I HI LI 11 111 ',i,1 mmL'l"fVl l!l'J'h1i 'Vl'l.

:l~'elf"J'cl

llyjtllhl 1-i 11'11111,l111,~1~,zq ·1·11·1hri:i111:j vim Jl1 fl1'111'fl1~u111>111lf

Table of contents page

1. Introduction
2. Obtaining antibiotic approval 4
3. Definition of Terms or Abbreviations 5
4. General Information of Selected Antibiotics 6
4.1 Colistin 6
4.2 Doripenem 8
4.3 Ertapenem 8
4.4 Linezolid 9
4.5 Fosfomycin 9
5. Interpreting microbiology report 11
6. Guidelines for the Treatment of Various Infections 12
6.1 Abdominal Infection 12
Biliary tract infections 12
Diverticulitis 14
Pancreatitis 15
Peritonitis 17
Primary peritonitis/ Spontaneous bacterial peritonitis (SBP) 17
Secondary peritonitis/ GI perforation 19
Peritonitis related to peritoneal dialysis 21
6.2 Helicobacter pylori infection 22
6.3 Clostridium difficile infection (CDI) 24
6.4 Catheter-Related Bloodstream Infection (CRBSI) 26
6.5 Endocarditis 29
6.6 Central Nervous System Infection 37
Meningitis 37
Brain abscess 41
CNS shunt infection 41
Antimicrobial dosage for CNS infections 42
6.7 Gynecologic Infection 43
Pelvic inflammatory disease 43
Gonococcal infection 44
Post-operative pelvic infection 44
 Suandok Antibiotic s

Table of contents
Suandok Antibiotics Guidelines
6.8 Pulmonary infection
46
Acute Exacerbation of COPD (AECOPD) 46
Community-acquired pneumonia (CAP) 48 Antibiotic resistance is now a major problem confronting physicians
Healthcare-associated pneumonia (HCAP) 50 nd their patients. Increasing antibiotic resistance, high costs of new antibiotics.
Hospital-acquired pneumonia (HAP) 51 ond toxicity of old antibiotic i.e . colistin, limit the option for treating patients
Ventilator-associated pneumonia (VAP) Inf cted with multidrug-resistant bacteria. which resulted in unfavorable
51
6.9 Skin, soft-tissue, and bone and joint infections ulcomes. We have learnt from the history that if we do not use antibiotics
53 arefully, we will lose their efficacy. Antibiotic stewardship program was first
Cellulitis
53 stablished at CMU hospital at the end of 2009. The mission of the program
Diabetic foot infections 54 led by the heads of the Divisions of Infectious Diseases of the Department
Surgical-site infections (SSI) 56 of Medicine and Pediatrics is to ensure that every patient at our hospital on
Serious, deep-tissue infections 57 ntibiotics gets optimal therapy and to reduce antibiotic resistance among
(necrotizing infections of skin, fascia, and muscle) pathogens. The committee comprised of representatives from the Department
Vertebral osteomyelitis, diskitis, epidural abscess of Medicine (the divisions of infectious diseases. pulmonology, critical care, and
58
Septic arthritis Immunology, and hematology), the Department of Pediatrics (the division of
59 Infectious diseases) , the Department of Surgery, the Department of Orthopedic
6.10 Bacterial Urinary Tract Infection
62 Surgery, pharmacists, clinical microbiologists, infection control practitioners,
6.11 Resistant Gram-negative Infections 66 and information technologists.
6.12 Candidiasis in the non-neutropenic patient 67 These guidelines are based on current literature reviews, including
6.13 Febrile neutropenia international, national guidelines, consensus statements, current microbiologic
71
7. Guidelines for the Use of Antimicrobial Prophylaxis data from our hospital. Faculty from various departments have reviewed
74
7.1 Antibiotic prophylaxis for surgical procedures and approved these guidelines. It is important as, stated by the Infectious
74 Diseases Society of America (IDSA), to realize that "guidelines cannot
7.2 Prophylactic antimicrobials for patients with 76 always account for individual variation among patients. They are not
solid organ transplants
intended to supplant physician judgment with respect to particular patients or
8. Infection Control
78 special clinical situations".
9. Appendix These guidelines followed the topics as in Antibiotic Guidelines:
85
A. Aminoglycoside dosing Treatment Recommendation for Adult Inpatients owned by the Johns Hopkins
85
B. Vancomycin dosing and therapeutic monitoring School of Medicine with permission. We would like to acknowledge them here.
87
C. Antimicrobial dosing in severe sepsis or septic shock We will update these guidelines biyearly. Please let us know the topics
90 you would like to see or improve in this handbook.
D. Antimicrobial dosing in renal failure
92
E. Drug dosing for continuous renal replacement therapy (CRRT) 99 Romanee Chaiwarith, MD, MHS. Peninnah Oberdorfer, MD, PhD
F. Oral antimicrobial use Head, Division of Infectious Diseases Head, Division of Infectious Diseases
101
Department of Medicine Department of Pediatrics

Acknowledgements
These guidelines were a team effort. We wish to thank everyone who helped review this document.
 Suandok Antibiotics 3
uandok Antibiotics

- Lii'ti~tltJ1ri1fl•Luuiltl1m~1f'1'tyvn•n11u'r't\'l!J1:illtJ'll1;j Lii'tiriti11l'lhi-i1'1:LUUL;itl
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... ~

I Tf'I .Yl(Y .?~N!J 'n!J11~\'lf (all chapters)

l tl.'r'tC\) .tl11'111;j 111ii (chapter 6.2, 6.7)
'l

fl \IV1 .UU\'ln1Ui UU\'l~\11 (chapter 6.5, 6 .9)

,1 \IVl .111~'llJIJU 1•ttfJ\.1111tJ (chapter 6.2 , 6 .7 . 9)
. .,I'
ijL~ !J'l'i!'ltlJ 'VI\ 111'Vl'U'Vl'l'IJ,r'l'll'tl 'IJLL 'IJ'l'Vl'l~L'iU.l'IJ

v,ty .nun'r't? hunl'l1• (chapter 6.9, 6 .11. 6.12)

n11fm,nn1,~111Lii'ti~tJ1J1jj~l'lfl'r'tY1~1ii~LYh~l'mu11:ti1'lii•ri'uLiiluii11111ili 1uti~111Lnjju\'lL11Ju
VIC\) . ll'lllll:'lU tY1'tif111u (chapter 6 .9, 6.12)
'l1nn111'1i1J11111u'll'liiYt~1iiL\.11J1:l'l1J'ih11XLii111n1,~tJ1J1m1J1J1tJ!l1•n111Ll1 n111'1i1J11111u'l!'ii.,..
11'1.UVI . '!111J'll1C\) 1Vlti1111U (chapter 6.8)
tl!l1.L\.11J1:l'IIJl'l11J11tl'D11J1JtJ•ri'Un11Lnil1L;tl~tJ!J1\Ji l'ltu:'li1•1U~LLiln111'1f1J1tJfiii1u:\il1ritJll1,l;U
B. Tf'I .U'r't.L'!lfllJ ~11'11ilfJl'I (chapter 6.8)
Ltititl1'11uil Yt.f'I . 2552 tl1t111u\.1u1ub1'1~111L;tJ1111'11'111fJ1J1m'!lf'l11'1111fo11:m1j1f'1111111f m11Jn1,
11'1 .UVl.'n!J'llJIJU u1t•ii'I (chapter 6.8)
tl1:ntiuili1u1>11u\'lU'l1nml'l1'111ti11j1f'l11'1111f (\.1u11J1'111bl'l~i11L;tiu11:L1'11f'l11'1111fL'll111i'tiu,\.1u1u1'111
. ?f'I .UVl .~l11tl1~ ~l'IIJ1'111'1 (chapter 6.8)
bi'11:tJtJ\'l1•L~umuh L1'11u1u1111n~111u11:1Jjju~. \.1U1u1•111t11il1111\'l1J1) 1111'11'111fJIJ11L1'11f'l11'1111f
t 1 ~f'I .UVl.ihn, ihii111~fJII (chapter 6 .8)
(\.1u1utu1~ 111Lii' ti) 1111'11'1111111uf'1111111f 1111'11'1111111uf'111'1111ftiti tfiil ~ nl \.1u1m111f'111Y1u1
12 . tl .U'r't .tl~fltll ilJ!\f'IUti (chapter 6 .8)
\.1U1uJti•ri'ULLll:Muf11Jt11'1~111Lii'ti1u1NYt1J1u111 \.1u1ulXti•tlfi~n1,n111•u11:111,11uLY1f'I
1 • tl .UVl .fol'l1" fol'l1"Yt•1"1 (chapter 6 .2)
1N'r't!J11J1111J\l111'11Ul'l1Lii!J•1\.1ii
14 . ~f'I .Vlty .tJnC\)C\)1 iirnuti (chapter 6.3)
f'lru:'li1•1ujji111*\.11J1EJL~ti11X~tl1u~L-ihfun11fm,n1ut, • .,..mu1111Jifutl,:1u'!lu
15 _!l.UVl.1Jffl•rf ii'liii11•fi1?1J (chapter 6 .1, 6 .2)
\l•l'Jlil'l1nn111iu11111uil'liiYtu11:1'1111n1niilililtymL;tJ~tJ1J1 <i•1tli{111'1i1uu1vn•n11Hm1111u'111iiYt
1111 u Luum,1i mtlfiii1u: 11il uti 111u-iiti1J11'11 n LL u1vn• 1:111uu1u1'111 ;j 1:iii'u'll1 ;ju11 :,: iii'u 16 . 11'1.m\j.UUYIU1 ni\1111uu~(chapter 6 .9)
17 . tl .VIC\J .num 11 ru 'l'll?:~n111ilflu (chapter 6.6)
1N'r't!J1tJ111 11ilujj~L~IJ1'111tyl'l1'!1111i1•11~l'11J\'l1J\'l1UUU1\'l1•Lfi1Jd ti!i1•hrim1J "UU1\'l1•"
ti1'11iil'l11J1m11liliri'u~tl1u'rjn11u 111ti•jjn1,tl,:1jn~LL11:f'i1il•ii•irm,1ru:mn1m1•f'liiiln111J 18 _11'1 .VICIJ .111 ru111•111•1l°l'lfC\J (chapter 6.5)
19 _?f'l.uv,.n;j~nt ~ll111i'llJIJU1111U (chapter 6 .1, 7 .1, 7 .2)
n•-iitilX11J1U~U11JLLllill:111J
20 . ~f'I .VIC\J .'llt1'1tll u'liuii• (chapter 6 .7)
l'l(\j.,~1U'!ltl'!ltltJljtllYll.J~LLl'ln111imiihu~ii'r't'lltJ• Johns Hopkins Medical Institute
21. tl .U'r't.'11'11~nt UVl')tll (Appmdix E)
~tl'tt\)111111Xt11•ii•11111Jztluuu'!lti• "Antibiotic guidelines: Treatment Recommendation for _llty .L!J1 1111 im'lfC\J111 ru (general drug information and chapter 4)
22
Adult Inpatients" LLll:1'1ru:'li1•1u1ili'tl11J1tlfu11XL-ii1ri'uu1uYILLl'l:LLU1Vl1•'11ti•tl1:LY1f'l1YIIJUil:
_llty .~1;jn,mf ;:;\'l 1" 1 (general drug information and chapter 4)
23
t11•ii•1111:i-iitil;!lll'l111J11'llti•L;tJ~tibl'l.itimtlfiii1u:,m•tNYt1J11J1111Jm11'!luf'l1Liiu•1.,.ii
24 l'ltutl11!J nruru: (chapter 8)
UU1\'l1•u~•L\.11J1:l'IIJrltJU 'r't\'l!JYl~Ui1atl1u1ub•Yt!J1tJ1111J\l111'11Ul'l1Lii!J•1\.1ii tl1'11iiL\.11J1:illJ
25 . ~rumirn~ci 111inf'i1 (chapter 8)
ri'uuruYl'lltJ• t N'r't lJ1tJ11'1 ~ULtiti•'l1n;1'ljj1:m 1111Y11J1 u11:1'1111J11'llti• Lii'tiriti t 11'111itimtlfiii1u:
111JO.IJ11111U'lil;;.,..~m;nutNYt!J11J11'1~LLlllnlli1•ri'u 26: ~ruLl'll1fln1"CU ~ilu1•rf (chapter 8)
27. fltl.lUUYIU1 i.ju•11J (chapter 8)
~·ru:'li1•1u11•LL~U~'l:tlfutl!•uu1vn•d"1n 3 il, mnvhujj-iiti~lilLilu -iitiLl'lutiuu: ~ ~ ' n,.. (general information on drug susceptibility patterns and chapter 5)
28. fltl.llJUl'IUU\'l ~·w I
\.11tiiliti•n1ni:;1JL~1Ji1-iiti11il1uuu1vn•Lii1Ju 1111J1m~•1J11ilivi
email address: cmuaboguide@gmail.com "ii!l?'ll1flJ'l'ln1'111JM!'l1Jl'i1U1Jl'IM1JJf11uii,,nu1111g31wfi,tlr:;imlri1,~1ru.'rnEJ Ulll'l?1JJ1?
LL u1Y11.d~1 L1'11Ji ili1EJ1'1111JT11JiltJ'lltl.l'ltu:'li1•1U'rj nvhu 111J ii•ti1'111!JU 'r't\'l!J
;tJ,i/tiritJf;l'l,itJEJ1tlfli1u:;'llti,fNwp11J1fl nu_m__'llull'll~W~ll!?u~ffi'll!l'J1ufNYl!J11J11l
LLil:~l'lf!1n1~1JiY1umuiX1-iiti11i1•1uu1Y11•Lfi1Jd - ' . -1~,"l-'n .. ,n·IJ?'D!l.Jrl!J!Jtl!tl'IIJ111r!l&lflll1nClJ'l'll'11.Jn11UYll'IIJIM7
lJll111'111Jl'l1L'llfN•lllJ lJ YOH .. ,w

'il'I.YH\j.'i>Jriirl ,l'v11qY1a' 11'1 .,iu,l\j.LYII\INU1>1 ttJL'Utif,i9fo,j9f

~,,..,l'1mhvt,,,;;"L:ftiuft:L1'1111111P1fL'IIP1itiu ~,,..,r,.,.u1vt-;11il,iL:fti 'lltl'lltl\Jf'!I\I
1111'11'111il1fj11'1111fllf IJ\411Y1!1111VLivlLMii mfl7'111f)>J11L1'111'11IIO!f >J\411Yl!l111VLiv•'\\4,j fltlll'IU.Ulll!J !iLn"l ~1\.1~n1~illiULft;i • ~ - ~ .j
tl1en1u11111:m•1u{,iti1uu1Y11•n1,;'\,i'v,t\'1u'!ftiY1'\ut-;•Ytv1u1ft>J\41'i1'11Ufl'iLiv•'\.,.,i fltl.lU11'11'1tltl '!ili~ll111U ~1\.11tln1l"'lill\'l1ill'IIU\.11L1fH
 Suandok Antibiotics 5
4 Suandok Antibiotics

I i3ijj#j obtaining Antibiotic Approval

,i i r1n11 u1ntjl.Jd"::1t111un11'fl'{mi"1n~L;tl'l'll1tl.J"1nmf'l1'11111h~1rif~d

!J1Ufi'D'lU::r;iti1ud4'flltl1.J1Urni1.J~i1itl~'lltltl~~"1n~L;U'l'll1tlJ 1.J1ntj1.Jd JI 11'1 ' 'O tl1tj1P111111lf

_,~, L .1. I 1 11r.1unmtjm111.Ji'l'tU. CCU, SubCCU. SublCU "::ti'{miLflltltl1"111JLL~:;
..,'lU1~t1JtltlnqY16f'lmUf'lljl.JL'lltln'l1~ (broad spectrum overage), 111i.n1t1intl1
L~Lnflln11it11.J11cli1fllu~1u (collateral damage), i11.n1.J1run11H'1.J1n~1t1Li'lu1.J1~ tL YiY11Ju1::41ii1ur;itiutlflli11'1111'111L1f'l~ 111L;tlLL ~::L'l'!ll'l111111fL'lllll1tiu
,,.. ._., ~ Ji .... ..i.Ji
11~'l\.l1'l 1'11 ... 1~ruL'!ltlU.Uf'\YIL1tJYlflltl!J11.J1nljl.JUu 1::nt1Ufll'ltJ
. Ji., •
Ltt.mn 1c u "::ti'{miLflltJtl1"111JLL~::LLYiY11JU1::41ii1ur;itiutiflli11'1111'111
1. Piperacillin/tazobactam 1:;uuY11~LcnUmtJL" L'l'll'U1Ufl\1nq111LL~::JJfaL.,;'
2. Carbapenems (imipenem/cilastatin, meropenem, doripenem) I. ~iJ'ltJLULL\:.IUntl1tj1n11l.J*'l'tUv\'tiiimnl!ni11'1111'1111::1.JUYl1~LcnUmtJL"'1LL~'l
3. Vancomycin ll1"111JLL~::LLYiYIIJU1::41ii1ur;itJUtlflli11it11'1111::1.JUYrnLcnU~1tJL"'1
4. Colistin " :;vi1n11ti\{miLmflltJLiiiliti~ittltl'{mi"1nw1.buL1f'l~(I\L;tl'1;n
LLYi~1J~~LL~~tl'l ut11i.n1mf~u1ntj1.Jd1i;'imu1u 72 i'lLl.J~u.m mmnuwh 1.4 qiJ'lu1.J::L'M~~1111VJU1LULL\:.IUn BMT "::ti'{miLflltJtJ1"11uu.~::LLYiVJIJ
72 'n'lLl.J~ LL~'lu~41 LUUilitl~ H'u1nii1.Jdt1,i . .. .
nrnnnjil OLL1.J1.J~ilil.J'll1~fl1~d tJ1::41ii1ur;itiut1111111ii11'111t~~r;i1Y11.J1 ~,J'lul.J::L1~fa~1111Y11.J1LULLi:.JUn
~,J'l ui'l'ttJ" ::ti'{miLfll ut11"11u u. ~:; LL YiVJIJU 1:;41ii1ur;it1Utl 111111'1111'111
<~g~~
- Ji Ji
An.......,....- ur,.... orm
Mat.1-'INl<ill.'nCl'o- . l , l t , j ~ I Sticker 2 111f'l1'111f1l.J11L'l'lll'l1t1111f ":;'tiii'1un11ti'{miLflltJtJ1"11u~u'lu1'111L1f'l~fllL'lltl
"--..,,....,. ~- a,-. :.i 11tt.J 11.~
!11f'l1'!11nl.J11L'l'll1'11!1f;if •
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1
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l'lru::vi1~1u . •
4 . /11f'\1'111~~Ul'l111111ftltlL6tlcnni ":;'tMun11ti\{miLflltJtl1"111JYILtlir°umrnr;i~rif~

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. 111f'l1'111Lt1111 11t1 u1~n . 4'nl,('iY1u1. 13~u°1L'l'II, L'l'll!"111111~u~ "::,ti'{~t111u
tl1's111JLL~::LL YiY11JU1::41ti1Uf;ltltJtl fl\111'1111'111L11'\ ~ (I\ L;'fl LL~:; L'l'll 1'1111 (I\ 1L'II (I\ 1tl\.l

_,
.~....... . . . . .
io VIII ...•- .....
1o~ ...... _,,_
15$W oefmition of Terms or Abbreviations
1. Severe Penicillin Allergy (Severe PCN Allergy): Anaphylaxis,
1o ... ....-...-. .,,.., ·- ••0• 0-0• M••H••0 •0• o<o•0•o••••••••"•u• •- •

ioUTI ·· - ..··-
0 : : ~ -·-·····---.. ·-· ·
f!11:'1.....«llt..,,,..,,,,,., ···-·- -··-- "' hypotension . laryngeal edema. wheezing, angioedema. Stevens-John
Syndrome, Ery1hema multiforme. Toxic epidermal necrolysis (TEN)

2. PO: per oral

3. IV: intravenous
4. IM: intramuscular
5. OD: once daily
6. BID: twice a day
7. TIO: three times a day
8. QID: four times a day
 6 Suandok Antibiotics Suandok Antibiotics 7

@Mfflff@ General Information of Selected Antibiotics m'i·u'hnn.11 Colistin

Selected antibiotics are summarized here. These include the recent available
..
("tl'U1f11!l1nTlll'Uf11L'U'itJLL1.J1.J Colistin base)

in our hospital i.e. ertapenem, doripenem, fosfomycin, the old antibiotic but
Colistin Intravenous Colistin Nebulization
increasing its use i.e. colistin Loading Dose = 5mg/kg IV infusion
u11130 u , M~ 1 i1L1J~ 1in11Hfl>Jtn colistio d1MftJYiY
4 .1 Colistin (Colistimethate) (I ading dose ~~i,111\ijifiu 300 mg) ~flJJ Colistin 150 mg 1u 2-4 ml 'ntN NSS. SWFI \tffl
It has in vitro activity against Acinetobacter spp. mcil CCr< 1OmVmin Loading dose= 150 mg mixture of NSS&SWFI L~flli11'~'d1u isotonic solution
.. .... .J - .. ' ....
udomonas spp. but does NOT have activity against Proteus, Maintenance dose: JlUl2m2:l : ft 17tl:ft1lJfllll1tlJJ11'1'8 nU fl?tll'ltuJJ
1uu~nai,u.:1inuiiu.r,111rou (l,JaonlwiuB1i1u
Gram-negative cocci, Gram-positive ,.;.J,;fJhi 1iftN11ntt1ffi::ttw~lvHu1u 011rifl htt1i11
n rob s. bronchoconstriction

CCr > 40 mUmin : 2.5 - 3.0 mg/kg IV 012H ~

(Max=JOOmg/day)
m nl of Inf ctions due to multi-drug resistant Acinetobacter and Cr 31- 40 mUmin : 1.5 - 2.0 mg/kg IV 012H
(Max=200mg/day)
on a case by case basis.
CO 21 • 30 mlJmin : 2.5 • 3.0 mg.Ilg IV 024H OR
Toxicity 1.25 - 1.5 mg/kg IV 012H (Max=150mg/day}
CCr 11 • 20 mllmin : 1.5 - 2.0 mg/kg IV Q24H
• R nal impairment: monitoring BUN, creatinine twice-weekly (Max=100mg/day)
• Neuromuscular blockade. neurotoxicity CCr < 10 mUmin: 1.25 - 1.5 mg/kg IV 024H
(Max= 75 mg/day)
• Inhalation: bronchospasm, administer solution promptly following preparation
to decrease possibility of potentially life-threatening lung toxicity
liih~1UlJ: 11:111u~~miliiu sterile water for
J1\tUni'l < 40 nn. \\4"1u 40 un. 'ln 8 1.1,1
J11,1Uni'J .e: 40 nn. H'riu so ,.m. '1" a 1uJ
ID1DllllJ
• n,N~thu\th,i1twli'ltJ\t1tJ1"'1 riu colistin U1ti set
,;uu, ;lJJ1l'fttlJJl1uL111fl-1,!10\t1u\"l1iirillu1
nmu:huUJ1th,i1&ri1m;nul"'I mJU'lu;etnebulizer
»
l"ul\4tJfu:,.1'&,n hanA'..itl
• ,i·m~i.itirinlM11f1..it11n1~~chwLf1~U'\ltNl'iufl::t:1tN
'hi,.nnn•h 6 L/min
... . ' ..i . .
• "111,nu.\t\NL11ff1..il'ft.1fl::flf1..im..i<111n endotracheal tube
tlr::u, ru 30 'D .JJ
• fll'ln4qriHu\°''1w,i1,i'l1i.J4u,::"'~1.nhn1ffluu1 Ll'ln::

Injection (SWFI) = 2 ml ~n1~~~lJ1i~U1LtJ11 "l::li1\\4t1\Vl11'1U1ll4('\jlfi\l

l~tlUtl~l1Un17L1i~vltl~ ~,mru,~tl~1~miliiu • r1"11ri1\tuM1ni1-11u,ifl..iL11lti-1,hmnul"'I l\4riu01
L'tln1 :::'1'l-1~ij1.huM1tJl"'ILf 1 l~fll \tt;;tf11.J1NU11'11\J
I00 ml 1tl~ NSS 1,111) 05W 1,111) 05NSS ,11~tlfl..in11
• U11.1111nfl..iu1ii'tf.,;~ 'l'lrljlf11.1111mhriu 'Dfl..i1ft
fl1Tfl::fl1U (aerosol storage chamber)
\11nihl(\1"1Lfirnn'un1rriuu1 colistin
C11imate Ideal bOdy weight In (kg)
I
Male: IBW = SOkg + 2.3 kg for each inch over 5 feet.
=
r emales: IBW 45.5 kg + 2.3 kg for each inch over 5 feet.
l ntcu1~,uitnmf 5857. 6489

References:
f Lawrence A Trissel.Handbook on Injectable Drugs 17th Edition. American Society of Health-System
Pharmacists: 2013
2.Mn,ull111ftt/'11. Colistin. 1u ~,rf.l tfu~u, ff?1f}ff ,,,run.,
"!triilfttJ>'f,J,( iJfu11f"f1.Jfl,J U1111 uunn,u~'}lt
um1niim1. efu•111tl'tnt: m,1iv1i1u1oi"mh ,ium:ou. ou1~u111tl',nmifN,.v1u10(1h:m,ilnvJ.
"qa, nwu 2556
3 Colistimithate sodium; Adult Parenteral Drug Monograph. WRHA Medication Administration Policy
Sutxommittee. Winnipeg Regional Health Authority. Winnipeg, Manitoba.Canada. revised: Feb 2011
4 McEvoy GK. Editor. AHFS Drug Information 2012. American Society of Health-System Pharmacists.
Bethesda, Maryland.

