Created by Krista Gens, PharmD, BCPS-AQ ID August 2016 Urinary Tract Infections Tip Sheet Uncomplicated Urinary Tract Infections 1 : • Nitrofurantoin x 5 days • TMP/SMX x 3 days • If E coli resistance not >20% • Fosfomycin 3g x1 • Expensive & broad, difficult to find • Fluoroquinolones x 3 days • Propensity for collateral damage • Beta-lactams x 3-7 days • Avoid ampicillin or amoxicillin alone empirically http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ Empiric Treatment Algorithm (Adapted from the IDSA Guidelines) 1 :
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Created by Krista Gens, PharmD, BCPS-AQ ID August 2016
Urinary Tract Infections Tip Sheet Uncomplicated Urinary Tract Infections1:
• Nitrofurantoin x 5 days • TMP/SMX x 3 days
• If E coli resistance not >20% • Fosfomycin 3g x1
• Expensive & broad, difficult to find • Fluoroquinolones x 3 days
• Propensity for collateral damage • Beta-lactams x 3-7 days
• Avoid ampicillin or amoxicillin alone empirically
Empiric Treatment Algorithm (Adapted from the IDSA Guidelines)1:
Created by Krista Gens, PharmD, BCPS-AQ ID August 2016
Most common organisms: E coli Interpretation of Culture Results: Urinary symptoms (e.g. dysuria, new onset frequency, new onset incontinence, etc) are the strongest indicator for treatment. ***Screening for and treatment of asymptomatic bacteriuria is not recommended for most2***
• When DO you treat asymptomatic bacteriuria? – Pregnancy – Preoperative evaluation of men before urological procedures
Urinalysis3: • Considered positive for infection if:
– Nitrites – Leukocyte esterase – Bacteria – >10 white blood cells per high-power field
• None of these markers used individually have adequate sensitivity and specificity for a definitive diagnosis or exclusion of UTI
Urine Cultures4:
>100,000 colon forming units (CFUs) is considered positive o However patient’s symptoms are still key in determining significance
False negatives may occur if patient has received antibiotics prior to urine collection
False positives may occur if the patient is colonized Duration of therapy: Typically 3-5 days for uncomplicated UTIs depending on drug (see algorithm); longer durations for complicated UTIs and pyelonephritis Clinical Pearls:
Avoiding making assumptions on susceptibilities (e.g if penicillin susceptible then must be cephalosporin susceptible)
o If uncertain, utilize references such as The Sanford Guide®, Johns Hopkins Antibiotic Guide®, or call the microbiology lab
Previous culture results can help guide empiric therapy
If the isolate is sensitive to therapy the patient is on but they are not improving, then consider the presence of complications (e.g. pyelonephritis, abscess, infected stone, etc).
Complicated UTIs include: male, patients with urinary tract abnormalities (e.g. strictures), diabetic patients, pyelonephritis, catheter-associated UTIs, etc.
o Primarily this extends the duration; may change the selection (e.g. NO nitrofurantoin for pyelonephritis)
There are no “complicated” UTI guidelines per se o Pyelonephritis is included in the IDSA Uncomplicated UTI and Pyelonephritis guidelines1 o Catheter-Associated UTI guidelines are available5 o For other forms of complications, refer to other references such as The Sanford Guide®, Johns Hopkins
Antibiotic Guide®, or UpToDate® References: 1. Gupta K, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women:
A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5):e103-e120
2. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. Mar 1 2005;40(5):643-5
3. Wilson, ML, et al. Laboratory diagnosis of urinary tract infections in adult patients. Clin Infect Dis. 2004; 38:1150-8 4. Meyrier, A. Sampling and evaluation of voided urine in the diagnosis of urinary tract infection in adults. UpToDate. www.uptodate.com.
Last Updated July 24, 2015. Accessed August 11, 2016. 5. Hooton TM, et al. Diagnosis, Prevention and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International
Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50:625-663.
Created by Krista Gens, PharmD, BCPS-AQ ID August 2016
Pneumonia Tip Sheet CAP Treatment Algorithm (Adapted from the IDSA CAP Guidelines)1:
Previously healthy and no risk factors for drug-resistant Streptococcus pneumoniae o Azithromycin o Doxycycline
Presence of comorbidities, use of antimicrobials within the past 3 months, or “other risks” o Levofloxacin or moxifloxacin o Amoxicillin or amoxicillin/clavulanate PLUS azithromycin
Alternatives to amoxicillin or amox/clav: cefuroxime, cefpodoxime, cefdinir Alternatives to azithromycin: doxycycline
Most common organisms: Streptococcus pneumoniae, Mycoplasma pneumoniae, Haemophilus influenzae, Chlamydophila pneumoniae, respiratory viruses (e.g. influenza A and B, adenovirus, RSV, parainfluenza)1. Interpretation of Culture Results:
Sputum cultures o Relatively reliable IF can obtain a good sample and obtained prior to antibiotics
If after antibiotics already started, may represent early colonization rather than superinfection with resistant bacteria1
o Yeast (EXcluding Cryptococcus) should be considered a colonizer unless immunocompromised
Influenza PCRs o Very reliable
Streptococcal pneumoniae and Legionella urinary antigens (usually only inpatients) o High specificity, low sensitivity
Duration of Therapy: Minimum goal of 5 days
should be afebrile 48-72 hours
should not have more than 1 sign of instability (e.g. tachycardia, tachypnea, etc)
complicating factors will extend duration
Clinical Pearls:
If you do have culture results, use the most narrow option1:
Organism Preferred Antibiotic(s) Alternative Antibiotic(s)
Streptococcus pneumoniae
