** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Northwestern Memorial Hospital SUGGESTED EMPIRIC ANTIMICROBIAL THERAPY BY SITE OF INFECTION
Empiric antimicrobial guidelines are based on the most likely organisms responsible for infection, NMH susceptibilities, and prevalence of
resistant organisms. Therapy may need to be adjusted once identification and susceptibility are determined.
Previous antimicrobial therapy may affect the susceptibility of organisms that subsequently cause infection. Close attention should be given to
courses of antimicrobial therapy administered to patients in the recent past. In many cases, obtaining the appropriate specimen(s) before antibiotics are started is critical to successful outcomes of an infectious disease. Alterations in empiric antimicrobial therapy may be required.
Anatomic site /diagnosis
Common Pathogens Preferred therapy Alternative** Comm ents
Bone Acute osteomyelitis Staphylococcus aureus
(MSSA and MRSA) vancomycin Bone biopsy and/or tissue biopsy
is strongly recommended prior to
starting antibiotics if patient is
hemodynamically stable. Acute osteomyelitis in patient with hemoglobinopathy (Sickle cell disease or Thalassemia)
Salmonella spp., other
Gram-negatives, S. aureus ceftriaxone +/- vancomycin ciprofloxacin +/-
vancomycin Bone biopsy and/or tissue biopsy is strongly recommended. Fluoroquinolone resistance is
increasingly reported among Salmonella spp.
Long bone status post internal
fixation of fracture
S. aureus, Staphylococcus epidermi dis,
Gram-negatives
vancomycin + cefepime Bone biopsy and/or tissue biopsy is strongly recommended.
Sternum, post-operative
S. aureus, S. epidermidis vancomycin Bone biopsy and/or tissue biopsy is strongly recommended.
Vertebral osteomyelitis +/-
epidural abscess
S. aureus most common (including MRSA), other
Gram-positives and
Gram-negatives also
possible
vancomycin + ceftriaxone, OR vancomycin + cefepime if risk factors for Pseudomonas aeruginosa
vancomycin +
fluoroquinolone OR daptomycin +/-
fluoroquinolone
Obtain blood cultures in non-surgery-associated cases. Bone biopsy and/or tissue biopsy is strongly recommended. In patient with acute neurologic
compromise, sepsis, or hemodynamic instability, ok to start empiric treatment prior to collecting bone or tissue cultures. IDSA Native Vertebral OM guidelines
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Contiguous osteomyelitis with
vascular insufficiency
polymicrobial Empiric antibiotic therapy is not
recommended; recommend
bone biopsy for directed
therapy CENTRAL NERVOUS SYSTEM
Meningitis—acute bacterial
Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes
vancomycin + ceftriaxone +/- ampicillin†
vancomycin + aztreonam +/- trimethoprim- sulfamethoxazole†
Empiric antibiotics are indicated prior to LP if acute bacterial meningitis is suspected. Penicillin testing necessary with Beta-lactam allergy; contact infectious diseases and allergy services. If pneumococcal meningitis suspected, administer dexamethasone before or with first dose of antibiotics: Dexamethasone 10mg IV q 6 hours x 2-4 days.
If S. pneumoniae is ruled out as cause, discontinue dexamethasone. IDSA Bacterial Meningitis Guidelines † Ampicillin or trimethoprim- sulfamethoxizole is given to
cover Listeria monocytogenes, more common in patients over age 50, alcoholics, pregnant
women, and patients with impaired cellular immunity.
Meningitis--post-surgical or post traumatic
S. aureus, S. epidermi dis , Gram-n egati v es
vancomycin + cefepime (preferred)
For true PCN allergy:
vancomycin +
meropenem
Brain abscess--
primary S. pneumoniae, Streptococcus
spp., Bacteroides spp., Enterobacteriaceae, S. aureus
vancomycin +ceftriaxone +
metronidazole +/- ampicillin
Biopsy for microbiology and
pathology is necessary for diagnosis.
