Adult Inpatient Antibiotic Guidelines
Antibiotic Guidelines "#$%-"#$&
Treatment Recommendations For Adult Inpatients Also available online at insidehopkinsmedicine.!rg/amp
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1. Introduction ...... 3 t n e
2. Johns Hopkins Hospital formulary and restriction status ...... 6 t 2.1 Obtaining ID approval ...... 6 n o
2.2 Formulary ...... 7 c f 3. Agent-specific guidelines ...... 8 o e l
3.1 Antibiotics ...... 8 b a
Ampicillin/sulbactam ...... 8 T Ceftaroline ...... 8 Colistin ...... 9 Daptomycin ...... 9 Ertapenem ...... 10 Fosfomycin ...... 11 Linezolid ...... 12 Tigecycline ...... 13 3.2 Antifungals ...... 14 AmBisome® ...... 14 Micafungin ...... 15 Posaconazole ...... 16 Voriconazole ...... 17 Azole drug interactions ...... 18 4. Organism-specific guidelines ...... 21 4.1 Anaerobes ...... 21 4.2 Propionibacterium acnes ...... 22 4.3 Streptococci ...... 24 4.4 Multi-drug resistant Gram-negative rods ...... 25 5. Microbiology information ...... 28 5.1 Interpreting the microbiology report ...... 28 5.2 Spectrum of antibiotic activity ...... 30 5.3 Interpretation of rapid diagnostic tests ...... 31 5.4 Johns Hopkins Hospital antibiogram ...... 34 6. Guidelines for the treatment of various infections ...... 36 6.1 Abdominal infections ...... 36 Biliary tract infections ...... 36 Diverticulitis ...... 37 Pancreatitis ...... 38 Peritonitis (including SBP, GI perforation and peritonitis related to peritoneal dialysis) ...... 39 6.2 Clostridium difficile infection (CDI) ...... 44 6.3 Infectious diarrhea ...... 48 6.4 H. pylori infection ...... 51 6.5 Catheter-related bloodstream infections ...... 53 6.6 Endocarditis ...... 57 6.7 Pacemaker/ICD infections ...... 63 6.8 Central nervous system (CNS) infections ...... 65 Meningitis ...... 65 Encephalitis ...... 67 Brain abscess ...... 68 CNS shunt infection ...... 68 Antimicrobial doses for CNS infections ...... 69 6.9 Gynecologic and sexually transmitted infections ...... 70
(continued on next page) 1 s
t PID ...... 70 n Endomyometritis ...... 70 e t
n Bacterial vaginosis ...... 71 o
c Trichomoniasis ...... 71 f Uncomplicated gonococcal urethritis, cervicitis, proctitis ...... 71 o
e Syphilis ...... 72 l b 6.10 Pulmonary infections ...... 74 a
T COPD exacerbations ...... 74 Community-acquired pneumonia ...... 75 Healthcare-acquired pneumonia...... 79 Ventilator-associated pneumonia ...... 80 Cystic fibrosis ...... 83 6.11 Respiratory virus diagnosis and management ...... 85 6.12 Tuberculosis (TB) ...... 87 6.13 Sepsis with no clear source ...... 91 6.14 Skin, soft-tissue, and bone infections ...... 92 Cellulitis ...... 92 Cutaneous abscess ...... 93 Management of recurrent MRSA infections ...... 94 Diabetic foot infections ...... 95 Surgical-site infections ...... 97 Serious, deep soft-tissue infections (necrotizing fasciitis) ...... 99 Vertebral osteomyelitis, diskitis, epidural abscess ...... 100 6.15 Urinary tract infections (UTI) ...... 102 Bacterial UTI (including pyelonephritis and urosepsis) ...... 102 6.16 Candidiasis in the non-neutropenic patient ...... 106 6.17 Guidelines for the use of prophylactic antimicrobials ...... 112 Pre-operative and pre-procedure antibiotic prophylaxis ...... 112 Prophylaxis against bacterial endocarditis ...... 115 Prophylactic antimicrobials for patients with solid organ transplants ...... 116 6.18 Guidelines for the use of antimicrobials in neutropenic hosts...... 119 Treatment of neutropenic fever ...... 119 Prophylactic antimicrobials for patients with expected prolonged neutropenia ...... 121 Use of antifungal agents in hematologic malignancy patients ...... 123 7. Informational guidelines ...... 127 7.1 Approach to the patient with a history of penicillin allergy ...... 127 7.2 Combination therapy or “double coverage” of Gram- negative infections ...... 129 8. Infection control ...... 131 8.1 Hospital Epidemiology & Infection Control ...... 131 8.2 Infection control precautions ...... 133 8.3 Disease-specific infection control recommendations ...... 135 9. Bioterrorism ...... 139 10. Appendix: A. Aminoglycoside dosing and therapeutic monitoring ...... 141 B. Vancomycin dosing and therapeutic monitoring ...... 146 C. Antimicrobial therapy monitoring ...... 148 D. Oral antimicrobial use ...... 149 E. Antimicrobial dosing in renal insufficiency ...... 150 F. Cost of select antimicrobial agents ...... 154
2 n o
Introduction i t c
Antibiotic resistance is now a major issue confronting healthcare u d providers and their patients. Changing antibiotic resistance patterns, o r t n rising antibiotic costs and the introduction of new antibiotics have I .
made selecting optimal antibiotic regimens more difficult now than ever 1 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. Finally, please let us know if there are sections that you think could be improved, and also let us know if there is more information you would like to see included. Our goal is for the Antimicrobial Stewardship Program to be a useful service in optimizing antibiotic use at Hopkins. We welcome your thoughts and comments to 443-287-4570 (7-4570) or to: [email protected]. 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
3 n The following people reviewed all the treatment guidelines o i t Paul Auwaerter, M.D. (Infectious Diseases) c u John Bartlett, M.D. (Infectious Diseases) d o
r Karen Carroll, M.D. (Pathology/Infectious Diseases) t n
I Patricia Charache, M.D., Ph.D. (Infectious Diseases and Pathology)
. Pam Lipsett, M.D. (Surgery and Critical Care) 1 Eric Nuermberger, M.D. (Infectious Diseases) Trish Perl, M.D., M.Sc. (Infectious Diseases) Paul Pham, Pharm.D. (Infectious Diseases) Stuart Ray, M.D. (Infectious Diseases) Annette Rowden, Pharm.D. (Pharmacy) Cynthia Sears, M.D. (Infectious Diseases) The following people served as section/topic reviewers N. Franklin Adkinson, M.D. (Allergy/Immunology) Michael Boyle, M.D. (Pulmonary) Robert Brodsky, M.D. (Oncology) Roy Brower, M.D. (Critical Care and Pulmonary) Michael Choi, M.D. (Nephrology) John Clarke, M.D. (Gastroenterology) Todd Dorman, M.D. (Critical Care) Emily Erbelding, M.D. (Infectious Diseases) Khalil Ghanem, M.D. (Infectious Diseases) Francis Giardiello, M.D. (Gastroenterology) Matthew Labreche, Pharm. D. Lisa Maragakis, M.D. (Infectious Diseases) Kieren Marr, M.D. (Infectious Diseases) Robin McKenzie, M.D. (Infectious Diseases) Michael Melia, M.D. (Infectious Diseases) Dennis Neofytos, M.D. (Infectious Diseases) Ikwo Oboho, M.D. (Infectious Diseases) Damani Piggott, M.D. (Infectious Diseases) Whitney Redding, Pharm.D. (Pharmacy) Anne Rompalo, M.D. (Infectious Diseases) Paul Scheel, M.D. (Nephrology) Amy Seung, Pharm.D. (Pharmacy) Maunank Shah, M.D. (Infectious Diseases) Robert Wise, M.D. (Pulmonary) Frank Witter, M.D. (OB-GYN) How to use this guide • Each section begins by giving recommendations for the choice and dose of antibiotics for the particular infection. • ALL DOSES IN THE TEXT ARE FOR ADULTS WITH NORMAL RENAL AND HEPATIC FUNCTION. • If your patient does NOT have normal renal or hepatic function, please refer to the sections on antibiotic dosing to determine the correct dose.
4 t A I b c b i w I • • C • • • o • t T A • • n n n r h h y e h u e l e f f f o “ F S h s y o p A A C I A M W s a w o e e n a e A a t r o o o e c n a n a n n d t o r f s t c c r n e i e • • • • t o e n c e i u a l m l r r p t t m t u m t , i p t t l g i d i i i e t a t o w d r r i n c l i i d b m s P P P a A p l c i l i o o f a p o e t e d i b a i c c w e c b t u e a e n r i a r L l l l a u u r o i . b e e e c I i l t o u e i o o n l e g t c n g v e r o e i i L l i . s s f n t m i a a a I i o l o d o m t p u e r o f p r r a n n i C t a p A c g g s s s o t t n i o s o f D D n s r l g r l a o t c p g r h o a m s a o l e e e i h b h r e l m a f a t t u s i i t p o i e a r e r p D d g s s s i i e A h i h i r a t e e u p e t i p i d d c s a h r n e d s e e e e e y r i e p e a t t n n s e p n c o l s o o a t e o e f i a a d e r a a P n i n p a d t e e l S e o f r m b r o s f a a n u s s l i n n o o t n r g i m i r n a r a n f P r t s i n n a t i b e e o o t t r d o o e p f r b o p e v r d e s t s i e t h o n s s : i e a g v i a t n t r a a a i i t n w l o e l o t S o b a e s r i r a a c c m 5 r c c l g t n i l f a e u ( c s s t n : a . r t t t i a . u e h 3 l y t r w h o e s - y e i e p u m a s e o s 6 a r U c e m T r c : P C C a e - b s t d e t g p n 8 y n t n w d s s 5 i h 6 t t s m 5 a g a r t i c u o s o d i r h s e e a 0 o a t o e o e 1 a ( e c g o i - t p r n h s t 7 u e v p 8 r e f g r r r n 2 u y n t i y r h n 0 e o v y a s e i e b c e e l P s - n e p 9 i e b t s 6 4 u f T e r e e r u g t s t c e a n ( w I t o P m ” t 9 , o t e N Z m ) d 5 h l c P h s s e o t c , m i . t r n h n i d i n a i 8 a e s h e G o 7 n o m e t r r a m p e o o a g o s y h o o : o u n u n 0 f ; a l r u J r t r t e s e g f i m g r o 3 s i l t e s d l h m w a o n ) s s c d e e . . w d a . u r e t u e s - i e s t i h e e 8 s e h a n s W P a i p n h N i i i t b r 7 n a n n n d m t o g 0 e . a e c L e g a t h e s i O r p d f 0 a o h e f c y 2 E o c t n g u a : v P a b n e h 0 T i t c H o l h 6 h A r n i e e t ( i i 7 I t d d i e o c r m 0 u Z n N a n n o k i r S s s e o - m “ e s r o v a i g 4 d ) e p t G o f a u E a x : a n t h e y y k i o 5 s h a k M p f n p c t i t s 5 a e f s i ( e g i e i r 7 t t p a o l i a n , s n s c t - U a c e d i s h l 6 l b t l t 0 n g y e s a w h i i a e i o e p t S e n n 1 i o m 3 a e n o n o a r e a n d H f r T o i 5 n r c m o 1 o a t t e n s u b e . t c o i f h e . 0 v c r 2 a f s b c o a l h p T b o s m p a i t d , e e l i d 1 n u h a t h ” i i p n r v o n t “ a e e t a ) t m e t e n i a e a t : s i t r a d c t h c t o t a n c p o s s i 5 A a o b r h t o a e o b l t h e t i p o r t t n - e o b i l o n n 6 i a i b t s s , c r m e o t s b l u j a o n e u e t 5 i i o t w s d v n m o e t i e h e d v d n . r 0 e m e i t i v W i n e t i i l g i n i n r l n n l 5 c i d c o t e e m m d f i o g h m p H f g r ” o i c y t o u s t i ) a s r p h e u n Y r t e e o a t s b s o t e n n m o c r m s n h p v t i r l d l i r a m t h e u a e g b p w t a a a l e s d a t o r u u a y t t h o s n e r a i i i y t d o e o v t e l t l e n n n a n h t d s i o l e p . t 5 y s
1. Introduction l a
v Obtaining ID approval o r p p The use of restricted and non-formulary antimicrobials requires pre- a D
I approval from Infectious Diseases. This approval can be obtained by any g of the following methods. n i n i a t Approval method Notes b
O PING: “antibiotic” The pager is answered between 8 a.m. 1 . and 10 p.m. Call the ID consult pager (3- 2 8026) if you fail to get a response from the ID approval pager within 10 minutes. Overnight Approval Restricted antibiotics ordered between 10 p.m. and 8 a.m. must be approved by noon the following morning. • Doses will be dispensed to last until noon • Methods to obtain approval • Antibiotic Approval Form (see above) • Page ID approval using PING after 8 a.m. • Please remember to sign out the need for approval if you go off shift before 8 a.m. Ordersets (e.g. neutropenic These forms are P&T-approved for fever, etc.) specific agents and specific indications.
6 s u
Selected formulary antimicrobials t a t
and restriction status s n o i t c
The following list applies to ALL adult floors and includes the status of i r t
both oral and injectable dosage forms, unless otherwise noted. s e r
Unrestricted Restricted (requires ID d approval) n a
Amoxicillin Amikacin y r
Amoxicillin/clavulanate Ampicillin/sulbactam a ® l Ampicillin IV (Unasyn ) u m
Azithromycin Aztreonam r o
Cefazolin Cefepime f Cefotetan Ceftaroline1 l a i
Cefpodoxime Ceftazidime b o
Ceftriaxone Chloramphenicol r c Cefuroxime IV Ciprofloxacin i m
Cephalexin Colistin IV i t
Clarithromycin Cytomegalovirus Immune n Clindamycin Globulin (Cytogam®)2 A 2 Dicloxacillin Daptomycin1 . Doxycycline Fosfomycin3 2 Ertapenem Linezolid Erythromycin Meropenem Gentamicin Moxifloxacin Metronidazole Nitazoxanide4 Minocycline Palivizumab (Synagis®)5 Nitrofurantoin Piperacillin/tazobactam Norfloxacin (Zosyn®) Oxacillin Quinupristin/ Penicillin V/G dalfopristin (Synercid®) Ribavirin oral Ribavirin inhaled5 Rifampin Telavancin1 Streptomycin Tigecycline Tobramycin Vancomycin Trimethoprim/ sulfamethoxazole Amphotericin B Liposomal amphotericin B deoxycholate (AmBisome®) (Fungizone®) Micafungin Flucytosine Fluconazole6 Itraconazole oral solution 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 s c i Antibiotics t o i b i t ® n Ampicillin/sulbactam (Unasyn ) A : s Ampicillin/sulbactam is a beta-lactam/beta-lactamase inhibitor e n i
l combination antibiotic. It has activity against MSSA, streptococci, e d enterococci, and anaerobes. Its activity against Gram-negative i u
g organisms is limited; an increasing number of E. coli and Proteus isolates c i
f are now resistant. i c e Acceptable uses p s
- • Treatment of human or animal bites if IV therapy is needed t n
e • Treatment of oral infections g
A • Treatment of lung abscess 1
. • Treatment of culture negative endocarditis 3 Unacceptable uses • Empiric treatment of biliary tract infections, diverticulitis, or secondary/peritonitis/GI perforation (use can be considered only in infections with organisms that are proven to be susceptible) Dose • 1.5-3 g IV Q6H • 3 g IV Q4H for multi-drug resistant Acinetobacter (see p. 25)
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) • Salvage therapy for MRSA bacteremia/endocarditis or other severe infections on case by case basis Unacceptable uses • Treatment of community-acquired bacterial pneumonia (CAP) or skin and soft tissue infections (SSTI) where other more established and less expensive options are available • Initial therapy for Gram-positive or Gram-negative infections
8 Dose s c i t
• 600 mg IV Q12H has been studied for CAP and SSTI; o i b i
• 600 mg IV Q8H for MRSA bacteremia salvage therapy or other serious t n
infections A :
• Must adjust for worsening renal function and dialysis (see p. 151 for s e n i
dose adjustment recommendation). l e d i
Laboratory interactions u • Ceftaroline may result in positive direct Coombs’ test without hemolytic g c i f anemia. However, if drug-induced hemolytic anemia is suspected, i c e
discontinue ceftaroline. p s - t n
Colistin (Colistimethate) e g Colistin is a polymixin antibiotic. It has in vitro activity against A 1 .
Acinetobacter spp. and Pseudomonas spp. but does NOT have activity 3 against Proteus, Serratia, Providentia, Burkholderia, Stenotrophomonas, Gram-negative cocci, Gram-positive organisms, or anaerobes. Acceptable uses • Management of infections due to multi-drug resistant Acinetobacter and Pseudomonas on a case by case basis. Unacceptable uses • Monotherapy for empiric treatment of suspected Gram-negative infections Dose • Loading dose: 5 mg/kg once • Maintenance dose: 2.5 mg/kg Q12H; must adjust for worsening renal function and dialysis (see p. 151 for dose adjustment recommendation). Toxicity • Renal impairment, neuromuscular blockade, neurotoxicity • Monitoring: BUN, creatinine twice-weekly
Reference: Loading dose of colistin: Clin Infect Dis 2012; 54:1720-6.
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) • Bacteremia or endocarditis caused by MRSA or Methicillin-resistant coagulase-negative staphylococci in a patient with serious allergy to Vancomycin 9 s • Therapy for MRSA infections other than pneumonia in which the MIC of c i t
o Vancomycin is > 2 mcg/mL i b i
t • Bacteremia or endocarditis caused by MRSA in a patient failing n
A Vancomycin therapy as defined by: : s • Clinical decompensation after 3–4 days e n i l • Failure to clear blood cultures after 7–9 days despite Vancomycin e d
i troughs of 15–20 mcg/mL (high risk of Daptomycin resistance; u
g check Daptomycin MIC and obtain follow up blood cultures) c i
f • MIC of Vancomycin is 2 mcg/mL i c • Therapy for VRE infections other than pneumonia, on a case by case e p s basis - t n e Unacceptable uses g
A • Daptomycin should NOT be used for treatment of pneumonia due to its 1 . inactivation by pulmonary surfactant. 3 • Initial therapy for Gram-positive infections • VRE colonization of the urine, respiratory tract, wounds, or drains Dose • Bacteremia: 6–12 mg/kg IV Q 24H • Endocarditis: 6–12 mg/kg IV Q 24H • Dose adjustment is necessary for CrCl Ͻ 30 ml/min (see p. 151 for dose adjustment recommendation). Toxicity • Myopathy (defined as CK Ն 10 times the upper limit of normal without symptoms or Ն 5 times the upper limit of normal with symptoms). • Eosinophilic pneumonia • Monitoring: CK weekly, more frequently during initial therapy.
References: Daptomycin in S. aureus bacteremia and infective endocarditis: N Engl J Med 2006; 355: 653–65.
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 Gram- positive activity is similar to that of other carbapenems, except it does not have activity against Enteroccocus spp. Acceptable uses • Mild to moderate intra-abdominal infections (biliary tract infections, diverticulitis, secondary peritonitis/GI perforation) • Moderate diabetic foot infections without osteomyelitis • Moderate surgical-site infections following contaminated procedure
10 • Urinary tract infections caused by ESBL-producing organisms s c i t
• Pyelonephritis in a patient who is not severely ill o i b i Unacceptable uses t n
• Severe infections in which Pseudomonas spp. are suspected. A : s e
Dose n i l
• 1 g IV or IM Q24H, must adjust for worsening renal function and e d i
dialysis (see p. 151 for dose adjustment recommendation) u g c
Toxicity i f i
• Diarrhea, nausea, headache, phlebitis/thrombophlebitis c e p s - t
Fosfomycin n e g
Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in A 1 vitro activity against large number of Gram-negative and Gram-positive . 3 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 • Management of uncomplicated UTI in patients with multiple antibiotic allergies and when no other oral therapy options are available. • Uncomplicated UTI due to VRE • Salvage therapy for UTI due to multi-drug resistant Gram-negative organisms (e.g. Pseudomonas spp.) on case by case basis. NOTE: Susceptibility to Fosfomycin should be confirmed prior to initiation of therapy. Unacceptable uses • Fosfomycin should NOT be used for management of any infections outside of the urinary tract because it does not achieve adequate concentrations at other sites. • Treatment of asymptomic bacteriuria (see p. 102) Dose • Uncomplicated UTI: 3 g (1 sachet) PO once. • Complicated UTI: 3 g (1 sachet) PO every 2-3 days (up to 21 days of treatment) • Frequency adjustment may be necessary in patients with CrCl < 50 mL/min. Contact the Antimicrobial Stewardship Program for dosing recommendations. • Powder should be mixed with 90–120 mL of cool water, stirred to dissolve and administered immediately. Toxicity • Diarrhea, nausea, headache, dizziness, asthenia and dyspepsia
11 s c i Linezolid t o i b i Acceptable uses t n • Documented Vancomycin intermediate Staphylococcus aureus (VISA) A :
s or Vancomycin resistant Staphylococcus aureus (VRSA) infection e n
i • Documented MRSA or Methicillin-resistant coagulase-negative l e staphylococcal infection in a patient with serious allergy to Vancomycin d i u • Documented MRSA or Methicillin-resistant coagulase-negative g c
i staphylococcal infection in a patient failing Vancomycin therapy (as f i c defined below): e p • Bacteremia/endocarditis: failure to clear blood cultures after s - t
n 7–9 days despite Vancomycin troughs of 15–20 mcg/mL. Should e
g be used in combination with another agent A • Pneumonia: worsening infiltrate or pulmonary status in a patient 1 .
3 with documented MRSA pneumonia after 2 to 3 days or if the MIC of Vancomycin is 2 mcg/mL. Cases should be discussed with Infectious Diseases or Antibiotic Management. • High suspicion of CA-MRSA necrotizing pneumonia in a seriously ill patient • Documented VRE infection • Gram-positive cocci in chains in blood cultures in an ICU, or oncology transplant patient known to be colonized with VRE Unacceptable uses • Prophylaxis • Initial therapy for staphylococcal infection • VRE colonization of the stool, urine, respiratory tract, wounds, or drains Dose • 600 mg IV/PO Q12H • Skin and skin-structure infections: 400 mg IV/PO Q12H Toxicity • Bone marrow suppression (usually occurs within first 2 weeks of therapy) • Optic neuritis and irreversible sensory motor polyneuropathy (usually occurs with prolonged therapy > 28 days) • Case reports of lactic acidosis • Case reports of serotonin syndrome when co-administered with serotonergic agents (SSRIs, TCAs, MAOIs, etc.) • Monitoring: CBC weekly
12 s c
Tigecycline i t o i b
Tigecycline is a tetracycline derivative called a glycylcycline. It has in vitro i t activity against most strains of staphylococci and streptococci (including n A :
MRSA and VRE), anaerobes, and many Gram-negative organisms with the s e n
exception of Proteus spp. and Pseudomonas aeruginosa. It is FDA i l approved for skin and skin-structure infections and intra-abdominal e d i infections. u g c i f
NOTE: Peak serum concentrations of Tigecycline do not exceed i c
1 mcg/mL which limits its use for treatment of bacteremia e p s - t
Acceptable uses n e
• Management of intra-abdominal infections in patients with g contraindications to both beta-lactams and fluoroquinolones A 1 .
• Management of infections due to multi-drug resistant Gram-negative 3 organisms including Acinetobacter spp. and Stenotrophomonas maltophilia on a case by case basis • Salvage therapy for MRSA/VRE infections on a case by case basis Dose • 100 mg IV once, then 50 mg IV Q12H • 100 mg IV once, then 25 mg IV Q12H if severe hepatic impairment (Child - Pugh 10–15) Toxicity • Nausea and vomiting
13 3.2 Agent-specific guidelines: Antifungals • 1 • N R P P D D • • • • • A Z A • a • • D • • L A n y o r m e e e 4 c o O A o s D s A c C A N Z C C I C N o n g t i s f n f f c i t s a i y r p l l B m r i a i b r a a o e e v T g f s t t o a n n d a e y u e g n e e t n a n n a i u u i s E n m i o g i b s p n c d i e p t o r p r t d d d s b t t i i f e o i S l n n e n r r g t t i o s m r h f e i y t i i i l d o o u o o v d d d a a e m i a : i a g n c o c o n e e r c p p r a a e t y t n l s b o y i i e e a t m o g e e c l v l v m o m a f e s l , g n n i e e e c e o n n e a ( m h i a s a h i h s e d c f l i i n n r d a i A a l s c n i i a n t e e i i o a s s s s v o i t c c a i g s v v t t A a e k e m l u : i c i p p p r r d d u m u e , r r l y a a d v t a h o a e u u N e e o m e e e l r s 5 f f s i o o l s s s i e o d l e n n m m x n e e s t s y p O a a r r r p d e i i n y p p a y t v v s g g g n d i m v v A ( m B a t t h o s r T c h i s c e e M l t t B i i i t m o o m e e e f l w t l l l d h h f e e e o i h l l l F h e o f m g o o o r r r c r s r A a p u i a a t e o r i s e u o u e e a , d n s s s s o t t r s / o r B B c m l l e l p h e l e s s r o n n n i i i u a i m c m s p m o k e s s s A A n m p o a e r a a c t g t t r o e a e p g g e i o f L L g e s r m t i i n i i i e i r n g u r h t o s n s t o n n y m , s h / e c e g i i x i i d o o o o e u t n t e s e s d - d f f o v R i i f i a i i i o e u . y n n r r p s r n l s m o n g n n n , , a i i l a c t i h n r d o t d d n t c r d D v t c - e r p r l t i e e e r i y n f a i o t i : s a . v e i i p v B d a o e o i z h o i r e c c . a n n r n o g n e i d d w a 5 i i m d s m s o s a a s s i d c o W v d d r d i a a r s i d ) i o i t t o p e t p - a t i n t i . v l p A o b o i e e m a i n s c h i i i l a a g e f s d s e v v u l e y a o a d d c s c c i t m s r r i e a n e t e e V s B g o v t i s h s g i a t a a v e i i c n s b b s i e o e o m b , e i / c i x i p p i n r r n a p l t u y y s a p r t n l l d k d u C d a h n e o i p y g y i t s e i h n c s s r a l g a a h b i i i s o e r w s t u c p c r p o t t o h d o e B o u a g , l e i / i i , r u r i n p p p s h s s e o d n s h r c i f g t o i d r c d b t e l f i n o o , , a s A e h r r l o u n e a f a o r d o a a a r g a r s s ( i e t z e o d C d C c r f i n u p l u m o s i l y n i i A o o i a d u n ( f i t t i u p a s t l c g i i m y n f N N c i i l d s e r l n s r o v v s r o t h e t e B g r b h e m . e e ) i f e e S i S , a r l i t s e d . n l n n s e y t a s o i o r s t i h s i C g g g s a i . c o m s a r e i w i p p c h B a n n a B o s s a a a t i e o a n d - p i g f f u s i , e n l l u m m p o n a a e e r n i s d e h e d p o g l u s a c c d i n i l b c c p l t a I r n r i e e y t t V o i t l r d s i o t t r v r i v l o o d ) i t u s i i o o i b o e – i : s e o o i o A c p m m a d a s u m c v t u a n f x 3 n n g n a m . c c a e , i o a a g e s d r t y i , – n i t u n : s t A n n t p p s g m i d e o c f o i l i C e s n n v t t s 3 h e e e i s e e s u r n h d a a p g ® e o . c s l p s – s s t n r i i n n n i o n i t t e e / p k r d c t e 5 e i e t ) g v w e k s i l c r a a u s s r t l r o a s e i u g g e a m s s i r t n o h c r t t A i r t w s s s n i u / o h . e f i a e u l e N n g a a e l g d d f e u s i t m n y y t D t / i i a B e i s r e l h h a e s k a c f f y s , n e c r r a p g r p o o e l r s e a r i / y n m m a o n t t r d i i e d p c o 9 d a u a y n 6 - y c l s t s Toxicity l a
• Infusion-related reactions: fever, chills, rigors, hypotension g n u f
• Renal impairment (enhanced in patients with concomitant nephrotoxic i t
drugs) n A :
• Electrolyte imbalances s e
• Pulmonary toxicity (chest pain, hypoxia, dyspnea), anemia, elevation in n i l
hepatic enzymes-rare e d i
• Monitoring: BUN/creatinine, K, Mg, Phos at baseline and daily in u g c
hospitalized patients; AST/ALT at baseline and every 1-2 weeks i f i c e p s
Micafungin - t n
NOTE: Micafungin does not have activity against Cryptococcus. e g A 2
Aspergillosis . 3 • Acceptable uses • Infusional toxicity or acute renal failure on AmBisome® and intolerance to Voriconazole defined as serious hepatoxicity, persistent visual disturbance, or allergic reaction. • Refractory disease- for use in combination with Voriconazole or AmBisome® for definite or probable invasive pulmonary aspergillosis in patients who are refractory to Voriconazole or AmBisome® alone. • Unacceptable uses • Micafungin alone or in combination with other antifungal agents is not recommended for empiric therapy in patients with CT findings suggestive of aspergillosis (e.g., possible aspergillosis) without plans for diagnostic studies. • Micafungin does not have good in vitro activity against zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.). Candidiasis • Acceptable uses • Treatment of invasive candidiasis due to C. glabrata or C. krusei. • Treatment of invasive candidiasis in patients who are NOT clinically stable due to candidemia or have received prior long-term azole therapy. • Alternative treatment of recurrent esophageal candidiasis. • Alternative treatment of endocarditis. • Unacceptable uses • Micafungin has poor penetration into the CNS and urinary tract. It should be avoided for infections involving those sites. • Monotherapy for zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
15 3.2 Agent-specific guidelines: Antifungals n N N D • U s • • • A a • • D • T • D 1 P • N P o t c o u 6 c n o r o O O e w M T C f a I s M C P P M a n t x o o s u t c a r u s s n i u r r t l a i f r T T v o i o e • • • • • • • a l i o t o g i e c u s e e e d l c c s i m t n h i o E E n a n c t t s p r a p s p S S I I N N Q C I R C c i d y i a w t t n o i t v I c o o e ( t : : o a A i f h t e n r r m O o e t e i i i y a a u i i 2 o v o t d n r r o a p i a a r f f y c a P E n m c n h t m n c o o e e n a n n p y n m r 4 a g i e c c l n e e t b a a g a a e o - i u o d d g d d s l l l e p t n r z H i i n o o a o y t c r n s m m i x r l a l c e r s i i i i i i t r d o g h e v t a d d a p p i n n n n a n r i i e i e i n s a l a b h s s n o e e l c a : u u g a a e a p i i i o c e a s t n n n t u v a / c c u g l n t t s s o A z z o l m e y i f e t d t t a a e e e e N n t f p a o , s i t i o o m e z r n S s r e i s i o – t r C d o f h n n i e l p e i a n u e t – n a l l o p a t a o i n p T v o e e c n e a o s v s a a u n s l s d l a , s r x a b b g t r e e e / e a i l v e n x s e n t i d l n o e t – i e o t i z l c e b A o r c v r z e r s n e m o e i t i d a i c v o g p e c s s o o e r s y i L n B e i v l x o c t i u e v e o i a p h n i T a d a n g h l t y l e a l l i s s r e s t f e l e l c y v a s a t e r s / a o s c e i o s o n . s e o d e v a i p d g b n o , o s t z c i m u r t o d I v o a n i l y s e i i e w t s y D i f s A m o e c l s e s l r s t i f p i y r g s a d r f i S a m s q i p : g o o i t o e N u i c f : l c C o ( t f p l h i e e u 1 i r f n a b r r b r o m c l a 1 i m s e a g l o p o f v c s i 0 o I n i h s a e e n n t u r n 5 s r e i l e t a n r t y s e l i 0 i g e n e d d r s i l m s h l 0 r a n n o c y g a s t i u m d i u s p i i s – , l i c d p d : s o u t a l m u e i i t h m u e 1 p d o v a i i e i r u o f s s l b a n s n e s n o t t 5 e r i t n d g r i p a e e s a a p o , u s s t p m a 0 n i s s i r z s z s r i a l Z w s I e z m o o t i i V i o y e a n t t s 7 o , m y w c o n n h g r i i g l l y c a s : g i e n Q i e l a c ) e n i i c e g d o 7 ) c y t 1 o e b o c , n n e e 2 h a a m u m f 5 m e I b m m p o n n d 4 n e V y M a t 0 a y e z h m s t r o v a y H a i b n a n i c Q o y i l e - c c y t e y i f d m l i f o c m o n p m i n u 2 r o u b a g b s t f r c s a e n e g o s f 4 e e l i e n i n e c t u i l r t n t g v i s l a a i s H e i s o s n I o e i n o m i e a . V n p c s . n a , g m n r d r a l c a e c a s y e a Q h f i a n e r n t d y e e w b c e e a i t d g 2 1 e d , v d i e h i i a a n l e s t 4 n e – . m , F i h d s a o n e t f 2 r H u m u e s a t u : o t r A v i s s . d o c w l 1 n o w e m a l e w I h , n i t 0 n e t r d m h e m p i s o i i h e 0 t t u t o , h t h h r w o a k e m o e n e o m a r s s f i a n a l t o a r t r i h f i a e s l g i q a e u d t r o n s o p p r f s u t r y . I t i n h r v p y V c e e i o i e d . i f a t r n o . t r o r B s • Loading dose: 200 mg PO Q6H for 7 days l a
• Maintenance dose: 400 mg PO Q8–Q12H g n u f i Drug Interactions: See Table on p. 19 t n A :
Toxicity s e
• GI upset (~40%), headaches, elevation in hepatic enzymes. Rare but n i l
serious effects include QTc prolongation. e d i
• Monitoring: AST/ALT/bilirubin at baseline and every 1–2 weeks after u g c i f
References: i
Clinical efficacy of new antifungal agents: Curr Opin Microbiol. 2006;9:483-88 c e
Posaconazole: a broad spectrum triazole antifungal: Lancet Infect Dis. 2005; 5:775-85 p s - t n e
Voriconazole g A 2
NOTE: Voriconazole does not cover zygomycoses (Mucor, . Rhizopus, Cunninghamella, etc.). 3 Acceptable uses • Aspergillosis • Pseudallescheria boydii (Scedosporium spp.), Fusarium spp. Voriconazole is recommended as first-line therapy. • Alternative therapy for C. krusei if susceptible and oral therapy is desired in stable patient. • Prophylaxis in patients with hematologic malignancy Unacceptable uses • Candidiasis / 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 • Loading dose: 6 mg/kg IV/PO Q12H x 2 doses • Maintenance dose: 4 mg/kg IV/PO Q12H • Patients receiving concomitant Phenytoin or Efavirenz should receive 5 mg/kg IV/PO Q12H following maintenance doses of Voriconazole due to induced hepatic clearance by Phenytoin and Efavirenz. • Efavirenz dose should be decreased to 300 mg PO daily. • Monitor Phenytoin levels and adverse events. • Dose escalation may be necessary for some patients due to subtherapeutic levels. Therapeutic monitoring • Obtaining Voriconazole trough levels should be considered in patients who are: • not responding to therapy after at least 5 days of therapy using a mg/kg dosing strategy 17 3.2 Agent-specific guidelines: Antifungals V V 1 i m T V R • • w • • T D C t C D a t d i P r d P P D P n n A h h e o o o e o l r r h - - o 8 y y o h t r r r r g g V h a G t M V e e e s r r r u u f d e e e x h t t z s u u u e i i i e t e o c c c s u i l l t g g o o o n e s y y a o r e e • • • b b a i a g g g o o o n s p o e r l f c c c s s a c c d u t c d n r c o n o o n n n b i n o i a c V e e r i a h h i l o o a n r e a a z l i y I m a o c l t n d d o e c ( ( t c t l e n o o x x e o r r p t z z C C y g l p p o e d o i n i b c y y l r o o y i r c o o t p p l a n i r t s d y a e e r r o w Y Y s r e i a e e i l l s m m i a : a s o e e o a e e : c ( ( i t i n d o m t u e P P n c z s o m ( i i o e r t e s C r r z a t v t n o p T i g f e e o n g i e t 4 4 e e n c a i i i d n r r i o d l e e g u n n b e D a i n z a h l C a i : n i i c p 5 5 g c n e v u ( ( l n n n n r c a y r M g y o e w : C C n a A e u l y b i I t 0 0 f t g c c i r z n n m g : > a s o l i d u b i ( i 1 r t t Y Y i e S a n c f t i o P o i i o u t g a o t s C e t n n s z r r s s s h – r a P P n e d o T i a n l o - n c m k o c F l o g g m d e g o c u u i 5 s i a c i s ) ) n u n / t b p e m u / c l s h l n e b b o r p u e z e e e . . A c D P P c e G a l s I g : l : p p r 5 e n s s i n c ) o u d m n s d t e o i o n L d o 4 4 o s f h I t t v e S t t t i o p T e i l e c i r i h m m v n r r m n e r a 5 5 d o ( e c a e M 2 c n : e n / a a l ~ p e e h l i f e r t y a b l n t 0 0 0 d y n e e i b e a t e s i c t t t o , r r t i n 3 v s . h D l / a 0 e e s b v i i s a a z s i g t o a W c l e i i P e f p T f e 3 0 i o Y s s i n n r i 2 o n s p e u a r / c t t n r m r a l ; e r 4 o a ) ) r e d h o % s , u : t l y n e m i 2 . a e b p 3 l e w n t u r r i 5 N t l b u r u F a c d a 0 b y ) p s e e 6 i l o t i : v e L c e r i T e ) o 0 j t 0 s ) i r o i m u n h E o : y s s . e o e r t i t d . u 6 e e h o 8 e n o . r n s o u u r o n s n i n e 3 g L s a u r a i ; k g n n u : r s l l u t n / s t d 0 t t c t e t s 4 s t s l s h a s s a h i i l a p i : n n J d r r 6 t v l o : b i n p l e i r b e u t f e l d s i g g e : M y n c o h d n a d t . 2 b g a i n t u i l f t h a c s e n r e s 0 1 u i i e s i s e o e l i n n o d e e t r g e i s c 1 u n e e 9 n t f e < n o c l v r r m 2 t i d p c i l t n n a P n e n f a o : e t k e b 0 t e - r 1 h o c s e l e a a t - i V l e r 0 i t g o c s i V m f e r e t a w a o y s o g 2 o e m p a n r o i c e c n > ; e r i n f u r t i a n 3 t r n m u i t h o c o s a e e c l i 5 s t d i o 4 o a c c n o e u m g h f s d o d e e 6 . f t t o r c n b e 5 e e / h t i , n e ( d d m o p P n 4 t h 5 s m s v d e a r i a i m n r ) a o e m - c e – t d a e : r g z e s i 2 r L z d n n a 7 r s r t o o e a p e e h c d 2 o y a v u r t h h t f l t e o f g i 5 r u o e d b l g o a e s o f , e u 1 a n e . f g l / l a o b u n u s r v f g v > – s m n c t e y b l x o i e h c d i i 2 n z i o s v v s n i s l L e I o n e y p i g n t e m e b s t w r t a m n c p u r c w r m e e e a d a a , f c r m e a e f e o t r c e i e r t n e f e t e t e a n e u n o f l o s h i p a d u n l e r k c t e g s n f c s , r x t t n s t t s v i a r a e e o o c i s r t o a t a p t e z a s r e x a i t n o t t u o o s f i r i r i a c t o s o c m u t n l t e e i i a n n n c t l s o r t p y i s s u i n > f n . i , r n i g i ) n n s l a g e d s n n t o u a n d f a n i s t l g i e t e n h i m v n s w o e n l a A c s o e l i n e r t l : e n o c c o v s e c e u z e h l e d d a d i w r e n r n r o o i o e e t v l i c e d s a i k n a s e o s s r o i e o t d l n i r d s s d i m b o n n r i ) g s r , c u s o e n o o h i e i i t g s i s t t d g s g d u i n i o u s n a a r a l e s p o a e d d d d e c n i r w f s i i v l m t n n s o o c g f e e , u , e e g l i v c e n v i e o e u a l t d l r c ( e r d m m l t c o o i o r n d f t e s z a r z i e m m a f ) r e n a a o n d p o o t e o n i x n o s y i n o t i l t c c s s e t i o n o u s n e - i n l e e m t b a c c o c v i t f r o c a R R a t e x e f s d l r m c r e n d n h s t o f n t e i i t t f e e e e d a d e l l f f f e d c n n 4 g p n o ⁄ o o o g n d r a 3 a u z u g a r o o n g 3 n n a ⁄ - A t s d o e c i 1 d n o t o o n s i i i i e g i s P n t r t t o c e o u d e u l 2 o a t a a o c e r u l . d r s f r r d o t y a t d d t t m t e a o o z n i r r n n 3 n n e f t s z , a d a i c r o s r e i a e e t o i a t o n i i r x e c e c c n e t d o n e o h n o n n n m l 4 s c o i t t c t o i s o r o o o o o c e e a A r n u f c c c z o c e e m a d s f g o o 3 a n p s s s f , e m o a r o a a i n s u u o t l o P e m p r e r l m o c o m m o t t p l d o r o d b Y r i s c s s i t ↓ t o o c i i o d e n c s a a s i a a n n l C y n l l n y s a n e s s o e t p c p p o o a u ↓ f h o o ↓ o v o o s f o p D M C ↓ ↓ w u m D A M I ↓ p r o , t s i , r r e b i e i v d k n i s i , h a c r d i n e m , n i o a l i n o f z a y u i r r r b n p q p e y a l d r e a t a a r p e r i r o w n s , , s s i t n o e v , , s v , e a , d ) l p s n i h a r i i d e i d t f i m e e i a o d l v n e e o m z n a h c o l l t a a , , , ) l a o c o e m a l o k n r a d l n p o i 4 i z k e o o m r l a z a i z m x t m a 2 h A s t i r a i a a p a u o r a d c i l t s i H 3 e i n t , g , n c ) s , o c v i , d b r P l o s i n m n o z s o , s d i i e l a g u v d Y i t s a e r i r v s d i i , c V i a s c a I n r p C o u e , i l e n , l t ( l t n c l ) i , , i , z y n f p s a r a , n i a m p e i d i i t e n h a r e k e l o t e v l , t n n l n v e d z i m o o a i n a n a r e r o l i i r a t i a o a i , p r i n m t f i t o r d i c c v s i , i i s i m z t d o r p e y i a a a d s n v n o f , i f t o a i l s v g , n , b a i e o r m p z e i u , c u n n n n i n , i m e d n o y s , q h b t i t m e o r s o e u , , c e r , s u n , a a h l i c s c b t e e i f n , t i e p b i i m ) d a , i s n y d d , r a d a l i i p s i r n m s f m c g g a a x n r r r i i , o i r e z t d e a t e a t v r i t r u u u n p p i i z i o n o l u s c , r r o , a o l t t a a f l n s s a l i e y t i f y ( n o e f n l u s s f i m l t D D i u f a , i i l s b i , x i m r e x b g a s o k o i , c c a a p l e t h t m a o a o z o n v i v n : : : i f l a , n s i p y n r b i r a t i g a p i d d d r r a o c o n r g o a y n a d m r i v e e e - d y a t s i t , e p p h c a y u l o b b b s s a c a , n h P e l i i l i i n m r m i q i h h o r r r : : : : p a e o t r o u v m v a z d t r c c c t d d d d , r i e o p s , a o a a s s s e y o z e e e e l h f o t s n t x , n d e e e n , m b b b b e v n i i r l i i i i r r r y r a e e i l e m e x a a r r r r o r y r p p p z ( r v t o , h m a t x a i o c c c c l e n t t a a l e o p v i e e y y y s s s s s t a o b l l l , r e n a d t a , d b n e e e e a i z n n n l n r f i p i m c a o r r r r i n i t , t a , a t o o o e e o , i r i o h c p p p p m e t a e t e i r r f n , s , t y e d n i a t m m m t d y y y y n i s , b , r r , e s i e l l l l , m , r s m u o e e i n n n p o n n n n n m m m , m n a i i r e a d r l n o n n a i o p o o o o o o o i o i a m r a d n p l t b n i o i r f i i v o s s l c c c l p p h t d c i p o i m m m m z a d d a i t e g o o o u i l i e l o o n d r s s s j a d r i n r a d s t t n m m m m o c e i e s s s t o e d c a o a m l u u e i t e f s o o l i y o o m u h t l e e e n i i a i e b b a L C r C n ( C L q M M T A n f a p C C ( C C e L m r t s d b n u a s n n ( o o E i i E t t L L u u d d O a a O e e t t Z c c Z a a e e A A r r c c i i N N p p d d / / O O n n g g i i C C n n a a i i A r r A t t n n S r r R n n O a a o o T P I W C C W 19 3.2 Agent-specific guidelines: Antifungals 2
0 VORICONAZOLE (substrate and inhibitor of CYP2C19, CYP2C9, and CYP3A4) Drug Recommendations Contraindicated Commonly prescribed: carbamazepine, rifabutin, rifampin, Do not use ritonavir 400 mg Q12H Less commonly prescribed: long-acting barbiturates, cisapride, ergot alkaloids, pimozide, quinidine, St. John’s Wort
1
2 Warning/precaution Cyclosporine ↓↓ cyclosporine dose to ⁄ and monitor levels Efavirenz voriconazole dose to 5 mg/kg IV/PO Q12H and ↓ efavirenz to 300 mg PO daily 1 Tacrolimus ↓ tacrolimus dose to ⁄3 and monitor levels Sirolimus ↓ sirolimus dose by 75% and monitor levels
1
Omeprazole ↓ omeprazole dose to ⁄2 Methadone M↓ onitor 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 Commonly prescribed: all benzodiazepines (avoid midazolam and Monitor effect of drugs and consider decreasing dose when voriconazole triazolam), all calcium channel blockers, fentanyl, oxycodone & other long is added acting opioids, NSAIDs, oral contraceptives, statins (avoid lovastatin and simvastatin), sulfonylureas, vinca alkaloids Less commonly prescribed: alfentanil FLUCONAZOLE (substrate of CYP3A4 and inhibitor of CYP3A4, CYP2C9, and CYP2C19, interactions are often dose dependent) Drug Recommendations Contraindicated Cisapride Do not use
Warning/precaution Commonly prescribed: cyclosporine, glipizide, glyburide, phenytoin, ↓ plasma concentration of the interacting drug, monitor levels when rifabutin, tacrolimus, warfarin possible, monitor for drug toxicity and consider dose reduction Less commonly prescribed: oral midazolam, theophylline, tolbutamide Rifampin ↓ plasma concentration of fluconazole, consider increasing fluconazole dose 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. • Gram-negative bacilli - Bacteroides spp., Prevotella spp., Porphyromonas spp., Fusobacterium spp. • Gram-negative cocci - Veillonella spp. • Gram-positive bacilli - Propionibacterium spp., Lactobacillus spp., Actinomyces spp., Clostridium spp. • Gram-positive cocci - Peptostreptococcus 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 4.1 guidelines: Anaerobes Organism-specific collection is critical; refer to specimen collection guidelines at http://www.hopkinsmedicine.org/microbiology/specimen/index.html Treatment Notes Patients # Penicillin Amox/Clav Pip/Tazo Cefotetan Ertapenem Clindamycin Metronidazole
NOTE: Results in the table above are based on small number of isolates from sterile body sites, brain abscess and tissue by request and may be subject to sampling bias. • Surgical debridement of anaerobic infections is important because anaerobic organisms can cause severe tissue damage. • Ampicillin/sulbactam and Clindamycin are considered to be effective empiric therapy against Gram-positive anaerobes seen in infections
21 4.1 Organism-specific guidelines: Anaerobes • • D • • • • 2 • I • • • • • • n P 2 i T C g C p M s a m i s b V M B t a ( ( E C a c s P p M s e B T t g O P C d a n A M h h r e h t u i a b c n u m a r e i r r m i r . a o u l i N t s f g g u o o p r e i i m o o o o c o a l h o s s a n c l n e i t o o c l a s f l t d l e e x s S s t p u h n l s p d m w s r t a p e u d c e r u r e v p u t p n u m i ) a i t a e c r s o o o t i e i t o p u f r r e o l r t e r c t r r g e r a i s d h - l g i g e s e y o i r c i g a p h i o n c e r i s l m i s c m t a c o i c e c h e d l o e e o c w m e s t d i i i e b y e e e t s s x i t l l o g a h u i i n s i N t i i s l r l a i e n s l y r u a i s p o d g i n r n n i a d i l i n l c p e s n f e n n i s c o i s e n t l t c d s j O m c o n e i e n o b y a e o o u / s c l t e n g h i p p i a t o c i d / i m , r c t s u s n s f b a T S s s l i n r a ( t o f i r h i o n r n o T e o n f i i i s y v i h s b o w o p t s a e s n u m u , f i t t a i a p w t l r h h f . e r . v p l t o s l i r o h o u e a p c l s i e e h g t l e m i z E b c a i e a e a d s e i p u n c e r p l c b e e c t h i s c c a a . o a t c a r s s c r s r n l c i . f t s t n i r l s d o t o c b n t a t l e t b i , t e e e e c h a r t u e s i s n i a e o a e t n t i u o i a u e e e m g e n a a n c n P t i v r e o a d t g d p v o s e d i i a l e e n s r s r t e c c s e t n s t t t t e r e h m . m e m t a i , e m u h a i s h r i a p ( o r i t f j — s a v o p e r i e o o d n s s e a - a e r e v n a o c t a a e e n u . t e o n t , e . l o c h e b i g c m i a e a d n d t u n o g b c s g n n M m B i P o r m c m i t s s n a t d v P r l t c s e . d d t e e i d ; h f f . u i o t o p e a e c e i i l t p i o i n o e ) o G e c o u e p t s n b r l i f c d n e e t w t a d h n e r s e r d m n o r a i s r y f e f i r a s d c c a a l a o e o e f o r t i a e p s n g a t r e 1 r s t e b c . i a i g s i g o r n c n h n m a m o a n d c o t s n a e 0 b c e ( t e c s o c i i t i e c a e p d v v l i d v i C t i e f M - n i e i i w n b o f s o c o 1 s s l i . i o e l u i r e n e o a l l o u t g s n l i l e t i o u f n t i i e i s 4 e n a r n i a e c r l r z d h n n m n g n t s e . e l c s e e t i - t / d g i o s e f d e s n l / s b m r r t s i m e d , S a c e T d n ( h o o e a l t s a i p s y e i a a c n s w u c a . d s e n e u n n e t a m v u r f z y t t s i t z p i a t l c h n v p i t i e n e s a i i i i n s d h s o e o t k o a n e y n e l e s y f t s c f m r u t e a x b e e g i b c n i o c g g o n i n i s n p t d l f c f z r G l a r s i a i e t / r o i y J o g n o o p s n a e r o e b h t c c ) f b c n r H t h u , r h . u n d u . o o b t i l l a u a t e t t , g e l s i o m H i a i s C s a e s c a s s s l r s m t s u t y y P h c c m n u u m a t A e h s b c w i n . P s m o o - t n e o 3 t s l - f i s e p N l t i e l o h , n . a ) o p h r i v a p f u a ) n u i d o g a g o g v D c c A e a e a a t c t r s n g i s s s e n i a c i u r e r n l r m t a t b b c u a t p h c r o o a i a h e c t a n a l e t e l a y d s i a n e o i i o i g u l o e o a m i l c s v s r i f s l m c B n r t u e a n l p b a n r r e l x e i n ) u i o m o o e , a o e p b . l . b t s ) a i i e x - d o i n c b a g p p n d s C s a b r a f . : p t a t t s i e r m i i i o e y t a , n b l p i c s v e n e a f l c i a t b f i b s - o a a e e e n e f d l r i g i r a a e i n o n i l e b i r s n e n / t r e e i s c a c a h i l x s r r C o l y e v i P u n o e s o e g t c t n i i h t e l m t b . s l a i c o a o d a n v t b o i e o n i e i m s a e t s i d t t v . a s e n n u t e , o d c y u n f D f s f t l a w d a r d n i o r s l d r a s s o o o n e ( i m r o t e e n n w f m d h s n r . o i e c i g t o a t d h . t s . Treatment s e n
• Penicillin G 2-3 million units IV Q4H (preferred) c a
OR . P :
• PCN allergy : Vancomycin (see dosing section, p. 146) s e n i NOTES l e d • ID consult recommended for assistance with choice and i u
duration of antibiotic therapy g c i f
• P. acnes is usually a contaminant in blood culture specimens. Draw i c
repeat cultures and consider clinical context before treatment e p s
• Rare reports of spinal infections have been noted for P. acnes - m
• All P. acnes isolutes at JHH are susceptible to Penicillin and s i
Vancomycin (see anaerobic antibiogram p. 21) n a g
• Metronidazole does not have activity against P. acnes. Tetracyclines r are not routinely tested and resistance rates are variable. O 2 .
