Clinical Approach To Initial Choice Of Antimicrobial Therapy PDF

TABLE 1 ~ CLINICAL APPROACH TO INITIAL CHOICE OF ANTIMICROBIAL THERAPY" Treatment based on presumed site or type of infection. In selected instances, treatment and prophylaxis based on identification of pathogens. Regimens should be reevaluated...

TABLE 1 ~ CLINICAL APPROACH TO INITIAL CHOICE OF ANTIMICROBIAL THERAPY" Treatment based on presumed site or type of infection. In selected instances, treatment and prophylaxis based on identification of pathogens. Regimens should be reevaluated based on pathogen isolated, antimicrobial susceptibility determination, and individual host characteristics. (Abbreviations on 2) ANATOMIC SITE/DIAGNOS1S/ ETIOLOGIES SUGGESTED REGIMENS* ! ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY ! ALTERNATIVES AND COMMENTS ABDOMEN: See Peritoneum, page 51; Gallbladder, page 18; and Pelvic Inflammatory Disease, page 28 BONE: Osteomyelitis. Microbiologic diagnosis is essential. I f blood culture negative, need culture of bone (EurJ Clin Microbiol Infect Dis 33=371, 2014). Culture of sinus tract drainage not predictive of bone culture. For comprehensive review of antimicrobial penetration i n t o bone, see Clinical Pharmacokinetics 48=89, 2009. Hematogenous Osteomyelitis (see IDSA guidelines for vertebra! osteo: CID July 29, 2015) Empiric therapy—Collect bone and blood cultures before empiric therapy Newborn (2i y’r’s) | Vanco 30-60 mg/kg/d i n |6apto 8-10 mg/kg I V q24h ORjCeftriaxone should not be used i f pseudomonas suspected. Vertebral osteo + epidural but variety other organisms. 2-3 div doses, t a r g e t AUC 24 Linezolid 600 m g q12h + Piperacillin/Tazobactam another option for pseudomonas o r other abscess Brucella, M. tuberculosis, 400-600 pg/mL x h + (Ceftriaxone 2 g m q24h OR Gram-negative coverage. (see IDSA guidelines Coccidioides important i n (Ceftriaxone 2 gm q24h OR CFP 2 g m q 8 h OR Dx: MRI diagnostic test of choice, indicated to rule out epidural abscess. for vertebral osteo: regions of high endemicity CFP 2 gm q8h OR Levo 750 m g q24h) Risk factors for recurrence: end-stage renal disease, MRSA infection, CID 61=859, 2015) for t h e organisms Levo 750 mg q24h) undrained paravertebral or psoas abscess; pathogen-specific therapy for >8 wks recommended if any of these are present (CID 62=1262, 2016); Blood & bone cultures 6 wks of pathogen-specific therapy comparable to 12 wks for less essential. complicated infection (CID 62=1261, 2016 and Lancet 385=875, 2015). Whenever possible empirical therapy should be administered after cultures are obtained. ________________________________________________________ - PRIMARY REGIMENS SUGGESTED are for adults (unless otherwise indicated) with clinically severe (often life-threatening) infections. Dosages also assume normal renal function, and not severe hepatic dysfunction. § ALTERNATIVE REGIMENS INCLUDE these considerations: allergy, pregnancy, pharmacology/pharmacokinetics, compliance, costs, local resistance profiles. 5  6 TABLE 1 (2) UJ ui IP in LU in o § ot. Q £ § tn ANATOMIC SiTE/DIAGNOSIS/ ETIOLOGIES ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES I | §3AU.VN8211V MODIFYING CIRCUMSTANCES PRIMARY AND COMMENTS BONE/Hematogenous Osteomyelitis (continued) Specific therapy—Culture and in vitro susceptibility results known. See C/DJul 29, 2015 for IDSA Guidelines MSSA Nafcillin or Oxacillin Vanco 30-60 mg/kg/d in 2-3 In children, therapy can be completed with high dose oral therapy 2 gm IV q4h or Cefazolin div doses, target AUC24 (JAMA Pediatr 169220,2015). 2 gm IV q8h 400-600 pg/mL x h OR Dapto Other options if susceptible in vitro and allergy/toxicity issues 8-10 mg/kg IV q24h OR (see NEJM 362:11, 2010): Linezolid 600 mg IV/poq12h 1) TMP-SMX 8-10 mg/kg/d po/IV div q8h + RIF 300-450 mg bid: limited MRSA—See Table 6, page 93; Vanco 30-60 mg/kg/d in 2-3 Linezolid 600 mg q12h IV/po ± data, particularly for MRSA (see AAC 532672, 2009); 2) Levo 750 mg po IDSA Guidelines CID 52:e18- div doses, target AUC24 RIF 300 mg po/IV bid OR q24h) + RIF 600 mg po q24h; 3) Fusidic acidwus 500 mg IV q8h + RIF 300 mg 55, 2011; CID 52285-92, 2011. 400-600 pg/mL x h ± Dapto 8-10 mg/kg q24h IV ± po bid. (CID 42394, 2006); 4) Ceftriaxone 2 gm IV q24h (CID 54385, 2012) Combination therapy lessens RIF 300-450 mg bid. RIF 300-450 mg po/IV bid (MSSA only): Duration of therapy: 6 weeks, provided that epidural or relapse rate paravertebral abscesses can be drained; consider longer course in those w i t h extensive infection or abscess particularly if not amenable to drainage because of increased risk of treatment failure (OFID Dec 5-1, 2014) (although data are lacking that this approach improves efficacy versus a 6 wks course) and >8 weeks in patients undergoing device implantation (CID 60:1330, 2015). Hemoglobinopathy: Salmonella; other Gm-neg. CIP 400 mg IVq12hOR Levo 750 mg IV/po q24h Due to increasing levels of FQ resistance, consider adding a second agent Sickle cell/thalassemia 'bacilli CIP 750 mg po bid (e.g., third generation cephalosporin) until susceptibility test results available. Alternative for salmonella is Ceftriaxone 2 gm IV q24h if nalidixic acid resistant which is predictive of fluoroquinolone resistance. Contiguous Osteomyelitis Without Vascular Insufficiency Empiric therapy: Get cultures'. Foot bone osteo due to nail P. aeruginosa CIP 750 mg po bid Ceftaz 2 gm IV q8h Empiric therapy not recommended: Get cultures. 5. aureus and through tennis shoe or Levo 750 mg po q24h or CFP 2 gm IV q8h polymicrobial infections more common in diabetics (J Am PodiatrMed Assoc. 2020 Nov 2;20-206). See also: Skin-Nail puncture, page 62. Need debridement to remove foreign body. Long bone, post-internal S. aureus, Gm-neg. bacilli, Vanco 30-60 mg/kg/d in 2-3 Linezolid 600 mg IV/po bidNAI Regimens listed are empiric. Adjust after culture data available. fixation of fracture P. aeruginosa div doses, target AUC24 + (Ceftaz or CFP). I f susceptible Gm-neg. bacillus, CIP 750 mg po bid or Levo 750 mg po q24h. 400-600 pg/mL x h + [Ceftaz See Comment For other 5. aureus options: See Hem. Osteo. Specific Therapy, page 6. or CFP], See Comment Osteonecrosis of the jaw Probably rare adverse reaction Infection may be secondary to bone necrosis and loss of overlying mucosa. to bisphosphonates Treatment: minimal surgical debridement, chlorhexidine rinses, antibiotics (e.g., Pip-tazo). Evaluate for concomitant actinomycosis, for which specific long-term antibiotic treatment wouid be warranted. Prosthetic joint _________1See prosthetic Joint, page 36 I Spinal implant infection 1S. aureus, coag-neg staphylo- 1Onset within 30 days: 1Onset after 30 days remove 