The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th The sandford guide to antimicrobial therapy 46th
Trang 2Editorial Note
To ourreaders,
We have madesignificantimprovementsinthis46th
editionofThe Sanford GuidetoAntimicrobial
Therapy.First,we thank youforyour comments,questionsandreviewsofourcontent.Youarean
integral partofthecollaborative process thatresultsineach updatededitionofThe SanfordGuide
Westrivetoprovide you with thecurrentrangeofevidence-basedoptionsfortreatment,
which means you shouldconsiderour recommendationsinlightoflocal resistanceand
susceptibility patterns, availability ofandvariationsinformulation of antimicrobialagents and
otherlocalconditions thatguidecareforyourpatients
Newmaterialandareas ofsignificantchangeinthis46th
edition include:
• Table 1:major updatesincludegenital tract infectionsbased on new CDC STDGuidelines,
kidney & bladderinfections,enterococcal endocarditis(alsoTable5A),empirictherapyforpneumonia,as well asupdated regimens and references
• Tables4A,4B and4C: Activityspectra(antibacterial,antifungalandantiviral).Thesetables
have been completely reworked, updated andarenowcolor-coded.Thecolorcoding
andassociatedsymbolsareintendedtoprovidemoredescriptive categorization ofthe
tabledata
• Table7:DrugDesensitization Desensitizationmethodsforadditionaldrugsareadded.
• Table8:PregnancyRiskandof AntimicrobialDuringLactation.Thisnewtableaddsdata
onsafety of antimicrobialsinlactatingmothers.
• Table 10A (andelsewhere):Newantibacterialsadded: ceftazidime-avibactam and
ceftoIoza ne-tazobactam.
• Table 1 1:Newantifungal drug: Isavuconazoleadded.
• Table 14 (HCV):Newdirect-actingagents and combination agents and updated HCV
treatment regimens
• Table 16:PediatricDosing Reinstated inthiseditionisanewtablesummarizing dosing
ofantimicrobialsinchildrenage 28 days andolder
• Table 17A:DosinginRenalImpairment This table hasalsobeen thoroughly reworked
and reviewedforimprovedclarity inour recommendations.
Asalways,allcontenthas been updatedwithnewreferencesfromthepublishedliterature,
includingnewpracticeand treatmentguidelines,updated prescribing informationand drug
safetyinformation
Some recommendations suggest the useofagentsforindicationsorindosesotherthan found
inproductlabeling.Such recommendationsarebased on publishedreportsinpeer-reviewed
literature;theyarenot based oninputfrom any pharmaceutical manufacturer Theyaremade
with dueconsideration ofthe concernsoftheU.S.Food and DrugAdministration(FDA)
regarding''off-label"uses.Weprovidereference(s) forand, insomecases,annotate such
recommendationswith the notation "NAI"meaningnotan FDA-approvedindicationordose
The Editors
January 2016
Trang 3Visit store.sanfordguide.com, click the Redeem Coupon
button and enter WEB16 to receive a complimentary 60-daytrial subscription to the Sanford Guide Web Edition
*Limit one per customer • OfferexpiresApril30,2017
GET MORE BOOKS AND
Trang 4The Sanford Guide to Antimicrobial Therapy 2016
46th Edition
Editors David N Gilbert, M.D.
ChiefofInfectious Diseases
Providence Portland MedicalCenter, Oregon
ProfessorofMedicine, Oregon Health
SciencesUniversity
Chief, JamesL Tullis Firm,
Beth Israel DeaconessHospital,
UCSFClinicalandTranslationalSciencesInstitute
University of CaliforniaatSan Francisco
Michael S Saag, M.D.
Director, UAB CenterforAIDS Research,
Professorof Medicine and Director,Division of Infectious Diseases,
University ofAlabama, Birmingham
AndrewT Pavia, M.D.
Chief, Division ofPediatric Infectious Diseases
University ofUtah, Salt Lake City
Professor ofMedicine, Microbiology & Immunology, Pathology
Albert EinsteinCollege ofMedicine
2007
Robert C Moellering, Jr., M.D.
1936-
2014
Publisher
Antimicrobial Therapy,
Trang 5ANTIMICROBIAL THERAPY,INC.
RO Box 276, 11771 Lee Highway
Sperryville,VA 22740-0276 USATel 540-987-9480 Fax 540-987-9486
Email: info@sanfordguide.com www.sanfordguide.com
Copyright © 1969-2016 byAntimicrobialTherapy, Inc
All rightsreserved No part ofthispublication may be may be reproduced, stored inaretrievalsystem ortransmitted inany formorby any means-digital, electronic, mechanical,optical,
photocopying, recording or otherwise-withoutpriorwrittenpermission from
AntimicrobialTherapy, Inc., 11771 Lee Hwy, P.O Box 276, Sperryville,VA 22740-0276 USA
“SanfordGuide”and “Hot Disease” logo are®registeredtrademarksofAntimicrobialTherapy,Inc
Acknowledgements
Thanks toUshuaiaSolutions SA.Argentina: AlcornPrinting, Harleysville, PA and FoxBindery,
Quakertown PAfordesign and production ofthisedition oftheSanfordGuide
NotetoReaders Since 1969, theSanford Guidehas been independently prepared and published Decisions regarding
thecontentoftheSanfordGuide aresolelythoseofthe editors andthe publisher.We welcome
questions, comments and feedback concerningthe SanfordGuide.Allofyour feedbackisreviewed
and takenintoaccountin updatingthe contentoftheSanfordGuide
Everyeffortismadetoensure accuracyofthe contentofthisguide However,currentfullprescribinginformationavailable inthepackage insert foreach drug should beconsulted before prescribingany
product Theeditorsandpublisherare notresponsibleforerrorsoromissionsorforany consequences
fromapplicationofthe information inthisbook and make nowarranty, expressor implied, withrespect
tothe currency, accuracy, orcompletenessofthecontentsofthis publication Applicationofthis
informationinaparticular situationremainsthe professionalresponsibility ofthepractitioner
Forthemostcurrent information, subscribe towebedition.sanfordguide.com
orSanfordGuide mobiledevice applications
PrintedintheUnited StatesofAmerica
ISBN 978-1-930808-93-5
Library Edition (English)
Trang 6QUICK PAGE GUIDE TO THE SANFORD GUIDE
RECOMMENDED TREATMENT— DIFFERENT SITES/MICROBES:
ParasitesCausingEosinophilia 165
ParasiticDrugs:Sources 165
DirectoryofResources 234
Trang 7—TABLE OF CONTENTS—
TABLE1 ClinicalApproachtoInitialChoiceof AntimicrobialTherapy 4TABLE2 RecommendedAntimicrobialAgentsAgainstSelected Bacteria 69
TABLE3 Suggested Durationof AntibioticTherapyinImmunocompetentPatients 72
TABLE 4A AntibacterialActivitySpectra 73
4C Antiviral ActivitySpectra 79TABLE 5A Treatment Options For SystemicInfectionDueToMulti-DrugResistantGram-Positive
5B TreatmentOptionsforSystemicInfectionDuetoSelected Multi-Drug Resistant
TABLE6 SuggestedManagementofSuspectedor Culture-PositiveCommunity-Associated
Methicillin-ResistantS.aureusInfections 82TABLE7 Antibiotic HypersensitivityReactions& DrugDesensitizationmethods 83
TABLE8 PregnancyRiskandSafetyinLactation 85
9C Enzyme-andTransporter-Mediated InteractionsofAntimicrobials 99
TABLE10A AntibioticDosage andSide-Effects 102
10B SelectedAntibacterialAgents—Adverse Reactions—Overview 115
10C AntimicrobialAgentsAssociatedwithPhotosensitivity 117
10D AminoglycosideOnce-DailyandMultiple DailyDosing Regimens 118
10E ProlongedorContinuousInfusionDosingofSelectedBeta Lactams 1 1
TABLE1 1A TreatmentofFungal Infections—AntimicrobialAgentsofChoice 121
1 1B AntifungalDrugs: Dosage, Adverse Effects,Comments 134
12B Dosageand AdverseEffects ofAntimycobacterialDrugs 148
TABLE 13A Treatmento'Parasitic Infections 151
13B DosageandSelectedAdverseEffects of AntiparasiticDrugs 162
13C Parasites thatCauseEosinophilia (Eosinophilia InTravelers) 165
14C AntiretroviralTherapy(ART)inTreatment-Naive Adults (HIV/AIDS) 181
14D AntiretroviralDrugsand AdverseEffects 192
14E HepatitisA & HBVTreatment 196
15B AntibioticProphylaxistoPreventSurgical InfectionsinAdults 200
15C AntimicrobialProphylaxisforthe PreventionofBacterialEndocarditisinPatients with
Underlying Cardiac Conditions 204
15D ManagementofExposuretoHIV-1 andHepatitisB and C 205
15E PreventionofSelected OpportunisticInfectionsinHuman HematopoieticCell
Transplantation (HCT)orSolidOrganTransplantation (SOT)inAdults WithNormal
TABLE16 Pediatricdosing (AGE >28DAYS) 21TABLE 17A DosagesofAntimicrobialDrugsinAdult Patients withRenalImpairment 214
17B No DosageAdjustmentwithRenalInsufficiencybyCategory 229
17C AntimicrobialDosing inObesity 229
TABLE18 Antimicrobialsand Hepatic Disease:DosageAdjustment 230
TABLE19 TreatmentofCAPDPeritonitisinAdults 231TABLE 20A Anti-TetanusProphylaxis,WoundClassification, Immunization 232
TABLE21 Selected Directory ofResources 234
22B Drug-DrugInteractionsBetweenNon-NucleosideReverseTranscriptaseInhibitors
TABLE 23 ListofGenericandCommonTradeNames 244
Trang 83TC =lamivudine
AB,% =percentabsorbed
ABC =abacavir
ABCD = amphotericinBcolloidaldispersion
ABLC = amphoBlipidcomplex
APAG =antipseudomonal aminoglycoside
ARDS =acuterespiratorydistresssyndrome
ARF =acuterheumaticfever
bid=2xperday
BL/BLI=beta-lactam/beta-lactamaseinhibitor
BSA =bodysurfacearea
BW =bodyweight
CARB =carbapenems
CAPD = continuousambulatoryperitonealdialysis
CDC =CentersforDiseaseControl
Cefpodox= cefpodoximeproxetil
CIP =ciprofloxacin; CIP-ER=CIP extendedrelease
Clarithro=clarithromycin;ER =extendedrelease
CrCI =creatinineclearance
CrCIn =CrCInormalizedforBSA
CRRT= continuousrenalreplacementtherapy
C/S =culture&sensitivity
DIC=disseminatedintravascular coagulationdiv=divided
EES =erythromycinethylsuccinate
EFZ =efavirenz
ELV =elvitegravir
EMB =ethambutolENT =entecavir
ER =extendedreleaseERTA =ertapenem
Erythro=erythromycin
ESBLs =extended spectrum(Wactamases
ESR =erythrocytesedimentationrate
ESRD =endstagerenaldiseaseFlu=fluconazole
LAB =liposomalamphoB
LCM =lymphocytic choriomeningitisvirusLCR =ligasechain reaction
Levo=levofloxacin
LP/R=lopinavir/ ritonavirmeg(orpg) =microgram
MSM = men whohave sexwithmen
MSSA/MRSA =methicillin-sensitive/resistant S.aureus
NNRTI =non-nucleosidereverse transcriptaseinhibitor
NRTI =nucleosidereverse transcriptaseinhibitor
NSAIDs =non-steroidalNUS =notavailable inthe U.S
NVP =nevirapine
O Ceph1 , 2,3=oralcephalosporinsOflox= ofloxacin
PCeph1, 2, 3,4=parenteralcephalosporins
PCeph3AP= parenteralcephalosporinswithantipseudomonalactivity
PCR =polymerasechain reactionPEP= post-exposureprophylaxis
PI=proteaseinhibitor
PIP-TZ= piperacillin-tazobactam
o = oraldosing
Q =primaquine
PRCT =Prospectiverandomizedcontrolledtrials
PTLD= post-transplant lymphoproliferativediseasePts = patients
Pyri=pyrimethamine
PZA = pyrazinamide
Trang 9RSV= respiratory syncytial virus
RTI=respiratory tract infection
RTV =ritonavir
rx= treatment
SA =Staph,aureussc =subcutaneous
SD = serumdruglevel after singledose
Sens =sensitive(susceptible)
SM =streptomycinSQV =saquinavir
SS= steadystateserumlevelSTD =sexuallytransmitteddisease
subcut =subcutaneousSulb=sulbactam
TNF =tumornecrosisfactor
Tobra=tobramycin
TPV =tipranavir
TST=tuberculin skintest
UTI = urinary tract infection
Vanco =vancomycin
VISA=vancomycinintermediatelyresistant S.aureus
VL =viralloadVori=voriconazole
VZV =varicella-zoster virusZDV =zidovudine
AAC:AntimicrobialAgents&Chemotherapy
AdvPID:Advancesin Pediatric InfectiousDiseases
AHJ:AmericanHeart Journal
AIDS Res HumRetrovir: AIDSResearch& Human Retroviruses
AJG:AmericanJournalofGastroenterology
AJM:AmericanJournalofMedicine
AJRCCM:AmericanJournalofRespiratoryCriticalCare Medicine
AJTMH:AmericanJournalofTropicalMedicine&Hygiene
AlimentPharmacolTher:AlimentaryPharmacology&Therapeutics
AmJ HlthPharm:AmericanJournalofHealth-SystemPharmacy
AmerJ Transpl: AmericanJournalofTransplantation
AnEM:AnnalsofEmergencyMedicine
AnIM:Annalsof InternalMedicine
AnnPharmacother:AnnalsofPharmacotherapy
AnSurg:AnnalsofSurgery
AntivirTher:AntiviralTherapy
ArDerm:ArchivesofDermatology
ArIM:Archivesof InternalMedicine
ARRD:AmericanReviewofRespiratoryDisease
BMJ:BritishMedicalJournal
BMT:Bone MarrowTransplantation
BritJDerm:BritishJournalofDermatology
CanJID:CanadianJournalof InfectiousDiseases
Canad MedJ:Canadian MedicalJournal
CCM:CriticalCare Medicine
CCTID: CurrentClinicalTopicsin InfectiousDisease
CDBSR:CochraneDatabaseofSystematic Reviews
CID:Clinical InfectiousDiseases
ClinMicroInf: ClinicalMicrobiologyandInfection
CMN:ClinicalMicrobiology Newsletter
ClinMicro Rev:ClinicalMicrobiologyReviews
CMAJ:Canadian MedicalAssociation Journal
COID:CurrentOpinionin InfectiousDisease
ABBREVIATIONS OF JOURNALTITLES
CurrMed ResOpin:CurrentMedicalResearchandOpinion
DermTher:DermatologicTherapy
DermatolClin:DermatologicClinics
Dig DisSci: DigestiveDiseases and Sciences
DMID:Diagnostic MicrobiologyandInfectiousDiseaseEID:EmergingInfectiousDiseases
EJCMID:EuropeanJournalof Clin.Micro.&InfectiousDiseasesEur J Neurol:EuropeanJournalofNeurology
Exp MolPath:Experimental&MolecularPathology
Exp RevAnti InfectTher:ExpertReviewof Anti-InfectiveTherapyGastro: Gastroenterology
Hpt: Hepatology
ICHE:InfectionControlandHospitalEpidemiology
IDCNo.Amer:InfectiousDiseaseClinics ofNorlhAmerica
IDCP:InfectiousDiseasesin ClinicalPractice
IJAA:InternationalJournalofAntimicrobialAgents
InfMed:Infections inMedicine
JAIDS& HR:JournalofAIDS andHumanRetrovirology
JAllClinImmun:Journalof AllergyandClinicalImmunology
JAmGerSoc:JournaloftheAmericanGeriatricsSociety
JChemother:JournalofChemotherapy
JClinMicro:Journalof ClinicalMicrobiology
JClinVirol:Journalof ClinicalVirology
JDermTreat: JournalofDermatologicalTreatment
JHpt: Journal ofHepatology
JInf:Journalof Infection
JMedMicro:JournalofMedicalMicrobiology
JMicroImmunolInf:JournalofMicrobiology,Immunology,&Infection
JPed:JournalofPediatrics
JViralHep:Journal ofViral Hepatitis
JAC:JournalofAntimicrobialChemotherapy
JACC:JournalofAmericanCollegeofCardiology
JAIDS: JAIDSJournalofAcquiredImmuneDeficiencySyndromes
JAMA:JournaloftheAmerican MedicalAssociation
JAVMA: Journalofthe VeterinaryMedicineAssociationJCI: Journalof Clinical Investigation
JCM:Journalof ClinicalMicrobiologyJIC: Journalof Infectionand Chemotherapy
JID: Journalof InfectiousDiseases
MedMycol: Medical Mycology
NEJM: NewEnglandJournalofMedicine
NephDialTranspl: NephrologyDialysisTransplantation
OFID:OpenForum InfectiousDiseases
PedAnn:PediatricAnnals
Peds:Pediatrics
Pharmacother:PharmacotherapyPIDJ:Pediatric InfectiousDiseaseJournal
QJM:Quarterly JournalofMedicine
ScandJInfDis:ScandinavianJournalof InfectiousDiseasesSem RespInf:SeminarsinRespiratoryInfections
SGO:Surgery GynecologyandObstetrics
SMJ:Southern MedicalJournal
Surg Neurol:SurgicalNeurologyTransplInfDis:Transplant InfectiousDiseasesTranspl:Transplantation
TRSM:TransactionsoftheRoyalSocietyofMedicine
3
Trang 10TABLE1 -CLINICAL APPROACH TOINITIALCHOICE OF ANTIMICROBIAL THERAPY*
Treatmentbased on presumedsiteortypeofinfection Inselectedinstances,treatmentandprophylaxisbased on identificationofpathogens
Regimensshouldbereevaluatedbased on pathogen isolated,antimicrobial susceptibility determination,andindividualhostcharacteristics.(Abbreviationsonpage2)
MODIFYING CIRCUMSTANCES
ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES
(usual)
BONE:Osteomyelitis Microbiologicdiagnosisisessential.Ifbloodculture negative, needculture ofbone(EurJClinMicrobiol InfectDis33:371,2014) Culture ofsinustractdrainaqenot predictive
ofboneculture.
