Professional Documents
Culture Documents
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-specic 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-specic 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 difcile infection (CDI) ............................................ 47
6.3 Infectious diarrhea ..................................................................... 51
6.4 H. pylori infection ....................................................................... 54
6.5 Gynecologic and sexually transmitted infections ..................... 56
Pelvic inamatory 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)
Table of contents
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 difcult now than
ever before. Furthermore, history has taught us that if we do not
use antibiotics carefully, they will lose their efcacy. 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 patients
chart.
Sara E. Cosgrove, M.D., M.S.
Director, Antimicrobial Stewardship Program
1. Introduction
Contacting us
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they are part of an approved order.
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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
}`iLV>}i>LV>}i}* i>V>LV
Infectious Diseases.
Also, please note that these guidelines contain cost information
that is condential. Copies of the book should not be distributed
outside of the institution without permission.
1. Introduction
when you are treating infections, as we think the information will prove
helpful. All references are on le in the ofce of the Antimicrobial
Stewardship Program (7-4570).
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
* \>LV
Overnight Approval
Notes
/i>}i>ii`Liiin>
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.
U*i>iiiLi}iii`
for approval if you go off shift before
8 a.m.
These forms are P&T-approved for
specic agents and specic indications.
The following list applies to ALL adult oors 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
Ciprooxacin
Colistin IV
Cytomegalovirus Immune
Globulin (Cytogam)2
Daptomycin1
Fosfomycin3
Linezolid
Meropenem
Moxioxacin
Nitazoxanide4
Palivizumab (Synagis)5
Piperacillin/tazobactam
<)
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.
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)
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Gram negative coverage is also needed
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Unacceptable uses
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*
and soft tissue infections (SSTI) where other more established and
less expensive options are available
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Dose
U}6+>Lii`i`v
*>`--/
U}6+nv,-L>Vii>>>}ii>i
serious infections
UMust adjust for worsening renal function and dialysis (see p. 155 for
dose adjustment recommendation).
Laboratory interactions
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hemolytic anemia. However, if drug-induced hemolytic anemia is
suspected, discontinue Ceftaroline.
Ceftolozane/tazobactam
Ceftolozane/tazobactam is a novel cephalosporin and -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
U
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or complicated urinary tract infections (cUTI) as current standard
regimens are sufcient for coverage of the typical pathogens involved
in these infections and less expensive options are available
Dose
Ux}6+n>Lii`i`vV1/>`VL>
metronidazole for cIAI
U-iviVV`}i>\}6+n
U>``ivi}i>vV>``>iixx
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
U>>}iivviV`i`}i>Acinetobacter
and Pseudomonas on a case by case basis.
Unacceptable uses
Ui>viVi>iviVi`>i}>iviV
Dose
U>`}`i\x}}Vi
U>i>Vi`i\x}}+>`vi}
renal function and dialysis (see p. 155 for dose adjustment
recommendation).
Toxicity
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Daptomycin
Daptomycin is a lipopeptide antibiotic. It has activity against most strains
of staphylococci and streptococci (including MRSA and VRE). It does
NOT have activity against Gram-negative organisms.
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
U >Vii>i`V>`V>i`L,-iVi>
coagulase-negative staphylococci in a patient with serious allergy to
Vancomycin
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6>VVi>>`iwi`L\
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check Daptomycin MIC and obtain follow up blood cultures)
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Unacceptable uses
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its inactivation by pulmonary surfactant.
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Dose
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Daptomycin in S. aureusL>Vii>>`viVii`V>`\
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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
U``i>i>>L`>viVL>>VviV]
diverticulitis, secondary peritonitis/GI perforation)
U`i>i`>LiVvviVii
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Unacceptable uses
U-iiiviVV Pseudomonas spp. are suspected.
Dose
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dialysis (see p. 155 for dose adjustment recommendation)
Toxicity
U>i>]>i>]i>`>Vi]iLLiL
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
U>>}iivVV>i`1/>ii>LV
allergies and/or when no other oral therapy options are available.
11
Toxicity
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10 times the upper limit of normal without
symptoms or 5 times the upper limit of normal with symptoms).
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U1VV>i`1/`i6,
U->>}ii>v1/`i`}i>>i}>i
organisms (e.g. Pseudomonas spp.) on case by case basis.
NOTE: Susceptibility to Fosfomycin should be conrmed prior to
initiation of therapy.
Unacceptable uses
UvV` "/Lii`v>>}iiv>viV
outside of the urinary tract because it does not achieve adequate
concentrations at other sites.
U/i>iv>VL>Vi>ii
Dose
U1VV>i`1/\}>Vi*"Vi
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treatment)
UiiV>`i>LiiVi>>i
50
mL/min. Contact the ID Pharmacist for dosing recommendations.
U*`i`Lii`qvV>i]i`
dissolve and administered immediately.
Toxicity
U>i>]>i>]i>`>Vi]`i]>i>>``i>
Linezolid
Acceptable uses
UVii`6>VVii`>iStaphylococcus aureus (VISA)
or Vancomycin resistant Staphylococcus aureus (VRSA) infection
UVii`,-iVi>V>}>ii}>i
staphylococcal infection in a patient with serious allergy to Vancomycin
UVii`,-iVi>V>}>ii}>i
staphylococcal infection in a patient failing Vancomycin therapy (as
`iwi`Li\
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`>`ii6>VV}vxqV}-`Li
used in combination with another agent
U*i>\i}w>i>>>>i
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)
U
>i`Li`Vi`viVi>i
Antimicrobial stewardship
UHigh suspicion of CA-MRSA necrotizing pneumonia in a seriously
ill patient
12
Dose
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Toxicity
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occurs with prolonged therapy > 28 days)
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serotonergic agents (SSRIs, TCAs, MAOIs, etc.)
U}\
ii
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
U>>}iiv>>L`>viV>i
contraindications to both beta-lactams and uoroquinolones
U>>}iivviV`i`}i>>i}>i
organisms including Acinetobacter spp. and Stenotrophomonas
maltophilia on a case by case basis
U->>}ii>v,-6,
viV>V>iLV>iL>
Dose
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U}6Vi]ix}6+viiii>V>i
`*}qx
Toxicity
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13
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viV
U>iVVVV>L`Vi>
1]V}
transplant patient known to be colonized with VRE
Unacceptable uses
U*>
U>i>v>VVV>viV
U6,
V>vi]i]i>>V]`]`>
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
U1>>VviV1/
US. aureus skin and soft-tissue infections (SSTI)
UPneumocystis jirovecii pneumonia (PCP) treatment and prophylaxis
US. maltophilia infections
U V>`>viV
U>i}>iL>Vii>i}>ViLi
U->>}ii>v,-L>Vii>VL>>i
agent
U
VVi>}ivListeria meningitis in patients with penicillin
allergies
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infections
Unacceptable uses
Ui>vS. aureus bacteremia
Dose
UTrimethoprim/sulfamethoxazole dosing is based on trimethoprim
component
U/*-8>iViiL>>>L]Viv6*"
\n{}6r-->Ln}6r->L
U1i>`i` 7rQ 7{ 7 7RLii>i
over IBW)
Treatment
U1/\->L+
U--/\->L+
U*
*\x}}`>``i``i]++n
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US. maltophiliaviV\x}}`>``i``i]++n
14
Prophylaxis
U*
*\--`>-iii
U/>\-`>
Toxicity
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\iin]i]i`ii>
Vi>in
U
}i`i\i>i>]ii
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severe G6PD deciency)
U,>i\>iVi}]i>V]Vi`i>iV
(TEN), SJS, Sweets syndrome
Drug Interaction
U7>v>]ii>i]i]`}]vi>]
procainamide, oral contraceptives
15
U V>`>viV\x}}`>``i``i]++ni
doses (5-10 mg/kg/day) can be used after several weeks of therapy
or cutaneous infections
Ui}\}}`>``i``i]+
U"iviV\n}}`>``i``i]+
U>``ivi}i>vV>``>iixx
for dose adjustment recommendation).
Antifungals
Liposomal Amphotericin B (AmBisome)
NOTES:
U}v i>`iV `iV>i
signicantly different. Do not use AmBisome doses when
ordering Amphotericin B deoxycholate and vice versa.
UiV `iV>iivii`>ii`
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
U
>``>i`>]i`V>`]
-viVqwii>
U
VVVi}wii>
U<}ViMucor, Rhizopus, Cunninghamellaqwii>
U iiVviiviVi}6V>i*>V>i
prophylaxis
Ui>ii>iv>i>i}
Ui>ii>ivV>``i>]V>``>i
Dose
U
>``i>]>]i>iV>``>viV\
3 mg/kg/day
U
>``>i`>]i`V>`]
-viV]C. krusei
V>``i>\x}}`>
U>iw>iv}\x}}`>
U iiVvii]V>``i>iiV>i\qx}}`>
U
VVV>i}\q{}}`>
Toxicity
Uvi>i`i>V\vii]V]}]i
U,i>>ii>Vi`>iVV>iV
drugs)
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iViL>>Vi
U*>VVi>]>]`i>]>i>]ii>
hepatic enzymes-rare
U}\ 1 Vi>i]]}]*>L>ii>``>
>i`>i-//>L>ii>`iiii
16
Aspergillosis
UVVi>Lii
UVL>6V>ivVwi`>i
aspergillosis (see p. 133)
U,iv>V`i>iviVL>6V>i]
Posaconazole or AmBisome for conrmed invasive aspergillosis.
U1>VVi>Lii
UV>v}>iVL>i>v}>>}i
not recommended for empiric therapy in patients with CT ndings
suggestive of aspergillosis (e.g., possible aspergillosis) without
plans for diagnostic studies.
UV>v}`i>i}`in vitro activity against
zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
Candidiasis
UVVi>Lii
U/i>iv>iV>``>`iC. glabrata or C. krusei.
U/i>iv>iV>``>>i>i "/VV>
stable due to candidemia or have received prior long-term azole
therapy.
Ui>ii>iviVii>}i>V>``>
Ui>ii>ivi`V>`
U1>VVi>Lii
UV>v}>ii>i
->`>>V
should be avoided for infections involving those sites.
Neutropenic fever
UV>v}V>Lii`viiVvii>i>i
suspected to have aspergillosis or zygomycosis.
Dose
U
>``i>]>iV>``>]iiVvii\}6
Q24H
U
>``>i`V>`\x}6+{
U,iVii>}i>V>``>\x}6+{
U>i>i}\qx}6+{
U"Lii>i
Uqx}\x}6+{
U> x}\
*>>V
Drug Interactions
U
i}iVi`i`iV>v}i`i
v}>}iVV>\
17
Micafungin
NOTE: Micafungin does not have activity against Cryptococcus.
U-qiiv->LiVi>i`]v
Sirolimus toxicity
U vi`iqiiv vi`i>LiVi>i`]v
Nifedipine toxicity
U>V>iqiiv>V>i>LiVi>i`]v
Itraconazole toxicity
Toxicity
Uvi>i`i>V>]]iL]i>`>Vi]>i>
and vomiting, and elevations in hepatic enzymes.
U}\-//LL>L>ii>`iiqii>vi
Posaconazole
Posaconazole is a broad spectrum azole anti-fungal agent. It has in vitro
activity against Candida, Aspergillus, Zygomycosis and Fusarium spp.
Acceptable uses
U/i>iv>i}VVL>iV
Ui>v}V>vi`>vVL>i>
with Amphotericin B
U*>>ii>}V>}>V
U/i>iv>i}>i6V>ii>Vi
Unacceptable uses
U
>``> iiVvii
Uii>iv>i}
Dose
"/
-\
U
>V`ivi`Li}i>vi>`
nutritional supplements if patients cannot tolerate full meals. Can also
be given with an acidic beverage (e.g. ginger ale).
Ui>i`ii>i>Li>`>iV>Lii`
interchangeably due to differences in the dosing of each formulation.
Prophylaxis
U">-i\}*"+n
U
i`i`,ii>i/>Li\}*"`>
Treatment
U">-i\}*"+v`>]i{}*"
Q8-Q12H
U
i`i`,ii>i/>Li\}*"+v`>]i}
PO daily
18
V>ivwV>Vvi>v}>>}i\
"VL\{nnn
*>V>i\>L>`iV>i>v}>\>ViviVxx\xnx
Voriconazole
NOTE: Voriconazole does not cover zygomycoses (Mucor,
Rhizopus, Cunninghamella, etc.).
Acceptable uses
UAspergillosis
UScedosporium apiospermum
UProphylaxis in patients with hematologic malignancy
Unacceptable uses
UCandidiasis / Neutropenic fever
Voriconazole should not be used as rst-line therapy for the treatment
of candidiasis or for empiric therapy in patients with neutropenic fever.
Dose
U>`}`i\}}6*"+`i
U>i>Vi`i\{}}6*"+
Ui>`iiVi>vi>VvwViV\
U
`*} \ >i>Vi`iLx
U
`*}
\1ivLiiwi}
19
Therapeutic monitoring:
U*>V>i}ii`LiV`ii`>i>i\
U i`}i>v>i>`>
U i}i>i`vViViLi}>
U
iiV}V>>L`i
U1>LiVi}v>i>viVi}ii
Therapeutic monitoring
U6V>i}ii`LiV`ii`>i>i\
U i`}i>>vi>i>x`>vi>}>
mg/kg dosing strategy
U,iVi}VV>`}>>Vi>i`iVi>i
Voriconazole levels
U
iiV}>`iiii`i6V>i
U
iiV}`vV
U6V>i}ii`LiL>i`xq`>>vi>v
i>ivi`q
U>}\qxxV}iiV}>iLii
associated with clinical failures and levels >5.5 mcg/mL with toxicity.
Drug Interactions: See Table on p. 21
Toxicity
U6>`L>ViH>ivi`]>]vii]ii>
in hepatic enzymes.
U}\-//LL>L>ii>`iiqii>vi
,iviiVi\
6Vi\
viV\
6V>iiiVvii\
}i`{{\x
6V>i/\
viVn{\
Vi
9**{xL\`iVi>iii>LvVi>
drugs (CYP450 substrates) resulting in increased drug concentrations in
the body (occurs immediately)
Vi
9**{x`Vi\Vi>iii>LvVi>
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:
*}Vi*}L\`iVi>iivVviivy]
resulting in increased absorption/penetration of P-gp substrates
*}Vi`Vi\Vi>iivVviivy]
resulting in decreased absorption/penetration of P-gp substrates
Potencyv
Vi*{xL\6V>i>V>i
Posaconazole > Fluconazole
20
Do not use
Recommendations
Drug
iVLi`\ sirolimus
iViVLi`\ cisapride, ergot alkaloids, pimozide,
quinidine, triazolam
Cyclosporine
Metoclopramide, proton pump inhibitors
Midazolam
Tacrolimus
Cimetidine, efavirenz, phenytoin, rifabutin, rifampin
Warning/precaution
Drug
Do not use
Recommendations
Contraindicated
ITRACONAZOLE and major metabolite hydroxyitraconazole (substrate and inhibitor of CYP3A4 and P-gp efux)
Warning/precaution
Contraindicated
21
Do not use
Recommendations
iVLi`\ 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
iViVLi`\ alfentanil
Drug
Contraindicated
Warning/precaution
Drug
Cisapride
Recommendations
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
22
Prevnar 13
Yes
Yes
Yes
Pneumovax 23
Yes
Yes
Yes, revaccinate 5
years after rst dose
Yes
Yes, revaccinate 5
years after rst dose
IV`}
]V>`>i]iV`}iiaV`}
"*]ii>]
asthma
23
Pneumococcal vaccination
There are two types of pneumococcal vaccines that are recommended
L
*}`iiv>`>i\*iVVV>>VV>`i
(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.
Organism-specic 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.
U>i}>iL>VBacteroides spp., Prevotella spp.,
Porphyromonas spp., Fusobacterium spp.
U>i}>iVVVVeillonella spp.
U>iL>VPropionibacterium spp., Lactobacillus spp.,
Actinomyces spp., Clostridium spp.
U>iVVVPeptostreptococcus 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
ViVVV>iviiViViV}`ii>\
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
.
U-}V>`iL`iiv>>iLVviV>LiV>i
anaerobic organisms can cause severe tissue damage.