1See CID 55:1481, 2012 cocci, gram-neg bacilli _ _ Iculture, treat for 3 mos. implant, culture & treat Sternum, post-op S. aureus, S. epidermldis, Vanco 30-60 mg/kg/d in 2-3 Linezolid 600 mg po/IV*1*' bid Sternal debridement for cultures & removal of necrotic bone. If setting or occasionally, gram-negative div doses, target AUC24 'gram stain suggests possibility of gram-negative bacilli, add appropriate bacilli 400-600 pg/mL x h coverage based on local antimicrobial susceptibility profiles (e.g., cefepime, recommended for serious Pip-tazo). infections. Abbreviations on page 2. *NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  TABLE 1 (3) ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS" ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY 1 ALTERNATIVE? AND COMMENTS BONE (continued) _________ _______________ ________ ________ ____ Contiguous Osteomyelitis With Vasicular Insufficiency. Most pts are diabetics with Polymicrobic [Gm+ cocci Debride overlying ulcer & submit bone for histology & Diagnosis of osteo: Culture bone biopsy (gold standard). Swab cultures peripheral neuropathy & (to include MRSA) (aerobic culture. Select antibiotic based on culture results & treat unreliable. Sampling by needle puncture inferior to biopsy infected skin ulcers & anaerobic) and Gm-neg. for 6 weeks. No empiric therapy unless acutely ill. (CID 48=888, 2009). Osteo likely if ulcer >2 cm2, positive probe to bone, (see Diabetic foot, page 18) bacilli (aerobic & anaerobic)] I f acutely ill, see suggestions, Diabetic foot, page 18. ESR >70 & abnormal plain x-ray. Revascularize i f possible. Treatment: (1) Revascularize if possible; (2) Culture bone; (3) Specific antimicrobial(s). Chronic Osteomyelitis: S. aureus, Enterobacteriaceae, Empiric rx not indicated. Base systemic rx on results of Important adjuncts: removal of orthopedic hardware, surgical debridement; Specific therapy |P. aeruginosa culture, sensitivity testing. I f acute exacerbation of chronic vascularized muscle flaps, distraction osteogenesis (Ilizarov) techniques. By definition, implies presence of osteo, rx as acute hematogenous osteo. Surgical NOTE: RIF + (Vanco or p-lactam) effective in animal model and in a clinical dead bone. Need valid cultures i debridement important. trial of S. aureus chronic osteo. BREAST:Mastitis—Obtain culture; need to know if MRSA present. Review of breast infections: BMJ 342:d396, 2011. Postpartum mastitis (Cochrane Review: Cochrane Database Syst Rev 2013 Feb 28;2:CD005458; see also CID 54=71, 2012) Mastitis without abscess S. aureus, strep, coag-neg. NO MRSA: MRSA Possible: i f no abscess & controllable pain, T freq of nursing may hasten response. staph, other Gram-positives Outpatient: Diclox 500 mg Outpatient: TMP-SMX-DS less common ipo qid or Cephalexin 500 mg tabs 1-2 po bid or, i f suscepti ipo qid. ble, Clinda 300 mg po tid Mastitis with abscess For painful abscess l&D is standard; needle aspiration reported successful. Inpatient: Nafcillin/ Inpatient: Vanco 30-60 mg/ Resume breast feeding from affected breast as soon as pain allows. Oxacillin 2 gm IV q4-6h kg/d in 2-3 div doses, target (Breastfeed Med 9=239, 2014) AUC24 400-600 pg/mL x h Non-puerperal mastitis S. aureus; less often See regimens for Postpartum If subareolar & odoriferous, most likely anaerobes; add Metro 500 mg IV/po with abscess Bacteroides sp., mastitis, page 7. tid. Need pretreatment aerobic/anaerobic cultures. Surgical drainage for peptostreptococcus abscess. I&D standard. Corynebacterium sp. assoc, with chronic (Peptoniphilus sp.), & selected granulomatous mastitis (JCM 53=2895, 2015). Consider TB in chronic coagulase-neg. staphylococci infections. 1 I 1 Acute; S. aureus, S. pyogenes. Acute: Vanco 30-60 mg/kg/d Chronic: Await culture Risk of complications higher with late-onset infection (>30 days post TSS reported. in 2-3 div doses, target AUC24 results. See Table 12A for implantation). Antibiotics alone may be sufficient for minor infections; Chronic: Look for rapidly 400-600 pg/mL x h mycobacteria treatment. explantation often required for more serious infections. P/ast. Reconstr growing Mycobacteria Surg 139=20, 2017. Abbreviations on page 2. -NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost. 7  8 TABLE 1 (4) ANATOMIC SITE/DIAGNOSIS/ I ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) | PRIMARY ALTERNATIVE® i AND COMMENTS CENTRAL NERVOUS SYSTEM Brain abscess Primary or contiguous source Streptococci (60-70%), (Cefotaxime 2 g m IV q4h or Pen G 3-4 million u n i t s I V q 4 h I f CT scan suggests cerebritis or abscesses 4 wks syphilis, Whipple's disease 1 1 Anti-helminthic therapy 1/3 lack peripheral eosinophilia. Need serology to confirm diagnosis. Steroid |j probably not beneficial ref.: Cochrane Database Syst Rev. 2015 Feb 17)(2):CD009088 § Meningitis, HIV-1 infected (AIDS) As in adults, >50 yrs: also I f etiology not identified: For crypto rx, see Table 11A, C. neoformans most common etiology in AIDS patients. H. influenzae, See Table 11, Sanford Guide to consider cryptococci, treat as adult >50 yrs + page 146 pneumococci, listeria, TBc, syphilis, viral, histoplasma & coccidioides also HIV/AIDS Therapy M. tuberculosis, syphilis, HIV obtain CSF/serum crypto- need to be considered. Obtain blood cultures. aseptic meningitis. Listeria coccal antigen monocytogenes \(see Comments) Abbreviations on page 2. -NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost. 11  12 TABLE 1 (8) ANATOMIC SITE/DIAGNOSIS/ ! ETIOLOGIES I SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES | (usual) ' PRIMARY I ALTERNATIVE® i AND COMMENTS EAR External otitis Acute external otitis: S. aureus, P. aeruginosa Ear drops: 1) CIP + (dexamethasone or hydrocortisone) bid x Antiseptics, acidifying agents, glucocorticoids & topical antibiotics have "Swimmer's ear", ear buds, 7 days; 2) Oflox qd x 7 days; 3) CIP single dose. FQ eardrops similar outcomes (CochrSys Rev 2010;1:CD004740). Topical antibiotic headsets assoc, with increased risk of tympanic membrane therapy favored with cure rates of 65-90%; al! are expensive ($70-300). Ref: JAMA 2018,3203375 ______ perforation (CID 703103, 2020) _____ Chronic Usually 2° to seborrhea Eardrops: Control seborrhea with dandruff shampoo containing selenium sulfide [(Polymyxin B + Neomycin + hydrocortisone qid) + (Selsun) or [(ketoconazole shampoo) + (medium potency steroid solution, selenium sulfide shampoo] triamcinolone 0.1%)]. ____________________________________ Fungal (Candida species IFluconazole 200 mg po x 1 dose & then 100 mg p o x 3-5 days.