• Broader spectrum agents such as Meropenem and 4 Piperacillin/tazobactam would be expected to be active for Penicillin susceptible isolates, but these are not first-line therapy • Susceptibility data should be used to help guide therapeutic decisions • Consider removal of associated hardware
23 i c
c Streptococci o c o Viridans group Streptococci (alpha-hemolytic streptococci) t p e r
t Normal microbiota of the oral cavity and GI tract; single blood cultures S
: growing these organisms often represent contamination or transient s e bacteremia n i l e Five groups d i u
g • S. anginosus group (contains S. intermedius, anginosus, and c i
f constellatus): commonly cause abscesses; majority are Penicillin i c
e susceptible p s • S. bovis group [contains S. gallolyticus subspecies gallolyticus - m (associated with colon cancer—colonoscopy mandatory, endocarditis s i n also present in > 50% of cases) and subspecies pasteurinus a g
r (associated with hepatobilliary disease, endocarditis less common)]; O majority are Penicillin susceptible 3 .
4 • S. mitis group (contains S. mitis, oralis, gordonii, and sanguinous): commonly cause bacteremia in neutropenic patients and endocarditis; many have Penicillin resistance • S. salivarius group: less common cause of endocarditis; majority are Penicillin susceptible • S. mutans group: common cause of dental caries; uncommon cause of endocarditis; majority are Penicillin susceptible Beta-hemolytic Streptococci All are susceptible to Penicillin Variable rates of resistance to Clindamycin; ask the microbiology 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 High rates of resistance to tetracyclines and TMP/SMX preclude their empiric use for infections suspected to be caused by beta-hemolytic streptococci • S. pyogenes (group A strep): pharyngitis, skin and soft tissue infections including erysipelas, cellulitis, necrotizing fasciitis; Clindamycin resistance in 1.5-5.2%; macrolide resistance in 4-7%. • S. agalactiae (group B strep): neonatal infections, infections of the female genital tract, skin and soft tissue infections, bacteremia; Clindamycin resistance in 16-26%; macrolide resistance in 7-32%.
24 • Group C and G streptococci: infections similar to S. pyogenes and s d o
S. agalactiae; associated with underlying diseases (e.g. diabetes, r e v
malignancy, cardiovascular disease); Clindamycin resistance in ~16% i t
of group C and ~33% of group G isolates; macrolide resistance in a g e
~25% of group C and ~28% of group G isolates. n - m
Streptococcus pneumoniae a r G
• Common cause of respiratory tract infections including otitis media, t n a
sinusitis, pneumonia via local spread from the nasopharynx; infections t s i
involving the CNS, bones/joints and endocarditis via hematogenous s e spread r g u
• Genetically, S. pneumoniae is in the S. mitis group of viridans group r d - i
streptococci; consequently, rapid molecular tests may not be able to t l distinguish S. pneumoniae and streptococci in the S. mitis group. u M
• Penicillin is the agent of first choice for serious S. pneumoniae : s e
infections when it is susceptible n i l
• Penicillin and Ceftriaxone susceptibility breakpoints are different for e d i
CNS and non-CNS sites u g c i f
MIC breakpoints for Penicillin and Ceftriaxone against i c
S. pneumoniae e p s m
Antibiotic Susceptible Intermediate Resistant s i
Penicillin (oral) ≤ 0.06 0.12-1 ≥ 2 n a
Penicillin (parenteral) g r
Non-CNS ≤ 24 ≥ 8 O 3
CNS ≤ 0.06 ≥ 0.12 .
Ceftriaxone 4 Non-CNS ≤ 12 ≥ 4 CNS ≤ 0.5 1 ≥ 2
• Addition of Vancomycin to Ceftriaxone is not indicated in the empiric 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. 134) Extended spectrum beta-lactamase (ESBL)-producing organisms • ESBLs are enzymes that confer resistance to all penicillins, cephalosporins, and Aztreonam. • They are most commonly seen in K. 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.
25 s • Risk factors for infection or colonization: recent hospitalization at an d o r institution with a high rate of ESBLs, residence in a long-term care e v i facility and prolonged use of broad spectrum antibiotics. t a g Treatment: e n
- • Meropenem 1 g IV Q8H (2 g IV Q8H for CNS infections) should be used m
a for ALL severe infections if the organism is susceptible. r
G • Ertapenem 1 g IV Q24H can be used for uncomplicated UTI or soft t n tissue infection with adequate source control if the organism is a t s i susceptible. s e
r • Ciprofloxacin or TMP/SMX can be used as alternatives to Ertapenem g for uncomplicated UTI or soft tissue infection with adequate source u r d
- control if the organism is susceptible. Nitrofurantoin may also be used i t l
u for uncomplicated UTI if the organism is susceptible. M :
s Carbapenemase-producing Enterobacteriacae (CRE) e n
i • Carbapenemases are enzymes that confer resistance to all penicillins, l e cephalosporins, carbapenems and Aztreonam. d i u • Enterobacteriaceae are automatically screened by the JHH g c i microbiology lab and a modified Hodge test is conducted to confirm f i c the presence of carbapenemases. e p s Hodge test result Susceptibility on panel Reporting m s i Hodge test (+) Resistant Reported as resistant n a g Hodge test (+) Susceptible or Intermediate MIC only without interpretation* r
O Hodge test (-) Susceptible, Intermediate Reported as tested, no 4 . or Resistant carbapenemase production 4
*Infections caused by organisms that are modified-Hodge test positive in the susceptible or intermediate range may respond to extended infusions of Meropenem in combination with an aminoglycoside. Consult ID or Antimicrobial Stewardship for recommendations. Treatment: • If Hodge test (+) and Meropenem susceptible or intermediate: Meropenem 2 g IV Q8H infused over 3 hours PLUS a second agent (e.g. Amikacin, Tigecycline, Colistin). • If carbapenem resistant and Colistin susceptible: Colistin PLUS a second agent • Combination therapy is recommended when possible for CRE infections except UTI.
Multi-drug resistant (MDR) gram-negative organisms: defined as organisms susceptible to NO MORE than ONE of the following antibiotic classes: carbapenems, aminoglycosides, fluoroquinolones, penicillins, or cephalosporins. Note: susceptibility to sulfonamides, tetracyclines, polymixins, and Sulbactam are NOT considered in this definition
26 Treatment s d o r MDR Pseudomonas aeruginosa MDR Acinetobacter baumannii/calcoaceticus e v i
complex t a
• Anti-pseudomonal -lactam PLUS • -lactam PLUS aminoglycoside if synergy predicted g aminoglycoside if synergy predicted or confirmed e n or confirmed OR - m
OR • Colistin (if susceptible) a r
• Colistin (if susceptible) OR G
• Ampicillin/sulbactam (if susceptible) PLUS t n a
aminoglycoside (Sulbactam component has in vitro t s activity against Acinetobacter spp.) i s
OR e r • Tigecycline (if susceptible; for infections other than g u
bacteremia) r d - i t
*Combination therapy should be considered in severe infections. l u M : s
Synergy: e n i • If the organism is intermediate to a beta-lactam and susceptible to l e d aminoglycosides, synergy can be assumed. i u
• The microbiology lab does not perform synergy testing. g c i f i
Antibiotic doses for MDR and carbapenemase-producing c e p
infections – normal renal function s
• Meropenem: 2 g IV Q8H, infuse over 3 hours m s i
• Cefepime: 2 g IV bolus loading dose over 30 minutes, then 6 g IV as n a g
continuous infusion over 24 hours r
• Ceftazidime: 2 g IV bolus loading dose over 30 minutes, then 6 g IV as O 4 .
continuous infusion over 24 hours 4 • Piperacillin/tazobactam: 3.375 g IV bolus loading dose over 30 minutes, then continuous infusion 3.375 g IV Q4H infused over 4 hours OR 4.5 g IV Q6H, infuse over 4 hours • Colistin: 5 mg/kg once, then 2.5 mg/kg IV Q12H (for additional information, see p. 9) • Ampicillin/sulbactam: 3 g IV Q4H (for MDR A. baumannii only) • Aminoglycosides (for dosing, see p. 141) • Tigecycline: 100 mg IV once, then 50 mg IV Q12H (for MDR non- bacteremic A. baumannii only)
References: ESBLs and clinical outcomes. Clin Infect Dis 2006:42;S164. Current therapies for P. aeruginosa. Crit Care Clin 2008;24:261. MMWR: Guidance for control of infections with carbapenem – resistant or carbapemase – producing Enterobacteriaceae in acute care facilities; 2009, March; 58(10): 256-260.
27 t r
o Interpreting the microbiology report p e
r Interpretation of preliminary microbiology data y g Gram-positive cocci Gram-negative cocci o l o i Aerobic Aerobic b Diplococcus: N. meningiditis, N. o In clusters r • Coagulase (+): S. aureus gonorrhoeae, Moraxella catarrhalis c i • Coagulase (–): S. epidermidis, Cocco-bacillus: H. flu, Acinetobacter spp., m S. lugdunensis HACEK organisms e
h In pairs/chains t • Diplococcus, Quellung positive: g
n S. pneumoniae i t • Alpha-hemolytic: Viridans group e r Streptococci, Enterococcus p r (faecalis and faecium) e t • Beta-hemolytic: n I Group A strep (S. pyogenes), 1
. Group B strep (S. agalactiae), 5 Group C, D, G strep
Anaerobic: Peptostreptococcus spp. Anaerobic: Veillonella spp.
Gram-positive rods Gram-negative rods Aerobic Aerobic Large: Bacillus spp. Lactose fermenting: Citrobacter spp., Cocco-bacillus: Listeria monocytogenes, Enterobacter spp., E. coli, Klebsiella Lactobacillus spp. spp., Serratia spp.* Small, pleomorphic: Corynebacterium spp. Non-lactose fermenting Branching filaments: Nocardia spp., • Oxidase (–): Acinetobacter spp., Streptomyces spp. Burkholderia spp., E. coli (rare), Proteus spp., Salmonella spp., Shigella spp., Serratia spp.*, Stenotrophomonas maltophilia • Oxidase (+): P. aeruginosa, Aeromonas spp., Vibrio spp., Campylobacter spp. (curved)
Anaerobic Anaerobic: Bacteroides spp., Large: Clostridium spp. Fusobacterium spp., Prevotella spp. Small, pleomorphic: P. acnes, Actinomyces 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 1 1 usually associated with clinical efficacy. MICs which are ⁄ 2– ⁄ 8 the
28 t breakpoint MIC are more frequently utilized to treat infections where r o antibiotic penetration is variable or poor (endocarditis, meningitis, p e osteomyelitis, pneumonia, etc.). Similarly, organisms yielding antibiotic r y g
MICs at the breakpoint frequently possess or have acquired a low-level o l o resistance determinant with the potential for selection of high-level i b o
expression and resistance. This is most notable with cephalosporins and r c Enterobacter spp., Serratia spp., Morganella spp., Providencia spp., i m
Citrobacter spp. and Pseudomonas aeruginosa. These organisms all e h possess a chromosomal beta-lactamase which frequently will be over- t g n expressed during therapy despite initial in vitro susceptibility. The i t e intermediate (I) category includes isolates with MICs that approach r p attainable blood and tissue levels, but response rates may be lower than r e t n fully susceptible isolates. Clinical efficacy can potentially be expected in I 1 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 5 (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.
29 5.2 Spectrum of antibiotic activity 3
0 GRAM-POSITIVE GRAM-NEGATIVE A b P d  E s o C e n - m h o t u O e S e i a V d n K r m r . g i o S a a H o P r e p . i o m l l e b r b . d n n o l a a E r a s a y i o e r n e t n n c . A t i n a e n e u f g i a a t c s f t l t a u m l e u a e e . y i l a a s s E M e r M s s p e r r s o o o . n t t c i s s s s s t S R n c V r r b b a z c a p p p p p e e i a S S R p a a e e o l p p p p p p p i l A A E e e h s s s s l ...... i 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 TMP/SMX Clindamycin Doxycycline Colistin Metronidazole Not active Less active or potential resistance Active s t
Interpretation of rapid diagnostic tests s e t c
The JHH microbiology lab performs rapid nucleic acid microarray testing i t s
on blood cultures growing Gram-positive organisms and peptide nucleic o n
acid fluorescence in situ hybridization (PNA-FISH) testing on blood g a i
cultures growing yeast. d d ® i Nucleic acid microarray testing (Verigine ) for Gram-positive p a r
cocci in blood cultures f • Detects and identifies the nucleic acids of 12 Gram-positive bacterial o n o i
genera/species and 3 resistance markers. t a • Bacteria species: S. aureus, Coagulase-negative staphylococci, S. t e r
lugdunensis, Staphylococcus spp. E. faecalis, E. faecium, S. pyogenes p r e
(group A streptococci), S. agalactiae (group B streptococci), S. t n pneumoniae, S. anginosus, Streptococcus spp. (e.g.,group C and G I 3 .
streptococci, viridans group streptococci, etc.), Listeria spp. 5 • Resistance markers: mecA, vanA, vanB • If S. aureus is mecA positive the organism is resistant to Methicillin and is reported as MRSA • If S. aureus is mecA negative the organism is susceptible to Methicillin and is reported as MSSA • If E. faecalis/faecium is vanA/B positive the organism is resistant to Vancomycin and is reported as VRE; note that all Vancomycin- resistant E. faecalis are susceptible to Ampicillin at JHH • Results of the test are reported within 3-4 hours after the blood cultures turn positive • Testing is performed only on the first positive blood culture • Testing is NOT performed on blood cultures growing more than one Gram positive organism but is performed on blood cultures growing both Gram positive and negative organisms • If the test is negative it will be reported as negative for the following organisms: Staphylococcus spp, Streptococcus spp., E. faecalis, E. faecium, Listeria spp.
31 s t Organism Preferred empiric therapy Alternative empiric therapy s e (% susceptible in blood at JHH) if PCN allergic t
c MSSA Oxacillin (100%) Non-severe PCN allergy: Cefazolin i t 1
s Severe PCN allergy: Vancomycin o MRSA Vancomycin (100%) Daptomycin n g Single positive cultures are often a contaminant; no treatment a i Coagulase-negative recommended. See page 54 of the JHH Antibiotic Guidelines for d staphylococci information and indications for treatment. Call the microbiology lab for d i
p more information and further work up if infection suspected (5-6510).
a 2
r S. lugdunensis Vancomycin (100%) Oxacillin (89%) or Daptomycin f E. faecalis Ampicillin (99%) Vancomycin (89%)1 o E. faecium (VRE) Linezolid (93%)3 Daptomycin (96.5%) n
o 3 i E. faecium (not VRE) Vancomycin (100%) Linezolid t 4 1 a Streptococcus spp. Non-oncology patient: Ceftriaxone Severe PCN allergy: Vancomycin t e Oncology patient: Vancomycin4 r p S. anginosus Penicillin G (100%) Non-severe PCN allergy: Ceftriaxone r
e 1
t Severe PCN allergy: Vancomycin n
I S. pyogenes Penicillin G (100%) Non-severe PCN allergy: Cefazolin 1 3 (group A strep) Severe PCN allergy: Vancomycin .
5 S. agalactiae Penicillin G (100%) Non-severe PCN allergy: Cefazolin (group B strep) Severe PCN allergy: Vancomycin1 S. pneumoniae Ceftriaxone (94%)4 Severe PCN allergy: Vancomycin1 (not meningitis) S. pneumoniae Ceftriaxone + Vancomycin Severe PCN allergy: (meningitis) Chloramphenicol + Vancomycin1 Listeria spp. Ampicillin (100%) Trimethoprim/sulfamethoxazole 1Consult allergy for skin testing /desensitization 2Narrow to Oxacillin if found to be susceptible 3Narrow to Ampicillin if found to be susceptible 4Narrow to Penicillin G if found to be susceptible
PNA-FISH for yeast • If PNA-FISH shows C. albicans, most non-oncology patients without prior azole exposure can be treated with fluconazole. For more information see p. 108 and 124. • If PNA-FISH shows C. glabrata, treat with Micafungin until susceptibilities available. For more information see p. 108 and 124. • If PNA-FISH negative for C. 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. 108 and 124.
32 s n Biliary tract infections – cholecystitis and o i t c cholangitis e f n i
l EMPIRIC TREATMENT a n
i Community-acquired infections in patients without previous m biliary procedures AND who are not severely ill o d • Ertapenem 1 g IV Q24H b A OR 1 .
6 • Severe PCN allergy: Ciprofloxacin 400 mg IV Q12H PLUS Metronidazole 500 mg IV Q8H Hospital-acquired infections OR patients with prior biliary procedures OR patients who are severely ill • Piperacillin/tazobactam 3.375 g IV Q6H OR • Severe PCN allergy: [Ciprofloxacin 400 mg IV Q12H OR Aztreonam 1 g IV Q8H] PLUS Metronidazole 500 mg IV Q8H Ϯ Vancomycin (see dosing section, p. 146) 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 • Uncomplicated cholecystitis: treat only until obstruction is relieved. NO post-procedure antibiotics are necessary if the obstruction is successfully relieved. • Complicated cholecystitis: 4–7 days, unless adequate source control is not achieved. • Biliary sepsis: 4–7 days, unless adequate source control is not achieved.
TREATMENT NOTES Microbiology • Gram-negative rods – E. coli, Klebsiella spp., Proteus spp., P. aeruginosa (mainly in patients already on broad-spectrum antibiotics or those who have undergone prior procedures) • Anaerobes – Bacteroides spp., generally in more serious infections, or in patients with a history of biliary manipulations • Enterococcus spp. – treatment not always indicated; use clinical judgment • Yeast – rare Management • In cases of uncomplicated acute cholecystitis, antibiotics should be given until the biliary obstruction is relieved (either by surgery, ERCP, or percutaneous drain). 36 • Treatment of enterococci is usually not needed in mild/moderate s n o i
disease. t c e
• Yeast generally should be treated only if they are recovered from biliary f n cultures, not empirically. i l a n Reference: i Biliary tract infections: Drugs 1999;57(1):81-91. m o
IDSA Guidelines for Intra-abdominal Infections: Clin Infect Dis 2010;50:133–164. d b A 1 .
Diverticulitis 6
EMPIRIC TREATMENT Mild/moderate infections – can be oral if patient can take PO • Amoxicillin/clavulanate 875 mg PO Q12H OR • Ertapenem 1 g IV Q24H OR • Severe PCN allergy: [Ciprofloxacin 400 mg IV Q12H OR Ciprofloxacin 500 mg PO Q12H] PLUS Metronidazole 500 mg IV/PO Q8H Severe infections • Piperacillin/tazobactam 3.375 g IV Q6H OR • Non-severe PCN allergy: Cefepime 1 g IV Q8H PLUS Metronidazole 500 mg IV Q8H OR • Severe PCN allergy: Ciprofloxacin 400 mg IV Q12H PLUS Metronidazole 500 mg IV Q8H Duration • 4–7 days, unless adequate source control is not achieved.
TREATMENT NOTES Microbiology • Almost all infections are polymicrobial • Most commonly isolated aerobic organisms – E. coli, K. pneumoniae, Enterobacter spp., Proteus spp., Enterococcus spp. • Most commonly isolated anaerobic organisms – B. fragilis, Prevotella, Peptostreptococci Other considerations CT scan is important in assessing need for drainage in severe disease. Some patients will present with diffuse peritonitis and pneumoperitoneum.
Reference: IDSA Guidelines for Intra-abdominal Infections: Clin Infect Dis 2010;50:133–164.
37 s n Pancreatitis o i t c
e TREATMENT f n i • Mild to moderate pancreatitis – no antibiotics l a • Severe acute pancreatitis (SAP)* – no prophylactic antibiotics n i
m • No necrosis – no antibiotics o
d • Sterile pancreatic necrosis – no antibiotics b
A • Infected pancreatic necrosis* – empiric antibiotic therapy as 1 . defined below: 6 • Meropenem 1 g IV Q8H OR • PCN allergy: Ciprofloxacin 400 mg IV Q12H PLUS Metronidazole 500 mg IV Q8H * Definitions • Severe acute pancreatitis (SAP) is defined as pancreatitis associated with one or more of the following: • > 30% pancreatic necrosis • APACHE II ≥ 8 • More than 3 Ranson’s criteria
Ranson’s criteria to predict severity of acute pancreatitis Zero Hours Age > 55 WBC > 16,000/mm3 Blood glucose > 200 mg/dL Lactate dehydrogenase > 350 U/L Aspartate aminotransferase (AST) > 250 U/L 48 Hours Hematocrit Fall by ≥ 10 percent Blood urea nitrogen Increase by ≥ 5 mg/dL despite fluids Serum calcium < 8 mg/dL pO2 < 60 mmHg Base deficit > 4 MEq/L Fluid sequestration > 6000 mL
• Infected pancreatic necrosis is defined as one or both of the following: • CT scan with gas • Percutaneous aspirate or surgical specimen with organisms evident on gram stain or culture
38 Duration s n o i
For infected pancreatic necrosis, continue antibiotics for 14 days after t c e
source control is obtained. Continuation of antibiotics beyond this time f n places the patient at risk for colonization or infection with resistant i l a
organisms and drug toxicity. n i m o
TREATMENT NOTES d b
• Penicillins and cephalosporins penetrate poorly into the pancreas A 1 • Infection develops in 30–50% of patients with necrosis documented by . 6 CT scan or at the time of surgery. • Peak incidence of infection occurs in the 3rd week of disease • Prophylactic antibiotics have been associated with a change in the spectrum of pancreatic isolates from enteric Gram-negatives to Gram- positive organisms and fungi. • There is insufficient evidence to recommend selective gut decontamination in management of pancreatitis.
References: Lack of utility of prophylactic antibiotics: Ann Surg 2007;245:674. Guidelines for management of SAP: Crit Care Med 2004;32:2524. Ranson’s criteria: Surg Gynecol Obstet 1974;139:69.
Peritonitis DEFINITIONS Primary peritonitis is spontaneous infection of the peritoneal cavity, usually associated with liver disease and ascites [spontaneous bacteria peritonitis (SBP)]. 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 • Ceftriaxone 1 g IV Q12H OR • Severe PCN allergy: Moxifloxacin 400 mg IV/PO Q24H (call ID or Antibiotic Management to discuss regimens for patients who have been taking fluoroquinolones for SBP prophylaxis). • Patients with serum creatinine >1 mg/dL, BUN >30 mg/dL or total bilirubin >4 mg/dL should also receive Albumin (25%) 1.5 g/kg on day 1 and 1 g/kg on day 3 (round to the nearest 12.5 g).
39 s Duration n o i t • Treat for 5 days. c e f
n PROPHYLAXIS i l
a Cirrhotic patients with gastrointestinal hemorrhage n i • Norfloxacin 400 mg PO BID for 7 days m o • Ceftriaxone 1 g IV Q24H can be used only if patient is NPO, then d b switch to Norfloxacin 400 mg PO BID once bleeding is controlled A
1 Non-bleeding cirrhotic patients with ascites . 6 • Norfloxacin 400 mg PO daily OR • TMP/SMX 1 DS PO once daily
TREATMENT NOTES Microbiology • Gram-negative rods (Enterobacteriaceae, esp. E. coli and K. pneumoniae), S. pneumoniae, enterococci, and other streptococci. • Polymicrobial infection should prompt suspicion of GI perforation. Diagnostic criteria • 250 PMN per mm3 of ascitic fluid. • Positive culture with < 250 PMN should prompt repeat tap. If PMN > 250 OR culture remains positive, patient should be treated. Follow-up • Consider repeat paracentesis after 48 hours of therapy. • Consider changing antibiotics if ascites fluid PMN has not dropped by 25% after 48 hours and/or patient is not clinically responding. Notes on prophylaxis against SBP • All patients with cirrhosis and upper GI bleed should receive prophylaxis for 7 days (50% develop SBP after bleed). • Patients who get SBP should get lifelong prophylaxis to prevent future episodes (40–70% risk of recurrence in 1 year). • Prophylaxis with Norfloxacin should be considered for those with low protein concentrations in ascites (< 10 g/L) or immunosuppression while patient is in hospital.
Reference: Diagnosis, treatment and prophylaxis of SBP: J Hepatol 2000;32:142. Management of variceal hemorrhage in cirrhosis: Hepatology 2007;46:922–38.
40 s
Secondary peritonitis/GI perforation n o i t c e EMPIRIC TREATMENT f n i
Perforation of esophagus, stomach, small bowel, colon, or l a n appendix i m
Patient mild to moderately ill o d
• Ertapenem 1 g IV Q24H b OR A 1 .
• Severe PCN allergy: Ciprofloxacin 400 mg IV Q12H PLUS 6 Metronidazole 500 mg IV Q8H Patient severely ill or immunosuppressed • Piperacillin/tazobactam 3.375 g IV Q6H OR • Non-severe PCN allergy: Cefepime 1 g IV Q8H PLUS Metronidazole 500 mg IV Q8H OR • Severe PCN allergy: Vancomycin (see dosing section, p. 146) PLUS [Aztreonam 1 g IV Q8H OR Ciprofloxacin 400 mg IV Q8H] PLUS 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 received prior long-term azole therapy: • Fluconazole 400-800 mg IV/PO Q24H Recommendations for patients who are NOT clinically stable or have received prior long-term azole therapy: • Micafungin 100 mg IV Q24H OR • AmBisome® 3 mg/kg IV Q24H
Duration of therapy for secondary peritonitis/GI perforation
Stomach Small Bowel Colon Appendix Uncomplicated Definition Operated on Operated on Operated on Non-necrotic or within within within gangrenous 24 hours 12 hours 12 hours appendix Duration 24–48 hours 24–48 hours 24–48 hours 24 hours Complicated Definition Late operation or no operation; or necrotic/gangrenous appendix Duration 4-7 days unless adequate source control is not achieved
41 s TREATMENT NOTES n o i t • Causative agents for small bowel, colon, appendix: anaerobes (esp. c e
f B. fragilis), Enterobacteriaceae (esp. E. coli, K. pneumoniae, n i Enterobacter spp., Proteus spp.); infections usually polymicrobial. l a
n • Pathogens causing tertiary peritonitis are variable and are often i
m resistant to or not covered by the initial antimicrobial regimen; thus, a o d change in antimicrobials is advised. b
A • A change in antimicrobials therapy should be considered in patients 1 . with hospital-acquired infections who are already on antimicrobials. 6 • Treatment of enterococci remains controversial but should be considered in critically ill or immunocompromised patients or when they are a dominant organism in the peritoneal culture. • Treatment of Candida 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. • Postoperative antibiotics for appendicitis are unnecessary unless there is clinical evidence of peritonitis, abscess, or gangrene. • Antibiotics are adjunctive to source control, which is an absolute necessity. • Lack of source control is defined as on-going contamination and/or an undrained collection of infection.
Reference: IDSA Guidelines for Intra-abdominal Infections: Clin Infec Dis 2010;50:133–164.
Peritonitis related to peritoneal dialysis
EMPIRIC TREATMENT Mild to moderate illness: intraperitoneal therapy is preferred in most cases. Anuric patient • Cefazolin 15 mg/kg in one bag Q24H (1 g if patient < 65 kg) PLUS • Gentamicin 2 mg/kg in one bag loading dose, then Gentamicin 0.6 mg/kg in one bag Q24H Patient with urine output > 100 mL/day • Ceftazidime 1 g in one bag Q24H Severe illness: systemic therapy is preferred. • FIRST DOSE: Vancomycin (see dosing section, p. 146) IV PLUS ONE of the following: [Gentamicin 2 mg/kg IV OR Ceftazidime 1 g IV OR Ciprofloxacin 400 mg IV] • MAINTENANCE DOSE: Dose per drug levels and/or renal function (See dosing section p. 141, 146, and 150) Duration of tailored therapy: 10–14 days
42 s n
TREATMENT NOTES o i t
Microbiology c e f
• Most cases caused by contamination of the catheter n i l
• Cultures may be negative in 5–20% a n • Gram-positive cocci (S. aureus, coagulase-negative staphylococci, i m
Enterococcus spp.), Gram-negative rods, yeast (much less common) o d b
Diagnosis A 1 • All patients with suspected PD-related peritonitis should have PD fluid . 6 sampled for cell count, differential, gram stain, culture AND amylase. WBC > 100/mm3 with > 50% PMN suggests infection. • Elevated amylase suggests pancreatitis or bowel perforation. • In symptomatic patients with cloudy fluid accompanied by abdominal pain and/or fever, empiric treatment should be started given the high likelihood of infection. • In symptomatic patients with clear fluid, another PD fluid exchange, 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. • In asymptomatic patients with cloudy fluid, it is reasonable to delay therapy pending the results of cell count, gram stain, and culture.
References: ISPD Guidelines for Peritoneal Dialysis-related Infections: Perit Dial Int 2010;30:393–423.
43 6.2 Clostridium difficile infection (CDI) • • • 4 • D • • • • • T • C R 4 i S i C O d D b c I T c S i w g S t D T r d l I i B M d o w n a n n a m V n r e l E e o o h o i e e h n e T t p e e a o o r i i f x a o g e c t t o e ≤ p p V a c e e l l m c n A c a e s a h h O r l o t c r t n e o N N c s a a l e r r e r u e a t a e c t i T n 2 s a m n o o o P h o m t c i l t t t n s m , O O u t v l i f o M o h e i i l m 4 v n e d n f r t o e s c l s r e s 7 s i t o e i x e T T i n s c e A e s i a o h e g f i a n n o w s e d E i e s i h n r o s r c r s t n g e d f n d L t r e m s s a a o r n o N o i i t a a s r o , y f C t o n t . e a a a L r e e p o z s b i t i r b u n f p y a u v t i f T r n . y t o I r u o n n n o o t y r h f i r d e s e c i i e i n t i A o s s i e t l c x d d d o s r r l d c e o e t 2 s m y i d e l c m h . l n n i N w / h e c i n o d n r s u C o f . A 4 e f s o s h h C o t e e f s l i o g u e . i s i f T s l i e t . o i l N t u - n r a i u c o s f c y v l a 4 o s s l . r y e I d l l f s d i n t r i i p a o b o D r r M d l c t t o n 8 l H i c s t l a e e t o l i o c C i o m e h w a a i f g C l i b n p t a r a b a f I e p n f e n h h e . o b l e f t i C s e - n o D r r c l m f e o u d e i a l g e o c r d t e d a o n n t i p i R u i p I h w l s r t u l u o n i . y i c e j x h o e s h f s m L f e a s e t s s O r C s r f i a a n C e i o . i t l a d t c e e s i i n r r b t e l t c e t i d n . l n o e B l b b i e . a t s s g i t o l d s a e i v p e d e e s e d l l o o n n P t e d I a e g e e a a A r d i d s s i w l p c t r t C i f t c f , i a i s f b t i o a i h o . t c i d f L e o v f r i o r h a b s R i , n f s i l o t c e r r i a T p i l s c i s e a n r e t o y u f s i A e i u a t n f y i r o t c i i i C l r n n i , h r s t l e w o i d e s l w l t e s G r e i i l s y d - e d D o e h v s i a t h t n p h > i d t i i C c v e E i o i e P d t f s t m M e I e n n b i e o r . i h c e v b . N C e P a t g g s t 9 e s n m u r f e e a r o e t o c i d : p T t C t R t 0 t T a d l i o e i o o c p a i l i o r n i o P h s p e t l y R c f i % i S i d n f o h o o d c f g t m u n s a C v C r s , i r y u e e l i p c u s l o s i e s e l n p e W c t R D d e m i n d t s r i s , f b i o s n e s l c r l o ( v e i u c e s a I i e n o a H i p p f a b t e C e o f m s o p t t i a b r r g u r f m g s a a e a s t l n t n e E i l o e l n h c t o d i p D s t t e t t b d d a d c e s f t p N m d h i i o e t o g a a o e e r a l e s a i e s e e t o d e o p I s m y r y E n r n s t l d r t t d ) y e . y f c a e s h l r p e e t t V C , t l r i e d s t s o t o t e n a ≥ t o e s t o d e h m e o E t t . o m t r o l b u c r e h w s d o o e t s e 3 R d d o n l . o e i e d s u t o b o n t t m h e i e o n s n r i t l f i u o r n s t a o t t s P i s f t o f n t a e o n o s n f i e s e h f s s c a c a o t O n i n n g x o a f c c a c t o i m i s o c s o t i p o s a h l r r g o S a s t e i n e i e u r p s r a o u s h p c p e t i m e t t S e t l m n e o v o s a s h i t i l c y n r y n f n n e y I o e c s v r e e e f i B o i p u c o f g i s c o a i e t i c q d m m b l a e o o L t t d o f n a b u s o c l c l r E s e i e n d e i I c i e h a u t x t V t r t i m a . n i i y e o e r z i l o s a v t n r n e d n u u . e o f b o h t t B r d l . l . e e e d f e s r a r . ) Treatment depends on clinical severity I D C Infection severity Clinical manifestations ( n o
Asymptomatic C. difficile PCR positive without diarrhea, i t carriage* ileus, or colitis c e f n
Mild or moderate C. difficile PCR positive with diarrhea but no i e
manifestations of severe disease l i c i
Severe C. difficile PCR positive with diarrhea and one or more f f of the following attributable to CDI: i d • WBC ≥ 15,000 m u
• Increase in serum creatinine > 50% from baseline i d i
Severe Complicated Criteria as above plus one or more of the following r t attributable to CDI: s o l
• Hypotension C
• Ileus 2 .
• Toxic megacolon or pancolitis on CT 6 • Perforation • Need for colectomy • ICU admission for severe disease
Infection severity Treatment Asymptomatic Do NOT treat; treatment can promote relapsing carriage disease Mild or moderate • Metronidazole 500 mg PO/NGT Q8H Unable to tolerate oral therapy • Metronidazole 500 mg IV Q8H (suboptimal; see note at start of CDI section above) Severe • Vancomycin solution 125 mg PO/NGT Q6H Severe Complicated • Consult surgery for evaluation for colectomy and ID • Vancomycin solution 500 mg by NGT Q6H PLUS Metronidazole 500 mg IV Q8H Unable to tolerate oral therapy or complete ileus • Vancomycin 500 mg in 500 ml NS Q6H as retention enema via Foley catheter in rectum + Metronidazole 500 mg IV Q8H
* ≥ 50% of hospital patients colonized by C. difficile are asymptomatic carriers; this may reflect natural immunity.
Other indications for oral Vancomycin use • No response to oral Metronidazole after 5 days of therapy • Second episode of recurrent disease • Patients with significant side effects to Metronidazole • Patients who are pregnant • Consider in patients > 80 years given reports of increased morbidity from CDI.
45 ) I Duration D C
( • 10–14 days n o i Approach to patients who need to continue broad spectrum t c antibiotic therapy e f n i • Determine the shortest possible course of antibiotic therapy. e l
i • Replace the antibiotic that induced CDI, particularly cephalosporins, c i f Clindamycin, and fluoroquinolones. f i d • If the inducing agent is replaced and the CDI resolves, complete a m standard 10-14 day course of CDI therapy; there is no need to extend u i d i CDI therapy until the end of the course of antibiotic therapy. r t s • If the inducing agent cannot be stopped or replaced, consider o l
C continuing CDI therapy until the end of the course of antibiotic therapy 2
. (data are limited); CDI therapy should not be continued beyond the end 6 of antibiotic therapy if the patient remains asymptomatic. Recurrent disease • Resistance to Metronidazole or Vancomycin has not been documented conclusively. • Recurrent disease after a complete course of therapy occurs in ~ 25% of patients. Relapse is due to failure to eradicate spores (60%) or acquisition of a new strain (40%). Document recurrent disease with repeat stool testing. • First recurrence should be treated the same as the initial episode; severe disease should be treated with Vancomycin. • Second recurrence should be treated with Vancomycin taper followed by pulse dosing. • If serious or multiple recurrences, consult ID.
Vancomycin taper regimen 125 mg 4 times daily x 10–14 days 125 mg BID X 7 days 125 mg daily X 7 days 125 mg every 2–3 days for 2–8 weeks (pulse dosing)
NOTES Management • Surgical intervention for colectomy should be considered early if the patient is clinically unstable secondary to CDI. • Treatment of CDI should be continued in patients who have a subtotal colectomy with preservation of the rectum. • Most patients with severe CDI should undergo abdominal CT to rule out toxic megacolon or pancolitis.
46 ) • Do NOT send follow-up C.difficile PCR to document resolution of I D C
disease. (
• Do not use antimotility agents. n o i t
• Stop proton pump inhibitors (PPIs) whenever possible as data suggest c e PPIs increase the risk of CDI. f n i
• The offending antimicrobial agents should be discontinued. If e l i c
antimicrobials are still required, it is best to avoid cephalosporins, i f f i
Clindamycin, and fluoroquinolones. d
• Prophylactic use of oral Metronidazole or Vancomycin in patients m u i
receiving antimicrobial therapy for treatment of underlying infection d i r (other than CDI) is not recommended and may increase the patient’s t s o risk for CDI. l C 2
Infection control . • Patients with CDI should be placed in contact precautions and single 6 rooms for the duration of hospitalization. • Use soap and water rather than alcohol-based hand gel upon exiting the room of a patient with CDI.
References: SHEA/IDSA Consensus Guidelines for CDI: Infect Control Hosp Epidemiol 2010; 31:431–454. Lack of utility of treating CDI carriers: Ann Intern Med 1992; 117:297-302. Colectomy in CDI: Ann Surg 2007; 245:267-72.
47 6.3 Infectious diarrhea 4 • • • • • • • • M • D • • • • • • I n 8 i T m M d d V s A A C S C f C d P s N m j f P d F y M p s F F C N i a u e e c i r y h u e e i i e e a i n n e a o f a . o y a e o o d s a r g o u e v c a o r n o b c c e t p t t t t a r c l r r l m d t e s g r e l o m s a a n h e n d d i i i s d t e m a a u b m e r l e l o a i i r c e m t o t l a o r b t . e i f h o p r f m l l l p , n i m n s o r d f m s c u o s o v g i s i o g r e i l i l s s t t n t a e t e d o n e c e o e e o a l p o t p t m s e e t e a e l i p i b i f t i e n i y e r a i u i n ; s t r l m o e c e n n o l h l m n n s n e o e e e i y t d w e l k e a t t e s c g c l a o r t t t c a u y m u i g n o o e n e o a e a l i i d t t b ( s g w f d e t w t m i , s u o i o o y c d o f m n , x o e s l h a h o s i a e e v i e a S s i n i a n i y t d r i I e g l t e e u t s s a s l s n . d e n r f s u h - l h t r h e i v d n e n s m e s t e r r e t t e o a s r n o p a t t s i o e h y i x s e b S n g h h d a v , r r / s s l e i i d a p u a e o d l s a r s t n e e r e l a n e a y h p s t a c i s h y o t i m e a f l f s a o a h r r l n t l i u o i o W r c e i l g e w r n i n a e l p f a r e o t l b d s C c o r i i s e b t i a r e a i p n r c a , B f i a h d o l m i / r s h d h t e f l a t o . p : a e n e h t h o S o , i a i f C u t s e i i v m d h a i t a e C t n d s a u e o q m r i u M i s t h p e i a e . o n a r c t o e d r o t s s x i u . m t l p r i i i r a i f r e d n m g s g e i o f a c n i s i a o h i i i c d f i c n i s r N t t t n d c e n u a i s s t e e l i y i r i n u i - a c a r a e h b s f p i o t n n o e s . c a e o a o f f n t t f d p i n e i a r s i o o r e i s b o l o o l u n q s c n o o t o s e t o v p n p c r l i e l r x s t o s p i u f i c l n h t e b d v l r t i n l f - o o e i u f c e n a i t a i l i o o o o s n o r i e u r o h i b n r r m m r e s s p e t a a r - v r m u c u o e e r i i p i f i e o s d e u s e p s c n a e c l e s i p i s s x r d n t c m p s s t i u n u r h o a e p p p c r o i s t a p g o o a e e c r n t t o . a r d , d o e e i t o u t n e r p n t s d e m s l o i m b i e E u e C a c n s s t d m o d r . c a c o c l c s w s l t u . i i m i e y i i n n f a e i n s o s z p o i l s i c m i R r c t s i n c t i , d e t e e e c o b m a m v r p e e o s o h g a m i ) d n d s u e m e r p b a h ) o . t l e m a i t : e d l c a l E h a t i o t u e o ) n ( f e s n e s i u . e G l v m e o i t e . u u n i l s w g m g g i n h y r i d t ( r n i r n l o c t e e h a o e d i o p a . u i c p t i r a n o > c . f r t . s s l s g e s . a o o s g y i d n n g o l r D t i q e l u - 4 ( , r v t 3 w o i . i c . m a c O a l i e n u f s i i m C t 4 h o m r c k e i , c s i d & t p p u t r e e b q m a h a . C h i i e a o i s r c P s m a c l m u e t e o y s y r m b s u r i ) n i i o ( y r o o m r s o t u C p r l c d a s a e o p n o e b n l s m y a M r u s y / i p d o t n s s i e e l t o o a u t h p f o y d l e o i V i o d y d l c o s s l o r p b d o s y d ) o r i e p f t . u o c a a - c . t f . u e m n d o s s o l r r a c l d l r i s l o i p r t n r y e u o a t v i h t i e w v e i n d m s r d a c a e e r r c o i e r e a , f u a h i i y t t c f l r m : e e i a b c a r t , e , e a Treatment of infectious diarrhea a e h r
Organism/Indications for treatment Treatment r a i
Bacteria d s
Campylobacter spp. • Azithromycin 500 mg PO daily for 1–3 days u o i t
Treatment recommended for: c e
• Severe illness f n • Age < 6 months or > 50 years I 3
• Gross blood in stool .
• High fever 6 • Worsening or relapsing symptoms • Pregnancy • Immunocompromised host
E. coli (enterotoxigenic, enteropathogenic, • Norfloxacin 400 mg PO BID enteroinvasive) or empiric therapy of OR traveler’s diarrhea • Ciprofloxacin 500 mg PO BID
Duration: 1–3 days
Shiga toxin producing E. coli (including Treatment not recommended. Antibiotic E. coli 0157:H7) use associated with development of hemolytic uremic syndrome.
