Johns hopkins 2016; antibiotic guidelines

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1. Treatment Recommendations
For Adult Inpatients
Also available online at
insidehopkinsmedicine.0rg/amp
Antibiotic Guidelines
2015-2016

3. 1. Introduction ............................................................................................3
2. Johns Hopkins Hospital formulary and restriction status ....................6
2.1 Obtaining ID approval ........................................................................6
2.2 Formulary .........................................................................................7
3. Agent-specific guidelines ......................................................................8
3.1 Antibiotics ........................................................................................8
Ceftaroline ......................................................................................8
Ceftolozane/tazobactam .................................................................8
Colistin ...........................................................................................9
Daptomycin ................................................................................. 10
Ertapenem ................................................................................... 11
Fosfomycin .................................................................................. 11
Linezolid ...................................................................................... 12
Tigecycline .................................................................................. 13
Trimethoprim/sulfamethoxazole ................................................... 14
3.2 Antifungals..................................................................................... 16
AmBisome
®
................................................................................ 16
Micafungin ................................................................................... 17
Posaconazole .............................................................................. 18
Voriconazole ................................................................................ 19
Azole drug interactions ................................................................. 20
3.3 Vaccines ....................................................................................... 23
Pneumococcal vaccines ............................................................... 23
4. Organism-specific guidelines ..............................................................24
4.1 Anaerobes ..................................................................................... 24
4.2 Propionibacterium acnes ................................................................ 25
4.3 Streptococci.................................................................................. 27
4.4 Multi-drug resistant Gram-negative rods .......................................... 28
5. Microbiology information ....................................................................31
5.1 Interpreting the microbiology report ................................................ 31
5.2 Spectrum of antibiotic activity ......................................................... 32
5.3 Interpretation of rapid diagnostic tests ............................................ 34
5.4 Johns Hopkins Hospital antibiogram ............................................... 36
6. Guidelines for the treatment of various infections ........................... 39
6.1 Abdominal infections ............................................................. 39
Biliary tract infections ................................................................... 39
Diverticulitis ................................................................................. 40
Pancreatitis ................................................................................. 41
Peritonitis (including SBP, GI perforation and peritonitis
related to peritoneal dialysis) ........................................................ 42
6.2 Clostridium difficile infection (CDI) ............................................47
6.3 Infectious diarrhea .....................................................................51
6.4 H. pylori infection .......................................................................54
6.5 Gynecologic and sexually transmitted infections .....................56
Pelvic inflamatory disease ............................................................ 56
Endomyometritis .......................................................................... 56
Bacterial vaginosis ....................................................................... 57
Trichomoniasis ............................................................................ 57
Uncomplicated gonococcal urethritis, cervicitis, proctitis ............... 57
Syphilis ........................................................................................ 58
6.6 Catheter-related bloodstream infections ..................................60
1
Table of contents
(continued on next page)

4. 6.7 Endocarditis ................................................................................65
6.8 Pacemaker/ICD infections.........................................................71
6.9 Central nervous system (CNS) infections .................................73
Meningitis .................................................................................... 73
Encephalitis ................................................................................. 75
Brain abscess .............................................................................. 76
CNS shunt infection ...................................................................... 76
Antimicrobial doses for CNS infections .......................................... 77
6.10 Acute bacterial rhinosinusitis (ABRS) ..................................... 78
6.11 Orbital cellulitis ..................................................................... 80
6.12 Pulmonary infections ..................................................................82
COPD exacerbations .................................................................... 82
Community-acquired pneumonia ................................................... 83
Healthcare-acquired pneumonia. ................................................... 87
Ventilator-associated pneumonia ................................................... 88
Cystic fibrosis .............................................................................. 91
6.13 Respiratory virus diagnosis and management .........................93
6.14 Tuberculosis (TB) ........................................................................95
6.15 Sepsis with no clear source .......................................................99
6.16 Skin, soft-tissue, and bone infections ......................................100
Cellulitis ..................................................................................... 100
Cutaneous abscess .................................................................... 101
Management of recurrent MRSA infections .................................. 102
Diabetic foot infections ............................................................... 103
Surgical-site infections ................................................................ 105
Serious, deep soft-tissue infections (necrotizing fasciitis).............. 107
Vertebral osteomyelitis, diskitis, epidural abscess ....................... 108
6.17 Urinary tract infections (UTI) ....................................................110
Bacterial UTI (including pyelonephritis and urosepsis) ................... 110
6.18 Candidiasis in the non-neutropenic patient ............................115
6.19 Guidelines for the use of prophylactic antimicrobials .................121
Pre-operative and pre-procedure antibiotic prophylaxis ................. 121
Prophylaxis against bacterial endocarditis .................................. 125
Prophylactic antimicrobials for patients with
solid organ transplants ............................................................... 126
6.20 Guidelines for the use of antimicrobials in
neutropenic hosts. ....................................................................129
Treatment of neutropenic fever ................................................... 129
Prophylactic antimicrobials for patients with
expected prolonged neutropenia ................................................ 131
Use of antifungal agents in hematologic
malignancy patients ............................................................. 133
7. Informational guidelines .................................................................137
7.1 Approach to the patient with a history of penicillin allergy ................ 137
8. Infection control ..............................................................................139
8.1 Hospital Epidemiology & Infection Control .................................... 139
8.2 Infection control precautions ....................................................... 141
8.3 Disease-specific infection control recommendations ..................... 142
10. Appendix:
A. Aminoglycoside dosing and therapeutic monitoring ........................ 145
B. Vancomycin dosing and therapeutic monitoring .............................. 150
C. Antimicrobial therapy monitoring ................................................... 153
D. Oral antimicrobial use ................................................................... 154
E. Antimicrobial dosing in renal insufficiency ....................................... 155
F. Cost of select antimicrobial agents ................................................ 159
2
Table of contents

