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Published by
Malaysian Society of Intensive Care (MSIC)
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Medical Academies of Malaysia
210 Jalan Tun Razak
50400 Kuala Lumpur
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any means without prior permission from the Publisher.
i
Guide to Antimicrobial
Therapy in the Adult ICU
2012
i
FOREWORD
Sepsis still remains one of the commonest cause of intensive care
admission here in Malaysia. In the last six years following the first
edition, there has been burgeoning increase in knowledge and
usage of antimicrobials. However the pressing issues of growing
antimicrobial resistance, inappropriate therapy and escalating cost
compel for a more responsible prescriber.
Dr Louisa Chan
Chairperson and Editor, Writing Committee for
Guide to Antimicrobial Therapy in the Adult ICU 2012
ii
WRITING COMMITTEE
Dr Louisa Chan (Chairperson & Editor)
Consultant Intensivist
Dept. of Anaesthesia and Intensive Care
Hospital Kuala Lumpur
Dr Tai Li Ling
Consultant Intensivist
Dept. of Anaesthesia and Intensive Care
Hospital Kuala Lumpur
iii
EXTERNAL EXPERT REVIEWERS
(in alphabetical order)
iv
TABLE OF CONTENTS
Contents Page
Foreword ii
Working Committee iii
External Expert Reviewers iv
Introduction 1
Principles of Empirical Antimicrobial Therapy 3
Microbiological Investigations 9
Community-Acquired Pneumonia 22
Aspiration Pneumonia 27
Lung Abscess 28
Healthcare-Associated Pneumonia 30
Genitourinary Tract Infection 35
Acute Infective Diarrhoea 39
Acute Infective Pancreatitis 42
Biliary Sepsis 44
Liver Abscess 45
Peritonitis 47
Catheter-Related Bloodstream Infection 50
Infective Endocarditis 56
Central Nervous System Infection 60
Skin and Soft Tissue Infections 66
Diabetic Foot Infection 71
Melioidosis 72
Tuberculosis 74
Leptospirosis 77
Severe Malaria 78
Candidiasis in the non-Neutropenic ICU patient 79
v
INTRODUCTION
Antimicrobials are commonly administered in the intensive
care unit (ICU). This is in association with the high incidence of
admissions with severe sepsis to ICUs and the increased risk of
acquiring infections in ICU. In the Extended Prevalence of Infection
in Intensive Care (EPIC II) study, an international study on the
prevalence and outcomes of infections in ICUs, 51% of patients
were infected while 71% were receiving antibiotics on the day of
the study. Of the infected patients, 16% were being treated with
antifungal agents. In Malaysia, 18.7% of patients had severe sepsis
on admission to ICU in 2011.
1
antibiotic therapy as early as possible once severe sepsis is
diagnosed. In a recent retrospective cohort study in patients with
septic shock, delay in the initiation of appropriate antimicrobial
therapy after the onset of hypotension was associated with a
significant increased risk of death. A study on compliance of SCC
targets in the management of severe sepsis in ICUs in Asia, one of
the three variables independently associated with hospital mortality
was the delay in administration of antibiotics.
Bibliography:
1. BMJ 2011 Jun 13; 342: d3245. Epub 2011 Jun 13.
2. Malaysian Registry of Intensive Care Report 2011
3. JAMA 2009; 302(21): 2323-9
4. Med J Malaysia 2007; 62(5): 370-4
5. Crit Care Med 2006; 34(6): 1589-96
2
PRINCIPLES OF EMPIRICAL
ANTIMICROBIAL THERAPY
3
Category Interval between diagnosis Examples
of suspected infection
and administration of
antibiotics
2. Patient factors
s Severity of illness
Patients in severe sepsis or septic shock require emergent and
broad spectrum antimicrobial therapy.
s Prior antimicrobial use or prolonged hospitalisation
Both are risk factors for the presence of resistant organisms.
s Immunosuppressive states
Patients with underlying malignancy, malnutrition, on steroids
or immunosuppressive drugs may require broad-spectrum
therapy including antifungal.
4
s Presence of renal or hepatic dysfunction
The risk-benefit of the antimicrobial must be determined on
a case-to-case basis. Maintenance doses are adjusted in line
with the severity of organ dysfunction.
s Others
Pregnancy, drug allergy
3. Antimicrobial profile
s Route of administration
The intravenous route should always be used in severe sepsis
as oral absorption is unpredictable even in drugs with good oral
bioavailability.
s Dose and interval
Pathophysiological changes in critically ill patients alter the
pharmacokinetic (PK) and pharmacodynamic (PD) profile of
the antimicrobials. Antibiotics can be categorised into three
different classes depending on the PK/PD indices associated
with their optimal killing activity.
5
Classification PK/PD index Goals of Therapy Examples
6
Empirical therapy should be re-evaluated after 48-72 hours or
when culture results become available. Once a causative pathogen
is identified, narrow the spectrum of antimicrobial therapy
(de-escalation). Sensitivity tests should be interpreted carefully.
In vitro sensitivity does not equate with clinical effectiveness
(e.g. ESCAPPM organisms: Enterobacter spp, Serratia spp,
Citrobacter freundii, Aeromonas spp, Proteus vulgaris, Providencia
spp, Morganella morganii).
7
Pathway in choosing the empirical antimicrobial
Choose antimicrobial:
Decide dose, route, interval and duration
8
MICROBIOLOGICAL INVESTIGATIONS
Identification of causative organisms is central to effective
antimicrobial therapy. Whenever possible, appropriate cultures
should always be obtained before commencing antimicrobials.
Blood specimen
All septic patients (irrespective of source) should have blood
cultures taken prior to commencement of antimicrobials.
9
Blood tests for viral infections include serology for herpes simplex
type 1 and 2, cytomegalovirus (CMV), dengue, viral hepatitis and
respiratory viruses. Consider Human Immunodeficiency Virus
(HIV) serology in patients at risk. Viral cultures are not routinely
performed.
Respiratory specimen
A good specimen of sputum or tracheal aspirate for Gram stain and
cultures should have less than 10 epithelial cells per low power
field reflecting a lower respiratory tract sample. Special stains can
be requested to diagnose Pneumocystis jiroveci or Mycobacterium
tuberculosis.
10
diffuse lung infiltrates in the immunocompromised host or
quantitative cultures for VAP.
11
> 10,000 /mm3 strongly suggests infection while counts
> 50,000 /mm3 is usually seen in empyema. Predominance
of polymorphs is suggestive of bacterial infection while
lymphocytic predominance is suggestive of TB, resolving
pneumonia or fungal infections. Gram stain is done to
enable direct observation of bacteria or fungi under
microscopic examination.
3. Glucose
Pleural fluid glucose levels < 3.3 mmol/L is suggestive of
infection. Levels of 1.7 2.8 mmol/L suggests tuberculous
infection while levels < 1.7 mmol/L suggests bacterial
empyema.
4. pH
Pleural fluid pH < 7.2 is suggestive of infection. Pleural fluid
pH < 7.1-7.2 is more predictive of complicated effusions
and indicates the need for urgent drainage of the effusion,
while pleural fluid pH > 7.3 suggests that the effusion may be
managed with systemic antibiotics alone.
5. Lactate dehydrogenase
Pleural fluid LDH levels > 1000 IU/L suggest complicated
parapneumonic effusions.
12
For Mycobacterium tuberculosis, the use of broth medium
(e.g. BACTEC) provides higher yields and faster results
(1-2 weeks) than conventional methods.
13
CSF analysis Minimum
Volume
Viral: PCR and /or serology 3ml
Herpes simplex type 1 & 2, varicella zoster virus, Japanese B
encephalitis virus, Nipah virus, Enterovirus
Parasite PCR 3mls
Toxoplasma gondii
Mycobacterium PCR and culture 10mls
Fungal antigen and culture 3mls
Aspergillus fumigatus, Cryptococcus neoformans
14
Non-infective causes may have similar biochemical findings
as infective causes. Partial treatment with antibiotics may alter
CSF parameters.
Urine specimen
Urine collection must be taken under aseptic technique to minimise
the degree of bacterial contamination. The sample should be
sent within 2 hours of collection since bacteria will continue to
proliferate. Urine samples not sent immediately should be stored
at 4oC.
15
Symptom Bacteriuria Pyuria No. of Nitirite Comments
cfu/ml WBC/mm3 species
With Present 105 in uncomplicated UTI Pyuria is common 2 not detected Treat as UTI.
catheter in patients with
104 in complicated UTI catheter. Its level Replace catheter if in
has no predictive place for > 7 days.
103 in pregnant women value.
