"
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Meningitis
1.Admit to:
2.Diagnosis: Meningitis.
3.Condition:
4.Vital Signs: q1h. Call physician if BP systolic
>160/90, <90/60; P >120, <50; R>25, <10; T >39 C
or less than 36 C
5.Activity: Bed rest with bedside commode.
6.Nursing: Respiratory isolation, inputs and outputs,
lumbar puncture tray at bedside.
7.Diet: NPO
8.IV Fluids: D5 ½ NS at 125 cc/h with KCL 20 mEq/L.
9.Special Medications:
Empiric Therapy 15-50 years old:
-Vancomycin 1 gm IV q12h AND EITHER
-Ceftriaxone (Rocephin) 2 gm IV q12h (max 4 gm/d)
OR
Cefotaxime (Claforan) 2 gm IV q4h.
Empiric Therapy >50 years old, Alcoholic, Cor-
ticosteroids or Hematologic Malignancy or other
Debilitating Condition:
-Ampicillin 2 gm IV q4h AND EITHER
-Cefotaxime (Claforan) 2 gm IV q6h OR
Ceftriaxone (Rocephin) 2 gm IV q12h.
-Use Vancomycin 1 gm IV q12h in place of ampicillin
if drug-resistant pneumococcus is suspected.
10. Symptomatic Medications:
-Dexamethasone (Decadron) 0.4 mg/kg IV q12h x 2
days to commence with first dose of antibiotic.
-Heparin 5000 U SC q12h or pneumatic compression
stockings.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn
temp >39°C.
-Docusate sodium 100-200 mg PO qhs.
11. Extras: CXR, ECG, PPD, CT scan.
12. Labs: CBC, SMA 7&12. Blood C&S x 2. UA with
micro, urine C&S. Antibiotic levels peak and trough
after 3rd dose, VDRL.
Lumbar Puncture:
CSF Tube 1: Gram stain, C&S for bacteria (1-4 mL).
CSF Tube 2: Glucose, protein (1-2 mL).
CSF Tube 3: Cell count and differential (1-2 mL).
CSF Tube 4: Latex agglutination or counterimmunoel-
ectrophoresis antigen tests for S. pneumoniae, H.
influenzae (type B), N. meningitides, E. coli, group
B strep, VDRL, cryptococcal antigen, toxoplasma
titers. India ink, fungal cultures, AFB (8-10 mL).
Infective Endocarditis
1.Admit to:
2.Diagnosis: Infective endocarditis
3.Condition:
4.Vital Signs: q4h. Call physician if BP systolic
>160/90, <90/60; P >120, <50; R>25, <10; T >38.5 C
5.Activity: Up ad lib, bathroom privileges.
6.Diet: Regular
7.IV Fluids: Heparin lock with flush q shift.
8.Special Medications:
Subacute Bacterial Endocarditis Empiric Therapy:
-Penicillin G 3-5 million U IV q4h or ampicillin 2 gm IV
q4h AND
Gentamicin 1-1.5/mg/kg IV q8h.
Acute Bacterial Endocarditis Empiric Therapy
-Gentamicin 2 mg/kg IV; then 1-1.5 mg/kg IV q8h
AND
Nafcillin or oxacillin 2 gm IV q4h OR
Vancomycin 1 gm IV q12h (1 gm in 250 mL of D5W
over 1h).
Streptococci viridans/bovis:
-Penicillin G 3-5 million U IV q4h for 4 weeks OR
Vancomycin 1 gm IV q12h for 4 weeks AND
Gentamicin 1 mg/kg q8h for first 2 weeks.
Enterococcus:
-Gentamicin 1 mg/kg IV q8h for 4-6 weeks AND
Ampicillin 2 gm IV q4h for 4-6 weeks OR
Vancomycin 1 gm IV q12h for 4-6 weeks.
Staphylococcus aureus (methicillin sensitive, native
valve):
-Nafcillin or Oxacillin 2 gm IV q4h for 4-6 weeks OR
Vancomycin 1 gm IV q12h for 4-6 weeks AND
Gentamicin 1 mg/kg IV q8h for first 3-5 days.
Methicillin-resistant Staphylococcus aureus (native
valve):
-Vancomycin 1 gm IV q12h (1 gm in 250 mL D5W
over 1h) for 4-6 weeks AND
Gentamicin 1 mg/kg IV q8h for 3-5 days.
Methicillin-resistant Staph aureus or epidermidis
(prosthetic valve):
-Vancomycin 1 gm IV q12h for 6 weeks AND
Rifampin 600 mg PO q8h for 6 weeks AND
Gentamicin 1 mg/kg IV q8h for 2 weeks.
Culture Negative Endocarditis:
-Penicillin G 3-5 million U IV q4h for 4-6 weeks OR
Ampicillin 2 gm IV q4h for 4-6 weeks AND
Gentamicin 1.5 mg/kg q8h for 2 weeks (or nafcillin, 2
gm IV q4h, and gentamicin if Staph aureus
suspected in drug abuser or prosthetic valve).
Fungal Endocarditis:
-Amphotericin B 0.5 mg/kg/d IV plus flucytosine (5-
FC) 150 mg/kg/d PO.
9. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
N
temp >39
C.
-Docusate sodium 100-200 mg PO qhs.
10.Extras: CXR PA and LAT, echocardiogram, ECG.
11. Labs: CBC with differential, SMA 7&12. Blood C&S x
3-4 over 24h, serum cidal titers, minimum inhibitory
concentration, minimum bactericidal concentration.
Repeat C&S in 48h, then once a week. Antibiotic
levels peak and trough at 3rd dose. UA, urine C&S.
Pneumonia
1.Admit to:
2.Diagnosis: Pneumonia
3.Condition:
4.Vital Signs: q4-8h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C or O
2
saturation <90%.
5.Activity: Up ad lib, bathroom privileges.
6.Nursing: Pulse oximeter, inputs and outputs,
nasotracheal suctioning prn, incentive spirometry.
7.Diet: Regular.
8.IV Fluids: IV D5 ½ NS at 125 cc/hr.
9.Special Medications:
-Oxygen by NC at 2-4 L/min, or 24-50% by Ventim-
ask, or 100% by non-rebreather (reservoir) to
maintain O
saturation >90%.
2
Moderately Ill Patients Without Underlying Lung
Disease From the Community:
-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR
Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h AND
EITHER
-Erythromycin 500 mg IV/PO q6h OR
Clarithromycin (Biaxin) 500 mg PO bid OR
Azithromycin (Zithromax) 500 mg PO x 1, then 250
mg PO qd x 4 OR
Doxycycline (Vibramycin) 100 mg IV/PO q12h.
Moderately Ill Patients With Recent Hospitalization
or Debilitated Nursing Home Patient:
-Ceftazidime (Fortaz) 1-2 gm IV q8h OR
Cefepime (Maxipime) 1-2 gm IV q12h AND EITHER
Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h OR
-Ciprofloxacin (Cipro) 400 mg IV q12h or 500 mg PO
q12h.
Critically Ill Patients:
-Initial treatment should consist of a macrolide with 2
antipseudomonal agents for synergistic activity:
-Erythromycin 0.5-1.0 gm IV q6h AND EITHER
-Cefepime (Maxipime) 20 mg IV q12h OR
Piperacillin/tazobactam (Zosyn) 3.75-4.50 gm IV q6h
OR
Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR
Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h
AND EITHER
-Levofloxacin (Levaquin) 500 mg IV q24h OR
Ciprofloxacin (Cipro) 400 mg IV q12h OR
Tobramycin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h or 7
mg/kg IV q24h.
Aspiration Pneumonia (community acquired):
-Clindamycin (Cleocin) 600-900 mg IV q8h (with
gentamicin or 3rd gen cephalosporin) OR
-Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h (with
gentamicin or 3rd gen cephalosporin)
Aspiration Pneumonia (nosocomial):
-Tobramycin 2 mg/kg IV then 1.5 mg/kg IV q8h or 7
mg/kg in 50 mL of D5W over 60 min IV q24h OR
Ceftazidime (Fortaz) 1-2 gm IV q8h AND EITHER
-Clindamycin (Cleocin) 600-900 mg IV q8h OR
Ampicillin/sulbactam or ticarcillin/clavulanate, or
piperacillin/tazobactam or imipenem/cilastatin (see
above) OR
Metronidazole (Flagyl) 500 mg IV q8h.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 650 mg 2 tab PO q4-6h prn
temp >38°C or pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Heparin 5000 U SQ q12h or pneumatic compression
stockings.
11. Extras: CXR PA and LAT, ECG, PPD.
12.Labs: CBC with differential, SMA 7&12, ABG. Blood
C&S x 2. Sputum Gram stain, C&S. Methenamine
silver sputum stain (PCP); AFB smear/culture.
Aminoglycoside levels peak and trough 3rd dose.
UA, urine culture.
Specific Therapy for Pneumonia
Pneumococcus:
-Ceftriaxone (Rocephin) 2 gm IV q12h OR
-Cefotaxime (Claforan) 2 gm IV q6h OR
-Erythromycin 500 mg IV q6h OR
-Levofloxacin (Levaquin) 500 mg IV q24h OR
-Vancomycin 1 gm IV q12h if drug resistance.
Staphylococcus aureus:
-Nafcillin 2 gm IV q4h OR
-Oxacillin 2 gm IV q4h.
Klebsiella pneumoniae:
-Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h OR
Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
Cefotaxime (Claforan) 1-2 gm IV q6h.
Methicillin-resistant staphylococcus aureus (MRSA):
-Vancomycin 1 gm IV q12h.
Vancomycin-Resistant Enterococcus:
-Linezolid (Zyvox) 600 mg IV/PO q12h; active against
MRSA as well OR
-Quinupristin/dalfopristin (Synercid) 7.5 mg/kg IV q8h
(does not cover E faecalis).
Haemophilus influenzae:
-Ampicillin 1-2 gm IV q6h (beta-lactamase negative)
OR
-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h OR
-Cefuroxime (Zinacef) 1.5 gm IV q8h (beta-lactamase
pos) OR
-Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
-Ciprofloxacin (Cipro) 400 mg IV q12h OR
-Ofloxacin (Floxin) 400 mg IV q12h.
-Levofloxacin (Levaquin) 500 mg IV q24h.
Pseudomonas aeruginosa:
-Tobramycin 1.5-2.0 mg/kg IV, then 1.5-2.0 mg/kg IV
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h AND EITHER
-Piperacillin, ticarcillin, mezlocillin or azlocillin 3 gm IV
q4h OR
-Cefepime (Maxipime) 2 gm IV q12h.
Enterobacter Aerogenes or Cloacae:
-Gentamicin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h
AND EITHER
Meropenem (Merrem) 1 gm IV q8h OR
Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h.
Serratia Marcescens:
-Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
-Aztreonam (Azactam) 1-2 gm IV q6h OR
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h OR
-Meropenem (Merrem) 1 gm IV q8h.
Mycoplasma pneumoniae:
-Clarithromycin (Biaxin) 500 mg PO bid OR
-Azithromycin (Zithromax) 500 mg PO x 1, then 250
mg PO qd for 4 days OR
-Erythromycin 500 mg PO or IV q6h OR
-Doxycycline (Vibramycin) 100 mg PO/IV q12h OR
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
Legionella pneumoniae:
-Erythromycin 1.0 gm IV q6h OR
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
-Rifampin 600 mg PO qd may be added to
erythromycin or levofloxacin.