UVL>V>>`
`>V>iV`ii`LiivviVi
empiric therapy against Gram-positive anaerobes seen in infections
24
Propionibacterium acnes
Indications for consideration of testing for P. acnes:
U
-viV
U*iV`iviV
U"i>>Li`iViviV
Diagnosis
U
i`Lii`v{`>v}VvP. acnes
as growth is slow
U
iVvi>`y`iVivViivii`
send swabs for culture
Uiiii>iiViivi>L`Lii
for shoulder joint infections to assist in distinguishing contaminants
from pathogenic isolates these could include synovial uid, any
inammatory tissue, and synovium
U Tissue specimens should also be sent for histopathology
25
Treatment
U*iV6+{ivii`
OR
U*
>i}\6>VVii`}iV]x
NOTES
UViVi`i`v>>ViVVi>`
duration of antibiotic therapy
UP. acnes is usually a contaminant in blood culture specimens. Draw
repeat cultures and consider clinical context before treatment
U,>iiv>viV>iLiii`vP. acnes
UP. acnes isolutes at JHH are susceptible to Penicillin (see anaerobic
antibiogram p. 24)
Ui`>i`i>i>V>}>P. acnes. Tetracyclines
are not routinely tested and resistance rates are variable.
U >`iiV>}iV>iii>`*i>V
tazobactam would be expected to be active for Penicillin susceptible
isolates, but these are not rst-line therapy
U-ViL`>>`Lii`i}`ii>iV`iV
U Consider removal of associated hardware
26
`>Vi>Vixx>V`ii>Vi{
US. agalactiae} i\i>>viV]viVvi
vi>i}i>>V]>`viviV]L>Vii>
`>Vi>Vi>V`ii>Vi
27
Streptococci
U
>`iVVV\viV>S. pyogenes and
S. agalactiae>V>i``i}`i>ii}`>Lii]
>}>V]V>`>V>`i>i
`>Vi>ViH
v}
>`Hv}>i>V`ii>Vi
Hxv}
>`Hnv}>i
Streptococcus pneumoniae
U
V>ivi>>VviVV`}i`>]
]i>>V>i>`vi>>viV
involving the CNS, bones/joints and endocarditis via hematogenous
spread
UiiV>]S. pneumoniae is in the S. mitis group of viridans group
iVVVVii]>`iV>i>Li>Li
distinguish S. pneumoniae and streptococci in the S. mitis group.
U*iVi>}ivwVViviS. pneumoniae
infections when it is susceptible
U*iV>`
iv>iViLLi>>i`vviiv
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
8
0.12
1
0.5
2
1
4
2
U``v6>VV
iv>i`V>i`iiV
treatment of non-CNS infections caused by S. pneumoniae due to low
rates of resistance
/i>i\
Uiii}6+n}6+nv
-viV`Li
used for ALL severe infections if the organism is susceptible.
U
>ii}6+{V>Lii`vVV>i`1/vi
infection with adequate source control if the organism is susceptible.
U
y>V/*-8V>Lii`>>i>i
>ii
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)
U
>L>ii>i>iii>Vvii>Vi>iV]
cephalosporins, carbapenems and Aztreonam.
UVL}>L}iiv}i`wi``}ii
UvV>L>iii>VL}>Li}>
>V>L>iii>ii]ii>ViV>v
resistance is not tested for at this time.
/i>i\
Uiii}6+nvi`i`LiV`i`
in most regimens based on data from small, retrospective studies
showing benet even when the isolate is intermediate or resistant.
Ui>i>``>>}i`Li>``i`L>i`ViLi
(e.g. Amikacin, Tigecycline, Colistin) except for UTI.
Multi-drug resistant (MDR) gram-negative organisms: dened as
organisms susceptible to NO MORE than ONE of the following antibiotic
V>i\V>L>ii]>}V`i]yi]iV]
or cephalosporins. Note: susceptibility to sulfonamides, tetracyclines,
polymixins, and Sulbactam are NOT considered in this denition
Treatment
MDR Pseudomonas aeruginosa
U
iv>i>L>V>
(if susceptible)
OR
Ui`>-lactam PLUS
>}V`ivi}i`Vi`
or conrmed
OR
U
vViLi
29
U,v>VvviVV>\iVi>>>>
institution with a high rate of ESBLs, residence in a long-term care
facility and prolonged use of broad spectrum antibiotics.
Synergy:
Uvi}>ii`>i>Li>>V>>`ViLi
aminoglycosides, synergy can be assumed.
U/iVL}>L`iivi}i}
Antibiotic doses for MDR and carbapenemase-producing
infections normal renal and hepatic function
Uiii\}6+n]vii
U
ivii\}6+n]vii
U
iv>`i
ivii\}6L>`}`iii]
then 6 g IV as continuous infusion over 24 hours
U*i>V>L>V>\x}6L>`}`ii
minutes, then continuous infusion 3.375 g IV Q4H infused over 4
hours OR 4.5 g IV Q6H, infuse over 4 hours
U
\x}}Vi]ix}}6+v>``>
information, see p. 9)
UVL>V>\}6+{v,A. baumannii only)
U}V`iv`}]ii{
U/}iVVi\x}6+
U
iv>i>L>V>x}6+n
,iviiVi\
- >`VV>Vi
viVx\\\x
Current therapies for P. aeruginosa
>i
n{\
L>i>v
,
VLviV{\n
30
Gram-positive cocci
Gram-negative cocci
Aerobic
In clusters
U
>}>i\S. aureus
U
>}>iq\S. epidermidis,
S. lugdunensis
In pairs/chains
UVVV]+i}i\
S. pneumoniae
U>iV\6`>}
Streptococci, Enterococcus
(faecalis and faecium)
U i>iV\
Group A strep (S. pyogenes),
Group B strep (S. agalactiae),
Group C, D, G strep
Aerobic
VVV\N. meningiditis, N.
gonorrhoeae, Moraxella catarrhalis
Gram-positive rods
Gram-negative rods
Aerobic
>}i\ Bacillus spp.
VVL>V\Listeria monocytogenes,
Lactobacillus spp.
->]iV\ Corynebacterium spp.
>V}w>i\ Nocardia spp.,
Streptomyces spp.
Aerobic
Lactose fermenting: Citrobacter spp.,
Enterobacter spp., E. coli, Klebsiella
spp., Serratia spp.*
Non-lactose fermenting
U"`>iq: Acinetobacter spp.,
Burkholderia spp., E. coli (rare), Proteus
spp., Salmonella spp., Shigella spp.,
Serratia spp.*, Stenotrophomonas
maltophilia
U"`>i \ P. aeruginosa, Aeromonas
spp., Vibrio spp., Campylobacter spp.
(curved)
Anaerobic
>}i\Clostridium spp.
Small, pleomorphic: P. acnes, Actinomyces
spp.
* Serratia spp. can appear initially as non-lactose fermenting due to slow fermentation.
32
Penicillin G
Ampicillin
Ampicillin/sulbactam
Oxacillin/Nafcillin
Piperacillin/tazobactam
Cefazolin
Cefotetan
Ceftriaxone
Cefepime
Aztreonam
Ertapenem
Meropenem
Moxioxacin
Ciprooxacin
Azithromycin
Gent/Tobra/Amikacin
Vancomycin
Linezolid
Daptomycin
/*-8
Clindamycin
Doxycycline
Colistin
Metronidazole
E. faecalis
Not active
GRAM-POSITIVE
E. coli
H. inuenzae
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.
MSSA
MRSA
VRE
33
Active
Atypicals
34
-iii*
>i}\6>VV1
MRSA
6>VV
>V
-}iiVi>ivi>V>>i>i
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).
">V>V
S. lugdunensis
6>VV2
E. faecalis
Vn
6>VVx1
3
E. faecium (VRE)
i`n
>V
E. faecium (not VRE)6>VV3
Linezolid
4
Streptococcus spp. V}>i\
iv>i -iii*
>i}\6>VV1
"V}>i\6>VV4
S. anginosus
*iV
iii*
>i}\
iv>i
-iii*
>i}\6>VV1
S. pyogenes
*iV
iii*
>i}\
iv>
(group A strep)
-iii*
>i}\6>VV1
S. agalactiae
*iV
iii*
>i}\
iv>
(group B strep)
-iii*
>i}\6>VV1
4
S. pneumoniae
iv>i
-iii*
>i}\6>VV1
(not meningitis)
S. pneumoniae
iv>i6>VV
-iii*
>i}\
(meningitis)
>iV6>VV1
Listeria spp.
V
/iv>i>i
1Consult
35
Organism
Management
UV>ivVV>i`>ViViV]>LV`Li
given until the biliary obstruction is relieved (either by surgery, ERCP,
or percutaneous drain).
U/i>iviiVVV>ii`i```i>i
disease.
U9i>}ii>`Lii>i`vi>iiVii`v
biliary cultures, not empirically.
,iviiVi\
>>VviV\}x\n
-`iiv>>L`>viV\
viVx\q{
-Vii>v\
}i`x\qx
Diverticulitis
EMPIRIC TREATMENT
NOTE: Patients with uncomplicated diverticulitis (dened as CT
Vwi`iv`i``i>i>LVivii>w> fever
and elevated inammatory markers), can be treated conservatively
without antibiotics based on a RCT.
Mild/moderate infections can be oral if patient can take PO
UVV>>>inx}*"+
OR
U
iv>i}6+{PLUS Metronidazole 500 mg IV/PO Q8H
OR
U
>ii}6+{
OR
U-iii*
>i}\Q
y>V{}6+",
y>V
x}*"+RPLUS Metronidazole 500 mg IV/PO Q8H
Severe infections
U*i>V>L>V>x}6+
OR
U iii*
>i}\
ivii}6+nPLUS Metronidazole
500 mg IV Q8H
OR
U-iii*
>i}\Q
y>V{}6+",i>
}6+nRPLUS Metronidazole 500 mg IV Q8H
Duration
U{`>]i>`i>iViV>Vii`
40
Microbiology
U>viV>iVL>
UV>i`>iLV}>qE. coli, K. pneumoniae,
Enterobacter spp., Proteus spp., Enterococcus spp.
UV>i`>>iLV}>qB. fragilis, Prevotella,
Peptostreptococci
Other considerations
UVL>i>iv>ViVV>i``iV>
accelerate recovery or prevent complications/recurrence.
U
/V>>>i}ii`v`>>}iiii`i>i
,iviiVi\
-`iiv>>L`>viV\
viVx\q{
LV>ViVV>i``iV -}\xqx
-Vii>v\
}i`x\qx
Pancreatitis
TREATMENT
ULV> "/`V>i`>iiii>Vi
pancreatitis (SAP), including those with sterile pancreatic necrosis.
UVL>i>>ivviVL`>`>]>`
prophylactic antibiotics have been associated with a change in the
spectrum of pancreatic isolates from enteric Gram-negatives to
Gram-positive organisms and fungi.
UviVi`>Vi>ViV`iwi`L
/V>}>i
pancreas and/or percutaneous or surgical specimen with organisms
evident on gram stain or culture. Therapy should be directed based on
culture results.
U>iii}iVi`>L`>i]V`i
iVi>\
U*i>V>L>V>{x}6+
OR
U iii*
>i}\
ivii}6+nPLUS Metronidazole
500 mg IV Q8H
OR
U-iii*
>i}\
y>V{}6+PLUS
Metronidazole 500 mg IV Q8H
41
TREATMENT NOTES
>ii`{\x{
Peritonitis
DEFINITIONS
Primary peritonitis is spontaneous infection of the peritoneal cavity,
>>V>i`i`i>i>`>ViQ>iL>Vi>
i- *R
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.
Duration
U/i>v5 days
PROPHYLAXIS
Cirrhotic patients with gastrointestinal hemorrhage
U
y>Vx}*" v`>
U
iv>i}6+{V>Lii`v>i *"]i
switch to Ciprooxacin 500 mg PO BID once bleeding is controlled
Non-bleeding cirrhotic patients with ascites
U/*-8-*"Vi`>
OR
Uvv>>i}V]
y>Vx}*"`>
TREATMENT NOTES
Microbiology
U>i}>i`
iL>Vi>Vi>i]iE. coli and K.
pneumoniae), S. pneumoniae, enterococci, and other streptococci.
U*VL>viV`Vviv>
Diagnostic criteria
Ux* i 3 of ascitic uid.
U*iVix* `ii>>v*
250 OR culture remains positive, patient should be treated.
Follow-up
U
`iii>>>Vii>vi{nvi>
U
`iV>}}>LVv>Viy`* >`i`L
x>vi{n>`>iVV>i`}
Notes on prophylaxis against SBP
U>iV>`iLii``iVii
>v`>x`ii- *>viLii`
U*>i}i- *`}ivi}>iivi
i`i{qviViVii>
U*>`LiV`ii`vii
VVi>>Vi}ii
patient is in hospital.
,iviiVi\
>}]i>i>`>v- *\i>\{
>>}iiv>Vi>i>}iV\i>}{\qn
43
U*>iiVi>i}`] 1 }`>
LL{}``>iViiLxx}}
day 1 and 1 g/kg on day 3 (round to the nearest 12.5 g).
>
Complicated
iw
Duration
44
Stomach
Small Bowel
Colon
Appendix
Operated on
within
24 hours
{q{n
Operated on
within
12 hours
{q{n
Operated on
within
12 hours
{q{n
Non-necrotic or
gangrenous
appendix
{
>ii>i>iVV}>}i>i`
4 days unless adequate source control is not achieved
,iviiVi\
-`iiv>>L`>viV\
viVx\q{
-Vii>v\
}i`x\qx
45
TREATMENT NOTES
U
>>i>}iv>Li]V]>i`\>>iLii
B. fragilis), Enterobacteriaceae (esp. E. coli, K. pneumoniae,
Enterobacter spp., Proteus spp.viV>VL>
U*>}iV>}i>i>i>>Li>`>ivi
i>Vii`Li>>VL>i}i]>
change in antimicrobials is advised.
UV>}i>VL>i>`LiV`ii`>i
with hospital-acquired infections who are already on antimicrobials.
U/i>iviiVVVi>Vi>L`Li
considered in critically ill or immunocompromised patients or when
they are a dominant organism in the peritoneal culture.
U/i>ivCandida 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.
U*i>i>LVv>i`V>iiVi>iii
is clinical evidence of peritonitis, abscess, or gangrene.
ULV>i>`ViViV]V>>Li
necessity.
U>VvViV`iwi`>}}V>>>`>
undrained collection of infection.
U /
"-
\ii`}ii>`i>vV
consult pharmacy for recommendations for redosing and monitoring
Duration:q{`>
TREATMENT NOTES
Microbiology
UV>iV>i`LV>>viV>ii
U
i>Lii}>ixq
U>iVVVS. aureus, coagulase-negative staphylococci,
Enterococcus spp.), Gram-negative rods, yeast (much less common)
Diagnosis
U>iiVi`*i>i`i`>i*y`
sampled for cell count, differential, gram stain, culture AND amylase.
WBC > 100/mm 3x* }}iviV
U
i>i`>>i}}i>Vi>Liiv>
U>V>iV`y`>VV>i`L>L`>
pain and/or fever, empiric treatment should be started given the high
likelihood of infection.
U>V>iVi>y`]>i*y`iV>}i]
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.
U>>V>iV`y`]i>>Li`i>
therapy pending the results of cell count, gram stain, and culture.
,iviiVi\
-*`iiv*ii>>i>i`viV\*i>\
q{
46
47
Clinical manifestations
Asymptomatic
carriage*
Mild or moderate
Severe
Severe Complicated
Infection severity
Treatment
>V
carriage
"/i>i>iV>ii>}
disease
``i>i
Ui`>ix}*" /+n
-iii
U6>VVx}*" /+
-iii
V>i`
U
}ivi>>vViV>`
U6>VVx}L /+PLUS
Metronidazole 500 mg IV Q8H
Ixxv>i`>i>iVi` C. difcile.
Vancomycin dose can be decreased to 125 mg PO Q6H and Metronidazole can be stopped once
the patient has stabilized.
48
49
Duration
Uq{`>
iV
\-}{x\
50
51
Infectious diarrhea
Treatment
Bacteria
Campylobacter spp.