Absent Routine urine culture in asymptomatic catheterised patients is not recommended. Do not treat
bacteriuria except in
Significant asymptomatic bacteriuria: - Pregnancy
- a single specimen 105 cfu/ml - Prior to genitourinary
- specimen collected by in and out catheter 102 cfu/ml. manipulation
16
Without Present 103 in pregnant women and acute >10 2 detected Treat as UTI
catheter uncomplicated cystitis in women (Only positive in
nitrite producing
104 in acute uncomplicated
bacteria e.g. E.
pyelonephritis in women.
coli, Serratia spp,
104 in complicated UTI in men Klebsiella spp and
105 in complicated UTI in women Proteus spp)
Absent Significant asymptomatic bacteriuria if 2 consecutive MSU grows 105 cfu/ml of Do not treat
the same bacterial species in women and 103 cfu/ml in men. bacteriuria except in
- Pregnancy
- Prior to genitourinary
manipulation
For definition of complicated and uncomplicated UTI refer to the chapter on genitourinary tract infection.
Peritoneal fluid specimen
Analysis of peritoneal fluid obtained through paracentesis should
be carried out to determine if there is presence of ascitic fluid
infection in a patient with ascites and in whom intra-abdominal
sepsis is suspected. The fluid should be evaluated for glucose,
protein, lactate dehydrogenase (LDH), cell count, Gram stain,
and aerobic and anaerobic cultures. Routine intraoperative
peritoneal fluid culture in acute abdomen e.g. perforated viscus
is controversial.
17
Secondary bacterial peritonitis should be considered in patients
diagnosed with SBP who display persistent symptoms, increasing
polymorphs, or a persistently positive ascitic fluid culture despite
appropriate antibiotic therapy for 48 hours.
1. Cell count:
Leucocytes > 500/ml or absolute neutrophils > 250/ml
suggests infection. Polymorphonuclear cells and lymphocytes
are predominantly seen in bacterial and tuberculous peritonitis
respectively. Secondary peritonitis should be suspected if
leucocytes are > 10,000/ml
2. Protein level
Protein levels < 1 g/dL is usually seen in spontaneous
peritonitis while levels > 1 g/dL in secondary peritonitis. In
tuberculous peritonitis, protein level is typically > 2.5 g/dL.
5. Increased LDH > 225 IU/ml (> upper limit of normal serum) is
suggestive of secondary peritonitis. In tuberculous peritonitis,
LDH level is usually > 90 IU/ml.
18
Stool specimen
At least 5 ml of diarrheal stool per rectal or per stoma is collected in
a clean leak proof container. The specimen should be transported
to the laboratory and processed within 2 hours after collection.
Culture of a single stool specimen has a sensitivity of > 95% for
detection of the enteric bacterial pathogen.
19
Clostridium difficile toxin detection falls into two categories
of laboratory tests: organism detection assay and toxin assay
[enterotoxin (toxin A) and cytotoxin (toxin B)]. Toxin assays available
are cytotoxicity assay, enzyme immunoassay (EIA) and PCR. EIA is
the preferred diagnostic assay in most clinical laboratories because
the technique is relatively simple, inexpensive with results available
within 24 hours. However, because of high false negative rates,
three consecutive samples are recommended. Positive organism
detection without toxin detection does not require treatment
because this represents colonisation.
Wound swabs
Wound infections should be diagnosed clinically. Routine cultures
of wounds are not indicated unless there are clinical signs of
infection. Culturing uninfected wounds may only be used as part of
an infection control surveillance protocol.
20
Bibliography:
1. European Handbook of neurological management
2nd Edition 2011
2. Guidelines on urological infections by European Association
of Urology 2011
3. World Diabetes: New insights in diabetic foot
infections 2011; 2(2): 24-32
4. Clinical Microbiology Procedures Handbook 3rd Edition 2010
5. Wound watch: Three techniques for collecting wound specimen.
Jan/Feb 2008 Vol 4 No.1
6. N Engl J Med 2002; 346: 1971-7
7. Hepatology 1984; 4: 447-450
21
COMMUNITY-ACQUIRED PNEUMONIA
Community-acquired pneumonia (CAP) is associated with
significant morbidity and mortality, particularly in the elderly.
10% of patients who are admitted to the hospital with a diagnosis
of CAP will require management in the ICU. The mortality for severe
CAP is between 20% to 50%.
Common Antimicrobials
Notes
Organisms Preferred Alternative
S. pneumoniae IV Amoxicillin/ IV Ceftriaxone The indiscriminate
H. influenzae Clavulanate 2g q24h use of 3rd generation
K. pneumoniae 1.2g q8h X 5-7 days cephalosporins may
M. pneumoniae PLUS promote the emergence
L. pneumophilia X 5-7 days IV Azithromycin of ESBL producers.
C. pneumoniae 500mg q24h
PLUS X 3-5 days Duration of treatment
for confirmed atypical
IV Azithromycin OR infection:
500mg q24h 1. Mycoplasma:
IV Levofloxacin Azithromycin 5 days
X 3-5 days 750 mg q24h Levofloxacin 7 days
3. Legionella:
Azithromycin:
immunocompetent 7-10
days, immunocompromised
up to 3 weeks
22
Common Antimicrobials
Notes
Organisms Preferred Alternative
PLUS OPTIONAL Risk factors (MSSA):
1. ESRF
S. aureus IV Cloxacillin 2. IVDUs
(MSSA) 2g q4-6h 3. Prior antibiotics use
especially quinolones
X 10-14 days 4. Prior influenza
23
Common Antimicrobials
Notes
Organisms Preferred Alternative
P. aeruginosa IV Piperacillin/ IV Imipenem Risk factors are severe
Tazobactam 500mg q6h structural lung disease
4.5g q6h OR (e.g. bronchiectasis),
OR IV Meropenem COPD, recent antibiotic
IV Cefepime 1g q8h therapy or hospitalisation.
2g q8-12h OR
IV Doripenem Ceftazidime is not
500mg q8h recommended for
empirical use because it
PLUS PLUS is the main offender in
OPTIONAL OPTIONAL promoting rapid selection
of resistant organism.
IV Amikacin IV Amikacin However if P. aeruginosa
15mg/kg/day 15mg/kg/day is sensitive to ceftazidime,
X 3-5 days X 3-5 days consider de-escalation.
OR OR
IV Ciprofloxacin IV Ciprofloxacin Dual therapy may be
400mg q8h 400mg q8h considered in :
X 7 days X 7 days 1. neutropenic patients
2. CAP with bacteraemia
3. septic shock
In confirmed P. aeruginosa
pneumonia, treat for 10-14
days.
24
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pneumocystis IV Trimethoprim/ IV Pentamidine Prednisolone should be
carinii Sulfamethoxazole 4mg/kg/day given 15-30 min before
(Pneumocystis 5mg/kg (TMP antimicrobials.
jiroveci) component) q8h x 21 days
PO Prednisolone 40mg
x 21 days q12h x 5days, then 40mg
q24h x 5days, then 20mg
q24h x 11days
Patients at risk :
1. HIV infection with CD4+
cells < 200/L
2. HIV infection with other
opportunistic infections e.g.
oral thrush
3. Long term
immunosuppressive
or chemotherapy
4. Primary immunodeficiencies
Viral pneumonias
Influenza A T. Oseltamivir Oseltamivir 150mg q12h for
(pandemic 75mg q12h 10 days should be considered
H1N1, seasonal in the critically ill.
H3N2, avian x 5 days
influenza)
Influenza B
x 7 days
Parainfluenza, No antiviral of
RSV, adenovirus, proven value
SARS, hantavirus
25
Patients with CAP should be treated for a minimum of 5 days, be
afebrile for 48 - 72 hours, and have no more than 1 CAP associated
sign of clinical instability (temperature > 37.8C, heart rate > 100,
respiratory rate > 24, systolic pressure < 90mmHg, SaO2 < 90%,
or PaO2 < 60mmHg) before discontinuation of therapy.
Bibliography:
1. WHO Guidelines for Pharmacological Management of Pandemic
Influnza A (H1N1) 2009 and other Influenza Viruses.
Revised February 2010
2. Thorax 2009; 64 Suppl 3: iii
3. Clin Infect Dis 2007; 44 Suppl 2: S27
4. Clin Infect Dis 2005; 41(Supplement 4): S269-S272
26
ASPIRATION PNEUMONIA
The usual causative organisms in aspiration pneumonia are those that
colonise the oropharynx. Risk factors for aspiration are conditions that
suppress cough and mucociliary clearance. In community-acquired
cases, oral anaerobes are the predominant organisms related to
poor dentition or oral care and periodontal disease. Hospitalised
and institutionalised patients are more likely to have oropharyngeal
colonisation with Gram-negative enteric bacilli and Staphylococcus
aureus. Antimicrobials are not indicated in aspiration without evidence
of infection.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Community-acquired
Oral anaerobes IV Amoxicillin/ IV Ceftriaxone Oral anaerobes are sensitive to
S. pneumoniae Clavulanate 2g q24h all -lactams. Additional enteric
H. influenzae 1.2g q8h anaerobic (Bacteroides fragilis)
S. aureus coverage is not needed.
Enterobacteriaceae
M. catarrhalis Treat for 7-10 days in patients
who respond promptly or
longer if complicated with lung
abscess or empyema.
