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==[[Smallpox]]==
==[[Smallpox]]==
{{Smallpox Treatment}}
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==[[Tularemia]]==
{{Tularemia antibiotics}}


=Environmental Exposure=
=Environmental Exposure=

Revisión del 07:02 27 abr 2015

For antibiotics by organism see Microbiology (Main)

Bone and Joint

Diabetic foot infection

Associated organisms include Staphylococcus, Streptococcus, Enterococcus, Enterobacteriaceae, Proteus, Bacteroides, and Pseudomonas, and Klebsiella

Superficial Mild Infections

Prior antibiotic treatment or moderate infections

Inpatient Treatment


Diskitis or Osteomyelitis

Inpatient Therapy

Use cefepime or ciprofloxacin if targeting Pseudomonas spp

Felon

Definitive treatment is drainage but antibiotic coverage for S. aureus and Strep with caution to identify Herpetic whitlow

Infectious Tenosynovitis

Treatment should cover S. aureus, Streptococcus, and MRSA

Animal Bites

Pediatrics

Mycobacteria related

Treatment should include usual therapy listed above in addition to:

Open fracture

Prophylactic Antibiotics for Open fractures

Initiate as soon as possible; increased infection rate when delayed[1]

Grade I & II Fractures Options

  • Cefazolin 2 g IV (immediately and q8 hours x 3 total doses) (Ancef)[2]
  • Cephalosporin allergy: Clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)[2]

Grade III Fracture Options

  • Ceftriaxone 2 g IV (immediately x 1 total dose) PLUS Vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]
  • Cephalosporin allergy: Aztreonam 2 g IV (immediately and q8 hours x 3) PLUS Vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]

Special Considerations

Pediatric

Grade I & II
  • Cefazolin 25mg/kg IV (max 2g) immediately then q8hrs x 3 doses
  • Cephalosporin allergy: Clindamycin 10mg/kg IV (max 900mg) immediately then q8hrs x 3 doses
Grade III
  • Ceftriaxone 50mg/kg IV (max 2g) x 1 + Vancomycin 15mg/kg IV (max 1g) then q12hrs x 2 doses
  • Cephalosporin allergy: Aztreonam 30mg/kg IV (max 2g) then q8hrs x 3 + Vancomycin

Osteomyelitis

Risk Factor Likely Organism Initial Empiric Antibiotic Therapy'
Elderly, hematogenous spread MRSA, MSSA, gram neg Vancomycin 1g IV q12h + (Piperacillin/Tazobactam 3.375g IV q6h OR Imipenem 500mg IV q6h)
Sickle Cell Disease Salmonella, gram-negative bacteria Ceftriaxone 50mg/kg IV once daily OR Cefotaxime 50mg/kg IV three times daily, PLUS
  • Vancomycin 15mg/kg IV four times daily OR
  • Clindamycin 10mg/kg IV PO four times daily OR
  • Nafcillin 50 mg/kg IV four times daily to cover K. Kingae (common in daycare population)
DM or vascular insufficiency Polymicrobial: Staph, strep, coliforms, anaerobes Vancomycin 1g IV q12h + (Piperacillin/Tazobactam 3.375g IV q6h OR Imipenem 500mg IV q6h)
IV drug user MRSA, MSSA, pseudomonas Vancomycin 1g IV q12h 
Newborn MRSA, MSSA, GBS, Gram Negative Vancomycin 15mg/kg load, then reduce dose, AND Ceftazidime 30mg/kg IV q12 h
Children MRSA, MSSA Vancomycin 10mg/kg q6 h AND Ceftazidime 50mg/kg q8hr
Postoperative (ortho) MRSA, MSSA Vancomycin 1g IV q12h
Human bite Strep, anaerobes, HACEK organism Piperacillin/Tazobactam 3.375gm OR Imipenem 500mg IV q6h
Animal bites Pasteurella, Eikenella, HACEK organism Piperacillin/Tazobactam 3.375gm OR Imipenem 500mg IV q6h
Foot puncture wound Pseudomonas Anti-pseudomonal, staph coverage
  • Dicloxacillin <40kg: 50-100mg/kg/day PO divided q6h; >40kg: 250-500mg PO q6h

Septic Arthritis

For adults treatment should be divided into Gonococcal and Non-Gonococcal

Gonococcal

Non-Gonococcal

Pediatrics

Neonates (<3 months)
Children (>3 months)

Sickle Cell

Coverage for Salmonella and Staphylococcus spp

Septic Bursitis

Cover Staphylococcus aureus (80-90%) and Streptococcus

Outpatient Options

Treatment followup with primary physician is important since the regimen may need extension to 3 weeks.

Inpatient Options

Cardiovascular

Endocarditis

Native Valves

Options:[4]

Suspected MRSA:[4]

Prosthetic Valves (Early)

Early prosthetic valve endocarditis defined as < 12 months post surgery[4]

IV Drug User without Prosthetic Valve

Prosthetic Valve (Late)

Late prosthetic valve endocarditis defined as ≥ 12 months post surgery[4]
  • Same as native valve endocarditis empiric therapy

Dental Procedure Prophylaxis

All antibiotics options are given as a single dose 1 hour prior to the dental procedure

Options:[5]

Pediatric Dosing:

Pediatric Empiric

ENT

Conjunctivitis

Newborn

Chlamydial

  • Doxycycline 100mg PO BID for 7 days OR
  • Azithromycin 1g (20mg/kg) PO one time dose
  • Newborn Treatment: Azithromycin 20mg/kg PO once daily x 3 days or erythromycin PO 50 mg/kg/day in 4 divided doses for 14 days [6]
    • Disease manifests 5 days post-birth to 2 weeks (late onset)

Gonococcal

  • Due to increasing resistance, CDC recommends dual therapy with Ceftriaxone and Azithromycin (even if patient is negative for Chlamydia).
  • Ceftriaxone 1g IM single dose PLUS
  • Azithromycin 1g PO one dose
  • Newborn Treatment:
    • Prophylaxis: Erythromycin ophthalmic 0.5% x1
    • Disease manifests 1st 5 days post delivery (early onset)
    • Treatment Ceftriaxone 25-50mg IV or IM, max 125mg or cefotaxime single dose of 100 mg/kg (preferred if the patient has hyperbilirubinemia)
    • Also requires evaluation for disseminated disease (meningitis, arthritis, etc.)

