Abia Antimicrobials Guidelines Version 1.

0 Updated July 10, 2020 Page 1

 ABIA ANTIMICROBIAL
TREATMENT GUIDELINES
Version 1.0 (2020)

Abia Antimicrobial Treatment Guidelines

Version 1.0 (2020)

Marjorie Bash Foundation

Department of Public Health, Abia State Ministry of Health
Initiative for Public Health Advancement and Research
Pfizer Inc (Grant #56154673)

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 2
Table of Contents
Contributors (in alphabetical order) ......................................................................................................................... 4
Foreword .................................................................................................................................................................. 5
INTRODUCTION ................................................................................................................................................... 6
Chapter 1 GASTROINTESTINAL & INTRA-ABDOMINAL INFECTIONS ....................................................... 8
Chapter 2 CENTRAL NERVOUS SYSTEM INFECTIONS ................................................................................ 11
Chapter 3 CARDIOVASCULAR INFECTIONS .................................................................................................. 12
Chapter 4 RESPIRATORY TRACT INFECTIONS ............................................................................................. 13
Overview of Coronavirus Disease 2019 (COVID-19) ....................................................................................... 14
Chapter 5 SKIN & SOFT TISSUE INFECTIONS ................................................................................................ 18
Chapter 6 BONES AND JOINT INFECTIONS .................................................................................................... 19
DIABETIC FOOT INFECTIONS AND ULCERS ........................................................................................... 19
Chapter 7 EYE INFECTIONS ............................................................................................................................... 22
Chapter 8 EAR INFECTIONS ............................................................................................................................... 23
Chapter 9 URINARY TRACT INFECTIONS ...................................................................................................... 24
Chapter 10 SEXUALLY TRANSMITTED INFECTIONS................................................................................... 25
Chapter 11 PARASITIC DISEASES ..................................................................................................................... 29
Chapter 12 FUNGAL INFECTIONS..................................................................................................................... 30
Chapter 13 SURGICAL ANTIBIOTIC PROPHYLAXIS (SAP) .......................................................................... 31
Chapter 14 OBSTETRICS AND GYNAECOLOGICAL INFECTIONS ............................................................. 32
Chapter 15 NEONATAL INFECTIONS ............................................................................................................... 36
Chapter 16 OLDER CHILDREN........................................................................................................................... 39
Chapter 17 GUIDELINES FOR OPTIMIZING USE OF KEY ANTIMICROBIALS ......................................... 44
Chapter 18 PREVENTIVE STRATEGIES FOR HEALTHCARE ASSOCIATED INFECTIONS ..................... 52
Chapter 19 DOSAGE GUIDE FOR COMMONLY USED ANTIMICROBIAL AGENTS ................................. 54
ABBREVIATIONS ........................................................................................................................................... 57

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 3
Contributors (in alphabetical order)
Bassey Ewa Ekeng, University of Calabar Teaching Hospital
Benedict Edelu, University of Nigeria Teaching Hospital
Chidinma Okoro, FloxyIyke Clinics
Chidiebere P. Echieh, University of Calabar Teaching Hospital
Chika Okoro, World Health Organization
Chinenye Onodugo, University of Nigeria Teaching Hospital
Chukwuemeka Oluoha, Abia State University
Gerald Ottih, Nigerian Christian Hospital
Kelechi Eguzo, Marjorie Bash Foundation
Kenechukwu Iloh, University of Nigeria Teaching Hospital
Kenneth Nkuma-Udah, Mother of Mercy Clinics
Kenneth Nwokocha, Abia State Ministry of Health
Kingsley Nnah, Nigerian Christian Hospital
Nnamdi Amaechi, Federal Medical Center – Umuahia
Ogochukwu Onwujekwe, University of Nigeria Teaching Hospital
Omotola Funsho, University of Nigeria Teaching Hospital
Peace Ndukwe, Mecure Laboratories
Uwaoma Fidelis Ewa, University of Nigeria Teaching Hospital
Victor Williams, Eswantini Ministry of Health
Vivien MesembeOtu, University of Calabar Teaching Hospital

Editors: Kelechi Eguzo, MBBCh, MPH, GPO, PhD (C) and Chinenye Onodugo, B. Pharm, Pharm D, M.
Pharm, PhD

Suggested citation:
Abia Antimicrobial Stewardship Project. 2020. Abia State Antimicrobial Treatment Guidelines for Common
Infections. [Version 1.0]. Aba: Marjorie Bash Foundation. [Date Accessed]. Available from:
www.mbashcollege.org

Selected references
1. Egwuenu A, Obasanya J, Okeke I, Aboderin O, Olayinka A, Kwange D, et al. Antimicrobial use and
resistance in Nigeria: situation analysis and recommendations, 2017. Pan African Medical Journal.
2018;8(2):18.

2. Eguzo K, Oluoha O, Nnah K, Nwokocha K, Onodugo C, Ottih G, Ndukwe P. Using blended-learning

approach to improve education on antimicrobial stewardship for healthcare providers in Abia State
(Nigeria): an action research. Pfizer Inc, through grant #56154673

3. National Center for Disease Control. 2016. National Treatment Guidelines for Antimicrobial Use in
Infectious Diseases. Ministry of Health and Family Welfare. New Delhi. [Accessed February 6, 2020].
Available from http://pbhealth.gov.in/AMR_guideline7001495889.pdf

4. Pharmaceutical Services Programme. 2019. National Antimicrobial Guideline. Ministry of Health

Malaysia. Selangor. [Accessed February 6, 2020]. Available from
https://www.pharmacy.gov.my/v2/sites/default/files/document-upload/national-antimicrobial-guideline-
2019-full-version-3rd-edition_0.pdf

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 4
Foreword

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 5
INTRODUCTION
Over 50% of Nigerians on daily medications take antibiotics.1 Globally and in Nigeria, there is an increase in the
development of resistance to antibiotics by bacteria. Although resistance is a natural phenomenon of microbes, the
rising prevalence and spread of antibiotic resistance in recent years are largely due to inappropriate use of
antibiotics both in health facilities and the community1. Evidence from Abia State (Nigeria) shows that up to 22%
of cases of malaria are treated with antibiotics, especially when primary anti-malarial is not effective, although
this inappropriate use is known to promote antimicrobial resistance2.

Factors which contribute to inappropriate antibiotics use in Nigeria include self-medication, patronage of over-
the-counter (OTC) vendors, weak restrictions on antibiotics advertisement and limited antibiotics-related
knowledge among healthcare providers. The impact of rising resistance includes rising cost of treatment,
increasing morbidity and mortality in the community. Infections with drug resistant organisms are known to be
associated with poor clinical and economic outcomes of drug therapy.3 Antimicrobial stewardship programmes
(ASPs) can reduce antimicrobial resistance (AMR), but this practice is not common in Abia State, like the rest of
Nigeria. These guidelines have been developed as part of an ASP program in Abia State, which is jointly led by
Marjorie Bash Foundation (MBF), Department for Public Health (Abia State Ministry of Health; DPH-SMOH)
and Initiative for Public Health Advancement and Research (IPHAR)

These clinical guidelines have been adapted from an earlier version that was developed by the National Centers
for Disease Control (India, 2016)3. Inputs from local experts, including doctors, nurses, pharmacists and laboratory
scientists have been used to adapt the Indian guideline to a Nigerian context. As part of the Abia State
Antimicrobial Stewardship Project, these guidelines will be deployed through an appropriate smartphone
application, to facilitate appropriate antibiotics use. These guidelines provide general recommendations for
appropriate antibiotic use in specific infectious diseases and are not a substitute for clinical judgment. When
prescribing antimicrobials, keep these in mind:
• Carefully consider if an antimicrobial is truly warranted in the given clinical situation
• Consult local antibiograms when selecting empiric therapy (this will be available through the App)
• Include a documented indication, appropriate dose, route and the planned duration of therapy in all
antimicrobial drug orders
• When possible, obtain microbiological cultures before the administration of antibiotics
• Reassess therapy after 24-72 hours to determine if antibiotic therapy is still warranted or effective for the
given organism or clinical situation. Reassess based on relevant clinical data, microbiologic and/or
radiographic information
• Assess for de-escalation as appropriate based on available microbiology culture and susceptibility results

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 6
How to use these guidelines?
These guidelines are organized by organ systems and clinical specialties. It lists appropriate therapy for common
infectious as first line (usually chosen due to less side effects and high clinical effectiveness) and second-line or
alternative drugs. It also includes appropriate behavioral modifications (e.g. counseling for handwashing), where
appropriate. The first section focuses on recommendations for adult patients, followed by paediatrics.

The recommendations are presented as tables. Row 1 lists the clinical condition. Row 2 lists the most likely agents
responsible for this condition, row 3 lists the first line antibiotics while row 4 lists the alternative antibiotic. The
alternate antibiotic may be prescribed in cases when the first line antibiotics cannot be used due to hypersensitivity
or patient’s clinical parameters or non-availability of first line drugs. The table is divided into following
subsections: Gastrointestinal and intra-abdominal Infections; Central nervous system Infections; Cardiovascular
infections; Skin and Soft Tissue Infections; Respiratory Tract Infections; Urinary Tract Infections; Obstetrics and
Gynaecological Infections; Bone and Joint Infections; Eye Infections; Ear Infections; Fungal Infections, Sexually
Transmitted Infections; Parasitic Diseases, Neonatal Infections; Older Children and Surgical Antibiotic
Prophylaxis (SAP). These guidelines are available on the Spectrum Clinical Decisions App
(https://play.google.com/store/apps/details?id=com.spectrum&hl=en_CA), which is available for Android and
iOS.

This document is dynamic, as our knowledge of antibiotics is evolving. The content of these treatment guidelines
will undergo a process of continuous review. Comments or suggestions for improvement are welcome. These
suggestions may be sent to: [email protected]. The Abia Antimicrobial Stewardship Project
acknowledges the support of several partners, including Pfizer Inc, Obong University, Abia State Ministry of
Health, Spectrum Clinical Decisions App, Marjorie Bash College of Health Sciences and Technology, amongst
many others.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 7
Chapter 1 GASTROINTESTINAL & INTRA-ABDOMINAL INFECTIONS
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Acute Viruses Not recommended None * Oral rehydration is the
Gastroenteritis (Noroviruses, cornerstone of treatment
Rotavirus), * Antibiotic therapy may
Entero-toxigenic prolong carriage state of
& Entero- salmonellosis
pathogenic E. coli *Screen patient for HIV if
recurrent acute gastroenteritis
within the last few weeks.

Food poisoning S. aureus, Azithromycin 1gm Oral Give antibiotics ONLY if the
B .cereus, stat patient is febrile with signs of
C. botulinum OR invasive disease (e.g., gross
SalmonellaSpp Ciprofloxacin 500mg BD hematochezia, leukocytes on
for 3 days fecal smear), if symptoms have
Note: antibiotics can lead persisted for more than one
to Clostridium difficile week or are severe (i.e., more
colitis than eight liquid stools per day)

Cholera V.cholerae Doxycycline 300mg Oral Azithromycin Rehydration (oral/IV)

stat 1gm Oral stat or is the mainstay of treatment
Azithromycin Oral in Ciprofloxacin
children (20mg/kg) and 500mg BD for 3 Antibiotics are adjunctive
pregnant women (1g) days therapy.
Bacterial dysentery Shigella sp., Ciprofloxacin 500mg Oral Azithromycin 1g For Campylobacter the drug of
Campylobacter, BD for 5 days or oral OD x 3days choice is azithromycin.
Non- typhoidal cefixime 10-15 mg/kg/day
salmonellosis x 5 days
Shiga toxin Antibiotic not Antibiotic use associated with
producing E. coli recommended development of hemolytic
uremic syndrome.

Amoebic dysentery E. histolytica Metronidazole 400mg Oral Tinidazole 2gm

TDS for 7-10 days Oral OD for 3
days

Giardiasis Giardia lamblia Metronidazole 400mg oral Tinidazole 2 gm

TID x 7-10 d oral x
1 dose

Enteric fever S. Typhi, Amoxycillin 500m TDS x Cotrimoxazole A single Widal test is NOT
S. Paratyphi A 5 days 960 mg BD for 2 diagnostic; Malaria parasites
Or weeks also raise the titres for Widal
Ciprofloxacin 500mg BD Or test.
x 5 days Ofloxacin 400mg *Blood and stool cultures are
BD X 7 days recommended

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 8
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Biliary tract Enterobacteriaceae Amoxicillin/clavulanate Ceftriaxone 1gm IV Surgical or endoscopic
infections (E. coli, Klebsiella 1.2gm IV q8h OD drainage to be considered if
(cholangitis, sp.) OR there is biliary obstruction,
cholecystitis) PLUS/MINUS Cefoperazoe- as antibiotics will not enter
Metronidazole 500mg IV Sulbactam 3gm IV bile in the presence of
q8h 12hourly obstruction.

PLUS/MINUS If high local prevalence of

Metronidazole ESBL producing E. coli,
500mg IV q8h Klebsiella sp. Strains, start
For 7-10 days with Meroponem as first line
antibiotic, and then de-
escalated once antibiotic
susceptibility is known
Hospital C. difficile Metronidazole 400 mg
Severe disease: start
acquired oral TDS for 10 days
Vancomycin 250
diarrhea mg oral 6h
empirically.
Spontaneous Enterobacteriaceae Cefotaxime 2gm IV q8h Meropenem 1g IV Duration: 7 days
bacterial (E. coli, Klebsiella OR q8h
Peritonitis sp.) Ceftriaxone 1gm IV
(primary) q12h
Spontaneous Ceftriaxone 1gm IV Meropenem 1g IV Duration: 7 days
bacterial q12h q8h
Peritonitis OR
(Cirrhotic) Cefotaxime 2gm IV q8h
Secondary Enterobacteriaceae Cefuroxime 1.5gm IV q8h Ampicillin/sulbacta Duration: 4-7 days
peritonitis, (E. coli, Klebsiella PLUS m 1.5-3gm IV q6- In very sick patients, if
Intra-abdominal sp.),Bacteroides Metronidazole 500mg IV 8h required, addition to cover for
abscess/ GI (colonic q8h OR yeast (Fluconazole IV 800
perforation perforation), Amoxicillin/clavul mg loading dose day 1,
Anaerobes anate 1.2gm IV q8h followed by 400 mg2nd day
OR onwards) & and for
Piperacillin/tazobac Enterococcus (vancomycin
tam 4.5gm IV q6- /teicoplanin) may be
8h contemplated for 7-10 days
Diverticulitis E. coli Amoxycillin- Clavulanate Ciprofloxacin
Mild- Anaerobes 625mg TDS for 7 days 500mg BD +
Outpatient Metronidazole
treatment 400mg TDS for 7
days
Abdominal E. coli and Amoxicillin/clavulanate Meropenem 1g IV Duration: 4-7 days (if
trauma anaerobes 1.2gm IV q8h q8h adequate source control, no
Stab Wound OR PLUS delay in surgical intervention
Suspected bowel Ceftriaxone 1gm IV q12h Metronidazole and patient has rapid clinical
or 500mg IV q8h recovery).
solid organ injury
Abdominal Polymicrobial Cefazolin 2gm IV q8h Ciprofloxacin * Piperacillin/tazobactam: If
trauma: PLUS Metronidazole 400mg IV q12h given as q8h, to be given as
(Severe / Infected 500mg IV q8h PLUS extended infusion (over 3-4
wound) OR Clindamycin 450- hours).
*Piperacillin/tazobactam 600mg IV q8h
4.5gm IV q6-8h
Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 9
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Diverticulitis Gram- Negative Amoxicillin/clavulanic Non-severe penicillin
moderate Bacteria Acid 625mg PO q8h for 5 allergy:
(Not undergoing a Anaerobes days Meropenem 1g IV q8h
source control OR PLUS
procedure) Ampicillin/sulbactam IV Metronidazole 500mg IV
3gm q6h q8h
Diverticulitis Gram- Negative *Piperacillin/tazobactam **Severe penicillin Piperacillin/tazobacta
Severe infection Bacteria 4.5gm IV q6-8h for 7 allergy: m: If given as q8h, to
/life threatening Anaerobes days Ciprofloxacin 400mg IV be given as extended
infection) PLUS q12h infusion (over 3-4
Metronidazole 500mg IV PLUS hours).
q8h Metronidazole 500mg IV
q8h

