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 UÊ >V ÊÃiVÌÊLi}ÃÊLÞÊ}Û}ÊÀiVi`>ÌÃÊvÀÊÌ iÊV ViÊ>`Ê dose of antibiotics for the particular infection. UÊALL DOSES IN THE TEXT ARE FOR ADULTS WITH NORMAL RENAL AND HEPATIC FUNCTION. UÊÊvÊÞÕÀÊ«>ÌiÌÊ`iÃÊ "/Ê >ÛiÊÀ>ÊÀi>ÊÀÊ i«>ÌVÊvÕVÌ]Ê please refer to the sections on antibiotic dosing to determine the correct dose. UÊÊÜ}ÊÌ iÊ>ÌLÌVÊÀiVi`>ÌÃ]ÊÜiÊ >ÛiÊÌÀi`ÊÌÊVÕ`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 UÊÌLÌVÊ>««ÀÛ>\Ê1ÃiÊ* ÆÊÃi>ÀV ʺ>ÌLÌV]»ÊÌ iÊÃiiVÌÊ ºÌLÌVÊ««ÀÛ>Ê*>}iÀ» UÊÊ*i>ÃiÊ`ÊÌÊÃi`ÊÕiÀVÊ«>}ià UÊÊ*i>ÃiÊV«iÌiÊÌ iÊvÀÊ>ÃÊ>VVÕÀ>ÌiÞÊ>ÃÊ«ÃÃLi° UÊÊÊÀ`iÀÃÊvÀÊÀiÃÌÀVÌi`Ê>ÌLÌVÃÊ1-/ÊLiÊ>««ÀÛi`ÊÕiÃÃÊ they are part of an approved order. UÊÊ*i>ÃiÊÃiiÊ«>}iÊÈÊvÀÊÀiÊvÀ>ÌÊ>LÕÌÊLÌ>}Ê>««ÀÛ>° UÊÌVÀL>Ê-ÌiÜ>À`à «Ê*À}À>\ÊÇ{xÇä UÊviVÌÕÃÊ Ãi>ÃiÃÊ ÃÕÌÃ\ÊÎnäÓÈ UÊ ÀÌV>Ê >ÀiÊ>`Ê-ÕÀ}iÀÞÊ* >À>VÞÊ­<>Þi`ÊΣӣ®\ÊxÈxäx UÊ`ÕÌÊ«>ÌiÌÊ* >À>VÞÊ­<>Þi`ÊÇäää®\ÊxÈ£xä UÊ7iLiÀ}Ê« >À>VÞ\Êxnn UÊ >ÞÛiÜÊ«>ÌiÌÊ* >À>VÞ\Êääxn UÊVÀL}ÞÊ>L\ÊxÈx£ä 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 }Õ`iÊLÞÊV>}ÊÌ iÊ>ÌLÌVÃÊ«>}iÀÊÕÃ}Ê* Ê­Ãi>ÀV ʺ>ÌLÌV»®ÊÀÊ 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>ÌLÌV»Ê Overnight Approval Ê Ordersets (e.g. neutropenic fever, etc.) 6 Notes Ê/ iÊ«>}iÀÊÃÊ>ÃÜiÀi`ÊLiÌÜiiÊnÊ>°°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>ÃiÊÀiiLiÀÊÌÊÃ}ÊÕÌÊÌ iÊii`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 ­<ÃÞ®) 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) UÊÊ-iiVÌÊV>ÃiÃÊvÊ,-Ê«iÕ>ÊÀÊÌ iÀÊÃiÛiÀiÊviVÌÃÊÜ iÊ Gram negative coverage is also needed UÊÊ >VÌiÀi>ÊÀÊi`V>À`ÌÃÊV>ÕÃi`ÊLÞÊ,-ÊÊ>Ê«>ÌiÌÊv>}Ê 6>VÞVÊÌ iÀ>«ÞÊ>ÃÊ`iwi`ÊLÞ\Ê UÊÊ V>Ê`iV«iÃ>ÌÊ>vÌiÀÊÎq{Ê`>Þà UÊÊ>ÕÀiÊÌÊVi>ÀÊL`ÊVÕÌÕÀiÃÊ>vÌiÀÊÇÊ`>ÞÃÊ`iëÌiÊ6>VÞVÊ ÌÀÕ} ÃÊvÊ£xqÓäÊV}ÉÊ UÊÊ ÊvÊ6>VÞVÊÃÊÓÊV}É Unacceptable uses UÊÊ/Ài>ÌiÌÊvÊVÕÌÞ>VµÕÀi`ÊL>VÌiÀ>Ê«iÕ>Ê­ *®ÊÀÊÃÊ and soft tissue infections (SSTI) where other more established and less expensive options are available UÊÌ>ÊÌ iÀ>«ÞÊvÀÊÀ>«ÃÌÛiÊÀÊÀ>i}>ÌÛiÊviVÌà Dose UÊÊÈääÊ}Ê6Ê+£ÓÊ >ÃÊLiiÊÃÌÕ`i`ÊvÀÊ *Ê>`Ê--/ UÊÊÈääÊ}Ê6Ê+nÊvÀÊ,-ÊL>VÌiÀi>ÊÃ>Û>}iÊÌ iÀ>«ÞÊÀÊÌ iÀÊ serious infections UÊMust adjust for worsening renal function and dialysis (see p. 155 for dose adjustment recommendation). Laboratory interactions UÊÊ ivÌ>ÀiÊ>ÞÊÀiÃÕÌÊÊ«ÃÌÛiÊ`ÀiVÌÊ LýÊÌiÃÌÊÜÌ ÕÌÊ 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 UÊÊ «ÀVÊÌÀi>ÌiÌÊvÊV«V>Ìi`ÊÌÀ>>L`>ÊviVÌÃÊ­V®Ê 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 UÊÊ£°xÊ}Ê6Ê+nÊ >ÃÊLiiÊÃÌÕ`i`ÊvÀÊV1/Ê>`ÊÊVL>ÌÊÜÌ Ê metronidazole for cIAI UÊÊ-iÀÕÃÊviVÌÃÊVÕ`}Ê«iÕ>\ÊÎÊ}Ê6Ê+n UÊÊÕÃÌÊ>`ÕÃÌÊ`ÃiÊvÀÊÜÀÃi}ÊÀi>ÊvÕVÌÊ>`Ê`>ÞÃÃÊ­ÃiiÊ«°£xxÊ 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 UÊÊ>>}iiÌÊvÊviVÌÃÊ`ÕiÊÌÊÕÌ`ÀÕ}ÊÀiÃÃÌ>ÌÊAcinetobacter and Pseudomonas on a case by case basis. Unacceptable uses UÊÊÌ iÀ>«ÞÊvÀÊi«ÀVÊÌÀi>ÌiÌÊvÊÃÕëiVÌi`ÊÀ>i}>ÌÛiÊviVÌÃÊ Dose UÊ>`}Ê`Ãi\ÊxÊ}É}ÊVi UÊÊ>Ìi>ViÊ`Ãi\ÊÓ°xÊ}É}Ê+£ÓÆÊÕÃÌÊ>`ÕÃÌÊvÀÊÜÀÃi}Ê renal function and dialysis (see p. 155 for dose adjustment recommendation). Toxicity UÊÊ,i>Ê«>ÀiÌ]ÊiÕÀÕÃVÕ>ÀÊLV>`i]ÊiÕÀÌÝVÌÞ UÊÊÌÀ}\Ê 1 ]ÊVÀi>ÌiÊÌÜViÜiiÞ 9 3.1 Agent-specific guidelines: Antibiotics Acceptable uses (Cases must be discussed with Infectious Diseases and Antimicrobial Stewardship Program) UÊÊ>>}iiÌÊvÊviVÌÃÊ`ÕiÊÌÊÕÌ`ÀÕ}ÊÀiÃÃÌ>ÌÊPseudomonas spp. infections on a case by case basis 3.1 Agent-specific guidelines: Antibiotics Hidden Content - JHH Internal use only ,iviÀiVi\ >`}Ê`ÃiÊvÊVÃÌ\Ê ÊviVÌÊ ÃÊÓä£ÓÆÊx{\£ÇÓäÈ° 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) UÊÊ >VÌiÀi>ÊÀÊi`V>À`ÌÃÊV>ÕÃi`ÊLÞÊ,-ÊÀÊiÌ VÀiÃÃÌ>ÌÊ coagulase-negative staphylococci in a patient with serious allergy to Vancomycin UÊÊ >VÌiÀi>ÊÀÊi`V>À`ÌÃÊV>ÕÃi`ÊLÞÊ,-ÊÊ>Ê«>ÌiÌÊv>}Ê 6>VÞVÊÌ iÀ>«ÞÊ>ÃÊ`iwi`ÊLÞ\Ê UÊÊ V>Ê`iV«iÃ>ÌÊ>vÌiÀÊÎq{Ê`>Þà UÊÊ>ÕÀiÊÌÊVi>ÀÊL`ÊVÕÌÕÀiÃÊ>vÌiÀÊÇÊ`>ÞÃÊ`iëÌiÊ6>VÞVÊ ÌÀÕ} ÃÊvÊ£xqÓäÊV}ÉÊ­ } ÊÀÃÊvÊ >«ÌÞVÊÀiÃÃÌ>ViÆÊ check Daptomycin MIC and obtain follow up blood cultures) UÊÊ ÊvÊ6>VÞVÊÃÊÓÊV}É UÊÊ/ iÀ>«ÞÊvÀÊ6, ÊviVÌÃÊÌ iÀÊÌ >Ê«iÕ>]ÊÊ>ÊV>ÃiÊLÞÊV>ÃiÊL>Ãà Unacceptable uses UÊÊ >«ÌÞVÊà Õ`Ê "/ÊLiÊÕÃi`ÊvÀÊÌÀi>ÌiÌÊvÊ«iÕ>Ê`ÕiÊÌÊ its inactivation by pulmonary surfactant. UÊÊÌ>ÊÌ iÀ>«ÞÊvÀÊÀ>«ÃÌÛiÊviVÌÃÊ UÊÊ6, ÊVâ>ÌÊvÊÌ iÊÕÀi]ÊÀiëÀ>ÌÀÞÊÌÀ>VÌ]ÊÜÕ`Ã]ÊÀÊ`À>ÃÊ Dose UÊÊ >VÌiÀi>\ÊÈq£ÓÊ}É}Ê6Ê+ÊÓ{ UÊÊ `V>À`ÌÃ\ÊÈq£ÓÊ}É}Ê6Ê+ÊÓ{ UÊÊ ÃiÊ>`ÕÃÌiÌÊÃÊiViÃÃ>ÀÞÊvÀÊ À Ê 30 ml/min (see p. 155 for dose adjustment recommendation). 10 ,iviÀiVi\Ê Daptomycin in S. aureusÊL>VÌiÀi>Ê>`ÊviVÌÛiÊi`V>À`ÌÃ\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 UÊÊ`ÊÌÊ`iÀ>ÌiÊÌÀ>>L`>ÊviVÌÃÊ­L>ÀÞÊÌÀ>VÌÊviVÌÃ]Ê diverticulitis, secondary peritonitis/GI perforation) UÊÊ`iÀ>ÌiÊ`>LiÌVÊvÌÊviVÌÃÊÜÌ ÕÌÊÃÌiÞiÌà UÊÊ`iÀ>ÌiÊÃÕÀ}V>ÃÌiÊviVÌÃÊvÜ}ÊVÌ>>Ìi`Ê«ÀVi`ÕÀi UÊ*iÛVÊy>>ÌÀÞÊ`Ãi>Ãi UÊÊ1À>ÀÞÊÌÀ>VÌÊviVÌÃÊV>ÕÃi`ÊLÞÊ - «À`ÕV}ÊÀ}>ÃÃÊ UÊÊ*Þii« ÀÌÃÊÊ>Ê«>ÌiÌÊÜ ÊÃÊÌÊÃiÛiÀiÞÊ Unacceptable uses UÊÊ-iÛiÀiÊviVÌÃÊÊÜ V Pseudomonas spp. are suspected. Dose UÊÊ£Ê}Ê6ÊÀÊÊ+Ó{]ÊÕÃÌÊ>`ÕÃÌÊvÀÊÜÀÃi}ÊÀi>ÊvÕVÌÊ>`Ê dialysis (see p. 155 for dose adjustment recommendation) Toxicity UÊÊ >ÀÀ i>]Ê>ÕÃi>]Ê i>`>V i]Ê« iLÌÃÉÌ ÀL« iLÌà 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>>}iiÌÊvÊÕV«V>Ìi`Ê1/ÊÊ«>ÌiÌÃÊÜÌ ÊÕÌ«iÊ>ÌLÌVÊ allergies and/or when no other oral therapy options are available. 11 3.1 Agent-specific guidelines: Antibiotics Toxicity UÊÊÞ«>Ì ÞÊ­`iwi`Ê>ÃÊ Ê 10 times the upper limit of normal without symptoms or 5 times the upper limit of normal with symptoms). UÊÊ Ã« VÊ«iÕ> UÊÊÌÀ}\Ê ÊÜiiÞ]ÊÀiÊvÀiµÕiÌÞÊ`ÕÀ}ÊÌ>ÊÌ iÀ>«Þ°Ê 3.1 Agent-specific guidelines: Antibiotics UÊÊ1V«V>Ìi`Ê1/Ê`ÕiÊÌÊ6, UÊÊÊ->Û>}iÊÌ iÀ>«ÞÊvÀÊ1/Ê`ÕiÊÌÊÕÌ`ÀÕ}ÊÀiÃÃÌ>ÌÊÀ>i}>ÌÛiÊ organisms (e.g. Pseudomonas spp.) on case by case basis. NOTE: Susceptibility to Fosfomycin should be confirmed prior to initiation of therapy. Unacceptable uses UÊÊÃvÞVÊà Õ`Ê "/ÊLiÊÕÃi`ÊvÀÊ>>}iiÌÊvÊ>ÞÊviVÌÃÊ outside of the urinary tract because it does not achieve adequate concentrations at other sites. UÊÊ/Ài>ÌiÌÊvÊ>ÃÞ«ÌVÊL>VÌiÀÕÀ>Ê­ÃiiÊ«°Ê££ä® Dose UÊÊ1V«V>Ìi`Ê1/\ÊÎÊ}Ê­£ÊÃ>V iÌ®Ê*"ÊVi°Ê UÊÊ «V>Ìi`Ê1/\ÊÎÊ}Ê­£ÊÃ>V iÌ®Ê*"ÊiÛiÀÞÊ£ÎÊ`>ÞÃÊ­Õ«ÊÌÊÓ£Ê`>ÞÃÊvÊ treatment) UÊÊÀiµÕiVÞÊ>`ÕÃÌiÌÊ>ÞÊLiÊiViÃÃ>ÀÞÊÊ«>ÌiÌÃÊÜÌ Ê À Ê 50 mL/min. Contact the ID Pharmacist for dosing recommendations. UÊÊ*Ü`iÀÊà Õ`ÊLiÊÝi`ÊÜÌ Êäq£ÓäÊÊvÊVÊÜ>ÌiÀ]ÊÃÌÀÀi`ÊÌÊ dissolve and administered immediately. Toxicity UÊÊ >ÀÀ i>]Ê>ÕÃi>]Ê i>`>V i]Ê`ââiÃÃ]Ê>ÃÌ i>Ê>`Ê`Þëi«Ã> Linezolid Acceptable uses UÊÊ VÕiÌi`Ê6>VÞVÊÌiÀi`>ÌiÊStaphylococcus aureus (VISA) or Vancomycin resistant Staphylococcus aureus (VRSA) infection UÊÊ VÕiÌi`Ê,-ÊÀÊiÌ VÀiÃÃÌ>ÌÊV>}Õ>Ãii}>ÌÛiÊ staphylococcal infection in a patient with serious allergy to Vancomycin UÊÊ VÕiÌi`Ê,-ÊÀÊiÌ VÀiÃÃÌ>ÌÊV>}Õ>Ãii}>ÌÛiÊ staphylococcal infection in a patient failing Vancomycin therapy (as `iwi`ÊLiÜ®\Ê UÊÊ >VÌiÀi>Éi`V>À`ÌÃ\Êv>ÕÀiÊÌÊVi>ÀÊL`ÊVÕÌÕÀiÃÊ>vÌiÀÊ ÇÊ`>ÞÃÊ`iëÌiÊ6>VÞVÊÌÀÕ} ÃÊvÊ£xqÓäÊV}É°Ê- Õ`ÊLiÊ used in combination with another agent UÊÊ*iÕ>\ÊÜÀÃi}ÊwÌÀ>ÌiÊÀÊ«Õ>ÀÞÊÃÌ>ÌÕÃÊÊ>Ê«>ÌiÌÊ 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 Õ`ÊLiÊ`ÃVÕÃÃi`ÊÜÌ ÊviVÌÕÃÊ Ãi>ÃiÃÊÀÊ Antimicrobial stewardship UÊHigh suspicion of CA-MRSA necrotizing pneumonia in a seriously ill patient 12 Dose UÊÊÈääÊ}Ê6É*"Ê+£Ó UÊÊ-Ê>`ÊÃÃÌÀÕVÌÕÀiÊviVÌÃ\Ê{ääÊ}Ê6É*"Ê+£Ó Toxicity UÊÊ iÊ>ÀÀÜÊÃÕ««ÀiÃÃÊ­ÕÃÕ>ÞÊVVÕÀÃÊÜÌ ÊwÀÃÌÊÓÊÜiiÃÊvÊÌ iÀ>«Þ® UÊÊ"«ÌVÊiÕÀÌÃÊ>`ÊÀÀiÛiÀÃLiÊÃiÃÀÞÊÌÀÊ«ÞiÕÀ«>Ì ÞÊ­ÕÃÕ>ÞÊ occurs with prolonged therapy > 28 days) UÊÊ >ÃiÊÀi«ÀÌÃÊvÊ>VÌVÊ>V`Ãà UÊÊ >ÃiÊÀi«ÀÌÃÊvÊÃiÀÌÊÃÞ`ÀiÊÜ iÊV>`ÃÌiÀi`ÊÜÌ Ê serotonergic agents (SSRIs, TCAs, MAOIs, etc.) UÊÊÌÀ}\Ê ÊÜiiÞ 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>>}iiÌÊvÊÌÀ>>L`>ÊviVÌÃÊÊ«>ÌiÌÃÊÜÌ Ê contraindications to both beta-lactams and fluoroquinolones UÊÊ>>}iiÌÊvÊviVÌÃÊ`ÕiÊÌÊÕÌ`ÀÕ}ÊÀiÃÃÌ>ÌÊÀ>i}>ÌÛiÊ organisms including Acinetobacter spp. and Stenotrophomonas maltophilia on a case by case basis UÊÊ->Û>}iÊÌ iÀ>«ÞÊvÀÊ,-É6, ÊviVÌÃÊÊ>ÊV>ÃiÊLÞÊV>ÃiÊL>Ãà Dose UÊÊ£ääÊ}Ê6ÊVi]ÊÌ iÊxäÊ}Ê6Ê+£Ó UÊÊ£ääÊ}Ê6ÊVi]ÊÌ iÊÓxÊ}Ê6Ê+£ÓÊvÊÃiÛiÀiÊ i«>ÌVÊ«>ÀiÌÊ ­ `ÊÊ*Õ} Ê£äq£x® Toxicity UÊÊ >ÕÃi>Ê>`ÊÛÌ}Ê 13 3.1 Agent-specific guidelines: Antibiotics UÊ ÊÊ VÕiÌi`Ê6, ÊviVÌÊ UÊÊÀ>«ÃÌÛiÊVVVÊÊV >ÃÊÊL`ÊVÕÌÕÀiÃÊÊ>Ê 1]ÊÀÊV}ÞÊ transplant patient known to be colonized with VRE Unacceptable uses UÊÊ*À« Þ>Ýà UÊÊÌ>ÊÌ iÀ>«ÞÊvÀÊÃÌ>« ÞVVV>ÊviVÌ UÊÊ6, ÊVâ>ÌÊvÊÌ iÊÃÌ]ÊÕÀi]ÊÀiëÀ>ÌÀÞÊÌÀ>VÌ]ÊÜÕ`Ã]ÊÀÊ`À>à 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 UÊ1À>ÀÞÊÌÀ>VÌÊviVÌÃÊ­1/® UÊS. aureus skin and soft-tissue infections (SSTI) UÊPneumocystis jirovecii pneumonia (PCP) treatment and prophylaxis UÊS. maltophilia infections UÊ V>À`>ÊviVÌÃÊ UÊÀ>i}>ÌÛiÊL>VÌiÀi>ÊÜ iÊÀ}>ÃÊÃÊÃÕÃVi«ÌLiÊ UÊÊ->Û>}iÊÌ iÀ>«ÞÊvÀÊ,-ÊL>VÌiÀi>ÊÊVL>ÌÊÜÌ Ê>Ì iÀÊ agent UÊÊ «ÀVÊVÛiÀ>}iÊvÊListeria meningitis in patients with penicillin allergies UÊÊ-Õ««ÀiÃÃÛiÊÌ iÀ>«ÞÊ>`ÊÊÃiÊV>ÃiÃÊÌÀi>ÌiÌÊvÀÊLiÊ>`ÊÌÊ infections Unacceptable uses UÊÌ iÀ>«ÞÊvÀÊS. aureus bacteremia Dose UÊTrimethoprim/sulfamethoxazole dosing is based on trimethoprim component UÊ/*É-8Ê >ÃÊiÝViiÌÊL>Û>>LÌÞ]ÊÌ ÕÃÊVÛiÀÃÊvÀÊ6ÊÌÊ*"Ê ÃÊ£\£Ê­näÉ{ääÊ}Ê6ÊrÊ£Ê--ÊÌ>LÆÊ£ÈäÉnääÊ}Ê6ÊrÊ£Ê -ÊÌ>L®Ê UÊ1ÃiÊ>`ÕÃÌi`Ê 7rÊQ 7ʳÊä°{Ê­ 7ÊÊ 7®RÊÊLiÃiÊ«>ÌiÌÃÊ­Îä¯Ê over IBW) Treatment UÊ1/\Ê£Ê -ÊÌ>LÊ+£ÓÊ UÊ--/\Ê£ÓÊ -ÊÌ>LÊ+£Ó UÊ* *\£xÓäÊ}É}É`>ÞÊ­Ê`Û`i`Ê`ÃiÃ]Ê+È+n® UÊ,-ÊL>VÌiÀi>\£ä£xÊ}É}É`>ÞÊ­Ê`Û`i`Ê`ÃiÃ]Ê+È+n® UÊS. maltophiliaÊviVÌÃ\£xÊ}É}É`>ÞÊ­Ê`Û`i`Ê`ÃiÃ]Ê+È+n®Ê 14 Prophylaxis UÊ* *\Ê£Ê--Ê`>ÞÊÀÊ£Ê -ÊÎÊÌiÃÉÜiiÊ UÊ/Ý«>ÃÃÃ\Ê£Ê -Ê`>ÞÊ Toxicity UÊ \Ê Þ«iÀÃiÃÌÛÌÞÊ­£°Èn¯®]ÊÕ«ÃiÌ]Ê«ÃiÕ`ÊiiÛ>ÌÊÊ VÀi>ÌiÊ­£n¯®Ê UÊ ÊÜÌ Ê } iÀÊ`ÃiÃ\Ê Þ«iÀ>i>]ÊÞiÃÕ««ÀiÃà UÊ"VV>Ã>\Êi« ÀÌÝVÌÞ]Ê« ÌÃiÃÌÛÌÞ]ÊiÌ i}Li>Ê­ÜÌ Ê severe G6PD deficiency) UÊ,>Ài\Ê>Ãi«ÌVÊi}ÌÃ]Ê i«>ÌÌÝVÌÞ]ÊÌÝVÊi«`iÀ>ÊiVÀÞÃÃÊ (TEN), SJS, Sweet’s syndrome Drug Interaction UÊ7>Àv>À]ÊiÌ ÌÀiÝ>Ìi]Ê« iÞÌ]Ê`}Ý]ÊÃÕvÞÕÀi>Ã]Ê procainamide, oral contraceptives 15 3.1 Agent-specific guidelines: Antibiotics UÊ V>À`>ÊviVÌÃ\Ê£xÊ}É}É`>ÞÊ­Ê`Û`i`Ê`ÃiÃ]Ê+È+n®ÆÊÜiÀÊ doses (5-10 mg/kg/day) can be used after several weeks of therapy or cutaneous infections UÊi}ÌÃ\ÊÓäÊ}É}É`>ÞÊ­Ê`Û`i`Ê`ÃiÃ]Ê+È® UÊ"Ì iÀÊviVÌÃ\Ên£äÊ}É}É`>ÞÊ­Ê`Û`i`Ê`ÃiÃ]Ê+È£Ó® UÊÕÃÌÊ>`ÕÃÌÊ`ÃiÊvÀÊÜÀÃi}ÊÀi>ÊvÕVÌÊ>`Ê`>ÞÃÃÊ­ÃiiÊ«°£xxÊ for dose adjustment recommendation). 3.2 Agent-specific guidelines: Antifungals Antifungals Liposomal Amphotericin B (AmBisome®) NOTES: UÊÊ Ã}ÊvÊ ÃiÊ>`Ê« ÌiÀVÊ Ê`iÝÞV >ÌiÊÃÊ significantly different. Do not use AmBisome doses when ordering Amphotericin B deoxycholate and vice versa. UÊÊ« ÌiÀVÊ Ê`iÝÞV >ÌiÊÃÊ«ÀiviÀÀi`ÊÊ«>ÌiÌÃÊÜÌ 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 >``>Êi`«Ì >ÌÃ]Êi`V>À`ÌÃ]Ê -ÊviVÌqwÀÃÌÊiÊÌ iÀ>«Þ UÊ ÀÞ«ÌVVVÕÃÊi}ÌÃwÀÃÌÊiÊÌ iÀ>«ÞÊÊ UÊ<Þ}ÞVÃiÃÊ­Mucor, Rhizopus, Cunninghamella®qwÀÃÌÊiÊÌ iÀ>«ÞÊ UÊÊ iÕÌÀ«iVÊviÛiÀÊvÊÀiViÛ}Ê6ÀV>âiÊÀÊ*Ã>V>âiÊ prophylaxis UÊÌiÀ>ÌÛiÊÌÀi>ÌiÌÊvÊÛ>ÃÛiÊ>ëiÀ}Ãà UÊÊÌiÀ>ÌÛiÊÌÀi>ÌiÌÊvÊV>``i>]ÊV>``>Ê«iÀÌÌÃÊ Dose UÊÊ >``i>]Ê ÃÌ«>ÃÃÃ]ÊÌ iÀÊÛ>ÃÛiÊV>``>ÊviVÌÃ\Ê 3 mg/kg/day UÊÊ >``>Êi`«Ì >ÌÃ]Êi`V>À`ÌÃ]Ê -ÊviVÌ]ÊC. krusei V>``i>\ÊxÊ}É}É`>Þ UÊÛ>ÃÛiÊw>iÌÕÃÊvÕ}\ÊxÊ}É}É`>Þ UÊ iÕÌÀ«iVÊviÛiÀ]ÊV>``i>ÊÊiÕÌÀ«iVÊ«>ÌiÌ\ÊÎqxÊ}É}É`>Þ UÊ ÀÞ«ÌVVV>Êi}ÌÃ\ÊÎq{Ê}É}É`>Þ Toxicity UÊvÕÃÀi>Ìi`ÊÀi>VÌÃ\ÊviÛiÀ]ÊV Ã]ÊÀ}ÀÃ]Ê Þ«Ìià UÊÊ,i>Ê«>ÀiÌÊ­i >Vi`ÊÊ«>ÌiÌÃÊÜÌ ÊVVÌ>ÌÊi« ÀÌÝVÊ drugs) UÊ iVÌÀÞÌiÊL>>Vià UÊÊ*Õ>ÀÞÊÌÝVÌÞÊ­V iÃÌÊ«>]Ê Þ«Ý>]Ê`Þëi>®]Ê>i>]ÊiiÛ>ÌÊÊ hepatic enzymes-rare UÊÊÌÀ}\Ê 1 ÉVÀi>Ìi]Ê]Ê}]Ê* ÃÊ>ÌÊL>ÃiiÊ>`Ê`>ÞÊÊ Ã«Ì>âi`Ê«>ÌiÌÃÆÊ-/É/Ê>ÌÊL>ÃiiÊ>`ÊiÛiÀÞÊ£ÓÊÜiiÃÊ 16 Aspergillosis UÊVVi«Ì>LiÊÕÃià UÊÊÊVL>ÌÊÜÌ Ê6ÀV>âiÊvÀÊVwÀi`ÊÛ>ÃÛiÊ aspergillosis (see p. 133) UÊÊ,ivÀ>VÌÀÞÊ`Ãi>ÃiÊvÀÊÕÃiÊÊVL>ÌÊÜÌ Ê6ÀV>âi]Ê Posaconazole or AmBisome® for confirmed invasive aspergillosis. UÊ1>VVi«Ì>LiÊÕÃià UÊÊV>vÕ}Ê>iÊÀÊÊVL>ÌÊÜÌ ÊÌ iÀÊ>ÌvÕ}>Ê>}iÌÃÊÃÊ not recommended for empiric therapy in patients with CT findings suggestive of aspergillosis (e.g., possible aspergillosis) without plans for diagnostic studies. UÊÊV>vÕ}Ê`iÃÊÌÊ >ÛiÊ}`Êin vitro activity against zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.). Candidiasis UÊVVi«Ì>LiÊÕÃià UÊ/Ài>ÌiÌÊvÊÛ>ÃÛiÊV>``>ÃÃÊ`ÕiÊÌÊC. glabrata or C. krusei. UÊÊ/Ài>ÌiÌÊvÊÛ>ÃÛiÊV>``>ÃÃÊÊ«>ÌiÌÃÊÜ Ê>ÀiÊ "/ÊVV>ÞÊ stable due to candidemia or have received prior long-term azole therapy. UÊÌiÀ>ÌÛiÊÌÀi>ÌiÌÊvÊÀiVÕÀÀiÌÊië >}i>ÊV>``>Ãð UÊÌiÀ>ÌÛiÊÌÀi>ÌiÌÊvÊi`V>À`Ìð UÊ1>VVi«Ì>LiÊÕÃià UÊÊV>vÕ}Ê >ÃÊ«ÀÊ«iiÌÀ>ÌÊÌÊÌ iÊ -Ê>`ÊÕÀ>ÀÞÊÌÀ>VÌ°ÊÌÊ should be avoided for infections involving those sites. Neutropenic fever UÊÊV>vÕ}ÊV>ÊLiÊÕÃi`ÊvÀÊiÕÌÀ«iVÊviÛiÀÊÊ«>ÌiÌÃÊÜ Ê>ÀiÊÌÊ suspected to have aspergillosis or zygomycosis. Dose UÊÊ >``i>]ÊÛ>ÃÛiÊV>``>ÃÃ]ÊiÕÌÀ«iVÊviÛiÀ\Ê£ääÊ}Ê6Ê Q24H UÊ >``>Êi`V>À`ÌÃ\Ê£xäÊ}Ê6Ê+Ó{ UÊ,iVÕÀÀiÌÊië >}i>ÊV>``>ÃÃ\Ê£xäÊ}Ê6Ê+Ó{ UÊÛ>ÃÛiÊ>ëiÀ}ÃÃ\Ê£ääq£xäÊ}Ê6Ê+Ó{ UÊ"LiÃiÊ«>ÌiÌà UÊÊ£ääq£xäÊ}\Ê£xäÊ}Ê6Ê+Ó{ UÊÊ> £xäÊ}\Ê ÃÕÌÊ Ê* >À>VÃÌ Drug Interactions UÊÊ ÃiÊÌÀ}ÊÃÊÀiVi`i`ÊÜ iÊV>vÕ}ÊÃÊÕÃi`ÊÜÌ ÊÌ iÊ vÜ}Ê>}iÌÃÊVVÌ>ÌÞ\ 17 3.2 Agent-specific guidelines: Antifungals Micafungin NOTE: Micafungin does not have activity against Cryptococcus. 3.2 Agent-specific guidelines: Antifungals UÊÊ-ÀÕÃÊqÊiÛiÃÊvÊ-ÀÕÃÊ>ÞÊLiÊVÀi>Ãi`]ÊÌÀÊvÀÊ Sirolimus toxicity UÊÊ vi`«iÊqÊiÛiÃÊvÊ vi`«iÊ>ÞÊLiÊVÀi>Ãi`]ÊÌÀÊvÀÊ Nifedipine toxicity UÊÊÌÀ>V>âiÊqÊiÛiÃÊvÊÌÀ>V>âiÊ>ÞÊLiÊVÀi>Ãi`]ÊÌÀÊvÀÊ Itraconazole toxicity Toxicity UÊÊvÕÃÀi>Ìi`ÊÀi>VÌÃÊ­À>à ]Ê«ÀÕÀÌî]Ê« iLÌÃ]Ê i>`>V i]Ê>ÕÃi>Ê and vomiting, and elevations in hepatic enzymes. UÊÌÀ}\Ê-/É/ÉLÀÕLÊ>ÌÊL>ÃiiÊ>`ÊiÛiÀÞÊ£qÓÊÜiiÃÊ>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>ÌiÌÊvÊÛ>ÃÛiÊâÞ}ÞVÃÃÊÊVL>ÌÊÜÌ Ê« ÌiÀVÊ UÊÊÌ iÀ>«ÞÊvÀÊâÞ}ÞVÃÃÊ>vÌiÀÊÇÊ`>ÞÃÊvÊVL>ÌÊÌ iÀ>«ÞÊ with Amphotericin B UÊ*À« Þ>ÝÃÊÊ«>ÌiÌÃÊÜÌ Ê i>Ì}VÊ>}>VÞ UÊ/Ài>ÌiÌÊvÊ>ëiÀ}ÃÃÊÊ«>ÌiÌÃÊÜÌ Ê6ÀV>âiÊÌiÀ>Vi Unacceptable uses UÊ >``>ÃÃÉ iÕÌÀ«iVÊviÛiÀ UÊÀÃÌiÊÌÀi>ÌiÌÊvÊ>ëiÀ}Ãà Dose "/ -\Ê UÊÊ >V Ê`ÃiÊvÊÃÕëiÃÊà Õ`ÊLiÊ}ÛiÊÜÌ Ê>ÊvÕÊi>ÊÀÊÜÌ ÊµÕ`Ê nutritional supplements if patients cannot tolerate full meals. Can also be given with an acidic beverage (e.g. ginger ale). UÊÊ i>Þi`ÊÀii>ÃiÊÌ>LiÌÃÊ>`ÊÀ>ÊÃÕëiÃÊV>ÌÊLiÊÕÃi`Ê interchangeably due to differences in the dosing of each formulation. Prophylaxis UÊ"À>Ê-ÕëiÃ\ÊÓääÊ}Ê*"Ê+n UÊ ÝÌi`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääÊ}Ê*"Ê`>Þ Treatment UÊÊ"À>Ê-ÕëiÃ\ÊÓääÊ}Ê*"Ê+ÈÊvÀÊÇÊ`>ÞÃ]ÊÌ iÊ{ääÊ}Ê*"Ê Q8-Q12H UÊÊ ÝÌi`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääÊ}Ê*"Ê+£ÓÊvÀÊ£Ê`>Þ]ÊÌ iÊÎääÊ}Ê PO daily 18 Drug Interactions: See Table on p. 21 Toxicity UÊÊÊÕ«ÃiÌÊ­H{䯮]Ê i>`>V iÃ]ÊiiÛ>ÌÊÊ i«>ÌVÊiâÞiðÊ,>ÀiÊLÕÌÊ serious effects include QTc prolongation. UÊÊÌÀ}\Ê-/É/ÉLÀÕLÊ>ÌÊL>ÃiiÊ>`ÊiÛiÀÞÊ£qÓÊÜiiÃÊ>vÌiÀ ,iviÀiViÃ\ V>ÊivwV>VÞÊvÊiÜÊ>ÌvÕ}>Ê>}iÌÃ\Ê ÕÀÀÊ"«ÊVÀL°ÊÓääÈÆ\{nÎnn° *Ã>V>âi\Ê>ÊLÀ>`ÊëiVÌÀÕÊÌÀ>âiÊ>ÌvÕ}>\Ê>ViÌÊviVÌÊ Ã°ÊÓääxÆÊx\ÇÇxnx° 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 UÊÊ>`}Ê`Ãi\ÊÈÊ}É}Ê6É*"Ê+£ÓÊÝÊÓÊ`Ãià UÊ>Ìi>ViÊ`Ãi\Ê{Ê}É}Ê6É*"Ê+£Ó UÊÊ ÃiÊ>`ÕÃÌiÌÊÃÊiViÃÃ>ÀÞÊvÀÊ i«>ÌVÊÃÕvwViVÞ\ UÊ `ÊÊ*Õ} Ê­ÊÀÊ ®\Ê↓ >Ìi>ViÊ`ÃiÊLÞÊxä¯ UÊÊ `ÊÊ*Õ} Ê­ ®\Ê1ÃiÊÞÊvÊLiiwÌÃÊÕÌÜi} ÊÀÃÃ°Ê ÃÕÌÊ ID pharmacist for dose adjustment recommendations. UÊÊ ÃiÊiÃV>>ÌÊ>ÞÊLiÊiViÃÃ>ÀÞÊvÀÊÃiÊ«>ÌiÌÃÊ`ÕiÊÌÊ subtherapeutic levels. UÊÊ ÃiÊL>Ãi`ÊÊ>VÌÕ>ÊL`ÞÊÜi} ÌÊÕiÃÃÊ«>ÌiÌÊÎä¯ÊÛiÀÊ 7ÆÊ then use adjusted body weight. (Adj. BW). `°Ê 7ÊrÊQ 7ʳÊä°{Ê­ 7ÊÊ 7®R IBW - Ideal Body Weight ABW - Actual Body Weight 19 3.2 Agent-specific guidelines: Antifungals Therapeutic monitoring: UÊ*Ã>V>âiÊÌÀÕ} ÊiÛiÃÊà Õ`ÊLiÊVÃ`iÀi`ÊÊ«>ÌiÌÃÊÜ Ê>Ài\ UÊ ÌÊÀië`}ÊÌÊÌ iÀ>«ÞÊvÀÊ>ÌÊi>ÃÌÊÇÊ`>Þà UÊ i}ÊÌÀi>Ìi`ÊvÀÊÕVÊÀÊiÃÃÊÃÕÃVi«ÌLiÊÀ}>Ãà UÊ Ý«iÀiV}ÊÕVÃÌÃÊÀÊ>>LÃÀ«ÌÊÃÞ`Ài UÊ1>LiÊÌÊVÃÕiÊ } Êv>ÌÊi>ÃÊ­vÊÀiViÛ}ÊÌ iÊÃÕëiî 3.2 Agent-specific guidelines: Antifungals Therapeutic monitoring UÊÊ6ÀV>âiÊÌÀÕ} ÊiÛiÃÊà Õ`ÊLiÊVÃ`iÀi`ÊÊ«>ÌiÌÃÊÜ Ê>Ài\ UÊÊ ÌÊÀië`}ÊÌÊÌ iÀ>«ÞÊ>vÌiÀÊ>ÌÊi>ÃÌÊxÊ`>ÞÃÊvÊÌ iÀ>«ÞÊÕÃ}Ê>Ê mg/kg dosing strategy UÊÊ,iViÛ}ÊVVÌ>ÌÊ`ÀÕ}ÃÊÌ >ÌÊ>ÞÊVÀi>ÃiÊÀÊ`iVÀi>ÃiÊ Voriconazole levels UÊÊ Ý«iÀiV}Ê>`ÛiÀÃiÊiÛiÌÃÊ`ÕiÊÌÊ6ÀV>âi UÊÊ Ý«iÀiV}ÊÊ`ÞÃvÕVÌ UÊÊ6ÀV>âiÊÌÀÕ} ÊiÛiÃÊà Õ`ÊLiÊLÌ>i`ÊxqÇÊ`>ÞÃÊ>vÌiÀÊÃÌ>ÀÌÊvÊ Ì iÀ>«ÞÊ­«iÀvÀi`Êq®° UÊÊ>ÊÌÀÕ} \ÊÓqx°xÊV}É°ÊiÛiÃÊÊ£ÊV}ÉÊ >ÛiÊLiiÊ associated with clinical failures and levels >5.5 mcg/mL with toxicity. Drug Interactions: See Table on p. 21 Toxicity UÊÊ6ÃÕ>Ê`ÃÌÕÀL>ViÃÊ­HÎ䯮ÊÕÃÕ>ÞÊÃivÌi`]ÊÀ>à ]ÊviÛiÀ]ÊiiÛ>ÌÃÊ in hepatic enzymes. UÊÊÌÀ}\Ê-/É/ÉLÀÕLÊ>ÌÊL>ÃiiÊ>`ÊiÛiÀÞÊ£qÓÊÜiiÃÊ>vÌiÀ ,iviÀiViÃ\ 6ÀVâi\Ê ÊviVÌÊ ÃÊÓääÎÆÊÎÈ\ÈÎä° 6ÀV>âiÊÊiÕÌÀ«iVÊviÛiÀ\Ê Ê }ÊÊi`ÊÓääÓÆÎ{È­{®\ÓÓx°Ê 6ÀV>âiÊ/ \Ê ÊviVÌÊ ÃÊÓäänÆÊ{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: ÞÌV ÀiÊ­ 9*®Ê*{xäÊ LÌÀÃ\Ê`iVÀi>ÃiÊÌ iÊiÌ>LÃÊvÊViÀÌ>Ê drugs (CYP450 substrates) resulting in increased drug concentrations in the body (occurs immediately) ÞÌV ÀiÊ­ 9*®Ê*{xäÊ`ÕViÀÃ\ÊVÀi>ÃiÊÌ iÊiÌ>LÃÊvÊViÀÌ>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: *}ÞV«ÀÌiÊ­*}«®Ê LÌÀ\Ê`iVÀi>ÃiÊÌ iÊvÕVÌÊvÊÌ iÊivyÕÝÊ«Õ«]Ê resulting in increased absorption/penetration of P-gp substrates *}ÞV«ÀÌiÊ`ÕViÀ\ÊVÀi>ÃiÊÌ iÊvÕVÌÊvÊÌ iÊivyÕÝÊ«Õ«]Ê resulting in decreased absorption/penetration of P-gp substrates PotencyÊvÊ ÞÌV ÀiÊ*{xäÊ LÌ\Ê6ÀV>âiÊÊÌÀ>V>âiÊÊ 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 ÞÊ«ÀiÃVÀLi`\ sirolimus iÃÃÊVÞÊ«ÀiÃVÀLi`\ cisapride, ergot alkaloids, pimozide, quinidine, triazolam Cyclosporine Metoclopramide, proton pump inhibitors Midazolam Tacrolimus Cimetidine, efavirenz, phenytoin, rifabutin, rifampin Warning/precaution Drug ÞÊ«ÀiÃVÀLi`\ statins (lovastatin, simvastatin) iÃÃÊVÞÊ«ÀiÃVÀLi`\ cisapride, dofetilide, ergot alkaloids, nisoldipine, oral midazolam, pimozide, quinidine, triazolam ÞÊ«ÀiÃVÀLi`\ 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 iÃÃÊVÞÊ«ÀiÃVÀLi`\ alfentanil, buspirone, cilostazol, disopyramide, felodipine, trimetrexate ÞÊ«ÀiÃVÀLi`\ 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 ↓ÊÃÀÕÃÊ`ÃiÊLÞÊÇx¯Ê>`ÊÌÀÊiÛià 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 ÞÊ«ÀiÃVÀLi`\ 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 iÃÃÊVÞÊ«ÀiÃVÀLi`\ alfentanil Drug ÞÊ«ÀiÃVÀLi`\ carbamazepine, rifabutin, rifampin, ritonavir 400 mg Q12H iÃÃÊVÞÊ«ÀiÃVÀLi`\ long-acting barbiturates, cisapride, ergot alkaloids, pimozide, quinidine, St. John’s Wort Cyclosporine Efavirenz Contraindicated Warning/precaution Drug Cisapride ÞÊ«ÀiÃVÀLi`\ cyclosporine, glipizide, glyburide, phenytoin, rifabutin, tacrolimus, warfarin iÃÃÊVÞÊ«ÀiÃVÀLi`\ 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 ÕV«ÀÃi`Ê ÃÌ\ÊV}iÌ>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 IVÕ`}Ê ]ÊV>À`Þ«>Ì iÃ]ÊiÝVÕ`}Ê Þ«iÀÌiÃÆÊaVÕ`}Ê "* ]Êi« ÞÃi>]Ê asthma Timing and sequential administration of pneumococcal vaccines UÊ Ê ÃÌÀÞÊÀÊÕÜÊ ÃÌÀÞÊvÊ«iÕVVV>ÊÛ>VV>ÌÊ>`ÊLÌ 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«>ÌiÌÊ >ÃÊÀiViÛi`Ê*iÕÛ>ÝÊÓή and both vaccines are indicated, the patient should receive Prevnar 13® (minimum 1 year separation) UÊvÊ«>ÌiÌÊ >ÃÊÀiViÛi`Ê*ÀiÛ>Àʣή ≥ 8 weeks ago, and both vaccines are indicated, the patient should receive Pneumovax 23® (minimum 8 weeks separation) UÊvÊ«>ÌiÌÊ >ÃÊÀiViÛi`ÊLÌ ÊÛ>VViÃÊ≥ 5 years ago and revaccination is needed with Pneumovax 23®, a second dose should be administered (minimum 5 years apart) UÊ*>ÌiÌÃÊÜ Ê>ÀiÊÃiÛiÀiÞÊÕV«ÀÃi`Ê­i°}°Ê /]ÊÃ`ÊÀ}>Ê transplant) should follow institutional policy when available or consult ID for optimal timing of vaccine administration ,iviÀiVi\Ê *Ê,iVi`>ÌÃ\Ê7,ÊÓä£{ÆÈέÎÇ®ÆnÓÓnÓxÊ>`Ê7,ÊÓä£ÓÆÈ£­{ä®Æn£Èn£°Ê 23 3.3 Agent-specific guidelines: Vaccines Pneumococcal vaccination There are two types of pneumococcal vaccines that are recommended LÞÊ *Ê}Õ`iiÃÊvÀÊ>`ÕÌÊ«>ÌiÌÃ\Ê*iÕVVV>Ê«ÞÃ>VV >À`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}>ÌÛiÊL>VÊÊBacteroides spp., Prevotella spp., Porphyromonas spp., Fusobacterium spp. UÊÊÀ>i}>ÌÛiÊVVVÊÊVeillonella spp. UÊÊÀ>«ÃÌÛiÊL>VÊÊPropionibacterium spp., Lactobacillus spp., Actinomyces spp., Clostridium spp. UÊÊÀ>«ÃÌÛiÊVVVÊÊPeptostreptococcus 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 ViVÌÊÃÊVÀÌV>ÆÊÀiviÀÊÌÊëiViÊViVÌÊ}Õ`iiÃÊ>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}V>Ê`iLÀ`iiÌÊvÊ>>iÀLVÊviVÌÃÊÃÊ«ÀÌ>ÌÊLiV>ÕÃiÊ anaerobic organisms can cause severe tissue damage. UÊÊ«VÉÃÕL>VÌ>Ê>`Ê `>ÞVÊ>ÀiÊVÃ`iÀi`ÊÌÊLiÊivviVÌÛiÊ empiric therapy against Gram-positive anaerobes seen in infections 24 Propionibacterium acnes Indications for consideration of testing for P. acnes: UÊ -Êà ÕÌÊviVÌà UÊ*ÀÃÌ iÌVÊà Õ`iÀÊÌÊviVÌÃÊ UÊ"Ì iÀÊ«>Ì>LiÊ`iÛViÊviVÌà Diagnosis UÊÊ ÕÌÕÀiÃÊà Õ`ÊLiÊ i`ÊvÀÊ£ä£{Ê`>ÞÃÊvÊ } ÊÃÕëVÊvÀÊP. acnes as growth is slow UÊÊ iVÌÊvÊÌÃÃÕiÊ>`ÊyÕ`ÊëiViÃÊvÀÊVÕÌÕÀiÊÃÊ«ÀiviÀÀi`°Ê ÊÌÊ send swabs for culture UÊÊÕÌ«iÊÀi«ÀiÃiÌ>ÌÛiÊëiViÃÊ­«ÀiviÀ>LÞÊήÊà Õ`ÊLiÊÃiÌÊ 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>VÞVÊÃÊ>ÃÊ>VÌÛiÊ>}>ÃÌÊ>ÞÊÀ>«ÃÌÛiÊ>>iÀLiÃÊ­i°}°Ê Clostridium spp., Peptostreptococcus spp., P. acnes). UÊÊ «ÀVÊ`ÕLiÊVÛiÀ>}iÊÜÌ ÊiÌÀ`>âiÊ ÊV>ÀL>«iiÃÊ (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). UÊÊÃÌÊÀiÃÃÌ>ViÊÊÌ 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 *«iÀ>VÉ/>âL>VÌ>ÆÊÌ iÀivÀi]ÊÜ iÊÌ ÃÊÀ}>ÃÊÃÊÃ>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/}iVÞViÊÃÊ>VÌÛiÊ>}>ÃÌÊ>ÊÜ`iÊëiVÌÀÕÊvÊ}À>«ÃÌÛiÊ>`Ê gram-negative anaerobic bacteria in vitro but clinical experience with this agent is limited. 