Antibiotic Guidelines
2015-2016
Treatment Recommendations
For Adult Inpatients
Also available online at
insidehopkinsmedicine.0rg/amp
Table of contents
1. Introduction ............................................................................................ 3
2. Johns Hopkins Hospital formulary and restriction status .................... 6
2.1 Obtaining ID approval ........................................................................6
2.2 Formulary .........................................................................................7
3. Agent-specific guidelines ...................................................................... 8
3.1 Antibiotics ........................................................................................8
Ceftaroline ......................................................................................8
Ceftolozane/tazobactam .................................................................8
Colistin ...........................................................................................9
Daptomycin ................................................................................. 10
Ertapenem................................................................................... 11
Fosfomycin .................................................................................. 11
Linezolid ...................................................................................... 12
Tigecycline .................................................................................. 13
Trimethoprim/sulfamethoxazole ................................................... 14
3.2 Antifungals..................................................................................... 16
AmBisome® ................................................................................ 16
Micafungin ................................................................................... 17
Posaconazole .............................................................................. 18
Voriconazole ................................................................................ 19
Azole drug interactions................................................................. 20
3.3 Vaccines ....................................................................................... 23
Pneumococcal vaccines ............................................................... 23
4. Organism-specific guidelines .............................................................. 24
4.1 Anaerobes..................................................................................... 24
4.2 Propionibacterium acnes................................................................ 25
4.3 Streptococci.................................................................................. 27
4.4 Multi-drug resistant Gram-negative rods .......................................... 28
5. Microbiology information .................................................................... 31
5.1 Interpreting the microbiology report................................................ 31
5.2 Spectrum of antibiotic activity......................................................... 32
5.3 Interpretation of rapid diagnostic tests ............................................ 34
5.4 Johns Hopkins Hospital antibiogram ............................................... 36
6. Guidelines for the treatment of various infections...........................39
6.1 Abdominal infections .............................................................39
Biliary tract infections ................................................................... 39
Diverticulitis ................................................................................. 40
Pancreatitis ................................................................................. 41
Peritonitis (including SBP, GI perforation and peritonitis
related to peritoneal dialysis) ........................................................ 42
6.2 Clostridium difficile infection (CDI) ............................................ 47
6.3 Infectious diarrhea ..................................................................... 51
6.4 H. pylori infection ....................................................................... 54
6.5 Gynecologic and sexually transmitted infections ..................... 56
Pelvic inflamatory disease ............................................................ 56
Endomyometritis .......................................................................... 56
Bacterial vaginosis ....................................................................... 57
Trichomoniasis ............................................................................ 57
Uncomplicated gonococcal urethritis, cervicitis, proctitis ............... 57
Syphilis........................................................................................ 58
6.6 Catheter-related bloodstream infections .................................. 60
(continued on next page)
1
Table of contents
6.7 Endocarditis ................................................................................ 65
6.8 Pacemaker/ICD infections......................................................... 71
6.9 Central nervous system (CNS) infections ................................. 73
Meningitis .................................................................................... 73
Encephalitis ................................................................................. 75
Brain abscess .............................................................................. 76
CNS shunt infection...................................................................... 76
Antimicrobial doses for CNS infections.......................................... 77
6.10 Acute bacterial rhinosinusitis (ABRS) .....................................78
6.11 Orbital cellulitis .....................................................................80
6.12 Pulmonary infections.................................................................. 82
COPD exacerbations .................................................................... 82
Community-acquired pneumonia ................................................... 83
Healthcare-acquired pneumonia. ................................................... 87
Ventilator-associated pneumonia ................................................... 88
Cystic fibrosis .............................................................................. 91
6.13 Respiratory virus diagnosis and management ......................... 93
6.14 Tuberculosis (TB) ........................................................................ 95
6.15 Sepsis with no clear source ....................................................... 99
6.16 Skin, soft-tissue, and bone infections......................................100
Cellulitis ..................................................................................... 100
Cutaneous abscess.................................................................... 101
Management of recurrent MRSA infections .................................. 102
Diabetic foot infections ............................................................... 103
Surgical-site infections................................................................ 105
Serious, deep soft-tissue infections (necrotizing fasciitis).............. 107
Vertebral osteomyelitis, diskitis, epidural abscess ....................... 108
6.17 Urinary tract infections (UTI)....................................................110
Bacterial UTI (including pyelonephritis and urosepsis) ................... 110
6.18 Candidiasis in the non-neutropenic patient ............................115
6.19 Guidelines for the use of prophylactic antimicrobials .................121
Pre-operative and pre-procedure antibiotic prophylaxis................. 121
Prophylaxis against bacterial endocarditis .................................. 125
Prophylactic antimicrobials for patients with
solid organ transplants ............................................................... 126
6.20 Guidelines for the use of antimicrobials in
neutropenic hosts. ....................................................................129
Treatment of neutropenic fever................................................... 129
Prophylactic antimicrobials for patients with
expected prolonged neutropenia ................................................ 131
Use of antifungal agents in hematologic
malignancy patients ............................................................. 133
7. Informational guidelines .................................................................137
7.1 Approach to the patient with a history of penicillin allergy ................ 137
8. Infection control ..............................................................................139
8.1 Hospital Epidemiology & Infection Control .................................... 139
8.2 Infection control precautions ....................................................... 141
8.3 Disease-specific infection control recommendations ..................... 142
10. Appendix:
A. Aminoglycoside dosing and therapeutic monitoring ........................ 145
B. Vancomycin dosing and therapeutic monitoring.............................. 150
C. Antimicrobial therapy monitoring ................................................... 153
D. Oral antimicrobial use ................................................................... 154
E. Antimicrobial dosing in renal insufficiency ....................................... 155
F. Cost of select antimicrobial agents ................................................ 159
2
1. Introduction
Introduction
Antibiotic resistance is now a major issue confronting healthcare
providers and their patients. Changing antibiotic resistance patterns,
rising antibiotic costs and the introduction of new antibiotics have
made selecting optimal antibiotic regimens more difficult now than
ever before. Furthermore, history has taught us that if we do not
use antibiotics carefully, they will lose their efficacy. As a response
to these challenges, the Johns Hopkins Antimicrobial Stewardship
Program was created in July 2001. Headed by an Infectious Disease
physician (Sara Cosgrove, M.D., M.S.) and an Infectious Disease
pharmacist (Edina Avdic, Pharm.D., M.B.A), the mission of the
program is to ensure that every patient at Hopkins on antibiotics
gets optimal therapy. These guidelines are a step in that direction.
The guidelines were initially developed by Arjun Srinivasan, M.D., and
Alpa Patel, Pharm.D., in 2002 and have been revised and expanded
annually.
These guidelines are based on current literature reviews, including
national guidelines and consensus statements, current microbiologic
data from the Hopkins lab, and Hopkins’ faculty expert opinion.
Faculty from various departments have reviewed and approved these
guidelines. As you will see, in addition to antibiotic recommendations,
the guidelines also contain information about diagnosis and other
useful management tips.
As the name implies, these are only guidelines, and we anticipate
that occasionally, departures from them will be necessary. When these
cases arise, we will be interested in knowing why the departure is
necessary. We want to learn about new approaches and new data as
they become available so that we may update the guidelines as needed.
You should also document the reasons for the departure in the patient’s
chart.
Sara E. Cosgrove, M.D., M.S.
Director, Antimicrobial Stewardship Program
Edina Avdic, Pharm.D., M.B.A
ID Pharmacist
Associate Director, Antimicrobial Stewardship Program
Kate Dzintars, Pharm.D.
ID Pharmacist
Janessa Smith, Pharm.D.
ID Pharmacist
3
1. Introduction
The following people served as section/topic reviewers
N. Franklin Adkinson, M.D. (Allergy/Immunology)
Paul Auwaerter, M.D. (Infectious Diseases)
Robin Avery, M.D. (Infectious Diseases)
John Bartlett, M.D. (Infectious Diseases)
Dina Benani, Pharm. D. (Pharmacy)
Michael Boyle, M.D. (Pulmonary)
Roy Brower, M.D. (Critical Care and Pulmonary)
Karen Carroll, M.D. (Pathology/Infectious Diseases)
Michael Choi, M.D. (Nephrology)
John Clarke, M.D. (Gastroenterology)
Todd Dorman, M.D. (Critical Care)
Christine Durand, M.D. (Infectious Diseases)
Khalil Ghanem, M.D. (Infectious Diseases)
James Hamilton, M.D. (Gastroenterology)
Carolyn Kramer, M.D. (Medicine)
Pam Lipsett, M.D. (Surgery and Critical Care)
Colin Massey, M.D. (Medicine)
Lisa Maragakis, M.D. (Infectious Diseases)
Kieren Marr, M.D. (Infectious Diseases)
Robin McKenzie, M.D. (Infectious Diseases)
Michael Melia, M.D. (Infectious Diseases)
George Nelson, M.D. (Infectious Diseases)
Eric Nuermberger, M.D. (Infectious Diseases)
Trish Perl, M.D., M.Sc. (Infectious Diseases)
Stuart Ray, M.D. (Infectious Diseases)
Anne Rompalo, M.D. (Infectious Diseases)
Annette Rowden, Pharm.D. (Pharmacy)
Paul Scheel, M.D. (Nephrology)
Cynthia Sears, M.D. (Infectious Diseases)
Maunank Shah, M.D. (Infectious Diseases)
Tiffeny Smith, Pharm.D. (Pharmacy)
Jennifer Townsend, M.D. (Infectious Diseases)
Robert Wise, M.D. (Pulmonary)
Frank Witter, M.D. (OB-GYN)
How to use this guide
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dose of antibiotics for the particular infection.
UÊALL DOSES IN THE TEXT ARE FOR ADULTS WITH NORMAL
RENAL AND HEPATIC FUNCTION.
UÊÊvÊޜÕÀÊ«>̈i˜ÌÊ`œiÃÊ "/Ê >ÛiʘœÀ“>ÊÀi˜>ÊœÀÊ i«>̈VÊv՘V̈œ˜]Ê
please refer to the sections on antibiotic dosing to determine the
correct dose.
UÊʜœÜˆ˜}ÊÌ iÊ>˜ÌˆLˆœÌˆVÊÀiVœ““i˜`>̈œ˜Ã]ÊÜiÊ >ÛiÊÌÀˆi`Ê̜ʈ˜VÕ`iÊ
some important treatment notes that explain a bit about WHY the
particular antibiotics were chosen and that provide some important
tips on diagnosis and management. PLEASE glance at these notes
4
Contacting us
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they are part of an approved order.
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A word from our lawyers
The recommendations given in this guide are meant to serve as
treatment guidelines. They should NOT supplant clinical judgment or
Infectious Diseases consultation when indicated. The recommendations
were developed for use at The Johns Hopkins Hospital and thus may
not be appropriate for other settings. We have attempted to verify
that all information is correct but because of ongoing research, things
may change. If there is any doubt, please verify the information in the
}Ո`iÊLÞÊV>ˆ˜}ÊÌ iÊ>˜ÌˆLˆœÌˆVÃÊ«>}iÀÊÕȘ}Ê* Ê­Ãi>ÀV ʺ>˜ÌˆLˆœÌˆV»®ÊœÀÊ
Infectious Diseases.
Also, please note that these guidelines contain cost information
that is confidential. Copies of the book should not be distributed
outside of the institution without permission.
5
1. Introduction
when you are treating infections, as we think the information will prove
helpful. All references are on file in the office of the Antimicrobial
Stewardship Program (7-4570).
2.1 Obtaining ID approval
Obtaining ID approval
The use of restricted and non-formulary antimicrobials requires preapproval from Infectious Diseases. This approval can be obtained by any
of the following methods.
Approval method
* \ʺ>˜ÌˆLˆœÌˆV»Ê
Overnight Approval
Ê
Ordersets (e.g. neutropenic
fever, etc.)
6
Notes
Ê/ iÊ«>}iÀʈÃÊ>˜ÃÜiÀi`ÊLiÌÜii˜ÊnÊ>°“°Ê
and 10 p.m. PING the ID consult pager
if you fail to get a response from the ID
approval pager within 10 minutes.
Restricted antibiotics ordered between
10 p.m. and 8 a.m. must be approved
by noon the following morning.
UÊÊ*i>ÃiÊÀi“i“LiÀÊ̜ÊÈ}˜ÊœÕÌÊÌ iʘii`Ê
for approval if you go off shift before
8 a.m.
These forms are P&T-approved for
specific agents and specific indications.
The following list applies to ALL adult floors and includes the status of
both oral and injectable dosage forms, unless otherwise noted.
Unrestricted
Amoxicillin
Amoxicillin/clavulanate
Ampicillin/sulbactam
(Unasyn®)
Ampicillin IV
Azithromycin
Cefazolin
Cefdinir
Cefotetan
Cefpodoxime
Ceftriaxone
Cefuroxime IV
Cephalexin
Clarithromycin
Clindamycin
Dicloxacillin
Doxycycline
Ertapenem
Erythromycin
Gentamicin
Metronidazole
Minocycline
Nitrofurantoin
Oxacillin
Penicillin V/G
Ribavirin oral
Rifampin
Streptomycin
Tobramycin
Trimethoprim/
sulfamethoxazole
Amphotericin B
deoxycholate
(Fungizone®)
Flucytosine
Itraconazole oral solution
Restricted (requires ID
approval)
Amikacin
Aztreonam
Cefepime
Ceftaroline1
Ceftazidime
Ceftolozane/tazobactam1
Ciprofloxacin
Colistin IV
Cytomegalovirus Immune
Globulin (Cytogam®)2
Daptomycin1
Fosfomycin3
Linezolid
Meropenem
Moxifloxacin
Nitazoxanide4
Palivizumab (Synagis®)5
Piperacillin/tazobactam
­<œÃޘ®)
Quinupristin/
dalfopristin (Synercid®)
Ribavirin inhaled5
Telavancin1
Tigecycline
Vancomycin
Liposomal amphotericin B
(AmBisome®)
Micafungin
Fluconazole6
Posaconazole
Voriconazole
1Approval must be obtained from Antimicrobial Stewardship Program 24h/7 days a week
2Approval required, except for solid organ transplant patients
3Approval must be obtained 24h/7 days a week
4Approval must be obtained from Polk Service or ID Consult
5Approval must be obtained from ID attending physician 24h/7 days a week
6Oral Fluconazole, when used as a single-dose treatment for vulvovaginal candidiasis or when
used in compliance with the SICU/WICU protocol, does not require ID approval
Restricted antimicrobials that are ordered as part of a P&T-approved critical pathway or order
set do NOT require ID approval.
REMINDER: the use of non-formulary antimicrobials is strongly discouraged. ID
approval MUST be obtained for ALL non-formulary antimicrobials.
NOTE: Formulary antivirals (e.g. Acyclovir, Ganciclovir) do NOT require ID approval.
7
2.2 Antimicrobial formulary and restriction status
Selected formulary antimicrobials
and restriction status
3.1 Agent-specific guidelines: Antibiotics
Antibiotics
Ceftaroline
Ceftaroline is a cephalosporin with in vitro activity against staphylococci
(including MRSA), most streptococci, and many Gram-negative bacteria.
It does NOT have activity against Pseudomonas spp. or Acinetobacter
spp. or Gram negative anaerobes.
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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Gram negative coverage is also needed
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Unacceptable uses
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and soft tissue infections (SSTI) where other more established and
less expensive options are available
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Dose
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serious infections
UÊMust adjust for worsening renal function and dialysis (see p. 155 for
dose adjustment recommendation).
Laboratory interactions
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hemolytic anemia. However, if drug-induced hemolytic anemia is
suspected, discontinue Ceftaroline.
Ceftolozane/tazobactam
Ceftolozane/tazobactam is a novel cephalosporin and β-lactamaseinhibitor combination. It has activity against Gram-negative organisms
and some strains of multi-resistant Pseudomonas spp. It does NOT have
activity against carbapenemase-producing Enterobacteriaceae. It also
has in vitro activity against some streptococci and some Gram-negative
anaerobes, but it does not have reliable Staphylococcus spp. activity.
8
Unacceptable uses
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or complicated urinary tract infections (cUTI) as current standard
regimens are sufficient for coverage of the typical pathogens involved
in these infections and less expensive options are available
Dose
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metronidazole for cIAI
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for dose adjustment recommendation).
Colistin (Colistimethate)
Colistin is a polymixin antibiotic. It has in vitro activity against
Acinetobacter spp. and Pseudomonas spp. but does NOT have activity
against Proteus, Serratia, Providentia, Burkholderia, Stenotrophomonas,
Gram-negative cocci, Gram-positive organisms, or anaerobes.
Acceptable uses
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and Pseudomonas on a case by case basis.
Unacceptable uses
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Dose
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renal function and dialysis (see p. 155 for dose adjustment
recommendation).
Toxicity
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9
3.1 Agent-specific guidelines: Antibiotics
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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spp. infections on a case by case basis
3.1 Agent-specific guidelines: Antibiotics
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Daptomycin
Daptomycin is a lipopeptide antibiotic. It has activity against most strains
of staphylococci and streptococci (including MRSA and VRE). It does
NOT have activity against Gram-negative organisms.
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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coagulase-negative staphylococci in a patient with serious allergy to
Vancomycin
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UÊÊ ˆ˜ˆV>Ê`iVœ“«i˜Ã>̈œ˜Ê>vÌiÀÊÎq{Ê`>ÞÃ
UÊÊ>ˆÕÀiÊ̜ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ>vÌiÀÊÇÊ`>ÞÃÊ`iëˆÌiÊ6>˜Vœ“ÞVˆ˜Ê
ÌÀœÕ} ÃʜvÊ£xqÓäʓV}ɓʭ ˆ} ÊÀˆÃŽÊœvÊ >«Ìœ“ÞVˆ˜ÊÀiÈÃÌ>˜ViÆÊ
check Daptomycin MIC and obtain follow up blood cultures)
UÊÊ ÊœvÊ6>˜Vœ“ÞVˆ˜ÊˆÃÊÓʓV}ɓ
UÊÊ/ iÀ>«ÞÊvœÀÊ6, ʈ˜viV̈œ˜ÃÊœÌ iÀÊÌ >˜Ê«˜iՓœ˜ˆ>]ʜ˜Ê>ÊV>ÃiÊLÞÊV>ÃiÊL>ÈÃ
Unacceptable uses
UÊÊ >«Ìœ“ÞVˆ˜Êà œÕ`Ê "/ÊLiÊÕÃi`ÊvœÀÊÌÀi>̓i˜ÌʜvÊ«˜iՓœ˜ˆ>Ê`ÕiÊ̜Ê
its inactivation by pulmonary surfactant.
UÊʘˆÌˆ>ÊÌ iÀ>«ÞÊvœÀÊÀ>“‡«œÃˆÌˆÛiʈ˜viV̈œ˜ÃÊ
UÊÊ6, ÊVœœ˜ˆâ>̈œ˜ÊœvÊÌ iÊÕÀˆ˜i]ÊÀiëˆÀ>̜ÀÞÊÌÀ>VÌ]Êܜ՘`Ã]ʜÀÊ`À>ˆ˜ÃÊ
Dose
UÊÊ >VÌiÀi“ˆ>\ÊÈq£Óʓ}Ɏ}Ê6Ê+ÊÓ{
UÊÊ ˜`œV>À`ˆÌˆÃ\ÊÈq£Óʓ}Ɏ}Ê6Ê+ÊÓ{
UÊÊ œÃiÊ>`ÕÃ̓i˜ÌʈÃʘiViÃÃ>ÀÞÊvœÀÊ À Ê 30 ml/min (see p. 155 for
dose adjustment recommendation).
10
,iviÀi˜Vi\Ê
Daptomycin in S. aureusÊL>VÌiÀi“ˆ>Ê>˜`ʈ˜viV̈ÛiÊi˜`œV>À`ˆÌˆÃ\Ê Ê ˜}ÊÊi`ÊÓääÈÆÊ
Îxx\ÊÈxÎqÈx°
Ertapenem
Ertapenem is a carbapenem antibiotic. It has in vitro activity against
many Gram-negative organisms including those that produce extended
spectrum beta-lactamases (ESBL), but it does not have activity against
Pseudomonas spp. or Acinetobacter spp. Its anaerobic and Grampositive activity is similar to that of other carbapenems, except it does
not have activity against Enteroccocus spp.
Acceptable uses
UÊʈ`Ê̜ʓœ`iÀ>Ìiʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜ÃÊ­Lˆˆ>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ã]Ê
diverticulitis, secondary peritonitis/GI perforation)
UÊʜ`iÀ>ÌiÊ`ˆ>LïVÊvœœÌʈ˜viV̈œ˜ÃÊÜˆÌ œÕÌʜÃÌiœ“ÞiˆÌˆÃ
UÊʜ`iÀ>ÌiÊÃÕÀ}ˆV>‡ÃˆÌiʈ˜viV̈œ˜ÃÊvœœÜˆ˜}ÊVœ˜Ì>“ˆ˜>Ìi`Ê«ÀœVi`ÕÀi
UÊ*iÛˆVʈ˜y>““>̜ÀÞÊ`ˆÃi>Ãi
UÊÊ1Àˆ˜>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜ÃÊV>ÕÃi`ÊLÞÊ - ‡«Àœ`ÕVˆ˜}ʜÀ}>˜ˆÃ“ÃÊ
UÊÊ*Þiœ˜i« ÀˆÌˆÃʈ˜Ê>Ê«>̈i˜ÌÊÜ œÊˆÃʘœÌÊÃiÛiÀiÞʈ
Unacceptable uses
UÊÊ-iÛiÀiʈ˜viV̈œ˜Ãʈ˜ÊÜ ˆV Pseudomonas spp. are suspected.
Dose
UÊÊ£Ê}Ê6ʜÀÊÊ+Ó{]ʓÕÃÌÊ>`ÕÃÌÊvœÀÊܜÀÃi˜ˆ˜}ÊÀi˜>Êv՘V̈œ˜Ê>˜`Ê
dialysis (see p. 155 for dose adjustment recommendation)
Toxicity
UÊÊ ˆ>ÀÀ i>]ʘ>ÕÃi>]Ê i>`>V i]Ê« iLˆÌˆÃÉÌ Àœ“Lœ« iLˆÌˆÃ
Fosfomycin
Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in
vitro activity against large number of Gram-negative and Gram-positive
organisms including E. coli, Klebsiella spp., Proteus spp., Pseudomonas
spp., and VRE. It does not have activity against Acinetobacter spp.
Fosfomycin is available in an oral formulation only in the U.S. and its
pharmacokinetics allow for one-time dosing.
Acceptable uses
UÊÊ>˜>}i“i˜ÌʜvÊ՘Vœ“«ˆV>Ìi`Ê1/ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê“ÕÌˆ«iÊ>˜ÌˆLˆœÌˆVÊ
allergies and/or when no other oral therapy options are available.
11
3.1 Agent-specific guidelines: Antibiotics
Toxicity
UÊÊޜ«>Ì ÞÊ­`iw˜i`Ê>ÃÊ Ê 10 times the upper limit of normal without
symptoms or 5 times the upper limit of normal with symptoms).
UÊÊ œÃˆ˜œ« ˆˆVÊ«˜iՓœ˜ˆ>
UÊʜ˜ˆÌœÀˆ˜}\Ê ÊÜiiŽÞ]ʓœÀiÊvÀiµÕi˜ÌÞÊ`ÕÀˆ˜}ʈ˜ˆÌˆ>ÊÌ iÀ>«Þ°Ê
3.1 Agent-specific guidelines: Antibiotics
UÊÊ1˜Vœ“«ˆV>Ìi`Ê1/Ê`ÕiÊ̜Ê6,
UÊÊÊ->Û>}iÊÌ iÀ>«ÞÊvœÀÊ1/Ê`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiÊ
organisms (e.g. Pseudomonas spp.) on case by case basis.
NOTE: Susceptibility to Fosfomycin should be confirmed prior to
initiation of therapy.
Unacceptable uses
UÊʜÃvœ“ÞVˆ˜Êà œÕ`Ê "/ÊLiÊÕÃi`ÊvœÀʓ>˜>}i“i˜ÌʜvÊ>˜Þʈ˜viV̈œ˜ÃÊ
outside of the urinary tract because it does not achieve adequate
concentrations at other sites.
UÊÊ/Ài>̓i˜ÌʜvÊ>Ãޓ«Ìœ“ˆVÊL>VÌiÀˆÕÀˆ>Ê­ÃiiÊ«°Ê££ä®
Dose
UÊÊ1˜Vœ“«ˆV>Ìi`Ê1/\ÊÎÊ}Ê­£ÊÃ>V iÌ®Ê*"ʜ˜Vi°Ê
UÊÊ œ“«ˆV>Ìi`Ê1/\ÊÎÊ}Ê­£ÊÃ>V iÌ®Ê*"ÊiÛiÀÞÊ£‡ÎÊ`>ÞÃÊ­Õ«Ê̜ÊÓ£Ê`>ÞÃʜvÊ
treatment)
UÊÊÀiµÕi˜VÞÊ>`ÕÃ̓i˜Ìʓ>ÞÊLiʘiViÃÃ>ÀÞʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê À Ê 50
mL/min. Contact the ID Pharmacist for dosing recommendations.
UÊÊ*œÜ`iÀÊà œÕ`ÊLiʓˆÝi`ÊÜˆÌ Ê™äq£ÓäʓʜvÊVœœÊÜ>ÌiÀ]ÊÃ̈ÀÀi`Ê̜Ê
dissolve and administered immediately.
Toxicity
UÊÊ ˆ>ÀÀ i>]ʘ>ÕÃi>]Ê i>`>V i]Ê`ˆâ∘iÃÃ]Ê>ÃÌ i˜ˆ>Ê>˜`Ê`Þëi«Ãˆ>
Linezolid
Acceptable uses
UÊÊ œVՓi˜Ìi`Ê6>˜Vœ“ÞVˆ˜Êˆ˜ÌiÀ“i`ˆ>ÌiÊStaphylococcus aureus (VISA)
or Vancomycin resistant Staphylococcus aureus (VRSA) infection
UÊÊ œVՓi˜Ìi`Ê,-ʜÀÊiÌ ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊ
staphylococcal infection in a patient with serious allergy to Vancomycin
UÊÊ œVՓi˜Ìi`Ê,-ʜÀÊiÌ ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊ
staphylococcal infection in a patient failing Vancomycin therapy (as
`iw˜i`ÊLiœÜ®\Ê
UÊÊ >VÌiÀi“ˆ>Éi˜`œV>À`ˆÌˆÃ\Êv>ˆÕÀiÊ̜ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ>vÌiÀÊ
ÇÊ`>ÞÃÊ`iëˆÌiÊ6>˜Vœ“ÞVˆ˜ÊÌÀœÕ} ÃʜvÊ£xqÓäʓV}ɓ°Ê- œÕ`ÊLiÊ
used in combination with another agent
UÊÊ*˜iՓœ˜ˆ>\ÊܜÀÃi˜ˆ˜}ʈ˜wÌÀ>ÌiʜÀʫՏ“œ˜>ÀÞÊÃÌ>ÌÕÃʈ˜Ê>Ê«>̈i˜ÌÊ
with documented MRSA pneumonia after 2 to 3 days or if the
MIC of Vancomycin is 2 mcg/mL, or if achieving appropriate
vancomycin trough is unlikely (e.g., obesity)
UÊÊ >ÃiÃÊà œÕ`ÊLiÊ`ˆÃVÕÃÃi`ÊÜˆÌ Ê˜viV̈œÕÃÊ ˆÃi>ÃiÃʜÀÊ
Antimicrobial stewardship
UÊHigh suspicion of CA-MRSA necrotizing pneumonia in a seriously
ill patient
12
Dose
UÊÊÈääʓ}Ê6É*"Ê+£Ó
UÊÊ-Žˆ˜Ê>˜`ÊΈ˜‡ÃÌÀÕVÌÕÀiʈ˜viV̈œ˜Ã\Ê{ääʓ}Ê6É*"Ê+£Ó
Toxicity
UÊÊ œ˜iʓ>ÀÀœÜÊÃÕ««ÀiÃȜ˜Ê­ÕÃÕ>ÞʜVVÕÀÃÊÜˆÌ ˆ˜ÊwÀÃÌÊÓÊÜiiŽÃʜvÊÌ iÀ>«Þ®
UÊÊ"«ÌˆVʘiÕÀˆÌˆÃÊ>˜`ʈÀÀiÛiÀÈLiÊÃi˜ÃœÀÞʓœÌœÀÊ«œÞ˜iÕÀœ«>Ì ÞÊ­ÕÃÕ>ÞÊ
occurs with prolonged therapy > 28 days)
UÊÊ >ÃiÊÀi«œÀÌÃʜvʏ>V̈VÊ>Vˆ`œÃˆÃ
UÊÊ >ÃiÊÀi«œÀÌÃʜvÊÃiÀœÌœ˜ˆ˜ÊÃޘ`Àœ“iÊÜ i˜ÊVœ‡>`“ˆ˜ˆÃÌiÀi`ÊÜˆÌ Ê
serotonergic agents (SSRIs, TCAs, MAOIs, etc.)
UÊʜ˜ˆÌœÀˆ˜}\Ê
ÊÜiiŽÞ
Tigecycline
Tigecycline is a tetracycline derivative called a glycylcycline. It has in
vitro activity against most strains of staphylococci and streptococci
(including MRSA and VRE), anaerobes, and many Gram-negative
organisms with the exception of Proteus spp. and Pseudomonas
aeruginosa. It is FDA approved for skin and skin-structure infections and
intra-abdominal infections.
NOTE: Peak serum concentrations of Tigecycline do not exceed
1 mcg/mL which limits its use for treatment of bacteremia
Acceptable uses
UÊÊ>˜>}i“i˜Ìʜvʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜Ãʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê
contraindications to both beta-lactams and fluoroquinolones
UÊÊ>˜>}i“i˜Ìʜvʈ˜viV̈œ˜ÃÊ`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiÊ
organisms including Acinetobacter spp. and Stenotrophomonas
maltophilia on a case by case basis
UÊÊ->Û>}iÊÌ iÀ>«ÞÊvœÀÊ,-É6, ʈ˜viV̈œ˜Ãʜ˜Ê>ÊV>ÃiÊLÞÊV>ÃiÊL>ÈÃ
Dose
UÊÊ£ääʓ}Ê6ʜ˜Vi]ÊÌ i˜Êxäʓ}Ê6Ê+£Ó
UÊÊ£ääʓ}Ê6ʜ˜Vi]ÊÌ i˜ÊÓxʓ}Ê6Ê+£ÓʈvÊÃiÛiÀiÊ i«>̈Vʈ“«>ˆÀ“i˜ÌÊ
­ ˆ`ʇÊ*Õ} Ê£äq£x®
Toxicity
UÊÊ >ÕÃi>Ê>˜`Êۜ“ˆÌˆ˜}Ê
13
3.1 Agent-specific guidelines: Antibiotics
UÊ ÊÊ œVՓi˜Ìi`Ê6, ʈ˜viV̈œ˜Ê
UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊˆ˜ÊV >ˆ˜Ãʈ˜ÊLœœ`ÊVՏÌÕÀiÃʈ˜Ê>˜Ê 1]ʜÀʜ˜Vœœ}ÞÊ
transplant patient known to be colonized with VRE
Unacceptable uses
UÊÊ*Àœ« ޏ>݈Ã
UÊʘˆÌˆ>ÊÌ iÀ>«ÞÊvœÀÊÃÌ>« ޏœVœVV>Êˆ˜viV̈œ˜
UÊÊ6, ÊVœœ˜ˆâ>̈œ˜ÊœvÊÌ iÊÃ̜œ]ÊÕÀˆ˜i]ÊÀiëˆÀ>̜ÀÞÊÌÀ>VÌ]Êܜ՘`Ã]ʜÀÊ`À>ˆ˜Ã
3.1 Agent-specific guidelines: Antibiotics
Trimethoprim/sulfamethoxazole
(Bactrim®, TMP/SMX)
Trimethoprim/sulfamethoxazole is a sulfonamide antibiotic. It has in vitro
activity against Enterobacteriaceae spp., B. cepacia, S. maltophilia,
Acinetobacter spp., Achromobacter spp., Nocardia spp., Listeria,
Pneumocystis jirovecii (PCP), staphylococci (including S. aureus and
Coagulase-negative staph), but does NOT cover Pseudomonas spp.
It has variable activity against streptococci and no activity against
anaerobes.
Acceptable uses
UÊ1Àˆ˜>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜ÃÊ­1/®
UÊS. aureus skin and soft-tissue infections (SSTI)
UÊPneumocystis jirovecii pneumonia (PCP) treatment and prophylaxis
UÊS. maltophilia infections
UÊ œV>À`ˆ>ʈ˜viV̈œ˜ÃÊ
UÊÀ>“‡˜i}>̈ÛiÊL>VÌiÀi“ˆ>ÊÜ i˜ÊœÀ}>˜ˆÃ“ʈÃÊÃÕÃVi«ÌˆLiÊ
UÊÊ->Û>}iÊÌ iÀ>«ÞÊvœÀÊ,-ÊL>VÌiÀi“ˆ>ʈ˜ÊVœ“Lˆ˜>̈œ˜ÊÜˆÌ Ê>˜œÌ iÀÊ
agent
UÊÊ “«ˆÀˆVÊVœÛiÀ>}iʜvÊListeria meningitis in patients with penicillin
allergies
UÊÊ-Õ««ÀiÃÈÛiÊÌ iÀ>«ÞÊ>˜`ʈ˜ÊܓiÊV>ÃiÃÊÌÀi>̓i˜ÌÊvœÀÊLœ˜iÊ>˜`ʍœˆ˜ÌÊ
infections
Unacceptable uses
Uʜ˜œÌ iÀ>«ÞÊvœÀÊS. aureus bacteremia
Dose
UÊTrimethoprim/sulfamethoxazole dosing is based on trimethoprim
component
UÊ/*É-8Ê >ÃÊiÝVii˜ÌÊLˆœ>Û>ˆ>LˆˆÌÞ]ÊÌ ÕÃÊVœ˜ÛiÀȜ˜ÊvÀœ“Ê6Ê̜Ê*"Ê
ˆÃÊ£\£Ê­näÉ{ääʓ}Ê6ÊrÊ£Ê--ÊÌ>LÆÊ£ÈäÉnääʓ}Ê6ÊrÊ£Ê -ÊÌ>L®Ê
UÊ1ÃiÊ>`ÕÃÌi`Ê 7rÊQ 7ʳÊä°{Ê­ 7Ê‡Ê 7®Rʈ˜ÊœLiÃiÊ«>̈i˜ÌÃÊ­€Îä¯Ê
over IBW)
Treatment
UÊ1/\Ê£Ê -ÊÌ>LÊ+£ÓÊ
UÊ--/\Ê£‡ÓÊ -ÊÌ>LÊ+£Ó
UÊ* *\£x‡Óäʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®
UÊ,-ÊL>VÌiÀi“ˆ>\£ä‡£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®
UÊS. maltophiliaʈ˜viV̈œ˜Ã\£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®Ê
14
Prophylaxis
UÊ* *\Ê£Ê--Ê`>ˆÞʜÀÊ£Ê -ÊÎÊ̈“iÃÉÜiiŽÊ
UÊ/œÝœ«>ӜÈÃ\Ê£Ê -Ê`>ˆÞÊ
Toxicity
UÊ œ““œ˜\Ê Þ«iÀÃi˜ÃˆÌˆÛˆÌÞÊ­£°È‡n¯®]ʇիÃiÌ]Ê«ÃiÕ`œÊiiÛ>̈œ˜Êˆ˜Ê
VÀi>̈˜ˆ˜iÊ­£n¯®Ê
UÊ œ““œ˜ÊÜˆÌ Ê ˆ} iÀÊ`œÃiÃ\Ê Þ«iÀŽ>i“ˆ>]ʓÞiœÃÕ««ÀiÃȜ˜
UÊ"VV>Ȝ˜>\ʘi« ÀœÌœÝˆVˆÌÞ]Ê« œÌœÃi˜ÃˆÌˆÛˆÌÞ]ʓiÌ i“œ}œLˆ˜i“ˆ>Ê­ÜˆÌ Ê
severe G6PD deficiency)
UÊ,>Ài\Ê>Ãi«ÌˆVʓi˜ˆ˜}ˆÌˆÃ]Ê i«>̜̜݈VˆÌÞ]Ê̜݈VÊi«ˆ`iÀ“>Ê˜iVÀœÞÈÃÊ
(TEN), SJS, Sweet’s syndrome
Drug Interaction
UÊ7>Àv>Àˆ˜]ʓiÌ œÌÀiÝ>Ìi]Ê« i˜Þ̜ˆ˜]Ê`ˆ}œÝˆ˜]ÊÃՏvœ˜ÞÕÀi>Ã]Ê
procainamide, oral contraceptives
15
3.1 Agent-specific guidelines: Antibiotics
UÊ œV>À`ˆ>ʈ˜viV̈œ˜Ã\Ê£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®ÆʏœÜiÀÊ
doses (5-10 mg/kg/day) can be used after several weeks of therapy
or cutaneous infections
UÊi˜ˆ˜}ˆÌˆÃ\ÊÓäʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+È®
UÊ"Ì iÀʈ˜viV̈œ˜Ã\Ên‡£äʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ£Ó®
UÊÕÃÌÊ>`ÕÃÌÊ`œÃiÊvœÀÊܜÀÃi˜ˆ˜}ÊÀi˜>Êv՘V̈œ˜Ê>˜`Ê`ˆ>ÞÈÃÊ­ÃiiÊ«°£xxÊ
for dose adjustment recommendation).
3.2 Agent-specific guidelines: Antifungals
Antifungals
Liposomal Amphotericin B (AmBisome®)
NOTES:
UÊÊ œÃˆ˜}ʜvʓ ˆÃœ“iÊ>˜`ʓ« œÌiÀˆVˆ˜Ê Ê`iœÝÞV œ>ÌiʈÃÊ
significantly different. Do not use AmBisome doses when
ordering Amphotericin B deoxycholate and vice versa.
UÊʓ« œÌiÀˆVˆ˜Ê Ê`iœÝÞV œ>ÌiʈÃÊ«ÀiviÀÀi`ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Êi˜`‡
stage renal disease on dialysis who are anuric.
AmBisome, like all Amphotericin B products, has broad spectrum
antifungal activity with in vitro activity against Candida, Aspergillus,
Zygomycosis and Fusarium.
Acceptable uses
UÊ >˜`ˆ`>Êi˜`œ«Ì >“ˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]Ê -ʈ˜viV̈œ˜qwÀÃÌʏˆ˜iÊÌ iÀ>«Þ
UÊ Àޫ̜VœVVÕÃʓi˜ˆ˜}ˆÌˆÃ‡wÀÃÌʏˆ˜iÊÌ iÀ>«ÞÊÊ
UÊ<Þ}œ“ÞVœÃiÃÊ­Mucor, Rhizopus, Cunninghamella®qwÀÃÌʏˆ˜iÊÌ iÀ>«ÞÊ
UÊÊ iÕÌÀœ«i˜ˆVÊviÛiÀʈvÊÀiViˆÛˆ˜}Ê6œÀˆVœ˜>✏iʜÀÊ*œÃ>Vœ˜>✏iÊ
prophylaxis
UʏÌiÀ˜>̈ÛiÊÌÀi>̓i˜Ìʜvʈ˜Û>ÈÛiÊ>ëiÀ}ˆœÃˆÃ
UÊʏÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊV>˜`ˆ`i“ˆ>]ÊV>˜`ˆ`>Ê«iÀˆÌœ˜ˆÌˆÃÊ
Dose
UÊÊ >˜`ˆ`i“ˆ>]Ê ˆÃ̜«>ӜÈÃ]ÊœÌ iÀʘœ˜‡ˆ˜Û>ÈÛiÊV>˜`ˆ`>ʈ˜viV̈œ˜Ã\Ê
3 mg/kg/day
UÊÊ >˜`ˆ`>Êi˜`œ«Ì >“ˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]Ê -ʈ˜viV̈œ˜]ÊC. krusei
V>˜`ˆ`i“ˆ>\Êxʓ}Ɏ}É`>Þ
UʘÛ>ÈÛiÊw>“i˜ÌœÕÃÊv՘}ˆ\Êxʓ}Ɏ}É`>Þ
UÊ iÕÌÀœ«i˜ˆVÊviÛiÀ]ÊV>˜`ˆ`i“ˆ>ʈ˜Ê˜iÕÌÀœ«i˜ˆVÊ«>̈i˜Ì\ÊÎqxʓ}Ɏ}É`>Þ
UÊ Àޫ̜VœVV>Ê“i˜ˆ˜}ˆÌˆÃ\ÊÎq{ʓ}Ɏ}É`>Þ
Toxicity
UʘvÕȜ˜‡Ài>Ìi`ÊÀi>V̈œ˜Ã\ÊviÛiÀ]ÊV ˆÃ]ÊÀˆ}œÀÃ]Ê Þ«œÌi˜Ãˆœ˜
UÊÊ,i˜>Êˆ“«>ˆÀ“i˜ÌÊ­i˜ >˜Vi`ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ ÊVœ˜Vœ“ˆÌ>˜Ìʘi« ÀœÌœÝˆVÊ
drugs)
UÊ iVÌÀœÞÌiʈ“L>>˜ViÃ
UÊÊ*Տ“œ˜>ÀÞÊ̜݈VˆÌÞÊ­V iÃÌÊ«>ˆ˜]Ê Þ«œÝˆ>]Ê`Þë˜i>®]Ê>˜i“ˆ>]ÊiiÛ>̈œ˜Êˆ˜Ê
hepatic enzymes-rare
UÊʜ˜ˆÌœÀˆ˜}\Ê 1 ÉVÀi>̈˜ˆ˜i]Ê]Ê}]Ê* œÃÊ>ÌÊL>Ãiˆ˜iÊ>˜`Ê`>ˆÞʈ˜Ê
œÃ«ˆÌ>ˆâi`Ê«>̈i˜ÌÃÆÊ-/É/Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£‡ÓÊÜiiŽÃÊ
16
Aspergillosis
UÊVVi«Ì>LiÊÕÃiÃ
UÊʘÊVœ“Lˆ˜>̈œ˜ÊÜˆÌ Ê6œÀˆVœ˜>✏iÊvœÀÊVœ˜wÀ“i`ʈ˜Û>ÈÛiÊ
aspergillosis (see p. 133)
UÊÊ,ivÀ>V̜ÀÞÊ`ˆÃi>Ãi‡ÊvœÀÊÕÃiʈ˜ÊVœ“Lˆ˜>̈œ˜ÊÜˆÌ Ê6œÀˆVœ˜>✏i]Ê
Posaconazole or AmBisome® for confirmed invasive aspergillosis.
UÊ1˜>VVi«Ì>LiÊÕÃiÃ
UÊʈV>v՘}ˆ˜Ê>œ˜iʜÀʈ˜ÊVœ“Lˆ˜>̈œ˜ÊÜˆÌ ÊœÌ iÀÊ>˜Ìˆv՘}>Ê>}i˜ÌÃʈÃÊ
not recommended for empiric therapy in patients with CT findings
suggestive of aspergillosis (e.g., possible aspergillosis) without
plans for diagnostic studies.
UÊʈV>v՘}ˆ˜Ê`œiÃʘœÌÊ >ÛiÊ}œœ`Êin vitro activity against
zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
Candidiasis
UÊVVi«Ì>LiÊÕÃiÃ
UÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃÊ`ÕiÊ̜ÊC. glabrata or C. krusei.
UÊÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃʈ˜Ê«>̈i˜ÌÃÊÜ œÊ>ÀiÊ "/ÊVˆ˜ˆV>ÞÊ
stable due to candidemia or have received prior long-term azole
therapy.
UʏÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊÀiVÕÀÀi˜ÌÊiÜ« >}i>ÊV>˜`ˆ`ˆ>Èð
UʏÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊi˜`œV>À`ˆÌˆÃ°
UÊ1˜>VVi«Ì>LiÊÕÃiÃ
UÊʈV>v՘}ˆ˜Ê >ÃÊ«œœÀÊ«i˜iÌÀ>̈œ˜Êˆ˜ÌœÊÌ iÊ -Ê>˜`ÊÕÀˆ˜>ÀÞÊÌÀ>VÌ°ÊÌÊ
should be avoided for infections involving those sites.
Neutropenic fever
UÊʈV>v՘}ˆ˜ÊV>˜ÊLiÊÕÃi`ÊvœÀʘiÕÌÀœ«i˜ˆVÊviÛiÀʈ˜Ê«>̈i˜ÌÃÊÜ œÊ>ÀiʘœÌÊ
suspected to have aspergillosis or zygomycosis.
Dose
UÊÊ >˜`ˆ`i“ˆ>]ʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃ]ʘiÕÌÀœ«i˜ˆVÊviÛiÀ\Ê£ääʓ}Ê6Ê
Q24H
UÊ >˜`ˆ`>Êi˜`œV>À`ˆÌˆÃ\Ê£xäʓ}Ê6Ê+Ó{
UÊ,iVÕÀÀi˜ÌÊiÜ« >}i>ÊV>˜`ˆ`ˆ>ÈÃ\Ê£xäʓ}Ê6Ê+Ó{
UʘÛ>ÈÛiÊ>ëiÀ}ˆœÃˆÃ\Ê£ääq£xäʓ}Ê6Ê+Ó{
UÊ"LiÃiÊ«>̈i˜ÌÃ
UÊÊ£ääq£xäʎ}\Ê£xäʓ}Ê6Ê+Ó{
UÊÊ> £xäʎ}\Ê œ˜ÃՏÌÊ Ê* >À“>VˆÃÌ
Drug Interactions
UÊÊ œÃiʓœ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊÜ i˜ÊˆV>v՘}ˆ˜ÊˆÃÊÕÃi`ÊÜˆÌ ÊÌ iÊ
vœœÜˆ˜}Ê>}i˜ÌÃÊVœ˜Vœ“ˆÌ>˜ÌÞ\
17
3.2 Agent-specific guidelines: Antifungals
Micafungin
NOTE: Micafungin does not have activity against Cryptococcus.
3.2 Agent-specific guidelines: Antifungals
UÊÊ-ˆÀœˆ“ÕÃÊqʏiÛiÃʜvÊ-ˆÀœˆ“ÕÃʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ
Sirolimus toxicity
UÊÊ ˆvi`ˆ«ˆ˜iÊqʏiÛiÃʜvÊ ˆvi`ˆ«ˆ˜iʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ
Nifedipine toxicity
UÊÊÌÀ>Vœ˜>✏iÊqʏiÛiÃʜvÊÌÀ>Vœ˜>✏iʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ
Itraconazole toxicity
Toxicity
UÊʘvÕȜ˜‡Ài>Ìi`ÊÀi>V̈œ˜ÃÊ­À>à ]Ê«ÀÕÀˆÌˆÃ®]Ê« iLˆÌˆÃ]Ê i>`>V i]ʘ>ÕÃi>Ê
and vomiting, and elevations in hepatic enzymes.
Uʜ˜ˆÌœÀˆ˜}\Ê-/É/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ°
Posaconazole
Posaconazole is a broad spectrum azole anti-fungal agent. It has in vitro
activity against Candida, Aspergillus, Zygomycosis and Fusarium spp.
Acceptable uses
UÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊâÞ}œ“ÞVœÃˆÃʈ˜ÊVœ“Lˆ˜>̈œ˜ÊÜˆÌ Ê“« œÌiÀˆVˆ˜Ê
UÊʜ˜œÌ iÀ>«ÞÊvœÀÊâÞ}œ“ÞVœÃˆÃÊ>vÌiÀÊÇÊ`>ÞÃʜvÊVœ“Lˆ˜>̈œ˜ÊÌ iÀ>«ÞÊ
with Amphotericin B
UÊ*Àœ« ޏ>݈Ãʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê i“>̜œ}ˆVʓ>ˆ}˜>˜VÞ
UÊ/Ài>̓i˜ÌʜvÊ>ëiÀ}ˆœÃˆÃʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê6œÀˆVœ˜>✏iʈ˜ÌœiÀ>˜Vi
Unacceptable uses
UÊ >˜`ˆ`ˆ>ÈÃÉ iÕÌÀœ«i˜ˆVÊviÛiÀ
UʈÀÃ̇ˆ˜iÊÌÀi>̓i˜ÌʜvÊ>ëiÀ}ˆœÃˆÃ
Dose
"/ -\Ê
UÊÊ >V Ê`œÃiʜvÊÃÕëi˜Ãˆœ˜Êà œÕ`ÊLiÊ}ˆÛi˜ÊÜˆÌ Ê>ÊvՏÊ“i>ÊœÀÊÜˆÌ ÊˆµÕˆ`Ê
nutritional supplements if patients cannot tolerate full meals. Can also
be given with an acidic beverage (e.g. ginger ale).
UÊÊ i>Þi`ÊÀii>ÃiÊÌ>LiÌÃÊ>˜`ʜÀ>ÊÃÕëi˜Ãˆœ˜ÊV>˜˜œÌÊLiÊÕÃi`Ê
interchangeably due to differences in the dosing of each formulation.
Prophylaxis
UÊ"À>Ê-Õëi˜Ãˆœ˜\ÊÓääʓ}Ê*"Ê+n
UÊ ÝÌi˜`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääʓ}Ê*"Ê`>ˆÞ
Treatment
UÊÊ"À>Ê-Õëi˜Ãˆœ˜\ÊÓääʓ}Ê*"Ê+ÈÊvœÀÊÇÊ`>ÞÃ]ÊÌ i˜Ê{ääʓ}Ê*"Ê
Q8-Q12H
UÊÊ ÝÌi˜`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääʓ}Ê*"Ê+£ÓÊvœÀÊ£Ê`>Þ]ÊÌ i˜ÊÎääʓ}Ê
PO daily
18
Drug Interactions: See Table on p. 21
Toxicity
UÊÊÊÕ«ÃiÌÊ­H{䯮]Ê i>`>V iÃ]ÊiiÛ>̈œ˜Êˆ˜Ê i«>̈VÊi˜âޓiðÊ,>ÀiÊLÕÌÊ
serious effects include QTc prolongation.
UÊʜ˜ˆÌœÀˆ˜}\Ê-/É/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ
,iviÀi˜ViÃ\
ˆ˜ˆV>ÊivwV>VÞʜvʘiÜÊ>˜Ìˆv՘}>Ê>}i˜ÌÃ\Ê ÕÀÀÊ"«ˆ˜ÊˆVÀœLˆœ°ÊÓääÈƙ\{n·nn°
*œÃ>Vœ˜>✏i\Ê>ÊLÀœ>`ÊëiVÌÀՓÊÌÀˆ>✏iÊ>˜Ìˆv՘}>\Ê>˜ViÌʘviVÌÊ ˆÃ°ÊÓääxÆÊx\ÇÇx‡nx°
Voriconazole
NOTE: Voriconazole does not cover zygomycoses (Mucor,
Rhizopus, Cunninghamella, etc.).
Acceptable uses
UÊAspergillosis
UÊScedosporium apiospermum
UÊProphylaxis in patients with hematologic malignancy
Unacceptable uses
UÊÊCandidiasis / Neutropenic fever
Voriconazole should not be used as first-line therapy for the treatment
of candidiasis or for empiric therapy in patients with neutropenic fever.
Dose
UÊʜ>`ˆ˜}Ê`œÃi\ÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊÝÊÓÊ`œÃiÃ
UÊ>ˆ˜Ìi˜>˜ViÊ`œÃi\Ê{ʓ}Ɏ}Ê6É*"Ê+£Ó
UÊÊ œÃiÊ>`ÕÃ̓i˜ÌʈÃʘiViÃÃ>ÀÞÊvœÀÊ i«>̈Vʈ˜ÃÕvwVˆi˜VÞ\
UÊ ˆ`ʇÊ*Õ} ʭʜÀÊ ®\Ê↓ “>ˆ˜Ìi˜>˜ViÊ`œÃiÊLÞÊxä¯
UÊÊ ˆ`ʇÊ*Õ} Ê­ ®\Ê1Ãiʜ˜ÞʈvÊLi˜iwÌÃʜÕÌÜiˆ} ÊÀˆÃŽÃ°Ê œ˜ÃՏÌÊ
ID pharmacist for dose adjustment recommendations.
UÊÊ œÃiÊiÃV>>̈œ˜Ê“>ÞÊLiʘiViÃÃ>ÀÞÊvœÀÊܓiÊ«>̈i˜ÌÃÊ`ÕiÊ̜Ê
subtherapeutic levels.
UÊÊ œÃiÊL>Ãi`ʜ˜Ê>VÌÕ>ÊLœ`ÞÊÜiˆ} ÌÊ՘iÃÃÊ«>̈i˜ÌʀÎä¯ÊœÛiÀÊ 7ÆÊ
then use adjusted body weight. (Adj. BW).
`°Ê 7ÊrÊQ 7ʳÊä°{Ê­ 7Ê‡Ê 7®R
IBW - Ideal Body Weight
ABW - Actual Body Weight
19
3.2 Agent-specific guidelines: Antifungals
Therapeutic monitoring:
UÊ*œÃ>Vœ˜>✏iÊÌÀœÕ} ʏiÛiÃÊà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊÜ œÊ>Ài\
UÊ œÌÊÀi뜘`ˆ˜}Ê̜ÊÌ iÀ>«ÞÊvœÀÊ>Ìʏi>ÃÌÊÇÊ`>ÞÃ
UÊ iˆ˜}ÊÌÀi>Ìi`ÊvœÀÊ՘Vœ““œ˜ÊœÀʏiÃÃÊÃÕÃVi«ÌˆLiʜÀ}>˜ˆÃ“Ã
UÊ Ý«iÀˆi˜Vˆ˜}ʓÕVœÃˆÌˆÃʜÀʓ>>LÜÀ«Ìˆœ˜ÊÃޘ`Àœ“i
UÊ1˜>LiÊ̜ÊVœ˜ÃՓiÊ ˆ} Êv>Ìʓi>ÃÊ­ˆvÊÀiViˆÛˆ˜}ÊÌ iÊÃÕëi˜Ãˆœ˜®
3.2 Agent-specific guidelines: Antifungals
Therapeutic monitoring
UÊÊ6œÀˆVœ˜>✏iÊÌÀœÕ} ʏiÛiÃÊà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊÜ œÊ>Ài\
UÊÊ œÌÊÀi뜘`ˆ˜}Ê̜ÊÌ iÀ>«ÞÊ>vÌiÀÊ>Ìʏi>ÃÌÊxÊ`>ÞÃʜvÊÌ iÀ>«ÞÊÕȘ}Ê>Ê
mg/kg dosing strategy
UÊÊ,iViˆÛˆ˜}ÊVœ˜Vœ“ˆÌ>˜ÌÊ`ÀÕ}ÃÊÌ >Ìʓ>Þʈ˜VÀi>ÃiʜÀÊ`iVÀi>ÃiÊ
Voriconazole levels
UÊÊ Ý«iÀˆi˜Vˆ˜}Ê>`ÛiÀÃiÊiÛi˜ÌÃÊ`ÕiÊ̜Ê6œÀˆVœ˜>✏i
UÊÊ Ý«iÀˆi˜Vˆ˜}ÊÊ`ÞÃv՘V̈œ˜
UÊÊ6œÀˆVœ˜>✏iÊÌÀœÕ} ʏiÛiÃÊà œÕ`ÊLiʜLÌ>ˆ˜i`ÊxqÇÊ`>ÞÃÊ>vÌiÀÊÃÌ>ÀÌʜvÊ
Ì iÀ>«ÞÊ­«iÀvœÀ“i`Êq®°
UÊʜ>ÊÌÀœÕ} \ÊÓqx°xʓV}ɓ°ÊiÛiÃʐʣʓV}É“Ê >ÛiÊLii˜Ê
associated with clinical failures and levels >5.5 mcg/mL with toxicity.
Drug Interactions: See Table on p. 21
Toxicity
UÊÊ6ˆÃÕ>Ê`ˆÃÌÕÀL>˜ViÃÊ­HÎ䯮ÊÕÃÕ>ÞÊÃiv‡ˆ“ˆÌi`]ÊÀ>à ]ÊviÛiÀ]ÊiiÛ>̈œ˜ÃÊ
in hepatic enzymes.
UÊʜ˜ˆÌœÀˆ˜}\Ê-/É/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ
,iviÀi˜ViÃ\
6œÀˆVœ˜âœi\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓääÎÆÊÎÈ\ÈÎä°
6œÀˆVœ˜>✏iʈ˜Ê˜iÕÌÀœ«i˜ˆVÊviÛiÀ\Ê Ê ˜}ÊÊi`ÊÓääÓÆÎ{È­{®\ÓÓx°Ê
6œÀˆVœ˜>✏iÊ/ \Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓäänÆÊ{È\Ó䣰
Azole drug interactions
The following list contains major drug interactions involving drug
metabolism and absorption. This list is not comprehensive and is
intended as a guide only. You must check for other drug interactions
when initiating azole therapy or starting new medication in patients
already receiving azole therapy.
Drug metabolism:
Þ̜V Àœ“iÊ­ 9*®Ê*{xäʈ˜ ˆLˆÌœÀÃ\Ê`iVÀi>ÃiÊÌ iʓiÌ>LœˆÃ“ÊœvÊViÀÌ>ˆ˜Ê
drugs (CYP450 substrates) resulting in increased drug concentrations in
the body (occurs immediately)
Þ̜V Àœ“iÊ­ 9*®Ê*{xäʈ˜`ÕViÀÃ\ʈ˜VÀi>ÃiÊÌ iʓiÌ>LœˆÃ“ÊœvÊViÀÌ>ˆ˜Ê
drugs (CYP450 substrates) resulting in decreased drug concentrations
in the body (may take up to 2 weeks for upregulation of enzymes to
occur)
Drug absorption/penetration:
*‡}ÞVœ«ÀœÌiˆ˜Ê­*‡}«®Êˆ˜ ˆLˆÌœÀ\Ê`iVÀi>ÃiÊÌ iÊv՘V̈œ˜ÊœvÊÌ iÊivyÕÝʫՓ«]Ê
resulting in increased absorption/penetration of P-gp substrates
*‡}ÞVœ«ÀœÌiˆ˜Êˆ˜`ÕViÀ\ʈ˜VÀi>ÃiÊÌ iÊv՘V̈œ˜ÊœvÊÌ iÊivyÕÝʫՓ«]Ê
resulting in decreased absorption/penetration of P-gp substrates
PotencyʜvÊ Þ̜V Àœ“iÊ*{xäʈ˜ ˆLˆÌˆœ˜\Ê6œÀˆVœ˜>✏iʀÊÌÀ>Vœ˜>✏iʀÊ
Posaconazole > Fluconazole
20
Do not use
Recommendations
↓ cyclosporine dose to 3⁄4 and monitor levels
May ↓ posaconazole concentrations when using suspension
Consider dose reducing
↓ tacrolimus dose to 1⁄3 and monitor levels
Avoid concomitant use unless benefit outweighs risk
If used together, monitor effects of drugs and consider decreasing dose
when posaconazole is added
Amiodarone, atazanavir, digoxin, erythromycin, all calcium channel blockers, Monitor effect of drugs and consider decreasing dose when
ritonavir, statins (avoid lovastatin and simvastatin), vinca alkaloids
posaconazole is added
Drug
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ sirolimus
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cisapride, ergot alkaloids, pimozide,
quinidine, triazolam
Cyclosporine
Metoclopramide, proton pump inhibitors
Midazolam
Tacrolimus
Cimetidine, efavirenz, phenytoin, rifabutin, rifampin
Warning/precaution
Drug
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ statins (lovastatin, simvastatin)
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cisapride, dofetilide, ergot alkaloids,
nisoldipine, oral midazolam, pimozide, quinidine, triazolam
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ atorvastatin, benzodiazepines, chemotherapy
(busulfan, docetaxel, vinca alkaloids), cyclosporine, digoxin, efavirenz,
eletriptan, fentanyl, oral hypoglycemics, indinavir, IV midazolam,
nifedipine, ritonavir, saquinavir, sirolimus, tacrolimus, verapamil, steroids
(budesonide, dexamethasone, fluticasone, methylprednisolone), warfarin
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ alfentanil, buspirone, cilostazol, disopyramide,
felodipine, trimetrexate
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ carbamazepine, efavirenz, isoniazid, nevirapine,
phenobarbital, phenytoin, rifabutin, rifampin, antacids, H2 receptor
antagonists, proton pump inhibitors
Clarithromycin, erythromycin, fosamprenavir, indinavir, ritonavir, saquinavir
Do not use
Recommendations
↓ plasma concentration of itraconazole, if possible avoid concomitant
use or monitor itraconazole levels
plasma concentration of the interacting drug, monitor levels when
possible, monitor for drug toxicity and consider dose reduction
3.2 Agent-specific guidelines: Antifungals
plasma concentration of itraconazole, monitor itraconazole levels and
monitor for toxicity
↓
Contraindicated
ITRACONAZOLE and major metabolite hydroxyitraconazole (substrate and inhibitor of CYP3A4 and P-gp efflux)
Warning/precaution
Contraindicated
POSACONAZOLE (substrate and inhibitor for P-gp efflux, inhibitor of CYP3A4)
↓
21
Do not use
Recommendations
3.2 Agent-specific guidelines: Antifungals
↓ cyclosporine dose to 1⁄2 and monitor levels
voriconazole dose to 5 mg/kg IV/PO Q12H and ↓ efavirenz to 300 mg
PO daily
Tacrolimus
↓ tacrolimus dose to 1⁄3 and monitor levels
Sirolimus
↓ÊÈÀœˆ“ÕÃÊ`œÃiÊLÞÊÇx¯Ê>˜`ʓœ˜ˆÌœÀʏiÛiÃ
Omeprazole
↓ omeprazole dose to 1⁄2
Maraviroc
↓ maraviroc dose to 150 mg twice daily
Methadone
Monitor effect of the interacting drug and consider decreasing dose
Phenytoin
voriconazole to 5 mg/kg IV/PO Q12H and monitor levels
Ritonavir low dose (100 mg Q12H)
Avoid this combination unless benefits outweigh risks
Warfarin
Monitor INR levels
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ all benzodiazepines (avoid midazolam and triazolam), Monitor effect of drugs and consider decreasing dose when voriconazole
all calcium channel blockers, fentanyl, oxycodone & other long acting opioids, is added
NSAIDs, oral contraceptives, statins (avoid lovastatin and simvastatin),
sulfonylureas, vinca alkaloids, pomalidomide, simeprevir, boceprevir, telaprevir
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ alfentanil
Drug
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ carbamazepine, rifabutin, rifampin,
ritonavir 400 mg Q12H
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ long-acting barbiturates, cisapride,
ergot alkaloids, pimozide, quinidine, St. John’s Wort
Cyclosporine
Efavirenz
Contraindicated
Warning/precaution
Drug
Cisapride
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cyclosporine, glipizide, glyburide, phenytoin,
rifabutin, tacrolimus, warfarin
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ oral midazolam, theophylline, tolbutamide
Rifampin
Recommendations
↓ plasma concentration of fluconazole, consider increasing fluconazole dose
Do not use
plasma concentration of the interacting drug, monitor levels when
possible, monitor for drug toxicity and consider dose reduction
↓
FLUCONAZOLE (substrate of CYP3A4 and inhibitor of CYP3A4, CYP2C9, and CYP2C19, interactions are often dose dependent)
Warning/precaution
Contraindicated
VORICONAZOLE (substrate and inhibitor of CYP2C19, CYP2C9, and CYP3A4)
↓
↓
22
Indications for pneumococcal vaccines for adults ≥ 19 years of age
Risk group
All adults ≥ 65 years of age
CSF leak or cochlear implants
Functional or anatomic asplenia
Prevnar 13®
Yes
Yes
Yes
Immunocompetent persons with certain No
chronic medical conditions (e.g. heart
disease*, lung disease†, liver disease,
DM), alcoholism, cigarette smoking
““Õ˜œVœ“«Àœ“ˆÃi`Ê œÃÌ\ÊVœ˜}i˜ˆÌ>É Yes
acquired immunodeficiencies, HIV,
chronic renal failure, nephrotic
syndrome, hematologic malignancies,
organ transplant, long-term
immunosuppressive therapy (e.g.
steroids, active chemotherapy, radiation)
Pneumovax 23®
Yes
Yes
Yes, revaccinate 5
years after first dose
Yes
Yes, revaccinate 5
years after first dose
I˜VÕ`ˆ˜}Ê ]ÊV>À`ˆœ“Þœ«>Ì ˆiÃ]ÊiÝVÕ`ˆ˜}Ê Þ«iÀÌi˜Ãˆœ˜ÆÊa˜VÕ`ˆ˜}Ê "* ]Êi“« ÞÃi“>]Ê
asthma
Timing and sequential administration of pneumococcal vaccines
UÊ œÊ ˆÃ̜ÀÞʜÀÊ՘Ž˜œÜ˜Ê ˆÃ̜ÀÞʜvÊ«˜iՓœVœVV>ÊÛ>VVˆ˜>̈œ˜Ê>˜`ÊLœÌ Ê
vaccines are indicated, patient should receive Prevnar 13® first followed
by Pneumovax 23® at a minimum of 8 weeks later (ideally 6-12 months)
UÊvÊ«>̈i˜ÌÊ >ÃÊÀiViˆÛi`Ê*˜iՓœÛ>ÝÊÓή and both vaccines are indicated,
the patient should receive Prevnar 13® (minimum 1 year separation)
UÊvÊ«>̈i˜ÌÊ >ÃÊÀiViˆÛi`Ê*Àiۘ>Àʣή ≥ 8 weeks ago, and both vaccines
are indicated, the patient should receive Pneumovax 23® (minimum 8
weeks separation)
UÊvÊ«>̈i˜ÌÊ >ÃÊÀiViˆÛi`ÊLœÌ ÊÛ>VVˆ˜iÃÊ≥ 5 years ago and revaccination
is needed with Pneumovax 23®, a second dose should be administered
(minimum 5 years apart)
UÊ*>̈i˜ÌÃÊÜ œÊ>ÀiÊÃiÛiÀiÞʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê­i°}°Ê /]Ê܏ˆ`ʜÀ}>˜Ê
transplant) should follow institutional policy when available or consult ID
for optimal timing of vaccine administration
,iviÀi˜Vi\Ê
*Ê,iVœ““i˜`>̈œ˜Ã\Ê7,ÊÓä£{ÆÈέÎÇ®ÆnÓӇnÓxÊ>˜`Ê7,ÊÓä£ÓÆÈ£­{ä®Æn£È‡n£™°Ê
23
3.3 Agent-specific guidelines: Vaccines
Pneumococcal vaccination
There are two types of pneumococcal vaccines that are recommended
LÞÊ *Ê}Ո`iˆ˜iÃÊvœÀÊ>`ՏÌÊ«>̈i˜ÌÃ\Ê*˜iՓœVœVV>Ê«œÞÃ>VV >Àˆ`iÊ
(Pneumovax 23®, PPV23) and Pneumococcal conjugate vaccine (Prevnar
13®, PCV13). Most patients should receive both vaccines in sequential
order, but NEVER together. See table below for indications for each vaccine.
