Mayo Clinic Antimicrobial Therapy quick guide - part 7 docx

Management of Complications •meropenem 1 g IV q8h for 4-6 weeks; or cefepime 2 g IV q12h for 4-6 weeks ciprofloxacin 750 mg oral q12h for 4-6 weeks; or ceftazidime 2 g IV q8h for 4-6 wee

nafcillin or oxacillin 1.5-2.0 g IV q4h for 4-6 weeks; or cefazolin 1-2 g IV q8h for 4-6 weeks vancomycin 15 mg/kg IV q12h for 4-6 weeks

vancomycin 15 mg/kg IV q12h for 4-6 weeks linezolid 600 mg oral or IV q12h for 4-6 weeks; or daptomycin 6 mg/kg IV q24h for 4-6 weeks

6 units per day IV

either continuously or in 6 equally divided doses for 4-6 weeks; orceftriaxone 2 g IV or IM q24h for 4-6 weeks; or cefazolin 1-2 g IV q8h for 4-6 weeks vancomycin 15 mg/kg IV q12h for 4-6 weeks

Management of Complications •

meropenem 1 g IV q8h for 4-6 weeks; or cefepime 2 g IV q12h for 4-6 weeks

ciprofloxacin 750 mg oral q12h for 4-6 weeks; or ceftazidime 2 g IV q8h for 4-6 weeks or aztreonam 1-2 g IV q8h for 4-6 weeks

Polymicrobial infection (eg, diabetic foot infection)

Treatment depends on type and severity; refer to published guidelines in Lipsky et al*

Chronic monoarticular swelling without systemic symptoms

vancomycin 15 mg/kg IV q12h for 3-4 weeks

vancomycin 15 mg/kg IV q12h for 3-4 weeks

linezolid 600 mg oral or IV q12h for 3-4 weeks

daptomycin 6 mg/kg IV q24h for 3-4 weeks

-Hemolytic streptococci or penicillin- sensitive pneumococci

penicillin G 20,000 units per day IV either continuously or in 6 equally divided doses for 2-3 weeks

vancomycin 15 mg/kg IV q12h for 2-3 weeks

ciprofloxacin 500-750 mg oral q12h for 3-4 weeks

e Avoid use for organisms that produce extended-spectrum

ciprofloxacin 750 mg oral q12h for 3-4 weeks

Reassess diagnosis, consider noninfectious etiology, rule out concomitant crystal arthritis, consider atypical organisms

Consider suboptimal medical treatment, reassess adequacy of surgical debridement, rule out periarticular osteomyelitis

Typically caused by oxacillin-resistant staphylococci; consider vancomycin therapy

Consider using piperacillin/tazobactam 3.375 IV q6h or ampicillin/ sulbactam 3 g IV q6h

Immunocompromised host or standard bacterial cultures that are negative

Gastrointestinal Infections Orofacial Infections, Esophagitis, and Gastritis Elements of Diagnosis Orofacial Infections •

dental origin; spreads rapidly and is bilateral; involves submandibular and sublingual spaces and can spread to neck; may include respiratory obstruction from edema

Acute necrotizing ulcerative gingivitis (eg, Vincent angina, trench mouth):

gingival ulcerations and gingival breakdown, usually due to poor dental hygiene

streptococci, often with anaerobic bacteria; often results in enlarged displaced tonsils, severe pharyngeal pain, dysphagia

radiotherapy, antineoplastic chemotherapy, aphthous ulcers (in 5% of AIDS patients and also in some patients with acute human immunodeficiency virus [HIV] infection)

chest pain; oral thrush common with HIV-associated candidal esophagitis; pain common with HSV and CMV esophagitis

4-fold increase in the risk for development of either gastric or duodenal ulceration; more than 90% of duodenal ulcerations are associated with

factor for development of gastric carcinoma and gastric mucosa-associated lymphoid tumors (MALT)

endoscopy and biopsy or by noninvasive techniques such as serologic analysis, breath test, or fecal antigen analysis

ampicillin/sulbactam, amoxicillin/ clavulanate, piperacillin/tazobactam, or carbapenem

penicillin G plus metronidazole; or clindamycin

Acute ulcerative or necrotizing gingivitis

voriconazole, amphotericin B, or lipid amphotericin product

foscarnet (for acyclovir-resistant strains)

without fever or dysentery; sometimes accompanied by fever 1)

mountainous regions or areas with untreated water) 1)

Association-American Nurses Foundation; Centers for Disease Control and Prevention; Center for Food Safety and Applied Nutrition, US Food and Drug Administration; Food Safety and Inspection Service, US Department of Agriculture MMWR Recomm Rep 2004;53:1-33.

