Sanford Guide to Antimicrobial Therapy

220 Pages·2010·5.88 MB·English

by  David N. Gilbert

—TABLE OF CONTENTS—
ABBREVIATIONS..................................................................................................................................................2
TABLE 1A Clinical Approach to Initial Choice of Antimicrobial Therapy........................................................4
TABLE 2 Recommended Antimicrobial Agents Against Selected Bacteria..............................................62
TABLE 3 Suggested Duration of Antibiotic Therapy in Immunocompetent Patients..................................65
TABLE 4 Comparison of Antibacterial Spectra............................................................................................66
TABLE 5 Treatment Options for Selected Highly Resistant Bacteria.......................................................72
TABLE 6 Suggested Management of Suspected or Culture-Positive Community-Associated
Methicillin-Resistant S. Aureus (CA-MRSA) Infections........................................................74
TABLE 7 Methods for Drug Desensitization..............................................................................................76
TABLE 8 Risk Categories of Antimicrobics in Pregnancy........................................................................77
TABLE 9A Selected Pharmacologic Features of Antimicrobial Agents......................................................78
9B Pharmacodynamics of Antibacterials......................................................................................83
TABLE 10A Selected Antibacterial Agents—Adverse Reactions—Overview................................................84
10B Antimicrobial Agents Associated with Photosensitivity..............................................................88
10C Antibiotic Dosage and Side-Effects.........................................................................................89
10D Aminoglycoside Once-Daily and Multiple Daily Dosing Regimens.....................................97
TABLE 11A Treatment of Fungal Infections—Antimicrobial Agents of Choice...........................................98
11B Antifungal Drugs: Dosage, Adverse Effects, Comments.........................................................112
11C At A Glance Summary of Suggested Antifungal Drugs Against
Treatable Pathogenic Fungi....................................................................................................115
TABLE 12A Treatment of Mycobacterial Infections....................................................................................116
12B Dosage and Adverse Effects of Antimycobacterial Drugs.........................................................126
TABLE 13A Treatment of Parasitic Infections.............................................................................................129
13B Dosage and Selected Adverse Effects of Antiparasitic Drugs...................................................139
13C Parasites that Cause Eosinophilia (Eosinophilia In Travelers).............................................142
TABLE 14A Antiviral Therapy (Non-HIV)......................................................................................................143
14B Antiviral Drugs (Non-HIV).........................................................................................................155
14C At A Glance Summary of Suggested Antiviral Agents
Against Treatable Pathogenic Viruses..................................................................................160
14D Antiretroviral Therapy in Treatment-Naïve Adults (HIV/AIDS).............................................161
14E Antiretroviral Drugs and Adverse Effects (HIV/AIDS)...............................................................171
TABLE 15A Antimicrobial Prophylaxis for Selected Bacterial Infections....................................................174
15B Surgical Antibiotic Prophylaxis..............................................................................................175
15C Antimicrobial Prophylaxis for the Prevention of Bacterial Endocarditis in Patients with
Underlying Cardiac Conditions...................................................................................................179
15D Management of Exposure to HIV-1 and Hepatitis B and C...................................................180
15E Prevention of Opportunistic Infection in Human Stem Cell Transplantation (HSCT)
or Solid Organ Transplantation (SOT) for Adults with Normal Renal Function...........................183
TABLE 16 Pediatric Dosages of Selected Antibacterial Agents................................................................185
TABLE 17A Dosages of Antimicrobial Drugs in Adult Patients with Renal Impairment...............................186
17B No Dosage Adjustment with Renal Insufficiency by Category.................................................194
TABLE 18 Antimicrobials and Hepatic Disease: Dosage Adjustment.......................................................194
TABLE 19 Treatment of CAPD Peritonitis in Adults...................................................................................194
TABLE 20A Recommended Childhood and Adolescent Immunization Schedule in The United States....195
20B Adult Immunization In The United States.................................................................................196
20C Anti-Tetanus Prophylaxis, Wound Classification, Immunization................................................198
20D Rabies Post-Exposure Prophylaxis........................................................................................199
TABLE 21 Selected Directory of Resources.............................................................................................200
TABLE 22A Anti-Infective Drug-Drug Interactions.......................................................................................201
22B Drug-Drug Interactions Between Non-Nucleoside Reverse Transcriptase Inhibitors
(NNRTIS) and Protease Inhibitors.........................................................................................208
TABLE 23 List of Generic and Common Trade Names.............................................................................209
INDEX OF MAJOR ENTITIES..........................................................................................................................211

1
ABBREVIATIONS
3TC = lamivudine CXR = chest x-ray IDSA = Infectious Diseases Society of America
AB,% = percent absorbed d4T = stavudine IDV = indinavir
ABC = abacavir Dapto = daptomycin IFN = interferon
ABCD = amphotericin B colloidal dispersion DBPCT = double-blind placebo-controlled trial IMP = imipenem-cilastatin
ABLC = ampho B lipid complex dc = discontinue INH = isoniazid
ACIP = Advisory Committee on Immunization Practices ddC = zalcitabine Inv = investigational
AD = after dialysis ddI = didanosine IP = intraperitoneal
ADF = adefovir DIC = disseminated intravascular coagulation IT = intrathecal
AG = aminoglycoside div. = divided Itra = itraconazole
AIDS = Acquired Immune Deficiency Syndrome DLV = delavirdine IVDU = intravenous drug user
AM-CL = amoxicillin-clavulanate Dori = doripenem IVIG = intravenous immune globulin
AM-CL-ER = amoxicillin-clavulanate extended release DOT = directly observed therapy Keto = ketoconazole
AMK = amikacin DOT group = B. distasonis, B. ovatus, B. thetaiotaomicron LAB = liposomal ampho B
Amox = amoxicillin Doxy = doxycycline LCM = lymphocytic choriomeningitis virus
AMP = ampicillin DRSP = drug-resistant S. pneumoniae LCR = ligase chain reaction
Ampho B = amphotericin B DS = double strength Levo = levofloxacin
AM-SB = ampicillin-sulbactam EBV = Epstein-Barr virus LP/R = lopinavir/ ritonavir
AP = atovaquone proguanil EES = erythromycin ethyl succinate M. Tbc = Mycobacterium tuberculosis
AP Pen = antipseudomonal penicillins EFZ = efavirenz Macrolides = azithro, clarithro, dirithro, erythro, roxithro
APAG = antipseudomonal aminoglycoside (tobra, gent, amikacin) ENT = entecavir mcg = microgram
ARDS = acute respiratory distress syndrome ERTA = ertapenem MER = meropenem
ARF = acute rheumatic fever Erythro = erythromycin Metro = metronidazole
ASA = aspirin ESBLs = extended spectrum β-lactamases mg = milligram
ATS = American Thoracic Society ESR = erythrocyte sedimentation rate Mino = minocycline
ATV = atazanavir ESRD = endstage renal disease Moxi = moxifloxacin
AUC = area under the curve ETB = ethambutol MQ = mefloquine
Azithro = azithromycin Flu = fluconazole MSSA/MRSA = methicillin-sensitive/resistant S. aureus
bid = twice a day Flucyt = flucytosine NB = name brand
BL/BLI = beta-lactam/beta-lactamase inhibitor FOS-APV = fosamprenavir NF = nitrofurantoin
BW = body weight FQ = fluoroquinolone (CIP, Oflox, Lome, Peflox, Levo, NAI = not FDA-approved indication
C&S = culture & sensitivity Gati, Moxi, Gemi) NFR = nelfinavir
CAPD = continuous ambulatory peritoneal dialysis FTC = emtricitabine NNRTI = non-nucleoside reverse transcriptase inhibitor
CARB = carbapenems (DORI, ERTA, IMP, MER) G = generic NRTI = nucleoside reverse transcriptase inhibitor
CDC = Centers for Disease Control GAS = Group A Strep NSAIDs = non-steroidal
Cefpodox = cefpodoxime proxetil Gati = gatifloxacin NUS = not available in the U.S.
Ceftaz = ceftazidime GC = gonorrhea NVP = nevirapine
Ceph= cephalosporin Gemi = gemifloxacin O Ceph 1,2,3 = oral cephalosporins—see Table 10C
CFB = ceftobiprole Gent = gentamicin Oflox = ofloxacin
CFP = cefepime gm = gram P Ceph 1,2,3,4 = parenteral cephalosporins—see Table 10C
Chloro = chloramphenicol GNB = gram-negative bacilli P Ceph 3 AP = parenteral cephalosporins with antipseudomonal
CIP = ciprofloxacin; CIP-ER = CIP extended release Griseo = griseofulvin activity—see Table 10C
Clarithro = clarithromycin; ER = extended release HEMO = hemodialysis PCR = polymerase chain reaction
Clav = clavulanate HHV = human herpesvirus PEP = post-exposure prophylaxis
Clinda = clindamycin HIV = human immunodeficiency virus PI = protease inhibitor
CLO = clofazimine HLR = high-level resistance PIP = piperacillin
Clot = clotrimazole H/O = history of PIP-TZ = piperacillin-tazobactam
CMV = cytomegalovirus HSCT = hematopoietic stem cell transplant po = per os (by mouth)
CQ = chloroquine phosphate HSV = herpes simplex virus PQ = primaquine
CrCl = creatinine clearance IA = injectable agent/anti-inflammatory drugs PRCT = Prospective randomized controlled trials
CRRT = continuous renal replacement therapy ICAAC = International Conference on Antimicrobial PTLD = post-transplant lymphoproliferative disease
CSD = cat-scratch disease Agents & Chemotherapy Pts = patients
CSF = cerebrospinal fluid
2
ABBREVIATIONS (2)

SA = Staph. aureus Tetra = tetracycline
Pyri = pyrimethamine SD = serum drug level after single dose Ticar = ticarcillin
PZA = pyrazinamide Sens = sensitive (susceptible) tid = 3 times a day
qid = 4 times a day SM = streptomycin TMP-SMX = trimethoprim-sulfamethoxazole
QS = quinine sulfate SQV = saquinavir TNF = tumor necrosis factor
Quinu-dalfo = Q-D = quinupristin-dalfopristin Tobra = tobramycin
SS = steady state serum level
R = resistant TPV = tipranavir
STD = sexually transmitted disease
RFB = rifabutin TST = tuberculin skin test
subcut = subcutaneous
RFP = rifapentine UTI = urinary tract infection
Sulb = sulbactam
Rick = Rickettsia Vanco = vancomycin
Tazo = tazobactam
RIF = rifampin VISA = vancomycin intermediately resistant S. aureus
TBc = tuberculosis
RSV = respiratory syncytial virus VL = viral load
TC-CL = ticarcillin-clavulanate
RTI = respiratory tract infection Vori = voriconazole
TDF = tenofovir
RTV = ritonavir VZV = varicella-zoster virus
TEE = transesophageal echocardiography
rx = treatment WHO = World Health Organization
Teico = teicoplanin
S = potential synergy in combination with penicillin, ZDV = zidovudine
Telithro = telithromycin
AMP, vanco, teico