Post necrotizing Entrobacteriaceae, *Piperacillin/tazobactam Meropenem 1g IV q8h In very sick patients,

pancreatitis: Enterococci, S. aureus, 4.5gm IV q6-8h for 7 PLUS if required,
infected S. epidermidis, days addFluconazole IV
pseudocyst; anaerobes, Candida PLUS Metronidazole 500mg IV 800 mg loading dose
pancreatic abscess sp. Metronidazole 500mg IV q8h day 1, followed by
q8h 400 mg 2nd day
onwards AND
OR Enterococcus
Cefoperazone- Sulbactam (vancomycin
3gm IV 8 hourly in /teicoplanin) may be
severe infections contemplated
For 7-10 days
Liver Abscess Polymicrobial Ceftriaxone 1-2gm IV OD Piperacillin/tazobactam Ultrasound guided
Enterobacteriaceae PLUS Metronidazole 4.5gm IV q6h drainage should be
(esp. Klebsiella sp.), 500mg IV TID, then OR attempted when
bacteroides, 800mg oral TID for 2 Ciprofloxacin 400mg IV practical and feasible.
enterococci, weeks q12h 14 days PLUS
Entamoeba histolytica, Metronidazole 500mg IV
Yersinia enterocolitica TID
Amoebic liver Entamoeba histolytica Metronidazole 400mg PO -May switch to PO
abscess q6h or 15mg/kg IV q12h when clinical
(max 4g/day) for10 days improvement occurs
Peptic ulcer Helicobacter Pylori Triple Therapy Bismuth Quadruple Proton Pump
disease PPI PO q12h regimen: Inhibitor (PP1)
PLUS PPIPO q12h Omeprazole 20 mg
Amoxicillin 1gm PO PLUS PO q12h
q12h Bismuth subsalicylate Pantoprazole 40 mg
PLUS 300mg OR PO q12h
Clarithromycin 500mg Bismuth subcitrate 120- Lansoprazole 30 mg
PO q12h 300mg PO q6h PO q12h
OR PLUS Esomeprazole 20 mg
Metronidazole 400mg PO Tetracycline PO q12h
q12h hydrochloride 500mg PO Rabeprazole 20 mg
q6h PO q12h
PLUS
Metronidazole 400mg PO Duration of therapy =
q8h 14 days
Pancreatitis No antibiotics Ensure bowel rest,
Mild- moderate fluid hydration, and
pain control.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 10
Chapter 2 CENTRAL NERVOUS SYSTEM INFECTIONS

Condition Likely Causative Empiric (presumptive) Alternative Comments

Organisms antibiotics/First Line /Second Line
Acute bacterial S. pneumoniae, Ceftriaxone 100mg/kg (max For penicillin Antibiotics should be
Meningitis H. influenzae, 4g/day), given as a short IV resistant strains started as soon as the
Neisseria infusion in Normal Saline Vancomycin 1gm IV possibility of bacterial
meningitides OR q12h PLUS meningitis becomes
Cefotaxime Ceftriaxone 2gm IV evident, ideally within
2 g IV 4-6hourly q12h 30 minutes.
10-14 days treatment OR
OR Cefotaxime 2-4gm IV Adjuvant treatment
Benzylpenicillin 4MU IV q8h with corticosteroids has
q4-6h for 10-14 days. OR been shown to reduce
Meropenem 1g IV mortality among adults
q8h with infections caused
by S. pneumoniae.

Meningitis Staphylococcus Meropenem 1g IV 8 May need intrathecal

Post-neurosurgery epidermidis, hourly therapy in severe cases
or Staphylococcus aureus, AND
Penetrating head Propionibacterium Vancomycin 15mg/kg IV 8
trauma acnes, Pseudomonas hourly
aeruginosa, For 14 days.
Acinetobacter
baumanii
Meningitis with S. pneumoniae, Ceftriaxone 100mg/kg (max Meropenem 1g IV Dexamethasone
basilar skull H. influenzae 4g/day), given as a short IV q8h 0.15mg/kg IV 6 hourly
fractures infusion in Normal Saline OR for 2-4days (1st dose
Chloramphenicol12.5 with or before first
For 14 days to 25 mg/kg IV q6h antibiotic dose)

Brain abscess, Streptococci, Ceftriaxone 100mg/kg (max Meropenem 1gm IV Exclude TB, Nocardia,
Subdural Bacteroides, 4g/day), given as a short IV 8hourly Aspergillus, Mucor
empyema Enterobacteriaceae, S. infusion in Normal Saline If abscess <2.5cm &
aureus OR patient neurologically
Cefotaxime stable, await response to
2 gm IV 4-6hourly antibiotics. Otherwise,
PLUS consider aspiration or
Metronidazole 1 gm IV surgical drainage, and
12hourly modify antibiotics as
per sensitivity of
Duration of treatment to be aspirated/drained
decided by clinical & secretions.
radiological response,
minimum two months
required.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 11
Chapter 3 CARDIOVASCULAR INFECTIONS

Condition Likely Causative Empiric (presumptive) Alternative Comments

Organisms antibiotics/First Line /Second Line

Infective Viridans Ampicillin/Sulbactam 3g Vancomycin 15mg/ Treatment can be

Streptococci, other IV q6h for 6 weeks kg IV 12 hourly modified once the
Endocarditis: Streptococci, OR (max 1g 12 hourly) blood culture result is
Enterococci Benzyl penicillin 4MU OR Teicoplanin known
Native valve
IV q4h (total 12mg/kg IV 12
(awaiting 24MU/24h) or 24MU IV hourly x 3 doses If there is a strong
continuously followed by 6 -12 possibility of
cultures)
PLUS mg once daily IV staphylococcal
Indolent Gentamicin 1mg/kg depending upon infection, (e.g. IV
IV/IM q8h severity drug abuse, infected
PLUS haemodialysis lines
Gentamicin 1mg/kg or pacemaker
IM or IV 8 hourly infection):
Duration: 4-6 weeks Cloxacillin 2gm IV
q4h PLUS
Gentamicin 1mg/kg
IM/IV q8h
Infective S. aureus (MSSA or Vancomycin 25-30 mg/ Daptomycin 6mg/kg Modify antibiotics
Endocarditis: MRSA) kg loading followed by IV once a day based on culture
Native valve Risk for gram- 15-20 mg/kg IV q12h AND results and complete
(awaiting negative bacilli (max 1g 12 hourly)/ Meropenem 1gm IV 4-6 weeks of
cultures) teicoplanin 12mg/kg IV q8h antibiotics
In Severe Sepsis 12 hourly x 3 doses Duration: 4-6 weeks
followed by 6 -12 mg
once daily IV
AND
Meropenem 1gm IV 8h
Duration: 4-6 weeks
Infective Vancomycin 15mg/kg Daptomycin can be Antibiotic choice as
Endocarditis: IV 12 hourly (maximum used in place of per sensitivity.
Prosthetic Valve 1gm 12 Vancomycin/
awaiting hourly)/Teicoplanin Teicoplanin for Guidance from
Cultures 12mg/kg IV 12 hourly x patients Infectious disease
3 doses followed by 6 - unresponsive to or specialist or
12 mg once daily IV intolerant of microbiologist is
depending upon severity Vancomycin/Teicop recommended.
+ lanin or with
Gentamicin 1mg/kg Vancomycin/Glycop
q12h IV eptide-resistant
isolates

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 12
Chapter 4 RESPIRATORY TRACT INFECTIONS
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Community S. pneumoniae, H. Mild to moderate cases Ceftriaxone 2 g IV If atypical pneumonia
acquired influenzae, Legionella, Amoxycillin- 500mg-1 g once daily + suspected, use*
Pneumonia E. coli, Klebsiella sp., S. TDS oral. [macrolide IV or PO Doxycycline 100mg BD
aureus If IV indicated, OR doxycycline 100 OR
amoxycillin-clavulanate mg PO bid] Azithromycin 500 mg
1.2 g IV TDS OR oral/IV OD
OR levofloxacin 750 mg *Instead of the empiric
Ceftriaxone 2g IV OD IV once daily + or alternative treatments
For severe cases ampicillin/sulbactam listed.
Amoxycillin-clavulanate 1.5-3 g IV q8h
1.2 g IV TDS Counsel on cough
OR hygiene and hand
Ceftriaxone 2g IV OD washing
Duration: 5-8 days
Lung abscess, S. pneumoniae, Amoxycillin/Clavulanate Clindamycin 600- Rule out TB if no
Empyema E. coli, 1.2gm IV q8h followed 900mg IV 8hourly response
Klebsiella sp., by 625mg PO q8h for and
Pseudomonas aeruginosa, 4-6 weeks Ampicillin/Sulbactam
S. aureus, anaerobes OR Ceftriaxone 2gm IV (1.5-3 gm IV q6h)
q24h OR
PLUS Piperacillin/Tazobact
Metronidazole 500mg IV am 4.5gm IV
q8hfollowed by 400mg q8hr for 4-6 weeks
PO q8h for 4-6weeks
Acute pharyngitis Viral Oral Penicillin v 500mg In case of penicillin Antibiotics are
(Sore throat) Group A ß-hemolytic BD allergy: Azithromycin recommended to reduce
Streptococci (GABHS), or 500mg OD for 5 days transmission rates and
Group C, G Amoxicillin 500 mg Oral or prevention of long term
Streptococcus, TDS for 10 days Benzathine penicillin sequaelae such as
12 MU IM stat rheumatic fever
Ludwig’s angina Polymicrobial Clindamycin 600 mg IV 8 Piperacillin- Duration based on
Vincent’s angina (Cover oral anaerobes) hourly or Tazobactam 4.5gm IV improvement
Amoxicillin-Clavulanate 6 hourly
1.2gm IV
Acute Usually viral, Amoxicillin500 mg q8h for Azithromycin500 mg Consider antibiotics if no
rhinosinusitis S. pneumoniae, 10 days OD for 3 days improvement in
H. influenzae, OR OR symptoms after seven
M. catarrhalis Amoxicillin/clavulanate Levofloxacin 500 mg days
625 mg q8h for 10 days OD for 10 to 14 days
OR
Cotrimoxazole 960mg BD
x 10 days
Acute bronchitis Viral Antibiotics not required Counsel on cough
hygiene, hydration and
handwashing
Acute bacterial S. pneumoniae Amoxicillin- clavulanate Azithromycin 500 mg
exacerbation of H. influenzae 1gm oral BD for 7 days oral OD × 3 days
COPD M. catarrhalis

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 13
Overview of Coronavirus Disease 2019 (COVID-19)
Background
The 2019-nCoV is a new strain of the virus that has not been previously identified in humans.
It was first reported to the World Health Organization (WHO) on December 31, 2019 in Wuhan, China. The biology,
clinical manifestations and treatment of COVID-19 are constantly evolving. Be sure to check the websites of the WHO
and other international agencies for current updates.

Microbiology
Coronaviruses are a large family of zoonotic viruses. COVID-19 virus is a Beta-coronavirus, related to the viruses that
cause SARS and MERS. COVID-19 is the name of the disease caused by the COVID-19 virus, also known as SARS-
CoV-2 virus. Incubation period is 4 days (median), but ranges from 2-14 days. Human coronaviruses cause infections
of the nose, throat and lungs. Concomitant viral or bacterial pathogens at presentation have not been widely described.
Secondary bacterial infection can occur, particularly in those receiving mechanical ventilation.

Transmission
Transmission occurs via droplets and fomites. Airborne spread is not known to occur outside of aerosol-generating
procedures. Fecal shedding has been identified but fecal-oral spread is not a driver of transmission
It is most commonly spread from an infected person through:
• Respiratory droplets that are spread when you cough or sneeze
• Close personal contact, such as touching or shaking hands
• Touching something with the virus on it, then touching your mouth, nose or eyes before washing your hands

Diagnosis
Current information indicates that symptoms may present themselves up to 14 days after exposure to the virus.
Symptoms are very similar to SARS, MERS and the flu. Patients present with cough, fever, myalgias and shortness of
breath. Symptoms can range from very mild to very severe.

What is the Nigerian national case definition for COVID-19

Suspected Case: Any person (including severely ill patients) with any of the following symptoms: fever, cough or
difficulty in breathing who within 14 days before the onset of illness had any of the following exposures:
• History of travel to any country with confirmed and ongoing community transmission of COVID-19 OR
• Close contact with a confirmed case of COVID-19 OR
• Exposure to a healthcare facility where COVID-19 case(s) have been reported
Probable case: A suspect case for whom testing for COVID-19 is inconclusive or for whom testing was positive
on a pan-coronavirus assay.
Confirmed case: A person with laboratory confirmation of SARS-CoV-2 infection with or without signs and
symptoms.

If you have a patient that matches the case definition above, please contact NCDC to arrange for sample collection and
testing on 0703 286 4444 or 0800-970 00010 (toll-free). You can find the information for State COVID-19 teams here:
https://covid19.ncdc.gov.ng/contact/

Disease Severity
Mild disease (80%) Severe disease (15%) Critical illness (5%)
Common • Dyspnea • Acute respiratory
• Fever (May be prolonged (7+ • Respiratory rate ≥ 30/min distress syndrome
days) and intermittent) • Reduced/decreased breath (ARDS), septic shock,
• Cough (new onset, continuous) sounds multiple organ
• Myalgia or fatigue • Dullness in chest dysfunction
• Dyspnea percussion
• Loss of taste or smell • Oxygen Saturation (SpO2)
Less Common <93% (<92% in children)
• Sore throat, Headache • PaO2/FiO2 <300
• Productive cough, Hemoptysis, • Lung infiltrates >50% of
• Nausea, Diarrhea lung field within 24-48 hrs
• Pneumonia may be present

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 14
Disease Progression and Predictive Features
Chest imaging often shows consolidation, ground-glass opacities, or bilateral infiltrates. Progression to ARDS occurs
late in the disease course at a median of 8 days after symptom onset. Children may have more mild presentations than
adults. Severe illness seems uncommon amongst children

Features associated with severe illness:

• Older age (>64), co-morbidities (e.g. poorly controlled diabetes, chronic kidney disease and liver disease)
• Elevated SOFA score, - Lymphocytopenia, elevated D-dimer and immunosuppression

Patient evaluation
ROTH SCORE
This observes how long it takes for a patient to take a breath while speaking
• Ask the patient to take a deep breath and count out loud from 1 to 30 in their native language.
• Count the number of seconds before they take another breath.
• 8 seconds = if the counting time is 8 seconds or less, this has a sensitivity of 78% and specificity of 71% for
identifying a pulse oximeter reading of <95%.
• 5 seconds = if the counting time is 5 seconds or less, sensitivity is 91
DO NOT USE THE ROTH SCORE WHEN CONSULTING OVER THE PHONE; THE ASSESSMENT CAN BE
WRONG!

Red Flag Symptoms

• Red flag symptoms which indicate that the patient needs urgent assessment
• severe breathlessness or difficulty breathing,
• pain or pressure in the chest,
• blue lips or face,
• history suggestive of shock (such as cold and clammy with mottled skin, new confusion, becoming difficult to
rouse, or significantly reduced urine output).
• Haemoptysis occurs in about 1% of covid-19 patients and seems to be a poor prognostic symptom.