Noninfectious Considerations •

Zollinger-Ellison syndrome, medullary carcinoma of the thyroid, villous adenoma of the rectum, vasoactive intestinal peptide-secreting pancreatic adenoma

ischemic colitis, radiation enteritis, eosinophilic gastroenteritisManagement and Empiric Therapy of Diarrhea Community-Acquired Diarrhea •

Stool culture (if there is fever, bloody stools, or abdominal pain) for

No fever or blood in stool 1)

Mild diarrhea of 1-2 loose stools per day: No treatment or only bismuth or loperamide

Moderate to severe diarrhea of >2 loose stools per day: Hydration plus bismuth or loperamide; can add

a fluoroquinolone for high stool output (to shorten duration of diarrhea); rifaximin is also an option

Fever, blood in stool, abdominal pain: A fluoroquinolone for 3 days; stool culture if possible

Persistent (>7 Days) Diarrhea •

metronidazole or oral vancomycin pending results of C difficile

Intra-Abdominal Infections Peritonitis and Polymicrobial Intra-Abdominal Infections Elements of Diagnosis Primary Peritonitis (Spontaneous Bacterial Peritonitis) •

Prompt abdominal and pelvic computed tomography (CT) scan is optimal for identification of source and definition of treatment; possible surgical options

Peritoneal, Retroperitoneal, or Pelvic Abscess •

Numerous potential sources such as primary or secondary peritonitis (especially due to enteric perforation), appendicitis, diverticulitis, inflammatory bowel disease, PID, postabdominal or pelvic surgery (eg, repair of an enteric or biliary anastomotic leak; splenectomy)

Ceftriaxone, cefotaxime, cefepime, or levofloxacin for 10-14 days (shorter durations are often successful); SBP recurrence common

carbapenem, piperacillin/tazobactam (Zosyn), ampicillin/sulbactam (Unasyn), ticarcillin/clavulanate (Timentin), moxifloxacin (use moxifloxacin with caution in patients with ESLD)

Depends on location and suspected source (polymicrobial or occasionally monomicrobial)

Percutaneous catheter drainage or surgical debridement to:

Evacuate devitalized or avascular infected material, define microbiology, and determine duration of antimicrobial therapy

Initial therapy as for secondary peritonitis (see below) Targeted antimicrobial therapy based on culture data and suspected source

Acute, uncomplicated (with luminal obstruction)Immediate surgery and perioperative antimicrobial prophylaxis: cefazolin plus metronidazoleOther standard surgical wound prophylaxis regimens

Consider surgery for repeated episodes, perforation, or fistula; otherwise, treat same as above

Hepatobiliary Infections Elements of Diagnosis Cholecystitis and Cholangitis •

Gallstone disease is the most common cause of cholecystitis in the United States

contaminated food or water); usually self-limiting; acute viral hepatitis in 40-60% of infections (more common in adults); fulminant disease in 8% of patients; no chronic infection; HAV vaccine and HAV immunoglobulins available

uses hepatitis B surface antigen as its structural shell (requires HBV coinfection or superinfection in patients with chronic HBV infection); more aggressive liver disease occurs when HDV superinfects patients with chronic HBV infection, with development of chronic hepatitis in

contaminated water); no chronic disease; 15-25% mortality in pregnant women, especially in 3rd trimester

Enterobacteriaceae, other aerobic gram-negative bacilli, enterococci and other gram-positive bacteria, occasionally

Initial Impiric Therapy •

Include coverage for anaerobic bacteria (eg, metronidazole, meropenem, imipenem, piperacillin/ tazobactam) if 1)

Persistent Fever Despite Empiric Antibiotic Therapy •

Reassess response to treatment on day 3 1)

If patient is stable, continue with same antibacterial program

Repeat diagnostic clinical examination (with or without radiographs, as indicated)

Duration of Antibiotic Therapy •

Stop antibiotic therapy when neutrophil count is cells/mm

3 for 2 consecutive days and patient is afebrile

a Recovery of these organisms in blood culture usually suggests an

b Prolonged use of ceftazidime may induce or select for

c Appropriate carbapenems include meropenem or imipenem/

cilastatin; ertapenem does not have reliable activity against Pseudomonas

d In patients known to be colonized with vancomycin-resistant

e Liposomal amphotericin B, amphotericin B lipid complex, or

f An amphotericin product is preferable for patients who have been

receiving voriconazole prophylaxis or if the clinical situation suggests possible zygomycosis.