I
8 Suandok Antibiotics
4.2 Doripenem
Doripenem is a carbapenem antibiotic. It has in vitro activity against aerobic
and anaerobic gram-positive and gram-negative bacteria. Its activity against
gram-positive bacteria is equivalent to imipenem and its activity against gram-
negative bacteria is equivalent to meropenem. It is generally 2 to 4-fold more
potent against P. aeruginosa compared to imipenem or meropenem. To maximize
pharmacokinetics/ pharmacodynamics, this can be infused over 4-hour.
Clinical uses are similar to meropenem and imipenem, except that doripenem
is FDA-approved for prolonged infusion and has greater activity against
P. aeruginosa.
Dose
• 500 mg IV infusion in 4 hours QBH (can be infused in 1 hour)
Toxicity
•n u . di rrhea . headache, phlebitis, increased hepatic enzyme
4 .3 rtapenem
rtapenem is a carbapenem antibiotic. It has in vitro activity against many
Gram-negative organisms including those that produce extended spectrum
beta-lactamases (ESBL), but it DOES NOT have activity against
Pseudomonas spp. or Acinetobacter spp. Its anaerobic and Gram-positive
activity is similar to that of other carbapenems, except it DOES NOT have
activity against Enteroccocus spp.
Acceptable uses
De-escalation therapy in culture proven ESBL - producing organisms
Unacceptable uses
• Empiric therapy for suspected gram negative infection.
Dose
• IV or IM 1 g Q24H
Toxicity
• Diarrhea, nausea, headache, phlebitis/ thrombophlebitis
Suandok Antibiotics 9
i I Llnezolid
I In zolid is a bacteriostatic oxazolidinone, inhibiting ribosomal protein
ynthesis. It is active against gram-positive bacteria including vancomycin-
II slstant enterococci and MRSA. It has limited in-vitro activity against
mm-negative bacteria.
Acceptable uses
• Documented vancomycin intermediate Staphylococcus aureus (VISA)
or vancomycin resistant Staphylococcus aureus (VRSA) infection
• Documented MRSA or methicillin-resistant coagu lase-negative
staphylococcal infection in a patient with serious allergy to vancomycin
• Documented VRE infection
· Documented MRSA or methicillin-resistant coagulase-negative
taphylococcal infection in a patient failing vancomycin therapy
Unacceptable uses
• Initial therapy for staphylococcal infection
• VRE colonization of the stool, urine, respiratory tract, wounds, or drains
Dose
• 600 mg IV/PO Q12H
• Skin and skin-structure infections: 400 mg IV/PO Q1 2H
Toxicity
- Bone marrow suppression (usually occurs within first 2 weeks) Monitoring :
CBC weekly is recommended
• Optic neuritis and irreversible sensory motor polyneuropathy (usually
occurs with prolonged therapy > 28 days)
4.5 Fosfomycin
Fosfomycin is a phosphonic acid derivative, inhibiting cell wall synthesis.
It is active in vitro against a broad spectrum of gram negative (including
SSL-producing E.coli, K.pneumoniae, P.aeruginosa, Enterobacter spp.,
S. marcescens) and gram positive bacteria (including MRSA, S. epidermidis,
E.faecalis, S.pneumoniae). It has good distribution into tissues, achieving
clinically relevant concentrations in serum, kidneys, bladder wall , lungs, bone,
nd CSF. Two forms of fosfomycin are available in Thailand i.e. fosfomycin
E 10 Suandok Antibiotics
Interpreting microbiology report
tro methamine (oral fo rmulation) and fosfomycin disodium (IV). Fosfomycin
tromethamine is a soluble salt and approved for the treatment of urinary tract
infections caused by E. coli and E. faecafis. Fosfomycin disodium for IV use is
l1tl rpretation of preliminary microbiology data
the only form available in our hospital.
Gram-positive cocci
Acceptable use
Infections due to fosfomycin susceptible strains of P. aeruginasa; Proteus spp; A robic :
~ Large: Bacillus spp.
S. marcescens, MRSA
:oogulase (+): S. aureus
Dose Coo ulase (-): S. epidennidis, S. lugdunensis,
Gram positive bacteria: 2 g IV Q12H •: uricularis, S. haemolyticus, S. saprophyticus
('~
ESBL: 2-4 g Q12H
()lpl coccus: S. pneumoniae
Severe MOR-gram-negative infection: 2-4 g Q6-8 H (NOT monotherapy)
()010-hemolytic: Group A streptococci
Meningitis 4 g Q8H (S pyogenes). Group B streptococci
O t omyelitis 4 g Q8H ( agalactiae) , Group C, D, G streptococci
Al1ha-hemolytic : S. pneumoniae, Viridans
Toxici ty ,w plococci , Enterococci., S. suis., S. bovis•
Not common: abdominal pain, headache, phlebitis, cough and asthma attack, •moy be no hemolysis
h patotoxic ity, nephrotoxicity Anaerobic: Peptostreptococcus spp.
Gram-negative cocci
Ae robic:
l)lplococci: N.meningitidis, N.gonorrhoeae,
M raxella catarrhalis, Acinetobacter spp.
'mall Coccobacilli: H. intluenzae, Pasteurella
pp.,
I rge Coccobacilli: Acinetobacter spp.
Anaerobic: Veillonella
Acid fast bacilli
Mycobacterium spp
Suandok Antibiotics 11
Gram-positive bacilli
Aerobic:
Small: L. monocytogenes,
Erysipelothrix rhusiopathiae , Lactobacilli,
Corynebacterium spp.
Branching !laments: Nocardia spp,
Streptomyces spp.
Anaerobic :
Large (spore forming): Clostridium spp.
Small (non-spore forming) :
Propionibacterium acnes
Bacilli with branching : Actinomyces spp.
Gram-negative bacilli
Aerobic :
Enterobacteriaceae: Citrobacter spp.,
Enterobacter spp., E. coli, Klebsiella spp,
Serratia spp.
Non·enterobacteriaceae: Aeromonas spp.,
Vibrio spp., Campylobacter spp. (curved)
Nonfermentative Gram-negative bacilli:
Acinetobacter spp., Burkholderia spp.,
P. aeruginosa, Stenotrophomonas maltophilia
Anaerobic : Bacteroides spp.,
Fusobacterium spp., Prevotella spp.
Modified acid fast
Bacilli: Mycobacterium spp.
Branching : Nocardia spp.
Coccobacilli, cocci: Rhodococcus spp.
12 Suandok Antibiotics Suandok Antibiotics 13

i3@@"3uid~lines for the Treatment of Various
Infections
Chapter 6.1: Abdominal Infection
Biliary tract infections - cholecystitis and cholangitis
Empiric Treatment
Community-acquired biliary infections (mild to moderate)
• Ceftriaxone 2 g IV Q24H ± Metronidazole 500 mg IV QSH
Severe PCN allergy: Ciprofloxacin 400 mg IV Q12H ± Metronidazole 500 mg
IVQSH
J:::l.Qlil: Metronidazole is warranted if a biliary-enteric anastomosis is present
llhcore-associated biliary tract infection of any severity••
• P,peracillin/tazobactam 4.5 g IV Q6H
ftazidime 2 g IV QSH ~ Metronidazole 500 mg IV QSH
• lmipenem/cilastatin 1 g IV QSH
• M ropenem 1 g IV QSH
( ' hould add Vancomycin 1 g IV QSH to each regimen)
Ih 11111 are-associated infection includes "community-onset" and "hospitalonset"
f ,1111111unity-onset healthcare-associated infection: with at least 1 of the following
• Presence of invasive device at time of admission
• History of MRSA infection or colonization
• History of surgery, hospitalization, dialysis, or residence in a long-term
facility in the 12 months preceding the culture date

Community-acquired biliary infections (severe) I lo;;p,tal-onset healthcare-associated infection: occurs > 48 hours after
• C ft zidime 2 g IV QSH .e.w..LS Metronidazole 500 mg IV QSH l11 mp,tal admission
• Pip racillin/lazobactam 4.5 g IV Q6H
I uratlon
S vere PCN allergy: Ciprofloxacin 400 mg IV Q12H .e.w..LS Metronidazole 500
• nee source of infection is controlled, duration of 4-7 days is recommended
m IVQ8H
• Biiiary sepsis: 5-14 days. Shorter course favored if source controlled.

S vere community-acquired biliary infection is defined as acute biliary infection • If bacteremia with Gram-positive cocci (such as Enterococcus spp. ,
I hat is associated with the onset of dysfunction in at least 1 of any of the iit,op tococcus spp.) is presented, minimum duration of 2 weeks is recommended
following systems: • In mild acute cholecystitis, antimicrobial therapy can be discontinued
within 24 h after cholecystectomy is performed

Cardiovascular dysfunction
Neurological dysfunction
Respiratory dysfunction
Renal dysfunction
Hepatic dysfunction
Hypotension requiring dopamine
~ 5 µg/kg/min OR any dose of
norepinephrine
Disturbance of consciousness
Pa0,1Fi02 ratio < 300
Oliguria, serum Cr > 2 mg/di
INR > 1.5
N te: Mild acute cholecystitis can be defined as acute cholecystitis with all of
111 se following conditions
· No organ dysfunction
• No severe local inflammation (gangrenous cholecystitis, pericholecystic
1bscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)
· No palpable tender mass in the right upper abdominal quadrant
· White blood cell counts 18,000/mm 3
• Duration of complaints s 72 hours

Hematological dysfunction Platelet count < 100,000/mm3

 Suandok Antibiotics 15
14 Suandok Antibiotics

I A fMENT NOTES
Microbiology
, Gram-negative rods - E. coli, Klebsiella spp., Proteus spp., P. aeruginosa h rnblology
(mainly in patients already on broad-spectrum antibiotics or those who Almo t all infections are polymicrobial
have undergone prior procedures) Mo t ommonly isolated aerobic organisms - E. coli, K. pneumoniae,
• Anaerobes - Bacteroides spp., generally in more serious infections, or in I 11/0 ~ bacter spp., Proteus spp. , Enterococcus spp.
patients with a history of biliary manipulations Mn•ll ommonly isolated anaerobic organisms - 8 . fragilis , Prevotella,
, Enterococcus spp. - treatment should be considered in healthcare-asso l't I t streptococci
ciated biliary infection
• Yeast - rare n is important in assessing need for drainage in severe disease.
11111 patients will present with d iffuse peritonitis and pneumoperitoneum .
References:
1. /DSA Guideline for Intra-abdominal Infections: Clin Infect Dis 2010; 50: I ti r nee:
133-64 II !II\ uidelines for Intra-abdominal Infections: Clin Infect Dis
2. TG 13 Guidelines for diagnosis and severity grading of acute cholangitis: 11 10:50: 133- 164.
J Hepatobifiary Pancreat Sci 2013; 20: 24-34
3. TG13 Guidelines for diagnosis and severity grading of acute cholecystitis:
J Hepatobiliary Pancreat Sci 2013; 20: 35-46 t~
4. TG 13 antimicrobial therapy for acute c hofangitis and chofecystitis: Ir 1tment
J Hepatobiliary Pancreat Sci 2013; 20: 60-70 • Miid to moderate pancreatitis - no antibiotics
• 'lt v re acute pancreatitis (SAP)* - no prophylactic antibiotics
Divertic ulitis • No necrosis - no antibiotics
Empiric Treatment • Sterile panc reatic necrosis - no antibiotics
Mild/moderate infections - can be oral if patient can take PO • Infected pancreatic necrosis.. - empiric antibiotic therapy as defined
, Amoxicillin/clavulanate 1.2 g IV Q SH OR below:
, Amoxicillin/clavulanate 875 mg/125mg (1g) PO Q1 2H , ub penems (imipenem/cilastatin, meropenem, doripenem)
OR t v re PCN allergy: Ciprofloxacin 400 mg IV Q12H !::lJ.§ Metronidazole 500
, Severe PCN allergy: Ciprofloxacin 400 mg IV Q12H (OR Ciprofloxacin
Ill / IVQ8H
500 mg PO Q12H) .El.l.!.S. Metronidazole 500 mg IV Q8H (OR Metronidazole
D finitions
400 mg PO Q8H)
vere acute pancreatitis (SAP) is defined as pancreatitis associated with
Severe infections
1111 or more of the following :
, Piperacillin/tazobactam 4 .5 g IV Q6H
• > 30% pancreatic necrosis
OR
• APACHE II ~ 8
, Non-severe PCN allergy: Cefoperazone/sulbactam 1.5-2 g IV Q12H
• More than 3 Ranson's criteria
(1.5 g if 1 vial contains cefoperazone 1000 mg/sulbactam 500 mg, 2 g if 1
• BISAP score ~ 3
vial contains cefoperazone 500 mg/ sulbactam 500 mg)
, Severe PCN allergy: ID consult
, Duration of treatment: 7- 10 days.
 16 Suandok Antibiotics
Suandok Antibiotics 17

Ranson's criteria to predict severity of acute pancreatitis

Zero Hours Parameters I111111 illins and cephalosporins penetrate poorly into the pancreas
Age > 55 111111 I+ n develops in 30-50% of patients with necrosis documented by CT
1.1 1n or at the time of surgery.
WBC > 16,000/mm'
I 1t111k incidence of infection occurs in the 3rd week of disease
Blood glucose > 200 mg/dl
• I 1111phylactic antibiotics have been associated with a change in the spectrum
Lactate dehydrogenase > 350 U/L
it pvncreatic isolates from enteric Gram negatives to Gram positive organisms
Aspartate aminotransferase (AST} > 250 U/L
111(1 fungi.
48 Hours
• 1IH r is insufficient evidence to recommend selective gut decontamination
Hematocrit Fall by~ 10 percent 111 m nagement of pancreatitis.
Blood urea nitrogen Increase by~ 5 mg/dl despite fiuids
Serum calcium < 8 mg/dl 1 ~ n nee:
p02 < 60mmHg lllt/11 an College of Gastroentero/ogy Guideline: Management of Acute
Base deficit > 4 MEq/L I Ill rea titis: Am J Gastroenterol 2013; 108: 1400-1415

Fluid sequestration > 6000 ml

I q IQnill§.
BI SAP score (1 point for each finding) ftnltions
• BUN > 25 mg/di f rlmary peritonitis is spontaneous infection of the peritoneal cavity,
• Impaired mental status (GCS < 15) II ua lly associated with liver disease and ascites [spontaneous bacteria
• SIRS p ritonitis (SBP)J.
• Age > 60 years condary peritonitis is infection of the peritoneal cavity due to spillage of
• Pleural effusion o+ganisms into the peritoneum, usually associated with GI perforation .
•• infected pancreatic necrosis is defined as one or both of the following: I r rtiary peritonitis is a recurrent infection of the peritoneal cavity following
• CT scan with gas in episode of secondary peritonitis.
• Percutaneous aspirate or surgical specimen with organisms evident on
gram stain or culture I' !mary peritonitis/Spontaneous bacterial peritonitis (SBP)
Duration mpiric Treatment
For infected pancreatic necrosis, continue antibiotics for 14 days after fotaxime 2 g IV Q8H OR Ceftriaxone 2 g IV Q24H
source control is obtained. IR
Continuation of antibiotics beyond this time places the patient at risk for vere PCN allergy: Ciprofloxacin 500 mg IV Q12H (call ID to discuss
colonization or infection with resistant organisms and drug toxicity. r gi mens for patients who have been taking fluoroquinolones for SBP
I rophylaxis).
uration
• Treat for 5 days.

~a
18 Suandok Antibiotics
Suandok Antibiotics 19

Prophylaxis ondary peritonitis/GI perforation

Cirrhotic patients with gastrointestinal hemorrhage
• Noriloxacin 400 mg PO BID for 7 days
• Ceftriaxone 1 g IV Q24H c an be used only if patient is NPO. then switch to
noriloxacin 400 mg PO BID once bleeding is controlled
Non-bleeding ci rrhotic patients with previous episode of SBP
• Noriloxacin 400 mg PO daily
TREATMENT NOTES
Microbiology
• Gram-negative rods (Enterobacteriaceae. esp. E.coli and K. pneumoniae) ,
S. pneumoniae, enterococci, and other streptococci.
• Polymicrobial infection should prompt suspicion of GI perforation.
Diagnostic criteria
• ;,: 250 PMN/mm3 of ascitic fluid .
• Positive c ulture with < 250 PMN should prompt repeat tap. If PMN ;,: 250
OR c ulture remains positive, patient should be treated.
• Cirrhotic patient with ascites that has convincing signs or symptoms of
infection (fever, abdominal pain and unexplained encephalopathy) should
receive empiric treatment until culture result is known regardless of the
PMN count
Follow-up
• Consider repeat paracentesis after 48 hours of therapy if poor response
to antibiotic
• Consider c hanging antibiotics if ascites fluid PMN has not dropped by
25% after 48 hours and/or patient is not c linically re sponding.
111plrlc treatment
I !lor lion of esophagus, stomach. small bowel, colon, or appendix
I 4111 nl mild to moderately ill
• ( ,t flrlaxone 2 g IV Q24H ~ Metronidazole 500 mg IV Q8H
t I
• ov re PCN allergy: Ciprofloxacin 400 mg IV Q12H .E.Ll.!.S. Metronidazole
10 mg IV Q8H
I 1tlonl severel y ill or immunosuppressed
• Pip rac illin/tazobactam 4 .5 g IV Q6H
I
• N n-severe PCN allergy: Cefoperazone/sulbactam 1.5-2 g IV Q12H
(I g if 1 vial contains cefoperazone 1000 mg/sulbactam 500 mg, 2 g
If I vial contains cefoperazone 500 mg/ sulbactam 500 mg)
m
• S v re PCN allergy: Vancomycin 1 g IV Q12H .E.Ll.!.S. Ciprofloxacin 400 mg
IV Q8H .E.Ll.!.S. Metronidazole 500 mg IV Q8H
I 111piric antifungal therapy is generally not indicated for GI perforation unless
j ll ltl nt has one of the following risk factors:
I ophageal perforation, immunosuppression, prolonged antacid or antibiotic
lllor PY, prolonged hospitalization. persistent GI leak.
Jlucommendations antifungal for patients who are clinically stable and have
JIP\ received prior long-term azole therapy·
• I luconazole 400-800 mg IV/PO Q24H

Notes on prophylaxis against SBP

• All patients with cirrho sis and upper GI bleed shou ld receive prophylaxis
]locommendations tor patients who are NOT clinically stable or have
1uceived prior long-term azole therapy·
for 7 days (50% develop SBP after bleed).
· /lmphoteracin 0.6-1 mg/kg Q24H
• Patients who get SBP should get lifelong prophylaxis to prevent future
episodes (40--70% risk of recurrence in 1 year) .
• Prophylaxis with noriloxacin should be considered for those with low protein
concentrations in ascites (< 1 g/L) or immunosuppression while patient is
in hospital.

Reference:
Management of Adult patients with Ascites due to Cirrhosis: Update 2012:
Hepatology 2013
20 Suandok Antibiotics Suandok Antibiotics 21

Duration of therapy for secondary peritonitis/GI perforation

111p1ric treatment
Stomach Small Colon Appendix
11111 t moderate illness: intraperitoneal therapy is preferred in most cases.
Bowel
111 11 1 patient
Uncomplicated
( 11fazolin 15 mg/kg in one bag Q24H (1 g if patient< 65 k g ) ~
De6nition Operated Operated Operated Non-necrotic or ( onlamicin 2 mg/kg in one bag loading dose, then gentamicin 0.6 mg/kg
on within on within on within gangrenous appendix
24 hours 12 hours 12 hours 111 on bag Q24H
1111 nt with urine output > 100 mUday
Duration 24---48 24--48 24--48 24 hours
hours hours hours ( ufazolin 15 mg/kg in one bag Q24H ~ Ceftazidime 1 g in one bag Q24H
Complicated
vore illness: systemic therapy is preferred.
De6nition Late operation or no operation; or necrotic/gangrenous appendix
, I lrst dose: Vancomycin (see page 87-88 for dosage) I V ~ ON E of the
Duration 4-7 days
11111 wi ng: Gentamicin 2 mg/kg IV OR Ceftazidime 1 g IV OR Ciprofloxacin
1100 mg IV
TREATMENT NOTES
, Mu,n tenance dose: dose per renal function and/or drug levels
, Causative agents for small bowel, colon, appendix: anaerobes
page 88-89)
(esp. B. fragilis), Enterobacteriaceae (esp. E. coli, K. pneumoniae,
Enterobacter spp., Proteus spp.); infections usually polymicrobial.
I 11r,1t1on of tailored therapy: 10-14 days
, Pathogens causing tertiary peritonitis are variable and are often resistant
to or not covered by the initial antimicrobial regimen; thus, a c hange in
HEATMENT NOTES
antimic robials is advised.
Microbiology
, A change in antimicrobials therapy should be considered in patients with
, M st c ases caused by contamination of the catheter
hospital-acquired infections who are already on antimicrobials.
, ' ultu res may be negative in 5-20%
, Treatment of enterococci remains controversial but should be considered
, C,ram-positive cocci (S. aureus, coagulase-negative staphylococci,
in critically ill or immunocompromised patients or when they are a dominant
[ nterococcus spp.), Gram-negative rods, yeast (much less common)
organism in the peritoneal cu lture.
, Treatment of Candida spp. is generally indicated only when they are
lllugnosis
recovered from blood or are a dominant organism in the peritoneal culture
, All patients with suspected PD-related peritonitis shou ld have PD fluid
in c riticall y ill or immunocompromised patients .
1mpled for cell count, differential, gram stain , culture AND amylase . WBC >
, Postoperative antibiotics for appendicitis are unnecessary unless there is
10 /mm 3 with > 50% PMN suggests infection.
clinical evidence of peritonitis, abscess, or gangrene.
, Antibiotics are adjunctive to source control, which is an absolute necessity.
, rI vated amylase suggests pancreatitis or bowel perforation.
, In symptomatic patients with cloudy fluid accompanied by abdominal pain
, Lack of source control is defined as on-going contamination and/or an
ond/or fever. empiric treatment should be started given the high likelihood
undrained col lection of infection.
or infection.
Reference: , In symptomatic patients with c lear fluid, another PD fluid exchange, with
IDSA Guidelines for Intra-abdominal Infections: Clin lnfec Dis 2010;50: 133-164. o dwell time of at least 2 hours, should be sampled. The decision to start
mpiric therapy in these cases will depend on how sick the patient appears.
22 Suandok Antibiotics Suandok Antibiotics 23

• In asymptomatic patients with cloudy fluid , it is rea sonable to delay

therapy pending the results of cell count, gram stain , and c ulture .
!oglmens Duration
11based triple therapy
1 1 10-14 days
Reference:
• PPI bid + amoxicillin 1 g BID + clarithromycin 500 mg BID
ISPD Guidelines for Peritoneal Dialysis -related Infections: Peril Dial Int
• PPI bid + metronidazole 400 OR 500 mg BID + clarithromycin
2005;25: 107
00 mg BID
• PPI bid + amoxicillin 1 g BID+ metronidazole 400 mg BID
II mulh-based quadruple therapy 14 days
· PPI bid + bismuth 240-525 mg BID + metronidazole 400 mg BID
Chapter 6.2: Helicobacter pylori infection
R TID + tetracycline 500 mg QID
Establi shed indication s for testing and treatment of H. pylori • PPI BID + bismuth 240-525 mg BID + melronidazole 400 mg BID
1. Active peptic ulcer disease (gastri c or duodenal ulcer), OR confirmed OR TID + clarithromycin 500 mg BID
h istory of peptic ulcer disease (not previously treated for H. pylori) 11qu nlial therapy Total 10 days
2. Hemorrhagic/erosive gastritis OR atrophic gastritis from gastroscopic · PPI BID + amoxicillin 1 g BID for 5 days, then

finding • PPI BID+ metronidazole 400 OR 500mg BID+ clarithromycin 1000 mg

3. Gastric MALT lym phoma (low grade), OR after endoscopic resection of OD OR 500 mg BID for 5 days

ea rly gastric cancer, OR gastric cancer in first-degree relative nv floxacin-based triple therapy 10 days
• PPI BID + levofloxacin 500 mg OD OR 250 mg BID+ amoxicillin
4 . Patients with high risk fo r PUD w ho requires long-term aspirin or NSAIDs
I g BID
5. Patient's wishes (after full consultation with their physici an)
·on omitant therapy 10 days
6. Uninvestigated dyspepsia
• PPI BID + amoxicillin 1 g BID + clarithromycin 500 mg BID+
7. Unexplained iron-deficiency anemia, OR chronic idiopathic thrombocytopenic
metronidazole 400 mg TID
purpura
l'PI = Omeprazole20mg, Lansoprazole30mg , Pantoprazole40mg , Esomeprazole20mg