Healthcare-associated
Gram-negative IV Piperacillin/ IV Imipenem Treat for 7-14 days or longer
bacilli Tazobactam 500mg q6h if complicated with lung
P. aeruginosa 4.5g q6h abscess or empyema.
S. aureus
Anaerobes OR OR
IV Cefepime IV Meropenem
2g q8-12h 1g q8h
PLUS
IV Metronidazole
500 mg q8h
Bibliography:
1. Clin Infect Dis 2007; 44 Suppl 2: S27
27
LUNG ABSCESS
Lung abscess is defined as necrosis of the pulmonary parenchyma
caused by microbial infection. Common causes include:
i. aspiration pneumonia
ii. severe necrotising pneumonia due to S. aureus or
K. pneumoniae
iii. septic emboli from right sided endocarditis
(tricuspid valve endocarditis)
iv. septic thrombophlebitis of internal jugular veins
(Lemierre syndrome)
Common Antimicrobials
Notes
Organisms Preferred Alternative
Secondary to aspiration pneumonia / Lemierre syndrome
Anaerobes: IV Clindamycin IV Piperacillin/ Use preferred therapy
Peptostreptococi 600mg q8h Tazobactam in community-acquired
Fusobacterium spp PLUS 4.5g q6h or Lemierre syndrome
Prevotella IV Ceftriaxone and alternative therapy
Bacteroides 2g q24h OR in healthcare-associated
(usually not infection.
Bacteroides OR IV Meropenem
fragilis) 1g q8h
IV Ampicillin/
S. aureus Sulbactam OR
E. coli 3g 6qh
K. pneumoniae IV Imipenem
P. aeruginosa 500mg 6qh
S. milleri
S. pneumoniae
H. Influenzae
28
Common Antimicrobials
Notes
Organisms Preferred Alternative
Secondary to tricuspid valve endocarditis
Methicillin- Refer to chapter
sensitive on Infective
S. aureus Endocarditis
Methicillin-
resistant
S. aureus
Others
Burkholderia Refer to chapter
pseudomallei on Melioidosis
Bibliography:
1. Thorax 2010; 65 Suppl 2
29
HEALTHCARE-ASSOCIATED PNEUMONIA
Healthcare-associated pneumonia (HCAP) is defined as pneumonia
in any patient who has been admitted to an acute care hospital
for 2 days of the preceding 90 days; resided in a nursing home
or long-term care facility; received recent intravenous antibiotic
therapy, chemotherapy within the past 30 days; or attended a
hospital or haemodialysis clinic. Hospital-acquired pneumonia
(HAP) is defined as pneumonia that occurs 48 hours or more after
hospitalisation while ventilator-associated pneumonia (VAP) is
pneumonia that occurs after 48 hours following intubation.
30
It is now recognised that MDR organisms are increasing in
frequency. The prevalence of these organisms varies from
unit to unit hence guidelines will not replace auditing of local
microbiological data. Occasionally the causative organisms in
pneumonia may be polymicrobial.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Empirical treatment in patients without risk factors for MDR pathogens
S. pneumoniae IV Amoxicillin/ IV Ceftriaxone S. aureus is more
H. influenzae Clavulanate 2g q24h common in diabetes
S. aureus 1.2g q8h mellitus, head trauma.
E. coli X 5-7days
K. pneumoniae OR
IV Cefuroxime
1.5g q8h
X 5-7 days
31
Common Antimicrobials
Notes
Organisms Preferred Alternative
Empirical treatment in patients with risk factors for MDR pathogens
P. aeruginosa IV Piperacillin/ IV Imipenem Consider the alternative
K. pneumoniae Tazobactam 500mg q6h regime if patient is
4.5g q6h haemodynamically
unstable.
OR OR
IV Cefepime IV Meropenem
2g q8-12h 1g q8h
PLUS PLUS
OPTIONAL OPTIONAL
OR
IV Ampicillin/
Sulbactam
3g q3h
PLUS PLUS
OPTIONAL OPTIONAL
32
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
P. aeruginosa IV Ceftazidime IV Imipenem Use the alternative
2g q8h 500mg q6h regime in gp 1
OR OR -lactamase.
IV Piperacillin/ IV Meropenem
Tazobactam 1g q8h Use IV polymyxin in
4.5g q6h carbapenem-resistant
OR P. aeruginosa.
IV Cefepime
2g q8-12h Combination therapy for
pseudomonal infection
X 10-14 days X 10-14 days has not been shown to be
superior to monotherapy.
IV Ampicillin/
Sulbactam
3g q3h
X 10-14 days
33
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
K. pneumoniae IV Imipenem The evidence for use of
(ESBL) 500mg q6h ertapenem in the critically
ill is limited at present.
OR
IV Meropenem
1g q8h
OR
IV Doripenem
500mg q8h
X 7-10 days
Methicillin- IV Vancomycin IV Linezolid For loading dose and
resistant 15-20mg/kg 600mg q12h monitoring of vancomycin
S. aureus q12h refer to Appendix B.
Bibliography:
1. Clin Infect Dis 2011: 52: 285-322
2. Clin Infect Dis 2010; 51 (Suppl 1): S42-47
3. J Infection 2008: 56; 432-436
4. Scand J Infect Dis. 2007; 39(1): 38-43.
5. Curr Anaes and Crit Care 2005; 16: 209-219
6. Am J Respir Crit Care Med 2005; 171: 388-416
34
GENITOURINARY TRACT INFECTION
Urinary tract infections (UTI) is the most common genitourinary
tract infection seen in the critically ill patient. It can manifest from
asymptomatic bacteriuria to severe sepsis. Acute pyelonephritis
is the commonest form of UTI. Mortality associated with septic
shock secondary to urosepsis is substantially lower compared to
other sites of infection. Sterile pyuria or asymptomatic bacteriuria is
common in catheterised patients and does not warrant treatment.
However catheter-associated urinary tract infection (CAUTI) is not
uncommon and should be treated.
35
Common Antimicrobials
Notes
Organisms Preferred Alternative
Acute Uncomplicated Pyelonephritis
E. coli IV Amoxicillin/ IV Cefuroxime
Klebsiella spp Clavulanate 1.5g q8h
P. mirabilis 1.2g q8h
OR OR
IV Ampicillin/ IV Ceftriaxone
Sulbactam 2g q24h
3g q6h
36
Common Antimicrobials
Notes
Organisms Preferred Alternative
Acute Complicated Pyelonephritis / CAUTI
Antibiotic nave
E. coli IV Amoxicillin/ IV Cefuroxime Do not use cephalosporin
Klebsiella spp Clavulanate 1.5g q8h for suspected
P. mirabilis 1.2g q8h enterococcal infection.
OR OR Use of ciprofloxacin is
associated with increased
IV Ampicillin/ IV Ceftriaxone incidence of resistant
Sulbactam 2g q24h strains.
3g q6h In CAUTI:
1. Catheters should be
X 14-21 days X 14-21 days removed or replaced.
Previous antibiotic exposure 2. Duration of treatment
E. coli IV Piperacillin/ IV Cefepime is 7 days if prompt
Klebsiella spp Tazobactam 2g q8-12h resolution of symptoms
P. mirabilis 4.5g q8h or 10-14 days in delayed
P. aeruginosa OR response whether still
Enterobacter spp X 14-21 days catheterised or not
Enterococci IV Imipenem
500mg q6h Obstructive uropathy
ESBL producing should be sought and
Enterobacteriacae OR relieved.
X 14-21 days
37
Common Antimicrobials
Notes
Organisms Preferred Alternative
Renal Abscess (intrarenal or perinephric)
Methicillin- IV Cloxacillin Consider image-guided
sensitive 2g q4-6h aspiration or surgical
S. aureus drainage of abscess.
X 7 days X 7 days
PLUS PLUS
PO Doxycycline PO Doxycycline
100mg q12h 100mg q12h
X 14 days X 14 days
Bibliography:
1. The Sanford Guide to Antimicrobial Therapy 2011: 30-31
2. Guidelines on urological infections by European Association
of Urology 2011
3. Clin Infect Dis 2011; 52(5): e103
4. Clin Infect Dis 2010; 50: 625
38
ACUTE INFECTIVE DIARRHOEA
Acute infective diarrhoea is usually self-limiting and does not require
antimicrobials. Patients admitted to the ICU are usually in shock
with systemic involvement and therefore, empirical antimicrobials
need to be started.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Empirical therapy (community acquired) : non bloody diarrhoea
Salmonella typhi IV Ceftriaxone IV Ciprofloxacin Addition of azithromycin/
and non typhi 2g q24h 400mg q12h doxycycline is for the
Vibrio cholerae coverage of Vibrio cholerae
Enterotoxigenic X 7-10 days X 7-10 days as ciprofloxacin resistance
E.coli (ETEC) is increasing.
