Module 26 · Infections

ICU infections, stewardship and the immunocompromised

NewPhase 2

Infections in the ICU: severe CAP, HAP/VAP, carbapenem-resistant Gram-negatives per ICMR, invasive fungal disease, TB and HIV, febrile neutropenia and TLS, and antibiotic PK/PD with stewardship - aligned with NCDC/ICMR National Treatment Guidelines 2025.

7 topics

Drugs in this module

Doses written for this module's context. The same drug may read differently in another module.

Ceftriaxone

Third-generation cephalosporin

Indications
Severe CAP (with macrolide/doxycycline)
Adult dose
2 g IV once daily for 5-7 days.

Azithromycin

Macrolide

Indications
Atypical cover in severe CAP
Adult dose
500 mg IV/oral once daily for 3-5 days.
Cautions
QT prolongation.

Hydrocortisone

Corticosteroid

Indications
Severe CAP (CAPE COD); septic shock
Adult dose
Severe CAP: 200 mg/day IV (infusion) for 4 days, extended to 8 days if still severe, then taper (total 8 or 14 days).
Cautions
Not studied in influenza pneumonia or septic shock at enrolment in CAPE COD; hyperglycaemia.

Oseltamivir

Neuraminidase inhibitor

Indications
Suspected/confirmed influenza (including H1N1) in severe CAP
Adult dose
75 mg orally/NG twice daily for 5 days (longer if still shedding/severe).
Renal / hepatic
CrCl 30-60: 30 mg BD; 10-30: 30 mg OD.

Piperacillin-tazobactam

Antipseudomonal beta-lactam/beta-lactamase inhibitor

Indications
HAP/VAP, febrile neutropenia, CAP with Pseudomonas risk
Adult dose
4.5 g IV q6h; extended infusion over 3-4 h (or continuous after loading) in critically ill.
Renal / hepatic
CrCl 20-40: 4.5 g q8h (keep extended infusion).

Meropenem

Carbapenem

Indications
ESBL infection; HAP/VAP after BL-BLI exposure; febrile neutropenia with instability
Adult dose
1 g IV q8h (2 g q8h over 3 h for high-MIC organisms, CNS infection or CRE with MIC < 16 per ICMR).
Renal / hepatic
CrCl 26-50: 1 g q12h; 10-25: 500 mg q12h.

Vancomycin

Glycopeptide

Indications
MRSA cover (pneumonia, line infection, febrile neutropenia with instability)
Adult dose
Load 20-35 mg/kg (actual weight, max 3 g), then 15-20 mg/kg q8-12h; AUC-guided 400-600 mg·h/L (trough 15-20 mg/L as surrogate if AUC not available).
Renal / hepatic
Dose by levels; extend interval in AKI.
Monitoring
Levels before 4th dose; creatinine daily.

Linezolid

Oxazolidinone

Indications
MRSA pneumonia (alternative to vancomycin)
Adult dose
600 mg IV/oral q12h.
Cautions
Thrombocytopenia after 10-14 days; serotonin syndrome; avoid as empirical in possible TB (ICMR).

Ceftazidime-avibactam (± aztreonam)

Cephalosporin + novel beta-lactamase inhibitor

Indications
KPC/OXA-48 CRE (alone); NDM (MBL) CRE with aztreonam after synergy testing
Adult dose
2.5 g IV q8h over 3 h; for MBL: plus aztreonam 2 g IV q8h over 3 h given simultaneously.
Renal / hepatic
CrCl 31-50: 1.25 g q8h; 16-30: 0.94 g q12h.
Cautions
Reserve agent; not for empirical use per national guidelines.

Polymyxin B

Polymyxin

Indications
CRE, CRAB, CRPA when no better agent (not for UTI)
Adult dose
Loading 2.5 mg/kg (25,000 units/kg) over 2 h, then 1.5 mg/kg (15,000 units/kg) q12h; Indian guidance: 15-20 lakh units load, then 7.5-10 lakh units q12h.
Renal / hepatic
No renal adjustment.
Cautions
Nephrotoxicity, neurotoxicity, skin pigmentation; use in combination for severe infections.

Colistin (colistimethate sodium)

Polymyxin

Indications
CRE/CRAB infections, preferred polymyxin for UTI
Adult dose
9 million units IV loading, then 4.5 million units q12h (normal renal function).
Renal / hepatic
Reduce maintenance by CrCl; supplement on CRRT.
Cautions
Nephrotoxicity (dose-related).

