
2g q8h
500mg q6h
OR
OR
IV Piperacillin/
IV Meropenem
Tazobactam
1g q8h
4.5g q6h
OR
IV Cefepime
2g q8-12h
Acinetobacter spp
X 10-14 days
X 10-14 days
PLUS
OPTIONAL
PLUS
OPTIONAL
IV Amikacin
15mg/kg/day
X 3-5 days
OR
IV Ciprofloxacin
400mg q8h
X 7 days
IV Amikacin
15mg/kg/day
X 3-5 days
OR
IV Ciprofloxacin
400mg q8h
X 7 days
IV
Cefoperazone/
Sulbactam
4g q6h
IV Polymyxin E
3 million units
q8h
OR
X 10-14 days
IV Ampicillin/
Sulbactam
3g q3h
X 10-14 days
33
Notes
Use the alternative
regime in gp 1
-lactamase.
Use IV polymyxin in
carbapenem-resistant
P. aeruginosa.
Combination therapy for
pseudomonal infection
has not been shown to be
superior to monotherapy.
Dual therapy may be
considered in
2. pneumonia with
bacteraemia
3. septic shock
8g/day is required.
Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific
IV Imipenem
K. pneumoniae
500mg q6h
(ESBL)
OR
Notes
The evidence for use of
ertapenem in the critically
ill is limited at present.
IV Meropenem
1g q8h
OR
IV Doripenem
500mg q8h
X 7-10 days
S. aureus
IV Vancomycin
15-20mg/kg
q12h
IV Linezolid
600mg q12h

X 10 - 14 days
X 10-14 days
Consider linezolid in
necrotising pneumonia.
Stenotrophomonas IV Trimetoprim/
maltophilia
Sulfamethoxazole
5mg/kg (TMP
component) q8h
Carbepenem therapy
is associated with the
emergence of this
organism.
X 10-14 days
Bibliography:
1.
2.
3.
4.
5.
6.
Clin Infect Dis 2011: 52: 285-322

Clin Infect Dis 2010; 51 (Suppl 1): S42-47
J Infection 2008: 56; 432-436
Scand J Infect Dis. 2007; 39(1): 38-43.
Curr Anaes and Crit Care 2005; 16: 209-219
Am J Respir Crit Care Med 2005; 171: 388-416
34
GENITOURINARY TRACT INFECTION

Urinary tract infections (UTI) is the most common genitourinary
tract infection seen in the critically ill patient. It can manifest from
asymptomatic bacteriuria to severe sepsis. Acute pyelonephritis
is the commonest form of UTI. Mortality associated with septic
shock secondary to urosepsis is substantially lower compared to
other sites of infection. Sterile pyuria or asymptomatic bacteriuria is
common in catheterised patients and does not warrant treatment.
However catheter-associated urinary tract infection (CAUTI) is not
uncommon and should be treated.
For purposes of practicality and differences in clinical approach, UTIs
are classified into uncomplicated or complicated. Uncomplicated
UTI is restricted to UTI in a non-pregnant immunocompetent
woman with no anatomical or functional abnormality of the urinary
tract.
A complicated UTI is associated with significant bacteriuria in an
underlying condition that increases the risk of treatment failure,
which includes:
1.
2.

3.
4.
5.
6.
7.

8.
9.

presence of indwelling catheter, stents or nephrostomy tubes

functional and/or anatomical abnormalities
e.g. neurogenic bladder, vesicoureteric reflux
obstructive uropathy
renal failure
pregnancy
diabetes mellitus
immunosuppressed states e.g. renal transplant,
febrile neutropenia, HIV
UTI caused by drug resistant pathogens
UTI in males (except young males with exclusively lower
UTI symptoms)
35
Common
Antimicrobials
Organisms
Preferred
Alternative
Acute Uncomplicated Pyelonephritis
E. coli
IV Amoxicillin/
IV Cefuroxime
Klebsiella spp
Clavulanate
1.5g q8h
P. mirabilis
1.2g q8h
OR
OR
IV Ampicillin/
Sulbactam
3g q6h
IV Ceftriaxone
2g q24h
X 7-14 days
X 7-14 days
36
Notes
Antimicrobials
Common
Organisms
Preferred
Alternative
Acute Complicated Pyelonephritis / CAUTI
Antibiotic nave
E. coli
IV Amoxicillin/
IV Cefuroxime
Klebsiella spp
Clavulanate
1.5g q8h
P. mirabilis
1.2g q8h
E. coli
Klebsiella spp
P. mirabilis
P. aeruginosa
Enterobacter spp
Enterococci
ESBL producing
Enterobacteriacae
OR
OR
IV Ampicillin/
Sulbactam
3g q6h
IV Ceftriaxone
2g q24h
X 14-21 days
X 14-21 days
Previous antibiotic exposure

IV Piperacillin/
IV Cefepime
Tazobactam
2g q8-12h
4.5g q8h
OR
X 14-21 days
IV Imipenem
500mg q6h
OR
IV Meropenem
1g q8h
X 14-21 days
Candida albicans
IV Fluconazole
800mg stat
then
400mg q24h
X 14-21 days
37
Notes
Do not use cephalosporin

for suspected
enterococcal infection.
Use of ciprofloxacin is
associated with increased
incidence of resistant
strains.
In CAUTI:
1. Catheters should be
removed or replaced.
2. Duration of treatment
is 7 days if prompt
resolution of symptoms
or 10-14 days in delayed
response whether still
catheterised or not
Obstructive uropathy
should be sought and
relieved.
Switch to oral therapy
when possible to
complete course.
Common
Antimicrobials
Organisms
Preferred
Alternative
Renal Abscess (intrarenal or perinephric)
MethicillinIV Cloxacillin
sensitive
2g q4-6h
S. aureus
Methicillin-resistant IV Vancomycin
S. aureus
15-20mg/kg
q12h
IV Linezolid
600mg q12h
Notes
Consider image-guided
aspiration or surgical
drainage of abscess.
Duration of therapy
should be prolonged.
Enterobacteriaceae Treat as acute

complicated
pyelonephritis
Pelvic Inflammatory Disease/ Tuboovarian Abscess

There is emerging
Bacteroides fragilis IV Ceftriaxone IV Ampicillin/
Sulbactam
evidence on the use of
2g q24h
G. vaginalis
3g q6h
azithromycin in mild to
H. influenzae
moderate PID.
Enterobacteriaceae PLUS
N. gonorrhoeae
IV
C. trachomatis
Metronidazole
500mg q8h
X 7 days
X 7 days
PLUS
PLUS
PO Doxycycline PO Doxycycline
100mg q12h
100mg q12h
X 14 days
X 14 days
Bibliography:
1.
2.

3.
4.
The Sanford Guide to Antimicrobial Therapy 2011: 30-31

Guidelines on urological infections by European Association
of Urology 2011
Clin Infect Dis 2011; 52(5): e103
Clin Infect Dis 2010; 50: 625
38
ACUTE INFECTIVE DIARRHOEA

Acute infective diarrhoea is usually self-limiting and does not require
antimicrobials. Patients admitted to the ICU are usually in shock
with systemic involvement and therefore, empirical antimicrobials
need to be started.
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Empirical therapy (community acquired) : non bloody diarrhoea
Salmonella typhi IV Ceftriaxone IV Ciprofloxacin Addition of azithromycin/
doxycycline is for the
and non typhi
2g q24h
400mg q12h
coverage of Vibrio cholerae
Vibrio cholerae
as ciprofloxacin resistance
Enterotoxigenic
X 7-10 days
X 7-10 days
is increasing.
E.coli (ETEC)
If ETEC is isolated, stop
PLUS
antibiotics.
PO
Azithromycin
1g single dose
OR
PO Doxycycline
300mg single
dose
Empirical therapy (community acquired) : bloody diarrhoea
Shigella spp
IV Ceftriaxone IV Ciprofloxacin If E.coli 0157 (commonest
Enterohaemorrhagic 2g q24h
400mg q12h
strain), is isolated, stop
E. coli 0157 (EHEC)
antibiotics and observe
X 3 days
for haemolytic uraemic
X 3 days
syndrome (HUS).
39
Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific: Community-acquired
IV Ciprofloxacin
Shigella spp
IV Ceftriaxone
400mg q12h
2g q24h
X 3 days
OR
Notes
If S. dysenteriae type 1 is
isolated or in patients with
HIV, treat for 5 - 7 days.
IV Azithromycin
500mg q24h
X 3 days
Vibrio cholerae
PO Azithromycin
1g
OR
PO Doxycycline
300mg
PO
Ciprofloxacin
500mg q12h
X 3 days
X 1 dose
Salmonella
typhi and
non-typhi
IV Ceftriaxone
2g q24h
IV Ciprofloxacin
400mg q12h
X 7-10 days
X 7-10 days
Clostridium difficile-associated disease

Clostridium difficile-associated disease (CDAD) is suspected when
patients present with watery diarrhoea, even for a day, associated with
fever (T > 38.5C) and abdominal pain. CDAD rarely presents as ileus.
Diagnosis is made by the detection of C. difficile toxin in the stools.
Colonoscopy may aid diagnosis should CDAD be suspected when
laboratory confirmation is delayed or negative, or when presentation is
atypical. Risk factors are hospitalisation, exposure to antibiotics (mainly
clindamycin, cephalosporins, quinolones and penicillin) and advanced
age. Offending antibiotics should be discontinued if possible.
40
Relapse occurs in up to 27% of cases, typically between 3 days to 3

weeks after treatment is discontinued. Metronidazole should not be
used after the first recurrence.
Consider infectious disease consultation in cases of relapse.
Severity of illness
Mild to moderate
Severe
Antimicrobials
Notes
Severity:
PO Metronidazole 400mg q8h 1. mild to moderate: TWC<15
and creat<1.5x baseline
X 10-14 days
PO Vancomycin 125 mg q6h
X 10-14 days
Severe complicated PO Vancomycin 500 mg q6h