Approach to clinical management

SYMPTOMS OF COVID-19

GREEN (Category 3) AMBER (Category 2) RED (Category 1)

• Non-productive cough • Mild to moderate chest • Severe shortness of breath
• No dyspnoea tightness/wheeze wheezing
• No Wheeze • Breathlessness – on walking one • Severe chest pains
• Mild flu like symptoms flight of stairs/ 50 metres • Extreme faintness or
• Fever better with • Faint/dizzy collapse
paracetamol • Significant headache • Signs of Sepsis
• Symptoms not significantly • Fever no better with paracetamol • Cardiac sounding symptoms
deteriorating • Significant reduction in fluid
intake/urine output
• Other clinical concerns

Note: The classification into categories 1-3 are based on the NHS, United Kingdom: https://www.pcrs-
uk.org/sites/pcrs-uk.org/files/resources/COVID19/Barnet-Primary-Care-Pathway-during-Covid19%20v1.0.pdf

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 15
 NEXT STEPS

GREEN (Category 3) AMBER RED (Category 1)

COMMUNITY FOLLOW UP (Category 2) • Patient is severely unwell
• Agree action plan as per clinical • See below • Ensure adequate protection (PPE) and
judgement – note that respiratory precautions
deterioration possible day 7-14 of • *ADL= • Admit patient to hospital and isolate
illness activities of • Inform hospital leadership and State
• Discuss self monitoring (Temperature, daily living COVID-19 team about COVID-19 risk
pulse oximeter, respiratory rate) (e.g. bathing) • Treat fever: Paracetamol
• Safety netting (advice to call if • Commence IV fluids once BP <
symptoms worsen 90/60mmHg.
Consider if at higher risk: • Start oxygen therapy at 10–15 L/min
• *Age>50 via face mask with reservoir bag
• *Comorbidities: Diabetes,
Hypertension, Cancer, COPD,

AMBER (Category 2); NEXT STEPS

Category 2A Category 2B Category 2C

Basic Assessment Basic Assessment Basic Assessment
• Completing full sentences • Completing full sentences • Completing full sentences
• No SOB or Chest Pain • Some SOB (new) • SOB on exertion (new)
• Able to do *ADLs • No Chest Pain • Mild chest tightness
• Able to get our bed • Able to do ADLS but lethargic • Able to do ADLs but
• Roth Score ≥8 second • Roth Score 6-8 seconds • lethargic
• Roth Score 6-8 seconds
Advanced Assessment Advanced Assessment
• Adults RR 14-20 • Adults RR 21-22 Advanced Assessment
• Adults HR 50-100 • Adults HR 100-110 • Adults RR 23-24
• Adults O2 Sats >96% • Adults O2 Sats >94% • Adults HR 110-130
• Adults O2 Sats ≥ 93

AMBER (Category 2); TREATMENT

Category 2A Category 2B Category 2C

• Treat fever: Paracetamol • Treat fever: Paracetamol • Treat fever: Paracetamol
• Commence IV fluids once • Commence IV fluids once BP < • Commence IV fluids once BP <
BP < 90/60mmHg. 90/60mmHg. 90/60mmHg.
• Do NOT give • Do NOT give prophylactic antibiotics • Do NOT give prophylactic
antibiotics
prophylactic antibiotics • Evaluate for secondary pneumonia
• • Evaluate for secondary pneumonia
Provide Safety Netting: • Provide Safety Netting: Advise to call
Advise to call clinic if clinic if symptoms are worse • Provide Safety Netting: Advise to
call clinic if symptoms are worse
symptoms are worse • Encourage self-monitoring
• Encourage self- (temperature, pulse oximeter & • Encourage self-monitoring
monitoring (temperature, respiratory rate) (temperature, pulse oximeter &
respiratory rate)
pulse oximeter & • If known Asthma/COPD do not use
respiratory rate) nebulizers. Increase use of SABA or • If known Asthma/COPD do not use
similar agents. nebulizers. Increase use of SABA or
similar agents.
Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 16
Patient under investigation process: A patient who meets guidelines should be immediately placed into a private
room and providers should follow contact, respiratory and eye protection. Contact your normal chain of command to
report a patient under investigation.

Any patient under investigation should be hospitalized, monitored for symptoms while waiting for testing confirmation.
Coronavirus patients are at high risk for developing secondary conditions like respiratory failure or acute respiratory
distress syndrome. Anyone who has more severe disease can decompensate quickly and should be offered early
supportive therapy.

Notes about hospitalization and treatment

• Hospitalization is not required for mild presentations. Patients should be aware of potential progression during the
second week of illness

• Supportive care is the only known effective therapy for COVID-19

➢ Use conservative fluid management when there is no evidence of shock
➢ Advanced organ support including hemodynamic support, mechanical ventilation, and renal replacement may
be necessary
➢ See 'Useful Resources' below for more information

• Antibiotics
➢ Antibiotics have no effect against the COVID-19 virus
➢ Give empiric antibiotics if sepsis is identified. Collect blood cultures, ideally before antibiotic therapy
➢ Give empiric antibiotics if secondary bacterial infection is suspected
➢ Empiric therapy should be de-escalated on basis of microbiology results and clinical judgment.

• Corticosteroids
➢ Dexamethasone 6mg daily (IV/Oral) improved outcome for patients who received oxygen therapy
(RECOVERY Trial, June 2020). This agent has not yet been approved for use in Nigeria.
➢ Do not routinely give systemic corticosteroids for COVID-19, unless other indications are present (e.g., COPD
exacerbation, oxygen therapy or septic shock)

Reassure patients: Review the patient under investigation guidelines with patients who are concerned they may have
the coronavirus. Confirm that unless they meet guidelines, they likely don't have the virus. People can stay healthy and
prevent the spread of infections by:
• Washing their hands often with soap and water for at least 20 seconds (i.e. sing ‘happy birthday’ song twice);
• Avoiding touching their eyes, nose or mouth with unwashed hands;
• Avoiding close contact with people who are sick;
• Coughing or sneezing into their sleeve and not your hands; and
• Staying home if they are sick to avoid spreading illness to others.

Infection Prevention and Control

Droplet / Contact Precautions
➢ Should be used for all suspected or confirmed COVID-19
➢ Gown, gloves, surgical mask, and protective eye wear/face shield within 2 meters of patient

Airborne Precautions (N95)

➢ Airborne Precautions (N95) in a negative pressure room should be used for any aerosol generating procedures
(AGPs)
➢ An N95 mask and protective eyewear/face shield should be used. If not available, use a surgical face mask
that covers the nose and mouth
➢ AGPs: endotracheal tube insertion, tracheotomy, bronchoscopy, nebulized therapy, aerosolized high-flow O2

The situation with COVID-19 is evolving. As such some of the information contained in this document might not be
relevant in certain situations. Be sure to consult authentic public health sources (e.g. http://covid19.ncdc.gov.ng/).
This guideline should not be substitute for sound clinical judgement.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 17
Chapter 5 SKIN & SOFT TISSUE INFECTIONS

Condition Likely Causative Empiric (presumptive) Alternative Comments

Organisms antibiotics/First Line /Second Line
Cellulitis Streptococcus Amoxicillin- Clavulanate Clindamycin 600- Treat for 5-7 days.
pyogenes(common), S. 1.2gm IV TDS/625 mg 900mg IV TDS/ 150-
aureus oral TDS 300mg PO q6-8h
OR OR
Ciprofloxacin 500mg PO Flucloxacillin 1gm IV
q12h q6h

Furunculosis S. aureus Amoxicillin- Clavulanate Clindamycin 600- Get wound/discharge

1.2gm IV/Oral 625 TDS 900mg IV TDS/ 150- cultures before starting
OR 300mg PO q6-8h antibiotics
Ciprofloxacin 500mg PO
q12h
Duration – 5-7 days
Necrotizing Streptococcus pyogenes, Piperacillin-Tazobactam Imipenem 1g IV q8h Early surgical
fasciitis S. aureus, anaerobes, 4.5gm IV q6h OR intervention crucial
Enterobacteriaceae OR Meropenem 1gm IV
(polymicrobial) Cefoperazone- Sulbactam q8h
3gm IV q12h AND
AND Clindamycin 600-
Clindamycin 600-900mg 900mg IV TDS
IV q8h Daptomycin
Duration 6mg/kg/day
depends on the progress
Fournier’s Escherichia coli Ceftriaxone 2gm IV q24h Ampicillin/sulbactam Aggressive surgical
Gangrene Klebsiella PLUS 3gm IV q6-8h debridement is
Proteus Metronidazole 500mg IV necessary to remove all
Enterococcus q8h OR necrotic tissue.
Pseudomonas Meropenem 1gm IV *Piperacillin/tazobacta
Anaerobes OR q8h m: If given as q8h, to be
*Piperacillin/tazobactam given as extended
4.5gm IV q6-8h infusion (over 3-4
hours).
Suppurative wound If there is surrounding As a monotherapy: Change antibiotics
infections, surgical cellulitis and/or systemic Cefuroxime 1.5gm IV accordingly after C&S
or traumatic symptoms are present: q8h result are available.
Ceftriaxone 2gm IV q24h PLUS *Topical antibiotics are
PLUS Metronidazole 500mg not recommended for
Metronidazole 500mg IV IV q8h treatment of wound
q8h infections as it may
PLUS/MINUS result in the emergence
Gentamicin 5mg/kg IV of resistant organisms.
q24h (If gram negative *Patient tetanus
organisms suspected or immunization status
known to be involved) should be assessed in all
cases.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 18
 Chapter 6 BONES AND JOINT INFECTIONS
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Acute S .aureus, Ceftriaxone 2g IV OD x 2 Piperacillin- Treat based on culture of
osteomyelitis Streptococcus weeks tazobactam blood/synovial
OR pyogenes OR 3.375gm IV q 6h fluid/bone biopsy
Septic arthritis Enterobacteriaceae Clindamycin 600mg1V/PO or Ampicillin-
q6h or metronidazole 500mg sulbactam 3gm Orthopedic Consultation
IV/PO q8h IV q 6h is essential for surgical
PLUS AND debridement
Ciprofloxacin 500mg IV /PO Clindamycin 600-
q12h 900mg IV TDS Duration: 4-8 weeks
Flucloxacillin 1gm IV q6h x (From initiation or
2 weeks last major
Followed with oral therapy debridement)
Cloxacillin-Flucloxacillin
500mg q8h x 6 weeks
OR
Amoxicillin/Clavulanic acid
1g q12h
Cephalexin 500mg q6h x 6
weeks
Prosthetic joint Coagulase negative Cloxacillin 2gm IV q4-6h Ceftriaxone 2g IV Duration: 2-6 weeks
infection staphylococci OR OD.
species Cefazolin 2gm IV q6-8h Rifampicin should be
Staphylococcus PLUS Add Vancomycin included if implant is in
aureus,
Streptococci Rifampicin 600mg PO q24h or 15-20mg/kg (actual situ.
species 450mg PO q12h body weight) IV q8-
Gram-negative 12h; not to exceed Ensure prompt culture
basilli 2gm/dose
Enterococcus,
Anaerobes
Polyarticular Ceftriaxone 2gm IV q24h for
Gonorrhoea 7days

DIABETIC FOOT INFECTIONS AND ULCERS

Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Mild Infections: Polymicrobial Amoxicillin/clavulanate Cephalexin 500mg Duration: 7 – 14 days
a. Local infection Streptococcus 625mgPO q8h PO q6h
involving skin & SC pyogenes, OR PLUS
tissues Staphylococcus Ampicillin/sulbactam 375- Metronidazole
aureus
b. Erythema, less Corynebacterium 750mg PO q12h 400mg PO q8h
than 2 cm around spp
the ulcer Proteus mirabilis,
c. No systemic signs Bacteroides spp
of infection

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 19
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Moderate Polymicrobial Ampicillin/sulbactam 3gm IV Cefazolin 2gm IV Duration: 7-14 days
Infections: Streptococcus q6-8h q8hrly Modify according to
a. Deep tissue pyogenes, If pseudomonas is suspected: PLUS clinical response. If
infection Staphylococcus **Piperacillin/tazobactam Metronidazole proven osteomyelitis or
aureus
b. Erythema more 3.375gm IV q6-8h 500mg IV q8h margin of resection is
Corynebacterium
than 2 cm around spp Penicillin Allergy: inadequate: at least 4-6
ulcer Proteus mirabilis, Ciprofloxacin weeks.
c. No systemic Bacteroides spp 500mg IV q8-12h A shorter duration (1 to
inflammatory PLUS 2 weeks) is enough if
response syndrome Clindamycin margin of surgical
(SIRS) 600mg IV q8h resection is adequate.

**Piperacillin/tazobacta
m: If given as q8h, to be
given as extended
infusion (over 3-4
hours).
Diabetic Foot *Piperacillin/tazobactam Cefepime 2gm IV Surgical debridement is
Severe Infections: Polymicrobial 4.5gm IV q6-8h q8h URGENT.
All of the above Streptococcus If given as q8h, to be given as PLUS
2 or more SIRS pyogenes, extended infusion (over 3-4 Metronidazole Based on intra-operative
• History of previous Staphylococcus hours). 500mg IV q8h culture and sensitivity,
antibiotics exposure aureus antibiotic should be
• Recurrent admission Corynebacterium
spp streamlined.
• Risk of
pseudomonas Proteus mirabilis, Duration: 7- 14 days
infection Bacteroides spp (subjected to clinical
•Immunocompromise improvement)
d If proven osteomyelitis
or margin of resection is
Note SIRS criteria inadequate: treat for at
*Temperature: least 4-6 weeks.
>38°C or <36°C, A shorter duration of
*Pulse >90 bpm, antibiotics can be
*Respiration >20 considered if the
breaths/minute or osteomyelitis is fully
Partial pressure of resected (i.e., amputation
arterial carbon with a clear margin):
dioxide <32 mmHg, • No surrounding soft
*White blood cell tissue infection: 5 days.
count (WBC) • Evidence of soft tissue
>12,000 cells or infection: 10-14 days.
<4,000 cells/μL
Fractures: Polymicrobial Cefazolin 1-2gm IV q8h Amoxicillin/clavula Duration:
Gustilo 1 & 2 S. aureus, OR nate 1.2gm IV q8h
Proteus Cefuroxime 1.5gm IV q8h
mirabilis,
P. aeruginosa
Gustilo 3 Polymicrobial As per Gustilo 1 & 2 fractures
S. aureus, Proteus PLUS
mirabilis, *Gentamicin 3-5mg/kg IV stat
P. aeruginosa dose
PLUS/MINUS
Metronidazole 500mg IV q8h

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 20
Note about fractures
Compound fractures: Antibiotics are administered as prophylaxis within 3 hours of injury

Pre-debridement and post debridement cultures are not representative of actual infection.
Duration of antibiotic for open fractures classification:
• Gustillo type I: stop after 24 hours
• Gustilo type II: discontinue after 24 hours to 48 hours
• Gustillo type III: 24 hours after wound closure or up to a maximum of 72 hours (whichever is earlier)
➢ Gentamicin: If initial debridement is expected to last more than 2 hours will need higher dose of gentamicin
5mg/kg IV stat dose.
➢ Metronidazole: In soil/rust contamination or heavy
➢ If soft tissue injury is of concern, to follow antibiotic guide for soft tissue injury

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 21
Chapter 7 EYE INFECTIONS
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Blepharitis Unclear Warm compresses Chloramphenicol Counselling
S. aureus, applied for 15 minutes ointment applied on lid Eye scrub with baby
S. epidermidis BID. margin, at night. Also shampoo
consider eyedrops if
persistent infection

Viral conjunctivitis Adenovirus (most No antibiotics needed Avoid topical Counselling:

(pain, occasional gritty common), corticosteroid therapy, Strict hand washing
discomfort with mild H. simplex type except under Avoid sharing personal
itching, watery 1&2 supervision of an items; food handlers and
discharge) Varicella–zoster ophthalmologist. health care workers
virus should not work until eye
discharge ceases

Bacterial S. aureus, S. Chloramphenicol Ciprofloxacin 0.3% This is often self-limiting

Conjunctivitis pneumoniae, S. Ointment four times Solution: One or two after 3-5 days.
(pain with stinging pyogenes, daily for one week drops four times daily Delay antibiotics, except
sensation, red eye with Haemophilus spp for one week if:
foreign body sensation, P. aeruginosa Gentamicin 0.3% *Immuno-compromised
purulent discharge) Neisseria Solution: One to two Ofloxacin 0.3% *Healthcare worker
gonorrhoeae drops four times daily solution One or two *Diabetes mellitus
for one week drops four times daily Encourage hand-washing,
for one week lid margin care with baby
shampoo & warm
compresses 24 hourly.
Allergic conjunctivitis Cromolyn sodium 4%
(Crolom)
OR
Ketotifen eyedrops
One or two drops every
four to six hours
Fungal keratitis Aspergillus, Natamycin (5%) 1drop Amphotericin B
Fusarium, 1-2 hourly for several (0.15%) 1 drop q1-2
Candida and others days, then 3¬4 hourly hourly for several days
for several days depending on the
depending on response response
Orbital Streptococcus IV Ceftriaxone 1g q12h Penicillin allergy: This condition is a
cellulitis/abscess pyogenes for 7-14 days Clindamycin 30- surgical emergency &
Streptococcus PLUS 40mg/kg/day PO in 3 requires immediate
pneumoniae Flucloxacillin 1gm IV or4 divided doses consultation with ENT
Staphylococcus q6h x 7-14 days surgeon &
aureus Also for CA-MRSA ophthalmologist.
Haemophilus Inpatient: (adjust accordingly
influenzae 48-72 hours antibiotic, with sensitivity) Urgent CT scan needed to
then oral to complete 14 exclude associated
days following good abscess & intracranial
response (no positive extension.
culture)