5. Introduction
Antibiotic resistance is now a major issue confronting healthcare
providers and their patients. Changing antibiotic resistance patterns,
rising antibiotic costs and the introduction of new antibiotics have
made selecting optimal antibiotic regimens more difficult now than
ever before. Furthermore, history has taught us that if we do not
use antibiotics carefully, they will lose their efficacy. As a response
to these challenges, the Johns Hopkins Antimicrobial Stewardship
Program was created in July 2001. Headed by an Infectious Disease
physician (Sara Cosgrove, M.D., M.S.) and an Infectious Disease
pharmacist (Edina Avdic, Pharm.D., M.B.A), the mission of the
program is to ensure that every patient at Hopkins on antibiotics
gets optimal therapy. These guidelines are a step in that direction.
The guidelines were initially developed by Arjun Srinivasan, M.D., and
Alpa Patel, Pharm.D., in 2002 and have been revised and expanded
annually.
These guidelines are based on current literature reviews, including
national guidelines and consensus statements, current microbiologic
data from the Hopkins lab, and Hopkins’ faculty expert opinion.
Faculty from various departments have reviewed and approved these
guidelines. As you will see, in addition to antibiotic recommendations,
the guidelines also contain information about diagnosis and other
useful management tips.
As the name implies, these are only guidelines, and we anticipate
that occasionally, departures from them will be necessary. When these
cases arise, we will be interested in knowing why the departure is
necessary. We want to learn about new approaches and new data as
they become available so that we may update the guidelines as needed.
You should also document the reasons for the departure in the patient’s
chart.
Sara E. Cosgrove, M.D., M.S.
Director, Antimicrobial Stewardship Program
Edina Avdic, Pharm.D., M.B.A
ID Pharmacist
Associate Director, Antimicrobial Stewardship Program
Kate Dzintars, Pharm.D.
ID Pharmacist
Janessa Smith, Pharm.D.
ID Pharmacist
3
1. Introduction

6. 4
1. Introduction
The following people served as section/topic reviewers
N. Franklin Adkinson, M.D. (Allergy/Immunology)
Paul Auwaerter, M.D. (Infectious Diseases)
Robin Avery, M.D. (Infectious Diseases)
John Bartlett, M.D. (Infectious Diseases)
Dina Benani, Pharm. D. (Pharmacy)
Michael Boyle, M.D. (Pulmonary)
Roy Brower, M.D. (Critical Care and Pulmonary)
Karen Carroll, M.D. (Pathology/Infectious Diseases)
Michael Choi, M.D. (Nephrology)
John Clarke, M.D. (Gastroenterology)
Todd Dorman, M.D. (Critical Care)
Christine Durand, M.D. (Infectious Diseases)
Khalil Ghanem, M.D. (Infectious Diseases)
James Hamilton, M.D. (Gastroenterology)
Carolyn Kramer, M.D. (Medicine)
Pam Lipsett, M.D. (Surgery and Critical Care)
Colin Massey, M.D. (Medicine)
Lisa Maragakis, M.D. (Infectious Diseases)
Kieren Marr, M.D. (Infectious Diseases)
Robin McKenzie, M.D. (Infectious Diseases)
Michael Melia, M.D. (Infectious Diseases)
George Nelson, M.D. (Infectious Diseases)
Eric Nuermberger, M.D. (Infectious Diseases)
Trish Perl, M.D., M.Sc. (Infectious Diseases)
Stuart Ray, M.D. (Infectious Diseases)
Anne Rompalo, M.D. (Infectious Diseases)
Annette Rowden, Pharm.D. (Pharmacy)
Paul Scheel, M.D. (Nephrology)
Cynthia Sears, M.D. (Infectious Diseases)
Maunank Shah, M.D. (Infectious Diseases)
Tiffeny Smith, Pharm.D. (Pharmacy)
Jennifer Townsend, M.D. (Infectious Diseases)
Robert Wise, M.D. (Pulmonary)
Frank Witter, M.D. (OB-GYN)
How to use this guide
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dose of antibiotics for the particular infection.
UÊALL DOSES IN THE TEXT ARE FOR ADULTS WITH NORMAL
RENAL AND HEPATIC FUNCTION.
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please refer to the sections on antibiotic dosing to determine the
correct dose.
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some important treatment notes that explain a bit about WHY the
particular antibiotics were chosen and that provide some important
tips on diagnosis and management. PLEASE glance at these notes

7. 1. Introduction
5
when you are treating infections, as we think the information will prove
helpful. All references are on file in the office of the Antimicrobial
Stewardship Program (7-4570).
Contacting us
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they are part of an approved order.
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A word from our lawyers
The recommendations given in this guide are meant to serve as
treatment guidelines. They should NOT supplant clinical judgment or
Infectious Diseases consultation when indicated. The recommendations
were developed for use at The Johns Hopkins Hospital and thus may
not be appropriate for other settings. We have attempted to verify
that all information is correct but because of ongoing research, things
may change. If there is any doubt, please verify the information in the
}Õˆ`iÊLÞÊV>ˆ˜}ÊÌ…iÊ>˜ÌˆLˆœÌˆVÃÊ«>}iÀÊÕȘ}Ê* Ê­Ãi>ÀV…ʺ>˜ÌˆLˆœÌˆV»®ÊœÀÊ
Infectious Diseases.
Also, please note that these guidelines contain cost information
that is confidential. Copies of the book should not be distributed
outside of the institution without permission.