Ampicillin-sulbactam (high dose)

Beta-lactam + inhibitor

Indications
CRAB (sulbactam backbone)
Adult dose
9 g (6 g ampicillin + 3 g sulbactam) IV q8h over 4 h (sulbactam 9 g/day), usually with a second active agent.

Caspofungin (or micafungin/anidulafungin)

Echinocandin

Indications
Candidaemia/invasive candidiasis first line
Adult dose
Caspofungin 70 mg IV load, then 50 mg daily; micafungin 100 mg daily; anidulafungin 200 mg load, then 100 mg daily.

Fluconazole

Triazole

Indications
Step-down for susceptible Candida
Adult dose
800 mg (12 mg/kg) load, then 400 mg (6 mg/kg) daily.
Renal / hepatic
Halve maintenance if CrCl < 50 (not on RRT).
Cautions
C. auris, C. krusei and many C. glabrata are resistant.

Voriconazole

Triazole

Indications
Invasive aspergillosis first line
Adult dose
6 mg/kg IV q12h × 2 doses, then 4 mg/kg q12h; TDM trough 1-5.5 mg/L.
Cautions
Many interactions, visual disturbance, hepatotoxicity; IV vehicle accumulates if CrCl < 50 (use oral).

Liposomal amphotericin B

Polyene

Indications
Mucormycosis; aspergillosis/candidiasis alternative; cryptococcal meningitis
Adult dose
Mucormycosis 5 mg/kg/day (10 mg/kg/day for CNS); candidiasis 3-5 mg/kg/day; cryptococcal meningitis single 10 mg/kg (WHO 2022).
Cautions
Hypokalaemia, hypomagnesaemia, nephrotoxicity (less than conventional); pre-hydrate with saline.

HRZE fixed-dose combination (NTEP)

First-line antitubercular therapy

Indications
Drug-sensitive TB including miliary and TB meningitis
Adult dose
Daily FDC (H 75/R 150/Z 400/E 275 mg) by weight band: 35-49 kg 3 tablets, 50-64 kg 4, 65-75 kg 5, > 75 kg 6. Equivalent H 5, R 10, Z 25, E 15 mg/kg.
Cautions
Hepatotoxicity (check LFT), rifampicin interactions (azoles, ART, warfarin); add pyridoxine 10 mg/day.

Dexamethasone

Corticosteroid

Indications
TB meningitis (HIV-negative)
Adult dose
0.4 mg/kg/day IV in divided doses, tapered over 6-8 weeks.

Trimethoprim-sulfamethoxazole

Antifolate combination

Indications
Pneumocystis pneumonia
Adult dose
15-20 mg/kg/day of trimethoprim component IV/oral in 3-4 divided doses for 21 days.
Cautions
Hyperkalaemia, marrow suppression, rash/SJS, AKI; G6PD.

Prednisolone

Corticosteroid

Indications
Moderate-severe PJP (PaO2 < 70 mmHg or A-a gradient ≥ 35)
Adult dose
40 mg BD days 1-5, 40 mg daily days 6-10, 20 mg daily days 11-21 (start within 72 h of PJP therapy).

Cefepime

Fourth-generation cephalosporin

Indications
Febrile neutropenia (where ESBL rates allow)
Adult dose
2 g IV q8h (extended infusion in critically ill).
Renal / hepatic
Reduce by CrCl (neurotoxicity in AKI).

Rasburicase

Recombinant urate oxidase

Indications
Established TLS or high risk of TLS
Adult dose
0.2 mg/kg IV over 30 min daily for up to 5 days (single fixed 3-6 mg doses often effective).
Cautions
Contraindicated in G6PD deficiency (haemolysis, methaemoglobinaemia); sample for uric acid on ice.

Allopurinol

Xanthine oxidase inhibitor

Indications
TLS prevention (low-intermediate risk)
Adult dose
100 mg/m² q8h orally (max 800 mg/day), starting 1-2 days before chemotherapy.
Renal / hepatic
Reduce in renal impairment.

Module references (26)

  1. 1

    Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019;200:e45-67.

  2. 2

    Martin-Loeches I, Torres A, Nagavci B, et al. ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia. Intensive Care Med 2023;49:615-32.

  3. 3

    Dequin PF, Meziani F, Quenot JP, et al. Hydrocortisone in severe community-acquired pneumonia (CAPE COD). N Engl J Med 2023;388:1931-41.