| "Necrotizing (malignant) Pseudomonas aeruginosa CIP 400 mg IV q8h; 750 mg Pip-tazo 3.375 gm q4h or Very high ESRs are typical. Debridement usually required. R/O osteomyelitis: otitis externa" in >95% (Oto! & Neuroto/ogy poq8-12h only for early extended infusion (3.375 gm CT or MRI scans. I f bone involved, treat for 6-8 wks. Other alternatives i f Risk groups: Diabetes mellitus, 34'620, 2013) disease over 4 hrs q8h) + Tobra P. aeruginosa is susceptible: IMP 0.5 gm q6h or MER 1 gm IV q8h or CFP AIDS, chemotherapy. See 2 gm IV q12h or Ceftaz 2 gm IV q8h. A m J Otolaryngol 37:425, 2016. Otitis media—infants, children, adults (Cochrane review: Cochrane Database Syst Rev. Jan 31;1:CD000219, 2013); American Academy of Pediatrics Guidelines: Pediatrics 131:e964, 2013) Acute Two RCTs indicate efficacy of antibiotic rx i f age 48 hrs of nasotracheal Pseudomonas sp., klebsiella, Ceftazidime or CFP or IMP or MER or (Pip-tazo) or CIP. With nasotracheal intubation >48 hrs, about U pts will have otitis media intubation ,enterobacter \(For dosages, see Ear, Necrotizing (malignant) otitis with effusion. $ aSI I ! l l Prophylaxis: acute otitis media Pneumococci, H. influenzae, Use of antibiotics to prevent otitis media is a major contributor to emergence of antibiotic-resistant 11 M. catarrhalis, Staph, aureus, S. pneumo. Group A strep (see Comments) Mastoiditis: Complication of acute or chronic otitis media. If chronic, look for cholesteatoma (Keratoma) Acute Generally too ill for I f complication of 1st episode Obtain cultures, then empiric therapy. Acute exacerbation of chronic otitis Diagnosis: CT or MRI outpatient therapy of acute otitis media: Vancomycin media: Surgical debridement of Look for complication: S. pneumoniae (most common)|Child: 40-60 mg/kg IV divided 2-4 times a day to achieve auditory canal, then [Vanco + osteomyelitis, suppurative lateral S. pyogenes preferred target AUC24 400-600 pg/mL x hr Pip-tazo 3.375 gm IV q6h] OR sinus thrombophlebitis, purulent Adult: 15-20 mg/kg IV q8-12h to achieve preferred target [Vanco (dose as above) + Ceftaz meningitis, brain abscess I f secondary to chronic otitis AUC24 400-600 pg/mL x hr 2 gm IV q8h (Adult), 50 mg/kg IV ENT consultation for possible media: q8h (Child) mastoidectomy Generally not ill enough As per 1st episode and: Culture ear drainage. May need surgical debridement. Topical Fluoroquinolone ear drops. Diagnosis: CT or MR! for parenteral antibiotics S. aureus ENT consult. P. aeruginosa Anaerobes Fungi ______________ 3 Drugs & peds dosage (all po unless specified) for acute otitis media: Amoxicillin UD (usual dose) = 40 mg/kg per day div q12h or q8h. Amoxicillin HD (high dose) = 90 mg/kg per day div q12h or q8h. AM-CL HD = 90 mg/kg per day of amox component. Extra-strength Amox-clav oral suspension (Augmentin ES-600) available with 600 mg A M & 42.9 mg CL / 5 mL—dose: 90/6.4 mg/kg per day div bid. Cefuroxime axetil 30 mg/kg per day div q12h. Ceftriaxone 50 mg/kg I M x 3 days. Clindamycin 20-30 mg/kg per day div qid (may be effective vs. DRSP but no activity vs. H. influenzae). Other drugs suitable for drug (e.g., Penicillin) - sensitive S. pneumo: TMP-SMX 4 mg/kg of TMP q12h. Erythro-sulfisoxazole 50 mg/kg per day of erythro div q6-8h. Clarithro 15 mg/kg per day div q12h; Azithro 10 mg/kg per day x 1 & then 5 mg/kg q24h on days 2-5. Other FDA-approved regimens: 10 mg/kg q24h x 3 days & 30 mg/kg x 1. Cefprozil15 mg/kg q12h; Cefpodoxime proxetil 10 mg/kg per day as single dose; Cefaclor 40 mg/kg per day div q8h. Cefdinir 7 mg/kg q12h or 14 mg/kg q24h. 13 Abbreviations on page 2. "NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  14 TABLE 1 (10) ANATOMIC SITE/DIAGNOSIS/ I ETIOLOGIES I SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES (jensn) MODIFYING CIRCUMSTANCES | PRIMARY | ALTERNATIVES AND COMMENTS EYE Eyelid: (See Cochrane Database Syst Rev 5:CD005556, 2012) Blepharitis lEtiol. unclear. Factors include Lid margin care w i t h baby shampoo & warm compresses Topical o i n t m e n t s of uncertain benefit (Cochrane Database Syst Rev. 2017 Staph, aureus & Staph, q24h. Artificial tears i f assoc, dry eye (see Comment). 'Feb 7;2:CD011965). iepidermidis, seborrhea, If associated rosacea, add doxy 100 mg po bid for 2 w k s and t h e n q24h. Irosacea, & dry eye Hordeolum (Stye) Cochrane review j of effectiveness of non-surgicf both vitreous and aqueous humor for culture prior to therapy. Intravitreal administration of antimicrobials essential. Postocular surgery (cataracts) Early, acute onset S. epidermidis 60%, Staph. Immediate ophthal. consult. I f only light perception or worse, immediate vitrectomy + intravitreal vanco 1 mg & intravitreal ceftazidime (incidence 0.05%) ;aureus, streptococci, & entero 2.25 mg. cocci each 5-10%, Gm-neg..bacilli 6% ________________ Low grade, chronic Cutibacterium acnes, Intraocular Vanco. Usually requires vitrectomy, lens removal. S. epidermidis, S. aureus.(rare) also, fungal Post filtering blebs Strep, species (viridans & Referral to ophthalmologist for intravitreal Vanco 1 mg + Ceftaz 2.25 mg and a topical ophthalmic antimicrobial. for glaucoma jOthers),_HL Post-penetrating trauma Bacillus sp., S. epiderm. Referral to ophthalmologist for intravitreal Vanco 1 mg + (Ceftaz 2.25 mg or Amikacin 0.4 mg) + systemic Vanco 30-60 mg/kg/d in 2-3 div doses, target AUC24 400-600 pg/mL x h + [Ceftaz 1 g IV q8h or CIP 400 mg IV/po q12h]. Vitrectomy may be required. Hematogenous S. pneumoniae, N. meningitidis, (Cefotaxime 2 gm IV q4h or Ceftriaxone 2 gm IV q24h or Ceftazidime 2 gm IV q8h) + Vanco 30-60 mg/kg/d in 2-3 div doses, target AUC24 Staph, aureus, Grp B Strep, 400-600 pg/mL x h pending cultures. Intravitreal antibiotics as with early postocular surgery. Urgent ophthalmological consultation. K-_pneumo____ IV heroin abuse S. aureus, Bacillus cereus, Empirically, as above for hematogenous w i t h definitive therapy based on etiology and antimicrobial susceptibility. Candida sp. Urgent ophthalmological consultation. Abbreviations on page 2. -NOTE: AU dosage recommendations are for adu/ts ( un/ess otherwise indicated) and assume norma! renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  TABLE 1 (13) ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS- ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY | ALTERNATIVE? AND COMMENTS EYE/Endophthalmitis (continued) ___________ Mycotic (fungal): Broad-spectrum iCandida sp., Aspergillus sp. Intravitreal Ampho B 0.005-0.01 mg in 0.1 mL. Also see Patients with Candida spp. chorioretinitis usually respond to systemically antibiotics, often corticosteroids, Table 11A, page 145 for concomitant systemic therapy. administered antifungals (CHn Infect Dis 53-262, 2011). Intravitreal ampho indwelling venous catheters See Comment and/or vitrectomy may be necessary for those with vitritis or endophthalmitis. (IDSA guidelines CID 62-409, 2016). Retinitis Acute retinal necrosis Varicella zoster virus (VZV), IV Acyclovir 10-12 mg/kg IV q8h x 5-7 days, then Acyclovir Strong association of VZ virus with atypical necrotizing herpetic retinopathy. Review: Clinical Ophthalmology Herpes simplex 800 mg po 5 x/day OR Valacyciovir 1000 mg po tid OR Ophthalmology consultation. 