Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 2) pptx

Sepsis without a Clear Focus Septic shock Pseudom onas spp., gram-negative Vancomycin 1 g q12h plus Adjust treatment when culture data 1 29, 130, 143,... Ceftriaxone 2 g q12h plus Ov

Chapter 115 Approach to the Acutely

Ill Infected Febrile Patient

(Part 2)

The Acutely Ill Patient: Treatment

In the acutely ill patient, empirical antibiotic therapy is critical and should

be administered without undue delay Increased prevalence of antibiotic resistance

in community-acquired bacteria must be considered when antibiotics are selected Table 115-1 lists first-line treatments for infections considered in this chapter In addition to the rapid initiation of antibiotic therapy, several of these infections require urgent surgical attention Neurosurgical evaluation for subdural empyema

or spinal epidural abscess, otolaryngologic surgery for possible mucormycosis, and cardiothoracic surgery for critically ill patients with acute endocarditis are as important as antibiotic therapy For infections such as necrotizing fasciitis and clostridial myonecrosis, rapid surgical intervention supersedes other diagnostic or therapeutic maneuvers

Table 115-1 Empirical Treatment for Common Infectious Disease Emergencies

Clinical

Syndrome

Possible Etiologies

nts

S

ee Chap

Sepsis without a Clear Focus

Septic

shock

Pseudom onas spp., gram-negative

Vancomycin

(1 g q12h) plus

Adjust treatment when culture data

1

29, 130,

143,

or

Cefepime (2 g q12h)

fludrocortisoneb may improve outcome in patients with septic shock

Ceftriaxone (2

g q12h) plus

Overwhel

post-splenectomy

sepsis

Streptoc occus

pneumoniae, Haemophilus influenzae, Neisseria meningitidis

Vancomycin (1 g q12h)

If a β-lactam–

sensitive strain

is identified, vancomycin can

be discontinued

2

65

Babesiosis Babesia

microti (U.S.),

2

01, 204

or

Atovaquone

(750 mg q12h) plus

Azithromycin (500-mg loading dose, then 250 mg/d)

with fewer side effects

Treatmen

doxycycline (100 mg bidc) for potential coinfection with

Borrelia burgdorferi or Ehrlichia spp

may be prudent

Sepsis with Skin Findings

Penicillin (4

mU q4h)

or

Meningoco

ccemia

N

meningitidis

Ceftriaxone (2

Consider protein C replacement in fulminant

meningococcem

1

36, 167

g q12h) ia

Rocky

Mountain spotted

fever (RMSF)

Rickettsi

a rickettsii

Doxycycline (100 mg bid)

If both meningococcem

ia and RMSF are being considered, use chloramphenico

l alone (50–75 mg/kg per day

in four divided doses)

or ceftriaxone

(2 g q12h)

plus doxycyclin

e (100 mg bidc)

If RMSF

is diagnosed, doxycycline is the proven

superior agent

Ceftriaxone (2

g q12h) plus

Purpura

fulminans

S

pneumoniae, H

influenzae, N

meningitidis Vancomycin

(1 g q12h)

If a β-lactam–

sensitive strain

is identified, vancomycin can

be discontinued

1

36, 265

Erythroder

ma: toxic shock

syndrome

Group A

Streptococcus, Staphylococcus

Vancomycin

(1 g q12h) plus

If a penicillin- or

oxacillin-1

29, 130

toxigenic bacteria should

be debrided; IV immunoglobuli

n can be used in severe cases.d

Sepsis with Soft Tissue Findings

Necrotizin

g fasciitis

Group A

Streptococcus,

mixed

Penicillin (2

mU q4h) plus

Urgent surgical evaluation is

1

19, 130

substituted for penicillin while culture data are pending

Penicillin (2

mU q4h) plus

Clostridial

myonecrosis

Clostridi

um perfringens

Clindamycin (600 mg q8h)

Urgent surgical evaluation is critical

1

35

Neurologic Infections

Bacterial

meningitis

S

pneumoniae, N

meningitidis

Ceftriaxone (2

g q12h) plus

If a β-lactam–

sensitive strain

is identified, vancomycin can

be discontinued

If the patient is

>50 years old or

3

76

has comorbid disease, add ampicillin (2 g

q4h) for Listeria

coverage

Vancomycin

(1 g q12h)

Dexamet hasone (10 mg q6h x 4 days) improves

outcome in adult patients with meningitis (especially pneumococcal) and cloudy CSF, positive CSF Gram's stain, or a CSF leukocyte count

>1000/µL

Vancomycin

(1 g q12h) plus

Metronidazole

(500 mg q8h) plus

Brain

abscess,

suppurative

intracranial

infections

Streptoc occus spp., Staphylococcus

spp., anaerobes, gram-negative bacilli

Ceftriaxone (2

g q12h)

Urgent surgical evaluation is critical If a penicillin- or

oxacillin-sensitive strain

is isolated, those agents are superior to vancomycin (penicillin, 4

mU q4h; or oxacillin, 2 g q4h)

3

76

Quinine (650

mg tid) plus

Cerebral

malaria

Plasmod ium falciparum

Tetracycline

Do not use

glucocorticoids

2

01, 203

(250 mg tid)

Spinal

epidural abscess

Vancomycin

(1 g q12h) plus

3

72

Staphylo coccus spp., gram-negative bacilli Ceftriaxone (2

g q24h)

Surgical evaluation is essential If a penicillin- or

oxacillin-sensitive strain

is isolated, those agents are superior to vancomycin (penicillin, 4

mU q4h; or oxacillin, 2 g q4h)

Focal Infections

Acute

bacterial

endocarditis

S

aureus, β-hemolytic

Ceftriaxone (2

g q12h) plus

Adjust treatment when culture data

1

18

endocarditis hemolytic

streptococci, HACEK group,e

Neisseria spp.,

S pneumoniae

Vancomycin (1 g q12h)

culture data become

available

Surgical evaluation is essential

a

Drotrecogin alfa (activated) is administered at a dose of 24 µg/kg per hour for 96 h It has been approved for use in patients with severe sepsis and a high risk

of death as defined by an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of ≥25 and/or multiorgan failure

b

Hydrocortisone (50-mg IV bolus q6h) with fludrocortisone (50-µg tablet daily for 7 days) may improve outcomes of severe sepsis, particularly in the setting of relative adrenal insufficiency

c

Tetracyclines can be antagonistic in action to β-lactam agents Adjust treatment as soon as the diagnosis is confirmed

d

The optimal dose of IV immunoglobulin has not been determined, but the median dose in observational studies is 2 g/kg (total dose administered over 1–5

days)

e

Haemophilus aphrophilus, H paraphrophilus, H parainfluenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae