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Flashcards in Treatment approaches Deck (27):
1

Asymptomatic bacteriuria

Positive urine cultures even if >100,000 CFU without presence of symptoms do not require antibiotic treatment unless the patient is pregnant or undergoing urinary surgery

Document as asymptomatic bacteriuria

2

Urinary tract infections

41% Proteus mirabilis and 28% E. coli strains are resistant to ciprofloxacin

consider alternative agent for empiric therapy

3

Skin and soft tissue infections

Clindamycin combination therapy only indicated in Group A Streptococcus infections

Purulent infections, moderate to severe: consider MRSA coverage with vancomycin

Non-purulent or diffuse-infections, mild to moderate: B-lactam (cefazolin) is preferred. Consider clindamycin as an allergic alternative

Avoid using TMP-SMX empirically due to lack of Streptococcus coverage

4

MSSA

Cefazolin (IV) or cqphalexin (PO) drugs of choice

Nafcillin is an alternative

51% MSSA are oxacillin sensitive

5

Enterococcal infections

Ampicillin (IV) or amoxicillin (PO) drugs of choice unless resistant

Adding a B-lactamase inhibitor (ampicillin/sulbactam or amoxicillin/clavulanate) does not add any benefit, as this is not the resistance mechanism of Enterococcus

Cephalosporins do not cover enterococcus

6

Extended-spectrum beta-lactamase producers (ESBLs)

Meropenem is preferred drug for ESBLs
6% of E. coli and 5% Klebsiella pneumoniae are ESBLs

7

Haemophillus influenzae and Moraxella catarrhalis

25% H. flu and 88% of M. catarrhalis are B-lactamase producing

Preferred therapy:
IV: ampicillin/sulbactam or ceftriaxone
PO: amoxicillin/clavulanate or cefuroxime

8

Candida infections

74% of Candida isolated from all sites is C. albicans
26% of Candida isolated in blood is C. albicans

Fluconazole drug of choice for C. albicans

For fungemia consider micafungin empirically and narrowing to fluconazole if C. albicans isolated

Micafungin is the echinocandin on formulary

9

Empiric antibiotic de-escalation if S. aureus not isolated

DC vancomycin

10

Empiric antibiotic de-escalation if resistant gram negative organisms are not isolated (Pseudomonas, Enterobacter)

De-escalate from zosyn or cefepime to ampicillin/sulbactam or ceftriaxone

11

Empiric antibiotic de-escalation if no isolate is identified or normal flora identified

De-escalate to an oral abx if patient is clinically stable to do so

12

Empiric antibiotic de-escalation if isolate is susceptible to a 1st gen cephalosporin

Do not use a 3rd generation cephalosporin (e.g. ceftriaxone), de-escalate to the narrowest spectrum (e.g. cefazolin (Ancef))

13

C. difficile

Mild to moderate: Metronidazole 500 mg PO q8 hr for 10-14 days

Severe: Vancomycin 125 mg PO q6 hrs for 10-14 days

Severe complicated: S/S of ileum, toxic megacolon, perforation, sepsis 2/2 CDI:
Metronidazole 500 mg IV q 8 hrs + Vancomycin 500 mg PO/NG q6 hrs +/- vancomycin 500 mg retention enema
Treat at least 14 days

14

Diabetic foot infections

Polymicrobial: b-hemolytic strep, S. aureus, Pseudomas, Gram-negative rods, Anaerobes

Ampicillin/sulbactam 3 gm IV q6 hrs

OR

If pseudomonas concern:
Piperacillin/tazobactam extended infusion 3.375 gm IV q 8 hrs (or 3.375 gm IV q6 hrs if facility uses traditional dosing)
+/- vancomycin 20-25 mg/kg load plus pharmacy to dose if MRSA concern

Duration: patient and pathogen dependent

15

Intra-abdominal infections

Abscess, cholecystitis, diverticulitis
Enterococcus, Enterobactericeae, anaerobes

Mild to moderate: Ceftriaxone 1 gm IV q24 hrs + Metronidazole 500 mg PO q12 hr

Severe: Piperacillin/Tazobactam extended infusion 3.375 gm IV q 8 hrs (or 3.375 gm IV q6 hrs if facility uses traditional dosing)

Duration:
After source control: 4-7 days

Abscess: varies based on patient response

16

Meningitis under 50 yo

S. pneumoniae, N. meningitides

Ceftriaxone 2 gm IV q 12 hrs + vancomycin (20-25 mg/kg load plus RX to dose)