PLUS If ETEC is isolated, stop
antibiotics.
PO
Azithromycin
1g single dose
OR
PO Doxycycline
300mg single
dose
Empirical therapy (community acquired) : bloody diarrhoea
Shigella spp IV Ceftriaxone IV Ciprofloxacin If E.coli 0157 (commonest
Enterohaemorrhagic 2g q24h 400mg q12h strain), is isolated, stop
E. coli 0157 (EHEC) antibiotics and observe
X 3 days X 3 days for haemolytic uraemic
syndrome (HUS).
39
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific: Community-acquired
Shigella spp IV Ceftriaxone IV Ciprofloxacin If S. dysenteriae type 1 is
2g q24h 400mg q12h isolated or in patients with
HIV, treat for 5 - 7 days.
X 3 days OR
IV Azithromycin
500mg q24h
X 3 days
Vibrio cholerae PO Azithromycin PO
1g Ciprofloxacin
500mg q12h
OR
X 3 days
PO Doxycycline
300mg
X 1 dose
Salmonella IV Ceftriaxone IV Ciprofloxacin
typhi and 2g q24h 400mg q12h
non-typhi
X 7-10 days X 7-10 days
40
Relapse occurs in up to 27% of cases, typically between 3 days to 3
weeks after treatment is discontinued. Metronidazole should not be
used after the first recurrence.
Severity:
Mild to moderate PO Metronidazole 400mg q8h 1. mild to moderate: TWC<15
and creat<1.5x baseline
X 10-14 days
Duration of treatment
depends on clinical response.
Bibliography:
1. Infect Control Hosp Epidemiol 2010; 31: 431-455
2. Cochrane Database Syst Rev. 2007
3. N Engl J Med 2004; 350(1): 38
4. Clin Infect Dis 2001; 32(3): 331
41
ACUTE INFECTIVE PANCREATITIS
Patients with severe acute pancreatitis who develop infection tend
to have more than 30% necrosis of the pancreas. Infection usually
occurs late (after 10 days) in the clinical course of the disease.
The important organisms causing infection in necrotising
pancreatitis are predominantly gut-derived, and the majority are
monomicrobial.
42
Common Antimicrobials
Notes
Organisms Preferred Alternative
Enterobacteriaceae IV Piperacillin/ IV Imipenem Infected pancreatic
(E. coli, Tazobactam 500mg q6h necrosis is an indication
Klebsiella spp. 4.5g q6h for surgical or
Proteus spp.) OR radiological-guided
Enterococcus spp drainage.
Bacteroides spp IV Meropenem
1g q8h Duration of treatment is
guided by repeated clinical
and serial radiological
assessments.
Bibliography:
1. Am J Gastroenterol 2008; 103(1): 104
2. Am J Gastroenterol 2006; 101(10): 2379
3. Gastroenterology 2007; 132(5): 2022
4. Cochrane Database Syst Re. 2006.
43
BILIARY SEPSIS
Acute cholangitis can be a life-threatening infection secondary to the
obstruction of common bile duct by gall stones or strictures. Besides
antimicrobial therapy, prompt decompression and drainage of the
biliary tract need to be considered.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Enterobacteriaceae IV Cefoperazone IV Piperacillin/ Consider the alternative
(E. coli, 2g 12qh Tazobactam regime in patients with
Klebsiella spp, 4.5g q6h recent ERCP, presence
Enterobacter spp) PLUS OR of stents or entero-biliary
Enterococci IV Cefepime surgery.
P. aeruginosa IV Metronidazole 2g q8-12h
Anaerobes 500mg 8qh PLUS Consider enterococcal cover
(Bacteroides IV Metronidazole in: immunocompromised
fragilis, X 7-10 days 500mg q8h (solid organ transplant or
C. perfringens) OR steroid therapy), valvular
heart disease, intravascular
IV Imipenem
500mg q6h prosthetic devices or
previous antimicrobial use.
OR
IV Meropenem Ceftriaxone may increase
1g q8h biliary sludging.
OR
IV Doripenem
500mg q8h
X 7-10 days
Bibliography:
1. Clin Infect Dis 2010; 50(2): 133-64
44
LIVER ABSCESS
Liver abscess is classified by aetiology into pyogenic, amoebic
and fungal abscess. Pyogenic abscess is the most common
and may occur following spread through the biliary tree, by
extension of adjacent infection or following instrumentation
e.g. chemoembolisation or biliary sphincterotomy. Invasive
Klebsiella pneumoniae liver abscess syndrome (KLAS) is a
community-acquired primary liver abscess that may have
metastatic manifestations (endophthalmitis, meningitis, brain
abscess). Abscess caused by Burkholderia pseudomallei should
be considered in patients who present with shock.
45
Common Antimicrobials
Notes
Organisms Preferred Alternative
Enterobacteriaceae Empirical therapy in the Consider carbapenem
(E. coli, Klebsiella haemodynamically unstable when melioidosis is
pneumoniae) IV Piperacillin/ IV Meropenem suspected.
S. milleri Tazobactam 1g q8h
Enterococcus spp 4.5g q6h Consider
S. aureus antifungal therapy in
Anaerobes OR OR immunocompromised or
(Bacteroides spp, neutropenic patients.
Fusobacterium spp, IV Cefepime IV Imipenem
Actinomyces spp, 2g q8-12h 500mg q6h Metronidazole is added
Clostridium spp) to cover Entamoeba
Entamoeba PLUS histolytica.
histolytica IV Metronidazole 500mg q8h
Empirical therapy in the
haemodynamically stable
IV Ceftriaxone IV Piperacillin/
2g q24h Tazobactam
4.5g q6h
PLUS PLUS
IV IV
Metronidazole Metronidazole
500mg q8h 500mg q8h
Bibliography:
1. The Sanford Guide to Antimicrobial Therapy 2011
2. Clin Infect Dis 2010; 50: 133-164
3. Clin Infect Dis 2007; 45(3): 284
46
PERITONITIS
In complicated intra-abdominal infections, the infective
process extends beyond the organ and causes either localised
peritonitis with abscess formation or diffuse peritonitis.
Complicated intra-abdominal infections can be classified into:
Common Antimicrobials
Notes
Organisms Preferred Alternative
Spontaneous bacterial peritonitis
E.coli IV Ceftriaxone IV Piperacillin/
Klebsiella spp 2g q24h Tazobactam
S.pneumoniae 4.5g q6h
Enterococci
X 5 days X 5 days
47
Common Antimicrobials
Notes
Organisms Preferred Alternative
Community-acquired secondary peritonitis
Enterobacteriaceae Mild to moderately ill Bowel perforation from
(esp. E. coli) IV Amoxicillin/ IV Ceftriaxone penetrating or blunt
Streptococcus Clavulanate 2g q24h trauma, repaired within
milleri 1.2g q8h OR 12h should only be
Anaerobes IV treated with antibiotics
(esp. Bacteroides X 5-7 days Cefoperazone for 24h.
fragilis) 2g q12h
Antimicrobial therapy is
PLUS only required for 24h post
operatively in:
IV 1. Acute perforations of
Metronidazole the stomach, duodenum,
500mg q8h proximal jejunum (with
absence of antacid
X 5-7 days therapy or malignancy)
Severely ill when source control is
achieved within 24h
IV Piperacillin/ IV Meropenem 2. Acute appendicitis
Tazobactam 1g q8h (without evidence of
4.5g q6h gangrene, perforation,
abscess, peritonitis).
OR OR
Use of anti-MRSA
IV Cefepime IV Imipenem or antifungal is not
2g q8-12h 500mg q6h recommended in the
PLUS absence of evidence
IV OR of infection by such
Metronidazole organisms.
500mg q8h IV Doripenem
500mg q8h
X 5-7 days
X 5-7 days
48
Common Antimicrobials
Notes
Organisms Preferred Alternative
Healthcare-associated secondary peritonitis and tertiary peritonitis
ESBLproducing Risk for ESBL-producing Following adequate
enterobacteriaceae enterobacteriaceae source control,
(E. coli, Klebsiella Low High antimicrobials should be
spp) discontinued when there
Enterobacter spp IV Piperacillin/ IV Meropenem is resolution of fever,
Proteus spp Tazobactam 1g q8h normalisation of WBC and
return of gastrointestinal
P. aeruginosa 4.5g q6h
function.