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Encephalitis HSV, arboviruses, enteroviruses, VZV, non-infectious causes.
IV acyclovir Obtain blood cultures. See IDSA guidelines for an extensive list of epidemiologic risk factors,
diagnostic work-up, and individualized empiric therapy for encephalitis:
IDSA Encephalitis Guidelines Prophylaxis for Neisseria
meningitidis contacts
ciprofloxacin or rifampin ceftriaxone 250
mg IM x 1 is
preferred agent
in pregnancy.
Contact Infection Control (pager 59196) for guidance.
Doses:
ciprofloxacin 500 mg po x 1
OR
rifampin 600 mg po q 12
hours x 4 doses
GASTROINTESTINAL GALLBLADDER
Cholecystitis (community- acquired) - Mild-moderate severity
Enterobacteriaceae ceftriaxone levofloxacin Community-acquired: symptoms
prior to admit or within 48h of
admit AND no hospitalization
within prior 90 days.
Cholangitis following biliary anastomosis – any severity
Enterobacteriaceae, anaerobes piperacillin/tazobactam aztreonam + metronidazole + vancomycin
Cholecystitis (community- acquired) – Severe physiologic
disturbance or high risk patient (advanced age or
immunocompromised),
Enterobacteriaceae, anaerobes piperacillin/tazobactam aztreonam +
metronidazole +
vancomycin
Cholecystitis (healthcare-
associated), biliary
sepsis or common
duct obstruction
Enterobacteriaceae, anaerobes
and the possibility of Gram-
negative resistance;
Enterococcus spp. in select
immunocompromised patients
piperacillin/tazobactam aztreonam +
metronidazo
le +/-
vancomycin
Healthcare-associated: prior
gallbladder instrumentation,
admitted longer than 48 hours,
hospitalized previously in the
past 90 days. See
IDSA Intra-abdominal Infection
Guidelines
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
C. difficile colitis Initial episode, any non-severe and severe: Oral vancomycin 125mg QID Initial episode, fulminant: Oral vancomycin 500mg QID plus metronidazole IV 500mg q8hours +/- vancomycin enema Recurrent episode: ID consult recommended
Vancomycin 125 mg PO QID is the drug of choice on formulary for initial episodes of CDI (non-
severe and severe). • For outpatients, fidaxomicin is an alternative recommended
oral therapy. • Fulminant CDI is defined as CDI with hypotension, shock,
ileus and/or toxic megacolon. Rectal administration of
vancomycin and IV metronidazole, and/or high dose vancomycin 500 mg PO may be
considered in fulminant cases of CDI. IDSA C. diff Guidelines
Diverticulitis, perirectal
abscess,
peritonitis
Community-acquired:
Enterobacteriaceae,
Bacteroides spp.
ceftriaxone +
metronidazole
levofloxacin +
metronidazole
Community-acquired: < 48h
of
admission, no hospitalization in past
90d.
High-risk: severe physiologic
disturbance, advanced age, or
immunocompromised state
IDSA Intra-abdominal Infections
Guidelines
Community-acquired, high-risk:
Enterobacteriaceae,
Bacteroides spp.,
Enterococcus spp., and the
possibility of Gram-negative
resistance
piperacillin-tazobactam aztreonam +
metronidazole + vancomycin
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Healthcare-associated or
severely ill: same as high-risk
community-acquired
piperacillin/tazobactam If patient has any of the following: post-op infections, recent cephalosporins use, immuncompromised, valvular heart disease or prosthetic intravascular material consider adding vancomycin
aztreonam +
metronidazole +
vancomycin
Both preferred and alternative therapies provide empiric Enterococcal coverage
(directed at E. faecali s ). E.
faecali s coverage is
recomm end ed, especially for
those with post-op infection,
those who have previously
received cephalosporins,
immunocompromised patients,
and those with prosthetic
intravascular material.