I Ines of treatm ent

Low prevalence of clarithromy- High prevalence of clarithromycin

cin resistant (<20%)
I ll sl line •PPl +clarithromycin+amoxicillin
or metronidazole
• Bismuth Quadruple therapy
resistance
• Bismuth Quadruple therapy
If not available: non- Bismuth
Quadruple therapy (either sequen-
tial or concomitant)

lo and line •Bismuth Quadruple therapy or •PPl +levofloxacin+amoxicillin

•PPl +levofloxacin+amoxicillin
ll1lrd line Based on susceptibility testing only
 Suandok Antibiotics 25
24 Suandok Antibiotics

COi severity scoring system and summary of recommended treatments

References: I Soverity Criteria Treatment Comment
1. Management of Helicobacter pylori infection-the Maastricht IV/ Florence
Sovere and compli- Any of the following Vancomycin 500 Surgical consultation
Consensus Report. Gut 2012; 61: 646-664.
coted disease attributable to COi: mg POQIDfor suggested with any
2. Current concepts in the management of Helicobacter pylori infection: the
- Admission to 10 days .eLUS one of the following
Maastricht Ill Consensus Report. Gut 2007;56:772-81
intensive care unit metronidazole 500 contributed to COi:
3. American College of Gastroenterology Guideline on the Management of
forCDI mglVQ8H clinically sepsis or
Helicobacter pylori Infection. Am J Gastroenterol 2007; 102: 1808-1825
- Hypotension with septic shock, WBC
4. 1:UJ1l'll.JII WY1EJr::uum-,,~ufl1U1rn u-,iJi::,Y1P1lm1 n. 111J?Y11"1'l'i1Uillffii1un1i
~
or without required If severe disease <". 50000 cells/mm' .
:ju'itlEIII fl!:fnl:t1 ejU'lEI~ ILJLJI iEJII fl!:ejU'lEJdiJn11~1n1/fllllflfl'l II lJl'l llilfl fl Wfifl l r use of Vasopressors with profound ileus: lactate <". 5 mmol/L,
1uiJr::mPl1YIEJ. 1 ed. nf-3LY1Wl.JU11JM: f:i11unwl.lr1n7-,mm?'!l~11; 2553. - Fever <". 38.5° c peritoneal signs,
- lieus or significant vancomycin 500 toxic megacolon. and
abdominal distention mg in NSS 500 ml failure to improve on
Chapter 6.3 C/ostridium difficile infection (COi) - Mental status enema QID medical therapy after
Definition of CD! changes 5 days
A case definition of CD! includes the following findings: (1) the presence of - WBC <". 35,000
diarrhea, defined as passage of 3 or more unformed stools in 24 or fewer cells I mm3 or <
consecutive hours; (2) a stool test result positive for the presence of toxigenic 2.000 cells /mm'
C.difflcile or its toxins or colonoscopic or histopathologic findings demonstrating - Serum lactate levels
>2.2 mmol / I
pseudomembranous colitis.
- End organ failure
(mechanical
Treatment
ventilation, renal
COi severity scoring system and summary of recommended treatments failure etc.\
Treatment Comment Hecurrent COi Recurrent COi Repeat metronidazole
Severity Criteria
If no improvement within 8 weeks of or vancomycin
Diarrhea with no Metronidazole 500
Mild-to-moderate completion of pulse regimen
mg PO TIO for 10 in 5- 7 days,
disease
signs or symptoms
consider changing theraov
of severe or compli- days. If unable to
take metronidazole, to vancomycin 125
cated disease NOTE. IV vancomyc1n unlike IV met ·d
vancomycin 125 mg PO QID for 10 IIS it is NOT excreted i~to colon roni azole, has no effect on on C. difnci/e
mg PO QID for 10 days

davs References:
Serum creatinine Vancomycin 125
Severe disease I Christina M. Surawicz, Lawrence J. Brandt. etc.Guidelines for . .
<". 1.5 times of mg PO QID for 10 I~ atment, and Prevention of Clostridium difficile Infections Am J G D1tagnos1s,
baseline OR days J013; 108:478-498 · as roenterol
WBC <". 15,000 J Stuart H. Cohen, MD; Dale N. Gerdin . . .
cells/mm' for Clostridium difficile Infection in Adult~; ;~;oci;~::::c:::SGuidelines
I :ealthcareEpidemiology of America (SHEA) and the lnfe:tious Doc,ety for
oc,ety of Am · (IDSA). Infect Control Hosp Epidemio/ 2010; 31(5):431-455
1seases
enca
22 Suandok Antibiotics Suandok Antibiotics 23

• In asymptomatic patients with cloudy fluid , it is re asonable to delay

therapy pending the results of cell count, gram stain, and c ulture.
Regimens Duration
l'PI based triple therapy 10-14 days
Reference:
• PPI bid + amoxicillin 1 g BID+ clarithromycin 500 mg BID
ISPD Guidelines for Peritoneal Dialysis-related Infections: Peril Dial Int
• PPI bid + metronidazole 400 OR 500 mg BID + clarithromycin
2005:25:107
500 mg BID
• PPI bid + amoxicillin 1 g BID + metronidazole 400 mg BID
llismuth-based quadruple therapy 14 days
• PPI bid + bismuth 240·525 mg BID + metronidazole 400 mg BID
Chapter 6.2: Helicobacter pylori infection
OR TIO+ tetracycline 500 mg 010
Established indications for testing and treatment of H. pylori • PPI BID+ bismuth 240-525 mg BID + metronidazole 400 mg BID
1. Active peptic ulcer disease (gastric or duodenal ulcer), OR confirmed OR TIO + clarithromycin 500 mg BID
history of peptic ulcer disease (not prev iously treated for H. pylori) Soquential therapy Total 1O days
2 . Hemorrhagic/erosive gastritis OR atrophic gastritis from gastroscopic • PPI BID + amoxicillin 1 g BID for 5 days, then
finding • PPI BID+ metronidazole 400 OR 500mg BID + clarithromycin 1000 mg

3. Gastric MALT lymphoma (low grade). OR after endoscopic resection of OD OR 500 mg BID for 5 days

early gastric cancer. OR gastric cancer in first-degree relative I evofloxacin-based triple therapy 10 days
• PPI BID + levofloxacin 500 mg OD OR 250 mg BID+ amoxicillin
4 . Patients with high risk for PUD who requires long-term aspirin or NSAIDs
1 g BID
5. Patient's wishes (after full consultation with their physician)
oncomitant therapy 10 days
6. Uninvestigated dyspepsia
• PPI BID + amoxicillin 1 g BID + clarithromycin 500 mg BID+
7. Unexplained iron-deficiency anemia. OR c hronic idiopathic thrombocytopenic
metronidazole 400 mg TIO
purpura
PPI = Omeprazole20mg, Lansoprazole30mg, Pantoprazole40mg, Esomeprazole20mg

Lines of treatment

Low prevalence of clarithromy- High prevalence of clarithromycin

cin resistant (<20%)
rirst line •PPl+clarithromycin+amoxicillin
or metronidazole
• Bismuth Quadruple therapy
resistance
• Bismuth Quadruple therapy
If not available: non- Bismuth
Quadruple therapy (either sequen-
tial or concomitant)

Second line • Bismuth Quadruple therapy or • PPl+levofloxacin+amoxicillin

•PPl+levofloxacin+amoxicillin

fhird line Based on susceptibility testing only

 Suandok Antibiotics 25
24 Suandok Antibiotics

t:DI severity scoring system and summary of recommended treatments

References:
1. Management of Helicobacter pylori infection-the Maastricht IV/ Florence tioverity Criteria Treatment Comment

Consensus Report. Gut 2012; 61: 646-664. 'iov re and compli- Any of the following Vancomycin 500 Surgical consultation
2. Current concepts in the management of Helicobacter pylori infection: the 1.n1 d disease attributable to CDI: mg PO QID for suggested with any

Maastricht Ill Consensus Report. Gut 2007;56:772-81 - Admission to 10 days ELU.S one of the following

3. American College of Gastroenterology Guideline on the Management of intensive care unit metronidazole 500 contributed to CDI:
forCDI mglVOBH clinically sepsis or
Helicobacter pylori Infection. Am J Gastroenterol 2007; 102: 1808-1825
- Hypotension with septic shock, WBC
4. 10.111'/l./lL w11rri::u1m1~1M1Je1mrn u~1h::\nf'flnfl n. IL 1J?m~1?'!1t.ifl!Jvii1Jn1r
or without required If severe disease ~ 50000 cells/mm' ,
?U~tlflIL li::fm,nrJ!l?fJMfl it.It.ILiflIL 1i::rJ!l?flniin1T~fil Lie Llf~fl'I LLlll'I IP!fl fl Wlifl lT
use of Vasopressors with profound ileus: lactate ~ 5 mmol/L,
iut.Jr::mf'fh'lfl. 1 ed. n7~Ll'IY1l.JU1!Jl'/r: fi111JnWl./Wn1~L!'IYll'l'!/1'11r; 2553.
- Fever~ 38.5° C peritoneal signs,
- lieus or signific ant vancomycin 500 toxic megacolon, and
abdominal distention mg in NSS 500 ml failure to improve on
Chapter 6.3 Clostridium difficile infection (COi) - Mental status enema QID medical therapy after
Definition of CDI changes 5 days
A case definition of CDI includes the following findings: (1) the presence of - WBC ~ 35,000
diarrhea, defined as passage of 3 or more unformed stools in 24 or fewer cells I mm3 or <
consecutive hours; (2) a stool test result positive for the presence of toxigenic 2.000 cells /mm'
C.difflcile or its toxins or colonoscopic or histopathologic findings demonstrating - Serum lactate levels
pseudomembranous colitis. >2.2 mmol / I
- End organ failure
Treatment (mechanical
ventilation, renal
CDI severity scoring system and summary of recommended treatments
failure etc.)
Criteria Treatment Comment H c urrent CDI Recurrent CDI Repeat metronidazole
Severity
Diarrhea with no Metronidazole 500 If no improvement within 8 weeks of or vancomycin
Mild-to-moderate
signs or symptoms mg PO TID for 10 in 5 - 7 days, completion of pulse regimen
disease
of severe or compli- days. If unable to consider changing theraov

cated disease take metronidazole, to vancomycin 125

NOTE: IV vancomycin, unlike IV metronidazole, has no effect on on C. dif~cile
vancomycin 125 mg PO QID for 10
ns it is NOT excreted into colon
mg PO QID for 10 days
davs
References:
Severe disease Serum creatinine Vancomycin 125
I Christina M. Surawicz, Lawrence J. Brandt, etc.Guidelines for Diagnosis,
~ 1.5 times of mg PO QID for 10
Treatment, and Prevention of Clostridium difficile Infections.Am J Gastroenterol
baseline OR days
2013; 108:478-498
WBC~ 15,000
2. Stuart H. Cohen, MD; Dale N. Gerding, etc. Clinical Practice Guidelines
cells/mm'
for Clostridium d ifficile Infection in Adults: 2010 Update by the Society for
I lealthcareEpidemiology of America (SHEA) and the Infectious Diseases
ociety of America (IDSA). Infect Control Hosp Epidemiol 2010; 3 1(5):431-455
26 Suandok Antibiotics
Suandok Antibiotics 27

Chapter 6.4: Catheter-Related Bloodstream Infection (CRBSI) Change to

Diagnostic method
• Two sets of blood cultures should be drawn from peripheral sites. One set
of blood cultures should be drawn from c atheter hub(s). All blood cultures
should be drawn at the same time
• Qualitative c ulture from catheter tip is DISCOURAGE.
• Quantitative culture from catheter tip, if performed, should ONLY be sent
when there is a clinical suspicion of infection. NOT routinely when lines
are removed . They MUST be accompanied by two sets of blood c ultures
obtained from peripheral sites as detailed above. However, quantitative
culture cannot be done in our hospital. Only semi-quantitative culture (roll
plate tec hnique) from catheter tip can be performed. Laboratory consulted
(5644) is recommended for performing semi-quantitative culture.
Diagnosis
1. The organisms g row from blood c ultures drawn from catheter hub
and peripheral veins are the same. AND Growth of mic robes from a
blood sample drawn from a catheter hub at least 2 hours before microbial
growth is detected in a blood sample obtained from a peripheral vein.
(Differential time to positivity -, 2 hours)
2. The organisms grow from blood c ulture drawn from peripheral veins
and catheter tip (semi-quantitative culture > 100 cfu) are the same.
Empiric treatment
• Vancomycin ± Carbapenems (imipenem/cilastatin, meropenem, doripenem)
OR
• Severe PCN allergy: Vancomycin (see page 87-89 for dosage)
± Ciprofloxacin 400 mg IV Q8H
• Cloxacillin 2 g IV Q4H if susceptible (preferred to Vancomycin)
Duration:
• 5-7 days if c atheter removed (preferred)
• 10-14 days if catheter salvage attempt (IV antibiotics plus antibiotic lock
lherapy)
An tibiotic lock therapy if required, please contact drug information service
(63 12)
laphylococcus aureus
• Vancomycin (see page 87-89 for dosage)
Change to
• Cloxacillin 2 g IV Q4H if susceptible
R
· Non-severe PCN allergy: Cefazolin 2 g IV Q8 H
R
• Severe PCN allergy or MRSA: Vancomycin (see page 87-89 for dosage)
TREATMENT NOTES
• Remove catheter. High relapse rates if catheter is not removed.
- Vancomycm is inferior to cloxacillin for treatment of MSSA.
• Patients with S. aureus bacteremia should have an echocardiogram to
rule out endo_card1t1s. Transthoracic echo is acceptable only if the study
adequately views the left-sided valves; most experts recommend TEE
• 14 days is the minimum course of therapy for S. aureus bacteremia a~d
should only be considered if endocarditis and other metastatic infection
have been ruled out.

Empiric treatment - Gram-positive cocci in clusters in 2 or more sets of • Linezolid should not be used as monotherapy for treatment of S. aureus
bacterem1a
blood cultures
• Vancomycin nterococci

Specific treatment NOTE: can be contaminants. Draw repeat cultures to confirm before
I rting treatment.
Coagulase-negative staphylococci (CoNS)
NOTE: Single positive cultures of CoNS should NOT be treated unless they • Ampicillin 2 g IV Q4H ± Gentamic in 1 mg/kg IV Q8H (see TREATMENT
NOTES below)
are confirmed by follow-up cultures, the patient is immunosuppressed and/or
R
c ritically ill, or the patient has implanted hardware. In these cases,
treatment can be started but repeat c ultures should be sent PRIOR to . PCN allergy: Vancomycin (see page 87-89 for dosage)
initiation of therapy to confirm the diagnosis. ± Gentamicin 1 mg/kg IV Q8H (see TREATMENT NOTES below)
Duration: 7-14 days
• Vancomycin (see page 87-89 for dosage)

28 Suandok Antibiotics
TREATMENT NOTES
• Consider echocardiogram if there is persistent bacteremia (> 3 days) on
antibiotics.
• Do not use Gentamicin if the lab reports no synergy with a cell wall agent.
• If synergy is present, Gentamicin should be added to Ampicillin or
Vancomycin in the treatment of endocarditis; however, the addition
of Gentamicin does not appear to change outcomes in CA-BSI caused
by Enterococcus in the absence of endocarditis if catheter has been
removed.
• Do not use Gentamicin with Linezolid given lack of supportive evidence
for synergy.
Gram-negative bacilli
Refer to susceptibility testing results
Duration: 7- 14 days
TREATMENT NOTES
• C th ters are less commonly the source of the infection: however, most
dvocate ca theter removal if the catheter is the source.
Candida spp .
• See page 69 for treatment of candidemia
GENERAL TREATMENT NOTES ON CRBSI
• In instances where the blood and catheter are cultured at the same time
and the blood cultures are negative but the catheter culture is positive,
antibiotics are generally not recommended, even for patients with
valvular heart disease or immunosuppression.
• The exception is patients whose catheter tips grow S. aureus and have
negative blood cultures. These patients should receive 5--7 days of
antibiotics.
• Blood cultures should be repeated at 72 hours after appropriate antibiotics
to determine persistent bacteremia. If hemocultures are still positive,
echocardiogram should be performed if not yet done, other metastatic
infections should be sought.
Microbiology - most common pathogens: Coagulase-negative staphylococci,
Enterococci, S. aureus, Gram-negative bacilli, Candida species
Suandok Antibiotics 29
Catheter salvage
• Catheter removal is STRONGLY recommended for infections withs. aureus,
yeast and Pseudomonas, as the chance of catheter salvage is low and the
ri sks of ongoing infection can be high.
• Catheters associated with tunnel infections CANNOT be salvaged and
should be removed .
• Catheter salvage can be considered in CRBSls caused by coagulase
negative staphylococci if the patient is clinically stable.
• When catheter salvage is attempted, antibiotics should be given through
the infected line.
• Duration of treatment for catheter salvage is similar to duration of treatment
when the catheter is removed .
• Antibiotic or ethanol lock therapy, in which an antibiotic or ethanol is infused
into the catheter and left in place, can be considered in the treatment of
tunneled catheter infections due to less virulent pathogens such as CoNS
nd some Gram-negatives.
Reference:
IDSA Guidelines for the Diagnosis and Management of lntravascular
atheter-related Infections: Clin Infect Dis 2009;49:1-45.
C hapter 6.5: Endocarditis
Modified Duke Criteria for Infective Endocarditis
efinite endocarditis
• Presence of 2 major criteria OR 1 major AND 3 minor OR 5 minor
Possible endocarditis
• Presence of 1 major AND 1 minor OR 3 minor criteria
Rejected endocarditis
• Firm alternate diagnosis that explains ALL manifestations of IE
(NOTE: simply having another infection dose NOT exclude endocarditis)
Ma jor criteria
M1crobiologic
• Two separate blood cultures positive for a typical organism: viridians
streptococci, S. bovis, HACEK, S. aureus, Enterococcus spp.
• Persistent bacteremia with any organism as evidence by: 2 positive
blood cultures draw at least 12 hours apart OR 3/3 positive blood
c ultures with at least 1 hour between the first and last OR the majority
of more than 4 cultures positive from any time period .
• Positive Coxiella burnetti (Q fever) culture or serology.
 Suandok Antibiotics 31
30 Suandok Antibiotics

Empirical Antibiotics Therapy for Native Valve Infective Endocarditis and

Echocardiographic (TEE strongly recommended for prosthetic valve)
Community onset
• Vegetation (on valve or supporting structure OR in path of regurgitant jet)
Consult ID for appropriate antibiotics within 24 hours of admission
• Abscess
• New dehiscence of prosthetic valve Acute IE Antibiotics (ABO)
Severe sepsis, septic shock S t a r t ~ hemocultures are drawn
Physical exam
• NEW regurgitant murmur (worsening of old murmur is NOT sufficient) Hemocultures
- >i11'1111J~:fl1i,\~1~u•ilhu 2% Ampicillin I sultactam 3 g IV Q4H OR
Minor criteria chlorhexidine gluconate Amoxicillin I clavulanate 2.2 g IV 04H OR
• Predisposing condition: previous endocarditis, injection drug use,
- ,~1:1ilti"' 20 ;;;; utl•l ri,1"' aerobic Ceftriaxone 2 g W 012H r'LUS Ampicillin 2 g W Q4H OR
prosthetic valve, ventricular septa! defect, coarctation of the aorta, c alcified
10 iiii!utt::11'".lf'\ anaerobic 10 ;!;! Vancomycin 1 g IV 012H (if severe PCN allergy)
valve, patent ductus, mitral valve prolapsed with regurgitation, IHSS or
.fl.I.&
other valvular heart disease Gentamicin 1 mg/kg 08H (if no renal impairment)
• Fever~ 38.0 °C NOT severe sepsis or septic shock Start after 2nd hemoculture is taken
• Embolic events: arterial or pulmonary emboli, conjunctiva! hemorrhage,
· ,;,,.111J~:m"'~1~u•ilhu 2% Ampicillin/ sultactam 3 g IV 04H OR
retinal hemorrhage, splinter hemorrhage, intracranial hemorrhage, mycotic chl,?rhexidine gluconate Amoxicillin/ clavulanate• 2.2 g IV Q4H OR
aneurysm - f'IN!l7n1ii,~1:1itti"' 20 ;;;; um1m1"' Ceftriaxone 2 g W 012H PLUS Ampicillin 2 g W Q4H OR
• Immunologic phenomenon: Osler nodes, glomerulonephritis, positive aerobic 10 1iaut1::11'"J11 anaerobic Vancomycin 1 g IV 0 12H (if severe PCN allergy)

rheumatoid factor 10;;;; El.US

• Positive blood cultures that don't meet criteria above OR serologic -Rf•~~ti•lii,~1:1ilti"'i.h•~1nRf•um Gentamicin 1 mg/kg 0 8H (if no renal impairment)
evidence of active infection with an organism know to cause endicarditis 1 i1t1J• 10 ;;;; 1ri11i1n: ,1"' aerobic
BUT single positive cultures for c oagulase-negative staphyloc occi are Subacute IE - No immediate empirical antibiotic(s) is needed,

NOT considered even a minor c riteria consult ID for appropriate antibiotics

(n1tiitr;ruu,~1ntrn,u1u1fl~u1J1ritiuliim1~1J~ti\tl)
Treatment of native valve endocarditis
He~ocultures x 5 specimens
NOTES: -,.,.um,~,: 20 ;;;; um1mn"' aerobic
• Beta-lactams are highly preferable to Vancomycin if the organism is
10 11utt::11'll'I anaerobic 10 ;!;I
susceptible and if the patient is not severely allergic. -,.¥.~ 2 ,~1:li10~1nR~u1n 1 ilti,a
10 ;i;ilri,1"' aerobic
- Rfavi 3 ,~1:m,~1nRN~ti• 1 fl~
1O;i;ilri,1"' aerobic
· ~,mru,~1: m fl:f'lfa~n 2 f'lfa
f'lfafl: 10 ;i;ilri,1"' aerobic
Antibiotics must be tailored to the appropriate ones once the culture is known
'Only amoxic illin/clavulanic acid formulation 2.2 gram/vial b!QI amoxicillin/
lavulanic acid 1.2 gram/vial
For specific pathogens
Viridans streptococci or S. bovis with PCN MIC :5 0.12 mcg/ml
• Penicillin G 3 million units IV Q4H for 4 weeks OR
• Non-severe PCN allergy: Ceftriaxone 2 g IV Q24H for 4 weeks OR
 Suandok Antibiotics
32 Suandok Antibiotics