8. Obtaining ID approval
The use of restricted and non-formulary antimicrobials requires pre-
approval from Infectious Diseases. This approval can be obtained by any
of the following methods.
Approval method Notes
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and 10 p.m. PING the ID consult pager
if you fail to get a response from the ID
approval pager within 10 minutes.
Overnight Approval Restricted antibiotics ordered between
10 p.m. and 8 a.m. must be approved
by noon the following morning.
Ê UÊÊ *i>ÃiÊÀi“i“LiÀÊÌœÊÈ}˜ÊœÕÌÊÌ…iʘii`Ê
for approval if you go off shift before
8 a.m.
Ordersets (e.g. neutropenic These forms are P&T-approved for
fever, etc.) specific agents and specific indications.
2.1 Obtaining ID approval
6

9. 7
2.2 Antimicrobial formulary and restriction status
Selected formulary antimicrobials
and restriction status
The following list applies to ALL adult floors and includes the status of
both oral and injectable dosage forms, unless otherwise noted.
Unrestricted
Amoxicillin
Amoxicillin/clavulanate
Ampicillin/sulbactam
(Unasyn
®
)
Ampicillin IV
Azithromycin
Cefazolin
Cefdinir
Cefotetan
Cefpodoxime
Ceftriaxone
Cefuroxime IV
Cephalexin
Clarithromycin
Clindamycin
Dicloxacillin
Doxycycline
Ertapenem
Erythromycin
Gentamicin
Metronidazole
Minocycline
Nitrofurantoin
Oxacillin
Penicillin V/G
Ribavirin oral
Rifampin
Streptomycin
Tobramycin
Trimethoprim/
sulfamethoxazole
Amphotericin B
deoxycholate
(Fungizone
®
)
Flucytosine
Itraconazole oral solution

Restricted (requires ID
approval)
Amikacin
Aztreonam
Cefepime
Ceftaroline
1
Ceftazidime
Ceftolozane/tazobactam
1
Ciprofloxacin
Colistin IV
Cytomegalovirus Immune
Globulin (Cytogam
®
)
2
Daptomycin
1
Fosfomycin
3
Linezolid
Meropenem
Moxifloxacin
Nitazoxanide
4
Palivizumab (Synagis
®
)
5
Piperacillin/tazobactam
­<œÃÞ˜
®
)
Quinupristin/
dalfopristin (Synercid
®
)
Ribavirin inhaled
5
Telavancin
1
Tigecycline
Vancomycin
Liposomal amphotericin B
(AmBisome
®
)
Micafungin
Fluconazole
6
Posaconazole
Voriconazole
1
Approval must be obtained from Antimicrobial Stewardship Program 24h/7 days a week
2
Approval required, except for solid organ transplant patients
3
Approval must be obtained 24h/7 days a week
4
Approval must be obtained from Polk Service or ID Consult
5
Approval must be obtained from ID attending physician 24h/7 days a week
6
Oral Fluconazole, when used as a single-dose treatment for vulvovaginal candidiasis or when
used in compliance with the SICU/WICU protocol, does not require ID approval
Restricted antimicrobials that are ordered as part of a P&T-approved critical pathway or order
set do NOT require ID approval.
REMINDER: the use of non-formulary antimicrobials is strongly discouraged. ID
approval MUST be obtained for ALL non-formulary antimicrobials.
NOTE: Formulary antivirals (e.g. Acyclovir, Ganciclovir) do NOT require ID approval.

10. Antibiotics
Ceftaroline
Ceftaroline is a cephalosporin with in vitro activity against staphylococci
(including MRSA), most streptococci, and many Gram-negative bacteria.
It does NOT have activity against Pseudomonas spp. or Acinetobacter
spp. or Gram negative anaerobes.
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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Gram negative coverage is also needed
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Unacceptable uses
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and soft tissue infections (SSTI) where other more established and
less expensive options are available
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Dose
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serious infections
UÊ
Must adjust for worsening renal function and dialysis (see p. 155 for
dose adjustment recommendation).
Laboratory interactions
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hemolytic anemia. However, if drug-induced hemolytic anemia is
suspected, discontinue Ceftaroline.
Ceftolozane/tazobactam
Ceftolozane/tazobactam is a novel cephalosporin and β-lactamase-
inhibitor combination. It has activity against Gram-negative organisms
and some strains of multi-resistant Pseudomonas spp. It does NOT have
activity against carbapenemase-producing Enterobacteriaceae. It also
has in vitro activity against some streptococci and some Gram-negative
anaerobes, but it does not have reliable Staphylococcus spp. activity.
8
3.1 Agent-specific guidelines: Antibiotics

11. Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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spp. infections on a case by case basis
Unacceptable uses
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or complicated urinary tract infections (cUTI) as current standard
regimens are sufficient for coverage of the typical pathogens involved
in these infections and less expensive options are available
Dose
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metronidazole for cIAI
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for dose adjustment recommendation).
Colistin (Colistimethate)
Colistin is a polymixin antibiotic. It has in vitro activity against
Acinetobacter spp. and Pseudomonas spp. but does NOT have activity
against Proteus, Serratia, Providentia, Burkholderia, Stenotrophomonas,
Gram-negative cocci, Gram-positive organisms, or anaerobes.
Acceptable uses
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and Pseudomonas on a case by case basis.
Unacceptable uses
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Dose
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renal function and dialysis (see p. 155 for dose adjustment
recommendation).
Toxicity
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3.1 Agent-specific guidelines: Antibiotics
9

