ADULT
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GASTROINTESTINAL & HEPATOBILIARY INFECTIONS
1. HELICOBACTER PYLORI INFECTION
1. HELICOBACTER PYLORI INFECTION
Preferred
First line Treatment
Triple Therapy:
*Proton Pump Inhibitors PO q12h
PLUS
Amoxicillin 1g PO q12h
PLUS
Clarithromycin 500mg PO q12h
Second Line Treatment
Bismuth Quadruple regimen:
*Proton Pump Inhibitors PO q12h
PLUS
Tetracycline hydrochloride 500mg PO q6h
PLUS
Metronidazole 400mg PO q8h
PLUS
Bismuth subsalicylate 300mg
OR
Bismuth subcitrate 120-300mg PO q6h
Fluoroquinolones triple therapy:
*Proton Pump Inhibitors PO q12h
PLUS
Levofloxacin 500mg PO q24h
PLUS
Amoxicillin 1g PO q12h
Alternative
Antibiotic allergy:
*Proton Pump Inhibitors PO q12h
PLUS
Clarithromycin 500mg PO q12h
PLUS
Metronidazole 400mg PO q12h
Second Line Treatment
Potassium-Competitive Acid Blockers Triple Therapy:
**Potassium-Competitive Acid Blockers PO q12h
PLUS
Amoxicillin 1g PO q12h
PLUS
Clarithromycin 500mg PO q12h
Comments
*Dosages of Proton Pump Inhibitors:
Omeprazole 20mg PO q12h
Pantoprazole 40mg PO q12h
Lansoprazole 30mg PO q12h
Esomeprazole 20mg PO q12h
Rabeprazole 20mg PO q12h
Dexlansoprazole 30mg PO q12h
**Potassium-Competitive Acid Blocker:
Vonoprazan 20mg q12h
(Not listed in MOH Drug Formulary)
First line therapy recommended in areas with < 15-20% clarithromycin resistance.
Consider second line treatment if clarithromycin resistance exceeds more than 15%.
Duration of therapy: 14 days
Meta-analysis of RCTs found 14 days duration of therapy showed greater eradication rate.
Refer to Appendix 3 for antibiotic allergy.
2. OROPHARYNGEAL CANDIDIASIS
2. OROPHARYNGEAL CANDIDIASIS
Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV section.
3. ESOPHAGITIS
3. ESOPHAGITIS
Candida spp: Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV section.
Herpes simplex virus: Refer to Sexually Transmitted Infections section.
4. INFECTIOUS DIARRHOEA
4. INFECTIOUS DIARRHOEA
Most community-acquired watery diarrhoea are self-limiting and viral in origin (norovirus, rotavirus, and adenovirus), therefore antibiotics should be discouraged. Rehydration and electrolyte replacement are the main treatment for acute infectious diarrhoea.
Antibiotics may be considered in the following conditions after blood and stool cultures collection:
Immunocompetent hosts with fever and bloody diarrhoea
Suspected to have enteric fever (Refer to chapter on Typhoid)
Ill immunocompromised hosts
4.1 Empirical Therapy
4.1.1 Mild Infective Diarrhoea
Antibiotic may not be necessary.
4.1.2 Moderate Infective Diarrhoea Requiring Hospitalisation
Preferred
Azithromycin 500mg PO/IV q24h single dose
Alternative
*Ciprofloxacin 500mg PO q12h
OR
Ciprofloxacin 400mg IV q12h
Duration: 3 days
Comments
*Fluroquinolone-resistant Campylobacter spp has been increasingly reported.
4.1.3 Severe Infective Diarrhoea Requiring Hospitalisation
Hypotension
Not responding to fluid resuscitation
Organ failure (E.g.: acute kidney injury)
Preferred
Ceftriaxone 1g IV q24h
Alternative
Ciprofloxacin 400mg IV q12h
Comments
Duration: 5 - 7days
4.2 Pathogen-directed therapy
4.2.1 Aeromonas spp / Plesiomonas shigelloides / Yersinia enterocolitica
Preferred
Trimethoprim/sulfamethoxazole 160/800mg PO q12h
Alternative
Ciprofloxacin 500mg PO q12h
Comments
Duration: 3 days
Aeromonas spp are uniformly resistant to ampicillin, amoxicilin/clavulanate and cefazolin.
