Antibiotic Guidelines 2015-2016

Treatment Recommendations For Adult Inpatients Also available online at insidehopkinsmedicine.0rg/amp

Table of contents

1. Introduction ............................................................................................ 3 2. Johns Hopkins Hospital formulary and restriction status .................... 6 2.1 Obtaining ID approval ........................................................................6 2.2 Formulary .........................................................................................7 3. Agent-specific guidelines ...................................................................... 8 3.1 Antibiotics ........................................................................................8 Ceftaroline ......................................................................................8 Ceftolozane/tazobactam .................................................................8 Colistin ...........................................................................................9 Daptomycin ................................................................................. 10 Ertapenem................................................................................... 11 Fosfomycin .................................................................................. 11 Linezolid ...................................................................................... 12 Tigecycline .................................................................................. 13 Trimethoprim/sulfamethoxazole ................................................... 14 3.2 Antifungals..................................................................................... 16 AmBisome® ................................................................................ 16 Micafungin ................................................................................... 17 Posaconazole .............................................................................. 18 Voriconazole ................................................................................ 19 Azole drug interactions................................................................. 20 3.3 Vaccines ....................................................................................... 23 Pneumococcal vaccines ............................................................... 23 4. Organism-specific guidelines .............................................................. 24 4.1 Anaerobes..................................................................................... 24 4.2 Propionibacterium acnes................................................................ 25 4.3 Streptococci.................................................................................. 27 4.4 Multi-drug resistant Gram-negative rods .......................................... 28 5. Microbiology information .................................................................... 31 5.1 Interpreting the microbiology report................................................ 31 5.2 Spectrum of antibiotic activity......................................................... 32 5.3 Interpretation of rapid diagnostic tests ............................................ 34 5.4 Johns Hopkins Hospital antibiogram ............................................... 36 6. Guidelines for the treatment of various infections...........................39 6.1 Abdominal infections .............................................................39 Biliary tract infections ................................................................... 39 Diverticulitis ................................................................................. 40 Pancreatitis ................................................................................. 41 Peritonitis (including SBP, GI perforation and peritonitis related to peritoneal dialysis) ........................................................ 42 6.2 Clostridium difficile infection (CDI) ............................................ 47 6.3 Infectious diarrhea ..................................................................... 51 6.4 H. pylori infection ....................................................................... 54 6.5 Gynecologic and sexually transmitted infections ..................... 56 Pelvic inflamatory disease ............................................................ 56 Endomyometritis .......................................................................... 56 Bacterial vaginosis ....................................................................... 57 Trichomoniasis ............................................................................ 57 Uncomplicated gonococcal urethritis, cervicitis, proctitis ............... 57 Syphilis........................................................................................ 58 6.6 Catheter-related bloodstream infections .................................. 60 (continued on next page)

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Table of contents

6.7 Endocarditis ................................................................................ 65 6.8 Pacemaker/ICD infections......................................................... 71 6.9 Central nervous system (CNS) infections ................................. 73 Meningitis .................................................................................... 73 Encephalitis ................................................................................. 75 Brain abscess .............................................................................. 76 CNS shunt infection...................................................................... 76 Antimicrobial doses for CNS infections.......................................... 77 6.10 Acute bacterial rhinosinusitis (ABRS) .....................................78 6.11 Orbital cellulitis .....................................................................80 6.12 Pulmonary infections.................................................................. 82 COPD exacerbations .................................................................... 82 Community-acquired pneumonia ................................................... 83 Healthcare-acquired pneumonia. ................................................... 87 Ventilator-associated pneumonia ................................................... 88 Cystic fibrosis .............................................................................. 91 6.13 Respiratory virus diagnosis and management ......................... 93 6.14 Tuberculosis (TB) ........................................................................ 95 6.15 Sepsis with no clear source ....................................................... 99 6.16 Skin, soft-tissue, and bone infections......................................100 Cellulitis ..................................................................................... 100 Cutaneous abscess.................................................................... 101 Management of recurrent MRSA infections .................................. 102 Diabetic foot infections ............................................................... 103 Surgical-site infections................................................................ 105 Serious, deep soft-tissue infections (necrotizing fasciitis).............. 107 Vertebral osteomyelitis, diskitis, epidural abscess ....................... 108 6.17 Urinary tract infections (UTI)....................................................110 Bacterial UTI (including pyelonephritis and urosepsis) ................... 110 6.18 Candidiasis in the non-neutropenic patient ............................115 6.19 Guidelines for the use of prophylactic antimicrobials .................121 Pre-operative and pre-procedure antibiotic prophylaxis................. 121 Prophylaxis against bacterial endocarditis .................................. 125 Prophylactic antimicrobials for patients with solid organ transplants ............................................................... 126 6.20 Guidelines for the use of antimicrobials in neutropenic hosts. ....................................................................129 Treatment of neutropenic fever................................................... 129 Prophylactic antimicrobials for patients with expected prolonged neutropenia ................................................ 131 Use of antifungal agents in hematologic malignancy patients ............................................................. 133 7. Informational guidelines .................................................................137 7.1 Approach to the patient with a history of penicillin allergy ................ 137 8. Infection control ..............................................................................139 8.1 Hospital Epidemiology & Infection Control .................................... 139 8.2 Infection control precautions ....................................................... 141 8.3 Disease-specific infection control recommendations ..................... 142 10. Appendix: A. Aminoglycoside dosing and therapeutic monitoring ........................ 145 B. Vancomycin dosing and therapeutic monitoring.............................. 150 C. Antimicrobial therapy monitoring ................................................... 153 D. Oral antimicrobial use ................................................................... 154 E. Antimicrobial dosing in renal insufficiency ....................................... 155 F. Cost of select antimicrobial agents ................................................ 159

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1. Introduction

Introduction Antibiotic resistance is now a major issue confronting healthcare providers and their patients. Changing antibiotic resistance patterns, rising antibiotic costs and the introduction of new antibiotics have made selecting optimal antibiotic regimens more difficult now than ever before. Furthermore, history has taught us that if we do not use antibiotics carefully, they will lose their efficacy. As a response to these challenges, the Johns Hopkins Antimicrobial Stewardship Program was created in July 2001. Headed by an Infectious Disease physician (Sara Cosgrove, M.D., M.S.) and an Infectious Disease pharmacist (Edina Avdic, Pharm.D., M.B.A), the mission of the program is to ensure that every patient at Hopkins on antibiotics gets optimal therapy. These guidelines are a step in that direction. The guidelines were initially developed by Arjun Srinivasan, M.D., and Alpa Patel, Pharm.D., in 2002 and have been revised and expanded annually. These guidelines are based on current literature reviews, including national guidelines and consensus statements, current microbiologic data from the Hopkins lab, and Hopkins’ faculty expert opinion. Faculty from various departments have reviewed and approved these guidelines. As you will see, in addition to antibiotic recommendations, the guidelines also contain information about diagnosis and other useful management tips. As the name implies, these are only guidelines, and we anticipate that occasionally, departures from them will be necessary. When these cases arise, we will be interested in knowing why the departure is necessary. We want to learn about new approaches and new data as they become available so that we may update the guidelines as needed. You should also document the reasons for the departure in the patient’s chart. Sara E. Cosgrove, M.D., M.S. Director, Antimicrobial Stewardship Program

Edina Avdic, Pharm.D., M.B.A ID Pharmacist Associate Director, Antimicrobial Stewardship Program

Kate Dzintars, Pharm.D. ID Pharmacist

Janessa Smith, Pharm.D. ID Pharmacist

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1. Introduction

The following people served as section/topic reviewers N. Franklin Adkinson, M.D. (Allergy/Immunology) Paul Auwaerter, M.D. (Infectious Diseases) Robin Avery, M.D. (Infectious Diseases) John Bartlett, M.D. (Infectious Diseases) Dina Benani, Pharm. D. (Pharmacy) Michael Boyle, M.D. (Pulmonary) Roy Brower, M.D. (Critical Care and Pulmonary) Karen Carroll, M.D. (Pathology/Infectious Diseases) Michael Choi, M.D. (Nephrology) John Clarke, M.D. (Gastroenterology) Todd Dorman, M.D. (Critical Care) Christine Durand, M.D. (Infectious Diseases) Khalil Ghanem, M.D. (Infectious Diseases) James Hamilton, M.D. (Gastroenterology) Carolyn Kramer, M.D. (Medicine) Pam Lipsett, M.D. (Surgery and Critical Care) Colin Massey, M.D. (Medicine) Lisa Maragakis, M.D. (Infectious Diseases) Kieren Marr, M.D. (Infectious Diseases) Robin McKenzie, M.D. (Infectious Diseases) Michael Melia, M.D. (Infectious Diseases) George Nelson, M.D. (Infectious Diseases) Eric Nuermberger, M.D. (Infectious Diseases) Trish Perl, M.D., M.Sc. (Infectious Diseases) Stuart Ray, M.D. (Infectious Diseases) Anne Rompalo, M.D. (Infectious Diseases) Annette Rowden, Pharm.D. (Pharmacy) Paul Scheel, M.D. (Nephrology) Cynthia Sears, M.D. (Infectious Diseases) Maunank Shah, M.D. (Infectious Diseases) Tiffeny Smith, Pharm.D. (Pharmacy) Jennifer Townsend, M.D. (Infectious Diseases) Robert Wise, M.D. (Pulmonary) Frank Witter, M.D. (OB-GYN)

How to use this guide UÊ >V…ÊÃiV̈œ˜ÊLi}ˆ˜ÃÊLÞÊ}ˆÛˆ˜}ÊÀiVœ““i˜`>̈œ˜ÃÊvœÀÊ̅iÊV…œˆViÊ>˜`Ê dose of antibiotics for the particular infection. UÊALL DOSES IN THE TEXT ARE FOR ADULTS WITH NORMAL RENAL AND HEPATIC FUNCTION. UÊÊvÊޜÕÀÊ«>̈i˜ÌÊ`œiÃÊ "/ʅ>ÛiʘœÀ“>ÊÀi˜>ÊœÀʅi«>̈VÊv՘V̈œ˜]Ê please refer to the sections on antibiotic dosing to determine the correct dose. UÊÊœœÜˆ˜}Ê̅iÊ>˜ÌˆLˆœÌˆVÊÀiVœ““i˜`>̈œ˜Ã]ÊÜiʅ>ÛiÊÌÀˆi`Ê̜ʈ˜VÕ`iÊ some important treatment notes that explain a bit about WHY the particular antibiotics were chosen and that provide some important tips on diagnosis and management. PLEASE glance at these notes 4

Contacting us UÊ
˜ÌˆLˆœÌˆVÊ>««ÀœÛ>\Ê1ÃiÊ* ÆÊÃi>ÀV…ʺ>˜ÌˆLˆœÌˆV]»Ê̅i˜ÊÃiiVÌÊ º
˜ÌˆLˆœÌˆVÊ
««ÀœÛ>Ê*>}iÀ» UÊÊ*i>ÃiÊ`œÊ˜œÌÊÃi˜`ʘՓiÀˆVÊ«>}ià UÊÊ*i>ÃiÊVœ“«iÌiÊ̅iÊvœÀ“Ê>ÃÊ>VVÕÀ>ÌiÞÊ>ÃÊ«œÃÈLi° UÊÊ
ʜÀ`iÀÃÊvœÀÊÀiÃÌÀˆVÌi`Ê>˜ÌˆLˆœÌˆVÃÊ1-/ÊLiÊ>««ÀœÛi`Ê՘iÃÃÊ they are part of an approved order. UÊÊ*i>ÃiÊÃiiÊ«>}iÊÈÊvœÀʓœÀiʈ˜vœÀ“>̈œ˜Ê>LœÕÌʜLÌ>ˆ˜ˆ˜}Ê>««ÀœÛ>° UÊ
˜Ìˆ“ˆVÀœLˆ>Ê-ÌiÜ>À`ň«Ê*Àœ}À>“\ÊLJ{xÇä UʘviV̈œÕÃÊ ˆÃi>ÃiÃÊ œ˜ÃՏÌÃ\Ê·näÓÈ UÊ ÀˆÌˆV>Ê >ÀiÊ>˜`Ê-ÕÀ}iÀÞÊ*…>À“>VÞÊ­<>Þi`ÊΣӣ®\Êx‡Èxäx UÊ
`ՏÌʘ«>̈i˜ÌÊ*…>À“>VÞÊ­<>Þi`ÊÇäää®\Êx‡È£xä UÊ7iˆ˜LiÀ}Ê«…>À“>VÞ\Êx‡n™™n UÊ >ÞۈiÜʘ«>̈i˜ÌÊ*…>À“>VÞ\Êä‡ä™xn UʈVÀœLˆœœ}Þʏ>L\Êx‡Èx£ä A word from our lawyers The recommendations given in this guide are meant to serve as treatment guidelines. They should NOT supplant clinical judgment or Infectious Diseases consultation when indicated. The recommendations were developed for use at The Johns Hopkins Hospital and thus may not be appropriate for other settings. We have attempted to verify that all information is correct but because of ongoing research, things may change. If there is any doubt, please verify the information in the }Ո`iÊLÞÊV>ˆ˜}Ê̅iÊ>˜ÌˆLˆœÌˆVÃÊ«>}iÀÊÕȘ}Ê* Ê­Ãi>ÀV…ʺ>˜ÌˆLˆœÌˆV»®ÊœÀÊ Infectious Diseases. Also, please note that these guidelines contain cost information that is confidential. Copies of the book should not be distributed outside of the institution without permission.

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1. Introduction

when you are treating infections, as we think the information will prove helpful. All references are on file in the office of the Antimicrobial Stewardship Program (7-4570).

2.1 Obtaining ID approval

Obtaining ID approval The use of restricted and non-formulary antimicrobials requires preapproval from Infectious Diseases. This approval can be obtained by any of the following methods. Approval method * \ʺ>˜ÌˆLˆœÌˆV»Ê

Overnight Approval

Ê

Ordersets (e.g. neutropenic fever, etc.)

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Notes Ê/…iÊ«>}iÀʈÃÊ>˜ÃÜiÀi`ÊLiÌÜii˜ÊnÊ>°“°Ê and 10 p.m. PING the ID consult pager if you fail to get a response from the ID approval pager within 10 minutes. Restricted antibiotics ordered between 10 p.m. and 8 a.m. must be approved by noon the following morning. UÊÊ*i>ÃiÊÀi“i“LiÀÊ̜ÊÈ}˜ÊœÕÌÊ̅iʘii`Ê for approval if you go off shift before 8 a.m. These forms are P&T-approved for specific agents and specific indications.

The following list applies to ALL adult floors and includes the status of both oral and injectable dosage forms, unless otherwise noted. Unrestricted Amoxicillin Amoxicillin/clavulanate Ampicillin/sulbactam (Unasyn®) Ampicillin IV Azithromycin Cefazolin Cefdinir Cefotetan Cefpodoxime Ceftriaxone Cefuroxime IV Cephalexin Clarithromycin Clindamycin Dicloxacillin Doxycycline Ertapenem Erythromycin Gentamicin Metronidazole Minocycline Nitrofurantoin Oxacillin Penicillin V/G Ribavirin oral Rifampin Streptomycin Tobramycin Trimethoprim/ sulfamethoxazole Amphotericin B deoxycholate (Fungizone®) Flucytosine Itraconazole oral solution

Restricted (requires ID approval) Amikacin Aztreonam Cefepime Ceftaroline1 Ceftazidime Ceftolozane/tazobactam1 Ciprofloxacin Colistin IV Cytomegalovirus Immune Globulin (Cytogam®)2 Daptomycin1 Fosfomycin3 Linezolid Meropenem Moxifloxacin Nitazoxanide4 Palivizumab (Synagis®)5 Piperacillin/tazobactam ­<œÃޘ®) Quinupristin/ dalfopristin (Synercid®) Ribavirin inhaled5 Telavancin1 Tigecycline Vancomycin

Liposomal amphotericin B (AmBisome®) Micafungin Fluconazole6 Posaconazole Voriconazole

1Approval must be obtained from Antimicrobial Stewardship Program 24h/7 days a week 2Approval required, except for solid organ transplant patients 3Approval must be obtained 24h/7 days a week 4Approval must be obtained from Polk Service or ID Consult 5Approval must be obtained from ID attending physician 24h/7 days a week 6Oral Fluconazole, when used as a single-dose treatment for vulvovaginal candidiasis or when

used in compliance with the SICU/WICU protocol, does not require ID approval Restricted antimicrobials that are ordered as part of a P&T-approved critical pathway or order set do NOT require ID approval. REMINDER: the use of non-formulary antimicrobials is strongly discouraged. ID approval MUST be obtained for ALL non-formulary antimicrobials. NOTE: Formulary antivirals (e.g. Acyclovir, Ganciclovir) do NOT require ID approval.

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2.2 Antimicrobial formulary and restriction status

Selected formulary antimicrobials and restriction status

3.1 Agent-specific guidelines: Antibiotics

Antibiotics Ceftaroline Ceftaroline is a cephalosporin with in vitro activity against staphylococci (including MRSA), most streptococci, and many Gram-negative bacteria. It does NOT have activity against Pseudomonas spp. or Acinetobacter spp. or Gram negative anaerobes. Acceptable uses (Cases must be discussed with Infectious Diseases and Antimicrobial Stewardship Program) UÊÊ-iiVÌÊV>ÃiÃʜvÊ,-
Ê«˜iՓœ˜ˆ>ʜÀʜ̅iÀÊÃiÛiÀiʈ˜viV̈œ˜ÃÊ܅i˜Ê Gram negative coverage is also needed UÊÊ >VÌiÀi“ˆ>ʜÀÊi˜`œV>À`ˆÌˆÃÊV>ÕÃi`ÊLÞÊ,-
ʈ˜Ê>Ê«>̈i˜ÌÊv>ˆˆ˜}Ê 6>˜Vœ“ÞVˆ˜Ê̅iÀ>«ÞÊ>ÃÊ`iw˜i`ÊLÞ\Ê UÊÊ ˆ˜ˆV>Ê`iVœ“«i˜Ã>̈œ˜Ê>vÌiÀÊÎq{Ê`>Þà UÊÊ>ˆÕÀiÊ̜ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ>vÌiÀÊÇÊ`>ÞÃÊ`iëˆÌiÊ6>˜Vœ“ÞVˆ˜Ê ÌÀœÕ}…ÃʜvÊ£xqÓäʓV}ɓÊ UÊÊ ʜvÊ6>˜Vœ“ÞVˆ˜ÊˆÃÊÓʓV}ɓ Unacceptable uses UÊÊ/Ài>̓i˜ÌʜvÊVœ““Õ˜ˆÌއ>VµÕˆÀi`ÊL>VÌiÀˆ>Ê«˜iՓœ˜ˆ>Ê­
*®ÊœÀÊΈ˜Ê and soft tissue infections (SSTI) where other more established and less expensive options are available UʘˆÌˆ>Ê̅iÀ>«ÞÊvœÀÊÀ>“‡«œÃˆÌˆÛiʜÀÊÀ>“‡˜i}>̈Ûiʈ˜viV̈œ˜Ã Dose UÊÊÈääʓ}Ê6Ê+£Óʅ>ÃÊLii˜ÊÃÌÕ`ˆi`ÊvœÀÊ
*Ê>˜`Ê--/ UÊÊÈääʓ}Ê6Ê+nÊvœÀÊ,-
ÊL>VÌiÀi“ˆ>ÊÃ>Û>}iÊ̅iÀ>«ÞʜÀʜ̅iÀÊ serious infections UÊMust adjust for worsening renal function and dialysis (see p. 155 for dose adjustment recommendation). Laboratory interactions UÊÊ ivÌ>Àœˆ˜iʓ>ÞÊÀiÃՏÌʈ˜Ê«œÃˆÌˆÛiÊ`ˆÀiVÌÊ œœ“LýÊÌiÃÌÊ܈̅œÕÌÊ hemolytic anemia. However, if drug-induced hemolytic anemia is suspected, discontinue Ceftaroline.

Ceftolozane/tazobactam Ceftolozane/tazobactam is a novel cephalosporin and β-lactamaseinhibitor combination. It has activity against Gram-negative organisms and some strains of multi-resistant Pseudomonas spp. It does NOT have activity against carbapenemase-producing Enterobacteriaceae. It also has in vitro activity against some streptococci and some Gram-negative anaerobes, but it does not have reliable Staphylococcus spp. activity. 8

Unacceptable uses UÊÊ “«ˆÀˆVÊÌÀi>̓i˜ÌʜvÊVœ“«ˆV>Ìi`ʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜ÃÊ­V
®Ê or complicated urinary tract infections (cUTI) as current standard regimens are sufficient for coverage of the typical pathogens involved in these infections and less expensive options are available Dose UÊÊ£°xÊ}Ê6Ê+nʅ>ÃÊLii˜ÊÃÌÕ`ˆi`ÊvœÀÊV1/Ê>˜`ʈ˜ÊVœ“Lˆ˜>̈œ˜ÊÜˆÌ…Ê metronidazole for cIAI UÊÊ-iÀˆœÕÃʈ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}Ê«˜iՓœ˜ˆ>\ÊÎÊ}Ê6Ê+n UÊÊÕÃÌÊ>`ÕÃÌÊ`œÃiÊvœÀÊܜÀÃi˜ˆ˜}ÊÀi˜>Êv՘V̈œ˜Ê>˜`Ê`ˆ>ÞÈÃÊ­ÃiiÊ«°£xxÊ for dose adjustment recommendation).

Colistin (Colistimethate) Colistin is a polymixin antibiotic. It has in vitro activity against Acinetobacter spp. and Pseudomonas spp. but does NOT have activity against Proteus, Serratia, Providentia, Burkholderia, Stenotrophomonas, Gram-negative cocci, Gram-positive organisms, or anaerobes. Acceptable uses UÊÊ>˜>}i“i˜Ìʜvʈ˜viV̈œ˜ÃÊ`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊAcinetobacter and Pseudomonas on a case by case basis. Unacceptable uses UÊÊœ˜œÌ…iÀ>«ÞÊvœÀÊi“«ˆÀˆVÊÌÀi>̓i˜ÌʜvÊÃÕëiVÌi`ÊÀ>“‡˜i}>̈Ûiʈ˜viV̈œ˜ÃÊ Dose UÊœ>`ˆ˜}Ê`œÃi\Êxʓ}Ɏ}ʜ˜Vi UÊÊ>ˆ˜Ìi˜>˜ViÊ`œÃi\ÊÓ°xʓ}Ɏ}Ê+£ÓÆʓÕÃÌÊ>`ÕÃÌÊvœÀÊܜÀÃi˜ˆ˜}Ê renal function and dialysis (see p. 155 for dose adjustment recommendation). Toxicity UÊÊ,i˜>Êˆ“«>ˆÀ“i˜Ì]ʘiÕÀœ“ÕÃVՏ>ÀÊLœVŽ>`i]ʘiÕÀœÌœÝˆVˆÌÞ UÊÊœ˜ˆÌœÀˆ˜}\Ê 1 ]ÊVÀi>̈˜ˆ˜iÊÌ܈Vi‡ÜiiŽÞ

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3.1 Agent-specific guidelines: Antibiotics

Acceptable uses (Cases must be discussed with Infectious Diseases and Antimicrobial Stewardship Program) UÊÊ>˜>}i“i˜Ìʜvʈ˜viV̈œ˜ÃÊ`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊPseudomonas spp. infections on a case by case basis

3.1 Agent-specific guidelines: Antibiotics

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10

,iviÀi˜Vi\Ê Daptomycin in S. aureusÊL>VÌiÀi“ˆ>Ê>˜`ʈ˜viV̈ÛiÊi˜`œV>À`ˆÌˆÃ\Ê Ê ˜}ÊÊi`ÊÓääÈÆÊ Îxx\ÊÈxÎqÈx°

Ertapenem Ertapenem is a carbapenem antibiotic. It has in vitro activity against many Gram-negative organisms including those that produce extended spectrum beta-lactamases (ESBL), but it does not have activity against Pseudomonas spp. or Acinetobacter spp. Its anaerobic and Grampositive activity is similar to that of other carbapenems, except it does not have activity against Enteroccocus spp. Acceptable uses UÊʈ`Ê̜ʓœ`iÀ>Ìiʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜ÃÊ­Lˆˆ>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ã]Ê diverticulitis, secondary peritonitis/GI perforation) UÊÊœ`iÀ>ÌiÊ`ˆ>LïVÊvœœÌʈ˜viV̈œ˜ÃÊ܈̅œÕÌʜÃÌiœ“ÞiˆÌˆÃ UÊÊœ`iÀ>ÌiÊÃÕÀ}ˆV>‡ÃˆÌiʈ˜viV̈œ˜ÃÊvœœÜˆ˜}ÊVœ˜Ì>“ˆ˜>Ìi`Ê«ÀœVi`ÕÀi UÊ*iÛˆVʈ˜y>““>̜ÀÞÊ`ˆÃi>Ãi UÊÊ1Àˆ˜>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜ÃÊV>ÕÃi`ÊLÞÊ - ‡«Àœ`ÕVˆ˜}ʜÀ}>˜ˆÃ“ÃÊ UÊÊ*Þiœ˜i«…ÀˆÌˆÃʈ˜Ê>Ê«>̈i˜ÌÊ܅œÊˆÃʘœÌÊÃiÛiÀiÞʈ Unacceptable uses UÊÊ-iÛiÀiʈ˜viV̈œ˜Ãʈ˜Ê܅ˆV… Pseudomonas spp. are suspected. Dose UÊÊ£Ê}Ê6ʜÀÊÊ+Ó{]ʓÕÃÌÊ>`ÕÃÌÊvœÀÊܜÀÃi˜ˆ˜}ÊÀi˜>Êv՘V̈œ˜Ê>˜`Ê dialysis (see p. 155 for dose adjustment recommendation) Toxicity UÊÊ ˆ>ÀÀ…i>]ʘ>ÕÃi>]ʅi>`>V…i]Ê«…iLˆÌˆÃÉ̅Àœ“Lœ«…iLˆÌˆÃ

Fosfomycin Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in vitro activity against large number of Gram-negative and Gram-positive organisms including E. coli, Klebsiella spp., Proteus spp., Pseudomonas spp., and VRE. It does not have activity against Acinetobacter spp. Fosfomycin is available in an oral formulation only in the U.S. and its pharmacokinetics allow for one-time dosing. Acceptable uses UÊÊ>˜>}i“i˜ÌʜvÊ՘Vœ“«ˆV>Ìi`Ê1/ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʓՏ̈«iÊ>˜ÌˆLˆœÌˆVÊ allergies and/or when no other oral therapy options are available. 11

3.1 Agent-specific guidelines: Antibiotics

Toxicity UÊÊޜ«>̅ÞÊ­`iw˜i`Ê>ÃÊ Ê 10 times the upper limit of normal without symptoms or  5 times the upper limit of normal with symptoms). UÊÊ œÃˆ˜œ«…ˆˆVÊ«˜iՓœ˜ˆ> UÊÊœ˜ˆÌœÀˆ˜}\Ê ÊÜiiŽÞ]ʓœÀiÊvÀiµÕi˜ÌÞÊ`ÕÀˆ˜}ʈ˜ˆÌˆ>Ê̅iÀ>«Þ°Ê

3.1 Agent-specific guidelines: Antibiotics

UÊÊ1˜Vœ“«ˆV>Ìi`Ê1/Ê`ÕiÊ̜Ê6, UÊÊÊ->Û>}iÊ̅iÀ>«ÞÊvœÀÊ1/Ê`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiÊ organisms (e.g. Pseudomonas spp.) on case by case basis. NOTE: Susceptibility to Fosfomycin should be confirmed prior to initiation of therapy. Unacceptable uses UÊÊœÃvœ“ÞVˆ˜ÊŜՏ`Ê "/ÊLiÊÕÃi`ÊvœÀʓ>˜>}i“i˜ÌʜvÊ>˜Þʈ˜viV̈œ˜ÃÊ outside of the urinary tract because it does not achieve adequate concentrations at other sites. UÊÊ/Ài>̓i˜ÌʜvÊ>Ãޓ«Ìœ“ˆVÊL>VÌiÀˆÕÀˆ>Ê­ÃiiÊ«°Ê££ä® Dose UÊÊ1˜Vœ“«ˆV>Ìi`Ê1/\ÊÎÊ}Ê­£ÊÃ>V…iÌ®Ê*"ʜ˜Vi°Ê UÊÊ œ“«ˆV>Ìi`Ê1/\ÊÎÊ}Ê­£ÊÃ>V…iÌ®Ê*"ÊiÛiÀÞÊ£‡ÎÊ`>ÞÃÊ­Õ«Ê̜ÊÓ£Ê`>ÞÃʜvÊ treatment) UÊÊÀiµÕi˜VÞÊ>`ÕÃ̓i˜Ìʓ>ÞÊLiʘiViÃÃ>ÀÞʈ˜Ê«>̈i˜ÌÃÊÜˆÌ…Ê À Ê 50 mL/min. Contact the ID Pharmacist for dosing recommendations. UÊÊ*œÜ`iÀÊŜՏ`ÊLiʓˆÝi`Ê܈̅ʙäq£ÓäʓʜvÊVœœÊÜ>ÌiÀ]ÊÃ̈ÀÀi`ÊÌœÊ dissolve and administered immediately. Toxicity UÊÊ ˆ>ÀÀ…i>]ʘ>ÕÃi>]ʅi>`>V…i]Ê`ˆâ∘iÃÃ]Ê>Ã̅i˜ˆ>Ê>˜`Ê`Þëi«Ãˆ>

Linezolid Acceptable uses UÊÊ œVՓi˜Ìi`Ê6>˜Vœ“ÞVˆ˜Êˆ˜ÌiÀ“i`ˆ>ÌiÊStaphylococcus aureus (VISA) or Vancomycin resistant Staphylococcus aureus (VRSA) infection UÊÊ œVՓi˜Ìi`Ê,-
ʜÀÊi̅ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊ staphylococcal infection in a patient with serious allergy to Vancomycin UÊÊ œVՓi˜Ìi`Ê,-
ʜÀÊi̅ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊ staphylococcal infection in a patient failing Vancomycin therapy (as `iw˜i`ÊLiœÜ®\Ê UÊÊ >VÌiÀi“ˆ>Éi˜`œV>À`ˆÌˆÃ\Êv>ˆÕÀiÊ̜ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ>vÌiÀÊ ÇÊ`>ÞÃÊ`iëˆÌiÊ6>˜Vœ“ÞVˆ˜ÊÌÀœÕ}…ÃʜvÊ£xqÓäʓV}ɓ°Ê-…œÕ`ÊLiÊ used in combination with another agent UÊÊ*˜iՓœ˜ˆ>\ÊܜÀÃi˜ˆ˜}ʈ˜wÌÀ>ÌiʜÀʫՏ“œ˜>ÀÞÊÃÌ>ÌÕÃʈ˜Ê>Ê«>̈i˜ÌÊ with documented MRSA pneumonia after 2 to 3 days or if the MIC of Vancomycin is 2 mcg/mL, or if achieving appropriate vancomycin trough is unlikely (e.g., obesity) UÊÊ >ÃiÃÊŜՏ`ÊLiÊ`ˆÃVÕÃÃi`Ê܈̅ʘviV̈œÕÃÊ ˆÃi>ÃiÃʜÀÊ Antimicrobial stewardship UÊHigh suspicion of CA-MRSA necrotizing pneumonia in a seriously ill patient

12

Dose UÊÊÈääʓ}Ê6É*"Ê+£Ó UÊÊ-Žˆ˜Ê>˜`ÊΈ˜‡ÃÌÀÕVÌÕÀiʈ˜viV̈œ˜Ã\Ê{ääʓ}Ê6É*"Ê+£Ó Toxicity UÊÊ œ˜iʓ>ÀÀœÜÊÃÕ««ÀiÃȜ˜Ê­ÕÃÕ>ÞʜVVÕÀÃÊ܈̅ˆ˜ÊwÀÃÌÊÓÊÜiiŽÃʜvÊ̅iÀ>«Þ® UÊÊ"«ÌˆVʘiÕÀˆÌˆÃÊ>˜`ʈÀÀiÛiÀÈLiÊÃi˜ÃœÀÞʓœÌœÀÊ«œÞ˜iÕÀœ«>̅ÞÊ­ÕÃÕ>ÞÊ occurs with prolonged therapy > 28 days) UÊÊ >ÃiÊÀi«œÀÌÃʜvʏ>V̈VÊ>Vˆ`œÃˆÃ UÊÊ >ÃiÊÀi«œÀÌÃʜvÊÃiÀœÌœ˜ˆ˜ÊÃޘ`Àœ“iÊ܅i˜ÊVœ‡>`“ˆ˜ˆÃÌiÀi`ÊÜˆÌ…Ê serotonergic agents (SSRIs, TCAs, MAOIs, etc.) UÊÊœ˜ˆÌœÀˆ˜}\Ê ÊÜiiŽÞ

Tigecycline Tigecycline is a tetracycline derivative called a glycylcycline. It has in vitro activity against most strains of staphylococci and streptococci (including MRSA and VRE), anaerobes, and many Gram-negative organisms with the exception of Proteus spp. and Pseudomonas aeruginosa. It is FDA approved for skin and skin-structure infections and intra-abdominal infections. NOTE: Peak serum concentrations of Tigecycline do not exceed 1 mcg/mL which limits its use for treatment of bacteremia Acceptable uses UÊÊ>˜>}i“i˜Ìʜvʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜Ãʈ˜Ê«>̈i˜ÌÃÊÜˆÌ…Ê contraindications to both beta-lactams and fluoroquinolones UÊÊ>˜>}i“i˜Ìʜvʈ˜viV̈œ˜ÃÊ`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiÊ organisms including Acinetobacter spp. and Stenotrophomonas maltophilia on a case by case basis UÊÊ->Û>}iÊ̅iÀ>«ÞÊvœÀÊ,-
É6, ʈ˜viV̈œ˜Ãʜ˜Ê>ÊV>ÃiÊLÞÊV>ÃiÊL>Èà Dose UÊÊ£ääʓ}Ê6ʜ˜Vi]Ê̅i˜Êxäʓ}Ê6Ê+£Ó UÊÊ£ääʓ}Ê6ʜ˜Vi]Ê̅i˜ÊÓxʓ}Ê6Ê+£ÓʈvÊÃiÛiÀiʅi«>̈Vʈ“«>ˆÀ“i˜ÌÊ ­ …ˆ`ʇÊ*Õ}…Ê£äq£x® Toxicity UÊÊ >ÕÃi>Ê>˜`Êۜ“ˆÌˆ˜}Ê 13

3.1 Agent-specific guidelines: Antibiotics

UÊ ÊÊ œVՓi˜Ìi`Ê6, ʈ˜viV̈œ˜Ê UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊˆ˜ÊV…>ˆ˜Ãʈ˜ÊLœœ`ÊVՏÌÕÀiÃʈ˜Ê>˜Ê 1]ʜÀʜ˜Vœœ}ÞÊ transplant patient known to be colonized with VRE Unacceptable uses UÊÊ*Àœ«…ޏ>݈à UÊʘˆÌˆ>Ê̅iÀ>«ÞÊvœÀÊÃÌ>«…ޏœVœVV>Êˆ˜viV̈œ˜ UÊÊ6, ÊVœœ˜ˆâ>̈œ˜ÊœvÊ̅iÊÃ̜œ]ÊÕÀˆ˜i]ÊÀiëˆÀ>̜ÀÞÊÌÀ>VÌ]Êܜ՘`Ã]ʜÀÊ`À>ˆ˜Ã

3.1 Agent-specific guidelines: Antibiotics

Trimethoprim/sulfamethoxazole (Bactrim®, TMP/SMX) Trimethoprim/sulfamethoxazole is a sulfonamide antibiotic. It has in vitro activity against Enterobacteriaceae spp., B. cepacia, S. maltophilia, Acinetobacter spp., Achromobacter spp., Nocardia spp., Listeria, Pneumocystis jirovecii (PCP), staphylococci (including S. aureus and Coagulase-negative staph), but does NOT cover Pseudomonas spp. It has variable activity against streptococci and no activity against anaerobes. Acceptable uses UÊ1Àˆ˜>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜ÃÊ­1/® UÊS. aureus skin and soft-tissue infections (SSTI) UÊPneumocystis jirovecii pneumonia (PCP) treatment and prophylaxis UÊS. maltophilia infections UÊ œV>À`ˆ>ʈ˜viV̈œ˜ÃÊ UÊÀ>“‡˜i}>̈ÛiÊL>VÌiÀi“ˆ>Ê܅i˜ÊœÀ}>˜ˆÃ“ʈÃÊÃÕÃVi«ÌˆLiÊ UÊÊ->Û>}iÊ̅iÀ>«ÞÊvœÀÊ,-
ÊL>VÌiÀi“ˆ>ʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê>˜œÌ…iÀÊ agent UÊÊ “«ˆÀˆVÊVœÛiÀ>}iʜvÊListeria meningitis in patients with penicillin allergies UÊÊ-Õ««ÀiÃÈÛiÊ̅iÀ>«ÞÊ>˜`ʈ˜ÊܓiÊV>ÃiÃÊÌÀi>̓i˜ÌÊvœÀÊLœ˜iÊ>˜`ʍœˆ˜ÌÊ infections Unacceptable uses UÊœ˜œÌ…iÀ>«ÞÊvœÀÊS. aureus bacteremia Dose UÊTrimethoprim/sulfamethoxazole dosing is based on trimethoprim component UÊ/*É-8ʅ>ÃÊiÝVii˜ÌÊLˆœ>Û>ˆ>LˆˆÌÞ]Ê̅ÕÃÊVœ˜ÛiÀȜ˜ÊvÀœ“Ê6Ê̜Ê*"Ê ˆÃÊ£\£Ê­näÉ{ääʓ}Ê6ÊrÊ£Ê--ÊÌ>LÆÊ£ÈäÉnääʓ}Ê6ÊrÊ£Ê -ÊÌ>L®Ê UÊ1ÃiÊ>`ÕÃÌi`Ê 7rÊQ 7ʳÊä°{Ê­
7ʇÊ 7®Rʈ˜ÊœLiÃiÊ«>̈i˜ÌÃÊ­€Îä¯Ê over IBW) Treatment UÊ1/\Ê£Ê -ÊÌ>LÊ+£ÓÊ UÊ--/\Ê£‡ÓÊ -ÊÌ>LÊ+£Ó UÊ* *\£x‡Óäʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n® UÊ,-
ÊL>VÌiÀi“ˆ>\£ä‡£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n® UÊS. maltophiliaʈ˜viV̈œ˜Ã\£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®Ê

14

Prophylaxis UÊ* *\Ê£Ê--Ê`>ˆÞʜÀÊ£Ê -ÊÎÊ̈“iÃÉÜiiŽÊ UÊ/œÝœ«>ӜÈÃ\Ê£Ê -Ê`>ˆÞÊ Toxicity UÊ œ““œ˜\ʅޫiÀÃi˜ÃˆÌˆÛˆÌÞÊ­£°È‡n¯®]ʇիÃiÌ]Ê«ÃiÕ`œÊiiÛ>̈œ˜Êˆ˜Ê VÀi>̈˜ˆ˜iÊ­£n¯®Ê UÊ œ““œ˜Ê܈̅ʅˆ}…iÀÊ`œÃiÃ\ʅޫiÀŽ>i“ˆ>]ʓÞiœÃÕ««ÀiÃȜ˜ UÊ"VV>Ȝ˜>\ʘi«…ÀœÌœÝˆVˆÌÞ]Ê«…œÌœÃi˜ÃˆÌˆÛˆÌÞ]ʓi̅i“œ}œLˆ˜i“ˆ>Ê­ÜˆÌ…Ê severe G6PD deficiency) UÊ,>Ài\Ê>Ãi«ÌˆVʓi˜ˆ˜}ˆÌˆÃ]ʅi«>̜̜݈VˆÌÞ]Ê̜݈VÊi«ˆ`iÀ“>Ê˜iVÀœÞÈÃÊ (TEN), SJS, Sweet’s syndrome Drug Interaction UÊ7>Àv>Àˆ˜]ʓi̅œÌÀiÝ>Ìi]Ê«…i˜Þ̜ˆ˜]Ê`ˆ}œÝˆ˜]ÊÃՏvœ˜ÞÕÀi>Ã]Ê procainamide, oral contraceptives

15

3.1 Agent-specific guidelines: Antibiotics

UÊ œV>À`ˆ>ʈ˜viV̈œ˜Ã\Ê£xʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®ÆʏœÜiÀÊ doses (5-10 mg/kg/day) can be used after several weeks of therapy or cutaneous infections UÊi˜ˆ˜}ˆÌˆÃ\ÊÓäʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+È® UÊ"̅iÀʈ˜viV̈œ˜Ã\Ên‡£äʓ}Ɏ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ£Ó® UÊÕÃÌÊ>`ÕÃÌÊ`œÃiÊvœÀÊܜÀÃi˜ˆ˜}ÊÀi˜>Êv՘V̈œ˜Ê>˜`Ê`ˆ>ÞÈÃÊ­ÃiiÊ«°£xxÊ for dose adjustment recommendation).

3.2 Agent-specific guidelines: Antifungals

Antifungals Liposomal Amphotericin B (AmBisome®) NOTES: UÊÊ œÃˆ˜}ʜvÊ
“ ˆÃœ“iÊ>˜`Ê
“«…œÌiÀˆVˆ˜Ê Ê`iœÝÞV…œ>ÌiʈÃÊ significantly different. Do not use AmBisome doses when ordering Amphotericin B deoxycholate and vice versa. UÊÊ
“«…œÌiÀˆVˆ˜Ê Ê`iœÝÞV…œ>ÌiʈÃÊ«ÀiviÀÀi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅Êi˜`‡ stage renal disease on dialysis who are anuric. AmBisome, like all Amphotericin B products, has broad spectrum antifungal activity with in vitro activity against Candida, Aspergillus, Zygomycosis and Fusarium. Acceptable uses UÊ >˜`ˆ`>Êi˜`œ«Ì…>“ˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]Ê -ʈ˜viV̈œ˜qwÀÃÌʏˆ˜iÊ̅iÀ>«Þ UÊ Àޫ̜VœVVÕÃʓi˜ˆ˜}ˆÌˆÃ‡wÀÃÌʏˆ˜iÊ̅iÀ>«ÞÊÊ UÊ<Þ}œ“ÞVœÃiÃÊ­Mucor, Rhizopus, Cunninghamella®qwÀÃÌʏˆ˜iÊ̅iÀ>«ÞÊ UÊÊ iÕÌÀœ«i˜ˆVÊviÛiÀʈvÊÀiViˆÛˆ˜}Ê6œÀˆVœ˜>✏iʜÀÊ*œÃ>Vœ˜>✏iÊ prophylaxis UÊ
ÌiÀ˜>̈ÛiÊÌÀi>̓i˜Ìʜvʈ˜Û>ÈÛiÊ>ëiÀ}ˆœÃˆÃ UÊÊ
ÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊV>˜`ˆ`i“ˆ>]ÊV>˜`ˆ`>Ê«iÀˆÌœ˜ˆÌˆÃÊ Dose UÊÊ >˜`ˆ`i“ˆ>]ʅˆÃ̜«>ӜÈÃ]ʜ̅iÀʘœ˜‡ˆ˜Û>ÈÛiÊV>˜`ˆ`>ʈ˜viV̈œ˜Ã\Ê 3 mg/kg/day UÊÊ >˜`ˆ`>Êi˜`œ«Ì…>“ˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]Ê -ʈ˜viV̈œ˜]ÊC. krusei V>˜`ˆ`i“ˆ>\Êxʓ}Ɏ}É`>Þ UʘÛ>ÈÛiÊw>“i˜ÌœÕÃÊv՘}ˆ\Êxʓ}Ɏ}É`>Þ UÊ iÕÌÀœ«i˜ˆVÊviÛiÀ]ÊV>˜`ˆ`i“ˆ>ʈ˜Ê˜iÕÌÀœ«i˜ˆVÊ«>̈i˜Ì\ÊÎqxʓ}Ɏ}É`>Þ UÊ Àޫ̜VœVV>Ê“i˜ˆ˜}ˆÌˆÃ\ÊÎq{ʓ}Ɏ}É`>Þ Toxicity UʘvÕȜ˜‡Ài>Ìi`ÊÀi>V̈œ˜Ã\ÊviÛiÀ]ÊV…ˆÃ]ÊÀˆ}œÀÃ]ʅޫœÌi˜Ãˆœ˜ UÊÊ,i˜>Êˆ“«>ˆÀ“i˜ÌÊ­i˜…>˜Vi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊVœ˜Vœ“ˆÌ>˜Ìʘi«…ÀœÌœÝˆVÊ drugs) UÊ iVÌÀœÞÌiʈ“L>>˜Vià UÊÊ*Տ“œ˜>ÀÞÊ̜݈VˆÌÞÊ­V…iÃÌÊ«>ˆ˜]ʅޫœÝˆ>]Ê`Þë˜i>®]Ê>˜i“ˆ>]ÊiiÛ>̈œ˜Êˆ˜Ê hepatic enzymes-rare UÊÊœ˜ˆÌœÀˆ˜}\Ê 1 ÉVÀi>̈˜ˆ˜i]Ê]Ê}]Ê*…œÃÊ>ÌÊL>Ãiˆ˜iÊ>˜`Ê`>ˆÞʈ˜Ê …œÃ«ˆÌ>ˆâi`Ê«>̈i˜ÌÃÆÊ
-/É
/Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£‡ÓÊÜiiŽÃÊ

16

Aspergillosis UÊ
VVi«Ì>LiÊÕÃià UÊʘÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê6œÀˆVœ˜>✏iÊvœÀÊVœ˜wÀ“i`ʈ˜Û>ÈÛiÊ aspergillosis (see p. 133) UÊÊ,ivÀ>V̜ÀÞÊ`ˆÃi>Ãi‡ÊvœÀÊÕÃiʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê6œÀˆVœ˜>✏i]Ê Posaconazole or AmBisome® for confirmed invasive aspergillosis. UÊ1˜>VVi«Ì>LiÊÕÃià UÊʈV>v՘}ˆ˜Ê>œ˜iʜÀʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅ʜ̅iÀÊ>˜Ìˆv՘}>Ê>}i˜ÌÃʈÃÊ not recommended for empiric therapy in patients with CT findings suggestive of aspergillosis (e.g., possible aspergillosis) without plans for diagnostic studies. UÊʈV>v՘}ˆ˜Ê`œiÃʘœÌʅ>ÛiÊ}œœ`Êin vitro activity against zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.). Candidiasis UÊ
VVi«Ì>LiÊÕÃià UÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃÊ`ÕiÊ̜ÊC. glabrata or C. krusei. UÊÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>ÀiÊ "/ÊVˆ˜ˆV>ÞÊ stable due to candidemia or have received prior long-term azole therapy. UÊ
ÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊÀiVÕÀÀi˜ÌÊiÜ«…>}i>ÊV>˜`ˆ`ˆ>Èð UÊ
ÌiÀ˜>̈ÛiÊÌÀi>̓i˜ÌʜvÊi˜`œV>À`ˆÌˆÃ° UÊ1˜>VVi«Ì>LiÊÕÃià UÊʈV>v՘}ˆ˜Ê…>ÃÊ«œœÀÊ«i˜iÌÀ>̈œ˜Êˆ˜ÌœÊ̅iÊ -Ê>˜`ÊÕÀˆ˜>ÀÞÊÌÀ>VÌ°ÊÌÊ should be avoided for infections involving those sites. Neutropenic fever UÊʈV>v՘}ˆ˜ÊV>˜ÊLiÊÕÃi`ÊvœÀʘiÕÌÀœ«i˜ˆVÊviÛiÀʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>ÀiʘœÌÊ suspected to have aspergillosis or zygomycosis. Dose UÊÊ >˜`ˆ`i“ˆ>]ʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃ]ʘiÕÌÀœ«i˜ˆVÊviÛiÀ\Ê£ääʓ}Ê6Ê Q24H UÊ >˜`ˆ`>Êi˜`œV>À`ˆÌˆÃ\Ê£xäʓ}Ê6Ê+Ó{ UÊ,iVÕÀÀi˜ÌÊiÜ«…>}i>ÊV>˜`ˆ`ˆ>ÈÃ\Ê£xäʓ}Ê6Ê+Ó{ UʘÛ>ÈÛiÊ>ëiÀ}ˆœÃˆÃ\Ê£ääq£xäʓ}Ê6Ê+Ó{ UÊ"LiÃiÊ«>̈i˜Ìà UÊÊ£ääq£xäʎ}\Ê£xäʓ}Ê6Ê+Ó{ UÊÊ> £xäʎ}\Ê œ˜ÃՏÌÊ Ê*…>À“>VˆÃÌ Drug Interactions UÊÊ œÃiʓœ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`Ê܅i˜ÊˆV>v՘}ˆ˜ÊˆÃÊÕÃi`Ê܈̅Ê̅iÊ vœœÜˆ˜}Ê>}i˜ÌÃÊVœ˜Vœ“ˆÌ>˜ÌÞ\ 17

3.2 Agent-specific guidelines: Antifungals

Micafungin NOTE: Micafungin does not have activity against Cryptococcus.

3.2 Agent-specific guidelines: Antifungals

UÊÊ-ˆÀœˆ“ÕÃÊqʏiÛiÃʜvÊ-ˆÀœˆ“ÕÃʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ Sirolimus toxicity UÊÊ ˆvi`ˆ«ˆ˜iÊqʏiÛiÃʜvÊ ˆvi`ˆ«ˆ˜iʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ Nifedipine toxicity UÊÊÌÀ>Vœ˜>✏iÊqʏiÛiÃʜvÊÌÀ>Vœ˜>✏iʓ>ÞÊLiʈ˜VÀi>Ãi`]ʓœ˜ˆÌœÀÊvœÀÊ Itraconazole toxicity Toxicity UÊʘvÕȜ˜‡Ài>Ìi`ÊÀi>V̈œ˜ÃÊ­À>Å]Ê«ÀÕÀˆÌˆÃ®]Ê«…iLˆÌˆÃ]ʅi>`>V…i]ʘ>ÕÃi>Ê and vomiting, and elevations in hepatic enzymes. UÊœ˜ˆÌœÀˆ˜}\Ê
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Posaconazole Posaconazole is a broad spectrum azole anti-fungal agent. It has in vitro activity against Candida, Aspergillus, Zygomycosis and Fusarium spp. Acceptable uses UÊ/Ài>̓i˜Ìʜvʈ˜Û>ÈÛiÊâÞ}œ“ÞVœÃˆÃʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê
“«…œÌiÀˆVˆ˜Ê UÊÊœ˜œÌ…iÀ>«ÞÊvœÀÊâÞ}œ“ÞVœÃˆÃÊ>vÌiÀÊÇÊ`>ÞÃʜvÊVœ“Lˆ˜>̈œ˜Ê̅iÀ>«ÞÊ with Amphotericin B UÊ*Àœ«…ޏ>݈Ãʈ˜Ê«>̈i˜ÌÃÊ܈̅ʅi“>̜œ}ˆVʓ>ˆ}˜>˜VÞ UÊ/Ài>̓i˜ÌʜvÊ>ëiÀ}ˆœÃˆÃʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê6œÀˆVœ˜>✏iʈ˜ÌœiÀ>˜Vi Unacceptable uses UÊ >˜`ˆ`ˆ>ÈÃÉ iÕÌÀœ«i˜ˆVÊviÛiÀ UʈÀÃ̇ˆ˜iÊÌÀi>̓i˜ÌʜvÊ>ëiÀ}ˆœÃˆÃ Dose "/ -\Ê UÊÊ >V…Ê`œÃiʜvÊÃÕëi˜Ãˆœ˜ÊŜՏ`ÊLiÊ}ˆÛi˜Ê܈̅Ê>ÊvՏÊ“i>ÊœÀÊ܈̅ʏˆµÕˆ`Ê nutritional supplements if patients cannot tolerate full meals. Can also be given with an acidic beverage (e.g. ginger ale). UÊÊ i>Þi`ÊÀii>ÃiÊÌ>LiÌÃÊ>˜`ʜÀ>ÊÃÕëi˜Ãˆœ˜ÊV>˜˜œÌÊLiÊÕÃi`Ê interchangeably due to differences in the dosing of each formulation. Prophylaxis UÊ"À>Ê-Õëi˜Ãˆœ˜\ÊÓääʓ}Ê*"Ê+n UÊ ÝÌi˜`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääʓ}Ê*"Ê`>ˆÞ Treatment UÊÊ"À>Ê-Õëi˜Ãˆœ˜\ÊÓääʓ}Ê*"Ê+ÈÊvœÀÊÇÊ`>ÞÃ]Ê̅i˜Ê{ääʓ}Ê*"Ê Q8-Q12H UÊÊ ÝÌi˜`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääʓ}Ê*"Ê+£ÓÊvœÀÊ£Ê`>Þ]Ê̅i˜ÊÎääʓ}Ê PO daily

18

Drug Interactions: See Table on p. 21 Toxicity UÊÊÊÕ«ÃiÌÊ­H{䯮]ʅi>`>V…iÃ]ÊiiÛ>̈œ˜Êˆ˜Ê…i«>̈VÊi˜âޓiðÊ,>ÀiÊLÕÌÊ serious effects include QTc prolongation. UÊÊœ˜ˆÌœÀˆ˜}\Ê
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ˆ˜ˆV>ÊivwV>VÞʜvʘiÜÊ>˜Ìˆv՘}>Ê>}i˜ÌÃ\Ê ÕÀÀÊ"«ˆ˜ÊˆVÀœLˆœ°ÊÓääÈƙ\{n·nn° *œÃ>Vœ˜>✏i\Ê>ÊLÀœ>`ÊëiVÌÀՓÊÌÀˆ>✏iÊ>˜Ìˆv՘}>\Ê>˜ViÌʘviVÌÊ ˆÃ°ÊÓääxÆÊx\ÇÇx‡nx°

Voriconazole NOTE: Voriconazole does not cover zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.). Acceptable uses UÊAspergillosis UÊScedosporium apiospermum UÊProphylaxis in patients with hematologic malignancy Unacceptable uses UÊÊCandidiasis / Neutropenic fever Voriconazole should not be used as first-line therapy for the treatment of candidiasis or for empiric therapy in patients with neutropenic fever. Dose UÊÊœ>`ˆ˜}Ê`œÃi\ÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊÝÊÓÊ`œÃià UÊ>ˆ˜Ìi˜>˜ViÊ`œÃi\Ê{ʓ}Ɏ}Ê6É*"Ê+£Ó UÊÊ œÃiÊ>`ÕÃ̓i˜ÌʈÃʘiViÃÃ>ÀÞÊvœÀʅi«>̈Vʈ˜ÃÕvwVˆi˜VÞ\ UÊ …ˆ`ʇÊ*Õ}…Ê­
ʜÀÊ ®\Ê↓ “>ˆ˜Ìi˜>˜ViÊ`œÃiÊLÞÊxä¯ UÊÊ …ˆ`ʇÊ*Õ}…Ê­ ®\Ê1Ãiʜ˜ÞʈvÊLi˜iwÌÃʜÕÌÜiˆ}…ÊÀˆÃŽÃ°Ê œ˜ÃՏÌÊ ID pharmacist for dose adjustment recommendations. UÊÊ œÃiÊiÃV>>̈œ˜Ê“>ÞÊLiʘiViÃÃ>ÀÞÊvœÀÊܓiÊ«>̈i˜ÌÃÊ`ÕiÊÌœÊ subtherapeutic levels. UÊÊ œÃiÊL>Ãi`ʜ˜Ê>VÌÕ>ÊLœ`ÞÊÜiˆ}…ÌÊ՘iÃÃÊ«>̈i˜ÌʀÎä¯ÊœÛiÀÊ 7ÆÊ then use adjusted body weight. (Adj. BW).
`°Ê 7ÊrÊQ 7ʳÊä°{Ê­
7ʇÊ 7®R IBW - Ideal Body Weight ABW - Actual Body Weight

19

3.2 Agent-specific guidelines: Antifungals

Therapeutic monitoring: UÊ*œÃ>Vœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>Ài\ UÊ œÌÊÀi뜘`ˆ˜}Ê̜Ê̅iÀ>«ÞÊvœÀÊ>Ìʏi>ÃÌÊÇÊ`>Þà UÊ iˆ˜}ÊÌÀi>Ìi`ÊvœÀÊ՘Vœ““œ˜ÊœÀʏiÃÃÊÃÕÃVi«ÌˆLiʜÀ}>˜ˆÃ“à UÊ Ý«iÀˆi˜Vˆ˜}ʓÕVœÃˆÌˆÃʜÀʓ>>LÜÀ«Ìˆœ˜ÊÃޘ`Àœ“i UÊ1˜>LiÊ̜ÊVœ˜ÃՓiʅˆ}…Êv>Ìʓi>ÃÊ­ˆvÊÀiViˆÛˆ˜}Ê̅iÊÃÕëi˜Ãˆœ˜®

3.2 Agent-specific guidelines: Antifungals

Therapeutic monitoring UÊÊ6œÀˆVœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>Ài\ UÊÊ œÌÊÀi뜘`ˆ˜}Ê̜Ê̅iÀ>«ÞÊ>vÌiÀÊ>Ìʏi>ÃÌÊxÊ`>ÞÃʜvÊ̅iÀ>«ÞÊÕȘ}Ê>Ê mg/kg dosing strategy UÊÊ,iViˆÛˆ˜}ÊVœ˜Vœ“ˆÌ>˜ÌÊ`ÀÕ}ÃÊ̅>Ìʓ>Þʈ˜VÀi>ÃiʜÀÊ`iVÀi>ÃiÊ Voriconazole levels UÊÊ Ý«iÀˆi˜Vˆ˜}Ê>`ÛiÀÃiÊiÛi˜ÌÃÊ`ÕiÊ̜Ê6œÀˆVœ˜>✏i UÊÊ Ý«iÀˆi˜Vˆ˜}ÊÊ`ÞÃv՘V̈œ˜ UÊÊ6œÀˆVœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊŜՏ`ÊLiʜLÌ>ˆ˜i`ÊxqÇÊ`>ÞÃÊ>vÌiÀÊÃÌ>ÀÌʜvÊ Ì…iÀ>«ÞÊ­«iÀvœÀ“i`Êq®° UÊÊœ>ÊÌÀœÕ}…\ÊÓqx°xʓV}ɓ°ÊiÛiÃʐʣʓV}ɓʅ>ÛiÊLii˜Ê associated with clinical failures and levels >5.5 mcg/mL with toxicity. Drug Interactions: See Table on p. 21 Toxicity UÊÊ6ˆÃÕ>Ê`ˆÃÌÕÀL>˜ViÃÊ­HÎ䯮ÊÕÃÕ>ÞÊÃiv‡ˆ“ˆÌi`]ÊÀ>Å]ÊviÛiÀ]ÊiiÛ>̈œ˜ÃÊ in hepatic enzymes. UÊÊœ˜ˆÌœÀˆ˜}\Ê
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Azole drug interactions The following list contains major drug interactions involving drug metabolism and absorption. This list is not comprehensive and is intended as a guide only. You must check for other drug interactions when initiating azole therapy or starting new medication in patients already receiving azole therapy. Drug metabolism:

Þ̜V…Àœ“iÊ­ 9*®Ê*{xäʈ˜…ˆLˆÌœÀÃ\Ê`iVÀi>ÃiÊ̅iʓiÌ>LœˆÃ“ÊœvÊViÀÌ>ˆ˜Ê drugs (CYP450 substrates) resulting in increased drug concentrations in the body (occurs immediately)

Þ̜V…Àœ“iÊ­ 9*®Ê*{xäʈ˜`ÕViÀÃ\ʈ˜VÀi>ÃiÊ̅iʓiÌ>LœˆÃ“ÊœvÊViÀÌ>ˆ˜Ê drugs (CYP450 substrates) resulting in decreased drug concentrations in the body (may take up to 2 weeks for upregulation of enzymes to occur) Drug absorption/penetration: *‡}ÞVœ«ÀœÌiˆ˜Ê­*‡}«®Êˆ˜…ˆLˆÌœÀ\Ê`iVÀi>ÃiÊ̅iÊv՘V̈œ˜ÊœvÊ̅iÊivyÕÝʫՓ«]Ê resulting in increased absorption/penetration of P-gp substrates *‡}ÞVœ«ÀœÌiˆ˜Êˆ˜`ÕViÀ\ʈ˜VÀi>ÃiÊ̅iÊv՘V̈œ˜ÊœvÊ̅iÊivyÕÝʫՓ«]Ê resulting in decreased absorption/penetration of P-gp substrates PotencyʜvÊ Þ̜V…Àœ“iÊ*{xäʈ˜…ˆLˆÌˆœ˜\Ê6œÀˆVœ˜>✏iʀÊÌÀ>Vœ˜>✏iÊ€Ê Posaconazole > Fluconazole 20

Do not use

Recommendations

↓ cyclosporine dose to 3⁄4 and monitor levels May ↓ posaconazole concentrations when using suspension Consider dose reducing ↓ tacrolimus dose to 1⁄3 and monitor levels Avoid concomitant use unless benefit outweighs risk If used together, monitor effects of drugs and consider decreasing dose when posaconazole is added Amiodarone, atazanavir, digoxin, erythromycin, all calcium channel blockers, Monitor effect of drugs and consider decreasing dose when ritonavir, statins (avoid lovastatin and simvastatin), vinca alkaloids posaconazole is added

Drug

œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ sirolimus iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cisapride, ergot alkaloids, pimozide, quinidine, triazolam Cyclosporine Metoclopramide, proton pump inhibitors Midazolam Tacrolimus Cimetidine, efavirenz, phenytoin, rifabutin, rifampin

Warning/precaution

Drug

œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ statins (lovastatin, simvastatin) iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cisapride, dofetilide, ergot alkaloids, nisoldipine, oral midazolam, pimozide, quinidine, triazolam

œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ atorvastatin, benzodiazepines, chemotherapy (busulfan, docetaxel, vinca alkaloids), cyclosporine, digoxin, efavirenz, eletriptan, fentanyl, oral hypoglycemics, indinavir, IV midazolam, nifedipine, ritonavir, saquinavir, sirolimus, tacrolimus, verapamil, steroids (budesonide, dexamethasone, fluticasone, methylprednisolone), warfarin iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ alfentanil, buspirone, cilostazol, disopyramide, felodipine, trimetrexate

œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ carbamazepine, efavirenz, isoniazid, nevirapine, phenobarbital, phenytoin, rifabutin, rifampin, antacids, H2 receptor antagonists, proton pump inhibitors Clarithromycin, erythromycin, fosamprenavir, indinavir, ritonavir, saquinavir

Do not use

Recommendations

↓ plasma concentration of itraconazole, if possible avoid concomitant use or monitor itraconazole levels

plasma concentration of the interacting drug, monitor levels when possible, monitor for drug toxicity and consider dose reduction

3.2 Agent-specific guidelines: Antifungals

plasma concentration of itraconazole, monitor itraconazole levels and monitor for toxicity

↓

Contraindicated

ITRACONAZOLE and major metabolite hydroxyitraconazole (substrate and inhibitor of CYP3A4 and P-gp efflux)

Warning/precaution

Contraindicated

POSACONAZOLE (substrate and inhibitor for P-gp efflux, inhibitor of CYP3A4)

↓

21

Do not use

Recommendations

3.2 Agent-specific guidelines: Antifungals

↓ cyclosporine dose to 1⁄2 and monitor levels voriconazole dose to 5 mg/kg IV/PO Q12H and ↓ efavirenz to 300 mg PO daily Tacrolimus ↓ tacrolimus dose to 1⁄3 and monitor levels Sirolimus ↓ÊÈÀœˆ“ÕÃÊ`œÃiÊLÞÊÇx¯Ê>˜`ʓœ˜ˆÌœÀʏiÛiÃ Omeprazole ↓ omeprazole dose to 1⁄2 Maraviroc ↓ maraviroc dose to 150 mg twice daily Methadone Monitor effect of the interacting drug and consider decreasing dose Phenytoin voriconazole to 5 mg/kg IV/PO Q12H and monitor levels Ritonavir low dose (100 mg Q12H) Avoid this combination unless benefits outweigh risks Warfarin Monitor INR levels

œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ all benzodiazepines (avoid midazolam and triazolam), Monitor effect of drugs and consider decreasing dose when voriconazole all calcium channel blockers, fentanyl, oxycodone & other long acting opioids, is added NSAIDs, oral contraceptives, statins (avoid lovastatin and simvastatin), sulfonylureas, vinca alkaloids, pomalidomide, simeprevir, boceprevir, telaprevir iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ alfentanil

Drug

œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ carbamazepine, rifabutin, rifampin, ritonavir 400 mg Q12H iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ long-acting barbiturates, cisapride, ergot alkaloids, pimozide, quinidine, St. John’s Wort Cyclosporine Efavirenz

Contraindicated Warning/precaution

Drug

Cisapride

œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cyclosporine, glipizide, glyburide, phenytoin, rifabutin, tacrolimus, warfarin iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ oral midazolam, theophylline, tolbutamide Rifampin

Recommendations

↓ plasma concentration of fluconazole, consider increasing fluconazole dose

Do not use plasma concentration of the interacting drug, monitor levels when possible, monitor for drug toxicity and consider dose reduction ↓

FLUCONAZOLE (substrate of CYP3A4 and inhibitor of CYP3A4, CYP2C9, and CYP2C19, interactions are often dose dependent)

Warning/precaution

Contraindicated

VORICONAZOLE (substrate and inhibitor of CYP2C19, CYP2C9, and CYP3A4)

↓

↓

22

Indications for pneumococcal vaccines for adults ≥ 19 years of age Risk group All adults ≥ 65 years of age CSF leak or cochlear implants Functional or anatomic asplenia

Prevnar 13® Yes Yes Yes

Immunocompetent persons with certain No chronic medical conditions (e.g. heart disease*, lung disease†, liver disease, DM), alcoholism, cigarette smoking ““Õ˜œVœ“«Àœ“ˆÃi`ʅœÃÌ\ÊVœ˜}i˜ˆÌ>É Yes acquired immunodeficiencies, HIV, chronic renal failure, nephrotic syndrome, hematologic malignancies, organ transplant, long-term immunosuppressive therapy (e.g. steroids, active chemotherapy, radiation)

Pneumovax 23® Yes Yes Yes, revaccinate 5 years after first dose Yes

Yes, revaccinate 5 years after first dose

I˜VÕ`ˆ˜}Ê ]ÊV>À`ˆœ“Þœ«>̅ˆiÃ]ÊiÝVÕ`ˆ˜}ʅޫiÀÌi˜Ãˆœ˜ÆÊa˜VÕ`ˆ˜}Ê "* ]Êi“«…ÞÃi“>]Ê asthma

Timing and sequential administration of pneumococcal vaccines UÊ œÊ…ˆÃ̜ÀÞʜÀÊ՘Ž˜œÜ˜Ê…ˆÃ̜ÀÞʜvÊ«˜iՓœVœVV>ÊÛ>VVˆ˜>̈œ˜Ê>˜`ÊLœÌ…Ê vaccines are indicated, patient should receive Prevnar 13® first followed by Pneumovax 23® at a minimum of 8 weeks later (ideally 6-12 months) UÊvÊ«>̈i˜Ìʅ>ÃÊÀiViˆÛi`Ê*˜iՓœÛ>ÝÊÓή and both vaccines are indicated, the patient should receive Prevnar 13® (minimum 1 year separation) UÊvÊ«>̈i˜Ìʅ>ÃÊÀiViˆÛi`Ê*Àiۘ>Àʣή ≥ 8 weeks ago, and both vaccines are indicated, the patient should receive Pneumovax 23® (minimum 8 weeks separation) UÊvÊ«>̈i˜Ìʅ>ÃÊÀiViˆÛi`ÊLœÌ…ÊÛ>VVˆ˜iÃÊ≥ 5 years ago and revaccination is needed with Pneumovax 23®, a second dose should be administered (minimum 5 years apart) UÊ*>̈i˜ÌÃÊ܅œÊ>ÀiÊÃiÛiÀiÞʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê­i°}°Ê /]Ê܏ˆ`ʜÀ}>˜Ê transplant) should follow institutional policy when available or consult ID for optimal timing of vaccine administration ,iviÀi˜Vi\Ê
*Ê,iVœ““i˜`>̈œ˜Ã\Ê7,ÊÓä£{ÆÈέÎÇ®ÆnÓӇnÓxÊ>˜`Ê7,ÊÓä£ÓÆÈ£­{ä®Æn£È‡n£™°Ê

23

3.3 Agent-specific guidelines: Vaccines

Pneumococcal vaccination There are two types of pneumococcal vaccines that are recommended LÞÊ
*Ê}Ո`iˆ˜iÃÊvœÀÊ>`ՏÌÊ«>̈i˜ÌÃ\Ê*˜iՓœVœVV>Ê«œÞÃ>VV…>Àˆ`iÊ (Pneumovax 23®, PPV23) and Pneumococcal conjugate vaccine (Prevnar 13®, PCV13). Most patients should receive both vaccines in sequential order, but NEVER together. See table below for indications for each vaccine.