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Daptomycin
Daptomycin is a lipopeptide antibiotic. It has activity against most strains
of staphylococci and streptococci (including MRSA and VRE). It does
NOT have activity against Gram-negative organisms.
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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coagulase-negative staphylococci in a patient with serious allergy to
Vancomycin
UÊÊ >VÌiÀi“ˆ>ÊœÀÊi˜`œV>À`ˆÌˆÃÊV>ÕÃi`ÊLÞÊ,-ʈ˜Ê>Ê«>̈i˜ÌÊv>ˆˆ˜}Ê
6>˜Vœ“ÞVˆ˜ÊÌ…iÀ>«ÞÊ>ÃÊ`iw˜i`ÊLÞ\Ê
UÊʏˆ˜ˆV>Ê`iVœ“«i˜Ã>̈œ˜Ê>vÌiÀÊÎq{Ê`>ÞÃ
UÊÊ>ˆÕÀiÊÌœÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ>vÌiÀÊÇÊ`>ÞÃÊ`iëˆÌiÊ6>˜Vœ“ÞVˆ˜Ê
ÌÀœÕ}…ÃÊœvÊ£xqÓäÊ“V}É“Ê­…ˆ}…ÊÀˆÃŽÊœvÊ>«Ìœ“ÞVˆ˜ÊÀiÈÃÌ>˜ViÆÊ
check Daptomycin MIC and obtain follow up blood cultures)
UÊÊÊœvÊ6>˜Vœ“ÞVˆ˜ÊˆÃÊÓÊ“V}É“
UÊÊ/…iÀ>«ÞÊvœÀÊ6,ʈ˜viV̈œ˜Ãʜ̅iÀÊÌ…>˜Ê«˜iÕ“œ˜ˆ>]Êœ˜Ê>ÊV>ÃiÊLÞÊV>ÃiÊL>ÈÃ
Unacceptable uses
UÊÊ>«Ìœ“ÞVˆ˜ÊÃ…œÕ`Ê "/ÊLiÊÕÃi`ÊvœÀÊÌÀi>Ì“i˜ÌÊœvÊ«˜iÕ“œ˜ˆ>Ê`ÕiÊÌœÊ
its inactivation by pulmonary surfactant.
UÊʘˆÌˆ>ÊÌ…iÀ>«ÞÊvœÀÊÀ>“‡«œÃˆÌˆÛiʈ˜viV̈œ˜ÃÊ
UÊÊ6,ÊVœœ˜ˆâ>̈œ˜ÊœvÊÌ…iÊÕÀˆ˜i]ÊÀiëˆÀ>ÌœÀÞÊÌÀ>VÌ]Êܜ՘`Ã]ÊœÀÊ`À>ˆ˜ÃÊ
Dose
UÊÊ >VÌiÀi“ˆ>\ÊÈq£ÓÊ“}ÉŽ}Ê6Ê+ÊÓ{
UÊʘ`œV>À`ˆÌˆÃ\ÊÈq£ÓÊ“}ÉŽ}Ê6Ê+ÊÓ{
UÊÊœÃiÊ>`ÕÃÌ“i˜ÌʈÃʘiViÃÃ>ÀÞÊvœÀÊÀÊ 30 ml/min (see p. 155 for
dose adjustment recommendation).
3.1 Agent-specific guidelines: Antibiotics
10
Hidden Content
- JHH Internal use only

13. 11
3.1 Agent-specific guidelines: Antibiotics
Toxicity
UÊÊÞœ«>Ì…ÞÊ­`iw˜i`Ê>ÃÊÊ 10 times the upper limit of normal without
symptoms or 5 times the upper limit of normal with symptoms).
UÊʜȘœ«…ˆˆVÊ«˜iÕ“œ˜ˆ>
UÊÊœ˜ˆÌœÀˆ˜}\ÊÊÜiiŽÞ]Ê“œÀiÊvÀiµÕi˜ÌÞÊ`ÕÀˆ˜}ʈ˜ˆÌˆ>ÊÌ…iÀ>«Þ°Ê
,iviÀi˜Vi\Ê
Daptomycin in S. aureusÊL>VÌiÀi“ˆ>Ê>˜`ʈ˜viV̈ÛiÊi˜`œV>À`ˆÌˆÃ\Ê Ê˜}ÊÊi`ÊÓääÈÆÊ
Îxx\ÊÈxÎqÈx°
Ertapenem
Ertapenem 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
UÊʈ`Ê̜ʓœ`iÀ>Ìiʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜ÃÊ­Lˆˆ>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ã]Ê
diverticulitis, secondary peritonitis/GI perforation)
UÊÊœ`iÀ>ÌiÊ`ˆ>LïVÊvœœÌʈ˜viV̈œ˜ÃÊ܈̅œÕÌÊœÃÌiœ“ÞiˆÌˆÃ
UÊÊœ`iÀ>ÌiÊÃÕÀ}ˆV>‡ÃˆÌiʈ˜viV̈œ˜ÃÊvœœÜˆ˜}ÊVœ˜Ì>“ˆ˜>Ìi`Ê«ÀœVi`ÕÀi
UÊ*iÛˆVʈ˜y>““>ÌœÀÞÊ`ˆÃi>Ãi
UÊÊ1Àˆ˜>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜ÃÊV>ÕÃi`ÊLÞÊ- ‡«Àœ`ÕVˆ˜}ÊœÀ}>˜ˆÃ“ÃÊ
UÊÊ*Þiœ˜i«…ÀˆÌˆÃʈ˜Ê>Ê«>̈i˜ÌÊÜ…œÊˆÃʘœÌÊÃiÛiÀiÞʈ
Unacceptable uses
UÊÊ-iÛiÀiʈ˜viV̈œ˜Ãʈ˜ÊÜ…ˆV… Pseudomonas spp. are suspected.
Dose
UÊÊ£Ê}Ê6ÊœÀÊÊ+Ó{]Ê“ÕÃÌÊ>`ÕÃÌÊvœÀÊÜœÀÃi˜ˆ˜}ÊÀi˜>ÊvÕ˜V̈œ˜Ê>˜`Ê
dialysis (see
p. 155 for dose adjustment recommendation)
Toxicity
UÊʈ>ÀÀ…i>]ʘ>ÕÃi>]Ê…i>`>V…i]Ê«…iLˆÌˆÃÉÌ…Àœ“Lœ«…iLˆÌˆÃ
Fosfomycin
Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in
vitro activity against large number of Gram-negative and Gram-positive
organisms including E. coli, Klebsiella spp., Proteus spp., Pseudomonas
spp., and VRE. It does not have activity against Acinetobacter spp.
Fosfomycin is available in an oral formulation only in the U.S. and its
pharmacokinetics allow for one-time dosing.
Acceptable uses
UÊÊ>˜>}i“i˜ÌÊœvÊÕ˜Vœ“«ˆV>Ìi`Ê1/ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʓՏ̈«iÊ>˜ÌˆLˆœÌˆVÊ
allergies and/or when no other oral therapy options are available.