PLUS
IV Metronidazole 500mg q8h
2. severe:TWC>15 and
creat>1.5x baseline
3. severe complicated:
presence of shock, ileus or
megacolon
IV vancomycin is not
effective. IV formulation can
be given orally.
In complete ileus, consider
concurrent rectal vancomycin
500mg q6h.
Fulminant colitis and toxic
megacolon may require
operative intervention.
depends on clinical response.
Bibliography:
1.
2.
3.
4.
Infect Control Hosp Epidemiol 2010; 31: 431-455

Cochrane Database Syst Rev. 2007
N Engl J Med 2004; 350(1): 38
Clin Infect Dis 2001; 32(3): 331
41
ACUTE INFECTIVE PANCREATITIS

Patients with severe acute pancreatitis who develop infection tend
to have more than 30% necrosis of the pancreas. Infection usually
occurs late (after 10 days) in the clinical course of the disease.
The important organisms causing infection in necrotising
pancreatitis are predominantly gut-derived, and the majority are
monomicrobial.
The diagnosis of infective pancreatitis is a combination of clinical
and laboratory investigations (persistent leucocytosis, CRP > 150
mg/L after 48 hrs of symptom onset). To further define infection,
CT/US guided aspiration with Gram-staining and cultures is
recommended.
There is disparate opinion as to the use of prophylactic
antimicrobial in severe necrotising pancreatitis. The prophylactic
use should be considered if the patient has severe necrosis
(> 30% confirmed on CT scan) with evidence of multi-organ failure
and high severity illness score.
The antibiotics for prophylaxis should penetrate necrotic
tissue effectively. The duration of prophylaxis is 7-14 days with
clinical reassessment of risk-benefit to be made on day 7.
The prophylactic antibiotic of choice is similar to that used in the
treatment of infected pancreatitis. There is no indication for the use
of prophylactic antifungal.
42
Common
Organisms
Antimicrobials
Preferred
Alternative
Enterobacteriaceae IV Piperacillin/
(E. coli,
Tazobactam
Klebsiella spp.
4.5g q6h
Proteus spp.)
Enterococcus spp
Bacteroides spp
IV Imipenem
500mg q6h
Candida albicans
Candida non
albicans
IV Fluconazole
800mg (loading
dose) followed
by
400mg q24h
IV Caspofungin
70mg (loading
dose) followed
by
50mg q24h
OR
OR
OR
IV Meropenem
1g q8h
IV
IV
Amphotericin B Anidulafungin
0.6-1mg/kg/day loading
dose 200mg
followed by
100mg q24h
Bibliography:
1.
2.
3.
4.
Am J Gastroenterol 2008; 103(1): 104

Am J Gastroenterol 2006; 101(10): 2379
Gastroenterology 2007; 132(5): 2022
Cochrane Database Syst Re. 2006.
43
Notes
Infected pancreatic
necrosis is an indication
for surgical or
radiological-guided
drainage.
Duration of treatment is
guided by repeated clinical
and serial radiological
assessments.
The risk of fungal infection
in severe pancreatitis
is high and empirical
treatment should be
considered early if no
improvement despite
broad spectrum
antimicrobials.
Consider amphotericin B
if patient has had recent
azole exposure in the past
3 months.
Echinocandins (or
lipid-based amphotericin
B) to be considered in
patients with recent
azole exposure and renal
dysfunction
BILIARY SEPSIS
Acute cholangitis can be a life-threatening infection secondary to the
obstruction of common bile duct by gall stones or strictures. Besides
antimicrobial therapy, prompt decompression and drainage of the
biliary tract need to be considered.
Acute cholecystitis is primarily an inflammatory process and secondary
infection of the gall bladder can occur as a result of cystic duct
obstruction and bile stasis. Antimicrobial therapy is instituted in the
presence of leukocytosis or fever, and radiologic findings of air in the
gallbladder or gall bladder wall. Antimicrobials are also recommended
in patients of advanced age, diabetics or immunocompromised.
Common
Organisms
Enterobacteriaceae
(E. coli,
Klebsiella spp,
Enterobacter spp)
Enterococci
P. aeruginosa
Anaerobes
(Bacteroides
fragilis,
C. perfringens)
Antimicrobials
Preferred
Alternative
IV Cefoperazone IV Piperacillin/
Tazobactam
2g 12qh
4.5g q6h
PLUS
OR
Notes
regime in patients with
recent ERCP, presence
of stents or entero-biliary
surgery.
IV Cefepime
IV Metronidazole 2g q8-12h
Consider enterococcal cover
500mg 8qh
PLUS
IV Metronidazole in: immunocompromised
500mg q8h
(solid organ transplant or
X 7-10 days
steroid therapy), valvular
OR
heart disease, intravascular
IV Imipenem
prosthetic devices or
500mg q6h
previous antimicrobial use.
OR
IV Meropenem
1g q8h
OR
IV Doripenem
500mg q8h
X 7-10 days
Bibliography:
1. Clin Infect Dis 2010; 50(2): 133-64
44
Ceftriaxone may increase

biliary sludging.
LIVER ABSCESS
Liver abscess is classified by aetiology into pyogenic, amoebic
and fungal abscess. Pyogenic abscess is the most common
and may occur following spread through the biliary tree, by
extension of adjacent infection or following instrumentation
e.g. chemoembolisation or biliary sphincterotomy. Invasive
Klebsiella pneumoniae liver abscess syndrome (KLAS) is a
community-acquired primary liver abscess that may have
metastatic manifestations (endophthalmitis, meningitis, brain
abscess). Abscess caused by Burkholderia pseudomallei should
be considered in patients who present with shock.
Amoebic liver abscess may be seen in patients who are from
or have visited endemic areas. Serological test is positive for
most patients with amoebic liver abscess. Fungal liver abscess
is usually due to Candida albicans and occurs in patients with
immunosuppression.
Besides antimicrobial therapy, drainage of the abscess need to
be considered. Pyogenic liver abscess will require 4-6 weeks
of antimicrobial therapy. Amoebic liver abscess will require 7-10
days of antimicrobial therapy followed by a luminal agent for
eradication of gut colonisation.
45
Antimicrobials
Preferred
Alternative
Enterobacteriaceae Empirical therapy in the
haemodynamically unstable
(E. coli, Klebsiella
pneumoniae)
IV Piperacillin/
IV Meropenem
S. milleri
Tazobactam
1g q8h
Enterococcus spp 4.5g q6h
S. aureus
Anaerobes
OR
OR
(Bacteroides spp,
Fusobacterium spp, IV Cefepime
IV Imipenem
Actinomyces spp, 2g q8-12h
500mg q6h
Clostridium spp)
PLUS
Entamoeba
IV Metronidazole 500mg q8h
histolytica
Empirical therapy in the
haemodynamically stable
Common
Organisms
IV Ceftriaxone
2g q24h
IV Piperacillin/
Tazobactam
4.5g q6h
PLUS
PLUS
IV
Metronidazole
500mg q8h
IV
Metronidazole
500mg q8h
Notes
Consider carbapenem
when melioidosis is
suspected.
Consider
antifungal therapy in
immunocompromised or
neutropenic patients.
Metronidazole is added
to cover Entamoeba
histolytica.
Bibliography:
1. The Sanford Guide to Antimicrobial Therapy 2011
2. Clin Infect Dis 2010; 50: 133-164
3. Clin Infect Dis 2007; 45(3): 284
46
PERITONITIS
In complicated intra-abdominal infections, the infective
process extends beyond the organ and causes either localised
peritonitis with abscess formation or diffuse peritonitis.
Complicated intra-abdominal infections can be classified into:
1. Primary or spontaneous bacterial peritonitis: a diffuse bacterial
infection without loss of integrity of the gastrointestinal tract.
2. Secondary peritonitis: acute peritoneal infection resulting from
loss of integrity of the gastrointestinal tract or from infected
viscera. It may be community-acquired or health care-associated
e.g. perforation of the gastrointestinal tract, anastomotic
dehiscence.
3. Tertiary peritonitis: persistent or recurrent infection that typically
occurs at least 48 hours after apparently adequate management
of primary or secondary peritonitis.
Source control to eradicate focus of infection and prevent ongoing
microbial contamination is fundamental to the management
of patients with complicated intra-abdominal infections.
Selection of empiric antimicrobial therapy depends mainly on the
severity of illness and whether the infection is community-acquired
or healthcare-associated.
Common
Antimicrobials
Organisms
Preferred
Alternative
Spontaneous bacterial peritonitis
E.coli
IV Ceftriaxone IV Piperacillin/
Klebsiella spp
2g q24h
Tazobactam
S.pneumoniae
4.5g q6h
Enterococci
X 5 days
X 5 days
47
Notes
Common
Antimicrobials
Organisms
Preferred
Alternative
Community-acquired secondary peritonitis
Mild to moderately ill
Enterobacteriaceae
(esp. E. coli)
IV Ceftriaxone
IV Amoxicillin/
Streptococcus
2g q24h
Clavulanate
milleri
OR
1.2g q8h
Anaerobes
IV
(esp. Bacteroides
Cefoperazone
X 5-7 days
fragilis)
2g q12h
PLUS
IV
Metronidazole
500mg q8h
X 5-7 days
Severely ill
IV Piperacillin/
Tazobactam
4.5g q6h
IV Meropenem
1g q8h
OR
OR
IV Cefepime
2g q8-12h
PLUS
IV
Metronidazole
500mg q8h
IV Imipenem
500mg q6h
X 5-7 days
OR
IV Doripenem
500mg q8h
X 5-7 days
48
Notes
Bowel perforation from
penetrating or blunt
trauma, repaired within
12h should only be
treated with antibiotics
for 24h.
Antimicrobial therapy is
only required for 24h post
operatively in:
1. Acute perforations of
the stomach, duodenum,
proximal jejunum (with
absence of antacid
therapy or malignancy)
when source control is
achieved within 24h
2. Acute appendicitis
(without evidence of
gangrene, perforation,
abscess, peritonitis).
Use of anti-MRSA
or antifungal is not
recommended in the
absence of evidence
of infection by such
organisms.
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Healthcare-associated secondary peritonitis and tertiary peritonitis
Risk for ESBL-producing
ESBLproducing
Following adequate
enterobacteriaceae
source control,
enterobacteriaceae
antimicrobials should be
(E. coli, Klebsiella
High
Low
discontinued when there
spp)
Enterobacter spp
IV Meropenem is resolution of fever,
IV Piperacillin/
normalisation of WBC and
Proteus spp
1g q8h
Tazobactam
return of gastrointestinal
P. aeruginosa
4.5g q6h
function.
Acinetobacter spp
OR
Risks of selection
Enterococci
OR
of ESBLproducing
Anaerobes
IV Imipenem
enterobacteriaceae:
500mg q6h
IV Cefepime
prior exposure to 3rd gen.
2g q8-12h
cephalosporins, multiple
OR
PLUS
antibiotics.
IV
Consider enterococcal
Metronidazole IV Doripenem
cover in tertiary
500mg q8h
500mg q8h
peritonitis, previously
on cephalosporins,
PLUS OPTIONAL
immunocompromised,
valvular heart disease or
IV Vancomycin
Methicillinprosthetic intravascular
15-20mg/kg
q12h
resistant
materials.
S. aureus
Consider anti-MRSA in
PLUS OPTIONAL
those colonised with
MRSA, prior MRSA
IV Fluconazole 800mg stat
Candida albicans
treatment failure or
and 400mg q24h
significant antibiotic
exposure.
Consider antifungal in
severe hospital-acquired
infections.
Bibliography:
1. World J Emerg Surg 2011, 6:2 doi: 10.1186/1749-7922-6-2