Moraxella catarrhalis:
-Trimethoprim/sulfamethoxazole (Bactrim, Septra)
one DS tab PO bid or 10 mL IV q12h OR
-Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h OR
-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR
-Erythromycin 500 mg IV q6h OR
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
Anaerobic Pneumonia:
-Penicillin G 2 MU IV q4h OR
-Clindamycin (Cleocin) 900 mg IV q8h OR
-Metronidazole (Flagyl) 500 mg IV q8h.
Pneumocystis Carinii Pneumonia
and HIV
1.Admit to:
2.Diagnosis: PCP pneumonia
3.Condition:
4.Vital Signs: q2-6h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C; O
sat
2
<90%
5.Activity: Bedrest, bedside commode.
6.Nursing: Pulse oximeter.
7.Diet: Regular, encourage fluids.
8.IV Fluids: D5 ½ NS at 125 cc/h.
9.Special Medications:
Pneumocystis Carinii Pneumonia:
-Oxygen at 2-4 L/min by NC or by mask.
-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 15
mg of TMP/kg/day (20 mL in 250 mL of D5W IVPB
q8h) for 21 days [inj: 80/400 mg per 5 mL].
-If severe PCP (PaO
<70 mm Hg): add prednisone
2
40 mg PO bid for 5 days, then 40 mg qd for 5 days
then 20 mg qd for 11 days OR Methylprednisolone
(Solu-Medrol) 30 mg IV q12h for 5 days, then 30
mg IV qd for 5 days, then 15 mg IV qd for 11 days.
-Pentamidine (Pentam) 4 mg/kg IV qd for 21 days,
with prednisone as above. Pentamidine is an
alternative if inadequate response or intolerant to
TMP-SMX.
Pneumocystis Carinii Prophylaxis (previous PCP or
CD4 <200, or constitutional symptoms):
-Trimethoprim/SMX DS (160/800 mg) PO qd OR
-Pentamidine, 300 mg in 6 mL sterile water via
Respirgard II nebulizer over 20-30 min q4 weeks
OR
-Dapsone (DDS) 50 mg PO bid or 100 mg twice a
week; contraindicated in G-6-PD deficiency.
Antiretroviral Therapy:
A. Combination therapy with 3 agents (two nucleoside
analogs and a protease inhibitor) is recommended
as initial therapy. Nucleotide analogs are similar to
nucleosides and may be used interchangeably.
Combination of atazanavir plus tenofovir or
lamivudine plus abacavir plus tenofovir should be
avoided because of the risk of treatment failure.
B.Nucleoside Analogs
1. Abacavir (Ziagen) 300 mg PO bid [300 mg, 20
mg/mL].
2. Didanosine (Videx, ddI) 200 mg bid for patients
>60 kg; or 125 mg bid for patients <60 kg.
[chewable tabs: 25, 50, 100, 150 mg; pwd 100,
167, 250 mg packets].
3. Emtricitabine (Emtriva) 200 mg PO qd.
4. Lamivudine (Epivir, 3TC) 150 mg twice daily
[150 mg].
5. Stavudine (Zerit, D4T) 40 mg bid [15 mg, 20
mg, 30 mg and 40 mg capsules].
6. Zalcitabine (Hivid, ddC) 0.75 mg tid [0.375,
0.75].
7. Zidovudine (Retrovir, AZT) 200 mg tid (100,
200 mg caps, 50 mg/5 mL syrup).
C.Protease Inhibitors
1. Amprenavir (Agenerase) 1200 mg bid [50, 150
mg].
2. Atazanavir (Reyataz) 400 mg PO qd.
3. Indinavir (Crixivan) 800 mg tid [200, 400 mg].
4. Lopinavir/ritonavir (Kaletra) 400 mg/100 mg PO
bid.
5. Nelfinavir (Viracept) 750 mg PO tid [250 mg].
6. Ritonavir (Norvir) 600 mg bid [100 mg, 80
mg/dL].
7. Saquinavir (Invirase) 600 mg tid with a meal
[cap 200 mg].
D.Non-Nucleoside Reverse Transcriptase
Inhibitors
1. Delavirdine (U-90) 400 mg tid.
2. Efavirenz (Sustiva) 600 mg PO qd [50, 100, 20
mg].
3. Nevirapine (Viramune) 200 mg qd for 2 weeks,
then bid [200 mg].
E.Nucleotide Analogs
1. Tenofovir (Viread) 300 mg PO qd with food.
Postexposure HIV Prophylaxis
A. The injury should be immediately washed and
scrubbed with soap and water.
B. Zidovudine 200 mg PO tid and lamivudine (3TC)
150 mg PO bid, plus indinavir (Crixivan) 800 mg
PO tid for highest risk exposures. Treatment is
continued for one month.
Zidovudine-Induced Neutropenia/Ganciclovir-
Induced Leucopenia
-Recombinant human granulocyte colony-stimulating
factor (G-CSF, Filgrastim, Neupogen) 1-2 mcg/kg
SQ qd until absolute neutrophil count 500-1000;
indicated only if endogenous erythropoietin level is
low.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache or fever.
-Docusate sodium 100-200 mg PO qhs.
10. Extras: CXR PA and LAT.
11. Labs: ABG, CBC, SMA 7&12. Blood C&S x 2.
Sputum for Gram stain, C&S, AFB. Giemsa
immunofluorescence for Pneumocystis. CD4 count,
HIV RNA, VDRL, serum cryptococcal antigen, UA.
Opportunistic Infections in HIV-
Infected Patients
Oral Candidiasis:
-Fluconazole (Diflucan) 100-200 mg PO qd OR
-Ketoconazole (Nizoral) 400 mg PO qd OR
-Itraconazole (Sporanox) 200 mg PO qd OR
-Clotrimazole (Mycelex) troches 10 mg dissolved
slowly in mouth 5 times/d.
Candida Esophagitis:
-Fluconazole (Diflucan) 200-400 mg PO qd for 14-21
days OR
-Ketoconazole (Nizoral) 200 mg PO bid OR
-Itraconazole (Sporanox) 200 mg PO qd for 2 weeks.
-Caspofungin (Cancidas) 50 mg IV qd x 2 weeks.
Primary or Recurrent Mucocutaneous HSV
-Acyclovir (Zovirax), 200-400 mg PO 5 times a day for
10 days, or 5 mg/kg IV q8h OR in cases of
acyclovir resistance, foscarnet, 40 mg/kg IV q8h fo
21 days.
Herpes Simplex Encephalitis (or visceral disease):
-Acyclovir (Zovirax) 10 mg/kg IV q8h for 10-21 days.
Herpes Varicella Zoster
-Acyclovir (Zovirax) 10 mg/kg IV over 60 min q8h for
7-14 days OR 800 mg PO 5 times/d for 7-10 days
OR
-Famciclovir (Famvir) 500 mg PO q8h for 7 days [500
mg] OR
-Valacyclovir (Valtrex) 1000 mg PO q8h for 7 days
[500 mg] OR
-Foscarnet (Foscavir) 40 mg/kg IV q8h.
Cytomegalovirus Retinitis:
-Ganciclovir (Cytovene) 5 mg/kg IV (dilute in 100 mL
D5W over 60 min) q12h for 14-21 days OR
-Foscarnet (Foscavir) 60 mg/kg IV q8h for 2-3 weeks
OR
-Cidofovir (Vistide) 5 mg/kg IV over 60 min q week for
2 weeks. Administer probenecid, 2 g PO 3 hours
prior to cidofovir, 1 g PO 2 hours after, and 1 g PO
8 hours after.
Suppressive Treatment for Cytomegalovirus
Retinitis:
-Ganciclovir (Cytovene) 5 mg/kg qd.
-Foscarnet (Foscavir) 90-120 mg IV qd OR
-Cidofovir (Vistide) 5 mg/kg IV over 60 min every 2
weeks with probenecid.
Acute Toxoplasmosis:
-Pyrimethamine 200 mg, then 50-75 mg qd, plus
sulfadiazine 1.0-1.5 gm PO q6h, plus folinic acid
10 mg PO qd OR
-Atovaquone (Mepron) 750 mg PO tid.
Suppressive Treatment for Toxoplasmosis:
-Pyrimethamine 25-50 mg PO qd plus sulfadiazine
0.5-1.0 gm PO q6h plus folinic acid 5 mg PO qd
OR
-Pyrimethamine 50 mg PO qd, plus clindamycin 300
mg PO qid, plus folinic acid 5 mg PO qd.
Cryptococcus Neoformans Meningitis:
-Amphotericin B 0.7-1.0 mg/kg/d IV; total dosage of 2
g, with or without 5-flucytosine 100 mg/kg PO qd in
divided doses, followed by fluconazole (Diflucan)
400 mg PO qd or itraconazole (Sporanox) 200 mg
PO bid 6-8 weeks OR
-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h
OR
-Fluconazole (Diflucan) 400-800 mg PO qd for 8-12
weeks
Suppressive Treatment of Cryptococcus:
-Fluconazole (Diflucan) 200 mg PO qd indefinitely.
Active Tuberculosis:
-Isoniazid (INH) 300 mg PO qd; and rifampin 600 mg
PO qd; and pyrazinamide 15-25 mg/kg PO qd (500
mg bid-tid); and ethambutol 15-25 mg/kg PO qd
(400 mg bid-tid).
-All four drugs are continued for 2 months; isoniazid
and rifampin are continued for a period of at least 9
months and at least 6 months after the last
negative cultures.
-Pyridoxine (Vitamin B6) 50 mg PO qd concurrent with
INH.
Prophylaxis for Inactive Tuberculosis:
-Isoniazid 300 mg PO qd; and pyridoxine 50 mg PO
qd for 12 months.
Disseminated Mycobacterium Avium Complex
(MAC):
-Clarithromycin (Biaxin) 500 mg PO bid AND
Ethambutol 800-1000 mg qd; with or without rifabutin
450 mg qd.
Prophylaxis against Mycobacterium Avium Complex:
-Azithromycin (Zithromax) 1200 mg once a week.
Disseminated Coccidioidomycosis:
-Amphotericin (Fungizone) B 0.5-0.8 mg/kg IV qd, to a
total dose 2.0 gm OR
-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h
OR
-Fluconazole (Diflucan) 400-800 mg PO or IV qd.
Disseminated Histoplasmosis:
-Amphotericin B (Fungizone) 0.5-0.8 mg/kg IV qd, to a
total dose 15 mg/kg OR
-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h
OR
-Fluconazole (Diflucan) 400 mg PO qd OR
-Itraconazole (Sporanox) 300 mg PO bid for 3 days,
then 200 mg PO bid.
Suppressive Treatment for Histoplasmosis:
-Fluconazole (Diflucan) 400 mg PO qd OR
-Itraconazole (Sporanox) 200 mg PO bid.
Septic Arthritis
1.Admit to:
2.Diagnosis: Septic arthritis
3.Condition:
4.Vital Signs: q shift
5.Activity: Up in chair as tolerated. Bedside commode
with assistance.
6.Nursing: Warm compresses prn, keep joint
immobilized. Passive range of motion exercises of the
affected joint bid.
7.Diet: Regular diet.