14. UÊÊ1˜Vœ“«ˆV>Ìi`Ê1/Ê`ÕiÊÌœÊ6,
UÊÊÊ ->Û>}iÊÌ…iÀ>«ÞÊvœÀÊ1/Ê`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiÊ
organisms (e.g. Pseudomonas spp.) on case by case basis.
NOTE: Susceptibility to Fosfomycin should be confirmed prior to
initiation of therapy.
Unacceptable uses
UÊÊœÃvœ“ÞVˆ˜ÊÃ…œÕ`Ê "/ÊLiÊÕÃi`ÊvœÀÊ“>˜>}i“i˜ÌÊœvÊ>˜Þʈ˜viV̈œ˜ÃÊ
outside of the urinary tract because it does not achieve adequate
concentrations at other sites.
UÊÊ/Ài>Ì“i˜ÌÊœvÊ>ÃÞ“«Ìœ“ˆVÊL>VÌiÀˆÕÀˆ>Ê­ÃiiÊ«°Ê££ä®
Dose
UÊÊ1˜Vœ“«ˆV>Ìi`Ê1/\ÊÎÊ}Ê­£ÊÃ>V…iÌ®Ê*"Êœ˜Vi°Ê
UÊÊœ“«ˆV>Ìi`Ê1/\ÊÎÊ}Ê­£ÊÃ>V…iÌ®Ê*"ÊiÛiÀÞÊ£‡ÎÊ`>ÞÃÊ­Õ«ÊÌœÊÓ£Ê`>ÞÃÊœvÊ
treatment)
UÊÊÀiµÕi˜VÞÊ>`ÕÃÌ“i˜ÌÊ“>ÞÊLiʘiViÃÃ>ÀÞʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊÀÊ 50
mL/min. Contact the ID Pharmacist for dosing recommendations.
UÊÊ*œÜ`iÀÊÃ…œÕ`ÊLiÊ“ˆÝi`Ê܈̅ʙäq£ÓäÊ“ÊœvÊVœœÊÜ>ÌiÀ]ÊÃ̈ÀÀi`ÊÌœÊ
dissolve and administered immediately.
Toxicity
UÊʈ>ÀÀ…i>]ʘ>ÕÃi>]Ê…i>`>V…i]Ê`ˆâ∘iÃÃ]Ê>ÃÌ…i˜ˆ>Ê>˜`Ê`Þëi«Ãˆ>
Linezolid
Acceptable uses
UÊÊœVÕ“i˜Ìi`Ê6>˜Vœ“ÞVˆ˜Êˆ˜ÌiÀ“i`ˆ>ÌiÊStaphylococcus aureus (VISA)
or Vancomycin resistant Staphylococcus aureus (VRSA) infection
UÊÊœVÕ“i˜Ìi`Ê,-ÊœÀÊiÌ…ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊ
staphylococcal infection in a patient with serious allergy to Vancomycin
UÊÊœVÕ“i˜Ìi`Ê,-ÊœÀÊiÌ…ˆVˆˆ˜‡ÀiÈÃÌ>˜ÌÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊ
staphylococcal infection in a patient failing Vancomycin therapy (as
`iw˜i`ÊLiœÜ®\Ê
UÊÊ >VÌiÀi“ˆ>Éi˜`œV>À`ˆÌˆÃ\Êv>ˆÕÀiÊÌœÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ>vÌiÀÊ
ÇÊ`>ÞÃÊ`iëˆÌiÊ6>˜Vœ“ÞVˆ˜ÊÌÀœÕ}…ÃÊœvÊ£xqÓäÊ“V}É“°Ê-…œÕ`ÊLiÊ
used in combination with another agent
UÊÊ*˜iÕ“œ˜ˆ>\ÊÜœÀÃi˜ˆ˜}ʈ˜wÌÀ>ÌiÊœÀʫՏ“œ˜>ÀÞÊÃÌ>ÌÕÃʈ˜Ê>Ê«>̈i˜ÌÊ
with documented MRSA pneumonia after 2 to 3 days or if the
MIC of Vancomycin is 2 mcg/mL, or if achieving appropriate
vancomycin trough is unlikely (e.g., obesity)
UÊÊ>ÃiÃÊÃ…œÕ`ÊLiÊ`ˆÃVÕÃÃi`Ê܈̅ʘviV̈œÕÃʈÃi>ÃiÃÊœÀÊ
Antimicrobial stewardship
UÊ
High suspicion of CA-MRSA necrotizing pneumonia in a seriously
ill patient
3.1 Agent-specific guidelines: Antibiotics
12