OR
• [Penicillin G 3 million units IV Q4H OR Ceftriaxone 2 g IV Q24H for ;~on-severe PCN allergy: Cefazolin 2 g IV 08H
2 weeks] ~ Gentamicin 3 mg/kg IV 024H for 2 weeks OR
• Severe PCN allergy: Vancomycin 1 g IV 012H for 4 weeks • Severe
1g IV QPCN
12H allergy: Strong Iy c ons1der
. PCN desensitization or Vancomycin
Criteria for 2 week treatment
• Patient does not have cardiac or extracardiac abscess • The addition of Gentamicin to a beta-lactam
faster but does not appear t ff may help clear blood cultures
• CrCI >20 mUmin
avoided in the elderly and inot~o::t mortality..It particularly should be
• Patient does not have impaired 8th cranial nerve function
Staphylococcus aureus - Meth' ·11· wit~ baseline renal impairment.
Viridans streptococci or S. bovis with PCN MIC> 0.12 mcg/ml and 1c1 m resistant native I
• Vancomycin 1 g IV 012 H • va ve
s 0.5 mcg/ml
• [Penicillin G 4 million units IV Q4H OR Ceftriaxone 2 g IV Q24H for 4 weeks] Duration
~ Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy • Uncomplicated: 4 weeks
• Complicated (perivalvular abscess formati .
OR poor controlled diabetes mellitus MRSA)· on, metastatic complication,
• Severe PCN allergy: Vancomycin 1g IV 012H for 4 weeks
• ID a d · · · 6 weeks
n cardiac surgery consults recommen .
Viridans streptococci or S. bovis with PCN MIC > 0.5 mcg/ml S. pneumoniae and Group A t ded for complicated diseases
. . . · s reptococci
• Treat as Enterococcal endocarditis • Penic1ll1n G 3 million units IV Q4H f or 4 weeks
OR
TREATMENT NOTES
• All patients with S. bovis endocarditis should undergo GI work-up to rule • Non-severe PCN allergy: Ceftriaxone 2
Cefazolin 2 g IV 08H for 4 weeks g IV Q24H for 4 weeks OR
out underlying cancer.
Staphylococcus aureus - Methicillin susceptible, native valve, right-sided OR
• Severe PCN allergy: Vancomycin 1 g IV 012H for 4
involvement only
• For S. pneumoniae, if PCN MIC.? 2 ·0 6t:IU cefotax1me
. weeks
MIC .? 1.0, consult ID
• Cloxacillin 2 g IV Q4H for 2 weeks
Qrjterja for 2-week treatment
• ADEQUATE transthoracic echo (TIE) or transesophageal echo (TEE) to ~ roups. B (S. agalactiae}, C and G streptococci
rule out left-sided involvement, as some series report a high frequency of Penic1ll1n G 3 million units IV Q4H f
024H for the first 2 weeks of th or 4---6 weeks ± Gentamicin 3 mg/kg IV
left-sided disease OR erapy
• Treatment with Cloxacillin
• Patient does not have AIDS (CD4 < 200) • Non-severe PCN allergy: Ceftriaxone 2 IV
3 mg/kg IV Q24H for the first 2 kg Q24H for 4-6 weeks± Gentamicin
• Patient does not have a vascular prosthesis (dialysis graft, etc) OR wee s of therapy
• Blood c ultures are negative within 4 days after starting therapy
• There is no evidence of embolic disease OTHER than septic pulmonary • Severe PCN allergy: Vancomycin 1 IV
3 mg/kg IV Q24H for the first 2 wee~s of~~:r: for 4---6 weeks ± Gentamicin
emboli
• Vegetations are all < 2 cm in size • Consider an ID Consult PY
• If patient Does NOT meet criteria for 2-week treatment, treat as MSSA, nterococci with PCN MIC S 16 mcg/ml AND ..
• [Ampicillin 2 g IV Q4H OR Pe . ·ir . Gentam1cm MIC S 500 mcg/ml
native valve, left-sided endocarditis
Staphylococcus aureus - Methicillin susceptible, native valve, left-sided
Gentamicin 1 mg/kg IV QBH ~~~~n 4
G million units IV Q4H] .El.U.S
J.LS.L.LU for 6 weeks

involvement
• Cloxacillin 2 g IV Q4H
34 Suandok Antibiotics
OR
• Severe PCN allergy: Vancomycin 1 g IV 012H .!:!J.& Gentamicin 1 mg/kg
IV OBH BOTH for 6 weeks
• Treat for 4 weeks only when symptoms have been present for < 3 months
AND there is a prompt response to therapy
Enterococci - Vancomycin, or Aminoglycoside resistant
• Consult ID
HACEK organisms (Haemophilus parainguenzae, H. aphrophilus,
Actinobacillus actinomycetemcomitans, Cardiobacterium hominus, Eikenella
corrodens, Kingella kingae)
• Ceftriaxone 2 g IV 024H for 4 weeks
OR
• Ampicillin/sulbactam 3 g IV 06H for 4 weeks
OR
• Severe PCN allergy: Consult ID
Gram-negative organisms, culture negative endocarditis, or fungal
endocarditis
• Consult ID
Nosocomial or hospital-acquired infective endocarditis (risk of MOR-pathogens)
'I.U.J1EJn~ develop IE 1,1f1'~<11n~utiuh~vm1u11111i1EJL~YiU evidence 'lltl~ IE
li1tlU~ admit
Vancomycin 1 g IV 012H E.L.U..S carbapenems (meropenem 2 g IV OBH OR
imipenem/cilastatin 1 g IV 06H )
Treatment of orosthelic valve endocardilis
• Generally caused by staphylococci in the first 1-2 years following valve
replacement (both S. aureus and coagulase-negative staph) . Etiologies
are similar to native valve infections 2 or more years post-op.
• Medical treatment alone is often NOT effective.
• All patients should have a TEE.
Empiric treatment
• Vancomycin 1g IV 012 H E.L.U..S Gentamicin 1 mg/kg IV OBH Considered
• Rifampin 300 mg PO OBH after blood cultu res have cleared
Viridans streptococci or S. bovis with PCN MIC :S 0.12 mcg/ml
• [Penicillin G 4 million units IV 04H OR Ceftriaxone 2 g IV 024H] for
6 weeks ± Gentamic in 3 mg/kg IV 024H for first 2 weeks of therapy OR
• Severe PCN allergy: Vancomycin 1 g IV 012H for 6 weeks
Suandok Antibiotics 35
Viridans streptococci or S. bovis with PCN MIC> 0.12 mcg/ml
• [Penicillin G 4 million units IV 04H OR Ceftriaxone 2 g IV 024H] EM
Gentamicin 3 mg/kg IV 024H for 6 weeks OR
• Severe PCN allergy: Vancomycin 1g IV 012H for 6 weeks
Staphylococcus aureus-Methicillin susceptible
• Cloxacillin 2 g IV 04H for 6 weeks EM Gentamicin 1 mg/kg IV OBH for
the first 2 weeks of therapy
AND
• Rifampin 300 mg PO OBH for 6 weeks after blood cultures have cleared
(case by case basis)
Staphylococcus aureus-Methicillin resistant or Coagulase-negative
staphylococci•
• Vanc omycin 1 g IV 012H for 6 weeks EM Gentamicin 1 mg/kg IV OBH
for the first 2 weeks of therapy 81::ill
• Rifampin 300 mg PO OBH for 6 weeks after blood cultures have cleared
(case by case basis)
• If coagulase-negative staphylococci is susceptible to Oxacillin then treat
as S. aureus - Methicillin susceptible.
Gram-negative organisms or culture negative endocarditis
• Consult ID
References:
1. Oral therapy: Am J Med 1996; 101:68-76.
2. Short course therapy: Ann Intern Med 1994; 121:873-6.
3. Duke c riteria: Clin Infect Dis 2000; 30:633-8.
4. AHA Scientific S/atement on Infective Endocarciitis: Circulation 2005; 111 {23): e394434.
5. TEE m S.aureus bacteremia: J Am Coll Cardiol 1997; 30:1072-8.
Permanent pacemaker (PPM) and implantable cardioverter-defibrillator (!CD)
infections
NOTE : Obta in at least 2 sets of blood cultures 6fEQBE initiation of antibiotic
therapy
Empiric treatment
• Vancomycin 1 g IV 012H. Narrow therapy based on culture results.
• ID consu lt recommended .
TREATMENT NOTES
Microbiology-Staphylococci in 70-80% of cases (50% Coagu lase-negative
staphylococci and 50% S. aureus)
Management
• If blood cultures are positive or endocarditis is suspected patients should
undergo transesophageal echocardiography (TEE)
36 Suandok Antibiotics
Suandok Antibiotics 37

• Complete extraction recommended for patients with pocket infection and/

Chapter 6.6: Central Nervous System Infection
or valvular or lead endocarditis Meningitis - Empiric treatment
• At the time of extraction , tissue (rather than swabs) from the generator
Clinical approach for acute bacterial meningitis
pocket shou ld be sent for Gram-stain and c ulture and lead tips should be
sent for culture. Clinical suspicion of
• Note that because leads are extracted through an open generator pocket, Acute Bacterial Meningitis
they may become contaminated by the infected pocket; therefore, positive
lead c ultu res are not always indicative of lead endocard itis in patient with
Hemocultures
negative blood c ultures.
• Blood cu ltures should be obtai ned after device removal.
• Device reimplantation should be on the contra-lateral side whenever possible. Dexamethasone (when suspected
Empirical antibiotic (s) +
• Complete extraction is strongly recommended in all patients presenting PSSP/CSSP/penicillin-sensitive S. suis)
wi th S. aureus bacteremia and no other source
• Complete extraction shou ld be considered in patients with persistent
positive blood c ultures wi th other organisms (e.g . coagulase-negative Indication for emergency cranial CT scan
staphylococci, enterococci, Gram-negative bacilli) on a case-by-case basis. - Altered consciousness (GCS s12)
• Complete device and lead removal is recommended for patients with - Focal neu rological deficit
valvular endocarditis. - Signs of increased ICP e.g . papilledema,
• Antimicrobial prophylaxis is NOT recommended for dental or other invasive 6"' nerve palsy, generalized hypertonicity,
procedures following p lacement generalized hyperreflexia
Re-implantation tim ing and duration of therapy
Re-implantation timing and duration of therapy
Diagnosis Timing of re-implantation Duration of therapy
Pocket site infection Blood culture negative 7-10 days if device erosion
for 72 hours and surgical Without inflammation 10-14
site healing days all others Oral therapy
can be considered
Positive blood cultures Post-explantation blood Non-S.aureus: 2 weeks
with rapid clearance Cultures negative for IV therapy
AND TEE with either no 72 hours S.aureus: 4 weeks
vegetatioo or uncomplicated IV therapy
lead vegetation Compatible with
Bacterial meningitis
Sustained positive blood Post-explantation blood 4 weeks IV therapy
cultures AND TEE with no Cultures negative for
vegetatioo or uncomplicated 72 hours Contirue empirical antitiotic (s)
lead vegetation Adjust antibiotic(s) as
indicated (Table 3)
+ other investigations as
Valve endocarditis Blood cultures negative 4-6 weeks IV therapy indicated
for 14 days (see Endocarditis page 29-36)
PSSP: penicillin-susceptible
References: S. pneumoniae
1. AHA Scientific Statement on Cardiovascular Implantable Electronic CSSP: cephalosporin -susceptible
2. Device Infections: Circulation 2010; 12 1:458- 77. S. pneumoniae

. ,
)_....
38 Suandok Antibiotics
Suandok Antibiotics

TREATMENT NOTES Empirical therapy (community-acquired infection)

• Antibiotics should be started as soon as possible, ideally within 30 minutes.
• DO NOT wait for CT scan or LP results. If LP must be delayed, get blood Gram-staining Potential pathogens Empiric therapy
cultures and start therapy.
Gram-positive cocci" S. pneumoniae, Ceftriaxone ±
• Adjust therapy once pathogen and susceptibilities are known.
S. suis, Vancomycin*
Potential pathogens causing acute bacterial meningitis S. agalactiae

Gram-negative cocci N. meningitidis Ceftriaxone

Host Pathogens Empiric therapy
Gram-positive bacilli L. monocytenes Ampicillin (penicillin G) ±
lmmunocompetent S. pneumoniae, Ceftriaxone ±
age < 50 N. meningitidis, Vancomycin" Aminoglycoside
H. influenzae, S. suis Gram-negative bacilli H. influenzae, E. coli, Ceftriaxone
K. pneumoniae, etc
lmmunocompetent S. pneumoniae, Ampicillin fl.US
age~50 N. meningitidis, Ceftriaxone ±
H. influenzae, Vancomycin"
L. monocytogenes, • Vancomycin is not recommended in our hospital due to low rate of
S. aga/acliae, aerobic cephalosporin-resistant S.pneumoniae. However, if the physician decides
gram-negative bacilli to prescribe vancomycin as empirically, it should be stopped after the
susceptibility result is known.
lmmunocompromised S. pneumoniae, Vancomycin fl.US
N. meningitidis, Ampicillin fl.US
H. influenzae, Ceftazidime OR Use of Dexamethasone
L. monocytogenes, Cefepime • Addition of dexamethasone is recommended in all adult patients with
S. agalactiae, aerobic suspected pneumococcal meningitis (note that this will be most adult
gram-negative bacilli patients).
Post neurosurgery S. ~ (WCSFleak), Vancomycin fl.US • Dose: 0.15 mg/kg IV Q6H for 4 days
or penetrating head H. influenzae, Ceftazidime OR • The ~rst dose must be administered 10-20 minutes before or concomitant
trauma Staphylococci, Cefepime OR with the ~rst dose of antibiotics.
Gram-negatives Meropenem
• Administration of antibiotics should not be delayed to give dexamethasone.
Infected shunt S. aureus, Coagulase- Vancomycin fl.US • Dexamethasone should not be given to patients who have already
negative staphylococci, Ceftazidime OR started antibiotics.
Gram-negatives (rare) Cefepime OR • Continue dexamethasone only if the CSF gram stain shows Gram positive
Meropenem diplococci or if blood or CSF grows S. pneumoniae or S. suis
lmmunocompromised is de~ned as HIV infection or AIDS, receiving
immunosuppressive therapy.
In patients with HIV infection, nonbacterial causes of meningitis must be
considered, particularly cryptococcal meningitis.
Vancomycin is not recommended in our hospital due to low rate of
cephalosporin-resistant S.pneumoniae. However. if the physician decides to
prescribe vancomycin as empirically, it should be stopped after the
susceptibility result is known.
40 Suandok Antibiotics
Suandok Antibiotics 41

Pathogen-specific therapy • N. meningitidis: 7 days

• L. monocytogenes: 21 days
Pathogens Preferred
• H. influenzae: 7 days
S. pneumoniae Penicillin OR Ceftriaxone • Gram-negative bacilli : 21 days
PCN MIC ::s;; 0.06 µg/ml AND/OR
Ceftriaxone MIC <0.5 µg/ml Brain abscess

S. pneumoniae PCN MIC >0.1-1 µg/ml Ceftriaxone • Empiric treatment is guided by suspected source and underlying condition.
AND Ceftriaxone MIC <1 µg/ml (ID consult While therapy should be adjusted based on c ulture results, anaerobic
recommended) coverage should ALWAYS continue even if none are grown

S. pneumoniae PCN MIC > 1 µg/ml Ceftriaxone ELU.S Vancomycin

Source/ Condition Pathogens
AN D/OR Ceftriaxone MIC ~1 µg/ml (ID ELU.S Rifampin Preferred
consult recommended) Unknown S. aureus, Streptococci, Ceftriaxone ELU.S
N. meningitidis PCN susceptible Penicillin OR Ceftriaxone* Gram negatives, Metronidazole
Anaerobes
H. influenza Non ll.-lactamase producer Ampicillin OR Ceftriaxone
Sinusitis Streptococci (including Ceftriaxone ELU.S
H. influenzae ll.-lactamase producer Ceftriaxone S. pneumoniae}, Metronidazole
Anaerobes
Listeria Ampicillin ± Gentamicin
Chronic otitis media Gram-negatives including Ceftazidime OR
P. aeruginosa (ID consult recommended) Ceftazidime OR Cefepime OR P. aeruginosa. Cefepime ELU.S
Meropenem Streptococci, Anaerobes Metronidazole
E. coli and other Enterobacteriaceae Ceftriaxone Post neurosurgery Staphylococci , Vancomycin ELU.S
Gram negatives Ceftazidime OR
S. aureus-MSSA Cloxacillin
Cefepime OR Meropenem
S. aureus-MRSA Vancomycin
References:
Coagulase-negative staphylococci if Vancomycin
1. IDSA Guidelines for Bacterial Meningitis: Clin Infect Dis 2004;39:1267.
sensitive to c loxacillin
2. Dexamethasone in adults with bacterial meningitis: N Eng J Med
Coagulase-negative staphylococci if Vancomycin 2002;34 7: 1549.
resistant to cloxacillin
CNS shunt infection
Enterococci Ampicillin ELU.S Gentamicin
Diagnosis
• Must give Ciprofloxacin 500 mg once to eradicate carrier state if PCN used • Culture of cerebrospinal fluid remains the mainstay of diagnosis. Clinical
as treatment symptoms may be mild and/or non-specific, and CSF chemistries and
Duration leukocY1e counts may be normal.
• STOP treatment if LP c ulture obtained prior to antibiotic therapy is negative Empiric Therapy
at 48 hours 8b!Q no PMNs on cell count in non-neutropenic patient • Vancomycin ELU.S Meropenem
• S. pneumoniae: 10-14 days • Severe PCN Allergy: Vancomyc in £l..l.!.S Ciprofloxacin
42 Suandok Antibiotics
Suandok Antibiotics 43

TREATMENT NOTES Chapter 6. 7: Gynecologic Infection

• Removal of all components of the infected shunt with external ventricular
P.elvic Inflammatory Disease
drainage or intermittent ventricular taps in combination with the appropriate
intravenous antibiotic therapy leads to the highest effective cure rates. • Definition: inflammation inflammatory disorders of the upper female genital

success rates are substantially lower when the infected shunt components tract, including any combination of endometritis, salpingitis, tuba-ovarian
a bscess, and pelvic peritonitis
are not removed .
• The role of intraventricular antibiotics is controversial, and generally limited - Causative organisms: Neisseria gonorrhoeae, C. trachomatis, anaerobes,
G. vagina/is, Haemophilusinfluenzae, enteric Gram-negative rods ,
to refractory cases or cases in which shunt removal is not possible.
Streptococcus agalactiae, Mycoplasma hominis, M. genitalium, and
lntraventricular injection should be administered only by experienced
Ureap/asmaurealyticum
physicians.
• Meningitis due to multidrug-resistantA. baumannii: ID consult recommended Treatment
• Severely ill patient:
References:
Recommended regimen :
1. /DSA Guidelines for the Management of Bacterial Meningitis: C/in Infect Dis
2004;39:1267.
Reg imen A: Cefoxitin 2 gm IV Q6H El.!.& Doxycycline 100 mg PO BID
2. Therapy in cerebrospinal fluid shunt infection . Neurosurgery 1980;7:459. Regimen B: Clindamycin 900 mg IV Q8H El.!.& Gentamicin 2 mg/kg IV load
then 5 mg/kg Q24H (PCN allergy)

Alternative regimen:
Antimicrobial doses for CNS infections - normal renal function Regemen C: Ampicillin/Sulbactam 3 gm IV Q6H OR Amoxicillin/Clavulanate
Antibiotics 1.2 gm IV Q8H El.!.& Doxycycline 100 mg PO BID
• Ampicillin: 2 g IV Q4H • Non-severely ill patient or OPD case:
• Ceftriaxone: 2 g IV Q12H
Recommended regimen:
• Ceftazidime: 2 g IV Q8H
• Cefepime: 2 g IV Q8H Regimen A: Ceftriaxone 250 mg IM in a single dose El.J.!.S Doxycycline 100 mg
PO BID 14 days± Metronidazole 500 mg PO BID for 14 days (see note)
• Chloramphenicol: 1.0-1.5 g IV Q6H (reduce dose for hepatic dysfunction)
• Ciprofloxacin : 400 mg IV Q8H (based on limited data) Regimen B: Cefoxitin 2 g IM single dose .EL.US Probenecid 1 g PO single
• Meropenem 2 g IV Q8H dose .EL.US Doxycycline 100 mg PO BID for 14 days ± Metronidazole 500 mg
• Metronidazole: 500 mg IV Q6H PO BID for 14 day
• Cloxacillin: 2 gm IV Q4H
Regimen C: Ofloxacin 400 mg PO BID OR Levofloxacin 500 mg PO OD 14 days
• Penicillin : 4 million units IV Q4H (24 million units per day) ± Metronidazole 500 mg PO BID 14 day (see note)
• Rifampin: 600 mg IV Q12-24H
TREATMENT NOTE:
• Vancomycin : load with 25-35 mg/kg, then 15-20 mg/kg Q8-12H
(minimum 1 g Q12H) Metronidazole is optional use. However if bacterial vaginosis is suspected ,
Metronidazole is recommended
• Vancomycin should be administered to maintain serum trough
concentrations close to 20 µg/ml. Fluoroquinolone can be used in a low quinolone-resistance GC including
our hospital setting
• lntraventricular antibiotics: ID consult recommended
44 Suandok Antibiotics
References:
1. Infection of the female pelvis. In: Mandell GL . Douglas RG, Bennette JE,
editors. Principles and practice of infectious disease . 8th ed. Philadelphia,
Churchill Livingstone Inc; 2005:p1378-80.
2. Sexually transmitted diseases treatment guidelines. 2010. MMWR 2010;59:
No RR-12.
Gonococcal infection
Uncomplicated of cervix urethra and rectum
Recommended regimen :
Ceftriaxone 250 mg IM in a single dose OR Cefixime 400 mg PO single dose
~ Meropenem 1g IV Q8H, OR
Azithromycin 1 gm PO single dose. OR Doxycycline 100 mg PO BID for 7
days
Alternative regimen: (not recommended for CG pharyngitis)
Azithromicin 2 gm PO use for PCN allergy
Uncomplicated gonococcal infections of the pharynx
Ceftriaxone 250 mg IM in a single dose E.Lu..S...
Azithromycin 1 gm PO single dose. OR Doxycycline 100 mg PO BID for 7 days
Reference:
Sexually transmitted diseases treatment guidelines. 2010. MMWR 2010; 59:
No RR-12.
Post-operativ e pe lvic infectio n:
• Sepsis work up is mandatory before empiric treatment
• Discharge or surgical fluid exam and culture are mandatory.
• Imaging for exclude collection is suggested when suspected.
Localized Infection with Minimal Systemic Findings:
Cefotaxime 1g IV Q8H, OR Cefoxitin 2g IV Q6H, OR Ceftriaxone 2g Q24H,
then 1g IV Q24H , OR Ampicillin/sulbactam 3g IV Q6H OR Amoxicillin/
clavulanate 1.2 g IV Q8H
Suandok Antibiotics 45
Extensive Infection with Moderate to Severe Systemic Findings :
Clindamycin 900mg IV Q8H ~ Gentamicin 2 mg/kg IV, then 5mg/kg
Q24H ± Ampicillin 2 g IV, then 1g IV Q4H, OR
Ampicillin 2g IV, then 1g IV Q4H .P.L...U.S Gentamicin 2 mg/kg IV, then 5mg/kg
Q24H .P.L...U.S Metronidazole 500 mg IV Q8H , OR
Clindamycin 900mg IV Q8H .P.L...U.S Ceftriaxone 2g IV Q24H, OR
Ceftriaxone 2g IV Q24H .P.L...U.S Metronidazole 500mg IV Q8H, OR
Suspected healthcare-associated infections or risk of infections caused by
MOR-pathogens
Piperacillin/tazobactam 4.5 g IV Q8H
lmipenem/cilastatin 500-1000 mg IV Q6H, OR
Ertapenem 1g IV Q24H , OR
Levofloxacin 500mg IV Q24H .P.L...U.S Metronidazole 500mg IV Q8H
Postprocedural pelvic inflammatory disease:
Ceftriaxone 2 g IV Q24H .P.L...U.S Doxycycline 100 mg PO BID± Metronidazole
500mg PO BID
References:
1. Larsen JW, Hager WO. Livengood CH, et al. Guidelines for the diagnosis,
treatment and prevention of postoperative infections. Infect Dis ObstetGyne-
col 2003; 11 :65-70.
2. OluwatosinJaiyeoba Postoperative Infections in Obstetrics and Gynecology.
Clinical Obstetrics and Gynecology Volume 55, Number 4, 904-913.
3. Infection of the female pelvis. In: Mandell GL, Douglas RG, Bennette JE,
editors. Principles and practice of infectious disease. 8th ed. Philadelphia,
Churchill Livingstone Inc; 2005:p1378-80.
46 Suandok Antibiotics
Suandok Antibiotics 47

Chapter 6.8: Pulmonary infections Regimens:

Acute Exacerbation of Chronic Bronchitis (AECOPD) 1. Out-patient (mild AECOPD, antibiotics are optional)
1.1 . Amoxicillin 500 mg PO Q8H for 5 days
NOTE: Antimicrobials are beneficial especially when patient presents with
1.2. Doxycycline 200 mg PO then 100 mg PO Q12H for 5 days
all three cardinal symptoms (increased dyspnea, sputum purulence. sputum
(if PCN allergy)
volume) or 2/3 symptoms when one is increased sputum purulence. They may
not be generally beneficial in mild exacerbations. Exacerbation severity is
2. Out-patient (moderate AECOPD)
graded as "mild" (the need for only an increased use of inhaled bronchodilators) ,
2.1. Amoxicillin/clavulanate 875/ 125 mg PO Q12H OR 500/125 mg
"moderate" (the need for systemic corticosteroids), "severe" (the need for
PO Q8H OR 2000/ 125 mg PO bid for 5 days
hospital admission)
2.2. Azithromycin 500 mg PO for 1st day, then 250 mg PO Q24H for
4 days OR 500 mg PO Q24H for 3 days
ANTIMICROBIAL OPTIONS FOR AECOPD BASED ON HOST AND
2.3. Clarithromycin extended release 1000 mg Q24H for 7 days or
PATHOGEN FACTORS
250-500 mg PO Q12H for 7-14 days
2.4. Cefuroxime 500 mg. PO Q12H for 5-10 days
Category Likely Pathogens Antimicrobial Options 2.5. Cefdinir 200 mg . PO Q12H for 5-10 days
Simple, uncomplicated H. influenzae Macrolide 2.6. Cefditoren 200 mg . PO Q12H for 5-10 days
•Age < 65 years S. pneumoniae Doxycycline 2. 7. Levofloxacin 500 mg PO Q24H for 7 days
• FEV1 > 50% predicted M. catarrhallis Amoxicillin 2.8. Moxifloxacin 400 mg PO Q24H for 5 days
• < 4 exacerbations/year H. parainfluenzae 2nd or 3rd generation 2.9. If suspected P.aeruginosa: sputum culture is required: use high dose
• No co-morbid Viral cephalosporins
levofloxacin 750 mg PO Q24H, ciprofloxacin 500 mg. PO Q8-12H
conditions M. pneumoniae Respiratory
C. pneumoniae fluoroquinolone'
(levofloxacin, moxifloxacin) 3. In-patient (moderate to severe AECOPD)
Sputum cultures should be collected before starting antimicrobial therapy
Complicated As above and Amoxicillin/clavulanate (initial oral antibiotics are also accepted in non-severe cases)
• Age > 65 years Gram-negative Respiratory
3.1. Amoxicillin/Clavulanate1 .2 g IV Q8H
• ~4 exacerbation/year enteric bacilli ftuoroquinolone
3.2. Azithromycin 500 mg IV Q24H
•Co-morbid illness
• FEV1 <50% predicted 3.3. Ceftriaxone 2 gm IV Q24H
3.4. Levofloxacin 500 mg IV Q24H
Complicated and at As above and Levofloxacin 3.5. Moxifloxacin 400 mg IV Q24H
risk for P. aeruginosa Gram-negative Ciprofloxacin
infection• enteric bacilli 3.6. If suspected P.aeruginosa: use high dose levofloxacin 750 mg IV
·FEV1 < 35% predicted including Q24H, ciprofloxacin 400 mg Q8-12H, or anti-pseudomonal 11-lactams
• Recurrent courses of P.aeruginosa
Switch therapy is recommended with a total course of treatment 5-14 days
antibiotics or steroids
depends on patient's condition.
• Bronchiectasis