Non-typhoid Salmonella spp. • Norfloxacin 400 mg PO BID (not for bacteremia) Treatment recommended for: OR • Severe illness requiring hospitalization • Ciprofloxacin 500 mg PO BID • Age < 6 months or > 50 years OR • Bacteremia • TMP/SMX 160/800 mg PO BID • Presence of prostheses (if susceptible) • Valvular heart disease OR • Severe atherosclerosis • Ceftriaxone 1 g IV Q24H • Malignancy or other immunocompromise Duration: 5–7 days; 14 days for immunocompromised host
Shigella spp. • TMP/SMX 160/800 mg PO BID (if susceptible) Treatment always recommended even if result OR returns when patient is asymptomatic. • Norfloxacin 400 mg PO BID (not for bacteremia) OR • Ciprofloxacin 500 mg PO BID
Duration: 3 days; 7 days for immuno- compromised host
Vibrio parahaemolyticus • Ciprofloxacin 500 mg PO BID x 3 days
Note: Associated with shellfish consumption Treatment recommended for severe illness
Yersinia spp. • TMP/SMX 160/800 mg PO BID x 3–5 days (if susceptible) Treatment recommmended for: OR • Immunocompromised host • Ciprofloxacin 500 mg PO BID x 3 days • Bacteremia OR • Pseudoappendicitis syndrome • Doxycycline 100 mg PO BID x 3 days (not for bacteremia)
49 6.3 Infectious diarrhea 5 I I R G E T E P r D n e r e . n a f i S e 0 q e a f d t r e A a u c a r a i r t t i s d e G r m i s o p e a n i u i a u a l c t o i l t s d e e r r e ( s e e s s e d & b p l : a v i i n a a p e t E e r m . n r s . h h e m a i e f s o n s a o t r t y o i s M m n l h y a d p k t n e o t i a o c v v g e m a s e l o k m a p i i t e e i i c n n d ) t f e a o n c f d t I i n o d f n e e c s v t e i d o l o o u p s i n n D o g i t a c r o r h u e n a • • • • • • A t r ; i s T M P P P T d M 7 a e O O C y f i s a i a a – L l n n e e R R t i m : y n r r 1 e U i i t t o o d d J s r r r 0 I p S o o m m n a a C t t f n n z z d h e o l o o a i o i i o e a n c d d l m m m l l l y t a a e e G c p s y y D z z a o a 2 1 a c c o o i t s s u t i i i l l n n i t g c g e e r e 2 r s o n 5 5 0 7 2 P P p e e t 0 0 0 O 5 5 O a s n o 1 0 0 t 0 0 t f e s ; o Q i - 3 e r m m h 5 1 m n o 1 2 n o 0 c s l g g 2 : g u t t e 3 0 2 s H l P P 3 d a 0 P m O O 1 g 0 O x r – e 5 g e 3 T T 5 T n : c 3 I I P 0 t I D D e d D 9 . O c i a v : x x o 7 x y e T m 5 s 7 7 5 I D 7 p – d d – l 1 x a a e 7 0 y y t 7 e s s 3 . n o
Helicobacter pylori infection i t c
Established indications for testing for H. pylori and treating e f n positive patients i i r
• Active peptic ulcer disease (PUD) – gastric or duodenal o l y
• Confirmed history of PUD (not previously treated for H. pylori) p r
• Gastric MALT lymphoma (low grade) e t c
• Following resection of gastric cancer a b
• Family history of gastric cancer in a 1st degree relative o c i • Atrophic gastritis l e H
Other indications where testing for H. pylori and treating positive 4 . patients can be considered: nonulcer dyspepsia, long term PPI use, 6 persons using NSAID/ASA, unexplained iron deficiency anemia, family members of patients with H. pylori with mild dyspepsia. First-line treatment • Amoxicillin 1 g PO Q12H PLUS Clarithromycin 500 mg PO Q12H PLUS Pantoprazole 40 mg PO Q12H OR • PCN allergy • Clarithromycin 500 mg PO Q12H PLUS Metronidazole 500 mg PO Q12H PLUS Pantoprazole 40 mg PO Q12H OR • Tetracycline 500 mg PO Q6H PLUS Metronidazole 500 mg PO Q8H PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS Pantoprazole 40 mg PO Q12H • Duration: 10–14 days Documented recurrence of H. pylori disease • If possible, avoid antibiotics previously used to treat H. pylori • Tetracycline 500 mg PO Q6H PLUS Metronidazole 500 mg PO Q8H PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS Pantoprazole 40 mg PO Q12H • Duration: 14 days
TREATMENT NOTES Diagnosis
• PPIs, H2RA, Bismuth, and antibiotics with activity against H. pylori should be withheld for at least 4 weeks prior to testing. • H. pylori stool antigen is the only FDA approved test (>90% sensitivity and specificity). • Urea breath test may be optimal but not commonly available.
51 6.4 Helicobacter pylori infection • • • 5 M R • A • • • M • C e a 2 I A f > D d A c b E T i H n F F H s a f f n G a a e e p a i o o u e n z m 2 . o s n r p r m 4 s G p i e e s e i n n t d l p - t a a r u 5 u o r t n n u a t h - c c i o i a c y e t l t s g c r i x - o y o t r d i e l i o s h 5 l e d f c e i e i e o o i e n e e t i t f c r c s c h 0 e h n d m l r n l e m I n m i : s i c o o I n i i e i l p t I s t . l t u s y e u f i p w y y C s t r o s t n t o e s r b e e o r c ) o y e o s a e . . e r n w a s n P r r i n r r t n r A a P e o s y t r t c c e L i i a m i t o s s t e s L t l l e f m U h n o i o u n o , f p u n U . r t J t s S g f t r n p i o e e p e a e S c u G y g a r c n n n o C g s a T a e D b a t s r o s d e o l R l s d s a a s l e i m o e t t d o e n e t e u r p r r t i p r x o i i e i v r a r n e s a m i t a t o e y i d a e s h o c c c t g d r n c s t t e r t y e t u o n e n t i . o y c t e c n c e o ( r o G s o c r m a o e a d e C l s o l . i s u t l n e n . f t i l e a t t l y n g i i a c d 2 e s r o m s d 2 c r e a . r e 0 o . e n e 0 i / i c t n a R 0 > r t c s e 0 M . h a r t . 7 s a u u 7 e a 4 r n ; s P i n m l o ; 1 n s t t – 5 e i P s N 0 m o G t t 8 6 e i s 2 I d c O ( e s : I n y 8 7 : w y i 1 e b n t c n T 7 o 0 c 8 d s l e e i c 2 e r n l – 0 b t o i e ) u - e n i 7 9 8 i m e s r k f r c e d 8 - e 5 r 1 c s a d 1 u i a e s n 8 f % o n r . s t o n p i g 2 u s e p e t r o b 5 , g s t d y d a i s . e T e n a n i i t e b n n s f t n s e c o t e t s t e r u r m e c e g t i a e m t b w r t e i c a a ( i v a s o 1 i e t y t a n i c t h t m n e 0 c i , y d t t e n i u l – ; w a a o e i r n t 1 9 t n n n 5 e e e i o n d 5 t 2 s 0 d i r . g o % – y t – s a h f r r 1 7 o ) h e r f t e o 0 o r a 5 a l o r 0 n u t % t a m h s d l a % d . s e / g e , o n e n P o o r t P r t I s
Management of catheter-related n o i t
bloodstream infections (CR-BSI) c e f n
Diagnosis i
• If there is more than minimal erythema or ANY purulence at the exit m a e
site, the catheter is likely infected. It should be removed and replaced r t at a different site. s d o
• Two sets of blood cultures should be drawn with AT LEAST one (and o l preferably both) from peripheral sites. Blood cultures drawn through b d e
non-tunneled catheters are more likely to yield contaminants. One set t a l
of cultures may be drawn through a catheter if it is tunneled. e r -
• The utility of cultures of the catheter tip itself is not well defined, and r e t
should ONLY be sent when there is a clinical suspicion of infection, NOT e h routinely when lines are removed. They MUST be accompanied by two t a
sets of blood cultures obtained as detailed above. C 5 • Technique: The exit site should be cleaned with alcohol. The . 6 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. • In instances where the blood and catheter tip are cultured at the same 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. • The exception is patients whose catheter tips grow S. aureus and have negative blood cultures. These patients should receive 5–7 days of antibiotics. • All patients should be followed closely, and repeat cultures should be sent if clinically indicated. • When a catheter-related BSI is associated with catheter dysfunction, consider the possibility of suppurative thrombophlebitis. EMPIRIC TREATMENT • Vancomycin (see dosing section, p. 146) ± Cefepime 1–2 g IV Q8H (use higher dose if pseudomonas suspected) OR • Severe PCN allergy: Vancomycin (see dosing section, p. 146) ± [Ciprofloxacin 400 mg IV Q8H OR Aztreonam 2 g IV Q8H] ± Tobramycin (see dosing section, p. 141) Empiric treatment – Gram-positive cocci in clusters in 2 or more sets of blood cultures • Vancomycin (see dosing section, p. 146)
53 6.5 Catheter-related bloodstream infections • • • • • T • • • • 5 M • • M • D • C • N s u C • h i m h n a R 4 h • • • • u o • O a b L r P A O N O O C V V R V V 3 O 1 V e e o l r m u a e E r d a a a a a a i a d n a e – 0 r n F o O x N C D t t x T n a E R R u l n a s i h h n n n n n e e c u a t w A g 7 m a a o e t – e n d l E n e a o R g i s d e t c c c c c n t q e p i i c c T g 1 l u - z a e d i p c c f o e l a : e o d r o o o o o o o o n u t h i i i t o a b M r l 4 q o l i l m t r u i i n a v h S a a l a l m m m m m t s e a y w l l n o e t i i l t e u t c s l l a n r e n i e y o i l u i s t . d i i E d p m m : o v a n - f a n n a y y y y y e p e s y u p s e o w I a e 2 2 l c N c g l t c c c c c n r a l s h - - i n p y i e p y e r n - y d a a a i t r s i l i i i i i n h f y d c f T n t e n n n n n g g i n r t s e e r t i c o a u b h v t l o i h t e i c o h e e t a n n e i s i r p i f a ( ( l s N I I i s e 6 u s e a s e o c P 1 s s S V c V f a g P d i l c c o s S l 8 s s s w t l 0 t a e e o t i O C d 4 c e . e R a i l h e o e s e i Q Q e e n t u p . - r e e c d 0 a s x r 1 a N e a I t T r d i l n n d f p r d O g r 4 t 4 e a . i c t c e u e t 0 i d d P o n f v i c E o t h m a v t y u c t e H H R l i H a h a r r a : u r i i o o e s u C t e t e S y e s r i t r b m l m e s n o g i o d c l t e l s s t g t b i . i e N S u t p h l e r f f d e c s c o r r o e u u i i e g e l h e s r e n n T I e t a e s t o r u / s s V g d r s n t i a a d / m r a g g i n s t , e f o o u l u u r n b S u s s a y k t t i l p Q e t p e e l w s u t r s s - r i b a s o a e : u n s s o g t s t O r l s h s n h c c r a i a e c y l i e l c r s e e v V i l a d 8 t t v e e d e g t x y e e I y p p d e h t t a r c c a V t s a r s f I H e a r e h i y p l i p D l a s d o t o t t t h n o g o a o T r c r o m : d i i i Q t t e o w c l o o c f o e n y n e c i l i c E i ( r C b o b l f a p o n n e m v t c u l n l a r o o 2 E i o o h l l w a e l n C , , a r m a e n e t e c l c e y c e 4 f 2 i i c t f l t n p p a - t i ( o v t a u f c e c y f ( ( r p c t H - o e o e i . . p n e c 4 e N a h z p l c s s u r l i m c l r e o a r r , 1 1 s o e p e y i h S e s r n d ( c c i c ; n t t o r 4 4 l f y f e o p C i f f r e a u a n h u m s r r e a o ( e 6 6 d u c t b s r y e o l p o h s t r r a u l ) a t r 2 ) ) e s e o d u d y r N h o e t t r t i e e a r s s m e h d u r g s a e t h e S m d t e u o e l t ) f d a s u a d e p ) ; a t a I e t r a t V e o v , c s n c e a r h o t e x n N e r m s c t t t o r t i p Q u e h g i i O V e s t e n o n a i e e e d s 8 h s h a p y n f T g f n r n e i H n n t r t p t b n q M t a s m b e c s d a o u i h u n b o e S c o e r t t a r t a i o l f i e c h t m t S e e s l r r t h i m i S o c t a e t r e n A i e y o y e i o o l c . p m m t e . c n a c n a m d e a T i ) i s l o t p u n , r y a u i T e a m d v l l ) p r t a t E d g i i e e u f o . n e c n d u r m t g t 1 n u e o h s e . d r l 4 s a e t s d a u 6 y i T m a s s r ) e E . r b t e u s E t e o d . y • The patient defervesces with 72 hours of initiation of effective s n o i
antistaphylococcal therapy t c
• The patient has no localizing signs or symptoms of metastatic e f n staphylococcal infection i
• Source control has been obtained m a e
• Absence of other conditions that may affect ability to clear infection r t s
based on clinical judgment (e.g. poorly controlled diabetes) d o o
• All other patients should receive 4-6 weeks of therapy based on extent l of infection b d e t a l
Enterococcus faecalis e r -
NOTE: Can be contaminants. Draw repeat cultures to confirm before r e t starting treatment. 100% of E. faecalis blood isolates at JHH are e h t
susceptible to Ampicillin, which should be used unless the patient has a a PCN allergy. C 5 .
• Ampicillin 2 g IV Q4H 6 OR • PCN allergy: Vancomycin (see dosing section p. 146) Duration: 7–14 days Enterococcus faecium NOTE: Can be contaminants. Draw repeat cultures to confirm before starting treatment. The majority (81%) of E. 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. • Linezolid 600 mg IV/PO Q12H OR • Daptomycin 8–12 mg/kg IV Q24H TREATMENT NOTES • Consider echocardiogram if there is persistent bacteremia (> 3 days) on antibiotics. • Do not use Gentamicin if the lab reports no synergy with a cell wall agent. • If synergy is present, Gentamicin should be added to Ampicillin or Vancomycin in the treatment of endocarditis; however, the addition of Gentamicin does not appear to change outcomes in CR-BSI caused by Enterococcus in the absence of endocarditis. • Do not use Gentamicin with Linezolid or Quinupristin/dalfopristin given lack of supportive evidence for synergy.
55 s n
o Gram-negative bacilli i t c e f Antibiotic selection based on organism and susceptibilities. n i Duration: 7–14 days m a e r t
s TREATMENT NOTES d o • Catheters are less commonly the source of the infection; however, o l
b most advocate catheter removal if the catheter is the source. d e t a l Candida spp. e r - r
e • Refer to p. 108 for treatment of candidemia t e h t a GENERAL TREATMENT NOTES ON CATHETER-RELATED BSIs C 5 .
6 Microbiology – most common pathogens: Coagulase-negative staphylococci, Enterococci, S. aureus, Gram-negative bacilli, Candida species Catheter salvage • Catheter removal is STRONGLY recommended for infections with S. aureus, yeast and Pseudomonas, as the chance of catheter salvage is low and the risks of ongoing infection can be high. • Catheters associated with tunnel infections CANNOT be salvaged and should be removed. • Catheter salvage can be considered in CR-BSIs caused by coagulase- negative staphylococci if the patient is clinically stable. • When catheter salvage is attempted, antibiotics should be given through the infected line. • Duration of treatment for catheter salvage is similar to duration of treatment when the catheter is removed unless otherwise noted above. • Antibiotic or ethanol lock therapy, in which an antibiotic or ethanol is infused into the catheter and left in place, can be considered in the treatment of tunneled catheter infections due to less virulent pathogens such as CoNS and some Gram-negatives. Call the Antimicrobial Stewardship Program (7-4570) for details.
Reference: IDSA Guidelines for the Diagnosis and Management of Intravascular Catheter-related Infections: Clin Infect Dis 2009;49:1-45.
56 s i t
Treatment of native valve endocarditis i d r a c
NOTES: o d
• Beta-lactams are highly preferable to Vancomycin if the organism is n E
susceptible and if the patient is not severely allergic. Strongly consider 6 .
PCN desensitization for allergic patients. 6 • Infectious Diseases consultation is advised for cases of left-sided 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. • Therapeutic monitoring: • Vancomycin • Goal trough level: 15–20 mcg/mL • Gentamicin for Gram-positive synergy • Daily dosing • Goal trough level: Ͻ1 mcg/mL • Traditional dosing (Q8H) • Goal peak level: 3–4 mcg/mL • Goal trough level: Ͻ1 mcg/mL • See p. 144 and p. 146 for details
Viridans streptococci or S. bovis with PCN MIC Յ 0.12 mcg/mL • Penicillin G 3 million units IV Q4H for 4 weeks OR • Non-severe PCN allergy: Ceftriaxone 2 g IV/IM Q24H for 4 weeks OR • [Penicillin G 3 million units IV Q4H OR Ceftriaxone 2 g IV/IM Q24H for 2 weeks] PLUS Gentamicin 3 mg/kg IV Q24H for 2 weeks OR • Severe PCN allergy: Vancomycin (see dosing section, p. 146) for 4 weeks Criteria for 2 week treatment: • Patient does not have cardiac or extracardiac abscess • CrCl Ͼ20 mL/min • Patient does not have impaired 8th cranial nerve function • Patient does not have Abiotrophia, Granulicatella, or Gemella spp.
Viridans streptococci or S. bovis with PCN MIC Ͼ 0.12 mcg/mL and Յ 0.5 mcg/mL • [Penicillin G 4 million units IV Q4H OR Ceftriaxone 2 g IV/IM Q24H for 4 weeks] PLUS Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy
57 6.6 Endocarditis • 5 • S S C • r S • V • T • • l • • • e i R i t t t 8 r g T a f n 4 S O O C u A V I O V N O S O f r a a a f i a t t v E h h a p i a a l e e o o x x e - s R R R d p p p p l • • • • • • • • • w o e t n n s t A v v a a n t n r p a i t a h h h - i e v c c i e i e e d q L U B P P T T V p P o c c T s - s a a a d t s y y y n e r o o r e r r e i e e u u h i i u a a a l s i d M t e l l e e e o e e r l l l d s l l f b m m i k d g f a l e l t t t e o o o i i d v e u n o m t a v t n n o d i i i e s u E l r e e e e a - P P i l n c c c s t i e r y y i s t I t e e d N t t n D o d n n n 2 2 t l m i N t C C t y i c c o o o r o d i v 2 a d s n d r a t t n t e o i c t e i i n o N N c c c s T t e e i n n T g g - h e o v f a d d i n i u u w , w s c e o P c c c n e p T d e o o r n o o l t ( ( v a a N I I l i s t i n y t u u u C e s s V V e E s l f t t a o l u e e e l o l l u e v o h s i e e l l e i O f s s s G N n n n e e e r s l s s n n t Q Q l n e d e e e c e k v - o r r S m a e o T d s a a a d f i e g g m v w 4 4 n n s a o e n o t r n t t d d i . e E o r u u u i d b o o e y y l r H H j d c i m t r l l m e a a o o r t b e e y e c S : : r r r a e o t t h e l c r c p a O s s y e e e o a r a n m f d V S e e l a e h h n g i o i t p l i i i t O v u u u r l x n n n t a n e i a a t c n m i d n y r o e e i n r c a < g g g s s s n s d x t v v e t : o g i a n r e 2 i c t e a c e e n c i n 2 C r – – – b i d c o s s g o s i n n c o S d l r w g t e e a i l a A o t n e a f t i o i i m o M M M r c o . t l i n t : l c c n n c l s I f e t l u e h y e t i D m - a y i n b c t t y a y i a a v e e e e g o r m n i i i r z S c m p o o c e i o e r f k s u t t t a o d b o f d i o u i e r b h h h n n n s e v e l n r . u ( p e w e l i n s f , , C o i i i i c t i n o c t I l c c c s s d N w i e s ( a i a p p l s t D t s e i e r i i i i i r c h n 2 a z i - . . d m l l l w o e t l n d 4 l l l a 2 h i e t f w i i i e 1 1 n e u d d e c i n n n c g o - t h < r w t b 4 4 i i d o i t h t r 4 s d l e a l I h a s r s w P t 6 6 c e i V e 2 o a n p p m e s u u P d C a e ) ) i a m l 0 s a t r e s i Q s s a r t k C h s o N i t 0 y d m l i n c c i y i 8 s i e n s n . t N t i T ) g s e e t d i t r H a t e i I s m i O E t a e h s p p e y a s M r e p a E n T s a t t e e f s h t s a i i t t H e l I n c b b m h e e ( , i r C p s n o a E t o l t r l l p n i e i e e r s t l o c R u ( e s > h a n i i d , , u c n m t l t f e d t i t t i l e a l n n , z 0 a , a e h i r p v r r a u p a a l r a t . a y r t a c l e r 5 t n . y i r e t t n s e i n i o i i o r d 1 d b v v i a s g m v m m s s n e ) e e l 4 h t a o e r e t g o o o o 6 c a g l o h p v v n v r r r u r s g ) e d o t t a b a a e l i . h d f r c / f i M l l o c G a d t i v v m g , b u r p i S I e e t h l e e i y t w L , , S e u t c s o A r e ) r , s k - • • • • • • • E • • G • S • D • • • • n . u r C B F w S O A C N O C A r s G N O 3 P P U w S O I C A d p P A A P P D o e t p u o r i o m m m m m e e e L L e e O n o e e o e o o e e s e R R R R s m u a s r n o U U n n n a c v v f f n n m e e n n e T r i p p p p p a t c p t s e e i i i r n e o S t s g o - - S S k k a r c c c H i s s i i i i i z a e p t s o i r r c c c c c d i m s s u s c / . a c i i i a d e e o e e m l l l p l S C i i i i i n l l l k e i f o x m n l l l l l p o B i i i e v v c c l ± p l l l l l o t n n n i g t i i i i i P P e o s i t n n i e e n n n n n n r c a a c r , b l r : o i f n C C G t e G G G e r r c t r c i I t a l r C A s 2 a s s 4 n e e V e e n e d r p u 2 o N N a e n u u u u n i m d 3 3 4 - : i i a t m t 6 3 l n P P a Q g 2 a s a s s s l d o e g I A e a a x t c D p C C ( m m m c c c e 2 o m n d a p w m o d l l I m f g G l l V i I e e e N N n a e e , m c 4 : d V s e n C i i i e y l l l e g p p p d p i r r i I u e l l l 4 a H e r Q a l V c i i i e g g o i Q a a n l G t t t o o o / i i i c r i c a v e n c i i i i k n 4 g n y y l l k t 2 b b b n w n n n 8 f i Q l l a b , a i a n d s e e o : : s g e H l s l l l 2 l l H e e e e e m 7 1 i u u u i g r r l v u r V V r t f n 3 i g g e G , , t I u y r n n n s . 2 O l a a V g w t P e i t f 5 I y y e k c 2 G G l i i i h o V r m H n n a t t t R c s C : : i s i Q p s s s o e I t r e e c c n r m V o g h Q C C g N m B t P u 2 o o n n 4 I I I n a f o s V V V / g Q e e 1 i c O e t t p I m m 4 s r b e V M u k a a c f f / w s 2 o n 4 u Q Q Q H T t a s l s g m m k y y o A l t r I i n Q H i l e H c z c C H c 4 4 4 t t c c i g c a 2 t f u s I i i e o e i 4 e V c c i i r s o H H H l B n n x c O s l f ≥ k I a l s p i H i i t r V o i r w n o n n , O n i Q s r e i s R P f f ( ( t n / r 0 t n s s e o o e i M c O G T 2 r r b h I L 2 d f e e e . M 4 P e e e r r p o o H e 1 l 4 U R R i e e e c k s s e - 4 t g 4 4 m r 2 6 , H S S : o Q s i i a f m n f P s s – d d i c o m A I m r w A t c i g w 1 V t t e 6 c o f G o o i s a o r a a o ) o m o e n 2 i i e : e f t s s t n e I l l Q n n n 4 r w V l l i c e i n e i i H i i o 6 t p 2 s c n t t n n o n s - 8 h t k c e , , d k 6 n u i i t Q g g h n c l e s w H B a w e G i s f l a a e , l i e t o 2 i r n w m k l s s u O n n d e e m l a r f I i 4 4 s f e e n d d D e n e o e G T p i i f c a e r H i c c e k o r k t H ± y m s S S 2 m i t s t t 4 s k n s r a 4 t i i f t t o o s i f o G g r r s i I l c – 2 o 1 o m n V l e e n n i r t o e o 6 f o r a I , , p p w V i Q m 4 m n n l g t t 4 t t p p l w h i i t o o e 4 o c l Q g a . . p u - w y e 6 e e m m H n / m n c l 1 1 4 r c e i e k c k a i o w y y 4 4 H o u t e s P k i g a s p c c c s n m 6 6 k e s L t i o y O i i i i n s e I I d n n e ) ) U t V V p ± f s R d k e f f S O l o o t i Q Q s s I h c V R r r : e 4 8 a 4 4 Q r t H H i a – o 4 p 6 5 n H y , 9
6.6 Endocarditis 6.6 Endocarditis • • • • • h A 6 V • • f G H U R • • O • E • • E • T u e s o n M i 0 c A r R S O A O C C R A Q T P a S m a r G [ V w O A C M r f n e r P e e a m t t r i a l r C m L l i e e o e o N e 8 e e g l P e R R R d i r l e f o e o e e p e m n n e a U v v f n n n e f p H E d i a a r n a I n l p D r a t n c n m a e e o R s C e s s o g S k r a t i i c - t K l i n c o c c i r r i c u h b u u e n r t s y e a c I t m p f e e e s a C a i m i e G f i m s l l o : s l a e e x l t o t t o i l Ϯ i l n l l r n m i i , s i P P r l o e n s n l c g i y n c A y I I r a t a T d D D n n C C t t E r e g 4 c 3 / i x e a a c N r G s r e R G l c o t e o s i l i N N a n n 0 e t n u a n t u a k D a w n c e E u s i o t a 4 n 0 m 2 p v s e t u e s n l ( t a h a a e A m p b ( s t i e s t n b n i t o s l l h m i r e f m g n T o h a a e l l c a e o a e e a e d o m e e u k o y c e e M c i c m d i g t r r n n I e t l r l i s f l l V n t i d g g r l t h o a t l e v s i t a d c t i a g E o i i b / 1 P c y y e c o e s c n p a m h o S I i n i y ( a r N : : i M O t s u n c o n c o l H a m s i v . o r n C S c l c s u m T i m v o y i a 3 a a o a 3 n Q n o Q i g t t n o e o o l r s r a e u c g e v w p i 8 y / g n s 2 o r m m t r r c p e r a m k s o r s h c H i n e 4 a s t s h o V I S g g u e d V l s i e g h T u e I H n y a o m V e a l . / n o , s e E l c t t l I f n y e n Q p o V k f e e f b f p c t n E Q t I d s c t a o g D i c h 6 e c m c t e o t o o u Q s . y o n 4 r o i r i t o H c n n m , r I l v l m i d c 8 H V c c t a o u 4 e n b , i K u N r H f c s o p n s s s y c d l p Q o O o r w v i i p s t O i m c i o n . d t e w r o p B o 2 i i R o e i a s n a T n e 1 2 g m 4 d a O i i 4 : e n n g t t r C 4 l e t C e r ( h a H s k T o s h e v u c w s P a 6 l e l f s e n i H r e l l u e g n f e P a h e a f C f i ) e s l o n t e m t a s I t a e f C P r f n N c o , u i r f k o e i v r t k f e d a o L t l e r N C i s e r u i f - i s t v e d x v o n c U n r i h t n r e e a 4 e t s o e e e s b g s S e M 1 D d n r . – s n g i t e y r h a n e – d i e e 6 z a G I s a e e 2 o a g e C 2 n i n p a t n a e o 2 v 2 w ) i c d s w s y v e r e 0 n y b Յ p i s e e e o g 1 t e a , t e a r i c a e c c 3 z a e p e H s c r l I 0 m t k ; a e V a r k s o t i d . t s s o 5 a t . a / s r e i e s i 1 c 6 a n p o I d r i n f t M r o e : i 2 o t , - h n p n 1 i t o i t d i f u l ) p 2 h l i p f s . Q i 1 m o s t f m o . 6 r . h E w 2 , 1 P r o 1 m e c t - 4 o i C 8 p i < 4 r n g o g H r a . N h g 6 l / 3 / o p ] i ) m k l v g y f u g o a i e s L l r v I , s V e 6 s i
• Severe PCN allergy: Vancomycin (see dosing section, p. 146) for 6 t i d
weeks r a c o
Viridans streptococci or S. bovis with PCN MIC Ͼ 0.12 mcg/mL d n
• [Penicillin G 4 million units IV Q4H OR Ceftriaxone 2 g IV/IM Q24H] E 6 .
PLUS Gentamicin 3 mg/kg IV Q24H for 6 weeks 6 OR • Severe PCN allergy: Vancomycin (see dosing section, p. 146) for 6 weeks
Staphylococcus aureus—Methicillin susceptible • Oxacillin 2 g IV Q4H for 6 weeks PLUS Gentamicin 1 mg/kg IV Q8H for first 2 weeks of therapy AND • Rifampin 300 mg PO Q8H for 6 weeks after blood cultures have cleared • ID and cardiac surgery consults recommended
Staphylococcus aureus—Methicillin resistant or Coagulase- negative staphylococci • Vancomycin (see dosing section, p. 146) for 6 weeks PLUS Gentamicin 1 mg/kg IV Q8H for the first 2 weeks of therapy AND • Rifampin 300 mg PO Q8H for 6 weeks after blood cultures have cleared • If coagulase-negative staphylococci is susceptible to Oxacillin then treat as S. aureus – Methicillin susceptible. • ID and cardiac surgery consults recommended
Gram-negative organisms or culture negative endocarditis • Consult ID
DUKE CRITERIA FOR INFECTIVE ENDOCARDITIS Diagnostic criteria (Modified Duke criteria) Definite endocarditis • Presence of 2 major criteria OR 1 major AND 3 minor OR 5 minor Possible endocarditis • Presence of 1 major AND 1 minor OR 3 minor criteria Rejected endocarditis • Firm alternate diagnosis that explains ALL manifestations of IE (NOTE: simply having another infection does NOT exclude endocarditis)
61 s i
t Major criteria i d
r Microbiologic a c • Two separate blood cultures positive for a typical organism: viridans o d streptococci, S. bovis, HACEK, S. aureus, Enterococcus spp. n
E • Persistent bacteremia with any organism as evidenced by: 2 positive 6 .
6 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. • Positive Coxiella burnetti (Q fever) culture or serology. Echocardiographic (TEE strongly recommended for prosthetic valve) • Vegetation (on valve or supporting structure OR in path of regurgitant jet) • Abscess • New dehiscence of prosthetic valve Physical exam • NEW regurgitant murmur (worsening of old murmur is NOT sufficient) Minor criteria • Predisposing condition: previous endocarditis, injection drug use, prosthetic valve, ventricular septal defect, coarctation of the aorta, calcified valve, patent ductus, mitral valve prolapse with regurgitation, IHSS or other valvular heart disease • Fever ≥ 38.0°C (100.4°F) • Embolic events: arterial or pulmonary emboli, conjunctival hemorrhage, retinal hemorrhage, splinter hemorrhage, intracranial hemorrhage, mycotic aneurysm • Immunologic phenomenon: Osler nodes, glomerulonephritis, positive rheumatoid factor • Positive blood cultures that don’t meet criteria above OR serologic 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
References: Oral therapy: Am J Med 1996; 101:68-76. Short course therapy: Ann Intern Med 1994; 121:873-6. Duke criteria: Clin Infect Dis 2000; 30:633-8. AHA Scientific Statement on Infective Endocardits: Circulation 2005; 111(23):e394-434. TEE in S. aureus bacteremia: J Am Coll Cardiol 1997; 30: 1072-8. MRSA bacteremia/endocarditis recommendations: Clin Infect Dis 2011; 52:e18-55
62 s
Permanent pacemaker (PPM) and implantable n o i t
cardioverter-defibrillator (ICD) infections c e f n NOTE: Obtain at least 2 sets of blood cultures before initiation of i D
antibiotic therapy C I / r
EMPIRIC TREATMENT e k
• Vancomycin (see dosing section, p. 146). Narrow therapy based on a m
culture results. e c a
TREATMENT NOTES P 7 Microbiology—staphylococci in 70-80% of cases (~50% coagulase- . 6 negative staphylococci and ~50% S. aureus) Management • If blood cultures are positive or endocarditis is suspected patients should undergo transesophageal echocardiography (TEE) • Complete extraction recommended for patients with pocket infection and/or valvular or lead endocarditis • At the time of extraction, tissue (rather than swabs) from the generator pocket should be sent for Gram-stain and culture and lead tips should be sent for culture. • Note that because leads are extracted through an open generator pocket, they may become contaminated by the infected pocket; therefore, positive lead cultures are not always indicative of lead endocarditis in patient with negative blood cultures. • Blood cultures should be obtained after device removal. • Device reimplantation should be on the contra-lateral side whenever possible. • Complete extraction is strongly recommended in all patients presenting with S. aureus bacteremia and no other source • Complete extraction should be considered in patients with persistent positive blood cultures with other organisms (e.g. coagulase-negative staphylococci, enterococci, Gram-negative bacilli) on a case-by-case basis. • Complete device and lead removal is recommended for patients with valvular endocarditis. • Antimicrobial prophylaxis is NOT recommended for dental or other invasive procedures following placement
Reference: AHA Scientific Statement on PPM and ICD infections: Circulation 2010; 121:458–477.
63 6.7 Pacemaker/ICD infections 6 v u n v u A n c 2 A R V S w P P D R e e H n o n o e a 0 u N o o u i 4 i e t f a g g c c l l 1 A s s c h t e v D v v i u o o 0 e e g t i k e r m e e S t a e r r ; m m t t i e T n v a g g e c a a n i e 1 n t E e o i p p c s e e t t p p e n 2 e i i s e E i s o o n t t l l d l d b 1 A d i i a a i : a c c t i t n n o l i : s w N e t t f o a a 4 c p n i i i c c o o o i t t 5 D l o i t e a e e t n n n h S 8 d a s a r d d f T – t d e o o i r e a c t t 7 E a i l l c i r r t i i t e e v u t 7 e o E i n t h s e a a l m i . t c o n e u d d w b e e n r r i n l e t t o t h i s o m o d n i C n a 7 7 h 1 B c P c P 7 B T g r e u u o o 2 2 2 4 i l l d o o m l l a s s i a t t o o o h h h d u u l t t i i v n d d n - - o o o r r a n e e a e e g u u u y d x x g s c c s s s r r r c p p u u s s s u o d n n l l l l a a t t l e e a a f u u u n n r g g n r r r t t r e e I a a d e a a m a s s t t t t i i i s p i i m t o o v v n n u l i a e e n n o e e r p n g g g b b n f f t l o o a i a a a l l c o o b r r n t t o a l o o i i e v v t l f d d a e e s E t t i l t f f e h i o o e o c e r r n t r r o a n i c p I S c O 1 ( 4 I w N D 4 7 V V s D y o 0 - - . o r i u e 6 1 w t e t t a n a h - n e r h h v 1 0 l e s w o u - a i e e S c 4 t i E e r u d d h t r r e e e . k n i a a t e a e d e o u I a s d p p n i y r r a k n n s u e f a o y y s I s y e f : V r d p c l s c o e a i 4 I f y a t V t u m f i a h o r d s w c d t l t e n m e l : h h a i e s r o t v e 2 n e a : i a e s i t r c p C r t h k b a w i e a p y o i e s r e p e c . p r n e y s u e 5 y r l k a o 7 t s s i ) o i o n n s
Meningitis – Empiric treatment n o i t c e TREATMENT f n • ANTIBIOTICS SHOULD BE STARTED AS SOON AS THE i m e
POSSIBILITY OF BACTERIAL MENINGITIS BECOMES EVIDENT, t s
IDEALLY WITHIN 30 MINUTES. y s
• DO NOT WAIT FOR CT SCAN OR LP RESULTS. IF LP MUST BE s u o
DELAYED, GET BLOOD CULTURES AND START THERAPY. v r
• Adjust therapy once pathogen and susceptibilities are known. e n l
• Some advocate penicillin desensitization for pathogen-specific therapy a r t
in patients with severe allergies (p. 127). n e
• Antibiotic doses are higher for CNS infections (p. 69). C 8
• Infectious Diseases consultation is advised for all CNS infections, . particularly those in which the preferred antibiotic cannot be used or in 6 which the organism is resistant to usual therapy. Empiric therapy Host Pathogens Preferred Abx Alternative forserious PCN allergy (ID consult recommended) Immunocompetent* S. pneumo, N. Vancomycin PLUS Chloramphenicol age < 50 mening, H. influenzae Ceftriaxone PLUS Vancomycin Immunocompetent* S. pneumo, Listeria, Vancomycin PLUS Chloramphenicol age > 50 H. influenzae, Ceftriaxone PLUS PLUS Vancomycin N. mening, Group B Ampicillin PLUS TMP/SMX streptococci Immuno- S. pneumo, N. Vancomycin PLUS Vancomycin PLUS compromised*+ mening, H. influenzae, Cefepime PLUS TMP/SMX PLUS Listeria, Ampicillin Ciprofloxacin (Gram-negatives) Post neurosurgery or S. pneumo (if CSF Vancomycin PLUS Vancomycin PLUS penetrating head leak), H. influenzae, Cefepime Ciprofloxacin trauma Staphylococci, Gram-negatives Infected shunt S. aureus, coagulase- Vancomycin PLUS Vancomycin PLUS negative staphylococci, Cefepime Ciprofloxacin Gram-negatives (rare)
+ Immunocompromised is defined as HIV infection or AIDS, receiving immunosuppressive therapy, or after transplantation. In patients with HIV infection, nonbacterial causes of meningitis must be considered, particularly cryptococcal meningitis. * Use of Dexamethasone • Addition of dexamethasone is recommended in all adult patients with suspected pneumococcal meningitis (note that this will be most adult patients). • Dose: 0.15 mg/kg IV Q6H for 2–4 days • The first dose must be administered 10–20 minutes before or concomitant with the first dose of antibiotics.
65 s • Administration of antibiotics should not be delayed to give n o i t dexamethasone. c e
f • Dexamethasone should not be given to patients who have already n i started antibiotics. m
e • Continue dexamethasone only if the CSF Gram stain shows Gram- t s
y positive diplococci or if blood or CSF grows S. pneumoniae s s u o Pathogen-specific therapy v r e Pathogens Preferred Alternative for serious n l PCN allergy (ID consult a r
t recommended) n S. pneumo PCN MIC Յ 0.06 Penicillin OR Ceftriaxone Vancomycin OR e
C µg/ml AND/OR Ceftriaxone Chloramphenicol*
8 MIC Ͻ0.5 µg/ml .
6 S. pneumo PCN MIC Ͼ0.1–1 Ceftriaxone Moxifloxacin OR Linezolid µg/ml AND Ceftriaxone MIC Ͻ1 µg/ml (ID consult recommended) S. pneumo PCN MIC Ͼ 1 Ceftriaxone PLUS Vancomycin Moxifloxacin OR Linezolid µg/ml AND/OR Ceftriaxone PLUS Rifampin MIC Ն1 µg/ml (ID consult recommended) N. meningitidis PCN Penicillin OR Ceftriaxone+ Chloramphenicol* susceptible (MIC Ͻ 0.1) H. flu Ampicillin OR Ceftriaxone Chloramphenicol* OR Non -lactamase producer Ciprofloxacin H. flu Ceftriaxone Chloramphenicol* OR -lactamase producer Ciprofloxacin Listeria Ampicillin ± Gentamicin‡ TMP/SMX P. aeruginosa (ID consult Cefepime OR Meropenem Any 2 of the following: recommended) Ciprofloxacin, Tobramycin‡, Aztreonam E. coli and other Ceftriaxone ± Ciprofloxacin Aztreonam OR Ciprofloxacin Enterobacteriaceae OR TMP/SMX S. aureus–MSSA Oxacillin Vancomycin S. aureus–MRSA Vancomycin Coagulase-negative Oxacillin Vancomycin staphylococci if Oxacillin MIC ≤ 0.25 Coagulase-negative Vancomycin staphylococci Oxacillin MIC Ͼ 0.25 Enterococcus Ampicillin PLUS Gentamicin‡ Vancomycin PLUS Gentamicin‡ Candida species Amphotericin B Cryptococcus Amphotericin B PLUS Flucytosine
* Consider penicillin desensitization + Must give Ciprofloxacin 500 mg once to eradicate carrier state if PCN used as treatment ‡ Administer aminoglycosides systemically, not intrathecally
66 s n
TREATMENT NOTES o i t c e
Indications for head CT prior to LP f n • History of CNS diseases (mass lesion, CVA) i m
• New-onset seizure (Յ 1 week) e t s
• Papilledema y s
• Altered consciousness s u
• Focal neurologic deficit o v r e
Duration n l a
• STOP treatment if LP culture obtained prior to antibiotic therapy is r t
negative at 48 hours OR no PMNs on cell count n e
• S. pneumoniae: 10–14 days C 8 • N. meningitidis: 7 days . 6 • Listeria: 21 days • H. influenzae: 7 days • Gram-negative bacilli: 21 days Adjunctive therapy • Consider intracranial pressure monitoring in patients with impaired mental status.
Encephalitis • Herpes viruses (HSV, VZV) remain the predominant causes of treatable encephalitis. • CSF PCRs are rapid diagnostic tests and appear quite sensitive and specific. • Have low threshold to treat if suspected as untreated mortality exceeds 70%. • Treatment: Acyclovir 10 mg/kg IV Q8H for 14–21 days
67 6.8 Central nervous system infections • • T • 6 • D D I R • • E S U d C S P C D C B e e i o R i n o y h m 8 s S i n i e t v R r I C P O E c a c C C V f x a a s n k r D u e h u e r A e N o e E a n o h f a t n n m C e i l u a f r s R g p r e f p i n a o o m e n p c n a e n n e s n i G A e m l t N i c t w t i n e r c S p e e i n t c c e i m d i s l r a c u e u i T o c c u r a o n / c o i o o t n i i o r t i p i r r t r A d a f M c e t h h e c i o o t c n i e i v C l s s m i i s e v p c e a s o l l t o s u d b a l i e s i o t l a e : s s e T u E a r i s o x h s l n r n y l i r t n u o o a r m c r s i y a h t g e r N f . c e c d o g b n u r p l e h m e s c e t i e c i W u s c f e y T t r n r a u d s i i n f y e r r n r i o o : p i a o n t n a n a h r e a e ( c n r N m r v t V l t a s t t t n i 4 l e a o l p c e e B r a i e e e O d c d c e n b a 0 a m i r y a o n e u o n o a i n r a n t s t T 0 c n l c l m o e h s e S S S S S A S G A n n S S P t m g t m t g d d t s E f s o e e e n n s . t t t . t t . e a s r u r m e i r a r r r e e o m a g g r m a a s p w a p v a S p m e e e e t p . r k i p l m h e e a a a i u n s p p p p a r e g v o o i o h i c o s S a t t r r t g o i l r e n e y t t t t - d i i i o o h e y p e n v v o o o o n r n n h n M c g u y u u a a c l t b b I u e e e n o c c c c n y m V e b g o e e g y n i e e e s c i i g s s l i o o o o c n b d o d n a s n n n o t , u s s , o n a o s f c c c c t c Q t ) e c s e s e u l n A i e t t h t l c c c c c e h n u ( e i d t n s s e i v n s d i i i i s 8 c a e g d , r c o i m e s a ( ( i d c e o r e m , e i i G H A o a s n o t e u a i s b ) a t s G i e , , f f r c i s r r f L r i l u n l p a l i y o o o d r l d e : e r t . a W m . a m t n t b d t a r n C h m i m s e e n t b b a n - o e t , A l e s s u i n a e o n i e n n t a s o Y p s i t s i s d m t i n i i b I n t S . p n n n a v s g / i r C P C V M M C [ M C V P C a i f c f g s d e 1 P a e e e o i i o e a a e t e e e e e r c s r e e e e c i y j c n n n 4 e m n s e f f f f f t r t c u t t t t s o n t t t e t e t c c h r r r i i h t f : t r r r c a 6 i s t o o o c b e e p p e n o o c n i i i r D o e s e N e a a a i n n n l i i t r i i m m n ) c e o l m m d t l x x x c i i u v e r l r i i i d s n t i i d d d o o o E n P t m e c n a n y y u e e e h b d a a a n i s n n n O c c 2 n d o u s - p L O e l z z z d s e e e e P s i i o a a o g 0 R n n o o o b h e n R U y ] L t . p r r P i r 0 u l l l w a P P P u n J , e e e U a m S a L e l e 4 r L L L t n e n s S s M p U i c a c p ; U U U v t t a t t a 3 e C S . e e p h i S S S i e a y a f l 9 d d w d 1 . e i s y n . c l : a s t l 1 f i 4 2 y o i t , n e o i i 2 m n h 0 f t 6 n d a p f l o 6 0 o n ) c n e i i d 7 c 2 m u w V C V V M A M V M C V r ( s A o n t P o d x I e . i e ; a a a a a u z h D i i l n a n e e e 3 g p p t e t L c m e n n n n n t r l e e t t t e d r C r r e g t 4 i c c c c c o r r r c r U e o o o r u o o o r o o o o o e o 2 7 b m o n o S n f f h u w n n n n a S r l l m m m m m o o : n r n a i f o s e i i i i F 1 m n d d d a r l a g g x x s h t y y y y y y s e s 5 a a a P i a a a m u l c c c c c v e h r e i z z z i c c 4 h n C I i i i i i l t e s e n n n n n n V t e o o o g n i i i P n n 9 g N o u . s d l l l P P P s f e e e r L . o P Q e t u n o n L L L U t a h P r L d U U U l S w 8 t l t L U e w ) l S S S s e U H S n i , r S t . g h y • • • I • • • T • • • I • • • • • • • • A R • • • • • • • A • D n r A h e n n S p I T t T G A F A O M M M C d C C C A A A P V V T R ( A F A e t e f n o m n e r A o t t r h h l l a a y M m m z m m m e m i t i h e e e x u u e e o r a i i n f a • p r y e b s n n b f e r t a G i t n a l f f n p c c a n t r P x o r e u r v B i p i p B s e t n f c c r i a m r k n u i V c o i y c e t o y o v r r i u i c f c o a m r i / e o n i h m f p a i i i o o o c a o i a r o c d p e t i o s s a i f l n n e a l i S l m n p o o a t n o n m l g i l l i l m m c e n g i n n o l o e m s o a n m i e a c i u x l i n i c M i t x l s c c l t f i n i : a c n d t i c l y i n n m a m o x z e m n t n i r y y y c n r : t e a u i c o e p : i s : o c e a n s X l e o e a o m i o : i n r c r c c : c s c 2 i c f : e e h e s 4 r i . i m 6 e z n n c r m n : l e n c 3 o n i i 1 u 2 e i b : y i n n ® ® e 2 u n o o t : : n i f 0 5 ) : i g : l s n 0 o r : r c y m n : : : a n 2 : l l t : : o g c 5 2 g a 0 2 i e r b 5 a : c g r : 8 r d i 2 2 l s m I 4 t a 5 4 c m o i a t 5 V t : i 4 g r l p Q 0 e m 0 i h i n i I i l 0 m s g m 0 v o I n o a V i 5 g g V i o a e 0 o g s m m n . e Q m 0 a e 1 j I l d n 0 s g 7 e V : g 0 / a m I g n : 0 M Q s n n V l – n Q I 2 s 4 h Q g c g l k V g – 1 0 w s t m Q a 1 Q 4 f t I u g o H o Q t H g 8 r / m / d 1 V l / Q 2 c e 0 n i i u i Q i n 2 o H b u 2 r k k c 6 m k t ) g H a 2 l i e 4 Q 1 0 d o ( o h g i Q m n g l g 0 u 8 g g i 4 c T t H d 4 o H g 2 0 s s 2 I e s l p a 1 0 s H V M 2 H a s I g I H I h e P t m V H – b V V 4 . s r I h 2 I i 5 ( e u / V V P Q O m c 1 c e e e H 1 o t n Q a – k – Q Q n o s o s s 5 t 2 u Q 4 Q n g c 2 g a 3 t 8 Q 2 2 n i l 0 t 4 n i o 1 2 d ( d o 4 4 6 5 n H i t f 6 4 4 I f Q I b 0 f V H m a e m 0 D H H H o b H w H i H B c m 2 o i ( n Q m e p b i t a r m h ( t n 4 c i s o f f 2 g c i o a 2 i c o i o a g H o c n t s c / 4 s n C e p s 4 d r r . h t n g k e r e I r e N ( m H V i C C i m g a s c N / e d s s n r e l m u a , a r s h e i t Q u n i M c o ) y l S n u e n l d t r l i L t o i 6 p h o e s I n o n d r V . n g s n t e t t v H r t n i e o o i i l u d t e a n i n i Q r n v m r r r c g a u ( e t g o c e e m r 6 i 1 i o f e n m v t e i v d o i t m H r e s 5 c e i i a e e d n t y m : o o c s ) i – r d e u c n C 1 v s n d a 2 n c m t p a l 9 i l d t i i l a a y n i 0 e v 8 l e n i a m l i e i , i o n I 0 b g r d n s d t m n a ; a f e y e i d 7 n e s o t n n d ) n g i d c : e a e s s o 4 d s i t e / y r n x e t 5 d D k u d g ) p g 9 p o – i g f m s e e ) i . o o t s r n i 2 r Q s s e i n t e e 0 s r h s 8 r n 0 o o i e ) a b – c 4 u l p l r 1 e l ; e g y 3 a m d . 2 9 h t l i H i : m c 1 a 2 i t 6 6 l e 7 d 9 .
