Professional Documents
Culture Documents
Approved by:
Dr. CE Eapen (Medical Superintendent)
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Contents
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Chapter 1: Introduction
Increasing antimicrobial resistance today poses a significant threat
to public health in India. This threat is compounded by the lack of
development of new antibiotics. Prudent antimicrobial utilization
and a stringent adherence to infection control practices therefore
remain the major strategies to counter this threat. A safe and effective
strategy for antibiotic use involves prescribing an antibiotic only
when it is needed and selecting an appropriate and effective agent
at the recommended dose, with the narrowest spectrum of
antimicrobial activity, fewest adverse effects and lowest cost.
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Chapter 2: Principles of rational antibiotic
prescribing
1. Empiric antimicrobial treatment should be limited to
conditions where immediate / early initiation of
antimicrobials has been shown to be beneficial. Some
examples are:
• Severe sepsis (sepsis-induced tissue hypoperfusion or organ
dysfunction) and septic shock
• Acute bacterial meningitis
• Community acquired pneumonia
• Ventilator associated pneumonia
• Necrotizing fasciitis
• Febrile neutropenia
2. Fever, leukocytosis or elevated c-reactive protein (CRP) levels
by themselves should not be considered indications for starting
empiric antimicrobials, as these have been shown to have very
poor specificity to diagnose bacterial sepsis. Always consider
multiple data points (history, physical findings and
investigation reports) together to make an accurate diagnosis.
3. Incomplete or inaccurate diagnosis is the most important
reason for inappropriate use of antimicrobials.
4. Always obtain cultures (two sets of blood cultures and other
appropriate samples as clinically indicated – e.g. normally
sterile body fluids, deep pus etc.) before starting empiric
antimicrobial treatment.
• Avoid the practice of obtaining “pan cultures” unless
clinically indicated
5. Avoid sending cultures from superficial wounds, decubitus
ulcers, and chronic wounds and draining sinuses. Surface swab
cultures are either inadequate or provide misleading
5
information regarding diagnosis (as they cannot differentiate
infection from colonization / contamination).
6. When starting antimicrobials, use full therapeutic doses,
paying close attention to dose, frequency, and route of
administration and duration of treatment.
7. Review all antimicrobial prescriptions after 48 to 72 hours
(“antimicrobial timeout”) with a view to modify or stop the
initial empiric therapy.
8. De-escalate (pathogen-specific therapy) the antimicrobial
regimen once culture and susceptibility reports are available,
and the patient is showing signs of improvement with the
initial empiric broad-spectrum antimicrobials.
· Examples of optimization include switch
i. To a narrow-spectrum antimicrobial,
ii. From combination to single agent,
iii. To less toxic or expensive drug, or
iv. From i.v. to an oral formulation.
9. Stop antimicrobials if the cause of initial symptoms is found
to be non-infectious
10. The doses mentioned in these guidelines are for patients with
normal renal function. The doses have to be modified for those
with renal insufficiency
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Chapter 3: Initial Empiric Antibiotics for
Common Infections
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Condition Most likely First choice Alternatives Comments
microbial
etiology
5. Cholangitis Enterobacteri- • Piperacillin- • Cefoperazone- • Duration: 7 days
aceae Tazobactam 4.5 g Sulbactam 3 g • Biliary drainage
Anaerobes i.v. Q8H i.v. BID
• Ertapenem 1 g i.v.
OD (for patients
with qSOFA score
≥2)
6. Acute Enterobacteri- • Piperacillin- • Cefoperazone- Patients undergoing
cholecystitis aceae Tazobactam 4.5 g Sulbactam 3 g cholecystectomy
i.v. Q8H i.v. BID should have antimicro-
• Ertapenem 1 g i.v. bials discontinued
OD (for patients within 24 h unless
with qSOFA score there is evidence of
≥ 2) infection outside the
wall of the gallbladder
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A2. CNS infections
I. Management protocol for acute meningitis (community
acquired)
1. Suspect if patient (no neurosurgical procedure in the previous
two weeks; not immuno-compromised) has any combination of
the following:
a. Symptoms: fever, headache, altered mental status (new
onset confusion, disorientation, drowsiness, coma)
b. Signs: Temp >38 °C, neck stiffness, other signs of meningeal
irritation.
2. Confirm by a lumbar puncture (to be done as soon as possible)
a. CSF findings highly suggestive of bacterial meningitis
i. Gross appearance turbid
ii. Total WBC count >1000 cells/mm3
iii. Neutrophilic pleocytosis
iv. Low CSF glucose (<50% of concomitant blood
glucose)
3. CT scan brain
a. Should NOT be ordered as a routine test before LP in all
cases of suspected acute meningitis
b. Indications for CT scan brain before LP
i. Papilledema
ii. New onset seizures
iii. Focal neurological deficits (e.g., hemiparesis)
iv. Decreased level of consciousness (GCS <10)
v. Immunocompromised patients (e.g., HIV infection)
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4. Lab tests
a. CSF analysis
i. WBC count (total and differential)
ii. Glucose
iii. Protein
iv. Gram stain and culture
v. Virology panel (PCR)
vi. Additional investigations if duration of symptoms
>5 days
1. Xpert MTB/RIF
2. Mycobacterial (MGIT) culture
3. India ink preparation
4. Cryptococc al antigen
5. Fungal culture
6. VDRL
b. Blood culture
c. CBC
d. Urea, creatinine, electrolytes
5. Antimicrobial management:
a. All patients should receive the first dose of antimicrobials as
soon as the diagnosis of acute bacterial meningitis is suspected.
b. DO NOT delay antimicrobials if there is a delay in obtaining
a CSF sample.