4.2.2 Shiga Toxin Producing E. coli (STEC) / Enteroinvasive E. coli (EIEC)
Supportive care is the mainstay of treatment. Treatment with antibiotics should be avoided due to the risk of inducing haemolytic ureamic syndrome (HUS).
4.2.3 Enteropathogenic E. coli (EPEC) / Enterotoxigenic E. coli (ETEC) & Enteroaggregative E. coli (EAEC)
Preferred
Supportive care, including rehydration is the mainstay of treatment.
For severe illness or in immunocompromised host, to consider:
Azithromycin 1g PO single dose
Alternative
Ciprofloxacin 750mg PO single dose
Comments
--
4.2.4 Campylobacter jejuni
Preferred
Azithromycin 500mg PO q24h
Alternative
Doxycycline 100mg PO q12h
Comments
Duration: 3 days
Consider longer duration of therapy in immunocompromised patients.
4.2.5 Salmonella spp, non-typhi
Preferred
*Trimethoprim/sulfamethoxazole 160/800mg PO q12h
In HIV patients:
Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV section.
Alternative
Azithromycin 500mg PO q24h
OR
Ciprofloxacin 500mg PO q12h
Comments
Duration:
Immunocompetent: 5-7 days
Immunocompromised: 14 days
If bacteremia or with foci of infection, treatment has to be individualized.
*Antibiotic is usually not indicated, except in the following conditions:
Severe illness or septic shock
Presence of prostheses, valvular heart disease or severe atherosclerosis
Malignancy
Immunocompromised hosts
4.2.6 Salmonella typhi
Refer to Tropical Infections section.
4.2.7 Cholera
Vibrio cholerae
Primary therapy is rehydration. Antibiotic is to reduce the shedding time.
Refer to Tropical Infections section.
4.2.8 Shigella spp
Fever and bloody stool
Preferred
*Moderate disease:
Ciprofloxacin 750mg PO q12h for 3 days
Severe disease:
Ceftriaxone 2g IV q24h for 5 days
Alternative
*Moderate disease:
*Azithromycin 500mg PO q24h for 3 days
OR
*Trimethoprim/sulfamethoxazole 160/800mg PO q12h for 3 days
Comments
*Moderate disease in individual such as food handler, residents of nursing home/ institutions, immunocompromised patients should be treated with antibiotic.
Duration of antibiotic in immunocompromised patients is 7-10 days.
4.2.9 Giardiasis
Giardia duodenalis
Preferred
Metronidazole 400mg PO q8h for 5-7 days*
Alternative
Albendazole 400mg PO q24h for 5 days
Comments
*There is no randomised controlled trials (RCT) on the duration of metronidazole treatment. The duration quoted is based on observational studies.
4.2.10 Entamoeba histolytica
Preferred
Metronidazole 800mg PO q8h for 5–10 days*
PLUS
**Paromomycin 500mg PO q8h for 7 days
Alternative
--
Comments
*There is no RCT on the duration of metronidazole treatment. The duration quoted is based on observational studies.
**Requires DG’s approval.
5. CLOSTRIDIUM DIFFICILE INFECTION (CDI)
5. CLOSTRIDIUM DIFFICILE INFECTION (CDI)
Discontinue therapy with the inciting antibiotic agent as soon as possible as this may influence risk of CDI recurrence. Treatment includes management of initial or recurrent disease. Recurrent disease is defined as resolution of CDI symptoms while on treatment followed by reappearance of symptoms within 2 months of discontinuing treatment.
5.1 Initial, Non-severe CDI
WCC ≤ 15x109/L and serum creatinine < 1.5mg/dL (133 µmol/L)
Preferred
Vancomycin 125mg PO q6h
Alternative
Metronidazole 400mg PO q8h (if vancomycin is not available)
Comments
RCTs have shown that oral vancomycin is superior to oral metronidazole.