Acinetobacter spp OR
Enterococci OR Risks of selection
Anaerobes IV Imipenem of ESBLproducing
IV Cefepime 500mg q6h enterobacteriaceae:
prior exposure to 3rd gen.
2g q8-12h
cephalosporins, multiple
PLUS OR
antibiotics.
IV
Metronidazole IV Doripenem Consider enterococcal
500mg q8h 500mg q8h cover in tertiary
peritonitis, previously
PLUS OPTIONAL on cephalosporins,
immunocompromised,
Methicillin- IV Vancomycin valvular heart disease or
15-20mg/kg q12h prosthetic intravascular
resistant
materials.
S. aureus
PLUS OPTIONAL Consider anti-MRSA in
those colonised with
Candida albicans IV Fluconazole 800mg stat MRSA, prior MRSA
and 400mg q24h treatment failure or
significant antibiotic
exposure.
For loading dose and
monitoring of vancomycin
refer to Appendix B.
Consider antifungal in
severe hospital-acquired
infections.
Bibliography:
1. World J Emerg Surg 2011, 6:2 doi: 10.1186/1749-7922-6-2
2. Clin Infect Dis 2010; 50: 133-64
49
CATHETER-RELATED BLOODSTREAM INFECTION
Patients with short term CVC are suspected to have catheter-related
infection if they have an acute febrile episode with or without
hypotension, hypoperfusion and organ dysfunction in the absence
of other identifiable sources of infection.
50
Common Antimicrobials
Notes
Organisms Preferred Alternative
Empirical therapy in the haemodynamically stable
Methicillin IV Cloxacillin Empirical therapy should
sensitive: 2g q6h be stopped if cultures are
Coagulase- negative.
negative
S. epidermidis Consider MRSA/MRSE in
(CoNS) patients with prosthetic
S. aureus valves or vascular graft,
prior antibiotic use, on
hemodialysis, prolonged
Methicillin IV Vancomycin hospital stay, HIV +ve and
resistant: 15-20mg/kg residence of long term
S. aureus q12h care facilities.
S. epidermidis
For loading dose and
monitoring of vancomycin
refer to Appendix B.
51
Common Antimicrobials
Notes
Organisms Preferred Alternative
Empirical therapy in the haemodynamically unstable
Gram-negative IV Cefepime IV Meropenem The choice of
bacilli 2g q8-12h 1g q8h antimicrobials depends
on the local flora and
OR OR susceptibility patterns.
IV Piperacillin/ IV Imipenem
Tazobactam 500mg q6h Consider Gram-negative
4.5g q6h cover in neutropenia,
severe sepsis or patients
OR OR known to be colonised
with such pathogens.
IV IV Polymyxin E
Cefoperazone/ 3 million units Consider MRSA cover in
Sulbactam q8h patients with prolonged
4g q6h
hospital stay, prior
PLUS OPTIONAL antibiotic use, on dialysis,
HIV +ve and residence of
MRSA IV Vancomycin long term care facilities.
15-20mg/kg
q12h For loading dose and
monitoring of vancomycin
PLUS OPTIONAL PLUS OPTIONAL refer to Appendix B.
52
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
Methicillin IV Cloxacillin Infected catheters must
sensitive: 2g q6h be removed.
CoNS
X 5-7 days Duration of therapy in
complicated infection:
S.aureus IV Cloxacillin a. endocarditis /
2g q6h suppurative
thrombophlebitis
X 14 days 4-6 wks
X 14 days X 14 days
53
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
Non-ESBL IV Amoxicillin/ IV Ceftriaxone Consider in patient with
E. coli Clavulanate 2g q24h femoral catheters.
Klebsiella spp 1.2g q8h
X 7-14 days
OR
IV Cefuroxime
1.5g q8h
X 7-14 days
OR
IV Doripenem
500mg q8h
X 10-14 days
Acinetobacter spp IV Ampicillin/ IV Polymyxin E Sulbactam component of
Sulbactam 3 million units 8g/day is required.
3g q3h q8h
OR X 10-14 days
IV
Cefoperazone/
Sulbactam
4g q6h
X10-14 days
54
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
P. aeruginosa IV Ceftazidime IV Meropenem Use the alternative
2g q8h 1g q8h regime in gp. 1
OR OR -lactamase.
IV Cefepime IV Imipenem
2g q8-12h 500mg q6h Use IV polymyxin in
OR OR carbapenem-resistant
IV Piperacillin/ IV Doripenem P. aeruginosa.
Tazobactam 1g q8h
4.5g q6h Dual therapy may be
considered in
X 10-14 days X 10-14 days 1. neutropenic patients
2. septic shock
PLUS OPTIONAL PLUS OPTIONAL
IV Amikacin IV Amikacin
15mg kg/q24h 15mg/kg q24h
X 3-5 days X 3-5 days
OR OR
IV Ciprofloxacin IV Ciprofloxacin
400mg q8h 400mg q8h
X 7 days X 7 days
Candida albicans IV Fluconazole Treat for 14 days after last
800mg stat positive blood culture.
then 400mg
q24h Consider echinocandins
(or lipid-based
Candida non IV Amphotericin IV Anidulafungin amphotericin B) in
albicans B 200mg stat then patients with recent
0.6-1mg/kg 100mg q24h azole exposure and renal
q24h dysfunction.
OR
IV Caspofungin
70mg stat then
50mg q24h
Bibliography:
1. Clin Infect Dis 2009; 49(1): 1-45
55
INFECTIVE ENDOCARDITIS
Dukes criteria is widely used for diagnosis of infective endocarditis
(IE). Three sets of blood cultures should be obtained prior to
initiation of antibiotic therapy. An echocardiogram should be done in
all suspected cases. Treatment is guided by presentation,
clinical findings, native or prosthetic valves and organism virulence.
Indications for surgery include the following: heart failure,
uncontrolled infection and large vegetations.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Empirical therapy
Native valve IV Benzylpenicillin IV Cefriaxone Consider cloxacillin in
3 million units 2g q24h intravenous drug users.
q4h
Benzylpenicillin:
PLUS 1 million units
= 600mg
IV Gentamicin
1mg/kg q8h
IV Cloxacillin IV Cloxacillin
2g q4h 2g q4h
PO Rifampicin
300mg q8h
56
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
S. viridans IV Benzlpenicillin IV Benzylpenicillin The alternative
S. bovis 3 million units 3 million units 2-week regime is not
Highly penicillin- q4h q4h recommended for
susceptible: OR patients age > 65 years
MIC 0.12 g/ml OR IV Ceftriaxone old, creatinine clearance
2g q24h < 20ml/min, deafness
IV Ceftriaxone and known cardiac or
2g q24h PLUS extra-cardiac abscesses
IV Gentamicin IV Gentamicin
1mg/kg q8h 1mg/kg q8h
X 2 weeks X 2 weeks
57
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
S. aureus IV Cloxacillin If MRSA : Uncomplicated right-sided
(Native valve- 2g q4h IV Vancomycin endocarditis: absence of
left side 15-20mg/kg heart failure,
and q12h extra-pulmonary
complicated metastatic infection such
X 6 weeks X 6 weeks
right sided) as osteomyelitis, aortic
PLUS PLUS or mitral valve
involvement, meningitis
IV Gentamicin IV Gentamicin or infection with MRSA.
1mg/kg q8h 1mg/kg q8h
X 3-5 days X 3-5 days
58
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
Enterococcus spp IV Ampicillin Duration of treatment:
(Ampicillin sensitive) 2g q4h Native valve with
symptoms
PLUS < 3 months - 4 weeks
Native valve with
IV Gentamicin symptoms
1mg/kg q8h > 3 months - 6 weeks
Enterococcus spp Prosthetic valve is
(Ampicillin resistant) minimum 6 weeks
IV Vancomycin
15-20 mg/kg
q12h
PLUS
IV Gentamicin
1mg/kg q8h
HACEK IV Ampicillin/ IV Ceftriaxone
Haemophilus spp Sulbactam 2g q24h
Actinobacillus 3g q6h
actinomycetemcomitans
Cardiobacterium hominis X 4 weeks X 4 weeks
Eikenella corrodens
Kingella spp
Bibliography:
1. Eur Heart J 2009; 30: 2369
2. Circulation 2005; 111: 3167
59
CENTRAL NERVOUS SYSTEM INFECTION
The approach to the patient with suspected acute central nervous
system infection is early recognition of the disease, performance of
rapid diagnostic tests, prompt antimicrobial therapy and adjunctive
therapy whenever appropriate.