• Prior administration of antimicrobials tends to have
minimal effects on the chemistry and cytology findings,
but can reduce the yield of Gram stain and culture
c. Initial empiric antimicrobials
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a. Ceftriaxone 2 g i.v. BID + Vancomycin 10–20 mg/kg q8 -
12h to achieve serum trough concentrations of 15–20 ìg/
mL
b. Modify antimicrobial regimen based on results of culture
& susceptibility reports
c. Duration: 10 – 14 days
d. Adjunctive steroid therapy (to be started for patients with
strong clinical suspicion of acute bacterial meningitis or
CSF results as described below):
a. Indications:
i. Cloudy CSF
ii. CSF WBC count >1000/ml, or
iii. Bacteria in CSF on Gram’s staining
b. Contra-indications
i. Septic shock
ii. Patients who have already received
antimicrobials
c. Dose and duration: Dexamethasone 0.15 mg/kg Q6H
x 4 days; first dose 15 min before or along with first
dose of antimicrobial
d. Discontinue if culture grows organisms other than
Strep pneumoniae
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II. Other CNS infections
13
A4. Skin and soft tissue infections (SSTI)
I. Management protocol for necrotizing fasciitis (NF)
1. Suspect NF in any patient presenting with SSTI who has severe
pain, severe sepsis or septic shock
2. Symptoms and signs:
a. Pain (out of proportion to physical findings), swelling,
redness and warmth of affected area;
b. Changes in skin color from red-purple to patches of blue-
gray;
c. Bullae containing thick pink or purple fluid; crepitus;
d. Cutaneous gangrene;
e. Compartment syndrome;
f. MOSF;
g. Hypotension
3. Obtain urgent surgical consultation. Surgical exploration is
the only way to definitively establish the diagnosis of
necrotizing infection.
4. Labs
a. CBC
b. Urea, creatinine, electrolytes
c. CPK
d. Blood culture
e. Gram stain and culture of tissue and pus sample obtained
at surgery
5. Imaging (plain x-rays, CT scan, MRI scan) to look for presence
of gas. The presence of gas in the fascial planes is a highly
specific finding, but not very sensitive. DO NOT delay surgical
intervention.
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6. Management
a. Surgery: Aggressive debridement of all necrotic tissue
b. Antimicrobials:
i. Initial empiric treatment: Meropenem 1 g i.v. TID +
Clindamycin 900 mg i.v. TID
ii. Modify antimicrobials according to culture and
sensitivity report
iii. For confirmed group A streptococcus infection:
Penicillin G 2 million units i.v. Q4H + Clndamycin
900 mg i.v. TID
II. Other SSTI
Condition Most likely First choice Alternative Comments
microbial etiology
1. Skin
infections
Cellulitis (no Strep pyogenes, 1. Cefazolin 1 g Cloxacillin 500 mg • Oral therapy for
purulent drainage) Staph aureus i.v. Q8H x 7-10 p.o. Q6H x 7-10 days milder illness and
days (for step-down following
hospitalized improvement with i.v.
patients with therapy
moderate • Duration: until clinical
illness) cure
2. Cloxacillin 1 g
i.v. Q6H
Furuncules, Staph aureus Cloxacillin 500 Incision & drainage
carbuncles, mg Q6H p.o. x 7-
cutaneous 10 days
abscesses
(purulent SSTI)
Tinea versicolor Malassezia furfur Topical Topical miconazole Duration 1- 2 weeks
clotrimazole 1% 2% OD
OD
Tinea corporis T. rubrum Topical Topical miconazole Duration 2- 4 weeks
clotrimazole 1% 2% OD
OD
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Condition Most likely First choice Alternative Comments
microbial etiology
Scabies Sarcoptes scabiei Permethrin cream • Wash off after 8-14
5% to be applied hours
all over the body
• Clothing should be
from neck
washed in hot water
downwards
and dried before reuse
2. Diabetic foot
infections
Mild (local Staph aureus Cefazolin 1 g i.v. Cloxacillin 500 - 1000 • Cultures should not
infection Strep pyogenes Q8H mg p.o. Q6H x 7-10 be taken form clini-
involving only days cally non-infected
skin and wounds
subcutaneous
tissue,
erythema <2
cm, no
systemic
signs)
Moderate (local Polymicrobial - • Piperacillin- Surgical consultation
infection with Staph aureus, Group Tazobactam for drainage or
erythema >2 A Strep, aerobic 4.5 g i.v. Q8H + debridement
cm, or Gram- negative Vancomycin 15
involving bacilli, anaerobes mg/kg i.v. Q12H
structures
deeper than
skin and
subcutaneous
tissues (e.g.,
abscess,
osteomyelitis,
septic arthritis,
fasciitis)
Severe (limb Polymicrobial - • Meropenem 1 g Tigecycline 100 mg Surgical consultation
threatening - Staph aureus, Group i.v. TID + i.v. x 1 dose followed for drainage or
severe A Strep, aerobic Vancomycin 15 by 50 mg i.v. BID debridement.
cellulitis / Gram- negative mg/kg i.v. Q12H
gangrene / bacilli, anaerobes
severe sepsis /
septic shock)
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Condition Most likely First choice Alternative Comments
microbial etiology
3. VZV
infections
Chickenpox Varicella zoster virus Valacyclovir 1000 Acyclovir 800 mg p.o. To be started within 24
mg p.o. TID x 7 five times / day x 7 hours of onset of rash.