14:1931, 2020 Famciclovir 500 mg po tid HIV+ (AIDS) CD4 usually iCytomegalovirus See Table 14A, page 194 Occurs in 5-10% of AIDS patients 0.12 pg/mL (CDC Health Alert Network, of bloody stools 51% Pockets of resistance (see Comment) Apr 18, 2017). Pockets of resistance reported, especially to FQ in Asia. Peds doses: Azithro 10 mg/kg/day once daily x 3 days. Resistance more common in international travelers and For severe disease, Ceftriaxone 50-75 mg/kg per day immunocompromised; clusters of resistance to FQ, Azithro, Ceftriaxone in x 2-5 days. CIP suspension 10 mg/kg bid x 5 days. MSM. For most individuals, treatment not necessary. May be associated I __________________________I ______________________________________________________ vy iu 1 t - „ 14.’« - y - 1 L 44c _ 2 5 4 ’4 44*14 u L i 14452’24’ 1 L 152? u 4 _ -4. [Spirochetosis (Brachyspira [ Benefit of treatment unclear. Susceptible to Metro, Anaerobic intestinal spirochete that colonizes colon of domestic & wild Ceftriaxone, and Moxi. animals plus humans. Called enigmatic disease due to uncertain status Vibrio cholerae Primary therapy is rehydration. Pregnancy: MtKiiiMViuuidt umfctpy biiui luhi, u u i d t i u i i u i iiuitibb, du i i ei lyut dtiui i lb (toxigenic - 01 & 039) Select antibiotics based on Azithro 1 gm po single dose paramount. When IV hydration is needed, use Ringer's lactate. Switch to po Treatment decreases duration susceptibility of locally OR Erythro 500 mg po qid x repletion with Oral Rehydration Salts (ORS) as soon as able to take oral of disease, volume losses, prevailing isolates. Options 3 days fluids. ORS are commercially available for reconstitution in potable water. & duration of excretion include: Doxy 300 mg po Peds: Azithro 20 mg/kg po as I f not available, WHO suggests a substitute can be made by dissolving single dose, Azithro 1 gm po single dose; for other age y2 teaspoon salt and 6 level teaspoons of sugar per liter of potable water single dose, Tetra 500 mg po specific alternatives, ( http://www. who. in t/cholera/technica t/en/). qid x 3 days, Erythro 500 mg see CDC website http:// po qid x 3 days. i-wvw.cdc.gov/haiticholera/ Vibrio parahaemolyticu us, Antimicrobial rx does not shorten course. Hydration. jShel I fish exposure common. Treat severe disease: FQ, Doxy, 3rd gen Ceph Vibrio vulnificus Adult: (Doxy or Minocycline 100 mg lv/po bid) + (Ceftriaxone 2 gm lv once daily or Ceftaz 1 gm Iv q8h). Peds: Doxy 4.4 mg/kg/day div bid Usual presentation is skin (max 200 mg/day). Alternatives: Levo or CIP. Ref: Epidemiol Infect. 142:878, 2014. lesions & bacteremia; life- threatening. ____________ Yersinia enterocolitica No treatment unless severe. I f severe, Doxy 100 mg IV bid + Mesenteric adenitis pain can mimic acute appendicitis. Lab diagnosis Fever in 68%, bloody stools (Tobra or Gent 5 mg/kg per day once q24h). TMP-SMX or difficult: requires "cold enrichment" and/or yersinia selective agar. in 26% FQs are alternatives. Desferrioxamine therapy increases severity, discontinue i f pt on it. Iron overload states predispose to yersinia. ___________________________ Gastroenteritis—Specific Risk Groups-Empiric Therapy Anoreceptive intercourse.Proctitis WistaH 5 cm only) ____Herpes_ y[ruses,_ gonococci, chlamydia, syphilis. See Genita[ Tract, page_25 _ _ _ ShigelLa, _salmon_ell_a2 Campylobacter, E. histolytica (see Tabfe_ 754) Isee _ _ HIV-rinfected’(AIDS): ' ” ’ G. lamblia >10 days diarrhea Acid fast: Cryptosporidium parvum or hominis, Cyclospora cayetanensis See Table 13A ____________________________ Other jCystis_o_s_poja_beJHL mjcros_pjsjidiaJ_Enterqc7tozoon_bieneiJsii Septata intestinajis) ___ Neutropenic enterocolitis Mucosal invasion by ______________________n;,,*-.,,. ICefepime -> Bowel rest and Pip-tazo _____________ 2 gm — IV i v.q8h ok + Need surgical consult. Surgical resection controversial but may be necessary. or — "typhlitis" Clostridium septicum and 4.5 gm IV q6h or IMP 500 mg Metro 500 mg !Vq8h NOTE: Resistance of Clostridia to clindamycin reported. Pip-tazo, IMP, MER, (CID 56-711, 2013) (World J others. Occasionally caused by IV q6h or MER 2 gm IV q8h DORI should cover most pathogens. Gastroenterol 23: 42, 2017) Abbreviations on page 2. *NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function, § Alternatives consider allergy, PK, compliance, local resistance, cost. 21  22 TABLE 1 (18) ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY | ALTERNATIVES AND COMMENTS GASTROINTESTINAL/Gastroenteritis— Specific Risk Groups-Empiric Therapy (continued) ________ Traveler's diarrhea, self- Acute: 60% due to Adult: Azithro 1000 mg po once or 500 mg po q24h for 3 days Antimotility agent: For non-pregnant adults w i t h no fever or blood i n stool, medication. Patient often afebrile diarrheagenic E. coli; shigella, CIP 500 mg po bid x 3 days OR add loperamide 4 m g po x 1, t h e n 2 mg po after each loose stool to a salmonella, o r Campylobacter. Levo 500 mg po q24h for 1-3 days OR m a x i m u m o f 16 mg per day. C. difficile, amebiasis Oflox 300 mg po bid for 3 days OR Rifaximin approved only for ages 12 and older. Works only for diarrhea due (see Table 13A). Rifaximin 200 mg po t i d for 3 days OR to non-invasive E. coli; do n o t use i f fever or bloody stool. If chronic: cyclospora, crypto Rifamycin SV 2 tabs bid x 3 days Rifamycin SB: adult only; for E. coli. Do not use i f fever or bloody diarrhea. sporidia, giardia, isospora Peds: Azithro 10 mg/kg/day as a single dose for 3 days o r Ref: NEJM 361=1560, 2009; Clin Micro Inf 21=744, 2015. Ceftriaxone 5 0 mg/kg/day as single dose for 3 days. NOTE: Self-treatment w i t h FQs associated w i t h acquisition of resistant Avoid FQs. Gm-neg bacilli (CID 60=837, 847, 872, 2015). Increasing resistance of Pregnancy: Use Azithro. Avoid FQs. Campylobacter to FQ, particularly in Asia. Azithro now f i r s t line choice, For loperamide, see Comment. Prevention of Traveler's Preventative treatment of trav eler's diarrhea i s not routinely indicated. diarrhea Preferred approach i n t h e current recommendation i s Azithro 1000 mg once + Imodium w i t h 1first loose stool. Consider CIP 500 mg po daily f( ?r short t r i p s w i t h v i t a l missions that cannot be disrupted anc1 i n immunocompromised patients and those with HIV and CD4 