Treatment of CAP – Adults
CID 2007:44(Suppl 2) S28-72
(Infectious Diseases Society of America/American Thoracic Society)
Can J Infect Dis 2000;11:237-48
(Canadian Infectious Disease Society/Canadian Thoracic Society)
Stanford Guide 2009
Outpatient
Most Common Pathogens
First Line Therapy
Alternate Therapy
No comorbid
Strep pneumonia,
Mycoplasma pneumonia,
Haemophilus influenza,
Chlamydophila pneumoniae
Azithromycin/clarithromycin
Doxycycline*
Levofloxacin
OR
Ceftriaxone + azithromycin
Azithromycin + amoxclavulin
S. pneumonia, M. pneumonia, C.
pneumoniae H. influenza,
Legionella, ,Anaerobes
S. pneumoniae
Staphylococcus aureus
(MSSA, CA-MRSA)
Legionella species
Gram-negative bacilli
H. influenzae
ICU bugs +MRSA
Levofloxacin
OR
Ceftriaxone + azithromycin
Levofloxaxin + ceftriaxone
Levofloxacin + azithromycin
Vancomycin + Levofloxacn
Linezolid + Levofloxacin
ICU bugs + p. aeruginosa
Antipneumococcal, antipseudomonal
β-lactamase° PLUS
Ciprofloxacin or levofloxacin
β-lactamase° +
aminoglycoside +
azithromycin
OR
β-lactamase° +
aminoglycoside +
cipro/levoquin
Comorbid
Abx in last 3 months
macrolide resist strep
pneumo (>25%)
Inpatient
Ward
ICU§
ICU + suspect MRSA
ICU + suspect
pseudomonas
Levofloxacin + piptazo
*level III evidence
§
This is the minimal regime, often will require coverage of MRSA or pseudomonas.
°pipercillin-tazobactam, cefepime, imipenem, meropenem
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Etiology:
 In the patients managed as outpatients, M. pneumonia accounts for 15-37% of patients. It is likely strep pneumo is under
diagnosed in this group.
 Strep pneumonia is accountable for about half of all cases requiring admission to hospital, followed by C. pneumonia and H
influenza.
 Anaerobic gram negative bacilli like E-coli and Klebsiella are less common but are important to consider in patients who require
ICU admission. They are also more common in a nursing home setting.
Risk Factors / Features of CA-MRSA pneumonia
 Resistant to fewer antimicrobials than are hospital-acquired MRSA strains.
 Most produce a toxin associated with the clinical features of
o necrotizing pneumonia
o shock
o respiratory failure F
o formation of abscesses and empyemas (in patients without RF’s for anaerobic aspiration pneumonia)
Risk Factors for Pseudomonas:
 Chronic oral steroid administration
 Severe underlying bronchopulmonary disease (ie COPD, asthma)
 Alcoholism
 Frequent antibiotic therapy
Drug Resistant S. pneumonia:
 Resistance to numerous classes of antibiotics: penicillins, cephalosporins, macrolides, fluoroquinolones, tetracyclines,
sulfonamides.
 Macrolide resistance in some parts of the world (ie Asia) approaches 50%
 Risk Factors: Unlcear on predictive values for these
o Age <2 or >65
o Beta lactam therapy in last 3 months (most predictive)
o Alcoholism, Immunosuppressive therapies or illness
o Medical co-morbidities
o Exposure to a child in daycare
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
Local S. Pneumoniae resistance Patterns 2010 from Calgary lab Services (% susceptible):
o Penicillin 95% (was 83-91% 2009)
o Ceftriaxone 95%
o Erythromycin 78%
o SXT 76%
o Levofloxacin 86%
o Tetracycline 87%
Treatment of CAP – Pediatrics
Paediatr Child Health. 2003:666-619
Alberta Clinical Practice Guideline 2008
Stanford guide 2009
Outpatient
Most Common Pathogens
First Line Therapy
1-3 month
C. trachomatis, S. pneumonia,
parainfluenzae, RSV, bordatella
Streptococcus pneumoniae
Erythromycin or
Azithromycin
Amoxicillin (80-90 mg/kg/day)
Mycoplasma pneumoniae,
Chlamydia pneumonia, S.