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 22
Chapter 8 EAR INFECTIONS
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Malignant otitis P. aeruginosa (in Ciprofloxacin 500mg IV Piperacilin+Tazobac Debridement is usually
externa or >90% cases) q8h tam 4.5gm IV 6h required. Rule out
Necrotizing Otitis OR osteomyelitis;
Externa Ceftazidime 2gm IV q8h Once showing clinical
response, consider
switching to oral therapy:

Acute otitis media S. pneumoniae For non-severe AOM: Ceftriaxone 1 gm Non-severe AOM:
(AOM) H. influenzae Amoxicillin 500mg PO q8h daily IM/IV for 3 *Mild otalgia
Morexella for 5 days days *Temp <39⁰C
catarrahalis PLUS OR
Metronidazole 500 mg PO May consider 48-72hours
q8h Azithromycin 500mg of observation with
If no improvement in 48-72 PO on day 1, symptomatic therapy
hours, treat as followed by 250mg before prescribing
PO q24h until day 5 antibiotic.
Severe AOM or perforated Severe AOM:
tympanic membrane: *Moderate to severe
Amoxicillin/clavulanate otalgia
625mg PO q8h x 5-7 days *Temperature >39⁰C
OR Amoxicillin/clavulanate If symptoms not resolving
1000mg PO q12h x 7 days after 48-72hours, refer
PLUS ENT.
Gentamicin 0.3% Ear Drops
6x daily
Acute S. pneumoniae Cefotaxime 1-2 gm iv 4- Modify as per culture
Mastoiditis S. aureus 8hourly Unusual causes-Nocardia,
H. infiuenzae Ceftriaxone 2 gm iv OD TB, Actinomyces.
P. aeruginosa
Acute Diffuse Pseudomonas Ofloxacin 0.3% otic Aural toileting required in
Otitis Externa aeruginosa solution. Instil 10 drops into discharging ears
Staphylococcus affected ear(s)q24h for 7
aureus days Ear swab MCS

Chronic Pseudomonas Ofloxacin 0.3% otic Aural toileting required in

suppurative aeruginosa solution. Instil 10 drops into discharging ears
Otitis Externa Staphylococcus affected ear(s)q24h for 7
aureus days Ear swab MCS

Otomycosis Aspergillus sp. Clotrimazole 1% ear Aural toileting required in

solution, applied q12h for 10 discharging ears.
to 14 days Therapy may be modified
based on ear swab mcs
results
Exudative/Diffu Mostly viral Penicillin V oral x10 days or Penicillin allergic,
se Erythema Group A, C, G Benzathine Penicillin 1.2 Clindamycin 300-450
Streptococcus, MU IM x 1 dose or Cefdinir mg orally 6-8 hourly x
Infectious or cefpodoxime x 5 days 5 days. Azithromycin
mononucleosis clarithromycin are
alternatives.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 23
Chapter 9 URINARY TRACT INFECTIONS
Note: Asymptomatic bacteriuria NOT to be treated except pregnant women and immunocompromised patients. All
cases of dysuria may not be UTI. Refer to Obstetrics and gynaecology infections for treatment of asymptomatic
bacteriuria in pregnant women.

Condition Likely Causative Empiric (presumptive) Alternative Comments

Organisms antibiotics/First Line /Second Line
Acute E. coli, Staphylococcus Nitrofurantoin 100 mg BD Cefuroxime 250 mg Get urine cultures before
uncomplicated saphrophyticus (in for 7 days BD for 3-5 days antibiotics & modify
Cystitis sexually active young OR OR therapy based on
women), Klebsiella Cotrimoxazole 960mg BD Ciprofloxacin 500 mg sensitivities.
pneumoniae for 3-5 days BD for 3-5 days

Acute E. coli, Ciprofloxacin 500mg PO Amoxycillin/Clavulan Urine culture and

uncomplicated Staphylococcus q12h for 7 days PLUS/ ate 625mg PO q8h for susceptibilities need to
Pyelonephritis saphrophyticus (in MINUS an initial 14 days be collected before
sexually active young Ciprofloxacin 500mg stat Ciprofloxacin 200mg starting antimicrobial
women), IV IV q12h for 7 days treatment to guide
Klebsiella pneumoniae, OR treatment.
Proteus mirabilis Ceftriaxone 1-2gm q24h
IV for 14 days PLUS/ May step down to oral
MINUS antibiotic following
Aminoglycoside. clinical improvement if
OR afebrile for 48 hours.
Amoxycillin/Clavulanate
1.2gm IV q8h for 14 days

Acute prostatitis Enterobacteriaceae (E. Mild-moderate infection: Moderate infection: Get urine and prostatic
coli, Klebsiella sp., Ciprofloxacin 500mg PO Levofloxacin500 mg massage cultures before
Proteus) q12h x 4 weeks PO daily x 4 weeks antibiotics & switch to
OR narrow spectrum agent
Cotrimoxazole 960mg q12h If severe infection: based on sensitivities
for 4 weeks IV Ceftriaxone 1g and then treat total for
If severe infection: q12h until afebrile 3-4 weeks.
Ciprofloxacin 200mg IV then
q12h Doxycycline 100 mg
PLUS/MINUS BD
Gentamicin 5mg/kg IV OR
q24h until afebrile Azithromycin 500 mg
Then mild infection daily for 4 weeks
protocol
Chronic Bacterial E. coli, Klebsiella sp., Ciprofloxacin 500mg PO Levofloxacin 500 mg Pending positive culture
Prostatitis Proteus q12h for 6 weeks PO daily x 6 weeks on prostatic secretion
Assess response after 2
weeks. If beneficial, to
continue for 4-6 weeks
Epididymo-orchitis E. coli, Klebsiella, Ciprofloxacin 500mg PO Levofloxacin 500 mg Consider sexually
Proteus, q12h minimum of 2 weeks PO daily x 2 weeks transmitted pathogens
Enterococcus, in sexually active men –
Pseudomonas Refer to Sexually
Transmitted
Infections Section

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 24
Chapter 10 SEXUALLY TRANSMITTED INFECTIONS
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Syphilis; Treponema pallidum Benzathine Penicillin Penicillin Allergy If therapy is interrupted
Primary, 2.4MU IM STAT Doxycycline 100mg for ≥ 1day at any point
Secondary or OR PO q12h for14 days during the treatment
Early Latent Procaine Penicillin course, it is recommended
that the entire course is
(History of syphilis 600,000units IM q24h restarted
infection within for 10 days Abstain from sex for 2
thelast 2 years) weeks after they and their
partner(s) have completed
treatment. Screen for HIV
Syphilis; Benzathine Penicillin Ceftriaxone 2gm IM For cardiovascular
Late Latent 2.4MU IM weekly or IV q24h Consider Prednisolone
Gummatous or for 3 weeks (Day 1, 8, & for 14 days (if no 40-60 mg OD for 3
Cardiovascular 15) anaphylaxis to days starting 24 hours
OR penicillin) before the
Procaine Penicillin OR antibiotics.
600,000units IM q24h Doxycycline 200mg If a patient defaults
for 14 days PO q12h for Benzathine Penicillin
28 days treatment by ≥ two weeks
in between the weekly
doses, the whole regime
needs to be restarted
Neurosyphilis Benzylpenicillin 4MU q4h Ceftriaxone 2gm Consider Prednisolone
IV for 14 days IM or IV q24h 40-60 mg OD for 3
OR for 14 days (if no days starting 24 hours
Procaine Penicillin 2.4MU anaphylaxis to before the antibiotics.
IM q24h
penicillin)
PLUS
Probenecid 500mg PO
OR
q6h, both for 14days Doxycycline 200mg
PO q12h x 28 days
Chlamydia Chlamydia Doxycycline 100mg PO Azithromycin 1gm Avoid unprotected sexual
Infections trachomatis q12h for 7 days PO stat, then 500mg intercourse for 1week
Uncomplicated PO q24h for 2 days following treatment
(urogenital, (partner(s) need to be
treated as well, even if
pharyngeal and
asymptomatic
rectal infection)

Chlamydia in Azithromycin 1gm PO Amoxicillin 500mg Doxycycline is

pregnancy stat, then 500mgPO q24h PO q8h for 7 days contraindicated in
for 2 days OR pregnancy
Erythromycin
Ethylsuccinate 800mg
POq6h for 7 days

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 25
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Syphilis in Treponema pallidum 1st & 2nd Trimesters Penicillin Allergy Tetracycline and
Pregnancy (up to and including 27 All trimesters Doxycycline are
Primary, weeks): contraindicated in
secondary, early Benzathine penicillin G Ceftriaxone 500mg pregnancy
latent 2.4MU IM single dose IM q24h for10 days
If Macrolide therapy:
OR Neonate require
3rd Trimester Azithromycin 500mg assessment and treatment
(from week 28 to term): PO q24h for 10days at birth
Benzathine penicillin G OR
2.4MU IM weekly for 2 Erythromycin
weeks (Day 1 & 8) Ethylsuccinate 800mg
POq6h for 14 days
OR
(All three trimesters)
Procaine penicillin G
600,000unit IMq24h for
10 days

Gonorrhoea Neisseria Ceftriaxone 500mg IM as Gentamicin 240mg Avoid unprotected sexual

Uncomplicated Gonorrhoeae a single dose IM as a single dose intercourse for 1week
(Urogenital, PLUS PLUS following treatment
Anorectal, *Azithromycin 1gm PO as *Azithromycin 2gm (partner(s) need to be
Pharyngeal) a single dose PO as a single dose treated as well)
Pregnancy and
breastfeeding: Test of cure in 2 weeks
Ceftriaxone 500mg post treatment with
I.M. as a single dose NAAT is advisable
PLUS
*Azithromycin 1gm
P.O as a single dose
Gonococcal IM Ceftriaxone 500mg Azithromycin 2gm
Conjunctivitis q24h for 3 days PO single dose
PLUS
Doxycycline 100mg
PO q12h for 7 days
PLUS
Ciprofloxacin 250mg
PO q24h for 3 days

Disseminated Ceftriaxone 1-2gm IV Cefotaxime 1gm IV May be switched to

Gonorrhoea q24h for 7 days q8h for 7 days Ciprofloxacin 500mg PO
q12h 24-48hrs after
symptoms improve.

Epididymitis/ N. gonorrhoea and Ceftriaxone 500mg IM STI related but

Epididymo- Chlamydia STAT unlikely gonorrhoea:
orchitis trachomatis PLUS Doxycycline 100mg
Azithromycin 1gm PO q12h for 14 days
STAT
PLUS Non-STI related
Doxycycline 100mg PO (Enteric organisms):
q12hfor 14 days Ciprofloxacin 500mg
q12h for 10 days

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 26
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Non-gonococcal Doxycycline 100mg PO Azithromycin 500mg
urethritis q12h for 7 days PO STAT then
(NGU)First 250mg q24h for 4
episode days
Nongonococcal If treated with Abstain from sexual
urethritis (NGU) Doxycycline first line: intercourse until patient
Recurrent and Azithromycin 500mg PO has
persistent stat then250mg PO q24h completed therapy and his
for the next 4 days partner(s) have been
PLUS treated for at least 1 week
Metronidazole 400mg PO
q12h for 5days Follow-up is
recommended after 2-3
If treated with weeks
Azithromycin first line:
Moxifloxacin 400mg PO Most common cause of
q24h for 10-14days recurrent or persistent
PLUS NGU is Mycoplasma
Metronidazole 400mg PO genitalium.
q24h for 5days

Herpes Genitalis Herpes Simplex Virus Acyclovir 400mg PO q8h Valaciclovir 500mg
Type-1 and 2 (HSV-1 for 5 days PO q12h for 5 days
First episode: &2

Herpes Genitalis Short-course Valaciclovir 500mg

Acyclovir 800mg PO q8h PO q12h for 3-5 days
Recurrent episode for 2 days
5-day regimens
Acyclovir 400mg PO q8h
Herpes Genitalis Acyclovir 400mg PO q8h Valaciclovir 500mg
in pregnancy for 5 days PO q12h for 5 days

Chancroid Haemophilus ducreyi Azithromycin 1gm PO in a Ceftriaxone 250mg Avoid unprotected sexual
single dose IM in a single dose intercourse until patient
OR and partner(s) have
*Ciprofloxacin 500mg PO completed treatment and
q12h for 3days follow-up. Sexual
contacts within 10 days
*recommended for HIV+ before onset of symptoms
patients should be examined and
treated even if
asymptomatic. Review in
3- 7 days.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 27
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Lymphogranuloma Chlamydia Doxycycline 100mg PO Azithromycin 1gm PO Fluctuant buboes: Should
Venereum trachomatis q12h for 21 days weekly for 3 weeks be aspirated through
Serovars L1,2,3 healthy adjacent skin.
Surgical incision
contraindicated.
Sexual contacts within 1
month prior to symptoms
onset, or the last 3 months
of detected asymptomatic
LGV, should be examined
and tested for Chlamydial
infection and treated with
the same regimen. Should
be followed up until
symptoms resolve.
Granuloma Klebsiella Azithromycin 1gm PO Doxycycline 100mg PO Treatment duration: for
Inguinale granulomatis weekly or 500mg q24h q12h at least 3 weeks or until all
(Donovanosis) PLUS/MINUS OR lesions completely heal
Gentamicin 1mg/kg IM/IV Cotrimoxazole
q8h 960mg PO q12h
(in patients whose lesions OR
do not respond in the first Ciprofloxacin 750mg
few days to other agents) PO q12h
PLUS/MINUS
Gentamicin 1mg/kg
IM/IV q8h

Trichomoniasis Trichomonas Metronidazole 2gm PO in Treatment failure Screen other STIs

vaginalis a single dose (Second regimen) Sexual contact(s) should be
OR treated simultaneously.
400mg PO q12h for 5 days Metronidazole 400mg Patients should be advised
PO q12h for 7 days to abstain for at least one
week
until they and their
partner(s) have completed
treatment and follow-up.
Any partners within the 4
weeks prior to presentation
should be screened for the
full range of STIs and
treated for trichomonas
vaginalis.
Bacterial Prevotella sp., Metronidazole 400mg PO Clindamycin 300mg PO Not an STI but frequently
vaginosis Mobiluncus sp., BD for 5-7days q12h for 7 days detected during STI
Gardnerella OR screening
vaginalis, 2gm PO as single dose
Mycoplasma hominis

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 28
Chapter 11 PARASITIC DISEASES
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Malaria Plasmodium Artemether/lumefantrine Amodiaquine 10mg/kg Avoid Artesunate/
(Uncomplicated) falciparum (20mg artemether/ 120mg and Artesunate 4 mg/kg x Amodiaquine in HIV+
lumefantrine per tablet) 3 days people on treatment with
OR efavirenz

Plasmodium Initial STAT dose, followed Artesunate 4 mg/kg &

malariae by second dose 8 hours Mefloquine 15-25mg/kg
later, then 1 dose q12h for (ASMQ)
the following two days OR
Dihydroartemisinin 2-
One dose = 4 tablets 10mg/kg & Piperaquine
16-27mg/kg/day x 3days

Malaria Quinine 600mg TDS with Doxycycline 100mg BD A positive malaria blood
(Treatment Clindamycin 450mg TDS may be used instead of smear 72 hours after
failure) for 7 days Clindamycin, for 7 days starting antimalarials may
OR be a predictor of
Artesunate 2mg/kg QD plus subsequent treatment
clindamycin 450mg TDS for failure and provides a
7 days simple screening measure
for artemisinin resistance
(or poor adherence).
Malaria Day 1: IV artesunate Day 1: IV Quinine loading Features of complication
(Severe or 2.4mg/kg on admission, dose 20mg/kg *Cerebral malaria, with
Complicated) then repeat again at 12 & 24 (dilute in 250 ml D5W) abnormal behavior or
hours run over 4 hours; followed impaired consciousness
Day 2-7: IV artesunate 2.4 by maintenance dose 8 *Severe anemia
mg/kg OD or switch to oral hours later; then, *Hemoglobinuria
ACT Quinine 10mg/kg IV q8h *Hypoglycemia
till Day 7 (max. 600mg
base) Notes
PLUS *Do not use IV artesunate
Doxycycline as monotherapy; add
2.2mg/kg/dose (max. clindamycin.
100mg/dose) PO q12h *Change to quinine PO if
OR able to tolerate orally
Clindamycin (max. quinine per dose =
10mg/kg/dose PO q12h 600 mg)
Duration: 7 days *Avoid using mefloquine
if patient presents initially
with impaired
consciousness, as it may
cause neuropsychiatric
complications.
Scabies Sarcoptes scabiei Benzyl Benzoate emulsion In pregnancy/
25% (EBB)apply from neck Immunocompromised:
down and leave for 24hours Permethrin 5%
for 2-3 days lotion/cream apply and
OR leave for 8 hours
Permethrin 5% lotion/cream
apply and leave for 8 hours. Repeat application after 1
Repeat application after 1 week
week

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 29
Chapter 12 FUNGAL INFECTIONS
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Tinea capitis Trichophyton, Griseofulvin 500mg PO Itraconazole 200mg *For kerion, Griseofulvin
Microsporum q12h for 6 to 12weeks or PO q24h should be considered as first
Tinea barbae longer till fungal cultures OR line unless Tricophyton
are negative Fluconazole 6mg/kg has been cultured as the
pathogen. Duration of
OR PO q24h treatment may be longer.
Terbinafine 250mg PO Duration is based on *Contacts of patient may be
q24h mycological agent: treated with 2%
PLUS Trichophyton sp: 2-4 Ketoconazole shampoo 2 – 3
2.5% Selenium sulphide weeks times per week for 2 weeks.
shampoo Microsporumsp: 8-12 *Surgical excision is to be
OR weeks avoided.
2% Ketoconazole *Topical therapy alone is not
shampoo,2 – 3 times per recommended for the
management of tinea capitis.
week for 2 weeks
*Consider adding oral
prednisolone in selected
cases.