days days
Herpes zoster Varicella zoster virus Valacyclovir 1000 Acyclovir 800 mg • Begin within 72 hours
mg p.o. TID x 7 p.o. five times / day of onset of rash
days x 7 days • Immunocompromised
patients: Acyclovir 10
mg/kg i.v. TID. Change
to valacyclovir 1000 mg
p.o. TID once infection
is controlled. Total
duration 7 – 10 days
4. Bites
Bites (cat, dog, • Pasteurella Amoxicillin- • Duration: 3 - 5 days
human, rat) multocida Clavulanate 625 • Administer rabies vac-
• Capnocytophaga mg p.o. TID cination as appropriate
• Eikenella
• Strep viridans
• Spirillum minus
• Streptobacillus
moniliformis
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A5. Bone and joint infections
Condition Most likely First choice Alternative Comments
microbial
etiology
Acute Staph aureus Cefazolin 2 g o For optimal treatment, microbial
osteomyelitis i.v. TID etiology should be confirmed
o Orthopedic referral for bone
biopsy and debridement of
necrotic material
o Modify initial empiric regimen
based on culture report
o Duration: 6 weeks from last
debridement
Chronic Staphylococci Avoid empiric o For optimal treatment, microbial
osteomyelitis Aerobic GNBS treatment etiology should be confirmed
• Secondary to treptococci o Orthopedic referral for bone
a contiguous Anaerobes biopsy and debridement of
focus of necrotic material
infection o Obtain cultures (bone and blood)
(e.g., before antimicrobialso Avoid
decubitus sending swab cultures form
ulcer), chronic discharging sinuses and
• Osteomyeli- ulcers
tis that o Duration: 6 weeks from last
develops as debridement
a result of
contami-
nated open
fractures or
surgical
treatment of
closed
fractures
Chronic Avoid empiric Vancomycin 1 g o For optimal treatment, microbial
osteomyelitis antimicrobials i.v. BID + etiology should be confirmed
with orthopedic unless patient Piperacillin- o Orthopedic referral
implants seriously ill Tazobactam 4.5
g i.v. TID o Obtain cultures (bone and blood)
before antimicrobialso Modify
initial empiric regimen based on
culture report
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Condition Most likely First choice Alternative Comments
microbial
etiology
Osteomyelitis See section on diabetic foot infections o Implant removal and debridement
associated with of necrotic material
diabetic foot
infection
Septic arthritis Staph aureus Cloxacillin 2 g Cefazolin 2 g i.v. o Orthopedic referral
i.v Q6H TID o Obtain joint fluid for culture
before starting antimicrobials
o Modify initial empiric regimen
based on culture report
o Duration: 4 weeks; change to p.o.
after 2 weeks i.v. therapy
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A6. Respiratory tract infections
I. Community acquired pneumonia (CAP) management
protocol
1. Suspect if patient (not been hospitalized in the previous 90
days; not immuno-compromised; no structural lung disease
like bronchiectasis) has any combination of the following:
a. Symptoms: fever, cough (with or without expectoration),
shortness of breath, chest pain
b. Signs: Temp >38 °C, tachypnea, tachycardia, impaired
percussion notes, bronchial breath sounds, crackles, altered
VF/VR.
*In a patient presenting with cough, normal vital signs
and physical examination findings rule out a diagnosis
of pneumonia
2. Confirm with chest x-ray (to be done as soon as possible). In
patients with a clinical suspicion of CAP, but no abnormalities
on chest x-ray, repeat the x-ray within 48 hours.
3. Severity assessment based on CURB 65 score:
a. 6 point score (range 0 - 5)
b. Gives one point each for:
i. Confusion (new onset disorientation in person, place,
or time)
ii. Urea >7 mmol/L
iii. Respiratory rate > 30/min
iv. Low Blood pressure (SBP < 90 mm Hg or DBP < 60
mm Hg)
v. Age > 65 years
c. Interpretation
i. CURB-65 score 0 or 1: low risk of death
ii. CURB-65 score 2: moderate risk of death
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iii. CURB-65 score >3: high risk of death
CURB 65 score is NOT a replacement for good
clinical judgment
4. Lab tests
a. CBC
b. Urea, creatinine, electrolytes
c. For patients with CURB 65 score e”2
i. ABG
ii. Blood culture
iii. Sputum Gram stain & culture *Sputum sample should
be transported promptly to the lab
iv. Respiratory sample (NP swab, throat swab, nasal
swab, ET aspirate or BAL) for respiratory viral panel
(includes influenza testing by RT-PCR)
• In patients with pneumonia, BAL or ET aspirate
should be collected for influenza testing if NP swab
is negative
5. Setting of care
a. CURB-65 score 0 or 1: out-patient
b. CURB-65 score 2: in-patient (ward)
c. CURB-65 score >3: in-patient (ICU)
6. Antimicrobial management:
a. All patients should receive the first dose of antimicrobials
as soon as the diagnosis of CAP is confirmed
b. Change to an oral regimen as soon as clinical
improvement occurs and the temperature has been normal
for 24 h, and there is no contraindication to the oral route.
c. Modify antimicrobial regimen based on results of culture
& susceptibility reports
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d. Consider unusual microbial etiology (e.g., Burkholderia
pseudomallei in poorly controlled diabetes and Staph aureus
(MSSA & MRSA) in post-influenza bacterial pneumonia
CURB-65 Most likely Preferred Alternate Comments
score microbial
etiology
0 or 1 • Respiratory Amoxicillin 500 1. Azithromycin See section on “influenza” for
viruses mg p.o. TID x 5 500 mg p.o. TID indications for oseltamivir
• Strep days x 3 days
pneumoniae 2. Doxycycline 100
• Mycoplasma mg p.o. BID x 5
pneumoniae· days
Chlamydophila 3. Levofloxacin
pneumoniae 750 mg p.o. OD
• Respiratory Ceftriaxone 1 g i.v. Penicillin G 20 L • Antiviral treatment might still
2
viruses OD + i.v. Q4H + be beneficial in patients with
• Strep Azithromycin 500 Azithromycin 500 severe, complicated, or pro-
pneumoniae mg i.v. O x 5 – 7 mg i.v. O x 5 – 7 gressive illness and in hospi-
days + days + Oseltamivir talized patients when started
• Mycoplasma Oseltamivir 75 mg 75 mg p.o. BID x 5 after 48 hours of illness onset,
pneumoniae p.o. BID x 5 days day as indicated by observational
• Chlamydophila studies (CDC, 2013)
pneumoniae • Discontinue oseltamivir if
• Legionella PCR negative
o Continue if clinical sus-
picion of influenza high
• No virological or clinical ad-
vantages with double dose
oseltamivir compared with
standard dose in patients with
severe influenza admitted to
hospital (BMJ, 2013)
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II. Ventilator associated pneumonia management protocol
1. Diagnosis
a. Develops 48 – 72 hours after endotracheal intubation
b. Clinical features: fever, alteration in sputum
characteristics (increased purulence and /or volume),
worsening oxygenation (increasing FiO2 &PEEP
requirement, worsening PF ratio)
c. Labs: leukocytosis (WBC >11000), leukopenia (WBC
<4000) or band forms >10%, elevated PCT / CRP
d. Chest x-ray: new or worsening infiltrates
*No gold standard for diagnosis of VAP; combination of
above findings increases probability of VAP
e. Obtain ET aspirate for Gram stain, cultures and virology
(No advantage of BAL over ETA)
f. Negative ET aspirate culture rules out VAP (very high
negative predictive value)
2. Antimicrobials (to be started after obtaining cultures) (H”65%
of VAP in CMC MICU caused by A. baumannii)
a. If hemodynamic instability (systolic BP <90 mm Hg)
requiring inotropes: Meropenem 2 g i.v. TID + Colistin 9
million units i.v. loading dose, followed by 4.5 million
units i.v. BID
b. If no hemodynamic instability: Meropenem 1 g i.v. TID +
Amikacin 15 mg/kg i.v. OD
c. Modify once culture and sensitivity reports available
d. Duration of appropriate antimicrobial therapy: 8 – 10 days.