4.1 Organism-specific guidelines: Anaerobes

Organism-specific guidelines Anaerobes Although anaerobic bacteria dominate the human intestinal microbiome only a few species seem to play an important role in human infections. Infections caused by anaerobes are often polymicrobial. UÊÊÀ>“‡˜i}>̈ÛiÊL>VˆˆÊ‡ÊBacteroides spp., Prevotella spp., Porphyromonas spp., Fusobacterium spp. UÊÊÀ>“‡˜i}>̈ÛiÊVœVVˆÊ‡ÊVeillonella spp. UÊÊÀ>“‡«œÃˆÌˆÛiÊL>VˆˆÊ‡ÊPropionibacterium spp., Lactobacillus spp., Actinomyces spp., Clostridium spp. UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊ‡ÊPeptostreptococcus spp. and related genera Clinical diagnosis of anaerobic infections should be suspected in the presence of foul smelling discharge, infection in proximity to a mucosal surface, gas in tissues or negative aerobic cultures. Proper specimen VœiV̈œ˜ÊˆÃÊVÀˆÌˆV>ÆÊÀiviÀÊ̜ÊëiVˆ“i˜ÊVœiV̈œ˜Ê}Ո`iˆ˜iÃÊ>ÌʅÌÌ«\ÉÉ www.hopkinsmedicine.org/microbiology/specimen/index.html Treatment Notes

Metronidazole

Clindamycin

Ertapenem

Cefotetan

Pip/Tazo

Amox/Clav

Penicillin

# Patients

Hidden Content - JHH Internal use only

. UÊÊ-ÕÀ}ˆV>Ê`iLÀˆ`i“i˜ÌʜvÊ>˜>iÀœLˆVʈ˜viV̈œ˜ÃʈÃʈ“«œÀÌ>˜ÌÊLiV>ÕÃiÊ anaerobic organisms can cause severe tissue damage. UÊÊ
“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê>˜`Ê ˆ˜`>“ÞVˆ˜Ê>ÀiÊVœ˜Ãˆ`iÀi`Ê̜ÊLiÊivviV̈ÛiÊ empiric therapy against Gram-positive anaerobes seen in infections 24

Propionibacterium acnes Indications for consideration of testing for P. acnes: UÊ -ÊÅ՘Ìʈ˜viV̈œ˜Ã UÊ*ÀœÃ̅ïVÊŜՏ`iÀʍœˆ˜Ìʈ˜viV̈œ˜ÃÊ UÊ"̅iÀʈ“«>˜Ì>LiÊ`iۈViʈ˜viV̈œ˜Ã Diagnosis UÊÊ ÕÌÕÀiÃÊŜՏ`ÊLiʅi`ÊvœÀʣ䇣{Ê`>ÞÃʈvʅˆ}…ÊÃÕëˆVˆœ˜ÊvœÀÊP. acnes as growth is slow UÊÊ œiV̈œ˜ÊœvÊ̈ÃÃÕiÊ>˜`ÊyՈ`ÊëiVˆ“i˜ÃÊvœÀÊVՏÌÕÀiʈÃÊ«ÀiviÀÀi`°Ê œÊ˜œÌÊ send swabs for culture UÊÊՏ̈«iÊÀi«ÀiÃi˜Ì>̈ÛiÊëiVˆ“i˜ÃÊ­«ÀiviÀ>LÞÊήÊŜՏ`ÊLiÊÃi˜ÌÊ for shoulder joint infections to assist in distinguishing contaminants from pathogenic isolates — these could include synovial fluid, any inflammatory tissue, and synovium U Tissue specimens should also be sent for histopathology

25

4.1 Organism-specific guidelines: Anaerobes

above the diaphragm. Metronidazole is not active against microaerophilic streptococci (e.g. S. anginosus group) and should not be used for these infections. UÊÊ6>˜Vœ“ÞVˆ˜ÊˆÃÊ>ÃœÊ>V̈ÛiÊ>}>ˆ˜ÃÌʓ>˜ÞÊÀ>“‡«œÃˆÌˆÛiÊ>˜>iÀœLiÃÊ­i°}°Ê Clostridium spp., Peptostreptococcus spp., P. acnes). UÊÊ “«ˆÀˆVÊ`œÕLiÊVœÛiÀ>}iÊ܈̅ÊiÌÀœ˜ˆ`>✏iÊ
ÊV>ÀL>«i˜i“ÃÊ (Meropenem, Ertapenem) or beta-lactam/beta-lactamase inhibitors (Ampicillin/Sulbactam, Piperacillin/Tazobactam, Amoxicillin/Clavulanic acid) is NOT recommended given the excellent anaerobic activity of these agents. UÊÊB. fragilis group resistance to Clindamycin, Cefotetan, Cefoxitin, and Moxifloxacin has increased and these agents should not be used empirically for treatment of severe infections where B. fragilis is suspected (e.g. intra-abdominal infections). UÊÊœÃÌÊÀiÈÃÌ>˜Viʈ˜Ê̅iÊB. fragilis group is caused by beta-lactamase production, which is screened for by the JHH micro lab. UÊÊBacteroides thetaiotaomicron is less likely to be susceptible to *ˆ«iÀ>Vˆˆ˜É/>âœL>VÌ>“ÆÊ̅iÀivœÀi]Ê܅i˜Ê̅ˆÃʜÀ}>˜ˆÃ“ʈÃʈ܏>Ìi`Ê or strongly suspected (e.g. Gram negative rods in anaerobic blood cultures in a patient on Piperacillin/tazobactam) alternative agents with anaerobic coverage should be used until susceptibilities are confirmed. UÊÊ/ˆ}iVÞVˆ˜iʈÃÊ>V̈ÛiÊ>}>ˆ˜ÃÌÊ>Ê܈`iÊëiVÌÀՓʜvÊ}À>“‡«œÃˆÌˆÛiÊ>˜`Ê gram-negative anaerobic bacteria in vitro but clinical experience with this agent is limited.

4.2 Organism-specific guidelines: P. acnes

Treatment UÊÊ*i˜ˆVˆˆ˜ÊÊӇÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê­«ÀiviÀÀi`® OR UÊ* Ê>iÀ}ÞÊ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä® NOTES UÊÊ ÊVœ˜ÃՏÌÊÀiVœ““i˜`i`ÊvœÀÊ>ÃÈÃÌ>˜ViÊ܈̅ÊV…œˆViÊ>˜`Ê duration of antibiotic therapy UÊÊP. acnes is usually a contaminant in blood culture specimens. Draw repeat cultures and consider clinical context before treatment UÊÊ,>ÀiÊÀi«œÀÌÃʜvÊ눘>Êˆ˜viV̈œ˜Ãʅ>ÛiÊLii˜Ê˜œÌi`ÊvœÀÊP. acnes UÊÊ
ÊP. acnes isolutes at JHH are susceptible to Penicillin (see anaerobic antibiogram p. 24) UÊÊiÌÀœ˜ˆ`>✏iÊ`œiÃʘœÌʅ>ÛiÊ>V̈ۈÌÞÊ>}>ˆ˜ÃÌÊP. acnes. Tetracyclines are not routinely tested and resistance rates are variable. UÊÊ Àœ>`iÀÊëiVÌÀՓÊ>}i˜ÌÃÊÃÕV…Ê>ÃÊiÀœ«i˜i“Ê>˜`Ê*ˆ«iÀ>Vˆˆ˜É tazobactam would be expected to be active for Penicillin susceptible isolates, but these are not first-line therapy UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊ`>Ì>ÊŜՏ`ÊLiÊÕÃi`Ê̜ʅi«Ê}Ո`iÊ̅iÀ>«iṎVÊ`iVˆÃˆœ˜Ã U Consider removal of associated hardware

26

Viridans group Streptococci (alpha-hemolytic streptococci) œÀ“>Ê“ˆVÀœLˆœÌ>ʜvÊ̅iʜÀ>ÊV>ۈÌÞÊ>˜`ÊÊÌÀ>VÌÆÊȘ}iÊLœœ`ÊVՏÌÕÀiÃÊ growing these organisms often represent contamination or transient bacteremia Five groups UÊÊS. anginosus group (contains S. intermedius, anginosus, and constellatus®\ÊÊVœ““œ˜ÞÊV>ÕÃiÊ>LÃViÃÃiÃÆʓ>œÀˆÌÞÊ>ÀiÊ*i˜ˆVˆˆ˜Ê susceptible UÊÊS. bovisÊ}ÀœÕ«ÊQVœ˜Ì>ˆ˜ÃÊS. gallolyticus subspecies gallolyticus (associated with colon cancer—colonoscopy mandatory, endocarditis >ÃœÊ«ÀiÃi˜Ìʈ˜Ê€Êxä¯ÊœvÊV>ÃiîÊ>˜`ÊÃÕLëiVˆiÃÊpasteurinus ­>ÃÜVˆ>Ìi`Ê܈̅ʅi«>̜Lˆˆ>ÀÞÊ`ˆÃi>Ãi]Êi˜`œV>À`ˆÌˆÃʏiÃÃÊVœ““œ˜®RÆÊ majority are Penicillin susceptible UÊS. mitis group (contains S. mitis, oralis, gordonii, and sanguinous®\Ê Vœ““œ˜ÞÊV>ÕÃiÊL>VÌiÀi“ˆ>ʈ˜Ê˜iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ>˜`Êi˜`œV>À`ˆÌˆÃÆÊ many have Penicillin resistance UÊÊS. salivariusÊ}ÀœÕ«\ʏiÃÃÊVœ““œ˜ÊV>ÕÃiʜvÊi˜`œV>À`ˆÌˆÃÆʓ>œÀˆÌÞÊ>ÀiÊ Penicillin susceptible UÊÊS. mutansÊ}ÀœÕ«\ÊVœ““œ˜ÊV>ÕÃiʜvÊ`i˜Ì>ÊV>ÀˆiÃÆÊ՘Vœ““œ˜ÊV>ÕÃiÊ œvÊi˜`œV>À`ˆÌˆÃÆʓ>œÀˆÌÞÊ>ÀiÊ*i˜ˆVˆˆ˜ÊÃÕÃVi«ÌˆLi Beta-hemolytic Streptococci All are susceptible to Penicillin 6>Àˆ>LiÊÀ>ÌiÃʜvÊÀiÈÃÌ>˜ViÊÌœÊ ˆ˜`>“ÞVˆ˜ÆÊ>ÎÊ̅iʓˆVÀœLˆœœ}ÞÊ laboratory to perform susceptibility testing if you plan to use Clindamycin or macrolides for moderate to severe infections. While anti-staphylococcal penicillins (Oxacillin and Nafcillin) are the agents of first choice for susceptible S. aureus infections, their activity against streptococci is sub-optimal ˆ}…ÊÀ>ÌiÃʜvÊÀiÈÃÌ>˜ViÊ̜ÊÌiÌÀ>VÞVˆ˜iÃÊ>˜`Ê/*É-8Ê«ÀiVÕ`iÊ̅iˆÀÊ empiric use for infections suspected to be caused by beta-hemolytic streptococci UÊÊS. pyogenesÊ­}ÀœÕ«Ê
ÊÃÌÀi«®\Ê«…>Àޘ}ˆÌˆÃ]ÊΈ˜Ê>˜`ÊÜvÌÊ̈ÃÃÕiÊ ˆ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ÊiÀÞÈ«i>Ã]ÊViÕˆÌˆÃ]ʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃÆÊ

ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜Ê£°x‡x°Ó¯Æʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜Ê{‡Ç¯°Ê UÊÊS. agalactiaeÊ­}ÀœÕ«Ê ÊÃÌÀi«®\ʘiœ˜>Ì>Êˆ˜viV̈œ˜Ã]ʈ˜viV̈œ˜ÃʜvÊ̅iÊ vi“>iÊ}i˜ˆÌ>ÊÌÀ>VÌ]ÊΈ˜Ê>˜`ÊÜvÌÊ̈ÃÃÕiʈ˜viV̈œ˜Ã]ÊL>VÌiÀi“ˆ>ÆÊ

ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜Ê£È‡ÓȯÆʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜ÊLJÎÓ¯°Ê

27

4.3 Organism-specific guidelines: Streptococci

Streptococci

4.3 Organism specific guidelines: Multi-drug resistant Gram-negative rods

UÊÊÀœÕ«Ê Ê>˜`ÊÊÃÌÀi«ÌœVœVVˆ\ʈ˜viV̈œ˜ÃÊȓˆ>ÀÊ̜ÊS. pyogenes and S. agalactiaeÆÊ>ÃÜVˆ>Ìi`Ê܈̅Ê՘`iÀÞˆ˜}Ê`ˆÃi>ÃiÃÊ­i°}°Ê`ˆ>LiÌiÃ]Ê “>ˆ}˜>˜VÞ]ÊV>À`ˆœÛ>ÃVՏ>ÀÊ`ˆÃi>Ãi®ÆÊ ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜ÊH£È¯Ê œvÊ}ÀœÕ«Ê Ê>˜`ÊHÎίʜvÊ}ÀœÕ«Êʈ܏>ÌiÃÆʓ>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜Ê HÓx¯ÊœvÊ}ÀœÕ«Ê Ê>˜`ÊHÓn¯ÊœvÊ}ÀœÕ«Êʈ܏>ÌiÃ°Ê Streptococcus pneumoniae UÊÊ œ““œ˜ÊV>ÕÃiʜvÊÀiëˆÀ>̜ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ʜ̈̈Ãʓi`ˆ>]Ê Ãˆ˜ÕÈ̈Ã]Ê«˜iՓœ˜ˆ>Êۈ>ʏœV>ÊëÀi>`ÊvÀœ“Ê̅iʘ>Ü«…>ÀޘÝÆʈ˜viV̈œ˜ÃÊ involving the CNS, bones/joints and endocarditis via hematogenous spread UÊÊi˜ïV>Þ]ÊS. pneumoniae is in the S. mitis group of viridans group ÃÌÀi«ÌœVœVVˆÆÊVœ˜ÃiµÕi˜ÌÞ]ÊÀ>«ˆ`ʓœiVՏ>ÀÊÌiÃÌÃʓ>ÞʘœÌÊLiÊ>LiÊÌœÊ distinguish S. pneumoniae and streptococci in the S. mitis group. UÊÊ*i˜ˆVˆˆ˜ÊˆÃÊ̅iÊ>}i˜ÌʜvÊwÀÃÌÊV…œˆViÊvœÀÊÃiÀˆœÕÃÊS. pneumoniae infections when it is susceptible UÊÊ*i˜ˆVˆˆ˜Ê>˜`Ê ivÌÀˆ>ݜ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊLÀi>Ž«œˆ˜ÌÃÊ>ÀiÊ`ˆvviÀi˜ÌÊvœÀÊ CNS and non-CNS sites MIC breakpoints for Penicillin and Ceftriaxone against S. pneumoniae Antibiotic Penicillin (oral) Penicillin (parenteral) Non-CNS CNS Ceftriaxone Non-CNS CNS

Susceptible ≤ 0.06

Intermediate 0.12-1

Resistant ≥2

≤2 ≤ 0.06

4

≥8 ≥ 0.12

≤1 ≤ 0.5

2 1

≥4 ≥2

UÊÊ
``ˆÌˆœ˜ÊœvÊ6>˜Vœ“ÞVˆ˜ÊÌœÊ ivÌÀˆ>ݜ˜iʈÃʘœÌʈ˜`ˆV>Ìi`ʈ˜Ê̅iÊi“«ˆÀˆVÊ treatment of non-CNS infections caused by S. pneumoniae due to low rates of resistance

Multi-drug resistant Gram-negative rods Patients with infection or colonization with the resistant organisms listed below should be placed on CONTACT precautions (see isolation chart on p. 141) Extended spectrum beta-lactamase (ESBL)-producing organisms UÊÊ - ÃÊ>ÀiÊi˜âޓiÃÊ̅>ÌÊVœ˜viÀÊÀiÈÃÌ>˜ViÊ̜Ê>Ê«i˜ˆVˆˆ˜Ã]Ê cephalosporins, and Aztreonam. UÊÊ/…iÞÊ>ÀiʓœÃÌÊVœ““œ˜ÞÊÃii˜Êˆ˜ÊK. pneumoniae and K. oxytoca, E. coli, and P. mirabilis, and these organisms are automatically screened by the JHH microbiology lab for the presence of ESBLs. 28

/Ài>̓i˜Ì\ UÊÊiÀœ«i˜i“Ê£Ê}Ê6Ê+nÊ­ÓÊ}Ê6Ê+nÊvœÀÊ -ʈ˜viV̈œ˜Ã®ÊŜՏ`ÊLiÊ used for ALL severe infections if the organism is susceptible. UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ÊV>˜ÊLiÊÕÃi`ÊvœÀÊ՘Vœ“«ˆV>Ìi`Ê1/ʜÀÊÜvÌÊ̈ÃÃÕiÊ infection with adequate source control if the organism is susceptible. UÊÊ ˆ«ÀœyœÝ>Vˆ˜ÊœÀÊ/*É-8ÊV>˜ÊLiÊÕÃi`Ê>ÃÊ>ÌiÀ˜>̈ÛiÃÊÌœÊ ÀÌ>«i˜i“Ê for uncomplicated UTI or soft tissue infection with adequate source control if the organism is susceptible. Nitrofurantoin may also be used for uncomplicated UTI if the organism is susceptible. Carbapenemase-producing Enterobacteriacae (CRE) UÊ >ÀL>«i˜i“>ÃiÃÊ>ÀiÊi˜âޓiÃÊ̅>ÌÊVœ˜viÀÊÀiÈÃÌ>˜ViÊ̜Ê>Ê«i˜ˆVˆˆ˜Ã]Ê cephalosporins, carbapenems and Aztreonam. UÊʓˆVÀœLˆœœ}Þʏ>LʈÃʘœÊœ˜}iÀÊ«iÀvœÀ“ˆ˜}Ê̅iʓœ`ˆwi`Êœ`}iÊÌiÃÌ UÊvÊV>ÀL>«i˜i“ʈÃÊÀiÈÃÌ>˜ÌÊʓˆVÀœLˆœœ}Þʏ>LÊ܈ÊÀi«œÀÌʜÀ}>˜ˆÃ“Ê >ÃʺV>ÀL>«i˜i“ÊÀiÈÃÌ>˜Ì»ÆʅœÜiÛiÀ]Ê̅iÊiÝ>VÌʓiV…>˜ˆÃ“ÊœvÊ resistance is not tested for at this time. /Ài>̓i˜Ì\Ê UÊiÀœ«i˜i“ÊÓÊ}Ê6Ê+nʈ˜vÕÃi`ʜÛiÀÊÎʅœÕÀÃÊŜՏ`ÊLiʈ˜VÕ`i`Ê in most regimens based on data from small, retrospective studies showing benefit even when the isolate is intermediate or resistant. UÊ
Ìʏi>ÃÌʜ˜iÊ>``ˆÌˆœ˜>Ê>}i˜ÌÊŜՏ`ÊLiÊ>``i`ÊL>Ãi`ʜ˜ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ (e.g. Amikacin, Tigecycline, Colistin) except for UTI. Multi-drug resistant (MDR) gram-negative organisms: defined as organisms susceptible to NO MORE than ONE of the following antibiotic V>ÃÃiÃ\ÊV>ÀL>«i˜i“Ã]Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]Êy՜ÀœµÕˆ˜œœ˜iÃ]Ê«i˜ˆVˆˆ˜Ã]Ê or cephalosporins. Note: susceptibility to sulfonamides, tetracyclines, polymixins, and Sulbactam are NOT considered in this definition Treatment MDR Pseudomonas aeruginosa

MDR Acinetobacter baumannii/calcoaceticus complex

UÊÊ iv̜œâ>˜iÉÌ>âœL>VÌ>“ÊÊ (if susceptible) ORÊ UÊÊ
˜Ìˆ‡«ÃiÕ`œ“œ˜>Ê-lactam PLUS ÊÊÊ>“ˆ˜œ}ÞVœÃˆ`iʈvÊÃޘiÀ}ÞÊ«Ài`ˆVÌi`ÊÊ or confirmed OR UÊÊ œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê Ê

UÊ-lactam PLUS aminoglycoside if synergy expected OR UÊÊ œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê OR UÊÊ
“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê­ˆvÊÃÕÃVi«ÌˆLi®ÊPLUS aminoglycoside (Sulbactam component has in vitro activity against Acinetobacter spp.) ÊÊÊOR UÊÊ/ˆ}iVÞVˆ˜iÊ­ˆvÊÃÕÃVi«ÌˆLiÆÊvœÀʈ˜viV̈œ˜Ãʜ̅iÀÊ̅>˜Ê bacteremia)

*Combination therapy should be considered in severe infections.

29

4.4 Organism specific guidelines: Multi-drug resistant Gram-negative rods

UÊÊ,ˆÃŽÊv>V̜ÀÃÊvœÀʈ˜viV̈œ˜ÊœÀÊVœœ˜ˆâ>̈œ˜\ÊÀiVi˜ÌʅœÃ«ˆÌ>ˆâ>̈œ˜Ê>ÌÊ>˜Ê institution with a high rate of ESBLs, residence in a long-term care facility and prolonged use of broad spectrum antibiotics.

4.4 Organism specific guidelines: Multi-drug resistant Gram-negative rods

Synergy: UÊvÊ̅iʜÀ}>˜ˆÃ“ʈÃʈ˜ÌiÀ“i`ˆ>ÌiÊ̜Ê>ÊLiÌ>‡>VÌ>“Ê>˜`ÊÃÕÃVi«ÌˆLiÊÌœÊ aminoglycosides, synergy can be assumed. UÊ/…iʓˆVÀœLˆœœ}Þʏ>LÊ`œiÃʘœÌÊ«iÀvœÀ“ÊÃޘiÀ}ÞÊÌiÃ̈˜}°Ê Antibiotic doses for MDR and carbapenemase-producing infections – normal renal and hepatic function UÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n]ʈ˜vÕÃiʜÛiÀÊÎʅœÕÀÃÊ UÊ ivi«ˆ“i\ÊÓÊ}Ê6Ê+n]ʈ˜vÕÃiʜÛiÀÊÎʅœÕÀà UÊ ivÌ>âˆ`ˆ“iÉ ivi«ˆ“i\ÊÓÊ}Ê6ÊLœÕÃʏœ>`ˆ˜}Ê`œÃiʜÛiÀÊÎäʓˆ˜ÕÌiÃ]Ê then 6 g IV as continuous infusion over 24 hours UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“\ÊΰÎÇxÊ}Ê6ÊLœÕÃʏœ>`ˆ˜}Ê`œÃiʜÛiÀÊÎäÊ minutes, then continuous infusion 3.375 g IV Q4H infused over 4 hours OR 4.5 g IV Q6H, infuse over 4 hours UÊ œˆÃ̈˜\Êxʓ}Ɏ}ʜ˜Vi]Ê̅i˜ÊÓ°xʓ}Ɏ}Ê6Ê+£ÓÊ­vœÀÊ>``ˆÌˆœ˜>Ê information, see p. 9) UÊ
“«ˆVˆˆ˜ÉÃՏL>VÌ>“\ÊÎÊ}Ê6Ê+{Ê­vœÀÊ ,ÊA. baumannii only) UÊ
“ˆ˜œ}ÞVœÃˆ`iÃÊ­vœÀÊ`œÃˆ˜}]ÊÃiiÊ«°Ê£{È® UÊ/ˆ}iVÞVˆ˜i\Ê£ä䇣xäʓ}Ê6Ê+£ÓÊ UÊ iv̜œâ>˜iÉÌ>âœL>VÌ>“Ê£°x‡ÎÊ}Ê6Ê+n ,iviÀi˜ViÃ\Ê

- ÃÊ>˜`ÊVˆ˜ˆV>ÊœÕÌVœ“iÃ°Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£x\ÊÈ䭙®\ʣΣ™\Óx° Current therapies for P. aeruginosa°Ê ÀˆÌÊ >ÀiÊ ˆ˜ÊÓäänÆÓ{\ÓÈ£°Ê

œ“Lˆ˜>̈œ˜Ê̅iÀ>«ÞÊvœÀÊ , °Ê ˆ˜ÊˆVÀœLˆœÊ˜viVÊÓä£{ÆÓä\ÊnÈӇÇÓ°

30

Gram-positive cocci

Gram-negative cocci

Aerobic In clusters UÊ œ>}Տ>ÃiÊ­³®\ÊS. aureus UÊÊ œ>}Տ>ÃiÊ­q®\ÊS. epidermidis, S. lugdunensis In pairs/chains UÊÊ ˆ«œVœVVÕÃ]Ê+ÕiÕ˜}Ê«œÃˆÌˆÛi\Ê S. pneumoniae UÊÊ
«…>‡…i“œÞ̈V\Ê6ˆÀˆ`>˜ÃÊ}ÀœÕ«ÊÊ Streptococci, Enterococcus (faecalis and faecium) UÊÊ iÌ>‡…i“œÞ̈V\Ê Group A strep (S. pyogenes), Group B strep (S. agalactiae), Group C, D, G strep

Aerobic ˆ«œVœVVÕÃ\ÊN. meningiditis, N. gonorrhoeae, Moraxella catarrhalis

œVVœ‡L>VˆÕÃ\ H. flu, Acinetobacter spp., HACEK organisms

Anaerobic: Peptostreptococcus spp.

Anaerobic: Veillonella spp.

Gram-positive rods

Gram-negative rods

Aerobic >À}i\ Bacillus spp.

œVVœ‡L>VˆÕÃ\ÊListeria monocytogenes, Lactobacillus spp. -“>]Ê«iœ“œÀ«…ˆV\ Corynebacterium spp. À>˜V…ˆ˜}Êw>“i˜ÌÃ\ Nocardia spp., Streptomyces spp.

Aerobic Lactose fermenting: Citrobacter spp., Enterobacter spp., E. coli, Klebsiella spp., Serratia spp.* Non-lactose fermenting UÊÊ"݈`>ÃiÊ­q®: Acinetobacter spp., Burkholderia spp., E. coli (rare), Proteus spp., Salmonella spp., Shigella spp., Serratia spp.*, Stenotrophomonas maltophilia UÊÊ"݈`>ÃiÊ ­³®\Ê P. aeruginosa, Aeromonas spp., Vibrio spp., Campylobacter spp. (curved)

Anaerobic >À}i\ÊClostridium spp. Small, pleomorphic: P. acnes, Actinomyces spp.

Anaerobic: Bacteroides spp., Fusobacterium spp., Prevotella spp.

* Serratia spp. can appear initially as non-lactose fermenting due to slow fermentation.

The Johns Hopkins microbiology laboratory utilizes standard reference methods for determining susceptibility. The majority of isolates are tested by the automated system. The minimum inhibitory concentration (MIC) value represents the concentration of the antimicrobial agent required at the site of infection for inhibition of the organism. The MIC of each antibiotic tested against the organism is reported with one of three interpretations S (susceptible), I (intermediate), or R (resistant). The highest MIC which is still considered susceptible represents the breakpoint concentration. This is the highest MIC which is usually associated with clinical efficacy. MICs which are 1⁄ 2 q 1⁄ 8 the 31

5.1 Interpreting the microbiology report

Interpreting the microbiology report Interpretation of preliminary microbiology data

5.1 Interpreting the microbiology report

breakpoint MIC are more frequently utilized to treat infections where antibiotic penetration is variable or poor (endocarditis, meningitis, osteomyelitis, pneumonia, etc.). Similarly, organisms yielding antibiotic MICs at the breakpoint frequently possess or have acquired a low-level resistance determinant with the potential for selection of high-level expression and resistance. This is most notable with cephalosporins and Enterobacter spp., Serratia spp., Morganella spp., Providencia spp., Citrobacter spp. and Pseudomonas aeruginosa. These organisms all possess a chromosomal beta-lactamase which frequently will be over-expressed during therapy despite initial in vitro susceptibility. The intermediate (I) category includes isolates with MICs that approach attainable blood and tissue levels, but response rates may be lower than fully susceptible isolates. Clinical efficacy can potentially be expected in body sites where the drug is concentrated (e.g., aminoglycosides and beta-lactams in urine) or when a higher dose of the drug can be used (e.g., beta-lactams). The resistant (R) category indicates the organism will not be inhibited by usually achievable systemic concentrations of the antibiotic of normal doses. NOTE: MIC values vary from one drug to another and from one bacterium to another, and thus MIC values are NOT comparable between antibiotics or between organisms.

Spectrum of antibiotic activity The spectrum of activity table is an approximate guide of the activity of commonly used antibiotics against frequently isolated bacteria. It takes into consideration JHH specific resistance rates, in vitro susceptibilities and expert opinion on clinically appropriate use of agents. For antibiotic recommendations for specific infections refer to relevant sections of the JHH Antibiotic Guidelines.

32

Penicillin G Ampicillin Ampicillin/sulbactam Oxacillin/Nafcillin Piperacillin/tazobactam Cefazolin Cefotetan Ceftriaxone Cefepime Aztreonam Ertapenem Meropenem Moxifloxacin Ciprofloxacin Azithromycin Gent/Tobra/Amikacin Vancomycin Linezolid Daptomycin Ê /*É-8 Clindamycin Doxycycline Colistin Metronidazole

E. faecalis

Not active

GRAM-POSITIVE

E. coli

H. influenzae

Viridans strep.

S. pneumoniae Less active or potential resistance

GRAM-NEGATIVE Enterobacter spp.

Abdominal anaerobes

Oral anaerobes

Pseudomonas spp.

Serratia spp.

Proteus spp.

Kebsiella spp.

-hemolytic strep.

Coag. neg. staph

MSSA

MRSA

VRE

33

5.2 Spectrum of antibiotic activity

Active

Atypicals

5.3 Interpretation of rapid diagnostic tests

Interpretation of rapid diagnostic tests The JHH microbiology lab performs rapid nucleic acid microarray testing on blood cultures growing Gram-positive organisms and peptide nucleic acid fluorescence in situ hybridization (PNA-FISH) testing on blood cultures growing yeast. Nucleic acid microarray testing (Verigine®) for Gram-positive cocci in blood cultures UÊÊ iÌiVÌÃÊ>˜`ʈ`i˜ÌˆwiÃÊ̅iʘÕViˆVÊ>Vˆ`ÃʜvÊ£ÓÊÀ>“‡«œÃˆÌˆÛiÊL>VÌiÀˆ>Ê genera/species and 3 resistance markers. UÊÊ >VÌiÀˆ>ÊëiVˆiÃ\ÊS. aureus, Coagulase-negative staphylococci, S. lugdunensis, Staphylococcus spp. E. faecalis, E. faecium, S. pyogenes (group A streptococci), S. agalactiae (group B streptococci), S. pneumoniae, S. anginosus, Streptococcus spp. (e.g.,group C and G streptococci, viridans group streptococci, etc.), Listeria spp. UÊ,iÈÃÌ>˜Viʓ>ÀŽiÀÃ\ʓiV
]ÊÛ>˜
]ÊÛ>˜ Ê UÊÊvÊS. aureus is mecA positive the organism is resistant to Methicillin and is reported as MRSA Ê UÊÊvÊS. aureus is mecA negative the organism is susceptible to Methicillin and is reported as MSSA Ê UÊÊvÊ °Êfaecalis/faecium is vanA/B positive the organism is resistant ̜Ê6>˜Vœ“ÞVˆ˜ÊÊ>˜`ʈÃÊÀi«œÀÌi`Ê>ÃÊ6, ÆʘœÌiÊ̅>ÌÊ>Ê6>˜Vœ“ÞVˆ˜‡ resistant E. faecalis are susceptible to Ampicillin at JHH UÊÊ,iÃՏÌÃʜvÊ̅iÊÌiÃÌÊ>ÀiÊÀi«œÀÌi`Ê܈̅ˆ˜Ê·{ʅœÕÀÃÊ>vÌiÀÊ̅iÊLœœ`Ê cultures turn positive UÊ/iÃ̈˜}ʈÃÊ«iÀvœÀ“i`ʜ˜Þʜ˜Ê̅iÊwÀÃÌÊ«œÃˆÌˆÛiÊLœœ`ÊVՏÌÕÀiÊ UÊÊ/iÃ̈˜}ʈÃÊ "/Ê«iÀvœÀ“i`ʜ˜ÊLœœ`ÊVՏÌÕÀiÃÊ}ÀœÜˆ˜}ʓœÀiÊ̅>˜Êœ˜iÊ Gram positive organism but is performed on blood cultures growing both Gram positive and negative organisms UÊÊvÊ̅iÊÌiÃÌʈÃʘi}>̈ÛiʈÌÊ܈ÊLiÊÀi«œÀÌi`Ê>Ãʘi}>̈ÛiÊvœÀÊ̅iÊvœœÜˆ˜}Ê œÀ}>˜ˆÃ“Ã\Ê-Ì>«…ޏœVœVVÕÃÊë«]ÊStreptococcus spp., E. faecalis, E. faecium, Listeria spp.

34

Preferred empiric therapy Alternative empiric therapy (% susceptible in blood at JHH) if PCN allergic MSSA Ê "Ý>Vˆˆ˜Ê­£ää¯®Ê œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜Ê Ê Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1 MRSAÊ 6>˜Vœ“ÞVˆ˜Ê­£ää¯®Ê >«Ìœ“ÞVˆ˜ Ê -ˆ˜}iÊ«œÃˆÌˆÛiÊVՏÌÕÀiÃÊ>ÀiʜvÌi˜Ê>ÊVœ˜Ì>“ˆ˜>˜ÌÆʘœÊÌÀi>̓i˜ÌÊ Coagulase-negative recommended. See p. 60 of the JHH Antibiotic Guidelines for staphylococci information and indications for treatment. Call the microbiology lab for more information and further work up if infection suspected (5-6510). "Ý>Vˆˆ˜Ê­™È¯®ÊœÀÊ >«Ìœ“ÞVˆ˜Ê S. lugdunensisÊ 6>˜Vœ“ÞVˆ˜Ê­£ä䯮2Ê E. faecalisÊ
“«ˆVˆˆ˜Ê­™n¯®Ê 6>˜Vœ“ÞVˆ˜Ê­™x¯®1 3 E. faecium (VRE)Ê ˆ˜i✏ˆ`Ê­nǯ® Ê >«Ìœ“ÞVˆ˜Ê­™Ç¯® E. faecium (not VRE)Ê6>˜Vœ“ÞVˆ˜Ê­£ä䯮3 Linezolid 4 Streptococcus spp.Ê œ˜‡œ˜Vœœ}ÞÊ«>̈i˜Ì\Ê ivÌÀˆ>ݜ˜i -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1 Ê "˜Vœœ}ÞÊ«>̈i˜Ì\Ê6>˜Vœ“ÞVˆ˜4 S. anginosus Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜i Ê Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1 S. pyogenes Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜ (group A strep) -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1 S. agalactiae Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜ (group B strep) Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1 4 S. pneumoniae Ê

ivÌÀˆ>ݜ˜iÊ­£ä䯮 Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜1 (not meningitis) S. pneumoniae Ê

ivÌÀˆ>ݜ˜iʳÊ6>˜Vœ“ÞVˆ˜ÊÊ -iÛiÀiÊ* Ê>iÀ}Þ\Ê (meningitis)

…œÀ>“«…i˜ˆVœÊ³Ê6>˜Vœ“ÞVˆ˜1 Listeria spp. Ê
“«ˆVˆˆ˜Ê­£ää¯®Ê /Àˆ“i̅œ«Àˆ“ÉÃՏv>“i̅œÝ>✏i 1Consult

allergy for skin testing /desensitization to Oxacillin if found to be susceptible to Ampicillin if found to be susceptible 4Narrow to Penicillin G if found to be susceptible 2Narrow 3Narrow

PNA-FISH for yeast UÊÊvÊ*
‡-ÊŜÜÃÊC. albicans, most non-oncology patients without prior azole exposure can be treated with fluconazole. For more information see p. 117 and 134. UÊÊvÊ*
‡-ÊŜÜÃÊC. glabrata, treat with Micafungin until susceptibilities available. For more information see p. 117 and 134. UÊÊvÊ*
‡-ʘi}>̈ÛiÊvœÀÊC. albicans or C. glabrata, most cases can be treated as unspeciated candidemia, unless cryptococcus is suspected (send serum cryptococcal antigen). For more information see p. 117 and 134.

35

5.3 Interpretation of rapid diagnostic tests

Organism

6.1 Abdominal infections

Biliary tract infections – cholecystitis and cholangitis EMPIRIC TREATMENT Community-acquired infections in patients without previous biliary procedures AND who are not severely ill UÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ OR UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£Ó Hospital-acquired infections OR patients with multiple therapeutic biliary manipulations (e.g. stent placement/exchange, bilio-enteric anastamosis of any severity) OR patients who are severely ill UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê
âÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H  Vancomycin (see dosing section, p. 150) In severely ill patients with cholangitis and complicated cholecystitis, adequate biliary drainage is crucial as antibiotics will not enter bile in the presence of obstruction. Duration UÊÊUncomplicated cholecystitis\ÊÌÀi>Ìʜ˜ÞÊ՘̈ÊœLÃÌÀÕV̈œ˜ÊˆÃÊÀiˆiÛi`°Ê NO post-procedure antibiotics are necessary if the obstruction is successfully relieved. UÊÊ œ“«ˆV>Ìi`ÊV…œiVÞÃ̈̈Ã\Ê{Ê`>ÞÃ]Ê՘iÃÃÊ>`iµÕ>ÌiÊÜÕÀViÊVœ˜ÌÀœÊˆÃÊ not achieved. U Ê ˆˆ>ÀÞÊÃi«ÃˆÃ\Ê{‡ÇÊ`>ÞÃ]Ê՘iÃÃÊ>`iµÕ>ÌiÊÜÕÀViÊVœ˜ÌÀœÊˆÃʘœÌÊ achieved. TREATMENT NOTES Microbiology UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`ÃÊqÊE. coli, Klebsiella spp., Proteus spp., P. aeruginosa (mainly in patients already on broad-spectrum antibiotics or those who have undergone prior procedures) UÊÊ
˜>iÀœLiÃÊqÊBacteroides spp., generally in more serious infections, or ˆ˜Ê«>̈i˜ÌÃÊ܈̅Ê>ʅˆÃ̜ÀÞʜvÊLˆˆ>ÀÞʓ>˜ˆ«Õ>̈œ˜ÃÆÊÀ>Àiʈ˜Ê՘Vœ“«ˆV>Ìi`Ê and community-acquired infections UÊÊEnterococcus spp°ÊqÊÌÀi>̓i˜ÌʘœÌÊ>Ü>ÞÃʈ˜`ˆV>Ìi`ÆÊÕÃiÊVˆ˜ˆV>ÊÕ`}“i˜Ì UÊÊ9i>ÃÌÊqÊÀ>Ài 39

6.1 Abdominal infections

Management UÊʘÊV>ÃiÃʜvÊ՘Vœ“«ˆV>Ìi`Ê>VÕÌiÊV…œiVÞÃ̈̈Ã]Ê>˜ÌˆLˆœÌˆVÃÊŜՏ`ÊLiÊ given until the biliary obstruction is relieved (either by surgery, ERCP, or percutaneous drain). UÊÊ/Ài>̓i˜ÌʜvÊi˜ÌiÀœVœVVˆÊˆÃÊÕÃÕ>ÞʘœÌʘii`i`ʈ˜Ê“ˆ`ɓœ`iÀ>ÌiÊ disease. UÊÊ9i>ÃÌÊ}i˜iÀ>ÞÊŜՏ`ÊLiÊÌÀi>Ìi`ʜ˜ÞʈvÊ̅iÞÊ>ÀiÊÀiVœÛiÀi`ÊvÀœ“Ê biliary cultures, not empirically. ,iviÀi˜ViÃ\ ˆˆ>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ã\Ê ÀÕ}ÃÊ£™™™ÆxÇ­£®\n£‡™£°  -
ÊՈ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£äÆxä\£ÎÎq£È{° -…œÀÌÊVœÕÀÃiÊ̅iÀ>«ÞÊvœÀÊ
\Ê Ê ˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°

Diverticulitis EMPIRIC TREATMENT NOTE: Patients with uncomplicated diverticulitis (defined as CT Vœ˜wÀ“i`ʏiv̇È`i`Ê`ˆÃi>ÃiÊ܈̅œÕÌÊ>LÃViÃÃÆÊvÀiiÊ>ˆÀʜÀÊwÃÌՏ>ʱ fever and elevated inflammatory markers), can be treated conservatively without antibiotics based on a RCT. Mild/moderate infections – can be oral if patient can take PO UÊÊ
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê+£Ó OR UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Metronidazole 500 mg IV/PO Q8H OR UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQ ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£ÓÊ",Ê ˆ«ÀœyœÝ>Vˆ˜Ê xääʓ}Ê*"Ê+£ÓRÊPLUS Metronidazole 500 mg IV/PO Q8H Severe infections UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQ ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£ÓÊ",Ê
âÌÀiœ˜>“Ê £Ê}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV Q8H Duration UÊ{Ê`>ÞÃ]Ê՘iÃÃÊ>`iµÕ>ÌiÊÜÕÀViÊVœ˜ÌÀœÊˆÃʘœÌÊ>V…ˆiÛi`°

40

Microbiology UÊÊ
“œÃÌÊ>Êˆ˜viV̈œ˜ÃÊ>ÀiÊ«œÞ“ˆVÀœLˆ> UÊÊœÃÌÊVœ““œ˜Þʈ܏>Ìi`Ê>iÀœLˆVʜÀ}>˜ˆÃ“ÃÊqÊE. coli, K. pneumoniae, Enterobacter spp., Proteus spp., Enterococcus spp. UÊÊœÃÌÊVœ““œ˜Þʈ܏>Ìi`Ê>˜>iÀœLˆVʜÀ}>˜ˆÃ“ÃÊqÊB. fragilis, Prevotella, Peptostreptococci Other considerations UÊÊ
˜Ìˆ“ˆVÀœLˆ>ÊÌÀi>̓i˜ÌÊvœÀÊ>VÕÌiÊ՘Vœ“«ˆV>Ìi`Ê`ˆÛiÀ̈VՏˆÌˆÃʓ>ÞʘœÌÊ accelerate recovery or prevent complications/recurrence. UÊÊ /ÊÃV>˜ÊˆÃʈ“«œÀÌ>˜Ìʈ˜Ê>ÃÃiÃȘ}ʘii`ÊvœÀÊ`À>ˆ˜>}iʈ˜ÊÃiÛiÀiÊ`ˆÃi>Ãi°ÊÊ ,iviÀi˜Vi\  -
ÊՈ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£äÆxä\£ÎÎq£È{°
˜ÌˆLˆœÌˆVÃʈ˜Ê>VÕÌiÊ՘Vœ“«ˆV>Ìi`Ê`ˆÛiÀ̈VՏˆÌˆÃ°Ê ÀÊÊ-ÕÀ}ÊÓä£Óƙ™\xÎÓqxΙ° -…œÀÌÊVœÕÀÃiÊ̅iÀ>«ÞÊvœÀÊ
\Ê Ê ˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°

Pancreatitis TREATMENT UÊÊ
˜ÌˆLˆœÌˆVÊ«Àœ«…ޏ>݈ÃʈÃÊ "/ʈ˜`ˆV>Ìi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊÃiÛiÀiÊ>VÕÌiÊ pancreatitis (SAP), including those with sterile pancreatic necrosis. UÊ
˜Ìˆ“ˆVÀœLˆ>Ê̅iÀ>«Þʅ>ÃʘœÊivviVÌʜ˜Ê“œÀLˆ`ˆÌÞÊ>˜`ʓœÀÌ>ˆÌÞ]Ê>˜`Ê prophylactic antibiotics have been associated with a change in the spectrum of pancreatic isolates from enteric Gram-negatives to Gram-positive organisms and fungi. UÊʘviVÌi`Ê«>˜VÀi>̈VʘiVÀœÃˆÃʈÃÊ`iw˜i`ÊLÞÊ /ÊÃV>˜Ê܈̅Ê}>Ãʈ˜Ê̅iÊ pancreas and/or percutaneous or surgical specimen with organisms evident on gram stain or culture. Therapy should be directed based on culture results. UÊʘʫ>̈i˜ÌÃÊ«ÀiÃi˜Ìˆ˜}Ê܈̅ÊÃÕëiVÌi`Ê>L`œ“ˆ˜>ÊÃi«ÃˆÃ]ÊVœ˜Ãˆ`iÀÊ i“«ˆÀˆVÊ̅iÀ>«Þ\ UÊÊ*ˆ«iÀ>Vˆˆ˜‡Ì>âœL>VÌ>“Ê{°xÊ}Ê6Ê+È OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£ÓÊPLUS Metronidazole 500 mg IV Q8H

41

6.1 Abdominal infections

TREATMENT NOTES

6.1 Abdominal infections

Pancreatic penetration of selected antibiotics Good (>40%; MIC exceeded for most relevant organisms): fluoroquinolones, carbapenems, Ceftazidime, Cefepime, Metronidazole, Piperacillin-tazobactam Poor (<40%): aminoglycosides, first-generation cephalosporins, Ampicillin Duration For infected pancreatic necrosis, continue antibiotics for 14 days after source control is obtained. Continuation of antibiotics beyond this time places the patient at risk for colonization or infection with resistant organisms and drug toxicity. TREATMENT NOTES UÊʘviV̈œ˜Ê`iÛiœ«Ãʈ˜ÊÎäqxä¯ÊœvÊ«>̈i˜ÌÃÊ܈̅ʘiVÀœÃˆÃÊ`œVՓi˜Ìi`ÊLÞÊ CT scan or at the time of surgery. UÊÊ*i>ŽÊˆ˜Vˆ`i˜Viʜvʈ˜viV̈œ˜ÊœVVÕÀÃʈ˜Ê̅iÊÎÀ`ÊÜiiŽÊœvÊ`ˆÃi>Ãi UÊÊ/…iÀiʈÃʈ˜ÃÕvwVˆi˜ÌÊiۈ`i˜ViÊ̜ÊÀiVœ““i˜`ÊÃiiV̈ÛiÊ}ÕÌÊ decontamination in management of pancreatitis. ,iviÀi˜ViÃ\ >VŽÊœvÊṎˆÌÞʜvÊ«Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃ\Ê
˜˜Ê-ÕÀ}ÊÓääÇÆÓ{x\ÈÇ{° Ո`iˆ˜iÃÊvœÀʓ>˜>}i“i˜ÌʜvÊ-
*\Ê ÀˆÌÊ >ÀiÊi`ÊÓää{ÆÎÓ\ÓxÓ{°

Peritonitis DEFINITIONS Primary peritonitis is spontaneous infection of the peritoneal cavity, ÕÃÕ>ÞÊ>ÃÜVˆ>Ìi`Ê܈̅ʏˆÛiÀÊ`ˆÃi>ÃiÊ>˜`Ê>ÃVˆÌiÃÊQ뜘Ì>˜iœÕÃÊL>VÌiÀˆ>Ê «iÀˆÌœ˜ˆÌˆÃÊ­- *®R°Ê Secondary peritonitis is infection of the peritoneal cavity due to spillage of organisms into the peritoneum, usually associated with GI perforation. Tertiary peritonitis is a recurrent infection of the peritoneal cavity following an episode of secondary peritonitis.

Primary peritonitis/Spontaneous bacterial peritonitis (SBP) EMPIRIC TREATMENT UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+£Ó OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê­V>Ê ʜÀÊ Antimicrobial Stewardship to discuss regimens for patients who have been taking fluoroquinolones for SBP prophylaxis). 42

Duration UÊÊ/Ài>ÌÊvœÀÊ5 days PROPHYLAXIS Cirrhotic patients with gastrointestinal hemorrhage UÊÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê  ÊvœÀÊÇÊ`>ÞÃÊ UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ÊV>˜ÊLiÊÕÃi`ʜ˜ÞʈvÊ«>̈i˜ÌʈÃÊ *"]Ê̅i˜Ê switch to Ciprofloxacin 500 mg PO BID once bleeding is controlled Non-bleeding cirrhotic patients with ascites UÊÊ/*É-8Ê£Ê -Ê*"ʜ˜ViÊ`>ˆÞ OR UÊÊvÊÃՏv>Ê>iÀ}ˆV]Ê ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê`>ˆÞÊ TREATMENT NOTES Microbiology UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`ÃÊ­ ˜ÌiÀœL>VÌiÀˆ>Vi>i]Êië°ÊE. coli and K. pneumoniae), S. pneumoniae, enterococci, and other streptococci. UÊÊ*œÞ“ˆVÀœLˆ>Êˆ˜viV̈œ˜ÊŜՏ`Ê«Àœ“«ÌÊÃÕëˆVˆœ˜ÊœvÊÊ«iÀvœÀ>̈œ˜° Diagnostic criteria UÊÊÓxäÊ* Ê«iÀʓ“ 3 of ascitic fluid. UÊÊ*œÃˆÌˆÛiÊVՏÌÕÀiÊ܈̅ʐÊÓxäÊ* ÊŜՏ`Ê«Àœ“«ÌÊÀi«i>ÌÊÌ>«°ÊvÊ* Ê€Ê 250 OR culture remains positive, patient should be treated. Follow-up UÊÊ œ˜Ãˆ`iÀÊÀi«i>ÌÊ«>À>Vi˜ÌiÈÃÊ>vÌiÀÊ{nʅœÕÀÃʜvÊ̅iÀ>«Þ° UÊÊ œ˜Ãˆ`iÀÊV…>˜}ˆ˜}Ê>˜ÌˆLˆœÌˆVÃʈvÊ>ÃVˆÌiÃÊyՈ`Ê* ʅ>ÃʘœÌÊ`Àœ««i`ÊLÞÊ Óx¯Ê>vÌiÀÊ{nʅœÕÀÃÊ>˜`ɜÀÊ«>̈i˜ÌʈÃʘœÌÊVˆ˜ˆV>ÞÊÀi뜘`ˆ˜}° Notes on prophylaxis against SBP UÊÊ
Ê«>̈i˜ÌÃÊ܈̅ÊVˆÀÀ…œÃˆÃÊ>˜`ÊÕ««iÀÊÊLii`ÊŜՏ`ÊÀiViˆÛiÊ «Àœ«…ޏ>݈ÃÊvœÀÊÇÊ`>ÞÃÊ­xä¯Ê`iÛiœ«Ê- *Ê>vÌiÀÊLii`®° UÊÊ*>̈i˜ÌÃÊ܅œÊ}iÌÊ- *ÊŜՏ`Ê}iÌʏˆviœ˜}Ê«Àœ«…ޏ>݈ÃÊ̜ʫÀiÛi˜ÌÊvÕÌÕÀiÊ i«ˆÃœ`iÃÊ­{äqÇä¯ÊÀˆÃŽÊœvÊÀiVÕÀÀi˜Viʈ˜Ê£ÊÞi>À®° UÊÊ*Àœ«…ޏ>݈ÃÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ÊvœÀÊ̅œÃiÊ܈̅ʏœÜÊ«ÀœÌiˆ˜Ê Vœ˜Vi˜ÌÀ>̈œ˜Ãʈ˜Ê>ÃVˆÌiÃÊ­Ê£äÊ}ɮʜÀʈ““Õ˜œÃÕ««ÀiÃȜ˜Ê܅ˆiÊ patient is in hospital. ,iviÀi˜ViÃ\ ˆ>}˜œÃˆÃ]ÊÌÀi>̓i˜ÌÊ>˜`Ê«Àœ«…ޏ>݈ÃʜvÊ- *\ÊÊi«>̜ÊÓäääÆÎÓ\£{Ó° >˜>}i“i˜ÌʜvÊÛ>ÀˆVi>Ê…i“œÀÀ…>}iʈ˜ÊVˆÀÀ…œÃˆÃ\Êi«>̜œ}ÞÊÓääÇÆ{È\™ÓÓqÎn°

43

6.1 Abdominal infections

UÊÊ*>̈i˜ÌÃÊ܈̅ÊÃiÀՓÊVÀi>̈˜ˆ˜iʀ£Ê“}É`]Ê 1 ʀÎäʓ}É`ʜÀÊ̜Ì>Ê LˆˆÀÕLˆ˜Ê€{ʓ}É`ÊŜՏ`Ê>ÃœÊÀiViˆÛiÊ
LՓˆ˜Ê­Óx¯®Ê£°xÊ}Ɏ}ʜ˜Ê day 1 and 1 g/kg on day 3 (round to the nearest 12.5 g).

6.1 Abdominal infections

Secondary peritonitis/GI perforation EMPIRIC TREATMENT Perforation of esophagus, stomach, small bowel, colon, or appendix Patient mild to moderately ill UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+£ÓÊPLUS Metronidazole 500 mg IV Q8H Patient severely ill or immunosuppressed UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole 500 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Q
âÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊORÊ ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV Q8H Empiric antifungal therapy is generally not indicated for GI perforation unless patient has one of the following risk factors: Esophageal perforation, immunosuppression, prolonged antacid or antibiotic therapy, prolonged hospitalization, persistent GI leak. Recommendations for patients who are clinically stable and have not ÀiViˆÛi`Ê«ÀˆœÀʏœ˜}‡ÌiÀ“Ê>✏iÊ̅iÀ>«Þ\ UÊʏÕVœ˜>✏iÊ{ää‡nääʓ}Ê6É*"Ê+Ó{ Recommendations for patients who are NOT clinically stable or have ÀiViˆÛi`Ê«ÀˆœÀʏœ˜}‡ÌiÀ“Ê>✏iÊ̅iÀ>«Þ\ UÊʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{Ê

Duration of therapy for secondary peritonitis/GI perforation Uncomplicated Definition

ÕÀ>̈œ˜Ê Complicated iw˜ˆÌˆœ˜Ê Duration

44

Stomach

Small Bowel

Colon

Appendix

Operated on within 24 hours Ó{q{nʅœÕÀÃÊ

Operated on within 12 hours Ó{q{nʅœÕÀÃÊ

Operated on within 12 hours Ó{q{nʅœÕÀÃÊ

Non-necrotic or gangrenous appendix Ó{ʅœÕÀÃ

>Ìiʜ«iÀ>̈œ˜ÊœÀʘœÊœ«iÀ>̈œ˜ÆʜÀʘiVÀœÌˆVÉ}>˜}Ài˜œÕÃÊ>««i˜`ˆÝ 4 days unless adequate source control is not achieved

,iviÀi˜Vi\  -
ÊՈ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\Ê ˆ˜Ê˜viVÊ ˆÃÊÓä£äÆxä\£ÎÎq£È{° -…œÀÌÊVœÕÀÃiÊ̅iÀ>«ÞÊvœÀÊ
\Ê Ê ˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°

Peritonitis related to peritoneal dialysis EMPIRIC TREATMENT Mild to moderate illness: intraperitoneal therapy is preferred in most cases. Anuric patient UÊÊ iv>✏ˆ˜Ê£xʓ}Ɏ}ʈ˜Êœ˜iÊL>}Ê+Ó{Ê­£Ê}ʈvÊ«>̈i˜ÌʐÊÈxʎ}®ÊPLUS UÊÊi˜Ì>“ˆVˆ˜ÊÓʓ}Ɏ}ʈ˜Êœ˜iÊL>}ʏœ>`ˆ˜}Ê`œÃi]Ê̅i˜Êi˜Ì>“ˆVˆ˜Êä°ÈÊ mg/kg in one bag Q24H Patient with urine output > 100 mL/day UÊÊ ivÌ>âˆ`ˆ“iÊ£Ê}ʈ˜Êœ˜iÊL>}Ê+Ó{ Severe illness: systemic therapy is preferred. UÊÊ,-/Ê "- \Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê6ÊPLUS ONE œvÊ̅iÊvœœÜˆ˜}\ Qi˜Ì>“ˆVˆ˜ÊÓʓ}Ɏ}Ê6Ê",Ê ivÌ>âˆ`ˆ“iÊ£Ê}Ê6Ê",Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ “}Ê6R

45

6.1 Abdominal infections

TREATMENT NOTES UÊÊ >ÕÃ>̈ÛiÊ>}i˜ÌÃÊvœÀÊÓ>ÊLœÜi]ÊVœœ˜]Ê>««i˜`ˆÝ\Ê>˜>iÀœLiÃÊ­ië°Ê B. fragilis), Enterobacteriaceae (esp. E. coli, K. pneumoniae, Enterobacter spp., Proteus spp.®Æʈ˜viV̈œ˜ÃÊÕÃÕ>ÞÊ«œÞ“ˆVÀœLˆ>°Ê UÊÊ*>̅œ}i˜ÃÊV>ÕȘ}ÊÌiÀ̈>ÀÞÊ«iÀˆÌœ˜ˆÌˆÃÊ>ÀiÊÛ>Àˆ>LiÊ>˜`Ê>ÀiʜvÌi˜Ê ÀiÈÃÌ>˜ÌÊ̜ʜÀʘœÌÊVœÛiÀi`ÊLÞÊ̅iʈ˜ˆÌˆ>Ê>˜Ìˆ“ˆVÀœLˆ>ÊÀi}ˆ“i˜ÆÊ̅ÕÃ]Ê>Ê change in antimicrobials is advised. UÊÊ
ÊV…>˜}iʈ˜Ê>˜Ìˆ“ˆVÀœLˆ>ÃÊ̅iÀ>«ÞÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ with hospital-acquired infections who are already on antimicrobials. UÊÊ/Ài>̓i˜ÌʜvÊi˜ÌiÀœVœVVˆÊÀi“>ˆ˜ÃÊVœ˜ÌÀœÛiÀÈ>ÊLÕÌÊŜՏ`ÊLiÊ considered in critically ill or immunocompromised patients or when they are a dominant organism in the peritoneal culture. UÊÊ/Ài>̓i˜ÌʜvÊCandida spp. is generally indicated only when they are recovered from blood or are a dominant organism in the peritoneal culture in critically ill or immunocompromised patients. UÊÊ*œÃ̜«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÃÊvœÀÊ>««i˜`ˆVˆÌˆÃÊ>ÀiÊ՘˜iViÃÃ>ÀÞÊ՘iÃÃÊ̅iÀiÊ is clinical evidence of peritonitis, abscess, or gangrene. UÊÊ
˜ÌˆLˆœÌˆVÃÊ>ÀiÊ>`Õ˜V̈ÛiÊ̜ÊÜÕÀViÊVœ˜ÌÀœ]Ê܅ˆV…ʈÃÊ>˜Ê>L܏ÕÌiÊ necessity. UÊÊ>VŽÊœvÊÜÕÀViÊVœ˜ÌÀœÊˆÃÊ`iw˜i`Ê>Ãʜ˜‡}œˆ˜}ÊVœ˜Ì>“ˆ˜>̈œ˜Ê>˜`ɜÀÊ>˜Ê undrained collection of infection.

6.1 Abdominal infections

UÊÊ
 /


Ê "- \Ê œÃiÊ«iÀÊ`ÀÕ}ʏiÛiÃÊ>˜`ɜÀÊÀi˜>Êv՘V̈œ˜ÆÊ consult pharmacy for recommendations for redosing and monitoring Duration:Ê£äq£{Ê`>Þà TREATMENT NOTES Microbiology UÊÊœÃÌÊV>ÃiÃÊV>ÕÃi`ÊLÞÊVœ˜Ì>“ˆ˜>̈œ˜ÊœvÊ̅iÊV>̅iÌiÀ UÊÊ ÕÌÕÀiÃʓ>ÞÊLiʘi}>̈Ûiʈ˜ÊxqÓä¯ UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊ­S. aureus, coagulase-negative staphylococci, Enterococcus spp.), Gram-negative rods, yeast (much less common) Diagnosis UÊÊ
Ê«>̈i˜ÌÃÊ܈̅ÊÃÕëiVÌi`Ê* ‡Ài>Ìi`Ê«iÀˆÌœ˜ˆÌˆÃÊŜՏ`ʅ>ÛiÊ* ÊyՈ`Ê sampled for cell count, differential, gram stain, culture AND amylase. WBC > 100/mm 3Ê܈̅ʀÊxä¯Ê* ÊÃÕ}}iÃÌÃʈ˜viV̈œ˜° UÊÊ iÛ>Ìi`Ê>“ޏ>ÃiÊÃÕ}}iÃÌÃÊ«>˜VÀi>̈̈ÃʜÀÊLœÜiÊ«iÀvœÀ>̈œ˜° UÊʘÊÃޓ«Ìœ“>̈VÊ«>̈i˜ÌÃÊ܈̅ÊVœÕ`ÞÊyՈ`Ê>VVœ“«>˜ˆi`ÊLÞÊ>L`œ“ˆ˜>Ê pain and/or fever, empiric treatment should be started given the high likelihood of infection. UÊʘÊÃޓ«Ìœ“>̈VÊ«>̈i˜ÌÃÊ܈̅ÊVi>ÀÊyՈ`]Ê>˜œÌ…iÀÊ* ÊyՈ`ÊiÝV…>˜}i]Ê with a dwell time of at least 2 hours, should be sampled. The decision to start empiric therapy in these cases will depend on how sick the patient appears. UÊʘÊ>Ãޓ«Ìœ“>̈VÊ«>̈i˜ÌÃÊ܈̅ÊVœÕ`ÞÊyՈ`]ʈÌʈÃÊÀi>ܘ>LiÊ̜Ê`i>ÞÊ therapy pending the results of cell count, gram stain, and culture. ,iviÀi˜Vi\ -* ÊՈ`iˆ˜iÃÊvœÀÊ*iÀˆÌœ˜i>Ê ˆ>ÞÈÇÀi>Ìi`ʘviV̈œ˜Ã\Ê*iÀˆÌÊ ˆ>Ê˜ÌÊÓä£äÆÎä\ ΙÎÊq{Óΰ

46

Diagnosis and testing UÊÊ >ÃiÊ`iw˜ˆÌˆœ˜ÊœvÊC. difficileÊ`ˆ>ÀÀ…i>\Ê«>ÃÃ>}iʜvÊ≥ 3 unformed stools in ≤ 24 hours AND either a positive stool test for C. difficile or colonoscopic/histopathologic finding of pseudomembranous colitis. UÊÊ/…iʓˆVÀœLˆœœ}Þʏ>LÊÕÃiÃÊ>ÊÀi>‡Ìˆ“iÊ* ,Ê>ÃÃ>ÞÊ̜Ê`iÌiVÌÊ̅iÊ̜݈˜Ê Ê gene, the toxin responsible for CDI. Thus, patients who are colonized with toxigenic strains will test positive even if they do not have active infection and clinical correlation with positive test results is important. /…iÊÃi˜ÃˆÌˆÛˆÌÞʜvÊÀi>Ê̈“iÊ* ,ʈÃʀʙä¯ÊVœ“«>Ài`Ê̜Ê̜݈}i˜ˆVÊ culture. UÊÊ œÊ "/ÊÃi˜`ÊÃ̜œÊvœÀÊC. difficile testing if patients do not have diarrhea or ileus. Hard stool, fluid obtained from colonoscopy and rectal swabs will be rejected by the microbiology lab. UÊʘʫ>̈i˜ÌÃÊÀiViˆÛˆ˜}ʏ>Ý>̈ÛiÃ]ʈÌʈÃÊÀiVœ““i˜`i`Ê̜Ê`ˆÃVœ˜Ìˆ˜ÕiÊ laxatives for 24-48 hours prior to C. difficile stool test to see if diarrhea improves, unless the patient is clinically unstable. UÊÊ iV>ÕÃiʜvÊi˜…>˜Vi`ÊÃi˜ÃˆÌˆÛˆÌÞʜvÊ* ,]Ê`Õ«ˆV>ÌiÊÌiÃ̈˜}ʈÃʘœÌÊ necessary or recommended. Testing is restricted to one specimen within 7 days. Call the Laboratory Medicine resident or faculty member on call for those rare instances when a second specimen is required. UÊÊ-̜œÊvœÀÊC. difficile testing should be collected prior to starting treatment for C. difficile. UÊÊ-«iVˆ“i˜ÃÊŜՏ`ÊLiʅ>˜`ÊV>ÀÀˆi`Ê̜Ê̅iʏ>LÊ>ÃÊܜ˜Ê>ÃÊ«œÃÈLiÊ>vÌiÀÊ collection. If they cannot be transported promptly, the samples should be refrigerated. UÊÊ œÊ "/ÊÃi˜`ÊvœœÜ‡Õ«ÊC. difficile PCR during treatment or to document resolution of disease, as utility of the results has not been demonstrated. TREATMENT UÊÊ-/"*Ê
Ê
/ ," 
Ê
 /-Ê7 6 ,Ê*"--  ° UÊÊ"À>Ê̅iÀ>«ÞʓÕÃÌÊLiÊÕÃi`Ê܅i˜iÛiÀÊ«œÃÈLiÊ>ÃÊ̅iÊivwV>VÞʜvÊ6Ê Metronidazole is poorly established for CDI and there is no efficacy of IV Vancomycin for CDI.

