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Antimicrobial Treatment Guidelines for Common Infections

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Antimicrobial Treatment Guidelines for Common Infections Antimicrobial Treatment Guidelines for Common Infections March 2019 Published by: The NB Provincial Health Authorities Anti-infective Stewardship Committee under the direction of the Drugs and Therapeutics Committee Introduction: These clinical guidelines have been developed or endorsed by the NB Provincial Health Authorities Anti-infective Stewardship Committee and its Working Group, a sub- committee of the New Brunswick Drugs and Therapeutics Committee. Local antibiotic resistance patterns and input from local infectious disease specialists, medical microbiologists, pharmacists and other physician specialists were considered in their development. These guidelines provide general recommendations for appropriate antibiotic use in specific infectious diseases and are not a substitute for clinical judgment. Website Links For Horizon Physicians and Staff: http://skyline/patientcare/antimicrobial For Vitalité Physicians and Staff: http://boulevard/FR/patientcare/antimicrobial To contact us: [email protected] When prescribing antimicrobials: Carefully consider if an antimicrobial is truly warranted in the given clinical situation Consult local antibiograms when selecting empiric therapy Include a documented indication, appropriate dose, route and the planned duration of therapy in all antimicrobial drug orders Obtain microbiological cultures before the administration of antibiotics (when possible) Reassess therapy after 24-72 hours to determine if antibiotic therapy is still warranted or effective for the given organism or clinical situation. Reassess based on relevant clinical data, microbiologic and/or radiographic information Assess for de-escalation as appropriate based on available microbiology culture and susceptibility results 2 Antimicrobial Treatment Guidelines For Common Infections (Click arrow buttons to navigate) Section 1: Anatomical Page Foot Diabetic Foot Infections 4 Gastrointestinal Clostridium difficile Infection 5 Intra-Abdominal Infections 7 Respiratory Acute Bacterial Rhinosinusitis 9 Acute Exacerbation of Chronic Obstructive Pulmonary Disease 10 Community Acquired Pneumonia 11 Hospital Acquired Pneumonia 13 Ventilator Acquired Pneumonia 15 Skin and Soft Tissue Cellulitis/Erysipelas 17 Genitourinary When to Send a Urine for Culture and Urinalysis 18 Positive Urine Culture Assessment Algorithm 19 Urinary Tract Infection Treatment Guideline 20 Drug Use Guidelines Aminoglycoside Dosing and Monitoring Guidelines 21 Antimicrobial Dosing Tool 37 Management of Penicillin and β-Lactam Allergy 49 Antimicrobial Allergy Evaluation Tool 58 IV-to-PO Conversion Criteria 64 Surgical Prophylaxis Guidelines 65 Vancomycin Dosing and Monitoring Guidelines 84 Other Splenectomy Vaccination Kit 91 References 98 3 EMPIRIC ANTIMICROBIAL THERAPY FOR DIABETIC FOOT INFECTION (Endorsed by NB Health Authorities Anti-Infective Stewardship Committee February 2016) 1 1 Infection Severity Preferred Empiric Regimens Alternative Regimens Comments Mild Wound less than 4 weeks duration Wound less than 4 weeks duration • Outpatient management • Cellulitis less than 2 cm • cephalexin 500 mg PO four times daily* • clindamycin 300 – 450 mg PO four times daily (only if recommended and without involvement of Wound greater than 4 weeks duration severe β-lactam allergy) • Tailor regimen based on C&S deeper tissues • sulfamethoxazole/trimethoprim 800/160 mg PO twice daily* + Wound greater than 4 weeks duration results & patient response • Non-limb threatening metroNIDAZOLE 500 mg PO twice daily • amoxicillin/clavulanate 875/125mg PO twice daily* OR • No signs of systemic toxicity • doxycycline 100 mg PO twice daily + metroNIDAZOLE 500 mg PO twice daily Moderate Wound less than 4 weeks duration Wound less than 4 weeks duration • Initial management with • Cellulitis greater than 2 • ceFAZolin 2 g IV q8h* OR • levofloxacin 750mg IV/PO once daily* (only if severe outpatient parenteral therapy cm or involvement of deeper • cefTRIAXone 2 g IV once daily (to facilitate outpatient management when β-lactam allergy) with rapid step-down to oral tissues ambulatory administration of ceFAZolin not possible) Wound greater than 4 weeks duration therapy after 48 to 72 hours • Non-limb threatening based on patient response Wound greater than 4 weeks duration • levofloxacin 750mg IV/PO once daily* + recommended • No signs of systemic toxicity • ceFAZolin 2 g IV q8h* + metroNIDAZOLE 500 mg PO twice daily OR metroNIDAZOLE 500 mg PO twice daily (only if severe β-lactam allergy) • Tailor regimen based on C&S • cefTRIAXone 2 g IV once daily + metroNIDAZOLE 500 mg PO twice daily results & patient response (to facilitate outpatient management