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III. Influenza-like illness (ILI) management protocol
Category B: Uncomplicated
Category A: Category C:
illness in patients at higher
Uncomplicated illness; risk for influenza
patient not at higher risk Severe illness (qSOFA
complications * (see list score >/=2)
for influenza complications
below)
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IV. Other respiratory infections
Condition Most likely microbial Preferred Alternative Comments
etiology
1. Acute • Group A streptococcus Amoxicillin 500 1. Azithromycin • Limit antibiotic
pharyngitis (GAS) mg p.o. TID x 10 500 mg p.o. OD prescriptions to
days x 5 days patients who
• Respiratory viruses
2. Penicillin 250 are most likely
mg p.o. QID x to have GAS
10 days infection
(identified by
Centor criteria -
fever, no
cough, tonsillar
exudates, &
tender anterior
cervical
lymphadenopa-
thy)
• The large
majority of
adults with
acute
pharyngitis
have a self-
limited viral
illness, for
which
supportive care
(analgesics,
antipyretics,
saline gargles)
only is needed
2. Acute H. influenzae Ceftriaxone 1 – 2 • Airway
epiglotitis g i.v. OD x 7 days management
3. Ludwig’s Polymicrobial (oral anaerobes) Clindamycin 600 Amoxicillin- • Airway
angina, mg i.v. Q8H x 14 Clavulanate 1000 management
Vincent’s days mg p.o. BID x 14 • Surgery
angina days
• Continue
antibiotics till
clear evidence
of clinical
improvement
25
Condition Most likely microbial Preferred Alternative Comments
etiology
4. Acute Viral None needed • Symptomatic
bronchitis treatment only
5. Acute Strep. pneumoniae Amoxicillin-
bacterial H. influenzae Clavulanate 1 g
rhinosinusitis M. catarrhalis p.o. BID x 7 days
(Antimicrobials
if symptoms of
fever, facial
pain and
purulent nasal
discharge
persist >7
days)
6. Acute Strep. pneumoniae Amoxicillin- • Azithromycin • Start
bacterial H. influenzae Clavulanate 1 g 500 mg p.o. OD oseltamivir if
exacerba- M. catarrhalis p.o. BID x 7 days x 3 days clinical
tion of Respiratory viruses suspicion of
• Doxycycline
COPD influenza high
100 mg p.o.
(presence BID x 7 days • Antimicrobials
of at least for all patients
2 of the who require
following 3 mechanical
symptoms: ventilation
a. Increased
dyspnea,
b. Increased
sputum
volume,
and
c. Increased
sputum
purulence)
Bronchiecta- H. influenzae • Initial empiric • Modify based
sis, acute S. pneumoniae therapy based on on culture
exacerbation P. aeruginosa previous sputum reports
(increased culture reports • Duration: 14
cough, sputum when available days
volume and
purulence)
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Condition Most likely microbial Preferred Alternative Comments
etiology
• If no report
available:
Piperacillin-
Tazobactam
4.5 g i.v. TID
Lung abscess • Oral anaerobes Amoxicillin- Clindamycin 600 Duration: Till
(Peptostreptococcus, Clavulanate 1.2 g mg i.v. TID clinical and
Prevotella, i.v. TID radiological
Bacteroides (usually resolution;
not B. fragilis), usually 3 to 4
and Fusobacterium spp.) weeks
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A7. Genitourinary infections
I. UTI management protocol
1. Symptoms and signs
a. Young women: dysuria, frequency of urination, and negative
history of vaginal discharge (post-test probability 90%); fever;
costo-vertebral angle tenderness
b. Older patients may have these additional symptoms
i. Cloudy, malodorous or bloody urine
ii. Worsening incontinence
iii. Systemic symptoms (altered mental status, MOSF,
hypotension)
c. Symptoms of urinary catheter associated UTI (CAUTI): new
onset or worsening of fever, rigors, altered mental status,
malaise, or lethargy with no other identified cause; flank pain;
costo-vertebral angle tenderness; acute hematuria; pelvic
discomfort
2. Lab tests
a. Urinalysis (leukocyte esterase and nitrite by dipstick). Absence
of pyuria and bacteriuria rules out UTI (high negative
predictive value)
b. CBC
c. U&E
d. Urine culture
e. Blood culture
f. Imaging (ultrasound or CT KUB) indicated for
i. Severe sepsis or septic shock
ii. Palpable kidneys
iii. Persistent symptoms after 72 hrs appropriate treatment
iv. DM
v. Immune suppression
vi. Recurrent UTI
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3. Antimicrobial management
Condition Most likely Comments
microbial etiology
Asymptomatic E. coli No antimicrobial Screening for and treat-
bacteriuria (positive needed ment of asymptomatic
urine culture from an bacteriuria is indicated
individual without for
symptoms or signs of 1. Pregnant women
UTI)
2. Patients undergoing
urologic procedures
in which mucosal
bleeding is antici-
pated
Acute uncomplicated E. coli Nitrofurantoin 100 Ciprofloxacin
cystitis in women – mg p.o. BID x 7 500 mg p.o. BID
dysuria and frequency days x 3 days
in healthy, adult, non-
pregnant women with
normal urinary tract
(no structural or
functional
abnormalities)
Pyelonephritis – E. coli • Mild to • Definitive therapy
uncomplicated (no moderate based on culture and
underlying GU illness: susceptibility report
disease) Piperacillin- • Duration:
Tazobactam
4.5 g i.v. TID • Mild to moderate
cases – 7 days
• Severe illness
(qSOFA >2): • Severe cases – 14
Ertapenem 1 g days
i.v. OD.
