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Extractions, dental implant placement and reimplantation of avulsed teeth, root canal instrumentation or surgery, professional cleaning or • Tonsillectomy and/or adenoidectomy Surgical conditions that involve penetration of intestinal or respiratory mucosa 8 hours after the initial dose. • • Bronchoscopy with a rigid bronchoscope Vancomycin I g intravenously (20 mg/kg in children) PLUS • Sclerotherapy for oesophageal varices gentamicin 1 . 5 mg/kg intravenously (2 mg/kg in children) 30 • Biliary tract surgery minutes before the procedure, as single dose only.

5 g intravenously for 1 0- 1 4 days plus Flucloxacillin 500 mg intravenously 6 hourly for 1 0- 1 4 days plus Metronidazole 500 mg intravenously 6 hourly for 1 0- 1 4 days or 50,000 U/kg intravenously 1 2 hourly for 1 0- 1 4 days or Procaine benzylpenicillin or Benzathine 50,000 U/kg intramuscularly once daily for 1 0 days for symptomatic infant or those with neurosyphilis 50,000 U/kg intramuscularly as a single injection for asymptomatic infant without neurosyphilis benzylpenicillin Benzylpenicillin or procaine benzylpenicillin is preferred to benzathine benzylpnicillin for infants with congenital syphylis.

Patic dysfunction including jaundice reported Co-amoxiclav Cholestatic jaundice reported, mon�or liver function in liver disease (mmolll) 1 50-350 >500 USE OF ANTIBIOTICS IN LIVER DISEASE Aminoglycosides 1 50-300 I ncrease dosing interval; avoid if possible Amoxicillin >500 I ncrease dosing interval Azathioprine >500 Decrease dose/ increase dosing interval Benzylpenicillin >500 Halve the dose Ceftazidine >1 50-300 Increase dosing interval Cefuroxime >500 Increase dosing interval Cefalexin >500 Increase dosing interval Ceftriaxone >500 No adjustment if hepatic function is normal Chloramphenicol >700 Avoid Co-trimoxazole Avoid in severe liver disease Chloroquine 1 50-300 300-500 Maximum 75 mg/day Maximum 50 mg/day Doxycycline Use with caution Ciprofloxacin 150-300 Halve the dose Erythromycin May cause idiosyncratic hepatotoxicity Cisplatin 150-300 I ncrease dosing interval Co-trimoxazole >500 Maximum 960 mg/day Flucloxacillin Cholestatic jaundice Cyclophosphamide 300-500 Fluconazole Monitor liver function, discontinue if liver function impaired Fusidic acid Impair biliary excretion; increased risk of hepatotoxicity; avoid or reduce dose Griseofulvin Avoid in sevEll'e liver disease Isoniazid Avoid if possible; idiosyncratic hepatotoxicity more common; monitor liver function regularly Itraconazole Half-life prolonged; dose reduction may be necessary Ketoconaiole Avoid Mefloquine Avoid for prophylaxis in severe liver disease Metronidazole Reduce the dose in severe liver disease Norfloxacin Hepatitis with necrosis; use in spontaneous bacterial peritonitis Ofloxacin Reduce dose Rifampicin Avoid in liver disease Decrease dose Decrease dose if GFR falls Cyclosporine Doxycycline 1 50-300 I ncrease dosing interval Ethumbutol 150-300 Increase dosing interval Fluconazole 1 50-300 Increase dosing interval Isoniazid >500 Maximum 200 mg/day Ketoconazole 1 50-300 Unchanged Methotrexate 300-500 I ncrease dosing interval Nalidixic acid 300-500 Avoid Neomycin 150-300 Avoid Nitrofurantoin 1 50-300 Avoid Sulfadiazine >500 Avoid Sulfasalazine >500 Ensure increase fluid intake Tetracycline 150-300 Avoid Vancomycin 1 50-300 Avoid Vincristine 1 50-300 Unchanged 66 67 ANTIBIOTIC GUIDELINE ANTIBIOTIC G U IDELI N E Drugs ANTIBIOTICS IN PREGNANCY Drugs Amikacin Use only when potential benefit outweighs risk 2, 3 alternatives are not available least 1 month after administration Use only i n life-threatening situations (toxicity at Ceftriaxone Not known to be harmful Chloramphenicol Neonatal 'Grey syndrome' 1 , 2, 3 Avoid- arthropathy in alternatives available animal studies; safer Not known to be harmful but use only if adequate alternatives are not available Clindamycin Not known to be harmful Co-amoxiclav 3 menstrual period 3 Mefloquine 1 1 Fansidar 3 Metronidazole Nitrofurantoin 3 Theoretical teratogenic risk (trimethoprim a folate antagonist) Norfloxacin 1 , 2, 3 Neonatal hemolysis and methemoglobinemia; fear of increased risk of kernicterus in neonates Ofloxacin 1 , 2, 3 Effects on skeletal development in animal studies Pentamidine Dental discoloration; maternal hepatotoxicity with Primaquine 3 Pyrimethamine 1 large parenteral doses Gentamicin 68 arthropathy in animal studies; safer alternatives available May produce neonatal hemolysis if use at term Avoid- arthropathy in animal studies; safer in animal studies; safer alternatives available Avoid- arthropathy alternatives available Avoid unless essential Neonatal hemolysis and methemoglobinemia antagonist); adequate folate supplements should be given to mother Possible teratogenic risk (trimethoprim a folate antagonist) Neonatal hemolysis and methemoglobinemi a; fear of increased risk of kernicterus in neonates appears to be unfounded Quinine Streptomycin Tetracyclines Teratogenic in animal studies; use only when potential benefit outweighs risk 2, 3 Avoid- Theoretical teratogenic risk (trimethoprim a folate May be teratogenic with long-term high doses Flucytosine Teratogenic in animal studies Avoid high-dose regimen essential Avoid- multiple congenital abnormalities reported Fluconazole Toxicity in animal studies 1 1 , 2, 3 Not known to be harmful Erythromycin warning to avoid in pregnancy Mebendazole appears to be unfounded 1 Teratogenic in animal studies; packs carry a Nalidixic acid No evidence of teratogenicity but avoid unless 1 Ethionamide contraception during treatment and until the next Ketoconazole Clarithromycin Doxycycline high doses in animal studies); ensure effective Itraconazole Not known to be harmful but use only if adequate alternatives are not available Co-trimoxazole effective contraception required during and for at Auditory or vestibular nerve damage Azithromycin Ciprofloxacin Griseofulvin Not known to be harmful but use only if adequate Amphotericin B Co mment Avoid (fetotoxicity and teratogenicity in animals); Comment Trimester Acyclovir Trimester Auditory or vestibular nerve damage Zidovudine 1 2, 3 1 3 Teratogenic at high doses; but in malaria benefit of treatment outweighs risk Auditory or vestibular nerve damage Effects on skeletal development in animal studies Dental discoloration; maternal hepatotoxicity with large parenteral doses Limited information available; use only if clearly indicated 69 ANTIBIOTIC G U I DELI N E ANTIBIOTIC GUI DELINE DRUGS PRESENT IN BREAST MILK Comment Drugs MANAGEMENT OF ANAPHYLACTIC SHOCK Management consists of stopping the offending drug, treating the acute reaction, and making a determination concerning futures use of Aciclovir Significant amount is found in milk after systemic administration the drug.

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