Tinea corporis/ Trichophyton, Mild infections: Extensive infections: Also consider, for extensive
Tinea cruris/ Microsporum, Topical Clotrimazole 1% Terbinafine 250mg infections:
Tinea faciei Epidermophyton OR PO q24h for 2 weeks
Topical Miconazole 2% OR Fluconazole 150-300mg per
OR Itraconazole 200mg week PO for
3-4 weeks
Topical Ketoconazole PO q24h for 2weeks
OR OR
Topical Terbinafine Griseofulvin 500mg
Duration: till clinical PO q12h or q24h for
clearance with additional 2 4-6 weeks
weeks
Tinea manuum/ Trichophyton, First line: Griseofulvin 500mg 1) Topical keratolytic agents
Tinea pedis Microsporum, Topical antifungals as PO q12h for 6-12 can be used in conjunction
Epidermophyton mentioned in tinea Weeks with antifungals for
corporis for 4-8 weeks hyperkeratotic type of tinea
pedis/manuum.
Resistant cases: OR
2) KMnO4 in 1:10,000
Terbinafine 250mg PO Fluconazole dilution wet dressings,
q24h for 2-4weeks 150mg/week PO for 4 applied for 20 min 2–3
OR weeks times/day, may be helpful if
Itraconazole 200mg PO vesiculation or maceration is
q24h for 2-4weeks present.

Candidiasis Candida albicans Mild cutaneous disease: Treatment of sexual

Topical Imidazole q12h partner is advisable in
till clear e.g., case of recurrent
Miconazole 2% cream, infection.
Clotrimazole 1% cream,
Tioconazole 1% cream *Itraconazole: Absorption
depends on gut acidity.
Extensive cutaneous Fluconazole 100mg Take capsule with food
candidiasis: PO q24h for 1 week and acidic beverage (e.g.:
*Itraconazole 200mg PO (in severe and Cola drinks). Avoid PPIs
q24h for 1week immunocompromised and H2blockers.
patients)

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 30
Chapter 13 SURGICAL ANTIBIOTIC PROPHYLAXIS (SAP)
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Cesarean Section Cefazolin 2gm IV (3 gm Ampicillin/sulbactam Administer within 120
IV for patients 3gm IV minutes before skin
weighing ≥120 kg) OR incision.
OR Amoxicillin/
Cefuroxime 1.5gm IV clavulanic acid1.2gm
PLUS IV
Metronidazole 500mg IV

Repair of perineal Cefazolin 2gm IV (3 gm Ampicillin/sulbactam

tear IV for patients 3gm IV
weighing ≥120 kg) OR
OR Amoxicillin/
Cefuroxime 1.5gm IV clavulanic acid1.2gm
PLUS IV
Metronidazole 500mg IV
Head and neck Cefazolin 2gm IV (3 gm Ampicillin/sulbactam
surgeries IV for patients 3gm IV
weighing ≥120 kg) OR
OR Amoxicillin/
Cefuroxime 1.5gm IV clavulanic acid1.2gm
PLUS IV
Metronidazole 500mg IV
Dental surgeries Cefazolin 2gm IV (3 gm Ampicillin/sulbactam
IV for patients 3gm IV
weighing ≥120 kg) OR
OR Amoxicillin/
Cefuroxime 1.5gm IV clavulanic acid1.2gm
PLUS IV
Metronidazole 500mg IV
Abdominal Cefazolin 2gm IV (3 gm Ampicillin/sulbactam
surgeries (e.g. IV for patients 3gm IV
appendectomy) weighing ≥120 kg) OR
OR Amoxicillin/
Cefuroxime 1.5gm IV clavulanic acid 1.2gm
PLUS IV
Metronidazole 500mg IV
Breast cancer Cefazolin 2gm IV (3 gm Ampicillin/sulbactam
surgery IV for patients 3gm IV
weighing ≥120 kg) OR
OR Amoxicillin/
Cefuroxime 1.5gm IV clavulanic acid 1.2gm
PLUS IV
Metronidazole 500mg IV
Orthopaedic Cefazolin 2gm IV (3 gm Ampicillin/sulbactam
surgery IV for patients 3gm IV
weighing ≥120 kg) OR
OR Amoxicillin/
Cefuroxime 1.5gm IV clavulanic acid 1.2gm
PLUS IV
Metronidazole 500mg IV

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 31
Chapter 14 OBSTETRICS AND GYNAECOLOGICAL INFECTIONS
• Fluoroquinolones are contraindicated in 1st trimester.
• Cotrimoxazole is contraindicated in 1st trimester.
• Doxycycline is not recommended in nursing mothers. If need to administer doxycycline discontinuation of
nursing may be contemplated.

Condition Likely Causative Empiric (presumptive) Alternative Comments

Organisms antibiotics/First Line /Second Line
Asymptomatic Nitrofurantoin 100 mg Co-trimoxazole 960 Screen in 1st trimester.
Bacteriuria Oral, BD for 7 days mg BD x 7 days Can cause pylonephritis in
> 1,00,000 cfu/ ml of OR up to 25% of all pregnant
bacteria of same Amoxicillin 500 mg Oral women.
species in 2 urine BD x 7-10 days. 30 % Chance of
cultures obtained 2-7 recurrence after
days apart. empirical therapy
Treat as per
sensitivity result for 7
days.

Group B Group B Streptococci IV Penicillin G 5 MU. Cefazolin 2 gm IV Associated with high risk
streptococcal (Loading dose) then 2.5 - (Loading Dose) and of pre-term labour, still
Disease, Prophylaxis 3 MU IV QID until then 1 gm TID birth and neonatal sepsis.
and Treatment delivery. OR
OR Clindamycin 900 Perform vaginal and
Ampicillin 2 gm IV mg IV TID until rectal swabs at 35 – 37
(Loading dose) then 1 gm delivery weeks gestation.
QID until delivery

Puerperal sepsis / Group B streptococcus, Ceftriaxone IV 1g q12h Meropenem 1gm IV Continue antibiotics until
Septic abortion / Gram negative bacilli, Plus q8h patient is afebrile or
Chorioamnionitis chlamydia, ureaplasma Metronidazole 500mg IV asymptomatic for at
and anaerobes TDS least 48 hours
Usually Polymicrobial

Manual removal of Amoxicillin/Clavulanic Ceftriaxone IV 2g Prophylactic antibiotics

placenta Acid 1.2g IV as single stat is not necessary. Clinical
dose judgement should guide
antibiotics use.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 32
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line

Preterm pre-labour Gram positive: GBS If non-GBS carrier: If PPROM before

rupture of Gram negative: Erythromycin 34weeks gestation
membranes Klebsiella, E. coli, Ethylsuccinate 400mg use corticosteroids,
(PPROM) Proteus, Ureaplasma, PO q6h for 7-10 days tocolytics and antibiotics
mycoplasma,
Anaerobes
(including G. vaginalis) If GBS carrier/Unknown: If PPROM after
Amoxicillin/clavulanic 34weeks gestation
acid 1.2g IV q8h for 48 Give antibiotics and plan
hours to deliver
Then
Amoxicillin/clavulanic
acid 625mg PO q8h for a
5-7 days or until delivery
whichever comes first
PLUS
Azithromycin 1gm Stat PO
upon admission (to cover
for Ureaplasmas

Pelvic Inflammatory Common organisms: Outpatient regimen

Disease Neisseria gonorrhoeae (Mild-moderate): Cefotaxime 1gm IM
Chlamydia trachomatis Ceftriaxone 1g IM Stat Stat
Bacteroides sp PLUS PLUS
Enterobacteriaceae
Metronidazole 400mg PO Azithromycin 1gm
Haemophilus influenza
Streptococcus sp q12h for 14 days PO once per week
especially PLUS for 2 weeks
Streptococcus Doxycycline 100mg PO
agalactiae (GBS) q12h for 14 days
Gardnerella vaginalis
Ureaplasma Inpatient regimen
urealyticum (Moderate-severe):
Mycoplasma hominis Cefuroxime 1.5gm IV q8h
OR
Ceftriaxone 2gm IV q24h
PLUS Tubo ovarian abscess:
Doxycycline 100mg PO Ampicillin/sulbact Surgical intervention for
q12h am 3gm IV q6h source control
PLUS PLUS may be required.
Metronidazole 500mg Doxycycline May need to consider
IV/PO q8h 100mg PO q12h tuberculosis if not
Duration of treatment: 14 responding to standard
days treatment

Bacterial vaginosis Polymicrobial, e.g. Metronidazole 400mg PO Clindamycin 300mg Metronidazole can be
Gardnerella q8h for 7 days PO q12h for 7 days used in any stage of
vaginalis, OR OR pregnancy
Ureaplasma Tinidazole 2 g orally OD x 2% Clindamycin
urealyticum 3 days Vaginal cream 5 gm Treat sexual partner
HS x 5 days
OR
Secnidazole 2g PO
stat

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 33
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Vaginal Candidiasis Candida albicans Clotrimazole 500mg as a Fluconazole 150- Pregnancy:
single vaginal pessary 200mg PO for one If indicated, treat with
Uncomplicated (Stat dose) dose topical therapy as
infection OR OR oral therapy is
Clotrimazole 200mg as Miconazole CONTRAINDICATED.
vaginal pessary for 3 pessaries
nights OR
Ticonazole pessaries
Vaginal Candidiasis Candida albicans Severe vaginitis:
Fluconazole 150-200mg
Complicated PO q72h for 2or 3 doses
infections
Recurrent vulvovaginal
candidiasis: Clotrimazole 500mg
Fluconazole 150-200mg vaginal suppository
PO q72h for 3 doses then once weekly for 6
weekly for 6 months months
Trichomoniasis Trichomonas vaginalis Metronidazole 400mg Tinidazole 2 gm If post-partum and
PO q8h for 7days Oral single dose breastfeeding, not
OR For treatment advisable to breastfeed
Metronidazole 2gm PO failure during treatment. May
as single dose Retreat with resume breastfeeding
Metronidazole 500 after 24 hrs of the last
mg Oral BD X 7 dose.
Days, if 2nd failure
Metronidazole 2 gm Treat sexual partner with
Oral OD X 3-5 days Metronidazole 2 gm
single dose

Cervicitis /Urethritis Polymicrobial Ceftriaxone 250 mg IM

Mucopurulent Single dose
gonoccocal PLUS
Azithromycin 1 gm stat
OR
Doxycycline 100mg BD
x 7 day

Postpartum mastitis Staphylococcus aureus Amoxycillin- If MRSA- based on Consider abscess

(MSSA) Streptococcus clavulunate625mg BD x sensitivities drainage
pyogenes (Grp A, B) 10 – 14 days Add Duration of therapy for
Escherichia coli OR Clindamycin 300 5-7 days may be
Bacteroides sp Cotrimoxazole 960 mg QID adequate but if poor
BD x 10 – 14 days Or
Corynebacterium Vancomycin I gm response, extend to 10-
spCoNS If severe infection, Or 14days.
consider Cefazolin 1-2gm IV *Milk culture for less
q8h severe infection
Ceftriaxone 2 g IV OD If severe infection
until afebrile (hemodynamic
instability) blood culture
required

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 34
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Varicella Note: If >20 wks of gestation, > 24 hrs from the VZIG should be offered
Chicken pox presenting within 24 onset of rash, to susceptible women <
Chickenpox during hours of the onset of the antivirals are not 10 days of the exposure.
pregnancy does not rash, then: found to be useful. VZIG has no role in
justify termination Acyclovir 800mg Oral 5 treatment once the rash
without prior prenatal times a day appears.
diagnosis as only. IV acyclovir The dose of VZIG is 125
A minority of fetuses recommended for the units / 10kg not
infected develop fetal treatment of severe exceeding 625 units, IM
varicella syndrome. complications,

Malaria in Plasmodium Uncomplicated disease Combination of

Pregnancy falciparum First trimester Artesunate 2mg/kg antimalarial with
(Treatment) Quinine 600mg TDS QD plus Clindamycin must not be
with Clindamycin 450mg clindamycin 450mg used routinely in
TDS for 7 days TDS for 7 days nonpregnant patients. It
should be avoided in
2nd and 3rd Trimesters pregnant patients who
Artemisinin-based Quinine 600mg TDS have passed their first
Combination Therapy with Clindamycin trimester
(Artemether- 450mg TDS for 7
Lumefantrine or days
Artesunate OR
Amodiaquine) Artesunate 2mg/kg
QD plus
clindamycin 450mg
TDS for 7 days

Malaria in Intermittent preventive Sulphadoxine-

Pregnancy therapy (IPT) Pyrimethamine must not
(prevention) be used in the first
Sulphadoxine- trimester of pregnancy.
Pyrimethamine (SP, e.g.
Fansidar®) Avoid SP in HIV+
One full treatment dose women who are taking
during the 2nd and 3rd Cotrimoxazole
trimesters. The last dose
should be given not Counsel on use of
later than one month insecticide treated bed
before the expected date nets.
of delivery.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 35
Chapter 15 NEONATAL INFECTIONS
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Meningitis Group B Ceftriaxone 100mg/kg/day Meropenem Once cultures are
Streptococcus IV in 2 divided doses 40mg/kg/dose q8h known, adjust
(GBS) OR antibiotics accordingly.
E. coli Ceftazidime 100mg/kg/day
If renal function is
Listeria IV in 2 divided doses
adequate, gentamicin may
other Gram- AND be added on but only in
negative bacilli/rod Gentamicin 5mg/Kg IV select cases.
(GNR) q12h

Necrotising Klebsiella, Ceftriaxone 100mg/kg/day

enterocolitis E. coli, IV in 2 divided doses
(NEC) Clostridia, OR
Coagulase-negative Ceftazidime 100mg/kg/day
Staphylococci,
IV in 2 divided doses
Enterococci,
Bacteroides AND
Gentamicin 5mg/Kg IV
q12h
AND
Metronidazole
7.5mg/kg/dose q8h

Early onset sepsis Group B Ceftriaxone 100mg/kg/day Meropenem Once cultures are
(<48 hours) Streptococcus IV in 2 divided doses 40mg/kg/dose q8h known, adjust
(GBS), OR antibiotics accordingly.
Listeria, Ceftazidime 100mg/kg/day
Streptococcus sp., IV in 2 divided doses If positive blood culture
E. coli, AND or strong clinical
Haemophilus Gentamicin 5mg/Kg IV suspicion of sepsis but
influenza, q12h negative culture, may
Klebsiella sp. etc. give 5 -7 days of
antibiotics.
Late onset sepsis Methicillin- Ceftriaxone 100mg/kg/day Meropenem Therapy may be
(>48 hours) sensitive/resistant S. IV in 2 divided doses 40mg/kg/dose q8h modified based on
aureus OR blood culture AST
(MSSA/MRSA), Ceftazidime 100mg/kg/day results or AST results
Coagulase- negative of other relevant
IV in 2 divided doses
Staphylococci cultures
(CONS), AND
Gram-negative rods Gentamicin 5mg/Kg IV
q12h
Congenital T. pallidum If age <30 days Procaine penicillin
syphilis Benzylpenicillin (Penicillin 50,000units/kg/dose
G) IM in a single daily
50,000units/kg/dose IV q12h dose for 10 days.
for first 7 days
thereafter: q8h x 10 days

If diagnosed with congenital

syphilis after age>30 days:
Benzylpenicillin (Penicillin
G):
200,000-300,000units/kg/day
IV in 4-6 divided doses for
10-14 days.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 36
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Congenital T. gondii Pyrimethamine/ Pyrimethamine
toxoplasmosis sulfadoxine 1mg/kg/day PO for 2
Pyrimethamine months, followed by
(1.25mg/kg/dose PO every 0.5 mg/kg/day PO for
10days) 10 months
PLUS PLUS
Sulfadoxine Sulfadiazine
(25mg/kg/dose PO every 100mg/kg/day PO in
10 days) 2
PLUS divided doses for 12
Folinic acid 50mg PO months
every 7 days for 12 PLUS
months Folinic Acid 50 mg
PO every 7 days
for12 months
Herpes simplex Herpes simplex virus Acyclovir 60mg/kg/day IV All infants surviving Screen for other STDs
neonatal in 3 divided doses neonatal HSV • Localized skin, eye &
Duration: infection of any mouth (SEM)
Skin, eyes, mouth: 14 days classification should • Central nervous system
CNS/disseminated: receive oral acyclovir (CNS) with or without
minimum of 21 days suppression at 300 SEM
mg/m2/dose • Disseminated disease
administered 3 times involving multiple organs
daily for 6 months
after completion of
parenteral therapy.