4.1 Organism-specific guidelines: Anaerobes
Organism-specific guidelines
Anaerobes
Although anaerobic bacteria dominate the human intestinal microbiome
only a few species seem to play an important role in human infections.
Infections caused by anaerobes are often polymicrobial.
UÊÊÀ>“‡˜i}>̈ÛiÊL>VˆˆÊ‡ÊBacteroides spp., Prevotella spp.,
Porphyromonas spp., Fusobacterium spp.
UÊÊÀ>“‡˜i}>̈ÛiÊVœVVˆÊ‡ÊVeillonella spp.
UÊÊÀ>“‡«œÃˆÌˆÛiÊL>VˆˆÊ‡ÊPropionibacterium spp., Lactobacillus spp.,
Actinomyces spp., Clostridium spp.
UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊ‡ÊPeptostreptococcus spp. and related genera
Clinical diagnosis of anaerobic infections should be suspected in the
presence of foul smelling discharge, infection in proximity to a mucosal
surface, gas in tissues or negative aerobic cultures. Proper specimen
VœiV̈œ˜ÊˆÃÊVÀˆÌˆV>ÆÊÀiviÀÊ̜ÊëiVˆ“i˜ÊVœiV̈œ˜Ê}Ո`iˆ˜iÃÊ>ÌÊ ÌÌ«\ÉÉ
www.hopkinsmedicine.org/microbiology/specimen/index.html
Treatment Notes
Metronidazole
Clindamycin
Ertapenem
Cefotetan
Pip/Tazo
Amox/Clav
Penicillin
# Patients
Hidden Content
- JHH Internal use only
.
UÊÊ-ÕÀ}ˆV>Ê`iLÀˆ`i“i˜ÌʜvÊ>˜>iÀœLˆVʈ˜viV̈œ˜ÃʈÃʈ“«œÀÌ>˜ÌÊLiV>ÕÃiÊ
anaerobic organisms can cause severe tissue damage.
UÊʓ«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê>˜`Ê ˆ˜`>“ÞVˆ˜Ê>ÀiÊVœ˜Ãˆ`iÀi`Ê̜ÊLiÊivviV̈ÛiÊ
empiric therapy against Gram-positive anaerobes seen in infections
24
Propionibacterium acnes
Indications for consideration of testing for P. acnes:
UÊ -Êà ՘Ìʈ˜viV̈œ˜Ã
UÊ*ÀœÃÌ ïVÊà œÕ`iÀʍœˆ˜Ìʈ˜viV̈œ˜ÃÊ
UÊ"Ì iÀʈ“«>˜Ì>LiÊ`iۈViʈ˜viV̈œ˜Ã
Diagnosis
UÊÊ ÕÌÕÀiÃÊà œÕ`ÊLiÊ i`ÊvœÀʣ䇣{Ê`>ÞÃʈvÊ ˆ} ÊÃÕëˆVˆœ˜ÊvœÀÊP. acnes
as growth is slow
UÊÊ œiV̈œ˜ÊœvÊ̈ÃÃÕiÊ>˜`ÊyՈ`ÊëiVˆ“i˜ÃÊvœÀÊVՏÌÕÀiʈÃÊ«ÀiviÀÀi`°Ê œÊ˜œÌÊ
send swabs for culture
UÊÊՏ̈«iÊÀi«ÀiÃi˜Ì>̈ÛiÊëiVˆ“i˜ÃÊ­«ÀiviÀ>LÞÊήÊà œÕ`ÊLiÊÃi˜ÌÊ
for shoulder joint infections to assist in distinguishing contaminants
from pathogenic isolates — these could include synovial fluid, any
inflammatory tissue, and synovium
U Tissue specimens should also be sent for histopathology
25
4.1 Organism-specific guidelines: Anaerobes
above the diaphragm. Metronidazole is not active against
microaerophilic streptococci (e.g. S. anginosus group) and should not
be used for these infections.
UÊÊ6>˜Vœ“ÞVˆ˜ÊˆÃÊ>ÃœÊ>V̈ÛiÊ>}>ˆ˜ÃÌʓ>˜ÞÊÀ>“‡«œÃˆÌˆÛiÊ>˜>iÀœLiÃÊ­i°}°Ê
Clostridium spp., Peptostreptococcus spp., P. acnes).
UÊÊ “«ˆÀˆVÊ`œÕLiÊVœÛiÀ>}iÊÜˆÌ ÊiÌÀœ˜ˆ`>✏iÊ ÊV>ÀL>«i˜i“ÃÊ
(Meropenem, Ertapenem) or beta-lactam/beta-lactamase inhibitors
(Ampicillin/Sulbactam, Piperacillin/Tazobactam, Amoxicillin/Clavulanic
acid) is NOT recommended given the excellent anaerobic activity of
these agents.
UÊÊB. fragilis group resistance to Clindamycin, Cefotetan, Cefoxitin, and
Moxifloxacin has increased and these agents should not be used
empirically for treatment of severe infections where B. fragilis is
suspected (e.g. intra-abdominal infections).
UÊʜÃÌÊÀiÈÃÌ>˜Viʈ˜ÊÌ iÊB. fragilis group is caused by beta-lactamase
production, which is screened for by the JHH micro lab.
UÊÊBacteroides thetaiotaomicron is less likely to be susceptible to
*ˆ«iÀ>Vˆˆ˜É/>âœL>VÌ>“ÆÊÌ iÀivœÀi]ÊÜ i˜ÊÌ ˆÃʜÀ}>˜ˆÃ“ʈÃʈ܏>Ìi`Ê
or strongly suspected (e.g. Gram negative rods in anaerobic blood
cultures in a patient on Piperacillin/tazobactam) alternative agents
with anaerobic coverage should be used until susceptibilities are
confirmed.
UÊÊ/ˆ}iVÞVˆ˜iʈÃÊ>V̈ÛiÊ>}>ˆ˜ÃÌÊ>Ê܈`iÊëiVÌÀՓʜvÊ}À>“‡«œÃˆÌˆÛiÊ>˜`Ê
gram-negative anaerobic bacteria in vitro but clinical experience with
this agent is limited.
4.2 Organism-specific guidelines: P. acnes
Treatment
UÊÊ*i˜ˆVˆˆ˜ÊÊӇÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê­«ÀiviÀÀi`®
OR
UÊ* Ê>iÀ}ÞÊ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
NOTES
UÊÊ ÊVœ˜ÃՏÌÊÀiVœ““i˜`i`ÊvœÀÊ>ÃÈÃÌ>˜ViÊÜˆÌ ÊV œˆViÊ>˜`Ê
duration of antibiotic therapy
UÊÊP. acnes is usually a contaminant in blood culture specimens. Draw
repeat cultures and consider clinical context before treatment
UÊÊ,>ÀiÊÀi«œÀÌÃʜvÊ눘>Êˆ˜viV̈œ˜ÃÊ >ÛiÊLii˜Ê˜œÌi`ÊvœÀÊP. acnes
UÊʏÊP. acnes isolutes at JHH are susceptible to Penicillin (see anaerobic
antibiogram p. 24)
UÊÊiÌÀœ˜ˆ`>✏iÊ`œiÃʘœÌÊ >ÛiÊ>V̈ۈÌÞÊ>}>ˆ˜ÃÌÊP. acnes. Tetracyclines
are not routinely tested and resistance rates are variable.
UÊÊ Àœ>`iÀÊëiVÌÀՓÊ>}i˜ÌÃÊÃÕV Ê>ÃÊiÀœ«i˜i“Ê>˜`Ê*ˆ«iÀ>Vˆˆ˜É
tazobactam would be expected to be active for Penicillin susceptible
isolates, but these are not first-line therapy
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊ`>Ì>Êà œÕ`ÊLiÊÕÃi`ÊÌœÊ i«Ê}Ո`iÊÌ iÀ>«iṎVÊ`iVˆÃˆœ˜Ã
U Consider removal of associated hardware
26
Viridans group Streptococci (alpha-hemolytic streptococci)
œÀ“>Ê“ˆVÀœLˆœÌ>ʜvÊÌ iʜÀ>ÊV>ۈÌÞÊ>˜`ÊÊÌÀ>VÌÆÊȘ}iÊLœœ`ÊVՏÌÕÀiÃÊ
growing these organisms often represent contamination or transient
bacteremia
Five groups
UÊÊS. anginosus group (contains S. intermedius, anginosus, and
constellatus®\ÊÊVœ““œ˜ÞÊV>ÕÃiÊ>LÃViÃÃiÃÆʓ>œÀˆÌÞÊ>ÀiÊ*i˜ˆVˆˆ˜Ê
susceptible
UÊÊS. bovisÊ}ÀœÕ«ÊQVœ˜Ì>ˆ˜ÃÊS. gallolyticus subspecies gallolyticus
(associated with colon cancer—colonoscopy mandatory, endocarditis
>ÃœÊ«ÀiÃi˜Ìʈ˜Ê€Êxä¯ÊœvÊV>ÃiîÊ>˜`ÊÃÕLëiVˆiÃÊpasteurinus
­>ÃÜVˆ>Ìi`ÊÜˆÌ Ê i«>̜Lˆˆ>ÀÞÊ`ˆÃi>Ãi]Êi˜`œV>À`ˆÌˆÃʏiÃÃÊVœ““œ˜®RÆÊ
majority are Penicillin susceptible
UÊS. mitis group (contains S. mitis, oralis, gordonii, and sanguinous®\Ê
Vœ““œ˜ÞÊV>ÕÃiÊL>VÌiÀi“ˆ>ʈ˜Ê˜iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ>˜`Êi˜`œV>À`ˆÌˆÃÆÊ
many have Penicillin resistance
UÊÊS. salivariusÊ}ÀœÕ«\ʏiÃÃÊVœ““œ˜ÊV>ÕÃiʜvÊi˜`œV>À`ˆÌˆÃÆʓ>œÀˆÌÞÊ>ÀiÊ
Penicillin susceptible
UÊÊS. mutansÊ}ÀœÕ«\ÊVœ““œ˜ÊV>ÕÃiʜvÊ`i˜Ì>ÊV>ÀˆiÃÆÊ՘Vœ““œ˜ÊV>ÕÃiÊ
œvÊi˜`œV>À`ˆÌˆÃÆʓ>œÀˆÌÞÊ>ÀiÊ*i˜ˆVˆˆ˜ÊÃÕÃVi«ÌˆLi
Beta-hemolytic Streptococci
All are susceptible to Penicillin
6>Àˆ>LiÊÀ>ÌiÃʜvÊÀiÈÃÌ>˜ViÊÌœÊ ˆ˜`>“ÞVˆ˜ÆÊ>ÎÊÌ iʓˆVÀœLˆœœ}ÞÊ
laboratory to perform susceptibility testing if you plan to use
Clindamycin or macrolides for moderate to severe infections.
While anti-staphylococcal penicillins (Oxacillin and Nafcillin) are the
agents of first choice for susceptible S. aureus infections, their activity
against streptococci is sub-optimal
ˆ} ÊÀ>ÌiÃʜvÊÀiÈÃÌ>˜ViÊ̜ÊÌiÌÀ>VÞVˆ˜iÃÊ>˜`Ê/*É-8Ê«ÀiVÕ`iÊÌ iˆÀÊ
empiric use for infections suspected to be caused by beta-hemolytic
streptococci
UÊÊS. pyogenesÊ­}ÀœÕ«ÊÊÃÌÀi«®\Ê« >Àޘ}ˆÌˆÃ]ÊΈ˜Ê>˜`ÊÜvÌÊ̈ÃÃÕiÊ
ˆ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ÊiÀÞÈ«i>Ã]ÊViÕˆÌˆÃ]ʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃÆÊ
ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜Ê£°x‡x°Ó¯Æʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜Ê{‡Ç¯°Ê
UÊÊS. agalactiaeÊ­}ÀœÕ«Ê ÊÃÌÀi«®\ʘiœ˜>Ì>Êˆ˜viV̈œ˜Ã]ʈ˜viV̈œ˜ÃʜvÊÌ iÊ
vi“>iÊ}i˜ˆÌ>ÊÌÀ>VÌ]ÊΈ˜Ê>˜`ÊÜvÌÊ̈ÃÃÕiʈ˜viV̈œ˜Ã]ÊL>VÌiÀi“ˆ>ÆÊ
ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜Ê£È‡ÓȯÆʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜ÊLJÎÓ¯°Ê
27
4.3 Organism-specific guidelines: Streptococci
Streptococci
4.3 Organism specific guidelines: Multi-drug resistant Gram-negative rods
UÊÊÀœÕ«Ê Ê>˜`ÊÊÃÌÀi«ÌœVœVVˆ\ʈ˜viV̈œ˜ÃÊȓˆ>ÀÊ̜ÊS. pyogenes and
S. agalactiaeÆÊ>ÃÜVˆ>Ìi`ÊÜˆÌ Ê՘`iÀÞˆ˜}Ê`ˆÃi>ÃiÃÊ­i°}°Ê`ˆ>LiÌiÃ]Ê
“>ˆ}˜>˜VÞ]ÊV>À`ˆœÛ>ÃVՏ>ÀÊ`ˆÃi>Ãi®ÆÊ ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜ÊH£È¯Ê
œvÊ}ÀœÕ«Ê Ê>˜`ÊHÎίʜvÊ}ÀœÕ«Êʈ܏>ÌiÃÆʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜Ê
HÓx¯ÊœvÊ}ÀœÕ«Ê Ê>˜`ÊHÓn¯ÊœvÊ}ÀœÕ«Êʈ܏>ÌiðÊ
Streptococcus pneumoniae
UÊÊ œ““œ˜ÊV>ÕÃiʜvÊÀiëˆÀ>̜ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ʜ̈̈Ãʓi`ˆ>]Ê
ȘÕÈ̈Ã]Ê«˜iՓœ˜ˆ>Êۈ>ʏœV>ÊëÀi>`ÊvÀœ“ÊÌ iʘ>Ü« >ÀޘÝÆʈ˜viV̈œ˜ÃÊ
involving the CNS, bones/joints and endocarditis via hematogenous
spread
UÊÊi˜ïV>Þ]ÊS. pneumoniae is in the S. mitis group of viridans group
ÃÌÀi«ÌœVœVVˆÆÊVœ˜ÃiµÕi˜ÌÞ]ÊÀ>«ˆ`ʓœiVՏ>ÀÊÌiÃÌÃʓ>ÞʘœÌÊLiÊ>LiÊ̜Ê
distinguish S. pneumoniae and streptococci in the S. mitis group.
UÊÊ*i˜ˆVˆˆ˜ÊˆÃÊÌ iÊ>}i˜ÌʜvÊwÀÃÌÊV œˆViÊvœÀÊÃiÀˆœÕÃÊS. pneumoniae
infections when it is susceptible
UÊÊ*i˜ˆVˆˆ˜Ê>˜`Ê ivÌÀˆ>ݜ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊLÀi>Ž«œˆ˜ÌÃÊ>ÀiÊ`ˆvviÀi˜ÌÊvœÀÊ
CNS and non-CNS sites
MIC breakpoints for Penicillin and Ceftriaxone against
S. pneumoniae
Antibiotic
Penicillin (oral)
Penicillin (parenteral)
Non-CNS
CNS
Ceftriaxone
Non-CNS
CNS
Susceptible
≤ 0.06
Intermediate
0.12-1
Resistant
≥2
≤2
≤ 0.06
4
≥8
≥ 0.12
≤1
≤ 0.5
2
1
≥4
≥2
UÊÊ``ˆÌˆœ˜ÊœvÊ6>˜Vœ“ÞVˆ˜ÊÌœÊ ivÌÀˆ>ݜ˜iʈÃʘœÌʈ˜`ˆV>Ìi`ʈ˜ÊÌ iÊi“«ˆÀˆVÊ
treatment of non-CNS infections caused by S. pneumoniae due to low
rates of resistance
Multi-drug resistant Gram-negative rods
Patients with infection or colonization with the resistant
organisms listed below should be placed on CONTACT
precautions (see isolation chart on p. 141)
Extended spectrum beta-lactamase (ESBL)-producing organisms
UÊÊ - ÃÊ>ÀiÊi˜âޓiÃÊÌ >ÌÊVœ˜viÀÊÀiÈÃÌ>˜ViÊ̜Ê>Ê«i˜ˆVˆˆ˜Ã]Ê
cephalosporins, and Aztreonam.
UÊÊ/ iÞÊ>ÀiʓœÃÌÊVœ““œ˜ÞÊÃii˜Êˆ˜ÊK. pneumoniae and K. oxytoca,
E. coli, and P. mirabilis, and these organisms are automatically
screened by the JHH microbiology lab for the presence of ESBLs.
28
/Ài>̓i˜Ì\
UÊÊiÀœ«i˜i“Ê£Ê}Ê6Ê+nÊ­ÓÊ}Ê6Ê+nÊvœÀÊ -ʈ˜viV̈œ˜Ã®Êà œÕ`ÊLiÊ
used for ALL severe infections if the organism is susceptible.
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ÊV>˜ÊLiÊÕÃi`ÊvœÀÊ՘Vœ“«ˆV>Ìi`Ê1/ʜÀÊÜvÌÊ̈ÃÃÕiÊ
infection with adequate source control if the organism is susceptible.
UÊÊ ˆ«ÀœyœÝ>Vˆ˜ÊœÀÊ/*É-8ÊV>˜ÊLiÊÕÃi`Ê>ÃÊ>ÌiÀ˜>̈ÛiÃÊÌœÊ ÀÌ>«i˜i“Ê
for uncomplicated UTI or soft tissue infection with adequate source
control if the organism is susceptible. Nitrofurantoin may also be used
for uncomplicated UTI if the organism is susceptible.
Carbapenemase-producing Enterobacteriacae (CRE)
UÊ >ÀL>«i˜i“>ÃiÃÊ>ÀiÊi˜âޓiÃÊÌ >ÌÊVœ˜viÀÊÀiÈÃÌ>˜ViÊ̜Ê>Ê«i˜ˆVˆˆ˜Ã]Ê
cephalosporins, carbapenems and Aztreonam.
UÊʓˆVÀœLˆœœ}Þʏ>LʈÃʘœÊœ˜}iÀÊ«iÀvœÀ“ˆ˜}ÊÌ iʓœ`ˆwi`ʜ`}iÊÌiÃÌ
UÊvÊV>ÀL>«i˜i“ʈÃÊÀiÈÃÌ>˜ÌÊʓˆVÀœLˆœœ}Þʏ>LÊ܈ÊÀi«œÀÌʜÀ}>˜ˆÃ“Ê
>ÃʺV>ÀL>«i˜i“ÊÀiÈÃÌ>˜Ì»ÆÊ œÜiÛiÀ]ÊÌ iÊiÝ>VÌʓiV >˜ˆÃ“ÊœvÊ
resistance is not tested for at this time.
/Ài>̓i˜Ì\Ê
UÊiÀœ«i˜i“ÊÓÊ}Ê6Ê+nʈ˜vÕÃi`ʜÛiÀÊÎÊ œÕÀÃÊà œÕ`ÊLiʈ˜VÕ`i`Ê
in most regimens based on data from small, retrospective studies
showing benefit even when the isolate is intermediate or resistant.
UÊÌʏi>ÃÌʜ˜iÊ>``ˆÌˆœ˜>Ê>}i˜ÌÊà œÕ`ÊLiÊ>``i`ÊL>Ãi`ʜ˜ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ
(e.g. Amikacin, Tigecycline, Colistin) except for UTI.
Multi-drug resistant (MDR) gram-negative organisms: defined as
organisms susceptible to NO MORE than ONE of the following antibiotic
V>ÃÃiÃ\ÊV>ÀL>«i˜i“Ã]Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]Êy՜ÀœµÕˆ˜œœ˜iÃ]Ê«i˜ˆVˆˆ˜Ã]Ê
or cephalosporins. Note: susceptibility to sulfonamides, tetracyclines,
polymixins, and Sulbactam are NOT considered in this definition
Treatment
MDR Pseudomonas aeruginosa
MDR Acinetobacter baumannii/calcoaceticus
complex
UÊÊ iv̜œâ>˜iÉÌ>âœL>VÌ>“ÊÊ
(if susceptible)
ORÊ
UÊʘ̈‡«ÃiÕ`œ“œ˜>Ê-lactam PLUS
ÊÊÊ>“ˆ˜œ}ÞVœÃˆ`iʈvÊÃޘiÀ}ÞÊ«Ài`ˆVÌi`ÊÊ
or confirmed
OR
UÊÊ œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê
Ê
UÊ-lactam PLUS aminoglycoside if synergy expected
OR
UÊÊ œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê
OR
UÊʓ«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê­ˆvÊÃÕÃVi«ÌˆLi®ÊPLUS
aminoglycoside (Sulbactam component has in vitro
activity against Acinetobacter spp.)
ÊÊÊOR
UÊÊ/ˆ}iVÞVˆ˜iÊ­ˆvÊÃÕÃVi«ÌˆLiÆÊvœÀʈ˜viV̈œ˜ÃÊœÌ iÀÊÌ >˜Ê
bacteremia)
*Combination therapy should be considered in severe infections.
29
4.4 Organism specific guidelines: Multi-drug resistant Gram-negative rods
UÊÊ,ˆÃŽÊv>V̜ÀÃÊvœÀʈ˜viV̈œ˜ÊœÀÊVœœ˜ˆâ>̈œ˜\ÊÀiVi˜ÌÊ œÃ«ˆÌ>ˆâ>̈œ˜Ê>ÌÊ>˜Ê
institution with a high rate of ESBLs, residence in a long-term care
facility and prolonged use of broad spectrum antibiotics.
4.4 Organism specific guidelines: Multi-drug resistant Gram-negative rods
Synergy:
UÊvÊÌ iʜÀ}>˜ˆÃ“ʈÃʈ˜ÌiÀ“i`ˆ>ÌiÊ̜Ê>ÊLiÌ>‡>VÌ>“Ê>˜`ÊÃÕÃVi«ÌˆLiÊ̜Ê
aminoglycosides, synergy can be assumed.
UÊ/ iʓˆVÀœLˆœœ}Þʏ>LÊ`œiÃʘœÌÊ«iÀvœÀ“ÊÃޘiÀ}ÞÊÌiÃ̈˜}°Ê
Antibiotic doses for MDR and carbapenemase-producing
infections – normal renal and hepatic function
UÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n]ʈ˜vÕÃiʜÛiÀÊÎÊ œÕÀÃÊ
UÊ ivi«ˆ“i\ÊÓÊ}Ê6Ê+n]ʈ˜vÕÃiʜÛiÀÊÎÊ œÕÀÃ
UÊ ivÌ>âˆ`ˆ“iÉ ivi«ˆ“i\ÊÓÊ}Ê6ÊLœÕÃʏœ>`ˆ˜}Ê`œÃiʜÛiÀÊÎäʓˆ˜ÕÌiÃ]Ê
then 6 g IV as continuous infusion over 24 hours
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“\ÊΰÎÇxÊ}Ê6ÊLœÕÃʏœ>`ˆ˜}Ê`œÃiʜÛiÀÊÎäÊ
minutes, then continuous infusion 3.375 g IV Q4H infused over 4
hours OR 4.5 g IV Q6H, infuse over 4 hours
UÊ œˆÃ̈˜\Êxʓ}Ɏ}ʜ˜Vi]ÊÌ i˜ÊÓ°xʓ}Ɏ}Ê6Ê+£ÓÊ­vœÀÊ>``ˆÌˆœ˜>Ê
information, see p. 9)
Uʓ«ˆVˆˆ˜ÉÃՏL>VÌ>“\ÊÎÊ}Ê6Ê+{Ê­vœÀÊ ,ÊA. baumannii only)
Uʓˆ˜œ}ÞVœÃˆ`iÃÊ­vœÀÊ`œÃˆ˜}]ÊÃiiÊ«°Ê£{È®
UÊ/ˆ}iVÞVˆ˜i\Ê£ä䇣xäʓ}Ê6Ê+£ÓÊ
UÊ iv̜œâ>˜iÉÌ>âœL>VÌ>“Ê£°x‡ÎÊ}Ê6Ê+n
,iviÀi˜ViÃ\Ê
- ÃÊ>˜`ÊVˆ˜ˆV>ÊœÕÌVœ“iÃ°Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£x\ÊÈ䭙®\ʣΣ™\Óx°
Current therapies for P. aeruginosa°Ê ÀˆÌÊ >ÀiÊ ˆ˜ÊÓäänÆÓ{\ÓÈ£°Ê
œ“Lˆ˜>̈œ˜ÊÌ iÀ>«ÞÊvœÀÊ , °Ê ˆ˜ÊˆVÀœLˆœÊ˜viVÊÓä£{ÆÓä\ÊnÈӇÇÓ°
30
Gram-positive cocci
Gram-negative cocci
Aerobic
In clusters
UÊ œ>}Տ>ÃiÊ­³®\ÊS. aureus
UÊÊ œ>}Տ>ÃiÊ­q®\ÊS. epidermidis,
S. lugdunensis
In pairs/chains
UÊÊ ˆ«œVœVVÕÃ]Ê+ÕiÕ˜}Ê«œÃˆÌˆÛi\Ê
S. pneumoniae
UÊʏ« >‡ i“œÞ̈V\Ê6ˆÀˆ`>˜ÃÊ}ÀœÕ«ÊÊ
Streptococci, Enterococcus
(faecalis and faecium)
UÊÊ iÌ>‡ i“œÞ̈V\Ê
Group A strep (S. pyogenes),
Group B strep (S. agalactiae),
Group C, D, G strep
Aerobic
ˆ«œVœVVÕÃ\ÊN. meningiditis, N.
gonorrhoeae, Moraxella catarrhalis
œVVœ‡L>VˆÕÃ\ H. flu, Acinetobacter spp.,
HACEK organisms
Anaerobic: Peptostreptococcus spp.
Anaerobic: Veillonella spp.
Gram-positive rods
Gram-negative rods
Aerobic
>À}i\ Bacillus spp.
œVVœ‡L>VˆÕÃ\ÊListeria monocytogenes,
Lactobacillus spp.
-“>]Ê«iœ“œÀ« ˆV\ Corynebacterium spp.
À>˜V ˆ˜}Êw>“i˜ÌÃ\ Nocardia spp.,
Streptomyces spp.
Aerobic
Lactose fermenting: Citrobacter spp.,
Enterobacter spp., E. coli, Klebsiella
spp., Serratia spp.*
Non-lactose fermenting
UÊÊ"݈`>ÃiÊ­q®: Acinetobacter spp.,
Burkholderia spp., E. coli (rare), Proteus
spp., Salmonella spp., Shigella spp.,
Serratia spp.*, Stenotrophomonas
maltophilia
UÊÊ"݈`>ÃiÊ ­³®\Ê P. aeruginosa, Aeromonas
spp., Vibrio spp., Campylobacter spp.
(curved)
Anaerobic
>À}i\ÊClostridium spp.
Small, pleomorphic: P. acnes, Actinomyces
spp.
Anaerobic: Bacteroides spp.,
Fusobacterium spp., Prevotella spp.
* Serratia spp. can appear initially as non-lactose fermenting due to slow fermentation.
The Johns Hopkins microbiology laboratory utilizes standard reference
methods for determining susceptibility. The majority of isolates are
tested by the automated system.
The minimum inhibitory concentration (MIC) value represents the
concentration of the antimicrobial agent required at the site of infection
for inhibition of the organism.
The MIC of each antibiotic tested against the organism is reported
with one of three interpretations S (susceptible), I (intermediate), or
R (resistant). The highest MIC which is still considered susceptible
represents the breakpoint concentration. This is the highest MIC which
is usually associated with clinical efficacy. MICs which are 1⁄ 2 q 1⁄ 8 the
31
5.1 Interpreting the microbiology report
Interpreting the microbiology report
Interpretation of preliminary microbiology data
5.1 Interpreting the microbiology report
breakpoint MIC are more frequently utilized to treat infections where
antibiotic penetration is variable or poor (endocarditis, meningitis,
osteomyelitis, pneumonia, etc.). Similarly, organisms yielding antibiotic
MICs at the breakpoint frequently possess or have acquired a low-level
resistance determinant with the potential for selection of high-level
expression and resistance. This is most notable with cephalosporins
and Enterobacter spp., Serratia spp., Morganella spp., Providencia
spp., Citrobacter spp. and Pseudomonas aeruginosa. These organisms
all possess a chromosomal beta-lactamase which frequently will be
over-expressed during therapy despite initial in vitro susceptibility. The
intermediate (I) category includes isolates with MICs that approach
attainable blood and tissue levels, but response rates may be lower than
fully susceptible isolates. Clinical efficacy can potentially be expected in
body sites where the drug is concentrated (e.g., aminoglycosides and
beta-lactams in urine) or when a higher dose of the drug can be used
(e.g., beta-lactams). The resistant (R) category indicates the organism
will not be inhibited by usually achievable systemic concentrations of the
antibiotic of normal doses.
NOTE: MIC values vary from one drug to another and from one
bacterium to another, and thus MIC values are NOT comparable
between antibiotics or between organisms.
Spectrum of antibiotic activity
The spectrum of activity table is an approximate guide of the activity of
commonly used antibiotics against frequently isolated bacteria. It takes
into consideration JHH specific resistance rates, in vitro susceptibilities
and expert opinion on clinically appropriate use of agents. For antibiotic
recommendations for specific infections refer to relevant sections of the
JHH Antibiotic Guidelines.
32
Penicillin G
Ampicillin
Ampicillin/sulbactam
Oxacillin/Nafcillin
Piperacillin/tazobactam
Cefazolin
Cefotetan
Ceftriaxone
Cefepime
Aztreonam
Ertapenem
Meropenem
Moxifloxacin
Ciprofloxacin
Azithromycin
Gent/Tobra/Amikacin
Vancomycin
Linezolid
Daptomycin
Ê
/*É-8
Clindamycin
Doxycycline
Colistin
Metronidazole
E. faecalis
Not active
GRAM-POSITIVE
E. coli
H. influenzae
Viridans strep.
S. pneumoniae
Less active or potential resistance
GRAM-NEGATIVE
Enterobacter spp.
Abdominal anaerobes
Oral anaerobes
Pseudomonas spp.
Serratia spp.
Proteus spp.
Kebsiella spp.
-hemolytic strep.
Coag. neg. staph
MSSA
MRSA
VRE
33
5.2 Spectrum of antibiotic activity
Active
Atypicals
5.3 Interpretation of rapid diagnostic tests
Interpretation of rapid diagnostic tests
The JHH microbiology lab performs rapid nucleic acid microarray testing
on blood cultures growing Gram-positive organisms and peptide nucleic
acid fluorescence in situ hybridization (PNA-FISH) testing on blood
cultures growing yeast.
Nucleic acid microarray testing (Verigine®) for Gram-positive
cocci in blood cultures
UÊÊ iÌiVÌÃÊ>˜`ʈ`i˜ÌˆwiÃÊÌ iʘÕViˆVÊ>Vˆ`ÃʜvÊ£ÓÊÀ>“‡«œÃˆÌˆÛiÊL>VÌiÀˆ>Ê
genera/species and 3 resistance markers.
UÊÊ >VÌiÀˆ>ÊëiVˆiÃ\ÊS. aureus, Coagulase-negative staphylococci, S.
lugdunensis, Staphylococcus spp. E. faecalis, E. faecium, S. pyogenes
(group A streptococci), S. agalactiae (group B streptococci), S.
pneumoniae, S. anginosus, Streptococcus spp. (e.g.,group C and G
streptococci, viridans group streptococci, etc.), Listeria spp.
UÊ,iÈÃÌ>˜Viʓ>ÀŽiÀÃ\ʓiV]ÊÛ>˜]ÊÛ>˜
Ê UÊÊvÊS. aureus is mecA positive the organism is resistant to Methicillin
and is reported as MRSA
Ê UÊÊvÊS. aureus is mecA negative the organism is susceptible to
Methicillin and is reported as MSSA
Ê UÊÊvÊ °Êfaecalis/faecium is vanA/B positive the organism is resistant
̜Ê6>˜Vœ“ÞVˆ˜ÊÊ>˜`ʈÃÊÀi«œÀÌi`Ê>ÃÊ6, ÆʘœÌiÊÌ >ÌÊ>Ê6>˜Vœ“ÞVˆ˜‡
resistant E. faecalis are susceptible to Ampicillin at JHH
UÊÊ,iÃՏÌÃʜvÊÌ iÊÌiÃÌÊ>ÀiÊÀi«œÀÌi`ÊÜˆÌ ˆ˜Ê·{Ê œÕÀÃÊ>vÌiÀÊÌ iÊLœœ`Ê
cultures turn positive
UÊ/iÃ̈˜}ʈÃÊ«iÀvœÀ“i`ʜ˜Þʜ˜ÊÌ iÊwÀÃÌÊ«œÃˆÌˆÛiÊLœœ`ÊVՏÌÕÀiÊ
UÊÊ/iÃ̈˜}ʈÃÊ "/Ê«iÀvœÀ“i`ʜ˜ÊLœœ`ÊVՏÌÕÀiÃÊ}ÀœÜˆ˜}ʓœÀiÊÌ >˜Êœ˜iÊ
Gram positive organism but is performed on blood cultures growing
both Gram positive and negative organisms
UÊÊvÊÌ iÊÌiÃÌʈÃʘi}>̈ÛiʈÌÊ܈ÊLiÊÀi«œÀÌi`Ê>Ãʘi}>̈ÛiÊvœÀÊÌ iÊvœœÜˆ˜}Ê
œÀ}>˜ˆÃ“Ã\Ê-Ì>« ޏœVœVVÕÃÊë«]ÊStreptococcus spp., E. faecalis, E.
faecium, Listeria spp.
34
Preferred empiric therapy
Alternative empiric therapy
(% susceptible in blood at JHH) if PCN allergic
MSSA Ê
"Ý>Vˆˆ˜Ê­£ä䯮Ê
œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜Ê
Ê
Ê
-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
MRSAÊ
6>˜Vœ“ÞVˆ˜Ê­£ä䯮Ê
>«Ìœ“ÞVˆ˜
Ê
-ˆ˜}iÊ«œÃˆÌˆÛiÊVՏÌÕÀiÃÊ>ÀiʜvÌi˜Ê>ÊVœ˜Ì>“ˆ˜>˜ÌÆʘœÊÌÀi>̓i˜ÌÊ
Coagulase-negative recommended. See p. 60 of the JHH Antibiotic Guidelines for
staphylococci
information and indications for treatment. Call the microbiology lab for
more information and further work up if infection suspected (5-6510).
"Ý>Vˆˆ˜Ê­™È¯®ÊœÀÊ >«Ìœ“ÞVˆ˜Ê
S. lugdunensisÊ
6>˜Vœ“ÞVˆ˜Ê­£ä䯮2Ê
E. faecalisÊ
“«ˆVˆˆ˜Ê­™n¯®Ê
6>˜Vœ“ÞVˆ˜Ê­™x¯®1
3
E. faecium (VRE)Ê
ˆ˜i✏ˆ`Ê­nǯ® Ê
>«Ìœ“ÞVˆ˜Ê­™Ç¯®
E. faecium (not VRE)Ê6>˜Vœ“ÞVˆ˜Ê­£ä䯮3
Linezolid
4
Streptococcus spp.Ê œ˜‡œ˜Vœœ}ÞÊ«>̈i˜Ì\Ê ivÌÀˆ>ݜ˜i -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
Ê
"˜Vœœ}ÞÊ«>̈i˜Ì\Ê6>˜Vœ“ÞVˆ˜4
S. anginosus Ê
*i˜ˆVˆˆ˜ÊÊ­£ä䯮Ê
œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜i
Ê
Ê
-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
S. pyogenes Ê
*i˜ˆVˆˆ˜ÊÊ­£ä䯮Ê
œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜
(group A strep)
-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
S. agalactiae Ê
*i˜ˆVˆˆ˜ÊÊ­£ä䯮Ê
œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜
(group B strep)
Ê
-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
4
S. pneumoniae Ê
ivÌÀˆ>ݜ˜iÊ­£ä䯮 Ê
-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1
(not meningitis)
S. pneumoniae Ê
ivÌÀˆ>ݜ˜iʳÊ6>˜Vœ“ÞVˆ˜ÊÊ
-iÛiÀiÊ* Ê>iÀ}Þ\Ê
(meningitis)
œÀ>“« i˜ˆVœÊ³Ê6>˜Vœ“ÞVˆ˜1
Listeria spp. Ê
“«ˆVˆˆ˜Ê­£ä䯮Ê
/Àˆ“iÌ œ«Àˆ“ÉÃՏv>“iÌ œÝ>✏i
1Consult
allergy for skin testing /desensitization
to Oxacillin if found to be susceptible
to Ampicillin if found to be susceptible
4Narrow to Penicillin G if found to be susceptible
2Narrow
3Narrow
PNA-FISH for yeast
UÊÊvÊ* ‡-Êà œÜÃÊC. albicans, most non-oncology patients without
prior azole exposure can be treated with fluconazole. For more
information see p. 117 and 134.
UÊÊvÊ* ‡-Êà œÜÃÊC. glabrata, treat with Micafungin until
susceptibilities available. For more information see p. 117 and 134.
UÊÊvÊ* ‡-ʘi}>̈ÛiÊvœÀÊC. albicans or C. glabrata, most cases can be
treated as unspeciated candidemia, unless cryptococcus is suspected
(send serum cryptococcal antigen). For more information see p. 117
and 134.
35
5.3 Interpretation of rapid diagnostic tests
Organism
6.1 Abdominal infections
Biliary tract infections – cholecystitis and
cholangitis
EMPIRIC TREATMENT
Community-acquired infections in patients without previous
biliary procedures AND who are not severely ill
UÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£Ó
Hospital-acquired infections OR patients with multiple therapeutic
biliary manipulations (e.g. stent placement/exchange, bilio-enteric
anastamosis of any severity) OR patients who are severely ill
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊPLUS Metronidazole 500
mg IV Q8H Vancomycin (see dosing section, p. 150)
In severely ill patients with cholangitis and complicated cholecystitis,
adequate biliary drainage is crucial as antibiotics will not enter bile in
the presence of obstruction.
Duration
UÊÊUncomplicated cholecystitis\ÊÌÀi>Ìʜ˜ÞÊ՘̈ÊœLÃÌÀÕV̈œ˜ÊˆÃÊÀiˆiÛi`°Ê
NO post-procedure antibiotics are necessary if the obstruction is
successfully relieved.
UÊÊ œ“«ˆV>Ìi`ÊV œiVÞÃ̈̈Ã\Ê{Ê`>ÞÃ]Ê՘iÃÃÊ>`iµÕ>ÌiÊÜÕÀViÊVœ˜ÌÀœÊˆÃÊ
not achieved.
U Ê ˆˆ>ÀÞÊÃi«ÃˆÃ\Ê{‡ÇÊ`>ÞÃ]Ê՘iÃÃÊ>`iµÕ>ÌiÊÜÕÀViÊVœ˜ÌÀœÊˆÃʘœÌÊ
achieved.
TREATMENT NOTES
Microbiology
UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`ÃÊqÊE. coli, Klebsiella spp., Proteus spp.,
P. aeruginosa (mainly in patients already on broad-spectrum antibiotics
or those who have undergone prior procedures)
UÊʘ>iÀœLiÃÊqÊBacteroides spp., generally in more serious infections, or
ˆ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê>Ê ˆÃ̜ÀÞʜvÊLˆˆ>ÀÞʓ>˜ˆ«Õ>̈œ˜ÃÆÊÀ>Àiʈ˜Ê՘Vœ“«ˆV>Ìi`Ê
and community-acquired infections
UÊÊEnterococcus spp°ÊqÊÌÀi>̓i˜ÌʘœÌÊ>Ü>ÞÃʈ˜`ˆV>Ìi`ÆÊÕÃiÊVˆ˜ˆV>ÊÕ`}“i˜Ì
UÊÊ9i>ÃÌÊqÊÀ>Ài
39
6.1 Abdominal infections
Management
UÊʘÊV>ÃiÃʜvÊ՘Vœ“«ˆV>Ìi`Ê>VÕÌiÊV œiVÞÃ̈̈Ã]Ê>˜ÌˆLˆœÌˆVÃÊà œÕ`ÊLiÊ
given until the biliary obstruction is relieved (either by surgery, ERCP,
or percutaneous drain).
UÊÊ/Ài>̓i˜ÌʜvÊi˜ÌiÀœVœVVˆÊˆÃÊÕÃÕ>ÞʘœÌʘii`i`ʈ˜Ê“ˆ`ɓœ`iÀ>ÌiÊ
disease.
UÊÊ9i>ÃÌÊ}i˜iÀ>ÞÊà œÕ`ÊLiÊÌÀi>Ìi`ʜ˜ÞʈvÊÌ iÞÊ>ÀiÊÀiVœÛiÀi`ÊvÀœ“Ê
biliary cultures, not empirically.
,iviÀi˜ViÃ\
ˆˆ>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ã\Ê ÀÕ}ÃÊ£™™™ÆxÇ­£®\n£‡™£°
-ÊՈ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£äÆxä\£ÎÎq£È{°
- œÀÌÊVœÕÀÃiÊÌ iÀ>«ÞÊvœÀÊ\Ê Ê ˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°
Diverticulitis
EMPIRIC TREATMENT
NOTE: Patients with uncomplicated diverticulitis (defined as CT
Vœ˜wÀ“i`ʏiv̇È`i`Ê`ˆÃi>ÃiÊÜˆÌ œÕÌÊ>LÃViÃÃÆÊvÀiiÊ>ˆÀʜÀÊwÃÌՏ>ʱ fever
and elevated inflammatory markers), can be treated conservatively
without antibiotics based on a RCT.
Mild/moderate infections – can be oral if patient can take PO
UÊʓœÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê+£Ó
OR
UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Metronidazole 500 mg IV/PO Q8H
OR
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQ ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£ÓÊ",Ê ˆ«ÀœyœÝ>Vˆ˜Ê
xääʓ}Ê*"Ê+£ÓRÊPLUS Metronidazole 500 mg IV/PO Q8H
Severe infections
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQ ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£ÓÊ",ÊâÌÀiœ˜>“Ê
£Ê}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV Q8H
Duration
UÊ{Ê`>ÞÃ]Ê՘iÃÃÊ>`iµÕ>ÌiÊÜÕÀViÊVœ˜ÌÀœÊˆÃʘœÌÊ>V ˆiÛi`°
40
Microbiology
UÊʏ“œÃÌÊ>Êˆ˜viV̈œ˜ÃÊ>ÀiÊ«œÞ“ˆVÀœLˆ>
UÊʜÃÌÊVœ““œ˜Þʈ܏>Ìi`Ê>iÀœLˆVʜÀ}>˜ˆÃ“ÃÊqÊE. coli, K. pneumoniae,
Enterobacter spp., Proteus spp., Enterococcus spp.
UÊʜÃÌÊVœ““œ˜Þʈ܏>Ìi`Ê>˜>iÀœLˆVʜÀ}>˜ˆÃ“ÃÊqÊB. fragilis, Prevotella,
Peptostreptococci
Other considerations
UÊʘ̈“ˆVÀœLˆ>ÊÌÀi>̓i˜ÌÊvœÀÊ>VÕÌiÊ՘Vœ“«ˆV>Ìi`Ê`ˆÛiÀ̈VՏˆÌˆÃʓ>ÞʘœÌÊ
accelerate recovery or prevent complications/recurrence.
UÊÊ /ÊÃV>˜ÊˆÃʈ“«œÀÌ>˜Ìʈ˜Ê>ÃÃiÃȘ}ʘii`ÊvœÀÊ`À>ˆ˜>}iʈ˜ÊÃiÛiÀiÊ`ˆÃi>Ãi°ÊÊ
,iviÀi˜Vi\
-ÊՈ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£äÆxä\£ÎÎq£È{°
˜ÌˆLˆœÌˆVÃʈ˜Ê>VÕÌiÊ՘Vœ“«ˆV>Ìi`Ê`ˆÛiÀ̈VՏˆÌˆÃ°Ê ÀÊÊ-ÕÀ}ÊÓä£Óƙ™\xÎÓqxΙ°
- œÀÌÊVœÕÀÃiÊÌ iÀ>«ÞÊvœÀÊ\Ê Ê ˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°
Pancreatitis
TREATMENT
UÊʘ̈LˆœÌˆVÊ«Àœ« ޏ>݈ÃʈÃÊ "/ʈ˜`ˆV>Ìi`ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ ÊÃiÛiÀiÊ>VÕÌiÊ
pancreatitis (SAP), including those with sterile pancreatic necrosis.
Uʘ̈“ˆVÀœLˆ>ÊÌ iÀ>«ÞÊ >ÃʘœÊivviVÌʜ˜Ê“œÀLˆ`ˆÌÞÊ>˜`ʓœÀÌ>ˆÌÞ]Ê>˜`Ê
prophylactic antibiotics have been associated with a change in the
spectrum of pancreatic isolates from enteric Gram-negatives to
Gram-positive organisms and fungi.
UÊʘviVÌi`Ê«>˜VÀi>̈VʘiVÀœÃˆÃʈÃÊ`iw˜i`ÊLÞÊ /ÊÃV>˜ÊÜˆÌ Ê}>Ãʈ˜ÊÌ iÊ
pancreas and/or percutaneous or surgical specimen with organisms
evident on gram stain or culture. Therapy should be directed based on
culture results.
UÊʘʫ>̈i˜ÌÃÊ«ÀiÃi˜Ìˆ˜}ÊÜˆÌ ÊÃÕëiVÌi`Ê>L`œ“ˆ˜>ÊÃi«ÃˆÃ]ÊVœ˜Ãˆ`iÀÊ
i“«ˆÀˆVÊÌ iÀ>«Þ\
UÊÊ*ˆ«iÀ>Vˆˆ˜‡Ì>âœL>VÌ>“Ê{°xÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£ÓÊPLUS
Metronidazole 500 mg IV Q8H
41
6.1 Abdominal infections
TREATMENT NOTES
6.1 Abdominal infections
Pancreatic penetration of selected antibiotics
Good (>40%; MIC exceeded for most relevant organisms):
fluoroquinolones, carbapenems, Ceftazidime, Cefepime, Metronidazole,
Piperacillin-tazobactam
Poor (<40%): aminoglycosides, first-generation cephalosporins,
Ampicillin
Duration
For infected pancreatic necrosis, continue antibiotics for 14 days after
source control is obtained. Continuation of antibiotics beyond this time
places the patient at risk for colonization or infection with resistant
organisms and drug toxicity.
TREATMENT NOTES
UÊʘviV̈œ˜Ê`iÛiœ«Ãʈ˜ÊÎäqxä¯ÊœvÊ«>̈i˜ÌÃÊÜˆÌ Ê˜iVÀœÃˆÃÊ`œVՓi˜Ìi`ÊLÞÊ
CT scan or at the time of surgery.
UÊÊ*i>ŽÊˆ˜Vˆ`i˜Viʜvʈ˜viV̈œ˜ÊœVVÕÀÃʈ˜ÊÌ iÊÎÀ`ÊÜiiŽÊœvÊ`ˆÃi>Ãi
UÊÊ/ iÀiʈÃʈ˜ÃÕvwVˆi˜ÌÊiۈ`i˜ViÊ̜ÊÀiVœ““i˜`ÊÃiiV̈ÛiÊ}ÕÌÊ
decontamination in management of pancreatitis.
,iviÀi˜ViÃ\
>VŽÊœvÊṎˆÌÞʜvÊ«Àœ« ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃ\ʘ˜Ê-ÕÀ}ÊÓääÇÆÓ{x\ÈÇ{°
Ո`iˆ˜iÃÊvœÀʓ>˜>}i“i˜ÌʜvÊ-*\Ê ÀˆÌÊ >ÀiÊi`ÊÓää{ÆÎÓ\ÓxÓ{°
Peritonitis
DEFINITIONS
Primary peritonitis is spontaneous infection of the peritoneal cavity,
ÕÃÕ>ÞÊ>ÃÜVˆ>Ìi`ÊÜˆÌ ÊˆÛiÀÊ`ˆÃi>ÃiÊ>˜`Ê>ÃVˆÌiÃÊQ뜘Ì>˜iœÕÃÊL>VÌiÀˆ>Ê
«iÀˆÌœ˜ˆÌˆÃÊ­- *®R°Ê
Secondary peritonitis is infection of the peritoneal cavity due to
spillage of organisms into the peritoneum, usually associated with GI
perforation.
Tertiary peritonitis is a recurrent infection of the peritoneal cavity
following an episode of secondary peritonitis.
Primary peritonitis/Spontaneous bacterial
peritonitis (SBP)
EMPIRIC TREATMENT
UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+£Ó
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê­V>Ê ʜÀÊ
Antimicrobial Stewardship to discuss regimens for patients who have
been taking fluoroquinolones for SBP prophylaxis).
42
Duration
UÊÊ/Ài>ÌÊvœÀÊ5 days
PROPHYLAXIS
Cirrhotic patients with gastrointestinal hemorrhage
UÊÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê ÊvœÀÊÇÊ`>ÞÃÊ
UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ÊV>˜ÊLiÊÕÃi`ʜ˜ÞʈvÊ«>̈i˜ÌʈÃÊ *"]ÊÌ i˜Ê
switch to Ciprofloxacin 500 mg PO BID once bleeding is controlled
Non-bleeding cirrhotic patients with ascites
UÊÊ/*É-8Ê£Ê -Ê*"ʜ˜ViÊ`>ˆÞ
OR
UÊÊvÊÃՏv>Ê>iÀ}ˆV]Ê ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê`>ˆÞÊ
TREATMENT NOTES
Microbiology
UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`ÃÊ­ ˜ÌiÀœL>VÌiÀˆ>Vi>i]Êië°ÊE. coli and K.
pneumoniae), S. pneumoniae, enterococci, and other streptococci.
UÊÊ*œÞ“ˆVÀœLˆ>Êˆ˜viV̈œ˜Êà œÕ`Ê«Àœ“«ÌÊÃÕëˆVˆœ˜ÊœvÊÊ«iÀvœÀ>̈œ˜°
Diagnostic criteria
UÊÊÓxäÊ* Ê«iÀʓ“ 3 of ascitic fluid.
UÊÊ*œÃˆÌˆÛiÊVՏÌÕÀiÊÜˆÌ ÊÊÓxäÊ* Êà œÕ`Ê«Àœ“«ÌÊÀi«i>ÌÊÌ>«°ÊvÊ* ʀÊ
250 OR culture remains positive, patient should be treated.
Follow-up
UÊÊ œ˜Ãˆ`iÀÊÀi«i>ÌÊ«>À>Vi˜ÌiÈÃÊ>vÌiÀÊ{nÊ œÕÀÃʜvÊÌ iÀ>«Þ°
UÊÊ œ˜Ãˆ`iÀÊV >˜}ˆ˜}Ê>˜ÌˆLˆœÌˆVÃʈvÊ>ÃVˆÌiÃÊyՈ`Ê* Ê >ÃʘœÌÊ`Àœ««i`ÊLÞÊ
Óx¯Ê>vÌiÀÊ{nÊ œÕÀÃÊ>˜`ɜÀÊ«>̈i˜ÌʈÃʘœÌÊVˆ˜ˆV>ÞÊÀi뜘`ˆ˜}°
Notes on prophylaxis against SBP
UÊʏÊ«>̈i˜ÌÃÊÜˆÌ ÊVˆÀÀ œÃˆÃÊ>˜`ÊÕ««iÀÊÊLii`Êà œÕ`ÊÀiViˆÛiÊ
«Àœ« ޏ>݈ÃÊvœÀÊÇÊ`>ÞÃÊ­xä¯Ê`iÛiœ«Ê- *Ê>vÌiÀÊLii`®°
UÊÊ*>̈i˜ÌÃÊÜ œÊ}iÌÊ- *Êà œÕ`Ê}iÌʏˆviœ˜}Ê«Àœ« ޏ>݈ÃÊ̜ʫÀiÛi˜ÌÊvÕÌÕÀiÊ
i«ˆÃœ`iÃÊ­{äqÇä¯ÊÀˆÃŽÊœvÊÀiVÕÀÀi˜Viʈ˜Ê£ÊÞi>À®°
UÊÊ*Àœ« ޏ>݈ÃÊà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊvœÀÊÌ œÃiÊÜˆÌ ÊœÜÊ«ÀœÌiˆ˜Ê
Vœ˜Vi˜ÌÀ>̈œ˜Ãʈ˜Ê>ÃVˆÌiÃÊ­Ê£äÊ}ɮʜÀʈ““Õ˜œÃÕ««ÀiÃȜ˜ÊÜ ˆiÊ
patient is in hospital.
,iviÀi˜ViÃ\
ˆ>}˜œÃˆÃ]ÊÌÀi>̓i˜ÌÊ>˜`Ê«Àœ« ޏ>݈ÃʜvÊ- *\ÊÊi«>̜ÊÓäääÆÎÓ\£{Ó°
>˜>}i“i˜ÌʜvÊÛ>ÀˆVi>Ê i“œÀÀ >}iʈ˜ÊVˆÀÀ œÃˆÃ\Êi«>̜œ}ÞÊÓääÇÆ{È\™ÓÓqÎn°
43
6.1 Abdominal infections
UÊÊ*>̈i˜ÌÃÊÜˆÌ ÊÃiÀՓÊVÀi>̈˜ˆ˜iʀ£Ê“}É`]Ê 1 ʀÎäʓ}É`ʜÀÊ̜Ì>Ê
LˆˆÀÕLˆ˜Ê€{ʓ}É`Êà œÕ`Ê>ÃœÊÀiViˆÛiʏLՓˆ˜Ê­Óx¯®Ê£°xÊ}Ɏ}ʜ˜Ê
day 1 and 1 g/kg on day 3 (round to the nearest 12.5 g).
6.1 Abdominal infections
Secondary peritonitis/GI perforation
EMPIRIC TREATMENT
Perforation of esophagus, stomach, small bowel, colon, or
appendix
Patient mild to moderately ill
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£ÓÊPLUS
Metronidazole 500 mg IV Q8H
Patient severely ill or immunosuppressed
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
QâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊORÊ ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nRÊPLUS
Metronidazole 500 mg IV Q8H
Empiric antifungal therapy is generally not indicated for GI
perforation unless patient has one of the following risk factors:
Esophageal perforation, immunosuppression, prolonged antacid or
antibiotic therapy, prolonged hospitalization, persistent GI leak.
Recommendations for patients who are clinically stable and have not
ÀiViˆÛi`Ê«ÀˆœÀʏœ˜}‡ÌiÀ“Ê>✏iÊÌ iÀ>«Þ\
UÊʏÕVœ˜>✏iÊ{ää‡nääʓ}Ê6É*"Ê+Ó{
Recommendations for patients who are NOT clinically stable or have
ÀiViˆÛi`Ê«ÀˆœÀʏœ˜}‡ÌiÀ“Ê>✏iÊÌ iÀ>«Þ\
UÊʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{Ê
Duration of therapy for secondary peritonitis/GI perforation
Uncomplicated
Definition
ÕÀ>̈œ˜Ê
Complicated
iw˜ˆÌˆœ˜Ê
Duration
44
Stomach
Small Bowel
Colon
Appendix
Operated on
within
24 hours
Ó{q{nÊ œÕÀÃÊ
Operated on
within
12 hours
Ó{q{nÊ œÕÀÃÊ
Operated on
within
12 hours
Ó{q{nÊ œÕÀÃÊ
Non-necrotic or
gangrenous
appendix
Ó{Ê œÕÀÃ
>Ìiʜ«iÀ>̈œ˜ÊœÀʘœÊœ«iÀ>̈œ˜ÆʜÀʘiVÀœÌˆVÉ}>˜}Ài˜œÕÃÊ>««i˜`ˆÝ
4 days unless adequate source control is not achieved
,iviÀi˜Vi\
-ÊՈ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\Ê ˆ˜Ê˜viVÊ ˆÃÊÓä£äÆxä\£ÎÎq£È{°
- œÀÌÊVœÕÀÃiÊÌ iÀ>«ÞÊvœÀÊ\Ê Ê ˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°
Peritonitis related to peritoneal dialysis
EMPIRIC TREATMENT
Mild to moderate illness: intraperitoneal therapy is preferred in
most cases.
Anuric patient
UÊÊ iv>✏ˆ˜Ê£xʓ}Ɏ}ʈ˜Êœ˜iÊL>}Ê+Ó{Ê­£Ê}ʈvÊ«>̈i˜ÌʐÊÈxʎ}®ÊPLUS
UÊÊi˜Ì>“ˆVˆ˜ÊÓʓ}Ɏ}ʈ˜Êœ˜iÊL>}ʏœ>`ˆ˜}Ê`œÃi]ÊÌ i˜Êi˜Ì>“ˆVˆ˜Êä°ÈÊ
mg/kg in one bag Q24H
Patient with urine output > 100 mL/day
UÊÊ ivÌ>âˆ`ˆ“iÊ£Ê}ʈ˜Êœ˜iÊL>}Ê+Ó{
Severe illness: systemic therapy is preferred.
UÊÊ,-/Ê "- \Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê6ÊPLUS ONE
œvÊÌ iÊvœœÜˆ˜}\
Qi˜Ì>“ˆVˆ˜ÊÓʓ}Ɏ}Ê6Ê",Ê ivÌ>âˆ`ˆ“iÊ£Ê}Ê6Ê",Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ
“}Ê6R
45
6.1 Abdominal infections
TREATMENT NOTES
UÊÊ >ÕÃ>̈ÛiÊ>}i˜ÌÃÊvœÀÊÓ>ÊLœÜi]ÊVœœ˜]Ê>««i˜`ˆÝ\Ê>˜>iÀœLiÃÊ­ië°Ê
B. fragilis), Enterobacteriaceae (esp. E. coli, K. pneumoniae,
Enterobacter spp., Proteus spp.®Æʈ˜viV̈œ˜ÃÊÕÃÕ>ÞÊ«œÞ“ˆVÀœLˆ>°Ê
UÊÊ*>Ì œ}i˜ÃÊV>ÕȘ}ÊÌiÀ̈>ÀÞÊ«iÀˆÌœ˜ˆÌˆÃÊ>ÀiÊÛ>Àˆ>LiÊ>˜`Ê>ÀiʜvÌi˜Ê
ÀiÈÃÌ>˜ÌÊ̜ʜÀʘœÌÊVœÛiÀi`ÊLÞÊÌ iʈ˜ˆÌˆ>Ê>˜Ìˆ“ˆVÀœLˆ>ÊÀi}ˆ“i˜ÆÊÌ ÕÃ]Ê>Ê
change in antimicrobials is advised.
UÊÊÊV >˜}iʈ˜Ê>˜Ìˆ“ˆVÀœLˆ>ÃÊÌ iÀ>«ÞÊà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ
with hospital-acquired infections who are already on antimicrobials.
UÊÊ/Ài>̓i˜ÌʜvÊi˜ÌiÀœVœVVˆÊÀi“>ˆ˜ÃÊVœ˜ÌÀœÛiÀÈ>ÊLÕÌÊà œÕ`ÊLiÊ
considered in critically ill or immunocompromised patients or when
they are a dominant organism in the peritoneal culture.
UÊÊ/Ài>̓i˜ÌʜvÊCandida spp. is generally indicated only when they are
recovered from blood or are a dominant organism in the peritoneal
culture in critically ill or immunocompromised patients.
UÊÊ*œÃ̜«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÃÊvœÀÊ>««i˜`ˆVˆÌˆÃÊ>ÀiÊ՘˜iViÃÃ>ÀÞÊ՘iÃÃÊÌ iÀiÊ
is clinical evidence of peritonitis, abscess, or gangrene.
UÊʘ̈LˆœÌˆVÃÊ>ÀiÊ>`Õ˜V̈ÛiÊ̜ÊÜÕÀViÊVœ˜ÌÀœ]ÊÜ ˆV ʈÃÊ>˜Ê>L܏ÕÌiÊ
necessity.
UÊÊ>VŽÊœvÊÜÕÀViÊVœ˜ÌÀœÊˆÃÊ`iw˜i`Ê>Ãʜ˜‡}œˆ˜}ÊVœ˜Ì>“ˆ˜>̈œ˜Ê>˜`ɜÀÊ>˜Ê
undrained collection of infection.
6.1 Abdominal infections
UÊÊ / Ê "- \Ê œÃiÊ«iÀÊ`ÀÕ}ʏiÛiÃÊ>˜`ɜÀÊÀi˜>Êv՘V̈œ˜ÆÊ
consult pharmacy for recommendations for redosing and monitoring
Duration:Ê£äq£{Ê`>ÞÃ
TREATMENT NOTES
Microbiology
UÊʜÃÌÊV>ÃiÃÊV>ÕÃi`ÊLÞÊVœ˜Ì>“ˆ˜>̈œ˜ÊœvÊÌ iÊV>Ì iÌiÀ
UÊÊ ÕÌÕÀiÃʓ>ÞÊLiʘi}>̈Ûiʈ˜ÊxqÓä¯
UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊ­S. aureus, coagulase-negative staphylococci,
Enterococcus spp.), Gram-negative rods, yeast (much less common)
Diagnosis
UÊʏÊ«>̈i˜ÌÃÊÜˆÌ ÊÃÕëiVÌi`Ê* ‡Ài>Ìi`Ê«iÀˆÌœ˜ˆÌˆÃÊà œÕ`Ê >ÛiÊ* ÊyՈ`Ê
sampled for cell count, differential, gram stain, culture AND amylase.
WBC > 100/mm 3ÊÜˆÌ Ê€Êxä¯Ê* ÊÃÕ}}iÃÌÃʈ˜viV̈œ˜°
UÊÊ iÛ>Ìi`Ê>“ޏ>ÃiÊÃÕ}}iÃÌÃÊ«>˜VÀi>̈̈ÃʜÀÊLœÜiÊ«iÀvœÀ>̈œ˜°
UÊʘÊÃޓ«Ìœ“>̈VÊ«>̈i˜ÌÃÊÜˆÌ ÊVœÕ`ÞÊyՈ`Ê>VVœ“«>˜ˆi`ÊLÞÊ>L`œ“ˆ˜>Ê
pain and/or fever, empiric treatment should be started given the high
likelihood of infection.
UÊʘÊÃޓ«Ìœ“>̈VÊ«>̈i˜ÌÃÊÜˆÌ ÊVi>ÀÊyՈ`]Ê>˜œÌ iÀÊ* ÊyՈ`ÊiÝV >˜}i]Ê
with a dwell time of at least 2 hours, should be sampled. The decision
to start empiric therapy in these cases will depend on how sick the
patient appears.
UÊʘÊ>Ãޓ«Ìœ“>̈VÊ«>̈i˜ÌÃÊÜˆÌ ÊVœÕ`ÞÊyՈ`]ʈÌʈÃÊÀi>ܘ>LiÊ̜Ê`i>ÞÊ
therapy pending the results of cell count, gram stain, and culture.
,iviÀi˜Vi\
-* ÊՈ`iˆ˜iÃÊvœÀÊ*iÀˆÌœ˜i>Ê ˆ>ÞÈÇÀi>Ìi`ʘviV̈œ˜Ã\Ê*iÀˆÌÊ ˆ>Ê˜ÌÊÓä£äÆÎä\
ΙÎÊq{Óΰ
46
Diagnosis and testing
UÊÊ >ÃiÊ`iw˜ˆÌˆœ˜ÊœvÊC. difficileÊ`ˆ>ÀÀ i>\Ê«>ÃÃ>}iʜvÊ≥ 3 unformed
stools in ≤ 24 hours AND either a positive stool test for C. difficile or
colonoscopic/histopathologic finding of pseudomembranous colitis.
UÊÊ/ iʓˆVÀœLˆœœ}Þʏ>LÊÕÃiÃÊ>ÊÀi>‡Ìˆ“iÊ* ,Ê>ÃÃ>ÞÊ̜Ê`iÌiVÌÊÌ iÊ̜݈˜Ê Ê
gene, the toxin responsible for CDI. Thus, patients who are colonized
with toxigenic strains will test positive even if they do not have active
infection and clinical correlation with positive test results is important.
/ iÊÃi˜ÃˆÌˆÛˆÌÞʜvÊÀi>Ê̈“iÊ* ,ʈÃʀʙä¯ÊVœ“«>Ài`Ê̜Ê̜݈}i˜ˆVÊ
culture.
UÊÊ œÊ "/ÊÃi˜`ÊÃ̜œÊvœÀÊC. difficile testing if patients do not have
diarrhea or ileus. Hard stool, fluid obtained from colonoscopy and
rectal swabs will be rejected by the microbiology lab.
UÊʘʫ>̈i˜ÌÃÊÀiViˆÛˆ˜}ʏ>Ý>̈ÛiÃ]ʈÌʈÃÊÀiVœ““i˜`i`Ê̜Ê`ˆÃVœ˜Ìˆ˜ÕiÊ
laxatives for 24-48 hours prior to C. difficile stool test to see if
diarrhea improves, unless the patient is clinically unstable.
UÊÊ iV>ÕÃiʜvÊi˜ >˜Vi`ÊÃi˜ÃˆÌˆÛˆÌÞʜvÊ* ,]Ê`Õ«ˆV>ÌiÊÌiÃ̈˜}ʈÃʘœÌÊ
necessary or recommended. Testing is restricted to one specimen
within 7 days. Call the Laboratory Medicine resident or faculty member
on call for those rare instances when a second specimen is required.
UÊÊ-̜œÊvœÀÊC. difficile testing should be collected prior to starting
treatment for C. difficile.
UÊÊ-«iVˆ“i˜ÃÊà œÕ`ÊLiÊ >˜`ÊV>ÀÀˆi`Ê̜ÊÌ iʏ>LÊ>ÃÊܜ˜Ê>ÃÊ«œÃÈLiÊ>vÌiÀÊ
collection. If they cannot be transported promptly, the samples should
be refrigerated.
UÊÊ œÊ "/ÊÃi˜`ÊvœœÜ‡Õ«ÊC. difficile PCR during treatment or to
document resolution of disease, as utility of the results has not been
demonstrated.
TREATMENT
UÊÊ-/"*ÊÊ / ," Ê /-Ê7
6 ,Ê*"-- °
UÊÊ"À>ÊÌ iÀ>«ÞʓÕÃÌÊLiÊÕÃi`ÊÜ i˜iÛiÀÊ«œÃÈLiÊ>ÃÊÌ iÊivwV>VÞʜvÊ6Ê
Metronidazole is poorly established for CDI and there is no efficacy of
IV Vancomycin for CDI.