UVx}*"`>vq`>
/i>iiVi`i`v\
U-iiii
U}ixi>
UL`
U}vii
U7i}i>}
U*i}>V
UVi`
E. coli (enterotoxigenic, enteropathogenic,
enteroinvasive) or empiric therapy of
travelers diarrhea
U
y>Vx}*"
Duration:q`>
U
y>Vx}*"
OR
U/*-8n}*"
(if susceptible)
OR
U
iv>i}6+{
/i>iiVi`i`v\
U-iiiii}>>
U}ixi>
U >Vii>
U*iiVivii
U6>>i>`i>i
U-iii>iVi
U>}>ViVi
Shigella spp.
Treatment always recommended even if result
returns when patient is asymptomatic.
Duration:xq`>{`>v
immunocompromised host
U/*-8n}*"
(if susceptible)
OR
U
y>Vx}*"
Duration:`>`>v
compromised host
Vibrio parahaemolyticus
U
y>Vx}*" `>
i\V>i`iwV
Treatment recommended for severe illness
Yersinia spp.
/i>iiVi`i`v\
UVi`
U >Vii>
U*i`>i`V`i
52
U/*-8n}*" qx
days (if susceptible)
OR
U
y>Vx}*" `>
OR
UVVi}*" `>
(not for bacteremia)
Entamoeba histolytica
Treat all (even asymptomatic)
E. dispar & E. moshkovskii infections do not
require treatment
Ui`>ix}*"/xq
days
OR
U/`>i}*"+`>
UPLUS all patients should receive
Paromomycin 500 mg PO TID x 7 days
after the course of 1st agent complete
Asymptomatic patients
U*>Vx}*"/`>
Giardia spp.
Ui`>ixx}*"/
q`>
OR
U Tinidazole 2 g PO once
,iviiVi\
-`iiv>>}iivviV>i>
viV\qx
viV`>i>`iii`>``ii}Vi\
>iix\\xq
53
Parasites
54
Management
Uii>ii>`V>>ii>i`Liiixqx
>ivi`i
>Vi>Viqx>`
non-adherence.
UiVi>>}i},>`iV>LiLi`vi
PPI if patients are unable to tolerate PPIs or if drug interactions are a
concern.
UVPLUS Tetracycline can NOT be used together in treatment
due to low response rates.
ULiVViVViv/i>VVi
Azithromycin for Clarithromycin.
U>iiiii`V>`>v>}i
> 45-50 years, presence of mass GI bleeding, anemia, weight loss, or
family history of gastric cancer.
U/ivViiVi`i`> {qniii>i
,iviiVi\
Maastricht III Consensus Report. Gutx\n
ACG Guidelines. Am J Gastroenterol\nnnx
55
UH. pylori stool antigen is the only FDA approved test (>i
and specicity).
U1i>Li>i>Li>LV>>>Li
U
`VPLUS>`i>iinqxiq
specicity).
UH. pylori serology does not document current infection and should not
be used for clinical diagnosis.
U
ivi>}6+PLUS Doxycycline* 100 mg PO BID for 14
days
OR
U
>ii}6+{PLUS Doxycycline* 100 mg PO BID for 14
days
OR
U*
>i}\
`>V}6+nPLUS Gentamicin (see
dosing section, p. 146)
Step-down therapy once patient is afebrile
U*ivii`\VVi}*" Q
`>V{x}*"
QID ORi`>ix}*" RVii{`>>
*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
Ui`>}i`>Vi*`Livvii`6i}
U>i>ivi>i*vi>i>>V
U-i>i>ivi>iv>i>i*`
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
U->i>v*Lii`v>``vVViV
Duration
U/i>>i>viLiv{q{n
56
TREATMENT
Ui`>i}ix]iv>V>x}>>}>]Vi
daily for 5 days (preferred)
OR
Ui`>ix}*" v`>
OR
U
`>V}*" v`>
TREATMENT NOTES
Microbiology: anaerobic bacteria (Prevotella spp, Mobiluncus spp.),
G. vaginalis, Ureaplasma, Mycoplasma.
U/i>iiVi`i`>>Vi>`}
asymptomatic pregnant women.
Trichomoniasis (T.vaginalis)
NOTE: Treatment of partner recommended.
TREATMENT
Ui`>i}*"Vi
OR
Ui`>ix}*" v`>
Bacterial vaginosis
Syphilis
SCREENING
U-Vii}>}>\>ii>iVwV>L`i
if positive, followed by RPR. A conrmatory FTA-ABS is provided if RPR
is negative.
Ui
]>i}>i,*,>`>i/>Li`i\
old treated syphilis (2) old untreated syphilis (3) early syphilis.
Ui>`V> >i
i>i>i{{{{n
for prior history of syphilis treatment in Maryland
UviV>i}V]ViVi`i`}`ii>
Algorithm for reverse sequence syphilis screening
CIA
RPR positive
CIA positive
RPR negative
CIA negative
U
i
Treponemal test that uses a different
UvVL>}
syphilis infection
>}i/q -/**
primary syphilis
(past or present)
FTA-ABS positive FTA-ABS negative is suspected,
U,iiV> U*Li U-i
treat for early
and clinical
syphilis
viV
Uv>i>}
evaluation to
U,ii
v]
determine prior
historical and
retest in one
treatment history
clinical
month
evaluation
Neurosyphilis diagnosis
U,iiLVV>i}V>>`>L>Vi>
U>L>Vi>>VL>v\i}V>i`iViv
]i
-6,xi}iVwV]
-
iVx7
v67
v6]
-
elevated protein concentration (>50 mg/dl)
UL>Vi*`LiL>i`>ii
serological tests for syphilis plus neurological symptoms, serological
treatment failure (lack of four-fold decline in RPR titer), evidence of
tertiary syphilis
U
`i*>>V6>i>
{V350
cells/ml or RPR titer \
58
Early syphilis (primary, secondary, and early latent syphilis within one
year after infection)
U*iV i>i V L-A) 2.4 million units IM once
U-iii*
>i}i\VVi}*" vii
Note:`iVi>i`i>ViH{xv> >i>i
resistant), Azithromycin is not recommended.
Late latent syphilis (asymptomatic infection with positive serology >1
year after infection or latent syphilis of unknown duration)
U*iV i>i V L-A) 2.4 million units IM weekly for 3
weeks (total of 3 doses)
Neurosyphilis (can occur during any stage of syphilis)
U*iVq{6+{vq{`>
Syphilis in pregnancy
U*iViiVi`i`i>i}>>i
any kind of syphilis. Allergy consult for penicillin desensitization is
recommended.
,iviiVi\
-i>>i``i>i
i>i}`ii7,x,,
q
VVViv*"LiiV\xq
Discordant Results from Reverse Sequence Syphilis Screening. MMWR 2011/60
xq
59
TREATMENT
Management of catheter-related
bloodstream infections (CR-BSI)
Diagnosis
Uviii>>ii> 9iVi>ii
site, the catheter is likely infected. It should be removed and replaced
at a different site.
U7i
, -iVi`]qivL`Vi`Li
drawn with AT LEAST one (and preferably > 1) from peripheral sites.
Blood cultures drawn through non-tunneled catheters are more likely
to yield contaminants.
U/ivViviV>iiivi`iwi`]>`
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.
U/iVi\/iii`LiVi>i`>V/i
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.
U>ViiiiL`>`V>ii>iVi`>i>i
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.
U/iiVi>iiV>ii}S. aureus and
>ii}>iL`Vi/ii>i`iViixq
days of antibiotics.
U>i`Livi`Vi]>`ii>Vi`
be sent if clinically indicated.
U7i>V>iii>i` ->V>i`V>ii`vV]
consider the possibility of suppurative thrombophlebitis.
EMPIRIC TREATMENT
U6>VVii`}iV]x
iviiq}6+n
(use higher dose if pseudomonas suspected)
OR
U-iii*
>i}\6>VVii`}iV]x
Q
y>V{}6+n",i>}6+nR
Tobramycin (see dosing section, p. 146)
Empiric treatment Gram-positive cocci in clusters in 2 or more
sets of blood cultures
U6>VVii`}iV]x
60
U6>VVii`}iV]x
Change to
U">V}6+{vViLiivii`6>VV
Duration:
Uq`>vV>iiii`ivii`
Uq{`>vV>ii>>}i>i
Methicillin-susceptible Staphylococcus aureus
U">V}6+{vViLi
OR
U >>>VV*
>i}\
iv>}6+n
OR
U>>VV*
>i}\6>VVii`}iV]x
Methicillin-resistant Staphylococcus aureus
U6>VVii`}iV]x
U6>VV>i}i>Vii`>`i
U>Vn}}6+{
OR
U
iv>i}6+n
U6>VVv>i\V
TREATMENT NOTES
U,iiV>ii}i>i>ivV>iiii`
U6>VVvi">Vvi>iv--
U*>iS. aureus bacteremia should have an echocardiogram to
rule out endocarditis. Transthoracic echo is acceptable only if the study
>`i>iiiiv`i`>iiiiVi`/
Ui``Lii`ivi>ivS. aureus
bacteremia
U
i>v>{`>Vivi>
U
`V>`iV`i`/
ivii`}>//
>Li
adequate in select patients
U >i`ii
UL`Vi`>{`>>vii>Vi>i
negative for S. aureus
61
U/i>i`iviiViv>vivviVi
antistaphylococcal therapy
U/i>i>V>}}vi>>V
staphylococcal infection
U-ViV>LiiL>i`
ULiViviV`>>>vviV>LVi>viV
based on clinical judgment (e.g. poorly controlled diabetes)
Ui>i`iVii{iivi>L>i`ii
of infection
Enterococcus faecalis
NOTE: Can be contaminants. Draw repeat cultures to conrm before
>}i>ivE. faecalis blood isolates at JHH are
susceptible to Ampicillin, which should be used unless the patient has a
PCN allergy.
UV}6+{
OR
U*
>i}\6>VVii`}iVx
Duration: q{`>
Enterococcus faecium
NOTE: Can be contaminants. Draw repeat cultures to conrm before
>}i>i/i>nvE. 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.
Ui`}6*"+
OR
U>Vnq}}6+{
TREATMENT NOTES
U
`iiVV>`}>viiiiL>Vii>> 3 days)
on antibiotics.
U/i>``vi>V`i>i>V>}iVi
CR-BSI caused by Enterococcus in the absence of endocarditis.
Gram-negative bacilli
Antibiotic selection based on organism and susceptibilities.
Duration: q`>
62
Candida spp.
U,ivivi>ivV>``i>
CATHETER SALVAGE
UCatheter 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.
UCatheters associated with tunnel infections CANNOT be salvaged and
should be removed.
UWhen catheter salvage is attempted, systemic antibiotics should be
given through the infected line.
ULVi`>Vi>`ivii>>V>LV
used for systemic therapy.
Antibiotic Lock Therapy (ALT)
ULVVi>V>Lii`vV>ii>>}iin addition to
systemic antibiotics when feasible.
U
>iii>`Liivi`vVii>i>vi
72 hours of appropriate antibiotic lock therapy
Acceptable uses:
U->>}iv}iV>ii>V>Liii`i}`>
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:
U-iiV>ii
U
V>i`
, -i}iViviV]iii
sepsis, septic shock, endocarditis, osteomyelitis and hematogenous
seeding at other sites)
U
>ii>>}iS. aureus infection.
Duration:q{`>
63
TREATMENT NOTES
U
>ii>iiViViviviVii]
most advocate catheter removal if the catheter is the source.
Heparin (optional)
6>VVx} -
i>Vx} -
x
x
U/`Lii`iiviV>iiii
Uii`Li>vnqi`>
{q{n
U/iii`i`>LivV>ii>`>>>LiLi
vi}ii>]qx`LivwVi
,iviiVi\
Stability and compatibility of antimicrobial lock solutions. Am J Health-Syst Pharm.
\nxn
IDSA Guidelines for the Diagnosis and Management of Intravascular Catheter-related
viV\Clin Infect Dis {\{x
64
NOTES:
U i>>V>>ihighly preferable to Vancomycin if the organism is
susceptible and if the patient is not severely allergic. Strongly consider
PCN desensitization for allergic patients.
UviVi>iV>>`i`vV>iviv`i`
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.
U/i>iV}\
U6>VV
U>}ii\xqV}
Ui>Vv>ii}
U>`}
U>}ii\1 mcg/mL
U/>`>`}+n
U>i>ii\q{V}
U>}ii\1 mcg/mL
U-ii{n>`xv`i>
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
U*iV6+{v{ii
OR
U iii*
>i}\
iv>i}6+{v{ii
OR
UQ*iV6+{",
iv>i}6+{v
iiRPLUS Gentamicin 3 mg/kg IV Q24H for 2 weeks
OR
U-iii*
>i}\6>VVii`}iV]xv{
weeks
i>viii>i\
U*>i`i>iV>`>Vi>V>`>V>LVi
U
20 mL/min
U*>i`i>i>i`nV>>iivV
U*>i`i>iAbiotrophia, Granulicatella, or Gemella spp.
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
and 0.5 mcg/mL
UQ*iV{6+{",
iv>i}6+{v
{iiRPLUS Gentamicin 3 mg/kg IV Q24H for the rst 2 weeks of
therapy
65
6.7 Endocarditis
6.7 Endocarditis
OR
U-iii*
>i}\6>VVii`}iV]xv
4 weeks
Viridans streptococci or S. bovis with PCN MIC > 0.5 mcg/mL
and Abiotrophia defectiva, Granulicatella spp. and Gemella spp.
U
TREATMENT NOTES
U>iS. bovis biotype I endocarditis should undergo GI
work-up to rule out underlying cancer.
Staphylococcus aureus Methicillin susceptible, native valve,
right-sided involvement only
U">V}6+{
U1i >vVv">V`Vi`i>
Criteria for 2-iii>i\
U*>i>iV}`}i>iVL`i
Uiv`i`i`V>`i`/
ivii`}
quality TTE
U/i>i">V >vV
U*>i`i>i-
{< 200)
U*>i`i>i>>i`i`>}>v]iV
U `Vi>ii}>i{`>>vi>}i>
U/iii`iViviLV`i>i"/
,>iV
pulmonary emboli
U6i}i>>i>< 2 cm in size
Uv>i`iiiVi>viii>i]i>v{
weeks
Staphylococcus aureus Methicillin susceptible, native valve,
left-sided involvement
U">V}6+{
OR
U iii*
>i}\
iv>}6+n
OR
U-iii*
>i}\-}V`i*
`ii>
Vancomycin (see dosing section, p. 150)
U/i>``vi>V>Li>>V>>iVi>L`Vi
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
U6>VVii`}iV]x
66
Enterococcus faecalis
UV>`i>VViLi\V}6+{",
Penicillin G 4 million units IV Q4H PLUS Gentamicin 1 mg/kg IV Q8H
BOTH for 4-6 weeks
UVViLiV>`V>v>}V`i
i>Vi>\V}6+{",*iV{
units IV Q4H PLUS Ceftriaxone 2 g IV Q12H BOTH for 4-6 weeks
67
6.7 Endocarditis
Duration
U1VV>i`\ii
U
V>i`i>>>LViv>]i>>VVV>]
Vi``>Liii\iiiL>i`VV>
picture and response to therapy
U>`V>`>V}iViVi`i`vVV>i`
diseases
6.7 Endocarditis
OR
U-iii*
>i}\-}V`i*
`ii>v*
allergy is anaphylactic or Vancomycin (see dosing section, p. 146)
PLUS Gentamicin 1 mg/kg IV Q8H BOTHv{qii
U/i>v{iii>iLiiiiv< 3
months AND there is a prompt response to therapy
Enterococcus faecium
U
,iviiVi\
1iv
iv>iiiVVV>i`V>`\
viVx\n
68
69
6.7 Endocarditis
6.7 Endocarditis
Major criteria
Microbiologic
U/i>>iL`Viiv>V>}>\
viridans streptococci, S. bovis, HACEK, S. aureus, Enterococcus
spp.
U*iiL>Vii>>}>>i`iVi`L\
positive blood cultures drawn at least 12 hours apart OR 3/3
positive blood cultures with at least 1 hour between the rst and
last OR the majority of more than 4 cultures positive from any time
period.
U*iCoxiella burnetti (Q fever) culture or serology.
