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AppendixAPP1CLINICAL PHARMACOKINETIC GUIDE (AMINOGLYCOSIDE & VANCOMYCIN)

Appendices

CLINICAL PHARMACOKINETIC GUIDE (AMINOGLYCOSIDE & VANCOMYCIN)

CLINICAL PHARMACOKINETIC GUIDE (AMINOGLYCOSIDE & VANCOMYCIN) 1. AMINOGLYCOSIDE DOSING GUIDE 2. VANCOMYCIN DOSING GUIDE 1. AMINOGLYCOSIDE DOSING GUIDE 1.1 Extended-interval Dosing / Single Daily Dosing (EID / SDD) EID/SDD is an approach of giving high-dose aminoglycoside over 30 minutes at an extended interval depending on the renal function (E.g.: 24 hourly, 36 hourly or more). EID is an alternative administration method for SDD when there is more time required to achieve adequate aminoglycoside clearance. The theoretical benefits of EID / SDD ^{1, 2} : • Aminoglycosides display concentration-dependent bactericidal action - that is, higher dose and peak serum concentrations result in more rapid bacterial killing. • Optimise concentration-dependent bacterial killing by achieving a high peak (>10x MIC). • Minimize nephrotoxicity by administering larger but less frequent doses and potentially decreasing renal cortical aminoglycoside concentrations. • Utilize the post-antibiotic effect (PAE) (2-8 hours), defined as a recovery period before organisms can resume growth after drug removal. • Minimize the development of adaptive resistance by allowing a recovery period during the dosing interval. SDD is reasonable in most patients, except for ^2,3 : • Pregnancy • Ascites • Burns (>20%) • Endocarditis • Creatinine clearance <30ml/min • Dialysis • Neutropenic patients • Patients with gram positive infections (such as Staphylococcus, Enterococcus) requiring synergistic effect • Heamodynamically unstable • History of hearing loss/vestibular dysfunction • Mycobacterium infection 1.1.1 Empiric Aminoglycoside Dosing Recommendations for ADULTS 2-5

Empiric Aminoglycoside Dosing Recommendations for ADULTS.pdf

1.1.2 Empiric Aminoglycoside Dosing Recommendations for CHILDREN 2,6

Empiric Aminoglycoside Dosing Recommendations for CHILDREN.pdf

1.1.3 Therapeutic Level Monitoring4-6 The target reference range may be individualized based on institutional MIC value. For children, both peak and trough levels monitoring should be considered in patients demonstrating acute renal function changes or suspicion of treatment failure. Subsequent monitoring should be considered at least once weekly. Please consult pharmacist for dosage adjustment.

3. Therapeutic Level Monitoring AMG.pdf

1.2 Conventional / Traditional Dosing Conventional/traditional dosing includes low doses with frequent administration of aminoglycosides using pharmacokinetic parameters to determine dose and frequency. However, in practice, dose below 7mg/kg for gentamicin at 24 hours interval is frequently used for patients with normal renal function. The use of conventional dosing is recommended for the indications or populations in which SDD aminoglycosides does not cover (for example staphylococci or enterococci endocarditis). 1.2.1 Empiric Aminoglycoside Dosing Recommendations

4. Empiric Aminoglycoside Dosing Recommendations CONVENTIONAL.pdf

1.1.3 Therapeutic Level Monitoring The target reference range may be individualized based on institutional MIC value. Both peak and trough levels monitoring should be considered in patients demonstrating acute renal function changes or suspicion of treatment failure. Subsequent monitoring should be considered at least once weekly.

5. Therapeutic Level Monitoring (Conventional) AMG.docx.pdf

2. VANCOMYCIN DOSING GUIDE Vancomycin is a Type III pharmacodynamic properties antibiotic which has mixed properties of time-dependent killing and moderate persistent effects (persistent suppression of bacterial growth following antibiotic exposure). Thus, the optimal dosing of vancomycin is important to ensure adequate antibiotic exposure. The 24h-AUC/MIC ratio is the parameter that correlates with vancomycin efficacy¹⁴. The AUC can be estimate using Bayesian software programs (gold standard) or alternative approach involves the use of 2 concentrations (peak and trough) and simple analytic PK equations to estimate AUC values¹⁵. TDM is indicated for all patients expected to receive vancomycin for longer than 48 hours. Some patient groups may require frequent monitoring, such as those in whom changes in vancomycin pharmacokinetics are anticipated over time. At least biweekly monitoring in clinically stable patients¹⁶. 2.1 Sample Parameters and Recommendation

6. Vancomycin Sample Parameters.pdf

2.2 Vancomycin Dosing Strategy for Intermittent Infusion

7a. Vanco Dosing Strategy for Intermittent Infusion V2 Sept 2024.pdf

2.3 Vancomycin Dosing Strategy for Continuous Infusion

8. Vancomycin Dosing Strategy for Continuous Inf.pdf

2.4 Vancomycin Dosing Strategy for Intraperitoneal22 CAPD or APD Intermittent dose (once/day): 15 - 30mg/kg every 5 - 7 days for CAPD 15 mg/kg every 4 days for APD Continuous dose (per/L exchange): Loading: 20–25 mg/kg Maintenance: 25mg/L 2.5 Vancomycin Dosing Strategy for Children15 Neonates: 10 – 20mg/kg every 8 – 48 hours (depending on postmenstrual age, weight, SrCr) 3 months to < 12 years: 60 – 80 mg/kg/day in divided doses (q6h for normal renal function) ≥ 12 years: 60 – 70 mg/kg/day in divided doses (q6-8h for normal renal function) References: 1. Drew RH, Hooper DC, Bloom A. Dosing and administration of parenteral aminoglycosides. Uptodate 2 Nov 2023. 2. Aminoglycosides: Recommendations for use, dosing and monitoring. Clinical Guideline Version 3. South Australian expert Advisory Group on Antimicrobial Resistance (SAAGAR), Infection Control Service. 11^th Dec 2020. ISBN: 978-1-76083-351-0. 3. Plajer S, Chin P, Vella-Brincat J, Buffery P, Begg E. Gentamicin and renal function: Lessons from 15 years’ experience of a pharmacokinetic service for extended interval dosing of gentamicin. Ther Drug Monitoring 2015; 37: 98-103. 4. Pérez-Blanco, JS; Sáez, Fernández, EM; Calvo, MV; Lanao,JM; Martín-Suárez, A. Evaluation of Current Amikacin Dosing Recommendations and Development of an Interactive Nomogram: The Role of Albumin. Pharmaceutics 2021,13, 264. 5. Bland CM, Pai, MP, Lodise TP. Reappraisal of Contemporary Pharmacokinetic and Pharmacodynamic Principles for Informing Aminoglycoside Dosing. Pharmacotherapy 2018;38(12):1229–1238. 6. Pacifici GM, Marchini G. Clinical Pharmacology of Amikacin in Infants and Children. Clin Med Invest, 2020, 5: 1-14. 7. Zhuang L, He Y, Xia H et al. Gentamicin dosing strategy in patients with end-stage renal disease receiving haemodialysis: evaluation using a semi-mechanistic pharmacokinetic/pharmacodynamic model. J Antimicrob Chemother 2016 Apr;71(4):1012-21. 8. Eschenauer, GA, Lam, SW, Mueller, BA. Dose Timing of Aminoglycosides in Hemodialysis Patients: A Pharmacology View. Seminars in Dialysis—Vol 29, No 3 (May–June) 201, 204–213. 9. He S, Cheng Z, Xie F. Population Pharmacokinetics and Dosing Optimization of Gentamicin in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy. Drug Design, Development and Therapy 2022:16 13–22. 10. Roger C, Wallis SC, Muller L, et al. Influence of Renal Replacement Modalities on Amikacin Population Pharmacokinetics in Critically Ill Patients on Continuous Renal Replacement Therapy. Antimicrob Agents Chemother. 2016. 60:4901–4909. 11. Kojya S, Shiohira H, Sunagawa Yet al. Therapeutic Drug Monitoring in Peritoneal Dialysis: A Case of Nontuberculous Mycobacterium Catheter-Related Infection Treated with Amikacin. Clin Case Rep. 2020;8:995–998. 12. Smeltzer BD, Shcwartzman MS, Bertino JSJ. AmikacinPharmacokineticsduring Continuous Ambulatory Peritoneal Dialysis. Antimicrob Agents Chemother. 1988. 32: 236-240. 13. Farkas A, Oikonomou K, Ghanbar M, et al. Population Pharmacokinetics of Intraperitoneal Gentamicin and the Impact of Varying Dwell Times on Pharmacodynamic Target Attainment in Patients with Acute Peritonitis Undergoing Peritoneal Dialysis. Antimicrob Agents Chemother. 2022 Feb 15;66(2):e0167921. 14. Lodise TP, Rosenkranz SL, Finnemeyer M et al. The emperor’s new clothes: prospective observational evaluation of the association between initial vancomycin exposure and failure rates among adult hospitalized patients with MRSA bloodstream infections (PROVIDE) [published online ahead of print June 3, 2019]. Clin Infect Dis. doi.10.1093/cid/ciz460. 15. Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: a revised consensus guideline and review by the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2020;77(11):835-864. https://doi.org/10.1093/ajhp/zxaa036 16. Reuter et al. Optimal Practice for Vancomycin Therapeutic Drug Monitoring: Position Statement From the Anti-infectives Committee of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology. Ther Drug Monit Volume 44, Number 1, February 2022. 17. van Hal SJ, Paterson DL, Lodise TP. Systematic review and metaanalysis of vancomycin-induced nephrotoxicity associated with dosing schedules that maintain troughs between 15 and 20 milligrams per liter. Antimicrob Agents Chemother. 2013;57:734–744. 18. SHC Vancomycin Dosing Guide. Stanford Health Care, Pharmacy Department Policies and Procedures. Last Approval: 03/2023 19. Ables M, Welch RW, Walley B. Development and Assessment of Vancomycin Dosing Utilizing AUC/MIC Protocol in Patients With End-Stage Renal Disease (ESRD) on Intermittent Hemodialysis (IHD). J Pharm Pract. 2023 Sep 16:8971900231198927. doi: 10.1177/08971900231198927. Epub ahead of print. PMID: 37715731 20. Susan J. Lewis and Bruce A. Mueller. Evaluation and Development of Vancomycin Dosing Schemes to Meet New AUC/MIC Targets in Intermittent Hemodialysis Using Monte Carlo Simulation Techniques. The Journal of Clinical Pharmacology / Vol 61 No 2 2021. 21. WACHS Specialised Medication – Intravenous Vancomycin in Adults Guideline. Date of Last Review: March 2020 22. Li PK-T, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Peritoneal Dialysis International. 2022;42(2):110-153. doi:10.1177/08968608221080586 23. Cardiff Critical Care Standard Operating Procedures. Vancomycin version 1.0. Issue date 06/07/2021

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.1 Empirical Treatment (native valve)

Preferred Regimen

Ampicillin 12g/day IV (2g q4h)

PLUS

Gentamicin 3mg/kg/day IV q24h, **MAY ADD Cloxacillin 12g/day IV (2g q4h)

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

PLUS

Gentamicin 3mg/kg IV q24h

Remarks & Clinical Comments:

To adjust antibiotics based on culture and sensitivity. If culture negative, to refer Infectious Disease (ID) physician. *Refer to Appendix 1 for vancomycin loading dose. **Cloxacillin: For patients with suspected Staphylococcus aureus infections (such as IVDU or patients with prosthesis) and acute presentation. Refer to Appendix 3 for antibiotic allergy.

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PaediatricB1CARDIOVASCULAR INFECTIONS

1. ACUTE MYOCARDITIS

1.1 Viral

(commonest cause) Enteroviruses Adenovirus Influenza Coronaviruses HIV etc.

Preferred Regimen

Treatment mainly supportive.

Remarks & Clinical Comments:

Among the viruses implicated are enteroviruses including Coxsackie & EV71. For severe HFMD with cardiopulmonary failure stage, use of IVIG may be considered if not used during CNS involvement or autonomic nervous system dysregulation stage. Immunomodulation may be considered in SARS-CoV-2 infection

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PathwayC1ACUTE BRONCHITIS AND PNEUMONIA

ACUTE BRONCHITIS AND PNEUMONIA

Acute bronchitis and pneumonia 13.02.2026.pdf

Attached Clinical Documents:

Acute bronchitis and pneumonia 13.02.2026.pdf

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.2 Empirical Treatment (prosthetic valve)

1.2.1 Empirical Treatment (prosthetic valve);

Early, < 1 year

Preferred Regimen

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

PLUS

Gentamicin 3mg/kg IV q24h

PLUS

**Cefepime 2g IV q8h

PLUS

***Rifampicin 300-450mg PO/IV q12h

Remarks & Clinical Comments:

*Refer to Appendix 1 for vancomycin loading dose. Cefepime is indicated if local epidemiology suggests for Gram-negative rod infections (such as Pseudomonas). *Rifampicin is only recommended for PVE and it should be started 3-5 days later than vancomycin and gentamicin.

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.2 Empirical Treatment (prosthetic valve)

1.2.2 Empirical Treatment (prosthetic valve);

Late, ≥ 1 year

Preferred Regimen

Ampicillin 12g/day IV (2g q4h)

PLUS

Gentamicin 3mg/kg IV q24h

PLUS

Cloxacillin 12g/day IV (2g q4h)

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

PLUS

Gentamicin 3mg/kg IV q24h

Remarks & Clinical Comments:

*Refer to Appendix 1 for vancomycin loading dose.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.3 Viridans Streptococci & Streptococcus bovis

1.3.1 Native and Prosthetic Valves - Penicillin-Susceptible Viridans

MIC: ≤ 0.12 μg/mL Streptococci & Streptococcus bovis

Preferred Regimen

Benzylpenicillin 3MU IV q4-6h for 4 weeks (native valves) or 6 weeks (prosthetic valves)

Alternative Regimen (Allergy / Resistance)

Ampicillin 2g IV q4h for 4 weeks (native valves) or 6 weeks (prosthetic valves)

Ceftriaxone 2g IV q24h for 4 weeks (native valves) or 6 weeks (prosthetic valves) (for non-severe hypersensitivity to penicillin)

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose, for 4 weeks (native valves) or 6 weeks (prosthetic valves) (for severe hypersensitivity to penicillin e.g., anaphylaxis, DRESS etc.)

Remarks & Clinical Comments:

For penicillin-susceptible Viridans streptococci, monotherapy with benzylpenicilin, ampicillin or ceftriaxone is adequate. 4 weeks for NVE and 6 weeks for PVE. *Refer to Appendix 1 for vancomycin loading dose. Refer to Appendix 3 for antibiotic allergy.

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.3 Viridans Streptococci & Streptococcus bovis

1.3.2 Native and Prosthetic Valves - Penicillin-Relatively Resistant Viridans

MIC: 0.25-2 μg/mL Streptococci & Streptococcus bovis

Preferred Regimen

Benzylpenicillin 4MU IV q4h (total 24 MU/24h) or 24MU IV continuously for 4 weeks (native valves) or 6 weeks (prosthetic valves)

PLUS

*Gentamicin 3mg/kg IV q24h for 2 weeks (native valves and prosthetic valves)

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h for 4 weeks (native valves) or 6 weeks (prosthetic valves) (for non-severe hypersensitivity to penicillin)

PLUS

*Gentamicin 3mg/kg IV q24h for 2 weeks (native valves and prosthetic valves)

Prosthetic Valve:

**Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose, for 6 weeks (for severe hypersensitivity to penicillin)

PLUS

*Gentamicin 3mg/kg IV q24h for 2 weeks

Native Valve:

**Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose, for 4 weeks (for severe hypersensitivity to penicillin)

Remarks & Clinical Comments:

*Gentamicin: aim for pre-dose (trough) serum level of < 1 mcg/ml. **Refer to Appendix 1 for vancomycin loading dose. Refer to Appendix 3 for antibiotic allergy.

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.3 Viridans Streptococci & Streptococcus bovis

1.3.3 Native and Prosthetic Valves - Penicillin-resistant Viridans

MIC ≥4 µg/ml Streptococci & Streptococcus bovis

Treat as resistant enterococcal endocarditis - Refer to Section 1.4: Enterococcus

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.3 Viridans Streptococci & Streptococcus bovis

1.3.4 Nutritionally variant streptococci; NVS

(Abiotrophia defective and Granulicatella species, both formerly known as NVS)

Preferred Regimen

Ampicillin 2g IV q4h for 6 weeks (native and prosthetic valves)

Benzylpenicillin 4MU IV q4h or 24MU/day as a continuous infusion for 6 weeks(native and prosthetic valves)

PLUS

Gentamicin 1mg/kg IV q8h for 2 weeks (prosthetic valves only)

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h for 6 weeks (for non-severe hypersensitivity to penicillin; native and prosthetic valves)

PLUS

Gentamicin 1mg/kg IV q8h for 2 weeks

(prosthetic valves only)

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2 g/dose, for 6 weeks (for severe hypersensitivity to penicillin)

PLUS

Gentamicin 1mg/kg IV q8h for 2 weeks(prosthetic valves only)

Remarks & Clinical Comments:

Ceftriaxone is preferred if clinically not responding to penicillin. *Refer to Appendix 1 for vancomycin loading dose.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.4 Enterococcus

1.4.1 Native and Prosthetic Valves Enterococcal Endocarditis

Sensitive to ampicillin and gentamicin

Preferred Regimen

Ampicillin 2g IV q4h

PLUS

*Gentamicin 1mg/kg IV q8h

Remarks & Clinical Comments:

Duration of therapy: ● Symptoms < 3 months and native valve: (4 weeks ampicillin, 2 weeks gentamicin). ● Symptoms > 3 months or prosthetic valves: 6 weeks therapy (6 weeks ampicillin and 2 weeks gentamicin). *Gentamicin: In order to maximise synergistic effect, administer gentamicin at the same time or temporally close to ampicillin. Consult ID specialist for enterococcal endocarditis with high level resistance to gentamicin.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.4 Enterococcus

1.4.2 Enterococcus - Sensitive to ampicillin and gentamicin

Renal impairment or elderly patients

Preferred Regimen

Ampicillin 2g IV q4h for 6 weeks

PLUS

Ceftriaxone 2g IV q12h for 6 weeks

Remarks & Clinical Comments:

This combination is not active against Enterococcus faecium. Ceftriaxone should not be used alone for enterococcus infection, as they are intrinsically resistant.

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.4 Enterococcus

1.4.3 Enterococcus - High level resistance to gentamicin

Sensitive to ampicillin and vancomycin

Preferred Regimen

Ampicillin 2g IV q4h for 6 weeks

PLUS

Ceftriaxone 2g IV q12h for 6 weeks

Remarks & Clinical Comments:

This combination is not active against Enterococcus faecium. Ceftriaxone should not be used alone for enterococcus infection, as they are intrinsically resistant.

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.4 Enterococcus

1.4.4 Enterococcus - Resistant to ampicillin and susceptible to aminoglycosides and vancomycin

Preferred Regimen

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2 g/dose, for 6 weeks

PLUS

**Gentamicin 1mg/kg IV q8h for 2 weeks

Remarks & Clinical Comments:

*Refer to Appendix 1 for vancomycin loading dose. **Gentamicin: aim for pre-dose (trough) serum level of < 1 mcg/ml.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.5 Staphylococcus aureus

1.5.1 Native valves

Methicillin-Susceptible Staphylococci (MSSA)

Preferred Regimen

Left sided endocarditis or complicated right sided endocarditis:

Cloxacillin 2g IV q4h for 4 to 6 weeks

* Right sided endocarditis (tricuspid valve) in uncomplicated endocarditis:

Cloxacillin 2g IV in q4h for 2 to 4 weeks

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Severe hypersensitivity to penicillin:

**Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose, for 4 to 6 weeks

For non-severe hypersensitivity:

Cefazolin 2g IV q8h for 4 to 6 weeks

Remarks & Clinical Comments:

*2 weeks’ regime is sufficient for right sided IE provided the patient fulfils all the following criteria (uncomplicated IE): ● MSSA ● Absence of associated prosthetic valve or left sided valve infection ● Good response to treatment ● Absence of metastatic sites of infection or empyema ● Absence of cardiac and extracardiac complications ● Vegetation < 10 mm ●Absence of severe immuno-suppression (< 200 CD4 cells/ml) with or without Acquired Immune Deficiency Syndrome (AIDS) **Refer to Appendix 1 for vancomycin loading dose.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.5 Staphylococcus aureus

1.5.2 Prosthetic Valves

Methicillin-Susceptible Staphylococci (MSSA)

Preferred Regimen

Cloxacillin 2g IV in q4h for ≥ 6 weeks

PLUS

Gentamicin 1mg/kg IM/IV q8h for 2 weeks

PLUS

*Rifampicin 300-450mg PO q12h for ≥ 6 weeks

Alternative Regimen (Allergy / Resistance)

Regimen for β-lactam allergic patients, replace cloxacillin with the following:

Severe hypersensitivity to penicillin:

**Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose, for at least 6 weeks

PLUS

Gentamicin 1mg/kg IM/IV q8h for 2 weeks

PLUS

*Rifampicn 300-450mg PO q12h for ≥ 6 weeks

For non-severe hypersensitivity:

Cefazolin 2g IV q8h for at least 6 weeks

PLUS

Gentamicin 1mg/kg IM/IV q8h for 2 weeks

PLUS

*Rifampicn 300-450mg PO q12h for ≥ 6 weeks

Remarks & Clinical Comments:

*Rifampicin: To avoid the development of resistance, it should be started after 3-5 days of effective initial cloxacillin therapy and/or once the bacteraemia has been cleared. **Refer to Appendix 1 for vancomycin loading dose.

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.5 Staphylococcus aureus

1.5.3 Native Valves

Methicillin-Resistant Staphylococci (MRSA)

Preferred Regimen

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose, for 4 to 6 weeks

Alternative Regimen (Allergy / Resistance)

**Daptomycin 10mg/kg IV q24h for 4 to 6 weeks

Remarks & Clinical Comments:

*Refer to Appendix 1 for vancomycin loading dose. **Daptomycin: Daptomycin might be more effective in IE caused by MRSA with higher MIC (above 1 mg/L) to vancomycin based on case-control studies. However, risk for MIC creep against daptomycin may be present in those exposed to vancomycin.

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.5 Staphylococcus aureus

1.5.4 Prosthetic Valves

Methicillin-Resistant Staphylococci (MRSA)

Preferred Regimen

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose, for ≥ 6 weeks

PLUS

Gentamicin 1mg/kg IV q8h for 2 weeks

PLUS

**Rifampicin 300-450mg PO q12h for ≥ 6 weeks*

Remarks & Clinical Comments:

Refer to [Appendix 1](https://sites.google.com/moh.gov.my/nag/appendices/appendix-1-clinical-pharmacokinetic-guide-aminoglycoside-vancomycin) for vancomycin loading dose. Rifampicin: To avoid the development of resistance, it should be started after 3-5 days of effective initial vancomycin therapy and/or once the bacteraemia has been cleared.

NAG MOH Malaysia 2024Official Site

AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.6 HACEK Microorganisms (Haemophilus parainfluenzae, Aggregatibacter species, Cardiobacterium species, Eikenella corrodens, and Kingella species)

1.6.1 Native and Prosthetic valves

Preferred Regimen

Ceftriaxone 2g IV q24h for 4 weeks (native valve) or 6 weeks (prosthetic valve)

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 3g IV q6h for 4 weeks (native valve) or 6 weeks (prosthetic valve)

Ciprofloxacin 400mg IV or 500mg PO q12h for 4 weeks (native valve) or 6 weeks (prosthetic valve)

Remarks & Clinical Comments:

HACEK-group bacilli produce beta lactamases; definitive treatment should be adjusted based on the cultures.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.7 Therapy for Candida Endocarditis (Native and Prosthetic valve)

1.7.1 Candida Endocarditis (native and prosthetic valve)

Preferred Regimen

Initial therapy:

Amphotericin B deoxycholate 0.6-1mg/ kg IV q24h for at least 6 weeks after surgery

Liposomal amphotericin B 3-5mg/kg IV q24h for at least 6 weeks after surgery

MAY ADD

*Flucytosine 25mg/kg PO q6h for at least 6 weeks after surgery

Step down therapy:

Fluconazole 400-800mg (6-12mg/kg) PO q24h for susceptible microorganism in stable patients with negative blood cultures (clearance of Candida from blood stream)

Alternative Regimen (Allergy / Resistance)

Initial therapy:

High dose of echinocandins are recommended. Options include:

● IV caspofungin 150mg daily OR

● IV micafungin 150mg daily OR

● IV anidulafungin 200mg daily

Remarks & Clinical Comments:

Valve replacement surgery is mandatory. Continue therapy for 6 weeks after surgical replacement or longer in patient with perivalvular abscess. If prosthetic valve cannot be replaced, lifelong suppressive therapy with fluconazole 400mg (6mg/kg) daily is recommended. The duration of therapy will depend on patient response and surgical intervention. Patients with Candida IE should be referred to ID physician. *Flucytosine: For synergistic effect. Causes dose-related marrow toxicity. Avoid using in patients with renal failure.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.8 Therapy for Culture-Negative Endocarditis

1.8.1 Brucella spp.

Preferred Regimen

Doxycycline 100mg PO q12h

PLUS

Rifampicin 300-600mg PO q24h

PLUS

Streptomycin 15mg/kg IM q24h

(For first 2-4 weeks only)

Gentamicin 5mg/kg IV q24h

(For first 2-4 weeks only)

Remarks & Clinical Comments:

Duration: 3-6 months depending on clinical response.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.8 Therapy for Culture-Negative Endocarditis

1.8.2 Coxiella burnetii (agent of Q fever)

Preferred Regimen

Doxycycline 100mg PO q12h

PLUS

Hydroxychloroquine 600mg PO q24h or 200mg PO q8h

Remarks & Clinical Comments:

Duration: 18-24 months depending on clinical and serological response.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.8 Therapy for Culture-Negative Endocarditis

1.8.3 Bartonella spp.

Preferred Regimen

Doxycycline 100mg PO q12h for 6 weeks

PLUS

Gentamicin 3mg/kg IV q24h for 2 weeks

Alternative Regimen (Allergy / Resistance)

Doxycycline 100mg PO q12h for 12 weeks

PLUS

Rifampicin 300mg PO q12h for 6 weeks

Remarks & Clinical Comments:

Avoid gentamicin-based regimen if suspecting glomerulonephritis due to infective endocarditis, OR in renal impaired patients.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

1. INFECTIVE ENDOCARDITIS

1.8 Therapy for Culture-Negative Endocarditis

1.8.3 Bartonella spp.

Footnotes for antibiotic treatment of endocarditis: • Vancomycin: aim for AUC24/MIC of 400–600 (preferred, if stable renal functions), or serum trough level of 15–20mg/L (10–14 µmol/L) for both adults and paediatrics. Vancomycin dose should be adjusted in patients with renal impairment. Refer to Appendix 2 (Antibiotic Dosage in Adult with Impaired Renal Function) for dosing of adult patients with renal impairment, obese patients and monitoring recommendations. • Gentamicin for gram positive synergy dosing: use adjusted body weight for obese patients. Monitor gentamicin levels at least weekly. For conventional dosing (1mg/kg/dose q8h), aim for gentamicin peak level (taken 30 mins after completion of a 30-minute infusion OR one hour after bolus injection) of 6–10 µmol/L (3-5 mcg/mL) and trough level (within 30 mins before the next dose) of < 2 µmol/L (< 1 mcg/mL). For gentamicin 3mg/kg q24h dosing, monitor trough levels only. Refer to Appendix 1 (Clinical Pharmacokinetic Guidelines (Aminoglycosides & Vancomycin). • There should be a high tendency for stopping gentamicin in patients with deteriorating renal function or other signs of toxicity. • If there is high level of gentamicin resistance, ampicillin or vancomycin will need to be continued for ≥ 6 weeks. Referral to an ID physician is recommended if high level gentamicin resistance is present. • Rifampicin should always be used in combination with another effective antistaphylococcal drug (ideally two active agents, i.e. cloxacillin) to minimize risk of resistance. Rifampicin increases hepatic clearance of warfarin and other drugs. • In selected patients of native valve endocarditis with a stable clinical course, it may be possible to switch from IV to oral antibiotics after careful assessment by both cardiologist and ID physician. If feasible, outpatient parenteral antimicrobial therapy (OPAT) can also be considered in this subset of patients.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

2. CATHETER RELATED INFECTIONS

2.1 Non- tunneled central venous catheter (subclavian, internal jugular, femoral)

Peripherally inserted central catheter

Preferred Regimen

Cloxacillin 2g IV q4-6 h

Cefazolin 2g IV q8h

MAY ADD

Ceftazidime 2g IV q8h

(For gram negative coverage if critically ill, OR patients with femoral lines)

Alternative Regimen (Allergy / Resistance)

If patient has risk factor for MRSA :

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

For patients with history of colonization or infected with ESBL and severely/critically ill patients:

Meropenem 2g IV q8h

Imipenem 1g IV q8h

Remarks & Clinical Comments:

BOTH peripheral blood C&S and cultures from the central line must be obtained if CRBSI is suspected. Change antibiotic to targeted therapy once cultures available. Antibiotic of choice depends on local epidemiology of CRBSI and guided by antibiogram results. Catheter removal is recommended. Duration of antibiotics depends on organisms, catheter removal, and presence of complications. Suggest ID consultation. **Refer to Appendix 1 for vancomycin loading dose.

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PaediatricB1CARDIOVASCULAR INFECTIONS

2. ACUTE PERICARDITIS

2.1 Viral

(commonest cause)

Treatment mainly supportive.

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PaediatricB1CARDIOVASCULAR INFECTIONS

2. ACUTE PERICARDITIS

2.2 Bacterial

Staphylococcus aureus Haemophilus influenza Salmonella spp. M. tuberculosis Non-infectious causes (especially post cardiac surgery) are becoming more common.

Preferred Regimen

* Empiric for purulent pericarditis:

Cloxacillin 200mg/kg/day IV in 4-6 divided doses (max. 12g/day)

PLUS

Cefotaxime 200-300mg/kg/day IV in 4 divided doses (max. 12g/day)

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Cefazolin 100mg/kg/day IV in 3 divided doses (max. 6g/day)

Remarks & Clinical Comments:

Need pericardial fluid to differentiate between different etiologic agent & C&S to adjust antibiotic. Consider surgical drainage for tamponade, pre-tamponade & ineffective conservative management. Duration of therapy: 4 weeks. Refer to Appendix 3 for antibiotic allergy. *Cover with IV Vancomycin in settings with high prevalence of MRSA

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AdultA1A1 CARDIOVASCULAR INFECTIONS

2. CATHETER RELATED INFECTIONS

2.2 Tunnel type indwelling venous catheters and ports (Broviac, Hickman)

Haemodialysis catheter

Preferred Regimen

Cloxacillin 2g IV q4-6h

Cefazolin 2g IV q8h

PLUS

Ceftazidime 2g IV q8h

Alternative Regimen (Allergy / Resistance)

If patient has risk factor for MRSA:

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

PLUS

Ceftazidime 2g IV q8h

Remarks & Clinical Comments:

Adjust dose according to renal function. Catheter removal is recommended in the following: ● Septic shock ● Septic phlebitis ● Endocarditis, or metastatic infections ● Persistent positive culture > 72 hours ● Pathogens: S.aureus, P.aeruginosa, fungi, mycobacteria ● Tunnel infections ● Port abscess Duration of antibiotics depends on organisms, catheter removal, and presence of complications. Suggest ID consultation. *Refer to Appendix 1 for vancomycin loading dose.

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AdultA1A1 CARDIOVASCULAR INFECTIONS

3. TREATMENT OF CARDIAC IMPLANTABLE ELECTRONIC DEVICES (CIED) INFECTIONS

3.1 Cardiac Implantable Electronic Devices (CIED) Infections

(E.g.: pacemaker infection)

Refer to Ministry of Health Malaysia’s CPG for the Prevention, Diagnosis & Management of Infective Endocarditis 2017 Section 7.4.

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PaediatricB1CARDIOVASCULAR INFECTIONS

3. INFECTIVE ENDOCARDITIS

3.1 Empirical Therapy for Infective Endocarditis

3.1.1 Community-acquired Organisms

Streptococcus Enterococcus HACEK Gram-negative organisms

Preferred Regimen

Ampicillin 200-300mg/kg/day IV/PO in 4-6 divided doses (max. 12g/day)

PLUS

Gentamicin 1mg/kg/dose IV q8h

MAY ADD

*Cloxacillin 200 mg/kg/day IV in 4-6 divided doses (max. 12g/day)

Remarks & Clinical Comments:

*For acute presentation, need to cover for MSSA since Streptococcus, Enterococcus & HACEK presentations are usually sub-acute.

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PaediatricB1CARDIOVASCULAR INFECTIONS

3. INFECTIVE ENDOCARDITIS

3.1 Empirical Therapy for Infective Endocarditis

3.1.2 Healthcare-associated Organisms

MRSA Non-HACEK Gram-negative organisms Enterococcus sp.

Preferred Regimen

Vancomycin 60mg/kg/day IV in 2- 3 divided doses (max. 2g/day unless unable to achieve therapeutic level)

PLUS

Gentamicin 1mg/kg/dose IV q8h

MAY ADD

*Rifampicin 20mg/kg/day IV/PO in 3 divided doses (max. 900mg/day)

Remarks & Clinical Comments:

*Rifampicin IS ONLY for prosthetic valve AND added after 3-5 days later than vancomycin & gentamicin. If non-HACEK Gram-negative organism like pseudomonas is suspected epidemiologically, add cefepime 50mg/kg/dose IV q8h until cultures are known. Once cultures are available, adjust accordingly.

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PaediatricB1CARDIOVASCULAR INFECTIONS

3. INFECTIVE ENDOCARDITIS

3.2 Specific Organisms

3.2.1 Streptococcus viridans

Preferred Regimen

Strains fully susceptible to penicillin (MIC < 0.125 mg/l):

Benzylpenicillin 200,000-300,000 units/kg/day IV in 4-6 divided doses (up to 12-18 million units/day)

Strains with MIC > 0.125 to 2 µg/ml:

Benzylpenicillin 200,000-300,000 units/kg/day IV in 4-6 divided doses (up to 12-18 million units/day)

PLUS

Gentamicin 1mg/kg/dose IV q8h for 2 weeks (add to first line regimen of penicillin/ceftriaxone)

Do not use ampicillin.

Alternative Regimen (Allergy / Resistance)

Strains fully susceptible to penicillin (MIC < 0.125 mg/l):

Ampicillin 300mg/kg/day IV in 4-6 divided doses (max. 12g/day)

Ceftriaxone 100mg/kg/day IV in 1-2 divided doses (max. 4g/day)

Antibiotic allergy

*Vancomycin 40mg/kg/day IV in

2-3 divided doses (max. 2g/ day)

Strains with MIC > 0.125 to 2 µg/ml:

Beta-lactam allergy

Vancomycin

PLUS

Gentamicin

Remarks & Clinical Comments:

Duration: • 4 weeks for native valve • 6 weeks for prosthetic valve Vancomycin dose adjusted for trough concentration of 10-15 mg/L. Refer to Appendix 3 for antibiotic allergy. * Vancomycin therapy is recommended only for patients with immediate type penicillin hypersensitivity. For this strain (MIC > 0.125): Antibiotic of choice is either penicillin with gentamicin OR ceftriaxone with gentamicin.

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PaediatricB1CARDIOVASCULAR INFECTIONS

3. INFECTIVE ENDOCARDITIS

3.2 Specific Organisms

3.2.2 Enterococcus sp.

Preferred Regimen

Penicillin-sensitive (MIC ≤ 8 mg/l):

Ampicillin 200-300mg/kg/day IV in 4-6 divided doses (max. 12g/day) for *4-6 weeks

PLUS

Gentamicin 1mg/kg/dose IV q8h for *2-6 weeks

Sensitive to penicillin & vancomycin but high-level resistance to gentamicin (MIC>500 mg/l):

Ampicillin 300mg/kg/day IV in 4-6 divided doses (max. 12g/day)

PLUS

Ceftriaxone 100mg/kg/day IV in 1-2 divided doses (max. 4g/day)

Duration: 6 weeks

Resistant to penicillin but susceptible to vancomycin & gentamicin:

**Vancomycin 40mg/kg/day IV in 3 divided doses (max. 2g/ day)

PLUS

Gentamicin 1mg/kg/dose IV q8h

Duration: 6 weeks

Alternative Regimen (Allergy / Resistance)

Penicillin-sensitive (MIC ≤ 8 mg/l):

Ampicillin 200-300mg/kg/day IV in 4-6 equally divided doses (max. 12g/day)

PLUS

Ceftriaxone 100mg/kg/day IV in 1-2 divided doses (max. 4g/day)

Remarks & Clinical Comments:

*Duration: • If symptoms less than 3 months & native valve: ampicillin for 4 weeks & gentamicin for 2 weeks. • If symptoms more than 3 months: ampicillin & gentamicin for 6 weeks. Ampicillin plus ceftriaxone is preferred for individuals with renal impairment (CrCl ≤50ml/min) ONLY. Do not use ceftriaxone alone since enterococcus is intrinsically resistant to this drug. This combination is NOT ACTIVE against E. faecium. **Maximum dose of vancomycin: 2g/day unless not able to achieve therapeutic range. Aim for serum trough of 10-20mg/L.

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PaediatricB1CARDIOVASCULAR INFECTIONS

3. INFECTIVE ENDOCARDITIS

3.2 Specific Organisms

3.2.3 Staphylococcus aureus

Preferred Regimen

Methicillin-sensitive (left-sided):

Cloxacillin 200-300mg/kg/day IV in 4-6 divided doses (max. 12g/day) for 4-6 weeks

Methicillin-sensitive (right-sided):

Cloxacillin 200-300mg/kg/day IV in 4-6 divided doses (max. 12g/day) for 4 weeks

Methicillin-resistant (left & right):

Vancomycin 60mg/kg/day IV in 2-3 divided doses (max. 2g/day) for 4-6 weeks

Methicillin-sensitive (prosthetic valve):

Cloxacillin 200-300mg/kg/day in 4-6 divided doses (max. 12g/day) for ≥ 6 weeks

PLUS

Gentamicin 1mg/kg/dose IV q8h for 2 weeks

PLUS

*Rifampicin 20mg/kg/day PO in 3 divided doses (max. 900mg/day) for ≥ 6 weeks

Methicillin-resistant (prosthetic valve):

Vancomycin 60mg/kg/day in 2-3 divided doses (max. 2g/day) for ≥ 6 weeks

PLUS

Gentamicin 1mg/kg/dose IV q8h for 2 weeks

PLUS

*Rifampicin 20mg/kg/day PO in 3 divided doses (max. 900mg/day) ≥ 6 weeks

Alternative Regimen (Allergy / Resistance)

Methicillin-sensitive (left-sided or right-sided):

Antibiotic allergy

Cefazolin 100mg/kg/day IV in 3 divided doses (max. 6g/day) for 4-6 weeks

Vancomycin 60mg/kg/day IV in

2-3 divided doses (max. 2g/day) for 4-6 weeks.

Methicillin-resistant (left & right):

*Daptomycin 10 mg/kg IV daily for 4-6 weeks

Remarks & Clinical Comments:

If allergy to penicillin but not immediate type hypersensitivity, use cefazolin. Refer to Appendix 3 for antibiotic allergy. Methicillin-sensitive (right sided): May shorten duration to 2 weeks if good response, no metastatic sites, no cardiac or extracardiac complications with size of vegetation less than 20mm. *Daptomycin: Registered in Malaysia however not in FUKKM. Daptomycin is superior to vancomycin for MRSA bacteremia with MIC >1 mg/L. *Rifampicin has better penetration but to protect against development of resistance, use only after 3-5 days of cloxacillin AND/OR bacteremia has been cleared. MRSA (prosthetic valve): vancomycin & rifampicin for 6 weeks or more.

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PaediatricB1CARDIOVASCULAR INFECTIONS

3. INFECTIVE ENDOCARDITIS

3.2 Specific Organisms

3.2.4 HACEK organisms

Slow growth or no growth in blood culture

Preferred Regimen

Ceftriaxone 100mg/kg/day in 2 divided doses (max. 4g/day) for 4 weeks

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PaediatricB1CARDIOVASCULAR INFECTIONS

4. CULTURE-NEGATIVE ENDOCARDITIS

Preferred Regimen

Ampicillin/sulbactam 300mg/kg/day IV in 4-6 divided doses (max. 8g/day ampicillin component) for 4-6 weeks

PLUS

Gentamicin 1mg/kg/dose IV q8h for 4-6 weeks

Remarks & Clinical Comments:

Culture-negative endocarditis (CNE) is diagnosed when a child has clinical & echocardiogram evidence of IE but persistent negative cultures. This is in individuals with no prior antimicrobial use. If fungi or fastidious organism is suspected, kindly ask microbiologist to prolong incubation. Patients with culture-negative endocarditis should be treated in consultation with an ID specialist.

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AppendixAPP2ANTIBIOTIC DOSAGES IN PATIENTS WITH IMPAIRED RENAL FUNCTION

Appendices

ANTIBIOTIC DOSAGES IN PATIENTS WITH IMPAIRED RENAL FUNCTION

ANTIBIOTIC DOSAGES IN PATIENTS WITH IMPAIRED RENAL FUNCTION 1. ADULT 2. PAEDIATRIC

1. Antibiotic dosages in renal impairment (adults).pdf

2. Antibiotic dosages in renal impairment (paeds).pdf

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.1 Empirical Treatment on Admission

Common organisms: Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae Other organisms: Listeria monocytogenes

Preferred Regimen

Ceftriaxone 2g IV q12h

PLUS

Ampicillin 2g IV q4h

(if suspecting listeriosis, please see comments)

Alternative Regimen (Allergy / Resistance)

Cefotaxime 2g IV q6h

PLUS

Ampicillin 2g IV q4h

(if suspecting listeriosis, please see comments)

*If allergic to Cephalosporin, consider meropenem 2g IV q8h

Remarks & Clinical Comments:

Antibiotics should not be delayed if lumbar puncture is delayed by radiological investigation. If no organism is isolated from CSF C&S but LP is suggestive of bacterial meningitis and the patient is responding, continue antibiotics for 10-14 days. Dexamethasone 10mg IV q6h is recommended 15 to 20 minutes before or at the time of first dose of antibiotics. Continue for 4 days if the Gram stain and/or cultures are consistent with S. pneumoniae. Discontinue if not Streptococcus pneumonia or if bacterial meningitis is subsequently thought not to be present. Incidence of listeriosis increases in people > 50 years of age, immunosuppressed and pregnancy. Consider empirical cover with IV ampicillin especially if the course of disease is indolent or there is epidemiological risk (refer section 1.4 - Listeriosis). Duration: 10-14 days

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PaediatricB2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS

1.1 Meningitis Empirical Treatment

Age groups: < 1 month: Group B streptococcus (GBS) E. coli 1-3 months: Group B streptococcus (GBS) E. coli S. pneumoniae N. meningitidis > 3 months: S. pneumoniae, Hib E. coli Salmonellosis N. meningitidis

Preferred Regimen

Cefotaxime 200-300mg/kg/day IV in 4 divided doses (max. 2g/dose)

Ceftriaxone 100mg/kg/day IV in 2 divided doses

(max. 2g/dose; 4g/day)

Remarks & Clinical Comments:

For children below 3 months of age: Cefotaxime is the preferred third generation cephalosporin since less drug-drug interactions (in terms of interaction with calcium-containing infusion & bilirubin displacement). Given the commonality of GBS in this age group, adding IV C Penicillin (Benzylpenicillin) to Cefotaxime while awaiting culture results can be considered. Once organism is known, please refer below to adjust antibiotics and duration.

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PaediatricB2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS

1.2 Specific Organisms

1.2.1 Group B streptococcus (GBS)

Preferred Regimen

Benzylpenicillin 300,000-400,000 units/kg/day IV in 4-6 divided doses (max. 24 million units/day)

Remarks & Clinical Comments:

Duration: 14 days

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.2 Causative Organism Isolated

1.2.1 Haemophilus influenzae (Gram-negative bacilli)

Preferred Regimen

Ceftriaxone 2g IV q12h

Alternative Regimen (Allergy / Resistance)

Cefotaxime 2g IV q6h

If organism is susceptible and patient is allergic to cephalosporins:

Ciprofloxacin 400mg IV q8h

Remarks & Clinical Comments:

Duration: 7-10 days

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PaediatricB2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS

1.2 Specific Organisms

1.2.2 Haemophilus influenza (HI)

Preferred Regimen

Cefotaxime 200-300mg/kg/day IV in 4 divided doses (max. 2g/dose)

Ceftriaxone 100mg/kg/day IV in 1 or 2 divided doses (max. 2g/dose; 4g/day)

Alternative Regimen (Allergy / Resistance)

Ampicillin 300mg/kg/day IV q6h (max. 12g/day)

(if MIC <1mcg/mL)

Remarks & Clinical Comments:

Duration: 10 days

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.2 Causative Organism Isolated

1.2.2 Streptococcus pneumoniae (Gram-positive cocci)

Preferred Regimen

Penicillin-sensitive strains (MIC to Penicillin ≤ 0.06 mcg/ml):

Benzylpenicillin 4MU IV q4h

Penicillin resistant strains (MIC to Penicillin ≥ 0.12 mcg/ml):

Ceftriaxone 2g IV q12h

Penicillin resistant and Cephalosporin intermediate strains (MIC to Cephalosporin ≥ 1 and < 2 mcg/ml):

*Vancomycin 25-30mg/kg loading dose then 15-20mg/kg IV q8-12h; not to exceed 2g per dose

PLUS

Ceftriaxone 2g IV q12h

Cefotaxime 2g IV q4h

Refer ID physician if patient not responding with above treatment

Penicillin resistant and cephalosporin resistant strains (MIC to Cephalosporin ≥ 2 mcg/ml):

Refer ID physician

Alternative Regimen (Allergy / Resistance)

Penicillin resistant strain

(MIC to Penicillin ≥ 0.12 mcg/ml)

Cefotaxime 2g IV q6h

Remarks & Clinical Comments:

All attempts should be made to ascertain the MIC of isolated pneumococcus. Ceftriaxone or cefotaxime should be de-escalated to benzylpenicillin once the MIC result has been confirmed. Duration: 10-14 days *Refer to Appendix 1 for vancomycin loading dose.

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PaediatricB2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS

1.2 Specific Organisms

1.2.3 Neisseria meningitidis

Preferred Regimen

Benzylpenicillin 300,000-400,000 units/kg/day; max. 12 million units/day) IV in 4-6 divided doses

Ceftriaxone 100mg/kg/day IV in 2 divided doses (max. 2g/dose; 4g/day)

Remarks & Clinical Comments:

Duration: 7 days Prophylaxis for all household contacts & health care workers involved in unprotected contact during intubation & suctioning of airway/mouth-to-mouth resuscitation.

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.2 Causative Organism Isolated

1.2.3 Neisseria meningitidis (Gram-negative diplococci)

Preferred Regimen

Benzylpenicillin 4MU IV q4h (if MIC to Penicillin ≤ 0.06 mcg/ml)

If MIC to penicillin is > 0.06 mcg/ml use:

Ceftriaxone 2g IV q12h

Cefotaxime 2g IV q6h

Alternative Regimen (Allergy / Resistance)

If organism is susceptible and patient is allergic to cephalosporins:

Ciprofloxacin 400mg IV q8h

Remarks & Clinical Comments:

Duration: 5-7 days

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PaediatricB2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS

1.2 Specific Organisms

1.2.4 Streptococcus pneumonia (SP)

Preferred Regimen

Penicillin-susceptible (MIC ≤ 0.06 mcg/mL):

Benzylpenicillin 300,000-400,000 units/kg/day in 4-6 divided doses (max. 24 million units/day)

Penicillin-resistant (MIC≥0.12 mcg/ml) & cefotaxime/ ceftriaxone- sensitive (MIC ≤0.5 mcg/mL):

Cefotaxime 200-300mg/kg/day IV in 4 divided doses (max. 2g/dose)

Ceftriaxone 100mg/kg/day IV in 2 divided doses (max. 2g/dose; 4g/day)

*Penicillin & cefotaxime/ceftriaxone-nonsusceptible (MIC ≥1.0 mcg/ml) (drug-resistant Streptococcus pneumoniae, DRSP):

High dose cefotaxime 300mg/kg/day IV in 4 divided doses (max. 12g/day) or ceftriaxone 100mg/kg/day IV in 1 or 2 divided doses (max. 2g/dose; 4g/day)

PLUS

Vancomycin 60mg/kg/day in 3 divided doses (max. 2g/day unless unable to achieve therapeutic level). Target AUC24 of 400-600 mg*hour/L

Remarks & Clinical Comments:

Duration: 14 days *Treat in consultation with ID specialist.

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PaediatricB2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS

1.2 Specific Organisms

1.2.5 Cryptococcal Meningitis

Cryptococcus neoformans

Preferred Regimen

Induction Therapy:

Amphotericin B 1.0mg/kg/day IV q24h

MAY ADD 5-flucytosine 25mg/kg/dose (max. 2g/dose) PO q6h for 2-4 weeks

Consolidation Therapy:

Fluconazole 6-12mg/kg/dose (max. 400mg/dose) IV/PO q24h for 8 weeks

Remarks & Clinical Comments:

Duration of induction with 5-flucytosine (5-FU) is at least 2 weeks & until CSF repeat culture is NEGATIVE.

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.3 Prophylaxis for Household and Close Contact of Meningococcal Meningitis Cases

Preferred Regimen

Age > 15 years:

Ciprofloxacin 500mg PO as single dose

(not recommended in pregnant or lactating women)

Rifampicin 600mg PO q12h for 2 days (4 doses) [not recommended in pregnant women]

Children/Adolescent < 15 years:

Refer to Paediatric Non-Surgical Chemoprophylaxis (Meningococcal Exposure) Section

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 250mg IM as single dose (especially in pregnancy and lactating mothers)

Azithromycin 500mg PO as single dose

Remarks & Clinical Comments:

Close contacts are defined as those individuals who have had contact for > 8 hours and within 1 meter of the index case. Individuals who were in contact with oropharyngeal secretions of the index case in the last 7 days before onset of symptoms up to 24 hours after appropriate antibiotics should also receive chemoprophylaxis. For index case who received only benzylpenicillin as therapy, chemoprophylaxis should also be given upon discharge to eliminate nasopharyngeal carriage.

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.4 Listeriosis

Listeria monocytogenes (Gram-positive rod)

Preferred Regimen

Ampicillin 2g IV q4h

Benzylpenicillin 4MU IV q4h, MAY ADD *Gentamicin 5mg/kg/day IV in 3 divided doses

Alternative Regimen (Allergy / Resistance)

Trimethoprim/sulfamethoxazole 10 to 20mg/kg/day [based on the TMP component] IV/PO q6-12h

Meropenem 2g IV q8h

Remarks & Clinical Comments:

Duration of treatment is 3 weeks depending on clinical response. May be longer in an immunocompromised host. *Current evidence supporting combination therapy with gentamicin is weak but it can be considered for severe infections for synergistic effect.

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.5 Brain abscess/subdural empyema

Common organisms: Streptococci Staphylococcus Gram-negative bacilli Anaerobes

Preferred Regimen

Oral/Sinus/Hematogenous source:

Ceftriaxone 2g IV q12h

Cefotaxime 2g IV q4-6h

PLUS

Metronidazole 500mg IV q8h

Otogenic source:

Ceftazidime 2g IV q8h

Ceftriaxone 2g IV q12h

PLUS

Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Duration to be determined by clinical response (usually 4-8 weeks with IV therapy for 2 weeks minimum depending on whether surgical drainage done, clinical and radiological response). De-escalate antibiotics based on culture result and sensitivity.

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.6 Spinal Epidural Abscess

Common organisms: Streptococci Staphylococcus Gram-negative bacilli

Preferred Regimen

Cloxacillin 2g IV q6h

PLUS

Ceftriaxone 2g IV q12h

Cefotaxime 2g IV q4-6h

Remarks & Clinical Comments:

Source control is strongly recommended. It is important to attempt to obtain specimen to guide antimicrobial therapy. Continue therapy for at least 6 weeks, with a minimum of 2 weeks IV therapy. Duration to be determined by clinical response, whether surgical drainage done, clinical and radiological response. Add on Vancomycin if suspecting MRSA infection or patient is deteriorating.

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AdultA2CENTRAL NERVOUS INFECTIONS

1. MENINGITIS (ACUTE)

1.7 Viral Encephalitis

Common organisms: Herpes simplex Varicella zoster

Preferred Regimen

Acyclovir 10mg/kg IV q8h

Remarks & Clinical Comments:

Use Ideal Body Weight in obese class 1 and 2 patients (BMI 30-39.9kg/m²). Use Adjusted Body Weight for class 3 obesity patients (BMI>40kg/m²). Duration: 14-21 days

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PaediatricB2CENTRAL NERVOUS INFECTIONS

2. ENCEPHALITIS

2.1 Herpes simplex Encephalitis

Preferred Regimen

Pediatric herpes CNS disease:

> 4month to 12 years old

Acyclovir 30-45mg/kg/day IV in 3 divided doses

> 12 years old

Acyclovir 30mg/kg/day IV in 3 divided doses

Neonatal herpes CNS disease:

IV Acyclovir 60mg/kg/day IV in 3 divided doses for minimum 21 days followed by oral suppressive therapy, PO aciclovir 300 mg/m2/dose, 3 times per day for 6 months

Remarks & Clinical Comments:

IV duration: 21 days minimum. Dosing exceeding 500mg/m² can be associated with acute kidney injury.

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AdultA2CENTRAL NERVOUS INFECTIONS

2. MENINGITIS (CHRONIC)

2.1 Tuberculous Meningitis

Mycobacterium tuberculosis

Refer to Clinical Practice Guidelines on Management of Tuberculosis (4th Edition) Treatment is continued for 12 months.