pnemoniae
Azithromycin
4mo – 5 yrs
>5 yrs
Alternative Therapy
PCN allergy: azitho, clinda, or
erythromycin
Amoxicillin + Doxycycline (if > 8
yrs old)
Amoxicillin + Clarithromycin
Amoxicillin + erythromycin
Inpatient
Most Common Pathogens
1-3 month
C. trachomatis, S. pneumonia,
parainfluenzae, RSV, bordatella
<5 yrs
Streptococcus pneumoniae
>5 yrs
Mycoplasma pneumoniae,
Chlamydia pneumonia, S.
pnemoniae*
Doxycycline if > 8 yrs old)
Non-ICU
Erythromycin or azithromycin
Add cefuroxime or cefotaxime if
febrile
Ampicillin
OR
Cefotaxime
OR
cefuroxime
Ceftriaxone + Azithro
ICU
Cefuroxime
OR
Cefotaxime + cloxacillin
cefotaxime + azithromycin +/vancomycin
Ceftriaxone + Azithro +/- Vanco
(if evidence of lung necrosis)
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Treatment of acute UTI and Pyelonephritis in Women
CID 2011;52:e103-120
(Infectious Diseases Society of America/European Society for Microbiology and Infectious Diseases)
Stanford Guide 2009
Uncomplicated UTI
Most Common Pathogens
First Line Therapy (TMP-SMX EColi resistance <20%)
Outpatient management
E. coli (75%–95%),
Klebsiella pneumonia, Staph
saprophyticus.
Most Common Pathogens
TMP-SMX°
Nitrofurantoin*
Fosomycin
Outpatient
E.Coli>enterococcus,
Klebsiella pneumonia, Staph
saprophyticus.
Cipro / copro-ER PO
TMP-SMX PO
(treatment for 14days)
Pyelonephritis
Uncomplicated pyelo
Alternative Therapy
(TMP-SMX E-Coli resistance
<20%, sulfa allergy)
ciprofloxacin°
ciprofloxacin-ER, nitrofurantoin
Inpatient/ HPTP
Gentamycin
Ciprofloxacin IV
Ceftriaxone
Pip-tazo
Ertapenem
Non-ICU
ICU
*for use only in acute uncomplicated cystitis, NOT to be used in pyelonepthritis. Poor suppression of pathogens in periurethral, vaginal and rectal flora.
°Know local resistance patterns
Cystitis:
 TMP-SMX is still a recommended first guideline in areas with E-Coli resisntance <20% (in Calgary it is 21% 2010)
 Fosomycin is not effective against staph saprophyticus.
o An anti-infective agent administered in a single 3g dose.
o In vitro activity against VRE, MRSA, ESBL – still require clinical data
o Not readily available, not often reported in routine susceptibilities.
 Β-lactms not recommended in treatment of acute uncomplicated cystitis.
 Local E-Coli susceptibility patterns:
o Amoxicillin 55%
o Cephalexin 73%
o Cefazolin 94%
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o
o
o
o
Ceftriaxone 97%
TMP-SMX 79%
Ciprofloxacin 94%
Nitrofurantoin 98%
Pyelonephritis:
 These recommendations are for acute uncomplicated pyelo only.
 Local E-Coli susceptibility patterns:
o Pip/tazo 98%
o Ceftriaxone 97%
o TMP-SMX 79%
o Ciprofloxacin 94%
o Gentamycin 95%
 In Calgary, our ID experts have recommended that if we are going to treat a pyelonephritis we use gentamycin as a first line
therapy.
o Higher resistance patterns of ceftriaxone to E-Coli are being seen
o Ceftriaxone excreted in bile (higher rate c. diff) compared to gentamycin excreted renally
o No need to monitor gent levels in short 1-4 day course therapy
o Toxicity very low with sort course, but a baseline creatinine is required.
