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SECTION 16

Appendix 114-1
Drugs of Choice, First Choice, Alternative(s)
GRAM-POSITIVE COCCI

Infectious Diseases

Enterococcus faecalis (generally not as resistant to antibiotics as

Enterococcus faecium)

Serious infection (endocarditis, meningitis, pyelonephritis

with bacteremia)
Ampicillin (or penicillin G) + (gentamicin or streptomycin)
Vancomycin + (gentamicin or streptomycin), daptomycin,
linezolid, telavancin, tigecyclinea
Urinary tract infection (UTI)
Ampicillin, amoxicillin
Fosfomycin or nitrofurantoin

E faecium (generally more resistant to antibiotics than E faecalis)

Recommend consultation with infectious disease specialist

Linezolid, quinupristin/dalfopristin, daptomycin, tigecyclinea

Staphylococcus aureus/Staphylococcus epidermidis

Methicillin (oxacillin)-sensitive
Nafcillin or oxacillin
FGC,b,c trimethoprim-sulfamethoxazole, clindamycin, BL/BLIj
Hospital-acquired methicillin (oxacillin)resistant
Vancomycin (gentamicin or rifampin)
Daptomycin, linezolid, telavancin, tigecycline,a trimethoprimsulfamethoxazole, or quinupristin-dalfopristin
Community-acquired methicillin (oxacillin)-resistant
Clindamycin, trimethoprim-sulfamethoxazole, doxycylcinea
Daptomycin, linezolid, telavancin, tigecycline,a or vancomycin

Streptococcus (groups A, B, C, G, and Streptococcus bovis)

Penicillin G or V or ampicillin
FGC,b,c erythromycin, azithromycin, clarithromycin

Streptococcus pneumoniae

Penicillin-sensitive (MIC <0.1 mcg/mL)

Penicillin G or V or ampicillin
FGC,b,c doxycycline,a azithromycin, clarithromycin,
erythromycin
Penicillin intermediate (MIC 0.11.0 mcg/mL)
High-dose penicillin (12 million units/day for adults) or
ceftriaxonec or cefotaximec
Levofloxacin,a moxifloxacin,a gemifloxacin,a or vancomycin
Penicillin-resistant (MIC 1.0 mcg/mL)
Recommend consultation with infectious disease specialist.
Vancomycin rifampin
Per sensitivities: cefotaxime,c ceftriaxone,c levofloxacin,a
moxifloxacin,a or gemifloxacina

Streptococcus, viridans group

Moraxella (Branhamella) catarrhalis

Amoxicillin-clavulanate, ampicillin-sulbactam
Trimethoprim-sulfamethoxazole, erythromycin, azithromycin,
clarithromycin, doxycycline,a SGC,c,e cefotaxime,c ceftriaxone,c
or TGC POc,f

Disseminated gonococcal infection

Ceftriaxonec or cefotaximec
Oral follow-up: cefpodoxime,c ciprofloxacin,a or levofloxacina
Uncomplicated infection
Ceftriaxone,c cefotaxime,c or cefpodoximec
Ciprofloxacina or levofloxacina

Neisseria meningitides

Penicillin G
Cefotaximec or ceftriaxonec

GRAM-POSITIVE BACILLI
Clostridium perfringens

Penicillin G clindamycin
Metronidazole,a clindamycin,
carbapenemg,h

doxycycline,a

cefazolin,c

Clostridium difficile

Oral metronidazolea
Oral vancomycin

GRAM-NEGATIVE BACILLI
Acinetobacter spp

Doripenem, imipenem or meropenem aminoglycosidei

(amikacin usually most effective)
Ampicillin-sulbactam, colistin,h or tigecyclinea

Bacteroides fragilis (and others)

Metronidazolea
BL/BLI,j clindamycin, cefoxitin,c cefotetan,c or carbapenemg,h

Enterobacter spp

Carbapenem,g or cefepime aminoglycosidei

Ciprofloxacin,a levofloxacin,a piperacillin-tazobactam, ticarcillinclavulanate

Escherichia coli

Penicillin G gentamicind
Cefotaxime,c ceftriaxone,c erythromycin, azithromycin,
clarithromycin, or vancomycin gentamicin

GRAM-NEGATIVE COCCI

Neisseria gonorrhoeae (also give concomitant treatment for

Chlamydia trachomatis)

Meningitis
Cefotaxime,c ceftriaxone,c meropenem
Systemic infection
Cefotaximec or ceftriaxonec
BL/BLI,j fluoroquinolone,a,k carbapenemg,h
Urinary tract infection
Most oral agents: check sensitivities
Ampicillin, amoxicillin-clavulanate, doxycyline,a or
cephalexinc
Aminoglycoside,i FGCb,c nitrofurantoin, fluoroquinolonea,k