+/- ampicillin 2 gm IV Q4 hrs if Listeria concern

Duration patient and pathogen dependent

17

Meningitis over 50 yo

S. pneumoniae, N. meningitides, Listeria

Ceftriaxone 2 gm IV q 12 hrs + vancomycin (20-25 mg/kg load plus RX to dose) + ampicillin 2 gm IV Q4 hrs

Duration patient and pathogen dependent

18

Neutropenic fever

S. epidermis, K. pneumoniae, P. aeruginosa, S. aureus, E. coli

Cefepime 2 gm IV Q8 hrs +/- Vancomycin (20-25 mg/kg load plus RX to dose)

Continue until neutropenia subsides (ANC >= 500) and afebrile or longer if clinically necessary depending on symptoms and pathogens

19

Community acquired pneumonia

S. pneumoniae
M. pneumoniae
C. pneumoniae
H. influenzae

Ceftriaxone 1 gm IV q 24 hrs + Azithromycin 500 mg IV/PO daily

Cephalosporin allergy:
Non-ICU: Levofloxacin 750 mg IV/PO q 24 hrs
ICU: Aztreonam 1 gm IV q8 hr + Levofloxacin 750 mg IV/PO q24 hrs

Duration: 5 days

Longer depending on symptoms and pathogens

20

Aspiration pneumonia

anaerobes

Ampicillin/sulbactam 3 gm IV q6 hrs

OR

Clindamycin 600 mg IV q8 hrs
or Metronidazole 500 mg IV q6 hr
+ Ceftriaxone 1 gm IV q24 hr or Levofloxacin 750 mg IV q24 hrs if cephalosporin allergy

Duration 5 days

21

Hospital acquired/ventilator acquired pneumonia

P. aeruginosa, K. pneumoniae, Acinetobacter, S. aureus (MRSA)

Cefepime 2 gm IV q8 hrs OR Zosyn 3.375 gm IV q 8 hr (or 4.5 gm IV q6 hr if traditional dosing used) OR Meropenem 1 g IV Q8 hrs
+ Vancomycin 20-25 mg/kg load plus RX to dose
+/- Tobramycin 7 mg/kg IV q24 hr OR Gentamicin 7 mg/kg IV q24 hr OR levofloxacin 750 mg IV daily OR cipro 400 mg IV q8 hrs*

*consider adding if patient has received IV abx therapy in preceding 90 days

Duration: 7 days

22

Septic joint

STD risk: N. gonorrhoeae, S. aureus, Streptococcus
Low STD risk: S. aureus

Ceftriaxone 1 g IV q24 hr + Vancomycin 20-25 mg/kg load plus RX to dose
+/- Azithromycin 1 gm PO once if STD risk to cover Chlamydia trachomatis

Duration: patient and pathogen dependent

23

Non-purulent cellulitis/erysipelas

B-hemolytic strep, S. aureus

Mild to mod: Cephazolin 1 gm IV q 8 hr OR Nafcillin 1 gm IV q 4 hr

Severe: Vancomycin 20-25 mg/kg load plus RX to dose + Piperacillin/Tazobactam extended infusion 3.375 gm IV q8 hrs (or 3.375 gm IV q6 hrs if traditional dosing used)

Uncomplicated: 5 days
Abscess/complicated: 7-10 days

Longer depending on symptoms and pathogens

24

Purulent/Abscess or Risk of MRSA (cellulitis)

S. aureus

Vancomycin 20-25 mg/kg load plus RX to dose

Uncomplicated: 5 days
Abscess/complicated: 7-10 days

Longer depending on symptoms and pathogens

25

Uncomplicated cystitis

E coli, Proteus, Klebsiella, Enterococcus

TMP-SMX 160/800 mg PO BID or Nitrofurantoin 100 mg PO BID or Cephalexin 500 mg PO q6 hrs if resistance or allergy

Duration: 3-5 days

26

Complicated cystitis

E coli, Proteus, Klebsiella, Enterococcus

Ampicillin 2 gm IV Q6 hrs + Gentamicin 5 mg/kg IV Q24 hr (or facility protocol) OR pipercillin/tazobactam extended infusion 3.375 gm IV Q8 hr (or 3.375 gm IV q6 hrs if traditional dosing used)

Duration 7-10 days
With structural abnormalities - 14 days

27

Pyelonephritis

E coli, Proteus, Klebsiella, Enterococcus

Ceftriaxone 1 gm IV q24 hrs

Duration: 14 days