Forcomprehensivereviewofantimicrobial penetrationintobone,seeClinicalPharmacokinetics48:89,2009
HematogenousOsteomyelitis(seeIDSAguidelinesforvertebralosteo:CIDJuly 29,2015)
Empirictherapy—Collectbone andbloodculturesbefore empiric therapy
Newborn (<4mos.) S.aureus,Gm-neg.bacilli,
Group Bstrep,Kingellakingaeinchildren
MRSApossible:Vanco +
(Ceftaz orCFP)
MRSAunlikely: (Nafcillin oroxacillin)+ (CeftazorCFP)
Severeallergyortoxicity:(LinezolidNA110mg/kgIV/poq8h +aztreonam)
Children(>4mos.)—Adult:
Osteoofextremity
(NEJM370:352,2014)
S.aureus,GroupAstrep.
Gm-neg bacilli rare,Kingellakingaeinchildren
MRSApossible:Vanco
40mg/kg/daydivq6h
AddCeftaz orCFPifGm-ne
Adultdosesbelow
MRSAunlikely: (Nafcillin
oroxacillin)150mg/kg/day
divq6h (max12gm)
;g bacillionGramstain
Severeallergy ortoxicity:ClindaorTMP-SMXorlinezolidNAI.
data,particularly forMRSA(seeAAC53:2672, 2009);2)Levo750mgpo
q24h) +RIF 600mgpoq24h;3)Fusidic acidNUS500mgIVq8h+RIF
300mgpobid.(CID42:394,2006);4) Ceftriaxone 2gmIVq24h
(CID54:585,2012)(MSSAonly):Durationoftherapy:6weeks, provided
thatepidural or paravertebralabscessescan bedrained;consider longercourseinthosewith extensiveinfectionorabscessparticularly ifnot
amenabletodrainagebecauseofincreasedrisk oftreatmentfailure
(OFIDDec5:1,2014) (althoughdata arelackingthat thisapproach
improvesefficacyversus a 6wkcourse)and >8weeks inpatientsundergoing deviceimplantation(CID 60:1330,2015)
MRSA SeeTable6,/»ge82;
IDSAGuidelinesCID52:e
i RIF 300-450mgpo/IVbid
andnotseverehepatic dysfunction
ALTERNATIVE THERAPY INCLUDEStheseconsiderations:allergy,pharmacology/pharmacokinetics, compliance,costs,local resistanceprofiles
Trang 11Levo /!>()mgIV/POq24h Thalassemia:transfusionandironchelationrisk factors.Becauseof
decreasinglevelsof susceptibilitytofluoroquinolonesamongSalmonellaspp.andgrowingresistanceamongothergram-negativebacilli,wouldaddasecondagent(e.g.,third-generationcephalosporin)until
susceptibilitytest resultsavailable AlternativeforsalmonellaisCeftriaxone
2gmIVq24hif nalidixicacidresistant.
ContiguousOsteomyelitisWithou
Empirictherapy:Getcultures!
Footboneosteodueto nail
throughtennisshoe
LinezolidGOOmyIV/po
l)idNAI 1 (ceftaz orCFP)
SeeComment
Oftennecessarytoremove hardwareafteruniontoachieveeradication
Mayneedrevascularization
Regimenslistedare empiric Adjustafterculturedataavailable If
susceptibleGm-neg.bacillus,CIP 750mgpobidorLevo750mg poq24h.ForotnerS.aureusoptions:SeeHem.Osteo.Specific Therapy,page4.
Osteonecrosisofthejaw Probablyrareadverse
reaction tobisphosphonates
Infectionmaybe secondarytobonenecrosisandloss of overlyingmucosa
Treatment: minimalsurgicaldebridement,chlorhexidinerinses,antibiotics(e.g.PIP-TZ).Evaluateforconcomitant actinomycosis,
forwhichspecificlong-termantibiotictreatmentwould bewarranted (CID 49:1729,2009)
Prostheticjoint |Seeprostheticjoint,page33
Spinalimplantinfection S.aureus,coag-neg
staphylococci,
gram-negbacilli
Onsetwithin30days:
culture, treat for3mos
(CID 55:1481,2012)
Onsetafter30 days remove
implant,culture&treat
See CID55:1481,2012
Sternum, post-op S.aureus,S.epidermidis,
occasionally,gram-negativebacilli
Vanco15-20mg/kg q8-12h
IV fortroughof15-20ng/mL
recommendedforserious
infections.
Linezolid600mgpo/IVNAIbid Sternaldebridementforcultures&removalofnecroticbone
ForS.aureusoptions:Hem. Osteo.SpecificTherapy,page4 Ifsetting or
gramstainsuggestspossibilityofgram-negativebacilli,addappropriate
coveragebased onlocalantimicrobial susceptibilityprofiles
(e.g.,cefepime, PIP-TZJ
ContiguousOsteomyelitisWithVi
Mostptsare diabeticswith
peripheralneuropathy&infected
skinulcers(seeDiabeticfoot,
page 16)
ascular Insufficiency
Polymicrobic[Gm+cocci
(toincludeMRSA)(aerobic
&anaerobic)andGm-neg
bacilli(aerobic&anaerobic)]
Debrideoverlying ulcer&submitboneforhistology&
culture.Selectantibioticbased onculture results&treat for6weeks.Noempirictherapy unlessacutelyill.
Ifacutelyill,seesuggestions,Diabeticfoot,page16.
Revascularizeifpossible
Diagnosisof osteo:Culturebonebiopsy(goldstandard) Poor
concordanceofcultureresultsbetweenswabofulcerandbone-need
bone (CID42:57, 63, 2006).Samplingby needle punctureinferiortobiopsy (CID48:888, 2009) Osteomorelikely ifulcer>2 cm2
,positiveprobetobone,ESR >70 &abnormalplainx-ray(JAMA299:806, 2008)
Treatment:(1)Revascularizeifpossible;(2)Culturebone;(3)Specificantimicrobial(s).Reviews:BMJ339:b4905, 2006;PlastReconstr Surg117:
(7Suppl) 2125, 2006
ChronicOsteomyelitis:
Specifictherapy
Bydefinition,impliespresenceof
deadbone Needvalidcultures
S.aureus,ceae,P.aeruginosa
Enterobacteria-Empiricrxnot indicated.Basesystemicrxonresultsof
culture, sensitivity testing Ifacute exacerbationofchronicosteo,rxas acutehematogenousosteo Surgical
debridementimportant
Importantadjuncts:removaloforthopedic hardware,surgicalment; vascularizedmuscleflaps,distractionosteogenesis(Ilizarov)tech-niques.Antibiotic-impregnatedcement&hyperbaricoxygenadjunctive
debride-NOTE:RIF+ (vancoor p-lactam)effective inanimalmodel and in
aclinical trial of S.aureuschronic osteo.Thecontributionofcontainingregimensin this setting isnotclear,however(AAC53:2672, 2009).Abbreviationsonpage2. *NCTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)and assumenormalrenal function.§Alternativesconsiderallergy, PK,compliance,local resistance,cost
rifampin-5
Trang 12AND COMMENTS
BREAST:Mastitis—Obtainculture;needtoknowifMRSApresent.Reviewwithdefinitions:Reviewofbreastinfections:BMJ342:d396, 2011.
Postpartummastitis(RecentCochraneReview:Cochrane DatabaseSystRev 2013 Feb 28;2:CD005458; seealsoCID54:71,2012)
Mastitiswithoutabscess S.aureus;lessoften
Ifno abscess&controllable pain,|freq ofnursingmayhasten response
Mastitiswithabscess Forpainfulabscessl&Disstandard;needleaspirationreported
successful.Resumebreastfeedingfromaffectedbreastassoonas painallows (BreastfeedMed9:239,2014)
Non-puerperalmastitis with
Seeregimensfor
Postpartummastitis,page6.
Smoking anddiabetesmayberiskfactors(BMJ342:d396,2011).Ifsubareolar&odoriferous,mostlikelyanaerobes;needtoaddmetro
500mgIV/potid Ifnot subareolar, staph.Needpretreatment aerobic/anaerobic
cultures.Surgicaldrainageforabscess.I&Dstandard Corynebacteriumsp.assoc,withchronicgranulomatousmastitis(JCM53:2895,2015)
ConsiderTBinchronicinfections
Breastimplantinfection Acute:S.aureus,S.
Chronic: Awaitculture
results.SeeTable 12Afor
etiologicagent, aspirateevensmallabscessesfordiagnosisif thiscanbedonesafely.
ExperiencewithPenG(HD) +metrowithout ceftriaxone ornafcillin/oxacillin
hasbeengood.Weuseceftriaxonebecauseoffrequencyof isolation of
Enterobacteriaceae S.aureusrarewithout positivebloodculture;
ifS.aureus,usevancountilsusceptibilityknown.Strep,anginosus
groupesp.pronetoproduceabscess Ceph/metrodoesnotcoverlisteria.
Durationof rx unclear;usually 4-6wksoruntil resolution
ForMRSA: Vanco
15-20mg/kg IVq8-12hfor
troughof15-20mcg/mL +
(ceftriaxoneorcefotaxime)
Empiricalcoverage, de-escalatedbasedonculture results.Aspiration of
abscessusuallynecessaryfordx&rx If P.aeruginosa suspected,
substitute(CefepimeorCeftazidime)for(Ceftriaxone or Cefotaxime).HIV-1 infected(AIDS) Toxoplasmagondii See Table13A,page 156
Abbreviationsonpage2. 'NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)andassumenormalrenal function.§Alternativesconsiderallergy,PK,compliance,local resistance,cost
Trang 13Treat with2 drugs x1 yr.
testing:Wallace (+1) 903-877-7680or U.S.CDC(+1) 404-639-3158.In
vitroresistance toTMP-SMX maybeincreasing(Clin InfectDis51:1445,2010), but whetherthis isassociatedwithworse outcomesisnotknown;
TMP-SMXremains a drugofchoiceforCNSnocardiainfection Ifsulfonamideresistantorsulfa-allergic,amikacinplusoneof:IMP, MER,ceftriaxone
orcefotaxime.N.farcinica isresistant to third-generationcephalosporins,which shouldnotbeusedfortreatment ofinfectioncausedbythisorganism
IfTMP-SMXresistance reported,seeJCM50:670,2012(beforestopping
TMP-SMX)
Subduralempyema: Inadult60-90%isextensionofsinusitisorotitismedia.Rxsameas primarybrainabscess.Surgicalemergency: mustdrain.ReviewinLnID7:62,2007
Encephalitis/encephalopathy
IDSAGuideline:CID47:303,2008:
Intidiagnosisconsensus:
CID57:1114,2013
(ForHerpesseeTable14A,page 169
andforrabies, Table20B,page233)
H.simplex (42%),VZV(15%),
M.TB(15%),Listeria(10%)(CID 49:1838, 2009) Other:
arbovirus, WestNile,rabies,Lyme, Parvo B19,Cat-scratch, Mycoplasma,
EBVandothers
Start IVacyclovirwhileawaiting resultsofCSF PCRforH
simplex.ForamebicencephalitisseeTable 13A Start
DoxyifsettingsuggestsR.rickettsii,Anaplasma,Ehrlichia
145:1143,2014;JClinNeuroscience 21:722& 1169,2014
Meningitis, “Aseptic”:Pleocytosis
ofupto100sofcells,CSFglucose
normal,neg.cultureforbacteria
(seeTable 14A,page 166)
Ref:CID47:783,2008
Enteroviruses,HSV-2,LCM,
HIV,other viruses,drugs
[NSAIDs, metronidazole,carbamazepine,lamotrigine
TMP-SMX,IVIG, (e.g.,
detuximab,infliximab)], rarelyleptospirosis
Forallbutleptospirosis,IV fluidsandanalgesics D/C
drugsthatmaybeetiologic.Forlepto(doxy100mg IV/poq12h)or(Pen G5million units IVq6h)or(AMP0.5-1 gm
IVq6h) Repeat LPifsuspectpartially-treated bacterialmeningitis.Acyclovir 5-10mg/kgIVq8h sometimesgiven
forHSV-2meningitis (Note:distinctfromHSVencephalitis
whereearlyrx ismandatory)
Ifavailable,PCRofCSFforenterovirus.HSV-2unusualwithoutconcomitantgenitalherpes(Mollaret'ssyndrome)
Forlepto,positiveepidemiologichistoryandconcomitanthepatitis, conjunctivitis,dermatitis,nephritis.Forlistofimplicateddrugs:
InfMed25:331, 2008
Abbreviationsonpage2. 'NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)and assumenormalrenal function.§Alternativesconsiderallergy, PK,compliance,local resistance,cost
7
Trang 14Meningitis,Bacterial,Acute:Goalisempiric therapy,thenCSF examwithin30min Iffocalneurologicdeficit,give empiric therapy,thenheadCT,thenLP.(NEJM354:44,2006:Ln ID10:32,2010)
NOTE:Inchildren,treatmentcausedCSFculturestoturn neg.in2hrs withmeningococci&partialresponsewithpneumococciin4hrs(Peds 108:1169,2001)
Fordistribution ofpathogens by agegroup,seeNEJM364:2016,2011.
EmpiricTherapy— CSF Gramstainisnegative— immunocompetent
Age: Pretermto <1 mo
InID10:32,2010
GroupBstrep49%,
E coli18%,listeria7%,misc.Gm-neg.10%,misc.Gm-pos 10%
AMP 100mg/kgIVq6h+ |AMP100mg/kg IVq6h+
cefotaxime50mg/kgIVq6h|gentamicin2.5mg/kgIVq8h
Intraventriculartreatment notrecommended.
RepeatCSFexam/culture24-36hr after startoftherapy
Regimensactivevs.Group Bstrep,mostcoliforms,&listeria.
IfprematureinfantwithIonanurserystay, S.aureus, enterococci,and
resistantcoliforms potentialpathogens Optionalempiricregimens
(exceptforlisteria): [nafcillin + (ceftazidime or cefotaxime)]
IfhighriskofMRSA,usevanco +cefotaxime.Alterregimenafter culture/sensitivitydataavailable
Age:1 mo-50yrs
Flearing lossismostcommon
adultpneumococcalmeningitis led toreducedmortalityandhearingloss
comparedwithhistoricalcontrolgroup(Neurology75:1533, 2010) Forpatients withseverep-lactamallergy,see below(EmpiricTherapy-
positivegramstainandSpecific Therapy)for alternativetherapies
Dexamethasone:0.15mg/kgIVq6hx2-4days.Givewith,
orjustbefore, 1stdoseofantibiotictoblockTNF
production (seeComment)
Seefootnote'forVancoAdultdosage and2
forped dosageAge: >50yrs oralcoholism
orother debilitatingassoc
vanco IVdexamethasone
MER2gmIVq8h + vanco + IVdexamethasone
For severe pen.Allergy,
Forvancodose, seefootnote’.Dexamethasonedose:
0.15mg/kgIVq6hx2-4days;I 'dosebefore, orconcomitantwith, 1sldoseofantibiotic.
Post-neurosurgery
Ventriculostomy/lumbar
catheter;ventriculoperitoneal
(atrial)shunt)or
Penetratingtraumaw/o
basilarskullfracture
Ref: intraventriculartherapy
(JMicroImmunol&Infect
47:204,2014)
S.epidermidis,S.aureus
P.acnes.Facultativeand
aerobicgram-negbacilli,
• Removeinfectedshuntandplaceexternal ventricular catheterfor
drainageorpressurecontrol.
• Intraventriculartherapyusediftheshuntcannotbe removedor cultures
failto clear withsystemictherapy.Logicfor intraventriculartherapy:achievea 10-20ratio ofCSFconcentrationtoMICof infectingbacteria
Useonlypreservative-free drug.Clamp/closecatheterfor 1 hrafter
dose ForpotentialtoxicitiesseeCMR23:858, 2010
•Systemicallyillpatient:systemic therapy+pathogen-directed
intraventriculartherapyoncecultureresultsareavailable
• Notsystemicallyill,indolentGram-positive:can D/Csystemic
vancomycin andtreatwithdaily intraventriculartherapy
• Shuntreimplantation: 1)Ifcoagulase-negativestaphylococci,diphtheroids, orP.acnesmayinternalizeshuntafter3serialCSFculturesarenegative,nofurthersystemic therapyneeded.2) For Staph,aureusandGram-negativebacilli,mayinternalizeshuntafter3serialCSFculturesare negativeandthentreatwithsystemic therapyforan
additionalweek.ReLNEngl JMed362:146, 2010
• IfseverePen/Cephallergy,lorpossiblegram-neg,substituteeither:Aztreonam? ginIV q(iHhorCIP
400mgIVq12h
IntraventricularRxifIVtherapyinadequateordevicenotremoved.Intraventricular dailydrugdoses Adult:
Vanco 1020 mg; Amikacin30mg;Tobra5-20mg;
Gent48mu,Colistin1raseactivity3.3/5mgoncedaily.
PolymyxinB5mg, Peds:Gent 1-2mg;PolymyxinB2 mg
dosewith orbeforeI ' antibioticdose)].SeeClinMicroRev21:519,2008
1 Vancoadultdose: 15-20mg/kgIVq8-12htoachieve troughlevelof15-20ng/mL
2 Dosageofdrugsusedtotreatchildren>1 moofage:Cefotaxime 50 mg/kgperdayIVq6h;ceftriaxone50mg/kgIVq12h:vanco15mg/kgIVq6htoachieve troughlevelof15-20 ng/mL
Abbreviationsonpage2. ’‘NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)and assumenormalrenal function.§Alternativesconsiderallergy,PK,compliance,local resistance,cost
Trang 151 (6)
MODIFYING CIRCUMSTANCES
ETIOLOGIES(usual)
PRIMARY | ALTERNATIVE5
AND COMMENTS
EmpiricTherapy —PositiveCSF
Gram-positivediplococci
Gramstain
S.pneumoniae (ceftriaxone2gmIVq12hoicefotaxime 2 cjmIVq4-6h) +
vanco15-20mg/kgIVq8-12h(toachieve 15-20 jig/mL trough)
+timeddexamethasone0.15mej/kgq6hIVx2 4days
Alternatives: MER2gmIVq8horMoxi400mgIVq24h
DexamethasonedoesnotblockpenetrationofvancointoCSF(CID44:250, 2007)
Gram-negativediplococci N meningitidis (Cefotaxime2gmIVq4 6horceftriaxone 2gmIVq12h) Alternatives: Pen G4mill, units IVq4horAMP2gmq4horMoxi
400mg IVq24horchloro1 gmIVq6h (Chloro lesseffectivethanother
alternatives:seeJAC70:979,2015)Gram-positivebacilli
or coccobacilli
Listeriamonocytogenes AMP2gmIVq4h ± gentamicin2mg/kgIVloadingdose
then1 7mg/kgIVq8h
Ifpen-allergic,useTMP-SMX5mg/kg q6-8horMER2gmIVq8h
Gram-negativebacilli H.influenzae, coliforms,
Alternatives:CIP 400mgIVq8-12h;MER2gmIVq8h;Aztreonam2gm
IVq6-8h.Consider addingintravenousGentamicintothe|$-lactam orCIP
ifgram-stainandclinical settingsuggestP.aeruginosaorresistantcoliforms.SpecificTherapy —Positiveculti
Pen.allergic:Chloro12.5mg/kgIVq6h(max 4 gm/day.) (Chloro less
effectivethanotheralternatives:seeJAC70:979, 2015);CIP400mg
Pen.allergic:TMP-SMX20mg/kgperdaydiv.q6-12h.Alternative:MER
2gmIVq8h.Successreported with linezolid+ RIF(CID40:907,2005)
afterAMPrx forbrainabscesswithmeningitis
N meningitidis PenMIC0.1-1 megpermL Ceftriaxone 2gmIVq12hx 7days(seeComment)-, if
(1-lactamallergic,chloro12.5mg/kg(upto 1gm)IVq6h(Chloro
less effectivethanotheralternatives:seeJAC70:979,2015)
Rareisolates chloro-resistant FQ-resistant isolatesencountered
Alternatives: MER2gmIVq8horMoxi400mgq24h
Pen G4million units IVq4horAMP2gmIVq4h Alternatives: Ceftriaxone 2gmIVql2h,chloro1 gmIVq6h(Chloroless
effectivethanotheralternatives:seeJAC70:979,2015)0.1-1 mcg/mL Ceftriaxone 2gmIVq12horcefotaxime2gmIVq4 6h Alternatives: Cefepime2gmIVq8horMER2gmlVq8h
>2mcg/mL Vanco15-20mg/kgIVq8-12h(15-20ng/mLtroughtarget)
+(ceftriaxoneorcefotaximeas above)
Alternatives: Moxi 400mgIVq24h
CeftriaxoneMIC>1 mcg/mL Vanco15-20mg/kgIVq8-12h(15-20 (ig/mL troughtarget)
+ (ceftriaxoneorcefotaximeasabove)
advised-needsusceptibilityresults
(Ceftazidimeorcefepime2gmIVq8h) + gentamicin
2mg/kgIVx1 dose, then1 7mg/kgIVq8hx21 days
RepeatCSFculturesin2-4 days
Alternatives: CIP400mgIVq8-12h; MER2gmIVq8h
Ifpos.CSFcultureafter2-4 days,start intraventriculartherapy;
seeMeningitis, Post-neurosurgery,page8.
Prophylaxisfor H.influenzae ar
Haemophilusinfluenzaetype
Householdand/ordaycarecoi
for>4hrsinaday.Daycarecc
facilityas indexcasefor5-7da
idN meningitidis
jB
ntact: residingwithindexcase
jntactorsamedaycare
ys before onset
Children: RIF 20 mg/kg po(nottoexceed600 mg)q24hx4 doses
Adults(non-pregnant):RIF600mg q24hx4days
Household: Ifthereisoneunvaccinated contactage <4yrsinthehousehold,giveRIFto allhouseholdcontacts except pregnantwomen.
ChildCareFacilities:With 1 case,ifattendedby unvaccinatedchildren
<2yrs,considerprophylaxis+vaccinatesusceptible.If allcontacts
>2yrs:noprophylaxis.If>2casesin60 days&unvaccinatedchildrenattend, prophylaxisrecommendedforchildren &personnel
(Am Acad Red RedBook2006,page313)
Abbreviationsonpage2. *NOTE:AH dosage recommendationsarefor adults (unlessotherwiseindicated)andassumenormalrenal function § Alternativesconsiderallergy,PK,compliance,local resistance,cost
9
Trang 16AND COMMENTS
ProphylaxisforNeisseria meningitidisexposure
(closecontact)
NOTE: CDCreportsCIP-resistantgroupB
meningococcusfrom selected countiesinN.Dakota
&Minnesota.AvoidCIP Useceftriaxone,RIF, or single
500mgdoseofazithro(MMVJR57:173,2008)
[Ceftriaxone250mgIMx1 dose(child<15yrs125mg
IM x1)]OR [RIF600mgpo q12hx4 doses (Children
>1 mo10mg/kg po q12hx4doses, <1 mo5mg/kgq12hx4doses)]ORIfnot CIP-resistant,CIP500mgpox
1 dose(adult)
Spreadbyrespiratory droplets,notaerosols,henceclosecontactreq.
| risk ifclose contactfor at least4hrsduringwkbeforeillnessonset
(e g.,housemates, daycarecontacts, cellmates) orexposuretopt’s
nasopharyngealsecretions(e.g., kissing,mouth-to-mouthresuscitation,intubation,nasotrachealsuctioning)
Meningitis,chronic
Defined assymptoms + CSF
pleocytosisfor>4wks
MTBcryptococcosis,otherfungal,neoplastic,Lyme,
syphilis,Whipple'sdisease
Treatmentdepends onetiology. Nourgentneedfor
empirictherapy,butwhen TBsuspectedtreatment should
beexpeditious
Longlist of possibilities: bacteria,parasites,fungi, viruses,neoplasms,
vasculitis,andother miscellaneous etiologies—see NeurolClin28:1061, 2010
SeeNEJM370:2408,2014fordiagnosisofneuroleptospirosisbynextgenerationsequencingtechnologies
Meningitis,eosinophilic
LnID8:621,2008
Angiostrongyliasis,gnathostomiasis,baylisascaris
Corticosteroids Not sureanthelmintictherapy
works
1/3lackperipheral eosinophilia Needserologytoconfirmdiagnosis
Steroidref.:LnID8:621,2008.AutomatedCSFcountmaynot correctly
identifyeosinophils(CID48: 322, 2009)
Meningitis, HIV-1 infected(AIDS)
See Table1 1,Sanford Guideto
HIV/AIDSTherapy
Asinadults,>50yrs:alsoconsidercryptococci,
M.tuberculosis,syphilis,HIVasepticmeningitis,Listeria
monocytogenes
Ifetiologynotidentified:
treatasadult >50yrs+
obtainCSF/serumcoccal antigen
crypto-(seeComments)
For cryptorx,seeTable 1 1A,
page 127
C.neoformans mostcommonetiologyinAIDSpatients.H influenzae,
pneumococci,listeria,TBc,syphilis, viral,histoplasma&coccidioidesalsoneedtobeconsidered Obtain bloodcultures.
EAR
Externalotitis
Chronic Usually2°toseborrhea Eardrops:[(polymyxin B + neomycin t-
hydrocorti-soneqid) +seleniumsulfideshampoo]
Controlseborrheawithdandruffshampoocontainingseleniumsulfide(Selsun) or[(ketoconazoleshampoo) + (medium potencysteroidsolution,
over4hrsq8h)+ Tobra
Very highESRsaretypical.Debridementusuallyrequired R/O
osteomyelitis:CTorMRIscan.Ifboneinvolved,treat for6-8wks.Otheralternativesif P.aeruginosaissusceptible: IMP0.5gmq6horMER1 gm
IVq8horCFP2gmIVq12horCeftaz2gmIVq8h
"Swimmer’sear";occlusive
devices (earphones); contact
Mild,eardrops:acetic acid i propyleneglycol + HC
(VosolHC)5gits3-4x/dayuntilresolved sovero:EardropsCIP i HC (CiproHCOtic)3gttsbodx
Moderate-7days
Alternative:Finafloxacin0.3%oticsuspension 4gtts
qI2hx7d( for P. aeruginosaandS.aureus)
Rxincludesgentle cleaning Recurrences prevented(ordecreased)
bydrying with alcoholdrops(1/3white vinegar, 2/3rubbingalcohol)after
swimming,thenantibioticdropsor2%aceticacidsolution.Ointmentsshouldnotbe usedin ear.Donotuseneomycinor otheraminoglycosidedropsiftympanicmembranepunctured
Abbreviationsonpage 'NO dosage recommendations
Trang 17acuteotitismedia(AOM)
NOTE:Treat children<2yrs
old If>2yrsold, afebrile,no
earpain,neg./questionable
treatment without
antimicrobials
Favorableresults inmostly
afebrilepts with waiting48hrs
before decidingonantibioticuse
Appropriatedurationunclea
forseveredisease(A
Foradultdosag page50,ar
Receivedantibiotics
inpriormonth:
orAM-CLextra-strength3orcefdinir
orcefpodoximeorcefprozilorcefuroxime
axetil
seefootnote'.
irepediatric
<10 days;>2yrs x5-7 days,
r.5daysmaybeinadequate
iEJM347:1169 2002)
es,seeSinusitis,
idTable10A
Ifallergic top-lactamdrugs?Ifhistoryunclearorrash, effective oral
ceph OK;avoidcephifIgE-mediatedallergy, e.g.,anaphylaxis High
failureratewithTMP-SMXifetiologyisDRSPor H influenzae;
macrolideshavelimited efficacyagainstS.pneumo andH influenza
Upto50%S.pneumoresistanttomacrolides
Spontaneousresolutionoccurredin:90%ptsinfected withM.catarrhalis,
50%with H influenzae, 10%withS.pneumoniae;overall80%resolvewithin
2-14 days(Ln363:465, 2004)
RiskofDRSPfifage <2yrs,antibioticslast3mos,&/or daycareattendance.Selectionofdrugbasedon(1) effectivenessagainst(5-lactamaseproducingH influenzae&M.catarrhalis &(2)effectivenessagainstS.pneumo,inc. DRSP.Cefaclor, loracarbef,&ceftibutenlessactivevs.resistantS.pneumo.thanotheragentslisted.Nobenefit of
antibiotics intreatmentof otitismediawith effusion(CochraneDatabase
Syst Rev.Sep12:9:CD009163,2012)
ForpersistentotorrheawithPEtubes, hydrocortisone/bacitracin/colistineardropsNUS5 dropstidx 7dmoreeffectivethanpoAM-CL
(NEJM.370.723,2014)
Treatmentfor clinical failure
after3days
Drug-resistantS.pneumoniaemainconcern
NOantibioticsinmonth
priortolast3 days:
AM-CLhighdoseorcefdinir
orcefpodoximeorcefprozil
orcefuroximeaxetilorIMceftriaxone x3days
SeeclindamycinComments
seefootnoteJ
irepediatric
rxasabove
Clindamycinnot activevs.H.influenzae orM.catarrhalis S.pneumo
resistanttomacrolidesare usuallyalsoresistanttoclindamycin
Definition offailure:nochangeinearpain,fever,bulgingTMorotorrhea
after3daysoftherapy.Tympanocentesiswillallowculture.
Newer FQsactivevs.drug-resistantS.pneumo(DRSP),butnot
approvedforuseinchildren(PIDJ23:390, 2004).Vancoisactive
CeftazidimeorCFPorIMPorMERor(PIP-TZ)orCIP
(Fordosages,seeEar, Necrotizing (malignant)otitis
Drugs& peds dosage(ailpounlessspecified) foracuteotitismedia:AmoxicillinUD =40mg/kgperday divq12horq8h.AmoxicillinHD =90 mg/kgperdaydivq12horq8h.AM-CL HD_=90mg/kg
perdayofamoxcomponent.Extra-strengthAM-CLoralsuspension(Augmentin ES-600)availablewith600mg AM &42.9mg CL/5mL —dose:90/6.4mg/kgperdaydivbid.Cefuroximeaxetil30 mg/kg
perdaydivq12h Ceftriaxone 50mg/kgIM x 3days.Clindamycin 20-30mg/kgperdaydivqid(may beeffective vs.DRSPbutnoactivity vs.H influenzae).
Otherdrugssuitablefordrug(e.g.,penicillin)-sensitiveS.pneumo: TMP-SMX4mg/kgofTMPq12h Erythro-sulfisoxazole 50mg/kgperdayoferythro divq6-8h Clarithro 15mg/kgperdaydivq12h;azithro 10mg/kgperdayx1 &then 5mg/kg q24hon days2-5.OtherFDA-approvedregimens: 10mg/kg q24hx3 days&30mg/kgx1 Cefprozil15mg/kgq12h;cefpodoximeproxetil10mg/kgperday
assingledose: cefaclor 40mg/kgperdaydivq8h; loracarbef15mg/kgq12h Cefdinir 7mg/kg q12hor14mg/kgq24h
Abbreviationsonpage2 *NOTE: Aildosage recommendationsarefor adults (unlessotherwiseindicated)and assumenormalrenal function.§Alternativesconsiderallergy,PK, compliance,local resistance,cost
Trang 18AND COMMENTS
EAR,OtitisMedia(continued)
Prophylaxis: acuteotitismedia
JLaryngolOtol 126:874,2012
Pneumococci, H.influenzae,
M.catarrhalis,Staph,aureus,
GroupAstrep(seeComments)
antibiotic-PneumococcalproteinconjugatevaccinedecreasesfreqAOMduetovaccineserotypes
Adenoidectomyattimeoftympanostomytubeslneedfor future hospitalization forAOM(NEJM344:1188, 2001).Mastoiditis: Complicationofacuteorchronicotitismedia.Ifchronic,lookforcholesteatoma (Keratoma)
Acute
Generally tooill foroutpatient
therapy.Complicationref:
OtolaryngClinNo Amer
Obtaincultures,then empirictherapy
1 stepisode:Ceftriaxone2gmIVoncedailyOR
Levofloxacin750mgIVoncedaily
Acute exacerbationofchronicotitis
media:Surgicaldebridementofauditory canal,then[Vancomycin
(dosetoachievetoughof
15-20mcg/mL) + PIP-TZ3.375gm IV
q6h]OR[Vancomycin(doseasabove) +Ciprofloxacin400mgIV
q8h]
• Diagnosis:CTorMRI
• Lookforcomplication:
osteomyelitis,supperativelateral
sinusthrombophlebitis, purulentmeningitis,brainabscess
• ENTconsultationforpossible
Etiol.unclear.Factors includeStaph,aureus&Staph,epidermidis, seborrhea,rosacea,&dryeye
ieDatabaseSystRev 5:CD005556,2012)Lidmargin carewithbabyshampoo & warmcompresses
q24h.Artificialtearsifassoc, dry eye (seeComment)
Usually topicalointmentsofnobenefit.
Ifassociated rosacea,add doxy 100mg pobidfor2wksandthenq24h
Hordeolum(Stye)
External(eyelashfollicle) Staph, aureus Hotpacksonly Willdrainspontaneously Infectionof superficialsebaceousgland
Internal (Meibomianglands):
Canbeacute,subacute
or chronic
Staph, aureus, MSSA Oral dicloxacillin +hotpacks Alsocalledacutemeibomianitis Rarely drainspontaneously;mayneed
l&Dandculture. Roleoffluoroquinoloneeye dropsisunclear: MRSAoftenresistant tolowercone.;maybesusceptibletohigherconcentrationofFQ
inophthalmologicsolutionsof gati,levo ormoxi
Staph, aureus,MRSA-CA TMP-SMX-DS,tabsiipobidStaph, aureus,MRSA-HA Linezolid600mgpobidpossible therapyifmulti-drugresistant.
Conjunctiva: Review:JAMA310:172
Conjunctivitis ofthenewborn(ophi
ofonsetpost-delivery—alldosepediatric
None Usual prophylaxisiserythroointment;hence,silver nitrate irritation rare.