6.8 Central nervous system infections s n Pelvic inflammatory disease o i t c
e • Includes salpingitis, tubo-ovarian abscess and pelvic peritonitis. f n i • For treatment of post-operative peritonitis or wound infection, d e see p. 41 and p. 97. t t i m
s TREATMENT n a r NOTE: Avoid use of fluoroquinolones for N. gonorrhoeae due to t y l resistance (~10% in Baltimore City) l a *
u • Cefotetan 2 g IV Q12H PLUS Doxycycline 100 mg PO BID for 14 days x e OR s
d • Ertapenem 1 g IV Q24H PLUS Doxycycline* 100 mg PO BID for 14 days n a OR c i • PCN allergy: Clindamycin 600-900 mg IV Q8H PLUS Gentamicin (see g o l dosing section, p. 141) o c e Step-down therapy once patient is afebrile n y • Preferred: Doxycycline 100 mg PO BID ± [Clindamycin 450 mg PO QID G 9
. OR Metronidazole 500 mg PO BID] to complete 14 days total 6 *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), Gram- negative rods, Streptococci Treatment of partners • All women diagnosed with acute PID should be offered HIV testing. • Male partners of women who have PID often are asymptomatic. • Sex partners (male or female) of patients who have PID should 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 • Same as for PID but no need for addition of Doxycycline/Azithromycin Duration • Treat until patient afebrile for 24–48 hours
70 s
Bacterial vaginosis n o i t c
TREATMENT e f n • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once i d
daily for 5 days (preferred) e t t OR i m •Metronidazole 500 mg PO BID for 7 days s n a
OR r t y
•Clindamycin 300 mg PO BID for 7 days l l a u x
TREATMENT NOTES e s
Microbiology: anaerobic bacteria (Prevotella spp, Mobiluncus spp.), d n
G. vaginalis, Ureaplasma, Mycoplasma. a c i g o • Treatment is recommended in all symptomatic women and high risk l o c
asymptomatic pregnant women. e n y G 9
Trichomoniasis (T.vaginalis) . 6 Note: Treatment of partner recommended.
TREATMENT • Metronidazole 2 g PO once OR • Metronidazole 500 mg PO BID for 7 days
Uncomplicated gonococcal urethritis, cervicitis, proctitis TREATMENT (includes treatment for C. trachomatis): • Ceftriaxone 250 mg IM once PLUS Azithromycin 1 g orally (preferred) OR • Ceftriaxone 250 mg IM once PLUS Doxycycline 100 mg PO BID for 7 days OR • Severe PCN allergy: Azithromycin 2 g PO once (premedicate with antiemetic or give snack before administration)
TREATMENT NOTES • HIV testing recommended • The use of Ceftriaxone is preferred over Cefixime and Cefpodoxime due to increasing MICs for oral cephalosporins.
71 s • Dual therapy recommended for N.gonorrhoeae even if C.trachomatis is n o i t excluded. c e
f • Send gonorrhea culture (not nucleic acid amplification test) if you n i suspect a treatment failure. d e t t i m Syphilis s n a r SCREENING t y l • Screening algorithm at JHH: a treponemal-specific antibody test (CIA) if l a
u positive, followed by RPR. A confirmatory FTA-ABS is provided if RPR is x e negative. s
d • A positive CIA, a negative RPR and a positive FTA may be due to: (1) n a old treated syphilis (2) old untreated syphilis (3) early syphilis. c i • Get history and call Baltimore City Health Department 410-396-4448 g o l for prior history of syphilis treatment in Maryland o c
e • If penicillin allergic, ID consults is recommended to guide therapy n y G 9
. Algorithm for reverse sequence syphilis screening 6 CIA CIA positive CIA negative RPR positive RPR negative • Consistent with Treponemal test that uses a different • If incubating or syphilis infection antigen (FTA–ABS or TPPA) primary syphilis (past or present) FTA-ABS positive FTA-ABS negative is suspected, • Requires historical • Possible syphilis • Syphilis unlikely treat for early and clinical infection • If patient at high syphilis evaluation to • Requires risk for syphilis, determine prior historical and retest in one treatment history clinical month evaluation
Neurosyphilis diagnosis • Requires both clinical (neurological symptoms) and laboratory criteria. • Laboratory criteria (any combination of): serological evidence of syphilis, positive CSF VDRL (50% sensitivity; high specificity), CSF pleocytosis (>5 WBC/ml if HIV-; >10-20 WBC/ml if HIV+), CSF elevated protein concentration (>50 mg/dl) • Lumbar puncture (LP) should be obtained in patients with positive serological tests for syphilis plus neurological symptoms, serological treatment failure (lack of four-fold decline in RPR titer), evidence of tertiary syphilis • Consider LP in asymptomatic HIV+ patients with a CD4 count ≤350 cells/ml or RPR titer ≥1:32
72 TREATMENT s n o i Early syphilis (primary, secondary, and early latent syphilis within one t c e year after infection) f n ® i
• Penicillin G Benzathine (Bicillin L-A) 2.4 million units IM once d e t
• Severe PCN allergies: Doxycycline 100 mg PO BID for 2 weeks t i
Note: due to increased resistance (~45% of strains in Baltimore are m s resistant), Azithromycin is not recommended. n a r t
Late latent syphilis (asymptomatic infection with positive serology >1 y l l year after infection or latent syphilis of unknown duration) a u • Penicillin G Benzathine (Bicillin® L-A) 2.4 million units IM weekly for 3 x e weeks (total of 3 doses) s d n
Neurosyphilis (can occur during any stage of syphilis) a c i
• Penicillin G 3–4 million units IV Q4H for 10–14 days g o l
Syphilis in pregnancy o c e
• Penicillin is the only recommended therapy in pregnant patients with n y
any kind of syphilis. Allergy consult for penicillin desensitization is G 9
recommended. . 6
References: Sexually transmitted diseases CDC treatment guidelines. MMWR 2010/59 (RR12); 1–110. Azithromycin vs. Doxycycline for PID. Obstet Gynecol 2007; 110(1):53–60. Discordant Results from Reverse Sequence Syphilis Screening. MMWR 2011/60 (05);133–137
73 s n COPD exacerbations o i t c
e Uncomplicated f n i • Patient presenting with increased cough, sputum volume, sputum y r purulence, and dyspnea relative to baseline and none of the risk a n factors for complicated exacerbation. o m
l • Doxycycline 100 mg PO BID u
P OR
0 • TMP/SMX 1 DS tab PO BID 1 .
6 OR • Amoxicillin 500 mg PO TID (see treatment notes below) Complicated • Patient presenting with increased cough, sputum volume, sputum purulence, and dyspnea relative to baseline and at least one of the following: FEV1 < 50% predicted, more than 4 exacerbations in last 12 months, significant coronary artery disease or heart failure, use of home oxygen, chronic oral steroid use, or antibiotic use in the past three months. • Azithromycin 500 mg PO/IV Q24H OR • Amoxicillin/clavulanate 875 mg PO BID OR • Cefuroxime 750 mg IV Q8H TREATMENT NOTES Microbiology • Predominantly H. influenzae, M. catarrhalis, S. pneumoniae • Gram-negative enteric bacilli suspected only in complicated patients Management • At JHH 33% of H. influenzae are resistant to Amoxicillin; most M. catarrhalis isolates are beta-lactamase producers and resistant to Amoxicillin. • Patients failing therapy should have sputum Gram-stain and culture. • Empiric use of fluoroquinolones is discouraged and should only be considered if past or present microbiologic evidence indicates infection with a pathogen(s) that is resistant to standard therapy (e.g. Pseudomonas spp., Enterobacteriaceae). • IV antibiotics should only be used if the patient cannot tolerate PO antibiotics. • Antibiotics are not indicated for asthma flares in the absence of pneumonia.
References: American College of Physicians Position Paper: Ann Intern Med 2001; 134:600. Canadian guidelines: Can Respir J. 2003; 10, Suppl B:3B.
74 s
Community-acquired pneumonia (CAP) in n o i t
hospitalized patients c e f n EMPIRIC TREATMENT i y r a
Patient NOT in the ICU n • Ceftriaxone 1 g IV Q24H PLUS Azithromycin 500 mg IV/PO once daily o m l
OR u P
• Moxifloxacin 400 mg IV/PO Q24H 0 1 .
In non-critically ill patients, consider switch to oral agents as soon as 6 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) • Ceftriaxone 1 g IV Q24H PLUS Azithromycin 500 mg IV Q24H OR • PCN allergy: Moxifloxacin 400 mg IV Q24H At risk for infection with Pseudomonas (see risks below) • Cefepime 1 g IV Q8H PLUS Azithromycin 500 mg IV Q24H OR • Piperacillin/tazobactam 4.5 g IV Q6H PLUS Azithromycin 500 mg IV Q24H OR • Severe PCN allergy: Moxifloxacin 400 mg IV Q24H PLUS Aztreonam 2 g IV Q8H • Sputum gram stain may help determine if Pseudomonas is present. • Narrow coverage if Pseudomonas is NOT present on culture at 48 hours. • Risks for Pseudomonas: prolonged hospital or long-term care facility stay (≥ 5 days), structural lung disease (e.g. CF, bronchiectasis), steroid therapy, broad-spectrum antibiotics for > 7 days in the past month, AIDS (CD4 <50), granulocytopenia (ANC <500)
DIAGNOSIS • Immunocompetent patients MUST have a chest X-ray infiltrate to meet diagnostic criteria for pneumonia. • Sputum and blood cultures should be sent on all patients admitted to the hospital BEFORE antibiotics are given. • S. pneumoniae urine antigen should be obtained in all patients with CAP. It has specificity of 96% and positive predictive value of 88.8-96.5%. It is particularly useful if antibiotics have already been started or cultures cannot be obtained. • The legionella urine antigen is the test of choice for diagnosing legionella infection. This test detects only L. pneumophila serogroup 1, which is responsible for 70–80% of infections.
75 6.10 Pulmonary infections • 3 • • 7 I R O • • • D • S D e . 6 S U d C T ( t Q c R r M c C c t p U c S e S j c e a C c a h T f p e u h e e e a A h b a o o u m s o o o s n o h e R u u n A n o 1 . s R r y s • • • • • c / e e g l p v o e s e e n n e u n n u s s g c s m t t - A 2 A t p o S M r u r u n e . i e c s g i u p r s t r p i p i i 1 s 7 d Ͻ 3 Ͼ H A A T o f g e r n o m n H m T i m a c s A a r i m u n n o r m c h S a t h i R i e e c f m f e 0 – a e g a N e s i r i i r e p I e o i l t c o c d m n i t a m a s c t m d t O S s c a u 5 b s o e 9 1 s d u i a C o – i h y a b e p D r i o a : g t a t a o a i c f t n a n n a A u c e o u e e 0 0 i N 1 n s N o u e e l o e n r t e l n l n d e n c y d i s f g t r i n c o l s o a q s i i s c t n % 0 i r n d v O t o 4 n a u l d a p , s n s a e y a a i p e s t n a y f u n v u e g e o a p b d c l r e e P t n a , - C l y n : a e e y b l a t n m a a r e a y d n a r r t d s c n t h e e v f r e p i m i o a ) e s t n r s s t s l o P c s e p e s i e t s l u e i . i f o d i b n a i i a u n o r e : p n o l n e o d a : u s b p k q e a l r m e a t r s o u r . f m e u w m g y A r s d r e g r d n a l P e d i i f u t t r t c u a s 4 e o r t o ( n I f b r C e s s i i r a n t a t l e d o G i t a i s p a c a a e o X l y e p e c l r s e g t i p 8 t u a a / : A i m o c h l e t c e t u v t , i o t r t n f n - n l s t t c n d m r h r i c o s r P r i – y o o i P i h i e e w n d t d o d d e I t n a i z a : l i e v y n : a o a s e t e l a p 7 s r m e n r a e i t m v a n i i s i d y e t i c c R n B o i n , w t s n d x M r h t t g p u e l t 2 c t e C - i : y h r e i s w o i / a M n t i l e , e i f a r e p s o l e n i e i s e h m w e n e e R o v n k e A A t m b a b s a h o a r R i a J t s C f n e t i d a m n n e t a s e l n S i h o 6 a - d M h s p s i n e t s o h g r r e M o t 2 R d f z d m t A n d h e e f d p r a t e A e o d p 0 a i i e s e u i , 0 a o o n r i c a l o a P m R c r l l n e y a r r d f : Ͼ t i i a e a 0 r r t 0 n i o s b t r s a i t w w h u m n a o u s S s c n r p i a s n t N a e 6 C e o d 2 e s f o n . a p e t s o p l t t e m a i p A d n a ; t a r s A 0 o 2 t a u i i o d e b n c t 3 y i t i i b r y z i h r m i e r e h o l P C s 1 t r c t r c y o t a e i a t 4 t 3 g , c u i l m t i u i h a b : e a y d o . u h 1 n n i i n r e c 2 p f l r m n o a r a e v s C o e t m m i t ; a . g I a I b e g o e : f t g i n o n 1 V i e n i f s t s r i 1 f . o l t c e t r s u t U o e r i ) m s e 7 h r p n o i c y o . e c u 3 e a s z w n r t r n e m b Q d i l P s t 1 c h n e e a a l r i s 5 u c I i s a o d o p a d n e n h i e i ( r l 8 L e o d a s x t s 5 e l m f o 2 w i s c t f c l i t o i w g s i o e a r h U s o y p s e u r . r H s d o ) t o c o l s o t t : i i c o i h a m g i e t s c a r 1 n i n n e i e S p n c n c u f t a r z m t h e c e l m / n c a 6 r e t i a d f i g n p a r i u L D c c c a a a y e n p m k o 6 a g a e p , t p d i e l e n e i a i a , o t s n o g n a r e s n a – s s n i r e a C a u p o r r i s s n l p : s t v b a o 7 e r n t t i e 2 i t c d t m r 4 g n p e y r i n g i c e b e u i 2 i e m o z a , c e e g s 0 d e e a e – s n n f o f l e i r o r w . v o n v m B a 0 u v e n e n s u a 6 , i y e u o s m u s e l i I a t n 7 t g t c i i p i p P r s a n i g m u L d t f b o n e e u ; i l w a t i i s h g a e o f i d a p i 4 m s c i e e t m n s i l e n s d Ͻ n d o p o m s o i e e 4 n d r a l a a s p c e w d i o d o f n e c n r e e : s s s s e s n r f . o p o S t z r o m . n p o i i o c 9 k t y e e , e i s p d t i t a s 2 o o r n n e m i i h l s r S n i r n F t , a a 0 a a u y – f y 7 s i o e u l e r d a t s i i c g o s s t t C n w a d u c m t c . o o s t c u w r u s e m p o e e o h r d c r b a o A u w m e h m p 6 f y r p r D i r e n t v y t c a a n i r m - o d o n o e u m i e M M h 0 t c r r o i i v g l c n t i o s i l ( r g r a l a l a a n n e o a H l 0 s r o i n p o a R d t c l e r m p s n e i y t g g o o , t e n m i s a r l g x a i / S a a i s d y m o c o o t r g i e l s l s c i o v s u , f s o h A f i s e e v n o n c f e : l i o b g r n e e r O o t p e o : o . n i n r a d v H g n l i r s i . x . o r s f s o n 2 I w e t s V R a i o 8 t o d i i s n / c d s d 5 n P a o e i e n , ) t O t . r Pathogen-specific and step-down therapy Organism Preferred therapy PCN allergy Notes S. pneumoniae PCN susceptible Penicillin G 1 million units IV Q6H Non-severe reaction: 85% of S. pneumoniae isolates at JHH OR Cefpodoxime 200 mg PO BID (excluding oncology) are susceptible and Amoxicillin 500 mg PO TID Severe reaction: 12% are intermediate to PCN, 64% are Azithromycin*[500 mg PO daily X 3 days susceptible to Erythromycin (Erythromycin OR 500 mg once, then 250 mg PO daily X 4 days] susceptibilities predict Azithromycin OR susceptibilities for S. pneumoniae), and Moxifloxacin 400 mg IV/PO daily 100% are susceptible to Moxifloxacin (if Erythromycin resistant) S. pneumoniae PCN intermediate Penicillin G 1 million units IV Q6H Same as above ( c
o or urine antigen positive OR
n Amoxicillin 1 g PO TID t i n
u S. pneumoniae PCN resistant, Ceftriaxone 1 g IV Q24 Moxifloxacin 400 mg IV/PO Q24H 3% of S. pneumoniae isolates at JHH e
d cephalosporin susceptible OR (excluding oncology) are resistant to PCN o Cefpodoxime 200 mg PO BID n n
e H. influenzae non-beta-lactamase Ampicillin 1 g IV Q6H Azithromycin*[500 mg PO daily X 3 days OR 67% of H. influenzae isolates at JHH x
t producing (Ampicillin susceptible) OR 500 mg once, then 250 mg PO daily X 4 days] (excluding oncology) are susceptible to p
a Amoxicillin 500 mg PO TID OR Ampicillin, 100% to Ceftriaxone, 62% to
g Cefpodoxime 200 mg PO BID Tetracycline, and 100% to Moxifloxacin e
) OR Doxycycline† 100 mg PO BID OR Moxifloxacin 400 mg IV/PO daily (if resistant to other options) 7
7 (continued on next page)
6.10 Pulmonary infections 6.10 Pulmonary infections 7 8 Pathogen-specific and step-down therapy Organism Preferred therapy PCN allergy Notes H. influenzae beta-lactamase Ampicillin/sulbactam 1.5 g Q6H Azithromycin*[500 mg PO daily X 3 days OR producing (Ampicillin resistant) OR 500 mg once, then 250 mg PO daily X 4 days] Amoxicillin/clavulanate 875 mg PO BID OR Cefpodoxime 200 mg PO BID OR Doxycycline† 100 mg PO BID OR Moxifloxacin 400 mg IV/PO Q24H (if resistant to other options) L. pneumophilia Azithromycin 500 mg IV/PO Q24H Azithromycin 500 mg IV/PO Q24H x 7-10 days OR OR Moxifloxacin 400 mg IV/PO Q24H Moxifloxacin 400 mg IV/PO Q24H X 10-14 days Culture and urine antigen negative Cefpodoxime 200 mg PO BID Moxifloxacin 400 mg IV/PO Q24H 64% of S. pneumoniae isolates at JHH OR (excluding oncology) are susceptible to Amoxicillin/clavulanate XR 1 g PO BID Erythromycin (Erythromycin susceptibilities predict Azithromycin susceptibilities for Note: Unless strong suspicion for S. pneumoniae) and 77% are susceptible L. pneumophilia, more than 3 days of to Tetracycline; therefore, these agents Azithromycin for atypical coverage is not are suboptimal for empiric step-down needed due to very long half-life in lung tissue therapy *if Erythromycin susceptible; † if Tetracycline susceptible • D t V N • • • r • • * A R • • • • a N • • • • • M T • • N E • ( H o e a n t i R M o u N O O s G c h E 7 G A S B S P P M C S C P S L A 6 P O O O N I A s i t n F b c r e k E r o o i e i n I n i r s s 0 t t e . r D r e e r T T r P b i c d R R R O o p D d e O o s r e a r o a a t s g i l t e a e A v a f f a 0 f o s o i u D e E E o e x h I e k a S r o l t e m a t T n a p e e u u i R o T c u k r o c i m n n o e i r T b r : : l y f p d t u c m i o d E i d r r f a n r A o o t l - t M t a I i i t i ( n s e o n o o i c z d M I f e i l C t C a u s y p o o n g f c h m : o o l c z a x s o e g e o i b r x u v l r c n E i a m m D i P i e t c o o i o t c l p l u f o l r l a g t c z a n o e e s h o l T h l i i g t e h I s a N y d i n s n t n C s c e 4 f t e l V c n i a i o o w s * e e o g R e z a h r t ; t ( e e f c c l d N n t / n i o f T o n o M n e u h r e r n n e e < i y Q o E * h i p p t 1 t v a r u s r a a p n o m ( c d r t t a r p R a g r o e > a a N a 8 A 4 p r e p u s s g e t s i 1 5 z g i f a s n d w a S t l y t i s P w y l H m T 0 o a l r o p n O o i i - 0 e i t 1 I d i a c e , o n e o d n A F s g s t e r I M i 0 i n i i a o b V e r a t ) t i T i i 0 n n d s c i g e e n v s t g a c a h s i n a N r n a Q t n t e w s c E h E m o e u n m ( Q n i e a l y s m c t s h 5 n A f M O o i d i 2 r t S N s i : t o n a s o e q m t 8 t r t k g o , d s i N 0 w o o o a g . h b T 4 h d r s C R c r - T H m a o u 0 m s f C m m a i I e I a i M i t H a S l E i o a V P n t P d d p r n o p i e s h n e o i e n c u A t / m * a i S o s d r < n s r r p g d i s n a c e P t a n o t c c H e , n i g S e e e o s t e s g 4 n o d n o s O f l u 5 a i o s o w A - r i A r o l p r n t t n o . v d n o s o d h s a r r s 0 I i e 5 a P f i ) e n e b V e i i Q u t x o b o o c c s c r g 0 l i h r i c / i r p o n a p n m a r g o a o a u 2 o m p i a e e l ) P i i r n c l p f c e P t l l t f n l > 4 i d p a e d n e , n O n i I o g i t r s i c V s c e J n V m a H s t e c e / t n t - H n e 7 a e a h t e t r t a t Q f s t Q p e 4 a e i p o a i i u r r h n H e e n a o r s u e o s e d 2 r 0 6 r z d t e e c d y n t c i n m o r m a v o 4 0 d m o H o r b ( f t e : ( o s v ) e s a a y s s d b o H m m e a e h c e f m s p c e a a a t e m o w m o n a e o t y i e y t e y c l i g r o d i n o u r c h ( n n n e ) t e t e e r e o a y i a l o t i a f d i I d a c n p . n s i V i r f b m g s s r f i s a t e o t a k a c a e o e h c b o . t Q r v s s ( r a c q a a v a d e e l s 3 K e e t a 8 t i e y u s n n b e l l i . r t i w c e m o H 3 c ) i t t e e e r ( r i b b o L n ≥ e r e i 7 e d l c o t o i e P s e r n s s h t c 5 l n i 5 a i i a w s g L f s , e c e c o r t a d s i k U i g l h o a ) i d n o o d l r n n s d a s l S m e t n a n l t . , i I i y l p s V t i r y b s e y m i E C e o a i t s i e l n l Q d b l . h d l t l i n a ) c . l i c e i e e o n e 6 e o t r u o r e d w n o o H l e s t i f n a , t r ) b p d s b o m i S i f o u a e p i k e n n t y l e u s n r c r n . m o i a n i w c t 7 i i , a n n 9 )
6.10 Pulmonary infections 6.10 Pulmonary infections • • 8 d O • • A R • A A • • C C ( O s C s T T r p P P o V T P s e a e u e r e 0 f n r r e a p u h x t I S c E t t i P I T A a t t s i o r S p f a f f m a m n d e i o c c h h e h r e i t i r t o r l e y i l i t t s b / u n r p m n e r c t n f O e i p t c g r i t r i e a e a c i o I g a r o p u s i n p m m e k h i t D s i m f e l u a h l c o a r n r n r a n u h 2 t t i t t i e p n g r e h p e b t i S l t e t a t r e e m u t o n c t o t e n e t c r l r / i u i m X h n r a e a i i A 4 i m i r o s a p a i c n u a e n e r o r i f p d a r F m y a a m q t l r - s o e l i n l e 8 s t y c t r v e G i n e p r t a p i n a a i g e l u t i t c u i : a O f , a i o a s t a a o t n i e n n t u o c s t h l r e n a o r c i e h r t t c s E e c i y b e i s o n 2 t s d g i e W e s e t t e s n d u o f o s s u i t e t h T i r n n ) i e r t m v n ( r i t a m I s l a . u e c ° d B o o t S e t l r s t r f e i t a b C r u u n t t r i h E a l o m a a o C a c e - h m a s s e r i y r o ) n l r i m s T m e y t s t a l i a e t e s p e n i i s m r c m t s n o e e t t s i t o o c i e f k s s s C o a m r f h g a o i r e n b i o a n n t u a e a r s l r a > g N N N N 4 3 n s r f e l h o w n e i t s l c t m i e t o r n n n h o H y r , 6 a a o o o o n o i h o n t 0 e o t n o d t 2 h r c o C A t t . n n n i d m o e a i g i s w 0 5 t o o i g i n 4 4 o z c c P n a u a c e e a t M k g r l s n e e 0 r f a n t i 0 0 i s f i / 8 e l a s a s t s n b o h p i d . n i a n e l p V o l m t p e a n t a p U p – w l i a o i n p r A i i n r A o o h i o r a l c c d b c n 3 e a i y r P p t a e P S i o r 1 t t e o t R w n h k t t i t d e e 8 a t a i : A p d u e i i u e 1 b T i s f c / n u . e E n o e f d i . n A t r l R m e l c , 4 e o o l y r i i n o t t n d s 0 J g l m o t . D P b s s a a N y v f r b R h t m u o 0 p o h e n o S r s t e e u C t e O a n p m t o n 0 e s n . f p b r a r e C l r f w p i a d n d T e m n i a e t “ a u o p j n M n u e r o l a a h m s a p y a r d e f e r s r o b e o t e o r 2 e s y r t o i s d r a t i f i y n a r a 0 r p l c n a e e g S H i N 1 > > < 3 D f s u l r n r d o a o . e 0 n i a p o e x s c e r i p 8 n i a a e i o f I e o f r e s r a r 5 1 4 5 i m t w n r : e r s m f m h a l t . a n r a e a t x v u m n 5 i c s ; 0 1 , y h N a r i v o f - e s d 1 t e 0 t s s p s e n e a t e h m i y % , r a r a e 7 o e t t i w 1 e p 0 0 t u p d E t a t l s I o e o h c o b s a o e n g 1 l n n r o e t 0 0 n t i b c h n o m e a r u p a n s p p n o t : r s n 3 g s t f a i 0 n r 3 a a n o l r o i c l i o s r e o o t a e u e l n o i 8 i s i d n t 8 a t t w f t s e p i c r J a s n i : c s c n c i o e i e . h d n w n 8 e v p o t a 9 a t v t e t a s s M r t e t a v r s a h . e t d t y n i i h g l i e d o . a v o S : c e n r ( e v o o a d a t h n b e a g d V o r f n i t e c o n i s o , n l y n n d u t y r i 1 n n h 2 o v A o d s s r l d g i i l t S e s a 0 i e t r b y ” r k a p y l u m 0 v P a e c n a e m e e i a s e k 1 n n o n s e A ≤ t ( P ≤ i L P l o s ) t n t ( y o A ; h p t v t s h o 3 i r s R r u n C s . f i f e o i R 2 3 c a o b t i e b c 4 r e u p D l m o u t n s P D u i 4 6 g s y o i a 4 i r n l o S u g o m p l t l t i a r i 0 . ( S l n a e I 2 ( n v n s n i 4 e o t 9 C h S z t t t e n , l i e c e e s i u s a t l c e e ) s a c p - c t w ) : o P C s b r n c 6 d u m i n s s o f i r s e i H d h f I o n 6 e o o t s S i i a ≥ c i l F o n o 5 n s w a r i b n k s ) a . t r s n 3 o i . e m e s a e o a s d 9 l l r y d t r o e i ) y c r e L E • • • E • c p E E I • I E • • • m I c h • • D L • f f f o a o e a a n t t a M u t ( t V T [ c V S I I 7 u I 3 l V b S C O O g t t i i e f f f r s C g s t h l t a t o o r h h o o n r a a A A r e i e e e e e P a e p e R R C V s e z i l o Q i a d d b l l l e e o n n s y p P P r v v f i s o o y e A - n o i k I o P n o t t t e i c a r a n 2 p e e R o - r z m t r t a g g b i e P a C C c r o i a o I c o s e d o i y r r a y s 4 S i n l a I 1 l h n a m h e y y e s i o f y p n r C m l P P o t s n s z s H l l s x a e g c 4 u o i s a o : : c r t s e e s t y P P I I o e s o e h t i y n o i s r S S x c S T f e f n i t c d a o d C n C o n S t c a m l m c o a c i i C n t R . i t t m r k a e g n n i b . N i i N o V c p h i a g n o a s s i a a s P e P y V E g s i e i p p a n A 1 a l ( s t n t i u s l 4 i I ( i a a s n l A A y > ≤ e p t S t d n p y s y n e i r P b p a i m e . l l s 4 g d e T e e e P e l e l i 5 c e e w e s t a 6 6 s c r e n 0 u r u e M r i ( ≤ m t e m r o r e I w t u a s a a i i ( V t g m s g g i 0 t o d m o e s n s n n i d l c h 6 E u i , s l s y y t n o c . p Q n d o I o i h n m a t V V N : h P f : l , q s c t a l e I a a i n s o 2 i i n . A d o a V M n n i S u p u g T f c n Q c i h n i c 4 a t a a s t n P a s / a r . g . d t a i e o g o 6 l e p e g r I t H n e 7 n i V 1 e s s a r ≤ a x t i t m , H r i c n s d t y s h t p n u i 4 z s u 3 i d f a Q c h o H g 6 t e a p l e r o e e g i s 1 a O o a l o l n m e c t . 8 i i d r r c b c e w z t i n i ) y x u R n n o u a t i i i H a i t t e a e y v i n s s a i e i l o c s h l o i m t d y , o e c c p d f C c s h a e s t n O n l c s i t b n u t a r i i i n e n l a c n s a , h o o o n , e a R , e t a p o f i , e u m e i t r p n m r a a ( e e n c 4 p a 7 s t e l d o y A s . t e n t r p n z t s . , 0 e 2 p m u e b , e t i z a t 1 e t o i d s t h 1 C e 0 m i r r s s e r t c b r a e 4 h e o f h e 3 e r e 4 l i e t o i y e d d , o w e n o m s r v 1 t e o r m 6 f n r - o m e o t e S u e u o n t ) i a e G 2 t g ) s i i d n s l m r p r . n c h a l d a o i t r P i e s a i d s i s s g e a I n t a m i n e V i c s L m n e b o e n e o u r g m t n c o h U I n d e i r h l e t r V Q f t a a t a ) o m e a s i - 2 S s a a n h t w c 2 o n u O u e t n ) e l d e o m i o 4 r g l [ s v i c u d d R C b t P g d s n e h H t r A e e p i I i P a i s s f b p n V o Q n z r s a t i i I i g e t e o s S n n d d t i 8 o n Q v a r t r g , m e a e e u t t H o l A a ≤ 8 i i r p r t z o m r p c z h e ] i e b H c o a . s 6 n i p o i a ± d t l a i e p t n ] 1 l ; a c h e m t i i c o n s u P e m t r 4 V r a T d o i o / o t n d e L l A o 6 n b u l b i m i , U t b P b d n a e m ) f o i l o a S r e / n l P y o o m i a o l r s d c c n i s L w n m r i o a o g . U n t v s y - S t 5 e c t e r 0 i r 8 n m 0 1
6.10 Pulmonary infections 6.10 Pulmonary infections • 1 D C M V C O 8 A R • • T • • • D • • T A e 6 P l e R i 2 i i t T n ( I r W t g V A r d i s n c T ( s e T V a B c Q n S P f t a 2 n n I p e h r e e e S i e o r i r E u e o a n o o A r e - r / : n c a e : u a B g e r v . B a r c s e a 5 o I t b s e d n a A e t s v l t s D P A m c a a d A e o h a c i 1 o i 0 n d C w l r n c c r c e r s i m S r t t L T n r e n e c i t n t r N h 5 c a o m i e 2 e n o i m e t o r e , e m : h A c t s c h t q M e i a e r i i m a h r c i z p O n s 9 s i C a t c m d e e n a t s f m o e G i u I n r a g g p d e . a o n n a a i : t h r : , ) e t E e T y s t n a n c i u o . l d t y o s n e i e t e t A v b e r c e w f t c a i N i i i n t t e c c e d s s e b t f m e d o h v n i o I r l n e i n s t n i e r t n e i o n c i c c e a e u i r m n T M n d e i t a d t a f l e 1 e e n e R r u l t i i u o t M e n a n o n e t s i l i c e m t 9 n n U a f v e d s e s l o N h l e o c e g i e t i t t d n s 9 u v c e f l d n t h r n . u s S e h n t d t l e i i e r i O V . t o 8 v a u l r o n a d o i o t z R r G e t e r o o T f A n e a n f 2 ; e o u o o l a n t e u t T o 1 r c n P t r t t t t i t i 0 r r s r s C n t r a s n t d l b h h h o 1 a e f o E a : d . e r o i 0 p i i H e a i p o f o s i a 3 e n e m s A d n i P m c “ a s i e S 0 q r r n A r y b n : n C u a , J e a e h s g s 4 ; c c m n P u - D R 1 m o p e g n t t w o r e e 1 s M n t o h / f a i m C h i 6 y n f e i s l h o H 2 h m a u o o u a g e o f s r e e C 0 o u g B - s A r e o 1 l d o d n n t s 2 n i r G l : M s o b v l o o V 1 a t 9 s A s n a u o o g e 0 ; r d i 2 i n r w i : 9 w o p t 9 u n e t b l c n L . 2 m n . e e ≥ a g d 0 i A 2 1 v c g p q n e a a s 0 o e e d d m 0 J 6 f e C ; o t 1 e i u b 0 t s e d s R r f 1 l 4 n i i i u - P n o o 6 t a - 1 i o e d e n 0 C 4 ; c V g n n a i b I i a . ; n s d n S s n c f n 3 C 3 4 o e o A 1 i i o t a s r . f c v : e 0 M a 6 v g l S a P m 1 w t c t r c s o e e : T r h h i e 3 a c 1 a l a o e e f 2 a n t n o 7 s a h e i e : o r u r 2 t h s c n 1 s f d 0 e y t 3 a e e r i r e y r / 1 v e i u 3 e e i 0 s i c a 5 l s g c s a m n h a – e o : n 7 r l d b 5 – p l t t o e s f 1 s e e i t a A s b n 1 o u a i n 7 ; e l o y r s 1 1 t n l p m o r - e r p 3 t n i c s i i 1 n a r e c c o 2 7 s t d e r o n c 8 t y t a u 3 w e n 9 e 1 u a J c d c f . a s c n 7 t G a 5 r f d . : l s l e s i R i i i t e 3 e a t u G 5 o o s t g d e u r t e l e b s 8 s l t d S s . t a a n n r e r s s n e e r i e 8 d u e a a n e t s m . . p o i n u t t d l . u l o m y g i i e i t r a t f s r z d o t r s - s s e c r u p r w e u c e C c t e - f ) i a d n u o i o o r s e a d o r o s i r a h c t e e m i u e u r s t p r . h f h m i b r h u a c g e g C i l d e t T t e t t r e s t i e b h a b h i h s a b o i v k h n s a o n d i r e t e i g i e i a n n e t u i r l s i l o n v t i r e g a d o t h a s t w c a M e t o i d o n n t e e ( t , e w o p e f e r e i ; i o s o i r n e g p f a n y l d n s e i o i t n c v . o f a m f ) a n e 2 s n e . e o a n s P i r t m 0 t i i o c r e n f h n z i t l s , 0 e i - t r t e a g s p i m 0 k t r a o t r l a i i ; n e r i s s a n o s l i o i i c e p s t n n y a w ” y g r n e . • • • • T • • f A R i a T s I a H P S S f b n E e v n h i t t s p • • • • • • • • • • • • g a e a d l e r t A e e o h i i n p o r C b P T t p a a b F I l p I T i p I S i h C w W i S O L l T c u a n m n n n f r s a b o a o i g m i o r a a e e h i h e d i . . t o l M x i c s f h c d n s s c s b p h p i e t e e p p n r e i t t d a t o y b a m a h t n a l e t i u a o l e e i a c i i y i f o u b r d o e c a a d n e e E r s i u c s l e e p u t l s z p r n o t r d o o m e d o l a i a t ; o m r t e n n a c s c h e e t i N n a r r t o a s p e i i l i d p m d v e n a c o e l e e l t t c g m t h i i e e , s u c t t i l t p l o r r s a s s e h T n e c i t l o - h i u n n n o a o d l e r i i o l i e b s T D i y P ; n n g e a n l y s t o m d s t t p . a o l l o w u c f o i t u n h i i t l c N i s f c / i c s s s e e c n n y a f o a r c h s e l m r o a c b s t e i i o c h t d i e e e t n e , a r c s s l a s O p n i l i c t g a u s l e r i l u o e c n o l s y a e u t i h n o d r i a C r n , o a e b a t n u t m s e T t w a o n x i a s i f t d i e l c l v d t s o m T a o t a n e f e c a i p b n a w t r e b i n E n e i o u o u i a o s b k e i s l r a b M i t f n h t a . d t e a c e l i g y s e l e h i S b m r e r i m a s i c t o a t a u n o M b l r i o s 2 e r w c P u i h i p c l l a d s l u o u l n s y l a p g p c a r t o y t b a f i e i 7 F / o g i i s e t n s n i m g g a n n e m t e a o l i e c f h t n a s e s S l O e h l r , e M a i o r e e t t e o n n f u n l s e n a a o s u m o o e o o e a d M o n d C i d r R n e n o t i e s s r s e n n s p o g c f m a f n , s t h r l a e O e e i m X r o r t d i d p f e z f i s i i m b h b e c a a o o l o S c p z m r r r f , l n a R e r n a a a o i g o a e s s h i n n C a o p r y n e p o P i n D t c e o o n z p l o u t d m e . c t i n e s l M n o t s M h a a a o t E y m i o a o r o r l u i i n u o I e i n d c c h l r e r - f C i s n i l d i i l C g x l t R c i l l c n s n e l r n s i e d a s o e n t u e i t n t o y e t b l e u a S i p o t o a h a h m I c , y t u o n m r v w c i F f w w f e o r n o g d a n u m i c c A t t T l f o i o s e y o d a I t a o i l m t s t r e h y y o C t e M r u r c c c f o u f b m p z h , r i c o e a s t s b C r s s l n a a i m r m M o i i a P n i n a l C s t n n n d i O n e e e s i S o n n d e e n c a e i / n d e S i s e a i s m i a d t m . p e i p v R e u t t S c u s n t n b i d p i t , m i S n t i s ; h s a b r s v i m t a i d t i e G M e o e o e z m o t a d g r A o t a u e u u d w e n i i e m o a e r c n a n n f A o i X s l a r u s e e c a l e n i n n m r p . t e t o o d b r t n c p l s N h t s n f r e a i y c x l h e c g i n n u h g x y e i u s e e o o t e a t s a i M e s e I l g e s e n a e s b e l m h p y d S u n x e r y . c i t r u u c d s i e e i t h t i ( l s c i n f a i M n g c o c m d h n s i a m c n i t , o p b e o n i o o r e a o u h o c t n a e s d c r c p r S i i i C f b s c o w n s - l z z l s t n e f e o e u d i o h o y M i a e t i a y t n e F a e i r s d s t r c s y d o , n s b d c a s c h s i t d t i S e e s t a u d e p i s A i l a s o t l n j e e d t z i o u i u t n f s o ; s S i e r e i n a l i z u t v a l r a b l n t f n i e n t , o i T e n i V e e h r t A t n i c b l s t t g l t s i l c r d e w C d e M i a a o e y t e y o e i o u i f o t o d a c n s n p u o ) o i i o n P a f e s w s v n a n t o c t g e l r b i n g s c / r e i r h s g c d o l h o s n h a e s o e S a y M e e o s e t e r m t e o d s n n t m i p M n u h n n n a R t i m i i e t s t y l c e z r t - d X S s i r c . a c t b c a a r e g a . A a a t i a b l t t n e i y n i e n p o . n o e 8 c d o y n i n n e 3 r .
6.10 Pulmonary infections 6.10 Pulmonary infections • • • • • • • • 8 • • • • • • • f A I • n u 4 n P c w n D I T A C P L I C T T M C P C t n n n r t o h o i M M e z i i o i o e e i c h h c i e p p a p t a b t t a a f f h s l a a a t r e e P P r r v i e t n s d i k i o a e e o l l a r r r o o e / / e e g p g t c i c p a a o s f z n S S i i n d d t n i o l n s e i h c c e m o i n i l g d M M c l c o : a d i i i i n a T C x r e n l l i a e l l l 3 u . m e d o X X e a m i i v / o d n n n : o c o s - b c m c e 6 l / : e o f f : f 2 i o s i r b s o o l d t n : T a 4 : s a 2 2 a e m m t e r r . : o g v 2 e i m 2 z 0 : n g I u S S 7 g m b g i f s o : n 1 I - g y l g V 3 5 . . r / a t b I c 7 I e 0 c f V r V a k 0 a m n 0 o a I o r Q I n i 5 V V g n e m a u Q m c r u Q d a a 8 - m / a r t 1 Q t g Q ( e 4 e e l n 8 c y d g a H T s t 5 g h d 8 o d : u H 8 m c H a y e / O 0 s p H 3 k H y s d i i P a t B s : n : h g r . t m f O I 1 o I 3 i u 2 t i V / ® t c l d e i o u p . d g a ) Q g 3 r d : o D g o f a : t 1 i i Q 7 3 s f h S o v y I b 5 i l V i r 2 o 5 0 i 1 n d r a s g 1 t w m H 0 Q o 2 a e g t t g i 2 v s b H d 4 d g 2 m O o e a i I l m H o V / s 3 e r n i R d n g n k s t t g e Q i s h d o g e o n 4 3 Q p / o v 4 , o P f 0 k I m e 1 e u e V d H 1 O g 0 n h r r 2 / c o o s / d i P h H 1 g s t m B d n i i o O w n e h o I a i h D g u g s t , i n y o t o Q r i h I s n o u V i r a 8 f t i n r g f – e n H . a Q t o e r t g d n 8 h v a r e : o a e H l q t l r < h d u s m e e a h 1 t l a e o i e v m n l u e d p l r d c r e e y g o b n a / f s k e a m y i s n l s L f t a u e . r s m e i o n t
Respiratory virus diagnosis and management n e m
Diagnosis e g
• Respiratory virus testing should be obtained year round on any patient a n for whom there is a clinical suspicion of respiratory virus infection. In a m
addition, during influenza and RSV season testing should be obtained in d n
patients with: a s i
• Fever and influenza-like symptoms (sore throat, myalgia, arthralgia, s o
cough, runny nose and/or headache) n g
• Suspected bronchiolitis or pneumonia a i • COPD/asthma exacerbation or respiratory failure d s u
• Unexplained CHF exacerbation r i • Elderly patients with unexplained new onset malaise v y r
• Pregnant patients with unexplained respiratory symptons o t a
• Nonspecific symptoms and a documented exposure to someone with r i p
a respiratory illness s e
• Respiratory virus testing at JHH R
• Standard panel for immunocompetent hosts: RSV, influenza A/B, 1 1 .
adenovirus, human metapneumovirus, and parainfluenza 1-3. 6 • One NP swab should be sent • DFA is performed first followed by shell vial culture if DFA negative • Extended panel for immunocompromised hosts: rhinovirus and parainfluenza 4 in addition to the viruses listed above • Two NP swabs in two separate transport tubes • DFA is performed first followed by multiplex PCR if DFA negative Treatment of influenza in inpatients • Empiric treatment of adult inpatients should be considered in the following situations during influenza season: • Patients with fever and influenza-like symptoms, unexplained interstitial pneumonia or new respiratory failure without an obvious non-influenza cause • Duration: 5 days unless an alternative diagnosis is identified, PCR is negative, or shell vial culture is negative and influenza is not suspected • Treatment should be initiated in all patients who are admitted to the hospital and have influenza with symptom onset in the past 48-72 hours • The utility of treatment of patients who present late in the course of disease is uncertain and the decision to treat these patients can be made on a case-by-case basis • Antiviral choice is dependent on the susceptibility of circulating strains which may vary from season to season (see www.hopkinsmedicine.org/amp for current recommendations) Infection control • All individuals with suspected respiratory virus infection should be placed on droplet precautions. A private room is required, unless
85 t
n patients are cohorted. When outside of their room (i.e. during e transport) patients should wear a mask. m e
g • All health care workers must receive the influenza vaccine yearly. a n • Personnel with direct patient care or working in clinical areas who have not a
m received the influenza vaccine are required to wear a mask when within d 6 feet of a patient. The dates of the mask requirement are determined by n a HEIC and based on influenza activity in the local community. s i s • No one with fever may work until at least 24 hours after fever has o n
g resolved (without antipyretics). All personnel with respiratory symptoms a i and fever must call or report to their supervisor and must call d s Occupational Health Services (OHS). u r i
v • Afebrile employees who have respiratory systems must wear a surgical y r mask during patient contact (≤ 6 ft). o t
a • If an unvaccinated HCW is exposed to a patient with documented r i
p influenza who was not on Droplet Precautions, notify HEIC and call s e Occupational Health Services (OHS) immediately. OHS will decide R
1 whether to recommend post-exposure prophylaxis. 1 . 6 Anti-influenza agents Medication Adult dosing Side effects Notes Oseltamivir Treatment: Common: nausea, Dose adjustment 75 mg PO twice a day vomiting needed for GFR for 5 days <30 mL/min Prophylaxis: Severe: 75 mg PO once a day hypersensitivity, neuropsychiatric Zanamivir Treatment: Common: diarrhea, Should NOT be used 10 mg (2 oral inhalations) nausea, cough, in patients with twice daily for 5 days headache, and chronic underlying Prophylaxis: dizziness airway diseases 10 mg (2 oral inhalations) once a day Severe: bronchospasm, hypersensitivity, laryngeal edema, facial swelling Amantadine Treatment/Prophylaxis: Common: nervousness, Dose adjustment 100 mg PO twice a day anxiety, difficulty needed for GFR or 200 mg once daily concentrating, Յ50 mL/min lightheadedness, nausea Severe: hypersensitivity, neuropsychiatric Rimantadine Treatment/Prophylaxis: Common: nervousness, Dose adjustment Ͻ 65 y/o 100 mg PO anxiety, difficulty needed for GFR twice a day concentrating, Յ 10 mL/min and Ն 65 y/o 100 mg PO lightheadedness, severe hepatic once daily nausea dysfunction Severe: hypersensitivity, neuropsychiatric
86 n o
Tuberculosis (TB) infection i t c e f n Definitions i ) B
Acid fast bacilli (AFB) Bacteria including Mycobacterium T ( s
tuberculosis and non-tuberculous i s o
mycobacteria (NTM) that are detected l u
in clinical specimens by direct c r e
microscopy using an acid-fast stain b u
• Negative AFB smear does not rule T 2
out active TB; cultures may yield 1 .
results after 6–8 weeks 6 Tuberculin skin test (TST) Intradermal injection of purified protein derivative (PPD) and measurement of induration diameter in 48–72 hours for diagnosis of latent TB infection (also positive in most active TB cases). Criteria for a positive test are: • Ն 5 mm – high risk of developing active TB (e.g. HIV infection, close contact of TB case, immunocompromised) • Ն 10 mm – other risk factors for TB infection (HCW, IDU, DM) • Ն 15 mm – no risk factors for TB Latent TB infection (LTBI) Previous infection with TB that has been contained by the host immune response • Patients may have a positive TST, a positive interferon gamma release assay, or suggestive radiographic findings such as calcified granulomata or minimal apical scarring, but do not have symptoms of active TB disease • Not infectious and does not require isolation Active TB disease Active replication of M. tuberculosis causing pulmonary or extrapulmonary symptoms and/or signs. • Confirmed by positive AFB smear, MTD test or culture • Requires airborne isolation
87 n When to suspect active TB disease o i t c
e High-risk individuals f n i • Recent exposure to a person with known TB; history of a positive TST; )
B HIV infection; injection or non-injection drug use; foreign birth or T (
s residence in a region in which TB incidence is high; residents and i s
o employees of high-risk congregate settings (e.g. prisons); membership l u in a medically underserved, low-income population; anti-TNF alpha c r e therapy b u T Clinical syndromes 2 1
. • Cough of Ն2 wk duration, with at least one additional symptom, 6 including fever, night sweats, weight loss, or hemoptysis • Any unexplained respiratory illness of Ն2 wk duration in a patient at high risk for TB • Any patient with HIV infection and unexplained cough and fever • Any patient on anti-TNF alpha therapy with unexplained fever • Community-acquired pneumonia which has not improved after 7 days of appropriate treatment • Incidental findings on chest radiograph suggestive of TB (even if symptoms are minimal or absent) in a patient at high risk for TB Radiographic findings • Primary TB (often unrecognized): Can resemble CAP and involve any lobes; hilar adenopathy, pleural effusions are common; cavitation is uncommon. Findings often resolve after 1–2 months. These are common findings in patients with advanced HIV infection and TB. • Reactivation TB: Infiltrates with or without cavitation in the upper lobes or the superior segments of the lower lobes; hilar adenopathy is variable; CT scan may have “tree-in-bud” appearance. Diagnosis • Patients with characteristic syndromes and radiographic findings should have expectorated sputum obtained for AFB smear and culture. • Sensitivity of AFB smear on expectorated sputum is 50–70%; it is lower in HIV+ patients. Morning expectorated sputum, induced sputum, bronchoscopy have higher sensitivity. AFB culture of lower respiratory tract specimens is considered the gold standard. • AFB smear and culture should be obtained regardless of CXR findings in patients with high clinical suspicion, HIV infection or other immunocompromised states. CXR is normal in approximately 10% of HIV-infected patients with pulmonary TB. Infection control Airborne precautions are required in the following cases: • Suspicion of disease sufficiently high to warrant obtaining sputum AFB smear/culture as described above 88 • Positive AFB smear or culture until diagnosis of TB vs. NTM is n o i t
confirmed c e • Known active pulmonary or laryngeal TB (if patient is currently on TB f n i
treatment, consult with HEIC and patient’s local health department to ) B T
obtain treatment history in order to determine if infectious at the time ( s of current hospitalization; in meantime airborne precautions are i s o required) l u c r e b u
Algorithm when active TB is suspected T 2 1 .
