Empiric Antibiotic Therapy [PDF]

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Pneumonia For nonhospitalized patients with an established diagnosis of CAP who also have comorbidities, a history of recent antibiotic use, or when the local rate of macrolide resistance is >25 percent (including all regions of the United States and certain other countries), we suggest empiric monotherapy with a respiratory fluoroquinolone or combination therapy with a beta-lactam plus either a macrolide or doxycycline.

For uncomplicated pneumonia in patients who have no significant comorbidities and/or risk factors for macrolide resistance (use of antibiotics within the last three months, local rate of macrolide resistance >25 percent), we suggest empiric treatment with an advanced macrolide.

Most outpatients with CAP should be treated for five days.

For hospitalized patients not requiring intensive care unit (ICU) admission, we suggest initial combination therapy with an anti-pneumococcal beta-lactam (ceftriaxone, cefotaxime, ceftaroline, ertapenem, or ampicillin-sulbactam) plus a macrolide (azithromycin or clarithromycin XL), or monotherapy with a respiratory fluoroquinolone (levofloxacin or moxifloxacin) (Grade 1B) Coverage for drug-resistant pathogens, such as Pseudomonas or MRSA, should be included in patients with risk factors.

For hospitalized patients requiring ICU care, we suggest initial combination therapy with an anti-pneumococcal betalactam (ceftriaxone, cefotaxime, ceftaroline, or ampicillin-sulbactam) plus either intravenous (IV) therapy with azithromycin or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) plus, if MRSA is suspected, vancomycin or linezolid (Grade 2B). Coverage for other drug-resistant pathogens, such as Pseudomonas, should be included in patients with risk factors. For most hospitalized patients who are at substantial risk of morbidity and mortality (eg, Pneumonia Severity Index score IV or V; CURB-65 score ≥2), we suggest adjunctive glucocorticoids. We suggest switching from intravenous to oral therapy when patients are hemodynamically stable, demonstrate some clinical improvement (in fever, respiratory status, white blood count), and are able to take oral medications.

Meningitis Initial therapy bacterial meningitis in adults: Same as table in QID 3245 (UW)

We recommend that antimicrobial therapy be initiated immediately after the performance of the lumbar puncture or, if a computed tomography (CT) scan is to be performed before LP, immediately after blood cultures are obtained For adults in the developed world with suspected bacterial meningitis in whom the organism is unknown or Streptococcus pneumoniae is confirmed, we recommend administration of dexamethasone No known immunodeficiency S. pneumoniae, Neisseria meningitidis, and, less often, Haemophilus influenzae and group B Streptococcus are the most likely causes of community-acquired bacterial meningitis in otherwise healthy adults up to the age of 60. Individuals aged over 50 years are also at substantial risk of Listeria monocytogenes meningitis. Ceftriaxone or Cefotaxime + Vancomycin + Ampicillin (In adults >50 years of age) With the worldwide increase in the prevalence of penicillin-resistant pneumococci, vancomycin should be added to cefotaxime or ceftriaxone as empiric treatment until culture and susceptibility results are available Impaired cell-mediated immunity (due, for example, to lymphoma, cytotoxic chemotherapy, or high-dose glucocorticoids), coverage must be directed against L. monocytogenes and gram-negative bacilli (including Pseudomonas aeruginosa) as well as S. pneumoniae. Vancomycin + Ampicillin + [Cefepime or Meropenem] Healthcare-associated meningitis Empiric therapy for healthcare-associated meningitis must cover both gram-positive and gram-negative (such as Klebsiella pneumoniae and P. aeruginosa) pathogens Vancomycin +[ Ceftazidime or Cefepime or Meropenem] Allergy to beta-lactams Vancomycin + Moxifloxacin + TMP/SFX (If Listeria coverage is required (in patients >50 years of age and/or in those with defects in cell-mediated immunity)

The 4 regimens require normal renal function.

Children with meningitis: In special circumstances: Vanco + cefotax, and If G –ve suspected or observed on gram stain, add aminoglycoside. We recommend the use of dexamethasone for children with Hib meningitis (Grade 1A). The agent of choice for empiric treatment of infections due to CoNS is methicillin-resistant CoNS infections.

vancomycin; it is generally the mainstay of treatment for

Bacterial meningitis in the neonate: Treatment and outcome

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Don’t take it seriously

In neonates zero through three days of age, the most common bacterial pathogens are group B Streptococcus (GBS), Escherichia coli, other enteric bacilli, and Listeria monocytogenes. In neonates four days of age or older, other gram-negative organisms must be considered in addition to GBS, E. coli, and other enterics In continuously hospitalized neonates seven days of age or older, a wide range of potential gram-positive organisms must be considered in addition to antimicrobial-resistant gram-negative organism Early-onset ●Initial empirical therapy for suspected bacterial meningitis within the first three to six days of age is ampicillin and an aminoglycoside, usually gentamicin. OR Ampicillin + Cefotaxime. Late-onset — Initial empirical therapy for suspected bacterial meningitis after the first week of life depends upon the preliminary CSF findings (particularly the Gram stain) and whether the neonate remains hospitalized or has been discharged from the hospital. In the non-hospitalized neonate who is strongly suspected to have bacterial meningitis), ampicillin plus an aminoglycoside plus cefotaxime should be initiated. Late-onset sepsis without meningitis in neonates who remain hospitalized is treated with vancomycin and an aminoglycoside. In general, drugs between amp, vanc, aminog, cefotax