4.2 Organism-specific guidelines: P. acnes Treatment UÊÊ*iVÊÊÓÎÊÊÕÌÃÊ6Ê+{Ê­«ÀiviÀÀi`® OR UÊ* Ê>iÀ}ÞÊ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä® NOTES UÊÊ ÊVÃÕÌÊÀiVi`i`ÊvÀÊ>ÃÃÃÌ>ViÊÜÌ ÊV ViÊ>`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«ÀÌÃÊvÊë>ÊviVÌÃÊ >ÛiÊLiiÊÌi`ÊvÀÊP. acnes UÊÊÊP. acnes isolutes at JHH are susceptible to Penicillin (see anaerobic antibiogram p. 24) UÊÊiÌÀ`>âiÊ`iÃÊÌÊ >ÛiÊ>VÌÛÌÞÊ>}>ÃÌÊP. acnes. Tetracyclines are not routinely tested and resistance rates are variable. UÊÊ À>`iÀÊëiVÌÀÕÊ>}iÌÃÊÃÕV Ê>ÃÊiÀ«iiÊ>`Ê*«iÀ>VÉ tazobactam would be expected to be active for Penicillin susceptible isolates, but these are not first-line therapy UÊÊ-ÕÃVi«ÌLÌÞÊ`>Ì>Êà Õ`ÊLiÊÕÃi`ÊÌÊ i«Ê}Õ`iÊÌ iÀ>«iÕÌVÊ`iVÃà U Consider removal of associated hardware 26 Viridans group Streptococci (alpha-hemolytic streptococci) À>ÊVÀLÌ>ÊvÊÌ iÊÀ>ÊV>ÛÌÞÊ>`ÊÊÌÀ>VÌÆÊÃ}iÊL`ÊVÕÌÕÀiÃÊ growing these organisms often represent contamination or transient bacteremia Five groups UÊÊS. anginosus group (contains S. intermedius, anginosus, and constellatus®\ÊÊVÞÊV>ÕÃiÊ>LÃViÃÃiÃÆÊ>ÀÌÞÊ>ÀiÊ*iVÊ susceptible UÊÊS. bovisÊ}ÀÕ«ÊQVÌ>ÃÊS. gallolyticus subspecies gallolyticus (associated with colon cancer—colonoscopy mandatory, endocarditis >ÃÊ«ÀiÃiÌÊÊÊxä¯ÊvÊV>ÃiîÊ>`ÊÃÕLëiViÃÊpasteurinus ­>ÃÃV>Ìi`ÊÜÌ Ê i«>ÌL>ÀÞÊ`Ãi>Ãi]Êi`V>À`ÌÃÊiÃÃÊV®RÆÊ majority are Penicillin susceptible UÊS. mitis group (contains S. mitis, oralis, gordonii, and sanguinous®\Ê VÞÊV>ÕÃiÊL>VÌiÀi>ÊÊiÕÌÀ«iVÊ«>ÌiÌÃÊ>`Êi`V>À`ÌÃÆÊ many have Penicillin resistance UÊÊS. salivariusÊ}ÀÕ«\ÊiÃÃÊVÊV>ÕÃiÊvÊi`V>À`ÌÃÆÊ>ÀÌÞÊ>ÀiÊ Penicillin susceptible UÊÊS. mutansÊ}ÀÕ«\ÊVÊV>ÕÃiÊvÊ`iÌ>ÊV>ÀiÃÆÊÕVÊV>ÕÃiÊ vÊi`V>À`ÌÃÆÊ>ÀÌÞÊ>ÀiÊ*iVÊÃÕÃVi«ÌLi Beta-hemolytic Streptococci All are susceptible to Penicillin 6>À>LiÊÀ>ÌiÃÊvÊÀiÃÃÌ>ViÊÌÊ `>ÞVÆÊ>ÃÊÌ iÊVÀL}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 } ÊÀ>ÌiÃÊvÊÀiÃÃÌ>ViÊÌÊÌiÌÀ>VÞViÃÊ>`Ê/*É-8Ê«ÀiVÕ`iÊÌ iÀÊ empiric use for infections suspected to be caused by beta-hemolytic streptococci UÊÊS. pyogenesÊ­}ÀÕ«ÊÊÃÌÀi«®\Ê« >ÀÞ}ÌÃ]ÊÃÊ>`ÊÃvÌÊÌÃÃÕiÊ viVÌÃÊVÕ`}ÊiÀÞëi>Ã]ÊViÕÌÃ]ÊiVÀÌâ}Êv>ÃVÌÃÆÊ `>ÞVÊÀiÃÃÌ>ViÊÊ£°xx°Ó¯ÆÊ>VÀ`iÊÀiÃÃÌ>ViÊÊ{ǯ°Ê UÊÊS. agalactiaeÊ­}ÀÕ«Ê ÊÃÌÀi«®\Êi>Ì>ÊviVÌÃ]ÊviVÌÃÊvÊÌ iÊ vi>iÊ}iÌ>ÊÌÀ>VÌ]ÊÃÊ>`ÊÃvÌÊÌÃÃÕiÊviVÌÃ]ÊL>VÌiÀi>ÆÊ `>ÞVÊÀiÃÃÌ>ViÊÊ£ÈÓȯÆÊ>VÀ`iÊÀiÃÃÌ>ViÊÊÇÎÓ¯°Ê 27 4.3 Organism-specific guidelines: Streptococci Streptococci 4.3 Organism specific guidelines: Multi-drug resistant Gram-negative rods UÊÊÀÕ«Ê Ê>`ÊÊÃÌÀi«ÌVVV\ÊviVÌÃÊÃ>ÀÊÌÊS. pyogenes and S. agalactiaeÆÊ>ÃÃV>Ìi`ÊÜÌ ÊÕ`iÀÞ}Ê`Ãi>ÃiÃÊ­i°}°Ê`>LiÌiÃ]Ê >}>VÞ]ÊV>À`Û>ÃVÕ>ÀÊ`Ãi>Ãi®ÆÊ `>ÞVÊÀiÃÃÌ>ViÊÊH£È¯Ê vÊ}ÀÕ«Ê Ê>`ÊHÎίÊvÊ}ÀÕ«ÊÊÃ>ÌiÃÆÊ>VÀ`iÊÀiÃÃÌ>ViÊÊ HÓx¯ÊvÊ}ÀÕ«Ê Ê>`ÊHÓn¯ÊvÊ}ÀÕ«ÊÊÃ>ÌiÃ°Ê Streptococcus pneumoniae UÊÊ ÊV>ÕÃiÊvÊÀiëÀ>ÌÀÞÊÌÀ>VÌÊviVÌÃÊVÕ`}ÊÌÌÃÊi`>]Ê ÃÕÃÌÃ]Ê«iÕ>ÊÛ>ÊV>ÊëÀi>`ÊvÀÊÌ iÊ>ë >ÀÞÝÆÊviVÌÃÊ involving the CNS, bones/joints and endocarditis via hematogenous spread UÊÊiiÌV>Þ]ÊS. pneumoniae is in the S. mitis group of viridans group ÃÌÀi«ÌVVVÆÊVÃiµÕiÌÞ]ÊÀ>«`ÊiVÕ>ÀÊÌiÃÌÃÊ>ÞÊÌÊLiÊ>LiÊÌÊ distinguish S. pneumoniae and streptococci in the S. mitis group. UÊÊ*iVÊÃÊÌ iÊ>}iÌÊvÊwÀÃÌÊV ViÊvÀÊÃiÀÕÃÊS. pneumoniae infections when it is susceptible UÊÊ*iVÊ>`Ê ivÌÀ>ÝiÊÃÕÃVi«ÌLÌÞÊLÀi>«ÌÃÊ>ÀiÊ`vviÀiÌÊvÀÊ 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``ÌÊvÊ6>VÞVÊÌÊ ivÌÀ>ÝiÊÃÊÌÊ`V>Ìi`ÊÊÌ iÊi«ÀVÊ 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>ÀiÊiâÞiÃÊÌ >ÌÊVviÀÊÀiÃÃÌ>ViÊÌÊ>Ê«iVÃ]Ê cephalosporins, and Aztreonam. UÊÊ/ iÞÊ>ÀiÊÃÌÊVÞÊÃiiÊÊK. 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>ÌiÌ\ UÊÊiÀ«iiÊ£Ê}Ê6Ê+nÊ­ÓÊ}Ê6Ê+nÊvÀÊ -ÊviVÌîÊà Õ`ÊLiÊ used for ALL severe infections if the organism is susceptible. UÊÊ ÀÌ>«iiÊ£Ê}Ê6Ê+Ó{ÊV>ÊLiÊÕÃi`ÊvÀÊÕV«V>Ìi`Ê1/ÊÀÊÃvÌÊÌÃÃÕiÊ infection with adequate source control if the organism is susceptible. UÊÊ «ÀyÝ>VÊÀÊ/*É-8ÊV>ÊLiÊÕÃi`Ê>ÃÊ>ÌiÀ>ÌÛiÃÊÌÊ ÀÌ>«iiÊ 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>«ii>ÃiÃÊ>ÀiÊiâÞiÃÊÌ >ÌÊVviÀÊÀiÃÃÌ>ViÊÌÊ>Ê«iVÃ]Ê cephalosporins, carbapenems and Aztreonam. UÊÊVÀL}ÞÊ>LÊÃÊÊ}iÀÊ«iÀvÀ}ÊÌ iÊ`wi`Ê`}iÊÌiÃÌ UÊvÊV>ÀL>«iiÊÃÊÀiÃÃÌ>ÌÊÊVÀL}ÞÊ>LÊÜÊÀi«ÀÌÊÀ}>ÃÊ >ÃʺV>ÀL>«iiÊÀiÃÃÌ>Ì»ÆÊ ÜiÛiÀ]ÊÌ iÊiÝ>VÌÊiV >ÃÊvÊ resistance is not tested for at this time. /Ài>ÌiÌ\Ê UÊiÀ«iiÊÓÊ}Ê6Ê+nÊvÕÃi`ÊÛiÀÊÎÊ ÕÀÃÊà Õ`ÊLiÊVÕ`i`Ê in most regimens based on data from small, retrospective studies showing benefit even when the isolate is intermediate or resistant. UÊÌÊi>ÃÌÊiÊ>``Ì>Ê>}iÌÊà Õ`ÊLiÊ>``i`ÊL>Ãi`ÊÊÃÕÃVi«ÌLÌiÃÊ (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>«iiÃ]Ê>}ÞVÃ`iÃ]ÊyÕÀµÕiÃ]Ê«iVÃ]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 ivÌâ>iÉÌ>âL>VÌ>ÊÊ (if susceptible) ORÊ UÊÊÌ«ÃiÕ`>Ê-lactam PLUS ÊÊÊ>}ÞVÃ`iÊvÊÃÞiÀ}ÞÊ«Ài`VÌi`ÊÊ or confirmed OR UÊÊ ÃÌÊ­vÊÃÕÃVi«ÌLi®Ê Ê UÊ-lactam PLUS aminoglycoside if synergy expected OR UÊÊ ÃÌÊ­vÊÃÕÃVi«ÌLi®Ê OR UÊÊ«VÉÃÕL>VÌ>Ê­vÊÃÕÃVi«ÌLi®ÊPLUS aminoglycoside (Sulbactam component has in vitro activity against Acinetobacter spp.) ÊÊÊOR UÊÊ/}iVÞViÊ­vÊÃÕÃVi«ÌLiÆÊvÀÊviVÌÃÊÌ iÀÊÌ >Ê bacteremia) *Combination therapy should be considered in severe infections. 29 4.4 Organism specific guidelines: Multi-drug resistant Gram-negative rods UÊÊ,ÃÊv>VÌÀÃÊvÀÊviVÌÊÀÊVâ>Ì\ÊÀiViÌÊ Ã«Ì>â>ÌÊ>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 iÊÀ}>ÃÊÃÊÌiÀi`>ÌiÊÌÊ>ÊLiÌ>>VÌ>Ê>`ÊÃÕÃVi«ÌLiÊÌÊ aminoglycosides, synergy can be assumed. UÊ/ iÊVÀL}ÞÊ>LÊ`iÃÊÌÊ«iÀvÀÊÃÞiÀ}ÞÊÌiÃÌ}°Ê Antibiotic doses for MDR and carbapenemase-producing infections – normal renal and hepatic function UÊiÀ«ii\ÊÓÊ}Ê6Ê+n]ÊvÕÃiÊÛiÀÊÎÊ ÕÀÃÊ UÊ ivi«i\ÊÓÊ}Ê6Ê+n]ÊvÕÃiÊÛiÀÊÎÊ ÕÀà UÊ ivÌ>â`iÉ ivi«i\ÊÓÊ}Ê6ÊLÕÃÊ>`}Ê`ÃiÊÛiÀÊÎäÊÕÌiÃ]Ê then 6 g IV as continuous infusion over 24 hours UÊ*«iÀ>VÉÌ>âL>VÌ>\ÊΰÎÇxÊ}Ê6ÊLÕÃÊ>`}Ê`ÃiÊÛiÀÊÎäÊ minutes, then continuous infusion 3.375 g IV Q4H infused over 4 hours OR 4.5 g IV Q6H, infuse over 4 hours UÊ ÃÌ\ÊxÊ}É}ÊVi]ÊÌ iÊÓ°xÊ}É}Ê6Ê+£ÓÊ­vÀÊ>``Ì>Ê information, see p. 9) UÊ«VÉÃÕL>VÌ>\ÊÎÊ}Ê6Ê+{Ê­vÀÊ ,ÊA. baumannii only) UÊ}ÞVÃ`iÃÊ­vÀÊ`Ã}]ÊÃiiÊ«°Ê£{È® UÊ/}iVÞVi\Ê£ää£xäÊ}Ê6Ê+£ÓÊ UÊ ivÌâ>iÉÌ>âL>VÌ>Ê£°xÎÊ}Ê6Ê+n ,iviÀiViÃ\Ê - ÃÊ>`ÊVV>ÊÕÌViÃ°Ê ÊviVÌÊ ÃÊÓä£x\ÊÈä­®\ʣΣ\Óx° Current therapies for P. aeruginosa°Ê ÀÌÊ >ÀiÊ ÊÓäänÆÓ{\ÓÈ£°Ê L>ÌÊÌ iÀ>«ÞÊvÀÊ , °Ê ÊVÀLÊviVÊÓä£{ÆÓä\ÊnÈÓÇÓ° 30 Gram-positive cocci Gram-negative cocci Aerobic In clusters UÊ >}Õ>ÃiÊ­³®\ÊS. aureus UÊÊ >}Õ>ÃiÊ­q®\ÊS. epidermidis, S. lugdunensis In pairs/chains UÊÊ «VVVÕÃ]Ê+ÕiÕ}Ê«ÃÌÛi\Ê S. pneumoniae UÊÊ« > iÞÌV\Ê6À`>ÃÊ}ÀÕ«ÊÊ Streptococci, Enterococcus (faecalis and faecium) UÊÊ iÌ> iÞÌV\Ê Group A strep (S. pyogenes), Group B strep (S. agalactiae), Group C, D, G strep Aerobic «VVVÕÃ\ÊN. meningiditis, N. gonorrhoeae, Moraxella catarrhalis VVL>VÕÃ\ H. flu, Acinetobacter spp., HACEK organisms Anaerobic: Peptostreptococcus spp. Anaerobic: Veillonella spp. Gram-positive rods Gram-negative rods Aerobic >À}i\ Bacillus spp. VVL>VÕÃ\ÊListeria monocytogenes, Lactobacillus spp. ->]Ê«iÀ« V\ Corynebacterium spp. À>V }Êw>iÌÃ\ Nocardia spp., Streptomyces spp. Aerobic Lactose fermenting: Citrobacter spp., Enterobacter spp., E. coli, Klebsiella spp., Serratia spp.* Non-lactose fermenting UÊÊ"Ý`>ÃiÊ­q®: Acinetobacter spp., Burkholderia spp., E. coli (rare), Proteus spp., Salmonella spp., Shigella spp., Serratia spp.*, Stenotrophomonas maltophilia UÊÊ"Ý`>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>`Ê`iÌwiÃÊÌ iÊÕViVÊ>V`ÃÊvÊ£ÓÊÀ>«ÃÌÛiÊL>VÌiÀ>Ê genera/species and 3 resistance markers. UÊÊ >VÌiÀ>ÊëiViÃ\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,iÃÃÌ>ViÊ>ÀiÀÃ\ÊiV]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 ÌÊ6>VÞVÊÊ>`ÊÃÊÀi«ÀÌi`Ê>ÃÊ6, ÆÊÌiÊÌ >ÌÊ>Ê6>VÞV resistant E. faecalis are susceptible to Ampicillin at JHH UÊÊ,iÃÕÌÃÊvÊÌ iÊÌiÃÌÊ>ÀiÊÀi«ÀÌi`ÊÜÌ ÊÎ{Ê ÕÀÃÊ>vÌiÀÊÌ iÊL`Ê cultures turn positive UÊ/iÃÌ}ÊÃÊ«iÀvÀi`ÊÞÊÊÌ iÊwÀÃÌÊ«ÃÌÛiÊL`ÊVÕÌÕÀiÊ UÊÊ/iÃÌ}ÊÃÊ "/Ê«iÀvÀi`ÊÊL`ÊVÕÌÕÀiÃÊ}ÀÜ}ÊÀiÊÌ >ÊiÊ Gram positive organism but is performed on blood cultures growing both Gram positive and negative organisms UÊÊvÊÌ iÊÌiÃÌÊÃÊi}>ÌÛiÊÌÊÜÊLiÊÀi«ÀÌi`Ê>ÃÊi}>ÌÛiÊvÀÊÌ iÊvÜ}Ê À}>ÃÃ\Ê-Ì>« ÞVVVÕÃÊë«]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>VÊ­£ää¯®Ê ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>âÊ Ê Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞV1 MRSAÊ 6>VÞVÊ­£ää¯®Ê >«ÌÞV Ê -}iÊ«ÃÌÛiÊVÕÌÕÀiÃÊ>ÀiÊvÌiÊ>ÊVÌ>>ÌÆÊÊÌÀi>ÌiÌÊ 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>Vʭȯ®ÊÀÊ >«ÌÞVÊ S. lugdunensisÊ 6>VÞVÊ­£ä䯮2Ê E. faecalisÊ «VÊ­n¯®Ê 6>VÞVÊ­x¯®1 3 E. faecium (VRE)Ê iâ`Ê­nǯ® Ê >«ÌÞVʭǯ® E. faecium (not VRE)Ê6>VÞVÊ­£ä䯮3 Linezolid 4 Streptococcus spp.Ê V}ÞÊ«>ÌiÌ\Ê ivÌÀ>Ýi -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞV1 Ê "V}ÞÊ«>ÌiÌ\Ê6>VÞV4 S. anginosus Ê *iVÊÊ­£ää¯®Ê ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀ>Ýi Ê Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞV1 S. pyogenes Ê *iVÊÊ­£ää¯®Ê ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>â (group A strep) -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞV1 S. agalactiae Ê *iVÊÊ­£ää¯®Ê ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>â (group B strep) Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞV1 4 S. pneumoniae Ê ivÌÀ>ÝiÊ­£ä䯮 Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞV1 (not meningitis) S. pneumoniae Ê ivÌÀ>ÝiʳÊ6>VÞVÊÊ -iÛiÀiÊ* Ê>iÀ}Þ\Ê (meningitis) À>« iVʳÊ6>VÞV1 Listeria spp. Ê «VÊ­£ää¯®Ê /ÀiÌ «ÀÉÃÕv>iÌ Ý>âi 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 ÜÃÊC. albicans, most non-oncology patients without prior azole exposure can be treated with fluconazole. For more information see p. 117 and 134. UÊÊvÊ* -Êà ÜÃÊC. glabrata, treat with Micafungin until susceptibilities available. For more information see p. 117 and 134. UÊÊvÊ* -Êi}>ÌÛiÊvÀÊC. 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 ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ OR UÊÊ ÀÌ>«iiÊ£Ê}Ê6Ê+Ó{ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê «ÀyÝ>VÊ{ääÊ}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*«iÀ>VÉÌ>âL>VÌ>ÊΰÎÇxÊ}Ê6Ê+È OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊâÌÀi>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>ÌÊÞÊÕÌÊLÃÌÀÕVÌÊÃÊÀiiÛi`°Ê NO post-procedure antibiotics are necessary if the obstruction is successfully relieved. UÊÊ «V>Ìi`ÊV iVÞÃÌÌÃ\Ê{Ê`>ÞÃ]ÊÕiÃÃÊ>`iµÕ>ÌiÊÃÕÀViÊVÌÀÊÃÊ not achieved. U Ê >ÀÞÊÃi«ÃÃ\Ê{ÇÊ`>ÞÃ]ÊÕiÃÃÊ>`iµÕ>ÌiÊÃÕÀViÊVÌÀÊÃÊÌÊ achieved. TREATMENT NOTES Microbiology UÊÊÀ>i}>ÌÛiÊÀ`ÃÊqÊE. coli, Klebsiella spp., Proteus spp., P. aeruginosa (mainly in patients already on broad-spectrum antibiotics or those who have undergone prior procedures) UÊÊ>iÀLiÃÊqÊBacteroides spp., generally in more serious infections, or Ê«>ÌiÌÃÊÜÌ Ê>Ê ÃÌÀÞÊvÊL>ÀÞÊ>«Õ>ÌÃÆÊÀ>ÀiÊÊÕV«V>Ìi`Ê and community-acquired infections UÊÊEnterococcus spp°ÊqÊÌÀi>ÌiÌÊÌÊ>Ü>ÞÃÊ`V>Ìi`ÆÊÕÃiÊVV>ÊÕ`}iÌ UÊÊ9i>ÃÌÊqÊÀ>Ài 39 6.1 Abdominal infections Management UÊÊÊV>ÃiÃÊvÊÕV«V>Ìi`Ê>VÕÌiÊV iVÞÃÌÌÃ]Ê>ÌLÌVÃÊà Õ`ÊLiÊ given until the biliary obstruction is relieved (either by surgery, ERCP, or percutaneous drain). UÊÊ/Ài>ÌiÌÊvÊiÌiÀVVVÊÃÊÕÃÕ>ÞÊÌÊii`i`ÊÊ`É`iÀ>ÌiÊ disease. UÊÊ9i>ÃÌÊ}iiÀ>ÞÊà Õ`ÊLiÊÌÀi>Ìi`ÊÞÊvÊÌ iÞÊ>ÀiÊÀiVÛiÀi`ÊvÀÊ biliary cultures, not empirically. ,iviÀiViÃ\ >ÀÞÊÌÀ>VÌÊviVÌÃ\Ê ÀÕ}ÃÊ£ÆxÇ­£®\n££° -ÊÕ`iiÃÊvÀÊÌÀ>>L`>ÊviVÌÃ\Ê ÊviVÌÊ ÃÊÓä£äÆxä\£ÎÎq£È{° - ÀÌÊVÕÀÃiÊÌ iÀ>«ÞÊvÀÊ\Ê Ê }ÊÊi`ÊÓä£xÆÎÇÓ\£ÈqÓääx° Diverticulitis EMPIRIC TREATMENT NOTE: Patients with uncomplicated diverticulitis (defined as CT VwÀi`ÊivÌÃ`i`Ê`Ãi>ÃiÊÜÌ ÕÌÊ>LÃViÃÃÆÊvÀiiÊ>ÀÊÀÊwÃÌÕ>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 UÊÊÝVÉV>ÛÕ>>ÌiÊnÇxÊ}Ê*"Ê+£Ó OR UÊÊ ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ÊPLUS Metronidazole 500 mg IV/PO Q8H OR UÊÊ ÀÌ>«iiÊ£Ê}Ê6Ê+Ó{ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQ «ÀyÝ>VÊ{ääÊ}Ê6Ê+£ÓÊ",Ê «ÀyÝ>VÊ xääÊ}Ê*"Ê+£ÓRÊPLUS Metronidazole 500 mg IV/PO Q8H Severe infections UÊÊ*«iÀ>VÉÌ>âL>VÌ>ÊΰÎÇxÊ}Ê6Ê+È OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQ «ÀyÝ>VÊ{ääÊ}Ê6Ê+£ÓÊ",ÊâÌÀi>Ê £Ê}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV Q8H Duration UÊ{Ê`>ÞÃ]ÊÕiÃÃÊ>`iµÕ>ÌiÊÃÕÀViÊVÌÀÊÃÊÌÊ>V iÛi`° 40 Microbiology UÊÊÃÌÊ>ÊviVÌÃÊ>ÀiÊ«ÞVÀL> UÊÊÃÌÊVÞÊÃ>Ìi`Ê>iÀLVÊÀ}>ÃÃÊqÊE. coli, K. pneumoniae, Enterobacter spp., Proteus spp., Enterococcus spp. UÊÊÃÌÊVÞÊÃ>Ìi`Ê>>iÀLVÊÀ}>ÃÃÊqÊB. fragilis, Prevotella, Peptostreptococci Other considerations UÊÊÌVÀL>ÊÌÀi>ÌiÌÊvÀÊ>VÕÌiÊÕV«V>Ìi`Ê`ÛiÀÌVÕÌÃÊ>ÞÊÌÊ accelerate recovery or prevent complications/recurrence. UÊÊ /ÊÃV>ÊÃÊ«ÀÌ>ÌÊÊ>ÃÃiÃÃ}Êii`ÊvÀÊ`À>>}iÊÊÃiÛiÀiÊ`Ãi>Ãi°ÊÊ ,iviÀiVi\ -ÊÕ`iiÃÊvÀÊÌÀ>>L`>ÊviVÌÃ\Ê ÊviVÌÊ ÃÊÓä£äÆxä\£ÎÎq£È{° ÌLÌVÃÊÊ>VÕÌiÊÕV«V>Ìi`Ê`ÛiÀÌVÕÌÃ°Ê ÀÊÊ-ÕÀ}ÊÓä£ÓÆ\xÎÓqxΰ - ÀÌÊVÕÀÃiÊÌ iÀ>«ÞÊvÀÊ\Ê Ê }ÊÊi`ÊÓä£xÆÎÇÓ\£ÈqÓääx° Pancreatitis TREATMENT UÊÊÌLÌVÊ«À« Þ>ÝÃÊÃÊ "/Ê`V>Ìi`ÊÊ«>ÌiÌÃÊÜÌ ÊÃiÛiÀiÊ>VÕÌiÊ pancreatitis (SAP), including those with sterile pancreatic necrosis. UÊÌVÀL>ÊÌ iÀ>«ÞÊ >ÃÊÊivviVÌÊÊÀL`ÌÞÊ>`ÊÀÌ>ÌÞ]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. UÊÊviVÌi`Ê«>VÀi>ÌVÊiVÀÃÃÊÃÊ`iwi`ÊLÞÊ /ÊÃV>ÊÜÌ Ê}>ÃÊÊÌ iÊ pancreas and/or percutaneous or surgical specimen with organisms evident on gram stain or culture. Therapy should be directed based on culture results. UÊÊÊ«>ÌiÌÃÊ«ÀiÃiÌ}ÊÜÌ ÊÃÕëiVÌi`Ê>L`>ÊÃi«ÃÃ]ÊVÃ`iÀÊ i«ÀVÊÌ iÀ>«Þ\ UÊÊ*«iÀ>VÌ>âL>VÌ>Ê{°xÊ}Ê6Ê+È OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê «ÀyÝ>VÊ{ääÊ}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 UÊÊviVÌÊ`iÛi«ÃÊÊÎäqxä¯ÊvÊ«>ÌiÌÃÊÜÌ ÊiVÀÃÃÊ`VÕiÌi`ÊLÞÊ CT scan or at the time of surgery. UÊÊ*i>ÊV`iViÊvÊviVÌÊVVÕÀÃÊÊÌ iÊÎÀ`ÊÜiiÊvÊ`Ãi>Ãi UÊÊ/ iÀiÊÃÊÃÕvwViÌÊiÛ`iViÊÌÊÀiVi`ÊÃiiVÌÛiÊ}ÕÌÊ decontamination in management of pancreatitis. ,iviÀiViÃ\ >VÊvÊÕÌÌÞÊvÊ«À« Þ>VÌVÊ>ÌLÌVÃ\ÊÊ-ÕÀ}ÊÓääÇÆÓ{x\ÈÇ{° Õ`iiÃÊvÀÊ>>}iiÌÊvÊ-*\Ê ÀÌÊ >ÀiÊi`ÊÓää{ÆÎÓ\ÓxÓ{° Peritonitis DEFINITIONS Primary peritonitis is spontaneous infection of the peritoneal cavity, ÕÃÕ>ÞÊ>ÃÃV>Ìi`ÊÜÌ ÊÛiÀÊ`Ãi>ÃiÊ>`Ê>ÃVÌiÃÊQëÌ>iÕÃÊL>VÌiÀ>Ê «iÀÌÌÃÊ­- *®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 ivÌÀ>ÝiÊ£Ê}Ê6Ê+£Ó OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}Ê6É*"Ê+Ó{Ê­V>Ê ÊÀÊ Antimicrobial Stewardship to discuss regimens for patients who have been taking fluoroquinolones for SBP prophylaxis). 42 Duration UÊÊ/Ài>ÌÊvÀÊ5 days PROPHYLAXIS Cirrhotic patients with gastrointestinal hemorrhage UÊÊ «ÀyÝ>VÊxääÊ}Ê*"Ê ÊvÀÊÇÊ`>ÞÃÊ UÊÊ ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ÊV>ÊLiÊÕÃi`ÊÞÊvÊ«>ÌiÌÊÃÊ *"]ÊÌ iÊ switch to Ciprofloxacin 500 mg PO BID once bleeding is controlled Non-bleeding cirrhotic patients with ascites UÊÊ/*É-8Ê£Ê -Ê*"ÊViÊ`>Þ OR UÊÊvÊÃÕv>Ê>iÀ}V]Ê «ÀyÝ>VÊxääÊ}Ê*"Ê`>ÞÊ TREATMENT NOTES Microbiology UÊÊÀ>i}>ÌÛiÊÀ`ÃÊ­ ÌiÀL>VÌiÀ>Vi>i]Êië°ÊE. coli and K. pneumoniae), S. pneumoniae, enterococci, and other streptococci. UÊÊ*ÞVÀL>ÊviVÌÊà Õ`Ê«À«ÌÊÃÕëVÊvÊÊ«iÀvÀ>Ì° Diagnostic criteria UÊÊÓxäÊ* Ê«iÀÊ 3 of ascitic fluid. UÊÊ*ÃÌÛiÊVÕÌÕÀiÊÜÌ ÊÊÓxäÊ* Êà Õ`Ê«À«ÌÊÀi«i>ÌÊÌ>«°ÊvÊ* ÊÊ 250 OR culture remains positive, patient should be treated. Follow-up UÊÊ Ã`iÀÊÀi«i>ÌÊ«>À>ViÌiÃÃÊ>vÌiÀÊ{nÊ ÕÀÃÊvÊÌ iÀ>«Þ° UÊÊ Ã`iÀÊV >}}Ê>ÌLÌVÃÊvÊ>ÃVÌiÃÊyÕ`Ê* Ê >ÃÊÌÊ`À««i`ÊLÞÊ Óx¯Ê>vÌiÀÊ{nÊ ÕÀÃÊ>`ÉÀÊ«>ÌiÌÊÃÊÌÊVV>ÞÊÀië`}° Notes on prophylaxis against SBP UÊÊÊ«>ÌiÌÃÊÜÌ ÊVÀÀ ÃÃÊ>`ÊÕ««iÀÊÊLii`Êà Õ`ÊÀiViÛiÊ «À« Þ>ÝÃÊvÀÊÇÊ`>ÞÃÊ­xä¯Ê`iÛi«Ê- *Ê>vÌiÀÊLii`®° UÊÊ*>ÌiÌÃÊÜ Ê}iÌÊ- *Êà Õ`Ê}iÌÊvi}Ê«À« Þ>ÝÃÊÌÊ«ÀiÛiÌÊvÕÌÕÀiÊ i«Ã`iÃÊ­{äqÇä¯ÊÀÃÊvÊÀiVÕÀÀiViÊÊ£ÊÞi>À®° UÊÊ*À« Þ>ÝÃÊà Õ`ÊLiÊVÃ`iÀi`ÊvÀÊÌ ÃiÊÜÌ ÊÜÊ«ÀÌiÊ VViÌÀ>ÌÃÊÊ>ÃVÌiÃÊ­Ê£äÊ}É®ÊÀÊÕÃÕ««ÀiÃÃÊÜ iÊ patient is in hospital. ,iviÀiViÃ\ >}ÃÃ]ÊÌÀi>ÌiÌÊ>`Ê«À« Þ>ÝÃÊvÊ- *\ÊÊi«>ÌÊÓäääÆÎÓ\£{Ó° >>}iiÌÊvÊÛ>ÀVi>Ê iÀÀ >}iÊÊVÀÀ ÃÃ\Êi«>Ì}ÞÊÓääÇÆ{È\ÓÓqÎn° 43 6.1 Abdominal infections UÊÊ*>ÌiÌÃÊÜÌ ÊÃiÀÕÊVÀi>ÌiÊ£Ê}É`]Ê 1 ÊÎäÊ}É`ÊÀÊÌÌ>Ê LÀÕLÊ{Ê}É`Êà Õ`Ê>ÃÊÀiViÛiÊLÕÊ­Óx¯®Ê£°xÊ}É}ÊÊ 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>«iiÊ£Ê}Ê6Ê+Ó{ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê «ÀyÝ>VÊ{ääÊ}Ê6Ê+£ÓÊPLUS Metronidazole 500 mg IV Q8H Patient severely ill or immunosuppressed UÊÊ*«iÀ>VÉÌ>âL>VÌ>ÊΰÎÇxÊ}Ê6Ê+È OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUS QâÌÀi>Ê£Ê}Ê6Ê+nÊORÊ «ÀyÝ>VÊ{ääÊ}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 ÀiViÛi`Ê«ÀÀÊ}ÌiÀÊ>âiÊÌ iÀ>«Þ\ UÊÊÕV>âiÊ{äänääÊ}Ê6É*"Ê+Ó{ Recommendations for patients who are NOT clinically stable or have ÀiViÛi`Ê«ÀÀÊ}ÌiÀÊ>âiÊÌ iÀ>«Þ\ UÊÊV>vÕ}Ê£ääÊ}Ê6Ê+Ó{Ê Duration of therapy for secondary peritonitis/GI perforation Uncomplicated Definition ÕÀ>ÌÊ Complicated iwÌÊ Duration 44 Stomach Small Bowel Colon Appendix Operated on within 24 hours Ó{q{nÊ ÕÀÃÊ Operated on within 12 hours Ó{q{nÊ ÕÀÃÊ Operated on within 12 hours Ó{q{nÊ ÕÀÃÊ Non-necrotic or gangrenous appendix Ó{Ê ÕÀà >ÌiÊ«iÀ>ÌÊÀÊÊ«iÀ>ÌÆÊÀÊiVÀÌVÉ}>}ÀiÕÃÊ>««i`Ý 4 days unless adequate source control is not achieved ,iviÀiVi\ -ÊÕ`iiÃÊvÀÊÌÀ>>L`>ÊviVÌÃ\Ê ÊviVÊ ÃÊÓä£äÆxä\£ÎÎq£È{° - ÀÌÊVÕÀÃiÊÌ iÀ>«ÞÊvÀÊ\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>âÊ£xÊ}É}ÊÊiÊL>}Ê+Ó{Ê­£Ê}ÊvÊ«>ÌiÌÊÊÈxÊ}®ÊPLUS UÊÊiÌ>VÊÓÊ}É}ÊÊiÊL>}Ê>`}Ê`Ãi]ÊÌ iÊiÌ>VÊä°ÈÊ mg/kg in one bag Q24H Patient with urine output > 100 mL/day UÊÊ ivÌ>â`iÊ£Ê}ÊÊiÊL>}Ê+Ó{ Severe illness: systemic therapy is preferred. UÊÊ,-/Ê "- \Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®Ê6ÊPLUS ONE vÊÌ iÊvÜ}\ QiÌ>VÊÓÊ}É}Ê6Ê",Ê ivÌ>â`iÊ£Ê}Ê6Ê",Ê «ÀyÝ>VÊ{ääÊ }Ê6R 45 6.1 Abdominal infections TREATMENT NOTES UÊÊ >ÕÃ>ÌÛiÊ>}iÌÃÊvÀÊÃ>ÊLÜi]ÊV]Ê>««i`Ý\Ê>>iÀLiÃÊ­ië°Ê B. fragilis), Enterobacteriaceae (esp. E. coli, K. pneumoniae, Enterobacter spp., Proteus spp.®ÆÊviVÌÃÊÕÃÕ>ÞÊ«ÞVÀL>°Ê UÊÊ*>Ì }iÃÊV>ÕÃ}ÊÌiÀÌ>ÀÞÊ«iÀÌÌÃÊ>ÀiÊÛ>À>LiÊ>`Ê>ÀiÊvÌiÊ ÀiÃÃÌ>ÌÊÌÊÀÊÌÊVÛiÀi`ÊLÞÊÌ iÊÌ>Ê>ÌVÀL>ÊÀi}iÆÊÌ ÕÃ]Ê>Ê change in antimicrobials is advised. UÊÊÊV >}iÊÊ>ÌVÀL>ÃÊÌ iÀ>«ÞÊà Õ`ÊLiÊVÃ`iÀi`ÊÊ«>ÌiÌÃÊ with hospital-acquired infections who are already on antimicrobials. UÊÊ/Ài>ÌiÌÊvÊiÌiÀVVVÊÀi>ÃÊVÌÀÛiÀÃ>ÊLÕÌÊà Õ`ÊLiÊ considered in critically ill or immunocompromised patients or when they are a dominant organism in the peritoneal culture. UÊÊ/Ài>ÌiÌÊvÊCandida 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*ÃÌ«iÀ>ÌÛiÊ>ÌLÌVÃÊvÀÊ>««i`VÌÃÊ>ÀiÊÕiViÃÃ>ÀÞÊÕiÃÃÊÌ iÀiÊ is clinical evidence of peritonitis, abscess, or gangrene. UÊÊÌLÌVÃÊ>ÀiÊ>`ÕVÌÛiÊÌÊÃÕÀViÊVÌÀ]ÊÜ V ÊÃÊ>Ê>LÃÕÌiÊ necessity. UÊÊ>VÊvÊÃÕÀViÊVÌÀÊÃÊ`iwi`Ê>ÃÊ}}ÊVÌ>>ÌÊ>`ÉÀÊ>Ê undrained collection of infection. 6.1 Abdominal infections UÊÊ / Ê "- \Ê ÃiÊ«iÀÊ`ÀÕ}ÊiÛiÃÊ>`ÉÀÊÀi>ÊvÕVÌÆÊ consult pharmacy for recommendations for redosing and monitoring Duration:Ê£äq£{Ê`>Þà TREATMENT NOTES Microbiology UÊÊÃÌÊV>ÃiÃÊV>ÕÃi`ÊLÞÊVÌ>>ÌÊvÊÌ iÊV>Ì iÌiÀ UÊÊ ÕÌÕÀiÃÊ>ÞÊLiÊi}>ÌÛiÊÊxqÓä¯ UÊÊÀ>«ÃÌÛiÊVVVÊ­S. aureus, coagulase-negative staphylococci, Enterococcus spp.), Gram-negative rods, yeast (much less common) Diagnosis UÊÊÊ«>ÌiÌÃÊÜÌ ÊÃÕëiVÌi`Ê* Ài>Ìi`Ê«iÀÌÌÃÊà Õ`Ê >ÛiÊ* ÊyÕ`Ê sampled for cell count, differential, gram stain, culture AND amylase. WBC > 100/mm 3ÊÜÌ ÊÊxä¯Ê* ÊÃÕ}}iÃÌÃÊviVÌ° UÊÊ iÛ>Ìi`Ê>Þ>ÃiÊÃÕ}}iÃÌÃÊ«>VÀi>ÌÌÃÊÀÊLÜiÊ«iÀvÀ>Ì° UÊÊÊÃÞ«Ì>ÌVÊ«>ÌiÌÃÊÜÌ ÊVÕ`ÞÊyÕ`Ê>VV«>i`ÊLÞÊ>L`>Ê pain and/or fever, empiric treatment should be started given the high likelihood of infection. UÊÊÊÃÞ«Ì>ÌVÊ«>ÌiÌÃÊÜÌ ÊVi>ÀÊyÕ`]Ê>Ì iÀÊ* ÊyÕ`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. UÊÊÊ>ÃÞ«Ì>ÌVÊ«>ÌiÌÃÊÜÌ ÊVÕ`ÞÊyÕ`]ÊÌÊÃÊÀi>Ã>LiÊÌÊ`i>ÞÊ therapy pending the results of cell count, gram stain, and culture. ,iviÀiVi\ -* ÊÕ`iiÃÊvÀÊ*iÀÌi>Ê >ÞÃÃÀi>Ìi`ÊviVÌÃ\Ê*iÀÌÊ >ÊÌÊÓä£äÆÎä\ ÎÎÊq{Óΰ 46 Diagnosis and testing UÊÊ >ÃiÊ`iwÌÊvÊC. difficileÊ`>ÀÀ i>\Ê«>ÃÃ>}iÊvÊ≥ 3 unformed stools in ≤ 24 hours AND either a positive stool test for C. difficile or colonoscopic/histopathologic finding of pseudomembranous colitis. UÊÊ/ iÊVÀL}ÞÊ>LÊÕÃiÃÊ>ÊÀi>ÌiÊ* ,Ê>ÃÃ>ÞÊÌÊ`iÌiVÌÊÌ iÊÌÝÊ 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. / iÊÃiÃÌÛÌÞÊvÊÀi>ÊÌiÊ* ,ÊÃÊÊä¯ÊV«>Ài`ÊÌÊÌÝ}iVÊ culture. UÊÊ Ê "/ÊÃi`ÊÃÌÊvÀÊC. 