15. 13
3.1 Agent-specific guidelines: Antibiotics
ÊUÊÊœVÕ“i˜Ìi`Ê6,ʈ˜viV̈œ˜Ê
UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊˆ˜ÊV…>ˆ˜Ãʈ˜ÊLœœ`ÊVՏÌÕÀiÃʈ˜Ê>˜Ê1]ÊœÀÊœ˜Vœœ}ÞÊ
transplant patient known to be colonized with VRE
Unacceptable uses
UÊÊ*Àœ«…ޏ>݈Ã
UÊʘˆÌˆ>ÊÌ…iÀ>«ÞÊvœÀÊÃÌ>«…ޏœVœVV>Êˆ˜viV̈œ˜
UÊÊ6,ÊVœœ˜ˆâ>̈œ˜ÊœvÊÌ…iÊÃÌœœ]ÊÕÀˆ˜i]ÊÀiëˆÀ>ÌœÀÞÊÌÀ>VÌ]Êܜ՘`Ã]ÊœÀÊ`À>ˆ˜Ã
Dose
UÊÊÈääÊ“}Ê6É*"Ê+£Ó
UÊÊ-Žˆ˜Ê>˜`ÊÃŽˆ˜‡ÃÌÀÕVÌÕÀiʈ˜viV̈œ˜Ã\Ê{ääÊ“}Ê6É*"Ê+£Ó
Toxicity
UÊÊ œ˜iÊ“>ÀÀœÜÊÃÕ««ÀiÃÈœ˜Ê­ÕÃÕ>ÞÊœVVÕÀÃÊ܈̅ˆ˜ÊwÀÃÌÊÓÊÜiiŽÃÊœvÊÌ…iÀ>«Þ®
UÊÊ"«ÌˆVʘiÕÀˆÌˆÃÊ>˜`ʈÀÀiÛiÀÈLiÊÃi˜ÃœÀÞÊ“œÌœÀÊ«œÞ˜iÕÀœ«>Ì…ÞÊ­ÕÃÕ>ÞÊ
occurs with prolonged therapy > 28 days)
UÊÊ>ÃiÊÀi«œÀÌÃÊœvʏ>V̈VÊ>Vˆ`œÃˆÃ
UÊÊ>ÃiÊÀi«œÀÌÃÊœvÊÃiÀœÌœ˜ˆ˜ÊÃÞ˜`Àœ“iÊÜ…i˜ÊVœ‡>`“ˆ˜ˆÃÌiÀi`Ê܈̅Ê
serotonergic agents (SSRIs, TCAs, MAOIs, etc.)
UÊÊœ˜ˆÌœÀˆ˜}\Ê ÊÜiiŽÞ
Tigecycline
Tigecycline is a tetracycline derivative called a glycylcycline. It has in
vitro activity against most strains of staphylococci and streptococci
(including MRSA and VRE), anaerobes, and many Gram-negative
organisms with the exception of Proteus spp. and Pseudomonas
aeruginosa. It is FDA approved for skin and skin-structure infections and
intra-abdominal infections.
NOTE: Peak serum concentrations of Tigecycline do not exceed
1 mcg/mL which limits its use for treatment of bacteremia
Acceptable uses
UÊÊ>˜>}i“i˜ÌÊœvʈ˜ÌÀ>‡>L`œ“ˆ˜>Êˆ˜viV̈œ˜Ãʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê
contraindications to both beta-lactams and fluoroquinolones
UÊÊ>˜>}i“i˜ÌÊœvʈ˜viV̈œ˜ÃÊ`ÕiÊ̜ʓՏ̈‡`ÀÕ}ÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiÊ
organisms including Acinetobacter spp. and Stenotrophomonas
maltophilia on a case by case basis
UÊÊ->Û>}iÊÌ…iÀ>«ÞÊvœÀÊ,-É6,ʈ˜viV̈œ˜ÃÊœ˜Ê>ÊV>ÃiÊLÞÊV>ÃiÊL>ÈÃ
Dose
UÊÊ£ääÊ“}Ê6Êœ˜Vi]ÊÌ…i˜ÊxäÊ“}Ê6Ê+£Ó
UÊÊ£ääÊ“}Ê6Êœ˜Vi]ÊÌ…i˜ÊÓxÊ“}Ê6Ê+£ÓʈvÊÃiÛiÀiÊ…i«>̈Vʈ“«>ˆÀ“i˜ÌÊ
­…ˆ`ʇÊ*Õ}…Ê£äq£x®
Toxicity
UÊÊ >ÕÃi>Ê>˜`ÊÛœ“ˆÌˆ˜}Ê