when ambulatory administration of ceFAZolin not possible) Severe • piperacillin-tazobactam 3.375 g IV q6h* • imipenem/cilastatin 500 mg IV q6h* OR • Inpatient management • Systemic signs of sepsis • levofloxacin 750 mg IV once daily* + metroNIDAZOLE recommended • Limb or foot threatening 500 mg PO/IV twice daily (only if severe β-lactam • Urgent vascular assessment if • Extensive soft tissue allergy) pulseless foot involvement • Tailor regimen based on C&S • Pulseless foot results & patient response Clinical Pearls: Duration of Therapy 1 If high risk for MRSA, should include sulfamethoxazole/ • Soft tissue only – 2 weeks trimethoprim 800/160 mg PO twice daily * or doxycycline 100 • Bone involvement with complete surgical resection of all infected bone – 2 weeks mg PO twice daily for mild infections and vancomycin weight- • Bone involvement with incomplete surgical debridement of infected bone – 4-6 weeks IV based dosing to a target trough of 15 – 20 mg/L for moderate- severe infections • Bone involvement with no surgical debridement or residual dead bone postoperatively – 6 weeks IV, followed by 6 weeks PO • Debridement, good glycemic control and proper wound care are References: important for the management of diabetic foot infections 1. Bowering K, Embil JM. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in • Cultures: prefer tissue specimens post-debridement and Canada: Foot Care. Can J Diabetes 37(2013) S145-S149 cleansing of wound; surface or wound drainage swabs not 2. Lipsky BA, Berendt AR, Cornia PB et al. 2012 Infectious Disease Society of America Clinical Practice Guidelines for the Diagnosis and Treatment recommended of Diabetic Foot Infections. CID 2012:54(12):132-173 • In a clinically infected wound a positive probe-to-bone (PTB) 3. Lipsky BA, Armstrong DG, Citron DM et al. Ertapenem versus piperacillin/tazobactam for diabetic foot infections (SIDESTEP): prospective, test is highly suggestive of osteomyelitis randomized, controlled, double-blinded, multicentre trial. Lancet 2005; 366:1695 – 1703 • Imaging: recommend plain radiography (radionuclide imaging 4. Blond-Hill E, Fryters S. Bugs & Drugs An Antimicrobial/Infectious Diseases Reference. 2012. Alberta Health Services unnecessary) * Dose adjustment required in renal impairment 9782-10650-04-2016 4 Antimicrobial Therapy for Clostridioides difficile Infection (CDI) (formerly Clostridium difficile) NB Provincial Health Authorities Anti-Infective Stewardship Committee, March 2019 Patient with 3 or more unformed or watery stools in 24 hours (NOT clearly attributable to underlying conditions or laxative use) Send stool for Clostridioides difficile testing Colonoscopic or Results pending but high Positive Clostridioides histopathologic findings of clinical suspicion difficile testing results pseudomembranous colitis Discontinue therapy with the inciting antimicrobial agent if possible o If discontinuation of antimicrobials is not possible, de-escalate therapy to narrowest effective spectrum of activity Begin infection control precautions o Accommodate patient in a private room (if possible) o Gowns and gloves (masks unnecessary) o Perform hand hygiene with soap and water at point of care; if not available, use alcohol hand sanitizer at point of care followed immediately with soap and water at the nearest clean sink (alcohol hand sanitizer does NOT effectively remove Clostridioides difficile spores) Stop all anti-peristaltic and pro-motility agents1 unless clearly indicated Treat according to severity of CDI (see below) Mild-to-moderate CDI Severe CDI Fulminant CDI Criteria: WBC lower than 15 x109/L AND Criteria: WBC greater than or equal to 15 9 Criteria: Hypotension/shock OR ileus OR serum creatinine less than 1.5 x baseline x10 /L OR serum creatinine greater than 2 2 megacolon level 1.5 x baseline level Initial episode Initial episode ANY episode Vancomycin 125 mg PO q6h Vancomycin 125 mg PO q6h Vancomycin 500 mg PO/NG q6h x 10 x 10 days3 x 10 days3 days3 PLUS metroNIDAZOLE 500 mg IV q8h4 If the patient is otherwise healthy and If contraindication to, treatment ambulatory, OR cannot access oral failure6 of or intolerance to oral If contraindication to, treatment vancomycin or fidaxomicin due to vancomycin: failure6 of or intolerance to oral prohibitive cost, may consider: vancomycin: metroNIDAZOLE 500 mg PO q8h Fidaxomicin 200 mg PO Fidaxomicin 200 mg PO q12h x 10 days3 q12h x 10 days PLUS metroNIDAZOLE 500 mg IV q8h4 If contraindication to, treatment failure6 of or intolerance to oral If ileus or vomiting, ADD vancomycin vancomycin: 500 mg in 100 mL NS retention enema q6h5 Fidaxomicin 200 mg PO q12h x 10 days 5 Recurrent CDI Definition: Recurrence of CDI within 8 weeks following the onset of a successfully treated previous episode. First recurrence: Vancomycin 125 mg PO q6h x 14
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