Onset 2-4 days N.gonorrhoeae Ceftriaxone25-50 mg/kgIVx1 dose(seeComment),
nottoexceed 125mg
Treatmotherandher sexual partners Hyperpurulent Topicalrxinadequate.TreatneonateforconcomitantChlamydiatrachomatis
Onset 3-10 days Chlamydiatrachomatis Erythrobaseor ethylsuccinatesyrup 12.5mg/kg q6h
x 14 days Notopicalrxneeded
Diagnosis byNAAT.Alternative:Azithrosuspension 20 mg/kg po q24hx
3 days.Treatmother &sexualpartner
’'NOTE: dosage recommendations andassume
Abbreviationsonpage
Trang 19TABLE1 (10)
MODIFYING CIRCUMSTANCES (usual)
EYE/Conjunctiva(continued)
Onset2-1 6days Herpessimplex types1 , Topicalanti-viral rxunderdirectionolophthalmologist Alsogive Acyclovir60 mg/kg/dayIVdiv3doses (RedBookonline,
accessed Jan2011)
Ophthalmianeonatorumprophylaxis:erythro0.5%ointmentx1 or tetra1%ointmentN":;
x1application; etlectivevs.gonococcusbutnot C.trachomatisPinkeye (viral conjunctivitis)
Usuallyunilateral
Adenovirus(types3&7in
children, 8, 11 &19in adults)
Notreatment.Ifsymptomatic,artificialtearsmayhelp,
(somestudiesshow2dayreductionofsymptomswithsteroids; notrecommended)
Highlycontagious.Onsetofocular painandphotophobiainanadultsuggests associatedkeratitis—rare.
Inclusionconjunctivitis(adult)
Usuallyunilateral&concomitant
Mayneedtorepeatdoseof azithro.
Trachoma—achronicbacterial
x 14days
Starts inchildhoodand canpersist foryearswithsubsequentdamage
tocornea Topicaltherapyofmarginalbenefit.Avoiddoxy/tetracycline
inyoungchildren.Masstreatmentworks(NEJM358:1777&1870, 2008:JAMA299:778,2008)
Suppurativeconjunctivitis, bacterial:ChildrenandAdults (Eyedropsspeedresolution ofsymptoms: Cochrane DatabaseSyst Rev.Sep 12;9:CD001211,2012)
JAMA310:1721,2013 Staph,aureus, S.
pneumo-niae,H influenzae,Viridans
Strep.,Moraxellasp
FQophthalmicsolns:CIP
(generic);othersexpensive(Besi,Levo, Moxi)All
FQsbestspectrumforempirictherapy.High concentrationsflikelihood
ofactivity vs S.aureus—evenMRSA.
TMPspectrummayincludeMRSA.PolymyxinB spectrumonlyGm-neg
bacillibutnoophthal.prepofonlyTMP.MostS.pneumoresistant togent
&tobra
Gonococcal(peds/adults) N.gonorrhoeae Ceftriaxone 25-50mg/kgIV/IM (nottoexceed 125 mg)asone doseinchildren; 1 gmIM/IVasone doseinadults
Cornea(keratitis): Usuallyserioi
Viral
H.simplex
isandoften sight-threatenin
Dgyindevelopedcountries;
H.simplex,types1 &2
g.Promptophthalmologic
bacterialandfungalinfecti
Trifluridineophthalmic
sol'n,one dropq2h upto
9 drops/dayuntil epithelialized,thenone dropq4h upto 5x/day,for total
re-not toexceed21 days
See Comment
consultation essentialfordi
Ganciclovir0.15%
ophthalmicgel:Indicatedfor
acuteherpetickeratitis.One
drop 5 times perdaywhile
awakeuntilcorneal ulcer
heals;then,onedropthreetimes perdayfor7 days
Vidarabine ointment—useful
in children.Use5x/dayforup
to21days(currently listed
Varicella-zosterophthalmicus Varicella-zostervirus Famciclovir500mg potid
orvalacyclovir1 gmpotid
x10days
Acyclovir800mg po5x/day
x10days
Clinicaldiagnosismostcommon:dendritic figures with fluorescein staining
inpatientwith varicella-zoster ofophthalmicbranchoftrigeminalnerve
Abbreviationsonpage2. *NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)andassumenormalrenal function.§Alternativesconsiderallergy,PK, compliance,local resistance,cost
13
Trang 201 dropqlhforthefirst48h
thentaperaccording
toresponse
trial,fungal,protozoanistopic
CIP 0.3%ophthal orLevo
0.5%ophthal.1 -2 gtts/hrx24-72hrs,then taper
:alunless otherwise indicated
Regimensvary:somestart rxbyapplingdropsq5minfor5 doses;some
applydropsq 15-30minforseveral hours; someextendintervaltoq2h
duringsleep.Inaclinical trial,dropswereappliedqlhfor48-72h,thenq2h
throughday6;thenq2hduringwakinghourson days7-9;thenq6huntil
healing(Cornea 29:751,2010)
Note: despite highconcentrations,mayfail vs.MRSA.Prioruseof
fluoroquinolones associatedwithincreasedMICs (JAMAOphthalmol
131:310, 2013)\ highMICsassociatedwithpooreroutcome
(Clin InfectDis54:1381,2012)
Contactlensusers P.aeruginosa CIP 0.3%ophthalmic
Corneaabrasions:treated withTobra, Gent,orCIPgttsqidfor3-5 days;
referraltoophthalmologistrecommendedcorneainfiltrateorulcer, visual loss,lack ofimprovementorworsening symptoms(AmFamPhysician.87:114, 2013)
Dry cornea,diabetes,
immunosuppression
Staph, aureus,S.epidermidis,
S.pneumoniae,S.pyogenes,Enterobacteriaceae,listeria
CIP 0.3%ophthalmicsolution1-2gttshourly
X24-72hrs,then taper
based onclinicalresponse
Vanco(50mg/mL) +Ceftaz(50mg/mL)hourly
for24-72h, taperdependinguponresponse
SeeComment.
Specifictherapyguided byresults of alginateswabculture.
Fungal Aspergillus, fusarium,
Candida andothers
Natamycin(5%): 1 dropevery1-2hforseveraldays;
thenq3-4hforseveraldays;
canreduce frequency
depending uponresponse
AmphotericinB(0.15%):
1 drop every1-2hoursfor
severaldays;canreducefrequencydepending upon
response
Obtainspecimensforfungalwetmountandcultures.
Numerousothertreatment options(1%topical Itra for6 wks,oral Itra100mg
bidfor3 wks,topicalvoriconazole1%hourlyfor2 wks,topicalmiconazole1%5x aday,topical silversulphadiazine0.5-1.0%5x a day)appeartohave
similarefficacy(CochraneDatabaseSystRev2:004241,2012)Mycobacteria: Post-refractive
eye surgery
M.chelonae; M.abscessus Moxieye drops: 1 gtt qid, probablyinconjunctionwith
otheractiveantimicrobials
Alternative:systemicrx:Doxy100mgpobid+Clarithro500mgpobid(PLoSOne10:doi16236, 2015)
Protozoan
Softcontactlens users
Ref:C/D35:434,2002
Acanthamoeba,sp Optimalregimenuncertain.Suggestedregimen:
[(Chlorhexidine0.02%orPolyhexamethylene biguanide0.02%) i (Propamidineisethionate0.1%orHexamidine
0.1%)] drops.Applyone dropeveryhourfor48h,then
one dropevery houronlywhileawakefor72h,then
onedropeverytwo hourswhileawakefor3-4weeks, thenreducing frequencybased onresponse(Ref:AmJ
Ophthalmol148:487,2009: CurrOpInfectDis 23:590, 2010)
Uncommon Traumaandsoftcontact lensesarerisk factors.
Toobtainsuggesteddrops: Leiter'sParkAve Pharmacy(800-292-6773;www.leiterrx.com) Cleaningsolutionoutbreak:MMWR56: 532,2007
Abbreviationsonpage *NOTE: dosage recommendations
Trang 21TABLE1 (12)
MODIFYING CIRCUMSTANCES
ETIOLOGIES(usual)
AND COMMENTS
PRIMARY ALTERNATIVE5
EYE/Cornea(keratitis)(continued)
Lacrimalapparatus
Canaliculitis ActinomycesStaph.,Strept.
Rarely,Arachnia,terium,nocardia,Candida
fusobac-Removegranules&
irrigatewithpen G
useofintracanalicplugs(OphthPlastReconstr Surg24: 241, 2008)
Child:AM-CLorcefprozil
Culture todetectMRSA.
Endophthalmitis:Endogenous (sec
Bacterial: Hazinessofvitreouskey
Postocular surgery(cataracts)
Early,acute onset
(incidence0.05%)
;ondarytobacteremiaorfunge
todiagnosis.Needleaspirate<
S.epidermidis60%,Staph,aureus,streptococci,&
enterococcieach 5-10%,Gm-neg bacilli6%
mia)and exogenous(post-injection,post-operative)types
Dfbothvitreousand aqueoushumorforcultureprior totherapy.Intravitrealadministrationofantimicrobials essential
Immediateophthal consult Ifonlylightperceptionorworse, immediatevitrectomy+intravitrealvanco 1mg &intravitrealceftazidime2.25mg.Nocleardataonintravitreal steroid. Mayneedtorepeatintravitreal antibiotics in2-3days.Canusuallyleavelensin.
Adjunctivesystemicantibiotics (e.g.,Vancomycin,Ceftazidime Moxifloxacin or GatifloxacinNUS)notofprovenvalue,butrecommended
inendogenousinfection.
Lowgrade,chronic Propionibacterium acnes,
S.epidermidis, S.aureus
(rare)
Intraocularvanco.Usually requires vitrectomy, lensremoval
Postfilteringblebs
forglaucoma
Strep,species(viridans&
others), H.influenzae
Intravitrealagent(e.g.,Vanco1 mg +Ceftaz2.25mg) andatopicalagent Considera systemic agentsuchasAmp-Sulb
orCefuroximeorCeftaz (addVancoifMRSAissuspected)Post-penetratingtrauma Bacillussp., S.epiderm Intravitrealagent asabove+ systemic clindaorvanco Usetopical antibioticspost-surgery(tobra&cefazolindrops)
None, suspecthematogenous S.pneumoniae,
N meningitidis,Staph, aureus,
GrpBStrep, K.pneumo
(cefotaxime 2gmIVq4horceftriaxone 2gmIVq24h) t vanco30-60mg/kg/dayin2-3divdosestoachievetargettroughserum
concentrationof15-20mcg/mLpendingcultures.Intravitrealantibioticsaswith earlypost-operative
IVheroinabuse Bacillus cereus,Candidasp Intravitrealagent+ systemic agentbasedonetiologyandantimicrobialsusceptibility.
Mycotic(fungal):Broad-spectrum
antibiotics,often corticosteroids,
indwellingvenouscatheters
Candidasp.,Aspergillus sp Intravitrealampho B0.005 0.01 mgin 0 1 mL.Alsosee
Table 1 1A,page 125forconcomitant systemictherapy
SeeComment
Patients withCandidaspp.chorioretinitisusuallyrespondtosystemicallyadministeredantifungals(Clin InfectDis 53:262,2011) Intravitrealamphotericinand/orvitrectomymaybe necessaryforthosewithvitritisorendophthalmitis(BrJOphthalmol92:466,2008; Pharmacotherapy 27:1711,2007)
Cytomegalovirus See Table 14A,page 168 Occursin5-10%ofAIDSpatients
Abbreviationsonpage2. *NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)and assumenormalrenal function.§Alternativesconsiderallergy, PK,compliance,local resistance,cost
15
Trang 22Progressiveouterretinalnecrosis VZV,H.simplex,CMV(rare) Acyclovir 10-12mg/kgIVq8hfor1-2weeks, then
(valacyclovir1000mgpotid,orfamciclovir500mgpotid,
oracyclovir800mgpotid).Ophthalmologyconsultationimperative:approacheshavealsoincludedintra-vitreal
injectionofanti-virals (foscarnet,ganciclovirimplant).
In rarecasesduetoCMVuseganciclovir/valganciclovir(seeCMVretinitis,Table14A).
Mostpatientsarehighlyimmunocompromised(HIV withlowCD4ortransplantation).IncontrasttoAcuteRetinalNecrosis, lackofintraocularinflammationorarteritis. Maybeabletostoporal antiviralswhen CD4recoverswithART(OculImmunolInflammation 15:425,2007)
Orbitalcellulitis(seepage54
forerysipelas, facial)
S.pneumoniae,H.influenzae,
M.catarrhalis, S.aureus,anaerobes,groupAstrep,occ
Gm-neg.bacillipost-trauma
Vancomycin15-20mg/kgIVq8-12h(targetvancomycin
troughserumconcentrationsof15-20 ng/mL)+([Ceftriaxone 2gmIVq24h+ Metronidazole1 gmIV
q12h]ORPIP-TZ3.375gmIVq6h
Ifpenicillin/cephallergy:Vanco + levo750mgIVoncedaily+metro
IV.Problemisfrequentinabilitytomakemicrobiologic diagnosis.Imageorbit
(CTorMRI).Riskofcavernoussinusthrombosis
Ifvancointolerant,anotheroptionfor s.aureusisdapto 6mg/kgIVq24h
FOOT
“Diabetic foot”— Twothirdsofpatie
Ulcerwithoutinflammation
ntshavetriadofneuropathy, dColonizingskinflora
eformityandpressure-induced trauma IDSAGuidelinesCIO
Noantibacterialtherapy.Moderatestrengthevidencefor
improvedhealing with biologic skin equivalent or negativepressurewoundtherapy.Lowstrengthevidencefor platelet
derivedgrowthfactorandsilvercream(AnIM159:532, 2013)
>54:e132,2012
General:
1 Glucosecontrol,eliminatepressureonulcer
2. Assessforperipheralvasculardisease
3. CautioninuseofTMP-SMXinpatients with diabetes,asmanyhaverisk
factorsforhyperkalemia(e.g.,advancedage,reducedrenal function,
concomitantmedications) (ArchInternMed170:1045, 2010)
Principles ofempiricantibacterialtherapy:
1 Obtainculture;coverforMRSAinmoderate,moresevereinfections
pendingculturedata,localepidemiology
2. Severelimband/orlife-threatening infectionsrequireinitialparenteraltherapywithpredictableactivity vs.Gm-positivecocci includingMRSA,
coliforms&otheraerobicGm-neg.rods,&anaerobicGm-neg.bacilli.
3. NOTE:Theregimenslistedare suggestionsconsistent withabove
principles.Otheralternativesexist& maybeappropriateforindividualpatients
4 Isthereanassociatedosteomyelitis? Riskincreasedifulcerarea
>2 cm2
, positiveprobetobone,ESR >70andabnormalplain x-ray.
NegativeMRIreduceslikelihood ofosteomyelitis(JAMA299:806, 2008)
MRIisbestimagingmodality(CID47:519&528, 2008).
Mildinfection S.aureus(assumeMRSA),
Osteomyelitis SeeComment.
Asabove,pluscoliformspossible
Oral:As above
Parenteral therapy: [basedonprevailingsusceptibilities:
(AM-SBorPIP-TZorERTAorothercarbapenem)] plus
[vanco(oralternativeanti-MRSAdrug as below)until
Parenteraltherapy: (Vancoplus |l-lactam/|!-lactamaseinhibitor) or(vancoplus|DORIorIMPor MER])
Otheralternatives:
1 Daptoorlinezolid(orvanco
2.(CIPor LevoorMoxioraztreonam)plus
metronidazolelor|)-lactam/|5-lactamaseinhibitor
Dosagesinfootnote7
Assessfor arterialinsufficiency!
5
TMP-SMX-DS 1-2tabspobid,minocycline 100mgpobid,Pen VK500mgpoqid,(OCeph2, 3:cefprozil500mgpoq12h,cefuroximeaxetil500mgpoq12h, cefdinir300mgpo q12hor600 mg
poq24h,cefpodoxime200mgpoq12h),CIP750mgpobid. Levo750mg poq24h.Diclox500mgqid.Cephalexin 500mgqid.AM-CL875/125bid.Doxy 100mgbid.CLINDA300-450mgtid
6
AM-CL-ER2000/125mgpobid,TMP-SMX-DS1-2tabspobid,CIP750mgpobid, Levo750mgpoq24h,Moxi 400mgpoq24h,linezolid600mgpobid.