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PathwayC2ACUTE OTITIS MEDIA

ACUTE OTITIS MEDIA

Acute otitis media 16.10.2025.pdf

Attached Clinical Documents:

Acute otitis media 16.10.2025.pdf

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AdultA2CENTRAL NERVOUS INFECTIONS

2. MENINGITIS (CHRONIC)

2.2 Cryptococcal Meningitis

Cryptococcus neoformans Cryptococcus gattii (non-HIV, non-transplant patient)

Preferred Regimen

Induction Therapy:

Amphotericin B deoxycholate 0.7-1.0mg/kg/day IV q24h

PLUS

5-Flucytosine 100mg/kg/day PO q6h

Consolidation Therapy:

Fluconazole 400-800mg PO q24h

Maintenance Therapy:

Fluconazole 200mg PO q24h

Alternative Regimen (Allergy / Resistance)

Induction Therapy:

Amphotericin B deoxycholate 0.7-1.0mg/kg/day IV q24h

PLUS

Fluconazole 800-1200mg PO q24h

Fluconazole 1200mg PO q24h

PLUS

5-Flucytosine 100mg/kg/day PO q6h

Consolidation Therapy:

Fluconazole 800mg PO q24h

Maintenance Therapy:

Fluconazole 200mg PO q24h

Remarks & Clinical Comments:

Lipid formulations of amphotericin may be used in cases of severe nephrotoxicity. Repeat lumbar puncture at end of 2 weeks of induction therapy. Duration of induction therapy: 4-6 weeks (consider 6 weeks if patient has neurological complications and positive CSF culture at 2 weeks). Duration of consolidation phase: 8 weeks Use fluconazole 800mg/day if induction phase is less than 4 weeks/ induction phase did not use flucytosine or amphotericin B. Duration of maintenance Phase: 12 months (longer therapy may be needed to achieve eradication). Prompt baseline lumbar puncture is strongly encouraged. If pressures are elevated, regular LP is recommended. Consider insertion of EVD/ VP shunting if persistent high CSF pressures. Use of mannitol/ steroids and acetazolamide are not recommended in managing pressures. In non-HIV/non-transplant patients, consider intermittent LP to look for relapse of cryptococcal infection during consolidation/ maintenance phase (relapse/persistent rate).

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AdultA2CENTRAL NERVOUS INFECTIONS

2. MENINGITIS (CHRONIC)

2.3 Healthcare-associated Ventriculitis and Meningitis

Empirical treatment should be decided by the primary team based on local antibiogram and CSF gram stain result.

Preferred Regimen

If C&S is not available:

Ceftazidime 2g IV q8h

MAY ADD

*Vancomycin 25-30mg/kg loading dose then 15-20mg/kg IV q8-12h; not to exceed 2g per dose

Alternative Regimen (Allergy / Resistance)

Meropenem 2g IV q8h

MAY ADD

*Vancomycin 25-30mg/kg loading dose then 15-20mg/kg IV q8-12h; not to exceed 2g per dose

Remarks & Clinical Comments:

De-escalate antibiotics to targeted therapy when the culture results are available. *Vancomycin trough level should be 10-14µmol/L or 15-20mcg/L *Refer to Appendix 1 for vancomycin loading dose.

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AdultA2CENTRAL NERVOUS INFECTIONS

2. MENINGITIS (CHRONIC)

2.4 Neurosyphilis

Refer to Sexually Transmitted Infections section Treatment is the same for neurosyphilis in patients with HIV infection

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AdultA2CENTRAL NERVOUS INFECTIONS

2. MENINGITIS (CHRONIC)

2.5 HIV related CNS infection

Refer to Infections in Immunocompromised Patients – Opportunistic Infections in HIV section

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PaediatricB2CENTRAL NERVOUS INFECTIONS

3. BRAIN ABSCESS

Preferred Regimen

Cefotaxime 200-300mg/kg/day IV in 4 divided doses (max. 2g/dose)

Ceftriaxone 100mg/kg/day IV in 2 divided doses (max. 2g/dose; 4g/day)

PLUS

Metronidazole 15mg/kg IV stat then 7.5mg/kg IV q8h (max. 4g/day)

Alternative Regimen (Allergy / Resistance)

If secondary to trauma:

PLUS

Cloxacillin 200-300mg/kg/day in 4-6 divided doses (max. 12g/day)

(Add to third generation cephalosporin)

Remarks & Clinical Comments:

Surgical drainage may be indicated if appropriate. Duration: 6-8 weeks, depending on response based on neuroimaging & clinical presentations.

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AppendixAPP3ANTIBIOTICS ALLERGY EVALUATION PROTOCOL

Appendices

ANTIBIOTICS ALLERGY EVALUATION PROTOCOL

ANTIBIOTICS ALLERGY EVALUATION PROTOCOL 1. BACKGROUND 2. EVALUATION OF PENICILLIN ALLERGY 3. ALGORITHM FOR PATIENTS SUSPECTED OF PENICILLIN/CEPHALOSPORIN ALLERGY 4. FOLLOW-UP DOCUMENTATION • The estimated true incidence of penicillin hypersensitivity worldwide is low; up to 90% of patients who reported penicillins allergy could be delabeled safely after formal testing. • Cross-reactivity between truly penicillin allergic patients with third and fourth generation cephalosporins and/or carbapenem is very low (Figures 1 and 2 and, Table 1). It is mainly determined by the R side chain. • Alterations in antibiotic prescribing due to reported penicillins allergy has been shown to result in poorer clinical outcomes, increased incidence of serious antibiotic-resistant infections, prolonged hospitalisation, and increased healthcare burden. • Careful drug allergy history paired with the PEN-FAST risk assessment (Table 2) should be performed, to decide if formal testing is needed; delabeling of allergy will result in more judicious use of narrow spectrum beta-lactam (BL) antibiotics when clinically indicated and improve patient safety. Figure 1: β-lactams antibiotics structure (adapted from Blumenthal KG et.al, 2019) Figure 2: Comparison of R1 & R2 structural similarities between B-lactams drugs. Drugs that have identical R1 or R2 are listed as R1 (red cell) or R2 (gold cell). If ONLY the ring or branch chain moiety of the R1 structure is identical, it is listed as R1’ or R’’, respectively. Drugs that have similar R1 or R2 structures are listed as r1 or r2. If ONLY the ring or branch chain moiety of R1 structure is similar, it is listed as r1’ or r1’’, respectively. Blank cells imply NO R1 or R2 structural similarities. (Zagursky & Pichichero, 2018³) Table 1: β-lactam cross reactivity in penicillins allergic patients. Table 2: PEN-FAST Penicillin Allergy Clinical Decision Rule Criteria and Interpretation The PEN-FAST clinical decision rule for patients reporting a penicillin allergy uses 3 clinical criteria of time from penicillin allergy episode, phenotype, and treatment required. A total score is calculated using PEN-FAST score in the upper panel, and interpretation for risk strategy is provided in the lower panel. a Includes unknown. b Forms of severe delayed reactions include potential Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, and acute generalized exanthematous pustulosis. Patients with a severe delayed rash with mucosal involvement should be considered to have a severe cutaneous adverse reaction. Acute interstitial nephritis, drug induced liver injury, serum sickness and isolated drug fever were excluded phenotypes from the derivation and validation cohorts. 2. EVALUATION OF PENICILLIN ALLERGY • Obtain a detailed history of the drug allergic reaction (Refer Section 2.1). • Conduct risk assessment of the patient using the PEN-FAST Clinical Decision Tool; proceed with either test-dose challenge (score <3) or refer if score more than 3. • Send bloods for in vitro tests; refer for skin and provocation testing to centers specialized in drug allergy testing for moderate and high-risk patients. • Refer to Table 3 for list of medications needed on-site when performing the test dose challenge for low-risk patients at the point-of-care. 2.1 Important Clinical Questions to Clarify a Beta-lactam Adverse Reaction History* 1. When did the reaction occur? 2. Which medication was prescribed, and what was the route of administration? 3. What was the indication for the medication? 4. How many courses of this medication or a related medication have been administered? 5. How many doses were received prior to onset of reaction? 6. How soon after the most recent dose did the reaction occur? 7. Were there any concurrent medications administered? 8. What was the nature of the reaction? Specifically ask about: • Raised, erythematous, pruritic rash with each lesion typically lasting <24 h? (hives/urticaria) • Swelling of the tongue, mouth, lips, or eyes (angioedema) • Respiratory or haemodynamic changes with skin manifestations (anaphylaxis) • Lesions or ulcers involving the mouth, lips, or eyes; skin desquamation (SJS, TEN, and other severe type IV reactions) • Organ involvement such as haematologic, renal, or hepatic (cytopenias, Acute Interstitial Nephritis (AIN), transaminitis) • Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, and other severe type IV reactions • Joint pain (serum-sickness like reaction) • Rashes that were not hives, were mild, or delayed in onset (mild type IV reaction or morbilliform rash) • Nausea, vomiting, diarrhea, minor laboratory abnormalities or local injection reactions 1. Was the medication stopped? 2. Was medical attention sought in an emergency room or from a community physician? 3. How was the reaction managed? 4. Were there symptoms of unexplained fever, arthritis/arthralgia, lymphadenopathy, skin exfoliation or mucous membrane involvement? 5. How long did symptoms last? 6. Were any symptoms consistent with severe cutaneous adverse reaction (SCAR – SJS/TEN, DRESS, AGEP, Exfoliative dermatitis)? 7. Has the same medication been taken subsequently? If yes, was there a reaction? 8. Has any recurrent signs and symptoms occurred with subsequent same drug exposure? 9. Are there other tolerated antimicrobial agents? *Adapted from Jeimy S et al. Practical guide for evaluation and management of beta-lactam allergy: position statement from the Canadian Society of allergy and clinical immunology. 2020.Allergy Asthma Clin Immunol;1695. 2.2 Risk Assessment Risk assessment before referring for testing, using the PEN-FAST Clinical Decision Tool for possible point-of-care testing: Risk assessment should be performed using the recently published and validated PEN-FAST clinical decision tool - a predictive screening tool for true penicillin allergy to identify low risk penicillin allergy patients that do not require referral for formal allergy testing. PEN-FAST is a validated clinical decision-making tool with a high negative predictive value for patients >12 years old. It is a point-of-care screening tool that identifies adult patients with low risk of penicillins allergy and therefore, do not require formal allergy testing when the total score is <3 (Table 2)¹³; therefore, a drug provocation test (DPT) by the treating physician is recommended. All routes of administration are possible for a DPT (oral, subcutaneous, intramuscular or intravenous). Nevertheless, the oral route is preferred as the risk of a severe reaction with the oral route is low. The cumulative dose should be documented and may be 10-20% more than the therapeutic dose. For patients with a PEN-FAST score of <3 (interpreted as very low risk and low risk), a test dose challenge is recommended. Test dose challenge: • Giving 1/10 of the normal concentration intravenous medication or ¼ of the oral dosage being given followed by a 20-minute observation. If no objective symptom(s) is/are observed, a full dose x 1 (or the remaining 9/10) is given followed by a 2-hour observation period (Table 3). * There is NO MERIT in drug skin testing referrals for SCREENING purposes (i.e. testing without prior history of exposure and subsequent reaction to the drug) Table 3: Test dose challenge and medications to have on-site 2.3 In Vitro Tests • Bloods should be sent for mast cell tryptase level during (up to 4 hours) a suspected acute anaphylaxis. • This should be repeated 24 hours later for baseline measurements. For normal acute tryptase level, the equation 1.2 x baseline tryptase + 2 should be used to interpret results. • In vitro quantification may be sent for specific IgE to penicilloyl G and penicilloyl V to the Allergy lab, Institute for Medical Research (IMR). The specific IgE:total IgE of > 0.002 has been shown to have high predictability of true penicillin allergy. 3. ALGORITHM FOR PATIENTS SUSPECTED OF PENICILLIN/CEPHALOSPORIN ALLERGY Figure 3: Penicillin allergy risk stratification, and relative contraindication to re-administration. 1. Type 1 or IgE-mediated reaction:symptoms within 2 hours after first dose, duration < 24 hours. 2. Type II, III, IV: symptoms >2 hours after drug administration. [Adapted and modified from Jeimy S et al. Practical guide for evaluation and management of beta-lactam allergy: position statement from the Canadian Society of allergy and clinical immunology. 2020.Allergy Asthma Clin Immunol;1695]. 4. FOLLOW-UP DOCUMENTATION • If provocation is not tolerated, document the BL(s) intolerance in the patient records • If provocation is tolerated, delabel and/or document the BL(s) tolerance in the patient records • An allergy card/passport/medic alert should be issued for future avoidance of the allergic BL(s)

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PaediatricB3CHEMOPROPHYLAXIS

1. CARDIAC SURGERY

S. epidermidis, S. aureus, Corynebacterium sp., Enteric Gram-negative bacilli

Preferred Regimen

Cefazolin 30 mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Alternative Regimen (Allergy / Resistance)

If known to have MRSA/MRSE colonisation, use vancomycin 15mg/kg IV

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg IV; max 900mg Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours Refer to Appendix 3 for antibiotic allergy.

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AdultA3CHEMOPROPHYXLAXIS

1. Prophylactic Regimens for High-risk Dental Procedures in High-risk Patients

Preferred Regimen

Amoxicillin 2g PO single dose 30 to 60 minutes before procedure

Ampicillin 2g IV single dose 30 to 60 minutes before procedure

Alternative Regimen (Allergy / Resistance)

* Antibiotic allergy:

For non-severe hypersensitivity to penicillin:

Cephalexin 2g PO

Cefazolin 1g IV single dose 30 to 60 minutes before procedure

For severe hypersensitivity to penicillin:

Doxycycline 100mg PO

Azithromycin 500mg PO single dose 30 to 60 minutes before procedure

Remarks & Clinical Comments:

See above for antibiotic prophylaxis in patients undergoing invasive surgical procedure to treat an established infection. *Refer to Appendix 3 for antibiotic allergy.

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AdultA3CHEMOPROPHYXLAXIS

1. CARDIAC SURGERY

1.1 Cardiac Surgeries (General)

Examples: • Aortic dissection • Thoracic endovascular aortic repair (TEVAR) • Valve repair or replacement • Left ventricular assist device (LVAD) placement

Preferred Regimen

Cefazolin 2g IV followed by 2g IV q8h

If MRSA colonized:

Cefazolin 2g IV STAT

PLUS

Vancomycin 15-20mg/kg IV STAT

Followed by:

Cefazolin 2g IV q8h

PLUS

Vancomycin 15mg/kg IV q12h

Alternative Regimen (Allergy / Resistance)

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV STAT followed by 15mg/kg IV q12h

Remarks & Clinical Comments:

IV vancomycin dose of 20mg/kg pre-operatively may be preferred to achieve sufficient tissue concentrations at the time of surgery. At onset of bypass: May consider additional 1-2g of IV cefazolin via cardiopulmonary bypass circuit.

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PaediatricB3CHEMOPROPHYLAXIS

1. CARDIOVASCULAR

1.1 Rheumatic Fever

Secondary prevention

Preferred Regimen

Benzathine penicillin

1.2MU (> 27kg);

0.6MU (≤ 27 kg)

IM every 3-4 weeks

Duration:

1. With carditis & residual heart disease (persistent valvular disease): 10 years since the last episode of ARF or 40 years of age whichever is longer. Consider lifelong prophylaxis.

2. With carditis but no residual heart disease (no valvular disease): 10 years since the last episode of ARF or 21 years of age whichever is longer.

3. Without carditis: 5 years since last ARF or until 21 years of age whichever is longer.

Alternative Regimen (Allergy / Resistance)

Phenoxymethylpenicillin (Penicillin V) 250 mg PO q12h

Antibiotic allergy:

Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h (max. 800mg/dose)

Remarks & Clinical Comments:

Refer to Appendix 3 for antibiotic allergy.

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AdultA3CHEMOPROPHYXLAXIS

1. CARDIAC SURGERY

1.2 Coronary Artery Bypass Surgery

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

Remarks & Clinical Comments:

Single dose Duration: 24-48 hours

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PaediatricB3CHEMOPROPHYLAXIS

1. CARDIOVASCULAR

1.2 Infective Endocarditis (IE)

Preferred Regimen

Amoxicillin 50mg/kg PO (max. 2g) 30-60 minutes before procedure

Ampicillin 50mg/kg IV (max. 2g) 30-60 minutes before procedure

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 20mg/kg IV/PO (max. 900mg) 30-60 minutes before procedure

Another alternative:

Cefazolin 50mg/kg IV (max. 2g) (cephalosporin should not be used in children with anaphylaxis, angioedema or urticaria)

Remarks & Clinical Comments:

IE prophylaxis is recommended for patients with the highest risk cardiac conditions undergoing procedures likely to result in bacteremia with a microorganism that has the potential ability to cause bacterial endocarditis. Prophylaxis is always required for: 1. Dental procedures that involve • Extraction • Periodontal procedure including surgery • Subgingival scaling • Root planning • Re-planting avulsed teeth • Other surgical procedure e.g.: implant placement & apicectomy 2. Incision & drainage of local abscess in the brain, skin, subcutaneous tissue (boils & carbuncle, eye (dacryocystitis), epidural, lung, orbital area, per rectal area, liver (pyogenic liver), tooth & surgical procedure through infected skin. 3. Percutaneous endoscopic gastrotomy. Prophylaxis is required in some circumstances. Please refer to Ministry of Health CPG for Prevention, Diagnosis & Management of Infective Endocarditis (2017). Maintenance of optimal oral hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE. Refer to Appendix 3 for antibiotic allergy.

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AdultA3CHEMOPROPHYXLAXIS

1. CARDIAC SURGERY

1.3 Cardiac Device Insertion Procedures

E.g.: Pacemaker implantation, defibrillator insertion

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

Remarks & Clinical Comments:

Single dose

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AdultA3CHEMOPROPHYXLAXIS

1. CARDIAC SURGERY

1.4 Thoracic Surgeries

Examples: • Decortication • Lobectomy • Thymemtomy • Video-assisted thoracoscopic surgery (VATS)

Preferred Regimen

Cefazolin 2g IV

MRSA colonized:

Vancomycin 15-20mg/kg IV

Alternative Regimen (Allergy / Resistance)

Severe penicillin allergy:

Clindamycin 600-900mg IV

Vancomycin 15-20mg/kg IV

Remarks & Clinical Comments:

Single dose

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PaediatricB3CHEMOPROPHYLAXIS

2. ABDOMINAL SURGERY

Clean contaminated Surgery (Examples: Gastroduodenal procedures, early appendicitis, closure of stoma)

Preferred Regimen

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 50mg/kg (of ampicillin component) IV

Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg IV; max 900mg Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours AND Gentamicin 2.5 mg/kg IV Refer to Appendix 3 for antibiotic allergy.

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AdultA3CHEMOPROPHYXLAXIS

2. Secondary Prevention of Rheumatic Fever

Preferred Regimen

Benzathine Penicillin 1.2MU IM every 4 weeks (*consider every 3 weeks for high-risk group)

Phenoxymethylpenicillin (Penicillin V) 250mg PO q12h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Erythromycin ethylsuccinate 800mg PO q12h

Remarks & Clinical Comments:

Refer to Appendix 3 for antibiotic allergy. *High risk group: • Breakthrough ARF despite complete adherence to a 28-day regimen, OR • Severe RHD, or a history of heart valve surgery

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PaediatricB3CHEMOPROPHYLAXIS

2. INFECTIONS IN IMMUNOCOMPROMISED

2.1 Post splenectomy

At risk for infection caused by Pneumococcus, Meningococcus, Haemophilus sp.

Preferred Regimen

Phenoxymethylpenicillin (Penicillin V)

125mg PO q12h for ≤5 years old

250mg PO q12h for >5 years old

Duration of chemoprophylaxis:

• Minimum 1 – 3 years post splenectomy

• Life-long prophylaxis for those with other cause of asplenia, previous episode of sepsis and remain immunocompromised.

Alternative Regimen (Allergy / Resistance)

Amoxicillin 20mg/kg/day (250 – 500mg PO q12h; 500mg daily if poor compliance i.e., adult dose)

Antibiotic allergy:

Erythromycin ethylsuccinate 15-20mg/kg/dose PO q12h (max. 800mg/dose)

Remarks & Clinical Comments:

Risk of sepsis is lifelong but especially high in the first 2 years after splenectomy. Important adjunct: • Immunisation against Pneumococcus, Haemophilus, Meningococcus at least 14 days prior to splenectomy (if not possible then as soon as possible, 14 days or more after surgery). • Pneumococcal conjugate vaccine is preferred for better immunogenicity • Yearly influenza vaccine is also recommended. Not all pneumococcal isolates are sensitive to these antibiotics. Limitation stressed to parents so that all febrile illness in this group of children are taken seriously since initial signs & symptoms of fulminant septicaemia can be subtle. Refer to Appendix 3 for antibiotic allergy.

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AdultA3CHEMOPROPHYXLAXIS

2. VASCULAR SURGERY

2.1 Vascular Surgeries (General)

Examples: • Artery or vein repair • Arteriovenous fistula (AVF) / Arteriovenous graft (AVG) creation, excision, jump graft • Aortic stent graft • Bypass surgery • Open & Endovascular repair of aneurysm

Preferred Regimen

Cefazolin 2g IV followed by 2g IV q8h

MRSA colonized:

Cefazolin 2g IV

PLUS

Vancomycin 15-20mg/kg IV

Followed by:

Cefazolin 2g IV q8h

PLUS

Vancomycin 15mg/kg IV q12h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV STAT followed by 600mg IV q8h

Vancomycin 15-20mg/kg IV STAT followed by 15mg/kg IV q12h

Remarks & Clinical Comments:

Single dose

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AdultA3CHEMOPROPHYXLAXIS

2. VASCULAR SURGERY

2.2 Amputation of Ischemic Limb

Suspected organism: Staphylococcus spp. Anaerobic organism

Preferred Regimen

Ampicillin/Sulbactam 3g IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/Clavulanate 1.2g IV

Remarks & Clinical Comments:

Single dose

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AdultA3CHEMOPROPHYXLAXIS

2. VASCULAR SURGERY

2.2 Amputation of Ischemic Limb

Suspected organism: Staphylococcus spp. Anaerobic organism

Reference: 1. Bratzler DW, Dellinger EP, Olsen KM et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm.2013; 70:195-283

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AdultA3CHEMOPROPHYXLAXIS

3. CARDIAC / VASCULAR SURGERY

Examples: • Angioplasty • Stent insertion

Surgical antibiotic prophylaxis not recommended. References: 1. Chung et al., National surgical antibiotic prophylaxis guideline in Singapore. Ann Acad Med Singap. 2022 Nov; 51(11):695-711.

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PaediatricB3CHEMOPROPHYLAXIS

3. HEPATOBILIARY SURGERY

Biliary tract (Cholecystectomy, Choledochal cysts excision, On Table Cholangiogram)

Preferred Regimen

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Ampicillin/sulbactam 50mg/kg (of ampicillin component) IV

Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 50-75mg/kg IV; max. 2g

Cefotaxime 50mg/kg; max. 1g

Recommended re-dosing interval from initiation of pre -operative dose: every 3 hours

PLUS

Metronidazole 15 mg/kg IV

(For neonates less than 1200g, to give 7.5 mg/kg)

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg IV; max 900mg Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours PLUS Gentamicin 2.5 mg/kg IV Refer to Appendix 3 for antibiotic allergy.

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PaediatricB3CHEMOPROPHYLAXIS

3. TROPICAL INFECTION

3.1 Malaria Prophylaxis

Preferred Regimen

For chloroquine-sensitive area:

Chloroquine dose: 5mg/kg base (8.3mg/kg salt) orally, once weekly, up to maximum adult dose of 300mg base (begin 1-2 weeks before travelling and take weekly through-out and 4 weeks after leaving area)

For chloroquine-resistant area:

Mefloquine^∞^: weekly dose by weight in kg (tablet with 250 mg base, 274 mg salt)

≤ 9 kg – 5mg/kg weekly

>9-19 kg – 1/4 adult tablet weekly

>19-30 kg – ½ adult tablet weekly

>30-45 kg – ¾ adult tablet weekly

>45 kg – 1 adult tablet weekly

Start 2-3 weeks before, continue weekly during exposure and for 4 weeks thereafter.

Age >8 years old:

Doxycycline 2.2mg/kg once daily up to 100mg/day. Take 1-2 days before, during and 4 weeks after travelling.

Alternative Regimen (Allergy / Resistance)

Atovaquone-proguanil (Malarone^®^)*

Paediatric dose:

5-8 kg – ½ paediatric tablet daily

9-10 kg – ¾ paediatric tablet daily

11-20 kg – 1 paediatric tablet daily

21-30 kg – 2 paediatric tablets daily

31-40 kg – 3 paediatric tablets daily

> 40 kg – 1 adult tablet daily

Start prophylactic treatment with Malarone^®^ 1 or 2 days before entering a malaria-endemic area and continue daily during the stay and for 7 days after return.

Remarks & Clinical Comments:

∞ Mefloquine: Not recommended if there are cardiac conduction abnormalities, seizures or psychiatric disorders. E.g.: depression, psychosis. (Black box warning: Neuropsychiatric reactions may persist even after discontinuation). If using Mefloquine: Start 2-3 weeks before, continue weekly during exposure and 4 weeks thereafter. * Atovaquone/proguanil is another drug used in malaria prophylaxis in children (for chloroquine-resistance) BUT not yet registered in Blue Book (available commercially in Malaysia). *To carefully assess risk and benefit of starting antimalarial prophylaxis to any children to prevent development of drug resistance.

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PathwayC3ACUTE PHARYNGITIS

ACUTE PHARYNGITIS

Acute pharyngitis 09.12.2025.pdf

Attached Clinical Documents:

Acute pharyngitis 09.12.2025.pdf

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PaediatricB3CHEMOPROPHYLAXIS

4. NEUROSURGERY

Elective craniotomy & cerebrospinal fluid-shunting procedures

Preferred Regimen

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Alternative Regimen (Allergy / Resistance)

Cefuroxime 50mg/kg IV; max. 1.5g

If known to have MRSA/MRSE colonisation, use vancomycin 15mg/kg IV

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg; max. 900 mg Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours Refer to Appendix 3 for antibiotic allergy.

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AdultA3CHEMOPROPHYXLAXIS

4. GENERAL SURGERY

4.1 Gastroduodenal and Oesophageal

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

Severe penicillin allergy:

Gentamicin 5mg/kg IV; MAY ADD Clindamycin 600-900mg IV

Remarks & Clinical Comments:

Single dose

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PaediatricB3CHEMOPROPHYLAXIS

4. OTHER INFECTIONS

4.1 Haemophilus influenza Type B Exposure

Preferred Regimen

Rifampicin

≤ 1 month of age:

10mg/kg/dose PO q24h for 4 days

>1 month of age:

20mg/kg/dose PO q24h for 4 days (max. 600mg/dose)

Remarks & Clinical Comments:

Chemoprophylaxis is indicated for: 1.ALL household contacts in the following circumstances (household contact is defined as a person who resides with the index patient or who spent ≥ 4 hours with the index patient for at least five of the seven days before the day of hospital admission of the index case): • Household with at least one contact <4 years old who is unimmunised or incompletely immunised. • Household with a contact who is an immunocompromised child, regardless of that child's Hib immunisation status. • Household with a child younger than 12 months who has not completed the primary Hib series. 2.Nursery Contact For ALL attendees in childcare & preschool (regardless of age or vaccination status) when unimmunised or incomplete immunised children attend the facility and two or more cases of Hib invasive disease have occurred within 60 days. 3. Index case Prior to discharge if did not receive at least ONE dose of cefotaxime/ ceftriaxone and infants younger than 2 years. For contacts < 2 years old who are not immunised: complete immunisation.

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AdultA3CHEMOPROPHYXLAXIS

4. GENERAL SURGERY

4.2 Appendectomy

Preferred Regimen

Cefazolin 2g

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Amoxicillin-clavulanate 1.2g IV

Severe penicillin allergy:

Gentamicin 5mg/kg IV; MAY ADD Clindamycin 600-900mg IV

Remarks & Clinical Comments:

The determinant of antibiotic duration is the surgical findings of perforation. If appendectomy shows no perforation, antibiotics are for prophylaxis only (single dose) and should not be continued postoperatively. Otherwise, antibiotics should be continued to treat perforated appendicitis (see section on Gastrointestinal & Hepatobiliary Infections . Clindamycin resistance has been increasing in Bacteroides species. Metronidazole may be preferred if the procedure transverses the lower gastrointestinal tract.

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4. OTHER INFECTIONS

4.2 Meningococcal Exposure

Preferred Regimen

Ciprofloxacin

< 1 year: 30mg per kg (max. 125mg) stat

1-4 years: 125mg stat

5-11 years: 250mg stat

≥ 12 years: 500mg stat

Alternative Regimen (Allergy / Resistance)

Ceftriaxone IM

< 15 years old: 125mg stat

≥ 15 years old: 250mg stat

Rifampicin

< 1 month old:

5mg/kg/dose PO q12h for 2 days

≥ 1 month old:

15-20mg/kg/dose (max. 600mg/dose) PO q12h for 2 days

Remarks & Clinical Comments:

Tailor antibiotic prophylaxis based on sensitivity of the index case. Chemoprophylaxis is provided to close contact at HIGH RISK which include: • All household especially children younger than 2 years old. • Childcare or preschool contact at any time during 7 days before onset of illness. • Direct exposure to index patient’s secretion through kissing or through sharing toothbrushes or eating utensils at any time during 7 days before onset of illness. • Frequently slept in same place as index patient during 7 days before onset of illness. Healthcare staff Routine prophylaxis is not recommended unless there is intimate exposure to respiratory secretion during mouth-to-mouth resuscitation, unprotected contact during intubation/suctioning at any time 7 days before onset of illness or within 24 hours of initiation of effective antimicrobial therapy. Give chemoprophylaxis to index case prior to discharge if treated with regimens other than cefotaxime or ceftriaxone. Chemoprophylaxis is ideally initiated within 24 hours after index patient is identified; prophylaxis is not indicated more than 2 weeks after exposure.

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4. OTHER INFECTIONS

4.3 Neonatal Group B Streptococcus Infection

Preferred Regimen

Intrapartum maternal prophylaxis:

Benzylpenicillin 5 million units IV loading, then 2.5-3.0 million units IV q6h till delivery

Alternative Regimen (Allergy / Resistance)

Ampicillin 2g IV loading, then 1g IV q6h till delivery

Antibiotic allergy:

Low risk anaphylaxis

Cefazolin 2g IV loading then 1g IV q8h till delivery

High risk anaphylaxis

Clindamycin 900mg IV q8h till delivery

Vancomycin 1g IV loading, then q12h till delivery (if clindamycin resistant)

Remarks & Clinical Comments:

Treat during labour if previously delivered infant with invasive GBS, GBS bacteriuria or antenatal screening swabs positive OR if GBS status is not known AND any of the following: • Preterm <37 weeks • PROM >18 hours • Intrapartum temperature >38ºC Refer to Appendix 3 for antibiotic allergy.

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4. GENERAL SURGERY

4.3 Small Intestine

Preferred Regimen

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Severe penicillin allergy:

Gentamicin 5mg/kg IV; MAY ADD Clindamycin 600-900mg IV

Remarks & Clinical Comments:

Single dose

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4. GENERAL SURGERY

4.4 Colorectal

Preferred Regimen

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

*To be used only in conjunction with Mechanical Bowel Preparation (MBP) (if given):

Neomycin sulfate 1g PO

PLUS

Erythromycin base 1g PO

Neomycin sulfate 1g PO

PLUS

Metronidazole 1g PO

Alternative Regimen (Allergy / Resistance)

Cefoperazone 2g IV

Ceftriaxone 2g IV

PLUS

Metronidazole 500mg IV

Severe penicillin allergy:

Gentamicin 5mg/kg IV;

MAY ADD Metronidazole 500mg IV OR Clindamycin 600-900mg IV

Remarks & Clinical Comments:

Single dose Clindamycin resistance has been increasing in Bacteroides species. Metronidazole may be preferred if the procedure transverses the lower gastrointestinal tract. *3 doses in conjunction with MBP over 10 hours the day before surgery (between 1pm – 11pm). The need for MBP + PO prophylaxis to be decided by individual institution.

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4. OTHER INFECTIONS

4.4 Pertussis

Post-exposure prophylaxis (PEP)

Preferred Regimen

*Azithromycin

<1 month old till 5 months old: 10mg/kg/day PO in a single dose q24h for 5 days

6 months & older:

10mg/kg/day PO in a single dose on Day 1, (max. 500mg) then 5mg/kg/dose (max. 250mg) on Day 2-Day 5.

Clarithromycin

< 1 month: not recommended

≥ 1 month till 12 years: 15mg/kg/day PO q12h (max. 1g/day)

≥ 12 years till adult: 1g per day PO q12h for 7 days

Alternative Regimen (Allergy / Resistance)

*Erythromycin

<1 months: not preferred. Use only if azithromycin is not available.

≥ 1 month till adult:

Erythromycin ethylsuccinate:

40-50mg/kg/day PO in 2 divided doses for 14 days (max. 2g/day)

Trimethoprim/sulfamethoxazole

2 months & older:

8mg (TMP)/kg/day PO in 2 divided doses for 14 days. (max. 320mg TMP/day)

Remarks & Clinical Comments:

Drug of choice for PEP and treatment is a macrolide. Azithromycin is the preferred macrolide. *Association between orally administered azithromycin and erythromycin with infantile hypertrophic pyloric stenosis (especially in infant <6 weeks) has been reported but azithromycin remains the drug of choice in very young infants because the risk of developing severe disease outweighs the potential risk. Antimicrobial prophylaxis is recommended for: 1. ALL household contacts of the index cases & other close contacts, including children in childcare, regardless of immunisation status. 2. When considering borderline degree of exposure for a non-household contact, PEP should be administered if contact personally is at high risk^∞^ or lives in a household with person at high risk of severe disease (E.g.: young infant, pregnant women, person who has contact with infants). 3. Close contacts who are unimmunised or under immunised should have pertussis immunisation initiated or continued using age-appropriate products according to the recommended schedule as soon as possible (this include off-label Tdap in children 7-9 years old who did not complete DTaP series.) ^∞^High risk: Infant, women at third trimester of pregnancy and people with pre-existing health conditions that may be exacerbated by pertussis infection (not limited to immunocompromised individuals & those with moderate to severe asthma).

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4. GENERAL SURGERY

4.5 Hernia Repair with Mesh

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV

Remarks & Clinical Comments:

Single dose. Includes laparoscopic repair. Antibiotic not required for hernia repair with no mesh placement.

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4. OTHER INFECTIONS

4.5 Varicella (Chicken pox)

Post-exposure prophylaxis

Preferred Regimen

Potential interventions for people without evidence of immunity exposed to varicella (chicken pox) following significant exposure*:

1. Varicella vaccine:

Within 3-5 days of exposure for susceptible healthy adult/child 12 months old or older (followed by a second dose at age-appropriate interval)

2. When indicated & available, Varicella zoster immune globulin (VZIG)**:

VZIG dose as per product information; weight-based as soon as possible after exposure up to 10 days after

AND

Acyclovir 20mg/kg/dose PO q6h (max. 3200mg/day) beginning 7-10 days after exposure & continue for 7 days to prevent breakthrough VZV after VZIG or IVIG if no contraindications.

3. When VZIG not available:

IVIG (400mg/kg) IV once

AND

Acyclovir 20mg/kg/dose PO q6h (max. 3200mg/day) beginning 7-10 days after exposure & continue for 7 days to prevent breakthrough VZV after VZIG or IVIG if no contraindications.

Remarks & Clinical Comments:

*Exposure is significant if: 1.Household: Residing in the same household 2.Playmate: Face-to-face indoor play ≥1 hour 3.Hospital: In same 2 to 4-bed room or adjacent beds in a large ward, face-to-face contact with an infectious staff member or patient, or visit by a person deemed contagious 4.Newborn infant For patients who are at high risk for severe infection & complications* & significant exposure^*^ (and have contraindications to vaccine). ***Susceptible hosts include: 1.Immunocompromised children 2.Pregnant women, newborns of mothers with Varicella shortly before or after delivery (i.e.: 5 days before or within 2 days after delivery) 3.Premature infants born at ≥28 weeks of gestation who are exposed during their hospitalization & whose mothers do not have evidence of immunity 4.Premature infants born at <28 weeks of gestation or birth weight ≤1000 g regardless of their mothers' immunity. Patients receiving monthly high dose IVIG (≥400 mg/kg) are likely to be protected & probably do not require VZIG if the most recent dose of IVIG was administered ≤3 weeks before exposure.

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4. GENERAL SURGERY

4.6 Breast Cancer Surgery

Without oncoplastic/ reconstruction surgery

Preferred Regimen

Surgical antibiotic prophylaxis not recommended.

*For patients with risk factors:

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Surgical antibiotic prophylaxis not recommended.

*Severe penicillin allergy for patients with risk factors:

Clindamycin 600-900mg IV

Vancomycin 15-20mg/kg IV

Remarks & Clinical Comments:

Single dose. *Risk factors: • Post neo-adjuvant chemotherapy • Immunocompromised individuals

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4. GENERAL SURGERY

4.7 Breast Lump Excision Biopsy

Wire localisation excision biopsy

Surgical antibiotic prophylaxis not recommended. Refer to Breast Cancer Surgery for antibiotic choices if prophylactic antibiotic is required. Prophylactic antibiotic should not exceed single dose.

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5. HEPATOBILIARY SURGERY

5.1 Biliary Tract Surgery

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/Clavulanate 1.2g IV

Ceftriaxone 2g IV

Severe Penicillin Allergy:

Vancomycin 15-20mg/kg IV

Clindamycin 600-900mg IV

PLUS

Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single Dose It is reasonable to give single dose prophylaxis for patients undergoing laparoscopic cholecystectomy although evidence showed that antibiotic not required in low risk patients. This is because some of these risk factors cannot be determined before surgery.

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5. ORTHOPAEDIC SURGERY

5.1 Clean Operations Involving Hand, Knee, or Foot & Not Involving Implantation of Foreign Materials

Surgical antibiotic prophylaxis not recommended.

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5. HEPATOBILIARY SURGERY

5.2 Hepatectomy

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/Clavulanate 1.2g IV

Ceftriaxone 2g IV

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV

Clindamycin 600-900mg IV

PLUS

Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single dose Duration: Up to 24 hours If procedure is expected to involve lower GI tract, consider adding anaerobic coverage.

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5. ORTHOPAEDIC SURGERY

5.2 Spinal Procedure with or without Instrumentation/Hip Surgery/ Implantation of Internal Fixation Devices (e.g.: nails, screws, plates, wires)

Preferred Regimen

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg; max. 900 mg Recommended re-dosing interval from initiation of pre -operative dose: q6h Refer to Appendix 3 for antibiotic allergy.

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5. HEPATOBILIARY SURGERY

5.3 Splenectomy or Left Sided Pancreatic Surgery

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV

Remarks & Clinical Comments:

Single Dose There is no need to extend duration for patients who are not immunized. Administer appropriate immunizations.

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5. HEPATOBILIARY SURGERY

5.4 Post Splenectomy - Antibiotic Prophylaxis

At risk for Pneumococcus, Meningococcus & Haemophilus infection

Preferred Regimen

Phenoxymethylpenicillin (Penicillin V) 250mg PO q12h

Alternative Regimen (Allergy / Resistance)

Amoxicillin 250mg PO q24h

Severe penicillin allergy:

Cephalexin 250mg PO q12h

Azithromycin 250mg PO q24h

Remarks & Clinical Comments:

Duration of chemoprophylaxis: At least 1 year following splenectomy. Risk of sepsis remains lifelong and is highest in immunocompromised patients. Duration of chemoprophylaxis should be individualized based on patient’s risk factors: • Severely immunosuppressed patient • Patient with hematological malignancy • Patient who has survived severe sepsis Post-splenectomy counselling with regards to need for repeated vaccinations and appropriate health-seeking behavior in the event of fever. • Pamphlet • Post splenectomy card

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5. HEPATOBILIARY SURGERY

5.5 Post Splenectomy - Vaccination

At risk for Pneumococcus, Meningococcus & Haemophilus infection

Preferred Regimen

Initial - Single dose only

• Pneumococcal PCV13 0.5ml IM/SC stat,

followed by PPV23 0.5ml IM/SC stat (8 weeks interval)

• *Meningococcal A,C,Y,W 135 0.5ml IM stat

• Haemophilus influenzae Type B conjugate 0.5ml IM/SC stat

*Co-administration of meningococcal ACYW135 (MenACWY-D) with PCV13 may result in immune blunting, hence should be administered at least 4 weeks apart.

Revaccination - Every 5 years

• **Pneumococcal PPV23 0.5ml IM/SC stat

• Meningococcal A,C,Y,W 135 0.5ml IM stat

Remarks & Clinical Comments:

Elective splenectomy: Administer vaccines at least 2 weeks before procedure Emergency splenectomy: Give vaccine at least 7 days postoperatively or on the day of discharge, whichever comes first It is safe to give all the initial vaccinations at the same time using different administration sites. A third dose is recommended at the age of 60 years OR** a minimum of 5 years after the second dose, whichever is later. You can have a maximum of 3 doses of Pneumovax 23(23vPPV) as an adult (> 18 years). If you have your spleen removed after 60 years of age, only a single booster dose is recommended (i.e. the third and final dose is not given).

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5. HEPATOBILIARY SURGERY

5.6 Whipple's Operation

No recent biliary intervention/stenting

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 1.2g IV

Ceftriaxone 2g IV

Severe penicillin allergy:

Vancomycin 15-20mg/kg IV

Clindamycin 600-900mg IV

PLUS

Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single dose Duration: Up to 24 hours For patients with recent biliary interventions/stenting, there is a higher incidence of bacteria with ESBL-producers. Antibiotic should be tailored to in-house antibiogram or recent bile/blood culture from the patients

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5. HEPATOBILIARY SURGERY

5.7 Endoscopic Retrograde Cholangio-pancreatography (ERCP)

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

Remarks & Clinical Comments:

Single dose Antibiotics are ONLY recommended when there is: • Incomplete biliary drainage • Obstructive biliary tract disease

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6. OTORHINOLARYNGOLOGY SURGERY (HEAD & NECK)

6.1 Clean

Tonsillectomy, adenoidectomy, tracheostomy, thyroglossal cyst excision, preauricular sinus, dermoid cyst, brachial anomaly, thyroidectomy, parotidectomy, lymph node biopsy etc.

Surgical antibiotic prophylaxis not recommended.

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6. NEUROSURGERY

6.1 Clean Wounds

• Uninfected operative wounds in which no inflammation is encountered • No viscus is entered during the procedures • E.g.: Elective craniotomy, spinal procedures

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

Severe penicillin allergy:

*Vancomycin 15-20mg/kg IV

Clindamycin 600mg-900mg IV

Remarks & Clinical Comments:

Single dose *Situation where the use of vancomycin is appropriate: • In patients previously colonized with MRSA • Those who are allergic to penicillins or cephalosporins • In hospitals in which MRSA or MRCoNS are frequent causes of postoperative wound infection Rapid IV administration of vancomycin may cause vancomycin infusion reaction AND/OR hypotension.

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6. OTORHINOLARYNGOLOGY SURGERY (HEAD & NECK)

6.2 Clean with Placement of Prosthesis

Excludes tympanostomy tubes

Preferred Regimen

Cefazolin 30mg/kg IV (max. 2g/dose)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 50mg/kg (of Ampicillin component; max.2g/dose) IV

Recommended re-dosing interval from initiation of pre-operative dose: every 2 hours

Cefuroxime 50mg/kg IV; (max. 1.5g/dose)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg IV (max. 900mg) Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours Refer to Appendix 3 for antibiotic allergy.

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6. NEUROSURGERY

6.2 Clean Wounds with Foreign Body or Instrumentation

• CSF shunting procedures • Implantation of cranial or spinal implants

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

Severe penicillin allergy:

*Vancomycin 15-20mg/kg IV

Clindamycin 600mg-900mg IV

Remarks & Clinical Comments:

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6. OTORHINOLARYNGOLOGY SURGERY (HEAD & NECK)

6.3 Clean-contaminated Procedures with the Exception of Tonsillectomy & Functional Endoscopic Sinus Procedure

Preferred Regimen

Cefazolin 30mg/kg IV (max. 12g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

PLUS

Metronidazole 15mg/kg IV (max. 1.5g/day)

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 50mg/kg (of ampicillin component; max. 8g/day) IV

Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours

Cefuroxime 50mg/kg IV; (max. 6g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

PLUS

Metronidazole 15mg/kg IV (max. 1.5g/day)

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg IV (max. 3.6g/day) Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours

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6. NEUROSURGERY

6.3 Clean-contaminated Wounds

Procedures that breach air cells or nasal or oral cavity: • Transphenoidal • Transoral • Trauma or surgery that causes a breach in air sinuses

Preferred Regimen

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

*Vancomycin 15-20mg/kg IV

PLUS

Gentamicin 5mg/kg IV

PLUS

Metronidazole 500mg IV

Remarks & Clinical Comments:

Single dose Consider escalation to ceftriaxone 2g IV if there is dura breach or CSF leak. *Situation where the use of vancomycin is appropriate: • In patients previously colonized with MRSA • Those who are allergic to penicillins or cephalosporins • In hospitals in which MRSA or MRCoNS are frequent causes of postoperative wound infection Rapid IV administration of vancomycin may cause Vancomycin infusion reaction AND/OR hypotension.

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6. OTORHINOLARYNGOLOGY SURGERY (HEAD & NECK)

6.4 Clean-contaminated Cancer Surgery

Preferred Regimen

Cefazolin 30mg/kg IV (max. 12g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

PLUS

Metronidazole 15mg/kg IV (max. 1.5g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 8 hours

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 50mg/kg (of ampicillin component) IV (max. 8g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours

Cefuroxime 50mg/kg IV (max. 6g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

PLUS

Metronidazole 15mg/kg IV (max. 1.5g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 8 hours

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg IV (max. 900mg) Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours

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7. PLASTIC SURGERY

7.1 Elective Soft Tissue Surgery

No prophylaxis unless complex prolonged procedure If complex, Cloxacillin 25mg/kg IV; max. 1g Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.1 Normal Vaginal Delivery - Non-operative/instrumental

Surgical antibiotic prophylaxis not recommended.

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7. PLASTIC SURGERY

7.2 Elective Hand or Foot Surgery Involving Bone

Preferred Regimen

Cloxacillin 25mg/kg IV; max. 1g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg IV; max. 900mg Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours Refer to Appendix 3 for antibiotic allergy.

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AdultA3CHEMOPROPHYXLAXIS

7. OBSTETRICS & GYNAECOLOGY SURGERY

7.2 Normal Vaginal Delivery - Operative Vaginal Deliveries

Preferred Regimen

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Ampicillin/Sulbactam 3g IV

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV

Remarks & Clinical Comments:

Single dose after delivery Please refer to Obstetrics & Gynaecology Infections section for: • Group B Streptococcus (GBS) • Preterm premature rupture of membranes (PPROM) prophylaxis

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.3 1st & 2nd Degree Perineal Tear

Surgical antibiotic prophylaxis not recommended.

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7. PLASTIC SURGERY

7.3 Cleft lip & palate surgery

Preferred Regimen

Amoxicillin/clavulanate 30mg/kg; max. 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg; max. 900mg Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours Refer to Appendix 3 for antibiotic allergy.

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.4 3rd & 4th Degree Perineal Tear

Preferred Regimen

Cefazolin 2g IV q8h

PLUS

Metronidazole 500mg IV q8h

Alternative Regimen (Allergy / Resistance)

Ampicillin/Sulbactam 3g IV q6h

Amoxicillin/Clavulanate 1.2g IV q8h

Severe penicillin allergy:

Clindamycin 600-900mg IV q6-8h

Remarks & Clinical Comments:

Duration: 5-7 days

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7. PLASTIC SURGERY

7.4 Excision & Grafting Surgery

Preferred Regimen

Amoxicillin/clavulanate 30mg/kg; max. 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg; max. 900mg Recommended re-dosing interval from initiation of pre -operative dose: every 6 hours Refer to Appendix 3 for antibiotic allergy.

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.5 Cesarean Section (Elective/Emergency)

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Ampicillin/Sulbactam 3g IV

Severe penicillin allergy:

Clindamycin 900mg IV

Remarks & Clinical Comments:

Single dose Continuation of antimicrobial prophylaxis (max up to 2 days) may be considered for patients with major risk factors for surgical infections. E.g.: • Obesity • Complicated cesarean • Immunocompromised

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.6 Manual Removal of Placenta

Preferred Regimen

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Ampicillin 2g IV

PLUS

Metronidazole 500mg IV

Amoxicillin/Clavulanate 1.2g IV

Remarks & Clinical Comments:

Single dose

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.7 Evacuation of Retained Product of Conception (ERPOC)

Preferred Regimen

1st trimester:

Doxycyline 400mg PO as a single dose

(1-2 hours prior to procedure)

2nd trimester:

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

1st trimester:

Azithromycin 1g PO (1-2 hours prior to procedure)

2nd trimester:

Ampicillin 2g IV

PLUS

Metronidazole 500mg IV

Amoxicillin/Clavulanate 1.2g IV

Remarks & Clinical Comments:

Single dose

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.8 Surgical Termination of Pregnancy

Preferred Regimen

Doxycyline 400mg PO as a single dose

(1-2 hours prior to procedure)

Alternative Regimen (Allergy / Resistance)

Azithromycin 1g PO (1-2 hours prior to procedure)

Remarks & Clinical Comments:

Single dose

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AdultA3CHEMOPROPHYXLAXIS

7. OBSTETRICS & GYNAECOLOGY SURGERY

7.9 Elective Surgery - Laparoscopic surgery

Vagina and/or uterus not entered

Surgical antibiotic prophylaxis not recommended.

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.10 Elective Surgeries - TAHBSO, Hysterectomy, Laparoscopy

• Vaginal or Abdominal Hysterectomy • Vagina and/or uterus entered during laparoscopy

Preferred Regimen

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Ampicillin/Sulbactam 3g IV

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV

PLUS

Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single dose

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AdultA3CHEMOPROPHYXLAXIS

7. OBSTETRICS & GYNAECOLOGY SURGERY

7.12 Hysterosalpingography (HSG) / Hysteroscopy

Surgical antibiotic prophylaxis not recommended. Risk of infection is very low, antibiotic prophylaxis generally not necessary unless high risk (associated with risk of post-operative PID/endometritis). E.g.: • Dilated fallopian tubes • History of pelvic inflammatory disease (PID) • Tubal damage • Abnormal tubal architecture (associated with risk of post-operative PID/ endometritis) If evidence of endometritis/ infection found at point of procedure, treat accordingly.

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.13 Endometrial biopsy / Cervical tissue excision / Cervical cone procedures

Surgical antibiotic prophylaxis not recommended.

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7. OBSTETRICS & GYNAECOLOGY SURGERY

7.14 Intra-uterine device (IUD) Insertion

Surgical antibiotic prophylaxis not recommended. Consider sexually transmitted infections (STI) screening in high-risk populations and advise to complete treatment prior procedure. Risk of infection is very low, antibiotic prophylaxis generally not necessary unless high risk (associated with risk of post-operative PID/endometritis). E.g.: • Dilated fallopian tubes, • History of pelvic inflammatory disease (PID) • Tubal damage • Abnormal tubal architecture If evidence of endometritis/ infection found at point of procedure, treat accordingly. References: 1. Chung et al., National surgical antibiotic prophylaxis guideline in Singapore. Ann Acad Med Singap. 2022 Nov; 51(11):695-711. 2. American Congress of Obstetrics & Gynecologist (ACOG) 2018 3. Prevention and Management of Third & Fourth Degree Tears, NHS Wales, Feb 2019 4. Heisterberg, L., Petersen, K., Sørensen, S. S., & Nielsen, D. (1986). A comparison of metronidazole and ampicillin prophylaxis to women with a history of pelvic inflammatory disease undergoing first-trimester abortion. International Journal of Gynecology & Obstetrics, 24(5), 343–346. doi:10.1016/0020-7292(86)90152-9

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8. THORACIC SURGERY

Non-cardiac including lobectomy, pneumonectomy, segmentectomy, lung biopsy & thoracotomy

Preferred Regimen

Cefazolin 30mg/kg IV (max. 12g/day)

Recommended re-dosing interval from initiation of pre -operative dose: every 4 hours

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 50mg/kg (of Ampicillin component; max. 2g/dose) IV

Recommended re-dosing interval from initiation of pre -operative dose: every 2 hours

Remarks & Clinical Comments:

Antibiotic allergy: Clindamycin 10mg/kg IV (max. 3.6g/day) Recommended re-dosing interval from initiation of pre-operative dose: every 6 hours Refer to Appendix 3 for antibiotic allergy.

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8. OPHTHALMOLOGY SURGERY

8.1 Intraocular Surgery - Preoperative

Preferred Regimen

Povidone Iodine 10% to the periorbital skin

Povidone Iodine 5% into the conjunctival sac

Remarks & Clinical Comments:

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AdultA3CHEMOPROPHYXLAXIS

8. OPHTHALMOLOGY SURGERY

8.2 Intraocular Surgery - Intraoperative

Preferred Regimen

Intracameral Injection of Cefuroxime 1mg / 0.1ml

Alternative Regimen (Allergy / Resistance)

*Intracameral Injection Moxifloxacin 0.5mg / 0.1ml (0.5%)

Remarks & Clinical Comments:

*Alternative in patients with penicillin allergy (OFF-LABEL) ● Guidelines on Off Label Drugs applies ● Informed consent required

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8. OPHTHALMOLOGY SURGERY

8.3 Intraocular Surgery - Postoperative

Preferred Regimen

Intracameral Injection of Cefuroxime 1mg / 0.1ml

Alternative Regimen (Allergy / Resistance)

*Intracameral Injection Moxifloxacin 0.5mg / 0.1ml (0.5%)

Remarks & Clinical Comments:

*Alternative in patients with penicillin allergy (OFF-LABEL) ● Guidelines on Off Label Drugs applies ● Informed consent required

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8. OPHTHALMOLOGY SURGERY

8.3 Intraocular Surgery - Postoperative

Preferred Regimen

Topical Antibiotics

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8. OPHTHALMOLOGY SURGERY

8.3 Intraocular Surgery - Postoperative

Reference: 1. Prophylaxis for intraocular surgery-CPG for Management of Post-Operative Endophthalmitis, Ministry of Health Malaysia, August 2006

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9. ORAL / DENTAL SURGERY

9.1 Clean Surgery (Class 1)

• Submandibular gland surgery • Temporomandibular joint (TMJ) surgery • Excision of benign tumours /cysts

Not indicated for most surgeries. May be indicated • If the duration of the surgery is expected to be very long • For open reduction and internal fixation of facial bone fractures Prophylaxis is recommended for all patients with an increased risk of surgical wound infection - i.e. in immunocompromised patients. Please refer section 9.3 for choices of antibiotic prophylaxis if indicated.

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9. UROLOGY SURGERY

9.1 Low Tract Instrumentation with Risk Factors for Infections

Preferred Regimen

Trimethoprim 2mg/kg PO; max. 100mg

Alternative Regimen (Allergy / Resistance)

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Remarks & Clinical Comments:

Antibiotic allergy: Gentamicin 2.5mg/kg IV Refer to Appendix 3 for antibiotic allergy.