2. Clin Infect Dis 2010; 50: 133-64
49
CATHETER-RELATED BLOODSTREAM INFECTION

Patients with short term CVC are suspected to have catheter-related
infection if they have an acute febrile episode with or without
hypotension, hypoperfusion and organ dysfunction in the absence
of other identifiable sources of infection.
In patients who are haemodynamically unstable, catheter must
be removed. In stable patients catheter may be left in-situ if still
needed. However it must be removed when cultures are positive or
fever persists with unidentified source of sepsis.
Diagnosing catheter-related bloodstream infection (CRBSI) requires
simultaneous blood sampling from the catheter hub and the
peripheral blood into appropriately labeled bottles. A definitive
diagnosis of CRBSI requires the same organism grown from the
blood cultures with either
1. quantitative cultures of blood samples having a ratio of
3:1 cfu/ml of blood (catheter: peripheral).
2. differential time to positivity (DTP) of at least 2 hours: growth
from the catheter hub at least 2 hours earlier than the periphery.
Qualitative culture of catheter tip is not recommended. If catheter
tip (5cm length) is cultured, a semi quantitative culture of > 15 cfu
or quantitative culture of > 102 cfu plus a peripheral blood culture of
the same organism confirms the diagnosis of CRBSI.
Presence of catheter site inflammation alone does not always
indicate CRBSI and vice versa. This section deals only with CRBSI
associated with short-term central venous catheters.
50
Common
Antimicrobials
Organisms
Preferred
Alternative
Empirical therapy in the haemodynamically stable
Methicillin
IV Cloxacillin
sensitive:
2g q6h
Coagulasenegative
S. epidermidis
(CoNS)
S. aureus
Methicillin
resistant:
S. aureus
S. epidermidis
IV Vancomycin
15-20mg/kg
q12h
Notes
Empirical therapy should
be stopped if cultures are
negative.
Consider MRSA/MRSE in
patients with prosthetic
valves or vascular graft,
prior antibiotic use, on
hemodialysis, prolonged
hospital stay, HIV +ve and
residence of long term
care facilities.
IV linezolid should not be
used as empirical therapy.
51
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Empirical therapy in the haemodynamically unstable
Gram-negative
IV Meropenem The choice of
IV Cefepime
1g q8h
2g q8-12h
bacilli
antimicrobials depends
on the local flora and
OR
OR
susceptibility patterns.
IV Piperacillin/
Tazobactam
4.5g q6h
IV Imipenem
500mg q6h
OR
OR
IV
Cefoperazone/
Sulbactam
4g q6h
IV Polymyxin E
3 million units
q8h
PLUS OPTIONAL
MRSA
IV Vancomycin
15-20mg/kg
q12h
Consider Gram-negative
cover in neutropenia,
severe sepsis or patients
known to be colonised
with such pathogens.
Consider MRSA cover in
patients with prolonged
hospital stay, prior
antibiotic use, on dialysis,
HIV +ve and residence of
long term care facilities.

PLUS OPTIONAL PLUS OPTIONAL refer to Appendix B.
Candida spp
IV Fluconazole
800mg stat
then 400mg
q24h
IV
Risk factors for Candida:
Amphotericin B
TPN, femoral line,
0.6-1mg/kg
prolonged use of broad
q24h
spectrum antibiotics,
OR
haematological malignancy
or candida colonisation at
IV Caspofungin
multiple sites.
70mg stat then
50mg q24h
Echinocandin (or
lipid-based amphotericin
OR
B) may be considered in
IV
patients who have prior
Anidulafungin
exposure to an azole in
200mg stat
the last 3 months with
then 100mg
renal dysfunction.
q24h
52
Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific
Methicillin
IV Cloxacillin
sensitive:
2g q6h
CoNS
X 5-7 days
S.aureus
IV Cloxacillin
2g q6h
X 14 days
Methicillin
resistant:
CoNS
S.aureus
Notes
Infected catheters must
be removed.
Duration of therapy in
complicated infection:
a. endocarditis /
suppurative
thrombophlebitis
4-6 wks
b. osteomyelitis 6-8 wks
IV Vancomycin
15-20mg/kg
q12h
IV Linezolid
600mg q12h
X 5-7 days
X 5-7 days
IV Vancomycin
15-20mg/kg
q12h
IV Linezolid
600mg q12h
X 14 days
X 14 days
Enteroccocus spp IV Ampicillin

Ampicillin sensitive 2g q6h

Refer to the above for the

duration of treatment in
complicated infections.
Ampicillin
resistant
IV Vancomycin
15-20mg/kg
q12h
Vancomycin
resistant
IV Linezolid
600mg q12h
IV Daptomycin
6mg/kg q24h
X 7-14 days
X 7-14 days
53
Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific
IV Amoxicillin/
Non-ESBL
IV Ceftriaxone
Clavulanate
E. coli
2g q24h
1.2g q8h
Klebsiella spp
X 7-14 days
OR
Notes
Consider in patient with
femoral catheters.
IV Cefuroxime
1.5g q8h
X 7-14 days
ESBL
E. coli
Klebsiella spp
The evidence for use

of ertapenem in the
critically ill is limited at
present.
IV Imipenem
500mg q6h
OR
ESBL or non-ESBL
Enterobacter spp IV Meropenem
1g q8h
OR
IV Doripenem
500mg q8h
X 10-14 days
Acinetobacter spp
IV Ampicillin/
Sulbactam
3g q3h
IV Polymyxin E
3 million units
q8h
OR
X 10-14 days
IV
Cefoperazone/
Sulbactam
4g q6h
X10-14 days
54
8g/day is required.
Common
Organisms
Pathogen specific
P. aeruginosa
Antimicrobials
Preferred
Alternative
IV Ceftazidime
2g q8h
OR
IV Cefepime
2g q8-12h
OR
IV Piperacillin/
Tazobactam
4.5g q6h
IV Meropenem
1g q8h
OR
IV Imipenem
500mg q6h
OR
IV Doripenem
1g q8h
X 10-14 days
X 10-14 days
PLUS OPTIONAL PLUS OPTIONAL