7
Vanco1 gmIVq12h, (parenteral p-lactam/p-lactamaseinhibitors;AM-SB3gmIVq6h.PIP-TZ3.375gmIVq6hor 4.5gmIVq8hor4hrinfusionof3.375gmq8h;carbapenems: Doripenem500mg
(1 -hr infusion)q8h, ERTA1 gmIVq24h,IMP0.5gm IVq6h,MER 1gm IVq8h.daptomycin6mgperkgIVq24h,linezolid600mgIVq12h.aztreonam 2gmIVq8h CIP400mgIVq12h,Levo750mg
IVq24h,Moxi 400mgIVq24h, metro1gm IVloadingdose&then0.5gmIVq6hor 1 gmIVq12h
page *NOTE:
Trang 23MODIFYING CIRCUMSTANCES
ETIOLOGIES(usual)
AND COMMENTS
FOOT(continued)
Onychomycosis:SeeTable11,page129,fungal infections
Puncturewound: Nail/Toothpick P.aeruginosa(Nail),
S.aureus,Strept (Toothpick)
Cleanse.Tetanusbooster.Observe Seepage4. 1-2%evolvetoosteomyelitis
GALLBLADDER
Cholecystitis, cholangitis,biliary
sepsis,orcommonductobstruction
(partial:2natotumor,stones,
stricture).Cholecystitis Ref:NEJM
tote'onpage16.
cactivity vs.nnterococci
Inseverelyill pts, antibiotictherapycomplements adequatebiliarydrainage
15-30%ptswillrequiredecompression:surgical, percutaneousor
ERCP-placedstent.Gallbladderbile isculturepos.in40-60%(J Infect51:128,2005) Nobenefittocontinuationof antibiotics aftersurgeryinpts withacute calculouscholecystitis(JAMA3312:145, 2014)
GASTROINTESTINAL
Gastroenteritis—EmpiricTherapy
Prematureinfant with
necrotizing enterocolitis
(laboratorystudiesnot perfAssociatedwithintestinal flora
ormedor culture, microscopy,toxin resultsNOTAVAIL
Treatment should coverbroadrangeofintestinalbacteriausingdrugs appropriatetoage andlocal susceptibility patterns, rationaleasin diverticulitis/peritonitis,page22
ABLE)
Pneumatosisintestinalis, ifpresentonx-rayconfirmsdiagnosis
Bacteremia-peritonitisin30-50%.IfStaph,epidermidisisolated,add vanco
(IV).For reviewandgeneralmanagement, seeNEJM364:255, 2011
Milddiarrhea(<3unformed
stools/day,minimal associated
symptomatology)
Bacterial(see Severe, below),
viral (norovirus), parasitic Viral
usuallycausesmildto
mod-eratedisease.Fortraveler's
diarrhea,seepage20
Fluidsonly+lactose-freediet,avoidcaffeine Rehydration: Forpofluidreplacement,seeCholera,page 19.
Antimotility(Donotuseif fever,bloodystools,orsuspicionofHUS):Loperamide(Imodium) 4mgpo,then 2mgaftereachloosestool tomax
of16mgper day Bismuthsubsalicylate(Pepto-Bismol)2tablets(262mg)
poqid.
Hemolyticuremicsyndrome(HUS):Riskinchildren infected withE coli
0157:H7is8-10%.Earlytreatment withTMP-SMXorFQs| risk ofHUS
Norovirus:Etiologyofover90%ofnon-bacterialdiarrhea(±nausea/vomiting) Lasts 12-60hrs.Hydrate.Noeffective antiviral.
Otherpotentialetiologies:Cryptosporidia—notreatmentincompetenthost.Cyclospora—usuallychronicdiarrhea,respondstoTMP-SMX(see Table 13A)
immuno-Klebsiellaoxytocaidentifiedascauseofantibiotic-associatedhemorrhagic
colitis(cytotoxinpositive):NEJM355:2418, 2006
Moderatediarrhea (>4
unformedstools/day &/or
systemicsymptoms)
Antimotilityagents (seeComments) +fluids
Severediarrhea(>6unformed
stools/day,&/ortemp>101°F,
tenesmus, blood, or fecal
leukocytes)
NOTE:Severeafebrilebloody
diarrheashould|suspicion
ofShiga-toxinE.coli0157:H7&
For typhoidfever,
Ifrecentantibiotictherapy(C.dadd:
Metro 500mgpotidtimes
10-14 days
ifficile toxin colitispossible)
Vanco 125mgpoqidtimes
10-14 days
Abbreviationsonpage2. 'NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)andassumenormalrenal function § Alternativesconsiderallergy,PK,compliance,local resistance,cost
17
Trang 24Gastroenteritis—SpecificTherapy(resultsofculture, microscopy,toxinassayAVAILABLE) (Ref.:NEJM370:1532, 2014)
Ifculturenegative,probably
Norovirus (Norwalk) othervirus
(EID 17:1381,2011)—see
Norovirus,page 174
NOTE: WBC > 15,000 suggestive
of C.difficile inhospitalizedpatient.
Aeromonas/Plesiomonas CIP 750mgpobidx3 days TMP-SMX DStab1 pobid
x3days
Althoughnoabsoluteproof, increasingevidenceforPlesiomonasascause
ofdiarrhealillness(NEJM361:1560,2009)
|Amebiasis(Entamoebahistolytica,Cyclospora, Cryptosporidia andGiardia),see Table13A
CampylobacterjejuniHistory of feverin53-83%
qidx5daysorCIP500mg
pobid(CIPresistanceincreasing)
Post-CampylobacterGuillain-Barre; assoc 15%ofcases(Ln366:1653,2005).Assoc,withsmall bowellymphoproliferativedisease;mayrespond
toantimicrobials(NEJM350:239, 2004).Reactivearthritisanotherpotentialsequelae.See Traveler'sdiarrhea,page20.
CampylobacterfetusDiarrheauncommon.
Moresystemicdisease
Drawbloodcultures Inbacteremicpts,32%ofC.fetus resistanttoFQs
(CID47:790, 2008).MeropeneminhibitsC fetusatlowconcentrationsin vitro.
Clinicalreview:CID58:1579,2014
Differentialdiagnosisof
bid x10days
myces)inconsistentresults(AnIM157:878,2012; Lancet 382:1249,2013)
D/Cantibioticifpossible;avoidantimotilityagents, hydration,entericisolation.Recent reviewsuggestsantimotilityagentscan
be usedcautiouslyincertain pts withmild diseasewhoarereceiving
10-14days.TouseIVvanco
po,see Table10A,page107.
Fidaxomicin 200mgpobid
x10days
Vancosuperior tometroinsickerpts.Relapsein10-20% Fidaxomicinhad
lowerrateofrecurrence thanVancofordiarrhea withnon-NAPI strains
starttaper (SeeComments)
Vancotaper(alldoses 125mgpo): week1-bid,week2 q24h;week3 qod;then every 3rddayfor5doses(NEJM359, 1932, 2008).Anotheroption: After initialvanco rifaximinNAI400-800mgpodailydivided bid ortidx2 wks
Fecal transplantmoreefficaciousthanvancomycin(15/16[93%] versus7/26[27%])incuring recurrent C.difficile infection(NewEngl JMed368:407,2013)Post-opileus;severedisease
withtoxicmegacolon
(NEJM359:1932 2008;
CID61:934, 2015)
Metro 500mgIVq6h+ vanco500mgq6hvianasogastrictube(ornaso-small boweltube)±retrogradeviacatheterin
cecum.Seecommentfordosage.Nodataonefficacy of
Fidaxomicininseverelife-threateningdisease
Forvancoinstillation intobowel,add500mgvancoto1 literofsalineand
perfuseat1-3mL/mintomaximumof2gmin24hrs(CID690,2002).Note:IVvanconoteffective Indicationsforcolectomy,seeICHE
31:431,2010 Reported successfuluseoftigecyclineNAiIVtotreatsevere
C.diffrefractory tostandardrx(CID 48:1732,2009)
(Continuedonnextpage)
EnterohemorrhagicE coli
(EHEC).SomeproduceShigatoxinE. coli(STEC)and cause hemolyticuremicsyndrome(HUS)
Strains:0157:H7,0104:H4andothers Classicallybloodydiarrheaandafebrile
Hydration: avoidantiperistalticdrugs.25%increasedrisk
of precipitatingHUSinchildren<agelOyrsgiven
TMP-SMX,betalactam,metronidazoleor azithromycinfordiarrhea(CID55:33,2012) Inuncontrolled study,antibiotictreatment
ofSTECoutbreak, shorter excretionof E coli,fewerseizures,
lowermortality(BMJ345:e4565,2012).Ifonempiric
antibiotics,thenDxofSTEC,reasonabletodiscontinue
antibiotics.Avoidall antibiotics inchildrenage <10yrs with
bloodydiarrhea.If antibioticsused,azithromycinmaybethesafestchoice(JAMA307:1046,2012)
• HUSmorecommonin children,15%inage< 10yrs;6-9%overall.
• Diagnosis:EIAforShigatoxins 1 &2in stool(MMWR58(RR-12), 2009)
• Treatment: In vitroandinvivo data,thatexposureofSTECtoTMP-SMX
andCIPcausesburstofHUStoxinproduction asbacteriadie (JID181:664, 2000)
• HUSbaddisease: 10%mortality;50%.somedeqreeofpermanentrenal
damage(CID38:1298,2004)
Abbreviationsonpage 'NOTE: dosage recommendations
Trang 25TABLE 1 (16)
MODIFYING CIRCUMSTANCES (usual)
PRIMARY ALTERNATIVE5 AND COMMENTS
GASTROINTESTINAL/Gastroenteritis —SpecificTherapy(continued)
(Continued frompreviouspage) Klebsiellaoxytoca
—
antibiotic-associateddiarrhea
Respondstostoppingantibiotic SuggestedthatstoppingNSAIDshelps.Ref.:NEJM355:2418, 2006
Listeriamonocytogenes Usuallyself-limited.Valueol oralantibiotics(e.g.,ampicillin
orTMP-SMX)unknown,buttheiruse mightbereasonable
inpopulationsat risk forseriouslisteria infections.Those
withbacteremia/meningitisrequireparenteral therapy:
seepages9&61
Recognized as a causeoffood-associatedfebrile gastroenteritis.Not detected
instandardstool cultures.Populationsat ] risk ofseveresystemicdisease:pregnantwomen,neonates, theelderly,andimmunocompromisedhosts(MMWR57:1097,2008).
Salmonella, non-typhi—Fortyphoid(enteric) fever,
seepage62
Feverin71-91%,history
ofbloodystoolsin34%
If ptasymptomaticorillnessmild, antimicrobialtherapynot indicated.Treatifage <1 yror>50yrs, ifimmunocompromised,ifvascular
graftsorprostheticjoints,bacteremic,hemoglobinopathy,orhospitalized with feverandseverediarrhea (seetyphoidfever,page62).
(CIP500mgbid)or
(Levo500mgq24h)x7-10days(14daysif
TresistancetoTMP-SMXandchloro.Ceftriaxone,cefotaximeusually active
if IVtherapyrequired(see footnote11,page25, fordosage) CLSIhasestablishednewinterpretivebreakpointsfor susceptibility toCIP:susceptible
strains,MIC <0.06 jig/mL(Clin InfectDis55:1107, 2012) Primary
treatment ofenteritisis fluidandelectrolytereplacement
ShigellaFeverin58%,history
ofbloodystools51%
CIP750mgpobidx 3days
Pocketsofresistance (see
Pedsdoses:Azithro 10mg
For severe disease,ceftriaxo
x2-5days.CIPsuspension
Azithro500mgpo once
dailyx3days
Comment)/kg/dayoncedailyx3 days
-\e50-75mg/kgperday
0mg/kgbid x5 days
RecommendedadultCIPdoseof750mgoncedaily for3 days(NEJM361:1560, 2009)
Immunocompromisedchildren&adults:Treatfor7-10days.
Pocketsofresistance:S flexneri resisttoCIP&ceftriaxone
(MMWR59:1619, 2010);S.sonneiresisttoCIPintravelers
(MMWR64:318, 2015);S.sonnei suscepttoCIP butresist toazithroinMSM (MMWR64:597, 2015)
Spirochetosis(Brachyspirapilosicoli)
Benefit oftreatmentunclear.Susceptibletometro,ceftriaxone,and Moxi
Anaerobicintestinalspirochetethatcolonizescolonofdomestic&wildanimalsplushumans.Calledenigmaticdiseaseduetouncertain status (Digest Dis&
Sci 58:202, 2013)
Vibriocholerae
(toxigenic-01 &039)
Treatmentdecreasesduration
ofdisease,volumelosses,
&duration of excretion
forother age-specific
alternatives,seeCDCwebsite
http://www cdc.gov/haiticholera/hcpgoingtohaiti.htm
Antimicrobialtherapyshortensduration ofillness,butrehydrationis
paramount.WhenIVhydrationisneeded, useRinger’slactate.Switchto
POrepletionwith OralRehydrationSalts(ORS)assoonas abletotakeoral fluids.ORSarecommerciallyavailableforreconstitutioninpotablewater
Ifnotavailable,WFtOsuggests asubstitutecanbemadebydissolving
’/?teaspoonsaltand6levelteaspoonsofsugar perliterofpotable water(http://www.who.int/cholera/technical/en/)
CDCrecommendationsforotheraspectsofmanagementdevelopedfor Haiti
outbreakcanbefoundathttp://www.cdc.gov/haiticholera/hcp_goingtohaiti.htm
Isolatesfromthisoutbreakdemonstrate reducedsusceptibility to ciprofloxacin
andresistanceto sulfisoxazole, nalidixicacidandfurazolidone
Abbreviationsonpage2. *NOTE:Alldosage recommendationsarelor adults (unlessotherwiseindicated)andassumenormalrenal function.§Alternativesconsiderallergy, PK,compliance,local resistance,cost
19
Trang 26Notreatment unlesssevere.Ifsevere,combinedoxy
100mgIVbid+ (tobraorgent5mg/kgperday once
q24h).TMP-SMXorFQsarealternatives.
Mesentericadenitispaincanmimicacuteappendicitis.Labdiagnosis
difficult:requires “coldenrichment"and/oryersiniaselectiveagar
Desferrioxamine therapy increasesseverity,discontinueifptonit Iron
overloadstatespredisposeto yersinia.
Gastroenteritis—SpecificRiskGr<
SeespecificGlpathoqens,Gastroenteritis,above
SeeTable 13A
Tenderrightlowerquadrantmaybeclue,butmaybediffuse
orabsentinimmunocompromised.Needsurgical consult Surgicalresection controversial butmaybenecessary
NOTE:ResistanceofClostridiatoclindamycinreported PIP-TZ, IMP,MER, DORIshould covermostpathoqens
Traveler’s diarrhea,
self-medication Patient oftenafebrile
Acute:60%duetodiarrheagenicE coli;
shigella,salmonella, orCampylobacter.C.difficile,
amebiasis (see Table13A)
Ifchronic: cyclospora,Cryptosporidia,giardia,
isospora
CIP 750mgpobidfor1-3daysOR
Levo500mgpo q24hfor1-3daysOR
Oflox300mgpobidfor3daysOR
Rifaximin200mg potid for3daysOR
Azithro1000mgpo onceor500mgpoq24hfor3daysForpediatrics:Azithro10mg/kg/dayas asingledosefor
3daysorCeftriaxone50mg/kg/dayassingledosefor
3 days Avoid FQs
Forpregnancy: UseAzithro.Avoid FQs
Antimotility agent: For non-pregnantadults withnofeverorbloodin
stool,addloperamide 4mgpox1 ,then 2mgpoaftereachloosestoolto
amaximumof16mgperday
Comments:Rifaximinapprovedonlyforages12andolder.Worksonly
fordiarrheadueto non-invasiveE coli;donotuseiffeverorbloodystool.
Ref:NEJM361:1560, 2009;
Note:SelftreatmentwithFQsassociatedwith acquisition ofresistant
Gm-negbacilli(CID60:837, 847, 872, 2015)
Preventionof Traveler’s
diarrhea
Notroutinelyindicated.Currentrecommendationis totake
FQ + ImodiumwithI *loosestool.
onpage 'NOTE: dosage recommendations
Trang 27MODIFYING CIRCUMSTANCES (usual)
PRIMARY ALTERNATIVE5 AND COMMENTS
GASTROINTESTINAL(continued)
GastrointestinalInfectionsbyAnatomicSite:EsophagustoRectum
Esophagitis Candidaalbicans,HSV,CMV |SeeSanford GuidetoHIV/AIDSTherapyunitTable1 1A.
Duodenal/Gastriculcer; gastric
cancer,MALT lymphomas
Canmodify bysubstituting
LevoforClarithro
metro 500mgtid i
omeprazole20mgbid.
Comment:Inmanylocations,20%failurerateswithpreviously
recommendedtripleregimens(PPI+ Amox + Clarithro)arenotacceptable.With 10daysofquadruple therapy[(omeprazole20mgpo
twicedaily) + (3capsulespofourtimes perday,eachcontaining Bismuth
subcitratepotassium 140mg + Metro 125mg+ Tetracycline
125 mg)],eradication rateswere93%ina perprotocolpopulationand80%
inanintention-to-treatpopulation,bothsignificantlybetterthanwith7-day
tripletherapyregimen(PPI + Amox +Clarithro)(Lancet 377:905,2011).Exercise caution regardingpotentialinteractions withotherdrugs,contraindicationsinpregnancyandwarningsforother specialpopulations.Dx:Stoolantigen—Monoclonal EIA>90%sens.& 92%specific.Othertests:
ifendoscoped,rapidurease&/or histology &/orculture;ureabreathtest,but
100%compliance/94%eradicationratereported:
(Pantoprazole 40mg + Clarithro500mg I Amox
1000mg +Metro 500 mg) pobidx7d (A4C58:5936,2014) High cureratesreportedinTaiwanwith
(Rabeprazole 20mg + Amox750mg)po4x/day
x 14days
someoffice-basedtestsunderperform.Testingref:BMJ344:44,2012
Testofcure: Repeatstoolantigenand/or urea breathtest>8 wks
post-treatment
Treatmentoutcome:Failure rateoftripletherapy20%dueto clarithro
resistance Curerate withsequentialtherapy90%
Smallintestine:Whipple’s
(Doxycycline 100mgpobid+Hydroxychloroquine
200mgpotid)x1 year,thenDoxycycline 100mgpobid
for life
Immunereconstitutioninflammatoryresponse(IRIS)
reactionsoccur:Thalidomide therapymaybebetterthansteroidsforIRISreaction(J Infect60:79,2010)
In vitrosusceptibilitytestingandcollectedclinicalexperience(JAC69:219,2014) In vitroresistancetoTMP-SMXplusfrequentclinical failures&relapses.Frequentin vitroresistancetocarbapenems.Completein vitro
resistance to Ceftriaxone
8
Cansubstitute otherprotonpumpinhibitors foromeprazoleor rabeprazole all bid esomeprazole20mg(FDA-approved),lanzoprazole 30mg(FDA-approved),pantoprazole40mg
(notFDA-approvedfor this indication).