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. UÊÊÊ«>ÌiÌÃÊÀiViÛ}Ê>Ý>ÌÛiÃ]ÊÌÊÃÊÀiVi`i`ÊÌÊ`ÃVÌÕiÊ laxatives for 24-48 hours prior to C. difficile stool test to see if diarrhea improves, unless the patient is clinically unstable. UÊÊ iV>ÕÃiÊvÊi >Vi`ÊÃiÃÌÛÌÞÊvÊ* ,]Ê`Õ«V>ÌiÊÌiÃÌ}ÊÃÊÌÊ 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-ÌÊvÀÊC. difficile testing should be collected prior to starting treatment for C. difficile. UÊÊ-«iViÃÊà Õ`ÊLiÊ >`ÊV>ÀÀi`ÊÌÊÌ iÊ>LÊ>ÃÊÃÊ>ÃÊ«ÃÃLiÊ>vÌiÀÊ collection. If they cannot be transported promptly, the samples should be refrigerated. UÊÊ Ê "/ÊÃi`ÊvÜÕ«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>«ÞÊÕÃÌÊLiÊÕÃi`ÊÜ iiÛiÀÊ«ÃÃLiÊ>ÃÊÌ iÊivwV>VÞÊvÊ6Ê 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 UÊÊVÀi>ÃiÊÊÃiÀÕÊVÀi>ÌiÊ> xä¯ÊvÀÊL>Ãii Ê Ê Severe Complicated Ê Ê Ê Ê Ê Ê Criteria as above plus one or more of the following attributable to CDI: UÊÞ«Ìià UÊiÕÃÊ UÊ/ÝVÊi}>VÊÀÊ«>VÌÃÊÊ / UÊ*iÀvÀ>Ì UÊ ii`ÊvÀÊViVÌÞ UÊ 1Ê>`ÃÃÊvÀÊÃiÛiÀiÊ`Ãi>Ãi Infection severity Treatment ÃÞ«Ì>ÌVÊÊ carriage Ê Ê "/ÊÌÀi>ÌÆÊÌÀi>ÌiÌÊV>Ê«ÀÌiÊÀi>«Ã}Ê disease `ÊÀÊ`iÀ>ÌiÊ UÊiÌÀ`>âiÊxääÊ}Ê*"É /Ê+nÊ Ê Unable to tolerate oral therapy UÊÊiÌÀ`>âiÊxääÊ}Ê6Ê+nÊ­ÃÕL«Ì>ÆÊÃiiÊÌiÊ at start of CDI section above) -iÛiÀiÊ UÊÊ6>VÞVÊÃÕÌÊ£ÓxÊ}Ê*"É /Ê+ÈÊ -iÛiÀiÊ «V>Ìi`Ê Ê UÊÊ ÃÕÌÊÃÕÀ}iÀÞÊvÀÊiÛ>Õ>ÌÊvÀÊViVÌÞÊ>`Ê Ê UÊÊ6>VÞVÊÃÕÌÊxääÊ}ÊLÞÊ /Ê+ÈÊPLUS Metronidazole 500 mg IV Q8H† Ê Unable to tolerate oral therapy or complete ileus UÊÊ6>VÞVÊxääÊ}ÊÊxääÊÊ -Ê+ÈÊ>ÃÊÀiÌiÌÊ enema via Foley catheter in rectum + Metronidazole 500 mg IV Q8H I£xÓx¯ÊvÊ Ã«Ì>âi`Ê«>ÌiÌÃÊ>ÀiÊVâi`ÊÜÌ 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 ÊÀiëÃiÊÌÊÀ>ÊiÌÀ`>âiÊ>vÌiÀÊxÊ`>ÞÃÊvÊÌ iÀ>«Þ UÊ-iV`Êi«Ã`iÊvÊÀiVÕÀÀiÌÊ`Ãi>Ãi UÊ*>ÌiÌÃÊÜÌ ÊÃ}wV>ÌÊÃ`iÊivviVÌÃÊÌÊiÌÀ`>âi UÊ*>ÌiÌÃÊÜ Ê>ÀiÊ«Ài}>Ì UÊÊ Ã`iÀÊÊ«>ÌiÌÃÊÊÈxÊÞi>ÀÃÊ}ÛiÊÀi«ÀÌÃÊvÊVÀi>Ãi`ÊÀL`ÌÞÊ from CDI. 48 Approach to patients who need to continue broad spectrum antibiotic therapy UÊ iÌiÀiÊÌ iÊà ÀÌiÃÌÊ«ÃÃLiÊVÕÀÃiÊvÊ>ÌLÌVÊÌ iÀ>«Þ°Ê UÊÊ,i«>ViÊÌ iÊ>ÌLÌVÊÌ >ÌÊ`ÕVi`Ê ]Ê«>ÀÌVÕ>ÀÞÊVi« >ëÀÃ]Ê Clindamycin, and fluoroquinolones. UÊÊvÊÌ iÊ`ÕV}Ê>}iÌÊÃÊÀi«>Vi`Ê>`ÊÌ iÊ ÊÀiÃÛiÃ]ÊV«iÌiÊ>Ê ÃÌ>`>À`Ê£ä£{Ê`>ÞÊVÕÀÃiÊvÊ ÊÌ iÀ>«ÞÆÊÌ iÀiÊÃÊÊii`ÊÌÊiÝÌi`Ê CDI therapy until the end of the course of antibiotic therapy. UÊÊvÊÌ iÊ`ÕV}Ê>}iÌÊV>ÌÊLiÊÃÌ««i`ÊÀÊÀi«>Vi`]ÊVÃ`iÀÊ continuing CDI therapy until the end of the course of antibiotic therapy ­`>Ì>Ê>ÀiÊÌi`®ÆÊ ÊÌ iÀ>«ÞÊà Õ`ÊÌÊLiÊVÌÕi`ÊLiÞ`ÊÌ iÊi`Ê of antibiotic therapy if the patient remains asymptomatic. Recurrent disease UÊÊ,iÃÃÌ>ViÊÌÊiÌÀ`>âiÊÀÊ6>VÞVÊ >ÃÊÌÊLiiÊ`VÕiÌi`Ê conclusively. UÊÊ,iVÕÀÀiÌÊ`Ãi>ÃiÊ>vÌiÀÊ>ÊV«iÌiÊVÕÀÃiÊvÊÌ iÀ>«ÞÊVVÕÀÃÊÊHÊ Óx¯ÊvÊ«>ÌiÌðÊ,i>«ÃiÊÃÊ`ÕiÊÌÊv>ÕÀiÊÌÊiÀ>`V>ÌiÊëÀiÃÊ­Èä¯®Ê ÀÊ>VµÕÃÌÊvÊ>ÊiÜÊÃÌÀ>Ê­{䯮°Ê VÕiÌÊÀiVÕÀÀiÌÊ`Ãi>ÃiÊÜÌ Ê repeat stool testing. UÊÊÀÃÌÊÀiVÕÀÀiViÊà Õ`ÊLiÊÌÀi>Ìi`ÊÌ iÊÃ>iÊ>ÃÊÌ iÊÌ>Êi«Ã`iÆÊ severe disease should be treated with Vancomycin. UÊÊ-iV`ÊÀiVÕÀÀiViÊà Õ`ÊLiÊÌÀi>Ìi`ÊÜÌ Ê6>VÞVÊÌ>«iÀÊvÜi`Ê by pulse dosing or fecal microbiota transplant (consult GI). UÊvÊÃiÀÕÃÊÀÊÕÌ«iÊÀiVÕÀÀiViÃ]ÊVÃÕÌÊ ° Vancomycin taper regimen 125 mg 4 times daily ×Ê£äq£{Ê`>Þà 125 mg BID × 7 days 125 mg daily × 7 days £ÓxÊ}ÊiÛiÀÞÊÓqÎÊ`>ÞÃÊvÀÊÓqnÊÜiiÃÊ­«ÕÃiÊ`Ã}® NOTES Management UÊÊ-ÕÀ}V>ÊÌiÀÛiÌÊvÀÊViVÌÞÊà Õ`ÊLiÊVÃ`iÀi`Êi>ÀÞÊvÊÌ iÊ patient is clinically unstable secondary to CDI. UÊÊ/Ài>ÌiÌÊvÊ Êà Õ`ÊLiÊVÌÕi`ÊÊ«>ÌiÌÃÊÜ Ê >ÛiÊ>ÊÃÕLÌÌ>Ê colectomy with preservation of the rectum. UÊÊÃÌÊ«>ÌiÌÃÊÜÌ ÊÃiÛiÀiÊ Êà Õ`ÊÕ`iÀ}Ê>L`>Ê /ÊÌÊÀÕiÊ out toxic megacolon or pancolitis. 49 6.2 Clostridium difficile infection (CDI) Duration UÊ£äq£{Ê`>Þà 6.2 Clostridium difficile infection (CDI) UÊÊ Ê "/ÊÃi`ÊvÜÕ«ÊC.difficile PCR to document resolution of disease. UÊÊ ÊÌÊÕÃiÊ>ÌÌÌÞÊ>}iÌð UÊÊ-Ì«Ê«ÀÌÊ«Õ«Ê LÌÀÃÊ­**îÊÜ iiÛiÀÊ«ÃÃLiÊ>ÃÊ`>Ì>ÊÃÕ}}iÃÌÊ PPIs increase the risk of CDI. UÊÊ/ iÊvvi`}Ê>ÌVÀL>Ê>}iÌÃÊà Õ`ÊLiÊ`ÃVÌÕi`°ÊvÊ antimicrobials are still required, it is best to avoid cephalosporins, Clindamycin, and fluoroquinolones. UÊÊ*À« Þ>VÌVÊÕÃiÊvÊÀ>ÊiÌÀ`>âiÊÀÊ6>VÞVÊÊ«>ÌiÌÃÊ 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*>ÌiÌÃÊÜÌ Ê Êà Õ`ÊLiÊ«>Vi`ÊÊVÌ>VÌÊ«ÀiV>ÕÌÃÊ>`ÊÃ}iÊ rooms for the duration of hospitalization. UÊÊ1ÃiÊÃ>«Ê>`ÊÜ>ÌiÀÊÀ>Ì iÀÊÌ >Ê>V L>Ãi`Ê >`Ê}iÊÕ«ÊiÝÌ}Ê the room of a patient with CDI. ,iviÀiViÃ\ - É -Ê ÃiÃÕÃÊÕ`iiÃÊvÀÊ \ÊviVÌÊ ÌÀÊÃ«Ê «`iÊÓä£äÆÊ Î£\{Σq{x{° >VÊvÊÕÌÌÞÊvÊÌÀi>Ì}Ê ÊV>ÀÀiÀÃ\ÊÊÌiÀÊi`Ê£ÓÆÊ££Ç\ÓÇÎäÓ° iVÌÞÊÊ \ÊÊ-ÕÀ}ÊÓääÇÆÊÓ{x\ÓÈÇÇÓ° 50 UÊFor treatment of C. difficile infection, see p. 47. UÊ >ÀivÕÞÊ>ÃÃiÃÃÊÌ iÊ«>ÌiÌÊLivÀiÊ«ÀiÃVÀL}Ê>ÌVÀL>ð UÊÊÃÌÊviVÌÕÃÊ`>ÀÀ i>ÊÃÊÃivÌi`Ê>`ÊÞÊÀiµÕÀiÃÊÃÕ««ÀÌÛiÊ management. UÊÊ/Ài>ÌiÌÊÜÌ Ê>ÌLÌVÃÊÃÊÌÊÀiVi`i`ÊvÀÊÃÌÊ` `iÀ>ÌiÊ`Ãi>ÃiÆÊÃiiÊëiVwVÊ`V>ÌÃÊÊÌ>LiÊLiÜ° UÊÊ6À>Ê«>Ì }iÃ]ÊÃÕV Ê>ÃÊ ÀÛÀÕÃÊ>`Ê,Ì>ÛÀÕÃÊVÞÊV>ÕÃiÊ diarrhea and do not require antibiotics. UÊÊÌLÌVÊÕÃiÊ>ÞÊi>`ÊÌÊ>`ÛiÀÃiÊÕÌViÃÊ­i°}°Ê iÞÌVÊÕÀiVÊ syndrome with Shiga toxin-producing E. coli). UÊÊÌÌÌÞÊ>}iÌÃÊà Õ`ÊÌÊLiÊÕÃi`ÊÊ«>ÌiÌÃÊÜÌ ÊL`ÞÊ`>ÀÀ i>]Ê fever, or elevated WBC. Microbiology UÊÊ ÊÛÀ>Ê«>Ì }iÃÊÊ>VÕÌiÊVÕÌÞ>VµÕÀi`Ê`>ÀÀ i>\Ê Salmonella, Shigella, Shiga toxin-producing E. coli, Campylobacter, C. difficile (usually with antibiotic exposure). UÊ ÃV>Ê`>ÀÀ i>\ÊC. difficile UÊÊ*iÀÃÃÌiÌÊ`>ÀÀ i>ÊvÊÕV«ÀÃi`Ê­ÃÌÊiÞÊV>ÕÃiÃÊÛ>ÀÞÊ `i«i`}ÊÊÌÞ«iÊvÊÕV«ÀÃi®\ÊGiardia, Cryptosporidium, Cyclospora, Isospora, Microsporidia, Cytomegalovirus (CMV). Diagnosis UÊÊ ÌÊiÛiÀÞÊ`>ÀÀ i>ÊiÃÃÊÀiµÕÀiÃÊÃÌÊVÕÌÕÀi°Ê iVÃÊÌÊÌiÃÌÊ should be based on suspicion for specific pathogens and/or clinical judgment of illness severity. UÊÊ*>ÌiÌÃÊÜÌ ÊviLÀiÊ`>ÀÀ i>ÊiÃÃiÃÊÜÌ ÊVV>Êvi>ÌÕÀiÃÊvÊ moderate to severe disease should receive empiric therapy only after a fecal specimen is obtained for appropriate testing. UÊÊiV>ÊëiViÃÊvÀÊ«>ÌiÌÃÊ Ã«Ì>âi`ÊvÀÊÊÎÊ`>ÞÃÊà Õ`ÊÌÊLiÊ submitted for routine stool culture unless a high suspicion for specific pathogen exists and/or if the patient is immunocompromised. UÊÊÕÌ«iÊÃÌÊiÝ>>ÌÃÊvÀÊÛ>Ê>`Ê«>À>ÃÌiÃÊ­"E*®Ê>ÀiÊvÊÜÊ yield. UÊÊiV>ÊiÕVÞÌiÉ>VÌviÀÀÊ>ÃÃiÃÃiÌÃÊà Õ`ÊÌÊLiÊÕÃi`ÊÌÊ 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. UÊâÌ ÀÞVÊxääÊ}Ê*"Ê`>ÞÊvÀÊ£qÎÊ`>Þà /Ài>ÌiÌÊÀiVi`i`ÊvÀ\ UÊ-iÛiÀiÊiÃà UÊ}iÊÊÈÊÌ ÃÊÀÊÊxäÊÞi>Àà UÊÀÃÃÊL`ÊÊÃÌ UÊ} ÊviÛiÀ UÊ7ÀÃi}ÊÀÊÀi>«Ã}ÊÃÞ«Ìà UÊ*Ài}>VÞ UÊÕV«ÀÃi`Ê ÃÌ E. coli (enterotoxigenic, enteropathogenic, enteroinvasive) or empiric therapy of traveler’s diarrhea UÊ «ÀyÝ>VÊxääÊ}Ê*"Ê Duration:Ê£qÎÊ`>Þà 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 «ÀyÝ>VÊxääÊ}Ê*"Ê Ê OR UÊÊ/*É-8Ê£ÈäÉnääÊ}Ê*"Ê Ê (if susceptible) OR UÊÊ ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ /Ài>ÌiÌÊÀiVi`i`ÊvÀ\ UÊ-iÛiÀiÊiÃÃÊÀiµÕÀ}Ê Ã«Ì>â>Ì UÊ}iÊÊÈÊÌ ÃÊÀÊÊxäÊÞi>Àà UÊ >VÌiÀi> UÊ*ÀiÃiViÊvÊ«ÀÃÌ iÃià UÊ6>ÛÕ>ÀÊ i>ÀÌÊ`Ãi>Ãi UÊ-iÛiÀiÊ>Ì iÀÃViÀÃà UÊ>}>VÞÊÀÊÌ iÀÊÕV«ÀÃi Shigella spp. Treatment always recommended even if result returns when patient is asymptomatic. Duration:ÊxqÇÊ`>ÞÃÆÊ£{Ê`>ÞÃÊvÀÊ immunocompromised host UÊÊ/*É-8Ê£ÈäÉnääÊ}ÊÊ*"Ê Ê (if susceptible) OR UÊ «ÀyÝ>VÊxääÊ}Ê*"Ê Ê Duration:ÊÎÊ`>ÞÃÆÊÇÊ`>ÞÃÊvÀÊÕ compromised host Vibrio parahaemolyticus UÊ «ÀyÝ>VÊxääÊ}Ê*"Ê ÊÝÊÎÊ`>Þà Ìi\ÊÃÃV>Ìi`ÊÜÌ Êà iwà ÊVÃÕ«Ì Treatment recommended for severe illness Yersinia spp. /Ài>ÌiÌÊÀiVi`i`ÊvÀ\ UÊÕV«ÀÃi`Ê ÃÌ UÊ >VÌiÀi> UÊ*ÃiÕ`>««i`VÌÃÊÃÞ`Ài 52 UÊÊ/*É-8Ê£ÈäÉnääÊ}Ê*"Ê ÊÝÊÎqxÊ days (if susceptible) OR UÊ «ÀyÝ>VÊxääÊ}Ê*"Ê ÊÝÊÎÊ`>Þà OR UÊÊ ÝÞVÞViÊ£ääÊ}Ê*"Ê ÊÝÊÎÊ`>Þà (not for bacteremia) Entamoeba histolytica Treat all (even asymptomatic) E. dispar & E. moshkovskii infections do not require treatment UÊÊiÌÀ`>âiÊÇxäÊ}Ê*"Ê/ ÊÝÊxq£äÊ days OR UÊÊ/`>âiÊ£Ê}Ê*"Ê+£ÓÊÝÊÎÊ`>Þà UÊÊPLUS all patients should receive Paromomycin 500 mg PO TID x 7 days after the course of 1st agent complete Asymptomatic patients UÊÊ*>ÀÞVÊxääÊ}Ê*"Ê/ ÊÝÊÇÊ`>Þà Giardia spp. UÊÊiÌÀ`>âiÊÓxäxääÊ}Ê*"Ê/ ÊÝÊ Çq£äÊ`>Þà OR U Tinidazole 2 g PO once ,iviÀiViÃ\Ê -ÊÕ`iiÃÊvÀÊ>>}iiÌÊvÊviVÌÕÃÊ >ÀÀ i>ÆÊ ÊviVÌÊ ÃÊÓää£ÆÎÓ\ÎΣqxä° viVÌÕÃÊ`>ÀÀ i>ÊÊ`iÛi«i`Ê>`Ê`iÛi«}ÊVÕÌÀiÃ\ÊÊ Ê>ÃÌÀiÌiÀÊÓääx\Î\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 UÊÊVÌÛiÊ«i«ÌVÊÕViÀÊ`Ãi>ÃiÊ­*1 ®ÊqÊ}>ÃÌÀVÊÀÊ`Õ`i> UÊÊ wÀi`Ê ÃÌÀÞÊvÊ*1 Ê­ÌÊ«ÀiÛÕÃÞÊÌÀi>Ìi`ÊvÀÊH. pylori) UÊÊ>ÃÌÀVÊ/ÊÞ« >Ê­ÜÊ}À>`i® UÊÜ}ÊÀiÃiVÌÊvÊ}>ÃÌÀVÊV>ViÀÊ UÊ>ÞÊ ÃÌÀÞÊvÊ}>ÃÌÀVÊV>ViÀÊÊ>Ê£ÃÌÊ`i}ÀiiÊÀi>ÌÛi UÊÌÀ« VÊ}>ÃÌÀÌà 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 UÊÊÝVÊ£Ê}Ê*"Ê+£ÓÊPLUS Clarithromycin 500 mg PO Q12H PLUS Pantoprazole 40 mg PO Q12H OR UÊ* Ê>iÀ}Þ UÊÊ >ÀÌ ÀÞVÊxääÊ}Ê*"Ê+£ÓÊPLUS Metronidazole 500 mg PO Q12H PLUS Pantoprazole 40 mg PO Q12H OR UÊÊ/iÌÀ>VÞViÊxääÊ}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`>Þà Documented recurrence of H. pylori disease UÊvÊ«ÃÃLi]Ê>Û`Ê>ÌLÌVÃÊ«ÀiÛÕÃÞÊÕÃi`ÊÌÊÌÀi>ÌÊH. pylori UÊÊ/iÌÀ>VÞViÊxääÊ}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 UÊÊÀÃÌÊiÊÌÀi>ÌiÌÊiÀ>`V>ÌÊÀ>ÌiÃÊiÃÌ>Ìi`ÊLiÌÜiiÊxäqÇx¯°Ê >ÕÀiÊÃÌÊvÌiÊ`ÕiÊÌÊ >ÀÌ ÀÞVÊÀiÃÃÌ>ViÊ­£äq£x¯®Ê>`ÉÀÊ non-adherence. UÊÊÓÀiVi«ÌÀÊ>Ì>}ÃÌÃÊ­i°}°Ê,>Ì`i®ÊV>ÊLiÊÃÕLÃÌÌÕÌi`ÊvÀÊÌ iÊ PPI if patients are unable to tolerate PPIs or if drug interactions are a concern. UÊÊÝVÊPLUS Tetracycline can NOT be used together in treatment due to low response rates. UÊÊ ÊÌÊÃÕLÃÌÌÕÌiÊ ÝÞVÞViÉVÞViÊvÀÊ/iÌÀ>VÞViÊÀÊÊ Azithromycin for Clarithromycin. UÊÊÊ«>ÌiÌÃÊÜÌ Ê«ÃÌÛiÊÌiÃÌÊÀiÃÕÌÃÊi`ÃV«ÞÊÃÊ>`>ÌÀÞÊvÀÊ>}iÊ > 45-50 years, presence of mass GI bleeding, anemia, weight loss, or family history of gastric cancer. UÊÊ/iÃÌÊvÊVÕÀiÊÃÊÀiVi`i`Ê> {qnÊÜiiÃÊ«ÃÌÊÌÀi>ÌiÌ°Ê ,iviÀiViÃ\ Maastricht III Consensus Report. GutÊÓääÇÆxÈ\ÇÇÓÇn£° 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¯ÊÃiÃÌÛÌÞÊ and specificity). UÊ1Ài>ÊLÀi>Ì ÊÌiÃÌÊ>ÞÊLiÊ«Ì>ÊLÕÌÊÌÊVÞÊ>Û>>Li° UÊÊ `ÃV«ÞÊPLUSÊÀ>«`ÊÕÀi>ÃiÊÌiÃÌÊ­näqx¯ÊÃiÃÌÛÌÞÆÊÓq£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 UÊVÕ`iÃÊÃ>«}ÌÃ]ÊÌÕLÛ>À>Ê>LÃViÃÃÊ>`Ê«iÛVÊ«iÀÌÌÃ°Ê UÊÊÀÊÌÀi>ÌiÌÊvÊ«ÃÌ«iÀ>ÌÛiÊ«iÀÌÌÃÊÀÊÜÕ`ÊviVÌ]Ê see p. 44 and p. 105. TREATMENT NOTE: Avoid use of fluoroquinolones for N. gonorrhoeae due to ÀiÃÃÌ>ViÊ­H£ä¯ÊÊ >ÌÀiÊ ÌÞ® UÊÊ ivÌiÌ>ÊÓÊ}Ê6Ê+£ÓÊPLUS Doxycycline* 100 mg PO BID for 14 days OR UÊÊ ÀÌ>«iiÊ£Ê}Ê6Ê+Ó{ÊPLUS Doxycycline* 100 mg PO BID for 14 days OR UÊÊ* Ê>iÀ}Þ\Ê `>ÞVÊÈääääÊ}Ê6Ê+nÊPLUS Gentamicin (see dosing section, p. 146) Step-down therapy once patient is afebrile UÊÊ*ÀiviÀÀi`\Ê ÝÞVÞViÊ£ääÊ}Ê*"Ê Ê´ÊQ `>ÞVÊ{xäÊ}Ê*"Ê QID ORÊiÌÀ`>âiÊxääÊ}Ê*"Ê RÊÌÊV«iÌiÊ£{Ê`>ÞÃÊÌÌ> *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 UÊÊÜiÊ`>}Ãi`ÊÜÌ Ê>VÕÌiÊ* Êà Õ`ÊLiÊvviÀi`Ê6ÊÌiÃÌ}° UÊÊ>iÊ«>ÀÌiÀÃÊvÊÜiÊÜ Ê >ÛiÊ* ÊvÌiÊ>ÀiÊ>ÃÞ«Ì>ÌV°Ê UÊÊ-iÝÊ«>ÀÌiÀÃÊ­>iÊÀÊvi>i®ÊvÊ«>ÌiÌÃÊÜ Ê >ÛiÊ* Êà Õ`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>ÃÊvÀÊ* ÊLÕÌÊÊii`ÊvÀÊ>``ÌÊvÊ ÝÞVÞViÉâÌ ÀÞV Duration UÊ/Ài>ÌÊÕÌÊ«>ÌiÌÊ>viLÀiÊvÀÊÓ{q{nÊ ÕÀà 56 TREATMENT UÊÊiÌÀ`>âiÊ}iÊä°Çx¯]ÊiÊvÕÊ>««V>ÌÀÊ­xÊ}®ÊÌÀ>Û>}>Þ]ÊViÊ daily for 5 days (preferred) OR UiÌÀ`>âiÊxääÊ}Ê*"Ê ÊvÀÊÇÊ`>Þà OR U `>ÞVÊÎääÊ}Ê*"Ê ÊvÀÊÇÊ`>Þà TREATMENT NOTES Microbiology: anaerobic bacteria (Prevotella spp, Mobiluncus spp.), G. vaginalis, Ureaplasma, Mycoplasma. UÊÊ/Ài>ÌiÌÊÃÊÀiVi`i`ÊÊ>ÊÃÞ«Ì>ÌVÊÜiÊ>`Ê } ÊÀÃÊ asymptomatic pregnant women. Trichomoniasis (T.vaginalis) NOTE: Treatment of partner recommended. TREATMENT UÊiÌÀ`>âiÊÓÊ}Ê*"ÊViÊ OR UÊiÌÀ`>âiÊxääÊ}Ê*"Ê ÊvÀÊÇÊ`>Þà Uncomplicated gonococcal urethritis, cervicitis, proctitis TREATMENT (includes treatment for C. trachomatis): UÊ ivÌÀ>ÝiÊÓxäÊ}ÊÊViÊPLUS Azithromycin 1 g orally (preferred) OR UÊÊ ivÌÀ>ÝiÊÓxäÊ}ÊÊViÊPLUS Doxycycline 100 mg PO BID for 7 days OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊâÌ ÀÞVÊÓÊ}Ê*"ÊViÊ­«Àii`V>ÌiÊÜÌ Ê antiemetic or give snack before administration) TREATMENT NOTES UÊ6ÊÌiÃÌ}ÊÀiVi`i` UÊÊ/ iÊÕÃiÊvÊ ivÌÀ>ÝiÊÃÊ«ÀiviÀÀi`ÊÛiÀÊ iwÝiÊ>`Ê iv«`ÝiÊ 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>«ÞÊÀiVi`i`ÊvÀÊN. gonorrhoeae even if C. trachomatis is excluded. UÊÊ-i`Ê}ÀÀ i>ÊVÕÌÕÀiÊ­ÌÊÕViVÊ>V`Ê>«wV>ÌÊÌiÃÌ®ÊvÊÞÕÊ suspect a treatment failure. Syphilis SCREENING UÊÊ-VÀii}Ê>}ÀÌ Ê>ÌÊ\Ê>ÊÌÀi«i>ëiVwVÊ>ÌL`ÞÊÌiÃÌÊ­ ®Ê if positive, followed by RPR. A confirmatory FTA-ABS is provided if RPR is negative. UÊÊÊ«ÃÌÛiÊ ]Ê>Êi}>ÌÛiÊ,*,Ê>`Ê>Ê«ÃÌÛiÊ/Ê>ÞÊLiÊ`ÕiÊÌ\Ê­£®Ê old treated syphilis (2) old untreated syphilis (3) early syphilis. UÊÊiÌÊ ÃÌÀÞÊ>`ÊV>Ê >ÌÀiÊ ÌÞÊi>Ì Ê i«>ÀÌiÌÊ{£äÎÈ{{{nÊ for prior history of syphilis treatment in Maryland UÊÊvÊ«iVÊ>iÀ}V]Ê ÊVÃÕÌÃÊÃÊÀiVi`i`ÊÌÊ}Õ`iÊÌ iÀ>«Þ Algorithm for reverse sequence syphilis screening CIA RPR positive CIA positive RPR negative CIA negative UÊÊ ÃÃÌiÌÊÜÌ Ê Treponemal test that uses a different UÊÊvÊVÕL>Ì}ÊÀÊ syphilis infection >Ì}iÊ­/q -ÊÀÊ/**® primary syphilis (past or present) FTA-ABS positive FTA-ABS negative is suspected, UÊÊ,iµÕÀiÃÊ ÃÌÀV>Ê ÊUÊ*ÃÃLiÊÃÞ« ÃÊÊ UÊ-Þ« ÃÊÕiÞ treat for early and clinical syphilis ÊÊÊÊviVÌÊ UÊvÊ«>ÌiÌÊ>ÌÊ } Ê evaluation to ÊUÊ,iµÕÀiÃÊÊ ÊÊÊÀÃÊvÀÊÃÞ« Ã] determine prior historical and retest in one treatment history clinical month evaluation Neurosyphilis diagnosis UÊÊ,iµÕÀiÃÊLÌ ÊVV>Ê­iÕÀ}V>ÊÃÞ«ÌîÊ>`Ê>LÀ>ÌÀÞÊVÀÌiÀ>°Ê UÊÊ>LÀ>ÌÀÞÊVÀÌiÀ>Ê­>ÞÊVL>ÌÊv®\ÊÃiÀ}V>ÊiÛ`iViÊvÊ ÃÞ« Ã]Ê«ÃÌÛiÊ -Ê6 ,Ê­xä¯ÊÃiÃÌÛÌÞÆÊ } ÊëiVwVÌÞ®]Ê -Ê «iVÞÌÃÃÊ­xÊ7 ÉÊvÊ6ÆÊ£äÓäÊ7 ÉÊvÊ6³®]Ê -Ê elevated protein concentration (>50 mg/dl) UÊÊÕL>ÀÊ«ÕVÌÕÀiÊ­*®Êà Õ`ÊLiÊLÌ>i`ÊÊ«>ÌiÌÃÊÜÌ Ê«ÃÌÛiÊ serological tests for syphilis plus neurological symptoms, serological treatment failure (lack of four-fold decline in RPR titer), evidence of tertiary syphilis UÊÊ Ã`iÀÊ*ÊÊ>ÃÞ«Ì>ÌVÊ6³Ê«>ÌiÌÃÊÜÌ Ê>Ê {ÊVÕÌÊ≤350 cells/ml or RPR titer ≥£\ÎÓ 58 Early syphilis (primary, secondary, and early latent syphilis within one year after infection) UÊÊ*iVÊÊ iâ>Ì iÊ­ V® L-A) 2.4 million units IM once UÊÊ-iÛiÀiÊ* Ê>iÀ}iÃ\Ê ÝÞVÞViÊ£ääÊ}Ê*"Ê ÊvÀÊÓÊÜiiÃÊÊ Note:Ê`ÕiÊÌÊVÀi>Ãi`ÊÀiÃÃÌ>ViÊ­H{x¯ÊvÊÃÌÀ>ÃÊÊ >ÌÀiÊ>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*iVÊÊ iâ>Ì iÊ­ V® L-A) 2.4 million units IM weekly for 3 weeks (total of 3 doses) Neurosyphilis (can occur during any stage of syphilis) UÊÊ*iVÊÊÎq{ÊÊÕÌÃÊ6Ê+{ÊvÀÊ£äq£{Ê`>Þà Syphilis in pregnancy UÊÊ*iVÊÃÊÌ iÊÞÊÀiVi`i`ÊÌ iÀ>«ÞÊÊ«Ài}>ÌÊ«>ÌiÌÃÊÜÌ Ê any kind of syphilis. Allergy consult for penicillin desensitization is recommended. ,iviÀiViÃ\Ê -iÝÕ>ÞÊÌÀ>ÃÌÌi`Ê`Ãi>ÃiÃÊ ÊÌÀi>ÌiÌÊ}Õ`iiðÊ7,ÊÓä£äÉxÊ­,,£Ó®ÆÊ £q££ä°Ê âÌ ÀÞVÊÛÃ°Ê ÝÞVÞViÊvÀÊ* °Ê"LÃÌiÌÊÞiVÊÓääÇÆÊ££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 iÀiÊÃÊÀiÊÌ >Ê>ÊiÀÞÌ i>ÊÀÊ 9Ê«ÕÀÕiViÊ>ÌÊÌ iÊiÝÌÊ site, the catheter is likely infected. It should be removed and replaced at a different site. UÊÊ7 iÊ , -ÊÃÊÃÕëiVÌi`]ÊÓqÎÊÃiÌÃÊvÊL`ÊVÕÌÕÀiÃÊà Õ`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/ iÊÕÌÌÞÊvÊVÕÌÕÀiÃÊvÊÌ iÊV>Ì iÌiÀÊÌ«ÊÌÃivÊÃÊÌÊÜiÊ`iwi`]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 µÕi\Ê/ iÊiÝÌÊÃÌiÊà Õ`ÊLiÊVi>i`ÊÜÌ Ê>V °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. UÊÊÊÃÌ>ViÃÊÜ iÀiÊÌ iÊL`Ê>`ÊV>Ì iÌiÀÊÌ«Ê>ÀiÊVÕÌÕÀi`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«ÌÊÃÊ«>ÌiÌÃÊÜ ÃiÊV>Ì iÌiÀÊÌ«ÃÊ}ÀÜÊS. aureus and >ÛiÊi}>ÌÛiÊL`ÊVÕÌÕÀiðÊ/ iÃiÊ«>ÌiÌÃÊà Õ`ÊÀiViÛiÊxqÇÊ days of antibiotics. UÊÊÊ«>ÌiÌÃÊà Õ`ÊLiÊvÜi`ÊVÃiÞ]Ê>`ÊÀi«i>ÌÊVÕÌÕÀiÃÊà Õ`Ê be sent if clinically indicated. UÊÊ7 iÊ>ÊV>Ì iÌiÀÀi>Ìi`Ê -ÊÃÊ>ÃÃV>Ìi`ÊÜÌ ÊV>Ì iÌiÀÊ`ÞÃvÕVÌ]Ê consider the possibility of suppurative thrombophlebitis. EMPIRIC TREATMENT UÊÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®Ê±Ê ivi«iÊ£qÓÊ}Ê6Ê+nÊ (use higher dose if pseudomonas suspected) OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®Ê ±ÊQ «ÀyÝ>VÊ{ääÊ}Ê6Ê+nÊ",ÊâÌÀi>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>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä® 60 UÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®Ê Change to UÊ"Ý>VÊÓÊ}Ê6Ê+{ÊvÊÃÕÃVi«ÌLiÊ­«ÀiviÀÀi`ÊÌÊ6>VÞV® Duration: UÊÎqÇÊ`>ÞÃÊvÊV>Ì iÌiÀÊÀiÛi`Ê­«ÀiviÀÀi`® UÊ£äq£{Ê`>ÞÃÊvÊV>Ì iÌiÀÊÃ>Û>}iÊ>ÌÌi«Ì Methicillin-susceptible Staphylococcus aureus UÊÊ"Ý>VÊÓÊ}Ê6Ê+{ÊvÊÃÕÃVi«ÌLi OR UÊÊ >>« Þ>VÌVÊ* Ê>iÀ}Þ\Ê iv>âÊÓÊ}Ê6Ê+n OR UÊÊ>« Þ>VÌVÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä® Methicillin-resistant Staphylococcus aureus UÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä® UÊ6>VÞVÊ>iÀ}ÞÊÀÊÌiÀ>ViÊ­ÌÊÀi`Ê>ÊÃÞ`Ài® Ê UÊ >«ÌÞVÊn£äÊ}É}Ê6Ê+ÊÓ{ OR Ê UÊ ivÌ>ÀiÊÈääÊ}Ê6Ê+Ên UÊ6>VÞVÊv>ÕÀi\ÊVÃÕÌÊ TREATMENT NOTES UÊ,iÛiÊV>Ì iÌiÀ°Ê} ÊÀi>«ÃiÊÀ>ÌiÃÊvÊV>Ì iÌiÀÊÃÊÌÊÀiÛi`° UÊ6>VÞVÊÃÊviÀÀÊÌÊ"Ý>VÊvÀÊÌÀi>ÌiÌÊvÊ--° UÊÊ*>ÌiÌÃÊÜÌ ÊS. aureus bacteremia should have an echocardiogram to rule out endocarditis. Transthoracic echo is acceptable only if the study >`iµÕ>ÌiÞÊÛiÜÃÊÌ iÊivÌÃ`i`ÊÛ>ÛiÃÆÊÃÌÊiÝ«iÀÌÃÊÀiVi`Ê/ ° UÊÊiâ`Êà Õ`ÊÌÊLiÊÕÃi`ÊÀÕÌiÞÊvÀÊÌÀi>ÌiÌÊvÊS. aureus bacteremia UÊ ÀÌiÀ>ÊvÀÊ>Ê£{Ê`>ÞÊVÕÀÃiÊvÊÌ iÀ>«Þ Ê UÊÊ `V>À`ÌÃÊiÝVÕ`i`ÊÜÌ Ê/ Ê­«ÀiviÀÀi`®ÆÊ } ʵÕ>ÌÞÊ// Ê>ÞÊLiÊ adequate in select patients Ê UÊ Ê«>Ìi`Ê«ÀÃÌ iÃiÃ Ê UÊÊÜÕ«ÊL`ÊVÕÌÕÀiÃÊ`À>ÜÊÓ{Ê`>ÞÃÊ>vÌiÀÊÌ iÊÌ>ÊVÕÌÕÀiÃÊ>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«>ÌiÌÊ`iviÀÛiÃViÃÊÜÌ ÊÇÓÊ ÕÀÃÊvÊÌ>ÌÊvÊivviVÌÛiÊ antistaphylococcal therapy Ê UÊÊ/ iÊ«>ÌiÌÊ >ÃÊÊV>â}ÊÃ}ÃÊÀÊÃÞ«ÌÃÊvÊiÌ>ÃÌ>ÌVÊ staphylococcal infection Ê UÊ-ÕÀViÊVÌÀÊ >ÃÊLiiÊLÌ>i` Ê UÊÊLÃiViÊvÊÌ iÀÊV`ÌÃÊÌ >ÌÊ>ÞÊ>vviVÌÊ>LÌÞÊÌÊVi>ÀÊviVÌÊ based on clinical judgment (e.g. poorly controlled diabetes) UÊÊÊÌ iÀÊ«>ÌiÌÃÊà Õ`ÊÀiViÛiÊ{ÈÊÜiiÃÊvÊÌ iÀ>«ÞÊL>Ãi`ÊÊiÝÌiÌÊ of infection Enterococcus faecalis NOTE: Can be contaminants. Draw repeat cultures to confirm before ÃÌ>ÀÌ}ÊÌÀi>ÌiÌ°Ê£ää¯ÊvÊE. faecalis blood isolates at JHH are susceptible to Ampicillin, which should be used unless the patient has a PCN allergy. UÊÊ«VÊÓÊ}Ê6Ê+{Ê OR UÊÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌÊ«°Ê£xä®Ê Duration: Çq£{Ê`>Þà Enterococcus faecium NOTE: Can be contaminants. Draw repeat cultures to confirm before ÃÌ>ÀÌ}ÊÌÀi>ÌiÌ°Ê/ iÊ>ÀÌÞÊ­Çn¯®ÊvÊE. 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. UÊÊiâ`ÊÈääÊ}Ê6É*"Ê+£Ó OR UÊ >«ÌÞVÊnq£ÓÊ}É}Ê6Ê+Ó{ TREATMENT NOTES UÊÊ Ã`iÀÊiV V>À`}À>ÊvÊÌ iÀiÊÃÊ«iÀÃÃÌiÌÊL>VÌiÀi>Ê­> 3 days) on antibiotics. UÊÊ/ iÊ>``ÌÊvÊiÌ>VÊ`iÃÊÌÊ>««i>ÀÊÌÊV >}iÊÕÌViÃÊÊ CR-BSI caused by Enterococcus in the absence of endocarditis. Gram-negative bacilli Antibiotic selection based on organism and susceptibilities. Duration: Çq£äÊ`>Þà 62 Candida spp. UÊ,iviÀÊÌÊ«°Ê££ÇÊvÀÊÌÀi>ÌiÌÊvÊV>``i> 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. UÊÊÌLÌVÊÕÃi`Ê>ÃÊVÊÌ iÀ>«ÞÊà Õ`Ê«ÀiviÀiÌ>ÞÊ>ÌV Ê>ÌLÌVÊ used for systemic therapy. Antibiotic Lock Therapy (ALT) UÊÊÌLÌVÊVÊÌ iÀ>«ÞÊV>ÊLiÊÕÃi`ÊvÀÊV>Ì iÌiÀÊÃ>Û>}iÊin addition to systemic antibiotics when feasible. UÊÊ >Ì iÌiÀÊÀiÛ>Êà Õ`ÊLiÊ«iÀvÀi`ÊvÊVÕÌÕÀiÃÊÀi>Ê«ÃÌÛiÊ>vÌiÀÊ 72 hours of appropriate antibiotic lock therapy Acceptable uses: UÊÊ->Û>}iÊvÊ}ÌiÀÊV>Ì iÌiÀÃÊÌ >ÌÊV>ÌÊLiÊÀiÛi`Ê­i°}°Ê`>ÞÃÃÊ 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- ÀÌÌiÀÊÛiÕÃÊV>Ì iÌiÀà UÊÊ «V>Ìi`Ê , -Ê­i°}°ÊÌÕiÊÀÊ«ÀÌ«ViÌÊviVÌ]ÊÃiÛiÀiÊ sepsis, septic shock, endocarditis, osteomyelitis and hematogenous seeding at other sites) UÊ >Ì iÌiÀÊÃ>Û>}iÊÜÌ ÊS. aureus infection. Duration:ÊÇq£{Ê`>ÞÃÊ 63 6.6 Catheter-related bloodstream infections TREATMENT NOTES UÊÊ >Ì iÌiÀÃÊ>ÀiÊiÃÃÊVÞÊÌ iÊÃÕÀViÊvÊÌ iÊviVÌÆÊ ÜiÛiÀ]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>VÞVÊxÊ}ÉÊÊä°¯Ê -Ê iÌ>VÊxÊ}ÉÊÊä°¯Ê -Ê äÊÀÊxäääÊÕÌà ÓxääÊÕÌÃÊ UÊÊ/Êà Õ`ÊLiÊÃÌi`ÊÊÌ iÊÕiÊvÊÌ iÊV>Ì iÌiÀÊÜ iÊÌÊÊÕÃi° UÊÊ ÜiÊÌiÃÊà Õ`ÊLiÊ>ÌÊÕÊvÊnq£ÓÊ ÕÀÃÊ«iÀÊ`>ÞÊ­Õ«ÊÌÊ Ó{q{nÊ ® UÊÊ/ÊÛÕiÊii`i`ÊÜÊÛ>ÀÞÊLÞÊÌÞ«iÊvÊV>Ì iÌiÀÊ>`Ê>Û>>LiÊÕLiÀÊ vÊÕiðÊÊ}iiÀ>]ÊÓqxÊÊà Õ`ÊLiÊÃÕvwViÌ° ,iviÀiViÃ\ Stability and compatibility of antimicrobial lock solutions. Am J Health-Syst Pharm. Óä£ÎÆÇä\Ó£nxÓ£n° IDSA Guidelines for the Diagnosis and Management of Intravascular Catheter-related viVÌÃ\ÊClin Infect Dis ÓääÆ{\£{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. UÊÊviVÌÕÃÊ Ãi>ÃiÃÊVÃÕÌ>ÌÊÃÊ>`ÛÃi`ÊvÀÊV>ÃiÃÊvÊivÌÃ`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>«iÕÌVÊÌÀ}\Ê UÊÊ6>VÞV UÊÊ>ÊÌÀÕ} ÊiÛi\Ê£xqÓäÊV}É UÊÊiÌ>VÊvÀÊÀ>«ÃÌÛiÊÃÞiÀ}Þ UÊÊ >ÞÊ`Ã} UÊÊ>ÊÌÀÕ} ÊiÛi\Ê1 mcg/mL UÊÊ/À>`Ì>Ê`Ã}Ê­+n® UÊÊ>Ê«i>ÊiÛi\ÊÎq{ÊV}É UÊÊ>ÊÌÀÕ} ÊiÛi\Ê1 mcg/mL UÊÊ-iiÊ«°Ê£{nÊ>`Ê«°Ê£xäÊvÀÊ`iÌ>à Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL UÊÊ*iVÊÊÎÊÊÕÌÃÊ6Ê+{ÊvÀÊ{ÊÜiià OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀ>ÝiÊÓÊ}Ê6ÉÊ+Ó{ÊvÀÊ{ÊÜiià OR UÊÊQ*iVÊÊÎÊÊÕÌÃÊ6Ê+{Ê",Ê ivÌÀ>ÝiÊÓÊ}Ê6ÉÊ+Ó{ÊvÀÊÓÊ ÜiiÃRÊPLUS Gentamicin 3 mg/kg IV Q24H for 2 weeks OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊvÀÊ{Ê weeks ÀÌiÀ>ÊvÀÊÓÊÜiiÊÌÀi>ÌiÌ\ UÊÊ*>ÌiÌÊ`iÃÊÌÊ >ÛiÊV>À`>VÊÀÊiÝÌÀ>V>À`>VÊ>LÃViÃà UÊÊ À Ê20 mL/min UÊÊ*>ÌiÌÊ`iÃÊÌÊ >ÛiÊ«>Ài`ÊnÌ ÊVÀ>>ÊiÀÛiÊvÕVÌÊ UÊÊ*>ÌiÌÊ`iÃÊÌÊ >ÛiÊAbiotrophia, Granulicatella, or Gemella spp. Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL and 0.5 mcg/mL UÊÊQ*iVÊÊ{ÊÊÕÌÃÊ6Ê+{Ê",Ê ivÌÀ>ÝiÊÓÊ}Ê6ÉÊ+Ó{ÊvÀÊ {ÊÜiiÃRÊPLUS 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>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊvÀÊ Viridans streptococci or S. bovis with PCN MIC > 0.5 mcg/mL and Abiotrophia defectiva, Granulicatella spp. and Gemella spp. UÊÊ ÃÕÌÊ TREATMENT NOTES UÊÊÊ«>ÌiÌÃÊÜÌ 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>VÊÓÊ}Ê6Ê+{ UÊÊ1ÃiÊ >vVÊvÀÊ"Ý>V`ÕVi`Ê i«>ÌÌà Criteria for 2-ÜiiÊÌÀi>ÌiÌ\ UÊ*>ÌiÌÊÃÊ>ÊiVÌ}Ê`ÀÕ}ÊÕÃiÀÊÜÌ Ê>ÊÌ iÀÊVÀL`ÌiÃÊ UÊÊivÌÃ`i`Êi`V>À`ÌÃÊÃÊÀÕi`ÊÕÌÊÜÌ Ê/ Ê­«ÀiviÀÀi`®ÊÀÊ } Ê quality TTE UÊÊ/Ài>ÌiÌÊÃÊÜÌ Ê"Ý>VÊÀÊ >vVÊ UÊÊ*>ÌiÌÊ`iÃÊÌÊ >ÛiÊ -Ê­ {Ê< 200) UÊÊ*>ÌiÌÊ`iÃÊÌÊ >ÛiÊ>Ê«>Ìi`Ê«ÀÃÌ iÃÃÊ­`>ÞÃÃÊ}À>vÌ]ÊiÌV® UÊÊ `ÊVÕÌÕÀiÃÊ>ÀiÊi}>ÌÛiÊÜÌ Ê{Ê`>ÞÃÊ>vÌiÀÊÃÌ>ÀÌ}ÊÌ iÀ>«ÞÊ UÊÊ/ iÀiÊÃÊÊiÛ`iViÊvÊiLVÊ`Ãi>ÃiÊ"/ ,ÊÌ >ÊÃi«ÌVÊ pulmonary emboli UÊÊ6i}iÌ>ÌÃÊ>ÀiÊ>Ê< 2 cm in size UÊÊvÊ«>ÌiÌÊ`iÃÊÌÊiiÌÊVÀÌiÀ>ÊvÀÊÓÜiiÊÌÀi>ÌiÌ]ÊÌÀi>ÌÊvÀÊ{Ê weeks Staphylococcus aureus – Methicillin susceptible, native valve, left-sided involvement UÊÊ"Ý>VÊÓÊ}Ê6Ê+{Ê OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>âÊÓÊ}Ê6Ê+nÊ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê-ÌÀ}ÞÊVÃ`iÀÊ* Ê`iÃiÃÌâ>ÌÊÀÊ Vancomycin (see dosing section, p. 150) UÊÊ/ iÊ>``ÌÊvÊiÌ>VÊÌÊ>ÊLiÌ>>VÌ>Ê>ÞÊ i«ÊVi>ÀÊL`ÊVÕÌÕÀiÃÊ 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>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä® 66 S. pneumoniae, and Group A streptococci UÊÊ*iVÊÊÎÊÊÕÌÃÊ6Ê+{ÊvÀÊ{ÊÜiià OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀ>ÝiÊÓÊ}Ê6Ê+Ó{ÊvÀÊ{ÊÜiiÃÊ",Ê Cefazolin 2 g IV Q8H for 4 weeks OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊvÀÊ{Ê weeks UÊÊÀÊS. pneumoniae, if PCN MIC ≥ 0.1, consult ID Groups B, C and G streptococci UÊÊ*iVÊÊÎÊÊÕÌÃÊ6Ê+{ÊvÀÊ{qÈÊÜiiÃÊ´ÊiÌ>VÊ 3 mg/kg IV Q24H for the first 2 weeks of therapy OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>âÊÓÊ}Ê6Ê+nÊvÀÊ{qÈÊÜiiÃʱ Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£{È®ÊvÀÊ{qÈÊ weeks ± Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy UÊÊ Ã`iÀÊ>Ê Ê ÃÕÌ Enterococcus faecalis UÊÊ«VÊ>`ÊiÌ>VÊÃÕÃVi«ÌLi\Ê«VÊÓÊ}Ê6Ê+{Ê",Ê Penicillin G 4 million units IV Q4H PLUS Gentamicin 1 mg/kg IV Q8H BOTH for 4-6 weeks UÊÊ«VÊÃÕÃVi«ÌLiÊÜÌ ÊVÌÀ>`V>ÌÃÊvÀÊ>}ÞVÃ`iÃÊÀÊ iÌ>VÊÀiÃÃÌ>Ì\Ê«VÊÓÊ}Ê6Ê+{Ê",Ê*iVÊÊ{ÊÊ units IV Q4H PLUS Ceftriaxone 2 g IV Q12H BOTH for 4-6 weeks 67 6.7 Endocarditis Duration UÊÊ1V«V>Ìi`\ÊÈÊÜiià UÊÊ «V>Ìi`Ê­«iÀÛ>ÛÕ>ÀÊ>LÃViÃÃÊvÀ>Ì]ÊiÌ>ÃÌ>ÌVÊV«V>Ì]Ê «ÀÊVÌÀi`Ê`>LiÌiÃÊiÌÕî\ÊÈÊÀÊÀiÊÜiiÃÊL>Ãi`ÊÊVV>ÊÊ picture and response to therapy UÊÊ Ê>`ÊV>À`>VÊÃÕÀ}iÀÞÊVÃÕÌÃÊÀiVi`i`ÊvÀÊV«V>Ìi`Ê diseases 6.7 Endocarditis OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê-ÌÀ}ÞÊVÃ`iÀÊ* Ê`iÃiÃÌâ>ÌÊvÊ* Ê allergy is anaphylactic or Vancomycin (see dosing section, p. 146) PLUS Gentamicin 1 mg/kg IV Q8H BOTHÊvÀÊ{qÈÊÜiià UÊÊ/Ài>ÌÊvÀÊ{ÊÜiiÃÊÞÊÜ iÊÃÞ«ÌÃÊ >ÛiÊLiiÊ«ÀiÃiÌÊvÀÊ< 3 months AND there is a prompt response to therapy Enterococcus faecium UÊ ÃÕÌÊ ,iviÀiVi\ 1ÃiÊvÊ ivÌÀ>ÝiÊÊiÌiÀVVV>Êi`V>À`ÌÃ\Ê ÊviVÌÊ ÃÊÓä£ÎÆÊxÈ\£ÓÈ£n° HACEK organisms (Haemophilus parainfluenzae, H. aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominus, Eikenella corrodens, Kingella kingae) UÊÊ ivÌÀ>ÝiÊÓÊ}Ê6ÉÊ+Ó{ÊvÀÊ{ÊÜiià OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê ÃÕÌÊ Gram-negative organisms, culture negative endocarditis, or fungal endocarditis UÊÊ ÃÕÌÊ Treatment of prosthetic valve endocarditis UÊÊiiÀ>ÞÊV>ÕÃi`ÊLÞÊÃÌ>« ÞVVVÊÊÌ iÊwÀÃÌÊ£qÓÊÞi>ÀÃÊvÜ}ÊÛ>ÛiÊ replacement (both S. aureus and coagulase-negative staph). Etiologies are similar to native valve infections 2 or more years post-op. UÊi`V>ÊÌÀi>ÌiÌÊ>iÊÃÊvÌiÊ "/ÊivviVÌÛi° UÊÊ«>ÌiÌÃÊà Õ`Ê >ÛiÊ>Ê/ ° EMPIRIC TREATMENT UÊÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUS Gentamicin 1 mg/kg IV Q8H Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL UÊÊQ*iVÊÊ{ÊÊÕÌÃÊ6Ê+{Ê",Ê ivÌÀ>ÝiÊÓÊ}Ê6ÉÊ+Ó{RÊvÀÊ 6 weeks Gentamicin 3 mg/kg IV Q24H for first 2 weeks of therapy OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊvÀÊÈÊ weeks 68 Staphylococcus aureus—Methicillin susceptible UÊÊ"Ý>VÊÓÊ}Ê6Ê+{ÊvÀÊÈÊÜiiÃÊPLUS Gentamicin 1 mg/kg IV Q8H for first 2 weeks of therapy AND UÊÊ,v>«ÊÎääÊ}Ê*"Ê+nÊvÀÊÈÊÜiiÃÊafter blood cultures have cleared UÊÊ Ê>`ÊV>À`>VÊÃÕÀ}iÀÞÊVÃÕÌÃÊÀiVi`i` Staphylococcus aureus—Methicillin resistant or Coagulasenegative staphylococci UÊÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊvÀÊÈÊÜiiÃÊPLUS Gentamicin 1 mg/kg IV Q8H for the first 2 weeks of therapy AND UÊÊ,v>«ÊÎääÊ}Ê*"Ê+nÊvÀÊÈÊÜiiÃÊafter blood cultures have cleared UÊÊvÊV>}Õ>Ãii}>ÌÛiÊÃÌ>« ÞVVVÊÃÊÃÕÃVi«ÌLiÊÌÊ"Ý>VÊÌ iÊ treat as S. aureusÊqÊiÌ VÊÃÕÃVi«ÌLi° UÊÊ Ê>`ÊV>À`>VÊÃÕÀ}iÀÞÊVÃÕÌÃÊÀiVi`i` Gram-negative organisms or culture negative endocarditis UÊÊ ÃÕÌÊ DUKE CRITERIA FOR INFECTIVE ENDOCARDITIS Diagnostic criteria (Modified Duke criteria) Definite endocarditis UÊÊ*ÀiÃiViÊvÊÓÊ>ÀÊVÀÌiÀ>Ê",Ê£Ê>ÀÊ ÊÎÊÀÊ",ÊxÊÀ Possible endocarditis UÊÊ*ÀiÃiViÊvÊ£Ê>ÀÊ Ê£ÊÀÊ",ÊÎÊÀÊVÀÌiÀ> Rejected endocarditis UÊÊÀÊ>ÌiÀ>ÌiÊ`>}ÃÃÊÌ >ÌÊiÝ«>ÃÊÊ>viÃÌ>ÌÃÊvÊ (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*iVÊÊ{ÊÊÕÌÃÊ6Ê+{Ê",Ê ivÌÀ>ÝiÊÓÊ}Ê6ÉÊ+Ó{RÊ PLUS Gentamicin 3 mg/kg IV Q24H for 6 weeks OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊvÀÊÈÊ weeks 6.7 Endocarditis Major criteria Microbiologic UÊÊ/ÜÊÃi«>À>ÌiÊL`ÊVÕÌÕÀiÃÊ«ÃÌÛiÊvÀÊ>ÊÌÞ«V>ÊÀ}>Ã\Ê viridans streptococci, S. bovis, HACEK, S. aureus, Enterococcus spp. UÊÊ*iÀÃÃÌiÌÊL>VÌiÀi>ÊÜÌ Ê>ÞÊÀ}>ÃÊ>ÃÊiÛ`iVi`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*ÃÌÛiÊCoxiella burnetti (Q fever) culture or serology. Echocardiographic (TEE strongly recommended for prosthetic valve) UÊÊ6i}iÌ>ÌÊ­ÊÛ>ÛiÊÀÊÃÕ««ÀÌ}ÊÃÌÀÕVÌÕÀiÊ",ÊÊ«>Ì ÊvÊ regurgitant jet) UÊÊLÃViÃà UÊÊ iÜÊ`i ÃViViÊvÊ«ÀÃÌ iÌVÊÛ>Ûi Physical exam UÊÊ 7ÊÀi}ÕÀ}Ì>ÌÊÕÀÕÀÊ­ÜÀÃi}ÊvÊ`ÊÕÀÕÀÊÃÊ "/Ê sufficient) Minor criteria UÊÊ*Ài`ëÃ}ÊV`Ì\Ê«ÀiÛÕÃÊi`V>À`ÌÃ]ÊiVÌÊ`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 LVÊiÛiÌÃ\Ê>ÀÌiÀ>ÊÀÊ«Õ>ÀÞÊiL]ÊVÕVÌÛ>Ê hemorrhage, retinal hemorrhage, splinter hemorrhage, intracranial hemorrhage, mycotic aneurysm UÊÊÕ}VÊ« ii\Ê"ÃiÀÊ`iÃ]Ê}iÀÕi« ÀÌÃ]Ê«ÃÌÛiÊ rheumatoid factor UÊÊ*ÃÌÛiÊL`ÊVÕÌÕÀiÃÊÌ >ÌÊ`½ÌÊiiÌÊVÀÌiÀ>Ê>LÛiÊ",ÊÃiÀ}VÊ 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 ,iviÀiViÃ\ "À>ÊÌ iÀ>«Þ\ÊÊÊi`Ê£ÈÆÊ£ä£\ÈnÇÈ° - ÀÌÊVÕÀÃiÊÌ iÀ>«Þ\ÊÊÌiÀÊi`Ê£{ÆÊ£Ó£\nÇÎÈ° ÕiÊVÀÌiÀ>\Ê ÊviVÌÊ ÃÊÓäääÆÊÎä\ÈÎÎn° Ê-ViÌwVÊ-Ì>ÌiiÌÊÊviVÌÛiÊ `V>À`ÌÃ\Ê ÀVÕ>ÌÊÓääxÆÊ£££­Óή\iÎ{{Î{° TEE in S. aureusÊL>VÌiÀi>\ÊÊÊ Ê >À`Ê£ÇÆÊÎä\Ê£äÇÓn° ,-ÊL>VÌiÀi>Éi`V>À`ÌÃÊÀiVi`>ÌÃ\Ê ÊviVÌÊ ÃÊÓ䣣ÆÊxÓ\i£nxx 70 NOTE: Obtain at least 2 sets of blood cultures before initiation of antibiotic therapy EMPIRIC TREATMENT UÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®°Ê >ÀÀÜÊÌ iÀ>«ÞÊL>Ãi`ÊÊ culture results. TREATMENT NOTES MicrobiologypÃÌ>« ÞVVVÊÊÇänä¯ÊvÊV>ÃiÃÊ­Hxä¯ÊV>}Õ>Ãi i}>ÌÛiÊÃÌ>« ÞVVVÊ>`ÊHxä¯ÊS. aureus) Management UÊvÊL`ÊVÕÌÕÀiÃÊ>ÀiÊ«ÃÌÛiÊÀÊi`V>À`ÌÃÊÃÊÃÕëiVÌi`Ê«>ÌiÌÃÊ should undergo transesophageal echocardiography (TEE) UÊ «iÌiÊiÝÌÀ>VÌÊÀiVi`i`ÊvÀÊ«>ÌiÌÃÊÜÌ Ê«ViÌÊviVÌÊ and/or valvular or lead endocarditis UÊÌÊÌ iÊÌiÊvÊiÝÌÀ>VÌ]ÊÌÃÃÕiÊ­À>Ì iÀÊÌ >ÊÃÜ>LîÊvÀÊÌ iÊ}iiÀ>ÌÀÊ pocket should be sent for Gram-stain and culture and lead tips should be sent for culture. UÊ ÌiÊÌ >ÌÊLiV>ÕÃiÊi>`ÃÊ>ÀiÊiÝÌÀ>VÌi`ÊÌ ÀÕ} Ê>Ê«iÊ}iiÀ>ÌÀÊ «ViÌ]ÊÌ iÞÊ>ÞÊLiViÊVÌ>>Ìi`ÊLÞÊÌ iÊviVÌi`Ê«ViÌÆÊ therefore, positive lead cultures are not always indicative of lead endocarditis in patient with negative blood cultures. UÊ `ÊVÕÌÕÀiÃÊà Õ`ÊLiÊLÌ>i`Ê>vÌiÀÊ`iÛViÊÀiÛ>° UÊ iÛViÊÀi«>Ì>ÌÊà Õ`ÊLiÊÊÌ iÊVÌÀ>>ÌiÀ>ÊÃ`iÊÜ iiÛiÀÊ possible. UÊ «iÌiÊiÝÌÀ>VÌÊÃÊÃÌÀ}ÞÊÀiVi`i`ÊÊ>Ê«>ÌiÌÃÊ presenting with S. aureus bacteremia and no other source UÊ «iÌiÊiÝÌÀ>VÌÊà Õ`ÊLiÊVÃ`iÀi`ÊÊ«>ÌiÌÃÊÜÌ Ê«iÀÃÃÌiÌÊ positive blood cultures with other organisms (e.g. coagulase-negative staphylococci, enterococci, Gram-negative bacilli) on a case-by-case basis. UÊ «iÌiÊ`iÛViÊ>`Êi>`ÊÀiÛ>ÊÃÊÀiVi`i`ÊvÀÊ«>ÌiÌÃÊÜÌ Ê valvular endocarditis. UÊÌVÀL>Ê«À« Þ>ÝÃÊÃÊ "/ÊÀiVi`i`ÊvÀÊ`iÌ>ÊÀÊÌ iÀÊ invasive procedures following placement ,iviÀiVi\Ê Ê-ViÌwVÊ-Ì>ÌiiÌÊÊ**Ê>`Ê ÊviVÌÃ\Ê ÀVÕ>ÌÊÓä£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\ÊÓÊÜiiÃÊ IV therapy S. aureus\Ê{ÊÜiiÃÊ 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) ,iviÀiVi\ Ê-ViÌwVÊ-Ì>ÌiiÌÊÊ >À`Û>ÃVÕ>ÀÊ«>Ì>LiÊ iVÌÀVÊ iÛViÊviVÌÃ\Ê ÀVÕ>ÌÊ 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>«ÞÊViÊ«>Ì }iÊ>`ÊÃÕÃVi«ÌLÌiÃÊ>ÀiÊÜ° UÊÊ-iÊ>`ÛV>ÌiÊ«iVÊ`iÃiÃÌâ>ÌÊvÀÊ«>Ì }iëiVwVÊÌ iÀ>«ÞÊ in patients with severe allergies (p. 137). UÊÊÌLÌVÊ`ÃiÃÊ>ÀiÊ } iÀÊvÀÊ -ÊviVÌÃÊ­«°ÊÇÇ®° UÊÊviVÌÕÃÊ Ãi>ÃiÃÊVÃÕÌ>ÌÊÃÊ>`ÛÃi`ÊvÀÊ>Ê -ÊviVÌÃ]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* >}iÊÊxä 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``ÌÊvÊ`iÝ>iÌ >ÃiÊÃÊÀiVi`i`ÊÊ>Ê>`ÕÌÊ«>ÌiÌÃÊÜÌ Ê suspected pneumococcal meningitis (note that this will be most adult patients). UÊÊ Ãi\Êä°£xÊ}É}Ê6Ê+ÈÊvÀÊÓq{Ê`>Þà UÊÊ/ iÊwÀÃÌÊ`ÃiÊÕÃÌÊLiÊ>`ÃÌiÀi`Ê£äqÓäÊÕÌiÃÊLivÀiÊÀÊ concomitant with the first dose of antibiotics. 73 6.9 Central nervous system infections Meningitis – Empiric treatment 6.9 Central nervous system infections UÊÊ`ÃÌÀ>ÌÊvÊ>ÌLÌVÃÊà Õ`ÊÌÊLiÊ`i>Þi`ÊÌÊ}ÛiÊ dexamethasone. UÊÊ iÝ>iÌ >ÃiÊà Õ`ÊÌÊLiÊ}ÛiÊÌÊ«>ÌiÌÃÊÜ Ê >ÛiÊ>Ài>`ÞÊ started antibiotics. UÊÊ ÌÕiÊ`iÝ>iÌ >ÃiÊÞÊvÊÌ iÊ -ÊÀ>ÊÃÌ>Êà ÜÃÊÀ> 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-8ÊÀÊ «ÀyÝ>V Vancomycin Vancomycin Vancomycin Ampicillin PLUS Gentamicin‡ Amphotericin B Amphotericin B PLUS Flucytosine Vancomycin PLUS Gentamicin‡ * Consider beta-lactam desensitization ³ÊÕÃÌÊ}ÛiÊ «ÀyÝ>VÊxääÊ}ÊViÊÌÊiÀ>`V>ÌiÊV>ÀÀiÀÊÃÌ>ÌiÊvÊ* ‡ Administer aminoglycosides systemically, not intrathecally 74 ÊÕÃi`Ê>ÃÊÌÀi>ÌiÌ 6.9 Central nervous system infections TREATMENT NOTES Indications for head CT prior to LP UÊÃÌÀÞÊvÊ -Ê`Ãi>ÃiÃÊ­>ÃÃÊiÃ]Ê 6® UÊ iÜÃiÌÊÃiâÕÀiÊ­ 1 week) UÊ*>«i`i> UÊÌiÀi`ÊVÃVÕÃiÃà UÊV>ÊiÕÀ}VÊ`iwVÌ Duration UÊÊ-/"*ÊÌÀi>ÌiÌÊvÊ*ÊVÕÌÕÀiÊLÌ>i`Ê«ÀÀÊÌÊ>ÌLÌVÊÌ iÀ>«ÞÊÃÊ negative at 48 hours OR no PMNs on cell count UÊS. pneumoniae\Ê£äq£{Ê`>Þà UÊN. meningitidis\ÊÇÊ`>Þà UÊListeria\ÊÓ£Ê`>Þà UÊH. influenzae\ÊÇÊ`>Þà UÊÀ>i}>ÌÛiÊL>V\ÊÓ£Ê`>Þà Adjunctive therapy UÊÊ Ã`iÀÊÌÀ>VÀ>>Ê«ÀiÃÃÕÀiÊÌÀ}ÊÊ«>ÌiÌÃÊÜÌ Ê«>Ài`Ê mental status. Encephalitis UÊÊiÀ«iÃÊÛÀÕÃiÃÊ­-6]Ê6<6®ÊÀi>ÊÌ iÊ«Ài`>ÌÊV>ÕÃiÃÊvÊÌÀi>Ì>LiÊ encephalitis. UÊ -Ê* ,ÃÊ>ÀiÊÀ>«`Ê`>}ÃÌVÊÌiÃÌÃÊ>`Ê>««i>ÀʵÕÌiÊÃiÃÌÛiÊ>`Ê specific. UÊ>ÛiÊÜÊÌ Àià `ÊÌÊÌÀi>ÌÊvÊÃÕëiVÌi`Ê>ÃÊÕÌÀi>Ìi`ÊÀÌ>ÌÞÊ iÝVii`ÃÊÇ䯰 UÊ/Ài>ÌiÌ\ÊVÞVÛÀÊ£äÊ}É}Ê6Ê+nÊvÀÊ£{qÓ£Ê`>Þà 75 6.9 Central nervous system infections Brain abscess UÊÊ «ÀVÊÌÀi>ÌiÌÊÃÊ}Õ`i`ÊLÞÊÃÕëiVÌi`ÊÃÕÀViÊ>`ÊÕ`iÀÞ}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*iVÊ",Ê ivÌÀ>ÝiRÊ*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 ,iviÀiViÃ\ -ÊÕ`iiÃÊvÀÊ >VÌiÀ>Êi}ÌÃ\Ê ÊviVÌÊ ÃÊÓää{ÆÎ\£ÓÈÇ° iÝ>iÌ >ÃiÊÊ>`ÕÌÃÊÜÌ ÊL>VÌiÀ>Êi}ÌÃ\Ê Ê }ÊÊi`ÊÓääÓÆÎ{Ç\£x{° CNS shunt infection Diagnosis UÊÊ ÕÌÕÀiÊvÊViÀiLÀë>ÊyÕ`ÊÀi>ÃÊÌ iÊ>ÃÌ>ÞÊvÊ`>}ÃÃ°Ê Clinical symptoms may be mild and/or non-specific, and CSF chemistries and leukocyte counts may be normal. Empiric Therapy UÊÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUS Cefepime 2 g IV Q8H OR UÊÊ* ÊiÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]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,iÛ>ÊvÊ>ÊV«iÌÃÊvÊÌ iÊviVÌi`Êà ÕÌÊÜÌ 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 ,iviÀiViÃ\ -ÊÕ`iiÃÊvÀÊÌ iÊ>>}iiÌÊvÊ >VÌiÀ>Êi}ÌÃ\Ê ÊviVÌÊ ÃÊ Óää{ÆÎ\£ÓÈÇ°Ê / iÀ>«ÞÊÊViÀiLÀë>ÊyÕ`Êà ÕÌÊviVÌ°Ê iÕÀÃÕÀ}iÀÞÊ£näÆÇ\{x° Antimicrobial doses for CNS infections – normal renal function Antibiotics UÊÊ}ÞVÃ`iÃ\ÊÃiiÊ«°Ê£{x UÊÊ«V\ÊÓÊ}Ê6Ê+{Ê UÊÊâÌÀi>\ÊÓÊ}Ê6Ê+È UÊÊ ivÌÀ>Ýi\ÊÓÊ}Ê6Ê+£Ó UÊÊ ivi«i\ÊÓÊ}Ê6Ê+n UÊÊ «ÀyÝ>V\Ê{ääÊ}Ê6Ê+nÊ­L>Ãi`ÊÊÌi`Ê`>Ì>® UÊÊÝyÝ>V\Ê{ääÊ}Ê6Ê+Ó{ UÊÊiÀ«ii\ÊÓÊ}Ê6Ê+n UÊÊiÌÀ`>âi\ÊxääÊ}Ê6Ê+È UÊÊ"Ý>V\ÊÓÊ}Ê6Ê+{ UÊÊ*iV\Ê{ÊÊÕÌÃÊ6Ê+{Ê­Ó{ÊÊÕÌÃÊ«iÀÊ`>Þ® UÊÊ,v>«\ÊÈääÊ}Ê6Ê+£ÓqÓ{ UÊÊ/*É-8\ÊxÊ}É}Ê­/*ÊV«iÌ®Ê6Ê+È UÊÊ6>VÞV\Ê>`ÊÜÌ ÊÓxqÎxÊ}É}]ÊÌ iÊ£xqÓäÊ}É}Ê+nq£ÓÊ (minimum 1 g Q12H) UÊÊ6>VÞVÊà Õ`ÊLiÊ>`ÃÌiÀi`ÊÌÊ>Ì>ÊÃiÀÕÊÌÀÕ} Ê concentrations close to 20 mcg/mL. Antifungals UÊÊ« ÌiÀV\Êä°Çq£Ê}É}Ê6Ê+Ó{ UÊ Ãi®\ÊÎ{Ê}É}Ê6Ê+Ó{ÊvÀÊ ÀÞ«ÌVVV>Êi}Ìà UÊÊ Ãi®\ÊxÊ}É}Ê6Ê+Ó{ÊvÀÊ >``>Êi}Ìà UÊÕV>âi\Ênääq£ÓääÊ}Ê6É*"Ê+Ó{Ê­V>Ê}ÛiÊÊ`Û`i`Ê`Ãiî UÊÊÕVÞÌÃi\ÊÓxÊ}É}Ê*"Ê+È Intraventricular antibiotics (ID consult recommended) UÊÊ>V\ÊÎäÊ}Ê+Ó{Ê­VÌ>ÃÊ«ÀiÃiÀÛ>ÌÛi® UÊÊiÌ>V\ÊxÊ}Ê+Ó{ UÊÊ/LÀ>ÞV\ÊxÊ}Ê+Ó{ UÊÊ6>VÞV\ÊÓäÊ}Ê+Ó{ 77 6.9 Central nervous system infections UÊÊ/ iÊÀiÊvÊÌÀ>ÛiÌÀVÕ>ÀÊ>ÌLÌVÃÊÃÊVÌÀÛiÀÃ>]Ê>`Ê}iiÀ>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 >`ÊÌ iÀÊiÃÃVÊ«>Ì }iÃÆÊVÃÕÌ>ÌÊÜÌ Ê Ê>`Ê /ÊÃÊ recommended to guide management and therapy. ÃÌÊÀ ÃÕÃÌÃÊ`iÃÊÌÊÀiµÕÀiÊ>ÌLÌVÊÌÀi>ÌiÌÆÊÌÀi>ÌiÌÊ Ã Õ`ÊLiÊVÃ`iÀi`ÊÊÌ iÊvÜ}ÊÃVi>ÀÃ\ UÊ*iÀÃÃÌiÌÊÃÞ«ÌÃÊvÊ>VÕÌiÊÀ ÃÕÃÌÕÃÊ≥ 10 days without improvement UÊiÛiÀÊ≥39°C and purulent nasal discharge or facial pain lasting >3-4 days from the beginning of illness UÊ iÜÊÃiÌÊvÊviÛiÀ]Ê i>`>V iÊÀÊVÀi>ÃiÊÊ>Ã>Ê`ÃV >À}iÊvÜ}Ê viral URI that lasted 5-6 days and was initially improving EMPIRIC TREATMENT Oral regimens UÊÝVÉV>ÛÕ>>ÌiÊnÇxÊ}Ê*"Ê+£Ó OR UÊÝVÉV>ÛÕ>>ÌiÊ8,ÊÓÊ}Ê*"Ê+£ÓÊÊvÀÊ«>ÌiÌÃÊÜÌ ÊÃiÛiÀiÊ infection (e.g. systemic toxicity with fever of 39°C), antibiotic use in previous 30 days, immunocompromised OR UÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv«`ÝiÊÓääÊ}Ê*"Ê+£Ó OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}Ê*"Ê`>ÞÊÊ Parenteral regimens UÊ«VÉÃÕL>VÌ>Ê£°xÊ}Ê6Ê+È OR UÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}Ê6Ê+Ó{ÊÊ Duration UÊxÇÊ`>ÞÃÊ TREATMENT NOTES Microbiology UÊ*Ài`>ÌÞÊS. pneumoniae, H. influenzae, M. catarrhalis UÊÀ>i}>ÌÛiÊiÌiÀVÊL>VÊ>ÀiÊÀ>Ài Management UÊ ,-ÊÃÊÀ>ÀiÞÊ«ÀiÃiÌÊ«ÀÀÊÌÊÇq£äÊ`>ÞÃÊvÊÃÞ«ÌÃÆÊÌÞ«V>Ê inciting etiologies of acute sinusitis include allergies and viral URI 78 ,iviÀiVi\Ê -Ê}Õ`iiÃÊvÀÊ ,-°Ê ÊviVÌÊ ÃÊÓä£ÓÆÊx{­n®\iÇÓi££Ó°Ê 79 6.10 Acute bacterial rhinosinusitis UÊ ÕÌÕÀiÃÊLÞÊ`ÀiVÌÊÃÕÃÊ>ëÀ>ÌÊÀÊi`ÃV«V>ÞÊ}Õ`i`ÊVÕÌÕÀiÊvÊ the middle meatus should only be obtained in patients who fail empiric antibiotic therapy. Nasopharyngeal swab is NOT recommended for obtaining culture data. UÊ wÀ>ÌÊvÊ`>}ÃÃÊÜÌ Ê>}}ÊÃÊÌÊÀiVi`i`ÊvÀÊ uncomplicated ABRS. Consider CT in those with severe disease with possible extension to the orbit or intracranial space. UÊÌÀ>>Ã>ÊÃ>iÊÀÀ}>ÌÊ­« ÞÃ}VÊÀÊ Þ«iÀÌV®Ê>`ÊÌÀ>>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>VÀ`iÃÊ­ >ÀÌ ÀÞV]ÊâÌ ÀÞV®Ê>ÀiÊÌÊÀiVi`i`ÊvÀÊ initial empiric therapy due to high rates of resistance of S. pneumoniae ­xx¯Ê>ÌÊ® UÊ iëÌiÊ -Ê}Õ`iiÃÊÃÕ««ÀÌ}ÊÕÃiÊvÊ ÝÞVÞViÊ>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,ÕÌiÊVÛiÀ>}iÊvÀÊ,-ÊÊÌ>Êi«ÀVÊÌ iÀ>«ÞÊvÀÊ ,-ÊÊÌÊ recommended 6.11 Orbital cellulitis Orbital cellulitis Preseptal cellulitisÊ­ä¯ÊvÊV>Ãiî UÊÛÛiÃÊÌÃÃÕiÃÊ>ÌiÀÀÊÌÊÌ iÊÀLÌ>ÊÃi«ÌÕÊ UÊ*ÀiÃiÌÃÊÜÌ ÊviÛiÀ]ÊiÞi`ÊiÀÞÌ i>Ê>`ÊÃvÌÊÌÃÃÕiÊÃÜi}ÊLÕÌÊÊ orbital congestion Postseptal cellultis UÊ-}ÃÊvÊ«iÀÀLÌ>ÊViÕÌÃÊ>ÃÊÜiÊ>ÃÊÌ>ÌÊvÊVÕ>ÀÊÛiiÌÃ]Ê pain with ocular movement, and/or proptosis UÊ-iÛiÀiÊviVÌÊV>Ê>ÃÊÛÛiÊÛÃÕ>ÊÃÃ]ÊÃÕL«iÀÃÌi>Ê>LÃViÃÃ]Ê globe displacement, abscess formation UÊ"vÌiÊ>ÃÃV>Ìi`ÊÜÌ ÊÃÕÃÌÃÊ UÊ >ÊLiÊ>ÃÃV>Ìi`ÊÜÌ ÊV>ÛiÀÕÃÊÃÕÃÊÌ ÀLÃà EMPIRIC TREATMENT UÊ«VÉÃÕL>VÌ>ÊÎÊ}Ê6Ê+È OR UÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀ>ÝiÊÓÊ}Ê6Ê`>Þ OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}Ê6Ê`>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) UÊÝVÉV>ÛÕ>>ÌiÊnÇxÊ}Ê*"Ê+£Ó OR UÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv«`ÝiÊ{ääÊ}Ê*"Ê+£Ó OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}Ê*"Ê`>Þ Duration UÊÇÊ`>ÞÃÊÕ«ÊÌÊÈÊÜiiÃÊvÊiÛ`iViÊvÊLÞÊÛÛiiÌ TREATMENT NOTES Microbiology UÊS. aureus, beta-hemolytic streptococci, S. pneumoniae, H. influenza, M. catarrhalis (cultures are infrequently positive) Management UÊ>}}ÊÃÊÀiVi`i`ÊÊ«ÃÌÃi«Ì>ÊViÕÌÃÊ­ /ÊÀÊ,® UÊ ÃÕÌ>ÌÊÜÌ Ê ]Ê /]Ê>`Ê« Ì >}ÞÊÀiVi`i` 80 81 6.11 Orbital cellulitis UÊ*ÃÌÃi«Ì>ÊViÕÌÃÊÊÕV«ÀÃi`Ê ÃÌÃÊV>ÊLiÊV>ÕÃiÊ LÞÊvÕ}Ê>`Ê`ÃÆÊi«ÀVÊ>ÌvÕ}>ÊÌ iÀ>«ÞÊÃÊÀiVi`i`ÊÊ consultation with ID UÊ*ÃÌÃi«Ì>ÊViÕÌÃÊÜÌ Ê>LÃViÃÃÊvÀ>ÌÊà Õ`Ê«À«ÌÊi`>ÌiÊ surgical intervention UÊ,iëÃiÊÌÊ>««À«À>ÌiÊ>ÌLÌVÊÌ iÀ>«ÞÊà Õ`ÊVVÕÀÊÊÓ{ÊqÊ{nÊ hours UÊ*ÀÊÀiëÃiÊÌÊ>ÌLÌVÃ]ÊÜÀÃi}ÊÛÃÕ>Ê>VÕÌÞÊÀÊ«Õ«>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 UÊÊâÌ ÀÞVÊxääÊ}Ê*"É6Ê+Ó{ÊvÀÊÎÊ`>Þà OR UÊÊÝVÉV>ÛÕ>>ÌiÊnÇxÊ}Ê*"Ê ÊvÀÊxÊ`>Þà OR UÊÊ iv«`ÝiÊÓääÊ}Ê*"Ê ÊvÀÊxÊ`>Þà OR UÊ iv`ÀÊÎääÊ}Ê*"Ê ÊvÀÊxÊ`>Þà TREATMENT NOTES Microbiology UÊÊ*Ài`>ÌÞÊH. influenzae, M. catarrhalis, S. pneumoniae UÊÊPseudomonas, Enterobacteriaceae are less common and seen in patients with severe COPD and extensive antibiotic exposure. Management UÊÊ «ÀVÊÕÃiÊvÊyÕÀµÕiÃÊÃÊ`ÃVÕÀ>}i`Ê>`Êà Õ`ÊÞÊ 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>ÌLÌVÃÊà Õ`ÊÞÊLiÊÕÃi`ÊvÊÌ iÊ«>ÌiÌÊV>ÌÊÌiÀ>ÌiÊ*"Ê antibiotics. UÊÊÌLÌVÃÊ>ÀiÊÌÊ`V>Ìi`ÊvÀÊ>ÃÌ >Êy>ÀiÃÊÊÌ iÊ>LÃiViÊvÊ pneumonia. Prophylactic antibiotics for the prevention of COPD exacerbations UÊ*À« Þ>VÌVÊ>ÌLÌVÃÊ >ÛiÊLiiÊà ÜÊÌÊÀi`ÕViÊÀ>ÌiÃÊvÊ exacerbations and improve reported quality of life but not to decrease all-cause or respiratory-associated mortality UÊ*À}i`ÊâÌ ÀÞVÊÕÃiÊ >ÃÊLiiÊ>ÃÃV>Ìi`ÊÜÌ Ê i>À}ÊÃÃÊ >`Ê+/Ê«À}>ÌÆÊ«>ÌiÌÃÊÜÌ ÊL>ÃiiÊ+/«À}>ÌÊÜiÀiÊÌÊ included in clinical trials UÊ/ iÊ`iVÃÊÌÊÌ>ÌiÊ«À« Þ>VÌVÊ>ÌLÌVÃÊà Õ`ÊLiÊ>`iÊÊ>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,iVi`i`ÊÀi}i\ÊâÌ ÀÞVÊÓxäÊ}Ê*"Ê`>Þ UÊ >ÃiiÊ>Õ`iÌÀÞÊ>`Ê ÊÃÊÀiVi`i` ,iviÀiViÃ\ iÀV>Ê i}iÊvÊ* ÞÃV>ÃÊ*ÃÌÊ*>«iÀ\ÊÊÌiÀÊi`ÊÓää£ÆÊ£Î{\Èää° ÕÀ>ÌÊvÊÌ iÀ>«Þ\Ê/ À>ÝÊÓäänÆÊÈέx®\{£xqÓÓ° âÌ ÀÞVÊvÀÊ«ÀiÛiÌ\Ê °Ê }°ÊÊi`ÊÓ䣣ÆÊÎÈx\ÊÈnÆÊ V 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 UÊ«VÉÃÕL>VÌ>Ê£°xÊ}Ê6Ê+ÈÊPLUS Azithromycin 500 mg IV/PO once daily OR UÊÊ ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ÊPLUS Azithromycin 500 mg IV/PO once daily OR UÊÝyÝ>VÊ{ääÊ}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 ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ÊPLUS Azithromycin 500 mg IV Q24H OR UÊÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}Ê6Ê+Ó{Ê At risk for infection with Pseudomonas (see risks below) UÊÊ ivi«iÊ£ÓÊ}Ê6Ê+nÊPLUS Azithromycin 500 mg IV Q24H OR UÊÊ*«iÀ>VÉÌ>âL>VÌ>Ê{°xÊ}Ê6Ê+ÈÊPLUS Azithromycin 500 mg IV Q24H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}Ê6Ê+Ó{ÊPLUS Aztreonam 2 g IV Q8H UÊÊ-«ÕÌÕÊ}À>ÊÃÌ>Ê>ÞÊ i«Ê`iÌiÀiÊvÊPseudomonas is present. UÊÊNarrow coverage if Pseudomonas is NOT present on culture at 48 hours. Risks for PseudomonasÊ>`ÊÌ iÀÊÀiÃÃÌ>ÌÊÀ>i}>ÌÛiÊÀ}>ÃÃ\ LÀV iVÌ>ÃÃÆÊLÀ>`ëiVÌÀÕÊ>ÌLÌVÃÊvÀÊÊÇÊ`>ÞÃÊÊÌ iÊ«>ÃÌÊ Ì ÆÊ«À}i`Ê Ã«Ì>â>ÌÊÊÇÊ`>ÞÃÆÊ`iLÌ>Ìi`ÊÕÀÃ}Ê iÊ ÀiÃ`iÌÆÊÀiViÌÊiV >V>ÊÛiÌ>ÌÊÊ{nÊÆÊÕV«ÀÃi`Ê due to solid organ transplant, hematologic malignancy, BMT, active chemotherapy, prednisone > 20 mg daily for > 3 weeks. DIAGNOSIS UÊÊÕV«iÌiÌÊ«>ÌiÌÃÊ1-/Ê >ÛiÊ>ÊV iÃÌÊ8À>ÞÊwÌÀ>ÌiÊÌÊiiÌÊ diagnostic criteria for pneumonia. UÊÊ-«ÕÌÕÊ>`ÊL`ÊVÕÌÕÀiÃÊà Õ`ÊLiÊÃiÌÊÊ>Ê«>ÌiÌÃÊ>`ÌÌi`ÊÌÊ the hospital BEFORE antibiotics are given. UÊÊS. pneumoniae urine antigen should be obtained in all patients with CAP. ÌÊ >ÃÊëiVwVÌÞÊvÊȯÊ>`Ê«ÃÌÛiÊ«Ài`VÌÛiÊÛ>ÕiÊvÊnn°nÈ°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/ iÊi}i>ÊÕÀiÊ>Ì}iÊÃÊÌ iÊÌiÃÌÊvÊV ViÊvÀÊ`>}Ã}Ê legionella infection. This test detects only L. pneumophila serogroup £]ÊÜ V ÊÃÊÀiëÃLiÊvÀÊÇäqnä¯ÊvÊviVÌð DURATION UÊ/ iÀ>«ÞÊV>ÊLiÊÃÌ««i`Ê>vÌiÀÊÌ iÊ«>ÌiÌÊÃ\ Ê UÊviLÀiÊvÀÊ{nqÇÓÊ ÕÀà AND Ê UÊÊ>ÃÊÊÀiÊÌ >ÊiÊvÊÌ iÊvÜ}ÊÃ}ÃÊ>`ÊÃÞ«ÌÃ\Ê,Ê 100 beats/min, RR 24 breaths/min, BP 90 mmHg, O2 sat Êä¯]Ê>ÌiÀi`ÊiÌ>ÊÃÌ>ÌÕÃ°Ê UÊÊ-Õ}}iÃÌi`Ê`ÕÀ>ÌÊvÊÌ iÀ>«ÞÊL>Ãi`ÊÊ«>ÌiÌÊëiVwVÊv>VÌÀÃ\ 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 UÊÊ1V«V>Ìi`ÊL>VÌiÀiVÊ«iÕVVV>Ê«iÕ>qÊ«À}i`Ê course of antibiotic therapy not necessary, treat as pneumonia UÊÊ Õ} Ê>`ÊV iÃÌÊ8À>ÞÊ>LÀ>ÌiÃÊ>ÞÊÌ>iÊ{qÈÊÜiiÃÊÌÊ«ÀÛi°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>ëÀ>Ì\ 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 