60
Common Antimicrobials
Notes
Organisms Preferred Alternative
Acute bacterial meningitis community-acquired
S. pneumoniae IV Ceftriaxone IV Cefotaxime Add IV vancomycin
N. meningitidis 2g q12h 2g q6h if prevalence of
H. influenzae cephalosporin-resistant
Duration of treatment: S. pneumoniae is > 2%.
Aerobic Gram-
negative bacilli N. meningitidis X 7days Add IV dexamethasone
(more common 0.15mg/kg (10mg) q6h
in age > 50, H. influenzae X 7 days X 4 days in pneumococcal
immuno- meningitis. 1st dose to be
compromised) S. pneumoniae X 14 days given 10-20 min before,
or concomitant with the
Listeria Aerobic Gram negative bacilli first dose of antibiotic.
monocytogenes X 21 days Omit if antibiotics have
(uncommon in been started.
Malaysia) L. monocytogenes X 21 days or
longer if immunocompromised Treat Listeria meningitis
with IV ampicillin 2g q4h
IV gentamicin if CSF
Gram-stain reveals
Gram-positive rods or
when confirmed.
Acute bacterial meningitis - Post head injury (base of skull fracture)
S. pneumoniae IV Ceftriaxone IV Cefotaxime
H. influenzae 2g q12h 2g q6h
Group A
-haemolytic
streptococci
61
Common Antimicrobials
Notes
Organisms Preferred Alternative
Acute bacterial meningitis - Penetrating trauma, post neurosurgery,
shunts including lumbar catheters
S. aureus IV Ceftriaxone IV Cefepime Remove infected shunt.
Coagulase- 2g q12h 2g q8h
negative OR Consider the alternative
staphylococci PLUS IV Meropenem regime if at risk for MDR
Aerobic 2g q8h pathogens e.g. prolonged
Gram-negative IV Cloxacillin hospital stay, previous
bacilli 2g q6h PLUS broad-spectrum antibiotic.
X 14 days IV Vancomycin
15-20mg/kg For loading dose and
q12h monitoring of vancomycin
refer to Appendix B.
X 14 days
Acute encephalitis
Herpes simplex IV Acyclovir If immunocompromised
Herpes zoster 10mg/kg q8h to treat for 21 days.
X 14 days
Arboviruses No antiviral of
Flaviviruses proven value
62
Common Antimicrobials
Notes
Organisms Preferred Alternative
Brain abscess - Haematogenous and contiguous spread
Streptococci IV Ceftriaxone IV Cefotaxime Contiguous spread can
Bacteroides spp 2g q12h 2g q6h occur from otitis media,
Enterobacteriaceae mastoiditis and sinusitis
S. aureus PLUS PLUS which will need surgical
drainage.
IV Metronidazole IV Metronidazole
500mg q8h 500mg q8h Consider surgical
drainage if brain abscess
is > 2.5cm.
S. aureus abscess is
rare in the absence of a
positive blood culture.
Minimum duration of
treatment is 4-6 weeks
and response is guided by
neuro imaging.
Brain abscess - Post surgery / post trauma
S. aureus IV Ceftriaxone IV Cefepime Consider surgical drainage
Aerobic 2g q12h 2g q8h if abscess is > 2.5cm.
Gram-negative OR
bacilli PLUS IV Meropenem Consider the alternative
2g q8h regime if at risk for MDR
IV Cloxacillin e.g. prolonged hospital
2g q4h PLUS stay, previous
broad-spectrum
IV Vancomycin antibiotic use.
15-20mg q12h
Minimum duration of
treatment is 4-6 weeks
and response is guided by
neuro imaging.
63
Common Antimicrobials
Notes
Organisms Preferred Alternative
Brain abscess - Cyanotic heart disease
Streptococci IV Ceftriaxone Consider surgical drainage
(esp. S. milleri) 2g q12h if abscess is > 2.5cm.
H.influenzae
Minimum duration of
S. aureus
treatment is 4-6 weeks
and response is guided by
neuro imaging.
Brain abscess - HIV infected
Toxoplasma PO IV Trimethoprim/ Folinic acid prevents
gondii Pyrimethamine Sulfamethoxazole pyrimethamine-induced
200mg X 1 day 5mg/kg haematologic toxicity.
then (trimethoprim
75mg q24h component) q12h Treat till CD4
X 30 days count >200/L for 3
PLUS months, even after
PO Sulfadiazine complete resolution of
1g q6h if < 60 kg lesions on CT/MRI.
or 1.5g q6h if
> 60 kg
PLUS
PO Folinic acid
20mg q24h
X 6 weeks after
resolution of
signs/symptoms
Suppression treatment
PO Sulfadiazine 2-4g in divided
2-4 doses/day
PLUS
PO Pyrimethamine 25-50mg q24h
PLUS
PO Folinic acid 20mg q24h
64
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
Cryptococcus Induction phase For HIV infected or
neoformans IV Amphotericin IV Liposomal transplant patients, refer
B 0.7-1.0 mg/kg Amphotericin B ID physician.
q24h 3-4mg/kg q24h
OR Induction phase of
IV Amphotericin 6 weeks or longer in
B lipid complex patients with neurological
5mg/kg q24h complications, if CSF
culture is still positive after
PLUS PLUS 2 weeks of treatment or if
flucytosine is not given or
PO Flucytosine PO Flucytosine treatment is interrupted.
25mg/kg q6h 25mg/kg q6h In patients at low risk
of therapeutic failure
X 4 weeks X 4 weeks (early diagnosis by
Consolidation phase history, no uncontrolled
PO Fluconazole underlying disease, not
400 mg q24h immunocompromised
and excellent clinical
X 8 weeks response to initial 2-week
antifungal combination),
Maintenance phase consider induction
therapy with combination
PO Fluconazole of amphotericin B plus
200mg q24h flucytosine for 2 weeks,
followed by consolidation
X 6 - 12 months with PO fluconazole
800mg q24h for 8 weeks.
Mycobacterium Refer to chapter on tuberculosis
tuberculosis
Bibliography:
1. The Sanford Guide to Antimicrobial Therapy 2011; 5-8, 99
2. Clin Infect Dis 2010; 50: 291-322
3. Clin Infect Dis 2008; 47: 303-27
4. Clin Infect Dis 2004; 39: 1267-84
65
SKIN AND SOFT TISSUE INFECTIONS
Skin and soft tissue infections (SSTIs) are usually caused by
bacterial entry through breaches in the skin. Its clinical severity
depends on host factors such as age, diabetes mellitus and state of
immunocompetence.
Cellulitis
Cellulitis is an acute diffuse infection of the epidermis, dermis
and subcutaneous tissue. It is usually caused by -haemolytic
streptococci (most commonly Group A) or S. aureus. S. aureus
cellulitis is usually associated with bullae or abscesses. Lack of
clinical response to antimicrobials could be due to resistant strains
of organisms e.g. MRSA or infection of the deeper tissues. There is
growing concern regarding the emergence of community-acquired
MRSA SSTIs.
Common Antimicrobials
Notes
Organisms Preferred Alternative
-haemolytic IV Cloxacillin IV Amoxicillin/ If streptococci is
Streptococci 2g q6h Clavulanate cultured consider IV
S. aureus 1.2g q8h benzylpenicillin 4 MU q6h.
X 5-10 days
X 5-10 days IV benzylpenicillin:
1 million units
= 600mg
Duration of treatment
depends on clinical
response.
66
Necrotising fasciitis
Necrotising fasciitis is an infection of the deeper tissues usually
involving the extremities, the parapharyngeal space, the abdominal
wall or the perineum (Fourniers gangrene). Patients are generally
more ill and septic. Although supportive management of organ
failure and antimicrobials play a major role, surgical debridement
often extensive and repeated is essential. Tissue cultures taken at
the time of debridement may help to identify the organism.
67
Common Antimicrobials
Notes
Organisms Preferred Alternative
-haemolytic IV Ampicillin/ IV Piperacillin/ Continue treatment until
streptococci Sulbactam Tazobactam surgical debridement is no
S.aureus 3g q6h 4.5g q6h longer needed and patient
Bacteroides spp OR has clinically improved.
Clostridium spp PLUS IV Imipenem
Peptostreptococci 500mg q6h If Clostridium spp or
Enterobacteriaceae IV Clindamycin haemolytic streptococci
900mg q8h PLUS is confirmed, deescalate
to IV benzylpenicillin 2
IV Clindamycin MU q4h but continue
900mg q8h clindamycin.
If streptococcal toxic
shock syndrome is
suspected consider IVIg.
If Aeromonas hydrophila
is isolated to stop
doxycycline.
68
Deep neck space infection
Deep neck space infections include the submandibular (Ludwigs
angina), parapharyngeal, retropharyngeal and peritonsillar space
infection. Infections of the deep neck tissues often need surgical
debridement and assessment for potential airway compromise.