Brain abscess For patients with a brain abscess arising from an oral, otogenic, or sinus source (eg, chronic otitis or mastoiditis, where the site of abscess is usually the temporal lobe or cerebellum; or frontal or ethmoid sinusitis, where the site of abscess is usually the frontal lobe), we recommend treatment with: ●Metronidazole PLUS either penicillin G for a suspected oral focus, OR ceftriaxone or cefotaxime for a suspected sinus or otogenic source. For patients with a brain abscess from hematogenous spread (eg, bacteremia or endocarditis with multiple abscesses in middle cerebral artery distribution), we recommend treatment with: ●Vancomycin for empiric coverage of methicillin-resistant S. aureus. Metronidazole and ceftriaxone or cefotaxime, may be added for initial empiric coverage if the bacteriology is uncertain. For brain abscess in postoperative neurosurgical patients, we recommend treatment with: (= meningitis) ●Vancomycin PLUS ceftazidime ,cefepime (2 g IV every eight hours), or meropenem . For brain abscess following penetrating trauma, we recommend treatment with: (Not like meningitis) ●Vancomycin PLUS either ceftriaxone or cefotaxime If the paranasal sinuses are involved, add metronidazole For brain abscesses with an unknown source, we recommend treatment with (To cover all): ●Vancomycin PLUS Either ceftriaxone or cefotaxime PLUS ●Metronidazole

PID Pelvic inflammatory disease: Treatment

Acute PID is caused by cervical microorganisms (including Chlamydia trachomatis and Neisseria gonorrhoeae) as well as the vaginal microflora, including enteric gram-negative rods, streptococci, genital mycoplasmas, and Gardnerella vaginalis. Anaerobic coverage is warranted in patients with a history of recent endometrial instrumentation and women with severe or complicated PID

For inpatient management of severe or complicated PID, we suggest use of a second generation cephalosporin (eg, cefoxitin IV or cefotetan IV) combined with doxycycline . Another option is clindamycin plus gentamicin (Both IV). (Which will kill which) For outpatient therapy of mild or moderate PID, we suggest ceftriaxone (250 mg intramuscularly in a single dose) plus doxycycline (orally for 14 days) (Grade 2B). We suggest the addition of metronidazole for those with a history of gynecological instrumentation in the preceding two to three weeks. The Antibiotic regimens for inpatient treatment of PID are also used for tuboovarian abscess treatment.

Postpartum endometritis The infection is polymicrobial, usually involving a mixture of two to three aerobes and anaerobes from the lower genital tract. Given the microbiology of these infections, we recommend broad spectrum antibiotics with coverage of beta-lactamase producing anaerobes (Grade 1A). We suggest clindamycin (IV) plus gentamicin (IV) (Grade 2B). Ampicillin-sulbactam (1.5 g intravenously every six hours) is a reasonable alternative in areas with significant clindamycin resistance in B. fragilis or if the patient is colonized with group B streptococcus (GBS) [or in patients with renal insufficiency] Metronidazole provides good activity against most anaerobes and can be useful with ampicillin and gentamicin, but is not the preferred choice for breastfeeding women if a drug with a better safety profile is available.

Osteomyelitis Osteomyelitis in adults: The reference standard for diagnosis of osteomyelitis is isolation of bacteria from a bone biopsy sample obtained via sterile technique, together with histologic findings of inflammation and osteonecrosis. Bone biopsy may not be needed for patients with radiologic studies consistent with osteomyelitis in the setting of positive blood cultures. Cultures obtained from sinus tract drainage are not reliable. Treatment of osteomyelitis often requires both surgical debridement of necrotic material and antimicrobial therapy for eradication of infection. The optimal duration of antibiotic therapy is not certain; we suggest continuing parenteral antimicrobial therapy at least six weeks from the last debridement

Empiric therapy: Vancomycin PLUS an agent with activity against gram-negative organisms MSSA: Oxacillin, Nafcillin, Cefazolin. MRSA or Coagulase-negative staphylococci: Vancomycin Gram-negative organisms (includingPseudomonas): Ciprofloxacin, Levofloxacin, Ceftazidime, Cefepime Hematogenous osteomyelitis in children: Management

We recommend empiric antimicrobial therapy for most children with clinical features compatible with osteomyelitis, even if the initial plain radiograph is normal. Initial antimicrobial therapy for acute hematogenous osteomyelitis usually is administered parenterally. The empiric regimen is determined by the most likely pathogens and antimicrobial susceptibilities based on epidemiologic factors including the child's age (table 2), clinical features (table 3), and organisms prevalent in the community •For infants