90% sens. & 92% specific. Other tests: antibiotic given. Vonoprazen + Clarithro if endoscoped, rapid urease &/or histology &/or culture; serology less sens Where available treatment (Inter Med 59=153, 2020) & spec; urea breath test, but some office-based tests underperform. should be guided by Testing ref: BM J 344=44, 2012. susceptibility testing or PCR Test of cure: Repeat stool antigen and/or urea breath test >8 wks typing of Clarith R; all H. pylori post-treatment. + should be treated. Test & Treatment outcome: Failure rate of triple therapy 20% due to clarithro treat without EGD i f age resistance. to 80 kg or max of 1000 mg / dose if < 80 kg). Efficacious and cost-saving (J Ped Infect Dis 2017:6-57-64). PK/PD justification of once daily metronidazole; studies in human volunteers: Antimicrob Agents Chemother_ 2004 48 :_45_97_ _ _ _ Perforation, peritonitis, shock Emergency surgery: MER 1 gm IV q8h or CIP 400 mg IV q8h + Metro 500 mg IV q8h (See Comments for other options) 23 Abbreviations on page 2. -NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  24 TABLE 1 (20) ANATOMIC SITE/DIAGNOSIS/ Ii ETIOLOGIES SUGGESTED REGIMENS- ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVES AND COMMENTS GASTROINTESTINAL/Gastrointestinal Infections by Anatomic Site: Esophagus to Rectum (continued) Diverticulitis, perirectal abscess, Enterobacteriaceae, Outpatient rx—mild diverticulitis, drained perirectal abscess: Must "cover" both Gm-neg. aerobic & Gm-neg. anaerobic bacteria. Drugs peritonitis occasionally P. aeruginosa, Amox-clav 875/125 mg po bid Moxi 400 mg po q24h active only vs. anaerobic Gm-neg. bacilli: clinda, metro. Drugs active only 6 Also see Peritonitis, page 51 Bacteroides sp., enterococci I f beta-lactam allergic or Duration varies with clinical vs. aerobic Gm-neg. bacilli: APAG , P Ceph 2/3/4 (see Table 10A, page 118), intolerant: [(TMP-SMX-DS response. Usually 7-10 days aztreonam, CIP, Levo. Drugs active vs. both aerobic/anaerobic Gm-neg. NEJM 2018)379:1635 tab po bid) or (CIP 750 mg po bacteria: cefoxitin, cefotetan, TC-CL, Pip-tazo, Amp-sulb, ERTA, DORI, IMP, bid or Levo 750 mg po q24h)] MER, Moxi, & tigecycline. + Metro 500 mg q6h. Resistance (B. fragilis): Metro, Pip-tazo rare. Resistance to FQ increased in Duration of treatment varies enteric bacteria, particularly i f any FQ used recently. based on clinical response. Concomitant surgical management important, esp. with moderate-severe Usually Treat for 7-10 days. disease. Role of enterococci remains debatable. Probably pathogenic in Can customize duration by infections of biliary tract. Probably need drugs active vs. enterococci in pts trending serum procalcitonin with valvular heart disease. serum levels. Treat until PCT Tigecydine: Black Box Warning: All cause mortality higher in pts treated level is 20 CSF WBCs count MMWR. PPP.PPP7 _________________________ \10 WBC/ nucleic acid amplification test Chlamydia trachomatis Treat for non-gonococcal urethritis, page 25. I f due to hpf of vaginal fluid is suggestive. Intracellular gram-neg diplococci are Mycoplasma genitalium, less likely to respond to doxy specific but insensitive. I f in doubt, send swab or urine for culture, EIA or and emerging resistance to both azithro and FQ. nucleic acid amplification test and treat for both. Endomyometritis/septic pelvic phlebitis Early postpartum (1st 48 hrs) Bacteroides, esp. Prevotella Severe: Pip-tazo or MER See Comments under Amnionitis, septic abortion, above (usually after C-section) bivia; Group B, A streptococci; Strep TSS: Ceftriaxone + Clinda Enterobacteriaceae; Mild: Amox-clav 875/125 po bid Associated C. trachomatis: add Doxy Dosage: seefootnote/ Late postpartum Chlamydia trachomatis, D o x y i d b mg IV or po q12h times 14 days Tetracyclines not recommended" in nursing mothers; discontinue nursing. (48 hrs to 6 wks) (usually M. hominis M. hominis sensitive to tetra, clinda, not erythro. n ! e ve. y?9l A A JL. f fl _______ Fitzhugh-Curtis syndrome C. trachomatis, [Treat as for pelvic inflammatory disease immediately below, [perihepatitis (violin-string adhesions). Sudden onset" of RUQ pain. _____ N;jonorrho_e_a_e_ Associated with salpingitis. Transaminases elevated in 24;hr befqr_e_switching to outpatient regimes _____________________ 7 P Ceph 2 (Cefoxitin 2 gm IV q6-8h, Cefotetan 2 gm IV q12h, Cefuroxime 750 mg IV q8h); Amp-sulb 3 gm IV q6h; Pip-tazo 4.5 gm load, then 4-hr infusion of 3.375 gm q8h; Doxy 100 mg IV/po q12h; Clinda 450-900 mg IV q8h; Aminoglycoside (Gent, see Table IOC, page 134); P Ceph 3 (Cefotaxime 2 gm IV q8h, Ceftriaxone 2 gm IV q24h); Dori 500 mg IV q8h (1-hr infusion); Erta 1 gm IV q24h; IMP 0.5 gm IV q6h; MER 1-2 gm IV q8h; Azithro 500 mg IV q24h; Linezolid 600 mg IV/po q12h; Vanco 30-60 mg/kg/d in 2-3 div doses, target AUC24 400-600 pg/mL x h. Abbreviations on page 2. *NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  TABLE 1 (25) ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS* 1 ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES 1 MODIFYING CIRCUMSTANCES ; PRIMARY ALTERNATIVES AND COMMENTS GENITAL TRACT/Women (continued) Vaginitis (MMWR 704, 2021) Candidiasis Candida albicans 80-90%. Oral azoles: Fluconazole Butoconazole, Clotrimazole, Nystatin vag. t a b s t i m e s 14 days less effective. Other rx for azole-resistant Pruritus, t h i c k cheesy C. glabrata, C. tropicalis may 150 mg po x 1; Itraconazole Miconazole, Tioconazole or strains: gentian violet, boric acid. discharge, pH 1:800; blood cultures only occ. 6 weeks + Gent 3 mg/kg/day Doxy 100 mg IV/po bid x 6 w k s positive, or PCR of tissue from surgery (J Clin Micro 57:e00114, 2019). IV divided in 3 equal doses x I + RIF nil- oaa 300 mg IV/po bid x I B. n quintana t r a n s m i t t e d u,, by body lice among homeless. Doxy considered 2 wks, then continue doxy for 2 wks, t h e n continue doxy for safe regardless of age for rx £21 days (AAP Redbook 2018). a n additional 3 m o n t h s unless a n additional 3 m o n t h s unless valve resected, t h e n 6 wks valve resected, t h e n 6 w k s Infective endocarditis— "culture negative" Fever, valvular disease, and ECHO vegetations + emboli and neg. Etiology i n 348 cases studied by serology, culture, histopath, & molecular detection: C. burnetii 48%, Bartonella sp. 28%, and rarely (Abiotrophia cultures. elegans (nutritionally variant strep), Mycoplasma hominis, Legionella pneumophila, Tropheryma whipplei—together 1%), & rest without etiology identified (most on antibiotic). ___ _____ ____ Infective endocarditis— Prosthetic valve— empiric theraov (cultures pending) S. aureus now most common etiology (JAMA 297=13'54, 2007). Early ( < 2 mos post-op) S. epidermidis, S. aureus. Vanco 