Neonatal tetanus Clostridium tetani Benzylpenicillin Metronidazole

(Penicillin G) PMA<34 weeks:
GA<34 weeks: 7.5 mg/kg/dose IV
100,000units/kg/dose IV q12h
postnatal age <7 days: PMA 35-40 weeks:
q12h 7.5 mg/kg/dose IV
postnatal age >7 days: q8h q8h
GA >34 weeks: PMA >40 weeks:
100,000units/kg/dose IV 10mg/kg/dose IV q8h
postnatal age <7 days: q8h Duration: 10 days
postnatal age >7 days: q6h

Duration: 10-14 days

Chlamydia Chlamydia Erythromycin Azithromycin 20 Initial treatment for

trachomatis trachomatis Ethylsuccinate mg/kg/day PO, once chlamydial conjunctivitis
conjunctivitis 12.5 mg/kg/dose PO q6h daily for 3 days. should be based upon a
positive diagnostic test.
Duration: 14 days. Re-swab after treatment;
20-30% will need a
Local eye scrubs with second course to clear
baby shampoo until infection.
discharge stops. Monitor baby for
hypertrophic pyloric
stenosis after treatment
with erythromycin.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 37
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Congenital Neisseria Non-disseminated If penicillin-sensitive, Immediate & frequent
gonococcal gonorrhoeae disease: may give saline eye irrigation.
ophthalmitis/conj Cefotaxime benzylpenicillin
unctivitis 100mg/kg/dose IV in a GA <34 weeks: Screen mother & baby
single dose. 100,000units/kg/dose for chlamydial infection.
IV Screen for other STDs.
Investigate & treat
May need to continue for -postnatal age <7 parents
48-72 hours until systemic days: q12h
infection has been ruled -postnatal age >7
out. days: q8h
GA >34 weeks:
Disseminated disease: 100,000units/kg/dose
Cefotaxime 50 mg/kg/dose IV
IV -postnatal age <7
< 1 week of age: q12h days: q8h
> 1 week of age: q8h -postnatal age >7
For 7 days, with a duration days: q6h
of 10–14 days, if
meningitis is documented.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 38
Chapter 16 OLDER CHILDREN
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Community Viral infections are Amoxicillin/clavulanate Cefpodoxime There is high likelihood
acquired more common 45mg/kg/day PO q12h Age: 2 months – 12 of bacterial co-infection.
Pneumonia (Influenza, RSV, years: 5 mg/kg PO Antibiotics are not
(outpatient) Parainfluenza, OR q12h routinely recommended
since viral infection is
Infant (≥3 Adenovirus) Cefuroxime (max=200mg/day) more common. For
months) & 3 months-12 years: Age >12 years: 200 infant & children
children Bacteria 125-250 mg PO q12hr mg PO q12h admitted to hospital,
(S. pneumoniae, >12 years: Duration: 10 days treat as presumed
Group A 250 mg PO q12hr OR bacterial unless viral
Streptococcus, Azithromycin origin is known.
S. aureus, H. Duration: 10 days 10mg/kg/dose (max.
influenza) 500mg) IV q24h on Duration: minimum 5
Day 1; then days & until afebrile
5mg/kg/dose (max. for 2-3 days in empiric
therapy
250mg) on Day 2-5

Pneumonia (S. pneumoniae, Cefuroxime 100- Amoxicillin/clavulana Macrolide antibiotics

(inpatient, fully Group A 150mg/kg/day IV in 3 te 30mg/kg/dose IV should be used if either
immunized) Streptococcus, divided doses (max. q8h mycoplasma or
S. aureus, H. 6gm/day) (max.1.2gm/dose) Chlamydia pneumonia is
influenza) PLUS/MINUS suspected.
Gentamicin 5mg/kg/day
IV qh8

Severe S. pneumoniae, Cefotaxime150- Cefuroxime 100- Rule out empyema, using

community- Group A 200mg/kg/day in 3 divided 150mg/kg/day IV in 3 chest x-ray, especially if
acquired Streptococcus, doses divided doses (max. poor response to
pneumonia S. aureus, H. OR 6gm/day) treatment or clinical
(child not fully influenza Ceftriaxone 75- PLUS/MINUS suspicion of compilation.
immunized/life- 100mg/kg/day in 2 divided Azithromycin
threatening) doses 10mg/kg/dose (max.
PLUS/MINUS 500mg) IV q24h on
Azithromycin Day 1;
10mg/kg/dose (max. then
500mg) IV q24h on Day 1; 5mg/kg/dose (max.
then 250mg) on Day 2-5 if
5mg/kg/dose (max. considering atypical
250mg) on Day 2-5 if organisms.
considering atypical
organisms.

Animal bites Pasteurella Amoxicillin/clavulanate Amoxicillin/clavulana Consider rabies

multocida, 45mg/kg/day PO in 2 te 30mg/kg/dose IV prophylaxis according to
Staphylococcus spp., divided doses for 5- q8h (max. 1.2gm) local epidemiology. Also
Streptococcus spp., 7 days tetanus toxoid and anti-
Capnocytophaga spp, tetanus serum
anaerobes

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 39
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Abscess Staphylococcus Flucloxacillin Cephalexin 25- Incision & drainage
aureus 12.5mg/kg/dose PO q6h 50mg/kg/day PO in 2 (I&D) is the
divided doses for 5- MAINSTAY of therapy.
*Flucloxacillin 100 7days Needle aspiration
is inadequate.
mg/kg/day IV q6h Use parenteral route for
OR severe infections.
Amoxicillin/clavulanate * In severe infection,
45mg/kg/day PO q12h for double dose: 200
5-7 days mg/kg/day IV q6h
Cellulitis Staphylococcus Flucloxacillin Amoxicillin 25- Administer using
aureus 12.5mg/kg/dose PO q6h 50mg/kg/day PO in 3 parenteral route for
divided doses for 7 extensive lesions.
*Flucloxacillin 100 days Total treatment until 3
mg/kg/day IV q6h OR days after acute
OR Cephalexin 25- inflammation resolves
Amoxicillin/clavulanate 50mg/kg/day PO in 2
45mg/kg/day PO q12h for divided doses for 5-
5-7 days 7days

Impetigo Staphylococcus Localized: Topical 2% fusidic

aureus Topical 2% Mupirocin acid 2-3 times daily
Streptococcus ointment 2-3 times daily for 7 days (outpatient)
pyogenes for 7 days (outpatient)

Diffused: Cephalexin 25-

Flucloxacillin 50mg/kg/day PO in 2
12.5mg/kg/dose PO q6h divided doses for 5-7
days

Scalded skin Staphylococcus Flucloxacillin 100 Amoxicillin/clavulana If no positive blood

syndrome (SSS) aureus mg/kg/day IV q6h te culture, switch to orals
100 mg/kg/day IV following clinical
Step down improvement.
Flucloxacillin
12.5mg/kg/dose PO q6h Amoxicillin/clavulana
te
Total treatment duration: 45mg/kg/day PO
7-10 days q12h

Enterocolitis Enterobacteriaceae, Ampicillin 200mg/kg/day Cefotaxime

Enterococci, IV in 4-6 divided 200mg/kg/day IV in 4
Bacteroides doses (max. 12gm/day) divided doses
PLUS PLUS
Metronidazole 15mg/kg Metronidazole
loading dose, followed by 15mg/kg loading
7.5mg/kg/dose IV q8h dose, followed by
7.5mg/kg/dose IV
q8h

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 40
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Septic arthritis 0-2 months old: 0-2 months old: Clindamycin 20 Empiric antibiotics should
(SA) & S. aureus Flucloxacillin 100 mg/kg/day PO or IV be started based on
Osteomyelitis S. agalactiae mg/kg/day IV q6h divided in 3-4 doses clinical diagnosis of SA
(OM) Gram-negative PLUS PLUS or OM.
Surgical debridement
enteric organism Cefotaxime 200mg/kg/day Vancomycin 50 often not required in OM.
Under 5 years: IV in 4 divided doses mg/kg/day IV divided Urgent wash out &
S. aureus in 2-4 doses drainage is needed in SA
S. pyogenes Less than 5 years old: OR in hip & other joints to
S. pneumoniae Cefuroxime 100- Cefazolin 100- reduce pressure on growth
Non-typeable 200mg/kg/day IV in 3 150mg/kg/day IV in 3 plate.
Haemophilus spp. divided doses divided doses *Switch IV antibiotics to
Kingellakingae (monotherapy) oral if no concurrent
bacteraemia when:
Older than 5 years: More than 5 years old: 1. Child afebrile & pain-
free for at least 24hours &
S. aureus Flucloxacillin 100 CRP <20mg/L or CRP
S. pyogenes mg/kg/day IV q6h decreased
by ≥2/3 of the highest
value.
Duration of antibiotics:
SA: total of 3-4 weeks
OM: 4-6 weeks

Empyema Staphylococcus Flucloxacillin 100 S. aureus All children with

thoracis (lung aureus mg/kg/day IV q6h (methicillin empyema need to receive
empyema) Streptococcus PLUS sensitive) high dose antibiotic
pneumoniae Cefotaxime 200mg/kg/day Cloxacillin 200- therapy via intravenous
IV in 4 divided doses 300mg/kg/day IV in route to ensure pleural
4-6 divided doses for penetration.
Duration: 4-6 weeks 4-6 weeks *Pneumatocoele on chest
S. pneumoniae x-ray indicate S. aureus
(penicillin sensitive): BUT they can also be
Benzylpenicillin seen in pneumococcal
200,000- disease.
300,00units/kg/day There is NO need to
IV in 4-6 divided routinely use a macrolide
doses antibiotic but its use
S. pneumoniae should be considered in
(penicillin resistant, children whom
use result of C&S): Mycoplasma
Cefotaxime 200- pneumonia is thought to
300mg/kg/day IV in 4 be the cause
divided doses (Mycoplasma usually
OR causes effusion, not
Ceftriaxone empyema)
100mg/kg/day IV in
1-2 divided doses
(max. 2gm/dose;
4gm/day)

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Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Tetanus Clostridium tetani Benzylpenicillin Metronidazole Primary tetanus infection:
200,000units/kg/day IV in 30mg/kg/day IV in 4Clinical diagnosis to be
4 divided doses (max. 12- divided doses for 10-
made as negative culture
18MU/day) for 14 days is often.
10-14 days Steps in care:
If TIG not available: 1. Early airway protection
Neutralization of toxin: IVIG 200-400mg/kg & treatment of reflex
Human tetanus globulin as a single dose spasm with
(TIG) 500IU IM benzodiazepine
as a single dose (diazepam or midazolam)
2. Neutralization of toxin:
TIG single dose, given IM
(optimal dose not
established)
3. Surgical debridement
of infected tissues

Malaria Plasmodium Artemether/lumefantrine Artesunate/Amodiaqu Administer using

(Uncomplicated) falciparum (20mg artemether/ 120mg ine FDC (ASAQ) parenteral route for
Plasmodium vivax lumefantrine per tablet) *≤8 kg: 25/67.5mg extensive lesions.
The patient should receive PO q12h (1/2 tab) Total treatment until 3
an initial *9-17 kg: 50/135 mg days after acute
STAT dose, followed by PO q12h (1/2 tab) inflammation resolves
second dose 8 hours later, *18-35 kg: 100/270
then 1 dose q12h for the mg PO q12h (1/2 tab) Care should be taken not
following two days *≥36 kg: 100/270mg to exceed the required
*5-14 kg: 1 tablet per dose PO q12h (1 tab) dose of amodiaquine
*15-24 kg: 2 tablet per because of the side effect:
dose If not FDC… excessive weakness.
*25-35 kg: 3 tablet per Artesunate 4mg/kg
dose /dose Duration: 3 days
*≥35 kg: 4 tablet per dose Amodiaquine: 8-
(or 1-tab of 80/480 10mg/kg/dose.
formulation)
OR
Duration: 3 days Artesunate/mefloquin
e FDC (ASMQ)
*5–8 kg: 25/55mg PO
q24h
*9-17 kg: 50/110mg
PO q24h
*18-29 kg:100/220mg
PO q24h
*>30 kg: 200/440mg
PO q24h

Malaria Oral Quinine 10mg/kg Doxycycline 100mg A positive malaria blood

(Treatment TDS with Clindamycin BD may be used smear 72 hours after
failure) 5mg/kg TDS for 7 days instead of starting antimalarials may
OR Clindamycin, for 7 be a predictor of
Artesunate 2mg/kg QD days. Only for kids 8 subsequent treatment
plus clindamycin 450mg years or older. failure and provides a
TDS for 7 days simple screening measure
for artemisinin resistance.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 42
Condition Likely Causative Empiric (presumptive) Alternative Comments
Organisms antibiotics/First Line /Second Line
Malaria Plasmodium Artesunate IV (3mg/kg if
(Complicated) falciparum weight <20kg) or (2.4
Plasmodium vivax mg/kg if weight >20kg, at
0,12,24 hours, and daily.
thereafter until child can
tolerate oral.

Malaria Mefloquine Atovaquone/Progua Mefloquine

(Chemoprophylax Adults (and kids >45kg): nil (Malarone) Start 2–3 weeks before
is for visitors to 250 mg (one tablet) once Adults: 250/100 mg arrival; Continue the drug
Nigeria) per week per day 1-2 days for 4 weeks after leaving
before travel, through malaria-risk area
Children:5 mg/kg seven days after
30 to 45 kg: 3/4 tablet return
20 to 30 kg: 1/2 tablet
Children: 62.5mg/25
mg
Malaria Adults: Proguanil PO Adults: Mefloquine
(/Chemoprophyla 200mg daily PO 250mg weekly
xis for children
and adults with Children: Proguanil PO Children: Mefloquine
sickle cell anemia) 100mg daily PO 125mg weekly

Uncomplicated Oral Cotrimoxazole (8- Cefixime 8-10 age> 2 months with lower
urinary tract 10mg of TMP component) mg/kg/day BD to be UTI, without any urinary
infection (UTI) /kg/day oral BD x 7-10 given for 7-10 days tract obstruction
days
OR
Co
Amoxycillin+Clavulanic
Acid (80mg/kg/day of
Amoxicillin) for 7-10
days.