ABBREVIATIONS OF JOURNAL TITLES

AAC: Antimicrobial Agents & Chemotherapy COID: Current Opinion in Infectious Disease JAC: Journal of Antimicrobial Chemotherapy
Adv PID: Advances in Pediatric Infectious Diseases Curr Med Res Opin: Current Medical Research and Opinion JACC: Journal of American College of Cardiology
AHJ: American Heart Journal Derm Ther: Dermatologic Therapy JAIDS: JAIDS Journal of Acquired Immune Deficiency Syndromes
AIDS Res Hum Retrovir: AIDS Research & Human Retroviruses Dermatol Clin: Dermatologic Clinics JAMA: Journal of the American Medical Association
AJG: American Journal of Gastroenterology Dig Dis Sci: Digestive Diseases and Sciences JAVMA: Journal of the Veterinary Medicine Association
AJM: American Journal of Medicine DMID: Diagnostic Microbiology and Infectious Disease JCI: Journal of Clinical Investigation
AJRCCM: American Journal of Respiratory Critical Care Medicine EID: Emerging Infectious Diseases JCM: Journal of Clinical Microbiology
AJTMH: American Journal of Tropical Medicine & Hygiene EJCMID: European Journal of Clin. Micro. & Infectious Diseases JIC: Journal of Infection and Chemotherapy
Aliment Pharmacol Ther: Alimentary Pharmacology & Therapeutics Eur J Neurol: European Journal of Neurology JID: Journal of Infectious Diseases
Am J Hlth Pharm: American Journal of Health-System Pharmacy Exp Mol Path: Experimental & Molecular Pathology JNS: Journal of Neurosurgery
Amer J Transpl: American Journal of Transplantation Exp Rev Anti Infect Ther: Expert Review of Anti-Infective Therapy JTMH: Journal of Tropical Medicine and Hygiene
AnEM: Annals of Emergency Medicine Gastro: Gastroenterology Ln: Lancet
AnIM: Annals of Internal Medicine Hpt: Hepatology LnID: Lancet Infectious Disease
AnPharmacother: Annals of Pharmacotherapy ICHE: Infection Control and Hospital Epidemiology Mayo Clin Proc: Mayo Clinic Proceedings
AnSurg: Annals of Surgery IDC No. Amer: Infectious Disease Clinics of North America Med Lett: Medical Letter
Antivir Ther: Antiviral Therapy IDCP: Infectious Diseases in Clinical Practice Med Mycol: Medical Mycology
ArDerm: Archives of Dermatology IJAA: International Journal of Antimicrobial Agents MMWR: Morbidity & Mortality Weekly Report
ArIM: Archives of Internal Medicine Inf Med: Infections in Medicine NEJM: New England Journal of Medicine
ARRD: American Review of Respiratory Disease J AIDS & HR: Journal of AIDS and Human Retrovirology Neph Dial Transpl: Nephrology Dialysis Transplantation
BMJ: British Medical Journal J All Clin Immun: Journal of Allergy and Clinical Immunology Ped Ann: Pediatric Annals
BMTr: Bone Marrow Transplantation J Am Ger Soc: Journal of the American Geriatrics Society Peds: Pediatrics
Brit J Derm: British Journal of Dermatology J Chemother: Journal of Chemotherapy Pharmacother: Pharmacotherapy
Can JID: Canadian Journal of Infectious Diseases J Clin Micro: Journal of Clinical Microbiology PIDJ: Pediatric Infectious Disease Journal
Canad Med J: Canadian Medical Journal J Clin Virol: Journal of Clinical Virology QJM: Quarterly Journal of Medicine
CCM: Critical Care Medicine J Derm Treat: Journal of Dermatological Treatment Scand J Inf Dis: Scandinavian Journal of Infectious Diseases
CCTID: Current Clinical Topics in Infectious Disease J Hpt: Journal of Hepatology Sem Resp Inf: Seminars in Respiratory Infections
CDBSR: Cochrane Database of Systematic Reviews J Inf: Journal of Infection SGO: Surgery Gynecology and Obstetrics
CID: Clinical Infectious Diseases J Med Micro: Journal of Medical Microbiology SMJ: Southern Medical Journal
Clin Micro Inf: Clinical Microbiology and Infection J Micro Immunol Inf: Journal of Microbiology, Immunology, Surg Neurol: Surgical Neurology
CMN: Clinical Microbiology Newsletter & Infection Transpl Inf Dis: Transplant Infectious Diseases
Clin Micro Rev: Clinical Microbiology Reviews J Ped: Journal of Pediatrics Transpl: Transplantation
CMAJ: Canadian Medical Association Journal J Viral Hep: Journal of Viral Hepatitis TRSM: Transactions of the Royal Society of Medicine
3
TABLE 1A – CLINICAL APPROACH TO INITIAL CHOICE OF ANTIMICROBIAL THERAPY*
Treatment based on presumed site or type of infection. In selected instances, treatment and prophylaxis based on identification of pathogens.
Regimens should be reevaluated based on pathogen isolated, antimicrobial susceptibility determination, and individual host characteristics. (Abbreviations on page 2)
ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES
MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVE§ AND COMMENTS
ABDOMEN: See Peritoneum, page 43; Gallbladder, page 15; and Pelvic Inflammatory Disease, page 23
BONE: Osteomyelitis. Microbiologic diagnosis is essential. If blood culture negative, need culture of bone. Culture of sinus tract drainage not predictive of bone culture. Review: Ln 364:369, 2004.
For comprehensive review of antimicrobial penetration into bone, see Clinical Pharmacokinetics 48:89, 2009.
Hematogenous Osteomyelitis
Empiric therapy—Collect bone and blood cultures before empiric therapy
Newborn (<4 mos.) S. aureus, Gm-neg. bacilli, MRSA possible: Vanco+ MRSA unlikely: (Nafcillin or Table 16 for dose. Severe allergy or toxicity: (LinezolidNAI 10 mg/kg IV/po q8h
See Table 16 for dose Group B strep (Ceftaz 2 gm IV q8h or CFP oxacillin) + (Ceftaz or CFP) + aztreonam). Could substitute clindamycin for linezolid.
2 gm IV q12h)
Children (>4 mos.)—Adult: S. aureus, Group A strep, MRSA possible: Vanco MRSA unlikely: Nafcillin or Severe allergy or toxicity: Clinda or TMP-SMX or linezolidNAI.
Osteo of extremity Gm-neg. bacilli rare oxacillin Adults: ceftaz 2 gm IV q8h, CFP 2 gm IV q12h.
Peds dosages in Table 16. See Table 10 for adverse reactions to drugs.
Add Ceftaz or CFP if Gm-neg. bacilli on Gram stain (Adult
doses below. Peds Doses: Table 16
Adult (>21 yrs) S. aureus most common but MRSA possible: Vanco MRSA unlikely: Nafcillin or Dx: MRI early to look for epidural abscess.