ÕÌÞ>VµÕÀi`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,iëÀ>ÌÀÞÊÛÀÕÃiÃ\ 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). ,iviÀiViÃ\ -É/-Ê ÃiÃÕÃÊÕ`iiÃÊvÀÊ *\Ê ÊviVÌÊ ÃÊÓääÇÆ{{\-ÓÇ° S. pneumo >Ì}i\ÊÀV ÊÌiÀÊi`ÊÓ䣣ƣǣ­Ó®\£ÈÈqÇÓ ÎÊ`>ÞÃÊvÊÌ iÀ>«ÞÊvÀÊ *\Ê ÊÓääÈÆÎÎÓ\£Îxx° 84 85 Ceftriaxone 1 g IV Q24 OR Cefpodoxime 200 mg PO BID OR Cefdinir 300 mg PO BID «VÊ£Ê}Ê6Ê+ÈÊ OR Amoxicillin 500 mg PO TID Ê S. pneumoniae PCN resistant, cephalosporin susceptible Ê H. influenzae 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 âÌ ÀÞVIQxääÊ}Ê*"Ê`>ÞÊ8ÊÎÊ`>ÞÃÊ",ÊÊ xääÊ}ÊVi]ÊÌ iÊÓxäÊ}Ê*"Ê`>ÞÊ8Ê{Ê`>ÞÃR ORÊ iv«`ÝiÊÓääÊ}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: âÌ ÀÞVIQxääÊ}Ê*"Ê`>ÞÊÊ8ÊÎÊ`>ÞÃÊÊ ",ÊxääÊ}ÊVi]ÊÌ iÊÓxäÊ}Ê*"Ê`>ÞÊ8Ê{Ê`>ÞÃRÊ OR Moxifloxacin 400 mg IV/PO daily (if Erythromycin resistant) Notes 6.12 Pulmonary infections Çx¯ÊvÊH. influenzae isolates at JHH (excluding oncology) are susceptible to «V]Ê£ää¯ÊÌÊ ivÌÀ>Ýi]ÊÈx¯ÊÌÊ /iÌÀ>VÞVi]Ê>`Ê£ää¯ÊÌÊÝyÝ>VÊ None of the S. pneumoniae isolates at (excluding oncology) are resistant JHH to PCN £¯ÊvÊS. pneumoniae isolates at JHH (excluding oncology) are susceptible and ¯Ê>ÀiÊÌiÀi`>ÌiÊÌÊ* ]Ê{x¯Ê>Ài susceptible to Erythromycin (Erythromycin susceptibilities predict Azithromycin ÃÕÃVi«ÌLÌiÃÊvÀÊS. pneumoniae), and £ää¯Ê>ÀiÊÃÕÃVi«ÌLiÊÌÊÝyÝ>V 86 PCN allergy Azithromycin 500 mg IV/PO Q24H x 7-10 days OR ÝyÝ>VÊ{ääÊ}Ê6É*"Ê+Ó{Ê8Ê£ä£{Ê`>Þà âÌ ÀÞVIQxääÊ}Ê*"Ê`>ÞÊ8ÊÎÊ`>ÞÃÊ",Ê xääÊ}ÊVi]ÊÌ iÊÓxäÊ}Ê*"Ê`>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«`ÝiÊÓääÊ}Ê*"Ê ÊÊ ÝyÝ>VÊ{ääÊ}Ê6É*"Ê+Ó{Ê OR Cefdinir 300 mg PO BID OR ÝVÉV>ÛÕ>>ÌiÊ8,ÊÓÊ}Ê*"Ê Ê Ê Ê Ê Ìi\Ê1iÃÃÊÃÌÀ}ÊÃÕëVÊvÀÊÊ Ê L. pneumophilia, more than 3 days of Azithromycin for atypical coverage is not needed due to very long half-life in lung tissue IvÊ ÀÞÌ ÀÞVÊÃÕÃVi«ÌLiÆÊaÊvÊ/iÌÀ>VÞViÊÃÕÃVi«ÌLi Ê Ê Ê ÕÌÕÀiÊ>`ÊÕÀiÊ>Ì}iÊi}>ÌÛiÊ Azithromycin 500 mg IV/PO Q24H OR ÝyÝ>VÊ{ääÊ}Ê6É*"Ê+Ó{Ê L. pneumophilia Ê Preferred therapy «VÉÃÕL>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¯ÊvÊS. pneumoniae isolates at JHH (excluding oncology) are susceptible to Erythromycin (Erythromycin susceptibilities predict Azithromycin susceptibilities for S. pneumoniae®Ê>`ÊÇίÊ>ÀiÊÃÕÃVi«ÌLiÊ ÌÊ/iÌÀ>VÞViÆÊÌ iÀivÀi]ÊÌ iÃiÊ>}iÌà >ÀiÊÃÕL«Ì>ÊvÀÊi«ÀVÊÃÌi«`Ü 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 ivÌÀ>ÝiIÊ£Ê}Ê6Ê+Ó{ OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}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«iIÊÓÊ}Ê6Ê+nʱ Vancomycin† (see dosing section, p. 150) OR UÊ*«iÀ>VÉÌ>âL>VÌ>IÊ{°xÊ}Ê6Ê+Èʱ Vancomycin† (see dosing section, p. 150) OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]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°}°]ÊLÀV iVÌ>ÃÃÆÊLÀ>`ëiVÌÀÕÊ >ÌLÌVÃÊvÀÊÊÇÊ`>ÞÃÊÊÌ iÊ«>ÃÌÊÌ ÆÊ«À}i`Ê Ã«Ì>â>ÌÊÊ ÇÊ`>ÞÃÆÊ`iLÌ>Ìi`ÊÕÀÃ}Ê iÊÀiÃ`iÌÆÊÀiViÌÊiV >V>ÊÛiÌ>ÌÊ Ê{nÊ ÕÀÃÆÊÕV«ÀÃi`Ê`ÕiÊÌÊÃ`ÊÀ}>ÊÌÀ>ë>Ì]Ê hematologic malignancy, BMT, active chemotherapy, prednisone > 20 }Ê`>ÞÊvÀÊÊÎÊÜiiî\ÊÌÀi>ÌÊ>ÃÊÃiÛiÀiÊiÃÃÊÜÌ ÊÌ>À}ÊvÊ>ÌLÌVÊ 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«`ÝiÊ{ääÊ}Ê*"Ê Ê­vÊÊ ivÌÀ>Ýi®Ê",ÊÝyÝ>VÊ{ääÊ mg PO daily Duration:ÊvÊ«iÕ>ÊVwÀi`ÊxÇÊ`>ÞÃÆÊvÊ«iÕ>Ê`>}ÃÃÊÃÊ questionable and patient improves, can considered stopping therapy after 3 days TREATMENT NOTES Microbiology UÊÊ ÌiÀVVVÊ>`ÊV>``>ÊëiViÃÊ>ÀiÊvÌiÊÃ>Ìi`ÊvÀÊÌ iÊëÕÌÕÊ 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*À« Þ>VÌVÊ>ÌLÌVÃÊ, Ê "/ÊÀiVi`i`ÊvÀÊ«>ÌiÌÃÊÜ Ê>ÀiÊ at increased risk for aspiration. UÊi`>ÌiÊÌÀi>ÌiÌÊÃÊ`V>Ìi`ÊvÀÊ«>ÌiÌÃÊÜ Ê >ÛiÊÃ>LÜiÊ obstructions or are on acid suppression therapy given the increased risk of gastric colonization. UÊÌLÌVÊÌÀi>ÌiÌÊvÊ«>ÌiÌÃÊÜ Ê`iÛi«ÊviÛiÀ]ÊiÕVÞÌÃÃÊ>`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>ÌiÌÊ-ÊÀiVi`i`ÊvÀÊ«>ÌiÌÃÊÜ Ê >ÛiÊÃÞ«ÌÃÊvÀÊ more than 48 hours or who are severely ill. ,iviÀiViÃ\ ëÀ>ÌÊ«iÕÌÃÊ>`Ê>ëÀ>ÌÊ«iÕ>\Ê Ê }ÊÊi`ÊÓää£ÆÎ{{­®\ÈÈx° /-É -ÊÕ`iiÃÊvÀÊ*É6*\Ê, ÊÓääxƣǣ\Înn° Ventilator-associated pneumonia (VAP) UÊÊ-«ÕÌÕÊVÕÌÕÀiÃÊà Õ`ÊLiÊLÌ>i`Ê«ÀÀÊÌÊÃÌ>ÀÌ}Ê>ÌLÌVÃÊÀÊ 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«>ÌiÌÊÃÊÊ>ÌLÌVÊÌ iÀ>«ÞÊÀÊ >ÃÊÀiViÌÞÊLiiÊÊ>ÌLÌVÊ 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{]äääÊÀÊ > 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*ÊÃÊÕiÞ UÊÊvÊ6*ÊÃÌÀ}ÞÊÃÕëiVÌi`ÊÃiiÊÌÀi>ÌiÌÊÀiVi`>ÌÃÊLiÜ UÊÊvÊ *-ÊÀi>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 ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ{ääÊ}Ê6Ê+Ó{ Late-onset VAP (all VAP that is not early-onset) Etiology: S. aureus, P. aeruginosa, other Gram-negative bacilli UÊÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUSÊQ*«iÀ>VÉ 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>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUS Q «ÀyÝ>VÊ{ääÊ}Ê6Ê+nÊ",ÊâÌÀi>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*ÊÃÊ unlikely UÊÊ7 days if the patient has clinical improvement UÊÊvÊÃÞ«ÌÃÊ«iÀÃÃÌÊ>ÌÊÇÊ`>ÞÃÊVÃ`iÀÊ>ÌiÀ>ÌÛiÊÃÕÀViÊ>`ÉÀÊ bronchoscopy with quantitative cultures UÊÊ6*Ê>ÃÃV>Ìi`ÊÜÌ 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/LÀ>ÞVÊÃÊÀiVi`i`Ê>ÃÊ>ÊÃiV`Ê>}iÌÊÌÊLÀ>`iÊi«ÀVÊ coverage rather than fluoroquinolones because of high rates of resistance to fluoroquinolones in the institution. UÊÊÌVÀL>ÊÌ iÀ>«ÞÊà Õ`ÊLiÊÌ>Ài`ÊViÊÃÕÃVi«ÌLÌiÃÊ>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 `VÕiÌi`ÆÊvÊÌÊÃÊ`iÃÀi`]ÊÌ iÊVÃ`iÀÊ}Û}ÊÌÊvÀÊÌ iÊwÀÃÌÊÇÓÊ hours of therapy only. Diagnosis UÊÊ6*ÊÃÊ`vwVÕÌÊÌÊ`>}Ãi° UÊÊ >VÌiÀ>ÊÊi`ÌÀ>V i>ÊÃÕVÌÊ>ÞÊÀi«ÀiÃiÌÊÌÀ>V i>ÊVâ>ÌÊ and NOT infection. UÊÊ+Õ>ÌÌ>ÌÛiÊVÕÌÕÀiÃÊvÊ ÊyÕ`ÊV>Ê i«Ê`ÃÌ}Õà ÊLiÌÜiiÊ Vâ>ÌÊ>`ÊviVÌÆÊ≥ 104 cfu/ml is considered significant growth. Other considerations UÊÊ/À>V i>ÊVâ>ÌÊvÊÀ>i}>ÌÛiÃÊ>`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. UÊÊ>`iµÕ>ÌiÊÌ>ÊÌÀi>ÌiÌÊvÊ6*ÊÃÊ>ÃÃV>Ìi`ÊÜÌ Ê } iÀÊÀÌ>ÌÞÊ (even if treatment is changed once culture results are known). ,iviÀiViÃ\ /-É -ÊÕ`iiÃÊvÀÊ*É6\Ê, ÊÓääxƣǣ\Înn° V>ÊÀiëÃiÊÌÊ6*\Ê, ÊÓää£Æ£ÈÎ\£ÎÇ££ÎÇx°Ê 6*\ÊÀV ÊÌiÀÊi`ÊÓäääÆ£Èä\£ÓÈÈ° \Ê iÃÌÊ£nÆ££Î\{£ÓÓä° *-ÊÃVÀi\ÊÊ,iÛÊ,iëÀÊ ÃÊ££Æ£{Î\££Ó£q££Ó°Ê iÌiÀ}ÊVÕÀÃiÊvÊÌ iÀ>«ÞÊÕÃ}Ê *-Ê-VÀi\ÊÊÊ,iëÀÊ ÀÌÊ >ÀiÊi`ÊÓäääÆÊ £ÈÓ\xäxÊ>`ÊÌiÃÛiÊ >ÀiÊi`ÊÓää{ÆÊÎä\ÊÇÎxqÇÎn° 90 UÊÊ/ iÀ>«ÞÊà Õ`ÊLiÊL>Ãi`ÊÊVÕÌÕÀiÊ>`ÊÃÕÃVi«ÌLÌÞÊ`>Ì>ÊÜ iÊ >Û>>LiÆÊÌ iÊ>}iÌÊÜÌ ÊÌ iÊ>ÀÀÜiÃÌÊëiVÌÀÕÊvÊ>VÌÛÌÞÊà Õ`ÊLiÊ selected preferentially UÊÊvÊ«ÃÃLi]ÊÃÌ«Êv>}Ê>ÌLÌVÃÊÜ iÊÌ>Ì}ÊiÜÊ>ÌLÌVà UÊÊ} Ê`ÃiÃÊvÊ>ÌLÌVÃÊà Õ`ÊLiÊÕÃi`ÊÌÊ>ÝâiÊÕ}Ê«iiÌÀ>ÌÊ and reduce the risk of emergence of resistance (see below) TREATMENT NOTES FOR SPECIFIC ORGANISMS UÊPseudomonas aeruginosa UÊÊ*«iÀ>V]Ê ivi«i]Ê>`Ê ivÌ>â`iÊà Õ`ÊLiÊÕÃi`Ê preferentially to Meropenem to minimize the induction of resistance to beta-lactams by Meropenem UÊÊ/ iÃiÊ>}iÌÃÊ>ÀiÊ}iiÀ>ÞÊVLi`ÊÜÌ Ê } `ÃiÊ aminoglycosides based on in vitro evidence that there is synergy against Pseudomonas UÊÊÀÊ«>ÌiÌÃÊÜÌ Ê«iVÊ>iÀ}Þ]Ê «ÀyÝ>VÊÀÊâÌÀi>Ê V>ÊLiÊVLi`ÊÜÌ Ê>Ê>}ÞVÃ`iÆÊ`iÃiÃÌâ>ÌÊÌÊLiÌ> lactams or carbapenems should be strongly considered UÊÊÊ«>ÌiÌÃÊÌiÀ>ÌÊÀÊÀiÃÃÌ>ÌÊÌÊ>}ÞVÃ`iÃ]Ê ÃÌÊV>Ê be added UÊÊ ÌÕÕÃÊvÕÃÊvÊLiÌ>>VÌ>ÃÊV>ÊLiÊVÃ`iÀi`ÊÊÃiÊ «>ÌiÌÃÆÊÃiiÊ«°ÊÓnÊvÀÊÀiÊvÀ>Ì° UÊÊ >i`Ê/LÀ>ÞVÊ>`Ê ÃÌÊV>ÊLiÊÕÃi`Ê>ÃÊ>`ÕVÌÛiÊÌ iÀ>«Þ UÊStenotrophomonas maltophilia UÊÊS. maltophilia isolated from sputum usually represents colonization. UÊÊvÊÃÕ«iÀviVÌÊÃÊÃÕëiVÌi`]Ê/*É-8ÊÃÊÌ iÊwÀÃÌÊiÊ>}iÌ°Ê UÊÊ/V>ÀVÉV>ÛÕ>>ÌiÊOR Minocycline may be used if susceptible in «>ÌiÌÃÊÜ Ê>ÀiÊ>iÀ}VÊÀÊÌiÀ>ÌÊÀÊÀiÃÃÌ>ÌÊÌÊ/*É-8°Ê UÊStaphylococcus aureus UÊÊS. aureus isolated from sputum can indicate colonization or infection. UÊÊ7 iÌ iÀÊÌÀi>Ì}ÊVâ>ÌÊÜÌ 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 `>ÞV]Ê/*É-8]Ê ÝÞVÞVi]Ê>`ÊVÞViÊvÀÊ,-°ÊÊ UÊÊ"Ý>VÊÃÊÌ iÊ`ÀÕ}ÊvÊV ViÊvÀÊ--Ê«iÕ>ÆÊ6>VÞVÊ 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>â`i\ÊÓÊ}Ê6Ê+nÊ UÊ*«iÀ>VÉÌ>âL>VÌ>\ÊΰÎÇxÊ}Ê6Ê+{ UÊ ivi«i\ÊÓÊ}Ê6Ê+n UÊiÀ«ii\ÊÓÊ}Ê6Ê+n UÊ «ÀyÝ>V\ÊÇxäÊ}Ê*"Ê+£ÓÊ",Ê{ääÊ}Ê6Ê+n UÊâÌÀi>\ÊÓÊ}Ê6Ê+n UÊ/V>ÀVÉV>ÛÕ>>Ìi\Êΰ£Ê}Ê6Ê+{ UÊ/*É-8ÊvÀÊS. maltophilia: 5 mg/kg IV/PO Q8H UÊ/*É-8ÊvÀÊS. aureus: 2 DS tablets PO BID UÊ ÃÌ\ÊÎÈÊ}É}É`>ÞÊ6Ê`Û`i`ÊÊÎÊ`ÃiÃÊ UÊ >i`Ê/LÀ>ÞVÊ­/" ®®\ÊÎääÊ}Ê+£Ó UÊ >i`Ê ÃÌ\ÊÇx£xäÊ}Ê+£ÓÊ`i«i`}ÊÊÌ iÊ`iÛiÀÞÊÃÞÃÌiÊÊ Intravenous Tobramycin dosing and monitoring: UÊ>`}Ê`Ãi\Ê£äÊ}É}É`>ÞÊ}ÛiÊÛiÀÊ£Ê ÕÀ°Ê UÊÊ*i>ÊÃÊÀiVi`i`Ê>vÌiÀÊwÀÃÌÊ`Ãi]Ê£Ê ÕÀÊ>vÌiÀÊÌ iÊi`ÊvÊvÕÃÊ ÜÌ Ê}>ÊvÊÓäÎäÊ>`ÊÌÀÕ} Ê>ÌÊÓÎÊ ÕÀÃÊÜÌ Ê}>ÊÊ£ÊV}É°Ê UÊÊ ÃiÃÊV>ÊLiÊVÀi>Ãi`ÊÕ«ÊÌÊ£ÓÊ}É}É`>ÞÊvÊ>`iµÕ>ÌiÊ«i>ÃÊ are not achieved. If trough is too low or too high, interval should be changed. 92 Diagnosis UÊÊ,iëÀ>ÌÀÞÊÛÀÕÃÊÌiÃÌ}Êà Õ`ÊLiÊLÌ>i`ÊÞi>ÀÊÀÕ`ÊÊ>ÞÊ«>ÌiÌÊ for whom there is a clinical suspicion of respiratory virus infection. In addition, during influenza and RSV season testing should be obtained Ê«>ÌiÌÃÊÜÌ \ Ê UÊÊiÛiÀÊ>`ÊyÕiâ>iÊÃÞ«ÌÃÊ­ÃÀiÊÌ À>Ì]ÊÞ>}>]Ê>ÀÌ À>}>]Ê cough, runny nose and/or headache) Ê U Suspected bronchiolitis or pneumonia Ê U COPD/asthma exacerbation or respiratory failure Ê UÊ1iÝ«>i`Ê ÊiÝ>ViÀL>Ì Ê UÊ `iÀÞÊ«>ÌiÌÃÊÜÌ ÊÕiÝ«>i`ÊiÜÊÃiÌÊ>>Ãi Ê UÊ*Ài}>ÌÊ«>ÌiÌÃÊÜÌ ÊÕiÝ«>i`ÊÀiëÀ>ÌÀÞÊÃÞ«ÌÃ Ê UÊÊ Ã«iVwVÊÃÞ«ÌÃÊ>`Ê>Ê`VÕiÌi`ÊiÝ«ÃÕÀiÊÌÊÃiiÊ with a respiratory illness UÊÊ,iëÀ>ÌÀÞÊÛÀÕÃÊÌiÃÌ}Ê>ÌÊÊ­iÊ *ÊyVi`ÊÃÜ>LÊà Õ`ÊLiÊ submitted for either panel) Ê UÊÊ/iÃÌ}ÊvÀÊÕV«iÌiÌÊ ÃÌÃ\ÊÀ>«`ÊÕViVÊ>V`ÊÌiÃÌÊvÀÊ,-6Ê and influenza A/B Ê UÊÊ/iÃÌ}ÊvÀÊÕV«ÀÃi`Ê ÃÌÃ]Ê«>ÌiÌÃÊLi}Ê>`ÌÌi`Ê ÌÊÌ iÊ 1]Ê>`Ê«>ÌiÌÃÊÜÌ ÊÃÌÀÕVÌÕÀ>ÊÕ}Ê`Ãi>Ãi\ÊiÝÌi`i`Ê panel for RSV, influenza A/B, adenovirus, human metapneumovirus, parainfluenza 1-3, and rhinovirus Treatment of influenza in inpatients UÊÊ «ÀVÊÌÀi>ÌiÌÊvÊ>`ÕÌÊ«>ÌiÌÃÊà Õ`ÊLiÊVÃ`iÀi`ÊÊÌ iÊ vÜ}ÊÃÌÕ>ÌÃÊ`ÕÀ}ÊyÕiâ>ÊÃi>Ã\Ê Ê UÊÊ*>ÌiÌÃÊÜÌ ÊviÛiÀÊ>`ÊyÕiâ>iÊÃÞ«ÌÃ]ÊÕiÝ«>i`Ê interstitial pneumonia or new respiratory failure without an obvious non-influenza cause UÊÊ/Ài>ÌiÌÊà Õ`ÊLiÊÌ>Ìi`ÊÊ>Ê«>ÌiÌÃÊÜ Ê>ÀiÊ>`ÌÌi`ÊÌÊÌ iÊ hospital and have influenza with symptom onset in the past 48-72 hours UÊÊ/ iÊÕÌÌÞÊvÊÌÀi>ÌiÌÊvÊ«>ÌiÌÃÊÜ Ê«ÀiÃiÌÊ>ÌiÊÊÌ iÊVÕÀÃiÊvÊ disease is uncertain and the decision to treat these patients can be made on a case-by-case basis UÊÊÌÛÀ>ÊV ViÊÃÊ`i«i`iÌÊÊÌ iÊÃÕÃVi«ÌLÌÞÊvÊVÀVÕ>Ì}ÊÃÌÀ>ÃÊ which may vary from season to season (see www.hopkinsmedicine.org/amp for current recommendations) UÊÊ ÕÀ>Ì\ÊxÊ`>ÞÃÊiÝVi«ÌÊvÀÊ«>ÌiÌÃÊÜÌ ÊÃ`ÊÀ}>ÊÌÀ>ë>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 UÊÊÊ`Û`Õ>ÃÊÜÌ ÊÃÕëiVÌi`ÊÀiëÀ>ÌÀÞÊÛÀÕÃÊviVÌÊà Õ`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. UÊÊÊ i>Ì ÊV>ÀiÊÜÀiÀÃÊÕÃÌÊÀiViÛiÊÌ iÊyÕiâ>ÊÛ>VViÊÞi>ÀÞ° UÊÊ*iÀÃiÊÜÌ Ê`ÀiVÌÊ«>ÌiÌÊV>ÀiÊÀÊÜÀ}ÊÊVV>Ê>Ài>ÃÊÜ Ê >ÛiÊÌÊ 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>ÊÕÛ>VV>Ìi`Ê 7ÊÃÊiÝ«Ãi`ÊÌÊ>Ê«>ÌiÌÊÜÌ Ê`VÕiÌi`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 vÀÊxÊ`>ÞÃÊ Prophylaxis:Ê 75 mg PO once a day \Ê>ÕÃi>]ÊÊ vomiting Ê -iÛiÀi\ hypersensitivity, neuropsychiatric ÃiÊ>`ÕÃÌiÌÊ needed for GFR ÈäÊÉÊ Treatment:Ê 10 mg (2 oral inhalations) twice daily for 5 days Prophylaxis: 10 mg (2 oral inhalations) ViÊ>Ê`>ÞÊÊ \Ê`>ÀÀ i>]ÊÊ nausea, cough, headache, and dizziness - Õ`Ê "/ÊLiÊÕÃi`Ê in patients with chronic underlying airway diseases Ê <>>ÛÀÊ Ê 94 Ê-iÛiÀi\ÊLÀV ë>Ã]Ê hypersensitivity, laryngeal edema, facial swelling Latent TB infection (LTBI) UÊÊ*ÀiÛÕÃÊviVÌÊÜÌ ÊM. tuberculosis (MTB) that has been contained by the host immune response UÊÊ*>ÌiÌÊ>ÞÊ >ÛiÊ>Ê«ÃÌÛiÊÌiÃÌÊ­ÃiiÊLiÜ®ÊÀÊÃÕ}}iÃÌÛiÊÀ>`}À>« VÊ findings such as calcified granulomata or minimal apical scarring, but do not have symptoms of active TB disease UÊÊ ÌÊviVÌÕÃÊ>`Ê`iÃÊÌÊÀiµÕÀiÊÃ>Ì Tests to diagnose latent LTBI UÊÊ Ì Ê/ÕLiÀVÕÊÃÊÌiÃÌÊ­/-/®Ê>`ÊÌiÀviÀÊ}>>ÊÀii>ÃiÊ>ÃÃ>ÞÊ­,®Ê >ÀiÊ«iÀviVÌ]Ê>`Ê>ÞÊvviÀÊ`ÃVÀ`>ÌÊÀiÃÕÌÃÊ­HÓ䯮°ÊÊ-iÃÌÛÌÞÊvÊ/-/Ê and IGRA are similar. UÊÊ Ì ÊÌiÃÌÃÊà Õ`ÊLiÊÌiÀ«ÀiÌi`ÊÊÌ iÊVÌiÝÌÊvÊi«`i}VÊÀÃÊvÊ/ Ê exposure UÊÊ/ ÊÌ iÀ>«ÞÊà Õ`ÊÌÊLiÊÌ>Ìi`ÊÕÌÊ>VÌÛiÊ/ ÊÃÊiÝVÕ`i`Ê­LÞÊ symptoms and radiography). Individuals with signs or symptoms of active TB require further diagnostic workup before LTBI therapy. UÊÊ/ ÊÌ iÀ>«ÞÊà Õ`ÊÌÊLiÊÃÌ>ÀÌi`ÊÊÌ iÊ Ã«Ì>ÊÜÌ ÕÌÊ>ÊVi>ÀÊvÜÕ«Ê plan Tuberculin skin test (TST) UÊÊÌÀ>`iÀ>ÊiVÌÊvÊ«ÕÀwi`Ê«ÀÌiÊ`iÀÛ>ÌÛiÊ­** ®Ê>`Êi>ÃÕÀiiÌÊ of induration diameter in 48-72 UÊÊÊ ÀÌiÀ>ÊvÀÊ>Ê«ÃÌÛiÊÌiÃÌÊ>Ài UÊÊÊxÊÊqÊ } ÊÀÃÊvÊ`iÛi«}Ê>VÌÛiÊ/ Ê­i°}°]Ê6ÊviVÌ]ÊVÃiÊ contact of TB case, immunocompromised) UÊÊÊ£äÊÊqÊÌ iÀÊÀÃÊv>VÌÀÃÊvÀÊ/ ÊviVÌÊ­ 7]Ê 1]Ê ® UÊÊÊ£xÊÊqÊÊÀÃÊv>VÌÀÃÊvÀÊ/ Interferon gamma release assay (IGRA) UÊ,ÃÊi>ÃÕÀiÊÞ« VÞÌiÊÀii>ÃiÊvÊÌiÀviÀÊ}>>ÊÊÀiëÃiÊÌÊ stimulation by MTB antigens. UÊ,ÃÊ>ÀiÊiÃÃÊ>vviVÌi`ÊLÞÊ ÊÛ>VV>ÌÊÃÌ>ÌÕÃÊÀÊviVÌÊÜÌ ÊÃÌÊ atypical mycobacteria (except M. marinum and M. kansasii) than TST UÊ+Õ>ÌviÀ`/ÕLiÊ­+/®ÊÃÊÕÃi`Ê>ÌÊ°Ê,iÃÕÌÃÊ>ÀiÊÀi«ÀÌi`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 >ÕÌÀÌÊQ>LÕÊΰxR°Ê`iÌiÀ>ÌiÊÀiÃÕÌÃÊvÌiÊÀiµÕÀiÊ>ÊÀi«i>ÌÊ test (ensure proper specimen collection). UÊ7 iÊ«ÀiÌiÃÌÊ«ÀL>LÌÞÊÀÊ«ÀiÛ>iViÊvÊ/ ÊÃÊx¯Ê­i°}°]Ê1-LÀÊ ÜÌ ÕÌÊvÀi}ÊÌÀ>Ûi®]Ê**6ÊvÊ,ÊÃÊÀi`ÕVi`Ê­Çää¯]Ê°i°]Êv>Ãi«ÃÌÛiÃ®Ê Ü iÊ *6ÊÃÊ } Ê­¯®°ÊÊ UÊ7 iÊ«ÀiÌiÃÌÊ«ÀL>LÌÞÊvÀÊviVÌÊÃÊ } Ê­i°}°]ÊvÀi}LÀ]ÊHÎä¯Ê/ Ê «ÀiÛ>iVi®]Ê**6ÊvÊ,ÊVÀi>ÃiÃÊÌÊHx¯]ÊLÕÌÊ *6Ê`iVÀi>ÃiÃÊ ­nää¯]Ê°i°]Êv>Ãii}>ÌÛiî°ÊÊ 95 6.14 Tuberculosis (TB) infection Tuberculosis (TB) infection 6.14 Tuberculosis (TB) infection UÊ+Õ>ÌÌ>ÌÛiÊÀiÃÕÌÃÊ>ÞÊLiÊ i«vÕÊÌÊ}Õ`iÊÌiÀ«ÀiÌ>Ì°Ê Ã`iÀÊ Ê VÃÕÌ>ÌÊvÀÊÀiÃÕÌÃÊi>ÀÊÌ iÊÌ Àià `ÊvÀÊ+/Ê«ÃÌÛi\Ê>Ì}i0.35. Serial testing is not advised without ID consultation. UÊ,ÃÊ`ÊÌÊ >ÛiÊ}`ÊÃiÃÌÛÌÞÊÀÊëiVwVÌÞÊvÀÊ`>}ÃÃÊvÊ>VÌÛiÊ/ Active TB infection UÊÊVÌÛiÊÀi«V>ÌÊvÊ/ ÊV>ÕÃ}Ê«Õ>ÀÞÊÀÊiÝÌÀ>«Õ>ÀÞÊÃ}ÃÊÀÊ symptoms UÊÊ wÀi`ÊLÞÊ«ÃÌÛiÊ ÊÃi>À]Ê/ Ê`ÀiVÌÊÌiÃÌÊÀÊVÕÌÕÀi UÊÊ,iµÕÀiÃÊ>ÀLÀiÊÃ>Ì When to suspect active TB disease High-risk individuals UÊÊ,iViÌÊiÝ«ÃÕÀiÊÌÊ>Ê«iÀÃÊÜÌ ÊÜÊ/ ÆÊ ÃÌÀÞÊvÊ>Ê«ÃÌÛiÊ/-/ÆÊ 6ÊviVÌÆÊiVÌÊÀÊiVÌÊ`ÀÕ}ÊÕÃiÆÊvÀi}ÊLÀÌ ÊÀÊÀiÃ`iViÊ Ê>ÊÀi}ÊÊÜ V Ê/ ÊV`iViÊÃÊ } ÆÊÀiÃ`iÌÃÊ>`Êi«ÞiiÃÊvÊ } ÀÃÊV}Ài}>ÌiÊÃiÌÌ}ÃÊ­i°}°Ê«ÀÃîÆÊiLiÀà «ÊÊ>Êi`V>ÞÊ Õ`iÀÃiÀÛi`]ÊÜViÊ««Õ>ÌÆÊ>Ì/ Ê>« >ÊÌ iÀ>«Þ Clinical syndromes UÊÊ Õ} ÊvÊ2 wk duration, with at least one additional symptom, including fever, night sweats, weight loss, or hemoptysis UÊÊÞÊÕiÝ«>i`ÊÀiëÀ>ÌÀÞÊiÃÃÊvÊ2 wk duration in a patient at high risk for TB UÊÊÞÊ«>ÌiÌÊÜÌ Ê6ÊviVÌÊ>`ÊÕiÝ«>i`ÊVÕ} Ê>`ÊviÛiÀÊ UÊÊÞÊ«>ÌiÌÊÊ>Ì/ Ê>« >ÊÌ iÀ>«ÞÊÜÌ ÊÕiÝ«>i`ÊviÛiÀ UÊÊ ÕÌÞ>VµÕÀi`Ê«iÕ>ÊÜ V Ê >ÃÊÌÊ«ÀÛi`Ê>vÌiÀÊÇÊ`>ÞÃÊvÊ appropriate treatment UÊÊV`iÌ>Êw`}ÃÊÊV iÃÌÊÀ>`}À>« ÊÃÕ}}iÃÌÛiÊvÊ/ Ê­iÛiÊvÊÃÞ«ÌÃÊ are minimal or absent) in a patient at high risk for TB Radiographic findings UÊÊ*À>ÀÞÊ/ Ê­vÌiÊÕÀiV}âi`®\Ê >ÊÀiÃiLiÊ *Ê>`ÊÛÛiÊ>ÞÊLiÃÆÊ >ÀÊ>`i«>Ì Þ]Ê«iÕÀ>ÊivvÕÃÃÊ>ÀiÊVÆÊV>ÛÌ>ÌÊÃÊÕV°Ê `}ÃÊvÌiÊÀiÃÛiÊ>vÌiÀÊ£qÓÊÌ Ã°Ê/ iÃiÊ>ÀiÊVÊw`}ÃÊÊ patients with advanced HIV infection and TB. UÊÊ,i>VÌÛ>ÌÊ/ \ÊwÌÀ>ÌiÃÊÜÌ ÊÀÊÜÌ ÕÌÊV>ÛÌ>ÌÊÊÌ iÊÕ««iÀÊLiÃÊÀÊ Ì iÊÃÕ«iÀÀÊÃi}iÌÃÊvÊÌ iÊÜiÀÊLiÃÆÊ >ÀÊ>`i«>Ì ÞÊÃÊÛ>À>LiÆÊ /Ê ÃV>Ê>ÞÊ >ÛiʺÌÀiiLÕ`»Ê>««i>À>Vi° Diagnosis UÊÊ*>ÌiÌÃÊÜÌ ÊV >À>VÌiÀÃÌVÊÃÞ`ÀiÃÊ>`ÊÀ>`}À>« VÊw`}ÃÊà Õ`Ê have expectorated sputum obtained for AFB smear and culture. UÊÊ-iÃÌÛÌÞÊvÊ ÊÃi>ÀÊÊiÝ«iVÌÀ>Ìi`ÊëÕÌÕÊÃÊxäqÇä¯ÆÊÌÊÃÊ ÜiÀÊÊ6³Ê«>ÌiÌðÊÀ}ÊiÝ«iVÌÀ>Ìi`ÊëÕÌÕ]Ê`ÕVi`ÊëÕÌÕ]Ê bronchoscopy have higher sensitivity. AFB culture of lower respiratory tract specimens is considered the gold standard. UÊÊ ÊÃi>ÀÊ>`ÊVÕÌÕÀiÊà Õ`ÊLiÊLÌ>i`ÊÀi}>À`iÃÃÊvÊ 8,Ê findings in patients with high clinical suspicion, HIV infection or other ÕV«ÀÃi`ÊÃÌ>ÌiÃ°Ê 8,ÊÃÊÀ>ÊÊ>««ÀÝ>ÌiÞÊ£ä¯ÊvÊ6 infected patients with pulmonary TB. 96 Infection control ÀLÀiÊ«ÀiV>ÕÌÃÊ>ÀiÊÀiµÕÀi`ÊÊÌ iÊvÜ}ÊV>ÃiÃ\ UÊÊ-ÕëVÊvÊ`Ãi>ÃiÊÃÕvwViÌÞÊ } ÊÌÊÜ>ÀÀ>ÌÊLÌ>}ÊëÕÌÕÊ Ê smear/culture as described above UÊÊ*ÃÌÛiÊ ÊÃi>ÀÊÀÊVÕÌÕÀiÊÕÌÊ`>}ÃÃÊvÊ/ ÊÛÃ°Ê /ÊÃÊVwÀi` 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>Ê>ÌÊi>ÃÌÊÎÊëÕÌÕÊëiViÃÊ­`ÕVi`ÊÀÊiÝ«iVÌÀ>Ìi`®ÊÜ iÊÌÀÞ}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 UÊÊÜÊ>VÌÛiÊ«Õ>ÀÞÊÀÊ>ÀÞ}i>Ê/ Ê­vÊ«>ÌiÌÊÃÊVÕÀÀiÌÞÊÊ/ 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 ëÌ>â>ÌÆÊÊi>ÌiÊ>ÀLÀiÊ«ÀiV>ÕÌÃÊ>ÀiÊÀiµÕÀi`®Ê TREATMENT Active TB UÊ ÊVÃÕÌÊÃÊÃÌÀ}ÞÊÀiVi`i`Ê UÊÊ/ iÀ>«ÞÊà Õ`ÊLiÊÌ>Ìi`ÊvÀÊ«>ÌiÌÃÊÜÌ Ê«ÃÌÛiÊ ÊÃi>ÀÊ>`ÊVV>Ê findings consistent with active TB. UÊÊ/ iÀ>«ÞÊà Õ`ÊLiÊVÃ`iÀi`ÊvÀÊ«>ÌiÌÃÊÜÌ Êi}>ÌÛiÊ ÊÃi>ÀÃÊ when suspicion of TB is high and no alternate diagnosis exists. Multiple specimens should be obtained for culture prior to treatment. UÊÕÀÊ`ÀÕ}ÃÊ>ÀiÊiViÃÃ>ÀÞÊvÀÊÌ>Ê« >ÃiÊ­ÓÊÌ Ã®°Ê UÊÃ>â`Ê­ ®ÊÎääIÊ}Ê­xÊ}É}®Ê*"Ê`>ÞÊ UÊ,v>«Ê­,®ÊÈääIÊ}Ê­£äÊ}É}®Ê*"Ê`>Þ UÊÊ*ÞÀ>â>`iÊ­*<®Ê£äääÊ}Ê*"Ê`>ÞÊ­{äqxxÊ}®Ê",Ê£xääÊ}Ê*"Ê `>ÞÊ­xÈqÇxÊ}®Ê",ÊÓäääIÊ}Ê*"Ê`>ÞÊ­ÇÈqäÊ}®Ê UÊÊ Ì >LÕÌÊ­ ®ÊnääÊ}Ê*"Ê`>ÞÊ­{äqxxÊ}®Ê",Ê£ÓääÊ}Ê*"Ê`>ÞÊ ­xÈqÇxÊ}®Ê",Ê£ÈääIÊ}Ê*"Ê`>ÞÊ­ÇÈqäÊ}®Ê *Max dose regardless of weight. UÊÊ*ÞÀ`ÝiÊÓxÊ}Ê*"Ê`>ÞÊÃÊÀiVi`i`ÊÌÊ«ÀiÛiÌÊ Ê>ÃÃV>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 UÊÊÃ>â`\Ê>ÃÞ«Ì>ÌVÊiiÛ>ÌÊÊ i«>ÌVÊiâÞiÃ]ÊÃiÀÕÃÊ>`Êv>Ì>Ê hepatitis, peripheral neurotoxicity UÊÊ,v>«\ÊÀ>}iÊ`ÃVÀ>ÌÊvÊL`ÞÊyÕ`Ã]Ê i«>ÌÌÝVÌÞ]Ê«ÀÕÀÌÃÊÜÌ Ê or without rash UÊÊ*ÞÀ>â>`i\Ê i«>ÌÌÝVÌÞ]Ê}ÕÌÞÊ«Þ>ÀÌ À>}>]Ê>ÃÞ«Ì>ÌVÊ hyperuricemia, acute gouty arthritis UÊÊ Ì >LÕÌ\ÊÀiÌÀLÕL>ÀÊ>`Ê«iÀ« iÀ>ÊiÕÀÌÃÊÊ U ÌÀ}\ÊL>ÃiiÊ i«>ÌVÊÌÀ>Ã>>ÃiÃ]ÊLÀÕL]Ê>>iÊ« ë >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. ,iviÀiViÃ\Ê /-É -É /-É -É 98 ÊÕ`iiÃÊvÀÊ`>}ÃÃÊvÊ/ \ÊÊÊ,iëÀÊ >ÀiÊi`ÊÓäääƣȣ\£ÎÇÈ° ÊÕ`iiÃÊvÀÊÌÀi>ÌiÌÊvÊ/ \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*«iÀ>VÉÌ>âL>VÌ>IÊ{°xÊ}Ê6Ê+ÈÊ",Ê ivi«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\ÊQâÌÀi>ÊÓÊ}Ê6Ê+nÊ",Ê «ÀyÝ>VÊ{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 iÌÀ>ÊÛiÕÃÊV>Ì iÌiÀÊÊ«>Vi UÊÊ"Ì iÀÊ`Üi}Ê >À`Ü>ÀiÊ UÊÊÜÊVâ>ÌÊÜÌ Ê,- UÊÊ,iViÌÊ­ÜÌ ÊÎÊÌ Ã®ÊÀÊVÕÀÀiÌÊ«À}i`Ê Ã«Ì>â>ÌÊ> 2 weeks UÊÊ/À>ÃviÀÊvÀÊ>ÊÕÀÃ}Ê iÊÀÊÃÕL>VÕÌiÊv>VÌÞ UÊÊiVÌÊ`ÀÕ}ÊÕÃi TREATMENT NOTES UÊÊÀÊ«>ÌiÌÃÊÜÌ ÊÀi>ÊÃÕvwViVÞÊÀÊ>}ÞVÃ`iÊÌiÀ>Vi]Ê>Ê beta-lactam may be combined with a fluoroquinolone IF 2 agents are needed. UÊÊ*ÌiÌ>ÊÃÕÀViÃÊ­i°}°]Ê«iÕ>]Ê«iÀÌÌÃ]ÊiÌV°®Êà Õ`ÊLiÊ considered when selecting therapy. UÊÊ «ÀVÊÌ iÀ>«ÞÊÃÊ" 9Ê>««À«À>ÌiÊÜ iÊVÕÌÕÀiÃÊ>ÀiÊ«i`}Ê (72 hours max). UÊÊ6>VÞVÊà Õ`Ê>ÃÌÊ>Ü>ÞÃÊLiÊÃÌ««i`ÊvÊÊÀiÃÃÌ>ÌÊÀ> positive organisms are recovered in cultures. 