Echocardiographic (TEE strongly recommended for prosthetic valve)
U6i}i>>i}Vi",>v
regurgitant jet)
ULVi
U i`iViViviV>i
Physical exam
U
7i}}>i}v` "/
sufcient)
Minor criteria
U*i`}V`\ii`V>`]iV`}i]
prosthetic valve, ventricular septal defect, coarctation of the aorta,
calcied valve, patent ductus, mitral valve prolapse with regurgitation,
IHSS or other valvular heart disease
Uii 38.0C (100.4F)
U
LVii\>i>>iL]VV>
hemorrhage, retinal hemorrhage, splinter hemorrhage, intracranial
hemorrhage, mycotic aneurysm
U}Vii\"i`i]}ii]i
rheumatoid factor
U*iL`Vi>`iiVi>>Li",i}V
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
,iviiVi\
">i>\i`\n
-Vii>\ii`{\n
iVi>\
viV\n
-ViwV->iiviVi
`V>`\
V>x\i{{{
TEE in S. aureusL>Vii>\
>`\n
,-L>Vii>i`V>`iVi`>\
viVx\inxx
70
71
Timing of reimplantation
Blood cultures negative for
72 hours and surgical site
healing
Post-explantation blood
cultures negative for
72 hours
Duration of therapy
7-10 days if device erosion
without inammation
10-14 days all others
Oral therapy can be
considered
Non-S. aureus\ii
IV therapy
S. aureus\{ii
IV therapy
Post-explantation blood
cultures negative for
72 hours
4 weeks IV therapy
,iviiVi\
-ViwV->ii
>`>V>>>Li
iVViViviV\
V>
\{xnq
72
TREATMENT
UANTIBIOTICS SHOULD BE STARTED AS SOON AS THE
POSSIBILITY OF BACTERIAL MENINGITIS BECOMES EVIDENT,
IDEALLY WITHIN 30 MINUTES.
UDO NOT WAIT FOR CT SCAN OR LP RESULTS. IF LP MUST BE
DELAYED, GET BLOOD CULTURES AND START THERAPY.
U`i>Vi>}i>`ViLi>i
U-i>`V>iiV`ii>v>}iiVwVi>
in patients with severe allergies (p. 137).
ULV`i>i}iv
-viV
UviVi>iV>>`i`v>
-viV]
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*
>}ix
Immunocompetent*
age > 50
S. pneumo, N.
mening, H. inuenzae
S. pneumo, Listeria,
H. inuenzae,
N. mening, Group B
streptococci
S. pneumo, N.
mening, H. inuenzae,
Listeria,
(Gram-negatives)
S. pneumo (if CSF
leak), H. inuenzae,
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)
Moxioxacin PLUS
Vancomycin
Moxioxacin PLUS
Vancomycin PLUS
/*-8
Vancomycin PLUS
Cefepime PLUS
Ampicillin
Vancomycin PLUS
/*-8PLUS
Ciprooxacin
Vancomycin PLUS
Cefepime
Vancomycin PLUS
Ciprooxacin
Vancomycin PLUS
Cefepime
Vancomycin PLUS
Ciprooxacin
Immunocompromised
Post neurosurgery or
penetrating head
trauma
Infected shunt
Immunocompromised is dened as solid organ transplant, BMT in the past year, leukemia
undergoing treatment, or neutropenia
Allergy consult for beta-lactam desensitization
* Use of Dexamethasone
U``v`i>i>iiVi`i`>>`>i
suspected pneumococcal meningitis (note that this will be most adult
patients).
Ui\x}}6+vq{`>
U/iw`iLi>`ii`qiLivi
concomitant with the rst dose of antibiotics.
73
U`>v>LV`Li`i>i`}i
dexamethasone.
Ui>i>i`Li}i>i>i>i>`
started antibiotics.
U
i`i>i>ivi
->>>
positive diplococci or if blood or CSF grows S. pneumoniae
Pathogen-specic therapy (ID consult recommended)
Pathogens
Preferred
Penicillin OR Ceftriaxone
E. coli
K. pneumoniae
Enterobacter spp.
S. aureusq--
->iq,-
Coagulase-negative
staphylococci if Oxacillin MIC
0.25
Coagulase-negative
staphylococci Oxacillin MIC
0.25
Enterococcus
Candida species
Cryptococcus
Ceftriaxone
Ceftriaxone
Moxioxacin OR Linezolid
Ceftriaxone PLUS
Vancomycin PLUS Rifampin
Moxioxacin OR Linezolid
Penicillin OR Ceftriaxone
Consult ID
Ampicillin OR Ceftriaxone
Ciprooxacin*
Ceftriaxone
Ciprooxacin*
Ampicillin
Cefepime OR Meropenem
Gentamicin
Meropenem
Oxacillin
Vancomycin
Oxacillin
/*-8
Ciprooxacin PLUS
Aztreonam
Aztreonam OR Ciprooxacin
",/*-8
/*-8
y>V
Vancomycin
Vancomycin
Vancomycin
74
TREATMENT NOTES
Indications for head CT prior to LP
Uv
-`i>i>i]
6
U iiii 1 week)
U*>i`i>
Uii`VVi
UV>i}V`iwV
Duration
U-/"*i>iv*ViL>i`>LVi>
negative at 48 hours OR no PMNs on cell count
US. pneumoniae\q{`>
UN. meningitidis\`>
UListeria\`>
UH. inuenzae\`>
U>i}>iL>V\`>
Adjunctive therapy
U
`i>V>>ii}>i>i`
mental status.
Encephalitis
Uiii-6]6<6i>ii`>V>ivi>>Li
encephalitis.
U
-*
,>i>``>}Vi>`>i>iii>`
specic.
U>ii`i>viVi`>i>i`>
iVii`
U/i>i\VV}}6+nv{q`>
75
Brain abscess
U
Vi>i}`i`LiVi`Vi>``i}
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*iV",
iv>iR*1-
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
Ciprooxacin PLUS
Metronidazole
Vancomycin PLUS
Metronidazole
Aztreonam PLUS
Metronidazole PLUS
Vancomycin
Vancomycin PLUS
Ciprooxacin
Vancomycin
,iviiVi\
-`iiv >Vi>i}\
viV{\
i>i>i>`L>Vi>i}\
}i`{\x{
,iviiVi\
-`iivi>>}iiv >Vi>i}\
viV
{\
/i>ViiL>y`viV i}in\{x
77
U/iiv>iV>>LVVi>]>`}ii>
limited to refractory cases or cases in which shunt removal is not
possible. Intraventricular injection should be administered only by
experienced physicians.
,iviiVi\
-}`iiv ,-
viVx{n\ii
79
U
iL`iV>>i`VV>}`i`Viv
the middle meatus should only be obtained in patients who fail empiric
antibiotic therapy. Nasopharyngeal swab is NOT recommended for
obtaining culture data.
U
w>v`>}>}}iVi`i`v
uncomplicated ABRS. Consider CT in those with severe disease with
possible extension to the orbit or intracranial space.
U>>>>i}>}ViV>`>>>
corticosteroids are recommended as an adjuncts to antibiotic therapy
and can also provide symptomatic relief in patients in whom antibiotic
are not indicated
U>V`i
>V]V>iiVi`i`v
initial empiric therapy due to high rates of resistance of S. pneumoniae
xx>
Uii-}`ii}ivVVi>>
alternative agent for ABRS, Doxycycline is NOT recommended for
initial empiric therapy at JHH due to high rates of resistance of S.
pneumoniae >` H. inuenzae x
U,iVi>}iv,->iVi>v ,-
recommended
Orbital cellulitis
Preseptal cellulitisvV>i
Uii>iiL>i
U*iivii]ii`ii>>`vii}L
orbital congestion
Postseptal cellultis
U-}viL>Vi>i>>vV>ii]
pain with ocular movement, and/or proptosis
U-iiiviVV>>i>]Lii>>LVi]
globe displacement, abscess formation
U"vi>V>i`
U
>Li>V>i`V>iL
EMPIRIC TREATMENT
UVL>V>}6+
OR
U iii*
>i}\
iv>i}6`>
OR
U-iii*
>i}\y>V{}6`>
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)
UVV>>>inx}*"+
OR
U iii*
>i}\
iv`i{}*"+
OR
U-iii*
>i}\y>V{}*"`>
Duration
U`>iivi`iVivLii
TREATMENT NOTES
Microbiology
US. aureus, beta-hemolytic streptococci, S. pneumoniae, H. inuenza,
M. catarrhalis (cultures are infrequently positive)
Management
U>}}iVi`i`i>Vi
/,
U
>]
/]>`>}iVi`i`
80
81
U*i>ViVi`V>LiV>i
Lv}>``iV>v}>i>iVi`i`
consultation with ID
U*i>Vi>LViv>`i`>i
surgical intervention
U,ii>>i>LVi>`VV{q{n
hours
U*ii>LV]i}>>V>
changes and/or evidence of an abscess are indications for surgery
COPD exacerbations
EMPIRIC TREATMENT
UDoxycycline 100 mg PO BID for 5 days
OR
UVx}*"6+{v`>
OR
UVV>>>inx}*" vx`>
OR
U
iv`i}*" vx`>
OR
U
iv`}*" vx`>
TREATMENT NOTES
Microbiology
U*i`>H. inuenzae, M. catarrhalis, S. pneumoniae
UPseudomonas, Enterobacteriaceae are less common and seen in
patients with severe COPD and extensive antibiotic exposure.
Management
U
Vivyi`V>}i`>``
be considered if past or present microbiologic evidence indicates
infection with a pathogen(s) that is resistant to standard therapy (e.g.
Pseudomonas, Enterobacteriaceae).
U6>LV`Lii`vi>iV>i>i*"
antibiotics.
ULV>i`V>i`v>>y>ii>LiViv
pneumonia.
Prophylactic antibiotics for the prevention of COPD exacerbations
U*>VV>LV>iLiii`Vi>iv
exacerbations and improve reported quality of life but not to decrease
all-cause or respiratory-associated mortality
U*}i`Vi>Lii>V>i`i>}
>`+/}>>iL>ii+/}>ii
included in clinical trials
U/i`iV>i>VV>LV`Li>`i>
case-by-case basis and should take in to account patient preferences,
nancial constraints, risk factors for adverse events and input from the
patients pulmonologist
U,iVi`i`i}i\Vx}*"`>
U >ii>`i>`
iVi`i`
,iviiVi\
iV>
i}iv*V>**>i\ii`{\
>vi>\/>nx\{xq
Vvii\
}i`x\n
V>i>>L>i-
Rev 2013 Nov 28.
82
U/ii}i>i>}iiivVViv`>}}
legionella infection. This test detects only L. pneumophila serogroup
]ViLivqnvviV
DURATION
U/i>V>Lii`>vii>i\
UviLiv{nq
AND
U>i>iviv}}>`\,
100 beats/min, RR 24 breaths/min, BP 90 mmHg, O2 sat
]>ii`i>>
U-}}ii``>vi>L>i`>iiVwVv>V\
U35 days: Patient without immunocompromise or structural lung
disease
U7 days: Patients with moderate immunocompromise and/or
structural lung disease
U1014 days: Patients with poor clinical response, who
received initial inappropriate therapy, or who are signicantly
immunocompromised
U1VV>i`L>ViiViVVV>i>q}i`
course of antibiotic therapy not necessary, treat as pneumonia
U
}>`Vi8>>L>i>>i{qiii
There is NO need to extend antibiotics if the patient is doing well
otherwise (e.g. no fever).
Other causes of pneumonia
U-iVi`>>\ Additional empiric coverage for aspiration is justied
only in classic aspiration syndromes suggested by loss of consciousness
(overdose, seizure) PLUS gingival disease or esophageal motility disorder.
Ceftriaxone, Cefepime, and Moxioxacin have adequate activity against
most oral anaerobes. For classic aspiration, Clindamycin 600 mg IV Q8H
can be added to regimens not containing Piperacillin/tazobactam.
U
>Vi`,-\ 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 inuenza-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.
U,i>i\ 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).
,iviiVi\
-/-
i`iiv
*\
viV{{\-
S. pneumo >}i\Vii`\q
`>vi>v
*\ \xx
84
85
Ceftriaxone 1 g IV Q24
OR
Cefpodoxime 200 mg PO BID
OR
Cefdinir 300 mg PO BID
V}6+
OR
Amoxicillin 500 mg PO TID
H. inuenzae Li>>V>>i
producing (Ampicillin susceptible)
Preferred therapy
Organism
PCN allergy
VIQx}*"`>8`>",
x}Vi]ix}*"`>8{`>R
OR
iv`i}*"
OR
Cefdinir 300 mg PO BID
OR
Doxycycline 100 mg PO BID
OR
Moxioxacin 400 mg IV/PO daily
(if resistant to other options)
Same as above
Non-severe reaction:
Cefpodoxime 200 mg PO BID
OR
Cefdinir 300 mg PO BID
Severe reaction:
VIQx}*"`>8`>
",x}Vi]ix}*"`>8{`>R
OR
Moxioxacin 400 mg IV/PO daily
(if Erythromycin resistant)
Notes
86
iv`i}*"
y>V{}6*"+{
OR
Cefdinir 300 mg PO BID
OR
VV>>>i8,}*"
i\1i}Vv
i>`i>}ii}>i
Iv VViLiav/i>VViViLi
L. pneumophilia
PCN allergy
VIQx}*"`>8`>",
x}Vi]ix}*"`>8{`>R
OR
Cefpodoxime 200 mg PO BID
OR
Cefdinir 300 mg PO BID
OR
Doxycycline 100 mg PO BID
OR
Moxioxacin 400 mg IV/PO Q24H
(if resistant to other options)
Preferred therapy
VL>V>x}+
OR
Amoxicillin/clavulanate 875 mg PO BID
H. inuenzae Li>>V>>i
producing (Ampicillin resistant)
Organism
Notes
Healthcare-acquired pneumonia
(NOT ventilator-associated)
x\nn
0 points
36.5 to 38.4
{]q]
Tracheal
secretions
Chest X-ray
None
Progression
of inltrate
from prior
radiographs
Culture of ET
suction
None
Oxygenation
(PaO2/FiO2)
88
No inltrate
No growth/light
growth
2 points
1 point
36.4 or 39
38.5 to 38.9
{]
> 11,000
> 50% bands: add
1 extra point
Purulent
Non-purulent
Diffuse or patchy
inltrates
Localized
inltrate
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
U6*i
Uv6*}iVi`iii>iiVi`>Li
Uv
*-i> 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. inuenzea, S. aureus
U
iv>i}6+{
OR
U-iii*
>i}\y>V{}6+{
Late-onset VAP (all VAP that is not early-onset)
Etiology: S. aureus, P. aeruginosa, other Gram-negative bacilli
U6>VVii`}iV]xPLUSQ*i>V
tazobactam 4.5 g IV Q6H OR Cefepime 2 g IV OR +nR Gentamicin
(see dosing section, p. 146)
OR
U-iii*
>i}\6>VVii`}iV]xPLUS
Q
y>V{}6+n",i>}6+nRPLUS
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
U3 days if CPIS remains 6 in patients with initial CPIS 6*
unlikely
U7 days if the patient has clinical improvement
Uvi>`>V`i>i>iVi>`
bronchoscopy with quantitative cultures
U6*>V>i`S. aureus bacteremia should be treated for at
least 14 days
89
EMPIRIC TREATMENT
TREATMENT NOTES
UTreatment MUST be narrowed based on culture results
U/L>ViVi`i`>>iV`>}iL>`iiV
coverage rather than uoroquinolones because of high rates of
resistance to uoroquinolones in the institution.
UVL>i>`Li>i`ViViLi>i
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 benets of
combination therapy in the treatment of Pseudomonas are not well
`Vii`v`ii`]iV`i}}viw
hours of therapy only.
Diagnosis
U6*`vwV`>}i
U >Vi>i`>Vi>V>iii>Vi>V>
and NOT infection.
U+>>iViv y`V>i`}Liii
V>>`viV 104 cfu/ml is considered signicant
growth.
Other considerations
U/>Vi>V>v>i}>i>`S. aureus is not
eradicated even though lower airways are sterilized. Thus, posttreatment cultures in the absence of clinical deterioration (fever,
rising WBC, new inltrates, worsening ventilatory status) are not
recommended.