These infections may extend resulting in mediastinitis and/or lung
empyema.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Streptococcus IV Benzylpenicillin IV Amoxicillin/ Most of these infections
spp 4 MU q6h Clavulanate have an odontogenic
Anaerobes 1.2g q8h source.
Peptostreptococi
Fusobacterium PLUS OR Gram negative rods to
spp be considered in the
Prevotella IV Metronidazole IV Ampicillin/ immunocompromised
Bacteroides 500mg q8h Sulbactam host.
(usually not 3g q6h
Bacteroides Continue treatment until
fragilis) surgical debridement is no
longer needed and patient
has clinically improved.
69
Common Antimicrobials
Notes
Organisms Preferred Alternative
Abdominal/Perineum
Mixed IV Ampicillin/ IV Piperacillin/
Gram-positive Sulbactam Tazobactam
and 3g q6h 4.5g q6h
Gram-negative
X 5-7 days X 5-7 days
Chest/Extremities
S. aureus IV Cloxacillin IV Amoxicillin/
Streptococcus 2g q6h Clavulanate
spp 1.2g q8h
X 5-7 days
X 5-7 days
Bibliography:
1. The Sanford Guide to Antimicrobial Therapy 2011: 39-41
2. Clin Infect Dis: 2005: 41; 1373-406
3. N Engl J Med 2004: 350(9): 904-912
70
DIABETIC FOOT INFECTIONS
Foot infections are common complications of diabetic patients.
Management of patients admitted in severe sepsis or septic
shock secondary to diabetic foot infection includes intravenous
antibiotics together with extensive wound debridement and/or
amputation of the limb. Appropriate wound swabs should be taken
prior to starting antibiotics (refer to chapter on microbiological
investigations). Duration of therapy should be based on severity
of infection, presence or absence of osteomyelitis and clinical
response to therapy. Routinely prescribing antibiotics for a fixed
duration is unnecessary.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Macerated ulcer with extensive necrosis/gangrene
S. aureus IV Piperacillin/ IV Imipenem If high risk for MRSA to
-haemolytic Tazobactam 500mg q6h add IV vancomycin.
streptococci 4.5gm q6h
Enterobacteriaceae
P. aeruginosa OR
Anaerobes
IV Cefepime
2g q8-12h
PLUS
IV Metronidazole
500mg q8h
Chronic ulcer previously treated with antibiotics
S. aureus IV Ampicillin/ IV Piperacillin/
-haemolytic Sulbactam Tazobactam
streptococci 3gm q6h 4.5gm q6h
Enterobacteriaceae
Bibliography:
1. Clin Infect Dis 2012: 54; 132-173
2. World J Diabetes 2011: 2(2); 24-32
71
MELIOIDOSIS
Melioidosis is a potentially fatal disease caused by Burkholderia
pseudomallei. There is no reliable pathognomonic feature and can
present as bacteremia with no obvious focal infection or as septic
shock with multiorgan failure. Common sites of infection include
the lung (50%), joints, spleen, liver and prostate.
72
Common Antimicrobials
Notes
Organisms Preferred Alternative
Phase 1: Treatment
Burkholderia IV Meropenem IV Ceftazidime Carbapenem is preferred
pseudomallei 1g q8h 2g q8h in severe sepsis as the
(2g q8h for benefits are: higher rate
CNS infection) X 14 days of bacterial killing in vitro
due to enhanced cell
OR
wall penetration, better
IV Imipenem post-antibiotic effect and
1g q8h decreased endotoxin
release.
X 14 days
PLUS OPTIONAL
IV Trimethoprim/ Sulfamethoxazole
5mg/kg (TMP component) q12h
(in deep seated focal infections,
neurological, joints, bones, prostate)
X 14 days
Phase 2: Eradication
Any 2 in order of
preference:
PO Trimethoprim/
Sulfamethoxazole
320:1600mg
q12 h
PO Doxycycline
100mg q12h
PO
Amoxicillin/
Clavulanate
500/125 mg q8h
X 12-20 weeks
Bibliography:
1. Pharmaceuticals 2010: 3; 1296-1303
2. Med J Malaysia 2009: 64(4); 266-274
73
TUBERCULOSIS
Tuberculosis (TB) is caused by Mycobacterium tuberculosis which
may affect pulmonary and/or extra-pulmonary sites. Patients at risk
of TB infections include:
74
Treatment phase Preferred agent Notes
Intensive EHRZ or SHRZ q24h SHRZ is the combination of choice for
TB meningitis.
X 8 weeks Renal profile, full blood count and liver
function test should be monitored at least
or 56 daily doses twice a week while the patient is in ICU.
PO pyridoxine 10mg q24h should be given
Continuation HR biweekly to prevent isoniazid induced neuropathy.
Duration may be extended in the
X 4 months immunocompromised and in those with
extrapulmonary TB.
or 32 doses
It is necessary to consult the TB specialist
in the following situations:-
1. Relapse, treatment failure or treatment
after interruption
2. Liver failure
3. Inability to tolerate oral medications
75
Steroids should be given in TB meningitis in non HIV patients,
however the evidence is not conclusive in patients with HIV.
Steroids are also indicated in TB pericarditis, TB adrenalitis and TB
lymphadenitis with compressive symptoms.
Bibliography:
1. WHO. Treatment of tuberculosis: Guidelines. 4th edition 2009
2. Guidelines on management of TB: KKM.
Academy of Medicine Malaysia
3. Clin Infect Dis 2000; 31: 633-9
76
LEPTOSPIROSIS
Leptospirosis is a zoonotic infection caused by pathogenic
spirochetes of the genus Leptospira. The clinical manifestations of
leptospirosis are variable and non-specific, ranging from mild febrile
illness to the icteric-haemorrhagic form with severe kidney and liver
involvement and pulmonary haemorrhage.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Leptospira spp IV Benzylpenicillin IV Ceftriaxone In less severe infection:
2 million units 2g q24h PO Doxycyline 100mg
q6h q12h x 7 days
X 7 days X 7 days OR
PO Azithromycin 500mg
q24h x 7 days
Bibliography:
1. The Sanford Guide to Antimicrobial Therapy 2011
2. Clin Infect Dis 2003; 36: 1507-14
77
SEVERE MALARIA
Patients diagnosed or suspected with severe malaria should be
started on parenteral antimalarial therapy immediately. Severe
malaria with complications such as haemolysis, acute renal failure
and lactic acidosis is usually due to Plasmodium falciparum. Patients
with severe malaria are at risk of concurrent bacterial infection.
Common Antimicrobials
Notes
Organisms Preferred Alternative
Plasmodium IV Artesunate IV Quinine Treat severe malaria due
falciparum 2.4mg/kg at Dihydrochloride to other plasmodium
0 hrs and 12 hrs, 20mg/kg in species with IV
then q24h 250mls D/5% artesunate.
over 4 hours
PLUS and then 10mg / Blood sugars and QT
kg q8h intervals need to be
PO Doxycyline monitored regularly
200mg q24h PLUS while on quinine.
Bibliography:
1. WHO. Guidelines for the treatment of malaria: 2nd edition 2010
78
CANDIDIASIS IN THE NON-NEUTROPENIC
ICU PATIENT
s )MMUNOCOMPROMISEDIMMUNOSUPPRESSIVE THERAPY
s .EUTROPENIA NEUTROPHIL COUNT MM3)
79
s 3OLID ORGAN OR BONE MARROW TRANSPLANTATION
s #ANDIDA COLONISATION AT MULTIPLE NON
STERILE SITES
s 5SE OF BROAD
SPECTRUM ANTIBIOTICS
s 0RESENCE OF CENTRAL VENOUS CATHETERS
s "URNS "3!
s -AJOR TRAUMA
s -AJOR ABDOMINAL SURGERY
s 0ARENTERAL NUTRITION
s 3EVERE ACUTE PANCREATITIS
s (IGH SEVERITY ILLNESS SCORE
s !CUTE RENAL FAILURE OR HAEMODIALYSIS
s $IABETES MELLITUS
s 0ROLONGED )#5 STAY DAYS
80
Common Antimicrobials
Notes
Organisms Preferred Alternative
Empirical therapy in haemodynamically unstable non-neutropenic patient
Candida spp IV Fluconazole IV Caspofungin Amphotericin B is
800mg (loading 70mg (loading preferred in patients with
dose) followed dose) followed recent azole exposure
by 400mg q24h by 50mg q24h (last 3 months) and at
high risk of developing
OR OR C. glabrata and
C. krusei (e.g. severe
IV Amphotericin B IV Anidulafungin acute pancreatitis, burns).