47
6.2 Clostridium difficile infection (CDI)
Clostridium difficile infection (CDI)
6.2 Clostridium difficile infection (CDI)
Treatment depends on clinical severity
Infection severity
Clinical manifestations
Asymptomatic
carriage*
C. difficile PCR positive without diarrhea,
ileus, or colitis
Mild or moderate
C. difficile PCR positive with diarrhea but no
manifestations of severe disease
Severe
C. difficile PCR positive with diarrhea and one or more
of the following attributable to CDI:
UÊÊ7 Ê≥ 15,000
UÊʘVÀi>Ãiʈ˜ÊÃiÀՓÊVÀi>̈˜ˆ˜iÊ> xä¯ÊvÀœ“ÊL>Ãiˆ˜i
Ê
Ê
Severe Complicated
Ê
Ê
Ê
Ê
Ê
Ê
Criteria as above plus one or more of the following
attributable to CDI:
UÊÞ«œÌi˜Ãˆœ˜
UʏiÕÃÊ
UÊ/œÝˆVʓi}>Vœœ˜ÊœÀÊ«>˜VœˆÌˆÃʜ˜Ê /
UÊ*iÀvœÀ>̈œ˜
UÊ ii`ÊvœÀÊVœiV̜“Þ
UÊ 1Ê>`“ˆÃȜ˜ÊvœÀÊÃiÛiÀiÊ`ˆÃi>Ãi
Infection severity
Treatment
Ãޓ«Ìœ“>̈VÊÊ
carriage
Ê œÊ "/ÊÌÀi>ÌÆÊÌÀi>̓i˜ÌÊV>˜Ê«Àœ“œÌiÊÀi>«Ãˆ˜}Ê
disease
ˆ`ʜÀʓœ`iÀ>ÌiÊ
UÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê*"É /Ê+nÊ
Ê
Unable to tolerate oral therapy
UÊÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê6Ê+nÊ­ÃÕLœ«Ìˆ“>ÆÊÃiiʘœÌiÊ
at start of CDI section above)
-iÛiÀiÊ
UÊÊ6>˜Vœ“ÞVˆ˜Ê܏Ṏœ˜Ê£Óxʓ}Ê*"É /Ê+ÈÊ
-iÛiÀiÊ œ“«ˆV>Ìi`Ê
Ê
UÊÊ œ˜ÃՏÌÊÃÕÀ}iÀÞÊvœÀÊiÛ>Õ>̈œ˜ÊvœÀÊVœiV̜“ÞÊ>˜`Ê Ê
UÊÊ6>˜Vœ“ÞVˆ˜Ê܏Ṏœ˜Êxääʓ}ÊLÞÊ /Ê+ÈÊPLUS
Metronidazole 500 mg IV Q8H†
Ê
Unable to tolerate oral therapy or complete ileus
UÊÊ6>˜Vœ“ÞVˆ˜Êxääʓ}ʈ˜ÊxääʓÊ -Ê+ÈÊ>ÃÊÀiÌi˜Ìˆœ˜Ê
enema via Foley catheter in rectum + Metronidazole
500 mg IV Q8H
I£x‡Óx¯ÊœvÊ œÃ«ˆÌ>ˆâi`Ê«>̈i˜ÌÃÊ>ÀiÊVœœ˜ˆâi`ÊÜˆÌ C. difficile.
† Vancomycin dose can be decreased to 125 mg PO Q6H and Metronidazole can be stopped once
the patient has stabilized.
Other indications for oral Vancomycin use
UÊ œÊÀi뜘ÃiÊ̜ʜÀ>ÊiÌÀœ˜ˆ`>✏iÊ>vÌiÀÊxÊ`>ÞÃʜvÊÌ iÀ>«Þ
UÊ-iVœ˜`Êi«ˆÃœ`iʜvÊÀiVÕÀÀi˜ÌÊ`ˆÃi>Ãi
UÊ*>̈i˜ÌÃÊÜˆÌ ÊÈ}˜ˆwV>˜ÌÊÈ`iÊivviVÌÃÊ̜ÊiÌÀœ˜ˆ`>✏i
UÊ*>̈i˜ÌÃÊÜ œÊ>ÀiÊ«Ài}˜>˜Ì
UÊÊ œ˜Ãˆ`iÀʈ˜Ê«>̈i˜ÌÃʀÊÈxÊÞi>ÀÃÊ}ˆÛi˜ÊÀi«œÀÌÃʜvʈ˜VÀi>Ãi`ʓœÀLˆ`ˆÌÞÊ
from CDI.
48
Approach to patients who need to continue broad spectrum
antibiotic therapy
UÊ iÌiÀ“ˆ˜iÊÌ iÊà œÀÌiÃÌÊ«œÃÈLiÊVœÕÀÃiʜvÊ>˜ÌˆLˆœÌˆVÊÌ iÀ>«Þ°Ê
UÊÊ,i«>ViÊÌ iÊ>˜ÌˆLˆœÌˆVÊÌ >Ìʈ˜`ÕVi`Ê ]Ê«>À̈VՏ>ÀÞÊVi« >œÃ«œÀˆ˜Ã]Ê
Clindamycin, and fluoroquinolones.
UÊÊvÊÌ iʈ˜`ÕVˆ˜}Ê>}i˜ÌʈÃÊÀi«>Vi`Ê>˜`ÊÌ iÊ ÊÀi܏ÛiÃ]ÊVœ“«iÌiÊ>Ê
ÃÌ>˜`>À`ʣ䇣{Ê`>ÞÊVœÕÀÃiʜvÊ ÊÌ iÀ>«ÞÆÊÌ iÀiʈÃʘœÊ˜ii`Ê̜ÊiÝÌi˜`Ê
CDI therapy until the end of the course of antibiotic therapy.
UÊÊvÊÌ iʈ˜`ÕVˆ˜}Ê>}i˜ÌÊV>˜˜œÌÊLiÊÃ̜««i`ʜÀÊÀi«>Vi`]ÊVœ˜Ãˆ`iÀÊ
continuing CDI therapy until the end of the course of antibiotic therapy
­`>Ì>Ê>Àiʏˆ“ˆÌi`®ÆÊ ÊÌ iÀ>«ÞÊà œÕ`ʘœÌÊLiÊVœ˜Ìˆ˜Õi`ÊLiޜ˜`ÊÌ iÊi˜`Ê
of antibiotic therapy if the patient remains asymptomatic.
Recurrent disease
UÊÊ,iÈÃÌ>˜ViÊ̜ÊiÌÀœ˜ˆ`>✏iʜÀÊ6>˜Vœ“ÞVˆ˜Ê >ÃʘœÌÊLii˜Ê`œVՓi˜Ìi`Ê
conclusively.
UÊÊ,iVÕÀÀi˜ÌÊ`ˆÃi>ÃiÊ>vÌiÀÊ>ÊVœ“«iÌiÊVœÕÀÃiʜvÊÌ iÀ>«ÞʜVVÕÀÃʈ˜ÊHÊ
Óx¯ÊœvÊ«>̈i˜ÌðÊ,i>«ÃiʈÃÊ`ÕiÊ̜Êv>ˆÕÀiÊ̜ÊiÀ>`ˆV>ÌiÊëœÀiÃÊ­È䯮Ê
œÀÊ>VµÕˆÃˆÌˆœ˜ÊœvÊ>ʘiÜÊÃÌÀ>ˆ˜Ê­{䯮°Ê œVՓi˜ÌÊÀiVÕÀÀi˜ÌÊ`ˆÃi>ÃiÊÜˆÌ Ê
repeat stool testing.
UÊʈÀÃÌÊÀiVÕÀÀi˜ViÊà œÕ`ÊLiÊÌÀi>Ìi`ÊÌ iÊÃ>“iÊ>ÃÊÌ iʈ˜ˆÌˆ>Êi«ˆÃœ`iÆÊ
severe disease should be treated with Vancomycin.
UÊÊ-iVœ˜`ÊÀiVÕÀÀi˜ViÊà œÕ`ÊLiÊÌÀi>Ìi`ÊÜˆÌ Ê6>˜Vœ“ÞVˆ˜ÊÌ>«iÀÊvœœÜi`Ê
by pulse dosing or fecal microbiota transplant (consult GI).
UÊvÊÃiÀˆœÕÃʜÀʓՏ̈«iÊÀiVÕÀÀi˜ViÃ]ÊVœ˜ÃՏÌÊ °
Vancomycin taper regimen
125 mg 4 times daily ×Ê£äq£{Ê`>ÞÃ
125 mg BID × 7 days
125 mg daily × 7 days
£Óxʓ}ÊiÛiÀÞÊÓqÎÊ`>ÞÃÊvœÀÊÓqnÊÜiiŽÃÊ­«ÕÃiÊ`œÃˆ˜}®
NOTES
Management
UÊÊ-ÕÀ}ˆV>Êˆ˜ÌiÀÛi˜Ìˆœ˜ÊvœÀÊVœiV̜“ÞÊà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`Êi>ÀÞʈvÊÌ iÊ
patient is clinically unstable secondary to CDI.
UÊÊ/Ài>̓i˜ÌʜvÊ Êà œÕ`ÊLiÊVœ˜Ìˆ˜Õi`ʈ˜Ê«>̈i˜ÌÃÊÜ œÊ >ÛiÊ>ÊÃÕL̜Ì>Ê
colectomy with preservation of the rectum.
UÊʜÃÌÊ«>̈i˜ÌÃÊÜˆÌ ÊÃiÛiÀiÊ Êà œÕ`Ê՘`iÀ}œÊ>L`œ“ˆ˜>Ê /Ê̜ÊÀՏiÊ
out toxic megacolon or pancolitis.
49
6.2 Clostridium difficile infection (CDI)
Duration
UÊ£äq£{Ê`>ÞÃ
6.2 Clostridium difficile infection (CDI)
UÊÊ œÊ "/ÊÃi˜`ÊvœœÜ‡Õ«ÊC.difficile PCR to document resolution of
disease.
UÊÊ œÊ˜œÌÊÕÃiÊ>˜Ìˆ“œÌˆˆÌÞÊ>}i˜Ìð
UÊÊ-̜«Ê«ÀœÌœ˜Ê«Õ“«Êˆ˜ ˆLˆÌœÀÃÊ­**îÊÜ i˜iÛiÀÊ«œÃÈLiÊ>ÃÊ`>Ì>ÊÃÕ}}iÃÌÊ
PPIs increase the risk of CDI.
UÊÊ/ iʜvvi˜`ˆ˜}Ê>˜Ìˆ“ˆVÀœLˆ>Ê>}i˜ÌÃÊà œÕ`ÊLiÊ`ˆÃVœ˜Ìˆ˜Õi`°ÊvÊ
antimicrobials are still required, it is best to avoid cephalosporins,
Clindamycin, and fluoroquinolones.
UÊÊ*Àœ« ޏ>V̈VÊÕÃiʜvʜÀ>ÊiÌÀœ˜ˆ`>✏iʜÀÊ6>˜Vœ“ÞVˆ˜Êˆ˜Ê«>̈i˜ÌÃÊ
receiving antimicrobial therapy for treatment of underlying infection
(other than CDI) is not recommended and may increase the patient’s
risk for CDI.
Infection control
UÊÊ*>̈i˜ÌÃÊÜˆÌ Ê Êà œÕ`ÊLiÊ«>Vi`ʈ˜ÊVœ˜Ì>VÌÊ«ÀiV>Ṏœ˜ÃÊ>˜`ÊȘ}iÊ
rooms for the duration of hospitalization.
UÊÊ1ÃiÊÜ>«Ê>˜`ÊÜ>ÌiÀÊÀ>Ì iÀÊÌ >˜Ê>Vœ œ‡L>Ãi`Ê >˜`Ê}iÊÕ«œ˜Êï݈˜}Ê
the room of a patient with CDI.
,iviÀi˜ViÃ\
- É -Ê œ˜Ãi˜ÃÕÃÊՈ`iˆ˜iÃÊvœÀÊ \ʘviVÌÊ œ˜ÌÀœÊœÃ«Ê «ˆ`i“ˆœÊÓä£äÆÊ
Σ\{Σq{x{°
>VŽÊœvÊṎˆÌÞʜvÊÌÀi>̈˜}Ê ÊV>ÀÀˆiÀÃ\ʘ˜Ê˜ÌiÀ˜Êi`Ê£™™ÓÆÊ££Ç\әLJÎäÓ°
œiV̜“Þʈ˜Ê \ʘ˜Ê-ÕÀ}ÊÓääÇÆÊÓ{x\ÓÈLJÇÓ°
50
UÊFor treatment of C. difficile infection, see p. 47.
UÊ >ÀivՏÞÊ>ÃÃiÃÃÊÌ iÊ«>̈i˜ÌÊLivœÀiÊ«ÀiÃVÀˆLˆ˜}Ê>˜Ìˆ“ˆVÀœLˆ>Ã°
UÊʜÃÌʈ˜viV̈œÕÃÊ`ˆ>ÀÀ i>ʈÃÊÃiv‡ˆ“ˆÌi`Ê>˜`ʜ˜ÞÊÀiµÕˆÀiÃÊÃÕ««œÀ̈ÛiÊ
management.
UÊÊ/Ài>̓i˜ÌÊÜˆÌ Ê>˜ÌˆLˆœÌˆVÃʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀʓœÃÌʓˆ`‡
“œ`iÀ>ÌiÊ`ˆÃi>ÃiÆÊÃiiÊëiVˆwVʈ˜`ˆV>̈œ˜Ãʈ˜ÊÌ>LiÊLiœÜ°
UÊÊ6ˆÀ>Ê«>Ì œ}i˜Ã]ÊÃÕV Ê>ÃÊ œÀœÛˆÀÕÃÊ>˜`Ê,œÌ>ۈÀÕÃÊVœ““œ˜ÞÊV>ÕÃiÊ
diarrhea and do not require antibiotics.
UÊʘ̈LˆœÌˆVÊÕÃiʓ>Þʏi>`Ê̜Ê>`ÛiÀÃiʜÕÌVœ“iÃÊ­i°}°Ê i“œÞ̈VÊÕÀi“ˆVÊ
syndrome with Shiga toxin-producing E. coli).
UÊʘ̈“œÌˆˆÌÞÊ>}i˜ÌÃÊà œÕ`ʘœÌÊLiÊÕÃi`ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ ÊLœœ`ÞÊ`ˆ>ÀÀ i>]Ê
fever, or elevated WBC.
Microbiology
UÊÊ œ““œ˜Ê˜œ˜‡ÛˆÀ>Ê«>Ì œ}i˜Ãʈ˜Ê>VÕÌiÊVœ““Õ˜ˆÌއ>VµÕˆÀi`Ê`ˆ>ÀÀ i>\Ê
Salmonella, Shigella, Shiga toxin-producing E. coli, Campylobacter,
C. difficile (usually with antibiotic exposure).
UÊ œÃœVœ“ˆ>Ê`ˆ>ÀÀ i>\ÊC. difficile
UÊÊ*iÀÈÃÌi˜ÌÊ`ˆ>ÀÀ i>ʈvʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê­“œÃÌʏˆŽiÞÊV>ÕÃiÃÊÛ>ÀÞÊ
`i«i˜`ˆ˜}ʜ˜ÊÌÞ«iʜvʈ““Õ˜œVœ“«Àœ“ˆÃi®\ÊGiardia, Cryptosporidium,
Cyclospora, Isospora, Microsporidia, Cytomegalovirus (CMV).
Diagnosis
UÊÊ œÌÊiÛiÀÞÊ`ˆ>ÀÀ i>Êˆ˜iÃÃÊÀiµÕˆÀiÃÊÃ̜œÊVՏÌÕÀi°Ê iVˆÃˆœ˜Ê̜ÊÌiÃÌÊ
should be based on suspicion for specific pathogens and/or clinical
judgment of illness severity.
UÊÊ*>̈i˜ÌÃÊÜˆÌ ÊviLÀˆiÊ`ˆ>ÀÀ i>Êˆ˜iÃÃiÃÊÜˆÌ ÊVˆ˜ˆV>Êvi>ÌÕÀiÃʜvÊ
moderate to severe disease should receive empiric therapy only after
a fecal specimen is obtained for appropriate testing.
UÊÊiV>ÊëiVˆ“i˜ÃÊvÀœ“Ê«>̈i˜ÌÃÊ œÃ«ˆÌ>ˆâi`ÊvœÀʀÊÎÊ`>ÞÃÊà œÕ`ʘœÌÊLiÊ
submitted for routine stool culture unless a high suspicion for specific
pathogen exists and/or if the patient is immunocompromised.
UÊÊՏ̈«iÊÃ̜œÊiÝ>“ˆ˜>̈œ˜ÃÊvœÀʜÛ>Ê>˜`Ê«>À>ÈÌiÃÊ­"E*®Ê>ÀiʜvʏœÜÊ
yield.
UÊÊiV>ÊiՎœVÞÌiɏ>V̜viÀÀˆ˜Ê>ÃÃiÃÓi˜ÌÃÊà œÕ`ʘœÌÊLiÊÕÃi`Ê̜Ê
determine the therapeutic approach.
51
6.3 Infectious diarrhea
Infectious diarrhea
6.3 Infectious diarrhea
Treatment of infectious diarrhea
Organism/Indications for treatment
Treatment
Bacteria
Campylobacter spp.
UÊâˆÌ Àœ“ÞVˆ˜Êxääʓ}Ê*"Ê`>ˆÞÊvœÀÊ£qÎÊ`>ÞÃ
/Ài>̓i˜ÌÊÀiVœ““i˜`i`ÊvœÀ\
UÊ-iÛiÀiʈ˜iÃÃ
UÊ}iʐÊÈʓœ˜Ì ÃʜÀʀÊxäÊÞi>ÀÃ
UÊÀœÃÃÊLœœ`ʈ˜ÊÃ̜œ
Uʈ} ÊviÛiÀ
UÊ7œÀÃi˜ˆ˜}ʜÀÊÀi>«Ãˆ˜}ÊÃޓ«Ìœ“Ã
UÊ*Ài}˜>˜VÞ
Uʓ“Õ˜œVœ“«Àœ“ˆÃi`Ê œÃÌ
E. coli (enterotoxigenic, enteropathogenic,
enteroinvasive) or empiric therapy of
traveler’s diarrhea
UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê Duration:Ê£qÎÊ`>ÞÃ
Shiga toxin producing E. coli (including
E. coliÊä£xÇ\Ç®
Treatment not recommended. Antibiotic
use associated with development of
hemolytic uremic syndrome.
Non-typhoid Salmonella spp.
UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê Ê
OR
UÊÊ/*É-8Ê£ÈäÉnääʓ}Ê*"Ê Ê
(if susceptible)
OR
UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{
/Ài>̓i˜ÌÊÀiVœ““i˜`i`ÊvœÀ\
UÊ-iÛiÀiʈ˜iÃÃÊÀiµÕˆÀˆ˜}Ê œÃ«ˆÌ>ˆâ>̈œ˜
UÊ}iʐÊÈʓœ˜Ì ÃʜÀʀÊxäÊÞi>ÀÃ
UÊ >VÌiÀi“ˆ>
UÊ*ÀiÃi˜ViʜvÊ«ÀœÃÌ iÃiÃ
UÊ6>ÛՏ>ÀÊ i>ÀÌÊ`ˆÃi>Ãi
UÊ-iÛiÀiÊ>Ì iÀœÃViÀœÃˆÃ
UÊ>ˆ}˜>˜VÞʜÀÊœÌ iÀʈ““Õ˜œVœ“«Àœ“ˆÃi
Shigella spp.
Treatment always recommended even if result
returns when patient is asymptomatic.
Duration:ÊxqÇÊ`>ÞÃÆÊ£{Ê`>ÞÃÊvœÀÊ
immunocompromised host
UÊÊ/*É-8Ê£ÈäÉnääʓ}ÊÊ*"Ê Ê
(if susceptible)
OR
UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê Ê
Duration:ÊÎÊ`>ÞÃÆÊÇÊ`>ÞÃÊvœÀʈ““Õ˜œ‡
compromised host
Vibrio parahaemolyticus
UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê ÊÝÊÎÊ`>ÞÃ
œÌi\ÊÃÜVˆ>Ìi`ÊÜˆÌ Êà iwà ÊVœ˜ÃՓ«Ìˆœ˜
Treatment recommended for severe illness
Yersinia spp.
/Ài>̓i˜ÌÊÀiVœ“““i˜`i`ÊvœÀ\
Uʓ“Õ˜œVœ“«Àœ“ˆÃi`Ê œÃÌ
UÊ >VÌiÀi“ˆ>
UÊ*ÃiÕ`œ>««i˜`ˆVˆÌˆÃÊÃޘ`Àœ“i
52
UÊÊ/*É-8Ê£ÈäÉnääʓ}Ê*"Ê ÊÝÊÎqxÊ
days (if susceptible)
OR
UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê ÊÝÊÎÊ`>ÞÃ
OR
UÊÊ œÝÞVÞVˆ˜iÊ£ääʓ}Ê*"Ê ÊÝÊÎÊ`>ÞÃ
(not for bacteremia)
Entamoeba histolytica
Treat all (even asymptomatic)
E. dispar & E. moshkovskii infections do not
require treatment
UÊÊiÌÀœ˜ˆ`>✏iÊÇxäʓ}Ê*"Ê/ ÊÝÊxq£äÊ
days
OR
UÊÊ/ˆ˜ˆ`>✏iÊ£Ê}Ê*"Ê+£ÓÊÝÊÎÊ`>ÞÃ
UÊÊPLUS all patients should receive
Paromomycin 500 mg PO TID x 7 days
after the course of 1st agent complete
Asymptomatic patients
UÊÊ*>Àœ“œ“ÞVˆ˜Êxääʓ}Ê*"Ê/ ÊÝÊÇÊ`>ÞÃ
Giardia spp.
UÊÊiÌÀœ˜ˆ`>✏iÊÓxä‡xääʓ}Ê*"Ê/ ÊÝÊ
Çq£äÊ`>ÞÃ
OR
U Tinidazole 2 g PO once
,iviÀi˜ViÃ\Ê
-ÊՈ`iˆ˜iÃÊvœÀÊ>˜>}i“i˜ÌʜvʘviV̈œÕÃÊ ˆ>ÀÀ i>ÆÊ ˆ˜Ê˜viVÌÊ ˆÃÊÓää£ÆÎÓ\ÎΣqxä°
˜viV̈œÕÃÊ`ˆ>ÀÀ i>ʈ˜Ê`iÛiœ«i`Ê>˜`Ê`iÛiœ«ˆ˜}ÊVœÕ˜ÌÀˆiÃ\ÊÊ ˆ˜Ê>ÃÌÀœi˜ÌiÀœÊÓääx\Ι\ÇxÇqÇÇΰ
53
6.3 Infectious diarrhea
Parasites
6.4 Helicobacter pylori infection
Helicobacter pylori infection
NOTE: CONSIDER WITHHOLDING THERAPY INITIATION UNTIL PATIENT
DISCHARGED FROM HOSPITAL UNLESS ACUTE ULCER IS PRESENT
Established indications for testing for H. pylori and treating
positive patients
UÊÊV̈ÛiÊ«i«ÌˆVÊՏViÀÊ`ˆÃi>ÃiÊ­*1 ®ÊqÊ}>ÃÌÀˆVʜÀÊ`՜`i˜>
UÊÊ œ˜wÀ“i`Ê ˆÃ̜ÀÞʜvÊ*1 Ê­˜œÌÊ«ÀiۈœÕÏÞÊÌÀi>Ìi`ÊvœÀÊH. pylori)
UÊÊ>ÃÌÀˆVÊ/ʏޓ« œ“>Ê­œÜÊ}À>`i®
UʜœÜˆ˜}ÊÀiÃiV̈œ˜ÊœvÊ}>ÃÌÀˆVÊV>˜ViÀÊ
UÊ>“ˆÞÊ ˆÃ̜ÀÞʜvÊ}>ÃÌÀˆVÊV>˜ViÀʈ˜Ê>Ê£ÃÌÊ`i}ÀiiÊÀi>̈Ûi
UÊÌÀœ« ˆVÊ}>ÃÌÀˆÌˆÃ
Other indications where testing for H. pylori and treating positive
patients can be considered: nonulcer dyspepsia, long term PPI
use, persons using NSAID/ASA, unexplained iron deficiency anemia or
vitamin B12 deficiency, family members of patients with H. pylori with
mild dyspepsia.
First-line treatment
UÊʓœÝˆVˆˆ˜Ê£Ê}Ê*"Ê+£ÓÊPLUS Clarithromycin 500 mg PO Q12H
PLUS Pantoprazole 40 mg PO Q12H
OR
UÊ* Ê>iÀ}Þ
UÊÊ >ÀˆÌ Àœ“ÞVˆ˜Êxääʓ}Ê*"Ê+£ÓÊPLUS Metronidazole 500 mg PO
Q12H PLUS Pantoprazole 40 mg PO Q12H
OR
UÊÊ/iÌÀ>VÞVˆ˜iÊxääʓ}Ê*"Ê+ÈÊPLUS Metronidazole 500 mg
PO Q8H PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS
Pantoprazole 40 mg PO Q12H
UÊDuration:Ê£äq£{Ê`>ÞÃ
Documented recurrence of H. pylori disease
UÊvÊ«œÃÈLi]Ê>ۜˆ`Ê>˜ÌˆLˆœÌˆVÃÊ«ÀiۈœÕÏÞÊÕÃi`Ê̜ÊÌÀi>ÌÊH. pylori
UÊÊ/iÌÀ>VÞVˆ˜iÊxääʓ}Ê*"Ê+ÈÊPLUS Metronidazole 500 mg PO Q8H
PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS Pantoprazole 40
mg PO Q12H
UÊDuration: 14 days
TREATMENT NOTES
Diagnosis
UÊÊ**Ã]Ê2RA, Bismuth, and antibiotics with activity against H. pylori
should be withheld for at least 4 weeks prior to testing.
54
Management
UÊʈÀÃÌʏˆ˜iÊÌÀi>̓i˜ÌÊiÀ>`ˆV>̈œ˜ÊÀ>ÌiÃÊiÃ̈“>Ìi`ÊLiÌÜii˜ÊxäqÇx¯°Ê
>ˆÕÀiʓœÃÌʜvÌi˜Ê`ÕiÊÌœÊ >ÀˆÌ Àœ“ÞVˆ˜ÊÀiÈÃÌ>˜ViÊ­£äq£x¯®Ê>˜`ɜÀÊ
non-adherence.
UÊÊӇÀiVi«ÌœÀÊ>˜Ì>}œ˜ˆÃÌÃÊ­i°}°Ê,>˜ˆÌˆ`ˆ˜i®ÊV>˜ÊLiÊÃÕLÃ̈ÌÕÌi`ÊvœÀÊÌ iÊ
PPI if patients are unable to tolerate PPIs or if drug interactions are a
concern.
UÊʓœÝˆVˆˆ˜ÊPLUS Tetracycline can NOT be used together in treatment
due to low response rates.
UÊÊ œÊ˜œÌÊÃÕLÃ̈ÌÕÌiÊ œÝÞVÞVˆ˜iɈ˜œVÞVˆ˜iÊvœÀÊ/iÌÀ>VÞVˆ˜iʜÀÊÊ
Azithromycin for Clarithromycin.
UÊʘʫ>̈i˜ÌÃÊÜˆÌ Ê«œÃˆÌˆÛiÊÌiÃÌÊÀiÃՏÌÃÊi˜`œÃVœ«ÞʈÃʓ>˜`>̜ÀÞÊvœÀÊ>}iÊ
> 45-50 years, presence of mass GI bleeding, anemia, weight loss, or
family history of gastric cancer.
UÊÊ/iÃÌʜvÊVÕÀiʈÃÊÀiVœ““i˜`i`Ê> {qnÊÜiiŽÃÊ«œÃÌÊÌÀi>̓i˜Ì°Ê
,iviÀi˜ViÃ\
Maastricht III Consensus Report. GutÊÓääÇÆxÈ\ÇÇӇÇn£°
ACG Guidelines. Am J GastroenterolÊÓääÇÆ£äÓ\£nän‡£nÓx°
55
6.4 Helicobacter pylori infection
UÊÊH. pylori stool antigen is the only FDA approved test (>™ä¯ÊÃi˜ÃˆÌˆÛˆÌÞÊ
and specificity).
UÊ1Ài>ÊLÀi>Ì ÊÌiÃÌʓ>ÞÊLiʜ«Ìˆ“>ÊLÕÌʘœÌÊVœ““œ˜ÞÊ>Û>ˆ>Li°
UÊÊ ˜`œÃVœ«ÞÊPLUSÊÀ>«ˆ`ÊÕÀi>ÃiÊÌiÃÌÊ­näq™x¯ÊÃi˜ÃˆÌˆÛˆÌÞÆʙÓq£ää¯Ê
specificity).
UÊÊH. pylori serology does not document current infection and should not
be used for clinical diagnosis.
6.5 Gynecologic and sexually transmitted infections
Pelvic inflammatory disease
UʘVÕ`iÃÊÃ>«ˆ˜}ˆÌˆÃ]ÊÌÕLœ‡œÛ>Àˆ>˜Ê>LÃViÃÃÊ>˜`Ê«iÛˆVÊ«iÀˆÌœ˜ˆÌˆÃ°Ê
UÊʜÀÊÌÀi>̓i˜ÌʜvÊ«œÃ̇œ«iÀ>̈ÛiÊ«iÀˆÌœ˜ˆÌˆÃʜÀÊܜ՘`ʈ˜viV̈œ˜]Ê
see p. 44 and p. 105.
TREATMENT
NOTE: Avoid use of fluoroquinolones for N. gonorrhoeae due to
ÀiÈÃÌ>˜ViÊ­H£ä¯Êˆ˜Ê >Ìˆ“œÀiÊ ˆÌÞ®
UÊÊ ivœÌiÌ>˜ÊÓÊ}Ê6Ê+£ÓÊPLUS Doxycycline* 100 mg PO BID for 14
days
OR
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ÊPLUS Doxycycline* 100 mg PO BID for 14
days
OR
UÊÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÈä䇙ääʓ}Ê6Ê+nÊPLUS Gentamicin (see
dosing section, p. 146)
Step-down therapy once patient is afebrile
UÊÊ*ÀiviÀÀi`\Ê œÝÞVÞVˆ˜iÊ£ääʓ}Ê*"Ê Ê´ÊQ ˆ˜`>“ÞVˆ˜Ê{xäʓ}Ê*"Ê
QID ORÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê*"Ê RÊ̜ÊVœ“«iÌiÊ£{Ê`>ÞÃÊ̜Ì>
*Azithromycin 1 g PO once weekly for 2 weeks can be used in the case of Doxycycline
contraindication or intolerance.
TREATMENT NOTES
Microbiology: N. gonorrhoeae, C. trachomatis, Gardnerella spp,
Ureaplasma urealyticum, anaerobes (Prevotella spp., B. fragilis), Gramnegative rods, Streptococci
Treatment of partners
UʏÊܜ“i˜Ê`ˆ>}˜œÃi`ÊÜˆÌ Ê>VÕÌiÊ* Êà œÕ`ÊLiʜvviÀi`Ê6ÊÌiÃ̈˜}°
UÊÊ>iÊ«>À̘iÀÃʜvÊܜ“i˜ÊÜ œÊ >ÛiÊ* ʜvÌi˜Ê>ÀiÊ>Ãޓ«Ìœ“>̈V°Ê
UÊÊ-iÝÊ«>À̘iÀÃÊ­“>iʜÀÊvi“>i®ÊœvÊ«>̈i˜ÌÃÊÜ œÊ >ÛiÊ* Êà œÕ`Ê
be examined and treated empirically for C. trachomatis and
N. gonorrhoeae if they have had sexual contact with the patient during
the 60 days preceding onset of symptoms in the patient, regardless
of the pathogens isolated from the patient.
Endomyometritis
TREATMENT
UÊÊ->“iÊ>ÃÊvœÀÊ* ÊLÕÌʘœÊ˜ii`ÊvœÀÊ>``ˆÌˆœ˜ÊœvÊ œÝÞVÞVˆ˜iÉâˆÌ Àœ“ÞVˆ˜
Duration
UÊ/Ài>ÌÊ՘̈Ê«>̈i˜ÌÊ>viLÀˆiÊvœÀÊÓ{q{nÊ œÕÀÃ
56
TREATMENT
UÊÊiÌÀœ˜ˆ`>✏iÊ}iÊä°Çx¯]ʜ˜iÊvՏÊ>««ˆV>̜ÀÊ­xÊ}®Êˆ˜ÌÀ>Û>}ˆ˜>Þ]ʜ˜ViÊ
daily for 5 days (preferred)
OR
UiÌÀœ˜ˆ`>✏iÊxääʓ}Ê*"Ê ÊvœÀÊÇÊ`>ÞÃ
OR
U ˆ˜`>“ÞVˆ˜ÊÎääʓ}Ê*"Ê ÊvœÀÊÇÊ`>ÞÃ
TREATMENT NOTES
Microbiology: anaerobic bacteria (Prevotella spp, Mobiluncus spp.),
G. vaginalis, Ureaplasma, Mycoplasma.
UÊÊ/Ài>̓i˜ÌʈÃÊÀiVœ““i˜`i`ʈ˜Ê>ÊÃޓ«Ìœ“>̈VÊܜ“i˜Ê>˜`Ê ˆ} ÊÀˆÃŽÊ
asymptomatic pregnant women.
Trichomoniasis (T.vaginalis)
NOTE: Treatment of partner recommended.
TREATMENT
UÊiÌÀœ˜ˆ`>✏iÊÓÊ}Ê*"ʜ˜ViÊ
OR
UÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê*"Ê ÊvœÀÊÇÊ`>ÞÃ
Uncomplicated gonococcal urethritis, cervicitis,
proctitis
TREATMENT (includes treatment for C. trachomatis):
UÊ ivÌÀˆ>ݜ˜iÊÓxäʓ}Êʜ˜ViÊPLUS Azithromycin 1 g orally (preferred)
OR
UÊÊ ivÌÀˆ>ݜ˜iÊÓxäʓ}Êʜ˜ViÊPLUS Doxycycline 100 mg PO BID for
7 days
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊâˆÌ Àœ“ÞVˆ˜ÊÓÊ}Ê*"ʜ˜ViÊ­«Ài“i`ˆV>ÌiÊÜˆÌ Ê
antiemetic or give snack before administration)
TREATMENT NOTES
UÊ6ÊÌiÃ̈˜}ÊÀiVœ““i˜`i`
UÊÊ/ iÊÕÃiʜvÊ ivÌÀˆ>ݜ˜iʈÃÊ«ÀiviÀÀi`ʜÛiÀÊ iw݈“iÊ>˜`Ê iv«œ`œÝˆ“iÊ
due to increasing MICs for oral cephalosporins.
57
6.5 Gynecologic and sexually transmitted infections
Bacterial vaginosis
6.5 Gynecologic and sexually transmitted infections
UÊÊ Õ>ÊÌ iÀ>«ÞÊÀiVœ““i˜`i`ÊvœÀÊN. gonorrhoeae even if C. trachomatis
is excluded.
UÊÊ-i˜`Ê}œ˜œÀÀ i>ÊVՏÌÕÀiÊ­˜œÌʘÕViˆVÊ>Vˆ`Ê>“«ˆwV>̈œ˜ÊÌiÃ̮ʈvÊޜÕÊ
suspect a treatment failure.
Syphilis
SCREENING
UÊÊ-VÀii˜ˆ˜}Ê>}œÀˆÌ “Ê>ÌÊ\Ê>ÊÌÀi«œ˜i“>‡Ã«iVˆwVÊ>˜ÌˆLœ`ÞÊÌiÃÌÊ­ ®Ê
if positive, followed by RPR. A confirmatory FTA-ABS is provided if RPR
is negative.
UÊÊÊ«œÃˆÌˆÛiÊ ]Ê>ʘi}>̈ÛiÊ,*,Ê>˜`Ê>Ê«œÃˆÌˆÛiÊ/ʓ>ÞÊLiÊ`ÕiÊ̜\Ê­£®Ê
old treated syphilis (2) old untreated syphilis (3) early syphilis.
UÊÊiÌÊ ˆÃ̜ÀÞÊ>˜`ÊV>Ê >Ìˆ“œÀiÊ ˆÌÞÊi>Ì Ê i«>À̓i˜ÌÊ{£ä‡Î™È‡{{{nÊ
for prior history of syphilis treatment in Maryland
UÊÊvÊ«i˜ˆVˆˆ˜Ê>iÀ}ˆV]Ê ÊVœ˜ÃՏÌÃʈÃÊÀiVœ““i˜`i`Ê̜Ê}Ո`iÊÌ iÀ>«Þ
Algorithm for reverse sequence syphilis screening
CIA
RPR positive
CIA positive
RPR negative
CIA negative
UÊÊ œ˜ÃˆÃÌi˜ÌÊÜˆÌ Ê
Treponemal test that uses a different
UÊÊvʈ˜VÕL>̈˜}ʜÀÊ
syphilis infection
>˜Ìˆ}i˜Ê­/q -ʜÀÊ/**®
primary syphilis
(past or present)
FTA-ABS positive FTA-ABS negative is suspected,
UÊÊ,iµÕˆÀiÃÊ ˆÃ̜ÀˆV>Ê ÊUÊ*œÃÈLiÊÃÞ« ˆˆÃÊÊ UÊ-Þ« ˆˆÃÊ՘ˆŽiÞ
treat for early
and clinical
syphilis
ÊÊÊʈ˜viV̈œ˜Ê
UÊvÊ«>̈i˜ÌÊ>ÌÊ ˆ} Ê
evaluation to
ÊUÊ,iµÕˆÀiÃÊÊ
ÊÊÊÀˆÃŽÊvœÀÊÃÞ« ˆˆÃ]
determine prior
historical and
retest in one
treatment history
clinical
month
evaluation
Neurosyphilis diagnosis
UÊÊ,iµÕˆÀiÃÊLœÌ ÊVˆ˜ˆV>Ê­˜iÕÀœœ}ˆV>ÊÃޓ«Ìœ“îÊ>˜`ʏ>LœÀ>̜ÀÞÊVÀˆÌiÀˆ>°Ê
UÊÊ>LœÀ>̜ÀÞÊVÀˆÌiÀˆ>Ê­>˜ÞÊVœ“Lˆ˜>̈œ˜Êœv®\ÊÃiÀœœ}ˆV>Êiۈ`i˜ViʜvÊ
ÃÞ« ˆˆÃ]Ê«œÃˆÌˆÛiÊ -Ê6 ,Ê­xä¯ÊÃi˜ÃˆÌˆÛˆÌÞÆÊ ˆ} ÊëiVˆwVˆÌÞ®]Ê -Ê
«iœVÞ̜ÈÃÊ­€xÊ7 ɓÊˆvÊ6‡Æʀ£ä‡ÓäÊ7 ɓÊˆvÊ6³®]Ê -Ê
elevated protein concentration (>50 mg/dl)
UÊÊՓL>Àʫ՘VÌÕÀiÊ­*®Êà œÕ`ÊLiʜLÌ>ˆ˜i`ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê«œÃˆÌˆÛiÊ
serological tests for syphilis plus neurological symptoms, serological
treatment failure (lack of four-fold decline in RPR titer), evidence of
tertiary syphilis
UÊÊ œ˜Ãˆ`iÀÊ*ʈ˜Ê>Ãޓ«Ìœ“>̈VÊ6³Ê«>̈i˜ÌÃÊÜˆÌ Ê>Ê {ÊVœÕ˜ÌÊ≤350
cells/ml or RPR titer ≥£\ÎÓ
58
Early syphilis (primary, secondary, and early latent syphilis within one
year after infection)
UÊÊ*i˜ˆVˆˆ˜ÊÊ i˜â>Ì ˆ˜iÊ­ ˆVˆˆ˜® L-A) 2.4 million units IM once
UÊÊ-iÛiÀiÊ* Ê>iÀ}ˆiÃ\Ê œÝÞVÞVˆ˜iÊ£ääʓ}Ê*"Ê ÊvœÀÊÓÊÜiiŽÃÊÊ
Note:Ê`ÕiÊ̜ʈ˜VÀi>Ãi`ÊÀiÈÃÌ>˜ViÊ­H{x¯ÊœvÊÃÌÀ>ˆ˜Ãʈ˜Ê >Ìˆ“œÀiÊ>ÀiÊ
resistant), Azithromycin is not recommended.
Late latent syphilis (asymptomatic infection with positive serology >1
year after infection or latent syphilis of unknown duration)
UÊÊ*i˜ˆVˆˆ˜ÊÊ i˜â>Ì ˆ˜iÊ­ ˆVˆˆ˜® L-A) 2.4 million units IM weekly for 3
weeks (total of 3 doses)
Neurosyphilis (can occur during any stage of syphilis)
UÊÊ*i˜ˆVˆˆ˜ÊÊÎq{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{ÊvœÀÊ£äq£{Ê`>ÞÃ
Syphilis in pregnancy
UÊÊ*i˜ˆVˆˆ˜ÊˆÃÊÌ iʜ˜ÞÊÀiVœ““i˜`i`ÊÌ iÀ>«Þʈ˜Ê«Ài}˜>˜ÌÊ«>̈i˜ÌÃÊÜˆÌ Ê
any kind of syphilis. Allergy consult for penicillin desensitization is
recommended.
,iviÀi˜ViÃ\Ê
-iÝÕ>ÞÊÌÀ>˜Ã“ˆÌÌi`Ê`ˆÃi>ÃiÃÊ
ÊÌÀi>̓i˜ÌÊ}Ո`iˆ˜iðÊ7,ÊÓä£äÉx™Ê­,,£Ó®ÆÊ
£q££ä°Ê
âˆÌ Àœ“ÞVˆ˜ÊÛÃ°Ê œÝÞVÞVˆ˜iÊvœÀÊ* °Ê"LÃÌiÌÊޘiVœÊÓääÇÆÊ££ä­£®\xÎqÈä°
Discordant Results from Reverse Sequence Syphilis Screening. MMWR 2011/60
­äx®Æ£ÎÎq£ÎÇ
59
6.5 Gynecologic and sexually transmitted infections
TREATMENT
6.6 Catheter-related bloodstream infections
Management of catheter-related
bloodstream infections (CR-BSI)
Diagnosis
UÊÊvÊÌ iÀiʈÃʓœÀiÊÌ >˜Ê“ˆ˜ˆ“>ÊiÀÞÌ i“>ʜÀÊ 9Ê«ÕÀՏi˜ViÊ>ÌÊÌ iÊi݈ÌÊ
site, the catheter is likely infected. It should be removed and replaced
at a different site.
UÊÊ7 i˜Ê ,‡ -ʈÃÊÃÕëiVÌi`]ÊÓqÎÊÃiÌÃʜvÊLœœ`ÊVՏÌÕÀiÃÊà œÕ`ÊLiÊ
drawn with AT LEAST one (and preferably > 1) from peripheral sites.
Blood cultures drawn through non-tunneled catheters are more likely
to yield contaminants.
UÊÊ/ iÊṎˆÌÞʜvÊVՏÌÕÀiÃʜvÊÌ iÊV>Ì iÌiÀÊ̈«ÊˆÌÃivʈÃʘœÌÊÜiÊ`iw˜i`]Ê>˜`Ê
should ONLY be sent when there is a clinical suspicion of infection,
NOT routinely when lines are removed. They MUST be accompanied
by two sets of blood cultures obtained as detailed above.
UÊÊ/iV ˜ˆµÕi\Ê/ iÊi݈ÌÊÈÌiÊà œÕ`ÊLiÊVi>˜i`ÊÜˆÌ Ê>Vœ œ°Ê/ iÊ
catheter should be grasped a few centimeters proximal to the exit
site. A 5 cm segment of catheter including the tip should be cut off
with sterile scissors and placed in a sterile container.
UÊʘʈ˜ÃÌ>˜ViÃÊÜ iÀiÊÌ iÊLœœ`Ê>˜`ÊV>Ì iÌiÀÊ̈«Ê>ÀiÊVՏÌÕÀi`Ê>ÌÊÌ iÊÃ>“iÊ
time and the blood cultures are negative but the catheter tip culture is
positive, antibiotics are generally not recommended, even for patients
with valvular heart disease or immunosuppression.
UÊÊ/ iÊiÝVi«Ìˆœ˜ÊˆÃÊ«>̈i˜ÌÃÊÜ œÃiÊV>Ì iÌiÀÊ̈«ÃÊ}ÀœÜÊS. aureus and
>Ûiʘi}>̈ÛiÊLœœ`ÊVՏÌÕÀiðÊ/ iÃiÊ«>̈i˜ÌÃÊà œÕ`ÊÀiViˆÛiÊxqÇÊ
days of antibiotics.
UÊʏÊ«>̈i˜ÌÃÊà œÕ`ÊLiÊvœœÜi`ÊVœÃiÞ]Ê>˜`ÊÀi«i>ÌÊVՏÌÕÀiÃÊà œÕ`Ê
be sent if clinically indicated.
UÊÊ7 i˜Ê>ÊV>Ì iÌiÀ‡Ài>Ìi`Ê -ʈÃÊ>ÃÜVˆ>Ìi`ÊÜˆÌ ÊV>Ì iÌiÀÊ`ÞÃv՘V̈œ˜]Ê
consider the possibility of suppurative thrombophlebitis.
EMPIRIC TREATMENT
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê±Ê ivi«ˆ“iÊ£qÓÊ}Ê6Ê+nÊ
(use higher dose if pseudomonas suspected)
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê
±ÊQ ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRʱ
Tobramycin (see dosing section, p. 146)
Empiric treatment – Gram-positive cocci in clusters in 2 or more
sets of blood cultures
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
60
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê
Change to
UÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ʈvÊÃÕÃVi«ÌˆLiÊ­«ÀiviÀÀi`Ê̜Ê6>˜Vœ“ÞVˆ˜®
Duration:
UÊÎqÇÊ`>ÞÃʈvÊV>Ì iÌiÀÊÀi“œÛi`Ê­«ÀiviÀÀi`®
UÊ£äq£{Ê`>ÞÃʈvÊV>Ì iÌiÀÊÃ>Û>}iÊ>ÌÌi“«Ì
Methicillin-susceptible Staphylococcus aureus
UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ʈvÊÃÕÃVi«ÌˆLi
OR
UÊÊ œ˜‡>˜>« ޏ>V̈VÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜ÊÓÊ}Ê6Ê+n
OR
UÊʘ>« ޏ>V̈VÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
Methicillin-resistant Staphylococcus aureus
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
UÊ6>˜Vœ“ÞVˆ˜Ê>iÀ}ÞʜÀʈ˜ÌœiÀ>˜ViÊ­˜œÌÊÀi`ʓ>˜ÊÃޘ`Àœ“i®
Ê UÊ >«Ìœ“ÞVˆ˜Ên‡£äʓ}Ɏ}Ê6Ê+ÊÓ{
OR
Ê UÊ ivÌ>Àœˆ˜iÊÈääʓ}Ê6Ê+Ên
UÊ6>˜Vœ“ÞVˆ˜Êv>ˆÕÀi\ÊVœ˜ÃՏÌÊ
TREATMENT NOTES
UÊ,i“œÛiÊV>Ì iÌiÀ°Êˆ} ÊÀi>«ÃiÊÀ>ÌiÃʈvÊV>Ì iÌiÀʈÃʘœÌÊÀi“œÛi`°
UÊ6>˜Vœ“ÞVˆ˜ÊˆÃʈ˜viÀˆœÀÊ̜Ê"Ý>Vˆˆ˜ÊvœÀÊÌÀi>̓i˜ÌʜvÊ--°
UÊÊ*>̈i˜ÌÃÊÜˆÌ ÊS. aureus bacteremia should have an echocardiogram to
rule out endocarditis. Transthoracic echo is acceptable only if the study
>`iµÕ>ÌiÞÊۈiÜÃÊÌ iʏiv̇È`i`ÊÛ>ÛiÃÆʓœÃÌÊiÝ«iÀÌÃÊÀiVœ““i˜`Ê/ °
UÊʈ˜i✏ˆ`Êà œÕ`ʘœÌÊLiÊÕÃi`ÊÀœṎ˜iÞÊvœÀÊÌÀi>̓i˜ÌʜvÊS. aureus
bacteremia
UÊ ÀˆÌiÀˆ>ÊvœÀÊ>Ê£{Ê`>ÞÊVœÕÀÃiʜvÊÌ iÀ>«Þ
Ê UÊÊ ˜`œV>À`ˆÌˆÃÊiÝVÕ`i`ÊÜˆÌ Ê/ Ê­«ÀiviÀÀi`®ÆÊ ˆ} ʵÕ>ˆÌÞÊ// ʓ>ÞÊLiÊ
adequate in select patients
Ê UÊ œÊˆ“«>˜Ìi`Ê«ÀœÃÌ iÃiÃ
Ê UÊʜœÜ‡Õ«ÊLœœ`ÊVՏÌÕÀiÃÊ`À>ܘÊӇ{Ê`>ÞÃÊ>vÌiÀÊÌ iʈ˜ˆÌˆ>ÊVՏÌÕÀiÃÊ>ÀiÊ
negative for S. aureus
61
6.6 Catheter-related bloodstream infections
Coagulase-negative staphylococci (CoNS)
NOTE: Single positive cultures of CoNS should NOT be treated
unless they are confirmed by follow-up cultures, the patient is
immunosuppressed and/or critically ill, or the patient has implanted
hardware. In these cases, treatment can be started but repeat cultures
should be sent PRIOR to initiation of therapy to confirm the diagnosis.
6.6 Catheter-related bloodstream infections
Ê UÊÊ/ iÊ«>̈i˜ÌÊ`iviÀÛiÃViÃÊÜˆÌ ÊÇÓÊ œÕÀÃʜvʈ˜ˆÌˆ>̈œ˜ÊœvÊivviV̈ÛiÊ
antistaphylococcal therapy
Ê UÊÊ/ iÊ«>̈i˜ÌÊ >ÃʘœÊœV>ˆâˆ˜}ÊÈ}˜ÃʜÀÊÃޓ«Ìœ“ÃʜvʓiÌ>ÃÌ>̈VÊ
staphylococcal infection
Ê UÊ-œÕÀViÊVœ˜ÌÀœÊ >ÃÊLii˜ÊœLÌ>ˆ˜i`
Ê UÊÊLÃi˜ViʜvÊœÌ iÀÊVœ˜`ˆÌˆœ˜ÃÊÌ >Ìʓ>ÞÊ>vviVÌÊ>LˆˆÌÞÊ̜ÊVi>Àʈ˜viV̈œ˜Ê
based on clinical judgment (e.g. poorly controlled diabetes)
UÊʏÊœÌ iÀÊ«>̈i˜ÌÃÊà œÕ`ÊÀiViˆÛiÊ{‡ÈÊÜiiŽÃʜvÊÌ iÀ>«ÞÊL>Ãi`ʜ˜ÊiÝÌi˜ÌÊ
of infection
Enterococcus faecalis
NOTE: Can be contaminants. Draw repeat cultures to confirm before
ÃÌ>À̈˜}ÊÌÀi>̓i˜Ì°Ê£ää¯ÊœvÊE. faecalis blood isolates at JHH are
susceptible to Ampicillin, which should be used unless the patient has a
PCN allergy.
UÊʓ«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê
OR
UÊÊ*
Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£xä®Ê
Duration: Çq£{Ê`>ÞÃ
Enterococcus faecium
NOTE: Can be contaminants. Draw repeat cultures to confirm before
ÃÌ>À̈˜}ÊÌÀi>̓i˜Ì°Ê/ iʓ>œÀˆÌÞÊ­Çn¯®ÊœvÊE. faecium blood isolates
at JHH are resistant to Vancomycin. If the isolate is susceptible to
Ampicillin or Vancomycin, these agents should be used preferentially at
the doses listed above for E. faecalis bacteremia.
UÊʈ˜i✏ˆ`ÊÈääʓ}Ê6É*"Ê+£Ó
OR
UÊ >«Ìœ“ÞVˆ˜Ênq£Óʓ}Ɏ}Ê6Ê+Ó{
TREATMENT NOTES
UÊÊ œ˜Ãˆ`iÀÊiV œV>À`ˆœ}À>“ʈvÊÌ iÀiʈÃÊ«iÀÈÃÌi˜ÌÊL>VÌiÀi“ˆ>Ê­> 3 days)
on antibiotics.
UÊÊ/ iÊ>``ˆÌˆœ˜ÊœvÊi˜Ì>“ˆVˆ˜Ê`œiÃʘœÌÊ>««i>ÀÊ̜ÊV >˜}iʜÕÌVœ“iÃʈ˜Ê
CR-BSI caused by Enterococcus in the absence of endocarditis.
Gram-negative bacilli
Antibiotic selection based on organism and susceptibilities.
Duration: Çq£äÊ`>ÞÃ
62
Candida spp.
UÊ,iviÀÊ̜ʫ°Ê££ÇÊvœÀÊÌÀi>̓i˜ÌʜvÊV>˜`ˆ`i“ˆ>
CATHETER SALVAGE
UÊÊCatheter removal is STRONGLY recommended for infections with
S. aureus, yeast and Pseudomonas, as the chance of catheter salvage
is low and the risk of recurrent infection is high.
UÊÊCatheters associated with tunnel infections CANNOT be salvaged and
should be removed.
UÊÊWhen catheter salvage is attempted, systemic antibiotics should be
given through the infected line.
UÊʘ̈LˆœÌˆVÊÕÃi`Ê>ÃʏœVŽÊÌ iÀ>«ÞÊà œÕ`Ê«ÀiviÀi˜Ìˆ>Þʓ>ÌV Ê>˜ÌˆLˆœÌˆVÊ
used for systemic therapy.
Antibiotic Lock Therapy (ALT)
UÊʘ̈LˆœÌˆVʏœVŽÊÌ iÀ>«ÞÊV>˜ÊLiÊÕÃi`ÊvœÀÊV>Ì iÌiÀÊÃ>Û>}iÊin addition to
systemic antibiotics when feasible.
UÊÊ >Ì iÌiÀÊÀi“œÛ>Êà œÕ`ÊLiÊ«iÀvœÀ“i`ʈvÊVՏÌÕÀiÃÊÀi“>ˆ˜Ê«œÃˆÌˆÛiÊ>vÌiÀÊ
72 hours of appropriate antibiotic lock therapy
Acceptable uses:
UÊÊ->Û>}iʜvʏœ˜}‡ÌiÀ“ÊV>Ì iÌiÀÃÊÌ >ÌÊV>˜˜œÌÊLiÊÀi“œÛi`Ê­i°}°Ê`ˆ>ÞÈÃÊ
catheters, implantable permanent ports or central venous catheters
for chemotherapy) when there are NO systemic complications
(hemodynamic instability, tissue hypoperfusion, septic thrombosis,
infectious endocarditis or distant septic metastases) or signs of local
infection.
Unacceptable uses:
UÊÊ- œÀ̇ÌiÀ“ÊÛi˜œÕÃÊV>Ì iÌiÀÃ
UÊÊ œ“«ˆV>Ìi`Ê , -Ê­i°}°ÊÌ՘˜iÊœÀÊ«œÀ̇«œVŽiÌʈ˜viV̈œ˜]ÊÃiÛiÀiÊ
sepsis, septic shock, endocarditis, osteomyelitis and hematogenous
seeding at other sites)
UÊ >Ì iÌiÀÊÃ>Û>}iÊÜˆÌ ÊS. aureus infection.
Duration:ÊÇq£{Ê`>ÞÃÊ
63
6.6 Catheter-related bloodstream infections
TREATMENT NOTES
UÊÊ >Ì iÌiÀÃÊ>ÀiʏiÃÃÊVœ““œ˜ÞÊÌ iÊÜÕÀViʜvÊÌ iʈ˜viV̈œ˜ÆÊ œÜiÛiÀ]Ê
most advocate catheter removal if the catheter is the source.
6.6 Catheter-related bloodstream infections
Standardized Concentrations of Antibiotics for ALT
Antibiotic
Heparin (optional)
6>˜Vœ“ÞVˆ˜Êxʓ}ɓʈ˜Ê䰙¯Ê -Ê
i˜Ì>“ˆVˆ˜Êxʓ}ɓʈ˜Ê䰙¯Ê -Ê
äʜÀÊxäääÊ՘ˆÌÃ
ÓxääÊ՘ˆÌÃÊ
UÊÊ/Êà œÕ`ÊLiʈ˜Ã̈i`ʈ˜ÊÌ iʏՓi˜ÊœvÊÌ iÊV>Ì iÌiÀÊÜ i˜Ê˜œÌʈ˜ÊÕÃi°
UÊÊ ÜiÊ̈“iÃÊà œÕ`ÊLiÊ>Ìʓˆ˜ˆ“Õ“ÊœvÊnq£ÓÊ œÕÀÃÊ«iÀÊ`>ÞÊ­Õ«Ê̜Ê
Ó{q{nÊ ®
UÊÊ/ÊۜÕ“iʘii`i`Ê܈ÊÛ>ÀÞÊLÞÊÌÞ«iʜvÊV>Ì iÌiÀÊ>˜`Ê>Û>ˆ>LiʘՓLiÀÊ
œvʏՓi˜Ã°Ê˜Ê}i˜iÀ>]ÊÓqxʓÊà œÕ`ÊLiÊÃÕvwVˆi˜Ì°
,iviÀi˜ViÃ\
Stability and compatibility of antimicrobial lock solutions. Am J Health-Syst Pharm.
Óä£ÎÆÇä\Ó£nx‡Ó£™n°
IDSA Guidelines for the Diagnosis and Management of Intravascular Catheter-related
˜viV̈œ˜Ã\ÊClin Infect Dis Óää™Æ{™\£‡{x°
64
NOTES:
UÊÊ iÌ>‡>VÌ>“ÃÊ>ÀiÊhighly preferable to Vancomycin if the organism is
susceptible and if the patient is not severely allergic. Strongly consider
PCN desensitization for allergic patients.
UÊʘviV̈œÕÃÊ ˆÃi>ÃiÃÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊ>`ۈÃi`ÊvœÀÊV>ÃiÃʜvʏiv̇È`i`Ê
infective endocarditis and prosthetic valve endocarditis, particularly in
those in which the preferred antibiotic cannot be used or in which the
organism is resistant to usual therapy.
UÊÊ/ iÀ>«iṎVʓœ˜ˆÌœÀˆ˜}\Ê
UÊÊ6>˜Vœ“ÞVˆ˜
UÊʜ>ÊÌÀœÕ} ʏiÛi\Ê£xqÓäʓV}ɓ
UÊÊi˜Ì>“ˆVˆ˜ÊvœÀÊÀ>“‡«œÃˆÌˆÛiÊÃޘiÀ}Þ
UÊÊ >ˆÞÊ`œÃˆ˜}
UÊʜ>ÊÌÀœÕ} ʏiÛi\Ê1 mcg/mL
UÊÊ/À>`ˆÌˆœ˜>Ê`œÃˆ˜}Ê­+n®
UÊʜ>Ê«i>ŽÊiÛi\ÊÎq{ʓV}ɓ
UÊʜ>ÊÌÀœÕ} ʏiÛi\Ê1 mcg/mL
UÊÊ-iiÊ«°Ê£{nÊ>˜`Ê«°Ê£xäÊvœÀÊ`iÌ>ˆÃ
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
UÊÊ*i˜ˆVˆˆ˜ÊÊÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{ÊvœÀÊ{ÊÜiiŽÃ
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ{ÊÜiiŽÃ
OR
UÊÊQ*i˜ˆVˆˆ˜ÊÊÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê",Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊÓÊ
ÜiiŽÃRÊPLUS Gentamicin 3 mg/kg IV Q24H for 2 weeks
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ{Ê
weeks
ÀˆÌiÀˆ>ÊvœÀÊÓÊÜiiŽÊÌÀi>̓i˜Ì\
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ >ÛiÊV>À`ˆ>VʜÀÊiÝÌÀ>V>À`ˆ>VÊ>LÃViÃÃ
UÊÊ À Ê20 mL/min
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ >Ûiʈ“«>ˆÀi`ÊnÌ ÊVÀ>˜ˆ>Ê˜iÀÛiÊv՘V̈œ˜Ê
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ >ÛiÊAbiotrophia, Granulicatella, or Gemella spp.
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
and 0.5 mcg/mL
UÊÊQ*i˜ˆVˆˆ˜ÊÊ{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê",Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ
{ÊÜiiŽÃRÊPLUS Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of
therapy
65
6.7 Endocarditis
Treatment of native valve endocarditis
6.7 Endocarditis
OR
UÊÊ-iÛiÀiÊ*
4 weeks
Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ
Viridans streptococci or S. bovis with PCN MIC > 0.5 mcg/mL
and Abiotrophia defectiva, Granulicatella spp. and Gemella spp.
UÊÊ œ˜ÃՏÌÊ
TREATMENT NOTES
UÊʏÊ«>̈i˜ÌÃÊÜˆÌ ÊS. bovis biotype I endocarditis should undergo GI
work-up to rule out underlying cancer.
Staphylococcus aureus – Methicillin susceptible, native valve,
right-sided involvement only
UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{
UÊÊ1ÃiÊ >vVˆˆ˜ÊvœÀÊ"Ý>Vˆˆ˜‡ˆ˜`ÕVi`Ê i«>̈̈Ã
Criteria for 2-ÜiiŽÊÌÀi>̓i˜Ì\
UÊ*>̈i˜ÌʈÃÊ>˜Êˆ˜iV̈˜}Ê`ÀÕ}ÊÕÃiÀÊÜˆÌ Ê“ˆ˜ˆ“>ÊœÌ iÀÊVœ“œÀLˆ`ˆÌˆiÃÊ
UÊÊiv̇È`i`Êi˜`œV>À`ˆÌˆÃʈÃÊÀՏi`ʜÕÌÊÜˆÌ Ê/ Ê­«ÀiviÀÀi`®ÊœÀÊ ˆ} Ê
quality TTE
UÊÊ/Ài>̓i˜ÌʈÃÊÜˆÌ Ê"Ý>Vˆˆ˜ÊœÀÊ >vVˆˆ˜Ê
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ >ÛiÊ -Ê­ {Ê< 200)
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ >ÛiÊ>˜Êˆ“«>˜Ìi`Ê«ÀœÃÌ iÈÃÊ­`ˆ>ÞÈÃÊ}À>vÌ]ÊiÌV®
UÊÊ œœ`ÊVՏÌÕÀiÃÊ>Àiʘi}>̈ÛiÊÜˆÌ ˆ˜Ê{Ê`>ÞÃÊ>vÌiÀÊÃÌ>À̈˜}ÊÌ iÀ>«ÞÊ
UÊÊ/ iÀiʈÃʘœÊiۈ`i˜ViʜvÊi“LœˆVÊ`ˆÃi>ÃiÊ"/ ,ÊÌ >˜ÊÃi«ÌˆVÊ
pulmonary emboli
UÊÊ6i}iÌ>̈œ˜ÃÊ>ÀiÊ>Ê< 2 cm in size
UÊÊvÊ«>̈i˜ÌÊ`œiÃʘœÌʓiiÌÊVÀˆÌiÀˆ>ÊvœÀÊӇÜiiŽÊÌÀi>̓i˜Ì]ÊÌÀi>ÌÊvœÀÊ{Ê
weeks
Staphylococcus aureus – Methicillin susceptible, native valve,
left-sided involvement
UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{Ê
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜ÊÓÊ}Ê6Ê+nÊ
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê-ÌÀœ˜}ÞÊVœ˜Ãˆ`iÀÊ* Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊœÀÊ
Vancomycin (see dosing section, p. 150)
UÊÊ/ iÊ>``ˆÌˆœ˜ÊœvÊi˜Ì>“ˆVˆ˜Ê̜Ê>ÊLiÌ>‡>VÌ>“Ê“>ÞÊ i«ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ
faster but does not appear to affect mortality. It particularly should be
avoided in the elderly and in those with baseline renal impairment.
Staphylococcus aureus – Methicillin resistant, native valve
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
66
S. pneumoniae, and Group A streptococci
UÊÊ*i˜ˆVˆˆ˜ÊÊÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{ÊvœÀÊ{ÊÜiiŽÃ
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6Ê+Ó{ÊvœÀÊ{ÊÜiiŽÃÊ",Ê
Cefazolin 2 g IV Q8H for 4 weeks
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ{Ê
weeks
UÊʜÀÊS. pneumoniae, if PCN MIC ≥ 0.1, consult ID
Groups B, C and G streptococci
UÊÊ*i˜ˆVˆˆ˜ÊÊÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{ÊvœÀÊ{qÈÊÜiiŽÃÊ´Êi˜Ì>“ˆVˆ˜Ê
3 mg/kg IV Q24H for the first 2 weeks of therapy
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜ÊÓÊ}Ê6Ê+nÊvœÀÊ{qÈÊÜiiŽÃʱ
Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£{È®ÊvœÀÊ{qÈÊ
weeks ± Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy
UÊÊ œ˜Ãˆ`iÀÊ>˜Ê Ê œ˜ÃՏÌ
Enterococcus faecalis
UÊʓ«ˆVˆˆ˜Ê>˜`Êi˜Ì>“ˆVˆ˜ÊÃÕÃVi«ÌˆLi\ʓ«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê",Ê
Penicillin G 4 million units IV Q4H PLUS Gentamicin 1 mg/kg IV Q8H
BOTH for 4-6 weeks
UÊʓ«ˆVˆˆ˜ÊÃÕÃVi«ÌˆLiÊÜˆÌ ÊVœ˜ÌÀ>ˆ˜`ˆV>̈œ˜ÃÊvœÀÊ>“ˆ˜œ}ÞVœÃˆ`iÃʜÀÊ
i˜Ì>“ˆVˆ˜ÊÀiÈÃÌ>˜Ì\ʓ«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê",Ê*i˜ˆVˆˆ˜ÊÊ{ʓˆˆœ˜Ê
units IV Q4H PLUS Ceftriaxone 2 g IV Q12H BOTH for 4-6 weeks
67
6.7 Endocarditis
Duration
UÊÊ1˜Vœ“«ˆV>Ìi`\ÊÈÊÜiiŽÃ
UÊÊ œ“«ˆV>Ìi`Ê­«iÀˆÛ>ÛՏ>ÀÊ>LÃViÃÃÊvœÀ“>̈œ˜]ʓiÌ>ÃÌ>̈VÊVœ“«ˆV>̈œ˜]Ê
«œœÀÊVœ˜ÌÀœi`Ê`ˆ>LiÌiÃʓiˆÌÕî\ÊÈʜÀʓœÀiÊÜiiŽÃÊL>Ãi`ʜ˜ÊVˆ˜ˆV>ÊÊ
picture and response to therapy
UÊÊ Ê>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i`ÊvœÀÊVœ“«ˆV>Ìi`Ê
diseases
6.7 Endocarditis
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê-ÌÀœ˜}ÞÊVœ˜Ãˆ`iÀÊ* Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊˆvÊ* Ê
allergy is anaphylactic or Vancomycin (see dosing section, p. 146)
PLUS Gentamicin 1 mg/kg IV Q8H BOTHÊvœÀÊ{qÈÊÜiiŽÃ
UÊÊ/Ài>ÌÊvœÀÊ{ÊÜiiŽÃʜ˜ÞÊÜ i˜ÊÃޓ«Ìœ“ÃÊ >ÛiÊLii˜Ê«ÀiÃi˜ÌÊvœÀÊ< 3
months AND there is a prompt response to therapy
Enterococcus faecium
UÊ œ˜ÃՏÌÊ
,iviÀi˜Vi\
1ÃiʜvÊ ivÌÀˆ>ݜ˜iʈ˜Êi˜ÌiÀœVœVV>Êi˜`œV>À`ˆÌˆÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£ÎÆÊxÈ\£ÓÈ£‡n°
HACEK organisms (Haemophilus parainfluenzae, H. aphrophilus,
Actinobacillus actinomycetemcomitans, Cardiobacterium
hominus, Eikenella corrodens, Kingella kingae)
UÊÊ ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ{ÊÜiiŽÃ
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê œ˜ÃՏÌÊ
Gram-negative organisms, culture negative endocarditis, or
fungal endocarditis
UÊÊ œ˜ÃՏÌÊ
Treatment of prosthetic valve endocarditis
UÊÊi˜iÀ>ÞÊV>ÕÃi`ÊLÞÊÃÌ>« ޏœVœVVˆÊˆ˜ÊÌ iÊwÀÃÌÊ£qÓÊÞi>ÀÃÊvœœÜˆ˜}ÊÛ>ÛiÊ
replacement (both S. aureus and coagulase-negative staph). Etiologies
are similar to native valve infections 2 or more years post-op.