16. 14
3.1 Agent-specific guidelines: Antibiotics
Trimethoprim/sulfamethoxazole
(Bactrim
®
, TMP/SMX)
Trimethoprim/sulfamethoxazole is a sulfonamide antibiotic. It has in vitro
activity against Enterobacteriaceae spp., B. cepacia, S. maltophilia,
Acinetobacter spp., Achromobacter spp., Nocardia spp., Listeria,
Pneumocystis jirovecii (PCP), staphylococci (including S. aureus and
Coagulase-negative staph), but does NOT cover Pseudomonas spp.
It has variable activity against streptococci and no activity against
anaerobes.
Acceptable uses
UÊ1Àˆ˜>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜ÃÊ­1/®
UÊS. aureus skin and soft-tissue infections (SSTI)
UÊPneumocystis jirovecii pneumonia (PCP) treatment and prophylaxis
UÊS. maltophilia infections
UÊ œV>À`ˆ>ʈ˜viV̈œ˜ÃÊ
UÊÀ>“‡˜i}>̈ÛiÊL>VÌiÀi“ˆ>ÊÜ…i˜ÊœÀ}>˜ˆÃ“ʈÃÊÃÕÃVi«ÌˆLiÊ
UÊÊ->Û>}iÊÌ…iÀ>«ÞÊvœÀÊ,-ÊL>VÌiÀi“ˆ>ʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê>˜œÌ…iÀÊ
agent
UÊÊ“«ˆÀˆVÊVœÛiÀ>}iÊœvÊListeria meningitis in patients with penicillin
allergies
UÊÊ-Õ««ÀiÃÈÛiÊÌ…iÀ>«ÞÊ>˜`ʈ˜ÊÃœ“iÊV>ÃiÃÊÌÀi>Ì“i˜ÌÊvœÀÊLœ˜iÊ>˜`ʍœˆ˜ÌÊ
infections
Unacceptable uses
UÊœ˜œÌ…iÀ>«ÞÊvœÀÊS. aureus bacteremia
Dose
UÊTrimethoprim/sulfamethoxazole dosing is based on trimethoprim
component
UÊ/*É-8Ê…>ÃÊiÝVii˜ÌÊLˆœ>Û>ˆ>LˆˆÌÞ]ÊÌ…ÕÃÊVœ˜ÛiÀÈœ˜ÊvÀœ“Ê6ÊÌœÊ*"Ê
ˆÃÊ£\£Ê­näÉ{ääÊ“}Ê6ÊrÊ£Ê--ÊÌ>LÆÊ£ÈäÉnääÊ“}Ê6ÊrÊ£Ê-ÊÌ>L®Ê
UÊ1ÃiÊ>`ÕÃÌi`Ê 7rÊQ 7ʳÊä°{Ê­ 7Ê‡Ê 7®Rʈ˜ÊœLiÃiÊ«>̈i˜ÌÃÊ­€Îä¯Ê
over IBW)
Treatment
UÊ1/\Ê£Ê-ÊÌ>LÊ+£ÓÊ
UÊ--/\Ê£‡ÓÊ-ÊÌ>LÊ+£Ó
UÊ**\£x‡ÓäÊ“}ÉŽ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®
UÊ,-ÊL>VÌiÀi“ˆ>\£ä‡£xÊ“}ÉŽ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®
UÊS. maltophiliaʈ˜viV̈œ˜Ã\£xÊ“}ÉŽ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®Ê

17. 15
3.1 Agent-specific guidelines: Antibiotics
UÊ œV>À`ˆ>ʈ˜viV̈œ˜Ã\Ê£xÊ“}ÉŽ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ+n®ÆʏœÜiÀÊ
doses (5-10 mg/kg/day) can be used after several weeks of therapy
or cutaneous infections
UÊi˜ˆ˜}ˆÌˆÃ\ÊÓäÊ“}ÉŽ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+È®
UÊ"Ì…iÀʈ˜viV̈œ˜Ã\Ên‡£äÊ“}ÉŽ}É`>ÞÊ­ˆ˜Ê`ˆÛˆ`i`Ê`œÃiÃ]Ê+ȇ£Ó®
UÊÕÃÌÊ>`ÕÃÌÊ`œÃiÊvœÀÊÜœÀÃi˜ˆ˜}ÊÀi˜>ÊvÕ˜V̈œ˜Ê>˜`Ê`ˆ>ÞÈÃÊ­ÃiiÊ«°£xxÊ
for dose adjustment recommendation).
Prophylaxis
UÊ**\Ê£Ê--Ê`>ˆÞÊœÀÊ£Ê-ÊÎÊ̈“iÃÉÜiiŽÊ
UÊ/œÝœ«>ӜÈÃ\Ê£Ê-Ê`>ˆÞÊ
Toxicity
UÊœ““œ˜\Ê…Þ«iÀÃi˜ÃˆÌˆÛˆÌÞÊ­£°È‡n¯®]ʇիÃiÌ]Ê«ÃiÕ`œÊiiÛ>̈œ˜Êˆ˜Ê
VÀi>̈˜ˆ˜iÊ­£n¯®Ê
UÊœ““œ˜Ê܈̅ʅˆ}…iÀÊ`œÃiÃ\Ê…Þ«iÀŽ>i“ˆ>]Ê“ÞiœÃÕ««ÀiÃÈœ˜
UÊ"VV>Èœ˜>\ʘi«…ÀœÌœÝˆVˆÌÞ]Ê«…œÌœÃi˜ÃˆÌˆÛˆÌÞ]Ê“iÌ…i“œ}œLˆ˜i“ˆ>ʭ܈̅Ê
severe G6PD deficiency)
UÊ,>Ài\Ê>Ãi«ÌˆVÊ“i˜ˆ˜}ˆÌˆÃ]Ê…i«>̜̜݈VˆÌÞ]Ê̜݈VÊi«ˆ`iÀ“>Ê˜iVÀœÞÈÃÊ
(TEN), SJS, Sweet’s syndrome
Drug Interaction
UÊ7>Àv>Àˆ˜]Ê“iÌ…œÌÀiÝ>Ìi]Ê«…i˜ÞÌœˆ˜]Ê`ˆ}œÝˆ˜]ÊÃՏvœ˜ÞÕÀi>Ã]Ê
procainamide, oral contraceptives