99 6.16 Skin, soft-tissue, and bone infections Skin, soft-tissue, and bone infections Cellulitis UÊÊÜ>ÞÃÊiiÛ>ÌiÊ>vviVÌi`ÊiÝÌÀiÌÞ°Ê/Ài>ÌiÌÊv>ÕÀiÊÃÊÀiÊ commonly due to failure to elevate than failure of antibiotics. UÊÊ«ÀÛiiÌÊvÊiÀÞÌ i>ÊV>ÊÌ>iÊ`>ÞÃ]ÊiëiV>ÞÊÊ«>ÌiÌÃÊÜÌ 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) UÊÝVÉV>ÛÕ>>ÌiÊnÇxÊ*"Ê+£Ó OR UÊ i« >iÝÊxääÊ}Ê*"Ê+È OR UÊ* Ê>iÀ}Þ\Ê `>ÞVÊÎääÊ}Ê*"Ê+n Parenteral (moderate to severe disease) UÊ«VÉÃÕL>VÌ>Ê£°xÊ}Ê6Ê+È OR UÊ iv>âÊ£Ê}Ê6Ê+n OR UÊ* Ê>iÀ}Þ\Ê `>ÞVÊÈääÊ}Ê6Ê+n Duration: 5-7 days TREATMENT NOTES UÊÊLiÌ> iÞÌVÊÃÌÀi«ÌVVVÊ>ÀiÊÃÕÃVi«ÌLiÊÌÊ«iV UÊÊ `>ÞVÊÀiÃÃÌ>ViÊÃÊÃiiÊÊ£ÈÎίÊvÊ}ÀÕ«Ê ]Ê ]Ê>`ÊÊÃÌÀi«Ê LÕÌÊÀi>ÃÊÜÊÊ}ÀÕ«ÊÊÃÌÀi«Ê­{qǯ® UÊ ÕÀ>Ì\ÊxÇÊ`>Þà 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 ÝÞVÞViÊ£ääÊ}Ê*"Ê Ê",ÊVÞViÊ£ääÊ}Ê*"Ê OR UÊ `>ÞVÊÎääÊ}Ê*"Ê+n 100 Parenteral (moderate to severe disease) UÊÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä® Duration: 5-7 days TREATMENT NOTES UÊÊ,iÃÃÌ>ViÊÌÊyÕÀµÕiÃÊÊS. aureus is common and develops µÕVÞÆÊÊx¯ÊvÊ,-ÊÃ>ÌiÃÊ>ÀiÊÀiÃÃÌ>ÌÊÌÊyÕÀµÕiÃ°Ê Monotherapy with fluoroquinolones for S. aureus infections is not recommended. UÊÊ,v>«Êà Õ`Ê 6 ,ÊLiÊÕÃi`Ê>ÃÊÌ iÀ>«ÞÊLiV>ÕÃiÊÀiÃÃÌ>ViÊ develops rapidly. UÊÊ/ iÀiÊÃÊÊiÛ`iViÊÌ >ÌÊiâ`ÊÃÊÃÕ«iÀÀÊÌÊ/*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 UÊÊ7Ì ÊLÕ>i]ÊÛiÃViÃ]Ê>`ÊÕViÀÃÊ>vÌiÀÊiÝ«ÃÕÀiÊÌÊÃi>Ü>ÌiÀÊÀÊÀ>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 iÕÌÀ«iV]ÊÃ`ÊÀ}>ÊÌÀ>ë>Ì]Ê>`ÊVÀÀ ÌVÊ«>ÌiÌÃÊ>ÞÊ have cellulitis due to Gram-negative organisms. Consider expanding coverage in these cases. UÊÊvÊiÃV >À]ÊVÃ`iÀÊ>}Û>ÃÛiÊÀ}>ÃÃÊ­ ,]Ê>ëiÀ}ÃÃ]Ê`®°Ê ID consult is recommended. UÊÊ>Ê>`Ê Õ>ÊLÌiÃ\ÊPasteurella multocida should be covered in cat and dog bites. Treat with Amoxicillin/clavulanate 875 mg PO BID ",Ê«VÉÃÕL>VÌ>Ê£°xqÎÊ}Ê6Ê+È°ÊvÊ* Ê>iÀ}Þ\ÊÝyÝ>VÊ 400 mg PO/IV Q24H. Cutaneous abscess UÊÊVÃÊ>`Ê`À>>}iÊ­E ®ÊÃÊÌ iÊ«À>ÀÞÊÌÀi>ÌiÌÊvÀÊ>ÊVÕÌ>iÕÃÊ abscess. UÊÊiÃÃÊÌ >ÌÊ>««i>ÀÊÃÕ«iÀwV>ÊV>ÊvÌiÊ >ÛiÊ>ÃÃV>Ìi`Ê>LÃViÃÃÊ formation that is not clearly appreciated without debridement of the wound or, on occasion, additional imaging. UÊÊÌÊÌ iÊÌiÊvÊE ]Ê>ÊÃ>«iÊà Õ`ÊLiÊLÌ>i`ÊvÀÊVÕÌÕÀiÊ>`Ê sensitivity testing. UÊÊÃÌÊÃÌÕ`iÃÊÌ >ÌÊ >ÛiÊLiiÊ«ÕLà i`ÊÌÊ`>ÌiÊÃÕ}}iÃÌÊÌ >ÌÊ>ÌLÌVÃÊ 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 `>ÞVÊÈääÊ}Ê6Ê+nÊ­vÊ«>ÀiÌiÀ>ÊÌ iÀ>«ÞÊÃÊii`i`® 6.16 Skin, soft-tissue, and bone infections UÊÊ`V>ÌÃÊvÀÊ>ÌVÀL>ÊÌ iÀ>«ÞÊÊ«>ÌiÌÃÊÜÌ ÊVÕÌ>iÕÃÊ >LÃViÃÃiÃ\ UÊÊ-iÛiÀiÊÀÊÀ>«`ÞÊ«À}ÀiÃÃÛiÊviVÌà UÊÊ/ iÊ«ÀiÃiViÊvÊiÝÌiÃÛiÊ>ÃÃV>Ìi`ÊViÕÌà UÊ-}ÃÊ>`ÊÃÞ«ÌÃÊvÊÃÞÃÌiVÊiÃà UÊÃÃV>Ìi`ÊÃi«ÌVÊ« iLÌà UÊÊ >LiÌiÃÊÀÊÌ iÀÊÕiÊÃÕ««ÀiÃà UÊ`Û>Vi`Ê>}i UÊÊV>ÌÊvÊÌ iÊ>LÃViÃÃÊÊ>Ê>Ài>ÊÜ iÀiÊV«iÌiÊ`À>>}iÊÃÊ difficult (e.g. face, genitalia) UÊÊ>VÊvÊÀiëÃiÊÌÊVÃÊ>`Ê`À>>}iÊ>i UÊÊ/ iÀ>«ÞÊà Õ`ÊLiÊ}ÛiÊbefore 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>VÌViÊvÀiµÕiÌÊ >`Ê Þ}iiÊÜÌ ÊÃ>«Ê>`ÊÜ>ÌiÀÊ>`ÉÀÊ alcohol based hand gels, especially after touching infected skin or wound bandages. UÊÊ ÛiÀÊ`À>}ÊÜÕ`ÃÊÜÌ ÊVi>]Ê`ÀÞÊL>`>}ià UÊÊ ÊÌÊà >ÀiÊ«iÀÃ>ÊÌiÃÊ­i°}°ÊÀ>âÀÃÆÊÕÃi`ÊÌÜiÃÊ>`ÊVÌ }Ê before washing) UÊÊ,i}Õ>ÀÊL>Ì } UÊÊÛ`Ê>Êà >Û}Ê UÊÊ>Õ`iÀÊVÌ }]Êà iiÌÃ]ÊÌÜiÃÊÊ ÌÌiÃÌÊÃÕÌ>LiÊÌi«iÀ>ÌÕÀi UÊÊ i>Ê>Ê«iÀÃ>ÊëÀÌ}ÊVÌ }ÉiµÕ«iÌÊ 2. Decontamination of the environment UÊÊ i>Ê } ÊÌÕV Ê>Ài>ÃÊÊÌ iÊL>Ì ÀÊÜÌ Ê>Ê`ÃviVÌ>ÌÊ>VÌÛiÊ against S. aureusÊ`>ÞÊ­i°}°]Ê£ä¯Ê`ÕÌiÊLi>V ®°Ê 3. Topical decolonization (consider if a patient has ≥ 2 episodes in 1 year or other household members develop infection) UÊÊÕ«ÀVÊÌÜViÊ`>ÞÊvÀÊxÊ`>ÞÃÊ>ÞÊLiÊVÃ`iÀi`ÊÊ«>ÌiÌÃÊ ÜÌ Ê`VÕiÌi`ÊiÛ`iViÊvÊ,-Ê>Ã>ÊVâ>ÌÆÊ 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. ,iviÀiViÃ\ /*É-8ÊvÀÊ,-\ÊÊÌiÀÊi`Ê£ÓÆ££Ç\Îän° -ÊÕ`iiÃÊvÀÊÌÀi>ÌiÌÊvÊ,-ÊviVÌÃ\Ê ÊviVÌÊ ÃÊÓ䣣ÆxÓ\£qÎn°Ê Ì}ÞÊvÊÃÕ««ÕÀ>ÌÛiÊViÕÌÃ\Êi`ViÊÓä£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>ÌÊi>ÃÌÊiÊvÊÌ iÊvÜ}\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 UÊÊÝVÉV>ÛÕ>>ÌiÊnÇxÊ}Ê*"Ê OR UÊÊ i« >iÝÊxääÊ}Ê*"Ê+ OR UÊÊ `>ÞVÊÎääÊ}Ê*"Ê/ Ê­VÛiÀÃÊ,-® Parenteral regimens UÊÊ `>ÞVÊÈääÊ}Ê6Ê+nÊ­VÛiÀÃÊ,-® OR 103 6.16 Skin, soft-tissue, and bone infections UÊÊ >Ì }ÊÀÊà ÜiÀ}ÊÜÌ ÊV À iÝ`iÊÀÊ iÝ>V À« iÊ­ÀÊ `ÕÌiÊLi>V ÊL>Ì Ã®ÊiÛiÀÞÊÌ iÀÊ`>ÞÊvÀÊ£ÊÜiiÊÌ iÊÌÜViÊÜiiÞÆÊ do not get these substances into ears or eyes UÊÊ-ÞÃÌiVÊ>ÌLÌVÃÊ>ÀiÊ "/ÊÀiVi`i`ÊÃiÞÊvÀÊ`iVâ>Ì 4. Evaluation of other family members UÊÊÌÀ>v>ÞÊÌÀ>ÃÃÃÊà Õ`ÊLiÊ>ÃÃiÃÃi`Ê>`ÊvÊ«ÀiÃiÌ]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>VÊ£ÓÊ}Ê6Ê+{ OR UÊÊ iv>âÊ£Ê}Ê6Ê+n MODERATE INFECTIONS UÊÊ ÀÌ>«iiÊ£Ê}Ê+Ó{ OR UÊÊQ «ÀyÝ>VIÊxääÊ}Ê*"Ê Ê",Ê «ÀyÝ>VIÊ{ääÊ}Ê6Ê+£ÓRÊ PLUS ONEÊvÊÌ iÊvÜ}ÊQ `>ÞVÊÈääÊ}Ê6Ê+nÉÎääÊ}Ê*"Ê / Ê",ÊiÌÀ`>âiÊxääÊ}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 UÊÊÃÌÀÞÊvÊVâ>ÌÊÀÊviVÌÊÜÌ Ê,- UÊÊ,iViÌÊ­ÜÌ ÊÎÊÌ Ã®ÊÀÊVÕÀÀiÌÊ«À}i`Ê Ã«Ì>â>ÌÊÊÓÊ weeks UÊÊ/À>ÃviÀÊvÀÊ>ÊÕÀÃ}Ê iÊÀÊÃÕL>VÕÌiÊv>VÌÞ UÊÊiVÌÊ`ÀÕ}ÊÕÃi SEVERE INFECTIONS UÊÊ*«iÀVÉÌ>âL>VÌ>Ê{°xÊ}Ê6Ê+È OR UÊÊQ «ÀyÝ>VIÊ{ääÊ}Ê6Ê+nÊ",ÊâÌÀi>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*«iÀ>VÉÌ>âL>VÌ>Ê{°xÊ}Ê6Ê+ÈÊPLUS Vancomycin (see dosing section, p. 150) OR UÊÊQ «ÀyÝ>VIÊ{ääÊ}Ê6Ê+nÊ",ÊâÌÀi>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 UÊÊÊÕÌ`ÃV«>ÀÞÊ>««À>V ÊÌÊ>>}iiÌÊà Õ`ÊVÕ`iÊÜÕ`Ê care consultation, assessment of vascular supply, vascular and/or general surgery consultation and infectious diseases consultation. UÊÊ Ã`iÀÊiVÀÌâ}Êv>ÃVÌÃÊÊ«>ÌiÌÃÊÜ Ê>ÀiÊÃiÛiÀiÞÊ° UÊÊÌLÌVÊÌ iÀ>«ÞÊà Õ`ÊLiÊ>ÀÀÜi`ÊL>Ãi`ÊÊVÕÌÕÀiÊÀiÃÕÌð 104 Diagnosis UÊÊ ÕÌÕÀiÃÊvÊÌ iÊÕViÀÊL>ÃiÊ>vÌiÀÊ`iLÀ`iiÌÊV>Ê i«Ê}Õ`iÊÌ iÀ>«Þ°Ê Biopsy of unexposed bone is NOT recommended. Avoid swabbing non-debrided ulcers or wound drainage. UÊÊ1ViÀÊyÀÊà Õ`ÊLiÊ«ÀLi`ÊV>ÀivÕÞ°ÊvÊLiÊV>ÊLiÊÌÕV i`ÊÜÌ Ê>Ê metal probe then the patient should be treated for osteomyelitis with antibiotics in addition to surgical debridement. UÊÊ*>Ì>ÀÊv>ÃVÌÃÊ>`Ê>Ê`ii«ÊvÌë>ViÊviVÌÊV>ÊLiÊ«ÀiÃiÌ°Ê Consider imaging to look for deep infections. UÊÊ*ÕÌÀ`Ê`ÃV >À}iÊÃÊ`>}ÃÌVÊvÊÌ iÊ«ÀiÃiViÊvÊ>>iÀLið UÊÊÊ,ÊÃÊÀiÊÃiÃÌÛiÊ>`ÊëiVwVÊÌ >ÊÌ iÀÊ`>ÌiÃÊvÀÊ`iÌiVÌÊ of soft-tissue lesions and osteomyelitis. Duration UÊÊ ÕÀ>ÌÊvÊÌÀi>ÌiÌÊÜÊ`i«i`ÊÊÀ>«`ÌÞÊvÊÀiëÃiÊ>`Ê presence of adequate blood supply. UÊÊiÞÊii`Êà ÀÌiÀÊÌÀi>ÌiÌÊÜÌ Ê>`iµÕ>ÌiÊÃÕÀ}V>ÊÌiÀÛiÌÊ ­Çq£äÊ`>ÞÃÊ«ÃÌ«®Ê>`Ê}iÀÊvÀÊÃÌiÞiÌð UÊÊ >}iÊÌÊÀ>ÊÀi}iÊÜ iÊ«>ÌiÌÊÃÊÃÌ>Li° ,iviÀiVi\ -ÊÕ`iiÃÊvÀÊ`>LiÌVÊvÌÊviVÌ°Ê ÊviVÌÊ ÃÊÓä£ÓÆx{\£ÎÓ£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>VÊ£qÓÊ}Ê6Ê+{ OR UÊÊ iv>âÊ£Ê}Ê6Ê+n OR 105 6.16 Skin, soft-tissue, and bone infections Microbiology UÊÊ iÕÌÃÊÜÌ ÕÌÊ«iÊÜÕ`ÊÀÊviVÌi`ÊÕViÀ]Ê>ÌLÌVÊ>Ûi\Ê beta-hemolytic streptococci, S. aureus UÊÊviVÌi`ÊÕViÀ]ÊV ÀVÊÀÊ«ÀiÛÕÃÞÊÌÀi>Ìi`ÊÜÌ Ê>ÌLÌVÃ\ÊS. aureus, beta-hemolytic streptococci, Enterobacteriaceae UÊÊ Ý«ÃÕÀiÊÌÊÃ>}]ÊÜ À«]Ê ÌÊÌÕL\ÊÕÃÕ>ÞÊ«ÞVÀL>]Ê>ÞÊ involve Pseudomonas UÊÊ ÀVÊÜÕ`ÃÊÜÌ Ê«À}i`ÊiÝ«ÃÕÀiÊÌÊ>ÌLÌVÃ\Ê>iÀLVÊÀ> positive cocci (GPC), Diphtheroids, Enterobacteriaceae, other Gramnegative rods (GNR) including Pseudomonas UÊÊ iVÀÃÃÊÀÊ}>}Àii\ÊÝi`Ê>iÀLVÊ* Ê>`Ê ,]Ê>>iÀLià 6.16 Skin, soft-tissue, and bone infections UÊÊ* Ê>iÀ}Þ\Ê `>ÞVÊÈääÊ}Ê6Ê+n OR UÊÊÛÛiiÌÊvÊ >À`Ü>ÀiÊÀÊ,-ÊÃÕëiVÌi`\Ê6>VÞVÊ (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>«iiÊ£Ê}Ê6Ê+Ó{ OR UÊÊ* Ê>iÀ}Þ\ÊQ «ÀyÝ>VÊxääÊ}Ê*"Ê Ê",Ê «ÀyÝ>VÊ{ääÊ}Ê 6Ê+£ÓRÊPLUS Clindamycin 600 mg IV Q8H Patients on broad-spectrum antibiotics at time of surgery or severely ill UÊÊ*«iÀ>VÉÌ>âL>VÌ>ÊΰÎÇxÊ}Ê6Ê+ÈÊ´Ê6>VÞVÊ (see dosing section, p. 150) (if hardware present or MRSA suspected) OR UÊÊ ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole xääÊ}Ê6Ê+nÊ´Ê6>VÞVÊ­ÃiiÊ`Ã}]Ê«°Ê£xä®Ê­vÊ >À`Ü>ÀiÊ present or MRSA suspected) OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUS Q «ÀyÝ>VÊ{ääÊ}Ê6Ê+nÊ",ÊâÌÀi>ÊÓÊ}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV/PO Q8H Deep fascia involvement UÊÊ/Ài>ÌÊ>ÃÊiVÀÌâ}Êv>ÃVÌÃÊ­ÃiiÊÃÕLÃiµÕiÌÊÃiVÌ® TREATMENT NOTES Microbiology UÊÊÜ}ÊVi>Ê«ÀVi`ÕÀiÃÊ­ÊiÌÀÞÊvÊÉ1ÊÌÀ>VÌî UÊÊStaphylococcus aureus UÊÊ-ÌÀi«ÌVVV]Ê}ÀÕ«ÊÊ­iëiV>ÞÊÜÌ Êi>ÀÞÊÃiÌ]ÊÊÇÓÊ ÕÀî UÊÊ >}Õ>Ãii}>ÌÛiÊÃÌ>« ÞVVV UÊÊÜ}ÊVi>VÌ>>Ìi`Ê>`ÊVÌ>>Ìi`Ê«ÀVi`ÕÀiÃÊ­iÌÀÞÊvÊ GI/GU tracts with or without gross contamination) UÊÊ"À}>ÃÃÊ>LÛi UÊÊÀ>i}>ÌÛiÊÀ`à UÊÊ>iÀLiÃÊ­VÃ`iÀÊClostridiaÊë«°ÊÊi>ÀÞÃiÌÊviVÌ]Ê£qÓÊ days) 106 Other management issues UÊÊ>ÞÊ>`ÛV>ÌiÊÌ >ÌÊÊviVÌi`ÊÜÕ`ÃÊLiÊiÝ«Ài`ÊLÌ ÊÌÊ`iLÀ`iÊ and to assess depth of involvement. UÊÊ-Õ«iÀwV>ÊviVÌÃÊ>ÞÊLiÊ>`iµÕ>ÌiÞÊÌÀi>Ìi`ÊÜÌ Ê`iLÀ`iiÌÊ alone. UÊÊ ii«iÀÊviVÌÃÊ­ViÕÌÃ]Ê«>VÕÌîÊii`Ê>`ÕVÌÛiÊ>ÌLÌVð UÊÊviVÌÃÊÌ >ÌÊiÝÌi`ÊÌÊÌ iÊv>ÃV>Êà Õ`ÊLiÊ>>}i`Ê>ÃÊiVÀÌâ}Ê fasciitis. UÊÊ*>ÌiÌÃÊÜÌ Ê Þ«ÌiÃÊà Õ`Ê >ÛiÊÌ iÀÊÜÕ`ÃÊiÝ«Ài`ÊiÛiÊvÊ 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>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUSÊQ*«iÀ>VÉÊ Ì>âL>VÌ>ÊΰÎÇxÊ}Ê6Ê+ÈÊ",Ê ivi«iÊ£Ê}Ê6Ê+nRÊPLUS Clindamycin 600-900 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUS Q «ÀyÝ>VÊ{ääÊ}Ê6Ê+nÊ´ÊiÌ>VÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê «°Ê£{È®RÊPLUS Clindamycin 600-900 mg IV Q8H TREATMENT NOTES Conventional nomenclature and microbiology Pyomyositis UÊÊS. aureus most commonly UÊÊ ÃÌÀ`>ÊÞiVÀÃÃÊqÊClostridia spp. (esp. C. perfringens) UÊÊÀÕ«ÊÊÃÌÀi«ÌVVV>ÊÞiVÀÃà 107 6.16 Skin, soft-tissue, and bone infections UÊÊiiÀ>Þ]Êi«ÀVÊÕÃiÊvÊ6>VÞVÊÃÊÌÊ`V>Ìi`ÊLiV>ÕÃiÊÌ iÊ percentage of SSIs caused by MRSA is low at Johns Hopkins Hospital ­£äqÓ䯮 Risk factors for MRSA UÊÃÌÀÞÊvÊVâ>ÌÊÀÊviVÌÊÜÌ Ê,- UÊÊ,iViÌÊ­ÜÌ ÊÎÊÌ Ã®ÊÀÊVÕÀÀiÌÊ«À}i`Ê Ã«Ì>â>ÌÊÓÊ weeks UÊÊ/À>ÃviÀÊvÀÊ>ÊÕÀÃ}Ê iÊÀÊÃÕL>VÕÌiÊv>VÌÞ UÊÊiVÌÊ`ÀÕ}ÊÕÃi 6.16 Skin, soft-tissue, and bone infections Fasciitis UÊÊ/Þ«iÊ£ÊqÊ*ÞVÀL>ÊviVÌÃÊÜÌ Ê>>iÀLiÃ]ÊÃÌÀi«ÌVVVÊ>`Ê Gram-negative rods (Fournier’s gangrene is a type 1 necrotizing fasciitis of the perineum) UÊÊ/Þ«iÊÓÊqÊÀÕ«ÊÊÃÌÀi«ÌVVVÊ«Ài`>Ìi UÊÊ >ÃiÃÊvÊv>ÃVÌÃÊV>ÕÃi`ÊLÞÊVÕÌÞ>ÃÃV>Ìi`Ê,-ÊÃÌÀ>ÃÊ >ÛiÊ been reported Diagnosis UÊÊ >ÊLiÊ`vwVÕÌÊqÊ}>ÃÊ«À`ÕVÌÊÃÊÌÊÕÛiÀÃ>Ê>`ÊÃÊ}iiÀ>ÞÊ absent in streptococcal diseases. UÊÊ>Ì>Ê } Ê`iÝÊvÊÃÕëVÊÜ i\ UÊÊ*>ÌiÌÃÊ>ÀiÊÛiÀÞÊÊvÀÊViÕÌÃÊ­ Þ«ÌiÃ]ÊÌÝVÊ>««i>À>Vi® UÊÊ*>ÊÕÌÊvÊ«À«ÀÌÊÌÊ« ÞÃV>Êw`}à UÊÊiÃÌ iÃ>ÊÛiÀÊ>vviVÌi`Ê>Ài> UÊÊ,ÃÊv>VÌÀÃÊÃÕV Ê>ÃÊ`>LiÌiÃ]ÊÀiViÌÊÃÕÀ}iÀÞÊÀÊLiÃÌÞ UÊÊ`}ÃÊÃÕV Ê>ÃÊÃÊiVÀÃÃÊÀÊLÕ>i UÊÊ*ÕÌÀ`Ê`ÃV >À}iÊÜÌ ÊÌ ]ʺ`à Ü>ÌiÀ»Ê«Õà UÊÊ /ÊÃV>ÊV>Ê i«ÊÜÌ Ê`>}ÃÃÊLÕÌÊvÊÃÕëVÊÃÊ`iÀ>ÌiÊÌÊ } ]Ê surgical exploration is the preferred diagnostic test. DO NOT delay surgical intervention to obtain CT. ,iviÀiVi\ -Ê}Õ`iiÃÊvÀÊ--/\Ê ÊviVÌÊ ÃÊÓääxÆÊ{£\£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>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®Ê±ÊQ ivÌÀ>ÝiÊÓÊ}Ê+£ÓÊOR ivi«iÊÓÊ}Ê6Ê+nRÊ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®Ê± Ciprofloxacin 400 mg IV Q8H UÊ >ÀÀÜÊÌ iÀ>«ÞÊL>Ãi`ÊÊVÕÌÕÀiÊÀiÃÕÌð TREATMENT NOTES Microbiology UÊÀ>«ÃÌÛiÊVVVÊÊÇx¯ÊvÊV>ÃiÃÊÜÌ Ê>ÀÌÞÊS. aureus UÊÀ>i}>ÌÛiÊÀ`ÃÊÊH£ä¯ 108 Duration UÊ «`ÕÀ>Ê>LÃViÃÃÊÜÌ ÕÌÊÃÌiÞiÌÃ\Ê{qÈÊÜiiÃÊ UÊ6iÀÌiLÀ>ÊÃÌiÞiÌÃʱÊi«`ÕÀ>Ê>LÃViÃÃ\ÊÈq£ÓÊÜiiÃÊ UÊÊÊ«>ÌiÌÃÊÜÌ Ê >À`Ü>ÀiÊ«ÀiÃiÌÊ«À}i`ÊÀ>ÊÃÕ««ÀiÃÃÛiÊÌ iÀ>«ÞÊ ÃÊ}iiÀ>ÞÊÀiµÕÀi`Ê>vÌiÀÊV«iÌÊvÊ6Ê>ÌLÌVÃÆÊÌ iÃiÊ`iVÃÃÊ should be made in consultation with infectious diseases. ,iviÀiViÃ\Ê -«>Êi«`ÕÀ>Ê>LÃViÃÃ\Ê Ê }ÊÊi`ÊÓääÈÆÎxx\Óä£ÓqÓä°Ê -«>Êi«`ÕÀ>Ê>LÃViÃÃ\Ê+ÊÊi`ÊÓäänÆ£ä£\£q£Ó°Ê 109 6.16 Skin, soft-tissue, and bone infections Management UÊÊ"LÌ>ÊÌÜÊÃiÌÃÊvÊL`ÊVÕÌÕÀiÃ]Ê -,]Ê>`Ê ,*Ê«ÀÀÊÌÊÃÌ>ÀÌ}Ê antibiotic therapy. UÊÊÃÌÊÌÀ>ÛiÕÃÊ`ÀÕ}ÊÕÃiÀÃÊ>`Ê«>ÌiÌÃÊÜÌ ÕÌÊÃ}wV>ÌÊ co-morbidities do not require empiric coverage for Gram-negative rods. UÊÊ «ÀVÊÀ>i}>ÌÛiÊVÛiÀ>}iÊà Õ`ÊLiÊÕÃi`ÊÊ«>ÌiÌÃÊÜÌ Ê`>LiÌiÃ]Ê hardware in place or recent surgery, and recurrent urinary tract infections. UÊ,ÊÜÌ ÊVÌÀ>ÃÌÊÃÊÌ iÊ>}}ÊiÌ `ÊvÊV Vi° UÊÊvÊL`ÊVÕÌÕÀiÃÊ>ÀiÊi}>ÌÛiÊ /Ê}Õ`i`Êii`iÊL«ÃÞÉ>ëÀ>ÌÊ should be obtained for Gram stain and cultures. UÊÊ iÀ}iÌÊÃÕÀ}V>ÊVÃÕÌ>ÌÊÃÊÀiVi`i`ÊvÀÊ«>ÌiÌÃÊÜÌ Ê signs and symptoms of spinal cord compromise. UÊÊ-ÕÀ}V>ÊÌ iÀ>«ÞÊÃÊ«ÀiviÀÀi`ÊÊ>ÞÊV>ÃiÃÊvÊi«`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*>ÌiÌÃÊà Õ`Ê >ÛiÊvÀiµÕiÌÊ>ÃÃiÃÃiÌÊvÊiÕÀ}VÊvÕVÌ]Ê particularly at the time of initial presentation. UÊÊÊ«>ÌiÌÃÊÀiµÕÀiÊÌÀ}ÊvÀÊ>`iµÕ>ÌiÊÀiëÃiÊÌ ÀÕ} ÕÌÊÌ iÊ ÌÀi>ÌiÌÊVÕÀÃiÆÊ ÊvÜÊÕ«Ê } ÞÊÀiVi`i`°Ê 110 Bacterial urinary tract infections (UTI) Empiric treatment ÊÌÀi>ÌiÌÊÕiÃÃÊÌ iÊ«>ÌiÌÊÃ\ UÊ*Ài}>ÌÊ UÊÊLÕÌÊÌÊÕ`iÀ}Ê>ÊÕÀ}VÊ«ÀVi`ÕÀiÊ UÊ*ÃÌÊÀi>ÊÌÀ>ë>Ì UÊ iÕÌÀ«iV 1V«V>Ìi`\ UÊÊ ÌÀvÕÀ>ÌÊ­>VÀL`®) 100 mg PO Q12H for xÊ`>ÞÃÊ­ "/ÊÊ«>ÌiÌÃÊÜÌ Ê À ÊxäÊÉ® OR UÊÊ i« >iÝÊxääÊ}Ê*"Ê+ÈÊvÀÊxÊ`>ÞÃÊ OR UÊÊ iv«`ÝiÊ£ääÊ}Ê*"Ê+£ÓÊvÀÊxÊ`>ÞÃÊ OR UÊÊ iv`ÀÊÎääÊ}Ê*"Ê+£ÓÊvÀÊxÊ`>ÞÃÊ OR UÊÊÊ/*É-8Ê£Ê -ÊÌ>LÊ*"Ê+£ÓÊvÀÊÎÊ`>Þà OR UÊÊ6Ê«Ì\Ê iv>âÊ£Ê}Ê6Ê+nÊvÀÊÎÊ`>Þà «V>Ìi`\ UÊÊ->iÊÀi}iÃÊ>ÃÊ>LÛiÊiÝVi«ÌÊ`ÕÀ>ÌÊÃÊ Çq£{Ê`>Þà 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/ÃÊÊiÊ>ÀiÊÌÀ>`Ì>ÞÊVÃ`iÀi`ÊV«V>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>«ÞÊÃÊ«ÀiviÀÀi`Ê>`Êà Õ`ÊLiÊ}ÛiÊÕiÃÃÊ patient is unable to tolerate oral therapy UÊÊvÊ6ÊLiÌ>>VÌ>ÃÊ>ÀiÊÕÃi`Êi«ÀV>ÞÊvÀÊÎÊ`>ÞÃ]ÊÊ additional therapy is needed for uncomplicated cystitis UÊÊvÊ6ÊLiÌ>>VÌ>ÃÊ>ÀiÊÕÃi`Êi«ÀV>ÞÊvÀÊÎÊ`>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>ÊÃvÞVÊV>ÊLiÊÕÃi`ÊvÊÃÕÃVi«ÌLiÊvÀÊÀ> negative MDR organisms (susceptibilities must be requested) Notes UÊÊ"LÌ>}ÊÀÕÌiÊVÕÌÕÀiÃÊÊ>ÃÞ«Ì>ÌVÊ«>ÌiÌÃÊÃÊ not recommended UÊÊÌLÌVÃÊ`ÊÌÊ`iVÀi>ÃiÊ>ÃÞ«Ì>ÌVÊL>VÌiÀÕÀ>ÊÀÊ prevent subsequent development of UTIs UÊÊÊ/ iÊ«ÀiÛ>iViÊvÊ>ÃÞ«Ì>ÌVÊL>VÌiÀÕÀ>ÊÃÊ } \Ê£¯x¯ÊÊ«Àii«>ÕÃ>ÊÜi]Êί¯ÊÊ «ÃÌi«>ÕÃ>ÊÜi]Ê{ä¯xä¯ÊÊ}ÌiÀÊV>ÀiÊ ÀiÃ`iÌÃÊ>`ʯÓǯÊÊÜiÊÜÌ Ê`>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«ÌLÌÞÊ­Ç£¯®°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 ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ OR UÊÊ ÀÌ>«iiÊ£Ê}Ê6Ê+Ó{Ê­vÊ ÃÌÀÞÊvÊ - ® OR UÊÊ* Ê>iÀ}Þ\ÊâÌÀi>Ê£Ê}Ê6Ê+nÊ",Ê Gentamicin (see dosing section, p. 147) UÊÊ ÕÀ>Ì\ÊÇq£{Ê`>Þà Hospitalized > 48H UÊÊ ivi«iÊ£Ê}Ê6Ê+n OR UÊÊ* Ê>iÀ}Þ\ÊâÌÀi>Ê£Ê}Ê6Ê+nÊ",Ê Gentamicin (see dosing section, p. 147) UÊ ÕÀ>Ì\ÊÇq£{Ê`>Þà UÊÊ ivi«iÊ£Ê}Ê6Ê+n OR UÊÊ* Ê>iÀ}Þ\ÊâÌÀi>Ê£Ê}Ê6Ê+nÊ´Ê Gentamicin (see dosing section, p. 147) UÊ ÕÀ>Ì\ÊÇq£äÊ`>Þà 6.17 Urinary tract infections UÊÊ"À>Ê «ÀyÝ>VÊÀÊ/*É-8Ê >ÛiÊiÝViiÌÊ bioavailability and should be used as step-down therapy if organism is susceptible UÊÊ"À>ÊLiÌ>>VÌ>ÃÊà Õ`ÊÌÊLiÊÕÃi`ÊvÀÊL>VÌiÀi>Ê due to inadequate blood concentrations UÊÊ ÕÀ>ÌÊvÊi«ÀVÊ6ÊÌ iÀ>«ÞÊà Õ`ÊLiÊVÕÌi`Ê towards total duration of therapy Notes UÊÊ"À>ÊÃÌi«`ÜÊÌ iÀ>«ÞÊà Õ`ÊLiÊÕÃi`ÊvÊÀ}>ÃÊÃÊ susceptible UÊÊ ÕÀ>ÌÊvÊi«ÀVÊ6ÊÌ iÀ>«ÞÊà Õ`ÊLiÊVÕÌi`Ê towards total duration of therapy "À>ÊÃÌi«`ÜÊÌ iÀ>«ÞÊvÊÀ}>ÃÊÃÊÃÕÃVi«ÌLi\ UÊ «ÀyÝ>VÊxääÊ}Ê*"Ê+£ÓÊvÀÊÇÊ`>ÞÃÊ UÊ/*É-8Ê£Ê -Ê*"Ê+£ÓÊvÀÊÇ£äÊ`>ÞÃÊ UÊ iv«`ÝiÊ{ääÊ}Ê*"Ê+£ÓÊvÀÊ£{Ê`>ÞÃÊ UÊÊ"À>ÊÃvÞVÊV>ÊLiÊVÃ`iÀi`ÊvÊÃÕÃVi«ÌLiÊvÀÊ 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 Õ`ÊLiÊVi>i`ÊÜÌ 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 UÊÊ1À>ÞÃÃÊ>`ÊÕÀiÊVÕÌÕÀiÃÊÕÃÌÊLiÊÌiÀ«ÀiÌi`ÊÌ}iÌ iÀÊÊ context of symptoms UÊUrinalysis/microscopy: UÊÊ «ÃÌV UÊ ÌÀÌiÃÊ`V>ÌiÊL>VÌiÀ>ÊÊÌ iÊÕÀi UÊiÕVÞÌiÊiÃÌiÀ>ÃiÊ`V>ÌiÃÊÜ ÌiÊL`ÊViÃÊÊÌ iÊÕÀi UÊÊ >VÌiÀ>\Ê«ÀiÃiViÊvÊL>VÌiÀ>ÊÊÕÀ>ÞÃÃÊà Õ`ÊLiÊ interpreted with caution and is not generally useful UÊÊ*ÞÕÀ>Ê­ÀiÊÃiÃÌÛiÊÌ >ÊiÕVÞÌiÊiÃÌiÀ>Ãi®\Ê£äÊ7 É «vÊÀÊ >27 WBC/microliter UÊ1ÀiÊVÕÌÕÀiÃ\ UÊÊvÊ1ÉÊÃÊi}>ÌÛiÊvÀÊ«ÞÕÀ>]Ê«ÃÌÛiÊVÕÌÕÀiÃÊ>ÀiÊiÞÊ contamination UÊÊÃÌÊ«>ÌiÌÃÊÜÌ Ê1/ÊÜÊ >ÛiÊ100,000 colonies of a uropathogen. Situations in which lower colony counts may be Ã}wV>ÌÊVÕ`i\Ê«>ÌiÌÃÊÜ Ê>ÀiÊ>Ài>`ÞÊÊ>ÌLÌVÃÊ>ÌÊÌ iÊ time of culture, symptomatic young women, suprapubic aspiration, and men with pyuria. TREATMENT NOTES UÊÊ*ÞÕÀ>ÊiÌ iÀÊÊÌ iÊÃiÌÌ}ÊvÊi}>ÌÛiÊÕÀiÊVÕÌÕÀiÃÊÀÊÊ«>ÌiÌÃÊ with asymptomatic bacteriuria usually requires no treatment. If pyuria persists consider other causes (e.g. interstitial nephritis or cystitis, fastidious organisms). UÊÊÜÕ«ÊÕÀiÊVÕÌÕÀiÃÊÀÊ1ÉÊ>ÀiÊÞÊÜ>ÀÀ>Ìi`ÊvÀÊ}}Ê symptoms. They should NOT be acquired routinely to monitor response to therapy. UÊÊ-iiÊ«°Ê££{ÊvÀÊ`ÃVÕÃÃÊvÊÌÀi>ÌiÌÊ«ÌÃÊvÀÊ6, 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 ÊÌÀi>ÌiÌÊÕiÃÃÊÌ iÊ«>ÌiÌÊÃ\ UÊ*Ài}>ÌÊ UÊLÕÌÊÌÊÕ`iÀ}Ê>ÊÕÀ}VÊ«ÀVi`ÕÀiÊ UÊ*ÃÌÊÀi>ÊÌÀ>ë>Ì "/ \ÊLÌ>}Ê UÊ iÕÌÀ«iV routine cultures in Antibiotics do not decrease asymptomatic asymptomatic patients bacteriuria or prevent subsequent development is not recommended of UTI Signs and symptoms CatheterUÊÊ,iÛiÊV>Ì iÌiÀÊÜ iÊ«ÃÃLi associated UTI (fever with no other Patient stable with no evidence of upper tract source is the most (CA-UTI) `Ãi>Ãi\ VÆÊ«>ÌiÌÃÊ>ÞÊ UÊÊvÊV>Ì iÌiÀÊÀiÛi`]ÊVÃ`iÀÊLÃiÀÛ>ÌÊ>i also have suprapubic OR or flank pain) UÊÊ ÀÌ>«iiÊ£Ê}Ê6Ê+Ó{ AND pyuria (10 OR WBC/hpf) UÊÊ ivÌÀ>ÝiÊ£Ê}Ê6Ê+Ó{ AND positive urine OR culture 1,000 UÊÊ «ÀyÝ>VÊxääÊ}Ê*"Ê ÊÀÊ{ääÊ}Ê6Ê+£ÓÊ CFU/mL (see (avoid in pregnancy and in patients with prior information below exposure to quinolones) regarding significant UÊ ÕÀ>Ì\ÊÃiiÊLiÜ colony counts) Patient severely ill, with evidence of upper tract disease, or hospitalized {nÊ\ UÊÊ ivi«iÊ£Ê}Ê6Ê+nÊ OR UÊ* Ê>iÀ}Þ\ÊâÌÀi>Ê£Ê}Ê6Ê+n UÊ ÕÀ>Ì\ÊÃiiÊLiÜ Urosepsis in a SIRS with urinary UÊ*«iÀ>VÉÌ>âL>VÌ>ÊΰÎÇxÊ}Ê6Ê+È source and patient with If prior urine culture data are available, tailor nephrostomy tubes nephrostomy therapy based on those results tubes DIAGNOSIS -«iViÊViVÌ\ 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. -Þ«ÌÃ\ Catheterized patients usually lack typical UTI symptoms. -Þ«ÌÃÊV«>ÌLiÊÜÌ Ê 1/ÊVÕ`i\ UÊÊ iÜÊviÛiÀÊÀÊÀ}ÀÃÊÜÌ ÊÊÌ iÀÊÃÕÀVi UÊÊ iÜÊÃiÌÊ`iÀÕ]Ê>>Ãi]ÊiÌ >À}ÞÊÜÌ ÊÊÌ iÀÊÃÕÀVi UÊÊ 6ÊÌi`iÀiÃÃ]Êy>Ê«>]Ê«iÛVÊ`ÃVvÀÌ UÊÊVÕÌiÊ i>ÌÕÀ> Interpretation of the urinalysis (U/A) and urine culture UÊÊ*ÞÕÀ>\ÊÊÌ iÊ«ÀiÃiViÊvÊ>ÊV>Ì iÌiÀ]Ê«ÞÕÀ>Ê`iÃÊÌÊVÀÀi>ÌiÊÜÌ 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*ÃÌÛiÊÕÀiÊVÕÌÕÀi\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`>ÞÃÊvÊ«À«ÌÊÀiÃÕÌÊvÊÃÞ«Ìà UÊÊ£äq£{Ê`>ÞÃÊvÊ`i>Þi`ÊÀiëÃi UÊÊÎÊ`>ÞÃÊvÊV>Ì iÌiÀÊÀiÛi`ÊÊvi>iÊ«>ÌiÌÊ 65 years with lower tract infection. TREATMENT NOTES UÊÊ,iÛiÊÌ iÊV>Ì iÌiÀÊÜ iiÛiÀÊ«ÃÃLi UÊÊ,i«>ViÊV>Ì iÌiÀÃÊÌ >ÌÊ >ÛiÊLiiÊÊ 2 weeks if still indicated UÊÊ*À« Þ>VÌVÊ>ÌLÌVÃÊ>ÌÊÌ iÊÌiÊvÊV>Ì iÌiÀÊÀiÛ>ÊÀÊÀi«>ViiÌÊ are NOT recommended due to low incidence of complications and concern for development of resistance. UÊÊ >Ì iÌiÀÊÀÀ}>ÌÊà Õ`ÊÌÊLiÊÕÃi`ÊÀÕÌiÞ Treatment of Enterococci UÊÊÊÃÌÊ>ÊE. faecalis isolates are susceptible to Amoxicillin 500 mg PO TID OR Ampicillin 1 g IV Q6H and should be treated with these >}iÌðÊÀÊ«>ÌiÌÃÊÜÌ Ê* Ê>iÀ}Þ\Ê ÌÀvÕÀ>ÌÊ­Ê>VÀL`®) £ääÊ}Ê*"Ê+£ÓÊ­`Ê "/ÊÕÃiÊÊ«>ÌiÌÃÊÜÌ Ê À ÊÊxäÊÉ®°Ê UÊE. faecium (often Vancomycin resistant) UÊÊ ÌÀvÕÀ>ÌÊ­>VÀL`®) 100 mg PO Q12H if susceptible (do NOT use in patients with CrCl 50 mL/min). UÊ/iÌÀ>VÞViÊxääÊ}Ê*"Ê+ÈÊvÊÃÕÃVi«ÌLi UÊÊÃvÞVÊÎÊ}Ê*"ÊViÊ­vÊvi>iÊÜÌ ÕÌÊV>Ì iÌiÀÊÀÊV>Ì iÌiÀÊ ÃÊÀiÛi`ÆÊ>ÃÊÌ iÊVÀÊ>LÊvÀÊÃÕÃVi«ÌLÌÞ® UÊÊiâ`ÊÈääÊ}Ê*"Ê Ê",ÊÃvÞVÊÎÊ}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«`Ýi]Êiâ`Ê­Î䯮]Ê ÝÞVÞViÊ ­Óqxx¯®]Ê ivÌÀ>Ýi]Ê/iÌÀ>VÞViÊ­HÈ䯮ÊÊ Poor (<30%): Azithromycin, Clindamycin, Moxifloxacin, Oxacillin, Tigecycline, Micafungin, Posaconazole, Voriconazole ,iviÀiViÃ\ *ÞÕÀ>Ê>`ÊÕÀ>ÀÞÊV>Ì iÌiÀÃ\ÊÀV ÊÌÊi`ÊÓäääÆ£Èä­x®\ÈÇÎÇÇ° IDSA Guidelines for treatment of uncomplicated acute bacterial cystitis and «Þii« ÀÌÃÊÊÜi\Ê ÊviVÌÊ ÃÊ£ÆÓ\Ç{x° -ÊÕ`iiÃÊvÀÊÌÀi>ÌiÌÊvÊ 1/\Ê ÊviVÌÊ ÃÊÓä£äÆxä\ÈÓxqÈΰ 114 Oropharyngeal disease (thrush) Initial treatment UÊÊ ÌÀ>âiÊ£äÊ}ÊÌÀV iÊxÊÌiÃÊ>Ê`>Þ OR UÊ ÞÃÌ>ÌÊÃÕëiÃÊxää]äääÊÕÌÃÉxÊ{ÊÌiÃÊ>Ê`>Þ Recurrent or intractable disease UÊÕV>âiÊ£ääqÓääÊ}Ê*"ÊViÊ`>Þ Duration: xq£äÊ`>Þà NOTE: If refractory to Fluconazole consider fungal culture and susceptibilities Esophageal candidiasis Initial treatment UÊÕV>âiÊÓääq{ääÊ}Ê6É*"ÊViÊ`>Þ Duration: £{qÓ£Ê`>Þà Relapse UÊÊÕV>âiÊ{ääqnääÊ}Ê6É*"ÊViÊ`>Þ Refractory to Fluconazole 800 mg daily (fungal culture and susceptibilities are recommended) UÊV>vÕ}Ê£xäÊ}Ê6ÊViÊ`>Þ OR UÊ« ÌiÀVÊ Êä°Îqä°ÇÊ}É}Ê6ÊViÊ`>Þ OR UÊ"À>ÊÌ iÀ>«Þ\ÊÌÀ>V>âiÊÀ>ÊÃÕÌÊÓääÊ}Ê`>Þ Duration: £{qÓ£Ê`>Þà Candiduria UÊ1À>ÀÞÊV>Ì iÌiÀÊÀiÛ>ÊÜÊÀiÃÛiÊÌ iÊV>``ÕÀ>ÊÊ{ä¯ÊvÊV>Ãið TREATMENT Asymptomatic cystitis UÊ/ iÀ>«ÞÊÌÊÕÃÕ>ÞÊ`V>Ìi` UÊÊ Ã`iÀÊÊÌ iÊvÜ}ÊV`ÌÃÊ­ÃiiÊÀi}iÃÊÕ`iÀÊ ºÃÞ«Ì>ÌVÊVÞÃÌÌû®\ UÊ iÕÌÀ«iVÊ«>ÌiÌÃÊ UÊ,i>ÊÌÀ>ë>Ì UÊ1À>ÀÞÊLÃÌÀÕVÌÊÀÊ>LÀ>Ê1ÊÌÀ>VÌ UÊ7 iÊÀiVÛiÀi`ÊÊÕÀiÊ«ÀÀÊÌÊÕÀ}VÊ«ÀVi`ÕÀià 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 UÊÊÕV>âiÊÓääÊ}Ê6É*"ÊViÊ`>ÞÊ Duration:ÊÇq£{Ê`>Þà Fluconazole-resistant organism suspected or confirmed UÊ« ÌiÀVÊ Êä°Îä°ÈÊ}É}Ê6ÊViÊ`>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 UÊÕV>âiÊÓääq{ääÊ}Ê6É*"ÊViÊ`>ÞÊ Duration: 14 days Fluconazole-resistant organism suspected or confirmed UÊ« ÌiÀVÊ Êä°xqä°ÇÊ}É}Ê6ÊViÊ`>ÞÊ OR UÊV>vÕ}Ê£ääÊ}Ê6ÊViÊ`>ÞÊ Duration: 14 days TREATMENT NOTES UÊ,iÛiÊÕÀ>ÀÞÊV>Ì iÌiÀÊvÊ«ÃÃLi° UÊÊ/ iÀ>«ÞÊvÊV>``ÕÀ>ÊÊÌ iÊiÕÌÀ«iV]Ê 1ÊV>Ì iÌiÀâi`Ê patient has not been shown to be beneficial and promotes resistance. UÊÊ Ãi®, Voriconazole, Itraconazole, and Posaconazole are not recommended due to poor penetration into the urinary tract. UÊÊV>vÕ}Ê«iiÌÀ>ÌiÃÊ«ÀÞÊÊÌ iÊÕÀi]ÊLÕÌÊ`iÃÊ«iiÌÀ>ÌiÊÌÊ renal tissue. UÊ« ÌiÀVÊ ÊL>``iÀÊÜ>à iÃÊ>ÀiÊÌÊÀiVi`i`° Candida vaginitis Initial Therapy UÊÕV>âiÊ£xäÊ}Ê*"Ê8Ê£Ê`ÃiÊ OR UÊV>âiÊÓ¯ÊVÀi>ÊxÊ}ÊÌÀ>Û>}>ÞÊViÊ`>ÞÊ8ÊÇÊ`>Þà Recurrent (> 4 episodes/year of symptomatic infection) UÊÊÕV>âiÊ£xäÊ}Ê*"Ê+ÇÓÊ8ÊÎÊ`ÃiÃ]ÊÌ iÊ£xäÊ}Ê>ÊÜiiÊ8Ê 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 UÊÕV>âiÊnääÊ}Ê6É*"Ê8Ê£Ê`Ãi]ÊÌ iÊ{ääÊ}Ê6É*"ÊViÊ`>Þ Patients who are NOT clinically stable due to Candidemia or have received prior long-term azole therapy UÊV>vÕ}Ê£ääÊ}Ê6ÊViÊ`>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 UÊÕV>âiÊnääÊ}Ê6É*"Ê8Ê£Ê`Ãi]ÊÌ iÊ{ääÊ}Ê6É*"ÊViÊ`>Þ Patients who are NOT clinically stable due to Candidemia or have received prior long-term azole therapy UÊV>vÕ}Ê£ääÊ}Ê6ÊViÊ`>ÞÊ Patients should be transitioned to Fluconazole once stable. Candida glabrata UÊV>vÕ}Ê£ääÊ}Ê6ÊViÊ`>Þ OR UÊÊÕV>âiÊnääÊ}Ê6É*"Ê8Ê£Ê`Ãi]ÊÌ iÊ{ääÊ}Ê6É*"ÊViÊ`>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 UÊV>vÕ}Ê£ääÊ}Ê6ÊViÊ`>ÞÊ Fluconazole should NEVER be used to treat infections due to C. krusei because the organism has intrinsic resistance to Fluconazole. This iV >ÃÊvÊÀiÃÃÌ>ViÊÃÊÌÊà >Ài`ÊÜÌ Ê6ÀV>âiÆÊÌ iÀivÀi]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 UÊÕV>âiÊnääÊ}Ê6É*"Ê8Ê£Ê`Ãi]ÊÌ iÊ{ääÊ}Ê6É*"ÊViÊ`>Þ C. lusitaniaeÊÃÊÀiÃÃÌ>ÌÊÌÊ« ÌiÀVÊ ÊÊ>««ÀÝ>ÌiÞÊÓä¯ÊvÊ cases. Candida parapsilosis UÊÕV>âiÊnääÊ}Ê6É*"Ê8Ê£Ê`Ãi]ÊÌ iÊ{ääÊ}Ê6É*"ÊViÊ`>Þ Fluconazole-intermediate isolate UÊÕV>âiÊnääÊ}Ê6É*"ÊViÊ`>Þ Fluconazole-resistant isolate UÊV>vÕ}Ê£ääÊ}Ê6ÊViÊ`>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 ÃÊ >ÃÊi`ÊÌÊVViÀÊÌ >ÌÊÃiÊviVÌÃÊÜÌ ÊC. parapsilosis may not respond well to echinocandins. Candida tropicalis UÊÕV>âiÊnääÊ}Ê6É*"Ê8Ê£Ê`Ãi]ÊÌ iÊ{ääÊ}Ê6É*"ÊViÊ`>Þ Fluconazole-intermediate isolate UÊÕV>âiÊnääÊ}Ê6É*"ÊViÊ`>Þ Fluconazole-resistant isolate