Following appendectomy, no
perforation
none none Surgical prophylaxis only
Following appendectomy, with
perforation
Enterobacteriaceae,
Bacteroides spp.
ceftriaxone + metronidazole
aztreonam +
metronidazole
Hepatic abscess Enterobacteriaceae,
Bacteroides spp., Enterococcus spp.
ceftriaxone + metronidazole
Blood cultures are recommended. Diagnostic aspiration and/or drainage is
often indicated. Consider serologic testing for amoebiasis (Entamoeba histolytica antibody
IgG)
Pancreatitis--acute/non-
necrotizing
noninfectious No antibiotic therapy necessary
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Pancreatitis—acute/necrotizing
or infected pseudocyst, abscess
Enterobacteriaceae,
Enterococcus spp., S.
aureus, S. epidermidis ,
anaerobes, Candida spp.
piperacillin/tazobactam levofloxacin + metronidazole
Strongly recommend attemptingaspiration for microbiologic diagnosis and therapy.
Pip/tazo has adequate
penetration into pancreatic
necrosis, thus carbapenem
therapy is not indicated unless
patient has history of MDR
organisms.
Otto, W, et al. HPB (Oxford).
2006; 8(1): 43–48.
Peritonitis--spontaneous
bacterial peritonitis (SBP)
S. pneumoniae, K.
pneumoniae, E. coli
ceftriaxone aztreonam +
vancomycin
Peritonitis--Peritoneal Dialysis
related
S. aureus, S. epidermi di s,
Gram-negatives,
Candida spp.
vancomycin + cefepime Contact ID pharmacist on call (55955) for dosing recommendations. Obtain PD
fluid for microbiologic diagnosis. Often intraperitoneal therapy is ideal to treat these infections. ISPD PD-Dialysis Related Infection Guidelines
GENITAL
Endometritis-Acute postpartum
Group B Streptococcus,
anaerobes,
Enterobacteriaceae
ampicillin + clindamycin +
gentamicin
OR
ceftriaxone + metronidazole
clindamycin + gentamicin
Salpingitis/PID Neisseria gonorrhoeae, Chlamydia trachom ati s,
Bacteroides spp.,
Enterobacteriaceae, Group
B Streptococcus. .
ceftriaxone + metronidazole
+ doxycycline
Testing for GC and Chlamydia are strongly recommended. Discharge patient on oral doxycycline to complete a 14-day course.
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
For patients with documented
GC or Chlamydia, sexual
partners within prior 60 days need
medical evaluation and
treatment.
CDC STI Guidelines
HEART
Endocarditis Refer to guidelines or Optimizer
ID consult recommended. Refer to AHA guidelines: IDSA/ AHA Endocarditis
Management guidelines
JOINT
Septic joint/ at risk for
STI
At risk for sexually transmitted infection (STI): Neisseria gonorrhoeae, S. aureus, Streptococcus spp., rarely
enteric Gram-negative bacilli
ceftriaxone +/- vancomycin
aztreonam + vancomycin
Send blood cultures before antibiotics are started. Early joint aspiration is strongly recommended for cell count,
differential, gram stain, crystals, and culture to guide diagnosis. For type-1 penicillin allergy, consult Infectious Diseases and Allergy. If gonorrhea is suspected, cultures from the joint may or may not be positive.
Septic Joint- not at risk for STI
S. aureus (MSSA and MRSA), Streptococcus spp., Gram-negative bacilli
vancomycin + ceftriaxone vancomcyin + aztreonam
Prosthetic joint infection
S. aureus (MSSA and MRSA),
S. epidermi di s , Streptococcus spp., rarely Gram-negative
bacilli
vancomycin See 2013 IDSA Guideline for Prosthetic Joint Infections: IDSA Prosthetic Joint Guidelines
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
KIDNEY, BLADDER AND PROSTATE Asymptomatic bacteriuria
E. coli , Enterobacteriaceae,
Should only be treated in pregnant women or patients
undergoing urologic procedures with anticipated mucosal bleeding --other patients should be evaluated on a case-by-case basis. See IDSA guidelines for asymptomatic bacteriuria: IDSA Asymptomatic Bacteriuria Guidelines
Cystitis E. coli , Enterobacteriaceae, S.