Duration: 10 days
5.2 Initial, Severe CDI
WCC > 15 x 109/L and/or serum creatinine ≥ 1.5mg/dL (133 µmol/L)
Preferred
Vancomycin 125mg PO q6h
Alternative
--
Comments
Duration: 10 days
5.3 Initial, Fulminant Colitis
Hypotension/shock, ileus or megacolon
Preferred
*Vancomycin 500mg PO q6h
PLUS
Metronidazole 500mg IV q8h
Alternative
--
Comments
*If ileus is present, consider rectal instillation of vancomycin (enema): Vancomycin 500mg (in 100 mL normal saline) q6h via enema or by nasogastric tube
Duration: 10 days (may extend to 14 days if recovery is delayed)
5.4 Recurrent CDI
Preferred
If vancomycin was used for the initial episode,
Vancomycin pulsed-tapered regimen:
125mg PO q6h for 10-14 days, then
125mg PO q12h for 7 days, then
125mg PO q24h for 7 days, then
125mg PO q48-72h for 2-8 weeks
Alternative
If metronidazole was used for the initial episode,
Vancomycin 125mg PO q6h for 10-14 days
Comments
--
6. SPONTANEOUS BACTERIAL PERITONITIS (SBP)
6. SPONTANEOUS BACTERIAL PERITONITIS (SBP)
6.1 Primary SBP
Common organisms:
Enterobacterales (E.g.: E. coli, K. pneumoniae, and Streptococcus spp.)
Preferred
Cefotaxime 2g IV q8h
OR
Ceftriaxone 2g IV q24h
Alternative
Amoxicillin/clavulanate 1.2g IV q6h
OR
*Ciprofloxacin 400mg IV q12h
Comments
Duration: 5-7 days
*May consider to convert IV to oral ciprofloxacin 500mg q12h.
6.2 In Cirrhosis with Upper Gastrointestinal Hemorrhage
Common organisms:
Enterobacterales (eg: E. coli, K. pneumoniae, and Streptococcus spp.)
Preferred
Cefotaxime 2g IV q8h for 7 days
OR
Ceftriaxone 2g IV q24h for 7 days
Alternative
Ciprofloxacin 400mg IV q12h
Comments
Antibiotics should be used judiciously for this indication in view of emergence of resistance.
Primary SBP prophylaxis in high risk patients:
RCTs’ demonstrate decreased in mortality and incidence of SBP with selective intestinal decontamination.
However, in most studies the efficacy to prevent death decreases over time due to the emergence of MDRO.
Ideally, antibiotics for SBP prophylaxis should have low systemic bioavailability.
For patients who may benefit from SBP prophylaxis, it is best to discuss with gastroenterologists or refer to a centre of specialisation.
Patient with recurrent SBP:
To discuss with gastroenterologists or refer to a centre of specialisation for the role of and option for secondary SBP prophylaxis.
7. LIVER ABSCESS
7. LIVER ABSCESS
7.1 Pyogenic liver abscess
Common pathogens:
Klebsiella spp
Escherichia coli
Preferred
Empirical therapy in non-sepsis:
Amoxycillin/clavulanate 1.2g IV q6h
OR
Ampicillin/sulbactam 3g IV q6h
Sepsis/organ failure:
*Piperacillin/tazobactam 4.5g IV q6-8h
Alternative
Empirical therapy in non-sepsis:
Third generation cephalosporins:
Cefoperazone 1-2g IV q12h
OR
Ceftriaxone 2g IV q24h
OR
Cefotaxime 2g IV q8h
OR
Cefuroxime 1.5g IV q8h
MAY ADD
**Metronidazole 500mg IV q8h
Comments
Duration: 2 - 6 weeks
Shorter duration when there is adequate drainage with fever resolution.
To convert IV to oral when there is clinical improvement. The duration of oral antibiotic depends on the complete resolution of the abscess clinically and radiologically.
To consider drainage if abscess size is ≥ 5cm or impending rupture.
*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).
**May add metronidazole in patients with risk factors of anaerobic liver abscess:
Acute and chronic inflammatory bowel disease with or without perforation
Malignancy of gastrointestinal tract
Surgery of the gastrointestinal tract or pelvic organs
Metronidazole has excellent bioavailability: consider IV to PO switch (refer to Appendix 6).
Reserve carbapenem for patients with history of biliary instrumentation suspecting multi-resistant gram negative organism.
7.2 Amoebic liver abscess
Entamoeba histolytica
Preferred
Amoebicidal agent:
*Metronidazole 750mg IV q8h for 10 days
followed by
Luminal agent: To eradicate intestinal colonization after amoebicidal treatment
**Paromomycin 25-35mg/kg/day PO q8h for 7 days
Alternative
--
Comments
*May consider IV to PO switch when there is satisfactory clinical improvement.