47

6.2 Clostridium difficile infection (CDI)

Clostridium difficile infection (CDI)

6.2 Clostridium difficile infection (CDI)

Treatment depends on clinical severity Infection severity

Clinical manifestations

Asymptomatic carriage*

C. difficile PCR positive without diarrhea, ileus, or colitis

Mild or moderate

C. difficile PCR positive with diarrhea but no manifestations of severe disease

Severe

C. difficile PCR positive with diarrhea and one or more of the following attributable to CDI: UÊÊ7 Ê≥ 15,000 UÊʘVÀi>Ãiʈ˜ÊÃiÀՓÊVÀi>̈˜ˆ˜iÊ> xä¯ÊvÀœ“ÊL>Ãiˆ˜i

Ê Ê Severe Complicated Ê Ê Ê Ê Ê Ê

Criteria as above plus one or more of the following attributable to CDI: UÊÞ«œÌi˜Ãˆœ˜ UʏiÕÃÊ UÊ/œÝˆVʓi}>Vœœ˜ÊœÀÊ«>˜VœˆÌˆÃʜ˜Ê / UÊ*iÀvœÀ>̈œ˜ UÊ ii`ÊvœÀÊVœiV̜“Þ UÊ 1Ê>`“ˆÃȜ˜ÊvœÀÊÃiÛiÀiÊ`ˆÃi>Ãi

Infection severity

Treatment


Ãޓ«Ìœ“>̈VÊÊ carriage

Ê œÊ "/ÊÌÀi>ÌÆÊÌÀi>̓i˜ÌÊV>˜Ê«Àœ“œÌiÊÀi>«Ãˆ˜}Ê disease

ˆ`ʜÀʓœ`iÀ>ÌiÊ

UÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê*"É /Ê+nÊ

Ê

Unable to tolerate oral therapy UÊÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê6Ê+nÊ­ÃÕLœ«Ìˆ“>ÆÊÃiiʘœÌiÊ at start of CDI section above)

-iÛiÀiÊ

UÊÊ6>˜Vœ“ÞVˆ˜Ê܏Ṏœ˜Ê£Óxʓ}Ê*"É /Ê+ÈÊ

-iÛiÀiÊ œ“«ˆV>Ìi`Ê Ê

UÊÊ œ˜ÃՏÌÊÃÕÀ}iÀÞÊvœÀÊiÛ>Õ>̈œ˜ÊvœÀÊVœiV̜“ÞÊ>˜`Ê Ê UÊÊ6>˜Vœ“ÞVˆ˜Ê܏Ṏœ˜Êxääʓ}ÊLÞÊ /Ê+ÈÊPLUS Metronidazole 500 mg IV Q8H†

Ê

Unable to tolerate oral therapy or complete ileus UÊÊ6>˜Vœ“ÞVˆ˜Êxääʓ}ʈ˜ÊxääʓÊ -Ê+ÈÊ>ÃÊÀiÌi˜Ìˆœ˜Ê enema via Foley catheter in rectum + Metronidazole 500 mg IV Q8H

I£x‡Óx¯ÊœvʅœÃ«ˆÌ>ˆâi`Ê«>̈i˜ÌÃÊ>ÀiÊVœœ˜ˆâi`Ê܈̅ C. difficile. † Vancomycin dose can be decreased to 125 mg PO Q6H and Metronidazole can be stopped once the patient has stabilized.

Other indications for oral Vancomycin use UÊ œÊÀi뜘ÃiÊ̜ʜÀ>ÊiÌÀœ˜ˆ`>✏iÊ>vÌiÀÊxÊ`>ÞÃʜvÊ̅iÀ>«Þ UÊ-iVœ˜`Êi«ˆÃœ`iʜvÊÀiVÕÀÀi˜ÌÊ`ˆÃi>Ãi UÊ*>̈i˜ÌÃÊ܈̅ÊÈ}˜ˆwV>˜ÌÊÈ`iÊivviVÌÃÊ̜ÊiÌÀœ˜ˆ`>✏i UÊ*>̈i˜ÌÃÊ܅œÊ>ÀiÊ«Ài}˜>˜Ì UÊÊ œ˜Ãˆ`iÀʈ˜Ê«>̈i˜ÌÃʀÊÈxÊÞi>ÀÃÊ}ˆÛi˜ÊÀi«œÀÌÃʜvʈ˜VÀi>Ãi`ʓœÀLˆ`ˆÌÞÊ from CDI.

48

Approach to patients who need to continue broad spectrum antibiotic therapy UÊ iÌiÀ“ˆ˜iÊ̅iÊŜÀÌiÃÌÊ«œÃÈLiÊVœÕÀÃiʜvÊ>˜ÌˆLˆœÌˆVÊ̅iÀ>«Þ°Ê UÊÊ,i«>ViÊ̅iÊ>˜ÌˆLˆœÌˆVÊ̅>Ìʈ˜`ÕVi`Ê ]Ê«>À̈VՏ>ÀÞÊVi«…>œÃ«œÀˆ˜Ã]Ê Clindamycin, and fluoroquinolones. UÊÊvÊ̅iʈ˜`ÕVˆ˜}Ê>}i˜ÌʈÃÊÀi«>Vi`Ê>˜`Ê̅iÊ ÊÀi܏ÛiÃ]ÊVœ“«iÌiÊ>Ê ÃÌ>˜`>À`ʣ䇣{Ê`>ÞÊVœÕÀÃiʜvÊ Ê̅iÀ>«ÞÆÊ̅iÀiʈÃʘœÊ˜ii`Ê̜ÊiÝÌi˜`Ê CDI therapy until the end of the course of antibiotic therapy. UÊÊvÊ̅iʈ˜`ÕVˆ˜}Ê>}i˜ÌÊV>˜˜œÌÊLiÊÃ̜««i`ʜÀÊÀi«>Vi`]ÊVœ˜Ãˆ`iÀÊ continuing CDI therapy until the end of the course of antibiotic therapy ­`>Ì>Ê>Àiʏˆ“ˆÌi`®ÆÊ Ê̅iÀ>«ÞÊŜՏ`ʘœÌÊLiÊVœ˜Ìˆ˜Õi`ÊLiޜ˜`Ê̅iÊi˜`Ê of antibiotic therapy if the patient remains asymptomatic. Recurrent disease UÊÊ,iÈÃÌ>˜ViÊ̜ÊiÌÀœ˜ˆ`>✏iʜÀÊ6>˜Vœ“ÞVˆ˜Ê…>ÃʘœÌÊLii˜Ê`œVՓi˜Ìi`Ê conclusively. UÊÊ,iVÕÀÀi˜ÌÊ`ˆÃi>ÃiÊ>vÌiÀÊ>ÊVœ“«iÌiÊVœÕÀÃiʜvÊ̅iÀ>«ÞʜVVÕÀÃʈ˜ÊHÊ Óx¯ÊœvÊ«>̈i˜ÌðÊ,i>«ÃiʈÃÊ`ÕiÊ̜Êv>ˆÕÀiÊ̜ÊiÀ>`ˆV>ÌiÊëœÀiÃÊ­Èä¯®Ê œÀÊ>VµÕˆÃˆÌˆœ˜ÊœvÊ>ʘiÜÊÃÌÀ>ˆ˜Ê­{䯮°Ê œVՓi˜ÌÊÀiVÕÀÀi˜ÌÊ`ˆÃi>ÃiÊÜˆÌ…Ê repeat stool testing. UÊʈÀÃÌÊÀiVÕÀÀi˜ViÊŜՏ`ÊLiÊÌÀi>Ìi`Ê̅iÊÃ>“iÊ>ÃÊ̅iʈ˜ˆÌˆ>Êi«ˆÃœ`iÆÊ severe disease should be treated with Vancomycin. UÊÊ-iVœ˜`ÊÀiVÕÀÀi˜ViÊŜՏ`ÊLiÊÌÀi>Ìi`Ê܈̅Ê6>˜Vœ“ÞVˆ˜ÊÌ>«iÀÊvœœÜi`Ê by pulse dosing or fecal microbiota transplant (consult GI). UÊvÊÃiÀˆœÕÃʜÀʓՏ̈«iÊÀiVÕÀÀi˜ViÃ]ÊVœ˜ÃՏÌÊ ° Vancomycin taper regimen 125 mg 4 times daily ×Ê£äq£{Ê`>Þà 125 mg BID × 7 days 125 mg daily × 7 days £Óxʓ}ÊiÛiÀÞÊÓqÎÊ`>ÞÃÊvœÀÊÓqnÊÜiiŽÃÊ­«ÕÃiÊ`œÃˆ˜}® NOTES Management UÊÊ-ÕÀ}ˆV>Êˆ˜ÌiÀÛi˜Ìˆœ˜ÊvœÀÊVœiV̜“ÞÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`Êi>ÀÞʈvÊ̅iÊ patient is clinically unstable secondary to CDI. UÊÊ/Ài>̓i˜ÌʜvÊ ÊŜՏ`ÊLiÊVœ˜Ìˆ˜Õi`ʈ˜Ê«>̈i˜ÌÃÊ܅œÊ…>ÛiÊ>ÊÃÕL̜Ì>Ê colectomy with preservation of the rectum. UÊÊœÃÌÊ«>̈i˜ÌÃÊ܈̅ÊÃiÛiÀiÊ ÊŜՏ`Ê՘`iÀ}œÊ>L`œ“ˆ˜>Ê /Ê̜ÊÀՏiÊ out toxic megacolon or pancolitis.

49

6.2 Clostridium difficile infection (CDI)

Duration UÊ£äq£{Ê`>ÞÃ

6.2 Clostridium difficile infection (CDI)

UÊÊ œÊ "/ÊÃi˜`ÊvœœÜ‡Õ«ÊC.difficile PCR to document resolution of disease. UÊÊ œÊ˜œÌÊÕÃiÊ>˜Ìˆ“œÌˆˆÌÞÊ>}i˜Ìð UÊÊ-̜«Ê«ÀœÌœ˜Ê«Õ“«Êˆ˜…ˆLˆÌœÀÃÊ­**îÊ܅i˜iÛiÀÊ«œÃÈLiÊ>ÃÊ`>Ì>ÊÃÕ}}iÃÌÊ PPIs increase the risk of CDI. UÊÊ/…iʜvvi˜`ˆ˜}Ê>˜Ìˆ“ˆVÀœLˆ>Ê>}i˜ÌÃÊŜՏ`ÊLiÊ`ˆÃVœ˜Ìˆ˜Õi`°ÊvÊ antimicrobials are still required, it is best to avoid cephalosporins, Clindamycin, and fluoroquinolones. UÊÊ*Àœ«…ޏ>V̈VÊÕÃiʜvʜÀ>ÊiÌÀœ˜ˆ`>✏iʜÀÊ6>˜Vœ“ÞVˆ˜Êˆ˜Ê«>̈i˜ÌÃÊ receiving antimicrobial therapy for treatment of underlying infection (other than CDI) is not recommended and may increase the patient’s risk for CDI. Infection control UÊÊ*>̈i˜ÌÃÊÜˆÌ…Ê ÊŜՏ`ÊLiÊ«>Vi`ʈ˜ÊVœ˜Ì>VÌÊ«ÀiV>Ṏœ˜ÃÊ>˜`ÊȘ}iÊ rooms for the duration of hospitalization. UÊÊ1ÃiÊÜ>«Ê>˜`ÊÜ>ÌiÀÊÀ>̅iÀÊ̅>˜Ê>Vœ…œ‡L>Ãi`ʅ>˜`Ê}iÊÕ«œ˜Êï݈˜}Ê the room of a patient with CDI. ,iviÀi˜ViÃ\ -
É -
Ê œ˜Ãi˜ÃÕÃÊՈ`iˆ˜iÃÊvœÀÊ \ʘviVÌÊ œ˜ÌÀœÊœÃ«Ê «ˆ`i“ˆœÊÓä£äÆÊ Î£\{Σq{x{° >VŽÊœvÊṎˆÌÞʜvÊÌÀi>̈˜}Ê ÊV>ÀÀˆiÀÃ\Ê
˜˜Ê˜ÌiÀ˜Êi`Ê£™™ÓÆÊ££Ç\әLJÎäÓ°

œiV̜“Þʈ˜Ê \Ê
˜˜Ê-ÕÀ}ÊÓääÇÆÊÓ{x\ÓÈLJÇÓ°

50

UÊFor treatment of C. difficile infection, see p. 47. UÊ >ÀivՏÞÊ>ÃÃiÃÃÊ̅iÊ«>̈i˜ÌÊLivœÀiÊ«ÀiÃVÀˆLˆ˜}Ê>˜Ìˆ“ˆVÀœLˆ>Ã° UÊÊœÃÌʈ˜viV̈œÕÃÊ`ˆ>ÀÀ…i>ʈÃÊÃiv‡ˆ“ˆÌi`Ê>˜`ʜ˜ÞÊÀiµÕˆÀiÃÊÃÕ««œÀ̈ÛiÊ management. UÊÊ/Ài>̓i˜ÌÊ܈̅Ê>˜ÌˆLˆœÌˆVÃʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀʓœÃÌʓˆ`‡ “œ`iÀ>ÌiÊ`ˆÃi>ÃiÆÊÃiiÊëiVˆwVʈ˜`ˆV>̈œ˜Ãʈ˜ÊÌ>LiÊLiœÜ° UÊÊ6ˆÀ>Ê«>̅œ}i˜Ã]ÊÃÕV…Ê>ÃÊ œÀœÛˆÀÕÃÊ>˜`Ê,œÌ>ۈÀÕÃÊVœ““œ˜ÞÊV>ÕÃiÊ diarrhea and do not require antibiotics. UÊÊ
˜ÌˆLˆœÌˆVÊÕÃiʓ>Þʏi>`Ê̜Ê>`ÛiÀÃiʜÕÌVœ“iÃÊ­i°}°Ê…i“œÞ̈VÊÕÀi“ˆVÊ syndrome with Shiga toxin-producing E. coli). UÊÊ
˜Ìˆ“œÌˆˆÌÞÊ>}i˜ÌÃÊŜՏ`ʘœÌÊLiÊÕÃi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊLœœ`ÞÊ`ˆ>ÀÀ…i>]Ê fever, or elevated WBC. Microbiology UÊÊ œ““œ˜Ê˜œ˜‡ÛˆÀ>Ê«>̅œ}i˜Ãʈ˜Ê>VÕÌiÊVœ““Õ˜ˆÌއ>VµÕˆÀi`Ê`ˆ>ÀÀ…i>\Ê Salmonella, Shigella, Shiga toxin-producing E. coli, Campylobacter, C. difficile (usually with antibiotic exposure). UÊ œÃœVœ“ˆ>Ê`ˆ>ÀÀ…i>\ÊC. difficile UÊÊ*iÀÈÃÌi˜ÌÊ`ˆ>ÀÀ…i>ʈvʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê­“œÃÌʏˆŽiÞÊV>ÕÃiÃÊÛ>ÀÞÊ `i«i˜`ˆ˜}ʜ˜ÊÌÞ«iʜvʈ““Õ˜œVœ“«Àœ“ˆÃi®\ÊGiardia, Cryptosporidium, Cyclospora, Isospora, Microsporidia, Cytomegalovirus (CMV). Diagnosis UÊÊ œÌÊiÛiÀÞÊ`ˆ>ÀÀ…i>Êˆ˜iÃÃÊÀiµÕˆÀiÃÊÃ̜œÊVՏÌÕÀi°Ê iVˆÃˆœ˜Ê̜ÊÌiÃÌÊ should be based on suspicion for specific pathogens and/or clinical judgment of illness severity. UÊÊ*>̈i˜ÌÃÊ܈̅ÊviLÀˆiÊ`ˆ>ÀÀ…i>Êˆ˜iÃÃiÃÊ܈̅ÊVˆ˜ˆV>Êvi>ÌÕÀiÃʜvÊ moderate to severe disease should receive empiric therapy only after a fecal specimen is obtained for appropriate testing. UÊÊiV>ÊëiVˆ“i˜ÃÊvÀœ“Ê«>̈i˜ÌÃʅœÃ«ˆÌ>ˆâi`ÊvœÀʀÊÎÊ`>ÞÃÊŜՏ`ʘœÌÊLiÊ submitted for routine stool culture unless a high suspicion for specific pathogen exists and/or if the patient is immunocompromised. UÊÊՏ̈«iÊÃ̜œÊiÝ>“ˆ˜>̈œ˜ÃÊvœÀʜÛ>Ê>˜`Ê«>À>ÈÌiÃÊ­"E*®Ê>ÀiʜvʏœÜÊ yield. UÊÊiV>ÊiՎœVÞÌiɏ>V̜viÀÀˆ˜Ê>ÃÃiÃÓi˜ÌÃÊŜՏ`ʘœÌÊLiÊÕÃi`ÊÌœÊ determine the therapeutic approach.

51

6.3 Infectious diarrhea

Infectious diarrhea

6.3 Infectious diarrhea

Treatment of infectious diarrhea Organism/Indications for treatment

Treatment

Bacteria Campylobacter spp.

UÊ
âˆÌ…Àœ“ÞVˆ˜Êxääʓ}Ê*"Ê`>ˆÞÊvœÀÊ£qÎÊ`>ÞÃ

/Ài>̓i˜ÌÊÀiVœ““i˜`i`ÊvœÀ\ UÊ-iÛiÀiʈ˜iÃà UÊ
}iʐÊÈʓœ˜Ì…ÃʜÀʀÊxäÊÞi>Àà UÊÀœÃÃÊLœœ`ʈ˜ÊÃ̜œ Uʈ}…ÊviÛiÀ UÊ7œÀÃi˜ˆ˜}ʜÀÊÀi>«Ãˆ˜}ÊÃޓ«Ìœ“à UÊ*Ài}˜>˜VÞ UÊ““Õ˜œVœ“«Àœ“ˆÃi`ʅœÃÌ E. coli (enterotoxigenic, enteropathogenic, enteroinvasive) or empiric therapy of traveler’s diarrhea

UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê  Duration:Ê£qÎÊ`>ÞÃ

Shiga toxin producing E. coli (including E. coliÊä£xÇ\Ç®

Treatment not recommended. Antibiotic use associated with development of hemolytic uremic syndrome.

Non-typhoid Salmonella spp.

UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê  Ê OR UÊÊ/*É-8Ê£ÈäÉnääʓ}Ê*"Ê  Ê (if susceptible) OR UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{

/Ài>̓i˜ÌÊÀiVœ““i˜`i`ÊvœÀ\ UÊ-iÛiÀiʈ˜iÃÃÊÀiµÕˆÀˆ˜}ʅœÃ«ˆÌ>ˆâ>̈œ˜ UÊ
}iʐÊÈʓœ˜Ì…ÃʜÀʀÊxäÊÞi>Àà UÊ >VÌiÀi“ˆ> UÊ*ÀiÃi˜ViʜvÊ«ÀœÃ̅iÃià UÊ6>ÛՏ>Àʅi>ÀÌÊ`ˆÃi>Ãi UÊ-iÛiÀiÊ>̅iÀœÃViÀœÃˆÃ UÊ>ˆ}˜>˜VÞʜÀʜ̅iÀʈ““Õ˜œVœ“«Àœ“ˆÃi Shigella spp. Treatment always recommended even if result returns when patient is asymptomatic.

Duration:ÊxqÇÊ`>ÞÃÆÊ£{Ê`>ÞÃÊvœÀÊ immunocompromised host UÊÊ/*É-8Ê£ÈäÉnääʓ}ÊÊ*"Ê  Ê (if susceptible) OR UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê  Ê Duration:ÊÎÊ`>ÞÃÆÊÇÊ`>ÞÃÊvœÀʈ““Õ˜œ‡ compromised host

Vibrio parahaemolyticus

UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê  ÊÝÊÎÊ`>ÞÃ

œÌi\Ê
ÃÜVˆ>Ìi`Ê܈̅ÊÅiwÅÊVœ˜ÃՓ«Ìˆœ˜ Treatment recommended for severe illness Yersinia spp. /Ài>̓i˜ÌÊÀiVœ“““i˜`i`ÊvœÀ\ UÊ““Õ˜œVœ“«Àœ“ˆÃi`ʅœÃÌ UÊ >VÌiÀi“ˆ> UÊ*ÃiÕ`œ>««i˜`ˆVˆÌˆÃÊÃޘ`Àœ“i

52

UÊÊ/*É-8Ê£ÈäÉnääʓ}Ê*"Ê  ÊÝÊÎqxÊ days (if susceptible) OR UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê  ÊÝÊÎÊ`>Þà OR UÊÊ œÝÞVÞVˆ˜iÊ£ääʓ}Ê*"Ê  ÊÝÊÎÊ`>Þà (not for bacteremia)

Entamoeba histolytica Treat all (even asymptomatic) E. dispar & E. moshkovskii infections do not require treatment

UÊÊiÌÀœ˜ˆ`>✏iÊÇxäʓ}Ê*"Ê/ ÊÝÊxq£äÊ days OR UÊÊ/ˆ˜ˆ`>✏iÊ£Ê}Ê*"Ê+£ÓÊÝÊÎÊ`>Þà UÊÊPLUS all patients should receive Paromomycin 500 mg PO TID x 7 days after the course of 1st agent complete Asymptomatic patients UÊÊ*>Àœ“œ“ÞVˆ˜Êxääʓ}Ê*"Ê/ ÊÝÊÇÊ`>ÞÃ

Giardia spp.

UÊÊiÌÀœ˜ˆ`>✏iÊÓxä‡xääʓ}Ê*"Ê/ ÊÝÊ Çq£äÊ`>Þà OR U Tinidazole 2 g PO once

,iviÀi˜ViÃ\Ê  -
ÊՈ`iˆ˜iÃÊvœÀÊ>˜>}i“i˜ÌʜvʘviV̈œÕÃÊ ˆ>ÀÀ…i>ÆÊ ˆ˜Ê˜viVÌÊ ˆÃÊÓää£ÆÎÓ\ÎΣqxä° ˜viV̈œÕÃÊ`ˆ>ÀÀ…i>ʈ˜Ê`iÛiœ«i`Ê>˜`Ê`iÛiœ«ˆ˜}ÊVœÕ˜ÌÀˆiÃ\ÊÊ ˆ˜Ê>ÃÌÀœi˜ÌiÀœÊÓääx\Ι\ÇxÇqÇÇΰ

53

6.3 Infectious diarrhea

Parasites

6.4 Helicobacter pylori infection

Helicobacter pylori infection NOTE: CONSIDER WITHHOLDING THERAPY INITIATION UNTIL PATIENT DISCHARGED FROM HOSPITAL UNLESS ACUTE ULCER IS PRESENT

Established indications for testing for H. pylori and treating positive patients UÊÊ
V̈ÛiÊ«i«ÌˆVÊՏViÀÊ`ˆÃi>ÃiÊ­*1 ®ÊqÊ}>ÃÌÀˆVʜÀÊ`՜`i˜> UÊÊ œ˜wÀ“i`ʅˆÃ̜ÀÞʜvÊ*1 Ê­˜œÌÊ«ÀiۈœÕÏÞÊÌÀi>Ìi`ÊvœÀÊH. pylori) UÊÊ>ÃÌÀˆVÊ
/ʏޓ«…œ“>Ê­œÜÊ}À>`i® UÊœœÜˆ˜}ÊÀiÃiV̈œ˜ÊœvÊ}>ÃÌÀˆVÊV>˜ViÀÊ UÊ>“ˆÞʅˆÃ̜ÀÞʜvÊ}>ÃÌÀˆVÊV>˜ViÀʈ˜Ê>Ê£ÃÌÊ`i}ÀiiÊÀi>̈Ûi UÊ
ÌÀœ«…ˆVÊ}>ÃÌÀˆÌˆÃ Other indications where testing for H. pylori and treating positive patients can be considered: nonulcer dyspepsia, long term PPI use, persons using NSAID/ASA, unexplained iron deficiency anemia or vitamin B12 deficiency, family members of patients with H. pylori with mild dyspepsia. First-line treatment UÊÊ
“œÝˆVˆˆ˜Ê£Ê}Ê*"Ê+£ÓÊPLUS Clarithromycin 500 mg PO Q12H PLUS Pantoprazole 40 mg PO Q12H OR UÊ* Ê>iÀ}Þ UÊÊ >ÀˆÌ…Àœ“ÞVˆ˜Êxääʓ}Ê*"Ê+£ÓÊPLUS Metronidazole 500 mg PO Q12H PLUS Pantoprazole 40 mg PO Q12H OR UÊÊ/iÌÀ>VÞVˆ˜iÊxääʓ}Ê*"Ê+ÈÊPLUS Metronidazole 500 mg PO Q8H PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS Pantoprazole 40 mg PO Q12H UÊDuration:Ê£äq£{Ê`>Þà Documented recurrence of H. pylori disease UÊvÊ«œÃÈLi]Ê>ۜˆ`Ê>˜ÌˆLˆœÌˆVÃÊ«ÀiۈœÕÏÞÊÕÃi`Ê̜ÊÌÀi>ÌÊH. pylori UÊÊ/iÌÀ>VÞVˆ˜iÊxääʓ}Ê*"Ê+ÈÊPLUS Metronidazole 500 mg PO Q8H PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS Pantoprazole 40 mg PO Q12H UÊDuration: 14 days TREATMENT NOTES Diagnosis UÊÊ**Ã]Ê2RA, Bismuth, and antibiotics with activity against H. pylori should be withheld for at least 4 weeks prior to testing.

54

Management UÊʈÀÃÌʏˆ˜iÊÌÀi>̓i˜ÌÊiÀ>`ˆV>̈œ˜ÊÀ>ÌiÃÊiÃ̈“>Ìi`ÊLiÌÜii˜ÊxäqÇx¯°Ê >ˆÕÀiʓœÃÌʜvÌi˜Ê`ÕiÊÌœÊ >ÀˆÌ…Àœ“ÞVˆ˜ÊÀiÈÃÌ>˜ViÊ­£äq£x¯®Ê>˜`ɜÀÊ non-adherence. UÊÊӇÀiVi«ÌœÀÊ>˜Ì>}œ˜ˆÃÌÃÊ­i°}°Ê,>˜ˆÌˆ`ˆ˜i®ÊV>˜ÊLiÊÃÕLÃ̈ÌÕÌi`ÊvœÀÊ̅iÊ PPI if patients are unable to tolerate PPIs or if drug interactions are a concern. UÊÊ
“œÝˆVˆˆ˜ÊPLUS Tetracycline can NOT be used together in treatment due to low response rates. UÊÊ œÊ˜œÌÊÃÕLÃ̈ÌÕÌiÊ œÝÞVÞVˆ˜iɈ˜œVÞVˆ˜iÊvœÀÊ/iÌÀ>VÞVˆ˜iʜÀÊÊ Azithromycin for Clarithromycin. UÊʘʫ>̈i˜ÌÃÊ܈̅ʫœÃˆÌˆÛiÊÌiÃÌÊÀiÃՏÌÃÊi˜`œÃVœ«ÞʈÃʓ>˜`>̜ÀÞÊvœÀÊ>}iÊ > 45-50 years, presence of mass GI bleeding, anemia, weight loss, or family history of gastric cancer. UÊÊ/iÃÌʜvÊVÕÀiʈÃÊÀiVœ““i˜`i`Ê> {qnÊÜiiŽÃÊ«œÃÌÊÌÀi>̓i˜Ì°Ê ,iviÀi˜ViÃ\ Maastricht III Consensus Report. GutÊÓääÇÆxÈ\ÇÇӇÇn£° ACG Guidelines. Am J GastroenterolÊÓääÇÆ£äÓ\£nän‡£nÓx°

55

6.4 Helicobacter pylori infection

UÊÊH. pylori stool antigen is the only FDA approved test (>™ä¯ÊÃi˜ÃˆÌˆÛˆÌÞÊ and specificity). UÊ1Ài>ÊLÀi>̅ÊÌiÃÌʓ>ÞÊLiʜ«Ìˆ“>ÊLÕÌʘœÌÊVœ““œ˜ÞÊ>Û>ˆ>Li° UÊÊ ˜`œÃVœ«ÞÊPLUSÊÀ>«ˆ`ÊÕÀi>ÃiÊÌiÃÌÊ­näq™x¯ÊÃi˜ÃˆÌˆÛˆÌÞÆʙÓq£ää¯Ê specificity). UÊÊH. pylori serology does not document current infection and should not be used for clinical diagnosis.

6.5 Gynecologic and sexually transmitted infections

Pelvic inflammatory disease UʘVÕ`iÃÊÃ>«ˆ˜}ˆÌˆÃ]ÊÌÕLœ‡œÛ>Àˆ>˜Ê>LÃViÃÃÊ>˜`Ê«iÛˆVÊ«iÀˆÌœ˜ˆÌˆÃ°Ê UÊÊœÀÊÌÀi>̓i˜ÌʜvÊ«œÃ̇œ«iÀ>̈ÛiÊ«iÀˆÌœ˜ˆÌˆÃʜÀÊܜ՘`ʈ˜viV̈œ˜]Ê see p. 44 and p. 105. TREATMENT NOTE: Avoid use of fluoroquinolones for N. gonorrhoeae due to ÀiÈÃÌ>˜ViÊ­H£ä¯Êˆ˜Ê >Ìˆ“œÀiÊ ˆÌÞ® UÊÊ ivœÌiÌ>˜ÊÓÊ}Ê6Ê+£ÓÊPLUS Doxycycline* 100 mg PO BID for 14 days OR UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ÊPLUS Doxycycline* 100 mg PO BID for 14 days OR UÊÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÈä䇙ääʓ}Ê6Ê+nÊPLUS Gentamicin (see dosing section, p. 146) Step-down therapy once patient is afebrile UÊÊ*ÀiviÀÀi`\Ê œÝÞVÞVˆ˜iÊ£ääʓ}Ê*"Ê  Ê´ÊQ ˆ˜`>“ÞVˆ˜Ê{xäʓ}Ê*"Ê QID ORÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê*"Ê  RÊ̜ÊVœ“«iÌiÊ£{Ê`>ÞÃÊ̜Ì> *Azithromycin 1 g PO once weekly for 2 weeks can be used in the case of Doxycycline contraindication or intolerance.

TREATMENT NOTES Microbiology: N. gonorrhoeae, C. trachomatis, Gardnerella spp, Ureaplasma urealyticum, anaerobes (Prevotella spp., B. fragilis), Gramnegative rods, Streptococci Treatment of partners UÊ
Êܜ“i˜Ê`ˆ>}˜œÃi`Ê܈̅Ê>VÕÌiÊ* ÊŜՏ`ÊLiʜvviÀi`Ê6ÊÌiÃ̈˜}° UÊÊ>iÊ«>À̘iÀÃʜvÊܜ“i˜Ê܅œÊ…>ÛiÊ* ʜvÌi˜Ê>ÀiÊ>Ãޓ«Ìœ“>̈V°Ê UÊÊ-iÝÊ«>À̘iÀÃÊ­“>iʜÀÊvi“>i®ÊœvÊ«>̈i˜ÌÃÊ܅œÊ…>ÛiÊ* ÊŜՏ`Ê be examined and treated empirically for C. trachomatis and N. gonorrhoeae if they have had sexual contact with the patient during the 60 days preceding onset of symptoms in the patient, regardless of the pathogens isolated from the patient.

Endomyometritis TREATMENT UÊÊ->“iÊ>ÃÊvœÀÊ* ÊLÕÌʘœÊ˜ii`ÊvœÀÊ>``ˆÌˆœ˜ÊœvÊ œÝÞVÞVˆ˜iÉ
âˆÌ…Àœ“ÞVˆ˜ Duration UÊ/Ài>ÌÊ՘̈Ê«>̈i˜ÌÊ>viLÀˆiÊvœÀÊÓ{q{nʅœÕÀÃ

56

TREATMENT UÊÊiÌÀœ˜ˆ`>✏iÊ}iÊä°Çx¯]ʜ˜iÊvՏÊ>««ˆV>̜ÀÊ­xÊ}®Êˆ˜ÌÀ>Û>}ˆ˜>Þ]ʜ˜ViÊ daily for 5 days (preferred) OR UiÌÀœ˜ˆ`>✏iÊxääʓ}Ê*"Ê  ÊvœÀÊÇÊ`>Þà OR U ˆ˜`>“ÞVˆ˜ÊÎääʓ}Ê*"Ê  ÊvœÀÊÇÊ`>Þà TREATMENT NOTES Microbiology: anaerobic bacteria (Prevotella spp, Mobiluncus spp.), G. vaginalis, Ureaplasma, Mycoplasma. UÊÊ/Ài>̓i˜ÌʈÃÊÀiVœ““i˜`i`ʈ˜Ê>ÊÃޓ«Ìœ“>̈VÊܜ“i˜Ê>˜`ʅˆ}…ÊÀˆÃŽÊ asymptomatic pregnant women.

Trichomoniasis (T.vaginalis) NOTE: Treatment of partner recommended. TREATMENT UÊiÌÀœ˜ˆ`>✏iÊÓÊ}Ê*"ʜ˜ViÊ OR UÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê*"Ê  ÊvœÀÊÇÊ`>ÞÃ

Uncomplicated gonococcal urethritis, cervicitis, proctitis TREATMENT (includes treatment for C. trachomatis): UÊ ivÌÀˆ>ݜ˜iÊÓxäʓ}Êʜ˜ViÊPLUS Azithromycin 1 g orally (preferred) OR UÊÊ ivÌÀˆ>ݜ˜iÊÓxäʓ}Êʜ˜ViÊPLUS Doxycycline 100 mg PO BID for 7 days OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê
âˆÌ…Àœ“ÞVˆ˜ÊÓÊ}Ê*"ʜ˜ViÊ­«Ài“i`ˆV>ÌiÊÜˆÌ…Ê antiemetic or give snack before administration) TREATMENT NOTES UÊ6ÊÌiÃ̈˜}ÊÀiVœ““i˜`i` UÊÊ/…iÊÕÃiʜvÊ ivÌÀˆ>ݜ˜iʈÃÊ«ÀiviÀÀi`ʜÛiÀÊ iw݈“iÊ>˜`Ê iv«œ`œÝˆ“iÊ due to increasing MICs for oral cephalosporins. 57

6.5 Gynecologic and sexually transmitted infections

Bacterial vaginosis

6.5 Gynecologic and sexually transmitted infections

UÊÊ Õ>Ê̅iÀ>«ÞÊÀiVœ““i˜`i`ÊvœÀÊN. gonorrhoeae even if C. trachomatis is excluded. UÊÊ-i˜`Ê}œ˜œÀÀ…i>ÊVՏÌÕÀiÊ­˜œÌʘÕViˆVÊ>Vˆ`Ê>“«ˆwV>̈œ˜ÊÌiÃ̮ʈvÊޜÕÊ suspect a treatment failure.

Syphilis SCREENING UÊÊ-VÀii˜ˆ˜}Ê>}œÀˆÌ…“Ê>ÌÊ\Ê>ÊÌÀi«œ˜i“>‡Ã«iVˆwVÊ>˜ÌˆLœ`ÞÊÌiÃÌÊ­ 
®Ê if positive, followed by RPR. A confirmatory FTA-ABS is provided if RPR is negative. UÊÊ
Ê«œÃˆÌˆÛiÊ 
]Ê>ʘi}>̈ÛiÊ,*,Ê>˜`Ê>Ê«œÃˆÌˆÛiÊ/
ʓ>ÞÊLiÊ`ÕiÊ̜\Ê­£®Ê old treated syphilis (2) old untreated syphilis (3) early syphilis. UÊÊiÌʅˆÃ̜ÀÞÊ>˜`ÊV>Ê >Ìˆ“œÀiÊ ˆÌÞÊi>Ì…Ê i«>À̓i˜ÌÊ{£ä‡Î™È‡{{{nÊ for prior history of syphilis treatment in Maryland UÊÊvÊ«i˜ˆVˆˆ˜Ê>iÀ}ˆV]Ê ÊVœ˜ÃՏÌÃʈÃÊÀiVœ““i˜`i`Ê̜Ê}Ո`iÊ̅iÀ>«Þ Algorithm for reverse sequence syphilis screening CIA RPR positive

CIA positive RPR negative

CIA negative

UÊÊ œ˜ÃˆÃÌi˜ÌÊÜˆÌ…Ê Treponemal test that uses a different UÊÊvʈ˜VÕL>̈˜}ʜÀÊ syphilis infection >˜Ìˆ}i˜Ê­/
q
-ʜÀÊ/**
® primary syphilis (past or present) FTA-ABS positive FTA-ABS negative is suspected, UÊÊ,iµÕˆÀiÃʅˆÃ̜ÀˆV>Ê ÊUÊ*œÃÈLiÊÃÞ«…ˆˆÃÊÊ UÊ-Þ«…ˆˆÃÊ՘ˆŽiÞ treat for early and clinical syphilis ÊÊÊʈ˜viV̈œ˜Ê UÊvÊ«>̈i˜ÌÊ>Ìʅˆ}…Ê evaluation to ÊUÊ,iµÕˆÀiÃÊÊ ÊÊÊÀˆÃŽÊvœÀÊÃÞ«…ˆˆÃ] determine prior historical and retest in one treatment history clinical month evaluation

Neurosyphilis diagnosis UÊÊ,iµÕˆÀiÃÊLœÌ…ÊVˆ˜ˆV>Ê­˜iÕÀœœ}ˆV>ÊÃޓ«Ìœ“îÊ>˜`ʏ>LœÀ>̜ÀÞÊVÀˆÌiÀˆ>°Ê UÊÊ>LœÀ>̜ÀÞÊVÀˆÌiÀˆ>Ê­>˜ÞÊVœ“Lˆ˜>̈œ˜Êœv®\ÊÃiÀœœ}ˆV>Êiۈ`i˜ViʜvÊ ÃÞ«…ˆˆÃ]Ê«œÃˆÌˆÛiÊ -Ê6 ,Ê­xä¯ÊÃi˜ÃˆÌˆÛˆÌÞÆʅˆ}…ÊëiVˆwVˆÌÞ®]Ê -Ê «iœVÞ̜ÈÃÊ­€xÊ7 ɓÊˆvÊ6‡Æʀ£ä‡ÓäÊ7 ɓÊˆvÊ6³®]Ê -Ê elevated protein concentration (>50 mg/dl) UÊÊՓL>Àʫ՘VÌÕÀiÊ­*®ÊŜՏ`ÊLiʜLÌ>ˆ˜i`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʫœÃˆÌˆÛiÊ serological tests for syphilis plus neurological symptoms, serological treatment failure (lack of four-fold decline in RPR titer), evidence of tertiary syphilis UÊÊ œ˜Ãˆ`iÀÊ*ʈ˜Ê>Ãޓ«Ìœ“>̈VÊ6³Ê«>̈i˜ÌÃÊ܈̅Ê>Ê {ÊVœÕ˜ÌÊ≤350 cells/ml or RPR titer ≥£\ÎÓ 58

Early syphilis (primary, secondary, and early latent syphilis within one year after infection) UÊÊ*i˜ˆVˆˆ˜ÊÊ i˜â>̅ˆ˜iÊ­ ˆVˆˆ˜® L-A) 2.4 million units IM once UÊÊ-iÛiÀiÊ* Ê>iÀ}ˆiÃ\Ê œÝÞVÞVˆ˜iÊ£ääʓ}Ê*"Ê  ÊvœÀÊÓÊÜiiŽÃÊÊ Note:Ê`ÕiÊ̜ʈ˜VÀi>Ãi`ÊÀiÈÃÌ>˜ViÊ­H{x¯ÊœvÊÃÌÀ>ˆ˜Ãʈ˜Ê >Ìˆ“œÀiÊ>ÀiÊ resistant), Azithromycin is not recommended. Late latent syphilis (asymptomatic infection with positive serology >1 year after infection or latent syphilis of unknown duration) UÊÊ*i˜ˆVˆˆ˜ÊÊ i˜â>̅ˆ˜iÊ­ ˆVˆˆ˜® L-A) 2.4 million units IM weekly for 3 weeks (total of 3 doses) Neurosyphilis (can occur during any stage of syphilis) UÊÊ*i˜ˆVˆˆ˜ÊÊÎq{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{ÊvœÀÊ£äq£{Ê`>Þà Syphilis in pregnancy UÊÊ*i˜ˆVˆˆ˜ÊˆÃÊ̅iʜ˜ÞÊÀiVœ““i˜`i`Ê̅iÀ>«Þʈ˜Ê«Ài}˜>˜ÌÊ«>̈i˜ÌÃÊÜˆÌ…Ê any kind of syphilis. Allergy consult for penicillin desensitization is recommended. ,iviÀi˜ViÃ\Ê -iÝÕ>ÞÊÌÀ>˜Ã“ˆÌÌi`Ê`ˆÃi>ÃiÃÊ ÊÌÀi>̓i˜ÌÊ}Ո`iˆ˜iðÊ7,ÊÓä£äÉx™Ê­,,£Ó®ÆÊ £q££ä°Ê
âˆÌ…Àœ“ÞVˆ˜ÊÛÃ°Ê œÝÞVÞVˆ˜iÊvœÀÊ* °Ê"LÃÌiÌÊޘiVœÊÓääÇÆÊ££ä­£®\xÎqÈä° Discordant Results from Reverse Sequence Syphilis Screening. MMWR 2011/60 ­äx®Æ£ÎÎq£ÎÇ

59

6.5 Gynecologic and sexually transmitted infections

TREATMENT

6.6 Catheter-related bloodstream infections

Management of catheter-related bloodstream infections (CR-BSI) Diagnosis UÊÊvÊ̅iÀiʈÃʓœÀiÊ̅>˜Ê“ˆ˜ˆ“>ÊiÀÞ̅i“>ʜÀÊ
9Ê«ÕÀՏi˜ViÊ>ÌÊ̅iÊi݈ÌÊ site, the catheter is likely infected. It should be removed and replaced at a different site. UÊÊ7…i˜Ê ,‡ -ʈÃÊÃÕëiVÌi`]ÊÓqÎÊÃiÌÃʜvÊLœœ`ÊVՏÌÕÀiÃÊŜՏ`ÊLiÊ drawn with AT LEAST one (and preferably > 1) from peripheral sites. Blood cultures drawn through non-tunneled catheters are more likely to yield contaminants. UÊÊ/…iÊṎˆÌÞʜvÊVՏÌÕÀiÃʜvÊ̅iÊV>̅iÌiÀÊ̈«ÊˆÌÃivʈÃʘœÌÊÜiÊ`iw˜i`]Ê>˜`Ê should ONLY be sent when there is a clinical suspicion of infection, NOT routinely when lines are removed. They MUST be accompanied by two sets of blood cultures obtained as detailed above. UÊÊ/iV…˜ˆµÕi\Ê/…iÊi݈ÌÊÈÌiÊŜՏ`ÊLiÊVi>˜i`Ê܈̅Ê>Vœ…œ°Ê/…iÊ catheter should be grasped a few centimeters proximal to the exit site. A 5 cm segment of catheter including the tip should be cut off with sterile scissors and placed in a sterile container. UÊʘʈ˜ÃÌ>˜ViÃÊ܅iÀiÊ̅iÊLœœ`Ê>˜`ÊV>̅iÌiÀÊ̈«Ê>ÀiÊVՏÌÕÀi`Ê>ÌÊ̅iÊÃ>“iÊ time and the blood cultures are negative but the catheter tip culture is positive, antibiotics are generally not recommended, even for patients with valvular heart disease or immunosuppression. UÊÊ/…iÊiÝVi«Ìˆœ˜ÊˆÃÊ«>̈i˜ÌÃÊ܅œÃiÊV>̅iÌiÀÊ̈«ÃÊ}ÀœÜÊS. aureus and …>Ûiʘi}>̈ÛiÊLœœ`ÊVՏÌÕÀiðÊ/…iÃiÊ«>̈i˜ÌÃÊŜՏ`ÊÀiViˆÛiÊxqÇÊ days of antibiotics. UÊÊ
Ê«>̈i˜ÌÃÊŜՏ`ÊLiÊvœœÜi`ÊVœÃiÞ]Ê>˜`ÊÀi«i>ÌÊVՏÌÕÀiÃÊŜՏ`Ê be sent if clinically indicated. UÊÊ7…i˜Ê>ÊV>̅iÌiÀ‡Ài>Ìi`Ê -ʈÃÊ>ÃÜVˆ>Ìi`Ê܈̅ÊV>̅iÌiÀÊ`ÞÃv՘V̈œ˜]Ê consider the possibility of suppurative thrombophlebitis. EMPIRIC TREATMENT UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê±Ê ivi«ˆ“iÊ£qÓÊ}Ê6Ê+nÊ (use higher dose if pseudomonas suspected) OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê ±ÊQ ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nÊ",Ê
âÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRʱ Tobramycin (see dosing section, p. 146) Empiric treatment – Gram-positive cocci in clusters in 2 or more sets of blood cultures UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®

60

UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê Change to UÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ʈvÊÃÕÃVi«ÌˆLiÊ­«ÀiviÀÀi`Ê̜Ê6>˜Vœ“ÞVˆ˜® Duration: UÊÎqÇÊ`>ÞÃʈvÊV>̅iÌiÀÊÀi“œÛi`Ê­«ÀiviÀÀi`® UÊ£äq£{Ê`>ÞÃʈvÊV>̅iÌiÀÊÃ>Û>}iÊ>ÌÌi“«Ì Methicillin-susceptible Staphylococcus aureus UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ʈvÊÃÕÃVi«ÌˆLi OR UÊÊ œ˜‡>˜>«…ޏ>V̈VÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜ÊÓÊ}Ê6Ê+n OR UÊÊ
˜>«…ޏ>V̈VÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä® Methicillin-resistant Staphylococcus aureus UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä® UÊ6>˜Vœ“ÞVˆ˜Ê>iÀ}ÞʜÀʈ˜ÌœiÀ>˜ViÊ­˜œÌÊÀi`ʓ>˜ÊÃޘ`Àœ“i® Ê UÊ >«Ìœ“ÞVˆ˜Ên‡£äʓ}Ɏ}Ê6Ê+ÊÓ{ OR Ê UÊ ivÌ>Àœˆ˜iÊÈääʓ}Ê6Ê+Ên UÊ6>˜Vœ“ÞVˆ˜Êv>ˆÕÀi\ÊVœ˜ÃՏÌÊ TREATMENT NOTES UÊ,i“œÛiÊV>̅iÌiÀ°Êˆ}…ÊÀi>«ÃiÊÀ>ÌiÃʈvÊV>̅iÌiÀʈÃʘœÌÊÀi“œÛi`° UÊ6>˜Vœ“ÞVˆ˜ÊˆÃʈ˜viÀˆœÀÊ̜Ê"Ý>Vˆˆ˜ÊvœÀÊÌÀi>̓i˜ÌʜvÊ--
° UÊÊ*>̈i˜ÌÃÊ܈̅ÊS. aureus bacteremia should have an echocardiogram to rule out endocarditis. Transthoracic echo is acceptable only if the study >`iµÕ>ÌiÞÊۈiÜÃÊ̅iʏiv̇È`i`ÊÛ>ÛiÃÆʓœÃÌÊiÝ«iÀÌÃÊÀiVœ““i˜`Ê/

° UÊʈ˜i✏ˆ`ÊŜՏ`ʘœÌÊLiÊÕÃi`ÊÀœṎ˜iÞÊvœÀÊÌÀi>̓i˜ÌʜvÊS. aureus bacteremia UÊ ÀˆÌiÀˆ>ÊvœÀÊ>Ê£{Ê`>ÞÊVœÕÀÃiʜvÊ̅iÀ>«Þ Ê UÊÊ ˜`œV>À`ˆÌˆÃÊiÝVÕ`i`Ê܈̅Ê/

Ê­«ÀiviÀÀi`®Æʅˆ}…ʵÕ>ˆÌÞÊ// ʓ>ÞÊLiÊ adequate in select patients Ê UÊ œÊˆ“«>˜Ìi`Ê«ÀœÃ̅iÃiÃ Ê UÊÊœœÜ‡Õ«ÊLœœ`ÊVՏÌÕÀiÃÊ`À>ܘÊӇ{Ê`>ÞÃÊ>vÌiÀÊ̅iʈ˜ˆÌˆ>ÊVՏÌÕÀiÃÊ>ÀiÊ negative for S. aureus 61

6.6 Catheter-related bloodstream infections

Coagulase-negative staphylococci (CoNS) NOTE: Single positive cultures of CoNS should NOT be treated unless they are confirmed by follow-up cultures, the patient is immunosuppressed and/or critically ill, or the patient has implanted hardware. In these cases, treatment can be started but repeat cultures should be sent PRIOR to initiation of therapy to confirm the diagnosis.

6.6 Catheter-related bloodstream infections

Ê UÊÊ/…iÊ«>̈i˜ÌÊ`iviÀÛiÃViÃÊ܈̅ÊÇÓʅœÕÀÃʜvʈ˜ˆÌˆ>̈œ˜ÊœvÊivviV̈ÛiÊ antistaphylococcal therapy Ê UÊÊ/…iÊ«>̈i˜Ìʅ>ÃʘœÊœV>ˆâˆ˜}ÊÈ}˜ÃʜÀÊÃޓ«Ìœ“ÃʜvʓiÌ>ÃÌ>̈VÊ staphylococcal infection Ê UÊ-œÕÀViÊVœ˜ÌÀœÊ…>ÃÊLii˜ÊœLÌ>ˆ˜i` Ê UÊÊ
LÃi˜Viʜvʜ̅iÀÊVœ˜`ˆÌˆœ˜ÃÊ̅>Ìʓ>ÞÊ>vviVÌÊ>LˆˆÌÞÊ̜ÊVi>Àʈ˜viV̈œ˜Ê based on clinical judgment (e.g. poorly controlled diabetes) UÊÊ
ÊœÌ…iÀÊ«>̈i˜ÌÃÊŜՏ`ÊÀiViˆÛiÊ{‡ÈÊÜiiŽÃʜvÊ̅iÀ>«ÞÊL>Ãi`ʜ˜ÊiÝÌi˜ÌÊ of infection Enterococcus faecalis NOTE: Can be contaminants. Draw repeat cultures to confirm before ÃÌ>À̈˜}ÊÌÀi>̓i˜Ì°Ê£ää¯ÊœvÊE. faecalis blood isolates at JHH are susceptible to Ampicillin, which should be used unless the patient has a PCN allergy. UÊÊ
“«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê OR UÊÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£xä®Ê Duration: Çq£{Ê`>Þà Enterococcus faecium NOTE: Can be contaminants. Draw repeat cultures to confirm before ÃÌ>À̈˜}ÊÌÀi>̓i˜Ì°Ê/…iʓ>œÀˆÌÞÊ­Çn¯®ÊœvÊE. faecium blood isolates at JHH are resistant to Vancomycin. If the isolate is susceptible to Ampicillin or Vancomycin, these agents should be used preferentially at the doses listed above for E. faecalis bacteremia. UÊʈ˜i✏ˆ`ÊÈääʓ}Ê6É*"Ê+£Ó OR UÊ >«Ìœ“ÞVˆ˜Ênq£Óʓ}Ɏ}Ê6Ê+Ó{ TREATMENT NOTES UÊÊ œ˜Ãˆ`iÀÊiV…œV>À`ˆœ}À>“ʈvÊ̅iÀiʈÃÊ«iÀÈÃÌi˜ÌÊL>VÌiÀi“ˆ>Ê­> 3 days) on antibiotics. UÊÊ/…iÊ>``ˆÌˆœ˜ÊœvÊi˜Ì>“ˆVˆ˜Ê`œiÃʘœÌÊ>««i>ÀÊ̜ÊV…>˜}iʜÕÌVœ“iÃʈ˜Ê CR-BSI caused by Enterococcus in the absence of endocarditis. Gram-negative bacilli Antibiotic selection based on organism and susceptibilities. Duration: Çq£äÊ`>ÞÃ

62

Candida spp. UÊ,iviÀÊ̜ʫ°Ê££ÇÊvœÀÊÌÀi>̓i˜ÌʜvÊV>˜`ˆ`i“ˆ> CATHETER SALVAGE UÊÊCatheter removal is STRONGLY recommended for infections with S. aureus, yeast and Pseudomonas, as the chance of catheter salvage is low and the risk of recurrent infection is high. UÊÊCatheters associated with tunnel infections CANNOT be salvaged and should be removed. UÊÊWhen catheter salvage is attempted, systemic antibiotics should be given through the infected line. UÊÊ
˜ÌˆLˆœÌˆVÊÕÃi`Ê>ÃʏœVŽÊ̅iÀ>«ÞÊŜՏ`Ê«ÀiviÀi˜Ìˆ>Þʓ>ÌV…Ê>˜ÌˆLˆœÌˆVÊ used for systemic therapy. Antibiotic Lock Therapy (ALT) UÊÊ
˜ÌˆLˆœÌˆVʏœVŽÊ̅iÀ>«ÞÊV>˜ÊLiÊÕÃi`ÊvœÀÊV>̅iÌiÀÊÃ>Û>}iÊin addition to systemic antibiotics when feasible. UÊÊ >̅iÌiÀÊÀi“œÛ>ÊŜՏ`ÊLiÊ«iÀvœÀ“i`ʈvÊVՏÌÕÀiÃÊÀi“>ˆ˜Ê«œÃˆÌˆÛiÊ>vÌiÀÊ 72 hours of appropriate antibiotic lock therapy Acceptable uses: UÊÊ->Û>}iʜvʏœ˜}‡ÌiÀ“ÊV>̅iÌiÀÃÊ̅>ÌÊV>˜˜œÌÊLiÊÀi“œÛi`Ê­i°}°Ê`ˆ>ÞÈÃÊ catheters, implantable permanent ports or central venous catheters for chemotherapy) when there are NO systemic complications (hemodynamic instability, tissue hypoperfusion, septic thrombosis, infectious endocarditis or distant septic metastases) or signs of local infection. Unacceptable uses: UÊÊ-…œÀ̇ÌiÀ“ÊÛi˜œÕÃÊV>̅iÌiÀà UÊÊ œ“«ˆV>Ìi`Ê , -Ê­i°}°ÊÌ՘˜iÊœÀÊ«œÀ̇«œVŽiÌʈ˜viV̈œ˜]ÊÃiÛiÀiÊ sepsis, septic shock, endocarditis, osteomyelitis and hematogenous seeding at other sites) UÊ >̅iÌiÀÊÃ>Û>}iÊ܈̅ÊS. aureus infection. Duration:ÊÇq£{Ê`>ÞÃÊ

63

6.6 Catheter-related bloodstream infections

TREATMENT NOTES UÊÊ >̅iÌiÀÃÊ>ÀiʏiÃÃÊVœ““œ˜ÞÊ̅iÊÜÕÀViʜvÊ̅iʈ˜viV̈œ˜ÆʅœÜiÛiÀ]Ê most advocate catheter removal if the catheter is the source.