saprophyticus
nitrofurantoin (if estimated creatinine clearance >30 mL/min); cephalexin or IV cefazolin (reserved for
those who are unable to swallow pills
trimethoprim-
sulfamethoxaz
ole or
ciprofloxacin**
Consider testing urethritis for gonorrhea, chlamydia, and trichomonas. IDSA Uncomplicated Cystitis\Pyelo Guidelines
Complicated UTI/catheters
E. coli, Enterobacteriaceae,
cefazolin
May consider
alternative therapy based on patient’s history of urinary
pathogens
See IDSA guidelines for
catheter-related UTIs (recommended to d/c or change catheter)
IDSA Catheter Assoc UTI Guidelines
Asymptomatic Candiduria (Treat ONLY patients who are at high risk for dissemination, such as neutropenic patients, low birth weight infants <1500 g, and patients
who will undergo urologic manipulation)
Candida spp.
Remove catheter
Neutropenic patients and very low–birth-weight
infants should be treated as recommended for candidemia (see below)
Patients undergoing
urologic procedures should be treated with oral fluconazole, 400 mg (6
mg/kg) daily before and after the procedure
See IDSA guidelines for
candidiasis,
IDSA Candidiasis Guidelines
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Symptomatic Candiduria
C. albicans (and other fluconazole susceptible spp)
Remove catheter, fluconazole See IDSA guidelines for candidiasis, IDSA Candidiasis Guidelines Micafungin, liposomal Ampho and voriconazole have poor renal excretion and are NOT considered effective against fungal UTI
Fluconazole-resistant Candida spp
Page ID Pharmacist for alternatives
Pyelonephritis--acute,
uncomplicated
E. coli, Enterobacteriaceae Cefazolin Aztreonam (severe, confirmed beta-lactam allergy)
NMH urinary antibiogram shows similar (>90% susceptibility) of ceftriaxone and cefazolin.
Increasing rates of
ciprofloxacin- resistance among
Enterobacteriaceae have been
noted. See IDSA guidelines for
uncomplicated
UTIs/pyelonephritis,
IDSA Uncomplicated
Cystitis\Pyelo Guidelines
Pyelonephritis, with sepsis
Enterobacteriaceae,
cefepime +/- amikacin aztreonam + amikacin
+\- vancomycin
(severe, confirmed beta-lactam allergy)
Patients at increased risk of enterococcal infections: elderly, urinary obstruction and post
instrumentation; septic patients with these risks may benefit from empiric E. faecalis coverage
(i.e., piperacillin-tazobactam). Also, review prior urinary isolates for antibiotic resistance.
Perinephric abscess Enterobacteriaceae piperacillin/tazobactam Recommend drainage of larger abscesses, may need aspiration for microbiologic diagnosis.
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Prostatitis Enterobacteriaceae ceftriaxone trimethoprim-
sulfamethoxazole or doxycycline or
ciprofloxacin
Review antibiogram and susceptibilities. Note that there have been increasing rates of ciprofloxacin- resistance among Enterobacteriaceae.
LUNG
Pneumonia--community acquired
S. pneumoniae, H. influen z a e Mycoplasma, pneumoniae, Chlamydophila pneumoniae , Legionella pneumophila, viruses
ceftriaxone + azithromycin (Preferred for ICU) OR Levofloxacin (severe, confirmed beta-lactam allergy)
Levofloxacin (severe, confirmed beta-lactam allergy)
See NMH Community Onset Pneumoniae (CAP) Treatment for Non-ICU Patients
ATS/IDSA CAP Guidelines
If patient is critically ill, draw 2 sets of blood cultures.