IV Amikacin
15mg kg/q24h
X 3-5 days
OR
IV Ciprofloxacin
400mg q8h
X 7 days
Candida albicans
Candida non
albicans
Notes
Use the alternative

regime in gp. 1
-lactamase.
Use IV polymyxin in
carbapenem-resistant
P. aeruginosa.
Dual therapy may be
considered in
2. septic shock
IV Amikacin
15mg/kg q24h
X 3-5 days
OR
IV Ciprofloxacin
400mg q8h
X 7 days
Treat for 14 days after last
positive blood culture.
IV Fluconazole
800mg stat
then 400mg
q24h
Consider echinocandins
(or lipid-based
IV Amphotericin IV Anidulafungin amphotericin B) in
B
200mg stat then patients with recent
0.6-1mg/kg
100mg q24h
q24h
dysfunction.
OR
IV Caspofungin
70mg stat then
50mg q24h
Bibliography:
1. Clin Infect Dis 2009; 49(1): 1-45
55
INFECTIVE ENDOCARDITIS
Dukes criteria is widely used for diagnosis of infective endocarditis
(IE). Three sets of blood cultures should be obtained prior to
initiation of antibiotic therapy. An echocardiogram should be done in
all suspected cases. Treatment is guided by presentation,
clinical findings, native or prosthetic valves and organism virulence.
Indications for surgery include the following: heart failure,
uncontrolled infection and large vegetations.
Common
Antimicrobials
Organisms
Preferred
Alternative
Empirical therapy
Native valve
IV Benzylpenicillin IV Cefriaxone
2g q24h
3 million units
q4h
PLUS
IV Gentamicin
1mg/kg q8h
Notes
Consider cloxacillin in
intravenous drug users.
Benzylpenicillin:
1 million units
= 600mg
PLUS OPTIONAL PLUS OPTIONAL

IV Cloxacillin
2g q4h
IV Cloxacillin
2g q4h
Prosthetic valve IV Vancomycin

15-20mg/kg
q12h

PLUS
There is increasing
evidence for single daily
dose of gentamicin
3mg/kg/day.
IV Gentamicin
1mg/kg q8h
PLUS
PO Rifampicin
300mg q8h
56
Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific
S. viridans
IV Benzlpenicillin IV Benzylpenicillin
S. bovis
3 million units
3 million units
Highly penicillin- q4h
q4h
susceptible:
OR
MIC 0.12 g/ml OR
IV Ceftriaxone
2g q24h
IV Ceftriaxone
2g q24h
PLUS
X 4 weeks
IV Gentamicin
1mg/kg q8h
X 2 weeks
S. viridans
S. bovis
Relatively
resistant to
penicillin:
MIC 0.12 g/ml
IV Benzylpenicillin IV Ceftriaxone
2g q24h
4 million units
q4h
X 4 weeks
X 4 weeks
PLUS
PLUS
IV Gentamicin
1mg/kg q8h
IV Gentamicin
1mg/kg q8h
X 2 weeks
X 2 weeks
57
Notes
The alternative
2-week regime is not
recommended for
patients age > 65 years
old, creatinine clearance
< 20ml/min, deafness
and known cardiac or
extra-cardiac abscesses
in prosthetic valve
endocarditis is 6 weeks
for preferred regime.
in prosthetic valve
endocarditis is
6 weeks
Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific
S. aureus
(Native valveleft side
and
complicated
right sided)
(Native valveuncomplicated
right sided)
IV Cloxacillin
2g q4h
If MRSA :
IV Vancomycin
15-20mg/kg
q12h
X 6 weeks
X 6 weeks
PLUS
PLUS
IV Gentamicin
1mg/kg q8h
IV Gentamicin
1mg/kg q8h
X 3-5 days
X 3-5 days
IV Cloxacillin
2g q4h
PLUS
IV Gentamicin
1mg/kg q8h
X 2 weeks
S. aureus
(Prosthetic
valve)
IV Cloxacillin
2g q4h
If MRSA:
IV Vancomycin
15-20mg/kg
q12h
X 6 weeks
X 6 weeks
PLUS
PLUS
PO Rifampicin
300mg q8h
PO Rifampicin
300mg q8h
X 6 weeks
X 6 weeks
PLUS
PLUS
IV Gentamicin
1mg/kg q8h
IV Gentamicin
1mg/kg q8h
X 2 weeks
X 2 weeks
58
Notes
Uncomplicated right-sided
endocarditis: absence of
heart failure,
extra-pulmonary
metastatic infection such
as osteomyelitis, aortic
or mitral valve
involvement, meningitis
or infection with MRSA.
Common
Organisms
Pathogen specific
Enterococcus spp
(Ampicillin sensitive)
Antimicrobials
Preferred
Alternative
IV Ampicillin
2g q4h
Duration of treatment:
Native valve with
symptoms
< 3 months - 4 weeks
Native valve with
symptoms
> 3 months - 6 weeks
Prosthetic valve is
minimum 6 weeks
PLUS
Enterococcus spp
(Ampicillin resistant)
IV Gentamicin
1mg/kg q8h
IV Vancomycin
15-20 mg/kg
q12h
PLUS
IV Gentamicin
1mg/kg q8h
HACEK
Haemophilus spp
Actinobacillus
actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella spp
Notes
IV Ampicillin/
Sulbactam
3g q6h
IV Ceftriaxone
2g q24h
X 4 weeks
X 4 weeks
Bibliography:
1. Eur Heart J 2009; 30: 2369
2. Circulation 2005; 111: 3167
59
CENTRAL NERVOUS SYSTEM INFECTION

The approach to the patient with suspected acute central nervous
system infection is early recognition of the disease, performance of
rapid diagnostic tests, prompt antimicrobial therapy and adjunctive
therapy whenever appropriate.
The choice of empirical antibiotic to treat acute bacterial meningitis
is influenced by the patients age, immune status and predisposing
conditions. The antibiotic used in meningitis should have bactericidal
action with high concentration of antibiotic in the CSF as the
immune activity in the CSF is poor. Current evidence suggests the
use of dexamethasone only in pneumococcal meningitis.
There is no specific antimicrobial for most viral encephalitis.
However, acyclovir should be initiated in all patients with suspected
encephalitis although it is only specific to herpes virus infection.
Limited case series have been reported on the use of intrathecal
antibiotics alongside parenteral treatment. The greatest clinical
experience is with vancomycin, gentamicin and polymyxin antibiotics that are known to have poor CNS penetration. Currently
there is no antibiotic approved by FDA for intrathecal use.
60
Common
Antimicrobials
Organisms
Preferred
Alternative
Acute bacterial meningitis community-acquired
S. pneumoniae IV Ceftriaxone
IV Cefotaxime
N. meningitidis 2g q12h
2g q6h
H. influenzae
Duration of treatment:
Aerobic Gramnegative bacilli N. meningitidis X 7days
(more common
H. influenzae X 7 days
in age > 50,
immunocompromised) S. pneumoniae X 14 days
Aerobic Gram negative bacilli
Listeria
monocytogenes X 21 days
(uncommon in
L. monocytogenes X 21 days or
Malaysia)
longer if immunocompromised
Notes
Add IV vancomycin
if prevalence of
cephalosporin-resistant
S. pneumoniae is > 2%.
Add IV dexamethasone
0.15mg/kg (10mg) q6h
X 4 days in pneumococcal
meningitis. 1st dose to be
given 10-20 min before,
or concomitant with the
first dose of antibiotic.
Omit if antibiotics have
been started.
Treat Listeria meningitis
with IV ampicillin 2g q4h
IV gentamicin if CSF
Gram-stain reveals
Gram-positive rods or
when confirmed.
Acute bacterial meningitis - Post head injury (base of skull fracture)

S. pneumoniae
H. influenzae
Group A
-haemolytic
streptococci
IV Ceftriaxone
2g q12h
IV Cefotaxime
2g q6h
61
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Acute bacterial meningitis - Penetrating trauma, post neurosurgery,
shunts including lumbar catheters
S. aureus
Coagulasenegative
staphylococci
Aerobic
Gram-negative
bacilli
IV Ceftriaxone
2g q12h
PLUS
IV Cloxacillin
2g q6h
X 14 days
IV Cefepime
2g q8h
OR
IV Meropenem
2g q8h
PLUS
IV Vancomycin
15-20mg/kg
q12h
X 14 days
Remove infected shunt.

regime if at risk for MDR
pathogens e.g. prolonged
hospital stay, previous
broad-spectrum antibiotic.
Acute encephalitis
If immunocompromised
to treat for 21 days.
Herpes simplex IV Acyclovir

Herpes zoster
10mg/kg q8h
X 14 days
Arboviruses
Flaviviruses
No antiviral of
proven value
62
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Brain abscess - Haematogenous and contiguous spread
Streptococci
IV Cefotaxime
Contiguous spread can
IV Ceftriaxone
Bacteroides spp 2g q12h
occur from otitis media,
2g q6h
Enterobacteriaceae
mastoiditis and sinusitis
S. aureus
which will need surgical
PLUS
PLUS
drainage.
IV Metronidazole IV Metronidazole
Consider surgical
500mg q8h
500mg q8h
drainage if brain abscess
is > 2.5cm.
S. aureus abscess is
rare in the absence of a
positive blood culture.
Minimum duration of
treatment is 4-6 weeks
and response is guided by
neuro imaging.
Brain abscess - Post surgery / post trauma
S. aureus
Aerobic
Gram-negative
bacilli
IV Ceftriaxone
2g q12h
PLUS
IV Cloxacillin
2g q4h
IV Cefepime
2g q8h
OR
IV Meropenem
2g q8h
PLUS
IV Vancomycin
15-20mg q12h
Consider surgical drainage

if abscess is > 2.5cm.
regime if at risk for MDR
e.g. prolonged hospital
stay, previous
broad-spectrum
antibiotic use.
Minimum duration of
neuro imaging.
63
Common
Antimicrobials
Organisms
Preferred
Alternative
Brain abscess - Cyanotic heart disease
Streptococci
IV Ceftriaxone
(esp. S. milleri) 2g q12h
H.influenzae
S. aureus
Brain abscess - HIV infected