Bacterial Conjunctivitis

  • Counsel patient/family on importance of hand hygiene/avoiding touching face to prevent spread!
  • Apply warm or cool compresses (for comfort and cleansing) every 4 hours, followed by instillation of ophthalmic antibiotic solutions

These options do not cover gonococcal or chlamydial infections

  • Polymyxin B/Trimethoprim (Polytrim) 2 drops every 6 hours for 7 days OR
  • Erythromycin applied to the conjunctiva q6hrs for 7 days OR
  • Levofloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
  • Moxifloxacin 0.5% ophthalmic 1-2 drops every 2 hours for 2 days THEN every 6 hours for 5 days OR
  • Gatifloxacin 0.5% ophthalmic solution 1-2 drops every 2 hours for 2 days THEN 1 drop every 6 hours for 5 days OR
  • Azithromycin 1% ophthalmic solution 1 drop BID for 2 days THEN 1 drop daily for 5 days
  • Chloramphenicol 0.5% ophthalmic solution 1 drop QID for 7 days

NB: levofloxacin is preferred for contact lens wearers for coverage of pseudomonas. Advise not to wear contacts for duration of treatment

Pediatric

Same topical regimens as adults; erythromycin ointment preferred in neonates and young infants

  • Erythromycin 0.5% ophthalmic ointment applied q6hrs x 7 days (preferred in neonates/infants) OR
  • Moxifloxacin 0.5% ophthalmic 1 drop TID x 7 days OR
  • Azithromycin 1% ophthalmic solution 1 drop BID x 2 days then daily x 5 days

Epiglottitis

Coverage targets Streptococcus pneumoniae, Staphylococcus pyogenes, and Haemophilus influenzae, and H. parainfluenzae

Immunocompetent

Immunocompromised

Coverage should extend to all of the typical organisms above as well as Pseudomonas, M. tuberculosis, and C. albicans

Pediatric Immunocompetent

Pediatric Immunocompromised

Dental Abscess

Treatment is broad and focused on polymicrobial infection

Pediatric

Ludwig's Angina

  • Must cover typical polymicrobial oral flora and tailored based on patient's immune status
  • Most commonly a 3rd generation cehpalosporin + (clindamycin or metronidazole)
  • If the patient is immuncompromised, the antibiotics need to also cover MRSA and gram-negative rods[8]

Immunocompetent Host[9]

Pediatric Immunocompetent

Immunocompromised[10]

Pediatric Immunocompromised

Mastoiditis

Coverage against S. pneumoniae, S. pyogenes, S. aureus, H. influenzae

Pediatric

Trench Mouth (Acute Necrotizing Ulcerative Gingivitis)

Options

also nystatin oral rinses of 5ml q6 hrs daily for 14 days will help with concominent fungal infection

HIV positive

in addition to antibiotic regimen consider an oral anti-fungal or nystatin

Otitis Media

Initial Treatment

High Dose Amoxicillin

  • <2 months
    • Amoxicillin 30mg/kg/day PO divided q12h x 10 days
    • First Dose: 15mg/kg PO x 1
  • 2 months - 5 years
    • Amoxicillin 80-90mg/kg/day PO divided q12h x 10 days
    • First Dose: 40-45mg/kg PO x 1
    • Max: 1000mg/dose
  • 6-12 years
    • Amoxicillin 80-90mg/kg/day PO divided q12h x 5-10 days
    • First Dose: 40-45mg/kg/day PO x 1
    • Max: 1000mg/dose

Treatment during prior Month

  1. If amoxicillin taken in past 30 days, Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea
  2. Cefdinir 14mg/kg/day BID x7-10 days
  3. Cefpodoxime 10mg/kg PO daily x7-10 days
  4. Cefuroxime 15mg/kg PO BID x7-10 days
  5. Cefprozil 15mg/kg PO BID x7-10 days

Otitis/Conjunctivitis

  • Suggestive of non-typeable H.flu
  1. Amoxicillin/Clavulanate
    • 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
    • Clavulanate increases vomiting/diarrhea

Treatment Failure

defined as treatment during the prior 7-10 days

  1. Amoxicillin/Clavulanate 80-90mg of amoxicillin per kg/day PO divided BID x 7-10 days
  2. Ceftriaxone 50mg/kg IM once as single injection x 3 days
    • Use if cannot tolerate PO

Penicillin Allergy

  1. Azithromycin 10mg/kg/day x 1 day and 5mg/kg/day x 4 remaining days
  2. Clarithromycin 7.5mg/kg PO BID x 10 days
  3. Clindamycin 10mg/kg PO three times daily
  • Cephalexin 75-100mg/kg/day PO divided q12h x 10 days; Max: 4,000mg/24h

Otitis Externa

  1. Ofloxacin 5 drops in affected ear BID x 7 days (Floxin otic)[11]
    • Safe with perforations
  2. Ciprofloxacin-hydrocortisone 3 drops in affected ear BID x 7 days
    • Contains hydrocortisone to promote faster healing
    • Not recommended for perforation since non-sterile preparation
  3. Ciprofloxacin-dexamethasone 4 drops in affected ear BID x 7 days
    • Similar to Cipro HC but safe for perforations
    • Often more expensive
  4. Cortisporin otic 4 drops in ear TID-QID x 7days (neomycin/polymixin B/hydrocortisone)
    • Use suspension (NOT solution) if possibility of perforation
    • Animal studies suggest possible toxicity from the neomycin although rigorous data is lacking[12]

Pediatric: Same topical regimens apply to children

  1. Ofloxacin 5 drops (>12yr) or 3 drops (<12yr) in affected ear BID x 7 days
  2. Ciprofloxacin 3-4 drops in affected ear BID x 7 days (with dexamethasone or hydrocortisone)

Streptococcal Pharyngitis

Treatment can be delayed for up to 9 days and still prevent major sequelae

Penicillin Options:

Penicillin allergic (mild):

Penicillin allergic (anaphylaxis):[13]

  • Clindamycin 7 mg/kg/dose TID (maximum = 300 mg/dose) x 10 days[19]
  • Azithromycin 12 mg/kg PO once (maximum = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days[20]
  • Clarithromycin 7.5 mg/kg/dose PO BID (maximum = 250 mg/dose) x 10 days[21]


Pediatric Dosing:

  • Amoxicillin 50mg/kg PO once daily x 10 days (max 1000mg)
  • Penicillin V <27kg: 250mg PO BID-TID x 10 days; >27kg: 500mg PO BID-TID x 10 days
  • Penicillin G Benzathine <27kg: 600,000 units IM x 1; >27kg: 1.2 million units IM x 1
  • PCN allergy (mild): Cephalexin 20mg/kg PO BID x 10 days (max 500mg/dose)
  • PCN allergy (mild): Cefadroxil 30mg/kg PO daily x 10 days (max 1g)
  • PCN allergy (severe): Azithromycin 12mg/kg PO day 1 (max 500mg), then 6mg/kg daily x 4 days (max 250mg)
  • PCN allergy (severe): Clindamycin 7mg/kg/dose PO TID x 10 days (max 300mg/dose)
  • PCN allergy (severe): Clarithromycin 7.5mg/kg PO BID x 10 days (max 250mg/dose)

Periorbital Cellulitis

Antibiotics

Outpatient

Treatment recommended for 5-7 days. If signs of cellulitis persist at the end of this period, treatment should be continued until the eyelid erythema and swelling have resolved or nearly resolved.