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9. UROLOGY SURGERY

9.2 Clean without entry into urinary tract/clean with entry into urinary tract (e.g.: hypospadias surgery)

Preferred Regimen

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 30mg/kg IV; max 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Remarks & Clinical Comments:

UTI should be treated before procedure when possible. Medical literature does not support continuing antimicrobial prophylaxis until urinary catheter have been removed.

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9. ORAL / DENTAL SURGERY

9.2 Minor Clean-contaminated surgery (Class 2)

• Soft tissue surgery • Dentoalveolar surgery • Periodontal surgery

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9. UROLOGY SURGERY

9.3 Clean-contaminated

Entering gastrointestinal tract

Preferred Regimen

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

PLUS

Metronidazole 15 mg/kg IV; max. 500mg

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 30mg/kg IV; max 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Remarks & Clinical Comments:

Antibiotic allergy: Gentamicin 2.5mg/kg IV Refer to Appendix 3 for antibiotic allergy.

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9. ORAL / DENTAL SURGERY

9.3 Minor Clean-contaminated surgery (Class 2)

• Insertion of dental implants and use of graft material • High degree of difficulty / long duration

Preferred Regimen

Benzylpenicillin 2MU IV

Alternative Regimen (Allergy / Resistance)

Oral (PO) prophylaxis options

Amoxicillin 2g PO

Amoxicillin/Clavulanate 1.25g PO

Cephalexin 2g PO

PLUS

Metronidazole 400mg PO

Intravenous (IV) prophylaxis options

Ampicillin 2gm IV

Amoxicillin/clavulanate 1.2gm IV

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Severe penicillin allergy:

Clindamycin 600-900mg PO/IV

Remarks & Clinical Comments:

Single dose *Additional of metronidazole only if choice of prophylaxis is cephalosporin. In patients with cardiac conditions with increased risk of Infective Endocarditis, chemoprophylaxis is indicated. Please refer to Chemoprophylaxis Non-Surgical section.

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9. ORAL / DENTAL SURGERY

9.4 Major Clean-contaminated Surgery (Class 3)

• Orthognathic surgery • Excision / enucleation of large benign tumours / cysts • All oral cancer surgery • Open reduction and internal fixation of facial bone fractures

Preferred Regimen

Benzylpenicillin 2MU IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 1.2g IV

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Remarks & Clinical Comments:

Single dose For oral & maxillofacial fractures, antibiotics is recommended for the immediate post trauma period and should be discontinued once open reduction and internal fixation is completed. Additional of metronidazole only if choice of prophylaxis is cephalosporin In patients with cardiac conditions with increased risk of Infective Endocarditis, chemoprophylaxis is indicated. Please refer to Chemoprophylaxis Non-Surgical section.

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9. ORAL / DENTAL SURGERY

9.4 Major Clean-contaminated Surgery (Class 3)

• Orthognathic surgery • Excision / enucleation of large benign tumours / cysts • All oral cancer surgery • Open reduction and internal fixation of facial bone fractures

Reference: 1. Oral Health Division Ministry of Health Malaysia. Antibiotic Prophylaxis in Oral Surgery for Prevention of Surgical Site Infection. Putrajaya: Dental Technology Section Oral Health Division (OHD) Ministry of Health Malaysia; 2015.

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10. ORTHOPAEDIC SURGERY

10.1 Clean Operation Involving Hand, Knee or Foot and Not Involving Implantation of Foreign Materials

Surgical antibiotic prophylaxis not recommended.

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10. INTERVENTIONAL RADIOLOGY

10.1 Percutaneous Endoscopic Gastrostomy (PEG) or Jejunostomy (PEJ) or Nephrostomy Tube Placement

Preferred Regimen

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 30mg/kg IV; max. 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

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10. ORTHOPAEDIC SURGERY

10.2 Fixations of Closed Fracture / Total Joint Replacement / Spine surgery (With and Without instrumentation) / Arthroscopy

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV

Remarks & Clinical Comments:

Single dose The benefits of routine postoperative antibiotic are uncertain. If used, postoperative prophylaxis should not exceed 24 hours.

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10. INTERVENTIONAL RADIOLOGY

10.2 Micturating Cystourethrogram (MCUG)

Preferred Regimen

Trimethoprim 2mg/kg PO; max. 150 mg

(If patient is already on existing antibiotic UTI prophylaxis, increase antibiotic to therapeutic dose for a single dose prior procedure)

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10. INTERVENTIONAL RADIOLOGY

10.3 Tenckhoff Peritoneal Dialysis Catheter Insertion

Preferred Regimen

Cefazolin 30mg/kg IV; max. 2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 30 mg/kg IV; max. 1.2g

Recommended re-dosing interval from initiation of pre -operative dose: q4h

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10. INTERVENTIONAL RADIOLOGY

10.4 Burns

Surgical antibiotic prophylaxis not recommended. ii. NON-SURGICAL

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11. OTORHINOLARYNGOLOGY (ORL) SURGERY

11.1 Clean Head and Neck Procedures

• Thyroidectomy • Parotidectomy • Salivary gland excisions

Surgical antibiotic prophylaxis not recommended.

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11. OTORHINOLARYNGOLOGY (ORL) SURGERY

11.2 Clean-contaminated Head and Neck Procedures

Including neck dissection procedures

Preferred Regimen

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Ampicillin/Sulbactam 3g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single dose Duration: Up to 24 hours Prolonged course of oral antibiotics has not been shown to reduce post-operative infections and may increase risk of complications. *Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site.

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11. OTORHINOLARYNGOLOGY (ORL) SURGERY

11.3 Clean Otologic Procedures

Surgical antibiotic prophylaxis not recommended.

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11. OTORHINOLARYNGOLOGY (ORL) SURGERY

11.4 Clean Otologic Procedures with Placement of Prosthesis

Excluding tympanostomy tubes

Preferred Regimen

Cefazolin 2g IV

Alternative Regimen (Allergy / Resistance)

Severe penicillin allergy:

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single dose *Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site

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11. OTORHINOLARYNGOLOGY (ORL) SURGERY

11.5 Clean-contaminated Otologic Procedures

Example: Mastoidectomy

Preferred Regimen

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single dose Duration: Up to 24 hours *Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site.

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11. OTORHINOLARYNGOLOGY (ORL) SURGERY

11.6 Tonsillectomy

Surgical antibiotic prophylaxis not recommended.

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11. OTORHINOLARYNGOLOGY (ORL) SURGERY

11.7 Septorhinoplasty

Preferred Regimen

Simple septorhinoplasty:

Surgical antibiotic prophylaxis not recommended. Infection rates are very low, especially when nasal packing/splint use ≤ 48 hours.

Complex septorhinoplasty:

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Complex septorhinoplasty:

Amoxicillin/Clavulanate 1.2g IV

Severe penicillin allergy:

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single dose Complex septorhinoplasty: Duration: Up to 24 hours *Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site.

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11. OTORHINOLARYNGOLOGY (ORL) SURGERY

11.8 Endoscopic Sinus Surgery

Preferred Regimen

Cefazolin 2g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/Clavulanate 1.2g IV

Severe Penicillin Allergy

Clindamycin 600-900mg IV; MAY ADD *Gentamicin 5mg/kg IV

Remarks & Clinical Comments:

Single Dose *Addition of gentamicin may be appropriate when there is an increase likelihood of gram-negative contamination of surgical site. Post-operative antibiotics should not be given if there is no mucous seen intra-operatively.

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12. PLASTIC SURGERY

12.1 Clean Procedures

Majority of plastic surgery cases, for example: • Breast reduction • Body contouring surgery • Face lift • Blepharoplasty

Prophylaxis not required unless the patient has risk factors for postoperative infection and poor wound healing. E.g: • Implantation of prosthetic material • Prior skin irradiation

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12. PLASTIC SURGERY

12.2 Clean-contaminated Procedures

• Ear cartilage surgeries • Nasal cartilage surgeries

Preferred Regimen

Cefazolin 2 g IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 1.2g IV

Remarks & Clinical Comments:

Single dose Duration: Up to 24 hours

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12. PLASTIC SURGERY

12.3 Cleft reconstruction and other cleft-related surgeries

Preferred Regimen

Amoxicillin/clavulanate 1.2gm IV q8h

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 3g IV q8h

Remarks & Clinical Comments:

Duration: 3-5 days There is no consensus on the use of post-operative prophylaxis antibiotics. However, studies have shown that postoperative pre-emptive antibiotics may reduce postoperative complications such as palatal fistula.

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12. PLASTIC SURGERY

12.4 Full Thickness Skin Graft Surgery

Non-related to burn injury

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12. PLASTIC SURGERY

12.5 Flap Reconstruction

There is no consensus on the use of antibiotic prophylaxis. The choice of antibiotic will depend on the most recent organism isolated from previous tissue culture and sensitivity obtained from the recipient site. As suggested by SICPRE guidelines, prophylaxis should be prolonged up to 72 hours for: • Microsurgical transplantation • Major skin cancer surgery • Large flap harvest

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12. PLASTIC SURGERY

12.6 Breast Augmentation

Preferred Regimen

Cefazolin 2g IV followed by 2g IV q8h

Remarks & Clinical Comments:

Duration: Up to 24 hour However, as suggested by SICPRE guidelines, prophylaxis can be prolonged up to 72 hours in case of high risk index such as: • Microsurgical transplantation • Major skin cancer surgery • Large flap harvest

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12. PLASTIC SURGERY

12.7 Breast Reconstruction Surgery

Preferred Regimen

Cefazolin 2g IV followed by 2g IV q8h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 1.2g IV followed by 1.2g IV q8h

Severe penicillin allergy

Clindamycin 600-900mg IV STAT followed by 600mg IV q8h

Vancomycin 15-20mg/kg IV STAT followed by 15mg/kg IV q12h

Remarks & Clinical Comments:

Duration: Up to 24 hour Unless a drain is present, antibiotics should be discontinued within 24 hours of the completion of the procedure. If a drain is present, the role of antibiotics is less clear and should be left to physician judgment.

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12. PLASTIC SURGERY

12.7 Breast Reconstruction Surgery

Reference: 1. Antibiotic Expert Groups. Therapeutic guidelines: antibiotics. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014. 2. National Surgical Antibiotic Prophylaxis Guideline Singapore 2022 3. Piccillo EM, Farsar CJ, Holmes DM. Prophylactic Antibiotics After Cleft Lip and Palate Reconstruction: A Review From a Global Health Perspective. Cureus. 2023 Mar 19;15(3):e36371. doi: 10.7759/cureus.36371. PMID: 37090369; PMCID: PMC10113116. 4. Homsy P.,Romo I. et al. Antibiotic Prophylaxis in clean and clean-contaminated plastic surgery: A Critical Review, Volume 83, P233-245. Published April 23, 2023.DOI: http://doi.org/10.1016/j.bjps.2023.04.071 5. Borrelli MR, Sinha V, Landin ML, Chicco M, Echlin K, Agha RA, Ross AM. A systematic review and meta-analysis of antibiotic prophylaxis in skin graft surgery: A protocol. Int J Surg Protoc. 2019 Feb 28;14:14-18. doi: 10.1016/j.isjp.2019.02.001. PMID: 31851735; PMCID: PMC6913549. 6. Brambullo T, Biffoli B, Scortecci L, Messana F, Vindigni V, Bassetto F. Antibiotic Prophylaxis in Plastic Surgery: From Systematic Review to Operative Algorithm. World J Plast Surg. 2022 Jul;11(2):24-36. doi: 10.52547/wjps.11.2.24. PMID: 36117892; PMCID: PMC9446112. 7. Alderman A, Gutowski K, Ahuja A, Gray D, Post Mastectomy Expander Implant Breast Reconstruction Guideline Work Group. ASPS Clnical Practice Guideline Summary on Breast Reconstruction with expanders and implants. Plastic Reconstr Surg. 2014; 134(4):648e-655e. doi:10.1097/PRS.0000000000000541 8. Gupta, R., Sinnett, D., Carpenter, R., Preece, P. E., & Royle, G. T. (2000). Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery. European Journal of Surgical Oncology (EJSO), 26(4), 363–366. doi:10.1053/ejso.1999.0899

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13. UROLOGICAL SURGERY

13.1 Transrectal Ultrasound and Prostate Biopsy

Common organisms: • Esherichia coli • Klebsiella sp • Proteus sp • Enterococcus sp • Pseudomonas aeruginosa

Preferred Regimen

Ampicillin/Sulbactam 3g IV

Amoxicillin/Clavulanate 1.2g IV

PLUS

Gentamicin 3mg/kg IV

Alternative Regimen (Allergy / Resistance)

Fosfomycin trometamol 3g PO 3 hours before procedure, followed by 3g PO 24 hours after procedure

Remarks & Clinical Comments:

Single dose Rectal wash out (rectal povidone-iodine preparation) to further decrease infection risk. Consider pre-operative rectal swab followed by targeted antibiotic prophylaxis

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13. UROLOGICAL SURGERY

13.2 Cystoscopy / Urodynamics study

Preferred Regimen

Surgical antibiotic prophylaxis not recommended

**Prophylaxis may be recommended in *high risk cases:**

Cefuroxime 500mg PO

Remarks & Clinical Comments:

Single dose *High-risk cases: • Immunocompromised patients • Debilitated patients on long term catheters • Patient with prosthesis/ heart valves • Diabetics • Transplant recipients Follow the recommendations outlined in the Non-Surgical Chemoprophylaxis section: Prophylactic Regimens for High-Risk Dental Procedures in High-Risk Patients.

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13. UROLOGICAL SURGERY

13.4 Transperineal Procedures

Clean procedures. E.g: • Prostate bracytherapy • Transperineal prostate biopsy

Preferred Regimen

Surgical antibiotic prophylaxis not recommended

*Prophylaxis may be recommended in patients with risk factors:

Ampicillin/Sulbactam 3g IV

Remarks & Clinical Comments:

Single dose *Risk factors: • Chronic steroid use • Immunocompromising condition • Recent systemic chemotherapy • Poorly controlled diabetes mellitus • Prior severe urosepsis • Post-biopsy infection

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13. UROLOGICAL SURGERY

13.5 Endourological Surgery

Transurethral cases and minimally invasive surgical therapy (MIST) to the prostate. Example: PCNL, URS, RIRS, TURP, TURBT

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV

Ampicillin/Sulbactam 3g IV

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV

Remarks & Clinical Comments:

Common organisms: • Esherichia coli • Klebsiella sp • Proteus sp • Enterococcus sp • Pseudomonas aeruginosa Single dose Antibiotics choices for urine culture negative cases. Consider tailor antibiotic prophylaxis based on pre-procedural latest urine cultures.

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13. UROLOGICAL SURGERY

13.7 Clean-contaminated Procedures (with Opening of Urinary Tract)

Examples: • Nephrectomy • Prostatectomy • Open stone surgery

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV

Ampicillin/sulbactam 3g IV

Alternative Regimen (Allergy / Resistance)

Cefazolin 2g IV

Ceftriaxone 2g IV

PLUS

Gentamicin 3-5mg/kg IV/IM

Remarks & Clinical Comments:

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AdultA3CHEMOPROPHYXLAXIS

13. UROLOGICAL SURGERY

13.8 Clean-contaminated Procedures (with Use of Bowel Segments)

Example: • Cystectomy with urinary diversion • Cystoplasty

Preferred Regimen

Cefuroxime 1.5g IV

PLUS

Metronidazole 500mg IV

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 1.2g IV

Cefoperazone 2g IV

PLUS

Metronidazole 500mg IV

Severe penicillin allergy:

Gentamicin 3-5mg/kg IV

PLUS

Metronidazole 500mg IV

Remarks & Clinical Comments:

Common organisms: • Esherichia coli • Klebsiella sp • Proteus sp • Enterococcus sp • Pseudomonas aeruginosa • Anaerobes Single dose

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13. UROLOGICAL SURGERY

13.9 Implant of Prosthetic Devices

Examples: • Insertion of penile prosthesis • Artificial urinary sphincter (AUS) • Artificial slings • Sacral neuromodulators

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV

Ampicillin/sulbactam 3g IV

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV

MRSA coloniser:

Vancomycin 15-20mg/kg IV

Severe penicillin allergy:

Clindamycin 600-900mg IV

PLUS

Gentamicin 3-5mg/kg IV

Remarks & Clinical Comments:

Common organism: Staphylococcus aureus Single dose

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13. UROLOGICAL SURGERY

13.11 Shock-wave Lithotripsy

Surgical antibiotic prophylaxis not recommended LAPAROSCOPIC SURGERY Recommendation as per open surgery, depending on the type of procedure performed i.e. clean or clean– contaminated. Reference: 1. Urological Infections - European Association of Urology Guidelines March 2023 2. Chung et al., National surgical antibiotic prophylaxis guideline in Singapore. Ann Acad Med Singap. 2022 Nov; 51(11):695-711. 3. Matthew Coates et al. Prophylactic Cefazolin Dosing in Obesity—a Systematic Review. https://doi.org/10.1007/s11695-022-06196-5

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AdultA3CHEMOPROPHYXLAXIS

13. UROLOGICAL SURGERY

13.11 Shock-wave Lithotripsy

ii. NON-SURGICAL CHEMOPROPHYLAXIS

Antibiotic prophylaxis is recommended in patients with cardiovascular diseases undergoing oro-dental procedures at increased risk for infective endocarditis (IE): 1. Patients with previous IE 2. Patients with surgically implanted prosthetic valves and with any material used for surgical cardiac valve repair 3. Patients with transcatheter implanted aortic and pulmonary valvular prostheses 4. Patients with untreated cyanotic CHD, and patients treated with surgery or transcatheter procedures with post-operative palliative shunts, conduits, or other prostheses. After surgical repair, in the absence of residual defects or valve prostheses, antibiotic prophylaxis is recommended only for the first 6 months after the procedure 5. Patients with ventricular assist devices 6. Should be considered in patients with transcatheter mitral and tricuspid valve repair. 7. May be considered in recipients of heart transplant 8. Established rheumatic heart disease Dental Procedures: For patients with increased risk of IE, antimicrobial prophylaxis is recommended for: • Dental extraction • Oral surgery procedures (including periodontal surgery, implant surgery and oral biopsies) • Dental procedures involving manipulation of gingival tissue or the periapical region of teeth (including scaling and root canal procedures) • Implant placement procedures and invasive dental procedures on established implants (Once dental implants are placed in high-risk patients, professional dental hygiene and follow-up should be performed at least twice yearly under antibiotic cover) Respiratory Tract Procedures: Antimicrobial prophylaxis is recommended for patients with increased risk of IE who undergo an invasive respiratory tract procedure that involve incision or biopsy of the respiratory mucosa. Patients who undergo an invasive respiratory tract procedure to treat an established infection, e.g., biopsy drainage of an abscess, should receive an antibiotic prophylaxis which contains an anti-staphylococcal agent. Gastrointestinal or genitourinary procedures: Routine pre-procedural antimicrobial prophylaxis is no longer recommended for patients undergoing genitourinary or gastrointestinal tract procedures. However, for high-risk cardiac patients who have an established gastrointestinal or genitourinary infection, or for those who receive antimicrobial therapy for surgical reasons, the antimicrobial regimen should include an agent active against enterococci, such as ampicillin or vancomycin. Dermatological or musculoskeletal procedures: For patients with increased risk of IE, undergoing surgical procedures involving infected skin (including local abscesses), skin structure or musculoskeletal tissue, it is reasonable that the therapeutic regimen contains an agent active against staphylococci and beta-hemolytic streptococci. Vancomycin or clindamycin may be used in patients unable to tolerate a β-lactam antibiotic. If the infection is known or suspected to be caused by MRSA, vancomycin or another suitable agent should be administered.

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AppendixAPP4ANTIBIOTIC IN PREGNANCY & LACTATION

Appendices

ANTIBIOTIC IN PREGNANCY & LACTATION

Attached Clinical Documents:

Appendix 4 Pregnancy July 2024.pdf

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AdultA4GASTROINTESTINAL INFECTIONS

1. HELICOBACTER PYLORI INFECTION

Preferred Regimen

First line Treatment

Triple Therapy:

*Proton Pump Inhibitors PO q12h

PLUS

Amoxicillin 1g PO q12h

PLUS

Clarithromycin 500mg PO q12h

Second Line Treatment

Bismuth Quadruple regimen:

*Proton Pump Inhibitors PO q12h

PLUS

Tetracycline hydrochloride 500mg PO q6h

PLUS

Metronidazole 400mg PO q8h

PLUS

Bismuth subsalicylate 300mg

Bismuth subcitrate 120-300mg PO q6h

Fluoroquinolones triple therapy:

*Proton Pump Inhibitors PO q12h

PLUS

Levofloxacin 500mg PO q24h

PLUS

Amoxicillin 1g PO q12h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

*Proton Pump Inhibitors PO q12h

PLUS

Clarithromycin 500mg PO q12h

PLUS

Metronidazole 400mg PO q12h

Second Line Treatment

Potassium-Competitive Acid Blockers Triple Therapy:

Potassium-Competitive Acid Blockers PO q12h

PLUS

Amoxicillin 1g PO q12h

PLUS

Clarithromycin 500mg PO q12h

Remarks & Clinical Comments:

*Dosages of Proton Pump Inhibitors: Omeprazole 20mg PO q12h Pantoprazole 40mg PO q12h Lansoprazole 30mg PO q12h Esomeprazole 20mg PO q12h Rabeprazole 20mg PO q12h Dexlansoprazole 30mg PO q12h First line therapy recommended in areas with < 15-20% clarithromycin resistance. Consider second line treatment if clarithromycin resistance exceeds more than 15%. Duration of therapy: 14 days Meta-analysis of RCTs found 14 days duration of therapy showed greater eradication rate. Refer to Appendix 3 for antibiotic allergy.

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AdultA4GASTROINTESTINAL INFECTIONS

2. OROPHARYNGEAL CANDIDIASIS

Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV section.

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PaediatricB4GASTROINTESTINAL INFECTIONS

2. DYSENTERY

2.1 Bacterial Infection

Common organisms: Shigella E. coli Campylobacter

Preferred Regimen

Most are mild infections which resolve spontaneously without antibiotics.

Mild or uncomplicated

Adequate fluid replacement. No antibiotics required.

Severe illness

(hospitalisation, invasive/other complications or immunocompromised patients*)

Ceftriaxone 75-100 mg/kg/day IV q24h (max. 2g/day) for 5 days (origin of infections: Asia)

Alternative Regimen (Allergy / Resistance)

Mild or uncomplicated

Ampicillin 100mg/kg/day PO in 4 divided doses (max. 2g/day) for 5-7 days for hospitalized children

Severe illness

**Ciprofloxacin 20-30mg/kg/day IV in 2 divided doses (max. 1.5g/day) for 3 days

***Azithromycin 10mg/kg/dose IV q24h (max. 500mg/dose).

Total course: 3 days

Remarks & Clinical Comments:

Resistance patterns towards amoxicillin, trimethoprim sulfamethoxazole, ciprofloxacin & azithromycin are on the rise. Adjust antibiotic once culture & sensitivity (C&S) results are available. *For immunocompromised host - treat longer (7-10 days). Reserve fluoroquinolone only for isolate where there is no other antibiotic option available due to its many side effects. *Alternative dosage regimen: Azithromycin 10mg/kg/dose IV q24h Day 1 (max. 500mg/dose) followed by 5mg/kg/dose IV q24h Day 2-5 (max. 250mg/dose). Total course: 5 days

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PaediatricB4GASTROINTESTINAL INFECTIONS

2. DYSENTERY

2.2 Parasitic Infection

2.2.1 Amoebiasis

Preferred Regimen

Metronidazole 30-50mg/kg/day PO in 3 divided doses (max. 800mg/dose) for 7-10 days

Alternative Regimen (Allergy / Resistance)

Remarks & Clinical Comments:

Similar dosage for extraintestinal disease.

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PaediatricB4GASTROINTESTINAL INFECTIONS

2. DYSENTERY

2.2 Parasitic Infection

2.2.2 Giardiasis

Preferred Regimen

Metronidazole 15mg/kg/day PO (max. 250mg) in 3 divided dose (max. 400mg/dose) for 5-7 days

Alternative Regimen (Allergy / Resistance)

Remarks & Clinical Comments:

Similar dosage for extraintestinal disease.

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AdultA4GASTROINTESTINAL INFECTIONS

3. ESOPHAGITIS

Candida spp: Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV section. Herpes simplex virus: Refer to Sexually Transmitted Infections section.

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PaediatricB4GASTROINTESTINAL INFECTIONS

3. TYPHOID FEVER

Common organisms: Salmonella typhi S. paratyphi A & B

Preferred Regimen

Empirical treatment

Ceftriaxone 75-100mg/kg/day IV q24h (max. 2g/day) for 7-14 days

Mild or uncomplicated

*Ciprofloxacin 30-40mg/kg/day PO in 2 divided doses (max. 1.5g/day) for 5-7 days

Severe infection or suspected resistant organism

Ceftriaxone 80-100mg/kg/day IV q24h (max. 2g/day) for 7-14 days

Chronic carrier state (> 1 year)

Ampicillin 100mg/kg/day PO in 4 divided doses (max. 2g/day) for 6 weeks

Amoxicillin 100mg/kg/day PO in 2 divided doses (max. 4g/day) for 6 weeks

Trimethoprim/sulfamethoxazole

8mg (TMP)/kg/day PO in two divided doses (max. 320mg TMP/day) for 6 weeks.

Alternative Regimen (Allergy / Resistance)

Mild or uncomplicated

Azithromycin 20mg/kg/dose PO q24h (max. 1g/dose)

Ampicillin 100mg/kg/day PO in 4 divided doses (max. 2g/day)

Severe infection or suspected resistant organism

*Ciprofloxacin 30-40mg/kg/day IV in 2 divided doses (max. 0.8-1.2g/day) for 7-10 days

Chronic carrier state (> 1 year)

*Ciprofloxacin 20-30mg/kg/day PO in 2 divided doses (max. 1.5g/day) for 4 weeks

Ampicillin 200-300mg/kg/day IV maximum in 4-6 divided doses (max. 12g/day).

(If oral therapy not tolerated & strain is susceptible)

Remarks & Clinical Comments:

Adjust antibiotic once C&S results are known. Duration of antibiotics: 7 days (uncomplicated) to 10 days (for severe disease) or 14 days (if using ampicillin) if patient is clinically improving and without a fever for 48 hours. Choice of antibiotics & duration depends on disease, C&S results & whether oral route is preferred. *Fluoroquinolones need to be used with caution in children due to possible arthropathy & rapid development of resistance. There is now increasing data of other side effects e.g: hypoglycaemia & neuropsychiatric d/o. Ampicillin & trimethoprim/ sulfamethaxazole may be considered for susceptible strain. More strains now becoming sensitive to these agents except for certain countries

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PaediatricB4GASTROINTESTINAL INFECTIONS

4. CHOLERA

Preferred Regimen

Azithromycin 20mg/kg/day PO in a single dose (max. 1g)

Erythromycin ethylsuccinate 12.5mg/kg/dose PO q6h (max. 400mg/dose) for 3 days

*Doxycycline 4.4mg/kg/day PO in a single dose (max. 200mg) for children > 8 years old

Remarks & Clinical Comments:

Oral or IV rehydration is the cornerstone of treatment. Prompt initiation of antibiotic therapy reduces the volume and duration of diarrhoea. Antibiotics should be considered for people who are moderately to severely ill. Antibiotic choice depends on age and pattern of resistance. Monitor antibiotic sensitivity pattern at the beginning of and during the outbreak as it can change. *Avoid using doxycycline for young children as they can cause staining of the teeth. Use of doxycycline should be considered in an epidemic caused by susceptible isolate. Fluoroquinolones are not approved for children younger than 18 years old for this indication.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

Most community-acquired watery diarrhoea are self-limiting and viral in origin (norovirus, rotavirus, and adenovirus), therefore antibiotics should be discouraged. Rehydration and electrolyte replacement are the main treatment for acute infectious diarrhoea. Antibiotics may be considered in the following conditions after blood and stool cultures collection: • Immunocompetent hosts with fever and bloody diarrhoea • Suspected to have enteric fever (Refer to chapter on Typhoid) • Ill immunocompromised hosts

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PathwayC4ACUTE RHINOSINUSITIS

ACUTE RHINOSINUSITIS

Acute rhinosinusitis 10.09.2025.pdf

Attached Clinical Documents:

Acute rhinosinusitis 10.09.2025.pdf

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.1 Empirical Therapy

4.1.1 Mild Infective Diarrhoea

Antibiotic may not be necessary.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.1 Empirical Therapy

4.1.2 Moderate Infective Diarrhoea Requiring Hospitalisation

Preferred Regimen

Azithromycin 500mg PO/IV q24h single dose

Alternative Regimen (Allergy / Resistance)

*Ciprofloxacin 500mg PO q12h

Ciprofloxacin 400mg IV q12h

Duration: 3 days

Remarks & Clinical Comments:

*Fluroquinolone-resistant Campylobacter spp has been increasingly reported.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.1 Empirical Therapy

4.1.3 Severe Infective Diarrhoea Requiring Hospitalisation

• Hypotension • Not responding to fluid resuscitation • Organ failure (E.g.: acute kidney injury)

Preferred Regimen

Ceftriaxone 1g IV q24h

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 400mg IV q12h

Remarks & Clinical Comments:

Duration: 5 - 7days

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.1 Aeromonas spp / Plesiomonas shigelloides / Yersinia enterocolitica

Preferred Regimen

Trimethoprim/sulfamethoxazole 160/800mg PO q12h

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 500mg PO q12h

Remarks & Clinical Comments:

Duration: 3 days Aeromonas spp are uniformly resistant to ampicillin, amoxicilin/clavulanate and cefazolin.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.2 Shiga Toxin Producing E. coli (STEC) / Enteroinvasive E. coli (EIEC)

Supportive care is the mainstay of treatment. Treatment with antibiotics should be avoided due to the risk of inducing haemolytic ureamic syndrome (HUS).

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.3 Enteropathogenic E. coli (EPEC) / Enterotoxigenic E. coli (ETEC) & Enteroaggregative E. coli (EAEC)

Preferred Regimen

Supportive care, including rehydration is the mainstay of treatment.

For severe illness or in immunocompromised host, to consider:

Azithromycin 1g PO single dose

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 750mg PO single dose

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.4 Campylobacter jejuni

Preferred Regimen

Azithromycin 500mg PO q24h

Alternative Regimen (Allergy / Resistance)

Doxycycline 100mg PO q12h

Remarks & Clinical Comments:

Duration: 3 days Consider longer duration of therapy in immunocompromised patients.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.5 Salmonella spp, non-typhi

Preferred Regimen

*Trimethoprim/sulfamethoxazole 160/800mg PO q12h

In HIV patients:

Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV section.

Alternative Regimen (Allergy / Resistance)

Azithromycin 500mg PO q24h

Ciprofloxacin 500mg PO q12h

Remarks & Clinical Comments:

Duration: • Immunocompetent: 5-7 days • Immunocompromised: 14 days If bacteremia or with foci of infection, treatment has to be individualized. *Antibiotic is usually not indicated, except in the following conditions: • Severe illness or septic shock • Presence of prostheses, valvular heart disease or severe atherosclerosis • Malignancy • Immunocompromised hosts

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.6 Salmonella typhi

Refer to Tropical Infections section.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.7 Cholera

Vibrio cholerae

Primary therapy is rehydration. Antibiotic is to reduce the shedding time. Refer to Tropical Infections section.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.8 Shigella spp

Fever and bloody stool

Preferred Regimen

* Moderate disease:

Ciprofloxacin 750mg PO q12h for 3 days

Severe disease:

Ceftriaxone 2g IV q24h for 5 days

Alternative Regimen (Allergy / Resistance)

* Moderate disease:

*Azithromycin 500mg PO q24h for 3 days

*Trimethoprim/sulfamethoxazole 160/800mg PO q12h for 3 days

Remarks & Clinical Comments:

*Moderate disease in individual such as food handler, residents of nursing home/ institutions, immunocompromised patients should be treated with antibiotic. Duration of antibiotic in immunocompromised patients is 7-10 days.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.9 Giardiasis

Giardia duodenalis

Preferred Regimen

Metronidazole 400mg PO q8h for 5-7 days*

Alternative Regimen (Allergy / Resistance)

Albendazole 400mg PO q24h for 5 days

Remarks & Clinical Comments:

*There is no randomised controlled trials (RCT) on the duration of metronidazole treatment. The duration quoted is based on observational studies.

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AdultA4GASTROINTESTINAL INFECTIONS

4. INFECTIOUS DIARRHOEA

4.2 Pathogen-directed therapy

4.2.10 Entamoeba histolytica

Preferred Regimen

Metronidazole 800mg PO q8h for 5–10 days*

PLUS

**Paromomycin 500mg PO q8h for 7 days

Remarks & Clinical Comments:

*There is no RCT on the duration of metronidazole treatment. The duration quoted is based on observational studies. **Requires DG’s approval.

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PaediatricB4GASTROINTESTINAL INFECTIONS

5. PERITONITIS

Common organisms: Gram-positive Gram-negative organisms Anaerobes

Preferred Regimen

Primary/spontaneous bacterial peritonitis

Cefotaxime 200mg-300mg/kg IV in 4 divided doses (max. 2g/dose)

Secondary peritonitis (secondary to perforated viscus)

Cefotaxime 200mg-300mg/kg IV in 4 divided doses (max. 2g/dose)

PLUS

Metronidazole 15mg/kg/dose loading dose followed by 7.5mg/kg/dose IV q8h (max. 750mg/dose)

Secondary (nosocomial) peritonitis

Piperacillin/tazobactam IV 300-400mg/kg/day in 3-4 divided doses (max. 16g/day)

If culture proven ESBL:

Imipenem/cilastatin 60-100mg/kg/day IV in 4 divided doses (max. 4g/day)

Meropenem 60-120mg/kg/day IV in 3 divided doses (max. 6g/day)

Alternative Regimen (Allergy / Resistance)

Ampicillin 200mg/kg/day IV in 4 divided doses (max. 2g/day)

PLUS

Gentamicin 5mg/kg/day IV OD

PLUS

Metronidazole 7.5mg/kg/dose IV q8h (max. 750mg/dose) for 7-14 days

Amoxicillin-clavulanate

• Age ≥ 3 months and weight ≥ 4kg: 75-90mg/kg/day (amoxicillin dose) IV in 3 divided doses

• Age < 3 months or < 4kg: 50mg/kg/day (amoxicillin dose) IV in 2 divided doses

Remarks & Clinical Comments:

May omit metronidazole in primary peritonitis. In immunocompetent patient with mild to moderate peritonitis and source control, suggest 5 days of therapy.

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AdultA4GASTROINTESTINAL INFECTIONS

5. CLOSTRIDIUM DIFFICILE INFECTION (CDI)

5.1 Initial, Non-severe CDI

WCC ≤ 15x10⁹/L and serum creatinine < 1.5mg/dL (133 µmol/L)

Preferred Regimen

Vancomycin 125mg PO q6h

Alternative Regimen (Allergy / Resistance)

Metronidazole 400mg PO q8h (if vancomycin is not available)

Remarks & Clinical Comments:

RCTs have shown that oral vancomycin is superior to oral metronidazole. Duration: 10 days

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AdultA4GASTROINTESTINAL INFECTIONS

5. CLOSTRIDIUM DIFFICILE INFECTION (CDI)

5.2 Initial, Severe CDI

WCC > 15 x 10⁹/L and/or serum creatinine ≥ 1.5mg/dL (133 µmol/L)

Preferred Regimen

Vancomycin 125mg PO q6h

Remarks & Clinical Comments:

Duration: 10 days

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AdultA4GASTROINTESTINAL INFECTIONS

5. CLOSTRIDIUM DIFFICILE INFECTION (CDI)

5.3 Initial, Fulminant Colitis

Hypotension/shock, ileus or megacolon

Preferred Regimen

*Vancomycin 500mg PO q6h

PLUS

Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

*If ileus is present, consider rectal instillation of vancomycin (enema): Vancomycin 500mg (in 100 mL normal saline) q6h via enema or by nasogastric tube Duration: 10 days (may extend to 14 days if recovery is delayed)

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AdultA4GASTROINTESTINAL INFECTIONS

5. CLOSTRIDIUM DIFFICILE INFECTION (CDI)

5.4 Recurrent CDI

Preferred Regimen

If vancomycin was used for the initial episode,

Vancomycin pulsed-tapered regimen:

125mg PO q6h for 10-14 days, then

125mg PO q12h for 7 days, then

125mg PO q24h for 7 days, then

125mg PO q48-72h for 2-8 weeks

Alternative Regimen (Allergy / Resistance)

If metronidazole was used for the initial episode,

Vancomycin 125mg PO q6h for 10-14 days

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PaediatricB4GASTROINTESTINAL INFECTIONS

6. LIVER ABSCESS

6.1 Liver abscess (amoebic)

Entamoeba histolytica

Preferred Regimen

Metronidazole 35-50mg/kg/day PO in 3 divided doses (max. 750mg/dose) for 7-10 days

Remarks & Clinical Comments:

Amoebic abscess tends to be a solitary lesion. Consider surgical drainage if needed.

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AdultA4GASTROINTESTINAL INFECTIONS

6. SPONTANEOUS BACTERIAL PERITONITIS (SBP)

6.1 Primary SBP

Common organisms: Enterobacterales (E.g.: E. coli, K. pneumoniae, and Streptococcus spp.)

Preferred Regimen

Cefotaxime 2g IV q8h

Ceftriaxone 2g IV q24h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 1.2g IV q6h

*Ciprofloxacin 400mg IV q12h

Remarks & Clinical Comments:

Duration: 5-7 days *May consider to convert IV to oral ciprofloxacin 500mg q12h.

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AdultA4GASTROINTESTINAL INFECTIONS

6. SPONTANEOUS BACTERIAL PERITONITIS (SBP)

6.2 In Cirrhosis with Upper Gastrointestinal Hemorrhage

Common organisms: Enterobacterales (eg: E. coli, K. pneumoniae, and Streptococcus spp.)

Preferred Regimen

Cefotaxime 2g IV q8h for 7 days

Ceftriaxone 2g IV q24h for 7 days

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 400mg IV q12h

Remarks & Clinical Comments:

Antibiotics should be used judiciously for this indication in view of emergence of resistance. Primary SBP prophylaxis in high risk patients: RCTs’ demonstrate decreased in mortality and incidence of SBP with selective intestinal decontamination. However, in most studies the efficacy to prevent death decreases over time due to the emergence of MDRO. Ideally, antibiotics for SBP prophylaxis should have low systemic bioavailability. For patients who may benefit from SBP prophylaxis, it is best to discuss with gastroenterologists or refer to a centre of specialisation. Patient with recurrent SBP: To discuss with gastroenterologists or refer to a centre of specialisation for the role of and option for secondary SBP prophylaxis.

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PaediatricB4GASTROINTESTINAL INFECTIONS

6. LIVER ABSCESS

6.2 Liver abscess (pyogenic)

Common organisms: Klebsiella spp. E. coli Streptococcus milleri Other Gram-negative organisms Anaerobes S. aureus

Preferred Regimen

Cefotaxime 200mg-300mg/kg/day IV in 4 divided doses (max. 2g/dose)

Ceftriaxone 100mg/kg/day IV in 1-2 divided doses (max. 2g/dose; 4 g/day)

PLUS

Metronidazole 22.5-40mg/kg/day IV in 3 divided doses (max. 800mg/dose)

Alternative Regimen (Allergy / Resistance)

Piperacillin/tazobactam 300-400mg/kg/day (of piperacillin component) IV in 3-4 divided doses (max. 16g/day)

ESBL-Klebsiella:

Ertapenem 30mg/kg/day in 2 divided doses (max. 1g/day) (above 3 months of age)

Remarks & Clinical Comments:

Surgical drainage is needed in most cases. Duration: 4-6 weeks.

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PaediatricB4GASTROINTESTINAL INFECTIONS

7. CHOLANGITIS

Preferred Regimen

Cefotaxime 200mg -300mg/kg IV in 4 divided doses (max. 2g/dose)

Ceftriaxone 100 mg/kg/day IV in 1-2 divided doses (max. 2g/dose; 4g/day)

PLUS

Metronidazole 22.5-40 mg/kg/day IV in 3 divided doses (max. 750mg/dose)

Alternative Regimen (Allergy / Resistance)

Piperacillin/tazobactam 300-400mg/kg/day (of piperacillin component) in 3-4 divided doses IV (max. 16g/day)

Ampicillin/sulbactam 200-300mg/kg/day (of ampicillin component) IV in 4-6 equally divided doses

Remarks & Clinical Comments:

Acute cholangitis Gram-positive & Gram-negative organisms, anaerobes Duration ∽ 7 days. Outcome is similar with less than 7 days to those with longer duration > 7 days in patients treated with percutaneous cholecystectomy. Source control is needed in cases of treatment failure.

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AdultA4GASTROINTESTINAL INFECTIONS

7. LIVER ABSCESS

7.1 Pyogenic liver abscess

Common pathogens: Klebsiella spp Escherichia coli

Preferred Regimen

Empirical therapy in non-sepsis:

Amoxycillin/clavulanate 1.2g IV q6h

Ampicillin/sulbactam 3g IV q6h

Sepsis/organ failure:

*Piperacillin/tazobactam 4.5g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Empirical therapy in non-sepsis:

Third generation cephalosporins:

Cefoperazone 1-2g IV q12h

Ceftriaxone 2g IV q24h

Cefotaxime 2g IV q8h

Cefuroxime 1.5g IV q8h

MAY ADD

**Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Duration: 2 - 6 weeks Shorter duration when there is adequate drainage with fever resolution. To convert IV to oral when there is clinical improvement. The duration of oral antibiotic depends on the complete resolution of the abscess clinically and radiologically. To consider drainage if abscess size is ≥ 5cm or impending rupture. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). **May add metronidazole in patients with risk factors of anaerobic liver abscess: • Acute and chronic inflammatory bowel disease with or without perforation • Malignancy of gastrointestinal tract • Surgery of the gastrointestinal tract or pelvic organs Metronidazole has excellent bioavailability: consider IV to PO switch (refer to Appendix 6 ). Reserve carbapenem for patients with history of biliary instrumentation suspecting multi-resistant gram negative organism.

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AdultA4GASTROINTESTINAL INFECTIONS

7. LIVER ABSCESS

7.2 Amoebic liver abscess

Entamoeba histolytica

Preferred Regimen

Amoebicidal agent:

*Metronidazole 750mg IV q8h for 10 days

followed by

Luminal agent: To eradicate intestinal colonization after amoebicidal treatment

**Paromomycin 25-35mg/kg/day PO q8h for 7 days

Remarks & Clinical Comments:

*May consider IV to PO switch when there is satisfactory clinical improvement. Dose: Metronidazole 800mg PO q8h Drainage of amoebic liver abscess is not usually required but is necessary if: • The patient does not respond to antibiotic therapy. • The abscess is > 5 cm in diameter. • The abscess is in the left lobe of the liver. • The diagnosis remains in doubt. ** Requires DG’s approval.

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AdultA4GASTROINTESTINAL INFECTIONS

8. CHOLECYSTITIS

Common pathogens: Klebsiella spp Escherichia coli Enterococci

Preferred Regimen

Non-sepsis:

Amoxicillin/clavulanate 1.2g q6h

Ampicillin/sulbactam 1.5-3g IV q6h

Sepsis/organ failure or complicated cholecystitis (E.g.: abscess or perforation):

*Piperacillin/tazobactam 4.5g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Non-sepsis:

Third generation cephalosporins:

Cefoperazone 1-2g IV q12h

Cefotaxime 2g IV q8h

Ceftriaxone 2g q24h

Remarks & Clinical Comments:

Duration : 4 -7days However, for mild to moderate acute cholecystitis, antibiotics may be ceased within 24h post-cholecystectomy, in the absence of gallbladder necrosis, pericholecystic abscess or biliary peritonitis. Reserve carbapenems for patients who are at high risk of antimicrobial resistance or history of biliary instrumentation. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).

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PaediatricB4GASTROINTESTINAL INFECTIONS

8. ENTEROCOLITIS

Common organisms: Enterobacteriaceae Enterococci Bacteroides

Preferred Regimen

Ampicillin 200mg/kg/day IV in 4-6 divided doses (max. 12g/day)

PLUS

Metronidazole 15mg/kg loading dose, followed by 7.5mg/kg/dose IV q8h (max. 4g/day)

Alternative Regimen (Allergy / Resistance)

Cefotaxime 200mg/kg/day IV in 4 divided doses (max. 2g/dose)

PLUS

Metronidazole 15mg/kg loading dose, followed by 7.5mg/kg/dose IV q8h (max. 4g/day)

Remarks & Clinical Comments:

Antibiotics should be adjusted with results of C&S. Duration: 5-7 days for uncomplicated enterocolitis.

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AdultA4GASTROINTESTINAL INFECTIONS

9. CHOLANGITIS

Community acquired Common pathogens: Klebsiella spp Escherichia coli Enterococci Appropriate source control to drain infected foci and restoration of anatomic and physiological function is recommended for all patients, as antibiotics will not penetrate the biliary system in the presence of obstruction.

Preferred Regimen

Non-sepsis:

Amoxicillin/clavulanate 1.2g q6h

Ampicillin/sulbactam 1.5-3g IV q6h

Sepsis/organ failure or complicated cholangitis (E.g.: abscess or perforation) and Hospital acquired infection:

*Piperacillin/tazobactam 4.5g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Non-sepsis:

Third generation cephalosporins:

Cefoperazone 1-2g IV q12h

Cefotaxime 2g IV q8h

Ceftriaxone 2g q24h

MAY ADD

**Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Duration: 4- 7 days Treatment may be reduced to 3 days post-biliary drainage with fever resolution. Reserve carbapenems for patients who are at high risk of antimicrobial resistance or history of biliary instrumentation. *Piperacillin/tazobactam: to be given as extended infusion over 3-4 hours. **Metronidazole is required if biliary enteric anastomosis is present.

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AdultA4GASTROINTESTINAL INFECTIONS

10. SURGICAL INFECTIONS

10.1 Diverticulitis

10.1.1 Uncomplicated Acute Diverticulitis

Preferred Regimen

Uncomplicated acute diverticulitis with any of the following:

• Systemic signs of infection

• Elderly

• Presence of significant comorbidities E.g.: diabetes, significant cardiac disease (IHD, cardiac failure) chronic liver disease or end stage renal disease

• Immunocompromised state

Amoxicillin/clavulanate 1.2g q6h

Ampicillin/sulbactam 1.5-3g IV q6h

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV q8h

PLUS

Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Uncomplicated acute diverticulitis in non-septic immunocompetent host: Antibiotics is usually not required Uncomplicated diverticulitis is defined as acute diverticulitis without perforation or abscess. Require close clinical monitoring and re-evaluation for antibiotics if symptoms progress. May convert to oral antibiotics if clinically improving. Duration: 7-10 days (IV and oral)

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AdultA4GASTROINTESTINAL INFECTIONS

10. SURGICAL INFECTIONS

10.1 Diverticulitis

10.1.2 Complicated Diverticulitis

Abscess, perforation or peritonitis

Preferred Regimen

Non-sepsis:

Amoxicillin/clavulanate 1.2g IV q6h

Ampicillin/sulbactam 1.5g-3g IV q6h

Sepsis or organ failure:

*Piperacillin/tazobactam 4.5g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Non-sepsis:

Ceftriaxone 2g IV q24h

Cefoperazone 1-2g IV q12h

PLUS

Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

*Piperacillin/tazobactam: If given as q8h, to be given as extended infusion (over 3-4 hours). Reserve carbapenem for patients who are at high risk of antimicrobial resistance.

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AdultA4GASTROINTESTINAL INFECTIONS

10. SURGICAL INFECTIONS

10.2 Appendicitis

10.2.1 Uncomplicated acute appendicitis

Uncomplicated acute appendicitis can be managed by two approaches: a) Non operative management (NOM) with antibiotics alone. b) Appendectomy (for patients who are not suitable for NOM approach or those who do not respond to antibiotics).

Preferred Regimen

Non operative management (NOM):

Amoxicillin/clavulanate 1.2g IV q6h

Ampicillin/sulbactam 1.5-3g IV q6h

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV q8h

PLUS

Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Non-operative management approach: May convert to oral antibiotics if clinically improving. Duration: 7-10 days (IV and oral) with close clinical monitoring and re-evaluation for surgery if symptoms do not resolve. Appendectomy done: Antibiotic treatment can be stopped once surgery is performed; provided adequate control of the source of infection is achieved and symptoms have resolved.

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AdultA4GASTROINTESTINAL INFECTIONS

10. SURGICAL INFECTIONS

10.2 Appendicitis

10.2.2 Complicated acute appendicitis

Abscess, perforation or peritonitis

Preferred Regimen

Non-sepsis:

Amoxicillin/clavulanate 1.2g IV q6h

Ampicillin/sulbactam 1.5-3g IV q6h

Sepsis or organ failure:

*Piperacillin/tazobactam 4.5g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Non-sepsis:

Ceftriaxone 2g IV q24h

Cefoperazone 1-2g IV q12h

PLUS

Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Duration: 4-7 days (if adequate source control, no delay in surgical intervention and patient has rapid clinical recovery). *Piperacillin/tazobactam: If given as q8h, to be given as extended infusion (over 3-4 hours). Reserve carbapenem for patients who are at high risk of antimicrobial resistance and adverse outcomes.

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AdultA4GASTROINTESTINAL INFECTIONS

10. SURGICAL INFECTIONS

10.3 Colorectal Surgery

10.3.1 Anorectal Abscess

Preferred Regimen

Mild:

Amoxicillin/clavulanate 1.2g IV or 625mg PO q8h

Ampicillin/sulbactam 1.5-3g IV q6h

Moderate to severe (E.g.: deep seated, sepsis/organ failure, immunocompromised):

Ceftriaxone 2g IV q24h

Cefoperazone 1-2g IV q12h

PLUS

Metronidazole 500mg IV q8h

Alternative Regimen (Allergy / Resistance)

Remarks & Clinical Comments:

Drainage procedure is mandatory. Duration: 4-7 days (advice to stop antibiotics once adequate source control, no delay in surgical intervention and patient has rapid clinical recovery).

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AdultA4GASTROINTESTINAL INFECTIONS

10. SURGICAL INFECTIONS

10.4 Hepatobiliary Surgery

10.4.1 Acute Pancreatitis

Preferred Regimen

Role of antibiotics even in severe pancreatitis is still unclear, except in:

• Extrapancreatic infection (E.g.: cholangitis, catheter-acquired infections, bacteremia, urinary tract infections and pneumonia)

• Infected pancreatic necrosis

*Piperacillin/tazobactam 4.5g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Severe pancreatitis:

Cefoperazone 1-2g IV q12h

Cetriaxone 2g q24h

Cefotaxime 2g q8h

PLUS

Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Mild to moderate: Self-limiting, often do not require antibiotics. Prophylactic antibiotics have not been shown to reduce mortality, rates of pancreatic or peripancreatic infection or need for surgery. If infective biliary calculi in origin, refer to severe pancreatitis. • Short course of antibiotics until surgically obtained cultures are available. • Modify antibiotics according to culture and sensitivity. • Reserve carbapenem for patients at high risk of resistant pathogens. • Duration depends on adequate source control. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).

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AppendixAPP5SPECIMEN COLLECTION & TRANSPORTATION GUIDE

Appendices

SPECIMEN COLLECTION & TRANSPORTATION GUIDE

SPECIMEN COLLECTION & TRANSPORTATION GUIDE The key to accurate laboratory diagnosis and confirmation is the appropriate microbiology specimen selection and collection. The impact is enormous, as it directly affects patient’s care and outcomes, influences therapeutic decisions, hospital infection control, patient length of stay, hospital and laboratory costs, as well as antibiotic stewardship. Result interpretation in microbiological culture depends entirely on the quality of specimens submitted for analysis. In order to achieve this, laboratories require that all clinical specimens (in particular) microbiology specimens to be properly selected, collected, and transported to optimize analysis and interpretation. Important principles of specimen management and testing in microbiology culture; 1) Specimens should be collected prior to administration of antibiotics. Once antibiotics are given, the microbiota changes and etiologic agents are impacted leading to potentially misleading culture results. 2) Specimens must be labelled accurately (with two patient identifiers) and completely. 3) It is always a good idea and preferred specimens to send actual tissues, aspirates, and fluids, especially from surgeries. Swab is not the specimen of choice as it picks up extraneous microbes, holds only a small volume of specimen and does not have uniform inoculums on the swab across different agar plates. 4) Whenever possible, normal or commensal microbiota must be avoided as it complicates the interpretation of culture results. The best outcomes for patients are the result of strong partnerships between clinicians and microbiologists. Clinicians and other medical personnel should consult the pathologist/microbiologist to ensure that selection, collection, transport, and storage of clinical specimens are managed appropriately. The following table illustrates the general guide of specimen types, collection and transportation requirements:

Appendix 5 Specimen type.pdf

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PaediatricB5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. FEBRILE NEUTROPENIA

1.1 First line

Fever >38°C, neutrophil<500mm³ Common organisms: Enterobacteriaceae (Klebsiella sp., E. coli etc.) Pseudomonas Aerobic Gram-positive (Staphylococci, Streptococci)

Preferred Regimen

Cefepime 50mg/kg/dose IV in q8h (max. 6g/day)

Alternative Regimen (Allergy / Resistance)

Piperacillin/tazobactam 300 - 400 mg/kg/day IV in 4 divided doses (max. 16g/day of piperacillin component)

Remarks & Clinical Comments:

Use monotherapy with an anti-pseudomonal β–lactam agents. Meta-analysis has shown that there is no clinical advantage with β-lactam and aminoglycoside combination therapy. Also need to look at local epidemiological data.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. HEMATOLOGY-ONCOLOGY

1.1 Suggested Empirical Antibiotic Therapy in Adult Febrile Neutropenic Patients

1.1.2 Low Risk (Outpatient)

Suitable low risk patients include: • no evidence of dehydration or hypotension • no evidence of pneumonia • no COAD • able to access prompt medical attention if deteriorates Outpatient oral antibiotics may be considered after careful risk assessment and consultation with a hemato-oncologist.