Toxoplasma
PO
gondii
Pyrimethamine
200mg X 1 day
then
75mg q24h
PLUS
IV Trimethoprim/
Sulfamethoxazole
5mg/kg
(trimethoprim
component) q12h
X 30 days
PO Sulfadiazine
1g q6h if < 60 kg
or 1.5g q6h if
> 60 kg
PLUS
PO Folinic acid
20mg q24h
X 6 weeks after
resolution of
signs/symptoms
Suppression treatment
PO Sulfadiazine 2-4g in divided
2-4 doses/day
PLUS
PO Pyrimethamine 25-50mg q24h
PLUS
PO Folinic acid 20mg q24h
64
Notes
Consider surgical drainage
if abscess is > 2.5cm.
Minimum duration of
neuro imaging.
Folinic acid prevents
pyrimethamine-induced
haematologic toxicity.
Treat till CD4
count >200/L for 3
months, even after
complete resolution of
lesions on CT/MRI.
Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific
Cryptococcus
Induction phase
neoformans
IV Amphotericin IV Liposomal
B 0.7-1.0 mg/kg Amphotericin B
q24h
3-4mg/kg q24h
OR
IV Amphotericin
B lipid complex
5mg/kg q24h
PLUS
PLUS
PO Flucytosine
25mg/kg q6h
PO Flucytosine
25mg/kg q6h
X 4 weeks
X 4 weeks
Consolidation phase
PO Fluconazole
400 mg q24h
X 8 weeks
Maintenance phase
PO Fluconazole
200mg q24h
X 6 - 12 months
Notes
For HIV infected or
transplant patients, refer
ID physician.
Induction phase of
6 weeks or longer in
patients with neurological
complications, if CSF
culture is still positive after
2 weeks of treatment or if
flucytosine is not given or
treatment is interrupted.
In patients at low risk
of therapeutic failure
(early diagnosis by
history, no uncontrolled
underlying disease, not
immunocompromised
and excellent clinical
response to initial 2-week
antifungal combination),
consider induction
therapy with combination
of amphotericin B plus
flucytosine for 2 weeks,
followed by consolidation
with PO fluconazole
800mg q24h for 8 weeks.
Mycobacterium Refer to chapter on tuberculosis

tuberculosis
Bibliography:
1.
2.
3.
4.
The Sanford Guide to Antimicrobial Therapy 2011; 5-8, 99

Clin Infect Dis 2010; 50: 291-322
Clin Infect Dis 2008; 47: 303-27
Clin Infect Dis 2004; 39: 1267-84
65
SKIN AND SOFT TISSUE INFECTIONS

Skin and soft tissue infections (SSTIs) are usually caused by
bacterial entry through breaches in the skin. Its clinical severity
depends on host factors such as age, diabetes mellitus and state of
immunocompetence.
Cellulitis
Cellulitis is an acute diffuse infection of the epidermis, dermis
and subcutaneous tissue. It is usually caused by -haemolytic
streptococci (most commonly Group A) or S. aureus. S. aureus
cellulitis is usually associated with bullae or abscesses. Lack of
clinical response to antimicrobials could be due to resistant strains
of organisms e.g. MRSA or infection of the deeper tissues. There is
growing concern regarding the emergence of community-acquired
MRSA SSTIs.
Common
Organisms
-haemolytic
Streptococci
S. aureus
Antimicrobials
Preferred
Alternative
IV Cloxacillin
2g q6h
X 5-10 days
Notes
IV Amoxicillin/
Clavulanate
1.2g q8h
If streptococci is
cultured consider IV
benzylpenicillin 4 MU q6h.
X 5-10 days
IV benzylpenicillin:
1 million units
= 600mg
depends on clinical
response.
66
Necrotising fasciitis
Necrotising fasciitis is an infection of the deeper tissues usually
involving the extremities, the parapharyngeal space, the abdominal
wall or the perineum (Fourniers gangrene). Patients are generally
more ill and septic. Although supportive management of organ
failure and antimicrobials play a major role, surgical debridement
often extensive and repeated is essential. Tissue cultures taken at
the time of debridement may help to identify the organism.
There are 3 types of necrotising fasciitis. Type 1 is polymicrobial
and is usually seen in patients with peripheral vascular disease,
alcoholics, diabetes, chronic kidney disease and after surgical
procedures. Type 2 is caused by -haemolytic streptococcus.
It commonly occurs in patients with no medical illnesses,
predisposed by blunt trauma, varicella infection, intravenous drug
abuse and surgical procedures. Type 3 infection is clostridial
myonecrosis, also known as gas gangrene. It often occurs
in penetrating wound or crush injury associated with local
devascularisation and can rapidly progress to death.
67
Common
Organisms
-haemolytic
streptococci
S.aureus
Bacteroides spp
Clostridium spp
Peptostreptococci
Enterobacteriaceae
Antimicrobials
Preferred
Alternative
IV Ampicillin/
Sulbactam
3g q6h
PLUS
IV Clindamycin
900mg q8h
IV Piperacillin/
Tazobactam
4.5g q6h
OR
IV Imipenem
500mg q6h
PLUS
IV Clindamycin
900mg q8h
Notes
Continue treatment until
surgical debridement is no
longer needed and patient
has clinically improved.
If Clostridium spp or
haemolytic streptococci
is confirmed, deescalate
to IV benzylpenicillin 2
MU q4h but continue
clindamycin.
If streptococcal toxic
shock syndrome is
suspected consider IVIg.
Aeromonas
hydrophila
Vibrio vulnificus
PO Doxycycline IV Ciprofloxacin If IV Clindamycin is not

available, PO Clindamycin
400mg q8h
100mg q12h
600mg q6h may be used.
X 7-10days
PLUS
Aeromonas spp and
Vibrio spp need to be
IV Ceftriaxone
considered in water
2g q24h
related injuries. At risk are
the immunocompromised,
X 7-10 days
diabetes and liver
cirrhosis.
If Aeromonas hydrophila
is isolated to stop
doxycycline.
68
Deep neck space infection

Deep neck space infections include the submandibular (Ludwigs
angina), parapharyngeal, retropharyngeal and peritonsillar space
infection. Infections of the deep neck tissues often need surgical
debridement and assessment for potential airway compromise.
These infections may extend resulting in mediastinitis and/or lung
empyema.
Common
Organisms
Streptococcus
spp
Anaerobes
Peptostreptococi
Fusobacterium
spp
Prevotella
Bacteroides
(usually not
Bacteroides
fragilis)
Antimicrobials
Preferred
Alternative
Notes
IV Benzylpenicillin IV Amoxicillin/
4 MU q6h
Clavulanate
1.2g q8h
Most of these infections

have an odontogenic
source.
PLUS
Gram negative rods to

be considered in the
immunocompromised
host.
OR
IV Metronidazole IV Ampicillin/
500mg q8h
Sulbactam
3g q6h
Continue treatment until

surgical debridement is no
longer needed and patient
has clinically improved.
Surgical Site infection

Most surgical site infections have no clinical manifestation for the
first 5 days after the operation. The most important intervention
is to open the wound, drain the infected material and continue to
dress the wound daily. Empiric antimicrobial is usually guided by the
site of infection.
69
Common
Antimicrobials
Organisms
Preferred
Alternative
Abdominal/Perineum
Mixed
Gram-positive
and
Gram-negative
IV Ampicillin/
Sulbactam
3g q6h
IV Piperacillin/
Tazobactam
4.5g q6h
X 5-7 days
X 5-7 days
Chest/Extremities
S. aureus
IV Cloxacillin
Streptococcus 2g q6h
spp
X 5-7 days
Notes
IV Amoxicillin/
Clavulanate
1.2g q8h
X 5-7 days
Bibliography:
1. The Sanford Guide to Antimicrobial Therapy 2011: 39-41
2. Clin Infect Dis: 2005: 41; 1373-406
3. N Engl J Med 2004: 350(9): 904-912
70
DIABETIC FOOT INFECTIONS