UÊi`ˆV>ÊÌÀi>̓i˜ÌÊ>œ˜iʈÃʜvÌi˜Ê "/ÊivviV̈Ûi°
UʏÊ«>̈i˜ÌÃÊà œÕ`Ê >ÛiÊ>Ê/ °
EMPIRIC TREATMENT
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Gentamicin 1 mg/kg
IV Q8H
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
UÊÊQ*i˜ˆVˆˆ˜ÊÊ{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê",Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{RÊvœÀÊ
6 weeks Gentamicin 3 mg/kg IV Q24H for first 2 weeks of therapy
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊ
weeks
68
Staphylococcus aureus—Methicillin susceptible
UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ÊvœÀÊÈÊÜiiŽÃÊPLUS Gentamicin 1 mg/kg IV Q8H for
first 2 weeks of therapy
AND
UÊÊ,ˆv>“«ˆ˜ÊÎääʓ}Ê*"Ê+nÊvœÀÊÈÊÜiiŽÃÊafter blood cultures have
cleared
UÊÊ Ê>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i`
Staphylococcus aureus—Methicillin resistant or Coagulasenegative staphylococci
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊÜiiŽÃÊPLUS
Gentamicin 1 mg/kg IV Q8H for the first 2 weeks of therapy
AND
UÊÊ,ˆv>“«ˆ˜ÊÎääʓ}Ê*"Ê+nÊvœÀÊÈÊÜiiŽÃÊafter blood cultures have
cleared
UÊÊvÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊÃÌ>« ޏœVœVVˆÊˆÃÊÃÕÃVi«ÌˆLiÊ̜Ê"Ý>Vˆˆ˜ÊÌ i˜Ê
treat as S. aureusÊqÊiÌ ˆVˆˆ˜ÊÃÕÃVi«ÌˆLi°
UÊÊ Ê>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i`
Gram-negative organisms or culture negative endocarditis
UÊÊ œ˜ÃՏÌÊ
DUKE CRITERIA FOR INFECTIVE ENDOCARDITIS
Diagnostic criteria (Modified Duke criteria)
Definite endocarditis
UÊÊ*ÀiÃi˜ViʜvÊÓʓ>œÀÊVÀˆÌiÀˆ>Ê",ʣʓ>œÀÊ ÊÎʓˆ˜œÀÊ",Êxʓˆ˜œÀ
Possible endocarditis
UÊÊ*ÀiÃi˜Viʜvʣʓ>œÀÊ Ê£Ê“ˆ˜œÀÊ",ÊÎʓˆ˜œÀÊVÀˆÌiÀˆ>
Rejected endocarditis
UÊʈÀ“Ê>ÌiÀ˜>ÌiÊ`ˆ>}˜œÃˆÃÊÌ >ÌÊiÝ«>ˆ˜ÃÊʓ>˜ˆviÃÌ>̈œ˜ÃʜvÊ
(NOTE: simply having another infection does NOT exclude
endocarditis)
69
6.7 Endocarditis
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
UÊÊQ*i˜ˆVˆˆ˜ÊÊ{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê",Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{RÊ
PLUS Gentamicin 3 mg/kg IV Q24H for 6 weeks
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊ
weeks
6.7 Endocarditis
Major criteria
Microbiologic
UÊÊ/ܜÊÃi«>À>ÌiÊLœœ`ÊVՏÌÕÀiÃÊ«œÃˆÌˆÛiÊvœÀÊ>ÊÌÞ«ˆV>ÊœÀ}>˜ˆÃ“\Ê
viridans streptococci, S. bovis, HACEK, S. aureus, Enterococcus
spp.
UÊÊ*iÀÈÃÌi˜ÌÊL>VÌiÀi“ˆ>ÊÜˆÌ Ê>˜ÞʜÀ}>˜ˆÃ“Ê>ÃÊiۈ`i˜Vi`ÊLÞ\ÊÓÊ
positive blood cultures drawn at least 12 hours apart OR 3/3
positive blood cultures with at least 1 hour between the first and
last OR the majority of more than 4 cultures positive from any time
period.
UÊÊ*œÃˆÌˆÛiÊCoxiella burnetti (Q fever) culture or serology.
Echocardiographic (TEE strongly recommended for prosthetic valve)
UÊÊ6i}iÌ>̈œ˜Ê­œ˜ÊÛ>ÛiʜÀÊÃÕ««œÀ̈˜}ÊÃÌÀÕVÌÕÀiÊ",ʈ˜Ê«>Ì ÊœvÊ
regurgitant jet)
UÊÊLÃViÃÃ
UÊÊ iÜÊ`i ˆÃVi˜ViʜvÊ«ÀœÃÌ ïVÊÛ>Ûi
Physical exam
UÊÊ 7ÊÀi}ÕÀ}ˆÌ>˜ÌʓÕÀ“ÕÀʭܜÀÃi˜ˆ˜}ʜvʜ`ʓÕÀ“ÕÀʈÃÊ "/Ê
sufficient)
Minor criteria
UÊÊ*Ài`ˆÃ«œÃˆ˜}ÊVœ˜`ˆÌˆœ˜\Ê«ÀiۈœÕÃÊi˜`œV>À`ˆÌˆÃ]ʈ˜iV̈œ˜Ê`ÀÕ}ÊÕÃi]Ê
prosthetic valve, ventricular septal defect, coarctation of the aorta,
calcified valve, patent ductus, mitral valve prolapse with regurgitation,
IHSS or other valvular heart disease
UÊÊiÛiÀÊ≥ 38.0°C (100.4°F)
UÊÊ “LœˆVÊiÛi˜ÌÃ\Ê>ÀÌiÀˆ>ÊœÀʫՏ“œ˜>ÀÞÊi“Lœˆ]ÊVœ˜Õ˜V̈Û>Ê
hemorrhage, retinal hemorrhage, splinter hemorrhage, intracranial
hemorrhage, mycotic aneurysm
UÊʓ“Õ˜œœ}ˆVÊ« i˜œ“i˜œ˜\Ê"ÏiÀʘœ`iÃ]Ê}œ“iÀՏœ˜i« ÀˆÌˆÃ]Ê«œÃˆÌˆÛiÊ
rheumatoid factor
UÊÊ*œÃˆÌˆÛiÊLœœ`ÊVՏÌÕÀiÃÊÌ >ÌÊ`œ˜½ÌʓiiÌÊVÀˆÌiÀˆ>Ê>LœÛiÊ",ÊÃiÀœœ}ˆVÊ
evidence of active infection with an organism known to cause
endocarditis BUT single positive cultures for coagulase-negative
staphylococci are NOT considered even a minor criterion
,iviÀi˜ViÃ\
"À>ÊÌ iÀ>«Þ\ʓÊÊi`Ê£™™ÈÆÊ£ä£\Èn‡ÇÈ°
- œÀÌÊVœÕÀÃiÊÌ iÀ>«Þ\ʘ˜Ê˜ÌiÀ˜Êi`Ê£™™{ÆÊ£Ó£\nÇ·Ȱ
ՎiÊVÀˆÌiÀˆ>\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓäääÆÊÎä\Èηn°
Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜Ìʜ˜Ê˜viV̈ÛiÊ ˜`œV>À`ˆÌÃ\Ê ˆÀVՏ>̈œ˜ÊÓääxÆÊ£££­Óή\iΙ{‡{Î{°
TEE in S. aureusÊL>VÌiÀi“ˆ>\ÊÊ“Ê œÊ >À`ˆœÊ£™™ÇÆÊÎä\Ê£äÇӇn°
,-ÊL>VÌiÀi“ˆ>Éi˜`œV>À`ˆÌˆÃÊÀiVœ““i˜`>̈œ˜Ã\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓ䣣ÆÊxÓ\i£n‡xx
70
NOTE: Obtain at least 2 sets of blood cultures before initiation of
antibiotic therapy
EMPIRIC TREATMENT
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®°Ê >ÀÀœÜÊÌ iÀ>«ÞÊL>Ãi`ʜ˜Ê
culture results.
TREATMENT NOTES
MicrobiologypÃÌ>« ޏœVœVVˆÊˆ˜ÊÇä‡nä¯ÊœvÊV>ÃiÃÊ­Hxä¯ÊVœ>}Տ>Ãi‡
˜i}>̈ÛiÊÃÌ>« ޏœVœVVˆÊ>˜`ÊHxä¯ÊS. aureus)
Management
UÊvÊLœœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«œÃˆÌˆÛiʜÀÊi˜`œV>À`ˆÌˆÃʈÃÊÃÕëiVÌi`Ê«>̈i˜ÌÃÊ
should undergo transesophageal echocardiography (TEE)
UÊ œ“«iÌiÊiÝÌÀ>V̈œ˜ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ Ê«œVŽiÌʈ˜viV̈œ˜Ê
and/or valvular or lead endocarditis
UÊÌÊÌ iÊ̈“iʜvÊiÝÌÀ>V̈œ˜]Ê̈ÃÃÕiÊ­À>Ì iÀÊÌ >˜ÊÃÜ>LîÊvÀœ“ÊÌ iÊ}i˜iÀ>̜ÀÊ
pocket should be sent for Gram-stain and culture and lead tips should
be sent for culture.
UÊ œÌiÊÌ >ÌÊLiV>ÕÃiʏi>`ÃÊ>ÀiÊiÝÌÀ>VÌi`ÊÌ ÀœÕ} Ê>˜Êœ«i˜Ê}i˜iÀ>̜ÀÊ
«œVŽiÌ]ÊÌ iÞʓ>ÞÊLiVœ“iÊVœ˜Ì>“ˆ˜>Ìi`ÊLÞÊÌ iʈ˜viVÌi`Ê«œVŽiÌÆÊ
therefore, positive lead cultures are not always indicative of lead
endocarditis in patient with negative blood cultures.
UÊ œœ`ÊVՏÌÕÀiÃÊà œÕ`ÊLiʜLÌ>ˆ˜i`Ê>vÌiÀÊ`iۈViÊÀi“œÛ>°
UÊ iۈViÊÀiˆ“«>˜Ì>̈œ˜Êà œÕ`ÊLiʜ˜ÊÌ iÊVœ˜ÌÀ>‡>ÌiÀ>ÊÈ`iÊÜ i˜iÛiÀÊ
possible.
UÊ œ“«iÌiÊiÝÌÀ>V̈œ˜ÊˆÃÊÃÌÀœ˜}ÞÊÀiVœ““i˜`i`ʈ˜Ê>Ê«>̈i˜ÌÃÊ
presenting with S. aureus bacteremia and no other source
UÊ œ“«iÌiÊiÝÌÀ>V̈œ˜Êà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê«iÀÈÃÌi˜ÌÊ
positive blood cultures with other organisms (e.g. coagulase-negative
staphylococci, enterococci, Gram-negative bacilli) on a case-by-case
basis.
UÊ œ“«iÌiÊ`iۈViÊ>˜`ʏi>`ÊÀi“œÛ>ÊˆÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ Ê
valvular endocarditis.
Uʘ̈“ˆVÀœLˆ>Ê«Àœ« ޏ>݈ÃʈÃÊ "/ÊÀiVœ““i˜`i`ÊvœÀÊ`i˜Ì>ÊœÀÊœÌ iÀÊ
invasive procedures following placement
,iviÀi˜Vi\Ê
Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜Ìʜ˜Ê**Ê>˜`Ê
ʈ˜viV̈œ˜Ã\Ê ˆÀVՏ>̈œ˜ÊÓä£äÆÊ£Ó£\{xnq{ÇÇ°
71
6.8 Pacemaker/ICD infections
Permanent pacemaker (PPM) and implantable
cardioverter-defibrillator (ICD) infections
6.8 Pacemaker/ICD infections
Reimplantation timing and duration of therapy
Diagnosis
Pocket site infection
Timing of reimplantation
Blood cultures negative for
72 hours and surgical site
healing
Positive blood cultures
with rapid clearance
AND TEE with either
no vegetation or
uncomplicated lead
vegetation
Sustained positive blood
cultures AND TEE with
no vegetation or
uncomplicated lead
vegetation
Valve endocarditis
Post-explantation blood
cultures negative for
72 hours
Duration of therapy
7-10 days if device erosion
without inflammation
10-14 days all others
Oral therapy can be
considered
Non-S. aureus\ÊÓÊÜiiŽÃÊ
IV therapy
S. aureus\Ê{ÊÜiiŽÃÊ
IV therapy
Post-explantation blood
cultures negative for
72 hours
4 weeks IV therapy
Blood cultures negative for
14 days
4-6 weeks IV therapy
(see Endocarditis p. 65)
,iviÀi˜Vi\
Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜Ìʜ˜Ê >À`ˆœÛ>ÃVՏ>Àʓ«>˜Ì>LiÊ iVÌÀœ˜ˆVÊ iۈViʘviV̈œ˜Ã\Ê ˆÀVՏ>̈œ˜Ê
Óä£äÆÊ£Ó£\{xnqÇÇ°
72
TREATMENT
UÊÊANTIBIOTICS SHOULD BE STARTED AS SOON AS THE
POSSIBILITY OF BACTERIAL MENINGITIS BECOMES EVIDENT,
IDEALLY WITHIN 30 MINUTES.
UÊDO NOT WAIT FOR CT SCAN OR LP RESULTS. IF LP MUST BE
DELAYED, GET BLOOD CULTURES AND START THERAPY.
UÊÊ`ÕÃÌÊÌ iÀ>«Þʜ˜ViÊ«>Ì œ}i˜Ê>˜`ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>Àiʎ˜œÜ˜°
UÊÊ-œ“iÊ>`ۜV>ÌiÊ«i˜ˆVˆˆ˜Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊvœÀÊ«>Ì œ}i˜‡Ã«iVˆwVÊÌ iÀ>«ÞÊ
in patients with severe allergies (p. 137).
UÊʘ̈LˆœÌˆVÊ`œÃiÃÊ>ÀiÊ ˆ} iÀÊvœÀÊ -ʈ˜viV̈œ˜ÃÊ­«°ÊÇÇ®°
UÊʘviV̈œÕÃÊ ˆÃi>ÃiÃÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊ>`ۈÃi`ÊvœÀÊ>Ê -ʈ˜viV̈œ˜Ã]Ê
particularly those in which the preferred antibiotic cannot be used or in
which the organism is resistant to usual therapy.
Empiric therapy
Host
Pathogens
Preferred Abx
Immunocompetent*
>}iʐÊxä
Immunocompetent*
age > 50
S. pneumo, N.
mening, H. influenzae
S. pneumo, Listeria,
H. influenzae,
N. mening, Group B
streptococci
S. pneumo, N.
mening, H. influenzae,
Listeria,
(Gram-negatives)
S. pneumo (if CSF
leak), H. influenzae,
Staphylococci,
Gram-negatives
S. aureus, coagulasenegative staphylococci,
Gram-negatives (rare)
Vancomycin PLUS
Ceftriaxone
Vancomycin PLUS
Ceftriaxone PLUS
Ampicillin
Alternative for
serious PCN
allergy (ID consult
recommended)
Moxifloxacin‡ PLUS
Vancomycin
Moxifloxacin‡ PLUS
Vancomycin PLUS
/*É-8
Vancomycin PLUS
Cefepime PLUS
Ampicillin
Vancomycin PLUS
/*É-8ÊPLUS
Ciprofloxacin
Vancomycin PLUS
Cefepime
Vancomycin PLUS
Ciprofloxacin
Vancomycin PLUS
Cefepime
Vancomycin PLUS
Ciprofloxacin
Immunocompromised†
Post neurosurgery or
penetrating head
trauma
Infected shunt
† Immunocompromised is defined as solid organ transplant, BMT in the past year, leukemia
undergoing treatment, or neutropenia
‡ Allergy consult for beta-lactam desensitization
* Use of Dexamethasone
UÊÊ``ˆÌˆœ˜ÊœvÊ`iÝ>“iÌ >ܘiʈÃÊÀiVœ““i˜`i`ʈ˜Ê>Ê>`ՏÌÊ«>̈i˜ÌÃÊÜˆÌ Ê
suspected pneumococcal meningitis (note that this will be most adult
patients).
UÊÊ œÃi\Êä°£xʓ}Ɏ}Ê6Ê+ÈÊvœÀÊÓq{Ê`>ÞÃ
UÊÊ/ iÊwÀÃÌÊ`œÃiʓÕÃÌÊLiÊ>`“ˆ˜ˆÃÌiÀi`Ê£äqÓäʓˆ˜ÕÌiÃÊLivœÀiʜÀÊ
concomitant with the first dose of antibiotics.
73
6.9 Central nervous system infections
Meningitis – Empiric treatment
6.9 Central nervous system infections
UÊÊ`“ˆ˜ˆÃÌÀ>̈œ˜ÊœvÊ>˜ÌˆLˆœÌˆVÃÊà œÕ`ʘœÌÊLiÊ`i>Þi`Ê̜Ê}ˆÛiÊ
dexamethasone.
UÊÊ iÝ>“iÌ >ܘiÊà œÕ`ʘœÌÊLiÊ}ˆÛi˜Ê̜ʫ>̈i˜ÌÃÊÜ œÊ >ÛiÊ>Ài>`ÞÊ
started antibiotics.
UÊÊ œ˜Ìˆ˜ÕiÊ`iÝ>“iÌ >ܘiʜ˜ÞʈvÊÌ iÊ -ÊÀ>“ÊÃÌ>ˆ˜Êà œÜÃÊÀ>“‡
positive diplococci or if blood or CSF grows S. pneumoniae
Pathogen-specific therapy (ID consult recommended)
Pathogens
Preferred
S. pneumo PCN MIC ≤ 0.06
μg/ml AND/OR Ceftriaxone
MIC 0.5 μg/ml
S. pneumo PCN MIC ä°£q£Ê
μg/ml AND Ceftriaxone
MIC 1 μg/ml (ID consult
recommended)
S. pneumo PCN MIC 1
μg/ml AND Ceftriaxone
MIC ≥1 μg/ml (ID consult
recommended)
N. meningitidis PCN
susceptible (MIC 0.1)
H. flu
Non -lactamase producer
H. flu
-lactamase producer
Listeria
P. aeruginosa
Penicillin OR Ceftriaxone
E. coli
K. pneumoniae
Enterobacter spp.
S. aureusq--
-°Ê>ÕÀiÕÃq,-Ê
Coagulase-negative
staphylococci if Oxacillin MIC
≤ 0.25
Coagulase-negative
staphylococci Oxacillin MIC
0.25
Enterococcus
Candida species
Cryptococcus
Ceftriaxone
Alternative for serious
PCN allergy (Consult
allergy for PCN skin
testing ± desensitization)
Vancomycin OR
Moxifloxacin OR Linezolid
Ceftriaxone
Moxifloxacin OR Linezolid
Ceftriaxone PLUS
Vancomycin PLUS Rifampin
Moxifloxacin OR Linezolid
Penicillin OR Ceftriaxone³
Consult ID
Ampicillin OR Ceftriaxone
Ciprofloxacin*
Ceftriaxone
Ciprofloxacin*
Ampicillin ±
Cefepime OR Meropenem
Gentamicin‡
Meropenem
Oxacillin
Vancomycin
Oxacillin
/*É-8Ê
Ciprofloxacin PLUS
Aztreonam
Aztreonam OR Ciprofloxacin
",Ê/*É-8
/*É-8ʜÀÊ ˆ«ÀœyœÝ>Vˆ˜
Vancomycin
Vancomycin
Vancomycin
Ampicillin PLUS Gentamicin‡
Amphotericin B
Amphotericin B PLUS
Flucytosine
Vancomycin PLUS Gentamicin‡
* Consider beta-lactam desensitization
³ÊÕÃÌÊ}ˆÛiÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}ʜ˜ViÊ̜ÊiÀ>`ˆV>ÌiÊV>ÀÀˆiÀÊÃÌ>ÌiʈvÊ*
‡ Administer aminoglycosides systemically, not intrathecally
74
ÊÕÃi`Ê>ÃÊÌÀi>̓i˜Ì
6.9 Central nervous system infections
TREATMENT NOTES
Indications for head CT prior to LP
UʈÃ̜ÀÞʜvÊ -Ê`ˆÃi>ÃiÃÊ­“>ÃÃʏiȜ˜]Ê 6®
UÊ i܇œ˜ÃiÌÊÃiˆâÕÀiÊ­ 1 week)
UÊ*>«ˆi`i“>
UʏÌiÀi`ÊVœ˜ÃVˆœÕØiÃÃ
UʜV>Ê˜iÕÀœœ}ˆVÊ`iwVˆÌ
Duration
UÊÊ-/"*ÊÌÀi>̓i˜ÌʈvÊ*ÊVՏÌÕÀiʜLÌ>ˆ˜i`Ê«ÀˆœÀÊ̜Ê>˜ÌˆLˆœÌˆVÊÌ iÀ>«ÞʈÃÊ
negative at 48 hours OR no PMNs on cell count
UÊS. pneumoniae\Ê£äq£{Ê`>ÞÃ
UÊN. meningitidis\ÊÇÊ`>ÞÃ
UÊListeria\ÊÓ£Ê`>ÞÃ
UÊH. influenzae\ÊÇÊ`>ÞÃ
UÊÀ>“‡˜i}>̈ÛiÊL>Vˆˆ\ÊÓ£Ê`>ÞÃ
Adjunctive therapy
UÊÊ œ˜Ãˆ`iÀʈ˜ÌÀ>VÀ>˜ˆ>Ê«ÀiÃÃÕÀiʓœ˜ˆÌœÀˆ˜}ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Êˆ“«>ˆÀi`Ê
mental status.
Encephalitis
UÊÊiÀ«iÃÊۈÀÕÃiÃÊ­-6]Ê6<6®ÊÀi“>ˆ˜ÊÌ iÊ«Ài`œ“ˆ˜>˜ÌÊV>ÕÃiÃʜvÊÌÀi>Ì>LiÊ
encephalitis.
UÊ -Ê* ,ÃÊ>ÀiÊÀ>«ˆ`Ê`ˆ>}˜œÃ̈VÊÌiÃÌÃÊ>˜`Ê>««i>ÀʵՈÌiÊÃi˜ÃˆÌˆÛiÊ>˜`Ê
specific.
UÊ>ÛiʏœÜÊÌ Àià œ`Ê̜ÊÌÀi>ÌʈvÊÃÕëiVÌi`Ê>ÃÊ՘ÌÀi>Ìi`ʓœÀÌ>ˆÌÞÊ
iÝVii`ÃÊÇ䯰
UÊ/Ài>̓i˜Ì\ÊVÞVœÛˆÀÊ£äʓ}Ɏ}Ê6Ê+nÊvœÀÊ£{qÓ£Ê`>ÞÃ
75
6.9 Central nervous system infections
Brain abscess
UÊÊ “«ˆÀˆVÊÌÀi>̓i˜ÌʈÃÊ}Ո`i`ÊLÞÊÃÕëiVÌi`ÊÜÕÀViÊ>˜`Ê՘`iÀÞˆ˜}Ê
condition. While therapy should be adjusted based on culture results,
anaerobic coverage should ALWAYS continue even if none are grown.
Source/ Condition
Pathogens
Preferred
Unknown
S. aureus,
Streptococci, Gramnegatives, Anaerobes
Streptococci (incl.
S. pneumoniae),
Anaerobes
Gram-negatives,
Streptococci
Anaerobes
Staphylococci, Gram
negatives
Streptococci (esp.
S. viridans)
Vancomycin PLUS
Ceftriaxone PLUS
Metronidazole
Q*i˜ˆVˆˆ˜Ê",Ê
ivÌÀˆ>ݜ˜iRÊ*1-Ê
Metronidazole
Cefepime PLUS
Metronidazole
Sinusitis
Chronic otitis
Post neurosurgery
Cyanotic heart
disease
Vancomycin PLUS
Cefepime
Penicillin OR
Ceftriaxone
Alternative for
serious PCN allergy
(ID consult
recommended)
Vancomycin PLUS
Ciprofloxacin PLUS
Metronidazole
Vancomycin PLUS
Metronidazole
Aztreonam PLUS
Metronidazole PLUS
Vancomycin
Vancomycin PLUS
Ciprofloxacin
Vancomycin
,iviÀi˜ViÃ\
-ÊՈ`iˆ˜iÃÊvœÀÊ >VÌiÀˆ>Êi˜ˆ˜}ˆÌˆÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓää{ÆΙ\£ÓÈÇ°
iÝ>“iÌ >ܘiʈ˜Ê>`ՏÌÃÊÜˆÌ ÊL>VÌiÀˆ>Ê“i˜ˆ˜}ˆÌˆÃ\Ê Ê ˜}ÊÊi`ÊÓääÓÆÎ{Ç\£x{™°
CNS shunt infection
Diagnosis
UÊÊ ÕÌÕÀiʜvÊViÀiLÀœÃ«ˆ˜>ÊyՈ`ÊÀi“>ˆ˜ÃÊÌ iʓ>ˆ˜ÃÌ>ÞʜvÊ`ˆ>}˜œÃˆÃ°Ê
Clinical symptoms may be mild and/or non-specific, and CSF
chemistries and leukocyte counts may be normal.
Empiric Therapy
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Cefepime 2 g IV Q8H
OR
UÊÊ* ʏiÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Ciprofloxacin 400 mg IV Q8H
TREATMENT NOTES
UÊID consult recommended for assistance with timing of shunt
replacement and length of antibiotic therapy.
UÊÊ,i“œÛ>ÊœvÊ>ÊVœ“«œ˜i˜ÌÃʜvÊÌ iʈ˜viVÌi`Êà ՘ÌÊÜˆÌ ÊiÝÌiÀ˜>Ê
ventricular drainage or intermittent ventricular taps in combination
with the appropriate intravenous antibiotic therapy leads to the highest
effective cure rates. Success rates are substantially lower when the
infected shunt components are not removed.
76
,iviÀi˜ViÃ\
-ÊՈ`iˆ˜iÃÊvœÀÊÌ iÊ>˜>}i“i˜ÌʜvÊ >VÌiÀˆ>Êi˜ˆ˜}ˆÌˆÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊ
Óää{ÆΙ\£ÓÈÇ°Ê
/ iÀ>«Þʈ˜ÊViÀiLÀœÃ«ˆ˜>ÊyՈ`Êà ՘Ìʈ˜viV̈œ˜°Ê iÕÀœÃÕÀ}iÀÞÊ£™näÆÇ\{x™°
Antimicrobial doses for CNS infections – normal
renal function
Antibiotics
UÊʓˆ˜œ}ÞVœÃˆ`iÃ\ÊÃiiÊ«°Ê£{x
UÊʓ«ˆVˆˆ˜\ÊÓÊ}Ê6Ê+{Ê
UÊÊâÌÀiœ˜>“\ÊÓÊ}Ê6Ê+È
UÊÊ ivÌÀˆ>ݜ˜i\ÊÓÊ}Ê6Ê+£Ó
UÊÊ ivi«ˆ“i\ÊÓÊ}Ê6Ê+n
UÊÊ ˆ«ÀœyœÝ>Vˆ˜\Ê{ääʓ}Ê6Ê+nÊ­L>Ãi`ʜ˜Êˆ“ˆÌi`Ê`>Ì>®
UÊʜ݈yœÝ>Vˆ˜\Ê{ääʓ}Ê6Ê+Ó{
UÊÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n
UÊÊiÌÀœ˜ˆ`>✏i\Êxääʓ}Ê6Ê+È
UÊÊ"Ý>Vˆˆ˜\ÊÓÊ}Ê6Ê+{
UÊÊ*i˜ˆVˆˆ˜\Ê{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê­Ó{ʓˆˆœ˜Ê՘ˆÌÃÊ«iÀÊ`>Þ®
UÊÊ,ˆv>“«ˆ˜\ÊÈääʓ}Ê6Ê+£ÓqÓ{
UÊÊ/*É-8\Êxʓ}Ɏ}Ê­/*ÊVœ“«œ˜i˜Ì®Ê6Ê+È
UÊÊ6>˜Vœ“ÞVˆ˜\ʏœ>`ÊÜˆÌ ÊÓxqÎxʓ}Ɏ}]ÊÌ i˜Ê£xqÓäʓ}Ɏ}Ê+nq£ÓÊ
(minimum 1 g Q12H)
UÊÊ6>˜Vœ“ÞVˆ˜Êà œÕ`ÊLiÊ>`“ˆ˜ˆÃÌiÀi`Ê̜ʓ>ˆ˜Ì>ˆ˜ÊÃiÀՓÊÌÀœÕ} Ê
concentrations close to 20 mcg/mL.
Antifungals
UÊʓ« œÌiÀˆVˆ˜\Êä°Çq£Ê“}Ɏ}Ê6Ê+Ó{
Uʓ ˆÃœ“i®\Ê·{ʓ}Ɏ}Ê6Ê+Ó{ÊvœÀÊ Àޫ̜VœVV>Ê“i˜ˆ˜}ˆÌˆÃ
UÊʓ ˆÃœ“i®\Êxʓ}Ɏ}Ê6Ê+Ó{ÊvœÀÊ >˜`ˆ`>ʓi˜ˆ˜}ˆÌˆÃ
UʏÕVœ˜>✏i\Ênääq£Óääʓ}Ê6É*"Ê+Ó{Ê­V>˜Ê}ˆÛiʈ˜Ê`ˆÛˆ`i`Ê`œÃiî
UÊʏÕVÞ̜Și\ÊÓxʓ}Ɏ}Ê*"Ê+È
Intraventricular antibiotics (ID consult recommended)
UÊʓˆŽ>Vˆ˜\ÊÎäʓ}Ê+Ó{Ê­Vœ˜Ì>ˆ˜ÃÊ«ÀiÃiÀÛ>̈Ûi®
UÊÊi˜Ì>“ˆVˆ˜\Êxʓ}Ê+Ó{
UÊÊ/œLÀ>“ÞVˆ˜\Êxʓ}Ê+Ó{
UÊÊ6>˜Vœ“ÞVˆ˜\ÊÓäʓ}Ê+Ó{
77
6.9 Central nervous system infections
UÊÊ/ iÊÀœiʜvʈ˜ÌÀ>Ûi˜ÌÀˆVՏ>ÀÊ>˜ÌˆLˆœÌˆVÃʈÃÊVœ˜ÌÀœÛiÀÈ>]Ê>˜`Ê}i˜iÀ>ÞÊ
limited to refractory cases or cases in which shunt removal is not
possible. Intraventricular injection should be administered only by
experienced physicians.
6.10 Acute bacterial rhinosinusitis
Acute bacterial rhinosinusitis (ABRS)
NOTE: Sinusitis in immunocompromised hosts can be caused by fungi
>˜`ÊœÌ iÀʏiÃÇVœ““œ˜Ê«>Ì œ}i˜ÃÆÊVœ˜ÃՏÌ>̈œ˜ÊÜˆÌ Ê Ê>˜`Ê /ʈÃÊ
recommended to guide management and therapy.
œÃÌÊÀ ˆ˜œÃˆ˜ÕÈ̈ÃÊ`œiÃʘœÌÊÀiµÕˆÀiÊ>˜ÌˆLˆœÌˆVÊÌÀi>̓i˜ÌÆÊÌÀi>̓i˜ÌÊ
à œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜ÊÌ iÊvœœÜˆ˜}ÊÃVi˜>ÀˆœÃ\
UÊ*iÀÈÃÌi˜ÌÊÃޓ«Ìœ“ÃʜvÊ>VÕÌiÊÀ ˆ˜œÃˆ˜ÕÈÌÕÃÊ≥ 10 days without
improvement
UÊiÛiÀÊ≥39°C and purulent nasal discharge or facial pain lasting >3-4
days from the beginning of illness
UÊ iÜʜ˜ÃiÌʜvÊviÛiÀ]Ê i>`>V iʜÀʈ˜VÀi>Ãiʈ˜Ê˜>Ã>Ê`ˆÃV >À}iÊvœœÜˆ˜}Ê
viral URI that lasted 5-6 days and was initially improving
EMPIRIC TREATMENT
Oral regimens
UʓœÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê+£Ó
OR
UʓœÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊ8,ÊÓÊ}Ê*"Ê+£ÓÊÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ ÊÃiÛiÀiÊ
infection (e.g. systemic toxicity with fever of 39°C), antibiotic use in
previous 30 days, immunocompromised
OR
UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv«œ`œÝˆ“iÊÓääʓ}Ê*"Ê+£Ó
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê*"Ê`>ˆÞÊÊ
Parenteral regimens
Uʓ«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+È
OR
UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+Ó{ÊÊ
Duration
UÊx‡ÇÊ`>ÞÃÊ
TREATMENT NOTES
Microbiology
UÊ*Ài`œ“ˆ˜>˜ÌÞÊS. pneumoniae, H. influenzae, M. catarrhalis
UÊÀ>“‡˜i}>̈ÛiÊi˜ÌiÀˆVÊL>VˆˆÊ>ÀiÊÀ>Ài
Management
UÊ ,-ʈÃÊÀ>ÀiÞÊ«ÀiÃi˜ÌÊ«ÀˆœÀÊ̜ÊÇq£äÊ`>ÞÃʜvÊÃޓ«Ìœ“ÃÆÊÌÞ«ˆV>Ê
inciting etiologies of acute sinusitis include allergies and viral URI
78
,iviÀi˜Vi\Ê
-Ê}Ո`iˆ˜iÃÊvœÀÊ ,-°Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£ÓÆÊx{­n®\iÇӇi££Ó°Ê
79
6.10 Acute bacterial rhinosinusitis
UÊ ÕÌÕÀiÃÊLÞÊ`ˆÀiVÌÊȘÕÃÊ>ëˆÀ>̈œ˜ÊœÀÊi˜`œÃVœ«ˆV>ÞÊ}Ո`i`ÊVՏÌÕÀiʜvÊ
the middle meatus should only be obtained in patients who fail empiric
antibiotic therapy. Nasopharyngeal swab is NOT recommended for
obtaining culture data.
UÊ œ˜wÀ“>̈œ˜ÊœvÊ`ˆ>}˜œÃˆÃÊÜˆÌ Êˆ“>}ˆ˜}ʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ
uncomplicated ABRS. Consider CT in those with severe disease with
possible extension to the orbit or intracranial space.
UʘÌÀ>˜>Ã>ÊÃ>ˆ˜iʈÀÀˆ}>̈œ˜Ê­« ÞȜœ}ˆVʜÀÊ Þ«iÀ̜˜ˆV®Ê>˜`ʈ˜ÌÀ>˜>Ã>Ê
corticosteroids are recommended as an adjuncts to antibiotic therapy
and can also provide symptomatic relief in patients in whom antibiotic
are not indicated
UÊ>VÀœˆ`iÃÊ­ >ÀˆÌ Àœ“ÞVˆ˜]ÊâˆÌ Àœ“ÞVˆ˜®Ê>ÀiʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ
initial empiric therapy due to high rates of resistance of S. pneumoniae
­xx¯Ê>ÌÊ®
UÊ iëˆÌiÊ -Ê}Ո`iˆ˜iÃÊÃÕ««œÀ̈˜}ÊÕÃiʜvÊ œÝÞVÞVˆ˜iÊ>ÃÊ>˜Ê
alternative agent for ABRS, Doxycycline is NOT recommended for
initial empiric therapy at JHH due to high rates of resistance of S.
pneumoniae ­Óǯ®Ê>˜` H. influenzae ­Îx¯®
UÊ,œṎ˜iÊVœÛiÀ>}iÊvœÀÊ,-ʈ˜Êˆ˜ˆÌˆ>Êi“«ˆÀˆVÊÌ iÀ>«ÞÊvœÀÊ ,-ʈ˜Ê˜œÌÊ
recommended
6.11 Orbital cellulitis
Orbital cellulitis
Preseptal cellulitisÊ­€™ä¯ÊœvÊV>Ãiî
UʘۜÛiÃÊ̈ÃÃÕiÃÊ>˜ÌiÀˆœÀÊ̜ÊÌ iʜÀLˆÌ>ÊÃi«ÌՓÊ
UÊ*ÀiÃi˜ÌÃÊÜˆÌ ÊviÛiÀ]ÊiÞiˆ`ÊiÀÞÌ i“>Ê>˜`ÊÜvÌÊ̈ÃÃÕiÊÃÜiˆ˜}ÊLÕÌʘœÊ
orbital congestion
Postseptal cellultis
UÊ-ˆ}˜ÃʜvÊ«iÀˆœÀLˆÌ>ÊViÕˆÌˆÃÊ>ÃÊÜiÊ>Ãʏˆ“ˆÌ>̈œ˜ÊœvʜVՏ>ÀʓœÛi“i˜ÌÃ]Ê
pain with ocular movement, and/or proptosis
UÊ-iÛiÀiʈ˜viV̈œ˜ÊV>˜Ê>ÃœÊˆ˜ÛœÛiÊۈÃÕ>ÊœÃÃ]ÊÃÕL«iÀˆœÃÌi>Ê>LÃViÃÃ]Ê
globe displacement, abscess formation
UÊ"vÌi˜Ê>ÃÜVˆ>Ìi`ÊÜˆÌ ÊȘÕÈ̈ÃÊ
UÊ >˜ÊLiÊ>ÃÜVˆ>Ìi`ÊÜˆÌ ÊV>ÛiÀ˜œÕÃÊȘÕÃÊÌ Àœ“LœÃˆÃ
EMPIRIC TREATMENT
Uʓ«ˆVˆˆ˜ÉÃՏL>VÌ>“ÊÎÊ}Ê6Ê+È
OR
UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6Ê`>ˆÞ
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê`>ˆÞ
Add Vancomycin (see dosing section, p. 150) in patients with history
of MRSA colonization or infection, evidence of abscess or bone
involvement, orbital trauma, recent ophthalmic surgery or severe
infection
Oral step down therapy (for patients without culture data to guide
therapy and without evidence of bony involvement or cavernous sinus
thrombosis)
UʓœÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê+£Ó
OR
UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv«œ`œÝˆ“iÊ{ääʓ}Ê*"Ê+£Ó
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê*"Ê`>ˆÞ
Duration
UÊÇÊ`>ÞÃÊÕ«Ê̜ÊÈÊÜiiŽÃʈvÊiۈ`i˜ViʜvÊLœ˜Þʈ˜ÛœÛi“i˜Ì
TREATMENT NOTES
Microbiology
UÊS. aureus, beta-hemolytic streptococci, S. pneumoniae, H. influenza,
M. catarrhalis (cultures are infrequently positive)
Management
Uʓ>}ˆ˜}ʈÃÊÀiVœ““i˜`i`ʈ˜Ê«œÃ̇Ãi«Ì>ÊViÕˆÌˆÃÊ­ /ʜÀÊ,®
UÊ œ˜ÃՏÌ>̈œ˜ÊÜˆÌ Ê ]Ê /]Ê>˜`ʜ« Ì >“œœ}ÞÊÀiVœ““i˜`i`
80
81
6.11 Orbital cellulitis
UÊ*œÃ̇Ãi«Ì>ÊViÕˆÌˆÃʈ˜Êˆ““Õ˜œVœ“«Àœ“ˆÃi`Ê œÃÌÃÊV>˜ÊLiÊV>ÕÃiÊ
LÞÊv՘}ˆÊ>˜`ʓœ`ÃÆÊi“«ˆÀˆVÊ>˜Ìˆv՘}>ÊÌ iÀ>«ÞʈÃÊÀiVœ““i˜`i`ʈ˜Ê
consultation with ID
UÊ*œÃ̇Ãi«Ì>ÊViÕˆÌˆÃÊÜˆÌ Ê>LÃViÃÃÊvœÀ“>̈œ˜Êà œÕ`Ê«Àœ“«Ìʈ““i`ˆ>ÌiÊ
surgical intervention
UÊ,i뜘ÃiÊ̜Ê>««Àœ«Àˆ>ÌiÊ>˜ÌˆLˆœÌˆVÊÌ iÀ>«ÞÊà œÕ`ʜVVÕÀʈ˜ÊÓ{ÊqÊ{nÊ
hours
UÊ*œœÀÊÀi뜘ÃiÊ̜Ê>˜ÌˆLˆœÌˆVÃ]ÊܜÀÃi˜ˆ˜}ÊۈÃÕ>Ê>VՈÌÞʜÀÊ«Õ«ˆ>ÀÞÊ
changes and/or evidence of an abscess are indications for surgery
6.12 Pulmonary infections
COPD exacerbations
EMPIRIC TREATMENT
UÊÊÊDoxycycline 100 mg PO BID for 5 days
OR
UÊÊâˆÌ Àœ“ÞVˆ˜Êxääʓ}Ê*"É6Ê+Ó{ÊvœÀÊÎÊ`>ÞÃ
OR
UÊʓœÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê ÊvœÀÊxÊ`>ÞÃ
OR
UÊÊ iv«œ`œÝˆ“iÊÓääʓ}Ê*"Ê ÊvœÀÊxÊ`>ÞÃ
OR
UÊ iv`ˆ˜ˆÀÊÎääʓ}Ê*"Ê ÊvœÀÊxÊ`>ÞÃ
TREATMENT NOTES
Microbiology
UÊÊ*Ài`œ“ˆ˜>˜ÌÞÊH. influenzae, M. catarrhalis, S. pneumoniae
UÊÊPseudomonas, Enterobacteriaceae are less common and seen in
patients with severe COPD and extensive antibiotic exposure.
Management
UÊÊ “«ˆÀˆVÊÕÃiʜvÊy՜ÀœµÕˆ˜œœ˜iÃʈÃÊ`ˆÃVœÕÀ>}i`Ê>˜`Êà œÕ`ʜ˜ÞÊ
be considered if past or present microbiologic evidence indicates
infection with a pathogen(s) that is resistant to standard therapy (e.g.
Pseudomonas, Enterobacteriaceae).
UÊÊ6Ê>˜ÌˆLˆœÌˆVÃÊà œÕ`ʜ˜ÞÊLiÊÕÃi`ʈvÊÌ iÊ«>̈i˜ÌÊV>˜˜œÌÊ̜iÀ>ÌiÊ*"Ê
antibiotics.
UÊʘ̈LˆœÌˆVÃÊ>ÀiʘœÌʈ˜`ˆV>Ìi`ÊvœÀÊ>ÃÌ “>Êy>ÀiÃʈ˜ÊÌ iÊ>LÃi˜ViʜvÊ
pneumonia.
Prophylactic antibiotics for the prevention of COPD exacerbations
UÊ*Àœ« ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊ >ÛiÊLii˜Êà œÜ˜Ê̜ÊÀi`ÕViÊÀ>ÌiÃʜvÊ
exacerbations and improve reported quality of life but not to decrease
all-cause or respiratory-associated mortality
UÊ*Àœœ˜}i`ÊâˆÌ Àœ“ÞVˆ˜ÊÕÃiÊ >ÃÊLii˜Ê>ÃÜVˆ>Ìi`ÊÜˆÌ Ê i>Àˆ˜}ʏœÃÃÊ
>˜`Ê+/Ê«Àœœ˜}>̈œ˜ÆÊ«>̈i˜ÌÃÊÜˆÌ ÊL>Ãiˆ˜iÊ+/‡«Àœœ˜}>̈œ˜ÊÜiÀiʘœÌÊ
included in clinical trials
UÊ/ iÊ`iVˆÃˆœ˜Ê̜ʈ˜ˆÌˆ>ÌiÊ«Àœ« ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊà œÕ`ÊLiʓ>`iʜ˜Ê>Ê
case-by-case basis and should take in to account patient preferences,
financial constraints, risk factors for adverse events and input from the
patient’s pulmonologist
UÊ,iVœ““i˜`i`ÊÀi}ˆ“i˜\ÊâˆÌ Àœ“ÞVˆ˜ÊÓxäʓ}Ê*"Ê`>ˆÞ
UÊ >Ãiˆ˜iÊ>Õ`ˆœ“iÌÀÞÊ>˜`Ê ÊˆÃÊÀiVœ““i˜`i`
,iviÀi˜ViÃ\
“iÀˆV>˜Ê œi}iʜvÊ* ÞÈVˆ>˜ÃÊ*œÃˆÌˆœ˜Ê*>«iÀ\ʘ˜Ê˜ÌiÀ˜Êi`ÊÓää£ÆÊ£Î{\Èää°
ÕÀ>̈œ˜ÊœvÊÌ iÀ>«Þ\Ê/ œÀ>ÝÊÓäänÆÊÈέx®\{£xqÓÓ°
âˆÌ Àœ“ÞVˆ˜ÊvœÀÊ«ÀiÛi˜Ìˆœ˜\Ê °Ê ˜}°ÊÊi`ÊÓ䣣ÆÊÎÈx\ÊÈn™ÆÊ œV À>˜iÊ >Ì>L>ÃiÊ-ÞÃÌÊ
Rev 2013 Nov 28.
82
NOTE: If patient is coming from a nursing home or long-term care
facility, see Healthcare-acquired pneumonia, p. 87.
EMPIRIC TREATMENT
Patient NOT in the ICU
Uʓ«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+ÈÊPLUS Azithromycin 500 mg IV/PO
once daily
OR
UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Azithromycin 500 mg IV/PO once daily
OR
Uʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê
In non-critically ill patients, consider switch to oral agents as soon as patient
is clinically improving and eating (see next page for oral options and doses).
Patient in the ICU
Not at risk for infection with Pseudomonas (see risks below)
UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Azithromycin 500 mg IV Q24H
OR
UÊÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+Ó{Ê
At risk for infection with Pseudomonas (see risks below)
UÊÊ ivi«ˆ“iÊ£‡ÓÊ}Ê6Ê+nÊPLUS Azithromycin 500 mg IV Q24H
OR
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+ÈÊPLUS Azithromycin 500 mg IV Q24H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+Ó{ÊPLUS Aztreonam
2 g IV Q8H
UÊÊ-«ÕÌՓÊ}À>“ÊÃÌ>ˆ˜Ê“>ÞÊ i«Ê`iÌiÀ“ˆ˜iʈvÊPseudomonas is present.
UÊÊNarrow coverage if Pseudomonas is NOT present on culture at 48 hours.
Risks for PseudomonasÊ>˜`ÊœÌ iÀÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiʜÀ}>˜ˆÃ“Ã\
LÀœ˜V ˆiVÌ>ÈÃÆÊLÀœ>`‡Ã«iVÌÀՓÊ>˜ÌˆLˆœÌˆVÃÊvœÀʀÊÇÊ`>ÞÃʈ˜ÊÌ iÊ«>ÃÌÊ
“œ˜Ì ÆÊ«Àœœ˜}i`Ê œÃ«ˆÌ>ˆâ>̈œ˜Ê€ÊÇÊ`>ÞÃÆÊ`iLˆˆÌ>Ìi`ʘÕÀȘ}Ê œ“iÊ
ÀiÈ`i˜ÌÆÊÀiVi˜ÌʓiV >˜ˆV>ÊÛi˜Ìˆ>̈œ˜Ê€Ê{nÊÆʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê
due to solid organ transplant, hematologic malignancy, BMT, active
chemotherapy, prednisone > 20 mg daily for > 3 weeks.
DIAGNOSIS
UÊʓ“Õ˜œVœ“«iÌi˜ÌÊ«>̈i˜ÌÃÊ1-/Ê >ÛiÊ>ÊV iÃÌÊ8‡À>Þʈ˜wÌÀ>ÌiÊ̜ʓiiÌÊ
diagnostic criteria for pneumonia.
UÊÊ-«ÕÌՓÊ>˜`ÊLœœ`ÊVՏÌÕÀiÃÊà œÕ`ÊLiÊÃi˜Ìʜ˜Ê>Ê«>̈i˜ÌÃÊ>`“ˆÌÌi`Ê̜Ê
the hospital BEFORE antibiotics are given.
UÊÊS. pneumoniae urine antigen should be obtained in all patients with CAP.
ÌÊ >ÃÊëiVˆwVˆÌÞʜvʙȯÊ>˜`Ê«œÃˆÌˆÛiÊ«Ài`ˆV̈ÛiÊÛ>ÕiʜvÊnn°n‡™È°x¯°ÊÌÊ
is particularly useful if antibiotics have already been started or cultures
cannot be obtained.
83
6.12 Pulmonary infections
Community-acquired pneumonia (CAP) in
hospitalized patients
6.12 Pulmonary infections
UÊÊ/ iʏi}ˆœ˜i>ÊÕÀˆ˜iÊ>˜Ìˆ}i˜ÊˆÃÊÌ iÊÌiÃÌʜvÊV œˆViÊvœÀÊ`ˆ>}˜œÃˆ˜}Ê
legionella infection. This test detects only L. pneumophila serogroup
£]ÊÜ ˆV ʈÃÊÀi뜘ÈLiÊvœÀÊÇäqnä¯Êœvʈ˜viV̈œ˜Ã°
DURATION
UÊ/ iÀ>«ÞÊV>˜ÊLiÊÃ̜««i`Ê>vÌiÀÊÌ iÊ«>̈i˜ÌʈÃ\
Ê UÊviLÀˆiÊvœÀÊ{nqÇÓÊ œÕÀÃ
AND
Ê UÊÊ>ÃʘœÊ“œÀiÊÌ >˜Êœ˜iʜvÊÌ iÊvœœÜˆ˜}ÊÈ}˜ÃÊ>˜`ÊÃޓ«Ìœ“Ã\Ê,Ê
100 beats/min, RR 24 breaths/min, BP 90 mmHg, O2 sat
ʙä¯]Ê>ÌiÀi`ʓi˜Ì>ÊÃÌ>ÌÕðÊ
UÊÊ-Õ}}iÃÌi`Ê`ÕÀ>̈œ˜ÊœvÊÌ iÀ>«ÞÊL>Ãi`ʜ˜Ê«>̈i˜ÌÊëiVˆwVÊv>V̜ÀÃ\
Ê UÊÊ3–5 days: Patient without immunocompromise or structural lung
disease
Ê UÊÊ7 days: Patients with moderate immunocompromise and/or
structural lung disease
Ê UÊÊ10–14 days: Patients with poor clinical response, who
received initial inappropriate therapy, or who are significantly
immunocompromised
UÊÊ1˜Vœ“«ˆV>Ìi`ÊL>VÌiÀi“ˆVÊ«˜iՓœVœVV>Ê«˜iՓœ˜ˆ>qÊ«Àœœ˜}i`Ê
course of antibiotic therapy not necessary, treat as pneumonia
UÊÊ œÕ} Ê>˜`ÊV iÃÌÊ8‡À>ÞÊ>L˜œÀ“>ˆÌˆiÃʓ>ÞÊÌ>ŽiÊ{qÈÊÜiiŽÃÊ̜ʈ“«ÀœÛi°Ê
There is NO need to extend antibiotics if the patient is doing well
otherwise (e.g. no fever).
Other causes of pneumonia
UÊÊ-ÕëiVÌi`Ê>ëˆÀ>̈œ˜\ Additional empiric coverage for aspiration is justified
only in classic aspiration syndromes suggested by loss of consciousness
(overdose, seizure) PLUS gingival disease or esophageal motility disorder.
Ceftriaxone, Cefepime, and Moxifloxacin have adequate activity against
most oral anaerobes. For classic aspiration, Clindamycin 600 mg IV Q8H
can be added to regimens not containing Piperacillin/tazobactam.
UÊÊ œ““Õ˜ˆÌއ>VµÕˆÀi`Ê,-\ Necrotizing pneumonia with cavitation in
absence of risk factors for aspiration listed above is concerning for
CA-MRSA pneumonia, particularly if associated with a preceding or
concomitant influenza-like illness. In these cases, Linezolid 600 mg IV/PO
Q12H can be added while awaiting culture data. Infectious Diseases
consult is strongly recommended. Use of Linezolid monotherapy for
MRSA bacteremia, even if associated with a pulmonary source, is not
recommended. In the absence of necrotizing pneumonia with cavitation,
empiric coverage for CA-MRSA can be deferred until sputum and blood
culture results return given their high diagnostic yield for CA-MRSA.
UÊÊ,iëˆÀ>̜ÀÞÊۈÀÕÃiÃ\ Respiratory viruses can cause primary viral
pneumonia as well as lead to bacterial superinfection. Strongly consider
testing all patients with CAP during respiratory virus season (see p. 93).
,iviÀi˜ViÃ\
-É/-Ê œ˜Ãi˜ÃÕÃÊՈ`iˆ˜iÃÊvœÀÊ *\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓääÇÆ{{\-ÓÇ°
S. pneumo >˜Ìˆ}i˜\ÊÀV ʘÌiÀ˜Êi`ÊÓ䣣ƣǣ­Ó®\£ÈÈqÇÓ
ÎÊ`>ÞÃʜvÊÌ iÀ>«ÞÊvœÀÊ *\Ê ÊÓääÈÆÎÎÓ\£Îxx°
84
85
Ceftriaxone 1 g IV Q24
OR
Cefpodoxime 200 mg PO BID
OR
Cefdinir 300 mg PO BID
“«ˆVˆˆ˜Ê£Ê}Ê6Ê+ÈÊ
OR
Amoxicillin 500 mg PO TID
Ê
S. pneumoniae PCN resistant,
cephalosporin susceptible
Ê
H. influenzae ˜œ˜‡LiÌ>‡>VÌ>“>ÃiÊÊ
producing (Ampicillin susceptible)
Penicillin G 1 million units IV Q6H
OR
Amoxicillin 1 g PO TID
S. pneumoniae PCN intermediate
or urine antigen positive
Amoxicillin 500 mg PO TID
Ê
Ê
Penicillin G 1 million units IV Q6H
OR
Ê
Ê
Preferred therapy
S. pneumoniae PCN susceptible
Pathogen-specific and step-down therapy
Organism
PCN allergy
âˆÌ Àœ“ÞVˆ˜IQxääʓ}Ê*"Ê`>ˆÞÊ8ÊÎÊ`>ÞÃÊ",ÊÊ
xääʓ}ʜ˜Vi]ÊÌ i˜ÊÓxäʓ}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃR
ORÊ
iv«œ`œÝˆ“iÊÓääʓ}Ê*"Ê ÊÊÊ
OR
Cefdinir 300 mg PO BID
OR
Doxycycline† 100 mg PO BID
OR
Moxifloxacin 400 mg IV/PO daily
(if resistant to other options)
Moxifloxacin 400 mg IV/PO Q24H
Same as above
Non-severe reaction:ÊÊ
Cefpodoxime 200 mg PO BID
OR
Cefdinir 300 mg PO BID
Severe reaction:
âˆÌ Àœ“ÞVˆ˜IQxääʓ}Ê*"Ê`>ˆÞÊÊ8ÊÎÊ`>ÞÃÊÊ
",Êxääʓ}ʜ˜Vi]ÊÌ i˜ÊÓxäʓ}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃRÊ
OR
Moxifloxacin 400 mg IV/PO daily
(if Erythromycin resistant)
Notes
6.12 Pulmonary infections
Çx¯ÊœvÊH. influenzae isolates at JHH
(excluding oncology) are susceptible to
“«ˆVˆˆ˜]Ê£ää¯ÊÌœÊ ivÌÀˆ>ݜ˜i]ÊÈx¯Ê̜Ê
/iÌÀ>VÞVˆ˜i]Ê>˜`Ê£ää¯Ê̜ʜ݈yœÝ>Vˆ˜Ê
None of the S. pneumoniae isolates at
(excluding oncology) are resistant JHH
to PCN
™£¯ÊœvÊS. pneumoniae isolates at JHH
(excluding oncology) are susceptible and
™¯Ê>Àiʈ˜ÌiÀ“i`ˆ>ÌiÊ̜Ê* ]Ê{x¯Ê>Ài
susceptible to Erythromycin (Erythromycin
susceptibilities predict Azithromycin
ÃÕÃVi«ÌˆLˆˆÌˆiÃÊvœÀÊS. pneumoniae), and
£ää¯Ê>ÀiÊÃÕÃVi«ÌˆLiÊ̜ʜ݈yœÝ>Vˆ˜
86
PCN allergy
Azithromycin 500 mg IV/PO Q24H x 7-10 days
OR
œÝˆyœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê8ʣ䇣{Ê`>ÞÃ
âˆÌ Àœ“ÞVˆ˜IQxääʓ}Ê*"Ê`>ˆÞÊ8ÊÎÊ`>ÞÃÊ",Ê
xääʓ}ʜ˜Vi]ÊÌ i˜ÊÓxäʓ}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃR
OR
Cefpodoxime 200 mg PO BID
OR
Cefdinir 300 mg PO BID
OR
Doxycycline† 100 mg PO BID
OR
Moxifloxacin 400 mg IV/PO Q24H
(if resistant to other options)
iv«œ`œÝˆ“iÊÓääʓ}Ê*"Ê ÊÊ
œÝˆyœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê
OR
Cefdinir 300 mg PO BID
OR
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊ8,ÊÓÊ}Ê*"Ê Ê
Ê
Ê
Ê
œÌi\Ê1˜iÃÃÊÃÌÀœ˜}ÊÃÕëˆVˆœ˜ÊvœÀÊÊ
Ê
L. pneumophilia, more than 3 days of
Azithromycin for atypical coverage is not
needed due to very long half-life in lung tissue
IˆvÊ ÀÞÌ Àœ“ÞVˆ˜ÊÃÕÃVi«ÌˆLiÆÊaʈvÊ/iÌÀ>VÞVˆ˜iÊÃÕÃVi«ÌˆLi
Ê
Ê
Ê
ՏÌÕÀiÊ>˜`ÊÕÀˆ˜iÊ>˜Ìˆ}i˜Ê˜i}>̈ÛiÊ
Azithromycin 500 mg IV/PO Q24H
OR
œÝˆyœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê
L. pneumophilia
Ê
Preferred therapy
“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê+ÈÊ
ORÊ
Amoxicillin/clavulanate 875 mg PO BID
H. influenzae LiÌ>‡>VÌ>“>ÃiÊÊ
producing (Ampicillin resistant)
Pathogen-specific and step-down therapy
Organism
{x¯ÊœvÊS. pneumoniae isolates at JHH
(excluding oncology) are susceptible to
Erythromycin (Erythromycin susceptibilities
predict Azithromycin susceptibilities for
S. pneumoniae®Ê>˜`ÊÇίÊ>ÀiÊÃÕÃVi«ÌˆLiÊ
̜Ê/iÌÀ>VÞVˆ˜iÆÊÌ iÀivœÀi]ÊÌ iÃiÊ>}i˜ÌÃ
>ÀiÊÃÕLœ«Ìˆ“>ÊvœÀÊi“«ˆÀˆVÊÃÌi«‡`œÜ˜
therapy
Notes
6.12 Pulmonary infections
NOTE: If the patient is on antibiotic therapy or has recently been on
antibiotic therapy, choose an agent from a different class.
EMPIRIC TREATMENT
Patient with mild to moderate illness (e.g., not in or transferring to
the ICU/intermediate care unit, no or minimal oxygen requirement, no
hypotension)
UÊ ivÌÀˆ>ݜ˜iIÊ£Ê}Ê6Ê+Ó{
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{
Patient with severe illness (e.g., in or transferring to the ICU/
intermediate care unit, concern for sepsis, significant oxygen
requirement, multi-lobar consolidation)
UÊ ivi«ˆ“iIÊÓÊ}Ê6Ê+nʱ Vancomycin† (see dosing section, p. 150)
OR
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“IÊ{°xÊ}Ê6Ê+Èʱ Vancomycin† (see dosing
section, p. 150)
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Ciprofloxacin 400 mg IV Q8H ± Gentamicin (see dosing section, p. 146)
*Consider adding Azithromycin 500 mg IV/PO Q24H if the patient is immunosuppressed
or coming from a nursing home or long term care facility to cover Legionella
†Add Vancomycin in patients with a history of MRSA colonization or infection,
necrotizing pneumonia, pneumonia after a respiratory viral illness, ill patients coming
from a nursing home or long term care facility, sepsis)
Patient with history of or risk factors for Pseudomonas and other
resistant Gram-negative organismsÊ­i°}°]ÊLÀœ˜V ˆiVÌ>ÈÃÆÊLÀœ>`‡Ã«iVÌÀՓÊ
>˜ÌˆLˆœÌˆVÃÊvœÀʀÊÇÊ`>ÞÃʈ˜ÊÌ iÊ«>ÃÌʓœ˜Ì ÆÊ«Àœœ˜}i`Ê œÃ«ˆÌ>ˆâ>̈œ˜Ê€Ê
ÇÊ`>ÞÃÆÊ`iLˆˆÌ>Ìi`ʘÕÀȘ}Ê œ“iÊÀiÈ`i˜ÌÆÊÀiVi˜ÌʓiV >˜ˆV>ÊÛi˜Ìˆ>̈œ˜Ê
€Ê{nÊ œÕÀÃÆʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê`ÕiÊ̜Ê܏ˆ`ʜÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê
hematologic malignancy, BMT, active chemotherapy, prednisone > 20
“}Ê`>ˆÞÊvœÀʀÊÎÊÜiiŽÃ®\ÊÌÀi>ÌÊ>ÃÊÃiÛiÀiʈ˜iÃÃÊÜˆÌ ÊÌ>ˆœÀˆ˜}ʜvÊ>˜ÌˆLˆœÌˆVÊ
based on past culture data
NOTE: Always narrow therapy based on cultures results
Oral step down therapy (if no sputum culture data to guide therapy)
UÊÊ iv«œ`œÝˆ“iÊ{ääʓ}Ê*"Ê Ê­ˆvʜ˜Ê ivÌÀˆ>ݜ˜i®Ê",ʜ݈yœÝ>Vˆ˜Ê{ääÊ
mg PO daily
Duration:ʈvÊ«˜iՓœ˜ˆ>ÊVœ˜wÀ“i`Êx‡ÇÊ`>ÞÃÆʈvÊ«˜iՓœ˜ˆ>Ê`ˆ>}˜œÃˆÃʈÃÊ
questionable and patient improves, can considered stopping therapy
after 3 days
TREATMENT NOTES
Microbiology
UÊÊ ˜ÌiÀœVœVVˆÊ>˜`ÊV>˜`ˆ`>ÊëiVˆiÃÊ>ÀiʜvÌi˜ÊˆÃœ>Ìi`ÊvÀœ“ÊÌ iÊëÕÌՓÊ
in hospitalized patients. In general, they should be considered to be
colonizing organisms and should not be treated with antimicrobials.
87
6.12 Pulmonary infections
Healthcare-acquired pneumonia
(NOT ventilator-associated)
6.12 Pulmonary infections
Antimicrobial management of “aspiration events”
UÊ*Àœ« ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊ, Ê "/ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜ œÊ>ÀiÊ
at increased risk for aspiration.
Uʓ“i`ˆ>ÌiÊÌÀi>̓i˜ÌʈÃʈ˜`ˆV>Ìi`ÊvœÀÊ«>̈i˜ÌÃÊÜ œÊ >ÛiÊÓ>‡LœÜiÊ
obstructions or are on acid suppression therapy given the increased
risk of gastric colonization.
Uʘ̈LˆœÌˆVÊÌÀi>̓i˜ÌʜvÊ«>̈i˜ÌÃÊÜ œÊ`iÛiœ«ÊviÛiÀ]ʏiՎœVÞ̜ÈÃÊ>˜`Ê
infiltrates in the first 48 hours after an aspiration is likely unnecessary
since most aspiration pneumonias are chemical and antibiotic
treatment may only select for more resistant organisms.
UÊ/Ài>̓i˜ÌÊ-ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜ œÊ >ÛiÊÃޓ«Ìœ“ÃÊvœÀÊ
more than 48 hours or who are severely ill.
,iviÀi˜ViÃ\
ëˆÀ>̈œ˜Ê«˜iՓœ˜ˆÌˆÃÊ>˜`Ê>ëˆÀ>̈œ˜Ê«˜iՓœ˜ˆ>\Ê Ê ˜}ÊÊi`ÊÓää£ÆÎ{{­™®\ÈÈx°
/-É -ÊՈ`iˆ˜iÃÊvœÀÊ*É6*\Ê, ÊÓääxƣǣ\Înn°
Ventilator-associated pneumonia (VAP)
UÊÊ-«ÕÌՓÊVՏÌÕÀiÃÊà œÕ`ÊLiʜLÌ>ˆ˜i`Ê«ÀˆœÀÊ̜ÊÃÌ>À̈˜}Ê>˜ÌˆLˆœÌˆVÃʜÀÊ
if patient is failing therapy by endotracheal suction or invasive
techniques. ET suction appears just as sensitive but less specific
than invasive methods.
UÊÊEmpiric treatment MUST be narrowed as soon as sputum
culture results are known.
UÊÊvÊÌ iÊ«>̈i˜ÌʈÃʜ˜Ê>˜ÌˆLˆœÌˆVÊÌ iÀ>«ÞʜÀÊ >ÃÊÀiVi˜ÌÞÊLii˜Êœ˜Ê>˜ÌˆLˆœÌˆVÊ
therapy, choose an agent from a different class.
Optimal treatment can likely be based on severity of illness as
determined by the Clinical Pulmonary Infection Score (CPIS).
