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Sulamyd (Sulfacetamide Ophthalmic) 1 gtt Q3H x 7-10 days Warn pt that this often burns upon applic $
Gentamicin Ophthalmic 1 gtt Q4H x 7 days Use for 1 day after symptoms resolve $
Ocuflox (Ofloxacin Ophthalmic) 1 gtt Q4H 1st 2 days, then QID x 5 days $$
Otitis Media Strep pneum, Hflu, Mcat Amoxicillin [250,500 mg caps] >3mo: 90 mg/kg/d twice daily x 5 -7 days* Longer better *<2 yo or severe infxn Treat x 10 days $
[125,200,250,400 mg chews + susp/5ml] Adults: 1 gm TID x 5 days New guideline – 6yrs old get 5-7 days $
(Think of Bacterial Augmentin ES [600/42.9 mg/5ml] >3mo or <40 kg: 90mg/kd/d div Q12H x 10 days Give w/food or milk to decr GI side-effects $$$
Sinusitis as “Adult Augmentin Tab 875 mg Adults: 1 tabs po BID x 10 days $$$
Otitis Media”) • Note: No regular forms of Augmentin for OM/Sinsuitis given incr prev of drug-resist Strep pneum (unable to dose reg forms at 90mg/kg or 2 gm BID given GI side-effects from clav acid)
• HOWEVER: When Augmentin becomes cheaper (no price advantage to doing this yet) you can come up with the ES or XR versions by dosing 50mg/kg Amox and 50 mg/kg Augmentin
for kids div Q12H, or the 500/125 mg Augmentin tab +3 500 mg Amoxil tabs for adults (still dosed BID).
Omnicef (Cefdinir) 6 mo-12 yr: 14mg/kg/d div Q12H x 5 days* (Max 600 mg/d) *<2 yo or severe infxn Treat x 10 days $$
[300 mg caps; 125,250 mg/5ml] >13 yo and Adults: 300 mg Q12H x 5 days* Warn parents this can TURN POOP RED
EARS
Zithromax (Azithromycin) >6mos: 10mg/kg/d QD day 1, then 5mg/kg/d QD days 2-5 Use ONLY if PCN & CEPH allergy $$
[250,500 mg tabs; 100,200 mg/5ml] Adults: Z-pak (500 mg day 1, then 250 mg days 2-5) Up to 50% S pneum resist to Macrolides
Ciprodex Otic (For pts w/ ear tubes ONLY) 4 gtt BID x 7 days - PUMP TRAGUS to get into middle ear $$$$$
Rocephin (Ceftriaxone) 50 mg/kg IM QD x 1 dose Use QD x 3 days for treatment failures or if IN
suspect resist Strep pneum OFFICE
Otitis Externa Pseudomonas, Gentamicin Ophthalmic (YES Ophthalmic) 4 gtt QID x 7 days (Use 48 hrs after symptoms resolve) Do not use if TM perf’d $
(ACUTE) Enterobacteriaceae, Cortisporin Otic [Susp only]-Soln has EtOH(bad) 5 gtt QID x 7 days (Max 10 days) Do not use if TM perf’d, Suspension ONLY $
Proteus, Staph aureus Acetasol HC (Acetic acid/Hydrocortisone Otic) 4 gtt QID x 5-7 days Do not use if TM perf’d, Will tx yeast/fungi $$$
(Yeast/Fungi-rare) Domeboro Soln (Acetic acid/Al acetate) 4 gtt QID x 5-7 days Now OTC $
(CHRONIC) Ciprodex Otic 4 gtt BID x 7 days If Tubes can tx BOTH OM & OE $$$$$