If gross hemoptysis, leukopenia, rapidly-progressing CXR, and/or lung necrosis or cavitation, add
empiric MRSA coverage with linezolid.
Antibiotic Therapy for Adults with CAP (Review). JAMA. Feb 2016
Pneumonia--community acquired
in ICU
as above ceftriaxone + azithromycin OR ceftriaxone + levofloxacin
Pneumonia--community acquired
in ICU
Pneumonia-community-acquired with identified increased risk for
resistant Gm Negative pathogens
Pseudomonas
spp.,
Enterobacteriaceae
cefepime + azithromycin
or
piperacillin-tazobactam +
azithromycin.
PNA
vancomycin +
aztreonam +/-
amikacin (severe, confirmed beta-lactam allergy)
"Hospital-acquired pneumonia"
refers to pneumonia that
develops >
48 hours after admission.
If MRSA is not isolated within 72
hours, MRSA coverage should
be stopped IDSA HAP/VAP guidelines
Pneumonia--hospital-
acquired
as above cefepime + vancomycin or
linezolid
Pneumonia--ventilator-
associated
as above Cefepime + vancomycin or linezolid
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Pneumonia—aspiration,
community acquired
Bacteroides spp., Peptostreptococcus spp,
Fusobacterium spp.,
viridians group
Streptococcusspp.
ampicillin/sulbactam or
ceftriaxone
+/-
metronidazole
clindamycin or levofloxacin + metronidazole (severe, confirmed beta-lactam allergy)
See review of aspiration pneumonia.\
Empyema Community-acquired
Streptococcus spp.,
Enterobacteriaceae, anaerobes
ceftriaxone + metronidazole Or ampicillin-sulbactam
ATS Empyema guidelines
Empyema Hospital-acquired
Streptococcus spp., S. aureus, Enterobacteriaceae, anaerobes
vancomycin + cefepime + metronidazole Or vancomycin + piperacillin-tazobactam
vancomycin + levofloxacin (severe, confirmed
beta-lactam allergy)
SEPSIS or ACUTE FEBRILE SYNDROME
Septic shock S. aureus (MSSA and MRSA), E. coli, Enterobacteriaceae vancomycin + cefepime + amikacin
vancomycin + aztreonam +
amikacin (severe, confirmed beta-lactam allergy)
See guidelines from Surviving Sepsis Campaign.
Surviving Sepsis Guidelines Consider adding empiric
doxycycline, particularly if recent exposure to woodlands, ticks, or developing countries.
Septic shock--post splenectomy
S. pneumoniae, N. meningitidis, H. influenz a e , Capnocytophaga spp.
ceftriaxone + vancomycin levofloxacin + vancomycin
(severe, confirmed beta-lactam allergy)
Toxic shock syndrome S. aureus (MSSA and MRSA), group A Streptococcus
vancomycin + clindamycin + penicillin G
Strongly recommend prompt
surgical evaluation for possible debridement and infectious diseases consultation.
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Not neutropenic, no hypotension, source unclear
S. aureus (MSSA and MRSA),
Streptococcus spp., E. coli vancomycin + ceftriaxone Consider adding empiric
doxycycline, particularly if recent exposure to woodlands, ticks, or
developing countries.
Not neutropenic, no hypotension,
suspect intra-abdominal source with
mild to moderate severity
Enterobacteriaceae Ceftriaxone + metronidazole
aztreonam +
metronidazole + vancomycin
(severe, confirmed beta-lactam allergy)
For patients with sepsis of high severity, see recommendations under Septic Shock.
Not neutropenic, no hypotension,
petechial rash
S. pneumoniae, N. meningitidis ceftriaxone + vancomycin Consider adding empiric
doxycycline, particularly if recent exposure to woodlands, ticks, or developing countries.