U>`i>i>i>iv6*>V>i`}i>
(even if treatment is changed once culture results are known).
,iviiVi\
/--`iiv*6\,
x\nn
V>ii6*\,
\x
6*\Vii`\
\
in\{
*-Vi\,i,i{\q
ii}Vivi>}
*--Vi\,i
>ii`
\xx>`ii
>ii`{\xqn
90
U/i>`LiL>i`Vi>`ViL`>>i
>>>Lii>}ii>iiVv>V`Li
selected preferentially
UvLi]v>}>LVi>}i>LV
U}`iv>LV`Lii`>i}ii>
and reduce the risk of emergence of resistance (see below)
TREATMENT NOTES FOR SPECIFIC ORGANISMS
UPseudomonas aeruginosa
U*i>V]
ivii]>`
iv>`i`Lii`
preferentially to Meropenem to minimize the induction of
resistance to beta-lactams by Meropenem
U/ii>}i>i}ii>VLi`}`i
aminoglycosides based on in vitro evidence that there is synergy
against Pseudomonas
U>iiV>i}]
y>Vi>
V>LiVLi`>>}V`i`ii>Li>
lactams or carbapenems should be strongly considered
U>ii>i>>}V`i]
V>
be added
U
vvLi>>V>V>LiV`ii`i
>iiinviv>
U>i`/L>V>`
V>Lii`>>`Vii>
UStenotrophomonas maltophilia
US. maltophilia isolated from sputum usually represents colonization.
UviviViVi`]/*-8iwi>}i
U/V>VV>>>iOR Minocycline may be used if susceptible in
>i>i>i}Vi>i>/*-8
UStaphylococcus aureus
US. aureus isolated from sputum can indicate colonization or
infection.
U7iii>}V>S. 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
`>V]/*-8]VVi]>`VViv,-
U">Vi`}vVViv--i>6>VV
or Linezolid can be used for MRSA pneumonia.
91
92
Diagnosis
U,i>i}`LiL>i`i>`>>i
for whom there is a clinical suspicion of respiratory virus infection. In
addition, during inuenza and RSV season testing should be obtained
>i\
Uii>`yi>ii>]>}>]>>}>]
cough, runny nose and/or headache)
U Suspected bronchiolitis or pneumonia
U COPD/asthma exacerbation or respiratory failure
U1i>i`
i>ViL>
U
`i>ii>i`ii>>i
U*i}>>ii>i`i>
U iVwV>`>`Vii`iiii
with a respiratory illness
U,i>i}>i *yVi`>L`Li
submitted for either panel)
U/i}vVii\>`ViV>V`iv,-6
and inuenza A/B
U/i}vVi`]>iLi}>`i`
i
1]>`>iV>}`i>i\ii`i`
panel for RSV, inuenza A/B, adenovirus, human metapneumovirus,
parainuenza 1-3, and rhinovirus
Treatment of inuenza in inpatients
U
Vi>iv>`>i`LiV`ii`i
v}>`}yi>i>\
U*>ivii>`yi>i]i>i`
interstitial pneumonia or new respiratory failure without an obvious
non-inuenza cause
U/i>i`Li>i`>>i>i>`i`i
hospital and have inuenza with symptom onset in the past 48-72 hours
U/ivi>iv>iii>iiViv
disease is uncertain and the decision to treat these patients can be
made on a case-by-case basis
U>VVi`ii`iiViLvVV>}>
which may vary from season to season (see
www.hopkinsmedicine.org/amp for current recommendations)
U>\x`>iViv>i`}>>>]
hematologic malignancy, or BMT in whom 10 days can be given
because of prolonged viral shedding
93
Infection control
U``>iVi`i>viV`Li
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.
Ui>V>iiiViiiyi>>VVii>
U*ii`iV>iV>i}VV>>i>>i
received the inuenza 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 inuenza 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).
UAfebrile employees who have respiratory systems must wear a
surgical mask during patient contact ( 6 ft).
Uv>>VV>i`
7ii`>>i`Vii`
inuenza 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-inuenza agents
Medication
Adult dosing
Side effects
Notes
Oseltamivir
Treatment:
75 mg PO twice a day
vx`>
Prophylaxis:
75 mg PO once a day
\>i>]
vomiting
-iii\
hypersensitivity,
neuropsychiatric
i>`i
needed for GFR
Treatment:
10 mg (2 oral inhalations)
twice daily for 5 days
Prophylaxis:
10 mg (2 oral inhalations)
Vi>`>
\`>i>]
nausea, cough,
headache, and
dizziness
-` "/Lii`
in patients with
chronic underlying
airway diseases
<>>
94
-iii\LV>]
hypersensitivity,
laryngeal edema,
facial swelling
95
U+>>ii>Liiv}`iii>
`i
V>vii>ii`v+/i\>}i0.35.
Serial testing is not advised without ID consultation.
U,`>i}`iiVwVv`>}v>Vi/
Active TB infection
UViiV>v/ V>}>i>>}
symptoms
U
wi`Li i>]/ `iViVi
U,ii>Li>
When to suspect active TB disease
High-risk individuals
U,iViii>i/ v>i/-/
6viViViV`}ivi}Li`iVi
>i}V/ V`iVi}i`i>`iiiv
}V}i}>ii}i}iLi>i`V>
`iii`]Vi>>/ >>i>
Clinical syndromes
U
}v2 wk duration, with at least one additional symptom, including
fever, night sweats, weight loss, or hemoptysis
Ui>i`i>iv2 wk duration in a patient at high
risk for TB
U>i6viV>`i>i`V}>`vii
U>i>/ >>i>i>i`vii
U
>Vi`i>V>i`>vi`>v
appropriate treatment
UV`i>w`}Vi>`}>}}iiv/ iiv
are minimal or absent) in a patient at high risk for TB
Radiographic ndings
U*>/ viiV}i`\
>iiLi
*>`i>Li
>>`i>]i>ivv>iVV>>V
`}viii>viq/ii>iVw`}
patients with advanced HIV infection and TB.
U,i>V>/ \w>iV>>iiLi
iii}iviiLi>>`i>>>Li
/
V>>>iiiL`>i>>Vi
Diagnosis
U*>iV>>ViV`i>`>`}>Vw`}`
have expectorated sputum obtained for AFB smear and culture.
U-iv i>iiV>i`xq
i6>i}iiV>i`]`Vi`]
bronchoscopy have higher sensitivity. AFB culture of lower respiratory tract
specimens is considered the gold standard.
U i>>`Vi`LiL>i`i}>`iv
8,
ndings in patients with high clinical suspicion, HIV infection or other
Vi`>i
8,>>>iv6
infected patients with pulmonary TB.
96
Infection control
LiiV>>iii`iv}V>i\
U-Vv`i>ivwVi}>>L>}
smear/culture as described above
U*i i>Vi`>}v/ /Vwi`
Smear
positive
Mycobacterium
Tuberculosis
Direct Test (MTD)
automatically
performed
Smear
negative
MTD
negative
Smear
positive
Obtain 2nd
and 3rd
specimen*
Smear
positive
MTD test
performed
MTD
positive
MTD
positive
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
97
U"L>>i>iVi`Vi`iiV>i`i}
to diagnose TB in patients who are smear negative so as to increase the
chance of isolating the organism for diagnosis and susceptibility testing.
U>Vi>>}i>/ v>iVi/
treatment, consult with HEIC and patients local health department to obtain
treatment history in order to determine if infectious at the time of current
>>i>i>LiiV>>iii`
TREATMENT
Active TB
UV}iVi`i`
U/i>`Li>i`v>ii i>>`VV>
ndings consistent with active TB.
U/i>`LiV`ii`v>ii}>i i>
when suspicion of TB is high and no alternate diagnosis exists. Multiple
specimens should be obtained for culture prior to treatment.
U`}>iiVi>v>>i
U>` I}x}}*"`>
U,v>,I}}}*"`>
U*>>`i*<}*"`>{qxx}",x}*"
`>xqx}",I}*"`>q}
U
>L
n}*"`>{qxx}",}*"`>
xqx}",I}*"`>q}
*Max dose regardless of weight.
U*`ix}*"`>iVi`i`ii >V>i`
peripheral neuropathy in patients with HIV, malnutrition, alcohol abuse,
diabetes mellitus, renal failure or in pregnant or breastfeeding women.
Drug toxicity and monitoring
U>`\>>Vii>i>Vii]i>`v>>
hepatitis, peripheral neurotoxicity
U,v>\>}i`V>vL`y`]i>V]
or without rash
U*>>`i\i>V]}>>}>]>>V
hyperuricemia, acute gouty arthritis
U
>L\iLL>>`ii>i
U }\L>iii>V>>>i]LL]>>i>>i]
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.
,iviiVi\
/--
`iiv`>}v/ \,i
>ii`\
/--
`iivi>iv/ \7,x\,,
98
99
OR
U
`>V}6+nv>ii>i>ii`i`
U`V>v>VL>i>>iV>i
>LVii\
U-iii>`}iiviV
U/iiiViviii>V>i`Vi
U-}>`viVi
UV>i`iViL
U>Liiiii
U`>Vi`>}i
UV>vi>LVi>>i>iiVii`>>}i
difcult (e.g. face, genitalia)
U>VviiV>``>>}i>i
U/i>`Li}ibefore 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
U*>VVivii>`}ii>>`>i>`
alcohol based hand gels, especially after touching infected skin or
wound bandages.
U
i`>}`Vi>]`L>`>}i
U>ii>ii}>i`i>`V}
before washing)
U,i}>L>}
U`>>}
U>`iV}]ii]ii>Liii>i
U
i>>i>}V}ii
2. Decontamination of the environment
U
i>}V>i>iL>>`viV>>Vi
against S. aureus`>i}]`iLi>V
3. Topical decolonization (consider if a patient has 2 episodes
in 1 year or other household members develop infection)
UVVi`>vx`>>LiV`ii`>i
`Vii`i`iViv,->>V>
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
Clinical Manifestations
No purulence or inammation*
Presence of purulence and 1 sign of inammation*
and cellulitis (if present) 2 cm around ulcer limited to
skin or supercial subcutaneous tissue
Moderate
Same as mild PLUS>i>iviv}\ 2
cm of cellulitis, lymphangitic streaking, spread beneath
the supercial 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
UVV>>>inx}*"
OR
U
i>ix}*"+
OR
U
`>V}*"/Vi,-
Parenteral regimens
U
`>V}6+nVi,-
OR
103
U >}i}Vi`ii>Vi
`iLi>VL>iii`>viiiViii
do not get these substances into ears or eyes
U-iV>LV>i "/iVi`i`iv`iV>
4. Evaluation of other family members
U>v>>`Li>ii`>`vii]
all members should participate in hygiene and decolonization
strategies above, starting at that same time and after the acute
infection is controlled.
U">V}6+{
OR
U
iv>}6+n
MODERATE INFECTIONS
U
>ii}+{
OR
UQ
y>VIx}*" ",
y>VI{}6+R
PLUS ONEviv}Q
`>V}6+n}*"
/",i`>ix}6*"/R
* BUT avoid uoroquinolones 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
UvV>viV,-
U,iViVi}i`>>
weeks
U/>viv>}iL>Viv>V
UiV`}i
SEVERE INFECTIONS
U*iV>L>V>{x}6+
OR
UQ
y>VI{}6+n",i>}6+nRPLUS
Clindamycin 600 mg IV Q8H
* Avoid uoroquinolones in patients who were on them as outpatients.
If patient at risk for MRSA (see above)
U*i>V>L>V>{x}6+PLUS Vancomycin (see dosing
section, p. 150)
OR
UQ
y>VI{}6+n",i>}6+nRPLUS
Metronidazole 500 mg IV Q8H PLUS Vancomycin (see dosing section,
p. 150)
* Avoid uoroquinolones in patients who were on them as outpatients
TREATMENT NOTES
Management
U`V>>>V>>}ii`V`i`
care consultation, assessment of vascular supply, vascular and/or
general surgery consultation and infectious diseases consultation.
U
`iiV}v>V>i>iiii
ULVi>`Li>i`L>i`Vii
104
Diagnosis
U
iviViL>i>vi`iL`iiV>i}`ii>
Biopsy of unexposed bone is NOT recommended. Avoid swabbing
non-debrided ulcers or wound drainage.
U1Viy`LiLi`V>ivvLiV>LiVi`>
metal probe then the patient should be treated for osteomyelitis with
antibiotics in addition to surgical debridement.
U*>>v>V>`>`iiv>ViviVV>Liii
Consider imaging to look for deep infections.
U*``V>}i`>}VviiiViv>>iLi
U,iii>`iVwV>i`>iv`iiV
of soft-tissue lesions and osteomyelitis.
Duration
U>vi>i`ii`>`vii>`
presence of adequate blood supply.
Uiii`ii>i>`i>i}V>ii
q`>>`}ivii
U
>}i>i}ii>i>Li
,iviiVi\
-`iiv`>LiVvviV
viVx{\
Microbiology
U
ii`viVi`Vi]>LV>i\
beta-hemolytic streptococci, S. aureus
UviVi`Vi]VVii>i`>LV\S. aureus,
beta-hemolytic streptococci, Enterobacteriaceae
U
i>}]]L\>VL>]>
involve Pseudomonas
U
V`}i`ii>LV\>iLV>
positive cocci (GPC), Diphtheroids, Enterobacteriaceae, other Gramnegative rods (GNR) including Pseudomonas
U iV}>}ii\i`>iLV*
>` ,]>>iLi
U*
>i}\
`>V}6+n
OR
Uiiv>`>i,-iVi`\6>VV
(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
U
>ii}6+{
OR
U*
>i}\Q
y>Vx}*" ",
y>V{}
6+RPLUS Clindamycin 600 mg IV Q8H
Patients on broad-spectrum antibiotics at time of surgery or
severely ill
U*i>V>L>V>x}6+6>VV
(see dosing section, p. 150) (if hardware present or MRSA suspected)
OR
U iii*
>i}\
ivii}6+nPLUS Metronidazole
x}6+n6>VVii`}]xv>`>i
present or MRSA suspected)
OR
U-iii*
>i}\6>VVii`}iV]xPLUS
Q
y>V{}6+n",i>}6+nRPLUS
Metronidazole 500 mg IV/PO Q8H
Deep fascia involvement
U/i>>iV}v>ViiLiiiV
TREATMENT NOTES
Microbiology
U}Vi>Vi`iiv1>V
UStaphylococcus aureus
U-iVVV]}iiV>i>i]
U
>}>ii}>i>VVV
U}Vi>V>>i`>`V>>i`Vi`iiv
GI/GU tracts with or without gross contamination)
U"}>>Li
U>i}>i`
U>iLiV`iClostridiai>iviV]q
days)
106
Uii>]iViv6>VV`V>i`LiV>ii
percentage of SSIs caused by MRSA is low at Johns Hopkins Hospital
q
Risk factors for MRSA
UvV>viV,-
U,iViVi}i`>>
weeks
U/>viv>}iL>Viv>V
UiV`}i
Fasciitis
U/iq*VL>viV>>iLi]iVVV>`
Gram-negative rods (Fourniers gangrene is a type 1 necrotizing
fasciitis of the perineum)
U/iqiVVVi`>i
U
>ivv>VV>i`LV>V>i`,->>i
been reported
Diagnosis
U
>Li`vwVq}>`Vi>>`}ii>
absent in streptococcal diseases.
U>>}`ivVi\
U*>i>iivVii]V>i>>Vi
U*>vV>w`}
Uii>i>vviVi`>i>
U,v>VV>`>Lii]iVi}iLi
U`}V>iVL>i
U*``V>}i]`>i
U
/V>V>i`>}LvV`i>i}]
surgical exploration is the preferred diagnostic test. DO NOT delay
surgical intervention to obtain CT.
,iviiVi\
-}`iiv--/\
viVx{\q{
ivii}6+nR
OR
U-iii*
>i}\6>VVii`}iV]x
Ciprooxacin 400 mg IV Q8H
U >i>L>i`Vii
TREATMENT NOTES
Microbiology
U>iVVVxvV>i>S. aureus
U>i}>i`H
108
Duration
U
`>>LViii\{qii
U6iiL>iii`>>LVi\qii
U>i>`>iii}i`>iii>
}ii>ii`>viViv6>LVii`iV
should be made in consultation with infectious diseases.