9 Bismuthpreparations:(1) In U.S.,bismuthsubsalicylate(Pepto-Bismol) 262mgtabs; adultdoseforhelicobacteris2 tabs (524mg)qid (2)OutsideU.S.,colloidalbismuthsubcitrate(De-Nol)
120mgchewabletablets;doseis 1 tabletqid Inthe U.S.,bismuthsubcitrateisavailableincombinationcaponly(Pylera:eachcapcontainsbismuthsubcitrate140mg + Metro 125mg +Tetracycline
125 mg), given as 3capspo4xdaily for10days togetherwith atwicedailyPPI
Abbreviationsonpage2 *NOTE: Alldosage recommendationsarefor adults (unlessotherwiseindicated)andassumenormalrenal function.§Alternativesconsiderallergy, PK,compliance,local resistance,cost
Trang 28TABLE1 (19)
MODIFYING CIRCUMSTANCES (usual)
PRIMARY [ ALTERNATIVE*
'
GASTRQINTESTINAL/Gastrointestinal Infectionsby AnatomicSite: EsophagustoRectum(continued)
ETIOLOGIES(usual)
Diverticulitis, perirectal
abscess,peritonitis
AlsoseePeritonitis,page46
Enterobacteriaceae,occasionallyP.aeruginosa,Bacteroidessp.,enterococci
Outpatientrx—milddiverticulitis,drainedperirectal
abscess:
l(TMP-SMX-DSbid)or(CIPAM-CL-ER 1000/62.5mg
750mgbid or 2 tabspobid x7-1 0days
Levo750mgq24h)] + ORMoxi 400mgpo q24hx
metro 500mgq6h.Allpo 7-10days
x7-10days
Mild-moderate disease—Inpatient—Parenteral Rx:
(e.g.,focalperiappendicealperitonitis, peridiverticular
abscess, endomyometritis)
PIP-TZ3.375gmIVq6hor [(CIP400mgIVq12h)or4.5gmIVq8hor (Levo 750mgIVq24h)] +
ERTA1 gmIVq24hor (metro500mgIVq6horMOXI400mgIVq24h 1gmIVq12h)ORMoxi
400mg[V_q24h
Severelife-threateningdisease, ICUpatient:
IMP500mgIVq6horMER AMP +metro+ (CIP
GENITAL TRACT: Mixture ofempiric&specific treatment.Divided by sexofthepatient.Forsexual assault(rape),see Table15A,page200
See CDCGuidelinesforSexuallyTransmitted Diseases,MMWR64(RR-3):1,2015
BothWomen & Men:
AND COMMENTS
Must“cover”bothGm-neg.aerobic&Gm-neg.anaerobicbacteria Drugs
active onlyvs.anaerobicGm-neg.bacilli: clinda,metro.Drugsactiveonlyvs.aerobicGm-neg.bacilli:APAG10
,PCeph2/3/4(seeTable 10A,
page102),aztreonam,PIP-TZ, CIP, Levo Drugsactivevs bothaerobic/anaerobicGm-neg.bacteria:cefoxitin,cefotetan,TC-CL,
PIP-TZ,AM-SB, ERTA,DORI, IMP,MER, Moxi,&tigecycline.
Increasing resistance ofB fragilisgroup
Clinda Moxi Cefoxitin Cefotetan
%Resistant: 42-80 34-45 48-60 19-35Ref:Anaerobe 17:147,2011:AAC56:1247, 2012; SurgInfect10:111, 2009
Resistance(B.fragilis):Metro,PIP-TZrare.ResistancetoFQincreased
inenteric bacteria,particularly ifanyFQusedrecently.
Ertapenempoorly activevs P.aeruginosa/Acinetobactersp
Concomitantsurgicalmanagementimportant, esp.withseveredisease.Roleofenterococciremains debatable Probablypathogenicininfections ofbiliary tract.Probablyneeddrugsactivevs.
moderate-enterococciinpts with valvularheartdisease
Tigecycline:BlackBoxWarning:Allcausemortalityhigherinptstreatedwithtigecycline (2.5%)thancomparators(1.8%)inmeta-analysisofclinical
trials.Causeof mortalityriskdifferenceof0.6% (95%Cl0.1, 1.2)notestablished.Tigecyclineshouldbereservedforuseinsituationswhen
alternativetreatmentsarenot suitable(FDAMedWatch Sep27,2013)
singledoseORazithro
1 gmposingledose
CIP 500mgbidpox3days InHIV+pts, failuresreportedwith singledoseazithro(CID21:409, 1995)
ORerythro base500mgpo Evaluateafter7days,ulcershouldobjectivelyimprove.Allpatientstreatedfor
tidx7days chancroidshould betestedforHIVandsyphilis Allsexpartnersofpts with
chancroidshould beexaii linedandtreatediftheyhave evidenceofdiseaseorhavehadsexwithindex(it withinthelast 10days
10
Aminoglycoside=antipseudomonal aminoglycosidic aminoglycoside,e.g.,amikacin,gentamicin,tobramycin
onpage *NOTE: dosage recommendations
Trang 29MODIFYING CIRCUMSTANCES
ETIOLOGIES(usual)
assingledose) Evaluate&
treatsexpartner
Inpregnancy: Azithromycin
1gmposingledoseOR
amox500mgpotidx7days
(Erythrobase500mgqid
pox7days)or(Oflox
300mgq12hpox7days)or
(Levo 500mg q24hx7days)
fnpregnancy: Erythrobase
500mgpoqidfor7days
Doxy&FQscontraindicated
Diagnosis:NAATforC.trachomatis&N.gonorrhoeaeonurineorcervixorurethraspecimens(AnIM142:914, 2005) Testall urethritis/cervicitisptsfor
HIV&syphilis.
Forproctitis: preferdoxyx7d (Sex TransDis 41:79,2014)
Evaluate&treatsexpartners.Re-testforcureinpregnancy
Azithromycin1 am wassuperiortodoxycyclineforM.genitaliummale
urethritis(CID 48:1649, 2009),butmayselect resistance leadingto T failure
ofmulti-dose azithromycinretreatmentregimens (CID 48:1655,2009)
250mgpo oncedailyx4days
Moxi 400mgoncedaily x10-14days
Diagnosis byNAAT, ifavailable.Doxyineffective.Nocellwallsolactamsineffective.Curewith singledoseAzithroonly67%
beta-(CID 61.1389, 2015)
Recurrent/persistenturethritis C.trachomatis(43%),
M genitalium(30%),
T.vaginalis (13%)(CID52:163, 2011)
Metro2gmpox1 dose+
Azithro1gmpox1 dose
Tinidazole 2gmpo X1 +
Azithromycin1gmpo X1
Highfailure rate ofAzithroifM.genitalium(CID56:934, 2013).CantryMoxi
400mgpo oncedailyx10 daysifAzithrofailure(PLoSOne3:e3618,2008).New FQresistanceinJapan(JAC69:2376, 2014)
Gonorrhea FQsnolonger recorr
Cephalosporinresistance:JAMA
Treatforaminimumof7 days.Owingtohigh-levelresistance tooral
cephalosporinsandfluoroquinolonesinthecommunity, "Step-down"therapyshouldbeavoided unlesssusceptibilitiesareknown and
demonstratefull activityofcephalosporinorfluoroquinoloneR/O
meningitis/ endocarditis.Treatpresumptively
forconcomitantC.trachomatis.Azithronow recommendedtocover
resistantGC(usuallytetra resistant,too)andC.trachomatisEndocarditis N.gonorrhoeae Ceftriaxone1-2gm IVq12-24hoursx4weeks +Azithro
1gm pox1
GCendocarditismayoccurintheabsenceofconcomitanturogenital
symptoms(Infection42: 425, 2014).Severevalve destructionmayoccur.Ceftriaxone resistanceinN.gonorrhoeae has beenreported
(AAC55:3538,2011)\determinesusceptibilityofanyisolaterecovered.Pharyngitis
PharyngealGCmoredifficultto eradicate.Repeat NAAT14days
post-rx.SpectinomycinNUS,cefixime,cefpodoxime &cefuroxime
not effectiveUrethritis, cervicitis,
proctitis(uncomplicated)
Forprostatitis,seepage27
Diagnosis: Nucleicacid
amplificationtest (NAAT)
onvaginalswab,
urine orurethralswab
MMWR64(RR-3):1 2015
N.gonorrhoeae (50%ofptswithurethritis, cervicitishave
concomitantC trachomatis—
treatforbotheven ifNAAT
indicatessinglepathogen)
Ceftriaxone250mgIM x1 + Azithro1 gmpox1
Alternative:Azithro 2gmpox1
Rxfailure:Ceftriaxone500mgIM x1 + Azithro 2gm
pox1 ; treatpartner:NAATfor test ofcureoneweek
post-treatment
SeverePen/Cephallergy:(Gent240mgIM f Azithro
2gmpox1 dose)OR(Gemi 320mg +Azithro 2gmpox
1 dose) (CID 59:1083, 2014) (nauseain>20%)
Screenfor syphilis.
OtheralternativesforGC (Test ofCure recommended one weekafterRxforALLoftheseapproaches listedbelow):
•Oral cephalosporinuseisnolongerrecommendedas primary therapyowingtoemergenceofresistance,MMWR61:590,2012
•Other single-dose cephalosporins: ceftizoxime500mgIM,cefotaxime500mgIM, cefoxitin2gmIM +probenecid 1 gmpo
Trang 30DoxyTOOmq_pobid x3wks
AND COMMENTS
Clinicalresponseusuallyseenin 1 wk Rxuntil all lesionshealed,maytake 4wks Treatmentfailures&recurrenceseenwithdoxy& TMP-SMX.
Relapsecanoccur6-10monthsafterapparentlyeffectiveRx
Ifimprovementnotevidencein firstfew days,someexpertsadd
gentamicin1 mp/kcjIVq8h
Herpes_s[mpje_x_virus_ See_Table_14A,_p_age 169
.Humanpapilloma,virus[HPV) §ee_fableJ4Alj:age 174_
Lymphogranuloma venereum ChlamydiaTrachomatis,
serovars LI, L2,L3Ref:C/D61:S865,2015
See fable 1~3A,page161
Dx based onserology;biopsy contraindicatedbecausesinustracts
develop.NucleicacidamplitestsforC.trachomatiswillbepositive In
MSM,presentsasfever, rectal ulcer,analdischarge (CID39:996,2004;DisColonRectum52:507, 2009}
Phthirus pubis(pubiclice,
“crabs”)&scabies
Phthiruspubis&SarcoptesscabieiSyphilis Diagnosis:JAMA312:1922, 2014;treatment:JAMA312:1905,2014;management: C/D61:S818, 2015
Early:primary,secondary,
orlatent<1 yr.Screenwith
T.pallidum Benzathinepen G(Bicillin (Doxy100mgpobidxtreponema-specificantibody
orRPR/VDRL, seeJCM50:2& NOTE:Testallpts with
148,2012;CID58:1116, 2014 syphilis forHIV;test allHIV
patientsfor latent syphilis.
L-A)2.4million unitsIM x1 14 days)or(tetracycline
orAzithro 2gm pox1dose 500mgpoqid x14 days)or(SeeComment) (ceftriaxone1 gmIM/lV
Ifnoother options:Azithro
Pen2.4Mx1 doseinearly
weekly x 3 wks
resistantsyphilisdocumentedin California, Ireland,&elsewhere(CID44:SI30,2007;AAC54:583,2010)
NOTE: Useof_benzathmeprocainepenicillinis inapp_rop_riateM
Morethan1 yr'sduration Forpenicillindesensitization
(latent ofindeterminate dura- method,seeTable7,
tion,cardiovascular,late page83 andMMWR64
benigngumma) (RR-3):1,2015
Benzathinepen G
(BicillinL-A)2.4million
unitsIMqweekx3=7.2million units total
Neurosyphilis—Verydifficult
to treat.Includes ocular
(retro-bulbarneuritis) syphilis
Allneed CSFexam
HIVinfection(AIDS
-)
C/D44.S130, 2007
Pregnancyandsyphilis
Pen G18-24millionunitsperdayeitheras continuousinfusionoras3-4million
daily for10-14daysMAYbe
analternative(Noclinical
data;_cpnsultan [Dspecialist)
_
(Procainepen G2.4million unitsIMq24h+ probenecid
0.5gmpoqid)both x
ID-14days— See Comment
Nopublished dataonefficacy ofalternatives.IndicationsforLP(CDC):neurologicsymptoms,treatmentfailure,any eyeorearinvolvement,otherevidenceof active syphilis(aortitis,gumma,iritis).
Treatmentsameas HIV uninfectedwith closer follow-up
Treat earlyneurosyphilisfor10-14daysregardlessofCD4count:MMWR56:625,_2007 _
Sameasfornon-pregnant, Skintest for penicillin allergy,
some recommend2'”dose Desensitizeifnecessary,
(2.4 million units)benza- asparenteralpen Gisonlythinepen G 1 wkafter initial therapywithdocumenteddoseesp.in3,fl
trimester efficacy!
or with 2"syphilis
Ceftriaxone 2gm(IVor IM)q24hx14 days.23%failure ratereported
(AJM93:481, 1992).Forpenicillin allergy: eitherdesensitizeto penicillinorobtain infectiousdiseasesconsultation Serologiccriteriaforresponse
to rx:4-foldorgreaterI inVDRLtiterover 6-12mos
(CID_28jSuppl.l)_S_2JJ999J_
SeeSyphilisdiscussioninCDCGuidelinesMMWR64(RR-3):1, 2015 Treatfor
neurosyphilisifCSF VDRLnegative but>20 CSF WBCs(STD39:291, 2012).MonthlyquantitativeVDRLorequivalent.If4-foldf,re-treat.Doxy,tetracyclinecontraindicated Erythro notrecommendedbecauseofhigh
riskoffailure tocurefetus.
|or_with_2^ syphilis
Trang 31TABLE 1 (22)
MODIFYING CIRCUMSTANCES
ETIOLOGIES(usual)
AND COMMENTS
PRIMARY ALTERNATIVE5GENITAL TRACT/Both Women & Men(continued)
Congenitalsyphilis
(UpdateonCongenitalSyphilis:
MMWR64(RR-3):1,2015)
T.pallidum Aqueouscrystalline
pen G50,000units/kgper
doseIVql2hx 7 days,thenq8hfor10daytotal
Ifmorethan1 dayof rxmissed,restart entirecourse Needserologicfollow-up!
Warts, anogenital See Table 14A,page174
Women:
Amnionitis, septic abortion Bacteroides, esp Prevotella
bivius;GroupB,Acocci; Enterobacteriaceae;
D&Cofuterus Inseptic abortion,Clostridium perfringensmaycause
fulminant intravascularhemolysis.Inpostpartumpatientswithenigmaticfeverand/orpulmonaryemboli,considerseptic pelvicvein
thrombophlebitis(see Vascularseptic pelvic vein thrombophlebitis,
page68).Afterdischarge:doxyorclindaforC.trachomatis
Cervicitis,mucopurulent
Treatmentbased onresultsof
nucleicacidamplificationtest
N.qonorrhoeae TreatforGonorrhea,page23 Criteria fordiagnosis: 1)(muco)purulentendocervicalexudate and/or
2)sustained endocervical bleedingafterpassageofcottonswab
>10 WBC/hpfofvaginalfluid issuggestive.Intracellulargram-neg
diplococci are specificbutinsensitive If indoubt, sendswabor urine
for culture, EIAor nucleicacidamplificationtestandtreat forboth
Chlamydiatrachomatis Treatfornon-gonococcalurethritis,page23 Ifdueto
Mycoplasmagenitalium, lesslikelytorespondtodoxy
bivius;GroupB,Acocci; Enterobacteriaceae;
strepto-C.trachomatis
[(Cefoxitin orERTAorIMPorMERorAM-SBorPIP-TZ)
+doxy]or[Clinda t- (aminoglycosideorceftriaxone)]
Dosage: seefootnote”
SeeCommentsunderAmnionitis,septic abortion,above
Doxy100mgIVorpo q12htimes14days Tetracyclinesnotrecommendedinnursingmothers; discontinuenursing
M.hominissensitive totetra, clinda,noterythro.