6.6 Catheter-related bloodstream infections

Standardized Concentrations of Antibiotics for ALT Antibiotic

Heparin (optional)

6>˜Vœ“ÞVˆ˜Êxʓ}ɓʈ˜Ê䰙¯Ê -Ê i˜Ì>“ˆVˆ˜Êxʓ}ɓʈ˜Ê䰙¯Ê -Ê

äʜÀÊxäääÊ՘ˆÌà ÓxääÊ՘ˆÌÃÊ

UÊÊ
/ÊŜՏ`ÊLiʈ˜Ã̈i`ʈ˜Ê̅iʏՓi˜ÊœvÊ̅iÊV>̅iÌiÀÊ܅i˜Ê˜œÌʈ˜ÊÕÃi° UÊÊ ÜiÊ̈“iÃÊŜՏ`ÊLiÊ>Ìʓˆ˜ˆ“Õ“ÊœvÊnq£ÓʅœÕÀÃÊ«iÀÊ`>ÞÊ­Õ«ÊÌœÊ Ó{q{nʅ® UÊÊ
/ÊۜÕ“iʘii`i`Ê܈ÊÛ>ÀÞÊLÞÊÌÞ«iʜvÊV>̅iÌiÀÊ>˜`Ê>Û>ˆ>LiʘՓLiÀÊ œvʏՓi˜Ã°Ê˜Ê}i˜iÀ>]ÊÓqxʓÊŜՏ`ÊLiÊÃÕvwVˆi˜Ì° ,iviÀi˜ViÃ\ Stability and compatibility of antimicrobial lock solutions. Am J Health-Syst Pharm. Óä£ÎÆÇä\Ó£nx‡Ó£™n° IDSA Guidelines for the Diagnosis and Management of Intravascular Catheter-related ˜viV̈œ˜Ã\ÊClin Infect Dis Óää™Æ{™\£‡{x°

64

NOTES: UÊÊ iÌ>‡>VÌ>“ÃÊ>ÀiÊhighly preferable to Vancomycin if the organism is susceptible and if the patient is not severely allergic. Strongly consider PCN desensitization for allergic patients. UÊʘviV̈œÕÃÊ ˆÃi>ÃiÃÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊ>`ۈÃi`ÊvœÀÊV>ÃiÃʜvʏiv̇È`i`Ê infective endocarditis and prosthetic valve endocarditis, particularly in those in which the preferred antibiotic cannot be used or in which the organism is resistant to usual therapy. UÊÊ/…iÀ>«iṎVʓœ˜ˆÌœÀˆ˜}\Ê UÊÊ6>˜Vœ“ÞVˆ˜ UÊÊœ>ÊÌÀœÕ}…ʏiÛi\Ê£xqÓäʓV}ɓ UÊÊi˜Ì>“ˆVˆ˜ÊvœÀÊÀ>“‡«œÃˆÌˆÛiÊÃޘiÀ}Þ UÊÊ >ˆÞÊ`œÃˆ˜} UÊÊœ>ÊÌÀœÕ}…ʏiÛi\Ê1 mcg/mL UÊÊ/À>`ˆÌˆœ˜>Ê`œÃˆ˜}Ê­+n® UÊÊœ>Ê«i>ŽÊiÛi\ÊÎq{ʓV}ɓ UÊÊœ>ÊÌÀœÕ}…ʏiÛi\Ê1 mcg/mL UÊÊ-iiÊ«°Ê£{nÊ>˜`Ê«°Ê£xäÊvœÀÊ`iÌ>ˆÃ Viridans streptococci or S. bovis with PCN MIC  0.12 mcg/mL UÊÊ*i˜ˆVˆˆ˜ÊÊÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{ÊvœÀÊ{ÊÜiiŽÃ OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ{ÊÜiiŽÃ OR UÊÊQ*i˜ˆVˆˆ˜ÊÊÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê",Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊÓÊ ÜiiŽÃRÊPLUS Gentamicin 3 mg/kg IV Q24H for 2 weeks OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ{Ê weeks

ÀˆÌiÀˆ>ÊvœÀÊÓÊÜiiŽÊÌÀi>̓i˜Ì\ UÊÊ*>̈i˜ÌÊ`œiÃʘœÌʅ>ÛiÊV>À`ˆ>VʜÀÊiÝÌÀ>V>À`ˆ>VÊ>LÃViÃà UÊÊ À Ê20 mL/min UÊÊ*>̈i˜ÌÊ`œiÃʘœÌʅ>Ûiʈ“«>ˆÀi`Ên̅ÊVÀ>˜ˆ>Ê˜iÀÛiÊv՘V̈œ˜Ê UÊÊ*>̈i˜ÌÊ`œiÃʘœÌʅ>ÛiÊAbiotrophia, Granulicatella, or Gemella spp. Viridans streptococci or S. bovis with PCN MIC  0.12 mcg/mL and  0.5 mcg/mL UÊÊQ*i˜ˆVˆˆ˜ÊÊ{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê",Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ {ÊÜiiŽÃRÊPLUS Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy 65

6.7 Endocarditis

Treatment of native valve endocarditis

6.7 Endocarditis

OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ 4 weeks Viridans streptococci or S. bovis with PCN MIC > 0.5 mcg/mL and Abiotrophia defectiva, Granulicatella spp. and Gemella spp. UÊÊ œ˜ÃՏÌÊ TREATMENT NOTES UÊÊ
Ê«>̈i˜ÌÃÊ܈̅ÊS. bovis biotype I endocarditis should undergo GI work-up to rule out underlying cancer. Staphylococcus aureus – Methicillin susceptible, native valve, right-sided involvement only UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ UÊÊ1ÃiÊ >vVˆˆ˜ÊvœÀÊ"Ý>Vˆˆ˜‡ˆ˜`ÕVi`ʅi«>̈̈à Criteria for 2-ÜiiŽÊÌÀi>̓i˜Ì\ UÊ*>̈i˜ÌʈÃÊ>˜Êˆ˜iV̈˜}Ê`ÀÕ}ÊÕÃiÀÊ܈̅ʓˆ˜ˆ“>ÊœÌ…iÀÊVœ“œÀLˆ`ˆÌˆiÃÊ UÊÊiv̇È`i`Êi˜`œV>À`ˆÌˆÃʈÃÊÀՏi`ʜÕÌÊ܈̅Ê/

Ê­«ÀiviÀÀi`®ÊœÀʅˆ}…Ê quality TTE UÊÊ/Ài>̓i˜ÌʈÃÊ܈̅Ê"Ý>Vˆˆ˜ÊœÀÊ >vVˆˆ˜Ê UÊÊ*>̈i˜ÌÊ`œiÃʘœÌʅ>ÛiÊ
 -Ê­ {Ê< 200) UÊÊ*>̈i˜ÌÊ`œiÃʘœÌʅ>ÛiÊ>˜Êˆ“«>˜Ìi`Ê«ÀœÃ̅iÈÃÊ­`ˆ>ÞÈÃÊ}À>vÌ]ÊiÌV® UÊÊ œœ`ÊVՏÌÕÀiÃÊ>Àiʘi}>̈ÛiÊ܈̅ˆ˜Ê{Ê`>ÞÃÊ>vÌiÀÊÃÌ>À̈˜}Ê̅iÀ>«ÞÊ UÊÊ/…iÀiʈÃʘœÊiۈ`i˜ViʜvÊi“LœˆVÊ`ˆÃi>ÃiÊ"/ ,Ê̅>˜ÊÃi«ÌˆVÊ pulmonary emboli UÊÊ6i}iÌ>̈œ˜ÃÊ>ÀiÊ>Ê< 2 cm in size UÊÊvÊ«>̈i˜ÌÊ`œiÃʘœÌʓiiÌÊVÀˆÌiÀˆ>ÊvœÀÊӇÜiiŽÊÌÀi>̓i˜Ì]ÊÌÀi>ÌÊvœÀÊ{Ê weeks Staphylococcus aureus – Methicillin susceptible, native valve, left-sided involvement UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{Ê OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜ÊÓÊ}Ê6Ê+nÊ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê-ÌÀœ˜}ÞÊVœ˜Ãˆ`iÀÊ* Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊœÀÊ Vancomycin (see dosing section, p. 150) UÊÊ/…iÊ>``ˆÌˆœ˜ÊœvÊi˜Ì>“ˆVˆ˜Ê̜Ê>ÊLiÌ>‡>VÌ>“Ê“>Þʅi«ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ faster but does not appear to affect mortality. It particularly should be avoided in the elderly and in those with baseline renal impairment. Staphylococcus aureus – Methicillin resistant, native valve UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä® 66

S. pneumoniae, and Group A streptococci UÊÊ*i˜ˆVˆˆ˜ÊÊÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{ÊvœÀÊ{ÊÜiiŽÃ OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6Ê+Ó{ÊvœÀÊ{ÊÜiiŽÃÊ",Ê Cefazolin 2 g IV Q8H for 4 weeks OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ{Ê weeks UÊÊœÀÊS. pneumoniae, if PCN MIC ≥ 0.1, consult ID Groups B, C and G streptococci UÊÊ*i˜ˆVˆˆ˜ÊÊÎʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{ÊvœÀÊ{qÈÊÜiiŽÃÊ´Êi˜Ì>“ˆVˆ˜Ê 3 mg/kg IV Q24H for the first 2 weeks of therapy OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv>✏ˆ˜ÊÓÊ}Ê6Ê+nÊvœÀÊ{qÈÊÜiiŽÃʱ Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£{È®ÊvœÀÊ{qÈÊ weeks ± Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy UÊÊ œ˜Ãˆ`iÀÊ>˜Ê Ê œ˜ÃÕÌ Enterococcus faecalis UÊÊ
“«ˆVˆˆ˜Ê>˜`Êi˜Ì>“ˆVˆ˜ÊÃÕÃVi«ÌˆLi\Ê
“«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê",Ê Penicillin G 4 million units IV Q4H PLUS Gentamicin 1 mg/kg IV Q8H BOTH for 4-6 weeks UÊÊ
“«ˆVˆˆ˜ÊÃÕÃVi«ÌˆLiÊ܈̅ÊVœ˜ÌÀ>ˆ˜`ˆV>̈œ˜ÃÊvœÀÊ>“ˆ˜œ}ÞVœÃˆ`iÃʜÀÊ i˜Ì>“ˆVˆ˜ÊÀiÈÃÌ>˜Ì\Ê
“«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê",Ê*i˜ˆVˆˆ˜ÊÊ{ʓˆˆœ˜Ê units IV Q4H PLUS Ceftriaxone 2 g IV Q12H BOTH for 4-6 weeks

67

6.7 Endocarditis

Duration UÊÊ1˜Vœ“«ˆV>Ìi`\ÊÈÊÜiiŽÃ UÊÊ œ“«ˆV>Ìi`Ê­«iÀˆÛ>ÛՏ>ÀÊ>LÃViÃÃÊvœÀ“>̈œ˜]ʓiÌ>ÃÌ>̈VÊVœ“«ˆV>̈œ˜]Ê «œœÀÊVœ˜ÌÀœi`Ê`ˆ>LiÌiÃʓiˆÌÕî\ÊÈʜÀʓœÀiÊÜiiŽÃÊL>Ãi`ʜ˜ÊVˆ˜ˆV>ÊÊ picture and response to therapy UÊÊ Ê>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i`ÊvœÀÊVœ“«ˆV>Ìi`Ê diseases

6.7 Endocarditis

OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê-ÌÀœ˜}ÞÊVœ˜Ãˆ`iÀÊ* Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊˆvÊ* Ê allergy is anaphylactic or Vancomycin (see dosing section, p. 146) PLUS Gentamicin 1 mg/kg IV Q8H BOTHÊvœÀÊ{qÈÊÜiiŽÃ UÊÊ/Ài>ÌÊvœÀÊ{ÊÜiiŽÃʜ˜ÞÊ܅i˜ÊÃޓ«Ìœ“Ãʅ>ÛiÊLii˜Ê«ÀiÃi˜ÌÊvœÀÊ< 3 months AND there is a prompt response to therapy Enterococcus faecium UÊ œ˜ÃՏÌÊ ,iviÀi˜Vi\ 1ÃiʜvÊ ivÌÀˆ>ݜ˜iʈ˜Êi˜ÌiÀœVœVV>Êi˜`œV>À`ˆÌˆÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£ÎÆÊxÈ\£ÓÈ£‡n°

HACEK organisms (Haemophilus parainfluenzae, H. aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominus, Eikenella corrodens, Kingella kingae) UÊÊ ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ{ÊÜiiŽÃ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê œ˜ÃՏÌÊ Gram-negative organisms, culture negative endocarditis, or fungal endocarditis UÊÊ œ˜ÃՏÌÊ

Treatment of prosthetic valve endocarditis UÊÊi˜iÀ>ÞÊV>ÕÃi`ÊLÞÊÃÌ>«…ޏœVœVVˆÊˆ˜Ê̅iÊwÀÃÌÊ£qÓÊÞi>ÀÃÊvœœÜˆ˜}ÊÛ>ÛiÊ replacement (both S. aureus and coagulase-negative staph). Etiologies are similar to native valve infections 2 or more years post-op. UÊi`ˆV>ÊÌÀi>̓i˜ÌÊ>œ˜iʈÃʜvÌi˜Ê "/ÊivviV̈Ûi° UÊ
Ê«>̈i˜ÌÃÊŜՏ`ʅ>ÛiÊ>Ê/

° EMPIRIC TREATMENT UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Gentamicin 1 mg/kg IV Q8H Viridans streptococci or S. bovis with PCN MIC  0.12 mcg/mL UÊÊQ*i˜ˆVˆˆ˜ÊÊ{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê",Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{RÊvœÀÊ 6 weeks  Gentamicin 3 mg/kg IV Q24H for first 2 weeks of therapy OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊ weeks

68

Staphylococcus aureus—Methicillin susceptible UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ÊvœÀÊÈÊÜiiŽÃÊPLUS Gentamicin 1 mg/kg IV Q8H for first 2 weeks of therapy AND UÊÊ,ˆv>“«ˆ˜ÊÎääʓ}Ê*"Ê+nÊvœÀÊÈÊÜiiŽÃÊafter blood cultures have cleared UÊÊ Ê>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i` Staphylococcus aureus—Methicillin resistant or Coagulasenegative staphylococci UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊÜiiŽÃÊPLUS Gentamicin 1 mg/kg IV Q8H for the first 2 weeks of therapy AND UÊÊ,ˆv>“«ˆ˜ÊÎääʓ}Ê*"Ê+nÊvœÀÊÈÊÜiiŽÃÊafter blood cultures have cleared UÊÊvÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊÃÌ>«…ޏœVœVVˆÊˆÃÊÃÕÃVi«ÌˆLiÊ̜Ê"Ý>Vˆˆ˜Ê̅i˜Ê treat as S. aureusÊqÊi̅ˆVˆˆ˜ÊÃÕÃVi«ÌˆLi° UÊÊ Ê>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i` Gram-negative organisms or culture negative endocarditis UÊÊ œ˜ÃՏÌÊ DUKE CRITERIA FOR INFECTIVE ENDOCARDITIS Diagnostic criteria (Modified Duke criteria) Definite endocarditis UÊÊ*ÀiÃi˜ViʜvÊÓʓ>œÀÊVÀˆÌiÀˆ>Ê",ʣʓ>œÀÊ
ÊÎʓˆ˜œÀÊ",Êxʓˆ˜œÀ Possible endocarditis UÊÊ*ÀiÃi˜Viʜvʣʓ>œÀÊ
ʣʓˆ˜œÀÊ",ÊÎʓˆ˜œÀÊVÀˆÌiÀˆ> Rejected endocarditis UÊʈÀ“Ê>ÌiÀ˜>ÌiÊ`ˆ>}˜œÃˆÃÊ̅>ÌÊiÝ«>ˆ˜ÃÊ
ʓ>˜ˆviÃÌ>̈œ˜ÃʜvÊ (NOTE: simply having another infection does NOT exclude endocarditis)

69

6.7 Endocarditis

Viridans streptococci or S. bovis with PCN MIC  0.12 mcg/mL UÊÊQ*i˜ˆVˆˆ˜ÊÊ{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê",Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6ÉÊ+Ó{RÊ PLUS Gentamicin 3 mg/kg IV Q24H for 6 weeks OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊ weeks

6.7 Endocarditis

Major criteria Microbiologic UÊÊ/ܜÊÃi«>À>ÌiÊLœœ`ÊVՏÌÕÀiÃÊ«œÃˆÌˆÛiÊvœÀÊ>ÊÌÞ«ˆV>ÊœÀ}>˜ˆÃ“\Ê viridans streptococci, S. bovis, HACEK, S. aureus, Enterococcus spp. UÊÊ*iÀÈÃÌi˜ÌÊL>VÌiÀi“ˆ>Ê܈̅Ê>˜ÞʜÀ}>˜ˆÃ“Ê>ÃÊiۈ`i˜Vi`ÊLÞ\ÊÓÊ positive blood cultures drawn at least 12 hours apart OR 3/3 positive blood cultures with at least 1 hour between the first and last OR the majority of more than 4 cultures positive from any time period. UÊÊ*œÃˆÌˆÛiÊCoxiella burnetti (Q fever) culture or serology. Echocardiographic (TEE strongly recommended for prosthetic valve) UÊÊ6i}iÌ>̈œ˜Ê­œ˜ÊÛ>ÛiʜÀÊÃÕ««œÀ̈˜}ÊÃÌÀÕVÌÕÀiÊ",ʈ˜Ê«>̅ʜvÊ regurgitant jet) UÊÊ
LÃViÃà UÊÊ iÜÊ`i…ˆÃVi˜ViʜvÊ«ÀœÃ̅ïVÊÛ>Ûi Physical exam UÊÊ 7ÊÀi}ÕÀ}ˆÌ>˜ÌʓÕÀ“ÕÀʭܜÀÃi˜ˆ˜}ʜvʜ`ʓÕÀ“ÕÀʈÃÊ "/Ê sufficient) Minor criteria UÊÊ*Ài`ˆÃ«œÃˆ˜}ÊVœ˜`ˆÌˆœ˜\Ê«ÀiۈœÕÃÊi˜`œV>À`ˆÌˆÃ]ʈ˜iV̈œ˜Ê`ÀÕ}ÊÕÃi]Ê prosthetic valve, ventricular septal defect, coarctation of the aorta, calcified valve, patent ductus, mitral valve prolapse with regurgitation, IHSS or other valvular heart disease UÊÊiÛiÀÊ≥ 38.0°C (100.4°F) UÊÊ “LœˆVÊiÛi˜ÌÃ\Ê>ÀÌiÀˆ>ÊœÀʫՏ“œ˜>ÀÞÊi“Lœˆ]ÊVœ˜Õ˜V̈Û>Ê hemorrhage, retinal hemorrhage, splinter hemorrhage, intracranial hemorrhage, mycotic aneurysm UÊÊ““Õ˜œœ}ˆVÊ«…i˜œ“i˜œ˜\Ê"ÏiÀʘœ`iÃ]Ê}œ“iÀՏœ˜i«…ÀˆÌˆÃ]Ê«œÃˆÌˆÛiÊ rheumatoid factor UÊÊ*œÃˆÌˆÛiÊLœœ`ÊVՏÌÕÀiÃÊ̅>ÌÊ`œ˜½ÌʓiiÌÊVÀˆÌiÀˆ>Ê>LœÛiÊ",ÊÃiÀœœ}ˆVÊ evidence of active infection with an organism known to cause endocarditis BUT single positive cultures for coagulase-negative staphylococci are NOT considered even a minor criterion ,iviÀi˜ViÃ\ "À>Ê̅iÀ>«Þ\Ê
“ÊÊi`Ê£™™ÈÆÊ£ä£\Èn‡ÇÈ° -…œÀÌÊVœÕÀÃiÊ̅iÀ>«Þ\Ê
˜˜Ê˜ÌiÀ˜Êi`Ê£™™{ÆÊ£Ó£\nÇ·Ȱ ՎiÊVÀˆÌiÀˆ>\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓäääÆÊÎä\Èηn°

Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜Ìʜ˜Ê˜viV̈ÛiÊ ˜`œV>À`ˆÌÃ\Ê ˆÀVՏ>̈œ˜ÊÓääxÆÊ£££­Óή\iΙ{‡{Î{° TEE in S. aureusÊL>VÌiÀi“ˆ>\ÊÊ
“Ê œÊ >À`ˆœÊ£™™ÇÆÊÎä\Ê£äÇӇn° ,-
ÊL>VÌiÀi“ˆ>Éi˜`œV>À`ˆÌˆÃÊÀiVœ““i˜`>̈œ˜Ã\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓ䣣ÆÊxÓ\i£n‡xx

70

NOTE: Obtain at least 2 sets of blood cultures before initiation of antibiotic therapy EMPIRIC TREATMENT UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®°Ê >ÀÀœÜÊ̅iÀ>«ÞÊL>Ãi`ʜ˜Ê culture results. TREATMENT NOTES MicrobiologypÃÌ>«…ޏœVœVVˆÊˆ˜ÊÇä‡nä¯ÊœvÊV>ÃiÃÊ­Hxä¯ÊVœ>}Տ>Ãi‡ ˜i}>̈ÛiÊÃÌ>«…ޏœVœVVˆÊ>˜`ÊHxä¯ÊS. aureus) Management UÊvÊLœœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«œÃˆÌˆÛiʜÀÊi˜`œV>À`ˆÌˆÃʈÃÊÃÕëiVÌi`Ê«>̈i˜ÌÃÊ should undergo transesophageal echocardiography (TEE) UÊ œ“«iÌiÊiÝÌÀ>V̈œ˜ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅ʫœVŽiÌʈ˜viV̈œ˜Ê and/or valvular or lead endocarditis UÊ
ÌÊ̅iÊ̈“iʜvÊiÝÌÀ>V̈œ˜]Ê̈ÃÃÕiÊ­À>̅iÀÊ̅>˜ÊÃÜ>LîÊvÀœ“Ê̅iÊ}i˜iÀ>̜ÀÊ pocket should be sent for Gram-stain and culture and lead tips should be sent for culture. UÊ œÌiÊ̅>ÌÊLiV>ÕÃiʏi>`ÃÊ>ÀiÊiÝÌÀ>VÌi`Ê̅ÀœÕ}…Ê>˜Êœ«i˜Ê}i˜iÀ>̜ÀÊ «œVŽiÌ]Ê̅iÞʓ>ÞÊLiVœ“iÊVœ˜Ì>“ˆ˜>Ìi`ÊLÞÊ̅iʈ˜viVÌi`Ê«œVŽiÌÆÊ therefore, positive lead cultures are not always indicative of lead endocarditis in patient with negative blood cultures. UÊ œœ`ÊVՏÌÕÀiÃÊŜՏ`ÊLiʜLÌ>ˆ˜i`Ê>vÌiÀÊ`iۈViÊÀi“œÛ>° UÊ iۈViÊÀiˆ“«>˜Ì>̈œ˜ÊŜՏ`ÊLiʜ˜Ê̅iÊVœ˜ÌÀ>‡>ÌiÀ>ÊÈ`iÊ܅i˜iÛiÀÊ possible. UÊ œ“«iÌiÊiÝÌÀ>V̈œ˜ÊˆÃÊÃÌÀœ˜}ÞÊÀiVœ““i˜`i`ʈ˜Ê>Ê«>̈i˜ÌÃÊ presenting with S. aureus bacteremia and no other source UÊ œ“«iÌiÊiÝÌÀ>V̈œ˜ÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʫiÀÈÃÌi˜ÌÊ positive blood cultures with other organisms (e.g. coagulase-negative staphylococci, enterococci, Gram-negative bacilli) on a case-by-case basis. UÊ œ“«iÌiÊ`iۈViÊ>˜`ʏi>`ÊÀi“œÛ>ÊˆÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ…Ê valvular endocarditis. UÊ
˜Ìˆ“ˆVÀœLˆ>Ê«Àœ«…ޏ>݈ÃʈÃÊ "/ÊÀiVœ““i˜`i`ÊvœÀÊ`i˜Ì>ÊœÀʜ̅iÀÊ invasive procedures following placement ,iviÀi˜Vi\Ê

Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜Ìʜ˜Ê**Ê>˜`Ê ʈ˜viV̈œ˜Ã\Ê ˆÀVՏ>̈œ˜ÊÓä£äÆÊ£Ó£\{xnq{ÇÇ°

71

6.8 Pacemaker/ICD infections

Permanent pacemaker (PPM) and implantable cardioverter-defibrillator (ICD) infections

6.8 Pacemaker/ICD infections

Reimplantation timing and duration of therapy Diagnosis Pocket site infection

Timing of reimplantation Blood cultures negative for 72 hours and surgical site healing

Positive blood cultures with rapid clearance AND TEE with either no vegetation or uncomplicated lead vegetation Sustained positive blood cultures AND TEE with no vegetation or uncomplicated lead vegetation Valve endocarditis

Post-explantation blood cultures negative for 72 hours

Duration of therapy 7-10 days if device erosion without inflammation 10-14 days all others Oral therapy can be considered Non-S. aureus\ÊÓÊÜiiŽÃÊ IV therapy S. aureus\Ê{ÊÜiiŽÃÊ IV therapy

Post-explantation blood cultures negative for 72 hours

4 weeks IV therapy

Blood cultures negative for 14 days

4-6 weeks IV therapy (see Endocarditis p. 65)

,iviÀi˜Vi\

Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜Ìʜ˜Ê >À`ˆœÛ>ÃVՏ>ÀÊ“«>˜Ì>LiÊ iVÌÀœ˜ˆVÊ iۈViʘviV̈œ˜Ã\Ê ˆÀVՏ>̈œ˜Ê Óä£äÆÊ£Ó£\{xnqÇÇ°

72

TREATMENT UÊÊANTIBIOTICS SHOULD BE STARTED AS SOON AS THE POSSIBILITY OF BACTERIAL MENINGITIS BECOMES EVIDENT, IDEALLY WITHIN 30 MINUTES. UÊDO NOT WAIT FOR CT SCAN OR LP RESULTS. IF LP MUST BE DELAYED, GET BLOOD CULTURES AND START THERAPY. UÊÊ
`ÕÃÌÊ̅iÀ>«Þʜ˜ViÊ«>̅œ}i˜Ê>˜`ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>Àiʎ˜œÜ˜° UÊÊ-œ“iÊ>`ۜV>ÌiÊ«i˜ˆVˆˆ˜Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊvœÀÊ«>̅œ}i˜‡Ã«iVˆwVÊ̅iÀ>«ÞÊ in patients with severe allergies (p. 137). UÊÊ
˜ÌˆLˆœÌˆVÊ`œÃiÃÊ>Àiʅˆ}…iÀÊvœÀÊ -ʈ˜viV̈œ˜ÃÊ­«°ÊÇÇ®° UÊʘviV̈œÕÃÊ ˆÃi>ÃiÃÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊ>`ۈÃi`ÊvœÀÊ>Ê -ʈ˜viV̈œ˜Ã]Ê particularly those in which the preferred antibiotic cannot be used or in which the organism is resistant to usual therapy. Empiric therapy Host

Pathogens

Preferred Abx

Immunocompetent* >}iʐÊxä Immunocompetent* age > 50

S. pneumo, N. mening, H. influenzae S. pneumo, Listeria, H. influenzae, N. mening, Group B streptococci S. pneumo, N. mening, H. influenzae, Listeria, (Gram-negatives) S. pneumo (if CSF leak), H. influenzae, Staphylococci, Gram-negatives S. aureus, coagulasenegative staphylococci, Gram-negatives (rare)

Vancomycin PLUS Ceftriaxone Vancomycin PLUS Ceftriaxone PLUS Ampicillin

Alternative for serious PCN allergy (ID consult recommended) Moxifloxacin‡ PLUS Vancomycin Moxifloxacin‡ PLUS Vancomycin PLUS /*É-8

Vancomycin PLUS Cefepime PLUS Ampicillin

Vancomycin PLUS /*É-8ÊPLUS Ciprofloxacin

Vancomycin PLUS Cefepime

Vancomycin PLUS Ciprofloxacin

Vancomycin PLUS Cefepime

Vancomycin PLUS Ciprofloxacin

Immunocompromised†

Post neurosurgery or penetrating head trauma Infected shunt

† Immunocompromised is defined as solid organ transplant, BMT in the past year, leukemia undergoing treatment, or neutropenia ‡ Allergy consult for beta-lactam desensitization

* Use of Dexamethasone UÊÊ
``ˆÌˆœ˜ÊœvÊ`iÝ>“i̅>ܘiʈÃÊÀiVœ““i˜`i`ʈ˜Ê>Ê>`ՏÌÊ«>̈i˜ÌÃÊÜˆÌ…Ê suspected pneumococcal meningitis (note that this will be most adult patients). UÊÊ œÃi\Êä°£xʓ}Ɏ}Ê6Ê+ÈÊvœÀÊÓq{Ê`>Þà UÊÊ/…iÊwÀÃÌÊ`œÃiʓÕÃÌÊLiÊ>`“ˆ˜ˆÃÌiÀi`Ê£äqÓäʓˆ˜ÕÌiÃÊLivœÀiʜÀÊ concomitant with the first dose of antibiotics. 73

6.9 Central nervous system infections

Meningitis – Empiric treatment

6.9 Central nervous system infections

UÊÊ
`“ˆ˜ˆÃÌÀ>̈œ˜ÊœvÊ>˜ÌˆLˆœÌˆVÃÊŜՏ`ʘœÌÊLiÊ`i>Þi`Ê̜Ê}ˆÛiÊ dexamethasone. UÊÊ iÝ>“i̅>ܘiÊŜՏ`ʘœÌÊLiÊ}ˆÛi˜Ê̜ʫ>̈i˜ÌÃÊ܅œÊ…>ÛiÊ>Ài>`ÞÊ started antibiotics. UÊÊ œ˜Ìˆ˜ÕiÊ`iÝ>“i̅>ܘiʜ˜ÞʈvÊ̅iÊ -ÊÀ>“ÊÃÌ>ˆ˜ÊŜÜÃÊÀ>“‡ positive diplococci or if blood or CSF grows S. pneumoniae Pathogen-specific therapy (ID consult recommended) Pathogens

Preferred

S. pneumo PCN MIC ≤ 0.06 μg/ml AND/OR Ceftriaxone MIC 0.5 μg/ml S. pneumo PCN MIC ä°£q£Ê μg/ml AND Ceftriaxone MIC 1 μg/ml (ID consult recommended) S. pneumo PCN MIC  1 μg/ml AND Ceftriaxone MIC ≥1 μg/ml (ID consult recommended) N. meningitidis PCN susceptible (MIC  0.1) H. flu Non -lactamase producer H. flu -lactamase producer Listeria P. aeruginosa

Penicillin OR Ceftriaxone

E. coli K. pneumoniae Enterobacter spp. S. aureusq--
-°Ê>ÕÀiÕÃq,-
Ê Coagulase-negative staphylococci if Oxacillin MIC ≤ 0.25 Coagulase-negative staphylococci Oxacillin MIC  0.25 Enterococcus Candida species Cryptococcus

Ceftriaxone

Alternative for serious PCN allergy (Consult allergy for PCN skin testing ± desensitization) Vancomycin OR Moxifloxacin OR Linezolid

Ceftriaxone

Moxifloxacin OR Linezolid

Ceftriaxone PLUS Vancomycin PLUS Rifampin

Moxifloxacin OR Linezolid

Penicillin OR Ceftriaxone³

Consult ID

Ampicillin OR Ceftriaxone

Ciprofloxacin*

Ceftriaxone

Ciprofloxacin*

Ampicillin ± Cefepime OR Meropenem Gentamicin‡

Meropenem Oxacillin Vancomycin Oxacillin

/*É-8Ê Ciprofloxacin PLUS Aztreonam Aztreonam OR Ciprofloxacin ",Ê/*É-8 /*É-8ʜÀÊ ˆ«ÀœyœÝ>Vˆ˜ Vancomycin Vancomycin

Vancomycin

Ampicillin PLUS Gentamicin‡ Amphotericin B Amphotericin B PLUS Flucytosine

Vancomycin PLUS Gentamicin‡

* Consider beta-lactam desensitization ³ÊÕÃÌÊ}ˆÛiÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}ʜ˜ViÊ̜ÊiÀ>`ˆV>ÌiÊV>ÀÀˆiÀÊÃÌ>ÌiʈvÊ* ÊÕÃi`Ê>ÃÊÌÀi>̓i˜Ì ‡ Administer aminoglycosides systemically, not intrathecally

74

6.9 Central nervous system infections

TREATMENT NOTES Indications for head CT prior to LP UʈÃ̜ÀÞʜvÊ -Ê`ˆÃi>ÃiÃÊ­“>ÃÃʏiȜ˜]Ê 6
® UÊ i܇œ˜ÃiÌÊÃiˆâÕÀiÊ­ 1 week) UÊ*>«ˆi`i“> UÊ
ÌiÀi`ÊVœ˜ÃVˆœÕØiÃà UÊœV>Ê˜iÕÀœœ}ˆVÊ`iwVˆÌ Duration UÊÊ-/"*ÊÌÀi>̓i˜ÌʈvÊ*ÊVՏÌÕÀiʜLÌ>ˆ˜i`Ê«ÀˆœÀÊ̜Ê>˜ÌˆLˆœÌˆVÊ̅iÀ>«ÞʈÃÊ negative at 48 hours OR no PMNs on cell count UÊS. pneumoniae\Ê£äq£{Ê`>Þà UÊN. meningitidis\ÊÇÊ`>Þà UÊListeria\ÊÓ£Ê`>Þà UÊH. influenzae\ÊÇÊ`>Þà UÊÀ>“‡˜i}>̈ÛiÊL>Vˆˆ\ÊÓ£Ê`>Þà Adjunctive therapy UÊÊ œ˜Ãˆ`iÀʈ˜ÌÀ>VÀ>˜ˆ>Ê«ÀiÃÃÕÀiʓœ˜ˆÌœÀˆ˜}ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʈ“«>ˆÀi`Ê mental status.

Encephalitis UÊÊiÀ«iÃÊۈÀÕÃiÃÊ­-6]Ê6<6®ÊÀi“>ˆ˜Ê̅iÊ«Ài`œ“ˆ˜>˜ÌÊV>ÕÃiÃʜvÊÌÀi>Ì>LiÊ encephalitis. UÊ -Ê* ,ÃÊ>ÀiÊÀ>«ˆ`Ê`ˆ>}˜œÃ̈VÊÌiÃÌÃÊ>˜`Ê>««i>ÀʵՈÌiÊÃi˜ÃˆÌˆÛiÊ>˜`Ê specific. UÊ>ÛiʏœÜÊ̅ÀiŜ`Ê̜ÊÌÀi>ÌʈvÊÃÕëiVÌi`Ê>ÃÊ՘ÌÀi>Ìi`ʓœÀÌ>ˆÌÞÊ iÝVii`ÃÊÇ䯰 UÊ/Ài>̓i˜Ì\Ê
VÞVœÛˆÀÊ£äʓ}Ɏ}Ê6Ê+nÊvœÀÊ£{qÓ£Ê`>ÞÃ

75

6.9 Central nervous system infections

Brain abscess UÊÊ “«ˆÀˆVÊÌÀi>̓i˜ÌʈÃÊ}Ո`i`ÊLÞÊÃÕëiVÌi`ÊÜÕÀViÊ>˜`Ê՘`iÀÞˆ˜}Ê condition. While therapy should be adjusted based on culture results, anaerobic coverage should ALWAYS continue even if none are grown.

Source/ Condition

Pathogens

Preferred

Unknown

S. aureus, Streptococci, Gramnegatives, Anaerobes Streptococci (incl. S. pneumoniae), Anaerobes Gram-negatives, Streptococci Anaerobes Staphylococci, Gram negatives Streptococci (esp. S. viridans)

Vancomycin PLUS Ceftriaxone PLUS Metronidazole Q*i˜ˆVˆˆ˜Ê",Ê

ivÌÀˆ>ݜ˜iRÊ*1-Ê Metronidazole Cefepime PLUS Metronidazole

Sinusitis

Chronic otitis

Post neurosurgery Cyanotic heart disease

Vancomycin PLUS Cefepime Penicillin OR Ceftriaxone

Alternative for serious PCN allergy (ID consult recommended) Vancomycin PLUS Ciprofloxacin PLUS Metronidazole Vancomycin PLUS Metronidazole Aztreonam PLUS Metronidazole PLUS Vancomycin Vancomycin PLUS Ciprofloxacin Vancomycin

,iviÀi˜ViÃ\  -
ÊՈ`iˆ˜iÃÊvœÀÊ >VÌiÀˆ>Êi˜ˆ˜}ˆÌˆÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓää{ÆΙ\£ÓÈÇ° iÝ>“i̅>ܘiʈ˜Ê>`ՏÌÃÊ܈̅ÊL>VÌiÀˆ>Ê“i˜ˆ˜}ˆÌˆÃ\Ê Ê ˜}ÊÊi`ÊÓääÓÆÎ{Ç\£x{™°

CNS shunt infection Diagnosis UÊÊ ÕÌÕÀiʜvÊViÀiLÀœÃ«ˆ˜>ÊyՈ`ÊÀi“>ˆ˜ÃÊ̅iʓ>ˆ˜ÃÌ>ÞʜvÊ`ˆ>}˜œÃˆÃ°Ê Clinical symptoms may be mild and/or non-specific, and CSF chemistries and leukocyte counts may be normal. Empiric Therapy UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Cefepime 2 g IV Q8H OR UÊÊ* Ê
iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Ciprofloxacin 400 mg IV Q8H TREATMENT NOTES UÊID consult recommended for assistance with timing of shunt replacement and length of antibiotic therapy. UÊÊ,i“œÛ>ÊœvÊ>ÊVœ“«œ˜i˜ÌÃʜvÊ̅iʈ˜viVÌi`ÊÅ՘ÌÊ܈̅ÊiÝÌiÀ˜>Ê ventricular drainage or intermittent ventricular taps in combination with the appropriate intravenous antibiotic therapy leads to the highest effective cure rates. Success rates are substantially lower when the infected shunt components are not removed. 76

,iviÀi˜ViÃ\  -
ÊՈ`iˆ˜iÃÊvœÀÊ̅iÊ>˜>}i“i˜ÌʜvÊ >VÌiÀˆ>Êi˜ˆ˜}ˆÌˆÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊ Óää{ÆΙ\£ÓÈÇ°Ê /…iÀ>«Þʈ˜ÊViÀiLÀœÃ«ˆ˜>ÊyՈ`ÊÅ՘Ìʈ˜viV̈œ˜°Ê iÕÀœÃÕÀ}iÀÞÊ£™näÆÇ\{x™°

Antimicrobial doses for CNS infections – normal renal function Antibiotics UÊÊ
“ˆ˜œ}ÞVœÃˆ`iÃ\ÊÃiiÊ«°Ê£{x UÊÊ
“«ˆVˆˆ˜\ÊÓÊ}Ê6Ê+{Ê UÊÊ
âÌÀiœ˜>“\ÊÓÊ}Ê6Ê+È UÊÊ ivÌÀˆ>ݜ˜i\ÊÓÊ}Ê6Ê+£Ó UÊÊ ivi«ˆ“i\ÊÓÊ}Ê6Ê+n UÊÊ ˆ«ÀœyœÝ>Vˆ˜\Ê{ääʓ}Ê6Ê+nÊ­L>Ãi`ʜ˜Êˆ“ˆÌi`Ê`>Ì>® UÊʜ݈yœÝ>Vˆ˜\Ê{ääʓ}Ê6Ê+Ó{ UÊÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n UÊÊiÌÀœ˜ˆ`>✏i\Êxääʓ}Ê6Ê+È UÊÊ"Ý>Vˆˆ˜\ÊÓÊ}Ê6Ê+{ UÊÊ*i˜ˆVˆˆ˜\Ê{ʓˆˆœ˜Ê՘ˆÌÃÊ6Ê+{Ê­Ó{ʓˆˆœ˜Ê՘ˆÌÃÊ«iÀÊ`>Þ® UÊÊ,ˆv>“«ˆ˜\ÊÈääʓ}Ê6Ê+£ÓqÓ{ UÊÊ/*É-8\Êxʓ}Ɏ}Ê­/*ÊVœ“«œ˜i˜Ì®Ê6Ê+È UÊÊ6>˜Vœ“ÞVˆ˜\ʏœ>`Ê܈̅ÊÓxqÎxʓ}Ɏ}]Ê̅i˜Ê£xqÓäʓ}Ɏ}Ê+nq£ÓÊ (minimum 1 g Q12H) UÊÊ6>˜Vœ“ÞVˆ˜ÊŜՏ`ÊLiÊ>`“ˆ˜ˆÃÌiÀi`Ê̜ʓ>ˆ˜Ì>ˆ˜ÊÃiÀՓÊÌÀœÕ}…Ê concentrations close to 20 mcg/mL. Antifungals UÊÊ
“«…œÌiÀˆVˆ˜\Êä°Çq£Ê“}Ɏ}Ê6Ê+Ó{ UÊ
“ ˆÃœ“i®\Ê·{ʓ}Ɏ}Ê6Ê+Ó{ÊvœÀÊ Àޫ̜VœVV>Ê“i˜ˆ˜}ˆÌˆÃ UÊÊ
“ ˆÃœ“i®\Êxʓ}Ɏ}Ê6Ê+Ó{ÊvœÀÊ >˜`ˆ`>ʓi˜ˆ˜}ˆÌˆÃ UʏÕVœ˜>✏i\Ênääq£Óääʓ}Ê6É*"Ê+Ó{Ê­V>˜Ê}ˆÛiʈ˜Ê`ˆÛˆ`i`Ê`œÃiî UÊʏÕVÞ̜Și\ÊÓxʓ}Ɏ}Ê*"Ê+È Intraventricular antibiotics (ID consult recommended) UÊÊ
“ˆŽ>Vˆ˜\ÊÎäʓ}Ê+Ó{Ê­Vœ˜Ì>ˆ˜ÃÊ«ÀiÃiÀÛ>̈Ûi® UÊÊi˜Ì>“ˆVˆ˜\Êxʓ}Ê+Ó{ UÊÊ/œLÀ>“ÞVˆ˜\Êxʓ}Ê+Ó{ UÊÊ6>˜Vœ“ÞVˆ˜\ÊÓäʓ}Ê+Ó{

77

6.9 Central nervous system infections

UÊÊ/…iÊÀœiʜvʈ˜ÌÀ>Ûi˜ÌÀˆVՏ>ÀÊ>˜ÌˆLˆœÌˆVÃʈÃÊVœ˜ÌÀœÛiÀÈ>]Ê>˜`Ê}i˜iÀ>ÞÊ limited to refractory cases or cases in which shunt removal is not possible. Intraventricular injection should be administered only by experienced physicians.

6.10 Acute bacterial rhinosinusitis

Acute bacterial rhinosinusitis (ABRS) NOTE: Sinusitis in immunocompromised hosts can be caused by fungi >˜`ʜ̅iÀʏiÃÇVœ““œ˜Ê«>̅œ}i˜ÃÆÊVœ˜ÃՏÌ>̈œ˜Ê܈̅Ê Ê>˜`Ê /ʈÃÊ recommended to guide management and therapy. œÃÌÊÀ…ˆ˜œÃˆ˜ÕÈ̈ÃÊ`œiÃʘœÌÊÀiµÕˆÀiÊ>˜ÌˆLˆœÌˆVÊÌÀi>̓i˜ÌÆÊÌÀi>̓i˜ÌÊ Ã…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê̅iÊvœœÜˆ˜}ÊÃVi˜>ÀˆœÃ\ UÊ*iÀÈÃÌi˜ÌÊÃޓ«Ìœ“ÃʜvÊ>VÕÌiÊÀ…ˆ˜œÃˆ˜ÕÈÌÕÃÊ≥ 10 days without improvement UÊiÛiÀÊ≥39°C and purulent nasal discharge or facial pain lasting >3-4 days from the beginning of illness UÊ iÜʜ˜ÃiÌʜvÊviÛiÀ]ʅi>`>V…iʜÀʈ˜VÀi>Ãiʈ˜Ê˜>Ã>Ê`ˆÃV…>À}iÊvœœÜˆ˜}Ê viral URI that lasted 5-6 days and was initially improving EMPIRIC TREATMENT Oral regimens UÊ
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê+£Ó OR UÊ
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊ8,ÊÓÊ}Ê*"Ê+£ÓÊÊvœÀÊ«>̈i˜ÌÃÊ܈̅ÊÃiÛiÀiÊ infection (e.g. systemic toxicity with fever of 39°C), antibiotic use in previous 30 days, immunocompromised OR UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv«œ`œÝˆ“iÊÓääʓ}Ê*"Ê+£Ó OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê*"Ê`>ˆÞÊÊ Parenteral regimens UÊ
“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+È OR UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+Ó{ÊÊ Duration UÊx‡ÇÊ`>ÞÃÊ TREATMENT NOTES Microbiology UÊ*Ài`œ“ˆ˜>˜ÌÞÊS. pneumoniae, H. influenzae, M. catarrhalis UÊÀ>“‡˜i}>̈ÛiÊi˜ÌiÀˆVÊL>VˆˆÊ>ÀiÊÀ>Ài Management UÊ
,-ʈÃÊÀ>ÀiÞÊ«ÀiÃi˜ÌÊ«ÀˆœÀÊ̜ÊÇq£äÊ`>ÞÃʜvÊÃޓ«Ìœ“ÃÆÊÌÞ«ˆV>Ê inciting etiologies of acute sinusitis include allergies and viral URI 78

,iviÀi˜Vi\Ê  -
Ê}Ո`iˆ˜iÃÊvœÀÊ
,-°Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£ÓÆÊx{­n®\iÇӇi££Ó°Ê

79

6.10 Acute bacterial rhinosinusitis

UÊ ÕÌÕÀiÃÊLÞÊ`ˆÀiVÌÊȘÕÃÊ>ëˆÀ>̈œ˜ÊœÀÊi˜`œÃVœ«ˆV>ÞÊ}Ո`i`ÊVՏÌÕÀiʜvÊ the middle meatus should only be obtained in patients who fail empiric antibiotic therapy. Nasopharyngeal swab is NOT recommended for obtaining culture data. UÊ œ˜wÀ“>̈œ˜ÊœvÊ`ˆ>}˜œÃˆÃÊ܈̅ʈ“>}ˆ˜}ʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ uncomplicated ABRS. Consider CT in those with severe disease with possible extension to the orbit or intracranial space. UʘÌÀ>˜>Ã>ÊÃ>ˆ˜iʈÀÀˆ}>̈œ˜Ê­«…ÞȜœ}ˆVʜÀʅޫiÀ̜˜ˆV®Ê>˜`ʈ˜ÌÀ>˜>Ã>Ê corticosteroids are recommended as an adjuncts to antibiotic therapy and can also provide symptomatic relief in patients in whom antibiotic are not indicated UÊ>VÀœˆ`iÃÊ­ >ÀˆÌ…Àœ“ÞVˆ˜]Ê
âˆÌ…Àœ“ÞVˆ˜®Ê>ÀiʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ initial empiric therapy due to high rates of resistance of S. pneumoniae ­xx¯Ê>ÌÊ® UÊ iëˆÌiÊ -
Ê}Ո`iˆ˜iÃÊÃÕ««œÀ̈˜}ÊÕÃiʜvÊ œÝÞVÞVˆ˜iÊ>ÃÊ>˜Ê alternative agent for ABRS, Doxycycline is NOT recommended for initial empiric therapy at JHH due to high rates of resistance of S. pneumoniae ­Óǯ®Ê>˜` H. influenzae ­Îx¯® UÊ,œṎ˜iÊVœÛiÀ>}iÊvœÀÊ,-
ʈ˜Êˆ˜ˆÌˆ>Êi“«ˆÀˆVÊ̅iÀ>«ÞÊvœÀÊ
,-ʈ˜Ê˜œÌÊ recommended

6.11 Orbital cellulitis

Orbital cellulitis Preseptal cellulitisÊ­€™ä¯ÊœvÊV>Ãiî UʘۜÛiÃÊ̈ÃÃÕiÃÊ>˜ÌiÀˆœÀÊ̜Ê̅iʜÀLˆÌ>ÊÃi«ÌÕ“Ê UÊ*ÀiÃi˜ÌÃÊ܈̅ÊviÛiÀ]ÊiÞiˆ`ÊiÀÞ̅i“>Ê>˜`ÊÜvÌÊ̈ÃÃÕiÊÃÜiˆ˜}ÊLÕÌʘœÊ orbital congestion Postseptal cellultis UÊ-ˆ}˜ÃʜvÊ«iÀˆœÀLˆÌ>ÊViÕˆÌˆÃÊ>ÃÊÜiÊ>Ãʏˆ“ˆÌ>̈œ˜ÊœvʜVՏ>ÀʓœÛi“i˜ÌÃ]Ê pain with ocular movement, and/or proptosis UÊ-iÛiÀiʈ˜viV̈œ˜ÊV>˜Ê>ÃœÊˆ˜ÛœÛiÊۈÃÕ>ÊœÃÃ]ÊÃÕL«iÀˆœÃÌi>Ê>LÃViÃÃ]Ê globe displacement, abscess formation UÊ"vÌi˜Ê>ÃÜVˆ>Ìi`Ê܈̅ÊȘÕÈ̈ÃÊ UÊ >˜ÊLiÊ>ÃÜVˆ>Ìi`Ê܈̅ÊV>ÛiÀ˜œÕÃÊȘÕÃÊ̅Àœ“LœÃˆÃ EMPIRIC TREATMENT UÊ
“«ˆVˆˆ˜ÉÃՏL>VÌ>“ÊÎÊ}Ê6Ê+È OR UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivÌÀˆ>ݜ˜iÊÓÊ}Ê6Ê`>ˆÞ OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê`>ˆÞ Add Vancomycin (see dosing section, p. 150) in patients with history of MRSA colonization or infection, evidence of abscess or bone involvement, orbital trauma, recent ophthalmic surgery or severe infection Oral step down therapy (for patients without culture data to guide therapy and without evidence of bony involvement or cavernous sinus thrombosis) UÊ
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê+£Ó OR UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê iv«œ`œÝˆ“iÊ{ääʓ}Ê*"Ê+£Ó OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê*"Ê`>ˆÞ Duration UÊÇÊ`>ÞÃÊÕ«Ê̜ÊÈÊÜiiŽÃʈvÊiۈ`i˜ViʜvÊLœ˜Þʈ˜ÛœÛi“i˜Ì TREATMENT NOTES Microbiology UÊS. aureus, beta-hemolytic streptococci, S. pneumoniae, H. influenza, M. catarrhalis (cultures are infrequently positive) Management UÊ“>}ˆ˜}ʈÃÊÀiVœ““i˜`i`ʈ˜Ê«œÃ̇Ãi«Ì>ÊViÕˆÌˆÃÊ­ /ʜÀÊ,® UÊ œ˜ÃՏÌ>̈œ˜Ê܈̅Ê ]Ê /]Ê>˜`ʜ«…Ì…>“œœ}ÞÊÀiVœ““i˜`i` 80

81

6.11 Orbital cellulitis

UÊ*œÃ̇Ãi«Ì>ÊViÕˆÌˆÃʈ˜Êˆ““Õ˜œVœ“«Àœ“ˆÃi`ʅœÃÌÃÊV>˜ÊLiÊV>ÕÃiÊ LÞÊv՘}ˆÊ>˜`ʓœ`ÃÆÊi“«ˆÀˆVÊ>˜Ìˆv՘}>Ê̅iÀ>«ÞʈÃÊÀiVœ““i˜`i`ʈ˜Ê consultation with ID UÊ*œÃ̇Ãi«Ì>ÊViÕˆÌˆÃÊ܈̅Ê>LÃViÃÃÊvœÀ“>̈œ˜ÊŜՏ`Ê«Àœ“«Ìʈ““i`ˆ>ÌiÊ surgical intervention UÊ,i뜘ÃiÊ̜Ê>««Àœ«Àˆ>ÌiÊ>˜ÌˆLˆœÌˆVÊ̅iÀ>«ÞÊŜՏ`ʜVVÕÀʈ˜ÊÓ{ÊqÊ{nÊ hours UÊ*œœÀÊÀi뜘ÃiÊ̜Ê>˜ÌˆLˆœÌˆVÃ]ÊܜÀÃi˜ˆ˜}ÊۈÃÕ>Ê>VՈÌÞʜÀÊ«Õ«ˆ>ÀÞÊ changes and/or evidence of an abscess are indications for surgery

6.12 Pulmonary infections

COPD exacerbations EMPIRIC TREATMENT UÊÊÊDoxycycline 100 mg PO BID for 5 days OR UÊÊ
âˆÌ…Àœ“ÞVˆ˜Êxääʓ}Ê*"É6Ê+Ó{ÊvœÀÊÎÊ`>Þà OR UÊÊ
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê  ÊvœÀÊxÊ`>Þà OR UÊÊ iv«œ`œÝˆ“iÊÓääʓ}Ê*"Ê  ÊvœÀÊxÊ`>Þà OR UÊ iv`ˆ˜ˆÀÊÎääʓ}Ê*"Ê  ÊvœÀÊxÊ`>Þà TREATMENT NOTES Microbiology UÊÊ*Ài`œ“ˆ˜>˜ÌÞÊH. influenzae, M. catarrhalis, S. pneumoniae UÊÊPseudomonas, Enterobacteriaceae are less common and seen in patients with severe COPD and extensive antibiotic exposure. Management UÊÊ “«ˆÀˆVÊÕÃiʜvÊy՜ÀœµÕˆ˜œœ˜iÃʈÃÊ`ˆÃVœÕÀ>}i`Ê>˜`ÊŜՏ`ʜ˜ÞÊ be considered if past or present microbiologic evidence indicates infection with a pathogen(s) that is resistant to standard therapy (e.g. Pseudomonas, Enterobacteriaceae). UÊÊ6Ê>˜ÌˆLˆœÌˆVÃÊŜՏ`ʜ˜ÞÊLiÊÕÃi`ʈvÊ̅iÊ«>̈i˜ÌÊV>˜˜œÌÊ̜iÀ>ÌiÊ*"Ê antibiotics. UÊÊ
˜ÌˆLˆœÌˆVÃÊ>ÀiʘœÌʈ˜`ˆV>Ìi`ÊvœÀÊ>Ã̅“>Êy>ÀiÃʈ˜Ê̅iÊ>LÃi˜ViʜvÊ pneumonia. Prophylactic antibiotics for the prevention of COPD exacerbations UÊ*Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃʅ>ÛiÊLii˜ÊŜܘÊ̜ÊÀi`ÕViÊÀ>ÌiÃʜvÊ exacerbations and improve reported quality of life but not to decrease all-cause or respiratory-associated mortality UÊ*Àœœ˜}i`Ê
âˆÌ…Àœ“ÞVˆ˜ÊÕÃiʅ>ÃÊLii˜Ê>ÃÜVˆ>Ìi`Ê܈̅ʅi>Àˆ˜}ʏœÃÃÊ >˜`Ê+/Ê«Àœœ˜}>̈œ˜ÆÊ«>̈i˜ÌÃÊ܈̅ÊL>Ãiˆ˜iÊ+/‡«Àœœ˜}>̈œ˜ÊÜiÀiʘœÌÊ included in clinical trials UÊ/…iÊ`iVˆÃˆœ˜Ê̜ʈ˜ˆÌˆ>ÌiÊ«Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊŜՏ`ÊLiʓ>`iʜ˜Ê>Ê case-by-case basis and should take in to account patient preferences, financial constraints, risk factors for adverse events and input from the patient’s pulmonologist UÊ,iVœ““i˜`i`ÊÀi}ˆ“i˜\Ê
âˆÌ…Àœ“ÞVˆ˜ÊÓxäʓ}Ê*"Ê`>ˆÞ UÊ >Ãiˆ˜iÊ>Õ`ˆœ“iÌÀÞÊ>˜`Ê ʈÃÊÀiVœ““i˜`i` ,iviÀi˜ViÃ\
“iÀˆV>˜Ê œi}iʜvÊ*…ÞÈVˆ>˜ÃÊ*œÃˆÌˆœ˜Ê*>«iÀ\Ê
˜˜Ê˜ÌiÀ˜Êi`ÊÓää£ÆÊ£Î{\Èää° ÕÀ>̈œ˜ÊœvÊ̅iÀ>«Þ\Ê/…œÀ>ÝÊÓäänÆÊÈέx®\{£xqÓÓ°
âˆÌ…Àœ“ÞVˆ˜ÊvœÀÊ«ÀiÛi˜Ìˆœ˜\Ê °Ê ˜}°ÊÊi`ÊÓ䣣ÆÊÎÈx\ÊÈn™ÆÊ œV…À>˜iÊ >Ì>L>ÃiÊ-ÞÃÌÊ Rev 2013 Nov 28.

82

NOTE: If patient is coming from a nursing home or long-term care facility, see Healthcare-acquired pneumonia, p. 87. EMPIRIC TREATMENT Patient NOT in the ICU UÊ
“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+ÈÊPLUS Azithromycin 500 mg IV/PO once daily OR UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Azithromycin 500 mg IV/PO once daily OR Uʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê In non-critically ill patients, consider switch to oral agents as soon as patient is clinically improving and eating (see next page for oral options and doses). Patient in the ICU Not at risk for infection with Pseudomonas (see risks below) UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Azithromycin 500 mg IV Q24H OR UÊÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+Ó{Ê At risk for infection with Pseudomonas (see risks below) UÊÊ ivi«ˆ“iÊ£‡ÓÊ}Ê6Ê+nÊPLUS Azithromycin 500 mg IV Q24H OR UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+ÈÊPLUS Azithromycin 500 mg IV Q24H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+Ó{ÊPLUS Aztreonam 2 g IV Q8H UÊÊ-«ÕÌՓÊ}À>“ÊÃÌ>ˆ˜Ê“>Þʅi«Ê`iÌiÀ“ˆ˜iʈvÊPseudomonas is present. UÊÊNarrow coverage if Pseudomonas is NOT present on culture at 48 hours. Risks for PseudomonasÊ>˜`ʜ̅iÀÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiʜÀ}>˜ˆÃ“Ã\ LÀœ˜V…ˆiVÌ>ÈÃÆÊLÀœ>`‡Ã«iVÌÀՓÊ>˜ÌˆLˆœÌˆVÃÊvœÀʀÊÇÊ`>ÞÃʈ˜Ê̅iÊ«>ÃÌÊ “œ˜Ì…ÆÊ«Àœœ˜}i`ʅœÃ«ˆÌ>ˆâ>̈œ˜Ê€ÊÇÊ`>ÞÃÆÊ`iLˆˆÌ>Ìi`ʘÕÀȘ}ʅœ“iÊ ÀiÈ`i˜ÌÆÊÀiVi˜ÌʓiV…>˜ˆV>ÊÛi˜Ìˆ>̈œ˜Ê€Ê{nÊÆʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê due to solid organ transplant, hematologic malignancy, BMT, active chemotherapy, prednisone > 20 mg daily for > 3 weeks. DIAGNOSIS UÊÊ““Õ˜œVœ“«iÌi˜ÌÊ«>̈i˜ÌÃÊ1-/ʅ>ÛiÊ>ÊV…iÃÌÊ8‡À>Þʈ˜wÌÀ>ÌiÊ̜ʓiiÌÊ diagnostic criteria for pneumonia. UÊÊ-«ÕÌՓÊ>˜`ÊLœœ`ÊVՏÌÕÀiÃÊŜՏ`ÊLiÊÃi˜Ìʜ˜Ê>Ê«>̈i˜ÌÃÊ>`“ˆÌÌi`ÊÌœÊ the hospital BEFORE antibiotics are given. UÊÊS. pneumoniae urine antigen should be obtained in all patients with CAP. Ìʅ>ÃÊëiVˆwVˆÌÞʜvʙȯÊ>˜`Ê«œÃˆÌˆÛiÊ«Ài`ˆV̈ÛiÊÛ>ÕiʜvÊnn°n‡™È°x¯°ÊÌÊ is particularly useful if antibiotics have already been started or cultures cannot be obtained. 83

6.12 Pulmonary infections

Community-acquired pneumonia (CAP) in hospitalized patients

6.12 Pulmonary infections

UÊÊ/…iʏi}ˆœ˜i>ÊÕÀˆ˜iÊ>˜Ìˆ}i˜ÊˆÃÊ̅iÊÌiÃÌʜvÊV…œˆViÊvœÀÊ`ˆ>}˜œÃˆ˜}Ê legionella infection. This test detects only L. pneumophila serogroup £]Ê܅ˆV…ʈÃÊÀi뜘ÈLiÊvœÀÊÇäqnä¯Êœvʈ˜viV̈œ˜Ã° DURATION UÊ/…iÀ>«ÞÊV>˜ÊLiÊÃ̜««i`Ê>vÌiÀÊ̅iÊ«>̈i˜ÌʈÃ\ Ê UÊ
viLÀˆiÊvœÀÊ{nqÇÓʅœÕÀà AND Ê UÊÊ>ÃʘœÊ“œÀiÊ̅>˜Êœ˜iʜvÊ̅iÊvœœÜˆ˜}ÊÈ}˜ÃÊ>˜`ÊÃޓ«Ìœ“Ã\Ê,Ê  100 beats/min, RR  24 breaths/min, BP  90 mmHg, O2 sat ʙä¯]Ê>ÌiÀi`ʓi˜Ì>ÊÃÌ>ÌÕÃ°Ê UÊÊ-Õ}}iÃÌi`Ê`ÕÀ>̈œ˜ÊœvÊ̅iÀ>«ÞÊL>Ãi`ʜ˜Ê«>̈i˜ÌÊëiVˆwVÊv>V̜ÀÃ\ Ê UÊÊ3–5 days: Patient without immunocompromise or structural lung disease Ê UÊÊ7 days: Patients with moderate immunocompromise and/or structural lung disease Ê UÊÊ10–14 days: Patients with poor clinical response, who received initial inappropriate therapy, or who are significantly immunocompromised UÊÊ1˜Vœ“«ˆV>Ìi`ÊL>VÌiÀi“ˆVÊ«˜iՓœVœVV>Ê«˜iՓœ˜ˆ>qÊ«Àœœ˜}i`Ê course of antibiotic therapy not necessary, treat as pneumonia UÊÊ œÕ}…Ê>˜`ÊV…iÃÌÊ8‡À>ÞÊ>L˜œÀ“>ˆÌˆiÃʓ>ÞÊÌ>ŽiÊ{qÈÊÜiiŽÃÊ̜ʈ“«ÀœÛi°Ê There is NO need to extend antibiotics if the patient is doing well otherwise (e.g. no fever). Other causes of pneumonia UÊÊ-ÕëiVÌi`Ê>ëˆÀ>̈œ˜\ Additional empiric coverage for aspiration is justified only in classic aspiration syndromes suggested by loss of consciousness (overdose, seizure) PLUS gingival disease or esophageal motility disorder. Ceftriaxone, Cefepime, and Moxifloxacin have adequate activity against most oral anaerobes. For classic aspiration, Clindamycin 600 mg IV Q8H can be added to regimens not containing Piperacillin/tazobactam. UÊÊ œ““Õ˜ˆÌއ>VµÕˆÀi`Ê,-
\ Necrotizing pneumonia with cavitation in absence of risk factors for aspiration listed above is concerning for CA-MRSA pneumonia, particularly if associated with a preceding or concomitant influenza-like illness. In these cases, Linezolid 600 mg IV/PO Q12H can be added while awaiting culture data. Infectious Diseases consult is strongly recommended. Use of Linezolid monotherapy for MRSA bacteremia, even if associated with a pulmonary source, is not recommended. In the absence of necrotizing pneumonia with cavitation, empiric coverage for CA-MRSA can be deferred until sputum and blood culture results return given their high diagnostic yield for CA-MRSA. UÊÊ,iëˆÀ>̜ÀÞÊۈÀÕÃiÃ\ Respiratory viruses can cause primary viral pneumonia as well as lead to bacterial superinfection. Strongly consider testing all patients with CAP during respiratory virus season (see p. 93). ,iviÀi˜ViÃ\  -
É
/-Ê œ˜Ãi˜ÃÕÃÊՈ`iˆ˜iÃÊvœÀÊ
*\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓääÇÆ{{\-ÓÇ° S. pneumo >˜Ìˆ}i˜\Ê
ÀV…ʘÌiÀ˜Êi`ÊÓ䣣ƣǣ­Ó®\£ÈÈqÇÓ ÎÊ`>ÞÃʜvÊ̅iÀ>«ÞÊvœÀÊ
*\Ê ÊÓääÈÆÎÎÓ\£Îxx°

84

85

Ceftriaxone 1 g IV Q24 OR Cefpodoxime 200 mg PO BID OR Cefdinir 300 mg PO BID
“«ˆVˆˆ˜Ê£Ê}Ê6Ê+ÈÊ OR Amoxicillin 500 mg PO TID Ê

S. pneumoniae PCN resistant, cephalosporin susceptible

Ê

H. influenzae ˜œ˜‡LiÌ>‡>VÌ>“>ÃiÊÊ producing (Ampicillin susceptible)

Penicillin G 1 million units IV Q6H OR Amoxicillin 1 g PO TID

S. pneumoniae PCN intermediate or urine antigen positive

Amoxicillin 500 mg PO TID Ê Ê

Penicillin G 1 million units IV Q6H OR

Ê Ê

Preferred therapy

S. pneumoniae PCN susceptible

Pathogen-specific and step-down therapy

Organism

PCN allergy


âˆÌ…Àœ“ÞVˆ˜IQxääʓ}Ê*"Ê`>ˆÞÊ8ÊÎÊ`>ÞÃÊ",ÊÊ xääʓ}ʜ˜Vi]Ê̅i˜ÊÓxäʓ}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃR ORÊ

iv«œ`œÝˆ“iÊÓääʓ}Ê*"Ê  ÊÊÊ OR Cefdinir 300 mg PO BID OR Doxycycline† 100 mg PO BID OR Moxifloxacin 400 mg IV/PO daily (if resistant to other options)

Moxifloxacin 400 mg IV/PO Q24H

Same as above

Non-severe reaction:ÊÊ Cefpodoxime 200 mg PO BID OR Cefdinir 300 mg PO BID Severe reaction:
âˆÌ…Àœ“ÞVˆ˜IQxääʓ}Ê*"Ê`>ˆÞÊÊ8ÊÎÊ`>ÞÃÊÊ ",Êxääʓ}ʜ˜Vi]Ê̅i˜ÊÓxäʓ}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃRÊ OR Moxifloxacin 400 mg IV/PO daily (if Erythromycin resistant)

Notes

6.12 Pulmonary infections

Çx¯ÊœvÊH. influenzae isolates at JHH (excluding oncology) are susceptible to
“«ˆVˆˆ˜]Ê£ää¯ÊÌœÊ ivÌÀˆ>ݜ˜i]ÊÈx¯ÊÌœÊ /iÌÀ>VÞVˆ˜i]Ê>˜`Ê£ää¯Ê̜ʜ݈yœÝ>Vˆ˜Ê

None of the S. pneumoniae isolates at (excluding oncology) are resistant JHH to PCN

™£¯ÊœvÊS. pneumoniae isolates at JHH (excluding oncology) are susceptible and ™¯Ê>Àiʈ˜ÌiÀ“i`ˆ>ÌiÊ̜Ê* ]Ê{x¯Ê>Ài susceptible to Erythromycin (Erythromycin susceptibilities predict Azithromycin ÃÕÃVi«ÌˆLˆˆÌˆiÃÊvœÀÊS. pneumoniae), and £ää¯Ê>ÀiÊÃÕÃVi«ÌˆLiÊ̜ʜ݈yœÝ>Vˆ˜

86

iv«œ`œÝˆ“iÊÓääʓ}Ê*"Ê  ÊÊ œÝˆyœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê OR Cefdinir 300 mg PO BID OR
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊ8,ÊÓÊ}Ê*"Ê  Ê Ê Ê Ê œÌi\Ê1˜iÃÃÊÃÌÀœ˜}ÊÃÕëˆVˆœ˜ÊvœÀÊÊ Ê L. pneumophilia, more than 3 days of Azithromycin for atypical coverage is not needed due to very long half-life in lung tissue

ՏÌÕÀiÊ>˜`ÊÕÀˆ˜iÊ>˜Ìˆ}i˜Ê˜i}>̈ÛiÊ

IˆvÊ ÀÞ̅Àœ“ÞVˆ˜ÊÃÕÃVi«ÌˆLiÆÊaʈvÊ/iÌÀ>VÞVˆ˜iÊÃÕÃVi«ÌˆLi

Ê Ê Ê

Ê

Azithromycin 500 mg IV/PO Q24H OR œÝˆyœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê

L. pneumophilia

PCN allergy

Azithromycin 500 mg IV/PO Q24H x 7-10 days OR œÝˆyœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{Ê8ʣ䇣{Ê`>ÞÃ


âˆÌ…Àœ“ÞVˆ˜IQxääʓ}Ê*"Ê`>ˆÞÊ8ÊÎÊ`>ÞÃÊ",Ê xääʓ}ʜ˜Vi]Ê̅i˜ÊÓxäʓ}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃR OR Cefpodoxime 200 mg PO BID OR Cefdinir 300 mg PO BID OR Doxycycline† 100 mg PO BID OR Moxifloxacin 400 mg IV/PO Q24H (if resistant to other options)

Preferred therapy


“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê+ÈÊ ORÊ Amoxicillin/clavulanate 875 mg PO BID

H. influenzae LiÌ>‡>VÌ>“>ÃiÊÊ producing (Ampicillin resistant)

Pathogen-specific and step-down therapy

Organism

{x¯ÊœvÊS. pneumoniae isolates at JHH (excluding oncology) are susceptible to Erythromycin (Erythromycin susceptibilities predict Azithromycin susceptibilities for S. pneumoniae®Ê>˜`ÊÇίÊ>ÀiÊÃÕÃVi«ÌˆLiÊ ÌœÊ/iÌÀ>VÞVˆ˜iÆÊ̅iÀivœÀi]Ê̅iÃiÊ>}i˜Ìà >ÀiÊÃÕLœ«Ìˆ“>ÊvœÀÊi“«ˆÀˆVÊÃÌi«‡`œÜ˜ therapy

Notes

6.12 Pulmonary infections

NOTE: If the patient is on antibiotic therapy or has recently been on antibiotic therapy, choose an agent from a different class. EMPIRIC TREATMENT Patient with mild to moderate illness (e.g., not in or transferring to the ICU/intermediate care unit, no or minimal oxygen requirement, no hypotension) UÊ ivÌÀˆ>ݜ˜iIÊ£Ê}Ê6Ê+Ó{ OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6É*"Ê+Ó{ Patient with severe illness (e.g., in or transferring to the ICU/ intermediate care unit, concern for sepsis, significant oxygen requirement, multi-lobar consolidation) UÊ ivi«ˆ“iIÊÓÊ}Ê6Ê+nʱ Vancomycin† (see dosing section, p. 150) OR UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“IÊ{°xÊ}Ê6Ê+Èʱ Vancomycin† (see dosing section, p. 150) OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Ciprofloxacin 400 mg IV Q8H ± Gentamicin (see dosing section, p. 146) *Consider adding Azithromycin 500 mg IV/PO Q24H if the patient is immunosuppressed or coming from a nursing home or long term care facility to cover Legionella †Add Vancomycin in patients with a history of MRSA colonization or infection, necrotizing pneumonia, pneumonia after a respiratory viral illness, ill patients coming from a nursing home or long term care facility, sepsis)

Patient with history of or risk factors for Pseudomonas and other resistant Gram-negative organismsÊ­i°}°]ÊLÀœ˜V…ˆiVÌ>ÈÃÆÊLÀœ>`‡Ã«iVÌÀÕ“Ê >˜ÌˆLˆœÌˆVÃÊvœÀʀÊÇÊ`>ÞÃʈ˜Ê̅iÊ«>ÃÌʓœ˜Ì…ÆÊ«Àœœ˜}i`ʅœÃ«ˆÌ>ˆâ>̈œ˜Ê€Ê ÇÊ`>ÞÃÆÊ`iLˆˆÌ>Ìi`ʘÕÀȘ}ʅœ“iÊÀiÈ`i˜ÌÆÊÀiVi˜ÌʓiV…>˜ˆV>ÊÛi˜Ìˆ>̈œ˜Ê €Ê{nʅœÕÀÃÆʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê`ÕiÊ̜Ê܏ˆ`ʜÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê hematologic malignancy, BMT, active chemotherapy, prednisone > 20 “}Ê`>ˆÞÊvœÀʀÊÎÊÜiiŽÃ®\ÊÌÀi>ÌÊ>ÃÊÃiÛiÀiʈ˜iÃÃÊ܈̅ÊÌ>ˆœÀˆ˜}ʜvÊ>˜ÌˆLˆœÌˆVÊ based on past culture data NOTE: Always narrow therapy based on cultures results Oral step down therapy (if no sputum culture data to guide therapy) UÊÊ iv«œ`œÝˆ“iÊ{ääʓ}Ê*"Ê  Ê­ˆvʜ˜Ê ivÌÀˆ>ݜ˜i®Ê",ʜ݈yœÝ>Vˆ˜Ê{ääÊ mg PO daily Duration:ʈvÊ«˜iՓœ˜ˆ>ÊVœ˜wÀ“i`Êx‡ÇÊ`>ÞÃÆʈvÊ«˜iՓœ˜ˆ>Ê`ˆ>}˜œÃˆÃʈÃÊ questionable and patient improves, can considered stopping therapy after 3 days TREATMENT NOTES Microbiology UÊÊ ˜ÌiÀœVœVVˆÊ>˜`ÊV>˜`ˆ`>ÊëiVˆiÃÊ>ÀiʜvÌi˜ÊˆÃœ>Ìi`ÊvÀœ“Ê̅iÊëÕÌÕ“Ê in hospitalized patients. In general, they should be considered to be colonizing organisms and should not be treated with antimicrobials. 87

6.12 Pulmonary infections

Healthcare-acquired pneumonia (NOT ventilator-associated)

6.12 Pulmonary infections

Antimicrobial management of “aspiration events” UÊ*Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊ
, Ê "/ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܅œÊ>ÀiÊ at increased risk for aspiration. UÊ““i`ˆ>ÌiÊÌÀi>̓i˜ÌʈÃʈ˜`ˆV>Ìi`ÊvœÀÊ«>̈i˜ÌÃÊ܅œÊ…>ÛiÊÓ>‡LœÜiÊ obstructions or are on acid suppression therapy given the increased risk of gastric colonization. UÊ
˜ÌˆLˆœÌˆVÊÌÀi>̓i˜ÌʜvÊ«>̈i˜ÌÃÊ܅œÊ`iÛiœ«ÊviÛiÀ]ʏiՎœVÞ̜ÈÃÊ>˜`Ê infiltrates in the first 48 hours after an aspiration is likely unnecessary since most aspiration pneumonias are chemical and antibiotic treatment may only select for more resistant organisms. UÊ/Ài>̓i˜ÌÊ-ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܅œÊ…>ÛiÊÃޓ«Ìœ“ÃÊvœÀÊ more than 48 hours or who are severely ill. ,iviÀi˜ViÃ\
ëˆÀ>̈œ˜Ê«˜iՓœ˜ˆÌˆÃÊ>˜`Ê>ëˆÀ>̈œ˜Ê«˜iՓœ˜ˆ>\Ê Ê ˜}ÊÊi`ÊÓää£ÆÎ{{­™®\ÈÈx°
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Ventilator-associated pneumonia (VAP) UÊÊ-«ÕÌՓÊVՏÌÕÀiÃÊŜՏ`ÊLiʜLÌ>ˆ˜i`Ê«ÀˆœÀÊ̜ÊÃÌ>À̈˜}Ê>˜ÌˆLˆœÌˆVÃʜÀÊ if patient is failing therapy by endotracheal suction or invasive techniques. ET suction appears just as sensitive but less specific than invasive methods. UÊÊEmpiric treatment MUST be narrowed as soon as sputum culture results are known. UÊÊvÊ̅iÊ«>̈i˜ÌʈÃʜ˜Ê>˜ÌˆLˆœÌˆVÊ̅iÀ>«ÞʜÀʅ>ÃÊÀiVi˜ÌÞÊLii˜Êœ˜Ê>˜ÌˆLˆœÌˆVÊ therapy, choose an agent from a different class. Optimal treatment can likely be based on severity of illness as determined by the Clinical Pulmonary Infection Score (CPIS). Calculating the Clinical Pulmonary Infection Score (CPIS) Temperature (°C) Peripheral WBC

