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AntibioticSusceptibilityChart(UWMedicine,2015)
ClevelandClinic– GuidelinesforAntimicrobialUsage,2012-2013
*Examplesofdrugswithexcellentbioavailability(>90%)eligibleforIVtoPOswitchover*
*Examplesofdrugswithgoodbioavailability(60-90%)eligibleforIVtoPOswitchover*
JPharmacol Pharmacother.2014Apr-Jun;5(2):83–87.
Clostridiumdifficle Infection(IDSA/SHEA,2010)
Initialepisode
Mild/Moderate(WBC15orlower,SCr level<
1.5xpremorbidlevel)
Metronidazole500mgPO3timesadayfor10-14days
Severe,noileus(WBC15orhigher,ORaserum
creatinine≥1.5timespremorbidlevel)
Vancomycin125mgPO4timesdailyfor10-14days
PLUSMetronidazoleIV500mgq8h
Hypotensionorshock,ileus,megacolon
Vancomycin500mgPOqidPLUS
MetronidazoleIV500mgq8hPLUS
Mayaddrectalvancomycinifileus
RecurrentEpisodes• First:Sameasforan“initial”episode• Second:Vancomycininataperedand/orpulsedregiment
• Refertoliterature
Community-AcquiredInfection–Adults
Mild/ModerateSeverity(Appendixperforated/abscessed,other
infections)
Cefoxitin,ertapenem aloneOR(oneofthefollowing)
cefazolin,cefuroxime,ceftriaxone,ciprofloxacin,levofloxacin
COMBINEDWITHmetronidazole
HighRiskorseverity(severephysiologicdisturbance,advanced
age,immunocompromised)
Meropenem,piperacillin-tazobactam alone
OR(oneofthefollowing)cefepime,ceftazidime,
ciprofloxacin,levofloxacinCOMBINEDWITHmetronidazole
InitialEmpiricTreatmentofExtra-biliaryComplicatedIntra-abdominalInfection(IDSA,2010)
Antibiotics…shouldbeactiveagainst• EntericGram-negative
aerobicandfacultativebacilli
• EntericGram-positivestreptococci
Unasyn =notrecommended• HighE.coliresistance
RecommendationsforEmpiricAntimicrobialTherapyforHealth-CareAssociatedComplicatedIntra-abdominalInfection(IDSA,2010)
Organismsseen inhealth-careassociatedinfectioninlocal
institution
Carbapenem(Meropenem
only)
Piperacillin-tazobactam
Ceftazidime orcefepime,each
withmetronidazole
Aminoglycoside Vancomycin
<20%resistantP.aeruginosa,ESBL-producing Enterobacteriaceae,
Acinetobacter,orotherMDRGNB*
Yes Yes Yes No No
ESBL-producingEnterobacteriaceae
Yes Yes No Yes No
P.aeruginosa >20%resistanttoceftazidime*
Yes Yes No Yes No
MRSA No No No No Yes
ESBL:Extended-spectrumbeta-lactamaseGNB:Gram-negativebacilliMDR:Multi-drugresistant
*Refertoinstitutionantibiogram ifneeded*
Limittreatmentto4-7days
DiabeticFootInfection– MildSeverity(IDSA,2012)
Formild-moderateinfectionswithnorecentantibiotics:• TherapyjusttargetingaerobicGram+sissufficientFormostsevereinfections:• Startbroad-spectrumempirictherapyConsidercoveringforMRSAif:• localprevalenceishighorifpatienthasprevious
historyofMRSA
EmpirictherapydirectedatP.aeruginosaisusuallyunnecessaryEXCEPTforpatientswithriskfactorsfortrueinfection• “…IncountrieswhereP.aeruginosaisa
frequentisolate,orinpatientswhohavebeensoakingtheirfeet,whohavefailedtherapywithnonpseudomonal therapy,whohaveasevereinfection,empiricantipseudomonaltherapymaybeadvisable.”