Foot infections are common complications of diabetic patients.
Management of patients admitted in severe sepsis or septic
shock secondary to diabetic foot infection includes intravenous
antibiotics together with extensive wound debridement and/or
amputation of the limb. Appropriate wound swabs should be taken
prior to starting antibiotics (refer to chapter on microbiological
investigations). Duration of therapy should be based on severity
of infection, presence or absence of osteomyelitis and clinical
response to therapy. Routinely prescribing antibiotics for a fixed
duration is unnecessary.
Common
Antimicrobials
Organisms
Preferred
Alternative
Macerated ulcer with extensive necrosis/gangrene
IV Imipenem
S. aureus
IV Piperacillin/
500mg q6h
-haemolytic
Tazobactam
streptococci
4.5gm q6h
Enterobacteriaceae
P. aeruginosa
OR
Anaerobes
IV Cefepime
2g q8-12h
PLUS
IV Metronidazole
500mg q8h
Chronic ulcer previously treated with antibiotics
IV Ampicillin/
S. aureus
Sulbactam
-haemolytic
3gm q6h
streptococci
Enterobacteriaceae
IV Piperacillin/
Tazobactam
4.5gm q6h
Bibliography:
1. Clin Infect Dis 2012: 54; 132-173
2. World J Diabetes 2011: 2(2); 24-32
71
Notes
If high risk for MRSA to
add IV vancomycin.
MELIOIDOSIS
Melioidosis is a potentially fatal disease caused by Burkholderia
pseudomallei. There is no reliable pathognomonic feature and can
present as bacteremia with no obvious focal infection or as septic
shock with multiorgan failure. Common sites of infection include
the lung (50%), joints, spleen, liver and prostate.
Predisposing host factors for melioidosis include diabetes mellitus,
renal failure, renal calculi, alcoholism, steroids, malignancy and
HIV infection.
Antibiotic therapy consists of 2 phases, an initial treatment phase
for 2 weeks followed by an eradication phase for 12 20 weeks
to prevent relapse and recurrence. The actual eradication phase is
guided by clinical response to therapy. Radiological imaging may be
necessary to identify deep-seated abscesses that may need to be
drained. Infected joints need surgical intervention.
72
Common
Organisms
Burkholderia
pseudomallei
Antimicrobials
Preferred
Alternative
Phase 1: Treatment
IV Meropenem
1g q8h
(2g q8h for
CNS infection)
IV Ceftazidime
2g q8h
X 14 days
OR
IV Imipenem
1g q8h
X 14 days
PLUS OPTIONAL
IV Trimethoprim/ Sulfamethoxazole
5mg/kg (TMP component) q12h
(in deep seated focal infections,
neurological, joints, bones, prostate)
X 14 days
Phase 2: Eradication
Any 2 in order of
preference:
PO Trimethoprim/
Sulfamethoxazole
320:1600mg
q12 h
PO Doxycycline
100mg q12h
PO
Amoxicillin/
Clavulanate
500/125 mg q8h
X 12-20 weeks
Bibliography:
1. Pharmaceuticals 2010: 3; 1296-1303
2. Med J Malaysia 2009: 64(4); 266-274
73
Notes
Carbapenem is preferred
in severe sepsis as the
benefits are: higher rate
of bacterial killing in vitro
due to enhanced cell
wall penetration, better
post-antibiotic effect and
decreased endotoxin
release.
TUBERCULOSIS
Tuberculosis (TB) is caused by Mycobacterium tuberculosis which
may affect pulmonary and/or extra-pulmonary sites. Patients at risk
of TB infections include:
the immunocompromised (e.g. HIV, substance abuse, diabetes
mellitus, malnourished, steroids, renal failure)
close contact with a person with infectious TB disease
persons who have immigrated from areas with high rates of TB
groups with high rates of TB transmission e.g. the homeless,
HIV patients and injecting drug users
persons who work or reside with people who are at high risk of
TB in facilities or institution e.g. hospitals, prisons.
The aim of treatment is to cure and render patients non-infectious,
prevent relapse and the emergence of resistant tubercle bacilli.
The current drug regime involves the five main drugs:
isoniazid, rifampicin, pyrazinamide, streptomycin and ethambutol.
The treatment regime for pulmonary TB involves an intensive phase
of 8 weeks and a continuation phase of 4 months.
74
Treatment phase
Preferred agent
Notes
Intensive
EHRZ or SHRZ q24h SHRZ is the combination of choice for
TB meningitis.
X 8 weeks
Renal profile, full blood count and liver
function test should be monitored at least
or 56 daily doses
twice a week while the patient is in ICU.
PO pyridoxine 10mg q24h should be given
to prevent isoniazid induced neuropathy.
HR biweekly
Continuation
Duration may be extended in the
X 4 months
immunocompromised and in those with
extrapulmonary TB.
or 32 doses
It is necessary to consult the TB specialist
in the following situations:1. Relapse, treatment failure or treatment
after interruption
2. Liver failure
3. Inability to tolerate oral medications
Drug
Dose
Max. dose
Adverse reaction
Tab Isoniazid (H)
5-8mg/kg/day
300mg
hepatitis, peripheral neuritis,

hypersensitivity
Tab Rifampicin (R)
10mg/kg/day
600mg
hepatitis, vomiting,
thrombocytopenia
Tab Ethambutol (E)
15-25mg/kg/day 1.2 g
optic neuritis, GI disturbances
Tab Pyrazinamide (Z) 20-40mg/kg/day 2 g
hepatotoxicity, hyperuricemia
IM Streptomycin (S)
15-20mg/kg/day 1 g
nephrotoxicity, ototoxcity,
skin rash. For patients
> 65 years old, dose should
not exceed 750 mg
Cap AKuriT-4:
Body weight:
Rifampicin 150mg
30-37kg: 2 caps
Isoniazid 75mg
38-54kg: 3 caps
Ethambutol 275mg 55-70kg: 4 caps

Pyrazinamide 400mg > 70kg: 5 caps
75
Steroids should be given in TB meningitis in non HIV patients,

however the evidence is not conclusive in patients with HIV.
Steroids are also indicated in TB pericarditis, TB adrenalitis and TB
lymphadenitis with compressive symptoms.
Conditions
Steroid Dose
TB meningitis
IV Dexamethasone 0.4mg/kg/day taper over

6-8 weeks
TB pericarditis
PO Prednisolone 60mg q24h, taper over

6-12 weeks
TB adrenalitis
IV Hydrocortisone 100mg q8h and taper
TB lymphadenitis with
PO Prednisolone 30-60mg q24h X 4-6 weeks
compressive symptoms
Bibliography:
1.
2.

3.
WHO. Treatment of tuberculosis: Guidelines. 4th edition 2009

Guidelines on management of TB: KKM.
Academy of Medicine Malaysia
Clin Infect Dis 2000; 31: 633-9
76
LEPTOSPIROSIS
Leptospirosis is a zoonotic infection caused by pathogenic
spirochetes of the genus Leptospira. The clinical manifestations of
leptospirosis are variable and non-specific, ranging from mild febrile
illness to the icteric-haemorrhagic form with severe kidney and liver
involvement and pulmonary haemorrhage.
Presumptive diagnosis is made with a positive rapid screening
test such as IgM ELISA. Diagnosis is confirmed with a fourfold or
greater rise in antibody titres or seroconversion in the microscopic
agglutination test (MAT) on paired samples obtained 2 weeks apart.
Blood for PCR testing can be done.
Common
Organisms
Leptospira spp
Antimicrobials
Preferred
Alternative
Notes
IV Benzylpenicillin IV Ceftriaxone
2 million units
2g q24h
q6h
In less severe infection:

PO Doxycyline 100mg
q12h x 7 days
X 7 days
OR
X 7 days
PO Azithromycin 500mg
q24h x 7 days
Bibliography:
1. The Sanford Guide to Antimicrobial Therapy 2011
2. Clin Infect Dis 2003; 36: 1507-14
77
SEVERE MALARIA
Patients diagnosed or suspected with severe malaria should be
started on parenteral antimalarial therapy immediately. Severe
malaria with complications such as haemolysis, acute renal failure
and lactic acidosis is usually due to Plasmodium falciparum. Patients
with severe malaria are at risk of concurrent bacterial infection.
Common
Organisms
Plasmodium
falciparum
Antimicrobials
Preferred
Alternative
IV Artesunate
2.4mg/kg at
0 hrs and 12 hrs,
then q24h
PLUS
PO Doxycyline
200mg q24h
X 7 days
IV Quinine
Dihydrochloride
20mg/kg in
250mls D/5%
over 4 hours
and then 10mg /
kg q8h
PLUS
PO Doxycyline
200mg q24h
X 7 days
Notes
Treat severe malaria due
to other plasmodium
species with IV
artesunate.
Blood sugars and QT
intervals need to be
monitored regularly
while on quinine.
Switch to oral Artemisinin
Combination Therapy
(ACT) if patient is able to
tolerate orally.
Oral Riamet (lumefantrine
and artemether) is
available in Malaysia
Bibliography:
1. WHO. Guidelines for the treatment of malaria: 2nd edition 2010
78
CANDIDIASIS IN THE NON-NEUTROPENIC

ICU PATIENT
Candidiasis is increasingly common in ICU patients and may result
in high mortality especially if treatment is delayed or inappropriate.
Although Candida albicans is the most common organism, there is
a growing proportion of non-albican species, which is associated
with fluconazole resistance. Other invasive fungal infections e.g.
aspergillosis is rare except in neutropenic or transplant recipients.
Colonisation with candida in the oropharynx, respiratory and
urinary tract is common in ICU patients. This is not an indication
for treatment. Broad-spectrum antibiotic therapy increases the
incidence of colonisation. Overall the risk of invasive infection
increases with the number of colonised sites.
Poor outcomes are in part associated with difficulty in establishing
microbiological diagnosis at an early stage of infection. Blood
culture results take time and are positive in only 50% of invasive
candidiasis. Nonculture-based diagnostic tests such as serological
(mannan, antimannan, betaglucan) and molecular (candida-specific
PCR) techniques may be useful adjuncts to early diagnosis but are
not routinely available here. Scoring systems and predictive rules
that combine risk factors and degree of colonisation lack sensitivity
although have high negative predictive value.
Assessing risks has become the cornerstone of empiric treatment
of fungal infections in the ICU setting. Patients at risk for invasive
fungal infection are:
Immunocompromised/immunosuppressive therapy
Neutropenia (neutrophil count < 1000/mm3)
79
Solid organ or bone marrow transplantation