0 points 36.5 to 38.4 {]äääÊqÊ££]äää

Tracheal secretions Chest X-ray

None

Progression of infiltrate from prior radiographs Culture of ET suction

None

Oxygenation (PaO2/FiO2)

> 240 or ARDS

88

No infiltrate

No growth/light growth

2 points 1 point ≤ 36.4 or ≥ 39 38.5 to 38.9 Ê{]äääʜÀÊ > 11,000 > 50% bands: add 1 extra point Purulent Non-purulent Diffuse or patchy infiltrates

Localized infiltrate Progression (ARDS, CHF thought unlikely)

Heavy growth Same bacteria on gram stain: add 1 extra point ≤ 240 and no ARDS

If the CPIS is ≤ 6 UÊÊ6
*ʈÃÊ՘ˆŽiÞ UÊÊvÊ6
*ÊÃÌÀœ˜}ÞÊÃÕëiVÌi`ÊÃiiÊÌÀi>̓i˜ÌÊÀiVœ““i˜`>̈œ˜ÃÊLiœÜ UÊÊvÊ *-ÊÀi“>ˆ˜ÃÊ≤ 6 after 3 days, antibiotics can be stopped in most cases If the CPIS is > 6 Early-onset VAP (occurring within 72 hours of hospitalization and patient has not been hospitalized or resided in a nursing home, longterm care or rehabilitation facility in the past 3 months) Etiology: S. pneumoniae, H. influenzea, S. aureus UÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+Ó{ Late-onset VAP (all VAP that is not early-onset) Etiology: S. aureus, P. aeruginosa, other Gram-negative bacilli UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUSÊQ*ˆ«iÀ>Vˆˆ˜É tazobactam 4.5 g IV Q6H OR Cefepime 2 g IV OR +nRʱ Gentamicin (see dosing section, p. 146) OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Q ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nÊ",Ê
âÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS Gentamicin (see dosing section, p. 146) Enterococci and candida species are often isolated from sputum in hospitalized patients. In general, they should be considered to be colonizing organisms and should not be treated with antimicrobials. If the patient is immunocompromised, consider adding Azithromycin 500 mg Q24H to Piperacillin/tazobactam, Cefepime or Aztreonam to cover Legionella Duration UÊÊ3 days if CPIS remains ≤ 6 in patients with initial CPIS ≤ ÈÆÊ6
*ʈÃÊ unlikely UÊÊ7 days if the patient has clinical improvement UÊÊvÊÃޓ«Ìœ“ÃÊ«iÀÈÃÌÊ>ÌÊÇÊ`>ÞÃÊVœ˜Ãˆ`iÀÊ>ÌiÀ˜>̈ÛiÊÜÕÀViÊ>˜`ɜÀÊ bronchoscopy with quantitative cultures UÊÊ6
*Ê>ÃÜVˆ>Ìi`Ê܈̅ÊS. aureus bacteremia should be treated for at least 14 days

89

6.12 Pulmonary infections

EMPIRIC TREATMENT

6.12 Pulmonary infections

TREATMENT NOTES UÊÊTreatment MUST be narrowed based on culture results UÊÊ/œLÀ>“ÞVˆ˜ÊˆÃÊÀiVœ““i˜`i`Ê>ÃÊ>ÊÃiVœ˜`Ê>}i˜ÌÊ̜ÊLÀœ>`i˜Êi“«ˆÀˆVÊ coverage rather than fluoroquinolones because of high rates of resistance to fluoroquinolones in the institution. UÊÊ
˜Ìˆ“ˆVÀœLˆ>Ê̅iÀ>«ÞÊŜՏ`ÊLiÊÌ>ˆœÀi`ʜ˜ViÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>ÀiÊ known. Vancomycin should be stopped if resistant Gram-positive organisms are not recovered. Gram-negative coverage can be reduced to a single susceptible agent in most cases. The benefits of combination therapy in the treatment of Pseudomonas are not well `œVՓi˜Ìi`ÆʈvʈÌʈÃÊ`iÈÀi`]Ê̅i˜ÊVœ˜Ãˆ`iÀÊ}ˆÛˆ˜}ʈÌÊvœÀÊ̅iÊwÀÃÌÊÇÓÊ hours of therapy only. Diagnosis UÊÊ6
*ʈÃÊ`ˆvwVՏÌÊ̜Ê`ˆ>}˜œÃi° UÊÊ >VÌiÀˆ>ʈ˜Êi˜`œÌÀ>V…i>ÊÃÕV̈œ˜Ê“>ÞÊÀi«ÀiÃi˜ÌÊÌÀ>V…i>ÊVœœ˜ˆâ>̈œ˜Ê and NOT infection. UÊÊ+Õ>˜ÌˆÌ>̈ÛiÊVՏÌÕÀiÃʜvÊ
ÊyՈ`ÊV>˜Ê…i«Ê`ˆÃ̈˜}ՈÅÊLiÌÜii˜Ê Vœœ˜ˆâ>̈œ˜Ê>˜`ʈ˜viV̈œ˜ÆÊ≥ 104 cfu/ml is considered significant growth. Other considerations UÊÊ/À>V…i>ÊVœœ˜ˆâ>̈œ˜ÊœvÊÀ>“‡˜i}>̈ÛiÃÊ>˜`ÊS. aureus is not eradicated even though lower airways are sterilized. Thus, posttreatment cultures in the absence of clinical deterioration (fever, rising WBC, new infiltrates, worsening ventilatory status) are not recommended. UÊʘ>`iµÕ>Ìiʈ˜ˆÌˆ>ÊÌÀi>̓i˜ÌʜvÊ6
*ʈÃÊ>ÃÜVˆ>Ìi`Ê܈̅ʅˆ}…iÀʓœÀÌ>ˆÌÞÊ (even if treatment is changed once culture results are known). ,iviÀi˜ViÃ\
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90

UÊÊ/…iÀ>«ÞÊŜՏ`ÊLiÊL>Ãi`ʜ˜ÊVՏÌÕÀiÊ>˜`ÊÃÕÃVi«ÌˆLˆˆÌÞÊ`>Ì>Ê܅i˜Ê >Û>ˆ>LiÆÊ̅iÊ>}i˜ÌÊ܈̅Ê̅iʘ>ÀÀœÜiÃÌÊëiVÌÀՓʜvÊ>V̈ۈÌÞÊŜՏ`ÊLiÊ selected preferentially UÊÊvÊ«œÃÈLi]ÊÃ̜«Êv>ˆˆ˜}Ê>˜ÌˆLˆœÌˆVÃÊ܅i˜Êˆ˜ˆÌˆ>̈˜}ʘiÜÊ>˜ÌˆLˆœÌˆVà UÊʈ}…Ê`œÃiÃʜvÊ>˜ÌˆLˆœÌˆVÃÊŜՏ`ÊLiÊÕÃi`Ê̜ʓ>݈“ˆâiʏ՘}Ê«i˜iÌÀ>̈œ˜Ê and reduce the risk of emergence of resistance (see below) TREATMENT NOTES FOR SPECIFIC ORGANISMS UÊPseudomonas aeruginosa UÊÊ*ˆ«iÀ>Vˆˆ˜]Ê ivi«ˆ“i]Ê>˜`Ê ivÌ>âˆ`ˆ“iÊŜՏ`ÊLiÊÕÃi`Ê preferentially to Meropenem to minimize the induction of resistance to beta-lactams by Meropenem UÊÊ/…iÃiÊ>}i˜ÌÃÊ>ÀiÊ}i˜iÀ>ÞÊVœ“Lˆ˜i`Ê܈̅ʅˆ}…‡`œÃiÊ aminoglycosides based on in vitro evidence that there is synergy against Pseudomonas UÊÊœÀÊ«>̈i˜ÌÃÊ܈̅ʫi˜ˆVˆˆ˜Ê>iÀ}Þ]Ê ˆ«ÀœyœÝ>Vˆ˜ÊœÀÊ
âÌÀiœ˜>“Ê V>˜ÊLiÊVœ“Lˆ˜i`Ê܈̅Ê>˜Ê>“ˆ˜œ}ÞVœÃˆ`iÆÊ`iÃi˜ÃˆÌˆâ>̈œ˜Ê̜ÊLiÌ>‡ lactams or carbapenems should be strongly considered UÊʘʫ>̈i˜ÌÃʈ˜ÌœiÀ>˜ÌʜÀÊÀiÈÃÌ>˜ÌÊ̜Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]Ê œˆÃ̈˜ÊV>˜Ê be added UÊÊ œ˜Ìˆ˜ÕœÕÃʈ˜vÕȜ˜ÊœvÊLiÌ>‡>VÌ>“ÃÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜ÊܓiÊ «>̈i˜ÌÃÆÊÃiiÊ«°ÊÓnÊvœÀʓœÀiʈ˜vœÀ“>̈œ˜° UÊʘ…>i`Ê/œLÀ>“ÞVˆ˜Ê>˜`Ê œˆÃ̈˜ÊV>˜ÊLiÊÕÃi`Ê>ÃÊ>`Õ˜V̈ÛiÊ̅iÀ>«Þ UÊStenotrophomonas maltophilia UÊÊS. maltophilia isolated from sputum usually represents colonization. UÊÊvÊÃÕ«iÀˆ˜viV̈œ˜ÊˆÃÊÃÕëiVÌi`]Ê/*É-8ʈÃÊ̅iÊwÀÃÌʏˆ˜iÊ>}i˜Ì°Ê UÊÊ/ˆV>ÀVˆˆ˜ÉV>ÛՏ>˜>ÌiÊOR Minocycline may be used if susceptible in «>̈i˜ÌÃÊ܅œÊ>ÀiÊ>iÀ}ˆVʜÀʈ˜ÌœiÀ>˜ÌʜÀÊÀiÈÃÌ>˜ÌÊ̜Ê/*É-8°Ê UÊStaphylococcus aureus UÊÊS. aureus isolated from sputum can indicate colonization or infection. UÊÊ7…i̅iÀÊÌÀi>̈˜}ÊVœœ˜ˆâ>̈œ˜Ê܈̅ÊS. aureus in CF patients improves outcomes is an area of active research, although historically such colonization has not been successfully eradicated with antimicrobial therapy. If this is attempted, possible agents include Dicloxacillin, Cefazolin or Cephalexin for MSSA and

ˆ˜`>“ÞVˆ˜]Ê/*É-8]Ê œÝÞVÞVˆ˜i]Ê>˜`ʈ˜œVÞVˆ˜iÊvœÀÊ,-
°ÊÊ UÊÊ"Ý>Vˆˆ˜ÊˆÃÊ̅iÊ`ÀÕ}ʜvÊV…œˆViÊvœÀÊ--
Ê«˜iՓœ˜ˆ>ÆÊ6>˜Vœ“ÞVˆ˜Ê or Linezolid can be used for MRSA pneumonia.

91

6.12 Pulmonary infections

Antibiotic selection and dosing for cystic fibrosis patients

6.12 Pulmonary infections

Antibiotic doses for cystic fibrosis infections – normal renal function UÊ ivÌ>âˆ`ˆ“i\ÊÓÊ}Ê6Ê+nÊ UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“\ÊΰÎÇxÊ}Ê6Ê+{ UÊ ivi«ˆ“i\ÊÓÊ}Ê6Ê+n UÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n UÊ ˆ«ÀœyœÝ>Vˆ˜\ÊÇxäʓ}Ê*"Ê+£ÓÊ",Ê{ääʓ}Ê6Ê+n UÊ
âÌÀiœ˜>“\ÊÓÊ}Ê6Ê+n UÊ/ˆV>ÀVˆˆ˜ÉV>ÛՏ>˜>Ìi\Êΰ£Ê}Ê6Ê+{ UÊ/*É-8ÊvœÀÊS. maltophilia: 5 mg/kg IV/PO Q8H UÊ/*É-8ÊvœÀÊS. aureus: 2 DS tablets PO BID UÊ œˆÃ̈˜\Ê·Èʓ}Ɏ}É`>ÞÊ6Ê`ˆÛˆ`i`ʈ˜ÊÎÊ`œÃiÃÊ Uʘ…>i`Ê/œLÀ>“ÞVˆ˜Ê­/" ®®\ÊÎääʓ}Ê+£Ó Uʘ…>i`Ê œˆÃ̈˜\ÊÇx‡£xäʓ}Ê+£ÓÊ`i«i˜`ˆ˜}ʜ˜Ê̅iÊ`iˆÛiÀÞÊÃÞÃÌi“ÊÊ Intravenous Tobramycin dosing and monitoring: UÊœ>`ˆ˜}Ê`œÃi\Ê£äʓ}Ɏ}É`>ÞÊ}ˆÛi˜ÊœÛiÀʣʅœÕÀ°Ê UÊÊ*i>ŽÊˆÃÊÀiVœ““i˜`i`Ê>vÌiÀÊwÀÃÌÊ`œÃi]ʣʅœÕÀÊ>vÌiÀÊ̅iÊi˜`ʜvʈ˜vÕȜ˜Ê ܈̅Ê}œ>ÊœvÊÓä‡ÎäÊ>˜`ÊÌÀœÕ}…Ê>ÌÊÓÎʅœÕÀÃÊ܈̅Ê}œ>ÊÊ£Ê“V}ɓ°Ê UÊÊ œÃiÃÊV>˜ÊLiʈ˜VÀi>Ãi`ÊÕ«Ê̜ʣÓʓ}Ɏ}É`>ÞʈvÊ>`iµÕ>ÌiÊ«i>ŽÃÊ are not achieved. If trough is too low or too high, interval should be changed.

92

Diagnosis UÊÊ,iëˆÀ>̜ÀÞÊۈÀÕÃÊÌiÃ̈˜}ÊŜՏ`ÊLiʜLÌ>ˆ˜i`ÊÞi>ÀÊÀœÕ˜`ʜ˜Ê>˜ÞÊ«>̈i˜ÌÊ for whom there is a clinical suspicion of respiratory virus infection. In addition, during influenza and RSV season testing should be obtained ˆ˜Ê«>̈i˜ÌÃÊ܈̅\ Ê UÊÊiÛiÀÊ>˜`ʈ˜yÕi˜â>‡ˆŽiÊÃޓ«Ìœ“ÃʭÜÀiÊ̅Àœ>Ì]ʓÞ>}ˆ>]Ê>À̅À>}ˆ>]Ê cough, runny nose and/or headache) Ê U Suspected bronchiolitis or pneumonia Ê U COPD/asthma exacerbation or respiratory failure Ê UÊ1˜iÝ«>ˆ˜i`Ê ÊiÝ>ViÀL>̈œ˜ Ê UÊ `iÀÞÊ«>̈i˜ÌÃÊ܈̅Ê՘iÝ«>ˆ˜i`ʘiÜʜ˜ÃiÌʓ>>ˆÃi Ê UÊ*Ài}˜>˜ÌÊ«>̈i˜ÌÃÊ܈̅Ê՘iÝ«>ˆ˜i`ÊÀiëˆÀ>̜ÀÞÊÃޓ«Ìœ˜Ã Ê UÊÊ œ˜Ã«iVˆwVÊÃޓ«Ìœ“ÃÊ>˜`Ê>Ê`œVՓi˜Ìi`ÊiÝ«œÃÕÀiÊ̜Êܓiœ˜iÊ with a respiratory illness UÊÊ,iëˆÀ>̜ÀÞÊۈÀÕÃÊÌiÃ̈˜}Ê>ÌÊÊ­œ˜iÊ *ÊyœVŽi`ÊÃÜ>LÊŜՏ`ÊLiÊ submitted for either panel) Ê UÊÊ/iÃ̈˜}ÊvœÀʈ““Õ˜œVœ“«iÌi˜ÌʅœÃÌÃ\ÊÀ>«ˆ`ʘÕViˆVÊ>Vˆ`ÊÌiÃÌÊvœÀÊ,-6Ê and influenza A/B Ê UÊÊ/iÃ̈˜}ÊvœÀʈ““Õ˜œVœ“«Àœ“ˆÃi`ʅœÃÌÃ]Ê«>̈i˜ÌÃÊLiˆ˜}Ê>`“ˆÌÌi`Ê ÌœÊ̅iÊ 1]Ê>˜`Ê«>̈i˜ÌÃÊ܈̅ÊÃÌÀÕVÌÕÀ>ÊÕ˜}Ê`ˆÃi>Ãi\ÊiÝÌi˜`i`Ê panel for RSV, influenza A/B, adenovirus, human metapneumovirus, parainfluenza 1-3, and rhinovirus Treatment of influenza in inpatients UÊÊ “«ˆÀˆVÊÌÀi>̓i˜ÌʜvÊ>`ՏÌʈ˜«>̈i˜ÌÃÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê̅iÊ vœœÜˆ˜}ÊÈÌÕ>̈œ˜ÃÊ`ÕÀˆ˜}ʈ˜yÕi˜â>ÊÃi>ܘ\Ê Ê UÊÊ*>̈i˜ÌÃÊ܈̅ÊviÛiÀÊ>˜`ʈ˜yÕi˜â>‡ˆŽiÊÃޓ«Ìœ“Ã]Ê՘iÝ«>ˆ˜i`Ê interstitial pneumonia or new respiratory failure without an obvious non-influenza cause UÊÊ/Ài>̓i˜ÌÊŜՏ`ÊLiʈ˜ˆÌˆ>Ìi`ʈ˜Ê>Ê«>̈i˜ÌÃÊ܅œÊ>ÀiÊ>`“ˆÌÌi`Ê̜Ê̅iÊ hospital and have influenza with symptom onset in the past 48-72 hours UÊÊ/…iÊṎˆÌÞʜvÊÌÀi>̓i˜ÌʜvÊ«>̈i˜ÌÃÊ܅œÊ«ÀiÃi˜Ìʏ>Ìiʈ˜Ê̅iÊVœÕÀÃiʜvÊ disease is uncertain and the decision to treat these patients can be made on a case-by-case basis UÊÊ
˜ÌˆÛˆÀ>ÊV…œˆViʈÃÊ`i«i˜`i˜Ìʜ˜Ê̅iÊÃÕÃVi«ÌˆLˆˆÌÞʜvÊVˆÀVՏ>̈˜}ÊÃÌÀ>ˆ˜ÃÊ which may vary from season to season (see www.hopkinsmedicine.org/amp for current recommendations) UÊÊ ÕÀ>̈œ˜\ÊxÊ`>ÞÃÊiÝVi«ÌÊvœÀÊ«>̈i˜ÌÃÊ܈̅Ê܏ˆ`ʜÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê hematologic malignancy, or BMT in whom 10 days can be given because of prolonged viral shedding

93

6.13 Respiratory virus diagnosis and management

Respiratory virus diagnosis and management

6.13 Respiratory virus diagnosis and management

Infection control UÊÊ
Êˆ˜`ˆÛˆ`Õ>ÃÊ܈̅ÊÃÕëiVÌi`ÊÀiëˆÀ>̜ÀÞÊۈÀÕÃʈ˜viV̈œ˜ÊŜՏ`ÊLiÊ placed on droplet precautions. A private room is required, unless patients are cohorted. When outside of their room (i.e. during transport) patients should wear a mask. UÊÊ
Ê…i>Ì…ÊV>ÀiÊܜÀŽiÀÃʓÕÃÌÊÀiViˆÛiÊ̅iʈ˜yÕi˜â>ÊÛ>VVˆ˜iÊÞi>ÀÞ° UÊÊ*iÀܘ˜iÊ܈̅Ê`ˆÀiVÌÊ«>̈i˜ÌÊV>ÀiʜÀÊܜÀŽˆ˜}ʈ˜ÊVˆ˜ˆV>Ê>Ài>ÃÊ܅œÊ…>ÛiʘœÌÊ received the influenza vaccine are required to wear a mask when within 6 feet of a patient. The dates of the mask requirement are determined by HEIC and based on influenza activity in the local community. U No one with fever may work until at least 24 hours after fever has resolved (without antipyretics). All personnel with respiratory symptoms and fever must call or report to their supervisor and must call Occupational Health Services (OHS). UÊAfebrile employees who have respiratory systems must wear a surgical mask during patient contact (≤ 6 ft). UÊÊvÊ>˜Ê՘Û>VVˆ˜>Ìi`Ê 7ʈÃÊiÝ«œÃi`Ê̜Ê>Ê«>̈i˜ÌÊ܈̅Ê`œVՓi˜Ìi`Ê influenza who was not on Droplet Precautions, notify HEIC and call Occupational Health Services (OHS) immediately. OHS will decide whether to recommend post-exposure prophylaxis. Anti-influenza agents Medication

Adult dosing

Side effects

Notes

Oseltamivir

Treatment:Ê 75 mg PO twice a day vœÀÊxÊ`>ÞÃÊ Prophylaxis:Ê 75 mg PO once a day

œ““œ˜\ʘ>ÕÃi>]ÊÊ vomiting Ê -iÛiÀi\ hypersensitivity, neuropsychiatric

œÃiÊ>`ÕÃ̓i˜ÌÊ needed for GFR Èäʓɓˆ˜Ê

Treatment:Ê 10 mg (2 oral inhalations) twice daily for 5 days Prophylaxis: 10 mg (2 oral inhalations) œ˜ViÊ>Ê`>ÞÊÊ

œ““œ˜\Ê`ˆ>ÀÀ…i>]ÊÊ nausea, cough, headache, and dizziness

-…œÕ`Ê "/ÊLiÊÕÃi`Ê in patients with chronic underlying airway diseases

Ê

<>˜>“ˆÛˆÀÊ

Ê

94

Ê-iÛiÀi\ÊLÀœ˜V…œÃ«>Ó]Ê hypersensitivity, laryngeal edema, facial swelling

Latent TB infection (LTBI) UÊÊ*ÀiۈœÕÃʈ˜viV̈œ˜Ê܈̅ÊM. tuberculosis (MTB) that has been contained by the host immune response UÊÊ*>̈i˜Ìʓ>Þʅ>ÛiÊ>Ê«œÃˆÌˆÛiÊÌiÃÌÊ­ÃiiÊLiœÜ®ÊœÀÊÃÕ}}iÃ̈ÛiÊÀ>`ˆœ}À>«…ˆVÊ findings such as calcified granulomata or minimal apical scarring, but do not have symptoms of active TB disease UÊÊ œÌʈ˜viV̈œÕÃÊ>˜`Ê`œiÃʘœÌÊÀiµÕˆÀiʈ܏>̈œ˜ Tests to diagnose latent LTBI UÊÊ œÌ…Ê/ÕLiÀVՏˆ˜ÊΈ˜ÊÌiÃÌÊ­/-/®Ê>˜`ʘÌiÀviÀœ˜Ê}>““>ÊÀii>ÃiÊ>ÃÃ>ÞÊ­,
®Ê >Àiʈ“«iÀviVÌ]Ê>˜`ʓ>ÞʜvviÀÊ`ˆÃVœÀ`>˜ÌÊÀiÃՏÌÃÊ­HÓ䯮°ÊÊ-i˜ÃˆÌˆÛˆÌÞʜvÊ/-/Ê and IGRA are similar. UÊÊ œÌ…ÊÌiÃÌÃÊŜՏ`ÊLiʈ˜ÌiÀ«ÀiÌi`ʈ˜Ê̅iÊVœ˜ÌiÝÌʜvÊi«ˆ`i“ˆœœ}ˆVÊÀˆÃŽÊœvÊ/ Ê exposure UÊÊ/ Ê̅iÀ>«ÞÊŜՏ`ʘœÌÊLiʈ˜ˆÌˆ>Ìi`Ê՘̈Ê>V̈ÛiÊ/ ʈÃÊiÝVÕ`i`Ê­LÞÊ symptoms and radiography). Individuals with signs or symptoms of active TB require further diagnostic workup before LTBI therapy. UÊÊ/ Ê̅iÀ>«ÞÊŜՏ`ʘœÌÊLiÊÃÌ>ÀÌi`ʈ˜Ê̅iʅœÃ«ˆÌ>Ê܈̅œÕÌÊ>ÊVi>ÀÊvœœÜ‡Õ«Ê plan Tuberculin skin test (TST) UÊʘÌÀ>`iÀ“>Êˆ˜iV̈œ˜ÊœvÊ«ÕÀˆwi`Ê«ÀœÌiˆ˜Ê`iÀˆÛ>̈ÛiÊ­** ®Ê>˜`ʓi>ÃÕÀi“i˜ÌÊ of induration diameter in 48-72 UÊÊÊ ÀˆÌiÀˆ>ÊvœÀÊ>Ê«œÃˆÌˆÛiÊÌiÃÌÊ>Ài UÊÊÊxʓ“Êqʅˆ}…ÊÀˆÃŽÊœvÊ`iÛiœ«ˆ˜}Ê>V̈ÛiÊ/ Ê­i°}°]Ê6ʈ˜viV̈œ˜]ÊVœÃiÊ contact of TB case, immunocompromised) UÊÊÊ£äʓ“Êqʜ̅iÀÊÀˆÃŽÊv>V̜ÀÃÊvœÀÊ/ ʈ˜viV̈œ˜Ê­ 7]Ê 1]Ê ® UÊÊÊ£xʓ“ÊqʘœÊÀˆÃŽÊv>V̜ÀÃÊvœÀÊ/ Interferon gamma release assay (IGRA) UÊ,
Ãʓi>ÃÕÀiʏޓ«…œVÞÌiÊÀii>Ãiʜvʈ˜ÌiÀviÀœ˜Ê}>““>ʈ˜ÊÀi뜘ÃiÊÌœÊ stimulation by MTB antigens. UÊ,
ÃÊ>ÀiʏiÃÃÊ>vviVÌi`ÊLÞÊ ÊÛ>VVˆ˜>̈œ˜ÊÃÌ>ÌÕÃʜÀʈ˜viV̈œ˜Ê܈̅ʓœÃÌÊ atypical mycobacteria (except M. marinum and M. kansasii) than TST UÊ+Õ>˜ÌˆviÀœ˜‡œ`‡˜‡/ÕLiÊ­+/®ÊˆÃÊÕÃi`Ê>ÌÊ°Ê,iÃՏÌÃÊ>ÀiÊÀi«œÀÌi`Ê>ÃÊ positive, negative, or indeterminate. An indeterminate result means that the test result is not valid, which can be due to errors in specimen collection (most common--insufficient/incorrect shaking of tubes after blood draw or processing delays), or associated with certain conditions such as HIV with a low CD4 count, steroid use or other immunosuppression, and “>˜ÕÌÀˆÌˆœ˜ÊQ>LՓˆ˜ÊΰxR°Ê˜`iÌiÀ“ˆ˜>ÌiÊÀiÃՏÌÃʜvÌi˜ÊÀiµÕˆÀiÊ>ÊÀi«i>ÌÊ test (ensure proper specimen collection). UÊ7…i˜Ê«Ài‡ÌiÃÌÊ«ÀœL>LˆˆÌÞʜÀÊ«ÀiÛ>i˜ViʜvÊ/ ʈÃÊx¯Ê­i°}°]Ê1-‡LœÀ˜Ê ܈̅œÕÌÊvœÀiˆ}˜ÊÌÀ>Ûi®]Ê**6ʜvÊ,
ʈÃÊÀi`ÕVi`Ê­Ç䇙ä¯]ʈ°i°]Êv>Ãi‡«œÃˆÌˆÛiÃ®Ê Ü…ˆiÊ *6ʈÃʅˆ}…Ê­™™¯®°ÊÊ UÊ7…i˜Ê«Ài‡ÌiÃÌÊ«ÀœL>LˆˆÌÞÊvœÀʈ˜viV̈œ˜ÊˆÃʅˆ}…Ê­i°}°]ÊvœÀiˆ}˜‡LœÀ˜]ÊHÎä¯Ê/ Ê «ÀiÛ>i˜Vi®]Ê**6ʜvÊ,
ʈ˜VÀi>ÃiÃÊ̜ÊH™x‡™™¯]ÊLÕÌÊ *6Ê`iVÀi>ÃiÃÊ ­n䇙ä¯]ʈ°i°]Êv>Ãi‡˜i}>̈Ûiî°ÊÊ

95

6.14 Tuberculosis (TB) infection

Tuberculosis (TB) infection

6.14 Tuberculosis (TB) infection

UÊ+Õ>˜ÌˆÌ>̈ÛiÊÀiÃՏÌÃʓ>ÞÊLiʅi«vՏÊ̜Ê}Ո`iʈ˜ÌiÀ«ÀiÌ>̈œ˜°Ê œ˜Ãˆ`iÀÊ Ê Vœ˜ÃՏÌ>̈œ˜ÊvœÀÊÀiÃՏÌÃʘi>ÀÊ̅iÊ̅ÀiŜ`ÊvœÀÊ+/Ê«œÃˆÌˆÛi\Ê>˜Ìˆ}i˜0.35. Serial testing is not advised without ID consultation. UÊ,
ÃÊ`œÊ˜œÌʅ>ÛiÊ}œœ`ÊÃi˜ÃˆÌˆÛˆÌÞʜÀÊëiVˆwVˆÌÞÊvœÀÊ`ˆ>}˜œÃˆÃʜvÊ>V̈ÛiÊ/ Active TB infection UÊÊ
V̈ÛiÊÀi«ˆV>̈œ˜ÊœvÊ/ ÊV>ÕȘ}ʫՏ“œ˜>ÀÞʜÀÊiÝÌÀ>«Õ“œ˜>ÀÞÊÈ}˜ÃʜÀÊ symptoms UÊÊ œ˜wÀ“i`ÊLÞÊ«œÃˆÌˆÛiÊ
 ÊÓi>À]Ê/ Ê`ˆÀiVÌÊÌiÃÌʜÀÊVՏÌÕÀi UÊÊ,iµÕˆÀiÃÊ>ˆÀLœÀ˜iʈ܏>̈œ˜ When to suspect active TB disease High-risk individuals UÊÊ,iVi˜ÌÊiÝ«œÃÕÀiÊ̜Ê>Ê«iÀܘÊ܈̅ʎ˜œÜ˜Ê/ ÆʅˆÃ̜ÀÞʜvÊ>Ê«œÃˆÌˆÛiÊ/-/ÆÊ 6ʈ˜viV̈œ˜Æʈ˜iV̈œ˜ÊœÀʘœ˜‡ˆ˜iV̈œ˜Ê`ÀÕ}ÊÕÃiÆÊvœÀiˆ}˜ÊLˆÀ̅ʜÀÊÀiÈ`i˜ViÊ ˆ˜Ê>ÊÀi}ˆœ˜Êˆ˜Ê܅ˆV…Ê/ ʈ˜Vˆ`i˜ViʈÃʅˆ}…ÆÊÀiÈ`i˜ÌÃÊ>˜`Êi“«œÞiiÃʜvÊ …ˆ}…‡ÀˆÃŽÊVœ˜}Ài}>ÌiÊÃiÌ̈˜}ÃÊ­i°}°Ê«ÀˆÃœ˜Ã®Æʓi“LiÀň«Êˆ˜Ê>ʓi`ˆV>ÞÊ Õ˜`iÀÃiÀÛi`]ʏœÜ‡ˆ˜Vœ“iÊ«œ«Õ>̈œ˜ÆÊ>˜Ìˆ‡/ Ê>«…>Ê̅iÀ>«Þ Clinical syndromes UÊÊ œÕ}…ÊœvÊ2 wk duration, with at least one additional symptom, including fever, night sweats, weight loss, or hemoptysis UÊÊ
˜ÞÊ՘iÝ«>ˆ˜i`ÊÀiëˆÀ>̜ÀÞʈ˜iÃÃʜvÊ2 wk duration in a patient at high risk for TB UÊÊ
˜ÞÊ«>̈i˜ÌÊ܈̅Ê6ʈ˜viV̈œ˜Ê>˜`Ê՘iÝ«>ˆ˜i`ÊVœÕ}…Ê>˜`ÊviÛiÀÊ UÊÊ
˜ÞÊ«>̈i˜Ìʜ˜Ê>˜Ìˆ‡/ Ê>«…>Ê̅iÀ>«ÞÊ܈̅Ê՘iÝ«>ˆ˜i`ÊviÛiÀ UÊÊ œ““Õ˜ˆÌއ>VµÕˆÀi`Ê«˜iՓœ˜ˆ>Ê܅ˆV…Ê…>ÃʘœÌʈ“«ÀœÛi`Ê>vÌiÀÊÇÊ`>ÞÃʜvÊ appropriate treatment UÊʘVˆ`i˜Ì>Êw˜`ˆ˜}Ãʜ˜ÊV…iÃÌÊÀ>`ˆœ}À>«…ÊÃÕ}}iÃ̈ÛiʜvÊ/ Ê­iÛi˜ÊˆvÊÃޓ«Ìœ“ÃÊ are minimal or absent) in a patient at high risk for TB Radiographic findings UÊÊ*Àˆ“>ÀÞÊ/ Ê­œvÌi˜Ê՘ÀiVœ}˜ˆâi`®\Ê >˜ÊÀiÃi“LiÊ
*Ê>˜`ʈ˜ÛœÛiÊ>˜ÞʏœLiÃÆÊ …ˆ>ÀÊ>`i˜œ«>̅Þ]Ê«iÕÀ>ÊivvÕȜ˜ÃÊ>ÀiÊVœ““œ˜ÆÊV>ۈÌ>̈œ˜ÊˆÃÊ՘Vœ““œ˜°Ê ˆ˜`ˆ˜}ÃʜvÌi˜ÊÀi܏ÛiÊ>vÌiÀÊ£qÓʓœ˜Ì…ðÊ/…iÃiÊ>ÀiÊVœ““œ˜Êw˜`ˆ˜}Ãʈ˜Ê patients with advanced HIV infection and TB. UÊÊ,i>V̈Û>̈œ˜Ê/ \ʘwÌÀ>ÌiÃÊ܈̅ʜÀÊ܈̅œÕÌÊV>ۈÌ>̈œ˜Êˆ˜Ê̅iÊÕ««iÀʏœLiÃʜÀÊ Ì…iÊÃÕ«iÀˆœÀÊÃi}“i˜ÌÃʜvÊ̅iʏœÜiÀʏœLiÃÆʅˆ>ÀÊ>`i˜œ«>̅ÞʈÃÊÛ>Àˆ>LiÆÊ /Ê ÃV>˜Ê“>Þʅ>ÛiʺÌÀii‡ˆ˜‡LÕ`»Ê>««i>À>˜Vi° Diagnosis UÊÊ*>̈i˜ÌÃÊ܈̅ÊV…>À>VÌiÀˆÃ̈VÊÃޘ`Àœ“iÃÊ>˜`ÊÀ>`ˆœ}À>«…ˆVÊw˜`ˆ˜}ÃÊŜՏ`Ê have expectorated sputum obtained for AFB smear and culture. UÊÊ-i˜ÃˆÌˆÛˆÌÞʜvÊ
 ÊÓi>Àʜ˜ÊiÝ«iV̜À>Ìi`ÊëÕÌՓʈÃÊxäqÇä¯ÆʈÌʈÃÊ œÜiÀʈ˜Ê6³Ê«>̈i˜ÌðÊœÀ˜ˆ˜}ÊiÝ«iV̜À>Ìi`ÊëÕÌՓ]ʈ˜`ÕVi`ÊëÕÌՓ]Ê bronchoscopy have higher sensitivity. AFB culture of lower respiratory tract specimens is considered the gold standard. UÊÊ
 ÊÓi>ÀÊ>˜`ÊVՏÌÕÀiÊŜՏ`ÊLiʜLÌ>ˆ˜i`ÊÀi}>À`iÃÃʜvÊ 8,Ê findings in patients with high clinical suspicion, HIV infection or other ˆ““Õ˜œVœ“«Àœ“ˆÃi`ÊÃÌ>ÌiÃ°Ê 8,ʈÃʘœÀ“>Êˆ˜Ê>««ÀœÝˆ“>ÌiÞÊ£ä¯ÊœvÊ6‡ infected patients with pulmonary TB.

96

Infection control
ˆÀLœÀ˜iÊ«ÀiV>Ṏœ˜ÃÊ>ÀiÊÀiµÕˆÀi`ʈ˜Ê̅iÊvœœÜˆ˜}ÊV>ÃiÃ\ UÊÊ-ÕëˆVˆœ˜ÊœvÊ`ˆÃi>ÃiÊÃÕvwVˆi˜ÌÞʅˆ}…Ê̜ÊÜ>ÀÀ>˜ÌʜLÌ>ˆ˜ˆ˜}ÊëÕÌՓÊ
 Ê smear/culture as described above UÊÊ*œÃˆÌˆÛiÊ
 ÊÓi>ÀʜÀÊVՏÌÕÀiÊ՘̈Ê`ˆ>}˜œÃˆÃʜvÊ/ ÊÛÃ°Ê /ʈÃÊVœ˜wÀ“i`

Algorithm for isolation when active TB is suspected AIRBORNE PRECAUTIONS IN NEGATIVE PRESSURE ROOM

Collect specimen(s) for AFB smear and culture

Expectorated sputum (3 required)*

Smear positive Mycobacterium Tuberculosis Direct Test (MTD) automatically performed

Induced sputum or bronchoscopy

Smear negative MTD negative

Smear positive Obtain 2nd and 3rd specimen* Smear positive

MTD test performed

MTD positive

MTD positive

Continue isolation until at least 14 days of therapy AND clinical improvement AND 3 consecutive negative smears (Call HEIC for approval to D/C isolation on smear positive patient.)

Smear negative

If pt highly suspected for TB, await culture result and continue isolation. Otherwise, CALL HEIC 5-8384 to DISCONTINUE ISOLATION

MTD negative

CALL HEIC 5-8384 TO DISCONTINUE ISOLATION

*One expectorated sputum must be a first morning specimen; samples should be collected at least 8 hours apart.

97

6.14 Tuberculosis (TB) infection

UÊÊ"LÌ>ˆ˜Ê>Ìʏi>ÃÌÊÎÊëÕÌՓÊëiVˆ“i˜ÃÊ­ˆ˜`ÕVi`ʜÀÊiÝ«iV̜À>Ìi`®Ê܅i˜ÊÌÀވ˜}Ê to diagnose TB in patients who are smear negative so as to increase the chance of isolating the organism for diagnosis and susceptibility testing.

6.14 Tuberculosis (TB) infection

UÊʘœÜ˜Ê>V̈ÛiʫՏ“œ˜>ÀÞʜÀʏ>Àޘ}i>Ê/ Ê­ˆvÊ«>̈i˜ÌʈÃÊVÕÀÀi˜ÌÞʜ˜Ê/ Ê treatment, consult with HEIC and patient’s local health department to obtain treatment history in order to determine if infectious at the time of current …œÃ«ˆÌ>ˆâ>̈œ˜Æʈ˜Ê“i>˜Ìˆ“iÊ>ˆÀLœÀ˜iÊ«ÀiV>Ṏœ˜ÃÊ>ÀiÊÀiµÕˆÀi`®Ê TREATMENT Active TB UÊ ÊVœ˜ÃՏÌʈÃÊÃÌÀœ˜}ÞÊÀiVœ““i˜`i`Ê UÊÊ/…iÀ>«ÞÊŜՏ`ÊLiʈ˜ˆÌˆ>Ìi`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅ʫœÃˆÌˆÛiÊ
 ÊÓi>ÀÊ>˜`ÊVˆ˜ˆV>Ê findings consistent with active TB. UÊÊ/…iÀ>«ÞÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅ʘi}>̈ÛiÊ
 ÊÓi>ÀÃÊ when suspicion of TB is high and no alternate diagnosis exists. Multiple specimens should be obtained for culture prior to treatment. UÊœÕÀÊ`ÀÕ}ÃÊ>ÀiʘiViÃÃ>ÀÞÊvœÀʈ˜ˆÌˆ>Ê«…>ÃiÊ­Óʓœ˜Ì…î°Ê UÊܘˆ>âˆ`Ê­ ®ÊÎääIʓ}Ê­xʓ}Ɏ}®Ê*"Ê`>ˆÞÊ UÊ,ˆv>“«ˆ˜Ê­,®ÊÈääIʓ}Ê­£äʓ}Ɏ}®Ê*"Ê`>ˆÞ UÊÊ*ÞÀ>∘>“ˆ`iÊ­*<
®Ê£äääʓ}Ê*"Ê`>ˆÞÊ­{äqxxʎ}®Ê",Ê£xääʓ}Ê*"Ê `>ˆÞÊ­xÈqÇxʎ}®Ê",ÊÓäääIʓ}Ê*"Ê`>ˆÞÊ­ÇÈq™äʎ}®Ê UÊÊ Ì…>“LÕ̜Ê­  ®Ênääʓ}Ê*"Ê`>ˆÞÊ­{äqxxʎ}®Ê",Ê£Óääʓ}Ê*"Ê`>ˆÞÊ ­xÈqÇxʎ}®Ê",Ê£ÈääIʓ}Ê*"Ê`>ˆÞÊ­ÇÈq™äʎ}®Ê *Max dose regardless of weight. UÊÊ*ÞÀˆ`œÝˆ˜iÊÓxʓ}Ê*"Ê`>ˆÞʈÃÊÀiVœ““i˜`i`Ê̜ʫÀiÛi˜ÌÊ Ê>ÃÜVˆ>Ìi`Ê peripheral neuropathy in patients with HIV, malnutrition, alcohol abuse, diabetes mellitus, renal failure or in pregnant or breastfeeding women. Drug toxicity and monitoring UÊÊܘˆ>âˆ`\Ê>Ãޓ«Ìœ“>̈VÊiiÛ>̈œ˜Êˆ˜Ê…i«>̈VÊi˜âޓiÃ]ÊÃiÀˆœÕÃÊ>˜`Êv>Ì>Ê hepatitis, peripheral neurotoxicity UÊÊ,ˆv>“«ˆ˜\ʜÀ>˜}iÊ`ˆÃVœœÀ>̈œ˜ÊœvÊLœ`ÞÊyՈ`Ã]ʅi«>̜̜݈VˆÌÞ]Ê«ÀÕÀˆÌˆÃÊÜˆÌ…Ê or without rash UÊÊ*ÞÀ>∘>“ˆ`i\ʅi«>̜̜݈VˆÌÞ]ʘœ˜}œÕÌÞÊ«œÞ>À̅À>}ˆ>]Ê>Ãޓ«Ìœ“>̈VÊ hyperuricemia, acute gouty arthritis UÊÊ Ì…>“LÕ̜\ÊÀiÌÀœLՏL>ÀÊ>˜`Ê«iÀˆ«…iÀ>Ê˜iÕÀˆÌˆÃÊÊ U œ˜ˆÌœÀˆ˜}\ÊL>Ãiˆ˜iʅi«>̈VÊÌÀ>˜Ã>“ˆ˜>ÃiÃ]ÊLˆˆÀÕLˆ˜]Ê>Ž>ˆ˜iÊ«…œÃ«…>Ì>Ãi]Ê creatinine and CBC are recommended for all adults initiating TB treatment. Monthly hepatic panel is recommended for patients with baseline abnormalities, history of liver disease or viral hepatitis, chronic alcohol consumption, HIV, IVDU, pregnancy or immediate post-partum state or those taking other potentially hepatotoxic medications. Therapy should be discontinued immediately if AST and ALT are 3 times the upper limit of normal (ULN) in the presence of jaundice or hepatitis symptoms or 5 times the ULN in the absence of symptoms. ,iviÀi˜ViÃ\Ê
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É ÊՈ`iˆ˜iÃÊvœÀÊ`ˆ>}˜œÃˆÃʜvÊ/ \Ê
“ÊÊ,iëˆÀÊ >ÀiÊi`ÊÓäääƣȣ\£ÎÇÈ°
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É ÊՈ`iˆ˜iÃÊvœÀÊÌÀi>̓i˜ÌʜvÊ/ \Ê7,ÆxÓ\,,‡££°Ê

98

6.15 Sepsis with no clear source

Sepsis with no clear source NOTE: Refer to specific sections of these guidelines for empiric treatment recommendations for specific sources of infection EMPIRIC TREATMENT Cultures MUST be sent to help guide therapy. UÊÊQ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“IÊ{°xÊ}Ê6Ê+ÈÊ",Ê ivi«ˆ“iIÊÓÊ}Ê6Ê+nRÊ ± Vancomycin (see dosing section, p. 150) (if at risk for MRSA) ± Gentamicin (see dosing section, p. 146) OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQ
âÌÀiœ˜>“ÊÓÊ}Ê6Ê+nÊ",Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ “}Ê6Ê+nRÊPLUS Gentamicin (see dosing section, p. 146) PLUS Vancomycin (see dosing section, p. 150) *NOTE: If patient has history of ESBL-producing organism or has suspected intra abdominal sepsis and recent prolonged exposure ( 7 days) to Piperacillin/tazobactam or Cefepime, substitute with Meropenem 1 g IV Q8H. Risk factors for MRSA UÊÊ i˜ÌÀ>ÊÛi˜œÕÃÊV>̅iÌiÀʈ˜Ê«>Vi UÊÊ"̅iÀʈ˜`Üiˆ˜}ʅ>À`Ü>ÀiÊ UÊʘœÜ˜ÊVœœ˜ˆâ>̈œ˜Ê܈̅Ê,-
UÊÊ,iVi˜Ìʭ܈̅ˆ˜ÊÎʓœ˜Ì…îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`ʅœÃ«ˆÌ>ˆâ>̈œ˜Ê> 2 weeks UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}ʅœ“iʜÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi TREATMENT NOTES UÊÊœÀÊ«>̈i˜ÌÃÊ܈̅ÊÀi˜>Êˆ˜ÃÕvwVˆi˜VÞʜÀÊ>“ˆ˜œ}ÞVœÃˆ`iʈ˜ÌœiÀ>˜Vi]Ê>Ê beta-lactam may be combined with a fluoroquinolone IF 2 agents are needed. UÊÊ*œÌi˜Ìˆ>ÊÜÕÀViÃÊ­i°}°]Ê«˜iՓœ˜ˆ>]Ê«iÀˆÌœ˜ˆÌˆÃ]ÊiÌV°®ÊŜՏ`ÊLiÊ considered when selecting therapy. UÊÊ “«ˆÀˆVÊ̅iÀ>«ÞʈÃÊ" 9Ê>««Àœ«Àˆ>ÌiÊ܅ˆiÊVՏÌÕÀiÃÊ>ÀiÊ«i˜`ˆ˜}Ê (72 hours max). UÊÊ6>˜Vœ“ÞVˆ˜ÊŜՏ`Ê>“œÃÌÊ>Ü>ÞÃÊLiÊÃ̜««i`ʈvʘœÊÀiÈÃÌ>˜ÌÊÀ>“‡ positive organisms are recovered in cultures.

99

6.16 Skin, soft-tissue, and bone infections

Skin, soft-tissue, and bone infections Cellulitis UÊÊ
Ü>ÞÃÊiiÛ>ÌiÊ>vviVÌi`ÊiÝÌÀi“ˆÌÞ°Ê/Ài>̓i˜ÌÊv>ˆÕÀiʈÃʓœÀiÊ commonly due to failure to elevate than failure of antibiotics. UÊÊ“«ÀœÛi“i˜ÌʜvÊiÀÞ̅i“>ÊV>˜ÊÌ>ŽiÊ`>ÞÃ]ÊiëiVˆ>Þʈ˜Ê«>̈i˜ÌÃÊÜˆÌ…Ê lymphedema, because dead bacteria in the skin continue to induce inflammation. Non-suppurative cellulitis Defined as cellulitis with intact skin and no evidence of purulent drainage. Usually caused by beta-hemolytic streptococci (e.g. group A, B, C, G streptococci) and MSSA. TREATMENT Oral (mild disease) UÊ
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxÊ*"Ê+£Ó OR UÊ i«…>i݈˜Êxääʓ}Ê*"Ê+È OR UÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÎääʓ}Ê*"Ê+n Parenteral (moderate to severe disease) UÊ
“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+È OR UÊ iv>✏ˆ˜Ê£Ê}Ê6Ê+n OR UÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+n Duration: 5-7 days TREATMENT NOTES UÊ
ÊLiÌ>‡…i“œÞ̈VÊÃÌÀi«ÌœVœVVˆÊ>ÀiÊÃÕÃVi«ÌˆLiÊ̜ʫi˜ˆVˆˆ˜ UÊÊ ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜ViʈÃÊÃii˜Êˆ˜Ê£È‡ÎίʜvÊ}ÀœÕ«Ê ]Ê ]Ê>˜`ÊÊÃÌÀi«Ê LÕÌÊÀi“>ˆ˜ÃʏœÜʈ˜Ê}ÀœÕ«Ê
ÊÃÌÀi«Ê­{qǯ® UÊ ÕÀ>̈œ˜\Êx‡ÇÊ`>Þà Suppurative cellulitis Defined as cellulitis with purulent drainage or exudates in the absence of a drainable abscess. Usually caused by S. aureus (MSSA and MRSA). TREATMENT Oral (mild disease) UÊ/*É-8Ê£‡ÓÊ -ÊÌ>LÊ*"Ê  OR UÊ œÝÞVÞVˆ˜iÊ£ääʓ}Ê*"Ê  Ê",ʈ˜œVÞVˆ˜iÊ£ääʓ}Ê*"Ê  OR UÊ ˆ˜`>“ÞVˆ˜ÊÎääʓ}Ê*"Ê+n 100

Parenteral (moderate to severe disease) UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä® Duration: 5-7 days TREATMENT NOTES UÊÊ,iÈÃÌ>˜ViÊ̜Êy՜ÀœµÕˆ˜œœ˜iÃʈ˜ÊS. aureus is common and develops µÕˆVŽÞÆÊʙx¯ÊœvÊ,-
ʈ܏>ÌiÃÊ>ÀiÊÀiÈÃÌ>˜ÌÊ̜Êy՜ÀœµÕˆ˜œœ˜iÃ°Ê Monotherapy with fluoroquinolones for S. aureus infections is not recommended. UÊÊ,ˆv>“«ˆ˜ÊŜՏ`Ê 6 ,ÊLiÊÕÃi`Ê>Ãʓœ˜œÌ…iÀ>«ÞÊLiV>ÕÃiÊÀiÈÃÌ>˜ViÊ develops rapidly. UÊÊ/…iÀiʈÃʘœÊiۈ`i˜ViÊ̅>Ìʈ˜i✏ˆ`ʈÃÊÃÕ«iÀˆœÀÊ̜Ê/*É-8]Ê Doxycycline, or Clindamycin in the management of skin infection or osteomyelitis. Linezolid should only be considered when the S. aureus isolate is resistant to or the patient is intolerant to these agents. Less common causes of cellulitis UÊÊ7ˆÌ…ÊLՏ>i]ÊÛiÈViÃ]Ê>˜`ÊՏViÀÃÊ>vÌiÀÊiÝ«œÃÕÀiÊ̜ÊÃi>Ü>ÌiÀʜÀÊÀ>ÜÊ oysters, consider Vibrio vulnificus, especially in patients with liver disease. Rare, but rapidly fatal if untreated. Treat with Ceftriaxone 1 g IV Q24H PLUS Doxycycline 100 mg PO BID. UÊÊ iÕÌÀœ«i˜ˆV]Ê܏ˆ`ʜÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê>˜`ÊVˆÀÀ…œÌˆVÊ«>̈i˜ÌÃʓ>ÞÊ have cellulitis due to Gram-negative organisms. Consider expanding coverage in these cases. UÊÊvÊiÃV…>À]ÊVœ˜Ãˆ`iÀÊ>˜}ˆœˆ˜Û>ÈÛiʜÀ}>˜ˆÃ“ÃÊ­ ,]Ê>ëiÀ}ˆœÃˆÃ]ʓœ`®°Ê ID consult is recommended. UÊÊ
˜ˆ“>Ê>˜`ʅՓ>˜ÊLˆÌiÃ\ÊPasteurella multocida should be covered in cat and dog bites. Treat with Amoxicillin/clavulanate 875 mg PO BID ",Ê
“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xqÎÊ}Ê6Ê+È°ÊvÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê 400 mg PO/IV Q24H. Cutaneous abscess UÊʘVˆÃˆœ˜Ê>˜`Ê`À>ˆ˜>}iÊ­E ®ÊˆÃÊ̅iÊ«Àˆ“>ÀÞÊÌÀi>̓i˜ÌÊvœÀÊ>ÊVÕÌ>˜iœÕÃÊ abscess. UÊÊiȜ˜ÃÊ̅>ÌÊ>««i>ÀÊÃÕ«iÀwVˆ>ÊV>˜ÊœvÌi˜Ê…>ÛiÊ>ÃÜVˆ>Ìi`Ê>LÃViÃÃÊ formation that is not clearly appreciated without debridement of the wound or, on occasion, additional imaging. UÊÊ
ÌÊ̅iÊ̈“iʜvÊE ]Ê>ÊÃ>“«iÊŜՏ`ÊLiʜLÌ>ˆ˜i`ÊvœÀÊVՏÌÕÀiÊ>˜`Ê sensitivity testing. UÊÊœÃÌÊÃÌÕ`ˆiÃÊ̅>Ìʅ>ÛiÊLii˜Ê«ÕLˆÃ…i`Ê̜Ê`>ÌiÊÃÕ}}iÃÌÊ̅>ÌÊ>˜ÌˆLˆœÌˆVÃÊ are adjunct to I&D in the management of uncomplicated skin abscesses caused by CA-MRSA. 101

6.16 Skin, soft-tissue, and bone infections

OR UÊ ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+nÊ­ˆvÊ«>Ài˜ÌiÀ>Ê̅iÀ>«ÞʈÃʘii`i`®

6.16 Skin, soft-tissue, and bone infections

UÊʘ`ˆV>̈œ˜ÃÊvœÀÊ>˜Ìˆ“ˆVÀœLˆ>Ê̅iÀ>«Þʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊVÕÌ>˜iœÕÃÊ >LÃViÃÃiÃ\ UÊÊ-iÛiÀiʜÀÊÀ>«ˆ`ÞÊ«Àœ}ÀiÃÈÛiʈ˜viV̈œ˜Ã UÊÊ/…iÊ«ÀiÃi˜ViʜvÊiÝÌi˜ÃˆÛiÊ>ÃÜVˆ>Ìi`ÊViÕˆÌˆÃ UÊ-ˆ}˜ÃÊ>˜`ÊÃޓ«Ìœ“ÃʜvÊÃÞÃÌi“ˆVʈ˜iÃà UÊ
ÃÜVˆ>Ìi`ÊÃi«ÌˆVÊ«…iLˆÌˆÃ UÊÊ ˆ>LiÌiÃʜÀʜ̅iÀʈ““Õ˜iÊÃÕ««ÀiÃȜ˜ UÊ
`Û>˜Vi`Ê>}i UÊÊœV>̈œ˜ÊœvÊ̅iÊ>LÃViÃÃʈ˜Ê>˜Ê>Ài>Ê܅iÀiÊVœ“«iÌiÊ`À>ˆ˜>}iʈÃÊ difficult (e.g. face, genitalia) UÊÊ>VŽÊœvÊÀi뜘ÃiÊ̜ʈ˜VˆÃˆœ˜Ê>˜`Ê`À>ˆ˜>}iÊ>œ˜i UÊÊ/…iÀ>«ÞÊŜՏ`ÊLiÊ}ˆÛi˜Êbefore incision and drainage in patients with prosthetic heart valves or other conditions placing them at high risk for endocarditis. EMPIRIC TREATMENT If antibiotic treatment is thought to be necessary, regimens are the same as for suppurative cellulitis above. Management of recurrent MRSA skin infections 1. Education regarding approaches to personal and hand hygiene UÊÊ*À>V̈ViÊvÀiµÕi˜Ìʅ>˜`ʅÞ}ˆi˜iÊ܈̅ÊÜ>«Ê>˜`ÊÜ>ÌiÀÊ>˜`ɜÀÊ alcohol based hand gels, especially after touching infected skin or wound bandages. UÊÊ œÛiÀÊ`À>ˆ˜ˆ˜}Êܜ՘`ÃÊ܈̅ÊVi>˜]Ê`ÀÞÊL>˜`>}ià UÊÊ œÊ˜œÌÊÅ>ÀiÊ«iÀܘ>ÊˆÌi“ÃÊ­i°}°ÊÀ>âœÀÃÆÊÕÃi`Ê̜ÜiÃÊ>˜`ÊVœÌ…ˆ˜}Ê before washing) UÊÊ,i}Տ>ÀÊL>̅ˆ˜} UÊÊ
ۜˆ`Ê>ÊÅ>ۈ˜}Ê UÊÊ>՘`iÀÊVœÌ…ˆ˜}]ÊÅiiÌÃ]Ê̜ÜiÃʈ˜Ê…œÌÌiÃÌÊÃՈÌ>LiÊÌi“«iÀ>ÌÕÀi UÊÊ i>˜Ê>Ê«iÀܘ>ÊëœÀ̈˜}ÊVœÌ…ˆ˜}ÉiµÕˆ«“i˜ÌÊ 2. Decontamination of the environment UÊÊ i>˜Ê…ˆ}…Ê̜ÕV…Ê>Ài>Ãʈ˜Ê̅iÊL>̅Àœœ“Ê܈̅Ê>Ê`ˆÃˆ˜viVÌ>˜ÌÊ>V̈ÛiÊ against S. aureusÊ`>ˆÞÊ­i°}°]Ê£ä¯Ê`ˆÕÌiÊLi>V…®°Ê 3. Topical decolonization (consider if a patient has ≥ 2 episodes in 1 year or other household members develop infection) UÊÊÕ«ˆÀœVˆ˜ÊÌ܈ViÊ`>ˆÞÊvœÀÊxÊ`>ÞÃʓ>ÞÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ ÜˆÌ…Ê`œVՓi˜Ìi`Êiۈ`i˜ViʜvÊ,-
ʘ>Ã>ÊVœœ˜ˆâ>̈œ˜ÆÊ Mupirocin therapy should be initiated after resolution of acute infection. Mupirocin should not be used in patients or patients’ family members who are not documented to have MRSA nasal colonization.

102

NOTE: Data on efficacy and durability of the decontamination and decolonization strategies described above are limited. ,iviÀi˜ViÃ\ /*É-8ÊvœÀÊ,-
\Ê
˜˜Ê˜ÌiÀ˜Êi`Ê£™™ÓÆ££Ç\Ιä‡n°  -
ÊՈ`iˆ˜iÃÊvœÀÊÌÀi>̓i˜ÌʜvÊ,-
ʈ˜viV̈œ˜Ã\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓ䣣ÆxÓ\£qÎn°Ê

̈œœ}ÞʜvÊÃÕ««ÕÀ>̈ÛiÊViÕˆÌˆÃ\Êi`ˆVˆ˜iÊÓä£äÆn™\Ó£ÇqÓÓÈ°

Diabetic foot infections EMPIRIC TREATMENT Treatment depends on clinical severity Infection Severity Uninfected Mild

Clinical Manifestations No purulence or inflammation* Presence of purulence and  1 sign of inflammation* and cellulitis (if present)  2 cm around ulcer limited to skin or superficial subcutaneous tissue Moderate Same as mild PLUSÊ>Ìʏi>ÃÌʜ˜iʜvÊ̅iÊvœœÜˆ˜}\Ê 2 cm of cellulitis, lymphangitic streaking, spread beneath the superficial fascia, deep tissue abscess, gangrene, involvement of muscle, tendon, joint, or bone Severe Any of above PLUS systemic toxicity or metabolic instability *erythema, pain, tenderness, warmth, induration

MILD INFECTIONS Oral regimens UÊÊ
“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxʓ}Ê*"Ê  OR UÊÊ i«…>i݈˜Êxääʓ}Ê*"Ê+ OR UÊÊ ˆ˜`>“ÞVˆ˜ÊÎääʓ}Ê*"Ê/ Ê­VœÛiÀÃÊ,-
® Parenteral regimens UÊÊ ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+nÊ­VœÛiÀÃÊ,-
® OR 103

6.16 Skin, soft-tissue, and bone infections

UÊÊ >̅ˆ˜}ʜÀÊŜÜiÀˆ˜}Ê܈̅ÊV…œÀ…i݈`ˆ˜iʜÀʅiÝ>V…œÀœ«…ˆ˜iÊ­œÀÊ `ˆÕÌiÊLi>V…ÊL>̅îÊiÛiÀÞʜ̅iÀÊ`>ÞÊvœÀÊ£ÊÜiiŽÊ̅i˜ÊÌ܈ViÊÜiiŽÞÆÊ do not get these substances into ears or eyes UÊÊ-ÞÃÌi“ˆVÊ>˜ÌˆLˆœÌˆVÃÊ>ÀiÊ "/ÊÀiVœ““i˜`i`Ê܏iÞÊvœÀÊ`iVœœ˜ˆâ>̈œ˜ 4. Evaluation of other family members UÊʘÌÀ>‡v>“ˆÞÊÌÀ>˜Ã“ˆÃȜ˜ÊŜՏ`ÊLiÊ>ÃÃiÃÃi`Ê>˜`ʈvÊ«ÀiÃi˜Ì]Ê all members should participate in hygiene and decolonization strategies above, starting at that same time and after the acute infection is controlled.