AIRBORNE PRECAUTIONS 6 IN NEGATIVE PRESSURE ROOM
Collect specimen(s) for AFB smear and culture
Expectorated sputum (3 required)* Induced sputum or bronchoscopy
Smear Smear Smear positive negative positive
Mycobacterium MTD Obtain 2nd Smear Tuberculosis negative and 3rd negative Direct Test (MTD) specimen* automatically performed Smear If pt highly suspected positive for TB, await culture result and continue isolation. Otherwise, MTD test CALL HEIC 5-8384 to DISCONTINUE ISOLATION MTD performed positive
MTD MTD positive negative
Continue isolation until at least 14 days of therapy CALL HEIC AND clinical improvement 5-8384 TO AND 3 consecutive negative DISCONTINUE smears (Call HEIC for ISOLATION approval to D/C isolation on smear positive patient.)
*One expectorated sputum must be a first morning specimen; samples should be collected at least 8 hours apart.
89 n TREATMENT o i t c
e Active TB f n i • ID consult is strongly recommended )
B • Therapy should be initiated for patients with positive AFB smear and T (
s clinical findings consistent with active TB. i s
o • Therapy should be considered for patients with negative AFB smears l u when suspicion of TB is high and no alternate diagnosis exists. Multiple c r e specimens should be obtained for culture prior to treatment. b u • Four drugs are necessary for initial phase (2 months). T
2 • Isoniazid (INH) 300* mg (5 mg/kg) PO daily 1 .
6 • Rifampin (RIF) 600* mg (10 mg/kg) PO daily • Pyrazinamide (PZA) 1000 mg PO daily (40–55 kg) OR 1500 mg PO daily (56–75 kg) OR 2000* mg PO daily (76–90 kg) • Ethambutol (EMB) 800 mg PO daily (40–55 kg) OR 1200 mg PO daily (56–75 kg) OR 1600* mg PO daily (76–90 kg) *Max dose regardless of weight. • Pyridoxine 25 mg PO daily is recommended to prevent INH associated peripheral neuropathy in patients with HIV, malnutrition, alcohol abuse, diabetes mellitus, renal failure or in pregnant or breastfeeding women. Latent TB • Treatment for latent tuberculosis should not be started in the hospital setting without a clear follow-up plan. Drug toxicity and monitoring • Isoniazid: asymptomatic elevation in hepatic enzymes, serious and fatal hepatitis, peripheral neurotoxicity • Rifampin: orange discoloration of body fluids, hepatotoxicity, pruritis with or without rash • Pyrazinamide: hepatotoxicity, nongouty polyarthralgia, asymptomatic hyperuricemia, acute gouty arthritis • Ethambutol: retrobulbar and peripheral neuritis • Monitoring: baseline hepatic transaminases, bilirubin, alkaline phosphatase, 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 Ͼ3 times the upper limit of normal (ULN) in the presence of jaundice or hepatitis symptoms or Ͼ5 times the ULN in the absence of symptoms.
References: ATS/IDSA/CDC Guidelines for diagnosis of TB: Am J Respir Care Med 2000;161:1376. ATS/IDSA/CDC Guidelines for treatment of TB: MMWR;52:RR-11. 90 R M ( • s • T • • N • * • C E t • • • • • • Ն S r u i R M e N u O e s n b S O V C I T V [ O F K P R ( E c T 2 V I p V n s P 7 e l a o r k E o e r a a a o o e t m o e n 7 O e e t p j T P R a o i 2 u t w e h b Q n n n p e r n t p s A o c t v n m e f E n T r I a p p c e d e c c c r a d e e s i e R e w t e p T 8 h c t s s a - : e t E i n r e r a o o o c i i l e r e r r n s a o i d v a M t H I a f n m o e a n t i i R n y : C t e m m m e k d i t c e t i u c e n l s o ] a e c n M s t i e s d c r I E y e ( P r t v r d f r y y y ( l P i m t ) w o T a r f s o e l c s U n d s e f h N C l w c c c e p w i s e t i L r r m n d R i l e i n t e n r o g S o t o n i i i m o r a c N f T s e U 1 n n n t u h e / o r o i E m r n a t u o T w t l g a P ( i t t S m a i a l w u o r n ( ( s a s i N n e g A i r a s m z s s h n p h i x c b s h e p l i n M z u e i a a T a T a e e l s 3 g e O s ) t y I e e m e o e . e o t s h V o c y b t c m e e M p n R n n r s i u T i r e h b m t h b o d a g s s e e d r b u Q a S i l d d s s a E E o a a o d ( r e t n e o y n c o r e c o e O h A a e o o 8 r c s n S n N : n s d m a i s d i . n w a e f m l s s l t N H a c i g t e [ i r a c l i h n o a w T t c i l t A n i i i e i n m l o h c n n n . . t t e L y t i g m n l g , s i o z a h i / Y s m g g s a t o c r n e r o t t i t r p ) e “ h e * n l i n s r o s a h M e i n a s b d s s a n n e o s c g o c s u e r e z t p e e 4 i o e R o e y o ( t m n r f o r c p l s p i f t a c c f p u . u n p S o e v o h i t c b l 5 o e c r e l t t a b m i a e s w n d s A e o r i i o u g a e f i o o c l m i r e s g e o r r n s p c a o o u s e E w n n e a r n d r , y t r i p n o e d , , S I d c a u p a c i i 2 V o s t p i a e s f n o p p a e n B m y h y s i r t . u c n t t Q . b g , d . . v e L i h t c b o a n i 1 e p e f p 1 1 h 6 o - c e r I i p g a r w 4 r r c V e e e f e 4 4 u r H s s o a c r l a 1 h u r r c l s o e 6 6 t s C Q g t l u a i m o i o o O ) t u e e d l o ) ) t e o e p e 8 g n p r r e n c u R i u ( ” o e f n y n H g u i p t t e c c f r . f i s q o i p i C c e t o e a p u p d i a i . n O u g . s e d d n c l e r i e t t g m i l o 1 , R s n , u i f y l r l h i i e i l e n o 2 f r c i p o e t o o s o C e p y e t l o n 9 . , r n o k f c s s i g i s o s m p g 1 s ) n p . i . a f n i ) a u r e 4 d e f o i r e o n f t o s r b e d e e a r 1 * e i f I r h s s s c l l F ) M o i e i o m t z i e p 2 n t s P i x x i u t a 2 R m t e o t u a L p o g l t a o S n d n t i c a U p o l o n e r d e A I i g i s b S V t n n r r i h ) n w u e i a e G c a > 4 Q ± g r n n i e r t s 0 t 8 c h a s 0 e H m a , ] m - r a ± e g 9 1
6.13 Sepsis with no clear source s n Skin, soft-tissue, and bone infections o i t c e f Cellulitis n i • Always elevate affected extremity. Treatment failure is more commonly e n due to failure to elevate than failure of antibiotics. o b • Improvement of erythema can take days, especially in patients with d n lymphedema, because dead bacteria in the skin continue to induce a ,
e inflammation. u s s Non-suppurative cellulitis i t - t Defined as cellulitis with intact skin and no evidence of purulent drainage. f o s Usually caused by beta-hemolytic streptococci (e.g. group A, B, C, G , n i streptococci) and MSSA. k S TREATMENT 4 1 . Oral 6 • Cephalexin 500 mg PO Q6H OR • Amoxicillin/clavulanate 875 PO Q12H OR • PCN allergy: Clindamycin 300 mg PO Q8H Parenteral • Cefazolin 1 g IV Q8H OR • Ampicillin/sulbactam 1.5 g IV Q6H OR • PCN allergy: Clindamycin 600 mg IV Q8H
TREATMENT NOTES • All beta-hemolytic streptococci are susceptible to penicillin • Clindamycin resistance is seen in 16-33% of group B, C, and G strep but remains low in group A strep (4–7%) • Duration: 5-10 days 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 • TMP/SMX 1-2 DS tab PO BID OR • Doxycycline 100 mg PO BID OR Minocycline 100 mg PO BID OR • Clindamycin 300 mg PO Q8H
92 • • • • • • • • T • P • C L • • • e R a u A w a M s a f L a q M N W o D T d R r R d o i c 1 I I c O c A I 4 C V O s n f D o e s r E e b r b e o a a e u e i h s y t t n i e 0 o l e R o o c s R e o o f i r e i e c s g a t s n t n n t l s i e s s a v v i A s c t m 0 u x i e l l u c m s h s n e o s a u n h t s e e c n i d c c A r m i a a o y c T t o I n a k c s e t o o e i m V l t e r i a t r l o e e m a o b a i m n c e d n t e o o l d s n M t h t o r e t s a p m y i t a s s m m l i d n u y h s v s j i m o Q e t s p a s i m p t u g ; s g r i p o i o i s s a n c n l i E , e u u s y m . r s l t a u n e y a y 2 d Ͼ e i a t n e . e d n c , r l y n d c l r e c P m N i R h t c c c , s l n n s o r n 4 e a e s n d r e u c o i i l o i O e t a t l i i h t e i a d i a i n o e T g p , l n d n t H e 9 c h s o e o i n a s t c o i o t h r s p n t / e n , y s v e a , s 5 o n t d e n o s i 6 a ( b u t r N b I f a u / i v P s h e . o s V t d d t s t o s e , i r % o w u s m i p l 0 i d i I h t f e s s L e I t r c d a L d O n . o & i l i c & a l b c s u d e y s Q p a e u i 0 G s c i U e i i g e t a l a C c o o n . n D n c e u l T i s e D N h t o e r e b d 2 e n r n . S n l u t m a f e a t d l m . d r e , E a a r h i a E V o 4 c s f n g c s z o s i t M o r o T s b a r m l n a a S D c m V o i b t e g u d s H a o e i a b e q r r , s o i v n t R s E y t o o g e c p a s t - s l . r s a u e i o t a e e n i I g n h u n ( S d V i a r R x l a m h a i e m i I o n C e d n r e s , o n e & i p g o y t a m n b o A s d a d : l s g Q A o y a q b t e c y v D f t . w e i m h e s r 1 h n c P t a p d l - u e i r u y 8 u o l M s e L r c ) e f e d i o y v f i . t l a i d c l t a a a n H l i o e n 5 n n i n i i u e a c h c c . u n v R s s l i n n p t a o i e l i t s – s t e i l i e a n l a e f s t p i S a ( s a n d p a A l i i o l t s e e 3 m i o u r c e l o t z h v h u p l g A t p o m e s n u d t i n o u o i l n o e i e b c f l e i e h g n r 1 i . s r a a r l , s t l e n a u d o e g a l e a u i n e m o i l i 0 n d p , p l s S s a l f s I c n x a n s t l y d V i t t r l d r 0 m h e m e . r a i i . e , n g t i c i i a f e s o i b m m s r e s n b o Q 1 s i r a a a i e m a t a s m f l e p d t e e e r s l r 4 u n t n i 6 o a e g a m n i n e e n e g d a o u u r d i S 6 c r x n t a t H i o s t e s n / n c e o s y p s f l o p o o g . ) t m w b P . c i c u g i e . d o e s u l a o h n t t ( e a e d t l O s i I i . ) m h r . a t C r c s r n f l a a t s s m u l r a a e i r h e y v i c o T i P i a v i o u d r h o n ( B s n t d a o u r r G e e o e r e n r C n i o a e t d a t e e n I l u e c u n D m m t a s N t t d N p a e a r t s t o s s t i o n i p o e t . c t d t R y r s u p e o h d o m f a o a d a a i T s g e o w , l n f n o p e b i t f t t l l t c o M s r m e r g l t u a i f e w u a b i h e e e s e t a e c o s e e f l c t h e r P c r h n k 8 d o c o t t a i i g i p r s x e u a o s e d a / e i t n o 7 t r C w n t s p y e b l n t e i S d u e n t o q e 5 s : a e r a u a a t t e i s m M w g n n h s u d a e s t f M n r t n e c m h t s f e a e i i c g v i k X e d d n l r e t m a l u e o t r e o i h i r o e n , o i g i n a c a b t e n s x d r v a a n s o t a S l x t n l e s g s i o e i e P i n y f i t r n n v o o o d s . c l i s n r v o t s O d e o e n f , r n h e a i e . e e b t x a i r o t e a t m a s u d s s l B a o i h w o u o v e n r s . c r e o I e i s p e t c D a n i i l u n s c s e d 9 s s e ) . 3 )
6.14 Skin, soft-tissue, and bone infections 6.14 Skin, soft-tissue, and bone infections 1 9 M • a I E • 3 2 f s M . 4 . . a I a e p T a n h E i T D n f b n r h d n P n o • • • • • • • • • • • • • • • • • o o t d y e s d e i i r a I s c b p c o g r 1 P D C b b S T D L d L b c m M t d M L A R a C C S A A R u c t h a a g s i e c i g o o a a i o a a e h v r i s d e h o e i c o l l o i I o f c u u e g p e e e e a u t y a C s e a f o c u e n s l c f s a c e g v v i t v a o p p n i r a o p o m b a a y n n c i e s n c n r e k d o i a a e i m u t e c a u d n t n i i p d t n n s p n e r l i t e T o e r r u d a d n t a m c r s c i r b l p a e i s i o o o a o s i r i t u e t c d s z l t R e e o c a t h g i r a a h t e e e y r t m d a f c c r i h h r e n e a : w e e s r l o e s n i n l f n e E o s r s a ( l t r g l S o i i a e r o n s t b e . n n s a h e d u c d a s i a c e e f s t i r t p r A n h o a r t n h . o r o r a . i a t d l . i o s e l n e h s v d g w s t e e n m d r o T r a f o o s n a a r t r a w o t h e c a p a d l t g h h i r q . e g s y t o u . t M u h o f n t n b o i e g s t v e p h o h i o i v n u a m i e f l e c r c u o n h g e t n d o e i o t p n r a i e i e n a e u g n E i e n p d r h c e e g o v m e e i t p n c e n l s l a u l g d w n z ) g s g b t N e l v h l i d f a r y l d a c e t r i i e d s r i u t a , e c i s , r e i o o c b s o e e n v T l e , a u a n l h p s h e t s o t m i r d u s i x e f s t p n t g r i g m i i o o o r n r a o n s h h l i o n c e t n a n p y o s c o h t r e t s e o b n i p o e u d a e a m i h n t a i o r e l e g l n n n b f b e d i t i y a e e u l s s s s o a a e o r p r c n i o s u b e b ( e c g t d o t i e s t t l e f ( t r h s p c a w i i i i t n e t e i i o e n s v e o n f h f t h t s h a s y u , i l 5 o e o h r d i . e i n i i m g v t c n M M s s e g y o t a l o s g o t t e l n r e h y u h i t o s s v r ) d e n a i a l a . v s a e R c r o e R . s d m e t u w i d f a a e c s n c a 1 l r e c S n i a t o ( p S i b d p y s l o o f e e e b n e m m 0 e e h n A i i a t t p s n o n e y r e n A l . n c e n h a a d % s r e g r f w i c e d e n i t r i r t c m r m n p e i e n s n s e n . h e i i d s i a a m i a , n d t c a s e i t g t i r d i o r a s o r k i e f s h l t p t o s d t t i o c l a / w a l o o e h y n n b i i u a u n i a a i o t e o r e e n z s i o n o e d l o h c l n e y t u t t b n n a o s m q s p o e n s t i c e h p a r t e t e s n s c t r u h i b a e s i s o p i r g s e n s a o b n n d a e i a a e p w r p c l l s e ; t f n g t l a o r o l v d n s e s l m o e i i d t y c u u a t c e e n r d o a a e o , h i n r c s o s l n w n i i e n i a l c a p n n z f v t r M s o u e d m t f a i n e g i t i h a g a a e e s i a i t n i n d d R t o t g h ) t e t w p c h c d l l a a e . i i e t o S o i n e s t t l h u b g i a m a a c e o r s e p n n A s e t e l t e u s n t i w e d e e ; t e n e m d t s d i n n a i f r ≥ e M n t i n s ’ e a d n e i s n l a n f k a h s f u c s f 2 r p m e e a n e i t a a a p t a n p a a m o c a d c r i h p e i l n n a n t r u e n t o / t i i e i o p d a i t g i e d l s t o r o o y i r t c g e i n h r h a a n s n w c i n t e n e c t . o a s r l ) o t u o i t s l d i s s c r i s u t w v e k h e a o n w e i i t m s d h n f i h o t o g h e r l I T E * S M M U I D R 4 • P • • • O M T E N d D n M t e e r e e n M . a o i S i f i r O O C A O C O C l o I f e r i v a e d c P e L d a n A r E y l m e l l e o a T P c R R R / r o • • • f i i b e e t D l n n e v r e G S g h p t t E r l I e o n n e r d d i o c a y e M s I S d B i m d m R u a h o n n c : e I x t t i a a m t t n t o i l d o N y a a X n e e I f t e l e r u i i e g D u e C m m e i r c e f s c s l t d a z a f e r F a m n a h S t l s c : i i n o t a i a , t l e a m n y y x e - o u l E i e T t r e t f f t i t n p t e b c c n p i i i l a m a o t i g n v M o C b o R s g a o e e p d i i / m r e n n o g i n l i R n o i u n f c e E r T n e n 5 e e c r o o e r s S t i n , l 6 3 s a i I i s A g 0 l a r p a s r o t s y A O t a t t i c y 0 0 s t T v 0 t i e e e i a : n f n s r t v m r t c h N h u e n 0 0 h f A M b e r n a t h f o f o m a o d l i a n e e i o S b a b t o e d c t c m m t e n n u E e n m s n e i v c a h g w n s a o r t l g s e I N l e d a n g g t r e n l e t c s t u e m h o P i e o i t n , t i e l T s r y e c S A i a P s c i t C N o r e p i s I P t n n l s t O h n s V s l i r i k u n m i s n r a e n o ) a s v s n s o s l f n e a O e t i i 8 d b y m a o : n t , n f g d s a r e d Q Q c a n s s a M p s o 7 s M t l M w i i m o r c . v v T e e e d r o b l o c i u 8 u I f w e t c t i e 5 D e e f e e R n a r s I i r n a a i p n d D l c H a n i i d m l d u i c a i r S r p c l t s l e n l N t i e s u m m i y g l y y 1 b e u c h s A c e u r a r e c M l l ( ( O i l 9 o i m i f r c c h n p t a t u n n o t g b o e i i a m c h a i n c 9 v e a c o e o o s e l T t l f t i e i s t , f h e b i l t 2 e n h r P e a d u v v o i p 2 e s ( d i i l s r f t ; i c i n n e l i i o e e P l f i O l 1 f h u e 0 o n f e d c , P i m t d f t e r r r L a r 1 m r i p 1 a r c a t i h o l y v L u a s s u h y o s U B b 7 b r 0 s d t o n b i y U e u r l l m e n e t e o : c S ; s o e a I M M a g m a s s s 3 S e e 8 f s D r x n : i f p t l v a y c u a t a 9 i e i 9 a i s r i c a R R e C i o m t h d a e t , b l m m o 0 n : y s e r y e h f s n l a n 2 S S t c i d i t s s o - n , n n e 8 a s e m n ) e 1 e l u a e A A t e s r t e . n g e e r I Յ o 7 t n e e n a ) ) a d e a a t d m 1 i s – d f n r p t t o s i e n e n i m 2 i e s 2 d c l o t i e c r e Ն i c w t d c 2 d e m o n i t o o e y s s c h o 6 n d e t * D n d u e s t m s o 1 i e . n , r t e a e i s u e s o e x s e a x t j n k s e o i a a a c l o t n d a c 2 e i d i i r k g m o s n f a i t d c . 0 o l t i h y n s t b y n t l a 1 h u , o i h u e i g s n f 1 f l o f n o o e n e o o n c t , a ; d f r p r e i 5 r e r f z s t i t o r m o r b n 2 i u s p a w o d e l p f o l s : t l r c e t l 1 n s e o a h i e , n i h c e t o – e w c m a e a e g i a r e 3 n n n o d b i a n n m 8 l e a t i o l n w g m o b d , . c a l g : i ( e n e a c i u t o r t Ͼ n i i e e e l o t z r l e e n d k n a a 2 e * l t y t t 9 , i o h o ; 5 n
6.14 Skin, soft-tissue, and bone infections 6.14 Skin, soft-tissue, and bone infections • • I • I * R i 9 • M T • • S • • • M • • • • • • * * n f f i R E 6 c p p s A C g P C O T M C H [ O E O P 2 R c A [ O s T I P [ O p o B A A a O n C C C l V r k E e a a a . I e r n L i i e u u v v i o e l U x n j D R R R R e p p a s i D m w e i i i t c n r t t o t o E p p p n U A t 1 c d a f n a f a T t e e t i i n e i p c a e e d t a E e b r e i o i e r r r c e O u T s R 4 S p d d i s r r g o t a o o o z o c n n a e i r a n c c R r i i a l i M 6 e o f R l d E t o o t n C a e f f f y t t l t n m e f k O v f t o i i c i i l l l n A t o d l l ) e l n e i n o o o l l m l , u o s l u r a a i d E i i M n ( i o N I i e c n l r y i T r n s n w n x x x N o l s o i p t t a 1 s d s f N i f d m c u / E t n e e a a a d E r n c r t 1 r i . z u r r s r F - o t c i t o h r / o c c c 2 t f T a n e i i n i u f h o a l g 1 s s p r o o E o t m t l e I 1 q i i i g q m c u o t g i N z a n n n a l k k e 4 l r n 6 f g e N l r C u i u r o o o n * * * t n z a r g y I 6 t o F 0 M i u i f f a V i 3 r O y n n i o o T b 5 a h I n o o p c d V t o s ) E 0 5 4 4 o Q i e r n b R a o i I 0 n i r r y z Q a T c z e m q n O y 0 0 0 C l Q , c a u l S a 2 o 0 m z o i M M E o f . 8 u s n 0 0 0 t N c r o a a o T t o 4 n 4 A n n i a h S g i H s g R R n m t s p o l n e l I s H H S e l m o m m m a e i O o o s S S n p t n s u f s I g m u h a V w e l g r g g g 5 A A N l o l t o s 4 i o s s d i n I a i , 0 n n Q V n ) S h r 4 c P I I a ( . s V V t s e a 5 0 b p g o o i i 8 c m p . i O o i Q e n s d 5 t a e m r Q Q h a H g i m n [ f e d e 8 s t C B e i t c 8 8 g i n n e t n i e H a I g c a e o u l I i V V a H H i D n t n n n p I t o b n r a r V P i I t m o r d d Q o V a r t p o r n O O s O e s o L f a Q t n / a v c 6 s a n i R R i R w w U n P v m e e t w o 6 u n H t w i a f S n O e h ) e A A m b a C e H h y p s i t o d n t g a z z c c o s r i V c y h T p t P o t t c e t i w s b a u c n r r I i w r w l u L D o M m e e o o n a l i e a n w t 6 U h e u o o ] c s f n e R r e r l o s r 0 h e n n S o o t e g S e n o s f o a a 0 d x m e d w a t o A u V m m o a d r i c a n s p o a e y s m e c n i r h c n e p r n l h g i t 2 2 e i e g n o t t h i c a l o n i y y h c * m u e o s s g g s o , I e u V l ( m e e m p d n e 4 s v m l I I t v s V V i a e Q n 0 u t y i t e a a n s s e h c r c 8 0 a Q Q r s e l c c e e o i i s H t d z n 8 8 l u m h m o l u n r a y o / l o H H e a ( d a s u t 3 g s s u i s t i ] ] u r t a e l o e i 0 l p t u n . l d P P s I a p n t e V a w 0 l g a o L L t n a t s > t o d Q U U i d t m s i e n . o i o u / e S S 1 e n o n g n s o n c t 2 t . d i s r t t n P H s i o g O . ] n , m r • M • I E S R • • • • • D I • • • • D • • • • D n e e M u S i u C b I b n p C i E O N C B d U m o P C P a C O C d D M L o O e f p i f a n n e c e A r r e n i o e a e e f f d x u l l i l e h u o h e u e x v f k P R R g R a r a o c e g r a c e t g e p y b t t t s G i s a a r l a o r l f n c e n a c o i t e p t I l I a a n r a n o a c b t s t i u i o a o r R d u u a c n s l r l i t t n c e i i i r c - - v b s y d o i z t n t s i o i l i h h a o t o s r d f g l e i i d o i v e p I i e e m l d y i a o t t e i f o i s l C e e s s r v u e p n n q n e c : e e - i o i d l t m o d e s t n o l s l i e n l i t i m m r o P e i e r i d f i u s s s c i - l n n s e s r e s o w a o c t o T o s u f e n w 1 s a o e s o o r t r s o o c s o o u b r i f 1 g R - l r o i o t s d e u t t n m f – c o f i u o t l l h e s c l e o i t r c e o y y s d c u u n o n y e 2 f E t h e e p t l a , g i s o a c t t h h r g i l d n e r e s s t b o s t r t i i ) A o r r h a o a e g o i c c e o , h g l i d i x r o a e g o I l e s u a d o n ( T d w l V o ( a p s m i e u p c s n G n m G n e s s a s t i u n r I r d t a o M f e a n l V o i h g s g e Q o m t t i d k t N y l e d P o b n w o i o n i c d n r r e r i s t s r , g i r e t t E e e p 8 Q C c n o g R i n d e e n t e i b r i h e o l t t r c i v s o o p p w e g d i N m s n H a t ) n r ) h 4 n e c e e d n t e r , u a c i n t t n i i , r e s i t o d a o H l b c a T o o a n f e p e p o D g l p p t b o : w a d u n w u e g a w n c n c c o n p a r o o e r o a i o n m n i c e p o s h a d n l o o o o i s t t l o k u r t r l n d y s w d m t e e l h i l o i c c b n i t r o i u d i e . n e o u f x p o o d p f ( t l h s c c e o s f d n p n o e n i a h S r e s e r n n p m e e t i i i g p d r d g r t e n o f f r e , , s c i t d g S p c t n o r a e e i t o t v e y o r o s e S E c d o c i o e N i o o I o o a c , i f n P h d o p w l s r a ) o n e . a c , n n r t i e i m O b a o t c s d f a f l t - u e . r d a i d e h e s e i i t r e g e r e u l c d t n s T C t s p h u e o y o o p e o x d i h r f l e u e o f , e l l e r d b o b s i u p y t a t a e m e r n u a i e d . n n b E h n l e e r l b i s o c c i t l d c r b u t t I o t i a r y f n y u p n c d d a t r e t i s r e e i e s . s e m f i n e e e d t b a r o G c s e e u a c s e q . e f I i l a d e : p c m f t n m r i r t n o P o t r t u s s e r e t t a m ( i i u o f i b d t d o n e e C u e s a e t e m r D e c h s b a o a t i i l d a n . . e t n c i a t c n h t e u o g s e b a a e n s y s t u n c t t c e e a r e w . c l n i e 2 n . r t e a e o s e r o r c l d e . m d t 0 o d l i , n n . u y n t a e c f a s o 1 r h e i a t r f o e G r a a n r t , 2 p i o f g c d n i b h e d a n a ; N v o a r a i p . h t 5 i o s c n c a o a i l n n b R e b 4 r o A p y p a t e l t s o i a : i l e i m , s i v t o l e b b p 1 o a c c c i e t o e i a n d 3 e i e t s u n t e i e o r g c i i o s n s 2 i c , o : l d t o c d t a p r u e a - e u i 1 b o a f o m c u r n r i s r e c o j d 7 e e t o e b a r s v a w p r h h r y 3 e e r s s e i : n o i n ï r e e a o e . a s v d . e n d o S b t t l d r l b e ) b , e h i n t c e t . i i p : G b t i e t o m c w e s s a e . r i r n r d n e u i c a G a a w t g u s h r t ( y p m r 7 e i i r e o t a y n e a u h – - n . n m o s s 9 1 c , n , - 7 e 0 -
6.14 Skin, soft-tissue, and bone infections 6.14 Skin, soft-tissue, and bone infections • I t • P • o E • 9 • • M T • s • n P • • D n r e o r a a R x e 8 e S O p N O I P O ( I O M [ 5 P E P ( F F T G f o i V n v s C s t t t c a e c r E o o e r r C i C 0 i i e p I o e v R R e R R e e p e e e • • • • • • s / e t i r t e c Q l l p p A v o e h 0 r n N N l l a e e t G o e n n a e s o o e t p e r d A G O C S S r a T 1 d l - p t t t r v i e v b s o o U w w f l m d d o r s s t a a a n a r t t y o r M r 2 e e a e n e a e n i i f r a w y g a o o y i i a l l n c o o l a n r e n n m t l l H g o n t s s v i o i n p e e s m a d e E s s r l e i i P s n g l e g g p l e o c t l n o g ] a x h o r r l ) i i n l e n a h r I N i C n n m u y : g g r t V t - i n a c r o P e y f n g i e o c c z n a b e g g s l o y y N S / E c o T l t a b a i L e M o t c l l o c Q r y l m s e e : : t 1 l l i P r n a s o l i e U g s s n a l l r o c o n a e N t 8 R a a o [ C o e p p C w a s s e e a z C a S o c g f b l v n n 4 S H w - t l r l h d O o c c 5 p t N n e i i c c i r i h ( a o o - t n i p 0 z A e c C c I - o t t p v b i e e h 0 r i c V s a T ± b c d i i n l , i r g n o 0 e o a o o n a r v a n g l u p 0 r o s o i e E a o o g g o y n Q n l n d g n n d e e c s a l V e u f r d v m m e S r c : r d u t s l , , m w - o t m m 2 t a c o s e o a s c u f r a a e i s V i a w p p d g v y a g d n t p 4 a x p m u r o g m u d a m r e e c . . e s s c 1 i e a v y r e p e H u t r n I u n e i i n c s V e 1 1 h : o I e c r c n n c y m s V r c 3 t g A , i o i t i m u C 4 4 a c t e t a i o C t n n / Q o t . 6 e r a o u s t i s i 3 6 6 P e I r m a ( u n l s m y e V d 8 g 0 p o 5 e t b f 7 ) ) O n m c M ( d ) e h r s s H 0 6 ( 0 s g n i y Q t ( 5 i s a n y p t p n i i t R c o 0 r 0 Q a f b r e a e f 2 m a O l o i e i t o i S g n 0 m i h ( n e d 8 n t e 4 o s t m s c R r c d h g A a e t i H n t s e i I H e a i ( m s i o c a V a r i s b g d t A c c e I d s u r a c r V c l e 1 s i g l s Q o z v o u y b w y P l c o p p d e t e n Q s t s a 6 g I a i O r a n o p o w i r V s p t c e e d n 8 t H o t r a f . s t I i e s a e o q o d B V Q t H t c m i G i h n s m c i n n u ± s I m a 8 p e D g Q i g I t a e i i t / e t n n i e e r H d e y n e , V m n G 8 e a a g O a d t n u a a t p i s H r i U t m o r : e n R t n e r l s . s 2 e l y i f y V f c e o c d e P e e t 1 n e - C s a o r o o g n s o c c L t c 4 a p u o n i l ) n n m t p t o U t o c ( 6 I r i r c i f i s G s V o o g r g o o r S t y ) o o e s e s n n I e n y c c Q / M ( m u t f t ) , ) M i s r e G l , i f p r o 8 n y i R p y g d n < e h U s r x H . c S f u o o e a t h a e r ] i 1 r 7 A r p r c n r o c o c e y d P 4 e r 2 u i n t s s n o w L i d 6 a l o i u d c h d U ( u n a 4 ) n s e e o a r d S r b P 0 , p n e d e u z e L 0 1 e t s o r u r U s c ) – r y l m e e ) t S 2 e o s g d f , ) • R • • • P C T • E I D A T • • • O • • • • • • • D S i R H M y N E o t s C t [ ( G R p I C S V a M T t P f I D a S p S G H O e n n C 1 a h a h s o r k E E a n l n B e . a e . u e T l l i e e r j f o P r R a s e z a h i o s 0 e e i e o m d n n r p t v A c 1 p S v e a n i R I f n n o c n y t o I s i c c – r B o c c d u a e e e R e o r e e T u p 4 E e y i s b t t u I e y t 2 o i t p o c a a u n r I D o n r m r r n t r r i e M . 1 I f i a l O o n e o i f e o i y a 0 f C a t d m r m e t t A s s d t r l i E A o c ) s e t n a o c u s d n l i a r T % ] E . , ( a P i l o R o i a t r y y a y M w s x i s i s T v n P w n a s u I a d f g s N t C f ) , c c d l n l s C a E r o f s i i R t m n l L a r m e t E o t s i e c i i e m N e c a e r f T t n c n o u h h S i r U o e E h g m c o n S m N s i e l a e o g a o i n y 3 n p r 6 ( S f t a b N l A s e U m t s A o h n t f s e i T o p p t o e . l 0 e u M 4 a T m e l 3 y t O n o 3 c o R e S d n R C ! e i - a n s r 0 0 p e M i t t t c x c R e c e n 7 m r S i z r G T l s e E e m h i c i g i - o 0 t o k o o o u c p n 9 S s a 5 d I E a e E n I s y t ( a e n r c r o d m n u t t s C O 0 A c o e t n m S o s N t h : i b g s n c s s o n a u c e 0 n s d A A i N m s V i l n u a e t m g T c n a o e e l i s s m I h i L l n a L V g l l s t L m u u l o f i t s o s o o y L o g a I n o ( Y e m a l V i s n u i i a E Q – ) h c f n g r n c n t t n d y e t i l s i e u y o o i n d y M v Q o V s A h 6 f i n C d s e n I o p b ( e s f o m r r , V a j e m H 3 8 N e h u f l c e E 6 n h e l o c b n p e c v c - H o e Q t f n y e y 8 R 0 c s O y u c a t e a i a a A t u o c s c c i 8 t 0 o e o 0 r t n s m G ± d R o l M n r i i n D i r r d t n c d m H o r n c 2 - i o e e n 9 , E d d e a R J C i T i t n 6 s q n s c ( h a w y i p 0 s o N n l o s a U S u e t i m ) a u u c w . s t e 0 e o b s b C f A N . ( a l v s p i s l 1 e x n e h i u r n i i a e t t u p t r m I c a C a p o h i 4 n e i E o e c s i s d p r m m s r t i d l u 6 g T l u m S g y c ) h M o o o . l l s o t ) n y d . e n e ! r s n b ( e I t e T R V e c w o P o r i e b i g r r i n b e O S s i o t f 1 L y e e t n e Q g a e w a a p i A U l i d ) d z n c o t P 8 e ( g t . o s m s e S d i i g a x H l J C h R n u e e i d I i t p d o V a c y o [ n c . y e g O P l j h n a w s d o u t p Q i i M n a d t p p s o n f r i e e t 8 s g e a o i e c n h t r P d e d H e s a s t f r , H x r i d T a i d l c v b ] n p i i b o p z n e c e e P i g . o a l p a g i i b o c l t L 1 s a l t t k e r s i i r h i a n U s n i o i 4 e n e d n n u / t ) S n d t 6 s c s e e i s o b ) t ) m c e > e H i i o o d P r v 2 e o t o n e t L e h i n t s , c b U w n e i t z p s r S e i i i i . n d f t e a g 9 e k l 9 s
6.14 Skin, soft-tissue, and bone infections 6.14 Skin, soft-tissue, and bone infections 1 I R • • D • • • F • • • g N • M T • s • E o D V e y b i a R M 0 S i O v f G M a C b C T T s s C C S O C V G N G e i f m a a t e c s A e y y E u u 0 a b e a e a a T i e r r r a r T P R g a r s • • • • • • p c r p p n r r p a a a n e s e g A i v t n s f r i c g g E o n I n r i e n n s e e e m c m m t r e u e n R A P P F P R e T i o t i e o i i o c b : b t o i c t p i o o c c n b i r d s n t a a u i f i a M 2 1 e n I d - - - r m s w e a e i i I i s l s n n p e C a a t m s e t t i e n m : r o o i d w k n o n l r n i i e e l l o i a i f – – E e s s p P x s d n l i i n t y o o a f d n e i e i g o g T s f o h t e n a n t h l o c N C i c a G P o r f h b f g h f x s i s a a g R e t u t c i a r f t a 2 o d i c g N e s f T o p s e h t n i s r t i G t t t r t f i y c n v E s h i r o i t i n s o e h s e o a r l l s s v v g e o e y o r a o u c e ( s a v N r A t u d i n p c p h e l e s a a m 4 p d r r i l r e f i u e l S p n t i T c I c e h y e l e i m s a p O t V e t n i 0 c n r r p o S o d n i i e – o a o l e M t e o o s c p A a r b h t T s 0 v T r - i g m e v Q r g c c s o i r d r d o l I g o e o a g u d e c E E : x i o w t c a s o y n 8 n m c s s p a r s c f n a a e y o C a r S b N : t i s c y e o i o H o n e h s r i b i t l u s e ( i g i n a i i s t V c w n e u h n n F f r a t T r d s ] i o i s a l f i l d a n p a a t m p o b l l i s a k f i I t I e c ~ d i 7 n t V t g s e n o l h r o o t f i u u i i n h c i f d n t o o n ) i r o 5 d c 1 e c e n s a n e r b s d o Q d o f s d t c c n t o i t % , e g 0 b r n p t i s m h i e p c e m t t c 8 u e o i a a c m c e n y o e % i d e i D c u d r c s c n m b i c H u o t o p c n e r a i t l i c y i c i t , p s c e t l ’ s o f o i a s u r r s f t s i i o u c e o o C e a o o u h i “ t k 2 n n c r n i e r e i s n d l g m n , e p r r y n s m l T 0 e s a t i s u e r s , w i t i s a a i . r c 0 s b l e s s . i l m i ( , e . i w p s r i i n 5 s s l s h h s t c e u d i e d r n i . o g ; e e , e u w i a s a t s n e s t o i 4 d r 1 r e h n n m c l o e i c u a s e ( f w m 1 i i : 4 f a b h a t e l t t p t a d n i p : t s y e n i r l y 1 u 6 g s i n t u n e o i o n l u - r d p h i 3 e l d a . t ) n n n a l ” s a s n a 7 i o s i s o u s i ± n s e m s i p t g v p e 3 n t s e t g u s r r o e e i – a u g [ a c o o a t c r a s C r 4 f n b s i g i j c b c s o o o l t s 0 s e a i e y i e a l n n 6 a r e i i a f b t o t p r i s l t s e . t c t y y s b r i n e e y a , i s , s t i d c a , s d i n o s t o o S 1 e e m x . c t d r t n r o M r s . r o D e n e a o o , s i x s n a s R e O s t p b d p i i e u i c g o S c s o t e g e . r o N n r r 2 n e A a s r e 1 o c s a O u b i p n t 4 s t g o s t s y o i p e a T e h z 6 t c n e n r r Q o i c ) n a a d t e d a u o 1 i g ± l i e r l n l y a c 2 d a l h s a n a n H i y b g d n h c e h O a e b , v ) R e e R • M • • • • • • • • S • • D S • e p p u a O m M s E I h E D a i o a p P o S t A I s g M V E a f i i n f n r n n e a h h r n n n e a s p m e m l a p u e i b n s a a b l o r R o s a r p o o t d t e r t r t t n r i l l a t t p d a l i i s d c e p I r i i e g t t n a o b b t e e a a u u e m e t e b i w a t i s w u g u o c i c r p p m i b i t r l l o i i o n r c g n b d d o o i e t y i s r i i i i i m u a d a e e c i d d i n d i z t n a a s t l r e e e t t m s s i r l u u l i t h n m b b e t i i : t a a l t l l e y G c c w n n n i y r r r y c i o t e e p l r a a t s e a e a c t t t , s m r u h e i l o n t t l l o r s n t h y b s l a v o h h h c s o m i e l o a a e n t w t s o e a m s s w n e e b b u r p a i o a u b q d r m s t t e n u n a c i e s s a t r r r r l r t e u u t t o - i a r g n a l o c c d t q d e a a e a h s t p ( d r o i t a h c e s e e e r g i p p u w u s s e s i h n y c n e m s e s s h o . g h s s i e e y y i e o o g a a s s r e n t d a a i i f a . a n e o m ; s y : : t f r l . f d w d a r r i t t s v e e s e N Q r a e I d i c i r b l e c r D m p m v e e p i o e c l f f r t u o w i t l e o x i E J o r t n n e t h i o n n t q h o g n e e e n f i f t n i n a t M r e s c o v r o e o o c e e u a g n . r f s e s r e g o o u e u e G o l d u i n l l i ± e u l r m c u q t i n d o t a s l f r J v m s s e c o r v l l o r c t u t e e w t p e t a o i i M 2 e a o e a r n v i a d m e a u e s r v r m r p i 0 s y m r d t e e n i a t s e u i l g n m e u t i d 0 s i t t i d o p i g d g o r s e u b t a p i e i i 8 e a g s n n n n l C p 2 u e c n e r o e e l a n ; a f t n g e e f 1 h i 0 r o o T n p a t m r e m s t i s s d w r a s 0 s c i 0 i ) i t m r i o g r s y m c c h . e n l 1 g , 6 o y e a i , p e p r n o t h t a s C a : p ; e u E n e s c h n i e a a 1 3 a s r o l u d b y T l r o i e s c o y o t S n a – n 5 i d s t l n o i e t h d s - i n i 1 n f o d v l n 5 d i r R g m d e e , c o q m s o c e 2 f t e I m d : b n e d u , e V a a r n : 2 p u e d c . e c r e i e t i r s c 0 a g t s a r 4 a s m s d u s n o n e a c i e o e 1 t o n e t e u g s u l e – t e m d u n i t e - e 2 f w o s d . n s r : d v u e d 6 e r o t g – n c u e e . m r i i r 6 i r o d b n f C t 2 e o d e e f e a h s d w r h – o f l 0 i n n e t r r R s e s e s o o s o e e 1 r . d a y i t e e n . n p p d P o t i u e b c b l 2 i i u p u G d i s o c i m t p r s k e s r f i r p r i e e o s a r n o d a i w a o s s u . n a e r d r a ; t s p r l u t i p l i a e i e m g o o i . s o e t a s e r c p r p c h e a n g r e n y b y n i - a r o t e r k n i l s i / t t h s e f c c t t a s m s s e o i a a . r i c r c s u e n e a g o b s f w e s a m m s n u d c p a u s i n s d t i t n v t / t c g t i e a s s s t h r e e i c o i v e t r n a n h , c c t a w r t d e s f d o t t i s i o i e o n i h n i s s i o e a u p t r c - c n e g i / h o b n d t o i t , e r n i e d n t o a s s e t h t s s o n p i 1 e . e g . s y s 0 n . , i s 1 s
6.14 Skin, soft-tissue, and bone infections s n Bacterial urinary tract infections (UTI) o i t c
e Management of patients WITHOUT a urinary catheter f n i NOTE: Ciprofloxacin is not recommended for empiric treatment for t c in-patients with non-catheter associated UTI at JHH due to the low rate of a r t E. coli susceptibility (67%). y r a Category Definition Empiric treatment n i r Asymptomatic Positive urine culture No treatment unless the patient is: U bacteriuria Ն 100,000 colonies • Pregnant 5
1 with no signs or • About to undergo a urologic procedure .