Vertebral osteo ± epidural variety other organisms. 1 gm IV q12h; if over oxacillin 2 gm IV q4h Allergy or toxicity: TMP-SMX 8–10 mg/kg per day div. IV q8h or linezolid
abscess; other sites Blood & bone cultures 100 kg, 1.5 gm IV q12h 600 mg IV/po q12h (AnIM 138:135, 2003)NAI. See MRSA specific therapy
(NEJM 355:2012, 2006) essential. comment. Epidural abscess ref.: ArIM 164:2409, 2004.
Specific therapy—Culture and in vitro susceptibility results known
MSSA Nafcillin or oxacillin Vanco 1 gm q12h IV; if over Other options if susceptible in vitro and allergy/toxicity issues:
2 gm IV q4h or cefazolin 100 kg, 1.5 gm IV q12h 1) TMP/SMX 8-10 mg/kg/d IV div q8h. Minimal data on treatment of
2 gm IV q8h osteomyelitis; 2) Clinda 600-900 mg IV q8h – have lab check for inducible
resistance especially if erythro resistant (CID 40:280,2005); 3) [(Cip 750 mg
MRSA—See Table 6, Vanco 1 gm IV q12h Linezolid 600 mg q12h IV/po
page 74 ± RIF 300 mg po/IV bid po bid or levo 750 mg po q24h) + rif 300 mg po bid]; 4) Daptomycin
6 mg/kg IV q24h; –clinical failure secondary to resistance reported (J Clin
Micro 44:595;2006); 5) Linezolid 600 mg po/IV bid – anecdotal reports of
efficacy (J Chemother 17:643,2005), optic & peripheral neuropathy with
long-term use (Neurology 64:926, 2005); 6) Fusidic acid NUS 500 mg IV q8h
+ rif 300 mg po bid. (CID 42:394, 2006).
Hemoglobinopathy: Salmonella; other Gm-neg. CIP 400 mg IV q12h Levo 750 mg IV q24h Thalassemia: transfusion and iron chelation risk factors.
Sickle cell/thalassemia bacilli
Contiguous Osteomyelitis Without Vascular Insufficiency
Empiric therapy: Get cultures!
Foot bone osteo due to nail P. aeruginosa CIP 750 mg po bid or Levo Ceftaz 2 gm IV q8h or CFP See Skin—Nail puncture, page 52. Need debridement to remove foreign body.
through tennis shoe 750 mg po q24h 2 gm IV q12h
Long bone, post-internal fixation S. aureus, Gm-neg. bacilli, Vanco 1 gm IV q12h + Linezolid 600 mg IV/po bidNAI Often necessary to remove hardware to allow bone union. May need revascularization.
of fracture P. aeruginosa [ceftaz or CFP]. + (ceftaz or CFP). Regimens listed are empiric. Adjust after culture data available. If
See Comment See Comment susceptible Gm-neg. bacillus, CIP 750 mg po bid or Levo 750 mg po q24h.
For other S. aureus options: See Hem. Osteo. Specific Therapy, page 4).

* DOSAGES SUGGESTED are for adults (unless otherwise indicated) with clinically severe (often life-threatening infections. Dosages also assume normal renal function, and not severe hepatic dysfunction.
§ ALTERNATIVE THERAPY INCLUDES these considerations: allergy, pharmacology/pharmacokinetics, compliance, costs, local resistance profiles.
4
TABLE 1A (2)
ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES
MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVE§ AND COMMENTS
BONE/Contiguous Osteomyelitis Without Vascular Insufficiency/Empiric therapy (continued)
Osteonecrosis of the jaw Probably rare adverse Infection is secondary to bone necrosis and loss of overlying mucosa.
reaction to bisphosphonates Treatment: minimal surgical debridement, chlorohexidine rinses, antibiotics (e.g. PIP-TZ). NEJM 355:2278, 2006.
Prosthetic joint See prosthetic joint, page 29
Spinal implant infection S. aureus, Onset within 30 days Onset after 30 days remove For details: CID 44:913, 2007.
coag-neg staphylococci, culture, treat & then implant, culture & treat
gram-neg bacilli suppress until fusion occurs
Sternum, post-op S. aureus, S. epidermidis Vanco 1 gm IV q12h; if over Linezolid 600 mg po/IVNAI bid Sternal debridement for cultures & removal of necrotic bone.
100 kg, 1.5 gm IV q12h. For S. aureus options: Hem. Osteo. Specific Therapy, page 4.
Contiguous Osteomyelitis With Vascular Insufficiency. Ref.: CID S115–22, 2004
Most pts are diabetics with Polymicrobic [Gm+ cocci Debride overlying ulcer & submit bone for histology & Diagnosis of osteo: Culture bone biopsy (gold standard). Poor concordance
peripheral neuropathy & infected (to include MRSA) (aerobic culture. Select antibiotic based on culture results & treat of culture results between swab of ulcer and bone – need bone. (CID 42:57,
skin ulcers (see Diabetic foot, & anaerobic) and Gm-neg. for 6 weeks. No empiric therapy unless acutely ill. If 63, 2006). Sampling by needle puncture inferior to biopsy (CID 48:888, 2009).
page 14) bacilli (aerobic & anaerobic)] acutely ill, see suggestions, Diabetic foot, page 14. Osteo more likely if ulcer >2 cm2, positive probe to bone, ESR >70 &
Revascularize if possible. abnormal plain x-ray (JAMA 299:806, 2008).
Treatment: (1) Revascularize if possible; (2) Culture bone; (3) Specific
antimicrobial(s).
Chronic Osteomyelitis: S. aureus, Enterobacteria- Empiric rx not indicated. Base systemic rx on results of Important adjuncts: removal of orthopedic hardware, surgical debridement,
Specific therapy ceae, P. aeruginosa culture, sensitivity testing. If acute exacerbation of chronic vascularized muscle flaps, distraction osteogenesis (Ilizarov) techniques.
By definition, implies presence of osteo, rx as acute hematogenous osteo. Surgical Antibiotic-impregnated cement & hyperbaric oxygen adjunctive.
dead bone. Need valid cultures debridement important. NOTE: RIF + (vanco or β-lactam) effective in animal model and in a clinical
trial of S. aureus chronic osteo (SMJ 79:947, 1986).