o Dose: 5-7 mg/kg LBW IV per day
 Lean Body Weight = (2.3 x height in inches over 5’ + 50kg M (45kg F))
o Exceptions, when to use ceftriaxone: (note that ceftriaxone does not cover enterococcus)
 Pregnant
 Renal impairment (GFR <60)
 Cirrhosis or liver transplant
 Previous aminoglycoside toxicity
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Treatment of Acute Bacterial Meningitis
Clinical Microbiology Reviews;2010:467–492
(Infectious Diseases Society of America)
Paediatr Child Health;2008:309
(Canadian Paediatric Society)
Stanford guide
Patient Demographic
Most Common Pathogens
First Line Therapy
Neonate (<1 mo)
L. monocytogenes, E-Coli, Group
B streptococcus, gram negative
bacilli
H. Influenza*, Strep.
pneumoniae , N. meningitides
Ampicillin +gentamycin
OR
Ampicillin +cefotaxime
Cefotaxime or ceftriaxone +
Vancomycinξ
Healthy children >1 mo and
Adults
if Gram –ve bacilli on Gram
stain
Ampicillin + gentamycin +
cefotaxime
Meropenem + Vancomyin
(+ Dexamethasone)
Adults >50,
immunocomprimised, alcoholic
All of above +
Enterobacteriaceae + Listeria
monocytogenes
(HIV +ve: staph aureus,
salmonella)
(+ Dexamethasone)
Cefotaxime or ceftriaxone +
Vancomycin
+ Ampicillin°
(+ Dexamethasone)
*Incidence of H. influenzus type b was dramatically reduced following vaccination.
°For coverage of L. Monocytogenes
ξThe addition of vancomycin is to provide double coverage of resistant S. pneumonia. Therapy can be narrowed based upon culture and sensitivity
results
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Treatment of Intra-abdominal sepsis
Can J Infect Dis Med Microbiol. 2010;21:11-37
(Canadian Surgical Society/Association of Medical Microbiology and Infectious Disease Canada)
CID 2010;50:133-164
(Guidelines from The Surgical Infection Society and the Infectious Diseases Society of America)
Outpatient
Most Common Pathogens
Monotherapy
Combination
Community Acquired with no
recent antimicrobial use
(low to moderate severity)*
Core pathogens: Streptococcus
sp, Enterobacteriaceae ( E-coli,
Klebsiella sp, Proteus sp,
Serratia marcescens) +
anaerobes (B. fragilis, nonfragilis Bacteroides sp,
Clostridium sp, Fusobacterium
sp, Lactobacillus sp,
Peptostreptococcus sp, and
Veillonella sp)
Core pathogens + resistant G–
bacilli, Enterococcus sp, P.
aeruginosa, MRSA
Cefoxitin or
ertapenem, or moxifloxacin or
tigecycline
2nd / 3rd cephalosporin +
metronidazole
ciprofloxacin + metronidazole
Pip-tazo or
Meropenem or
imipenem
3rd / 4th cephalosporin
+metronidazole
ciprofloxacin + metronidazole
Tigecycline + ciprofoxacin
Pip-tazo + gent
Meropenem + gent
Community Acquired + recent
antimicrobial use
AND
Health care associated +/recent antibiotic use
AND
Severely ill patients°
*APACHE II <15
°APACHE II >15
Notes:
 Up to 15 different specimens can be cultured from same infected peritoneal cavity, and it is not always clear which ones are the
key pathogens and which are commensals.
 Classification:
o Uncomplicated (isolated organ system)
o Complicated (infection beyond organ source + peritonitis)
 Community acquired
 Health care associated
 Primary – obvious source ie SBP, peritoneal dialysis
 Secondary – Soiling from hollow viscus ie. Perfed DU
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
Tertiary – recurrent infection
Treatment of Skin and Soft tissue Infections
CID 2005;41:1373-1406 (Infectious Diseases Society of America)
CID 2011:52:18-55 (Infectious Diseases Society of America)
Outpatient
Most Common
Pathogens
β-hemolytic strep,
strep B, C, G, staph
aureus
First Line Therapy
Second Line Therapy
Cephazolin/cephalexin
Clindamycin or
Clarithromycin,
azithromycin or
amox-clavulin, TMPSMX
Cellulitis, purulent +MRSA
RF’s
β-hemolytic strep,
strep B, C, G, staph
aureus (MRSA)
Diabetic,
immunocomprimised
β-hemolytic strep,
strep B, C, G, staph
aureus (MRSA),
enterobacteriae,
anaerobes
TMP-SMX
clindamycin
Doxycycline
Linezolid
(mild-moderte)
Clindamycin + gentamycin
Or
Clindamycin + Ciprofloxacin
Cellulitis, non-purulent, no
MRSA RF
Severe)
Vancomycin +piptazo
Or
Vanco/cipro/metroni
dazole
Inpatient
Complicated cellulitis
β-hemolytic strep,
strep B, C, G, staph
aureus
Vancomycin
Linezolid
Daptomycin
Notes:
 Complicated Skin and soft tissue infection: patients with deeper soft-tissue infections, surgical or traumatic wound infection,
major abscesses, cellulitis, and infected ulcers and burns.