6 symptoms • Post renal transplant • Neutropenic NOTE: obtaining routine cultures in Antibiotics do not decrease asymptomatic asymptomatic patients bacteriuria or prevent subsequent development of is not recommended UTI Acute cystitis Signs and symptoms Uncomplicated: female, no urologic abnormalities, (e.g. dysuria, urgency no stones, no catheter frequency, suprapubic • Cephalexin 500 mg PO Q6H for 7 days pain) OR AND pyuria (>5–10 • Cefpodoxime 100 mg PO Q12H for 7 days WBC/hpf ) OR AND positive urine • Nitrofurantoin (Macrobid®) 100 mg PO Q12H for culture Ն100,000 5 days (do NOT use in patients with colonies CrCl <50 ml/min) OR • TMP/SMX 1 DS tab PO Q12H for 3 days Complicated: male gender, possible stones, urologic abnormalities, pregnancy Same regimens as above except duration is 7–14 days Acute Signs and symptoms • Ceftriaxone 1 g IV Q24H pyelonephritis (e.g. fever, flank pain) OR AND pyuria • Ertapenem 1 g IV Q24H (if history of ESBL) AND positive urine OR culture Ն100,000 • PCN allergy: Aztreonam 1 g IV Q8H OR colonies Gentamicin (see dosing section, p. 141) Many patients will have • Duration: 7–14 days other evidence of Hospitalized > 48H upper tract disease • Cefepime 1 g IV Q8H (i.e. leukocytosis, WBC OR casts, or abnormali- • PCN allergy: Aztreonam 1 g IV Q8H OR ties upon imaging) Gentamicin (see dosing section, p. 141) • Duration: 7–14 days Oral step-down therapy if organism susceptible • Ciprofloxacin 500 mg PO Q12H for 7 days • TMP/SMX 1 DS PO Q12H for 14 days Urosepsis SIRS with urinary • Cefepime 1 g IV Q8H source of infection OR • PCN allergy: Aztreonam 1 g IV Q8H ± Gentamicin (see dosing section, p. 141) • Duration: 7–14 days
102 • • S D • d o a I s • T • • • n h n r r R p I t U c U P w p F c w 4 p T c s r S U a A o t e e e o E y o o y o i y r h y 0 e i r r r i i s • • • • u r n G s c e t t b m i s u u l e n n i A i p e % n h h e l l a n p n i m d o t D P M c o u I t s a t r N r t c m r T f a p p i i a g p i e o - i e a p i m r n e o t a d w r y a e 5 i a g l e U o M • • • O o n t i i t p e x e r y n d u . t n s s n l i i n > o n - 0 n e s a e y o p c a c / s t s p u e n s r t y , S e i B N L 1 t E i m n t b o A m b v 2 a % i a t s t f t i u p r e e i m o a o e d s f a i c i I t i 0 i t a c N m a p a p c e t i 7 o t c a S b r h l e s f u e f i s h c l r t u l ( o s t 5 g p a i t a s t a o a b k n s e e r i . m e T n k n i o u o c t / i s e t W n r t n l i p o t u n e t t y e n o r n l s i T u i g y o o m f r s o i h e a e t o w l n s r s n d r N t d o B s e c c t o e l m h e i e . m r f t i h c f t n r e e s i a n s a i i g r r e i y a n C u n i e e t t O s n o o i u e t t e c n t t l n p : h e t c a r n a s g i c . c h y : d / t a o n u r e r o o e t s d w T s r p t d h l t t d m i a o - . e u k u p i S f s o w n i o n i , t h e f i s s r e E v e c o c p d e e l n y w e i a m e : n t t i s s c h e i a t u s o c a m S t c u y e h s u r n u s s n s y b c i h o u T s t r m r t r t . s c r a i : e r f a e e e m i t i e o h g d a e s o i u o y h f t e n i u a U t p t n r r i t b l c s e a m n l v e h r u i s p a i p a b o c t . l c d o c a t T t i e i t i , n r e r e l o s p t a o a n y m u a e n t e p y I u o i o i N i t 3 r e n u o y c t g s n r t r : e s w s r t r e r m i h o e e u e t o t % i e m t c O n i a u i r i i e s i a o h o f n s U r o l n m t s t a i l r r - T i s r z n s e s h d f 9 f a b n c / . e i t h ( i m w a a a a ) a r i r U i , a t o A % n c l b s a c w . a a e m r t t h c p / u c l e i i v a u i e e i n l l h n u d o y a c i e t A o e s i a g t c s p a d o a k e n o e e n r a c t t s ) u h u a l t b o e r r Ն u h n e s . c i m i t a p s i e a a b t s t c a a n e i l t i S i q o o r o e o w n a l 1 v v e s s y g c e l e n u o y w u n p e n s d e s t h 0 h t n o s e a i i r n w e l a e t o n e r i 0 r y t c h i ( t h t m u u n n e l r e c e t r e u o e r u , u a o o r r g i d e e w d e 0 q i . u l s m e r i c i l m t d g u p b e n t n r a i 0 r u t a n n u o 9 p r l a e l n e e t . i e d e d o i 0 a r o b a r o l i % r r r e r o o n e y r i n o e l e u e a n e p c c y a r b , n i c n s - s d s s t t s o a 2 t u u a s n y e s o s e i c e n e l n a n l i l u 7 t c l c u s n h t t l d o o r y c o ) e r e u c f u s % o p s : e o i a e o t l o g s n d l r a r l u l t t l r l y > n e e l e e r u h l o i r h i a s s t l l e e i t t i a e c f r 5 n n o s k g t : i e i p V w o s c b e a i o n t l t e u – n f i u e R 1 e s r t w o i a l o a u e o o l l 1 e b t y d m d E % n t r t b l m o d o h f m t 0 d h i m i c e l n b - i c e m a o m e e a n 5 e w a p W u e g s e r a n n n y % e u h i a i s n p o s i d d t i B a , t r n n r n i h t b a p i o n s i t i n i C . n d t r n e t i t g r r a t i g e e i I / r s h e a f n e h n a e t n 1 o p a a i o t r m f l 0 s n 3 ,
6.15 Urinary tract infections 6.15 Urinary tract infections • S ( a C b 1 • S D A C M c I • • c • • S a b n C s a s a n a a a a y p y 0 t A I s N P A N c p C P d c y t a t e t A t t g m m h e - o m e t 4 i l U h h r i c y o V e e e b i r n a e c . g e c G n T e e p u p r u p p s t A w w i i g o a i a I i s e i o I t u r t t m n t c ) r i N t t o r t r t n e e e i e r e o o g t e t y - a i a m f o i i v o e a p r r n e O d e t c m m e : l h n e a a n s c a n v s p b U s I t S m e s t s s d i n i t e e s o e u i T c c e c i m o a : I e e r I . r f c r e S t e t o o r n o C i r n h t a o e o n n n n f l d c r N s i c c A W o a c s a r w Ն A ( S i P r t e l a n s u t f o e a r e o m e e s y o e l s o o u o r e N N o s i e u t O s i f s B g t g s u t m r f n o y l c u l l m v 1 p s r s h f h o y t D D r o o l t c T n t C p i a w m c i l o o i u e r r i i o a 0 t i t a i n r p s r m n n g t e c m E s n m r a u n / r t h r i h a i o p p i n e d 0 f p t o y i i r v . g e e e , : u h o t e o a t l o r a o k o y e w a t e D t i t l t p , s e h e p n n o s v l c T m i f o p 0 m n u e Ն i c t n r u s e s b i s a e l p c e g e f i t r b o t u : d m r s a u ; u 0 o i h ) i ( d r h o l a t s c i o f 1 a g i l s s r t u , n o t l a z i e n e p 0 s i T s r n e a t i v a h s . i m n e n , m t n w n n e t n u o c i u e m a i n 0 e i : t y e k i ( h n g b s e i t n e i o c ) r n f i Ͼ w p t m t p a s m e 0 d c g e i e e n i Ն i a i e a o u t m n r o e i g a o ) c p o t 0 b n s i l 5 h e i a r l p n p t f l o g n r t i n o o u p l t y i f t i o a c n i u p – s a n t h c a i e h w t c a e l n t n o 1 n s s f d t s a 1 u e i a r t e e c i u i s n r m t i s t e e b o i i C 0 n e t , a r t C s m r n s n m e , i s 0 d i i e e t n o s e c W p A e c c A a o t c p , n 0 ( n s e y U e - h c - t a U e l s U 0 I t h e c n T / a s t l a o T v T e h t i i A t • d P • U • • P • • b A • • d N • • • • • R m c H q m h f I i u h r e I c i i a n a a e ) T o o s s u a I R C e E O O ( C O C O D D N P P A P i p s e f a c t a e t t t m n I p s e e a x r e b o C r i l i i i e a e e r e u u e t d R R R R t c v b u e e p o y t n e t n c p a a g r o l e m o o s n f f r r u N e a o , a r e n n i r e i u g a e t s s o d a a n o . r l t s o v u , t u y r p d i t u t t u a r o i e e p n r N t t s d r t l i e h u i t a f r c e U a i i l o s r s t i p e s s v l : , d u a i i o o m e y r c e o r l w m m a c t n x u p l e t e o t O h r n i i o n s n n o e y r s t i e x a a h n o e e ( e e v e r e n t e l i i a : : u o r r m a u c b e s a n Ն t n : m d e i T u g n r n o l t n c s s h p s a h l a u r 1 e u o c n r e o i y e t c r t r c i e e f t e i o r e n t r d l 1 : e a f g o E h r k a e u 1 n e e d q 2 g p a l n w s r s e y m A e t b 5 n m y g r u g n r o o p c o g h r i b b d g t h I t e z l t 0 t i b n i s g V e o t w e i e e n y l u e m h p e e t t v l I o o a p 0 c v o s , a o r I V r o e t d p l l e i l V Q s e e e o o n n l e i r s t l u e w l e a a n w t i n m o a i i u Q o r t c z 8 o w w d e t Q d h c c c n l s t i t s n t h e h d n y t t , r H 2 g h u r t k e e 2 a e r h e s e h e d a t e e e c 4 r n a r a s v s 4 u a r P r l n m o b a e o e e H i Ͼ ) o p b w p n n ) H O d U s l u v n e a s p o , s d a t e e r t 1 i 4 s r o n t d g T o e B e a e t r n m i i 8 c i c s e a i d e q n i g e I I u c c l t n D r f s t n s o e o u e e n p e e H r s r e i I y c p r e b t V n o l c o p r d : l y m l e r o r n a l e t o r c i r a m o e e n s m Q f t e p b c o b t c o 4 c : a u 8 i d t l s f e e e 0 t p a a l o p t H e t e l e n u d 0 e i m h p s t t v r v t p t u d e o v c e e s e e h m e a p r a r l m e t o t e d e w b t g w i i t i c o p r o r e s i i I o m a t n t n t V h f . r c h n o e a a Q t c n p l r t 1 o t t t e r h h n 2 i o o e e e H f r DURATION s n o i
The duration of treatment has not been well studied for CA-UTI and t c e
optimal duration is not known. f n • 7 days if prompt resolution of symptoms i t c
• 10–14 days if delayed response a r • 3 days if catheter removed in female patient Յ 65 years with lower t y r
tract infection. a n i r
TREATMENT NOTES U 5
• Remove the catheter whenever possible 1 .
• Replace catheters that have been in Ն 2 weeks if still indicated 6 • Prophylactic antibiotics at the time of catheter removal or replacement are NOT recommended due to low incidence of complications and concern for development of resistance. • Catheter irrigation should not be used routinely
Treatment of Enterococci • Almost all E. faecalis isolates are susceptible to Amoxicillin 500 mg PO TID OR Ampicillin 1 g IV Q6H and should be treated with these agents. For patients with PCN allergy: Nitrofurantoin ( Macrobid®) 100 mg PO Q12H (do NOT use in patients with CrCl < 50 mL/min). • E. faecium (often Vancomycin resistant) • Nitrofurantoin (Macrobid®) 100 mg PO Q12H if susceptible (do NOT use in patients with CrCl Ͻ 50 mL/min). • Tetracycline 500 mg PO Q6H if susceptible • Fosfomycin 3 g PO once (if female without catheter or catheter is removed; ask the micro lab for susceptibility) • Linezolid 600 mg PO BID OR Fosfomycin 3 g PO every 2–3 days (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%): Cefpodoxime, Linezolid (30%), Doxycycline (29–55%), Ceftriaxone, Tetracycline (~60%) Poor (<30%): Azithromycin, Clindamycin, Moxifloxacin, Oxacillin, Tigecycline, Micafungin, Posaconazole, Voriconazole
References: Pyuria and urinary catheters: Arch Int Med 2000;160(5):673-77. IDSA Guidelines for treatment of uncomplicated acute bacterial cystitis and pyelonephritis in women: Clin Infect Dis 1999;29:745. IDSA Guidelines for treatment of CA-UTI: Clin Infect Dis 2010;50:625–63.
105 t n Candidiasis in the non-neutropenic patient e i t a p Oropharyngeal disease (thrush) c i n
e Initial treatment p o • Clotrimazole 10 mg troche 5 times a day r t u OR e n
- • Nystatin suspension 500,000 units/5mL 4 times a day n o n Recurrent or intractable disease e
h • Fluconazole 100–200 mg PO once daily t n i Duration: 5–10 days s i s a NOTE: If refractory to Fluconazole consider fungal culture and i d i susceptibilities d n a
C Esophageal candidiasis 6 1
. Initial treatment 6 • Fluconazole 200–400 mg IV/PO once daily Duration: 14-–21 days Relapse • Fluconazole 400–800 mg IV/PO once daily Refractory to Fluconazole 800 mg daily (fungal culture and susceptibilities are recommended) • Micafungin 150 mg IV once daily OR • Amphotericin B 0.3–0.7 mg/kg IV once daily OR • Oral therapy: Itraconazole oral solution 200 mg daily Duration: 14–21 days
Candiduria • Urinary catheter removal will resolve the candiduria in 40% of cases. TREATMENT Asymptomatic cystitis • Therapy not usually indicated • Consider in the following conditions (see regimens under “symptomatic cystitis”): • Neutropenic patients • Renal transplant • Urinary obstruction or abnormal GU tract • When recovered in urine prior to urologic procedures • When recovered in urine prior to surgery to implant hardware (joints, valves, etc.) 106 • • T • F • N P • F D • P S • • I C D • D s P u D • R • • • n p l l r r r e R y y u u i u u u u a O r F 6 F p t A T M A F A M M F R A O o t e e r i c e m e c i c E s l l r r r r l l n a h e m m m m g e a f f u u u u T R i i i O u c m o a o a a a e e c c c s l e t a d A l m e c c c c o E p r i o B p p p r r n n u a a o t t t t e R r T d n T r i o o o o o r r n i i i i m : t a d o h h h a a e f f i e n n o o o o e e h i s o n n n n n u M u t e e p o o o z z v . C a n a t e d d n n n n a o m t a a a a n n m e o o x y p t t t t z h a r h E l m : : : : z z g z z g e e e c v t t l l a o s e h ( a t n e e o o o o o u a h h N r r r 7 1 1 1 i i > e a r p n n l e n r d s i i i - - r e f e e l l l l a t c c c r r – 4 4 – p e e e e T g y i ® d i i i e e r r n p c 1 t c 4 i i i d c n 1 7 t 2 n n n e a a i i , s s 2 1 2 1 a d d t a e n s 0 N a o 4 f . p p % d e i i c r V d a a B B B n o 5 0 n 0 5 s s i t 0 y O y y t p p o a y y d y e d r t t 0 0 0 0 d i b c a a 0 0 b y i s s s r y m c i t s T a s u p – d e r r i e n n l s . . m m m c t a y o a e E e a 4 a 5 3 e u g i t t l o s t o t d d a t t S r n g g 0 g - – h i o o t e i 0 n i n m d e s I e o a 0 e V 0 r r s s a e . I P P s e n g g V t 6 . h p i z p e / o O r 7 O t m 5 p n a a / s o o o y h r n m P o w n n t g e m w l g o Q r X c w e i i i h o O f i a s s g a r t e n , 7 e r g I i i i 1 m m s p r V / n t s l p o I 2 y h / h d t t k o / n t o o e r d n k r i H e g a P s s s o s i a r f a n c n g o s e i u u s O b n c l v s e e u I X s y n s s V i t - e o I a a b y n t s V e h a p p o d r 3 g n m r l e u o e b e a l e e e n a o a i a u n n t e t . p d c c c i u z n i r t l l n c a o n l y t t t e o r a r o y c o o e e e o l e n i n s l n l e y d t d d e m s p f e s e d i i , a e r n c e d o p s , o o a a e i c t a i n a n , l l a t i r r o b c y a l o n i i i c y t l c c l u o n c c y h d n t e a , t t m h o o e d i n n n P e d d o n n n a d m f o o o f f a r e r u i i 1 n y r r s i e p c e a l r m m - y 5 a s t r n i I b t n C i o c o 0 o d e e X n a p U m o n e d d o r h e m 7 n ) y d r o e c n a m . g t m a d t e z e r t a t a o a a s h a r y l c a l i e t e t w s r o t t i t e e . e e g e a s s r e r e i i i n e s z k o n t t e o f o n a X d u o t n r h s c t e 1 e e n 0 . a 7 l
6.16 Candidiasis in the non-neutropenic patient 6.16 Candidiasis in the non-neutropenic patient P b f P 1 V V m b F • C I • • C P • r • C O I • r • a • C P U T N F c f f o e e l l o o z o e e a a a a R 0 n t u u a a a a O i t Y C F t F M F M M M O e l c c s h o l r r h n l c h t t t t c c o s o E 8 l l l n n n n E c e e i i i i i i O o u e u u T l R i i i i e e s e e e e a c c o o e p c c c c w w h d d d d A i i A c c c l r u v v E u n n n n N o o a n n a a a a e i w a y , T i i i i S o o o s t e e l s t t t t n n t : d d d d t t a a T f f f f h e n s s s s c e o u h i n n n d d M u u u u e T a a s A z z M e a a a I e a i i D n e l a a a n n n n s z z w w s w a e o o a i M r s p p t m I E s l z z z m g g g g N o o h . h i a t g k a e , l l t r t h h h r r c e e e o o o N I i i i i e e o l l e p O s i i i r N l a n n n n l i o o o e e i n o o - a b A l l l a a s o c r u u s d y e e e s i T w t t s A o r r e f 1 1 1 1 i b s c a a a o f l h e h s c C d B u a t N s r 8 8 8 l l c p 0 0 0 a 0 r r r s e m r o r r e h o o g a n i e e e i L . e m 0 0 0 u a T t n a e s b r 0 0 0 0 e u i n n a O n m g a s . s t c 0 0 0 e t s n l N N c a g g n e b a d a p i l s c m m m m i O i p s b l d z e i f - - n d O O n e i t s m m m t t e a i n t e N o i r D c n e e i g g g g i t c a m p t T T a d a i d u c l d c g g g r r i E a e s n e t g t n m m e C I I I I s i o a a i c c e V V V V a n V t c s b n h s u I I I e r m l U t V V V e l l t s E e l t l a i i i a i i t y d o o o o i e s n n t a a o d / / / o s L o R s i i b i o u n n n n i i o i z z n T P P P n e s a c c n s w i e f c r n o o c c c c s F n i s U l b O O O t a a n i i c a b h n e e e e n i l l l e o t C e l l s e e u R t d f h l l o b o e e r d y y X X X t o o c . a d d d d E u i m u l t t t s f n M r e o l s h o g h h s s e a a a a t a 1 1 1 s , s s S o n e t t C e e a r i i i i l I t e a V l l l l C a p i h a a t e y y y y e H c a d d d s r r o v . d n F o b a . b b a a z o o o O e Յ m l d a i r r c r r l l 1 u p p s o t t e e s e s s e i a l h U l o c c b y y 7 i o l h a e e e s d t n e s e 8 o d d L o i a a d ) , i , , c t c i u s . c n u u D r n w a v s i m t a t t t s e b f t a a e e a h h h e n i a y a i c n v a a t N z l c z e e e d i m l n h s e t t n i y n t s o o g n n n o o t O c g p o e o y i e l V o l / u n e e e T t 4 4 4 d C C t r m o r n i t f a m a b e 0 h 0 0 s t r r a a o B s C o o L l e g l i e c h 0 0 0 e n n c t e n E n t c . a a r t o d d h a c o c F i a e ( b m m m g o u i P C n e i i l e f h n n d d u p i o l l n l d v r e N a a a O d g g g c e e y s s r a s e n z b A o m m t t N t o p n d I d I I a o i h a r d V V V s n n C y o S a s o e F l i i b / u / / m e a p a a t t I I s r i P l P P F e D S z a r ; r p s e y i b o o e i l O O O n o o o u H t a . E t p n e r r d c h g l o c t f r R e o i o e e t o o o h h r e o u r o . l E s e t C r s m o n a a n n e n s n e e T c e s D i c c c v v n s . t r e a d m f e u h o e e e e e e g i o k i d z s A s l i d c b t s - r e r o t t d d d s e u i , a c s e e n n l , a a a e s , n t l r d u o a i i i . e m o c l l l e s y y y b w i e r d l a . I e . F l . • • • D F c m F C F s A A T • • • C e I • F • • C • C • • D f p l l l l a c m R . m u u u u u o a a a t P s A ( 1 c a s l A F F M F F F M A O a u s p h e h c c c c l E y u r s l l l l l n n n n o y m m a m 4 p u s u u u u u e i R i i e . . p a o o o o n m c c s e d g n ; t d d d A s h i c c c c c s n t i h p B p o n n n n d c a a t v e s p i . t o a T i i i o o o o o . p t o i e h d d d h h a a a a o f f c e i a e o a n a n e s t n n n n n M u u t t v f i o o z z z z e a p y a a a n t t n o s t n i o o n a a a a a n n a a e s r i o o o o s t t n r t t i e E m d m e z z z z z g g e r e a l i i i e h t p l r l l l l u d o b c n w u e e e e o o o o o f o r N s e r r i i i a ; s a C a n n o e i n i l c o t i i - - - - n s p n e l l l l l p c c i r i i r s h e e e e e T t t a ® l n n i r i e e a p i i s l o s 1 1 i h h i i s n o o t o a B n n l s t t l s s 8 8 8 8 8 n i a t n e e e 0 0 N w 3 w a A n c r t p p h . n i i B B B d 0 0 0 0 0 r d d e n r r s s 0 0 r m a a O e o i e s a T m m b e n m t t s 0 0 0 0 0 i i l w r i a a t v i l i d 0 a t h u m m m y g i T s n p l i o s e e s h e o g s n n e r e . e m m m m m e s s E h i t d d 7 O e i i h g g r s t t d / s c g t e l a m o , l m S i i i g g g g g s i o t k o i p i i a a s o g n h m s s e s t t I I a p g V V v i c , i e o h t t t i n e h o o n I I I I I n z a n e e e o V V V V V g u t r e c r l t l l t o I o o i y h e i r a a n / / / / / V o m m / C c e n i i f l n n c a s s P P P P P c t t d e k A o e i d r e e o A u a c c n a o o l e h O O O O O i n g s m r f m o n m n e e n m l l n n f i a a B n g e c C a t c d I o t o X o X X p d V h t t o d d e ) p c a n e . e e i i l n n h t i d a n o c a a d t r h 1 1 1 d d o o p c c o i d t h e d g a i i v o l l e n a e e c t y y i i e m d d d M e s n a y t t b e c r m l e i c o d o o o i e s d d a i r l i e i a a t y c r h a i m i s s s a ) o a a p c n i i n g a i c a e e e d r n ( n i i r s s i a d e l l a i n a f i y y y , , , f a e o n i . u n i l n n o i I t t t p e i B c n d c l D n h h h c B y s s d a a g o / f e e e . e t p i e t n o i s n i n n n n a i n r a c e d o r c o t l t n 4 4 4 i t l f a l e h m n i o d h o t C 0 0 0 p a b n s n u e n e c p n t 0 0 0 l a g c n o r s a t a r n a t a e o a o r m m m n s c d w t e s r n d x n i o i o t g g g d i y d d i o t f a n m c n h a u a u t t o s I I I u s V V V v e i a r c i C t t s l o d a / / / t o h t ( t p u . e M P P P t r e c e o l i e e r p l p o r o O O O y r e I d r C . t a n m c a s o C 2 e o o o r s i h t x o n a a p 0 a e x ) n n n a i f p n l c c n c c c % o i n c d t s i d e e e e f t g h a i y i p o l d e i o c t . d d d n t f i a r l o s a a a g i a f n i n i i i o s p l l l 1 i t y y y s c r o y 0 a C 9 l .
6.16 Candidiasis in the non-neutropenic patient 6.16 Candidiasis in the non-neutropenic patient coadorpycnb osdrdi h ain a persistent has patient the if considered be Echocardiography can • exclude ophthalmologic to examination an have should Patients • until day other every or daily cultures blood have should Patients • highly is catheters venous central existing all of Removal • Non-pharmacologic management 110 required. likely Fluconazolesuppression is life-long then surgery for candidate a not is thepatient If cure. for component critical a considered replacement is valve recommended. Surgical is Surgery Cardiac and ID Consultation with Endocarditis Duration: mg/kg Flucytosine 25 ± daily once IV/PO mg/kg 400-800 Fluconazole • AmBisome • Q6H PO mg/kg Flucytosine 25 ± daily once IV mg/kg 1 Amphotericin B • therapyPreferred echinocandins with penetration, treatment vitreal and CNS poor to Due • Ophthalmology with conjunction in Management • Endophthalmitis Microbiology lent therapyAlternate addmao appropriate therapy. on candidemia controlled. is candidemia the discharge, once preferably to endophthalmitiscandidal prior cleared. is candidemia recommended. OQ6H PO recommended. NOT is OR 4– ® weeks 6 gk Voc al lctsn 5m/gP Q6H PO mg/kg Flucytosine 25 ± daily once IV mg/kg 5 00 0 8 • • N F • • • • N D • • P R • A • • • I D l e u l r S u o o t F F m t i o N w I C F S S r i ( O F p S M A A O e f c m s f r e o e e A l l l l r a n t t e m m u o u u . f o r o u u i u u R t r i r • • • • • • y c e e t a e c g m e n c t h s G p s s c n l h c c c c n l c u i o p B a r a n s s a t a e c e e c P t N I ( P F T c B M u o a a o o y o - r C o i s u C z c r m r t h e f i i n e n r o l e e e n t t a a d r s l e e o o n n n o o e u e u i n l o d u e o U o i o n t r o i t t p e p d p v d n l t t o s m s a a a a n a u c u n n o e i e s c a r a o d i i t s r t l s g t : e t e e t i i g m m : t z z z g n t e t o e e n d i d c o i t t i i p i d o e m b i r l a y b b n n n F a i o o o h i e n a y r h i 6 n r c o t o n e r c a n s e c n i r i s e o a t t h i i i e e l l l l n l n c a a c e o l a l l g e m i m u p e e e e s s u c d a ® a i i t p e s , w r t i t 1 f t u s z i t n y v t s e o n a s y h y r b e h c a f i a r a o p p a p t w e i a o l e 5 t e d m f a r s r y n t u n r a N a p t d o n 5 n n n u o x r r r s t t u B l l r a a e e i h u , f 0 T a i s e p e t e o o o t y d c e p e o n d O d t r m b n r n t x s i k o i s i c i e m y s e s s e n p p m h n 1 d s o e i r a m e t s s g c T s C p 5 e a M M o , t t s i a h h a c u n f i z t g i l H e t i a i a a f p i - m n . n e m g m s u e o v y y n m h n b r 6 s t r g i i a o p / c t c o e g t g e l u e g l l e o s t r e r p e i a a s 1 e i g k r y e e t I l e r a a c b p k d e f s d u m V s e u e n i a e x x l e p g e o f M 4 s / b n r n o f f a e i k r u d i t e o i i l t u u n m l d g k o h l t r p i s s i o l l 8 t p n n i i m i p o n t i e . e s I o r b n e t n n s i g c o V s y c c a c n g d e f s i e g t r c ) r s s T s s g n g l F a a i t u o a o t m C o c r t u r i o a e d I t i o h h - m e , d h t l i l e i i u f V t o s l e e s S o u e a n n n n / d r u p p i i o o n i t i m o p d w m a s i n p s e a n s c v l a d d h s a I n o y c u u h s i C d n d t i t b e t s t s s t o i y t e e e . e g o e a m c t n i l l i e f i i , u d y a e e d d d U n e . n i b h r n d r n s i r i c h p s n n i i o l f i i n n n g t g ( p a i n d l a i a i l , I o t i e y b b c c o C e e l n o p t m a o ) s i o s h i z a s i M l x a i o e e e c t a r t i g n n y : o r n . n t c s i o d o i y n f o i n o l p n A a d : i r r d r a I o e y s g l a m t l s l p p t C g i e d e p i e n s n C t o i v h l m t r l s t F i i o a n i f s a s i l h , i e b e l m o A a p e s s y d i r f b , l b t n s p u b o i y S r I a i s p m i h t i e t l o o e e i e N S n N i l c o e I r u r r t c t t a t n p o r n a n i r a i d r p y h o d n I v O f e t O o n a x g e t r e C e t t o c a h e h e n d d i a t r a c d r g T T s t 2 p o r w h o l e r U a n o o m t m r y o 0 t a a w e c n t e d z w r s u r D h o e r 0 n n e n e r a t a a i o o t o t t h o i a t h h s r 1 r o u g i c c c r i t n z l o r n p e i F e s n e e e r ; c r d 2 o r e o i o d 2 r e e o n l . h s F g p e n , W i u g 0 y d m n 3 l m i f l a : t l w e d o e a y t c o u 0 ; a c h 3 S h t I , B e r s b m m c o 9 l n m l C p : a o o l e t i I t 5 o m V n y ; C o n i e r l r t 4 f s n i e n m U 4 e e o s a o w i r a n d U c 8 m c i 2 n 1 n a n a n r p t z a 8 i i : a d a – f d t h i d n n – 5 t o s o c s o h o z i 0 8 l o . o l s e e g s e l 0 2 l p n o o y l y r r i . n e 0 b r I n p d 3 d l D l w l n f a s a W ≥ e a e m y u g - l ) i i 5 a a n r m . e n x i i l n n c t l s 3 I r r 7 n z c i t t t C h s o e s p i o t g 5 h a t o t g s 2 a i t q U u s a . e n n t y a o l i / n i e I n t u . t s o e g V h b m i l i n , a e e u a n o / s o l e e t s n L l P s u t e t l o t t h y t 1 O r . d s i s r s s e 1 . u f r o e 1 r
6.16 Candidiasis in the non-neutropenic patient 6.17 Guidelines for use of prophylactic antimicrobials • • • 1 V M G C C C C D p F • I • • m p P o a r 1 i l e e e r i i T e G t P a P C p i P s m V t p i o n n n n n r r i h r u f f n p h s 2 t a d r i r a o r p e e o a c d o f c e r m • • • • • u e o s t o o g t s o o n d t u s o p h z n a t o a a s i p i c p f u e c u p e r i w U p t F h F I p s t D - o y n t s h m i l t b m m f t h - e e o e n a h t t o l o i o o n o i p l a r i l e a d s o o e a h l a a o d o i b e c d o x y m e i g n m t y y r r r u t l e c p d i n x p n s a o n n n e a l i i o u g c ) b c y c n a e f r l i V a . i i e a a y z n i c s i s r c t c a e h o i e i e c x n r w d s C b n l a n n e i l n S c o s p i e i e c d s t i a t n n t n i d t n a s e e r i O i i t p a l i o c c t d n i n u d e t ( n r o w b c o n f u t m x s a l r h d s r e e M f f r u r y o g o r o t o t i c a a o u i e e i h a o u o i i d n s r i i t e r t s l v n a b P c m u l n s r e e e h s o e t t s s i c o i e i s a s i b e i i m e d d n L v o u p o c e s i 6 y n s d d p n i c d o d g a E e n l o n s a t e c e e C o d d o o . 0 a o i u d i T c l c r t i n o n p . r s s 1 i o a n n t i r r y i p E b w e s m o s t C e v m r e e a n : A t 4 a 5 4 6 ≥ < ≥ < U > 7 < 5 ” a r e n e L b h i e w i s s s d r f o o R a l l Y n 1 b 1 0 0 0 n t - l a o s l e i e C r o h 1 1 m g e s n f n l 1 1 1 7 e a t p a a ) s t u m 0 0 - 0 e r r l i a d l 1 p 9 o i r i 2 2 i a u n d n 2 2 0 0 r g c t r v b a g w a e e < t l e e u 0 x e 9 i d f 0 0 d f m m m o e t e h h 0 0 0 h l n i n / u l n r a w e k d r - o – p m d s i n a f p t i e k g a a 2 s e k d a d g g g m k k g c i f s k k k 2 t e w o n e g r a u l e t e g r e v g i g g 0 o a i i o : g g g o n i n 0 c s s i d f n . v e p d n e : z a c s V c e : : u 1 i s i : : : c . e e n s m s l y e e r m a a e 1 n t 3 3 m n e a e - 1 2 2 b a f s t i i r g n r t s u i o c m a e . v o p L p d t f e a . i u s d 2 i g g d c s o l s g g 5 n t n e n r / p r u l f l f s i i r e l 5 e o u i o t x e s o . m t y . d r n r t p i i a o t g d h i e s m o e r b s w n g c o o T a g b N e n i o t e n p i c i e l o s o p t h y h e t t e O p , i i r i t b y e r e v a c r t n “ b e e i h Q Q N Q Q Q Q Q R k . i u o a g T P d e e n v c i t i c e y n i i o s d t h p f i o 1 1 8 6 6 4 4 n e e r o e t s v e i n : e t i a h s s i n 8 r s d 2 2 H H H H H s e i 3 n u i n e b H s g c i n y i m s e e - h n 2 H H o c – o e o e s h e r l o k ( ( t ≥ a o i 8 5 s Q Q d e n p o h : e o s o n e i l m x n d u i d e e . n i f 2 2 e 2 e u v n o h i m s l d g i r e l r r 5 s H H 0 c d g o a n e a a . s a s / i r t i % n u v ( s t n a l k m k n i e f f b d l i h O s e r y o o v e n g i I x e s a e u V o l n t g e N r r . d s m c d f o v i v r / h f i c c E p b e c o a w e n e i i r e k a a n n g a a p u n o g c r g d i h H v N p g r r s / t t o m t m e d d e i i i e a i d O a h d O o b t v . i i o t p s n i m o a a e p e i n p U n T o j i C s u r s c c a s a u c m l R p t t o a e e s e n l l i s t h i c s s a s n e d c t a t e b s a e u u u e r d s e x b e o e n p e s n r r l . a i d e d g g d d d y m o i t n m n f i e e y u s l o c i o i n z r r t r 1 y r e t - y y e e c e e ) ) i d n s Procedure Prophylaxis PCN allergy l a recommendations alternate prophylaxis i b
Urologic surgery/procedures o 1 2 r c
Transrectal prostate biopsy Cefotetan Ciprofloxacin OR [Gentamicin i
PLUS Metronidazole] m i Transurethral surgery (e.g. TURP, TURBT, Cefazolin Gentamicin2 t n
ureteroscopy, cystouretoscopy) a 2 Lithotripsy Cefazolin Gentamicin c i Nephrectomy or radical prostatectomy Cefazolin Clindamycin t c a
Radical cystectomy, ileal conduit, Cefotetan Clindamycin PLUS l cystoprostatectomy or anterior exenteration Gentamicin2 y h
Penile or other prostheses Cefazolin OR [Vancomycin [Clindamycin OR Vancomycin] p
2 2 o ± Gentamicin ] ± Gentamicin r p
Cardiac surgery f o Median sternotomy, heart transplant3 Cefazolin Vancomycin e
Median sternotomy, heart transplant with Cefazolin PLUS Vancomycin s previous VAD or MRSA colonization/infection3 Vancomycin u r o
Pacemaker or ICD insertion Cefazolin Clindamycin OR Vancomycin f
Pacemaker or ICD insertion with MRSA Cefazolin PLUS Vancomycin s colonization/infection Vancomycin e n i VAD insertion Cefazolin Vancomycin l e
VAD insertion with MRSA colonization/infection Cefazolin PLUS Vancomycin d i
Vancomycin u
VAD insertion with open chest Cefazolin PLUS Vancomycin PLUS G
Vancomycin until closure Ciprofloxacin until closure 7 1 Lung transplant4 Cefazolin Vancomycin . 6 Vascular surgery Carotid and brachiocephalic procedures Prophylaxis not Prophylaxis not without prosthetic grafts recommended recommended Upper extremity procedures with prosthetic Cefazolin Clindamycin OR Vancomycin grafts and lower extremity procedures Abdominal aorta procedure or groin incision Cefotetan Vancomycin + Gentamicin2 Thoracic surgery Lobectomy, pneumonectomy, lung resection, Cefazolin Clindamycin thoracotomy, VATS Esophageal cases Cefotetan Clindamycin Neurosurgery Craniotomy, cerebrospinal fluid-shunting Cefazolin Clindamycin procedures, implantation of intrathecal pumps Laminectomy Cefazolin Clindamycin Spinal fusion Cefazolin Clindamycin OR Vancomycin Spinal fusion with MRSA colonization/infection Cefazolin PLUS Vancomycin Vancomycin Transsphenoidal procedures Ceftriaxone Moxifloxacin 400 mg over 60 minutes
Orthopedic surgery Clean operations involving hand, knee, or Prophylaxis not Prophylaxis not foot, arthroscopy recommended recommended Total joint replacement Cefazolin Vancomycin Total joint replacement with MRSA Cefazolin PLUS Vancomycin colonization/infection Vancomycin Open reduction of fracture/internal fixation Cefazolin Clindamycin OR Vancomycin Lower limb amputation Cefotetan Clindamycin PLUS Gentamicin2 Spinal fusion Cefazolin Clindamycin OR Vancomycin Spinal fusion with MRSA colonization/infection Cefazolin PLUS Vancomycin Vancomycin Laminectomy Cefazolin Clindamycin
113 6.17 Guidelines for use of prophylactic antimicrobials 1 4 3 2 1 L R P A R T C P M A R P H R O H C G M M h C I t C t A P S W H c B G P G P p v o p n r r o o m L F D I a e h i a l i r d p a a E r e h e e m i e f e e y o l e o l r a b I n g v y e a s a a a l h e a o 1 o i g f r i o r o n o i n r s n c p e p t a s G u e p a s c m a l m p s c d n g u s s j n g n i a n o o a r c o r s p o t c l c t a c o t n a a e t m d r o r a u r e e i t t o a e a o r 4 n i e e n r e l n t e t a p r p y e a e e r t r o I l l o i r n n e a t e l a e i d m c i V t p r n o e r c o e o m d a d r a d e a e n c l l - c c t b r n w p s d i n e i s e d c o t t o / i r l d a r a m c a t a l g o o e n a d e u c s a r t t e , e o t e e s e a c r t P p i i c u o o e t s a h a s r l n d c n s r t f m y x g t i s l p a e n n c g w p p n i c b y n t u o h e o O h c u c e c r m m t s p e s t t o c l i r c t p , k a o l a a s t e p u v d c o n e y s s o e m g a o o t t p r r c u c a o p y r m o e N p s e i o l y y r d l n t i r e e ; m g l e n r d i d a c l i f h p o n s r m r i i s o m a r y t c l m i v , t n c l p i p p o t y n a g r i e e a u w e r i d a t i s s r n k r s y c n v r e v o k i e o r y a t r c n m o I d s d s u a e c r e d e , f y s s ( e i t e D o e o o r t r f c m v c n t e y 4 t , e d u s p c d e r u a s n e t r ( a h r d a r / c p , l e b a e i c e h d v c r y n y o r e r t f u p r ( i c c r a e s i c u e t n h e c # g a y o l n h y r i l d y u e g r n e s i n y a c t t p d r r t e p d o d f y p o g l r s i i c 4 i o u g r u p e e t m n u n g o o i o e p o u a l l r u n e r s a a o e o n e e a r r r a 0 e s t o n c a o n r m l e r i s e r a c e s s t s i r p t t m r d r e d c b n d n t l 2 p e y i c i r / t y p s l , r o s n o h e n t l u p r i t o i l o o r s e l t e i k 4 y o t i e d a a v e n u p m e c t c r l o ( r p r o p i e ) d n i r 2 n s e e e o n s d s e c c e p t a n y r n r l o u a r y c / u o t c . ) s i n t a n o a e c s i w d g y a , a o r i d b l t r m i r e r e m t e p e i c n , e a i g e r o e n . r h e c g e s / d s s y t e a e e t s t t y i p t n a i p p d e c r ) o o m e e i u g i n r d , o d a o t b o e t h f r l l c m f m r r e a h e - o o u o t i t n l e o f c i a r o a s u y o o i o n l c r r n r s y n i o r o t G s l n m n e n t n t e t m g t p i p n r s e s i o a e s h d c s s s n c - e t / a e p d c m e l e , e n a i h g y a ) l n a p l t r t l l e d l t i s b o s a e m u i e i n f y l a e r o b l i : o o t d u n c i o s e c m n e n n f i u r l u f t o t n p t . l d a t c a a o l i s i a s m u k v h c l t p t m e b t i p e o e y i n w e s i n e n p l m d y g C a d i a e , t p x , t i y h l p a r o i , s i r n s l o o u C C P C r P C C C C C r P C C C N C C C C C C C C C C C r C C o t f r - e e e n o l r r e e e e e e e e e e e e e e e e e e e e e e e e e r o o r c c o o t c o p d e f f f f f f f f f f f f f f f f f f f f f f f f i x o o o a a a p o p o o a o o o a a a a a a o a o o o l o a p o p l a f e m m c z z z z z z z z z z z z b h h t t t t t t t t t t t t r m o h c e e e e e e e e e e e e o v o o o o o o o o o o o o l y y a o r m m i y t t t t t t t t t t t t a p n l l l l l l l l l l l l l l s m a a a a a a a a a a a a a a i i i i i i i i i i i i s p l n n n n n n n n n n n n n h e e e a n n n n n n n n n n n n x x u i t r f y e d n n i i O O r x o s s O l m s e n d d a i p R R o s u n n R x e e d i h n c s o o i d d C C a s y C c r t t k l o e e t a e O l n i i b f f o x n p o o o R i i d n t o s t t w i e e a b s l o n t t m l e a a g m n n y y a c i s d c i n a r f o i t r a b s C C P r C C N C C G C G P C G C C G C C C a P C C C C C C C C G C C C r C C C i t e e t o r r l l l l l l l l l l l l i l i i l l l l l l l l l l l l C e e e e e o h p i p p i i i i i i i i i i i i i i i i i i i i i i i t c c l o o l n n n n n n n n n n n n n n n n n n n n n n n n i e n n n n n o a n N o o r r r p p p d d d d d d d d d d d d d d d d d d d d d d d d t t t t t o o o g r t e m m a a a a a h h r a a a a a a a a a a a a a a a a a a a a a a a a n f f f y w o a y y m m m m m l l l a m m m m m m m m m m m m m m m m m m m m m m m m o o o m m a p l l l o d n a a l x x x i i i i i t y y y y y y y y y y y y y y y y y y y y y y y y h e c c c c c e e u d a x x e a a a c c c c c c c c c c c c c c c c c c c c c c c c y i i i i i l n n r t i i n n n n n c c c d s s i i i i i i i i i i i i i i i i i i i i i i i i a T l g p n n n n n n n n n n n n n n n n n n n n n n n n d d a 2 2 2 2 2 i i i n n n M n n y s x e e r w P P P ± P ± P P ± P P ± ± o u i o o d d P s i L L L L L L L L t g p t t / G G G G G h U U U U U U U U O g h S e e e e e S S S S S S S S a e R y M n n n n n s s l t t t t t a X s t a a a a a i x r m m m m m s 1 e i t s 6 a i i i i i s c c c c c n 0 i s i i i i i n n n n n c / t 2 2 2 2 2 a e 8 n 0 t c P p w v l • N † * p ( P L U C b B I P p a p • A w C r • • • s r i e n v P a y r e r o e i n P l l e e i r h r / L k l a a . l e t o t i m o n s i c o h a g e r r a O e C r n P C C P P a e e y c c r c c c s c t e l o i u r . r c m m r o / r r p e e e t e i u r e n y u - a r r y ( y m a s o r p c T t v e g c o e i m m h f • • • o t d e l / e o o d r p t a a b e e a s e t e i d . a e r o n o G n c u i h E g h z m e e r u i n n o v s n m e d n a i u r m d n e a r p s R i m C U i a I o g . n n r e t a p ; m n e g m t t o i S g i r l t r a t r i b l t t a m / o M i o i n y r s c i a i e i e a p n h o o e m t t n e c o c a l o a h b o a o o t u u . h l t : e e e t e u n r l g r p c m c e o l i n m s f f r n f l e o o d i y s t d i n o e z c a r e n r s l y g i t o e / m c e r a i t i m a i t l a z r u o d e d p i r l v t i t p * i v p m n u m w p t a w n c r i o a p n o ) u r o r l y p e i e p e f r ; i s o t a a n i a a r t l a a r a / s / r l i e l a t e v e h d e a n h o n t e p t n i b r a r d e t i c i ® o e a n m a t n c ; r i e u n h l d l l o o t m o e ( i t d y x i a e n b e r n t a n m ; n o p s e s n n ) i d b a e o u p t o l t o o t b a p f e l a l i d i d r i b o C o o s e i p o i h a l u b a e a b t t c o r r r t l y d l n l n n s c c i s h g i e o m i i a r o w o d l a a l l o z H r i x t ; c o o / a u z i f d , t y b a n a t t r a y a / t p b a s v h s e v t i a o i y d i t D l n t a c e n c e a a r e d o p ( a i t i s c n e l k t r o / o d p h t n s a i c r t s t t l a o p e r h e v o s o u i i u n x e n e z e a o c o e i n n c w r r c g r . i ) v r / r s i o a e a x s u f n i G p r ; i c c s a s a r t o n e o o a t l u s a l ) o i e i t i i a n i e l i e e h n i a f o e s o t r U c t i s c t n r l s d r a c h i n e b v i y g c t , n c e f u e † e s i e a s e d l e s s r n o w a r p i o c d t e c k v e r C l o e c h x a r o e i c s h e n c s o u s t t H l n i e ( t c o e s i e i d u C i s G m i v r c t s a d D n i i n t l d e f p e h H s d f y h I a u i t e g , o b m r e s i u e r e e D n t a e s r o e i e r t g n r e d r a t n d l t n a o e ) r n o a i c e r P C C C r P r P C b t d i f d p e e 6 n e i n n c o p s r r l e e e e c r n w t c c p u o o i e g c o o l r a f f f f o d d a r o o d p p a a a o t o t d m p f w i p r v o c l m m z z z h h t t t c e m e o e h a a e e i p o o o i y y p h h a n s h c m m s t t y o e c l l l l l c d i m a a a i i i v c e r e n n n r g t r l r o s e e n a d n x x t a u h n d o a e o e n n s a i i i x s s l t p t a r e p d d f n s i a d c i n h b r c t d r s o n n e e h d a r t a i t w e s e o o t s y d d g e i i l a r i t c i t l / t t o r v d l g t d i e d a i a i s s s t C a e e o e r f d h u h t n f u u O u . n t l f t o s e e i n t r s P r r e d v e r h r o g g e D p v e e o c r d o s i i e i u s s o c s t c i s c t c l s t d r r o . k h e a w e o a y h a h i r e l n e / c r u m o i r o o o c t d p a P P P P P P v n d h p e f a l C C C L C r r C r i r t e o t i e a U r v e i o N N N N s N e p c t a b e o r l r S c i p u v d n a a a a n r d y s p d c a a r G l l l l a o h i l l l l r v r l e e e e e d j e n n e l o e t a c e i i s y r r r r a e n n p g g g g d n s d o g t r c a l t t t l h y y y y g a p a v i h u t c p e y : : : : t c n y m r s a x u l o h i e r C G C C a o n a n o o e s i i l x l l l l c e e p t s i i i o t t n n n r i n f i n i s - h t n t a o c d d d e d p t t d e y d a b a a a o n l a c m i s m m m u r a o t t d t x t i i i r y y y t c t h u s e i c c c h n s i s n c i i i y n n n e o d 1 t f i v o t 1 e r 5
6.17 Guidelines for use of prophylactic antimicrobials 6.17 Guidelines for use of prophylactic antimicrobials 1 A R • p A • A • • • r A • • C C C A C A A A C P P C I K r N K A n e s P e H e a i M M M M M M C n n c n n i d r O 1 n n n d d d p b P M A I P P P O O O f n o s A o n u t t t t i n e P r u V V V V V V c t t t T n 6 i i i i c r e a m e C C p t c - - - - e R R R r i i i a c c a o o G l E r e e v v f f b b b e D D D D D D f t r p y e e i N N t u u i n i o e i i i o c s y u : n f i r + + - - + + e r r r d d i i i p o a r n n / / o i , i c o o o r i A o e d a a x a p d e s n o R R n / / a a g g e e C k r o o l p h l l i e d t t t j R R u l u t - - t c n a a l l a a e : i i i i o r r r l p p o l l h d d - - u i l p c c c e e C n r i c l l t n y u a l D D r r y o o n r i r d l e r r e r r I p p t o o o n i t . l s e - - y l g g o n i p r p e r a s / / i g s o r r p p k a e n o a e R R y o o c y y x r r i n b s h h f 2 b t d n - + + o g a o o p p O i : : e c o r y y p s i n l a t r o h h e a p p d C A i l l f o g r e a N n s t a a m P y y e p y u c z s n h h f o l i x x t r l l i a L P s u a a n r c i o c e t r y y g i i e t Y t t e s s m y x x v O a r d h e l l i p n r e e t i i n a a : l ( ( r e a d s s O o a a n C C a a s o r g 1 m x x m t k n f o s w R M M m i n i o i i n o e v , t u h s s c V V F A A V V T S F A C C i y n r h V V t a p C t y i l a a a a c o h m c c g c s h e l l e r u o , , o o e i i l i o a c l l l l s i y y c e o e V V a N c g g g g u i s s r d m t t a p r H H n T f t t c c n d i o n r r a a e o a a a a f r a s y r n i l i i h l l I u l S S s c t a n l l r r r m m n e o o n n n n n i s l r l a a 6 a l n o i b y d e e e r s V V a a f n a c c c c z t v v r 5 i s c c e a a m e s a e 0 m n n i i z e c e , , e y y y y u o y y c c r r p : l z z 0 c o t a i n a o d c c c c : 0 c c n V V i f e s o o l e T 4 4 t n o l o o i r l o s l l l l l 0 i i D i r l l e e o o o o z n Z Z l l v d o o s M t 0 0 g f d e e o a m m s : r m e u O a v v v v e t V V o v v s 0 0 4 l e m i u P r t i i i i n 1 A d p o o t t i i c r r r r s ) ) b r r a o E 0 r r s N / g m m c † † † † s t b m m e o o r a P p o p g n n 5 5 S 0 r t o g 9 4 9 4 i u c c i L t e e d v y g g s p o r 0 0 P M n e e a i h h 0 5 0 5 l m a Y o n P n o o p n i e 0 0 I e O e e X n P P m n n M q 0 0 0 0 t s c ; c l l * O : n g a s s r a O O u i m m s a d d d o o o e i m : m m m m / u 1 n o 1 a P r 1 1 o n n r e e g g 1 I d d B B A n c t 0 a V O p g g g g 0 0 e s s f i 5 I I e h M d d u d t o 0 P P D D m e i o i h P P P P S c m m 0 d s 5 o i r O O 1 s n u m o m O O O O e : O O a S f f 0 a p u e r g g 5 a r o o i C m u B B , R R l l o g i o r 0 t y d d d d 0 c P P r r i a I I r r d m r D D p a a a a 0 0 b i P i e O O c b i n l i i i i b f t t 0 l l l l l O u l e o i g y y y y m i a e u h h c n Q Q e l n f a t u i a t d g e e o o f I I t t e a n t D D 2 P o a i i i n o r i o P b O t i f f e e r l p O n s n y O g o o e o ( s d u R n 2 Q O p O l l d f a I l l p s m 0 M I r o o R K a D i t t h l o r 0 y i e a T s w w o l / y 7 c y e 3 p I c i i ; V e n n t b ) r w e 1 h d i e g g o 1 d 1 u i i r 6 u n t r 3 3 6 1 D 3 3 1 6 3 1 h d d : e r t h 1 u o e o e i m m m m m m m m m m c r 7 u a a n o o o o o o o o o o 3 r t t n n n n n n n n n n t i e 6 o a t t t t t t t t t t d – n h h h h h h h h h h l 5 s ‡ s s s s s s f o 4 r . o n R C C P C C C C A I H A I L I P I L T T A A P P C A T n n n n o o o o r u i R e M M M M M M M C C C n n n n n d d d d e v x x n x c n B C d t t t t t i i i i a e P P P V V V V V V V c c c c o o - i i i i i o e o g l C - - - - - M r r e a a a a f f v v v i p D D D D D D D n D R t p p p v s t t t t u u u V t t i i i i i i i o e l + + + + - - + - r r r r r r + t o o o o k r r a n n / / / r o o o d r a a a a a u o n n n n R R R / / g g s a o o p p p o l l l n s n n r R R - - - m a a n e r r s r t p p p h h h s s - - a l l d s c D D p p o r r r y y y u t p u p p r o o o u n l l l l s l - - e a a a / / c a a l r r p p p s k i a e R R o o s e x x x n n n h h h n n + + d p p i i i t o t p y y y s s s e t s s h h w s l l l r d a a a y y o n x x x l l p - a a i i i h s s s x x y i i ( ( s s l C C a M M x F V V A V N f Q 1 F F V A A T A S F S F T S P A S F N G S i s V V o i l i i i i a a a a h h c g g g g O 4 e e e e e a o y 2 u r r r r r , , l l l l l l s s s s s i i y c c c c c s e e e e n 5 V p t x a P P T c g g g g o r r 4 H H d h p t t t t t B c d d t o o o o o n n n n c a e o M o w y y 0 a a a a H a 3 e a r l l l l l l S S I t t t t i n n n n n l r r r n o s n n n n i i i i i D o 0 c l l a t e P n n n n n n y o i i i i d d d d d i V a V a a a a i m m n n x c c c c v m l c p n t d s e e e e e / o s m i n n n n i z e e o V , , i y i y y v r h S , c c : : : : : l l l l l 1 o e e v o s i i i i i o d d d d c c : : b a r c e n n n n n V V y l l t M g T T T T T 4 i t t 6 l n u o o r l l l l i y h D A l e e e e e h h l . A e o o g z Z Z d d d d o a M M M M M 0 t s v v X e 5 a a P : : : : : t e h I d a v v c a A V V x o o o o v f p i i o 0 4 n P P P P P r r m m i i s A A D D D O d p a y n i i o c r r s s s s ) ) e † † p s v m r 0 / / / / / c † † y s t t c a a a m G e e e e n y a i i n o P o o 5 S S S S S n n 9 9 B 0 s l u o y g c p p p e o 9 4 q s a s e v v e e g , 0 M M M M M 0 0 n c I n l / s s s i v D u 0 5 n i m o a a n o D t l t l e 0 k 0 0 o o o i e a a o o X X X X X c i P h q q v 0 0 r t n v S g * g a n n n n n s v n i i e O u u e m m m c 8 r o o S o o e e e m s d d 5 i m m e n o o t I r 1 P l 0 V 2 n n n n a o S * * * s g g g B 0 n n H 0 a L L O 4 g g 1 V e e e e 0 b e 0 v 0 I e e Q d 1 1 1 e e o 0 P D S P P 5 a i 5 l r 0 r e P P S S S S , d m o i u u 1 n 0 0 0 l O O O V 1 1 0 n 0 0 a t m O O 5 O a S S S S c c l e m 2 0 0 0 e o 5 5 c 0 0 g P I i o o m B d d R g l H g g y m 0 0 t t t t t y d d 0 g O m m m v v a a P a a a a a m I G c y g D a a 0 0 o o P x g i i b b b b b O , u l P l l g g g t i i o g y y r r l l O h o / P l l l l l n y y m m V O e e e e e i i v n n k r T P P P r i O a P t t t t t t i e x d g g g r I s O O O T l V O D e P P P P P a a d 5 3 I Z P P I Q c D O O O O O i V d d d t a l x 0 d V y i y O O m I m a a a i D a 0 l c d d d d d 1 y I O i i i i g l l l o d d l e a a a a a l y y y o y m R y G n s a a i i i i i v l l l l l P P e y y y y y / t i i g i l l h r y y w a L L O s r U U e R e S S k 3 6 3 1 6 L 3 6 3 m D D 6 D 1 D p d U L m 1 2 m m m w i i o r 2 2 f n u u u u f o g e m m m m e m e e s t r r r r o o o n d / i l m m a a a a l e e l o o o o o o n n n o d t n t t t t k n h n n n n n t t t o o i i i i n ≤ i o o o o h h h s s x g s t t t t g n n t n n n n h h h h s s s o h 1 1 t t 3 s s s s h h s n 0 1 s s e 7
6.17 Guidelines for use of prophylactic antimicrobials 6.17 Guidelines for use of prophylactic antimicrobials * ( F T T N D A r N 1 ‡ † I L A C P o R C C n o e I I o o M r R u s e N f M M M C n o d O 1 r c = x r p c e n C V c t i K P P o V V V c D o T A i 8 e e c s a o g - M T / d m a p s o E r f i p o l D D D l p S v g g P o o t u l p V x t S l a m m i e - + + e r M o a r n n i – n / y e ( l s o d : l Ϫ a n n o i n 3 R m c / e u r g z X m o p e g c n R r s y n - l a a ) , e e m r c h y i c t o s d - t l P l c h u l R n l i t D l p y u : s o o o i o e o k R p d i n s i n l l - v n n = s m o a / r l a e e B r o i i a t , t R r o r x d n h C i i n e r p i a z b + f p i i e s t i s s d s y s t e z u s P h c : i u c o a d t s r C i y c p r t n e t d i e p l N o e o i d a o e o e a p d n u x n e f n a t p c i t i s i l e A s , e n l e e n c n g d ( s r – t y o g s ) p f r l V S F I T N P V A V G 2 8 ( s V 8 t G G 1 5 v t y o o , n i u h = r s i u i o a a a h ) g O 0 0 0 0 e e a a a a v y r r h a i n e y k o r l l l s i r i i c s e l l n n n S 1 e Ն Յ Ͻ Ͻ t 0 0 0 0 a a g g n r t s r s G n i e v i r h t m T i d c t n o o n c c c x l t c l 0 a a S e e a e a o 6 r i r m m m m I t o l V e t t i i i n f b C y D 1 9 6 6 n n i e i r i 3 r e c c c l o d t u r n l n P i a o m n g , t d l c i a a n i c c e M 0 4 9 9 g g g g a l l l c n 0 n b a e a o o o V l D a n l l a r t A n c e i i a i n o o f g b c c : a l h e 0 t f a V v v v t z e 5 i t P P P p m k k k e d t : m c e e c n i v m l l t i e l d c e T i i i m o l o o g v e g g g c r r r o 0 O O O e P a y A l e i e m s n g d o o r r e M p r e l t v v t m a : : c c d e 0 O 5 5 5 : t h i e i t i B o n m f a h s i i b 5 o g T T T o t l P A y V V o , P r r d i e s f , D o i c e g l s ( o k I r r 0 v m m m v I I I c 0 n Q o o O D c d t a m l / / D D D 9 9 v o o P i p n a l e . . Ͻ a t e h e l 0 w r r 0 S y i o i o e 6 w g g g 0 0 v m n d p l r O r q e i i , e o n y d c x x 0 c c o s M r v i e H c / / / e s 0 0 a n u m i 9 n ( 5 c r i a l o o t e i p + c o k k k e B h o 1 1 d r 6 o l h X d u y 4 i 0 n n A d u C h m m g g g l i g k v o n I n ) y n n n f e D a a 0 f n y y L y c i p m o o s l e e k r = o i e b d o g g O I I I P t z z e e l t i B y r V V V n r c a g * s g s i r m y 2 o t i o o O l a a c R 1 e o d o r x P P t s a : a Q d Q p 1 n 0 p l l r r e l N i 1 w i g 5 r e e u p e o m n O O , t V s T D t B a e r r 0 1 1 i 0 f r G r h y 0 t v e v y t e o t i o M i 4 2 r P a o a I i S a o w l h 2 2 ) 0 i d d e D v e i d y 0 r r m , l g s t z 0 0 O p p Q l e i P i H h a a a i i o s n r c i t t u t o o 8 f h m x n o r 0 0 o n m a g a / i i h r 6 h r p i w o l l o r B x t . l s n i 0 o y y s x r S l e b e t 3 v ) p H g A n t m m g o A e P i I i m 0 p 1 e a l o M n D A t o x ( . 1 a e c t d n m i u O m , P r t u i v g g r c 4 P f c z l t 4 y o m X e i V 3 n o l o N e o 3 n O o a b y o t o O c o P a T p t P P c d h t r n c d n d g l o o y i l x l m n i l l I h m O e o h e O O d a l a D c l d a A o n i c t o C o c y A e P v r y a c o h e y a e s o a c l a v f i i B B M s s c l a O i y l s n r s i i e r l y n l i p l f B y D i , r y c x d I I y , , t n e c V 2 D D t y h c T i l t A h i a t t l s l o a h 0 o s o 5 h h l I s p L d o . D v e n 0 e v e 0 h s ) s u v i n , i r g n n e p r 0 o i x e m r . l p n l t m g . e o 3 3 s h D L , . L L g t D o i – – a u f i a n i i e s 6 6 n f f u r P y e e t i l p d r n o o O l l m m a i o o g n t l e t a n n g i o o B r o i l g g n i a n n I z n D i n t t t a h h i c a t s s i e l o , n C • • p c • D * • • I I A T • p N • T † c f N n I o n I f l i a l R R n p e i O t w O C N A S P F D u S s P a e l i n O s o d t h r t e E E u f e e n n i t z i o L i e t e i a i e n T i R e e p c r c i s R m r a c v t c f t o n i A A U v f y u u z o a l n E e a i c r o e e b n l t o p e l a s i t e T T t e S t n l r i o x t i : g p t r r n l o t o i s r a a o y f i a a o M M i g o : n t i r o e o T n i a e n c V t c c m a n r t a l p n t T T s o i u , o h y n i i e a E E v i i i n P a . c e e n p n h l e l s n n e f e l o s n n p e m o N N i c s C e d m m 4 c u i . n s n s s t c r r v e o r 2 0 e i t N 1 e / T T e t a a e o m p p V r i a a 0 n 2 o s t n r 4 r : a m g m a n b n e s g e a r N a > > m n f 6 h A z g i t l i o l u e c o i e u y y d I i l O y o g s ) V N b e r c o r i 3 3 s c c e I d p a t b n V p m i r n I T C a i o o V 8 8 Q r l g e o n e ( o a a y f E o s r t s Q . . p l y Q a t 8 c t t i < c i t e 3 0 r ( e e c n i h S i e s l t 8 8 i t e H b ( l n p r e ° ° i n s e a e a v d e : s H o 5 : n H h e s s m r n t C C e ± a s s b t e 0 g o f p t i s a u r o f v P e o w a x y y 0 u d r s r t t ” r e p V 3 i c L n o s c i i p l e o / m m t T l a h c ( g . t i e U y p e r o t o o m r 3 s i n e y y o e o c e d e e h b S r p i a a 7 l c t a n n a m n a r y s s e l p p o d a o o n 5 t s g T x l d m m a o o d p 3 t e o t n m u o i f h w s C u x g s e s n l v y n l n b i t e c s i c y R e c v i e o o s e o t r o P I u r t i c - a e c e V l n a B o r w s o p s ( a e i . b r t ) S m n i A r t . p i S s Q c t i n i o l i v I s * o s e m , e e i y t l e 4 n r , e c e s e d c p ( r i h p , f k H i a n s v l l i u i t i u i l f i n s p n f i e s e i c y o n n b o o t ± † . t e o n i a r s i l r t a o l l a r n 1 s 2 ( h i i t y V q d t n s l d u a l - l 4 e y l J e u a e e o o s h b s o o r i 6 r f n n e p r s e o o l g r g h e o M i ) c i f r n u n y t d l n i , o y V o o - R n s r t g , s o n f i s a s S m i s t i n o e B p s a l e n s A s e a y n u i . n M e c u p e n s i p e c n s c 1 o a g c S T f “ e a i e i e n m t 2 n t T , y r i i c s s f * e a r o 7 c t n e t y e e . n n i a n c d o ) O c ( a c n d t t s n r i i s p t R t o n o e s m i o l n o . ) u e e m w r s b n 1 w e u , i s d e , t n k 4 h t h o ) i p e t t 6 : e u s . m o n ) t i e 1 n f i 1 a g 4 1 1 9 )
6.18 Guidelines for use of antimicrobials in neutropenic hosts s t
s Persistent fever or new fever after 4-7 days in clinically o h stable patients without established bacterial infection c i n • Continue antibiotics above and ADD antifungal coverage e p o r t If receiving Fluconazole prophylaxis or no fungal prophylaxis: u e
n • Micafungin 100 mg IV Q24H if sinus and/or chest CT not suggestive of n i fungal infection s l
a OR i b • Voriconazole 6 mg/kg IV/PO Q12H times two doses then 4 mg/kg o r c
i IV/PO Q12H OR AmBisome® 5mg/kg IV Q24H if sinus and/or if chest m i CT suggestive of fungal infection t n a f
o If receiving Voriconazole or Posaconazole prophylaxis: e
s • AmBisome® 5mg/kg IV Q24H u r o f
s Clinically unstable patient and/or persistent fever despite e n appropriate antibacterial and antifungal coverage i l e d