BREAST: Mastitis—Obtain culture; need to know if MRSA present. Review with definitions: Ob & Gyn Clin No Amer 29:89, 2002
Postpartum mastitis
Mastitis without abscess S. aureus; less often NO MRSA: MRSA Possible: If no abscess, ↑ freq of nursing may hasten response; discuss age-specific
Ref.: JAMA 289:1609, 2003 S. pyogenes (Gp A or B), Outpatient: Dicloxacillin Outpatient: TMP-SMX-DS risks to infant of drug exposure through breast milk with pediatrician. Coryne-
E. coli, bacteroides species, 500 mg po qid or cepha- tabs 1-2 po bid or, if bacterium sp. assoc. with chronic granulomatous mastitis (CID 35:1434,
maybe Corynebacterium lexin 500 mg po qid. susceptible, clinda 300 mg 2002). Bartonella henselae infection reported (Ob & Gyn 95:1027, 2000).
sp., & selected coagulase- Inpatient: Nafcillin/oxacil- po qid
Mastitis with abscess With abscess, d/c nursing. I&D standard; needle aspiration reported
neg. staphylococci (e.g., lin 2 gm IV q4h Inpatient: Vanco 1 gm IV
successful (Am J Surg 182:117, 2001). Resume breast feeding from affected
S. lugdunensis) q12h; if over 100 kg, 1.5 gm
breast as soon as pain allows.
IV q12h.
Non-puerperal mastitis with abscess S. aureus; less often Bacter- See regimens for If subareolar & odoriferous, most likely anaerobes; need to add metro
oides sp., peptostreptococ- Postpartum mastitis, page 5. 500 mg IV/po tid. If not subareolar, staph. Need pretreatment
cus, & selected coagulase- aerobic/anaerobic cultures. Surgical drainage for abscess.
neg. staphylococci
Breast implant infection Acute: S. aureus, S. Acute: Vanco 1 gm Chronic: Await culture results. Lancet Infect Dis 5:94, 462, 2005. Coag-negative staph also common
pyogenes. TSS reported. IV q12h; if over 100 kg, See Table 12 for mycobacteria (Aesthetic Plastic Surg 31:325, 2007).
Chronic: Look for rapidly 1.5 gm q12h. treatment.
growing Mycobacteria
Abbreviations on page 2. NOTE: All dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. 5
TABLE 1A (3)
ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES
MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVE§ AND COMMENTS
CENTRAL NERVOUS SYSTEM
Brain abscess
Primary or contiguous source Streptococci (60–70%), bac- P Ceph 3 ([cefotaxime Pen G 3-4 million units IV q4h If CT scan suggests cerebritis or abscesses <2.5 cm and pt neurologically
Ref.: CID 25:763, 1997 teroides (20–40%), Entero- 2 gm IV q4h or ceftriaxone + metro 7.5 mg/kg q6h or stable and conscious, start antibiotics and observe. Otherwise, surgical drainage
bacteriaceae (25–33%), S. 2 gm IV q12h) + (metro 15 mg/kg IV q12h necessary. Experience with Pen G (HD) + metro without ceftriaxone or
aureus (10–15%), S. milleri. 7.5 mg/kg q6h or nafcillin/oxacillin has been good. We use ceftriaxone because of frequency
Rare: Nocardia (below) 15 mg/kg IV q12h)] of isolation of Enterobacteriaceae. S. aureus rare without positive blood
Listeria (CID 40:907, 2005) culture; if S. aureus, include vanco until susceptibility known. Strep. milleri
Duration of rx unclear; treat until response by neuroimaging
group esp. prone to produce abscess.
(CT/MRI)
Post-surgical, post-traumatic S. aureus, Enterobacteria- For MSSA: (Nafcillin or For MRSA: Vanco 1 gm IV
ceae oxacillin) 2 gm IV q4h + q12h + (ceftriaxone or
(ceftriaxone or cefotaxime) cefotaxime)
HIV-1 infected (AIDS) Toxoplasma gondii See Table 13A, page 134
Nocardia: Haematogenous N. asteroides & N. TMP-SMX: 15 mg/kg/day of TMP-SMX + amikacin as in Measure peak sulfonamide levels: target 100-150 mcg/mL 2 hrs post dose.
basiliensis TMP & 75 mg/kg/day of primary and add IMP 500 mg Linezolid 600 mg po bid reported effective (Ann Pharmacother 41:1694,
abscess
SMX, IV/po div in 2-4 doses IV q6h. 2007). For in vitro susceptibility testing: Wallace ([phone] or U.S.
Ref: Can Med J 171:1063, 2004
+ ceftriaxone 2 gm IV CDC ([phone]. If sulfonamide resistant or sulfa-allergic, amikacin
q12h. If multiorgan plus one of: IMP, MER, ceftriaxone or cefotaxime.
involvement some add
amikacin 7.5 mg/kg q12h.
After 3-6 wks of IV therapy, switch to po therapy.
Immunocompetent pts: TMP-SMX, minocycline or AM-CL x
3+ months. Immunocompromised pts: Treat with 2 drugs
for at least one year.
Subdural empyema: In adult 60–90% are extension of sinusitis or otitis media. Rx same as primary brain abscess. Surgical emergency: must drain (CID 20:372, 1995). Review in LnID 7:62, 2007.
Encephalitis/encephalopathy Herpes simplex, arbo- Start IV acyclovir while awaiting results of CSF PCR for H. Newly recognized strain of bat rabies. May not require a break in the skin to
IDSA Guideline: CID 47:303, 2008. viruses, rabies, West Nile simplex. For amebic encephalitis see Table 13A. infect. Eastern equine encephalitis causes focal MRI changes in basal ganglia
(For Herpes see Table 14A page 147, and other flaviruses. Rarely: and thalamus (NEJM 336:1867, 1997). Cat-scratch ref.: PIDJ 23:1161, 2004.
and for rabies, Table 20D, page 199) listeria, cat-scratch disease; Ref. on West Nile & related viruses: NEJM 351:370, 2004. Parvovirus B19
amebic (CID 48:879, 2009). (CID 48:1713, 2009).