'Risks for P. aeruginosa include recent hospitalization, recent antibiotic use,

isolation of those organisms during previous exacerbation or colonization
during stable period
.. Fluoroqu inolone should be carefully used in patients who probably TB cases

.-Z.:. ,'! ' . '

48 Suandok Antibiotics
Suandok Antibiotics 49

References:
Regimens:
1. Anthonisen NR. Ann Intern Med 1987;106:196-204
1. Out-patient
2. Celli BR .EurRespir J 2004;23:932-946
1.1.Primary Regimens
3. Anzueto A Proc Am Thorac Soc 2007:554-564
4. Siempos II. Expert Opin Pharmacother 2009; 10: 1173- 1182 1.1 .1. Azithromycin 500 mg PO for 1" day. then 250 mg/day for 4 days
5. Rabe KF. Am J RespirCrit Care Med 2007;176:532-55 OR Azithromycin 500 mg PO Q24H for 3-5 days
6. Shapiro SD. In Mason:Murray and Nadel's Textbook of Respiratory 1.1.2. Clarithromycin 500 mg PO Q12H for 7 days

Medicine.5th ed: 919-966 1.1.3. Clarithromycin extended release 1 gm PO Q24H for 7 days
7. Punturieri A In Mandell, Douglas and Bennett's Principle and Practice of
1.2. Alternative Regimens
infectious diseases. 7th ed. 877-883
1.2.1. Doxycycline 200 mg PO then 100 mg PO BID for 7-10 days
Community-acquired pneumonia (CAP)
NOTE: Calculate CURB-65 score as followed 1.3. Co-morbidity present (chronic heart. lung, liver or renal disease; diabetes
C (Confusion) = 1 point mellitus; alcoholism ; malignancies ; asplenia) or received antibiotics.
U (BUN > 19 mg/di)= 1 point immunosuppresiving drugs in the previous 3 months

R (RR > 30/min) = 1 point 1.3.1. Azithromycin OR Clarithromycin (as aboved dosages) for
B (BP < 90/60) = 1 point 5 days+ Amoxicillin (875/125) 1 tab PO BID OR cefdinir 200 mg
65 (Age .? 65 years) = 1 point PO BID OR cefditoren 200 mg. PO BID for 7-14 days

• If score = 0-1 ~ additional risks (Live alone, homeless.
nursing home resident. multilobar. temp < 36°C) . consider
out- patient treatment
• If score= 0-1 ~ above additional risks. consider in-patient
1.3.2. Levofloxacin 750 mg PO Q24H x 5 days OR 500 mg PO Q24H
for 7-10 days
1.3.3. Moxifloxacin 400 mg . PO Q24H for 7-10 days
Fluoroquinolone should be carefully used in patients who probably TB cases

treatment
2. In-patient (non-ICU)
• If score > 1, consider in-patient treatment
2.1. Primary Regimens
• If criteria for severe CAP is (are) met. consider ICU admission
2.1.1. Ceftriaxone 2 gm IV Q24H OR amoxicillin/clavulanate 1.2 g. IV
Common Pathogens: Q8H OR ampicillin/sulbactam 1.5 g. IV Q6H EL.US Azithromycin
• Outpatient: S.pneumoniae. M.pneumoniae. C.pneumoniae. 500 mg IV Q24H OR Doxycycline 200 mg. PO then 100 mg PO BID
Respiratory viruses (Influenza A & B, Adenovirus. Parainfluenza.
2.2. Alternative regimens
RSV)
2.2.1. Levofloxacin 750 mg. IV Q24H
• Inpatient: S.pneumoniae. M.pneumoniae. C.pneumoniae.
2.2.2. Moxifloxacin 400 mg. IV Q24H
Gram- negative bac illi
Fluoroquinolone should be carefully use in patients who probably TB cases

Note: treat for a minimum of 5 days, and afebrile 48-72 hours with stable BP
adequate oral intake, room air 02 sat > 90% .
50 Suandok Antibiotics
Suandok Antibiotics 51

3. ICU patient (severe CAP) Regimens:

3.1. Primary Regimens Empiric antibiotics:
3.1.1 . Ceftriaxone 2 gm IV Q24H OR amoxicillin/clavulanate 1.2 g. IV 1. If MOR-pathogen (s) is/ are not suspected: Amoxycillin/ clavulanate
Q8H OR ampicillin/sulbactam 1.5 g. IV Q6H .El.l.!.S Azithromycin +ceftazidime
500 mg IV Q24H OR Doxycycline 200 mg. PO then 100 mg 2. If MOR-pathogen (s) is/ are suspected:
PO BID 2.1 Piperacillin/ tazobactam OR carbapenems
3.2. Alternative regimens 2.2 Anti-pseudomonal cephalosporins + aminoglycosides or
3.2.1. Levofloxacin 750 mg. IV Q24H anti-pseudomonal fluoroquinolones
3.2.2. Moxifloxacin 400 mg. IV Q24H 3. If MOR-A. baumanii or P. aeruginosa is susppected: colistin ±
carbapenems
3.3. Other considerations
4. If MRSA is suspected : add vancomycin
3.3.1. If Influenza is suspected: add OseltamMr 75 mg PO BID for 5 days
3.3.2. If P. aeruginosa is suspected: bronchiectasis with purulent
References:
sputum, COPD stage 4, steroid use, severe malnourished
1. Anand N. Semin Respir Grit Care Med. 2009 Feb:30( 1):3-9.
: anti-pneumococcal, anti-pseudomonal f:1.-lactams
2. Kol/et MH. Chest 2005;128:3854-3862.
(piperacillin/tazobactam, cefepime, imipenem/cilastatin,
3. Micek ST. Antimicrob Agents Chemother 2007;51:3568-3573
meropenem. doripenem) .El.l.!.S azithromycin QE respiratory
4. ATS/IDSA guideline. Am J Respir Grit Care Med 2005; 171 :388-416
fluoroquinolones
3.3.3 If 8 . pseudomallei is suspected: ceftazidime 2 gm IV Q8H
Hospital-acquired pneumonia (HAP) and ventilator-associated
(OR 150 mg/kg/d ) +/- TMP-SMX (8 mg/kg/d)
pneumonia (VAP)

References: REMINDER
1. IDSNATS guideline. Clinical Infectious Diseases 2007; 44: 527-72 n~1-;ii~1,;ru1~iflnt11tljji?u::1~flfffflUfff!JJl:fflriflffff'h1ilufJti1JiiJ;/~::6ifJJ'YIMU
2. Wattanathum A. Chest 2003;123;1512- 1519 r
'!lfl~flf::U,ll?'Yltl1'!1fJJI :ff) rifl f ft 1u ullifl::Ufl{rJw1u ffJfltl1 U1fl I itfJJ~,n l,ffJUU? ti
3. Reechaipichitkul W. Southeast Asian J Trap Med Public Health 2 005; 36: t11'7ryfl,fjfnffJJ uE{uw?nQ111fl,fjfMrn UflUU?t1t11'7ryifflt1nff1J •
156-61 l,ffl{uw?nQ/111'fltlnff1Jl,fff)l,ffJ&U?tJiru '}tif11Jif::U,fl?'Yltl1'!1fJJ1:fflriflffftl1i1JT11J
4. flU'11'1/.JfJ71?'11'8'1 i.i.Jth::ml'f1rm.11 u?m.Jm1fm:t1fuulf1'1tJntfllll/.J'111Jiu ft?Wl?llifJt11tljji?u::R11i1Jn1J ,itf)J,i?tljjft?WUlllnlli,Jnu1ut1n'l,ff11::#u11u'!lfJJU
1h::ml'f1m1 (tforfll11'1u{I/) n;.Jmr1:1flflwm1iimf. 2544 UWUfl::IR111rum-;1,i't1,tljji?u::1uufJurJwifu 'I •
rt'!~~ • ..,. ..,. ~ • "
~IJ?'Yl1JIJ fl~fl'Yl1'!11JUIJflUJ1TJ'!lfl~fl'!lflm1flf?JJ'YIJffJfltl1U1fl;Jfl1~7,J,r::nflTJ
Healthcare-associated pneumonia (HCAP) Mf::U,fl?'Yltl1'!1fJJUllifl::Ufl{U?tJfJti,Jun~iJ fffll::ti1J11J?,,iiiu1J?'Yl1J'!lfJW1
tljji?
•
u::;/,t?fii~1,;ru11ifln1,iiJu fl'YIVUflUflUU? t111iflJl'i1 uJOJ'DflJJfl #u«11J'!lflJ
... -' ., ., ., ., 'J
NOTE: HCAP is included in the spectrum of CAP with increased risk of GNB U/llfl::UfJf!UW'YIH1U!JUflf)t ;J~::ti11iims-1'1it11tljji?u::1nf1tls-::ft1'!1Ul1Jflfl.fJ111'fJ
both susceptible or MOR-pathogens e.g. P. aeruginosa, A. baumannii, or {rJWUfl::UfJJT11Jn1flnfl1iflffJt111UfllJ1ft/11 •
ESBL-producing enterobacteriaceae. HCAP should be suspected in patient
who was hospitalized in an acute care hospital .? 2 days within 90 days of NOTE:
the infection; resided in a nursing home or long-term care facility; received 1. Must meet the following criteria
recent intravenous antibiotic therapy, chemotherapy, or wound care within • Onset .? 48 hours after hospital admission
the past 30 days of the current infection; or attended a hospital or • New or worsening pulmonary infiltration on CXR (no change or normal in
hemodialysis clinic. ventilator-associated tracheobronchitis)
52 Suandok Antibiotics
Suandok Antibiotics 53

• Present of at least two of the following Cha pter 6.9: Skin, soft-tissue, and bone and joint infections
o Temp > 38 ·c or < 36 ·c Cellulitis
o WBC > 12,000/mm' or < 4,000/mm'
Empiric Treatment
o Purulent sputum
In case of community-acquired MRSA is not considered, such as our community
2. Obtain lower respiratory tract (LRT) specimens for Gram stain and culture
• Dicloxacillin 250-500 mg PO QID OR
with drug sensitivity testing (DST) before starting antibiotics
• Cloxacillin 500 mg. PO QID OR
3. Start empiric antibiotic (s) as soon as possible and within 1 hour if septic
• Cephalexin 250-500 mg PO QID
shock
4 . Serial evaluate clinical responses and de-escalation of antibiotic once
The following regimens include coverage for MSSA, community-acquired
culture and DST results are available
MRSA and streptococci:
Oral Regimens
Common Pathogens*: Common organisms at Maharaj Nakorn Chiang Mai
• Clindamycin 300 mg PO TIO OR
hospitals are A.baumanii, P.aeruginosa, MRSA, ESBL-producing GNB (i.e.
• TMP/SMX 1- 2 DS tab PO BID .E.i.JJ..S Amoxicillin 500 mg PO TIO* OR
K.pneumoniae, E.coli and Enterobacter spp .) and S.maltophilia Although
• Doxycycline 100 mg PO BID E!.J..!.S Amoxicillin 500 mg PO TIO*
treatment could be given as monotherapy, combination treatment may be
*TMP/SMX, Doxycycline have poor activity against Group A streptococci.
more effective in sicker patient (i.e. hemodynamic instability) or neutropenia.

Parenteral regimens
Regimens
• Clindamycin 600 mg IV Q8H (mild disease) OR
Could be one or combination of the following antibiotics
• Cloxacillin 1g IV Q6H OR
1) Carbapenems: imipenem/cilastatin, meropenem, doripenem
• Vancomycin 1 g IV Q 12H (moderate to severe disease or nosocomial
(see page 67 for dosage)
acquisition) if MRSA is considered
2) Vancomycin if MRSA is suspected e.g. Gram-positive cocci in cluster
Duration: 7-10 days
found in sputum Gram stain, previous infected or colonized with MRSA
(see page 87-89 for dosage)
Other causes of cellulitis in select patient populations
3) Colistin if suspected MOR-A. baumannii or P. aerugiosa
• With bullae. vesicles, and ulcers after exposure to seawater or raw oysters,
(see page 7 for dosage)
consider Vibrio vulni~cus, especially in patients with liver disease. Rare,
but rapidly fatal if untreated. Treat with Ceftriaxone 2 g IV Q24H l:LJ.&.
References:
Doxycycline 100 mg PO BID.
1. ATS/IDSA guideline. Am J Respir Grit Care Med 2005; 171:388-416
• Neutropenic, solid organ transplant, and cirrhotic patients may have
2. Johanson WG Jr. Ann Intern Med 1972, 77:701-706
cellulitis due to Gram-negative organisms. Consider expanding coverage
3. Torres A. NEJM 2004 ; 350: 433-5
in these cases.
• If eschar, consider angioinvasive organisms (GNR, aspergillosis, mold).
ID consult is recommended.
• Animal and human bites: Pasteurella multocida and Capnocytophaga
canimorsus should be covered in cat and dog bites. Treat with Amoxicillin/
c lavulanate 875/ 125 mg PO BID OR Amoxicillin/clavulanate 500/ 125 PO
TIO OR Amoxicillin/clavulanate 1.2 g IV Q8H.
• PCN allergy: Doxycycline 100 mg PO BID.
54 Suandok Antibiotics
Suandok Antibiotics 55

Diabetic foot infections

Empiric Treatment
Trea tment dep ends on clinical severity
Infection Severity Clinical Manifestations
Uninfected No purulence or inflammation•
Mild Presence of purulence and ~ 1 signs of
inflammation• and cellulitis (if present) ~ 2 ems
around ulcer limited to skin or superficial
Subcutaneous tissue
Moderate Same as mild J:LUS at least one of the following:
> 2 cm of cellulitis,
Lymphagitic streaking, spread beneath the
superficial fascia.deep tissue abscess, gangrene,
involvement of muscle, tendon, joint, or bone
If patient at risk for MRSA, add Vancomycin to regimens that do not include
Clindamycin.
Risk factors for MRSA
• History of colonization or infection with MRSA
• Recent (within 3 months) or current prolonged hospitalization > 2 weeks
• Injection drug use
Severe Infections
• Pipercillin/tazobactam 4.5 g IV Q6H OR
• Clindamycin 900 mg IV QBH EU& Ciprofloxacin" 400 mg IV QBH
• Avoid fluoroquinolones in patients who were on them as outpatients.
If patient at risk for MRSA (see above)
• Antipseudomonal ~-lactams .Ell& Vancomycin 1 g IV Q12H OR
• Vancomycin 1g IV Q12H .Ell& Ciprofloxacin• 400 mg IV QBH .Ell&
Metronidazole 500 mg IV QBH

Severe Any of above J:LUS systemic toxicity or • Avoid fluoroquinolones in patients who were on them as outpatients.
metabolic instability Duration

•ery1hema, pain, tenderness, warmth, induration • Duration of treatment will depend on rapidity of response and presence of
adequate blood supply.

Mild Infections • Likely need shorter treatment with adequate surgical intervention (7-10 days
Oral regimens post-op) and longer for osteomyelitis.
• Cephalexin 500 mg PO QID OR • Change to oral regimen when patient is stable.
• Cloxacillin 500 mg PO QID OR TREATMENT NOTES
• Dicloxacillin 250-500 mg PO QID OR Management
• Clindamycin 300 mg PO TIO (cover MRSA) OR • Consider necrotizing fasciitis in patients who are severely ill.
• Amoxicillin/clavulanate 875/ 125 mg PO BID • Antibiotic therapy should be narrowed based on culture results .
Parenteral regimens Microbiology
• Clindamycin 600-900 mg IV QBH (covers MRSA) OR • Cellulitis without open wound or infected ulcer, antibiotic naive:
• Cloxacillin 1 g IV Q4H OR beta-hemolytic streptococci, S.aureus
• Cefazolin 1 g IV QBH • Infected ulcer, chronic or previously treated with antibiotics: S.aureus,
beta-hemolytic streptococci, Enterobacteriaceae
Moderate Infections . •
• Clindamycin 600 mg IV QBH OR 300 mg PO TIO .Ell& Ciprofloxac1n • Exposure to soaking, whirlpool, hot tub: usually polymicrobial, may involve
Pseudomonas
500 mg PO BID OR Ciprofloxacin• 400 mg IV 012H
• Ceftriaxone 2 g IV Q24H J:LUS Metronidazole 500 mg IV QBH OR • Chronic wounds with prolonged exposure to antibiotics: aerobic
Metronidazole 500 mg PO TIO Gram-positive cocci (GPC), diptheroids, Enterobacteriaceae, other
• Avoid fluoroquinolones in patients who were on them as outpatients Gram-negative rods (GNR) including Pseudomonas spp.
• Necrosis or gangrene: mixed aerobic GPC and GNR, anaerobes
 Suandok Antibiotics 57
56 Suandok Antibiotics

Other management issues

Diagnosis - Many advocate that ALL infected wounds be explored both to debride
• Culture of the ulcer base after debridement can help guide therapy. and to assess depth of involvement.
• Biopsy of unexposed bone is NOT recommended. Avoid swabbing non • Superlicial infections may be adequately treated with debridement alone.
debrided ulcers or wound drainage. • Deeper infections (cellulitis, pannicullitis) need adjunctive antibiotics.
• Ulcer floor should be probed carefully. If bone can be touched with a metal • Infections that extend to the fascia should be managed as necrotizing
probe then the patient should be treated for osteomyelitis with antibiotics fa sciitis.
in addition to su rgical debridement. • Patients with hypotension should have their wounds explored even if they
• Plantar fasciitis and a deep foot-space infection can be present. Consider are unremarkable on physical exam.
imaging to look for deep infections.
Serious. deep-tissue infections (necrotizing infections of skin. fascia.
• Putrid discharge is diagnostic of the presence of anaerobes.
and muscle)
Duration
THESE ARE SURGICAL EMERGENCIES! ANTIBIOTICS ARE ONLY AN
• Duration of treatment will depend on rapidity of response and presence of
ADJUNCT TO PROMPT DEBRIDEMENT!
adequate blood supply
ID should also be consulted
• Likely need shorter treatment with adequate surgical intervention (7-10 days
post-op) and longer for osteomyelitis. Empiric Treatment (adjunct to surgery)
• Change to oral regimen when patient is stable. • Ceftriaxone 2 g IV OD E.Ll.!..S. Clindamycin 600-900 mg IV Q8H OR
Metronidazole 500 mg IV Q8H
Reference:
• If resistant-gram negative rods is suspected: Piperacillin/tazobactam 4.5 g
IDSA Guidelines: Clin Infect Dis 2004;39:885-910.
IV Q6H E.Ll.!..S. Clindamycin 600-900 mg IV Q8H
• Post-surgical procedures:
Surgical-site infections (SSI)
Vancomycin 1g IV Q12H E.Ll.!..S. Piperacillin/ tazobactam 4.5 g IV Q6H
Empiric Treatment • Non-severe PCN allergy: Cefepime 1 g IV Q8H E.Ll.!..S. Clindamycin
Infections following clean procedures (e.g . orthopedic joint replacements, 600-900 mg I~ Q8H OR Carbapenems (imipenem/cilastatin, meropenem)
open redu ction of closed fractures, vascular procedures, median sternotomy, Note: mnLi'.lumtil'l~iu P.aeruginosa 1'ii Cefepime 2 gm IV Q8H
craniotomy, breast and hernia procedures) • Severe PCN allergy: Vancomycin 1 g IV Q12H E.Ll.!..S. Ciprofloxacin 400 mg
• Cloxacillin 1-2 g IV Q4H OR IV Q8H E.Ll.!..S. Clindamycin 600-900 mg IV Q8H
• Cefazolin 1 g IV Q8H OR
TREATMENT NOTES
• PCN allergy: Clindamycin 600 mg IV Q8H
Pyomyositis
• Involvement of hardware: Vancomycin 1 g IV Q12H
• S.aureus most commonly
• Clostridial myonecrosis-C/oslridia spp.(esp. C. perfringens)
Infections following contaminated procedures (G I/GU procedures,
• Group A streptococcal myonecrosis
oropharyngeal procedures. obstetrical and gynecology procedures)
Fascitis
• Piperacillin/tazobactam 4.5 g IV Q6H ± Vancomycin if hardware present or
• Type 1 - Polymicrobial infections with anaerobes, streptococci and Gram-
MRSA suspected OR
negative rods (Fournier's gangrene is a type 1 necrotizing fasciitis of the
• Non severe PCN allergy: Cefepime 1 g IV Q8H E.Ll.!..S. Metronidazole 500 mg
perineum)
IV/PO Q8H ± Vancomycin if hardware present or MRSA suspected
• Type 2 - Group A streptococci predominate
Note: mm1h.11,11til'l~iu P.aeruginosa 1'ii Cefepime 2 gm IV Q8H
• Cases of fasciitis caused by community-associated MRSA strain s have
• Severe PCN allergy: Vancomycin 1 g IV Q12H E.Ll.!..S. Ciprofloxacin 400 mg
been reported
IV Q8H E.Ll.!..S. Metronidazole 500 mg IV/PO Q8H
58 Suandok Antibiotics Suandok Antibiotics 59

Diag nosis
• Can be difficult - gas production is not universal and is generally absent in
streptococcal diseases.
• Maintain high index of suspicion when:
• Patients are very ill from cellulitis (hypotension, toxic appearance)
• Pain out of proportion to physical findings
• Anesthesia over affected area
• Risk factors such as skin necrosis or bullae
• Putrid discharge with thin, "dishwater"pus
Vertebral osteomyelitis. diskitis epidural abscess
NOTE: In absence of bacteremia, clinical instability, or signs and symptoms
of spinal cord compromise strong consideration should be given to withholding
• Emergent surgical consultation is recommended for patients with signs
and symptoms of spinal cord compromise.
• Surgical therapy is preferred in many cases of epidural abscess/
osteomyelitis (e.g.extensive infection, pre-vertebral abscess, spine instability,
hardware involvement). CT-guided aspiration and/or antibiotic therapy
alone may be considered in some circumstances. Discussion with infectious
diseases and surgery is recommended to optimize management.
• Patients should have frequent assessment of neurologic function, particularly
at the time of initial presentation.
• All patients require monitoring for adequate response throughout the
treatment course.
Duration

antibiotics until samples of abscess or bone can be obtained for Gram-stain • Epidural abscess without osteomyelitis : 4-6 weeks
and culture . • Vertebral osteomyelitis ± epidural abscess: 6-12 weeks
• In patients with hardware present prolonged oral suppressive therapy is
generally required after completion of IV antibiotics; these decisions
Empiric Treatment
should be made in consultation with infectious diseases.
• Ceftriaxone 2 g Q12H OR
• Severe PCN allergy: Clindamycin 600-900 mg IV Q8H OR Ciprofloxacin References:

400 mg IVQ8H 1. Spinal epidural abscess: N Engl J Med 2006;335:2012-20.

• Narrow therapy based on culture results. 2. Spinal epidural abscess: Q J Med 2008; 1O1: 1-12.

TREATMENT NOTES Septic arthritis

Microbiology Empiric Treatment

• Gram-positive cocci in 75% of cases with majority S. aureus • Depends on clinical manifestations, underlying diseases, and gram stain
• Gram-negative rods in - 10% of synovial fluid analysis

Management
Gram stain/Organ ism Treatment
• Obtain two sets of blood cultures, ESR, and CRP prior to starting antibiotic
therapy. Gram positive cocci in cluster; • Cloxacillin 2 g IV Q4 - 6 H
• Most intravenous drug users and patients without significant co-morbidities S. aureus (8- 12 g/ day) QB
do not require empiric coverage for Gram-negative rods. • Cefazolin 1 g IV Q6H
• Empiric Gram-negative coverage should be used in patients with diabetes, Sellere ect::i alle[Oll
hardware inplace or recent surgery, and recurrent urinary tract infection. • Clindamycin 600 mg IV Q6H
• If blood cultures are negative, CT guided needle biopsy/aspi ration should eatieot bas [isl\ faQIO[ fo[ MB.SA
be obtained for Gram stain and culture. • Vancomycin 1 g IV Q1 2H
58 Suandok Antibiotics Suandok Antibiotics 59

Diagnosis • Emergent surgical consultation is recommended for patients with signs

• Can be difficult - gas production is not universal and is generally absent in
streptococcal diseases.
• Maintain high index of suspicion when:
• Patients are very ill from cellulitis (hypotension, toxic appearance)
• Pain out of proportion to physical findings
• Anesthesia over affected area
• Risk factors such as skin necrosis or bullae
• Putrid discharge with thin, "dishwater"pus
Vertebral osteomyelitis. diskitis. epidural abscess
and symptoms of spinal cord compromise.
• Surgical therapy is preferred in many cases of epidural abscess/
osteomyelitis (e.g.extensive infection. pre-vertebral abscess. spine instability,
hardware involvement). CT-guided aspiration and/or antibiotic therapy
alone may be considered in some circumstances. Discussion with infectious
diseases and surgery is recommended to optimize management.
• Patients should have frequent assessment of neurologic function, particularly
at the time of initial presentation .
• All patients require monitoring for adequate response throughout the
treatment course.