Preferred Regimen

Amoxicillin/clavulanate 625mg PO q8h

MAY ADD

*Ciprofloxacin 500mg PO q12h

Remarks & Clinical Comments:

Treat until patient recovers. Can consider stopping the antibiotic after reassessing the patient following 2 days afebrile at the discretion of the treating hemato-oncologists – if the patient has stable vital signs, no evidence of ongoing infection, are educated about their condition and stay near to hospital facilities. *Add ciprofloxacin if patient is previously colonized by Pseudomonas aeruginosa.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. HEMATOLOGY-ONCOLOGY

1.1 Suggested Empirical Antibiotic Therapy in Adult Febrile Neutropenic Patients

1.1.3 High Risk (Inpatient)

Risk assessment for complication of severe infection should be done during triage. Patient is deemed high risk if there is: • prolonged and profound neutropenia with ANC < 0.1x10⁹/L • hypotension • pneumonia • new onset abdominal pain or neurological signs The administration of the first dose of empirical antibiotic with anti-pseudomonal coverage should be done as soon as possible following triage (within the first hour) after taking blood cultures. The suggested antibiotics are listed below. Consider IV to PO antibiotic switch in a clinically stable patient who has no gastrointestinal absorption issue.

Preferred Regimen

First line therapy:

*Piperacillin/tazobactam 4.5g IV q6h

MAY ADD

**Amikacin 15mg/kg IV q24h

Alternative Regimen (Allergy / Resistance)

Cefepime 2g IV q8h

MAY ADD

**Amikacin 15mg/kg IV q24h

MAY ADD

***Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours). Amikacin may be added in patient with severe sepsis for broader gram negative coverage. It can be discontinued if microbiological cultures showed isolated organisms sensitive to piperacillin/tazobactam or cefepime and patient is clinically stable. *Metronidazole may be added in the presence of: • severe mucositis • intra-abdominal infections • peri-anal abscesses • colitis

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. HEMATOLOGY-ONCOLOGY

1.1 Suggested Empirical Antibiotic Therapy in Adult Febrile Neutropenic Patients

1.1.3 High Risk (Inpatient)

Preferred Regimen

Severe sepsis or

Second line therapy for persistent fever of 4 - 7 days and deterioration of signs:

Meropenem 1g IV q8h

MAY ADD

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

Alternative Regimen (Allergy / Resistance)

Imipenem 500mg q6h or 1g IV q8h (in severe sepsis)

MAY ADD

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

Remarks & Clinical Comments:

*Refer to Appendix 1 for vancomycin loading dose. *Vancomycin is not a routine in the initial antibiotic regime. Consider add vancomycin for these patients: • colonized with MRSA • suspected to have catheter-related infection, skin and soft-tissue infection • in septic shock Stop vancomycin after 48 hours if no evidence of gram positive cocci. Linezolid is an alternative in those patients with no clinical response to vancomycin and in those with suspected or confirmed VRE, VISA or VRSA.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. HEMATOLOGY-ONCOLOGY

1.2 De-escalation Strategies

• Modification of antibiotic regime if deterioration of clinical status or if there is no clinical improvement over 72-96 hours in a stable patient. • The antibiotics are generally kept for a minimal duration of 5 to 7 days or stopped if afebrile for 2 days in patients who is asymptomatic with negative cultures and improving neutrophil *count. (*refer to comment on low risk out-patient). • In instances where cultures are positive and the patient is improving with targeted therapy, consider discontinuing non-relevant combination therapy. For example: patient with MRSA positive cultures on combination therapy meropenem and vancomycin, to stop meropenem.

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PaediatricB5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. FEBRILE NEUTROPENIA

1.2 Second line:

Persistent fever > 72 hours* Common organisms: Enterobacteriaceae (Klebsiella sp, E. coli etc.) Pseudomonas Aerobic Gram-positive (Staphylococci, Streptococci) Enterococci Other resistant organisms *DO NOT MODIFY INITIAL COVERAGE BASED SOLELY ON PERSISTENCE OF FEVER.

Preferred Regimen

Meropenem 60-120mg/kg/day IV in 3 divided doses (max. 6g/day)

MAY ADD

Vancomycin 60 mg/kg/day in 3-4 divided doses (max. 2g/day)

Remarks & Clinical Comments:

Escalate to second line if patient is unstable, to cover resistant gram negative, gram positive and anaerobes. Consider adding vancomycin in suspected catheter-related infections, positive blood culture for gram positive cocci, hypotensive patients and patients who are known to be colonised with MRSA. In patients responding to initial empiric antibiotic therapy, discontinue double coverage (empirical vancomycin, if initiated) or double gram negative after 24-72 hours if there is no specific microbiologic indication to continue combination therapy.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. HEMATOLOGY-ONCOLOGY

1.3 Infection Prevention Strategies

• Strict isolation measures. • Patient’s personal hygiene and diet. • Regular surveillance culture. • Hand washing and strict aseptic technique. • Prevention of HCAI (E.g.: BSI, HAP, VAP)

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PaediatricB5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. FEBRILE NEUTROPENIA

1.3 Third line

Fever > 4-7 days with no identified source of fever Bacterial: Candida sp. Aspergillus sp., Fusarium sp. Viral: Respiratory viruses are the most common, HSV, VZV

Preferred Regimen

Imipenem/cilastatin 60-100 mg/kg/day IV in 4 divided doses (max. 4g/day)

PLUS

Amphotericin B 0.5mg/kg/dose IV q24h & gradually escalate by (0.25- 1mg/kg/dose) q24h

(max. 1.5mg/kg/day)

Lipid formulation of amphotericin B 3-5mg/kg/day

Alternative Regimen (Allergy / Resistance)

Imipenem/cilastatin 60-100 mg/kg/day IV in 4 divided doses (max. 4g/day)

PLUS

Caspofungin 70mg/m²/dose IV q24h at Day 1, then 50mg/m²/dose IV q24h (max. 70mg/dose for loading and maintenance dose)

Remarks & Clinical Comments:

1/3 of febrile neutropenic patients with persistent fever >1 week have systemic fungal infections. Initiate antifungal in patients at high risk of invasive fungal disease with prolonged (≥ 96 hours) febrile neutropenia unresponsive to broad spectrum antibacterial agents. Amphotericin based antifungal is considered broader spectrum than echinocandin (E.g.: caspofungin).

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. HEMATOLOGY-ONCOLOGY

1.4 Antifungal Therapy

Preferred Regimen

Micafungin 100mg IV q24H

Alternative Regimen (Allergy / Resistance)

Anidulafungin 200mg IV single dose, then 100mg IV q24h

Caspofungin 70mg IV single dose, then 50mg IV q24h

Remarks & Clinical Comments:

It should be initiated earlier in the presence of: • severe mucositis • oral thrush • dysphagia • suspicious skin infiltrates or pulmonary infiltrates • fundal exudates • prolonged steroid use more than 2 weeks IV amphotericin B remains the empirical therapy of choice for invasive fungal infections. For patients who are intolerant, refractory or those with toxicity to conventional amphotericin B, the lipid formulations of amphotericin B, voriconazole and echinocandins are alternatives for empirical therapy based on local availability and costs. Voriconazole is an alternative to amphotericin B for pre-emptive and directed therapy for invasive aspergillosis. In candidiasis, echinocandins, azoles and amphotericin B are antifungals of choice. Daily Dose of Antifungal Agent • Amphotericin B lipid complex (ABLC): 5mg/kg q24h • Amphotericin B deoxycholate (conventional): 0.7-1.0mg/kg q24h • Liposomal amphotericin B: 3-5mg/kg q24h • Anidulafungin: 200mg loading dose, followed by 100mg q24h • Caspofungin: 70mg loading dose, followed by 50mg q24h • Micafungin: 100mg q24h • Fluconazole: 12mg/kg/day for 1 day, then 6mg/kg q24h • Itraconazole: 200mg q8h for 3 days, followed by 200mg q12h • Posaconazole: (Tablet) 300mg q12h for 1 day, followed by 300mg q24h • Voriconazole: 6mg/kg q12h for 2 doses, followed by 3-4 mg/kg q12h a) For patients on fluconazole or no antifungal prophylaxis, if • New clinical signs or symptoms suggestive of invasive fungal infections (IFI)* • Fever persists ≥ 7days with no identified fever source *If sinus and/or chest CT scan findings not suggestive of fungal infection, it is less likely to be aspergillus or mold infections.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

1. HEMATOLOGY-ONCOLOGY

1.4 Antifungal Therapy

Preferred Regimen

Voriconazole 6mg/kg IV q12h for 2 doses, then 4mg/kg IV q12h

Alternative Regimen (Allergy / Resistance)

*Amphotericin B deoxycholate

0.7-1mg/kg IV q24h

*Liposomal Amphotericin B 3-5mg/kg IV q24h

Remarks & Clinical Comments:

**b) If signs and symptoms suggestive of invasive fungal infections (IFI)* AND sinus ± chest CT suggestive of fungal infection.** *For patients on voriconazole or posaconazole as prophylaxis, empirical antifungal of choice will be amphotericin B.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

2. OPPORTUNISTIC INFECTION (OI) IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)

2.1 Pneumocystis jiroveci (carinii) Interstitial Pneumonia (PJP/PCP)

2.1.1 Treatment

Preferred Regimen

Trimethoprim/ sulfamethoxazole 15-20mg/kg/day [TMP component] IV/PO in 3-4 divided doses

Alternative Regimen (Allergy / Resistance)

For mild to moderate cases:

(PO2 70-80mmHg)

Clindamycin 600mg IV/PO q8h

PLUS

Primaquine 30mg (base) PO q24h

Dapsone 100mg PO q24h

PLUS

Trimethoprim 15mg/kg/day PO in 3-4 divided doses

For severe cases:

(PO2 < 70mmHg)

Pentamidine 4mg/kg/day IV

(in 1 pint D5% or NS run over 1-2 hours)

Clindamycin 600mg IV q6h or 900mg IV q8h

PLUS

Primaquine 30mg (base) PO q24h

Remarks & Clinical Comments:

Comment Duration: 21 days Patients with severe disease should receive adjunctive corticosteroids as soon as possible (within 72 hours of starting PCP treatment): Prednisolone dose: 40mg PO q12h for 5 days, then 40mg PO q24h for 5 days, then 20mg PO q24h for 11 days (Total duration is 21 days) Trimethoprim/sulfamethoxazole & clindamycin has excellent bioavailability, may consider IV to PO switch after clinical improvement. Patients given dapsone or primaquine should be tested for G6PD deficiency.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

2. OPPORTUNISTIC INFECTION (OI) IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)

2.1 Pneumocystis jiroveci (carinii) Interstitial Pneumonia (PJP/PCP)

2.1.2 Prophylaxis (primary and secondary)

Indications: • CD4 count < 200 cells/μL • CD4 count 200-250 cells/μL if ART cannot be initiated

Preferred Regimen

Trimethoprim/sulfamethoxazole (80/400mg) 1–2 tablets PO q24h

Alternative Regimen (Allergy / Resistance)

*Dapsone 100mg PO q24h

Aerosolized Pentamidine 300mg monthly via ultrasonic nebulizer

Remarks & Clinical Comments:

Comment Discontinuation: Can consider when CD4 100-200 cells/μL if HIV RNA is suppressed for 3-6 months with ART. Restarting prophylaxis: CD4 count falls to < 200 cells/μL or PCP occurs at a CD4 > 200 cells/μL (lifelong prophylaxis should be considered). Patients receiving Sulfadiazine/ Pyrimethamine or Sulfadoxine/ Pyrimethamine for treatment or suppression of toxoplasmosis do not require additional prophylaxis for PCP. *Requires DG’s approval.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

2. OPPORTUNISTIC INFECTION (OI) IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)

2.2 Toxoplasma gondii Encephalitis

2.2.1 Acute Infection

Up to 97% patients are Toxo IgG +ve

Preferred Regimen

Trimethoprim/sulfamethoxazole 10mg/kg/day (TMP component) IV/PO in 2 divided doses

*Pyrimethamine 200mg PO loading dose followed by Pyrimethamine:

• 50mg PO q24h (if BW ≤ 60kg)

• 75mg PO q24h (if BW > 60kg)

PLUS

Folinic acid 10-25mg IV q24h OR 15mg PO q24h

PLUS

*Sulfadiazine 1g PO q6h

Alternative Regimen (Allergy / Resistance)

*Pyrimethamine 200mg PO loading dose followed by Pyrimethamine:

• 50mg PO q24h (if BW ≤ 60kg)

• 75mg PO q24h (if BW > 60kg)

PLUS

Folinic acid 10-25mg IV q24h OR

15mg PO q24h

PLUS

Clindamycin 600mg IV/PO q6h

Remarks & Clinical Comments:

Duration: At least 6 weeks Longer duration if clinical and radiologic disease is extensive or response is incomplete in 6 weeks. Adjunctive corticosteroids (E.g.: dexamethasone) should be administered when clinically indicated to treat mass effect associated with focal lesions or associated oedema but should be discontinued as soon as clinically feasible. To use trimethoprim/sulfamethoxazole if pyrimethamine not available. In the case of sulfa allergy and pyrimethamine is not available, sulfa desensitization should be attempted in those without a history of severe reaction (E.g.: Stevens-Johnson syndrome). If clindamycin is used, additional therapy must be added for primary prophylaxis for PCP. *Requires DG’s approval.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

2. OPPORTUNISTIC INFECTION (OI) IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)

2.2 Toxoplasma gondii Encephalitis

2.2.2 Suppressive/ Maintenance Therapy

Preferred Regimen

Trimethoprim/ Sulfamethoxazole

(80/400mg) 2 tablets PO q12h

Alternative Regimen (Allergy / Resistance)

*Dapsone 100mg PO q24h OR

Clindamycin 600mg PO q8h

PLUS

*Pyrimethamine 50mg PO q24h

MAY ADD

Folinic acid 15mg PO q24h

*Sulfadiazine 0.5-1gm PO q6h

PLUS

*Pyrimethamine 25-50mg PO q24h

PLUS

Folinic acid 15mg PO q24h

Remarks & Clinical Comments:

Discontinuation: Consider when CD4 >200 cells/μL if HIV RNA is suppressed for 6 months with ART. *Requires DG’s approval.

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AdultA5INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

2. OPPORTUNISTIC INFECTION (OI) IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV)

2.2 Toxoplasma gondii Encephalitis

2.2.3 Primary Prophylaxis

Indications: Toxoplasma IgG +ve with CD4<100

Preferred Regimen

Trimethoprim/ Sulfamethoxazole (80/400mg) 2 tablets PO q24h

Alternative Regimen (Allergy / Resistance)

*Dapsone 50mg PO q24h

PLUS

*Pyrimethamine 50mg PO once weekly

PLUS

Folinic acid 30mg PO once weekly

*Dapsone 200mg PO once weekly

PLUS

*Pyrimethamine 75mg PO once weekly

PLUS

Folinic Acid 30mg PO once weekly

Remarks & Clinical Comments:

Discontinuation: CD4 > 200 cells/μL for > 3months CD4 > 100 cells/μL, if HIV viral load suppressed for 3 to 6 months. *Requires DG’s approval.

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2.3 Mucocutaneous Candidiasis

2.3.1 Oropharyngeal (oral thrush)

Preferred Regimen

Fluconazole 100mg PO q24h

Nystatin suspension 500,000 units PO 4 times daily

Alternative Regimen (Allergy / Resistance)

*Itraconazole 200mg PO q24h

Remarks & Clinical Comments:

Duration: 7-14 days Chronic suppressive therapy is usually not recommended. *Itraconazole: Absorption depends on gut acidity. Take capsule with a full meal. Oral solution should be taken on an empty stomach. Avoid PPIs and H2 blockers.

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2.3 Mucocutaneous Candidiasis

2.3.2 Oesophageal

Preferred Regimen

Fluconazole 200-400mg PO/IV q24h

Alternative Regimen (Allergy / Resistance)

*Itraconazole 200mg PO q24h

Remarks & Clinical Comments:

Duration: 14-21 days Infection with other pathogens (E.g.: CMV, HSV that causes esophagitis) can result in symptoms that mimic esophageal candidiasis, a diagnostic and therapeutic trial of antifungal therapy is usually warranted before endoscopy. Endoscopy is required with unusual presentations or lack of response to azole within several days.

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2.4 Cryptococcal Meningitis or Meningoencephalitis (Cryptococcus neoformans)

2.4.1 Induction Therapy

Preferred Regimen

*Amphotericin B deoxycholate 1mg/kg IV q24h

PLUS

Flucytosine 25mg/kg PO q6h

(Duration : 1 week)

Followed by:

Fluconazole 1200mg PO q24h

(Duration : 1 week)

**Liposomal Amphotericin B 10mg/kg (single high dose)

Followed by:

Fluconazole 1200mg IV/PO q24h

PLUS

Flucytosine 25mg/kg PO q6h

(Duration : 2 weeks)

Alternative Regimen (Allergy / Resistance)

*Amphotericin B deoxycholate 0.7-1mg/kg IV q24h

PLUS

Fluconazole 800-1200mg IV/PO q24h (may be given in divided dosing)

(Duration : 2 weeks)

Fluconazole 1200mg IV/PO q24h

PLUS

Flucytosine 25mg/kg PO q6h

(Duration: 2 weeks)

Remarks & Clinical Comments:

**Liposomal Amphotericin B may be used instead if available. For severe/recurrent infection, please refer to ID physician.

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2.4 Cryptococcal Meningitis or Meningoencephalitis (Cryptococcus neoformans)

2.4.2 Consolidation Therapy

Continued after successful induction therapy; defined as substantial clinical improvement and negative CSF culture after repeat LP.

Preferred Regimen

*Fluconazole 400mg - 800mg PO/IV q24h

Use actual body weight** for weight-based dose calculations: 6 mg/kg once daily (maximum dose [not well established]: 800mg to 1600mg).

Alternative Regimen (Allergy / Resistance)

Itraconazole 200mg PO q12h

Remarks & Clinical Comments:

Duration: 8 weeks *The dose can then be reduced to 400mg/day to complete the 8-week consolidation phase if all of the following criteria are met: (i) The patient received induction therapy with amphotericin B plus flucytosine for 2 weeks. (ii) CSF cultures obtained after 2 weeks of induction therapy are negative. (iii) ART has been started. Consider weight-based dosing for Class 1, 2, or 3 obesity (BMI ≥30 kg/m2)** patients.

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2.4 Cryptococcal Meningitis or Meningoencephalitis (Cryptococcus neoformans)

2.4.3 Maintenance Therapy

Continued after consolidation therapy

Preferred Regimen

Fluconazole 200mg PO q24h

Alternative Regimen (Allergy / Resistance)

Itraconazole 200mg PO q24h for patients intolerant or failed fluconazole (however, less effective and higher relapse rate)

Remarks & Clinical Comments:

Discontinuation: Completed initial (induction, consolidation) therapy AND At least 1 year on maintenance therapy AND Remains asymptomatic from cryptococcal infection AND CD4 count ≥ 100 cells/µL and suppressed HIV RNA in response to effective ART for ≥ 6 months

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2.4 Cryptococcal Meningitis or Meningoencephalitis (Cryptococcus neoformans)

2.4.4 Secondary prophylaxis

Preferred Regimen

Fluconazole 200mg PO q24h

Remarks & Clinical Comments:

Restarting secondary prophylaxis: CD4 count < 100 cells/μL

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2.5 Cryptococcosis (Localized Non-meningeal Disease)

2.5.1 Mild-moderate pulmonary infection or extra-pulmonary non-CNS disease OR Asymptomatic with positive lung/blood culture or positive antigen test (no CNS disease)

Preferred Regimen

Fluconazole 400mg-800mg PO q24h for 10 weeks.

Use actual body weight** for weight-based dose calculations: 6mg/kg once daily (maximum dose [not well established]: 800mg to 1600mg).

Then, maintenance (secondary prophylaxis): Fluconazole 200mg q24h.

Alternative Regimen (Allergy / Resistance)

*Itraconazole 200mg PO given q8h for 3 days.

Then, consolidation: Itraconazole 200mg PO given q12h for 8 weeks.

Then, maintenance (secondary prophylaxis): Itraconazole 200mg q24h.

Remarks & Clinical Comments:

Discontinuation of maintenance: At least 1 year of treatment AND CD4 count ≥ 100 cells/µL and suppressed HIV RNA in response to effective ART for ≥ 6 months. In the case of treatment failure, all patients initially treated with fluconazole should have their therapy changed to amphotericin B until clinical response is achieved. *Itraconazole: Absorption depends on gut acidity. Take capsule with a full meal. Oral solution should be taken on an empty stomach. Consider weight-based dosing for Class 1, 2, or 3 obesity (BMI ≥30 kg/m2)** patients.

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2.5 Cryptococcosis (Localized Non-meningeal Disease)

2.5.2 Severe Pulmonary or Extra-pulmonary Non-CNS Disease

Treat as per cryptococcal meningitis.

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2.6 Histoplasmosis (Histoplasma capsulatum)

2.6.1 Moderate to Severe Disseminated Disease

Preferred Regimen

Induction therapy:

*Amphotericin B deoxycholate 0.7-1.0mg/kg IV q24h for at least 2 weeks

Liposomal amphotericin B at 3 mg/kg IV daily (for 2 weeks or until clinically improved)

Followed by,

Maintenance therapy:

Itraconazole 200mg PO q8h for 3 days, then 200mg q12h for at least 12 months

Remarks & Clinical Comments:

*Liposomal amphotericin B may be used instead if available. All triazole antifungals have the potential to interact with certain ARV agents and other anti-infective agents. Therapeutic drug monitoring is recommended for azoles therapy.

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2.6 Histoplasmosis (Histoplasma capsulatum)

2.6.2 Meningitis

Preferred Regimen

Induction therapy:

*Amphotericin B deoxycholate 0.7-1.0mg/kg IV q24h for at least 2 weeks

Liposomal amphotericin B at 5 mg/kg IV daily (for 2 weeks or until clinically improved)

Followed by,

Maintenance therapy:

Itraconazole 200mg PO q8h for at least 12 months and until resolution of CSF abnormalities

Remarks & Clinical Comments:

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2.6 Histoplasmosis (Histoplasma capsulatum)

2.6.3 Mild Disseminated Disease

Blood culture positive but patient is asymptomatic.

Preferred Regimen

Induction & maintenance therapy:

*Itraconazole 200mg PO q8h for 3 days, then 200mg PO q12h

Alternative Regimen (Allergy / Resistance)

For patients intolerant to itraconazole:

Fluconazole 800mg PO q24h

Voriconazole 400mg PO q12h on Day 1, then 200mg PO q12h

Remarks & Clinical Comments:

Duration: At least 12 months *Itraconazole: Absorption depends on gut acidity. Take capsule with a full meal. Oral solution should be taken on an empty stomach. Avoid PPIs and H2 blockers.

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2.6 Histoplasmosis (Histoplasma capsulatum)

2.6.4 Chronic Suppressive therapy (Secondary prophylaxis)

Indication: • Severe disseminated or CNS infection after completion of at least 12 months of treatment. • Relapsed despite appropriate initial therapy.

Preferred Regimen

*Itraconazole 200mg PO q24h

Alternative Regimen (Allergy / Resistance)

Fluconazole 400mg PO q24h

Remarks & Clinical Comments:

Discontinuation: Received azole for > 1 year AND Negative fungal blood cultures AND CD4 count > 150 cells/μL for ≥ 6 months on ART Restarting secondary prophylaxis: CD4 count < 150 cells/μL *Itraconazole: Absorption depends on gut acidity. Take capsule with a full meal. Oral solution should be taken on an empty stomach. Avoid PPIs and H2 blockers.

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2.7 Penicilliosis (Penicillium/Talaromyces marneffei)

2.7.1 Acute Infection

Preferred Regimen

Moderate to severe disease

Induction therapy:

*Amphotericin B deoxycholate 0.7-1.0mg/kg/day IV

Liposomal amphotericin B 3-5mg/kg/day IV for 2 weeks

Must be followed by consolidation therapy.

Consolidation therapy:

**Itraconazole 200mg PO q12h for 10 weeks

Must be followed by maintenance therapy.

Alternative Regimen (Allergy / Resistance)

Induction therapy:

Voriconazole 6mg/kg IV q12h on Day 1, then 4mg/kg IV q12h for at least 3 days

Voriconazole 600mg PO q12h on Day 1, then 400mg q12h for 2 weeks if IV therapy not available

Must be followed by consolidation therapy.

Consolidation therapy:

**Itraconazole 200mg PO q12h for 10 weeks

Must be followed by maintenance therapy.

Remarks & Clinical Comments:

All triazole antifungals have the potential to interact with certain ARV agents and other anti-infective agents. **Itraconazole: Absorption depends on gut acidity. Take capsule with a full meal. Oral solution should be taken on an empty stomach. Avoid PPIs and H2 blockers. Therapeutic drug monitoring is recommended for azoles therapy.

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2.7 Penicilliosis (Penicillium/Talaromyces marneffei)

2.7.1 Acute Infection

Preferred Regimen

Mild disease

**Only skin involvement; no fungaemia

**Itraconazole 200mg PO q12h for at least 8-12 weeks

Loading dose: 200mg q8h for 3 days and then reduce to q12 therapy

Must be followed by maintenance therapy.

Alternative Regimen (Allergy / Resistance)

Voriconazole 400mg PO q12h on Day 1 followed by 200mg q12h for 12 weeks.

Must be followed by maintenance therapy.

Remarks & Clinical Comments:

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2.7 Penicilliosis (Penicillium/Talaromyces marneffei)

2.7.2 Maintenance Therapy/ Secondary Prophylaxis

Preferred Regimen

**Itraconazole 200mg PO q24h

Alternative Regimen (Allergy / Resistance)

Voriconazole 200mg PO q12h

Remarks & Clinical Comments:

Discontinuation: CD4 count > 100 cells/μL for ≥ 6 months on ART

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2.8 Mycobacterium Tuberculosis Infection and Diseases

Refer to Ministry of Health CPG on Management of Tuberculosis 4th Edition (2021) .

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2.9 Mycobacterium avium Complex (MAC) Disease

2.9.1 Treatment

Preferred Regimen

Clarithromycin 500mg PO q12h

PLUS

Ethambutol 15mg/kg PO q24h

PLUS

***Rifampicin 10mg/kg PO q24h

MAY ADD

4^th drug:

Amikacin 10-15mg/kg IV q24h

Streptomycin 15mg/kg IM q24h

Levofloxacin 500mg PO q24h

Ciprofloxacin 500-750mg PO q12h

Moxifloxacin 400mg PO q24h

Alternative Regimen (Allergy / Resistance)

*Azithromycin 500mg PO q24h

PLUS

Ethambutol 15mg/kg PO q24h

PLUS

***Rifampicin 10mg/kg PO q24h

MAY ADD

4^th drug:

Amikacin 10-15mg/kg IV q24h

Streptomycin 15mg/kg IM q24h

Levofloxacin 500mg PO q24h

Ciprofloxacin 500-750mg PO q12h

Moxifloxacin 400mg PO q24h

Remarks & Clinical Comments:

Duration: At least 12 months *Azithromycin: use if drug interaction or intolerance precludes the use of clarithromycin. Addition of 4^th^ drug should be considered for patients with disseminated disease, require IV/IM. *Concomitant tuberculosis needs to be ruled out if monotherapy rifampicin is used. Treatment of choice shall be tailored according to culture and susceptibility testing results. Discontinuation: Consider if patient is on ART and viral load is suppressed, CD4 > 100 cells/μL > 6 months, asymptomatic of MAC, and has completed > 12 months of therapy.

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2.9 Mycobacterium avium Complex (MAC) Disease

2.9.2 Maintenance Treatment/ Secondary Prophylaxis

Same as the treatment regimen. Restarting secondary prophylaxis: CD4 < 100 cells/μL again

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2.9 Mycobacterium avium Complex (MAC) Disease

2.9.3 Primary Prophylaxis

Indications: • CD4 < 50 cells/μL • Ruled out active MAC and TB

Preferred Regimen

Azithromycin 1250mg PO once weekly

Alternative Regimen (Allergy / Resistance)

Clarithromycin 500mg PO q12h

Remarks & Clinical Comments:

Discontinuation: Consider if patient is on ART AND Viral load is suppressed, CD4 > 100 cells/μL > 3 months

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2.10 Cytomegalovirus (CMV) Disease

2.10.1 CMV Retinitis

For treatment of: • Immediate Sight-Threatening Lesions - Adjacent to the Optic nerve or Fovea • Small Peripheral Lesions

Refer to Ocular infection section.

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2.10 Cytomegalovirus (CMV) Disease

2.10.2 Extraocular CMV diseases (Treatment)

Oesophagitis, colitis, interstitial pneumonitis, neurological disease.

Preferred Regimen

Ganciclovir 5mg/kg IV q12h, may consider switch to valganciclovir 900mg PO q12h once patient tolerate orally (In CMV oesophagitis and colitis only).

Followed by maintenance therapy.

Alternative Regimen (Allergy / Resistance)

*Foscarnet 60mg/kg IV q8h or 90mg/kg IV q12h

Followed by maintenance therapy.

Remarks & Clinical Comments:

Duration: 21-42 days or until signs and symptoms have been resolved. Immune recovery is essential for successful treatment. Start ART within 2 weeks if possible. *For patients with treatment limiting toxicities to ganciclovir or with ganciclovir resistant. Requires DG’s approval.

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2.10 Cytomegalovirus (CMV) Disease

2.10.3 Extraocular CMV diseases (Maintenance Treatment / Secondary prophylaxis)

CD4 <100 cells/μL

Preferred Regimen

Ganciclovir 5mg/kg IV q24h 5–7 times weekly

Alternative Regimen (Allergy / Resistance)

Valganciclovir 900mg PO q24h

Remarks & Clinical Comments:

Discontinuation: Consider if patient is on ART and viral load well suppressed, CD4 > 100 cells/μL > 3 months and after 3-6 months of CMV treatment. Maintenance therapy is generally not necessary; ART offers best hope for prevention of relapses.

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2.11 Herpes simplex Virus (HSV) Infections

Refer to Sexually Transmitted Infection section.

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2.12 Varicella-zoster Virus (VZV) Infections

Refer to Skin and Soft Tissue Infection (SSTI) section.

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2.13 Bacterial Enteric Infections

2.13.1 Salmonellosis

Salmonella non-typhi

Preferred Regimen

Ciprofloxacin 500-750mg PO or 400mg IV q12h

Ceftriaxone 2g IV q24h

Alternative Regimen (Allergy / Resistance)

Ampicillin 2g IV q4-6h

Trimethoprim/sulfamethoxazole (80/400mg) 2 tablets PO or 2 ampoules IV q12h

Remarks & Clinical Comments:

Susceptibility profile may help guide final choice. Duration: • CD4 ≥ 200: 7-14 days. • CD4 ≥ 200 and with bacteraemia: 14 days is appropriate provided documented clearance of bacteraemia. • CD4 < 200 and with bacteraemia: 6 weeks. Longer course with debridement and drainage needed for persistent bacteraemia or metastatic disease.

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2.14 Rhodococcus Infections (Rhodococcus equi, formerly corynebacterium equi)

2.14.1 Induction Treatment

Preferred Regimen

Azithromycin 500mg STAT and then 250mg IV/PO q24h

Ciprofloxacin 500-750mg PO q12h or 400mg IV q8-12h or levofloxacin 500-750mg IV/PO q24h

PLUS

Rifampicin 600mg PO q24h

Alternative Regimen (Allergy / Resistance)

Azithromycin 500mg STAT and then 250mg IV/PO q24h

Ciprofloxacin 500-750mg PO q12h or 400mg IV q8-12h or levofloxacin 500-750mg IV/PO q24h

Rifampicin 600mg PO q24h

PLUS

Imipenem/Cilastatin 500mg IV q6h

Vancomycin 15-20mg/kg (actual body weight) IV q8-12H; not to exceed 2g/dose

Remarks & Clinical Comments:

Duration: Immunocompromised – at least 2 months Duration will depend on the extent of the diseases. Adjust antibiotics according to susceptibility data. Use at least two or more susceptible agents. Concomitant tuberculosis needs to be ruled out with use of rifampicin monotherapy. For CNS involvement, to consider antibiotics with good CNS penetration.

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2.14 Rhodococcus Infections (Rhodococcus equi, formerly corynebacterium equi)

2.14.2 Maintenance Treatment / Secondary Prophylaxis

Preferred Regimen

Azithromycin 250mg PO q24h

PLUS

Ciprofloxacin 500-750mg PO q12h

Levofloxacin 500-750mg PO q24h

Alternative Regimen (Allergy / Resistance)

*Rifampicin 600mg PO q24h

PLUS

Azithromycin 250mg PO q24h

Ciprofloxacin 500-750mg PO q12h

Levofloxacin 500-750mg PO q24h

Remarks & Clinical Comments:

Duration: Until CD4 > 200 cells/μL Choice to be based on susceptibility test. Concomitant tuberculosis needs to be ruled out with use of rifampicin monotherapy.

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2.15 Progressive Multifocal Leukoencephalopathy (PML)

Polyoma virus JC virus (JCV)

No effective therapy exists. With ART, some patients improve and others stabilize. Few may deteriorate due to immune reconstitution.

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2.16 Isospora belli Infection

2.16.1 Initial Therapy

Preferred Regimen

Trimethoprim/sulfamethoxazole 160/800mg IV/PO q6h

Alternative Regimen (Allergy / Resistance)

*Pyrimethamine 50-75mg PO q24h

PLUS

Folinic acid 15mg PO q24h

Ciprofloxacin 500mg PO q12h

Remarks & Clinical Comments:

Duration: 10 days For patients whose symptoms persist after 10 days, the treatment duration can be extended to 3-4 weeks. *Requires DG’s approval. Discontinuation: CD4 count > 200 cells/μL for ≥ 6 months on ART.

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2.16 Isospora belli Infection

2.16.2 Secondary Prophylaxis

Preferred Regimen

Trimethoprim/sulfamethoxazole 160/800mg PO q24h

Alternative Regimen (Allergy / Resistance)

*Pyrimethamine 25mg PO q24h

PLUS

Folinic acid 15mg PO q24h (if sulfa-intolerant)

Ciprofloxacin 500mg PO three times a week

Remarks & Clinical Comments:

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2.17 Cryptosporidiosis

Cryptosporidium sp.

Symptomatic treatment of diarrhoea. Effective ART (to increase CD4 > 100 cells/μL) can result in complete, sustained clinical, microbiological and histologic resolution.

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2.18 Microsporidiosis

Microsporidium sp.

Preferred Regimen

Albendazole 400mg PO q12h for 2-4 weeks

PLUS

Symptomatic treatment of diarrhoea (the best treatment option is ART and fluid support)

Remarks & Clinical Comments:

Effective ART (to increase CD4 > 100 cells/μL) can result in complete, sustained clinical, microbiological and histologic resolution.

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2.19 Syphilis (Treponema pallidum Infection)

Refer to Sexually Transmitted Infections section.

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2.20 Bartonellosis

2.20.1 Bacillary Angiomatosis, Peliosis Hepatis, Bacteraemia, and Osteomyelitis

Preferred Regimen

Doxycycline 100mg PO q12h

Erythromycin 500mg PO/IV q6h

Alternative Regimen (Allergy / Resistance)

Azithromycin 500mg PO q24h

Clarithromycin 500mg PO q12h

Remarks & Clinical Comments:

Duration: At least 3 months If relapse occurs after initial (> 3 month) course of therapy, long-term suppression with doxycycline or a macrolide is recommended as long as CD4 <200 cells/μL.

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2.20 Bartonellosis

2.20.2 Other Severe Infections (or CNS involvement)

Preferred Regimen

Doxycycline 100mg PO/IV q12h

Erythromycin 500mg PO/IV q6h

MAY ADD

Rifampicin 300mg PO/IV q12h

Remarks & Clinical Comments:

Duration: At least 3 months If relapse occurs after initial (> 3 month) course of therapy, long-term suppression with doxycycline or a macrolide is recommended as long as CD4 <200 cells/μL.

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2.20 Bartonellosis

2.20.3 Confirmed Bartonella endocarditis

Refer to Cardiovascular infections section.

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PathwayC5ACUTE GASTROENTERITIS

ACUTE GASTROENTERITIS

AGE 15.08.2024.pdf

Attached Clinical Documents:

AGE 15.08.2024.pdf

NAG MOH Malaysia 2024Official Site

AppendixAPP6IV TO ORAL SWITCH

Appendices

IV TO ORAL SWITCH

IV TO ORAL SWITCH 1. INTRODUCTION 2. TIMING OF INTRAVENOUS ANTIMICROBIAL REVIEW 3. CRITERIA FOR INTRAVENOUS TO ORAL ANTIMICROBIAL CONVERSION (IVOC) 4. IV TO ORAL ANTIMICROBIAL CONVERSION PROTOCOL 5. ANTIMICROBIALS FOR CONVERSION/STEP-DOWN THERAPY Unnecessary prolonged courses of Intravenous (IV) antimicrobials are associated with longer length of hospital stay, increased risk of morbidity and mortality related to IVline infections, as well as higher treatment cost^1-3. Therefore, one of the core elements in antimicrobial stewardship (AMS) programme is to promote timely oral (PO) antimicrobials conversion (IVOC) once the patient is clinically stable, able to tolerate oral feeding and has no contraindications^4-6. Multiple studies have highlighted the benefits of IVOC, including decreased risk of healthcare-associated and cannula-related infections, reduced medical and hospitalisation costs, shorter hospital length-of-stay, with increased patient mobility and comfort^2,3,5,7-10. Early IVOC also has been demonstrated to be safe and equally effective to prolonged IV antimicrobial courses with no negative impact on patient outcomes in terms of mortality, readmission or adverse drug reactions^{3, 9, 11}. 2. TIMING OF INTRAVENOUS ANTIMICROBIAL REVIEW IVOC should be considered within 48 to 72 hours of IV antimicrobial therapy^{5, 10, 12, 13}. This period of time allows the clinician to evaluate patients’ microbiology results and assess their response to treatment. 3. CRITERIA FOR INTRAVENOUS TO ORAL ANTIMICROBIAL CONVERSION (IVOC) 3.1 Considerations for Early IVOC^{2, 6, 10} 3.1.1 Criteria of Patients for Early IVOC9-13 • Stable vital signs - Temperature >36°C and <38°C for 24 to 48 hours - Stable blood pressure (no unexplained hypotension) - No tachycardia (heart rate below 90 beats/min) - No tachypnoea (respiratory rate below 20 breaths/min) • Stable immune response - White cell count between 4 and 12 x 10⁹/L or normalising - C-reactive protein reducing trend • Gastrointestinal tract intact and functional - Oral fluids/food are tolerated (at least 1L/day of oral fluids or 40mL/hour of enteral nutrition) - No concerns about malabsorption • Oral absorption is not compromised - No diarrhoea, vomiting, malabsorptive disorder, short bowel syndrome or swallowing disorder • An appropriate oral antimicrobial is available, considering oral bioavailability, any clinically significant drug interactions or patient allergies • No significant concerns over patient adherence to oral antimicrobial treatment 3.1.2 Types of infections where IVOC may be considered • Pneumonia • Skin and soft tissue infections • Urinary tract infections • Intra-abdominal infections without deep-seated collection • Uncomplicated Gram-negative bacteraemia 3.2 Conditions where early IVOC is NOT appropriate Early IVOC is not appropriate in infections which warrant prolonged course of IV antimicrobial or require very high tissue concentration which cannot be delivered via equivalent oral antimicrobial preparations such as^{5, 6, 10, 11}: • Bone and joint infections • Central nervous system infections: meningitis, encephalitis, intracranial abscess • Deep-seated abscess, abscess without incision or inadequately drained • Endocarditis • Exacerbation of cystic fibrosis or bronchiectasis • Empyema • High-risk neutropenia or severe infections during chemotherapy-related neutropenia • Infections of implants/prostheses/IV catheters • Melioidosis (at least 14 days of IV therapy) • Septicaemia or critical infection with high risk of mortality • Severe soft tissue infections such as: necrotising fasciitis, Group A Streptococcal infections etc. • Severely immunocompromised: solid organ transplant, bone marrow transplant • Staphylococcus aureus bacteraemia • Treatment for liver abscesses, adequately drained abscesses and empyema, osteomyelitis and septic arthritis can be changed to oral therapy after ≥ 2 weeks of IV therapy 4. IV TO ORAL ANTIMICROBIAL CONVERSION PROTOCOL

Appendix 6 IV to PO Conversion Protocol.pdf

5. ANTIMICROBIALS FOR CONVERSION/STEP-DOWN THERAPY

Appendix 6 Conversion Table.pdf

References: 1. Barlow GD, Nathwani D. Sequential antibiotic therapy. Current Opinion in Infectious Diseases. 2000;13(6):599-607. 2. Cyriac JM, James E. Switch over from intravenous to oral therapy: A concise overview. J Pharmacol Pharmacother. 2014;5(2):83-7. 3. Garwan YM, Alsalloum MA, Thabit AK, Jose J, Eljaaly K. Effectiveness of antimicrobial stewardship interventions on early switch from intravenous-to-oral antimicrobials in hospitalized adults: A systematic review. Am J Infect Control. 2023;51(1):89-98. 4. Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-77. 5. Sevinç F, Prins JM, Koopmans RP, Langendijk PN, Bossuyt PM, Dankert J, et al. Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital. J Antimicrob Chemother. 1999;43(4):601-6. 6. MOH Malaysia. Protocol on Antimicrobial Stewardship (AMS) Programme in Healthcare Facilities. Second Edition ed. Petaling Jaya: Pharmaceutical Services Programme, Ministry of Health Malaysia; 2022. 7. Mouwen AMA, Dijkstra JA, Jong E, Buijtels P, Pasker-de Jong PCM, Nagtegaal JE. Early switching of antibiotic therapy from intravenous to oral using a combination of education, pocket-sized cards and switch advice: A practical intervention resulting in reduced length of hospital stay. Int J Antimicrob Agents. 2020;55(1):105769. 8. Schuts EC, Hulscher M, Mouton JW, Verduin CM, Stuart J, Overdiek H, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16(7):847-56. 9. Nguyen AD, Mai-Phan T-A, Tran MH, Pham HT. The effect of early switching from intravenous to oral antibiotic therapy: A randomized controlled trial. J Pharm Pharmacogn Res. 2021;9:695-703. 10. Harvey EJ, McLeod M, De Brún C, Ashiru-Oredope D. Criteria to achieve safe antimicrobial intravenous-to-oral switch in hospitalised adult populations: a systematic rapid review. BMJ Open. 2023;13(7):e068299. 11. McCarthy K, Avent M. Oral or intravenous antibiotics? Aust Prescr. 2020;43(2):45-8. 12. Akhloufi H, Hulscher M, Melles DC, Prins JM, van der Sijs H, Verbon A. Development of operationalized intravenous to oral antibiotic switch criteria. J Antimicrob Chemother. 2017;72(2):543-6. 13. Harvey EJ, Hand K, Weston D, Ashiru-Oredope D. Development of National Antimicrobial Intravenous-to-Oral Switch Criteria and Decision Aid. J Clin Med. 2023;12(6). 14. The Sanford Guide to Antimicrobial Therapy app Sperryville, VA, USA: Antimicrobial Therapy Inc.; 2023. 15. Lexicomp. Version 7.7.4. ed: Wolters Kluwer: UpToDate Inc.; 2023.

NAG MOH Malaysia 2024Official Site

PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.1 Meningitis

Common organisms: GBS E. coli Listeria Other Gram-negative bacilli/rod (GNR)

Preferred Regimen

Empirical therapy

Benzylpenicillin (Penicillin G) 150,000 units/kg/dose

GA ≤ 34 weeks:

PNA ≤ 7 days: q12h

PNA > 7 days: q8h

GA >34 weeks:

PNA ≤ 7 days: q8h

PNA > 7 days: q6h

Ampicillin

≤ 1 week of age: 200-300mg/kg/day IV in 3 divided doses

> 1 week of age: 300mg/kg/day IV in 4 divided doses

PLUS

Cefotaxime 50mg/kg/dose IV

≤ 1 week of age: q12h

> 1 week of age: q6h

Alternative Regimen (Allergy / Resistance)

Cefepime 50mg/kg/dose IV q12h

SEVERE CNS infections (if hospital-acquired):

Meropenem 40mg/kg/dose IV

< 32 weeks, <14 days: q12h

< 32 weeks, ≥14 days: q8h

≥ 32 weeks: q8h

Remarks & Clinical Comments:

Adjust antibiotics and duration accordingly once cultures are known (refer to 2.1.2)

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AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

1. PELVIC INFLAMMATORY DISEASE (PID)

1.1 Outpatient (mild)

Preferred Regimen

Ceftriaxone 500mg IM in a single dose

(if BW>150kg, 1g IM STAT)

PLUS

Metronidazole 400mg PO q12h for 14 days

PLUS

Doxycycline 100mg PO q12h for 14 days

Alternative Regimen (Allergy / Resistance)

If cephalosporin allergy and low risk for gonorrhoea:

Levofloxacin 500mg PO q24h for 14 days

PLUS

Metronidazole 400mg PO q12h for 14 days

Remarks & Clinical Comments:

Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically for chlamydia and gonorrhoea, regardless of PID aetiology or pathogen isolated. Abstain from sex until the patient and partner(s) have completed treatment and symptoms are resolved.

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AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

1. PELVIC INFLAMMATORY DISEASE (PID)

1.2 Inpatient (moderate-severe)

Preferred Regimen

Ceftriaxone 2g IV q24h

PLUS

Doxycycline 100mg PO q12h

PLUS

Metronidazole 400mg PO or 500mg IV q12h

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 3g IV q6h

PLUS

Doxycycline 100mg PO q12h

Clindamycin 900mg IV q8h

PLUS

Gentamicin 3-5mg/kg IV q24h

* Oral step-down therapy:

Clindamycin 450mg PO q6h or 600mg PO q8h

Doxycycline 100mg PO q12h

PLUS

Metronidazole 400mg PO q12h

Remarks & Clinical Comments:

Duration: 14 days Tubo-ovarian abscess: Surgical intervention for source control may be required. May need to consider tuberculosis if not responding to standard treatment. *Patients with clinical improvement after 24-48 hours can be transitioned to oral therapy to complete the 14 days of treatment.

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PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.2 Necrotising Enterocolitis (NEC)

Common organisms: Klebsiella E. coli Clostridia Coagulase-negative Staphylococci Enterococci Bacteroides

Preferred Regimen

Stage 1

Ampicillin 100mg/kg/dose IV

≤ 1 week of age: q12h

>1 week of age: q8h

PLUS

Gentamicin 5mg/kg/dose IV

< 30 weeks of CGA: q48h

30-34 weeks of CGA: q36h

≥ 35 weeks CGA: q24h

Amikacin 15mg/kg/dose IV

< 30 weeks of CGA: q48h

30-34 weeks of CGA: q36h

≥35 weeks of CGA: q24h

PLUS

Metronidazole

Loading dose: 15mg/kg/dose IV

Maintenance dose:

≤ 34 weeks of age: 7.5mg/kg/dose IV q12h

35-40 weeks of age: 7.5mg/kg/dose IV q8h

> 40 weeks of age: 10mg/kg/dose IV q8h

Stage 2 / Stage 3

Cefotaxime 50mg/kg/dose IV

≤ 1 week of age: q12h

> 1 week of age: q8h

PLUS

Metronidazole

Loading dose:15mg/kg/dose IV

Maintenance dose:

≤ 34 weeks of age: 7.5mg/kg/dose IV q12h

35-40 weeks of age: 7.5mg/kg/dose IV q8h

>40 weeks of age: 10mg/kg/dose IV q8h

Duration: 10-14 days

Alternative Regimen (Allergy / Resistance)

ONLY consider IV Piperacillin/tazobactam after recent exposure to first line antibiotics.

Piperacillin/tazobactam IV

PMA ≤30 weeks: 100mg/kg/dose q8h

PMA >30 weeks: 80mg/kg/dose q6h

Remarks & Clinical Comments:

There is insufficient evidence regarding the duration of antibiotic treatment for NEC. This suggested regimen for NEC is empirical. Once culture is known, decisions regarding choice of antibiotics are best guided by culture results. Use vancomycin if CoNS/MRSA is suspected (substitute Ampicillin with Vancomycin).

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PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.3 Early Onset Sepsis (< 48 hours)

Common organisms: Group B Streptococcus (GBS) Listeria Streptococcus sp. E. coli Haemophilus influenza Klebsiella sp. etc.

Preferred Regimen

Benzylpenicillin (Penicillin G) 100,000 units/kg/dose IV

GA ≤ 34 weeks:

PNA ≤ 7 days: q12h

PNA >7 days: q8h

GA > 34 weeks:

PNA ≤ 7 days: q8h

PNA >7 days: q6h

Ampicillin 200-300mg/kg/day IV

≤ 1 week of age: in 3 divided doses

> 1 week of age: in 4 divided doses

PLUS

Gentamicin 5mg/kg/dose IV

< 30 weeks of CGA: q48h

30-34 weeks of CGA: q36h

≥ 35 weeks CGA: q24h

Remarks & Clinical Comments:

Consider stopping antibiotics at 36-48 hours if negative blood culture, initial clinical suspicion not strong and reassuring baby’s condition with low CRP. If positive blood culture or strong clinical suspicion of sepsis but negative culture, may give 7 days of antibiotics. Consider antibiotics for more than 7 days if baby not fully recovered and based on pathogen identified on blood culture. In this empiric therapy - meningitis is not a consideration. Once cultures are known, adjust antibiotics accordingly.

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PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.4 Late Onset Sepsis (> 48 hours)

Common organisms: Methicillin-sensitive/resistant S. aureus (MSSA/MRSA) Coagulase- negative Staphylococci (CoNS) Gram-negative rods (Depending on local epidemiological data)

Preferred Regimen

First line

Cloxacillin 50mg/kg/dose IV

≤ 1 week of age: q12h

> 1 week of age: q8h

PLUS

Gentamicin 5mg/kg/dose IV

< 30 weeks of CGA: q48h

30-34 weeks of CGA: q36h

≥ 35 weeks of CGA: q24h

Second line

Piperacillin/tazobactam IV

PMA ≤ 30 weeks: 100mg/kg/dose q8h

PMA > 30 weeks: 80mg/kg/dose q6h

< 30 weeks

0-28 days: 100mg/kg q12h

> 28 days: 100mg/kg q8h

30-36 weeks

0-14 days: 100mg/kg q12h

> 14 days: 100mg/kg q8h

37-44 weeks

0-7 days:100mg/kg q12h

> 7 days: 100mg/kg q8h

≥ 45 weeks: 100mg/kg q8h

Alternative Regimen (Allergy / Resistance)

First line

Amikacin 15mg/kg/dose IV

< 30 weeks of CGA: q48h

30-34 weeks of CGA: q36h

≥ 35 weeks of CGA: q24h

Second line

Cefepime IV

Term and Prem younger than 28 days of life: 30mg/kg/dose q12h

Term and Prem greater than 28 days of life: 50mg/kg/dose q12h

Remarks & Clinical Comments:

For late onset sepsis, the most common organisms are predominantly Gram-positive cocci, namely Staphylococci, especially CONS, in premature neonates and also neonates with central catheters. Piperacillin/tazobactam is a good second line option in pneumonia and intra-abdominal sepsis (non–CONS sepsis with good coverage against Gram-positive, Gram-negative & anaerobes). There is possibility of Gram-negative rods with inducible β-lactamases and ESBL producing organism such as Klebsiella, Serratia and E. coli in some NICU in Malaysia hence need to look at local epidemiology before deciding on suitable second line. Cefepime is the preferred agent when there are Gram-negative bacteria with extended spectrum cephalosporin resistance due to AmpC-β-lactamases (also termed Class C or Group 1). Duration: If positive blood culture or strong clinical suspicion of sepsis but negative culture, may give 7 days of antibiotics. Consider antibiotics for more than 7 days if baby not fully recovered, based on site of infection & pathogen identified on blood culture.

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PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.5 Congenital Syphilis

T. pallidum

Preferred Regimen

Benzylpenicillin (Penicillin G) 50,000 units/kg/dose IV

For first 7 days of life: q12h

Thereafter: q8h

Duration: 10 days*

If diagnosed with congenital syphilis after one month of age

Benzylpenicillin (Penicillin G) 200,000-300,000 units/kg/day IV in 4-6 divided doses for 10-14 days.

In infants considered less likely to have syphilis and normal CSF examination including normal physical examination & long bone radiograph

Benzathine penicillin 50,000 units/kg/dose IM in a single dose can be given.

Alternative Regimen (Allergy / Resistance)

Procaine penicillin 50,000 units/kg/dose IM in a single daily dose for 10 days.*

Remarks & Clinical Comments:

Only severe cases are clinically apparent at birth. Refer to algorithm for diagnosing & evaluation. Re-evaluate & possibly re-treat. Please refer Red Book 2021 & Malaysian Paediatric Protocol 4^th edition. *14 days if CSF abnormal

NAG MOH Malaysia 2024Official Site

PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.6 Congenital Toxoplasmosis

T. gondii

Preferred Regimen

*Pyrimethamine/sulfadoxine (Fansidar^®^)

*Pyrimethamine 1.25mg/kg/dose PO every 10 days

PLUS

Sulfadoxine 25mg/kg/dose PO every 10 days

PLUS

Folinic acid 50mg PO every 7 days for 12 months*

Alternative Regimen (Allergy / Resistance)

*Pyrimethamine 1mg/kg/day PO for 2 months, followed by 0.5 mg/kg/day PO for 10 months

< 60kg: up to 50mg/day

≥ 60kg: up to 75mg/day

PLUS

*Sulfadiazine 100mg/kg/day PO in 2 divided doses for 12 months*

PLUS

Folinic Acid 50 mg PO every 7 days for 12 months

Remarks & Clinical Comments:

Drug regimen is not definitively established. Clinical trials are ongoing. Prednisolone 0.5 mg/kg (max. 20 mg/dose) q12h can be added if CSF protein ≥ 1g/dL or active severe chorioretinitis. Steroids given till CSF protein < 1g/dL or resolution of severe chorioretinitis. Fansidar is currently an “orphan” drug that needs special procurement measures to buy. Refer to paediatric ID consultant for treatment and availability of drug. *Requires DG’s Approval *Total duration may be extended up to 2 years depending on severity and response to treatment.

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PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.7 Herpes simplex Neonatal

• Localised skin, eye & mouth (SEM) • Central nervous system (CNS) with or without SEM • Disseminated disease involving multiple organs

Preferred Regimen

Acyclovir 20mg/kg/dose IV

< 30 weeks: q12h

≥ 30 weeks: q8h

Duration:

• Skin, eyes, mouth: 14 days

• CNS/disseminated: minimum of 21 days

All infants surviving neonatal HSV infection of any classification should receive oral acyclovir suppression at 300mg/m²/dose administered 3 times daily for 6 months after completion of parenteral therapy (adjust dose monthly to account for growth).