  • TMP/SMX 1-2 double-strength tablets BID OR

- In children: TMP/SMX 8 to 12 mg/kg QD of the TMP component divided every 12 hours

  • Clindamycin 300mg Q8H - In children: Clindamycin 30 to 40 mg/kg per day in three to four equally divided doses, maximum 1.8 grams per day

PLUS one of the following agents:

- In children: Amoxicillin 45-90 mg/kg per day divided every 12 hours

- In children: Cefpodoxime 10 mg/kg per day divided every 12 hours, max 200 mg

  • Cefdinir 300 mg BID - In children: Cefdinir 14 mg/kg per day, divided every 12 hours, max daily 600 mg

Inpatient

Pediatric:

Peritonsillar Abscess

Coverage for Streptococcus species, anerobes, Eikenella, H. influenza, S. auresus

Outpatient Options

Inpatient Options

Pediatric Outpatient

Pediatric Inpatient

Pertussis

  • Antibiotics do not help with severity or duration but may decrease infectivity.
  • A reasonable guideline is to treat persons aged >1 year within 3 weeks of cough onset and infants aged <1 year and pregnant women (especially near term) within 6 weeks of cough onset. [24]
  • TMP--SMZ should not be administered to pregnant women, nursing mothers, or infants aged <2 months.[25]
  • The following regemins are for active disease or postexposure prophylaxis. If a patient is has confirmed disease and is likely to be in contact with infants or pregnant women then the patient should be treated as up to 6-8 weeks after the onset of their illness.

< 1 month old

Same antibiotics for active disease and postexposure prophylaxis

>1 month old

  • Azithromycin 10mg/kg (max 500mg/day) daily x 5 days
    • if > 6 months old then day 2-5 of treatment should be reduced to 5mg/kg (250mg/day max)
  • TMP/SMX 4mg/kg PO BID daily for 14 days (if > 2 months old)


Adults

any of the following antibiotics are acceptable although azithromycin is most commonly prescribed

Suppurative Parotitis

Treatment targeted at S. aureus, gram negative bacilli, mumps, enteroviruses, and influenza virus

Pediatric

Thrush

  • Nystatin oral suspension 400,000-600,000 units (swish and swallow) Q6H until 48 hours after symptoms disappear OR
  • Clotrimazole 10 mg troches 5 times/day for 14 consecutive days OR
  • Fluconazole 200 mg PO on day one, followed by 100 mg daily for two weeks
    • Fluconazole is reserved for moderate to severe disease

Pediatric Dosing

If the patient is breast feeding it is important for the mother to treat her nipples before and after feeding

  • Nystatin Oral Suspension 100,000 units/ml for 14 days for all ages
    • Premature infants should only have 0.5 - 1 mL given to each side of the mouth every 6 hours
  • Clotrimazole 10mg PO five times daily for 14 days
    • reserved for patients > 3 years old
  • Fluconazole 6 mg/kg PO on day one, followed by 3 mg/kg daily for two weeks

Eye

Corneal Abrasion

Does Not Wear Contact Lens

Wears Contact Lens

Antibiotics should cover pseudomonas and favor 3rd or 4th generation fluoroquinolones

  • Levofloxacin 0.5% solution 2 drops ever 2 hours for 2 days THEN q6hrs for 5 days OR
  • Moxifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
  • Tobramycin 0.3% solution 2 drops q6hrs for 5 days OR
  • Gatifloxacin 0.5% solution 2 drops every 2 hours for 2 days THEN q6hrs for 5 days OR
  • Gentamicin 0.3% solution 2 drops six times for 5 days

Pediatric

Same topical regimens as adults

  • Erythromycin 0.5% ointment applied QID x 3-5 days (preferred in young children)
  • Moxifloxacin 0.5% ophthalmic solution 1-2 drops QID x 5 days

Orbital Cellulitis

Pediatric:

GI

Appendicitis

Coverage should extend to E. coli, Klebsiella, Proteus, and Bacteroides (an anaerobe)

Adult Simple Appendicitis

Antibiotic prophylaxis should be coordinated with surgical consult

Options:

Pediatric Simple Appendicitis

Options:

Adult Complicated Appendicitis

Defined as perforation, abscess, or phlegmon

Options:

Pediatric Complicated Appendicitis

Options:

Cautious use should be applied to use of fluoroquinolones in complicated pediatric appendicitis due to the risk of tendon injury

Cholecystitis

Most often isolated organisms are Escherichia coli, Klebsiella pneumonia, and anaerobes, especially Bacteroides fragilis

Uncomplicated

Pathogenicity of Enterococci remains unclear and specific coverage is not routinely suggested for community-acquired infections[26]

Complicated or Healthcare Associated

Examples of complication include severe sepsis or hemodynamic instability

  • Vancomycin 15-20mg/kg PLUS any of the following options

Options:

Pediatric

Clostridium Difficile

Moderate Infection

  • Vancomycin 125 mg PO four times daily for 10 days
  • Fidaxomicin 200 mg PO two times daily for 10 days
  • Metronidazole 500mg PO or IV three times daily for 10 days (third line therapy)

Pediatric:

  • Vancomycin 10mg/kg PO QID x 10 days (max 125mg/dose)
  • Fidaxomicin 200mg PO BID x 10 days (>12yr and >40kg); weight-based for younger
  • Metronidazole 7.5mg/kg PO/IV TID x 10 days (max 500mg/dose) (third line)

Serous Infection

Diverticulitis

Uncomplicated

First, consider whether antibiotics are needed:

  • In immunocompetent patients with mild uncomplicated diverticulitis (no systemic signs, able to tolerate PO, reliable follow-up), a trial of supportive care alone (bowel rest, hydration, pain control) without antibiotics is reasonable[27][28]
  • Antibiotics ARE indicated if: immunocompromised, significant comorbidities/frailty, CRP >140 mg/L, WBC >15 × 10⁹/L, refractory symptoms, vomiting, or CT showing fluid collection or longer segment of inflammation[27]

If antibiotics are prescribed (4-7 day course preferred):[27]

Preferred:

  • Amoxicillin/Clavulanate 875/125mg PO Q8hrs x 5 days (or Augmentin XR 2 tablets BID [each tablet 1gm amoxicillin 62.5mg clavulanate])[29][30]
    • Equally effective as fluoroquinolone + metronidazole with lower C. difficile risk (especially in patients ≥65 years)[30]
    • Avoids FDA black box fluoroquinolone risks (tendinopathy, neuropathy, aortic dissection, CNS effects)[31]

Alternatives (penicillin allergy or intolerance):

Complicated

Options:

Peritonitis

Intra-Abdominal Sepsis/Peritonitis

Harbor-UCLA Santa Monica-UCLA Other
Primary
Allergy or prior exposure

Pediatric

Infectious Diarrhea

Campylobacter jejuni

Pediatric:

Entamoeba Histolytica

Giardia lamblia

Microsporidium

Cryptosporidium

Salmonella (non typhoid)

  • Treatment is not recommended routinely but should be considered if:
  • Immunocompromised
  • Age<6 mo or >50yo
  • Has any prostheses
  • Valvular heart disease
  • Severe Atherosclerosis
  • Active Malignancy
  • Uremic

Options: Immunocompromised patients should have 14 days of therapy

Pediatric:

  • Treatment recommended if age <6 months, immunocompromised, or bacteremia
  • Ceftriaxone 50-75mg/kg IV daily x 5 days (max 2g)
  • TMP/SMX 8mg/kg/day (TMP) PO divided BID x 5 days
  • Azithromycin 10mg/kg PO day 1, then 5mg/kg/day x 4 days

Shigella

Treatment extended for 10 days if immunocompromised'

Pediatric:

  • Azithromycin 10mg/kg PO day 1 (max 500mg), then 5mg/kg/day x 4 days
  • Ceftriaxone 50mg/kg IM/IV daily x 5 days (max 2g)
  • TMP/SMX 8mg/kg/day (TMP) PO divided BID x 5 days (if susceptible)

Vibrio Cholerae

Yersinia enterocolitica

Antibiotics are not required unless patient is immunocompromised or systemically ill


Traveler's Diarrhea

Options for Adults:

Typhoid Fever

Oral therapy with Quinolone Susceptibility

Parenteral Therapy with Quinolone Susceptibility

Parenteral Therapy with Quinolone Resistance

if nalidixic acid resistant, assume fluoroquinolone resistant
OR
  • Cefixime 10-15 mg/kg IV q 12 hrs x 8 days

Oral Therapy with Quinolone Resistance

  • Azithromycin 1 g PO daily x 5 days
  • Amoxicillin Not 1st line treatment; 50-100mg/kg/day PO divided q6-8h x 14 days; First Dose: 12.5mg-33.3mg/kg PO x 1
  • Amoxicillin Not 1st line treatment; 50-100mg/kg/day PO divided q6-8h x 14 days

Pediatric

  • Ceftriaxone 50-80mg/kg IV daily x 10-14 days (max 2g)
  • Azithromycin 10-20mg/kg PO daily x 5-7 days (max 1g)
  • Cefixime 15-20mg/kg/day PO divided BID x 7-14 days (max 400mg/dose)

GU

Candida vaginitis

Uncomplicated

There is little resistance to azole medications; treatment often dictated by patient preference.

  • Fluconazole 150mg PO once[39]
  • Intravaginal therapy
    • Clotrimazole 1% cream applied vaginally for 7 days OR 2% applied vaginally for 3 days
    • Miconazole 2% cream applied vaginally for 7 days OR 4% cream x 3 days
    • Butoconazole 2% applied vaginally x 3 days
    • Tioconazole 6.5% applied vaginally x 1

Complicated

Severe or immunosuppressed

Non-albicans species

  • For example, C. glabrata, C. krusei and other atypical Candida spp.
  • Boric acid vaginal suppository intravaginal qday x ≥14 days
    • Can be fatal if taken orally
  • If empirically treated and later is found to have non-albicans Candida spp., no change in therapy is needed if patient is improving (otherwise switch to boric acid.

Recurrent (≥ 4 infections in a year)

  • Treat as for uncomplicated (see above)
  • Once therapy completed, prescribe long-term treatment
    • Fluconazole 150mg PO qweek x 6 months OR
    • Intravaginal medication, such as clotrimazole 500mg PV qweek or 200mg PV twice a week

Pregnant Patients

  • Intravaginal clotrimazole or miconazole are the only recommended treatments
  • Duration is 7 days
  • PO fluconazole associated with congenital malformations and spontaneous abortions[40]

Balanoposthitis

Common organisms are Candida, anaerobes, and Group B Streptococcus

Antifungal

  • Clotrimazole 1% applied topically to glans q12hrs until resolution
  • Nystatin cream 100,000 units/gm if infection is recurrent after clotrimazole therapy


Antibacterial

  • Topical triple antibiotic ointment QID or Mupirocin cream BID

Epididymitis/Epididymorchitis

  • For acute epididymitis likely caused by STI [41]
  • For acute epididymitis most likely caused by STI and enteric organisms (MSM)
  • For acute epididymitis most likely caused by enteric organisms

For persons weighing ≥150 kg, 1 g of ceftriaxone should be administered.

Cervicitis/Urethritis

Presumed GC/chlamydia of cervix, urethra, or rectum (uncomplicated)[42]

Typically, treatment for both gonorrhea and chlamydia is indicated, if one entity is suspected.