NOTE: In absence of bacteremia, clinical instability, or signs and symptoms

Duration
of spinal cord compromise strong consideration should be given to withholding
• Epidural abscess without osteomyelitis : 4-6 weeks
antibiotics until samples of abscess or bone can be obtained for Gram-stain
• Vertebral osteomyelitis ± epidural abscess: 6-12 weeks
and culture.
• In patients with hardware present prolonged oral suppressive therapy is
generally required after completion of IV antibiotics; these decisions
Empiric Treatment should be made in consultation with infectious diseases.
• Ceftriaxone 2 g Q12H OR
References:
• Severe PCN allergy: Clindamycin 600-900 mg IV QBH OR Ciprofloxacin
1. Spinal epidural abscess: N Engl J Med 2006;335:2012-20.
400 mg IV QBH
2. Spinal epidural abscess: Q J Med 2008; 101 : 1-12.
• Narrow therapy based on culture results.

Septic arthritis
TREATMENT NOTES
Empiric Treatment
Microbiology
• Depends on clinical manifestations, underlying diseases, and gram stain
• Gram-positive cocci in 75% of cases with majority S. aureus
of synovial fluid analysis
• Gram-negative rods in - 10%

Management Gram sta in/Organism T reatment

• Obtain two sets of blood cultures, ESR, and CRP prior to starting antibiotic
Gram positive cocci in cluster; • Cloxacillin 2 g IV 04 - 6 H
therapy.
S. aureus (8- 12 g/ day) QB
• Most intravenous drug users and patients without significant co-morbidities
• Cefazolin 1 g IV Q6H
do not require empiric coverage for Gram-negative rods.
• Empiric Gram-negative coverage should be used in patients with diabetes,
Se111m: ECl',l allerg~
• Clindamycin 600 mg IV Q6H
hardware inplace or recent surgery, and recurrent urinary tract infection.
eatieot bas [is~ fas;!Q[ fQ[ MBSl'.
• If blood cultures are negative, CT guided needle biopsy/aspiration should
• Vancomycin 1 g IV Q12H
be obtained for Gram stain and culture.
60 Suandok Antibiotics
Gram stain/Organism
Gram positive cocci in chain;
Streptococcus spp.
Gram positive diplococci ;
S. pneumoniae
Gram negative rod; Salmonella spp.,
P. aeruginosa, E. coli, etc.
Burkholderia pseudomallei
Gram negative cooci;
Neisseria gonorrhoeae
No organisms found
T reatment
, Penicillin G 2 - 3 mu IV Q4H
(18- 20 mU/ day) QB
• Cefazolin 1 g IV Q6H QB
• Ceftriaxone 2 g IV Q24H
Sellere penicillin allerg)I
• Clindamycin 600 mg IV Q6H
• Ceftriaxone 2 g IV Q24H QB
• Cefotaxime 1 g IV Q6H
Selle[e penicillin alle[g)I
• Levofloxacin 500 mg IV Q24H
• Ceftriaxone 2 g IV Q24H
Se'.'e[e penicillin alle[g)I
• Levofioxacin 500 mg IV Q24H
lrnrnuoocornprornised bost
(Cover P. aeruginosa)
• PiperacillinfTazobactam 4.5 gm
IVQ6H
• Ceftazidime 2 gm IV Q6-8H ±
trimethoprim (TMP)/
sulfamethoxazole (SMZ) (10 mg
/kg/day of trimethoprim dividing
Q8H) (1 vial: TMP/SMZ =
400/80 mg)..QB
• Meropenem 1 gm IV Q8H QB
• lmipenem 1 gm IV Q8H
• Ceftriaxone 2 g IV Q24H QB
• Cefotaxime 1 g IV Q8H
• Ceftriaxone 2 g IV Q24H
Suandok Antibiotics 61
Duration
• Gram positive cooci: IV antibiotic at least 2 weeks. switch to oral antibiotic
if clinical improve (total duration 4-6 weeks)
• S. aureus (hematogenous spreading) and gram negative rod : IV antibiotic
4-6 weeks for prevent relapse
• N. gonorrhoeae : IV antibiotic 7-10 days, switch to oral antibiotic if clinical
improve, e.g . ciprofloxacin (500) 1 tab PO BID OR ofloxacin 400 mg PO
OD (total duration 2-4 weeks) .
• Salmonella spp.: IV antibiotic at least 2 weeks, switch to oral antibiotic if
clinical improve (total duration 12 weeks)
• B. pseudomaflei: IV antibiotic at least 2 weeks, switch to oral antibiotic if
clinical improve. Oral antibiotics: trimethoprim/ sulfamethoxazole and/ or
doxycycline (100) 1 cap PO BID (total duration 20 weeks)
TREATMENT NOTES
• Common pathogens : S. aureus, Streptococcus spp., N. gonorrhoeae,
Salmonella spp.
• All patients should perform hemocultures and arthrocenthesis for synovial
fluid analysis before starting antibiotic
• Synovial fluid analysis: cell count, differential count. gram stain, culture
• Diagnosis: synovial fluid WBC count >50,000 cell/mm3 and neutrophil >90%
• Drainage: arthrocenthesis every day for synovial fluid analysis
• Surgical drainage: consider when no respon se in 7 days (WBC in synovial
fluid > 50% of previous treatment}, loculated effusion, difficult joints
(shoulder, hip, wrist, sternoclavicular, sacroiliac joint}, complicated with
osteomyelitis or myositis, prosthetic joint
References:
•r r f"' .. ~ v -~•7•
1. ?n>w ,111m1~. tl'l!lfl m::~n ,rn::nli1l-lLJJfifinLl'ILJlilfilL'llf1. L'llfN im:
fN~1-J>YLLl'l~i;lilJ. 2549. UU1 97-145.
2. 7Y1~111tf ~l'f?Jil.lLJM. Essential in clinical rheumatology. nim?Yl'1:
uJilni~YlnJ'YI 41ri'lil, 2555. uu1179-201 .
62 Suandok Antibiotics Suandok Antibiotics 63

Chapter 6.10: Bacterial Urinary Tract Infection Definition Empiric treatment

NOTES:
culture ~100 ,000 • Ceftriaxone 2 gm IV OD
• Signs and symptoms, the presence of a urinary catheter, and the quality
colonies Many • PCN allergy: Ciprofloxacin
of specimen collection must be considered before initiation of treatment.
patients will have 400 mg Q12H
• Collection of cultures in the absence of signs and symptoms is not
other evidence of • Duration: 7-14days
recommended .
upper tract disease Hospital onset, OR
• All recommendations below are for empiric treatment: narrow coverage
(i.e. leukocytosis, healthcare-associated , OR
based on susceptibilities.
WBC casts, or risk of MOR-
Management of patients WITHOUT a urinary catheter abnormalities upon pathogens including
imaging) ESBL-producing entero-
Category Definition Empiric treatment
bacteriaceae
Urosepsis SIRS with urinary
Asymptomatic Positive urine culture No treatment unless the • Carbapenems
source of infection
bacteriuria ~100,000 colonies patient is: (im ipenem/ci lastatin,
with no signs or • Pregnant meropenem, doripenem)
symptoms • About to undergo a • Severe PCN allergy:
urologic procedure
Ciprofioxacin 400 mg
• Post renal transplant
012H ± Aminoglycoside
• Neutropenic
(see dosing in append ix A)
Acute cystitis Signs and symptoms Uncomplicated: female,
(e .g. dysuria, no urologic abnormalities, Diagnosis
urgency frequency, no stones, no catheter Interpretation of the urinalysis (U/Al and urine culture
suprapubic pain) • Norfloxacin (400) PO • Urinalysis and urine cultures must be interpreted together in context of
AND pyuria BID for 3-5 days OR symptoms
(>5-10 WBC/HPF) • Ofloxacin 200 mg PO • Urinalysis/microscopy: Pyuria >5-10 WBC/HPF
AND positive urine BID for 3-5 days OR
• Urine cultures:
culture ~100,000 • Nitrofurantoin 100 mg
• If U/A is negative for pyuria, positive cultures are likely contamination
colonies PO BID for 5 days
• Positive cultures with pyuria are defined as ~1 .000 colonies. This cutoff is
Complicated : male the most sensitive for a true UTI. Situations in which lower colony counts
gender. possible stones, < 1000 are significant include: patients who are already on antibiotics at
urologic the time of culture, symptomatic young women, suprapubic aspiration ,
abnormalities, pregnancy and men with pyuria .
Same regimens as above
TREATMENT NOTES
except duration is 7-14
• Sterile pyuria (positive U/A, but negative urine cultures) usually requires
days
no treatment, although if the patient has received antibiotics, the patient
Acute Signs and symptoms Community onset. AND may still have a UTI. If sterile pyuria persists consider other causes (e.g.
Pyelonephritis (e .g. fever, flank no risk of MOR-pathogens interstitial nephritis or cystitis, fastidious organisms).
pain) AND pyuria including ESBL-producing
• Follow-up U/A is recommended at 48-72 hours after appropriate therapy.
AND positive urine enterobacteriaceae
64 Suandok Antibiotics Suandok Antibiotics 65

• Follow-up U/C is indicated only in those who do not response to treatment, Diag nosis
history of recurrent pyelonephritis, and pregnancy Specimen collection: The urine sample should be drawn from the catheter
port using aseptic technique , NOT from the urine collection bag . In patients
Management of patients WITH a urinary catheter with long term catheters (;,,2 weeks), replace the catheter before collecting
a specimen. Urine should be collected before antibiotics are started .
Category Definition Empiric treatm ent
Symptoms: Catheterized patients usually lack typical UTI symptoms.
Asymptomatic Positive urine culture Remove the catheter Symptoms compatible with CA-UTI include:
Bacteriuria ~100,000 colonies No treatment unless the • New fever or rigors with no other source
with no signs or patient is:
• New onset delirium, malaise, lethargy with no other source
symptoms of infec- • Pregnant
tion • About to undergo a • CVA tenderness, flank pain , pelvic discomfort
urologic procedure • Acute hematuria
NOTE: obtaining • Post renal transplant Interpretation of the urinalysis {U/Al and urine culture
routine cultures • Neutropenic Antibiotics
• Pyuria : In the presence of a catheter, pyuria does not correlate with the
in asymptomatic do not decrease
patients is not asymptomatic bacteriuria presence of symptomatic CA-UTI and must be interpreted based on the
recommended or prevent subsequent clinical scenario . The absence of pyuria suggests an alternative diagnosis.
development of UTI • Positive urine culture: ;,,1,000 colonies

Catheter associated UTI Signs and symptoms • Remove catheter Duration

(CA-UTI) (fever with no other when possible The duration of treatment has not been well studied for CA-UTI and optimal
source is the most duration is not known.
common; patients Community onset, AND • 7 days if prompt resolution of symptoms
may also have supra- no other risk of MOR-
• 10-14 days if delayed response
pubic or flank pain) pathogens, AND clinically
AND pyuria (>5--10 stable TREATMENT NOTES
WBC/HPF) AND • Ceftriaxone 2 g IV • Remove the catheter whenever possible
positive urine culture Q24H OR
• Replace catheters that have been in ;,, 2 weeks if still indicated
~1.000 colonies (see • Ciprofloxacin 500 mg
• Prophylactic antibiotics at the time of catheter removal or replacement are
information below PO BID or 400 mg IV
regarding significant Q12H (avoid in patients NOT recommended due to low incidence of complications and concern
colony counts) with prior exposure to for development of resistance.
quinolones) • Catheter irrigation should not be used routinely
• Duration: see below Treatment of Enterococci
Hospital onset, OR
• Almost all E. faecalis isolates are susceptible to Amoxicillin 500 mg PO TIO
healthcare-associated ,
OR Ampicillin 1 g IV Q6H and should be treated with these agents.
OR risk of MOR- pathogens,
OR clinically ill: For patients with PCN allergy: Vancomycin 1 g IV Q12H
• Carbepenems (imipenem • E. faecium : Vancomycin 1 g IV Q12H
/cilastatin, meropenem, Renal excretion/concentration of selected antibiotics
doripenem) Good (::>:60%): Aminoglycosides, Amoxicillin, Amoxicillin/clavulanate, Fosfomycin,
• Duration: see below
Cefazolin, Cefepime, Ciprofloxacin, Colistin, Ertapenem, Trimethoprim/
sulfamethoxazole, Vancomycin, Amphotericin B. Fluconazole, Flucytosine
66 Suandok Antibiotics Suandok Antibiotics 67

Variable (30-60%): Ceftriaxone, Linezolid {30%). Doxycycline {29-55%), Treatment based on drug susceptibility pattern (ID consult should be
Tetracycline (-60%) considered)
Poor (<30%): Azithromycin, Clindamycin, Oxacillin, Tigecycline, Antibiotic doses for MOR - normal renal function
Echinocandins, Voriconazole • Piperacillin/tazobactam: 4.5 g IV infuse over 30 minutes, and then 4.5 g IV
infuse over 3 hours Q6H
References: • lmipenem/cilastatin: 1 g IV infuse over 30 minutes, and then 1 g IV infuse
1. Pyuria and urinary catheters: Arch Int Med 2000;160:673-77. over 3 hours Q8H OR 500 mg IV infuse over 3 hours Q6H
2. IDSA Guidelines for treatment of acute uncomplicated cystitis and • Meropenem: 1 g IV infuse over 30 minutes, and then 1 g IV infuse over 3
pyelone- phritis in women: Clin Infect Dis 2010;52:e103-120. hours Q8H
3. IDSA Guidelines for treatment of CA-UT/: Clin Infect Dis 2010;50:625--03. • Doripenem: 500 mg IV infuse over 1 hour, and then 500 mg IV infuse over
4. Urinary tract infections. In: Mandell GL, Bennett JE, Dolin R, Eds. Mandell, 4 hours Q8H
Douglas, and Bennette's Principles and Practice of Infectious Diseases, 7th • Colistin: see page 7
Edition. Churchill Livingstone, 2010: 957-86.
References:
1. ESBLs and clinical outcomes. Clin Infect Dis 2006: 42; 5164.
Chapter 6.11: Resistant Gram-negative Infections 2. Current therapies for P. aeruginosa. Grit Care Clin 2008; 24:261 .
Resistant Gram-negative infections
Patients with infection or colonization with the resistant organisms listed Chapter 6.12: Candidiasis in the non-neutropenic patient
below should be placed on CONTACT precautions Oropharyngeal disease (thrush)
Initial treatment
Extended spectrum beta-lactamase (ESBL)-producing organisms • Nystatin suspension 500,000 units/5mL 4 times a day
• ESBLs are enzymes that confer resistance to all penicillins, cephalosporins, Recurrent or intractable disease
and aztreonam. • Fluconazole 100-200 mg PO once daily
• They are most commonly seen in K. pneumoniae, K. oxy1oca, E. coli, and Duration: 5-10 days
P. mirabilis, and these organisms are automatically screened by the Maharaj Esophageal candidiasis
Nakorn Chiang Mai Hospital microbiology lab for the presence of ESBLs. Initial treatment
• Risk factors for infection or colonization: recent hospitalization at an institution • Fluconazole 200-400 mg IV/PO once daily
with a high rate of ESBLs, residence in a long-term care facility and prolonged Duration: 14-21 days
use of broad spectrum antibiotics. .BeJ.aQse
Treatment • Fluconazole 400--800 mg IV/PO once daily
• Carbarpenems (lmipenem/cilastatin, Meropenem, Doripenem) should be Duration: 14-21 days
used for ALL severe infections. Candiduria
• Ertapenem can be used as de-escalation therapy. • Urinary catheter removal will resolve the candiduria in 40% of cases.
• Ciprofloxacin can be used for uncomplicated UTI if the organism is susceptible
TREATMENT
and the patient is not clinically sepsis.
Asymptomatic cystitis
Multi-drug resistant (MOR) gram-negative organisms: defined as organisms • Therapy not usually indicated
resistance to 2: 2 of the following antibiotic classes: carbapenems, • Consider in the following conditions (see regimens under "symptomatic
aminoglycosides, fluoroquinolones, penicillins. or cephalosporins. cystitis"):
68 Suandok Antibiotics Suandok Antibiotics 69

• Neutropenic patients Candidemia

• Renal transplant
• Urinary obstruction or abnormal GU tract
• When recovered in urine prior to urologic procedures
• When recovered in urine prior to surgery to implant hardware Ooints,
valves, etc.)
Symptomatic cystitis
• Fluconazole 200 mg IV/PO once daily
Duration: 7-14 days
Pyelonephritis
NOTE: Candida pyelonephritis is usually secondary to hematogenous spread
except for patients with renal transplant or abnormalities of the urogenital
tract.
• Fluconazole 200-400 mg IV/PO once daily
Duration: 14 days
TREATMENT NOTES
• Remove urinary catheter if possible.
• Therapy of candiduria in the non-neutropenic, non-ICU catheterized patient
has not been shown to be benekial and promotes resistance.
• Liposomal amphotericin B, Voriconazole, and ltraconazole are not
recommended due to poor penetration into the urinary tract.
• Echinocandins (caspofungin, micafungin, anidurafungin) penetrates poorly
in the urine, but does penetrate into renal tissue
• Amphotericin B bladder washes are not recommended.
Candida vaginitis
Initial Therapy
• Fluconazole 150 mg PO x 1 dose QB
• Clotrimazole vaginal tablet 100 mg intravaginally once daily for 7 days
Recurrent (> 4 episodes/year of symptomatic infection)
• Fluconazole 150 mg PO Q72H for 3 doses. then 150 mg a week for 6
months
• Yeast in a blood culture should not be considered a contaminant .
Epidemiology of candidemia in Maharaj Nakorn Chiang Mai Hospital from
2004 to 2009 from 138 patients.
C. tropicalis 45%, C. albicans 30%, C. parapsilosis 13%, C. krusei 4%,
C. glabrata 1%, unidentified 7%
Epidemiology of candidemia in Maharaj Nakorn Chiang Mai Hospital from
oo
2012-2013 from 1 patients
C. albicans 46%, C. tropicalis 24%, C. parapsilosis 16%, C. g/abrata 11 %,
C. krusei 1%, unidentified 2%
TREATMENT
Unspeciated candidemia
Patients who are clinically stable and have not received prjor long-term azole
the[aQy
• Fluconazole 800 mg IV/PO x 1 dose, then 400 mg IV/PO once daily
Patjents who are NOT cljnjcaUy stable due to Candidemia or have received
prior long-term azole therapy
• Amphotericin B 0.7 mg/kg IV once daily
• Echinocandins is the recommended drug class (ID consult recommended)
NOTE: Amphotericin B is highly effective against all Candida spp. except for
C. lusitaniae; however, azoles and echinocandins are favored in susceptible
strains over Amphotericin B products due to toxicity.
Candida albicans
• Fluconazole 800 mg IV/PO x 1 dose, then 400 mg IV/PO once daily
Patients who are NOT clinically stable due to candidemia or have received
prior long-term azole therapy
• Echinocandins or Amphotericin B
Patients should be transitioned to Fluconazole once stable.
Candida glabrata
• Echinocandins OR
• Amphotericin B OR
• Fluconazole 800 mg IV/PO x 1 dose, then 400 mg IV/PO once daily
70 Suandok Antibiotics Suandok Antibiotics 71

Candida krusei Endocarditis

• Echinocandins OR
• Amphotericin B OR
• Fluconazole should NEVER be used to treat infections due to C. krusei
because the organism has intrinsic resistance to Fluconazole.
Candida lusitaniae
• Fluconazole 800 mg IV/PO x 1 dose, then 400 mg IV/PO once daily
C. lusitaniae is resistant to Amphotericin B in approximately 20% of cases.
Candida parapsi/osis
• Fluconazole 800 mg IV/PO x 1 dose, then 400 mg IV/PO once daily
Candida tropicalis
• Fluconazole 800 mg IV/PO x 1 dose, then 400 mg IV/PO once daily
Duration
• 14 days following documented clearance of blood cultures and clinical
symptoms (14 days after last negative hemoculturs)
• Patients with persistent candidemia and/or metastatic complications (e.g.
endophthalmitis, endocarditis) need a longer duration of therapy and
evaluation by Ophthalmology and ID.
Non-pharmacoloqic management
• Removal of all existing central venous catheters is highly recommended.
• Patients should have blood cultures once weekly until candidemia is
cleared.
• Patients should have an ophthalmologic examination to exclude candidal
endophthalmitis.
• Echocardiography can be considered if the patient has persistent candidemia
on appropriate therapy
Endophthalmitis
• Management in conjunction with Ophthalmology
• Due to poor CNS and vitreal penetration, treatment with echinocandins is
NOT recommended.
Preferred therapy
• Amphotericin B 1 mg/kg IV once daily
Alternate therapy
• Fluconazole 400-800 mg/kg IV/PO once daily
Duration: 4-6 weeks
Consultation with ID and Cardiac Surgery is recommended . Surgical valve
replacement is considered a critical component for cure. If the patient is
not a candidate for surgery then life-long Fluconazole suppression is likely
required.
Preferred therapy
• Amphotericin B 1 mg/kg IV once daily
Alternative therapy
• Echinocandins
Duration: 6 weeks or longer
References:
IDSA Guidelines for Treatment of Candidiasis: Clin Infect Dis 2009;48:503-535.
Chapter 6.13: Febrile neutropenia
Neutropenic fever
NOTE: These guidelines were developed for use in BMT, leukemia, and
chemotherapy-induced neutropenic patients, and may not be fully applicable
in other instances e.g. drug induced agranulocytosis or HIV-infected patients.
Definitions
• Neutropenia: ANC < 500/mm' or an ANC that is expected to decrease to
< 500/mm3 during the next 48 hours
• Fever: Temp > 38.0° C sustained over 1-h period OR a single measurement
of Temp > 38.3°C
Common Bacterial Pathogens in Patients with Hematologic Malignancies
who developed Febrile Neutropenia at Maharaj Nakorn Chiang Mai Hospital
(2005-2009)
• 20-25% of febrile neutropenic episodes had positive hemocultures
, 74.5% grew Gram-negative bacteria, 19.6% grew Gram-positive bacteria
• Gram-negative bacteria: E.coli (20.4%), ESBL-producing E. coli (13.7%),
K. pneumoniae (7.8%), ESBL-producing K. pneumoniae (2%), Aeromonas spp.
(13.7%), P. aeruginosa (5.9%)
• Gram-positive bacteria: S. viridians (5.9%), S. pneumoniae (3.9%),
S. aureus (MRSA) 3.9%, S. epidermidis (2.0%)
72 Suandok Antibiotics Suandok Antibiotics 73

TREATMENT
Initial fever
• A: Piperacill in/tazobactam 4.5 g IV Q6H OR
• B: Cefoperazone/sulbactam 1.5-2 g IV Q8-12 H (1.5 g if 1 vial contains
cefoperazone 1000 mg/sulbactam 500 mg, 2 g if 1 vial contains cefoperazone
500 mg/ sulbactam 500 mg) EL!..!.S. Amikacin (see page 86) OR
• C: Ceftazidime 2 g IV Q8H ELJ..!.S. Amikacin (see page 86) OR
• D: Carbapenems (imipenem/cilastatin , meropenem , doripenem) if the
patient is HYPOTENSIVE or otherwise unstable, or has a history of
ESBL-producing enterobacteriaceae infection in the prior 90 days OR
Severe PCN allergy:
• E: Ciproffoxacin 400 mg IV Q8H ELJ..!.S. Amikacin (see page 86)
NOTES:
• Consider adding Vancomycin if 1) a serious CRBSI is suspected (e.g., there
is warmth and redness at the catheter site). QB 2) a history of infection or
colonization with MRSA or Penicillin 8NQ Cephalosporin-resistant
S. pneumoniae, QB 3) severe mucositis is presented.
• Always modify antibiotics according to culture results and/ or infection site.
NOTES:
• Consider adding Vancomycin if it is not added in the current regimen and if
1) a serious CRBSI (e.g., there is warmth and redness at the catheter site)
is suspected, QB 2) severe mucositis is presented , QB 3) patient has a
history of previous MRSA infection or colonization .
For patients who remain febrile or develop a new fever after 72-96 hours
on both antibacterial agents AND Amphotericin B ("persistent fever or third
fever"):
Option 1: Add Vancomycin if it is not added in the first regimen and if 1) a
serious CRBSI (e.g., there is warmth and redness at the catheter site) is
suspected, QB 2) severe mucositis is presented , QB 3) patient has a history
of previous MRSA infection or colonization .
Option 2: Continue current regimen (some patients will take longer to
defervesce)
Option 3: Adding metronidazole if C. difficile infection is suspected
TREATMENT NOTE
• Antibiotics should ALWAYS be narrowed based on positive cu ltures .