Meningitis, “Aseptic”: Pleocytosis Enteroviruses, HSV-2, LCM, For all but leptospirosis, IV fluids and analgesics. D/C drugs If available, PCR of CSF for enterovirus. HSV-2 unusual without concomitant
of 100s of cells, CSF glucose HIV, other viruses, drugs that may be etiologic. For lepto (doxy 100 mg IV/po q12h) genital herpes. Drug-induced aseptic meningitis: Inf In Med 25:331, 2008.
normal, neg. culture for bacteria (NSAIDs, metronidazole, or (Pen G 5 million units IV q6h) or (AMP 0.5–1 gm IV q6h). For lepto, positive epidemiologic history and concomitant hepatitis,
(see Table 14A, page 143) carbamazepine, TMP-SMX, Repeat LP if suspect partially-treated bacterial meningitis. conjunctivitis, dermatitis, nephritis. For complete list of implicated drugs: Inf
Ref: CID 47:783, 2008 IVIG), rarely leptospirosis Med 25:331, 2008.
Abbreviations on page 2. NOTE: All dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. 6
TABLE 1A (4)
ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES
MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVE§ AND COMMENTS
CENTRAL NERVOUS SYSTEM (continued)
Meningitis, Bacterial, Acute: Goal is empiric therapy, then CSF exam within 30 min. If focal neurologic deficit, give empiric therapy, then head CT, then LP. (NEJM 354:44,2006; Ln ID 7:191, 2007;
IDSA Pract. Guid., CID 39:1267, 2004) NOTE: In children, treatment caused CSF cultures to turn neg. in 2 hrs with meningococci & partial response with pneumococci in 4 hrs (Peds 108:1169, 2001)
Empiric Therapy—CSF Gram stain is negative—immunocompetent
Age: Preterm to <1 mo Group B strep 49%, AMP + cefotaxime AMP + gentamicin Primary & alternative reg active vs Group B strep, most coliforms, & listeria.
Ln 361:2139, 2003 E. coli 18%, listeria 7%, If premature infant with long nursery stay, S. aureus, enterococci, and resistant
Intraventricular treatment not recommended.
misc. Gm-neg. 10%, coliforms potential pathogens. Optional empiric regimens: [nafcillin +
Repeat CSF exam/culture 24–36 hr after start of therapy
misc. Gm-pos. 10% (ceftazidime or cefotaxime)]. If high risk of MRSA, use vanco + cefotaxime.
For dosage, see Table 16
Alter regimen after culture/sensitivity data available.
Age: 1 mo– 50 yrs S. pneumo, meningococci, Adult dosage: [(Cefotaxime [(MER 2 gm IV q8h) (Peds: For pts with severe pen. allergy: Chloro 12.5 mg/kg IV q6h (max. 4 gm/day)
See footnote1 for empiric H. influenzae now very rare, 2 gm IV q4–6h OR 40 mg/kg IV q8h)] + IV (for meningococcus) + TMP-SMX 5 mg/kg q6–8h (for listeria if immunocom-
listeria unlikely if young & ceftriaxone 2 gm IV q12h)] dexamethasone + vanco promised) + vanco. Rare meningococcal isolates chloro-resistant (NEJM
treatment rationale.
immuno-competent (add + (dexamethasone) + (see footnote2) 339:868, 1998). High chloro failure rate in pts with resistant S. pneumo (Ln 339:
For meningococcal
ampicillin if suspect listeria: vanco (see footnote2). Peds: see footnote3 405, 1992; Ln 342:240, 1993). So far, no vanco-resistant S. pneumo.
immunization,
2 gm IV q4h) Peds: see footnote3 Value of dexamethasone documented in children with H. influenzae and
see Table 20A, page 195.
adults with S. pneumo (NEJM 347:1549 & 1613, 2002; NEJM 357:2431 &
Dexamethasone: 0.15 mg/kg IV q6h x 2–4 days. Give with
2441, 2007; LnID 4:139, 2004). Decreased inflammatory markers in adults
or just before 1st dose of antibiotic to block TNF
(CID 49:1387, 2009). Give 1st dose 15–20 min. prior to or con-comitant
production (see Comment).
with 1st dose of antibiotic. Dose: 0.15 mg/kg IV q6h x 2–4 days.
See footnote3 for rest of ped. dosage
Age: >50 yrs or alcoholism S. pneumo, listeria, Gm-neg. (AMP 2 gm IV q4h) + MER 2 gm IV q8h + vanco + Severe penicillin allergy: Vanco 500–750 mg IV q6h + TMP-SMX 5 mg/kg
or other debilitating assoc bacilli. (ceftriaxone 2 gm IV q12h IV dexamethasone. q6–8h pending culture results. Chloro has failed vs resistant S. pneumo
diseases or impaired Note absence of meningo- or cefotaxime 2 gm IV q6h) For severe pen. Allergy, (Ln 342:240, 1993).
cellular immunity coccus. + vanco + IV see Comment
dexamethasone
For vanco dose, see footnote2. Dexamethasone:
0.15 mg/kg IV q6h x 2–4 days; 1st dose before or
concomitant with 1st dose of antibiotic.
Post-neurosurgery, post- S. pneumoniae most Vanco (until known not MER 2 gm IV q8h + vanco Vanco alone not optimal for S. pneumo. If/when suscept. S. pneumo
head trauma, or post- common, esp. if CSF leak. MRSA) 500–750 mg IV q6h2 1 gm IV q6–12h identified, quickly switch to ceftriaxone or cefotaxime.
cochlear implant Other: S. aureus, coliforms, + (cefepime or ceftaz- If coliform or pseudomonas meningitis, some add intrathecal gentamicin
(NEJM 349:435, 2003) P. aeruginosa idime 2 gm IV q8h)(see (4 mg q12h into lateral ventricles). Cure of acinetobacter meningitis with
Comment) intraventricular or intrathecal colistin (JAC 53:290, 2004; JAC 58:1078, 2006).