,iviiVi\
->i`>>LVi\
}i`xx\q
->i`>>LVi\+i`n\q
109
Management
U"L>ivL`Vi]
-,]>`
,*>}
antibiotic therapy.
U>i`}i>`>i}wV>
co-morbidities do not require empiric coverage for Gram-negative
rods.
U
V>i}>iVi>}i`Lii`>i`>Lii]
hardware in place or recent surgery, and recurrent urinary tract infections.
U,V>i>}}i`vVVi
UvL`Vi>ii}>i
/}`i`ii`iL>>
should be obtained for Gram stain and cultures.
U
i}i}V>V>iVi`i`v>i
signs and symptoms of spinal cord compromise.
U-}V>i>ivii`>V>ivi`>>LVi
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.
U*>i`>ivii>iivi}VvV]
particularly at the time of initial presentation.
U>iii}v>`i>iii}i
i>iViv}iVi`i`
110
Empiric treatment
i>iii>i\
U*i}>
UL`i}>}VVi`i
U*i>>>
U iiV
1VV>i`\
U v>>VL`) 100 mg PO Q12H for
x`> "/>i
x
OR
U
i>ix}*"+vx`>
OR
U
iv`i}*"+vx`>
OR
U
iv`}*"+vx`>
OR
U/*-8->L*"+v`>
OR
U6\
iv>}6+nv`>
V>i`\
U->ii}i>>LiiVi`>
q{`>
Denition
Positive urine culture 100,000 CFU/mL
with no signs or symptoms
Category
Asymptomatic
bacteriuria
Acute cystitis
U1/i>i>`>V`ii`VV>i`
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.
U">i>ivii`>``Li}ii
patient is unable to tolerate oral therapy
Uv6Li>>V>>ii`iV>v`>]
additional therapy is needed for uncomplicated cystitis
Uv6Li>>V>>ii`iV>v`>
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
U">vVV>Lii`vViLiv>
negative MDR organisms (susceptibilities must be
requested)
Notes
U"L>}iVi>>V>i
not recommended
ULV``iVi>i>>VL>Vi>
prevent subsequent development of UTIs
U/ii>iViv>>VL>Vi>
}\xii>>i]
i>>i]{x}iV>i
i`i>`i`>Lii
NOTE: Ciprooxacin is not recommended for empiric treatment for in-patients with non-catheter associated UTI at JHH due to the low rate of E. coli
ViL
111
Denition
Signs and symptoms (e.g. fever, ank 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)
Category
Acute
pyelonephritis
Urosepsis
Empiric treatment
U
iv>i}6+{
OR
U
>ii}6+{vv
-
OR
U*
>i}\i>}6+n",
Gentamicin (see dosing section, p. 147)
U>\q{`>
Hospitalized > 48H
U
ivii}6+n
OR
U*
>i}\i>}6+n",
Gentamicin (see dosing section, p. 147)
U>\q{`>
U
ivii}6+n
OR
U*
>i}\i>}6+n
Gentamicin (see dosing section, p. 147)
U>\q`>
U">
y>V/*-8>iiVii
bioavailability and should be used as step-down therapy
if organism is susceptible
U">Li>>V>`Lii`vL>Vii>
due to inadequate blood concentrations
U>viV6i>`LiVi`
towards total duration of therapy
Notes
U">i`i>`Lii`v}>
susceptible
U>viV6i>`LiVi`
towards total duration of therapy
">i`i>v}>ViLi\
U
y>Vx}*"+v`>
U/*-8-*"+v`>
U
iv`i{}*"+v{`>
U">vVV>LiV`ii`vViLiv
Gram-negative MDR organisms (susceptibilities must be
requested). Consult ID Pharmacist for dosing.
DIAGNOSIS
Specimen collection\/ii>>i>`LiVi>i`>
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
U1>>`iViLiiii`}ii
context of symptoms
UUrinalysis/microscopy:
UV
U i`V>iL>Vi>ii
UiViii>i`V>iiL`Viii
U >Vi>\iiVivL>Vi>>`Li
interpreted with caution and is not generally useful
U*>iii>iViii>i\7
v
>27 WBC/microliter
U1iVi\
Uv1i}>iv>]iVi>ii
contamination
U>i1/>i100,000 colonies of a
uropathogen. Situations in which lower colony counts may be
}wV>V`i\>i>i>i>`>LV>i
time of culture, symptomatic young women, suprapubic aspiration,
and men with pyuria.
TREATMENT NOTES
U*>iiii}vi}>iiVi>i
with asymptomatic bacteriuria usually requires no treatment. If
pyuria persists consider other causes (e.g. interstitial nephritis or
cystitis, fastidious organisms).
UiVi1>i>>i`v}}
symptoms. They should NOT be acquired routinely to monitor
response to therapy.
U-ii{v`Vvi>iv6,
>`i>
concentrations of antibiotics.
112
Category
Asymptomatic
bacteriuria
Denition
Positive urine culture
100,000 CFU/mL
with no signs or
symptoms of infection
Empiric treatment
Remove the catheter
i>iii>i\
U*i}>
UL`i}>}VVi`i
U*i>>>
"/
\L>}
U iiV
routine cultures in
Antibiotics do not decrease asymptomatic
asymptomatic patients bacteriuria or prevent subsequent development
is not recommended
of UTI
Signs and symptoms
CatheterU,iiV>iiiLi
associated UTI (fever with no other
Patient stable with no evidence of upper tract
source is the most
(CA-UTI)
`i>i\
V>i> UvV>iiii`]V`iLi>>i
also have suprapubic
OR
or ank pain)
U
>ii}6+{
AND pyuria (10
OR
WBC/hpf)
U
iv>i}6+{
AND positive urine
OR
culture 1,000
U
y>Vx}*" {}6+
CFU/mL (see
(avoid in pregnancy and in patients with prior
information below
exposure to quinolones)
regarding signicant
U>\iiLi
colony counts)
Patient severely ill, with evidence of upper tract
disease, or hospitalized {n\
U
ivii}6+n
OR
U*
>i}\i>}6+n
U>\iiLi
Urosepsis in a SIRS with urinary
U*i>V>L>V>x}6+
source and
patient with
If prior urine culture data are available, tailor
nephrostomy tubes
nephrostomy
therapy based on those results
tubes
DIAGNOSIS
-iViViV\ 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.
-\ Catheterized patients usually lack typical UTI symptoms.
-V>Li
1/V`i\
U ivii}iVi
U ii`i]>>i]i>}iVi
U
6i`ii]y>>]iV`Vv
UVii>>
Interpretation of the urinalysis (U/A) and urine culture
U*>\iiiViv>V>ii]>`iVi>i
the presence of symptomatic CA-UTI and must be interpreted based
on the clinical scenario. The absence of pyuria suggests an alternative
diagnosis.
U*iiVi\ 1,000 colonies
113
DURATION
The duration of treatment has not been well studied for CA-UTI and
optimal duration is not known.
U`>viv
Uq{`>v`i>i`ii
U`>vV>iiii`vi>i>i 65 years with lower
tract infection.
TREATMENT NOTES
U,iiiV>iiiiiLi
U,i>ViV>ii>>iLii 2 weeks if still indicated
U*>VV>LV>iivV>iii>i>Vii
are NOT recommended due to low incidence of complications and
concern for development of resistance.
U
>ii}>`Lii`i
Treatment of Enterococci
U>E. faecalis isolates are susceptible to Amoxicillin 500 mg
PO TID OR Ampicillin 1 g IV Q6H and should be treated with these
>}i>i*
>i}\ v>>VL`)
}*"+` "/i>i
x
UE. faecium (often Vancomycin resistant)
U v>>VL`) 100 mg PO Q12H if susceptible (do NOT
use in patients with CrCl 50 mL/min).
U/i>VVix}*"+vViLi
UvV}*"Vivvi>iV>iiV>ii
ii`>iV>LvViL
Ui`}*" ",vV}*"iiq`>
(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, Ciprooxacin,
Colistin, Ertapenem, Trimethoprim/sulfamethoxazole, Vancomycin,
Amphotericin B, Fluconazole, Flucytosine
Variable (30-60%):
iv`i]i`]VVi
qxx]
iv>i]/i>VViH
Poor (<30%): Azithromycin, Clindamycin, Moxioxacin, Oxacillin,
Tigecycline, Micafungin, Posaconazole, Voriconazole
,iviiVi\
*>>`>V>ii\Vi`x\
IDSA Guidelines for treatment of uncomplicated acute bacterial cystitis and
iii\
viV\{x
-`iivi>iv
1/\
viVx\xq
114
115
Symptomatic cystitis
Preferred therapy
UV>i}6*"Vi`>
Duration:q{`>
Fluconazole-resistant organism suspected or conrmed
UiV }}6Vi`>
Duration:q`>
Pyelonephritis
NOTE: Candida pyelonephritis is usually secondary to hematogenous
spread except for patients with renal transplant or abnormalities of the
urogenital tract.
Preferred therapy
UV>iq{}6*"Vi`>
Duration: 14 days
Fluconazole-resistant organism suspected or conrmed
UiV xq}}6Vi`>
OR
UV>v}}6Vi`>
Duration: 14 days
TREATMENT NOTES
U,ii>V>iivLi
U/i>vV>``>iiiV]
1V>iii`
patient has not been shown to be benecial and promotes resistance.
U i, Voriconazole, Itraconazole, and Posaconazole are not
recommended due to poor penetration into the urinary tract.
UV>v}ii>iii]L`iii>i
renal tissue.
UiV L>``i>i>iiVi`i`
Candida vaginitis
Initial Therapy
UV>ix}*"8`i
OR
UV>iVi>x}>>}>Vi`>8`>
Recurrent (> 4 episodes/year of symptomatic infection)
UV>ix}*"+8`i]ix}>ii8
6 months
116
U9
-/ ""
1/1,
-"1 "/
" -
,
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
UV>in}6*"8`i]i{}6*"Vi`>
Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy
UV>v}}6Vi`>
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
UV>in}6*"8`i]i{}6*"Vi`>
Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy
UV>v}}6Vi`>
Patients should be transitioned to Fluconazole once stable.
Candida glabrata
UV>v}}6Vi`>
OR
UV>in}6*"8`i]i{}6*"Vi`>
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
UV>v}}6Vi`>
Fluconazole should NEVER be used to treat infections due to C. krusei
because the organism has intrinsic resistance to Fluconazole. This
iV>vi>Vi>i`6V>iiivi]
oral Voriconazole can be used if isolate is susceptible (for dosing see
Voriconazole specic guidelines, p. 19).
117
Candidemia
Candida lusitaniae
UV>in}6*"8`i]i{}6*"Vi`>
C. lusitaniaei>iV >>iv
cases.
Candida parapsilosis
UV>in}6*"8`i]i{}6*"Vi`>
Fluconazole-intermediate isolate
UV>in}6*"Vi`>
Fluconazole-resistant isolate
UV>v}}6Vi`>
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.>i`VVi>iviVC. parapsilosis
may not respond well to echinocandins.
Candida tropicalis
UV>in}6*"8`i]i{}6*"Vi`>
Fluconazole-intermediate isolate
UV>in}6*"Vi`>
Fluconazole-resistant isolate
UV>v}}6Vi`>
TREATMENT NOTES
Amphotericin B use in Candidemia
UiV }ivviVi>}>>Candida spp. except
for C. lusitaniaeii]>i>`iVV>`>iv>i`
susceptible strains over Amphotericin B products due to toxicity.
Doses for Candidemia
UiV }}6Vi`>
OR
U i 3 mg/kg IV once daily (if patient cannot tolerate
conventional Amphotericin B)
Duration
U{`>v}`Vii`Vi>>VivL`Vi>`VV>
symptoms
U*>iiiV>``i>>`i>>VVV>
(e.g. endophthalmitis, endocarditis) need a longer duration of therapy
and evaluation by Ophthalmology and ID.
118
Hidden Content
- JHH Internal use only
Non-pharmacologic management
U,i>v>i}Vi>iV>ii}
recommended.
U*>i`>iL`Vi`>iii`>
candidemia is cleared.
U*>i`>i>>}Vi>>iV`i
candidal endophthalmitis prior to discharge, preferably once the
candidemia is controlled.
U
VV>`}>V>LiV`ii`vi>i>ii
candidemia on appropriate therapy.
Endophthalmitis
U>>}iiVV">}
Ui
->`i>ii>]i>iiVV>`
is NOT recommended.
Preferred therapy
UiV }}6Vi`>Vix}}*"+
OR
U ix}}6Vi`>Vix}}*"+
Alternate therapy
UV>i{n}6*"Vi`>Vix}}
PO Q6H
Duration: {qii
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
Preferred therapy
U ix}}6Vi`>
Alternative therapy
UV>v}x}6Vi`>V>i{qn}6*"
once daily
Duration: 6 weeks or longer
Notes on antifungal susceptibility testing
U-ViLi}vV>i]>V>i]6V>i]
Flucytosine, and Micafungin is performed routinely on the rst yeast
isolate recovered from blood.
UV>i>`V>v}ViL>iii`>>i
U"}>>>iV>v}
i>}ivqV}
(reported as susceptible) may not respond to treatment. ID consult is
recommended in these cases.
U-ViLi}vVi>iV `ii
for C. lusitaniae and C. guillermondii, and for other organisms by
request.
Uvi}>ii`>iV>i]in}6
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.
U-ViLi}`LiV`ii`i\
UVV>iV>``>iv>VV>i
U/i>}ii]i}]i`>
Fluconazole
U `Vi>iiiiV>i
U iViLi}V>Li>>}i`LV>}i
mycology lab at 5-6148
Notes on Fluconazole prophylaxis
UV>i>`Lii`iv}i}
U*>iiiVi`i>iSICU or WICU for 72 hours
i>v-
1>`>i
ICUs has NOT been studied and is NOT recommended).
U iiV>i`i}}Li>>>>
treatment for leukemia/lymphoma
U*>i>ivi>Vi>>>
UV>i>`Lii`i-
17
1
patients are transferred to the oor
,iviiVi\
-`iiv/i>iv
>``>\
viV{n\xxx
V>i>}V>>i\-}\x{qn
120
iVwVVi`i>`>}iii*ii>i>LV
>`Vi>`ii`Vi}>
Drug
iv>
ivi>
Clindamycin
Ciprooxacin
Gentamicin
Metronidazole
6>VV
Usual dose
}\}
}\}
}\}
}\}
600 mg
400 mg
5 mg/kg
500 mg
}\}
}\x}
}\x}
Important notes
U/}VV>LVLiiii
incision is made to be effective.
U
i>V>Li>`ii`iqx6Livi
the procedure and will achieve appropriate skin levels in minutes.
Vancomycin and Ciprooxacin must be given over 60 min. Clindamycin
`Livi`iq
U>LV}ivii}6>VV]
Ciprooxacin) the infusion should start 30 minutes prior to incision
UPost-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.
U*>iiVi}ii>i>LV}ii>` "/ii`
additional antibiotics for endocarditis prophylaxis.
U*>v>i>i>`>LV\
U>LVi>6>VV\`>`}`i
1 hour before incision
U6>VV\,i`i>v`ivn>i>i`Vi
the last dose or a half dose if fewer than 8 hours have passed in
patient with normal renal function
Ui>V`Li}i>>}i`ivx}}>i
tissue penetration and minimize toxicity.