For patients who remain febrile or develop a new fever after 72-96 hours on
antibiotics above ("persistent fever or second fever"):
Documented infection
• Review antibiotic coverage for adequacy of dosing and spectrum
• Examine and re-image for new or worsening sites of infection
• Consider addi ng empiric antifungal therapy

unexplained fever
Option 1: If patient is not receiving regimen D: change to regimen D ±
• Amphotericin B 0.5-0 .7 mg/kg IV Q24H for patients with a history of
neutropenia :ilQ..Qays and without evidence of fungal infection QB
• Amphotericin B 1.0 mg/kg IV Q24H for patients with a history of neutropenia
~ or evidence of fungal infection

Option 2: If patient is receiving regimen D:

• Continue regimen D and AQQ
• Amphotericin B 0.5-0 .7 mg/kg IV Q24H for patients with a history of
neutropenia :ilQ..Qays and without evidence of fungal infection QB
• Amphotericin B 1.0 mg/kg IV Q24H for patients with a history of
neutropenia > 10 days or evidence of fungal infection
74 Suandok Antibiotics Suandok Antibiotics 75

H3Mffl#j Guideline~
Prophylaxis
for the Use of Antimicrobial Procedures Agents

Vascular and cardiac Cefazolin

surgery Cloxacillin
7 .1 Antibiotic prophylaxis for surgical procedures PCN allergy: Clindamycin OR Vancomycin
Pacemaker/ ICD Cefazolin
Drug Usual dose Re-dosing during procedure placement PCN allergy: Clindamycin OR Vancomycin
from initiation of preoperative
Thoracic, Cefazolin, ampicillin/sulbactam
dose
non-cardiac su rgery PCN allergy: Clindamycin OR Vancomycin
Ampicillin 2g 2 Total joint replace- Cefazolin
ment PCN allergy: Clindamycin OR Vancomycin
Cefazolin 1-2g Q4H (Q2H for cardiac surgery)
Urologic procedures Lower tract instrumentation with risk for infections:
Cefoxitin 1-2g Q2-3H Ciprofloxacin, Cefazolin
PCN allergy: Aminoglycoside ± Clindamycin
Amoxicillin/Clavulanate 1-2 g QBH Clean without entry into urinary tract:
Cefazolin ± Gentamicin (if placement of
Clindamycin 900 mg Q6H
prosthetic material)
Ciprofloxacin 400 mg Q12H PCN allergy: Clindamycin ± Aminoglycoside
Clean with entry into urinary tract:
Gentamicin 5 mg/kg None Cefazolin ± Gentamicin (if placement of
prosthetic material)
Metronidazole 500 mg None Clean-contaminated:
Cefazolin el.US Metronidazole, Cefoxitin
Vancomycin 1g None PCN allergy: Ciprofloxacin el.US Metronidazole or
Clindamycin
Important notes
Neurosurgery Cefazolin
• Timing is crucial . Antibiotics must be in the skin when the incision is PCN allergy: Clindamycin OR Vancomycin
made to be effective. They should be given NO more than 1 hour before
General surgery
the procedure .
• Cephalosporins can be administered over 3--5 min IV push just before the Inguinal hernia repair Cefazolin
(hernioplasty and PCN allergy: Clindamycin OR Vancomycin
procedure and will achieve appropriate skin levels in minutes.
hernioorhaphy)
• Vancomycin and Ciprofloxacin must be given over ONE HOUR and must
be COMPLETELY infused before the incision is made. Percutaneous Cefazolin OR Cefoxitin OR Arnoxicillin/Clavulanate
esophagogastrostomy PCN allergy: Clindamycin ± Gentamicin
• Clindamycin should be infused over 10-20 min. (PEG)
• Antibiotic prophylaxis should be discontinued within 24 hours after the
Gastrectomy/ Amoxicillin/Clavulanate, Cefoxitin
end of surgery, EXCEPT for cardiac surgery where 48 hours after the end
hepatectorny/ PCN allergy: Clindamycin ± Gentamicin
of surgery is acceptable. cholecystectomy
Liver transplantation Cefotaxime+Ampicillin
PCN allergy: Clindamycin or Vancornycin +
Ciprofloxacin or Gentarnicin
Reference:
Bratz/er OW. Am J Health-Syst Pharm 2013; 70: 195-283.
76 Suandok Antibiotics Suandok Antibiotics 77

Procedures Agents Indication Agent and dose Duration

Small bowel or colon Amoxicillin/Clavulanate, Cefoxitin PCP prophylaxis First line: TMP/SMX one SS tablet 6 Months
surgery PCN allergy: Metronidazole OR Clindamycin PO daily
E.LJ.!S Aminoglycoside, Second line: Dapsone 100 mg PO daily
OR Quinolone
Acute rejection treated with Thymoglobulin or Muromonab (OKT3)
Whipple procedure or Amoxicillin/Clavulanate, Cefoxitin
pancreatectomy PCN allergy: Clindamycin E.Ll.!S Ciprofloxacin Anti-viral prophylaxis (CMV, HSV, VZV)

Appendectomy Amoxicillin/Clavulanate, Cefoxitin CMVD-/R- Acyclovir 400 mg PO BID OR 3 Months

(uncomplicated}, PCN allergy: Clindamycin E.Ll.!S Gentamicin Valacyclovir 500 mg PO BID
if complicated or
perforated , treat as CMV D+ or D-/R+ Valganciclovir* 450 mg PO daily 3 Months
secondary peritonitis
CMVD+/R- Valganciclovir* 900 mg PO daily 3 Months
Penetrating abdomi- Amoxicillin/Clavulanate, Cefoxitin
PCP prophylaxis First line: TMP/SMX one SS tablet 3 Months
nal trauma PCN allergy: Clindamycin E.LJ.!S Gentamicin
PO daily Second line: Dapsone*
Hysterectomy Ampicillin/Gentamicin 100 mg PO daily
Amoxicillin/Clavulnate
Liver transplants
Cefoxitin
Cefazolin Anti-viral prophylaxis (CMV, HSV, VL'./)
Complicated : Cefazolin E.Ll.!S Metronidazole
PCN allergy: Ciprofloxacin E.Ll.!S Clindamycin , CMV D-/R- Acyclovir 400 mg PO BID OR 3 Months
Ciprofloxacin E.Ll.!S Metronidazole Valacyclovir 500 mg PO BID

CMV D+ or D-/R+ Valgancyclovir* 450 mg PO daily 3 Months

7 .2 Prophylactic antimicrobials for patients with solid organ transplants
CMVD+/R- Valgancyclovir* 900 mg PO daily x 6 Months
NOTE: All doses assume normal renal function; dose modi~cations may be 3 months then Valganciclovir 450
indicated for reduced CrCI mg PO daily x 3 months

Anti-fungal prophylaxis Fluconazole 400 mg PO daily 6 Weeks

Indication Agent and dose Duration
PCP prophylaxis TMP/SMX one SS tablet PO daily 12months
Kidney
D = donor, R =recipient, (-)= seronegative , (+) = seropositive
Anti-viral prophylaxis (CMV, HSV, VL'./)
NOTES
CMV D-/R- Acyclovir 400 mg PO BID OR 3 Months TMP/SMX therapy reduces risk of infection with Listeria spp. , Nocardia spp.,
Valacyclovir 500 mg PO BID
and Toxoplasmosis, but does not eliminate risk.
CMV D+ or D-/R+ Valgancyclovir* 450 mg PO daily 3 Months *If Valganciclovir is stopped prior to recommended duration of therapy
due to intolerance, recommend initiation of Acyc lovir or Valacyclovir for
CMV D+/R- Valgancyclovir* 900 mg PO daily 6 Months
antiviral prophylaxis .
Anti-fungal prophylaxis
 78 Suandok Antibiotics Suandok Antibiotics 79

@@@:i Infection Control - After contact with inanimate objects in the immediate vicinity of the
patient.
Infection Control and Hospital Epidemiology • Use soap and water upon exiting the room of a patient with C. dif~ci/e
• Infection control unit is located on 7th floor of Boonsom Martin building, infection (to remove spore)

phone# 5714 • No artikial fingernails are permitted for any staff member who has patient
• Office hours are Monday-Friday, 8:30 a.m. to 4:30 p.m. contact or handles sterile supplies .
• After office hours, nurse administrative superviser is served as infection
control nurse, and can be reached by phone# 081-5682230 Maharaj Nakorn Chiang Mai Hospital : Precautions Categories
• IC Web site (www.med.cmu .ac.th/etc/icc/2012/index.php/report) for IC These precaution categories must be used in addition to Standard Precautions.
policies, manuals, exposure guidelines, and surveillance information The following table includes general requirements for precaution categories.
The complete table and the type of isolation requ ired for each organism is
Infection control precautions
available at IC website.
Standard Precautions
If recommendations on this table cannot be followed, please contact IC unit
All employees are required to follow Standard Precautions for patients care;
• Routine hand hygiene by means of hand rubbing or hand washing
• Appropriate use of personal protective equipment (PPE) i.e. gloves, mask, Contact Droplet Airborne
eye protection or face shields based on the assessment of risk to healthcare Precautions Precautions
personnel exposure and cross infections among patients. Precautions
• Respiratory hygiene and cough etiquette Isolation I Required unless Required unless Required
• Strict adherence to occupational safety requirements single room cohorted cohorted
• Regular cleaning of environmental surfaces
Door closed No No Yes
• Bag contaminated linen at point of use
• Ensure safe waste management Mask/Eye No If within 3-6 feet of N95** to
• Routine cleaning of patient-care equipment Protection patient enter room

Gown and To enter room To enter room No

Hand hygiene Gloves
• Hand hygiene measures are the single most important strategy for
Examples Multidrug-resistant Influenza. pertussis. TB,
preventing healthcare-associated infections.
pathogens* e.g . pharyngeal measles,
• If hands are not visibly soiled, then alcohol-based hand sanitizers are
MRSA, MOR-Gram- diphtheria, mumps, disseminated
recommended for cleaning. If hands are visibly soiled, washing hands negative, VRE, German measles zoster***
with soap or antiseptics and water for 10-15 seconds. zoster, scabies (Rubella) Neisseria
• Hand hygiene is required meningitidis for the
- Before and after any direct patient contact and between patients, first 24 hou rs of
antimicrobial therapy,
whether gloves are worn.
- Before handling an invasive device Group A streptococci
- After touching blood, body fluid , secretions, excretions for the first 24 hours
- During patient care, when moving from a contaminated to a clean of antibiomicrobial
therapy
body site of the patient

··-----------------------------------11--~'··~.;...__________....::::::::::::r:::::
80 Suandok Antibiotics Suandok Antibiotics 81

NOTE: 5. Diphtheria
*HCWs who are varicella-immune do not have to wear N95 if patient is in 6. Japanese Encephalitis
isolation for zoster or chickenpox 7. Dengue hemorrhagic fever
**Multidrug-resistant pathogens require contact and cohort unit. To remove 8. Food poisoning outbreak
from isolation precautions, please contact IC unit If VRE (vancomycin-resistant 9. Meningococcal meningitis
enterococci) or carbapenems-resistant enterobacteriaceae (CRE) e.g. 10. Rabies
E. coli, Klebsiella spp is documented, contact IC unit immediately and ID unit 11 . Streptococcus suis
consult is mandatory 12. Acute severely ill or death of unknown infection
***Disseminated zoster, zoster in an immunocompromised host, and chickenpox 13. Cluster of diseases with unknown etiology
require both contact and airborne precautions (see page 79) 14. Severe Adverse Event following lmmunization(AEFI)

Bloodborne pathogen exposures (needlestick or other exposure)

The prompt treatment of injuries and exposures is vital to prevent the
Disease-specific infection control recommendations
transmission of disease. Whatever the exposure, IMMEDIATE cleaning of the
Creutzfeldt-Jakob disease (CJD)
exposure site is the first priority.
, Skin wounds should be cleaned with soap and water and appropriate CJD , variant CJD and other diseases caused by prions are resistant to a number

antiseptic of standard sterilization and disinfection procedures. Iatrogenic transmission

• Mucous membranes should be flushed thoroughly with water of CJD has been associated with percutaneous exposure to medical instruments
c ontaminated with prion/central nervous system (CNS)
• Eyes should be irrigated with a liter of normal saline
After cleaning the exposure site, call 5714 tissue residues, transplantation of CNS and corneal tissues and recipients

• HCWs are required to report 7500, 7500/1 needlestick/ sharp injury report of human growth hormone and gonadotropin. Transmission of CJD has not
been associated with environmental contamination or from person-to-person
form
via skin contact.
• Injury site examination by physician
• Consult ID physician for post-exposure management
Infection control
Communicable diseases-exposures and reporting
The following additional precautions must be made when processing equipment
IC should be notified:
that could be contaminated with prion related material:
• If HCWs are exposed to a communicable disease (i.e. meningococcal
• Notify IC unit immediately of any suspected or confirmed CJD case.
disease, varicella, TB etc .)
• Use disposable equipment whenever possible.
• About any unusual occurrence of disease or cluster, particularly diseases
• Label all laboratory and pathology requisitions as suspected CJD and
that have potential to expose many susceptible individuals
notify the lab before sending specimens.
• Suspicion or diagnoses of the following communicable diseases are
• The following are considered highly infective and should be handled with
required to report IC unit immediately (5714 or 5724)
extreme c aution: brain , spinal cord, optic tissues and pituitary gland
1. Anthrax
• The following are considered to be of lower infectivity: CSF, kidney, liver,
2. Acute flaccid paralysis (AFP) i.e. poliomyelitis
lung , lymph nodes, spleen, placenta, tonsillar tissue and olfactory tissue .
3. Atypical pneumonia suspected SARS, Avian influenza
4. Cholera
82 Suandok Antibiotics
Neisseria meningitidis
When infection with N. meningitidis is suspected, the patient should be
placed on droplet precaution for the first 24 hours of appropriate antimicrobial
therapy.
Prophylaxis is required for close contact with patient which is defined as
direct exposure to index patient's secretions (i.e. mouth-to-mouth resuscitation,
unprotected intubation or unprotected suctioning
Regimens: ciprofloxacin 500 mg. PO single dose, rifampicin 600 mg. PO BID
for 2 days, ceftriaxone 250 mg. IM for pregnant women. Prophylaxis should
ideally be administered within 24 hours of exposure.
Scabies
Infection control
All patients with conventional or Norwegian scabies should be placed on
Contact Precautions. Norwegian scabies is a severe form of heavy mite
infestation.
• Isolation I single room is required.
• Infested clothing and linen should be sealed in a plastic bag for 48 hours.
The mite will not survive off a human host for more than 48 hours.
• Linens and clothing should be washed in the washing machine on the hot
cycle.
• If prolonged skin-to-skin contact occurs with a scabies patient, prophylactic
treatment is required. Healthcare workers should contact IC if an exposure
is suspected.
Varicella-Zoster Virus
Infection control
lmmunocompetent patients with disseminated zoster and all immunosup-
pressed patients with zoster need contact AND airborne precautions.
The following definitions apply to patients with zoster:
• lmmunosuppressed: bone marrow transplant within the past year; acute
leukemia; lymphomas under treatment; solid organ transplant recipients;
patients receiving cytotoxic or immunosuppressive treatments, including
long-standing steroid treatment; HIV+ patients with CD4 s 200
• Disseminated: lesions outside of 2 contiguous dermatomes
HCWs who are varicella-immune do not have to wear N95 if patient is in
isolation for zoster or chickenpox. HCWs who are not varicella-immune and
exposure to varicella patient (zoster or chickenpox) should wear N95 mask.
Suandok Antibiotics 83
HCWs are encourage to vaccinate for chicken pox vaccine before rotation to
the units where exposure to varicella patient is likely e.g. pediatrics, internal
medicine unit
Central vascular access device (VAD) recommendations
Infection control
All healthcare workers who place central lines are required to take the VAD
training. To prevent central VAD-related infections follow the central line
bundle:
Insertion
• Clean hands thoroughly
• 2 % Chlorhexidine in alcohol for patient skin antisepsis
• Avoid femoral vein for central line insertion
• Use full barrier precautions (mask, gown, glove. cap and drape patient
from head to toe) and aseptic technique
• Lines placed emergently should be changed as soon as the patient is
medically stable
Care
• Change a semipermeable transparent dressing every 7 days or gauze
dressing every 48 days, unless it is damp, loose or soiled. in which case
change the dressing immediately
• Change peripheral IV site and tubing every 72 hours
• Remove line as soon as possible
• Refer to the CRBSI prevention guideline on the IC Web site for more
details.
Evidenced-based recommendations for prevention of surgical site
infections (SSI)
Pre-operative interventions
• Identify and treat remote site infections
• Postpone elective procedures until remote infection is resolved
• Encourage the patient to stop smoking at least 30 days pre-operatively
• Instruct high-risk patient to bath with 4% chlorhexid ine gluconate the
night before and the morning of surgery.
• Use appropriate pen-operative antibiotic prophylaxis that is given prior to,
but no more than 1 hour before. skin incision (2 hours are allowed for
Vancomycin and Fluoroquinolones)
84 Suandok Antibiotics
Intra-operative interventions
• Clean hands with surgical scrub sponge 2-5 minutes and brush nails. For
subsequent cases , antiseptic surgical hand scrub with 4% ch lorhexidine
gluconate can be used
• Do not remove hair at incision unless necessary for the operation
• Never shave. only use clippers
• Hair removal , if necessary, should take place immediately before surgery
• If CHG bath not done by patient, clean incision site with CHG immediately
prior to surgery
• Prepare the surgical site and surrounding area with an approved antiseptic
and allow to DRY prior to placing drapes
• Maintain normal core temperature (36.5°C) throughout the procedure
• Control serum blood glucose levels using insulin as necessary
• Use aseptic technique when placing IV devices
• Use aseptic technique when manipulating stopcocks and ports
• Assemble steri le equipment and solutions immediately before use
Optimize tissue oxygenation by supplemental oxygen during and immediately
following procedures using mechanical ventilation
Post-operative interventions
• Place a sterile dressing (as anatomically possible) 24-48 hours post
surgery
• Change dressing using sterile supplies and good hand hygiene
• Control serum blood glucose levels using insulin as necessary
References:
1. Guidelines for prevention of SS/: Infect Control Hosp Epidemiol 1999;20:247.
2. Perioperative oxygen: N Engl J Med 2000;242:161 .
Environmental cleaning in healthcare setting
• Please strictly follow the hospital environmental cleaning policy
• Please contact IC unit if you have any questions
Suandok Antibiotics 85
A . Aminoglycoside dosing
• Aminoglycosides enhance the efficacy of some antibiotics. EXC EPT for
urinary tract infections, aminoglycosides should seldom be used alone to
treat infections
• Aminoglycosides are known to aggravate the symptoms of myasthenia
gravis and should NOT be used in these patients.
• Estimation of creatinine clearance (CrCI) by Cockcroft-Gault equation:
(140-age)(weight in kg*)
CrCI = __:...__.....::__ _:__ _ _ x0 .85 (if female)
72x serum creatinine**
*use actual body weight (ABW) unless patient is obese (2, 20% over ideal body
weight, IBW)
For obese patients, use Dosing Body Weight (DBW)
DBW = [IBW+0.4(ABW-IBW)
IBW female (kg) = 50 kg + 2.3 kg for each inch over 5 feet tall
IBW male (kg) = 45.5 + 2.3 kg for each inch over 5 feet tall
5 feet = 152.4 ems
•• For patient with low muscle mass i.e. many patients > 65 years. some sug-
gest using a minimum value of 1.0 to avoid overestimation of CrCI
Once-daily aminoglycoside dosing
Rationale for once-daily dosing
1. Optimization of peak concentration/ MIC ratio
2. Allowing for a drug-free period
a. Take advantage of post-antibiotic effect (PAE) of aminoglycosides
b . May decrease risk of toxicity
c. May lower incidence of adaptive resistance
3. Convenience of less frequent administration
4. Decrease frequency of drug level monitoring
5. At least as efficacious as trad itional dosing
Dosing
Gentamicin: In most patients , a dose of 5 mg/ kg IV once daily is
recommended.
86 Suandok Antibiotics Suandok Antibiotics 87

Amikacin: In most patients. a dose of 15-20 mg/ kg IV once daily is

Antimicrobial Typical dose CrCI (mUmin) Dose adjustment for renal
recommended insufficiency
Aminoglycoside dosing for Gram-positive synergy
Gentamicin and streptomycin provide synergistic effect to 1).-lactams against Aminoglycosides traditional dose for enterococcal endocarditis
Gram-positive cocci. However, only high level gentamicin disk is available for Gentamicin 1 mg/kg Q8H > 50 1 mg/kg Q8H
determining synergy in our hospital. 10-50 1 mg/kg Q12-24H
Dosing: < 10 1 mg/kg Q48H
Gentamicin: 3 mg/kg IV once daily is recommended for treatment of HD 0.5 mg/kg AD
CRRT 1 mg/kg Q24H
endocarditis with viridians streptococci or S. bovis in patients with normal
renal function (CrCI 2: 60 ml/min) HD= hemodialysis. CRRT=Continuous Renal Replacement Therapy,
Gentamicin: 1 mg/kg IV Q8H is recommended for treatment of AD= after hemodialysis
enterococcal endocarditis with normal renal function (CrCI 2: 60 ml/min) References:
Monitoring for toxicity 1. Aminoglycoside levels and Gram-negative pneumonia: Am J Med
Nephrotoxicity 1984;77:657.
• Serum creatinine should be monitored at least every other day. 2. Daily dosing: Antimicrob Agents and Chemother 1995; 39:650.
Ototoxicity 3. Daily dosing: Antimicrob Agents and Chemother 1999; 43: 1549.
4. Nephortoxicity: Antimicrob Agents and Chemother 2003; 47:1010.
Antimicrobial Typical dose CrCI (mU Dose adjustment for renal 5. Gram-positive Synergy: Circulation 2005; 111 (23):e394-434.
min) insufficiency 6. Individualized pharmacokinetic dosing: Grit Care Med 1991;19:1480.