  4. 4

    National Centre for Disease Control (DGHS, MoHFW) and Indian Council of Medical Research. National Treatment Guidelines for Antimicrobial Use in Infectious Disease Syndromes, Version 2.0. New Delhi: MoHFW; November 2025.

  5. 5

    Kalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the IDSA and ATS. Clin Infect Dis 2016;63:e61-111.

  6. 6

    Torres A, Niederman MS, Chastre J, et al. International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia and ventilator-associated pneumonia. Eur Respir J 2017;50:1700582.

  7. 7

    Indian Council of Medical Research. Guidance on Diagnosis and Management of Carbapenem Resistant Gram-negative Infections. New Delhi: ICMR; 2022.

  8. 8

    Indian Council of Medical Research. Annual Report: Antimicrobial Resistance Research and Surveillance Network, January 2023-December 2023. New Delhi: ICMR; 2024.

  9. 9

    Tamma PD, Heil EL, Justo JA, Mathers AJ, Satlin MJ, Bonomo RA. Infectious Diseases Society of America 2024 guidance on the treatment of antimicrobial-resistant gram-negative infections. Clin Infect Dis 2024 (online ahead of print).

  10. 10

    Tsuji BT, Pogue JM, Zavascki AP, et al. International consensus guidelines for the optimal use of the polymyxins. Pharmacotherapy 2019;39:10-39.

  11. 11

    Pappas PG, Kauffman CA, Andes DR, et al. Clinical practice guideline for the management of candidiasis: 2016 update by the IDSA. Clin Infect Dis 2016;62:e1-50.

  12. 12

    Patterson TF, Thompson GR 3rd, Denning DW, et al. Practice guidelines for the diagnosis and management of aspergillosis: 2016 update by the IDSA. Clin Infect Dis 2016;63:e1-60.

  13. 13

    Cornely OA, Alastruey-Izquierdo A, Arenz D, et al. Global guideline for the diagnosis and management of mucormycosis: an initiative of the ECMM in cooperation with the MSG ERC. Lancet Infect Dis 2019;19:e405-21.

  14. 14

    Department of Health Research, MoHFW / ICMR. Standard Treatment Workflow: Drug-sensitive TB treatment as per NTEP. New Delhi; March 2022.

  15. 15

    Thwaites GE, Nguyen DB, Nguyen HD, et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med 2004;351:1741-51.

  16. 16

    World Health Organization. Guidelines for diagnosing, preventing and managing cryptococcal disease among adults, adolescents and children living with HIV. Geneva: WHO; 2022.

  17. 17

    Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Pneumocystis Pneumonia. NIH/CDC/HIVMA-IDSA; continuously updated.

  18. 18

    Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the IDSA. Clin Infect Dis 2011;52:e56-93.

  19. 19

    Coiffier B, Altman A, Pui CH, Younes A, Cairo MS. Guidelines for the management of pediatric and adult tumor lysis syndrome: an evidence-based review. J Clin Oncol 2008;26:2767-78.

  20. 20

    Cairo MS, Bishop M. Tumour lysis syndrome: new therapeutic strategies and classification. Br J Haematol 2004;127:3-11.

  21. 21

    Dulhunty JM, Brett SJ, De Waele JJ, et al. Continuous vs intermittent beta-lactam antibiotic infusions in critically ill patients with sepsis (BLING III). JAMA 2024;332:629-37.

  22. 22

    Abdul-Aziz MH, Hammond NE, Brett SJ, et al. Prolonged vs intermittent infusions of beta-lactam antibiotics in adults with sepsis or septic shock: a systematic review and meta-analysis. JAMA 2024;332:638-48.

  23. 23

    Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious methicillin-resistant Staphylococcus aureus infections: a revised consensus guideline. Am J Health Syst Pharm 2020;77:835-64.

  24. 24

    de Jong E, van Oers JA, Beishuizen A, et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients (SAPS). Lancet Infect Dis 2016;16:819-27.

  25. 25

    Sawyer RG, Claridge JA, Nathens AB, et al. Trial of short-course antimicrobial therapy for intraabdominal infection (STOP-IT). N Engl J Med 2015;372:1996-2005.

  26. 26

    BALANCE Investigators. Antibiotic treatment for 7 versus 14 days in patients with bloodstream infections. N Engl J Med 2025;392:1065-78.