Not neutropenic, no hypotension,
suspect urinary source
Enterobacteriaceae,
Enterococcus spp.
piperacillin/tazobactam
aztreonam
Fever & neutropenia (no hypotension, no apparent source) in a cancer patient receiving chemotherapy
Enterobacteriaceae,
Pseudomonas aeruginosa.
cefepime vancomycin +
aztreonam (severe, confirmed
beta-lactam allergy)
Empiric vancomycin is unnecessary unless patient is hemodynamically unstable, has pneumonia or PCN allergy, severe mucositis, or there is evidence of catheter-related infection on exam. Discontinue vancomycin after 72
hours if started for suspected or
confirmed gram-positive
bacteremia that was
later identified as non-MRSA or
as a single isolate of coagulase
negative staphylococcus. See
IDSA guidelines for neutropenic
fever:
IDSA Neutropenic Fever
Guidelines
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Fever & neutropenia -- febrile longer than 96 hours
as above (fever & neutropenia) + fungal infection
add micafungin Micafungin has broad coverage for Candida spp. It is not the preferred antifungal agent for all cancer patients, however, as this drug does not treat Aspergillus spp. or Mucor spp. High risk cancer patients are considered at increased risk of mold infections. For more information, see:
IDSA Neutropenic Fever Guidelines
SKIN
Bite--animal Pasteurella multocida, Fusobacterium spp,
Capnocytophaga spp. (dog bite)
amoxicillin-clavulanate or ampicillin-sulbactam
ciprofloxacin + clindamycin **
More specific therapy depends upon animal involved Evaluate the need for tetanus
and/or rabies vaccination
Bite--human viridans group Streptococcus spp., S.epidermi di s , Corynebacterium spp., S.
aureus , Eikenella spp., Bacteroides spp., Peptostreptococcus spp.,
Fusobacterium spp., Prevotella spp.
amoxicillin-clavulanate or ampicillin-sulbactam
ciprofloxacin + clindamycin **
Boils (furunculosis) or cutaneous abscesses
S. aureus (MSSA and
MRSA)
Incision and drainage is the primary treatment. Antibiotic therapy is needed only if associated fever or systemic infection or if extensive surrounding cellulitis is present: trimethoprim- sulfamethoxazole or
doxycycline
clindamycin Hot packs, incision and drainage serves as primary therapy. If incision and drainage is performed, sampling for culture and sensitivity is beneficial. Note: clindamycin resistance is present in > 50% of MRSA isolates. See IDSA SSTI
Guidelines Cellulitis Non-purulent: Group A
Streptococcus spp., Group
B, C, G Streptococcus
spp
(S. aureus i s uncommon in
absence of abscess, necrosis,
or purulent drainage.)
cefazolin clindamycin See Antibiotic Resources for
NMH guidelines (Skin and Soft tissue Infection Treatment Algorithm)
IDSA SSTI Guidelines.
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Purulent: Cellulitis with purulent exudates or at risk for MRSA (Cellulitis associated
with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization
with MRSA, injection drug use, purulent drainage, or SIRS)
Mild: incision and drainage Moderate: incision and drainage + trimethoprim- sulfamethoxazole OR doxycycline Severe: incision and drainage +
vancomycin
Culture and sensitivities
are indicated for de-
escalation.
See IDSA guidelines for
MRSA infections,
IDSA MRSA Guidelines
Cellulitis--IV catheter-related
Coagulase-negative Staphylococcus spp., S. aureus (MSSA and MRSA),
Remove catheter + vancomycin
IDSA SSTI Guidelines
Decubitus ulcer Streptococcus spp., Enterococcus spp,
Enterobacteriaceae,
Pseudomonas spp.,
Bacteroides spp., S. aureus
(MSSA and MRSA),
polymicrobial
Wound care; vancomycin +
piperacillin/tazobactam
Consider wound care alone (no
antibiotic therapy) with no signs
of systemic illness, soft tissue
abscess, or local cellulitis. With
exposed bone, obtain bone
biopsy prior to administering
antimicrobials to guide therapy.
