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1 Cover Design John Michael L. Roque Layout Design Adell R. Azuelo Lora Alaine D. Raymundo John Michael L. Roque All rights reserved 2017 National Antibiotic Guidelines Committee Pharmaceutical Division Department of Health Philippine Blood Center, Lung Center Compound, Quezon Avenue, Quezon City, 1100 ISBN - 978-621-95675-1-0 Any part of the book or its entirety may be reproduced or transmitted without any alteration, in any form or by any means, with permission from DOH provided it is not used for commercial purposes. National Antibiotic Guidelines 2017 Department of Health Manila, Philippines TABLE OF CONTENTS MESSAGE OF THE SECRETARY OF HEALTH .. i ACKNOWLEDGMENTS .. ii EDITORIAL TEAM .. iv ACRONYMS AND ABBREVIATIONS .. v INTRODUCTION TO THE NATIONAL ANTIBIOTIC GUIDELINES .. viii BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES.

2 1 BONE AND JOINT INFECTIONS IN PEDIATRICS .. 19 BONE AND JOINT INFECTIONS IN ADULTS .. 26 CARDIOVASCULAR INFECTIONS .. 33 CENTRAL NERVOUS SYSTEM INFECTIONS .. 47 DENTAL AND oral INFECTIONS .. 55 GASTROINTESTINAL TRACT INFECTIONS .. 61 OCULAR INFECTIONS .. 74 UPPER RESPIRATORY INFECTIONS .. 86 LOWER RESPIRATORY INFECTIONS .. 105 SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRICS .. 124 SKIN AND SOFT TISSUE INFECTIONS IN ADULTS .. 150 URINARY TRACT INFECTIONS .. 170 PUBLIC HEALTH PROGRAMS FILARIASIS .. 183 LEPROSY .. 184 MALARIA .. 186 SCHISTOSOMIASIS .. 195 SEXUALLY TRANSMITTED INFECTIONS .. 196 TUBERCULOSIS .. 219 SURGICAL PROPHYLAXIS .. 230 i ii ACKNOWLEDGMENTS The participation and assistance of the following experts and reviewers of this document are gratefully acknowledged: Dr.

3 Estrella B. Paje-Villar, former NAG Committee Chair Dr. Ivan Olegario, former editor DOH offices: Disease Prevention and Control Bureau (DPCB) Epidemiology Bureau (EB) Food and Drug Administration (FDA) Health Facility Development Bureau (HFDB) Professional Associations: Pediatric Infectious Disease Society of the Philippines Pediatric Nephrology Society of the Philippines (PNSP) Philippine Academy of Family Physicians (PAFP) Philippine Academy of Ophthalmology (PAO) Philippine Academy of Pediatric Pulmonologist (PAPP) Philippine Coalition Against Tuberculosis (PhilCAT) Philippine College of Chest Physicians (PCCP) Philippine College of Physicians (PCP) Philippine College of Surgeons (PCS) Philippine Dental Association (PDA) Philippine Dermatological Society (PDS) Philippine Hospital Infection Control Society, Inc. (PHICS) Philippine Neurological Association (PNA) Philippine Obstetrical and Gynecological Society (POGS) Philippine Orthopedic Association (POA) Philippine Pediatric Society (PPS) Philippine Pharmacists Association, Inc.

4 (PPhA) Philippine Society for Microbiology and Infectious Disease (PSMID) Philippine Society of Nephrology (PSN) Philippine Society of Newborn Medicine (PSNBM) Philippine Society of Otolaryngology Head and Neck Surgery (PSO-HNS) Philippine Society for Pediatric Gastroenterology, Hepatology and Nutrition (PSPGHAN) iii Philippine Society of Pediatric Surgeons (PSPS) Philippine Urological Association (PUA) Hospitals: Philippine Children s Medical Center (PCMC) Research Institute for Tropical Medicine (RITM) San Lazaro Hospital (SLH) The Medical City (TMC) UP- Philippine General Hospital (UP-PGH) Development Partners: World Health Organization iv EDITORIAL TEAM National Antibiotic Guidelines Committee Chair MEDIADORA C. SANIEL, MD, MBA-H, FPCP Members CELIA C. CARLOS, MD, FPPS, FPIDSP, FPSMID CARMINA A. DELOS REYES, MD, FPPS, FPAPP MARI ROSE A.