Complicated UTI E. coli, Proteus, Meropenem 1 g i.v. • Definitive therapy
(underlying GU Pseudomonas TID based on culture and
disease, e.g., aeruginosa susceptibility report·
neurogenic bladder, Duration: 10 - 14
renal stones, days
hydronephrosis etc.)
29
Condition Most likely Comments
microbial etiology
Foley catheter E. coli, Proteus, No empiric • Do not send urine
associated UTI Pseudomonas treatment culture from an
aeruginosa, asymptomatic
Acinetobacter spp. patient with
indwelling urinary
catheter
• Urinalysis for
pyuria NOT
useful in
diagnosing CAUTI
• Treat only when
patient has
symptoms
attributable to UTI
• Urine sample for
culture should be
obtained either
through
9 A new catheter
(after removing the
indwelling
catheter), or
9 Through sample
port near junction of
drainage tubing and
Foley catheter
9 Do not send
samples from the
drainage bag· Re-
move urinary
catheter
• Replace urinary
catheter only if
essential; consider
alternatives (e.g.,
condom catheter,
intermittent
catheterization etc.)
• Duration of
antimicrobials: 7 –
14 days
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Chapter 4: Targeted (Definitive) Therapy of
Common Infections
1. Infective endocarditis
Condition Etiology First choice Alternative Comments
Infective a. Penicillin 1. Penicillin G 2 - 3 1. Penicillin G 2 2-week regimen only for
endocarditis susceptible million units i.v. million units i.v. uncomplicated cases (no
(native (MIC <0.12 Q4H x 4 weeks Q4H + cardiac / extra-cardiac
valve) µgm/ml) 2. Ceftriaxone 2 g i.v. Gentamicin 3 abscess, eGFR >20 ml/min) of
Strep OD x 4 weeks mg/kg i.v. OD x native valve IE due to highly
viridans 2 weeks (see penicillin-susceptible Strep
comments) viridans (MIC <0.12 µgm/ml).
2. Ceftriaxone 2 g For patients with beta-lactam
i.v. OD + allergy, use Vancomycin 15 mg/
Gentamicin 3 kg i.v. BID
mg/kg i.v. OD x
2 weeks (see
comments)
b. Strep Penicillin G 2 million Ceftriaxone 2 g i.v. For patients with beta-lactam
viridans units i.v. Q2H x 4 OD + Gentamicin allergy, use Vancomycin 15 mg/
with weeks +Gentamicin 3 mg/kg i.v. OD x kg i.v. BID
Penicillin 3 mg/kg i.v. OD x 2 2 weeks (if isolate
MIC >0.12 weeks susceptible to
µgm/ml ceftriaxone)
c. Enterococ- Ampicillin 2 g i.v. Ampicillin 2 g i.v.
cus Q4H + Ceftriaxone 2 Q4H + Gentamicin
g i.v. Q12H x 6 1 mg/kg i.v. Q8H x
weeks 4 – 6 weeks
d. MSSA Cloxacillin 2 g i.v. Cefazolin 2 g i.v. For patients with beta-lactam
Q4H x 6 weeks TID x 6 weeks allergy, use Vancomycin 15 - 30
mg/kg i.v. BID
e. MRSA Vancomycin 15 - 30
mg/kg i.v. Q12H x 6
weeks (Adjust dose
to obtain vancomycin
trough level 15 – 20
µg/ml)
d. HACEK Ceftriaxone 2 g i.v.
Ampicillin 2 g i.v.
OD x 4 weeks
Q4H x 4 weeks
31
Condition Etiology First choice Alternative Comments
Infective MSSA Cloxacillin 2 g i.v. • Cardiothoracic surgery
endocarditis Q4H x 6 weeks + consultation
(prosthetic Rifampicin 600 mg • Start rifampicin 3 – 5 days
valve) p.o. BID x 6 weeks after cloxacillin and
+ Gentamicin 1 mg/ gentamicin
kg i.v. Q8H x 2
weeks • Cardiothoracic surgery
consultation
MRSA Vancomycin 15 mg/ • Start rifampicin 3 – 5 days
kg i.v. Q12H x 6 after vancomycin and
weeks + gentamicin
Rifampicin 600 mg • Teicoplanin may be used
p.o. BID x 6 weeks instead of vancomycin (6
+ Gentamicin 1 mg/ mg/kg/12 h x 3 days,
kg i.v. Q8H x 2 followed by 6 - 10 mg/kg/
weeks day).
32
2. Bloodstream infections
a. Candidemia (Candida isolated from a single peripheral
or central-line blood culture):
i. Start treatment with Caspofungin 70 mg i.v. x one
dose, followed by 50 mg i.v. OD
1. Start Fluconazole 400 mg i.v. OD if isolate
susceptible to fluconazole and patient clinically
stable
ii. Obtain blood cultures on alternate days until negative
to document clearance of candidemia
iii. Ophthalmology evaluation (fundoscopic
examination) to r/o retinal involvement
iv. Echocardiography for patients with persistently
positive (>96 hours after antifungal therapy) or
clinical features suggestive of IE
v. Central venous catheters should be removed as early
as possible when presumed to be the source and the
catheter can be removed safely; decision should be
individualized for each patient
vi. Duration of treatment: 14 days from end of
candidemia (for patients without obvious metastatic
complications); change to Fluconazole 400 mg p.o.
OD after 5 to 7 days if isolate susceptible and patient
clinically stable
b. Staphylococcus aureus bacteremia (SAB)
i. Detailed history and physical examination to:
1. Determine source of bacteremia
2. Ascertain presence of prosthetic devices
3. Evidence of metastatic infection (e.g.,
endocarditis, bone and joint infection, splenic
abscess, renal abscess etc.)