Candida colonisation at multiple non-sterile sites
Use of broad-spectrum antibiotics
Presence of central venous catheters
Burns (> 50% BSA)
Major trauma
Major abdominal surgery
Parenteral nutrition
Severe acute pancreatitis
High severity illness score
Acute renal failure or haemodialysis
Diabetes mellitus
Prolonged ICU stay (> 7 days)
Empirical therapy should be started in a clinically deteriorating
patient with unexplained sepsis who has risk factors for systemic
candidiasis or has multiple site colonisation. The agent of choice
depends on the causative pathogen, severity of illness and site of
infection.
80
Common
Antimicrobials
Notes
Organisms
Preferred
Alternative
Empirical therapy in haemodynamically unstable non-neutropenic patient
Candida spp
IV Fluconazole
IV Caspofungin Amphotericin B is
preferred in patients with
800mg (loading 70mg (loading
recent azole exposure
dose) followed
dose) followed
(last 3 months) and at
by 400mg q24h by 50mg q24h
high risk of developing
C. glabrata and
OR
OR
C. krusei (e.g. severe
IV Amphotericin B IV Anidulafungin acute pancreatitis, burns).
0.6-1mg/kg/day loading dose
200mg followed Consider echinocandins
by 100mg q24h (or lipid-based
amphotericin B) in
patients with recent
dysfunction.
Empirical therapy in haemodynamically stable non-neutropenic patient
Candida spp
IV Fluconazole
800mg (loading
dose) followed
by 400mg q24h
IV Amphotericin B Consider amphotericin B

0.6-1mg/kg/day if patient had recent
azole exposure in the
last 3 months.
81
Common
Antimicrobials
Organisms
Preferred
Alternative
Pathogen specific
C. albicans
IV Amphotericin B
IV Fluconazole
800mg (loading 0.6-1mg/kg/day
dose) followed
by 400mg q24h
C. glabrata
C. krusei
IV Amphotericin B IV Caspofungin
0.6-1mg/kg/day loading dose
70mg followed
by 50mg q24h
Notes
without metastatic
complication is
14 days after last positive
blood culture and
resolution of signs and
symptoms of infection.
OR
Repeat cultures every

72 hours till negative.
IV Anidulafungin
loading dose
200mg followed
by 100mg q24h
Ophthalmic examination
is recommended
for all patients with
candidaemia.
IV Amphotericin B IV Voriconazole
0.6-1mg/kg/day 6mg/kg q12h for
1 day followed
by 4mg/kg q12h
OR
IV Caspofungin
loading dose
70mg followed
by 50mg q24h
OR
IV Anidulafungin
loading dose
200mg followed
by 100mg q24h
C. parapsilosis
C. tropicalis
C. lusitaniae
IV Fluconazole
IV Amphotericin B C. lusitaniae may be
800mg loading
0.6-1mg/kg/day resistant to
amphotericin B.
dose followed by
400mg q24h
82
Algorithm for empirical antifungal therapy in the

non-neutropenic ICU patient
Review of microbiological
specimens to assess extent of
non sterile sites colonised
Identify patients
at risk
(refer to list above)
Clinical Situation
- Deteriorating clinical condition
- Unexplained fever/ sepsis
- No response to broad-spectrum antibiotics
Start empirical antifungal treatment.

Evaluate if patient is stable or unstable
Haemodynamically
stable
Haemodynamically
unstable
Refer to above table for choice of antifungal
Bibliography:
1. Ann Intensive Care 2011; 1: 37
2. Clin Infect Dis 2009; 48: 503-535
83
APPENDIX A
DOSAGE ADJUSTMENT FOR RENAL IMPAIRMENT
Below is the formula used to calculate the creatinine clearance:
Males: Cr Cl (mls/min) = (140 Age) x IBW
Females: Cr Cl (mls/min) = (140 Age) x IBW

0.8 x Sr. creat (mol/L)
Sr. creat (mol/L)
Drug
Normal dose
Cr clearance
Cr clearance
10-50ml/min
< 10ml/min
10mg/kg q12 - 24h
5mg/kg q24h
Renal replacement therapy

HD: 5mg/kg q24h
Acyclovir
10mg/kg q8h
Amikacin
Refer to Appendix B
Amphotericin B
0.6 - 1 mg/kg q24h
0.6 - 1 mg/kg q24h
0.6 - 1 mg/kg q48h
0.6 - 1 mg/kg q24h
Ampicillin/sulbactam
3g q6h
3g q8-12h
3g q24h
HD: 3g q24h
Amoxicillin/clavulanate
1.2g q8h
1.2g q12h
1.2g q24h
1.2g q24h
Benzylpenicillin
2 - 4 MU q6h
1.5 - 3 MU q6h
1 - 2 MU q6h
HD: 1 - 2 MU q6h
Cefepime
2g q8-12h
1-2g q12-24h
0.5-1g q24h
Cefotaxime
2g q8h
2g q12-24h
2g q24h
Ceftazidime
2g q8h
2g q12-24h
2g q24h
Ceftriaxone
2g q24h
Unchanged
Unchanged
Unchanged
Cefuroxime
1.5g q8h
1.5g q8-12h
1.5g q24h
HD: 1.5g q24h
CRRT: 10mg/kg q24h
84
CRRT: 3g q12h
CRRT: 2 MU q6h
HD: 1g q24h+extra 1g AD
CRRT: 2g q24h
HD: 2g q24h+extra 1g AD
CRRT: 2g q24h
HD: 2g q24h+extra 1gAD
CRRT: 2g q12h
CRRT: 1.5g q8 - 12h
Ciprofloxacina
400mg q8-12h
200mg q12h
200mg q12h
200mg q12h
Cloxacillin
2g q4-6h
Unchanged
Unchanged
Unchanged
Doripenem
500mg q8h
250mg q8 - 12h
No data
No data
Ethambutol
15-25mg/kg/q24h
15-25mg/kg/q24-36h
15-25mg/kg/q48h
HD: 15-25mg/kg after HD (3x/ week)
Fluconazole
400mg q24h
200mg q24h
200mg q24h
Gentamicin
Refer to Appendix C
Imipenem
500mg q6h
500mg q8-12h
250mg q12h
Meropenem
1g q8h
0.5-1g q12h
0.5g q24h
Metronidazole
500mg q8h
500mg q8h
500mg q12h
Piperacillin/tazobactam
4.5g q6h
4.5g q8h - 2.25g q6h
2.25g q8h
2.25g q6h
Streptomycin
15-20mg/kg/q24h
15-20mg/kg/q24-72h
15-20mg/kg/q72-96h
HD: 7.5-10mg/kg after HD
Trimethoprim/
5mg/kg q8h
5mg/kg q12h
5mg/kg q24h
CRRT: 15 - 25mg/kg/q24-36h
HD: 200mg after HD
CRRT: 400mg q24h
HD: 250mg q12h
CRRT: 500mg q8h
HD: 0.5g q24h
CRRT: 1g q12h
85
HD: 500mg q12h

CRRT: 500mg q8h
CRRT: 15-20mg/kg/q24-72h
Sulfamethoxazole
Vancomycin
HD: 5mg/kg q24h

CRRT: 5mg/kg q12h
Refer to Appendix B
CRRT: continuous renal replacement therapy. Drug dosage adjustment during CRRT has many variables including
mode of CRRT. The values here are simplified for continuous veno-venous haemofiltration (CVVH).
HD: haemodialysis AD: after dialysis
a
Ciprofloxacin 400mg q8h to be used for P. aeruginosa infections
Polymyxin E
Body weight (kg) Estimated creatinine clearance (ml/min)

>50
20 - 50
<20

Continuous renal
replacement therapy
Intermittent haemodialysis
> 60
3 MU q8h
3 MU q12h
3 MU q24h
2 MU q12h
3 MU q24h + 2 MU AD
50 - 60
2 MU q8h
2 MU q12h
2 MU q24h
1.5 MU q12h
2 MU q24h + 1.5 MU AD
40 - 49
1.5 MU q8h
1.5 MU q12h
1.5 MU q24h
1 MU q12h
1.5 MU q24h + 1 MU AD
30 - 39
1 MU q8h
1 MU q12h
1 MU q24h
0.5 MU q12h
1 MU q24h + 0.5 MU AD
MU: million units
86
Sulbactam (to give in divided doses)

In Sulperazone, the ratio of cefoperazone to sulbactam is 1:1
In Unasyn, the ratio of ampicillin to sulbactam is 1:0.5

Estimated creatinine clearance (ml/min)
>50
20-50
<20
Continuous renal replacement therapy
Intermittent haemodialysis
8g/day
6g/day
4g/day
4g/day
4g/day
APPENDIX B
THERAPEUTIC DRUG DOSING AND MONITORING
Aminoglycoside (traditional dosing/ multiple daily dosing)
Initial dose and
Dose and interval
dosing interval
CrCL (ml/min) Gentamicin
Amikacin
> 60
1.5 - 2 mg/kg q8h
5 - 7.5 mg/kg q8h
40 - 60
1.5 - 2 mg/kg q12h
5 - 7.5 mg/kg q12h
20 - 40
1.5 - 2 mg/kg q24h
5 - 7.5 mg/kg q24h
< 20
1.5 - 2 mg/kg q48 - 72h 5 - 7.5 mg/kg q48 - 72h
In endocarditis, the dose of gentamicin is 1 mg/kg q8h when

given with penicillin or cloxacillin.
(Use actual BW if malnourished and adjusted BW if > 20% ideal
BW. In others, use ideal BW)
Initial assay:
Trough and peak with 3rd dose
Repeat assay: Every 3 - 7 days or more frequent if changing renal profile

Sampling time: Trough: hour before next dose

Peak: 1 hour at end of infusion
Target serum
concentration
(g/ml):
Peak level
Conditions
Gentamicin
Amikacin
Pneumonia
8 - 10
28 - 35
Sepsis
7 - 10
25 - 35
Intra-abdominal
6 - 8
22 - 24
Endocarditis/UTI
Dose
adjustment:
15 - 20
Trough level
Gentamicin
Amikacin
All conditions as above
< 2
<8
Consult pharmacist
87
Aminoglycoside (high dose extended interval dosing/ single daily dosing)

Exclusion
criteria:
- Age < 13
- Burns > 20%
- Ascites
- Synergistic dosing for Gram-positive infections
(e.g. endocarditis)
- History of ototoxicity
- Pregnancy
Initial dose:
Gentamicin: 7 mg/kg
Amikacin: 15 mg/kg
(Use actual BW if malnourished and adjusted BW if > 20%
ideal BW. In others, use ideal BW)
Initial assay:
Single assay 6 - 14 hours after infusion of first dose.