DiabeticFootInfection– ModerateSeverity(IDSA,2012)
DiabeticFootInfection– ModerateSeverityCont’d(IDSA,2012)
“Wesuggestaninitialantibioticcourseforasofttissueinfectionofabout1–2weeksformildinfectionsand2–3weeksformoderateto
severeinfections”
ProstheticJointInfections(IDSA,2013)– Page1
ProstheticJointInfections(IDSA,2013)– Page2
Followingdebridement+retentionofprosthesis:• Staphylococcal:
• 2-6weeksofpathogen-specificIVtherapyPLUSrifampin300-450mgbid
• Non-staphyloccocal:• 2-6weeksofpathogen-specificIVorhighly
bioavailablePOtherapy
NEngl JMed.2009August20;361(8):787–794
COPD(GOLDGuidelines,2017)
Antibioticsshouldbegiventopatientswhohave3cardinalsymptoms:• Increaseindyspnea• Sputumvolume• Sputumpurulence
OR
Twoofthecardinalsymptoms• IFincreasedpurulenceis
oneofthose2• or[patientrequires]
mechanicalventilation
*Cultureifpatienthasfrequentexacerbations**Treatwithamoxicillin+clavulanicacidORazithromycinfor5-7days*
CommunityAcquiredPneumonia
Inpatient,non-ICU
Respiratoryfluoroquinolone(levofloxacin)OR
Β-lactamPLUSmacrolide(azithromycin)
Inpatient,ICU
B-lactam(cefotaxime,ceftriaxone,orampicillin-
sulbactam)PLUSEitherazithromycinOR a
respiratoryfluoroquinolone
IFPseudomonas isaconcern
Zosyn,cefepime,imipenem/meropenem PLUS
Levofloxacin(mayaddaminoglycosidealso)
IFCommunityAcquiredMRSA(rare,riskfactorincludeslung
abscess)AddvancomycinORlinezolid
*PatientswithCAPshouldbetreatedforaminimumof5days(levelIevidence),shouldbeafebrilefor48–72h,andshouldhavenomorethan1CAP-associatedsignofclinicalinstability(table10)beforediscontinuation
oftherapy
MostCommonPathogens
Inpatient(non-ICU)StreptococcuspneumoniaeMycoplasmapneumoniaeChlamydiapneumoniaeHaemophilus influenzae (unvaccinated)Legionellaspecies(rare)Stomach contents(aspiration)Respiratoryviruses
Inpatient(ICU)StreptococcuspneumoniaeStaphyloccocus aureusLegionellaspecies(rarely)Gram-negativebacilliH.influenzae (unvaccinated)
Community-AcquiredPneumonia(IDSA,2007)
Hospital-AcquiredPneumonia(HAP)(IDSA,2016)
Hospital-AcquiredPneumonia
MRSARisk?- Prior IVantibioticusewithin90days
- Hospitalizationinaunitwhere>20%ofS.aureusisolatesareMRSA
- Highriskofmortalityduetosepticshock,ventsupport(weakevidence)
Oneofthefollowing:Zosyn OR cefepime ORlevofloxacin
TheabovetherapyPLUS VancomycinORlinezolid(vancomycinfirst)
Highriskofmortality?- Sepsis
- Intubation
Twoofthefollowing(avoid2betalactams):Zosyn ORcefepime
OR levofloxacin/ciprofloxacinOR imipenem/meropenemOR anaminoglycosideOR
aztreonamPLUS vancomycinOR linezolid
No
Yes
MostCommon Pathogens• Pseudomonas aeroginosa• Staphylococcusaureus• Klebsiella pneumoniae• Escherichiacoli• Acinetobacter (lesscommon)
RiskFactorsformulti-drug resistantorganisms• PriorIVantibioticusewithin90days
Yes
PregnancyCategories– ClevelandClinicGuidelinesforAntibioticUsage,2012-2013
Antibiotic PregnancyCategory
Antibiotic PregnancyCategory
Amoxicillin B Clarithromycin C
Ampicillin(with/withoutsulbactam)
B Clindamycin B
Azithromycin B Daptomycin C
Aztreonam B Dicloxacillin B
Cefazolin B Ertapenem B
Cephalexin B Levofloxacin C
Cefdinir B Meropenem B
Cefepime B Metronidazole B(Butcontraindicatedin1st trimester
Cefotaxime B Nitrofurantoin B
Cefotetan B Penicillin G B
Ceftazidime B Piperacillin/Tazobactam B
Ceftriaxone B Sulfamethoxazole/Trimethoprim
D
Cefuroxime B Vancomycin C