Likely Seborrhea Acetasol HC as above PLUS tx for Seborrhea of Scalp: Selsun 2.5% Shampoo/Lotion OR Nizoral (Ketoconazole) Shampoo/Lotion
Thrush Oral Candidiasis Nystatin [100,000 units/ml] – Disp 2oz. bottle Infants: 1ml each side of mouth QID Use 48hr after symptoms resolve $$
Herpes Labialis HSV-1, 2 Acyclovir [200 mg caps; 400 mg tabs] 400 mg po TID x 5 days Use 200mg cap 2 po TID-only form on $4 $
(Cold Sores) Valtrex [1000 mg tabs] 2 gm BID x 1 day (use within 48-72h onset) $$$
Recurrent outbrks Zovirax Cream Apply 5x/day x 4 days Prevents transmission/soothes-not good tx $$$
Abreva Cream OTC Apply 5x/day until healed (Max 10 days) alone (use in combo with oral tx) $
MOUTH
Lidocaine Ointment for PAIN (5%) Apply w/ Q-tip QID prn Disp 1 tube (35 gm) $
Herpes Zoster VZV Acyclovir [400,800 mg tabs] 800 mg po 5x/d x 7 days Start within 72 hrs of symptom onset $$
(Shingles) Valtrex [500,1000 mg tabs] 1 gm Q8H x 7 days Start within 48 hrs of symptom onset $$$$$
Consider Zostavax Vaccine: Can give after Shingles outbreak – Good ages 50-80 (NNT 60), No benefit >80yo for prevention of shingles episode
Dental Abscess Polymicrobial/Anaerobes PCN VK [250,500 mg tabs; 250 mg/5ml susp] 1 gm BID x 7 days $
Augmentin [875/125 mg tabs] 1 tab BID x 7 days $$$
Use po Abx + Peridex Clindamycin [300 mg caps; 75mg/5ml] 300 mg Q8H x 7 days $$$
GET TO DENTIST !!! Peridex (Chlorhexidine topical) 15 mL swish for 30 sec and spit out BID 1 bottle (473ml) $
strep results/high school after 24hrs po Abx) Keflex (Cephalexin) <12 yo: 40mg/kg/d div Q12H x 10 days (Max 4 g/day) Good for Resist Strep given co-exist $
level clinical [125,250 mg/5ml; 250,500 mg caps] >12 yo and ADULTS: 1 gm po BID x 10 days w/Staph/Hflu/Mcat – ?becoming 1st line?
suspicion) Clindamycin susp (75 mg/5 ml) < 12 yo: 21 mg/kg/d div TID (Max 900 mg/day) $$$
Zithromax (Azithromycin) > 2 yo: *12mg/kg/d x 5 days (Max 500 mg/d) *Note the dosing differences for STREP $$
[250,500 mg tabs; 100,200 mg/5ml] Adults: Z-pak Pharyngitis
Consider for Pharyngitis: MAGIC MOUTHWASH (Compounded) 1:1:1 mixture of Viscous Lidocaine/Benadryl/Maalox (write this out on Rx) Sig: Swish, gargle, spit-out 10-20 cc QID prn pain Disp 12 oz $$
Acute Sinusitis MOST ARE VIRAL: Rec 7-10d tx w/Antihist/Decongestants, reasonable regimen: Bromfed caps Q12H for adults and Atrovent Nasal [0.06%] 2 sprays QID prn congestion…if need Abx SEE OM ABOVE
Sinus Chronic Sinusitis NO ABX NEEDED: Consider Nasal Steroids (Flonase/Nasonex/etc.) 2 sprays/nostril QD x 1 wk, then 1 spray QD - AND/OR - PO steroids x 5 days (Orapred/Orapred ODT/Prednisone, etc.)