33
ii. Echocardiography required for all patients with SAB
to r/o endocarditis. TTE may be adequate for patients
without identified risk factors for IE
1. Indications for TEE: persistently positive (>96
hours after appropriate antimicrobials) blood
cultures, presence of prosthetic heart valve,
peripheral stigmata of IE, cardiac valvular
abnormalities, metastatic infections,
iii. Obtain blood cultures on alternate days to document
clearance of bacteremia
iv. Antimicrobials:
1. MRSA: Vancomycin 15 mg/kg i.v. BID
2. MSSA: Cloxacillin 2 g i.v. Q4H (alternative
Cefazolin 2 g i.v. Q8H)
v. Duration: 14 days from end of bacteremia for
uncomplicated illness; longer duration for IE,
metastatic infections, delayed clearance of bacteremia
34
3. Other infections
Condition Etiology Preferred Alternative Comments
3.1 Bacterial
infections
1. Enteric fever • S. Typhi 1. Azithromycin 20 Ceftriaxone 2 g i.v.
• S.Paratyphi A mg/kg/day x 7 OD x 14 days
days (for MDR &
cipro resistant
isolates)
2. Co-trimoxazole
1 double-
strength tablet
p.o.BID x 14
days (if suscep-
tible)
2. Melioidosis • B. Intensive phase: Intensive phase: • Prolonged i.v. therapy
Pseudomallai • Ceftazidime 2 g • Meropenem 1 g (4 - 8 weeks or longer)
i.v. Q6H x 14 i.v. TID x 14 for
days days (for o Complicated
Eradication patients in ICU) pneumonia,
phase: • Meropenem 2 g o Deep-seated
• Co-trimoxazole i.v. TID x 14 infection including
2 double- days (for prostatic
strength tablets neurological abscesses,
BID x 3 months melioidosis)
o Neurological
melioidosis,
o Osteomyelitis
o Septic arthritis
• Abscess drainage
3. Brucellosis 1. Uncomplicated Obtain ID consult for
Brucella abortus,
brucellosis: patients with focal
B. melitensis
Doxycycline disease (spondylitis,
100 mg p.o. BID endocarditis,
+ Rifampicin 600 neurobrucellosis)
mg p.o. OD x 6
weeks
2. C o m p l i c a t e d
brucellosis:
Doxycycline
35
Condition Etiology Preferred Alternative Comments
100 mg p.o. BID
x 6 weeks +
Rifampicin 600
mg p.o. OD +
Gentamicin 5
mg/kg/day x 2
weeks
4. C. difficile colitis C. difficile • Non-severe dis- • Testing for C. difficile
ease: Metronida- or its toxins should
zole 500 mg p.o. be performed only on
TID x 10 days diarrheal (unformed)
stool, unless ileus or
• Severe disease:
toxic megacolon due
Vancomycin 125
to C. difficile is
mg p.o. QID x 10
suspected
days
• Discontinue
unnecessary
antimicrobials
• Fluid and electrolytes
replacement
• Avoid anti-motility
drugs
• Review proton pump
inhibitor use
• Surgery for
9 Colonic perforation
9 Severe disease
not responding to
antimicrobials
5. Carbapenem • CR K. • Colistin 9 million If isolate sensitive • Obtain ID consult
resistant Gram pneumoniae units i.v. loading to Amikacin: • Antimicrobials only
negative bacilli dose, followed Amikacin 15 mg/kg for invasive infection
• CR A.
(CR by 4.5 million i.v. OD +
Meropenem 2 g i.v. • Don’t treat
baumannii
GNB)causing units i.v. BID +
Meropenem 2 g TID given as 3 hr, colonization and
BSI, pneumonia
i.v. TID given as infusion contamination
3 hr. infusion • Follow infection
control precautions
36
Condition Etiology Preferred Alternative Comments
3.2 Parasitic
infections
6. Malaria Plasmodium Chloroquine Primaquin contraindicated
vivax phosphate Day 1: for patients with G6PD
1000 mg (=600 mg deficiency
base=4 tablets)
p.o. x 1 doseDay
2: 4 tablets p.o. x
1 doseDay 3: 2
tablets p.o. x 1
dose + Primaquine
15 mg p.o. OD x
14 days
Plasmodium • Artesunate 2.4 • Primaquin 45 mg p.o. x
falciparum mg/kg body 1 dose after completion
weight i.v. at of artesunate treatment
admission, then ·
at 12, 24 and 48
hours (4 doses),
followed by
Coartem 4
tablets p.o. BID
x 3 days
Severe malaria • Artesunate 2.4
mg/kg body
weight i.v. at
admission, then
at 12 h and 24
h, then once a
day x 7 days +
Doxycycline
100 mg p.o. BID
x 7 days
37
Condition Etiology Preferred Alternative Comments
by: Diloxanide • Large abscesses
furoate 500 mg (diameter >10 cm)
p.o. TID x 10 • Signs of imminent
days, or ruptureNo response to
Paromomycin 25 medical treatment
mg/kg/day p.o.in
3 divided doses
x 7 days
9. Taenia solium Albendazole 400 • Antiepileptic therapy
Neurocysticercosis mg p.o. BID + • Patients with multiple
Praziquantel cysts with significant
100mg/kg/day in 3 contral edema, only
divided doses on corticosteroid therapy
day 1 followed by + antiepileptic should
50mg/kg/day in 3 be given.
divided doses +
Dexamethasone 2
mg TID x 15 days
3.3 Viralinfections
10. Influenza Influenza A and B Oseltamivir 75 Indications for antiviral
viruses mg p.o. BID x 5 treatment:
days
1. Persons with suspected
or confirmed influenza
who are at higher risk for
influenza complications
2. Severe influenza
(suspected or confirmed
influenza who require
hospitalization)
3.4 Mycobacterial
infections
11. Tuberculosis Mycobacterium Rifampicin 10 If GeneXpert shows
tuberculosis mg/kg/dayp.o. rifampicin resistance,
(max. 600 mg obtain ID consult
OD) + Isoniazid
5 mg/kg/day p.o.
(max. 300 mg
OD) + Pyridoxine
10 mg p.o. OD +
Ethambutol
38
Condition Etiology Preferred Alternative Comments
20 mg/kg/day p.o.