Dose: Metronidazole 800mg PO q8h
Drainage of amoebic liver abscess is not usually required but is necessary if:
The patient does not respond to antibiotic therapy.
The abscess is > 5 cm in diameter.
The abscess is in the left lobe of the liver.
The diagnosis remains in doubt.
** Requires DG’s approval.
8. CHOLECYSTITIS
8. CHOLECYSTITIS
Common pathogens:
Klebsiella spp
Escherichia coli
Enterococci
Preferred
Non-sepsis:
Amoxicillin/clavulanate 1.2g q6h
OR
Ampicillin/sulbactam 1.5-3g IV q6h
Sepsis/organ failure or complicated cholecystitis (E.g.: abscess or perforation):
*Piperacillin/tazobactam 4.5g IV q6-8h
Alternative
Non-sepsis:
Third generation cephalosporins:
Cefoperazone 1-2g IV q12h
OR
Cefotaxime 2g IV q8h
OR
Ceftriaxone 2g q24h
Comments
Duration : 4 -7days
However, for mild to moderate acute cholecystitis, antibiotics may be ceased within 24h post-cholecystectomy, in the absence of gallbladder necrosis, pericholecystic abscess or biliary peritonitis.
Reserve carbapenems for patients who are at high risk of antimicrobial resistance or history of biliary instrumentation.
*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).
9. CHOLANGITIS
9. CHOLANGITIS
Community acquired
Common pathogens:
Klebsiella spp
Escherichia coli
Enterococci
Appropriate source control to drain infected foci and restoration of anatomic and physiological function is recommended for all patients, as antibiotics will not penetrate the biliary system in the presence of obstruction.
Preferred
Non-sepsis:
Amoxicillin/clavulanate 1.2g q6h
OR
Ampicillin/sulbactam 1.5-3g IV q6h
Sepsis/organ failure or complicated cholangitis (E.g.: abscess or perforation) and Hospital acquired infection:
*Piperacillin/tazobactam 4.5g IV q6-8h
Alternative
Non-sepsis:
Third generation cephalosporins:
Cefoperazone 1-2g IV q12h
OR
Cefotaxime 2g IV q8h
OR
Ceftriaxone 2g q24h
MAY ADD
**Metronidazole 500mg IV q8h
Comments
Duration: 4- 7 days
Treatment may be reduced to 3 days post-biliary drainage with fever resolution.
Reserve carbapenems for patients who are at high risk of antimicrobial resistance or history of biliary instrumentation.
*Piperacillin/tazobactam: to be given as extended infusion over 3-4 hours.
**Metronidazole is required if biliary enteric anastomosis is present.
10. SURGICAL INFECTIONS
10. SURGICAL INFECTIONS
10.1 Diverticulitis
Common organisms:
Enterobacterales
Enterococcus spp
Bacteroides
10.1.1 Uncomplicated Acute Diverticulitis
Uncomplicated acute diverticulitis in non-septic immunocompetent host:
Antibiotics is usually not required
Preferred
Uncomplicated acute diverticulitis with any of the following:
Systemic signs of infection
Elderly
Presence of significant comorbidities E.g.: diabetes, significant cardiac disease (IHD, cardiac failure) chronic liver disease or end stage renal disease
Immunocompromised state
Amoxicillin/clavulanate 1.2g q6h
OR
Ampicillin/sulbactam 1.5-3g IV q6h
Alternative
Cefuroxime 1.5g IV q8h
PLUS
Metronidazole 500mg IV q8h
Comments
Uncomplicated diverticulitis is defined as acute diverticulitis without perforation or abscess.
Require close clinical monitoring and re-evaluation for antibiotics if symptoms progress.
May convert to oral antibiotics if clinically improving.
Duration: 7-10 days (IV and oral)
10.1.2 Complicated Diverticulitis
Abscess, perforation or peritonitis
Preferred
Non-sepsis:
Amoxicillin/clavulanate 1.2g IV q6h
OR
Ampicillin/sulbactam 1.5g-3g IV q6h
Sepsis or organ failure:
*Piperacillin/tazobactam 4.5g IV q6-8h
Alternative
Non-sepsis:
Ceftriaxone 2g IV q24h
OR
Cefoperazone 1-2g IV q12h
PLUS
Metronidazole 500mg IV q8h
Comments
*Piperacillin/tazobactam: If given as q8h, to be given as extended infusion (over 3-4 hours).