i • Consult Oncology/Transplant ID u
G • Vancomycin (see dosing section, page 142) PLUS Meropenem 1 g IV
8 Q8H ± Amikacin or Tobramycin if patient unstable (see dosing section 1 .
6 p. 141) OR • Severe PCN allergy: Consult Oncology/Transplant ID
120 A ( A I 2 P A S G I 1 r N A A P i n n n l e e P y n n n n n C C t . . I d d O r m d h t t t t t d P P e L L i i x i i i i i i r u c c v f b f v T g e p p y e u u i i c p p a a a o c r r h E h t p m n n u a a o e c r r t t o o g g : o o k i i r l l t c d p o o n p m i e a a e p p p p e s A o t n n h l l r h h k a C r r m a l c h i l c p p o o o a y y m c r p d o r r p p l l l m i C a a a y o o a a t i p n o h h n x x l p p I t a e l y y r . s a i i i y l p p o s s h h e l l , t e a ) a a r a ‡ y y n p i d o o m x x s l l t t h a a i i p n c s i s s y e a x x y h l i i n s a p e t y s s s x t l l i a s o i u r c s x m m i o s a e a l o p n n a o n I 8 A F I V F A S F F I I P A N A F M T S 8 V I S T f V V f f t r t i l i i l a a i h h m l O 0 0 e e e m g g o u r r r u v s v t o e g Q Q l l s i s s i i e c c c 0 0 c c a a o o r e e r r e x n p m a t t t T d d f r o o o 1 1 o o c c m m v i n n l n i t f e l m m o I l l l c n n n e y y n n l s D 2 2 i i i t t l l a o n n n r i i i i x i d d d c c r a a n n t t l H H g g e t a a x e e e l d a e i i i l l i i z z n n e e o o n v a n : : : † † l l l n n c c i i i o o P P g g : : P e n n n v v c a d d V T T i 2 l l n O O A A e e e i i s C e e i r l o r r o o M M n n : : : : t t d d g 4 N f r r r 5 5 o o o B B 4 2 P P u M i P D D o o 0 e c v v d d 0 0 0 0 I I I n / / a o D D V a a s s o a a i b 0 i i 0 S S 0 c 0 0 c a a l s p p e e u n q q l Q e a M M r r t a m s s a u u i m m m m i r r f r o c 6 o o t u h h z a g o o X X g g g o g g n H o n n n e e r y n n o o n ; e e g a l a l : P e e e P P o P P O n n a s : : i d V O n 1 1 O O O O 7 7 e e z ( R A A a o p s 0 0 o 5 5 1 B n c c S S B B e s d d f A l 0 0 0 0 0 c e y y I e e e a a S S I I D o m D D c c o 0 m m i i m m 2 l l d l l m m t t y y n o o o O O r a a 0 m o g g g g x v v y b b o 0 R R s i i i i g c P P c r r P P d i a p n P P i m A A i O O 2 2 n O O l i I g l f O O V c c i i 5 5 n g a c 1 d d y y B B i Q 0 0 n d d a c c 5 a a P I I g t a a 2 D D t l l i i B 0 m m O o o l l i i i i y y 4 o l l I 0 M v v y y V e g g H n T i i r r T / / m Q s I n D O m m s 1 g m R e 2 2 t 2 c a s H t y i o b n w e ) i i n t A D 1 A D 1 1 A D g t t c r r m o a “ i D D p h t c a 5 A D D c D s i D a D D a c n m h h h d e e F u i n l l l h h h h h a r r N N N N 0 0 0 0 a a a a a a a a a g i u u l l l e e e u s s i t i a p t e e m e e r t c y y y y y y y y y c c c w i 0 0 0 0 C C C C r r h i r r r c o o i a s d b r m m m m e a a a a a a y y y / / / / o u e h t l l t 1 1 1 8 1 7 7 1 7 e r i n v v c c c Ͼ Ͼ Ͼ Ͼ t t p p p i t m m m m o n o o o o e o s s i F i i e e e t s l l l o o y y y 0 u u u u t o t u t t o e e e s s i n - - - n e m m m m s d t k h h h i d u c n n n n n n n f . i i s s s - i v 1 o s r r r o n n o t t t t t s 3 3 3 3 t o o o e f i i i i i n o o o o r t f l l l l l o h 2 u u u r i l f f f ” 1 a r g g g 1 s h h h
6.18 Guidelines for use of antimicrobials in neutropenic hosts s t
s 3. Bone marrow transplant patients/peripheral blood stem cell transplant patients o h Indication Agent and dose Duration c i
n Antibacterial prophylaxis* Moxifloxacin 400 mg PO daily Day zero until e ANC Ͼ p
o 3
r 500/mm t u Antifungal prophylaxis Fluconazole 400 mg PO daily Day zero until e n ANC Ͼ n 3 i 500/mm s l
a Antifungal prophylaxis in First line: Posaconazole 200 mg PO TID i ¶ b patients with GVHD Second line: Voriconazole (dosed by weight) o r Ͻ69 kg Voriconazole 200 mg PO BID c i Յ69 kg to Ͻ94 kg Voriconazole 300 mg PO BID m i t Ն94 kg Voriconazole 400 mg PO BID n a Antiviral prophylaxis Valacyclovir 500 mg PO BID OR Day zero f
o Acyclovir 800 mg PO BID until 1 yr e If vomiting or diarrhea: Acyclovir 250 mg/m2 (allogeneic s u IV Q12H † transplants) r
o or 6 months f
s (autologous e transplants) n i l † e PCP prophylaxis First line: TMP/SMX one SS tab PO daily Allogeneic d i Second line:TMP/SMX DS tab 2 times weekly transplant: u
G OR Dapsone 100 mg PO daily Day 21 or
8 Third line: Atovaquone 750 mg PO BID engraftment 1 . Fourth line: Pentamidine 300 mg INH Q28 days (whichever 6 is later) until at least 1 year (longer if steroids or ongoing risk) Autologous transplant: Engraftment until 6 months
NOTES: TMP/SMX therapy reduces risk of infection with encapsulated bacteria, Listeria 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 ‡Myeloma patients if on steroids; Lymphoma patients if HIV+, on chronic steroids, fludarabine. ¶Other prophylaxis in acute GVHD: Moxifloxacin, TMP/SMX.
122 s t
Guidelines for the use of antifungal agents in s o hematologic malignancy patients h c i n e
Filamentous fungi p o r t u
TREATMENT e n n i
Aspergillus spp. s l a i
Initial therapy b o • Voriconazole 6 mg/kg IV/PO Q12H times two doses then 4 mg/kg r c i
IV/PO Q12H (see Voriconazole guidelines, p. 17, for more information). m i t
OR n a
• AmBisome® 5mg/kg IV Q24H f o e
NOTES: s u
• Voriconazole is considered by many to be the first-line treatment of r o suspected filamentous fungal infections in the immunocompromised f s e
host as most of these infections are caused by Aspergillus species. n i l
Although the data are limited, Voriconazole appears more effective e d i
than Amphotericin for this very serious infection. u G
• Combination antifungal therapy is not recommended for empiric 8 1 therapy of aspergillosis. . 6 Treatment failure • The Oncology/Transplant ID consult service (#4-0242) should be involved in these cases to assist in antifungal selection and eligibility for ongoing clinical trials. • Treatment failure defined as: • Persistent fever beyond 96 hours • Worsening clinical status at ANY time after starting therapy defined as: hypotension, worsening respiratory status, evidence of embolization • Worsening radiologic findings • Patients receiving Voriconazole should be appropriately dosed using actual body weight (mg/kg) and have therapeutic levels before being considered treatment failures. See p. 17 for dosing and therapeutic monitoring. • Micafungin PLUS [Voriconazole OR AmBisome®] NOTE: There is no convincing evidence to suggest that any of the agents would be superior in patients who fail to respond to the first agent. In vitro data suggest that Micafungin in combination with Voriconazole may be the most effective approach in those who fail to respond to Voriconazole alone.
123 6.18 Guidelines for use of antimicrobials in neutropenic hosts 1 • • U • T C Z • N • P • • F • • • • N a a I f w l u y R 2 s n b a O O t C I D I a Q V T V V I P s Y V a S A A M O D V V h g e s a s i r E t 4 o o o o c c n E o m m u O o c 8 T T / / R i e a e • a i u o p c u i r r r r c d A r t A s a P P s d H E E b N a i i i i g B B r a d t m e y c c c c o t S a n e T i S s O O o e t l i h : : d i T f i i e e o o o o a u c n m c c s p – s s e M u T s l e y A e M a y . a s o n n n n a m o o l i Q Q e e n i r n l e a Q s c s M s u I I a a a a E n l e m m c g a i D N 1 1 i o n , l c t s t o l c 1 d z z z z l a t i N s p I i e s a t 2 2 t N a e n h e e o o o o p i s z e a c 2 c A e s y s p d t T l y c w H H ® ® e o A l l l l a a b . o i h f 1 d H h e e e e o p p t C B u t l s t i N r o n c i e 0 e t ( ( i n 3 5 i e o i . b a 6 6 a e n o h L s s . c d s u T a 0 r ( r n – e p n n 2 e e O n a b g u l a e M . g m i d n o m m s 5 a d l t p e e n l 0 e l m m o i l O t b m t d y n g u e b o f h g g b 0 w m M b i V V b r c D o i e g c a / e c r e a e e d / / d o o e e o r n k m a i r g y o r k k c q l c f e e C I i r r m o o s t g V y o n n g g / c a u i i r a a g m b c c U w e v , s d r a m k t o n i i f g Q I a r o o e o I I o V u s L n g i R V V o P e n i o e i o ) o T n n b l 2 n a d v / / u n s d O b h o r n n I d ( a n a a U e g 4 e V P P i t e S . e t n c i d o r i z z C p i R d z f s H Q O O e c e n f c c o Q y o o e t a o . t o E m e 6 e i i h r h e r l l s c t n n 2 l c Q Q e e g p s r e l i a e H o S d h e p r g e 4 d o l s d t 1 1 u i a s g g o w n i t h o c H a b a H v r f i s t 2 2 b u u t u c e i t i o y s h i e r O e e n c , l i r H H i i l y a s y o m i p r e d d d d s a e r U C e c l t n r e e t o . . t f 7 l h t t o L d C a n o o a u i i l l o c I r e m m o i i n f D o p e , m n n r d i r n a p r f o u d t t y e e t y e e a a s s n h t b h N u t m s s b i p y s s o p e h a e o d i e i n E , , n n s e m y s t e s n i t t d s o a y p p V g r . w w s r t u a e e e r a e t a c b . . E h p h e i o o s n r c p o a p e u o 1 1 R p p l a c e d y o p s n y t n d d c 7 7 a o . m d i m t B o n ) t o o o c t o , , w m 4 h i i i g E a s s n s e n e m u n f f e 0 i o o m s t e e t n c l s r C h p n 0 i l e r r s s n d i t a e a s e o a O s n g A a m m , m k t t n t t . d t s N h h t m h h d e r a o o C a f i g e e o n e S e a e t B r r t . n n a g g c s i e e c I d P o D p i a r u s e l . t 4 4 O e n e a i i ) o l E b l o n n n b t . s t r s e R m m a m - f f l i i s s i c o o e . m l g f E o p o g g a e n r r ( e D m m w e e i n t r ® / / t n e c . k k s . i C a a A g t s i d i g g , . f n t t . . i . i i c o o t h n n e ) ) . . u b • • • N i N • C • C • C • C • • C • • N n s e f a a a a a O O O A A A A A T c M M M M M A O O O O e e n n n n n a h s m m m m m m T T T c d R R R R o i i i i c c c c n e w d d d d d t E E E s B B B B p B a a a a i i r i i i i i o i f t b e S : : t d d d d d h f f f f i i i i i s s s s s c n u u u u s e C o P C a a a a a : o o o o o a h s n n n n u t . a . u r m m m m m e g g g g e s t p k g a e c t p s k r d c r i i i i i r l a n n n n l a e e e e e e a o e i r b a e l c u i u n ® ® ® ® ® t n r r d m p 1 1 1 1 p i i b o a s a s n t c i b t s 0 0 0 0 r e i p 3 5 3 3 3 e i c p i a n F t B b e a 0 0 0 0 e s i i – – – – a w l s n m l u s t i i d e 5 5 5 5 d i s l l i a s h m m m m c o n t l i o g s i a o d a o f s i m m m m n g g g g t f b / s n a i n i h s t a c k i l g g g g d t a r e e s I I I I r u g a V V V V i / / / / i z n e s s l o a k k k k t o e s t I Q Q Q Q o V r g g g n g h c t l i a l e c 2 2 2 2 o d i a a l n i Q l I I I I a n 4 4 4 4 t t V V V V i f t t e n f i l 2 e h r s c l H H H H y o s Q Q Q Q e t c 4 u e a h n a t r 2 2 2 2 g r r H l e i l e - e t a o y n 4 4 4 4 g . s m p o n e H H H e H s I i n y s s r u t s a g a . t t t i s i a r a s n b o t t n n a l h d p s e t i b a s u e e t a t l m o s s n e n M c i i r c F d p i e e s i l c a u p p d n a t s c t a . o i i e f u o b t ( u i S n s l n e l o n e c t e a n g n s e e z t t , g i o s p n o V e p . t l F m e o i r . b l r u n 1 l a a i e c c e 7 y n . o o u d b f n n t o r e t a a o h r z z p i e n d o o e s f o l l e e e n e s r i , c i c i n o w a g c r h n a ) 1 t i . c o n b 2 h e 5
6.18 Guidelines for use of antimicrobials in neutropenic hosts 6.18 Guidelines for use of antimicrobials in neutropenic hosts 126 2009;48:503. Dis Infect Candidiasis: Clin Treatment of for Guidelines IDSA Reference: • to dose-dependent (DD-S) susceptible or (R) resistant is isolate the If • mcg/mL 1–2 of range the in MICs Micafungin have that Organisms • blood all on reported susceptibilities Micafungin are and Fluconazole • Fluconazole, Itraconazole, Voriconazole, for Susceptibility testing • susceptibility antifungal testing on Notes NOTESTREATMENT o-otn ucpiiiytsigcnb ragdb aln the calling by arranged be can Non-routine susceptibility testing • when: considered be should Susceptibility testing • for routinely done is conventional Amphotericin B for Susceptibility testing request. lcnzl,te iaugnssetblt ilb reported. be susceptibility Micafungin will Fluconazole, then cases. these is recommended in consult ID treatment. to respond not susceptible) may as (reported isolates. blood. from recovered isolate yeast first the on routinely performed is Micafungin and (5-FC), Flucytosine yooylba 5-6148 at lab mycology lo utrsaepritnl oiieo Fluconazole on persistently positive are cultures Blood • endophthalmitis with Treating osteomyelitis, or meningitis, • Fluconazole to refractory Mucocutaneous is candidiasis • .lusitaniae C. Fluconazole and .guillemondiiC. n o te raim by organisms other for and y
Approach to the patient with a history g r e l of penicillin allergy l a n i l
Penicillin reactions – Incidence l i c • 80-90% of patients who report they are “allergic” to PCN actually have i n e
negative skin tests and are not at increased risk of an allergic reaction. p f
• Penicillin reactions of some type occur in 0.7 to 10% of all patients o y
who get the drug. r o t
• BUT: The incidence of anaphylactic reactions is 0.004% to 0.015%. s i • Rates of cross-reaction allergies to cephalosporins are unknown but h a
thought to be low. h t i
• Rates of PCN and carbapenem skin test cross reactivity are 47%, w t
although clinical rates of hypersensitivity reactions in patients with n e i reported PCN allergy who receive carbapenems are 9–11%. t a • Cross reactions to monobactams (Aztreonam) do NOT appear to occur. p e h t
Penicillin skin testing o t
• When done correctly, is highly predictive of serious, anaphylactic reactions. h c
• Patients with a negative skin test are NOT at risk for anaphylactic reactions. a o r
• Rarely, skin test negative patients may get mild hives and itching p p
following penicillin administration but these RESOLVE with continued A 1 treatment. . • Skin tests cannot predict dermatologic or GI reactions or drug fevers. 7 • Skin testing is now available at JHH. Please consult Allergy and Immunology. Penicillin reactions—Types • Immediate (type 1) – Anaphylaxis, hypotension, laryngeal edema, wheezing, angioedema, urticaria • Almost always occur within 1 hour of administration. Hypotension always occurs soon after administration • Can be predicted by skin tests • Accelerated – Laryngeal edema, wheezing, angioedema, urticaria (NOT hypotension) • Occur within 1-72 hours of administration • Can be predicted by skin tests • Late – Rash (maculopapular or morbilliform or contact dermatitis), destruction of RBC, WBC, platelets, serum sickness • Almost always occur after 72 hours of administration • Rashes sometimes go away despite continued treatment • Maculopapular and morbilliform rashes DO NOT progress to Stevens-Johnson syndrome • Late reactions are NOT predicted by skin tests • Stevens-Johnson Syndrome – exfoliative dermatitis with mucous membrane involvement
127 y • Almost always occur after 72 hours of administration g r e
l • NOT predicted by a history of rash OR by skin tests l a n i Approach to the patient with reported penicillin allergy l l i c i
n • Brief, focused history can be VERY helpful. e p • Questions to ask: f o 1. How long after beginning penicillin did the reaction occur? y r 2. Was there any wheezing, throat or mouth swelling, urticaria? o t s i 3. If a rash occurred, what was the nature of the rash? Where was it h
a and what did it look like? h t 4. Was the patient on other medications at the time of the reaction? i w 5. Since then, has the patient ever received another penicillin or t n
e cephalosporin (ask about trade names like: Augmentin, Keflex, i t a Trimox, Ceftin, Vantin)? p
e 6. If the patient received a beta-lactam, what happened? h t o t Interpreting the history of the patient reporting penicillin allergy h c a • ANY patient who has a history consistent with an immediate o r
p reaction (laryngeal edema, wheezing, angioedema, urticaria) p
A SHOULD NOT receive beta-lactams without undergoing skin 1
. testing first EVEN IF they have received beta-lactams with no 7 problems after the serious reaction. • Patients who report non-anaphylactic reactions and have received other penicillins without problems DO NOT have penicillin allergy and are not at increased risk for an allergic reaction compared to the general population. • Patients who report non-anaphylactic reactions and have received cephalosporins can get cephalosporins but not necessarily PCNs. • Patients who report a history of a non-urticarial rash that is NOT 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. • Patients who report reactions consistent with serum sickness (rare) can receive either penicillins or cephalosporins with careful monitoring for recurrence. • Patients who report GI symptoms (diarrhea, nausea) probably do 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. References: JAMA 2001;285:2498. Use of carbapenems in patients with PCN allergy: J Antimicrob. Chemother 2004;54: 1155–7. Ann Intern Med 2007;146:266–9. 128 ”
Combination therapy or “double-coverage” of e g a Gram-negative bacterial infections r e v o
Reasons to consider combination therapy c e l
Synergy b u • Occurs when inhibitory or bactericidal activity of combination therapy is o D greater than would be expected from the sum of the activities of the “ 2 .
individual agents 7 • Synergy for Gram-negative infections is of major value only when the bacterium is resistant to one or both of the drugs in the combination. • Synergy has been best established for beta-lactam and aminoglycoside combinations. • Synergy between other drug combinations is less predictable and has unclear clinical significance. Prevention of emergence of resistance • Emergence of resistance on therapy is uncommon, occurring in 5–10% of infections treated. • Emergence of resistance to cephalosporins while on therapy with these agents occurs in ~20% of patients infected with Enterobacter spp., and are best avoided in these patients if other options are available. • Emergence of resistance is more common in pneumonia, intraabdominal infections with poor source control and osteomyelitis due to decreased antibiotic penetration at these sites; attention should be given to appropriate dosing in these patients. • The addition of additional agents may lead to increased toxicity from adverse drug reactions.
Broadening empiric coverage in the event that the causative organism is resistant to one agent • Should be considered in patients with life-threatening infections (ventilator-associated pneumonia, sepsis). • Second agent should offer additional coverage and generally will be an aminoglycoside at JHH. • Coverage MUST be narrowed based on culture results; negative cultures can be used to rule out infections with most organisms.
Data regarding combination therapy • An early study by Hilf suggested that combination therapy was superior to monotherapy in patients with Pseudomonas bacteremia BUT 84% of monotherapy patients received inadequate monotherapy with an aminoglycoside. Five more recent studies have not shown a difference in mortality when patients received appropriate monotherapy for Pseudomonas bacteremia.
129 7.2 “Double coverage” I C B B • 1 P A A R • • R • A • • n n m n h e M M l t 3 i e p T t a i t R D i T G D o F T n t t a f n n J h h i i J J e w c m m 0 l r l a h h r J e a o r I u f f o r m e e 2 1 3 A g n 2 2 e e a e o e e t c M i i o t o u f n n c c r i 0 0 a n a a . . . e c c m e l e m a b t r r r e e a u s c 0 0 c c n i r o o t t E ( o D ( h E b s w D l t o n m n p d l a s e o t e p p i i t e - 4 3 s e i e b b o o n y v m y t e f q t s n t m s y t u h c o o i D ; ; c e a r c s 1 s e c h s n p e n n 3 3 m : A A t u i i p b g e t i r c c e 9 n r t o e m g e r o s e e 2 2 s s g o g a g p o w i o i t n r e b g r 8 n n f n u u s n r i v 8 6 i r e e b g n m o 1 t a e v f i a c o t 9 e i s 1 i g o g t e e d r n n e m m : : n t t 9 a e r t s d c a A r 6 1 u 2 ; 9 h h b t h t i t l y s / n i o m r 8 9 i o s s - c v p n a t g t ( 6 1 l a a l 9 b l o e a a t e e a s y 3 i a u 7 5 e s m n a t e - e o 8 1 C C g 5 e J t o l u m c i t e r t : t p n n c ; a - n e o e g b i . 1 c t H 5 n o ; 8 2 h h h l t r e l i t t o o s 1 t y o t d c n t t a p . n e e h i e 4 a t e e s 0 a a h 0 n H n e e r t 5 n n i i s t f m m - s , 0 s v c r ( P n i e t a a a m b 1 t e a b o 5 2 ( n n . d d o t , s i 3 e . p t t o o s s n 9 s d o m r m c t ) e g s g p o 6 e s t : ) a o t t m i r e 9 a : 1 h f p i i t h c h h s s l o n r 2 e o ) n n n a y o o i / l a 9 s t u 2 l e e e . o i i o p t t o - y 7 o a o m s d e a c r n f f n a u d ; r r r h 1 d r n h i u s m 1 9 e e l r s m n o e a n o d n 7 o f 1 1 e o i t s i S l i 1 . u e b o t c c g g d s s p ( r u c . 9 9 t i t n b w m e . : e i p e e h s b u r n 7 i t t h t 9 9 y e i d o s d b s o s n i i r n e e a r s r r o . e o 7 4 d o o o h e d r f i i e e n a i p t r l n ; ; g r s t n h a a e e n n p o 4 3 a o e s u e o t e p c a a l n t p a i i 1 8 e p w y t n e c f m n o i c n r w w o s h v a n o e t : ( c n y r o o c a n 6 1 e e t c h e , h e m ) o i n f i i o r i i o v ) d m t t s 1 a c d u e i o d a : u w A d h h n s t s 1 e n t 2 b u v m t h s e m m s r c i m e A r i n f 3 h o n 7 a a s i d a a s e e o o n n h i n i 0 o e N . d t n n , ) n u e a o b c l o a p o i . c 9 r h l n a n t e e o s o f D o t n e d e i t r a e u . e i f c m f g n c t h i g g s w i s a o e i g l n o c s o f a d n r o e o a t h l o i n f e c n i i y e e i b s u e m m a e n e e n f w l t r t n . t c y n a t s a o i i g u r t n i n t a b o t n o t o b o o m C s e p s c o m t r t r e n i n n r i n o t s s e e n e e t o a n a a o f e p t e a y s g i i c d s f a b o c t l a d t f c l t p h r e G i u b i e t . t t s e c r h t b s e m , I G h r e e e e l i a D e r e i o o t e t e t C a i r d n a p d u r t a i n n h a i r n t n t s i r a n i m s t i e i o o n 5 e e n a c t o s w o a G ) o m i e r n m t n . c x i f - – u - f o p i t u p r i d n e a i s e t a d o C t 7 r - s c a b o n t h y a e . e l t : s l i t r c t i o m s r a e s t o g t g G h d a v t a o b y i c n e c t g e o e a t a a - . r t e m c n s u m t d c a n i a n n u t y o e t o e i s i t a t d m s i t v g a e e r n b s s i s g i m v s e l e , - s h n m a y . l o - a e a e t n r s b t t o o f o t a p c s i e y i i o o a r v n t t f a . t n g t g h i n a f f e a o h t e t a e a i m m t e e e n r t i n r g o i r n a v s o i c s y s n t e p i a s s m t y e t n i n l o
Hospital Epidemiology and Infection Control r t n
(HEIC) o C n
• HEIC is located is located in Osler 425, phone 5-8384 o i t
• Office hours are Monday-Friday, 8:00 a.m. to 5:30 p.m. c e f
• After hours, an Infection Control Practitioner (ICP) can be reached by n I
pager at 3-3855 & y
• Consult the HEIC Web site or JHH policies online (HPO) g o l
(www.hopkinsmedicine.org/heic) for detailed isolation charts, HEIC o i
policies, and surveillance information m e d i p
Hand hygiene E l a
• Hand hygiene measures are the single most important strategy for t i p
preventing healthcare-associated infections. s o
• If hands are not visibly soiled, then alcohol-based hand sanitizers are H 1
recommended for cleaning. If hands are visibly soiled, wash hands with . soap and water for at least 15 seconds. 8 • Hand hygiene is required upon entering a patient room, upon exiting, between patients in a semi-private room, and other times per hospital policy. • Use soap and water upon exiting the room of a patient with C. difficile infection. • No artificial fingernails are permitted for any staff member who has 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. • Skin wounds should be cleaned with soap and water • Mucous membranes should be flushed thoroughly with water • Eyes should be irrigated with a liter of normal saline After cleaning the exposure site, call 5-STIX (5-7849) and follow instructions to contact the ID physician. Workplace injuries should be reported immediately on the “Employee Report of Incident Form” and to the Occupational Injury Clinic (Blalock 139, Monday–Friday, 7:30 a.m. to 4 p.m., 5-6433), and to your supervisor.
131 8.1 Hospital Epidemiology & Infection Control H 1 C r P D C c Q P P P M M M M L H G D C B B A A V e o h e R v n o l e E 3 i H r o i r i l o a u o e e t p g p a u F e i g t m y r l S y t a I m g a n i n 2 M m n h h h o e u c t C u o i s • • • • n A u i o s k u d r t l l e v n t H p m r y p i h i a H s z l e ) s e n e c m e e g l I t s H m 4 r C A I A S i d s l e l n x s f e m y r n f ¤ e . o y e r r e s i e o h e ¤ a f r a i i s b b W p 2 u e C a a l d s s s ¤ l t p u i l l e q c u s o a o d ( s n o e l s o o i ¤ m l 1 r e i ¤ i W s o a i n e n t e ¤ u t v t s u p s u x s p h ¤ i u u - a c , n t s i l J i i b i i t b p l , s x n i d r i i t t ¤ d c a c z a s s e a c M e e D y g n u n a a k s t a e H a o n r i o l b o t e o o l o o a e o i i n s o ¤ b t r l C t m d a e o b n p l s t n c e b y s f l i ) r t i W r t f s a d o e , m a h g d e h n o o ¤ y c u e r a c i e a c h q s a o s r o r n a t e d H y n c t t m e u t t s m u d B d H t e w i i – i a a E s i e f p s h s r i r i e i C F C s m l a i a m e e I e , : a t u C ¤ e n r / d h g t H W d d s v o a a i e u / t d i ( n e : D s a l r C a s i ( n s t ( a d i o n e o . n o 4 e c J i p t e y c e W s o a a D h d c u 1 s , . n r a h e r t s e ) c t — e V e e 0 7 e i O a b e s f e ¤ u I p b u i - S p : . l c 3 , c r e e 3 d e o h m o A o r a s c v 9 x h e 0 e f x r , d t t i a u o p t 6 m e t p n i t p i o e r p a n h o s n c c - a i o 4 n h , c a i . e e s t o e t a m s . i 4 i e t w e a a t b m m i f u i r o o l 3 s d o . l s w l y e a r m f a n e t 6 R V T T S S S S S S R R Y V z d l t q l w e t o , A o p o a u u e o r s a d i i a u i t m h c A a o , s r c u u y r s l b T l , s r h . l , w a b b i l a a i l R e e e i g m f 4 b i o s n l i a n t e c l H o B a e a b i r B a r s a p S e e e x i a w e l i a e r : i h e n l o l i c n n s x t n e t p r e l s c e 0 l p m c a a o n e l l o l e ¤ ) g n o e o l : t a d e g o u F s e a a o 0 m x o ¤ c s i e ¤ d t s ( r i m l e b x . 4 a l ¤ o i G c o d s l e o m n t g ( i t h l v o s c l C p o h s 1 ( h . c e e e r i ¤ o e r o o o r ) s h ¤ i s o . m c e r e s , r 0 r r r ( m i v s e m p i h d m c a r 9 s t e p S - ¤ ¤ / p h a u a H 6 k a l i a h . 8 c s S o o a a g G e i n s , g 2 E n t e e l p n i n l r i a i u e r c 5 m e N t c I 5 a o a o m p t y C e l s s r a - i l f u x . o - s 6 o t a n P t ) e 0 e s b p h . e x ( e W B v v d 2 n a g a d 6 u . l r I i e A o e s r e r m f o g 1 i , t e s 8 s u r o l r o l e r d c e b o p 1 l s d e 8 i ¤ a g a d s s i r e e s a t ) i a s d ) ) , i / s s s h s s . / p B r i e s a w i e S m s i ) e t w t F o t e a i c e i e ¤ a i c h a n o b n h m s s B m d , s v i u y l r g a e e a . a e , t w i l e h n t a e h a s l S - i d t a t i t ( r i s e l v i t m i l o t l m u i . a h y e e a e i - i , n d l t t o . . ¤ e e r a l e y s
Infection control precautions n o i t u
Standard Precautions a c
All employees must follow Standard Precautions for all patients as e r follows: p l o r t
• Routine hand hygiene • Bag contaminated linen at point of use n o
• Consistent and correct glove use • Regular cleaning of environmental c n
surfaces o i • Appropriate use of gowns to prevent • Routine cleaning or disposal of t c e
contamination of uniform/clothing patient-care equipment f n • Appropriate use of masks, eye • Strict adherence to I 2
protection and face shields (i.e., when occupational safety requirements . suctioning, or when splash likely) 8
IC admission codes Used to inform HCWs of the need for isolation on readmission to JHH based on the following code system:
Code Precautions Reason for Precautions IC01 Contact Vancomycin Resistant Enterococcus (VRE) IC02 Contact Methicillin Resistant Staphylococcus aureus (MRSA) IC03 Maximum Determined by HEIC IC04 Contact + Airborne Chickenpox or disseminated zoster IC05 Airborne, Neg. Pressure MDR Tuberculosis (TB) IC06 Infection Control use only IC07 Contact, Private Room Both VRE and MRSA IC08 Contact, Specified location Burkholderia cepacia IC09 Contact, Private room MDR Acinetobacter IC10 Contact, Private room MDR Gram negative rod IC11 Airborne Known or suspected TB
133 8.2 Infection control precautions 1 3 4
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. Contact Droplet Airborne Maximun Precautions Precautions Precautions Precautions (sign color) (pink) (orange) (blue) (red) ¶ Private room Required unless Required unless Required cohorted cohorted* Door closed No No Yes Mask/Eye Protection No If within 6 feet PAPR or N95† to of patient enter room‡ Gown and Gloves To enter room To enter room No Examples MRSA, C.diff, zoster§ Influenza, bacterial TB, disseminated meningitis zoster§ * 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 ¶ Organisms that require this category of precautions, the room designation and PPE protocol shall be defined by HEIC. s
Disease-specific infection control n o i t
recommendations a d n e
Creutzfeldt-Jakob disease (CJD) m m
CJD, variant CJD and other diseases caused by prions are resistant to a o c number of standard sterilization and disinfection procedures. Iatrogenic e r l
transmission of CJD has been associated with percutaneous exposure to o r t
medical instruments contaminated with prion/central nervous system n o
(CNS) tissue residues, transplantation of CNS and corneal tissues and c n
recipients of human growth hormone and gonadotropin. Transmission of o i t
CJD has not been associated with environmental contamination or from c e f
person-to-person via skin contact. The following additional precautions n i c must be made when processing equipment that could be contaminated i f i with prion related material: c e
• Notify HEIC and the unit manager/charge nurse immediately of any p s -
suspected or confirmed CJD case and refer to the CJD policy on the e s a
HEIC Web site. e s • Use disposable equipment whenever possible. If non-disposable i D 3
equipment is used, Central Sterile Department shall be notified prior to . the start of the procedure. 8 • Label all laboratory and pathology requisitions as suspected CJD and notify the lab before sending specimens. • The following are considered highly infective and should be handled with extreme caution: brain, spinal cord, optic tissues and pituitary gland • The following are considered to be of lower infectivity: CSF, kidney, 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. Surveillance culture results are found in the electronic patient record with the test name “MRSA Surv. Cult.” 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 represents colonization, not infection, and should not prompt any antimicrobial therapy. Surveillance cultures should be obtained upon admission and weekly in the following units: MICU, WICU, CVSICU, SICU, CTU (9W), NCCU, CCU/PCCU, PICU, NICU, oncology units, Osler 8. A swab of the anterior nares should be obtained and sent for culture.