UÊV>vÕ}Ê£ääÊ}Ê6ÊViÊ`>Þ TREATMENT NOTES Amphotericin B use in Candidemia UÊÊ« ÌiÀVÊ ÊÃÊ } ÞÊivviVÌÛiÊ>}>ÃÌÊ>ÊCandida spp. except for C. lusitaniaeÆÊ ÜiÛiÀ]Ê>âiÃÊ>`ÊiV V>`ÃÊ>ÀiÊv>ÛÀi`ÊÊ susceptible strains over Amphotericin B products due to toxicity. Doses for Candidemia UÊ« ÌiÀVÊ Êä°ÇÊ}É}Ê6ÊViÊ`>Þ OR UÊÊ Ãi® 3 mg/kg IV once daily (if patient cannot tolerate conventional Amphotericin B) Duration UÊÊ£{Ê`>ÞÃÊvÜ}Ê`VÕiÌi`ÊVi>À>ViÊvÊL`ÊVÕÌÕÀiÃÊ>`ÊVV>Ê symptoms UÊÊ*>ÌiÌÃÊÜÌ Ê«iÀÃÃÌiÌÊV>``i>Ê>`ÉÀÊiÌ>ÃÌ>ÌVÊV«V>ÌÃÊ (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,iÛ>ÊvÊ>ÊiÝÃÌ}ÊViÌÀ>ÊÛiÕÃÊV>Ì iÌiÀÃÊÃÊ } ÞÊ recommended. UÊÊ*>ÌiÌÃÊà Õ`Ê >ÛiÊL`ÊVÕÌÕÀiÃÊ`>ÞÊÀÊiÛiÀÞÊÌ iÀÊ`>ÞÊÕÌÊ candidemia is cleared. UÊÊ*>ÌiÌÃÊà Õ`Ê >ÛiÊ>Ê« Ì >}VÊiÝ>>ÌÊÌÊiÝVÕ`iÊ candidal endophthalmitis prior to discharge, preferably once the candidemia is controlled. UÊÊ V V>À`}À>« ÞÊV>ÊLiÊVÃ`iÀi`ÊvÊÌ iÊ«>ÌiÌÊ >ÃÊ«iÀÃÃÌiÌÊ candidemia on appropriate therapy. Endophthalmitis UÊ>>}iiÌÊÊVÕVÌÊÜÌ Ê"« Ì >}Þ UÊÊ ÕiÊÌÊ«ÀÊ -Ê>`ÊÛÌÀi>Ê«iiÌÀ>Ì]ÊÌÀi>ÌiÌÊÜÌ ÊiV V>`ÃÊ is NOT recommended. Preferred therapy UÊ« ÌiÀVÊ Ê£Ê}É}Ê6ÊViÊ`>ÞÊ´ÊÕVÞÌÃiÊÓxÊ}É}Ê*"Ê+È OR UÊ Ãi®ÊxÊ}É}Ê6ÊViÊ`>ÞÊ´ÊÕVÞÌÃiÊÓxÊ}É}Ê*"Ê+È Alternate therapy UÊÊÕV>âiÊ{äänääÊ}Ê6É*"ÊViÊ`>ÞÊ´ÊÕVÞÌÃiÊÓxÊ}É}Ê PO Q6H Duration: {qÈÊÜiià 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 UÊ ÃiÁÊxÊ}É}Ê6ÊViÊ`>Þ Alternative therapy UÊÊV>vÕ}Ê£xäÊ}Ê6ÊViÊ`>ÞÊ´ÊÕV>âiÊ{ääqnääÊ}Ê6É*"Ê once daily Duration: 6 weeks or longer Notes on antifungal susceptibility testing UÊÊ-ÕÃVi«ÌLÌÞÊÌiÃÌ}ÊvÀÊÕV>âi]ÊÌÀ>V>âi]Ê6ÀV>âi]Ê Flucytosine, and Micafungin is performed routinely on the first yeast isolate recovered from blood. UÊÊÕV>âiÊ>`ÊV>vÕ}ÊÃÕÃVi«ÌLÌÞÊ>ÀiÊÀi«ÀÌi`ÊÊ>ÊÃ>Ìið UÊÊ"À}>ÃÃÊÌ >ÌÊ >ÛiÊV>vÕ}Ê ÃÊÊÌ iÊÀ>}iÊvÊ£qÓÊV}ÉÊ (reported as susceptible) may not respond to treatment. ID consult is recommended in these cases. UÊÊ-ÕÃVi«ÌLÌÞÊÌiÃÌ}ÊvÀÊVÛiÌ>Ê« ÌiÀVÊ ÊÃÊ`iÊÀÕÌiÞÊ for C. lusitaniae and C. guillermondii, and for other organisms by request. UÊÊvÊÌ iÊÀ}>ÃÊÃÊÌiÀi`>ÌiÊ­®ÊÌÊÕV>âi]ÊÌ iÊnääÊ}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«ÌLÌÞÊÌiÃÌ}Êà Õ`ÊLiÊVÃ`iÀi`ÊÜ i\ UÊÕVVÕÌ>iÕÃÊV>``>ÃÃÊÃÊÀivÀ>VÌÀÞÊÌÊÕV>âi UÊÊ/Ài>Ì}ÊÃÌiÞiÌÃ]Êi}ÌÃ]ÊÀÊi`« Ì >ÌÃÊÜÌ Ê Fluconazole UÊ `ÊVÕÌÕÀiÃÊ>ÀiÊ«iÀÃÃÌiÌÞÊ«ÃÌÛiÊÊÕV>âi UÊÊ ÀÕÌiÊÃÕÃVi«ÌLÌÞÊÌiÃÌ}ÊV>ÊLiÊ>ÀÀ>}i`ÊLÞÊV>}ÊÌ iÊ mycology lab at 5-6148 Notes on Fluconazole prophylaxis UÊÊÕV>âiÊ«À« Þ>ÝÃÊà Õ`ÊLiÊÌi`ÊÌÊÌ iÊvÜ}ÊÃiÌÌ}à UÊÊ*>ÌiÌÃÊiÝ«iVÌi`ÊÌÊÀi>ÊÊÌ iÊSICU or WICU for ≥ 72 hours ­ ÀÌiÀ>ÊvÀÊ«ÃÊ- 1Ê«À« Þ>ÝÃÊÃÌÕ`ÞÆÊ«À« Þ>ÝÃÊÊÌ iÀÊ ICUs has NOT been studied and is NOT recommended). UÊÊ iÕÌÀ«iVÊ«>ÌiÌÃÊÕ`iÀ}}ÊLiÊ>ÀÀÜÊÌÀ>ë>Ì>ÌÊÀÊ treatment for leukemia/lymphoma UÊÊ*>ÌiÌÃÊÜ Ê>ÀiÊ«ÃÌ«ÊvÀÊÛiÀÊÀÊ«>VÀi>ÃÊÌÀ>ë>Ìð UÊÊÕV>âiÊ«À« Þ>ÝÃÊà Õ`ÊLiÊÃÌ««i`ÊÜ iÊ- 1ÊÀÊ7 1Ê patients are transferred to the floor ,iviÀiViÃ\ -ÊÕ`iiÃÊvÀÊ/Ài>ÌiÌÊvÊ >``>ÃÃ\Ê ÊviVÌÊ ÃÊÓääÆ{n\xäÎxÎx° ÕV>âiÊ«À« Þ>ÝÃÊÊÃÕÀ}V>Ê«>ÌiÌÃ\ÊÊ-ÕÀ}ÊÓää£ÆÓÎÎ\x{Óqn° 120 ÀÊëiVwVÊ«ÀVi`ÕÀiÃÊ>`Ê>}iÌÃÊÃiiʺ*iÀ«iÀ>ÌÛiÊ>ÌLÌVÊ «À« Þ>ÝÃÊ`VÕiÌ»Ê>ÌÊÜÜÜ°Ã`i «Ãi`Vi°À}É>« Drug iv>âÊ ivÌiÌ>Ê Clindamycin Ciprofloxacin Gentamicin Metronidazole 6>VÞVÊ Ê Ê Usual dose Ê£ÓäÊ}\ÊÓÊ}Ê ≥Ê£ÓäÊ}\ÊÎÊ}Ê Ê£ÓäÊ}\ÊÓÊ}Ê ≥Ê£ÓäÊ}\ÊÎÊ} 600 mg 400 mg 5 mg/kg 500 mg ÊÇäÊ}\Ê£Ê}Ê Ç£Ê}\Ê£°ÓxÊ} Ê£ääÊ}\Ê£°xÊ} Redosing during procedure +{Ê­+ÓÊvÀÊV>À`>VÊÃÕÀ}iÀÞ® +{Ê­+ÓÊvÀÊV>À`>VÊÃÕÀ}iÀÞ® +È Q6H None None None +£Ó Important notes UÊÊ/}ÊÃÊVÀÕV>°ÊÌLÌVÃÊÕÃÌÊLiÊÊÌ iÊÃÊÜ iÊÌ iÊ incision is made to be effective. UÊÊ i« >ëÀÃÊV>ÊLiÊ>`ÃÌiÀi`ÊÛiÀÊÎqxÊÊ6Ê«Õà ÊÕÃÌÊLivÀiÊ the procedure and will achieve appropriate skin levels in minutes. Vancomycin and Ciprofloxacin must be given over 60 min. Clindamycin à Õ`ÊLiÊvÕÃi`ÊÛiÀÊ£äqÓäÊ°Ê UÊÊÀÊ>ÌLÌVÃÊÜÌ Ê}iÀÊvÕÃÊÌiÃÊ­i°}°Ê6>VÞV]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*>ÌiÌÃÊÀiViÛ}Ê«Ài«iÀ>ÌÛiÊ>ÌLÌVÃÊ}iiÀ>ÞÊ`Ê "/Êii`Ê additional antibiotics for endocarditis prophylaxis. UÊÊ*À« Þ>ÝÃÊvÀÊ«>ÌiÌÃÊ>Ài>`ÞÊÊ>ÌLÌVÃ\ UÊÊÀÊ>ÌLÌVÃÊÌ iÀÊÌ >Ê6>VÞV\Ê`ÊÃÌ>`}Ê`ÃiÊÕÌÊ 1 hour before incision UÊÊÀÊ6>VÞV\Ê,i`ÃiÊ>ÊvÕÊ`ÃiÊvÊnÊ ÕÀÃÊ >ÛiÊ«>ÃÃi`ÊÃViÊ the last dose or a half dose if fewer than 8 hours have passed in patient with normal renal function UÊÊiÌ>VÊà Õ`ÊLiÊ}ÛiÊ>ÃÊ>ÊÃ}iÊ`ÃiÊvÊxÊ}É}ÊÌÊ>ÝâiÊ tissue penetration and minimize toxicity. UÊÊvÊÊ`>ÞÃÃÊÀÊ À ÊÊÓäÊÉ]ÊÕÃiÊÓÊ}É} UÊ ÊÌÊÀi`Ãi UÊÊ1ÃiÊ>VÌÕ>ÊL`ÞÊÜi} ÌÊÕiÃÃÊ«>ÌiÌÊÃÊ≥ÊÓä¯ÊÛiÀÊ`i>ÊL`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 *iiÊÀÊÌ iÀÊ«ÀÃÌ 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>âÊ",Ê6>VÞVRÊÊQ `>ÞVÊ",Ê6>VÞVR 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`>Ê>ÀÌ>Ê«ÀVi`ÕÀiÊÀÊ}ÀÊVÃÊÊ ivÌiÌ>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>VÞVʳÊiÌ>V2 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 *ÀVi`ÕÀiÃÊÛÛ}ÊiÌÀÞÊÌÊÕiÊvÊÕ««iÀÊÊ ivÌiÌ>Ê GI tract, gastric bypass procedures, pancreaticoduodenectomy, highly selective vagotomy, Nissen fundoplication >ÀÞÊÌÀ>VÌÊ«ÀVi`ÕÀiÃÊ­i°}°ÊV iVÞÃÌiVÌÞ]ÊÊ ivÌiÌ>Ê choledochoenterostomy) i«>ÌiVÌÞÊ ivÌiÌ>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 «V>Ìi`]ÊiiÀ}iÌÊÀÊÀi«i>ÌÊ}Õ>ÊÊ hernia repair Mastectomy iv>âÊ",Ê ivÌiÌ>Ê Cefotetan Cefotetan Cefazolin ivÌiÌ>Ê PCN allergy alternate prophylaxis `>ÞVÊ´ÊiÌ>V2 `>ÞVÊ´ÊiÌ>V2 `>ÞVÊ´ÊiÌ>V2 Clindamycin PLUS Ciprofloxacin Clindamycin PLUS Gentamicin2 `>ÞVÊ´ÊiÌ>V2 Clindamycin PLUS Gentamicin2 Clindamycin PLUS Gentamicin2 Clindamycin `>ÞVÊ´ÊiÌ>V2 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«ÊÀiVÌ>ÊÃVÀiiÊ«iÀvÀi`\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 ÀiÃÃÌ>ÌÊÀ}>ÃÃÆÊ«À« Þ>VÌVÊÀi}iÊà Õ`ÊLiÊÌ>Ài`ÊL>Ãi`ÊÊÜÊVÀL}ÞÊ`>Ì>ÊÜÌ 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 >ÀÞÉÆÊV iÊiLâ>ÌÉÊÊ ivÌiÌ>ÊÊ `>ÞVÊ percutaneous liver ablation (hx. of PLUS Gentamicin L>ÀÞÊÃÕÀ}iÀÞÉÃÌÀÕiÌ>Ì®ÆÊ cecostomy iÊiLâ>ÌÆÊwLÀ`ÉÕÀiÊ *À« Þ>ÝÃÊÌÊ >ÀÌiÀÞÊiLâ>ÌÆÊ«iÀVÕÌ>iÕÃÊÊ ÀiVi`i` ÛiÀÉÀi>ÉÕ}IÊ>L>ÌÆÊÛ>ÃVÕ>ÀÊ vascular malformation embolization† Urologic procedure (not ablation) Cefazolin Gentamicin Lymphangiogram/embolization Cefazolin Clindamycin Placement of tunneled catheters Prophylaxis not ­i°}°ÊViÌÀ>Êi®ÆÊÛiÕÃÉ>ÀÌiÀ>ÊÊ ÀiVi`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 vÕVÌÊÊÊ Ciprofloxacin 500 mg PO once 12 hours after the procedure. If GFR ÎäÊÉÊÊii`ÊvÀÊ«ÃÌ«Ê`Ãi°Ê «ÀyÝ>VÊÊ ÀiÃÃÌ>Ì]Ê/*É-8Ê susceptible /*É-8Ê£Ê -Ê£Ê ÕÀÊLivÀiÊÊ «ÀVi`ÕÀi]Ê>`Ê£Ê -ÊÎÊ ÕÀÃÊÊ before /*É-8Ê£Ê -Ê*"ÊViÊ£ÓÊ ÕÀÃÊ >vÌiÀÊÌ iÊ«ÀVi`ÕÀi°ÊvÊ,ÊÎäÊ ml/min no need for post-op dose. Ciprofloxacin and /*É-8ÊÀiÃÃÌ>Ì]ÊÊ Cefazolin susceptible Cefazolin 2 g IV push (3-5 min) ÜÌ Ê>Ê£Ê ÕÀÊvÊ«ÀVi`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 ÎäÈäÊÊÊ OR Ceftriaxone 1 g IV over 30 min if susceptible No need for additional doses as iÌ>VÊ>`Ê ivÌÀ>ÝiÊÀiÌ>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*>ÌiÌÃÊÜ Ê >ÛiÊÀiViÛi`Ê>ÌLÌVÃÊvÀÊÃÕÀ}V>Ê«À« Þ>ÝÃÊ`ÊÌÊ 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*ÀÃÌ iÌVÊV>À`>VÊÛ>Ûi UÊ*ÀiÛÕÃÊi«Ã`iÊvÊviVÌÛiÊi`V>À`Ìà UÊ }iÌ>Ê i>ÀÌÊ`Ãi>ÃiÊ­ ® UÊÊÊ1Ài«>Ài`ÊVÞ>ÌVÊ ]ÊVÕ`}Ê«>>ÌÛiÊà ÕÌÃÊ>`ÊV`ÕÌà UÊÊ «iÌiÞÊÀi«>Ài`ÊV}iÌ>Ê i>ÀÌÊ`iviVÌÊÜÌ Ê«ÀÃÌ iÌVÊ material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure UÊÊ,i«>Ài`Ê ÊÜÌ ÊÀiÃ`Õ>Ê`iviVÌÃÊ>ÌÊÌ iÊÃÌiÊÀÊ>`>ViÌÊÌÊÌ iÊ site of a prosthetic patch or prosthetic device UÊÊ >À`>VÊÌÀ>ë>Ì>ÌÊÀiV«iÌÃÊÜ Ê`iÛi«ÊV>À`>VÊÛ>ÛÕ«>Ì Þ Antibiotic prophylaxis is recommended for the following dental procedures ONLY: UÊ>«Õ>ÌÊvÊ}}Û>ÊÌÃÃÕiÃÊÀÊ«iÀ>«V>ÊÀi}ÊvÊÌiiÌ UÊ*iÀvÀ>ÌÊvÊÀ>ÊÕVÃ> Antibiotic prophylaxis is recommended for the following respiratory tract procedures ONLY: UÊVÃÊÀÊL«ÃÞÊvÊÌ iÊÀiëÀ>ÌÀÞÊÕVÃ> Antibiotic regimens UÊÝVÊÓÊ}Ê*"Ê£Ê ÕÀÊLivÀiÊ«ÀVi`ÕÀi OR UÊ* Ê>iÀ}Þ\Ê `>ÞVÊÈääÊ}Ê*"Ê£Ê ÕÀÊLivÀiÊ«ÀVi`ÕÀi OR UÊ* Ê>iÀ}Þ\ÊâÌ ÀÞVÊxääÊ}Ê*"Ê£Ê ÕÀÊLivÀiÊ«ÀVi`ÕÀi OR UÊÊ*>ÌiÌÊÕ>LiÊÌÊÌ>iÊÀ>Êi`V>Ì\Ê«VÊÓÊ}ÊÉ6Ê£Ê ÕÀÊ before procedure OR Cefazolin 1 g IM/IV 5 minute push prior to procedure ,iviÀiVi\ ÊÕ`iiÃÊvÀÊ*ÀiÛiÌÊvÊviVÌÛiÊ `V>À`ÌÃ\Ê ÀVÕ>ÌÊÓääÇÆÊ££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:ÊÊ`ÃiÃÊ>ÃÃÕiÊÀ>ÊÀi>ÊvÕVÌÆÊ`ÃiÊ`wV>ÌÃÊ>ÞÊLiÊ`V>Ìi`ÊvÀÊ 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 ³ÊÀÊ É,³Ê 6>}>VVÛÀ† 450 mg PO daily 6Ê ³É,Ê 6>}>VVÛÀ† 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 ÀÃÌÊi\Ê/*É-8ÊiÊ--ÊÌ>LiÌÊ*"Ê`>ÞÊ -iV`Êi\ÊÌÛ>µÕiÊ£xääÊ}Ê*"Ê`>Þ / À`Êi\Ê >«ÃiIÊ£ääÊ}Ê*"Ê`>ÞÊ",Ê aerosolized Pentamidine ÈÊÌ 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 ³ÊÀÊ É,³Ê 6>}>VVÛÀ† 450 mg PO daily 3 months 6Ê ³É,Ê 6>}>VVÛÀ† 900 mg PO daily Anti-fungal prophylaxis Clotrimazole troches 10 mg PO QID 1 month PCP prophylaxis Ê Ê ÀÃÌÊi\Ê/*É-8ÊiÊ--ÊÌ>LiÌÊ*"Ê`>ÞÊ -iV`Êi\ÊÌÛ>µÕiÊ£xääÊ}Ê*"Ê`>Þ / À`Êi\Ê >«ÃiIÊ£ääÊ}Ê*"Ê`>ÞÊ", aerosolized Pentamadine ÈÊÌ 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 ³ÊÀÊ É,³Ê 6>}>VVÛÀ† 450 mg PO daily 6Ê ³É,Ê 6>}>VVÛÀ† 900 mg PO daily, followed by PCR monitoring Anti-fungal prophylaxis Fluconazole 400 mg PO daily PCP prophylaxisÊ ÀÃÌÊi\Ê/*É-8ÊiÊ--ÊÌ>LiÌÊ*"Ê`>ÞÊÊ Ê ÌiÀ>ÌÛiÃ\ÊÌÛ>µÕiÊ£xääÊ}Ê*"Ê`>ÞÊ or Dapsone 100 mg PO daily 126 3 months 3 months 6 months 6 weeks £ÓÊÌ Ã Indication Agent and dose Anti-viral prophylaxis (CMV, HSV, VZV) 6Ê É,Ê Ê«À« Þ>ÝÃÊÕiÃÃÊ-6Ê}ÊÀÊ6<6Ê}ÊÊ positive. If positive serology, Valacyclovir 500 mg PO BID 6Ê ³ÊÀÊ É,³Ê 6>}>VVÛÀ† 900 mg PO daily 6Ê ³É,Ê 6>}>VVÛÀ† 900 mg PO daily Anti-fungal prophylaxis Nystatin suspension 500,000 units QID PCP prophylaxisÊ Ê Ê Ê Duration ÎÊÌ Ã 3 months 6 months Until prednisone dose ≤ 10 mg/d x 3 months ÀÃÌÊi\Ê/*É-8Ê--ÊiÊÌ>LiÌÊ*"Ê`>ÞÊ",Ê £ÓÊÌ Ã Ê Ê /*É-8ÊiÊ -ÊÌ>LiÌÊ*"ÊÌ ÀiiÊÌiÃÉÜiiÊ -iV`Êi\Ê >«ÃiIÊ£ääÊ}Ê*"Ê`>Þ / À`Êi\ÊÌÛ>µÕiÊ£xääÊ}Ê*"Ê`>ÞÊ Toxoplasmosis prophylaxis ÀÃÌÊi\Ê/*É-8ÊiÊ--ÊÌ>LiÌÊ*"Ê`>ÞÊÊ £ÓÊÌ Ã /ÝÊ,³Ê Ê -iV`Êi\Ê >«ÃiIÊ£ääÊ}Ê*"Ê`>ÞÊPLUS Pyrimethamine and Leucovorin /ÝÊ ³ÊÀÊÕÜÊ ÀÃÌÊi\Ê/*É-8ÊiÊ--ÊÌ>LiÌÊ*"Ê`>ÞÊ £ÓÊÌ ÃÊ Ê Ê `ÀÊÃÌ>ÌÕÃÊ -iV`Êi\Ê >«ÃiIÊ£ääÊ}Ê*"Ê`>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 ³ÊÀÊ É,³Ê >VVÛÀÊxÊ}É}Ê6Ê+£ÓÊÝÊ£{Ê`>ÞÃ]ÊÌ iÊÊ vi} 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 >VVÛÀÊxÊ}É}Ê6Ê+£Ó ÊÝÊ£{Ê`>ÞÃ]ÊÌ iÊÊ vi} 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 AspergillusÊVâ>ÌÊ PCP prophylaxisÊ Ê Ê Ê ÞÃÌ>ÌÊxää]äääÊÕÌÃÊ Ê+ÈÊÕÌÊÊÊ extubated, then Clotrimazole troches 10 mg PO Q6H until prednisone dose 10 mg daily 6ÀV>âiÊ­`Ãi`ÊLÞÊÜi} Ì®ÊÊÊ ÊÈÊ}\Ê6ÀV>âiÊÓääÊ}Ê*"Ê 69 kg to Ê{Ê}\Ê6ÀV>âi 300 mg PO BID Ê{Ê}\Ê6ÀV>âiÊ{ääÊ}Ê*"Ê ÀÃÌÊi\Ê/*É-8ÊiÊ -ÊÌ>LiÌÊ*"ÊÊ Ê Ê Ì ÀiiÊÌiÃÉÜiiÊ",Ê/*É-8ÊiÊ SS tablet PO daily -iV`Êi\Ê >«ÃiIÊ£ääÊ}Ê*"Ê`>ÞÊÊ / À`Êi\ÊÌÛ>µÕiÊ£xääÊ}Ê*"Ê`>ÞÊ During initial hospitalization stay ÎqÈÊÌ ÃÊ ÎqÈÊÌ ÃÊ vi} ÊrÊ`À]Ê,ÊrÊÀiV«iÌ]Ê­q®ÊrÊÃiÀi}>ÌÛi]Ê­³®ÊrÊÃiÀ«ÃÌÛi NOTES: /*É-8ÊÌ iÀ>«ÞÊÀi`ÕViÃÊÀÃÊvÊviVÌÊÜÌ 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. ‡ /*qÎÊÌ 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 iÕÌÀ«i>\Ê ÊÊxääÉ3 UÊÊiÛiÀ\ÊÊ/i«ÊÊÎn°äcÊ ÊÌiÃÊÌÜÊ>ÌÊi>ÃÌÊÓÊ ÕÀÃÊ>«>ÀÌÊ",Ê Temp > 38.3° C times one TREATMENT Always tailor antibiotics based on susceptibility profiles vÊÌ iÊ«>ÌiÌÊÃÊ Þ«ÌiÃÛiÊÀÊÌ iÀÜÃiÊÕÃÌ>Li]ÊÃiiʺ/Ài>ÌiÌÊvÊ VV>ÞÊÕÃÌ>LiÊ«>ÌiÌûʭ««ÃÌi®° Initial fever UÊÊ ivi«iÊÓÊ}Ê6Ê+nÊ´Ê6>VÞVIÊ­ÃiiÊ`Ã}ÊÃiVÌÊ«°Ê£xä® OR UÊ*«iÀ>VÉÌ>âL>VÌ>ÊΰÎÇxÊ}Ê6Ê+{Ê´Ê6>VÞVIÊ­ÃiiÊ`Ã}Ê section p. 150) I`V>ÌÃÊvÀÊ6>VÞV\ÊÃÕëiVÌi`Ê , -]ÊÃÊ>`ÊÃvÌÌÃÃÕiÊviVÌÃ]Ê pneumonia, severe oral or pharyngeal mucositis, history of MRSA infection or colonization. OR UÊ-iÛiÀiÊ* Ê>iÀ}ÞÊ­>>« Þ>ÝÃÊÀÊ-ÌiÛià ÃÊ-Þ`Ài®\Ê Strongly consider allergy consult to verify allergy in patients with unclear histories (see section on Penicillin allergy, p. 137) UÊâÌÀi>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 UÊÝyÝ>VÊ{ääÊ}Ê*"Ê`>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 ÌÕiÊ>ÌLÌVÃÊ>LÛiÊ>`Ê Ê>ÌvÕ}>ÊVÛiÀ>}iÊ vÊÀiViÛ}ÊÕV>âiÊ«À« Þ>ÝÃÊÀÊÊvÕ}>Ê«À« Þ>ÝÃ\ UÊV>vÕ}Ê£ääÊ}Ê6Ê+Ó{ÊvÊÃÕÃÊ>`ÉÀÊV iÃÌÊ /ÊÌÊÃÕ}}iÃÌÛiÊ of fungal infection OR UÊ6ÀV>âiÊÈÊ}É}Ê6É*"Ê+£ÓÊÌiÃÊÌÜÊ`ÃiÃÊÌ iÊ{Ê}É}Ê6É PO Q12H if chest CT suggestive of fungal infection If receiving Voriconazole or Posaconazole prophylaxis or sinus CT ÃÕ}}iÃÌÛiÊvÊvÕ}>ÊviVÌ\ UÊ ÃiÁÊxÊ}É}Ê6Ê+Ó{Ê Clinically unstable patient and/or persistent fever despite appropriate antibacterial and antifungal coverage UÊ ÃÕÌÊ"V}ÞÉ/À>ë>ÌÊ Ê UÊ6>VÞVÊ­ÃiiÊ`Ã}ÊÃiVÌ]Ê«°Ê£xä®ÊPLUS Meropenem 1 g IV +nÊ´Ê>VÊvÊ«>ÌiÌÊÕÃÌ>LiÊ­ÃiiÊ`Ã}ÊÃiVÌÊ«°Ê£{È®Ê OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê ÃÕÌÊ"V}ÞÉ/À>ë>ÌÊ Ê 130 NOTE:ÊÊ`ÃiÃÊ>ÃÃÕiÊÀ>ÊÀi>ÊvÕVÌÆÊ`ÃiÊ`wV>ÌÃÊ>ÞÊLiÊ`V>Ìi`ÊvÀÊ 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 ºÀÃÌÊiÛiÀ»Ê antibiotics ÌvÕ}>Ê«À« Þ>ÝÃÊ Ê ÀÃÌÊi\Ê6ÀV>âiÊ­ÃiiÊ`Ã}ÊÊ /ÊÃiVÌ®Ê >ÞÊ£ÊÕÌÊÊ -iV`Êi\Ê*Ã>V>âiÊÃÕëiÃÊÓääÊ}ÊÊ Ê PO TID OR 300 mg tablet daily 100/mm3 ÌiÀ>ÌÛiÃ\ÊV>vÕ}Ê£ääÊ}Ê6Ê+Ó{Ê",ÊÊ Ê Ê Fluconazole 400 mg PO daily Antiviral prophylaxis Ê * *Ê«À« Þ>ÝÃÊÊ in high risk patients‡Ê Ê Valacyclovir 500 mg PO BID OR Acyclovir 800 mg PO BID vÊÛÌ}ÊÀÊ`>ÀÀ i>\ÊVÞVÛÀÊÓxäÊ}É2 IV Q12H† Day 1 until ANC 100/mm3 ÀÃÌÊi\Ê/*É-8ÊiÊ--ÊÌ>LÊ*"Ê`>ÞÊÊ -iV`Êi\Ê >«ÃiÊ£ääÊ}Ê*"Ê`>ÞÊ / À`Êi\ÊÌÛ>µÕiÊÇxäÊ}Ê*"Ê Ê >ÞÊ£ÊÕÌÊÊ ÕÊÊ ÃÕ«ÀiÃÃÊ 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 vÊÛÌ}ÊÀÊ`>ÀÀ i>\ÊVÞVÛÀÊÓxäÊ}É2 IV Q12H† Day 7 through all cycles of chemotherapy ÀÃÌÊi\Ê/*É-8ÊiÊ--ÊÌ>LÊ*"Ê`>ÞÊÊ -iV`Êi\Ê >«ÃiÊ£ääÊ}Ê*"Ê`>ÞÊ / À`Êi\ÊÌÛ>µÕiÊÇxäÊ}Ê*"Ê Ê >ÞÊÇÊÌ ÀÕ} Ê >ÊVÞViÃÊvÊÊ V iÊÊ therapy Ê * *Ê«À« Þ>ÝÃÊÊ 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 ÌvÕ}>Ê«À« Þ>ÝÃÊÊÊ patients with GVHD¶ Ê ÀÃÌÊi\Ê*Ã>V>âiÊÃÕëiÃÊÓääÊ}Ê*" TID OR 300 mg tablets daily -iV`Êi\Ê6ÀV>âiÊ­`Ãi`ÊLÞÊÜi} 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 vÊÛÌ}ÊÀÊ`>ÀÀ i>\ÊVÞVÛÀÊÓxäÊ}É2 IV Q12H † Day zero until 1 yr (allogeneic transplants) or 6 months (autologous transplants) Ê Ê ÀÃÌÊi\Ê/*É-8ÊiÊ--ÊÌ>LÊ*"Ê`>ÞÊ -iV`Êi\/*É-8Ê -ÊÌ>LÊÓÊÌiÃÊÜiiÞÊÊ OR Dapsone 100 mg PO daily / À`Êi\ÊÌÛ>µÕiÊÇxäÊ}Ê*"Ê Ê ÕÀÌ Êi\Ê*iÌ>`iÊÎääÊ}Ê Ê+ÓnÊ`>ÞÃÊ Ê Ê }iiVÊ ÌÀ>ë>Ì\Ê Day 21 or i}À>vÌiÌÊ ­Ü V iÛiÀÊ is later) until at least 1 year (longer if steroids or ongoing risk) Autologous ÊÌÀ>ë>Ì\Ê Engraftment until 6 months Ê PCP prophylaxis†Ê Ê NOTES: /*É-8ÊÌ iÀ>«ÞÊÀi`ÕViÃÊÀÃÊvÊviVÌÊÜÌ ÊiV>«ÃÕ>Ìi`ÊL>VÌiÀ>]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>Ê«>ÌiÌÃÊvÊÊÃÌiÀ`ÃÆÊÞ« >Ê«>ÌiÌÃÊvÊ6³]ÊÊV ÀVÊÃÌiÀ`Ã]ÊyÕ`>À>Li° iÕi>Ê«>ÌiÌÃ\Ê]ÊV ÀVÊÃÌiÀ`Ã]ÊÃÉ«Ê /ÊÕÌÊ£ÊÞi>ÀÊ>vÌiÀÊÌÀ>ë>Ì]ÊÀÊ«>ÌiÌÊÜ Ê received cladribine, fludarabine, or alemtuzumab. ¬"Ì iÀÊ«À« Þ>ÝÃÊÊ>VÕÌiÊ6 \ÊÝyÝ>V]Ê/*É-8° 132 Filamentous fungi ID consult recommended for assistance with antifungal selection TREATMENT Aspergillus spp. Initial therapy UÊÊ6ÀV>âiÊÈÊ}É}Ê6É*"Ê+£ÓÊÌiÃÊÌÜÊ`ÃiÃÊÌ iÊ{Ê}É}Ê6É PO Q12H (see Voriconazole guidelines, p. 19, for more information). OR UÊ Ãi® 5 mg/kg IV Q24H NOTES: UÊÊ6ÀV>âiÊÃÊVÃ`iÀi`ÊLÞÊ>ÞÊÌÊLiÊÌ iÊwÀÃÌiÊÌÀi>ÌiÌÊvÊ 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 L>ÌÊ>ÌvÕ}>ÊÌ iÀ>«ÞÊVÃÃÌ}ÊvÊ6ÀV>âiÊPLUS 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 ÊVÃÕÌÊà Õ`ÊLiÊÛÛi`ÊÊÌ iÃiÊV>Ãið UÊÊ6ÀV>âiÊÈÊ}É}Ê6É*"Ê+£ÓÊÌiÃÊÌÜÊ`ÃiÃÊÌ iÊ{Ê}É}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 UÊÊ6ÀV>âiÊÈÊ}É}Ê6É*"Ê+£ÓÊÌiÃÊÌÜÊ`ÃiÃÊÌ iÊ{Ê}É}Ê IV/PO Q12H PLUS Micafungin 100 mg IV Q24H (see Voriconazole guidelines, p. 19, for more information). NOTE: UÊÊ/Ài>ÌiÌÊÜÌ ÊÌ iÀÊ>}iÌÃÊ >ÃÊÞi`i`Ê`Ã>««Ì}ÊÀiÃÕÌÃ°Ê 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.). UÊ Ãi® 5 mg/kg IV once daily PLUS a second antifungal agent UÊÊ ÊVÃÕÌÊÀiµÕÀi`° UÊÊ-ÕÀ}V>Ê`iLÀ`iiÌÊ>`ÊVÀÀiVÌÊvÊÕ`iÀÞ}ÊÀÃÊv>VÌÀÃÊ­i°}°Ê acidosis, hyperglycemia) are critical. Candida TREATMENT UÊÊ9 -/Ê ÊÊ "" Ê 1/1, Ê-"1 Ê 6 ,Ê Ê " - , ÊÊ CONTAMINANT. UÊÊ-iiÊÃiVÌÃÊLiÜÊÊi«ÀVÊÌ iÀ>«ÞÊ>`ÊÊ«>Ì }iëiVwVÊ therapy. Unspeciated candidemia UÊV>vÕ}Ê£ääÊ}Ê6Ê+Ó{ OR UÊ Ãi® 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 UÊV>vÕ}Ê£ääÊ}Ê6Ê+Ó{ OR UÊÊ Ãi®ÊÎqxÊ}É}Ê6Ê+Ó{ NOTE: Patients who are clinically stable and no longer neutropenic can be switched to Fluconazole if the organism is susceptible. Candida glabrata UÊV>vÕ}Ê£ääÊ}Ê6Ê+Ó{ OR UÊÊ Ãi® 5 mg/kg IV Q24H Candida krusei UÊV>vÕ}Ê£ääÊ}Ê6Ê+Ó{ OR UÊÊ Ãi® 5 mg/kg IV Q24H 134 Candida parapsilosis UÊ Ãi®ÊÎqxÊ}É}Ê6Ê+Ó{Ê NOTES: UÊÊÃÌÊC. parapsilosis isolates remain susceptible to Fluconazole, which can be used in stable and non-neutropenic patients. UÊÊ/ iÀiÊ>ÀiÊÌi`Ê`>Ì>ÊÌ >ÌÊÃÕ}}iÃÌÊÌ >ÌÊV>vÕ}Ê>ÞÊLiÊviÀÀÊÌÊ Amphotericin B in these infections. Candida tropicalis UÊV>vÕ}Ê£ääÊ}Ê6Ê+Ó{ OR UÊÊ Ãi®ÊÎqxÊ}É}Ê6Ê+Ó{ TREATMENT NOTES Hidden Content - JHH Internal use only Notes on antifungal susceptibility testing UÊÊ-ÕÃVi«ÌLÌÞÊÌiÃÌ}ÊvÀÊÕV>âi]ÊÌÀ>V>âi]Ê6ÀV>âi]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 UÊÊÕV>âiÊ>`ÊV>vÕ}ÊÃÕÃVi«ÌLÌiÃÊ>ÀiÊÀi«ÀÌi`ÊÊ>ÊL`Ê isolates. UÊÊ"À}>ÃÃÊÌ >ÌÊ >ÛiÊV>vÕ}Ê ÃÊÊÌ iÊÀ>}iÊvÊ£qÓÊV}ÉÊ (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«ÌLÌÞÊÌiÃÌ}Êà Õ`ÊLiÊVÃ`iÀi`ÊÜ i\Ê UÊÊÕVVÕÌ>iÕÃÊV>``>ÃÃÊÃÊÀivÀ>VÌÀÞÊÌÊÕV>âi UÊÊ/Ài>Ì}ÊÃÌiÞiÌÃ]Êi}ÌÃ]ÊÀÊi`« Ì >ÌÃÊÜÌ Ê Fluconazole UÊÊ `ÊVÕÌÕÀiÃÊ>ÀiÊ«iÀÃÃÌiÌÞÊ«ÃÌÛiÊÊÕV>âi UÊÊ ÀÕÌiÊÃÕÃVi«ÌLÌÞÊÌiÃÌ}ÊV>ÊLiÊ>ÀÀ>}i`ÊLÞÊV>}ÊÌ iÊ mycology lab at 5-6148 ,iviÀiVi\ -ÊÕ`iiÃÊvÀÊ/Ài>ÌiÌÊvÊ >``>ÃÃ\Ê ÊviVÌÊ ÃÊÓääÆ{n\xäΰ 136 Penicillin reactions – Incidence UÊÊÊnää¯ÊvÊ«>ÌiÌÃÊÜ ÊÀi«ÀÌÊÌ iÞÊ>Àiʺ>iÀ}V»ÊÌÊ* Ê>VÌÕ>ÞÊ >ÛiÊ negative skin tests and are not at increased risk of an allergic reaction. UÊÊ*iVÊÀi>VÌÃÊvÊÃiÊÌÞ«iÊVVÕÀÊÊä°ÇÊÌÊ£ä¯ÊvÊ>Ê«>ÌiÌÃÊ who get the drug. UÊÊ 1/\Ê/ iÊV`iViÊvÊ>>« Þ>VÌVÊÀi>VÌÃÊÃÊä°ää{¯ÊÌÊä°ä£x¯° UÊÊ,>ÌiÃÊvÊVÀÃÃÀi>VÌÊ>iÀ}iÃÊÌÊVi« >ëÀÃÊ>ÀiÊÕÜÊLÕÌÊ thought to be low. UÊÊ,>ÌiÃÊvÊ* Ê>`ÊV>ÀL>«iiÊÃÊÌiÃÌÊVÀÃÃÊÀi>VÌÛÌÞÊ>ÀiÊ{ǯ]Ê although clinical rates of hypersensitivity reactions in patients with Ài«ÀÌi`Ê* Ê>iÀ}ÞÊÜ ÊÀiViÛiÊV>ÀL>«iiÃÊ>ÀiÊq££¯° UÊÊ ÀÃÃÊÀi>VÌÃÊÌÊL>VÌ>ÃÊ­âÌÀi>®Ê`Ê "/Ê>««i>ÀÊÌÊVVÕÀ° Penicillin skin testing UÊÊ7 iÊ`iÊVÀÀiVÌÞ]ÊÃÊ } ÞÊ«Ài`VÌÛiÊvÊÃiÀÕÃ]Ê>>« Þ>VÌVÊÀi>VÌð UÊÊ*>ÌiÌÃÊÜÌ Ê>Êi}>ÌÛiÊÃÊÌiÃÌÊ>ÀiÊNOT at risk for anaphylactic reactions. UÊÊ,>ÀiÞ]ÊÃÊÌiÃÌÊi}>ÌÛiÊ«>ÌiÌÃÊ>ÞÊ}iÌÊ`Ê ÛiÃÊ>`ÊÌV }Ê following penicillin administration but these RESOLVE with continued treatment. UÊÊ-ÊÌiÃÌÃÊV>ÌÊ«Ài`VÌÊ`iÀ>Ì}VÊÀÊÊÀi>VÌÃÊÀÊ`ÀÕ}ÊviÛiÀð UÊÊ-ÊÌiÃÌ}ÊÃÊÜÊ>Û>>LiÊ>ÌÊ°Ê*i>ÃiÊVÃÕÌÊiÀ}ÞÊ>`Ê Immunology. Penicillin reactions—Types UÊImmediateÊ­ÌÞ«iÊ£®ÊqÊ>« Þ>ÝÃ]Ê Þ«ÌiÃ]Ê>ÀÞ}i>Êi`i>]Ê wheezing, angioedema, urticaria UÊÊÃÌÊ>Ü>ÞÃÊVVÕÀÊwithin 1 hour of administration. Hypotension always occurs soon after administration UÊÊ >ÊLiÊ«Ài`VÌi`ÊLÞÊÃÊÌiÃÌà UÊAcceleratedÊqÊ>ÀÞ}i>Êi`i>]ÊÜ iiâ}]Ê>}i`i>]ÊÕÀÌV>À>Ê (NOT hypotension) UÊÊ"VVÕÀÊÜÌ Ê£ÇÓÊ ÕÀÃÊvÊ>`ÃÌÀ>Ì UÊÊ >ÊLiÊ«Ài`VÌi`ÊLÞÊÃÊÌiÃÌà UÊLateÊqÊ,>à ʭ>VÕ«>«Õ>ÀÊÀÊÀLvÀÊÀÊVÌ>VÌÊ`iÀ>ÌÌî]Ê destruction of RBC, WBC, platelets, serum sickness UÊÊÃÌÊ>Ü>ÞÃÊVVÕÀÊ>vÌiÀÊÇÓÊ ÕÀÃÊvÊ>`ÃÌÀ>Ì UÊÊ,>à iÃÊÃiÌiÃÊ}Ê>Ü>ÞÊ`iëÌiÊVÌÕi`ÊÌÀi>ÌiÌ UÊÊ>VÕ«>«Õ>ÀÊ>`ÊÀLvÀÊÀ>à iÃÊ "Ê "/Ê«À}ÀiÃÃÊÌÊ Stevens-Johnson syndrome UÊÊ>ÌiÊÀi>VÌÃÊ>ÀiÊ "/Ê«Ài`VÌi`ÊLÞÊÃÊÌiÃÌà UÊStevens-Johnson SyndromeÊqÊiÝv>ÌÛiÊ`iÀ>ÌÌÃÊÜÌ ÊÕVÕÃÊ 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 UÊÊÃÌÊ>Ü>ÞÃÊVVÕÀÊ>vÌiÀÊÇÓÊ ÕÀÃÊvÊ>`ÃÌÀ>Ì UÊÊ "/Ê«Ài`VÌi`ÊLÞÊ>Ê ÃÌÀÞÊvÊÀ>à Ê",ÊLÞÊÃÊÌiÃÌà Approach to the patient with reported penicillin allergy UÊÊ Àiv]ÊvVÕÃi`Ê ÃÌÀÞÊV>ÊLiÊ6 ,9Ê i«vÕ° UÊÊ+ÕiÃÌÃÊÌÊ>Ã\ 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« >ëÀÊ­>ÃÊ>LÕÌÊÌÀ>`iÊ>iÃÊi\ÊÕ}iÌ]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*>ÌiÌÃÊÜ ÊÀi«ÀÌÊ>>« Þ>VÌVÊÀi>VÌÃÊ>`Ê >ÛiÊÀiViÛi`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*>ÌiÌÃÊÜ ÊÀi«ÀÌÊ>>« Þ>VÌVÊÀi>VÌÃÊ>`Ê >ÛiÊÀiViÛi`Ê cephalosporins can get cephalosporins but not necessarily PCNs. UÊÊ*>ÌiÌÃÊÜ ÊÀi«ÀÌÊ>Ê ÃÌÀÞÊvÊ>ÊÕÀÌV>À>ÊÀ>à ÊÌ >ÌÊÃÊ "/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*>ÌiÌÃÊÜ ÊÀi«ÀÌÊÀi>VÌÃÊVÃÃÌiÌÊÜÌ ÊÃiÀÕÊÃViÃÃÊ (rare) can receive either penicillins or cephalosporins with careful monitoring for recurrence. UÊÊ*>ÌiÌÃÊÜ ÊÀi«ÀÌÊÊÃÞ«ÌÃÊ­`>ÀÀ i>]Ê>ÕÃi>®Ê«ÀL>LÞÊ`Ê 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. ,iviÀiViÃ\Ê ÊÓää£ÆÓnx\Ó{n° 1ÃiÊvÊV>ÀL>«iiÃÊÊ«>ÌiÌÃÊÜÌ Ê* ££xxqÇ°Ê ÊÌiÀÊi`ÊÓääÇÆ£{È\ÓÈÈq° 138 Ê>iÀ}Þ\ÊÊÌVÀL°Ê iÌ iÀÊÓää{Æx{\Ê UÊÊ ÃÕÌÊÌ iÊ ÊÜiLÃÌiÊÀÊÊ«ViÃÊiÊ­*"®Ê­ÜÜÜ° hopkinsmedicine.org/heic) for detailed isolation charts, HEIC policies, and surveillance information Hand hygiene UÊÊvÊ >`ÃÊ>ÀiÊÌÊÛÃLÞÊÃi`]ÊÌ iÊ>V L>Ãi`Ê >`ÊÃ>ÌâiÀÃÊ>ÀiÊ recommended for cleaning. If hands are visibly soiled, wash hands with soap and water for at least 15 seconds. UÊÊ>`Ê Þ}iiÊÃÊÀiµÕÀi`ÊÕ«ÊiÌiÀ}Ê>Ê«>ÌiÌÊÀ]ÊÕ«ÊiÝÌ}]Ê between patients in a semi-private room, and other