Peak and trough serum levels are not routinely done.
Repeat assay:
Once weekly or more frequent in patients requiring

q36h or q48h dosing, changing renal function or on other
nephrotoxic drugs.
Dosing interval
following 1st
dose:
For gentamicin, plot concentration on the Hartford

nomogram below to determine the dosing interval.
If the level:
- falls on a borderline, use the longer interval.
- falls above the q48h dosing interval, reevaluate the need
for continued therapy
- is < 2 g/ml, and continue current regimen if the patient
is clinically stable or improving. If not, re-evaluate clinical
situation (e.g. repeat level, change to traditional dosing,
change antibiotics)
For amikacin, divide the measured concentration by 2
before plotting on the nomogram to determine the dosing
interval.
88
Concentration (mg/L)
Hartford Hospital High Dose Extended Interval

Aminoglycoside Nomogram
14
13
12
11
10
9
8
7
6
5
4
3
2
Q48h
Q36h
Q24h
7
8
9
10
11
12
13
14
Time between start of infusion and sample draw (h)
Applicable only to gentamicin dosing of 7mg/kg (or amikacin 15mg/kg)

Unit: mg/L = ug/ml
Calculation of ideal and adjusted body weight in kg

Ideal weight (male): 50 + [0.9 x (height in cm - 150)]
Ideal weight (female): 45 + [0.9 X (height in cm - 150)]
Adjusted weight:
0.4 (Actual BW Ideal BW) + Ideal BW
Vancomycin
Loading dose: 25 - 30mg/kg (not to exceed 2g per dose)
(use actual BW) Consider in seriously ill patients i.e. severe sepsis,
meningitis, pneumonia, endocarditis.
Maintenanace 15 - 20mg/kg/dose
dose:
(use actual BW)
Dosing interval:
(based on
creatinine
clearance)
CrCl (mL/min)
> 50
30 - 50
< 30
Dosing Interval
q12h
q24h
single dose, then check random level in
24 - 48 hours, redose when level is below
therapeutic level
Haemodialysis 500 - 750mg after each haemodialysis
89
Initial assay:
Trough level before 4th dose if renal function remains

stable.
Repeat assay:
Once-weekly monitoring in haemodynamically stable

patients. More frequent or daily monitoring in patients
who are haemodynamically unstable and changing renal
function.
Sampling time:
Trough: 30 mins prior to next dose.

Peak: not recommended due to extreme inter-patient
variability and lack of correlation with either efficacy or
toxicity.
Target serum
concentrations
(trough):
10 - 15 g/ml in conditions other than listed below.

15 - 20 g/ml in bacteremia, endocarditis, osteomyelitis,
meningitis, pneumonia.
For isolates with MIC of 1 - 2 g/ml, the minimum trough
concentration should be at least 15 - 20 g/ml.
Dose
adjustment
(based on
trough
concentration)
If < 10 g/ml (or < 15 g/ml in target levels of 15 - 20 g/

ml), decrease the dosing interval by one step in steps of
q12h, q24h, q36h, and q48h. If receiving the dose q12h,
increase the dose by 250 - 500mg or consider q8h.
If > 15 g/ml (or > 20 g/ml in target levels of 15 - 20 g/
ml), increase the dosing interval by one step.
Bibliography:
1.

2.
3.

Therapeutic Guidelines: Antibiotic, Therapeutic Guidelines.

Edition 14, Melbourne, Victoria 2010
Am J Health Syst Pharm: 2009; 66:82-98
Bedside ICU Handbook: Tan Tock Seng Hospital, Singapore.
2nd Edition 2007
90
APPENDIX C
EXTENDED INFUSIONS OF -LACTAMS
The use of extended infusions of -lactam antibiotics has been
shown to improve the time the free drug remains above MIC that
predicts the killing characteristic of the antibiotic. The ambient
temperature for the antibiotic infusions should be 25C or less
to ensure stability. A loading dose must be given prior to regular
dosing of the antimicrobial.
Do not infuse the antibiotics with omeprazole, pantoprazole or
magnesium sulphate infusions
Antibiotic
Loading dose Duration of

over 30mins infusion
Dilution
Meropenem
1-2g
Extended
over 4 hours
500mg or 1g: dilute in 50mls

normal saline.
2g: dilute in 100mls normal saline
Imipenem
500mg
Extended
over 4 hours
250mg, 500mg or 1g: dilute in

50mls normal saline.
Doripenem
500mg
Extended
over 4 hours
500mg: dilute in 50mls normal

saline
Piperacillin/
Tazobactam
4.5g
Extended
over 4 hours
2.25g or 4.5g: dilute in 50mls

normal saline.
Cefepime
1-2g
Continuous
infusion
over interval
prescribed
1 or 2 g: dilute in 50mls
normal saline.
For q24h, infuse at rate of 2mls/h
For q8h, infuse at rate of 6.2mls/h
Ceftriaxone
2g
Continuous
infusion
over interval
prescribed
1-2g: dilute in 50mls normal saline

For q12h dose, infuse at rate
of 4mls/h
91
Antibiotic
Loading dose Duration of

over 30mins infusion
Dilution
Ceftazidime
2g
1-2g: dilute in 50mls normal saline

For q8h, infuse at rate of 6.2mls/h
Continuous
infusion
over interval
prescribed
Reconstitution directions
1. Each vial should be reconstituted with water or 0.9% sodium
chloride (as per the usual practice) and then dilute the
reconstituted solution with 0.9% sodium chloride to a volume of
50mls or 100mls.
2. Infuse over 4 hours immediately to reduce the risk of microbial
contamination.
3. Flush IV access before and after infusion of the antibiotic with
0.9% sodium chloride.
4. Preferably to infuse the antibiotic using a dedicated iv access.
5. The ambient temperature for the infusions of antibiotics should
be 25oC.
92

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Guide to Antimicrobial Therapy in the Adult ICU 2012

Dose schedules are being continually revised and new

By Malaysian Society of Intensive Care

This guide can be downloaded from the Malaysian Society

Chairperson and Editor, Writing Committee for

EXTERNAL EXPERT REVIEWERS

Dr Norazim bin Mohd Yunos

Senior Lecturer and

Prof Dr Rohaizak Muhammad

Datuk Dr Christopher K.C Lee

Dr Liew Ngoh Chin

Dr Tan Jit Ern Jonathan

Prof Dr Victor Lim

Appendix A Dose Adjustment for Renal Impairment

antibiotic therapy as early as possible once severe sepsis is

Interval between diagnosis

Severe sepsis or septic shock

Interval between diagnosis

When initiating appropriate empirical antimicrobials in patients with

Presence of renal or hepatic dysfunction

Concentration- Cmax /MIC

MIC: Minimum Inhibitory Concentration

Achievable antimicrobial concentrations in tissue

Empirical therapy should be re-evaluated after 48-72 hours or

Pathway in choosing the empirical antimicrobial

Decide if community or healthcare-acquired infection

Identify site of infection

Know local susceptibility patterns

Consider patient factors

Know the antimicrobial profiles

diffuse lung infiltrates in the immunocompromised host or

> 10,000 /mm3 strongly suggests infection while counts

For Mycobacterium tuberculosis, the use of broth medium

Microscopy and stain (Indian ink and Ziehl Neelsen)

Culture and sensitivity (aerobic and anaerobic)

Latex agglutination test:

Viral: PCR and /or serology

Mycobacterium PCR and culture

Fungal antigen and culture

The results of the bacterial antigen testing should be interpreted

Non-infective causes may have similar biochemical findings

Significant asymptomatic bacteriuria if 2 consecutive MSU grows 105 cfu/ml of

105 in complicated UTI in women

104 in complicated UTI in men

104 in acute uncomplicated

103 in pregnant women and acute

Significant asymptomatic bacteriuria:

105 in uncomplicated UTI

Peritoneal fluid specimen

Culture negative 250

For definition of peritonitis, refer to the chapter on peritonitis.

Secondary bacterial peritonitis should be considered in patients

Salmonella, Campylobacter, Shigella, Vibrio cholera, Yersinia,

Protozoal Cryptosporidium, Giardia lambia, Cyclospora,

Novovirus, rotavirus, enteric adenovirus, astrovirus

Stool culture is not routine in all patients presenting with diarrhea

Clostridium difficile toxin detection falls into two categories

European Handbook of neurological management

Suspect MSSA pneumonia

Risks factors: diabetes