Reserve carbapenem for patients who are at high risk of antimicrobial resistance.
10.2 Appendicitis
Common organisms:
Enterobacterales
Enterococcus spp
Bacteroides
10.2.1 Uncomplicated acute appendicitis
Uncomplicated acute appendicitis can be managed by two approaches:
a) Non operative management (NOM) with antibiotics alone.
b) Appendectomy (for patients who are not suitable for NOM approach or those who do not respond to antibiotics).
Preferred
Non operative management (NOM):
Amoxicillin/clavulanate 1.2g IV q6h
OR
Ampicillin/sulbactam 1.5-3g IV q6h
Alternative
Cefuroxime 1.5g IV q8h
PLUS
Metronidazole 500mg IV q8h
Comments
Non-operative management approach:
May convert to oral antibiotics if clinically improving.
Duration: 7-10 days (IV and oral) with close clinical monitoring and re-evaluation for surgery if symptoms do not resolve.
Appendectomy done:
Antibiotic treatment can be stopped once surgery is performed; provided adequate control of the source of infection is achieved and symptoms have resolved.
10.2.2 Complicated acute appendicitis
Abscess, perforation or peritonitis
Preferred
Non-sepsis:
Amoxicillin/clavulanate 1.2g IV q6h
OR
Ampicillin/sulbactam 1.5-3g IV q6h
Sepsis or organ failure:
*Piperacillin/tazobactam 4.5g IV q6-8h
Alternative
Non-sepsis:
Ceftriaxone 2g IV q24h
OR
Cefoperazone 1-2g IV q12h
PLUS
Metronidazole 500mg IV q8h
Comments
Duration: 4-7 days (if adequate source control, no delay in surgical intervention and patient has rapid clinical recovery).
*Piperacillin/tazobactam: If given as q8h, to be given as extended infusion (over 3-4 hours).
Reserve carbapenem for patients who are at high risk of antimicrobial resistance and adverse outcomes.
10.3 Abdominal Injury
Patients who do not require surgery:
No antibiotics required
Patients who require surgery:
Antibiotic choice will be based on organs involved. Duration:
If hollow viscus injury is repaired early (within 12 hours): Antibiotics should be continued for no more than 24 hours.
If hollow viscus injury is repaired late (> 12hours): Antibiotics should be limited to 7 days.
If hollow viscus injury is incompletely repaired or clinical signs persist in patients with traumatic abdominal injury: Antibiotics can be used for more than 7 days.
10.4 Colorectal Surgery
10.4.1 Anorectal Abscess
Preferred
Mild:
Amoxicillin/clavulanate 1.2g IV or 625mg PO q8h
OR
Ampicillin/sulbactam 1.5-3g IV q6h
Moderate to severe (E.g.: deep seated, sepsis/organ failure, immunocompromised):
Ceftriaxone 2g IV q24h
OR
Cefoperazone 1-2g IV q12h
PLUS
Metronidazole 500mg IV q8h
Alternative
--
Comments
Drainage procedure is mandatory.
Duration: 4-7 days (advice to stop antibiotics once adequate source control, no delay in surgical intervention and patient has rapid clinical recovery).
10.5 Hepatobiliary Surgery
10.5.1 Acute Pancreatitis
Mild to moderate:
Self-limiting, often do not require antibiotics. Prophylactic antibiotics have not been shown to reduce mortality, rates of pancreatic or peripancreatic infection or need for surgery.
If infective biliary calculi in origin, refer to severe pancreatitis.
Preferred
Role of antibiotics even in severe pancreatitis is still unclear, except in:
Extrapancreatic infection (E.g.: cholangitis, catheter-acquired infections, bacteremia, urinary tract infections and pneumonia)
Infected pancreatic necrosis
*Piperacillin/tazobactam 4.5g IV q6-8h
Alternative
Severe pancreatitis:
Cefoperazone 1-2g IV q12h
OR
Cetriaxone 2g q24h
OR
Cefotaxime 2g q8h
PLUS
Metronidazole 500mg IV q8h
Comments
Short course of antibiotics until surgically obtained cultures are available.
Modify antibiotics according to culture and sensitivity.
Reserve carbapenem for patients at high risk of resistant pathogens.
Duration depends on adequate source control.
*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours).
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