Bronchitis Acute (non-smoker) VIRAL: NO ANTIBIOTICS NEEDED. Offer Sx Rx (they want a Rx) Bromfed DM Syrup, Tussionex, Hycodan, Albuterol HFA, maybe 5 days Prednisone if wheezing/tight
Acute(SMOKERS) Doxycycline [100 mg caps] 1 cap po BID day 1, then 1 daily x 9 days Can substitute minocycline for cost issues $
-Often colonized w/ Zithromax [250,500 mg tabs] Z-pak $$
Hflu/Atypicals Bactrim (TMP/SMX) [DS tabs] 1 tab po BID x 10 days $
Pneumonia Strep, Mycoplasma, Hflu Azithromycin [Zithromax] Z-Pak (for uncomplicated patients) If pt has been in HOSP tx for 14d TOTAL $
(Community Levaquin [500,750 mg tabs] - for complicated 750 mg QD x 5 days -OR - 500 mg QD x 10 days Remember Quinolones are conc dep killers, $$$$$
Acquired Pneum) patients – can use Augmentin + macrolide or so higher dose is better for fewer days
doxycycline in place of Levaquin
Avelox [400 mg tab] 400 mg QD x 10 days $$$$$
Pertussis Bordetella pertussis Zithromax (Azithromycin) >6mos: 10mg/kg/d QD day 1, then 5mg/kg/d QD days 2-5 -Think of pertussis in pts w/ characteristic $$
LUNG
[250,500 mg tabs; 100,200 mg/5ml] Adults: Z-pak “whooping cough” or persistent cough(>14d)
Bactrim (TMP/SMX) Kids: 10mg/kg/d div BID x 14d (based on TMP dose) -We are missing a lot of this - up to 20% of $
[40/200 mg/5ml; DS tabs] Adults: 1 Bactrim DS tab BID x 14d adults w/ persist cough(>14d) have pertussis
- Tx ALL household/close contacts as well
Pertussis Info: Can Dx based on Nasopharyngeal (NP) secretion culture, PCR of secretions, or Pertussis toxin Ab. 3 stages: Catarrhal(1-2wks), Paroxysmal Coughing(2-6wks),
Convalescence(1-2wks). Note: Tx may abort symptoms in Catarrhal stage, but NOT in Paroxysmal stage…Increasing amts of Pertussis led to new recs for Tdap booster
Flu Influenza A & B Tamiflu (Oseltamivir) Treatment: -At best will shorten duration of symptoms by $$$$$
[75 mg caps, 60 mg/5ml] Kids < 1 yo: 3 mg/kg/dose BID x 5d 1-2 days (if started within 48hrs of sx onset)
Kids (>1 yo), <15 kg: 30mg po BID x 5d -Prophylaxis in children < 3 mths is not
15-23 kg: 45mg po BID x 5d recommended unless critical situation
23-40 kg: 60mg po BID x 5d
>40 kg and Adults: 75 mg po BID x 5d
Prophylaxis of Household Contacts: same doses as above, but treat only QD x 7d $$$$$
Gastritis H. pylori Amoxicillin 1 gm po BID, Flagyl 500 mg po BID, Prilosec OTC BID x 14d, then cont Prilosec QD x 2 mos -Remember take PPI’s on EMPTY STOMACH $$
Amoxicillin 1 gm po BID, Clarithromycin 500 mg BID, Prilosec OTC BID x 14 d, then cont Prilosec QD x 2 mos -H. pylori Stool Antigen test (>90% $$$$
Bismuth 262 mg 2 tabs po QID, Tetracycline 500 mg QID, Flagyl 500 mg TID, Prilosec OTC BID x 14 days, then sens/spec) can repeat test 8 wks after tx to $$
cont Prilosec QD x 2 mos test for cure
ABDOMEN
1 day regimen: Bismuth 262 mg 2 tabs po QID, Amox susp 2 gms QID, Flagyl 500 mg QID, Prevacid 60 mg x 1 Amox Susp (250mg/5ml – 8 tsp QID) $$
dose (No organization has confirmed these findings and recommend as first-line therapy)