6.16 Skin, soft-tissue, and bone infections

UÊÊ"Ý>Vˆˆ˜Ê£‡ÓÊ}Ê6Ê+{ OR UÊÊ iv>✏ˆ˜Ê£Ê}Ê6Ê+n MODERATE INFECTIONS UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê+Ó{ OR UÊÊQ ˆ«ÀœyœÝ>Vˆ˜IÊxääʓ}Ê*"Ê  Ê",Ê ˆ«ÀœyœÝ>Vˆ˜IÊ{ääʓ}Ê6Ê+£ÓRÊ PLUS ONEʜvÊ̅iÊvœœÜˆ˜}ÊQ ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+nÉÎääʓ}Ê*"Ê / Ê",ÊiÌÀœ˜ˆ`>✏iÊxääʓ}Ê6É*"Ê/ R * BUT avoid fluoroquinolones in patients who were on them as outpatients If patient at risk for MRSA, add Vancomycin to regimens that do not include Clindamycin. Risk factors for MRSA UÊʈÃ̜ÀÞʜvÊVœœ˜ˆâ>̈œ˜ÊœÀʈ˜viV̈œ˜Ê܈̅Ê,-
UÊÊ,iVi˜Ìʭ܈̅ˆ˜ÊÎʓœ˜Ì…îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`ʅœÃ«ˆÌ>ˆâ>̈œ˜Ê€ÊÓÊ weeks UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}ʅœ“iʜÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi SEVERE INFECTIONS UÊÊ*ˆ«iÀVˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+È OR UÊÊQ ˆ«ÀœyœÝ>Vˆ˜IÊ{ääʓ}Ê6Ê+nÊ",Ê
âÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS Clindamycin 600 mg IV Q8H * Avoid fluoroquinolones in patients who were on them as outpatients. If patient at risk for MRSA (see above) UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+ÈÊPLUS Vancomycin (see dosing section, p. 150) OR UÊÊQ ˆ«ÀœyœÝ>Vˆ˜IÊ{ääʓ}Ê6Ê+nÊ",Ê
âÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV Q8H PLUS Vancomycin (see dosing section, p. 150) * Avoid fluoroquinolones in patients who were on them as outpatients TREATMENT NOTES Management UÊÊ
ʓՏ̈`ˆÃVˆ«ˆ˜>ÀÞÊ>««Àœ>V…Ê̜ʓ>˜>}i“i˜ÌÊŜՏ`ʈ˜VÕ`iÊܜ՘`Ê care consultation, assessment of vascular supply, vascular and/or general surgery consultation and infectious diseases consultation. UÊÊ œ˜Ãˆ`iÀʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃʈ˜Ê«>̈i˜ÌÃÊ܅œÊ>ÀiÊÃiÛiÀiÞʈ° UÊÊ
˜ÌˆLˆœÌˆVÊ̅iÀ>«ÞÊŜՏ`ÊLiʘ>ÀÀœÜi`ÊL>Ãi`ʜ˜ÊVՏÌÕÀiÊÀiÃՏÌð 104

Diagnosis UÊÊ ÕÌÕÀiÃʜvÊ̅iÊՏViÀÊL>ÃiÊ>vÌiÀÊ`iLÀˆ`i“i˜ÌÊV>˜Ê…i«Ê}Ո`iÊ̅iÀ>«Þ°Ê Biopsy of unexposed bone is NOT recommended. Avoid swabbing non-debrided ulcers or wound drainage. UÊÊ1ViÀÊyœœÀÊŜՏ`ÊLiÊ«ÀœLi`ÊV>ÀivՏÞ°ÊvÊLœ˜iÊV>˜ÊLiÊ̜ÕV…i`Ê܈̅Ê>Ê metal probe then the patient should be treated for osteomyelitis with antibiotics in addition to surgical debridement. UÊÊ*>˜Ì>ÀÊv>ÃVˆˆÌˆÃÊ>˜`Ê>Ê`ii«ÊvœœÌ‡Ã«>Viʈ˜viV̈œ˜ÊV>˜ÊLiÊ«ÀiÃi˜Ì°Ê Consider imaging to look for deep infections. UÊÊ*ÕÌÀˆ`Ê`ˆÃV…>À}iʈÃÊ`ˆ>}˜œÃ̈VʜvÊ̅iÊ«ÀiÃi˜ViʜvÊ>˜>iÀœLið UÊÊÊ,ʈÃʓœÀiÊÃi˜ÃˆÌˆÛiÊ>˜`ÊëiVˆwVÊ̅>˜ÊœÌ…iÀʓœ`>ˆÌˆiÃÊvœÀÊ`iÌiV̈œ˜Ê of soft-tissue lesions and osteomyelitis. Duration UÊÊ ÕÀ>̈œ˜ÊœvÊÌÀi>̓i˜ÌÊ܈Ê`i«i˜`ʜ˜ÊÀ>«ˆ`ˆÌÞʜvÊÀi뜘ÃiÊ>˜`Ê presence of adequate blood supply. UÊʈŽiÞʘii`ÊŜÀÌiÀÊÌÀi>̓i˜ÌÊ܈̅Ê>`iµÕ>ÌiÊÃÕÀ}ˆV>Êˆ˜ÌiÀÛi˜Ìˆœ˜Ê ­Çq£äÊ`>ÞÃÊ«œÃ̇œ«®Ê>˜`ʏœ˜}iÀÊvœÀʜÃÌiœ“ÞiˆÌˆÃ° UÊÊ …>˜}iÊ̜ʜÀ>ÊÀi}ˆ“i˜Ê܅i˜Ê«>̈i˜ÌʈÃÊÃÌ>Li° ,iviÀi˜Vi\  -
ÊՈ`iˆ˜iÃÊvœÀÊ`ˆ>LïVÊvœœÌʈ˜viV̈œ˜°Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£ÓÆx{\£ÎӇ£Çΰ

Surgical-site infections (SSI) EMPIRIC TREATMENT Infections following clean procedures (e.g. orthopedic joint replacements, open reduction of closed fractures, vascular procedures, median sternotomy, craniotomy, breast and hernia procedures) UÊÊ"Ý>Vˆˆ˜Ê£qÓÊ}Ê6Ê+{ OR UÊÊ iv>✏ˆ˜Ê£Ê}Ê6Ê+n OR 105

6.16 Skin, soft-tissue, and bone infections

Microbiology UÊÊ iÕˆÌˆÃÊ܈̅œÕÌʜ«i˜Êܜ՘`ʜÀʈ˜viVÌi`ÊՏViÀ]Ê>˜ÌˆLˆœÌˆVʘ>‹Ûi\Ê beta-hemolytic streptococci, S. aureus UÊʘviVÌi`ÊՏViÀ]ÊV…Àœ˜ˆVʜÀÊ«ÀiۈœÕÏÞÊÌÀi>Ìi`Ê܈̅Ê>˜ÌˆLˆœÌˆVÃ\ÊS. aureus, beta-hemolytic streptococci, Enterobacteriaceae UÊÊ Ý«œÃÕÀiÊ̜ÊÜ>Žˆ˜}]Ê܅ˆÀ«œœ]ʅœÌÊÌÕL\ÊÕÃÕ>ÞÊ«œÞ“ˆVÀœLˆ>]ʓ>ÞÊ involve Pseudomonas UÊÊ …Àœ˜ˆVÊܜ՘`ÃÊ܈̅ʫÀœœ˜}i`ÊiÝ«œÃÕÀiÊ̜Ê>˜ÌˆLˆœÌˆVÃ\Ê>iÀœLˆVÊÀ>“‡ positive cocci (GPC), Diphtheroids, Enterobacteriaceae, other Gramnegative rods (GNR) including Pseudomonas UÊÊ iVÀœÃˆÃʜÀÊ}>˜}Ài˜i\ʓˆÝi`Ê>iÀœLˆVÊ* Ê>˜`Ê ,]Ê>˜>iÀœLiÃ

6.16 Skin, soft-tissue, and bone infections

UÊÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê6Ê+n OR UÊʘۜÛi“i˜Ìʜvʅ>À`Ü>ÀiʜÀÊ,-
ÊÃÕëiVÌi`\Ê6>˜Vœ“ÞVˆ˜Ê (see dosing section, p. 150) Exception: Saphenous vein graft harvest site infections should be treated with Ertapenem 1 g IV Q24H Infections following contaminated procedures (GI/GU procedures, oropharyngeal procedures, obstetrical and gynecology procedures) Patients not on broad-spectrum antibiotics at time of surgery and not severely ill UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ OR UÊÊ* Ê>iÀ}Þ\ÊQ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê  Ê",Ê ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê 6Ê+£ÓRÊPLUS Clindamycin 600 mg IV Q8H Patients on broad-spectrum antibiotics at time of surgery or severely ill UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+ÈÊ´Ê6>˜Vœ“ÞVˆ˜Ê (see dosing section, p. 150) (if hardware present or MRSA suspected) OR UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole xääʓ}Ê6Ê+nÊ´Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}]Ê«°Ê£xä®Ê­ˆvʅ>À`Ü>ÀiÊ present or MRSA suspected) OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Q ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nÊ",Ê
âÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV/PO Q8H Deep fascia involvement UÊÊ/Ài>ÌÊ>ÃʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃÊ­ÃiiÊÃÕLÃiµÕi˜ÌÊÃiV̈œ˜® TREATMENT NOTES Microbiology UÊÊœœÜˆ˜}ÊVi>˜Ê«ÀœVi`ÕÀiÃÊ­˜œÊi˜ÌÀÞʜvÊÉ1ÊÌÀ>VÌî UÊÊStaphylococcus aureus UÊÊ-ÌÀi«ÌœVœVVˆ]Ê}ÀœÕ«Ê
Ê­iëiVˆ>ÞÊ܈̅Êi>ÀÞʜ˜ÃiÌ]ʐÊÇÓʅœÕÀî UÊÊ œ>}Տ>Ãi‡˜i}>̈ÛiÊÃÌ>«…ޏœVœVVˆ UÊÊœœÜˆ˜}ÊVi>˜‡Vœ˜Ì>“ˆ˜>Ìi`Ê>˜`ÊVœ˜Ì>“ˆ˜>Ìi`Ê«ÀœVi`ÕÀiÃÊ­i˜ÌÀÞʜvÊ GI/GU tracts with or without gross contamination) UÊÊ"À}>˜ˆÃ“ÃÊ>LœÛi UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`à UÊÊ
˜>iÀœLiÃÊ­Vœ˜Ãˆ`iÀÊClostridiaÊ뫰ʈ˜Êi>ÀÞ‡œ˜ÃiÌʈ˜viV̈œ˜]Ê£qÓÊ days) 106

Other management issues UÊÊ>˜ÞÊ>`ۜV>ÌiÊ̅>ÌÊ
ʈ˜viVÌi`Êܜ՘`ÃÊLiÊiÝ«œÀi`ÊLœÌ…Ê̜Ê`iLÀˆ`iÊ and to assess depth of involvement. UÊÊ-Õ«iÀwVˆ>Êˆ˜viV̈œ˜Ãʓ>ÞÊLiÊ>`iµÕ>ÌiÞÊÌÀi>Ìi`Ê܈̅Ê`iLÀˆ`i“i˜ÌÊ alone. UÊÊ ii«iÀʈ˜viV̈œ˜ÃÊ­ViÕˆÌˆÃ]Ê«>˜˜ˆVՏˆÌˆÃ®Ê˜ii`Ê>`Õ˜V̈ÛiÊ>˜ÌˆLˆœÌˆVð UÊʘviV̈œ˜ÃÊ̅>ÌÊiÝÌi˜`Ê̜Ê̅iÊv>ÃVˆ>ÊŜՏ`ÊLiʓ>˜>}i`Ê>ÃʘiVÀœÌˆâˆ˜}Ê fasciitis. UÊÊ*>̈i˜ÌÃÊ܈̅ʅޫœÌi˜Ãˆœ˜ÊŜՏ`ʅ>ÛiÊ̅iˆÀÊܜ՘`ÃÊiÝ«œÀi`ÊiÛi˜ÊˆvÊ they are unremarkable on physical exam. Serious, deep-tissue infections (necrotizing fasciitis) THESE ARE SURGICAL EMERGENCIES! ANTIBIOTICS ARE ONLY AN ADJUNCT TO PROMPT DEBRIDEMENT! ID should also be consulted EMPIRIC TREATMENT (adjunct to surgery) UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUSÊQ*ˆ«iÀ>Vˆˆ˜ÉÊ Ì>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+ÈÊ",Ê ivi«ˆ“iÊ£Ê}Ê6Ê+nRÊPLUS Clindamycin 600-900 mg IV Q8H OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Q ˆ«ÀœyœÝ>Vˆ˜Ê{ääʓ}Ê6Ê+nÊ´Êi˜Ì>“ˆVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê «°Ê£{È®RÊPLUS Clindamycin 600-900 mg IV Q8H TREATMENT NOTES Conventional nomenclature and microbiology Pyomyositis UÊÊS. aureus most commonly UÊÊ œÃÌÀˆ`ˆ>Ê“Þœ˜iVÀœÃˆÃÊqÊClostridia spp. (esp. C. perfringens) UÊÊÀœÕ«Ê
ÊÃÌÀi«ÌœVœVV>Ê“Þœ˜iVÀœÃˆÃ 107

6.16 Skin, soft-tissue, and bone infections

UÊÊi˜iÀ>Þ]Êi“«ˆÀˆVÊÕÃiʜvÊ6>˜Vœ“ÞVˆ˜ÊˆÃʘœÌʈ˜`ˆV>Ìi`ÊLiV>ÕÃiÊ̅iÊ percentage of SSIs caused by MRSA is low at Johns Hopkins Hospital ­£äqÓ䯮 Risk factors for MRSA UʈÃ̜ÀÞʜvÊVœœ˜ˆâ>̈œ˜ÊœÀʈ˜viV̈œ˜Ê܈̅Ê,-
UÊÊ,iVi˜Ìʭ܈̅ˆ˜ÊÎʓœ˜Ì…îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`ʅœÃ«ˆÌ>ˆâ>̈œ˜Ê€ÓÊ weeks UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}ʅœ“iʜÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi

6.16 Skin, soft-tissue, and bone infections

Fasciitis UÊÊ/Þ«iÊ£ÊqÊ*œÞ“ˆVÀœLˆ>Êˆ˜viV̈œ˜ÃÊ܈̅Ê>˜>iÀœLiÃ]ÊÃÌÀi«ÌœVœVVˆÊ>˜`Ê Gram-negative rods (Fournier’s gangrene is a type 1 necrotizing fasciitis of the perineum) UÊÊ/Þ«iÊÓÊqÊÀœÕ«Ê
ÊÃÌÀi«ÌœVœVVˆÊ«Ài`œ“ˆ˜>Ìi UÊÊ >ÃiÃʜvÊv>ÃVˆˆÌˆÃÊV>ÕÃi`ÊLÞÊVœ““Õ˜ˆÌއ>ÃÜVˆ>Ìi`Ê,-
ÊÃÌÀ>ˆ˜Ãʅ>ÛiÊ been reported Diagnosis UÊÊ >˜ÊLiÊ`ˆvwVՏÌÊqÊ}>ÃÊ«Àœ`ÕV̈œ˜ÊˆÃʘœÌÊ՘ˆÛiÀÃ>Ê>˜`ʈÃÊ}i˜iÀ>ÞÊ absent in streptococcal diseases. UÊÊ>ˆ˜Ì>ˆ˜Ê…ˆ}…ʈ˜`iÝʜvÊÃÕëˆVˆœ˜Ê܅i˜\ UÊÊ*>̈i˜ÌÃÊ>ÀiÊÛiÀÞʈÊvÀœ“ÊViÕˆÌˆÃÊ­…Þ«œÌi˜Ãˆœ˜]Ê̜݈VÊ>««i>À>˜Vi® UÊÊ*>ˆ˜ÊœÕÌʜvÊ«Àœ«œÀ̈œ˜Ê̜ʫ…ÞÈV>Êw˜`ˆ˜}à UÊÊ
˜iÃ̅iÈ>ʜÛiÀÊ>vviVÌi`Ê>Ài> UÊÊ,ˆÃŽÊv>V̜ÀÃÊÃÕV…Ê>ÃÊ`ˆ>LiÌiÃ]ÊÀiVi˜ÌÊÃÕÀ}iÀÞʜÀʜLiÈÌÞ UÊʈ˜`ˆ˜}ÃÊÃÕV…Ê>ÃÊΈ˜Ê˜iVÀœÃˆÃʜÀÊLՏ>i UÊÊ*ÕÌÀˆ`Ê`ˆÃV…>À}iÊ܈̅Ê̅ˆ˜]ʺ`ˆÃ…Ü>ÌiÀ»Ê«Õà UÊÊ /ÊÃV>˜ÊV>˜Ê…i«Ê܈̅Ê`ˆ>}˜œÃˆÃÊLÕÌʈvÊÃÕëˆVˆœ˜ÊˆÃʓœ`iÀ>ÌiÊ̜ʅˆ}…]Ê surgical exploration is the preferred diagnostic test. DO NOT delay surgical intervention to obtain CT. ,iviÀi˜Vi\  -
Ê}Ո`iˆ˜iÃÊvœÀÊ--/\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓääxÆÊ{£\£ÎÇÎq{äÈ°

Vertebral osteomyelitis, diskitis, epidural abscess NOTE: In absence of bacteremia, clinical instability, or signs and symptoms of spinal cord compromise strong consideration should be given to withholding antibiotics until samples of abscess or bone can be obtained for Gram-stain and culture. EMPIRIC TREATMENT UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê±ÊQ ivÌÀˆ>ݜ˜iÊÓÊ}Ê+£ÓÊOR

ivi«ˆ“iÊÓÊ}Ê6Ê+nRÊ OR UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê± Ciprofloxacin 400 mg IV Q8H UÊ >ÀÀœÜÊ̅iÀ>«ÞÊL>Ãi`ʜ˜ÊVՏÌÕÀiÊÀiÃՏÌð TREATMENT NOTES Microbiology UÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊˆ˜ÊÇx¯ÊœvÊV>ÃiÃÊ܈̅ʓ>œÀˆÌÞÊS. aureus UÊÀ>“‡˜i}>̈ÛiÊÀœ`Ãʈ˜ÊH£ä¯

108

Duration UÊ «ˆ`ÕÀ>Ê>LÃViÃÃÊ܈̅œÕÌʜÃÌiœ“ÞiˆÌˆÃ\Ê{qÈÊÜiiŽÃÊ UÊ6iÀÌiLÀ>ÊœÃÌiœ“ÞiˆÌˆÃʱÊi«ˆ`ÕÀ>Ê>LÃViÃÃ\ÊÈq£ÓÊÜiiŽÃÊ UÊʘʫ>̈i˜ÌÃÊ܈̅ʅ>À`Ü>ÀiÊ«ÀiÃi˜ÌÊ«Àœœ˜}i`ʜÀ>ÊÃÕ««ÀiÃÈÛiÊ̅iÀ>«ÞÊ ˆÃÊ}i˜iÀ>ÞÊÀiµÕˆÀi`Ê>vÌiÀÊVœ“«ïœ˜ÊœvÊ6Ê>˜ÌˆLˆœÌˆVÃÆÊ̅iÃiÊ`iVˆÃˆœ˜ÃÊ should be made in consultation with infectious diseases. ,iviÀi˜ViÃ\Ê -«ˆ˜>Êi«ˆ`ÕÀ>Ê>LÃViÃÃ\Ê Ê ˜}ÊÊi`ÊÓääÈÆÎxx\Óä£ÓqÓä°Ê -«ˆ˜>Êi«ˆ`ÕÀ>Ê>LÃViÃÃ\Ê+ÊÊi`ÊÓäänÆ£ä£\£q£Ó°Ê

109

6.16 Skin, soft-tissue, and bone infections

Management UÊÊ"LÌ>ˆ˜ÊÌܜÊÃiÌÃʜvÊLœœ`ÊVՏÌÕÀiÃ]Ê -,]Ê>˜`Ê ,*Ê«ÀˆœÀÊ̜ÊÃÌ>À̈˜}Ê antibiotic therapy. UÊÊœÃÌʈ˜ÌÀ>Ûi˜œÕÃÊ`ÀÕ}ÊÕÃiÀÃÊ>˜`Ê«>̈i˜ÌÃÊ܈̅œÕÌÊÈ}˜ˆwV>˜ÌÊ co-morbidities do not require empiric coverage for Gram-negative rods. UÊÊ “«ˆÀˆVÊÀ>“‡˜i}>̈ÛiÊVœÛiÀ>}iÊŜՏ`ÊLiÊÕÃi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê`ˆ>LiÌiÃ]Ê hardware in place or recent surgery, and recurrent urinary tract infections. UÊ,Ê܈̅ÊVœ˜ÌÀ>ÃÌʈÃÊ̅iʈ“>}ˆ˜}ʓi̅œ`ʜvÊV…œˆVi° UÊÊvÊLœœ`ÊVՏÌÕÀiÃÊ>Àiʘi}>̈ÛiÊ /Ê}Ո`i`ʘii`iÊLˆœ«ÃÞÉ>ëˆÀ>̈œ˜Ê should be obtained for Gram stain and cultures. UÊÊ “iÀ}i˜ÌÊÃÕÀ}ˆV>ÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜˆÌ…Ê signs and symptoms of spinal cord compromise. UÊÊ-ÕÀ}ˆV>Ê̅iÀ>«ÞʈÃÊ«ÀiviÀÀi`ʈ˜Ê“>˜ÞÊV>ÃiÃʜvÊi«ˆ`ÕÀ>Ê>LÃViÃÃÉÊ osteomyelitis (e.g. extensive infection, pre-vertebral abscess, spine instability, hardware involvement). CT-guided aspiration and/or antibiotic therapy alone may be considered in some circumstances. Discussion with infectious diseases and surgery is recommended to optimize management. UÊÊ*>̈i˜ÌÃÊŜՏ`ʅ>ÛiÊvÀiµÕi˜ÌÊ>ÃÃiÃÓi˜ÌʜvʘiÕÀœœ}ˆVÊv՘V̈œ˜]Ê particularly at the time of initial presentation. UÊÊ
Ê«>̈i˜ÌÃÊÀiµÕˆÀiʓœ˜ˆÌœÀˆ˜}ÊvœÀÊ>`iµÕ>ÌiÊÀi뜘ÃiÊ̅ÀœÕ}…œÕÌÊ̅iÊ ÌÀi>̓i˜ÌÊVœÕÀÃiÆÊ ÊvœœÜÊիʅˆ}…ÞÊÀiVœ““i˜`i`°Ê

110

Bacterial urinary tract infections (UTI)

Empiric treatment œÊÌÀi>̓i˜ÌÊ՘iÃÃÊ̅iÊ«>̈i˜ÌʈÃ\ UÊ*Ài}˜>˜ÌÊ UÊÊ
LœÕÌÊ̜Ê՘`iÀ}œÊ>ÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÊ UÊ*œÃÌÊÀi˜>ÊÌÀ>˜Ã«>˜Ì UÊ iÕÌÀœ«i˜ˆV

1˜Vœ“«ˆV>Ìi`\ UÊÊ ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­>VÀœLˆ`®) 100 mg PO Q12H for xÊ`>ÞÃÊ­ "/ʈ˜Ê«>̈i˜ÌÃÊÜˆÌ…Ê À ÊxäʓÉ“ˆ˜® OR UÊÊ i«…>i݈˜Êxääʓ}Ê*"Ê+ÈÊvœÀÊxÊ`>ÞÃÊ OR UÊÊ iv«œ`œÝˆ“iÊ£ääʓ}Ê*"Ê+£ÓÊvœÀÊxÊ`>ÞÃÊ OR UÊÊ iv`ˆ˜ˆÀÊÎääʓ}Ê*"Ê+£ÓÊvœÀÊxÊ`>ÞÃÊ OR UÊÊÊ/*É-8Ê£Ê -ÊÌ>LÊ*"Ê+£ÓÊvœÀÊÎÊ`>Þà OR UÊÊ6ʜ«Ìˆœ˜\Ê iv>✏ˆ˜Ê£Ê}Ê6Ê+nÊvœÀÊÎÊ`>ÞÃ

œ“«ˆV>Ìi`\ UÊÊ->“iÊÀi}ˆ“i˜ÃÊ>ÃÊ>LœÛiÊiÝVi«ÌÊ`ÕÀ>̈œ˜ÊˆÃÊ Çq£{Ê`>ÞÃ

Definition Positive urine culture  100,000 CFU/mL with no signs or symptoms

Signs and symptoms (e.g. dysuria, urgency frequency, suprapubic pain) AND pyuria (>10 WBC/hpf ) AND positive urine culture 100,000 CFU/mL UÊÊUncomplicated: female, no urologic abnormalities, no stones, no catheter UÊÊComplicated: male gender, possible stones, urologic abnormalities, pregnancy

Category Asymptomatic bacteriuria

Acute cystitis

UÊÊ1/Ãʈ˜Ê“i˜Ê>ÀiÊÌÀ>`ˆÌˆœ˜>ÞÊVœ˜Ãˆ`iÀi`ÊVœ“«ˆV>Ìi`°Ê UTIs in men in the absence of obstructive pathology (e.g. BPH, stones, strictures) are uncommon. Please critically evaluate your diagnosis of UTI in male patients. UÊÊ"À>Ê̅iÀ>«ÞʈÃÊ«ÀiviÀÀi`Ê>˜`ÊŜՏ`ÊLiÊ}ˆÛi˜Ê՘iÃÃÊ patient is unable to tolerate oral therapy UÊÊvÊ6ÊLiÌ>‡>VÌ>“ÃÊ>ÀiÊÕÃi`Êi“«ˆÀˆV>ÞÊvœÀÊÎÊ`>ÞÃ]ʘœÊ additional therapy is needed for uncomplicated cystitis UÊÊvÊ6ÊLiÌ>‡>VÌ>“ÃÊ>ÀiÊÕÃi`Êi“«ˆÀˆV>ÞÊvœÀʐÎÊ`>ÞÃÊ or treating complicated cystitis, the patient can be switched to an appropriate oral beta-lactam and duration of IV therapy should be counted towards total duration of therapy UÊÊ"À>ÊœÃvœ“ÞVˆ˜ÊV>˜ÊLiÊÕÃi`ʈvÊÃÕÃVi«ÌˆLiÊvœÀÊÀ>“‡ negative MDR organisms (susceptibilities must be requested)

Notes UÊÊ"LÌ>ˆ˜ˆ˜}ÊÀœṎ˜iÊVՏÌÕÀiÃʈ˜Ê>Ãޓ«Ìœ“>̈VÊ«>̈i˜ÌÃʈÃÊ not recommended UÊÊ
˜ÌˆLˆœÌˆVÃÊ`œÊ˜œÌÊ`iVÀi>ÃiÊ>Ãޓ«Ìœ“>̈VÊL>VÌiÀˆÕÀˆ>ʜÀÊ prevent subsequent development of UTIs UÊÊÊ/…iÊ«ÀiÛ>i˜ViʜvÊ>Ãޓ«Ìœ“>̈VÊL>VÌiÀˆÕÀˆ>ʈÃÊ …ˆ}…\Ê£¯‡x¯Êˆ˜Ê«Ài“i˜œ«>ÕÃ>Êܜ“i˜]Êί‡™¯Êˆ˜Ê «œÃ̓i˜œ«>ÕÃ>Êܜ“i˜]Ê{䯇xä¯Êˆ˜Êœ˜}‡ÌiÀ“ÊV>ÀiÊ ÀiÈ`i˜ÌÃÊ>˜`ʙ¯‡Óǯʈ˜Êܜ“i˜Ê܈̅Ê`ˆ>LiÌið

NOTE: Ciprofloxacin is not recommended for empiric treatment for in-patients with non-catheter associated UTI at JHH due to the low rate of E. coli ÃÕÃVi«ÌˆLˆˆÌÞÊ­Ç£¯®°Ê

Management of patients WITHOUT a urinary catheter

6.17 Urinary tract infections

111

Definition Signs and symptoms (e.g. fever, flank pain) AND pyuria AND positive urine culture 100,000 CFU/mL Many patients will have other evidence of upper tract disease (i.e. leukocytosis, WBC casts, or abnormalities upon imaging)

SIRS with urinary source of infection

Category Acute pyelonephritis

Urosepsis

Empiric treatment UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ OR UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{Ê­ˆvʅˆÃ̜ÀÞʜvÊ - ® OR UÊÊ* Ê>iÀ}Þ\Ê
âÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ",Ê Gentamicin (see dosing section, p. 147) UÊÊ ÕÀ>̈œ˜\ÊÇq£{Ê`>Þà Hospitalized > 48H UÊÊ ivi«ˆ“iÊ£Ê}Ê6Ê+n OR UÊÊ* Ê>iÀ}Þ\Ê
âÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ",Ê Gentamicin (see dosing section, p. 147) UÊ ÕÀ>̈œ˜\ÊÇq£{Ê`>Þà UÊÊ ivi«ˆ“iÊ£Ê}Ê6Ê+n OR UÊÊ* Ê>iÀ}Þ\Ê
âÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ´Ê Gentamicin (see dosing section, p. 147) UÊ ÕÀ>̈œ˜\ÊÇq£äÊ`>ÞÃ

6.17 Urinary tract infections

UÊÊ"À>Ê ˆ«ÀœyœÝ>Vˆ˜ÊœÀÊ/*É-8ʅ>ÛiÊiÝVii˜ÌÊ bioavailability and should be used as step-down therapy if organism is susceptible UÊÊ"À>ÊLiÌ>‡>VÌ>“ÃÊŜՏ`ʘœÌÊLiÊÕÃi`ÊvœÀÊL>VÌiÀi“ˆ>Ê due to inadequate blood concentrations UÊÊ ÕÀ>̈œ˜ÊœvÊi“«ˆÀˆVÊ6Ê̅iÀ>«ÞÊŜՏ`ÊLiÊVœÕ˜Ìi`Ê towards total duration of therapy

Notes UÊÊ"À>ÊÃÌi«‡`œÜ˜Ê̅iÀ>«ÞÊŜՏ`ÊLiÊÕÃi`ʈvʜÀ}>˜ˆÃ“ʈÃÊ susceptible UÊÊ ÕÀ>̈œ˜ÊœvÊi“«ˆÀˆVÊ6Ê̅iÀ>«ÞÊŜՏ`ÊLiÊVœÕ˜Ìi`Ê towards total duration of therapy "À>ÊÃÌi«‡`œÜ˜Ê̅iÀ>«ÞʈvʜÀ}>˜ˆÃ“ʈÃÊÃÕÃVi«ÌˆLi\ UÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê+£ÓÊvœÀÊÇÊ`>ÞÃÊ UÊ/*É-8Ê£Ê -Ê*"Ê+£ÓÊvœÀÊLJ£äÊ`>ÞÃÊ UÊ iv«œ`œÝˆ“iÊ{ääʓ}Ê*"Ê+£ÓÊvœÀÊ£{Ê`>ÞÃÊ UÊÊ"À>ÊœÃvœ“ÞVˆ˜ÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈvÊÃÕÃVi«ÌˆLiÊvœÀÊ Gram-negative MDR organisms (susceptibilities must be requested). Consult ID Pharmacist for dosing.

6.17 Urinary tract infections

DIAGNOSIS Specimen collection\Ê/…iÊÕÀi̅À>Ê>Ài>ÊŜՏ`ÊLiÊVi>˜i`Ê܈̅Ê>˜Ê antiseptic cloth and the urine sample should be collected midstream or obtained by fresh catheterization. Specimens collected using a drainage bag or taken from a collection hat are not reliable and should not be sent. Interpretation of the urinalysis (U/A) and urine culture UÊÊ1Àˆ˜>ÞÈÃÊ>˜`ÊÕÀˆ˜iÊVՏÌÕÀiÃʓÕÃÌÊLiʈ˜ÌiÀ«ÀiÌi`Ê̜}i̅iÀʈ˜Ê context of symptoms UÊUrinalysis/microscopy: UÊÊ ˆ«Ã̈VŽ UÊ ˆÌÀˆÌiÃʈ˜`ˆV>ÌiÊL>VÌiÀˆ>ʈ˜Ê̅iÊÕÀˆ˜i UÊiՎœVÞÌiÊiÃÌiÀ>Ãiʈ˜`ˆV>ÌiÃÊ܅ˆÌiÊLœœ`ÊViÃʈ˜Ê̅iÊÕÀˆ˜i UÊÊ >VÌiÀˆ>\Ê«ÀiÃi˜ViʜvÊL>VÌiÀˆ>ʜ˜ÊÕÀˆ˜>ÞÈÃÊŜՏ`ÊLiÊ interpreted with caution and is not generally useful UÊÊ*ÞÕÀˆ>Ê­“œÀiÊÃi˜ÃˆÌˆÛiÊ̅>˜ÊiՎœVÞÌiÊiÃÌiÀ>Ãi®\ʀ£äÊ7 Ʌ«vʜÀÊ >27 WBC/microliter UÊ1Àˆ˜iÊVՏÌÕÀiÃ\ UÊÊvÊ1É
ʈÃʘi}>̈ÛiÊvœÀÊ«ÞÕÀˆ>]Ê«œÃˆÌˆÛiÊVՏÌÕÀiÃÊ>ÀiʏˆŽiÞÊ contamination UÊÊœÃÌÊ«>̈i˜ÌÃÊ܈̅Ê1/Ê܈Ê…>ÛiÊ100,000 colonies of a uropathogen. Situations in which lower colony counts may be È}˜ˆwV>˜Ìʈ˜VÕ`i\Ê«>̈i˜ÌÃÊ܅œÊ>ÀiÊ>Ài>`Þʜ˜Ê>˜ÌˆLˆœÌˆVÃÊ>ÌÊ̅iÊ time of culture, symptomatic young women, suprapubic aspiration, and men with pyuria. TREATMENT NOTES UÊÊ*ÞÕÀˆ>ÊiˆÌ…iÀʈ˜Ê̅iÊÃiÌ̈˜}ʜvʘi}>̈ÛiÊÕÀˆ˜iÊVՏÌÕÀiÃʜÀʈ˜Ê«>̈i˜ÌÃÊ with asymptomatic bacteriuria usually requires no treatment. If pyuria persists consider other causes (e.g. interstitial nephritis or cystitis, fastidious organisms). UÊÊœœÜ‡Õ«ÊÕÀˆ˜iÊVՏÌÕÀiÃʜÀÊ1É
Ê>Àiʜ˜ÞÊÜ>ÀÀ>˜Ìi`ÊvœÀʜ˜}œˆ˜}Ê symptoms. They should NOT be acquired routinely to monitor response to therapy. UÊÊ-iiÊ«°Ê££{ÊvœÀÊ`ˆÃVÕÃȜ˜ÊœvÊÌÀi>̓i˜Ìʜ«Ìˆœ˜ÃÊvœÀÊ6, Ê>˜`ÊÀi˜>Ê concentrations of antibiotics.

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Category Asymptomatic bacteriuria

Definition Positive urine culture  100,000 CFU/mL with no signs or symptoms of infection

Empiric treatment Remove the catheter œÊÌÀi>̓i˜ÌÊ՘iÃÃÊ̅iÊ«>̈i˜ÌʈÃ\ UÊ*Ài}˜>˜ÌÊ UÊ
LœÕÌÊ̜Ê՘`iÀ}œÊ>ÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÊ UÊ*œÃÌÊÀi˜>ÊÌÀ>˜Ã«>˜Ì "/ \ʜLÌ>ˆ˜ˆ˜}Ê UÊ iÕÌÀœ«i˜ˆV routine cultures in Antibiotics do not decrease asymptomatic asymptomatic patients bacteriuria or prevent subsequent development is not recommended of UTI Signs and symptoms CatheterUÊÊ,i“œÛiÊV>̅iÌiÀÊ܅i˜Ê«œÃÈLi associated UTI (fever with no other Patient stable with no evidence of upper tract source is the most (CA-UTI) `ˆÃi>Ãi\ Vœ““œ˜ÆÊ«>̈i˜ÌÃʓ>ÞÊ UÊÊvÊV>̅iÌiÀÊÀi“œÛi`]ÊVœ˜Ãˆ`iÀʜLÃiÀÛ>̈œ˜Ê>œ˜i also have suprapubic OR or flank pain) UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ AND pyuria (10 OR WBC/hpf) UÊÊ ivÌÀˆ>ݜ˜iÊ£Ê}Ê6Ê+Ó{ AND positive urine OR culture 1,000 UÊÊ ˆ«ÀœyœÝ>Vˆ˜Êxääʓ}Ê*"Ê  ʜÀÊ{ääʓ}Ê6Ê+£ÓÊ CFU/mL (see (avoid in pregnancy and in patients with prior information below exposure to quinolones) regarding significant UÊ ÕÀ>̈œ˜\ÊÃiiÊLiœÜ colony counts) Patient severely ill, with evidence of upper tract disease, or hospitalized {nÊ\ UÊÊ ivi«ˆ“iÊ£Ê}Ê6Ê+nÊ OR UÊ* Ê>iÀ}Þ\Ê
âÌÀiœ˜>“Ê£Ê}Ê6Ê+n UÊ ÕÀ>̈œ˜\ÊÃiiÊLiœÜ Urosepsis in a SIRS with urinary UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxʓ}Ê6Ê+È source and patient with If prior urine culture data are available, tailor nephrostomy tubes nephrostomy therapy based on those results tubes

DIAGNOSIS -«iVˆ“i˜ÊVœiV̈œ˜\ The urine sample should be drawn from the catheter port using aseptic technique, NOT from the urine collection bag. In patients with long term catheters ( 2 weeks), replace the catheter before collecting a specimen. Urine should be collected before antibiotics are started. -ޓ«Ìœ“Ã\ Catheterized patients usually lack typical UTI symptoms. -ޓ«Ìœ“ÃÊVœ“«>̈LiÊ܈̅Ê
‡1/ʈ˜VÕ`i\ UÊÊ iÜÊviÛiÀʜÀÊÀˆ}œÀÃÊ܈̅ʘœÊœÌ…iÀÊÜÕÀVi UÊÊ iÜʜ˜ÃiÌÊ`iˆÀˆÕ“]ʓ>>ˆÃi]ʏi̅>À}ÞÊ܈̅ʘœÊœÌ…iÀÊÜÕÀVi UÊÊ 6
ÊÌi˜`iÀ˜iÃÃ]Êy>˜ŽÊ«>ˆ˜]Ê«iÛˆVÊ`ˆÃVœ“vœÀÌ UÊÊ
VÕÌiʅi“>ÌÕÀˆ> Interpretation of the urinalysis (U/A) and urine culture UÊÊ*ÞÕÀˆ>\ʘÊ̅iÊ«ÀiÃi˜ViʜvÊ>ÊV>̅iÌiÀ]Ê«ÞÕÀˆ>Ê`œiÃʘœÌÊVœÀÀi>ÌiÊÜˆÌ…Ê the presence of symptomatic CA-UTI and must be interpreted based on the clinical scenario. The absence of pyuria suggests an alternative diagnosis. UÊÊ*œÃˆÌˆÛiÊÕÀˆ˜iÊVՏÌÕÀi\Ê 1,000 colonies 113

6.17 Urinary tract infections

Management of patients WITH a urinary catheter

6.17 Urinary tract infections

DURATION The duration of treatment has not been well studied for CA-UTI and optimal duration is not known. UÊÊÇÊ`>ÞÃʈvÊ«Àœ“«ÌÊÀi܏Ṏœ˜ÊœvÊÃޓ«Ìœ“à UÊÊ£äq£{Ê`>ÞÃʈvÊ`i>Þi`ÊÀi뜘Ãi UÊÊÎÊ`>ÞÃʈvÊV>̅iÌiÀÊÀi“œÛi`ʈ˜Êvi“>iÊ«>̈i˜ÌÊ 65 years with lower tract infection. TREATMENT NOTES UÊÊ,i“œÛiÊ̅iÊV>̅iÌiÀÊ܅i˜iÛiÀÊ«œÃÈLi UÊÊ,i«>ViÊV>̅iÌiÀÃÊ̅>Ìʅ>ÛiÊLii˜Êˆ˜Ê 2 weeks if still indicated UÊÊ*Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊ>ÌÊ̅iÊ̈“iʜvÊV>̅iÌiÀÊÀi“œÛ>ÊœÀÊÀi«>Vi“i˜ÌÊ are NOT recommended due to low incidence of complications and concern for development of resistance. UÊÊ >̅iÌiÀʈÀÀˆ}>̈œ˜ÊŜՏ`ʘœÌÊLiÊÕÃi`ÊÀœṎ˜iÞ Treatment of Enterococci UÊÊÊ
“œÃÌÊ>ÊE. faecalis isolates are susceptible to Amoxicillin 500 mg PO TID OR Ampicillin 1 g IV Q6H and should be treated with these >}i˜ÌðÊœÀÊ«>̈i˜ÌÃÊ܈̅Ê* Ê>iÀ}Þ\Ê ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­Ê>VÀœLˆ`®) £ääʓ}Ê*"Ê+£ÓÊ­`œÊ "/ÊÕÃiʈ˜Ê«>̈i˜ÌÃÊÜˆÌ…Ê À ÊÊxäʓɓˆ˜®°Ê UÊE. faecium (often Vancomycin resistant) UÊÊ ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­>VÀœLˆ`®) 100 mg PO Q12H if susceptible (do NOT use in patients with CrCl  50 mL/min). UÊ/iÌÀ>VÞVˆ˜iÊxääʓ}Ê*"Ê+ÈʈvÊÃÕÃVi«ÌˆLi UÊÊœÃvœ“ÞVˆ˜ÊÎÊ}Ê*"ʜ˜ViÊ­ˆvÊvi“>iÊ܈̅œÕÌÊV>̅iÌiÀʜÀÊV>̅iÌiÀÊ ˆÃÊÀi“œÛi`ÆÊ>ÎÊ̅iʓˆVÀœÊ>LÊvœÀÊÃÕÃVi«ÌˆLˆˆÌÞ® UÊʈ˜i✏ˆ`ÊÈääʓ}Ê*"Ê  Ê",ÊœÃvœ“ÞVˆ˜ÊÎÊ}Ê*"ÊiÛiÀÞÊÓqÎÊ`>ÞÃÊ (max 21 days) if complicated UTI or catheter can not be removed Renal excretion/concentration of selected antibiotics Good (≥60%): aminoglycosides, Amoxicillin, Amoxicillin/clavulanate, Fosfomycin, Cefazolin, Cefepime, Cephelexin, Ciprofloxacin, Colistin, Ertapenem, Trimethoprim/sulfamethoxazole, Vancomycin, Amphotericin B, Fluconazole, Flucytosine Variable (30-60%):Ê iv«œ`œÝˆ“i]ʈ˜i✏ˆ`Ê­Î䯮]Ê œÝÞVÞVˆ˜iÊ ­Ó™qxx¯®]Ê ivÌÀˆ>ݜ˜i]Ê/iÌÀ>VÞVˆ˜iÊ­HÈ䯮ÊÊ Poor (<30%): Azithromycin, Clindamycin, Moxifloxacin, Oxacillin, Tigecycline, Micafungin, Posaconazole, Voriconazole ,iviÀi˜ViÃ\ *ÞÕÀˆ>Ê>˜`ÊÕÀˆ˜>ÀÞÊV>̅iÌiÀÃ\Ê
ÀV…ʘÌÊi`ÊÓäääÆ£Èä­x®\ÈÇ·ÇÇ° IDSA Guidelines for treatment of uncomplicated acute bacterial cystitis and «Þiœ˜i«…ÀˆÌˆÃʈ˜Êܜ“i˜\Ê ˆ˜Ê˜viVÌÊ ˆÃÊ£™™™Æә\Ç{x°  -
ÊՈ`iˆ˜iÃÊvœÀÊÌÀi>̓i˜ÌʜvÊ
‡1/\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓä£äÆxä\ÈÓxqÈΰ

114

Oropharyngeal disease (thrush) Initial treatment UÊÊ œÌÀˆ“>✏iÊ£äʓ}ÊÌÀœV…iÊxÊ̈“iÃÊ>Ê`>Þ OR UÊ ÞÃÌ>̈˜ÊÃÕëi˜Ãˆœ˜Êxää]äääÊ՘ˆÌÃÉx“Ê{Ê̈“iÃÊ>Ê`>Þ Recurrent or intractable disease UʏÕVœ˜>✏iÊ£ääqÓääʓ}Ê*"ʜ˜ViÊ`>ˆÞ Duration: xq£äÊ`>Þà NOTE: If refractory to Fluconazole consider fungal culture and susceptibilities Esophageal candidiasis Initial treatment UʏÕVœ˜>✏iÊÓääq{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ Duration: £{‡qÓ£Ê`>Þà Relapse UÊʏÕVœ˜>✏iÊ{ääqnääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ Refractory to Fluconazole 800 mg daily (fungal culture and susceptibilities are recommended) UʈV>v՘}ˆ˜Ê£xäʓ}Ê6ʜ˜ViÊ`>ˆÞ OR UÊ
“«…œÌiÀˆVˆ˜Ê Êä°Îqä°Çʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞ OR UÊ"À>Ê̅iÀ>«Þ\ÊÌÀ>Vœ˜>✏iʜÀ>Ê܏Ṏœ˜ÊÓääʓ}Ê`>ˆÞ Duration: £{qÓ£Ê`>Þà Candiduria UÊ1Àˆ˜>ÀÞÊV>̅iÌiÀÊÀi“œÛ>Ê܈ÊÀi܏ÛiÊ̅iÊV>˜`ˆ`ÕÀˆ>ʈ˜Ê{ä¯ÊœvÊV>Ãið TREATMENT Asymptomatic cystitis UÊ/…iÀ>«ÞʘœÌÊÕÃÕ>Þʈ˜`ˆV>Ìi` UÊÊ œ˜Ãˆ`iÀʈ˜Ê̅iÊvœœÜˆ˜}ÊVœ˜`ˆÌˆœ˜ÃÊ­ÃiiÊÀi}ˆ“i˜ÃÊ՘`iÀÊ ºÃޓ«Ìœ“>̈VÊVÞÃ̈̈û®\ UÊ iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ UÊ,i˜>ÊÌÀ>˜Ã«>˜Ì UÊ1Àˆ˜>ÀÞʜLÃÌÀÕV̈œ˜ÊœÀÊ>L˜œÀ“>Ê1ÊÌÀ>VÌ UÊ7…i˜ÊÀiVœÛiÀi`ʈ˜ÊÕÀˆ˜iÊ«ÀˆœÀÊ̜ÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÃ

115

6.18 Candidiasis in the non-neutropenic patient

Candidiasis in the non-neutropenic patient

6.18 Candidiasis in the non-neutropenic patient

Symptomatic cystitis Preferred therapy UÊʏÕVœ˜>✏iÊÓääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞÊ Duration:ÊÇq£{Ê`>Þà Fluconazole-resistant organism suspected or confirmed UÊ
“«…œÌiÀˆVˆ˜Ê Êä°Î‡ä°Èʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞÊ Duration:Ê£qÇÊ`>ÞÃÊ Pyelonephritis NOTE: Candida pyelonephritis is usually secondary to hematogenous spread except for patients with renal transplant or abnormalities of the urogenital tract. Preferred therapy UʏÕVœ˜>✏iÊÓääq{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞÊ Duration: 14 days Fluconazole-resistant organism suspected or confirmed UÊ
“«…œÌiÀˆVˆ˜Ê Êä°xqä°Çʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞÊ OR UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞÊ Duration: 14 days TREATMENT NOTES UÊ,i“œÛiÊÕÀˆ˜>ÀÞÊV>̅iÌiÀʈvÊ«œÃÈLi° UÊÊ/…iÀ>«ÞʜvÊV>˜`ˆ`ÕÀˆ>ʈ˜Ê̅iʘœ˜‡˜iÕÌÀœ«i˜ˆV]ʘœ˜‡ 1ÊV>̅iÌiÀˆâi`Ê patient has not been shown to be beneficial and promotes resistance. UÊÊ
“ ˆÃœ“i®, Voriconazole, Itraconazole, and Posaconazole are not recommended due to poor penetration into the urinary tract. UÊʈV>v՘}ˆ˜Ê«i˜iÌÀ>ÌiÃÊ«œœÀÞʈ˜Ê̅iÊÕÀˆ˜i]ÊLÕÌÊ`œiÃÊ«i˜iÌÀ>Ìiʈ˜ÌœÊ renal tissue. UÊ
“«…œÌiÀˆVˆ˜Ê ÊL>``iÀÊÜ>ÅiÃÊ>ÀiʘœÌÊÀiVœ““i˜`i`° Candida vaginitis Initial Therapy UʏÕVœ˜>✏iÊ£xäʓ}Ê*"Ê8Ê£Ê`œÃiÊ OR UʈVœ˜>✏iÊÓ¯ÊVÀi>“ÊxÊ}ʈ˜ÌÀ>Û>}ˆ˜>Þʜ˜ViÊ`>ˆÞÊ8ÊÇÊ`>Þà Recurrent (> 4 episodes/year of symptomatic infection) UÊʏÕVœ˜>✏iÊ£xäʓ}Ê*"Ê+ÇÓÊ8ÊÎÊ`œÃiÃ]Ê̅i˜Ê£xäʓ}Ê>ÊÜiiŽÊ8Ê 6 months 116

UÊÊ9
-/Ê Ê
Ê "" Ê 1/1, Ê-"1 Ê "/Ê Ê " - , Ê
Ê CONTAMINANT. NOTE: Micafungin does not have activity against Cryptococcus TREATMENT Unspeciated candidemia Patients who are clinically stable and have not received prior long-term azole therapy UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]Ê̅i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ Patients who are NOT clinically stable due to Candidemia or have received prior long-term azole therapy UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞÊ If the yeast is C. albicans or C. glabrata based on PNA FISH results, follow the recommendations for C. albicans or C. glabrata noted below. Otherwise, await speciation before modifying therapy as recommended below, unless the patient becomes clinically unstable on Fluconazole. Candida albicans UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]Ê̅i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ Patients who are NOT clinically stable due to Candidemia or have received prior long-term azole therapy UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞÊ Patients should be transitioned to Fluconazole once stable. Candida glabrata UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞ OR UÊʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]Ê̅i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞÊÊ the isolate is susceptible with MIC  8 mcg/mL and the patient is stable. If isolate is intermediate to Fluconazole and oral therapy is desired, consult ID. Other azoles such as Voriconazole should not be used in Fluconazole-resistant strains due to the same mechanism of resistance. Candida krusei UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞÊ Fluconazole should NEVER be used to treat infections due to C. krusei because the organism has intrinsic resistance to Fluconazole. This “iV…>˜ˆÃ“ÊœvÊÀiÈÃÌ>˜ViʈÃʘœÌÊÅ>Ài`Ê܈̅Ê6œÀˆVœ˜>✏iÆÊ̅iÀivœÀi]Ê oral Voriconazole can be used if isolate is susceptible (for dosing see Voriconazole specific guidelines, p. 19). 117

6.18 Candidiasis in the non-neutropenic patient

Candidemia

6.18 Candidiasis in the non-neutropenic patient

Candida lusitaniae UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]Ê̅i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ C. lusitaniaeʈÃÊÀiÈÃÌ>˜ÌÊ̜Ê
“«…œÌiÀˆVˆ˜Ê ʈ˜Ê>««ÀœÝˆ“>ÌiÞÊÓä¯ÊœvÊ cases. Candida parapsilosis UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]Ê̅i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ Fluconazole-intermediate isolate UʏÕVœ˜>✏iÊnääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ Fluconazole-resistant isolate UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞ If the patient is not responding to Micafungin then consider changing to Amphotericin B. The minimum inhibitory concentrations (MICs) of echinocandins are higher for C. parapsilosis than any other Candida spp.ÆÊ̅ˆÃʅ>Ãʏi`Ê̜ÊVœ˜ViÀ˜Ê̅>ÌÊܓiʈ˜viV̈œ˜ÃÊ܈̅ÊC. parapsilosis may not respond well to echinocandins. Candida tropicalis UʏÕVœ˜>✏iÊnääʓ}Ê6É*"Ê8Ê£Ê`œÃi]Ê̅i˜Ê{ääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ Fluconazole-intermediate isolate UʏÕVœ˜>✏iÊnääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞ Fluconazole-resistant isolate UʈV>v՘}ˆ˜Ê£ääʓ}Ê6ʜ˜ViÊ`>ˆÞ TREATMENT NOTES Amphotericin B use in Candidemia UÊÊ
“«…œÌiÀˆVˆ˜Ê ʈÃʅˆ}…ÞÊivviV̈ÛiÊ>}>ˆ˜ÃÌÊ>ÊCandida spp. except for C. lusitaniaeÆʅœÜiÛiÀ]Ê>✏iÃÊ>˜`ÊiV…ˆ˜œV>˜`ˆ˜ÃÊ>ÀiÊv>ۜÀi`ʈ˜Ê susceptible strains over Amphotericin B products due to toxicity. Doses for Candidemia UÊ
“«…œÌiÀˆVˆ˜Ê Êä°Çʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞ OR UÊÊ
“ ˆÃœ“i® 3 mg/kg IV once daily (if patient cannot tolerate conventional Amphotericin B) Duration UÊÊ£{Ê`>ÞÃÊvœœÜˆ˜}Ê`œVՓi˜Ìi`ÊVi>À>˜ViʜvÊLœœ`ÊVՏÌÕÀiÃÊ>˜`ÊVˆ˜ˆV>Ê symptoms UÊÊ*>̈i˜ÌÃÊ܈̅ʫiÀÈÃÌi˜ÌÊV>˜`ˆ`i“ˆ>Ê>˜`ɜÀʓiÌ>ÃÌ>̈VÊVœ“«ˆV>̈œ˜ÃÊ (e.g. endophthalmitis, endocarditis) need a longer duration of therapy and evaluation by Ophthalmology and ID. 118

6.18 Candidiasis in the non-neutropenic patient

Ê

Hidden Content - JHH Internal use only

Non-pharmacologic management UÊÊ,i“œÛ>ÊœvÊ>Êi݈Ã̈˜}ÊVi˜ÌÀ>ÊÛi˜œÕÃÊV>̅iÌiÀÃʈÃʅˆ}…ÞÊ recommended. UÊÊ*>̈i˜ÌÃÊŜՏ`ʅ>ÛiÊLœœ`ÊVՏÌÕÀiÃÊ`>ˆÞʜÀÊiÛiÀÞʜ̅iÀÊ`>ÞÊ՘̈Ê candidemia is cleared. UÊÊ*>̈i˜ÌÃÊŜՏ`ʅ>ÛiÊ>˜Êœ«…Ì…>“œœ}ˆVÊiÝ>“ˆ˜>̈œ˜Ê̜ÊiÝVÕ`iÊ candidal endophthalmitis prior to discharge, preferably once the candidemia is controlled. UÊÊ V…œV>À`ˆœ}À>«…ÞÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈvÊ̅iÊ«>̈i˜Ìʅ>ÃÊ«iÀÈÃÌi˜ÌÊ candidemia on appropriate therapy. Endophthalmitis UÊ>˜>}i“i˜Ìʈ˜ÊVœ˜Õ˜V̈œ˜Ê܈̅Ê"«…Ì…>“œœ}Þ UÊÊ ÕiÊ̜ʫœœÀÊ -Ê>˜`ÊۈÌÀi>Ê«i˜iÌÀ>̈œ˜]ÊÌÀi>̓i˜ÌÊ܈̅ÊiV…ˆ˜œV>˜`ˆ˜ÃÊ is NOT recommended. Preferred therapy UÊ
“«…œÌiÀˆVˆ˜Ê ʣʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxʓ}Ɏ}Ê*"Ê+È OR UÊ
“ ˆÃœ“i®Êxʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxʓ}Ɏ}Ê*"Ê+È Alternate therapy UÊʏÕVœ˜>✏iÊ{ää‡nääʓ}Ê6É*"ʜ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxʓ}Ɏ}Ê PO Q6H Duration: {qÈÊÜiiŽÃ Endocarditis Consultation with ID and Cardiac Surgery is recommended. Surgical valve replacement is considered a critical component for cure. If the patient is not a candidate for surgery then life-long Fluconazole suppression is likely required. 119

6.18 Candidiasis in the non-neutropenic patient

Preferred therapy UÊ
“ ˆÃœ“iÁÊxʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞ Alternative therapy UÊʈV>v՘}ˆ˜Ê£xäʓ}Ê6ʜ˜ViÊ`>ˆÞʴʏÕVœ˜>✏iÊ{ääqnääʓ}Ê6É*"Ê once daily Duration: 6 weeks or longer Notes on antifungal susceptibility testing UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀʏÕVœ˜>✏i]ÊÌÀ>Vœ˜>✏i]Ê6œÀˆVœ˜>✏i]Ê Flucytosine, and Micafungin is performed routinely on the first yeast isolate recovered from blood. UÊʏÕVœ˜>✏iÊ>˜`ʈV>v՘}ˆ˜ÊÃÕÃVi«ÌˆLˆˆÌÞÊ>ÀiÊÀi«œÀÌi`ʜ˜Ê>ÊˆÃœ>Ìið UÊÊ"À}>˜ˆÃ“ÃÊ̅>Ìʅ>ÛiʈV>v՘}ˆ˜Ê Ãʈ˜Ê̅iÊÀ>˜}iʜvÊ£qÓʓV}ɓÊ (reported as susceptible) may not respond to treatment. ID consult is recommended in these cases. UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀÊVœ˜Ûi˜Ìˆœ˜>Ê
“«…œÌiÀˆVˆ˜Ê ʈÃÊ`œ˜iÊÀœṎ˜iÞÊ for C. lusitaniae and C. guillermondii, and for other organisms by request. UÊÊvÊ̅iʜÀ}>˜ˆÃ“ʈÃʈ˜ÌiÀ“i`ˆ>ÌiÊ­®Ê̜ʏÕVœ˜>✏i]Ê̅i˜Ênääʓ}Ê6É PO once daily can be used. This choice is NOT recommended in an immunocompromised patient, in a patient who is clinically unstable due to candidemia, or in patients with endocarditis, meningitis or endophthalmitis. UÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`Ê܅i˜\ UÊÕVœVÕÌ>˜iœÕÃÊV>˜`ˆ`ˆ>ÈÃʈÃÊÀivÀ>V̜ÀÞÊ̜ʏÕVœ˜>✏i UÊÊ/Ài>̈˜}ʜÃÌiœ“ÞiˆÌˆÃ]ʓi˜ˆ˜}ˆÌˆÃ]ʜÀÊi˜`œ«…Ì…>“ˆÌˆÃÊÜˆÌ…Ê Fluconazole UÊ œœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«iÀÈÃÌi˜ÌÞÊ«œÃˆÌˆÛiʜ˜ÊÕVœ˜>✏i UÊÊ œ˜‡ÀœṎ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊV>˜ÊLiÊ>ÀÀ>˜}i`ÊLÞÊV>ˆ˜}Ê̅iÊ mycology lab at 5-6148 Notes on Fluconazole prophylaxis UÊʏÕVœ˜>✏iÊ«Àœ«…ޏ>݈ÃÊŜՏ`ÊLiʏˆ“ˆÌi`Ê̜Ê̅iÊvœœÜˆ˜}ÊÃiÌ̈˜}à UÊÊ*>̈i˜ÌÃÊiÝ«iVÌi`Ê̜ÊÀi“>ˆ˜Êˆ˜Ê̅iÊSICU or WICU for ≥ 72 hours ­ ÀˆÌiÀˆ>ÊvÀœ“Êœ«Žˆ˜ÃÊ- 1Ê«Àœ«…ޏ>݈ÃÊÃÌÕ`ÞÆÊ«Àœ«…ޏ>݈Ãʈ˜ÊœÌ…iÀÊ ICUs has NOT been studied and is NOT recommended). UÊÊ iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ՘`iÀ}œˆ˜}ÊLœ˜iʓ>ÀÀœÜÊÌÀ>˜Ã«>˜Ì>̈œ˜ÊœÀÊ treatment for leukemia/lymphoma UÊÊ*>̈i˜ÌÃÊ܅œÊ>ÀiÊ«œÃ̇œ«ÊvÀœ“ʏˆÛiÀʜÀÊ«>˜VÀi>ÃÊÌÀ>˜Ã«>˜Ìð UÊʏÕVœ˜>✏iÊ«Àœ«…ޏ>݈ÃÊŜՏ`ÊLiÊÃ̜««i`Ê܅i˜Ê- 1ʜÀÊ7 1Ê patients are transferred to the floor ,iviÀi˜ViÃ\  -
ÊՈ`iˆ˜iÃÊvœÀÊ/Ài>̓i˜ÌʜvÊ >˜`ˆ`ˆ>ÈÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓää™Æ{n\xä·xÎx° ÕVœ˜>✏iÊ«Àœ«…ޏ>݈Ãʈ˜ÊÃÕÀ}ˆV>Ê«>̈i˜ÌÃ\Ê
˜˜Ê-ÕÀ}ÊÓää£ÆÓÎÎ\x{Óqn°

120

œÀÊëiVˆwVÊ«ÀœVi`ÕÀiÃÊ>˜`Ê>}i˜ÌÃÊÃiiʺ*iÀˆ‡œ«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÊ «Àœ«…ޏ>݈ÃÊ`œVՓi˜Ì»Ê>ÌÊÜÜÜ°ˆ˜Ãˆ`i…œ«Žˆ˜Ã“i`ˆVˆ˜i°œÀ}É>“« Drug

iv>✏ˆ˜Ê

ivœÌiÌ>˜Ê Clindamycin Ciprofloxacin Gentamicin Metronidazole 6>˜Vœ“ÞVˆ˜Ê Ê Ê

Usual dose Ê£Óäʎ}\ÊÓÊ}Ê ≥Ê£Óäʎ}\ÊÎÊ}Ê Ê£Óäʎ}\ÊÓÊ}Ê ≥Ê£Óäʎ}\ÊÎÊ} 600 mg 400 mg 5 mg/kg 500 mg ÊÇäʎ}\Ê£Ê}Ê Ç£‡™™ÊŽ}\Ê£°ÓxÊ} €Ê£ääʎ}\Ê£°xÊ}

Redosing during procedure +{Ê­+ÓÊvœÀÊV>À`ˆ>VÊÃÕÀ}iÀÞ® +{Ê­+ÓÊvœÀÊV>À`ˆ>VÊÃÕÀ}iÀÞ® +È Q6H None None None +£Ó

Important notes UÊÊ/ˆ“ˆ˜}ʈÃÊVÀÕVˆ>°Ê
˜ÌˆLˆœÌˆVÃʓÕÃÌÊLiʈ˜Ê̅iÊΈ˜Ê܅i˜Ê̅iÊ incision is made to be effective. UÊÊ i«…>œÃ«œÀˆ˜ÃÊV>˜ÊLiÊ>`“ˆ˜ˆÃÌiÀi`ʜÛiÀÊÎqxʓˆ˜Ê6Ê«ÕÅʍÕÃÌÊLivœÀiÊ the procedure and will achieve appropriate skin levels in minutes. Vancomycin and Ciprofloxacin must be given over 60 min. Clindamycin ŜՏ`ÊLiʈ˜vÕÃi`ʜÛiÀÊ£äqÓäʓˆ˜°Ê UÊÊœÀÊ>˜ÌˆLˆœÌˆVÃÊ܈̅ʏœ˜}iÀʈ˜vÕȜ˜Ê̈“iÃÊ­i°}°Ê6>˜Vœ“ÞVˆ˜]Ê Ciprofloxacin) the infusion should start 30 minutes prior to incision UÊÊPost-procedure doses are NOT needed (exceptions are noted in table). Single doses pre-procedure have been as effective as post-procedure doses in all studies. UÊÊ*>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê«Ài‡œ«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÃÊ}i˜iÀ>ÞÊ`œÊ "/ʘii`Ê additional antibiotics for endocarditis prophylaxis. UÊÊ*Àœ«…ޏ>݈ÃÊvœÀÊ«>̈i˜ÌÃÊ>Ài>`Þʜ˜Ê>˜ÌˆLˆœÌˆVÃ\ UÊÊœÀÊ>˜ÌˆLˆœÌˆVÃʜ̅iÀÊ̅>˜Ê6>˜Vœ“ÞVˆ˜\Êœ`ÊÃÌ>˜`ˆ˜}Ê`œÃiÊ՘̈Ê 1 hour before incision UÊÊœÀÊ6>˜Vœ“ÞVˆ˜\Ê,i`œÃiÊ>ÊvՏÊ`œÃiʈvÊnʅœÕÀÃʅ>ÛiÊ«>ÃÃi`ÊȘViÊ the last dose or a half dose if fewer than 8 hours have passed in patient with normal renal function UÊÊi˜Ì>“ˆVˆ˜ÊŜՏ`ÊLiÊ}ˆÛi˜Ê>ÃÊ>ÊȘ}iÊ`œÃiʜvÊxʓ}Ɏ}Ê̜ʓ>݈“ˆâiÊ tissue penetration and minimize toxicity. UÊÊvʜ˜Ê`ˆ>ÞÈÃʜÀÊ À ÊÊÓäʓɓˆ˜]ÊÕÃiÊÓʓ}Ɏ} UÊ œÊ˜œÌÊÀi`œÃi UÊÊ1ÃiÊ>VÌÕ>ÊLœ`ÞÊÜiˆ}…ÌÊ՘iÃÃÊ«>̈i˜ÌʈÃÊ≥ÊÓä¯ÊœÛiÀʈ`i>ÊLœ`ÞÊ weight (see p. 145) 121

6.19 Guidelines for use of prophylactic antimicrobials

Pre-operative and pre-procedure antibiotic prophylaxis

6.19 Guidelines for use of prophylactic antimicrobials

Procedure Urologic surgery/procedures Transrectal prostate biopsy1 Transurethral surgery (e.g. TURP, TURBT, ureteroscopy, cystouretoscopy) Lithotripsy Nephrectomy or radical prostatectomy Radical cystectomy, ileal conduit, cystoprostatectomy or anterior exenteration *i˜ˆiʜÀʜ̅iÀÊ«ÀœÃ̅iÃiÃÊ Cardiac surgery Median sternotomy, heart transplant3 Median sternotomy, heart transplant with previous VAD or MRSA colonization/infection3 Pacemaker or ICD insertion Pacemaker or ICD insertion with MRSA colonization/infection or generator exchange VAD insertion VAD insertion with MRSA colonization/infection VAD insertion with open chest3 Lung transplant4 Vascular surgery Carotid and brachiocephalic procedures without prosthetic grafts Upper extremity procedures with prosthetic grafts and lower extremity procedures
L`œ“ˆ˜>Ê>œÀÌ>Ê«ÀœVi`ÕÀiʜÀÊ}Àœˆ˜Êˆ˜VˆÃˆœ˜ÊÊ

Prophylaxis recommendations

PCN allergy alternate prophylaxis

Cefazolin Cefazolin

Ciprofloxacin OR Gentamicin2 Gentamicin2

Gentamicin2 Clindamycin Clindamycin PLUS Gentamicin2 Q iv>✏ˆ˜Ê",Ê6>˜Vœ“ÞVˆ˜RÊÊQ ˆ˜`>“ÞVˆ˜Ê",Ê6>˜Vœ“ÞVˆ˜R PLUS Gentamicin2 PLUS Gentamicin2

Cefazolin Cefazolin Cefotetan

Cefazolin Cefazolin PLUS Vancomycin Cefazolin Cefazolin PLUS Vancomycin Cefazolin Cefazolin PLUS Vancomycin Cefazolin PLUS Vancomycin Cefepime

Vancomycin PLUS Ciprofloxacin Consult transplant ID

Prophylaxis not recommended Cefazolin

Prophylaxis not recommended Clindamycin OR Vancomycin

ivœÌiÌ>˜ÊÊ

6>˜Vœ“ÞVˆ˜Ê³Êi˜Ì>“ˆVˆ˜2

Thoracic surgery Lobectomy, pneumonectomy, lung resection, Cefazolin thoracotomy, VATS Esophageal cases Cefotetan Neurosurgery Craniotomy, cerebrospinal fluid-shunting procedures, implantation of intrathecal pumps Laminectomy Spinal fusion Spinal fusion with MRSA colonization/infection

Vancomycin Vancomycin Clindamycin OR Vancomycin Vancomycin Vancomycin Vancomycin

Clindamycin Clindamycin

Cefazolin

Clindamycin Clindamycin Clindamycin OR Vancomycin Vancomycin

Transsphenoidal procedures

Cefazolin Cefazolin Cefazolin PLUS Vancomycin Ceftriaxone

Orthopedic surgery Clean operations involving hand, knee, or foot, arthroscopy Total joint replacement Total joint replacement with MRSA colonization/infection Open reduction of fracture/internal fixation Lower limb amputation

Prophylaxis not recommended Cefazolin Cefazolin PLUS Vancomycin Cefazolin Cefotetan

Prophylaxis not recommended Vancomycin Vancomycin

Spinal fusion Cefazolin Spinal fusion with MRSA colonization/infection Cefazolin PLUS Vancomycin Laminectomy Cefazolin

122

Moxifloxacin 400 mg

Clindamycin OR Vancomycin Clindamycin PLUS Gentamicin2 Clindamycin OR Vancomycin Vancomycin Clindamycin

Prophylaxis recommendations

General surgery *ÀœVi`ÕÀiÃʈ˜ÛœÛˆ˜}Êi˜ÌÀÞʈ˜ÌœÊÕ“i˜ÊœvÊÕ««iÀÊÊ ivœÌiÌ>˜Ê GI tract, gastric bypass procedures, pancreaticoduodenectomy, highly selective vagotomy, Nissen fundoplication ˆˆ>ÀÞÊÌÀ>VÌÊ«ÀœVi`ÕÀiÃÊ­i°}°ÊV…œiVÞÃÌiV̜“Þ]ÊÊ ivœÌiÌ>˜Ê choledochoenterostomy) i«>ÌiV̜“ÞÊ

ivœÌiÌ>˜Ê Whipple procedure or pancreatectomy Cefotetan Small bowel procedures

Cefotetan

* Ê Appendectomy (if complicated or perforated, treat as secondary peritonitis) Colorectal procedures, penetrating abdominal trauma Inguinal hernia repair

œ“«ˆV>Ìi`]Êi“iÀ}i˜ÌʜÀÊÀi«i>Ìʈ˜}Ո˜>ÊÊ hernia repair Mastectomy

iv>✏ˆ˜Ê",Ê ivœÌiÌ>˜Ê Cefotetan Cefotetan Cefazolin

ivœÌiÌ>˜Ê

PCN allergy alternate prophylaxis

ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2

ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2

ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2 Clindamycin PLUS Ciprofloxacin Clindamycin PLUS Gentamicin2

ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2 Clindamycin PLUS Gentamicin2 Clindamycin PLUS Gentamicin2 Clindamycin

ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜2

Mastectomy with lymph node dissection

Prophylaxis not recommended Cefazolin

Prophylaxis not recommended Clindamycin PLUS Gentamicin2

Gynecologic surgery Cesarean delivery procedures

Cefazolin

Clindamycin PLUS Gentamicin2 Clindamycin PLUS Gentamicin2 Clindamycin PLUS Gentamicin2 Clindamycin

Hysterectomy (vaginal or abdominal)

Cefazolin OR Cefotetan

Oncology procedures

Cefotetan

Repair of cystocele or rectocele

Cefazolin

Head and neck surgery Parotidectomy, thyroidectomy, tonsillectomy

Prophylaxis not recommended Reconstructive procedure w/prosthesis Cefazolin placement Adenoidectomy, rhinoplasty, tumor-debulking, Cefotetan OR Clindamycin or mandibular fracture repair Major neck dissection Cefazolin Plastic surgery Clean with risk factors or clean-contaminated Tissue expander insertion/implants/all flaps Rhinoplasty

Prophylaxis not recommended Clindamycin Clindamycin Clindamycin

Cefazolin Cefazolin No prophylaxis OR Cefazolin

Clindamycin Clindamycin No prophylaxis OR Clindamycin

Abdominal transplant surgery Pancreas or pancreas/kidney transplant

Cefotetan

Renal transplant/adult live donor Liver transplant4

Cefazolin Cefotetan

Clindamycin PLUS Ciprofloxacin Clindamycin Clindamycin PLUS Ciprofloxacin

1vÊ«Ài‡œ«ÊÀiVÌ>ÊÃVÀii˜Ê«iÀvœÀ“i`\ÊÃiiÊ«°Ê£Ó{Ê 2Do

not give additional doses of Gentamicin post-op for prophylaxis open chest, continue antibiotic prophylaxis until closure recommendations are for patients with no relevant microbiology data that would suggest ÀiÈÃÌ>˜ÌʜÀ}>˜ˆÃ“ÃÆÊ«Àœ«…ޏ>V̈VÊÀi}ˆ“i˜ÊŜՏ`ÊLiÊÌ>ˆœÀi`ÊL>Ãi`ʜ˜ÊŽ˜œÜ˜Ê“ˆVÀœLˆœœ}ÞÊ`>Ì>ÊÜˆÌ…Ê assistance of transplant ID (page in PING)

3For

4Listed

123

6.19 Guidelines for use of prophylactic antimicrobials

Procedure

6.19 Guidelines for use of prophylactic antimicrobials

Procedure

Prophylaxis recommendations

PCN allergy alternate prophylaxis

Interventional radiology procedures ˆˆ>ÀÞÉÆÊV…i“œÊi“Lœˆâ>̈œ˜ÉÊÊ

ivœÌiÌ>˜ÊÊ

ˆ˜`>“ÞVˆ˜Ê percutaneous liver ablation (hx. of PLUS Gentamicin Lˆˆ>ÀÞÊÃÕÀ}iÀÞɈ˜ÃÌÀՓi˜Ì>̈œ˜®ÆÊ cecostomy

…i“œÊi“Lœˆâ>̈œ˜ÆÊwLÀœˆ`ÉÕÀˆ˜iÊ *Àœ«…ޏ>݈ÃʘœÌÊ >ÀÌiÀÞÊi“Lœˆâ>̈œ˜ÆÊ«iÀVÕÌ>˜iœÕÃÊÊ ÀiVœ““i˜`i` ˆÛiÀÉÀi˜>ÉÕ˜}IÊ>L>̈œ˜ÆÊÛ>ÃVՏ>ÀÊ vascular malformation embolization† Urologic procedure (not ablation) Cefazolin Gentamicin Lymphangiogram/embolization Cefazolin Clindamycin Placement of tunneled catheters Prophylaxis not ­i°}°ÊVi˜ÌÀ>Êˆ˜i®ÆÊÛi˜œÕÃÉ>ÀÌiÀˆ>ÊÊ ÀiVœ““i˜`i` procedures. Placement of implantable access Cefazolin Clindamycin port (e.g. Mediport®) *Pre-treatment w/ antibiotics can be considered for patients w/ COPD or h/o recurrent post-obstructive pneumonia † Lymphatic or patients w/ necrotic skin undergoing vascular graft should receive prophylaxis w/Cefazolin Prophylaxis for Prostate Biopsy Based on Rectal Screen Results Pre-op prophylaxis regimen1

Post-op oral options2

Ciprofloxacin susceptible Ê

Ciprofloxacin 750 mg PO 2 hours before procedure for any renal v՘V̈œ˜ÊÊÊ

Ciprofloxacin 500 mg PO once 12 hours after the procedure. If GFR ÎäʓÉ“ˆ˜Ê˜œÊ˜ii`ÊvœÀÊ«œÃ̇œ«Ê`œÃi°Ê

ˆ«ÀœyœÝ>Vˆ˜ÊÊ ÀiÈÃÌ>˜Ì]Ê/*É-8Ê susceptible

/*É-8Ê£Ê -ʣʅœÕÀÊLivœÀiÊÊ «ÀœVi`ÕÀi]Ê>˜`Ê£Ê -ÊÎʅœÕÀÃÊÊ before

/*É-8Ê£Ê -Ê*"ʜ˜ViÊ£ÓʅœÕÀÃÊ >vÌiÀÊ̅iÊ«ÀœVi`ÕÀi°ÊvÊ,ʐÎäÊ ml/min no need for post-op dose.