Calculating the Clinical Pulmonary Infection Score (CPIS)
Temperature (°C)
Peripheral WBC
0 points
36.5 to 38.4
{]äääÊqÊ££]äää
Tracheal
secretions
Chest X-ray
None
Progression
of infiltrate
from prior
radiographs
Culture of ET
suction
None
Oxygenation
(PaO2/FiO2)
> 240 or ARDS
88
No infiltrate
No growth/light
growth
2 points
1 point
≤ 36.4 or ≥ 39
38.5 to 38.9
Ê{]äääʜÀÊ
> 11,000
> 50% bands: add
1 extra point
Purulent
Non-purulent
Diffuse or patchy
infiltrates
Localized
infiltrate
Progression
(ARDS, CHF
thought unlikely)
Heavy growth
Same bacteria on
gram stain: add 1
extra point
≤ 240 and no
ARDS
If the CPIS is ≤ 6
UÊÊ6*ʈÃÊ՘ˆŽiÞ
UÊÊvÊ6*ÊÃÌÀœ˜}ÞÊÃÕëiVÌi`ÊÃiiÊÌÀi>̓i˜ÌÊÀiVœ““i˜`>̈œ˜ÃÊLiœÜ
UÊÊvÊ *-ÊÀi“>ˆ˜ÃÊ≤ 6 after 3 days, antibiotics can be stopped in most
cases
If the CPIS is > 6
Early-onset VAP (occurring within 72 hours of hospitalization and
patient has not been hospitalized or resided in a nursing home, longterm care or rehabilitation facility in the past 3 months)
Etiology: S. pneumoniae, H. influenzea, S. aureus
UÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+Ó{
Late-onset VAP (all VAP that is not early-onset)
Etiology: S. aureus, P. aeruginosa, other Gram-negative bacilli
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUSÊQ*ˆ«iÀ>Vˆˆ˜É
tazobactam 4.5 g IV Q6H OR Cefepime 2 g IV OR +nRʱ Gentamicin
(see dosing section, p. 146)
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Q ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS
Gentamicin (see dosing section, p. 146)
Enterococci and candida species are often isolated from sputum in
hospitalized patients. In general, they should be considered to be
colonizing organisms and should not be treated with antimicrobials.
If the patient is immunocompromised, consider adding Azithromycin
500 mg Q24H to Piperacillin/tazobactam, Cefepime or Aztreonam to
cover Legionella
Duration
UÊÊ3 days if CPIS remains ≤ 6 in patients with initial CPIS ≤ ÈÆÊ6*ʈÃÊ
unlikely
UÊÊ7 days if the patient has clinical improvement
UÊÊvÊÃޓ«Ìœ“ÃÊ«iÀÈÃÌÊ>ÌÊÇÊ`>ÞÃÊVœ˜Ãˆ`iÀÊ>ÌiÀ˜>̈ÛiÊÜÕÀViÊ>˜`ɜÀÊ
bronchoscopy with quantitative cultures
UÊÊ6*Ê>ÃÜVˆ>Ìi`ÊÜˆÌ ÊS. aureus bacteremia should be treated for at
least 14 days
89
6.12 Pulmonary infections
EMPIRIC TREATMENT
6.12 Pulmonary infections
TREATMENT NOTES
UÊÊTreatment MUST be narrowed based on culture results
UÊÊ/œLÀ>“ÞVˆ˜ÊˆÃÊÀiVœ““i˜`i`Ê>ÃÊ>ÊÃiVœ˜`Ê>}i˜ÌÊ̜ÊLÀœ>`i˜Êi“«ˆÀˆVÊ
coverage rather than fluoroquinolones because of high rates of
resistance to fluoroquinolones in the institution.
UÊʘ̈“ˆVÀœLˆ>ÊÌ iÀ>«ÞÊà œÕ`ÊLiÊÌ>ˆœÀi`ʜ˜ViÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>ÀiÊ
known. Vancomycin should be stopped if resistant Gram-positive
organisms are not recovered. Gram-negative coverage can be
reduced to a single susceptible agent in most cases. The benefits of
combination therapy in the treatment of Pseudomonas are not well
`œVՓi˜Ìi`ÆʈvʈÌʈÃÊ`iÈÀi`]ÊÌ i˜ÊVœ˜Ãˆ`iÀÊ}ˆÛˆ˜}ʈÌÊvœÀÊÌ iÊwÀÃÌÊÇÓÊ
hours of therapy only.
Diagnosis
UÊÊ6*ʈÃÊ`ˆvwVՏÌÊ̜Ê`ˆ>}˜œÃi°
UÊÊ >VÌiÀˆ>ʈ˜Êi˜`œÌÀ>V i>ÊÃÕV̈œ˜Ê“>ÞÊÀi«ÀiÃi˜ÌÊÌÀ>V i>ÊVœœ˜ˆâ>̈œ˜Ê
and NOT infection.
UÊÊ+Õ>˜ÌˆÌ>̈ÛiÊVՏÌÕÀiÃʜvÊ ÊyՈ`ÊV>˜Ê i«Ê`ˆÃ̈˜}Ոà ÊLiÌÜii˜Ê
Vœœ˜ˆâ>̈œ˜Ê>˜`ʈ˜viV̈œ˜ÆÊ≥ 104 cfu/ml is considered significant
growth.
Other considerations
UÊÊ/À>V i>ÊVœœ˜ˆâ>̈œ˜ÊœvÊÀ>“‡˜i}>̈ÛiÃÊ>˜`ÊS. aureus is not
eradicated even though lower airways are sterilized. Thus, posttreatment cultures in the absence of clinical deterioration (fever,
rising WBC, new infiltrates, worsening ventilatory status) are not
recommended.
UÊʘ>`iµÕ>Ìiʈ˜ˆÌˆ>ÊÌÀi>̓i˜ÌʜvÊ6*ʈÃÊ>ÃÜVˆ>Ìi`ÊÜˆÌ Ê ˆ} iÀʓœÀÌ>ˆÌÞÊ
(even if treatment is changed once culture results are known).
,iviÀi˜ViÃ\
/-É -ÊՈ`iˆ˜iÃÊvœÀÊ*É6\Ê, ÊÓääxƣǣ\Înn°
ˆ˜ˆV>ÊÀi뜘ÃiÊ̜Ê6*\Ê, ÊÓää£Æ£ÈÎ\£ÎÇ£‡£ÎÇx°Ê
6*\ÊÀV ʘÌiÀ˜Êi`ÊÓäääÆ£Èä\£™ÓȇȰ
ˆ˜ˆ‡ \Ê iÃÌÊ£™™nÆ££Î\{£Ó‡Óä°
*-ÊÃVœÀi\ʓÊ,iÛÊ,iëˆÀÊ ˆÃÊ£™™£Æ£{Î\££Ó£q££Ó™°Ê
iÌiÀ“ˆ˜ˆ˜}ÊVœÕÀÃiʜvÊÌ iÀ>«ÞÊÕȘ}Ê *-Ê-VœÀi\ʓÊÊ,iëˆÀÊ ÀˆÌÊ >ÀiÊi`ÊÓäääÆÊ
£ÈÓ\xäxÊ>˜`ʘÌi˜ÃˆÛiÊ >ÀiÊi`ÊÓää{ÆÊÎä\ÊÇÎxqÇÎn°
90
UÊÊ/ iÀ>«ÞÊà œÕ`ÊLiÊL>Ãi`ʜ˜ÊVՏÌÕÀiÊ>˜`ÊÃÕÃVi«ÌˆLˆˆÌÞÊ`>Ì>ÊÜ i˜Ê
>Û>ˆ>LiÆÊÌ iÊ>}i˜ÌÊÜˆÌ ÊÌ iʘ>ÀÀœÜiÃÌÊëiVÌÀՓʜvÊ>V̈ۈÌÞÊà œÕ`ÊLiÊ
selected preferentially
UÊÊvÊ«œÃÈLi]ÊÃ̜«Êv>ˆˆ˜}Ê>˜ÌˆLˆœÌˆVÃÊÜ i˜Êˆ˜ˆÌˆ>̈˜}ʘiÜÊ>˜ÌˆLˆœÌˆVÃ
UÊʈ} Ê`œÃiÃʜvÊ>˜ÌˆLˆœÌˆVÃÊà œÕ`ÊLiÊÕÃi`Ê̜ʓ>݈“ˆâiʏ՘}Ê«i˜iÌÀ>̈œ˜Ê
and reduce the risk of emergence of resistance (see below)
TREATMENT NOTES FOR SPECIFIC ORGANISMS
UÊPseudomonas aeruginosa
UÊÊ*ˆ«iÀ>Vˆˆ˜]Ê ivi«ˆ“i]Ê>˜`Ê ivÌ>âˆ`ˆ“iÊà œÕ`ÊLiÊÕÃi`Ê
preferentially to Meropenem to minimize the induction of
resistance to beta-lactams by Meropenem
UÊÊ/ iÃiÊ>}i˜ÌÃÊ>ÀiÊ}i˜iÀ>ÞÊVœ“Lˆ˜i`ÊÜˆÌ Ê ˆ} ‡`œÃiÊ
aminoglycosides based on in vitro evidence that there is synergy
against Pseudomonas
UÊʜÀÊ«>̈i˜ÌÃÊÜˆÌ Ê«i˜ˆVˆˆ˜Ê>iÀ}Þ]Ê ˆ«ÀœyœÝ>Vˆ˜ÊœÀÊâÌÀiœ˜>“Ê
V>˜ÊLiÊVœ“Lˆ˜i`ÊÜˆÌ Ê>˜Ê>“ˆ˜œ}ÞVœÃˆ`iÆÊ`iÃi˜ÃˆÌˆâ>̈œ˜Ê̜ÊLiÌ>‡
lactams or carbapenems should be strongly considered
UÊʘʫ>̈i˜ÌÃʈ˜ÌœiÀ>˜ÌʜÀÊÀiÈÃÌ>˜ÌÊ̜Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]Ê œˆÃ̈˜ÊV>˜Ê
be added
UÊÊ œ˜Ìˆ˜ÕœÕÃʈ˜vÕȜ˜ÊœvÊLiÌ>‡>VÌ>“ÃÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜ÊܓiÊ
«>̈i˜ÌÃÆÊÃiiÊ«°ÊÓnÊvœÀʓœÀiʈ˜vœÀ“>̈œ˜°
UÊʘ >i`Ê/œLÀ>“ÞVˆ˜Ê>˜`Ê œˆÃ̈˜ÊV>˜ÊLiÊÕÃi`Ê>ÃÊ>`Õ˜V̈ÛiÊÌ iÀ>«Þ
UÊStenotrophomonas maltophilia
UÊÊS. maltophilia isolated from sputum usually represents colonization.
UÊÊvÊÃÕ«iÀˆ˜viV̈œ˜ÊˆÃÊÃÕëiVÌi`]Ê/*É-8ʈÃÊÌ iÊwÀÃÌʏˆ˜iÊ>}i˜Ì°Ê
UÊÊ/ˆV>ÀVˆˆ˜ÉV>ÛՏ>˜>ÌiÊOR Minocycline may be used if susceptible in
«>̈i˜ÌÃÊÜ œÊ>ÀiÊ>iÀ}ˆVʜÀʈ˜ÌœiÀ>˜ÌʜÀÊÀiÈÃÌ>˜ÌÊ̜Ê/*É-8°Ê
UÊStaphylococcus aureus
UÊÊS. aureus isolated from sputum can indicate colonization or
infection.
UÊÊ7 iÌ iÀÊÌÀi>̈˜}ÊVœœ˜ˆâ>̈œ˜ÊÜˆÌ ÊS. aureus in CF patients
improves outcomes is an area of active research, although
historically such colonization has not been successfully eradicated
with antimicrobial therapy. If this is attempted, possible agents
include Dicloxacillin, Cefazolin or Cephalexin for MSSA and
ˆ˜`>“ÞVˆ˜]Ê/*É-8]Ê œÝÞVÞVˆ˜i]Ê>˜`ʈ˜œVÞVˆ˜iÊvœÀÊ,-°ÊÊ
UÊÊ"Ý>Vˆˆ˜ÊˆÃÊÌ iÊ`ÀÕ}ʜvÊV œˆViÊvœÀÊ--Ê«˜iՓœ˜ˆ>ÆÊ6>˜Vœ“ÞVˆ˜Ê
or Linezolid can be used for MRSA pneumonia.
91
6.12 Pulmonary infections
Antibiotic selection and dosing for cystic
fibrosis patients
6.12 Pulmonary infections
Antibiotic doses for cystic fibrosis infections – normal renal
function
UÊ ivÌ>âˆ`ˆ“i\ÊÓÊ}Ê6Ê+nÊ
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“\ÊΰÎÇxÊ}Ê6Ê+{
UÊ ivi«ˆ“i\ÊÓÊ}Ê6Ê+n
UÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n
UÊ ˆ«ÀœyœÝ>Vˆ˜\ÊÇxäʓ}Ê*"Ê+£ÓÊ",Ê{ääʓ}Ê6Ê+n
UÊâÌÀiœ˜>“\ÊÓÊ}Ê6Ê+n
UÊ/ˆV>ÀVˆˆ˜ÉV>ÛՏ>˜>Ìi\Êΰ£Ê}Ê6Ê+{
UÊ/*É-8ÊvœÀÊS. maltophilia: 5 mg/kg IV/PO Q8H
UÊ/*É-8ÊvœÀÊS. aureus: 2 DS tablets PO BID
UÊ œˆÃ̈˜\Ê·Èʓ}Ɏ}É`>ÞÊ6Ê`ˆÛˆ`i`ʈ˜ÊÎÊ`œÃiÃÊ
Uʘ >i`Ê/œLÀ>“ÞVˆ˜Ê­/" ®®\ÊÎääʓ}Ê+£Ó
Uʘ >i`Ê œˆÃ̈˜\ÊÇx‡£xäʓ}Ê+£ÓÊ`i«i˜`ˆ˜}ʜ˜ÊÌ iÊ`iˆÛiÀÞÊÃÞÃÌi“ÊÊ
Intravenous Tobramycin dosing and monitoring:
Uʜ>`ˆ˜}Ê`œÃi\Ê£äʓ}Ɏ}É`>ÞÊ}ˆÛi˜ÊœÛiÀÊ£Ê œÕÀ°Ê
UÊÊ*i>ŽÊˆÃÊÀiVœ““i˜`i`Ê>vÌiÀÊwÀÃÌÊ`œÃi]Ê£Ê œÕÀÊ>vÌiÀÊÌ iÊi˜`ʜvʈ˜vÕȜ˜Ê
ÜˆÌ Ê}œ>ÊœvÊÓä‡ÎäÊ>˜`ÊÌÀœÕ} Ê>ÌÊÓÎÊ œÕÀÃÊÜˆÌ Ê}œ>ÊÊ£Ê“V}ɓ°Ê
UÊÊ œÃiÃÊV>˜ÊLiʈ˜VÀi>Ãi`ÊÕ«Ê̜ʣÓʓ}Ɏ}É`>ÞʈvÊ>`iµÕ>ÌiÊ«i>ŽÃÊ
are not achieved. If trough is too low or too high, interval should be
changed.
92
Diagnosis
UÊÊ,iëˆÀ>̜ÀÞÊۈÀÕÃÊÌiÃ̈˜}Êà œÕ`ÊLiʜLÌ>ˆ˜i`ÊÞi>ÀÊÀœÕ˜`ʜ˜Ê>˜ÞÊ«>̈i˜ÌÊ
for whom there is a clinical suspicion of respiratory virus infection. In
addition, during influenza and RSV season testing should be obtained
ˆ˜Ê«>̈i˜ÌÃÊÜˆÌ \
Ê UÊÊiÛiÀÊ>˜`ʈ˜yÕi˜â>‡ˆŽiÊÃޓ«Ìœ“ÃʭÜÀiÊÌ Àœ>Ì]ʓÞ>}ˆ>]Ê>ÀÌ À>}ˆ>]Ê
cough, runny nose and/or headache)
Ê U Suspected bronchiolitis or pneumonia
Ê U COPD/asthma exacerbation or respiratory failure
Ê UÊ1˜iÝ«>ˆ˜i`Ê ÊiÝ>ViÀL>̈œ˜
Ê UÊ `iÀÞÊ«>̈i˜ÌÃÊÜˆÌ Ê՘iÝ«>ˆ˜i`ʘiÜʜ˜ÃiÌʓ>>ˆÃi
Ê UÊ*Ài}˜>˜ÌÊ«>̈i˜ÌÃÊÜˆÌ Ê՘iÝ«>ˆ˜i`ÊÀiëˆÀ>̜ÀÞÊÃޓ«Ìœ˜Ã
Ê UÊÊ œ˜Ã«iVˆwVÊÃޓ«Ìœ“ÃÊ>˜`Ê>Ê`œVՓi˜Ìi`ÊiÝ«œÃÕÀiÊ̜Êܓiœ˜iÊ
with a respiratory illness
UÊÊ,iëˆÀ>̜ÀÞÊۈÀÕÃÊÌiÃ̈˜}Ê>ÌÊÊ­œ˜iÊ *ÊyœVŽi`ÊÃÜ>LÊà œÕ`ÊLiÊ
submitted for either panel)
Ê UÊÊ/iÃ̈˜}ÊvœÀʈ““Õ˜œVœ“«iÌi˜ÌÊ œÃÌÃ\ÊÀ>«ˆ`ʘÕViˆVÊ>Vˆ`ÊÌiÃÌÊvœÀÊ,-6Ê
and influenza A/B
Ê UÊÊ/iÃ̈˜}ÊvœÀʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê œÃÌÃ]Ê«>̈i˜ÌÃÊLiˆ˜}Ê>`“ˆÌÌi`Ê
̜ÊÌ iÊ 1]Ê>˜`Ê«>̈i˜ÌÃÊÜˆÌ ÊÃÌÀÕVÌÕÀ>ÊÕ˜}Ê`ˆÃi>Ãi\ÊiÝÌi˜`i`Ê
panel for RSV, influenza A/B, adenovirus, human metapneumovirus,
parainfluenza 1-3, and rhinovirus
Treatment of influenza in inpatients
UÊÊ “«ˆÀˆVÊÌÀi>̓i˜ÌʜvÊ>`ՏÌʈ˜«>̈i˜ÌÃÊà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜ÊÌ iÊ
vœœÜˆ˜}ÊÈÌÕ>̈œ˜ÃÊ`ÕÀˆ˜}ʈ˜yÕi˜â>ÊÃi>ܘ\Ê
Ê UÊÊ*>̈i˜ÌÃÊÜˆÌ ÊviÛiÀÊ>˜`ʈ˜yÕi˜â>‡ˆŽiÊÃޓ«Ìœ“Ã]Ê՘iÝ«>ˆ˜i`Ê
interstitial pneumonia or new respiratory failure without an obvious
non-influenza cause
UÊÊ/Ài>̓i˜ÌÊà œÕ`ÊLiʈ˜ˆÌˆ>Ìi`ʈ˜Ê>Ê«>̈i˜ÌÃÊÜ œÊ>ÀiÊ>`“ˆÌÌi`Ê̜ÊÌ iÊ
hospital and have influenza with symptom onset in the past 48-72 hours
UÊÊ/ iÊṎˆÌÞʜvÊÌÀi>̓i˜ÌʜvÊ«>̈i˜ÌÃÊÜ œÊ«ÀiÃi˜Ìʏ>Ìiʈ˜ÊÌ iÊVœÕÀÃiʜvÊ
disease is uncertain and the decision to treat these patients can be
made on a case-by-case basis
UÊʘ̈ۈÀ>ÊV œˆViʈÃÊ`i«i˜`i˜Ìʜ˜ÊÌ iÊÃÕÃVi«ÌˆLˆˆÌÞʜvÊVˆÀVՏ>̈˜}ÊÃÌÀ>ˆ˜ÃÊ
which may vary from season to season (see
www.hopkinsmedicine.org/amp for current recommendations)
UÊÊ ÕÀ>̈œ˜\ÊxÊ`>ÞÃÊiÝVi«ÌÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ Ê܏ˆ`ʜÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê
hematologic malignancy, or BMT in whom 10 days can be given
because of prolonged viral shedding
93
6.13 Respiratory virus diagnosis and management
Respiratory virus diagnosis and management
6.13 Respiratory virus diagnosis and management
Infection control
UÊʏÊˆ˜`ˆÛˆ`Õ>ÃÊÜˆÌ ÊÃÕëiVÌi`ÊÀiëˆÀ>̜ÀÞÊۈÀÕÃʈ˜viV̈œ˜Êà œÕ`ÊLiÊ
placed on droplet precautions. A private room is required, unless
patients are cohorted. When outside of their room (i.e. during
transport) patients should wear a mask.
UÊʏÊ i>Ì ÊV>ÀiÊܜÀŽiÀÃʓÕÃÌÊÀiViˆÛiÊÌ iʈ˜yÕi˜â>ÊÛ>VVˆ˜iÊÞi>ÀÞ°
UÊÊ*iÀܘ˜iÊÜˆÌ Ê`ˆÀiVÌÊ«>̈i˜ÌÊV>ÀiʜÀÊܜÀŽˆ˜}ʈ˜ÊVˆ˜ˆV>Ê>Ài>ÃÊÜ œÊ >ÛiʘœÌÊ
received the influenza vaccine are required to wear a mask when within 6
feet of a patient. The dates of the mask requirement are determined by
HEIC and based on influenza activity in the local community.
U No one with fever may work until at least 24 hours after fever
has resolved (without antipyretics). All personnel with respiratory
symptoms and fever must call or report to their supervisor and must
call Occupational Health Services (OHS).
UÊAfebrile employees who have respiratory systems must wear a
surgical mask during patient contact (≤ 6 ft).
UÊÊvÊ>˜Ê՘Û>VVˆ˜>Ìi`Ê 7ʈÃÊiÝ«œÃi`Ê̜Ê>Ê«>̈i˜ÌÊÜˆÌ Ê`œVՓi˜Ìi`Ê
influenza who was not on Droplet Precautions, notify HEIC and call
Occupational Health Services (OHS) immediately. OHS will decide
whether to recommend post-exposure prophylaxis.
Anti-influenza agents
Medication
Adult dosing
Side effects
Notes
Oseltamivir
Treatment:Ê
75 mg PO twice a day
vœÀÊxÊ`>ÞÃÊ
Prophylaxis:Ê
75 mg PO once a day
œ““œ˜\ʘ>ÕÃi>]ÊÊ
vomiting
Ê
-iÛiÀi\
hypersensitivity,
neuropsychiatric
œÃiÊ>`ÕÃ̓i˜ÌÊ
needed for GFR
Èäʓɓˆ˜Ê
Treatment:Ê
10 mg (2 oral inhalations)
twice daily for 5 days
Prophylaxis:
10 mg (2 oral inhalations)
œ˜ViÊ>Ê`>ÞÊÊ
œ““œ˜\Ê`ˆ>ÀÀ i>]ÊÊ
nausea, cough,
headache, and
dizziness
- œÕ`Ê "/ÊLiÊÕÃi`Ê
in patients with
chronic underlying
airway diseases
Ê
<>˜>“ˆÛˆÀÊ
Ê
94
Ê-iÛiÀi\ÊLÀœ˜V œÃ«>Ó]Ê
hypersensitivity,
laryngeal edema,
facial swelling
Latent TB infection (LTBI)
UÊÊ*ÀiۈœÕÃʈ˜viV̈œ˜ÊÜˆÌ ÊM. tuberculosis (MTB) that has been contained by
the host immune response
UÊÊ*>̈i˜Ìʓ>ÞÊ >ÛiÊ>Ê«œÃˆÌˆÛiÊÌiÃÌÊ­ÃiiÊLiœÜ®ÊœÀÊÃÕ}}iÃ̈ÛiÊÀ>`ˆœ}À>« ˆVÊ
findings such as calcified granulomata or minimal apical scarring, but do
not have symptoms of active TB disease
UÊÊ œÌʈ˜viV̈œÕÃÊ>˜`Ê`œiÃʘœÌÊÀiµÕˆÀiʈ܏>̈œ˜
Tests to diagnose latent LTBI
UÊÊ œÌ Ê/ÕLiÀVՏˆ˜ÊΈ˜ÊÌiÃÌÊ­/-/®Ê>˜`ʘÌiÀviÀœ˜Ê}>““>ÊÀii>ÃiÊ>ÃÃ>ÞÊ­,®Ê
>Àiʈ“«iÀviVÌ]Ê>˜`ʓ>ÞʜvviÀÊ`ˆÃVœÀ`>˜ÌÊÀiÃՏÌÃÊ­HÓ䯮°ÊÊ-i˜ÃˆÌˆÛˆÌÞʜvÊ/-/Ê
and IGRA are similar.
UÊÊ œÌ ÊÌiÃÌÃÊà œÕ`ÊLiʈ˜ÌiÀ«ÀiÌi`ʈ˜ÊÌ iÊVœ˜ÌiÝÌʜvÊi«ˆ`i“ˆœœ}ˆVÊÀˆÃŽÊœvÊ/ Ê
exposure
UÊÊ/ ÊÌ iÀ>«ÞÊà œÕ`ʘœÌÊLiʈ˜ˆÌˆ>Ìi`Ê՘̈Ê>V̈ÛiÊ/ ʈÃÊiÝVÕ`i`Ê­LÞÊ
symptoms and radiography). Individuals with signs or symptoms of active
TB require further diagnostic workup before LTBI therapy.
UÊÊ/ ÊÌ iÀ>«ÞÊà œÕ`ʘœÌÊLiÊÃÌ>ÀÌi`ʈ˜ÊÌ iÊ œÃ«ˆÌ>ÊÜˆÌ œÕÌÊ>ÊVi>ÀÊvœœÜ‡Õ«Ê
plan
Tuberculin skin test (TST)
UÊʘÌÀ>`iÀ“>Êˆ˜iV̈œ˜ÊœvÊ«ÕÀˆwi`Ê«ÀœÌiˆ˜Ê`iÀˆÛ>̈ÛiÊ­** ®Ê>˜`ʓi>ÃÕÀi“i˜ÌÊ
of induration diameter in 48-72
UÊÊÊ ÀˆÌiÀˆ>ÊvœÀÊ>Ê«œÃˆÌˆÛiÊÌiÃÌÊ>Ài
UÊÊÊxʓ“ÊqÊ ˆ} ÊÀˆÃŽÊœvÊ`iÛiœ«ˆ˜}Ê>V̈ÛiÊ/ Ê­i°}°]Ê6ʈ˜viV̈œ˜]ÊVœÃiÊ
contact of TB case, immunocompromised)
UÊÊÊ£äʓ“ÊqÊœÌ iÀÊÀˆÃŽÊv>V̜ÀÃÊvœÀÊ/ ʈ˜viV̈œ˜Ê­ 7]Ê 1]Ê ®
UÊÊÊ£xʓ“ÊqʘœÊÀˆÃŽÊv>V̜ÀÃÊvœÀÊ/
Interferon gamma release assay (IGRA)
UÊ,Ãʓi>ÃÕÀiʏޓ« œVÞÌiÊÀii>Ãiʜvʈ˜ÌiÀviÀœ˜Ê}>““>ʈ˜ÊÀi뜘ÃiÊ̜Ê
stimulation by MTB antigens.
UÊ,ÃÊ>ÀiʏiÃÃÊ>vviVÌi`ÊLÞÊ ÊÛ>VVˆ˜>̈œ˜ÊÃÌ>ÌÕÃʜÀʈ˜viV̈œ˜ÊÜˆÌ Ê“œÃÌÊ
atypical mycobacteria (except M. marinum and M. kansasii) than TST
UÊ+Õ>˜ÌˆviÀœ˜‡œ`‡˜‡/ÕLiÊ­+/®ÊˆÃÊÕÃi`Ê>ÌÊ°Ê,iÃՏÌÃÊ>ÀiÊÀi«œÀÌi`Ê>ÃÊ
positive, negative, or indeterminate. An indeterminate result means that the
test result is not valid, which can be due to errors in specimen collection
(most common--insufficient/incorrect shaking of tubes after blood draw
or processing delays), or associated with certain conditions such as HIV
with a low CD4 count, steroid use or other immunosuppression, and
“>˜ÕÌÀˆÌˆœ˜ÊQ>LՓˆ˜ÊΰxR°Ê˜`iÌiÀ“ˆ˜>ÌiÊÀiÃՏÌÃʜvÌi˜ÊÀiµÕˆÀiÊ>ÊÀi«i>ÌÊ
test (ensure proper specimen collection).
UÊ7 i˜Ê«Ài‡ÌiÃÌÊ«ÀœL>LˆˆÌÞʜÀÊ«ÀiÛ>i˜ViʜvÊ/ ʈÃÊx¯Ê­i°}°]Ê1-‡LœÀ˜Ê
ÜˆÌ œÕÌÊvœÀiˆ}˜ÊÌÀ>Ûi®]Ê**6ʜvÊ,ʈÃÊÀi`ÕVi`Ê­Ç䇙ä¯]ʈ°i°]Êv>Ãi‡«œÃˆÌˆÛiîÊ
Ü ˆiÊ *6ʈÃÊ ˆ} Ê­™™¯®°ÊÊ
UÊ7 i˜Ê«Ài‡ÌiÃÌÊ«ÀœL>LˆˆÌÞÊvœÀʈ˜viV̈œ˜ÊˆÃÊ ˆ} Ê­i°}°]ÊvœÀiˆ}˜‡LœÀ˜]ÊHÎä¯Ê/ Ê
«ÀiÛ>i˜Vi®]Ê**6ʜvÊ,ʈ˜VÀi>ÃiÃÊ̜ÊH™x‡™™¯]ÊLÕÌÊ *6Ê`iVÀi>ÃiÃÊ
­n䇙ä¯]ʈ°i°]Êv>Ãi‡˜i}>̈Ûiî°ÊÊ
95
6.14 Tuberculosis (TB) infection
Tuberculosis (TB) infection
6.14 Tuberculosis (TB) infection
UÊ+Õ>˜ÌˆÌ>̈ÛiÊÀiÃՏÌÃʓ>ÞÊLiÊ i«vՏÊ̜Ê}Ո`iʈ˜ÌiÀ«ÀiÌ>̈œ˜°Ê œ˜Ãˆ`iÀÊ Ê
Vœ˜ÃՏÌ>̈œ˜ÊvœÀÊÀiÃՏÌÃʘi>ÀÊÌ iÊÌ Àià œ`ÊvœÀÊ+/Ê«œÃˆÌˆÛi\Ê>˜Ìˆ}i˜0.35.
Serial testing is not advised without ID consultation.
UÊ,ÃÊ`œÊ˜œÌÊ >ÛiÊ}œœ`ÊÃi˜ÃˆÌˆÛˆÌÞʜÀÊëiVˆwVˆÌÞÊvœÀÊ`ˆ>}˜œÃˆÃʜvÊ>V̈ÛiÊ/
Active TB infection
UÊÊV̈ÛiÊÀi«ˆV>̈œ˜ÊœvÊ/ ÊV>ÕȘ}ʫՏ“œ˜>ÀÞʜÀÊiÝÌÀ>«Õ“œ˜>ÀÞÊÈ}˜ÃʜÀÊ
symptoms
UÊÊ œ˜wÀ“i`ÊLÞÊ«œÃˆÌˆÛiÊ ÊÓi>À]Ê/ Ê`ˆÀiVÌÊÌiÃÌʜÀÊVՏÌÕÀi
UÊÊ,iµÕˆÀiÃÊ>ˆÀLœÀ˜iʈ܏>̈œ˜
When to suspect active TB disease
High-risk individuals
UÊÊ,iVi˜ÌÊiÝ«œÃÕÀiÊ̜Ê>Ê«iÀܘÊÜˆÌ ÊŽ˜œÜ˜Ê/ ÆÊ ˆÃ̜ÀÞʜvÊ>Ê«œÃˆÌˆÛiÊ/-/ÆÊ
6ʈ˜viV̈œ˜Æʈ˜iV̈œ˜ÊœÀʘœ˜‡ˆ˜iV̈œ˜Ê`ÀÕ}ÊÕÃiÆÊvœÀiˆ}˜ÊLˆÀÌ ÊœÀÊÀiÈ`i˜ViÊ
ˆ˜Ê>ÊÀi}ˆœ˜Êˆ˜ÊÜ ˆV Ê/ ʈ˜Vˆ`i˜ViʈÃÊ ˆ} ÆÊÀiÈ`i˜ÌÃÊ>˜`Êi“«œÞiiÃʜvÊ
ˆ} ‡ÀˆÃŽÊVœ˜}Ài}>ÌiÊÃiÌ̈˜}ÃÊ­i°}°Ê«ÀˆÃœ˜Ã®Æʓi“LiÀà ˆ«Êˆ˜Ê>ʓi`ˆV>ÞÊ
՘`iÀÃiÀÛi`]ʏœÜ‡ˆ˜Vœ“iÊ«œ«Õ>̈œ˜ÆÊ>˜Ìˆ‡/ Ê>« >ÊÌ iÀ>«Þ
Clinical syndromes
UÊÊ œÕ} ʜvÊ2 wk duration, with at least one additional symptom, including
fever, night sweats, weight loss, or hemoptysis
UÊʘÞÊ՘iÝ«>ˆ˜i`ÊÀiëˆÀ>̜ÀÞʈ˜iÃÃʜvÊ2 wk duration in a patient at high
risk for TB
UÊʘÞÊ«>̈i˜ÌÊÜˆÌ Ê6ʈ˜viV̈œ˜Ê>˜`Ê՘iÝ«>ˆ˜i`ÊVœÕ} Ê>˜`ÊviÛiÀÊ
UÊʘÞÊ«>̈i˜Ìʜ˜Ê>˜Ìˆ‡/ Ê>« >ÊÌ iÀ>«ÞÊÜˆÌ Ê՘iÝ«>ˆ˜i`ÊviÛiÀ
UÊÊ œ““Õ˜ˆÌއ>VµÕˆÀi`Ê«˜iՓœ˜ˆ>ÊÜ ˆV Ê >ÃʘœÌʈ“«ÀœÛi`Ê>vÌiÀÊÇÊ`>ÞÃʜvÊ
appropriate treatment
UÊʘVˆ`i˜Ì>Êw˜`ˆ˜}Ãʜ˜ÊV iÃÌÊÀ>`ˆœ}À>« ÊÃÕ}}iÃ̈ÛiʜvÊ/ Ê­iÛi˜ÊˆvÊÃޓ«Ìœ“ÃÊ
are minimal or absent) in a patient at high risk for TB
Radiographic findings
UÊÊ*Àˆ“>ÀÞÊ/ Ê­œvÌi˜Ê՘ÀiVœ}˜ˆâi`®\Ê >˜ÊÀiÃi“LiÊ *Ê>˜`ʈ˜ÛœÛiÊ>˜ÞʏœLiÃÆÊ
ˆ>ÀÊ>`i˜œ«>Ì Þ]Ê«iÕÀ>ÊivvÕȜ˜ÃÊ>ÀiÊVœ““œ˜ÆÊV>ۈÌ>̈œ˜ÊˆÃÊ՘Vœ““œ˜°Ê
ˆ˜`ˆ˜}ÃʜvÌi˜ÊÀi܏ÛiÊ>vÌiÀÊ£qÓʓœ˜Ì ðÊ/ iÃiÊ>ÀiÊVœ““œ˜Êw˜`ˆ˜}Ãʈ˜Ê
patients with advanced HIV infection and TB.
UÊÊ,i>V̈Û>̈œ˜Ê/ \ʘwÌÀ>ÌiÃÊÜˆÌ ÊœÀÊÜˆÌ œÕÌÊV>ۈÌ>̈œ˜Êˆ˜ÊÌ iÊÕ««iÀʏœLiÃʜÀÊ
Ì iÊÃÕ«iÀˆœÀÊÃi}“i˜ÌÃʜvÊÌ iʏœÜiÀʏœLiÃÆÊ ˆ>ÀÊ>`i˜œ«>Ì ÞʈÃÊÛ>Àˆ>LiÆÊ /Ê
ÃV>˜Ê“>ÞÊ >ÛiʺÌÀii‡ˆ˜‡LÕ`»Ê>««i>À>˜Vi°
Diagnosis
UÊÊ*>̈i˜ÌÃÊÜˆÌ ÊV >À>VÌiÀˆÃ̈VÊÃޘ`Àœ“iÃÊ>˜`ÊÀ>`ˆœ}À>« ˆVÊw˜`ˆ˜}ÃÊà œÕ`Ê
have expectorated sputum obtained for AFB smear and culture.
UÊÊ-i˜ÃˆÌˆÛˆÌÞʜvÊ ÊÓi>Àʜ˜ÊiÝ«iV̜À>Ìi`ÊëÕÌՓʈÃÊxäqÇä¯ÆʈÌʈÃÊ
œÜiÀʈ˜Ê6³Ê«>̈i˜ÌðʜÀ˜ˆ˜}ÊiÝ«iV̜À>Ìi`ÊëÕÌՓ]ʈ˜`ÕVi`ÊëÕÌՓ]Ê
bronchoscopy have higher sensitivity. AFB culture of lower respiratory tract
specimens is considered the gold standard.
UÊÊ ÊÓi>ÀÊ>˜`ÊVՏÌÕÀiÊà œÕ`ÊLiʜLÌ>ˆ˜i`ÊÀi}>À`iÃÃʜvÊ 8,Ê
findings in patients with high clinical suspicion, HIV infection or other
ˆ““Õ˜œVœ“«Àœ“ˆÃi`ÊÃÌ>ÌiÃ°Ê 8,ʈÃʘœÀ“>Êˆ˜Ê>««ÀœÝˆ“>ÌiÞÊ£ä¯ÊœvÊ6‡
infected patients with pulmonary TB.
96
Infection control
ˆÀLœÀ˜iÊ«ÀiV>Ṏœ˜ÃÊ>ÀiÊÀiµÕˆÀi`ʈ˜ÊÌ iÊvœœÜˆ˜}ÊV>ÃiÃ\
UÊÊ-ÕëˆVˆœ˜ÊœvÊ`ˆÃi>ÃiÊÃÕvwVˆi˜ÌÞÊ ˆ} Ê̜ÊÜ>ÀÀ>˜ÌʜLÌ>ˆ˜ˆ˜}ÊëÕÌÕ“Ê Ê
smear/culture as described above
UÊÊ*œÃˆÌˆÛiÊ ÊÓi>ÀʜÀÊVՏÌÕÀiÊ՘̈Ê`ˆ>}˜œÃˆÃʜvÊ/ ÊÛÃ°Ê /ʈÃÊVœ˜wÀ“i`
Algorithm for isolation when active TB is suspected
AIRBORNE PRECAUTIONS
IN NEGATIVE PRESSURE ROOM
Collect specimen(s) for AFB smear and culture
Expectorated sputum (3 required)*
Smear
positive
Mycobacterium
Tuberculosis
Direct Test (MTD)
automatically
performed
Induced sputum or bronchoscopy
Smear
negative
MTD
negative
Smear
positive
Obtain 2nd
and 3rd
specimen*
Smear
positive
MTD test
performed
MTD
positive
MTD
positive
Continue isolation until at
least 14 days of therapy
AND clinical improvement
AND 3 consecutive negative
smears (Call HEIC for
approval to D/C isolation on
smear positive patient.)
Smear
negative
If pt highly suspected
for TB, await culture
result and continue
isolation. Otherwise,
CALL HEIC 5-8384 to
DISCONTINUE ISOLATION
MTD
negative
CALL HEIC
5-8384 TO
DISCONTINUE
ISOLATION
*One expectorated sputum must be a first morning specimen; samples should
be collected at least 8 hours apart.
97
6.14 Tuberculosis (TB) infection
UÊÊ"LÌ>ˆ˜Ê>Ìʏi>ÃÌÊÎÊëÕÌՓÊëiVˆ“i˜ÃÊ­ˆ˜`ÕVi`ʜÀÊiÝ«iV̜À>Ìi`®ÊÜ i˜ÊÌÀވ˜}Ê
to diagnose TB in patients who are smear negative so as to increase the
chance of isolating the organism for diagnosis and susceptibility testing.
6.14 Tuberculosis (TB) infection
UÊʘœÜ˜Ê>V̈ÛiʫՏ“œ˜>ÀÞʜÀʏ>Àޘ}i>Ê/ Ê­ˆvÊ«>̈i˜ÌʈÃÊVÕÀÀi˜ÌÞʜ˜Ê/ Ê
treatment, consult with HEIC and patient’s local health department to obtain
treatment history in order to determine if infectious at the time of current
œÃ«ˆÌ>ˆâ>̈œ˜Æʈ˜Ê“i>˜Ìˆ“iÊ>ˆÀLœÀ˜iÊ«ÀiV>Ṏœ˜ÃÊ>ÀiÊÀiµÕˆÀi`®Ê
TREATMENT
Active TB
UÊ ÊVœ˜ÃՏÌʈÃÊÃÌÀœ˜}ÞÊÀiVœ““i˜`i`Ê
UÊÊ/ iÀ>«ÞÊà œÕ`ÊLiʈ˜ˆÌˆ>Ìi`ÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ Ê«œÃˆÌˆÛiÊ ÊÓi>ÀÊ>˜`ÊVˆ˜ˆV>Ê
findings consistent with active TB.
UÊÊ/ iÀ>«ÞÊà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ Ê˜i}>̈ÛiÊ ÊÓi>ÀÃÊ
when suspicion of TB is high and no alternate diagnosis exists. Multiple
specimens should be obtained for culture prior to treatment.
UʜÕÀÊ`ÀÕ}ÃÊ>ÀiʘiViÃÃ>ÀÞÊvœÀʈ˜ˆÌˆ>Ê« >ÃiÊ­Óʓœ˜Ì î°Ê
UÊܘˆ>âˆ`Ê­ ®ÊÎääIʓ}Ê­xʓ}Ɏ}®Ê*"Ê`>ˆÞÊ
UÊ,ˆv>“«ˆ˜Ê­,®ÊÈääIʓ}Ê­£äʓ}Ɏ}®Ê*"Ê`>ˆÞ
UÊÊ*ÞÀ>∘>“ˆ`iÊ­*<®Ê£äääʓ}Ê*"Ê`>ˆÞÊ­{äqxxʎ}®Ê",Ê£xääʓ}Ê*"Ê
`>ˆÞÊ­xÈqÇxʎ}®Ê",ÊÓäääIʓ}Ê*"Ê`>ˆÞÊ­ÇÈq™äʎ}®Ê
UÊÊ Ì >“LÕ̜Ê­ ®Ênääʓ}Ê*"Ê`>ˆÞÊ­{äqxxʎ}®Ê",Ê£Óääʓ}Ê*"Ê`>ˆÞÊ
­xÈqÇxʎ}®Ê",Ê£ÈääIʓ}Ê*"Ê`>ˆÞÊ­ÇÈq™äʎ}®Ê
*Max dose regardless of weight.
UÊÊ*ÞÀˆ`œÝˆ˜iÊÓxʓ}Ê*"Ê`>ˆÞʈÃÊÀiVœ““i˜`i`Ê̜ʫÀiÛi˜ÌÊ Ê>ÃÜVˆ>Ìi`Ê
peripheral neuropathy in patients with HIV, malnutrition, alcohol abuse,
diabetes mellitus, renal failure or in pregnant or breastfeeding women.
Drug toxicity and monitoring
UÊÊܘˆ>âˆ`\Ê>Ãޓ«Ìœ“>̈VÊiiÛ>̈œ˜Êˆ˜Ê i«>̈VÊi˜âޓiÃ]ÊÃiÀˆœÕÃÊ>˜`Êv>Ì>Ê
hepatitis, peripheral neurotoxicity
UÊÊ,ˆv>“«ˆ˜\ʜÀ>˜}iÊ`ˆÃVœœÀ>̈œ˜ÊœvÊLœ`ÞÊyՈ`Ã]Ê i«>̜̜݈VˆÌÞ]Ê«ÀÕÀˆÌˆÃÊÜˆÌ Ê
or without rash
UÊÊ*ÞÀ>∘>“ˆ`i\Ê i«>̜̜݈VˆÌÞ]ʘœ˜}œÕÌÞÊ«œÞ>ÀÌ À>}ˆ>]Ê>Ãޓ«Ìœ“>̈VÊ
hyperuricemia, acute gouty arthritis
UÊÊ Ì >“LÕ̜\ÊÀiÌÀœLՏL>ÀÊ>˜`Ê«iÀˆ« iÀ>Ê˜iÕÀˆÌˆÃÊÊ
U œ˜ˆÌœÀˆ˜}\ÊL>Ãiˆ˜iÊ i«>̈VÊÌÀ>˜Ã>“ˆ˜>ÃiÃ]ÊLˆˆÀÕLˆ˜]Ê>Ž>ˆ˜iÊ« œÃ« >Ì>Ãi]Ê
creatinine and CBC are recommended for all adults initiating TB treatment.
Monthly hepatic panel is recommended for patients with baseline
abnormalities, history of liver disease or viral hepatitis, chronic alcohol
consumption, HIV, IVDU, pregnancy or immediate post-partum state or
those taking other potentially hepatotoxic medications. Therapy should
be discontinued immediately if AST and ALT are 3 times the upper limit
of normal (ULN) in the presence of jaundice or hepatitis symptoms or 5
times the ULN in the absence of symptoms.
,iviÀi˜ViÃ\Ê
/-É -É
/-É -É
98
ÊՈ`iˆ˜iÃÊvœÀÊ`ˆ>}˜œÃˆÃʜvÊ/ \ʓÊÊ,iëˆÀÊ >ÀiÊi`ÊÓäääƣȣ\£ÎÇÈ°
ÊՈ`iˆ˜iÃÊvœÀÊÌÀi>̓i˜ÌʜvÊ/ \Ê7,ÆxÓ\,,‡££°Ê
6.15 Sepsis with no clear source
Sepsis with no clear source
NOTE: Refer to specific sections of these guidelines for empiric
treatment recommendations for specific sources of infection
EMPIRIC TREATMENT
Cultures MUST be sent to help guide therapy.
UÊÊQ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“IÊ{°xÊ}Ê6Ê+ÈÊ",Ê ivi«ˆ“iIÊÓÊ}Ê6Ê+nRÊ
± Vancomycin (see dosing section, p. 150) (if at risk for MRSA) ±
Gentamicin (see dosing section, p. 146)
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nÊ",Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ
“}Ê6Ê+nRÊPLUS Gentamicin (see dosing section, p. 146) PLUS
Vancomycin (see dosing section, p. 150)
*NOTE: If patient has history of ESBL-producing organism or has
suspected intra abdominal sepsis and recent prolonged exposure
( 7 days) to Piperacillin/tazobactam or Cefepime, substitute with
Meropenem 1 g IV Q8H.
Risk factors for MRSA
UÊÊ i˜ÌÀ>ÊÛi˜œÕÃÊV>Ì iÌiÀʈ˜Ê«>Vi
UÊÊ"Ì iÀʈ˜`Üiˆ˜}Ê >À`Ü>ÀiÊ
UÊʘœÜ˜ÊVœœ˜ˆâ>̈œ˜ÊÜˆÌ Ê,-
UÊÊ,iVi˜ÌÊ­ÜˆÌ ˆ˜ÊÎʓœ˜Ì îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`Ê œÃ«ˆÌ>ˆâ>̈œ˜Ê>
2 weeks
UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}Ê œ“iʜÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ
UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi
TREATMENT NOTES
UÊʜÀÊ«>̈i˜ÌÃÊÜˆÌ ÊÀi˜>Êˆ˜ÃÕvwVˆi˜VÞʜÀÊ>“ˆ˜œ}ÞVœÃˆ`iʈ˜ÌœiÀ>˜Vi]Ê>Ê
beta-lactam may be combined with a fluoroquinolone IF 2 agents are
needed.
UÊÊ*œÌi˜Ìˆ>ÊÜÕÀViÃÊ­i°}°]Ê«˜iՓœ˜ˆ>]Ê«iÀˆÌœ˜ˆÌˆÃ]ÊiÌV°®Êà œÕ`ÊLiÊ
considered when selecting therapy.
UÊÊ “«ˆÀˆVÊÌ iÀ>«ÞʈÃÊ" 9Ê>««Àœ«Àˆ>ÌiÊÜ ˆiÊVՏÌÕÀiÃÊ>ÀiÊ«i˜`ˆ˜}Ê
(72 hours max).
UÊÊ6>˜Vœ“ÞVˆ˜Êà œÕ`Ê>“œÃÌÊ>Ü>ÞÃÊLiÊÃ̜««i`ʈvʘœÊÀiÈÃÌ>˜ÌÊÀ>“‡
positive organisms are recovered in cultures.
99
6.16 Skin, soft-tissue, and bone infections
Skin, soft-tissue, and bone infections
Cellulitis
UÊʏÜ>ÞÃÊiiÛ>ÌiÊ>vviVÌi`ÊiÝÌÀi“ˆÌÞ°Ê/Ài>̓i˜ÌÊv>ˆÕÀiʈÃʓœÀiÊ
commonly due to failure to elevate than failure of antibiotics.
UÊʓ«ÀœÛi“i˜ÌʜvÊiÀÞÌ i“>ÊV>˜ÊÌ>ŽiÊ`>ÞÃ]ÊiëiVˆ>Þʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê
lymphedema, because dead bacteria in the skin continue to induce
inflammation.
Non-suppurative cellulitis
Defined as cellulitis with intact skin and no evidence of purulent
drainage. Usually caused by beta-hemolytic streptococci (e.g. group A,
B, C, G streptococci) and MSSA.
TREATMENT
Oral (mild disease)
UʓœÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxÊ*"Ê+£Ó
OR
UÊ i« >i݈˜Êxääʓ}Ê*"Ê+È
OR
UÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÎääʓ}Ê*"Ê+n
Parenteral (moderate to severe disease)
Uʓ«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+È
OR
UÊ iv>✏ˆ˜Ê£Ê}Ê6Ê+n
OR
UÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+n
Duration: 5-7 days
TREATMENT NOTES
UʏÊLiÌ>‡ i“œÞ̈VÊÃÌÀi«ÌœVœVVˆÊ>ÀiÊÃÕÃVi«ÌˆLiÊ̜ʫi˜ˆVˆˆ˜
UÊÊ ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜ViʈÃÊÃii˜Êˆ˜Ê£È‡ÎίʜvÊ}ÀœÕ«Ê ]Ê ]Ê>˜`ÊÊÃÌÀi«Ê
LÕÌÊÀi“>ˆ˜ÃʏœÜʈ˜Ê}ÀœÕ«ÊÊÃÌÀi«Ê­{qǯ®
UÊ ÕÀ>̈œ˜\Êx‡ÇÊ`>ÞÃ
Suppurative cellulitis
Defined as cellulitis with purulent drainage or exudates in the absence of
a drainable abscess. Usually caused by S. aureus (MSSA and MRSA).
TREATMENT
Oral (mild disease)
UÊ/*É-8Ê£‡ÓÊ -ÊÌ>LÊ*"Ê OR
UÊ œÝÞVÞVˆ˜iÊ£ääʓ}Ê*"Ê Ê",ʈ˜œVÞVˆ˜iÊ£ääʓ}Ê*"Ê OR
UÊ ˆ˜`>“ÞVˆ˜ÊÎääʓ}Ê*"Ê+n
100
Parenteral (moderate to severe disease)
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
Duration: 5-7 days
TREATMENT NOTES
UÊÊ,iÈÃÌ>˜ViÊ̜Êy՜ÀœµÕˆ˜œœ˜iÃʈ˜ÊS. aureus is common and develops
µÕˆVŽÞÆÊʙx¯ÊœvÊ,-ʈ܏>ÌiÃÊ>ÀiÊÀiÈÃÌ>˜ÌÊ̜Êy՜ÀœµÕˆ˜œœ˜iðÊ
Monotherapy with fluoroquinolones for S. aureus infections is not
recommended.
UÊÊ,ˆv>“«ˆ˜Êà œÕ`Ê 6 ,ÊLiÊÕÃi`Ê>Ãʓœ˜œÌ iÀ>«ÞÊLiV>ÕÃiÊÀiÈÃÌ>˜ViÊ
develops rapidly.
UÊÊ/ iÀiʈÃʘœÊiۈ`i˜ViÊÌ >Ìʈ˜i✏ˆ`ʈÃÊÃÕ«iÀˆœÀÊ̜Ê/*É-8]Ê
Doxycycline, or Clindamycin in the management of skin infection or
osteomyelitis. Linezolid should only be considered when the S. aureus
isolate is resistant to or the patient is intolerant to these agents.
Less common causes of cellulitis
UÊÊ7ˆÌ ÊLՏ>i]ÊÛiÈViÃ]Ê>˜`ÊՏViÀÃÊ>vÌiÀÊiÝ«œÃÕÀiÊ̜ÊÃi>Ü>ÌiÀʜÀÊÀ>ÜÊ
oysters, consider Vibrio vulnificus, especially in patients with liver
disease. Rare, but rapidly fatal if untreated. Treat with Ceftriaxone
1 g IV Q24H PLUS Doxycycline 100 mg PO BID.
UÊÊ iÕÌÀœ«i˜ˆV]Ê܏ˆ`ʜÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê>˜`ÊVˆÀÀ œÌˆVÊ«>̈i˜ÌÃʓ>ÞÊ
have cellulitis due to Gram-negative organisms. Consider expanding
coverage in these cases.
UÊÊvÊiÃV >À]ÊVœ˜Ãˆ`iÀÊ>˜}ˆœˆ˜Û>ÈÛiʜÀ}>˜ˆÃ“ÃÊ­ ,]Ê>ëiÀ}ˆœÃˆÃ]ʓœ`®°Ê
ID consult is recommended.
UÊʘˆ“>Ê>˜`Ê Õ“>˜ÊLˆÌiÃ\ÊPasteurella multocida should be covered in
cat and dog bites. Treat with Amoxicillin/clavulanate 875 mg PO BID
",ʓ«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xqÎÊ}Ê6Ê+È°ÊvÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê
400 mg PO/IV Q24H.
Cutaneous abscess
UÊʘVˆÃˆœ˜Ê>˜`Ê`À>ˆ˜>}iÊ­E ®ÊˆÃÊÌ iÊ«Àˆ“>ÀÞÊÌÀi>̓i˜ÌÊvœÀÊ>ÊVÕÌ>˜iœÕÃÊ
abscess.
UÊÊiȜ˜ÃÊÌ >ÌÊ>««i>ÀÊÃÕ«iÀwVˆ>ÊV>˜ÊœvÌi˜Ê >ÛiÊ>ÃÜVˆ>Ìi`Ê>LÃViÃÃÊ
formation that is not clearly appreciated without debridement of the
wound or, on occasion, additional imaging.
UÊÊÌÊÌ iÊ̈“iʜvÊE ]Ê>ÊÃ>“«iÊà œÕ`ÊLiʜLÌ>ˆ˜i`ÊvœÀÊVՏÌÕÀiÊ>˜`Ê
sensitivity testing.
UÊʜÃÌÊÃÌÕ`ˆiÃÊÌ >ÌÊ >ÛiÊLii˜Ê«ÕLˆÃ i`Ê̜Ê`>ÌiÊÃÕ}}iÃÌÊÌ >ÌÊ>˜ÌˆLˆœÌˆVÃÊ
are adjunct to I&D in the management of uncomplicated skin
abscesses caused by CA-MRSA.
101
6.16 Skin, soft-tissue, and bone infections
OR
UÊ ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+nÊ­ˆvÊ«>Ài˜ÌiÀ>ÊÌ iÀ>«ÞʈÃʘii`i`®
6.16 Skin, soft-tissue, and bone infections
UÊʘ`ˆV>̈œ˜ÃÊvœÀÊ>˜Ìˆ“ˆVÀœLˆ>ÊÌ iÀ>«Þʈ˜Ê«>̈i˜ÌÃÊÜˆÌ ÊVÕÌ>˜iœÕÃÊ
>LÃViÃÃiÃ\
UÊÊ-iÛiÀiʜÀÊÀ>«ˆ`ÞÊ«Àœ}ÀiÃÈÛiʈ˜viV̈œ˜Ã
UÊÊ/ iÊ«ÀiÃi˜ViʜvÊiÝÌi˜ÃˆÛiÊ>ÃÜVˆ>Ìi`ÊViÕˆÌˆÃ
UÊ-ˆ}˜ÃÊ>˜`ÊÃޓ«Ìœ“ÃʜvÊÃÞÃÌi“ˆVʈ˜iÃÃ
UÊÃÜVˆ>Ìi`ÊÃi«ÌˆVÊ« iLˆÌˆÃ
UÊÊ ˆ>LiÌiÃʜÀÊœÌ iÀʈ““Õ˜iÊÃÕ««ÀiÃȜ˜
UÊ`Û>˜Vi`Ê>}i
UÊʜV>̈œ˜ÊœvÊÌ iÊ>LÃViÃÃʈ˜Ê>˜Ê>Ài>ÊÜ iÀiÊVœ“«iÌiÊ`À>ˆ˜>}iʈÃÊ
difficult (e.g. face, genitalia)
UÊÊ>VŽÊœvÊÀi뜘ÃiÊ̜ʈ˜VˆÃˆœ˜Ê>˜`Ê`À>ˆ˜>}iÊ>œ˜i
UÊÊ/ iÀ>«ÞÊà œÕ`ÊLiÊ}ˆÛi˜Êbefore incision and drainage in patients with
prosthetic heart valves or other conditions placing them at high risk
for endocarditis.
EMPIRIC TREATMENT
If antibiotic treatment is thought to be necessary, regimens are the
same as for suppurative cellulitis above.
Management of recurrent MRSA skin infections
1. Education regarding approaches to personal and hand
hygiene
UÊÊ*À>V̈ViÊvÀiµÕi˜ÌÊ >˜`Ê Þ}ˆi˜iÊÜˆÌ ÊÜ>«Ê>˜`ÊÜ>ÌiÀÊ>˜`ɜÀÊ
alcohol based hand gels, especially after touching infected skin or
wound bandages.
UÊÊ œÛiÀÊ`À>ˆ˜ˆ˜}Êܜ՘`ÃÊÜˆÌ ÊVi>˜]Ê`ÀÞÊL>˜`>}iÃ
UÊÊ œÊ˜œÌÊà >ÀiÊ«iÀܘ>ÊˆÌi“ÃÊ­i°}°ÊÀ>âœÀÃÆÊÕÃi`Ê̜ÜiÃÊ>˜`ÊVœÌ ˆ˜}Ê
before washing)
UÊÊ,i}Տ>ÀÊL>Ì ˆ˜}
UÊÊۜˆ`Ê>Êà >ۈ˜}Ê
UÊÊ>՘`iÀÊVœÌ ˆ˜}]Êà iiÌÃ]Ê̜ÜiÃʈ˜Ê œÌÌiÃÌÊÃՈÌ>LiÊÌi“«iÀ>ÌÕÀi
UÊÊ i>˜Ê>Ê«iÀܘ>ÊëœÀ̈˜}ÊVœÌ ˆ˜}ÉiµÕˆ«“i˜ÌÊ
2. Decontamination of the environment
UÊÊ i>˜Ê ˆ} Ê̜ÕV Ê>Ài>Ãʈ˜ÊÌ iÊL>Ì Àœœ“ÊÜˆÌ Ê>Ê`ˆÃˆ˜viVÌ>˜ÌÊ>V̈ÛiÊ
against S. aureusÊ`>ˆÞÊ­i°}°]Ê£ä¯Ê`ˆÕÌiÊLi>V ®°Ê
3. Topical decolonization (consider if a patient has ≥ 2 episodes
in 1 year or other household members develop infection)
UÊÊÕ«ˆÀœVˆ˜ÊÌ܈ViÊ`>ˆÞÊvœÀÊxÊ`>ÞÃʓ>ÞÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ
ÜˆÌ Ê`œVՓi˜Ìi`Êiۈ`i˜ViʜvÊ,-ʘ>Ã>ÊVœœ˜ˆâ>̈œ˜ÆÊ
Mupirocin therapy should be initiated after resolution of acute
infection. Mupirocin should not be used in patients or patients’
family members who are not documented to have MRSA nasal
colonization.
102
NOTE: Data on efficacy and durability of the decontamination and
decolonization strategies described above are limited.
,iviÀi˜ViÃ\
/*É-8ÊvœÀÊ,-\ʘ˜Ê˜ÌiÀ˜Êi`Ê£™™ÓÆ££Ç\Ιä‡n°
-ÊՈ`iˆ˜iÃÊvœÀÊÌÀi>̓i˜ÌʜvÊ,-ʈ˜viV̈œ˜Ã\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓ䣣ÆxÓ\£qÎn°Ê
̈œœ}ÞʜvÊÃÕ««ÕÀ>̈ÛiÊViÕˆÌˆÃ\Êi`ˆVˆ˜iÊÓä£äÆn™\Ó£ÇqÓÓÈ°
Diabetic foot infections
EMPIRIC TREATMENT
Treatment depends on clinical severity
Infection Severity
Uninfected
Mild
Clinical Manifestations
No purulence or inflammation*
Presence of purulence and 1 sign of inflammation*
and cellulitis (if present) 2 cm around ulcer limited to
skin or superficial subcutaneous tissue
Moderate
Same as mild PLUSÊ>Ìʏi>ÃÌʜ˜iʜvÊÌ iÊvœœÜˆ˜}\Ê 2
cm of cellulitis, lymphangitic streaking, spread beneath
the superficial fascia, deep tissue abscess, gangrene,
involvement of muscle, tendon, joint, or bone
Severe
Any of above PLUS systemic toxicity or metabolic
instability
*erythema, pain, tenderness, warmth, induration
MILD INFECTIONS
Oral regimens
UÊʓœÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê OR
UÊÊ i« >i݈˜Êxääʓ}Ê*"Ê+
OR
UÊÊ ˆ˜`>“ÞVˆ˜ÊÎääʓ}Ê*"Ê/ Ê­VœÛiÀÃÊ,-®
Parenteral regimens
UÊÊ ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+nÊ­VœÛiÀÃÊ,-®
OR
103
6.16 Skin, soft-tissue, and bone infections
UÊÊ >Ì ˆ˜}ʜÀÊà œÜiÀˆ˜}ÊÜˆÌ ÊV œÀ i݈`ˆ˜iʜÀÊ iÝ>V œÀœ« ˆ˜iÊ­œÀÊ
`ˆÕÌiÊLi>V ÊL>Ì Ã®ÊiÛiÀÞÊœÌ iÀÊ`>ÞÊvœÀÊ£ÊÜiiŽÊÌ i˜ÊÌ܈ViÊÜiiŽÞÆÊ
do not get these substances into ears or eyes
UÊÊ-ÞÃÌi“ˆVÊ>˜ÌˆLˆœÌˆVÃÊ>ÀiÊ "/ÊÀiVœ““i˜`i`Ê܏iÞÊvœÀÊ`iVœœ˜ˆâ>̈œ˜
4. Evaluation of other family members
UÊʘÌÀ>‡v>“ˆÞÊÌÀ>˜Ã“ˆÃȜ˜Êà œÕ`ÊLiÊ>ÃÃiÃÃi`Ê>˜`ʈvÊ«ÀiÃi˜Ì]Ê
all members should participate in hygiene and decolonization
strategies above, starting at that same time and after the acute
infection is controlled.
6.16 Skin, soft-tissue, and bone infections
UÊÊ"Ý>Vˆˆ˜Ê£‡ÓÊ}Ê6Ê+{
OR
UÊÊ iv>✏ˆ˜Ê£Ê}Ê6Ê+n
MODERATE INFECTIONS
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê+Ó{
OR
UÊÊQ ˆ«ÀœyœÝ>Vˆ˜IÊxääʓ}Ê*"Ê Ê",Ê ˆ«ÀœyœÝ>Vˆ˜IÊ{ääʓ}Ê6Ê+£ÓRÊ
PLUS ONEʜvÊÌ iÊvœœÜˆ˜}ÊQ ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+nÉÎääʓ}Ê*"Ê
/ Ê",ÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê6É*"Ê/ R
* BUT avoid fluoroquinolones in patients who were on them as
outpatients
If patient at risk for MRSA, add Vancomycin to regimens that do not
include Clindamycin.
Risk factors for MRSA
UÊʈÃ̜ÀÞʜvÊVœœ˜ˆâ>̈œ˜ÊœÀʈ˜viV̈œ˜ÊÜˆÌ Ê,-
UÊÊ,iVi˜ÌÊ­ÜˆÌ ˆ˜ÊÎʓœ˜Ì îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`Ê œÃ«ˆÌ>ˆâ>̈œ˜Ê€ÊÓÊ
weeks
UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}Ê œ“iʜÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ
UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi
SEVERE INFECTIONS
UÊÊ*ˆ«iÀVˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+È
OR
UÊÊQ ˆ«ÀœyœÝ>Vˆ˜IÊ{ääʓ}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS
Clindamycin 600 mg IV Q8H
* Avoid fluoroquinolones in patients who were on them as outpatients.
If patient at risk for MRSA (see above)
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+ÈÊPLUS Vancomycin (see dosing
section, p. 150)
OR
UÊÊQ ˆ«ÀœyœÝ>Vˆ˜IÊ{ääʓ}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS
Metronidazole 500 mg IV Q8H PLUS Vancomycin (see dosing section,
p. 150)
* Avoid fluoroquinolones in patients who were on them as outpatients
TREATMENT NOTES
Management
UÊÊʓՏ̈`ˆÃVˆ«ˆ˜>ÀÞÊ>««Àœ>V Ê̜ʓ>˜>}i“i˜ÌÊà œÕ`ʈ˜VÕ`iÊܜ՘`Ê
care consultation, assessment of vascular supply, vascular and/or
general surgery consultation and infectious diseases consultation.
UÊÊ œ˜Ãˆ`iÀʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃʈ˜Ê«>̈i˜ÌÃÊÜ œÊ>ÀiÊÃiÛiÀiÞʈ°
UÊʘ̈LˆœÌˆVÊÌ iÀ>«ÞÊà œÕ`ÊLiʘ>ÀÀœÜi`ÊL>Ãi`ʜ˜ÊVՏÌÕÀiÊÀiÃՏÌð
104
Diagnosis
UÊÊ ÕÌÕÀiÃʜvÊÌ iÊՏViÀÊL>ÃiÊ>vÌiÀÊ`iLÀˆ`i“i˜ÌÊV>˜Ê i«Ê}Ո`iÊÌ iÀ>«Þ°Ê
Biopsy of unexposed bone is NOT recommended. Avoid swabbing
non-debrided ulcers or wound drainage.
UÊÊ1ViÀÊyœœÀÊà œÕ`ÊLiÊ«ÀœLi`ÊV>ÀivՏÞ°ÊvÊLœ˜iÊV>˜ÊLiÊ̜ÕV i`ÊÜˆÌ Ê>Ê
metal probe then the patient should be treated for osteomyelitis with
antibiotics in addition to surgical debridement.
UÊÊ*>˜Ì>ÀÊv>ÃVˆˆÌˆÃÊ>˜`Ê>Ê`ii«ÊvœœÌ‡Ã«>Viʈ˜viV̈œ˜ÊV>˜ÊLiÊ«ÀiÃi˜Ì°Ê
Consider imaging to look for deep infections.
UÊÊ*ÕÌÀˆ`Ê`ˆÃV >À}iʈÃÊ`ˆ>}˜œÃ̈VʜvÊÌ iÊ«ÀiÃi˜ViʜvÊ>˜>iÀœLið
UÊÊÊ,ʈÃʓœÀiÊÃi˜ÃˆÌˆÛiÊ>˜`ÊëiVˆwVÊÌ >˜ÊœÌ iÀʓœ`>ˆÌˆiÃÊvœÀÊ`iÌiV̈œ˜Ê
of soft-tissue lesions and osteomyelitis.
Duration
UÊÊ ÕÀ>̈œ˜ÊœvÊÌÀi>̓i˜ÌÊ܈Ê`i«i˜`ʜ˜ÊÀ>«ˆ`ˆÌÞʜvÊÀi뜘ÃiÊ>˜`Ê
presence of adequate blood supply.
