Empiric antibiotic therapy is initially selected based on the suspected infection before definitive microbiological identification. It is important to de-escalate or narrow therapy based on culture results to help reduce antimicrobial resistance. The appropriate duration of therapy depends on the infection severity and site as well as the patient's response. Limiting duration is an effective way to improve antibiotic stewardship. For urinary tract infections, urine culture should be obtained before treatment and antibiotics should be modified based on culture and sensitivity results as well as the patient's kidney function. Proper treatment depends on factors like the type and location of infection as well as patient characteristics.

1. EMPIRICAL ANTIBIOTICS

2. Approach to selection of antimicrobial therapy.

4. • Empiric therapy is generally defined as the initial antibiotic regimen
selected in the absence of definitive microbiological pathogen
identification and susceptibility testing.

6. De-escalation
discontinuing use or narrowing therapy on the basis of culture and
sensitivity results.
The action is important to help decrease antimicrobial resistance, to
avoid superinfection with other pathogenic or resistant organisms, and
to prevent the side effects and costs possible with overuse of broad-
spectrum antimicrobial agents .De-escalation also may involve
switching the administration route from intravenous to oral or enteral

7. Duration of therapy
• The appropriate duration of antimicrobial drug therapy depends on
the site of infection as well as the patient’s response to treatment.
Duration should be individualized on the basis of the severity of
illness, the type of infection, whether source control has been
obtained, and diagnostic assessments of improvement or cure.
• Along with de-escalation, limiting the duration of therapy can be one
of the most effective means of improving antimicrobial stewardship

14. Urinary tract infection
• Urine culture should be taken before starting antibiotics or antifungal
except for uncomplicated cystitis
• *Modify antibiotic according to culture result.
• *Modify antibiotic doses according to patient eGFR.
• *If there is no improvement in patient manifestations despite the use
of proper antibiotics, please assess for surgical cause e.g., stones

15. Urinary tract infection
• 1-Uncomplicated lower UTI (cystitis):
• Dysuria, frequency, urgency +/- hematuria and suprapubic discomfort.
• 1st choice:
• Nitrofurantion (1*2*5)
• Or TMP/SMX 1*2*3
• Or Amoxicillin clavulanate 500mg 1*2*5)
• 2nd choice:
• Ciprofloxacin(250MG 1*2*3 or 500mg 1*1*3
• Or Levofloxacin(250 or 500mg 1*1*3)

16. • 2-Uncomplicated upper UTI (pyelonephritis):
• Costovertebral angle pain +/- fever, nausea and vomiting.
• 1st choice:
• TMP/SMX 14 days Or Amoxicillin clavulanate 500mg 1*2*10-14
• 2nd choice:
• Ciprofloxacin 500mg 1*2*7 Or Levofloxacin 750mg 1*1*7

17. • 3- Complicated UTI:
• Geriatric, children, male, uncontrolled DM, structural abnormality or
immunocompromised.
• 1st choice:
• Piperacillin/ tazobactam (4.5gm/6/10-14d)
• 2nd choice:
• Levofloxacin(500mg 1*1*10-14)

19. • 4- UTI with MDR risk factors:
• If history of previous MDR urinary isolate or admission to health care
facility or use of broad- spectrum antibiotic in the past 3 months.
• extended infusion (infusion over 3 hrs) Meropenem 1gm/8h
• Or Imipenem / cilastatin .5/6h for 14d

20. • 5- UTI + sepsis: 2 or more SIRS criteria:
• SIRS criteria: tachycardia >90 beats/min, tachypnea >20 breaths/min,
fever or hypothermia temperature >38 or <36 °C, and leukocytosis or
leucopenia white blood cells 12000/mm3 or <4,000/mm3
• Meropenem Or Imipenem / cilastatin

21. • 6- Candiduria:
• Treat only if symptomatic UTI or undergoing urologic procedure.
• 1st choice:
• Fluconazole 400mg daily(cystitis 7-10 .pyelonephritis 14d.perinephric
abscess 4weeks)
• 2nd choice:
• Amphotericin B deoxycholate

22. Infective Endocarditis
• 1- Native valve / Late prosthetic (4-6 weeks):
• 1st choice:
• Ampicillin sulbactam 3gm/6h
• 2nd choice:
• Gentamicin

23. • 2- Early prosthesis valve/ Hospital related:
• 1st choice:
• Vancomycin + Gentamicin
• 2nd choice:
• Rifampicin Or Teicoplanin(targocid)

24. • 3- Prophylaxis before device implantation:
• Teicoplanin
• 400 mg/ IV in 2 doses 30 minutes before the procedure and 6 hours
after the procedure

25. • 4- Prophylaxis against IE:
• Ampicillin sulbactam 3gm iv + Gentamicin 1.5mg/kg IV 30 minutes
before surgical intervention
• Or Amoxicillin 1gm oral 6 hours after surgery

26. Skin and soft tissue infection
• necrotizing fasciitis:
• Predisposing factors include:
• *History of blunt trauma *Injection drug use *Exposure to burns
*Penetrating injury such as laceration, surgical procedures, childbirth

27. • 1- Necrotizing fasciitis Type 1 :
• 1st choice:
• Ampicillin Or Ampicillin sulbactam
• + Clindamycin Or Metronidazole
• 2nd choice:
• Piperacillin tazobactam
• Type 2:
• Penicillin G + Clindamycin

28. 2- Diabetic infection of lower extremities
• Mild to moderate :
• 1st:Clindamycin
• 2nd:TMP-SMX + Amoxicillin clavulanate 1gm/12
• Moderate to severe:
• Vancomycin + Ampicillin sulbactam + Meropenem
• 2nd: metronidazole+ ceftazidim or cefepime

29. • 3- Erysipelas:
• Penicillin 500mg/ 6 hrs orally
• Erythromycin 250mg/6h for 10-14d

30. 4- Cellulitis
• uncomplicated non purulent:
• Cephalexin Or Clindamycin
• Purulent or MRSA is suspected:
• Clindamycin Or TMP-SMX
• 2nd: doxycycline 100mh/12h
• Diabetic or decubitus ulcers complicated by cellulitis:
• Peracillin tazobactam
• 2nd: iv Metronidazole + Ciprofloxacin

31. Thank you