Uv`>
]i}}
Ui`i
U1i>V>L`i}i>ii`i>L`
weight (see p. 145)
121
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
*iiiii
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`>>>Vi`i}V
Prophylaxis
recommendations
PCN allergy
alternate prophylaxis
Cefazolin
Cefazolin
Ciprooxacin OR Gentamicin2
Gentamicin2
Gentamicin2
Clindamycin
Clindamycin PLUS
Gentamicin2
Q
iv>",6>VVRQ
`>V",6>VVR
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
Ciprooxacin
Consult transplant ID
Prophylaxis not
recommended
Cefazolin
Prophylaxis not
recommended
Clindamycin OR Vancomycin
ivi>
6>VVi>V2
Thoracic surgery
Lobectomy, pneumonectomy, lung resection, Cefazolin
thoracotomy, VATS
Esophageal cases
Cefotetan
Neurosurgery
Craniotomy, cerebrospinal uid-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 xation
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
Moxioxacin 400 mg
Clindamycin OR Vancomycin
Clindamycin PLUS
Gentamicin2
Clindamycin OR Vancomycin
Vancomycin
Clindamycin
Prophylaxis
recommendations
General surgery
*Vi`i}iivi
ivi>
GI tract, gastric bypass procedures,
pancreaticoduodenectomy, highly selective
vagotomy, Nissen fundoplication
>>VVi`ii}ViViV]
ivi>
choledochoenterostomy)
i>iV
ivi>
Whipple procedure or pancreatectomy
Cefotetan
Small bowel procedures
Cefotetan
*
Appendectomy (if complicated or perforated,
treat as secondary peritonitis)
Colorectal procedures, penetrating abdominal
trauma
Inguinal hernia repair
V>i`]ii}iii>}>
hernia repair
Mastectomy
iv>",
ivi>
Cefotetan
Cefotetan
Cefazolin
ivi>
PCN allergy
alternate prophylaxis
`>Vi>V2
`>Vi>V2
`>Vi>V2
Clindamycin PLUS
Ciprooxacin
Clindamycin PLUS
Gentamicin2
`>Vi>V2
Clindamycin PLUS
Gentamicin2
Clindamycin PLUS
Gentamicin2
Clindamycin
`>Vi>V2
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
Cefazolin OR Cefotetan
Oncology procedures
Cefotetan
Cefazolin
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 aps
Rhinoplasty
Prophylaxis not
recommended
Clindamycin
Clindamycin
Clindamycin
Cefazolin
Cefazolin
No prophylaxis OR
Cefazolin
Clindamycin
Clindamycin
No prophylaxis OR
Clindamycin
Cefotetan
Cefazolin
Cefotetan
Clindamycin PLUS
Ciprooxacin
Clindamycin
Clindamycin PLUS
Ciprooxacin
1viiV>Viiivi`\ii{
2Do
3For
4Listed
123
Procedure
Procedure
Prophylaxis
recommendations
PCN allergy
alternate prophylaxis
ivi>
`>V
percutaneous liver ablation (hx. of
PLUS Gentamicin
L>}ii>
cecostomy
iiL>wL`i
*>
>iiL>iV>i
iVi`i`
ii>}I>L>>V>
vascular malformation embolization
Urologic procedure (not ablation)
Cefazolin
Gentamicin
Lymphangiogram/embolization
Cefazolin
Clindamycin
Placement of tunneled catheters
Prophylaxis not
i}Vi>ii>i>
iVi`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
Ciprooxacin
susceptible
y>V
i>]/*-8
susceptible
/*-8-Livi
Vi`i]>`-
before
/*-8-*"Vi
>viiVi`iv,
ml/min no need for post-op dose.
Ciprooxacin and
/*-8i>]
Cefazolin susceptible
Ciprooxacin,
/*-8]
Cefazolin resistant
OR
Ceftriaxone 1 g IV over 30 min if
susceptible
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:
U*>i>iiVii`>LVv}V>>`
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
U*iVV>`>V>i
U*ii`ivviVii`V>`
U
}i>i>`i>i
U1i>i`V>V
]V`}>>i>`V`
U
iii>i`V}i>i>`iviViV
material or device, whether placed by surgery or by catheter
intervention, during the rst 6 months after the procedure
U,i>i`
i`>`iviV>ii>`>Vii
site of a prosthetic patch or prosthetic device
U
>`>V>>>iVi`iiV>`>V>>
Antibiotic prophylaxis is recommended for the following dental
procedures ONLY:
U>>v}}>ii>V>i}vii
U*iv>v>V>
Antibiotic prophylaxis is recommended for the following
respiratory tract procedures ONLY:
UVLvii>V>
Antibiotic regimens
UV}*"LiviVi`i
OR
U*
>i}\
`>V}*"LiviVi`i
OR
U*
>i}\Vx}*"LiviVi`i
OR
U*>i>Li>i>i`V>\V}6
before procedure OR Cefazolin 1 g IM/IV 5 minute push prior to
procedure
,iviiVi\
`iiv*iivviVi
`V>`\
V>\qx{
125
Duration
6,
6>}>VV 450 mg PO daily
6,
6>}>VV 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 prophylaxis
i\/*-8i-->Li*"`>
-iV`i\>ix}*"`>
/`i\>iI}*"`>",
aerosolized Pentamidine
6,
6>}>VV 450 mg PO daily
3 months
6,
6>}>VV 900 mg PO daily
Anti-fungal prophylaxis Clotrimazole troches 10 mg PO QID
1 month
PCP prophylaxis
i\/*-8i-->Li*"`>
-iV`i\>ix}*"`>
/`i\>iI}*"`>",
aerosolized Pentamadine
Duration
Liver transplants
Indication
6,
6>}>VV 450 mg PO daily
6,
6>}>VV 900 mg PO daily,
followed by PCR monitoring
Anti-fungal prophylaxis Fluconazole 400 mg PO daily
PCP prophylaxis
i\/*-8i-->Li*"`>
i>i\>ix}*"`>
or Dapsone 100 mg PO daily
126
3 months
3 months
6 months
6 weeks
Indication
6,
>i-6}6<6}
positive. If positive serology, Valacyclovir
500 mg PO BID
6,
6>}>VV 900 mg PO daily
6,
6>}>VV 900 mg PO daily
Anti-fungal prophylaxis Nystatin suspension 500,000 units QID
PCP prophylaxis
Duration
3 months
6 months
Until
prednisone
dose 10
mg/d x 3
months
i\/*-8--i>Li*"`>",
/*-8i->Li*"iiiii
-iV`i\>iI}*"`>
/`i\>ix}*"`>
Toxoplasmosis prophylaxis
i\/*-8i-->Li*"`>
/,
-iV`i\>iI}*"`>PLUS
Pyrimethamine and Leucovorin
/
i\/*-8i-->Li*"`>
`>
-iV`i\>iI}*"`>PLUS Lifelong
Pyrimethamine and Leucovorin
Lung transplants
Indication
Duration
Anti-viral prophylaxis
CMV D-/RReceived
non-leukoreduced
or CMV unscreened
PRBCs
Lifelong
6,
>VVx}}6+{`>]i vi}
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.
6,
>VVx}}6+{`>]i vi}
Ganciclovir 5 mg/kg IV daily x 3 months, then
Valganciclovir 900 mg PO daily (until CMV shell
127
Heart transplants
AspergillusV>
PCP prophylaxis
>x] +
extubated, then Clotrimazole troches
10 mg PO Q6H until prednisone dose
10 mg daily
6V>i`i`Li}
}\6V>i}*"
69 kg to {}\6V>i
300 mg PO BID
{}\6V>i{}*"
i\/*-8i->Li*"
iiiii",/*-8i
SS tablet PO daily
-iV`i\>iI}*"`>
/`i\>ix}*"`>
During initial
hospitalization
stay
q
vi}
r`],riVi]qrii}>i]rii
NOTES:
/*-8i>i`VivviVListeria 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 deciency 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.
/*q
128
NOTE: These guidelines were developed for use in BMT and leukemia
patients and may not be fully applicable in other instances.
Denitions
U ii>\
x3
Uii\/inc
i>i>>>",
Temp > 38.3 C times one
TREATMENT
Always tailor antibiotics based on susceptibility proles
vi>iiiii>Li]ii/i>iv
VV>>Li>ii
Initial fever
U
ivii}6+n6>VVIii`}iVx
OR
U*i>V>L>V>x}6+{6>VVIii`}
section p. 150)
I`V>v6>VV\iVi`
, -]>`viviV]
pneumonia, severe oral or pharyngeal mucositis, history of MRSA infection or
colonization.
OR
U-iii*
>i}>>>-ii-`i\
Strongly consider allergy consult to verify allergy in patients with
unclear histories (see section on Penicillin allergy, p. 137)
Ui>}6+nPLUS Gentamicin (see dosing section, p. 146)
PLUS Vancomycin (see dosing section, p. 150)
If strong concern for nephrotoxicity and no prior uoroquinolone use, can substitute
Ciprooxacin 400 mg IV Q8H for Gentamicin.
129
Neutropenic fever
130
NOTE:`i>i>i>vV`i`wV>>Li`V>i`v
reduced CrCI.
1. Leukemia patients
Indication
Duration
Antibacterial prophylaxis
Day 1 until
ANC
100/mm3 OR
initiation of
ii
antibiotics
v}>>
i\6V>iii`} /iV
-iV`i\*>V>ii}
PO TID OR 300 mg tablet daily
i>i\V>v}}6+{",
>
100/mm3
*
*>
in high risk patients
Day 1 until
ANC
100/mm3
i\/*-8i-->L*"`>
-iV`i\>i}*"`>
/`i\>ix}*"
>
i
resolves
Indication
Duration
Antibacterial prophylaxis
(lymphoma only)
Antifungal prophylaxis
Day 7 of
chemo until
ANC
500/mm3
Day 1
through all
cycles of
chemotherapy in
high risk
patients.
Antiviral prophylaxis
Day 7 through
all cycles of
chemotherapy
i\/*-8i-->L*"`>
-iV`i\>i}*"`>
/`i\>ix}*"
>}
>VViv
Vi
therapy
*
*>
in high risk patients
131
Indication
Duration
Antibacterial prophylaxis*
Antifungal prophylaxis
v}>>
patients with GVHD
i\*>V>ii}*"
TID OR 300 mg tablets daily
-iV`i\6V>i`i`Li}
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
Day zero
until 1 yr
(allogeneic
transplants)
or 6 months
(autologous
transplants)
i\/*-8i-->L*"`>
-iV`i\/*-8->Liii
OR Dapsone 100 mg PO daily
/`i\>ix}*"
i\*i>`i} +n`>
}iiV
>>\
Day 21 or
i}>vi
Vii
is later)
until at least
1 year
(longer if
steroids or
ongoing risk)
Autologous
>>\
Engraftment
until 6 months
PCP prophylaxis
NOTES:
/*-8i>i`VivviViV>>i`L>Vi>]Listeria spp., Nocardia
spp., and Toxoplasmosis, but does not eliminate risk. It is the preferred antibiotic regimen for
PCP prophylaxis.
*In patients with uoroquinolone allergy or who cannot tolerate a uoroquinolone due to QTc
prolongation, consider Cefpodoxime 400 mg PO BID.
Acyclovir should be dosed by ideal body weight
i>>ivi`>>iv6]VVi`]y`>>Li
ii>>i\]VVi`] /i>>vi>>]>i
received cladribine, udarabine, or alemtuzumab.
"i>>Vi6\y>V]/*-8
132
Filamentous fungi
ID consult recommended for assistance with antifungal selection
TREATMENT
Aspergillus spp.
Initial therapy
U6V>i}}6*"+i`ii{}}6
PO Q12H (see Voriconazole guidelines, p. 19, for more information).
OR
U i 5 mg/kg IV Q24H
NOTES:
U6V>iV`ii`L>Liiwii>iv
suspected lamentous 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.
U
L>>v}>i>V}v6V>iPLUS
Micafungin should be considered for the treatment of conrmed
invasive aspergillosis that is documented by culture, positive
galuctomannan assay, or histopathology for the rst two weeks
of therapy. Longer duration of combination therapy has not been
evaluated.
Fusarium spp.
UV`Lii`iiV>i
U6V>i}}6*"+i`ii{}}
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
U6V>i}}6*"+i`ii{}}
IV/PO Q12H PLUS Micafungin 100 mg IV Q24H (see Voriconazole
guidelines, p. 19, for more information).
NOTE:
U/i>ii>}i>i`i``>}i
Voriconazole appears to be the best option but the data are limited.
133
Candida parapsilosis
U iqx}}6+{
NOTES:
UC. parapsilosis isolates remain susceptible to Fluconazole, which
can be used in stable and non-neutropenic patients.
U/ii>ii``>>>}}i>V>v}>Livi
Amphotericin B in these infections.
Candida tropicalis
UV>v}}6+{
OR
U iqx}}6+{
TREATMENT NOTES
Hidden Content
- JHH Internal use only
135
A
6.20 Guidelines for use of antimicrobials in neutropenic hosts
UV>i>`V>v}ViLi>iii`>L`
isolates.
U"}>>>iV>v}
i>}ivqV}
(reported as susceptible) may not respond to treatment. ID consult is
recommended in these cases.
USusceptibility testing for conventional Amphotericin B is done routinely
for C. lusitaniae and C. guillemondii and for other organisms by
request.
U-ViLi}`LiV`ii`i\
UVV>iV>``>iv>VV>i
U/i>}ii]i}]i`>
Fluconazole
U `Vi>iiiiV>i
U iViLi}V>Li>>}i`LV>}i
mycology lab at 5-6148
,iviiVi\
-`iiv/i>iv
>``>\
viV{n\x
136
U>>VV>viv>`>
U "/i`Vi`L>v>",Li
Approach to the patient with reported penicillin allergy
U iv]vVi`V>Li6
,9iv
U+i>\
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>>>L>`i>ii\}i]iyi]
Trimox, Ceftin, Vantin)?
6. If the patient received a beta-lactam, what happened?
Interpreting the history of the patient reporting penicillin allergy
UANY patient who has a history consistent with an immediate
reaction (laryngeal edema, wheezing, angioedema, urticaria)
SHOULD NOT receive beta-lactams without undergoing skin
testing rst EVEN IF they have received beta-lactams with no
problems after the serious reaction.
U*>ii>>>VVi>V>`>iiVii`
other penicillins without problems DO NOT have penicillin allergy
and are not at increased risk for an allergic reaction compared to
the general population.
U*>ii>>>VVi>V>`>iiVii`
cephalosporins can get cephalosporins but not necessarily PCNs.
U*>ii>v>V>>>> "/
consistent with Stevens-Johnson syndrome (target lesions with
mucous membrane inammation) 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.
U*>iii>VViiVi
(rare) can receive either penicillins or cephalosporins with careful
monitoring for recurrence.
U*>ii`>i>]>i>L>L`
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.
,iviiVi\
nx\{n
1ivV>L>ii>i*
>i}\VL
ii{x{\
xxq
ii`{\q
138
U
i
iLiVii*"
hopkinsmedicine.org/heic) for detailed isolation charts, HEIC policies,
and surveillance information
Hand hygiene
Uv>`>iLi`]i>VL>i`>`>i>i
recommended for cleaning. If hands are visibly soiled, wash hands
with soap and water for at least 15 seconds.
U>`}iiii`ii}>>i]i}]
between patients in a semi-private room, and other times per hospital
policy.
U1i>>`>iexiting the room of a patient with
C. difcile infection.
U >wV>w}i>>iii`v>>vviLi>
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 rst priority.
U-``LiVi>i`>>`>i
UViL>i`Liyi`}>i
U
i`Li}>i`>iv>>i
viVi>}iiii]V>x-/8xn{>`v
instructions to contact the ID physician. Workplace injuries should be
ii`i`>ii
ii,ivV`i>`
to the Occupational Injury Clinic >V]`>q`>]\
a.m. to 4 p.m., 5-6433), and to your supervisor.
Standard Precautions
U,i>`}ii
U
i>`ViV}ii
U >}V>>i`i>vi
U,i}>Vi>}vii>
surfaces
U>iiv}ii U,iVi>}`>v
contamination of uniform/clothing
patient-care equipment
U>iiv>]ii
U-V>`iiVi
protection and face shields (i.e., when
occupational safety requirements
suctioning, or when splash likely)
139
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
140
141
To enter room
MRSA, C.diff, zoster
Door closed
Mask/Eye Protection
Droplet
Precautions
(orange)
Required unless
cohorted*
No
If within 6 feet
of patient
To enter room
Inuenza, bacterial
meningitis
Yes
PAPR or N95 to
enter room
No
TB, disseminated
zoster
Airborne
Precautions
(blue)
Required
(sign color)
Private room
Contact
Precautions
(pink)
Required unless
cohorted
No
No
1]
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 deagging.
Pertussis
All patients with pertussis should be placed on Droplet Precautions
for ve 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.
/i>i\
UVx}*"Vi`>]ix}*"`>
`>qx
OR
U>V`i>i}\/*-8->Li*" v{`>
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.