UÊʈŽiÞʘii`Êà œÀÌiÀÊÌÀi>̓i˜ÌÊÜˆÌ Ê>`iµÕ>ÌiÊÃÕÀ}ˆV>Êˆ˜ÌiÀÛi˜Ìˆœ˜Ê
­Çq£äÊ`>ÞÃÊ«œÃ̇œ«®Ê>˜`ʏœ˜}iÀÊvœÀʜÃÌiœ“ÞiˆÌˆÃ°
UÊÊ >˜}iÊ̜ʜÀ>ÊÀi}ˆ“i˜ÊÜ i˜Ê«>̈i˜ÌʈÃÊÃÌ>Li°
,iviÀi˜Vi\
-ÊՈ`iˆ˜iÃÊvœÀÊ`ˆ>LïVÊvœœÌʈ˜viV̈œ˜°Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£ÓÆx{\£ÎӇ£Çΰ
Surgical-site infections (SSI)
EMPIRIC TREATMENT
Infections following clean procedures (e.g. orthopedic joint
replacements, open reduction of closed fractures, vascular procedures,
median sternotomy, craniotomy, breast and hernia procedures)
UÊÊ"Ý>Vˆˆ˜Ê£qÓÊ}Ê6Ê+{
OR
UÊÊ iv>✏ˆ˜Ê£Ê}Ê6Ê+n
OR
105
6.16 Skin, soft-tissue, and bone infections
Microbiology
UÊÊ iÕˆÌˆÃÊÜˆÌ œÕÌʜ«i˜Êܜ՘`ʜÀʈ˜viVÌi`ÊՏViÀ]Ê>˜ÌˆLˆœÌˆVʘ>‹Ûi\Ê
beta-hemolytic streptococci, S. aureus
UÊʘviVÌi`ÊՏViÀ]ÊV Àœ˜ˆVʜÀÊ«ÀiۈœÕÏÞÊÌÀi>Ìi`ÊÜˆÌ Ê>˜ÌˆLˆœÌˆVÃ\ÊS. aureus,
beta-hemolytic streptococci, Enterobacteriaceae
UÊÊ Ý«œÃÕÀiÊ̜ÊÜ>Žˆ˜}]ÊÜ ˆÀ«œœ]Ê œÌÊÌÕL\ÊÕÃÕ>ÞÊ«œÞ“ˆVÀœLˆ>]ʓ>ÞÊ
involve Pseudomonas
UÊÊ Àœ˜ˆVÊܜ՘`ÃÊÜˆÌ Ê«Àœœ˜}i`ÊiÝ«œÃÕÀiÊ̜Ê>˜ÌˆLˆœÌˆVÃ\Ê>iÀœLˆVÊÀ>“‡
positive cocci (GPC), Diphtheroids, Enterobacteriaceae, other Gramnegative rods (GNR) including Pseudomonas
UÊÊ iVÀœÃˆÃʜÀÊ}>˜}Ài˜i\ʓˆÝi`Ê>iÀœLˆVÊ* Ê>˜`Ê ,]Ê>˜>iÀœLiÃ
6.16 Skin, soft-tissue, and bone infections
UÊÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+n
OR
UÊʘۜÛi“i˜ÌʜvÊ >À`Ü>ÀiʜÀÊ,-ÊÃÕëiVÌi`\Ê6>˜Vœ“ÞVˆ˜Ê
(see dosing section, p. 150)
Exception: Saphenous vein graft harvest site infections should be
treated with Ertapenem 1 g IV Q24H
Infections following contaminated procedures (GI/GU procedures,
oropharyngeal procedures, obstetrical and gynecology procedures)
Patients not on broad-spectrum antibiotics at time of surgery and
not severely ill
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ* Ê>iÀ}Þ\ÊQ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê Ê",Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê
6Ê+£ÓRÊPLUS Clindamycin 600 mg IV Q8H
Patients on broad-spectrum antibiotics at time of surgery or
severely ill
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+ÈÊ´Ê6>˜Vœ“ÞVˆ˜Ê
(see dosing section, p. 150) (if hardware present or MRSA suspected)
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
xääʓ}Ê6Ê+nÊ´Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}]Ê«°Ê£xä®Ê­ˆvÊ >À`Ü>ÀiÊ
present or MRSA suspected)
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Q ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS
Metronidazole 500 mg IV/PO Q8H
Deep fascia involvement
UÊÊ/Ài>ÌÊ>ÃʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃÊ­ÃiiÊÃÕLÃiµÕi˜ÌÊÃiV̈œ˜®
TREATMENT NOTES
Microbiology
UÊʜœÜˆ˜}ÊVi>˜Ê«ÀœVi`ÕÀiÃÊ­˜œÊi˜ÌÀÞʜvÊÉ1ÊÌÀ>VÌî
UÊÊStaphylococcus aureus
UÊÊ-ÌÀi«ÌœVœVVˆ]Ê}ÀœÕ«ÊÊ­iëiVˆ>ÞÊÜˆÌ Êi>ÀÞʜ˜ÃiÌ]ʐÊÇÓÊ œÕÀî
UÊÊ œ>}Տ>Ãi‡˜i}>̈ÛiÊÃÌ>« ޏœVœVVˆ
UÊʜœÜˆ˜}ÊVi>˜‡Vœ˜Ì>“ˆ˜>Ìi`Ê>˜`ÊVœ˜Ì>“ˆ˜>Ìi`Ê«ÀœVi`ÕÀiÃÊ­i˜ÌÀÞʜvÊ
GI/GU tracts with or without gross contamination)
UÊÊ"À}>˜ˆÃ“ÃÊ>LœÛi
UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`Ã
UÊʘ>iÀœLiÃÊ­Vœ˜Ãˆ`iÀÊClostridiaÊ뫰ʈ˜Êi>ÀÞ‡œ˜ÃiÌʈ˜viV̈œ˜]Ê£qÓÊ
days)
106
Other management issues
UÊÊ>˜ÞÊ>`ۜV>ÌiÊÌ >ÌÊʈ˜viVÌi`Êܜ՘`ÃÊLiÊiÝ«œÀi`ÊLœÌ Ê̜Ê`iLÀˆ`iÊ
and to assess depth of involvement.
UÊÊ-Õ«iÀwVˆ>Êˆ˜viV̈œ˜Ãʓ>ÞÊLiÊ>`iµÕ>ÌiÞÊÌÀi>Ìi`ÊÜˆÌ Ê`iLÀˆ`i“i˜ÌÊ
alone.
UÊÊ ii«iÀʈ˜viV̈œ˜ÃÊ­ViÕˆÌˆÃ]Ê«>˜˜ˆVՏˆÌˆÃ®Ê˜ii`Ê>`Õ˜V̈ÛiÊ>˜ÌˆLˆœÌˆVð
UÊʘviV̈œ˜ÃÊÌ >ÌÊiÝÌi˜`Ê̜ÊÌ iÊv>ÃVˆ>Êà œÕ`ÊLiʓ>˜>}i`Ê>ÃʘiVÀœÌˆâˆ˜}Ê
fasciitis.
UÊÊ*>̈i˜ÌÃÊÜˆÌ Ê Þ«œÌi˜Ãˆœ˜Êà œÕ`Ê >ÛiÊÌ iˆÀÊܜ՘`ÃÊiÝ«œÀi`ÊiÛi˜ÊˆvÊ
they are unremarkable on physical exam.
Serious, deep-tissue infections (necrotizing fasciitis)
THESE ARE SURGICAL EMERGENCIES!
ANTIBIOTICS ARE ONLY AN ADJUNCT TO PROMPT
DEBRIDEMENT!
ID should also be consulted
EMPIRIC TREATMENT (adjunct to surgery)
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUSÊQ*ˆ«iÀ>Vˆˆ˜ÉÊ
Ì>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+ÈÊ",Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nRÊPLUS
Clindamycin 600-900 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Q ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nÊ´Êi˜Ì>“ˆVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê
«°Ê£{È®RÊPLUS Clindamycin 600-900 mg IV Q8H
TREATMENT NOTES
Conventional nomenclature and microbiology
Pyomyositis
UÊÊS. aureus most commonly
UÊÊ œÃÌÀˆ`ˆ>Ê“Þœ˜iVÀœÃˆÃÊqÊClostridia spp. (esp. C. perfringens)
UÊÊÀœÕ«ÊÊÃÌÀi«ÌœVœVV>Ê“Þœ˜iVÀœÃˆÃ
107
6.16 Skin, soft-tissue, and bone infections
UÊÊi˜iÀ>Þ]Êi“«ˆÀˆVÊÕÃiʜvÊ6>˜Vœ“ÞVˆ˜ÊˆÃʘœÌʈ˜`ˆV>Ìi`ÊLiV>ÕÃiÊÌ iÊ
percentage of SSIs caused by MRSA is low at Johns Hopkins Hospital
­£äqÓ䯮
Risk factors for MRSA
UʈÃ̜ÀÞʜvÊVœœ˜ˆâ>̈œ˜ÊœÀʈ˜viV̈œ˜ÊÜˆÌ Ê,-
UÊÊ,iVi˜ÌÊ­ÜˆÌ ˆ˜ÊÎʓœ˜Ì îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`Ê œÃ«ˆÌ>ˆâ>̈œ˜Ê€ÓÊ
weeks
UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}Ê œ“iʜÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ
UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi
6.16 Skin, soft-tissue, and bone infections
Fasciitis
UÊÊ/Þ«iÊ£ÊqÊ*œÞ“ˆVÀœLˆ>Êˆ˜viV̈œ˜ÃÊÜˆÌ Ê>˜>iÀœLiÃ]ÊÃÌÀi«ÌœVœVVˆÊ>˜`Ê
Gram-negative rods (Fournier’s gangrene is a type 1 necrotizing
fasciitis of the perineum)
UÊÊ/Þ«iÊÓÊqÊÀœÕ«ÊÊÃÌÀi«ÌœVœVVˆÊ«Ài`œ“ˆ˜>Ìi
UÊÊ >ÃiÃʜvÊv>ÃVˆˆÌˆÃÊV>ÕÃi`ÊLÞÊVœ““Õ˜ˆÌއ>ÃÜVˆ>Ìi`Ê,-ÊÃÌÀ>ˆ˜ÃÊ >ÛiÊ
been reported
Diagnosis
UÊÊ >˜ÊLiÊ`ˆvwVՏÌÊqÊ}>ÃÊ«Àœ`ÕV̈œ˜ÊˆÃʘœÌÊ՘ˆÛiÀÃ>Ê>˜`ʈÃÊ}i˜iÀ>ÞÊ
absent in streptococcal diseases.
UÊÊ>ˆ˜Ì>ˆ˜Ê ˆ} ʈ˜`iÝʜvÊÃÕëˆVˆœ˜ÊÜ i˜\
UÊÊ*>̈i˜ÌÃÊ>ÀiÊÛiÀÞʈÊvÀœ“ÊViÕˆÌˆÃÊ­ Þ«œÌi˜Ãˆœ˜]Ê̜݈VÊ>««i>À>˜Vi®
UÊÊ*>ˆ˜ÊœÕÌʜvÊ«Àœ«œÀ̈œ˜Ê̜ʫ ÞÈV>Êw˜`ˆ˜}Ã
UÊʘiÃÌ iÈ>ʜÛiÀÊ>vviVÌi`Ê>Ài>
UÊÊ,ˆÃŽÊv>V̜ÀÃÊÃÕV Ê>ÃÊ`ˆ>LiÌiÃ]ÊÀiVi˜ÌÊÃÕÀ}iÀÞʜÀʜLiÈÌÞ
UÊʈ˜`ˆ˜}ÃÊÃÕV Ê>ÃÊΈ˜Ê˜iVÀœÃˆÃʜÀÊLՏ>i
UÊÊ*ÕÌÀˆ`Ê`ˆÃV >À}iÊÜˆÌ ÊÌ ˆ˜]ʺ`ˆÃ Ü>ÌiÀ»Ê«ÕÃ
UÊÊ /ÊÃV>˜ÊV>˜Ê i«ÊÜˆÌ Ê`ˆ>}˜œÃˆÃÊLÕÌʈvÊÃÕëˆVˆœ˜ÊˆÃʓœ`iÀ>ÌiÊÌœÊ ˆ} ]Ê
surgical exploration is the preferred diagnostic test. DO NOT delay
surgical intervention to obtain CT.
,iviÀi˜Vi\
-Ê}Ո`iˆ˜iÃÊvœÀÊ--/\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓääxÆÊ{£\£ÎÇÎq{äÈ°
Vertebral osteomyelitis, diskitis, epidural abscess
NOTE: In absence of bacteremia, clinical instability, or signs and
symptoms of spinal cord compromise strong consideration should be
given to withholding antibiotics until samples of abscess or bone can be
obtained for Gram-stain and culture.
EMPIRIC TREATMENT
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê±ÊQ ivÌÀˆ>ݜ˜iÊÓÊ}Ê+£ÓÊOR
ivi«ˆ“iÊÓÊ}Ê6Ê+nRÊ
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê±
Ciprofloxacin 400 mg IV Q8H
UÊ >ÀÀœÜÊÌ iÀ>«ÞÊL>Ãi`ʜ˜ÊVՏÌÕÀiÊÀiÃՏÌð
TREATMENT NOTES
Microbiology
UÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊˆ˜ÊÇx¯ÊœvÊV>ÃiÃÊÜˆÌ Ê“>œÀˆÌÞÊS. aureus
UÊÀ>“‡˜i}>̈ÛiÊÀœ`Ãʈ˜ÊH£ä¯
108
Duration
UÊ «ˆ`ÕÀ>Ê>LÃViÃÃÊÜˆÌ œÕÌʜÃÌiœ“ÞiˆÌˆÃ\Ê{qÈÊÜiiŽÃÊ
UÊ6iÀÌiLÀ>ÊœÃÌiœ“ÞiˆÌˆÃʱÊi«ˆ`ÕÀ>Ê>LÃViÃÃ\ÊÈq£ÓÊÜiiŽÃÊ
UÊʘʫ>̈i˜ÌÃÊÜˆÌ Ê >À`Ü>ÀiÊ«ÀiÃi˜ÌÊ«Àœœ˜}i`ʜÀ>ÊÃÕ««ÀiÃÈÛiÊÌ iÀ>«ÞÊ
ˆÃÊ}i˜iÀ>ÞÊÀiµÕˆÀi`Ê>vÌiÀÊVœ“«ïœ˜ÊœvÊ6Ê>˜ÌˆLˆœÌˆVÃÆÊÌ iÃiÊ`iVˆÃˆœ˜ÃÊ
should be made in consultation with infectious diseases.
,iviÀi˜ViÃ\Ê
-«ˆ˜>Êi«ˆ`ÕÀ>Ê>LÃViÃÃ\Ê Ê ˜}ÊÊi`ÊÓääÈÆÎxx\Óä£ÓqÓä°Ê
-«ˆ˜>Êi«ˆ`ÕÀ>Ê>LÃViÃÃ\Ê+ÊÊi`ÊÓäänÆ£ä£\£q£Ó°Ê
109
6.16 Skin, soft-tissue, and bone infections
Management
UÊÊ"LÌ>ˆ˜ÊÌܜÊÃiÌÃʜvÊLœœ`ÊVՏÌÕÀiÃ]Ê -,]Ê>˜`Ê ,*Ê«ÀˆœÀÊ̜ÊÃÌ>À̈˜}Ê
antibiotic therapy.
UÊʜÃÌʈ˜ÌÀ>Ûi˜œÕÃÊ`ÀÕ}ÊÕÃiÀÃÊ>˜`Ê«>̈i˜ÌÃÊÜˆÌ œÕÌÊÈ}˜ˆwV>˜ÌÊ
co-morbidities do not require empiric coverage for Gram-negative
rods.
UÊÊ “«ˆÀˆVÊÀ>“‡˜i}>̈ÛiÊVœÛiÀ>}iÊà œÕ`ÊLiÊÕÃi`ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê`ˆ>LiÌiÃ]Ê
hardware in place or recent surgery, and recurrent urinary tract infections.
UÊ,ÊÜˆÌ ÊVœ˜ÌÀ>ÃÌʈÃÊÌ iʈ“>}ˆ˜}ʓiÌ œ`ʜvÊV œˆVi°
UÊÊvÊLœœ`ÊVՏÌÕÀiÃÊ>Àiʘi}>̈ÛiÊ /Ê}Ո`i`ʘii`iÊLˆœ«ÃÞÉ>ëˆÀ>̈œ˜Ê
should be obtained for Gram stain and cultures.
UÊÊ “iÀ}i˜ÌÊÃÕÀ}ˆV>ÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ Ê
signs and symptoms of spinal cord compromise.
UÊÊ-ÕÀ}ˆV>ÊÌ iÀ>«ÞʈÃÊ«ÀiviÀÀi`ʈ˜Ê“>˜ÞÊV>ÃiÃʜvÊi«ˆ`ÕÀ>Ê>LÃViÃÃÉÊ
osteomyelitis (e.g. extensive infection, pre-vertebral abscess, spine
instability, hardware involvement). CT-guided aspiration and/or
antibiotic therapy alone may be considered in some circumstances.
Discussion with infectious diseases and surgery is recommended to
optimize management.
UÊÊ*>̈i˜ÌÃÊà œÕ`Ê >ÛiÊvÀiµÕi˜ÌÊ>ÃÃiÃÓi˜ÌʜvʘiÕÀœœ}ˆVÊv՘V̈œ˜]Ê
particularly at the time of initial presentation.
UÊʏÊ«>̈i˜ÌÃÊÀiµÕˆÀiʓœ˜ˆÌœÀˆ˜}ÊvœÀÊ>`iµÕ>ÌiÊÀi뜘ÃiÊÌ ÀœÕ} œÕÌÊÌ iÊ
ÌÀi>̓i˜ÌÊVœÕÀÃiÆÊ ÊvœœÜÊÕ«Ê ˆ} ÞÊÀiVœ““i˜`i`°Ê
110
Bacterial urinary tract infections (UTI)
Empiric treatment
œÊÌÀi>̓i˜ÌÊ՘iÃÃÊÌ iÊ«>̈i˜ÌʈÃ\
UÊ*Ài}˜>˜ÌÊ
UÊÊLœÕÌÊ̜Ê՘`iÀ}œÊ>ÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÊ
UÊ*œÃÌÊÀi˜>ÊÌÀ>˜Ã«>˜Ì
UÊ iÕÌÀœ«i˜ˆV
1˜Vœ“«ˆV>Ìi`\
UÊÊ ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­>VÀœLˆ`®) 100 mg PO Q12H for
xÊ`>ÞÃÊ­ "/ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê À ÊxäʓÉ“ˆ˜®
OR
UÊÊ i« >i݈˜Êxääʓ}Ê*"Ê+ÈÊvœÀÊxÊ`>ÞÃÊ
OR
UÊÊ iv«œ`œÝˆ“iÊ£ääʓ}Ê*"Ê+£ÓÊvœÀÊxÊ`>ÞÃÊ
OR
UÊÊ iv`ˆ˜ˆÀÊÎääʓ}Ê*"Ê+£ÓÊvœÀÊxÊ`>ÞÃÊ
OR
UÊÊÊ/*É-8Ê£Ê -ÊÌ>LÊ*"Ê+£ÓÊvœÀÊÎÊ`>ÞÃ
OR
UÊÊ6ʜ«Ìˆœ˜\Ê iv>✏ˆ˜Ê£Ê}Ê6Ê+nÊvœÀÊÎÊ`>ÞÃ
œ“«ˆV>Ìi`\
UÊÊ->“iÊÀi}ˆ“i˜ÃÊ>ÃÊ>LœÛiÊiÝVi«ÌÊ`ÕÀ>̈œ˜ÊˆÃÊ
Çq£{Ê`>ÞÃ
Definition
Positive urine culture 100,000 CFU/mL
with no signs or symptoms
Signs and symptoms (e.g. dysuria, urgency
frequency, suprapubic pain)
AND pyuria (>10 WBC/hpf )
AND positive urine culture 100,000
CFU/mL
UÊÊUncomplicated: female, no urologic
abnormalities, no stones, no catheter
UÊÊComplicated: male gender, possible
stones, urologic abnormalities, pregnancy
Category
Asymptomatic
bacteriuria
Acute cystitis
UÊÊ1/Ãʈ˜Ê“i˜Ê>ÀiÊÌÀ>`ˆÌˆœ˜>ÞÊVœ˜Ãˆ`iÀi`ÊVœ“«ˆV>Ìi`°Ê
UTIs in men in the absence of obstructive pathology
(e.g. BPH, stones, strictures) are uncommon. Please
critically evaluate your diagnosis of UTI in male patients.
UÊÊ"À>ÊÌ iÀ>«ÞʈÃÊ«ÀiviÀÀi`Ê>˜`Êà œÕ`ÊLiÊ}ˆÛi˜Ê՘iÃÃÊ
patient is unable to tolerate oral therapy
UÊÊvÊ6ÊLiÌ>‡>VÌ>“ÃÊ>ÀiÊÕÃi`Êi“«ˆÀˆV>ÞÊvœÀÊÎÊ`>ÞÃ]ʘœÊ
additional therapy is needed for uncomplicated cystitis
UÊÊvÊ6ÊLiÌ>‡>VÌ>“ÃÊ>ÀiÊÕÃi`Êi“«ˆÀˆV>ÞÊvœÀʐÎÊ`>ÞÃÊ
or treating complicated cystitis, the patient can be
switched to an appropriate oral beta-lactam and duration
of IV therapy should be counted towards total duration
of therapy
UÊÊ"À>ÊœÃvœ“ÞVˆ˜ÊV>˜ÊLiÊÕÃi`ʈvÊÃÕÃVi«ÌˆLiÊvœÀÊÀ>“‡
negative MDR organisms (susceptibilities must be
requested)
Notes
UÊÊ"LÌ>ˆ˜ˆ˜}ÊÀœṎ˜iÊVՏÌÕÀiÃʈ˜Ê>Ãޓ«Ìœ“>̈VÊ«>̈i˜ÌÃʈÃÊ
not recommended
UÊʘ̈LˆœÌˆVÃÊ`œÊ˜œÌÊ`iVÀi>ÃiÊ>Ãޓ«Ìœ“>̈VÊL>VÌiÀˆÕÀˆ>ʜÀÊ
prevent subsequent development of UTIs
UÊÊÊ/ iÊ«ÀiÛ>i˜ViʜvÊ>Ãޓ«Ìœ“>̈VÊL>VÌiÀˆÕÀˆ>ʈÃÊ
ˆ} \Ê£¯‡x¯Êˆ˜Ê«Ài“i˜œ«>ÕÃ>Êܜ“i˜]Êί‡™¯Êˆ˜Ê
«œÃ̓i˜œ«>ÕÃ>Êܜ“i˜]Ê{䯇xä¯Êˆ˜Êœ˜}‡ÌiÀ“ÊV>ÀiÊ
ÀiÈ`i˜ÌÃÊ>˜`ʙ¯‡Óǯʈ˜Êܜ“i˜ÊÜˆÌ Ê`ˆ>LiÌið
NOTE: Ciprofloxacin is not recommended for empiric treatment for in-patients with non-catheter associated UTI at JHH due to the low rate of E. coli
ÃÕÃVi«ÌˆLˆˆÌÞÊ­Ç£¯®°Ê
Management of patients WITHOUT a urinary catheter
6.17 Urinary tract infections
111
Definition
Signs and symptoms (e.g. fever, flank pain)
AND pyuria
AND positive urine culture 100,000
CFU/mL
Many patients will have other evidence of
upper tract disease (i.e. leukocytosis,
WBC casts, or abnormalities upon imaging)
SIRS with urinary source of infection
Category
Acute
pyelonephritis
Urosepsis
Empiric treatment
UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{Ê­ˆvÊ ˆÃ̜ÀÞʜvÊ - ®
OR
UÊÊ* Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ",Ê
Gentamicin (see dosing section, p. 147)
UÊÊ ÕÀ>̈œ˜\ÊÇq£{Ê`>ÞÃ
Hospitalized > 48H
UÊÊ ivi«ˆ“iÊ£Ê}Ê6Ê+n
OR
UÊÊ* Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ",Ê
Gentamicin (see dosing section, p. 147)
UÊ ÕÀ>̈œ˜\ÊÇq£{Ê`>ÞÃ
UÊÊ ivi«ˆ“iÊ£Ê}Ê6Ê+n
OR
UÊÊ* Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ´Ê
Gentamicin (see dosing section, p. 147)
UÊ ÕÀ>̈œ˜\ÊÇq£äÊ`>ÞÃ
6.17 Urinary tract infections
UÊÊ"À>Ê ˆ«ÀœyœÝ>Vˆ˜ÊœÀÊ/*É-8Ê >ÛiÊiÝVii˜ÌÊ
bioavailability and should be used as step-down therapy
if organism is susceptible
UÊÊ"À>ÊLiÌ>‡>VÌ>“ÃÊà œÕ`ʘœÌÊLiÊÕÃi`ÊvœÀÊL>VÌiÀi“ˆ>Ê
due to inadequate blood concentrations
UÊÊ ÕÀ>̈œ˜ÊœvÊi“«ˆÀˆVÊ6ÊÌ iÀ>«ÞÊà œÕ`ÊLiÊVœÕ˜Ìi`Ê
towards total duration of therapy
Notes
UÊÊ"À>ÊÃÌi«‡`œÜ˜ÊÌ iÀ>«ÞÊà œÕ`ÊLiÊÕÃi`ʈvʜÀ}>˜ˆÃ“ʈÃÊ
susceptible
UÊÊ ÕÀ>̈œ˜ÊœvÊi“«ˆÀˆVÊ6ÊÌ iÀ>«ÞÊà œÕ`ÊLiÊVœÕ˜Ìi`Ê
towards total duration of therapy
"À>ÊÃÌi«‡`œÜ˜ÊÌ iÀ>«ÞʈvʜÀ}>˜ˆÃ“ʈÃÊÃÕÃVi«ÌˆLi\
UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê+£ÓÊvœÀÊÇÊ`>ÞÃÊ
UÊ/*É-8Ê£Ê -Ê*"Ê+£ÓÊvœÀÊLJ£äÊ`>ÞÃÊ
UÊ iv«œ`œÝˆ“iÊ{ääʓ}Ê*"Ê+£ÓÊvœÀÊ£{Ê`>ÞÃÊ
UÊÊ"À>ÊœÃvœ“ÞVˆ˜ÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈvÊÃÕÃVi«ÌˆLiÊvœÀÊ
Gram-negative MDR organisms (susceptibilities must be
requested). Consult ID Pharmacist for dosing.
6.17 Urinary tract infections
DIAGNOSIS
Specimen collection\Ê/ iÊÕÀiÌ À>Ê>Ài>Êà œÕ`ÊLiÊVi>˜i`ÊÜˆÌ Ê>˜Ê
antiseptic cloth and the urine sample should be collected midstream
or obtained by fresh catheterization. Specimens collected using
a drainage bag or taken from a collection hat are not reliable and
should not be sent.
Interpretation of the urinalysis (U/A) and urine culture
UÊÊ1Àˆ˜>ÞÈÃÊ>˜`ÊÕÀˆ˜iÊVՏÌÕÀiÃʓÕÃÌÊLiʈ˜ÌiÀ«ÀiÌi`Ê̜}iÌ iÀʈ˜Ê
context of symptoms
UÊUrinalysis/microscopy:
UÊÊ ˆ«Ã̈VŽ
UÊ ˆÌÀˆÌiÃʈ˜`ˆV>ÌiÊL>VÌiÀˆ>ʈ˜ÊÌ iÊÕÀˆ˜i
UÊiՎœVÞÌiÊiÃÌiÀ>Ãiʈ˜`ˆV>ÌiÃÊÜ ˆÌiÊLœœ`ÊViÃʈ˜ÊÌ iÊÕÀˆ˜i
UÊÊ >VÌiÀˆ>\Ê«ÀiÃi˜ViʜvÊL>VÌiÀˆ>ʜ˜ÊÕÀˆ˜>ÞÈÃÊà œÕ`ÊLiÊ
interpreted with caution and is not generally useful
UÊÊ*ÞÕÀˆ>Ê­“œÀiÊÃi˜ÃˆÌˆÛiÊÌ >˜ÊiՎœVÞÌiÊiÃÌiÀ>Ãi®\ʀ£äÊ7 É «vʜÀÊ
>27 WBC/microliter
UÊ1Àˆ˜iÊVՏÌÕÀiÃ\
UÊÊvÊ1ÉʈÃʘi}>̈ÛiÊvœÀÊ«ÞÕÀˆ>]Ê«œÃˆÌˆÛiÊVՏÌÕÀiÃÊ>ÀiʏˆŽiÞÊ
contamination
UÊʜÃÌÊ«>̈i˜ÌÃÊÜˆÌ Ê1/Ê܈Ê >ÛiÊ100,000 colonies of a
uropathogen. Situations in which lower colony counts may be
È}˜ˆwV>˜Ìʈ˜VÕ`i\Ê«>̈i˜ÌÃÊÜ œÊ>ÀiÊ>Ài>`Þʜ˜Ê>˜ÌˆLˆœÌˆVÃÊ>ÌÊÌ iÊ
time of culture, symptomatic young women, suprapubic aspiration,
and men with pyuria.
TREATMENT NOTES
UÊÊ*ÞÕÀˆ>ÊiˆÌ iÀʈ˜ÊÌ iÊÃiÌ̈˜}ʜvʘi}>̈ÛiÊÕÀˆ˜iÊVՏÌÕÀiÃʜÀʈ˜Ê«>̈i˜ÌÃÊ
with asymptomatic bacteriuria usually requires no treatment. If
pyuria persists consider other causes (e.g. interstitial nephritis or
cystitis, fastidious organisms).
UÊʜœÜ‡Õ«ÊÕÀˆ˜iÊVՏÌÕÀiÃʜÀÊ1ÉÊ>Àiʜ˜ÞÊÜ>ÀÀ>˜Ìi`ÊvœÀʜ˜}œˆ˜}Ê
symptoms. They should NOT be acquired routinely to monitor
response to therapy.
UÊÊ-iiÊ«°Ê££{ÊvœÀÊ`ˆÃVÕÃȜ˜ÊœvÊÌÀi>̓i˜Ìʜ«Ìˆœ˜ÃÊvœÀÊ6, Ê>˜`ÊÀi˜>Ê
concentrations of antibiotics.
112
Category
Asymptomatic
bacteriuria
Definition
Positive urine culture
100,000 CFU/mL
with no signs or
symptoms of infection
Empiric treatment
Remove the catheter
œÊÌÀi>̓i˜ÌÊ՘iÃÃÊÌ iÊ«>̈i˜ÌʈÃ\
UÊ*Ài}˜>˜ÌÊ
UÊLœÕÌÊ̜Ê՘`iÀ}œÊ>ÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÊ
UÊ*œÃÌÊÀi˜>ÊÌÀ>˜Ã«>˜Ì
"/ \ʜLÌ>ˆ˜ˆ˜}Ê
UÊ iÕÌÀœ«i˜ˆV
routine cultures in
Antibiotics do not decrease asymptomatic
asymptomatic patients bacteriuria or prevent subsequent development
is not recommended
of UTI
Signs and symptoms
CatheterUÊÊ,i“œÛiÊV>Ì iÌiÀÊÜ i˜Ê«œÃÈLi
associated UTI (fever with no other
Patient stable with no evidence of upper tract
source is the most
(CA-UTI)
`ˆÃi>Ãi\
Vœ““œ˜ÆÊ«>̈i˜ÌÃʓ>ÞÊ UÊÊvÊV>Ì iÌiÀÊÀi“œÛi`]ÊVœ˜Ãˆ`iÀʜLÃiÀÛ>̈œ˜Ê>œ˜i
also have suprapubic
OR
or flank pain)
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
AND pyuria (10
OR
WBC/hpf)
UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{
AND positive urine
OR
culture 1,000
UÊÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê ÊœÀÊ{ääʓ}Ê6Ê+£ÓÊ
CFU/mL (see
(avoid in pregnancy and in patients with prior
information below
exposure to quinolones)
regarding significant
UÊ ÕÀ>̈œ˜\ÊÃiiÊLiœÜ
colony counts)
Patient severely ill, with evidence of upper tract
disease, or hospitalized {nÊ\
UÊÊ ivi«ˆ“iÊ£Ê}Ê6Ê+nÊ
OR
UÊ* Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+n
UÊ ÕÀ>̈œ˜\ÊÃiiÊLiœÜ
Urosepsis in a SIRS with urinary
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxʓ}Ê6Ê+È
source and
patient with
If prior urine culture data are available, tailor
nephrostomy tubes
nephrostomy
therapy based on those results
tubes
DIAGNOSIS
-«iVˆ“i˜ÊVœiV̈œ˜\ The urine sample should be drawn from the
catheter port using aseptic technique, NOT from the urine collection
bag. In patients with long term catheters ( 2 weeks), replace the
catheter before collecting a specimen. Urine should be collected before
antibiotics are started.
-ޓ«Ìœ“Ã\ Catheterized patients usually lack typical UTI symptoms.
-ޓ«Ìœ“ÃÊVœ“«>̈LiÊÜˆÌ Ê ‡1/ʈ˜VÕ`i\
UÊÊ iÜÊviÛiÀʜÀÊÀˆ}œÀÃÊÜˆÌ Ê˜œÊœÌ iÀÊÜÕÀVi
UÊÊ iÜʜ˜ÃiÌÊ`iˆÀˆÕ“]ʓ>>ˆÃi]ʏiÌ >À}ÞÊÜˆÌ Ê˜œÊœÌ iÀÊÜÕÀVi
UÊÊ 6ÊÌi˜`iÀ˜iÃÃ]Êy>˜ŽÊ«>ˆ˜]Ê«iÛˆVÊ`ˆÃVœ“vœÀÌ
UÊÊVÕÌiÊ i“>ÌÕÀˆ>
Interpretation of the urinalysis (U/A) and urine culture
UÊÊ*ÞÕÀˆ>\ʘÊÌ iÊ«ÀiÃi˜ViʜvÊ>ÊV>Ì iÌiÀ]Ê«ÞÕÀˆ>Ê`œiÃʘœÌÊVœÀÀi>ÌiÊÜˆÌ Ê
the presence of symptomatic CA-UTI and must be interpreted based
on the clinical scenario. The absence of pyuria suggests an alternative
diagnosis.
UÊÊ*œÃˆÌˆÛiÊÕÀˆ˜iÊVՏÌÕÀi\Ê 1,000 colonies
113
6.17 Urinary tract infections
Management of patients WITH a urinary catheter
6.17 Urinary tract infections
DURATION
The duration of treatment has not been well studied for CA-UTI and
optimal duration is not known.
UÊÊÇÊ`>ÞÃʈvÊ«Àœ“«ÌÊÀi܏Ṏœ˜ÊœvÊÃޓ«Ìœ“Ã
UÊÊ£äq£{Ê`>ÞÃʈvÊ`i>Þi`ÊÀi뜘Ãi
UÊÊÎÊ`>ÞÃʈvÊV>Ì iÌiÀÊÀi“œÛi`ʈ˜Êvi“>iÊ«>̈i˜ÌÊ 65 years with lower
tract infection.
TREATMENT NOTES
UÊÊ,i“œÛiÊÌ iÊV>Ì iÌiÀÊÜ i˜iÛiÀÊ«œÃÈLi
UÊÊ,i«>ViÊV>Ì iÌiÀÃÊÌ >ÌÊ >ÛiÊLii˜Êˆ˜Ê 2 weeks if still indicated
UÊÊ*Àœ« ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊ>ÌÊÌ iÊ̈“iʜvÊV>Ì iÌiÀÊÀi“œÛ>ÊœÀÊÀi«>Vi“i˜ÌÊ
are NOT recommended due to low incidence of complications and
concern for development of resistance.
UÊÊ >Ì iÌiÀʈÀÀˆ}>̈œ˜Êà œÕ`ʘœÌÊLiÊÕÃi`ÊÀœṎ˜iÞ
Treatment of Enterococci
UÊÊʏ“œÃÌÊ>ÊE. faecalis isolates are susceptible to Amoxicillin 500 mg
PO TID OR Ampicillin 1 g IV Q6H and should be treated with these
>}i˜ÌðʜÀÊ«>̈i˜ÌÃÊÜˆÌ Ê* Ê>iÀ}Þ\Ê ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­Ê>VÀœLˆ`®)
£ääʓ}Ê*"Ê+£ÓÊ­`œÊ "/ÊÕÃiʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê À ÊÊxäʓɓˆ˜®°Ê
UÊE. faecium (often Vancomycin resistant)
UÊÊ ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­>VÀœLˆ`®) 100 mg PO Q12H if susceptible (do NOT
use in patients with CrCl 50 mL/min).
UÊ/iÌÀ>VÞVˆ˜iÊxääʓ}Ê*"Ê+ÈʈvÊÃÕÃVi«ÌˆLi
UÊʜÃvœ“ÞVˆ˜ÊÎÊ}Ê*"ʜ˜ViÊ­ˆvÊvi“>iÊÜˆÌ œÕÌÊV>Ì iÌiÀʜÀÊV>Ì iÌiÀÊ
ˆÃÊÀi“œÛi`ÆÊ>ÎÊÌ iʓˆVÀœÊ>LÊvœÀÊÃÕÃVi«ÌˆLˆˆÌÞ®
UÊʈ˜i✏ˆ`ÊÈääʓ}Ê*"Ê Ê",ʜÃvœ“ÞVˆ˜ÊÎÊ}Ê*"ÊiÛiÀÞÊÓqÎÊ`>ÞÃÊ
(max 21 days) if complicated UTI or catheter can not be removed
Renal excretion/concentration of selected antibiotics
Good (≥60%): aminoglycosides, Amoxicillin, Amoxicillin/clavulanate,
Fosfomycin, Cefazolin, Cefepime, Cephelexin, Ciprofloxacin,
Colistin, Ertapenem, Trimethoprim/sulfamethoxazole, Vancomycin,
Amphotericin B, Fluconazole, Flucytosine
Variable (30-60%):Ê iv«œ`œÝˆ“i]ʈ˜i✏ˆ`Ê­Î䯮]Ê œÝÞVÞVˆ˜iÊ
­Ó™qxx¯®]Ê ivÌÀˆ>ݜ˜i]Ê/iÌÀ>VÞVˆ˜iÊ­HÈ䯮ÊÊ
Poor (<30%): Azithromycin, Clindamycin, Moxifloxacin, Oxacillin,
Tigecycline, Micafungin, Posaconazole, Voriconazole
,iviÀi˜ViÃ\
*ÞÕÀˆ>Ê>˜`ÊÕÀˆ˜>ÀÞÊV>Ì iÌiÀÃ\ÊÀV ʘÌÊi`ÊÓäääÆ£Èä­x®\ÈÇ·ÇÇ°
IDSA Guidelines for treatment of uncomplicated acute bacterial cystitis and
«Þiœ˜i« ÀˆÌˆÃʈ˜Êܜ“i˜\Ê ˆ˜Ê˜viVÌÊ ˆÃÊ£™™™Æә\Ç{x°
-ÊՈ`iˆ˜iÃÊvœÀÊÌÀi>̓i˜ÌʜvÊ ‡1/\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£äÆxä\ÈÓxqÈΰ
114
Oropharyngeal disease (thrush)
Initial treatment
UÊÊ œÌÀˆ“>✏iÊ£äʓ}ÊÌÀœV iÊxÊ̈“iÃÊ>Ê`>Þ
OR
UÊ ÞÃÌ>̈˜ÊÃÕëi˜Ãˆœ˜Êxää]äääÊ՘ˆÌÃÉx“Ê{Ê̈“iÃÊ>Ê`>Þ
Recurrent or intractable disease
UʏÕVœ˜>✏iÊ£ääqÓääʓ}Ê*"ʜ˜ViÊ`>ˆÞ
Duration: xq£äÊ`>ÞÃ
NOTE: If refractory to Fluconazole consider fungal culture and
susceptibilities
Esophageal candidiasis
Initial treatment
UʏÕVœ˜>✏iÊÓääq{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
Duration: £{‡qÓ£Ê`>ÞÃ
Relapse
UÊʏÕVœ˜>✏iÊ{ääqnääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
Refractory to Fluconazole 800 mg daily (fungal culture and
susceptibilities are recommended)
UʈV>v՘}ˆ˜Ê£xäʓ}Ê6ʜ˜ViÊ`>ˆÞ
OR
Uʓ« œÌiÀˆVˆ˜Ê Êä°Îqä°Çʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞ
OR
UÊ"À>ÊÌ iÀ>«Þ\ÊÌÀ>Vœ˜>✏iʜÀ>Ê܏Ṏœ˜ÊÓääʓ}Ê`>ˆÞ
Duration: £{qÓ£Ê`>ÞÃ
Candiduria
UÊ1Àˆ˜>ÀÞÊV>Ì iÌiÀÊÀi“œÛ>Ê܈ÊÀi܏ÛiÊÌ iÊV>˜`ˆ`ÕÀˆ>ʈ˜Ê{ä¯ÊœvÊV>Ãið
TREATMENT
Asymptomatic cystitis
UÊ/ iÀ>«ÞʘœÌÊÕÃÕ>Þʈ˜`ˆV>Ìi`
UÊÊ œ˜Ãˆ`iÀʈ˜ÊÌ iÊvœœÜˆ˜}ÊVœ˜`ˆÌˆœ˜ÃÊ­ÃiiÊÀi}ˆ“i˜ÃÊ՘`iÀÊ
ºÃޓ«Ìœ“>̈VÊVÞÃ̈̈û®\
UÊ iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ
UÊ,i˜>ÊÌÀ>˜Ã«>˜Ì
UÊ1Àˆ˜>ÀÞʜLÃÌÀÕV̈œ˜ÊœÀÊ>L˜œÀ“>Ê1ÊÌÀ>VÌ
UÊ7 i˜ÊÀiVœÛiÀi`ʈ˜ÊÕÀˆ˜iÊ«ÀˆœÀÊ̜ÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÃ
115
6.18 Candidiasis in the non-neutropenic patient
Candidiasis in the non-neutropenic patient
6.18 Candidiasis in the non-neutropenic patient
Symptomatic cystitis
Preferred therapy
UÊʏÕVœ˜>✏iÊÓääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞÊ
Duration:ÊÇq£{Ê`>ÞÃ
Fluconazole-resistant organism suspected or confirmed
Uʓ« œÌiÀˆVˆ˜Ê Êä°Î‡ä°Èʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞÊ
Duration:Ê£qÇÊ`>ÞÃÊ
Pyelonephritis
NOTE: Candida pyelonephritis is usually secondary to hematogenous
spread except for patients with renal transplant or abnormalities of the
urogenital tract.
Preferred therapy
UʏÕVœ˜>✏iÊÓääq{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞÊ
Duration: 14 days
Fluconazole-resistant organism suspected or confirmed
Uʓ« œÌiÀˆVˆ˜Ê Êä°xqä°Çʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞÊ
OR
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞÊ
Duration: 14 days
TREATMENT NOTES
UÊ,i“œÛiÊÕÀˆ˜>ÀÞÊV>Ì iÌiÀʈvÊ«œÃÈLi°
UÊÊ/ iÀ>«ÞʜvÊV>˜`ˆ`ÕÀˆ>ʈ˜ÊÌ iʘœ˜‡˜iÕÌÀœ«i˜ˆV]ʘœ˜‡ 1ÊV>Ì iÌiÀˆâi`Ê
patient has not been shown to be beneficial and promotes resistance.
UÊʓ ˆÃœ“i®, Voriconazole, Itraconazole, and Posaconazole are not
recommended due to poor penetration into the urinary tract.
UÊʈV>v՘}ˆ˜Ê«i˜iÌÀ>ÌiÃÊ«œœÀÞʈ˜ÊÌ iÊÕÀˆ˜i]ÊLÕÌÊ`œiÃÊ«i˜iÌÀ>Ìiʈ˜ÌœÊ
renal tissue.
Uʓ« œÌiÀˆVˆ˜Ê ÊL>``iÀÊÜ>à iÃÊ>ÀiʘœÌÊÀiVœ““i˜`i`°
Candida vaginitis
Initial Therapy
UʏÕVœ˜>✏iÊ£xäʓ}Ê*"Ê8Ê£Ê`œÃiÊ
OR
UʈVœ˜>✏iÊÓ¯ÊVÀi>“ÊxÊ}ʈ˜ÌÀ>Û>}ˆ˜>Þʜ˜ViÊ`>ˆÞÊ8ÊÇÊ`>ÞÃ
Recurrent (> 4 episodes/year of symptomatic infection)
UÊʏÕVœ˜>✏iÊ£xäʓ}Ê*"Ê+ÇÓÊ8ÊÎÊ`œÃiÃ]ÊÌ i˜Ê£xäʓ}Ê>ÊÜiiŽÊ8Ê
6 months
116
UÊÊ9 -/Ê ÊÊ "" Ê 1/1, Ê-"1 Ê "/Ê Ê " - , ÊÊ
CONTAMINANT.
NOTE: Micafungin does not have activity against Cryptococcus
TREATMENT
Unspeciated candidemia
Patients who are clinically stable and have not received prior long-term
azole therapy
UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞÊ
If the yeast is C. albicans or C. glabrata based on PNA FISH results,
follow the recommendations for C. albicans or C. glabrata noted below.
Otherwise, await speciation before modifying therapy as recommended
below, unless the patient becomes clinically unstable on Fluconazole.
Candida albicans
UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞÊ
Patients should be transitioned to Fluconazole once stable.
Candida glabrata
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞ
OR
UÊʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞÊÊ
the isolate is susceptible with MIC 8 mcg/mL and the patient is stable.
If isolate is intermediate to Fluconazole and oral therapy is desired,
consult ID. Other azoles such as Voriconazole should not be used in
Fluconazole-resistant strains due to the same mechanism of resistance.
Candida krusei
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞÊ
Fluconazole should NEVER be used to treat infections due to C. krusei
because the organism has intrinsic resistance to Fluconazole. This
“iV >˜ˆÃ“ÊœvÊÀiÈÃÌ>˜ViʈÃʘœÌÊà >Ài`ÊÜˆÌ Ê6œÀˆVœ˜>✏iÆÊÌ iÀivœÀi]Ê
oral Voriconazole can be used if isolate is susceptible (for dosing see
Voriconazole specific guidelines, p. 19).
117
6.18 Candidiasis in the non-neutropenic patient
Candidemia
6.18 Candidiasis in the non-neutropenic patient
Candida lusitaniae
UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
C. lusitaniaeʈÃÊÀiÈÃÌ>˜ÌÊ̜ʓ« œÌiÀˆVˆ˜Ê ʈ˜Ê>««ÀœÝˆ“>ÌiÞÊÓä¯ÊœvÊ
cases.
Candida parapsilosis
UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
Fluconazole-intermediate isolate
UʏÕVœ˜>✏iÊnääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
Fluconazole-resistant isolate
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞ
If the patient is not responding to Micafungin then consider changing
to Amphotericin B. The minimum inhibitory concentrations (MICs) of
echinocandins are higher for C. parapsilosis than any other Candida
spp.ÆÊÌ ˆÃÊ >Ãʏi`Ê̜ÊVœ˜ViÀ˜ÊÌ >ÌÊܓiʈ˜viV̈œ˜ÃÊÜˆÌ ÊC. parapsilosis
may not respond well to echinocandins.
Candida tropicalis
UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
Fluconazole-intermediate isolate
UʏÕVœ˜>✏iÊnääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ
Fluconazole-resistant isolate
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞ
TREATMENT NOTES
Amphotericin B use in Candidemia
UÊʓ« œÌiÀˆVˆ˜Ê ʈÃÊ ˆ} ÞÊivviV̈ÛiÊ>}>ˆ˜ÃÌÊ>ÊCandida spp. except
for C. lusitaniaeÆÊ œÜiÛiÀ]Ê>✏iÃÊ>˜`ÊiV ˆ˜œV>˜`ˆ˜ÃÊ>ÀiÊv>ۜÀi`ʈ˜Ê
susceptible strains over Amphotericin B products due to toxicity.
Doses for Candidemia
Uʓ« œÌiÀˆVˆ˜Ê Êä°Çʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞ
OR
UÊʓ ˆÃœ“i® 3 mg/kg IV once daily (if patient cannot tolerate
conventional Amphotericin B)
Duration
UÊÊ£{Ê`>ÞÃÊvœœÜˆ˜}Ê`œVՓi˜Ìi`ÊVi>À>˜ViʜvÊLœœ`ÊVՏÌÕÀiÃÊ>˜`ÊVˆ˜ˆV>Ê
symptoms
UÊÊ*>̈i˜ÌÃÊÜˆÌ Ê«iÀÈÃÌi˜ÌÊV>˜`ˆ`i“ˆ>Ê>˜`ɜÀʓiÌ>ÃÌ>̈VÊVœ“«ˆV>̈œ˜ÃÊ
(e.g. endophthalmitis, endocarditis) need a longer duration of therapy
and evaluation by Ophthalmology and ID.
118
6.18 Candidiasis in the non-neutropenic patient
Ê
Hidden Content
- JHH Internal use only
Non-pharmacologic management
UÊÊ,i“œÛ>ÊœvÊ>Êi݈Ã̈˜}ÊVi˜ÌÀ>ÊÛi˜œÕÃÊV>Ì iÌiÀÃʈÃÊ ˆ} ÞÊ
recommended.
UÊÊ*>̈i˜ÌÃÊà œÕ`Ê >ÛiÊLœœ`ÊVՏÌÕÀiÃÊ`>ˆÞʜÀÊiÛiÀÞÊœÌ iÀÊ`>ÞÊ՘̈Ê
candidemia is cleared.
UÊÊ*>̈i˜ÌÃÊà œÕ`Ê >ÛiÊ>˜Êœ« Ì >“œœ}ˆVÊiÝ>“ˆ˜>̈œ˜Ê̜ÊiÝVÕ`iÊ
candidal endophthalmitis prior to discharge, preferably once the
candidemia is controlled.
UÊÊ V œV>À`ˆœ}À>« ÞÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈvÊÌ iÊ«>̈i˜ÌÊ >ÃÊ«iÀÈÃÌi˜ÌÊ
candidemia on appropriate therapy.
Endophthalmitis
UÊ>˜>}i“i˜Ìʈ˜ÊVœ˜Õ˜V̈œ˜ÊÜˆÌ Ê"« Ì >“œœ}Þ
UÊÊ ÕiÊ̜ʫœœÀÊ -Ê>˜`ÊۈÌÀi>Ê«i˜iÌÀ>̈œ˜]ÊÌÀi>̓i˜ÌÊÜˆÌ ÊiV ˆ˜œV>˜`ˆ˜ÃÊ
is NOT recommended.
Preferred therapy
Uʓ« œÌiÀˆVˆ˜Ê ʣʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxʓ}Ɏ}Ê*"Ê+È
OR
Uʓ ˆÃœ“i®Êxʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxʓ}Ɏ}Ê*"Ê+È
Alternate therapy
UÊʏÕVœ˜>✏iÊ{ää‡nääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxʓ}Ɏ}Ê
PO Q6H
Duration: {qÈÊÜiiŽÃ
Endocarditis
Consultation with ID and Cardiac Surgery is recommended. Surgical
valve replacement is considered a critical component for cure. If
the patient is not a candidate for surgery then life-long Fluconazole
suppression is likely required.
119
6.18 Candidiasis in the non-neutropenic patient
Preferred therapy
Uʓ ˆÃœ“iÁÊxʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞ
Alternative therapy
UÊʈV>v՘}ˆ˜Ê£xäʓ}Ê6ʜ˜ViÊ`>ˆÞʴʏÕVœ˜>✏iÊ{ääqnääʓ}Ê6É*"Ê
once daily
Duration: 6 weeks or longer
Notes on antifungal susceptibility testing
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀʏÕVœ˜>✏i]ÊÌÀ>Vœ˜>✏i]Ê6œÀˆVœ˜>✏i]Ê
Flucytosine, and Micafungin is performed routinely on the first yeast
isolate recovered from blood.
UÊʏÕVœ˜>✏iÊ>˜`ʈV>v՘}ˆ˜ÊÃÕÃVi«ÌˆLˆˆÌÞÊ>ÀiÊÀi«œÀÌi`ʜ˜Ê>ÊˆÃœ>Ìið
UÊÊ"À}>˜ˆÃ“ÃÊÌ >ÌÊ >ÛiʈV>v՘}ˆ˜Ê Ãʈ˜ÊÌ iÊÀ>˜}iʜvÊ£qÓʓV}ɓÊ
(reported as susceptible) may not respond to treatment. ID consult is
recommended in these cases.
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀÊVœ˜Ûi˜Ìˆœ˜>Ê“« œÌiÀˆVˆ˜Ê ʈÃÊ`œ˜iÊÀœṎ˜iÞÊ
for C. lusitaniae and C. guillermondii, and for other organisms by
request.
UÊÊvÊÌ iʜÀ}>˜ˆÃ“ʈÃʈ˜ÌiÀ“i`ˆ>ÌiÊ­®Ê̜ʏÕVœ˜>✏i]ÊÌ i˜Ênääʓ}Ê6É
PO once daily can be used. This choice is NOT recommended in an
immunocompromised patient, in a patient who is clinically unstable
due to candidemia, or in patients with endocarditis, meningitis or
endophthalmitis.
UÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}Êà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊÜ i˜\
UÊÕVœVÕÌ>˜iœÕÃÊV>˜`ˆ`ˆ>ÈÃʈÃÊÀivÀ>V̜ÀÞÊ̜ʏÕVœ˜>✏i
UÊÊ/Ài>̈˜}ʜÃÌiœ“ÞiˆÌˆÃ]ʓi˜ˆ˜}ˆÌˆÃ]ʜÀÊi˜`œ« Ì >“ˆÌˆÃÊÜˆÌ Ê
Fluconazole
UÊ œœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«iÀÈÃÌi˜ÌÞÊ«œÃˆÌˆÛiʜ˜ÊÕVœ˜>✏i
UÊÊ œ˜‡ÀœṎ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊV>˜ÊLiÊ>ÀÀ>˜}i`ÊLÞÊV>ˆ˜}ÊÌ iÊ
mycology lab at 5-6148
Notes on Fluconazole prophylaxis
UÊʏÕVœ˜>✏iÊ«Àœ« ޏ>݈ÃÊà œÕ`ÊLiʏˆ“ˆÌi`Ê̜ÊÌ iÊvœœÜˆ˜}ÊÃiÌ̈˜}Ã
UÊÊ*>̈i˜ÌÃÊiÝ«iVÌi`Ê̜ÊÀi“>ˆ˜Êˆ˜ÊÌ iÊSICU or WICU for ≥ 72 hours
­ ÀˆÌiÀˆ>ÊvÀœ“Êœ«Žˆ˜ÃÊ- 1Ê«Àœ« ޏ>݈ÃÊÃÌÕ`ÞÆÊ«Àœ« ޏ>݈Ãʈ˜ÊœÌ iÀÊ
ICUs has NOT been studied and is NOT recommended).
UÊÊ iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ՘`iÀ}œˆ˜}ÊLœ˜iʓ>ÀÀœÜÊÌÀ>˜Ã«>˜Ì>̈œ˜ÊœÀÊ
treatment for leukemia/lymphoma
UÊÊ*>̈i˜ÌÃÊÜ œÊ>ÀiÊ«œÃ̇œ«ÊvÀœ“ʏˆÛiÀʜÀÊ«>˜VÀi>ÃÊÌÀ>˜Ã«>˜Ìð
UÊʏÕVœ˜>✏iÊ«Àœ« ޏ>݈ÃÊà œÕ`ÊLiÊÃ̜««i`ÊÜ i˜Ê- 1ʜÀÊ7 1Ê
patients are transferred to the floor
,iviÀi˜ViÃ\
-ÊՈ`iˆ˜iÃÊvœÀÊ/Ài>̓i˜ÌʜvÊ >˜`ˆ`ˆ>ÈÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓää™Æ{n\xä·xÎx°
ÕVœ˜>✏iÊ«Àœ« ޏ>݈Ãʈ˜ÊÃÕÀ}ˆV>Ê«>̈i˜ÌÃ\ʘ˜Ê-ÕÀ}ÊÓää£ÆÓÎÎ\x{Óqn°
120
œÀÊëiVˆwVÊ«ÀœVi`ÕÀiÃÊ>˜`Ê>}i˜ÌÃÊÃiiʺ*iÀˆ‡œ«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÊ
«Àœ« ޏ>݈ÃÊ`œVՓi˜Ì»Ê>ÌÊÜÜÜ°ˆ˜Ãˆ`i œ«Žˆ˜Ã“i`ˆVˆ˜i°œÀ}É>“«
Drug
iv>✏ˆ˜Ê
ivœÌiÌ>˜Ê
Clindamycin
Ciprofloxacin
Gentamicin
Metronidazole
6>˜Vœ“ÞVˆ˜Ê
Ê
Ê
Usual dose
Ê£Óäʎ}\ÊÓÊ}Ê
≥Ê£Óäʎ}\ÊÎÊ}Ê
Ê£Óäʎ}\ÊÓÊ}Ê
≥Ê£Óäʎ}\ÊÎÊ}
600 mg
400 mg
5 mg/kg
500 mg
ÊÇäʎ}\Ê£Ê}Ê
Ç£‡™™ÊŽ}\Ê£°ÓxÊ}
€Ê£ääʎ}\Ê£°xÊ}
Redosing during procedure
+{Ê­+ÓÊvœÀÊV>À`ˆ>VÊÃÕÀ}iÀÞ®
+{Ê­+ÓÊvœÀÊV>À`ˆ>VÊÃÕÀ}iÀÞ®
+È
Q6H
None
None
None
+£Ó
Important notes
UÊÊ/ˆ“ˆ˜}ʈÃÊVÀÕVˆ>°Ê˜ÌˆLˆœÌˆVÃʓÕÃÌÊLiʈ˜ÊÌ iÊΈ˜ÊÜ i˜ÊÌ iÊ
incision is made to be effective.
UÊÊ i« >œÃ«œÀˆ˜ÃÊV>˜ÊLiÊ>`“ˆ˜ˆÃÌiÀi`ʜÛiÀÊÎqxʓˆ˜Ê6Ê«Õà ʍÕÃÌÊLivœÀiÊ
the procedure and will achieve appropriate skin levels in minutes.
Vancomycin and Ciprofloxacin must be given over 60 min. Clindamycin
à œÕ`ÊLiʈ˜vÕÃi`ʜÛiÀÊ£äqÓäʓˆ˜°Ê
UÊʜÀÊ>˜ÌˆLˆœÌˆVÃÊÜˆÌ Êœ˜}iÀʈ˜vÕȜ˜Ê̈“iÃÊ­i°}°Ê6>˜Vœ“ÞVˆ˜]Ê
Ciprofloxacin) the infusion should start 30 minutes prior to incision
UÊÊPost-procedure doses are NOT needed (exceptions are noted
in table). Single doses pre-procedure have been as effective as
post-procedure doses in all studies.
UÊÊ*>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê«Ài‡œ«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÃÊ}i˜iÀ>ÞÊ`œÊ "/ʘii`Ê
additional antibiotics for endocarditis prophylaxis.
UÊÊ*Àœ« ޏ>݈ÃÊvœÀÊ«>̈i˜ÌÃÊ>Ài>`Þʜ˜Ê>˜ÌˆLˆœÌˆVÃ\
UÊʜÀÊ>˜ÌˆLˆœÌˆVÃÊœÌ iÀÊÌ >˜Ê6>˜Vœ“ÞVˆ˜\ʜ`ÊÃÌ>˜`ˆ˜}Ê`œÃiÊ՘̈Ê
1 hour before incision
UÊʜÀÊ6>˜Vœ“ÞVˆ˜\Ê,i`œÃiÊ>ÊvՏÊ`œÃiʈvÊnÊ œÕÀÃÊ >ÛiÊ«>ÃÃi`ÊȘViÊ
the last dose or a half dose if fewer than 8 hours have passed in
patient with normal renal function
UÊÊi˜Ì>“ˆVˆ˜Êà œÕ`ÊLiÊ}ˆÛi˜Ê>ÃÊ>ÊȘ}iÊ`œÃiʜvÊxʓ}Ɏ}Ê̜ʓ>݈“ˆâiÊ
tissue penetration and minimize toxicity.
UÊÊvʜ˜Ê`ˆ>ÞÈÃʜÀÊ À ÊÊÓäʓɓˆ˜]ÊÕÃiÊÓʓ}Ɏ}
UÊ œÊ˜œÌÊÀi`œÃi
UÊÊ1ÃiÊ>VÌÕ>ÊLœ`ÞÊÜiˆ} ÌÊ՘iÃÃÊ«>̈i˜ÌʈÃÊ≥ÊÓä¯ÊœÛiÀʈ`i>ÊLœ`ÞÊ
weight (see p. 145)
121
6.19 Guidelines for use of prophylactic antimicrobials
Pre-operative and pre-procedure antibiotic
prophylaxis
6.19 Guidelines for use of prophylactic antimicrobials
Procedure
Urologic surgery/procedures
Transrectal prostate biopsy1
Transurethral surgery (e.g. TURP, TURBT,
ureteroscopy, cystouretoscopy)
Lithotripsy
Nephrectomy or radical prostatectomy
Radical cystectomy, ileal conduit,
cystoprostatectomy or anterior exenteration
*i˜ˆiʜÀÊœÌ iÀÊ«ÀœÃÌ iÃiÃÊ
Cardiac surgery
Median sternotomy, heart transplant3
Median sternotomy, heart transplant with
previous VAD or MRSA colonization/infection3
Pacemaker or ICD insertion
Pacemaker or ICD insertion with MRSA
colonization/infection or generator exchange
VAD insertion
VAD insertion with MRSA colonization/infection
VAD insertion with open chest3
Lung transplant4
Prophylaxis
recommendations
PCN allergy
alternate prophylaxis
Cefazolin
Cefazolin
Ciprofloxacin OR Gentamicin2
Gentamicin2
Gentamicin2
Clindamycin
Clindamycin PLUS
Gentamicin2
Q iv>✏ˆ˜Ê",Ê6>˜Vœ“ÞVˆ˜RÊÊQ ˆ˜`>“ÞVˆ˜Ê",Ê6>˜Vœ“ÞVˆ˜R
PLUS Gentamicin2
PLUS Gentamicin2
Cefazolin
Cefazolin
Cefotetan
Cefazolin
Cefazolin PLUS
Vancomycin
Cefazolin
Cefazolin PLUS
Vancomycin
Cefazolin
Cefazolin PLUS
Vancomycin
Cefazolin PLUS
Vancomycin
Cefepime
Vascular surgery
Carotid and brachiocephalic procedures
Prophylaxis not
without prosthetic grafts
recommended
Upper extremity procedures with prosthetic
Cefazolin
grafts and lower extremity procedures
L`œ“ˆ˜>Ê>œÀÌ>Ê«ÀœVi`ÕÀiʜÀÊ}Àœˆ˜Êˆ˜VˆÃˆœ˜ÊÊ
ivœÌiÌ>˜ÊÊ
Thoracic surgery
Lobectomy, pneumonectomy, lung resection, Cefazolin
thoracotomy, VATS
Esophageal cases
Cefotetan
Neurosurgery
Craniotomy, cerebrospinal fluid-shunting
procedures, implantation of intrathecal pumps
Laminectomy
Spinal fusion
Spinal fusion with MRSA colonization/infection
Vancomycin
Vancomycin
Clindamycin OR Vancomycin
Vancomycin
Vancomycin
Vancomycin
Vancomycin PLUS
Ciprofloxacin
Consult transplant ID
Prophylaxis not
recommended
Clindamycin OR Vancomycin
6>˜Vœ“ÞVˆ˜Ê³Êi˜Ì>“ˆVˆ˜2
Clindamycin
Clindamycin
Cefazolin
Clindamycin
Clindamycin
Clindamycin OR Vancomycin
Vancomycin
Transsphenoidal procedures
Cefazolin
Cefazolin
Cefazolin PLUS
Vancomycin
Ceftriaxone
Orthopedic surgery
Clean operations involving hand, knee, or
foot, arthroscopy
Total joint replacement
Total joint replacement with MRSA
colonization/infection
Open reduction of fracture/internal fixation
Lower limb amputation
Prophylaxis not
recommended
Cefazolin
Cefazolin PLUS
Vancomycin
Cefazolin
Cefotetan
Prophylaxis not
recommended
Vancomycin
Vancomycin
Spinal fusion
Cefazolin
Spinal fusion with MRSA colonization/infection Cefazolin PLUS
Vancomycin
Laminectomy
Cefazolin
122
Moxifloxacin 400 mg
Clindamycin OR Vancomycin
Clindamycin PLUS
Gentamicin2
Clindamycin OR Vancomycin
Vancomycin
Clindamycin
Prophylaxis
recommendations
General surgery
*ÀœVi`ÕÀiÃʈ˜ÛœÛˆ˜}Êi˜ÌÀÞʈ˜ÌœÊÕ“i˜ÊœvÊÕ««iÀÊÊ ivœÌiÌ>˜Ê
GI tract, gastric bypass procedures,
pancreaticoduodenectomy, highly selective
vagotomy, Nissen fundoplication
ˆˆ>ÀÞÊÌÀ>VÌÊ«ÀœVi`ÕÀiÃÊ­i°}°ÊV œiVÞÃÌiV̜“Þ]ÊÊ ivœÌiÌ>˜Ê
choledochoenterostomy)
i«>ÌiV̜“ÞÊ
ivœÌiÌ>˜Ê
Whipple procedure or pancreatectomy
Cefotetan
Small bowel procedures
Cefotetan
* Ê
Appendectomy (if complicated or perforated,
treat as secondary peritonitis)
Colorectal procedures, penetrating abdominal
trauma
Inguinal hernia repair
œ“«ˆV>Ìi`]Êi“iÀ}i˜ÌʜÀÊÀi«i>Ìʈ˜}Ո˜>ÊÊ
hernia repair
Mastectomy
iv>✏ˆ˜Ê",Ê ivœÌiÌ>˜Ê
Cefotetan
Cefotetan
Cefazolin
ivœÌiÌ>˜Ê
PCN allergy
alternate prophylaxis
ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2
ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2
ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2
Clindamycin PLUS
Ciprofloxacin
Clindamycin PLUS
Gentamicin2
ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2
Clindamycin PLUS
Gentamicin2
Clindamycin PLUS
Gentamicin2
Clindamycin
ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2
Mastectomy with lymph node dissection
Prophylaxis not
recommended
Cefazolin
Prophylaxis not
recommended
Clindamycin PLUS
Gentamicin2
Gynecologic surgery
Cesarean delivery procedures
Cefazolin
Clindamycin PLUS
Gentamicin2
Clindamycin PLUS
Gentamicin2
Clindamycin PLUS
Gentamicin2
Clindamycin
Hysterectomy (vaginal or abdominal)
Cefazolin OR Cefotetan
Oncology procedures
Cefotetan
Repair of cystocele or rectocele
Cefazolin
Head and neck surgery
Parotidectomy, thyroidectomy, tonsillectomy
Prophylaxis not
recommended
Reconstructive procedure w/prosthesis
Cefazolin
placement
Adenoidectomy, rhinoplasty, tumor-debulking, Cefotetan OR Clindamycin
or mandibular fracture repair
Major neck dissection
Cefazolin
Plastic surgery
Clean with risk factors or clean-contaminated
Tissue expander insertion/implants/all flaps
Rhinoplasty
Prophylaxis not
recommended
Clindamycin
Clindamycin
Clindamycin
Cefazolin
Cefazolin
No prophylaxis OR
Cefazolin
Clindamycin
Clindamycin
No prophylaxis OR
Clindamycin
Abdominal transplant surgery
Pancreas or pancreas/kidney transplant
Cefotetan
Renal transplant/adult live donor
Liver transplant4
Cefazolin
Cefotetan
Clindamycin PLUS
Ciprofloxacin
Clindamycin
Clindamycin PLUS
Ciprofloxacin
1vÊ«Ài‡œ«ÊÀiVÌ>ÊÃVÀii˜Ê«iÀvœÀ“i`\ÊÃiiÊ«°Ê£Ó{Ê
2Do
not give additional doses of Gentamicin post-op for prophylaxis
open chest, continue antibiotic prophylaxis until closure
recommendations are for patients with no relevant microbiology data that would suggest
ÀiÈÃÌ>˜ÌʜÀ}>˜ˆÃ“ÃÆÊ«Àœ« ޏ>V̈VÊÀi}ˆ“i˜Êà œÕ`ÊLiÊÌ>ˆœÀi`ÊL>Ãi`ʜ˜ÊŽ˜œÜ˜Ê“ˆVÀœLˆœœ}ÞÊ`>Ì>ÊÜˆÌ Ê
assistance of transplant ID (page in PING)
3For
4Listed
123
6.19 Guidelines for use of prophylactic antimicrobials
Procedure
6.19 Guidelines for use of prophylactic antimicrobials
Procedure
Prophylaxis
recommendations
PCN allergy
alternate prophylaxis
Interventional radiology procedures
ˆˆ>ÀÞÉÆÊV i“œÊi“Lœˆâ>̈œ˜ÉÊÊ
ivœÌiÌ>˜ÊÊ
ˆ˜`>“ÞVˆ˜Ê
percutaneous liver ablation (hx. of
PLUS Gentamicin
Lˆˆ>ÀÞÊÃÕÀ}iÀÞɈ˜ÃÌÀՓi˜Ì>̈œ˜®ÆÊ
cecostomy
i“œÊi“Lœˆâ>̈œ˜ÆÊwLÀœˆ`ÉÕÀˆ˜iÊ
*Àœ« ޏ>݈ÃʘœÌÊ
>ÀÌiÀÞÊi“Lœˆâ>̈œ˜ÆÊ«iÀVÕÌ>˜iœÕÃÊÊ
ÀiVœ““i˜`i`
ˆÛiÀÉÀi˜>ÉÕ˜}IÊ>L>̈œ˜ÆÊÛ>ÃVՏ>ÀÊ
vascular malformation embolization†
Urologic procedure (not ablation)
Cefazolin
Gentamicin
Lymphangiogram/embolization
Cefazolin
Clindamycin
Placement of tunneled catheters
Prophylaxis not
­i°}°ÊVi˜ÌÀ>Êˆ˜i®ÆÊÛi˜œÕÃÉ>ÀÌiÀˆ>ÊÊ
ÀiVœ““i˜`i`
procedures.