Ventriculitis/meningitis due S. epidermidis, S. aureus, Vanco 500–750 mg IV q6h Vanco 500–750 mg IV q6h + Usual care: 1st, remove infected shunt & culture; external ventricular catheter
to infected ventriculo- coliforms, diphtheroids + (cefepime or ceftazi- MER 2 gm IV q8h for drainage/pressure control; antimicrobic for 14 days. For timing of new
peritoneal (atrial) shunt (rare), P. acnes dime 2 gm IV q8h) shunt, see CID 39:1267, 2004.
If unable to remove shunt, consider intraventricular therapy;
for dosages, see footnote4

1 Rationale: Hard to get adequate CSF concentrations of anti-infectives, hence MIC criteria for in vitro susceptibility are lower for CSF isolates (ArIM 161:2538, 2001).
2 Low & erratic penetration of vanco into the CSF (PIDJ 16:895, 1997); children’s dosage 15 mg/kg IV q6h (2x standard adult dose). In adults, max dose of 2-3 gm/day is suggested: 500–750 mg IV q6h.
3 Dosage of drugs used to treat children ≥1 mo of age: Cefotaxime 200 mg/kg per day IV div. q6–8h; ceftriaxone 100 mg/kg per day IV div. q12h; vanco 15 mg/kg IV q6h.
4 Dosages for intraventricular therapy. The following are daily adult doses in mg: amikacin 30, gentamicin 4–8, polymyxin E (Colistin) 10, tobramycin 5–20, vanco 10–20. Ref.: CID 39:1267, 2004.
Abbreviations on page 2. NOTE: All dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. 7
TABLE 1A (5)
ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES
MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVE§ AND COMMENTS
CENTRAL NERVOUS SYSTEM/Meningitis, Bacterial, Acute (continued)
Empiric Therapy—Positive CSF Gram stain
Gram-positive diplococci S. pneumoniae Either (ceftriaxone 2 gm IV q12h or cefotaxime 2 gm IV Alternatives: MER 2 gm IV q8h or Moxi 400 mg IV q24h. Dexamethasone
q4–6h) + vanco 500–750 mg IV q6h + timed dexametha- does not block penetration of vanco into CSF (CID 44:250, 2007).
sone 0.15 mg/kg q6h IV x 2–4 days.
Gram-negative diplococci N. meningitidis (Cefotaxime 2 gm IV q4–6h or ceftriaxone 2 gm IV q12h) Alternatives: Pen G 4 mill. units IV q4h or AMP 2 gm q4h or Moxi 400 mg IV
q24h or chloro 1 gm IV q6h
Gram-positive bacilli or Listeria monocytogenes AMP 2 gm IV q4h ± gentamicin 2 mg/kg loading dose then If pen-allergic, use TMP-SMX 5 mg/kg q6–8h or MER 2 gm IV q8h
coccobacilli 1.7 mg/kg q8h
Gram-negative bacilli H. influenzae, coliforms, (Ceftazidime or cefepime 2 gm IV q8h) + gentamicin Alternatives: CIP 400 mg IV q8–12h; MER 2 gm IV q8h
P. aeruginosa 2 mg/kg 1st dose then 1.7 mg/kg q8h
Specific Therapy—Positive culture of CSF with in vitro susceptibility results available. Interest in monitoring/reducing intracranial pressure: CID 38:384, 2004
H. influenzae β-lactamase positive Ceftriaxone (peds): 50 mg/kg IV q12h Pen. allergic: Chloro 12.5 mg/kg IV q6h (max. 4 gm/day.)
Listeria monocytogenes AMP 2 gm IV q4h ± gentamicin 2 mg/kg loading dose, Pen. allergic: TMP-SMX 20 mg/kg per day div. q6–12h. One report of
(CID 43:1233, 2006) then 1.7 mg/kg q8h greater efficacy of AMP + TMP-SMX as compared to AMP + gentamicin
(JID 33:79, 1996). Alternative: MER 2 gm IV q8h. Success reported with
linezolid + RIF (CID 40:908, 2005).
N. meningitidis Pen MIC 0.1–1 mcg per mL Ceftriaxone 2 gm IV q12h x 7 days (see Comment); if β-lactam Rare isolates chloro-resistant (NEJM 339:868 & 917, 1998).
allergic, chloro 12.5 mg/kg (up to 1 gm) IV q6h Alternatives: MER 2 gm IV q8h or Moxi 400 mg q24h.
S. pneumoniae Pen G MIC Pen G 4 million units IV q4h or AMP 2 gm IV q4h Alternatives: Ceftriaxone 2 gm IV q12h, chloro 1 gm IV q6h
<0.1 mcg/mL
NOTES:
1. Assumes dexamethasone 0.1–1 mcg/mL Ceftriaxone 2 gm IV q12h or cefotaxime 2 gm IV q4–6h Alternatives: Cefepime 2 gm IV q8h or MER 2 gm IV q8h
just prior to 1st dose & ≥2 mcg/mL Vanco 500–750 mg IV q6h + (ceftriaxone or cefotaxime Alternatives: Moxi 400 mg IV q24h
x 4 days.
as above)
2. If MIC ≥1, repeat CSF
exam after 24–48h. Ceftriaxone MIC ≥1 mcg/mL Vanco 500–750 mg IV q6h + (ceftriaxone or cefotaxime Alternatives: Moxi 400 mg IV q24h
3. Treat for 10–14 days as above) If MIC to ceftriaxone >2 mcg/mL, add RIF 600 mg 1x/day.
E. coli, other coliforms, or P. Consultation advised— (Ceftazidime or cefepime 2 gm IV q8h) ± gentamicin Alternatives: CIP 400 mg IV q8–12h; MER 2 gm IV q8h.
aeruginosa need susceptibility results For discussion of intraventricular therapy: CID 39:1267, 2004
Prophylaxis for H. influenzae and N. meningitides
Haemophilus influenzae type b Children: RIF 20 mg/kg po (not to exceed 600 mg) q24h Household: If there is one unvaccinated contact ≤4 yr in the household, give
Household and/or day care contact: residing with index x 4 doses. RIF to all household contacts except pregnant women. Child Care Facilities:
case or ≥4 hrs. Day care contact: same day care as index Adults: RIF 600 mg q24h x 4 days With 1 case, if attended by unvaccinated children ≤2 yr, consider prophylaxis +
case for 5–7 days before onset vaccinate susceptibles. If all contacts >2 yr: no prophylaxis. If ≥2 cases in
60 days & unvaccinated children attend, prophylaxis recommended for children
& personnel (Am Acad Ped Red Book 2006, page 313).