Gardnerella vaginalis

Metronidazolea
Clindamycin

Haemophilus influenzae

Meningitis
Cefotaximec or ceftriaxonec
Meropenemh

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Klebsiella pneumoniae

BL/BLI,j cefotaxime,c ceftriaxone,c cefepimec

Carbapenem,g,h fluoroquinolonea,k

Legionella spp

Pasteurella multocida

Penicillin G, ampicillin, amoxicillin

Doxycycline,a BL/BLI,j trimethoprim-sulfamethoxazole or
ceftriaxonec

Chlamydia pneumoniae

Doxycyclinea
Azithromycin, clarithromycin, erythromycin, or fluoroquinolonea,k

Chlamydia trachomatis

Azithromycin or doxycyclinea
Levofloxacin,a erythomycin

Mycoplasma pneumoniae

Azithromycin, clarithromycin, erythromycin, fluoroquinolonea,k

Doxycyclinea

Proteus mirabilis

Ampicillin
Trimethoprim-sulfamethoxazole

Proteus (indole-positive) (including Providencia rettgeri, Morganella

morganii, and Proteus vulgaris)

Cefotaxime,c ceftriaxone,c or fluoroquinolonea,k

BL/BLI,j aztreonam,l aminoglycosides,i carbapenemg,h

Providencia stuartii

Amikacin, cefotaxime,c ceftriaxone,c fluoroquinolonea,k

Trimethoprim-sulfamethoxazole, aztreonam,l carbapenemg,h

Pseudomonas aeruginosa

UTI only
Aminoglycosidei
Ciprofloxacin,a levofloxacina
Systemic infection
Cefepime,c ceftazidime,c doripenem,h imipenem,h meropenem,h piperacillin-tazobactam, or ticarcillin-clavulanate +
aminoglycosidei
Aztreonam,l ciprofloxacin,a levofloxacin,a colistinh

Salmonella typhi

Ciprofloxacin,a levofloxacin,a ceftriaxone,c cefotaximec

Trimethoprim-sulfamethoxazole

Serratia marcescens

Ceftriaxone,c cefotaxime,c cefepime,c ciprofloxacin,a

levofloxacina
Aztreonam,l carbapenem,g,h piperacillin-tazobactam, ticarcillinclavulanate

Stenotrophomonas (Xanthomonas) maltophilia (generally very

resistant to all antimicrobials)

Trimethoprim-sulfamethoxazole
Check sensitivities to ceftazidime,c doxycycline,a minocycline,a
and ticarcillin-clavulanate

SPIROCHETES
Treponema pallidum

Neurosyphilis
Penicillin G
Ceftriaxonec
Primary or secondary
Benzathine penicillin G
Ceftriaxonec or doxycyclinea

Borrelia burgdorferi (choice depends on stage of disease)

Ceftriaxonec or cefuroxime axetil,c doxycycline,a amoxicillin

High-dose penicillin, cefotaximec

MIC, minimal inhibitory concentration; PO, orally

a
Not for use in pregnant patients or children.
b
First-generation cephalosporinsIV: cefazolin; PO: cephalexin, cephradine, or cefadroxil.
c
Some penicillin-allergic patients may react to cephalosporins.
d
Gentamicin should be added if tolerance or moderately susceptible (MIC
>0.1 g/mL) organisms are encountered; streptomycin is used but can be
more toxic.
e
Second-generation cephalosporinsIV: cefuroxime; PO: cefaclor, cefditoren, cefprozil, cefuroxime axetil, and loracarbef.
f
Third-generation cephalosporinsPO: cefdinir, cefixime, cefetamet, cefpodoxime proxetil, and ceftibuten.
g
Carbapenem: doripenem, ertapenem, imipenem/cilastatin, meropenem.
h
Reserve for serious infection.
i
Aminoglycosides: gentamicin, tobramycin, and amikacin; use per sensitivities.
j
-lactam/-lactamase inhibitor combinationIV: ampicillin-sulbactam,
piperacillin-tazobactam, ticarcillin-clavulanate; PO: amoxicillinclavulanate.
k
Fluoroquinolones - IV/PO: ciprofloxacin, levofloxacin, and moxifloxacin.
l
Generally reserved for patients with hypersensitivity reactions to penicillin.

Antimicrobial Regimen Selection

Azithromycin, erythromycin rifampin, or fluoroquinolonea,k

Trimethoprim-sulfamethoxazole, clarithromycin, or doxycyclinea

MISCELLANEOUS MICROORGANISMS

CHAPTER 114

Other infections
BL/BLI,j or if -lactamase-negative, ampicillin or amoxicillin
Trimethoprim-sulfamethoxazole, cefuroxime,c azithromycin,
clarithromycin, or fluoroquinolonea,k