 RF’s for CA-MRSA: prison and jail inmates, injection drug users, Native American populations, gay men, participants in contact
sports, and children
8
Treatment of postpartum endometritis
Stanford Guide
Population
Most Common
Pathogens
First Line Therapy Second Line
Therapy
(includes both post C/S
and post vaginal
delivery)°
G+: Group B
streptococci,strep viridans,
enterococci,
G-: E. coli, P. bivia,
anaer: bacteroides, aerobic
streptococci, G. vaginalis,
peptostreptococci
other: C. trachomonatis, M.
hominis
(Cefoxitin or piptazo )+
doxycycline*
Clindamycin +
gentamycin
Clindamycin +
ceftriaxone
°48hrs – 6 days MUST cover for C. trachomonatis
*doxycycline cannot be administered during breastfeeding
Pregnancy
A) Controlled studies in women fail to demonstrate a risk to the fetus.
B) Animal studies have not revealed toxicity but there are no adequate human studies, or animal studies have shown toxicity that
was not confirmed in human studies.
C) Animal studies have revealed toxicity and there are no adequate human studies, or studies in humans and animals are not
available. Drug should only be given if potential benefit justifies the potential risk to the fetus.
D) Positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk. X. Human
and/or animal studies have shown a risk to the fetus, and risks outweigh benefits. Contraindicated in pregnancy.
Lactation
 L1 = SAFEST: Drug used in a large number of breastfeeding women without affecting infant, or studies indicate that the possibility of
harm to infant is remote, or the drug is not orally bioavailable in infants. L2 = SAFER: Drug used in a limited number of
breastfeeding women without affecting infant, and/or risk to infant by using drug is remote.
 L3 = MODERATELY SAFE: There are no controlled studies. The risk of adverse effects in the infant is possible, or studies show only
minimal non-threatening adverse reactions. Benefit versus risk to the infant must be considered.
 L4 = POSSIBLY HAZARDOUS: There is evidence of risk to the breastfed infant or breast milk production, but the benefits to the
mother may outweigh the risk to the infant (e.g. in life-threatening situations or when safer drugs cannot be used).
 L5 = CONTRAINDICATED: Studies show a significant and documented risk to infants, or it is a drug that has a high risk of causing
significant infant harm. The drug is contraindicated in breastfeeding, as the possible harm to the infant outweighs any potential
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benefits from breastfeeding. AAP ratings: Recommendations from American Academy of Pediatrics (AAP), published in Pediatrics
2001;108:776-89.
AAP ratings: Recommendations from American Academy of Pediatrics (AAP), published in Pediatrics 2001;108:776-89.
= approved drug is usually compatible with breastfeeding.
Breastfeeding and Lactation Guidelines
Briggs GG, et al. Drugs in pregnancy and lactation. 7th ed. 2005/FDA
Antibiotic
Safe Pregnancy
Safe Lactation
Penicillins
Pipercillin-Tazobactam
Cephaolsporins
Meropenem
Aminoglycosides
B
B
B
B
C
L1
L2
L1/2
L3
L2
Azithromycin
B
L2
Clarithromycin
Fluoroquinolones
C
C
L2
L3 (Do not use)
CLindamycin
B
L3
Metronidazole
Nitrofurantoin
B (NOT in 1st trimester)
B (NOT in 3rd trimester)
L2
L2
Sulfonamides
C / D 3rd trimester
L3
Tetracyclines
Vancomycin
D
B
L3/L4 (DO NOT use)
L1
Notes
(small amount excreted
into milk, clinically not
significant levels in
infant)
(small amount excreted,
clinically not significant
levels in infant)
Greenish discoloration of
teeth
(infant may develop
diarrhea)
-G6PD and term fetuses
may develop hemolytic
anemia
-G6PD and term fetuses
may develop hemolytic
anemia
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