Ciprofloxacin and /*É-8ÊÀiÈÃÌ>˜Ì]ÊÊ Cefazolin susceptible

Cefazolin 2 g IV push (3-5 min) ܈̅ˆ˜Ê>˜Ê£Ê…œÕÀʜvÊ«ÀœVi`ÕÀiÊ

Cefpodoxime 100 mg PO once OR Cefdinir 300 mg PO once

Ciprofloxacin, /*É-8]ÊÊ Cefazolin resistant

Gentamicin 5 mg/kg IV once over Îä‡Èäʓˆ˜ÊÊ OR Ceftriaxone 1 g IV over 30 min if susceptible

No need for additional doses as i˜Ì>“ˆVˆ˜Ê>˜`Ê ivÌÀˆ>ݜ˜iÊÀiÌ>ˆ˜Ê therapeutic levels for 24 hours

Other resistance Call ID Pharmacist patterns 1 All doses are for any renal function 2 Post-op antibiotics are not required by SCIP

124

NOTES: UÊÊ*>̈i˜ÌÃÊ܅œÊ…>ÛiÊÀiViˆÛi`Ê>˜ÌˆLˆœÌˆVÃÊvœÀÊÃÕÀ}ˆV>Ê«Àœ«…ޏ>݈ÃÊ`œÊ˜œÌÊ need additional prophylaxis for endocarditis. Antibiotic prophylaxis solely to prevent endocarditis is not recommended for GU or GI tract procedures. Cardiac conditions associated with a high risk of endocarditis for which prophylaxis is recommended prior to some dental and respiratory tract procedures and procedures involving infected skin or musculoskeletal tissue UÊ*ÀœÃ̅ïVÊV>À`ˆ>VÊÛ>Ûi UÊ*ÀiۈœÕÃÊi«ˆÃœ`iʜvʈ˜viV̈ÛiÊi˜`œV>À`ˆÌˆÃ UÊ œ˜}i˜ˆÌ>Ê…i>ÀÌÊ`ˆÃi>ÃiÊ­  ® UÊÊÊ1˜Ài«>ˆÀi`ÊVÞ>˜œÌˆVÊ  ]ʈ˜VÕ`ˆ˜}Ê«>ˆ>̈ÛiÊÅ՘ÌÃÊ>˜`ÊVœ˜`ՈÌà UÊÊ œ“«iÌiÞÊÀi«>ˆÀi`ÊVœ˜}i˜ˆÌ>Ê…i>ÀÌÊ`iviVÌÊ܈̅ʫÀœÃ̅ïVÊ material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure UÊÊ,i«>ˆÀi`Ê  Ê܈̅ÊÀiÈ`Õ>Ê`iviVÌÃÊ>ÌÊ̅iÊÈÌiʜÀÊ>`>Vi˜ÌÊ̜Ê̅iÊ site of a prosthetic patch or prosthetic device UÊÊ >À`ˆ>VÊÌÀ>˜Ã«>˜Ì>̈œ˜ÊÀiVˆ«ˆi˜ÌÃÊ܅œÊ`iÛiœ«ÊV>À`ˆ>VÊÛ>ÛՏœ«>Ì…Þ Antibiotic prophylaxis is recommended for the following dental procedures ONLY: UÊ>˜ˆ«Õ>̈œ˜ÊœvÊ}ˆ˜}ˆÛ>Ê̈ÃÃÕiÃʜÀÊ«iÀˆ>«ˆV>ÊÀi}ˆœ˜ÊœvÊÌii̅ UÊ*iÀvœÀ>̈œ˜ÊœvʜÀ>Ê“ÕVœÃ> Antibiotic prophylaxis is recommended for the following respiratory tract procedures ONLY: UʘVˆÃˆœ˜ÊœÀÊLˆœ«ÃÞʜvÊ̅iÊÀiëˆÀ>̜ÀÞʓÕVœÃ> Antibiotic regimens UÊ
“œÝˆVˆˆ˜ÊÓÊ}Ê*"ʣʅœÕÀÊLivœÀiÊ«ÀœVi`ÕÀi OR UÊ* Ê>iÀ}Þ\Ê ˆ˜`>“ÞVˆ˜ÊÈääʓ}Ê*"ʣʅœÕÀÊLivœÀiÊ«ÀœVi`ÕÀi OR UÊ* Ê>iÀ}Þ\Ê
âˆÌ…Àœ“ÞVˆ˜Êxääʓ}Ê*"ʣʅœÕÀÊLivœÀiÊ«ÀœVi`ÕÀi OR UÊÊ*>̈i˜ÌÊ՘>LiÊ̜ÊÌ>ŽiʜÀ>Ê“i`ˆV>̈œ˜\Ê
“«ˆVˆˆ˜ÊÓÊ}ÊÉ6ʣʅœÕÀÊ before procedure OR Cefazolin 1 g IM/IV 5 minute push prior to procedure ,iviÀi˜Vi\

ÊՈ`iˆ˜iÃÊvœÀÊ*ÀiÛi˜Ìˆœ˜ÊœvʘviV̈ÛiÊ ˜`œV>À`ˆÌˆÃ\Ê ˆÀVՏ>̈œ˜ÊÓääÇÆÊ££È\£ÇÎÈqx{°

125

6.19 Guidelines for use of prophylactic antimicrobials

Prophylaxis against bacterial endocarditis

6.19 Guidelines for use of prophylactic antimicrobials

Prophylactic antimicrobials for patients with solid organ transplants NOTE:Ê
Ê`œÃiÃÊ>ÃÃՓiʘœÀ“>ÊÀi˜>Êv՘V̈œ˜ÆÊ`œÃiʓœ`ˆwV>̈œ˜Ãʓ>ÞÊLiʈ˜`ˆV>Ìi`ÊvœÀÊ reduced CrCI. Kidney, kidney-pancreas, pancreas transplants Indication

Agent and dose

Duration

Anti-viral prophylaxis (CMV, HSV, VZV) CMV D-/RAcyclovir 400 mg PO BID OR Valacyclovir 500 mg PO BID

6Ê ³ÊœÀÊ ‡É,³Ê 6>}>˜VˆVœÛˆÀ† 450 mg PO daily

6Ê ³É,‡Ê 6>}>˜VˆVœÛˆÀ† 900 mg PO daily

3 months 3 months 6 months

Anti-fungal prophylaxis Kidney Clotrimazole troches 10 mg PO QID OR Nystatin suspension 500,000 units QID Pancreas and kidney Fluconazole 400 mg PO daily

1 month‡ 1 month

PCP prophylaxisÊ Ê Ê

ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ -iVœ˜`ʏˆ˜i\Ê
̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞ /…ˆÀ`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊ",Ê aerosolized Pentamidine

Èʓœ˜Ì…Ã

Acute rejection treated with Thymoglobulin or Muromonab (OKT3) Anti-viral prophylaxis (CMV, HSV, VZV) CMV D-/RAcyclovir 400 mg PO BID OR 3 months Valacyclovir 500 mg PO BID 3 months

6Ê ³ÊœÀÊ ‡É,³Ê 6>}>˜VˆVœÛˆÀ† 450 mg PO daily 3 months

6Ê ³É,‡Ê 6>}>˜VˆVœÛˆÀ† 900 mg PO daily Anti-fungal prophylaxis Clotrimazole troches 10 mg PO QID

1 month

PCP prophylaxis Ê Ê

ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ -iVœ˜`ʏˆ˜i\Ê
̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞ /…ˆÀ`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊ", aerosolized Pentamadine

Èʓœ˜Ì…Ã

Agent and dose

Duration

Liver transplants Indication

Anti-viral prophylaxis (CMV, HSV, VZV) CMV D-/RAcyclovir 400 mg PO BID OR Valacyclovir 500 mg PO BID

6Ê ³ÊœÀÊ ‡É,³Ê 6>}>˜VˆVœÛˆÀ† 450 mg PO daily

6Ê ³É,‡Ê 6>}>˜VˆVœÛˆÀ† 900 mg PO daily, followed by PCR monitoring Anti-fungal prophylaxis Fluconazole 400 mg PO daily PCP prophylaxisÊ ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊÊ Ê
ÌiÀ˜>̈ÛiÃ\Ê
̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞÊ or Dapsone 100 mg PO daily

126

3 months 3 months 6 months 6 weeks £Óʓœ˜Ì…Ã

Indication

Agent and dose

Anti-viral prophylaxis (CMV, HSV, VZV)

6Ê ‡É,‡Ê œÊ«Àœ«…ޏ>݈ÃÊ՘iÃÃÊ-6Ê}ʜÀÊ6<6Ê}ÊÊ positive. If positive serology, Valacyclovir 500 mg PO BID

6Ê ³ÊœÀÊ ‡É,³Ê 6>}>˜VˆVœÛˆÀ† 900 mg PO daily

6Ê ³É,‡Ê 6>}>˜VˆVœÛˆÀ† 900 mg PO daily Anti-fungal prophylaxis Nystatin suspension 500,000 units QID

PCP prophylaxisÊ Ê Ê Ê

Duration Îʓœ˜Ì…Ã

3 months 6 months Until prednisone dose ≤ 10 mg/d x 3 months

ˆÀÃÌʏˆ˜i\Ê/*É-8Ê--ʜ˜iÊÌ>LiÌÊ*"Ê`>ˆÞÊ",Ê £Óʓœ˜Ì…Ã Ê Ê /*É-8ʜ˜iÊ -ÊÌ>LiÌÊ*"Ê̅ÀiiÊ̈“iÃÉÜiiŽÊ -iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞ /…ˆÀ`ʏˆ˜i\Ê
̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞÊ

Toxoplasmosis prophylaxis ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊÊ £Óʓœ˜Ì…à /œÝœÊ,³Ê Ê -iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊPLUS Pyrimethamine and Leucovorin /œÝœÊ ³ÊœÀÊ՘Ž˜œÜ˜‡Ê ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ £Óʓœ˜Ì…Ã‡Ê Ê Ê `œ˜œÀÊÃÌ>ÌÕÃÊ -iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊPLUS Lifelong Pyrimethamine and Leucovorin Lung transplants Indication

Agent and dose

Duration

Anti-viral prophylaxis CMV D-/RReceived non-leukoreduced or CMV unscreened PRBCs

Ganciclovir 5 mg/kg IV Q12H x 14 days, then Ganciclovir 5 mg/kg IV Q24H x 16 days, then Valacyclovir 500 mg PO BID or Acyclovir 800 mg PO TID x 1 year followed by Acyclovir 200 mg PO TID

Lifelong

CMV D-/RReceived leukoreduced or CMV() PRBCs

Valacyclovir 500 mg PO BID or Acyclovir Lifelong 800 mg PO TID x 1 year followed by Acyclovir 200 mg PO TID

6Ê ³ÊœÀÊ ‡É,³Ê

>˜VˆVœÛˆÀÊxʓ}Ɏ}Ê6Ê+£ÓÊÝÊ£{Ê`>ÞÃ]Ê̅i˜ÊÊ ˆviœ˜} Valganciclovir 900 mg PO daily x 3 months (until CMV shell vial negative from 3 month surveillance bronchoscopy), then Valacyclovir 500 mg po BID or Acyclovir 800 mg PO TID x 1 year, then Acyclovir 200 mg PO TID lifelong.

6Ê ³É,‡ÊÊÊ

>˜VˆVœÛˆÀÊxʓ}Ɏ}Ê6Ê+£Ó…ÊÝÊ£{Ê`>ÞÃ]Ê̅i˜ÊÊ ˆviœ˜} Ganciclovir 5 mg/kg IV daily x 3 months, then Valganciclovir 900 mg PO daily (until CMV shell

127

6.19 Guidelines for use of prophylactic antimicrobials

Heart transplants

6.19 Guidelines for use of prophylactic antimicrobials

vial negative from 6 month surveillance BAL), then Valacyclovir 500 mg PO BID or Acyclovir 800 mg PO TID x 1 year, then Acyclovir 200 mg PO TID lifelong. Anti-fungal prophylaxis No Aspergillus Inhaled Amphotericin B per protocol colonization Ê

AspergillusÊVœœ˜ˆâ>̈œ˜Ê

PCP prophylaxisÊ Ê Ê Ê

ÞÃÌ>̈˜Êxää]äääÊ՘ˆÌÃÊ Ê+ÈÊ՘̈ÊÊÊ extubated, then Clotrimazole troches 10 mg PO Q6H until prednisone dose  10 mg daily 6œÀˆVœ˜>✏iÊ­`œÃi`ÊLÞÊÜiˆ}…Ì®ÊÊÊ Êșʎ}\Ê6œÀˆVœ˜>✏iÊÓääʓ}Ê*"Ê   69 kg to ʙ{ʎ}\Ê6œÀˆVœ˜>✏i 300 mg PO BID ʙ{ʎ}\Ê6œÀˆVœ˜>✏iÊ{ääʓ}Ê*"Ê  ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ -ÊÌ>LiÌÊ*"ÊÊ Ê Ê Ì…ÀiiÊ̈“iÃÉÜiiŽÊ",Ê/*É-8ʜ˜iÊ SS tablet PO daily -iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iIÊ£ääʓ}Ê*"Ê`>ˆÞÊÊ /…ˆÀ`ʏˆ˜i\Ê
̜Û>µÕœ˜iÊ£xääʓ}Ê*"Ê`>ˆÞÊ

During initial hospitalization stay ÎqÈʓœ˜Ì…ÃÊ

ÎqÈʓœ˜Ì…ÃÊ

ˆviœ˜}

ÊrÊ`œ˜œÀ]Ê,ÊrÊÀiVˆ«ˆi˜Ì]Ê­q®ÊrÊÃiÀœ˜i}>̈Ûi]Ê­³®ÊrÊÃiÀœ«œÃˆÌˆÛi NOTES: /*É-8Ê̅iÀ>«ÞÊÀi`ÕViÃÊÀˆÃŽÊœvʈ˜viV̈œ˜Ê܈̅ÊListeria spp., Nocardia spp., and Toxoplasmosis, but does not eliminate risk. For splenectomized patients, antibacterial prophylaxis with Amoxicillin 500 mg PO BID (or Doxycycline if PCN allergy) is recommended for 1 year. *Recommended screening for G6PD deficiency prior to initiation of Dapsone. †If Valgancylovir is stopped prior to recommended duration of therapy due to intolerance, recommend initiation of Acylovir or Valacyclovir for antiviral prophylaxis. ‡ /*qÎʓœ˜Ì…Ã

128

NOTE: These guidelines were developed for use in BMT and leukemia patients and may not be fully applicable in other instances. Definitions UÊ iÕÌÀœ«i˜ˆ>\Ê
ʐÊxääɓ“3 UÊÊiÛiÀ\ÊÊ/i“«Ê€ÊÎn°äcÊ Ê̈“iÃÊÌܜÊ>Ìʏi>ÃÌÊÓʅœÕÀÃÊ>«>ÀÌÊ",Ê Temp > 38.3° C times one TREATMENT Always tailor antibiotics based on susceptibility profiles vÊ̅iÊ«>̈i˜ÌʈÃʅޫœÌi˜ÃˆÛiʜÀʜ̅iÀ܈ÃiÊ՘ÃÌ>Li]ÊÃiiʺ/Ài>̓i˜ÌʜvÊ Vˆ˜ˆV>ÞÊ՘ÃÌ>LiÊ«>̈i˜Ìûʭœ««œÃˆÌi®° Initial fever UÊÊ ivi«ˆ“iÊÓÊ}Ê6Ê+nÊ´Ê6>˜Vœ“ÞVˆ˜IÊ­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£xä® OR UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+{Ê´Ê6>˜Vœ“ÞVˆ˜IÊ­ÃiiÊ`œÃˆ˜}Ê section p. 150) I˜`ˆV>̈œ˜ÃÊvœÀÊ6>˜Vœ“ÞVˆ˜\ÊÃÕëiVÌi`Ê ,‡ -]ÊΈ˜Ê>˜`ÊÜv̇̈ÃÃÕiʈ˜viV̈œ˜Ã]Ê pneumonia, severe oral or pharyngeal mucositis, history of MRSA infection or colonization.

OR UÊ-iÛiÀiÊ* Ê>iÀ}ÞÊ­>˜>«…ޏ>݈ÃʜÀÊ-ÌiÛi˜Ã‡œ…˜Ãœ˜Ê-ޘ`Àœ“i®\Ê Strongly consider allergy consult to verify allergy in patients with unclear histories (see section on Penicillin allergy, p. 137) UÊ
âÌÀiœ˜>“ÊÓÊ}Ê6Ê+nÊPLUS Gentamicin† (see dosing section, p. 146) PLUS Vancomycin (see dosing section, p. 150) †If strong concern for nephrotoxicity and no prior fluoroquinolone use, can substitute Ciprofloxacin 400 mg IV Q8H for Gentamicin.

Step-down therapy for discharge UÊÊCiprofloxacin 750 mg PO BID PLUS Amoxicillin/clavulanate 875 mg PO BID OR Uʜ݈yœÝ>Vˆ˜Ê{ääʓ}Ê*"Ê`>ˆÞ

129

6.20 Guidelines for use of antimicrobials in neutropenic hosts

Neutropenic fever

6.20 Guidelines for use of antimicrobials in neutropenic hosts

Persistent fever or new fever after 4-7 days in clinically stable patients without established bacterial infection UÊ œ˜Ìˆ˜ÕiÊ>˜ÌˆLˆœÌˆVÃÊ>LœÛiÊ>˜`Ê
Ê>˜Ìˆv՘}>ÊVœÛiÀ>}iÊ vÊÀiViˆÛˆ˜}ʏÕVœ˜>✏iÊ«Àœ«…ޏ>݈ÃʜÀʘœÊv՘}>Ê«Àœ«…ޏ>݈Ã\ UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{ʈvÊȘÕÃÊ>˜`ɜÀÊV…iÃÌÊ /ʘœÌÊÃÕ}}iÃ̈ÛiÊ of fungal infection OR UÊ6œÀˆVœ˜>✏iÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌܜÊ`œÃiÃÊ̅i˜Ê{ʓ}Ɏ}Ê6É PO Q12H if chest CT suggestive of fungal infection If receiving Voriconazole or Posaconazole prophylaxis or sinus CT ÃÕ}}iÃ̈ÛiʜvÊv՘}>Êˆ˜viV̈œ˜\ UÊ
“ ˆÃœ“iÁÊxʓ}Ɏ}Ê6Ê+Ó{Ê Clinically unstable patient and/or persistent fever despite appropriate antibacterial and antifungal coverage UÊ œ˜ÃՏÌÊ"˜Vœœ}ÞÉ/À>˜Ã«>˜ÌÊ Ê UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Meropenem 1 g IV +nÊ´Ê
“ˆŽ>Vˆ˜ÊˆvÊ«>̈i˜ÌÊ՘ÃÌ>LiÊ­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£{È®Ê OR UÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê œ˜ÃՏÌÊ"˜Vœœ}ÞÉ/À>˜Ã«>˜ÌÊ Ê

130

NOTE:Ê
Ê`œÃiÃÊ>ÃÃՓiʘœÀ“>ÊÀi˜>Êv՘V̈œ˜ÆÊ`œÃiʓœ`ˆwV>̈œ˜Ãʓ>ÞÊLiʈ˜`ˆV>Ìi`ÊvœÀÊ reduced CrCI. 1. Leukemia patients

Indication

Agent and dose

Duration

Antibacterial prophylaxis

Moxifloxacin 400 mg PO daily PLUS Amoxicillin 500 mg PO TID (start on day 5)

Day 1 until ANC  100/mm3 OR initiation of ºˆÀÃÌÊiÛiÀ»Ê antibiotics


˜Ìˆv՘}>Ê«Àœ«…ޏ>݈ÃÊ Ê

ˆÀÃÌʏˆ˜i\Ê6œÀˆVœ˜>✏iÊ­ÃiiÊ`œÃˆ˜}ʈ˜Ê /ÊÃiV̈œ˜®Ê -iVœ˜`ʏˆ˜i\Ê*œÃ>Vœ˜>✏iÊÃÕëi˜Ãˆœ˜ÊÓääʓ}ÊÊ PO TID OR 300 mg tablet daily
ÌiÀ˜>̈ÛiÃ\ʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{Ê",ÊÊ

>ÞÊ£Ê՘̈ÊÊ
Ê 100/mm3 Ê

Ê

Fluconazole 400 mg PO daily Antiviral prophylaxis Ê * *Ê«Àœ«…ޏ>݈ÃÊÊ in high risk patients‡Ê Ê

Valacyclovir 500 mg PO BID OR Acyclovir 800 mg PO BID vÊۜ“ˆÌˆ˜}ʜÀÊ`ˆ>ÀÀ…i>\Ê
VÞVœÛˆÀÊÓxäʓ}ɓ2 IV Q12H†

Day 1 until ANC  100/mm3

ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊÊ -iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iÊ£ääʓ}Ê*"Ê`>ˆÞÊ /…ˆÀ`ʏˆ˜i\Ê
̜Û>µÕœ˜iÊÇxäʓ}Ê*"Ê  Ê

>ÞÊ£Ê՘̈ÊÊ ˆ““Õ˜œ‡ÊÊ ÃÕ«ÀiÃȜ˜Ê resolves

2. Lymphoma, myeloma patients

Indication

Agent and dose

Duration

Antibacterial prophylaxis (lymphoma only)

Moxifloxacin 400 mg PO daily

Antifungal prophylaxis

Fluconazole 200 mg PO daily

Day 7 of chemo until ANC  500/mm3 Day 1 through all cycles of chemotherapy in high risk patients.

Antiviral prophylaxis

Valacyclovir 500 mg PO BID OR Acyclovir 800 mg PO BID vÊۜ“ˆÌˆ˜}ʜÀÊ`ˆ>ÀÀ…i>\Ê
VÞVœÛˆÀÊÓxäʓ}ɓ2 IV Q12H†

Day 7 through all cycles of chemotherapy

ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊÊ -iVœ˜`ʏˆ˜i\Ê >«Ãœ˜iÊ£ääʓ}Ê*"Ê`>ˆÞÊ /…ˆÀ`ʏˆ˜i\Ê
̜Û>µÕœ˜iÊÇxäʓ}Ê*"Ê  Ê

>ÞÊÇÊ̅ÀœÕ}…Ê >ÊVÞViÃʜvÊÊ V…i“œ‡ÊÊ therapy

Ê * *Ê«Àœ«…ޏ>݈ÃÊÊ in high risk patients‡Ê Ê

131

6.20 Guidelines for use of antimicrobials in neutropenic hosts

Prophylactic antimicrobials for patients with expected prolonged neutropenia

6.20 Guidelines for use of antimicrobials in neutropenic hosts

3. Bone marrow transplant patients/peripheral blood stem cell transplant patients

Indication

Agent and dose

Duration

Antibacterial prophylaxis*

Moxifloxacin 400 mg PO daily

Day zero until engraftment

Antifungal prophylaxis

Fluconazole 400 mg PO daily

Day zero until ANC  500/mm3


˜Ìˆv՘}>Ê«Àœ«…ޏ>݈Ãʈ˜ÊÊ patients with GVHD¶ Ê

ˆÀÃÌʏˆ˜i\Ê*œÃ>Vœ˜>✏iÊÃÕëi˜Ãˆœ˜ÊÓääʓ}Ê*" TID OR 300 mg tablets daily -iVœ˜`ʏˆ˜i\Ê6œÀˆVœ˜>✏iÊ­`œÃi`ÊLÞÊÜiˆ}…Ì® 69 kg Voriconazole 200 mg PO BID 69 kg to 94 kg Voriconazole 300 mg PO BID 94 kg Voriconazole 400 mg PO BID

Antiviral prophylaxis

Valacyclovir 500 mg PO BID OR Acyclovir 800 mg PO BID vÊۜ“ˆÌˆ˜}ʜÀÊ`ˆ>ÀÀ…i>\Ê
VÞVœÛˆÀÊÓxäʓ}ɓ2 IV Q12H †

Day zero until 1 yr (allogeneic transplants) or 6 months (autologous transplants)

Ê Ê

ˆÀÃÌʏˆ˜i\Ê/*É-8ʜ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊ -iVœ˜`ʏˆ˜i\/*É-8Ê -ÊÌ>LÊÓÊ̈“iÃÊÜiiŽÞÊÊ OR Dapsone 100 mg PO daily /…ˆÀ`ʏˆ˜i\Ê
̜Û>µÕœ˜iÊÇxäʓ}Ê*"Ê  Ê œÕÀ̅ʏˆ˜i\Ê*i˜Ì>“ˆ`ˆ˜iÊÎääʓ}Ê Ê+ÓnÊ`>ÞÃÊ

Ê

Ê


œ}i˜iˆVÊ ÌÀ>˜Ã«>˜Ì\Ê Day 21 or i˜}À>v̓i˜ÌÊ ­Ü…ˆV…iÛiÀÊ is later) until at least 1 year (longer if steroids or ongoing risk) Autologous ÊÌÀ>˜Ã«>˜Ì\Ê Engraftment until 6 months

Ê

PCP prophylaxis†Ê Ê

NOTES: /*É-8Ê̅iÀ>«ÞÊÀi`ÕViÃÊÀˆÃŽÊœvʈ˜viV̈œ˜Ê܈̅Êi˜V>«ÃՏ>Ìi`ÊL>VÌiÀˆ>]ÊListeria spp., Nocardia spp., and Toxoplasmosis, but does not eliminate risk. It is the preferred antibiotic regimen for PCP prophylaxis. *In patients with fluoroquinolone allergy or who cannot tolerate a fluoroquinolone due to QTc prolongation, consider Cefpodoxime 400 mg PO BID. †Acyclovir should be dosed by ideal body weight ‡Þiœ“>Ê«>̈i˜ÌÃʈvʜ˜ÊÃÌiÀœˆ`ÃÆÊޓ«…œ“>Ê«>̈i˜ÌÃʈvÊ6³]ʜ˜ÊV…Àœ˜ˆVÊÃÌiÀœˆ`Ã]ÊyÕ`>À>Lˆ˜i° iՎi“ˆ>Ê«>̈i˜ÌÃ\Ê
]ÊV…Àœ˜ˆVÊÃÌiÀœˆ`Ã]ÊÃÉ«Ê /Ê՘̈Ê£ÊÞi>ÀÊ>vÌiÀÊÌÀ>˜Ã«>˜Ì]ʜÀÊ«>̈i˜ÌÊ܅œÊ received cladribine, fludarabine, or alemtuzumab. ¬"̅iÀÊ«Àœ«…ޏ>݈Ãʈ˜Ê>VÕÌiÊ6 \ʜ݈yœÝ>Vˆ˜]Ê/*É-8°

132

Filamentous fungi ID consult recommended for assistance with antifungal selection TREATMENT Aspergillus spp. Initial therapy UÊÊ6œÀˆVœ˜>✏iÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌܜÊ`œÃiÃÊ̅i˜Ê{ʓ}Ɏ}Ê6É PO Q12H (see Voriconazole guidelines, p. 19, for more information). OR UÊ
“ ˆÃœ“i® 5 mg/kg IV Q24H NOTES: UÊÊ6œÀˆVœ˜>✏iʈÃÊVœ˜Ãˆ`iÀi`ÊLÞʓ>˜ÞÊ̜ÊLiÊ̅iÊwÀÃ̇ˆ˜iÊÌÀi>̓i˜ÌʜvÊ suspected filamentous fungal infections in the immunocompromised host as most of these infections are caused by Aspergillus species. Although the data are limited, Voriconazole appears more effective than Amphotericin for this very serious infection. UÊÊ œ“Lˆ˜>̈œ˜Ê>˜Ìˆv՘}>Ê̅iÀ>«ÞÊVœ˜ÃˆÃ̈˜}ʜvÊ6œÀˆVœ˜>✏iÊPLUS Micafungin should be considered for the treatment of confirmed invasive aspergillosis that is documented by culture, positive galuctomannan assay, or histopathology for the first two weeks of therapy. Longer duration of combination therapy has not been evaluated. Fusarium spp. UÊÊ ÊVœ˜ÃՏÌÊŜՏ`ÊLiʈ˜ÛœÛi`ʈ˜Ê̅iÃiÊV>Ãið UÊÊ6œÀˆVœ˜>✏iÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌܜÊ`œÃiÃÊ̅i˜Ê{ʓ}Ɏ}Ê IV/PO Q12H PLUS Ambisome 5 mg/kg IV Q24H (see Voriconazole guidelines, p. 19, for more information). Dose escalation may be necessary for some patients. Scedosporium apiospermum UÊÊ6œÀˆVœ˜>✏iÊÈʓ}Ɏ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌܜÊ`œÃiÃÊ̅i˜Ê{ʓ}Ɏ}Ê IV/PO Q12H PLUS Micafungin 100 mg IV Q24H (see Voriconazole guidelines, p. 19, for more information). NOTE: UÊÊ/Ài>̓i˜ÌÊ܈̅ʜ̅iÀÊ>}i˜ÌÃʅ>ÃÊވi`i`Ê`ˆÃ>««œˆ˜Ìˆ˜}ÊÀiÃՏÌÃ°Ê Voriconazole appears to be the best option but the data are limited.

133

6.20 Guidelines for use of antimicrobials in neutropenic hosts

Guidelines for the use of antifungal agents in hematologic malignancy patients

6.20 Guidelines for use of antimicrobials in neutropenic hosts

Zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.). UÊ
“ ˆÃœ“i® 5 mg/kg IV once daily PLUS a second antifungal agent UÊÊ ÊVœ˜ÃՏÌÊÀiµÕˆÀi`° UÊÊ-ÕÀ}ˆV>Ê`iLÀˆ`i“i˜ÌÊ>˜`ÊVœÀÀiV̈œ˜ÊœvÊ՘`iÀÞˆ˜}ÊÀˆÃŽÊv>V̜ÀÃÊ­i°}°Ê acidosis, hyperglycemia) are critical. Candida TREATMENT UÊÊ9
-/Ê Ê
Ê "" Ê 1/1, Ê-"1 Ê 6 ,Ê Ê " - , Ê
Ê CONTAMINANT. UÊÊ-iiÊÃiV̈œ˜ÃÊLiœÜʜ˜Êi“«ˆÀˆVÊ̅iÀ>«ÞÊ>˜`ʜ˜Ê«>̅œ}i˜‡Ã«iVˆwVÊ therapy. Unspeciated candidemia UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{ OR UÊ
“ ˆÃœ“i® 5 mg/kg IV Q24H If the yeast is C. albicans or C. glabrata, the recommendations for C. albicans noted below can be followed. If the yeast is not C. albicans, await speciation before modifying therapy as recommended below. NOTE: Micafungin does not cover Cryptococcus Candida albicans UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{ OR UÊÊ
“ ˆÃœ“i®ÊÎqxʓ}Ɏ}Ê6Ê+Ó{ NOTE: Patients who are clinically stable and no longer neutropenic can be switched to Fluconazole if the organism is susceptible. Candida glabrata UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{ OR UÊÊ
“ ˆÃœ“i® 5 mg/kg IV Q24H Candida krusei UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{ OR UÊÊ
“ ˆÃœ“i® 5 mg/kg IV Q24H 134

Candida parapsilosis UÊ
“ ˆÃœ“i®ÊÎqxʓ}Ɏ}Ê6Ê+Ó{Ê NOTES: UÊÊœÃÌÊC. parapsilosis isolates remain susceptible to Fluconazole, which can be used in stable and non-neutropenic patients. UÊÊ/…iÀiÊ>Àiʏˆ“ˆÌi`Ê`>Ì>Ê̅>ÌÊÃÕ}}iÃÌÊ̅>ÌʈV>v՘}ˆ˜Ê“>ÞÊLiʈ˜viÀˆœÀÊÌœÊ Amphotericin B in these infections. Candida tropicalis UʈV>v՘}ˆ˜Ê£ääʓ}Ê6Ê+Ó{ OR UÊÊ
“ ˆÃœ“i®ÊÎqxʓ}Ɏ}Ê6Ê+Ó{ TREATMENT NOTES

Hidden Content - JHH Internal use only

Notes on antifungal susceptibility testing UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀʏÕVœ˜>✏i]ÊÌÀ>Vœ˜>✏i]Ê6œÀˆVœ˜>✏i]Ê Flucytosine (5-FC), and Micafungin is performed routinely on the first yeast isolate recovered from blood.

135

6.20 Guidelines for use of antimicrobials in neutropenic hosts A

NOTE: C. krusei is intrinsically resistant to Fluconazole and these infections can be difficult to treat. In stable patients, Voriconazole can be used if susceptible and oral therapy is desired. (See p. 19 for dosing).

A 6.20 Guidelines for use of antimicrobials in neutropenic hosts

UÊʏÕVœ˜>✏iÊ>˜`ʈV>v՘}ˆ˜ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>ÀiÊÀi«œÀÌi`ʜ˜Ê>ÊLœœ`Ê isolates. UÊÊ"À}>˜ˆÃ“ÃÊ̅>Ìʅ>ÛiʈV>v՘}ˆ˜Ê Ãʈ˜Ê̅iÊÀ>˜}iʜvÊ£qÓʓV}ɓÊ (reported as susceptible) may not respond to treatment. ID consult is recommended in these cases. UÊÊSusceptibility testing for conventional Amphotericin B is done routinely for C. lusitaniae and C. guillemondii and for other organisms by request. UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`Ê܅i˜\Ê UÊÊÕVœVÕÌ>˜iœÕÃÊV>˜`ˆ`ˆ>ÈÃʈÃÊÀivÀ>V̜ÀÞÊ̜ʏÕVœ˜>✏i UÊÊ/Ài>̈˜}ʜÃÌiœ“ÞiˆÌˆÃ]ʓi˜ˆ˜}ˆÌˆÃ]ʜÀÊi˜`œ«…Ì…>“ˆÌˆÃÊÜˆÌ…Ê Fluconazole UÊÊ œœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«iÀÈÃÌi˜ÌÞÊ«œÃˆÌˆÛiʜ˜ÊÕVœ˜>✏i UÊÊ œ˜‡ÀœṎ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊV>˜ÊLiÊ>ÀÀ>˜}i`ÊLÞÊV>ˆ˜}Ê̅iÊ mycology lab at 5-6148 ,iviÀi˜Vi\  -
ÊՈ`iˆ˜iÃÊvœÀÊ/Ài>̓i˜ÌʜvÊ >˜`ˆ`ˆ>ÈÃ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓää™Æ{n\xäΰ

136

Penicillin reactions – Incidence UÊÊÊn䇙ä¯ÊœvÊ«>̈i˜ÌÃÊ܅œÊÀi«œÀÌÊ̅iÞÊ>Àiʺ>iÀ}ˆV»Ê̜Ê* Ê>VÌÕ>Þʅ>ÛiÊ negative skin tests and are not at increased risk of an allergic reaction. UÊÊ*i˜ˆVˆˆ˜ÊÀi>V̈œ˜ÃʜvÊܓiÊÌÞ«iʜVVÕÀʈ˜Êä°ÇÊ̜ʣä¯ÊœvÊ>Ê«>̈i˜ÌÃÊ who get the drug. UÊÊ 1/\Ê/…iʈ˜Vˆ`i˜ViʜvÊ>˜>«…ޏ>V̈VÊÀi>V̈œ˜ÃʈÃÊä°ää{¯Ê̜Êä°ä£x¯° UÊÊ,>ÌiÃʜvÊVÀœÃÇÀi>V̈œ˜Ê>iÀ}ˆiÃÊ̜ÊVi«…>œÃ«œÀˆ˜ÃÊ>ÀiÊ՘Ž˜œÜ˜ÊLÕÌÊ thought to be low. UÊÊ,>ÌiÃʜvÊ* Ê>˜`ÊV>ÀL>«i˜i“ÊΈ˜ÊÌiÃÌÊVÀœÃÃÊÀi>V̈ۈÌÞÊ>ÀiÊ{ǯ]Ê although clinical rates of hypersensitivity reactions in patients with Ài«œÀÌi`Ê* Ê>iÀ}ÞÊ܅œÊÀiViˆÛiÊV>ÀL>«i˜i“ÃÊ>Àiʙq££¯° UÊÊ ÀœÃÃÊÀi>V̈œ˜ÃÊ̜ʓœ˜œL>VÌ>“ÃÊ­
âÌÀiœ˜>“®Ê`œÊ "/Ê>««i>ÀÊ̜ʜVVÕÀ° Penicillin skin testing UÊÊ7…i˜Ê`œ˜iÊVœÀÀiV̏Þ]ʈÃʅˆ}…ÞÊ«Ài`ˆV̈ÛiʜvÊÃiÀˆœÕÃ]Ê>˜>«…ޏ>V̈VÊÀi>V̈œ˜Ã° UÊÊ*>̈i˜ÌÃÊ܈̅Ê>ʘi}>̈ÛiÊΈ˜ÊÌiÃÌÊ>ÀiÊNOT at risk for anaphylactic reactions. UÊÊ,>ÀiÞ]ÊΈ˜ÊÌiÃÌʘi}>̈ÛiÊ«>̈i˜ÌÃʓ>ÞÊ}iÌʓˆ`ʅˆÛiÃÊ>˜`ʈÌV…ˆ˜}Ê following penicillin administration but these RESOLVE with continued treatment. UÊÊ-Žˆ˜ÊÌiÃÌÃÊV>˜˜œÌÊ«Ài`ˆVÌÊ`iÀ“>̜œ}ˆVʜÀÊÊÀi>V̈œ˜ÃʜÀÊ`ÀÕ}ÊviÛiÀð UÊÊ-Žˆ˜ÊÌiÃ̈˜}ʈÃʘœÜÊ>Û>ˆ>LiÊ>ÌÊ°Ê*i>ÃiÊVœ˜ÃՏÌÊ
iÀ}ÞÊ>˜`Ê Immunology. Penicillin reactions—Types UÊImmediateÊ­ÌÞ«iÊ£®ÊqÊ
˜>«…ޏ>݈Ã]ʅޫœÌi˜Ãˆœ˜]ʏ>Àޘ}i>Êi`i“>]Ê wheezing, angioedema, urticaria UÊÊ
“œÃÌÊ>Ü>ÞÃʜVVÕÀÊwithin 1 hour of administration. Hypotension always occurs soon after administration UÊÊ >˜ÊLiÊ«Ài`ˆVÌi`ÊLÞÊΈ˜ÊÌiÃÌà UÊAcceleratedÊqÊ>Àޘ}i>Êi`i“>]Ê܅ii∘}]Ê>˜}ˆœi`i“>]ÊÕÀ̈V>Àˆ>Ê (NOT hypotension) UÊÊ"VVÕÀÊ܈̅ˆ˜Ê£‡ÇÓʅœÕÀÃʜvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜ UÊÊ >˜ÊLiÊ«Ài`ˆVÌi`ÊLÞÊΈ˜ÊÌiÃÌà UÊLateÊqÊ,>Åʭ“>VՏœ«>«Õ>ÀʜÀʓœÀLˆˆvœÀ“ÊœÀÊVœ˜Ì>VÌÊ`iÀ“>̈̈î]Ê destruction of RBC, WBC, platelets, serum sickness UÊÊ
“œÃÌÊ>Ü>ÞÃʜVVÕÀÊ>vÌiÀÊÇÓʅœÕÀÃʜvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜ UÊÊ,>ÅiÃÊܓï“iÃÊ}œÊ>Ü>ÞÊ`iëˆÌiÊVœ˜Ìˆ˜Õi`ÊÌÀi>̓i˜Ì UÊÊ>VՏœ«>«Õ>ÀÊ>˜`ʓœÀLˆˆvœÀ“ÊÀ>ÅiÃÊ "Ê "/Ê«Àœ}ÀiÃÃÊÌœÊ Stevens-Johnson syndrome UÊÊ>ÌiÊÀi>V̈œ˜ÃÊ>ÀiÊ "/Ê«Ài`ˆVÌi`ÊLÞÊΈ˜ÊÌiÃÌà UÊStevens-Johnson SyndromeÊqÊiÝvœˆ>̈ÛiÊ`iÀ“>̈̈ÃÊ܈̅ʓÕVœÕÃÊ membrane involvement 137

7.1 Approach to the patient with a history of penicillin allergy

Approach to the patient with a history of penicillin allergy

7.1 Approach to the patient with a history of penicillin allergy

UÊÊ
“œÃÌÊ>Ü>ÞÃʜVVÕÀÊ>vÌiÀÊÇÓʅœÕÀÃʜvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜ UÊÊ "/Ê«Ài`ˆVÌi`ÊLÞÊ>ʅˆÃ̜ÀÞʜvÊÀ>ÅÊ",ÊLÞÊΈ˜ÊÌiÃÌà Approach to the patient with reported penicillin allergy UÊÊ Àˆiv]ÊvœVÕÃi`ʅˆÃ̜ÀÞÊV>˜ÊLiÊ6 ,9ʅi«vՏ° UÊÊ+ÕiÃ̈œ˜ÃÊ̜Ê>Î\ 1. How long after beginning penicillin did the reaction occur? 2. Was there any wheezing, throat or mouth swelling, urticaria? 3. If a rash occurred, what was the nature of the rash? Where was it and what did it look like? 4. Was the patient on other medications at the time of the reaction? 5. Since then, has the patient ever received another penicillin or Vi«…>œÃ«œÀˆ˜Ê­>ÎÊ>LœÕÌÊÌÀ>`iʘ>“iÃʏˆŽi\Ê
Õ}“i˜Ìˆ˜]ÊiyiÝ]Ê Trimox, Ceftin, Vantin)? 6. If the patient received a beta-lactam, what happened? Interpreting the history of the patient reporting penicillin allergy UÊÊANY patient who has a history consistent with an immediate reaction (laryngeal edema, wheezing, angioedema, urticaria) SHOULD NOT receive beta-lactams without undergoing skin testing first EVEN IF they have received beta-lactams with no problems after the serious reaction. UÊÊ*>̈i˜ÌÃÊ܅œÊÀi«œÀÌʘœ˜‡>˜>«…ޏ>V̈VÊÀi>V̈œ˜ÃÊ>˜`ʅ>ÛiÊÀiViˆÛi`Ê other penicillins without problems DO NOT have penicillin allergy and are not at increased risk for an allergic reaction compared to the general population. UÊÊ*>̈i˜ÌÃÊ܅œÊÀi«œÀÌʘœ˜‡>˜>«…ޏ>V̈VÊÀi>V̈œ˜ÃÊ>˜`ʅ>ÛiÊÀiViˆÛi`Ê cephalosporins can get cephalosporins but not necessarily PCNs. UÊÊ*>̈i˜ÌÃÊ܅œÊÀi«œÀÌÊ>ʅˆÃ̜ÀÞʜvÊ>ʘœ˜‡ÕÀ̈V>Àˆ>ÊÀ>ÅÊ̅>ÌʈÃÊ "/Ê consistent with Stevens-Johnson syndrome (target lesions with mucous membrane inflammation) and developed after ≥ 72 hours of penicillin are not at increased risk for an adverse reaction. They should, however, be watched closely for development of rashes. UÊÊ*>̈i˜ÌÃÊ܅œÊÀi«œÀÌÊÀi>V̈œ˜ÃÊVœ˜ÃˆÃÌi˜ÌÊ܈̅ÊÃiÀՓÊÈVŽ˜iÃÃÊ (rare) can receive either penicillins or cephalosporins with careful monitoring for recurrence. UÊÊ*>̈i˜ÌÃÊ܅œÊÀi«œÀÌÊÊÃޓ«Ìœ“ÃÊ­`ˆ>ÀÀ…i>]ʘ>ÕÃi>®Ê«ÀœL>LÞÊ`œÊ not have penicillin allergy and do not appear to be at increased risk for an adverse reaction. They should be closely observed for recurrent symptoms and be given supportive therapy if they occur. ,iviÀi˜ViÃ\Ê 

ÊÓää£ÆÓnx\Ó{™n° 1ÃiʜvÊV>ÀL>«i˜i“Ãʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê* Ê>iÀ}Þ\ÊÊ
˜Ìˆ“ˆVÀœL°Ê …i“œÌ…iÀÊÓää{Æx{\Ê ££xxqÇ°Ê
˜˜Ê˜ÌiÀ˜Êi`ÊÓääÇÆ£{È\ÓÈÈq™°

138

UÊÊ œ˜ÃՏÌÊ̅iÊ  ÊÜiLÈÌiʜÀÊÊ«œˆVˆiÃʜ˜ˆ˜iÊ­*"®Ê­ÜÜÜ° hopkinsmedicine.org/heic) for detailed isolation charts, HEIC policies, and surveillance information Hand hygiene UÊÊvʅ>˜`ÃÊ>ÀiʘœÌÊۈÈLÞÊ܈i`]Ê̅i˜Ê>Vœ…œ‡L>Ãi`ʅ>˜`ÊÃ>˜ˆÌˆâiÀÃÊ>ÀiÊ recommended for cleaning. If hands are visibly soiled, wash hands with soap and water for at least 15 seconds. UÊÊ>˜`ʅÞ}ˆi˜iʈÃÊÀiµÕˆÀi`ÊÕ«œ˜Êi˜ÌiÀˆ˜}Ê>Ê«>̈i˜ÌÊÀœœ“]ÊÕ«œ˜Êï݈˜}]Ê between patients in a semi-private room, and other times per hospital policy. UÊÊ1ÃiÊÜ>«Ê>˜`ÊÜ>ÌiÀÊÕ«œ˜Êexiting the room of a patient with C. difficile infection. UÊÊ œÊ>À̈wVˆ>Êw˜}iÀ˜>ˆÃÊ>ÀiÊ«iÀ“ˆÌÌi`ÊvœÀÊ>˜ÞÊÃÌ>vvʓi“LiÀÊ܅œÊ…>ÃÊ patient contact or handles sterile supplies. Bloodborne pathogen exposures (needlestick or other exposure) The prompt treatment of injuries and exposures is vital to prevent the transmission of disease. Whatever the exposure, IMMEDIATE cleaning of the exposure site is the first priority. UÊÊ-Žˆ˜Êܜ՘`ÃÊŜՏ`ÊLiÊVi>˜i`Ê܈̅ÊÜ>«Ê>˜`ÊÜ>ÌiÀ UÊÊÕVœÕÃʓi“LÀ>˜iÃÊŜՏ`ÊLiÊyÕÅi`Ê̅œÀœÕ}…ÞÊ܈̅ÊÜ>ÌiÀ UÊÊ ÞiÃÊŜՏ`ÊLiʈÀÀˆ}>Ìi`Ê܈̅Ê>ʏˆÌiÀʜvʘœÀ“>ÊÃ>ˆ˜i
vÌiÀÊVi>˜ˆ˜}Ê̅iÊiÝ«œÃÕÀiÊÈÌi]ÊV>Êx‡-/8Ê­x‡Çn{™®Ê>˜`ÊvœœÜÊ instructions to contact the ID physician. Workplace injuries should be Ài«œÀÌi`ʈ““i`ˆ>ÌiÞʜ˜Ê̅iʺ “«œÞiiÊ,i«œÀÌʜvʘVˆ`i˜ÌÊœÀ“»Ê>˜`Ê to the Occupational Injury ClinicÊ­ >œVŽÊ£Î™]Êœ˜`>ÞqÀˆ`>Þ]ÊÇ\ÎäÊ a.m. to 4 p.m., 5-6433), and to your supervisor. Standard Precautions UÊÊ,œṎ˜iʅ>˜`ʅÞ}ˆi˜iÊ UÊÊ œ˜ÃˆÃÌi˜ÌÊ>˜`ÊVœÀÀiVÌÊ}œÛiÊÕÃiÊÊ

UÊÊ >}ÊVœ˜Ì>“ˆ˜>Ìi`ʏˆ˜i˜Ê>ÌÊ«œˆ˜ÌʜvÊÕÃi UÊÊ,i}Տ>ÀÊVi>˜ˆ˜}ʜvÊi˜ÛˆÀœ˜“i˜Ì>Ê surfaces UÊ
««Àœ«Àˆ>ÌiÊÕÃiʜvÊ}œÜ˜ÃÊ̜ʫÀiÛi˜ÌÊÊ UÊ,œṎ˜iÊVi>˜ˆ˜}ʜÀÊ`ˆÃ«œÃ>Êœv contamination of uniform/clothing patient-care equipment UÊ
««Àœ«Àˆ>ÌiÊÕÃiʜvʓ>ÎÃ]ÊiÞiÊÊ UÊ-ÌÀˆVÌÊ>`…iÀi˜ViÊ̜ protection and face shields (i.e., when occupational safety requirements suctioning, or when splash likely)

139

8.1 Hospital Epidemiology & Infection Control A

Hospital Epidemiology and Infection Control (HEIC)

8.1 Hospital Epidemiology & Infection Control A

Communicable diseases—exposures and reporting   ÊŜՏ`ÊLiʘœÌˆwi`\ UÊÊvÊ«>̈i˜ÌÃʜÀÊ 7ÃÊ>ÀiÊiÝ«œÃi`Ê̜Ê>ÊVœ““Õ˜ˆV>LiÊ`ˆÃi>ÃiÊ­ˆ°i°Ê meningococcal disease, varicella, TB etc.) UÊÊ
LœÕÌÊ 7ÃÊ܈̅Ê>VÕÌiʅi«>̈̈ÃÊ
]Ê ÊœÀÊ ]Ê->“œ˜i>]Ê-…ˆ}i>]Ê Campylobacter, or pneumonia requiring hospital admission UÊÊ
LœÕÌÊ>˜ÞÊ՘ÕÃÕ>ÊœVVÕÀÀi˜ViʜvÊ`ˆÃi>ÃiʜÀÊVÕÃÌiÀ]Ê«>À̈VՏ>ÀÞÊ diseases that have the potential to expose many susceptible individuals UÊÊ-ÕëˆVˆœ˜ÊœÀÊ`ˆ>}˜œÃiÃʜvÊ̅iÊvœœÜˆ˜}Ê`ˆÃi>ÃiÃÊ­`ˆÃi>ÃiÃÊÜˆÌ…Ê require immediate notification by phone or pager). If disease is in a HCW, notify HEIC and Occupational Health (98 N. Broadway, -ՈÌiÊ{Ó£]Êœ˜`>ÞqÀˆ`>Þ]ÊÇ\ÎäÊ>°“°Ê̜Ê{\ääÊ«°“°]Êx‡ÈÓ££®Ê immediately Anthrax  Avian Influenza  Botulism  Brucellosis Creutzfeldt-Jakob disease (CJD)  Diphtheria  Glanders  Highly resistant organisms (i.e. VISA, VRSA)  Legionellosis Measles (rubeola)  Meningococcal disease  Monkeypox  Mumps Pertussis  Plague  Poliomyelitis Q Fever

Rabies  Ricin toxin  Rubella (German measles) Salmonellosis SARS  Scabies Shigellosis Smallpox (orthopox viruses)  Streptococcal Group A or B invasive disease  Tuberculosis  Tularemia  Varicella (chickenpox or disseminated zoster)  Viral hemorrhagic fever  Yellow Fever 

Physicians are required to report communicable disease to the >Ìˆ“œÀiÊ ˆÌÞÊi>Ì…Ê i«>À̓i˜ÌÊ­{£ä‡Î™È‡{{ÎÈ]Êv>Ý\Ê{£ä‡ÈÓx‡äÈnn®°Ê For a complete list of communicable diseases, see the HEIC Web site, ̅iÊ Ê7iLÊÈÌi]ʅÌÌ«\ÉɈ`i…>°`…“…°“>Àޏ>˜`°}œÛÉ-ˆÌi*>}iÃÉ܅>̇ to-report.aspx or the BCHD Web site, www.baltimorehealth.org/acd. html.

140

141

To enter room MRSA, C.diff, zoster§

Door closed Mask/Eye Protection

Gown and Gloves Examples

Droplet Precautions (orange) Required unless cohorted* No If within 6 feet of patient To enter room Influenza, bacterial meningitis Yes PAPR or N95† to enter room‡ No TB, disseminated zoster§

Airborne Precautions (blue) ¶ Required

8.2 Infection control precautions

* Required for pertussis and diphtheria † Fit-testing is required to use an N95 mask for airborne precautions ‡ HCWs who are Varicella-immune do not have to wear a PAPR or N95 if patient is in isolation for zoster or chickenpox § Disseminated zoster, zoster in an immunocompromised host, and chickenpox require both Contact and Airborne Precautions

(sign color) Private room

Contact Precautions (pink) Required unless cohorted No No

JHH Precautions Categories These precaution categories must be used in addition to Standard Precautions. The following table includes general requirements for precaution categories. The complete table and the type of isolation required for each organism can be found on the HEIC website. If recommendations on this table cannot be followed, please contact HEIC.

8.3 Disease-specific infection control recommendations

Disease-specific infection control recommendations Carbapenem-resistant Enterobacteriaceae (CRE) Routine active surveillance cultures for CRE are performed in patients who have been hospitalized in a country other than the U.S. in the past 6 months. Patients are placed on Contact Precautions pending cullture results. The results are to be used for isolation purposes, not to guide therapy or clinical care. The overwhelming majority of positive surveillance cultures represents colonization, not infection, and should not prompt any antimicrobial therapy. Creutzfeldt-Jakob disease (CJD) CJD, variant CJD and other diseases caused by prions are resistant to a number of standard sterilization and disinfection procedures. Iatrogenic transmission of CJD has been associated with percutaneous exposure to medical instruments contaminated with prion/central nervous system (CNS) tissue residues, transplantation of CNS and corneal tissues and recipients of human growth hormone and gonadotropin. Transmission of CJD has not been associated with environmental contamination or from person-to-person via skin contact. The following additional precautions must be made when processing equipment that could be contaminated ܈̅ʫÀˆœ˜ÊÀi>Ìi`ʓ>ÌiÀˆ>\ UÊÊ œÌˆvÞÊ  Ê>˜`Ê̅iÊ՘ˆÌʓ>˜>}iÀÉV…>À}iʘÕÀÃiʈ““i`ˆ>ÌiÞʜvÊ>˜ÞÊ suspected or confirmed CJD case and refer to the CJD policy on the HEIC Web site. UÊÊ1ÃiÊ`ˆÃ«œÃ>LiÊiµÕˆ«“i˜ÌÊ܅i˜iÛiÀÊ«œÃÈLi°Êvʘœ˜‡`ˆÃ«œÃ>LiÊ equipment is used, Central Sterile Department shall be notified prior to the start of the procedure. UÊÊ>LiÊ>Ê>LœÀ>̜ÀÞÊ>˜`Ê«>̅œœ}ÞÊÀiµÕˆÃˆÌˆœ˜ÃÊ>ÃÊÃÕëiVÌi`Ê  Ê>˜`Ê notify the lab before sending specimens. UÊÊ/…iÊvœœÜˆ˜}Ê>ÀiÊVœ˜Ãˆ`iÀi`ʅˆ}…Þʈ˜viV̈ÛiÊ>˜`ÊŜՏ`ÊLiʅ>˜`i`Ê ÜˆÌ…ÊiÝÌÀi“iÊV>Ṏœ˜\ÊLÀ>ˆ˜]Ê눘>ÊVœÀ`]ʜ«ÌˆVÊ̈ÃÃÕiÃÊ>˜`Ê«ˆÌՈÌ>ÀÞÊ gland UÊÊ/…iÊvœœÜˆ˜}Ê>ÀiÊVœ˜Ãˆ`iÀi`Ê̜ÊLiʜvʏœÜiÀʈ˜viV̈ۈÌÞ\Ê -]ʎˆ`˜iÞ]Ê liver, lung, lymph nodes, spleen, placenta, tonsillar tissue and olfactory tissue. Methicillin-resistant Staphylococcus aureus (MRSA) Routine active surveillance cultures for MRSA are performed on select units to identify patients with MRSA. When a culture is positive for MRSA the patient is placed on Contact Precautions. The results are to be used for isolation purposes, not to guide therapy or clinical care. The overwhelming majority of positive surveillance cultures 142

Surveillance cultures should be obtained upon admission and weekly ˆ˜Ê̅iÊvœœÜˆ˜}Ê՘ˆÌÃ\Ê 1]Ê7 1]Ê 6- 1]Ê- 1]Ê /1Ê­™7®]Ê

1]Ê CCU/PCCU, PICU, NICU, oncology units, Nelson 4. To remove a patient from MRSA precautions, cultures from the original site of infection and 2 nares cultures taken ≥ 72 hours apart must be negative. Nares cultures should not be sent if the patient has received antibiotics active against MRSA in the previous 48 hours. Once this is accomplished, call HEIC to review culture data and initiate deflagging. Pertussis All patients with pertussis should be placed on Droplet Precautions for five days from the start of therapy. If the patient is not on therapy, Droplet Precautions should be continued for three weeks from the onset of cough. Private room is required. /Ài>̓i˜Ì\ UÊÊ
âˆÌ…Àœ“ÞVˆ˜Êxääʓ}Ê*"ʜ˜Viʜ˜Ê`>ÞÊ£]Ê̅i˜ÊÓxäʓ}Ê*"Ê`>ˆÞʜ˜Ê `>ÞÃÊÓqx OR UÊÊ>VÀœˆ`iÊ>iÀ}Þ\Ê/*É-8Ê£Ê -ÊÌ>LiÌÊ*"Ê  ÊvœÀÊ£{Ê`>Þà Prophylaxis with the above regimens is required for all household contacts within three weeks of exposure. Use the same antibiotic as for treatment. All household contacts and HCWs with exposure to the patient should also have up-to-date immunizations for Bordetella pertussis. Scabies All patients with conventional or Norwegian scabies should be placed on Contact Precautions. Norwegian scabies is a severe form of heavy mite infestation. UÊÊ*ÀˆÛ>ÌiÊÀœœ“ÊÀiµÕˆÀi`° UÊÊ*>̈i˜ÌÃÊ܈̅ÊVœ˜Ûi˜Ìˆœ˜>ÊÃV>LˆiÃʓÕÃÌÊLiÊÌÀi>Ìi`Ê܈̅Ê>ÊÃV>LˆVˆ`iÊ once, and the precautions may be discontinued 24 hours after the treatment is completed. UÊÊ*>̈i˜ÌÃÊÜˆÌ…Ê œÀÜi}ˆ>˜ÊÃV>LˆiÃÊÀiµÕˆÀiÊÓÊÌÀi>̓i˜ÌÃÊ܈̅Ê>ÊÃV>LˆVˆ`iÊ 1 week apart. Contact precautions may be discontinued 24 hours after the second treatment is completed. UÊʘviÃÌi`ÊVœÌ…ˆ˜}Ê>˜`ʏˆ˜i˜ÊŜՏ`ÊLiÊÃi>i`ʈ˜Ê>Ê«>Ã̈VÊL>}ÊvœÀÊ{nÊ hours. The mite will not survive off a human host for more than 48 hours. Clothing/patient belongings should be sent home with the patient’s family/caretaker. Linens and clothing should be washed in the washing machine on the hot cycle. 143

8.3 Disease-specific infection control recommendations

represents colonization, not infection, and should not prompt any antimicrobial therapy.