30-60 mg/kg/d i n 2-3 div doses, target AUC24 Early surgical consultation advised especially i f etiology is S. aureus, Rarely, Enterobacteriaceae, 400-600 pg/mL x h + Gent 1 mg/kg IV q8h + RIF 600 mg evidence of heart failure, presence of diabetes and/or renal failure, or diphtheroids, fu ngi_ _ _ _ po q 2 4 h concern for valve r i n g abscess. Early valve surgery not associated w i t h Late ( > 2 mos post-op) S. epidermidis, viridans strep, improved 1 year survival in patients w i t h S. aureus prosthetic valve enterococci, S. aureus infection (CID 60=741, 2015). A bbre via tions on page 2. -NO TE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  TABLE 1 (29) ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS- ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY I ALTERNATIVES AND COMMENTS HEART (continued) Infective endocarditis— Prosthetic Staph, epidermidis (Vanco 30-60 mg/kg/d in 2-3 div doses, target AUC24 I f S. epidermidis is susceptible to nafcil lin/oxacillin in vitro, then substitute valve—positive blood cultures 400-600 pg/mL x h + RIF 300 mg po q8h) x 6 wks + Gent nafcillin (or oxacillin) for vanco. Surgical consultation advised: 1 mg/kg IV q8h x 14 days. Some clinicians prefer to wait 2-3 days after starting vanco/ gent before Indications for surgery: severe starting RIF, to decrease bacterial density and thus minimize risk of heart failure, S. aureus infection, selecting rifampin-resistant subpopulations. prosthetic dehiscence, resistant Staph, aureus Methicillin sensitive: (Nafcillin/Oxacillin 2 gm IV q4h + RIF 3C)0 mg po q8h) x 6 wks + Gent 1 mg per kg IV q8h x 2 wks. organism, emboli due to large Methicillin resistant: (Vanco 30-60 mg/kg/d in 2-3 div doses, 'target AUC24 400-600 pg/mL x h + RIF 300 mg po q8h) x 6 wks + vegetat/b/? (See AHA guidelines; Gent 1 mg per kg IV q8h x 2 wks. Circulation 132:1435, 2015). Vi/idans strep, enterococd See infective endocarditis, native valve, culture positive, pagi? 30. Treat for 6 weeks. Enterobacteriaceae or [(Cefepime 2 gm IV q8h or MER 1 gm IV q8h) or (Pip-tazo In theory, could substitute CIP for aminoglycoside, but no clinical data and P. aeruginosa 4.5 gm IV q6h) + Tobra 1.5-2 mg/kg IV q8h] resistance is common. Select definitive regimen based on susceptibility |results. Candida, aspergillus Table 11, page 142 High mortality. Valve replacement plus antifungal therapy standard therapy but some success with antifungal therapy alone. Infective endocarditis—Q fever Coxiella burnetii Doxy 100 mg po bid + hydroxychloroquine 600 mg/day for at Dx: IFA > 800 phase I IgG plus evidence of endocarditis or vasculopathy Emerg Infect Dis 214183, 2015 least 18 mos (Mayo Clin Proc 83-574, 2008). or signs of chronic Q fever OR positive Coxiella burnetii PCR of blood or JCM 524637, 2014 Pregnancy: Need long term TMP-SMX (see CID 45548, 2007). tissue. Possible chronic Q fever = IFA > 800 phase I IgG. Treatment duration: 18 mos for native valve, 24 mos for prosthetic valve. Monitor serologicallyfor 5 yrs. 1 i 1 S. aureus (40%), MRSA/MRSE: Device removal MRSA/MRSE: Device removal Duration of rx after device removal:For "pocket" or subcutaneous 1 S. epidermidis (40%), + Vanco 30-60 mg/kg/d in + Dapto 8-10 mg per kg IV infection, 10-14 days; i f lead-assoc. endocarditis, 4-6 wks depending Gram-negative bacilli (5%), 2-3 div doses, target AUC24 q24h NAI on organism. Device removal and absence of valvular vegetation assoc, fungi (5%). 400-600 pg/mL x h. with significantly higher survival at 1 yr (JAMA 3074727, 2012). British MSSA/MSSE: Nafcillin/ guidelines: JAC 70325, 2015. Prophylaxis: Antibiotic eluting envelope Oxacillin 2 gm IV q4h OR (Tyrx) reduced infection of implantable devices (NEJM 3804895, 2019). Cefazolin 2 gm IV q8h Pericarditis, bacterial Staph, aureus, Strep, pneu [Vanco 30-60 mg/kg/d in Vanco + CIP 400 mg q12h Drainage required i f signs of tamponade. moniae, Group A strep, 2-3 div doses, target AUC24 (see footnote?) Adjust regimen based on results of organism ID and susceptibility. Enterobacteriaceae 400-600 pg/mL x h + Use Nafcillin, Oxacillin, or Cefazolin for confirmed MSSA infection. (Ceftriaxone 2 gm q24h OR Cefepime 2 gm IV q8h)] (Dosage, see footnote?) Rheumatic fever with carditis Post-infectious sequelae ASA, and usually prednisone 2 mg/kg po q24h for ICIinical features: Carditis, polyarthritis, chorea, subcutaneous nodules, Ref.: Ln 366455, 2005 of Group A strep infection symptomatic treatment of fever, arthritis, arthralgia. erythema marginatum. Prophylaxis: seepage 68. (usually pharyngitis) May not influence carditis. ASA dose: 80-100 mg/kg/day (pediatric), 4-8 gm/day (adult). Eradication of group A streptococcus also recommended: Child, Penicillin V, 250 mg po tid x 10 days; adult, Penicillin V 500 mg po tid x 10 days. 9 Aminoglycosides (see Table IOC, page 134), IMP 0.5 gm IV q6h, MER 1 gm IV q8h, Nafcillin or Oxacillin 2 gm IV q4h, Pip-Tazo 3.375 gm IV q6h or 4.5 gm q8h, Amp-sulb 3 gm IV q6h, P Ceph1 (cephalothin 2 gm IV q4h or cefazolin 2 gm IV q8h), CIP 750 mg po bid or 400 mg IV bid, Vanco 30-60 mg/kg/d in 2-3 div doses, target AUC24 400-600 pg/mL x h, RIF 600 mg po q24h, Aztreonam 2 gm IV q8h, Cefepime 2 gm IV q12h 33 Abbreviations on page 2. *N0TE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  34 TABLE 1 (30) ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS- ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY 1 ALTERNATIVES AND COMMENTS HEART (continued) Ventricular assist device-related S. aureus, S. epidermidis, After culture of blood, wounds, drive line, device pocket and Can s u b s t i t u t e Daptomycin 10 mg/kg/d NAI for Vanco, (CIP 400 mg I V q12h infection aerobic gm-neg bacilli, imaybe pump: Vanco 30-60 mg/kg/d i n 2-3 div doses, target or Levo 750 mg IV q24h) for cefepime, and (Vori, Caspo, Micafungin or 1 Manifest & mgmt: CID 57:1438, 2013 Candida sp AUC24 400-600 pg/mL x h + (Cefepime 2 g m IV ql 2h) + Anidulafungin) for Fluconazole. Modify regimen based o n results of culture Prevent & m g m t : CID 64: 222, 2017 Fluconazole 800 m g I V q24h. and susceptibility tests. Higher t h a n FDA-approved Dapto dose because of potential emergence of resistance. JOINT—A Iso see Lyme Disease, page 65 Reactive arthritis Reiter's syndrome Occurs wks after infection Only treatment i s non-steroidal anti-inflammatory drugs Definition: Urethritis, conjunctivitis, a r t h r i t i s , and sometimes uveitis (See Comment for definition) w i t h C. trachomatis, land rash. Arthritis: asymmetrical oligoarthritis of ankles, knees, feet, iCampylobacter Jejuni, sacroiliitis. Rash: palms and soles-keratoderma blennorrhagica; circinate Yersinia enterocolitica, balanitis of glans penis. HLA-B27 positive predisposes to Reiter's. Shigejla/Sahponella sp.