Fitzhugh-Curtissyndrome C trachomatis,
N.gonorrhoeae
Treatasforpelvicinflammatorydisease immediatelybelow Perihepatitis(violin-stringadhesions).SuddenonsetofRUQpain
Associatedwithsalpingitis. Transaminaseselevatedin < 30%ofcases.Pelvicactinomycosis;usually
Complicationofintrauterinedevice(IUD). RemoveIUD.CanusePen G
10-20millionunits/dayIVinstead ofAMPx4-6 wks
11 P Ceph2 (cefoxitin2gmIVq6-8h, cefotetan 2gmIVq12h,cefuroxime 750mgIVq8h);AM-SB3gmIVq6h;PIP-TZ3.375gmq6horfornosocomial pneumonia:4.5gmIVq6hor4-hr infusion of3.375gmq8h;doxy100mgIV/poq12h; clinda450-900 mgIVq8h;aminoglycoside(gentamicin,seeTable 10D,page118)]PCeph3 (cefotaxime 2gmIVq8h, ceftriaxone 2gmIVq24h);
doripenem500mgIVq8h(1 -hr infusion):ertapenem 1 gmIVq24h;IMP0.5gmIVq6h; MER1 gmIVq8h;azithro500mgIVq24h;linezolid600mgIV/poq12h;vanco1 gmIVq12h
Abbreviationsonpage2. *NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)and assumenormalrenal function.§Alternativesconsiderallergy, PK,compliance,local resistance,cost
25
Trang 32MODIFYING CIRCUMSTANCES
ETIOLOGIES(usual)GENITAL TRACT/Women(continued)
PelvicInflammatoryDisease(PID), salpingitis,tubo-ovarian
Outpatientrx: limit topts with N.gonorrhoeae, chlamydia,
temp <38°C,WBC <1 1,000 bacteroides,
assingledose)plus(doxy
100mgpobid withmetro
500mg bid—both times
14 days)
Vaginitis—MMWR64(RR-3)~:1~2015 ’
Candidiasis Candidaalbicans80-90%
Pruritus,thickcheesy C.glabrata,C.tropicalismay
discharge,pH<4.5 beincreasing—they areless
See Table1 1A,page 125 susceptibletoazoles
Oral azoles: Fluconazole
Remember:Evaluateandtreatsexpartner.FQsnotrecommendeddueto
increasing resistanceMMWR64(RR-3):1,2015&www.cdc.gov/std/treatment).(Clinda900~mgiv"q8h)"+ c , , , , (iU , ,
(gentamicin 2mg/kgloading Su 99estm'tial inpatientevaluation/therapyforpts withtubo-ovarianabscess
4 mn/tfnnnrp^nprHax^thpn Forinpatientregimens,continuetreatmentuntilsatisfactoryresponse
doxv 00modobid x14riavs !
or-jr4"hr be,ore switchingtooutpatientregimen.Improvedroutine testing
aoxyluumgpobidx 14days
forchlamydiaandN.gonorrhoeaeamongoutpatients resultedinreduced
ho_spita[izatiqn_andectopicpregnancy,rates[J[AdolescentHealt_h_51
:_80,_2012J_
Anotheralternative parenteralregimen:
AM-SB3gmIVq6n + doxy100mgl\
Intravaginalazoles:variety
ofstrengths—from1 doseto
7-14days.Drugsavailable
(allendin-azole):butocon,clotrim,micon,tiocon,tercon (doses: Table 11A)
Nystatinvag.tabs times14dayslesseffective.Otherrx forazole-resistant
strains:gentianviolet,boric acid
Ifrecurrent candidiasis(4ormoreepisodes peryr):6mos.suppression
with:fluconazole 150mgpoqweekoritraconazole100mgpo q24horclotrimazolevag.suppositories500mgq week.
Trichomonasvaginalis Metro2gmassingledose
Dx:NAAT & PCRavailable or500mgpobidx 7days
&mostsensitive;;wetmount OR
notsensitive. Tinidazole 2gmposingleRef:JCM54:7,2016 dose
Pregnancy:See Comment
Forrx failure:Re-treat withmetro500mg pobid x
7days;if2ndfailure:metro
Clinda0.3gmbidpox
7daysorclindaovules
1applicatorcontains 5gmof gel with37.5mgmetronidazole
Abbreviationson page2. *NOTE:Alldosage recommendationsare for adults (unlessotherwiseindicated)andassume
Trang 33TABLE1 (24)
MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVE'1 AND COMMENTS
GENITAL TRACT(continued)
Men:
Balanitis Candida 40%, Group Bstrep,
gardnorella
Metro2gmpoasasingledone< )lt Flue: I.M)mg goxl
ORItra200mgpobid x 1day
Occurs in1/4ofmalesexpartnersofwomeninfectedwithCandida
Excludecircinatebalanitis (Reiter'ssyndrome);(non-infectious)responds
(Ceftriaxone250mgIMx1 I doxy MX)mg|>nhid
x10 days) +bedrest,scrotal elevation, niialgesMs
Enterobacteriaceaeoccasionallyencountered Testallptsage <35yrs
forHIVandsyphilis.
pobid)or(400mgIVtwicedaily)
| lor It) 14day
AM-SB, PCeph3,PIP-TZ(Dosaye seehminute/1 h je25)
forMSM can be mixed GC/chlamy(liawith« Mih 'in •; •;<> lioal
withFQ ANDCeftriaxone250mgIMx1
Also:bedrest,scrotal elevation,analgesics
Midstreampyuriaandscrotalpainand edema
NOTE:DourineNAAT(nucleicacidamplificationtest)toensureabsence
ofN.gonorrhoeaewithconcomitantriskofFQ-resistantgonorrhoeae
or ofchlamydiaifusing agentswithoutreliable activity.
Othercausesinclude:mumps,brucella,TB,intravesicular BCG,
B.pseudomallei,coccidioides, Behcet's
Non-gonococcalurethritis See paue23(CID 61:S763, 2015)
p://onlinelibrary.wiley.com/doi/10.1 1 l/bju/3/d//e/x//
ceftriaxone250mgIM x1thendoxy lot)mgbidx
10 days
1Qsnolongerrecommendedforgonococcalinfections.TestforHIV
InAIDSpts,prostatemaybefocusofCryptococcusneoformans
Uncomplicatedwithlow
riskofSTD
Enterobacteriaceae(coliforms)
FQ(dosage:seeEpididymo-orchitis,>35yis.above)
10-14days(minimum).Someauthoritiesrecommend
4weeksoftherapy
1 reatas acuteurinary infection,14days(not singledoseregimen).Some
iccommend3-4 wkstherapy.If uncertain,doNAATforC trachomatisand
N.gonorrhoeae.If resistantenterobacteriaceae,useERTA1gmIVqd.If
msislantpseudomonas,useIMPorMER(500mgIVq6orq8respectively)Chronicbacterial Enterobacteriaceae80%,
enterococci 15%,
P.aeruginosa
CIP 500mgpobidx4-6wks OR Levo750mgpoq24hx 4wks
TMP-SMX-DS 1 labpohid x1-3mos
(Fosfomycin:seeComment)
With treatmentfailuresconsiderinfected prostaticcalculi. FDAapproveddoseot levois500 mg;editorspreferhigherdose Fosfomycin penetratesproslate;easereport ofsuccesswith3gm po q24hx12-16wks
HAND (Bites:SeeSkin)
Paronychia
Nail biting,manicuring Staph,aureus(maybeMRSA) Incision&drainage;culture TMP-SMX-DS1-2tabs|x>hid
whilewaitingforcultureresull.
See table6loralternatives Occasionally-candida, gram-negativerods
Contactwith saliva—dentists,
Gramstainandroutine culture negative
lamciclovir/valacyclovirforprimarygenitalherpes;seeTable 14A,page 169Dishwasher (prolonged
waterimmersion)
Candidasp Clotrimazole(topical) Avoidimmersionofhands inwater asmuchaspossible
Abbreviationsonpage2. *NOTE:Alldosage recommendationsare for adults (unlessotherwiseindicated)andassumenormalrenal function.§Alternativesconsiderallergy,PK,compliance,local resistance,cost
27
Trang 34cultures— No IVillicitdrugs
Valvular orcongenitalheart
disease butnomodifying
circumstances
See Table 15C,page204
forprophylaxis
Infectiveendocarditis—Native
valve—IVillicitdruguse ±
evidencert-sidedendocarditis
empirictherapy
NOTE:Diagnosticcriteriaincludeevidenceofcontinuousbacteremia(multiple positivebloodcultures),new murmur(worseningofoldmurmur)ofvalvular
insufficiency, definiteemboli,andechocardiographic(transthoracic ortransesophageal)evidenceofvalvularvegetations.Refs.:Circulation 132:1435,2015
Forantimicrobialprophylaxis,see Table 15C,page204
SubstituteDapto6mg/kgIV
q24h(orq48hforCrCI<
30mlVmin)forVanco
Viridans strep30-40%,
“other"strep15-25%,
enterococci 5-1 8%,staphylococci20-35%
(includingcoag-neg
staphylococci-C/D46:232,2008)
Vanco15-20mg/kg q8-12h
(targettroughconeof
15-20pg/mL)+Ceftriaxone2g 24h
S.aureus/MSSA&MRSA)
Allothersrare
Dapto6mg/kgIVq24hApprovedforright-sidedendocarditis
Ifpatientnot acutelyillandnotinheartfailure,waitforbloodcultureresults.
If initial3 bloodculturesneg.after24-48hrs,obtain2-3morebloodculturesbeforeempirictherapystarted.Gentdoseis forCrCIof80mLVminorgreater;
even low-dose Gentamicinforonlya fewdayscarries risk ofnephrotoxicity(CID48:713, 2009).Gentisusedforsynergy;peaklevelsneednotexceed
4pg/mL andtroughsshouldbe <1 pg/mL Coagulase-negativestaphylococcicanoccasionallycausenativevalve endocarditis(CID46:232,2008).Modify therapybasedonidentification of specificpathogenassoon
as possibletoobtainbest coverageandtoavoidtoxicities.
Surgeryindications:SeeNEJM368:1425, 2013.Roleofsurgeryinptswithleft-sidedendocarditis&largevegetation(NEJM366:2466,2012)
Nodifferencein15yrsurvivalbetweenbioprostheticandmechanicalvalve
(JAMA
31_2.1_323,_201_4J_ _
Viridansstrep,S.bovis
/S gallolyticus)with penicillinG
Viridansstrep, S.bovis(S.
gallolyticus)withpenicillinG
MIC>0.12to<0.5mcg/mL
Viridans strep, S.bovis,nutritionallyvariantstreptococci,
(e.g.S.abiotrophia)tolerantstrep,:i
Pen G18millionunits/day
IV(dividedq4h)x wks
PLUS Gent1 mg/kgIVq8h
x2wks NOTE: Low doseofGent
Vanco15mg/kgIVq12htomax 2gm/dayunlessserum
levelsdocumentedx 4wks
Forviridans strep orS.boviswith
pen G MIC >0.5 andenterococci
susceptibletoAMP/penG, vanco,
gentamicin (synergypositive)
NOTE:Inf Dis.consultation
suggested
“Susceptible” enterococci,viridansstrep, S.bovis,nutritionallyvariantstreptococci(newnames
are:Abiotrophia sp
&Granulicatellasp.)
((PenG 18-30million units
per24hIV,dividedq4hx
4-6wks)PLUS(gentamicin
1mq/kg q8hIVx4-6wks)]
OR (AMP12gm/dayIV,
dividedq4h +gentasabove
x4-6 wks)
Vanco15mg/kgIVq12hto
maxof2gm/dayunless
serumlevelsmeasured
PLUSgentamicin1 mg/kgq8hIVx4-6wks
NOTE: Low doseofgent
Targetgentlevels:peak3mcg/mL,trough <1 mcg/mL.Ifveryobesept,
recommendconsultationfordosageadjustment
Infusevancoover>1 hrtoavoid“redman”syndrome
S.bovissuggestsoccultbowel pathology (newname:S gallolyticus).Since relapseratemaybegreaterinptsill for>3mos.priortostart of rx,
the penicillin-gentamicinsynergismtheoreticallymaybeadvantageousin
thisgroup
CanusecefazolinforpenGinptwith allergythat isnotIgE-mediated
(e.g.,anaphylaxis).Alternatively,can usevanco /SeeCommentabove
ongentandvanco)
NOTE:Ifnecessarytoremoveinfected valve&valve culture neg.,
2weeksantibiotictreatmentpost-op s ufficien\_(CID_4 1:187,2005)
4wksofrxifsymptoms <3mos.;6wksofrxifsymptoms >3 mos.
Vancoforpen-allergicpts;donotusecephalosporins
Donot give gentonce-q24hforenterococcalendocarditis.Targetgent
levels: peak3mcg/mL,trough •
1mcg/mL Vancotargetserumlevels:
peak 20-50mcg/mL,trough 5 12mcg/mL
NOTE:Becauseof |frequencyofresistance (see below),allenterococcicausingendocarditisshouldbetestedin vitro forsusceptibilitytopenicillin, ge_nta_micinand_vancomycinplus|i_lactamase_prod_uction__
Trang 35TABLE 1 (26)
MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVE5 AND COMMENTS
HEART/Infective endocarditis—Nativevalve—culture positive(continued) Ref:Circulation 132 1435.:’or.
&AIIAlit in Ittimes)
10-25%E.faecalisand45-50%E.faeciumrosislanl Inhighgentlevels.
Mayhavetoconsidersurgicalremovalofinfectedvalve. Theoryofefficacy
ofcombinationofAmp + Ceftriaxone:sequentialblockingofPBPs 4&5
(Amp)and2&3(ceftriaxone).
positive AM-SB 1gmIVqGh
4 Gent 1mg/kqIVgBli
TargetVancotroughlevels at10-20mcg/mL
Gentamicin usedforsynergy;peaklevelsneednotexceed4mcg/mLand
troughshouldbe<1
Enterococci:
Pen/AMPresistant+high-level
gent/strep resistant +vanco
resistant;usuallyVRE
Consultationsuggested
Enterococci,vanco-resistant,resistant tobeta-lactams
AMPorCeftarolinelessensriskofdevelopingDaptoresistance&reversesresistanceifpresent.Quinu-dalfo7.5mg/kgIV (central line)q8his
alternativefor E. faecium(E.faecalisis resistant).Quinu-dalfo+ AMP:see
Circulation127:1810,2013) (successreported) Linezolidmono-or
combo-therapyforbothE.faecium/ E faecalis:variablesuccess;bacteriostatic
forenterococci(CurrInfectDisRep16:431, 2014)
andCefazolinbetter tolerated(A4C55:5122, 2011)
Aorticand/ormitralvalve
dayin2-3divideddoses
toachievetargettroughconcentrationsof15-20mcg/mL recommended
forseriousinfections.
Dapto8-10mg/kgc)24h IV
(NOT FDAapprovedIni this
indicationordose)
In clinical trial(NEJM355:653, 2006), highfailure ratewithbothvancoand
daptoinsmallnumbersof pts.Forotheralternatives,seeTable6,pg82.
Daptomycinreferences:JAC68:936&2921, 2013.CasereportsofsuccesswithTelavancin(JAC65:1315,2010:AAC545376,2010;JAC(Jun8),2011)
andceftaroline(JAC67:1267,2012;JInfectChemoonline7/14/12).
Tricuspid valve infection
(usuallyIVDUs):MSSA
Staph,aureus, sensitive
2-weekregimennot longenoughifmetastaticinfection (e.g.,osteo)
orleft-sidedendocarditis.IfDaptoisusedtreat for at least4 weeks
Daptoresistancecanoccurdenovo,afterorduringvanco,or after/during
daptotherapy Cefazolin2gmq8halsoanoption.Feweradverse events
anddiscontinuationsvsnafcillin (Clin InfectDis59:369, 2014)
Abbreviationsonpage2. *NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)and assumenormalrenal function.§Alternativesconsiderallergy, PK,compliance, local resistance,cost
29
Trang 36of15-20mcg/mL recommendedforseriousinfectionsx4-6wks
Dapto6mg/kg IVq24hx4-6wksequivtovancofor
rt-sidedendocarditis;both
vanco&daptodidpoorly
if It-sidedendocarditis
(NEJM355:653,2006).(See
Comments &table6,page82)
Linezolid:Limitedexperience (seeJAC58:273, 2006)inpatientswithfew treatmentoptions;64%curerate;clearfailure in21%;
-AM-SB3gmIVq6hx4wks
orCIP(400mgIVq12hor
500mgpobid)x4wks
aggregatibacter, Actinobacillus, Bartonella, Cardiobacterium,Eikenella, Kingella)
Penicillinase-positiveHACEKorganismsshouldbesusceptibletoAM-SB
+qentamicin.Ref: Circulation 111:e394,2005
Bartonellaspecies anyvalve B.henselae,B. quintana (Doxy 100mgIV/po bid + RIF 300mgIV/pobid)x
6-8wks
Dx:Immunofluorescent antibodytiter>1:800;bloodculturesonly occ
positive,orPCRoftissuefromsurgery
Surgery: OverV?.pts require valve surgery;relationtocureunclear
B.quintanatransmittedbybodyliceamonghomeless
Infectiveendocarditis—“cultureneqative”
Fever, valvulardisease,andECHOvegetations+emboliand
neg.cultures.