8.IV Fluids: Heparin lock
9.Special Medications:
Empiric Therapy for Adults without Gonorrhea
Contact:
-Nafcillin or oxacillin 2 gm IV q4h AND
Ceftizoxime (Cefizox) 1 gm IV q8h or ceftazidime 1
gm IV q8h or ciprofloxacin 400 mg IV q12h if Gram
stain indicates presence of Gram negative
organisms.
Empiric Therapy for Adults with Gonorrhea:
-Ceftriaxone (Rocephin) 1 gm IV q12h OR
-Ceftizoxime (Cefizox) 1 gm IV q8h OR
-Ciprofloxacin (Cipro) 400 mg IV q12h.
-Complete course of therapy with cefuroxime axetil
(Ceftin) 400 mg PO bid.
10. Symptomatic Medications:
-Acetaminophen and codeine (Tylenol 3) 1-2 PO q4-
6h prn pain.
-Heparin 5000 U SQ bid.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate sodium 100-200 mg PO qhs.
11. Extras: X-ray views of joint (AP and lateral), CXR.
Synovial fluid culture. Physical therapy consult for
exercise program.
12. Labs: CBC, SMA 7&12, blood C&S x 2, VDRL, UA.
Gonorrhea cultures of urethra, cervix. Antibiotic levels.
Blood cultures x 2 for gonorrhea.
Synovial fluid:
Tube 1 - Glucose, protein, lactate, pH.
Tube 2 - Gram stain, C&S.
Tube 3 - Cell count.
Septic Shock
1.Admit to:
2.Diagnosis: Sepsis
3.Condition:
4.Vital Signs: q1h; Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C; urine
output < 25 cc/hr for 4h, O
saturation <90%.
2
5.Activity: Bed rest.
6.Nursing: Inputs and outputs, pulse oximeter. Foley
catheter to closed drainage.
7.Diet: NPO
8.IV Fluids: 1 liter of normal saline wide open, then D5
½ NS at 125 cc/h
9.Special Medications:
-Oxygen at 2-5 L/min by NC or mask.
Antibiotic Therapy
A. Initial treatment of life-threatening sepsis should
include a third-generation cephalosporin
(cefepime, ceftazidime, cefotaxime, ceftizoxime or
ceftriaxone), or piperacillin/tazobactam, or
ticarcillin/clavulanic acid or imipenem, each with an
aminoglycoside (gentamicin, tobramycin or
amikacin). If Enterobacter aerogenes or cloacae is
suspected, treatment should begin with
meropenem or imipenem with an aminoglycoside.
B.Intra-abdominal or pelvic infections, likely to
involve anaerobes, should be treated with
ampicillin, gentamicin and metronidazole; or either
ticarcillin/clavulanic acid, ampicillin/sulbactam,
piperacillin/tazobactam, imipenem, cefoxitin or
cefotetan, each with an aminoglycoside.
C.Febrile neutropenic patients with neutrophil
3
counts <500/mm
should be treated with
vancomycin and ceftazidime, or
piperacillin/tazobactam and tobramycin or
imipenem and tobramycin.
D.Dosages for Antibiotics Used in Sepsis
-Ampicillin 1-2 gm IV q4h.
-Cefepime (Maxipime) 2 gm IV q12h.
-Cefotaxime (Claforan) 2 gm q4-6h.
-Ceftizoxime (Cefizox) 1-2 gm IV q8h.
-Ceftriaxone (Rocephin) 1-2 gm IV q12h (max 4
gm/d).
-Cefoxitin (Mefoxin) 1-2 gm q6h.
-Cefotetan (Cefotan) 1-2 gm IV q12h.
-Ceftazidime (Fortaz) 1-2 g IV q8h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h
(200-300 mg/kg/d).
-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h.
-Piperacillin/tazobactam (Zosyn) 3.375-4.5 gm IV
q6h.
-Piperacillin or ticarcillin 3 gm IV q4-6h.
-Imipenem/cilastatin (Primaxin) 1.0 gm IV q6h.
-Meropenem (Merrem) 0.5-1.0 gm IV q8h.
-Gentamicin, tobramycin 100-120 mg (1.5 mg/kg)
IV, then 80 mg IV q8h (1 mg/kg) or 7 mg/kg in 50
mL of D5W over 60 min IV q24h.
-Amikacin (Amikin) 7.5 mg/kg IV loading dose;
then 5 mg/kg IV q8h.
-Vancomycin 1 gm IV q12h.
-Metronidazole (Flagyl) 500 mg (7.5 mg/kg) IV q6-
8h.
-Clindamycin (Cleocin) 900 mg IV q8h.
-Aztreonam (Azactam) 1-2 gm IV q6-8h; max 8
g/day.
Nosocomial sepsis with IV catheter or IV drug abuse
-Nafcillin or oxacillin 2 gm IV q4h OR
-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over 60
min) AND
Gentamicin or tobramycin as above AND EITHER
Ceftazidime (Fortaz) or ceftizoxime (Cefizox)1-2 gm
IV q8h OR
Piperacillin, ticarcillin or mezlocillin 3 gm IV q4-6h.
Recombinant human activated protein C
-Drotrecogin alfa, (Xigris), 24 mg/kg/h IV infusion for
96 hours.
Blood Pressure Support
-Dopamine 4-20 mcg/kg/min (400 mg in 250 cc D5W,
1600 mcg/mL).
-Norepinephrine 2-8 mcg/min IV infusion (8 mg in 250
mL D5W).
-Albumin 25 gm IV (100 mL of 25% solution) OR
-Hetastarch (Hespan) 500-1000 cc over 30-60 min
(max 1500 cc/d).
-Dobutamine 5 mcg/kg/min, and titrate blood pressure
to keep systolic BP >90 mm Hg; max 10
mcg/kg/min.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 650 mg PR q4-6h prn temp
>39 C.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Heparin 5000 U SQ q12h or pneumatic compression
stockings.
-Docusate sodium 100-200 mg PO qhs.
11. Extras: CXR, KUB, ECG. Ultrasound, lumbar punc-
ture.
12. Labs: CBC with differential, SMA 7&12, blood C&S x
3, T&C for 3-6 units PRBC, INR/PTT, drug levels peak
and trough at 3rd dose. UA. Cultures of urine, sputum,
wound, IV catheters, decubitus ulcers, pleural fluid.
Peritonitis
1.Admit to:
2.Diagnosis: Peritonitis
3.Condition:
4.Vital Signs: q1-6h. Call physician if BP >160/90, <90-
/60; P >120, <50; R>25, <10; T >38.5 C.
5.Activity: Bed rest.
6.Nursing: Guaiac stools.
7.Diet: NPO
8.IV Fluids: D5 ½ NS at 125 cc/h.
9.Special Medications:
Primary Bacterial Peritonitis - Spontaneous:
Option 1:
-Ampicillin 1-2 gm IV q 4-6h (vancomycin 1 gm IV
q12h if penicillin allergic) AND EITHER
Cefotaxime (Claforan) 1-2 gm IV q6h OR
Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
Gentamicin or tobramycin 1.5 mg/kg IV, then 1 mg/kg
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h.
Option 2:
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV q6h OR
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h OR
-Meropenem (Merrem) 500-1000 mg IV q8h.
Secondary Bacterial Peritonitis – Abdominal
Perforation or Rupture:
Option 1:
-Ampicillin 1-2 gm IV q4-6h AND
Gentamicin or tobramycin as above AND
Metronidazole (Flagyl) 500 mg IV q8h OR
Cefoxitin (Mefoxin) 1-2 gm IV q6h OR
Cefotetan (Cefotan) 1-2 gm IV q12h.
Option 2:
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h
(200-300 mg/kg/d) with an aminoglycoside as
above OR
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV q6h with
an aminoglycoside as above OR
-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h with
aminoglycoside as above OR
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h
OR
-Meropenem (Merrem) 500-1000 mg IV q8h.
Fungal Peritonitis:
-Amphotericin B peritoneal dialysis, 2 mg/L of dialysis
fluid over the first 24 hours, then 1.5 mg in each
liter OR
-Fluconazole (Diflucan) 200 mg IV x 1, then 100 mg
IV qd.
-Caspofungin (Candidas) 70 mg IV x1, then 50 mg IV
qd.
10. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 325 mg PO/PR q4-6h prn
temp >38.5 C.
-Heparin 5000 U SQ q12h.
11. Extras: Plain film, upright abdomen, lateral decub-
itus, CXR PA and LAT; surgery consult; ECG,
abdominal ultrasound, CT scan.
12. Labs: CBC with differential, SMA 7&12, amylase,
lactate, INR/PTT, UA with micro, C&S; drug levels
peak and trough 3rd dose.
Paracentesis Tube 1: Cell count and differential (1-2
mL, EDTA purple top tube).
Tube 2: Gram stain of sediment; inject 10-20 mL into an
aerobic and aerobic culture bottle; AFB, fungal C&S
(3-4 mL).
Tube 3: Glucose, protein, albumin, LDH, triglycerides,
specific gravity, bilirubin, amylase (2-3 mL, red top
tube).
Syringe: pH, lactate (3 mL).
Diverticulitis
1.Admit to:
2.Diagnosis: Diverticulitis
3.Condition:
4.Vital Signs: qid. Call physician if BP systolic >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C.
5.Activity: Up ad lib.
6.Nursing: Inputs and outputs.
7.Diet: NPO. Advance to clear liquids as tolerated.
8.IV Fluids: 0.5-2 L NS over 1-2 hr then, D5 ½ NS at
125 cc/hr. NG tube at low intermittent suction (if
obstructed).
9.Special Medications:
Regimen 1:
-Gentamicin or tobramycin 100-120 mg IV (1.5-2
mg/kg), then 80 mg IV q8h (5 mg/kg/d) or 7 mg/kg
in 50 mL of D5W over 60 min IV q24h AND
EITHER
Cefoxitin (Mefoxin) 2 gm IV q6-8h OR
Clindamycin (Cleocin) 600-900 mg IV q8h.
Regimen 2:
-Metronidazole (Flagyl) 500 mg q8h AND
Ciprofloxacin (Cipro) 250-500 mg PO bid or 200-300
mg IV q12h.
Outpatient Regimen:
-Metronidazole (Flagyl) 500 mg PO q6h AND EITHER
Ciprofloxacin (Cipro) 500 mg PO bid OR
Trimethoprim/SMX (Bactrim) 1 DS tab PO bid.
10. Symptomatic Medications:
-Meperidine (Demerol) 50-100 mg IM or IV q3-4h prn
pain.
-Zolpidem (Ambien) 5-10 mg qhs PO prn insomnia.
11. Extras: Acute abdomen series, CXR PA and LAT,
ECG, CT scan of abdomen, ultrasound, surgery and
GI consults.
12. Labs: CBC with differential, SMA 7&12, amylase,
lipase, blood cultures x 2, drug levels peak and trough
3rd dose. UA, C&S.
Lower Urinary Tract Infection
1.Admit to:
2.Diagnosis: UTI.
3.Condition:
4.Vital Signs: q shift. Call physician if BP <90/60; >160-
/90; R >30, <10; P >120, <50; T >38.5 C.