(max. 1600 mg OD)
+ Pyrazinamide 25
mg/kg/day p.o.
(max. 2000 mg OD)
x 2 months,
followed by
Rifampicin + Iso-
niazid + Pyridoxine
+ Ethambutol x 4
months (total dura-
tion: 6 months)
12. Surgical site M. cheloniei Clarithromycin 500 Surgical debridement
infection M. abscessus mg p.o. BID +
caused by M. fortuitum Levofloxacin 750
rapidly growing mg OD + Amikacin
mycobacteria 500 mg i.v. OD x 3
months
3.5 Fungal
infections
13. Pneumocystis Pneumocystis Cotrimoxazole Adjunctive therapy for se-
pneumonia jiroveci (p.o. or i.v.) vere PCP (PaO2 <70 mm
• Dose: Hg on room air)
Trimethoprim • Day 1 to 5: Predniso-
15 mg/kg/day lone 40 mg p.o. BID
given in 3 or 4 • Day 6 to 10: Predniso-
divided doses lone 40 mg p.o. OD
• Duration: 21 • Day 11 to 21: Predniso-
days lone 20 mg p.o. OD
39
Condition Etiology Preferred Alternative Comments
15. Invasive Mucorales Ambisome 5 mg/ Amphotericin B • Surgical debridement·
mucormycosis kg/day i.v. till deoxycholate 1 Consider changing to
resolution of mg/kg/day till Posaconazole 400 mg
symptom, signs resolution of p.o. BID after 2 weeks
and radiologic symptom, signs of Amphotericin in pa-
changes and radiologic tients with good clini-
changes cal response
16. Candiduria: Candida spp. Fluconazole 400 • Asymptomatic
Treatment only if mg p.o. OD x 14 patients need no
patients are days antifungals
• Symptomatic • Remove urinary
or catheterNeutropenic
patients treated as for
• Neutropenic or
candidemia
• Undergoing
urologic
manipulation
40
Chapter 5 : Infective Endocarditis Prophylaxis
High risk conditions requiring IE prophylaxis:
1. Prosthetic heart valves and prosthetic material used for cardiac
valve repair, such as annuloplasty rings and chords
2. Prior history of IE
3. Unrepaired cyanotic congenital heart disease
4. Repaired congenital heart disease with residual shunts or
valvular regurgitation at the site or adjacent to the site of the
prosthetic patch or prosthetic device
5. Repaired congenital heart defects with catheter-based
intervention involving an occlusion device or stent during
the first six months after the procedure
6. Valve regurgitation due to a structurally abnormal valve in a
transplanted heart
Recommendation: InjCefazolin 1 gm IV
Procedure involving entry Enteric gram negative Cefazolin. <120 Kg: 1 g IV 4 hours
into lumen of bacilli, gram-positive >120 Kg: 2 g IV
gastrointestinal tract cocci.
Procedures not involving Enteric gram-negative *High risk only: <120 kg: 1 g IV 4 hours
entry into lumen of bacilli, gram-positive
gastrointestinal tract Cefazolin >120 kg: 2 g IV
cocci
(selective vagotomy,
antireflux)
PLUS 15mg/kg NA
Amikacin
PLUS
Metronidazole 500 mg IV N/A
44
Colorectal Surgery
Nature of Etiology Recommended Usual adult dose Redose Interval
Operation antimicrobials
Colorectal surgery Enteric gram-negative Cefazolin <120 kg: 1 g IV 4 hours
bacilli, anaerobes, >120 kg: 2 g IV
enterococci PLUS
Metronidazole 500 mg IV N/A
Hernia Surgery
Nature of Etiology Recommended Usual adult dose Redose Interval
Operation antimicrobials
Hernia Aerobic gram- Cefazolin <120 kg: 1 g IV 4 hours
positive organisms >120 kg: 2 g IV
45
Vascular Surgery
Nature of Operation Etiology Recommended Usual adult dose Redose Interval
antimicrobials
Arterial surgery Cefazolin
S.aureus, <120 kg: 1 g IV 4 hours
involving prosthesis,
S.epidermidis >120 kg: 2 g IV
abdominal aorta or
groin incision
Superficial venous S.aureus, NA NA NA
system surgery S.epidermidis
Mastectomy
Orthopedic Surgery
46
Chapter 7: Dosing of antimicrobial agents in renal insufficiency
Cockcroft-Gault equation to calculate creatinine clearance (CrCl) for drug dosing in renal impairment:
CrCl (ml/min) = (140-age) x weight (kg) (x 0.85 if female)
72 x serum creatinine (mg/dl)
NB If anuric, morbidly obese or in acute renal failure, this equation will NOT give a true reflection of the creatinine clearance. Anuric and oliguric
(<500ml/day) patients assumed to have CrCl < 10ml/min.