Remarks & Clinical Comments:

Screen for other STDs. For CNS disease: Repeat lumbar puncture at end of therapy for HSV PCR. If PCR remains positive, continue IV acyclovir for another one week. Recurrence of HSV can occur and may be a lifelong problem.

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PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.8 Tetanus Neonatorum

Preferred Regimen

Metronidazole

PMA < 34 weeks:7.5 mg/kg/dose IV q12h

PMA 35-40 weeks: 7.5 mg/kg/dose IV q8h

PMA > 40 weeks: 10mg/kg/dose IV q8h

Duration: 7 to 10 days

Alternative Regimen (Allergy / Resistance)

Benzylpenicillin (Penicillin G) 100,000 units/kg/dose IV

GA < 34 weeks:

PNA ≤ 7 days: q12h

PNA > 7 days: q8h

GA > 34 weeks:

PNA ≤ 7 days: q8h

PNA > 7 days: q6h

Remarks & Clinical Comments:

IM Human Tetanus Immunoglobulin 250-500 IU for neutralizing of unbound toxin. Antibiotics may fail to eradicate C. tetani unless adequate wound debridement is performed.

NAG MOH Malaysia 2024Official Site

PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.9 Congenital Gonococcal Ophthalmitis/Conjunctivitis

Preferred Regimen

Immediate & frequent saline eye irrigation.

Non-disseminated disease:

Cefotaxime 100mg/kg/dose IV in a single dose.

May need to continue for 48-72h until systemic infection has been ruled out.

Disseminated disease:

Cefotaxime 50mg/kg/dose IV

≤ 1 week of age: q12h

> 1 week of age: q8h

Duration: 7 days. 10–14 days if meningitis is documented.

Remarks & Clinical Comments:

Evaluate for signs of disseminated infection (E.g.: sepsis, arthritis & meningitis). Screen mother & baby for chlamydial infection. Screen for other STDs. Investigate and treat parents.

NAG MOH Malaysia 2024Official Site

PaediatricB6NEONATAL INFECTIONS

1. CONGENITAL & PERINATAL INFECTIONS

1.10 Chlamydia trachomatis Conjunctivitis

Preferred Regimen

Erythromycin ethylsuccinate 12.5mg/kg/dose q6h PO

Duration: 14 days*

Local eye toilet until discharge stops.

Alternative Regimen (Allergy / Resistance)

Azithromycin 20 mg/kg/day PO, once daily for 3 days. (Limited data on efficacy)

Remarks & Clinical Comments:

Initial treatment for chlamydial conjunctivitis should be based upon a positive diagnostic test. Re-swab after treatment; 20-30% will need a second course to clear infection. * Second course of treatment might be required

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AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

2. ENDOMETRITIS

2.1 In Non-pregnant Women

Refer to treatment guideline for severe PID

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PaediatricB6NEONATAL INFECTIONS

2. GROUP B STREPTOCOCCUS (GBS)

2.1 Streptococcus agalactiae

2.1.1 Sepsis

Preferred Regimen

Benzylpenicillin (Penicillin G) 100,000 units/kg/dose IV

GA ≤ 34 weeks:

PNA ≤ 7 days: q12h

PNA > 7 days: q8h

GA >34 weeks:

PNA ≤ 7 days: q8h

PNA >7 days: q6h

Ampicillin

≤ 1 week of age: 200-300 mg/kg/day IV in 3 divided doses

> 1 week of age: 300 mg/kg/day IV in 4 divided doses

PLUS

*Gentamicin 5 mg/kg/dose IV

< 30 weeks of CGA: q48h

> 30-34 weeks of CGA: q36h

≥ 35 weeks of CGA: q24h

Remarks & Clinical Comments:

Duration of treatment for GBS: Uncomplicated (bacteremia without a defined focus): 10-14 days *Gentamicin can be discontinued once the infection is under control.

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PaediatricB6NEONATAL INFECTIONS

2. GROUP B STREPTOCOCCUS (GBS)

2.1 Streptococcus agalactiae

2.1.2 Meningitis

Preferred Regimen

Benzylpenicillin (Penicillin G) 150,000 units/kg/dose

≤ 34 weeks of age:

PNA ≤ 7 days: q12h

PNA >7 days: q8h

> 34 weeks of age:

PNA ≤ 7 days: q8h

PNA >7 days: q6h

Ampicillin

≤ 1 week of age: 200-300 mg/kg/day IV in 3 divided doses

> 1 week of age: 300 mg/kg/day IV in 4 divided doses

PLUS

Gentamicin 5 mg/kg/dose IV

< 30 weeks of CGA: q48h

> 30-34 weeks of CGA: q36h

≥ 35 weeks CGA: q24h

Remarks & Clinical Comments:

Duration for treatment: 14-21 days • Uncomplicated meningitis: 14 days • Complicated: minimum 21 days For uncomplicated meningitis, may consider repeat lumbar puncture 48-72 hours. If CSF culture negative, gentamicin can be stopped and continue penicillin/ampicillin for 2 weeks Doses of penicillin for meningitis is higher as recommended by experts (as high as 500,000 unit/kg/day (> 7 days of age).

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AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

2. ENDOMETRITIS

2.2 Postpartum Endometritis

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h

Ampicillin/sulbactam 3g IV q6h

Alternative Regimen (Allergy / Resistance)

Cefotaxime 1g IV q8h

PLUS

Metronidazole 500mg IV q8h

PLUS

Gentamicin 5mg/kg IV x 1 dose

Clindamycin 900mg IV q8h

PLUS

*Gentamicin 5mg/kg q24h

Remarks & Clinical Comments:

IV treatment is typically continued until the patient is clinically improved (no fundal tenderness) and afebrile for 24 - 48 hours. If an oral antibiotic regimen is administered, duration: 14 days. *TDM for gentamicin is required

NAG MOH Malaysia 2024Official Site

PaediatricB6NEONATAL INFECTIONS

2. GROUP B STREPTOCOCCUS (GBS)

2.2 E. coli

2.2.1 Sepsis/Meningitis

Preferred Regimen

Cefotaxime 50mg/kg/dose IV

All GA with PNA < 7 days: q12h

GA <32 weeks with PNA ≥ 7 days: q8h

GA ≥ 32 weeks with PNA ≥ 7 days: q6h

PLUS

Gentamicin 5 mg/kg/dose IV

≤ 30 weeks of CGA: q48h

> 30-34 weeks of CGA: q36h

≥35 weeks CGA: q24h

Remarks & Clinical Comments:

Duration in bacteremia: 14 days. Duration for meningitis: 21 days. All cases of bacteremia need lumbar puncture to exclude meningitis. Treatment duration of 14 days can be decided on a case-by-case basis if meningitis is excluded and good clinical response.

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AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

2. ENDOMETRITIS

2.3 Atrophic Endometritis

Example: Post-menopause Post-chemoradiotherapy Antibiotic not required.

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AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

3. SEPTIC MISCARRIAGE

Common organisms: Bacteroides sp. especially Prevotella bivia Streptococcus sp. (Grp A, Grp B), Enterobacterales Chlamydia trachomatis Ureaplasma urealyticum

Preferred Regimen

Ampicillin/sulbactam 3g IV q6h

PLUS

Doxycycline 100mg PO q12h

Alternative Regimen (Allergy / Resistance)

Ampicillin 2g IV q4-6h

PLUS

Metronidazole 500mg IV q8h

PLUS

Gentamicin 5mg/kg IV q24h

Clindamycin 900mg IV q8h

PLUS

*Gentamicin 5mg/kg IV q24h

Remarks & Clinical Comments:

Duration: 10-14 days Intravenous antibiotics are administered until the patient has improved and afebrile for 48 hours, then are typically followed by oral antibiotics. *TDM for gentamicin is required

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AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

4. CHORIOAMNIONITIS

Preferred Regimen

Ampicillin/sulbactam 3g IV q6h

(Regardless of the mode of delivery)

Alternative Regimen (Allergy / Resistance)

Ampicillin 2g IV q6h

PLUS

Gentamicin 5mg/kg IV q24h

If the patient is undergoing a cesarean delivery:

Ampicillin 2g IV q6h

PLUS

Gentamicin 5mg/kg IV q24h

PLUS

Metronidazole 500mg IV q8h

Mild antibiotic allergy:

Cefazolin 2g IV q8h

PLUS

Gentamicin 5mg/kg IV q24h

Severe antibiotic allergy:

Clindamycin 900mg IV q8h

Remarks & Clinical Comments:

Antibiotic regimen is continued postpartum until the patient is afebrile and asymptomatic for at least 48 hours. There is no evidence that continuation with oral antibiotic are beneficial after discontinuation of parenteral therapy.

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AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

5. INTRAPARTUM ANTIBIOTIC PROPHYLAXIS (IAP) FOR GROUP B STREPTOCOCCUS (GBS) POSITIVE MOTHERS

Indications of IAP: Previous infant with invasive GBS disease, preterm labour, GBS carriage in previous pregnancy, PPROM with known GBS carrier, GBS carriage in current pregnancy, GBS bacteriuria

Preferred Regimen

Benzylpenicillin 5MU IV initial dose, then 2.5–3MU IV q4h until delivery

Alternative Regimen (Allergy / Resistance)

Ampicillin 2g IV initial dose, then 1g IV q4h until delivery

Mild antibiotic allergy:

Cefazolin 2g IV initial dose, then 1g q8h until delivery

Cefuroxime 1.5g IV STAT and 750mg IV q8h until delivery

Severe antibiotic allergy:

Vancomycin 15-20mg/kg IV q8-12h until delivery

Clindamycin 900mg IV q8h until delivery

Remarks & Clinical Comments:

Prophylaxis begins at hospital admission for labour or rupture of membrane and continued every four hours until the infant is delivered. Treatment is not indicated if Caesarean section is performed before onset of labour with intact membrane (please use standard surgical prophylaxis). Antenatal treatment is not recommended for GBS cultured from a vaginal or rectal swab.

NAG MOH Malaysia 2024Official Site

AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

6. PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM)

6.1 Non-GBS carrier

Preferred Regimen

Erythromycin ethylsuccinate 400mg PO q6h or 800mg PO q12h for 7-10 days

NAG MOH Malaysia 2024Official Site

PathwayC6SKIN AND SOFT TISSUE INFECTION

SKIN AND SOFT TISSUE INFECTION

SSTI 30.01.2026.pdf

Attached Clinical Documents:

SSTI 30.01.2026.pdf

NAG MOH Malaysia 2024Official Site

AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

6. PRETERM PREMATURE RUPTURE OF MEMBRANES (PPROM)

6.2 GBS carrier

Preferred Regimen

Ampicillin 2g IV q6h for 48 hours

PLUS

*Azithromycin 1g PO STAT upon admission

Followed by:

Amoxicillin 500mg PO q8h for an additional 5-7 days or until delivery whichever comes first

Remarks & Clinical Comments:

*To cover for Ureaplasmas – important cause of chorioamnionitis & Chlamydia

NAG MOH Malaysia 2024Official Site

AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

7. POSTPARTUM MASTITIS

7.1 Outpatient

Preferred Regimen

Cloxacillin 500mg PO q6h

Alternative Regimen (Allergy / Resistance)

Cephalexin 500mg PO q6h

Remarks & Clinical Comments:

Duration: 5-7 days. If poor response, may consider extending to 10-14 days.

NAG MOH Malaysia 2024Official Site

AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

7. POSTPARTUM MASTITIS

7.2 Inpatient

Preferred Regimen

Cloxacillin 2g IV q4-6h

Alternative Regimen (Allergy / Resistance)

Cefazolin 1-2g IV q8h

Remarks & Clinical Comments:

Duration: 5-7 days. If poor response, may consider extending to 10-14 days.

NAG MOH Malaysia 2024Official Site

AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

8. LOWER SEGMENT CAESAREAN SECTION (LSCS) WOUND INFECTION

8.1 Mild

Preferred Regimen

Cloxacillin 500mg PO q6h for 5-7 days

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Erythromycin ethylsuccinate 400mg PO q6h or 800mg PO q12h for 5-7 days

Remarks & Clinical Comments:

Appropriate dressing is the mainstay of treatment.

NAG MOH Malaysia 2024Official Site

AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

8. LOWER SEGMENT CAESAREAN SECTION (LSCS) WOUND INFECTION

8.2 Moderate - Severe

Preferred Regimen

Cloxacillin 2g IV q6h

Cefazolin 1-2g IV q8h

Alternative Regimen (Allergy / Resistance)

Risk of gram negative or anaerobic infection (e.g. diabetes):

Amoxicillin/clavulanate 1.2g IV q8h

Ampicillin/sulbactam 3g IV q6h

Remarks & Clinical Comments:

Duration: 10-14 days but shorter duration (5-7 days) can be considered if adequate source control and local wound management result in clinical improvement.

NAG MOH Malaysia 2024Official Site

AdultA6OBSTETRICS & GYNEACOLOGICAL INFECTIONS

9. BARTHOLIN'S GLAND ABSCESS

Preferred Regimen

Amoxicillin/clavulanate 625mg PO q8h

Alternative Regimen (Allergy / Resistance)

Trimethoprim/sulfamethoxazole 160mg/800mg PO q12h

Remarks & Clinical Comments:

Duration: 5-7 days If the patient has risk factors for sexually transmitted infections (STIs), appropriate investigations should be performed, and empirical treatment initiated as outlined in the STI chapter. Surgical management is recommended if the abscess does not drain spontaneously.

NAG MOH Malaysia 2024Official Site

PaediatricB7OCULAR INFECTIONS

1. PRESEPTAL CELLULITIS

Common organisms: Streptococcus pneumoniae Staphylococcus aureus Streptococcus pyogenes Haemophilus influenzae

Preferred Regimen

Mild

Amoxicillin/clavulanate

Suspension (Formulation 14:1)

Amoxicillin / Clavulanate 80-90mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day)

Suspension (Formulation 7:1)

Amoxicillin / Clavulanate 40-50mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day)

Systemically Unwell

Cloxacillin 200mg/kg/day IV in 4 divided doses (max. 12g/day)

PLUS

Cefotaxime 150-200mg/kg/day IV in 3 divided doses (max. 6g/day)

Ceftriaxone 50mg/kg/dose IV q12h (max. 4g/day)

Alternative Regimen (Allergy / Resistance)

Cephalexin 25-50mg/kg/day PO in 2 divided doses (max. 2g/day) for 10 days

Remarks & Clinical Comments:

Failure to respond within 24-48 hours may indicate orbital cellulitis or underlying sinus disease. When improving and no organism identified, change to amoxicillin/clavulanate and complete for 7 days.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

1. EYELID

1.1 Anterior Blepharitis

Common organisms: Staphylococcus aureus Staphylooccus epidermidis

Preferred Regimen

Eyelid hygiene/scrubs is the mainstay of therapy.

Topical antibiotics are not indicated as an initial therapy.

Alternative Regimen (Allergy / Resistance)

Chloramphenicol ointment 1% applied q12h to the lid margin for 1-2 weeks

Oxytetracycline with Polymyxin B eye ointment applied q12h to the lid margin

Fusidic Acid 1% eye ointment applied q12h to the lid margin

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AdultA7OCULAR INFECTIONS

1. EYELID

1.2 Meibomian Gland Dysfunction/ Posterior Blepharitis

Preferred Regimen

Warm compresses and massage.

Systemic therapy is not indicated as an initial therapy.

Alternative Regimen (Allergy / Resistance)

*Doxycycline 100mg PO daily or q12h for 4-6 weeks

**Azithromycin 500mg PO q24h for 3 days weekly intervals with a minimum of 3 cycles

Remarks & Clinical Comments:

*Tetracyclines are contraindicated in children < 8 years. **Off-label use.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

1. EYELID

1.3 Internal Hordeolum with Secondary Infection

Staphylococcus aureus

Preferred Regimen

Warm compresses.

Systemic antibiotics are indicated in the presence of superficial cellulitis or abscess.

Mild Infections:

Cloxacillin 500mg IV/PO q6h

Severe Infections:

Cloxacillin 1-2g IV/PO q6h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 625mg PO q8h

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

1. EYELID

1.4 External Hordeolum (Stye)

Staphylococcus aureus

Preferred Regimen

Epilation of affected eye lash and warm compresses.

Systemic antibiotics are indicated in the presence of superficial cellulitis or abscess

Mild Infections:

Cloxacillin 500mg IV/PO q6h

Severe Infections:

Cloxacillin 1-2g IV/PO q6h

Alternative Regimen (Allergy / Resistance)

Mild Infections:

Amoxicillin/clavulanate 625mg PO q8h

Severe Infections:

Cefazolin 1-2g IV q8h

Cephalexin 500mg PO q6h

MRSA or penicillin allergy:

Trimethoprim/sulfamethoxazole 5-10mg/kg/day of TMP component q12h

NAG MOH Malaysia 2024Official Site

PaediatricB7OCULAR INFECTIONS

2. ORBITAL CELULLITIS / ABSCESS

Common organisms: Streptococcus pyogenes Streptococcus pneumoniae Staphylococcus aureus Haemophilus influenzae Anaerobes

Preferred Regimen

Ceftriaxone 50mg/kg/dose IV q12h (max. 4g/day) for 7-14 days

PLUS

Cloxacillin 200mg/kg/day IV in 4 divided doses (max. 12g/day) for 7-14 days

**If associated with chronic sinusitis / complicated with intracranial abscess, to add on IV Metronidazole 30mg/kg/day q8hr (max. 1500mg/day)

Inpatient:

48-72 hours IV antibiotic, then oral to complete 14 days following good response (no positive culture)

Amoxicillin/clavulanate

Suspension (Formulation 14:1)

Amoxicillin / Clavulanate 80-90mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day)

Suspension (Formulation 7:1)

Amoxicillin / Clavulanate 40-50mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day)

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 30-40mg/kg/day PO in 3 or 4 divided doses (max. 450mg/dose)

CA-MRSA:

Adjust accordingly with sensitivity

E.g.: Vancomycin 60mg/kg/day IV in 3-4 divided doses

Remarks & Clinical Comments:

This condition is considered a surgical emergency and requires immediate consultation with ENT surgeon and ophthalmologist. Urgent CT scan needed to exclude associated abscess and intracranial extension. Urgent surgical drainage of the ethmoid sinuses or of an orbital, subperiosteal or intracranial abscess may be needed. Refer to Appendix 3 for antibiotic allergy.

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AdultA7OCULAR INFECTIONS

2. CONJUCTIVA

2.1 Bacterial Conjunctivitis

Common organisms: Staphylococcus aureus Streptococcus pneumonia Haemophilus influenzae

Preferred Regimen

Chloramphenicol 0.5% eye drop q6h

MAY ADD

Chloramphenicol eye ointment at night

Alternative Regimen (Allergy / Resistance)

Moxifloxacin 0.5% eye drop q6h

Ciprofloxacin 0.3% eye drop q6h

Levofloxacin 0.5% eye drop q6h

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

2. CONJUCTIVA

2.2 Chlamydial Conjunctivitis

Chlamydial trachomatis

Preferred Regimen

Azithromycin PO 1g STAT

MAY ADD

Topical tetracycline eye ointment 1% q12h for 6 weeks

Alternative Regimen (Allergy / Resistance)

Doxycycline PO 100mg q12h for 7 days

Remarks & Clinical Comments:

Requires systemic therapy. Doxycycline not recommended for pregnancy.

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AdultA7OCULAR INFECTIONS

2. CONJUCTIVA

2.3 Chlamydial Conjunctivitis

Trachoma C

Preferred Regimen

Azithromycin PO 1g STAT

Alternative Regimen (Allergy / Resistance)

Doxycycline PO 100mg q12h for minimum of 21 days

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AdultA7OCULAR INFECTIONS

2. CONJUCTIVA

2.4 Gonococcal Conjunctivitis

Preferred Regimen

Ceftriaxone IM/IV 1g STAT

Remarks & Clinical Comments:

Frequent eye toileting of the infected eye with topical saline eye drops until discharge reduces. Topical antibiotics may be considered as ancillary therapy.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

3. CORNEA

3.1 Bacterial Keratitis

Preferred Regimen

Monotherapy:

Ciprofloxacin 0.3% eye drop q1-2h

Moxifloxacin 0 .5% eye drop q1-2h

Levofloxacin 0.5% eye drop q1-2h

Alternative Regimen (Allergy / Resistance)

Combination therapy of two:

Moxifloxacin 0.5% q1-2h

Ciprofloxacin 0.3% eye drop q1-2h

Levofloxacin 0.5% eye drop q1-2h

PLUS

*Gentamicin 0.9% eye drop q1-2h

MRSA:

*Vancomycin 5% eye drop q1-2h

Remarks & Clinical Comments:

Monotherapy is indicated for mild bacterial keratitis. Combination therapy is indicated for severe bacterial keratitis. *Prepared extemporaneously using injectable forms.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

3. CORNEA

3.2 Contact Lens Related Bacterial Keratitis

Preferred Regimen

Monotherapy:

Ciprofloxacin 0.3% eye drop q1-2h

Levofloxacin 0.5/1.5% eye drop q1-2h

Alternative Regimen (Allergy / Resistance)

Combination therapy of two:

*Ceftazidime 5% eye drop q1-2h

Ciprofloxacin 0.3% eye drop q1-2h

Levofloxacin 0.5/1.5% eye drop q1-2h

PLUS

*Gentamicin 0.9% eye drop q1-2h

Remarks & Clinical Comments:

*Prepare extemporaneously using injectable forms

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

3. CORNEA

3.3 Bacterial Keratitis

3.3.1 Gram-negative Rods

Preferred Regimen

Monotherapy:

Ciprofloxacin 0.3% eye drop q1-2h

Levofloxacin 0.5/1.5% eye drop q1-2h

Alternative Regimen (Allergy / Resistance)

Combination therapy of two:

*Ceftazidime 5% eye drop q1-2h

Ciprofloxacin 0.3% eye drop q1-2h

Levofloxacin 0.5% eye drop q1-2h

PLUS

*Gentamicin 0.9% eye drop q1-2h

Remarks & Clinical Comments:

Monotherapy is indicated for mild bacterial keratitis. Combination therapy is indicated for severe bacterial keratitis. *Prepare extemporaneously using injectable forms.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

3. CORNEA

3.3 Bacterial Keratitis

3.3.1 Gram-positive Cocci

Preferred Regimen

Moxifloxacin 0 .5% eye drop q1-2h

Alternative Regimen (Allergy / Resistance)

*Cefuroxime 5% eye drop q1-2h

MRSA:

*Vancomycin 5% eye drop q1-2h

Remarks & Clinical Comments:

*Prepare extemporaneously using injectable forms.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

3. CORNEA

3.4 Acanthamoeba Keratitis

Acanthamoeba sp.

Preferred Regimen

*Chlorhexidine 0.02% eye drop q1-2h

PLUS

**Propamidine isethionate 0.1% eye drop q1-2h

Remarks & Clinical Comments:

*Prepare extemporaneously using injectable forms. **Requires DG’s approval.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

3. CORNEA

3.5 Fungal Keratitis

Common organisms: Aspergillus sp. Fusarium sp. Candida sp.

Preferred Regimen

Polyenes:

**Natamycin 5% eye drop q1-2h

*Amphotericin B 0.05-0.15% eye drop q1-2h

Azoles:

*/**Voriconazole 1% eye drop q1-2h

*Fluconozole 0.2% eye drop q1-2h

Oral Therapy:

May be considered in the absence of contraindications.

Fluconazole 200mg PO q24h

Itraconazole 200mg PO q24h

Remarks & Clinical Comments:

Dual combination therapy of polyene and azole antifungal may be used. Natamycin is the choice of therapy for Fusarium sp. Amphotericin B is the choice of therapy for yeasts. *Prepare extemporaneously using injectable forms. **Requires DG’s approval. Minimum: 3 weeks duration

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

3. CORNEA

3.7 Herpes Simplex Keratitis (Herpes Simplex Type 1 & 2)

Preferred Regimen

Acyclovir 3% eye ointment 5 times/day for 10 – 14 days or for at least 3 days after healing, whichever shorter.

In the presence of stromal or endothelial disease:

Acyclovir 400mg PO 5 times/day for 7-10days

Prophylaxis for recurrent cases:

Acyclovir 400mg PO q12h for 12 months

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

3. CORNEA

3.8 Herpes Zoster Ophthalmicus

Requires systemic therapy. Refer to Skin and Soft Tissue Infection section.

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AdultA7OCULAR INFECTIONS

4. RETINA

4.1 Acute Retinal Necrosis

Common organism: Varicella Zoster virus Herpes Simplex Cytomegalovirus (rarely)

Preferred Regimen

Acyclovir 10-12mg/kg/dose IV q8h (not more than 800mg) for 7-10 days until disease stabilize, then oral therapy for a minimum 6 weeks as below:

Acyclovir 800mg PO 5 times/day

PLUS (if retinitis is threatening the macular/ optic disc)

Intravitreal therapy:

*Intravitreal foscarnet 1.2-2.4mg/0.1ml

Intravitreal ganciclovir 0.2-2mg/0.1ml biweekly

Alternative Regimen (Allergy / Resistance)

*Valacyclovir 1g PO q8H for 6 weeks

Remarks & Clinical Comments:

*Requires DG’s approval Recommended to switch to definitive treatment once microbiology results available.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

4. RETINA

4.2 CMV Retinitis

Cytomegalovirus

Preferred Regimen

Systemic therapy:

Ganciclovir 5mg/kg IV q12h for 2-3 weeks

Intravitreal therapy:

Intravitreal ganciclovir 2mg/0.1ml biweekly

Alternative Regimen (Allergy / Resistance)

Systemic therapy:

*Valganciclovir 900mg PO q12h for 2-3 weeks (induction) followed by 900mg PO q24h (maintenance)

*Foscarnet IV 60mg/kg q8H or 90mg/kg q12h for patients with treatment limiting toxicities to ganciclovir or with ganciclovir resistance

Intravitreal therapy:

*Intravitreal foscarnet 2.4mg/0.1ml (1-2weekly)

Remarks & Clinical Comments:

Systemic therapy is indicated in all cases. Maintenance therapy may need to be continued until CD4 count is > 100 cells/mm3 for 3 consecutive months. Intravitreal therapy is indicated in zone 1 and 2 lesions. Intravitreal therapy to be tapered according to clinical response. Ganciclovir implant 4.5g is an option for prolonged usage of intravitreal ganciclovir. *Requires DG’s approval

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AdultA7OCULAR INFECTIONS

5. ENDOPHTHALMITIS

5.1 Bacterial Endophthalmitis (Post-operative/ Post trauma)

Early, Acute: Staphylococcus epidermidis, Staphylococcus aureus, Streptococcus sp., Pseudomonas aeruginosa, Enterococcus sp., Candida Albicans Low grade, Chronic: Cutibacterium Acnes, Staphylococcus epidermidis

Preferred Regimen

Intravitreal antibiotic injections:

*Vancomycin 1-2mg/0.1ml

PLUS

*Ceftazidime 2mg/0.1ml

Systemic therapy:

Vancomycin 15 – 20mg/kg IV q8-12h; not to exceed 2g/dose

PLUS

Ceftazidime 1-2g IV q8h

Deescalate to,

Ciprofloxacin 500mg - 750mg PO q12h with evidence of clinical improvement after 2 weeks of intravenous antibiotic.

For culture negative,

ADD

Clarithromycin 500mg PO q12h for 2 weeks

If suspicious of fungal endopthalmitis, refer section fungal endopthalmitis.

Topical therapy:

Moxifloxacin 5% eye drop

Alternative Regimen (Allergy / Resistance)

Intravitreal antibiotic injections:

*Vancomycin 1-2mg/0.1ml

PLUS

*Amikacin 0.4mg/0.1ml

Systemic therapy:

Ciprofloxacin 750mg PO q12h for 10 days

Moxifloxacin 400mg PO q24h for 10 days

Topical therapy:

Ceftazidime 5% eye drop

Remarks & Clinical Comments:

Systemic antibiotics are indicated in severe, virulent endophthalmitis. Repeat intravitreal antibiotics after 48 to 72 hours if indicated. *Prepare extemporaneously using injectable forms Systemic treatment only indicated in cases of delay of transfer to ophthalmology centre. Systemic antibiotics are typically continued for a minimum of 2–4 weeks, and up to 6 weeks, depending on observed ophthalmologic improvement.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

5. ENDOPHTHALMITIS

5.2 Fungal Endophthalmitis (Post-operative/ Endogenous)

Preferred Regimen

Intravitreal therapy:

Amphotericin B 0.005mg/0.1ml

PLUS

Systemic therapy:

Fluconazole IV 800mg (12mg/kg) loading dose then 400-800mg (6-12mg/kg daily)

For severe condition:

Amphotericin B 0.5-1mg/kg IV q24h; MAY ADD

**Flucytosine 25mg/kg q6h

Step down therapy:

Fluconazole 200mg PO q24h for total 4-6 weeks (minimum)

Alternative Regimen (Allergy / Resistance)

Intravitreal therapy:

*Voriconazole 50ug-100ug/0.1ml

PLUS

Systemic therapy:

*Voriconazole 400mg (6mg/kg) IV/PO q12h for 2 doses, followed by 200mg (4mg/kg) PO q12h

Remarks & Clinical Comments:

Intravitreal and systemic therapy are indicated in all cases. Refer to microbiological sensitivity. Systemic therapy is typically continued for at least 4-6 weeks depending on observed ophthalmologic improvement. *Requires DG’s approval **Flucytosine is recommended for less susceptible azole isolates.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

5. ENDOPHTHALMITIS

5.3 Endogenous Endophthalmitis

Common organism: Streptococcus pneumonia or other streptococcus Neisseria Meningitidis Staphylococcus aureus Klebsiella pneumoneia or other gram negative organism Candida sp

Preferred Regimen

*Systemic therapy:

Ceftriaxone 2g IV q24h

Cefotaxime 2g IV q4h

For culture negative cases,

ADD

Clarithromycin 500mg PO q12h for 7-14 days

AND

Intravitreal antibiotic injections:

Vancomycin 1-2mg/0.1ml

PLUS

Ceftazidime 2mg/0.1ml

If suspicious of fungal endopthalmitis, refer section fungal endopthalmitis.

Topical treatment:

Moxifloxacin 5% eye drop

Alternative Regimen (Allergy / Resistance)

Systemic therapy:

Ciprofloxacin 750mg PO q12h for 10 days

Moxifloxacin 400mg PO q24h for 10 days

Intravitreal antibiotic injections:

Vancomycin 1-2mg/0.1ml

PLUS

Amikacin 0.4mg/0.1ml

Topical treatment:

Ceftazidime 5% eye drop

Remarks & Clinical Comments:

Treatment is based on primary infection (bacterial/fungal) and culture and sensitivity results. All cases require systemic therapy. Intravitreal injection is indicated in cases with vitreous involvement and sight threatening choroidal lesions. Topical therapy may supplement therapy. Not to use systemic steroids in these cases. Review antibiotic regimen after microbiology results. Repeat intravitreal antibiotics after 48 to 72 hours if indicated. *Systemic antibiotics are typically continued for a minimum of 2–4 weeks, and up to 6 weeks, depending on observed ophthalmologic improvement.

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

6. OCULAR

6.1 Ocular Toxoplasmosis

Toxoplasma gondii

Preferred Regimen

Trimethoprim/sulfamethoxazole 160/800mg PO q12h for at least 6 weeks

Prophylaxis for recurrent lesions:

Trimethoprim/sulfamethoxazole 80/400mg q12h PO for 3 times a week

Alternative Regimen (Allergy / Resistance)

*Pyrimethamine 100mg PO on Day 1

Followed by:

*Pyrimethamine 25-50mg PO q24h

PLUS

Folinic acid 10-25mg PO q24h

PLUS

*Sulfadiazine 1g PO q6h for at least 6 weeks

Azithromycin 500mg PO q24h for 3 weeks

Clindamycin 300mg PO q6h for 3 weeks

Remarks & Clinical Comments:

Pregnancy: May consider intravitreal clindamycin 1.0mg/0.1ml. Systemic steroids are usually indicated in immunocompromised patients. *Requires DG’s approval.

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AdultA7OCULAR INFECTIONS

6. OCULAR

6.2 Ocular Syphilis

Treponema Pallidum

Ocular syphilis (syphilitic uveitis) should be treated as neurosyphilis. Refer to Sexually Transmitted Infections section .

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

6. OCULAR

6.3 Ocular Tuberculosis

Mycobacterium Tuberculosis

Requires systemic therapy. Refer to Ministry of Health’s CPG on Management of Tuberculosis (Extra pulmonary TB). Ethambutol may cause optic neuropathy and should be avoided depending on the case. Ocular TB presents as a unilateral/ bilateral infective uveitis characterized by multifocal choroiditis/ granuloma and there may be supportive FFA findings of occlusive vasculitis. The diagnosis may be clinical as vitreous sampling for AFB or TB PCR may not be very sensitive due to small sample size and sensitivity of the tests. Clinical response to anti-TB is often diagnostic. Uveitis secondary to TB Hypersensitivity is an immune response to acid fast bacilli in the eye and manifests predominantly as an inflammatory uveitis. Treatment includes anti-TB in combination with an immunosuppressive dose of systemic steroids for at least 6-9 months. Systemic steroids may be indicated but is only for ● Non-active systemic TB ● Immunocompetent patients ● Severe ocular inflammation developing after starting anti-TB treatment ● Vision threatening condition

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AdultA7OCULAR INFECTIONS

6. OCULAR

6.4 Ocular Melioidosis

For ocular manifestations of melioidosis, refer to Tropical Infections section.

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AdultA7OCULAR INFECTIONS

6. OCULAR

6.5 Ocular Bartonellosis

Preferred Regimen

Doxycycline 100mg PO q12h

Azithromycin 500mg PO on Day 1, then 250mg PO q24h

Remarks & Clinical Comments:

Duration: 2 – 6 weeks

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AdultA7OCULAR INFECTIONS

6. OCULAR

6.6 Ocular Leptospirosis

Refer to Tropical Infections section

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AdultA7OCULAR INFECTIONS

7. DACRYOCYSTITIS

7.1 Dacryocystitis

Common organisms: Streptococcus pneumonia Staphylococcus aureus Gram-negative anaerobes

Preferred Regimen

Amoxicillin/clavulanate 625mg PO q8h

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam PO 375mg q12h

Remarks & Clinical Comments:

Consider intravenous antibiotics in severe infections. Duration: 7 days

NAG MOH Malaysia 2024Official Site

PathwayC7URINARY TRACT INFECTION IN NON-PREGNANCY

URINARY TRACT INFECTION IN NON-PREGNANCY

UTI in non pregnancy 30.01.2026.pdf

Attached Clinical Documents:

UTI in non pregnancy 30.01.2026.pdf

NAG MOH Malaysia 2024Official Site

AdultA7OCULAR INFECTIONS

8. CELLULITIS

8.1 Preseptal Cellulitis

Common organisms: Streptococcus pneumoniae Staphylococcus aureus Streptococcus sp.

Preferred Regimen

Cloxacillin 500-1000mg PO q6h for 5-7 days

Cephalexin PO 500mg q6H for 7 days

Cefuroxime 500mg q12h for 7 days

Alternative Regimen (Allergy / Resistance)

Oral Therapy:

Clindamycin PO 300mg-600mg q8h (if penicillin allergy) for 7 days

Amoxicillin/clavulanate 625mg PO q8h for 7 days (for concurrent sinusitis)

IV Therapy:

Cloxacillin IV 2g q6h for 7 days

Clindamycin IV 600mg q8h for 7 days (if penicillin allergy)

Ceftriaxone IV 2g q24h for 7 days (for concurrent sinusitis)

Remarks & Clinical Comments:

Consider intravenous antibiotics in severe infections.

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AdultA7OCULAR INFECTIONS

8. CELLULITIS

8.2 Orbital Cellulitis/abscess

Common organisms: Streptococcus pneumoniae Staphylococcus aureus Streptococcus sp. Gram-negative anaerobes (odontogenic source) Haemophillus influenza

Preferred Regimen

Cefotaxime IV 2g q8h

Ceftriaxone IV 2g q24h

Amoxicillin/clavulanate 1.2g IV q8h for 7-10days

If anaerobes suspected,

ADD

Metronidazole 500mg IV q8h

Alternative Regimen (Allergy / Resistance)

Penicillin/cephalosporin allergy:

Vancomycin 15-20mg/kg IV q8-12h

PLUS

Ciproflxacin 400mg IV q12h

Remarks & Clinical Comments:

Duration: 7-14 days depending on clinical response

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PaediatricB8ORTHOPAEDIC INFECTIONS

ORTHOPAEDIC INFECTIONS

Preferred Regimen

0 - 3 months old

Cloxacillin 200mg/kg/day IV in 4-6 divided doses (max. 2g/dose)

PLUS

Cefotaxime 200mg/kg/day IV in 4 divided doses (max. 2g/dose)

>3 months to 5 years old

Cloxacillin 200mg/kg/day IV in 4-6 divided doses (max. 2g/dose)

MAY ADD

Cefuroxime 100-200mg/kg/day IV in 3 divided doses (max. 1.5g/dose) (monotherapy)

Cefotaxime 200mg/kg/day IV in 4 divided doses (max. 2g/dose)

Older than 5 years old

Cloxacillin 200 mg/kg/day IV in 4-6 divided doses (max. 2g/dose)

Alternative Regimen (Allergy / Resistance)

0 - 3 months old

Cefazolin is alternative anti-staphylococcal agent for infants age 1-3 months if no CNS involvement

>3 months

Cefazolin 100-150mg/kg/day IV in 3 divided doses (max. 1g/dose)

(Can be used in children with suspected S. aureus or S. pyogenes. Less hypersensitivity reaction compared to cloxacillin & more convenient dosing)

Kingella kingae: uncommon organism causing infection in <5 years old; indolent onset; preceding oral ulcers; may affect nontubular bones; sensitive to β-lactam antibiotics e.g., cefuroxime or amoxicillin/clavulanate

Remarks & Clinical Comments:

PAEDIATRIC ORTHOPAEDIC INFECTIONS SEPTIC ARTHRITIS (SA) & OSTEOMYELITIS (OM) Common organisms according to age groups: ≤ 3 months S. aureus Streptococcus agalactiae Gram-negative enteric organism >3 months to 5 years old Staphylococcus aureus Streptococcus pyogenes Streptococcus pneumoniae Non-typeable Haemophilus spp. Kingella kingae Older than 5 years Staphylococcus aureus Streptococcus pyogenes Polymicrobial infection: More likely with penetrating trauma or contagious spread Empiric antibiotics should be started based on clinical diagnosis of SA or OM. CBC, blood cultures and CRP +/- ESR should be taken prior to antibiotic therapy. Optimise antimicrobial treatment based on C&S. Surgical debridement often not required in OM. Urgent wash out & drainage is needed in SA in hip and other joints to reduce pressure on growth plate. Synovial fluid and bone culture/analysis is part of diagnostic work up if child is subjected to drainage or debridement. Duration of antibiotics: SA: total of 3-4 weeks (*4-6 weeks if hip is involved) OM: 4-6 weeks For both SA and OM, transition to oral antibiotic is based on clinical and laboratory improvement if compliance and follow up is assured. Shorter duration of 3-4 weeks antibiotics for uncomplicated MSSA or culture negative OM responded to initial therapy for children > 3 months old. Neonatal OM: Similar duration for other age group but at least 4 weeks of IV antibiotics. Choice of oral regimen is based on culture and susceptibility results. If cultures are negative, oral therapy is directed toward the most likely pathogen with similar spectrum of activity as parenteral therapy. Higher doses are generally given to ensure adequate bone penetration. Uncomplicated OM is defined as single bone involvement, rapid resolution of bacteremia, rapid clinical response to medical and surgical treatment, rapid fall of CRP with no identified acute or late sequalae of infection. Complex OM (multifocal, significant bone destruction, immunocompromised host & resistant/unusual pathogens), prolonged IV antibiotics are needed & duration might exceed 6 weeks.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.1 Infections of the Teeth and Supporting Structures

1.1.1 Reversible/ Irreversible Pulpitis

Symptomatic treatment. Antibiotic use is not recommended.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.1 Infections of the Teeth and Supporting Structures

1.1.2 Localised Dentoalveolar Abscess / Apical / Periapical / Periodontal abscess

Preferred Regimen

Superficial:

Systemic antibiotic use not recommended (immunocompetent).

Deep Infection / Immunocompromised patient:

Amoxicillin 500mg PO q8h

MAY ADD

Metronidazole 400mg PO q8h

Alternative Regimen (Allergy / Resistance)

Deep Infection / Immunocompromised patient:

Amoxicillin/clavulanate 625mg PO q8h

Antibiotic allergy:

Clindamycin 300mg PO q6h for 7 days

Remarks & Clinical Comments:

The definitive treatment involves aggressive surgical intervention for source control, which includes drainage of the abscess with or without tooth extraction. If the procedure is successful, a minimum duration of 3 days of antibiotic therapy should be administered. Duration: 3 – 7 days Refer to Appendix 3 for antibiotic allergy.

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AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.1 Infections of the Teeth and Supporting Structures

1.1.3 Dry Socket

Systemic antibiotic use is not recommended. Local treatment with saline irrigation and antiseptic/ analgesic dressings and symptomatic relief of pain.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.1 Infections of the Teeth and Supporting Structures

1.1.4 Localised Pericoronitis

Preferred Regimen

Systemic antibiotic use is not recommended in the absence of regional or systemic signs and symptoms.

Once systemic spread of infection is suspected:

Amoxicillin 500mg PO q8h

MAY ADD

Metronidazole 400mg PO q8h

Remarks & Clinical Comments:

Local treatment with antiseptic irrigation and mouthwash and symptomatic relief of pain. Duration: 5 days

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.1 Infections of the Teeth and Supporting Structures

1.1.5 Chronic Gingivitis

Systemic antibiotic use is not recommended. First line treatment: Mechanical and chemical plaque control. 0.2% Aqueous Chlorhexidine Gluconate is not used alone but as an adjunct to mechanical debridement. Second line treatment: Antimicrobial mouth rinse

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.1 Infections of the Teeth and Supporting Structures

1.1.6 Chronic Periodontitis

Antibiotic use can be considered in cases of: 1. Unresponsive to conventional mechanical therapy. 2. Acute infection associated with systemic manifestation. 3. Immunocompromised. 4. Generalized periodontitis stage III in young adults.

Preferred Regimen

Systemic antibiotic use is generally not recommended.

Amoxicillin 500mg PO q8h

PLUS

Metronidazole 400mg PO q8h

Amoxicillin/clavulanate 625mg PO q8h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 300mg PO q6h

Remarks & Clinical Comments:

First line treatment: Mechanical plaque control Duration: 3-7 days Refer to Appendix 3 for antibiotic allergy.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.1 Infections of the Teeth and Supporting Structures

1.1.7 Aggressive Periodontitis

Common organisms: Aggregatibacter actinomycetemcomitans Porphyromonas gingivalis Tannerella forsythia Prevotella intermedia Treponema denticola

Preferred Regimen

Amoxicillin 500mg PO q8h

PLUS

Metronidazole 400mg PO q8h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 300mg PO q6h

Azithromycin 500mg PO q24h for 3 days

Remarks & Clinical Comments:

Duration: 7 days Antibiotics are used as an adjunct to scaling and root debridement. Refer to Appendix 3 for antibiotic allergy.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.2 Infections of the Jaws

1.2.1 Osteomyelitis of the jaws of dental origin

Different organisms may be involved

Preferred Regimen

For acute cases, start with:

Amoxicillin 500mg PO q8h

PLUS

Metronidazole 400mg PO q8h

Amoxicillin/clavulanate 625mg PO q8h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 300-450mg PO q6h or 600-900mg IV q8h

Remarks & Clinical Comments:

Culture and sensitivity are necessary to guide the antibiotic. For chronic cases, start with surgical treatment first. Start antibiotics only when causative organisms are identified. Duration of antibiotic therapy: 4-6 weeks depending on patient response / microbiological clearance of the pathogen. Refer to Appendix 3 for antibiotic allergy.

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AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.3 Spreading Infections and Infections of Fascial Spaces (with/without Systemic Signs)

1.3.1 Cellulitis ± Abscess of Dental Origin

Preferred Regimen

Benzylpenicillin 2-4MU IV q4-6h

PLUS

Metronidazole 500mg IV q8h

Amoxicillin/Clavulanate 1.2g IV q8h

Cefuroxime 1.5g IV q8h

PLUS

Metronidazole 500mg IV q8h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 300-450mg PO q6h or 600-900mg IV q8h

Remarks & Clinical Comments:

Common organisms (polymicrobial including): Prevotella Peptostreptococcus Fusobacterium nucleatum Viridans Streptococci Streptococcus anginosus group Clostridium sp Surgical site infection: Infection is usually by endogenous organisms rather than exogenous Common organisms: Viridans Streptococci Staphylococci Prevotella intermedia Peptostreptococcus Eubacterium Fusobacterium nucleatum Incision and drainage are advised and change antibiotics in accordance with the result of culture and sensitivity. Continue IV therapy for 1 to 2 days following successful abscess drainage, then switch to oral therapy. Refer to Appendix 6 for IV to PO switch. Refer to Appendix 3 for antibiotic allergy.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.3 Spreading Infections and Infections of Fascial Spaces (with/without Systemic Signs)

1.3.2 Traumatic Wound Infection

Infection is usually by endogenous organisms rather than exogenous Refer to section Trauma-related Infections – Dental Infections.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS

1.4 Post Implant Infections (Peri Implantitis)

Heterogeneous mixed infection: Actinomyces sp. Eubacterium sp. Propionibacterium sp. Lactobacillus sp. Veillonella sp. Porphyromonas gingivalis Prevotella intermedia Fusobacterium nucleatum

Preferred Regimen

Systemic antibiotics are generally not recommended unless in severe cases.

Severe cases (e.g. deep pockets ≥7 mm, extensive suppuration):

Amoxicillin/clavulanate 625mg PO q8h

Amoxicillin 500mg PO q8h

PLUS

Metronidazole 400mg PO q8h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Doxycycline 100mg PO q12h

Clindamycin 300mg PO q6h

Remarks & Clinical Comments:

Refer to Appendix 3 for antibiotic allergy.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

2. ANTIMICROBIAL USE FOR FUNGAL INFECTIONS

2.1 ORAL CANDIDIASIS

Refer to section Infections in Immunocompromised Patients - Opportunistic Infections (OI) in Patients with HIV.

NAG MOH Malaysia 2024Official Site

AdultA8ORAL/DENTAL INFECTIONS

3. ANTIMICROBIAL USE FOR VIRAL INFECTIONS

Common oral viral infections: Herpes simplex virus type 1 (HSV-1) Primary herpetic gingivostomatitis Herpes labialis Herpes simplex virus type 2 (HSV-2)

Symptomatic treatment in most cases. Refer to section Sexually Transmitted Infections - Genital Herpes.

NAG MOH Malaysia 2024Official Site

PathwayC8C8. URINARY TRACT INFECTION IN PREGNANCY (ASYMPTOMATIC BACTERIURIA)

C8. URINARY TRACT INFECTION IN PREGNANCY (ASYMPTOMATIC BACTERIURIA)

UTI in pregnancy (asymptomatic bacteriuria) 30.01.2026.pdf

Attached Clinical Documents:

UTI in pregnancy (asymptomatic bacteriuria) 30.01.2026.pdf

NAG MOH Malaysia 2024Official Site

PaediatricB9OTORHINOLARYNGOLOGY INFECTIONS

1. TONSILLITIS/PHARYNGITIS

Group A Streptococcus

Preferred Regimen

Phenoxymethylpenicillin (penicillin V) 25-50mg/kg/day (max. 2g/day) PO in 4 divided doses

Amoxicillin 50mg/kg/day PO in 1 or 2 divided doses (max. 1g/day)

*Benzylpenicillin 100,000-200,000units/kg IV in 4 divided doses (max. 24 million unit/day)

Switch to oral therapy (penicillin V / amoxicillin) when improving and being able to tolerate orally.

Total duration: 10 days

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy (non-life-threatening)

Cephalexin 25-50mg/kg/day (max. 2g/day) PO in 2 divided doses

Erythromycin ethylsuccinate 40-50mg/kg/day (max. 800mg/dose) PO in 2 divided doses

Duration: 10 days

Remarks & Clinical Comments:

Once-daily dose amoxicillin (50 mg/kg; max:1g/day) for 10 days, is as effective as penicillin V or multiple dose amoxicillin for 10 days endorsed by the American Heart Association and the Infectious Disease Society of America in its guidelines for the treatment of GAS pharyngitis and the prevention of ARF. Adherence is important for once-daily dosing regimens. *IV antibiotics are not routinely recommended for uncomplicated tonsillopharyngitis but may be considered in severe cases or if the child is unable to tolerate oral therapy.

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AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.1 Osteomyelitis

1.1.1 Acute Osteomyelitis

Common organisms: Staphylococcus aureus (80%) Group A Streptococcus pyogenes Rarely gram negative bacilli

Preferred Regimen

Empirical coverage:

Cloxacillin 2g IV q6h

To tailor antibiotics according to definitive cultures.

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Cefazolin 2g IV q6-8h

Remarks & Clinical Comments:

Duration: Initial IV therapy for 2-4 weeks followed by oral therapy. Minimum duration: 6 weeks. Modify according to clinical response. Antibiotic therapy tailored to tissue/bone C&S result. 4 weeks of IV antibiotics is required for Staphylococcus aureus osteomyelitis associated with bacteraemia. Conversion from IV to PO therapy with good bioavailability can be done after minimum 2 weeks of IV antibiotics provided: • Patient has no significant comorbidity • Uncomplicated infection with source control • Clinical response seen • Patient able to tolerate orally • Suitable oral antibiotics with good oral bioavailability & proven sensitivity to causative organism A shorter duration of antibiotics can be considered if the osteomyelitis is fully resected (E.g.: amputation with a clear margin): • No surrounding soft tissue infection: 5 days. • Evidence of soft tissue infection: 10-14 days. Refer to Appendix 3 for antibiotic allergy.

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AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.1 Osteomyelitis

1.1.2 Chronic Osteomyelitis

Commonest organism: Staphylococcus aureus

Definition: • Relapsing infection despite adequate duration of appropriate antibiotic • Chronic pain/swelling/bone tenderness associated with tissue necrosis, increased drainage or persistent sinus tracts • Presence of bone destruction and presence of sequestra on imaging Empirical treatment before taking adequate cultures is not recommended. Choice of antibiotic depends on C&S result from tissue/bone as superficial swab culture NOT reliable. Thorough surgical debridement required (removal of dead bone / orthopaedic hardware). Treat until inflammatory parameters are normal. Duration: 6 weeks to 3 months. A shorter duration of antibiotics can be considered if the osteomyelitis is fully resected (E.g.: amputation with a clear margin): • No surrounding soft tissue infection: 5 days • Evidence of soft tissue infection: 10-14 days

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.1 Osteomyelitis

1.1.3 Vertebral Osteomyelitis

This includes pyogenic spine infections, both acute and chronic. Common organisms: Staphylococcus aureus (main), Brucella, Salmonella, Gram negative Bacilli

Preferred Regimen

Empirical therapy should be withheld unless the patient is septic or in patients with neurologic compromise.

CT-guided needle biopsy & aspiration should be done & specimen sent for C&S.

Cloxacillin 2g IV q4h

Alternative Regimen (Allergy / Resistance)

Cefazolin 2g IV q6-8h

Remarks & Clinical Comments:

Empiric gram negative (3rd or 4th generation cephalosporin) should be covered if patient had: • Recent spinal hardware inserted or surgery • Intra-abdominal infections • Co-existing or synchronous genitourinary infection • Immunocompromised Antibiotic therapy tailored to tissue/bone C&S result. Conversion from IV to oral therapy with good bioavailability can be done after minimum 2 weeks of IV antibiotics. Duration: • Minimum 6 weeks. • Minimum 8 weeks if undrained paravertebral abscess(es) and/or infection due to drug-resistant organisms. • Up to 12 weeks if extensive bone destruction or infection due to Brucella sp. Refer to brucellosis under Tropical Infections section for infection due to Brucella sp.

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AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.1 Osteomyelitis

1.1.4 Implant-associated vertebral osteomyelitis

• Early onset (within 30 days of implant insertion): Staphylococcus aureus, Beta-hemolytic streptococci, Gram-negative bacilli • Late onset (>30 days of implant insertion): Staphylococcus aureus, CoNS, Corynebacterium spp., P. acnes

Empirical treatment before taking adequate cultures is not recommended. Antibiotic selection is based on bone C&S. Duration: Minimum 12 week, final treatment duration depends on hardware retention/removal.

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.2 Septic Arthritis

Common organisms: Staphylococcus/ Streptococcus

Preferred Regimen

Cloxacillin 2g IV q4-6h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Cefazolin 2g IV q6-8h

Clindamycin 600mg IV q6h, followed by oral therapy (same dose)

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

Remarks & Clinical Comments:

Drainage, debridement and washout of infected joints is important to limit further damage. Duration: Parenteral therapy 2-4 weeks, then oral therapy to complete total 4-6 weeks. A shorter duration of therapy is possible in immunocompetent patients who have had adequate surgical drainage. Refer to Appendix 3 for antibiotic allergy. *Vancomycin: If suspected/confirmed MRSA. Consider loading dose 25-30mg/kg for critically ill or septic patients to achieve faster steady state. Empirical therapy wherever possible should be directed by the result of the gram stain of the joint aspirate. To consider gonococcal arthritis In a sexually active patient. Refer to the Sexually Transmitted Infections section.

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.3 Prosthetic Joint Infection & Implant Related Infection after Fracture Fixation

1.3.1 Prosthetic Joint Infections

• Early onset (<3 months after surgery): Staphylococcus aureus, Gram negative Bacilli • Delayed onset (from 3 to 12 months after surgery): Less virulent organism; CoNS/Enterococcus/anaerobes • Late onset (>12 months after surgery): Staphylococcus aureus, Enterobacteriaceae, B hemolytic Streptococcus, Anaerobes

Empirical therapy is not recommended. Treatment concepts: • Treatment is based on culture and sensitivity. • In staphylococcal infection, rifampicin should be added in combination with at least one other anti-staphylococcal agent, several days after surgical debridement when implant is retained/exchanged following surgery. • Treatment strategy and duration of treatment depends on surgical strategy.