Etiologyin348casesstudiedbyserology,culture,histopath,&moleculardetection: C.burnetii48%,Bartonellasp.28%, andrarely
(Abiotrophiaelegans(nutritionally variant strep),Mycoplasmahominis, Legionellapneumophila,Tropherymawhipplei—together 1%),
&restwithout etiologyidentified(mostonantibiotic).See CID51:131,2010forapproachtowork-up.ChronicQfever:JCM52:1637,2014.Infectiveendocarditis—Prosthetic
Early(<2mospost-op)
Late(>2mospost-op)
:valve—empiric therapv(cu
S.epidermidis,S.aureus
Rarely,Enterobacteriaceae,diphtheroids, fungi
S.epidermidis, viridansstrep,
Surgicalconsultationadvised:
Indicationsforsurgery:severe
heartfailure, S.aureusinfection,
prostheticdehiscence,resistant
organism,emboliduetolarge
vegetation(JACC48:e1, 2006)
Seealso,Eur JClinMicroInfect
Dis 38:528,2010
Staph,epidermidis (Vanco15-20mg/kgIVq8-12h i RIF 300mgpoq8h)x
6wks + gentamicin1 mg/kgIVq8hx14days
If S.epidermidisissusceptibletonafci 1 1 in/oxaci1 nin vitro(notcommon),
thensubstitutenafcillin (or oxacillin) forvanco Targetvancotroughconcentrations15-20 pg/mL
Somecliniciansprefertowait2-3daysafter startingvanco/ gent before
startingRIF, todecreasebacterialdensityandthusminimizerisk of
selecting rifampin-resistantsubpopulations
Staph,aureus Methicillin sensitive: :Nafcillin2gmIV c|4h i RIF 300mgpoq8h)times6wks+ gentamicin1 mgperkg IVq8h times 14 days
Methicillin resistant: (Vanco 15-20mg/kg IVq8-12h (toachieveatargettroughof15-20mcg/mL) + RIF 300mgpoq8h)times6wks
i gentamicin 1 mgperkgIVq8h times 14days
Viridansstrep,enterococci Seeinfectiveendocarditis, nativevalve,culturepositive,page28.Treatfor6 weeks
Enterobacteriaceaeor
P.aeruginosa
Aminoglycoside(tobraif P.aeruginosa) i (PIP-TZor
PCeph3APorP Ceph4oran anti-pseudomonalPen)
Intheory,couldsubstituteCIPforaminoglycoside,butnoclinicaldataand
resistanceiscommon.Selectdefinitiveregimenbased onsusceptibility
results.Canoccurwithnativevalvesalso
Candida,aspergillus Table 11.page122 Highmortality.Valvereplacementplus antifungaltherapystandard therapy
butsomesuccesswithantifungaltherapyalone
Trang 37TABLE 1 (20)
MODIFYING CIRCUMSTANCES
ETIOLOGIES(usual)
Coxiclla Innm‘In Doxy100mgpobid+hydroxychloroquineummi|/day
for at least18mos(MayoClin I'm*-in i m1
dPregnancy:Needlong termTMP-SMX
(seeCID45:548, 2007)
Dx:Phase1IgGtiter>800plusclinicalevidenceof endocarditis
Treatmentduration:18mosfornative valve,24mosforprostheticvalve.
Monitorserologicallyfor5yrs.
(nod.il.i);«kimg|hihid
Duration ofrxafterdeviceremoval:For"[rocket"orsubcutaneous
infection, 10-14days;iflead-assoc.endocarditis,4-6wks depending
onorganism.Device removalandabsence!ofvalvularvegetationassoc,withsignificantlyhighersurvival at 1 yr(JAMA307:1727,2012)
Pericarditis,purulent—empiric
(SCOloot III ill- )
Drainagerequiredifsignsoftamponade.Forcedtouse empiricvancodue
lohigh prevalenceofMRSA.
Rheumaticfeverwithcarditis
Ref.:Ln 366:155, 2005
Post-infectioussequelae
ofGroupAstrepinfection
(usually pharyngitis)
ASA, andusuallyprednisone 2nu|/k< 1 m i: '•II 1 1< *i
symptomatictreatmentof fever, arlhnlr nihi.il' |i.i
Maynot influencecarditis.
Clinicalfeatures:Carditis, polyarthritis,chorea,subcutaneousnodules,t’lylhomamarginatum.Prophylaxis:seepage62
Ventricular assist device-related
infection
CID57:1438,2013
S.aureus,S.epidermidis,aerobicgm-negbacilli,
Candida sp
Aftercultureofblood,wounds,diiveline,device pnekcl
andmaybepump:Vanco 15-20 mg/k(|IV i |ti L’li i
(Cefepime2gmIVq12h) +fluconazoleMill)mgIVgi’-lh
Cansubstitutedaptomycin10mg/kg/dNAI
forvanco,(CIP400mgIVq12h
i n Levo 750mgIVq24h)forcefepime,and(vori,caspo, micafunginoranidulafungin)forfluconazole.Modifyregimenbased onresults ofcultureandsusceptibilitytests.Higher than FDA-approved Dapto dosebecauseofpotentialemerqenceofresistance
JOINT —AlsoseeLymeDisease,pagt
Reactivearthritis
Reiter’ssyndrome
(SeeCommentfor definition)
358Occurswksafter infection
with C trachomatis,
Campylobacterjejuni,
Yersiniaenterocolitica,
Shigella/Salmonellasp
Only treatmentisnon-steroidal anti-inflamm.iloiydnur 1 tclmilion: Urethritis, conjunctivitis, arthritis,and sometimesuveitisand
insh.Arthritis:asymmetricaloligoarthritis ofankles,knees,feet, sacroiliitis.
Kush:palmsandsoles—keratodermablennorrhagica;circinatebalanitis
clglanspenis HLA-B27positivepredisposestoReiter's.
Poststreptococcalreactive
arthritis
(SeeRheumaticfever,above)
Immunereactionafterstrep
pharyngitis:(1) arthritisonset
in<10days,(2) lastsmonths,
(3)unresponsivetoASA
Treatstrep pharyngitisandthenNSAIDs(pic :< li ii: ( >iu•
neededinsomepts)
Aleaclivoarthritis afteraji-hemolyticstrepinfection inabsenceof
suflicicnlJonescriteria foracute rheumaticfever Ref.:MayoClinProc
75.N4,2tXX).
14
Aminoglycosides(see Table 10D,page118), IMP0.5gmIVq6h,MER 1gmIVq8h.nafcillin or oxacillin2gmIVq4h, PIP-TZ3.375gmIVq6hor 4.5gmq8h,AM-SB3gm
IVq6h,PCeph1 (cephalothin2gmIVq4horcefazolin2gmIVq8h),CIP750mg pobidor400mgIV bid,vanco 1 gmIVq12h, RIF600mgpoq24h.aztreonam2gmIVq8h,CFP2gmIVq12h
Abbreviationsonpage2. *NOTE:Alldosage recommendationsarefor adults (unlessotherwiseindicated)andassumenormalrenal function.§Alternativesconsiderallergy,PK, compliance,local resistance,cost
Trang 38TABLE1 (29)
MODIFYING ClKCUMb TANCES (usual)
PRIMARY ALTERNATIVE5 AND COMMENTS
JOINT(continued)
Septicarthritis:Treatmentrequiresbothadequatedrainageofpurulentjoint fluidandappropriateantimicrobialtherapy.Thereisno needtoinjectantimicrobialsinto joints.Empirictherapyafter
collectionofbloodandjoint fluid for culture;reviewGramstain of joint fluid.
Infants <3 mos(neonate) Staph, aureus,
Bloodcultures frequentlypositive.Adjacentboneinvolvedin2/3pts.
GroupBstrepandgonococcimostcommoncommunity-acquiredetiologies.
Children(3mos-14yrs) S.aureus27%,S.pyogenes
&S.pneumo14%,H.influ3%,
Gm-neg.bacilli6%,other(GC,N.mening) 14%,unk36%
Vanco +(Cefotaxime, ceftizoxime or ceftriaxone)
untilcultureresultsavailable
Steroids—seeComment
Marked | inH.influenzaesinceuseofconjugatevaccine
NOTE:Septicarthritisduetosalmonellahasnoassociation with sicklecell
disease,unlikesalmonellaosteomyelitis
10daysoftherapy aseffectiveas a 30-daytreatmentcourseifthereisagood
clinicalresponseandCRPlevelsnormalizequickly(CID48:1201, 2009)
Adults(reviewGramstain):Seeps
ige58forgonococcalarthritis
Gramstainnegative:
Ceftriaxone1 gmIVq24h
orcefotaxime 1gmIVq8h
orceftizoxime1 gmIVq8h
IfGramstainshowsGm+
cocciinclusters:vanco
15-20mg/kgIVq8-12h
Fortreatmentcomments, seeDisseminatedGC,page23
Notat riskfor
sexually-transmitteddisease
S.aureus,streptococci,
Gm-neg.bacilli
Allempiricchoicesguided byGramstain
Vanco + P Ceph3 |Vanco+ (CIPorLevo)
For treatmentduration,seeTable3,page72
Differentialincludes goutandchondrocalcinosis(pseudogout).Lookforcrystalsinjointfluid.
NOTE:SeeTable 6forMRSAtreatment
Chronic monoarticular Brucella,nocardia,
rubella vaccine,puivoHI!)
GramstainusuallynegativeforGC.Ifsexuallyactive,
cultureurethra, cervix,anal canal,throat,blood,joint fluid,
andthen:ceftriaxone1gmIVq24h
IIGC,usuallyassociated petechiae and/orpustular skin lesionsand
tenosynovitis.ConsiderLymediseaseifexposureareasknowntoharborinfectedticks.See page58.
Expandeddifferentialincludes gout,pseudogout, reactivearthritis
NOempirictherapy Arthroscopyfor culluro/sensitivity, crystals,washout
Treatbased onculture resultsx14days(assumesnoforeignbodypresent)
page
Trang 39Infected prostheticjoint (PJI)
• Suspectinfectionifsinus
tractorwounddrainage;
acutely painful prosthesis;
chronicallypainful
prosthesis; orhighESR/CRP
assoc,w/painful prosthesis
• EmpirictherapyisNOT
MSSA/MSSr Debridement/Retention |(Nnfcillin3i|inIV<|4hor
Oxacillin 2gmIVq4hIV) i Rifampin toomgnohid]OR
(Cefazolin 2gmIVq8h i Rifampin:toomogolud) x
2-6weeksfollowedby[(Ciprofloxacin A‘>0mggohidOR
Levofloxacin 750mgpoq?4h) t Rifampin 300mk|pobid]
for3-6months(shorter dt ir; ili< >i ik>i »liilhip.nilm>|>1 tsly)
forfluoroquinolone-resistantisolate
consider using otheractive highly
bioavailableagent,e.g.,TMP-SMX,Doxy,Minocycline,Amoxiciliii i-Clavulanate,
Clindamycin, orLinezolid
• Enterococcalinfection:additionofMRSA/MRSE Debridement/Retention:(Vancomycin IS;‘Om<|/kyIV
q8-12h + Rifampin 300mgpohid) x3i;week:; followed
by [(Ciprofloxacin750mggobidC)RLevofloxacin
750mgpoq24h) +Rifampin 300mgpi i bit
l| It n3
6months(shorterdurationlot lolnlhip ailhioplasly)
1 stage exchange:IV/POingimeiia:,abovelot 3mos2-
staqe exchanqe: regimenasabovelot -1dwks
(but if thisimprovesoutcomeunclear).
• Prosthesisretentionmostimportantrisk
factor fortreatmentfailure
(ClinMicrobiolInfect16:1789, 2010).Streptococci (GrpsA,B,C,
D,viridans,other)
Debridement/Retention:Penicillin( i ;’() millionunitsIV
continuousinfusionq24h orin6 divideddosesOH
maybeeffectiveas salvagetherapy
ifdevice removalnotpossible (AntimicrobAgentsChemother55:4308,2011)
C/D56:e1,2013
• Datadonotallow
assessmentofvalueof
addingantibacterialcement
totemporaryjointspacers
Enterococci Debridement/Retention:Pen-susceptible: Ampicillin
12gmIVORPenicillinG20millionunitsIVcontinuousinfusionq24horin6divideddosesx4-6weeks
Pen-resistant:Vancomycin15mg/kgIVq!3hx4-6weeks
1 or 2staqeexchanqe: reqimen asabovelot46wks
long-staphylococcalinfections:depending on
in vitro susceptibilityoptions include
• Othertreatment consideration:Rifampin
Gm-negentericbacilli Debridement/Retention:Ertapenem 1gmq?4hIVOR
otherbeta-lactam(e.g.,Ceftriaxone 2gmIVq?4h<)R
Cefepime2gmIVq12h,based onsusceptibilily) x
4-6weeks
1 or 2staqe exchanqe: reqimen asabovefor4(iwks
Ciprofloxacin750mgpobid isbactericidal vs.biofilm-producing
bacteria.NeveruseRifampinalonedue
torapiddevelopmentof resistance.
Rifampin300mgpo/IV bid+Fusidicacid” 500mgpo/IVtid isanother
P.aeruginosa Debridement/Retention:Cefepime2gmIVq12liOR
Meropenem1gmIVq8h + Tobramycin5.1 mg/kg once
daily IV
1or 2staqe exchanqe: reqimenasabovefor4-6wks
Ciprofloxacin750mgpobid
or400mgIVq8h
option(ClinMicroInf12(S3):93, 2006)
• Watchfor toxicity if Linezolid isused
formorethan2weeksoftherapy
Rheumatoidarthritis TNFinhibitors (adalimumab, certolizumab,etanercept,golimumab,infliximab)andothernnli inflammatorybiologies (tolacitinib,rituximab, tocilizumab,abatacept)
t riskofTBc,fungalinfection, legionella, listeria,andmalignancy.SeeMedLett55:1,2013lor full listing.
q8-bid) ifMRSA
EmpiricMRSAcoveragerecommendedif risk factorsarepresentandinhighprevalence ureas.Immunosuppression,not durationof therapy, isarisk factor tor
recurrence; 7daysoftherapymaybesufficient forimmunocompetentpatients
undergoing one-stage bursectomy (JAC65:1008, 2010).IfMSSADicloxacillin
500mgpoqidasoralstep-down.IfMRSADaptomycin6mg/kgIVq24h.Abbreviationsonpage2. *NOTE: Altdosage recommendationsarefor adults (unlessotherwiseindicated)and assumenormalrenal function.§Alternativesconsiderallergy,PK,compliance,local resistance,cost
33
Trang 40TABLE 1 (31)
MODIFYING CIRCUMSTANCES (usual)
PRIMARY ALTERNATIVE5 AND COMMENTS
KIDNEY & BLADDER
AcuteUncomplicatedCystitis& PyelonephritisinWomen
Cystitis
Diagnosis:dysuria,frequency,
urgency,suprapubic pain&no
3days.Avoidif20%ormore
local E coliareresistant
Fosfomycin3gm po
x1 dose
• Pyridium (phenazopyridine)mayhastenresolution ofdysuria
• Other beta lactamsare lesseffective
• Nitrofurantoin&Fosfomycinactivevs. ESBLs;however,ifearlypyelonephritisavoidthesedrugsduetolowrenalconcentrations
• Onoccasionvaginitiscanmimicsymptomsofcystitis
Presenceofenterococci,
GrpBstreptococcus,other
S.epidermidissuggestscontamination
Pyelonephritis
Diagnosis:fever,CVA,pain,
nausea/vomiting
Sameasfor Cystitis,
above.Needurine culture
&sensitivitytesting
Culturo/sonsresultsmayallowTMP-SMX DS 1labpobid
Inpatient:
Local resistancedataimportantCeftriaxone1gmIVq24hOR
(CIP400mgIVq12hORLevo
750mgIVoncedailyORMoxi
4(M)mgIVnna;daily IIESBLS
&[ coli MER0.5-1gmIVgHli
•Whentoleratingpofluids,cantransition to oraltherapy;drug choice
based onculture/sensresults
• Noneedforfollow-up urine culturesinptswhorespondtotherapy
• Ifsymptomsdonotabatequickly,imagingofurinarytract for
complications,e.g., silentstoneorstricture
•Avoid Fosfomycin,Nitrofurantoin,Pivmecillinamduetolowrenalconcentrations
Pregnancy:Asymptomatic
bacteriuria&cystitis
Drugchoicebased onculture/
sensitivity results;dofollow-up
cultureoneweekafter lastdose
of antibiotic
E coli(70%)Klebsiella sp
• Untreatedbacteriuriaassociatedwithincreasedrisk oflowbirth wt,
pretermbirth&increasedperinatal mortality
• Ifpost-treatmentculturepositive, re-treatwithdifferentdrugoflongercourseofsamedrug
• Ifdocumentedfailure after2ndcourse,Nitrofurantoin50or100 g po qhs
fordurationofpreqnancyPregnancy:Acute
pyelonephritis
Diagnosis:CVApain,fever,
nausea/vomitingin2nd/3rd
trimester.SeeComment
Sameasloi Cyslilis,aboveRegimens;uenmpiiit.
therapy (seeComment)
Moderatelyill Ceftriaxone
1gmIV ( |?4f iOR Cefepime
1gmIVgIPh.If Pen-allergic,
Aztreonam 1gmIVq8h(no
; u livily v; ; Cirain-pos cocci)
Severelyill:Pip-Tazo
3.375gmIVq6hOR MER
1 gmIVq24h
• Differentialdxincludes: placentalabruption&infectionofamnioticfluid
• TrytoavoidFQsandAGsduringpregnancy
• Switchtopotherapyafter afebrilex48hrs
• Treatfor10-14days
• Ifpyelorecurs,re-treat.Onceasymptomaticcontinuesuppressivetherapyfordurationofpregnancy:Nitrofurantoin50-100mgpo qhsOR
Cephalexin250-500mq poqhsRecurrentUTIsinWomen
(2ormoreinfectionsin6mos/3
ormoreinfectionsin 1 yr)
Riskfactors: familyhistory,
spermicideuse,presenceof
cystocele,elevatedpost-void
residual urinevolume
Sameasfor Cystitis,above;
Regimensareoptionsfor
antimicrobialprophylaxis
r.oiilinnoiis (TMP-SMX SS OIITMP 100mg OR
• Nostrongevidencetosupportuseolcranberryjuice
•Topical estrogencream reducesrisk ofrecurrentUTIinpostmenopausal
women
• Probioticsneedmorestudy
onpage dosage recommendations