5 DE LOS REYES, MD, FPCP BENILDA B. GALVEZ, MD, FPCCP MARY ANN D. LANSANG, MD, MMEDSC CECILIA C. MARAMBA-LAZARTE, MD, MSCID, MSCCT ROSALIND G. VIANZON, MD, MPH CYNTHIA S. FABREGAS, MD, DPCOM OLIVIA M. LIMUACO, RPh, PhD YOLANDA R. ROBLES, RPh, PhD VITO G. ROQUE, Jr. MD Antimicrobial Resistance Program Secretariat CORAZON I. FLORES, MD, MPH, CESO IV ANNA MELISSA M. GUERRERO, MD, MPH (HTA) IRENE V. FLORENTINO-FARI AS, RPH, MD, MNSA MS. ANNE JULIENNE M. GENUINO, RPH MS. NI A ISABELLE M. TOLENTINO, RPH MS. LORA ALAINE D. RAYMUNDO, RPH v ABBREVIATIONS AND ACRONYMS ABECB Acute bacterial exacerbation of chronic bronchitis ABP Acute bacterial prostatitis ABRS Acute bacterial rhinosinusitis ABSSSI Acute bacterial skin and skin structure infections AL Artemether-lumefantrine ALT Alanine aminotransferase AOM Acute otitis media ARSP Antimicrobial Resistance Surveillance Program ART Antiretroviral therapy ASB Asymptomatic bacteriuria AUC Acute uncomplicated cystitis BMI Body mass index BUN Blood urea nitrogen CAMRSA Community associated MRSA CAP Community acquired pneumonia CBP Chronic bacterial prostatitis CHD Congenital heart disease CMV Cytomegalovirus CNS Central nervous system CRP C-reactive protein CRS Chronic rhinosinusitis CSF Cerebrospinal fluid CSOM Chronic suppurative otitis media CT Computed tomography CVC Central venous catheter

6 CVS Cardiovascular system DAIR Debridement and retention of prosthesis DEC Diethyl carbamazine DFI Diabetic foot infections DOT Duration of Therapy EIA Enzyme immunoassay ELISA Enzyme-linked immunosorbent assay ENT Ears, nose and throat EPTB Extra pulmonary tuberculosis ESBL Extended spectrum -Lactamase ESR Erythrocyte sedimentation rate ETEC Entero-toxigenic Escherichia coli FDC Fixed dose combination vi FQ Fluoroquinolone FTA-ABS Fluorescent treponemal antibody absorption test GIT Gastro-intestinal tract GABHS Group A Beta-hemolytic Streptococci GAS Group A streptococcus GCSF Granulocyte stimulating factor GNB Gram-negative bacteria GUT Genitourinary tract HACEK Haemophilus sp., Aggregatibacter sp., Cardiobacterium hominis, Eikinella corrodens, and Kingella sp. HAI Hospital-associated Infections HAP Hospital acquired pneumonia HBIG Hepatitis B Immunoglobulin HBeAg Hepatitis B envelope antigen HBsAg Hepatitis B surface antigen HBV Hepatitis B virus HCV Hepatitis C virus HR Isoniazid + Rifampicin HRZE/S Isoniazid + Rifampicin + Pyrazinamide + Ethambutol/Streptomycin HSV Herpes simplex virus HIV Human immunodeficiency virus ICT Immunochromatographic test IDSA Infectious Diseases Society of America IE Infective Endocarditis I & D Incision and drainage IRIS Immune reconstitution inflammatory syndrome ISPD International Society for Peritoneal Dialysis LBW Low birth weight LP Lumbar puncture MAP Mean arterial pressure MDR-TB Multiple drug resistant tuberculosis MDT Multidrug therapy MIC Minimum inhibitory concentration MMR Mumps, Measles.