5.Activity: Up ad lib
6.Nursing:
7.Diet: Regular
8.IV Fluids:
9.Special Medications:
Lower Urinary Tract Infection (treat for 3-7 days):
-Trimethoprim-sulfamethoxazole (Septra) 1 double
strength tab (160/800 mg) PO bid.
-Norfloxacin (Noroxin) 400 mg PO bid.
-Ciprofloxacin (Cipro) 250 mg PO bid.
-Levofloxacin (Levaquin) 500 mg IV/PO q24h.
-Lomefloxacin (Maxaquin) 400 mg PO qd.
-Enoxacin (Penetrex) 200-400 mg PO q12h; 1h
before or 2h after meals.
-Cefpodoxime (Vantin) 100 mg PO bid.
-Cephalexin (Keflex) 500 mg PO q6h.
-Cefixime (Suprax) 200 mg PO q12h or 400 mg PO
qd.
-Cefazolin (Ancef) 1-2 gm IV q8h.
Complicated or Catheter-Associated Urinary Tract
Infection:
-Ceftizoxime (Cefizox) 1 gm IV q8h.
-Gentamicin 2 mg/kg, then 1.5/kg q8h or 7 mg/kg in
50 mL of D5W over 60 min IV q24h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h
-Ciprofloxacin (Cipro) 500 mg PO bid.
-Levofloxacin (Levaquin) 500 mg IV/PO q24h.
Prophylaxis ( 3 episodes/yr):
-Trimethoprim/SMX single strength tab PO qhs.
Candida Cystitis
-Fluconazole (Diflucan) 100 mg PO or IV x 1 dose,
then 50 mg PO or IV qd for 5 days OR
-Amphotericin B continuous bladder irrigation, 50
mg/1000 mL sterile water via 3-way Foley catheter
at 1 L/d for 5 days.
10. Symptomatic Medications:
-Phenazopyridine (Pyridium) 100 mg PO tid.
-Docusate sodium (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
N
C.
temp >39
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Renal ultrasound.
12. Labs: CBC, SMA 7. UA with micro, urine Gram stain,
C&S.
Pyelonephritis
1.Admit to:
2.Diagnosis: Pyelonephritis
3.Condition:
4.Vital Signs: tid. Call physician if BP <90/60; >160/90;
R >30, <10; P >120, <50; T >38.5 C.
5.Activity:
6.Nursing: Inputs and outputs.
7.Diet: Regular
8.IV Fluids: D5 ½ NS at 125 cc/h.
9.Special Medications:
-Trimethoprim-sulfamethoxazole (Septra) 160/800 mg
(10 mL in 100 mL D5W IV over 2 hours) q12h or 1
double strength tab PO bid.
-Ciprofloxacin (Cipro) 500 mg PO bid or 400 mg IV
q12h.
-Norfloxacin (Noroxin) 400 mg PO bid.
-Ofloxacin (Floxin) 400 mg PO or IV bid.
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
-In more severely ill patients, treatment with an IV
third-generation cephalosporin, or
ticarcillin/clavulanic acid, or piperacillin/tazobactam
or imipenem is recommended with an
aminoglycoside.
-Ceftizoxime (Cefizox) 1 gm IV q8h.
-Ceftazidime (Fortaz) 1 gm IV q8h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h.
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV/PB q6
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h.
-Gentamicin or tobramycin, 2 mg/kg IV, then 1.5
mg/kg q8h or 7 mg/kg in 50 mL of D5W over 60
min IV q24h.
10. Symptomatic Medications:
-Phenazopyridine (Pyridium) 100 mg PO tid.
-Meperidine (Demerol) 50-100 mg IM q4-6h prn pain
-Docusate sodium (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
N
C.
temp >39
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Renal ultrasound, KUB.
12. Labs: CBC with differential, SMA 7. UA with micro,
urine Gram stain, C&S; blood C&S x 2. Drug levels
peak and trough third dose.
Osteomyelitis
1.Admit to:
2.Diagnosis: Osteomyelitis
3.Condition:
4.Vital Signs: qid. Call physician if BP <90/60; T
>38.5 C.
5.Activity: Bed rest with bathroom privileges.
6.Nursing: Keep involved extremity elevated. Range o
motion exercises tid.
7.Diet: Regular, high fiber.
8.IV Fluids: Heparin lock with flush q shift.
9.Special Medications:
Adult Empiric Therapy:
-Nafcillin or oxacillin 2 gm IV q4h OR
-Cefazolin (Ancef) 1-2 gm IV q8h OR
-Vancomycin 1 gm IV q12h (1 gm in 250 cc D5W ove
1h).
-Add 3rd generation cephalosporin if gram negative
bacilli on Gram stain. Treat for 4-6 weeks.
Post-Operative or Post-Trauma:
-Vancomycin 1 gm IV q12h AND ceftazidime (Fortaz
1-2 gm IV q8h.
-Imipenem/cilastatin (Primaxin)(single-drug
treatment) 0.5-1.0 gm IV q6-8h.
-Ticarcillin/clavulanate (Timentin)(single-drug
treatment) 3.1 gm IV q4-6h.
-Ciprofloxacin (Cipro) 500-750 mg PO bid or 400 mg
IV q12h AND
Rifampin 600 mg PO qd.
Osteomyelitis with Decubitus Ulcer:
-Cefoxitin (Mefoxin), 2 gm IV q6-8h.
-Ciprofloxacin (Cipro) and metronidazole 500 mg IV
q8h.
-Imipenem/cilastatin (Primaxin), 0.5-1.0 gm IV q6-8h
-Nafcillin, gentamicin and clindamycin; see dosage
above.
10. Symptomatic Medications:
-Meperidine (Demerol) 50-100 mg IM q3-4h prn pain
-Docusate (Colace) 100 mg PO qhs.
-Heparin 5000 U SQ bid.
11. Extras: Technetium/gallium bone scans, multiple X
ray views, CT/MRI.
12. Labs: CBC with differential, SMA 7, blood C&S x 3,
MIC, MBC, UA with micro, C&S. Needle biopsy of
bone for C&S. Trough antibiotic levels.
Active Pulmonary Tuberculosis
1.Admit to:
2.Diagnosis: Active Pulmonary Tuberculosis
3.Condition:
4.Vital Signs: q shift
5.Activity: Up ad lib in room.
6.Nursing: Respiratory isolation.
7.Diet: Regular
8.Special Medications:
-Isoniazid 300 mg PO qd (5 mg/kg/d, max 300 mg/d)
AND
Rifampin 600 mg PO qd (10 mg/kg/d, 600 mg/d max
AND
Pyrazinamide 500 mg PO bid-tid (15-30 mg/kg/d,
max 2.5 gm) AND
Ethambutol 400 mg PO bid-tid (15-25 mg/kg/d, 2.5
gm/d max).
-Empiric treatment consists of a 4-drug combination
isoniazid (INH), rifampin, pyrazinamide (PZA), an
either ethambutol or streptomycin. A modified
regimen is recommended for patients known to
have INH-resistant TB. Treat for 8 weeks with the
four-drug regimen, followed by 18 weeks of INH
and rifampin.
-Pyridoxine 50 mg PO qd with INH.
Prophylaxis
-Isoniazid 300 mg PO qd (5 mg/kg/d) x 6-9 months.
9.Extras: CXR PA, LAT, ECG.
10. Labs: CBC with differential, SMA7 and 12, LFTs,
HIV serology. First AM sputum for AFB x 3 samples.
Cellulitis
1.Admit to:
2.Diagnosis: Cellulitis
3.Condition:
4.Vital Signs: tid. Call physician if BP <90/60; T
>38.5 C
5.Activity: Up ad lib.
6.Nursing: Keep affected extremity elevated; warm
compresses prn.
7.Diet: Regular, encourage fluids.
8.IV Fluids: Heparin lock with flush q shift.
9.Special Medications:
Empiric Therapy Cellulitis
-Nafcillin or oxacillin 1-2 gm IV q4-6h OR
-Cefazolin (Ancef) 1-2 gm IV q8h OR
-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over
1h) OR
-Erythromycin 500 IV/PO q6h OR
-Dicloxacillin 500 mg PO qid; may add penicillin VK,
500 mg PO qid, to increase coverage for
streptococcus OR
-Cephalexin (Keflex) 500 mg PO qid.
Immunosuppressed, Diabetic Patients, or Ulcerated
Lesions:
-Nafcillin or cefazolin and gentamicin or aztreonam.
Add clindamycin or metronidazole if septic.
-Cefazolin (Ancef) 1-2 gm IV q8h.
-Cefoxitin (Mefoxin) 1-2 gm IV q6-8h.
-Gentamicin 2 mg/kg, then 1.5 mg/kg IV q8h or 7
mg/kg in 50 mL of D5W over 60 min IV q24h OR
aztreonam (Azactam) 1-2 gm IV q6h PLUS
-Metronidazole (Flagyl) 500 mg IV q8h or clindamycin
900 mg IV q8h.
-Ticarcillin/clavulanate (Timentin) (single-drug
treatment) 3.1 gm IV q4-6h.
-Ampicillin/Sulbactam (Unasyn) (single-drug
therapy) 1.5-3.0 gm IV q6h.
-Imipenem/cilastatin (Primaxin) (single-drug therapy)
0.5-1 mg IV q6-8h.
10. Symptomatic Medications:
-Acetaminophen/codeine (Tylenol #3) 1-2 PO q4-6h
prn pain.
-Docusate (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
N
temp >39
C.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Technetium/Gallium scans.
12. Labs: CBC, SMA 7, blood C&S x 2. Leading edge
aspirate for Gram stain, C&S; UA, antibiotic levels.
Pelvic Inflammatory Disease
1.Admit to:
2.Diagnosis: Pelvic Inflammatory Disease
3.Condition:
4.Vital Signs: q8h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C
5.Activity: Up ad lib.
6.Nursing: Inputs and outputs.
7.Diet: Regular
8.IV Fluids: D5 ½ NS at 100-125 cc/hr.
9.Special Medications:
-Cefotetan (Cefotan), 2 g IV q12h, or cefoxitin
(Mefoxin, 2 g IV q6h) plus doxycycline (100 mg IV
or PO q12h) OR
-Clindamycin (Cleocin), 900 mg IV q8h, plus
gentamicin (1-1.5 mg/kg IV q8h)
-Ampicillin-sulbactam (Unasyn), 3 g IV Q6h plus
doxycycline (100 mg IV or PO Q12h)
-Parenteral administration of antibiotics should be
continued for 24 hours after clinical response,
followed by doxycycline (100 mg PO BID) or
clindamycin (Cleocin, 450 mg PO QID) for a total
of 14 days.
-Levofloxacin (Levaquin), 500 mg IV q24h, plus
metronidazole (Flagyl, 500 mg IV q8h). With this
regimen, azithromycin (Zithromax, 1 g PO once)
should be given as soon as the patient is tolerating
oral intake.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 1-2 tabs PO q4-6h prn pain
or temperature >38.5 C.
-Meperidine (Demerol) 25-100 mg IM q4-6h prn pain.
-Zolpidem (Ambien) 10 mg PO qhs prn insomnia.
11. Labs: beta-HCG pregnancy test, CBC, SMA 7&12,
ESR. GC culture, chlamydia direct fluorescent
antibody stain. UA with micro, C&S, VDRL, HIV, blood
cultures x 2. Pelvic ultrasound.