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.3 Prosthetic Joint Infection & Implant Related Infection after Fracture Fixation

1.3.2 Definitive Prosthetic Joint Infection treatment- Methicillin-sensitive Staphylococcus aureus (MSSA)

Preferred Regimen

Initial treatment:

Cloxacillin 2g IV q4-6h

Cefazolin 2g IV q6-8h

PLUS

Rifampicin 300mg PO q12h OR 600mg PO q24h

Remarks & Clinical Comments:

Duration: 2-6 weeks for IV therapy (according to treatment strategy). Followed by an oral combination therapy according to susceptibility. Rifampicin should be included if the implant is in situ.

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.3 Prosthetic Joint Infection & Implant Related Infection after Fracture Fixation

1.3.3 Definitive Prosthetic Joint Infection treatment- Methicillin-resistant Staphylococcus aureus (MRSA)

Preferred Regimen

Initial treatment:

*Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

PLUS

Rifampicin 300mg PO q12h OR 600mg PO q24h

Remarks & Clinical Comments:

Duration: 2-6 weeks for IV therapy (according to treatment strategy) Followed by an oral combination therapy according to susceptibility. Rifampicin should be included if the implant is in situ. *Refer to Appendix 1 for vancomycin loading dose.

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

1.BONE AND JOINT INFECTIONS

1.3 Prosthetic Joint Infection & Implant Related Infection after Fracture Fixation

1.3.4 Fracture fixation device infection

Fracture fixation devices include plates, screws, intramedullary nails, rods, and pins from external fixation devices. • Early onset (less than 2 weeks): Highly virulent organisms (Staphylococcus aureus or gram-negative bacilli) • Delayed onset (2–10 weeks): Less virulent organisms (Staphylococcus epidermidis or Cutibacterium acnes) • Late onset (more than 10 weeks): Low virulence organisms (Staphylococcus epidermidis)

Preferred Regimen

Intraoperative tissue culture should be taken to guide antibiotic regimen.

Empirical therapy is not recommended unless patient is septic.

Ampicillin/sulbactam 3g IV q6h

Remarks & Clinical Comments:

Treatment concepts: • Treatment is based on culture and sensitivity. • In staphylococcal infection, rifampicin should be added in combination with at least one other anti-staphylococcal agent, several days after surgical debridement when implant is retained/exchanged following surgery. • Treatment strategy and duration of treatment depends on surgical strategy.

NAG MOH Malaysia 2024Official Site

PaediatricB9OTORHINOLARYNGOLOGY INFECTIONS

2. RHINOSINUSITIS

(Most common cause is due to viral infection) Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Group A Streptococcus

Preferred Regimen

Amoxicillin 80-90mg/kg/day (max.2g/day) PO for 5 days in 2 divided doses

Alternative Regimen (Allergy / Resistance)

Non-life-threatening allergy

Cefuroxime 30mg /kg/day (max. 1g/day) PO for 5 days in 2 divided doses

Severe antibiotic allergy

Erythromycin ethylsuccinate 40-50mg/kg/day (max. 800mg/dose) PO for 5 days in 2 divided doses

Remarks & Clinical Comments:

The most common causes are viral infections. Acute bacterial sinusitis is suspected when child with URI presents with: 1. Persistent illness (nasal discharge or daytime cough or both for ≥ 10 days without improvement) 2. Worsening course 3. Severe onset (concurrent fever & purulent discharge for 3 days) For rhinosinusitis, most experts recommend using high dose amoxicillin (90mg/kg/day).

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

2.COMPLICATED SKIN & SOFT TISSUE INFECTION

2.1 Diabetic Foot Infections

2.1.1 Mild Infections

At least 2 of these items are present: • Local swelling / induration • Erythema > 0.5 but < 2cm around the wound • Local tenderness / pain • Local increased warmth • Purulent discharge And no other cause of an inflammatory response of the skin (E.g.: trauma, gout, thrombosis).

Preferred Regimen

Cloxacillin 500mg PO q6h

Cephalexin 1g PO q12h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 625mg PO q8h

Ampicillin/sulbactam 375-750mg PO q12h

Remarks & Clinical Comments:

Duration: 1-2 weeks* *10 days following surgical debridement

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

2.COMPLICATED SKIN & SOFT TISSUE INFECTION

2.1 Diabetic Foot Infections

2.1.2 Moderate to severe diabetic foot infections

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h

Ampicillin/sulbactam 3g IV q6h

If pseudomonas is suspected:

** Piperacillin/tazobactam 4.5g IV q6-8h

Cefepime 2g IV q8h

If MRSA is suspected:

***Vancomycin 15-20mg/kg q8-12h; not to exceed 2g/dose

Alternative Regimen (Allergy / Resistance)

Cefuroxime 1.5g IV q8h

PLUS

*Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Moderate infections Infection with no systemic manifestations and involving: • Erythema extending ≥ 2cm from the wound margin, and/or • Tissue deeper than skin and subcutaneous tissues (e.g.: tendon, muscle, joint, and bone) Severe infections Any foot infection with associated systemic manifestations (≥ 2 SIRS) Duration for skin & soft tissues involvement: Total duration 2-4 weeks Duration for bone/joint involvement: • Resected: total duration 2-5 days • Debrided for infected soft tissue: total duration 1-2 weeks • Positive culture or histology of bone margins after bone resection: total duration 3 weeks • No surgery or dead bone: total duration 6 weeks IV to PO switch can be considered if adequate source control is performed. *Metronidazole: In ischemia limb / necrosis / gas forming. Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours) *Refer to Appendix 1 for vancomycin loading dose. Refer to Appendix 3 for antibiotic allergy. Surgical debridement is URGENT for severe infections. Antibiotics should be streamlined based on intraoperative culture and sensitivity.

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

2.COMPLICATED SKIN & SOFT TISSUE INFECTION

2.2 Necrotizing Fasciitis

Necrotizing fasciitis is a rapidly progressing, life-threatening soft tissue infection with extensive fascial necrosis & relative sparing of underlying muscle caused by a toxin-producing bacterium. Presentation is acute (over hours); rarely, subacute (over days), and is followed by rapid progression to extensive destruction, which can lead to systemic toxicity, limb loss, and/or death. The rapidness of erythema progression (~1-2 hours) helps differentiate necrotizing fasciitis from cellulitis and indicates the need for urgent surgical intervention. Immediate aggressive surgical debridement is the primary treatment modality. Repeated surgical debridement for source control is normally necessary. Etiology may be polymicrobial (mixed aerobic-anaerobic microbes) or monomicrobial (most commonly Group A streptococcus). Empirical therapy should be broad and antibiotics should be streamlined based on intraoperative culture & sensitivity. Necrotizing fasciitis commonly involves the extremities. Refer to the respective organ/system sections for other presentations i.e. necrotizing fasciitis of the perineum (Fournier gangrene), head and neck region, and neonatal infection.

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

2.COMPLICATED SKIN & SOFT TISSUE INFECTION

2.2 Necrotizing Fasciitis

2.2.1 Type 1: Polymicrobial infection

Risk factor: older age group, immunocompromised or chronic diseases. E.g.: diabetes. Organisms: • Anaerobes (E.g.: Bacteroides, Clostridium or Peptostreptococcus) • Facultative anaerobic • Enterobacteriaceae (E.g.: Escherichia coli, Enterobacter, Klebsiella, Proteus) • Facultative anaerobic streptococci (other than Group A streptococcus [GAS]) • Obligate aerobes (E.g.: Pseudomonas aeruginosa)

Preferred Regimen

*Piperacillin/tazobactam 4.5g IV q6-8h

MAY ADD

**Clindamycin 600-900mg IV q8h

Alternative Regimen (Allergy / Resistance)

Meropenem 1g IV q8h

Imipenem 1g IV q6-8h

MAY ADD

**Clindamycin 600-900mg IV q8h

Remarks & Clinical Comments:

Duration: There is a lack of any convincing evidence regarding the ideal duration of antibiotic therapy, which varies between 7 and 14 days. In general, antibiotics should be continued until no further debridement is needed and the patient’s hemodynamic status has normalized. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours) **Clindamycin should be started empirically if there is risk of Group A Streptococcus or presence of gas crepitus. Duration: 3-5 days. To stop clindamycin if there is no evidence of Group A Streptococcus.

NAG MOH Malaysia 2024Official Site

AdultA9ORTHOPAEDIC INFECTIONS

2.COMPLICATED SKIN & SOFT TISSUE INFECTION

2.2 Necrotizing Fasciitis

2.2.2 Type 2: Monomicrobial infection

Group A Streptococcus (most common)

Preferred Regimen

Benzylpenicillin 2-4MU IV q4h

PLUS

*Clindamycin 600-900mg IV q8h

Remarks & Clinical Comments:

Duration: There is a lack of any convincing evidence regarding the ideal duration of antibiotic therapy, which varies between 7 and 14 days. In general, antibiotics should be continued until no further debridement is needed and the patient’s hemodynamic status has normalized. *If confirmed Group A Streptococcus: Clindamycin & penicillin combination therapy is given until patients are clinically and hemodynamically stable for at least 48 to 72 hours; followed by penicillin monotherapy thereafter.

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AdultA9ORTHOPAEDIC INFECTIONS

2.COMPLICATED SKIN & SOFT TISSUE INFECTION

2.2 Necrotizing Fasciitis

2.2.3 Water Related Wound Infection

Common organisms: Vibrio vulnificus (ocean water), Aeromonas hydrophilia (fresh / brackish water)

Preferred Regimen

Ceftriaxone 2g IV q24h

PLUS

Doxycycline 100mg PO q12h

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 400mg IV q8h

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AdultA9ORTHOPAEDIC INFECTIONS

2.COMPLICATED SKIN & SOFT TISSUE INFECTION

2.3 Myonecrosis / Gas Gangrene

Common organisms: Clostridium sp (80-95%)

Preferred Regimen

Mild:

Benzylpenicillin 4MU IV q4h

PLUS

Clindamycin 600-900mg IV q8h

Moderate to severe:

*Piperacillin/tazobactam 4.5g IV q6-8h

PLUS

Clindamycin 600-900mg IV q8h

Remarks & Clinical Comments:

Aggressive surgical debridement is necessary to remove all necrotic tissue. Duration: total 10-28 days Refer to Urinary Tract Infection and Gastrointestinal Infection sections for other gas forming infections (E.g.: emphysematous pyelonephritis and emphysematous cholecystitis) *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours).

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PaediatricB9OTORHINOLARYNGOLOGY INFECTIONS

3. ACUTE OTITIS MEDIA

Common organisms: Streptococcus pneumonia Haemophilus influenzae Moraxella catarrhalis

Preferred Regimen

Amoxicillin 80-90mg/kg/day (max. 1g/dose) PO in 2-3 divided doses

For clinical failure, history of using amoxicillin in the last 30 days and has concurrent purulent conjunctivitis:

Suspension (Formulation 14:1)

Amoxicillin / Clavulanate 80-90mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 3g/day)

Suspension (Formulation 7:1)

Amoxicillin / Clavulanate 40-50mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 3g/day)

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy (non-life-threatening)

Cefuroxime 30mg/kg/day (max. 1g/day) PO in 2 divided doses

Severe antibiotic allergy

Erythromycin ethylsuccinate 40-50mg/kg/day PO (max. 800mg/dose) in 2 divided doses

Azithromycin 10mg/kg/dose PO on Day 1 (max. 500mg/day), followed by 5mg/kg/dose PO q24h on Day 2-Day 5 (max. 250mg/day)

Remarks & Clinical Comments:

Most uncomplicated otitis media do not require antibiotics with certain exception: • children <2 years • immunosuppression • severe disease Duration: < 2yrs: 7- 10 days > 2yrs: 5 - 7 days 90 mg/kg/day of amoxicillin, with 6.4 mg/kg/day of clavulanate, a ratio of amoxicillin to clavulanate of 14:1, given in 2 divided doses, which is less likely to cause diarrhea than other amoxicillin clavulanate preparations. Amoxicillin/Clavulanate (40-50mg/kg/day) may not be adequate to treat AOM due to penicillin nonsusceptible S. pneumoniae.

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PaediatricB9OTORHINOLARYNGOLOGY INFECTIONS

4. ACUTE OTITIS EXTERNA

Common organisms: Pseudomonas aeruginosa Staphylococcus aureus

Preferred Regimen

Mild to moderate:

Topical antibiotic with/without topical steroids.

E.g.:

• Gentamicin 0.3% ear drops: 3-4 drops 3 times/day for 7 days

• Polymyxin B sulphate 10,000U, neomycin sulphate 5mg & hydrocortisone 10g ear drops: 4 drops 3 or 4 times/day for 7 days

• Ofloxacin 0.3% otic solution: Instill 5 drops into affected ear(s) once daily for 7 days (Indication: for 1-12 years old)

Remarks & Clinical Comments:

Consult ORL surgeon Ototoxic agents like gentamicin or neomycin should not be used in the presence of tympanostomy tubes or perforated tympanic membrane. Clinical response should be seen within 48 to 72 hours, but full response may take up 6 days. Non-response should prompt an evaluation for obstruction, presence of foreign body, non-adherence or an alternative diagnosis.

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PaediatricB9OTORHINOLARYNGOLOGY INFECTIONS

5. DIPHTHERIA

Corynebacterium diphtheriae

Preferred Regimen

Diphtheria Antitoxin (refer to the table above)

PLUS

Azithromycin 10mg/kg/day IV/PO q24h (max. 500mg/dose) for 14 days

Benzylpenicillin 100,000 – 150,000 units/kg/day in 4 divided doses (max. 1 MU/dose), followed by Phenoxymethylpenicillin (Penicillin V) 50mg/kg/day in 4 divided doses PO (max. 500mg/dose) for total of 14 days of therapy (intravenous + oral)

Alternative Regimen (Allergy / Resistance)

Diphtheria Antitoxin (refer to the table above)

PLUS

Erythromycin 40-50mg/kg/day IV/PO in 4 divided doses (max. IV 500mg/dose; PO 800mg/dose) for 14 days

Remarks & Clinical Comments:

Antibiotics are not a substitute for treatment with diphtheria antitoxin. The role of adjunctive antibiotic treatment is to eradicate C.diphtheriae, which prevents further toxin production. IV to PO switch: Parenteral treatment is preferred for patients unable to swallow. Once the patient improves and can swallow comfortably, switch to oral therapy. Refer to Appendix 6 for IV to PO switch. Close contact prophylaxis: IM Benzathine Penicillin BW < 30kg 600,000 U BW > 30kg 1.2 MU single dose OR Erythromycin ethylsuccinate 40-50mg/kg/day PO q6h for 7-10 days OR Azithromycin 10mg/kg/day PO OD for 7-10 days

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PaediatricB9OTORHINOLARYNGOLOGY INFECTIONS

6. ACUTE EPIGLOTTITIS

Preferred Regimen

Ceftriaxone 50-75mg/kg/dose IV daily (max.2g/dose)

Cefotaxime 150-200mg/kg/day (max. 4g/day) IV in 4 divided doses

Alternative Regimen (Allergy / Resistance)

Clindamycin 30 – 40mg/kg per day IV (max. 1.8g/day) in 3 divided doses

Remarks & Clinical Comments:

Duration: 7 – 10 days Switch to oral therapy (E.g.: amoxicillin/clavulanate) when improving and able to tolerate orally.

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PathwayC9C9. URINARY TRACT INFECTION IN PREGNANCY (SYMPTOMATIC)

C9. URINARY TRACT INFECTION IN PREGNANCY (SYMPTOMATIC)

UTI in pregnancy (symptomatic) 30.01.2026.pdf

Attached Clinical Documents:

UTI in pregnancy (symptomatic) 30.01.2026.pdf

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PaediatricB10RESPIRATORY INFECTIONS

1. COMMUNITY-ACQUIRED PNEUMONIA (CAP)

1.1 Outpatient

Pneumonia (outpatient) Infant (≥3 months) & children Viral infection is more common (Influenza, RSV, human metapneumovirus (hMPV), Parainfluenza, Adenovirus) Bacteria (S. pneumoniae, Group A Streptococcus, S. aureus, H. influenza)

Preferred Regimen

*High dose amoxicillin (80-90mg/kg/day) PO in 2-3 divided doses (max. 1g/dose, 3g/day) for 5 days

Oral weight bands*:

3-5kg: 250mg q12h

6-9kg: 375mg q12h

10-14kg: 500mg q12h

15-19kg: 750mg q12h

> 20kg: 500mg q8h or 1g q12h

*Prescribers can use either weight-band or mg/kg dosing. The World Health Organization endorses weight-band dosing to streamline prescribing and minimize errors. Higher doses resulting from weight-band ranges are considered safe and appropriate, given amoxicillin’s wide therapeutic index.

For influenza: If suspected, treatment to be initiated as early as possible.

Oseltamivir

<9 months old: 3mg/kg PO q12h for 5 days

9-11 months old: 3.5mg/kg PO q12h for 5 days

1-12 years old:

≤15 kg: 30mg PO q12h

>15-23kg: 45mg PO q12h

>23-40kg: 60mg PO q12h

>40 kg: 75mg PO q12h

Treatment for 5 days

Alternative Regimen (Allergy / Resistance)

Erythromycin ethylsuccinate 40-50mg/kg/day PO in 2 divided doses (max. 800mg/dose)

Remarks & Clinical Comments:

Antibiotics are not routinely recommended since viral infection is more common. For infant & children admitted to hospital, treat as presumed bacterial unless viral origin is known. Macrolide antibiotics should be used if either mycoplasma or chlamydia pneumonia is suspected. It may be started in school-going children where disease predominates. Duration: minimum 5 days and until afebrile for 2-3 days in empiric therapy with absence of an identified specific etiology and specific therapy with known pneumonia due to pneumococcus, HI & Moraxella catarrhalis. *At least 40mg/kg/dose, children who do not respond to oral amoxicillin should be referred to the center with appropriate second line treatment. Experts recommend using high dose amoxicillin to overcome resistance conferred by cell wall changes of the bacteria (pneumococcus). Standard dose: Amoxicillin 45-50mg/kg/day PO in 3 divided doses (max. 500mg/dose) for 5 days, to be considered only for children who cannot tolerate high doses.

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

1. THROAT AND UPPER RESPIRATORY TRACT

1.1 Tonsilitis/Pharyngitis (Sore throat)

Common organism: Respiratory virus (>80% of cases) Group A Streptococcus

Preferred Regimen

Phenoxymethylpenicillin (Pen V) 500mg PO q6h or 1g PO q12h

Benzathine Penicillin 1.2MU IM, one single dose

Alternative Regimen (Allergy / Resistance)

Amoxicillin 500mg PO q8h

Antibiotic allergy:

Erythromycin ethylsuccinate 800mg q12h

Remarks & Clinical Comments:

Use Modified Centor Score to determine infection origin (bacterial or viral) and whether antibiotics are necessary. Treatment for Modified Centor Score <3: Modified Centor Score < 3 does not require antibiotic treatment, as sore throats are commonly viral in origin. Give symptomatic treatment only (E.g.: analgesics, antipyretics). Treatment for Modified Centor Score 3-5: Modified Centor Score ≥ 3 requires antibiotic therapy due to a higher risk of Group A Streptococcus (GAS) infection. Duration: 5-10 days Consider 10 days in settings with a high prevalence of rheumatic fever or in patients with a history of rheumatic fever or rheumatic heart disease and who are aged between 3 and 21 years. Refer to Appendix 3 for antibiotic allergy.

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

1. THROAT AND UPPER RESPIRATORY TRACT

1.2 Acute Peritonsillar Abscess (Quinsy)

Common organisms: Group A Streptococcus Fusobacterium necrophorum Streptococcus anginosus group

Preferred Regimen

Benzylpenicillin 2MU IV q6h

PLUS

Metronidazole 500mg IV q6-8h

Ampicillin/sulbactam 3g IV q6h

Amoxicillin/clavulanate 1.2g IV q8h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 600 - 900mg IV q8h

Remarks & Clinical Comments:

Drainage or aspiration of the abscess is the mainstay of treatment for peritonsillar abscess. Duration: 10-14 days of therapy (Intravenous + Oral) Refer to Appendix 6 for IV to PO switch. Refer to Appendix 3 for antibiotic allergy.

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PaediatricB10RESPIRATORY INFECTIONS

1. COMMUNITY-ACQUIRED PNEUMONIA (CAP)

1.2 Inpatient

Pneumonia (inpatient, fully immunised)

Preferred Regimen

Benzylpenicillin 150,000-200,000units/kg/day IV in 3-4 divided doses (max. 24million unit/day) for 5-7 days

Alternative Regimen (Allergy / Resistance)

Second line/partially treated

Cefuroxime 100-150mg/kg/day IV in 3 divided doses (max. 6g/day)

Amoxicillin/clavulanate 30mg/kg/dose IV q8h (max. 1.2g/dose) *

Remarks & Clinical Comments:

Macrolide antibiotics should be used if either mycoplasma or Chlamydia pneumonia is suspected. • Amoxicillin dosage, 5:1 formulation

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

1. THROAT AND UPPER RESPIRATORY TRACT

1.3 Diphteria

Corynebacterium diphtheriae

Preferred Regimen

*Erythromycin lactobionate 500mg IV q6h,

followed by **Erythromycin ethylsuccinate 800 mg PO q6h

*Benzylpenicillin 25,000 units/kg q6h to a maximum of 1 MU IV/IM q6h, followed by Phenoxymethylpenicillin (Pen V) 500mg PO q6h

PLUS

Diphtheria Antitoxin

Alternative Regimen (Allergy / Resistance)

***Azithromycin 500mg OD IV/PO

***(There is no CLSI / EUCAST breakpoint for azithromycin. Thus, azithromycin is adviced to be given only for patients who cannot tolerate penicillin or erythromycin)

PLUS

Diphtheria Antitoxin

Remarks & Clinical Comments:

Duration: 14 days (intravenous + oral therapy) Antibiotics are not a substitute for treatment with diphtheria antitoxin. The role of adjunctive antibiotic treatment is to eradicate C.diphtheriae, which prevents further toxin production. * IV to PO switch: Parenteral treatment is preferred for patients who are unable to swallow. Once the patient improves and can swallow comfortably, switch to oral therapy. Refer to Appendix 6 for IV to PO switch. Close contact management: IM Benzathine Penicillin 1.2 MU single dose OR Erythromycin ethylsuccinate 800mg q6h for 7-10 days OR *Azithromycin 500mg OD for 7-10 days Erythromycin base 250mg = Erythromycin Ethylsuccinate 400mg

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

1. THROAT AND UPPER RESPIRATORY TRACT

1.3 Diphteria

Diphtheria Antitoxin (dose depends on severity):

• Pharyngeal/ laryngeal disease of 2 days duration : 20,000 - 40,000 units • Nasopharyngeal disease : 40,000 – 60,000 units • Systemic disease of ≥3 days or any patient with diffuse neck swelling : 80,000 – 120,000 units Administer over 60 mins to inactivate toxins rapidly

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

1. THROAT AND UPPER RESPIRATORY TRACT

1.4 Acute Epiglottitis (Supraglottitis)

Common organisms: Streptococcus pneumoniae Group A Streptococcus Haemophilus influenzae Type B Virus

Preferred Regimen

Ceftriaxone 2g IV q24h

Ampicillin/sulbactam 3g IV q6h

Amoxycillin/clavulanate 1.2g IV q8h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 600-900mg IV q8h

PLUS

Ciprofloxacin 400mg IV q12h

Remarks & Clinical Comments:

Duration: 7 to 10 days (intravenous + oral). Longer in cases of bacteremia, concomitant meningitis or immunocompromised. Requires urgent hospitalisation. May present with life-threatening upper airway obstruction, especially in paediatrics. Consider adding vancomycin for patients with moderate to severe sepsis, concomitant meningitis or previously colonized with MRSA. Refer to Appendix 3 for antibiotic allergy. Refer to Appendix 6 for IV to PO switch.

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

1. THROAT AND UPPER RESPIRATORY TRACT

1.5 Deep Neck Space Abscess / Parapharyngeal Abscess / Retropharyngeal Abscess / Ludwig Angina

Common organisms (usually polymicrobial): Anaerobes (eg Fusobacteria sp, Prevotella sp) Streptococcus spp. Staphylococcus aureus

Preferred Regimen

Ampicillin/sulbactam 3g IV q6h

Amoxycillin/clavulanate 1.2g IV q8h

Cefuroxime 1.5g IV q8h

PLUS

Metronidazole 500mg IV q6h

Alternative Regimen (Allergy / Resistance)

Penicillin Allergy:

Immediate / Delayed Non-Severe:

Cefazolin 2g IV q8h

Ceftriaxone 2g IV q24h

PLUS

Metronidazole 500mg IV q6h

Immediate / Delayed Severe Penicillin Allergy:

Clindamycin 600-900mg IV q8h

Remarks & Clinical Comments:

Duration: 10-14 days (intravenous + oral) For significant abscess, surgical drainage and debridement are required. If there is evidence of necrotising fasciitis (clinical / radiological evidence), may add IV clindamycin. Once the patient improves, switch to oral therapy after a minimum of 3 to 5 days of intravenous therapy. Refer to Appendix 6 for IV to PO switch.

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PaediatricB10RESPIRATORY INFECTIONS

2. SEVERE COMMUNITY-ACQUIRED PNEUMONIA

Child not fully immunised/life-threatening

Preferred Regimen

Cefotaxime 150-200mg/kg/day in 3 to 4 divided doses (max. 8g/day)

Ceftriaxone 75-100mg/kg/day in 2 divided doses (max. 4g/day)

MAY ADD

*Azithromycin 10mg/kg/dose (max. 500mg) IV q24h on Day 1; then 5mg/kg/dose (max. 250mg) on Day 2-5 if considering atypical organisms

Alternative Regimen (Allergy / Resistance)

Cefuroxime 75-150mg/kg/day IV in 3 divided doses (max. 6g/day)

MAY ADD

*Azithromycin 10mg/kg/dose (max. 500mg/day) IV q24h on Day 1; then 5mg/kg/dose (max. 250mg/day) on Day 2-5 if considering atypical organisms

Remarks & Clinical Comments:

Duration: 5-7 days. Consider longer treatment and assess for complications e.g empyema, if patient not fully recovered. For the management of empyema, refer to Empyema thoracis section. *The role of antimicrobials in treating both M. pneumoniae and C. pneumoniae is unknown because most children resolve infection without macrolides, treatment may be appropriate to hasten recovery in children who are more seriously ill or have a persistent cough. Macrolide resistance is now very common in M. pneumoniae in Asia and routine use should be avoided.

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

2. NOSE

2.1 Acute Rhinosinusitis (ARS)

Common organisms: Virus (most common) Bacterial (0.5 - 2%)

Antibiotics are not needed in the great majority of cases. Most cases of sinusitis occur as a complication of a viral upper respiratory tract infection and are self-limited. Use the algorithm below to determine the infection origin (bacterial or viral) and whether antibiotics are necessary.

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

2. NOSE

2.2 Acute Bacterial Rhinosinusitis (ABRS)

Common organisms: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis

Preferred Regimen

Amoxicillin 500-1000mg PO q8h

Amoxicillin/clavulanate 625mg PO q8h

*If no improvement after 3 days of oral antibiotic, refer to Otorhinolaryngology department.

Alternative Regimen (Allergy / Resistance)

Penicillin allergy:

Doxycycline 100mg q12h

Pregnant patients with antibiotic allergy would need to be treated with:

Azithromycin 500mg PO q24hr for 3 days

Remarks & Clinical Comments:

*Refer to the algorithm for Acute Rhinosinusitis in Adults. Duration: 5 days Refer to Appendix 3 for antibiotic allergy.

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PaediatricB10RESPIRATORY INFECTIONS

3. EMPYEMA THORACIS

Preferred Regimen

Cefuroxime 100-200mg/kg/day IV in 3 divided doses (max. 6g/day)

Cefotaxime 200-300mg/kg/day IV in 4 divided doses (max.8g/day)

PLUS

Cloxacillin 200-300mg/kg/day IV in 4-6 divided doses (max.12g/day)

Duration: 4-6 weeks

Alternative Regimen (Allergy / Resistance)

Staphylococcus aureus (methicillin-sensitive)

Cloxacillin 200-300mg/kg/day IV in 4-6 divided doses (max.12g/day) for 4-6 weeks

Streptococcus pneumoniae (penicillin-sensitive)

Benzylpenicillin 200,000-300,000 units/kg/day IV in 4-6 divided doses (max. 24 million unit/day)

Streptococcus pneumoniae (penicillin- resistant, use result of C&S)

Cefotaxime 200-300mg/kg/day IV in 4 divided doses (max. 8g/day)

Ceftriaxone 100mg/kg/day IV in 1-2 divided doses (max. 4g/day)

Remarks & Clinical Comments:

Empyema thoracis (lung empyema) Staphylococcus aureus Streptococcus pneumoniae Empirical treatment needs to cover organisms mentioned above. Other bacteria implicated: Streptococcus pyogenes, Haemophilus influenzae & other Gram-negative organisms in immunocompromised individuals If patient is not responding to treatment, need to rule out TB Based on C&S of pleural fluid/tissue or blood culture. All children with empyema need to receive high dose antibiotic therapy via intravenous route to ensure pleural penetration. Pneumatocele on chest x-ray indicate S. aureus BUT they can also be seen in pneumococcal disease. There is NO CONSENSUS on how long antibiotic needs to be given. Most recommend 3-6 weeks of total antibiotics depending on severity. For moderate to severe or Stage 1-2 parapneumonic effusion, to consider pleural drainage and intrapleural fibrinolytic agent on top of antimicrobial therapy. Stage 2 failed medical therapy and stage 3 empyema thoracis need surgical intervention. (Refer Empyema Thoracic in Children: Consensus Guideline from Malaysia Pediatric Empyema Thoracic Working Group 2020 Edition)

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

3. EAR

3.1 Acute otitis media (AOM)

Refer to section Clinical Pathway in Primary Care – Acute Otitis Media .

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

3. EAR

3.2 Malignant Otitis Externa/ Necrotizing Otitis Externa

Common organism: Pseudomonas aeruginosa (95%) Staphylococcus aureus

Preferred Regimen

Ceftazidime 2g IV q8h

*Piperacillin/tazobactam 4.5g IV q6–8h

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 400mg IV q8h (option for beta-lactam allergic patients)

Remarks & Clinical Comments:

Duration: 6 weeks (intravenous + oral) Once showing a clinical response, consider switching to oral therapy: Ciprofloxacin 750mg PO q12h to complete 6 weeks. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

3. EAR

3.3 Acute Localised Otitis Externa

Common organisms: Staphylococcus aureus Streptococcus pyogenes

Preferred Regimen

Cloxacillin 500mg PO q6h

Cephalexin 500mg PO q6h

Alternative Regimen (Allergy / Resistance)

Penicillin allergy:

Clindamycin 600mg PO q8h

Remarks & Clinical Comments:

Duration: 5 days

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

3. EAR

3.4 Acute Diffuse Otitis Externa (Swimmer’s ear)

Common organisms: Pseudomonas aeruginosa Staphylococcus aureus

Preferred Regimen

Ofloxacin 0.3% otic solution. Instill 10 drops into affected ear(s) q24h

MAY ADD

Steroid ear drops (when fungal infection is NOT suspected

Remarks & Clinical Comments:

Aural toileting is required in discharging ears. Duration: 7 days

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

3. EAR

3.5 Chronic Suppurative Otitis Media

Common organism (often polymicrobial): Anaerobes Staphylococcus aureus Enterobacterales Pseudomonas aeruginosa Mycobacterium tuberculosis

Preferred Regimen

Ofloxacin 0.3% otic solution. Instill 10 drops into affected ear(s) q12h

Referral to ENT is recommended for further examination to exclude cholesteatoma or chronic osteitis.

Remarks & Clinical Comments:

Aural toileting required in discharging ears. Duration:10-14 days

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AdultA10OTORHINOLARYNGOLOGY INFECTIONS

3. EAR

3.6 Otomycosis

Common organism: Candida sp. Aspergillus sp.

Preferred Regimen

Clotrimazole 1% ear solution, apply q6-8h

Remarks & Clinical Comments:

Aural toileting required. Duration:10-14 days

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

1. ABSCESS

Staphylococcus aureus

Preferred Regimen

Mild

*Cloxacillin 50-100mg/kg/day PO in 4 divided doses (max. 2g/day) for 5-7 days

Severe

Cloxacillin 200mg/kg/day IV in 4 divided doses (max. 12g/day) for 5-7 days

CA-MRSA

Clindamycin 30-40mg/kg/day PO in 3-4 divided doses (max. 2.7g/day) for 5-7 days

Trimethoprim/sulfamethoxazole 8-12mg/kg/day (TMP dose) PO in 2 divided doses (max. 320mg/day) for 5-7 days

Alternative Regimen (Allergy / Resistance)

Mild

Cephalexin 25-50mg/kg/day PO in 2 divided doses (max. 2g/day) for 5-7 days

Remarks & Clinical Comments:

Incision & drainage (I&D) is the MAINSTAY of therapy. If needle aspiration is inadequate, can send pus obtained during I&D for C&S. Use parenteral route for severe infections. Consider CA-MRSA if poorly resolving, based on local epidemiology (still generally uncommon). *Doses recommended are for children weighing less than 25kg. For children weighing more than 25kg, use adult dosage (500mg PO q6h).

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AdultA11RESPIRATORY INFECTIONS

1. COMMUNITY ACQUIRED PNEUMONIA (CAP)

1.1 Outpatient

Preferred Regimen

Amoxicillin 500mg-1g PO q8h for 5-7 days

Alternative Regimen (Allergy / Resistance)

Doxycycline 100mg PO q12h for 5-7 days

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AdultA11RESPIRATORY INFECTIONS

1. COMMUNITY ACQUIRED PNEUMONIA (CAP)

1.2 Outpatient (With Comorbidities)

Preferred Regimen

Amoxicillin/clavulanate 625mg PO q8h for 5-7 days

MAY ADD

*Azithromycin 500mg PO q24h for 3 days

*Doxycycline 100mg PO q12h for 5-7 days

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

**Levofloxacin 750mg PO q24h for 5 days

Remarks & Clinical Comments:

Comorbidities: Chronic heart, lung, liver, or renal disease, diabetes mellitus, alcoholism, malignancy, or asplenia. *If atypical pathogen is suspected (E.g.: extrapulmonary manifestations and diffuse infiltrations radiologically). **Levofloxacin should be strictly reserved for antibiotic allergy due to higher risk of adverse events. Refer to Appendix 3 for antibiotic allergy.

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AdultA11RESPIRATORY INFECTIONS

1. COMMUNITY ACQUIRED PNEUMONIA (CAP)

1.3 Inpatient - Moderate CAP

CURB-65 Score 2 or SMART-COP Score 3-4

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h for 5-7 days

MAY ADD

*Azithromycin 500mg IV/PO q24h for 3 days

*Doxycycline 100mg PO q12h for 5-7 days

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h for 5-7 days

MAY ADD

*Azithromycin 500mg IV/PO q24h for 3 days

Antibiotic allergy:

**Levofloxacin 750mg IV/PO q24h for 5-7 days

Remarks & Clinical Comments:

*If atypical pathogen is suspected (E.g.: extrapulmonary manifestations and diffuse infiltrations radiologically). May need a longer duration of therapy among immunocompromised patients or those with confirmed Legionella pneumonia. **Levofloxacin should be strictly reserved for antibiotic allergy due to higher risk of adverse events. To switch to oral therapy when clinical condition improves and patient is able to tolerate orally. If suspected melioidosis infection, refer to Tropical Infection section.

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AdultA11RESPIRATORY INFECTIONS

1. COMMUNITY ACQUIRED PNEUMONIA (CAP)

1.4 Inpatient - Severe CAP

CURB-65 score ≥ 3 or SMART-COP score ≥ 5

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h for 5-7 days

MAY ADD

*Azithromycin 500mg IV/PO q24h for 3 days

*Doxycycline 100mg PO q12h for 5-7 days

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h for 5-7 days

If at risk of pseudomonal infection:

**Piperacillin/tazobactam 4.5g IV q6-8h for 7 days

Cefepime 2g IV q8h for 7 days

MAY ADD

*Azithromycin 500mg IV/PO q24h for 3 days

Remarks & Clinical Comments:

Strong risk factors for pseudomonal infection: • Prior respiratory infection or isolation of Pseudomonas aeruginosa • Hospitalization with receipt of IV antibiotics in past 3 months • Detection of gram-negative rods on a good-quality sputum gram stain Other risk factors for pseudomonal infection: • Recent hospitalization or stay in a long-term care facility • Recent antibiotic use • Frequent COPD exacerbations requiring glucocorticoid/antibiotic • Structural lung diseases (E.g.: bronchiectasis) • Immunosuppressed *If atypical pathogen is suspected (E.g.: extrapulmonary manifestations and diffuse infiltrations radiologically). May need a longer duration of therapy among immunocompromised patients or those with confirmed Legionella pneumonia. **Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours) IV Ceftazidime is not recommended for empirical therapy due to poor activity against Streptococcus pneumoniae. If suspected melioidosis infection, refer to Tropical Infections section.

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

2. CELLULITIS

Common organisms: Staphylococcus aureus Streptococcus pyogenes

Preferred Regimen

Mild

*Cloxacillin 50-100mg/kg/day PO in 4 divided doses (max. 2g/day) for 5-7 days

Severe

Cloxacillin 200mg/kg/day IV in 4 divided doses (max. 12g/day) for 5-7 days

Alternative Regimen (Allergy / Resistance)

Cephalexin 25-50mg/kg/day PO in 2 divided doses (max. 2g/day) for 5-7 days

Remarks & Clinical Comments:

Administer using parenteral route for extensive lesions. Total treatment until 3 days after acute inflammation disappears. *Doses recommended are for children weighing less than 25kg. For children weighing more than 25kg, use adult dosage (500mg PO q6h).

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AdultA11RESPIRATORY INFECTIONS

2. VIRAL PNEUMONIA

2.1 COVID-19

Refer to COVID-19 Management Guidelines in Malaysia .

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AdultA11RESPIRATORY INFECTIONS

2. VIRAL PNEUMONIA

2.2 Influenza

Preferred Regimen

Oseltamivir 75mg PO q12h for 5 days

Alternative Regimen (Allergy / Resistance)

*Baloxavir

40-80kg: 40mg PO single dose

≥80kg: 80mg PO single dose

Remarks & Clinical Comments:

Clinical benefit is greatest if initiated within 48 hours. In hospitalized / immunocompromised patients, treatment is started regardless of symptom duration, and may need longer duration of treatment. *Not listed in MOH Drug Formulary.

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AdultA11RESPIRATORY INFECTIONS

2. VIRAL PNEUMONIA

2.3 Varicella Zoster

Preferred Regimen

Acyclovir 10mg/kg IV q8h for 7 days

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

3. HANSEN'S DISEASE (LEPROSY)

Mycobacterium leprae

Preferred Regimen

˂ 10 years old or < 40kg

Rifampicin 10mg/kg PO (max. 600mg/day) once a month

PLUS

Dapsone 2mg/kg PO q24h (max. 100mg/day)

PLUS

Clofazimine 100mg PO once a month, 50mg twice weekly

10-14 years old and > 40kg

Rifampicin 450mg PO (max. 600mg/day) once a month

PLUS

Dapsone 50mg PO q24h (max. 100mg/day)

PLUS

Clofazimine 150mg PO once a month & 50mg alternate day

Remarks & Clinical Comments:

Duration: Paucibacillary: 6 months Surveillance 5 years Multibacillary: 12 months Surveillance 15 years

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AdultA11RESPIRATORY INFECTIONS

3. LUNG ABSCESS AND EMPYEMA

3.1 Empirical treatment

Preferred Regimen

No recent thoracic surgery/ procedure or HAP/VAP:

Amoxicillin/clavulanate 1.2g IV q6-8h

Ampicillin/sulbactam 3g IV q6h

Post-procedure (E.g. pleural interventions, thoracic or oesophageal surgery) or presence of HAP/VAP:

*Piperacillin-tazobactam 4.5g IV q6-8h

Cefepime 2g IV q8h

PLUS

Metronidazole 500mg IV q8h

**MAY ADD Vancomycin 15-20mg/kg (actual body weight) IV q8-12h; not to exceed 2g/dose

Alternative Regimen (Allergy / Resistance)

No recent thoracic surgery/ procedure or HAP/VAP:

Ceftriaxone 2g IV q24h

PLUS

Metronidazole 500mg IV q8h

Antibiotic allergy:

Clindamycin 600mg IV/PO q8h

Post-procedure (E.g. pleural interventions, thoracic or oesophageal surgery) or presence of HAP/VAP:

Meropenem 1g IV q8h

MAY ADD

**Vancomycin 15-20mg/kg IV q8-12h

Remarks & Clinical Comments:

Duration of treatment: • Adequate source control: 2-4 weeks of antibiotics from the time of drainage/surgery and defervescence. • Inadequate source control: 4-6 weeks of antibiotics. Lung empyema: Attempts should be made to drain the collection to improve clinical outcome. Change to oral regime once clinical improvement is seen. Refer to Appendix 6 for IV to PO switch. Avoid aminoglycosides in the management of empyema. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours). **MRSA coverage is to be based on local hospital MRSA prevalence. Refer to Appendix 1 for vancomycin dose. If melioidosis is suspected, refer to Tropical Infection section. Refer to Appendix 3 for antibiotic allergy.

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AdultA11RESPIRATORY INFECTIONS

3. LUNG ABSCESS AND EMPYEMA

3.2 Methicillin-susceptible Staphylococcus aureus (MSSA)

Preferred Regimen

Cloxacillin 2g IV q4h

Alternative Regimen (Allergy / Resistance)

Cefazolin 2g IV q8h

Remarks & Clinical Comments:

Duration: 4-6 weeks, depending on clinical response. In rare cases (slow response to antibiotics) may need prolonged therapy. Change to oral therapy (E.g. Amoxicillin/clavulanate 625mg PO q8h or cephalexin 1g PO q6h) to complete the duration once patient stabilized and improved.

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

4. IMPETIGO

Common organisms: Staphylococcus aureus Streptococcus pyogenes

Preferred Regimen

Localised:

Topical 2% fusidic acid 2-3 times daily for 7 days (outpatient)

Generalised:

*Cloxacillin 50-100mg/kg/day PO in 4 divided doses (max. 1g/day) for 5-7 days

Alternative Regimen (Allergy / Resistance)

Localised:

Topical 2% Mupirocin cream 2-3 times daily for 7 days

Generalised:

Cephalexin 25-50mg/kg/day PO in 2 divided doses (max. 2g/day) for 5-7 days

Remarks & Clinical Comments:

*Doses recommended are for children weighing less than 25kg. For children weighing more than 25kg, use adult dosage (500mg PO q6h).

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AdultA11RESPIRATORY INFECTIONS

4. INFECTIVE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

4.1 Outpatient

Preferred Regimen

Amoxicillin/clavulanate 625mg PO q8h for 5 days

Alternative Regimen (Allergy / Resistance)

Cefuroxime 500mg PO q12h for 5 days

Doxycycline 100mg PO q12h for 5 days

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AdultA11RESPIRATORY INFECTIONS

4. INFECTIVE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

4.2 Inpatient

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h for 5-7days

MAY ADD

Azithromycin 500mg IV/PO for 3 days

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h for 5-7 days

MAY ADD

Azithromycin 500mg IV/PO for 3 days

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AdultA11RESPIRATORY INFECTIONS

4. INFECTIVE EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

4.3 Inpatient with Risk Factor of Pseudomonal Infection

Preferred Regimen

*Piperacillin-tazobactam 4.5g IV q6-8h for 7 days

MAY ADD

Azithromycin 500mg IV/PO for 3 days

Alternative Regimen (Allergy / Resistance)

Cefepime 2g IV q8h for 7 days

MAY ADD

Azithromycin 500mg IV/PO for 3 days

Remarks & Clinical Comments:

Risk factors for pseudomonal infection: • Chronic colonization of previous isolation of Pseudomonas aeruginosa from sputum • Very severe COPD (FEV1<30% predicted) • Bronchiectasis • Broad spectrum antibiotic use within the past 3 months • Chronic systemic glucocorticoid use *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours)

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AdultA11RESPIRATORY INFECTIONS

5. HOSPITAL ACQUIRED PNEUMONIA (HAP/VAP)

5.1 Early Onset HAP/VAP

2 - 4 days of admission/intubation

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h for 5-7days

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h for 5-7 days

Remarks & Clinical Comments:

Need to adjust to local antibiogram/ prevalent organisms. Consider broader spectrum antibiotic if deteriorated while on adequate antibiotic therapy.

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

5. NECROTISING FASCIITIS

5.1 Streptococcal Necrotising Fasciitis

Preferred Regimen

Benzylpenicillin 200,000-300,000units/kg/day IV in 4-6 divided doses (max. 24 million units/day)

PLUS

Clindamycin 30-40mg/kg/day IV in 3-4 divided doses (max. 2.7g/day)

Remarks & Clinical Comments:

50% of patients have associated streptococcal toxic shock syndrome (STSS). Prompt and aggressive surgical debridement of the deep-seated infection is the mainstay of therapy. Tissues should be sent for Gram stain and culture to determine etiology. Combination therapy is needed with clindamycin to block toxin production whether or not patient manifests toxic shock syndrome. IVIG can be used as an adjunct in Group A streptococcal infection, typically at 1g/kg on Day 1, followed by 0.5g/kg on 1-2 subsequent days. Duration: at least 2 weeks if no foci is found (no deep-seated involvement plus no involvement of heart, bone, joint etc.)

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AdultA11RESPIRATORY INFECTIONS

5. HOSPITAL ACQUIRED PNEUMONIA (HAP/VAP)

5.2 Late Onset HAP/VAP OR Severe Pneumonia OR At Risk of Pseudomonal Infection

Late onset HAP/VAP: 5 days or more of admission/intubation

Preferred Regimen

*Piperacillin-tazobactam 4.5g IV q6-8h for 7 days

Cefepime 2g IV q8h for 7 days

Alternative Regimen (Allergy / Resistance)

High risk of MDR organisms:

Meropenem 1g IV q8h for 7 days

Imipenem/cilastatin 500mg IV q6h for 7 days

Remarks & Clinical Comments:

Refer to CAP section for Risk of Pseudomonal Infection. Severe pneumonia: • Septic shock • Respiratory failure, need for ventilation support • Rapid progression of infiltrates on chest X-ray Ideal empirical antibiotic coverage depends on local prevalence of organisms. To de-escalate antibiotics according to culture and sensitivity results. Longer duration may be indicated depending upon clinical, radiological and laboratory parameters. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours).

NAG MOH Malaysia 2024Official Site

PaediatricB11SKIN & SOFT TISSUE INFECTIONS

5. NECROTISING FASCIITIS

5.2 Staphylococcal Necrotising Fasciitis

Preferred Regimen

Cloxacillin 200mg/kg/day IV in 4-6 divided doses (max. 2g/dose, 12g/day)

PLUS

Clindamycin 30-40mg/kg/day IV in 3-4 divided doses (max: 2.7g/day)

Alternative Regimen (Allergy / Resistance)

If CA-MRSA is suspected:

Vancomycin 60mg/kg/day IV in 3-4 divided doses (max. 2g/day)

Remarks & Clinical Comments:

Prompt and aggressive surgical debridement of the deep-seated infection is the mainstay of therapy. Tissues should be sent for Gram stain and culture to determine etiology. Combination therapy is needed with clindamycin to block toxin production whether or not patient manifests toxic shock syndrome. Vancomycin is NOT RECOMMENDED for the treatment of serious MSSA infections because outcomes are INFERIOR compared with cases in which anti-staphylococcus β-lactam (cloxacillin) is used AND to minimise the emergence of vancomycin resistance. Duration: at least 2 weeks if no foci is found (no deep-seated involvement plus no involvement of heart, bone, joint etc.)

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AdultA11RESPIRATORY INFECTIONS

6. ASPIRATION PNEUMONIA

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h

MAY ADD

*Metronidazole 500mg IV q8h

Antibiotic allergy:

Clindamycin 600mg IV/PO q8h

Remarks & Clinical Comments:

It is important to distinguish aspiration pneumonia from aspiration events/ aspiration pneumonitis. Aspiration pneumonia: a bacterial infection caused by aspiration of organisms from oropharynx. Aspiration (chemical) pneumonitis: acute chemical injury to the lung parenchyma after aspiration of acidic stomach contents. Antibiotic is not indicated. Indications of antibiotic therapy: • Delayed symptoms (suggestive of aspiration pneumonia, as compared to rapid onset within hours in pneumonitis) • Patients taking gastric acid suppression therapy or with bowel obstruction Duration: 7 days *Anaerobic coverage is not routinely required for suspected aspiration pneumonia unless lung abscess or empyema is suspected. To switch to oral therapy when clinical condition improves and patient is able to tolerate orally.

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

6. SCALDED SKIN SYNDROME (SSSS)

Staphylococcus aureus

Preferred Regimen

Cloxacillin 200mg/kg/day IV in 4-6 divided doses (max. 12g/day)

Step down

Cloxacillin 50-100mg/kg/day PO in 4 divided doses (max. 2g/day)

Total treatment duration: 7-10 days

Alternative Regimen (Allergy / Resistance)

Cefazolin 100mg/kg/day IV in 3-4 divided doses (max. 6g/day)

Step down

Cephalexin 50mg/kg/day PO in 2 divided doses (max. 2g/day)

Remarks & Clinical Comments:

Switch to oral therapy when the patient shows clinical improvement and negative blood culture results. Doses recommended are for children weighing less than 25kg. For children weighing more than 25kg, use adult dosage.

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

7. ANIMAL BITES

7.1 Cat Bites

Common organisms: Pasteurella multocida Staphylococcus spp. Streptococcus spp. Neisseria Moraxella

Preferred Regimen

Amoxicillin/clavulanate

Suspension (Formulation 14:1)

Amoxicillin / Clavulanate 80-90mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day) for 5-7 days

Suspension (Formulation 7:1)

Amoxicillin / Clavulanate 40-50mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day) or 5-7 days

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 30mg/kg/dose (amoxicillin component) IV q8h (max.1.2g/dose)

Remarks & Clinical Comments:

Consider rabies prophylaxis according to local epidemiology. Other animal bites: to discuss with ID Physician.

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

7. ANIMAL BITES

7.2 Dog Bites

Common organisms: Pasteurella canis Staphylococcus sp Streptococcus sp Fusobacterium

Preferred Regimen

Amoxicillin/clavulanate

Suspension (Formulation 14:1)

Amoxicillin / Clavulanate 80-90mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day) for 5-7 days

Suspension (Formulation 7:1)

Amoxicillin / Clavulanate 40-50mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day) or 5-7 days

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 30mg/kg/dose (amoxicillin component) IV q8h (max. 1.2g/dose)

Clindamycin 20-40mg/kg/day IV in 3 divided doses (max. 2.7g/day)

PLUS

Co-trimoxazole 8-10mg (TMP)/kg/day IV in 2 divided doses (max. 320mg TMP/day)

Remarks & Clinical Comments:

Consider rabies prophylaxis according to local epidemiology. Other animal bites, to discuss with ID Physician.

NAG MOH Malaysia 2024Official Site

PaediatricB11SKIN & SOFT TISSUE INFECTIONS

8. SCABIES

Preferred Regimen

Infant < 2 months

Sulphur 6% in petroleum in ointment base for 3 days

Children < 2 years

Two applications of Permethrin 5% for 8-12 hours at one week apart

Children < 12 years

Two applications of permethrin 5% for 8-12hours at one week apart

Nodular scabies

Children < 2 years

Crotamiton cream TDS for 5-7 days

Children < 12 years

Crotamiton cream TDS for 7-14 days

Alternative Regimen (Allergy / Resistance)

Children < 2 years

Sulphur 6% in petroleum in ointment base for 3 days

Children < 12 years

Benzyl Benzoate 12.5% Whole body neck and below for 3 consecutive days

Remarks & Clinical Comments:

Treat whole body including the face (avoid eyes and mouth). Treat all family members/close contacts simultaneously. Refer to Ministry of Health Guideline for Management of Scabies in Adults and Children (2015) for cautions and topical application method.

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PaediatricB11SKIN & SOFT TISSUE INFECTIONS

9. TINEA CAPITIS

Trichophyton spp., Microsporum spp.

Preferred Regimen

Griseofulvin 10-20mg/kg/day PO daily (max. 750mg/day) for at least 6 weeks until clinically clear

Alternative Regimen (Allergy / Resistance)

Terbinafine 4-6mg/kg/day PO daily (max. 250mg/day) for 4 weeks or longer depend on pathogen

10-20kg: 62.5mg daily

20-40kg: 125mg daily

> 40kg: 250mg daily

Itraconazole 3-5mg/kg/day PO daily (max. 200mg/day) for 2-6 weeks

Fluconazole 5-6mg/kg/day PO (max. 300mg/day) for 3-6 weeks

Remarks & Clinical Comments:

Griseofulvin: First line treatment for Microsporum sp Take with fatty food. Monitor liver function if treatment duration > 8 weeks Adjunctive selenium or ketoconazole shampoo can reduce transmissibility.

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PaediatricB12TROPICAL INFECTIONS

1. SCRUB TYPHUS

Rickettsia tsutsugamushi

Preferred Regimen

Doxycycline 2-4mg/kg/day IV/PO in 1-2 divided dose (max. 200mg/day) for 5-7 days

Severe disease

IV doxycycline and azithromycin combination

Alternative Regimen (Allergy / Resistance)

Azithromycin 10mg/kg/dose PO q24h (max. 500mg/dose) for 3 days

Remarks & Clinical Comments:

Doxycycline can be used in young children (even below 8 years old) since safety data approved its use for rickettsial diseases.