Standard


Ceftriaxone contraindicated

^Additional chlamydia coverage only needed if treated with cefixime only

Partner Treatment

Associated Bacterial Vaginosis or Trichomonas vaginalis

Non-Pregnant

Pregnant

Only treat if the patient is symptomatic

Sexual Partner Treatment

Acute cystitis

===Outpatient=== Women, Uncomplicated

  • Nitrofurantoin ER 100mg BID x 5d, OR
  • TMP/SMX DS (160/800mg) 1 tab BID x 3d (Females) x7days (Males), OR
  • Cephalexin 250mg QID x 5d, OR
  • Ciprofloxacin 250mg BID x3d
    • Avoid using fluoroquinolone for the first-line treatment of uncomplicated urinary tract infections (UTIs) in women.[46]
  • Fosfomycin 3 g PO once
    • Lower clinical and microbiologic success compared to nitrofurantoin TID for 5 days [47]

Women, Complicated

Women, Concern for Urethritis

Men


===Inpatient Options=== *Ciprofloxacin 400mg IV q12hr, OR

Pediatric

  • TMP/SMX 6-12mg/kg/day (TMP) PO divided BID x 7-10 days
  • Cephalexin 25-50mg/kg/day PO divided q6-8h x 7-10 days (max 500mg/dose)
  • Nitrofurantoin 5-7mg/kg/day PO divided q6h x 7-10 days; avoid in infants <1 month
  • Cefpodoxime 10mg/kg/day PO divided BID (max 200mg/dose)
  • Cefixime 8mg/kg/day PO daily (max 400mg)

Pediatric Inpatient

Bacterial Vaginosis

First Line Therapy[48]

  • Metronidazole 500 mg PO Twice Daily for 7 days OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, Daily for 5 days OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally Nightly for 7 days

Metronidazole does not cause a disulfiram-like reaction with alcohol.[49]

Alternative Regimin

  • Clindamycin 300 mg PO BID for 7 days OR
  • Clindamycin ovules 100 mg intravaginally qHS for 3 days (do not use if patient has used latex condom in last 72 hours)

Other regimens have been studied and have varying efficacy compared to placebo but due to cost and availability do not represent alternatives outside of absolute contraindications to preferred regimens.

Pregnant

  • Metronidazole 500mg PO Twice a day x 7 days[48]
  • Metronidazole 250mg PO Three times a day has also been studied[50][51]
  • Although metronidazole crosses the placenta, no evidence of teratogenicity or mutagenic effects among infants has been reported in multiple cross-sectional, case-control, and cohort studies of pregnant women[48]

Prophylaxis (Sexual Assault)

Prostatitis

Associated with STD

Target organisms are E. coli, and STDs (GC)

No Associated STD and Chronic Bacterial Prostatitis

Aimed at Enterobacteriaceae, enterococci, Pseudomonas

  • Ciprofloxacin 500mg PO q12hrs x 28 days OR
  • Levofloxacin 500mg PO daily x 28 days OR
  • TMP/SMX 1 DS tablet PO q12hrs x 28 days
  • Consider extension to 6 wks of empiric therapy

Septic

Pyelonephritis

Treatment is targeted at E. coli, Enterococcus, Klebsiella, Proteus mirabilis, S. saprophyticus.

Outpatient

Consider one dose of Ceftriaxone 1g IV or Gentamicin 7mg/kg IV if the regional susceptibility of TMP/SMX or Fluoroquinolones is <80%

Adult Inpatient Options


Pediatric Outpatient Options

  • Cephalexin 25-50mg/kg/day PO divided q6-8h x 10-14 days (max 500mg/dose) OR
  • Cefixime 8mg/kg PO daily x 10-14 days (max 400mg) OR
  • Cefdinir 14mg/kg/day PO divided BID x 10 days (max 600mg/day) OR
  • Cefpodoxime 10mg/kg/day PO divided BID x 10 days (max 200mg/dose) OR
  • TMP/SMX 6-12mg/kg/day (TMP) PO divided BID x 10-14 days

Pediatric Inpatient Options

Lymphogranuloma venereum

  • Doxycycline 100mg PO BID x 21 days (first choice) OR
  • Erythromycin 500mg PO QID x 21 days OR
    • Preferred for pregnant and lactating females
  • Azithromycin 1g PO weekly for 3 weeks OR
    • Alternative for pregnant women - poor evidence for this treatment currently
  • Tetracycline, Minocycline, or Moxifloxacin (x21 days) are also acceptable alternatives to Doxycycline
  • Treat sexual partner

Herpes

Initial Episode[57][58]

Recurrence[57]

  • Acyclovir 400mg PO q8hrs x 5 days or 800mg PO q12hrs x 5 days or 800mg PO q8hrs x 2 days OR
  • Valacyclovir 500mg PO q12hrs x 3 days or 1g PO qd x 5 days OR
  • Famciclovir 125mg PO q12hrs for 5 days or 1g PO q12hrs for 1 day or 500mg PO once then 250mg PO q12hrs for 2 days

Suppressive Therapy[57]

Syphilis

Early Stage

This is classified as primary, secondary, and early latent syphilis less than one year.

Treatment Options:

  • Penicillin G Benzathine 2.4 million units IM x 1
    • Repeat dose after 7 days for pregnant patients and HIV infection
  • Doxycycline 100mg oral twice daily for 14 days as alternative

Congenital Syphilis:

Older Children:

Late Stage

Late stage is greater than one year duration, presence of gummas, or cardiovascular disease

Treatment Options:

Neurosyphilis

There are 3 Major options with none showing greater efficacy than others:

  • Penicillin G 3-4 million units IV every 4 hours x 10-14 days
  • Penicillin G 24 million units continuous IV infusion x 10-14 days
  • Penicillin G Procaine 2.4 million units IM daily + probenecid 500mg oral every 6 hours for 10-14 days.
  • Alternative:
  • Desensitization to the penicillin allergy is still the preferred method of treatment for patients with early and late stage disease (especially during pregnancy)

Pregnancy

  • Penicillin, dosage depends on stage [59]

Neuro

Bell's Palsy

Eye Protection

  • Cornea eye protection (Level X)[60]
    • Artificial tears qhr while patient is awake
    • Ophthalmic ointment at night
    • Eye should be taped shut at night
    • Protective glasses or goggles

Steroids

Should be started within 72hrs of symptom onset[61]

Antivirals

Most likely no added benefit when combined with steroids.[64] However also little harm associated with antivirals especially in patients with normal renal function[63]

Antibiotics

  • Consider empiric empiric dosing if high index of suspicion for Lyme based on clinical presentation or lab data

Encephalitis

Often it is unclear which type of encephalitis is present and starting Acyclovir empirically is appropriate. In addition to the pathogens below, possible causes can include West Nile Virus, EBV, HIV, toxoplasmosis, or rabies.