Placement of implantable access
Cefazolin
Clindamycin
port (e.g. Mediport®)
*Pre-treatment w/ antibiotics can be considered for patients w/ COPD or h/o recurrent post-obstructive
pneumonia
† Lymphatic or patients w/ necrotic skin undergoing vascular graft should receive prophylaxis
w/Cefazolin
Prophylaxis for Prostate Biopsy Based on Rectal Screen Results
Pre-op prophylaxis regimen1
Post-op oral options2
Ciprofloxacin
susceptible
Ê
Ciprofloxacin 750 mg PO 2 hours
before procedure for any renal
v՘V̈œ˜ÊÊÊ
Ciprofloxacin 500 mg PO once
12 hours after the procedure. If GFR
ÎäʓÉ“ˆ˜Ê˜œÊ˜ii`ÊvœÀÊ«œÃ̇œ«Ê`œÃi°Ê
ˆ«ÀœyœÝ>Vˆ˜ÊÊ
ÀiÈÃÌ>˜Ì]Ê/*É-8Ê
susceptible
/*É-8Ê£Ê -Ê£Ê œÕÀÊLivœÀiÊÊ
«ÀœVi`ÕÀi]Ê>˜`Ê£Ê -ÊÎÊ œÕÀÃÊÊ
before
/*É-8Ê£Ê -Ê*"ʜ˜ViÊ£ÓÊ œÕÀÃÊ
>vÌiÀÊÌ iÊ«ÀœVi`ÕÀi°ÊvÊ,ʐÎäÊ
ml/min no need for post-op dose.
Ciprofloxacin and
/*É-8ÊÀiÈÃÌ>˜Ì]ÊÊ
Cefazolin susceptible
Cefazolin 2 g IV push (3-5 min)
ÜˆÌ ˆ˜Ê>˜Ê£Ê œÕÀʜvÊ«ÀœVi`ÕÀiÊ
Cefpodoxime 100 mg PO once
OR
Cefdinir 300 mg PO once
Ciprofloxacin,
/*É-8]ÊÊ
Cefazolin resistant
Gentamicin 5 mg/kg IV once over
Îä‡Èäʓˆ˜ÊÊ
OR
Ceftriaxone 1 g IV over 30 min if
susceptible
No need for additional doses as
i˜Ì>“ˆVˆ˜Ê>˜`Ê ivÌÀˆ>ݜ˜iÊÀiÌ>ˆ˜Ê
therapeutic levels for 24 hours
Other resistance
Call ID Pharmacist
patterns
1 All doses are for any renal function 2 Post-op antibiotics are not required by SCIP
124
NOTES:
UÊÊ*>̈i˜ÌÃÊÜ œÊ >ÛiÊÀiViˆÛi`Ê>˜ÌˆLˆœÌˆVÃÊvœÀÊÃÕÀ}ˆV>Ê«Àœ« ޏ>݈ÃÊ`œÊ˜œÌÊ
need additional prophylaxis for endocarditis.
Antibiotic prophylaxis solely to prevent endocarditis is not
recommended for GU or GI tract procedures.
Cardiac conditions associated with a high risk of endocarditis
for which prophylaxis is recommended prior to some dental and
respiratory tract procedures and procedures involving infected
skin or musculoskeletal tissue
UÊ*ÀœÃÌ ïVÊV>À`ˆ>VÊÛ>Ûi
UÊ*ÀiۈœÕÃÊi«ˆÃœ`iʜvʈ˜viV̈ÛiÊi˜`œV>À`ˆÌˆÃ
UÊ œ˜}i˜ˆÌ>Ê i>ÀÌÊ`ˆÃi>ÃiÊ­ ®
UÊÊÊ1˜Ài«>ˆÀi`ÊVÞ>˜œÌˆVÊ ]ʈ˜VÕ`ˆ˜}Ê«>ˆ>̈ÛiÊà ՘ÌÃÊ>˜`ÊVœ˜`ՈÌÃ
UÊÊ œ“«iÌiÞÊÀi«>ˆÀi`ÊVœ˜}i˜ˆÌ>Ê i>ÀÌÊ`iviVÌÊÜˆÌ Ê«ÀœÃÌ ïVÊ
material or device, whether placed by surgery or by catheter
intervention, during the first 6 months after the procedure
UÊÊ,i«>ˆÀi`Ê ÊÜˆÌ ÊÀiÈ`Õ>Ê`iviVÌÃÊ>ÌÊÌ iÊÈÌiʜÀÊ>`>Vi˜ÌÊ̜ÊÌ iÊ
site of a prosthetic patch or prosthetic device
UÊÊ >À`ˆ>VÊÌÀ>˜Ã«>˜Ì>̈œ˜ÊÀiVˆ«ˆi˜ÌÃÊÜ œÊ`iÛiœ«ÊV>À`ˆ>VÊÛ>ÛՏœ«>Ì Þ
Antibiotic prophylaxis is recommended for the following dental
procedures ONLY:
UÊ>˜ˆ«Õ>̈œ˜ÊœvÊ}ˆ˜}ˆÛ>Ê̈ÃÃÕiÃʜÀÊ«iÀˆ>«ˆV>ÊÀi}ˆœ˜ÊœvÊÌiiÌ
UÊ*iÀvœÀ>̈œ˜ÊœvʜÀ>Ê“ÕVœÃ>
Antibiotic prophylaxis is recommended for the following
respiratory tract procedures ONLY:
UʘVˆÃˆœ˜ÊœÀÊLˆœ«ÃÞʜvÊÌ iÊÀiëˆÀ>̜ÀÞʓÕVœÃ>
Antibiotic regimens
UʓœÝˆVˆˆ˜ÊÓÊ}Ê*"Ê£Ê œÕÀÊLivœÀiÊ«ÀœVi`ÕÀi
OR
UÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê*"Ê£Ê œÕÀÊLivœÀiÊ«ÀœVi`ÕÀi
OR
UÊ* Ê>iÀ}Þ\ÊâˆÌ Àœ“ÞVˆ˜Êxääʓ}Ê*"Ê£Ê œÕÀÊLivœÀiÊ«ÀœVi`ÕÀi
OR
UÊÊ*>̈i˜ÌÊ՘>LiÊ̜ÊÌ>ŽiʜÀ>Ê“i`ˆV>̈œ˜\ʓ«ˆVˆˆ˜ÊÓÊ}ÊÉ6Ê£Ê œÕÀÊ
before procedure OR Cefazolin 1 g IM/IV 5 minute push prior to
procedure
,iviÀi˜Vi\
ÊՈ`iˆ˜iÃÊvœÀÊ*ÀiÛi˜Ìˆœ˜ÊœvʘviV̈ÛiÊ ˜`œV>À`ˆÌˆÃ\Ê ˆÀVՏ>̈œ˜ÊÓääÇÆÊ££È\£ÇÎÈqx{°
125
6.19 Guidelines for use of prophylactic antimicrobials
Prophylaxis against bacterial endocarditis
6.19 Guidelines for use of prophylactic antimicrobials
Prophylactic antimicrobials for patients with
solid organ transplants
NOTE:ʏÊ`œÃiÃÊ>ÃÃՓiʘœÀ“>ÊÀi˜>Êv՘V̈œ˜ÆÊ`œÃiʓœ`ˆwV>̈œ˜Ãʓ>ÞÊLiʈ˜`ˆV>Ìi`ÊvœÀÊ
reduced CrCI.
Kidney, kidney-pancreas, pancreas transplants
Indication
Agent and dose
Duration
Anti-viral prophylaxis (CMV, HSV, VZV)
CMV D-/RAcyclovir 400 mg PO BID OR
Valacyclovir 500 mg PO BID
6Ê ³ÊœÀÊ ‡É,³Ê
6>}>˜VˆVœÛˆÀ† 450 mg PO daily
6Ê ³É,‡Ê
6>}>˜VˆVœÛˆÀ† 900 mg PO daily
3 months
3 months
6 months
Anti-fungal prophylaxis
Kidney
Clotrimazole troches 10 mg PO QID OR
Nystatin suspension 500,000 units QID
Pancreas and kidney
Fluconazole 400 mg PO daily
1 month‡
1 month
PCP prophylaxisÊ
Ê
Ê
ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ
-iVœ˜`ʏˆ˜i\Ê̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞ
/ ˆÀ`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊ",Ê
aerosolized Pentamidine
Èʓœ˜Ì Ã
Acute rejection treated with Thymoglobulin or Muromonab (OKT3)
Anti-viral prophylaxis (CMV, HSV, VZV)
CMV D-/RAcyclovir 400 mg PO BID OR
3 months
Valacyclovir 500 mg PO BID
3 months
6Ê ³ÊœÀÊ ‡É,³Ê
6>}>˜VˆVœÛˆÀ† 450 mg PO daily
3 months
6Ê ³É,‡Ê
6>}>˜VˆVœÛˆÀ† 900 mg PO daily
Anti-fungal prophylaxis Clotrimazole troches 10 mg PO QID
1 month
PCP prophylaxis
Ê
Ê
ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ
-iVœ˜`ʏˆ˜i\Ê̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞ
/ ˆÀ`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊ",
aerosolized Pentamadine
Èʓœ˜Ì Ã
Agent and dose
Duration
Liver transplants
Indication
Anti-viral prophylaxis (CMV, HSV, VZV)
CMV D-/RAcyclovir 400 mg PO BID OR
Valacyclovir 500 mg PO BID
6Ê ³ÊœÀÊ ‡É,³Ê
6>}>˜VˆVœÛˆÀ† 450 mg PO daily
6Ê ³É,‡Ê
6>}>˜VˆVœÛˆÀ† 900 mg PO daily,
followed by PCR monitoring
Anti-fungal prophylaxis Fluconazole 400 mg PO daily
PCP prophylaxisÊ
ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊÊ
Ê
ÌiÀ˜>̈ÛiÃ\Ê̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞÊ
or Dapsone 100 mg PO daily
126
3 months
3 months
6 months
6 weeks
£Óʓœ˜Ì Ã
Indication
Agent and dose
Anti-viral prophylaxis (CMV, HSV, VZV)
6Ê ‡É,‡Ê
œÊ«Àœ« ޏ>݈ÃÊ՘iÃÃÊ-6Ê}ʜÀÊ6<6Ê}ÊÊ
positive. If positive serology, Valacyclovir
500 mg PO BID
6Ê ³ÊœÀÊ ‡É,³Ê
6>}>˜VˆVœÛˆÀ† 900 mg PO daily
6Ê ³É,‡Ê
6>}>˜VˆVœÛˆÀ† 900 mg PO daily
Anti-fungal prophylaxis Nystatin suspension 500,000 units QID
PCP prophylaxisÊ
Ê
Ê
Ê
Duration
Îʓœ˜Ì Ã
3 months
6 months
Until
prednisone
dose ≤ 10
mg/d x 3
months
ˆÀÃÌʏˆ˜i\Ê/*É-8Ê--ʜ˜iÊÌ>LiÌÊ*"Ê`>ˆÞÊ",Ê £Óʓœ˜Ì Ã
Ê Ê /*É-8ʜ˜iÊ -ÊÌ>LiÌÊ*"ÊÌ ÀiiÊ̈“iÃÉÜiiŽÊ
-iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞ
/ ˆÀ`ʏˆ˜i\Ê̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞÊ
Toxoplasmosis prophylaxis
ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊÊ
£Óʓœ˜Ì Ã
/œÝœÊ,³Ê
Ê
-iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊPLUS
Pyrimethamine and Leucovorin
/œÝœÊ ³ÊœÀÊ՘Ž˜œÜ˜‡Ê
ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ
£Óʓœ˜Ì ÇÊ
Ê Ê `œ˜œÀÊÃÌ>ÌÕÃÊ
-iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊPLUS Lifelong
Pyrimethamine and Leucovorin
Lung transplants
Indication
Agent and dose
Duration
Anti-viral prophylaxis
CMV D-/RReceived
non-leukoreduced
or CMV unscreened
PRBCs
Ganciclovir 5 mg/kg IV Q12H x
14 days, then Ganciclovir 5 mg/kg IV
Q24H x 16 days, then Valacyclovir 500 mg
PO BID or Acyclovir 800 mg PO TID x 1 year
followed by Acyclovir 200 mg PO TID
Lifelong
CMV D-/RReceived leukoreduced
or CMV() PRBCs
Valacyclovir 500 mg PO BID or Acyclovir
Lifelong
800 mg PO TID x 1 year followed by Acyclovir
200 mg PO TID
6Ê ³ÊœÀÊ ‡É,³Ê
>˜VˆVœÛˆÀÊxʓ}Ɏ}Ê6Ê+£ÓÊÝÊ£{Ê`>ÞÃ]ÊÌ i˜ÊÊ ˆviœ˜}
Valganciclovir 900 mg PO daily x 3 months
(until CMV shell vial negative from 3 month
surveillance bronchoscopy), then Valacyclovir
500 mg po BID or Acyclovir 800 mg PO TID x
1 year, then Acyclovir 200 mg PO TID lifelong.
6Ê ³É,‡ÊÊÊ
>˜VˆVœÛˆÀÊxʓ}Ɏ}Ê6Ê+£Ó ÊÝÊ£{Ê`>ÞÃ]ÊÌ i˜ÊÊ ˆviœ˜}
Ganciclovir 5 mg/kg IV daily x 3 months, then
Valganciclovir 900 mg PO daily (until CMV shell
127
6.19 Guidelines for use of prophylactic antimicrobials
Heart transplants
6.19 Guidelines for use of prophylactic antimicrobials
vial negative from 6 month surveillance BAL),
then Valacyclovir 500 mg PO BID or Acyclovir
800 mg PO TID x 1 year, then Acyclovir 200 mg
PO TID lifelong.
Anti-fungal prophylaxis
No Aspergillus
Inhaled Amphotericin B per protocol
colonization
Ê
AspergillusÊVœœ˜ˆâ>̈œ˜Ê
PCP prophylaxisÊ
Ê
Ê
Ê
ÞÃÌ>̈˜Êxää]äääÊ՘ˆÌÃÊ Ê+ÈÊ՘̈ÊÊÊ
extubated, then Clotrimazole troches
10 mg PO Q6H until prednisone dose
10 mg daily
6œÀˆVœ˜>✏iÊ­`œÃi`ÊLÞÊÜiˆ} Ì®ÊÊÊ
Êșʎ}\Ê6œÀˆVœ˜>✏iÊÓääʓ}Ê*"Ê 69 kg to ʙ{ʎ}\Ê6œÀˆVœ˜>✏i
300 mg PO BID
ʙ{ʎ}\Ê6œÀˆVœ˜>✏iÊ{ääʓ}Ê*"Ê ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ -ÊÌ>LiÌÊ*"ÊÊ
Ê Ê Ì ÀiiÊ̈“iÃÉÜiiŽÊ",Ê/*É-8ʜ˜iÊ
SS tablet PO daily
-iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊÊ
/ ˆÀ`ʏˆ˜i\Ê̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞÊ
During initial
hospitalization
stay
ÎqÈʓœ˜Ì ÃÊ
ÎqÈʓœ˜Ì ÃÊ
ˆviœ˜}
ÊrÊ`œ˜œÀ]Ê,ÊrÊÀiVˆ«ˆi˜Ì]Ê­q®ÊrÊÃiÀœ˜i}>̈Ûi]Ê­³®ÊrÊÃiÀœ«œÃˆÌˆÛi
NOTES:
/*É-8ÊÌ iÀ>«ÞÊÀi`ÕViÃÊÀˆÃŽÊœvʈ˜viV̈œ˜ÊÜˆÌ ÊListeria spp., Nocardia spp., and
Toxoplasmosis, but does not eliminate risk.
For splenectomized patients, antibacterial prophylaxis with Amoxicillin 500 mg PO BID
(or Doxycycline if PCN allergy) is recommended for 1 year.
*Recommended screening for G6PD deficiency prior to initiation of Dapsone.
†If Valgancylovir is stopped prior to recommended duration of therapy due to intolerance,
recommend initiation of Acylovir or Valacyclovir for antiviral prophylaxis.
‡ /*qÎʓœ˜Ì Ã
128
NOTE: These guidelines were developed for use in BMT and leukemia
patients and may not be fully applicable in other instances.
Definitions
UÊ iÕÌÀœ«i˜ˆ>\Ê ÊÊxääɓ“3
UÊÊiÛiÀ\ÊÊ/i“«Ê€ÊÎn°äcÊ Ê̈“iÃÊÌܜÊ>Ìʏi>ÃÌÊÓÊ œÕÀÃÊ>«>ÀÌÊ",Ê
Temp > 38.3° C times one
TREATMENT
Always tailor antibiotics based on susceptibility profiles
vÊÌ iÊ«>̈i˜ÌʈÃÊ Þ«œÌi˜ÃˆÛiʜÀÊœÌ iÀ܈ÃiÊ՘ÃÌ>Li]ÊÃiiʺ/Ài>̓i˜ÌʜvÊ
Vˆ˜ˆV>ÞÊ՘ÃÌ>LiÊ«>̈i˜Ìûʭœ««œÃˆÌi®°
Initial fever
UÊÊ ivi«ˆ“iÊÓÊ}Ê6Ê+nÊ´Ê6>˜Vœ“ÞVˆ˜IÊ­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£xä®
OR
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+{Ê´Ê6>˜Vœ“ÞVˆ˜IÊ­ÃiiÊ`œÃˆ˜}Ê
section p. 150)
I˜`ˆV>̈œ˜ÃÊvœÀÊ6>˜Vœ“ÞVˆ˜\ÊÃÕëiVÌi`Ê ,‡ -]ÊΈ˜Ê>˜`ÊÜv̇̈ÃÃÕiʈ˜viV̈œ˜Ã]Ê
pneumonia, severe oral or pharyngeal mucositis, history of MRSA infection or
colonization.
OR
UÊ-iÛiÀiÊ* Ê>iÀ}ÞÊ­>˜>« ޏ>݈ÃʜÀÊ-ÌiÛi˜Ã‡œ ˜Ãœ˜Ê-ޘ`Àœ“i®\Ê
Strongly consider allergy consult to verify allergy in patients with
unclear histories (see section on Penicillin allergy, p. 137)
UÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nÊPLUS Gentamicin† (see dosing section, p. 146)
PLUS Vancomycin (see dosing section, p. 150)
†If strong concern for nephrotoxicity and no prior fluoroquinolone use, can substitute
Ciprofloxacin 400 mg IV Q8H for Gentamicin.
Step-down therapy for discharge
UÊÊCiprofloxacin 750 mg PO BID PLUS Amoxicillin/clavulanate 875 mg
PO BID
OR
Uʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê*"Ê`>ˆÞ
129
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Neutropenic fever
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Persistent fever or new fever after 4-7 days in clinically
stable patients without established bacterial infection
UÊ œ˜Ìˆ˜ÕiÊ>˜ÌˆLˆœÌˆVÃÊ>LœÛiÊ>˜`Ê
Ê>˜Ìˆv՘}>ÊVœÛiÀ>}iÊ
vÊÀiViˆÛˆ˜}ʏÕVœ˜>✏iÊ«Àœ« ޏ>݈ÃʜÀʘœÊv՘}>Ê«Àœ« ޏ>݈Ã\
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{ʈvÊȘÕÃÊ>˜`ɜÀÊV iÃÌÊ /ʘœÌÊÃÕ}}iÃ̈ÛiÊ
of fungal infection
OR
UÊ6œÀˆVœ˜>✏iÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌܜÊ`œÃiÃÊÌ i˜Ê{ʓ}Ɏ}Ê6É
PO Q12H if chest CT suggestive of fungal infection
If receiving Voriconazole or Posaconazole prophylaxis or sinus CT
ÃÕ}}iÃ̈ÛiʜvÊv՘}>Êˆ˜viV̈œ˜\
Uʓ ˆÃœ“iÁÊxʓ}Ɏ}Ê6Ê+Ó{Ê
Clinically unstable patient and/or persistent fever despite
appropriate antibacterial and antifungal coverage
UÊ œ˜ÃՏÌÊ"˜Vœœ}ÞÉ/À>˜Ã«>˜ÌÊ Ê
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Meropenem 1 g IV
+nʴʓˆŽ>Vˆ˜ÊˆvÊ«>̈i˜ÌÊ՘ÃÌ>LiÊ­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£{È®Ê
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê œ˜ÃՏÌÊ"˜Vœœ}ÞÉ/À>˜Ã«>˜ÌÊ Ê
130
NOTE:ʏÊ`œÃiÃÊ>ÃÃՓiʘœÀ“>ÊÀi˜>Êv՘V̈œ˜ÆÊ`œÃiʓœ`ˆwV>̈œ˜Ãʓ>ÞÊLiʈ˜`ˆV>Ìi`ÊvœÀÊ
reduced CrCI.
1. Leukemia patients
Indication
Agent and dose
Duration
Antibacterial prophylaxis
Moxifloxacin 400 mg PO daily PLUS
Amoxicillin 500 mg PO TID (start on day 5)
Day 1 until
ANC 100/mm3 OR
initiation of
ºˆÀÃÌÊiÛiÀ»Ê
antibiotics
˜Ìˆv՘}>Ê«Àœ« ޏ>݈ÃÊ
Ê
ˆÀÃÌʏˆ˜i\Ê6œÀˆVœ˜>✏iÊ­ÃiiÊ`œÃˆ˜}ʈ˜Ê /ÊÃiV̈œ˜®Ê >ÞÊ£Ê՘̈ÊÊ
-iVœ˜`ʏˆ˜i\Ê*œÃ>Vœ˜>✏iÊÃÕëi˜Ãˆœ˜ÊÓääʓ}ÊÊ Ê
PO TID OR 300 mg tablet daily
100/mm3
ÌiÀ˜>̈ÛiÃ\ʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{Ê",ÊÊ
Ê
Ê
Fluconazole 400 mg PO daily
Antiviral prophylaxis
Ê
* *Ê«Àœ« ޏ>݈ÃÊÊ
in high risk patients‡Ê
Ê
Valacyclovir 500 mg PO BID OR Acyclovir
800 mg PO BID
vÊۜ“ˆÌˆ˜}ʜÀÊ`ˆ>ÀÀ i>\ÊVÞVœÛˆÀÊÓxäʓ}ɓ2
IV Q12H†
Day 1 until
ANC 100/mm3
ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊÊ
-iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iÊ£ääʓ}Ê*"Ê`>ˆÞÊ
/ ˆÀ`ʏˆ˜i\Ê̜Û>µÕœ˜iÊÇxäʓ}Ê*"Ê Ê
>ÞÊ£Ê՘̈ÊÊ
ˆ““Õ˜œ‡ÊÊ
ÃÕ«ÀiÃȜ˜Ê
resolves
2. Lymphoma, myeloma patients
Indication
Agent and dose
Duration
Antibacterial prophylaxis
(lymphoma only)
Moxifloxacin 400 mg PO daily
Antifungal prophylaxis
Fluconazole 200 mg PO daily
Day 7 of
chemo until
ANC 500/mm3
Day 1
through all
cycles of
chemotherapy in
high risk
patients.
Antiviral prophylaxis
Valacyclovir 500 mg PO BID OR Acyclovir
800 mg PO BID
vÊۜ“ˆÌˆ˜}ʜÀÊ`ˆ>ÀÀ i>\ÊVÞVœÛˆÀÊÓxäʓ}ɓ2
IV Q12H†
Day 7 through
all cycles of
chemotherapy
ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊÊ
-iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iÊ£ääʓ}Ê*"Ê`>ˆÞÊ
/ ˆÀ`ʏˆ˜i\Ê̜Û>µÕœ˜iÊÇxäʓ}Ê*"Ê Ê
>ÞÊÇÊÌ ÀœÕ} Ê
>ÊVÞViÃʜvÊÊ
V i“œ‡ÊÊ
therapy
Ê
* *Ê«Àœ« ޏ>݈ÃÊÊ
in high risk patients‡Ê
Ê
131
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Prophylactic antimicrobials for patients with
expected prolonged neutropenia
6.20 Guidelines for use of antimicrobials in neutropenic hosts
3. Bone marrow transplant patients/peripheral blood stem cell transplant patients
Indication
Agent and dose
Duration
Antibacterial prophylaxis*
Moxifloxacin 400 mg PO daily
Day zero until
engraftment
Antifungal prophylaxis
Fluconazole 400 mg PO daily
Day zero until
ANC 500/mm3
˜Ìˆv՘}>Ê«Àœ« ޏ>݈Ãʈ˜ÊÊ
patients with GVHD¶
Ê
ˆÀÃÌʏˆ˜i\Ê*œÃ>Vœ˜>✏iÊÃÕëi˜Ãˆœ˜ÊÓääʓ}Ê*"
TID OR 300 mg tablets daily
-iVœ˜`ʏˆ˜i\Ê6œÀˆVœ˜>✏iÊ­`œÃi`ÊLÞÊÜiˆ} Ì®
69 kg Voriconazole 200 mg PO BID
69 kg to 94 kg Voriconazole 300 mg PO BID
94 kg Voriconazole 400 mg PO BID
Antiviral prophylaxis
Valacyclovir 500 mg PO BID OR
Acyclovir 800 mg PO BID
vÊۜ“ˆÌˆ˜}ʜÀÊ`ˆ>ÀÀ i>\ÊVÞVœÛˆÀÊÓxäʓ}ɓ2
IV Q12H †
Day zero
until 1 yr
(allogeneic
transplants)
or 6 months
(autologous
transplants)
Ê
Ê
ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊ
-iVœ˜`ʏˆ˜i\/*É-8Ê -ÊÌ>LÊÓÊ̈“iÃÊÜiiŽÞÊÊ
OR Dapsone 100 mg PO daily
/ ˆÀ`ʏˆ˜i\Ê̜Û>µÕœ˜iÊÇxäʓ}Ê*"Ê Ê
œÕÀÌ Êˆ˜i\Ê*i˜Ì>“ˆ`ˆ˜iÊÎääʓ}Ê Ê+ÓnÊ`>ÞÃÊ
Ê
Ê
œ}i˜iˆVÊ
ÌÀ>˜Ã«>˜Ì\Ê
Day 21 or
i˜}À>v̓i˜ÌÊ
­Ü ˆV iÛiÀÊ
is later)
until at least
1 year
(longer if
steroids or
ongoing risk)
Autologous
ÊÌÀ>˜Ã«>˜Ì\Ê
Engraftment
until 6 months
Ê
PCP prophylaxis†Ê
Ê
NOTES:
/*É-8ÊÌ iÀ>«ÞÊÀi`ÕViÃÊÀˆÃŽÊœvʈ˜viV̈œ˜ÊÜˆÌ Êi˜V>«ÃՏ>Ìi`ÊL>VÌiÀˆ>]ÊListeria spp., Nocardia
spp., and Toxoplasmosis, but does not eliminate risk. It is the preferred antibiotic regimen for
PCP prophylaxis.
*In patients with fluoroquinolone allergy or who cannot tolerate a fluoroquinolone due to QTc
prolongation, consider Cefpodoxime 400 mg PO BID.
†Acyclovir should be dosed by ideal body weight
‡Þiœ“>Ê«>̈i˜ÌÃʈvʜ˜ÊÃÌiÀœˆ`ÃÆÊޓ« œ“>Ê«>̈i˜ÌÃʈvÊ6³]ʜ˜ÊV Àœ˜ˆVÊÃÌiÀœˆ`Ã]ÊyÕ`>À>Lˆ˜i°
iՎi“ˆ>Ê«>̈i˜ÌÃ\Ê]ÊV Àœ˜ˆVÊÃÌiÀœˆ`Ã]ÊÃÉ«Ê /Ê՘̈Ê£ÊÞi>ÀÊ>vÌiÀÊÌÀ>˜Ã«>˜Ì]ʜÀÊ«>̈i˜ÌÊÜ œÊ
received cladribine, fludarabine, or alemtuzumab.
¬"Ì iÀÊ«Àœ« ޏ>݈Ãʈ˜Ê>VÕÌiÊ6 \ʜ݈yœÝ>Vˆ˜]Ê/*É-8°
132
Filamentous fungi
ID consult recommended for assistance with antifungal selection
TREATMENT
Aspergillus spp.
Initial therapy
UÊÊ6œÀˆVœ˜>✏iÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌܜÊ`œÃiÃÊÌ i˜Ê{ʓ}Ɏ}Ê6É
PO Q12H (see Voriconazole guidelines, p. 19, for more information).
OR
Uʓ ˆÃœ“i® 5 mg/kg IV Q24H
NOTES:
UÊÊ6œÀˆVœ˜>✏iʈÃÊVœ˜Ãˆ`iÀi`ÊLÞʓ>˜ÞÊ̜ÊLiÊÌ iÊwÀÃ̇ˆ˜iÊÌÀi>̓i˜ÌʜvÊ
suspected filamentous fungal infections in the immunocompromised
host as most of these infections are caused by Aspergillus species.
Although the data are limited, Voriconazole appears more effective
than Amphotericin for this very serious infection.
UÊÊ œ“Lˆ˜>̈œ˜Ê>˜Ìˆv՘}>ÊÌ iÀ>«ÞÊVœ˜ÃˆÃ̈˜}ʜvÊ6œÀˆVœ˜>✏iÊPLUS
Micafungin should be considered for the treatment of confirmed
invasive aspergillosis that is documented by culture, positive
galuctomannan assay, or histopathology for the first two weeks
of therapy. Longer duration of combination therapy has not been
evaluated.
Fusarium spp.
UÊÊ ÊVœ˜ÃՏÌÊà œÕ`ÊLiʈ˜ÛœÛi`ʈ˜ÊÌ iÃiÊV>Ãið
UÊÊ6œÀˆVœ˜>✏iÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌܜÊ`œÃiÃÊÌ i˜Ê{ʓ}Ɏ}Ê
IV/PO Q12H PLUS Ambisome 5 mg/kg IV Q24H (see Voriconazole
guidelines, p. 19, for more information). Dose escalation may be
necessary for some patients.
Scedosporium apiospermum
UÊÊ6œÀˆVœ˜>✏iÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌܜÊ`œÃiÃÊÌ i˜Ê{ʓ}Ɏ}Ê
IV/PO Q12H PLUS Micafungin 100 mg IV Q24H (see Voriconazole
guidelines, p. 19, for more information).
NOTE:
UÊÊ/Ài>̓i˜ÌÊÜˆÌ ÊœÌ iÀÊ>}i˜ÌÃÊ >ÃÊވi`i`Ê`ˆÃ>««œˆ˜Ìˆ˜}ÊÀiÃՏÌðÊ
Voriconazole appears to be the best option but the data are limited.
133
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Guidelines for the use of antifungal agents in
hematologic malignancy patients
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
Uʓ ˆÃœ“i® 5 mg/kg IV once daily PLUS a second antifungal agent
UÊÊ ÊVœ˜ÃՏÌÊÀiµÕˆÀi`°
UÊÊ-ÕÀ}ˆV>Ê`iLÀˆ`i“i˜ÌÊ>˜`ÊVœÀÀiV̈œ˜ÊœvÊ՘`iÀÞˆ˜}ÊÀˆÃŽÊv>V̜ÀÃÊ­i°}°Ê
acidosis, hyperglycemia) are critical.
Candida
TREATMENT
UÊÊ9 -/Ê ÊÊ "" Ê 1/1, Ê-"1 Ê 6 ,Ê Ê " - , ÊÊ
CONTAMINANT.
UÊÊ-iiÊÃiV̈œ˜ÃÊLiœÜʜ˜Êi“«ˆÀˆVÊÌ iÀ>«ÞÊ>˜`ʜ˜Ê«>Ì œ}i˜‡Ã«iVˆwVÊ
therapy.
Unspeciated candidemia
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{
OR
Uʓ ˆÃœ“i® 5 mg/kg IV Q24H
If the yeast is C. albicans or C. glabrata, the recommendations for C.
albicans noted below can be followed. If the yeast is not C. albicans,
await speciation before modifying therapy as recommended below.
NOTE: Micafungin does not cover Cryptococcus
Candida albicans
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{
OR
UÊʓ ˆÃœ“i®ÊÎqxʓ}Ɏ}Ê6Ê+Ó{
NOTE: Patients who are clinically stable and no longer neutropenic can
be switched to Fluconazole if the organism is susceptible.
Candida glabrata
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{
OR
UÊʓ ˆÃœ“i® 5 mg/kg IV Q24H
Candida krusei
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{
OR
UÊʓ ˆÃœ“i® 5 mg/kg IV Q24H
134
Candida parapsilosis
Uʓ ˆÃœ“i®ÊÎqxʓ}Ɏ}Ê6Ê+Ó{Ê
NOTES:
UÊʜÃÌÊC. parapsilosis isolates remain susceptible to Fluconazole, which
can be used in stable and non-neutropenic patients.
UÊÊ/ iÀiÊ>Àiʏˆ“ˆÌi`Ê`>Ì>ÊÌ >ÌÊÃÕ}}iÃÌÊÌ >ÌʈV>v՘}ˆ˜Ê“>ÞÊLiʈ˜viÀˆœÀÊ̜Ê
Amphotericin B in these infections.
Candida tropicalis
UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{
OR
UÊʓ ˆÃœ“i®ÊÎqxʓ}Ɏ}Ê6Ê+Ó{
TREATMENT NOTES
Hidden Content
- JHH Internal use only
Notes on antifungal susceptibility testing
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀʏÕVœ˜>✏i]ÊÌÀ>Vœ˜>✏i]Ê6œÀˆVœ˜>✏i]Ê
Flucytosine (5-FC), and Micafungin is performed routinely on the first
yeast isolate recovered from blood.
135
6.20 Guidelines for use of antimicrobials in neutropenic hosts
A
NOTE: C. krusei is intrinsically resistant to Fluconazole and these
infections can be difficult to treat. In stable patients, Voriconazole can be
used if susceptible and oral therapy is desired. (See p. 19 for dosing).
A
6.20 Guidelines for use of antimicrobials in neutropenic hosts
UÊʏÕVœ˜>✏iÊ>˜`ʈV>v՘}ˆ˜ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>ÀiÊÀi«œÀÌi`ʜ˜Ê>ÊLœœ`Ê
isolates.
UÊÊ"À}>˜ˆÃ“ÃÊÌ >ÌÊ >ÛiʈV>v՘}ˆ˜Ê Ãʈ˜ÊÌ iÊÀ>˜}iʜvÊ£qÓʓV}ɓÊ
(reported as susceptible) may not respond to treatment. ID consult is
recommended in these cases.
UÊÊSusceptibility testing for conventional Amphotericin B is done routinely
for C. lusitaniae and C. guillemondii and for other organisms by
request.
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}Êà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊÜ i˜\Ê
UÊÊÕVœVÕÌ>˜iœÕÃÊV>˜`ˆ`ˆ>ÈÃʈÃÊÀivÀ>V̜ÀÞÊ̜ʏÕVœ˜>✏i
UÊÊ/Ài>̈˜}ʜÃÌiœ“ÞiˆÌˆÃ]ʓi˜ˆ˜}ˆÌˆÃ]ʜÀÊi˜`œ« Ì >“ˆÌˆÃÊÜˆÌ Ê
Fluconazole
UÊÊ œœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«iÀÈÃÌi˜ÌÞÊ«œÃˆÌˆÛiʜ˜ÊÕVœ˜>✏i
UÊÊ œ˜‡ÀœṎ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊV>˜ÊLiÊ>ÀÀ>˜}i`ÊLÞÊV>ˆ˜}ÊÌ iÊ
mycology lab at 5-6148
,iviÀi˜Vi\
-ÊՈ`iˆ˜iÃÊvœÀÊ/Ài>̓i˜ÌʜvÊ >˜`ˆ`ˆ>ÈÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓää™Æ{n\xäΰ
136
Penicillin reactions – Incidence
UÊÊÊn䇙ä¯ÊœvÊ«>̈i˜ÌÃÊÜ œÊÀi«œÀÌÊÌ iÞÊ>Àiʺ>iÀ}ˆV»Ê̜Ê* Ê>VÌÕ>ÞÊ >ÛiÊ
negative skin tests and are not at increased risk of an allergic reaction.
UÊÊ*i˜ˆVˆˆ˜ÊÀi>V̈œ˜ÃʜvÊܓiÊÌÞ«iʜVVÕÀʈ˜Êä°ÇÊ̜ʣä¯ÊœvÊ>Ê«>̈i˜ÌÃÊ
who get the drug.
UÊÊ 1/\Ê/ iʈ˜Vˆ`i˜ViʜvÊ>˜>« ޏ>V̈VÊÀi>V̈œ˜ÃʈÃÊä°ää{¯Ê̜Êä°ä£x¯°
UÊÊ,>ÌiÃʜvÊVÀœÃÇÀi>V̈œ˜Ê>iÀ}ˆiÃÊ̜ÊVi« >œÃ«œÀˆ˜ÃÊ>ÀiÊ՘Ž˜œÜ˜ÊLÕÌÊ
thought to be low.
UÊÊ,>ÌiÃʜvÊ* Ê>˜`ÊV>ÀL>«i˜i“ÊΈ˜ÊÌiÃÌÊVÀœÃÃÊÀi>V̈ۈÌÞÊ>ÀiÊ{ǯ]Ê
although clinical rates of hypersensitivity reactions in patients with
Ài«œÀÌi`Ê* Ê>iÀ}ÞÊÜ œÊÀiViˆÛiÊV>ÀL>«i˜i“ÃÊ>Àiʙq££¯°
UÊÊ ÀœÃÃÊÀi>V̈œ˜ÃÊ̜ʓœ˜œL>VÌ>“ÃÊ­âÌÀiœ˜>“®Ê`œÊ "/Ê>««i>ÀÊ̜ʜVVÕÀ°
Penicillin skin testing
UÊÊ7 i˜Ê`œ˜iÊVœÀÀiV̏Þ]ʈÃÊ ˆ} ÞÊ«Ài`ˆV̈ÛiʜvÊÃiÀˆœÕÃ]Ê>˜>« ޏ>V̈VÊÀi>V̈œ˜Ã°
UÊÊ*>̈i˜ÌÃÊÜˆÌ Ê>ʘi}>̈ÛiÊΈ˜ÊÌiÃÌÊ>ÀiÊNOT at risk for anaphylactic reactions.
UÊÊ,>ÀiÞ]ÊΈ˜ÊÌiÃÌʘi}>̈ÛiÊ«>̈i˜ÌÃʓ>ÞÊ}iÌʓˆ`Ê ˆÛiÃÊ>˜`ʈÌV ˆ˜}Ê
following penicillin administration but these RESOLVE with continued
treatment.
UÊÊ-Žˆ˜ÊÌiÃÌÃÊV>˜˜œÌÊ«Ài`ˆVÌÊ`iÀ“>̜œ}ˆVʜÀÊÊÀi>V̈œ˜ÃʜÀÊ`ÀÕ}ÊviÛiÀð
UÊÊ-Žˆ˜ÊÌiÃ̈˜}ʈÃʘœÜÊ>Û>ˆ>LiÊ>ÌÊ°Ê*i>ÃiÊVœ˜ÃՏÌʏiÀ}ÞÊ>˜`Ê
Immunology.
Penicillin reactions—Types
UÊImmediateÊ­ÌÞ«iÊ£®Êqʘ>« ޏ>݈Ã]Ê Þ«œÌi˜Ãˆœ˜]ʏ>Àޘ}i>Êi`i“>]Ê
wheezing, angioedema, urticaria
UÊʏ“œÃÌÊ>Ü>ÞÃʜVVÕÀÊwithin 1 hour of administration. Hypotension
always occurs soon after administration
UÊÊ >˜ÊLiÊ«Ài`ˆVÌi`ÊLÞÊΈ˜ÊÌiÃÌÃ
UÊAcceleratedÊqÊ>Àޘ}i>Êi`i“>]ÊÜ ii∘}]Ê>˜}ˆœi`i“>]ÊÕÀ̈V>Àˆ>Ê
(NOT hypotension)
UÊÊ"VVÕÀÊÜˆÌ ˆ˜Ê£‡ÇÓÊ œÕÀÃʜvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜
UÊÊ >˜ÊLiÊ«Ài`ˆVÌi`ÊLÞÊΈ˜ÊÌiÃÌÃ
UÊLateÊqÊ,>à ʭ“>VՏœ«>«Õ>ÀʜÀʓœÀLˆˆvœÀ“ÊœÀÊVœ˜Ì>VÌÊ`iÀ“>̈̈î]Ê
destruction of RBC, WBC, platelets, serum sickness
UÊʏ“œÃÌÊ>Ü>ÞÃʜVVÕÀÊ>vÌiÀÊÇÓÊ œÕÀÃʜvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜
UÊÊ,>à iÃÊܓï“iÃÊ}œÊ>Ü>ÞÊ`iëˆÌiÊVœ˜Ìˆ˜Õi`ÊÌÀi>̓i˜Ì
UÊÊ>VՏœ«>«Õ>ÀÊ>˜`ʓœÀLˆˆvœÀ“ÊÀ>à iÃÊ "Ê "/Ê«Àœ}ÀiÃÃÊ̜Ê
Stevens-Johnson syndrome
UÊÊ>ÌiÊÀi>V̈œ˜ÃÊ>ÀiÊ "/Ê«Ài`ˆVÌi`ÊLÞÊΈ˜ÊÌiÃÌÃ
UÊStevens-Johnson SyndromeÊqÊiÝvœˆ>̈ÛiÊ`iÀ“>̈̈ÃÊÜˆÌ Ê“ÕVœÕÃÊ
membrane involvement
137
7.1 Approach to the patient with a history of penicillin allergy
Approach to the patient with a history
of penicillin allergy
7.1 Approach to the patient with a history of penicillin allergy
UÊʏ“œÃÌÊ>Ü>ÞÃʜVVÕÀÊ>vÌiÀÊÇÓÊ œÕÀÃʜvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜
UÊÊ "/Ê«Ài`ˆVÌi`ÊLÞÊ>Ê ˆÃ̜ÀÞʜvÊÀ>à Ê",ÊLÞÊΈ˜ÊÌiÃÌÃ
Approach to the patient with reported penicillin allergy
UÊÊ Àˆiv]ÊvœVÕÃi`Ê ˆÃ̜ÀÞÊV>˜ÊLiÊ6 ,9Ê i«vՏ°
UÊÊ+ÕiÃ̈œ˜ÃÊ̜Ê>Î\
1. How long after beginning penicillin did the reaction occur?
2. Was there any wheezing, throat or mouth swelling, urticaria?
3. If a rash occurred, what was the nature of the rash? Where was it
and what did it look like?
4. Was the patient on other medications at the time of the reaction?
5. Since then, has the patient ever received another penicillin or
Vi« >œÃ«œÀˆ˜Ê­>ÎÊ>LœÕÌÊÌÀ>`iʘ>“iÃʏˆŽi\ÊÕ}“i˜Ìˆ˜]ÊiyiÝ]Ê
Trimox, Ceftin, Vantin)?
6. If the patient received a beta-lactam, what happened?
Interpreting the history of the patient reporting penicillin allergy
UÊÊANY patient who has a history consistent with an immediate
reaction (laryngeal edema, wheezing, angioedema, urticaria)
SHOULD NOT receive beta-lactams without undergoing skin
testing first EVEN IF they have received beta-lactams with no
problems after the serious reaction.
UÊÊ*>̈i˜ÌÃÊÜ œÊÀi«œÀÌʘœ˜‡>˜>« ޏ>V̈VÊÀi>V̈œ˜ÃÊ>˜`Ê >ÛiÊÀiViˆÛi`Ê
other penicillins without problems DO NOT have penicillin allergy
and are not at increased risk for an allergic reaction compared to
the general population.
UÊÊ*>̈i˜ÌÃÊÜ œÊÀi«œÀÌʘœ˜‡>˜>« ޏ>V̈VÊÀi>V̈œ˜ÃÊ>˜`Ê >ÛiÊÀiViˆÛi`Ê
cephalosporins can get cephalosporins but not necessarily PCNs.
UÊÊ*>̈i˜ÌÃÊÜ œÊÀi«œÀÌÊ>Ê ˆÃ̜ÀÞʜvÊ>ʘœ˜‡ÕÀ̈V>Àˆ>ÊÀ>à ÊÌ >ÌʈÃÊ "/Ê
consistent with Stevens-Johnson syndrome (target lesions with
mucous membrane inflammation) and developed after ≥ 72 hours
of penicillin are not at increased risk for an adverse reaction. They
should, however, be watched closely for development of rashes.
UÊÊ*>̈i˜ÌÃÊÜ œÊÀi«œÀÌÊÀi>V̈œ˜ÃÊVœ˜ÃˆÃÌi˜ÌÊÜˆÌ ÊÃiÀՓÊÈVŽ˜iÃÃÊ
(rare) can receive either penicillins or cephalosporins with careful
monitoring for recurrence.
UÊÊ*>̈i˜ÌÃÊÜ œÊÀi«œÀÌÊÊÃޓ«Ìœ“ÃÊ­`ˆ>ÀÀ i>]ʘ>ÕÃi>®Ê«ÀœL>LÞÊ`œÊ
not have penicillin allergy and do not appear to be at increased
risk for an adverse reaction. They should be closely observed for
recurrent symptoms and be given supportive therapy if they occur.
,iviÀi˜ViÃ\Ê
ÊÓää£ÆÓnx\Ó{™n°
1ÃiʜvÊV>ÀL>«i˜i“Ãʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê*
££xxqÇ°Ê
˜˜Ê˜ÌiÀ˜Êi`ÊÓääÇÆ£{È\ÓÈÈq™°
138
Ê>iÀ}Þ\Êʘ̈“ˆVÀœL°Ê
i“œÌ iÀÊÓää{Æx{\Ê
UÊÊ œ˜ÃՏÌÊÌ iÊ ÊÜiLÈÌiʜÀÊÊ«œˆVˆiÃʜ˜ˆ˜iÊ­*"®Ê­ÜÜÜ°
hopkinsmedicine.org/heic) for detailed isolation charts, HEIC policies,
and surveillance information
Hand hygiene
UÊÊvÊ >˜`ÃÊ>ÀiʘœÌÊۈÈLÞÊ܈i`]ÊÌ i˜Ê>Vœ œ‡L>Ãi`Ê >˜`ÊÃ>˜ˆÌˆâiÀÃÊ>ÀiÊ
recommended for cleaning. If hands are visibly soiled, wash hands
with soap and water for at least 15 seconds.
UÊÊ>˜`Ê Þ}ˆi˜iʈÃÊÀiµÕˆÀi`ÊÕ«œ˜Êi˜ÌiÀˆ˜}Ê>Ê«>̈i˜ÌÊÀœœ“]ÊÕ«œ˜Êï݈˜}]Ê
between patients in a semi-private room, and other times per hospital
policy.
UÊÊ1ÃiÊÜ>«Ê>˜`ÊÜ>ÌiÀÊÕ«œ˜Êexiting the room of a patient with
C. difficile infection.
UÊÊ œÊ>À̈wVˆ>Êw˜}iÀ˜>ˆÃÊ>ÀiÊ«iÀ“ˆÌÌi`ÊvœÀÊ>˜ÞÊÃÌ>vvʓi“LiÀÊÜ œÊ >ÃÊ
patient contact or handles sterile supplies.
Bloodborne pathogen exposures (needlestick or other exposure)
The prompt treatment of injuries and exposures is vital to prevent the
transmission of disease. Whatever the exposure, IMMEDIATE cleaning of
the exposure site is the first priority.
UÊÊ-Žˆ˜Êܜ՘`ÃÊà œÕ`ÊLiÊVi>˜i`ÊÜˆÌ ÊÜ>«Ê>˜`ÊÜ>ÌiÀ
UÊÊÕVœÕÃʓi“LÀ>˜iÃÊà œÕ`ÊLiÊyÕà i`ÊÌ œÀœÕ} ÞÊÜˆÌ ÊÜ>ÌiÀ
UÊÊ ÞiÃÊà œÕ`ÊLiʈÀÀˆ}>Ìi`ÊÜˆÌ Ê>ʏˆÌiÀʜvʘœÀ“>ÊÃ>ˆ˜i
vÌiÀÊVi>˜ˆ˜}ÊÌ iÊiÝ«œÃÕÀiÊÈÌi]ÊV>Êx‡-/8Ê­x‡Çn{™®Ê>˜`ÊvœœÜÊ
instructions to contact the ID physician. Workplace injuries should be
Ài«œÀÌi`ʈ““i`ˆ>ÌiÞʜ˜ÊÌ iʺ “«œÞiiÊ,i«œÀÌʜvʘVˆ`i˜ÌʜÀ“»Ê>˜`Ê
to the Occupational Injury ClinicÊ­ >œVŽÊ£Î™]ʜ˜`>ÞqÀˆ`>Þ]ÊÇ\ÎäÊ
a.m. to 4 p.m., 5-6433), and to your supervisor.
Standard Precautions
UÊÊ,œṎ˜iÊ >˜`Ê Þ}ˆi˜iÊ
UÊÊ œ˜ÃˆÃÌi˜ÌÊ>˜`ÊVœÀÀiVÌÊ}œÛiÊÕÃiÊÊ
UÊÊ >}ÊVœ˜Ì>“ˆ˜>Ìi`ʏˆ˜i˜Ê>ÌÊ«œˆ˜ÌʜvÊÕÃi
UÊÊ,i}Տ>ÀÊVi>˜ˆ˜}ʜvÊi˜ÛˆÀœ˜“i˜Ì>Ê
surfaces
UÊ««Àœ«Àˆ>ÌiÊÕÃiʜvÊ}œÜ˜ÃÊ̜ʫÀiÛi˜ÌÊÊ UÊ,œṎ˜iÊVi>˜ˆ˜}ʜÀÊ`ˆÃ«œÃ>Êœv
contamination of uniform/clothing
patient-care equipment
UÊ««Àœ«Àˆ>ÌiÊÕÃiʜvʓ>ÎÃ]ÊiÞiÊÊ
UÊ-ÌÀˆVÌÊ>` iÀi˜ViÊ̜
protection and face shields (i.e., when
occupational safety requirements
suctioning, or when splash likely)
139
8.1 Hospital Epidemiology & Infection Control
A
Hospital Epidemiology and Infection Control
(HEIC)
8.1 Hospital Epidemiology & Infection Control
A
Communicable diseases—exposures and reporting
Êà œÕ`ÊLiʘœÌˆwi`\
UÊÊvÊ«>̈i˜ÌÃʜÀÊ 7ÃÊ>ÀiÊiÝ«œÃi`Ê̜Ê>ÊVœ““Õ˜ˆV>LiÊ`ˆÃi>ÃiÊ­ˆ°i°Ê
meningococcal disease, varicella, TB etc.)
UÊÊLœÕÌÊ 7ÃÊÜˆÌ Ê>VÕÌiÊ i«>̈̈ÃÊ]Ê ÊœÀÊ ]Ê->“œ˜i>]Ê- ˆ}i>]Ê
Campylobacter, or pneumonia requiring hospital admission
UÊÊLœÕÌÊ>˜ÞÊ՘ÕÃÕ>ÊœVVÕÀÀi˜ViʜvÊ`ˆÃi>ÃiʜÀÊVÕÃÌiÀ]Ê«>À̈VՏ>ÀÞÊ
diseases that have the potential to expose many susceptible
individuals
UÊÊ-ÕëˆVˆœ˜ÊœÀÊ`ˆ>}˜œÃiÃʜvÊÌ iÊvœœÜˆ˜}Ê`ˆÃi>ÃiÃÊ­`ˆÃi>ÃiÃÊÜˆÌ Ê
require immediate notification by phone or pager). If disease is
in a HCW, notify HEIC and Occupational Health (98 N. Broadway,
-ՈÌiÊ{Ó£]ʜ˜`>ÞqÀˆ`>Þ]ÊÇ\ÎäÊ>°“°Ê̜Ê{\ääÊ«°“°]Êx‡ÈÓ££®Ê
immediately
Anthrax Avian Influenza Botulism Brucellosis
Creutzfeldt-Jakob disease (CJD) Diphtheria Glanders Highly resistant organisms (i.e. VISA,
VRSA) Legionellosis
Measles (rubeola) Meningococcal disease Monkeypox Mumps
Pertussis Plague Poliomyelitis
Q Fever
Rabies Ricin toxin Rubella (German measles)
Salmonellosis
SARS Scabies
Shigellosis
Smallpox (orthopox viruses) Streptococcal Group A or B invasive
disease Tuberculosis Tularemia Varicella (chickenpox or disseminated
zoster) Viral hemorrhagic fever Yellow Fever Physicians are required to report communicable disease to the
>Ìˆ“œÀiÊ ˆÌÞÊi>Ì Ê i«>À̓i˜ÌÊ­{£ä‡Î™È‡{{ÎÈ]Êv>Ý\Ê{£ä‡ÈÓx‡äÈnn®°Ê
For a complete list of communicable diseases, see the HEIC Web site,
Ì iÊ Ê7iLÊÈÌi]Ê ÌÌ«\ÉɈ`i >°` “ °“>Àޏ>˜`°}œÛÉ-ˆÌi*>}iÃÉÜ >̇
to-report.aspx or the BCHD Web site, www.baltimorehealth.org/acd.
html.
140
141
To enter room
MRSA, C.diff, zoster§
Door closed
Mask/Eye Protection
Gown and Gloves
Examples
Droplet
Precautions
(orange)
Required unless
cohorted*
No
If within 6 feet
of patient
To enter room
Influenza, bacterial
meningitis
Yes
PAPR or N95† to
enter room‡
No
TB, disseminated
zoster§
Airborne
Precautions
(blue) ¶
Required
8.2 Infection control precautions
* Required for pertussis and diphtheria
† Fit-testing is required to use an N95 mask for airborne precautions
‡ HCWs who are Varicella-immune do not have to wear a PAPR or N95 if patient is in isolation for zoster or chickenpox
§ Disseminated zoster, zoster in an immunocompromised host, and chickenpox require both Contact and Airborne Precautions
(sign color)
Private room
Contact
Precautions
(pink)
Required unless
cohorted
No
No
JHH Precautions Categories
These precaution categories must be used in addition to Standard Precautions. The following table includes general requirements for precaution
categories. The complete table and the type of isolation required for each organism can be found on the HEIC website. If recommendations on this table
cannot be followed, please contact HEIC.
8.3 Disease-specific infection control recommendations
Disease-specific infection control
recommendations
Carbapenem-resistant Enterobacteriaceae (CRE)
Routine active surveillance cultures for CRE are performed in patients
who have been hospitalized in a country other than the U.S. in the past
6 months. Patients are placed on Contact Precautions pending cullture
results. The results are to be used for isolation purposes, not to guide
therapy or clinical care. The overwhelming majority of positive
surveillance cultures represents colonization, not infection, and
should not prompt any antimicrobial therapy.
Creutzfeldt-Jakob disease (CJD)
CJD, variant CJD and other diseases caused by prions are resistant to a
number of standard sterilization and disinfection procedures. Iatrogenic
transmission of CJD has been associated with percutaneous exposure
to medical instruments contaminated with prion/central nervous system
(CNS) tissue residues, transplantation of CNS and corneal tissues and
recipients of human growth hormone and gonadotropin. Transmission of
CJD has not been associated with environmental contamination or from
person-to-person via skin contact. The following additional precautions
must be made when processing equipment that could be contaminated
ÜˆÌ Ê«Àˆœ˜ÊÀi>Ìi`ʓ>ÌiÀˆ>\
UÊÊ œÌˆvÞÊ Ê>˜`ÊÌ iÊ՘ˆÌʓ>˜>}iÀÉV >À}iʘÕÀÃiʈ““i`ˆ>ÌiÞʜvÊ>˜ÞÊ
suspected or confirmed CJD case and refer to the CJD policy on the
HEIC Web site.
UÊÊ1ÃiÊ`ˆÃ«œÃ>LiÊiµÕˆ«“i˜ÌÊÜ i˜iÛiÀÊ«œÃÈLi°Êvʘœ˜‡`ˆÃ«œÃ>LiÊ
equipment is used, Central Sterile Department shall be notified prior to
the start of the procedure.
UÊÊ>LiÊ>Ê>LœÀ>̜ÀÞÊ>˜`Ê«>Ì œœ}ÞÊÀiµÕˆÃˆÌˆœ˜ÃÊ>ÃÊÃÕëiVÌi`Ê Ê>˜`Ê
notify the lab before sending specimens.
UÊÊ/ iÊvœœÜˆ˜}Ê>ÀiÊVœ˜Ãˆ`iÀi`Ê ˆ} Þʈ˜viV̈ÛiÊ>˜`Êà œÕ`ÊLiÊ >˜`i`Ê
ÜˆÌ ÊiÝÌÀi“iÊV>Ṏœ˜\ÊLÀ>ˆ˜]Ê눘>ÊVœÀ`]ʜ«ÌˆVÊ̈ÃÃÕiÃÊ>˜`Ê«ˆÌՈÌ>ÀÞÊ
gland
UÊÊ/ iÊvœœÜˆ˜}Ê>ÀiÊVœ˜Ãˆ`iÀi`Ê̜ÊLiʜvʏœÜiÀʈ˜viV̈ۈÌÞ\Ê -]ʎˆ`˜iÞ]Ê
liver, lung, lymph nodes, spleen, placenta, tonsillar tissue and olfactory
tissue.
Methicillin-resistant Staphylococcus aureus (MRSA)
Routine active surveillance cultures for MRSA are performed on select
units to identify patients with MRSA. When a culture is positive for
MRSA the patient is placed on Contact Precautions. The results are
to be used for isolation purposes, not to guide therapy or clinical care.
The overwhelming majority of positive surveillance cultures
142
Surveillance cultures should be obtained upon admission and weekly
ˆ˜ÊÌ iÊvœœÜˆ˜}Ê՘ˆÌÃ\Ê 1]Ê7 1]Ê 6- 1]Ê- 1]Ê /1Ê­™7®]Ê
1]Ê
CCU/PCCU, PICU, NICU, oncology units, Nelson 4.
To remove a patient from MRSA precautions, cultures from the original
site of infection and 2 nares cultures taken ≥ 72 hours apart must be
negative. Nares cultures should not be sent if the patient has received
antibiotics active against MRSA in the previous 48 hours. Once this is
accomplished, call HEIC to review culture data and initiate deflagging.
Pertussis
All patients with pertussis should be placed on Droplet Precautions
for five days from the start of therapy. If the patient is not on therapy,
Droplet Precautions should be continued for three weeks from the onset
of cough. Private room is required.
/Ài>̓i˜Ì\
UÊÊâˆÌ Àœ“ÞVˆ˜Êxääʓ}Ê*"ʜ˜Viʜ˜Ê`>ÞÊ£]ÊÌ i˜ÊÓxäʓ}Ê*"Ê`>ˆÞʜ˜Ê
`>ÞÃÊÓqx
OR
UÊÊ>VÀœˆ`iÊ>iÀ}Þ\Ê/*É-8Ê£Ê -ÊÌ>LiÌÊ*"Ê ÊvœÀÊ£{Ê`>ÞÃ
Prophylaxis with the above regimens is required for all household
contacts within three weeks of exposure. Use the same antibiotic as
for treatment. All household contacts and HCWs with exposure to
the patient should also have up-to-date immunizations for Bordetella
pertussis.
Scabies
All patients with conventional or Norwegian scabies should be placed on
Contact Precautions. Norwegian scabies is a severe form of heavy
mite infestation.
UÊÊ*ÀˆÛ>ÌiÊÀœœ“ÊÀiµÕˆÀi`°
UÊÊ*>̈i˜ÌÃÊÜˆÌ ÊVœ˜Ûi˜Ìˆœ˜>ÊÃV>LˆiÃʓÕÃÌÊLiÊÌÀi>Ìi`ÊÜˆÌ Ê>ÊÃV>LˆVˆ`iÊ
once, and the precautions may be discontinued 24 hours after the
treatment is completed.
UÊÊ*>̈i˜ÌÃÊÜˆÌ Ê œÀÜi}ˆ>˜ÊÃV>LˆiÃÊÀiµÕˆÀiÊÓÊÌÀi>̓i˜ÌÃÊÜˆÌ Ê>ÊÃV>LˆVˆ`iÊ
1 week apart. Contact precautions may be discontinued 24 hours
after the second treatment is completed.
UÊʘviÃÌi`ÊVœÌ ˆ˜}Ê>˜`ʏˆ˜i˜Êà œÕ`ÊLiÊÃi>i`ʈ˜Ê>Ê«>Ã̈VÊL>}ÊvœÀÊ{nÊ
hours. The mite will not survive off a human host for more than 48
hours. Clothing/patient belongings should be sent home with the
patient’s family/caretaker. Linens and clothing should be washed in
the washing machine on the hot cycle.
143
8.3 Disease-specific infection control recommendations
represents colonization, not infection, and should not prompt
any antimicrobial therapy.
8.3 Disease-specific infection control recommendations
UÊÊvÊ«Àœœ˜}i`ÊΈ˜‡Ìœ‡ÃŽˆ˜ÊVœ˜Ì>VÌʜVVÕÀÃÊÜˆÌ Ê>ÊÃV>LˆiÃÊ«>̈i˜Ì]Ê
prophylactic treatment is required. Healthcare workers should contact
HEIC if an exposure is suspected.
Vancomycin-resistant enterocci (VRE)
Routine active surveillance cultures for VRE are performed on select
units to identify patients with VRE. Surveillance culture results are found
ˆ˜ÊÌ iÊiiVÌÀœ˜ˆVÊ«>̈i˜ÌÊÀiVœÀ`ÊÜˆÌ ÊÌ iÊÌiÃÌʘ>“iʺ >VÌiÀˆœœ}އ-̜œ‡
6, Ê-̜œÊ-ÕÀÛ°Ê ÕÌ°»Ê7 i˜Ê>ÊVՏÌÕÀiÊ}ÀœÜÃÊ6, ]ÊÌ iÊ«>̈i˜ÌʈÃÊy>}}i`Ê
for Contact Precautions. The results are to be used for isolation
purposes, not to guide therapy or clinical care. The overwhelming
majority of positive surveillance cultures represents colonization,
not infection, and should not prompt any antimicrobial therapy.
Surveillance cultures should be obtained upon admission and weekly
ˆ˜ÊÌ iÊvœœÜˆ˜}Ê՘ˆÌÃ\Ê 1]Ê7 1]Ê 6- 1]Ê- 1]Ê /1Ê­™7®]Ê /Ê>˜`Ê
Leukemia units, NCCU, PICU.
The patient must be off antibiotics for ≥ 48 hours and cultures from
original site of infection AND 3 stool or perirectal cultures taken ≥ 1
week apart must be negative. Once this is accomplished, call HEIC to
review culture data and initiate deflagging.
