Mayo Clinic Antimicrobial Therapy quick guide - part 5 docx

doxycycline plus gentamicin or doxycycline plus streptomycin or doxycycline plus rifampin tmp/smx, ciprofloxacin, chloramphenicol; each with or without either gentamicin or streptomyci

doxycycline plus gentamicin or doxycycline plus streptomycin or doxycycline plus rifampin

tmp/smx, ciprofloxacin, chloramphenicol; each with or without either gentamicin or streptomycin or rifampin

Often a colonizer not requiring treatment; tmp/smx

clindamycin, amoxicillin/ clavulanate

Acute: doxycycline Chronic (eg, endocarditis): doxycycline plus hydroxychloroquine; or doxycycline plus fluoroquinolone

Francisella tularensis (tularemia)

streptomycin, gentamicin CNS infections: doxycycline plus either gentamicin or streptomycin

d doxycycline, tmp/smx, any of these 3

ampicillin, amoxicillin, penicillin

penicillin, ampicillin, amoxicillin

doxycycline, 2nd- or 3rd-gen cephalosporin, tmp/smx, β-lactam/

penicillin, ampicillin, amoxicillin

Propionibacterium acnes (systemic infection)

(Common blood culture contaminant not requiring treatment) penicillin

Treatment not indicated for uncomplicated disease; fluoroquinolone, ceftriaxone

amoxicillin, ampicillin, chloramphenicol, tmp/smx, another 3rd- or 4th-gen cephalosporin, furazolidone

Any of the agents listed under first-line or alternate treatment is active below

oxacillin/ methicillin- sensitivenafcillin, oxacillin, 1st-gen cephalosporin, dicloxacillin

clindamycin (if double-disk diffusion test is negative), tmp/smx, minocycline Broad-spectrum agents with activity against oxacillin-sensitive staphylococci include cefepime, ceftriaxone, β-lactam/

oxacillin-resistant (MRSA, MRSE)

vancomycin, linezolid, daptomycin

vancomycin- intermediate or vancomycin- resistant (VISA, VRSA)

g or any of the agents listed below under

penicillin- intermediate (MIC 0.1 to

ceftriaxone, cefotaxime, newer fluoroquinolone

g; high-dose

penicillin, ampicillin, or amoxicillin

vancomycin with or without cefotaxime or ceftriaxone

penicillin, cephalosporin; for endocarditis and infections in immunocompromised patients, base treatment on susceptibility testing

fluoroquinolone, gentamicin, tmp/smx, doxycycline

d Macrolides include erythromycin, clarithromycin, and azithromycin.

e Add gentamicin or streptomycin when cidal activity is required (eg, for infective endocarditis) and agents are susceptible for

Generally resistant to penicillins and cephalosporins

a; may appear susceptible to

piperacillin/tazobactam but with potentially higher failure rate than with a carbapenem

First-line: carbapenem (Note: Some regions have seen considerable carbapenem resistance by a different mechanism in Klebsiella

-lactamase production), which can lead to development of resistance during treatment

First-line: carbapenem Alternates (depending on susceptibility testing): fluoroquinolone, tmp/smx, tigecycline, piperacillin/tazobactam, aminoglycoside, cefepime (better activity than 3rd-gen cephalosporins

c Daptomycin should not be used for pneumonia because it is inactivated by surfactant It has in vitro activity against enterococ

d Newer fluoroquinolone (eg, moxifloxacin, levofloxacin, gemifloxacin) Staphylococcal resistance to fluoroquinolone has been re

nosocomial and community-acquired strains are seen

CA-MRSA isolates tend to be more susceptible to non–

smx, clindamycin, tetracycline, fluoroquinolone) than nosocomial isolates

First-line: vancomycin, linezolid, daptomycin

Organisms with reduced susceptibility or complete resistance to vancomycin have been reported

Contact infection control immediately and obtain infectious diseases consultation

First-line: linezolid Alternates: daptomycin,

life-threatening disease or unstable patient or with azole preexposure)

b voriconazole (if no azole

preexposure or with documented susceptibility)

d (if no preexposure or with

Candidal oropharyngeal or thrush

nystatin (topical), clotrimazole, fluconazole

voriconazole, amphotericin (oral liquid), itraconazole, echinocandin,

fluconazole, itraconazole, amphotericin product

a (initial therapy for diffuse or

c Speciation and susceptibility testing for serious infections is recommended. d Both fluconazole and itraconazole MICs for

e May exhibit higher MICs with amphotericin; consider use of higher than usual doses Some resistance seen. f Do

tmp/smx; add corticosteroids for severe disease

pentamidine IV, tmp plus dapsone, atovaquone, clindamycin plus primaquine, trimetrexate

Viruses: Preferred and Alternate Treatment Options Table 28 Antiviral Organism–Specific Treatment (Non-HIV Infections) a Ocular implants and intravitreal injections for cytomegalovirus retinitis should generally be used in combination with systemi

b Intravenous acyclovir should be used for herpes simplex virus CNS disease and for sight-threatening disease or severe varicell

c Active against acyclovir-susceptible strains of HSV, but not the preferred treatment due to its toxicity and cost. d HBV vaccine should be administered as a preventive strategy to persons at risk (including health care workers).

e Lamivudine, emtricitabine, and tenofovir also have anti-HIV activity and thus are commonly used in HIV patients with HCV coinf

Influenza virus (treatment or prophylaxis)

Clinical Approach to Patients With Infection Four-Step Approach to Successful Management of Infectious Diseases 1)

of infection, disease progression, and prognosis, which include: a)

Host factors such as patient age, immune status (eg, immunosuppression; presence or absence of a spleen), other comorbid conditions, and medical problems; and

pathogen(s) on the basis of the host and syndrome information above or identify the confirmed pathogen(s) from available laboratory testing (eg, cultures, stains, serologies, antigens)

Respiratory Tract Infections Clinical Syndromes and Common Pathogens Acute Bronchitis

of upper respiratory infection, and negative findings on chest radiographs Viral agents are the most common cause; antibiotics are therefore not beneficial •

Less common but potentially antibiotic-responsive infectious agents:

(CAP) include acute or subacute onset of fever, cough, dyspnea, or pleuritic chest pain that develops in previously healthy persons •

varicella, respiratory syncytial virus (seasonal in infants and immunocompromised adults)

infiltrate in a lower lung field after a single or recurrent aspiration event Acute aspiration may cause chemical lung injury, which does not require antibiotic therapy Not all aspiration results in bacterial pneumonia •

Mixed oral or upper intestinal bacterial flora; may include anaerobes

skilled care facility for >2 days are at risk of hospital- acquired or health care–associated pneumonia; the diagnosis excludes patients in whom the organism was incubating at admission This type of infection is most common in patients who are intubated for >2-3 days Diagnostic criteria include fever, new pulmonary infiltrate, and respiratory distress Clinical diagnosis is difficult in intubated patients •

care facility, with no risk factors for multidrug-resistant (MDR) organisms (see

care facility or risk factors for MDR pathogens (Table 29): Organisms as delineated above, for early onset, plus

Data from Mandell et al Clin Infect Dis 2007;44 Suppl 2:S27-72. Table 29 Risk Factors for MDR Pathogens Causing Hospital-Acquired Pneumonia, Health Care–Associated Pneumonia, and Ventilator-Associated Pneumonia From American Thoracic Society et al Am J Respir Crit Care Med

pleuritic chest pain Dyspnea may be more pronounced than indicated by findings on chest radiographs Management often requires invasive procedures (bronchoscopy or open-lung biopsy) for diagnosis of

opportunistic infections •

Cell-Mediated (T-Cell) Immune Dysfunction (HIV, Organ Transplant, Chronic Corticosteroids) 1)

occasional pleural effusion; chest radiographs and examination findings often discordant with mild symptoms; extrapulmonary findings include erythema multiforme and Stevens-Johnson syndrome, hemolytic anemia, changes in cardiac conduction, myocarditis or pericarditis, aseptic meningitis or encephalitis, Guillain- Barré syndrome, Raynaud phenomenon, glomerulonephritis, bullous myringitis

Antimicrobial therapy in preceding 90 days Current hospitalization of

Residence in nursing home or extended-care facility Home infusion therapy (including antibiotics) Chronic dialysis in preceding 30 days Home wound care Family member with MDR pathogen

biphasic symptoms; variable findings on chest radiographs; less common extrapulmonary findings include endocarditis, meningoradiculitis, encephalitis

nonproductive or minimally productive cough; variable presentation with sometimes severe symptoms; rapidly progressive and often fatal; findings on chest radiographs include segmental to lobar infiltrate; hyponatremia and diarrhea