Sexually Transmitted Diseases* Elements of Diagnosis Urethritis •

Abrupt-onset, purulent urethral discharge and dysuria more common with

Genital Ulcerative Diseases •

ulcers (chancres); nontender, nonfluctuant adenopathy in primary syphilis

Common Pathogens and Clinical Characteristics Urethritis: Urethral Discharge and Dysuria (Common) •

more common than gonorrhea in the US and developed countries 1)

Cervicitis: Possible Cervical Discharge or Asymptomatic •

Vaginitis: Vaginal Discharge, Vaginal Irritation •

hydrogen peroxide–producing lactobacilli with anaerobic bacteria (eg,

sexually transmitted disease (STD) pathogen 1)

Genital Ulcerative Diseases: Cutaneous Ulcerations, Commonly With Adenopathy •

multiple; sharply demarcated border; indurated with red or smooth base

indurated; erythematous border with rough yellow- gray base

tender; frequently suppurative; “groove sign” common (lymphadenopathy above and below inguinal ligament)

spectinomycin 2 g IM once ceftizoxime 500 mg IM once cefotaxime 500 mg IM once erythromycin base 500 mg oral qid for 7 days

were treated appropriately) Ureaplasma urealyticum

Primary syphilis Chancroid

benzathine penicillin G 2.4 million units IM once azithromycin 1 g oral once

erythromycin base 500 mg oral qid for 7 days

First episode Recurrent disease Suppressive therapy Severe disease or complications (eg, disseminated infection, pneumonitis, hepatitis, meningitis, encephalitis)

a Nondisseminated.

erythromycin base 500 mg oral qid for 21 days

Other Conditions Human Papillomavirus •

Types 6 and 11: Condyloma acuminatum (anogenital warts); most common viral STD in US

Types 16, 18, 31, 33, and 35: Cervical infection; oncogenic association with cervical cancer

Most HPV infections are clinically asymptomatic; gynecologic examinations with Papanicolaou test recommended

Molluscum Contagiosum: Benign Disease Caused by Poxviridae Virus •

Classically 2- to 10-mm dome-shaped papules, often with central umbilication

Pelvic Inflammatory Disease: Endometriosis, Salpingitis, Tubo-Ovarian Abscess, Pelvic Peritonitis •

Clinical diagnosis with findings of cervical motion tenderness; uterine or adnexal tenderness

Treatment: Non-IV regimen 1)

ceftriaxone 250 mg intramuscular (IM) once or cefoxitin 2 g IM plus probenecid 1 g oral once plus doxycycline 100 mg oral bid for 14 days with or without metronidazole 500 mg oral bid for 14 days

sensitized, memory T-cells by in vitro stimulation by M tuberculosis

bacille Calmette Guérin vaccination and most nontuberculosis mycobacteria infections

Both NAA assays are intended to complement acid- fast bacillus (AFB) smear and mycobacterial culture and to offer a more sensitive and rapid early detection method for active TB

Treatment of Latent Tuberculosis Infection in Adults With No Clinical or Radiologic Evidence of Active Disease •

isoniazid 5 mg/kg q24h (300 mg maximum) oral for 9 months

rifampin 10 mg/kg q24h (600 mg maximum) oral for 4 months

Alternate treatment or select regimens 1)

isoniazid 900 mg twice weekly (by directly observed therapy [DOT]) for 9 months

Infectious Syndromes rifampin, and (initially, for 2 months) pyrazinamide 2)All 9-month regimens should contain isoniazid and rifampin 3)DOT strongly recommended for all patients

Standard Therapy for Drug-Susceptible Pulmonary M tuberculosis Option 1 •

a daily for 2 weeks (14 doses); then isoniazid,

7-month continuation phase recommended for 3 groups of patients (9-month total treatment) 1)

Patients with cavitary disease caused by drug- susceptible organisms whose sputum culture at end of 2-month initial treatment period is positive