HSV encephalitis

  • Acyclovir 10mg/kg (10-15mg/kg for pediatrics) every 8hrs

HZV encephalitis

CMV encephalitis

Tick Associated (Borrelia burgdorferi, Ehrlichiosis or Rickettsia)

  • Doxycycline 200 mg IV once followed by 100 mg IV twice daily

Pediatric

HSV Encephalitis

  • Acyclovir 20mg/kg IV q8hrs x 21 days (neonates); 10-15mg/kg IV q8hrs x 14-21 days (children)

CMV Encephalitis

Tick Associated

Epidural Abscess

Treat for 6-8 weeks

Pediatric

Meningitis

Neonates (up to 1 month of age)[66]

MRSA is uncommon in the neonate

  • Ampicillin 75mg/kg IV q6hrs PLUS
  • Cefotaxime 50mg/kg IV q6hrs OR 2.5mg/kg IV q8hrs
    • Per AAP, ceftazidime 50mg/kg IV (q12hr for babies < 8 days of age, q8hr for >7 days old) is a reasonable alternative to cefotaxime, offering virtually the same coverage for enteric bacilli and is FDA approved for all age groups[67]
  • If suspecting S. pneumoniae or MRSA, add standard neonatal dosing
  • Consider acyclovir for HSV

> 1 month old[68]

Alternatives (e.g. penicillin/cephalosporin allergy):

Adult < 50 yr[69]

Adult > 50 yr and Immunocompromised[70]

Post Procedural (or penetrating trauma)[72]

Cryptococcosis Meningitis

Options

  • Amphotericin B 1mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily
  • Amphotericin B 5mg/kg IV once daily AND Flucytosine 25mg/kg PO q6hrs daily

Meningitis with severe PCN allergy

Meningitis with VP shunt

Neisseria meningitidis Prophylaxis

  • Ceftriaxone 250mg IM once
  • Ceftriaxone 125mg IM once (if <=15yr)
  • Ciprofloxacin 500mg PO once
  • Rifampin 600 mg PO BID x 2 days
  • Rifampin <1mo: 5mg/kg PO BID x 2 days; >=1mo: 10mg/kg PO BID x 2 days
  • Ampicillin/Sulbactam 400mg ampicillin/kg/day IM/IV divided q6 hours; First Dose: 100mg ampicillin/kg IM/IV x 1 (150mg Unasyn/kg IM/IV x 1); Max: 2000mg ampicillin (3000mg Unasyn) per DOSE
  • Meropenem 2g IV every 8 hours.
  • Nafcillin 100-200mg/kg/day IV divided q4-6h; Max: 12 g/day

Tetanus

Metronidazole:

(<1200g)

  • 7.5 mg/kg PO/IV q48h
  • First Dose: 7.5 mg/kg PO/IV x 1

(>1200g AND <1 Month Old)

  • <7 days old
    • 7.5-15 mg/kg/day PO/IV q12-24h
    • First Dose: 7.5-15 mg/kg PO/IV x 1
  • >7 days old
    • 15-30 mg/kg/day PO/IV q12h
    • First Dose: 7.5-15 mg/kg PO/IV x 1

(>1 Month Old)

  • 30 mg/kg/day PO/IV q6h
  • First Dose: 7.5 mg/kg PO/IV x 1
  • Max: 4 g/day


OBGYN

Mastitis

  • No need to routinely interrupt breastfeeding with puerperal mastitis.
  • For mild symptoms <24 hours, supportive care may be sufficient[73]
    • Effective milk removal (frequent breast feeding - use pumping to augment milk removal)
    • Analgesia (NSAIDs)

Treatment directed at S. aureus and Strep and E. coli

Endometritis

<48hrs Post Partum

Treatment is targeted against polymicrobial infections, most often 2-3 organisms of normal vaginal flora

>48hrs Post Partum

  • Doxycycline 100mg IV or PO q12hrs + Metronidazole 500mg IV or PO q8hrs
    • Use Metronidazole with caution in breastfeeding mothers as its active metabolite is present in breast milk at concentrations similar to maternal plasma concentrations

PID

Antibiotics

  • No sexual activity for 2 weeks;
  • Treat all partners who had sex with patient during previous 60 days prior to symptom onset

Outpatient Antibiotic Options

Inpatient Antibiotic Options

Pulmonary

Pneumonia

Outpatient

Coverage targeted at S. pneumoniae, H. influenzae, M. pneumoniae, C. pneumoniae, and Legionella

Healthy[82]

No comorbidities (chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; or asplenia) and no risk factors for MRSA or Pseudomonas aeruginosa (include prior respiratory isolation of MRSA or P. aeruginosa or recent hospitalization AND receipt of parenteral antibiotics (in the last 90 d))

  • Amoxicillin 1 g three times daily (strong recommendation, moderate quality of evidence), OR
  • Doxycycline 100 mg twice daily (conditional recommendation, low quality of evidence), OR
  • Macrolide in areas with pneumococcal resistance to macrolides <25% (conditional recommendation, moderate quality of evidence).
  • Duration of therapy 5 days minimum

Unhealthy[82]

If patient has comorbidities or risk factors for MRSA or Pseudomonas aeruginosa

  • Combination therapy:
    • Amoxicillin/Clavulanate
      • 500 mg/125 mg TID OR amox/clav 875 mg/125 mg BID OR 2,000 mg/125 mg BID. Duration is for a minimum of 5 days and varies based on disease severity and response to therapy; patients should be afebrile for ≥48 hours and clinically stable before therapy is discontinued[83]
    • OR cephalosporin
    • AND macrolide
      • Azithromycin 500 mg on first day then 250 mg daily
      • OR clarithromycin 500 mg BID OR clarithromycin ER 1,000 mg daily (strong recommendation, moderate quality of evidence for combination therapy)
    • OR doxycycline 100 mg BID (conditional recommendation, low quality of evidence for combination therapy)
  • Monotherapy: respiratory fluoroquinolone (strong recommendation, moderate quality of evidence):

Inpatient

  • Monotherapy or combination therapy is acceptable
  • Combination therapy includes a cephalosporin and macrolide targeting atypicals and Strep Pneumonia[84]
  • Adjunctive corticosteroids in severe CAP: The SCCM 2024 Focused Update strongly recommends corticosteroids for hospitalized adults with severe bacterial CAP (strong recommendation, moderate certainty)[85]
    • CAPE COD trial (NEJM 2023): Hydrocortisone 200 mg IV daily (50 mg q6h) in severe CAP requiring ICU/intermediate care → ↓ 28-day mortality (6.2% vs 11.9%, NNT ~18), ↓ intubation, ↓ vasopressor use[86]
    • Duration: 200 mg/day for 4–7 days based on clinical improvement, then tapered (total 8–14 days)
    • Excluded patients already in septic shock
    • No recommendation for or against steroids in less severe CAP[85]
    • Avoid in influenza pneumonia (without bacterial superinfection)[82]
  • Duration: Minimum 5 days; continue until clinically stable (temp ≤37.8°C, HR ≤100, RR ≤24, SBP ≥90, SpO2 ≥90% on RA, tolerating PO, baseline mental status) for ≥48 hours[82]
  • De-escalation: If empiric MRSA or Pseudomonas coverage was started, de-escalate to standard CAP therapy within 48 hours if cultures/MRSA nasal PCR are negative and patient is improving[82]