__ I ______________________ _______ _______ _______ ______ ______ Poststreptococcal reactive I m m u n e reaction after strep Treat strep pharyngitis and then NSAIDs (prednisone |A reactive a r t h r i t i s after a p-hemolytic strep infection i n absence of arthritis pharyngitis: (1) a r t h r i t i s onset needed in some pts) sufficient Jones criteria for acute rheumatic fever. Ref.; Pediatr Emerg (See Rheumatic fever, above) i n 6 mos. of age) 8 mg/kg/day (TMP component) div bid. 41 Abbreviations on page 2. "NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  42 TABLE 1 (38) ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS" ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY | ALTERNATIVES AND COMMENTS 1 1 ,12 z 3 Z co o Is S«K61 way 6* Acute bacterial exacerbation Role of antimicrobial therapy is debated even for severe disesise. For mild or moderate disease, no antimicrobial treatment or maybe of chronic bronchitis (ABECB), Amox, Doxy, TMP-SMX, or 0 Ceph. adults (almost always smokers For severe disease: with COPD) Amox-clav 875/125 mg po bid Ref; NEJM 359=2355, 2008. Azithro 500 mg po x 1 dose, then 250 mg q24h x 4 days or 500 mg po q24h x 3 days Severe ABECB = T dyspnea, Clarithro extended release 1000 mg po q24h T sputum viscosity/purulence, Levo 750 mg po q24h or Moxi 400 mg po q24h T sputum volume. For severe Hospitalized patients, severe disease: ABECB: (1) consider chest x-ray, High risk for pseudomonas (confirm w i t h culture): esp. i f febrile &/or low 02 sat.; Levo 750 mg IV/po q24h (2) inhaled anticholinergic Cefepime 2 gm q8h bronchodilator; (3) oral Pip-tazo 4.5 IV q6h corticosteroid for just 5 days Low risk for pseudomonas: (JAMA 309:2223, 2013); (4) D/C Levo 750 mg IV/po q24h or Moxi 400 mg IV/po q24h tobacco use; (5) non-invasive Ceftriaxone 2 gm q24h positive pressure ventilation, Drugs & doses in footnote. Guidelines suggest duration of 5 days (Ann intern Med 174=822, 2021) I- I iiS i i iii if Bronchiectasis Gemi, Levo, or Moxi x 7-10 days. Dosage in footnote’ 10. Many potential etiologies: obstruction, 1 immune globulins, cystic fibrosis, Thorax 65 (Suppl 1): H, 2010; dyskinetic cilia, tobacco, prior severe or recurrent necrotizing bronchitis: Am J Respir Crit Care Med e.g., pertussis. 188=647, 2013.. _________ i 'I Prevention of exacerbation Two randomized trials of Erythro 250 mg bid (JAMA Caveats: higher rates of macrolide resistance in oropharyngeal flora; 309=1260, 2013) or Azithro 250 mg qd (JAMA 309=1251, potential for increased risk of a) cardiovascular deaths from macrolide- 2013) x 1 year showed significant reduction in the rate of induced QTc prolongation, b) liver toxicity, or c) hearing loss (see JAMA acute exacerbations, better preservation of lung function, 309=1295, 2013). and better quality of life versus placebo in adults with Pre-treatment screening: baseline liver function tests, electrocardiogram; non-cystic fibrosis bronchiectasis. assess hearing; sputum culture to exclude mycobacterial disease. is I ® W Specific organisms Pneumonia: Neonatal: Birth to 1 month Viruses: CMV, rubella, AMP + Gent ± Cefotaxime. Add Vanco i f MRSA Blood cultures indicated. Consider C. trachomatis if afebrile pneumonia, H. simplex a concern. For chlamydia therapy, Erythro 12.5 mg per kg po staccato cough, IgM >1=8; therapy with erythro or sulfisoxazole. Bacteria: Group B strep, or IV qid times 14 days. If MRSA documented, Vanco, Clinda, & Linezolid alternatives. Linezolid listeria, coliforms, S. aureus, dosage from birth to age 11 yrs is 10 mg per kg q8h. P. aeruginosa Other: Chlamydia trachomatis, syphilis Abbreviations on page 2. -NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume norma! renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  TABLE 1 (39) ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES i SUGGESTED REGIMENS* _____ J ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES 1 (jensn) j MODIFYING CIRCUMSTANCES PRIMARY i ALTERNATIVE? ! AND COMMENTS LUNG/Bronchi/Pneumonia (continued) Age 1-3 months Pneumonitis syndrome. C. trachomatis, RSV, Outpatient: po Inpatient: Pneumonitis syndrome: Cough, tachypnea, dyspnea, d i f f u s e infiltrates, Usually afebrile parainfluenza virus 3, Amox 90-100 mg/kg/d If afebrile: Erythro 10 mg/ afebrile. Usually requires hospital care. Reports of hypertrophic pyloric human metapneumovirus, x 10-14 days OR Azithro kg I V q6h or Azithro stenosis after e r y t h r o under age 6 wks; not sure about azithro; bid azithro Bordetella, S. pneumoniae, 10 mg/kg x 1 dose t h e n 2.5 mg/kg IV q12h dosing theoretically m i g h t I risk of hypertrophic pyloric stenosis. I f lobar S. aureus (rare) 5 mg/kg once daily x 4 days (see Comment). pneumonia, give A M P 2 0 0 - 3 0 0 mg per kg per day for S. pneumoniae. If febrile: Cefotaxime N o empiric coverage for S. aureus, as it i s rare etiology. 200 mg/kg per day div q8h OR Ceftriaxone......................... ] _ 75-100_mg/kg q24h_ _ ___ _____ _______________ ________ _ _ _ _ ____________1 __________fPf.RSVzSee ~Bronch_ioljtis, page 47. ___ Infants and Children, age >3 months to 18 yrs (IDS A treatment Guidelines: ciD~5~3=61~7, 2011). Outpatient RSV, human metapneu lAmox 90 mg/kg i n 2 divided Azithro 10 mg/kg x 1 dose Antimicrobial therapy may not be necessary for preschool-aged children movirus, rhinovirus, influenza doses x 5 days (max 500 mg), t h e n 5 mg/kg w i t h CAP as most infections are viral etiologies. 2011 Guidelines virus, adenovirus, parain ( m a x 2 5 0 mg) x 4 days OR recommend 10-14 days but shorter duration (5-7 days) equally effective fluenza virus, Mycoplasma, Amox-clav 90 mg/kg ( A m o x i n adults. H. influenzae, S. pneumoniae, comp) i n 2 divided doses x S- aureus_(rare)___ Inpatient (3 mos - 18 yrs) As above (Fully immunized: AMP Fully immunized: Cefotaxime Tlf i i atypical dt.ypu.cn infection 1111 i i ui i isuspected, u s p e t - i e u , add Azithro 10 ouu miuiiv i u mg/kg my/Ky x x 1i u dose use 50 mg/kg I V q6h 150 mg/kg IV divided q 8 h (max 500 mg), t h e n 5 mg/kg (max 250 mg) x 4 days. Not f u l l y immunized: I f community MRSA suspected, add Vanco 3 0 - 6 0 mg/kg/d in 2-3 div doses, Cefotaxime 150 mg/kg I V target AUC 24 400-600 pg/mL x h OR Clinda 40 mg/kg/day divided q6-8h x divided q8h or Ceftriaxone 10-14d; may switch to oral agents as early as 2-3 days if good clinical response. 