Diverticulitis Enterobacteriaceae, Bactrim DS tabs (or Cipro) + Flagyl Bactrim DS 1 tab po BID (or Cipro 500 mg 2 tabs BID) + Remember no EtOH with Flagyl ?? $
Bacteroides Flagyl 500 mg BID x 10 days
Augmentin XR [1000/62.5 mg ER tabs] 2 tabs po BID x 10 days SINGLE DRUG REGIMEN $$$
Colitis C. diff Flagyl (Metronidazole) [500 mg tabs] 1 tab po TID x 14 days If sick, skip Flagyl $
Vancocin (Vancomycin) [125 mg caps] 1 cap po QID x 14 days Use for WBC>20k, Prior Tx failures w/Flagyl $$$$$
Fidaxomicin (Dificid) {200 mg tabs) 1 tab po BID x 10 days ~3,000/10 days therapy $$$$$$
Cost Legend: $<12, $$~25, $$$~50, $$$$~75, $$$$$~100 and above
Bucher/Jones Table of ANTIINFECTIVES: From Head to Toes 3
Recurrent (>3 episodes/yr) Bactrim DS (TMP/SMX) 2 tabs po x 1 at symptom onset -OR- 1 tab after sex (if frequent UTIs post-coitus) $
Pyelonephritis Same as above and Cipro (Ciprofloxacin) [500 mg tabs] 1 tab po BID x 7 days $
Pseudomonas Levaquin [500,750 mg tabs] 750 mg po QD x 5 days -OR- 500 mg po QD x 7 days $$
Bactrim (TMP/SMX) [DS tabs] 1 tab po BID x 14 days $
UTI’s in KIDS E. coli, Proteus, Klebsiella Omnicef (Cefdinir) 6 mo-12 yo: 14mg/kg/d div Q12H x 10 days - 3rd gen Ceph 1st line tx – due to emerging $$
[125,250 mg/5ml; 300 mg cap] >12 yo: 300 mg BID x 10 days E. coli resistance to Amox
Bactrim (TMP/SMX) 10mg/kg/d div BID x 10 days (based on TMP component) Workup(Renal U/S+VCUG) for 1st UTI if… $
[40/200 mg/5ml] <5 yo with febrile UTI or boys of any age or
girls <3 yo w/ 1st UTI
Acute Prostatitis Enterobacteriaceae Cipro (Ciprofloxacin) [500 mg tabs] 1 tab po BID x 14 days $
Levaquin [500 mg tab] 1 tab po QD x 14 days $$
PROSTATE *Bactrim (TMP/SMX) [DS tabs] 1 tab po BID x 28 days * not as good as quinolones in prostatitis $
Chronic Same as above Same as above Cipro/Levo x 4 wks; Bactrim DS x 6wk-3mos Most chronic forms are not bacterial
Prostatitis
Urethritis/Cervicitis Gonorrhea (GC) Rocephin (Ceftriaxone) + TX FOR CHLAMYDIA 250 mg IM x 1 dose Tx w/Quinolones are considered resistant
If allergy, Zithromax [250 mg tab] *2 gm single dose *Should bring back in 7 days for test of cure
Chlamydia Zithromax [250 mg, 1 gm powder pkt] 1 gm po x 1 dose Use 4-250 mg tabs – MUCH CHEAPER $
Doxycycline [100 mg caps] 1 cap po BID x 7 days $
Levaquin [500 mg tabs] 1 tab po QD x 7 days (Remember-no longer reliable for GC tx) $$
Vaginitis Trichomonas Flagyl (Metronidazole) [500 mg tab] 2 gms po x 1 dose [500 mg-7 day dose is ALTERNATIVE] No EtOH while taking Flagyl/Tindamax $
MUST TX PARTNER(S) Tindamax [500 mg tabs] 2 gms po x 1 dose $$
Candida Vagistat (Tioconazole) OTC 1 Applicatorful PV QHS x 1 dose $
Gynazole-1 (butoconazole) 1 Applicatorful PV QHS x 1 dose OB’s love this one $$$
OTC version Femstat-3 cream 1 Applicatorful PV QHS x 3 doses
GENITALS
(>6 episodes/yr) Acyclovir [400,800 mg tab] 400 mg BID ($400/yr) -If still w/outbrks at 500mg → incr to 1000mg $$
Valtrex [500,1000 mg tab] 500 or 1000 mg po QD ($1600 or $3200/yr) To Reduce TRANSMISSION to partner use $$$$
suppressive therapy regimen