Diabetic foot ulcer
(superficial) without
evidence of surrounding cellulitis or exposed bone
skin flora No antibiotic therapy necessary
Diabetic foot ulcer--mild; small,
only skin with
minimal
surrounding
inflammation,
pulses present
Polymicrobial: S. aureus
(MSSA and MRSA),
streptococcus spp,
amoxicillin-clavulanate or cephalexin
trimethoprim-
sulfamethoxazole
or doxycycline
See IDSA guidelines for diabetic foot Infections,
IDSA Diabetic Foot Guidelines
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Diabetic foot ulcer--severe; limb-
threatening, skin,
subcutaneous,
possibly bone,
inflammation, fever,
neutrophilia
Polymicrobial: S. aureus
(MSSA and MRSA),
streptococcus spp, coliforms,
anaerobes, Pseudomonas
aeruginosa
piperacillin/tazobactam +/-
vancomycin
clindamycin +
ciprofloxacin
Send tissue specimen (bone
preferable) for culture prior to starting empiric therapy. See
IDSA guidelines for diabetic foot infections,
IDSA Diabetic Foot Guidelines
Infected wound--post-operative
Surgery not involving GI tract:
S. aureus (MSSA and MRSA),
Group A, B, C, or G
Streptococcus spp.
vancomycin + piperacillin/tazobactam
vancomycin + ceftriaxone + metronidazole
IDSA SSTI Guidelines.
Surgery involving GI tract: S.
aureus (MSSA and MRSA),
coliforms, Bacteroides spp.
vancomycin + piperacillin-
tazobactam
VASCULAR Necrotizing fasciitis Streptococci (group A, C, G),
Clostridium spp.,
polymicrobial, including
S. aureus
vancomycin + clindamycin
+ piperacillin/tazobactam
For confirmed
severe PCN allergy: Aztreonam + vancomycin
Prompt surgical consult for immediate surgical debridement is indicated.
If streptococcal necrotizing
fasciitis, consider management for toxic shock syndrome.
Recommend infectious diseases consult. See IDSA SSTI Guidelines.
Catheter-associated bloodstream infection
Coagulase-negative
staphylococci, S. aureus
(MSSA and MRSA);
Enterococcus spp.
Remove line Vancomycin If high suspicion for Gram-
negative: + cefepime
May be able to salvage a long-term line if infection is due to S. epidermidis AND no evidence of tunnel infection or complicated
blood stream infection.
IDSA Cath Related Bloodstream Infection Guidelines
** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018
Impaired host catheter-associated bloodstream infection
S. epidermi di s , other
coagulase-negative
staphylococci, S. aureus
(MSSA and MRSA),
Enterobacteriaceae,
Pseudomonas
aeruginosa, Candida
species, VRE
vancomycin + cefepime +/- amikacin
Consider short course of amikacin in addition to other antibiotics if patient is clinically unstable. Consider coverage for
vancomycin-resistant Enterococcus (VRE) if patient is colonized with this organism
(replace vancomycin with linezolid or daptomycin). If hemodynamically unstable,
consider adding fungal coverage (micafungin or fluconazole).
IDSA Cath Related Bloodstream Infection Guidelines
Hyperalimentation-associated line infection
As with impaired host line
infection, Candida spp.
is more common
+micafungin or fluconazole in addition to
above recommendations based on anatomic
site/diagnosis
Consider micafungin rather than
fluconazole if patient has
been receiving fluconazole
in the month prior to
fungemia.
Documented candidemia
micafungin if neutropenic, critically ill, or prior exposure to fluconazole in past month
fluconazole Consider micafungin rather than
fluconazole if patient has
been receiving fluconazole
in the month prior to
fungemia or if the patient is
critically ill. Review patient’s
recent microbiology for any
recent history of resistant
Candida spp.
IDSA Candidasis Guidelines