Varicella-Zoster
Immunocompetent patients with disseminated zoster and all
immunosuppressed patients with zoster need Contact AND Airborne
Precautions°Ê/ iÊvœœÜˆ˜}Ê`iw˜ˆÌˆœ˜ÃÊ>««ÞÊ̜ʫ>̈i˜ÌÃÊÜˆÌ ÊâœÃÌiÀ\
UÊÊImmunosuppressed:ÊLœ˜iʓ>ÀÀœÜÊÌÀ>˜Ã«>˜ÌÊÜˆÌ ˆ˜ÊÌ iÊ«>ÃÌÊÞi>ÀÆÊ
>VÕÌiʏiՎi“ˆ>ÆÊ܏ˆ`ʜÀ}>˜ÊÌÀ>˜Ã«>˜ÌÊÀiVˆ«ˆi˜ÌÃÆÊ«>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê
cytotoxic or immunosuppressive treatments, including steroid
treatment for ≥ ÎäÊ`>ÞÃÊÜˆÌ ÊÌ iÊvœœÜˆ˜}Ê`œÃiÃ\Ê`iÝ>“iÌ >ܘiÊ
3 mg daily, cortisone 100 mg daily, hydrocortisone 80 mg daily,
«Ài`˜ˆÃœ˜iÊÓäʓ}Ê`>ˆÞ]ʓiÌ Þ«Ài`˜ˆÃœ˜iÊ£Èʓ}Ê`>ˆÞÆÊ6³Ê«>̈i˜ÌÃÊ
with CD4 < 200
UÊÊDisseminated: lesions outside of 2 contiguous dermatomes
144
Aminoglycoside dosing weight:
Calculate Ideal Body Weight (IBW)
IBW female (kg)ÊrÊ(2.3 x inches over 5’)ʳÊ45.5
IBW male (kg) r (2.3 x inches over 5’)ʳÊ50
For patients < 20% over IBW, use Actual Body Weight
(ABW)
For patients ≥ 20% over IBW, use Dosing Body Weight
(DBW)
­ 7®ÊrÊQ 7ʳÊä°{Ê­ 7ÊqÊ 7®RÊ
Estimation of creatinine clearance (CrCl) by Cockcroft-Gault
equation:
(If a patient’s renal function is declining, this equation may overestimate CrCl)
Ê
À Êr ­£{äÊqÊ>}i®Ê­Üiˆ} Ìʈ˜ÊŽ}I® x 0.85 (if female)
72 (serum creatinine)
* Use Actual Body Weight (ABW) unless patient ≥ÊÓä¯ÊœÛiÀÊ 7]ÊÕÃiÊ
above
7Ê>ÃÊ`iÃVÀˆLi`Ê
Extended-interval dosing, also sometimes referred to as “oncedaily” administration, utilizes higher dose and less frequent
aminoglycoside administration, whereas patient-specific dosing,
previous referred to as “traditional dosing”, typically utilizes smaller
doses with more frequent administration. See table below for dosing
recommendation based on indication and patient’s renal function. For
mycobacterial infections, urinary tract infections, SICU/WICU
protocol and gram-positive synergy (e.g. endocarditis), please
see separate sections below. For cystic fibrosis patients, see the
Cystic Fibrosis section (p.92)
145
A. Aminoglycoside dosing and monitoring
A
Aminoglycoside dosing and monitoring
Aminoglycosides enhance the efficacy of some antibiotics. Except for
urinary tract infections, aminoglycosides should seldom be used alone
to treat infections.
A. Aminoglycoside dosing and monitoring
A
Aminoglycoside dosing for Gram-negative
infections
IndicationsÊ
DosingÊ
Ê
Ê
Ê
Ê
Ê
Ê
Ê
Ê
Patient-specific dosing
,i˜>Êv>ˆÕÀi]ʜ˜Ê É 66 ]Êi˜`œV>À`ˆÌˆÃ]ÊÊ
Gram-negative infections (in combination with
beta-lactams), CNS infections, septic shock,
burn patients, patients with altered volume
status (e.g. ascites, anasarca, trauma)
Ê œÃiÊ­“}®ÊrÊ`iÈÀi`Ê«i>ŽÊÝÊQ7iˆ} ÌÊ­Ž}®ÊÝÊ6`ÊÊ
­ÉŽ}®RÊ
UÊÊ iÈÀi`Ê«i>Ž\ choose from below
UÊÊ7iˆ} Ì\ ABW or DBW
UÊÊVolume of distribution (Vd) typically ranges
LiÌÜii˜Êä°ÓxÊqÊä°xÊɎ}ʈ˜Ê“œÃÌÊ«>̈i˜ÌðÊ
Higher Vd should be used in critically ill and
volume overloaded
patients.
Extended-interval dosing
UÊÊ œÀ“>ÊÀi˜>Êv՘V̈œ˜Ê­ À Ê
>60 mL/min) and all other
indications not listed under
patient specific dosing
i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\
x‡Çʓ}Ɏ}Ê6Ê+Ó{
“ˆŽ>Vˆ˜\
15-20 mg/kg IV Q24H
œÃˆ˜}ʈ˜ÌiÀÛ>ÊL>Ãi`ʜ˜Ê À \
À Ê€Èä\Ê+nI
À ÊÎä‡Èä\Ê+£Ó
À ÊÎäÉ 66 É \Ê`œÃiÊLÞʏiÛi
*If targeting high peaks, use maintenance dose
frequency of Q12-24H.
Desired
Peaks and
Troughs
Peak
Pneumonia
Septic shock
Endocarditis
Osteomyelitis
MDR
organismsÊ
Trough
Gentamicin/
Tobramycin
10 mcg/mL
Amikacin
8-10 mcg/mL
20-30 mcg/mL
25-35 mcg/mL
This dosing strategy is designed
̜ÊÌ>À}iÌÊÌ iÊvœœÜˆ˜}\
Peak
i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\ʣȇÓä
mcg/mL
“ˆŽ>Vˆ˜\Ê{ä‡ÈäʓV}ɓ
Trough
i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\Ê
£Ê“V}ɓ
“ˆŽ>Vˆ˜\ʐ{ʓV}ɓ
10-20 mcg/mL 45-50 mcg/mL
L>Ãi`ʜ˜Ê Ê L>Ãi`ʜ˜Ê Ê
Gentamicin/ Amikacin
Tobramycin
All IndicationsÊ £‡ÓʓV}É“Ê £äʓV}ɓ
Therapeutic Trough: draw 30 minutes prior to the 3rd dose If the patient meets ANY of the
Drug
criteria below, a trough level
Monitoring Peak: obtain 1 hour after end of infusion, after is recommended prior to the
the 3rd dose.
Ә`Ê`œÃi\
UÊÊ œ˜Vœ“ˆÌ>˜Ìʘi« ÀœÌœÝˆVÊ
Frequency of monitoring
medications
Ê
UÊÊ"˜ViÊ>ÊÜiiŽÊ>vÌiÀÊ`iÈÀi`Ê«i>ŽÉÌÀœÕ} ʈÃÊ
UÊÊ œ˜ÌÀ>ÃÌÊiÝ«œÃÕÀiÊ
established in patients with normal renal
UÊ}iÊ≥ 60 years
function
UÊÊ*>̈i˜ÌʈÃʈ˜ÊÌ iÊ 1
Ê
UÊʜÀiÊÌ >˜Êœ˜ViÊÜiiŽÞ\Ê
UÊÊ"Ì iÀÊÀˆÃŽÃÊvœÀʘi« ÀœÌœÝˆVˆÌÞÊ
After changes in dosing regimen
­i°}°Ê`ˆ>LiÌiÃ]ʎˆ`˜iÞÊ/8®
Patient is on dialysis
If trough higher than desired
Patient in acute renal failure, SCr increased troughs, use patient specific
LÞÊä°xʓ}É`ʜÀÊÎä¯vÀœ“ÊL>Ãiˆ˜iÊ
dosing to adjust dose.
Major changes in the patient’s volume status
146
Amikacin is the preferred agent to treat all mycobacterial infections,
except Mycobacterium chelonae. For M. chelonae infections,
Tobramycin is the recommended aminoglycoside. Streptomycin
is another aminoglycoside sometimes used to treat mycobacterial
infections such as M. tuberculosis. Please contact the Antimicrobial
Stewardship Program pharmacist for Tobramycin/Streptomycin dosing
recommendation for this indication.
Amikacin:
œÀ“>ÊÀi˜>Êv՘V̈œ˜\
"˜ViÊ`>ˆÞ\Ê£xʓ}Ɏ}Ê6Ê+Ó{Ê­œÀÊ£äʓ}Ɏ}Ê6Ê+Ó{ʈvʀxäÊÞi>ÀÃʜvÊ
age)
/ ÀˆViÊÜiiŽÞ\ÊÓxʓ}Ɏ}Ê6ÊÌ ÀiiÊ̈“iÃÊ>ÊÜiiŽÊ­“>ÞÊLiʓœÀiÊ`ˆvwVՏÌÊ
to tolerate)
L˜œÀ“>ÊÀi˜>Êv՘V̈œ˜\ Discuss with pharmacy clinical specialist
Therapeutic drug monitoring: Peak and trough not generally
˜iViÃÃ>ÀÞ]ÊiÝVi«Ìʈ˜ÊÌ œÃiÊÜˆÌ ÊÀi˜>Êˆ˜ÃÕvwVˆi˜VÞÊ­,ʐÈäʓɓˆ˜®Ê
>˜`ʈvÊ- Àʈ˜VÀi>ÃiÃÊLÞÊä°xʓ}É`ʜÀʀÎä¯ÊvÀœ“ÊL>Ãiˆ˜iÊÜ ˆiÊ«>̈i˜ÌÊ
on aminoglycoside therapy. Check a trough concentration to monitor for
toxicity. Peaks in the low 20 mcg/mL range are acceptable, and trough
Vœ˜Vi˜ÌÀ>̈œ˜ÃÊ>ÀiÊ«ÀiviÀ>LÞʐ{ʓVɓʜÀÊ՘`iÌiVÌ>Li°
Aminoglycoside dosing in urinary tract infections
CrCl (mL/min)
≥60
40-59
20-39
ÓäÊ
Gentamicin/Tobramycin
3 mg/kg IV Q24H or
1 mg/kg IV Q8H
1 mg/kg Q12H
1 mg/kg Q24H
£Ê“}Ɏ}Ê"
IÊ
Amikacin
10 mg/kg IV Q24H or
3 mg/kg IV Q8H
3 mg/kg IV Q12H
3 mg/kg IV Q24H
Îʓ}Ɏ}Ê6Ê"
I
*Give one dose, check level in 24 hours, redose when Gentamicin/Tobramycin level
£Ê“V}ɓʜÀʓˆŽ>Vˆ˜Ê{ʓV}ɓ
“ˆ˜œ}ÞVœÃˆ`iÃÊ>ÀiÊ ˆ} ÞÊVœ˜Vi˜ÌÀ>Ìi`ʈ˜ÊÕÀˆ˜iÆÊÌ iÀivœÀi]ÊÌ iÀ>«iṎVÊ
drug monitoring is not necessary in patients with normal renal function.
Suggested doses in the above table will likely provide adequate urine
concentrations for highly susceptible organisms. Trough should be
checked to monitor for toxicity in patients with renal insufficiency
­,ʐÈäʓɓˆ˜®Ê>˜`ʈvÊ- Àʈ˜VÀi>ÃiÃÊLÞÊä°xʓ}É`ʜÀʀÎä¯ÊvÀœ“Ê
baseline while patient on aminoglycoside therapy.
UÊÊGentamicin/Tobramycin:Ê`iÈÀi`ÊÌÀœÕ} ʐ£Ê“V}ɓʜÀÊ՘`iÌiVÌ>Li°Ê
UÊÊAmikacin:Ê`iÈÀi`ÊÌÀœÕ} ʐ{ʓV}ɓʜÀÊ՘`iÌiVÌ>Li°
147
A. Aminoglycoside dosing and monitoring
A
Aminoglycoside dosing in mycobacterial
infections
A. Aminoglycoside dosing and monitoring
A
Aminoglycoside dosing in the SICU/WICU
Gentamicin/Tobramycin
Loading dose 4 mg/kg using actual body weight, followed by a
patient-specific maintenance dose.
Amikacin
Loading dose 16 mg/kg using actual body weight, followed by a
patient-specific maintenance dose.
Therapeutic Drug Monitoring
vÌiÀʏœ>`ˆ˜}Ê`œÃi\Ê£Ê œÕÀÊ«i>ŽÊ>˜`ÊnÊ œÕÀʏiÛiÊ>vÌiÀÊÌ iÊi˜`ʜvÊÌ iÊ
infusion to facilitate calculating patient specific kinetic parameters.
Aminoglycoside dosing for Gram-positive synergy
Dosing for patients with normal renal function:
UÊGentamicin\ÊÎʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞʈÃÊÀiVœ““i˜`i`ÊvœÀÊÌÀi>̓i˜ÌÊ
of endocarditis with Viridans streptococci or S. bovis in patients with
normal renal function (CrCl 60 ml/min).
UÊÊGentamicin: 1 mg/kg IV Q8H is recommended for treatment
Enterococcal and other Gram-positive endocarditis infections in
patients with normal renal function (CrCl 60 ml/min). Patients >65
years old should be started on Q12H if normal renal function.
Dosing adjustment for renal insufficiency
CrCl (mL/min)
{äqx™ÊÊ
ÓäqΙÊÊ
ÓäÊ
Dosing
£Ê“}Ɏ}Ê+£Ó
£Ê“}Ɏ}Ê+Ó{
£Ê“}Ɏ}Ê"
I
IÊʈÛiʜ˜iÊ`œÃi]ÊV iVŽÊiÛiÊˆ˜ÊÓ{Ê œÕÀÃ]ÊÀi`œÃiÊÜ i˜ÊiÛiÊ£Ê“}É
NOTE: See infective endocarditis guidelines (p. 65) for duration.
THERAPEUTIC DRUG MONITORING
UÊÊ*i>ŽÊ>˜`ÊÌÀœÕ} Ê>ÀiÊÀiVœ““i˜`i`Ê>ÀœÕ˜`ÊÌ iÊÌ ˆÀ`Ê`œÃiÊ̜Ê>ÃÃÕÀiÊ
appropriate dosing.
UÊÊ iÈÀi`ÊÃiÀՓÊVœ˜Vi˜ÌÀ>̈œ˜ÃʜvÊGentamicin
Peak levels:ÊÎqxʓV}ɓ
Trough levels:ʐʣʓV}ɓ
148
NEPHROTOXICITY
UÊÊSerum creatinine should be measured at least every other day. If
VÀi>̈˜ˆ˜iʈ˜VÀi>ÃiÃÊLÞÊä°xʓ}É`ʜÀʀÎä¯ÊvÀœ“ÊL>Ãiˆ˜i]ÊÕÃiÊ«>̈i˜ÌÊ
specific dosing.
UÊÊi>ÃÕÀiÊserum aminoglycoside levels as needed. See each dosing
section above for frequency.
UÊÊ-œ“iÊ`>Ì>ÊÃÕ}}iÃÌÊÌ >ÌʏœÜiÃÌʏiÛiÊœvʘi« ÀœÌœÝˆVˆÌÞʜVVÕÀÃÊÜ i˜Ê
aminoglycosides are administered during the activity period (e.g.
£Î\Îä®]ÊÌ iÀivœÀiÊ>vÌiÀ˜œœ˜Ê>`“ˆ˜ˆÃÌÀ>̈œ˜ÊˆÃÊ«ÀiviÀÀi`°Ê
OTOTOXICITY
UÊÊ œ˜Ãˆ`iÀÊLˆÜiiŽÞÊVˆ˜ˆV>ÊÃVÀii˜ˆ˜}ÊvœÀʜ̜̜݈VˆÌÞ
Ê UÊÊ iVŽÊL>Ãiˆ˜iÊۈÃÕ>Ê>VՈÌÞÊÕȘ}Ê>Ê-˜ii˜Ê«œVŽiÌÊV>À`
Ê UÊÊ/œÊÃVÀii˜ÊvœÀʜ̜̜݈VˆÌÞ]Ê >ÛiÊ«>̈i˜ÌÊà >ŽiÊ i>`Ê>˜`ÊÌ i˜ÊÀi‡Ài>`Ê
card.
Ê UÊÊ œ˜ViÀ˜Êà œÕ`ÊLiÊÀ>ˆÃi`ʈvÊ«>̈i˜ÌʏœÃiÃÊÓʏˆ˜iÃʜvÊۈÃÕ>Ê>VՈÌÞ°Ê
Consider formal audiology testing.
Ê UÊÊ œ˜Ì>VÌÊÕ`ˆœœ}ÞÊ­x‡È£xήÊvœÀÊ i«ÊÜˆÌ ÊÌiÃ̈˜}ÊvœÀʜ̜̜݈VˆÌÞ
,iviÀi˜ViÃ\
*É* Ê«>À>“iÌiÀ\ÊʘviVÌÊ ˆÃÊ£™nÇÆÊ£xx\™Îq™™
"˜ViÊ`>ˆÞʘœ“œ}À>“ÃÊÀiۈiÜ\ÊPharmacotherapy ÓääÓÆÊÓÓ­™®\£äÇÇq£änΰ
*>̈i˜Ì‡Ã«iVˆwVÊ`œÃˆ˜}\ÊCrit Care MedÊ£™™£ÆÊ£™\£{näq£{nx°
- 1É7 1Ê`œÃˆ˜}\ÊSurgeryÊ£™™nÆÊ£Ó{\Ç·n°
i« ÀœÌœÝˆVˆÌÞ\ÊAntimicrob Agents and ChemotherÊÓääÎÆÊ{Ç\£ä£ä°
/-É -ÊÞVœL>VÌiÀˆÕ“ÊՈ`iˆ˜iÃ\ÊAm J Respir Crit Care MedÊÓääÇÆÊ£Çx\ÎÈÇq{£È°
À>“‡«œÃˆÌˆÛiÊ-ޘiÀ}Þ\ÊCirculationÊÓääxÆÊ£££­Óή\ÊiΙ{Êq{Î{°
149
A. Aminoglycoside dosing and monitoring
A
Monitoring for toxicity for inpatients
B. Vancomycin dosing and monitoring
A
Vancomycin dosing and monitoring
DOSING
£°Ê Ã̈“>ÌiÊVÀi>̈˜ˆ˜iÊVi>À>˜ViÊ­ À ®ÊÕȘ}Ê œVŽVÀœv̇>ՏÌÊiµÕ>̈œ˜\
À Êr
­£{äÊqÊ>}i®Ê­Üiˆ} Ìʈ˜ÊŽ}®Ê
72 (serum creatinine*)
x 0.85 (if female)
* For patients with low muscle mass (i.e. many patients > 65 yrs), some advocate using
a minimum value of 1 to avoid overestimation of CrCl
2. Patients who are seriously ill with complicated infections such as
meningitis, pneumonia, osteomyelitis, endocarditis, and
bacteremia and normal renal function should receive initial loading
dose of 20-25 mg/kg, followed by 15-20 mg/kg Q8-12H using
Actual Body Weight (ABW). For other indications see nomogram
dosing below.
3. Calculate maintenance dose (using ABW) based on estimated or
actual CrCl. See suggested nomogram dosing below.
Note: Younger patients with normal renal function may need higher or
more frequent dosing than suggested below.
Weight
(kg)
{äÊ
{äqÈäÊ
>60
30–59
Consult Pharmacy
Çxäʓ}Ê
Çxäʓ}ÊÊ
Q12H
Q24H
ÈäqÇxÊ £äääʓ}Ê £äääʓ}ÊÊ
Q12H
Q24H
Çxq™äÊ £Óxäʓ}Ê £Óxäʓ}ÊÊ
Q12H
Q24H
™äq££äÊ £xääʓ}Ê £xääʓ}ÊÊ
Q12H
Q24H
££äq£ÓxÊ £Çxäʓ}Ê £Çxäʓ}ÊÊ
Q12H
Q24H
£Óxq£{äÊ Óäääʓ}Ê Óäääʓ}ÊÊ
Q12H
Q24H
>140
Consult Pharmacy
CrCl (mL/min)
15–29
<15
Çxäʓ}Ê
Q48H
£äääʓ}Ê
Q48H
£Óxäʓ}Ê
Q48H
£xääʓ}Ê
Q48H
£Çxäʓ}Ê
Q48H
Óäääʓ}Ê
Q48H
£äääʓ}]ÊÌ i˜ÊÀi`œÃiÊLÞʏiÛi†
£äääʓ}]ÊÌ i˜ÊÀi`œÃiÊLÞʏiÛi†
£Óxäʓ}]ÊÌ i˜ÊÀi`œÃiÊLÞʏiÛi†
£xääʓ}]ÊÌ i˜ÊÀi`œÃiÊLÞʏiÛi†
£Çxäʓ}]ÊÌ i˜ÊÀi`œÃiÊLÞʏiÛi†
Óäääʓ}]ÊÌ i˜ÊÀi`œÃiÊLÞʏiÛi†
œÀÊ«>̈i˜ÌÃÊÜˆÌ Ê À Ê£xʓɓˆ˜Ê>˜`ʘœÌÊÀiViˆÛˆ˜}Ê i“œ`ˆ>ÞÈÃÊÀi`œÃiÊÜ i˜ÊÀ>˜`œ“Ê
iÛiÊ£xqÓäʓV}ɓ°Ê
†
DOSING IN RENAL REPLACEMENT THERAPY
Dosing is dependent on type of renal replacement therapy.
Intermittent Hemodialysis (iHD)
UÊInitial dose: 15-20 mg/kg once
UÊÊ*>̈i˜ÌÃÊà œÕ`ÊLiÊÀi‡`œÃi`ÊL>Ãi`ʜ˜ÊÃiÀՓʏiÛiÃÊ`À>ܘÊ>ÀœÕ˜`ÊÌ iÊ
dialysis session. Consider redosing at 5-10 mg/kg.
150
Continuous Renal Replacement Therapy (e.g. CVVHD)
UÊLoading dose: 25-30 mg/kg once
UÊÊMaintenance: 15-20 mg/kg q24h (assuming no interruption in CRRT,
e.g. line clotting)
Ê UÊ œÌi\Ê ˆ>ÞÈÃÊyœÜÊÀ>ÌiÃʀӰxÊÉ Ê‡ÊVœ˜ÃՏÌÊ« >À“>VÞ
UÊMonitoring:
Ê UÊÊ*>̈i˜ÌÃÊÜˆÌ ÊV >˜}ˆ˜}Ê`ˆ>ÞÈÃÊyœÜÊÀ>ÌiÃʜÀÊ`ˆ>ÞÈÃÊ i`ÊvœÀʀ{Ê
hours may need more frequent monitoring (consult pharmacy)
Ê UÊÊ*>̈i˜ÌÃʜ˜ÊÃÌ>LiÊ`ˆ>ÞÈÃÊyœÜÊÀ>ÌiÃÊà œÕ`Ê >ÛiÊÌÀœÕ} ʏiÛiÊ
checked prior to 4th dose
Peritoneal Dialysis (PD)
UÊInitial dose: 15-20 mg/kg once
UÊÊÊ œ˜ÃՏÌÊ« >À“>VÞÊvœÀÊÀiVœ““i˜`>̈œ˜ÃÊvœÀÊÀi‡`œÃˆ˜}Ê>˜`ʓœ˜ˆÌœÀˆ˜}Ê
serum levels.
THERAPEUTIC DRUG MONITORING (LEVELS)
UÊTrough levels are the most accurate and practical method for
monitoring Vancomycin effectiveness and toxicity.
UÊPeak levels should NOT be obtained.
Measuring serum Vancomycin levels
UÊÊ/ÀœÕ} ʏiÛiÃÊà œÕ`ÊLiʜLÌ>ˆ˜i`ÊÜˆÌ ˆ˜ÊÎäʓˆ˜ÕÌiÃʜvÊÌ iʘiÝÌÊ`œÃiÊ>ÌÊ
steady-state conditions (approximately before the 4th dose).
UÊʘʫ>̈i˜ÌÃÊÜˆÌ Ê -, ʜ˜Ê i“œ`ˆ>ÞÈÃ]ʈÌʈÃÊ«ÀiviÀ>LiÊ̜ʜLÌ>ˆ˜Ê>Ê
pre-hemodialysis level with the routine laboratory venipuncture on the
morning of hemodialysis. In the event a pre-hemodialysis level is not
obtained, a post-hemodialysis level may be drawn at least six hours
after the dialysis session.
UÊÊ/ÀœÕ} ʏiÛiÃÊà œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ Ê>˜ÞÊÌ iÊvœœÜˆ˜}Ê
VˆÀVՓÃÌ>˜ViÃ\
UÊÊ,iViˆÛˆ˜}Ê>}}ÀiÃÈÛiÊ`œÃˆ˜}Ê­€£xääʓ}Ê+£Ó®ÊœÀÊ+nʈ˜ÌiÀÛ>
U Serious infections such as meningitis, endocarditis, osteomyelitis,
and MRSA pneumonia.
UÊÊ1˜ÃÌ>LiÊÀi˜>Êv՘V̈œ˜Ê­V >˜}iʈ˜Ê- ÀʜvÊä°xʓ}É`ʜÀÊxä¯ÊvÀœ“Ê
baseline) or dialysis
151
A
B. Vancomycin dosing and monitoring
Ê UÊÊÊ*Ài‡`ˆ>ÞÈÃʏiÛiÊ(preferred)\ʐÓxʓV}ɓʭvœÀʓi˜ˆ˜}ˆÌˆÃÊVœ˜Ãˆ`iÀÊ
Ài‡`œÃˆ˜}ʈvʐÎäʓV}ɓ®
Ê UÊ*œÃ̇`ˆ>ÞÈÃʏiÛi\ʐÓäʓV}ɓ®
Note:ʓÕÃÌÊÜ>ˆÌÊÎqÈÊ œÕÀÃÊ>vÌiÀÊÌ iÊi˜`ʜvÊÌ iÊ`ˆ>ÞÈÃÊ̜Ê>VVœÕ˜ÌÊvœÀÊ
redistribution of tissue and plasma levels
UÊʜÀÊ«>̈i˜ÌÃÊÜˆÌ Ê -, ʜ˜Ê>ÊÃÌ>LiÊ ÊÃV i`Տi]Ê>ÊÀi}ˆ“i˜Êà œÕ`ÊLiÊ
established that coincides with HD (e.g. 500 mg qHD). Once weekly
serum levels can be drawn to monitor for accumulation.
B. Vancomycin dosing and monitoring
A
UÊÊ œ˜VÕÀÀi˜ÌÊÌ iÀ>«ÞÊÜˆÌ Ê˜i« ÀœÌœÝˆVÊ>}i˜ÌÃÊ­i°}°Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]Ê
Colistin, Amphotericin B)
UÊ*Àœœ˜}i`ÊVœÕÀÃiÃÊ­≥ 5 days) of therapy.
UÊÀiµÕi˜VÞʜvʓœ˜ˆÌœÀˆ˜}Ê6>˜Vœ“ÞVˆ˜ÊÌÀœÕ} ʏiÛiÃ\Ê
UÊÊ"˜Vi‡ÜiiŽÞʓœ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ ÊÃÌ>LiÊ
renal function who have achieved desired trough levels.
UÊʜÀiÊvÀiµÕi˜Ìʓœ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜ œÊ>ÀiÊ
hemodynamically unstable and/or with changing renal function.
Desired Vancomycin trough levels
UÊÊ*˜iՓœ˜ˆ>]ʜÃÌiœ“ÞiˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]ÊL>VÌiÀi“ˆ>\Ê£x‡ÓäʓV}ɓ
UÊÊ -ʈ˜viV̈œ˜Ã\ÊÓäʓV}ɓ
UÊÊ iÕÌÀœ«i˜ˆVÊviÛiÀ]ÊΈ˜Ê>˜`ÊΈ˜‡ÃÌÀÕVÌÕÀiʈ˜viV̈œ˜Ã\ʣ䇣xʓV}ɓ
UÊʈ˜ˆ“Õ“ÊÃiÀՓÊÌÀœÕ} ÊVœ˜Vi˜ÌÀ>̈œ˜Ãʀ£äʓV}ɓÊà œÕ`Ê>Ü>ÞÃÊ
be maintained to avoid development of resistance.
Monitoring for Toxicity
UÊÊ-iÀՓÊVÀi>̈˜ˆ˜iÊà œÕ`ÊLiʓi>ÃÕÀi`Ê>Ìʏi>ÃÌÊiÛiÀÞÊœÌ iÀÊ`>Þʈ˜ˆÌˆ>Þ]Ê
then weekly if patient’s renal function remains stable.
UÊʈ“ˆÌi`Ê`>Ì>ÊÃÕ}}iÃÌÊ>Ê`ˆÀiVÌÊV>ÕÃ>ÊÀi>̈œ˜Ã ˆ«ÊLiÌÜii˜Ê
nephrotoxicity and higher serum trough concentrations (>15-20 mcg/
mL). Monitor Vancomycin trough levels (see above for frequency and
indications).
UÊʜÀ“>Ê>Õ`ˆœœ}ÞÊÌiÃ̈˜}ʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê
Vancomycin, unless signs and symptoms of ototoxicity became
apparent.
,iviÀi˜ViÃ\
-É-*É- *ÊՈ`iˆ˜iÃÊÌ iÀ>«iṎVʓœ˜ˆÌœÀˆ˜}ʜvÊ6>˜Vœ“ÞVˆ˜\ʓÊÊi>Ì ‡-ÞÃÌÊ
* >À“°ÊÓää™ÆÊÈÈÆÊnÓ°Ê
œÀÃiÊiÌÊ>°Ê˜Ìˆ“ˆVÀœLˆ>Ê}i˜ÌÃÊ i“œÌ iÀÊ£™nÇÆÊΣ\£Ç·ǰ
6>˜`iV>ÃÌiiiÊiÌÊ>°Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓ䣣ÆÊxÎ\£Ó{q™°
>ÀÌ ÊiÌÊ>°Êˆ`˜iÞʘÌÊ£™™ÈÆÊxä\™Ó™qÎÈ°
152
153
œÀ“>ÊÀi˜>Êv՘V̈œ˜\
CBC, BUN, Creatinine
ÊÊÊÊ6>˜Vœ“ÞVˆ˜ÊiÛiÊqÊtrough
(see dosing section p. 150)
ˆ>ÞÈÃ\
Vancomycin level
(see dosing section p. 150)
At each dialysis session
C. Antimicrobial therapy monitoring
A
Weekly
Weekly, unless change in creatinine
( xä¯ÊvÀœ“ÊL>Ãiˆ˜i®]ÊÌ i˜ÊÌ܈ViÊÜiiŽÞÊ
,iviÀi˜Vi\Ê*À>V̈ViÊՈ`iˆ˜iÃÊvœÀÊ"ÕÌ«>̈i˜ÌÊ*>Ài˜ÌiÀ>Ê˜Ìˆ“ˆVÀœLˆ>Ê/ iÀ>«Þ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓää{ÆÊÎn\£Èx£°
Vancomycin
UÊʜ˜}ÊÌiÀ“Ê`iw˜i`Ê>ÃÊ≥ 1 week, except for aminoglycosides and Amphotericin B (see below)
UÊʜÀÊÕÃiʜ˜Viʈ˜ˆÌˆ>Ê`œÃˆ˜}Ê>˜`ÊÃiÀՓʏiÛiÃÊ >ÛiÊLii˜ÊiÃÌ>LˆÃ i`
UÊÊ/ iÃiʓœ˜ˆÌœÀˆ˜}ÊÀiVœ““i˜`>̈œ˜ÃÊ>˜`ʓœ˜ˆÌœÀˆ˜}ÊvœÀÊ>}i˜ÌÃʘœÌʏˆÃÌi`Êà œÕ`ÊLiʈ˜`ˆÛˆ`Õ>ˆâi`]ÊL>Ãi`ʜ˜Êi>V Ê«>̈i˜Ì½ÃÊVˆ˜ˆV>Êvi>ÌÕÀiÃ]ʈ˜VÕ`ˆ˜}Ê}i˜iÀ>Ê i>Ì ÊÃÌ>ÌÕÃ]Ê>}i]Ê
underlying conditions and organ dysfunction, concomitant medications, drug treatment history, type of infection, and type and dose of antibiotic
Test
Frequency
Antimicrobial agent(s)
Other
CBC
Weekly
Aminoglycosides (Amikacin, Gentamicin,
Clinical monitoring and patient education
BUN, Creatinine
Twice weekly
Tobramycin, Streptomycin)
for hearing/vestibular dysfunction at
“ˆ˜œ}ÞVœÃˆ`iʏiÛiÊqÊtrough
Weekly
each visit (see p. 149 for vestibular
(see dosing section p. 145)
(twice weekly, if increased risk)
screening method)
BUN, Creatinine, K, Mg, Phos
Twice weekly
Amphotericin B, AmBisome®
CBC, AST, ALT
£qÓÊÜiiŽÃÊ
CBC, BUN, Creatinine
Weekly
-lactams (Aztreonam, carbapenems,
cephalosporins, penicillins)
add AST/ALT/bilirubin
Weekly
Oxacillin, Nafcillin, carbapenems
add K
Weekly
Penicillin G potassium
AST/ALT/bilirubin
Weekly
Micafungin
BUN, Creatinine
Weekly
Colistin
Clinical monitoring for neurotoxicity
(twice weekly, if increased risk)
(dizziness, paresthesia, vertigo,
confusion, visual disturbances, ataxia)
CBC, BUN, Creatinine , CPK
Weekly
Daptomycin
Clinical monitoring for myopathy
CBC
Weekly
Linezolid
Clinical monitoring for peripheral
neuropathy and optic neuritis
CBC, AST/ALT/bilirubin
Weekly
Rifampin
Drug interactions (monitor start of any
new medications)
CBC, AST/ALT/ bilirubin
£ÊqÊÓÊÜiiŽÃ
Voriconazole /Posaconazole
Drug interactions (monitor start of any
new medication), visual changes
Recommendations for monitoring patients receiving long-term antimicrobial therapy
°
D. Oral antimicrobial use
A
Oral antimicrobial use in hospitalized patients
When using an agent that is considered to be bioequivalent (no
significant difference in rate and extent of absorption of the therapeutic
ingredient) via the parenteral and oral route, the oral formulation is
preferred if the patient does not have the contraindications listed below.
Contraindications to oral therapy
UÊ *"Ê­ˆ˜VÕ`ˆ˜}ʓi`ˆV>̈œ˜Ã®Ê
UÊʘ>LˆˆÌÞÊ̜ÊÌ>ŽiÊœÌ iÀʜÀ>Ê“i`ˆV>̈œ˜ÃÊ",ʘœÌÊ̜iÀ>̈˜}Ê>ʏˆµÕˆ`Ê
diet/tube feeds
UÊi“œ`ޘ>“ˆVʈ˜ÃÌ>LˆˆÌÞÊ
UÊ,iViˆÛˆ˜}ÊVœ˜Ìˆ˜ÕœÕÃÊ ÊÃÕV̈œ˜ˆ˜}Ê
UÊÊ-iÛiÀiʘ>ÕÃi>]Êۜ“ˆÌˆ˜}]Ê`ˆ>ÀÀ i>]ÊʜLÃÌÀÕV̈œ˜]Ê`ÞӜ̈ˆÌÞ]Ê
mucositis
UÊʓ>>LÜÀ«Ìˆœ˜ÊÃޘ`Àœ“iÊ
U A concomitant disease state that contraindicates the use of oral
medications
NOTE: There are only a limited number of agents that can be
used orally for bacteremia or fungemia; these are noted in
the table below.
Bioavailability of oral antimicrobials
Antimicrobial
% Oral absorption
Should NOT be used orally for bacteremia
“œÝˆVˆˆ˜Ê
Ç{Êqʙä¯
Amoxicillin/Clavulanate (Augmentin®®ÊÊÊ
Ç{Êqʙä¯
Azithromycin*Ê
ÎnÊqÊnί
i« >i݈˜ÊÊ
™ä¯
Cefpodoxime*ÊÊ
{£ÊqÊxä¯
ˆ˜`>“ÞVˆ˜ÊÊ
™ä¯
œÝÞVÞVˆ˜iÊ
™äÊqÊ£ää¯
/iÌÀ>VÞVˆ˜iÊÊ
ÇxÊqÊnä¯
Can be used orally for bacteremia or fungemia
Ciprofloxacin Ê
ÈxÊqÊnx¯
Fluconazole
>™ä¯
Linezolid†Ê
£ää¯
iÌÀœ˜ˆ`>✏iÊ
£ää¯
Moxifloxacin Ê
™ä¯
Trimethoprim/sulfamethoxazole†Ê
£ää¯
Voriconazole‡¶Ê
ÈäÊqʙȯ
* Oral absorption is enhanced in presence of food
† Should not be used for S. aureus bacteremia
‡ Oral absorption is decreased in presence of food
¶ Inter-patient variability
œÊ˜œÌÊÕÃiÊÜˆÌ ÊVœ˜Ìˆ˜ÕœÕÃÊÌÕLiÊvii`ÃÊ­6Ê«ÀiviÀÀi`®°Ê*>̈i˜ÌÃÊÜˆÌ ÊVÞVˆVÊÌÕLiÊvii`Ã\Ê
separate oral fluoroquinolone by 2 hours before and 6 hours after tube feeds.
154
Dosing recommendations can vary according to indication and patientspecific parameters. All dosage adjustments are based on creatinine
clearance calculated by Cockcroft-Gault equation.
CrCl =
(140 – age) (weight in kg) x 0.85 (if female)
72 (serum creatinine*)
*
For patients with low muscle, some advocate using a minimum of 1 to avoid
overestimation of CrCl.
†
If patient is on hemodialysis (HD) schedule administration so that patient
receives daily dose immediately AFTER dialysis. For assistance with dosage
adjustments for patients receiving CVVHD or CVVHDF, please call pharmacy.
Drug
Typical dose
(may vary)
CrCl
(mL/min)
Dose adjustment for
renal insufficiency
VÞVœÛˆÀÊ6ÊÊÊ
Ê
Ê
Ê
Acyclovir PO
­i˜ˆÌ>Ê iÀ«iîÊ
Acyclovir PO
­iÀ«iÃÊ<œÃÌiÀ®ÊÊ
Ê
Amikacin
xq£äʓ}Ɏ}Ê+nÊ
Ê
Ê
Ê
200 mg 5x daily
Ê
800 mg 5x daily
Ê
Ê
€xäÊ
ÓxqxäÊ
£äqÓ{Ê
†
£äʜÀÊ Ê
>10
£äÊ
>25
£äqÓxÊ
†
£äʜÀÊ
“œÝˆVˆˆ˜Ê
Ê
Ê
Amoxicillin
­«˜iՓœ˜ˆ>®Ê
Ê
“œÝˆVˆˆ˜ÉÊ
V>ÛՏ>˜>ÌiÊ
Ê
“« œÌiÀˆVˆ˜Ê Ê
AmBisome®Ê
“«ˆVˆˆ˜Ê
Ê
Ê
“«ˆVˆˆ˜ÉÊ
ÃՏL>VÌ>“Ê
xääq£äääʓ}Ê+£ÓÊ
Ê
Ê
1 g Q8H
Ê
Ê
xääq£äääʓ}Ê+£ÓÊ
Ê
Ê
ä°Çq£Ê“}Ɏ}Ê+Ó{Ê
Îqxʓ}Ɏ}Ê+Ó{Ê
£qÓÊ}Ê+{qÈÊÊ
Ê
Ê
£°xqÎÊ}Ê+ÈÊ
Ê
Ampicillin/
ÃՏL>VÌ>“Ê­vœÀÊ
Acinetobacter,
E. faecalis)
âˆÌ Àœ“ÞVˆ˜Ê
âÌÀiœ˜>“ÊÊ
Ê
Ê
iv>✏ˆ˜Ê
Ê
Ê
3 g Q4H
Ê
€ÎäÊ
£äqÎäÊ
†
£äʜÀÊ Ê
>30
£äqÎäÊ
†
£äʜÀÊ
€ÎäÊ
£äqÎäÊ
†
£äʜÀÊ
qÊ
qÊ
€xäÊ
£äqxäÊ
†
£äʜÀÊ Ê
≥ÎäÊ
£xqәÊ
†
≤14 or HD Ê
≥50
£äqxäÊ
†
HD
xq£äʓ}Ɏ}Ê+n
xq£äʓ}Ɏ}Ê+£Ó
xq£äʓ}Ɏ}Ê+Ó{
Ó°xqxʓ}Ɏ}Ê+Ó{
200 mg 5x daily
Óääʓ}Ê+£ÓÊ
800 mg 5x daily
nääʓ}Ê+n
800 mg Q12H
See section on
aminoglycoside dosing
xääq£äääʓ}Ê+£Ó
ÓxäqnÇxʓ}Ê+£Ó
ÓxäqnÇxʓ}Ê+Ó{
1g Q8H
£}Ê+£Ó
1g Q24H
xääq£äääʓ}Ê+£Ó
Óxäqxääʓ}Ê+£Ó
Óxäqxääʓ}Ê+Ó{
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
£qÓÊ}Ê+{qÈ
£qÓÊ}Ê+Èqn
£qÓÊ}Ê+n
£°xqÎÊ}Ê+È
£°xqÎÊ}Ê+£Ó
£°xqÎÊ}Ê+Ó{
3 g Q4H
ÎÊ}Ê+È
3 g Q8H
Óxäqxääʓ}Ê+Ó{Ê
£qÓÊ}Ê+nÊÊ
Ê
Ê
£qÓÊ}Ê+nÊ
Ê
Ê
qÊ
≥ÎäÊ
£äqәÊ
†
£äʜÀÊ Ê
≥ÎxÊ
££qÎ{Ê
£äʜÀÊ
†
intermittent HD
†
HD
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
£qÓÊ}Ê+nÊ
£qÓÊ}Ê+£ÓÊ
£qÓÊ}Ê+Ó{
£qÓÊ}Ê+n
£Ê}Ê+£Ó
£Ê}Ê+Ó{
2 g Q HD, if HD in 2 days
OR 3g Q HD, if HD in 3 days
155
E. Antimicrobial dosing in renal failure insufficiency
A
Antimicrobial dosing in renal insufficiency
E. Antimicrobial dosing in renal failure insufficiency
A
Drug
Typical dose
(may vary)
CrCl
(mL/min)
Dose adjustment for
renal insufficiency
Cefdinir
Ê
300 mg Q12H
Ê
≥30
ÎäÊ
HD†
>60
ÎäqÈäÊ
Ó™ÊœÀÊ
>60
ÎäqÈäÊ
££qәÊ
££ÊœÀÊ
≥ÎäÊ
£äqәÊ
£äʜÀÊ
≥ÎäÊ
ÎäÊ
HD†Ê
Ê
Ê
Ceftolozane/
Ì>âœL>VÌ>“Ê
Ê
Ê
600 mg Q12H
Ê
Ê
Ê
600 mg Q8H
Ê
Ê
Ê
£qÓÊ}Ê+nÊ
For PseudomonasÊ
ÓÊ}Ê+nÊ
Ê
1.5 g Q8H
Ê
Ê
Ê
>50
ÎäqxäÊ
£xqәÊ
£xʜÀÊ
>50
ÎäqxäÊ
£xqәÊ
£xʜÀÊ
€xäÊ
ÎäqxäÊ
£xqәÊ
£xʜÀÊ
>50
ÎäqxäÊ
£xqәÊ
Ó™ÊœÀÊ
Ceftolozane/
Ì>âœL>VÌ>“Ê
­-iÀˆœÕÃʘviV̈œ˜Ã®Ê
Ê
3 g Q8H
Ê
Ê
Ê
>50
ÎäqxäÊ
£xqәÊ
ÉәʜÀÊ
ivÌÀˆ>ݜ˜iÊ
ivÌÀˆ>ݜ˜iÊÊ
(Central nervous
system infections)
Cephalexin
Ê
Ê
Cidofovir
£qÓÊ}Ê+Ó{Ê
ÓÊ}Ê+£ÓÊ
qÊ
qÊ
300 mg Q12H
Î
Ê ääʓ}Ê+Ó{
300 mg QHD
1 g Q8H
Ê£Ê}Ê+£Ó
1 g Q24H
2 g Q8H
£Ê}Ê+nÊ
£Ê}Ê+£Ó
1 g Q24H
£qÓÊ}Ê+£Ó
£qÓÊ}Ê+Ó{
500 mg Q24H
£ääq{ääʓ}Ê+£Ó
£ääq{ääʓ}Ê+Ó{
Ê£ääq{ääʓ}ÊÌ ÀiiÊ̈“iÃÉ
week
600 mg Q12H
{ääʓ}Ê+£Ó
Îääʓ}Ê+£Ó
200 mg Q12H
600 mg Q8H
{ääʓ}Ê+n
Îääʓ}Ê+n
400 mg Q12H
£qÓÊ}Ê+n
£qÓÊ}Ê+£Ó
£qÓÊ}Ê+Ó{
1 g Q24H
1.5 g Q8H
Çxäʓ}Ê+n
ÎÇxʓ}Ê+n
Load with 750 mg, then
150 mg Q8H
3 g Q8H
£°xÊ}Ê+n
Çxäʓ}Ê+n
Load with 1.5 g, then
375 mg Q8H
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
500 mg PO Q6H
Ê
Ê
5 mg/kg Q week for
2 weeks, then every
other week
{ääʓ}Ê+nq£ÓÊÊ
Ê
ÓxäqÇxäʓ}Ê+£ÓÊ
Ê
Óxäqxääʓ}Ê+£ÓÊ
Ê
*"\ÊÎääʓ}Ê+nÊ
6\ÊÈääʓ}Ê+nÊ
2.5 mg/kg Q12H
Ê
>50
£äqxäÊ
£äʜÀÊ †
≤55 or Cr>1.5
500 mg Q6H
xääʓ}Ê+n
500 mg Q12H
Not recommended
≥ÎäÊ
ÎäʜÀÊ †
≥ÎäÊ
ÎäʜÀÊ †Ê
≥ÎäÊ
ÎäÊ
qÊ
Ê
≥50
ÓäqxäÊ
≤20 or HD†
{ääʓ}Ê+nq£ÓÊ
400 mg Q24H
ÓxäqÇxäʓ}Ê+£Ó
Óxäqxääʓ}Ê+Ó{
Óxäqxääʓ}Ê+£Ó
Óxäqxääʓ}Ê+Ó{
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
Cefepime
1 g Q8H
Ê
Ê
Ê
Ê
Cefepime
2 g Q8H
­ i˜ÌÀ>Ê˜iÀۜÕÃÊÊ
Ê
ÃÞÃÌi“ʈ˜viV̈œ˜ÃʜÀÊÊ Ê
Pseudomonas®Ê
Ê
ivœÌiÌ>˜Ê
£qÓÊ}Ê+£ÓÊÊ
Ê
Ê
Ê
Ê
iv«œ`œÝˆ“iÊ
£ääq{ääʓ}Ê+£ÓÊ
Ê
Ê
Ceftaroline
Ê
Ê
Ê
Ceftaroline for
,-Ê
Ê
Ê
ivÌ>âˆ`ˆ“iÊ
ˆ«ÀœyœÝ>Vˆ˜Ê6Ê
Ê
ˆ«ÀœyœÝ>Vˆ˜Ê*"Ê
Ê
>ÀˆÌ Àœ“ÞVˆ˜Ê
Ê
ˆ˜`>“ÞVˆ˜Ê
Ê
Colistin
­ œˆÃ̈“iÌ >Ìi®Ê
156
†
†
†
†
†
†
†
†
2.5 mg/kg Q12H
Ó°xʓ}Ɏ}Ê+Ó{
1.25 mg/kg Q24H
Typical dose
(may vary)
CrCl (mL/min)
Dose adjustment for
renal insufficiency
>«Ìœ“ÞVˆ˜ÊÊ
vœÀÊi˜`œV>À`ˆÌˆÃÉÊ
bacteremia
ˆVœÝ>Vˆˆ˜Ê
œÝÞVÞVˆ˜iÊ
Ertapenem
Ê
Ì >“LÕ̜Ê
Ê
Èq£äʓ}Ɏ}Ê+Ó{ÊÊ
Ê
ÕVœ˜>✏iÊ
Óääqnääʓ}Ê+Ó{Ê
≥ÎäÊ
ÎäÊ
HD†Ê
qÊ
qÊ
≥30
ÎäʜÀÊ
≥10
£äÊ
HD†
≥50
Ê
Ê
ÕVÞ̜ȘiÊ­xq ®Ê
Ê
Ê
Ê
Ganciclovir
­˜`ÕV̈œ˜Ê`œÃi®Ê
Ê
Ê
Ê
Ê
Ê
£Ó°xqÓxʓ}Ɏ}Ê+ÈÊ
Ê
Ê
Ê
5 mg/kg Q12H
Ê
Ê
Ê
Ê
xäʜÀÊ †
ÊÊ
€{äÊ
Óäq{äÊ
£äq£™Ê
£äʜÀÊ †Ê
≥70
xäqșÊ
Óxq{™Ê
£äqÓ{Ê
£äʜÀÊ †
Ganciclovir
­>ˆ˜Ìi˜>˜ViÊÊ
`œÃi®Ê
Ê
Ê
5 mg/kg Q24H
Ê
Ê
Ê
Ê
≥70
xäqșÊ
Óxq{™Ê
£äqÓ{Ê
£äʜÀÊ
i˜Ì>“ˆVˆ˜Ê
qÊ
qÊ
ܘˆ>âˆ`Ê
ˆ˜i✏ˆ`Ê
Meropenem
Ê
Ê
Ê
Meropenem
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ˆ˜viV̈œ˜Ã®ÊÊ
Ê
iÌÀœ˜ˆ`>✏iÊ
ˆV>v՘}ˆ˜Ê
œÝˆyœÝ>Vˆ˜Ê
Nitrofurantoin
(Macrobid®®Ê
Oseltamivir
­/Ài>̓i˜Ì®Ê
Ê
Ê
Oseltamivir
­*Àœ« ޏ>݈îÊ
Ê
Ê
"Ý>Vˆˆ˜Ê
*i˜ˆVˆˆ˜ÊÊÊ
Ê
Ê
Îääʓ}Ê+Ó{Ê
Èääʓ}Ê+£ÓÊ
1 g Q8H
Ê
Ê
Ê
2 g Q8H
Ê
Ê
Ê
xääʓ}Ê+nÊ
£ääq£xäʓ}Ê+Ó{Ê
{ääʓ}Ê+Ó{ÊÊ
100 mg Q12H
Ê
75 mg Q12H
Ê
Ê
Ê
75 mg Q24H
Ê
Ê
Ê
£qÓÊ}Ê+{qÈÊÊ
Îq{ʓˆˆœ˜Ê՘ˆÌÃÊ+{Ê
Ê
Ê
qÊ
qÊ
>51
ÓÈqxäÊ
£äqÓxÊ
£äʜÀÊ
>51
ÓÈqxäÊ
£äqÓxÊ
£äʜÀÊ
qÊ
qÊ
qÊ
≥50
xäÊ
>60
ÎäqÈäÊ
£äqәÊ
£äʜÀÊ
>60
ÎäqÈäÊ
£äqәÊ
£äʜÀÊ
qÊ
≥xäÊ
£äq{™Ê
£äʜÀÊ
Èq£äʓ}Ɏ}Ê+Ó{
Èq£äʓ}Ɏ}Ê+{n
Èq£äʓ}Ɏ}Ê+{n
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
1 g Q24H
500 mg Q24H
Normal dose Q24H
œÀ“>Ê`œÃiÊ+{n
Normal dose QHD session
Normal dose (e.g. 100, 400,
800 mg) Q24H
Load w/normal dose, then
xä¯ÊœvʘœÀ“>Ê`œÃiÊ+Ó{
£Ó°xqÓxʓ}Ɏ}Ê+È
£Ó°xqÓxʓ}Ɏ}Ê+£Ó
£Ó°xqÓxʓ}Ɏ}Ê+Ó{
£Ó°xqÓxʓ}Ɏ}Ê+Ó{q{n
5 mg/kg Q12H
Ó°xʓ}Ɏ}Ê+£Ó
Ó°xʓ}Ɏ}Ê+Ó{
£°Óxʓ}Ɏ}Ê+Ó{
1.25 mg/kg three times/week,
administer after HD
5 mg/kg Q24H
Ó°xʓ}Ɏ}Ê+Ó{
£°Óxʓ}Ɏ}Ê+Ó{
ä°ÈÓxʓ}Ɏ}Ê+Ó{
0.625 mg/kg three times/
week, administer after HD
Ê iiÊÃiV̈œ˜Êœ˜Ê>“ˆ˜œ}ÞVœÃˆ`iÊ
dosing
œÊ`œÃ>}iÊ>`ÕÃ̓i˜ÌÊ
œÊ`œÃ>}iÊ>`ÕÃ̓i˜ÌÊ
1 g Q8H
£Ê}Ê+£Ó
xääʓ}Ê+£Ó
500 mg Q24H
2 g Q8H
£Ê}Ê+nÊ
£Ê}Ê+£Ó
1 g Q24H
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
100 mg Q12H
œÌÊÀiVœ““i˜`i`
75 mg Q12H
Çxʓ}Ê+Ó{
Îäʓ}Ê+Ó{
30 mg QHD session
75 mg Q24H
Îäʓ}Ê+Ó{
Îäʓ}Ê+{n
30 mg every other HD session
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
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£°xʓˆˆœ˜Ê՘ˆÌÃÊ+{
1.5 million units Q6H
Óxäqxääʓ}Ê+ÈÊÊ
£ääʓ}Ê+£ÓÊ
1 g Q24H
Ê
£xqÓxʓ}Ɏ}Ê+Ó{ÊÊ
Ê
†
†
†
†
†
†
†
157
E. Antimicrobial dosing in renal failure insufficiency
A
Drug
E. Antimicrobial dosing in renal failure insufficiency
A
Drug
Typical dose
(may vary)
CrCl (mL/min)
Dose adjustment for
renal insufficiency
*ˆ«iÀ>Vˆˆ˜ÉÊ
tazobactam
Ê
ΰÎÇxq{°xÊ}Ê+ÈÊ
€{äÊ
ÊÊ
Óäq{äÊ
Ê
Ê
ÓäÊÊ
qÊ
Î
Ê °ÎÇxÊ}Ê+ÈÊ­{°xÊ}Ê+È
for Pseudomonas)
Ó
Ê °ÓxÊ}Ê+ÈʭΰÎÇxÊ}Ê+ÈÊvœÀÊ
Pseudomonas)
Ó
Ê °ÓxÊ}Ê+nÊ­Ó°ÓxÊ}Ê+ÈÊvœÀÊ
Pseudomonas)
2.25 g Q12H (2.25 g Q8H for
Pseudomonas)
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
≥£äÊ
£äÊ
HD†Ê
qÊ
£xqÎäʓ}Ɏ}Ê+Ó{
£ÓqÓäʓ}Ɏ}Ê+Ó{
ÓxqÎäʓ}Ɏ}Ê+ ÊÃiÃȜ˜
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
HD†
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*ÞÀ>∘>“ˆ`iÊ
Ê
+Ո˜Õ«ÀˆÃ̈˜ÉÊ
dalfopristin
,ˆv>“«ˆ˜Ê­/ ®Ê
,ˆv>“«ˆ˜Ê
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/*É-8ÊÊ
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Ê
Ê
/*É-8ÊÊÊ
­* *ʜÀÊÃiÀˆœÕÃÊÊ
systemic infections)
6>>VÞVœÛˆÀÊ
­i˜ˆÌ>Ê iÀ«iîÊ
Ê
Valacyclovir
­iÀ«iÃÊ<œÃÌiÀ®Ê
Ê
Ê
Valganciclovir
­˜`ÕV̈œ˜Ê`œÃi®Ê
Ê
Ê
Ê
Valganciclovir
­>ˆ˜Ìi˜>˜ViÊ`œÃi®Ê
Ê
Ê
Ê
6>˜Vœ“ÞVˆ˜Ê
6œÀˆVœ˜>✏iÊ
†
-iiÊ*œÃ>Vœ˜>✏iÊ
guidelines p. 18
£xqÎäʓ}Ɏ}Ê+Ó{Ê
Ê
Ç°xʓ}Ɏ}Ê+nÊÊ
Èääʓ}Ê+Ó{Ê
Îääʓ}Ê+nq£ÓÊ
£ääʓ}ʜ˜Vi]ÊÌ i˜ÊÊ
50 mg Q12H
*"\Ê£qÓÊ -ÊÌ>LÊ+£ÓÊ
6\Ê£ÈäqÎÓäʓ}Ê+£ÓÊ
­ œÃˆ˜}ʈÃÊL>Ãi`ʜ˜ÊÊ
/*ÊVœ“«œ˜i˜Ì®Ê
xʓ}Ɏ}Ê+ÈqnÊ
Ê
xääq£äääʓ}Ê+£ÓÊ
Ê
Ê
1 g Q8H
Ê
Ê
Ê
900 mg Q12H
Ê
Ê
Ê
Ê
900 mg Q24H
Ê
Ê
Ê
Ê
qÊ
-iiÊ6œÀˆVœ˜>✏iÊÊ
guidelines p. 19
qÊ
qÊ
qÊ
≥ÎäÊ
Ê
†
ÎäʜÀÊ Ê
Ê
≥ÎäÊ
ÎäÊ
HD†
≥ÎäÊ
£äqәÊ
£äʜÀÊ †
≥50
Îäq{™Ê
£äqәÊ
£äʜÀÊ †
≥60
{äqx™Ê
ÓxqΙÊ
£äqÓ{
£äʜÀÊ †
≥60
{äqx™Ê
ÓxqΙÊ
£äqÓ{
£äʜÀÊ †
qÊ
qÊ
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì
£qÓÊ -ÊÌ>LÊ+£ÓʜÀÊ
£ÈäqÎÓäʓ}Ê6Ê+£ÓÊÊ
£qÓÊ -ÊÌ>LÊ+Ó{ʜÀ
£ÈäqÎÓäʓ}Ê6Ê+Ó{
xʓ}Ɏ}Ê+ÈqnÊ
Ó°xʓ}Ɏ}Ê+Èqn
2.5 mg/kg Q8H
xääq£äääʓ}Ê+£Ó
xääq£äääʓ}Ê+Ó{
500 mg Q24H
1 g Q8H
£Ê}Ê+£Ó
£Ê}Ê+Ó{
500 mg Q24H
900 mg Q12H
{xäʓ}Ê+£Ó
{xäʓ}Ê+Ó{
450 mg Q48H
Not recommended
900 mg Q24H
{xäʓ}Ê+Ó{
{xäʓ}Ê+{n
450 mg twice weekly
Not recommended
Ê-iiÊÃiV̈œ˜Êœ˜ÊÛ>˜Vœ“ÞVˆ˜Ê
dosing
œÊ`œÃ>}iÊ>`ÕÃ̓i˜ÌʈÃ
necessary for PO. IV should
not be administered to patients
with CrCl ≤50 mL/min due to
accumulation of the vehicle.
If patient is on hemodialysis (HD) schedule administration so that patient receives
daily dose immediately AFTER dialysis. For assistance with dosage adjustments for
patients receiving CVVHD or CVVHDF, please call pharmacy.
158
HH
Abdominal infections
Biliary tract infections ..... 39-40
Diverticulitis ......................... 40
Pancreatitis .................... 41-42
Peritonitis, peritoneal
dialysis-related .................. 45
Peritonitis/GI perforation . 42-45
SBP .............................. 42-43
Acute bacterial
rhinosinusitis................... 78-79
Allergy, penicillin ................... 137
Anaerobes......................... 24-25
Amikacin
See Aminoglycosides
Aminoglycosides
Gram-negative infection
dosing ...............................146
Gram-positive synergy
dosing ............................ 148
Mycobacterial infection
dosing ............................ 147
SICU/WICU dosing ............. 148
UTI dosing ......................... 147
Amphotericin B, lipid ............... 16
Antibiotic lock therapy............. 63
Antibiogram....................... 37-38
Antimicrobial dosing
Aminoglycosides
See Aminoglycosides
CNS infections ..................... 73
Renal insufficiency....... 155-158
Surgical prophylaxis .... 121-124
Vancomycin
See Vancomycin
Aspergillosis ......................... 133
Aspiration pneumonia........ 84, 88
Azole drug interactions ...... 21-22
Biliary tract infections......... 39-40
Bloodstream infections
Catheter-related .............. 60-64
Candida ..................117, 134
Enterococcus spp. ............ 62
Gram-negative rods ........... 62
S. aureus.......................... 61
Staph, coagulase-negative . 61
Brain abscess ........................ 76
H H
Candidemia ....................117-118
Candidiasis
Hematologic patient .....134-136
Non-neutropenic host ...115-120
Candiduria ......................115-116
Catheter-related
bloodstream infections.....60-64
Cellulitis..........................100-101
Ceftaroline.................................8
Ceftolozane/tazobactam.........8-9
Central nervous system (CNS)
infections
Antibiotic dosing ...................77
Brain abscess..................76-77
Encephalitis ..........................75
Meningitis ........................73-75
Shunt infection .................76-77
Cholangitis .........................39-40
Cholecystitis .......................39-40
Clostridium difficile
infections.........................47-50
Colistin .................................9-10
Communicable diseases,
reporting ............................140
Community-acquired pneumonia
Empiric therapy ...............83-84
Pathogen-specific therapy . 85-86
COPD exacerbations................82
Cost of antimicrobials .....159-160
Cystic fibrosis.....................91-92
H H
H H
Bacterial vaginosis.................. 57
Daptomycin ....................... 10-11
161
10. Index
A
Index
10. Index
Diarrhea ............................ 51-53
Diabetic foot
infections.................... 103-105
Diverticulitis ............................ 40
Dosing, antimicrobials
See Antimicrobial dosing
H H
Encephalitis ............................ 75
Endocarditis ...................... 65-70
Treatment
Culture-negative ................ 68
Diagnosis .................... 69-70
Fungal ..................... 119-120
Pathogen-specific
therapy ..................... 65-69
Prosthetic valve ........... 68-69
Prophylaxis ........................ 125
Endomyometritis .................... 56
Epidural abscess ........... 108-109
Ertapenem ............................. 11
HH
Febrile neutropenia ........ 129-130
Formulary................................. 7
Fosfomycin ....................... 11-12
Fungal infections
Candida spp
................ 115-120, 134-136
Filamentous fungi ........ 133-134
Prophylaxis, SICU/WICU ..... 120
Fusarium .............................. 133
HH
Gentamicin
See Aminoglycosides
GI perforation ......................... 45
Gonococcal urethritis,
cervicitis, proctitis........... 57-58
Gynecologic infections
Endomyometritis.................. 56
Pelvic inflammatory
disease ............................ 56
162
HH
Healthcare-acquired pneumonia
(not VAP) .........................87-88
H. pylori infection ................54-55
HH
ICD infection ...................... 71-72
ID approval
Antimicrobials ........................ 7
Pager .................................... 6
Infection control............. 139-144
Infectious diarrhea ............. 51-53
Influenza............................ 93-94
Isolation precautions ............. 141
HH
Linezolid.............................12-13
Long-term antimicrobial
therapy...............................153
HH
Meningitis, bacterial ............73-75
Antimicrobial dosing..............77
Empiric therapy ....................73
Pathogen-specific therapy .....74
MDR Gram-negative
organisms .......................28-30
Micafungin..........................17-18
Microbiology.......................31-35
MRSA
Decolonization .............102-103
Soft-tissue infections ....100-101
Surveillance .................142-143
H H
Necrotizing fasciitis ....... 107-108
Neutropenic fever .......... 129-130
Nosocomial pneumonia...... 87-88
H"H
Oncology
Neutropenic fever ........129-130
H*H
P. acnes infection ...............25-26
Pacemaker infection ...........71-72
Pancreatitis ........................41-42
Parasites.................................53
Pelvic inflammatory disease .....56
Penicillin allergy .....................137
Peritonitis/GI perforation .....42-45
Peritoneal dialysis-related ......45
Spontaneous bacterial .....42-43
Post-op / post-procedure
infections ..................105-107
Pneumonia
Community-acquired ........83-84
Healthcare-acquired .........87-88
Ventilator-associated ........88-90
Pneumococcal vaccine ............23
Posaconazole .....................18-19
Pre-operative prophlyaxis.121-124
Price of antimicrobials ....159-160
Prophylactic use of antimicrobials
Endocarditis .......................125
Fluconazole in ICUs .............120
Hematologic
malignancy................ 131-132
Pre-op / pre-procedure 121-124
Solid organ ..................126-128
H,H
Renal insufficiency
Antimicrobial dosing.....155-158
Reported diseases.................140
Resistant Gram-negative
infections.........................28-30
Respiratory viruses .............93-94
Restricted antimicrobials ............7
H-H
SBP ...................................42-43
Sepsis.....................................99
Sexually transmitted
diseases..........................57-59
Shunt infection....................76-77
Sinusitis .............................78-79
Skin, soft-tissue and
bone infections
Cellulitis .......................100-101
Cutaneous abscess .....101-102
Diabetic foot
infection ...................103-105
Necrotizing fasciitis......107-108
Post-op infections ........105-107
Recurrent MRSA ..........102-103
Surgical-site
infections ..................105-107
Vertebral osteomyelitis,
diskitis, epidural
abscess....................108-109
Streptococci ......................24-25
Surgical prophylaxis........121-124
Surgical-site infections ....105-107
Surveillance
CRE ...................................142
MRSA ..........................142-143
VRE ....................................144
Susceptibility testing ...........31-32
Syphilis ..............................58-59
H/H
Therapeutic monitoring
Aminoglycosides..........145-149
Vancomycin .................150-152
Outpatient long-term
antimicrobial therapy ........153
Tigecycline ..............................13
Tobramycin
See Aminoglycosides
Transplant
Antimicrobial prophylaxis
Hematologic
malignancy ............. 131-132
Solid organ................ 126-128
163
10. Index
Oral antimicrobials .................154
Orbital cellulitis ...................80-81
10. Index
Trichomoniasis......................... 57
Trimethoprim/
sulfamethoxazole ..............14-15
Tuberculosis ........................95-98
H1H
Urinary tract infections
Bacterial
Cystitis ........................... 110
Pyelonephritis ................. 111
Urosepsis ....................... 111
Catheter-related .......... 113-114
Fungal ........................ 115-116
H6H
Vancomycin
164
Dosing ....................... 150-152
Monitoring .................. 151-152
Ventilator-associated
pneumonia (VAP) ............. 88-90
Vertebral osteomyelitis, diskitis,
epidural abscess ........ 108-109
Voriconazole ..................... 19-20
VRE Surveillance ................... 144
H7H
Wound infections,
post-op........................105-107
Important Phone Numbers
THE JOHNS HOPKINS HOSPITAL
Antibiotic Approval: . . . . PING “JHH Antibiotic Approval Pager”
Antimicrobial Stewardship Program: . . . . . . . . . . . . . . . . . . . . . . 7-4570
Infectious Diseases Consults: . . . . PING “JHH Infectious Diseases”
Oncology/Transplant Service (Transplant ID) . . . . PING “Transplant/
Oncology Infectious Diseases”
Adult Inpatient Pharmacy (Zayed 7000): . . . . . . . . . . . . . . . . . . . 5-6150
Critical Care and Surgery Pharmacy (Zayed 3121):. . . . . . . . . . . 5-6505
Weinberg Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-8998
Microbiology Lab: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6510
Hospital Epidemiology & Infection Control: . . . . . . . . . . . . . . . . 5-8384
HEIC Emergency Beeper: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3855
JOHNS HOPKINS BAYVIEW MEDICAL CENTER
Antibiotic Approval: . . . . . . . PING “Bayview Antibiotic Approval”
Infectious Disease Consults:. . PING “Bayview Infectious Diseases”
Bayview Inpatient Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-0958
Microbiology Lab: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6510
Hospital Epidemiology & Infection Control: . . . . . . . . . . . . . . . . . 0-0515
The Johns Hopkins Hospital
Antimicrobial Stewardship Program
Intranet: insidehopkinsmedicine.org/amp
Internet: hopkinsmedicine.org/amp
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may be reproduced without permission in writing from The Johns
Hopkins Hospital Antimicrobial Stewardship Program.
Cover art: Charlotte Ford Cosgrove, Line Drawing II 33, 2008.