Community Acquired (Non-ICU)

Coverage against community acquired organisms plus M. catarrhalis, Klebsiella, S. aureus[82]

ICU, Low Risk of MRSA/Pseudomonas

ICU, Risk of Pseudomonas (without MRSA risk)

2019 guidelines recommend single antipseudomonal β-lactam (changed from double gram-negative coverage in 2007 guidelines)[82]

ICU, Risk of MRSA

Add MRSA coverage to appropriate regimen above[82]

  • Vancomycin 15–20 mg/kg IV q8-12h (target AUC/MIC 400-600) OR Linezolid 600 mg IV q12h
  • MRSA nasal PCR has a high negative predictive value (~95%); if negative, MRSA coverage can be safely discontinued[87]

Hospital Acquired Pneumonia (HAP)

Pneumonia developing ≥48 hours after hospital admission in non-intubated patients[88]

High risk of MRSA or high mortality risk (ventilatory support for HAP or septic shock)
Low risk of MRSA and low mortality risk

Ventilator Associated Pneumonia (VAP)

Pneumonia developing ≥48 hours after endotracheal intubation[88]

High risk of MRSA or IV antibiotics in the last 90 days or unit MRSA prevalence >10-20% or unknown
Low risk of MRSA and Pseudomonas (no risk factors for antimicrobial resistance, unit MRSA <10-20%)
  • Single antipseudomonal β-lactam monotherapy (from list above) is acceptable[88]
  • Duration: 7 days recommended[88]


Skin and Soft Tissue

Erysipelas

Coverage for S. pyogenes

  • Penicillin G 300K U/d IM for <30 kg, 600K to 1 million U/d IM for >30 kg (first line therapy[90]) OR
  • Clindamycin 450mg (5mg/kg) PO q8hrs x 10 days (if PCN allergic) OR
  • Cephalexin 500mg (6.25mg/kg) PO q6hrs x 10 days OR
  • Ceftriaxone 1g (50mg/kg) IV once daily x 10 days OR
  • Levofloxacin 500mg PO/IV daily x 10 days OR
  • Amoxicillin/Clavulanate 500mg PO BID x 10 days (generally reserved for failure of first line therapy)

Bullous Erysipela or MRSA suspected: trimethoprim-sulfamethoxazole, clindamycin, doxycycline, or minocycline

Pediatric

  • Penicillin G <30kg: 300,000 U/day IM; >30kg: 600,000-1 million U/day IM OR
  • Cephalexin 25-50mg/kg/day PO divided q6-8h x 10 days (max 500mg/dose) OR
  • Clindamycin 30mg/kg/day PO divided TID x 10 days (max 1.8g/day) OR
  • Ceftriaxone 50mg/kg IV daily (max 2g) x 10 days

Cellulitis/Superficial Abscess with Cellulitis

Tailor antibiotics by regional antibiogram

Outpatient

  • 5 day treatment duration
    • Cephalexin 500mg PO q6hrs OR
      • Add DS 1 tab PO BID if MRSA suspected
    • Clindamycin 450mg PO TID covers Strep and Staph


Pediatric Outpatient

  • Cephalexin 25-50mg/kg/day PO divided q6-8h (max 500mg/dose) OR
    • Add 8-12mg/kg/day (TMP) PO divided BID if MRSA suspected
  • Clindamycin 30-40mg/kg/day PO divided TID (max 1.8g/day)

Inpatient


Pediatric Inpatient

Saltwater related cellulitis

Freshwater related cellulitis

Impetigo

Coverage for MSSA, MRSA, Group A Strep

Topical therapy

Oral Therapy

Pediatric

Bioterrorism

Anthrax

Postexposure Prophylaxis

Patient should be vaccinated at day #0, #14, #28

Cutaneous Anthrax (not systemically ill)

Inhalation or Cutaneous with systemic illness

Pediatric Postexposure Prophylaxis

Pediatric Cutaneous Anthrax (not ill)

  • Same as pediatric postexposure dosing and duration

Pediatric Inhalational or Cutaneous (systemically ill)

  • Ciprofloxacin 15mg/kg IV q12hrs OR
  • Doxycycline 2.2mg/kg IV q12hrs PLUS
  • Imipenem/Cilastatin 1g IV q6h for at least 2wk
  • Imipenem/Cilastatin Neonates >32 wk gestation; 40-75 mg/kg/day IV divided q8-12h for at least 2wk; 1 month and older; 100 mg/kg/day IV divided q6h for at least 2wk
  • Rifampin 600 mg IV q12h for at least 2 wk as part of a multi-drug regimen; Switch to PO abx x60 days total if inhalational exposure
  • Rifampin Neonates >32 wk gestation; 10-20 mg/kg/day IV divided q12-24h for at least 2 wk as part of multi-drug regimen; 1+ mo; 20 mg/kg/day IV divided q12h for at least 2 wk as part of multi-drug regimen; Max: 300 mg/dose
  • Imipenem/Cilastatin 1g IV q6h for at least 2wk
  • Imipenem/Cilastatin Neonates >32 wk gestation; 40-75 mg/kg/day IV divided q8-12h for at least 2wk; 1 month and older; 100 mg/kg/day IV divided q6h for at least 2wk
  • Rifampin 600 mg IV q12h for at least 2 wk as part of a multi-drug regimen; Switch to PO abx x60 days total if inhalational exposure
  • Rifampin Neonates >32 wk gestation; 10-20 mg/kg/day IV divided q12-24h for at least 2 wk as part of multi-drug regimen; 1+ mo; 20 mg/kg/day IV divided q12h for at least 2 wk as part of multi-drug regimen; Max: 300 mg/dose

Botulism

Supportive Care

  • Early ventilatory support
    • Consider intubation when vital capacity <30% predicted or <12cc/kg
  • Wound Managment
    • Early wound debreedment with surgical consult.
    • Also exclude Necrotizing fasciitis and coverage with same broad antibiotic coverage


Foodborne Botulism

  • Equine Serum Botulism Antitoxin
    • only for patients > 1yo
  • Antitoxin obtained through CDC or local Department of Health.


