ANTIMICROBIAL THERAPY

GOAL: Use targeted and most appropriate antibiotic therapy when possible.

Antibiotic regimens: See the JTS Acute Traumatic Wound Management in the Prolonged Field Care Setting CPG.

- Minimum: Moxifloxacin 400 mg PO daily (or levofloxacin 750 mg PO daily to provide better coverage of bacteria found in wet terrain/jungle environment).
- Better: Ertapenem (Invanz) 1 gram IV/IO once per day (q24 hrs) given over 5 to 10 minutes or IM (not preferred), OR ceftriaxone (Rocephin) 2 grams IV/IO given over 10 minutes q24hrs.
- Best: Ceftriaxone (Rocephin) 2 gm IV/IO q24 hrs given over 30 minutes, PLUS vancomycin (Vancocin) 15 mg/kg IV/IO q12 hrs. (given after ceftriaxone, given over 2 hours) PLUS metronidazole (Flagyl) 500 mg IV/PO/IO q8hrs, given over one hour.

ANTIPARASITIC REGIMENS

If sepsis is suspected in a malaria-endemic area and there is no other clearly identified source, conduct a malaria point-of-care test BINAX Now® and thick and thin smears, if available. If positive, administer both antibiotics and antimalarials. If unable to test for malaria, empiric antimalarial therapy can also be considered. Additionally, in a malaria-endemic area, when a patient is initially unresponsive to antibiotic therapy, add antimalarials.

- Minimum: Atovaquone/progauanil (Malarone) 4x3 regimen – 4 tablets PO once a day for 3 days.
- Best: Artemether/lumafantrine (Coartem) 4 tablets PO initially, then 4 tablets after 8 hours, then 4 tablets PO twice daily for 2 more days (24 tablets total).
- Severe Malaria: The optimal treatment for severe malaria (defined as malaria with associated findings such as altered mental status, acidosis with lactate >5 mmol/L, prostration, hypoglycemia, parasitemia >10%, hemoglobin <7 g/dL, creatinine >3 mg/dL, pulmonary edema, shock, or pathologic bleeding), the drug of choice is IV artesunate 2.4 mg/kg IV/IO at 0, 12, 24, and 48 hours (4 doses), followed by 3 days of either Malarone (4 tablets PO, for 3 days) or Coartem (4 tablets initial dose, followed by 4 tablets given 8 hours later, followed by 4 tablets twice daily for the next 2 days; 24 total tablets).
  - NOTE 1: Although artesunate may be available in tropical countries, the quality of formulation may not be at FDA standards and telemedicine assistance and initiation of medevac should be initiated for severe malaria.
  - NOTE 2: If unable to obtain artesunate, we recommend Coartem or Malarone with teleconsultation assistance and initiation of medevac.

ANTIFUNGAL REGIMENS

Do NOT administer without telemedicine. When advised, antifungal drugs are administered in conjunction with the antibiotic regimen mentioned above.

- Minimum: Fluconazole 400 mg PO or IV daily (note that PO is equipotent to IV).
- Better/Best: Due to the complexity and toxicity of many anti-fungal medications, this CPG will not extend beyond the minimum recommendation.