0.6-1mg/kg/day loading dose
200mg followed Consider echinocandins
by 100mg q24h (or lipid-based
amphotericin B) in
patients with recent
azole exposure and renal
dysfunction.
Empirical therapy in haemodynamically stable non-neutropenic patient
Candida spp IV Fluconazole IV Amphotericin B Consider amphotericin B
800mg (loading 0.6-1mg/kg/day if patient had recent
dose) followed azole exposure in the
by 400mg q24h last 3 months.
81
Common Antimicrobials
Notes
Organisms Preferred Alternative
Pathogen specific
C. albicans IV Fluconazole IV Amphotericin B Duration of treatment
800mg (loading 0.6-1mg/kg/day without metastatic
dose) followed complication is
by 400mg q24h 14 days after last positive
blood culture and
C. glabrata IV Amphotericin B IV Caspofungin
resolution of signs and
0.6-1mg/kg/day loading dose
symptoms of infection.
70mg followed
by 50mg q24h
Repeat cultures every
OR 72 hours till negative.
OR
IV Caspofungin
loading dose
70mg followed
by 50mg q24h
OR
IV Anidulafungin
loading dose
200mg followed
by 100mg q24h
82
Algorithm for empirical antifungal therapy in the
non-neutropenic ICU patient
Clinical Situation
- Deteriorating clinical condition
- Unexplained fever/ sepsis
- No response to broad-spectrum antibiotics
Haemodynamically Haemodynamically
stable unstable
Bibliography:
1. Ann Intensive Care 2011; 1: 37
2. Clin Infect Dis 2009; 48: 503-535
83
APPENDIX A
DOSAGE ADJUSTMENT FOR RENAL IMPAIRMENT
Below is the formula used to calculate the creatinine clearance:
Males: Cr Cl (mls/min) = (140 Age) x IBW Females: Cr Cl (mls/min) = (140 Age) x IBW
0.8 x Sr. creat (mol/L) Sr. creat (mol/L)
Drug Normal dose Cr clearance Cr clearance Renal replacement therapy
10-50ml/min < 10ml/min
Acyclovir 10mg/kg q8h 10mg/kg q12 - 24h 5mg/kg q24h HD: 5mg/kg q24h
CRRT: 10mg/kg q24h
Amikacin Refer to Appendix B
Amphotericin B 0.6 - 1 mg/kg q24h 0.6 - 1 mg/kg q24h 0.6 - 1 mg/kg q48h 0.6 - 1 mg/kg q24h
Ampicillin/sulbactam 3g q6h 3g q8-12h 3g q24h HD: 3g q24h
84
CRRT: 3g q12h
Amoxicillin/clavulanate 1.2g q8h 1.2g q12h 1.2g q24h 1.2g q24h
Benzylpenicillin 2 - 4 MU q6h 1.5 - 3 MU q6h 1 - 2 MU q6h HD: 1 - 2 MU q6h
CRRT: 2 MU q6h
Cefepime 2g q8-12h 1-2g q12-24h 0.5-1g q24h HD: 1g q24h+extra 1g AD
CRRT: 2g q24h
Cefotaxime 2g q8h 2g q12-24h 2g q24h HD: 2g q24h+extra 1g AD
CRRT: 2g q24h
Ceftazidime 2g q8h 2g q12-24h 2g q24h HD: 2g q24h+extra 1gAD
CRRT: 2g q12h
Ceftriaxone 2g q24h Unchanged Unchanged Unchanged
Cefuroxime 1.5g q8h 1.5g q8-12h 1.5g q24h HD: 1.5g q24h
CRRT: 1.5g q8 - 12h
Ciprofloxacina 400mg q8-12h 200mg q12h 200mg q12h 200mg q12h
Cloxacillin 2g q4-6h Unchanged Unchanged Unchanged
Doripenem 500mg q8h 250mg q8 - 12h No data No data
Ethambutol 15-25mg/kg/q24h 15-25mg/kg/q24-36h 15-25mg/kg/q48h HD: 15-25mg/kg after HD (3x/ week)
CRRT: 15 - 25mg/kg/q24-36h
Fluconazole 400mg q24h 200mg q24h 200mg q24h HD: 200mg after HD
CRRT: 400mg q24h
Gentamicin Refer to Appendix C
Imipenem 500mg q6h 500mg q8-12h 250mg q12h HD: 250mg q12h
CRRT: 500mg q8h
Meropenem 1g q8h 0.5-1g q12h 0.5g q24h HD: 0.5g q24h
CRRT: 1g q12h
85
Metronidazole 500mg q8h 500mg q8h 500mg q12h HD: 500mg q12h
CRRT: 500mg q8h
Piperacillin/tazobactam 4.5g q6h 4.5g q8h - 2.25g q6h 2.25g q8h 2.25g q6h
Streptomycin 15-20mg/kg/q24h 15-20mg/kg/q24-72h 15-20mg/kg/q72-96h HD: 7.5-10mg/kg after HD
CRRT: 15-20mg/kg/q24-72h
Trimethoprim/ 5mg/kg q8h 5mg/kg q12h 5mg/kg q24h HD: 5mg/kg q24h
Sulfamethoxazole CRRT: 5mg/kg q12h
Vancomycin Refer to Appendix B
CRRT: continuous renal replacement therapy. Drug dosage adjustment during CRRT has many variables including
mode of CRRT. The values here are simplified for continuous veno-venous haemofiltration (CVVH).
HD: haemodialysis AD: after dialysis
a
Ciprofloxacin 400mg q8h to be used for P. aeruginosa infections
Polymyxin E
Body weight (kg) Estimated creatinine clearance (ml/min)
>50 20 - 50 <20 Continuous renal Intermittent haemodialysis
replacement therapy
> 60 3 MU q8h 3 MU q12h 3 MU q24h 2 MU q12h 3 MU q24h + 2 MU AD
50 - 60 2 MU q8h 2 MU q12h 2 MU q24h 1.5 MU q12h 2 MU q24h + 1.5 MU AD
40 - 49 1.5 MU q8h 1.5 MU q12h 1.5 MU q24h 1 MU q12h 1.5 MU q24h + 1 MU AD
30 - 39 1 MU q8h 1 MU q12h 1 MU q24h 0.5 MU q12h 1 MU q24h + 0.5 MU AD
MU: million units
86
Sulbactam (to give in divided doses)
In Sulperazone, the ratio of cefoperazone to sulbactam is 1:1
In Unasyn, the ratio of ampicillin to sulbactam is 1:0.5
87
Aminoglycoside (high dose extended interval dosing/ single daily dosing)
Exclusion - Age < 13
criteria: - Burns > 20%
- Ascites
- Synergistic dosing for Gram-positive infections
(e.g. endocarditis)
- History of ototoxicity
- Pregnancy
88
Hartford Hospital High Dose Extended Interval
Aminoglycoside Nomogram
14
13
12
Concentration (mg/L)
11
10
9
Q48h
8
7
6 Q36h
5 Q24h
4
3
2
6 7 8 9 10 11 12 13 14
Time between start of infusion and sample draw (h)
Vancomycin
Loading dose: 25 - 30mg/kg (not to exceed 2g per dose)
(use actual BW) Consider in seriously ill patients i.e. severe sepsis,
meningitis, pneumonia, endocarditis.
Maintenanace 15 - 20mg/kg/dose
dose:
(use actual BW)
89
Initial assay: Trough level before 4th dose if renal function remains
stable.
Bibliography:
1. Therapeutic Guidelines: Antibiotic, Therapeutic Guidelines.
Edition 14, Melbourne, Victoria 2010
2. Am J Health Syst Pharm: 2009; 66:82-98
3. Bedside ICU Handbook: Tan Tock Seng Hospital, Singapore.
2nd Edition 2007
90
APPENDIX C
EXTENDED INFUSIONS OF -LACTAMS
The use of extended infusions of -lactam antibiotics has been
shown to improve the time the free drug remains above MIC that
predicts the killing characteristic of the antibiotic. The ambient
temperature for the antibiotic infusions should be 25C or less
to ensure stability. A loading dose must be given prior to regular
dosing of the antimicrobial.
91
Antibiotic Loading dose Duration of Dilution
over 30mins infusion
Ceftazidime 2g Continuous 1-2g: dilute in 50mls normal saline
infusion For q24h, infuse at rate of 2mls/h
over interval For q12h, infuse at rate of 4mls/h
prescribed For q8h, infuse at rate of 6.2mls/h
Reconstitution directions
1. Each vial should be reconstituted with water or 0.9% sodium
chloride (as per the usual practice) and then dilute the
reconstituted solution with 0.9% sodium chloride to a volume of
50mls or 100mls.
92
Guide to Antimicrobial Therapy in the Adult ICU 2012