Complicated or Cefotaxime IV (150- Amikacin 15mg/kg Complicated / Severe

severe urinary 200mg/kg/day q8h OD UTI (Fever, Systemic
tract infection OR Duration: 10-14 days toxicity, renal angle
(UTI) Ceftriaxone tenderness or with any
(100mg/kg/day OD urinary structural
AND abnormality) and all UTI
Gentamicin 3-5mg/kg/day in children less than 2
in 3 divided doses months should be treated
with parenteral
Duration: 10-14 days antibiotics. Review
treatment with culture
results.

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Chapter 17 GUIDELINES FOR OPTIMIZING USE OF KEY ANTIMICROBIALS
Antimicrobial Prescribing: Good Practice
1. Send for the appropriate investigations in all suspected infections as recommended. These are the minimum
required for diagnosis, prognosis and follow up of these infections.
2. All attempts shall be made to send microbiological samples prior to initiating antimicrobial therapy. Rapid
tests, such as Gram stain, can help determine therapeutic choices when decision on empiric therapy is
required.
3. Differentiation between contamination, colonization and infection is important to prevent overuse of
antimicrobials. Use hospital guidelines based on local antibiograms when choosing antimicrobial therapy
whenever possible. If alternatives to those recommended as used, reasons in the case records should be
documented.
4. Prescribing antibiotics just in case an infection is present is rarely justified. Where patients are in hospital,
close observation is usually a better option till the diagnosis is made.
5. Choice of antibiotics: This depends on antibiotic susceptibility of the causative organism. There are some
infections, which can be treated by one of several drugs. The choice can be based on Toxicity, Efficacy,
Rapidity of action, Pharmacokinetics and Cost. Use the most effective, least toxic and least expensive
antibiotic for the precise duration of time needed to cure or prevent infection. Pathogens specific guidance in
hospital policy is encouraged.

Before prescribing consider the following:

a. Which organism is likely to cause the disease?
b. What is the clinical diagnosis and what other steps should be taken to reach diagnostic precision?
c. Which antimicrobial agents are available and active against the presumed cause of the illness? Is their range
of antimicrobial activity appropriate and what information available about the likelihood of drug resistance?
d. Check for factors, which will affect choice of drug and dose, e.g., renal function, interactions, allergy,
pregnancy and lactation.
e. Check that the appropriate dose is prescribed. If uncertain, contact Infectious Diseases Physician, Pharmacist
or clinical microbiologist. Alternatively, check in the formulary.
f. What is the duration of treatment?
g. Is treatment working?

6. Clinical Diagnosis: The antibiotic treatment chosen must be based on presumptive diagnosis made on some
assumption regarding the nature of disease. The treating doctor may not have difficulty in choosing the
appropriate antibiotic to treat a disease caused by a single microorganisms e.g. scarlet fever, typhoid, anthrax,
as microbiological diagnosis is implicit in clinical diagnosis. However, diseases such as pneumonia,
meningitis and urinary tract infection can be caused by spectrum of bacterial species and the doctor may be
wrong if he has to guess which antimicrobial agent to use. In such instances one should seek a bacteriological
diagnosis.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 44
7. Empiric Therapy – If the causative agent is not known and where delay in initiating therapy would be life
threatening or risk serious morbidity, antimicrobial therapy based on a clinically defined infection is justified
and the following points should be taken into consideration:
a. Do not rush to treat.
b. Collect the necessary specimens before commencing therapy.
c. Cover all possible microbial causes.
d. Try to attain synergy.
e. Consider possible interaction with other drugs.
f. Accuracy of diagnosis should be reviewed regularly and treatment altered/stopped when microbiological
results become available.
g. Use less costly drugs where possible.

8. The need for antimicrobial therapy should be reviewed on a daily basis. For most infections 5 – 7 days of
antimicrobial therapy is sufficient (simple UTI can be adequately treated with 3 days of antibiotic).
9. All IV antibiotics may only be given for 48 – 72 hours without review and consideration of oral alternatives.
New microbiological or other information (e.g. fever defevescence for at least 24h, marked clinical
improvement; low CRP) should at this stage often permit a switch to oral antibiotic(s), or switch to an IV
narrow spectrum alternative, or cessation of antibiotics (no infection present).
10. Once culture reports are available, the physician should step down to the narrowest spectrum, most
efficacious and most cost-effective option. If there is no step down available, the reason shall be documented
and is subjected to clinical audit.
11. Some guiding principles for de-escalation /Escalation:
a. If ESBL positive: drug choice is monotherapy with carbapenems. Preferably choose group I carbapenem.
Piperacillin –Tazobactam and Cefoperazone –Sulbactam can be used if in-vitro sensitive and for mild
infections.
b. Vancomycin should be used only for confirmed MRSA infections and not in MSSA infections.
c. In case of Pan drug resistant Pseudomonas /Acinetobacter spp. combination therapy using colistin along
with beta-lactams (using PK/PD principles) should be discussed with microbiologist / physician.
12. . Treatment with antibiotic combinations: In order to avoid antagonism between drugs and undesirable
side effects of several antibiotics it is advisable to use a single drug wherever possible. There are situations
however, when the use of antibiotic combination is desirable. The situations are:
a. A temporary expedient during the investigation of an obscure illness.
b. To prevent the development of bacterial resistance in long term therapy e.g treatment of tuberculosis.
c. To achieve synergistic effect, e.g. in treating infective endocarditis.
d. Mixed infection, when one drug is not effective against the pathogen.
e. To permit a reduction of the dose of potentially toxic drug.

13. The choice of the drug should be that they act synergistically. The following combinations are synergistic
1. Aminoglycoside and beta–lactam antibiotic.

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 45
 2. Beta –lactam antibiotic and beta–lactamase inhibitor.
3. Beta –lactam antibiotic and Glycopeptide (vancomycin/teicoplanin)
4. Sulphamethoxazole and Trimethoprim.

14. Is Treatment working? Where treatment is apparently failing, advice from an ID physician/clinical
microbiologist and a clinical pharmacist should normally be sought rather than blindly changing to an
alternative choice of antimicrobial agent. Antimicrobial drug therapy cannot be considered in isolation and
other aspects of therapy must be taken into account in judging the effect of treatment. Even an appropriate
antibiotic may be ineffective unless pus is drained, septic shock treated and hypoxia and anaemia corrected.
There are several conditions in which chemotherapy alone cannot eliminate an infection. Obstructive lesions
can cause infection to recur, unless they can be dealt with surgically. Also, chemotherapy cannot obviate the
necessity for draining an abscess or removing sequestra or calculi. Failure of treatment can also be due to a
super-added infection, e.g. phlebitis, development of resistance during therapy or poor tissue penetration.

15. Laboratory control of the effects of treatment: Whether treatment has been successful or not is best judged
by clinical criteria, but it is useful to know whether the infecting organism has been eliminated. Repeated
cultures are, therefore sometimes indicated.

Reserve Antimicrobials
These reserve antimicrobials will be made available following a recommendation from the Microbiology Department
as per culture report or if included in an antimicrobial policy for a clinical specialty that has been agreed with
antibiotic management team. They are held in reserve to maintain their effectiveness in treating certain difficult
infections by reducing the spread of microbial resistance and to encourage cost effective prescribing. Before a reserve
antibiotic is issued to the ward, the pharmacist is instructed to ascertain the indication and if this falls outside the
approved policy, to request that the prescriber consult the ID Physician/clinical microbiologist.
The following criteria has been proposed to protect the Carbapenems and Linezolid from overuse –
1. Severe sepsis as defined by more than one organ failure of new onset and/or elevated serum lactate.
2. Clinical failure of other classes of antibiotics over 48 hours in terms of worsening inflammatory markers,
unresolving fever and new/worsening hemodynamic instability.
3. Underlying severe immuno-suppression – Neutropenia, immuno-suppressive therapy, Diabetic Ketoacidosis
(DKA) etc.
4. The organism is susceptible to only carbapenems / linezolid, as per culture report.

The following criteria has been proposed for initiating Colistin –

1. Pan-resistant organism as per culture report with evidence of invasive disease – fever/ leucocytosis/elevated
procalcitonin (PCT) or culture from a sterile site.
2. Clinical failure of all other classes of antibiotics over 72 hours.

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The following criteria has been proposed for initiating Rifampicin –
1. Empiric or proven TB as a part of ATT (4 drug regimen)
Rifampicin should not be prescribed in our country for any treatment other than for Mycobacteria and for
chemoprophylaxis of meningococcal meningitis in clinically indicated population. Rifampicin should not be
prescribed alone as an anti-bacterial.

The following criteria has been proposed for initiating Aminoglycosides –

I. The focus of infection is not lung or an anaerobic abscess.
II. Only as a part of initial empiric regimen of a combination therapy – shall step down to single drug after
culture report.
III. Other safer drug options have been ruled out in a culture report.

C. Hypersensitivity
All patients should be asked about drug allergies. This is the responsibility of the doctor caring the patient. If a patient
reports a drug allergy clarify whether this is an allergy or drug intolerance. In some cases, there will be an overlap
between drug allergy and drug intolerance.
Clinical features suggestive of drug allergy:
One or more symptoms developed during or following drug administration including difficulty breathing,
swelling, itching, rash, and anaphylaxis, swelling of the lips, loss of consciousness, seizures or congestion
involving mucous membranes of eyes, nose and mouth.
Clinical features suggestive of drug intolerance:
One or more symptoms developed during or following drug administration including gastrointestinal
symptoms e.g. nausea, vomiting, diarrhoea, abdominal pain and feeling faint.

If patients are unable to give an allergy history, the doctor caring in the patient should take reasonable steps to contact
someone who can provide a reliable allergy history. It is the prime responsibility of the prescribing doctor to ensure
that:
i. The allergy box on the patient’s drug chart is completed, when a new prescription chart is written or
transcribed. If no allergy - specify "No known allergy". The box should be signed and dated. If allergy history
cannot be obtained, then specify "history not available." Under no circumstances should the allergy box be
left blank. A pharmacist or nurse may complete the allergy box if the allergy status is documented in the
clerking in notes.
ii. The allergy box is completed before prescribing a new drug, except in exceptional circumstances. If patients
have a suspected drug allergy then the drug and suspected reaction. Should be documented in the clerking-
in notes and the drug chart.

D. Alert Antimicrobials
To Prevent and Control the Emergence and Spread of Antimicrobial-Resistant Micro-organisms in Hospitals” one
major strategic goal is to “define guidelines for use of key antibiotics”, (“Alert” antibiotics) targeted in these
guidelines are ciprofloxacin, ceftazidime, cefotaxime, ceftriaxone, vancomycin (or teicoplanin), imipenem,

Abia Antimicrobials Guidelines Version 1.0 Updated July 10, 2020 Page 47
levofloxacin, meropenem, moxifloxacin, piperacillin-tazobactam, linezolid (oral/IV), voriconazole, ertapenem
and newer preparations of amphotericin.

Collectively, these are among the drugs most frequently prescribed irrationally which is largely responsible for the
current escalation of antibiotic costs. They also account for a significant proportion of serious antibiotic toxicity
including Clostridium Difficile diarrhoea and CNS toxicity/seizures as well as the emergence of major antimicrobial
resistance. Safer, cheaper and equally effective alternatives are often available which allow such agents to be kept in
reserve for occasions when there are clear cut microbiological indications. It is critical, therefore, that these Alert
antibiotics be prescribed only on the recommendation of senior medical staff or after discussion with the on-call
Clinical Microbiologist or ID physician.

E. Alert Antibiotics And Their Indications

1. CIPROFLOXACIN, INTRAVENOUS
Oral ciprofloxacin is well absorbed and this is therefore the preferred route of administration. Intravenous
therapy is only indicated in the following situations:
• When the patient is unable to swallow or the oral route is otherwise compromised.
• In serious sepsis (e.g. nosocomial pneumonia in ITU) when the recommended dose is 400mg 8 hourly.

Common indications for ciprofloxacin in the Antibiotic Policy, either alone or in combination, are as follows:
• second line therapy in exacerbation of chronic bronchitis
• pyelonephritis
• acute inflammatory infective diarrhoeas
• serious infected diabetic ulcers infected burn wounds with coliforms or Pseudomonas infection present
• treatment of documented or presumed gram negative bacilli resistant to penicillins or cephalosporins or when
the patient is allergic (history of anaphylactic reaction or rash) to these agents
• selected haematology patients requiring prophylaxis
• severe acute pelvic inflammatory disease

2. CEFTAZIDIME
Limited use only. Main indication is documented or suspected Pseudomonas aeruginosa infection. Other indications
currently
listed in the Antibiotic Policy are as follows:
• Second line agent in neutropenic patients with septicaemia or pneumonia
• Empiric therapy of CAPD associated peritonitis (not children), 1g IV stat then 125mg/litre in each bag
• Empiric therapy of post-operative, post traumatic or shunt associated meningitis
• Empiric therapy of infective exacerbation of cystic fibrosis

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3. PIPERACILLIN - TAZOBACTAM
Currently listed in the antibiotic policy for the following:
• Pneumonia or septicaemia in neutropenic patients (+ Gentamicin)
• As a single agent (or in combination with Gentamicin) for treatment of sepsis which has not responded to
first line treatment or if it is not appropriate for gentamicin to be added to first-line therapy.

4. CEFTRIAXONE
IV Ceftriaxone is currently listed in the antibiotic policy for the following:
• Epiglottitis,
• Brain abscess,

• Bacterial meningitis,
• Pyelonephritis in children,
• Empiric therapy of septicaemia in children,
• In ascites for treatment of sub-acute bacterial peritonitis,
• Skin and soft tissue infections managed via out-patients or the home IV antibiotic programme,
• Acute septic monoarthritis if penicillin allergic,
• Spontaneous bacterial peritonitis.

5. APPROPRIATE USE OF CARBEPENEMS

• Very high rates (60-75%) of resistance to 3rd and 4th generation cephalosporins {due to extended
spectrum beta-lactamases (ESBL) production} observed in E. coli and Klebsiella species.
• This pattern of resistance although seen primarily among nosocomially acquired infections, is also seen
isolates of E coli and Klebsiella species isolated from community acquired infections.
• These strains of bacteria are frequently resistant to other major classes of antibiotics (fluoroquinolones, β-
lactam + β-lactamase inhibitor (BL + BLI) combinations and aminoglycosides)
• Carbapenems (imipenem, meropenem and ertapenem), beta-lactam antibiotics with exceptionally broad
spectrum of activity, are the only class of antimicrobials which remain effective against ESBL-producing
isolates of E coli and Klebsiella species
• Imipenem is susceptible to degradation by the enzyme dehydropeptidase-1 (DHP-1) located in renal
tubules and requires co-administration with a DHP-1 inhibitor cilastatin. Meropenem and ertapenem are
administered without a DHP-1 inhibitor.

Indications for carbapenem use:

1. Infections [e.g., bacteremia, pyelonephritis, intra-abdominal infections (peritonitis, cholangitis, abscesses),
nosocomial pneumonia etc.] confirmed (by appropriate culture and susceptibility studies) to be caused by
Gram-negative bacteria (E coli, Klebsiella spp., Enterobacter spp., Pseudomonas aeruginosa, other non-
fermenting Gram-negative bacilli) resistant to other classes of antimicrobials and susceptible only to
carbapenems in-vitro

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2. Initial empiric treatment for severe, life-threatening infections (associated with multi-organ dysfunction,
septic shock) caused by Gram-negative bacteria.
• Febrile neutropenia
• Ventilator associated / nosocomial pneumonia
• Pyelonephritis / complicated urinary tract infections
• Complicated intra-abdominal infections
Once the culture and susceptibility reports are available, choose the most appropriate antibiotic based on
spectrum of activity, toxicity and cost (‘de-escalation’).

Indications for Ertapenem use:

Ertapenem has excellent in-vitro and in-vivo activity against ESBL producing Enterobacteriaceae, but lacks activity
against Pseudomonas aeruginosa, and is therefore not considered appropriate for the treatment of conditions like
febrile neutropenia and serious nosocomial infections. Ertapenem does not select Carbapenem-resistant
Pseudomonas aeruginosa (at least in the short-term). Its use should be restricted to severe Gram-negative or
polymicrobial community acquired infections confirmed to be caused by susceptible bacterial pathogens. Hence,
this drug may be recommended as the initial choice for ESBL producing strains of E coli and Klebsiella spp..