Cellulitis: Staph/Strep Keflex (Cephalexin) Kids <12: 50mg/kg/d div Q12H x 10 days (Max 4gm/d) If abscess present NEED I&D, consider $
Consider MRSA if tx [125,250 mg/5ml; 250,500 mg caps] >12 and Adults: 1 gm BID x 10 days culture
-Boils/Abscesses failure/recurrent episodes
Bactroban (Mupirocin) Ointment Apply TID x 10-14 days Great MRSA coverage $$
-severe/recurrent consider Bactroban (Mupirocin) Nasal Apply BID to nares x 5d for eradication of Staph colonization Apply ½ of single-use tube BID (Box of 10) $
-Impetigo Staph/Strep See Above: Keflex -OR- Bactroban ointment------Newer agent: Altabax [1% oint]: Apply BID x 5 days (no indication for MRSA – YET?) $$$$
-Erysipelas Group A Strep/Staph Keflex (Cephalexin) Kids <12: 50mg/kg/d div Q12H x 10 days (Max 3gm/d) SHARP BORDERS should clue you in to dx $
[125,250 mg/5ml; 250,500 mg caps] >12 and Adults: 1 gm BID x 10 days
Consider MRSA if tx Augmentin [875/125 mg tab] 1 po BID x 7-10 days; see CAT BITES for kids dosing Give w/ food or milk to decr GI side-effects $$$$$
failure/recurrent episodes
Zithromax (Azithromycin) Kids >45kg and Adults: Z-pak $$
[250,500 mg tabs; 100,200 mg/5ml susp] Kids <45kg: 10mg/kg QD day 1, then 5 mg/kd QD days 2-5
-Diabetic cellulitis Staph, Strep, Bactrim + Flagyl BactrimDS 2 tabs po BID + Flagyl 500 mg BID x 10-14 days No EtOH w/Flagyl $$
and foot ulcers Enterobacteriaceae, Cipro(Ciprofloxacin) + Clindamycin Cipro 500mg 2 tabs po BID+ Clinda 300mg po Q8H x 10-14d $$$
ANAEROBES Augmentin [875/125 mg tabs] 1 tab po BID x 10-14 days $$$$
Consider MRSA if tx
failure/recurrent episodes
Levaquin + Flagyl Levaquin 750 mg po QD + Flagyl 500 mg po BID x 10-14 d $$$
NOT INFECTIOUS, BUT A FEW SKIN PEARLES FROM THE KELLY JONES LIBRARY
Atopic Dermatitis Basic Regimen (watch for co-existing Staph infxn or tx Staph empirically if no better with initial therapy - ?allergic rxn to skin Staph)
GET CONTROL Orapred [15 mg/5ml, or ODT 10, 15, 30 mg] Kids 2 mg/kg div BID x 2 days, then 1mg/kg QD x 3 days Adults: consider Prednisone 40 mg QD x 5d $-$$
Break Itch/Scratch Cycle Hydroxyzine at Bedtime Kids: [10 mg/5mL Syrup] Start 1 tsp po QHS and titrate up Adults: Atarax 25-50 mg tabs po QHS $
SKIN continued…
Antibiotics: Don’t forget to think about the coverage and the gaps…
Antibiotic Coverage Gaps Things to Remember…
Penicillin Gram + [Group A Strep (GAS), GBS], Enterococcus, NO STAPH, Atypicals, or Bad Gram – RENAL DOSING
Syphilis, Anaerobes (Pseudomonas)
Amoxicillin Gram + (no Staph), Enterococcus, Anaerobes, Basic NO STAPH, Atypicals, or Bad Gram – RENAL DOSING
Gram – (E. coli, Proteus, Salmonella, H. flu) (Pseudomonas)
Augmentin (Amoxicillin/clav) STAPH (No MRSA), Better Gram – coverage than No MRSA, Atypicals or Pseudomonas RENAL DOSING
Amox, Anaerobes - GI side effects(diarrhea) with clavulanate
Keflex (Cephalexin) Broad Gram +, includes STAPH (No MRSA) No Gram –, MRSA, Atypicals, or Anaerobes RENAL DOSING
Omnicef (Cefdinir) Broad Gram +, Broad Gram – No MRSA, Atypicals, Pseudomonas, or -MAY TURN BMs RED!