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PaediatricB12TROPICAL INFECTIONS

2. BRUCELLOSIS

B. Melitensis B. Abortus B. Suis B..Canis

Preferred Regimen

Rifampicin 15-20mg/kg/day PO in 1-2 divided doses (max. 600-900mg/day) for 6 weeks

PLUS

For children <8 years old:

Trimethoprim/sulfamethoxazole (TMP dose) 10mg/kg/day (max. 480mg TMP/day) PO in 2 divided doses for 6 weeks

For children >8 years old:

Doxycycline 4.4mg/kg/day PO in 2 divided doses (max. 200mg/day) for 6 weeks

Serious illness

Rifampicin 15-20mg/kg/day PO in 1-2 divided doses (max. 600-900mg/day) for 6 weeks

PLUS

For children <8 years old:

Trimethoprim/sulfamethoxazole (TMP dose) 10mg/kg/day (max. 480mg TMP/day) PO in 2 divided doses for 6 weeks

For children >8 years old:

Doxycycline 4.4mg/kg/day PO in 2 divided doses (max. 200mg/day) for 6 weeks

PLUS

Gentamicin 5mg/kg/dose IV q24h for 7-14 days

Remarks & Clinical Comments:

For non-localised disease: Can use two-drug combination. Drug of choice for Brucellosis for children >8 years old: Doxycycline (plus rifampicin)

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PaediatricB12TROPICAL INFECTIONS

3. LEPTOSPIROSIS

3.1 Mild disease

Preferred Regimen

Amoxicillin 40-45 mg/kg/day PO in 3 divided doses (max. 500 mg/dose)

Alternative Regimen (Allergy / Resistance)

For children >8 years old:

Doxycycline 2mg/kg/dose PO q12h (max. 200mg/day)

Remarks & Clinical Comments:

Duration: 7 days

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PaediatricB12TROPICAL INFECTIONS

3. LEPTOSPIROSIS

3.2 Moderate to severe disease

Preferred Regimen

Benzylpenicillin 200,000units/kg/day IV in 4 divided doses (max. 24 million units/day)

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 100mg/kg/day IV in 1-2 divided doses (max. 2g/day)

Cefotaxime 150-200mg/kg/day IV in 3-4 divided doses (max. 12g/day)

Remarks & Clinical Comments:

Duration: 7 days

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PaediatricB12TROPICAL INFECTIONS

4.TETANUS

Clostridium tetani

Preferred Regimen

Metronidazole 30mg/kg/day IV in 3-4 divided doses (max. 750 mg/dose) for 7-10 days

Neutralisation of toxin:

Human tetanus globulin (TIG) 500IU IM as a single dose.

Alternative Regimen (Allergy / Resistance)

Benzylpenicillin 200,000units/kg/day IV in 4 divided doses (max. 24 million units/day) for 7-10 days

Neutralisation of toxin:

If TIG not available: IVIG 200-400mg/kg as a single dose

Remarks & Clinical Comments:

Primary tetanus infection: Clinical diagnosis to be made as negative culture is often negative. Steps in care: 1. Early airway protection & treatment of reflex spasm with benzodiazepine (midazolam). 2. Neutralisation of toxin: TIG single dose, administered IM 250-500IU. 3. Surgical debridement of infected tissues. 4. Refer Table for tetanus wound prophylaxis

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PaediatricB12TROPICAL INFECTIONS

5. MELIOIDOSIS

5.1 Intensive / Induction Therapy

Preferred Regimen

Ceftazidime 200mg/kg/day IV in 3-4 divided doses (max. 6g/day)

Alternative Regimen (Allergy / Resistance)

Imipenem/cilastatin 75-100mg/kg/day IV in 4 divided doses (max. 1g/ dose)

Meropenem 75mg/kg/day IV in 3 divided doses

(Neurological melioidosis: 120-150mg/kg/day IV in 3 divided dose)

(max. 2g/dose)

Remarks & Clinical Comments:

Duration: 2-8 weeks • Uncomplicated: 2 weeks • Complicated pneumonia, deep-seated infection, neurological melioidosis, osteomyelitis & septic arthritis: 4-8 weeks

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PaediatricB12TROPICAL INFECTIONS

5. MELIOIDOSIS

5.2 Maintenance Therapy

Preferred Regimen

Trimethoprim/sulfamethoxazole 4-6 mg/kg/dose (of TMP component) PO q12h up to 240mg then to follow adult dose

PLUS (if high risk relapse)*

Doxycycline 4mg/kg/day PO in 2 divided doses (children above 8 years old) (max. 200mg/day)

Alternative Regimen (Allergy / Resistance)

Children below 8 years old:

Amoxicillin/clavulanate 20mg/kg/dose (of amoxicillin component) PO q8h

(higher relapse rate)

Ratio dose depends on product available (7:1 or 14:1)

Remarks & Clinical Comments:

Duration:12- 20 weeks Folic acid 5mg PO q24h to be given for patients on Trimethoprim/sulfamethoxazole. *Consider combination therapy of two drugs in maintenance phase if high risk of relapse.

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PaediatricB12TROPICAL INFECTIONS

6. MALARIA

6.1 Plasmodium falciparum

6.1.1 Uncomplicated

Preferred Regimen

Artemether/lumefantrine (Riamet^®^) (20mg artemether/ 120mg lumefantrine per tablet)

The patient should receive an initial STAT dose, followed by second dose 8 hours later, then 1 dose q12h for the following two days

5-14kg: 1 tablet per dose

15-24kg: 2 tablet per dose

25-35kg: 3 tablet per dose

≥35 kg: 4 tablet per dose

PLUS

Primaquine 0.25mg base/kg to be given on Day 1 as a single dose in addition to artemisinin-based combination therapy (ACT) (G6PD testing is not required prior to administration of this dose).

Alternative Regimen (Allergy / Resistance)

Artesunate/mefloquine FDC (ASMQ)

(ASMQ is available as FDC tablet 25/55mg & 100/220mg)

5-8kg: 25/55mg PO q24h

9-17kg: 50/110mg PO q24h

18-29kg: 100/220mg PO q24h

>30kg: 200/440mg PO q24h

Duration: 3 days

PLUS

Primaquine 0.25mg base/kg to be given on Day 1 as a single dose in addition to artemisinin-based combination therapy (ACT) (G6PD testing is not required prior to administration of this dose).

Remarks & Clinical Comments:

Artesunate/mefloquine may cause seizure in children with epilepsy. Riamet^®^ should be served with high-fat diet e.g. milk to enhance absorption.

NAG MOH Malaysia 2024Official Site

PaediatricB12TROPICAL INFECTIONS

6. MALARIA

6.1 Plasmodium falciparum

6.1.2 Treatment failure

Preferred Regimen

An alternative artemisinin-based combination therapy (ACT) regimen to be used.

(If Riamet^®^ is used as the first line regimen, use ASMQ & vice versa)

PLUS

Primaquine 0.25mg base/kg to be given on Day 1 as a single dose in addition to artemisinin-based combination therapy (ACT) (G6PD testing is not required prior to administration of this dose).

Alternative Regimen (Allergy / Resistance)

Artesunate 4mg/kg/dose PO q24h

PLUS

Clindamycin 10mg/kg/dose PO q12h for 7 days

Quinine 10mg salt/kg/dose PO q8h

PLUS

Clindamycin 10mg/kg/dose PO q12h for 7 days

Remarks & Clinical Comments:

Artesunate/mefloquine may cause seizure in children with epilepsy. Riamet^®^ should be served with high-fat diet e.g. milk to enhance absorption.

NAG MOH Malaysia 2024Official Site

PaediatricB12TROPICAL INFECTIONS

6. MALARIA

6.1 Plasmodium falciparum

6.1.3 Complicated

Almost always due to P. falciparum. Suspect mixed infections if P. vivax/P. knowlesi malaria appears more severe than usual.

Preferred Regimen

Children > 20 kg

Day 1:

IV artesunate 2.4mg/kg on admission, then repeat again at 12 & 24 hours

Day 2-7:

IV artesunate 2.4 mg/kg OD or switch to oral ACT

Children < 20 kg

Day 1:

IV artesunate 3.0mg/kg on admission, then repeat again at 12 & 24 hours

Day 2-7:

IV artesunate 3.0mg/kg OD or switch to oral ACT

Duration: 7 days

(Parenteral artesunate should be given for a minimum of 24 hours (3 doses) or until patient is able to tolerate orally and thereafter to complete treatment with a complete course of oral ACT (3 days of ASMQ or Riamet^®^).

Alternative Regimen (Allergy / Resistance)

Day 1: *Quinine loading dose 20mg/kg IV (dilute in 250 ml D5%) run over 4 hours; followed by maintenance dose 8 hours later;

Quinine 10mg/kg IV q8h till Day 7 (max. 600mg base)

PLUS

Doxycycline 2.2mg/kg/dose (max. 100mg/dose) PO q12h

Clindamycin 10mg/kg/dose PO q12h

Duration: 7 days

Remarks & Clinical Comments:

Avoid using ASMQ (artesunate/ mefloquine) if patient presents initially with impaired consciousness as increased incidence of neuropsychiatric complications associated with mefloquine following cerebral malaria have been reported. Do not use IV artesunate as monotherapy. If IV artesunate needs to be continued indefinitely, clindamycin must be added to the regimen to complete 7 days of treatment. IM artesunate (same dose as IV) can be used in patients with difficult intravenous access. Children with severe malaria should be started on broad-spectrum antibiotic treatment immediately at the same time as antimalarial treatment. *Change to quinine PO if able to tolerate orally (max. quinine per dose = 600 mg). Reduce quinine IV dose by one third of total dose if unable to change to quinine PO after 48 hours (10 mg/kg q8h to 10 mg/kg q12h) or in renal failure or liver impairment.

NAG MOH Malaysia 2024Official Site

PaediatricB12TROPICAL INFECTIONS

6. MALARIA

6.2 Plasmodium vivax, Plasmodium malariae, Plasmodium knowlesi

6.2.1 Uncomplicated

Preferred Regimen

ACT (Riamet^®^ or ASMQ)

(dosing as per P. falciparum treatment)

PLUS

Primaquine 0.5mg/kg PO q24h for 14 days (max. 30mg base/dose)

(Primaquine is ONLY needed for P. vivax)

Alternative Regimen (Allergy / Resistance)

Quinine 10mg salt/kg PO q8h for 7 days

PLUS

Primaquine 0.5mg/kg PO q24h for 14 days (max. 30mg base/dose)

(Primaquine is ONLY needed for P. vivax)

Mefloquine 15 mg/kg single dose combined with primaquine have been found to be effective (except for P. knowlesi)

Remarks & Clinical Comments:

Primaquine (0.5mg/kg) may cause haemolysis in individuals with G6PD deficiency, hence G6PD testing is required before administration of primaquine above 0.25mg/kg. For those found to have mild to moderate G6PD deficiency, an intermittent primaquine regimen of 0.75 mg base/kg weekly for 8 weeks can be given under medical supervision. In severe G6PD deficiency, primaquine is contraindicated and should not be used. P. knowlesi (zoonotic malaria) can cause severe malaria and should be treated as severe malaria secondary to P. falciparum.

NAG MOH Malaysia 2024Official Site

PaediatricB12TROPICAL INFECTIONS

6. MALARIA

6.2 Plasmodium vivax, Plasmodium malariae, Plasmodium knowlesi

6.2.2 Severe & complicated P. vivax, P. knowlesi or P. malariae

Treat as per severe P. falciparum malaria

NAG MOH Malaysia 2024Official Site

PaediatricB12TROPICAL INFECTIONS

6. MALARIA

6.3 Mixed Infection

Treat as P. falciparum

NAG MOH Malaysia 2024Official Site

PaediatricB13URINARY TRACT INFECTIONS

1. ACUTE PYELONEPHRITIS

Common organisms: Escherichia coli Proteus spp. Klebsiella spp. Enterobacter spp

Preferred Regimen

0-2 months old

First line:

Ampicillin 50mg/kg/dose IV

≤ 1 week of age: q12h

> 1 week of age: q8h

PLUS

Gentamicin 5mg/kg/dose IV

≤ 30 week of CGA: q48h

> 30-34 week of CGA: q36h

> 35 weeks of CGA: q24h

Second line:

Cefotaxime 150-200mg/kg/day IV in 3 divided doses (max. 6g/day), MAY ADD

Amikacin 15mg/kg/dose IV daily

≥ 3 months old

First line:

Cephalexin 25-50mg/kg/day PO in 2 divided doses (max. 2g/day)

Amoxicillin/clavulanate

Suspension (Formulation 14:1)

Amoxicillin/clavulanate 80-90mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day)

Suspension (Formulation 7:1)

Amoxicillin/clavulanate 40-50mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day)

Second line:

Cefotaxime 150-200 mg/kg/day IV in 3 divided doses (max. 6g/day)

Ceftriaxone 100mg/kg/day IV in 1-2 divided doses (max. 2g/day)

MAY ADD

Amikacin 15mg/kg/dose IV daily

Remarks & Clinical Comments:

Duration: 7 – 10 days Adjust therapy based on culture result. Switch to oral therapy when improving and able to tolerate oral therapy. For Aminoglycoside (Gentamicin): In obese patients, use ideal weight for height to calculate parenteral dose and monitor serum concentration closely.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.1 Syphilis

1.1.1 Primary syphilis, Secondary syphilis, Early latent syphilis (history of syphilis infection within the last 2 years)

Preferred Regimen

Benzathine Penicillin 2.4MU IM STAT

Procaine Penicillin 600,000units IM q24h for 10 days

Alternative Regimen (Allergy / Resistance)

For penicillin allergy:

Doxycycline 100mg PO q12h for 14 days

Remarks & Clinical Comments:

Sexual partner(s) should be examined, investigated and treated epidemiologically. Abstain from sex for 1 week after the patient and partner(s) have completed treatment. If drug administration is interrupted for ≥ 1 day at any point during the treatment course, the entire course may need to be restarted. Patients should be warned of possible reactions to treatment: • Jarisch-Herxheimer reaction • Anaphylaxis/allergy

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.1 Syphilis

1.1.2 Late latent syphilis, Gumma (benign tertiary) syphilis, Cardiovascular syphilis

Preferred Regimen

Benzathine Penicillin 2.4MU IM weekly for 3 weeks (Day 1, 8, and 15)

Procaine penicillin 600,000units IM q24h for 14 days

Alternative Regimen (Allergy / Resistance)

For penicillin allergy:

Doxycycline 100mg PO q12h for 28 days

Remarks & Clinical Comments:

Sexual partner(s) should be examined, investigated and treated epidemiologically. Abstain from sex for 1 week after the patient and partner(s) have completed treatment. Cardiovascular syphilis: Consider prednisolone 40-60mg PO q24h for 3 days starting 24 hours before the antibiotics. If benzathine penicillin is interrupted by ≥ 2 weeks in between the weekly doses, the entire course needs to be restarted.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.1 Syphilis

1.1.3 Neurosyphilis

Preferred Regimen

Benzylpenicillin 4MU q4h IV for 14 days

Procaine penicillin 2.4MU IM q24h for 14 days

PLUS

*Probenecid 500mg PO q6h for 14 days

Alternative Regimen (Allergy / Resistance)

For penicillin allergy without anaphylaxis:

Ceftriaxone 2g IM or IV q24h for 14 days

If anaphylaxis to penicillin:

Doxycycline 200mg PO q12h for 28 days

Remarks & Clinical Comments:

Consider Prednisolone 40-60mg PO q24h for 3 days starting 24 hours before the antibiotics. *Indication not listed in MOH Drug Formulary.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.1 Syphilis

1.1.4 Syphilis in HIV (Primary, secondary, early and late latent and neurosyphilis)

Treatment as appropriate for stage of infection.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.1 Syphilis

1.1.5 Incubating syphilis / epidemiological treatment

Preferred Regimen

Benzathine penicillin 2.4MU IM STAT

Alternative Regimen (Allergy / Resistance)

For penicillin allergy:

Doxycycline 100mg PO q12h for 14 days

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.2 Syphilis in Pregnancy

1.2.1 Primary syphilis, Secondary syphilis, Early latent syphilis (history of syphilis infection within the last 2 years)

Preferred Regimen

Benzathine Penicillin 2.4MU IM STAT

Procaine Penicillin 600,000units IM q24h for 10 days

Alternative Regimen (Allergy / Resistance)

For penicillin allergy:

*Desensitize and treat with penicillin as there are no proven alternatives.

If failed desensitization:

Ceftriaxone 500mg IM q24h for 10 days

Azithromycin 2g PO STAT

Erythromycin ethylsuccinate 800mg PO q6h for 14 days

Remarks & Clinical Comments:

Sexual partner(s) should be examined, investigated and treated epidemiologically. If macrolide is used, for neonate assessment and treatment at birth. *The benefit of treatment outweighs the risk of allergic reaction in skin test and desensitization. Refer to Appendix 3 for the penicillin desensitization protocol.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.2 Syphilis in Pregnancy

1.2.2 Late latent syphilis, Gumma (benign tertiary) syphilis, Cardiovascular syphilis

Preferred Regimen

Benzathine Penicillin 2.4MU IM weekly for 3 weeks (Day 1, 8, and 15)

Procaine penicillin 600,000units IM q24h for 14 days

Alternative Regimen (Allergy / Resistance)

For penicillin allergy:

Erythromycin ethylsuccinate 800mg PO q6h for 28 days

Remarks & Clinical Comments:

Sexual partner(s) should be examined, investigated and treated epidemiologically. If macrolide is used, for neonate assessment and treatment at birth. Cardiovascular syphilis: Consider prednisolone 40-60mg PO q24h for 3 days starting 24 hours before the antibiotics.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.2 Syphilis in Pregnancy

1.2.3 Neurosyphilis

Preferred Regimen

Benzylpenicillin 4MU q4h IV for 14 days

Procaine penicillin 2.4MU IM q24h for 14 days

PLUS

*Probenecid 500mg PO q6h for 14 days

Alternative Regimen (Allergy / Resistance)

For penicillin allergy without anaphylaxis:

Ceftriaxone 2g IM or IV q24h for 14 days

Remarks & Clinical Comments:

Consider Prednisolone 40-60mg PO q24h for 3 days starting 24 hours before the antibiotics. *Indication not listed in MOH Drug Formulary.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.3 Genital Herpes

1.3.1 First episode

Preferred Regimen

Acyclovir 400mg PO q8h for 7-10 days

Alternative Regimen (Allergy / Resistance)

*Valacyclovir 1g PO q12h for 7-10 days

Remarks & Clinical Comments:

Physical supportive measures (saline bathing, analgesia, local anaesthetics) are recommended. Oral antiviral drugs indicated within 5 days of the start of the episode and while new lesions are still forming. Topical antivirals are less effective than oral agents and not recommended, due to the association with acyclovir resistant strain. Addition of topical antivirals to oral treatment is of no benefit. *Not listed in MOH Drug Formulary.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.3 Genital Herpes

1.3.2 Recurrent episode

Preferred Regimen

Short course:

Acyclovir 800mg PO q8h for 2 days

5-day course:

Acyclovir 800mg PO q12h for 5 days

Alternative Regimen (Allergy / Resistance)

Short course:

*Valacyclovir 500mg PO q12h for 3 days

5-day course:

*Valacyclovir 1g PO q24h for 5 days

Remarks & Clinical Comments:

*Not listed in MOH Drug Formulary.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.3 Genital Herpes

1.3.3 Suppressive therapy

If ≥ 6 recurrences/year, severe, prolonged or with psychosocial problems.

Preferred Regimen

Acyclovir 400mg PO q12h for up to 1 year, then reassess.

If break-through recurrences occur:

Increase to Acyclovir 400mg PO q8h for 7-10 days

Alternative Regimen (Allergy / Resistance)

*Valacyclovir 500mg PO q24h for up to 1 year, then reassess

If ≥ 10 recurrences/year:

*Valacyclovir 1g PO q24h for up to 1 year, then reassess

Remarks & Clinical Comments:

*Not listed in MOH Drug Formulary.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.3 Genital Herpes

1.3.4 Severe disease

Requiring hospitalisation.

Preferred Regimen

Acyclovir 5-10mg/kg/dose IV q8h for 10-14 days

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.3 Genital Herpes

1.3.5 First episode (in pregnancy)

Preferred Regimen

Acyclovir 400mg PO q8h for 7-10 days

For 3rd trimester acquisition:

Continue treatment till delivery

Alternative Regimen (Allergy / Resistance)

*Valacyclovir 500mg PO q12h for 7-10 days

Remarks & Clinical Comments:

*Not listed in MOH Drug Formulary.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.3 Genital Herpes

1.3.6 Recurrent episode (in pregnancy)

Preferred Regimen

Acyclovir 400mg PO q8h

Treatment recommended starting at 36 weeks’ gestation.

Alternative Regimen (Allergy / Resistance)

*Valacyclovir 500mg PO q12h

Treatment recommended starting at 36 weeks’ gestation.

Remarks & Clinical Comments:

*Not listed in MOH Drug Formulary.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.4 Other Anogenital Ulcer Diseases

1.4.1 Chancroid

Haemophilus ducreyi

Preferred Regimen

Azithromycin 1g PO STAT

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 250mg IM STAT

Ciprofloxacin 500mg PO q12h for 3 days

Erythromycin ethylsuccinate 800mg PO q8h for 7 days

Remarks & Clinical Comments:

Sexual partner(s) within 10 days before onset of the patient’s symptoms should be examined and treated even in the absence of symptoms. Patients should be re-examined 3-7 days after initiation of therapy. Successful treatment: Ulcers improve symptomatically within 3 days and substantial re-epithelization occurs within 7 days after onset of therapy. In pregnancy/breastfeeding, to use azithromycin, ceftriaxone or erythromycin.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.4 Other Anogenital Ulcer Diseases

1.4.2 Lymphogranuloma Venereum (LGV)

Chlamydia trachomatis serovars L1,2,3

Preferred Regimen

*Doxycycline 100mg PO q12h for 21 days

Alternative Regimen (Allergy / Resistance)

Azithromycin 1g PO weekly for 3 weeks

Erythromycin ethylsuccinate 800mg PO q6h for 21 days

Remarks & Clinical Comments:

Sexual partner(s) within 60 days should be evaluated and treated if symptomatic. If asymptomatic, they should be empirically treated for exposure with doxycycline 100mg PO q12h for 7 days. Proctitis and anorectal discharge are common especially in the MSM population. Fluctuant buboes: Should be aspirated through healthy adjacent skin. Surgical incision contraindicated. If an alternative treatment regimen is given or pregnant, consider test-of-cure 4 weeks after completion of treatment. *Doxycycline is contraindicated in pregnancy.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.4 Other Anogenital Ulcer Diseases

1.4.3 Granuloma Inguinale (Donovanosis)

Klebsiella granulomatis

Preferred Regimen

Azithromycin 1g PO weekly or 500mg q24h

Alternative Regimen (Allergy / Resistance)

*Doxycycline 100mg PO q12h

Trimethoprim/Sulfamethoxazole 160/800mg PO q12h

Erythromycin ethylsuccinate 800mg PO q6h

Remarks & Clinical Comments:

Sexual partner(s) within 60 days before onset of the patient’s symptoms must be screened and treated. Duration of treatment: at least 3 weeks or until all lesions have completely healed. *Doxycycline is contraindicated in pregnancy.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

1. ANOGENITAL ULCER DISEASE

1.5 Mpox

Monkeypox virus

Refer to Guidelines on Mpox Management in Malaysia .

NAG MOH Malaysia 2024Official Site

PaediatricB13URINARY TRACT INFECTIONS

2. LOWER URINARY TRACT INFECTION

Preferred Regimen

Amoxicillin/clavulanate

Suspension (Formulation 14:1)

Amoxicillin/clavulanate 80-90mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day)

Suspension (Formulation 7:1)

Amoxicillin/clavulanate 40-50mg/kg/day PO in 2 divided doses (Amoxicillin component, max. 2g/day)

Cefuroxime 30 mg /kg/day PO in 2 divided doses (max. 500mg/day)

Trimethoprim/sulfamethoxazole 8-10mg/kg/day (TMP dose) PO in 2 divided doses

Alternative Regimen (Allergy / Resistance)

Nitrofurantoin 2mg/kg/dose PO q12h (sustained-release) or 1mg/kg/dose q6h (immediate-release tablets)

(max. 100mg/dose)

Remarks & Clinical Comments:

Duration: 3-5 days

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.1 Gonorrhoea

2.1.1 Uncomplicated (cervix, urethra, rectum, pharynx)

Preferred Regimen

Cervix, urethra, rectum:

Ceftriaxone 500mg IM STAT (if BW>150kg, 1g IM STAT)

PLUS

*Doxycycline 100mg PO q12h for 7 days

(if Chlamydia has not been excluded)

Pharynx:

Ceftriaxone 500mg IM STAT (if BW>150kg, 1g IM STAT)

PLUS

*Doxycycline 100mg PO q12h for 7 days

(if Chlamydia has not been excluded)

Alternative Regimen (Allergy / Resistance)

Cervix, urethra, rectum:

Cephalosporin allergy:

Gentamicin 240mg IM STAT

PLUS

Azithromycin 2g PO STAT

Pharynx:

Anaphylaxis or severe reaction to cephalosporin:

Consult for expert opinion

Remarks & Clinical Comments:

Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically irrespective of the test results. Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved. *Doxycycline is contraindicated in pregnancy.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.1 Gonorrhoea

2.1.2 In Pregnancy

Preferred Regimen

Ceftriaxone 500mg IM STAT

(if BW>150kg, 1g IM STAT)

PLUS

Azithromycin 1g PO STAT

(if Chlamydia has not been excluded)

Alternative Regimen (Allergy / Resistance)

Anaphylaxis or severe reaction to cephalosporin:

Consult for expert opinion

Remarks & Clinical Comments:

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.1 Gonorrhoea

2.1.4 Disseminated gonococcal infection (DGI)

Preferred Regimen

With arthritis-dermatitis syndrome:

Ceftriaxone 1g IV or IM q24h for 7 days

With purulent arthritis:

Ceftriaxone 1g IV or IM q24h for 7-14 days

With meningitis:

Ceftriaxone 1-2g IV q12h-24h for 10-14 days

With endocarditis:

Ceftriaxone 1-2g IV q12h-24h for 4-6 weeks

Alternative Regimen (Allergy / Resistance)

With arthritis-dermatitis syndrome:

Cefotaxime 1g IV q8h for 7 days

Remarks & Clinical Comments:

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.1 Gonorrhoea

2.1.5 Conjunctivitis

Refer Ocular Infections section

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.2 Chlamydia

2.2.1 Uncomplicated (cervix, urethra, rectum, pharynx)

Preferred Regimen

Doxycycline 100mg PO q12h for 7 days

Alternative Regimen (Allergy / Resistance)

Azithromycin 1g PO STAT

*Levofloxacin 500mg PO q24h for 7 days

Remarks & Clinical Comments:

Sexual partner(s) within 60 days should be examined, investigated and treated epidemiologically, irrespective of the test results. Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved. * Indication not listed in MOH Drug Formulary.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.2 Chlamydia

2.2.2 In pregnancy

Preferred Regimen

Azithromycin 1g PO STAT

Alternative Regimen (Allergy / Resistance)

Amoxicillin 500mg PO q8h for 7 days

Remarks & Clinical Comments:

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.3 Non-Gonococcal Urethritis (NGU)

2.3.1 First episode

Preferred Regimen

Doxycycline 100mg PO q12h for 7 days

Alternative Regimen (Allergy / Resistance)

Azithromycin 500mg PO STAT, then 250mg q24h for 4 days

Remarks & Clinical Comments:

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.3 Non-Gonococcal Urethritis (NGU)

2.3.2 Recurrent and persistent

Preferred Regimen

If treated with doxycycline as first line:

Azithromycin 500mg PO STAT, then 250mg PO q24h for the next 4 days

PLUS

Metronidazole 400mg PO q12h for 5 days

If treated with azithromycin as first line:

*Moxifloxacin 400mg PO q24h for 10-14 days

PLUS

Metronidazole 400mg PO q24h for 5 days

Remarks & Clinical Comments:

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.4 Epididymo-orchitis / Epididymitis

2.4.1 STI - related

Preferred Regimen

Ceftriaxone 500mg IM STAT

PLUS

Doxycycline 100mg PO q12h for 10 days

Alternative Regimen (Allergy / Resistance)

Remarks & Clinical Comments:

Abstain from sex until the patient and partner(s) have completed treatment and symptoms are resolved. To review the diagnosis if no clinical improvement after 3 days. Review at 2 weeks to assess treatment compliance, partner(s) notification and resolution of symptoms. Look out for complications i.e., hydrocoele, abscess, infarction, infertility.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

2. URETHRAL DISCHARGE

2.4 Epididymo-orchitis / Epididymitis

2.4.2 STI-related but Unlikely Gonorrhoea

Preferred Regimen

Doxycycline 100mg PO q12h for 10 days

Remarks & Clinical Comments:

Abstain from sex until the patient and partner(s) have completed treatment and symptoms are resolved. To review the diagnosis If no clinical improvement after 3 days. Review at 2 weeks to assess treatment compliance, partner(s) notification and resolution of symptoms. Look out for complications i.e., hydrocoele, abscess, infarction, infertility.

NAG MOH Malaysia 2024Official Site

PaediatricB13URINARY TRACT INFECTIONS

3. PROPHYLAXIS FOR UTI

Prophylaxis for infants & children with recurrent UTI

Preferred Regimen

Trimethoprim 1-2mg/kg PO at night (max. 100mg ON)

Trimethoprim/sulfamethoxazole 2mg/kg (TMP dose) PO at night

Nitrofurantoin 1-2mg/kg PO at night (max. 100mg ON)

Alternative Regimen (Allergy / Resistance)

Cephalexin 12.5mg/kg PO at night (max. 250mg/dose)

Remarks & Clinical Comments:

Antibiotic prophylaxis should not be routinely recommended in children with first-time UTI. Prophylactic antibiotics should be given for 3 days with MCUG (micturatingcystourethogram) taking place on the second day. Children with Grade I-IV vesicoureteral reflux (VUR) may experience a decrease in recurrent UTI by 50% following first or second febrile or symptomatic UTI with increased detection of resistant organisms following antibiotic prophylaxis.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

3. VAGINAL DISCHARGE

3.1 Trichomoniasis

Trichomonas vaginalis

Preferred Regimen

Metronidazole 400mg PO q12h for 7 days

Metronidazole 2g PO STAT*

Remarks & Clinical Comments:

Sexual partner(s) should be treated simultaneously. Abstain from sex for 1 week after the patient and partner(s) have completed treatment and symptoms are resolved. *Single high dose metronidazole is associated with gastrointestinal side effects and higher failure rate, especially if partner(s) are not treated concurrently.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

3. VAGINAL DISCHARGE

3.2 Cervicitis

Preferred Regimen

*Doxycycline 100mg PO q12h for 7 days

Alternative Regimen (Allergy / Resistance)

Azithromycin 1g PO STAT

Remarks & Clinical Comments:

Presumptive treatment of chlamydia. *Doxycycline is contraindicated in pregnancy.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

3. VAGINAL DISCHARGE

3.3 Bacterial Vaginosis

Common organisms: Anaerobic bacteria (E.g.: Prevotella sp., Mobiluncus sp., Gardnerella vaginalis, Mycoplasma hominis)

Preferred Regimen

Metronidazole 400mg PO q12h for 7 days

Metronidazole 2g PO STAT*

Alternative Regimen (Allergy / Resistance)

Clindamycin 300mg PO q12h for 7 days

Remarks & Clinical Comments:

Not an STI but frequently detected during STI screening. *Single high dose metronidazole is associated with gastrointestinal side effects.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

3. VAGINAL DISCHARGE

3.4 Vulvovaginal candidiasis

3.4.1 Uncomplicated Infection

Preferred Regimen

Clotrimazole 500mg as a single vaginal pessary STAT

Alternative Regimen (Allergy / Resistance)

Fluconazole 150-200mg PO STAT

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

3. VAGINAL DISCHARGE

3.4 Vulvovaginal candidiasis

3.4.2 Complicated Infection (Severe Vaginitis Symptoms)

Preferred Regimen

Fluconazole 150-200mg PO q72h for 2 doses (Day 1 and 4)

Alternative Regimen (Allergy / Resistance)

Clotrimazole 500mg vaginal pessary q72h for 2 doses (Day 1 and 4)

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

3. VAGINAL DISCHARGE

3.4 Vulvovaginal candidiasis

3.4.3 Recurrent Infection (≥ 3 Episodes of Symptomatic Vulvovaginal Candidiasis in <1 year)

Preferred Regimen

Fluconazole 150-200mg PO q72h for 3 doses (Day 1,4 and 7), then weekly for 6 months

Alternative Regimen (Allergy / Resistance)

Clotrimazole 500mg vaginal pessary weekly for 6 months

Remarks & Clinical Comments:

Treat each episode with a longer course of topical azole.

NAG MOH Malaysia 2024Official Site

AdultA13SEXUALLY TRANSMITTED INFECTIONS

3. VAGINAL DISCHARGE

3.4 Vulvovaginal candidiasis

3.4.4 In Pregnancy

Preferred Regimen

Clotrimazole pessary 500mg as a single vaginal pessary STAT

Alternative Regimen (Allergy / Resistance)

Topical azole at least for 1 week

Remarks & Clinical Comments:

Oral azole is contraindicated in pregnancy.

NAG MOH Malaysia 2024Official Site

AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

• Human bite • Cat bite • Delayed presentation > 8 hours • Deep puncture wound extending or close to bone and joint • Crush associated injury • Immunocompromised patients 1. For all bite-related wounds, thorough wound irrigation and/or debridement must be of utmost priority. All injuries with broken skin require exploration and washout. 1. Consultation with a Plastic Surgeon should be considered for involvement of high-risk or special areas such as the face, hands, feet, and genitalia. 1. Role of ATT: The risk of tetanus needs to be evaluated to provide adequate post-exposure prophylaxis by vaccination. For further information on tetanus vaccine, please refer to Guidelines for Adult Immunisation . 1. For management of rabies, please refer to MOH Guideline on Rabies Management in Human and Animals .

Preferred Regimen

Dog/cat/human/rodent/reptile bite:

Amoxicillin/clavulanate 625mg PO q8h or 1.2g IV q8h

Monkey bite:

Amoxicillin/clavulanate 625mg PO q8h or 1.2g IV q8h

PLUS

*Acyclovir 800 mg PO 5 times daily for 14 days

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Cefuroxime 750mg-1.5g IV q8h

Ceftriaxone 2g IV q24h

PLUS

Metronidazole 500mg IV q8h

Oral Option:

Doxycycline 200mg PO q24h on Day 1 followed by 100mg-200mg PO q24h

Cefuroxime 500mg PO q12h

PLUS

Metronidazole 400mg PO q8h

Remarks & Clinical Comments:

Duration: • Prophylaxis: 3 days • Treatment: 5 days *Add acyclovir only when exposed to a macaque via bites and scratches, exposure to tissue culture material, exposure to tissue obtained during autopsies of monkeys, needlestick injuries, cage scratches, mucosal splash.

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PaediatricB14VASCULAR INFECTIONS

1. CATHETER-RELATED BLOODSTREAM INFECTION (CRBSI)

1.1 Coagulase-negative Staphylococcus (CoNS)

Preferred Regimen

Methicillin-sensitive (MSCoNS):

Cloxacillin 200mg/kg/day IV in 4-6 divided doses (max. 2g/dose)

Methicillin-resistant (MRCoNS):

Vancomycin 45-60mg/kg/day IV in 3-4 divided doses (max. 3600mg/day)

Target AUC24 of 400-600 mg*hour/L

Alternative Regimen (Allergy / Resistance)

Methicillin-sensitive (MSCoNS):

Cefazolin 100mg/kg/day IV in 3 divided doses (max. 6 g/day if no endocarditis)

Remarks & Clinical Comments:

Diagnosis needs: 1. Paired blood cultures drawn from both catheters and peripheral vein. 2. If blood cultures cannot be drawn from peripheral vein, it is recommended that two or more blood cultures should be drawn through different catheter lumen. Long term catheters should be removed in patients with CRBSI with: Severe sepsis, suppurative thrombophlebitis, endocarditis, blood stream infections that continue despite 72 hours of antimicrobial therapy or longer to which the infecting organism is susceptible or infections due to Staphylococcus aureus, Pseudomonas aeruginosa, fungi & mycobacterium. Attempts at catheter salvage are only recommended in uncomplicated CRBSI or CLABSI caused by bacteria that are neither too virulent nor too difficult to eradicate. Exact optimal duration of therapy has not been established in children with or without catheter removal. 10-14 days after first negative blood culture is usually recommended. *For CoNS, need to decide whether isolates from blood culture is coloniser or true pathogen.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. PURULENT SKIN & SOFT TISSUE INFECTION

1.1 Folliculitis

1.1.1 Mild

Usually self-limiting and no treatment is required. Consider good skin hygiene. Warm compresses for comfort.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. PURULENT SKIN & SOFT TISSUE INFECTION

1.1 Folliculitis

1.1.2 Known or Suspected Staphylococcal

Preferred Regimen

Topical 2% fusidic acid q8-12h

Topical 2% mupirocin q8h

(Outpatient use only)

Remarks & Clinical Comments:

General measures include warm compress, antiseptic washes, good skin hygiene and clean sharp razors when shaving. Obtain a pus or swab for culture and sensitivity if accessible. Topical antibiotic therapy is preferred for folliculitis that persists with general measures and involves a limited area of the skin.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. PURULENT SKIN & SOFT TISSUE INFECTION

1.1 Folliculitis

1.1.3 Deep or Extensive Lesions

Preferred Regimen

Cloxacillin 500mg PO q6h

Cephalexin 1000mg PO q12h

Remarks & Clinical Comments:

Systemic antimicrobial therapy with S. aureus coverage is suggested for patients with deep or extensive folliculitis that fails to resolve or recurs after topical therapy. Consider the etiology of the folliculitis and the severity and the distribution of the lesions. Referral to a dermatologist if other etiologies are considered, especially when initial systemic treatment fails: 1.Gram-negative folliculitis (e.g. Enterobacter, Klebsiella, Escherichia, Serratia, Morganella, and Proteus species): primarily in patients on long-term antibiotic therapy, most often during treatment for acne. 2. Pseudomonal folliculitis: appears 8-48 hours after exposure to contaminated water (e.g. hot tub/spa) or wet suits. 3. Folliculitis caused by Malassezia furfur, Demodex mites or herpes simplex virus: seen in immunocompromised patients.

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PaediatricB14VASCULAR INFECTIONS

1. CATHETER-RELATED BLOODSTREAM INFECTION (CRBSI)

1.2 Coagulase-positive Staphylococcus

Preferred Regimen

Methicillin-sensitive (MSSA):

Cloxacillin 200mg/kg/day IV in 4-6 divided doses (max. 2g/dose)

Methicillin-resistant (MRSA):

Vancomycin 45-60mg/kg/day in 3-4 divided doses (max. 3600mg/day)

Target AUC24 of 400-600 mg*hour/L

Alternative Regimen (Allergy / Resistance)

Methicillin-sensitive (MSSA):

Cefazolin 100mg/kg/day IV in 3 divided doses (max. 6 g/day if no endocarditis)

Remarks & Clinical Comments:

Diagnosis needs: 1. Paired blood cultures drawn from both catheters and peripheral vein. 2. If blood cultures cannot be drawn from peripheral vein, it is recommended that two or more blood cultures should be drawn through different catheter lumen. Long term catheters should be removed in patients with CRBSI with: Severe sepsis, suppurative thrombophlebitis, endocarditis, blood stream infections that continue despite 72 hours of antimicrobial therapy or longer to which the infecting organism is susceptible or infections due to Staphylococcus aureus, Pseudomonas aeruginosa, fungi & mycobacterium. Attempts at catheter salvage are only recommended in uncomplicated CRBSI or CLABSI caused by bacteria that are neither too virulent nor too difficult to eradicate. Exact optimal duration of therapy has not been established in children with or without catheter removal. 10-14 days after first negative blood culture is usually recommended. *For CONS, need to decide whether isolates from blood culture is coloniser or true pathogen.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. PURULENT SKIN & SOFT TISSUE INFECTION

1.2 Furuncles (“Boils”)

Preferred Regimen

Mild (Localised):

Cloxacillin 500mg PO q6h

Moderate to severe (Extensive/generalised; with or without systemic symptoms, or immunocompromised patients):

Amoxicillin/clavulanate 1.2g IV q8h

Ampicillin/sulbactam 3g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Mild (Localised):

Amoxicillin/clavulanate 625mg PO q8h

Remarks & Clinical Comments:

Duration: 5 days Consider warm compresses and drainage first; if these measures fail, then initiate antibiotic therapy. For moderate to severe boils, or those presenting with systemic manifestations, manage according to the treatment protocol for carbuncles. Consider switching from IV to PO therapy if condition improves.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. PURULENT SKIN & SOFT TISSUE INFECTION

1.3 Carbuncles

Common organism: Staphylococcus aureus

Preferred Regimen

Cloxacillin 1-2g IV q6h

Cefazolin 1-2g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 1.2g IV q8h

Ampicillin/sulbactam 3g IV q6h

Remarks & Clinical Comments:

Duration: 7-10 days Surgical drainage is the mainstay of treatment. Consider IV to PO switch if adequate surgical treatment and rapid clinical response. Consider targeted therapy once culture results are available.

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PaediatricB14VASCULAR INFECTIONS

1. CATHETER-RELATED BLOODSTREAM INFECTION (CRBSI)

1.3 Gram-negative Bacilli Enterobacteriaeceae

1.3.1 ESBL Negative

Preferred Regimen

*Piperacillin/tazobactam:

300-400mg of piperacillin/kg/day in 3-4 divided doses (max. 16g/day)

Remarks & Clinical Comments:

*Empiric treatment with piperacillin/ tazobactam covers most of the Gram-negative organisms (Enterobacteriaceae), Gram-positive organisms and pseudomonas; follow through with C&S.

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PaediatricB14VASCULAR INFECTIONS

1. CATHETER-RELATED BLOODSTREAM INFECTION (CRBSI)

1.3 Gram-negative Bacilli Enterobacteriaeceae

1.3.2 ESBL Positive

Preferred Regimen

Imipenem 60-100mg/kg/day IV in 4 divided doses (max. 4g/day)

Meropenem 60-120mg/kg/day IV in 3 divided doses (max. 6g/day)

Alternative Regimen (Allergy / Resistance)

Ertapenem 30mg/kg/day IV in 2 divided doses (max. 1g/day)

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PaediatricB14VASCULAR INFECTIONS

1. CATHETER-RELATED BLOODSTREAM INFECTION (CRBSI)

1.3 Gram-negative Bacilli Enterobacteriaeceae

1.3.3 Pseudomonas aeruginosa

Preferred Regimen

Ceftazidime 150-200 mg/kg/day in 3 divided doses (max. 6g/day)

Piperacillin/tazobactam:

300-400mg of piperacillin/kg/day in 3-4 divided doses (max. 16 g/day)

Alternative Regimen (Allergy / Resistance)

Cefepime 50mg/kg/dose IV q8h (max. 2g/dose)

Remarks & Clinical Comments:

Not all pseudomonas is drug resistant. If ceftazidime remains susceptible, please use ceftazidime with/without an anti-pseudomonas aminoglycoside to treat. De-escalation is important to preserve antibiotic for future use.

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PaediatricB14VASCULAR INFECTIONS

1. CATHETER-RELATED BLOODSTREAM INFECTION (CRBSI)

1.4 Candida albicans or Other Candida Species

Preferred Regimen

Fluconazole 12mg/kg IV q24h (max. 800mg/dose)

Alternative Regimen (Allergy / Resistance)

*Caspofungin loading dose 70 mg/m²/dose IV q24hr on Day 1, followed by 50 mg/m²/dose IV q24hr thereafter (max. 70 mg/dose)

Amphotericin B lipid complex 3-5 mg/kg/dose IV q24hr (max. 5mg/kg/dose)

Remarks & Clinical Comments:

Fungaemia: treatment without catheter removal is associated with low success rate and higher mortality. *Example of alternative echinocandins that may also be used: • Micafungin 2-4mg/kg q24h (max. 150mg) • Anidulafungin 1.5-3mg/kg loading dose (max. 200mg/dose), then 0.75-1.5mg/kg q24h (age >28 days) (max. 100mg/dose)

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PaediatricB14VASCULAR INFECTIONS

2. SUPPURATIVE THROMBOPHLEBITIS

Staphylococcus aureus

Preferred Regimen

MSSA:

Cloxacillin 200mg/kg/day IV in 4-6 divided doses (max. 2g/dose)

MRSA:

Vancomycin 45-60mg/kg/day in 3-4 divided doses (max. 3600mg/day)

Target AUC24 of 400-600 mg*hour/L

Alternative Regimen (Allergy / Resistance)

MSSA:

Cefazolin 100mg/kg/day IV in 3 divided doses (max. 6g/day)

Remarks & Clinical Comments:

Diagnosis requires positive blood culture plus radiographic demonstration of thrombus. Remove catheter and a minimum antibiotic treatment of 3-4 weeks. Surgical resection of involved vein if failed conservative therapy.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

2. NON-PURULENT SKIN & SOFT TISSUE INFECTION

2.1 Localised Impetigo

Common organism: Staphylococcus aureus Streptococcus pyogenes

Preferred Regimen

Topical 2% fusidic acid q8-12h

Topical 2% mupirocin q8h

(Outpatient use only)

Alternative Regimen (Allergy / Resistance)

Cloxacillin 500mg PO q6h

Cephalexin 500mg PO q12h

Remarks & Clinical Comments:

Duration: 5 days

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AdultA14SKIN & SOFT TISSUE INFECTIONS

2. NON-PURULENT SKIN & SOFT TISSUE INFECTION

2.2 Generalised Impetigo/Ecthyma

Preferred Regimen

Cloxacillin 500mg PO q6h

Cephalexin 1000mg PO q12h

Antibiotic allergy:

Erythromycin ethylsuccinate 800mg PO q12h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 625mg PO q8h

Other alternative/in case of CA-MRSA:

Clindamycin 300mg PO q6h

Trimethoprim/sulfamethoxazole 160/800mg PO q12h

Remarks & Clinical Comments:

Duration: 5-7 days (based on clinical response) Refer to Appendix 3 for antibiotic allergy.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

2. NON-PURULENT SKIN & SOFT TISSUE INFECTION

2.3 Erysipelas

Common organism: Streptococcus pyogenes

Preferred Regimen

Phenoxymethylpenicillin 500mg PO q6h

Amoxicillin 500mg PO q8h

If severe:

Benzylpenicillin 2-4MU IV q4-6h

* CA-MRSA:

Clindamycin 300mg PO q6h

Trimethoprim/sulfamethoxazole 160/800mg PO q12h

Alternative Regimen (Allergy / Resistance)

Cephalexin 1000mg PO q12h

If severe:

Cefazolin 1g IV q8h

Cefuroxime 750mg IV q8h

CA-MRSA:

**Vancomycin 15-20mg/kg q8-12h; not to exceed 2g/dose

Remarks & Clinical Comments:

Duration: 5 days *CA-MRSA: IV Vancomycin is used if oral therapy is not feasible **Refer to Appendix 1 for vancomycin loading dose.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

2. NON-PURULENT SKIN & SOFT TISSUE INFECTION

2.4 Ecthyma gangrenosum

Most common causative organism is Pseudomonas sp., however antibiotics need to be tailored according to susceptibility result.

Preferred Regimen

Ciprofloxacin 400mg IV q12h

*Piperacillin/tazobactam 4.5g IV q6 – 8h

Alternative Regimen (Allergy / Resistance)

Ceftazidime 2g IV q8h

Cefepime 2g IV q8h

Remarks & Clinical Comments:

Duration: 7 days (based on clinical response) Consider IV to PO switch once patient's condition improves. Refer to Appendix 6 . *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).

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AdultA14SKIN & SOFT TISSUE INFECTIONS

2. NON-PURULENT SKIN & SOFT TISSUE INFECTION

2.5 Cellulitis

Preferred Regimen

Mild:

Cloxacillin 500mg PO q6h

Cephalexin 1000mg PO q12h

Amoxicillin 500mg PO q8h

Moderate:

Cloxacillin 1-2g IV q6h

Cefazolin 1-2g IV q8h

Severe:

*Piperacillin/tazobactam 4.5g IV q6h-8h

(Deescalate once cultures are available/ Necrotizing fasciitis ruled out)

**Antibiotic Prophylaxis:

Phenoxymethylpenicillin (Penicillin V) 250mg PO q12h (500mg PO q12h if BMI ≥ 33)

Alternative Regimen (Allergy / Resistance)

Mild:

Amoxicillin/clavulanate 625mg PO q8h

Ampicillin/sulbactam 375mg PO q12h

Cefuroxime 500mg PO q12h

Moderate:

Ampicillin/sulbactam 3g IV q6h

Amoxicillin/clavulanate 1.2g IV q8h

Cefuroxime 750mg-1.5g IV q8h

Severe:

Ampicillin/sulbactam 3g IV q6h

Amoxicillin/clavulanate 1.2g IV q8h

Antibiotic allergy:

Clindamycin 600mg IV q6h

(Deescalate once cultures are available/ Necrotizing fasciitis ruled out)

Antibiotic Prophylaxis:

Antibiotic allergy:

Clarithromycin 250mg PO q24h

Erythromycin ethylsuccinate 400mg PO q12h

Remarks & Clinical Comments:

Mild cellulitis: without systemic signs of infection. Common organisms: Streptococcus pyogenes & Staphylococcus aureus Moderate cellulitis: with *SIRS but no hypotension. Common organisms: Streptococcus pyogenes & Staphylococcus aureus Severe cellulitis: with *SIRS and hypotension. Common organisms:Streptococcus pyogenes & Staphylococcus aureus *Systemic inflammatory response syndrome (SIRS): 1. fever, 2. tachypnea, 3. tachycardia 4. abnormal white cell count Duration: 5-10 days (longer duration may be required in case of no clinical improvement or if an underlying medication condition is present). Consider IV to PO switch once patient's condition improves. Refer to Appendix 6 . Refer to Appendix 3 for antibiotic allergy. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). **Antibiotic prophylaxis may be considered in patients with 3 to 4 episodes of recurrent cellulitis per year despite attempts to treat or control predisposing factors such as lymphoedema, obesity, inflammatory dermatoses, tinea pedis and venous insufficiency. Duration of antibiotic prophylaxis: 6-12 months depending on recurrence of event. Reassess the need for further prophylaxis if indicated thereafter.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

2.7 Cat Scratch Disease

Common organisms: Bartonella henselae

Preferred Regimen

Azithromycin 500mg PO on Day 1, then 250mg PO q24h for 4 days

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

2.8 Sea Water Exposure

Common organisms: Vibrio sp.

Preferred Regimen

Doxycycline 200mg STAT, then 100mg PO q12h

MAY ADD

*Ceftriaxone 2g IV q24h

Remarks & Clinical Comments:

*Consider adding third generation cephalosporins in severe infections.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

2.9 Fresh or Brackish Water Exposure

Preferred Regimen

Trimethoprim/sulfamethoxazole 320/1600mg PO q12h

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 400mg IV q12h

Ciprofloxacin 750mg PO q12h

PLUS

Cloxacillin 500mg PO q6h

MAY ADD

*Metronidazole 400mg PO q8h

Remarks & Clinical Comments:

Common organisms: Aeromonas sp. Plesiomonas Staphylococcus aureus Streptococcus pyogenes Oral therapy is encouraged if wounds are not associated with systemic features or involving deeper tissues. Add metronidazole if wounds immersed in soil- or sewage-contaminated water.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

2.10 Neutropenic Patients

Common organisms: Pseudomonas aeruginosa Other Gram-negatives

Preferred Regimen

*Piperacillin/tazobactam 4.5g IV q6-8h

Cefepime 2g IV q8h

Remarks & Clinical Comments:

*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

2.11 Methicillin Resistance Staphylococcus aureus (MRSA) Skin & Soft Tissue Infection

Preferred Regimen

Vancomycin 15-20mg/kg IV q8-12h

In severe infections:

To load with vancomycin 25-30mg/kg IV, followed by 15-20mg/kg (actual body weight) IV q8-12h; not exceeding 2g/dose

Alternative Regimen (Allergy / Resistance)

Linezolid 600mg IV/PO q12h

Depending on culture and susceptibility testing, can consider the following options:

Clindamycin 300-600mg IV/PO q6-8h

Trimethoprim/sulfamethoxazole 160/800mg PO q12h

Doxycyline 100mg PO q12h

Remarks & Clinical Comments:

Consider IV to PO switch if condition improves. Refer to Appendix 6 for IV to PO switch. Refer to Appendix 1 for vancomycin loading dose. MRSA Decolonisation strategy: 1. Use mupirocin 2% for nasal application bilateral nostrils. 2. Use chlorhexidine 4% bath or 2% wipe for body application (especially for high carriage sites such as axilla, groin and perineal region). Consider CA-MRSA if: • Outbreaks of known CA-MRSA • Non-resolving cellulitis

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

3.0 PERIPHERAL PHLEBITIS/THROMBOPHLEBITIS

Common organisms: Staphylococcus aureus Coagulase negative Staphylococcus Gram-negative organisms

Preferred Regimen

Grade 3-5:

Empirical treatment:

Cloxacillin 1g IV q6h

If blood culture negative and clinical improvement, to switch to oral:

Cloxacillin 500mg PO q6h

Cephalexin 1000mg PO q12h

Alternative Regimen (Allergy / Resistance)

Grade 3-5:

Cefazolin 2g IV q8h

Remarks & Clinical Comments:

Grade 1: Observe cannula Grade 2: Resite/Remove the intravenous cannula Grade 3-4: • Remove the intravenous cannula and take blood culture; • Consider treatment Grade 5: • Take blood culture • Resite/remove cannula • Initiate treatment Duration: 5 days (depending on clinical response) Peripheral intravenous catheters with associated pain, induration, erythema, or exudate should be removed. VISUAL INFUSION PHLEBITIS SCORE Score 0: Insertion site healthy, no signs of phlebitis Score 1: Presence of one of the following signs: Slight pain or slight redness at IV insertion site. Score 2: Presence of 2 of the following signs: Pain at IV site, redness or swelling. Score 3: Presence of all of the following signs: Pain along the path of the cannula, redness around the insertion site and swelling. Score 4: Presence of all of the following signs: Pain along the path of the cannula, redness around the insertion site, swelling, palpable venous cord. Score 5: Presence of all of the following signs: Pain along the path of the cannula, redness around the insertion site, swelling, palpable venous cord, febrile.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

4.0 PRESSURE INJURY (BED SORE/PRESSURE SORE/DECUBITUS ULCER)

Common organisms: Polymicrobial organism The mainstay of management is prevention.

Preferred Regimen

Management depends on local assessment and grading of the pressure injury, using the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages .

To consider antibiotic if presence of systemic infection:

Ampicillin/sulbactam 3g IV q6h

Amoxicillin/clavulanate 1.2g IV q8h

Remarks & Clinical Comments:

To consider other sources of infection and escalate antibiotics accordingly. May consider oral antibiotics in localised infection. Consider IV to PO switch if condition improves. Refer to Appendix 6 for IV to PO switch.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

5.1 Hansen’s Disease (Leprosy)

Mycobacterium Leprae

Preferred Regimen

Rifampicin 600mg PO once a month (supervised)

PLUS

Dapsone 100mg PO q24h

PLUS

Clofazimine 300mg PO once a month and 50mg PO q24h

Duration:

Paucibacillary: 6 months

Multibacillary: 1 year

Alternative Regimen (Allergy / Resistance)

*Bacterial resistance or hypersensitivity to first line:

Can be substituted with one of the following:

Ofloxacin 400mg PO q24h

Minocycline 100mg PO q24h

Clarithromycin 500mg PO q24h

Remarks & Clinical Comments:

*Second line or drug-resistant regimen can only be initiated by a dermatologist. Prophylaxis of leprosy with single dose rifampicin for contacts of leprosy patients after excluding leprosy and TB disease, and in the absence of other contraindication: 10-14 years old: 450 mg ≥15 years old: 600 mg

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

5.2 Non-tuberculous Mycobacterial (NTM) Skin and Soft Tissue Infections

Treatment depends on the patient’s individual susceptibility and the site of infection. It often involves combination therapy with two to three antimicrobial agents for a prolonged period of time (often 6 months to a year). NTM are intrinsically resistant to many antibiotics. Antibiotic susceptibility testing can be performed at appropriate reference laboratories. Selection of antibiotics are often empirically chosen based on guideline.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

5.2 Non-tuberculous Mycobacterial (NTM) Skin and Soft Tissue Infections

5.2.1 Mycobacterium marinum, Mycobacterium kansasii, Mycobacterium fortuitum/chelonae/abscessus complex

Preferred Regimen

Clarithromycin 500mg PO q12h

Azithromycin 500mg PO q24h

PLUS

Rifampicin 600mg PO q24h

Ethambutol 25mg/kg PO q24h

Doxycycline 100mg PO q12h

Alternative Regimen (Allergy / Resistance)

Amikacin 15mg/kg IV q24h

Remarks & Clinical Comments:

Duration: 6-12 months or until clinical resolution

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AdultA14SKIN & SOFT TISSUE INFECTIONS

1. Consider antibiotic prophylaxis in these cases:

5.2 Non-tuberculous Mycobacterial (NTM) Skin and Soft Tissue Infections

5.2.3 Mycobacterium ulcerans (Buruli ulcer)

Preferred Regimen

Rifampicin 10mg/kg PO q24h

PLUS

Clarithromycin 7.5mg/kg PO q12h

Alternative Regimen (Allergy / Resistance)

Rifampicin 10mg/kg PO q24h

PLUS

Streptomycin 15mg/kg IM q24h for 4 weeks

Followed by:

Rifampicin 10mg/kg PO q24h

PLUS

Clarithromycin 7.5mg/kg PO q12h

Remarks & Clinical Comments:

Wide surgical excision and debridement are important. Duration WHO category 1: Pre-ulcerative lesions and skin lesions smaller than 5 cm, duration of antibiotic 4 weeks with simple excision or 8 weeks of antibiotic therapy only WHO category 2: Antibiotic at least 8 weeks with supportive care (E.g.: surgery) WHO category 3: Lesions > 15cm, antibiotic plus surgical debridement and reconstruction. Duration of treatment depends on clinical response as complications are common (joint and bone involvement)

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.1 Tinea capitis

Common organism: Trichophyton Microsporum

Preferred Regimen

Griseofulvin 500mg PO q12h for 6 to 12 weeks or longer until fungal cultures are negative

Terbinafine 250mg PO q24h

PLUS

2.5% selenium sulphide shampoo

2% ketoconazole shampoo,

2 – 3 times per week for 2 weeks

Alternative Regimen (Allergy / Resistance)

*Itraconazole 5mg/kg PO q24h

Fluconazole 6mg/kg PO q24h

Duration is based on mycological result/ type of treatment agent and clinical response. E.g.:

Trichophyton sp : 2-4 weeks

Microsporum sp : 8-12 weeks

Remarks & Clinical Comments:

Other recommendations: • For kerion, griseofulvin should be considered as first line unless Tricophyton has been cultured as the pathogen. Duration of treatment may be longer. • Contacts of patient may be treated with 2% ketoconazole shampoo 2 – 3 times per week for 2 weeks. • Surgical excision is to be avoided. • Topical therapy alone is not recommended for the management of tinea capitis. • Consider adding oral prednisolone in selected cases. *Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or oranges drinks). Avoid PPIs and H2 blockers.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.2 Tinea barbae

Same as treatment of tinea capitis

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.3 Tinea corporis/Tinea cruris/Tinea faciei

Common organism: Trichophyton Microsporum Epidermophyton

Preferred Regimen

Mild infections:

Topical imidazoles or allylamines cream/lotion. E.g.:

Clotrimazole 1% LA q12h

Miconazole 2% LA q12h

Ketoconazole 2% shampoo LA q12h

Terbinafine 1% LA q12h

Duration: Until clinical clearance with additional 2 weeks.

Extensive infections:

Terbinafine 250mg PO q24h for 2 weeks

*Itraconazole 200mg PO q24h for 2 weeks

Griseofulvin 500mg PO q12h or q24h for 4-6 weeks

Alternative Regimen (Allergy / Resistance)

Extensive Infections:

Fluconazole 100mg PO daily for 1-2 weeks

Fluconazole 200mg PO once weekly for 3-4 weeks

Remarks & Clinical Comments:

Other recommendations: • In patients with renal or hepatic impairment, caution should be exercised while prescribing systemic antifungals. • Terbinafine clearance is significantly reduced in patient with renal impairment. Other systemic antifungals are preferred in these patients. • Topical nystatin should not be used in dermatophytosis as they are not effective against dermatophytes. *Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers. Antifungal therapy should be adjusted based on culture results and susceptibility findings.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.4 Tinea manuum/ Tinea pedis

Common organism: Trichophyton Microsporum Epidermophyton

Preferred Regimen

First line:

Topical antifungals as mentioned in tinea corporis for 4-8 weeks

Resistant cases:

Terbinafine 250mg PO q24h for 2-4 weeks

*Itraconazole 200mg PO q24h for 2-4 weeks

Griseofulvin 500mg PO q12h for 6-12 weeks

Alternative Regimen (Allergy / Resistance)

Resistant cases:

Fluconazole 150mg/week PO for 4 weeks

Remarks & Clinical Comments:

Other recommendations: ● Topical keratolytic agents can be used in conjunction with antifungals for hyperkeratotic type of tinea pedis/manuum. ● Potassium permanganate in 1:10,000 dilution wet dressings, applied for 20 min 2–3 times/day, may be helpful if vesiculation or maceration is present. ● Systemic antifungals can be prescribed as first line treatment in severe moccasin-type tinea pedis or severe recurrent tinea with blisters. *Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.5 Tinea unguium (onychomycosis)

Common organism: Trichophyton Microsporum Epidermophyton

Preferred Regimen

*Amorolfine 5% Nail Lacquer once weekly application

Duration:

Fingernails: 6 months

Toenails: 12 months

**Pulse itraconazole 200mg PO q12h for 1 week per month

Duration:

Fingernails: 2 months

Toenails: 3 months

Terbinafine 250mg PO q24h

Duration:

Fingernails: 6 weeks

Toenails: 12 weeks

Alternative Regimen (Allergy / Resistance)

Griseofulvin 500mg PO q12h

Duration:

Fingernails: 6 months

Toenails: 12 months

Fluconazole 150mg PO once weekly

Duration:

Fingernails: ≥ 3 months

Toenails: 6-12 months

Remarks & Clinical Comments:

*Amorolfine 5% Nail Lacquer is not indicated for children less than 12 years old. Patients with contraindications to systemic agents may consider topical antifungal agents. Diagnosis of onychomycosis should be confirmed with a KOH preparation test, culture, or PAS Stain. Empirical treatment is not recommended. **Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.6 Tinea versicolor

Common organism: Malassezia furfur Pityrosporum orbiculare

Preferred Regimen

First line: Topical treatment only

Selenium sulphide 2% shampoo;

Apply to affected areas 10 minutes before bathing, or

Dilute to 1:1 with water, apply and leave overnight (treat for 1-2 weeks)

Ketoconazole 2% shampoo, apply to affected areas 10 minutes before bathing

For face:

Topical imidazole for 4-6 weeks. E.g.: Miconazole 2% cream, clotrimazole 1% cream LA q12h

For recurrent or resistant cases:

*Itraconazole 200mg PO q24h for 1 week or 400mg single dose

Fluconazole 300mg PO weekly dose for 2 weeks

Alternative Regimen (Allergy / Resistance)

Alternative for selenium sulphide and ketoconazole shampoo:

Sulfur preparation

Salicylic solution

Remarks & Clinical Comments:

Recommendations: Ketoconazole shampoo or selenium sulphide shampoo can be used once every two to four weeks for approximately six months in order to try and prevent recurrence. *Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (e.g.: Cola or orange drinks). Avoid PPIs and H2 blockers.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.7 Candidiasis

Common organism: Candida albicans

Preferred Regimen

Mild cutaneous candidiasis:

Topical imidazole q12h until clear. E.g.:

Miconazole 2% cream

Clotrimazole 1% cream

Extensive cutaneous candidiasis:

*Itraconazole 200mg PO q24h for 1 week

Alternative Regimen (Allergy / Resistance)

Extensive cutaneous candidiasis:

Fluconazole 100mg PO q24h for 1 week (in severe and immunocompromised patients)

Remarks & Clinical Comments:

Treatment of sexual partner is advisable in case of recurrent infection. *Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.8 Subcutaneous Fungal Infections

Lymphocutaneous and Cutaneous Sporotrichosis / Chromoblastomycosis

Preferred Regimen

*Itraconazole 200mg PO q12h until all lesions have resolved

(usually for a total of 3–6 months)

Alternative Regimen (Allergy / Resistance)

For patients not able to tolerate itraconazole:

Terbinafine 500mg PO q12h

Fluconazole 400mg q24h

Remarks & Clinical Comments:

In some immunocompromised condition such as AIDS, longer treatment may be necessary. Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV Patients section. *Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers. **Avoid azole in pregnancy

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.9 Systemic sporotrichosis

(pulmonary, osteoarticular, meningeal, or disseminated sporotrichosis)

Preferred Regimen

Amphotericin B deoxycholate 0.7-1mg/kg IV q24h for 2 weeks

*Amphotericin B (lipid formulation) 3–5mg/kg q24h for 2 weeks

Followed by;

**Itraconazole 200mg PO q12-24h for at least of 12 months duration

* In pregnancy and breastfeeding:**

Terbinafine 500mg PO q12h

Alternative Regimen (Allergy / Resistance)

In pregnancy and breastfeeding:**

Amphotericin B deoxycholate 0.7-1mg/kg IV q24h for 2 weeks

*Amphotericin B (lipid formulation) 3–5mg/kg q24h for 2 weeks

Remarks & Clinical Comments:

In some immunocompromised condition such as AIDS, longer treatment may be necessary. Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV Patients section. *Not listed in MOH Drug Formulary. Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers. *Avoid azole in pregnancy.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.10 Cutaneous fungal infection in immunocompromised patients

Refer to treatment of disseminated fungal infection in Infections in Immunocompromised Patients - Opportunistic Infections in HIV patients section. Skin biopsy for histopathological examination (HPE) and culture are advised before commencing treatment.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.11 Aspergillus sp, Scedosporium apiospermum, Lomentospora prolificans and Fusarium sp infection

Preferred Regimen

Voriconazole 6mg/kg IV q12h for 2 doses,

followed by 4mg/kg IV q12h

Alternative Regimen (Allergy / Resistance)

Amphotericin B (deoxycholate) 0.7–1mg/kg q24h

*Amphotericin B (lipid formulation) 3–5mg/kg q24h

Remarks & Clinical Comments:

For Lomentospora prolificans, consider surgical debridement and reduction of immunosuppression. Consider IV to PO switch once clinically improving and can tolerate orally. *Not listed in MOH Drug Formulary.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.12 Cryptococcal skin infections

Preferred Regimen

Fluconazole 400mg PO q24 h

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

6.13 Peniciliosis, disseminated Histoplasmosis and disseminated Cryptococcosis

Refer to treatment of disseminated fungal infection in Infections in Immunocompromised Patients - Opportunistic Infections in HIV patients section.

NAG MOH Malaysia 2024Official Site

AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

7.1 Herpes Simplex Infections

7.1.1 Non-genitalia

Preferred Regimen

Acyclovir 400mg PO q8h

Alternative Regimen (Allergy / Resistance)

*Valacyclovir 1g PO q12h

*Famciclovir 500mg PO q12-24h

Remarks & Clinical Comments:

Duration: 7 days Vesiculation for trunk and limbs: Potassium permanganate in 1:10,000 dilution wet dressings, applied for 20 min 2–3 times/day, may be helpful. Vesiculation for head and neck: Normal saline wet dressings, applied for 20 min 2–3 times/day, may be helpful. *Not listed in MOH Drug Formulary.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

7.1 Herpes Simplex Infections

7.1.2 Genitalia

Refer to Sexually Transmitted Infections section.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

7.2 Varicella zoster (Chickenpox)

Preferred Regimen

Immunocompetent:

Acyclovir 800mg PO 5 times daily for 7 days

Immunocompromised:

Acyclovir 10mg/kg IV q8h for 7 days (change to oral once there is an improvement)

Remarks & Clinical Comments:

Advisable to start treatment early within 48 hours. Vesiculation for trunk and limbs: Potassium permanganate in 1:10,000 dilution wet dressings, applied for 20 min 2–3 times/day, may be helpful. Vesiculation for head and neck: Normal saline wet dressings, applied for 20 min 2–3 times/day, may be helpful.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

7.3 Herpes zoster

Preferred Regimen

Refer to varicella zoster treatment.

Remarks & Clinical Comments:

Topical antiviral treatment is not recommended for herpes zoster. Vesiculation for trunk and limbs: Potassium permanganate in 1:10,000 dilution wet dressings, applied for 20 min 2–3 times/day, may be helpful. Vesiculation for head and neck: Normal saline wet dressings, applied for 20 min 2–3 times/day, may be helpful. Systemic antiviral treatment is recommended for all immunocompromised patients or for immunocompetent patients with the following criteria: 1. >50 years of age 2. Moderate or severe pain 3. Moderate or severe rash 4. Non-truncal involvement Advisable to start treatment early within 48-72 hours.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

8.1 Scabies

Common organism: Sarcoptes scabiei

Preferred Regimen

Apply benzyl benzoate emulsion 25% (EBB) from neck down and leave for 24 hours for 2-3 days

Apply permethrin 5% lotion/cream and leave for 8 hours

Repeat application after 1 week.

In pregnancy/Immunocompromised:

Apply permethrin 5% lotion/cream and leave for 8 hours.

Repeat application after 1 week.

Remarks & Clinical Comments:

Clothing and bedding of persons with scabies should be washed in hot water and dried.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

8.2 Head Lice

Common organism: Pediculus humanus capitis

Preferred Regimen

Apply permethrin 1% lotion to scalp for 10 minutes and wash off

Apply malathion 1% shampoo and leave for 15 minutes and wash off

Repeat application after 1 week.

Remarks & Clinical Comments:

Use special fine-toothed nit comb to reduce risk of re-infestation.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

6. FUNGAL INFECTIONS

8.3 Body Lice/Pubic Lice

Common organism: Pediculus humanus

Preferred Regimen

Apply malathion lotion 0.5% for 8-12 hours and wash off

Apply permethrin 1% cream to affected area for 10 minutes and wash off

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AdultA14SKIN & SOFT TISSUE INFECTIONS

9. SURGICAL INFECTIONS

9.1 Breast Infections

9.1.1 Breast Abscess/Mastitis

Common organism: Staphylococcus aureus

Preferred Regimen

Cloxacillin 1-2g IV q6h

Cefazolin 1-2g IV q8h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 625mg PO q8h

Ampicillin/sulbactam 750mg PO q12h

Antibiotic allergy:

Clindamycin 600mg IV/PO q8h

Remarks & Clinical Comments:

Surgical drainage is the mainstay of management. Duration: 10 to 14 days but shorter antibiotic duration (5 to 7 days) can be considered if adequate source control and local wound management has shown clinical improvement. Refer to Appendix 3 for antibiotic allergy.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

9. SURGICAL INFECTIONS

9.1 Breast Infections

9.1.2 Other Complicated Breast Infections

(E.g.: foreign body-related infections)

Empirical antibiotics are not recommended. Early referral to primary/plastic surgery for input.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

9. SURGICAL INFECTIONS

9.2 Burn-Related Infections

9.2.1 Severe Burn and High-risk Group

Preferred Regimen

Cefazolin 1-2g IV q8h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate 1.2g IV q8h

Ampicillin/sulbactam 3g IV q6-8h

Remarks & Clinical Comments:

Antibiotics may be necessary in certain high-risk groups: • Inhalation injury • Immunocompromised patients (E.g.: extreme age groups (elderly and children), diabetes mellitus, obesity, impaired immunity) • Delay in burn wound excision • Mechanical ventilation • Total body surface area (TBSA) burn > 20%

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AdultA14SKIN & SOFT TISSUE INFECTIONS

9. SURGICAL INFECTIONS

9.3 Orofacial-Related Infections

9.3.1 Odontogenic Infections

Refer to Oral/Dental Infections section

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AdultA14SKIN & SOFT TISSUE INFECTIONS

9. SURGICAL INFECTIONS

9.3 Orofacial-Related Infections

9.3.2 Non-odontogenic Infections

Pyogenic infections of the face and neck. E.g.: facial cellulitis/abscess

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h

Alternative Regimen (Allergy / Resistance)

Antibiotic allergy:

Clindamycin 600mg IV/PO q8h

Remarks & Clinical Comments:

Surgical drainage +/- debridement is the mainstay of therapy. Refer to Otorhinolaryngology Infections section for deep neck space abscess.

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AdultA14SKIN & SOFT TISSUE INFECTIONS

9. SURGICAL INFECTIONS

9.3 Orofacial-Related Infections

9.3.3 Musculoskeletal Infections

Cartilage infections - pinna (external ear/auricle) and nose

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q8h

Alternative Regimen (Allergy / Resistance)

Ampicillin/sulbactam 3g IV q6-8h

For cartilage penetration:

Ciprofloxacin 400mg IV BD

Ciprofloxacin 500mg PO BD

Remarks & Clinical Comments:

Duration: 5-7 days Refer to Otorhinolaryngology Infections section for Malignant Otitis Externa.

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AdultA15TRAUMA RELATED INFECTIONS

1. ABDOMINAL

1.1 Abdominal Injury

Patients who do not require surgery: No antibiotics required Patients who require surgery: Antibiotic choice will be based on organs involved. Duration: • If hollow viscus injury is repaired early (within 12 hours): Antibiotics should be continued for no more than 24 hours. • If hollow viscus injury is repaired late (> 12hours): Antibiotics should be limited to 7 days. • If hollow viscus injury is incompletely repaired or clinical signs persist in patients with traumatic abdominal injury: Antibiotics can be used for more than 7 days.

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AdultA15TRAUMA RELATED INFECTIONS

2. ORAL & DENTAL

2.1 Spreading infections and infections of fascial spaces (with/without systemic signs)

Traumatic wound infection is usually caused by endogenous organisms rather than exogenous. Common organisms: Viridans Streptococci Staphylococci Prevotella intermedia Peptostreptococcus Eubacterium Fusobacterium nucleatum

Preferred Regimen

Benzylpenicillin 2-4MU IV q4-6h

PLUS

Metronidazole 500mg IV q8h

Amoxicillin/Clavulanate 1.2gm IV q8h

Cefuroxime 1.5g IV q8h

PLUS

Metronidazole 500mg IV q8h

Alternative Regimen (Allergy / Resistance)

If not responding to first-line antibiotics:

Ceftriaxone 1-2g IV q24h

PLUS

Metronidazole 500mg IV q8h

Antibiotic allergy:

Clindamycin 300-450mg PO q6h or 600-900mg IV q8h

Remarks & Clinical Comments:

Empirical antibiotics are started. Incision and drainage are advised and the antibiotic is changed in accordance with the result of culture and sensitivity. Continue intravenous therapy for 1 to 2 days following successful abscess drainage, then switch to oral therapy. Refer to Appendix 6 for IV to PO switch.

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AdultA15TRAUMA RELATED INFECTIONS

3. ORTHOPAEDIC

3.1 Simple Soft Tissue Injuries

3.1.1 Minor Wounds with Simple Repair

Gunshot wound and superficial stab wound of extremities.

Antibiotic not required. Good wound care is required: • Debridement of devitalized tissue • Irrigation and remove all foreign material • Hemostasis • Closure of the wound when safe and appropriate

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AdultA15TRAUMA RELATED INFECTIONS

3. ORTHOPAEDIC

3.2 Complex Soft Tissue Injuries

3.2.1 Penetrating and puncture-type wounds / Complex soft tissue wounds without open fractures

Common organisms: Staphylococcus aureus Beta-haemolytic streptococci Polymicrobial infection

Preferred Regimen

Cloxacillin 2g IV q6h

MAY ADD

*Metronidazole 500mg IV q8h

MAY ADD

**Gentamicin 5mg/kg IV q24h

Alternative Regimen (Allergy / Resistance)

Cefazolin 2g IV q6-8h

Cefuroxime 1.5g IV q8h

PLUS

*Metronidazole 500mg IV q8h

Amoxicillin/Clavulanate 1.2g IV q8h

Remarks & Clinical Comments:

*Metronidazole: In soil/rust contamination or heavy machinery. Gentamicin: If there’s extensive skin and soft tissue involvement (for gram negative coverage). Tetanus immunization should be given in addition to appropriate antibiotics. Antibiotic therapy should be tailored to the susceptibility of deep wound cultures isolates once available. Duration: depends on the extent of infection. • For combat-related isolated soft tissue injury, antibiotic duration of 1 - 3 days may be adequate. • For severe penetrating injuries, especially those involving joints and/or tendons, antibiotics must be given for at least 5 days.**

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AdultA15TRAUMA RELATED INFECTIONS

3. ORTHOPAEDIC

3.2 Complex Soft Tissue Injuries

3.2.2 Plantar Wounds

E.g.: penetrating injury through the plantar foot Common organisms: Pseudomonas aeruginosa Staphylococcus aureus

Preferred Regimen

*Piperacillin/tazobactam 4.5g IV q6-8h

Cefepime 2g IV q8h

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 750mg PO q12h

Remarks & Clinical Comments:

Tetanus immunization should be given in addition to appropriate antibiotics. Antibiotic therapy should be tailored to the susceptibility of deep wound cultures isolates once available. Duration: total 7-14 days following adequate surgical debridement if no evidence of established osteomyelitis upon presentation. If there is osteomyelitis, refer to the Orthopaedic Infection section – Bone and Joint Infections: Osteomyelitis. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 -4 hours).

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AdultA15TRAUMA RELATED INFECTIONS

3. ORTHOPAEDIC

3.3 Compound fractures / Open fractures

Compound fractures: Antibiotics are administered as prophylaxis within 3 hours of injury.

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AdultA15TRAUMA RELATED INFECTIONS

3. ORTHOPAEDIC

3.3 Compound fractures / Open fractures

3.3.1 Gustilo Type I & II Fractures

Common organisms: Gram positive organisms

Preferred Regimen

Cefazolin 2g IV q8h

Cefuroxime 1.5g IV q8h

MAY ADD

*Metronidazole 500mg IV q8h

Remarks & Clinical Comments:

Pre-debridement and post-debridement cultures are not representative of actual infection. Duration: • Gustilo Type I: stop after 24 hours • Gustilo Type II: discontinue after 24 hours to 48 hours *Metronidazole: In soil/rust contamination or heavy machinery.

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AdultA15TRAUMA RELATED INFECTIONS

3. ORTHOPAEDIC

3.3 Compound fractures / Open fractures

3.3.2 Gustilo Type III Fractures

Common organisms: Gram positive organisms Gram negative organisms

Preferred Regimen

As per Gustilo Type I & II fractures

PLUS

Gentamicin 5mg/kg IV q24h

MAY ADD

*Metronidazole 500mg IV q8h

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h

MAY ADD

*Metronidazole 500mg IV q8h

Presence of water contamination

Fresh water contamination:

**Piperacillin/tazobactam 4.5g IV q6-8h

Sea water contamination:

**Piperacillin/tazobactam 4.5g IV q6-8h

PLUS

Doxycycline 100mg PO q12h

Remarks & Clinical Comments:

Pre-debridement and post-debridement cultures are not representative of actual infection. Duration: Gustilo Type III: 24 hours after wound closure or up to a maximum of 72 hours (whichever is earlier) *Metronidazole: In soil/rust contamination or heavy machinery. **Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3-4 hours).

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AdultA15TRAUMA RELATED INFECTIONS

4. CENTRAL NERVOUS SYSTEM

4.1 Cranial Trauma

4.1.1 Open Fracture / Penetrating Injuries without Dura Breach

Preferred Regimen

Cefazolin 2g IV q8h

Cefuroxime 1.5g IV q8h

MAY ADD

Metronidazole 500mg IV q8h

Alternative Regimen (Allergy / Resistance)

Amoxicillin clavulanate 1.2g IV q8h

Remarks & Clinical Comments:

Duration: Until 24 hours after wound closure or 72 hours total (whichever occurs first). The use on antibiotic here is pre-emptive antibiotics and should not be continued beyond a short course.

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AdultA15TRAUMA RELATED INFECTIONS

4. CENTRAL NERVOUS SYSTEM

4.1 Cranial Trauma

4.1.2 Penetrating Injuries with Dura Breach

Preferred Regimen

Ceftriaxone 2g IV q12h

PLUS

Metronidazole 500mg IV q8h

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AdultA15TRAUMA RELATED INFECTIONS

5. RESPIRATORY

5.1 Chest Trauma

5.1.1 Penetrating Chest Trauma Requiring Chest Tube Insertion

Preferred Regimen

Cefazolin IV 2g q8h for 1 day (prophylaxis)

Remarks & Clinical Comments:

Prophylactic antibiotic use is not indicated in patients with blunt chest trauma (non-penetrating trauma).

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AdultA16TROPICAL INFECTIONS

1. TYPHOID FEVER

1.1 Mild

Preferred Regimen

Ceftriaxone 50-75mg/kg/24h (2-4 g/day) IV q12-24h

Cefotaxime 40-80mg/kg/24h (2-6 g/day) IV q8-12h

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 500-750 mg PO q12h

Azithromycin 20mg/kg PO q24h (maximum 1 g q24h)

(Refer susceptibility testing result before considering alternative treatment regime)

Remarks & Clinical Comments:

Notifiable disease IV to PO switch is recommended once symptoms improve based on susceptibility testing result. Refer Appendix 6 . Duration: minimum 7-14 days Notes: longer duration of fever defervescence may be observed in patients treated with cephalosporin.

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AdultA16TROPICAL INFECTIONS

1. TYPHOID FEVER

1.2 Moderate to Severe

Severe sepsis or shock, gastrointestinal bleeding, intestinal perforation, encephalopathy, metastatic infection or other complications.

Preferred Regimen

Ceftriaxone 50-75mg/kg/24h (2-4 g/day) IV q12-24h

Cefotaxime 40-80mg/kg/24h (2-6 g/day) IV q8-12h

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 400mg IV q8-12h

Azithromycin 20mg/kg IV q24h (maximum 1 g q24h)

(Refer susceptibility testing result before considering alternative treatment regime)

Remarks & Clinical Comments:

Consult ID Physician for complicated/severe typhoid or drug-resistant typhoid. Duration: 10-14 days. Once symptoms improve, may consider IV to oral antibiotic switch based on susceptibility testing results. Refer Appendix 6 . In case of persistent fever after 5-7 days of effective antimicrobial therapy, re-evaluate and repeat culture. Longer duration of antimicrobial therapy may be necessary in the presence of metastatic or deep seated infection. Adjunctive corticosteroid may be considered after consultation with an ID physician in severe typhoid with delirium, obtundation, coma or shock. In such cases, administer IV dexamethasone 3 mg/kg followed by 8 doses of 1 mg/kg every q6h for 48 hours. Monitor patients closely as corticosteroid use is associated with increased risk of gastrointestinal bleeding and perforation.

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AdultA16TROPICAL INFECTIONS

1. TYPHOID FEVER

1.3 Extensively Drug Resistant

Resistant to ceftriaxone, ciprofloxacin, amoxicillin, chloramphenicol and cotrimoxazole.

Preferred Regimen

Meropenem IV 1g q8h

Remarks & Clinical Comments:

Consult ID Physician

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AdultA16TROPICAL INFECTIONS

1. TYPHOID FEVER

1.4 Chronic Carrier

Individual excreting Salmonella Typhi in stool/urine for > 1 year after onset of acute illness.

Preferred Regimen

Ciprofloxacin susceptible:

Ciprofloxacin 750mg PO q12h for 4 weeks

Ciprofloxacin resistant:

Trimethoprim/Sulphamethoxazole 160/800mg PO q12h for 6 weeks

Remarks & Clinical Comments:

Consult ID Physician

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AdultA16TROPICAL INFECTIONS

2. CHOLERA

Vibrio cholerae

Preferred Regimen

Doxycycline 300mg PO single dose

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 1g PO single dose

*Azithromycin 1g PO single dose

*Erythromycin Ethylsuccinate 800mg PO q12h for 3 days

Remarks & Clinical Comments:

Notifiable disease Indication for antibiotics: • Oral or intravenous hydration is the mainstay of cholera treatment. • Antibiotics are recommended for patients with moderate to severe illness who are hospitalized. *Azithromycin / Erythromycin is recommended in pregnancy.

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AdultA16TROPICAL INFECTIONS

3. RICKETTSIAL DISEASES

3.1 Mild

Preferred Regimen

Doxycycline 100mg PO q12h for 5 days

Alternative Regimen (Allergy / Resistance)

*Azithromycin 500mg PO q24h for 3 days

Remarks & Clinical Comments:

*Azithromycin is recommended in pregnancy.

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3. RICKETTSIAL DISEASES

3.2 Moderate to Severe

ARDS, septic shock, myocarditis, meningoencephalitis, hepatitis, renal failure.

Preferred Regimen

Azithromycin 500mg IV q12h on Day 1 then 500mg q24h for 6 days

PLUS

Doxycycline 200mg PO q12h Day 1 then 100mg q12h for 6 days

Remarks & Clinical Comments:

IV to PO switch is recommended once symptoms improve.

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4. BRUCELLOSIS

4.1 Systemic Disease

In the absence of focal disease due to spondylitis, neurobrucellosis or endocarditis.

Preferred Regimen

Doxycycline 100mg PO q12h for 6 weeks

PLUS

Gentamicin 5mg/kg/24h IM/IV for the first 7 days

Streptomycin 1g (5mg/kg) IM q24h for 2-3 weeks

Alternative Regimen (Allergy / Resistance)

Doxycycline 100mg PO q12h for 6 weeks

PLUS

Rifampicin 600-900mg (15mg/kg) PO q24h for 6 weeks

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4. BRUCELLOSIS

4.2 Pregnancy

Preferred Regimen

< 36 weeks gestation:

Rifampicin 600-900mg (15 mg/kg) PO q24h for 6 weeks

PLUS

Trimethoprim/Sulphamethoxazole 160/800mg PO q12h for 6 weeks

> 36 weeks gestation:

*Rifampicin 600-900mg (15mg/kg) PO q24h monotherapy until delivery.

Remarks & Clinical Comments:

*After delivery, to continue combination therapy as in non-pregnant regime.

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4. BRUCELLOSIS

4.3 Spondylitis

Preferred Regimen

Doxycycline 100mg PO q12h for at least 12 weeks

PLUS

Rifampicin 600-900mg (15mg/kg) PO q24h for at least 12 weeks

PLUS

Gentamicin 5mg/kg/24h IM/IV for the first 7 days

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4. BRUCELLOSIS

4.4 Endocarditis

Refer to Cardiovascular Infection section for Infective Endocarditis.

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4. BRUCELLOSIS

4.4 Neurobrucellosis

Preferred Regimen

Ceftriaxone 2g IV q12h for 4-6 weeks

PLUS

Doxycycline 100mg PO q12h for 6 weeks

PLUS

Rifampicin 600-900mg 15mg/kg PO q24h for at least 12 weeks

Alternative Regimen (Allergy / Resistance)

Doxycycline 100mg PO q12h for 12 weeks

PLUS

Rifampicin 600-900mg 15mg/kg PO q24h for at least 12 weeks

PLUS

Trimethoprim/Sulphamethoxazole 160/800mg PO q12h for 12 weeks

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4. BRUCELLOSIS

4.5 Chemoprophylaxis

For high-risk laboratory exposures to Brucella isolates

Preferred Regimen

Doxycycline 100mg PO q12h for 3 weeks

PLUS

Rifampicin 600mg for 3 weeks

Alternative Regimen (Allergy / Resistance)

*Doxycycline 100mg PO q12h for 3 weeks

PLUS

Trimethoprim/Sulphamethoxazole 160/800mg PO q12h for 3 weeks

* In case of exposure to Brucella abortus RB51 strain (which is resistant to rifampicin)

Remarks & Clinical Comments:

PEP should be offered as soon as high-risk laboratory exposure to Brucella isolates has been identified and be administered for up to six months following exposure. PEP may be considered for low risk exposure in pregnant women or immunosuppressed individuals (consult ID physician).

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5. LEPTOSPIROSIS

5.1 Mild

Preferred Regimen

Doxycycline 100mg PO q12h for 5-7 days

*Amoxicillin 25-50mg/kg/day PO in 3 divided doses or 500mg PO q8h for 7 days

Alternative Regimen (Allergy / Resistance)

*Azithromycin 500mg PO q24h for 3 days

Remarks & Clinical Comments:

Notifiable disease Early antibiotic therapy is recommended if leptospirosis is clinically suspected following recent high risk exposure (E.g.: flood, recreational activities). *Amoxicillin or azithromycin is recommended for pregnant women.

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5. LEPTOSPIROSIS

5.2 Moderate to Severe

Leptospiral pulmonary syndrome, multiorgan involvement, sepsis.

Preferred Regimen

*Benzylpenicillin 1.5MU IV q6h

Alternative Regimen (Allergy / Resistance)

*Ceftriaxone 2g IV q24h

Remarks & Clinical Comments:

*IV to PO switch is recommended once symptoms improve. Refer to Appendix 6 . Duration: 7 - 10 days There is insufficient evidence to support routine use of corticosteroid therapy. However, use of steroids as an adjunct to antibiotic therapy may be considered in severe leptospirosis with pulmonary haemorrhage (consult ID physician).

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5. LEPTOSPIROSIS

5.3 Chemoprophylaxis

Consider on a case-by-case basis in short periods of high risk exposure (E.g.: soldiers, outbreak response personnel involved in occupational/recreational activities (see comments))

Preferred Regimen

Doxycycline 200 mg PO weekly starting 1-2 days before exposure and continue during exposure

Remarks & Clinical Comments:

The mainstay prevention of leptospirosis is avoidance of direct contact with contaminated water or environment. Evidence on effectiveness of prophylactic antibiotics in prevention of leptospirosis is limited. Routine use of prophylactic antibiotics is not recommended. In situations of major outbreaks, the use of mass chemoprophylaxis is not recommended. Notes: Doxycycline is contraindicated in pregnancy and breastfeeding. Gastrointestinal side effects are common.

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6. TETANUS

Clostridium tetani

Preferred Regimen

Metronidazole 500mg IV q6-8h for 7-10 days

PLUS

Human Tetanus Immunoglobulin single dose 500IU IM

PLUS

Anti-tetanus toxoid vaccine IM (initiate age appropriate active immunization at a different site)

Alternative Regimen (Allergy / Resistance)

Benzylpenicillin 100,000-200,000 unit/kg/24h IV q6h for 7-10 days

PLUS

Human Tetanus Immunoglobulin single dose 500IU IM

PLUS

Anti-tetanus toxoid vaccine IM (initiate age appropriate active immunization at a different site)

Remarks & Clinical Comments:

Notifiable disease All patients with tetanus should undergo wound debridement to eradicate spores and necrotic tissue. *IV to oral switch is recommended once symptoms improve.

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7. MELIOIDOSIS

7.1 Intensive Therapy

Preferred Regimen

Mild to Moderate (Non-Neurological):

Ceftazidime 2g IV q6h

Severe (persistent bacteremia or severe sepsis):

Meropenem 1g IV q8h

Imipenem 50mg/kg/24h IV q6h or maximum 4g/day

(usual dose : 500mg IV q6h; 1g q6-8h for severe infection)

Neuromelioidosis and adults with septic shock requiring intensive care support and with augmented renal clearance:

Meropenem 2g IV q8h

For neurological melioidosis, osteomyelitis and septic arthritis, genitourinary infection including prostatic abscesses, and skin and soft tissue infections,

MAY ADD

*Trimethoprim 80mg/ Sulphamethoxazole 400mg

• < 40 kg: 160/800mg PO q12h

• 40-60kg: 240/1200mg PO q12h

• > 60kg: 320/1600 mg PO q12h

Refer to comment section for graded dosing.

(Consider de-escalate to ceftazidime once symptoms improve/stable)

Remarks & Clinical Comments:

*Add on Trimethoprim/Sulphamethoxazole in eye, neurologic, testicular, prostatic, pericardium, bone and joint melioidosis. To minimise side effects, trimethoprim/sulfamethoxazole should be introduced gradually, except in neurological melioidosis or critically ill patients with multifocal abscess where full dosage is administered as soon as feasible. The graded dose will take 1-2 weeks to reach full dose, depending on circumstances. Cessation of intravenous therapy and commencement of timed eradication phase is set only once the full planned dose of trimethoprim/sulfamethoxazole is reached. Refer below for graded dosing of trimethoprim/sulfamethoxazole: Body weight > 60kg with normal renal function • Day 1- Day 2: 40/200mg (½ tab of 80/400mg) q12h • Day 3 - Day 4: 80/400mg (1 tab of 80/400mg) q12h • Day 5 - Day 6: 160/800mg (2 tabs of 80/400mg) q12h • Day 7 - Day 8: 240/1200mg (3 tabs of 80/400mg) q12h • Day 9 onwards: 320/1600mg (4 tabs of 80/400mg) q12h Body weight <60kg or impaired renal function Consult ID physicians to determine graded dosing schedule. All patients who undergo intensive therapy and eradication therapy for melioidosis require counselling regarding monitoring for adverse effects of medication Drainage of abscesses should be attempted wherever appropriate such as prostatic, empyema and pericardium. Duration of intensive therapy: • Skin and soft tissue infection, mild pneumonia: 2 weeks • Bacteraemia with no foci: 2-4 weeks • Complicated pneumonia, prostatic, deep-seated foci, septic arthritis: 4 - 6 weeks • Osteomyelitis: 6 weeks • Neurologic/CNS: 8 weeks • Arterial infection e.g.: mycotic aneurysm: 8 weeks Use clinical judgement to guide prolongation of intensive phase in patients with slow clinical improvement or persistent bacteraemia. Carbapenems are potentially neurotoxic especially at higher doses. Use with caution in patients with renal impairment or CNS disorders.

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7. MELIOIDOSIS

7.2 Eradication Therapy

Preferred Regimen

Trimethoprim 80mg / Sulphamethoxazole 400mg

• < 40 kg: 160/800mg PO q12h

• 40-60kg: 240/1200mg PO q12h

• > 60kg: 320/1600 mg PO q12h

Alternative Regimen (Allergy / Resistance)

Amoxicillin/clavulanate

• < 60kg: 1250mg (2 tabs of 625 mg) PO q8h

• > 60kg: 1875mg (3 tabs of 625 mg) PO q8h

Remarks & Clinical Comments:

Duration of eradication therapy: • Osteomyelitis, neurologic/CNS: 24 weeks • Others: minimum 12 weeks

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8. MALARIA

Refer to the Ministry of Health's latest Garis Panduan Pengurusan Malaria Knowlesi di Malaysia and Director General of Health Circular Letter 14/2016 .

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9. FILARIASIS

Refer to the World Health Organization's Guideline on Alternative Mass Drug Administration Regimens to Eliminate Lymphatic Filariasis .

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AdultA17URINARY TRACT INFECTIONS

1. ASYMPTOMATIC BACTERIURIA

Urine bacterial growth ≥105cfu/mL in 2 serial samples in women or a single sample in men without urinary tract infection (UTI) symptoms.

Preferred Regimen

Treatment is NOT indicated unless:

• *In pregnant women

• **Prior to transurethral resection of prostate (TURP) or urological procedures breaching the mucosa

Remarks & Clinical Comments:

*Duration of treatment for pregnant women: 5 days. **Duration of treatment for preemptive treatment of ABU before TURP or urological procedures breaching the mucosa: 3-5 days. Follow up urine culture is not necessary prior to the procedure. Do not screen or treat asymptomatic bacteriuria in the following conditions: • Women without risk factors • Post-menopausal women • Patients with indwelling or suprapubic catheters and nephrostomy tubes • Elderly institutionalized patients • Patients with dysfunctional and/or reconstructed lower urinary tracts • Patients with renal transplants • Patients prior to arthroplasty surgeries • Patients with history of recurrent urinary tract infections

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2. UNCOMPLICATED UTI

Infection confined to the bladder in afebrile men and women. Common organisms: Escherichia coli Klebsiella pneumoniae Streptococcus agalactiae

Preferred Regimen

*Nitrofurantoin 50-100mg PO q6h (macrocrystals, immediate-release)

Nitrofurantoin 100mg PO q12h (monohydrate/macrocrystals, sustained-release)

Amoxicillin/clavulanate 625mg PO q8h

Ampicillin/sulbactam 375-750mg PO q12h

Alternative Regimen (Allergy / Resistance)

Cephalexin 500mg PO q12h

Cefuroxime 250-500mg PO q12h

**Fosfomycin 3g PO x 1 dose

(Unlikely to be effective for gram negative other than E. coli. Other gram-negative infection carry FosA hydrolase gene that may deactivate fosfomycin and leads to clinical failure)

Remarks & Clinical Comments:

Duration: 3-5 days. The treatment duration is counted starting from the first day of effective antibiotic therapy. *Avoid Nitrofurantoin if GFR < 30ml/min and pregnant women at third trimester. Trimethoprim-sulfamethoxazole is not recommended to be used as empirical therapy for UTI as the local resistance rates of E. coli and Klebsiella pneumoniae has been consistently > 30%. Amoxicillin or ampicillin should not be used for empirical treatment given the relatively poor efficacy and the very high prevalence of antimicrobial resistance. **If confirmed ESBL E.coli sensitive to fosfomycin, to give every 48hrs for total 3 doses.

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3. COMPLICATED UTI

Common organisms: Escherichia coli Klebsiella pneumoniae Enterococcus faecalis Streptococcus agalactiae Pseudomonas aeruginosa

Infection beyond the bladder in men and women • Pyelonephritis • Febrile or bacteremic UTI • Catheter-associated (CAUTI) • Prostatitis (Refer to section prostatitis) For patients with sepsis due to complicated UTI, please refer to the section on Urosepsis.

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3. COMPLICATED UTI

Common organisms: Escherichia coli Klebsiella pneumoniae Enterococcus faecalis Streptococcus agalactiae Pseudomonas aeruginosa

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q6-8h

Ampicillin/sulbactam 1.5-3g IV q6h

MAY ADD

*Aminoglycoside

Alternative Regimen (Allergy / Resistance)

Cefuroxime 750mg-1500mg IV q8h

Ceftriaxone 2g IV q24h

*Ceftazidime 2g IV q8h

Remarks & Clinical Comments:

Duration: 5-7 days *Consider using ceftazidime or adding aminoglycoside (E.g.: amikacin) in patients at risk of Pseudomonas aeruginosa infection. Consider stepping down to oral antibiotics based on culture and sensitivity result once patient is afebrile for > 48 hours, clinically improving and able to take oral medications. Pyuria alone in the absence of other symptoms is not diagnostic of CA-UTI and treatment is not indicated.

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4. UROSEPSIS

Systemic urinary tract infections that may lead to organ dysfunction. Common organisms: Escherichia coli Klebsiella pneumoniae Enterococcus faecalis Streptococcus agalactiae Pseudomonas aeruginosa

Preferred Regimen

Urosepsis WITHOUT shock:

Ceftriaxone 2g IV q24h

Cefotaxime 2g IV q8h

Urosepsis WITH shock:

*Piperacillin-tazobactam 4.5g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Urosepsis WITHOUT shock:

Ceftazidime 2g IV q8h

Cefepime 2g IV q8h

Urosepsis WITH shock:

**Meropenem 1g IV q8h

**Imipenem 500mg IV q6h

Remarks & Clinical Comments:

Early source control should be the mainstay of treatment for urosepsis. For patients with urosepsis, broad-spectrum antibiotic therapy should be selected based on the following criteria: 1. Severity of illness 2. Patient-specific risk factors for resistant organisms 3. Local antibiogram, if available 4. Other patient-specific consideration (allergies, immunocompromised state, elderly, etc) Duration: 7 days or more For patients with abscesses in the urinary tract or bacterial prostatitis, please refer to respective sections for the duration and choice of antibiotics. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). **Carbapenem should be reserved for urosepsis with risk factors for MDR or ESBL-producing organism.

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5. BALANITIS

5.1 Bacterial Balanitis

Common organisms for Aerobic infection: Staphylococcus sp. Streptococcus sp

Preferred Regimen

Aerobic infection:

Mupirocin ointment 2% LA q12h to q8h for 7-10 days

MAY ADD

Amoxicillin/clavulanate 625 mg PO q8h for 7 days (for severe cases)

Anaerobic infection:

Amoxicillin/clavulanate 625 mg PO q8h for 7 days

Remarks & Clinical Comments:

Antibiotics are only indicated if there is clinical suspicion or evidence of bacterial balanitis. Please refer to the Sexually Transmitted Infection section for antibiotic choice if there is evidence of STI

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5. RECURRENT UTI

5.1 Prophylaxis for Recurrent Urinary Tract Infections (rUTIs)

Preferred Regimen

Nitrofurantoin 50-100mg PO ON (macrocrystals)

Nitrofurantoin 100mg PO ON (monohydrate/macrocrystals, dual release)

Cephalexin 250mg PO ON

Alternative Regimen (Allergy / Resistance)

Trimethoprim/sulfamethoxazole 80/400mg PO ON

Trimethoprim 100mg PO ON

Remarks & Clinical Comments:

Antimicrobial prophylaxis is indicated if non-antimicrobial measures (behavioral and personal hygiene) fail. Continuous prophylaxis for 3-12 months or intermittent post-coital prophylaxis (a single dose of antibiotics taken within the 2-hour period after sexual intercourse). Long-term use of nitrofurantoin has been associated with an increased risk of rare adverse effects, including pulmonary toxicity, hepatotoxicity and peripheral polyneuropathy.

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5. BALANITIS

5.2 Candida Balanitis

Common organisms for Aerobic infection: Candida sp.

Preferred Regimen

Clotrimazole cream 1% q12h for 7-14 days

Miconazole cream 2% q12h 7-14 days

For severe cases,

MAY ADD

Fluconazole 200 mg PO q24h

MAY ADD

Hydrocortisone cream 1% q12h (if marked inflammation is present)

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7. SURGICAL INFECTIONS

7.1 Renal Abscess

7.1.1 Pyonephrosis/ Perinephric Abscess/ Renal Abscess

Common organisms: Escherichia coli Klebsiella pneumoniae Staphylococcus aureus Enterococcus faecalis Streptococcus agalactiae Pseudomonas aeruginosa Less common organism: Mycobacterium tuberculosis

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q6-8h

Ampicillin/sulbactam 3g IV q6h

MAY ADD

Gentamicin 5mg/kg IV q24h

Alternative Regimen (Allergy / Resistance)

Cefuroxime 750mg-1500mg IV q8h

Ceftriaxone 2g IV q24h

MAY ADD

Gentamicin 5mg/kg IV q24h

Remarks & Clinical Comments:

Source control by surgical or pigtail drainage is the mainstay of treatment. Duration of antibiotics: 2-3 weeks (of both IV and oral). The duration of antibiotics should be determined by the extent of infection, source control, clinical response, resolution on follow-up imaging, and normalization of inflammatory markers. Consider stepping down to oral antibiotics based on culture and sensitivity results once the patient is afebrile for >48 hours, clinically improving and able to take oral medications.

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7. SURGICAL INFECTIONS

7.2 Bacterial Prostatitis

7.2.1 Acute Bacterial Prostatitis (ABP)

Common organisms: Escherichia coli Klebsiella pneumoniae Enterococcus faecalis Pseudomonas aeruginosa

Preferred Regimen

Outpatient treatment:

Ciprofloxacin 500-750mg PO q12h

Inpatient treatment:

*Ciprofloxacin 400mg IV q12h

Amoxicillin/clavulanate 1.2g IV q6h

Ampicillin/sulbactam 3g IV q6h

MAY ADD

**Aminoglycoside

Alternative Regimen (Allergy / Resistance)

Outpatient treatment:

Trimethoprim/Sulfamethoxazole 160/800mg PO q12h

Inpatient treatment:

Cefuroxime 750mg-1500mg IV q8h

Ceftriaxone 2g IV q24h

**Ceftazidime 2g IV q8h

Remarks & Clinical Comments:

Obtain urine culture before starting treatment. Duration of antibiotics: Minimum 10-14 days or up to 6 weeks depending on the severity and clinical response. Consider stepping down to oral antibiotics based on culture and sensitivity results once the patient is afebrile for >48 hours, clinically improving and able to take oral medications. If the patient has risk factors for sexually transmitted disease, please refer to Sexually Transmitted Infection section for choice of antibiotics. *PO ciprofloxacin may be considered for patients who are not septic and can tolerate orally, as it has similar bioavailability to the IV formulation. **Consider using ceftazidime or adding aminoglycoside (E.g.: amikacin) in patients at risk of Pseudomonas aeruginosa infection.

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7. SURGICAL INFECTIONS

7.2 Bacterial Prostatitis

7.2.2 Chronic Bacterial Prostatitis (CBP)

Chronic or recurrent urogenital symptoms that persist for at least 3 months.

Preferred Regimen

Ciprofloxacin 500-750mg PO q12h for 4-6 weeks

Alternative Regimen (Allergy / Resistance)

Trimethoprim/ Sulfamethoxazole 160/800mg PO q12h for 4-12 weeks

*Doxycycline 100mg PO q24h for 10 days

**Azithromycin 500mg PO q24h for 3 weeks

Remarks & Clinical Comments:

Referral to urologist is recommended to differentiate from chronic non-bacterial prostatitis before starting antibiotics. Ciprofloxacin, despite the high resistance rates of uropathogens, is recommended as first line agent in the empirical treatment of chronic bacterial prostatitis due to the favorable pharmacokinetic properties. *Doxycycline - Only for C. trachomatis or mycoplasma infections **Azithromycin - Only for Trichomonas vaginalis infections

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7. SURGICAL INFECTIONS

7.3 Testicular/Scrotal Infection

7.3.1 Epididymo-orchitis (non-STD related)

Common organisms: Escherichia coli Klebsiella pneumoniae Enterococcus faecalis Pseudomonas aeruginosa

Preferred Regimen

Levofloxacin 500mg PO q24h for 10 days

Alternative Regimen (Allergy / Resistance)

Ciprofloxacin 500mg PO q12h for 10-14 days

Trimethoprim/ Sulfamethoxazole 160/800mg PO q12h for 10 days

Ofloxacin 200mg PO q12h for 14 days

Remarks & Clinical Comments:

If patient has risk factors for sexually transmitted disease or sexually active, please refer to Sexually Transmitted Infection section for choice of antibiotics.

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7. SURGICAL INFECTIONS

7.3 Testicular/Scrotal Infection

7.3.2 Testicular/ Scrotal Abscess

Common organisms: Escherichia coli Klebsiella pneumoniae Enterococcus faecalis Pseudomonas aeruginosa

Preferred Regimen

Amoxicillin/clavulanate 1.2g IV q6-8h

Ampicillin/sulbactam 3g IV q6h

Alternative Regimen (Allergy / Resistance)

Cefuroxime 750mg-1500mg IV q8h

Ceftriaxone 2g IV q24h

*Ciprofloxacin 400mg IV q12h

Remarks & Clinical Comments:

Surgical drainage is the mainstay of treatment. *Ciprofloxacin 500-750mg PO q12h may be considered as outpatient treatment for small testicular abscesses that are not suitable for drainage.

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7. SURGICAL INFECTIONS

7.3 Testicular/Scrotal Infection

7.3.3 Fournier’s Gangrene

Common organisms: Escherichia coli Klebsiella pneumoniae Enterococcus faecalis Pseudomonas aeruginosa Staphylococcus spp Anaerobes

Preferred Regimen

*Piperacillin-tazobactam 4.5g IV q6-8h

Alternative Regimen (Allergy / Resistance)

Ceftriaxone 2g IV q24h

PLUS

Metronidazole 500mg IV q8h

**Meropenem 1g IV q8h

**Imipenem 500mg IV q6h

Remarks & Clinical Comments:

Aggressive surgical debridement is the mainstay of treatment. Antibiotics are given until source control is achieved. *Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). **Carbapenem should be reserved for Fournier’s Gangrene with risk factors for MDR or ESBL-producing organisms.

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7. SURGICAL INFECTIONS

7.3 Testicular/Scrotal Infection

7.3.3 Fournier’s Gangrene

Common organisms: Escherichia coli Klebsiella pneumoniae Enterococcus faecalis Pseudomonas aeruginosa Staphylococcus spp Anaerobes

Reference: 1. The WHO AWaRe (Access, Watch, Reserve) antibiotic book. Technical document. 9 December 2022 2. National Institute for health and care excellence. Summary of antimicrobial prescribing guidance – managing common infections. August 2021. Approved by APC Jan 2022. Review Jan 2024 3. South Australian Health Urinary Tract Infections (adult) Empirical Treatment Clinical Guidelines 2022. 4. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases 5. The Sanford Guide to Antimicrobial Therapy 2023 6. IDSA Clinical Practice Guideline for the Management of Asymptomatic Bacteriuria in Adults 2019 7. Diagnosis, Prevention, and Treatment of Catheter- Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America 8. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 50, Issue 5, 1 March 2010 9. Hooton TM. Urinary tract infections and asymptomatic bacteriuria in pregnancy. In: UpToDate, Gupta K (Ed), UpToDate, Waltham, MA. Last updated Jun 15, 2022. 10. Scottish Intercollegiate Guidelines Network (SIGN). Management of suspected bacterial urinary tract infection in adults. Edinburgh: SIGN; September 2022. 11. European Academy of Dermatology and Venereology, 2022. 12. EAU Guidelines. Urological Infections – Limited Update March 2025. 13. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA): 2025 Guideline on Management and Treatment of Complicated Urinary Tract Infections: Executive Summary. Infectious Diseases Society of America (IDSA); 2025.

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