U*>iii`
U*>iVi>V>LiLii>i`>V>LV`i
once, and the precautions may be discontinued 24 hours after the
treatment is completed.
U*>i i}>V>Liiii>i>V>LV`i
1 week apart. Contact precautions may be discontinued 24 hours
after the second treatment is completed.
Uvii`V}>`i`Lii>i`>>VL>}v{n
hours. The mite will not survive off a human host for more than 48
hours. Clothing/patient belongings should be sent home with the
patients family/caretaker. Linens and clothing should be washed in
the washing machine on the hot cycle.
143
Uv}i`V>VVV>V>Li>i]
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
iiiVV>iiV`ii>i >Vi}-
6,
--
7i>Vi}6,
]i>iy>}}i`
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
iv}\
1]7
1]
6-
1]-
1]
/17] />`
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 deagging.
Varicella-Zoster
Immunocompetent patients with disseminated zoster and all
immunosuppressed patients with zoster need Contact AND Airborne
Precautions/iv}`iw>>ii\
UImmunosuppressed:Li>>>i>i>
>Viii>`}>>>iVi>iiVi}
cytotoxic or immunosuppressive treatments, including steroid
treatment for `>iv}`i\`i>i>i
3 mg daily, cortisone 100 mg daily, hydrocortisone 80 mg daily,
i`i}`>]ii`i}`>6>i
with CD4 < 200
UDisseminated: lesions outside of 2 contiguous dermatomes
144
Extended-interval dosing, also sometimes referred to as oncedaily administration, utilizes higher dose and less frequent
aminoglycoside administration, whereas patient-specic 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 patients 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 brosis patients, see the
Cystic Fibrosis section (p.92)
145
Dosing
Patient-specic dosing
,i>v>i]
66]i`V>`]
Gram-negative infections (in combination with
beta-lactams), CNS infections, septic shock,
burn patients, patients with altered volume
status (e.g. ascites, anasarca, trauma)
i}r`ii`i>Q7i}}6`
}R
}i>L>i`
\+nI
\+
66\`iLii
Extended-interval dosing
U >i>vV
Peak
Pneumonia
Septic shock
Endocarditis
Osteomyelitis
MDR
organisms
Trough
Gentamicin/
Tobramycin
10 mcg/mL
Amikacin
8-10 mcg/mL
20-30 mcg/mL
25-35 mcg/mL
Gentamicin/ Amikacin
Tobramycin
All Indications V} V}
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.
``i\
U
V>iV
Frequency of monitoring
medications
U"Vi>ii>vi`ii`i>}
U
>ii
established in patients with normal renal
U}i 60 years
function
U*>ii
1
Ui>Viii\
U"iviV
After changes in dosing regimen
i}`>Lii]`i/8
Patient is on dialysis
If trough higher than desired
Patient in acute renal failure, SCr increased troughs, use patient specic
Lx}`vL>ii
dosing to adjust dose.
Major changes in the patients volume status
146
Gentamicin/Tobramycin
3 mg/kg IV Q24H or
1 mg/kg IV Q8H
1 mg/kg Q12H
1 mg/kg Q24H
}}"
I
Amikacin
10 mg/kg IV Q24H or
3 mg/kg IV Q8H
3 mg/kg IV Q12H
3 mg/kg IV Q24H
}}6"
I
*Give one dose, check level in 24 hours, redose when Gentamicin/Tobramycin level
V}>V{V}
}V`i>i}VVi>i`iiivi]i>iV
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 insufciency
,>`v-
Vi>iLx}`v
baseline while patient on aminoglycoside therapy.
UGentamicin/Tobramycin:`ii`}V}`iiV>Li
UAmikacin:`ii`}{V}`iiV>Li
147
Dosing
}}+
}}+{
}}"
I
Iii`i]ViVii{]i`iiii}
148
NEPHROTOXICITY
USerum creatinine should be measured at least every other day. If
Vi>iVi>iLx}`vL>ii]i>i
specic dosing.
Ui>iserum aminoglycoside levels as needed. See each dosing
section above for frequency.
U-i`>>}}i>iiiviVVVi
aminoglycosides are administered during the activity period (e.g.
\]iivi>vi>`>ivii`
OTOTOXICITY
U
`iLiiVV>Vii}vV
U
iVL>ii>>V}>-iiViV>`
U/ViivV]>i>i>ii>`>`iii>`
card.
U
Vi`Li>i`v>iiiv>>V
Consider formal audiology testing.
U
>V`}xxvii}vV
,iviiVi\
**>>ii\viVnxx\q
"Vi`>}>ii\Pharmacotherapy \qn
*>iiVwV`}\Crit Care Med\{nq{nx
-
17
1`}\Surgeryn{\n
iV\Antimicrob Agents and Chemother{\
/--VL>Vi`ii\Am J Respir Crit Care Medx\q{
>i-i}\Circulationx\i{q{{
149
}
VVv>i>\
{q>}ii}}
72 (serum creatinine*)
* 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
>60
3059
Consult Pharmacy
x}
x}
Q12H
Q24H
qx } }
Q12H
Q24H
xq x} x}
Q12H
Q24H
q x} x}
Q12H
Q24H
qx x} x}
Q12H
Q24H
xq{ } }
Q12H
Q24H
>140
Consult Pharmacy
CrCl (mL/min)
1529
<15
x}
Q48H
}
Q48H
x}
Q48H
x}
Q48H
x}
Q48H
}
Q48H
}]ii`iLii
}]ii`iLii
x}]ii`iLii
x}]ii`iLii
x}]ii`iLii
}]ii`iLii
>i
x>`iVi}i`>i`ii>`
iixqV}
151
A
B. Vancomycin dosing and monitoring
U*i`>ii(preferred)\xV}vi}V`i
i`}vV}
U*`>ii\V}
Note:>q>viii`vi`>>VVv
redistribution of tissue and plasma levels
U>i
-,>>LiVi`i]>i}i`Li
established that coincides with HD (e.g. 500 mg qHD). Once weekly
serum levels can be drawn to monitor for accumulation.
U
Vii>iV>}ii}>}V`i]
Colistin, Amphotericin B)
U*}i`Vi 5 days) of therapy.
UiiVv}6>VV}ii\
U"Viii}iVi`i`v>i>Li
renal function who have achieved desired trough levels.
Uivii}iVi`i`v>i>i
hemodynamically unstable and/or with changing renal function.
Desired Vancomycin trough levels
U*i>]ii]i`V>`]L>Vii>\xV}
U
-viV\V}
U iiVvii]>`ViviV\xV}
Ui}VVi>V}`>>
be maintained to avoid development of resistance.
Monitoring for Toxicity
U-iVi>i`Lii>i`>i>iii`>>]
then weekly if patients renal function remains stable.
Ui``>>}}i>`iVV>>i>Liii
nephrotoxicity and higher serum trough concentrations (>15-20 mcg/
mL). Monitor Vancomycin trough levels (see above for frequency and
indications).
U>>`}i}iVi`i`v>iiVi}
Vancomycin, unless signs and symptoms of ototoxicity became
apparent.
,iviiVi\
--*-*`iii>iV}v6>VV\i>-
*>n
ii>VL>}i
iin\
6>`iV>iiii>
viVx\{q
>i>`ix\q
152
153
>i>vV\
CBC, BUN, Creatinine
6>VViiqtrough
(see dosing section p. 150)
>\
Vancomycin level
(see dosing section p. 150)
Weekly
Weekly, unless change in creatinine
( xvL>ii]iViii
,iviiVi\*>VVi`iiv">i*>ii>VL>/i>\
viV{n\x
Vancomycin
Antimicrobial
% Oral absorption
Should NOT be used orally for bacteremia
V
{q
Amoxicillin/Clavulanate (Augmentin
{q
Azithromycin*
nqn
i>i
Cefpodoxime*
{qx
`>V
VVi
q
/i>VVi
xqn
Can be used orally for bacteremia or fungemia
Ciprooxacin
xqnx
Fluconazole
>
Linezolid
i`>i
Moxioxacin
Trimethoprim/sulfamethoxazole
Voriconazole
q
* 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
iVLivii`6ivii`*>iVVVLivii`\
separate oral uoroquinolone by 2 hours before and 6 hours after tube feeds.
154
Dosing recommendations can vary according to indication and patientspecic parameters. All dosage adjustments are based on creatinine
clearance calculated by Cockcroft-Gault equation.
CrCl =
For patients with low muscle, some advocate using a minimum of 1 to avoid
overestimation of CrCl.
Drug
Typical dose
(may vary)
CrCl
(mL/min)
VV6
Acyclovir PO
i>ii
Acyclovir PO
ii<i
Amikacin
xq}}+n
200 mg 5x daily
800 mg 5x daily
x
xqx
q{
>10
>25
qx
V
Amoxicillin
i>
V
V>>>i
iV
AmBisome
V
V
L>V>
xq}+
1 g Q8H
xq}+
q}}+{
qx}}+{
q}+{q
xq}+
Ampicillin/
L>V>v
Acinetobacter,
E. faecalis)
V
i>
iv>
3 g Q4H
>30
q
q
q
x
qx
xq
14 or HD
50
qx
HD
xq}}+n
xq}}+
xq}}+{
xqx}}+{
200 mg 5x daily
}+
800 mg 5x daily
n}+n
800 mg Q12H
See section on
aminoglycoside dosing
xq}+
xqnx}+
xqnx}+{
1g Q8H
}+
1g Q24H
xq}+
xqx}+
xqx}+{
`>}i>`i
`>}i>`i
q}+{q
q}+qn
q}+n
xq}+
xq}+
xq}+{
3 g Q4H
}+
3 g Q8H
xqx}+{
q}+n
q}+n
x
q{
intermittent HD
HD
`>}i>`i
q}+n
q}+
q}+{
q}+n
}+
}+{
2 g Q HD, if HD in 2 days
OR 3g Q HD, if HD in 3 days
155
Drug
Typical dose
(may vary)
CrCl
(mL/min)
Cefdinir
300 mg Q12H
30
HD
>60
q
>60
q
q
q
HD
Ceftolozane/
>L>V>
600 mg Q12H
600 mg Q8H
q}+n
For Pseudomonas
}+n
1.5 g Q8H
>50
qx
xq
x
>50
qx
xq
x
x
qx
xq
x
>50
qx
xq
Ceftolozane/
>L>V>
-iviV
3 g Q8H
>50
qx
xq
iv>i
iv>i
(Central nervous
system infections)
Cephalexin
Cidofovir
q}+{
}+
q
q
300 mg Q12H
}+{
300 mg QHD
1 g Q8H
}+
1 g Q24H
2 g Q8H
}+n
}+
1 g Q24H
q}+
q}+{
500 mg Q24H
q{}+
q{}+{
q{}iii
week
600 mg Q12H
{}+
}+
200 mg Q12H
600 mg Q8H
{}+n
}+n
400 mg Q12H
q}+n
q}+
q}+{
1 g Q24H
1.5 g Q8H
x}+n
x}+n
Load with 750 mg, then
150 mg Q8H
3 g Q8H
x}+n
x}+n
Load with 1.5 g, then
375 mg Q8H
`>}i>`i
`>}i>`i
500 mg PO Q6H
xqx}+
xqx}+
*"\}+n
6\}+n
2.5 mg/kg Q12H
>50
qx
55 or Cr>1.5
500 mg Q6H
x}+n
500 mg Q12H
Not recommended
50
qx
20 or HD
{}+nq
400 mg Q24H
xqx}+
xqx}+{
xqx}+
xqx}+{
`>}i>`i
Cefepime
1 g Q8H
Cefepime
2 g Q8H
i>i
iviV
Pseudomonas
ivi>
q}+
iv`i
q{}+
Ceftaroline
Ceftaroline for
,-
iv>`i
y>V6
y>V*"
>V
`>V
Colistin
i>i
156
Typical dose
(may vary)
CrCl (mL/min)
>V
vi`V>`
bacteremia
V>V
VVi
Ertapenem
>L
q}}+{
V>i
qn}+{
HD
q
q
30
10
HD
50
Vixq
Ganciclovir
`V`i
xqx}}+
5 mg/kg Q12H
x
{
q{
q
70
xq
xq{
q{
Ganciclovir
>i>Vi
`i
5 mg/kg Q24H
70
xq
xq{
q{
i>V
>`
i`
Meropenem
Meropenem
i}]
,
viV
i`>i
V>v}
y>V
Nitrofurantoin
(Macrobid
Oseltamivir
/i>i
Oseltamivir
*>
">V
*iV
}+{
}+
1 g Q8H
2 g Q8H
x}+n
qx}+{
{}+{
100 mg Q12H
75 mg Q12H
75 mg Q24H
q}+{q
q{+{
q
q
>51
qx
qx
>51
qx
qx
q
q
q
50
x
>60
q
q
>60
q
q
q
x
q{
q}}+{
q}}+{n
q}}+{n
`>}i>`i
`>}i>`i
1 g Q24H
500 mg Q24H
Normal dose Q24H
>`i+{n
Normal dose QHD session
Normal dose (e.g. 100, 400,
800 mg) Q24H
Load w/normal dose, then
xv>`i+{
xqx}}+
xqx}}+
xqx}}+{
xqx}}+{q{n
5 mg/kg Q12H
x}}+
x}}+{
x}}+{
1.25 mg/kg three times/week,
administer after HD
5 mg/kg Q24H
x}}+{
x}}+{
x}}+{
0.625 mg/kg three times/
week, administer after HD
iiiV>}V`i
dosing
`>}i>`i
`>}i>`i
1 g Q8H
}+
x}+
500 mg Q24H
2 g Q8H
}+n
}+
1 g Q24H
`>}i>`i
`>}i>`i
`>}i>`i
100 mg Q12H
iVi`i`
75 mg Q12H
x}+{
}+{
30 mg QHD session
75 mg Q24H
}+{
}+{n
30 mg every other HD session
`>}i>`i
q{+{
x+{
1.5 million units Q6H
xqx}+
}+
1 g Q24H
xqx}}+{
157
Drug
Drug
Typical dose
(may vary)
CrCl (mL/min)
*i>V
tazobactam
xq{x}+
q{
x}+{x}+
for Pseudomonas)
x}+x}+v
Pseudomonas)
x}+nx}+v
Pseudomonas)
2.25 g Q12H (2.25 g Q8H for
Pseudomonas)
`>}i>`i
HD
q
xq}}+{
q}}+{
xq}}+i
`>}i>`i
HD
*>V>i
*>>`i
+
dalfopristin
,v>/
,v>
/}iVVi
/*-8
1/Vi
/*-8
*
*i
systemic infections)
6>>VV
i>ii
Valacyclovir
ii<i
Valganciclovir
`V`i
Valganciclovir
>i>Vi`i
6>VV
6V>i
-ii*>V>i
guidelines p. 18
xq}}+{
x}}+n
}+{
}+nq
}Vi]i
50 mg Q12H
*"\q->L+
6\q}+
}L>i`
/*Vi
x}}+qn
xq}+
1 g Q8H
900 mg Q12H
900 mg Q24H
q
-ii6V>i
guidelines p. 19
q
q
q
HD
q
50
q{
q
60
{qx
xq
q{
60
{qx
xq
q{
q
q
`>}i>`i
`>}i>`i
`>}i>`i
q->L+
q}6+
q->L+{
q}6+{
x}}+qn
x}}+qn
2.5 mg/kg Q8H
xq}+
xq}+{
500 mg Q24H
1 g Q8H
}+
}+{
500 mg Q24H
900 mg Q12H
{x}+
{x}+{
450 mg Q48H
Not recommended
900 mg Q24H
{x}+{
{x}+{n
450 mg twice weekly
Not recommended
-iiiV>VV
dosing
`>}i>`i
necessary for PO. IV should
not be administered to patients
with CrCl 50 mL/min due to
accumulation of the vehicle.
158
HH
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 insufciency....... 155-158
Surgical prophylaxis .... 121-124
Vancomycin
See Vancomycin
Aspergillosis ......................... 133
Aspiration pneumonia........ 84, 88
Azole drug interactions ...... 21-22
H H
HH
Bacterial vaginosis.................. 57
10. Index
A
Index
10. Index
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
Inuenza............................ 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-specic 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 inammatory 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 insufciency
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
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