Indication of Meropenem and Imipenem

Meropenem and Imipenem regarded as third line agents and are reserved for:
• serious infections due to multiple resistant strains (e.g. ESBL)
• empiric use in the seriously ill patient in either ITU or Haematology
• the treatment of infective exacerbations in Cystic fibrosis (CF)
• severe acute narcotizing pancreatitis
• Outside these clinical settings it should only be used after consultation with a Clinical Microbiologist or ID
physician.

Unlike imipenem, meropenem has not been associated with CNS toxicity. Also, it is administered by convenient IV
bolus injection. Clinicians must be aware that mechanism of resistance to meropenem and imipenem are
different and hence in-vitro test for one carbapenem cannot be used to interpret the other.
Dose
Imipenem*: 500 mg IV q6h
Meropenem: 1 gm IV q8h
Ertapenem: 1gm IV/IM q24h

*Note: Optimum plasma concentrations are more reliably maintained with 6-hourly dosing.

7. VANCOMYCIN
Vancomycin is the drug of choice for in-patient treatment of the following infections.
• Serious (e.g. bacteraemia, osteomyelitis) coagulase negative staphylococcal and MRSA infections and
penicillin resistant enterococcal infections
• Empiric therapy in febrile neutropenic patients not responding to first line therapy
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 • Continuous ambulatory peritoneal dialysis (CAPD) associated peritonitis
• Prosthetic valve endocarditis

8. TEICOPLANIN
Teicoplanin is a suitable alternative to vancomycin for all indications for Vancomycin except meningitis:
• patients receiving out-patient/home parenteral therapy with glycopeptides after loading dosages
• inability to tolerate vancomycin
• oncology/haematology patients
• Rare cases of vancomycin resistant and teicoplanin sensitive strains.

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Chapter 18 PREVENTIVE STRATEGIES FOR HEALTHCARE ASSOCIATED INFECTIONS

A. Healthcare Associated Infections

Health Care Associated Infections or HCAI are a worldwide phenomenon. HCAI have been defined variously at
different times and by different organizations. Current definitions incorporate infections which were neither incubating
nor did they manifest or present, during the period of admission in patients admitted in the hospital but were present
on or after the 3rd calendar day of admission, (the day of hospital admission being calendar day 1).

B. Reducing the risk of Health care associated infections

B1. Development of an effective Infection Prevention and Control Program

Infection Prevention and Control Programs are directed towards patient safety and health care professionals’ safety.
Reducing the preventable part of health care associated infections (HCAI) is central to any Infection Control program.
An effective Infection Prevention and Control Program would have the following components:
1. Infection Control Committee with its defined role and constituents
2. Infection Control Core Team for day to day working with defined roles
3. Infection Control Manual with policies, guidelines, recommendations and working protocols including
activities and practices under the program with Hand hygiene and Standard Precautions being the mainstay
4. Annual Plan for each healthcare setup with prioritization based on risk matrix for that unit and review
5. Should incorporate Antimicrobial Stewardship programs

B2. Hand-hygiene and Standard Precautions’

Health care workers and professionals anywhere and at all levels should be well oriented to concepts of hand hygiene.
Practicing ‘Standard Precautions’, prevents direct contact with all body fluids (including blood), secretions, excretions,
non-intact skin (including rashes), and mucous membranes.
Hand hygiene in the form of tap, sink and appropriate antiseptic/ rubs for washing or hand-rub or surgical scrub should
be facilitated. At least hand rubs should be available in all patient care areas including patient’s bed side or easily
available within vicinity.

Indications for hand washing and hand antisepsis should be made known amongst all engaged in providing patient
care. Protocols and procedures of any area should always include hand hygiene as applicable and these should be
mandatory steps.

B3. Antimicrobial Stewardship Program

Antimicrobial Stewardship Program shall form another main focus of the Infection Prevention and Control Program.
This shall include all components of antimicrobial stewardship so as to stress upon advocacy of safe use of
antimicrobials, which shall be strengthened, with periodic review of antimicrobial guidelines and implementation
locally in each of the health care setups.

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B4. Educational Programs and Strategies
Appropriate educational material should be made available to all. These shall be based upon recent evidences and part
of relevant national and international guidelines and appropriately indigenized for effective implementation. This
would be augmented by periodic CME or educational interactive programs and awareness drives. Local Health care
setup should provide antimicrobial susceptibility patterns, appropriate usage of antimicrobials and have updates on
antimicrobials communicated to all relevant personnel in patient care, locally and periodically. Specific infectious
diseases and their prevention and control awareness should be made available as and when required to relevant staff
locally and may be extended to community if so desired by the health departments of that district/city/area.

B5. Notification All relevant information as required by law on communicable diseases would be notified as
appropriate to relevant authority. In case of specific reports from public health agencies requiring action on their
recommendations, appropriate action should be taken.

B6. Prophylaxis including Immunization

Staff should be immunized against diseases, which have risk of transmission through exposure from patients and to
limit transmission of diseases from healthcare workers to patients. Immunisation in high-risk group may be required
for influenza, meningococcal infections among exposure prone healthcare workers in outbreak situations, hepatitis B
vaccination for all staff, varicella vaccine to high-risk group etc. Among the diseases that have potential of being
transmitted from healthcare workers to patients, typhoid vaccine should be included among the food handling staff.
Immunize all health care workers and others involved in handling of bio-medical waste for protection against diseases
including Hepatitis B and Tetanus that are likely to be transmitted by handling of bio-medical waste. All the staff
including medical and nursing students should be immunized for potential occupational risk exposures (e.g. hepatitis
B vaccination to the students).

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Chapter 19 DOSAGE GUIDE FOR COMMONLY USED ANTIMICROBIAL AGENTS
DRUG PAEDIATRIC DAILY MAX ADULT DOSE DAILY MAX
DOSE PAEDIATRIC ADULT
Amikacin 15 mg/Kg/day in 2- 1.5g for a maximum 15mg/Kg/day in 1.5g for a maximum
3 doses IV/IM of 10 days 2-3 doses IV/IM of 10 days
Amoxycillin 20-50mg /Kg/day 1000mg/day 250-500mg q8h 4g/day
q8h PO PO
Amoxycillin- <3 months old: 90mg/kg/day in 2 625mg- 1000mg 2000mg/day
Clavulanate (dosages 30mg per kg/day, divided doses if q12h PO
based on q12h penicillin resistant S.
Amoxycillin) >3 months: 20-40 pneumonia suspected
mg per kg/day, q8- or in otitis media
12h
Max 1.5g/day 1.2 g q8h IV
Ampicillin 100-400 4g/day PO; 12g/day 500 mg-1gm q 6 4g/day PO; 12g/day
mg/kg/day in 4 IV hourly IV
doses (IV) Intravenous or
Oral
Ampicillin/sulbactam 25 to 50 mg/kg 8 g/day (ampicillin) Ampicillin/sulbac IV
(ampicillin 4 g/day (sulbactam) tam 1.5-3gm IV
component) q6h q6h
Azithromycin 10 mg/kg/day once 500mg/day PO 500mg daily PO 500mg/day PO
daily PO
Enteric fever 20
mg/kg/day once
daily
Benzathine 1,200,000 units( >30 1.2million units/dose 1.2-2.4 million 2.4million
penicillin Kg) as single dose units/dose as a units/dose
600,000 units ( <30 single dose
Kg) as single dose
Cefazolin 100 mg/kg/day IV in 6g/day 100 mg/kg/day 6g/day
3-4 divided doses IV in 3-4 divided
Intravenous doses

Cefepime 50mg/kg 12hrly 4g/day 1-4gm/day in 2-3 4g/day

for 10days. doses
Intravenous
Cefixime 8mg/kg/day q12 or 400mg/day 400mg/day in 1-2 400mg/day
24h; 15- divided doses.
20mg/kg/day q12h
for enteric fever

Cefotaxime 100mg/kg/day in 3-4 12g/day 1-2gm 6-8 hourly 12g/day

divided doses, Intravenous
200mg/kg/day in 4
divided doses for
meningitis

Cefpodoxime 5mg/kg/day PO in 200mg/dose 100-200mg q12h 400mg/day PO;

2 divided doses. PO 800mg/day for skin
and skin structure
infections

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DRUG PAEDIATRIC DAILY MAX ADULT DOSE DAILY MAX
DOSE PAEDIATRIC ADULT
Ceftazidime 75-100mg/kg/day in 3 6g/day 1-2g q 8-12 6g/day
divided doses hourly (IV)
100mg/kg/day in
meningitis (IV)
Ceftriaxone 50-100 mg/kg/day in 2 4g/day 1-2gm q 12-24 4g/day
divided doses hourly
Meningitis
100mg/kg/day in 2
divided doses
Cefuroxime 75-100mg/kg/day IV in 1g/day PO; 3g/day 750mg- 1.5g q 8h 1g/day PO; 6g/day
2 divided doses; IV IV
30mg/kg/day PO in 2
divided doses
Cephalexin 30-40mg/kg/day in 3 1000mg/day 250-500mg q 8 1.5g/day
divided doses hourly
Chloramphenicol 75-100mg/kg/day in 4 4g/day 50mg/kg/day in 4 4g/day
divided doses Avoid in divided doses
infants less than 3
months
Ciprofloxacin 20-30mg/kg/day in 2 750mg/dose PO; 250-750mg q 12 750mg/dose PO;
divided doses 400mg/dose IV hourly 400mg/dose IV
Clarithromycin 15mg/kg/day in 2 divided 250-500mg bid 500 mg/dose
doses Ig/day
Clindamycin 40-60mg/kg/day in 3- 4 1.8kg/day 150-300 mg q 6-8 4.8g/day; single IM
divided doses hourly (oral, IV) injection 600mg;
Severe infections single IV infusion
300-600 mg q8h IV 1.2g
Cloxacillin 50-100mg/kg/day in 3-4 4g/day 250-500mg q6h; 1- 8g/day
divided doses. 100- 2g q6h in severe
200mg/kg/day divides q infections
6 hourly
Cotrimoxazole 5-10mg/kg/day in 2 960mg/day 480-960mg q12h 960mg/day
divided doses
(trimethoprim content)
20mg/kg/day in 4 divided
doses in Pneumocystis
jirovecii pneumonia
Erythromycin 30-50mg/kg/day PO in 4 2g/day 250-500mg q6h 2g/day
divided doses. Severe
infection 50-100mg/kg/day

Fluconazole 3-12mg/kg 600mg/day 150mg stat; 100- Up to 800mg/day

200mg daily based on diagnosis
depending on
diagnosis
Gentamicin 2.5-5 mg/kg/day in 2- 3 5mg/kg/day in 2-3 3-5 mg/kg/day in 3 15mg/kg/day in 3
divided doses divided doses divided doses; 5- divided doses
7mg/kg /dose IV
q24h

Imipenem cilastin 10-25mg/kg/dose IV q6h; 2g/day for fully 250-500mg q6h; 50mg/kg/day or
60mg/kg/day in 3-4 susceptible 500-750mg q12h 4g/day, whichever
divided doses organisms; 4g/day for is lower
moderately
susceptible organisms

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DRUG PAEDIATRIC DAILY MAX ADULT DOSE DAILY MAX
DOSE PAEDIATRIC ADULT

Levofloxacin 20mg/kg PO or IV Q12h ; 250mg/dose 500-750mg PO or 750mg

Children 50kg or more: IV daily
500mg PO or IV Q24hr

Meropenem 60mg/kg/day IV q8h; 1.5g/day 1.5 -3gm/day in 3 6g/day

120mg/kg/day IV q8h divided doses
in severe infections 6gm/day in
meningitis
Metronidazole 7.5 mg/kg/day dose 3 1.2g/day Po or IV 500-700 IV q 8 4g/day
times/day 30- hourly; 200-400mg
50mg/kg/day in 3 divided q8h PO
doses for liver abscess

Nitrofurantoin 8 mg/kg/day in 2 divided 400mg/day 50-100 mg q 6 400mg/day

doses hourly (5-
7mg/kg/day in 4
divided doses
Ofloxacin Not recommended for 200-400 q 12 800mg/day
use in children hourly

Penicillin G 50,000units/kg/ dose 6 24million units / day 2-24 million units 24million units /
hourly (neonates) day in divided day
200,000-400,000 doses q4-6h (IV)
units/kg/day in 4 divided
doses (IV)
Penicillin V 20-50 mg/kg/day in 4 2g/day 250-500 mg q6- 2g/day
divided doses 8h.

Piperacillin 100mg/kg IV/IM q12h 24g/day 3-4g/dose q4-6h 24g/day

(neonates); 200- IV; 2-3g/dose q6-
500mg/kg/day IV/IM q4- 12h IM
6h
Piperacillin – 200-400mg/kg/day in 3-4 18g/day 3.375g - 4.5 gm 18g/day
Tazobactam divided doses q6- 8h

Vancomycin 40-60 mg/kg/day in 3-4 2g/day 0.5gm q 6 hourly 2g/day

divided doses IV or 1gm q12h
IV/PO

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ABBREVIATIONS
AIDS Acute Immuno Deficiency Syndrome GBS- Guillain Barre syndrome
ALT- Alanine Amino Transferase GI-Gastro-Intestinal
AM-CL- Amoxicillin/clavulanate HIV-Human Immunodeficiency Virus
AMR – Antimicrobial Resistance HSV- Herpes Simplex virus
ANC- Ante-Natal Care ICU-Intensive Care Unit
AOM- Acute otitis media ID- Infectious disease
ART- Anti retroviral treatment IU- International unit
AST- Anti microbial susceptibility test IUD- Intra Uterine Device
ATT- Anti Tubercular Treatment IV-Intra Venous
BAL- Broncho Alveolar lavage LBW-Low Birth Weight
BCG- Bacillus Calmette Guerin MDR-Multi Drug Resistant
BD- Bis in Die (12 hourly) MIC- Minimum Inhibitory Concentration
BL-BLI- Beta lactam-beta-lactam inhibitor MRSA- Methicillin Resistant Staphylococus aureus
BMT- Bone Marrow Transplantation MSSA- Methicillin Sensitive Staphylococcus aureus
BP- Blood Pressure NICU- Neonatal Intensive Care Unit
CABG- Coronary Artery Bypass graft OD- Once a day
CAPD- Continuous Ambulatory Peritoneal Dialysis OPD-Outdoor Patient Department
CI- Confidence Interval OT-Operation Theatre
CLSI- Clinical and Laboratory Standards Institute PANDAS- Paediatric Autoimmune Neuropsychiatric
CME- Continuing medical education Disorders Associated with Streptococcal Infections
CMV- CytoMegalo Virus PCR- Polymerase chain reaction
CNS-Central Nervous System PICU-Paediatric Intensive Care Unit
COVID-19 – Corona virus disease 2019 PJI-Periprosthetic Joint Infection
CRBSI-Catheter Related Bloodstream Infection RNTCP-Revised National Tuberculosis Control Programme
CRP- C reactive protein RTI- Reproductive tract infection
CRS-Congenital Rubella Syndrome SOP- Standard operating procedure
CSF- Cerebro Spinal Fluid STI-Sexually Transmitted Infection
CSSD- Central Stores and Supply Department TB-Tuberculosis
CTVS- Cardio Thoracic and Vascular Surgery TDS - Ter die sumendum (8 hourly)
CVS- Cardiovascular System TMP-SMX- Trimethoprim sulphamethoxazole
DS- Double Strength TMP-SMX-DS- Trimethoprim sulphamethoxazole double
DT-Dispersible Tablet strength
DVT- Deep Venous Thrombosis URI-Upper Respiratory Infection
E.T.O-Ethylene Oxide Sterilization UTI-Urinary Tract Infection
ECG- Echo Cardiogram VAP-Ventilator Associated Pneumonia
ECHO- Echo Cardiography HAP-Hospital Acquired Pneumonia
EGA-Estimated Gestational Age VDRL-Venereal Disease Research Laboratory
ENT-Ear Nose Throat VRE-Vancomycin Associated Enterococci
ESBL-Extended-Spectrum Beta- Lactamase VZIG- Varicella Zoster immunoglobulin
ESRD- End Stage Renal Disease WBC-White Blood Cell
FDA- Food and Drug Authority WHO-World Health Organization
FQ- Fluoroquinolone
G6PD- Glucose 6- phosphate dehydrogenase

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