8.3 Disease-specific infection control recommendations

UÊÊvÊ«Àœœ˜}i`ÊΈ˜‡Ìœ‡ÃŽˆ˜ÊVœ˜Ì>VÌʜVVÕÀÃÊ܈̅Ê>ÊÃV>LˆiÃÊ«>̈i˜Ì]Ê prophylactic treatment is required. Healthcare workers should contact HEIC if an exposure is suspected. Vancomycin-resistant enterocci (VRE) Routine active surveillance cultures for VRE are performed on select units to identify patients with VRE. Surveillance culture results are found ˆ˜Ê̅iÊiiVÌÀœ˜ˆVÊ«>̈i˜ÌÊÀiVœÀ`Ê܈̅Ê̅iÊÌiÃÌʘ>“iʺ >VÌiÀˆœœ}އ-̜œ‡ 6, Ê-̜œÊ-ÕÀÛ°Ê ÕÌ°»Ê7…i˜Ê>ÊVՏÌÕÀiÊ}ÀœÜÃÊ6, ]Ê̅iÊ«>̈i˜ÌʈÃÊy>}}i`Ê for Contact Precautions. The results are to be used for isolation purposes, not to guide therapy or clinical care. The overwhelming majority of positive surveillance cultures represents colonization, not infection, and should not prompt any antimicrobial therapy. Surveillance cultures should be obtained upon admission and weekly ˆ˜Ê̅iÊvœœÜˆ˜}Ê՘ˆÌÃ\Ê 1]Ê7 1]Ê 6- 1]Ê- 1]Ê /1Ê­™7®]Ê /Ê>˜`Ê Leukemia units, NCCU, PICU. The patient must be off antibiotics for ≥ 48 hours and cultures from original site of infection AND 3 stool or perirectal cultures taken ≥ 1 week apart must be negative. Once this is accomplished, call HEIC to review culture data and initiate deflagging. Varicella-Zoster Immunocompetent patients with disseminated zoster and all immunosuppressed patients with zoster need Contact AND Airborne Precautions°Ê/…iÊvœœÜˆ˜}Ê`iw˜ˆÌˆœ˜ÃÊ>««ÞÊ̜ʫ>̈i˜ÌÃÊ܈̅ÊâœÃÌiÀ\ UÊÊImmunosuppressed:ÊLœ˜iʓ>ÀÀœÜÊÌÀ>˜Ã«>˜ÌÊ܈̅ˆ˜Ê̅iÊ«>ÃÌÊÞi>ÀÆÊ >VÕÌiʏiՎi“ˆ>ÆÊ܏ˆ`ʜÀ}>˜ÊÌÀ>˜Ã«>˜ÌÊÀiVˆ«ˆi˜ÌÃÆÊ«>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê cytotoxic or immunosuppressive treatments, including steroid treatment for ≥ ÎäÊ`>ÞÃÊ܈̅Ê̅iÊvœœÜˆ˜}Ê`œÃiÃ\Ê`iÝ>“i̅>ܘiÊ 3 mg daily, cortisone 100 mg daily, hydrocortisone 80 mg daily, «Ài`˜ˆÃœ˜iÊÓäʓ}Ê`>ˆÞ]ʓi̅ޏ«Ài`˜ˆÃœ˜iÊ£Èʓ}Ê`>ˆÞÆÊ6³Ê«>̈i˜ÌÃÊ with CD4 < 200 UÊÊDisseminated: lesions outside of 2 contiguous dermatomes

144

Aminoglycoside dosing weight: Calculate Ideal Body Weight (IBW) IBW female (kg)ÊrÊ(2.3 x inches over 5’)ʳÊ45.5 IBW male (kg) r (2.3 x inches over 5’)ʳÊ50 For patients < 20% over IBW, use Actual Body Weight (ABW) For patients ≥ 20% over IBW, use Dosing Body Weight (DBW) ­ 7®ÊrÊQ 7ʳÊä°{Ê­
7ÊqÊ 7®RÊ Estimation of creatinine clearance (CrCl) by Cockcroft-Gault equation: (If a patient’s renal function is declining, this equation may overestimate CrCl)

Ê

À Êr ­£{äÊqÊ>}i®Ê­Üiˆ}…Ìʈ˜ÊŽ}I® x 0.85 (if female) 72 (serum creatinine)

* Use Actual Body Weight (ABW) unless patient ≥ÊÓä¯ÊœÛiÀÊ 7]ÊÕÃiÊ 7Ê>ÃÊ`iÃVÀˆLi`Ê above

Extended-interval dosing, also sometimes referred to as “oncedaily” administration, utilizes higher dose and less frequent aminoglycoside administration, whereas patient-specific dosing, previous referred to as “traditional dosing”, typically utilizes smaller doses with more frequent administration. See table below for dosing recommendation based on indication and patient’s renal function. For mycobacterial infections, urinary tract infections, SICU/WICU protocol and gram-positive synergy (e.g. endocarditis), please see separate sections below. For cystic fibrosis patients, see the Cystic Fibrosis section (p.92)

145

A. Aminoglycoside dosing and monitoring A

Aminoglycoside dosing and monitoring Aminoglycosides enhance the efficacy of some antibiotics. Except for urinary tract infections, aminoglycosides should seldom be used alone to treat infections.

A. Aminoglycoside dosing and monitoring A

Aminoglycoside dosing for Gram-negative infections IndicationsÊ

DosingÊ Ê

Patient-specific dosing ,i˜>Êv>ˆÕÀi]ʜ˜Ê É 66 ]Êi˜`œV>À`ˆÌˆÃ]ÊÊ Gram-negative infections (in combination with beta-lactams), CNS infections, septic shock, burn patients, patients with altered volume status (e.g. ascites, anasarca, trauma) Ê œÃiÊ­“}®ÊrÊ`iÈÀi`Ê«i>ŽÊÝÊQ7iˆ}…ÌÊ­Ž}®ÊÝÊ6`ÊÊ ­Ɏ}®RÊ

Ê Ê Ê

UÊÊ iÈÀi`Ê«i>Ž\ choose from below UÊÊ7iˆ}…Ì\ ABW or DBW UÊÊVolume of distribution (Vd) typically ranges LiÌÜii˜Êä°ÓxÊqÊä°xÊɎ}ʈ˜Ê“œÃÌÊ«>̈i˜ÌÃ°Ê Higher Vd should be used in critically ill and volume overloaded patients.

Ê Ê Ê Ê

œÃˆ˜}ʈ˜ÌiÀÛ>ÊL>Ãi`ʜ˜Ê À \

À Ê€Èä\Ê+nI

À ÊÎä‡Èä\Ê+£Ó

À ÊÎäÉ 66 É \Ê`œÃiÊLÞʏiÛi

Extended-interval dosing UÊÊ œÀ“>ÊÀi˜>Êv՘V̈œ˜Ê­ À Ê >60 mL/min) and all other indications not listed under patient specific dosing i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\ x‡Çʓ}Ɏ}Ê6Ê+Ó{
“ˆŽ>Vˆ˜\ 15-20 mg/kg IV Q24H

*If targeting high peaks, use maintenance dose frequency of Q12-24H. Desired Peaks and Troughs

Peak Pneumonia Septic shock Endocarditis Osteomyelitis MDR organismsÊ Trough

Gentamicin/ Tobramycin 10 mcg/mL

Amikacin

8-10 mcg/mL

20-30 mcg/mL

25-35 mcg/mL

This dosing strategy is designed ̜ÊÌ>À}iÌÊ̅iÊvœœÜˆ˜}\ Peak i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\ʣȇÓä mcg/mL
“ˆŽ>Vˆ˜\Ê{ä‡ÈäʓV}ɓ Trough i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\Ê £Ê“V}ɓ
“ˆŽ>Vˆ˜\ʐ{ʓV}ɓ

10-20 mcg/mL 45-50 mcg/mL L>Ãi`ʜ˜Ê Ê L>Ãi`ʜ˜Ê Ê Gentamicin/ Amikacin Tobramycin All IndicationsÊ £‡ÓʓV}ɓÊ £äʓV}ɓ Therapeutic Trough: draw 30 minutes prior to the 3rd dose If the patient meets ANY of the Drug criteria below, a trough level Monitoring Peak: obtain 1 hour after end of infusion, after is recommended prior to the the 3rd dose. Ә`Ê`œÃi\ UÊÊ œ˜Vœ“ˆÌ>˜Ìʘi«…ÀœÌœÝˆVÊ Frequency of monitoring medications Ê UÊÊ"˜ViÊ>ÊÜiiŽÊ>vÌiÀÊ`iÈÀi`Ê«i>ŽÉÌÀœÕ}…ʈÃÊ UÊÊ œ˜ÌÀ>ÃÌÊiÝ«œÃÕÀiÊ established in patients with normal renal UÊ
}iÊ≥ 60 years function UÊÊ*>̈i˜ÌʈÃʈ˜Ê̅iÊ 1 Ê UÊÊœÀiÊ̅>˜Êœ˜ViÊÜiiŽÞ\Ê UÊÊ"̅iÀÊÀˆÃŽÃÊvœÀʘi«…ÀœÌœÝˆVˆÌÞÊ After changes in dosing regimen ­i°}°Ê`ˆ>LiÌiÃ]ʎˆ`˜iÞÊ/8® Patient is on dialysis If trough higher than desired Patient in acute renal failure, SCr increased troughs, use patient specific LÞÊä°xʓ}É`ʜÀÊÎä¯vÀœ“ÊL>Ãiˆ˜iÊ dosing to adjust dose. Major changes in the patient’s volume status

146

Amikacin is the preferred agent to treat all mycobacterial infections, except Mycobacterium chelonae. For M. chelonae infections, Tobramycin is the recommended aminoglycoside. Streptomycin is another aminoglycoside sometimes used to treat mycobacterial infections such as M. tuberculosis. Please contact the Antimicrobial Stewardship Program pharmacist for Tobramycin/Streptomycin dosing recommendation for this indication. Amikacin: œÀ“>ÊÀi˜>Êv՘V̈œ˜\ "˜ViÊ`>ˆÞ\Ê£xʓ}Ɏ}Ê6Ê+Ó{Ê­œÀÊ£äʓ}Ɏ}Ê6Ê+Ó{ʈvʀxäÊÞi>ÀÃʜvÊ age) /…ÀˆViÊÜiiŽÞ\ÊÓxʓ}Ɏ}Ê6Ê̅ÀiiÊ̈“iÃÊ>ÊÜiiŽÊ­“>ÞÊLiʓœÀiÊ`ˆvwVՏÌÊ to tolerate)
L˜œÀ“>ÊÀi˜>Êv՘V̈œ˜\ Discuss with pharmacy clinical specialist Therapeutic drug monitoring: Peak and trough not generally ˜iViÃÃ>ÀÞ]ÊiÝVi«Ìʈ˜Ê̅œÃiÊ܈̅ÊÀi˜>Êˆ˜ÃÕvwVˆi˜VÞÊ­,ʐÈäʓɓˆ˜®Ê >˜`ʈvÊ- Àʈ˜VÀi>ÃiÃÊLÞÊä°xʓ}É`ʜÀʀÎä¯ÊvÀœ“ÊL>Ãiˆ˜iÊ܅ˆiÊ«>̈i˜ÌÊ on aminoglycoside therapy. Check a trough concentration to monitor for toxicity. Peaks in the low 20 mcg/mL range are acceptable, and trough Vœ˜Vi˜ÌÀ>̈œ˜ÃÊ>ÀiÊ«ÀiviÀ>LÞʐ{ʓVɓʜÀÊ՘`iÌiVÌ>Li°

Aminoglycoside dosing in urinary tract infections CrCl (mL/min) ≥60 40-59 20-39 ÓäÊ

Gentamicin/Tobramycin 3 mg/kg IV Q24H or 1 mg/kg IV Q8H 1 mg/kg Q12H 1 mg/kg Q24H £Ê“}Ɏ}Ê"

IÊ

Amikacin 10 mg/kg IV Q24H or 3 mg/kg IV Q8H 3 mg/kg IV Q12H 3 mg/kg IV Q24H Îʓ}Ɏ}Ê6Ê"

I

*Give one dose, check level in 24 hours, redose when Gentamicin/Tobramycin level £Ê“V}ɓʜÀÊ
“ˆŽ>Vˆ˜Ê{ʓV}ɓ


“ˆ˜œ}ÞVœÃˆ`iÃÊ>Àiʅˆ}…ÞÊVœ˜Vi˜ÌÀ>Ìi`ʈ˜ÊÕÀˆ˜iÆÊ̅iÀivœÀi]Ê̅iÀ>«iṎVÊ drug monitoring is not necessary in patients with normal renal function. Suggested doses in the above table will likely provide adequate urine concentrations for highly susceptible organisms. Trough should be checked to monitor for toxicity in patients with renal insufficiency ­,ʐÈäʓɓˆ˜®Ê>˜`ʈvÊ- Àʈ˜VÀi>ÃiÃÊLÞÊä°xʓ}É`ʜÀʀÎä¯ÊvÀœ“Ê baseline while patient on aminoglycoside therapy. UÊÊGentamicin/Tobramycin:Ê`iÈÀi`ÊÌÀœÕ}…ʐ£Ê“V}ɓʜÀÊ՘`iÌiVÌ>Li°Ê UÊÊAmikacin:Ê`iÈÀi`ÊÌÀœÕ}…ʐ{ʓV}ɓʜÀÊ՘`iÌiVÌ>Li° 147

A. Aminoglycoside dosing and monitoring A

Aminoglycoside dosing in mycobacterial infections

A. Aminoglycoside dosing and monitoring A

Aminoglycoside dosing in the SICU/WICU Gentamicin/Tobramycin Loading dose 4 mg/kg using actual body weight, followed by a patient-specific maintenance dose. Amikacin Loading dose 16 mg/kg using actual body weight, followed by a patient-specific maintenance dose. Therapeutic Drug Monitoring
vÌiÀʏœ>`ˆ˜}Ê`œÃi\ʣʅœÕÀÊ«i>ŽÊ>˜`ÊnʅœÕÀʏiÛiÊ>vÌiÀÊ̅iÊi˜`ʜvÊ̅iÊ infusion to facilitate calculating patient specific kinetic parameters.

Aminoglycoside dosing for Gram-positive synergy Dosing for patients with normal renal function: UÊGentamicin\ÊÎʓ}Ɏ}Ê6ʜ˜ViÊ`>ˆÞʈÃÊÀiVœ““i˜`i`ÊvœÀÊÌÀi>̓i˜ÌÊ of endocarditis with Viridans streptococci or S. bovis in patients with normal renal function (CrCl  60 ml/min). UÊÊGentamicin: 1 mg/kg IV Q8H is recommended for treatment Enterococcal and other Gram-positive endocarditis infections in patients with normal renal function (CrCl  60 ml/min). Patients >65 years old should be started on Q12H if normal renal function. Dosing adjustment for renal insufficiency CrCl (mL/min) {äqx™ÊÊ ÓäqΙÊÊ ÓäÊ

Dosing £Ê“}Ɏ}Ê+£Ó £Ê“}Ɏ}Ê+Ó{ £Ê“}Ɏ}Ê"

I

IÊʈÛiʜ˜iÊ`œÃi]ÊV…iVŽÊiÛiÊˆ˜ÊÓ{ʅœÕÀÃ]ÊÀi`œÃiÊ܅i˜ÊiÛiÊ£Ê“}É

NOTE: See infective endocarditis guidelines (p. 65) for duration. THERAPEUTIC DRUG MONITORING UÊÊ*i>ŽÊ>˜`ÊÌÀœÕ}…Ê>ÀiÊÀiVœ““i˜`i`Ê>ÀœÕ˜`Ê̅iÊ̅ˆÀ`Ê`œÃiÊ̜Ê>ÃÃÕÀiÊ appropriate dosing. UÊÊ iÈÀi`ÊÃiÀՓÊVœ˜Vi˜ÌÀ>̈œ˜ÃʜvÊGentamicin Peak levels:ÊÎqxʓV}ɓ Trough levels:ʐʣʓV}ɓ

148

NEPHROTOXICITY UÊÊSerum creatinine should be measured at least every other day. If VÀi>̈˜ˆ˜iʈ˜VÀi>ÃiÃÊLÞÊä°xʓ}É`ʜÀʀÎä¯ÊvÀœ“ÊL>Ãiˆ˜i]ÊÕÃiÊ«>̈i˜ÌÊ specific dosing. UÊÊi>ÃÕÀiÊserum aminoglycoside levels as needed. See each dosing section above for frequency. UÊÊ-œ“iÊ`>Ì>ÊÃÕ}}iÃÌÊ̅>ÌʏœÜiÃÌʏiÛiÊœvʘi«…ÀœÌœÝˆVˆÌÞʜVVÕÀÃÊ܅i˜Ê aminoglycosides are administered during the activity period (e.g. £Î\Îä®]Ê̅iÀivœÀiÊ>vÌiÀ˜œœ˜Ê>`“ˆ˜ˆÃÌÀ>̈œ˜ÊˆÃÊ«ÀiviÀÀi`°Ê OTOTOXICITY UÊÊ œ˜Ãˆ`iÀÊLˆÜiiŽÞÊVˆ˜ˆV>ÊÃVÀii˜ˆ˜}ÊvœÀʜ̜̜݈VˆÌÞ Ê UÊÊ …iVŽÊL>Ãiˆ˜iÊۈÃÕ>Ê>VՈÌÞÊÕȘ}Ê>Ê-˜ii˜Ê«œVŽiÌÊV>À` Ê UÊÊ/œÊÃVÀii˜ÊvœÀʜ̜̜݈VˆÌÞ]ʅ>ÛiÊ«>̈i˜ÌÊÅ>Žiʅi>`Ê>˜`Ê̅i˜ÊÀi‡Ài>`Ê card. Ê UÊÊ œ˜ViÀ˜ÊŜՏ`ÊLiÊÀ>ˆÃi`ʈvÊ«>̈i˜ÌʏœÃiÃÊÓʏˆ˜iÃʜvÊۈÃÕ>Ê>VՈÌÞ°Ê Consider formal audiology testing. Ê UÊÊ œ˜Ì>VÌÊ
Õ`ˆœœ}ÞÊ­x‡È£xήÊvœÀʅi«Ê܈̅ÊÌiÃ̈˜}ÊvœÀʜ̜̜݈VˆÌÞ ,iviÀi˜ViÃ\ *É* Ê«>À>“iÌiÀ\ÊʘviVÌÊ ˆÃÊ£™nÇÆÊ£xx\™Îq™™ "˜ViÊ`>ˆÞʘœ“œ}À>“ÃÊÀiۈiÜ\ÊPharmacotherapy ÓääÓÆÊÓÓ­™®\£äÇÇq£änΰ *>̈i˜Ì‡Ã«iVˆwVÊ`œÃˆ˜}\ÊCrit Care MedÊ£™™£ÆÊ£™\£{näq£{nx° - 1É7 1Ê`œÃˆ˜}\ÊSurgeryÊ£™™nÆÊ£Ó{\Ç·n° i«…ÀœÌœÝˆVˆÌÞ\ÊAntimicrob Agents and ChemotherÊÓääÎÆÊ{Ç\£ä£ä°
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ÊÞVœL>VÌiÀˆÕ“ÊՈ`iˆ˜iÃ\ÊAm J Respir Crit Care MedÊÓääÇÆÊ£Çx\ÎÈÇq{£È° À>“‡«œÃˆÌˆÛiÊ-ޘiÀ}Þ\ÊCirculationÊÓääxÆÊ£££­Óή\ÊiΙ{Êq{Î{°

149

A. Aminoglycoside dosing and monitoring A

Monitoring for toxicity for inpatients

B. Vancomycin dosing and monitoring A

Vancomycin dosing and monitoring DOSING £°Ê Ã̈“>ÌiÊVÀi>̈˜ˆ˜iÊVi>À>˜ViÊ­ À ®ÊÕȘ}Ê œVŽVÀœv̇>ՏÌÊiµÕ>̈œ˜\

À Êr

­£{äÊqÊ>}i®Ê­Üiˆ}…Ìʈ˜ÊŽ}®Ê 72 (serum creatinine*)

x 0.85 (if female)

* For patients with low muscle mass (i.e. many patients > 65 yrs), some advocate using a minimum value of 1 to avoid overestimation of CrCl

2. Patients who are seriously ill with complicated infections such as meningitis, pneumonia, osteomyelitis, endocarditis, and bacteremia and normal renal function should receive initial loading dose of 20-25 mg/kg, followed by 15-20 mg/kg Q8-12H using Actual Body Weight (ABW). For other indications see nomogram dosing below. 3. Calculate maintenance dose (using ABW) based on estimated or actual CrCl. See suggested nomogram dosing below. Note: Younger patients with normal renal function may need higher or more frequent dosing than suggested below. Weight (kg) {äÊ {äqÈäÊ

>60 30–59 Consult Pharmacy Çxäʓ}Ê Çxäʓ}ÊÊ Q12H Q24H ÈäqÇxÊ £äääʓ}Ê £äääʓ}ÊÊ Q12H Q24H Çxq™äÊ £Óxäʓ}Ê £Óxäʓ}ÊÊ Q12H Q24H ™äq££äÊ £xääʓ}Ê £xääʓ}ÊÊ Q12H Q24H ££äq£ÓxÊ £Çxäʓ}Ê £Çxäʓ}ÊÊ Q12H Q24H £Óxq£{äÊ Óäääʓ}Ê Óäääʓ}ÊÊ Q12H Q24H >140 Consult Pharmacy

CrCl (mL/min) 15–29 <15 Çxäʓ}Ê Q48H £äääʓ}Ê Q48H £Óxäʓ}Ê Q48H £xääʓ}Ê Q48H £Çxäʓ}Ê Q48H Óäääʓ}Ê Q48H

£äääʓ}]Ê̅i˜ÊÀi`œÃiÊLÞʏiÛi† £äääʓ}]Ê̅i˜ÊÀi`œÃiÊLÞʏiÛi† £Óxäʓ}]Ê̅i˜ÊÀi`œÃiÊLÞʏiÛi† £xääʓ}]Ê̅i˜ÊÀi`œÃiÊLÞʏiÛi† £Çxäʓ}]Ê̅i˜ÊÀi`œÃiÊLÞʏiÛi† Óäääʓ}]Ê̅i˜ÊÀi`œÃiÊLÞʏiÛi†

œÀÊ«>̈i˜ÌÃÊÜˆÌ…Ê À Ê£xʓɓˆ˜Ê>˜`ʘœÌÊÀiViˆÛˆ˜}ʅi“œ`ˆ>ÞÈÃÊÀi`œÃiÊ܅i˜ÊÀ>˜`œ“Ê iÛiÊ£xqÓäʓV}ɓ°Ê

†

DOSING IN RENAL REPLACEMENT THERAPY Dosing is dependent on type of renal replacement therapy. Intermittent Hemodialysis (iHD) UÊInitial dose: 15-20 mg/kg once UÊÊ*>̈i˜ÌÃÊŜՏ`ÊLiÊÀi‡`œÃi`ÊL>Ãi`ʜ˜ÊÃiÀՓʏiÛiÃÊ`À>ܘÊ>ÀœÕ˜`Ê̅iÊ dialysis session. Consider redosing at 5-10 mg/kg. 150

Continuous Renal Replacement Therapy (e.g. CVVHD) UÊLoading dose: 25-30 mg/kg once UÊÊMaintenance: 15-20 mg/kg q24h (assuming no interruption in CRRT, e.g. line clotting) Ê UÊ œÌi\Ê ˆ>ÞÈÃÊyœÜÊÀ>ÌiÃʀӰxÊɅʇÊVœ˜ÃՏÌÊ«…>À“>VÞ UÊMonitoring: Ê UÊÊ*>̈i˜ÌÃÊ܈̅ÊV…>˜}ˆ˜}Ê`ˆ>ÞÈÃÊyœÜÊÀ>ÌiÃʜÀÊ`ˆ>ÞÈÃʅi`ÊvœÀʀ{Ê hours may need more frequent monitoring (consult pharmacy) Ê UÊÊ*>̈i˜ÌÃʜ˜ÊÃÌ>LiÊ`ˆ>ÞÈÃÊyœÜÊÀ>ÌiÃÊŜՏ`ʅ>ÛiÊÌÀœÕ}…ʏiÛiÊ checked prior to 4th dose Peritoneal Dialysis (PD) UÊInitial dose: 15-20 mg/kg once UÊÊÊ œ˜ÃՏÌÊ«…>À“>VÞÊvœÀÊÀiVœ““i˜`>̈œ˜ÃÊvœÀÊÀi‡`œÃˆ˜}Ê>˜`ʓœ˜ˆÌœÀˆ˜}Ê serum levels. THERAPEUTIC DRUG MONITORING (LEVELS) UÊTrough levels are the most accurate and practical method for monitoring Vancomycin effectiveness and toxicity. UÊPeak levels should NOT be obtained. Measuring serum Vancomycin levels UÊÊ/ÀœÕ}…ʏiÛiÃÊŜՏ`ÊLiʜLÌ>ˆ˜i`Ê܈̅ˆ˜ÊÎäʓˆ˜ÕÌiÃʜvÊ̅iʘiÝÌÊ`œÃiÊ>ÌÊ steady-state conditions (approximately before the 4th dose). UÊʘʫ>̈i˜ÌÃÊÜˆÌ…Ê -, ʜ˜Ê…i“œ`ˆ>ÞÈÃ]ʈÌʈÃÊ«ÀiviÀ>LiÊ̜ʜLÌ>ˆ˜Ê>Ê pre-hemodialysis level with the routine laboratory venipuncture on the morning of hemodialysis. In the event a pre-hemodialysis level is not obtained, a post-hemodialysis level may be drawn at least six hours after the dialysis session. UÊÊ/ÀœÕ}…ʏiÛiÃÊŜՏ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê>˜ÞÊ̅iÊvœœÜˆ˜}Ê VˆÀVՓÃÌ>˜ViÃ\ UÊÊ,iViˆÛˆ˜}Ê>}}ÀiÃÈÛiÊ`œÃˆ˜}Ê­€£xääʓ}Ê+£Ó®ÊœÀÊ+nʈ˜ÌiÀÛ> U Serious infections such as meningitis, endocarditis, osteomyelitis, and MRSA pneumonia. UÊÊ1˜ÃÌ>LiÊÀi˜>Êv՘V̈œ˜Ê­V…>˜}iʈ˜Ê- ÀʜvÊä°xʓ}É`ʜÀÊxä¯ÊvÀœ“Ê baseline) or dialysis

151

A B. Vancomycin dosing and monitoring

Ê UÊÊÊ*Ài‡`ˆ>ÞÈÃʏiÛiÊ(preferred)\ʐÓxʓV}ɓÊ­vœÀʓi˜ˆ˜}ˆÌˆÃÊVœ˜Ãˆ`iÀÊ Ài‡`œÃˆ˜}ʈvʐÎäʓV}ɓ® Ê UÊ*œÃ̇`ˆ>ÞÈÃʏiÛi\ʐÓäʓV}ɓ® Note:ʓÕÃÌÊÜ>ˆÌÊÎqÈʅœÕÀÃÊ>vÌiÀÊ̅iÊi˜`ʜvÊ̅iÊ`ˆ>ÞÈÃÊ̜Ê>VVœÕ˜ÌÊvœÀÊ redistribution of tissue and plasma levels UÊÊœÀÊ«>̈i˜ÌÃÊÜˆÌ…Ê -, ʜ˜Ê>ÊÃÌ>LiÊ ÊÃV…i`Տi]Ê>ÊÀi}ˆ“i˜ÊŜՏ`ÊLiÊ established that coincides with HD (e.g. 500 mg qHD). Once weekly serum levels can be drawn to monitor for accumulation.

B. Vancomycin dosing and monitoring A

UÊÊ œ˜VÕÀÀi˜ÌÊ̅iÀ>«ÞÊ܈̅ʘi«…ÀœÌœÝˆVÊ>}i˜ÌÃÊ­i°}°Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]Ê Colistin, Amphotericin B) UÊ*Àœœ˜}i`ÊVœÕÀÃiÃÊ­≥ 5 days) of therapy. UÊÀiµÕi˜VÞʜvʓœ˜ˆÌœÀˆ˜}Ê6>˜Vœ“ÞVˆ˜ÊÌÀœÕ}…ʏiÛiÃ\Ê UÊÊ"˜Vi‡ÜiiŽÞʓœ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅ÊÃÌ>LiÊ renal function who have achieved desired trough levels. UÊÊœÀiÊvÀiµÕi˜Ìʓœ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܅œÊ>ÀiÊ hemodynamically unstable and/or with changing renal function. Desired Vancomycin trough levels UÊÊ*˜iՓœ˜ˆ>]ʜÃÌiœ“ÞiˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]ÊL>VÌiÀi“ˆ>\Ê£x‡ÓäʓV}ɓ UÊÊ -ʈ˜viV̈œ˜Ã\ÊÓäʓV}ɓ UÊÊ iÕÌÀœ«i˜ˆVÊviÛiÀ]ÊΈ˜Ê>˜`ÊΈ˜‡ÃÌÀÕVÌÕÀiʈ˜viV̈œ˜Ã\ʣ䇣xʓV}ɓ UÊʈ˜ˆ“Õ“ÊÃiÀՓÊÌÀœÕ}…ÊVœ˜Vi˜ÌÀ>̈œ˜Ãʀ£äʓV}ɓÊŜՏ`Ê>Ü>ÞÃÊ be maintained to avoid development of resistance. Monitoring for Toxicity UÊÊ-iÀՓÊVÀi>̈˜ˆ˜iÊŜՏ`ÊLiʓi>ÃÕÀi`Ê>Ìʏi>ÃÌÊiÛiÀÞʜ̅iÀÊ`>Þʈ˜ˆÌˆ>Þ]Ê then weekly if patient’s renal function remains stable. UÊʈ“ˆÌi`Ê`>Ì>ÊÃÕ}}iÃÌÊ>Ê`ˆÀiVÌÊV>ÕÃ>ÊÀi>̈œ˜Ã…ˆ«ÊLiÌÜii˜Ê nephrotoxicity and higher serum trough concentrations (>15-20 mcg/ mL). Monitor Vancomycin trough levels (see above for frequency and indications). UÊÊœÀ“>Ê>Õ`ˆœœ}ÞÊÌiÃ̈˜}ʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê Vancomycin, unless signs and symptoms of ototoxicity became apparent. ,iviÀi˜ViÃ\  -
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“ÊÊi>Ì…‡-ÞÃÌÊ *…>À“°ÊÓää™ÆÊÈÈÆÊnÓ°Ê œÀÃiÊiÌÊ>°Ê
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}i˜ÌÃÊ …i“œÌ…iÀÊ£™nÇÆÊΣ\£Ç·ǰ 6>˜`iV>ÃÌiiiÊiÌÊ>°Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓ䣣ÆÊxÎ\£Ó{q™° >À̅ÊiÌÊ>°Êˆ`˜iÞʘÌÊ£™™ÈÆÊxä\™Ó™qÎÈ°

152

153

œÀ“>ÊÀi˜>Êv՘V̈œ˜\ CBC, BUN, Creatinine ÊÊÊÊ6>˜Vœ“ÞVˆ˜ÊiÛiÊqÊtrough (see dosing section p. 150) ˆ>ÞÈÃ\ Vancomycin level (see dosing section p. 150)

At each dialysis session

C. Antimicrobial therapy monitoring A

Weekly Weekly, unless change in creatinine ( xä¯ÊvÀœ“ÊL>Ãiˆ˜i®]Ê̅i˜ÊÌ܈ViÊÜiiŽÞÊ

,iviÀi˜Vi\Ê*À>V̈ViÊՈ`iˆ˜iÃÊvœÀÊ"ÕÌ«>̈i˜ÌÊ*>Ài˜ÌiÀ>Ê
˜Ìˆ“ˆVÀœLˆ>Ê/…iÀ>«Þ\Ê ˆ˜Ê˜viVÌÊ ˆÃÊÓää{ÆÊÎn\£Èx£°

Vancomycin

UÊÊœ˜}ÊÌiÀ“Ê`iw˜i`Ê>ÃÊ≥ 1 week, except for aminoglycosides and Amphotericin B (see below) UÊÊœÀÊÕÃiʜ˜Viʈ˜ˆÌˆ>Ê`œÃˆ˜}Ê>˜`ÊÃiÀՓʏiÛiÃʅ>ÛiÊLii˜ÊiÃÌ>LˆÃ…i` UÊÊ/…iÃiʓœ˜ˆÌœÀˆ˜}ÊÀiVœ““i˜`>̈œ˜ÃÊ>˜`ʓœ˜ˆÌœÀˆ˜}ÊvœÀÊ>}i˜ÌÃʘœÌʏˆÃÌi`ÊŜՏ`ÊLiʈ˜`ˆÛˆ`Õ>ˆâi`]ÊL>Ãi`ʜ˜Êi>V…Ê«>̈i˜Ì½ÃÊVˆ˜ˆV>Êvi>ÌÕÀiÃ]ʈ˜VÕ`ˆ˜}Ê}i˜iÀ>Ê…i>Ì…ÊÃÌ>ÌÕÃ]Ê>}i]Ê underlying conditions and organ dysfunction, concomitant medications, drug treatment history, type of infection, and type and dose of antibiotic Test Frequency Antimicrobial agent(s) Other CBC Weekly Aminoglycosides (Amikacin, Gentamicin, Clinical monitoring and patient education BUN, Creatinine Twice weekly Tobramycin, Streptomycin) for hearing/vestibular dysfunction at
“ˆ˜œ}ÞVœÃˆ`iʏiÛiÊqÊtrough Weekly each visit (see p. 149 for vestibular (see dosing section p. 145) (twice weekly, if increased risk) screening method) BUN, Creatinine, K, Mg, Phos Twice weekly Amphotericin B, AmBisome® CBC, AST, ALT £qÓÊÜiiŽÃÊ CBC, BUN, Creatinine Weekly -lactams (Aztreonam, carbapenems, cephalosporins, penicillins) add AST/ALT/bilirubin Weekly Oxacillin, Nafcillin, carbapenems add K Weekly Penicillin G potassium AST/ALT/bilirubin Weekly Micafungin BUN, Creatinine Weekly Colistin Clinical monitoring for neurotoxicity (twice weekly, if increased risk) (dizziness, paresthesia, vertigo, confusion, visual disturbances, ataxia) CBC, BUN, Creatinine , CPK Weekly Daptomycin Clinical monitoring for myopathy CBC Weekly Linezolid Clinical monitoring for peripheral neuropathy and optic neuritis CBC, AST/ALT/bilirubin Weekly Rifampin Drug interactions (monitor start of any new medications) CBC, AST/ALT/ bilirubin £ÊqÊÓÊÜiiŽÃ Voriconazole /Posaconazole Drug interactions (monitor start of any new medication), visual changes

Recommendations for monitoring patients receiving long-term antimicrobial therapy

°

When using an agent that is considered to be bioequivalent (no significant difference in rate and extent of absorption of the therapeutic ingredient) via the parenteral and oral route, the oral formulation is preferred if the patient does not have the contraindications listed below. Contraindications to oral therapy UÊ *"Ê­ˆ˜VÕ`ˆ˜}ʓi`ˆV>̈œ˜Ã®Ê UÊʘ>LˆˆÌÞÊ̜ÊÌ>Žiʜ̅iÀʜÀ>Ê“i`ˆV>̈œ˜ÃÊ",ʘœÌÊ̜iÀ>̈˜}Ê>ʏˆµÕˆ`Ê diet/tube feeds UÊi“œ`ޘ>“ˆVʈ˜ÃÌ>LˆˆÌÞÊ UÊ,iViˆÛˆ˜}ÊVœ˜Ìˆ˜ÕœÕÃÊ ÊÃÕV̈œ˜ˆ˜}Ê UÊÊ-iÛiÀiʘ>ÕÃi>]Êۜ“ˆÌˆ˜}]Ê`ˆ>ÀÀ…i>]ÊʜLÃÌÀÕV̈œ˜]Ê`ÞӜ̈ˆÌÞ]Ê mucositis UÊ
ʓ>>LÜÀ«Ìˆœ˜ÊÃޘ`Àœ“iÊ U A concomitant disease state that contraindicates the use of oral medications NOTE: There are only a limited number of agents that can be used orally for bacteremia or fungemia; these are noted in the table below. Bioavailability of oral antimicrobials





Antimicrobial % Oral absorption Should NOT be used orally for bacteremia
“œÝˆVˆˆ˜Ê Ç{ÊqÊ™ä¯ Amoxicillin/Clavulanate (Augmentin®®ÊÊÊ Ç{ÊqÊ™ä¯ Azithromycin*Ê ÎnÊqÊnί

i«…>i݈˜ÊÊ ™ä¯ Cefpodoxime*ÊÊ {£ÊqÊxä¯

ˆ˜`>“ÞVˆ˜ÊÊ ™ä¯ œÝÞVÞVˆ˜iÊ ™äÊqÊ£ää¯ /iÌÀ>VÞVˆ˜iÊÊ ÇxÊqÊnä¯ Can be used orally for bacteremia or fungemia Ciprofloxacin Ê ÈxÊqÊnx¯ Fluconazole >™ä¯ Linezolid†Ê £ää¯ iÌÀœ˜ˆ`>✏iÊ £ää¯ Moxifloxacin Ê ™ä¯ Trimethoprim/sulfamethoxazole†Ê £ää¯ Voriconazole‡¶Ê ÈäÊqʙȯ * Oral absorption is enhanced in presence of food † Should not be used for S. aureus bacteremia ‡ Oral absorption is decreased in presence of food ¶ Inter-patient variability œÊ˜œÌÊÕÃiÊ܈̅ÊVœ˜Ìˆ˜ÕœÕÃÊÌÕLiÊvii`ÃÊ­6Ê«ÀiviÀÀi`®°Ê*>̈i˜ÌÃÊ܈̅ÊVÞVˆVÊÌÕLiÊvii`Ã\Ê separate oral fluoroquinolone by 2 hours before and 6 hours after tube feeds.



D. Oral antimicrobial use A

Oral antimicrobial use in hospitalized patients

154

Dosing recommendations can vary according to indication and patientspecific parameters. All dosage adjustments are based on creatinine clearance calculated by Cockcroft-Gault equation. CrCl =

(140 – age) (weight in kg) x 0.85 (if female) 72 (serum creatinine*)

*

For patients with low muscle, some advocate using a minimum of 1 to avoid overestimation of CrCl.

† If patient is on hemodialysis (HD) schedule administration so that patient receives daily dose immediately AFTER dialysis. For assistance with dosage adjustments for patients receiving CVVHD or CVVHDF, please call pharmacy.

Drug

Typical dose (may vary)

CrCl (mL/min)

Dose adjustment for renal insufficiency


VÞVœÛˆÀÊ6ÊÊÊ Ê Ê Ê Acyclovir PO ­i˜ˆÌ>Ê…iÀ«iÃ®Ê Acyclovir PO ­iÀ«iÃÊ<œÃÌiÀ®ÊÊ Ê Amikacin

xq£äʓ}Ɏ}Ê+nÊ Ê Ê Ê 200 mg 5x daily Ê 800 mg 5x daily Ê Ê

€xäÊ ÓxqxäÊ £äqÓ{Ê † £äʜÀÊ Ê >10 £äÊ >25 £äqÓxÊ † £äʜÀÊ


“œÝˆVˆˆ˜Ê Ê Ê Amoxicillin ­«˜iՓœ˜ˆ>®Ê Ê
“œÝˆVˆˆ˜ÉÊ V>ÛՏ>˜>ÌiÊ Ê
“«…œÌiÀˆVˆ˜Ê Ê AmBisome®Ê
“«ˆVˆˆ˜Ê Ê Ê
“«ˆVˆˆ˜ÉÊ ÃՏL>VÌ>“Ê

xääq£äääʓ}Ê+£ÓÊ Ê Ê 1 g Q8H Ê Ê xääq£äääʓ}Ê+£ÓÊ Ê Ê ä°Çq£Ê“}Ɏ}Ê+Ó{Ê Îqxʓ}Ɏ}Ê+Ó{Ê £qÓÊ}Ê+{qÈÊÊ Ê Ê £°xqÎÊ}Ê+ÈÊ Ê

Ampicillin/ ÃՏL>VÌ>“Ê­vœÀÊ Acinetobacter, E. faecalis)
âˆÌ…Àœ“ÞVˆ˜Ê
âÌÀiœ˜>“ÊÊ Ê Ê

iv>✏ˆ˜Ê Ê Ê

3 g Q4H Ê

€ÎäÊ £äqÎäÊ † £äʜÀÊ Ê >30 £äqÎäÊ † £äʜÀÊ €ÎäÊ £äqÎäÊ † £äʜÀÊ qÊ qÊ €xäÊ £äqxäÊ † £äʜÀÊ Ê ≥ÎäÊ £xqÓ™Ê † ≤14 or HD Ê ≥50 £äqxäÊ † HD

xq£äʓ}Ɏ}Ê+n xq£äʓ}Ɏ}Ê+£Ó xq£äʓ}Ɏ}Ê+Ó{ Ó°xqxʓ}Ɏ}Ê+Ó{ 200 mg 5x daily Óääʓ}Ê+£ÓÊ 800 mg 5x daily nääʓ}Ê+n 800 mg Q12H See section on aminoglycoside dosing xääq£äääʓ}Ê+£Ó ÓxäqnÇxʓ}Ê+£Ó ÓxäqnÇxʓ}Ê+Ó{ 1g Q8H £}Ê+£Ó 1g Q24H xääq£äääʓ}Ê+£Ó Óxäqxääʓ}Ê+£Ó Óxäqxääʓ}Ê+Ó{ œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì £qÓÊ}Ê+{qÈ £qÓÊ}Ê+Èqn £qÓÊ}Ê+n £°xqÎÊ}Ê+È £°xqÎÊ}Ê+£Ó £°xqÎÊ}Ê+Ó{ 3 g Q4H ÎÊ}Ê+È 3 g Q8H

Óxäqxääʓ}Ê+Ó{Ê £qÓÊ}Ê+nÊÊ Ê Ê £qÓÊ}Ê+nÊ Ê Ê

qÊ ≥ÎäÊ £äqÓ™Ê † £äʜÀÊ Ê ≥ÎxÊ ££qÎ{Ê £äʜÀÊ † intermittent HD † HD

œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì £qÓÊ}Ê+nÊ £qÓÊ}Ê+£ÓÊ £qÓÊ}Ê+Ó{ £qÓÊ}Ê+n £Ê}Ê+£Ó £Ê}Ê+Ó{ 2 g Q HD, if HD in 2 days OR 3g Q HD, if HD in 3 days

155

E. Antimicrobial dosing in renal failure insufficiency A

Antimicrobial dosing in renal insufficiency

E. Antimicrobial dosing in renal failure insufficiency A

Drug

Typical dose (may vary)

CrCl (mL/min)

Dose adjustment for renal insufficiency

Cefdinir Ê

300 mg Q12H Ê

≥30 ÎäÊ HD† >60 ÎäqÈäÊ Ó™ÊœÀÊ † >60 ÎäqÈäÊ ££qÓ™Ê ££ÊœÀÊ † ≥ÎäÊ £äqÓ™Ê £äʜÀÊ † ≥ÎäÊ ÎäÊ HD†Ê

Ê Ê Ceftolozane/ Ì>âœL>VÌ>“Ê Ê Ê

600 mg Q12H Ê Ê Ê 600 mg Q8H Ê Ê Ê £qÓÊ}Ê+nÊ For PseudomonasÊ ÓÊ}Ê+nÊ Ê 1.5 g Q8H Ê Ê Ê

>50 ÎäqxäÊ £xqÓ™Ê £xʜÀÊ † >50 ÎäqxäÊ £xqÓ™Ê £xʜÀÊ † €xäÊ ÎäqxäÊ £xqÓ™Ê £xʜÀÊ † >50 ÎäqxäÊ £xqÓ™Ê † Ó™ÊœÀÊ

Ceftolozane/ Ì>âœL>VÌ>“Ê ­-iÀˆœÕÃʘviV̈œ˜Ã®Ê Ê

3 g Q8H Ê Ê Ê

>50 ÎäqxäÊ £xqÓ™Ê † ÉәʜÀÊ

ivÌÀˆ>ݜ˜iÊ

ivÌÀˆ>ݜ˜iÊÊ (Central nervous system infections) Cephalexin Ê Ê Cidofovir

£qÓÊ}Ê+Ó{Ê ÓÊ}Ê+£ÓÊ

qÊ qÊ

300 mg Q12H Î Ê ääʓ}Ê+Ó{ 300 mg QHD 1 g Q8H Ê£Ê}Ê+£Ó 1 g Q24H 2 g Q8H £Ê}Ê+nÊ £Ê}Ê+£Ó 1 g Q24H £qÓÊ}Ê+£Ó £qÓÊ}Ê+Ó{ 500 mg Q24H £ääq{ääʓ}Ê+£Ó £ääq{ääʓ}Ê+Ó{ Ê£ääq{ääʓ}Ê̅ÀiiÊ̈“iÃÉ week 600 mg Q12H {ääʓ}Ê+£Ó Îääʓ}Ê+£Ó 200 mg Q12H 600 mg Q8H {ääʓ}Ê+n Îääʓ}Ê+n 400 mg Q12H £qÓÊ}Ê+n £qÓÊ}Ê+£Ó £qÓÊ}Ê+Ó{ 1 g Q24H 1.5 g Q8H Çxäʓ}Ê+n ÎÇxʓ}Ê+n Load with 750 mg, then 150 mg Q8H 3 g Q8H £°xÊ}Ê+n Çxäʓ}Ê+n Load with 1.5 g, then 375 mg Q8H œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì

500 mg PO Q6H Ê Ê 5 mg/kg Q week for 2 weeks, then every other week {ääʓ}Ê+nq£ÓÊÊ Ê ÓxäqÇxäʓ}Ê+£ÓÊ Ê Óxäqxääʓ}Ê+£ÓÊ Ê *"\ÊÎääʓ}Ê+nÊ 6\ÊÈääʓ}Ê+nÊ 2.5 mg/kg Q12H Ê

>50 £äqxäÊ £äʜÀÊ † ≤55 or Cr>1.5

500 mg Q6H xääʓ}Ê+n 500 mg Q12H Not recommended

≥ÎäÊ ÎäʜÀÊ † ≥ÎäÊ ÎäʜÀÊ †Ê ≥ÎäÊ ÎäÊ qÊ Ê ≥50 ÓäqxäÊ ≤20 or HD†

{ääʓ}Ê+nq£ÓÊ 400 mg Q24H ÓxäqÇxäʓ}Ê+£Ó Óxäqxääʓ}Ê+Ó{ Óxäqxääʓ}Ê+£Ó Óxäqxääʓ}Ê+Ó{ œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì

Cefepime 1 g Q8H Ê Ê Ê Ê Cefepime 2 g Q8H ­ i˜ÌÀ>Ê˜iÀۜÕÃÊÊ Ê ÃÞÃÌi“ʈ˜viV̈œ˜ÃʜÀÊÊ Ê Pseudomonas®Ê Ê

ivœÌiÌ>˜Ê £qÓÊ}Ê+£ÓÊÊ Ê Ê Ê Ê

iv«œ`œÝˆ“iÊ £ääq{ääʓ}Ê+£ÓÊ Ê Ê Ceftaroline Ê Ê Ê Ceftaroline for ,-
Ê Ê Ê

ivÌ>âˆ`ˆ“iÊ

ˆ«ÀœyœÝ>Vˆ˜Ê6Ê Ê

ˆ«ÀœyœÝ>Vˆ˜Ê*"Ê Ê

>ÀˆÌ…Àœ“ÞVˆ˜Ê Ê

ˆ˜`>“ÞVˆ˜Ê Ê Colistin ­ œˆÃ̈“i̅>Ìi®Ê

156

2.5 mg/kg Q12H Ó°xʓ}Ɏ}Ê+Ó{ 1.25 mg/kg Q24H

Typical dose (may vary)

CrCl (mL/min)

Dose adjustment for renal insufficiency

>«Ìœ“ÞVˆ˜ÊÊ vœÀÊi˜`œV>À`ˆÌˆÃÉÊ bacteremia ˆVœÝ>Vˆˆ˜Ê œÝÞVÞVˆ˜iÊ Ertapenem Ê

̅>“LÕ̜Ê Ê

Èq£äʓ}Ɏ}Ê+Ó{ÊÊ Ê

ÕVœ˜>✏iÊ

Óääqnääʓ}Ê+Ó{Ê

≥ÎäÊ ÎäÊ HD†Ê qÊ qÊ ≥30 ÎäʜÀÊ † ≥10 £äÊ HD† ≥50

Ê Ê ÕVÞ̜ȘiÊ­xq ®Ê Ê Ê Ê Ganciclovir ­˜`ÕV̈œ˜Ê`œÃi®Ê Ê Ê Ê

Ê Ê £Ó°xqÓxʓ}Ɏ}Ê+ÈÊ Ê Ê Ê 5 mg/kg Q12H Ê Ê Ê Ê

xäʜÀÊ † ÊÊ €{äÊ Óäq{äÊ £äq£™Ê £äʜÀÊ †Ê ≥70 xäqÈ™Ê Óxq{™Ê £äqÓ{Ê £äʜÀÊ †

Ganciclovir ­>ˆ˜Ìi˜>˜ViÊÊ `œÃi®Ê Ê Ê

5 mg/kg Q24H Ê Ê Ê Ê

≥70 xäqÈ™Ê Óxq{™Ê £äqÓ{Ê £äʜÀÊ †

i˜Ì>“ˆVˆ˜Ê

qÊ

qÊ

ܘˆ>âˆ`Ê ˆ˜i✏ˆ`Ê Meropenem Ê Ê Ê Meropenem ­i˜ˆ˜}ˆÌˆÃ]Ê , ÊÊ ˆ˜viV̈œ˜Ã®ÊÊ Ê iÌÀœ˜ˆ`>✏iÊ ˆV>v՘}ˆ˜Ê œÝˆyœÝ>Vˆ˜Ê Nitrofurantoin (Macrobid®®Ê Oseltamivir ­/Ài>̓i˜Ì®Ê Ê Ê Oseltamivir ­*Àœ«…ޏ>ÝˆÃ®Ê Ê Ê "Ý>Vˆˆ˜Ê *i˜ˆVˆˆ˜ÊÊÊ Ê Ê

Îääʓ}Ê+Ó{Ê Èääʓ}Ê+£ÓÊ 1 g Q8H Ê Ê Ê 2 g Q8H Ê Ê Ê xääʓ}Ê+nÊ £ääq£xäʓ}Ê+Ó{Ê {ääʓ}Ê+Ó{ÊÊ 100 mg Q12H Ê 75 mg Q12H Ê Ê Ê 75 mg Q24H Ê Ê Ê £qÓÊ}Ê+{qÈÊÊ Îq{ʓˆˆœ˜Ê՘ˆÌÃÊ+{Ê Ê Ê

qÊ qÊ >51 ÓÈqxäÊ £äqÓxÊ £äʜÀÊ † >51 ÓÈqxäÊ £äqÓxÊ £äʜÀÊ † qÊ qÊ qÊ ≥50 xäÊ >60 ÎäqÈäÊ £äqÓ™Ê £äʜÀÊ † >60 ÎäqÈäÊ £äqÓ™Ê £äʜÀÊ † qÊ ≥xäÊ £äq{™Ê £äʜÀÊ †

Èq£äʓ}Ɏ}Ê+Ó{ Èq£äʓ}Ɏ}Ê+{n Èq£äʓ}Ɏ}Ê+{n œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì 1 g Q24H 500 mg Q24H Normal dose Q24H œÀ“>Ê`œÃiÊ+{n Normal dose QHD session Normal dose (e.g. 100, 400, 800 mg) Q24H Load w/normal dose, then xä¯ÊœvʘœÀ“>Ê`œÃiÊ+Ó{ £Ó°xqÓxʓ}Ɏ}Ê+È £Ó°xqÓxʓ}Ɏ}Ê+£Ó £Ó°xqÓxʓ}Ɏ}Ê+Ó{ £Ó°xqÓxʓ}Ɏ}Ê+Ó{q{n 5 mg/kg Q12H Ó°xʓ}Ɏ}Ê+£Ó Ó°xʓ}Ɏ}Ê+Ó{ £°Óxʓ}Ɏ}Ê+Ó{ 1.25 mg/kg three times/week, administer after HD 5 mg/kg Q24H Ó°xʓ}Ɏ}Ê+Ó{ £°Óxʓ}Ɏ}Ê+Ó{ ä°ÈÓxʓ}Ɏ}Ê+Ó{ 0.625 mg/kg three times/ week, administer after HD Ê iiÊÃiV̈œ˜Êœ˜Ê>“ˆ˜œ}ÞVœÃˆ`iÊ dosing œÊ`œÃ>}iÊ>`ÕÃ̓i˜ÌÊ œÊ`œÃ>}iÊ>`ÕÃ̓i˜ÌÊ 1 g Q8H £Ê}Ê+£Ó xääʓ}Ê+£Ó 500 mg Q24H 2 g Q8H £Ê}Ê+nÊ £Ê}Ê+£Ó 1 g Q24H œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì 100 mg Q12H œÌÊÀiVœ““i˜`i` 75 mg Q12H Çxʓ}Ê+Ó{ Îäʓ}Ê+Ó{ 30 mg QHD session 75 mg Q24H Îäʓ}Ê+Ó{ Îäʓ}Ê+{n 30 mg every other HD session œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì Îq{ʓˆˆœ˜Ê՘ˆÌÃÊ+{ £°xʓˆˆœ˜Ê՘ˆÌÃÊ+{ 1.5 million units Q6H

Óxäqxääʓ}Ê+ÈÊÊ £ääʓ}Ê+£ÓÊ 1 g Q24H Ê £xqÓxʓ}Ɏ}Ê+Ó{ÊÊ Ê

157

E. Antimicrobial dosing in renal failure insufficiency A

Drug

E. Antimicrobial dosing in renal failure insufficiency A

Drug

Typical dose (may vary)

CrCl (mL/min)

Dose adjustment for renal insufficiency

*ˆ«iÀ>Vˆˆ˜ÉÊ tazobactam Ê

ΰÎÇxq{°xÊ}Ê+ÈÊ

€{äÊ

ÊÊ

Óäq{äÊ

Ê

Ê

ÓäÊÊ

qÊ

Î Ê °ÎÇxÊ}Ê+ÈÊ­{°xÊ}Ê+È for Pseudomonas) Ó Ê °ÓxÊ}Ê+ÈʭΰÎÇxÊ}Ê+ÈÊvœÀÊ Pseudomonas) Ó Ê °ÓxÊ}Ê+nÊ­Ó°ÓxÊ}Ê+ÈÊvœÀÊ Pseudomonas) 2.25 g Q12H (2.25 g Q8H for Pseudomonas) œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì

≥£äÊ £äÊ HD†Ê qÊ

£xqÎäʓ}Ɏ}Ê+Ó{ £ÓqÓäʓ}Ɏ}Ê+Ó{ ÓxqÎäʓ}Ɏ}Ê+ ÊÃiÃȜ˜ œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì

HD† *œÃ>Vœ˜>✏iÊ *ÞÀ>∘>“ˆ`iÊ Ê +Ո˜Õ«ÀˆÃ̈˜ÉÊ dalfopristin ,ˆv>“«ˆ˜Ê­/ ®Ê ,ˆv>“«ˆ˜Ê /ˆ}iVÞVˆ˜iÊ /*É-8ÊÊ ­1/ÃʜÀÊViÕˆÌˆÃ®Ê Ê Ê /*É-8ÊÊÊ ­* *ʜÀÊÃiÀˆœÕÃÊÊ systemic infections) 6>>VÞVœÛˆÀÊ ­i˜ˆÌ>Ê…iÀ«iÃ®Ê Ê Valacyclovir ­iÀ«iÃÊ<œÃÌiÀ®Ê Ê Ê Valganciclovir ­˜`ÕV̈œ˜Ê`œÃi®Ê Ê Ê Ê Valganciclovir ­>ˆ˜Ìi˜>˜ViÊ`œÃi®Ê Ê Ê Ê 6>˜Vœ“ÞVˆ˜Ê 6œÀˆVœ˜>✏iÊ

†

-iiÊ*œÃ>Vœ˜>✏iÊ guidelines p. 18 £xqÎäʓ}Ɏ}Ê+Ó{Ê Ê Ç°xʓ}Ɏ}Ê+nÊÊ Èääʓ}Ê+Ó{Ê Îääʓ}Ê+nq£ÓÊ £ääʓ}ʜ˜Vi]Ê̅i˜ÊÊ 50 mg Q12H *"\Ê£qÓÊ -ÊÌ>LÊ+£ÓÊ 6\Ê£ÈäqÎÓäʓ}Ê+£ÓÊ ­ œÃˆ˜}ʈÃÊL>Ãi`ʜ˜ÊÊ /*ÊVœ“«œ˜i˜Ì®Ê xʓ}Ɏ}Ê+ÈqnÊ Ê xääq£äääʓ}Ê+£ÓÊ Ê Ê 1 g Q8H Ê Ê Ê 900 mg Q12H Ê Ê Ê Ê 900 mg Q24H Ê Ê Ê Ê qÊ -iiÊ6œÀˆVœ˜>✏iÊÊ guidelines p. 19

qÊ qÊ qÊ ≥ÎäÊ Ê † ÎäʜÀÊ Ê Ê ≥ÎäÊ ÎäÊ HD† ≥ÎäÊ £äqÓ™Ê £äʜÀÊ † ≥50 Îäq{™Ê £äqÓ™Ê £äʜÀÊ † ≥60 {äqx™Ê ÓxqÎ™Ê £äqÓ{ £äʜÀÊ † ≥60 {äqx™Ê ÓxqÎ™Ê £äqÓ{ £äʜÀÊ † qÊ qÊ

œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ì £qÓÊ -ÊÌ>LÊ+£ÓʜÀÊ £ÈäqÎÓäʓ}Ê6Ê+£ÓÊÊ £qÓÊ -ÊÌ>LÊ+Ó{ʜÀ £ÈäqÎÓäʓ}Ê6Ê+Ó{ xʓ}Ɏ}Ê+ÈqnÊ Ó°xʓ}Ɏ}Ê+Èqn 2.5 mg/kg Q8H xääq£äääʓ}Ê+£Ó xääq£äääʓ}Ê+Ó{ 500 mg Q24H 1 g Q8H £Ê}Ê+£Ó £Ê}Ê+Ó{ 500 mg Q24H 900 mg Q12H {xäʓ}Ê+£Ó {xäʓ}Ê+Ó{ 450 mg Q48H Not recommended 900 mg Q24H {xäʓ}Ê+Ó{ {xäʓ}Ê+{n 450 mg twice weekly Not recommended Ê-iiÊÃiV̈œ˜Êœ˜ÊÛ>˜Vœ“ÞVˆ˜Ê dosing œÊ`œÃ>}iÊ>`ÕÃ̓i˜Ìʈà necessary for PO. IV should not be administered to patients with CrCl ≤50 mL/min due to accumulation of the vehicle.

If patient is on hemodialysis (HD) schedule administration so that patient receives daily dose immediately AFTER dialysis. For assistance with dosage adjustments for patients receiving CVVHD or CVVHDF, please call pharmacy.

158

H
H Abdominal infections Biliary tract infections ..... 39-40 Diverticulitis ......................... 40 Pancreatitis .................... 41-42 Peritonitis, peritoneal dialysis-related .................. 45 Peritonitis/GI perforation . 42-45 SBP .............................. 42-43 Acute bacterial rhinosinusitis................... 78-79 Allergy, penicillin ................... 137 Anaerobes......................... 24-25 Amikacin See Aminoglycosides Aminoglycosides Gram-negative infection dosing ...............................146 Gram-positive synergy dosing ............................ 148 Mycobacterial infection dosing ............................ 147 SICU/WICU dosing ............. 148 UTI dosing ......................... 147 Amphotericin B, lipid ............... 16 Antibiotic lock therapy............. 63 Antibiogram....................... 37-38 Antimicrobial dosing Aminoglycosides See Aminoglycosides CNS infections ..................... 73 Renal insufficiency....... 155-158 Surgical prophylaxis .... 121-124 Vancomycin See Vancomycin Aspergillosis ......................... 133 Aspiration pneumonia........ 84, 88 Azole drug interactions ...... 21-22

Biliary tract infections......... 39-40 Bloodstream infections Catheter-related .............. 60-64 Candida ..................117, 134 Enterococcus spp. ............ 62 Gram-negative rods ........... 62 S. aureus.......................... 61 Staph, coagulase-negative . 61 Brain abscess ........................ 76 H H Candidemia ....................117-118 Candidiasis Hematologic patient .....134-136 Non-neutropenic host ...115-120 Candiduria ......................115-116 Catheter-related bloodstream infections.....60-64 Cellulitis..........................100-101 Ceftaroline.................................8 Ceftolozane/tazobactam.........8-9 Central nervous system (CNS) infections Antibiotic dosing ...................77 Brain abscess..................76-77 Encephalitis ..........................75 Meningitis ........................73-75 Shunt infection .................76-77 Cholangitis .........................39-40 Cholecystitis .......................39-40 Clostridium difficile infections.........................47-50 Colistin .................................9-10 Communicable diseases, reporting ............................140 Community-acquired pneumonia Empiric therapy ...............83-84 Pathogen-specific therapy . 85-86 COPD exacerbations................82 Cost of antimicrobials .....159-160 Cystic fibrosis.....................91-92

H H

H H

Bacterial vaginosis.................. 57

Daptomycin ....................... 10-11 161

10. Index A

Index

10. Index

Diarrhea ............................ 51-53 Diabetic foot infections.................... 103-105 Diverticulitis ............................ 40 Dosing, antimicrobials See Antimicrobial dosing H H Encephalitis ............................ 75 Endocarditis ...................... 65-70 Treatment Culture-negative ................ 68 Diagnosis .................... 69-70 Fungal ..................... 119-120 Pathogen-specific therapy ..................... 65-69 Prosthetic valve ........... 68-69 Prophylaxis ........................ 125 Endomyometritis .................... 56 Epidural abscess ........... 108-109 Ertapenem ............................. 11 HH Febrile neutropenia ........ 129-130 Formulary................................. 7 Fosfomycin ....................... 11-12 Fungal infections Candida spp ................ 115-120, 134-136 Filamentous fungi ........ 133-134 Prophylaxis, SICU/WICU ..... 120 Fusarium .............................. 133 HH Gentamicin See Aminoglycosides GI perforation ......................... 45 Gonococcal urethritis, cervicitis, proctitis........... 57-58 Gynecologic infections Endomyometritis.................. 56 Pelvic inflammatory disease ............................ 56 162

HH Healthcare-acquired pneumonia (not VAP) .........................87-88 H. pylori infection ................54-55 HH ICD infection ...................... 71-72 ID approval Antimicrobials ........................ 7 Pager .................................... 6 Infection control............. 139-144 Infectious diarrhea ............. 51-53 Influenza............................ 93-94 Isolation precautions ............. 141 HH Linezolid.............................12-13 Long-term antimicrobial therapy...............................153 HH Meningitis, bacterial ............73-75 Antimicrobial dosing..............77 Empiric therapy ....................73 Pathogen-specific therapy .....74 MDR Gram-negative organisms .......................28-30 Micafungin..........................17-18 Microbiology.......................31-35 MRSA Decolonization .............102-103 Soft-tissue infections ....100-101 Surveillance .................142-143 H H Necrotizing fasciitis ....... 107-108 Neutropenic fever .......... 129-130 Nosocomial pneumonia...... 87-88 H"H Oncology Neutropenic fever ........129-130

H*H P. acnes infection ...............25-26 Pacemaker infection ...........71-72 Pancreatitis ........................41-42 Parasites.................................53 Pelvic inflammatory disease .....56 Penicillin allergy .....................137 Peritonitis/GI perforation .....42-45 Peritoneal dialysis-related ......45 Spontaneous bacterial .....42-43 Post-op / post-procedure infections ..................105-107 Pneumonia Community-acquired ........83-84 Healthcare-acquired .........87-88 Ventilator-associated ........88-90 Pneumococcal vaccine ............23 Posaconazole .....................18-19 Pre-operative prophlyaxis.121-124 Price of antimicrobials ....159-160 Prophylactic use of antimicrobials Endocarditis .......................125 Fluconazole in ICUs .............120 Hematologic malignancy................ 131-132 Pre-op / pre-procedure 121-124 Solid organ ..................126-128 H,H Renal insufficiency Antimicrobial dosing.....155-158 Reported diseases.................140 Resistant Gram-negative infections.........................28-30 Respiratory viruses .............93-94 Restricted antimicrobials ............7 H-H SBP ...................................42-43

Sepsis.....................................99 Sexually transmitted diseases..........................57-59 Shunt infection....................76-77 Sinusitis .............................78-79 Skin, soft-tissue and bone infections Cellulitis .......................100-101 Cutaneous abscess .....101-102 Diabetic foot infection ...................103-105 Necrotizing fasciitis......107-108 Post-op infections ........105-107 Recurrent MRSA ..........102-103 Surgical-site infections ..................105-107 Vertebral osteomyelitis, diskitis, epidural abscess....................108-109 Streptococci ......................24-25 Surgical prophylaxis........121-124 Surgical-site infections ....105-107 Surveillance CRE ...................................142 MRSA ..........................142-143 VRE ....................................144 Susceptibility testing ...........31-32 Syphilis ..............................58-59 H/H Therapeutic monitoring Aminoglycosides..........145-149 Vancomycin .................150-152 Outpatient long-term antimicrobial therapy ........153 Tigecycline ..............................13 Tobramycin See Aminoglycosides Transplant Antimicrobial prophylaxis Hematologic malignancy ............. 131-132 Solid organ................ 126-128 163

10. Index

Oral antimicrobials .................154 Orbital cellulitis ...................80-81

10. Index

Trichomoniasis......................... 57 Trimethoprim/ sulfamethoxazole ..............14-15 Tuberculosis ........................95-98 H1H Urinary tract infections Bacterial Cystitis ........................... 110 Pyelonephritis ................. 111 Urosepsis ....................... 111 Catheter-related .......... 113-114 Fungal ........................ 115-116 H6H Vancomycin

164

Dosing ....................... 150-152 Monitoring .................. 151-152 Ventilator-associated pneumonia (VAP) ............. 88-90 Vertebral osteomyelitis, diskitis, epidural abscess ........ 108-109 Voriconazole ..................... 19-20 VRE Surveillance ................... 144 H7H Wound infections, post-op........................105-107

Important Phone Numbers THE JOHNS HOPKINS HOSPITAL

Antibiotic Approval: . . . . PING “JHH Antibiotic Approval Pager” Antimicrobial Stewardship Program: . . . . . . . . . . . . . . . . . . . . . . 7-4570 Infectious Diseases Consults: . . . . PING “JHH Infectious Diseases” Oncology/Transplant Service (Transplant ID) . . . . PING “Transplant/ Oncology Infectious Diseases” Adult Inpatient Pharmacy (Zayed 7000): . . . . . . . . . . . . . . . . . . . 5-6150 Critical Care and Surgery Pharmacy (Zayed 3121):. . . . . . . . . . . 5-6505 Weinberg Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-8998 Microbiology Lab: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6510 Hospital Epidemiology & Infection Control: . . . . . . . . . . . . . . . . 5-8384 HEIC Emergency Beeper: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3855 JOHNS HOPKINS BAYVIEW MEDICAL CENTER

Antibiotic Approval: . . . . . . . PING “Bayview Antibiotic Approval” Infectious Disease Consults:. . PING “Bayview Infectious Diseases” Bayview Inpatient Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-0958 Microbiology Lab: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6510 Hospital Epidemiology & Infection Control: . . . . . . . . . . . . . . . . . 0-0515

The Johns Hopkins Hospital Antimicrobial Stewardship Program Intranet: insidehopkinsmedicine.org/amp Internet: hopkinsmedicine.org/amp Osler 425 (443) 287-4570 (7-4570) © Copyright 2015 by The Johns Hopkins Hospital Antimicrobial Stewardship Program. All rights reserved. No part of this publication may be reproduced without permission in writing from The Johns Hopkins Hospital Antimicrobial Stewardship Program.

Cover art: Charlotte Ford Cosgrove, Line Drawing II 33, 2008.