times per hospital policy. UÊÊ1ÃiÊÃ>«Ê>`ÊÜ>ÌiÀÊÕ«Êexiting the room of a patient with C. difficile infection. UÊÊ Ê>ÀÌwV>Êw}iÀ>ÃÊ>ÀiÊ«iÀÌÌi`ÊvÀÊ>ÞÊÃÌ>vvÊiLiÀÊÜ Ê >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-ÊÜÕ`ÃÊà Õ`ÊLiÊVi>i`ÊÜÌ ÊÃ>«Ê>`ÊÜ>ÌiÀ UÊÊÕVÕÃÊiLÀ>iÃÊà Õ`ÊLiÊyÕà i`ÊÌ ÀÕ} ÞÊÜÌ ÊÜ>ÌiÀ UÊÊ ÞiÃÊà Õ`ÊLiÊÀÀ}>Ìi`ÊÜÌ Ê>ÊÌiÀÊvÊÀ>ÊÃ>i vÌiÀÊVi>}ÊÌ iÊiÝ«ÃÕÀiÊÃÌi]ÊV>Êx-/8Ê­xÇn{®Ê>`ÊvÜÊ instructions to contact the ID physician. Workplace injuries should be Ài«ÀÌi`Êi`>ÌiÞÊÊÌ iʺ «ÞiiÊ,i«ÀÌÊvÊV`iÌÊÀ»Ê>`Ê to the Occupational Injury ClinicÊ­ >VÊ£Î]Ê`>ÞqÀ`>Þ]ÊÇ\ÎäÊ a.m. to 4 p.m., 5-6433), and to your supervisor. Standard Precautions UÊÊ,ÕÌiÊ >`Ê Þ}iiÊ UÊÊ ÃÃÌiÌÊ>`ÊVÀÀiVÌÊ}ÛiÊÕÃiÊÊ UÊÊ >}ÊVÌ>>Ìi`ÊiÊ>ÌÊ«ÌÊvÊÕÃi UÊÊ,i}Õ>ÀÊVi>}ÊvÊiÛÀiÌ>Ê surfaces UÊ««À«À>ÌiÊÕÃiÊvÊ}ÜÃÊÌÊ«ÀiÛiÌÊÊ UÊ,ÕÌiÊVi>}ÊÀÊ`ëÃ>Êv contamination of uniform/clothing patient-care equipment UÊ««À«À>ÌiÊÕÃiÊvÊ>ÃÃ]ÊiÞiÊÊ UÊ-ÌÀVÌÊ>` iÀiViÊÌ 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 Õ`ÊLiÊÌwi`\ UÊÊvÊ«>ÌiÌÃÊÀÊ 7ÃÊ>ÀiÊiÝ«Ãi`ÊÌÊ>ÊVÕV>LiÊ`Ãi>ÃiÊ­°i°Ê meningococcal disease, varicella, TB etc.) UÊÊLÕÌÊ 7ÃÊÜÌ Ê>VÕÌiÊ i«>ÌÌÃÊ]Ê ÊÀÊ ]Ê->i>]Ê- }i>]Ê Campylobacter, or pneumonia requiring hospital admission UÊÊLÕÌÊ>ÞÊÕÕÃÕ>ÊVVÕÀÀiViÊvÊ`Ãi>ÃiÊÀÊVÕÃÌiÀ]Ê«>ÀÌVÕ>ÀÞÊ diseases that have the potential to expose many susceptible individuals UÊÊ-ÕëVÊÀÊ`>}ÃiÃÊvÊÌ iÊvÜ}Ê`Ãi>ÃiÃÊ­`Ãi>ÃiÃÊÜÌ Ê require immediate notification by phone or pager). If disease is in a HCW, notify HEIC and Occupational Health (98 N. Broadway, -ÕÌiÊ{Ó£]Ê`>ÞqÀ`>Þ]ÊÇ\ÎäÊ>°°ÊÌÊ{\ääÊ«°°]ÊxÈÓ££®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 >ÌÀiÊ ÌÞÊi>Ì Ê i«>ÀÌiÌÊ­{£äÎÈ{{ÎÈ]Êv>Ý\Ê{£äÈÓxäÈnn®°Ê For a complete list of communicable diseases, see the HEIC Web site, Ì iÊ Ê7iLÊÃÌi]Ê ÌÌ«\ÉÉ`i >°` °>ÀÞ>`°}ÛÉ-Ìi*>}iÃÉÜ >Ì 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 ÜÌ Ê«ÀÊÀi>Ìi`Ê>ÌiÀ>\ UÊÊ ÌvÞÊ Ê>`ÊÌ iÊÕÌÊ>>}iÀÉV >À}iÊÕÀÃiÊi`>ÌiÞÊvÊ>ÞÊ suspected or confirmed CJD case and refer to the CJD policy on the HEIC Web site. UÊÊ1ÃiÊ`ëÃ>LiÊiµÕ«iÌÊÜ iiÛiÀÊ«ÃÃLi°ÊvÊ`ëÃ>LiÊ equipment is used, Central Sterile Department shall be notified prior to the start of the procedure. UÊÊ>LiÊ>Ê>LÀ>ÌÀÞÊ>`Ê«>Ì }ÞÊÀiµÕÃÌÃÊ>ÃÊÃÕëiVÌi`Ê Ê>`Ê notify the lab before sending specimens. UÊÊ/ iÊvÜ}Ê>ÀiÊVÃ`iÀi`Ê } ÞÊviVÌÛiÊ>`Êà Õ`ÊLiÊ >`i`Ê ÜÌ ÊiÝÌÀiiÊV>ÕÌ\ÊLÀ>]Êë>ÊVÀ`]Ê«ÌVÊÌÃÃÕiÃÊ>`Ê«ÌÕÌ>ÀÞÊ gland UÊÊ/ iÊvÜ}Ê>ÀiÊVÃ`iÀi`ÊÌÊLiÊvÊÜiÀÊviVÌÛÌÞ\Ê -]Ê`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 ÊÌ iÊvÜ}ÊÕÌÃ\Ê 1]Ê7 1]Ê 6- 1]Ê- 1]Ê /1Ê­7®]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>ÌiÌ\ UÊÊâÌ ÀÞVÊxääÊ}Ê*"ÊViÊÊ`>ÞÊ£]ÊÌ iÊÓxäÊ}Ê*"Ê`>ÞÊÊ `>ÞÃÊÓqx OR UÊÊ>VÀ`iÊ>iÀ}Þ\Ê/*É-8Ê£Ê -ÊÌ>LiÌÊ*"Ê ÊvÀÊ£{Ê`>Þà 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*ÀÛ>ÌiÊÀÊÀiµÕÀi`° UÊÊ*>ÌiÌÃÊÜÌ ÊVÛiÌ>ÊÃV>LiÃÊÕÃÌÊLiÊÌÀi>Ìi`ÊÜÌ Ê>ÊÃV>LV`iÊ once, and the precautions may be discontinued 24 hours after the treatment is completed. UÊÊ*>ÌiÌÃÊÜÌ Ê ÀÜi}>ÊÃV>LiÃÊÀiµÕÀiÊÓÊÌÀi>ÌiÌÃÊÜÌ Ê>ÊÃV>LV`iÊ 1 week apart. Contact precautions may be discontinued 24 hours after the second treatment is completed. UÊÊviÃÌi`ÊVÌ }Ê>`ÊiÊà Õ`ÊLiÊÃi>i`ÊÊ>Ê«>ÃÌVÊL>}ÊvÀÊ{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«À}i`ÊÃÌÃÊVÌ>VÌÊVVÕÀÃÊÜÌ Ê>ÊÃV>LiÃÊ«>ÌiÌ]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 ÊÌ iÊiiVÌÀVÊ«>ÌiÌÊÀiVÀ`ÊÜÌ ÊÌ iÊÌiÃÌÊ>iʺ >VÌiÀ}Þ-Ì 6, Ê-ÌÊ-ÕÀÛ°Ê ÕÌ°»Ê7 iÊ>ÊVÕÌÕÀiÊ}ÀÜÃÊ6, ]ÊÌ iÊ«>ÌiÌÊÃÊy>}}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 ÊÌ iÊvÜ}ÊÕÌÃ\Ê 1]Ê7 1]Ê 6- 1]Ê- 1]Ê /1Ê­7®]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/ iÊvÜ}Ê`iwÌÃÊ>««ÞÊÌÊ«>ÌiÌÃÊÜÌ ÊâÃÌiÀ\ UÊÊImmunosuppressed:ÊLiÊ>ÀÀÜÊÌÀ>ë>ÌÊÜÌ ÊÌ iÊ«>ÃÌÊÞi>ÀÆÊ >VÕÌiÊiÕi>ÆÊÃ`ÊÀ}>ÊÌÀ>ë>ÌÊÀiV«iÌÃÆÊ«>ÌiÌÃÊÀiViÛ}Ê cytotoxic or immunosuppressive treatments, including steroid treatment for ≥ ÎäÊ`>ÞÃÊÜÌ ÊÌ iÊvÜ}Ê`ÃiÃ\Ê`iÝ>iÌ >ÃiÊ 3 mg daily, cortisone 100 mg daily, hydrocortisone 80 mg daily, «Ài`ÃiÊÓäÊ}Ê`>Þ]ÊiÌ Þ«Ài`ÃiÊ£ÈÊ}Ê`>ÞÆÊ6³Ê«>ÌiÌÃÊ 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®Ê­Üi} ÌÊÊ}I® x 0.85 (if female) 72 (serum creatinine) * Use Actual Body Weight (ABW) unless patient ≥ÊÓä¯ÊÛiÀÊ 7]ÊÕÃiÊ above 7Ê>ÃÊ`iÃVÀLi`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>ÕÀi]ÊÊ É 66 ]Êi`V>À`ÌÃ]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 ÃiÊ­}®ÊrÊ`iÃÀi`Ê«i>ÊÝÊQ7i} ÌÊ­}®ÊÝÊ6`ÊÊ ­É}®RÊ UÊÊ iÃÀi`Ê«i>\ choose from below UÊÊ7i} Ì\ ABW or DBW UÊÊVolume of distribution (Vd) typically ranges LiÌÜiiÊä°ÓxÊqÊä°xÊÉ}ÊÊÃÌÊ«>ÌiÌÃ°Ê Higher Vd should be used in critically ill and volume overloaded patients. Extended-interval dosing UÊÊ À>ÊÀi>ÊvÕVÌÊ­ À Ê >60 mL/min) and all other indications not listed under patient specific dosing iÌ>VÉ/LÀ>ÞV\ xÇÊ}É}Ê6Ê+Ó{ >V\ 15-20 mg/kg IV Q24H Ã}ÊÌiÀÛ>ÊL>Ãi`ÊÊ À \ À ÊÈä\Ê+nI À ÊÎäÈä\Ê+£Ó À ÊÎäÉ 66 É \Ê`ÃiÊLÞÊiÛi *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 ÌÊÌ>À}iÌÊÌ iÊvÜ}\ Peak iÌ>VÉ/LÀ>ÞV\Ê£ÈÓä mcg/mL >V\Ê{äÈäÊV}É Trough iÌ>VÉ/LÀ>ÞV\Ê £ÊV}É >V\Ê{ÊV}É 10-20 mcg/mL 45-50 mcg/mL L>Ãi`ÊÊ Ê L>Ãi`ÊÊ Ê Gentamicin/ Amikacin Tobramycin All IndicationsÊ £ÓÊV}ÉÊ £äÊV}É 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. Ó`Ê`Ãi\ UÊÊ VÌ>ÌÊi« ÀÌÝVÊ Frequency of monitoring medications Ê UÊÊ"ViÊ>ÊÜiiÊ>vÌiÀÊ`iÃÀi`Ê«i>ÉÌÀÕ} ÊÃÊ UÊÊ ÌÀ>ÃÌÊiÝ«ÃÕÀiÊ established in patients with normal renal UÊ}iÊ≥ 60 years function UÊÊ*>ÌiÌÊÃÊÊÌ iÊ 1 Ê UÊÊÀiÊÌ >ÊViÊÜiiÞ\Ê UÊÊ"Ì iÀÊÀÃÃÊvÀÊi« ÀÌÝVÌÞÊ After changes in dosing regimen ­i°}°Ê`>LiÌiÃ]Ê`iÞÊ/8® Patient is on dialysis If trough higher than desired Patient in acute renal failure, SCr increased troughs, use patient specific LÞÊä°xÊ}É`ÊÀÊÎä¯vÀÊL>ÃiiÊ 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: À>ÊÀi>ÊvÕVÌ\ "ViÊ`>Þ\Ê£xÊ}É}Ê6Ê+Ó{Ê­ÀÊ£äÊ}É}Ê6Ê+Ó{ÊvÊxäÊÞi>ÀÃÊvÊ age) / ÀViÊÜiiÞ\ÊÓxÊ}É}Ê6ÊÌ ÀiiÊÌiÃÊ>ÊÜiiÊ­>ÞÊLiÊÀiÊ`vwVÕÌÊ to tolerate) LÀ>ÊÀi>ÊvÕVÌ\ Discuss with pharmacy clinical specialist Therapeutic drug monitoring: Peak and trough not generally iViÃÃ>ÀÞ]ÊiÝVi«ÌÊÊÌ ÃiÊÜÌ ÊÀi>ÊÃÕvwViVÞÊ­,ÊÈäÊÉ®Ê >`ÊvÊ- ÀÊVÀi>ÃiÃÊLÞÊä°xÊ}É`ÊÀÊÎä¯ÊvÀÊL>ÃiiÊÜ iÊ«>ÌiÌÊ on aminoglycoside therapy. Check a trough concentration to monitor for toxicity. Peaks in the low 20 mcg/mL range are acceptable, and trough VViÌÀ>ÌÃÊ>ÀiÊ«ÀiviÀ>LÞÊ{ÊVÉÊÀÊÕ`iÌiVÌ>Li° 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}É}Ê" IÊ Amikacin 10 mg/kg IV Q24H or 3 mg/kg IV Q8H 3 mg/kg IV Q12H 3 mg/kg IV Q24H ÎÊ}É}Ê6Ê" I *Give one dose, check level in 24 hours, redose when Gentamicin/Tobramycin level £ÊV}ÉÊÀÊ>VÊ{ÊV}É }ÞVÃ`iÃÊ>ÀiÊ } ÞÊVViÌÀ>Ìi`ÊÊÕÀiÆÊÌ iÀivÀi]ÊÌ iÀ>«iÕÌVÊ 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 ­,ÊÈäÊÉ®Ê>`ÊvÊ- ÀÊVÀi>ÃiÃÊLÞÊä°xÊ}É`ÊÀÊÎä¯ÊvÀÊ baseline while patient on aminoglycoside therapy. UÊÊGentamicin/Tobramycin:Ê`iÃÀi`ÊÌÀÕ} Ê£ÊV}ÉÊÀÊÕ`iÌiVÌ>Li°Ê UÊÊAmikacin:Ê`iÃÀi`ÊÌÀÕ} Ê{ÊV}ÉÊÀÊÕ`iÌiVÌ>Li° 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 vÌiÀÊ>`}Ê`Ãi\Ê£Ê ÕÀÊ«i>Ê>`ÊnÊ ÕÀÊiÛiÊ>vÌiÀÊÌ iÊi`ÊvÊÌ iÊ infusion to facilitate calculating patient specific kinetic parameters. Aminoglycoside dosing for Gram-positive synergy Dosing for patients with normal renal function: UÊGentamicin\ÊÎÊ}É}Ê6ÊViÊ`>ÞÊÃÊÀiVi`i`ÊvÀÊÌÀi>ÌiÌÊ 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) {äqxÊÊ ÓäqÎÊÊ ÓäÊ Dosing £Ê}É}Ê+£Ó £Ê}É}Ê+Ó{ £Ê}É}Ê" I IÊÊÛiÊiÊ`Ãi]ÊV iVÊiÛiÊÊÓ{Ê ÕÀÃ]ÊÀi`ÃiÊÜ iÊiÛiÊ£Ê}É NOTE: See infective endocarditis guidelines (p. 65) for duration. THERAPEUTIC DRUG MONITORING UÊÊ*i>Ê>`ÊÌÀÕ} Ê>ÀiÊÀiVi`i`Ê>ÀÕ`ÊÌ iÊÌ À`Ê`ÃiÊÌÊ>ÃÃÕÀiÊ appropriate dosing. UÊÊ iÃÀi`ÊÃiÀÕÊVViÌÀ>ÌÃÊvÊGentamicin Peak levels:ÊÎqxÊV}É Trough levels:ÊÊ£ÊV}É 148 NEPHROTOXICITY UÊÊSerum creatinine should be measured at least every other day. If VÀi>ÌiÊVÀi>ÃiÃÊLÞÊä°xÊ}É`ÊÀÊÎä¯ÊvÀÊL>Ãii]ÊÕÃiÊ«>ÌiÌÊ specific dosing. UÊÊi>ÃÕÀiÊserum aminoglycoside levels as needed. See each dosing section above for frequency. UÊÊ-iÊ`>Ì>ÊÃÕ}}iÃÌÊÌ >ÌÊÜiÃÌÊiÛiÊvÊi« ÀÌÝVÌÞÊVVÕÀÃÊÜ iÊ aminoglycosides are administered during the activity period (e.g. £Î\Îä®]ÊÌ iÀivÀiÊ>vÌiÀÊ>`ÃÌÀ>ÌÊÃÊ«ÀiviÀÀi`°Ê OTOTOXICITY UÊÊ Ã`iÀÊLÜiiÞÊVV>ÊÃVÀii}ÊvÀÊÌÌÝVÌÞ Ê UÊÊ iVÊL>ÃiiÊÛÃÕ>Ê>VÕÌÞÊÕÃ}Ê>Ê-iiÊ«ViÌÊV>À` Ê UÊÊ/ÊÃVÀiiÊvÀÊÌÌÝVÌÞ]Ê >ÛiÊ«>ÌiÌÊà >iÊ i>`Ê>`ÊÌ iÊÀiÀi>`Ê card. Ê UÊÊ ViÀÊà Õ`ÊLiÊÀ>Ãi`ÊvÊ«>ÌiÌÊÃiÃÊÓÊiÃÊvÊÛÃÕ>Ê>VÕÌÞ°Ê Consider formal audiology testing. Ê UÊÊ Ì>VÌÊÕ`}ÞÊ­xÈ£xήÊvÀÊ i«ÊÜÌ ÊÌiÃÌ}ÊvÀÊÌÌÝVÌÞ ,iviÀiViÃ\ *É* Ê«>À>iÌiÀ\ÊÊviVÌÊ ÃÊ£nÇÆÊ£xx\Îq "ViÊ`>ÞÊ}À>ÃÊÀiÛiÜ\ÊPharmacotherapy ÓääÓÆÊÓÓ­®\£äÇÇq£änΰ *>ÌiÌëiVwVÊ`Ã}\ÊCrit Care MedÊ££ÆÊ£\£{näq£{nx° - 1É7 1Ê`Ã}\ÊSurgeryÊ£nÆÊ£Ó{\ÇÎn° i« ÀÌÝVÌÞ\ÊAntimicrob Agents and ChemotherÊÓääÎÆÊ{Ç\£ä£ä° /-É -ÊÞVL>VÌiÀÕÊÕ`iiÃ\ÊAm J Respir Crit Care MedÊÓääÇÆÊ£Çx\ÎÈÇq{£È° À>«ÃÌÛiÊ-ÞiÀ}Þ\ÊCirculationÊÓääxÆÊ£££­Óή\ÊiÎ{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 ÃÌ>ÌiÊVÀi>ÌiÊVi>À>ViÊ­ À ®ÊÕÃ}Ê VVÀvÌ>ÕÌÊiµÕ>Ì\ À Êr ­£{äÊqÊ>}i®Ê­Üi} ÌÊÊ}®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 ÇxäÊ}Ê ÇxäÊ}ÊÊ Q12H Q24H ÈäqÇxÊ £äääÊ}Ê £äääÊ}ÊÊ Q12H Q24H ÇxqäÊ £ÓxäÊ}Ê £ÓxäÊ}ÊÊ Q12H Q24H äq££äÊ £xääÊ}Ê £xääÊ}ÊÊ Q12H Q24H ££äq£ÓxÊ £ÇxäÊ}Ê £ÇxäÊ}ÊÊ Q12H Q24H £Óxq£{äÊ ÓäääÊ}Ê ÓäääÊ}ÊÊ Q12H Q24H >140 Consult Pharmacy CrCl (mL/min) 15–29 <15 ÇxäÊ}Ê Q48H £äääÊ}Ê Q48H £ÓxäÊ}Ê Q48H £xääÊ}Ê Q48H £ÇxäÊ}Ê Q48H ÓäääÊ}Ê Q48H £äääÊ}]ÊÌ iÊÀi`ÃiÊLÞÊiÛi† £äääÊ}]ÊÌ iÊÀi`ÃiÊLÞÊiÛi† £ÓxäÊ}]ÊÌ iÊÀi`ÃiÊLÞÊiÛi† £xääÊ}]ÊÌ iÊÀi`ÃiÊLÞÊiÛi† £ÇxäÊ}]ÊÌ iÊÀi`ÃiÊLÞÊiÛi† ÓäääÊ}]ÊÌ iÊÀi`ÃiÊLÞÊiÛi† ÀÊ«>ÌiÌÃÊÜÌ Ê À Ê£xÊÉÊ>`ÊÌÊÀiViÛ}Ê i`>ÞÃÃÊÀi`ÃiÊÜ iÊÀ>`Ê iÛiÊ£xqÓäÊV}É°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*>ÌiÌÃÊà Õ`ÊLiÊÀi`Ãi`ÊL>Ãi`ÊÊÃiÀÕÊiÛiÃÊ`À>ÜÊ>ÀÕ`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 Ìi\Ê >ÞÃÃÊyÜÊÀ>ÌiÃÊÓ°xÊÉ ÊÊVÃÕÌÊ« >À>VÞ UÊMonitoring: Ê UÊÊ*>ÌiÌÃÊÜÌ ÊV >}}Ê`>ÞÃÃÊyÜÊÀ>ÌiÃÊÀÊ`>ÞÃÃÊ i`ÊvÀÊ{Ê hours may need more frequent monitoring (consult pharmacy) Ê UÊÊ*>ÌiÌÃÊÊÃÌ>LiÊ`>ÞÃÃÊyÜÊÀ>ÌiÃÊà Õ`Ê >ÛiÊÌÀÕ} ÊiÛiÊ checked prior to 4th dose Peritoneal Dialysis (PD) UÊInitial dose: 15-20 mg/kg once UÊÊÊ ÃÕÌÊ« >À>VÞÊvÀÊÀiVi`>ÌÃÊvÀÊÀi`Ã}Ê>`ÊÌÀ}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/ÀÕ} ÊiÛiÃÊà Õ`ÊLiÊLÌ>i`ÊÜÌ ÊÎäÊÕÌiÃÊvÊÌ iÊiÝÌÊ`ÃiÊ>ÌÊ steady-state conditions (approximately before the 4th dose). UÊÊÊ«>ÌiÌÃÊÜÌ Ê -, ÊÊ i`>ÞÃÃ]ÊÌÊÃÊ«ÀiviÀ>LiÊÌÊLÌ>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/ÀÕ} ÊiÛiÃÊà Õ`ÊLiÊVÃ`iÀi`ÊÊ«>ÌiÌÃÊÜÌ Ê>ÞÊÌ iÊvÜ}Ê VÀVÕÃÌ>ViÃ\ UÊÊ,iViÛ}Ê>}}ÀiÃÃÛiÊ`Ã}Ê­£xääÊ}Ê+£Ó®ÊÀÊ+nÊÌiÀÛ> U Serious infections such as meningitis, endocarditis, osteomyelitis, and MRSA pneumonia. UÊÊ1ÃÌ>LiÊÀi>ÊvÕVÌÊ­V >}iÊÊ- ÀÊvÊä°xÊ}É`ÊÀÊxä¯ÊvÀÊ baseline) or dialysis 151 A B. Vancomycin dosing and monitoring Ê UÊÊÊ*Ài`>ÞÃÃÊiÛiÊ(preferred)\ÊÓxÊV}ÉÊ­vÀÊi}ÌÃÊVÃ`iÀÊ Ài`Ã}ÊvÊÎäÊV}É® Ê UÊ*ÃÌ`>ÞÃÃÊiÛi\ÊÓäÊV}É® Note:ÊÕÃÌÊÜ>ÌÊÎqÈÊ ÕÀÃÊ>vÌiÀÊÌ iÊi`ÊvÊÌ iÊ`>ÞÃÃÊÌÊ>VVÕÌÊvÀÊ redistribution of tissue and plasma levels UÊÊÀÊ«>ÌiÌÃÊÜÌ Ê -, ÊÊ>ÊÃÌ>LiÊ ÊÃV i`Õi]Ê>ÊÀi}iÊà Õ`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 VÕÀÀiÌÊÌ iÀ>«ÞÊÜÌ Êi« ÀÌÝVÊ>}iÌÃÊ­i°}°Ê>}ÞVÃ`iÃ]Ê Colistin, Amphotericin B) UÊ*À}i`ÊVÕÀÃiÃÊ­≥ 5 days) of therapy. UÊÀiµÕiVÞÊvÊÌÀ}Ê6>VÞVÊÌÀÕ} ÊiÛiÃ\Ê UÊÊ"ViÜiiÞÊÌÀ}ÊÃÊÀiVi`i`ÊvÀÊ«>ÌiÌÃÊÜÌ ÊÃÌ>LiÊ renal function who have achieved desired trough levels. UÊÊÀiÊvÀiµÕiÌÊÌÀ}ÊÃÊÀiVi`i`ÊvÀÊ«>ÌiÌÃÊÜ Ê>ÀiÊ hemodynamically unstable and/or with changing renal function. Desired Vancomycin trough levels UÊÊ*iÕ>]ÊÃÌiÞiÌÃ]Êi`V>À`ÌÃ]ÊL>VÌiÀi>\Ê£xÓäÊV}É UÊÊ -ÊviVÌÃ\ÊÓäÊV}É UÊÊ iÕÌÀ«iVÊviÛiÀ]ÊÃÊ>`ÊÃÃÌÀÕVÌÕÀiÊviVÌÃ\Ê£ä£xÊV}É UÊÊÕÊÃiÀÕÊÌÀÕ} ÊVViÌÀ>ÌÃÊ£äÊV}ÉÊà Õ`Ê>Ü>ÞÃÊ be maintained to avoid development of resistance. Monitoring for Toxicity UÊÊ-iÀÕÊVÀi>ÌiÊà Õ`ÊLiÊi>ÃÕÀi`Ê>ÌÊi>ÃÌÊiÛiÀÞÊÌ iÀÊ`>ÞÊÌ>Þ]Ê then weekly if patient’s renal function remains stable. UÊÊÌi`Ê`>Ì>ÊÃÕ}}iÃÌÊ>Ê`ÀiVÌÊV>ÕÃ>ÊÀi>Ìà «ÊLiÌÜiiÊ nephrotoxicity and higher serum trough concentrations (>15-20 mcg/ mL). Monitor Vancomycin trough levels (see above for frequency and indications). UÊÊÀ>Ê>Õ`}ÞÊÌiÃÌ}ÊÃÊÌÊÀiVi`i`ÊvÀÊ«>ÌiÌÃÊÀiViÛ}Ê Vancomycin, unless signs and symptoms of ototoxicity became apparent. ,iviÀiViÃ\ -É-*É- *ÊÕ`iiÃÊÌ iÀ>«iÕÌVÊÌÀ}ÊvÊ6>VÞV\ÊÊÊi>Ì -ÞÃÌÊ * >À°ÊÓääÆÊÈÈÆÊnÓ°Ê ÀÃiÊiÌÊ>°ÊÌVÀL>Ê}iÌÃÊ iÌ iÀÊ£nÇÆÊΣ\£ÇÎÇ° 6>`iV>ÃÌiiiÊiÌÊ>°Ê ÊviVÌÊ ÃÊÓ䣣ÆÊxÎ\£Ó{q° >ÀÌ ÊiÌÊ>°Ê`iÞÊÌÊ£ÈÆÊxä\ÓqÎÈ° 152 153 À>ÊÀi>ÊvÕVÌ\ CBC, BUN, Creatinine ÊÊÊÊ6>VÞVÊiÛiÊqÊtrough (see dosing section p. 150) >ÞÃÃ\ Vancomycin level (see dosing section p. 150) At each dialysis session C. Antimicrobial therapy monitoring A Weekly Weekly, unless change in creatinine ( xä¯ÊvÀÊL>Ãii®]ÊÌ iÊÌÜViÊÜiiÞÊ ,iviÀiVi\Ê*À>VÌViÊÕ`iiÃÊvÀÊ"ÕÌ«>ÌiÌÊ*>ÀiÌiÀ>ÊÌVÀL>Ê/ iÀ>«Þ\Ê ÊviVÌÊ ÃÊÓää{ÆÊÎn\£Èx£° Vancomycin UÊÊ}ÊÌiÀÊ`iwi`Ê>ÃÊ≥ 1 week, except for aminoglycosides and Amphotericin B (see below) UÊÊÀÊÕÃiÊViÊÌ>Ê`Ã}Ê>`ÊÃiÀÕÊiÛiÃÊ >ÛiÊLiiÊiÃÌ>Là i` UÊÊ/ iÃiÊÌÀ}ÊÀiVi`>ÌÃÊ>`ÊÌÀ}ÊvÀÊ>}iÌÃÊÌÊÃÌi`Êà Õ`ÊLiÊ`Û`Õ>âi`]ÊL>Ãi`ÊÊi>V Ê«>Ìi̽ÃÊVV>Êvi>ÌÕÀiÃ]ÊVÕ`}Ê}iiÀ>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 }ÞVÃ`iÊiÛiÊqÊtrough 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 £qÓÊÜiiÃÊ 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 £ÊqÊÓÊÜiià 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 *"Ê­VÕ`}Êi`V>ÌÃ®Ê UÊÊ>LÌÞÊÌÊÌ>iÊÌ iÀÊÀ>Êi`V>ÌÃÊ",ÊÌÊÌiÀ>Ì}Ê>ʵÕ`Ê diet/tube feeds UÊi`Þ>VÊÃÌ>LÌÞÊ UÊ,iViÛ}ÊVÌÕÕÃÊ ÊÃÕVÌ}Ê UÊÊ-iÛiÀiÊ>ÕÃi>]ÊÛÌ}]Ê`>ÀÀ i>]ÊÊLÃÌÀÕVÌ]Ê`ÞÃÌÌÞ]Ê mucositis UÊÊ>>LÃÀ«ÌÊÃÞ`ÀiÊ 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 ÝVÊ Ç{ÊqÊä¯ Amoxicillin/Clavulanate (Augmentin®®ÊÊÊ Ç{ÊqÊä¯ Azithromycin*Ê ÎnÊqÊnί i« >iÝÊÊ ä¯ Cefpodoxime*ÊÊ {£ÊqÊxä¯ `>ÞVÊÊ ä¯ ÝÞVÞViÊ äÊqÊ£ää¯ /iÌÀ>VÞViÊÊ ÇxÊqÊnä¯ Can be used orally for bacteremia or fungemia Ciprofloxacin Ê ÈxÊqÊnx¯ Fluconazole >ä¯ Linezolid†Ê £ää¯ iÌÀ`>âiÊ £ää¯ Moxifloxacin Ê ä¯ Trimethoprim/sulfamethoxazole†Ê £ää¯ Voriconazole‡¶Ê ÈäÊqÊȯ * 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 ÊÌÊÕÃiÊÜÌ ÊVÌÕÕÃÊÌÕLiÊvii`ÃÊ­6Ê«ÀiviÀÀi`®°Ê*>ÌiÌÃÊÜÌ ÊVÞVVÊÌÕLiÊvii`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 VÞVÛÀÊ6ÊÊÊ Ê Ê Ê Acyclovir PO ­iÌ>Ê iÀ«iÃ®Ê Acyclovir PO ­iÀ«iÃÊ<ÃÌiÀ®ÊÊ Ê Amikacin xq£äÊ}É}Ê+nÊ Ê Ê Ê 200 mg 5x daily Ê 800 mg 5x daily Ê Ê xäÊ ÓxqxäÊ £äqÓ{Ê † £äÊÀÊ Ê >10 £äÊ >25 £äqÓxÊ † £äÊÀÊ ÝVÊ Ê Ê Amoxicillin ­«iÕ>®Ê Ê ÝVÉÊ V>ÛÕ>>ÌiÊ Ê « ÌiÀVÊ Ê AmBisome®Ê «VÊ Ê Ê «VÉÊ ÃÕL>VÌ>Ê xääq£äääÊ}Ê+£ÓÊ Ê Ê 1 g Q8H Ê Ê xääq£äääÊ}Ê+£ÓÊ Ê Ê ä°Çq£Ê}É}Ê+Ó{Ê ÎqxÊ}É}Ê+Ó{Ê £qÓÊ}Ê+{qÈÊÊ Ê Ê £°xqÎÊ}Ê+ÈÊ Ê Ampicillin/ ÃÕL>VÌ>Ê­vÀÊ Acinetobacter, E. faecalis) âÌ ÀÞVÊ âÌÀi>ÊÊ Ê Ê iv>âÊ Ê Ê 3 g Q4H Ê ÎäÊ £äqÎäÊ † £äÊÀÊ Ê >30 £äqÎäÊ † £äÊÀÊ ÎäÊ £äqÎäÊ † £äÊÀÊ qÊ qÊ xäÊ £äqxäÊ † £äÊÀÊ Ê ≥ÎäÊ £xqÓÊ † ≤14 or HD Ê ≥50 £äqxäÊ † HD xq£äÊ}É}Ê+n xq£äÊ}É}Ê+£Ó xq£äÊ}É}Ê+Ó{ Ó°xqxÊ}É}Ê+Ó{ 200 mg 5x daily ÓääÊ}Ê+£ÓÊ 800 mg 5x daily nääÊ}Ê+n 800 mg Q12H See section on aminoglycoside dosing xääq£äääÊ}Ê+£Ó ÓxäqnÇxÊ}Ê+£Ó ÓxäqnÇxÊ}Ê+Ó{ 1g Q8H £}Ê+£Ó 1g Q24H xääq£äääÊ}Ê+£Ó ÓxäqxääÊ}Ê+£Ó ÓxäqxääÊ}Ê+Ó{ Ê`Ã>}iÊ>`ÕÃÌiÌ Ê`Ã>}iÊ>`ÕÃÌiÌ £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 ÓxäqxääÊ}Ê+Ó{Ê £qÓÊ}Ê+nÊÊ Ê Ê £qÓÊ}Ê+nÊ Ê Ê qÊ ≥ÎäÊ £äqÓÊ † £äÊÀÊ Ê ≥ÎxÊ ££qÎ{Ê £äÊÀÊ † intermittent HD † HD Ê`Ã>}iÊ>`ÕÃÌiÌ £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 ÓÊÀÊ >60 ÎäqÈäÊ ££qÓÊ ££ÊÀÊ ≥ÎäÊ £äqÓÊ £äÊÀÊ ≥ÎäÊ ÎäÊ HD†Ê Ê Ê Ceftolozane/ Ì>âL>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 £xqÓÊ £xÊÀÊ >50 ÎäqxäÊ £xqÓÊ £xÊÀÊ xäÊ ÎäqxäÊ £xqÓÊ £xÊÀÊ >50 ÎäqxäÊ £xqÓÊ ÓÊÀÊ Ceftolozane/ Ì>âL>VÌ>Ê ­-iÀÕÃÊviVÌÃ®Ê Ê 3 g Q8H Ê Ê Ê >50 ÎäqxäÊ £xqÓÊ ÉÓÊÀÊ ivÌÀ>ÝiÊ ivÌÀ>ÝiÊÊ (Central nervous system infections) Cephalexin Ê Ê Cidofovir £qÓÊ}Ê+Ó{Ê ÓÊ}Ê+£ÓÊ qÊ qÊ 300 mg Q12H Î Ê ääÊ}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{ääÊ}Ê+£Ó £ääq{ääÊ}Ê+Ó{ Ê£ääq{ääÊ}ÊÌ ÀiiÊÌiÃÉ week 600 mg Q12H {ääÊ}Ê+£Ó ÎääÊ}Ê+£Ó 200 mg Q12H 600 mg Q8H {ääÊ}Ê+n ÎääÊ}Ê+n 400 mg Q12H £qÓÊ}Ê+n £qÓÊ}Ê+£Ó £qÓÊ}Ê+Ó{ 1 g Q24H 1.5 g Q8H ÇxäÊ}Ê+n ÎÇxÊ}Ê+n Load with 750 mg, then 150 mg Q8H 3 g Q8H £°xÊ}Ê+n ÇxäÊ}Ê+n Load with 1.5 g, then 375 mg Q8H Ê`Ã>}iÊ>`ÕÃÌiÌ Ê`Ã>}iÊ>`ÕÃÌiÌ 500 mg PO Q6H Ê Ê 5 mg/kg Q week for 2 weeks, then every other week {ääÊ}Ê+nq£ÓÊÊ Ê ÓxäqÇxäÊ}Ê+£ÓÊ Ê ÓxäqxääÊ}Ê+£ÓÊ Ê *"\ÊÎääÊ}Ê+nÊ 6\ÊÈääÊ}Ê+nÊ 2.5 mg/kg Q12H Ê >50 £äqxäÊ £äÊÀÊ † ≤55 or Cr>1.5 500 mg Q6H xääÊ}Ê+n 500 mg Q12H Not recommended ≥ÎäÊ ÎäÊÀÊ † ≥ÎäÊ ÎäÊÀÊ †Ê ≥ÎäÊ ÎäÊ qÊ Ê ≥50 ÓäqxäÊ ≤20 or HD† {ääÊ}Ê+nq£ÓÊ 400 mg Q24H ÓxäqÇxäÊ}Ê+£Ó ÓxäqxääÊ}Ê+Ó{ ÓxäqxääÊ}Ê+£Ó ÓxäqxääÊ}Ê+Ó{ Ê`Ã>}iÊ>`ÕÃÌiÌ Cefepime 1 g Q8H Ê Ê Ê Ê Cefepime 2 g Q8H ­ iÌÀ>ÊiÀÛÕÃÊÊ Ê ÃÞÃÌiÊviVÌÃÊÀÊÊ Ê Pseudomonas®Ê Ê ivÌiÌ>Ê £qÓÊ}Ê+£ÓÊÊ Ê Ê Ê Ê iv«`ÝiÊ £ääq{ääÊ}Ê+£ÓÊ Ê Ê Ceftaroline Ê Ê Ê Ceftaroline for ,-Ê Ê Ê ivÌ>â`iÊ «ÀyÝ>VÊ6Ê Ê «ÀyÝ>VÊ*"Ê Ê >ÀÌ ÀÞVÊ Ê `>ÞVÊ Ê Colistin ­ ÃÌiÌ >Ìi®Ê 156 † † † † † † † † 2.5 mg/kg Q12H Ó°xÊ}É}Ê+Ó{ 1.25 mg/kg Q24H Typical dose (may vary) CrCl (mL/min) Dose adjustment for renal insufficiency >«ÌÞVÊÊ vÀÊi`V>À`ÌÃÉÊ bacteremia VÝ>VÊ ÝÞVÞViÊ Ertapenem Ê Ì >LÕÌÊ Ê Èq£äÊ}É}Ê+Ó{ÊÊ Ê ÕV>âiÊ ÓääqnääÊ}Ê+Ó{Ê ≥ÎäÊ ÎäÊ HD†Ê qÊ qÊ ≥30 ÎäÊÀÊ ≥10 £äÊ HD† ≥50 Ê Ê ÕVÞÌÃiÊ­xq ®Ê Ê Ê Ê Ganciclovir ­`ÕVÌÊ`Ãi®Ê Ê Ê Ê Ê Ê £Ó°xqÓxÊ}É}Ê+ÈÊ Ê Ê Ê 5 mg/kg Q12H Ê Ê Ê Ê xäÊÀÊ † ÊÊ {äÊ Óäq{äÊ £äq£Ê £äÊÀÊ †Ê ≥70 xäqÈÊ Óxq{Ê £äqÓ{Ê £äÊÀÊ † Ganciclovir ­>Ìi>ViÊÊ `Ãi®Ê Ê Ê 5 mg/kg Q24H Ê Ê Ê Ê ≥70 xäqÈÊ Óxq{Ê £äqÓ{Ê £äÊÀÊ iÌ>VÊ qÊ qÊ Ã>â`Ê iâ`Ê Meropenem Ê Ê Ê Meropenem ­i}ÌÃ]Ê , ÊÊ viVÌîÊÊ Ê iÌÀ`>âiÊ V>vÕ}Ê ÝyÝ>VÊ Nitrofurantoin (Macrobid®®Ê Oseltamivir ­/Ài>ÌiÌ®Ê Ê Ê Oseltamivir ­*À« Þ>ÝÃ®Ê Ê Ê "Ý>VÊ *iVÊÊÊ Ê Ê ÎääÊ}Ê+Ó{Ê ÈääÊ}Ê+£ÓÊ 1 g Q8H Ê Ê Ê 2 g Q8H Ê Ê Ê xääÊ}Ê+nÊ £ääq£xäÊ}Ê+Ó{Ê {ääÊ}Ê+Ó{ÊÊ 100 mg Q12H Ê 75 mg Q12H Ê Ê Ê 75 mg Q24H Ê Ê Ê £qÓÊ}Ê+{qÈÊÊ Îq{ÊÊÕÌÃÊ+{Ê Ê Ê qÊ qÊ >51 ÓÈqxäÊ £äqÓxÊ £äÊÀÊ >51 ÓÈqxäÊ £äqÓxÊ £äÊÀÊ qÊ qÊ qÊ ≥50 xäÊ >60 ÎäqÈäÊ £äqÓÊ £äÊÀÊ >60 ÎäqÈäÊ £äqÓÊ £äÊÀÊ qÊ ≥xäÊ £äq{Ê £äÊÀÊ Èq£äÊ}É}Ê+Ó{ Èq£äÊ}É}Ê+{n Èq£äÊ}É}Ê+{n Ê`Ã>}iÊ>`ÕÃÌiÌ Ê`Ã>}iÊ>`ÕÃÌiÌ 1 g Q24H 500 mg Q24H Normal dose Q24H À>Ê`ÃiÊ+{n Normal dose QHD session Normal dose (e.g. 100, 400, 800 mg) Q24H Load w/normal dose, then xä¯ÊvÊÀ>Ê`ÃiÊ+Ó{ £Ó°xqÓxÊ}É}Ê+È £Ó°xqÓxÊ}É}Ê+£Ó £Ó°xqÓxÊ}É}Ê+Ó{ £Ó°xqÓxÊ}É}Ê+Ó{q{n 5 mg/kg Q12H Ó°xÊ}É}Ê+£Ó Ó°xÊ}É}Ê+Ó{ £°ÓxÊ}É}Ê+Ó{ 1.25 mg/kg three times/week, administer after HD 5 mg/kg Q24H Ó°xÊ}É}Ê+Ó{ £°ÓxÊ}É}Ê+Ó{ ä°ÈÓxÊ}É}Ê+Ó{ 0.625 mg/kg three times/ week, administer after HD Ê iiÊÃiVÌÊÊ>}ÞVÃ`iÊ dosing Ê`Ã>}iÊ>`ÕÃÌiÌÊ Ê`Ã>}iÊ>`ÕÃÌiÌÊ 1 g Q8H £Ê}Ê+£Ó xääÊ}Ê+£Ó 500 mg Q24H 2 g Q8H £Ê}Ê+nÊ £Ê}Ê+£Ó 1 g Q24H Ê`Ã>}iÊ>`ÕÃÌiÌ Ê`Ã>}iÊ>`ÕÃÌiÌ Ê`Ã>}iÊ>`ÕÃÌiÌ 100 mg Q12H ÌÊÀiVi`i` 75 mg Q12H ÇxÊ}Ê+Ó{ ÎäÊ}Ê+Ó{ 30 mg QHD session 75 mg Q24H ÎäÊ}Ê+Ó{ ÎäÊ}Ê+{n 30 mg every other HD session Ê`Ã>}iÊ>`ÕÃÌiÌ Îq{ÊÊÕÌÃÊ+{ £°xÊÊÕÌÃÊ+{ 1.5 million units Q6H ÓxäqxääÊ}Ê+ÈÊÊ £ääÊ}Ê+£ÓÊ 1 g Q24H Ê £xqÓxÊ}É}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 *«iÀ>VÉÊ tazobactam Ê Î°ÎÇxq{°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+ÈÊvÀÊ Pseudomonas) Ó Ê °ÓxÊ}Ê+nÊ­Ó°ÓxÊ}Ê+ÈÊvÀÊ Pseudomonas) 2.25 g Q12H (2.25 g Q8H for Pseudomonas) Ê`Ã>}iÊ>`ÕÃÌiÌ ≥£äÊ £äÊ HD†Ê qÊ £xqÎäÊ}É}Ê+Ó{ £ÓqÓäÊ}É}Ê+Ó{ ÓxqÎäÊ}É}Ê+ ÊÃiÃà Ê`Ã>}iÊ>`ÕÃÌiÌ HD† *Ã>V>âiÊ *ÞÀ>â>`iÊ Ê +ÕÕ«ÀÃÌÉÊ dalfopristin ,v>«Ê­/ ®Ê ,v>«Ê /}iVÞViÊ /*É-8ÊÊ ­1/ÃÊÀÊViÕÌÃ®Ê Ê Ê /*É-8ÊÊÊ ­* *ÊÀÊÃiÀÕÃÊÊ systemic infections) 6>>VÞVÛÀÊ ­iÌ>Ê iÀ«iÃ®Ê Ê Valacyclovir ­iÀ«iÃÊ<ÃÌiÀ®Ê Ê Ê Valganciclovir ­`ÕVÌÊ`Ãi®Ê Ê Ê Ê Valganciclovir ­>Ìi>ViÊ`Ãi®Ê Ê Ê Ê 6>VÞVÊ 6ÀV>âiÊ † -iiÊ*Ã>V>âiÊ guidelines p. 18 £xqÎäÊ}É}Ê+Ó{Ê Ê Ç°xÊ}É}Ê+nÊÊ ÈääÊ}Ê+Ó{Ê ÎääÊ}Ê+nq£ÓÊ £ääÊ}ÊVi]ÊÌ iÊÊ 50 mg Q12H *"\Ê£qÓÊ -ÊÌ>LÊ+£ÓÊ 6\Ê£ÈäqÎÓäÊ}Ê+£ÓÊ ­ Ã}ÊÃÊL>Ãi`ÊÊÊ /*ÊV«iÌ®Ê xÊ}É}Ê+ÈqnÊ Ê xääq£äääÊ}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 -iiÊ6ÀV>âiÊÊ guidelines p. 19 qÊ qÊ qÊ ≥ÎäÊ Ê † ÎäÊÀÊ Ê Ê ≥ÎäÊ ÎäÊ HD† ≥ÎäÊ £äqÓÊ £äÊÀÊ † ≥50 Îäq{Ê £äqÓÊ £äÊÀÊ † ≥60 {äqxÊ ÓxqÎÊ £äqÓ{ £äÊÀÊ † ≥60 {äqxÊ ÓxqÎÊ £äqÓ{ £äÊÀÊ † qÊ qÊ Ê`Ã>}iÊ>`ÕÃÌiÌ Ê`Ã>}iÊ>`ÕÃÌiÌ Ê`Ã>}iÊ>`ÕÃÌiÌ £qÓÊ -ÊÌ>LÊ+£ÓÊÀÊ £ÈäqÎÓäÊ}Ê6Ê+£ÓÊÊ £qÓÊ -ÊÌ>LÊ+Ó{ÊÀ £ÈäqÎÓäÊ}Ê6Ê+Ó{ xÊ}É}Ê+ÈqnÊ Ó°xÊ}É}Ê+Èqn 2.5 mg/kg Q8H xääq£äääÊ}Ê+£Ó xääq£äääÊ}Ê+Ó{ 500 mg Q24H 1 g Q8H £Ê}Ê+£Ó £Ê}Ê+Ó{ 500 mg Q24H 900 mg Q12H {xäÊ}Ê+£Ó {xäÊ}Ê+Ó{ 450 mg Q48H Not recommended 900 mg Q24H {xäÊ}Ê+Ó{ {xäÊ}Ê+{n 450 mg twice weekly Not recommended Ê-iiÊÃiVÌÊÊÛ>VÞVÊ dosing Ê`Ã>}iÊ>`ÕÃÌiÌÊà 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 Osler 425 (443) 287-4570 (7-4570) © Copyright 2015 by The Johns Hopkins Hospital Antimicrobial Stewardship Program. All rights reserved. No part of this publication 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.