Aminoglycosides once-daily dose B . Vancomycin dosing and therapeutic monitoring

Gentamicin 5 mg/kg >80 5mg/kg Q24H DOSING
(For Gram- Q24H 60-80 4mg/kg Q24H 1.Estimate creatinine clearance (CrCI) using Cockcroft-Gault equation:
negative 40-59 3.5mg/kg Q24H
bacteria) 30-39 2.5 mg/kg Q24H
20-29 4 mg/kg Q48H (140-age)(weight in kg')
CrCI = - - - - - - - - - x 0.85 (if female)
10-19 3 mg/kg Q48H 72 x serum creatinine'
< 10 2 mg/kg Q72H and AD

Gentamicin 3 mg/kg >60 3 mg/kg Q24H ' For patients with low muscle mass (i.e .. many patients>65 yrs) . some
(For Gram- Q24H 40-60 2 mg/kg Q24H
advocate using a minimum value of 1 to avoid overestimation of CrCI
positive 20-39 1 mg/kg Q24H
<20 1 mg/kg Q48-72H and AD 2. Patients who are seriously ill with complicated infection such as meningitis,
synergy)
pneumonia, osteomyelitis, endocarditis, and bacteremia and normal renal
Amikacin 15 mg/kg >80 15mg/kg Q24H function should receive initial loading dose of 20-25 mg/kg, followed by
Q24H 60-80 12mg/kg Q24H
15-20 mg/kg Q8-12H using Actual Body Weight (Af3W). For other indications
40-60 7.5mg/kg Q24H
see dosing below.
30-40 4 mg/kg Q24H
20-30 7 .5 mg/kg Q48H 3. Calculate maintenance dose (using ABW) based on estimated or actual
10-20 4 mg/kg Q48H CrCI. See suggested dosing below.
< 10 3 mg/kg Q72H and AD
Note: Younger patients with normal renal function may need higher or more
frequent dosing than suggested below.
88 Suandok Antibiotics Suandok Antibiotics 89

• Receiving aggressive dosing (> 1500 mg Q12H) or Q8H interval

Weight (kg) CrCI (mUmin)
• Serious infections such as meningitis, endocarditis, osteomyelitis,
>60 30-59 15-29 < 15 or hemodialysis and MRSA pneumonia.
• Unstable renal function (change in serum creatinine of 0.5 mg/dL or
<40 Consider ID consult
50% from baseline) or dialysis
40-49 750 mg 750 mg 750 mg 1000 mg, then redose • Concurrent therapy with nephrotoxic agents (e.g.aminoglycosides.
Q12H Q24H Q48H by level Colistin, Amphotericin B)
50-59 1000 mg 1000 mg 1000 mg 1000 mg, then redose • Prolonged courses (>3-5 days) of therapy.
Q12H Q24H Q48H by level • Frequency of monitoring Vancomycin trough levels:
• Once-weekly monitoring is recommended for patients with stable
60-75 1000 mg 1000 mg 1000 mg 1000 mg, then redose
renal function who have achieved desired trough level.
Q12H Q24H Q48H by level
• More frequent monitoring is recommended for patients who are
76-90 1250 mg 1250 mg 1250 mg 1250 mg, then redose hemodynamically unstable and/or with changing renal function.
Q12H Q24H Q48H by level
Desired Yancomycin trough levels
90-110 1500 mg 1500 mg 1500 mg 1500 mg, then redose • Pneumonia, osteomyelitis, endocarditis, bacteremia: 15-20 mcg/ml
Q12H Q24H Q48H by level • CNS infections: 20 mcg/ml
> 110 • Neutropenic fever, skin and skin-structure infections: 10-15 mcg/ml
Consider ID consult
• For MRSA infections serum trough concentration> 10 mcg/ml should
• Re-dosing by trough level is the best approach. However, if the trough always be maintained to avoid development of resistance.
levels are not available for some reasons, maintenance dose with 7.5 mg/kg
Q48-72H . Monitoring for Toxicity
• Serum creatinine should be measured at least every other day initially, then
THERAPEUTIC DRUG MONITORING (LEVELS) (Vancomycin drug
weekly if patient's renal function remains stable.
monitoring is available in our hospital starting from 2012)
• Limited data suggest a direct causal relationship between nephrotoxicity
• Trough levels are the most accurate and practical method for monitoring
and higher serum trough levels (see above for frequency and indications).
Vancomycin effectiveness and toxicity.
• Formal audiology testing is not recommended for patients receiving
Measuring serum Yancomycin levels Vancomycin, unless signs and symptoms of ototoxicity became apparent.
• Trough levels should be obtained just prior to the next dose at steady state
conditions (approximately before the 4'" dose). References:
• In patients with ESRD on hemodialysis, it is preferable to obtain a pre- 1. IDSAIASHPISIDP Guidelines therapeutic monitoring of Vancomycin: Am J
hemodialysis level with the routine laboratory venipuncture on the morning Health-Syst Pharm. 2009;66;82.
of hemodialysis. In the event a pre- hemodialysis level is not obtained, 2. A TS/IDSA Guidelines for HAPNAP: AJRCCM 2005; 171:338.
a post- hemodialysis level may be draw at least six hours after the dialysis 3. IDSA Guideline for Bacterial Meningitis: Clin Infect Dis 2004:39:1267.
session.
• Trough levels should be considered in patients with any the following
circumstances:
90 Suandok Antibiotics Suandok Antibiotics 91

C. Antimicrobial dosing in severe sepsis or septic shock • Therapeutic drug monitoring (TDM) should be performed whenever possible
• TDM is available for vancomycin in our hospital (see appendix B)
• Appropriate antimicrobials should be prescribed within 1 hour of
• Reassess daily for potential de-escalation
recognition.
• Empirical combination therapy should not be administered for > 3-5 days
• Specimen collection should be obtained prior to antimicrobial prescription
• De-escalation to the most appropriate single therapy as soon as the
(if no significant delay in antimicrobial initiation).
susceptibility profile is known
• Empiric ~
1 antimicrobials that have activity against all likely pathogens and
• Examples of commonly used antimicrobial dosage in patients with severe
penetrate well into infection site (s) .
sepsis or septic shock
• Empirical combination therapy should be considered for
• Piperacillin/tazobactam
• Neutropenic patients
4.5 g IV infuse over 30 minutes, and then 4.5 g infuse over 3 hours Q6H
• Difficult to treat MOR-pathogens e.g . A. baumannii
• lmipenem/cilastatin
• Suspected P.aeruginosa bacteremia (extended spectrum ~-lactam and
1 g IV infuse over 30 minutes, and then 1 g infuse over 3 hours Q8H OR
either an aminoglycoside or a fluoroquinolone)
500 mg IV infuse over 3 hours Q6H
• Suspected bacteremic S.pneumoniae infections (~-lactam and macrolide)
• Meropenem
• The first dose of antibiotic is equally important to the timing .
1 g IV infuse over 30 minutes, and then 1 g infuse over 3 hours Q8H
• Loading dose of any drug depends upon the volume of distribution (Vd)
• Colistin: see page 7
and required plasma concentration (Cp) .
• Vancomycin: see page 87-89
• Changes in volume of distribution (Vd) as a result of sepsis with or without
a positive fluid balance as a result of acute kidney injury (AKI) affect the
References:
pharmacokinetics of hydrophilic antibiotics (i.e. ~-lactams, aminoglycosides ,
1. Eyler RF. Nat Rev Nephrol 2011 ; 7: 226-235.
vancomycin , colistin, and linezolid).
2. Roberts JA. Grit Care Med 2009; 37: 840-851 .
• Obese patients affect pharmacokinetics of lipophilic antibiotics
3. Blot S. Diagn Microbial Infect Dis 2014; 79: 77-84 .
(e.g . fluoroquinolones and macrolides).
4. McKenzie C. J Antimicrob Chemother 2011; 66:ii25-ii31 .
• Time-dependent and concentration-dependent antibiotics required different
5. Matzke GR. Kidney International 2011; 80: 1122-113 7.
plasma concentrations .
• Dose reductions may NOT always be necessary in the presence of AKI
during the first 24-48 hours of treatment
• Initial dose regardless of CrCI
• ~-lac tams: normal dose or 25-50% greater than normal dose, followed
immediately by continuous or prolonged infusion
• Aminoglycosides, fluoroquinolones : normal dose or 25-50% greater than
normal dose
• Vancomycin: < 70 kg . 1 g, ~ 70 kg 1.25 g
• Colistin : see page 7
I
• Maintenance dose
• The first 24-48 hours regardless of CrCI : as a standard dose for normal
renal function (see appendix D)
• After the first 24-48 hours: adjust dose according to CrCI
92 Suandok Antibiotics Suandok Antibiotics 93

D. Antimicrobial dosing in renal failure Antimicrobial Ty p ical dose C rCI D o se adj ustm e nt for
• All dosage adjustments are based on creatinine clearance calculated by ren a l insuffic iency
Cockcroft-Gault equation. Cefepime 1-2 g QBH >60 1-2 g QSH
For Pseudomonas 30-60 1-2 g Q12H
2g QBH <29 1-2 g Q24H
(140-age)(weight in kg•) HD' Load with 1-2 g, then
CrCI= - - -- - - - - - x 0.85 (if female) 500 mg Q24H
72 x serum creatinine*
Cefixime 400mgQ24H >50 400 mg Q24H
10-50 300 mg Q24H
• For patient with low musc le mass i.e. many patients > 65 years. some suggest <10 200 mg Q24H
using a minimum value of 1.0 to avoid overestimation of CrCI HD 300 mg Q24H, dose AD
on dialysis days
• If patient is on hemodialysis (HD) schedule administration so that patient
receives daily dose immediately after dialysis. Cefotaxime 2g Q8H >50 2 g Q8-12H
10-50 2 g Q12-24H
< 10 2 g Q24H
Antim icrobial Typical dose CrCI Dose adjustment for HD Additional 1 g AD
renal insufficiency
Cefoxitin 2gQ8H >50 2 g QSH
Amikacin See page 86 10-50 2 g Q8-12H
< 10 2 g Q24-48H
Amoxicillin 500-1000 mg > 30 500-1000 mg Q12H HD Additional 1 g AD
Q12H 10-30 250-875 mg Q12H Cefoperazone/ 2g Q8-12H >30 2 g Q8-12H
< 10 or HD' 250-875 mg Q24H sulbactam 15-30 1 g Q8-12H
(500 mg/ 500 mg) < 15 500 mg Q8-12H
Amoxicillin/ 500-1000 mg >30 500-1000 mg Q12H
clavulanate Q12H 10-30 250-500 mg Q12H Cefoperazone/ 1.5gQ12H > 15 1.5gQ12H
sulbactam <15 750 mg Q12H
< 10 or HD* 250-500 mg Q24H
(1000 mg/ 500 mg)
Ampic illin 1-2 g Q4-6H > 50 1-2 g Q4-6H Cephalexin 500 mg PO Q6H >50 500 mg PO Q6H
10-50 1-2 g Q6-8H 10-50 500 mg PO Q12H
< 10 or Ho· 1-2 g Q8H <10 250 mg PO Q12H
HD 500 mg AD
Ampic illin/ 1.5-3 g Q6H 2".30 1.5-3 g Q6H
sulbactam 15-29 1.5-3 g Q12H Cefpirome 2 g Q12H >50 2 g Q12H
10-50 1 gQ12H
~14orHD* 1.5-3 g Q24H
<10 1 gQ12H
HD Dose AD on dialysis days
Cefazolin 1-2 g Q8H 2".35 1-2 g Q8H
11-34 500 mg-1 g Q12H Ceftazidime 1-2 g QSH >50 1-29 QBH
< 10 500 mg-1 g Q24H For pseudomonas 3Q-50 1-2 g Q12H
HD* 2 g Q HD. if HD in 3 days 2g QBH 15-29 1-2 g Q24H
5-15 500 mg-2 g Q24H
Cefdinir 300 mg Q12 H 2".30 300 mg Q12H HD' Load with 1 g, then 500
<30 300 mg Q24H mg Q24H
HD 300 mg Q24H dose AD
on dialysis days
94 Suandok Antibiotics

Antimicrobial Typical dose CrCI Dose adjustment for

1111.
Antimicrobial Typical dose CrCI
Suandok Antibiotics

Dose adjustment for

95

renal insufficiency renal insufficiency

Ciprofloxacin IV 400 mg Q8-12H 230 400 mg Q8-12H Meropenem 2g Q8H > 51 2g Q8H
<30orHD• 400 mg Q24H (CNS) 26-50 1 gQ8H
10-25 1 gQ12H
Ciprofloxacin 250-750 mg Q12H 230 250-750 mg Q12H <10 or Ho• 1 g Q24H
PO <30 or HD• 250-500 mg Q24H
Moxifloxacin 400 mg Q24H No dosage adjustment
Clarithromycin 250-500 mg Q12H 230 250-500 mg 012H
<30 250-500 mg Q24H Norfoxacin 400 mg Q12H 230 400 mg Q12H
<30 or Ho• 400 mg Q24H
Colistin see page 7 HD•
Ofloxacin 200 mg Q12H > 50 200 mg Q12H
Doripenem 500 mg Q8H >50 500 mg Q8H 10-50 200 mg Q24H
30-50 250 mg Q8H <10 or HD 100 mg Q24H
10-29 250 mg Q12H
<10 No data Penicillin G 3-4 million units 250 3-4 million units Q4H
Q4H 10-50 1.5 million units Q4H
Ertapenem 1 g Q24H 230 1 g Q24H <10 or Ho• 1.5 million units Q6H
<30orHD• 500mgQ24H
Piperacillin/ 3.375-4 .5 g Q6H >40 4.5 g Q8H {4.5 g Q6H for
Fosfomycin 2 g Q12H or >80 100% tazobactam Pseudomonas)
2-4 g Q6-8H in 40-50 Decrease dose 50% , 2Q-40 2.25 g Q6H {4 .5 g Q8H
severe infection same interval for Pseudomonas)
20-39 Decrease dose 75%, <20 2.25 g Q8H (2.25 g Q6H
same interval for Pseudomonas)
HD No data HD• 2.25 g Q12H (2.25 g Q6H
for Pseudomonas)
Gentamicin See page 87
TMP/SMX (PCP 5 mg/kg Q6-8H 230 5 mg/kg Q6-8H
lmipenem/ 500 mg Q6H >50 250-500 mg Q6-8H or serious <30 2.5 mg/kg Q6-8H
cilastatin 10-50 250 mg Q8-12H infections) HD• 2.5 mg/kg Q8H
<10 125-250 mg Q12H
HD Dose AD Vancomycin See page 87-89 See section on
vancomycin dosing
Levofloxacin 500 mg PO/IV >50 500 mg Q24H
Q24h 2Q-50 500 mg Q48H Antiviral drugs
<20orHD 500 mg once, then 250
mg Q48H Acyclovir IV 5-10 mg/kg Q8H >50 5-10 mg/kg Q8H
25-50 5-10 mg/kg Q12H
Levofloxacin 750 mg PO/IV >50 750 mg Q24H 10-24 5-10 mg/kg Q24H
(anti- Q24h 2Q-50 750 mg Q48H <10orHo• 2.5-5 mg/kg Q24H
pseudomonal <20orHD 750 mg once , then 500
activity) mg Q48H Acyclovir PO 200 mg 5x daily >10 200 mg 5x daily
(HSV) <10 200 mg Q12H
Meropenem 1 gQ8H >51 1 g Q8H
26-50 1 gQ12H Acyclovir PO 800 mg 5x daily >25 800 mg 5x daily
10-25 500 mg Q12H {HZV) 10-25 800 mg Q8H
<10orHo• 500 mg Q24H <10orHD• 800 mg Q12H
96 Suandok Antibiotics
Suandok Antibiotic 97

Antimicrobial Typical dose CrCI Dose adjustment for

Antimicrobial Typical dose CrCI Dose adjustment for
renal insufficiency
renal insufficiency
Valacyclovir 500-1000 mg ~30 500-1000 mg Q12H
Antifungal drugs
(HSV) Q12H 10-29 500-1000 mg Q24H
<10orHo• 500 mg Q24H Fluconazole 200-800 mg ~50 Normal dose (e.g . 100,
Q24H 400, 800 mg) Q24H
Valacyclovir 1 gQ8H ~50 1 gQ8H
<50 or HD• Load w/normal dose,
(HZV) 30-49 1 gQ12H
then 50% of normal dose
10-29 1 g Q24H
Q24H
< 10 or Ho• 500 mg Q24H
ltraconazole 100-200 mg > 50 100%
Ganciclovir (In- 5 mg/kg Q12H ~70 5 mg/kg Q12H
Q12H 10-50 100%
duction dose) 50-69 2.5 mg/kg Q12H
< 10 50%
25-49 2.5 mg/kg Q24H
HD 100 mg Q12-24H
10-25 1.25 mg/kg Q24H
<10 or Ho• 1.25 mg/kg three time/ Voriconazole IV 6 mg/kg IV/PO IV form should not be
week, administer after HD Q12Hfor administered to patients
2 doses, then withCrc1:s;
Ganciclovir 5 mg/kg Q24H ~70 5 mg/kg Q24H
4 mg/kg Q12H 50 mUmin due to
(Maintenance 50-69 2.5 mg/kg Q24H
dose) accumulation of the
25-49 12.5 mg/kg Q24H
10-25 vehicle
0.625 mg/kg Q24H
< 10 or Ho• 0.625 mg/kg three time/ Antituberculous
week, administer after HD drugs
Valganciclovir 900 mg Q12H ~60 900 mg Q12H Ethambutal 15-25 mg/kg ~10 Normal dose Q24H
(Induction 40-59 450 mg Q12H Q24H <10 Normal dose Q48H
dose) 25-39 450 mg Q24H HD• Normal dose QHD ses-
10-24 450 mg Q48H sion
< 10orHo· Not recommended
lsoniazid 300 mg Q24H - No dosage adjustment
Valganciclovir 900 mg Q24H ~60 900mgQ24H
(maintenance 40-59 450mgQ24H Rifampicin 300 mg QB-12H No dosage adjustment
dose) 25-39 450mgQ48H
10-24 450 mg twice weekly Pyrazinamide 15-30 mg/kg ~10 15-30 mg/kg Q24H
<10orHo• Not recommended Q24H <10 12-20 mg/kg Q24H
HD• 25-30 mg/kg QHD session
Amantadine 100mgQ12H >50 100 mg Q12H
30-50 200 mg x 1 day, then Streptomycin 15 mg/kg IM >50 15 mg/kg IM Q24H
100 mg Q24H Q24H (Max 1 g 10-50 15 mg/kg IM Q24-72H
15-29 200 mg x 1 day, then Q24H) OR <10 15 mg/kg IM Q72-96H
100 mg Q48H 25-30 mg/kg IM HD 50% of normal renal function
<15or Ho• 200 mg weekly 3xlweek dose

Oseltamivir 75 mg Q12-24H ~30 75 mg Q12-24H

10-29 75 mg Q24-48H • If patient is on hemodialysis (HD) schedule administration so that patient
<10orHo• 30 mg Q every other HD receives daily dose immediately AFTER dialysis.
session
98 Suandok Antibiotics Suandok Antibiotics 99

Commonly used medications which are not required for dose adjustment E . Drug dosing for continuous renal replacement therapy (CRRT)
• CRRT is frequently used for critically ill patients who need renal supportive
Antibacteri al Antifungal therapy.
Azithromycin Ceftriaxone Anidurafungin • Modes of CRRT vary widely depending on technique used (diffusive therapies
Chloramphenicol Clindamycin Micafungin or convective therapies) . Hemofilters vary by material , surface area , pore
Cloxacillin Doxycycline Caspofungin size , water permeability, and the efficacy of removal of low-molecular-weight
Linezolid Metronidazole ltraconazole oral solution and mid-molecular-weight solutes.
Moxifloxacin Pyrimethamine Ketoconazole
Tigecycline • The pharmacokinetics of antimicrobial prescribed fo r critically ill patients are
Voriconazole PO
significantly altered during CRRT.
References: • Increased Vd, decreased protein binding due to hypoalbuminemia in critical
1. The SANFORD GUIDE to antimicrobial therapy. 2011 . illness, decreased drug elimination as a result of AKI , and increased clearance
2. Johns Hopkins Medicine. 2010-2011 antibiotic guidelines owing to CRRT not only affect antimicrobial pharmacokinetics, but also influence
whether optimal pharmacodynamic targets can be met.
• Individual patient-spec ific, CRRT-specific , and drug specific characteristics
should guide initial and maintenance dosing , and doses should be adjusted
continually as a patient's clinical status changes . There is no "one size fits
all"
• There are at least 3 drug information resources to help select drug dosing
recommendations. The reference dosing described here are mostly based
on the most recent edition of the Drug Prescribing in Renal Failure or DPRF
(DPRF5) in reference#1, which provided drug dosage for most of the medi
cations used in critically ill patients. Exceptions are ceftazidime, colistin, and
fluconazole, which follow the Martindale database in reference#1 .
• The most important CRRT-related factor affecting drug removal is effluent
volume, which determined by both flow rate and therapy duration.
• Drug dosing information described here is mostly based on an effluent rate of
2 Uh , lower or higher effluent rate may need lower or higher dosage.

Antibacte rial Ma inte nance dose

Acyclovir 5-10 mg/kg IV Q24H

Amikacin 7.5 mg/kg IV Q24-72H

Cefepime 1-2 g IV Q12H

Cefotaxime 1 g IVQ1 2H

Ceftazidime 1-2 g Q 8-12H

Ceftriaxone 250 mg-2 g IV Q1 2-24H

100 Suandok Antibiotics Suandok Antibiotics 1 01

F. Oral antimicrobial use

Antibacterial Maintenance dose Oral antimicrobial use in hospitalized patients
Cefuroxime 1 g IVQ12H Switch therapy: switching from intravenous to oral administration of antimicrobials.
Principle: Bioavailability of oral route is as equal as intravenous route.
Ciprofloxacin 400 mg IV Q24H
Eligibility c riteria: Patient does not have the contraindications listed below
Colistin 2.5-3.0 mg/kg IV Q12-48H Contraindications to oral therapy
Cotrimoxazole 2.5-10 mg/kg IV Q12H
Patient factors Site/ Type of Infection Medications
Fluconazole 200-800 mg IV/PO Q24H
• NPO (including • Meningitis or brain • No oral antimicrobial
Ganciclovir 1.25-2.5 mg/kg IV Q24H medications) abscess available
• Inability to take oral • Endocarditis • Oral bioavailability is
Gentamicin 1. 7 mg/kg IV Q12-48H
medication • Febrile neutropenia not as equal as
lmipenem/cilastatin 500 mg IVQ6H • Hemodynamic • Undrained abscesses, intravenous
instability empyema, or administration
Levofloxacin 500 mg IV/PO Q48H
• Receiving continuous mediastinitis
Linezolid 600 mg IV/PO Q12H NG suctioning • Infected vascular
• Severe nausea, prosthesis
Meropenem 1-2 g IV Q12H vomiting, diarrhea.
G I obstruction
Metronidazole 250-500 mg IV Q8-12H
• A malabsorption
Moxifloxac in 400 mg IV/PO Q24H syndrome

Piperacillin/tazobactam 4.5 g IV Q8H

NOTES:
Vancomycin 1 g IV Q24-96H* • Switch therapy can be considered if patient has significant clinical
Voriconazole 400 mg IV/PO Q12H x 2, then 200 mg IV/ improvement, hemodynamic stability, evident normalizing body temperature
PO Q12H {24-48 hours after afebrile), normalizing leukocyte count, and good compliance
to oral medications
*Assume 70 kg body weight • Liver abscesses. undrained abscesses. empyema. osteomyelitis, and
NOTE: arthritis can SOMETIMES be switched after 2 weeks of IV administration. on
• For initial dose. see appendix C a case by case basis.
• If patient is on Slow Continuous Ultrafitration (SCUF), adjust antimicrobial • Good candidates for switch therapy: ciprofloxacin, fluconazole, linezolid,
dosage according to CrCI as the drugs are not removed. metronidazole, TMP/SMX, voriconazole. Other oral medications are on a
• Consult ID if drugs are not on the list. case by case basis.

Reference:
References:
Arch Intern Med.2004; 164: 1206-1212
1. Gorman SK. Can J Hosp Pharm 2012; 65: 188-95.
2. Eyler RF. Nat Rev Nephrol 2011; 7: 226-235.
102 Suandok Antibiotics
Suandok Antibiotics 103

Index D
A Deep-tissue infections 57
Dexamethasone 39
Abdominal Infection
12 Diabetic foot infections 54
Acute Exacerbation of Chronic Bronchitis (AECOPD) Diskitis 58
AECOPD 46
47 Diverticulitis 14
Aminoglycoside dosing
85 Doripenem 8
Antibiotic prophylaxis
Antimicrobial Prophylaxis 74
74 E
B Endocarditis 29, 71
Endophthalmitis 70
Bacterial Urinary Tract Infection
62 Epidural abscess 58
Biliary tract infections
12 Ertapenem 8
Bloodborne pathogen exposures
80 Esophageal candidiasis 67
Brain abscess
41
c F
Fascitis 57
Candida albicans
69 Febrile neutropenia 71
Candida glabrata
69 Fosfomycin 9
Candida tropicalis
Candida vaginitis 70
Candidemia 68 G
69 GI perforation 19
Candidiasis
67 Gonococcal infection 44
Candidiasis, Oral see Thrush
Gram-negative bacilli 11
Candiduria
67 Gram-negative cocci 11
Catheter-Related Bloodstream Infection (CRBSI) Gram-negative infections 66
Cellulitis 26
54 Gram-positive bacilli 11
Central Nervous System Infection
37 Gram-positive cocci 11
Cholangitis
12 Gynecologic Infection 43
Cholecystitis
Clostridium difficile infection (CDI) 12
CNS shunt infection 24 H
41 Healthcare-associated pneumonia (HCAP) 50
Colistimethate
Colistin 6 Helicobacter pylori infection 22
6 Hospital-acquired pneumonia (HAP) 51
Communicable diseases
80 Hospital Epidemiology 78
Community-acquired pneumonia (CAP)
48
Continuous renal replacement therapy (CRRT)
99 I
Creutzfeldt-Jakob disease (CJD)
Cystitis 81 Implantable cardioverter-defibrillator{ICD) 35
68 Infection Control 78
Interpreting microbiology report 11
 104 Suandok Antibiotics
Suandok Antibiotics 105

L
Linezolid s
9 Scabies 82
M Septic arthritis 59
Meningitis Septic shock 90
37 Severe sepsis 90
N Shock, septic 90
Native valve endocarditis Spontaneous bacterial peritonitis (SBP) 17
Necrotizing infections 30 Surgical site infections (SSI) 56, 83
Neisseria meningitidis 57 Symptomatic cystitis 68
Neutropenia,febrile 82
Neutropenic fever 71 T
71 Thrush 67
0
Oral antimicrobial use v
Oropharyngeal disease 101 Vancomycin dosing 87
Osteomyelitis 67 Varicella-Zoster Virus 82
58 Vascular access device (VAD) 83
p Ventilator-associated pneumonia (VAP) 51
Pancreatitis Vertebral osteomyelitis 58
Pelvic infection - postoperative 15
Peritonitis 44
Peritoneal dialysis 17, 21
Peritonitis, primary 21
Peritonitis, secondary 17
Permanent pacemaker (PPM) 19
Post-operative pelvic infection 35
Preliminary microbiology data 44
Prophylactic antimicrobials 11
Pulmonary infections 76
Pyelonephritis 46
Pyomyositis 68
57
R
Ranson's criteria
Renal failure 16
92