1.Admit to:
2.Diagnosis: Meningitis.
3.Condition:
4.Vital Signs: q1h. Call physician if BP systolic
>160/90, <90/60; P >120, <50; R>25, <10; T >39 C
or less than 36 C
5.Activity: Bed rest with bedside commode.
6.Nursing: Respiratory isolation, inputs and outputs,
lumbar puncture tray at bedside.
7.Diet: NPO
8.IV Fluids: D5 ½ NS at 125 cc/h with KCL 20 mEq/L.
9.Special Medications:
Empiric Therapy 15-50 years old:
-Vancomycin 1 gm IV q12h AND EITHER
-Ceftriaxone (Rocephin) 2 gm IV q12h (max 4 gm/d)
OR
Cefotaxime (Claforan) 2 gm IV q4h.
Empiric Therapy >50 years old, Alcoholic, Cor-
ticosteroids or Hematologic Malignancy or other
Debilitating Condition:
-Ampicillin 2 gm IV q4h AND EITHER
-Cefotaxime (Claforan) 2 gm IV q6h OR
Ceftriaxone (Rocephin) 2 gm IV q12h.
-Use Vancomycin 1 gm IV q12h in place of ampicillin
if drug-resistant pneumococcus is suspected.
10. Symptomatic Medications:
-Dexamethasone (Decadron) 0.4 mg/kg IV q12h x 2
days to commence with first dose of antibiotic.
-Heparin 5000 U SC q12h or pneumatic compression
stockings.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn
temp >39°C.
-Docusate sodium 100-200 mg PO qhs.
11. Extras: CXR, ECG, PPD, CT scan.
12. Labs: CBC, SMA 7&12. Blood C&S x 2. UA with
micro, urine C&S. Antibiotic levels peak and trough
after 3rd dose, VDRL.
Lumbar Puncture:
CSF Tube 1: Gram stain, C&S for bacteria (1-4 mL).
CSF Tube 2: Glucose, protein (1-2 mL).
CSF Tube 3: Cell count and differential (1-2 mL).
CSF Tube 4: Latex agglutination or counterimmunoel-
ectrophoresis antigen tests for S. pneumoniae, H.
influenzae (type B), N. meningitides, E. coli, group
B strep, VDRL, cryptococcal antigen, toxoplasma
titers. India ink, fungal cultures, AFB (8-10 mL).
Infective Endocarditis
1.Admit to:
2.Diagnosis: Infective endocarditis
3.Condition:
4.Vital Signs: q4h. Call physician if BP systolic
>160/90, <90/60; P >120, <50; R>25, <10; T >38.5 C
5.Activity: Up ad lib, bathroom privileges.
6.Diet: Regular
7.IV Fluids: Heparin lock with flush q shift.
8.Special Medications:
Subacute Bacterial Endocarditis Empiric Therapy:
-Penicillin G 3-5 million U IV q4h or ampicillin 2 gm IV
q4h AND
Gentamicin 1-1.5/mg/kg IV q8h.
Acute Bacterial Endocarditis Empiric Therapy
-Gentamicin 2 mg/kg IV; then 1-1.5 mg/kg IV q8h
AND
Nafcillin or oxacillin 2 gm IV q4h OR
Vancomycin 1 gm IV q12h (1 gm in 250 mL of D5W
over 1h).
Streptococci viridans/bovis:
-Penicillin G 3-5 million U IV q4h for 4 weeks OR
Vancomycin 1 gm IV q12h for 4 weeks AND
Gentamicin 1 mg/kg q8h for first 2 weeks.
Enterococcus:
-Gentamicin 1 mg/kg IV q8h for 4-6 weeks AND
Ampicillin 2 gm IV q4h for 4-6 weeks OR
Vancomycin 1 gm IV q12h for 4-6 weeks.
Staphylococcus aureus (methicillin sensitive, native
valve):
-Nafcillin or Oxacillin 2 gm IV q4h for 4-6 weeks OR
Vancomycin 1 gm IV q12h for 4-6 weeks AND
Gentamicin 1 mg/kg IV q8h for first 3-5 days.
Methicillin-resistant Staphylococcus aureus (native
valve):
-Vancomycin 1 gm IV q12h (1 gm in 250 mL D5W
over 1h) for 4-6 weeks AND
Gentamicin 1 mg/kg IV q8h for 3-5 days.
Methicillin-resistant Staph aureus or epidermidis
(prosthetic valve):
-Vancomycin 1 gm IV q12h for 6 weeks AND
Rifampin 600 mg PO q8h for 6 weeks AND
Gentamicin 1 mg/kg IV q8h for 2 weeks.
Culture Negative Endocarditis:
-Penicillin G 3-5 million U IV q4h for 4-6 weeks OR
Ampicillin 2 gm IV q4h for 4-6 weeks AND
Gentamicin 1.5 mg/kg q8h for 2 weeks (or nafcillin, 2
gm IV q4h, and gentamicin if Staph aureus
suspected in drug abuser or prosthetic valve).
Fungal Endocarditis:
-Amphotericin B 0.5 mg/kg/d IV plus flucytosine (5-
FC) 150 mg/kg/d PO.
9. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
N
temp >39
C.
-Docusate sodium 100-200 mg PO qhs.
10.Extras: CXR PA and LAT, echocardiogram, ECG.
11. Labs: CBC with differential, SMA 7&12. Blood C&S x
3-4 over 24h, serum cidal titers, minimum inhibitory
concentration, minimum bactericidal concentration.
Repeat C&S in 48h, then once a week. Antibiotic
levels peak and trough at 3rd dose. UA, urine C&S.
Pneumonia
1.Admit to:
2.Diagnosis: Pneumonia
3.Condition:
4.Vital Signs: q4-8h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C or O
2
saturation <90%.
5.Activity: Up ad lib, bathroom privileges.
6.Nursing: Pulse oximeter, inputs and outputs,
nasotracheal suctioning prn, incentive spirometry.
7.Diet: Regular.
8.IV Fluids: IV D5 ½ NS at 125 cc/hr.
9.Special Medications:
-Oxygen by NC at 2-4 L/min, or 24-50% by Ventim-
ask, or 100% by non-rebreather (reservoir) to
maintain O
saturation >90%.
2
Moderately Ill Patients Without Underlying Lung
Disease From the Community:
-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR
Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h AND
EITHER
-Erythromycin 500 mg IV/PO q6h OR
Clarithromycin (Biaxin) 500 mg PO bid OR
Azithromycin (Zithromax) 500 mg PO x 1, then 250
mg PO qd x 4 OR
Doxycycline (Vibramycin) 100 mg IV/PO q12h.
Moderately Ill Patients With Recent Hospitalization
or Debilitated Nursing Home Patient:
-Ceftazidime (Fortaz) 1-2 gm IV q8h OR
Cefepime (Maxipime) 1-2 gm IV q12h AND EITHER
Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h OR
-Ciprofloxacin (Cipro) 400 mg IV q12h or 500 mg PO
q12h.
Critically Ill Patients:
-Initial treatment should consist of a macrolide with 2
antipseudomonal agents for synergistic activity:
-Erythromycin 0.5-1.0 gm IV q6h AND EITHER
-Cefepime (Maxipime) 20 mg IV q12h OR
Piperacillin/tazobactam (Zosyn) 3.75-4.50 gm IV q6h
OR
Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR
Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h
AND EITHER
-Levofloxacin (Levaquin) 500 mg IV q24h OR
Ciprofloxacin (Cipro) 400 mg IV q12h OR
Tobramycin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h or 7
mg/kg IV q24h.
Aspiration Pneumonia (community acquired):
-Clindamycin (Cleocin) 600-900 mg IV q8h (with
gentamicin or 3rd gen cephalosporin) OR
-Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h (with
gentamicin or 3rd gen cephalosporin)
Aspiration Pneumonia (nosocomial):
-Tobramycin 2 mg/kg IV then 1.5 mg/kg IV q8h or 7
mg/kg in 50 mL of D5W over 60 min IV q24h OR
Ceftazidime (Fortaz) 1-2 gm IV q8h AND EITHER
-Clindamycin (Cleocin) 600-900 mg IV q8h OR
Ampicillin/sulbactam or ticarcillin/clavulanate, or
piperacillin/tazobactam or imipenem/cilastatin (see
above) OR
Metronidazole (Flagyl) 500 mg IV q8h.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 650 mg 2 tab PO q4-6h prn
temp >38°C or pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Heparin 5000 U SQ q12h or pneumatic compression
stockings.
11. Extras: CXR PA and LAT, ECG, PPD.
12.Labs: CBC with differential, SMA 7&12, ABG. Blood
C&S x 2. Sputum Gram stain, C&S. Methenamine
silver sputum stain (PCP); AFB smear/culture.
Aminoglycoside levels peak and trough 3rd dose.
UA, urine culture.
Specific Therapy for Pneumonia
Pneumococcus:
-Ceftriaxone (Rocephin) 2 gm IV q12h OR
-Cefotaxime (Claforan) 2 gm IV q6h OR
-Erythromycin 500 mg IV q6h OR
-Levofloxacin (Levaquin) 500 mg IV q24h OR
-Vancomycin 1 gm IV q12h if drug resistance.
Staphylococcus aureus:
-Nafcillin 2 gm IV q4h OR
-Oxacillin 2 gm IV q4h.
Klebsiella pneumoniae:
-Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h OR
Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
Cefotaxime (Claforan) 1-2 gm IV q6h.
Methicillin-resistant staphylococcus aureus (MRSA):
-Vancomycin 1 gm IV q12h.
Vancomycin-Resistant Enterococcus:
-Linezolid (Zyvox) 600 mg IV/PO q12h; active against
MRSA as well OR
-Quinupristin/dalfopristin (Synercid) 7.5 mg/kg IV q8h
(does not cover E faecalis).
Haemophilus influenzae:
-Ampicillin 1-2 gm IV q6h (beta-lactamase negative)
OR
-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h OR
-Cefuroxime (Zinacef) 1.5 gm IV q8h (beta-lactamase
pos) OR
-Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
-Ciprofloxacin (Cipro) 400 mg IV q12h OR
-Ofloxacin (Floxin) 400 mg IV q12h.
-Levofloxacin (Levaquin) 500 mg IV q24h.
Pseudomonas aeruginosa:
-Tobramycin 1.5-2.0 mg/kg IV, then 1.5-2.0 mg/kg IV
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h AND EITHER
-Piperacillin, ticarcillin, mezlocillin or azlocillin 3 gm IV
q4h OR
-Cefepime (Maxipime) 2 gm IV q12h.
Enterobacter Aerogenes or Cloacae:
-Gentamicin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h
AND EITHER
Meropenem (Merrem) 1 gm IV q8h OR
Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h.
Serratia Marcescens:
-Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
-Aztreonam (Azactam) 1-2 gm IV q6h OR
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h OR
-Meropenem (Merrem) 1 gm IV q8h.
Mycoplasma pneumoniae:
-Clarithromycin (Biaxin) 500 mg PO bid OR
-Azithromycin (Zithromax) 500 mg PO x 1, then 250
mg PO qd for 4 days OR
-Erythromycin 500 mg PO or IV q6h OR
-Doxycycline (Vibramycin) 100 mg PO/IV q12h OR
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
Legionella pneumoniae:
-Erythromycin 1.0 gm IV q6h OR
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
-Rifampin 600 mg PO qd may be added to
erythromycin or levofloxacin.