Ciprofloxacin C
PregnancyCategories– CommonlyUsedAntibiotics
Source:Lexicomp,ClevelandClinic
SepsisEmpiricAntimicrobialTherapy(UWMedicine,2016)Page1
SepsisEmpiricAntimicrobialTherapy(UWMedicine,2016)Page2
SepsisEmpiricAntimicrobialTherapy(UWMedicine,2016)Page3
SkinandSkinStructureInfections(IDSA,2014)
MostCommonPathogens:StreptococcusspeciesStaphylococus aureusAerobicGram-negativebacilli(diabeticfoot)Anaerobes(diabeticfoot)
Abscess:5- to10-daycourseofanantibioticactiveagainstthepathogenisolatedErysipelasandcellulitis:5days,canextendifinfectionstillpresent
BacterialVaginosis(CDC2015Guidelines)
Superscript:1.Therecommendedregimensareequallyefficacious.2.Thesecreamsareoil-basedandmayweakenlatexcondomsanddiaphragms
*Treatmentisrecommendedforallsymptomaticpregnantwomen
GramNegative GramVariable Other
Prevotella species Gardnerellavaginalis
Ureaplasmaurealyticum
Poryphromonasspecies
Mobiluncusspecies
Bacteroidesspecies
Peptostreptococcus species
Somecommonlyseenpathogens:
Sources:UpToDate,CDC2015STDGuidelines
ChlamydiatrachomatisInfections(CDC2015Guidelines)
Superscriptnumbersintableabove:3.Forpregnantwomen:seecompleteCDCguidelines4.Doxycyclineshouldnotbeadministeredduringpregnancy,lactation,ortochildren<8yearsofage.5.Ifpatientcannottoleratehigh-doseerythromycinbaseschedules,changeto250mg4x/dayfor14days.6.Ifpatientcannottoleratehigh-doseerythromycinethylsuccinate schedules,changeto400mgorally4timesadayfor14days.7. Levofloxaciniscontraindicatedforpregnantorlactatingwomen8.Azithromycinsafeandeffectiveperclinicalexperienceandpublishedstudies9.Erythromycinestolate iscontraindicatedduringpregnancy10.Effectivenessoferythromycintreatmentisapproximately80%;asecondcourseoftherapymayberequired.
GonococcalInfections(CDC2015Guidelines)
Mostcommonpathogen:Neisseriagonorrhoeae(Gram-negative)
Superscriptnumbersintableabove:8.Clinicalexperienceandpublishedstudiessuggestthatazithromycinissafeandeffective10.Effectivenessoferythromycintreatmentisapproximately80%; asecondcourseoftherapymayberequired.
PelvicInflammatoryDisease(CDC2015Guidelines)
GramNegatives:NeisseriagonorrhoeaeChlamydiatrachomatisHaemophilus influenzae
GramPositive:Streptococcusagalactiae
GramVariableGardnerella vaginalis
Ureaplasma urealyticumMycoplasmagenitalium
Somecommonlyseenpathogens:
Syphilis(CDC2015Guidelines)
Superscriptnumbersintableabove:3.Forpregnantwomen:seecompleteCDCguidelines7.Doxycycline,tetracyclinecontraindicatedforpregnantwomen24.Pregnantpatientsallergictopenicillinshouldbetreatedwithpenicillinafterdesensitization.
AsymptomaticBacteriuria(IDSA,2005)
MostCommonPathogens:• Escherichiacoli(moresoinwomen)• Proteusmirabilis(moresoinmen)• Enterococcus species• Klebsiella pneumoniae
Cathetersareariskfactorforpolymicrobial bacteriuriainmenandwomen.Culturesmaygrow:• Pseudomonasaeruginosa• Providenciastuartii• Morganella morgannii
Doesthepatienthavealong-term,indwellingcatheter?• Considerifthisiscolonizationvsacuteinfection
• Pyruria =notindicationfortreatmentIFaccompaniedbyasymptomaticbacteriuria
UncomplicatedCystitisandPyelonephritisinWomen(IDSA,2010)
Nitrofurantoin:avoidin65orgreaterandthosewithCrCl <30mls/min
Pivmecillinam:notapprovedinUSA
Fluoroquinolones:RarechanceofCNSsideeffectsinelderly
TreatUTIsfor3-7daysdependingondrugchosen
IDSA,Lexicomp