Abbreviations on page 2. NOTE: All dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. 8
TABLE 1A (6)
ANATOMIC SITE/DIAGNOSIS/ ETIOLOGIES SUGGESTED REGIMENS* ADJUNCT DIAGNOSTIC OR THERAPEUTIC MEASURES
MODIFYING CIRCUMSTANCES (usual) PRIMARY ALTERNATIVE§ AND COMMENTS
CENTRAL NERVOUS SYSTEM/Meningitis, Bacterial, Acute/Prophylaxis for H. influenzae and N. meningitides (continued)
Prophylaxis for Neisseria meningitidis exposure [CIP (adults) 500 mg po single dose] OR Spread by respiratory droplets, not aerosols, hence close contact req. ↑ risk if
(close contact) [Ceftriaxone 250 mg IM x 1 dose (child <15 yr 125 mg close contact for at least 4hrs during wk before illness onset (e.g., housemates,
NOTE: CDC reports CIP-resistant group B IM x 1)] OR day care contacts, cellmates) or exposure to pt’s nasopharyngeal secretions
meningococcus from selected counties in N. Dakota [RIF 600 mg po q12h x 4 doses. (Children >1 mo 10 mg/kg (e.g., kissing, mouth-to-mouth resuscitation, intubation, nasotracheal
& Minnesota. Use ceftriaxone, RIF, or single 500 mg dose po q12h x 4 doses, <1 mo 5 mg/kg q12h x 4 doses)] suctioning). Since RIF-resistant N. meningitidis documented, post-exposure
of azithro (MMWR 57:173, 2008). OR prophylaxis with CIP or ceftriaxone preferred (EID 11:977, 2005).
SpiramycinNUS 500 mg po q6h x 5 days. Primary prophylactic regimen in many European countries.
Children 10 mg/kg po q6h x 5 days.
Meningitis, chronic M. tbc 40%, cryptococcosis Treatment depends on etiology. No urgent need for empiric Long list of possibilities: bacteria, parasites, fungi, viruses, neoplasms,
Defined as symptoms + CSF 7%, neoplastic 8%, Lyme, therapy, but when TB suspected treatment should be vasculitis, and other miscellaneous etiologies—see chapter on chronic
pleocytosis for ≥4 wks syphilis, Whipple’s disease expeditious. meningitis in latest edition of Harrison’s Textbook of Internal Medicine.
Whipple’s: JID 188:797 & 801, 2003.
Meningitis, eosinophilic Angiostrongyliasis, gnatho- Corticosteroids Not sure antihelminthic 1/3 lack peripheral eosinophilia. Need serology to confirm diagnosis. Steroid
LnID 8:621, 2008 stomiasis, baylisascaris therapy works ref.: CID 31:660, 2001; LnID 6:621, 2008. Automated CSF count may not
correctly identify eosinophils (CID 48: 322, 2009).
Meningitis, HIV-1 infected (AIDS) As in adults, >50 yr: also If etiology not identified: For crypto rx, see Table 11A, C. neoformans most common etiology in AIDS patients. H. influenzae,
See Table 11, Sanford Guide to consider cryptococci, M. treat as adult >50 yr + page 106 pneumococci, Tbc, syphilis, viral, histoplasma & coccidioides also need to be
HIV/AIDS Therapy tuberculosis, syphilis, HIV obtain CSF/serum crypto- considered. Obtain blood cultures. L. monocytogenes risk >60x ↑, ¾ present
aseptic meningitis, Listeria coccal antigen as meningitis (CID 17:224, 1993).
monocytogenes (see Comments)
EAR
External otitis
Chronic Usually 2° to seborrhea Eardrops: [(polymyxin B + neomycin + hydrocortisone Control seborrhea with dandruff shampoo containing selenium sulfide
qid) + selenium sulfide shampoo] (Selsun) or [(ketoconazole shampoo) + (medium potency steroid solution,
triamcinolone 0.1%)].
Fungal Candida species Fluconazole 200 mg po x 1 dose & then 100 mg po x 3-5 days.
“Malignant otitis externa” Pseudomonas aeruginosa (IMP 0.5 gm IV q6h) or (MER 1 gm IV q8h) or [CIP CIP po for treatment of early disease. Debridement usually required. R/O
Risk groups: Diabetes mellitus, in >90% 400 mg IV q12h (or 750 mg po q12h)] or (ceftaz 2 gm IV osteomyelitis: CT or MRI scan. If bone involved, treat for 4–6 wks. PIP without
AIDS, chemotherapy. Ref: q8h) or (CFP 2 gm q12h) or (PIP 4–6 gm IV q4–6h + tobra) Tazo may be hard to find: extended infusion of PIP-TZ (4 hr infusion of
Oto Clinics N Amer 41:537, 2008 or (TC 3 gm IV q4h + tobra dose Table 10D) 3.375 gm every 8h) may improve efficacy (CID 44:357, 2007).
“Swimmer’s ear” Pseudomonas sp., Entero- Eardrops: Oflox 0.3% soln bid or [(polymyxin B + neo- Rx includes gentle cleaning. Recurrences prevented (or decreased)
PIDJ 22:299, 2003 bacteriaceae, Proteus sp. mycin + hydrocortisone) qid] or (CIP + hydrocortisone by drying with alcohol drops (1/3 white vinegar, 2/3 rubbing alcohol) after
(Fungi rare.) Acute infection bid) --active vs gm-neg bacilli. swimming, then antibiotic drops or 2% acetic acid solution. Ointments should
usually 2° S. aureus For acute disease: dicloxacillin 500 mg po 4x/day. If MRSA not be used in ear. Do not use neomycin drops if tympanic membrane
a concern, use TMP-SMX, doxy or clinda punctured.
Abbreviations on page 2. NOTE: All dosage recommendations are for adults (unless otherwise indicated) and assume normal renal function. 9