75-100 mg/kg/day ________ Adults (over age 18) — IDSA/ATS Guideline for CAP i n adults: Am J Crit Care Med 2019, 200:e45. Community-acquired, empiric S. pneumo, atypicals and No co-morbidity: Amox 1 gm No co-morbidity: if local Levo substitutes: Moxi 400 mg po q24h or Gemi 3 2 0 mg po q24h therapy for outpatient mycoplasma in particular, po t i d OR Doxy 100 mg po bid rates of macrolide resistant Amox-clav substitutes: Cefpodoxime 200 mg po bid or Cefuroxime 500 mg CAP p a t i e n t s w i t h Pneumonia Hemophilus, Moraxella, viral Co-morbidity present: S. pneumo < 25%: Azithro po bid. Treat for 5-7 days Severity Index (PSI) bacteria of r i s k factors (e.g., prior isolation of t h e pathogen or hospitalization AND (NEJM 373=415, 2015) Levo 750 m g IV/po q24h Moxi 400 mg IV/po q24h treatment w i t h parenteral antibiotics w i t h i n prior 90 days; additional risk (not recommended as factors for MRSA include IVDU and influenza-associated CAP. i f empirical monotherapy for severe CAP) For severe CAP beta-lactam coverage is used obtain cultures/nasal PCR to allow de-escalation (cultures respiratory fluoroquinolone negative) o r confirmation for need of continued therapy (cultures positive). For severe CAP use beta- lactam + macrolide Treat for 5-7 days (NEJM 370=543, 2014 and A m J Respir Crit Care Med 200:e45-e67, 2019). Safe to discontinue antibiotics w i t h normalization of procalcitqninto 0.V0.2 mcg/mL. _ _ ______ _______________ ___________ Hospital-acquired or Ventilator- A s above + M D R Cefepime 2 g m I V q12h OR MER 1 g m IV q 8 h OR Add Vanco or Linezolid if it u n i t or hospital hospital MRSA prevalence >iu-2O%, >10-20%, prior associated pneumonia Gram-negatives. In 39 of 174 Pip tazo 4.5 g m q6h ________ 750jmg JV/po q24h _____IV antibiotic use w i t h i n 90 days, acute renal replacement therapy prior to 1DSA guidelines: pts w i t h non-ventilator HAP, Note: no supportive evidence for use of nebulized/inhaled VAP onset, septic shock o r high risk of mortality, ARDS preceding VAP, CID 63:e61, 2016 respiratory virus detected antibiotics (CCM 47: 890 & e470, 2019); Lancet ID unknown M R S A prevalence or presence of MRSA risk factors (e.g., IVDU, (Resp Med 2017,12276) 20=330, 2020. prior MRSA infection or colonization). Suscept, testing may identify other active agents, e.g., For suspected pseudomonas or high risk of mortality add CIP 400 mg IV Ceftaz-avibactam, MER-vabor, Ceftaz-avibactam, q 8 h or Levo 750 m g I V q24h or Tobra 5 mg/kg I V q24h or AMK 15 mg/kg MER-vabor, Cefiderocol. Duration: 8 days treatment as I V q24h. effective as 15 days (PLoS 7:e41290, 2012) Aztreonam 2 gm I V q8h can substitute for other beta-lactams i f there i s beta-lactam hypersensitivity, b u t lacks coverage for S. aureus. Colistin i f carbapenem-resistant Gram-negative i s suspected. ___________ Pneumonia —Selected specific therapy after culture results (sputum, blood, pleural fluid, etc.) available. Also see Table 2, page 76 Acinetobacter baumannii Patients w i t h VAP; long ICU Empiric rx: positive culture, Specific rx: culture & suscept Cefiderocol non-inferior to meropenem in RCT of HAP/VAP/HCAP; for (See also Table 5E); stay w i t h repeated antibiotic no i n v i t r o suscept results, results known, susceptible 16 patients w i t h Acinetobacter spp w i t h meropenem MICs > 64 pg/mL, CID 2018;67=1455; exposure prevalence of resistance < 20%: organism: Cefepime, day 14 all-cause mortality 0% (none of five) i n t h e cefiderocol group and A AC 2017;61:e01268-16 Cefepime, Ceftazidime, Ceftazidime, Amp-sulb or FQ. 46% ( f i v e of 11) i n t h e meropenem group (Lancet infect Dis 2021;21=213). Amp-sulb (Doses in For carbapenem-resistant In an open-label RCT (Lancet infect Dis 2021; 21=226) comparing best footnote"). strain: Cefiderocol 2 gm IV, 3h available therapy (BAT) to Cefiderocol in patients w i t h nosocomial infusion, q 8 h pneumonia, sepsis, cUTI, o r bacteremia due to carbapenemase producing bacteria, 2 8 day all cause m o r t a l i t y was numerically higher i n t h e cefiderocol patients: 4/22 (18%) for BAT vs 14/45 (31%) for Cefiderocol i n t h e pneumonia subgroup, not a statistically significant difference. I n a double-blind RCT (Lancet Infect Dis 2021;21=213) Cefiderocol was non inferior to Meropenem for Gram-negative HAP/VAP/HCAP; i n 16 patients w i t h Acinetobacter spp. w i t h Meropenem MICs > 64 pg/mL, day 14 all-cause mortality was 0% (0/5) i n t h e Cefiderocol group and 46% (5/11) J n_the M.e _r PP?D?01 9 (ou p. _ 11 Doses of antibiotics used to treat pneumonia due to Adnetobacter sp., Klebs iel ia sp. and Pseudomonas sp. Penicillins: Pip-Tazo loading dose 4.5 gm over 30 min, then, 4 hrs later, s t a r t 3.375 g m IV over 4 hrs & repeat q8h; Amp-sulb 3 g m IV q6h. Cephalosporins: Ceftazidime 2 g m IV q8h; Ceftaz-avi 2.5 g m I V q8h; Ceftolo-tazo 3 gm IV q8h. Aztreonam 2 gm IV q8h. FQs: CIP 400 m g I V q 8 h (septic shock: m a y need 600 mg q8h); Levo 7 5 0 mg IV q24h. Carbapenems: MER 1-2 g m I V q8h; MER-vabor 4 g m IV over 3 hrs q8h; IMP 0.5-1 g m q8h. Aminoglycosides: Gent/Tobra 7 mg/kg IV x 1, then 5 mg/kg IV q8h. Polymyxin B 2.5 mg/kg I V over 2 hrs, t h e n 12 hrs later, 1.5 mg/kg over 1 h r & repeat q12h. Minocycline 200 m g IV x 1, t h e n 100 mg I V q12h Abbreviations on page 2. '-NOTE: AH dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. § Alternatives consider allergy, PK, compliance, local resistance, cost.  ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES ______________SUGGESTED REGIMENS- ______________ ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES MODIFYING CIRCUMSTANCES (usual) PRIMARY~~ f ALTERNATIVE® AND COMMENTS LUNG/Bronchi/Pneumonia/Selected specific therapy after culture results (sputum, blood, pleural fluid, etc.) available, (continued) _________ _ _________________________ _________ _ Actinomycosis A. Israelii and rarely others AMP 200 mg/kg/day in 3-4 Doxy or Ceftriaxone OR |Can use Pen G instead of AMP: 10-20 million units/day IV x 4-6 wks, then divided doses x 4-6 wks then Clinda IV x 4-6 wks, then po Pen VK po 6-12 mo. Pen VK 2-4 gm/day in 4 x 6-12 mo divided doses x_6-12_mo_ Anthrax Bacillus anthracis Adults (including pregnancy):[Children: CIP 10"mg/kg IV q8h fl. Meropenem i f meningitis cannot be excluded; Linezolid preferred over Inhalation To report possible CIP 400 mg IV q8h + (max 400 mg per dose) + Clinda for meningitis. (applies to oropharyngeal bioterrorism event: (Linezolid 600 mg IV q12h or [Linezolid10 mg/kg IV q8h 2. Pen G 4 million units IV (adults) or 67,000 units/kg (children, max & gastrointestinal forms): 770-488-7100 Clinda 900 mg IV q8h) + (age 12 yr) for pen-susceptible strain. (Cutaneous: See page 56) Plague, tularemia: comments) + raxibacumab (max 600 mg per dose)] + 3. For children 100 cell/pL w i t h NEJM 385:1786, 2021. yeast. Use intraperitoneal dos ng, unless bacteremia (rare), perforation and need for catheter removal.