Moraxella catarrhalis:
-Trimethoprim/sulfamethoxazole (Bactrim, Septra)
one DS tab PO bid or 10 mL IV q12h OR
-Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h OR
-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR
-Erythromycin 500 mg IV q6h OR
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
Anaerobic Pneumonia:
-Penicillin G 2 MU IV q4h OR
-Clindamycin (Cleocin) 900 mg IV q8h OR
-Metronidazole (Flagyl) 500 mg IV q8h.
Pneumocystis Carinii Pneumonia
and HIV
1.Admit to:
2.Diagnosis: PCP pneumonia
3.Condition:
4.Vital Signs: q2-6h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C; O
sat
2
<90%
5.Activity: Bedrest, bedside commode.
6.Nursing: Pulse oximeter.
7.Diet: Regular, encourage fluids.
8.IV Fluids: D5 ½ NS at 125 cc/h.
9.Special Medications:
Pneumocystis Carinii Pneumonia:
-Oxygen at 2-4 L/min by NC or by mask.
-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 15
mg of TMP/kg/day (20 mL in 250 mL of D5W IVPB
q8h) for 21 days [inj: 80/400 mg per 5 mL].
-If severe PCP (PaO
<70 mm Hg): add prednisone
2
40 mg PO bid for 5 days, then 40 mg qd for 5 days
then 20 mg qd for 11 days OR Methylprednisolone
(Solu-Medrol) 30 mg IV q12h for 5 days, then 30
mg IV qd for 5 days, then 15 mg IV qd for 11 days.
-Pentamidine (Pentam) 4 mg/kg IV qd for 21 days,
with prednisone as above. Pentamidine is an
alternative if inadequate response or intolerant to
TMP-SMX.
Pneumocystis Carinii Prophylaxis (previous PCP or
CD4 <200, or constitutional symptoms):
-Trimethoprim/SMX DS (160/800 mg) PO qd OR
-Pentamidine, 300 mg in 6 mL sterile water via
Respirgard II nebulizer over 20-30 min q4 weeks
OR
-Dapsone (DDS) 50 mg PO bid or 100 mg twice a
week; contraindicated in G-6-PD deficiency.
Antiretroviral Therapy:
A. Combination therapy with 3 agents (two nucleoside
analogs and a protease inhibitor) is recommended
as initial therapy. Nucleotide analogs are similar to
nucleosides and may be used interchangeably.
Combination of atazanavir plus tenofovir or
lamivudine plus abacavir plus tenofovir should be
avoided because of the risk of treatment failure.
B.Nucleoside Analogs
1. Abacavir (Ziagen) 300 mg PO bid [300 mg, 20
mg/mL].
2. Didanosine (Videx, ddI) 200 mg bid for patients
>60 kg; or 125 mg bid for patients <60 kg.
[chewable tabs: 25, 50, 100, 150 mg; pwd 100,
167, 250 mg packets].
3. Emtricitabine (Emtriva) 200 mg PO qd.
4. Lamivudine (Epivir, 3TC) 150 mg twice daily
[150 mg].
5. Stavudine (Zerit, D4T) 40 mg bid [15 mg, 20
mg, 30 mg and 40 mg capsules].
6. Zalcitabine (Hivid, ddC) 0.75 mg tid [0.375,
0.75].
7. Zidovudine (Retrovir, AZT) 200 mg tid (100,
200 mg caps, 50 mg/5 mL syrup).
C.Protease Inhibitors
1. Amprenavir (Agenerase) 1200 mg bid [50, 150
mg].
2. Atazanavir (Reyataz) 400 mg PO qd.
3. Indinavir (Crixivan) 800 mg tid [200, 400 mg].
4. Lopinavir/ritonavir (Kaletra) 400 mg/100 mg PO
bid.
5. Nelfinavir (Viracept) 750 mg PO tid [250 mg].
6. Ritonavir (Norvir) 600 mg bid [100 mg, 80
mg/dL].
7. Saquinavir (Invirase) 600 mg tid with a meal
[cap 200 mg].
D.Non-Nucleoside Reverse Transcriptase
Inhibitors
1. Delavirdine (U-90) 400 mg tid.
2. Efavirenz (Sustiva) 600 mg PO qd [50, 100, 20
mg].
3. Nevirapine (Viramune) 200 mg qd for 2 weeks,
then bid [200 mg].
E.Nucleotide Analogs
1. Tenofovir (Viread) 300 mg PO qd with food.
Postexposure HIV Prophylaxis
A. The injury should be immediately washed and
scrubbed with soap and water.
B. Zidovudine 200 mg PO tid and lamivudine (3TC)
150 mg PO bid, plus indinavir (Crixivan) 800 mg
PO tid for highest risk exposures. Treatment is
continued for one month.
Zidovudine-Induced Neutropenia/Ganciclovir-
Induced Leucopenia
-Recombinant human granulocyte colony-stimulating
factor (G-CSF, Filgrastim, Neupogen) 1-2 mcg/kg
SQ qd until absolute neutrophil count 500-1000;
indicated only if endogenous erythropoietin level is
low.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache or fever.
-Docusate sodium 100-200 mg PO qhs.
10. Extras: CXR PA and LAT.
11. Labs: ABG, CBC, SMA 7&12. Blood C&S x 2.
Sputum for Gram stain, C&S, AFB. Giemsa
immunofluorescence for Pneumocystis. CD4 count,
HIV RNA, VDRL, serum cryptococcal antigen, UA.
Opportunistic Infections in HIV-
Infected Patients
Oral Candidiasis:
-Fluconazole (Diflucan) 100-200 mg PO qd OR
-Ketoconazole (Nizoral) 400 mg PO qd OR
-Itraconazole (Sporanox) 200 mg PO qd OR
-Clotrimazole (Mycelex) troches 10 mg dissolved
slowly in mouth 5 times/d.
Candida Esophagitis:
-Fluconazole (Diflucan) 200-400 mg PO qd for 14-21
days OR
-Ketoconazole (Nizoral) 200 mg PO bid OR
-Itraconazole (Sporanox) 200 mg PO qd for 2 weeks.
-Caspofungin (Cancidas) 50 mg IV qd x 2 weeks.
Primary or Recurrent Mucocutaneous HSV
-Acyclovir (Zovirax), 200-400 mg PO 5 times a day for
10 days, or 5 mg/kg IV q8h OR in cases of
acyclovir resistance, foscarnet, 40 mg/kg IV q8h fo
21 days.
Herpes Simplex Encephalitis (or visceral disease):
-Acyclovir (Zovirax) 10 mg/kg IV q8h for 10-21 days.
Herpes Varicella Zoster
-Acyclovir (Zovirax) 10 mg/kg IV over 60 min q8h for
7-14 days OR 800 mg PO 5 times/d for 7-10 days
OR
-Famciclovir (Famvir) 500 mg PO q8h for 7 days [500
mg] OR
-Valacyclovir (Valtrex) 1000 mg PO q8h for 7 days
[500 mg] OR
-Foscarnet (Foscavir) 40 mg/kg IV q8h.
Cytomegalovirus Retinitis:
-Ganciclovir (Cytovene) 5 mg/kg IV (dilute in 100 mL
D5W over 60 min) q12h for 14-21 days OR
-Foscarnet (Foscavir) 60 mg/kg IV q8h for 2-3 weeks
OR
-Cidofovir (Vistide) 5 mg/kg IV over 60 min q week for
2 weeks. Administer probenecid, 2 g PO 3 hours
prior to cidofovir, 1 g PO 2 hours after, and 1 g PO
8 hours after.
Suppressive Treatment for Cytomegalovirus
Retinitis:
-Ganciclovir (Cytovene) 5 mg/kg qd.
-Foscarnet (Foscavir) 90-120 mg IV qd OR
-Cidofovir (Vistide) 5 mg/kg IV over 60 min every 2
weeks with probenecid.
Acute Toxoplasmosis:
-Pyrimethamine 200 mg, then 50-75 mg qd, plus
sulfadiazine 1.0-1.5 gm PO q6h, plus folinic acid
10 mg PO qd OR
-Atovaquone (Mepron) 750 mg PO tid.
Suppressive Treatment for Toxoplasmosis:
-Pyrimethamine 25-50 mg PO qd plus sulfadiazine
0.5-1.0 gm PO q6h plus folinic acid 5 mg PO qd
OR
-Pyrimethamine 50 mg PO qd, plus clindamycin 300
mg PO qid, plus folinic acid 5 mg PO qd.
Cryptococcus Neoformans Meningitis:
-Amphotericin B 0.7-1.0 mg/kg/d IV; total dosage of 2
g, with or without 5-flucytosine 100 mg/kg PO qd in
divided doses, followed by fluconazole (Diflucan)
400 mg PO qd or itraconazole (Sporanox) 200 mg
PO bid 6-8 weeks OR
-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h
OR
-Fluconazole (Diflucan) 400-800 mg PO qd for 8-12
weeks
Suppressive Treatment of Cryptococcus:
-Fluconazole (Diflucan) 200 mg PO qd indefinitely.
Active Tuberculosis:
-Isoniazid (INH) 300 mg PO qd; and rifampin 600 mg
PO qd; and pyrazinamide 15-25 mg/kg PO qd (500
mg bid-tid); and ethambutol 15-25 mg/kg PO qd
(400 mg bid-tid).
-All four drugs are continued for 2 months; isoniazid
and rifampin are continued for a period of at least 9
months and at least 6 months after the last
negative cultures.
-Pyridoxine (Vitamin B6) 50 mg PO qd concurrent with
INH.
Prophylaxis for Inactive Tuberculosis:
-Isoniazid 300 mg PO qd; and pyridoxine 50 mg PO
qd for 12 months.
Disseminated Mycobacterium Avium Complex
(MAC):
-Clarithromycin (Biaxin) 500 mg PO bid AND
Ethambutol 800-1000 mg qd; with or without rifabutin
450 mg qd.
Prophylaxis against Mycobacterium Avium Complex:
-Azithromycin (Zithromax) 1200 mg once a week.
Disseminated Coccidioidomycosis:
-Amphotericin (Fungizone) B 0.5-0.8 mg/kg IV qd, to a
total dose 2.0 gm OR
-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h
OR
-Fluconazole (Diflucan) 400-800 mg PO or IV qd.
Disseminated Histoplasmosis:
-Amphotericin B (Fungizone) 0.5-0.8 mg/kg IV qd, to a
total dose 15 mg/kg OR
-Amphotericin B liposomal (Abelcet) 5 mg/kg IV q24h
OR
-Fluconazole (Diflucan) 400 mg PO qd OR
-Itraconazole (Sporanox) 300 mg PO bid for 3 days,
then 200 mg PO bid.
Suppressive Treatment for Histoplasmosis:
-Fluconazole (Diflucan) 400 mg PO qd OR
-Itraconazole (Sporanox) 200 mg PO bid.
Septic Arthritis
1.Admit to:
2.Diagnosis: Septic arthritis
3.Condition:
4.Vital Signs: q shift
5.Activity: Up in chair as tolerated. Bedside commode
with assistance.
6.Nursing: Warm compresses prn, keep joint
immobilized. Passive range of motion exercises of the
affected joint bid.