135 8.3 Disease-specific infection control recommendations u P • 1 V A S s t c • f A P T a a n s D C T o R • • • • m • i r o r v h i n e c n o f a l l r o e c 3 e r t o l l M d A I t 1 P t o P P H p h I w h p e O i o e o e n f o i t t g c n h r c u a n t a r p p r 6 o o n i a e a r a n z a a r e E p a f s b p u o R p a t e e a o t o t w t i c d e a a o b t i c u u y t a t t t v a i m s h I u t l i l c m r t m i n m i i i u C p a d o e t a s t t s o n h e f r r e e a e e c i s i o t h y o s r i i v e e g s s h m t t e e e t y c f r n t e , e m n n t i o p o e l l i e a s 2 e i n e i a o o n e . . s s y h s c n n n f t P t t t i k c a a l l n v l i e . d f d s i i ’ x – g s s m n l T C . s s s t t t y s d s e a a o r e c n w r t P f n . s s t i e N a 5 g o e : h o r P s h c e l n c c a c d t w w n m y a f o t o r i n A p a i e c e a e t o a w w r t t t i l v d c e c h w t o h i i t e n m i a i a i i i l t d a r t t a d m s m e o o c h v l i i p i i h a t m c e h h i f t l n x r - t t i t u n c a l i , h i y n n t h h h e e a v v r r t n s c p s i a s t h t t h l t . o e i N c c . 5 i e r r e e y h t r k i t g t o n p e u o a u o e e p c i p i g e h c o a u C a / t n 0 s e e i o g / r m a n s n a q h n u a o t e r r u t y s c n l r v e i o n p r 0 l i w t u e d e m - s o e s p g t u s n r : o e l t v w a e a i p t t n H a m e r e c o t t o o t i - i v a e u h T r n i m n e l 2 e u r t l s a t a e t a f l n e l a E - e e o e l m n i r a n r o i e s M d w s a n s h n b e r g n t n e t o u t g I i n d - n c t k n l s s t C s e . t o n s d a n t o d e o i i s t P t m l t a o a . t i h t i i i i d t c o u k a n i i N t P s n s v e o t w s o s / e r n t e n c p s i e e . l t f M e e b e o O s k u S n d o s n M c e r i a s n h o r c r t s t n s s h e e s s u r a e M c . R o h h r l o h r t n r o b R c o w i o p q e l r e e l e c u m s L o n o S s e o c u t m X m e v a V n S e t g u a o q e l v a c r i t h u r n u l f t A i n b c d m R a v c i o A c i i a a c u u r g u a c p 1 o l r g l e m e e d t e i e c t e E t p r y i y t c e b i i o l N u u n u w r i e x n a s n e p e i n t D d c e o e . y s i c b n r l o o n o p b d n s e o d s t r g . e l o . n t d a n S S t e c e i e i e n t f o e . s h r r z i s s I s f c a n s s . f n b u d e u . w f c ( b s e a o p d t c V c d n m a d u H l q r e . a s t t i u a m e t t e r s l a v a u d h a e i p i u R a h u u e r b s o h H u g e s y r k e V b e s d r a r c o t i r a c E l u n c s s r i e e e i C i e e e R i e . a y l o e e u 1 e l o p m s t l l ) f t a v t n a o q n W n w E U d o l n d h s n , a b d b i l 2 n u t P t f o a e s r c a s ≥ i t t o h t e s s e a t o i c i i n u i O d i h , b s e a r t h n e t f t i c r r e n n a e 7 s r h w e d c e t r u e n a t h e i a B t r g a e d B r n n 2 h i u e D h i c a t e b 4 s o e a t s p o I e l s d h e s n u w a s c D f i i t a s 2 e 8 t r e h e s e r o u e m c d l h t o o t d p t n 5 o o e 2 s s r e r r p v w f u a h o n n p f f e t a e o r u e a x 0 i 4 d e l o o r b n o a o s u t k a e t t s l p r h m n r e i r e r r i i e l h i u l t e n s s e m w e t l e h e d o o t m 1 f i l o r t s u e r r t m o k h a n l o s r m s i a s i a e s g 4 f t b u e o c s e o P t n t u o u w h p . a o s e p l d e e m d p s u r d h r P r r d b n f a u O t r i a s e a m r h t s e e h a d e O t w a 2 r a l w o o h t b n t o i e t r e t s c e i a b s s t y g 4 h n e m a t c i t e o h u o a r t f d a m s f c h u i e r n h s o e l a t a o l f a s f h e a a a s d p u e t o t s h p t t u r l e g o h , o t i h c s n b t h d i l r e t c l e r c a h s y h c y l e i r g i e e u e i e a s , o d t c c t e 4 i i 4 o f h s g a r i a i o c . b o v n p i e n b o s 8 n 8 d e v i s i t n e n i g u n i a d s e n t c s y e a d a n a t . f s i t i o o d f f c d l e h e o t r e n e t e n t r r t in the electronic patient record with the test name “Bacteriology-Stool- s n o i
VRE Stool Surv. Cult.” When a culture grows VRE, the patient is flagged t a for Contact Precautions. The results are to be used for isolation d n purposes, not to guide therapy or clinical care. The overwhelming e majority of positive surveillance cultures represents colonization, m m o
not infection, and should not prompt any antimicrobial therapy. c e r l
Surveillance cultures should be obtained upon admission and weekly o r t
in the following units: MICU, WICU, CVSICU, SICU, CTU (9W), BMT and n o
Leukemia units, NCCU, PICU. c n o i
A peri-rectal swab should be obtained and sent for culture. t c e f
The patient must be off antibiotics for ≥ 48 hours and cultures from n i c original site of infection AND 3 stool or perirectal cultures taken ≥ 1 i f i week apart must be negative. Once this is accomplished, call HEIC to c e review culture data and initiate deflagging. p s - e s
Varicella-Zoster a e s Immunocompetent patients with disseminated zoster and all i immunosuppressed patients with zoster need Contact AND Airborne D 3 .
Precautions. The following definitions apply to patients with zoster: 8 • Immunosuppressed: bone marrow transplant within the past year; acute leukemia; solid organ transplant recipients; patients receiving cytotoxic or immunosuppressive treatments, including steroid treatment for ≥ 30 days with the following doses: dexamethasone 3 mg daily, cortisone 100 mg daily, hydrocortisone 80 mg daily, prednisone 20 mg daily, methylprednisone 16 mg daily; HIV+ patients with CD4 < 200 • Disseminated: lesions outside of 2 contiguous dermatomes
Central vascular access device (VAD) recommendations All healthcare workers who place central lines are required to take the online VAD training (see HEIC Web site). To prevent central VAD-related infections follow the central line bundle and use the central line checklist: Insertion • Clean hands thoroughly • ChloraPrep® for patient skin antisepsis and allow to dry completely • Subclavian is the preferred site for central line insertion • Use full barrier precautions (drape patient from head to toe and rail to rail) and aseptic technique • Lines placed emergently should be changed as soon as the patient is medically stable Care • Scrub the hub ten times with alcohol
137 s • Change a semipermeable transparent central line dressing every 7 n o i
t days, unless it is damp, loose or soiled, in which case change the a d dressing immediately. Change gauze dressing every 48 hours n e • Change peripheral IV site and tubing every 96 hours m • Remove line as soon as possible m o
c • Refer to the VAD policy on the HEIC Web site for more details. e r l o r Evidenced-based recommendations for prevention of surgical t n
o site infections (SSI) c n Pre-operative interventions o i t • Identify and treat remote site infections c e f • Postpone elective procedures until remote infection is resolved n i
c • Control glucose pre- and post-operatively i f i • Encourage the patient to stop smoking at least 30 days pre-operatively c e
p • Instruct patient to wash with 4% chlorhexidine gluconate (CHG or s
- ®
e Hibiclens ) the night before and the morning of surgery. (Directions s a can be found at www.hopkinsmedicine.org/heic) e s i • Use appropriate peri-operative antibiotic prophylaxis (see p. 112) that D
3 is given prior to, but no more than 1 hour before, skin incision . 8 Intra-operative interventions • Clean hands with surgical scrub sponge 2–5 minutes and pick nails. For subsequent cases Avagard ® can be used • Do not remove hair at incision unless necessary for the operation • Never shave, only use clippers • Hair removal, if necessary, should take place immediately before surgery • Prepare the surgical site and surrounding area with an approved antiseptic and allow to DRY prior to placing drapes • Maintain normal core temperature (36.5°C) throughout the procedure • Control serum blood glucose levels using insulin as necessary • Use aseptic technique when placing IV devices • Use aseptic technique when manipulating stopcocks and ports • Assemble sterile equipment and solutions immediately before use • Administer 80% O2 when possible Post-operative interventions • Place a sterile dressing (as anatomically possible) 24–48 hours post surgery • Change dressing using sterile supplies and good hand hygiene • Control serum blood glucose levels using insulin as necessary
References: Guidelines for prevention of SSI: Infect Control Hosp Epidemiol 1999;20:247. Perioperative oxygen: N Engl J Med 2000;242:161.
138 m
Bioterrorism s i r o
Below are recommendations for treatment, prophylaxis, and infection r r e
control for the Category A agents of bioterrorism. Information about t o other potential agents of bioterrorism can be found on the CDC website i B .
at http://www.bt.cdc.gov/index.asp. 9 Contact HEIC immediately if any of the following agents/diseases are suspected. The microbiology lab should be notified prior to sending specimens (5-6510). Specimens should not be sent via the pneumatic tube. Important phone numbers: • HEIC Infection Control: 5-8384 (3-3855) • Microbiology Lab: 5-6510 • Maryland Department of Health and Mental Hygiene: physician on call 410-407-6154, back up 410-706-7813 • Baltimore City Health Department: 410-396-4436, after hours 410-396-3100 • U.S. Army Medical Research Institute of Infectious Diseases USAMRID: hotline 301-619-4027 • CDC Emergency Response Office: 770-488-7100
Agent & infection control Treatment & prophylaxis Anthrax Treatment • Ciprofloxacin 400 mg IV Q12H Infection Control OR Standard precautions; there is no • Doxycycline 100 mg IV Q12H evidence for person to person If inhalational anthrax, ADD Clindamycin transmission of anthrax. 600 mg IV Q8H Patients with meningitis • Vancomycin 22.5 mg/kg IV Q12H PLUS Ciprofloxacin 400 mg IV Q8H PLUS Rifampin 600 mg IV Q24H Prophylaxis • Ciprofloxacin 500 mg PO BID x 60 days OR • Doxycycline 100 mg PO BID x 60 days Anthrax vaccine may also be recommended by HEIC. Botulism Treatment This is a toxin-mediated disease; • Equine antitoxin (acquire from CDC) there is not a role for antibiotics. Prophylaxis None Infection Control Standard precautions
139 9. Bioterrorism s p p r p M I V I S T 4 e S 1 T S P A R V t p s i P A s I I r M p D p p p B s n n n n r e e u h h h H u v n u l r l u r l u l e m o 8 t i m a n r a a a a 4 g a a f f f f q q e e r a l r o i o o o t r f r r t l a F n e e e e d g e c c c e x x a h e a a u u c u c p p p n e h 0 p u u u a r : s e u c c c c i i e e e r r q u l l e l i i a a d r o o o m m o l i l l l l r r a e J n m l p n e d d d n e d d d t t t t e u m m e e l u u h a s s s A u x n i i i i p u o : c u u t t i o o o o m t t d d e e e r i e : r r M b b b c o o o m i s x i i J o e m m d a o p e s o o . . n n n n s s s J & e m e e e A : n n n s A : x i d r n : A n n M M s f a p o i M J e o o o o o J C C C C + + l l l . t t t s s J M i : o 2 A i i i r f h h h c c A i m m m o o n n n A n r A . . e M n o o o o r M 0 A e e e t a M l l l A A v v M y y y c p A A r h i i i p n n n n o 0 2 f o u t t t e e A , , , i i h A 2 a p p p e e e e e e r r A f l t t t t 2 0 t v m m p p b b a a a a a u r r r r i 0 r r a a a d d d 1 o e c t ; 2 0 a 2 r r s o o o o n n n o o t g u 2 t t t g 0 e e 9 i i m n i 0 0 i i i o p t t t t v v 0 d d d o l l l l r r l e e e 8 u n n 2 i o o o a 9 s i n n a a 0 ; n y c 0 n o n n n e t t 7 2 ; e r a a a 9 . e e t t - 1 2 e e e s f e 1 t t t n t e e : 8 o o n f o ; A o 2 ; ; 8 s s s m m m m t 2 ; e d d d 2 f f 3 r 2 - r r 3 s s s 7 t p 8 o u u u v c p o o 8 p p : h a a a i 8 t e e e 9 a 2 : r r r e 1 f e h r o o a a 5 e 2 s s s o 5 i i i n n n . 1 i 2 r n n n : p e r v t t k k k m m r : 2 2 : t t t s n i i 2 8 g g g e s a 1 a i i i e e 3 a a a o f 1 s s s 7 t 1 t t 0 i n n i i i l l l r t t t 6 e n i r h h h 2 s s s 6 e r r r t t s 5 m m m o o o o s s 7 a a a n 3 t r 9 n u u u o n n n l t e e e o s l l l s s s o d d d d d d p p p m i i i c c c b b b o o o a a a e e e r r r l l l t t t . . . T P • • T P P • S T • • • • T N T • P P • • • • r r r r r a u r r r o r S D h • V O Q Q ( O O A L s E G C C D S P S D D e e e e e p o o o v t o p n i e e a r b r t i t m i i h o o n e 1 1 a a a a a R R R o 5 Q d R r e s p p p p g p r e a r e p m n s e o l c n e x x c e 2 2 t t t t o n e x o 0 i r o e e h h h 6 a s e b h t m m m m f y y l e t o p c p t y a o s H H a r e n 0 x l r m a a y y y H z a s c c l y a f i t t c t p e s , r p r t n l m u l l e e e e l l o o v i y y a o r m i l a f a a a v m e , y o w M n a x o e a e i e h c c m n n n n m s r e x b i c : x x x x t e t s c l i p a v i l l g x t a 4 t t t t n h a a t i n i i l l s i i i y o , y u n n y i e h t g h i v s s s r ) n e n c i n h t c u c n r e e s B v b 3 r d e a i n I i w e m c , e e p i n V i a 5 h u n a & c o n n 0 r 1 1 r R i p c e 1 e r a y t i c f e l 5 a 1 Q c i m 1 g 0 0 1 e h o i c m m v s c 6 n i n f p 0 p o n 0 i 8 v , t 5 0 0 i 5 i r , n d o i a g n y e g o n l e 0 t 0 m r Y H V t m n i a / m 2 m m g m v 4 r r / h p o e a s , k , t r m g e k m e i 5 x o m l i l h t p h g g g g l o g l B d K g o / i e n s g a s o t 6 / n / g a m h k e r y w h y t I P I g u k ( a k V V 8 . g e y a n e m P y d O g g i l P g f z s s x d c d f r e O Q Q a m l ( e i / a O p a a l e a m v ( ( o i B y k f b v 1 2 a m x m p n o d g e e B s x f g e I e a . n 2 B 4 u y D s v r / I a a e r i i x , , D 2 r u H H e f k I , I s g x x V D x . o o r g r F > O . i . p g e 1 v r r o Q 1 1 o m e ) ( 3 e r m g 6 s n I e V g i s g ) t u H y s a h k ) ) r I e i t x V n e e I I M a M . i r ) t r i / / a s I I l V V g n
Aminoglycoside dosing and monitoring i r o t Aminoglycosides enhance the efficacy of some antibiotics. Except for i n urinary tract infections, aminoglycosides should seldom be used alone to o m
treat infections. d n a
Aminoglycoside dosing weight: g n i
Calculate Ideal Body Weight (IBW) s o
IBW female (kg) = (2.3 x inches over 5') + 45.5 d e
IBW male (kg) = (2.3 x inches over 5') + 50 d i s o
For patients < 20% over IBW, use Actual Body Weight (ABW) c y l g
For patients ≥ 20% over IBW, use Dosing Body Weight (DBW) o n (DBW) = [IBW + 0.4 (ABW – IBW)] i m A
Estimation of creatinine clearance (CrCl) by Cockcroft-Gault . A equation: (If a patient’s renal function is declining, this equation may overestimate CrCl)
CrCl = (140 – age) (weight in kg*) x 0.85 (if female) 72 (serum creatinine) * Use Actual Body Weight (ABW) unless patient ≥ 20% over IBW, use DBW as described above Extended-interval dosing, also sometimes referred to as “once- daily” 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.83)
141 A. Aminoglycoside dosing and monitoring T 1 P D D I T M D n i A r h e e o r n d 4 o o u e a s s i n u m c g 2 r i i k f r n i g a a t
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Aminoglycoside dosing in mycobacterial i r o t
infections i n o m
Amikacin is the preferred agent to treat all mycobacterial infections, d except Mycobacterium chelonae. For M. chelonae infections, Tobramycin n a
is the recommended aminoglycoside. Streptomycin is another g n i
aminoglycoside sometimes used to treat mycobacterial infections such s o
as M. tuberculosis. Please contact the Antimicrobial Stewardship d
Program pharmacist for Tobramycin/Streptomycin dosing e d i recommendation for this indication. s o c y Amikacin: l g
Normal renal function: o n i
Once daily: 15 mg/kg IV Q24H (or 10 mg/kg IV Q24H if >50 years of m A
age) . Thrice weekly: 25 mg/kg IV three times a week (may be more difficult to A tolerate) Abnormal renal function: Discuss with pharmacy clinical specialist Therapeutic drug monitoring: Peak and trough not generally necessary, except in those with renal insufficiency (GFR <60 mL/min) and if SCr increases by 0.5 mg/dL or >30% from baseline while patient on aminoglycoside therapy. Check a trough concentration to monitor for toxicity. Peaks in the low 20 mcg/mL range are acceptable, and trough concentrations are preferably <4 mc/mL or undetectable.
Aminoglycoside dosing in urinary tract infections
CrCl (mL/min) Gentamicin/Tobramycin Amikacin ≥60 3 mg/kg IV Q24H or 10 mg/kg IV Q24H or 1 mg/kg IV Q8H 3 mg/kg IV Q8H 40-59 1 mg/kg Q12H 3 mg/kg IV Q12H 20-39 1 mg/kg Q24H 3 mg/kg IV Q24H <20 1 mg/kg ONCE* 3 mg/kg IV ONCE* *Give one dose, check level in 24 hours, redose when Gentamicin/Tobramycin level <1 mcg/mL or Amikacin <4 mcg/mL Aminoglycosides are highly concentrated in urine; therefore, therapeutic 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 (GFR <60 mL/min) and if SCr increases by 0.5 mg/dL or >30% from baseline while patient on aminoglycoside therapy. • Gentamicin/Tobramycin: desired trough <1 mcg/mL or undetectable. • Amikacin: desired trough <4 mcg/mL or undetectable. 143 A. Aminoglycoside dosing and monitoring D 1 • N • • T N * < 2 4 C • • D L G i A T p L A p n M A A
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o f creatinine increases by 0.5 mg/dL or >30% from baseline, use patient g n i specific dosing. r o t i
• Measure serum aminoglycoside levels as needed. See each dosing n section above for frequency. o m
• Some data suggest that lowest level of nephrotoxicity occurs when d n a
aminoglycosides are administered during the activity period (e.g. g n
13:30), therefore afternoon administration is preferred. i s o d
OTOTOXICITY e d i
• Consider biweekly clinical screening for ototoxicity s o
• Check baseline visual acuity using a Snellen pocket card c y l
• To screen for ototoxicity, have patient shake head and then re-read g o n card. i m
• Concern should be raised if patient loses 2 lines of visual acuity. A
.
Consider formal audiology testing. A • Contact Audiology (5-6153) for help with testing for ototoxicity
References: PK/PD parameter: J Infect Dis 1987; 155:93–99 Once daily nomograms review: Pharmacotherapy 2002; 22(9):1077–1083. Patient-specific dosing: Crit Care Med 1991; 19:1480–1485. SICU/WICU dosing: Surgery 1998; 124:73-8. Nephrotoxicity: Antimicrob Agents and Chemother 2003; 47:1010. ATS/IDSA Mycobacterium Guidelines: Am J Respir Crit Care Med 2007; 175:367–416. Gram-positive Synergy: Circulation 2005; 111(23): e394– 434.
145 g n
i Vancomycin dosing and monitoring r o t i n DOSING o m 1. Estimate creatinine clearance (CrCl) using Cockcroft-Gault equation: d n a CrCl = (140 – age) (weight in kg) x 0.85 (if female) g n 72 (serum creatinine*) i s o
d * For patients with low muscle mass (i.e. many patients > 65 yrs), some advocate using
n a minimum value of 1 to avoid overestimation of CrCl i c y 2. Patients who are seriously ill with complicated infections such as m o
c meningitis, pneumonia, osteomyelitis, endocarditis, and n a bacteremia and normal renal function should receive initial loading V
. dose of 20-25 mg/kg, followed by 15-20 mg/kg Q8-12H using B 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 CrCl (mL/min) (kg) >60 30–59 15–29 <15 or dialysis, (HD,CVVHD) <40 Consider ID/Abx Mgmt input (7-4570) 40–49 750 mg 750 mg 750 mg 1000 mg, then redose by level† Q12H Q24H Q48H 50–59 1000 mg 1000 mg 1000 mg 1000 mg, then redose by level† Q12H Q24H Q48H 60–75 1000 mg 1000 mg 1000 mg 1000 mg, then redose by level† Q12H Q24H Q48H 76–90 1250 mg 1250 mg 1250 mg 1250 mg, then redose by level† Q12H Q24H Q48H 90–110 1500 mg 1500 mg 1500 mg 1500 mg, then redose by level† Q12H Q24H Q48H > 110 Consider ID/Abx Mgmt input (7-4570)
†For patients with CrCl <15 mL/min and not receiving hemodialysis redose when random level <15–20 mcg/mL. For patients receiving maintenance hemodialysis, redose after hemodialysis session if pre-hemodialysis level <25 mcg/mL for pneumonia, osteomyelitis, endocarditis or bacteremia. For meningitis, consider redosing patient if pre-hemodialysis level <30 mcg/mL. Loading dose should not be used in these patients.
THERAPEUTIC DRUG MONITORING (LEVELS) • Peak levels should NOT be obtained. • Trough levels are the most accurate and practical method for monitoring Vancomycin effectiveness and toxicity.
146 Measuring serum Vancomycin levels g n i • Trough levels should be obtained just prior to the next dose at steady- r o t i
state conditions (approximately before the 4th dose). n • In patients with ESRD on hemodialysis, it is preferable to obtain a pre- o m
hemodialysis level with the routine laboratory venipuncture on the d n a
morning of hemodialysis. In the event a pre-hemodialysis level is not g n
obtained, a post-hemodialysis level may be drawn at least six hours i s
after the dialysis session. o d
n
• Trough levels should be considered in patients with any the following i c
circumstances: y m
• Receiving aggressive dosing (>1500 mg Q12H) or Q8H interval o c
• Serious infections such as meningitis, endocarditis, osteomyelitis, n a V
and MRSA pneumonia. .
• Unstable renal function (change in SCr of 0.5 mg/dL or 50% from B baseline) or dialysis • Concurrent therapy with nephrotoxic agents (e.g. aminoglycosides, Colistin, Amphotericin B) • Prolonged courses (>3-5 days) of therapy. • Frequency of monitoring Vancomycin trough levels: • Once-weekly monitoring is recommended for patients with stable renal function who have achieved desired trough levels. • More frequent monitoring is recommended for patients who are hemodynamically unstable and/or with changing renal function. Desired Vancomycin trough levels • Pneumonia, osteomyelitis, endocarditis, bacteremia: 15-20 mcg/mL • CNS infections: 20 mcg/mL • Neutropenic fever, skin and skin-structure infections: 10-15 mcg/mL • For MRSA infections serum trough concentrations >10 mcg/mL should always be maintained to avoid development of resistance. Monitoring for Toxicity • Serum creatinine should be measured at least every other day initially, then weekly if patient’s renal function remains stable. • Limited data suggest a direct causal relationship between nephrotoxicity and higher serum trough concentrations (>15-20 mcg/mL). Monitor Vancomycin trough levels (see above for frequency and indications). • Formal audiology testing is not recommended for patients receiving Vancomycin, unless signs and symptoms of ototoxicity became apparent. References: IDSA/ASHP/SIDP Guidelines therapeutic monitoring of Vancomycin: Am J Health-Syst Pharm. 2009; 66; 82. ATS/IDSA Guidelines for HAP/VAP: AJRCCM 2005; 171:338. IDSA Guidelines for Bacterial Meningitis: Clin Infect Dis 2004:39:1267.
147 C. Antimicrobial therapy monitoring 1 4
8 Recommendations for monitoring patients receiving long-term antimicrobial therapy • Long term defined as ≥ 1 week, except for aminoglycosides and Amphotericin B (see below) • For use once initial dosing and serum levels have been established • These monitoring recommendations and monitoring for agents not listed should be individualized, based on each patient’s clinical features, including general health status, age, underlying conditions and organ dysfunction, concomitant medications, drug treatment history, type of infection, and type and dose of antibiotic Antimicrobial agent(s) Test Frequency Other Aminoglycosides (Amikacin, Gentamicin, CBC Weekly Clinical monitoring and patient education Tobramycin, Streptomycin) BUN, Creatinine Twice weekly for hearing/vestibular dysfunction at Aminoglycoside level – trough Weekly each visit (see page 145 for vestibular (see dosing section page 141) (twice weekly, if increased risk) screening method) Amphotericin B, AmBisome® BUN, Creatinine, K, Mg, Phos Twice weekly CBC, AST, ALT 1–2 weeks -lactams (Aztreonam, carbapenems, CBC, BUN, Creatinine Weekly cephalosporins, penicillins) Oxacillin, Nafcillin, carbapenems add AST/ALT/bilirubin Weekly Antipseudomonal penicillins add K Weekly Micafungin AST/ALT/bilirubin Weekly Colistin BUN, Creatinine Weekly Clinical monitoring for neurotoxicity (twice weekly, if increased risk) (dizziness, paresthesia, vertigo, confusion, visual disturbances, ataxia) Daptomycin CBC, BUN, Creatinine , CPK Weekly Clinical monitoring for myopathy Linezolid CBC Weekly Clinical monitoring for peripheral neuropathy and optic neuritis Rifampin CBC, AST/ALT/bilirubin Weekly Drug interactions (monitor start of any new medications) Voriconazole /Posaconazole CBC, AST/ALT/ bilirubin 1 – 2 weeks Drug interactions (monitor start of any new medication), visual changes Vancomycin Normal renal function: Weekly CBC, BUN, Creatinine Every two weeks, unless change in creatinine
Vancomycin level – trough ( ¬ 50% from baseline) (see dosing section p. 146) Dialysis: At each dialysis session Vancomycin level (see dosing section p. 146) Reference: Practice Guidelines for Outpatient Parenteral Antimicrobial Therapy: Clin Infect Dis 2004; 38:1651. e s
Oral antimicrobial use in hospitalized patients u
l a i b
When using an agent that is considered to be bioequivalent (no o r c significant difference in rate and extent of absorption of the therapeutic i m i
ingredient) via the parenteral and oral route, the oral formulation is t n
preferred if the patient does not have the contraindications listed below. a
l a r O
Contraindications to oral therapy .
• NPO (including medications) D • Inability to take other oral medications OR not tolerating a liquid diet/tube feeds • Hemodynamic instability • Receiving continuous NG suctioning • Severe nausea, vomiting, diarrhea, GI obstruction, dysmotility, mucositis • A malabsorption syndrome • 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 Amoxicillin 74 – 90% Amoxicillin/Clavulanate (Augmentin®) 74 – 90% Azithromycin* 38 – 83% Cephalexin 90% Cefpodoxime* 41 – 50% Clindamycin 90% Doxycycline 90 – 100% Tetracycline 75 – 80% Can be used orally for bacteremia or fungemia Ciprofloxacin† 65 – 85% Fluconazole >90% Linezolid† 100% Metronidazole 100% Moxifloxacin† 90% Trimethoprim/sulfamethoxazole† 85 – 90% Voriconazole‡¶ ~96% * 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 149 y c Antimicrobial dosing in renal insufficiency n e i c i Dosing recommendations can vary according to indication and patient- f f
u specific parameters. All dosage adjustments are based on creatinine s n i clearance calculated by Cockcroft-Gault equation. e r u
l (140 – age) (weight in kg) i CrCl = x 0.85 (if female) a f 72 (serum creatinine*) l a *For patients with low muscle, some advocate using a minimum of 1 to avoid n e overestimation of CrCl. r n
i †
If patient is on hemodialysis (HD) schedule administration so that patient g receives daily dose immediately AFTER dialysis. For assistance with dosage n i s adjustments for patients receiving CVVHD or CVVHDF, please call pharmacy. o d l
a Drug Typical dose CrCl Dose adjustment for i b (may vary) (mL/min) renal insufficiency o r Acyclovir IV 5–10 mg/kg Q8H >50 5–10 mg/kg Q8H c i 25–50 5–10 mg/kg Q12H m i 10–24 5–10 mg/kg Q24H t † n <10 or HD 2.5–5 mg/kg Q24H A
. Acyclovir PO 200 mg 5x daily >10 200 mg 5x daily E (Genital herpes) <10 200 mg Q12H Acyclovir PO 800 mg 5x daily >25 800 mg 5x daily (Herpes Zoster) 10–25 800 mg Q8H † <10 or HD 800 mg Q12H Amantadine 100 mg Q12H >50 100 mg Q12H 30–50 200 mg x 1 day, then 100 mg Q24H 15–29 200 mg x 1 day, then 100 mg Q48H † <15 or HD 200 mg weekly Amoxicillin 500–1000 mg Q12H >30 500–1000 mg Q12H 10–30 250–875 mg Q12H † <10 or HD 250–875 mg Q24H Amoxicillin 1 g Q8H >30 1g Q8H (pneumonia) 10–30 1g Q12H † <10 or HD 1g Q24H Amoxicillin/ 500–1000 mg Q12H >30 500–1000 mg Q12H clavulanate 10–30 250–500 mg Q12H † <10 or HD 250–500 mg Q24H Amphotericin B 0.7–1 mg/kg Q24H – No dosage adjustment AmBisome® 3–5 mg/kg Q24H – No dosage adjustment Ampicillin 1–2 g Q4–6H >50 1–2 g Q4–6H 10–50 1–2 g Q6–8H † <10 or HD 1–2 g Q8H Ampicillin/ 1.5–3 g Q6H ≥30 1.5–3 g Q6H sulbactam 15–29 1.5–3 g Q12H † ≤14 or HD 1.5–3 g Q24H Azithromycin 250–500 mg Q24H – No dosage adjustment Aztreonam 1–2 g Q8H ≥30 1–2 g Q8H 10–29 1–2 g Q12H † <10 or HD 1–2 g Q24H
150 Drug Typical dose CrCl Dose adjustment for y c
(may vary) (mL/min) renal insufficiency n e i c
Cefazolin 1–2 g Q8H ≥35 1–2 g Q8H i f 11–34 500 mg–1 g Q12H f u
<10 500 mg–1 g Q24H s † n i
HD 2 g Q HD, if HD in 2 days e
OR 3g Q HD, if HD in r u l
3 days i a f
Cefepime 1 g Q8H >60 1 g Q8H l
30–60 1 g Q12H a <29 or HD† 1 g Q24H n e r
Cefepime 2 g Q8H >60 2 g Q8H n (Central nervous 30–60 1 g Q8H i
system infections or 11–29 1 g Q12H g
† n Pseudomonas) <11 or HD 1 g Q24H i s
Cefotetan 1–2 g Q12H ≥30 1–2 g Q12H o d
10–29 1–2 g Q24H l † a
<10 or HD 500 mg Q24H i Cefpodoxime 100–400 mg Q12H ≥30 100–400 mg Q12H b o <30 100–400 mg Q24H r c HD† 100–400 mg three i m times/week i t
Ceftaroline 600 mg Q12H >50 600 mg Q12H n A
30–50 400 mg Q12H .
15–29 300 mg Q12H E <15 or HD† 200 mg Q12H Ceftaroline for 600 mg Q8H >50 600 mg Q8H MRSA 30–50 400 mg Q8H 15–29 300 mg Q8H <15 or HD† 400 mg Q12H Ceftazidime 1–2 g Q8H >50 1–2 g Q8H For Pseudomonas 30–50 1–2 g Q12H 2 g Q8H 15–29 1–2 g Q24H 5–15 500 mg–1 g Q24H HD† Load with 1 g, then 500 mg Q24H Ceftriaxone 1–2 g Q24H – No dosage adjustment Ceftriaxone 2 g Q12H – No dosage adjustment (Central nervous system infections) Cephalexin 500 mg PO Q6H >50 500 mg Q6H 10–50 500 mg Q8H <10 or HD† 500 mg Q12H Cidofovir 5 mg/kg Q week for ≤55 or Cr>1.5 Not recommended 2 weeks, then every other week Ciprofloxacin IV 400 mg Q8–12H ≥30 400 mg Q8–12H <30 or HD† 400 mg Q24H Ciprofloxacin PO 250–750 mg Q12H ≥30 250–750 mg Q12H <30 or HD† 250–500 mg Q24H Clarithromycin 250–500 mg Q12H ≥30 250–500 mg Q12H <30 250–500 mg Q24H Clindamycin PO: 300 mg Q8H – No dosage adjustment IV: 600 mg Q8H Colistin 2.5 mg/kg Q12H ≥50 2.5 mg/kg Q12H (Colistimethate) 20–50 2.5 mg/kg Q24H ≤20 or HD† 1.25 mg/kg Q24H Daptomycin 6–10 mg/kg Q24H ≥30 6–10 mg/kg Q24H for endocarditis/ <30 6–10 mg/kg Q48H bacteremia HD† 6–10 mg/kg Q48H
151 y Drug Typical dose CrCl (mL/min) Dose adjustment for c n (may vary) renal insufficiency e i c i Dicloxacillin 250–500 mg Q6H – No dosage adjustment f f Doxycycline 100 mg Q12H – No dosage adjustment u s Ertapenem 1 g Q24H ≥30 1 g Q24H n † i
<30 or HD 500 mg Q24H e Ethambutol 15–25 mg/kg Q24H 10 Normal dose Q24H r ≥ u l <10 Normal dose Q48H i † a HD Normal dose QHD session f l Fluconazole 200–800 mg Q24H ≥50 Normal dose (e.g. 100, 400, a
n 800 mg) Q24H † e <50 or HD Load w/normal dose, then r
n 50% of normal dose Q24H i Flucytosine (5–FC) 12.5–25 mg/kg Q6H >40 12.5–25 mg/kg Q6H g
n 20–40 12.5–25 mg/kg Q12H i s 10–19 12.5–25 mg/kg Q24H o †
d <10 or HD 12.5–25 mg/kg Q24–48H l Ganciclovir 5 mg/kg Q12H ≥70 5 mg/kg Q12H a i (Induction dose) 50–69 2.5 mg/kg Q12H b o 25–49 2.5 mg/kg Q24H r c
i 10–24 1.25 mg/kg Q24H †
m <10 or HD 1.25 mg/kg three i t times/week, administer after n
A HD
. Ganciclovir 5 mg/kg Q24H ≥70 5 mg/kg Q24H E (Maintenance 50–69 2.5 mg/kg Q24H dose) 25–49 1.25 mg/kg Q24H 10–24 0.625 mg/kg Q24H <10 or HD† 0.625 mg/kg three times/week, administer after HD Gentamicin ––See section on aminoglycoside dosing Isoniazide 300 mg Q24H – No dosage adjustment Linezolid 600 mg Q12H – No dosage adjustment Meropenem 1 g Q8H >51 1 g Q8H 26–50 1 g Q12H 10–25 500 mg Q12H <10 or HD† 500 mg Q24H Meropenem 2 g Q8H >51 2 g Q8H (Central nervous 26–50 1 g Q8H system infections) 10–25 1 g Q12H <10 or HD† 1 g Q24H Metronidazole 500 mg Q8H – No dosage adjustment Micafungin 100–150 mg Q24H – No dosage adjustment Moxifloxacin 400 mg Q24H – No dosage adjustment Nitrofurantoin 100 mg Q12H ≥50 100 mg Q12H (Macrobid®) <50 Not recommended Norfloxacin 400 mg Q12H ≥30 400 mg Q12H <30 or HD† 400 mg Q24H Oseltamivir 75 mg Q12–24H ≥30 75 mg Q12–24H 10–29 75 mg Q24–48H <10 or HD† 30 mg Q every other HD session Oxacillin 1–2 g Q4–6H – No dosage adjustment Penicillin G 3–4 million units Q4H ≥50 3–4 million units Q4H 10–49 1.5 million units Q4H <10 or HD† 1.5 million units Q6H Piperacillin/ 3.375–4.5 g Q6H >40 3.375 g Q6H (4.5 g Q6H tazobactam for Pseudomonas) 20–40 2.25 g Q6H (3.375 g Q6H for Pseudomonas) 152 Drug Typical dose CrCl (mL/min) Dose adjustment for y c
(may vary) renal insufficiency n e i
<20 2.25 g Q8H (2.25 g Q6H for c i f
Pseudomonas) f
† u
HD 2.25 g Q12H (2.25 g Q8H for s n
Pseudomonas) i
Posaconazole 400 mg Q12H – No dosage adjustment e r
Pyrazinamide 15–30 mg/kg Q24H ≥10 15–30 mg/kg Q24H u l <10 12–20 mg/kg Q24H i a
† f
HD 25–30 mg/kg QHD session l
Quinupristin/ 7.5 mg/kg Q8H – No dosage adjustment a n
dalfopristin e r Rifampin (TB) 600 mg Q24H – No dosage adjustment n i
Rifampin 300 mg Q8–12H – No dosage adjustment Rimantadine 100 mg Q12H >10 100 mg Q12H g n i
≤10 100 mg Q24H s Telavancin 10 mg/kg Q24H >50 10 mg/kg Q24H o d
30–50 7.5 mg/kg Q24H l a 10–29 10 mg/kg Q48H i † b
<10 or HD No data o r
Tigecycline 100 mg once, then – No dosage adjustment c i 50 mg Q12H m i
TMP/SMX PO: 1–2 DS tab Q12H ≥30 1–2 DS tab Q12 or t (UTIs or cellulitis) IV: 160–320 mg Q12H 160–320 mg IV Q12H n A
(Dosing is based on <30 1–2 DS tab Q24H or . TMP component) 160–320 mg IV Q24H E TMP/SMX 5 mg/kg Q6–8H ≥30 5 mg/kg Q6–8H (PCP or serious <30 2.5 mg/kg Q6–8H systemic infections) HD† 2.5 mg/kg Q8H Valacyclovir 500–1000 mg Q12H ≥30 500–1000 mg Q12H (Genital herpes) 10–29 500–1000 mg Q24H <10 or HD† 500 mg Q24H Valacyclovir 1 g Q8H ≥50 1 g Q8H (Herpes Zoster) 30–49 1 g Q12H 10–29 1 g Q24H <10 or HD† 500 mg Q24H Valganciclovir 900 mg Q12H ≥60 900 mg Q12H (Induction dose) 40–59 450 mg Q12H 25–39 450 mg Q24H 10–24 450 mg Q48H <10 or HD† Not recommended Valganciclovir 900 mg Q24H ≥60 900 mg Q24H (Maintenance dose) 40–59 450 mg Q24H 25–39 450 mg Q48H 10–24 450 mg twice weekly <10 or HD† Not recommended Vancomycin ––See section on vancomycin dosing Voriconazole See Voriconazole – No dosage adjustment is guidelines page 18 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.
153 10. Index A A A A A B A A A A A A 1 B ~ A ~ I z s s n n m m m m n l b i a n B A 5 l l V S R C A U S M G G S S D B P P P e i o p p t t a d c a 6 ~ a ~ i i m d e e a e p p i i u I e B i T r N i r r m b y e n k l l i e S S d d d d C t v o r a g e i r a n n r r r n e e i h I a P c y a o e i r S o r c a o o i e
i m g e e m U i i o
m c a y i c n a g o o t t d
r r
o c c d r g s i t s s
e e A o o , i t i o l y g l / o r x l i c b t t i o a i i l
y - . r b r i i
r - o l i i n l n n i e
n e i n n n
m p W p
l n n m y i r n o a g c a u s l e V A s o n t a . n e f
a g a a i i r c e g g o r /
c b e g t t v l i u l i s a s s m I i c i
s g
y . y n l a t m i i C n c s o n
s a t p s s p
l c i
n i u i . c t - c i a i . . g a c t
. s o i u i r
t i n i s i g U / , e
r t n n i i n .
c c f t n . o i i e l t n s t . . . i o
. l s f g n
f
G i i r i o i e t p b
o
i v d . .
o . i v e d n l s f l e i B . . . . c i . d p a
. l l e a n u e n I e a e m
y e
i . g . . .
c o i o
r n i d . . . . o t h
. ,
. l f m p c e s
c r c s . a
e t
l s . . .
s e i s y y i
e y s . . . . . i n l i
. t n e t o t n . c i o d i
i .
. . .
y c i o l p c a c s o i n
s f . . . . o
. . a c r
. n s f t . e n n
.
t . . . .
n o m i i g f n
e i x y n . . . . n
d . . . g i i
. o . c s o e d o
. i
. . . .
s e
c i s a . . . .
. . . t s
. . n r r e n i
. .
a i
t . . . . .
g d a o ......
s
. . . . .
. i s s
l o
. . .
......
t e y n
......
. . . .
.
i
n
. . .
o .
......
s ......
. . . .
.
1 1 1
n
......
1 ......
.
1 5 2
......
4 7 ......
1 3 3 2 3 1 4 3 4 3 2 0 5 1 6 ......
8 3 6 1 9 4 1 6 2 8 - - - - 1 1 1 1 1 1 1 1 , . . . 1 .
------6 7 3 2 4 4 4 4 2 3 3 2 4 1 4 3 4 3 8 1 5 2 4 .
8 9 1 7 3 3 4 3 4 0 5 7 3 0 5 2 7 3 9 0 5 3 6 2 C C C C C C B B C C C C B C ~ C C C C C C l i r C y o O o o o o l h h a a a e e e a o o P E ( r C i S M S N H B A i b E o a n n s s e o o n n n t n f l s m m m l P l o t l a ~ m n n i s h e r e a t h o i f f o e u e s t E C S G S e p d d d n t t l l a a e e t t c t e a i D d u e e t m r
n m b m l t e o c n h
r r i n o i i i p . t i a h r o r i c c a i b d d d n e c n t s a
n t
- a i r
n i o
i
a o d t n d i r C i n e n e a n a f t t e l u u o D f g i t p y s t e u i r b
e
p .
o t i i a m l g i s e
r a a i d t i g u r n t o o i n n
x b a N s r i r u m h i c i s r n o e h e n o s . - t t t n e u i b t i r i e a o i i r i n n t n r
. s m - i i a r a c
d e t c t S i , u a g r e i c s n l e i f t . n
o o t i e s s c r y o i
s s t c t m - a l e
r . e a s . a b h m c u e r
i i v - i l . .
s
c - n o a
e t s s m a g o d i e a c
. . s
d b . . . . e . l o n s o i g . i .
e e m p . s
p r t
c s i o
l c t s
. . . t i r l
. . . . . f c u . a i e a i b a . f e i
s . e
. . e h n c .
e a c
o q s
f C
. . .
s
t ...... g d t . a
s . c i e f n r . i
. . c p p . u
e i
i n c u d n
e
n . . .
o v
o
...... t u . i i r . s t s . a
y . . . d f .
i i i c
f i c e
g r a o i l
l b . . .
i v
...... s . e y o e a c . t .
. . e . .
.
t
s e
p i n i e
. . .
h
...... s c .
s e n r i a . d .
......
o p t
r s y o
a o t
. . .
t
...... e s n h . l . a
. e
. . . . . s . i n
p
s d
s p o
. . . -
e t
...... g . n m s .
......
e
t s
n n r
. . . . .
...... e e . .
a
...... s .
e s
......
...... g . ) 1 ( p , .
......
u
C
1 1 1 1 1 1
...... a . y 0 ...... m .
N
5 3 0 2 0 0 t
...... 8 ......
i
v
o
8 7 5 4 4 3 3 6 6 5 9 9 6 4 8 6 S . , ......
e n
3 6 3 - 4 6 6 8 5 3 2 - - - - - . ) 1 1 1 1 1 1 1 1 ......
i
- - 8 ------a 7 7 3 5 5 5 5 6 6 6 8 7 5 5 4 3 3 6 6 5 9 4 1 2 1 0 2 .
- 4 5 9 2 5 6 4 4 7 8 9 4 8 9 6 5 7 7 7 9 7 6 3 0 1 6 0 7 4 ~D~ Gonococcal urethritis, x e d
Daptomycin...... 9-10 cervicitis, proctitis . . . . . 71-72 n I
Diarrhea ...... 48-50 Gynecologic infections . 0
Diabetic foot infections . . . 95-97 Endomyometritis ...... 70 1 Diverticulitis ...... 37 Pelvic inflammatory Dosing, antimicrobials disease ...... 70 See Antimicrobial dosing Double coverage...... 129-130 ~H~ ~E~ Healthcare-acquired pneumonia (not VAP) ...... 79-80 Encephalitis H. pylori infection...... 51-52 See CNS infections Endocarditis ...... 57-62 Treatment ~I~ Culture-negative ...... 60 ICD infection ...... 63-64 Diagnosis ...... 61-62 ID approval Fungal...... 110-111 Antimicrobials ...... 7 Pathogen-specific Pager ...... 6 therapy...... 57-61 Infection control ...... 131-138 Prosthetic valve ...... 60-61 Infectious diarrhea...... 48-50 Prophylaxis ...... 115 Influenza ...... 85-86 Endomyometritis ...... 70 Isolation precautions . . . 133-134 Endophthalmitis ...... 110 Epidural abscess...... 100-101 ~L~ Ertapenem ...... 10-11 Linezolid ...... 12 ~F~ Long-term antimicrobial therapy...... 148 Febrile neutropenia See Neutropenic fever ~M~ Formulary ...... 7 Fosfomycin ...... 11 Meningitis, bacterial...... 65-67 Fungal infections Antimicrobial dosing ...... 69 Candida spp 106-111, 124-126 Empiric therapy...... 65 Filamentous fungi . . . . 123-124 Pathogen-specific therapy . . 66 Prophylaxis, SICU/WICU . . 111 MDR Gram-negative Fusarium ...... 124 organisms ...... 25-27 Micafungin ...... 15-16 ~G~ Microbiology ...... 28-35 Gentamicin MRSA See Aminoglycosides Decolonization ...... 94-95 GI perforation ...... 41-42 Soft-tissue infections. . . . 93-94 Surveillance ...... 135-136
157 x Resistant Gram-negative e ~N~ d
n infections ...... 25-27 I
Necrotizing fasciitis . . . . . 99-100 . Restricted antimicrobials...... 7 0
1 Neutropenic fever . . . . . 119-120 Nosocomial pneumonia . . . 79-80 ~S~ ~O~ SBP Oncology See Peritonitis Neutropenic fever. . . . 119-120 Sepsis ...... 91 Oral antimicrobials ...... 149 Sexually transmitted diseases ...... 71-73 Shunt infection ~P~ See CNS infections P. acnes infection ...... 22-23 Skin, soft-tissue and Pacemaker infection . . . . . 63-64 bone infections Pancreatitis...... 38-39 Cellulitis ...... 92-93 Parasites ...... 50 Cutaneous abscess . . . . 93-94 Pelvic inflammatory disease . . 70 Diabetic foot infection. . . 95-97 Penicillin allergy...... 127-128 Necrotizing fasciitis . . . 99-100 Peritonitis/GI perforation . . 41-42 Post-op infections...... 97-99 Peritoneal dialysis-related. . . 42 Recurrent MRSA...... 94-95 Spontaneous bacterial . . 39-40 Surgical-site infections . . 97-99 Post-op / post-procedure Vertebral osteomyelitis, infections ...... 97-99 diskitis, epidural Pneumonia abscess ...... 100-101 Community-acquired. . . . 75-78 Streptococci ...... 24-25 Healthcare-acquired . . . . 79-80 Surgical prophylaxis . . . 112-115 Ventilator-associated. . . . 81-82 Surgical-site infections . . . . 97-99 Posaconazole ...... 16-17 Prevention...... 138 Pre-operative prophlyaxis 112-115 Surveillance Price of antimicrobials. . 154-155 MRSA ...... 135-136 Prophylactic use of antimicrobials VRE ...... 136-137 Endocarditis ...... 115 Susceptibility testing . . . . . 28-29 Fluconazole in ICUs ...... 111 Synergy...... 129 Hematologic Syphilis ...... 72-73 malignancy...... 121-122 Pre-op / pre-procedure 112-115 ~T~ Solid organ ...... 116-118 Therapeutic monitoring Aminoglycosides . . . . 141-145 ~R~ Vancomycin ...... 146-147 Renal insufficiency Outpatient long-term Antimicrobial dosing . . 150-153 antimicrobial therapy . . . 148 Reported diseases...... 132 Tigecycline...... 13
158 Tobramycin x ~V~ e d
See Aminoglycosides n I
Vancomycin Transplant . 0
Dosing...... 146-147 1 Antimicrobial prophylaxis Monitoring ...... 146-147 Hematologic Ventilator-associated pneumonia malignancy ...... 121-122 (VAP) ...... 80-82 Solid organ...... 116-118 Vertebral osteomyelitis, diskitis, Trichomoniasis...... 71 epidural abscess . . . . 100-101 Tuberculosis ...... 87-90 Voriconazole ...... 17-18 VRE Surveillance ...... 136-137 ~U~ Urinary tract infections Bacterial ~W~ Cystitis ...... 102-103 Wound infections, post-op . 97-99 Pyelonephritis . . . . . 102-103 Urosepsis ...... 102-103 Catheter-related . . . . . 104-105 Fungal ...... 106-107
159
Important Phone Numbers
Antibiotic Approval: ...... PING “antibiotic” and select “Antibiotic Approval Pager” Antimicrobial Stewardship Program: ...... 7-4570 Infectious Diseases Consults: ...... 3-8026 Oncology/Transplant Service (Transplant ID) . . . . . # 4-0242 Adult Inpatient Pharmacy (Zayed 7000): ...... 5-6!50 Critical Care and Surgery Pharmacy (Zayed 3!2!): . 5-6505 Weinberg Pharmacy: ...... 5-8998 Microbiology Lab: ...... 5-65!0 Hospital Epidemiology & Infection Control: ...... 5-8384 HEIC Emergency Beeper: ...... 3-3855
The Johns Hopkins Hospital Antimicrobial Stewardship Program Intranet: insidehopkinsmedicine.org/amp Internet: hopkinsmedicine.org/amp Osler 425 (443) 287-4570 (7-4570)
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Cover art: Charlotte Ford Cosgrove, Line Drawing II 33, 2008.