Infant Botulism (<1yo)

  • Human-based Botulism IG 100mg/kg IV x 1 dose (BabyBIG)
    • infusion divided into 25mg/kg/hr IV x 15 min followed by 50mg/kg/hr if no allergic reactions
    • Stop infusion after total of 100mg/kg infused
  • BabyBIG obtained through CDC or local Department of Health


Inhalational Botulism

  • Equine Serum Botulism Antitoxin
    • only for patients > 1yo
  • Antitoxin obtained through CDC or local Department of Health


Wound Botulism

  • Individualize therapy with ID consultant
  • Broad antibiotic coverage same as for Necrotizing fasciitis while awaiting wound cultures

Smallpox

  • IMMEDIATE NOTIFICATION OF PUBLIC HEALTH AUTHORITIES
  • Vaccine administered up to 3 days post-exposure was effective in preventing infection as well as lessening the severity of the disease if infection occurred [91]

Post-Exposure Prophylaxis

  • Vaccinia Vaccine (administer within 72hrs of exposure)

Active Disease

  • Supportive care and wound care for open lesions
  • Vaccinia Vaccine within the first 72hrs can decrease total disease severity and within 7 days may decrease symptoms
    • Vaccination is not efficacious once the patient has developed rash[92]

Tularemia

Postexposure Prophylaxis

Active Disease

  • Streptomycin 1g (15mg/kg) IM q12hrs daily x 10 days (First line) OR
  • Gentamicin 5mg/kg/day IV/IM once daily x 10 days OR
  • Ciprofloxacin 400mg (15mg/kg) IV q12hrs x 10 days OR
  • Doxycycline 100mg (2.2mg/kg) IV q12hrs x 14 days OR
  • Chloramphenicol 15mg/kg IV q6hrs x 14 days
  • Streptomycin 1g IM q12h x10 days; Maximum dose: 2 g/day (adjust dose based on serum levels)
  • Streptomycin 15mg/kg IM q12h x10 days; Maximum dose: 2 g/day (adjust dose based on serum levels)

Pediatric

  • Gentamicin 2.5mg/kg IV/IM q8hrs x 10 days
  • Doxycycline 2.2mg/kg PO/IV q12hrs x 14 days (max 100mg/dose)
  • Ciprofloxacin 15mg/kg PO/IV q12hrs x 10 days (max 500mg PO / 400mg IV)

Environmental Exposure

Immunocompromised

Neutropenic Fever

Zosyn 4.5g IV

OR

Meropenem 1g IV

PLUS/MINUS

Gentamicin 2mg/kg IV

ADD

Vancomycin 1g IV for catheter related infection, colonization with MRSA, gram-positive culture unknown susceptibility, suspected sepsis

Post Exposure Prophylaxis

Pediatric

See Antibiotics By Diagnosis (Peds)

Sepsis

Arthropod and Parasitic Infections

See Also

References

  1. ↑ Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 Garner MR, et al. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. Journal of the American Academy of Orthopaedic Surgeons. April 15, 2020. 28(8):309-315
  3. ↑ HoffWS, Bonadies JA, Cachecho R, Dorlac WC: East practice management guidelines work group: Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011;70:751-754.
  4. ↑ 4.0 4.1 4.2 4.3 ESC Task Force Guidelines on the prevention, diagnosis, and treatment of infective endocarditis. European Heart Journal (2009) 30, 2369–2413 doi:10.1093/eurheartj/ehp285 PDF
  5. ↑ AHA Pocket Card Dental Prophylaxis Endocarditis
  6. ↑ Zikic A, Schünemann H, Wi T, Lincetto O, Broutet N, Santesso N. Treatment of Neonatal Chlamydial Conjunctivitis: A Systematic Review and Meta-analysis. J Pediatric Infect Dis Soc. 2018 Aug 17;7(3):e107-e115. doi: 10.1093/jpids/piy060. PMID: 30007329; PMCID: PMC6097578.
  7. ↑ Young LS, Price CS. Complicated adult epiglottitis due to methicillin-resistant Staphylococcus aureus. Am J Otolaryngol. Nov-Dec 2007;28(6):441-3.
  8. ↑ Costain N, Marrie T. Ludwig’s Angina. American Journal of Medicine. Feb 2011. 124(2): 115-117
  9. ↑ Barton E, Blair A. Ludwig's Angina. J Emerg Med. 2008. 34(2): 163-169.
  10. ↑ Spitalnic SJ, Sucov A. Ludwig's angina: case report and review. J Emerg Med. 1995;13:499-503
  11. ↑ Clinical Practice Guideline: Acute Otitis Externa Executive Summary. Otolaryngology -- Head and Neck Surgery 2014 150: 161 DOI: 10.1177/0194599813517659 PDF
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  13. ↑ 13.0 13.1 13.2 Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82
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  31. ↑ 31.0 31.1 FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. July 26, 2016.
  32. ↑ Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.
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  37. ↑ Steffen R, et al. Traveler's Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
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  41. ↑ https://www.cdc.gov/std/treatment-guidelines/epididymitis.htm
  42. ↑ Cyr SS et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR. Center for Disease Control and Prevention. 2020. 69(50):1911-1916
  43. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
  44. ↑ CDC Trichomoniasis 2021. https://www.cdc.gov/std/treatment-guidelines/trichomoniasis.htm
  45. ↑ Workowski KA, Bachmann LH, Chan PA, et al. Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep 2021;70(No. RR-4):1–187. DOI: http://dx.doi.org/10.15585/mmwr.rr7004a1external icon
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  49. ↑ Is combining metronidazole and alcohol really hazardous?[2]
  50. ↑ Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis[3]
  51. ↑ Effect of metronidazole in patients with preterm birth in preceding pregnancy and bacterial vaginosis: a placebo-controlled, double-blind study[4]
  52. ↑ Sexual Assault and Abuse and STIs – Adolescents and Adults[5]
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  56. ↑ Sandberg T. et al. Ciprofloxacin for 7 days versus 14 days in women with acute pyelonephritis: a randomised, open-label and double-blind, placebo-controlled, non-inferiority trial. Lancet. 2012 Aug 4;380(9840):484-90.
  57. ↑ 57.0 57.1 57.2 Workoski KA and Bolan GA. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommen and Reports. 2015; 64(3):1-140.
  58. ↑ https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf
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