If morbidly obese, use ideal body weight (IBW):
IBW (in kg) for males = 50kg + 2.3kg for each inch over 5 feet (Devine formula –Average BMI of 23.0 )
IBW (in kg) for women = 49kg + 1.7kg for each inch over 5 feet (Robinson formula—average BMI of 21.1)
47 48
ANTIBIOTICS, ANTIFUNGALS, Normal Dose CrCl (ml/min) Comments
ANTIVIRALS
Mild 20-50 Moderate 10-20 Severe <10 AD = After haemodialysis
Ceftazidime IV 1-2 g q8h CrCl-31-50:1-2g 12h CrCl-10-30: 1-2g q24h 500 mg – 1g q24h AD
Ceftriaxone IV 1-2g q12-24h Normal Normal Normal
IV 400 mg q8h IV 200-400 mg q12h IV 200-400 mg q12h
Ciprofloxacin IV + po Normal PO 250–500 mg q12h
PO 750 mg q12h PO 250–500 mg q12h
IV 500 mg q12h
Clarithromycin IV + po Normal 250-500mg q24h AD
PO 500 mg q12h 250–500 mg q12h
IV 600mg q6-8h
Clindamycin IV + po Normal Normal
PO 300–450 mg q6h Normal
IV 1-2g q4-6h
Cloxacillin IV + po Normal Normal (Max 6g/day)
PO 500 mg-1g q6h
Co-amoxiclav IV + po IV-1.2gm q8h Normal IV 1.2 g q24h
Normal AD
(Augmentin® etc) PO 1000 mg q12h PO 625 mg q8-12h
9MU Loading dose (LD) CrCl-60-80: Normal IV 1.2g q12h
[If <60kg 0.15MU/kg] CrCl-50-59: Normal LD
PO 625 mg q8-12h
then
Normal LD then 2MU q12h on
4MU q12h [If <60kg
THEN after 12 hours 1.5 MU q12h dialysis days
Colistimethate sodium IV 0.044MU/kg q8h] CrCl-20-
Normal LD then [If <60kg 0.038MU/kg q12h]NB If <
49: Normal LD then [If <60kg 0.023MU/kg q12h]
2MU q8h (If >60kg)[If <60kg 2 MU q12h 60kg round to nearest 0.5g
3MU q8h
0.038MU/kg q8h] [If <60kg .038MU/kg q12h]
[If <60kg 0.05MU/kg q8h]
49 50
ANTIBIOTICS, ANTIFUNGALS, Normal Dose CrCl (ml/min) Comments
ANTIVIRALS
Mild 20-50 Moderate 10-20 Severe <10 AD = After haemodialysis
Soft tissue infections 4-6mg/kg Soft tissue infections AD Monitor creatine kinase initially
Daptomycin IV q24hBacteremia and Endocarditis: Normal 4-6mg/kg q48h and at least weekly
8-10mg/kg q24h Bacteremia and Endocarditis: 8-10mg/kg q48h
IV 1-2g q4-6h Normal (Max 6g/day)
Dicloxacillin IV + po Normal Normal
PO 500 mg-1g q6h
Doxycycline IV + po 100 mg q12h Normal Normal Normal
Ertapenem IV 1g q24h Normal Normal 500 mg q24h AD
Ethambutol po 20 mg/kg q24h Normal 20mg/kg q24-36h 20mg/kg q48h AD
Start normal dose then AD
50%
Single dose:
Fluconazole IV + po 50-800 mg daily Start normal dose then 50% Start normal dose then 50% HD: 100% after each dialysis [on
non-dialysis days dose according Normal
to CrCl) CRRT: Normal
CrCl-50-69
2.5 mg/kg q12h
Ganciclovir IV (Induction) 5 mg/kg q12h CrCl-10-24 1.25 mg/kg q24h 1.25 mg/kg 3 times a week AD
CrCl-25-49
2.5 mg/kg q24h
51 52
ANTIBIOTICS, ANTIFUNGALS, Normal Dose CrCl (ml/min) Comments
ANTIVIRALS
Mild 20-50 Moderate 10-20 Severe <10 AD = After haemodialysis
Levofloxacin IV + po 750 mg q24h 750 mg q48h 500 mg q48h 250-500 mg q24-48h
Linezolid IV + po 600 mg q12h Normal Normal Normal AD <10
Monitor platelets
Meropenem IV 1-2g q8h 1-2g q12h 500-1g q12h 500 mg -1g q24h AD
CRO: Infuse each dose over 3 hours
Metronidazole IV + po IV 500 mg q8h Normal Normal Normal AD
Loading dose (LD) 100 mg then Normal Normal Normal For CRO use 200mg as loading
Tigecycline IV
50 mg q12h dose followed by 100mg q12
53 54
ANTIBIOTICS, ANTIFUNGALS, Normal Dose CrCl (ml/min) Comments
ANTIVIRALS
Mild 20-50 Moderate 10-20 Severe <10 AD = After haemodialysis
CrCl-40-59
I-450 mg q12h
CrCl-10-24 I 450 mg Not recommendedLimited data: I
Induction 900 mg q12h M 450 mg 24h AD
Valganciclovir IV q48hM 450 mg twice 450 mg 2-3 times a weekM 450 mg
Maintenance 900 mg q24h 25-39 weekly 1-2 times a week
I 450 mg q24h
M 450 mg q48h
20-30mg/kg loading (max 1.5gm) 15mg/kg q48h 15mg/kg once followed by monitor trough levels before 5th dose
Vancomycin IV 15mg/kg q24h
Followed by 15mg/kg q12h redosing based on trough levels to achieve 15—20mcg/ml
Voriconazole IV and PO IV 6mg/kg q12h x 2 doses, then 4 Normal but PO preferred, ideally AVOID IV as solubilising
mg/kg q12hPO 400 mg q12 h x 2 AD
doses then 200-300 mg q12h agent may lead to renal damage. If IV essential monitor creatinine.
55 56
Antimicrobial susceptibility profile of Blood stream
infections - 2017
Table 1 : AST Profile of BSI organisms - Susceptible percentage
Escherichia coli K.pneumoniae Enterobacter
(n=725) (n=349) spp (n=90)
Gentamicin 60% 54% 68%
Amikacin 91% 65% 82%
Netilmicin 90% 63% 83%
Ciprofloxacin 30% 48% 70%
Piperacillin / Tazobactam 73% 59% 78%
Cefoperazone / Sulbactam 75% 56% 78%
Imipenem 92% 64% 81%
Meropenem 92% 64% 81%
Cefepime 35% 48% 71%
Tigecycline 99% 87% 78%
Colistin 99% 98% 88%
*Cefotaxime / Ceftazidime 21% 41%
*Surrogate marker of ESBL Production
57
Table 3 : AST Profile of BSI organisms- Susceptible percentage
Salmonella Typhi (n=102) Salmonella paratyphi (n=28)
Ampicillin 84% 71%
Chloramphenicol 84% 75%
Co- trimoxazole 84% 71%
Ceftriaxone 81% 71%
Ciprofloxacin 1% 0%
Nalidixic acid 16% 0%
Azithromicin 87% 90%
58
Table 6 : AST Profile of BSI organisms- Susceptible percentage
Enterococcus spp (n=201)
Ampicillin 65%
High level Gentamicin 57%
Levofloxacin 40%
Vancomycin 92%
Linezolid 96%
>80% Susceptible
70 – 79% Susceptible
<69% Susceptible
59
Hand Hygiene Technique
60