RENAL DOSING
Anaerobes
Rocephin (Ceftriaxone) Gonorrhea, Broad Gram +, Broad Gram – No MRSA, Atypicals, Pseudomonas, or NO RENAL DOSING
Anaerobes
Zithromax (Azithromycin) Broad Gram +, H. flu, min Gram – Not great for Strep pneum, -Up to 50% Strep pneum resist to macrolides
Atypicals (Chlamydia/Mycoplasma/Legionella) No Pseudomonas or Anaerobes NO RENAL DOSING
Biaxin (Clarithromycin) Broad Gram +, H. flu, H. pylori, minimal Gram –, Not great for Strep pneum, -Up to 50% Strep pneum resist to macrolides.
Atypicals No Pseudomonas or Anaerobes RENAL DOSING Dysgeusia(bad taste)
Doxycycline Broad Gram + (includes Strep pneum, Staph, Not great for GAS (Strep throat), Minimal -Don’t use in kids <8 because of staining of the teeth NO
RENAL DOSING
MRSA), Acne (P. acnes), Atypicals Gram – and Anaerobes
Minocycline Better skin coverage for MRSA than Doxy, Broad Not great for GAS (Strep throat), Minimal -Don’t use in kids <8 because of staining of the teeth
Gram + (includes Strep pneum, Staph, MRSA), Gram – and Anaerobes - Warn pts about possible Vertigo/Dizziness side-effect
NO RENAL DOSING
Acne (P. acnes), Atypicals
Bactrim (TMP/SMX) Broad Gram + and Gram –, MRSA (2 DS tabs BID) No GAS (Strep throat), Enterococcus, RENAL DOSING
Caution: Hyperkalemia possible
Anaerobes, Atypicals or Pseudomonas
Macrobid (Nitrofurantoin) Gram – (URINE ONLY DRUG) Contraindicated if Cr Cl<60 !!
Risk of Pulm Fibrosis for chronic supp therapy
Cleocin (Clindamycin) Broad Gram +, MRSA (Community-acquired), No Gram –, No Atypicals -Causes yeast infxns (give Diflucan)
NO RENAL DOSING
Anaerobes
Flagyl (Metronidazole) Broad Anaerobe, BV, Trich No Gram + or – (Anaerobes ONLY) -Disulfiram rxn – NO ETOH
RENAL DOSING
Tindamax (Tinidazole) Broad Anaerobe, BV, Trich No Gram + or – (Anaerobes ONLY) -Disulfiram rxn – NO ETOH
RENAL DOSING
Cipro (Ciprofloxacin) Gram – ONLY (includes Pseudomonas), Atypicals No Gram + or Anaerobes RENAL DOSING
Levaquin (Levofloxacin) Broad Gram + (includes MRSA, great Strep), Broad No Anaerobes, Not used for Gonorrhea RENAL DOSING
Gram –, Atypicals anymore
Avelox (Moxifloxacin) Broad Gram + (includes MRSA, great Strep), Broad No Anaerobes, DOES NOT GET INTO NO RENAL DOSING
Gram –, Atypicals URINE (hepatic metabolism)
Zyvox (Linezolid) GRAM + POWERHOUSE (MRSA, VRE) No Anaerobes, Atypicals or Gram – $$$$$$$ NO RENAL DOSING watch for serotonin syn
Vancocin (Vancomycin) PO USE ONLY FOR C. diff
Remember - The only Pseudomonas Abx are Zosyn, Cefepime, Quinolones, Tobramycin, Imi/Meropenem, and Aztreonam…The concentration dependant killers are Q,A,M (Quinolones,
Aminoglycosides, and Metronidazole/Tindamax) – so if you have the option in renal failure dosing, choose the dosing with the highest dose less often over lower doses more frequently.
Cost Legend: $<12, $$~25, $$$~50, $$$$~75, $$$$$~100 and above