Penicillin-S
Penicillin-R
Penicillin or amoxicillin Based on susceptibility (e.g. levofloxacin)
Cefuroxime, cefpodoxime, cefdinir, levofloxacin or moxifloxacin Linezolid, high-dose amoxicillin if MIC < 4
Streptococcus pneumoniae is 93% susceptible to amoxicillin and 96% susceptible to penicillin in Minnesota2
Created by Krista Gens, PharmD, BCPS-AQ ID August 2016
Streptococcus pneumoniae resistance to azithromycin is becoming increasingly common2
In 2013, FDA released a drug safety communication regarding azithromycin and the risk of fatal heart arrhythmias3
o followed up on a FDA statement released on May 17th, 2012, the same date the highly publicized study appeared in the New England Journal of Medicine4
o subsequent studies showed no difference in mortality compared to penicillin5 o consider doxycycline instead of azithromycin in patients with prolonged QTc
Amoxicillin and Amoxicillin/clavulanate dosing: o IDSA guidelines recommend “high-dose” amoxicillin 1g TID or amoxicillin/clavulanate 2g BID1
Specifically for those at risk for penicillin-resistant Strep pneumo
May also consider for obese patients Majority of patients will be fine with standard dosing Consider “poor man’s amoxicillin/clavulanate XR” for those that cannot afford:
Recommended levofloxacin dose = 750 mg daily o Higher dose preferred due to concentration dependent killing
New IDSA CAP guidelines are coming soon (Summer 2017) o Available at IDSA website: www.idsociety.org o Healthcare-Associated pneumonia (HCAP) was removed from the new HAP/VAP guidelines6
It is thought HCAP will be in the new CAP guidelines and will be treated like CAP
References: 1. Mandell LA, et al. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of
Community-Acquired Pneumonia in Adults. Clin Infect Dis. 2007;44:S27-72. 2. 2014 Minnesota Department of Health Antimicrobial Susceptibilities of Selected Pathogens (MDH Antibiogram).
http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/abx/index.html. Accessed on August 12, 2016. 3. FDA Drug Safety Communication: Azithromycin (Zithromax or Zmax) and the risk of potentially fatal heart rhythms. March 12, 2013.
http://www.fda.gov/Drugs/DrugSafety/ucm341822.htm. Accessed August 16, 2016. 4. Ray WA, Murray KT, Hall K, et al. Azithromycin and the risk of cardiovascular death. N Engl Med 2012; 366:1881-1890. 5. Svanström H et al. Use of azithromycin and death from cardiovascular causes. N Engl J Med 2013 May 2; 368:1704. 6. Kalil AC, et al. Management of Adults with Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by
the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; :1-51.
Created by Krista Gens, PharmD, BCPS-AQ ID August 2016
Skin and Soft Tissue Infections (SSTIs) Tip Sheet SSTI Treatment Algorithm (Adapted from the IDSA SSTI Guidelines)1:
I&D = Incision and drainage; C&S = culture and sensitivities
Most common organisms: Staphylococcus spp and Streptococcus spp unless other specific risk factors or previous culture history
Coverage for methicillin-resistant Staphylococcus aureus (MRSA): Indicted IF there is purulence, or if patient does not respond to initial therapy1,2.
Interpretation of Culture Results:
Cultures typically not recommended for simple cellulitis
If purulence, cultures of the pus can be helpful
Caution interpreting cultures from chronic wounds o Often colonized o Enterococcus often non-pathogenic
Duration of Therapy:
For most cellulitis, the recommendation duration is 5 days1 o But treatment should be extended if has not improved
For simple abscess or boils (e.g. no surrounding cellulitis; easily drained), incision and drainage alone2
For purulent cellulitis, recommendation duration is 5-10 days2
Clinical Pearls:
Diabetic patients usually do NOT require empiric Pseudomonas or MRSA coverage.
Created by Krista Gens, PharmD, BCPS-AQ ID August 2016
o Most can fall into the usual SSTI algorithm o See the ISDA Diabetic Foot Infectious guidelines for diabetic foot infections3
Staphylococcus aureus that is oxacillin or methicillin susceptible (MSSA) does NOT mean penicillin susceptible
o Oxacillin and methicillin are anti-Staphylococcal penicillins that retain activity despite Staph aureus’s common beta-lactamases
o Do NOT use penicillin or amoxicillin o However, MSSA IS susceptible amoxicillin/clavulanate, and you can assume susceptibility to
cephalosporins (e.g. cephalexin).
Almost all Streptococcus spp that cause SSTIs will be susceptible to penicillins, cephalosporins, and clindamycin.
o Increasing resistance of group B strep to clindamycin4 o Also typically susceptible to levofloxacin, but would only use if allergies preclude first line
Avoid fluoroquinolones for Staphylococcus aureus unless no other options available o Despite susceptibility, Staph aureus frequently becomes resistant while on therapy2.
Clindamycin is no longer recommended for empiric MRSA coverage due to increasing resistance o Doxycycline or trimethoprim/sulfamethoxazole (TMP/SMX) are preferred instead
References: 1. Stevens DL, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the
Infectious Diseases Society of America. Clin Infect Dis. 2014; :1-43. 2. Liu C, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant
Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis. 2011;52:1-38. 3. Lipsky BA, et al. 2010 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Treatment of Diabetic Foot
Infections. Clin Infect Dis. 201;54(12):1679-84. 4. Minnesota Department of Health Antimicrobial Susceptibilities of Selected Pathogens (MDH Antibiogram).
http://www.health.state.mn.us/divs/idepc/dtopics/antibioticresistance/abx/index.html. Accessed on August 12, 2016.
