What are the commonly prescribed antibiotics in India for various infections in general practice?

Commonly Prescribed Antibiotics in Indian General Practice

For safe and effective general practice in India, amoxicillin-clavulanic acid should be the first-line empiric antibiotic for most common infections, followed by cephalosporins and fluoroquinolones as second-line options when necessary. 1

Common Infections and First-Line Antibiotic Choices

Respiratory Tract Infections

• Acute Otitis Media:

  • First choice: Amoxicillin oral 40 mg/kg twice daily for 5 days 1
  • Second choice: Co-trimoxazole (if no known resistance) 4 mg/kg trimethoprim plus 20 mg/kg sulfamethoxazole twice daily for 5 days 1

• Pneumonia:

  • Mild-moderate: Amoxicillin-clavulanic acid oral
  • Severe: Ampicillin IV (50 mg/kg four times daily) plus gentamicin IV (7.5 mg/kg daily) for at least 5 days 1
  • Second line: Ceftriaxone IV 80 mg/kg daily for at least 5 days 1

• Upper Respiratory Tract Infections:

  • First choice: Amoxicillin or cefalexin
  • Avoid antibiotics for common cold/viral infections (though studies show 81% of URTIs in India receive antibiotics) 2, 3

Gastrointestinal Infections

• Dysentery:

  • First choice: Ciprofloxacin oral 15 mg/kg twice daily for 3 days 1
  • Second line: Ceftriaxone IV 50-80 mg/kg daily for 3 days 1

• Typhoid:

  • First choice: Ciprofloxacin oral 15 mg/kg twice daily for 7-10 days 1
  • Second line: Ceftriaxone IV 80 mg/kg daily for 5-7 days or azithromycin oral 20 mg/kg daily for 5-7 days 1

• Intra-abdominal Infections:

  • Mild-moderate: Amoxicillin-clavulanic acid 1
  • Severe: Ceftriaxone + metronidazole or piperacillin-tazobactam 1

Urinary Tract Infections

• Simple UTI:

  • First choice: Co-trimoxazole oral 10 mg/kg trimethoprim plus 40 mg/kg sulfamethoxazole twice daily for 5 days 1
  • Second line: Ampicillin IV plus gentamicin IV 1

• Complicated UTI:

  • First choice: Ceftriaxone + metronidazole
  • Alternative: Ciprofloxacin + metronidazole 1

Skin and Soft Tissue Infections

• Cellulitis/Erysipelas:

  • First choice: Cloxacillin/flucloxacillin oral 1
  • Alternative: Cefalexin 1

• Mild Skin Infections:

  • First choice: Amoxicillin-clavulanic acid or cloxacillin 1

• Necrotizing Fasciitis:

  • Clindamycin + piperacillin-tazobactam or ceftriaxone + metronidazole (with or without vancomycin) 1

Dosing Guidelines for Common Antibiotics in Adults

1. Amoxicillin: 500 mg three times daily
2. Amoxicillin-clavulanic acid: 625 mg three times daily
3. Ciprofloxacin: 500 mg twice daily
4. Ceftriaxone: 1-2 g daily IV
5. Azithromycin: 500 mg on day 1, then 250 mg daily for 4 days 4
6. Metronidazole: 400 mg three times daily
7. Co-trimoxazole: 960 mg (double strength) twice daily
8. Cloxacillin: 500 mg four times daily

Pediatric Dosing Considerations

• Amoxicillin: 40-90 mg/kg/day in 2-3 divided doses 1
• Ceftriaxone: 50-80 mg/kg/day IV 1
• Ciprofloxacin: 15 mg/kg twice daily 1
• Gentamicin: 5-7.5 mg/kg daily 1
• Clindamycin: 30-40 mg/kg/day in 3 doses 5

Common Prescribing Pitfalls in Indian General Practice

1. Overuse of broad-spectrum antibiotics: Studies show 95% of antibiotics prescribed in India are broad-spectrum 2. Prefer narrow-spectrum when appropriate.

2. Excessive use of fluoroquinolones: Fluoroquinolones (31%) are the most commonly prescribed antibiotics in India 2, but should be reserved for specific indications due to resistance concerns.

3. Inappropriate antibiotic use for viral infections: 87% of fever cases and 81% of URTIs receive antibiotics in India 2, despite most being viral.

4. Overreliance on fixed-dose combinations (FDCs): FDCs comprise 18% of prescriptions in non-teaching hospitals 6. Use single agents when possible.

5. Inadequate duration of therapy: Complete the full course (typically 5-7 days for most common infections).

6. Prescribing based on non-clinical factors: Patient expectations (29%) and satisfaction often drive antibiotic prescribing 7. Resist these pressures.

Seasonal Considerations

• Monsoon season: Higher antibiotic prescribing rates (76%) 2. Be vigilant about water-borne diseases.
• Winter: Increased respiratory infections. Distinguish viral from bacterial causes.
• Summer: Higher incidence of gastrointestinal infections and skin conditions.

Safe Empiric Therapy Algorithm

1. Assess severity: Determine if outpatient or inpatient management is needed
2. Consider local resistance patterns: If available, consult local antibiograms
3. Start with Access category antibiotics (WHO classification) for most infections
4. Reserve Watch category antibiotics for specific indications or treatment failures
5. Avoid Reserve category antibiotics in general practice
6. Reassess in 48-72 hours: If no improvement, consider alternative diagnosis or therapy

By following these guidelines, general practitioners in India can provide safe and effective antibiotic therapy while helping to combat the growing problem of antimicrobial resistance.