Outpatient, no previous antibiotic therapy

b),

c (levofloxacin, moxifloxacin,

Outpatient, recent antibiotic therapy, presence of comorbid conditions

d or other risk factors for

sulbactam) plus fluoroquinolone (levofloxacin or moxifloxacin); azithromycin may be substituted for fluoroquinolone

c Levofloxacin 750 mg for 5 days or 500 mg for 10 days Fluoroquinolones should generally not be used as first-line treatment fo

d Comorbid conditions include chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; aspleni

f De-escalate antimicrobials on the basis of culture results For hospital-acquired or health care–associated pneumonia, shorten

clavulanate) or 3rd- or 4th-gen cephalosporin combined with metronidazole or clindamycin; or fluoroquinolone combined with metronidazole or clindamycin; or carbapenem

Early onset and no risk factors for MDR organism

ceftriaxone, cefotaxime, respiratory fluoroquinolone, ampicillin/sulbactam, piperacillin/tazobactam, ticarcillin/clavulanate, or ertapenem

Late onset or risk factors for MDR organisms

tazobactam) plus ciprofloxacin, levofloxacin, or aminoglycoside; if MRSA is suspected, add vancomycin or linezolid

decreases incidence and severity of CAP (now a core measure of the Centers for Medicare and Medicaid Services and the Joint Commission on Accreditation of Healthcare Organizations for hospitalized patients)

demonstrated evidence of cardiac involvement and persistent bacteremia due to microorganisms that typically cause endocarditis Establishing a microbiologic diagnosis is critical to therapeutic decisions Every effort should be made to identify the causative organism.

Table 32 Definition of Terms Used in the Modified Duke Criteria for the Diagnosis of Infective Endocarditis Major criteria • a Excludes single positive cultures for coagulase-negative staphylococci and organisms that do not cause endocarditis. Modified from Li et al Clin Infect Dis 2000;30:633-8 Used with permission.

Blood culture positive for IE •

Typical microorganisms consistent with IE from 2 separate blood cultures: •

Microorganisms consistent with IE from persistently positive blood cultures, defined as follows: •

Echocardiogram positive for IE (TEE recommended in patients with prosthetic valves, rated at least “possible IE” by clinical criteria, or complicated IE [paravalvular abscess]; TTE as first test in other patients), defined as follows: •

Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomical explanation; or

Erratum in: Circulation 2005;112:2373 Circulation 2007;115:e408 Used with permission.

Table 34 Echocardiographic Features That Suggest Potential Need for Surgical Intervention a Surgery may be required because of risk of embolization b Surgery may be required because of heart failure or failure of

c Echocardiography should not be the primary modality used to

Erratum in: Circulation 2005;112:2373 Circulation 2007;115:e408 Used with permission.

nerve function, or infection with Abiotrophia

Use vancomycin only for patients unable to tolerate penicillin or ceftriaxone

Use 6 weeks for complicated right-sided IE and for left-sided IE; or use 2 weeks for uncomplicated right-sided IE Clinical benefit of aminoglycosides has not been established

For penicillin-allergic (non- anaphylactoid type) patients: cefazolin

b Recommended dosages are for adult patients with normal renal function.

c Adjust gentamicin dosage to achieve a peak serum level of 3-4 mcg/mL and a trough level of <1 mcg/mL Patients with Cl

d Adjust vancomycin dosage to obtain a peak (1 hour after infusion) serum level of 30-45 mcg/mL and a trough level of 10-15 mcg/m

for patients with symptoms lasting >3 monthsProsthetic valve or other prosthetic cardiac material: Use 6-week minimum therapy

b Recommended dosages are for adult patients with normal renal function. c Patients should be informed that IM injection of ceftriaxone is painful. d Fluoroquinolones are highly active in vitro against HACEK microorganisms Published data on use of fluoroquinolone therapy for

Other Treatment Considerations Role of Surgery

congestive heart failure, fungal IE, multiresistant organisms, gram-negative IE, or endocarditis of prosthetic valves, and of patients with echocardiographic features suggesting the need for surgical intervention (see preceding Elements of Diagnosis section) Care During and After Completion of Antimicrobial Treatment •

Initiate before or at completion of antimicrobial therapy: 1)

Transthoracic echocardiogram to establish new baseline

Encourage scrupulous oral hygiene and frequent professional office visits

in: Circulation 2005;112:2373 Circulation 2007;115:e408 Used with permission.