7.Diet: Regular diet.
8.IV Fluids: Heparin lock
9.Special Medications:
Empiric Therapy for Adults without Gonorrhea
Contact:
-Nafcillin or oxacillin 2 gm IV q4h AND
Ceftizoxime (Cefizox) 1 gm IV q8h or ceftazidime 1
gm IV q8h or ciprofloxacin 400 mg IV q12h if Gram
stain indicates presence of Gram negative
organisms.
Empiric Therapy for Adults with Gonorrhea:
-Ceftriaxone (Rocephin) 1 gm IV q12h OR
-Ceftizoxime (Cefizox) 1 gm IV q8h OR
-Ciprofloxacin (Cipro) 400 mg IV q12h.
-Complete course of therapy with cefuroxime axetil
(Ceftin) 400 mg PO bid.
10. Symptomatic Medications:
-Acetaminophen and codeine (Tylenol 3) 1-2 PO q4-
6h prn pain.
-Heparin 5000 U SQ bid.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate sodium 100-200 mg PO qhs.
11. Extras: X-ray views of joint (AP and lateral), CXR.
Synovial fluid culture. Physical therapy consult for
exercise program.
12. Labs: CBC, SMA 7&12, blood C&S x 2, VDRL, UA.
Gonorrhea cultures of urethra, cervix. Antibiotic levels.
Blood cultures x 2 for gonorrhea.
Synovial fluid:
Tube 1 - Glucose, protein, lactate, pH.
Tube 2 - Gram stain, C&S.
Tube 3 - Cell count.
Septic Shock
1.Admit to:
2.Diagnosis: Sepsis
3.Condition:
4.Vital Signs: q1h; Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C; urine
output < 25 cc/hr for 4h, O
saturation <90%.
2
5.Activity: Bed rest.
6.Nursing: Inputs and outputs, pulse oximeter. Foley
catheter to closed drainage.
7.Diet: NPO
8.IV Fluids: 1 liter of normal saline wide open, then D5
½ NS at 125 cc/h
9.Special Medications:
-Oxygen at 2-5 L/min by NC or mask.
Antibiotic Therapy
A. Initial treatment of life-threatening sepsis should
include a third-generation cephalosporin
(cefepime, ceftazidime, cefotaxime, ceftizoxime or
ceftriaxone), or piperacillin/tazobactam, or
ticarcillin/clavulanic acid or imipenem, each with an
aminoglycoside (gentamicin, tobramycin or
amikacin). If Enterobacter aerogenes or cloacae is
suspected, treatment should begin with
meropenem or imipenem with an aminoglycoside.
B.Intra-abdominal or pelvic infections, likely to
involve anaerobes, should be treated with
ampicillin, gentamicin and metronidazole; or either
ticarcillin/clavulanic acid, ampicillin/sulbactam,
piperacillin/tazobactam, imipenem, cefoxitin or
cefotetan, each with an aminoglycoside.
C.Febrile neutropenic patients with neutrophil
3
counts <500/mm
should be treated with
vancomycin and ceftazidime, or
piperacillin/tazobactam and tobramycin or
imipenem and tobramycin.
D.Dosages for Antibiotics Used in Sepsis
-Ampicillin 1-2 gm IV q4h.
-Cefepime (Maxipime) 2 gm IV q12h.
-Cefotaxime (Claforan) 2 gm q4-6h.
-Ceftizoxime (Cefizox) 1-2 gm IV q8h.
-Ceftriaxone (Rocephin) 1-2 gm IV q12h (max 4
gm/d).
-Cefoxitin (Mefoxin) 1-2 gm q6h.
-Cefotetan (Cefotan) 1-2 gm IV q12h.
-Ceftazidime (Fortaz) 1-2 g IV q8h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h
(200-300 mg/kg/d).
-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h.
-Piperacillin/tazobactam (Zosyn) 3.375-4.5 gm IV
q6h.
-Piperacillin or ticarcillin 3 gm IV q4-6h.
-Imipenem/cilastatin (Primaxin) 1.0 gm IV q6h.
-Meropenem (Merrem) 0.5-1.0 gm IV q8h.
-Gentamicin, tobramycin 100-120 mg (1.5 mg/kg)
IV, then 80 mg IV q8h (1 mg/kg) or 7 mg/kg in 50
mL of D5W over 60 min IV q24h.
-Amikacin (Amikin) 7.5 mg/kg IV loading dose;
then 5 mg/kg IV q8h.
-Vancomycin 1 gm IV q12h.
-Metronidazole (Flagyl) 500 mg (7.5 mg/kg) IV q6-
8h.
-Clindamycin (Cleocin) 900 mg IV q8h.
-Aztreonam (Azactam) 1-2 gm IV q6-8h; max 8
g/day.
Nosocomial sepsis with IV catheter or IV drug abuse
-Nafcillin or oxacillin 2 gm IV q4h OR
-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over 60
min) AND
Gentamicin or tobramycin as above AND EITHER
Ceftazidime (Fortaz) or ceftizoxime (Cefizox)1-2 gm
IV q8h OR
Piperacillin, ticarcillin or mezlocillin 3 gm IV q4-6h.
Recombinant human activated protein C
-Drotrecogin alfa, (Xigris), 24 mg/kg/h IV infusion for
96 hours.
Blood Pressure Support
-Dopamine 4-20 mcg/kg/min (400 mg in 250 cc D5W,
1600 mcg/mL).
-Norepinephrine 2-8 mcg/min IV infusion (8 mg in 250
mL D5W).
-Albumin 25 gm IV (100 mL of 25% solution) OR
-Hetastarch (Hespan) 500-1000 cc over 30-60 min
(max 1500 cc/d).
-Dobutamine 5 mcg/kg/min, and titrate blood pressure
to keep systolic BP >90 mm Hg; max 10
mcg/kg/min.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 650 mg PR q4-6h prn temp
>39 C.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Heparin 5000 U SQ q12h or pneumatic compression
stockings.
-Docusate sodium 100-200 mg PO qhs.
11. Extras: CXR, KUB, ECG. Ultrasound, lumbar punc-
ture.
12. Labs: CBC with differential, SMA 7&12, blood C&S x
3, T&C for 3-6 units PRBC, INR/PTT, drug levels peak
and trough at 3rd dose. UA. Cultures of urine, sputum,
wound, IV catheters, decubitus ulcers, pleural fluid.
Peritonitis
1.Admit to:
2.Diagnosis: Peritonitis
3.Condition:
4.Vital Signs: q1-6h. Call physician if BP >160/90, <90-
/60; P >120, <50; R>25, <10; T >38.5 C.
5.Activity: Bed rest.
6.Nursing: Guaiac stools.
7.Diet: NPO
8.IV Fluids: D5 ½ NS at 125 cc/h.
9.Special Medications:
Primary Bacterial Peritonitis - Spontaneous:
Option 1:
-Ampicillin 1-2 gm IV q 4-6h (vancomycin 1 gm IV
q12h if penicillin allergic) AND EITHER
Cefotaxime (Claforan) 1-2 gm IV q6h OR
Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
Gentamicin or tobramycin 1.5 mg/kg IV, then 1 mg/kg
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h.
Option 2:
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV q6h OR
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h OR
-Meropenem (Merrem) 500-1000 mg IV q8h.
Secondary Bacterial Peritonitis – Abdominal
Perforation or Rupture:
Option 1:
-Ampicillin 1-2 gm IV q4-6h AND
Gentamicin or tobramycin as above AND
Metronidazole (Flagyl) 500 mg IV q8h OR
Cefoxitin (Mefoxin) 1-2 gm IV q6h OR
Cefotetan (Cefotan) 1-2 gm IV q12h.
Option 2:
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h
(200-300 mg/kg/d) with an aminoglycoside as
above OR
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV q6h with
an aminoglycoside as above OR
-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h with
aminoglycoside as above OR
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h
OR
-Meropenem (Merrem) 500-1000 mg IV q8h.
Fungal Peritonitis:
-Amphotericin B peritoneal dialysis, 2 mg/L of dialysis
fluid over the first 24 hours, then 1.5 mg in each
liter OR
-Fluconazole (Diflucan) 200 mg IV x 1, then 100 mg
IV qd.
-Caspofungin (Candidas) 70 mg IV x1, then 50 mg IV
qd.
10. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 325 mg PO/PR q4-6h prn
temp >38.5 C.
-Heparin 5000 U SQ q12h.
11. Extras: Plain film, upright abdomen, lateral decub-
itus, CXR PA and LAT; surgery consult; ECG,
abdominal ultrasound, CT scan.
12. Labs: CBC with differential, SMA 7&12, amylase,
lactate, INR/PTT, UA with micro, C&S; drug levels
peak and trough 3rd dose.
Paracentesis Tube 1: Cell count and differential (1-2
mL, EDTA purple top tube).
Tube 2: Gram stain of sediment; inject 10-20 mL into an
aerobic and aerobic culture bottle; AFB, fungal C&S
(3-4 mL).
Tube 3: Glucose, protein, albumin, LDH, triglycerides,
specific gravity, bilirubin, amylase (2-3 mL, red top
tube).
Syringe: pH, lactate (3 mL).
Diverticulitis
1.Admit to:
2.Diagnosis: Diverticulitis
3.Condition:
4.Vital Signs: qid. Call physician if BP systolic >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C.
5.Activity: Up ad lib.
6.Nursing: Inputs and outputs.
7.Diet: NPO. Advance to clear liquids as tolerated.
8.IV Fluids: 0.5-2 L NS over 1-2 hr then, D5 ½ NS at
125 cc/hr. NG tube at low intermittent suction (if
obstructed).
9.Special Medications:
Regimen 1:
-Gentamicin or tobramycin 100-120 mg IV (1.5-2
mg/kg), then 80 mg IV q8h (5 mg/kg/d) or 7 mg/kg
in 50 mL of D5W over 60 min IV q24h AND
EITHER
Cefoxitin (Mefoxin) 2 gm IV q6-8h OR
Clindamycin (Cleocin) 600-900 mg IV q8h.
Regimen 2:
-Metronidazole (Flagyl) 500 mg q8h AND
Ciprofloxacin (Cipro) 250-500 mg PO bid or 200-300
mg IV q12h.
Outpatient Regimen:
-Metronidazole (Flagyl) 500 mg PO q6h AND EITHER
Ciprofloxacin (Cipro) 500 mg PO bid OR
Trimethoprim/SMX (Bactrim) 1 DS tab PO bid.
10. Symptomatic Medications:
-Meperidine (Demerol) 50-100 mg IM or IV q3-4h prn
pain.
-Zolpidem (Ambien) 5-10 mg qhs PO prn insomnia.
11. Extras: Acute abdomen series, CXR PA and LAT,
ECG, CT scan of abdomen, ultrasound, surgery and
GI consults.
12. Labs: CBC with differential, SMA 7&12, amylase,
lipase, blood cultures x 2, drug levels peak and trough
3rd dose. UA, C&S.
Lower Urinary Tract Infection
1.Admit to:
2.Diagnosis: UTI.
3.Condition:
4.Vital Signs: q shift. Call physician if BP <90/60; >160-
/90; R >30, <10; P >120, <50; T >38.5 C.
5.Activity: Up ad lib
6.Nursing:
7.Diet: Regular
8.IV Fluids:
9.Special Medications:
Lower Urinary Tract Infection (treat for 3-7 days):
-Trimethoprim-sulfamethoxazole (Septra) 1 double
strength tab (160/800 mg) PO bid.
-Norfloxacin (Noroxin) 400 mg PO bid.
-Ciprofloxacin (Cipro) 250 mg PO bid.
-Levofloxacin (Levaquin) 500 mg IV/PO q24h.
-Lomefloxacin (Maxaquin) 400 mg PO qd.
-Enoxacin (Penetrex) 200-400 mg PO q12h; 1h
before or 2h after meals.
-Cefpodoxime (Vantin) 100 mg PO bid.
-Cephalexin (Keflex) 500 mg PO q6h.
-Cefixime (Suprax) 200 mg PO q12h or 400 mg PO
qd.
-Cefazolin (Ancef) 1-2 gm IV q8h.
Complicated or Catheter-Associated Urinary Tract
Infection:
-Ceftizoxime (Cefizox) 1 gm IV q8h.
-Gentamicin 2 mg/kg, then 1.5/kg q8h or 7 mg/kg in
50 mL of D5W over 60 min IV q24h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h
-Ciprofloxacin (Cipro) 500 mg PO bid.
-Levofloxacin (Levaquin) 500 mg IV/PO q24h.
Prophylaxis ( 3 episodes/yr):
-Trimethoprim/SMX single strength tab PO qhs.
Candida Cystitis
-Fluconazole (Diflucan) 100 mg PO or IV x 1 dose,
then 50 mg PO or IV qd for 5 days OR
-Amphotericin B continuous bladder irrigation, 50
mg/1000 mL sterile water via 3-way Foley catheter
at 1 L/d for 5 days.
10. Symptomatic Medications:
-Phenazopyridine (Pyridium) 100 mg PO tid.
-Docusate sodium (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
N
C.
temp >39
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Renal ultrasound.
12. Labs: CBC, SMA 7. UA with micro, urine Gram stain,
C&S.
Pyelonephritis
1.Admit to:
2.Diagnosis: Pyelonephritis
3.Condition:
4.Vital Signs: tid. Call physician if BP <90/60; >160/90;
R >30, <10; P >120, <50; T >38.5 C.
5.Activity:
6.Nursing: Inputs and outputs.
7.Diet: Regular
8.IV Fluids: D5 ½ NS at 125 cc/h.
9.Special Medications:
-Trimethoprim-sulfamethoxazole (Septra) 160/800 mg
(10 mL in 100 mL D5W IV over 2 hours) q12h or 1
double strength tab PO bid.
-Ciprofloxacin (Cipro) 500 mg PO bid or 400 mg IV
q12h.
-Norfloxacin (Noroxin) 400 mg PO bid.
-Ofloxacin (Floxin) 400 mg PO or IV bid.
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
-In more severely ill patients, treatment with an IV
third-generation cephalosporin, or
ticarcillin/clavulanic acid, or piperacillin/tazobactam
or imipenem is recommended with an
aminoglycoside.
-Ceftizoxime (Cefizox) 1 gm IV q8h.
-Ceftazidime (Fortaz) 1 gm IV q8h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h.
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV/PB q6
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h.
-Gentamicin or tobramycin, 2 mg/kg IV, then 1.5
mg/kg q8h or 7 mg/kg in 50 mL of D5W over 60
min IV q24h.
10. Symptomatic Medications:
-Phenazopyridine (Pyridium) 100 mg PO tid.
-Meperidine (Demerol) 50-100 mg IM q4-6h prn pain
-Docusate sodium (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
N
C.
temp >39
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Renal ultrasound, KUB.
12. Labs: CBC with differential, SMA 7. UA with micro,
urine Gram stain, C&S; blood C&S x 2. Drug levels
peak and trough third dose.
Osteomyelitis
1.Admit to:
2.Diagnosis: Osteomyelitis
3.Condition:
4.Vital Signs: qid. Call physician if BP <90/60; T
>38.5 C.
5.Activity: Bed rest with bathroom privileges.
6.Nursing: Keep involved extremity elevated. Range o
motion exercises tid.
7.Diet: Regular, high fiber.
8.IV Fluids: Heparin lock with flush q shift.
9.Special Medications:
Adult Empiric Therapy:
-Nafcillin or oxacillin 2 gm IV q4h OR
-Cefazolin (Ancef) 1-2 gm IV q8h OR
-Vancomycin 1 gm IV q12h (1 gm in 250 cc D5W ove
1h).
-Add 3rd generation cephalosporin if gram negative
bacilli on Gram stain. Treat for 4-6 weeks.
Post-Operative or Post-Trauma:
-Vancomycin 1 gm IV q12h AND ceftazidime (Fortaz
1-2 gm IV q8h.
-Imipenem/cilastatin (Primaxin)(single-drug
treatment) 0.5-1.0 gm IV q6-8h.
-Ticarcillin/clavulanate (Timentin)(single-drug
treatment) 3.1 gm IV q4-6h.
-Ciprofloxacin (Cipro) 500-750 mg PO bid or 400 mg
IV q12h AND
Rifampin 600 mg PO qd.
Osteomyelitis with Decubitus Ulcer:
-Cefoxitin (Mefoxin), 2 gm IV q6-8h.
-Ciprofloxacin (Cipro) and metronidazole 500 mg IV
q8h.
-Imipenem/cilastatin (Primaxin), 0.5-1.0 gm IV q6-8h
-Nafcillin, gentamicin and clindamycin; see dosage
above.
10. Symptomatic Medications:
-Meperidine (Demerol) 50-100 mg IM q3-4h prn pain
-Docusate (Colace) 100 mg PO qhs.
-Heparin 5000 U SQ bid.
11. Extras: Technetium/gallium bone scans, multiple X
ray views, CT/MRI.
12. Labs: CBC with differential, SMA 7, blood C&S x 3,
MIC, MBC, UA with micro, C&S. Needle biopsy of
bone for C&S. Trough antibiotic levels.
Active Pulmonary Tuberculosis
1.Admit to:
2.Diagnosis: Active Pulmonary Tuberculosis
3.Condition:
4.Vital Signs: q shift
5.Activity: Up ad lib in room.
6.Nursing: Respiratory isolation.
7.Diet: Regular
8.Special Medications:
-Isoniazid 300 mg PO qd (5 mg/kg/d, max 300 mg/d)
AND
Rifampin 600 mg PO qd (10 mg/kg/d, 600 mg/d max
AND
Pyrazinamide 500 mg PO bid-tid (15-30 mg/kg/d,
max 2.5 gm) AND
Ethambutol 400 mg PO bid-tid (15-25 mg/kg/d, 2.5
gm/d max).
-Empiric treatment consists of a 4-drug combination
isoniazid (INH), rifampin, pyrazinamide (PZA), an
either ethambutol or streptomycin. A modified
regimen is recommended for patients known to
have INH-resistant TB. Treat for 8 weeks with the
four-drug regimen, followed by 18 weeks of INH
and rifampin.
-Pyridoxine 50 mg PO qd with INH.
Prophylaxis
-Isoniazid 300 mg PO qd (5 mg/kg/d) x 6-9 months.
9.Extras: CXR PA, LAT, ECG.
10. Labs: CBC with differential, SMA7 and 12, LFTs,
HIV serology. First AM sputum for AFB x 3 samples.
Cellulitis
1.Admit to:
2.Diagnosis: Cellulitis
3.Condition:
4.Vital Signs: tid. Call physician if BP <90/60; T
>38.5 C
5.Activity: Up ad lib.
6.Nursing: Keep affected extremity elevated; warm
compresses prn.
7.Diet: Regular, encourage fluids.
8.IV Fluids: Heparin lock with flush q shift.
9.Special Medications:
Empiric Therapy Cellulitis
-Nafcillin or oxacillin 1-2 gm IV q4-6h OR
-Cefazolin (Ancef) 1-2 gm IV q8h OR
-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over
1h) OR
-Erythromycin 500 IV/PO q6h OR
-Dicloxacillin 500 mg PO qid; may add penicillin VK,
500 mg PO qid, to increase coverage for
streptococcus OR
-Cephalexin (Keflex) 500 mg PO qid.
Immunosuppressed, Diabetic Patients, or Ulcerated
Lesions:
-Nafcillin or cefazolin and gentamicin or aztreonam.
Add clindamycin or metronidazole if septic.
-Cefazolin (Ancef) 1-2 gm IV q8h.
-Cefoxitin (Mefoxin) 1-2 gm IV q6-8h.
-Gentamicin 2 mg/kg, then 1.5 mg/kg IV q8h or 7
mg/kg in 50 mL of D5W over 60 min IV q24h OR
aztreonam (Azactam) 1-2 gm IV q6h PLUS
-Metronidazole (Flagyl) 500 mg IV q8h or clindamycin
900 mg IV q8h.
-Ticarcillin/clavulanate (Timentin) (single-drug
treatment) 3.1 gm IV q4-6h.
-Ampicillin/Sulbactam (Unasyn) (single-drug
therapy) 1.5-3.0 gm IV q6h.
-Imipenem/cilastatin (Primaxin) (single-drug therapy)
0.5-1 mg IV q6-8h.
10. Symptomatic Medications:
-Acetaminophen/codeine (Tylenol #3) 1-2 PO q4-6h
prn pain.
-Docusate (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
N
temp >39
C.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Technetium/Gallium scans.
12. Labs: CBC, SMA 7, blood C&S x 2. Leading edge
aspirate for Gram stain, C&S; UA, antibiotic levels.
Pelvic Inflammatory Disease
1.Admit to:
2.Diagnosis: Pelvic Inflammatory Disease
3.Condition:
4.Vital Signs: q8h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5 C
5.Activity: Up ad lib.
6.Nursing: Inputs and outputs.
7.Diet: Regular
8.IV Fluids: D5 ½ NS at 100-125 cc/hr.
9.Special Medications:
-Cefotetan (Cefotan), 2 g IV q12h, or cefoxitin
(Mefoxin, 2 g IV q6h) plus doxycycline (100 mg IV
or PO q12h) OR
-Clindamycin (Cleocin), 900 mg IV q8h, plus
gentamicin (1-1.5 mg/kg IV q8h)
-Ampicillin-sulbactam (Unasyn), 3 g IV Q6h plus
doxycycline (100 mg IV or PO Q12h)
-Parenteral administration of antibiotics should be
continued for 24 hours after clinical response,
followed by doxycycline (100 mg PO BID) or
clindamycin (Cleocin, 450 mg PO QID) for a total
of 14 days.
-Levofloxacin (Levaquin), 500 mg IV q24h, plus
metronidazole (Flagyl, 500 mg IV q8h). With this
regimen, azithromycin (Zithromax, 1 g PO once)
should be given as soon as the patient is tolerating
oral intake.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 1-2 tabs PO q4-6h prn pain
or temperature >38.5 C.
-Meperidine (Demerol) 25-100 mg IM q4-6h prn pain.
-Zolpidem (Ambien) 10 mg PO qhs prn insomnia.
11. Labs: beta-HCG pregnancy test, CBC, SMA 7&12,
ESR. GC culture, chlamydia direct fluorescent
antibody stain. UA with micro, C&S, VDRL, HIV, blood
cultures x 2. Pelvic ultrasound.
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