7 Rubella MRI Magnetic resonance imaging MSSA Methicillin-susceptible Staphylococcus aureus MRSA Methicillin-resistant Staphylococcus aureus MTB Mycobacterium tuberculosis NAAT Nucleic acid amplification testing NBE Nocturnal blood examinations vii NT Neutralization test OC oral contraceptive ogtt oral glucose tolerance test PANDAS Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus Infections PCAP Pediatric community acquired pneumonia PCR Polymerase chain reaction PHN Post-herpetic neuralgia PICC Peripherally inserted central catheter PID Pelvic Inflammatory Disease PLHIV People living with HIV PMDT Programmatic Management for drug-resistant Tuberculosis PT Prothrombin time PVL Panton valentin leukocidin PWID People who inject drugs RHD Rheumatic Heart Disease RPR Rapid plasma reagin RSU Respiratory syncytial virus SIRS Systemic inflammatory response syndrome SLDs Second line drugs SLE Systemic Lupus Erythematosus SOFA Sequential organ failure assessment STD Sexually Transmitted Disease STI Sexually Transmitted Infections TALF Treatment after lost to follow up TB Tuberculosis TMP-SMX Trimethoprim-sulfamethoxazole TCA Trichloroacetic acid TSS Toxic shock syndrome TEE Transesophageal echo TPHA Treponema pallidum haemagglutination TTE Transthoracic echocardiogram ULN Upper limit of normal UTI Urinary tract infection VAP Ventilator associated pneumonia VDRL Venereal Disease Research Laboratory VP Ventriculoperitoneal VSD Ventricular septal defect VZIG Varicella zoster immunoglobulin VZV Varicella zoster virus WHO World Health Organization viii INTRODUCTION The National Antimicrobial

8 Stewardship (AMS) Program, an integral component of the Philippine Action Plan to Combat Antimicrobial Resistance (AMR), gives structure and direction to healthcare facilities to adopt a proactive multidisciplinary approach to promote rational antimicrobial use. One of the six core elements of AMS is the development and implementation of policies, guidelines and clinical pathways to improve antimicrobial prescribing and dispensing. Specifically, Core Element 2 states that all hospitals shall adopt or adapt to their local context the National Antibiotic Guidelines to optimize antimicrobial use and help improve the quality of patient care and patient safety. Armed with enhanced knowledge provided by the Guidelines, health practitioners at all levels of healthcare are then empowered to appropriately treat common infectious disease syndromes seen among children and adults ( respiratory and urinary tract infections, diarrhea, skin and soft tissue infections, tuberculosis) as well as other diseases for which much irrational antibiotic use prevails in the country.

9 The challenging task of formulating the Guidelines was given by the Department of Health to the National Antibiotic Guidelines Committee (NAGCOM), a multidisciplinary group of experts in the fields of infectious diseases, epidemiology, pharmacology and public health program management. It was decided from the outset that there would be no need to reinvent the wheel. Divided into subgroups, the NAGCOM reviewed existing evidence-based local and international guidelines and relevant literature, with priority given to guidelines that utilized the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Adaptations of available guidelines and treatment recommendations were made taking into consideration the latest national Antimicrobial Resistance Surveillance Program resistance rates, list of approved drugs in the National Formulary, quality of the evidence, balance of potential benefits and harm, cost-effectiveness, availability of diagnostic tests , feasibility and resource implications.

10 Interim recommendations were ix discussed en banc and a consensus was usually reached. The interim guidelines were then sent to the specialty/subspecialty societies for their inputs prior to finalizing the Guidelines. Consultations with external technical experts and public health program implementers were also done as needed. The Guidelines in this handbook contain treatment recommendations for infectious diseases grouped by organ systems and presented in a tabular format for ease of use. Brief descriptions of disease categories with their etiologic agents, corresponding antibiotic regimens (dose, route, frequency and duration) for pediatric and adult patients, relevant comments and key references are presented. A section on surgical prophylaxis, although not treatment-focused, has been added since antibiotic misuse to prevent surgical site infections also needs urgent attention.