18. 3.2 Agent-specific guidelines: Antifungals
16
Antifungals
Liposomal Amphotericin B (AmBisome
®
)
NOTES:
UÊʜȘ}ÊœvÊ“ ˆÃœ“iÊ>˜`Ê“«…œÌiÀˆVˆ˜Ê Ê`iœÝÞV…œ>ÌiʈÃÊ
significantly different. Do not use AmBisome doses when
ordering Amphotericin B deoxycholate and vice versa.
UÊÊ“«…œÌiÀˆVˆ˜Ê Ê`iœÝÞV…œ>ÌiʈÃÊ«ÀiviÀÀi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅Êi˜`‡
stage renal disease on dialysis who are anuric.
AmBisome, like all Amphotericin B products, has broad spectrum
antifungal activity with in vitro activity against Candida, Aspergillus,
Zygomycosis and Fusarium.
Acceptable uses
UÊ>˜`ˆ`>Êi˜`œ«Ì…>“ˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]Ê -ʈ˜viV̈œ˜qwÀÃÌʏˆ˜iÊÌ…iÀ>«Þ
UÊÀÞ«ÌœVœVVÕÃÊ“i˜ˆ˜}ˆÌˆÃ‡wÀÃÌʏˆ˜iÊÌ…iÀ>«ÞÊÊ
UÊ<Þ}œ“ÞVœÃiÃÊ­Mucor, Rhizopus, Cunninghamella®qwÀÃÌʏˆ˜iÊÌ…iÀ>«ÞÊ
UÊÊ iÕÌÀœ«i˜ˆVÊviÛiÀʈvÊÀiViˆÛˆ˜}Ê6œÀˆVœ˜>✏iÊœÀÊ*œÃ>Vœ˜>✏iÊ
prophylaxis
UʏÌiÀ˜>̈ÛiÊÌÀi>Ì“i˜ÌÊœvʈ˜Û>ÈÛiÊ>ëiÀ}ˆœÃˆÃ
UÊʏÌiÀ˜>̈ÛiÊÌÀi>Ì“i˜ÌÊœvÊV>˜`ˆ`i“ˆ>]ÊV>˜`ˆ`>Ê«iÀˆÌœ˜ˆÌˆÃÊ
Dose
UÊÊ>˜`ˆ`i“ˆ>]Ê…ˆÃÌœ«>ӜÈÃ]ʜ̅iÀʘœ˜‡ˆ˜Û>ÈÛiÊV>˜`ˆ`>ʈ˜viV̈œ˜Ã\Ê
3 mg/kg/day
UÊÊ>˜`ˆ`>Êi˜`œ«Ì…>“ˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]Ê -ʈ˜viV̈œ˜]ÊC. krusei
V>˜`ˆ`i“ˆ>\ÊxÊ“}ÉŽ}É`>Þ
UʘÛ>ÈÛiÊw>“i˜ÌœÕÃÊvÕ˜}ˆ\ÊxÊ“}ÉŽ}É`>Þ
UÊ iÕÌÀœ«i˜ˆVÊviÛiÀ]ÊV>˜`ˆ`i“ˆ>ʈ˜Ê˜iÕÌÀœ«i˜ˆVÊ«>̈i˜Ì\ÊÎqxÊ“}ÉŽ}É`>Þ
UÊÀÞ«ÌœVœVV>Ê“i˜ˆ˜}ˆÌˆÃ\ÊÎq{Ê“}ÉŽ}É`>Þ
Toxicity
UʘvÕÈœ˜‡Ài>Ìi`ÊÀi>V̈œ˜Ã\ÊviÛiÀ]ÊV…ˆÃ]ÊÀˆ}œÀÃ]Ê…Þ«œÌi˜Ãˆœ˜
UÊÊ,i˜>Êˆ“«>ˆÀ“i˜ÌÊ­i˜…>˜Vi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊVœ˜Vœ“ˆÌ>˜Ìʘi«…ÀœÌœÝˆVÊ
drugs)
UʏiVÌÀœÞÌiʈ“L>>˜ViÃ
UÊÊ*Տ“œ˜>ÀÞÊ̜݈VˆÌÞÊ­V…iÃÌÊ«>ˆ˜]Ê…Þ«œÝˆ>]Ê`Þë˜i>®]Ê>˜i“ˆ>]ÊiiÛ>̈œ˜Êˆ˜Ê
hepatic enzymes-rare
UÊÊœ˜ˆÌœÀˆ˜}\Ê 1 ÉVÀi>̈˜ˆ˜i]Ê]Ê}]Ê*…œÃÊ>ÌÊL>Ãiˆ˜iÊ>˜`Ê`>ˆÞʈ˜Ê
…œÃ«ˆÌ>ˆâi`Ê«>̈i˜ÌÃÆÊ-/É/Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£‡ÓÊÜiiŽÃÊ

19. Micafungin
NOTE: Micafungin does not have activity against Cryptococcus.
Aspergillosis
UÊVVi«Ì>LiÊÕÃiÃ
UÊʘÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê6œÀˆVœ˜>✏iÊvœÀÊVœ˜wÀ“i`ʈ˜Û>ÈÛiÊ
aspergillosis (see p. 133)
UÊÊ,ivÀ>VÌœÀÞÊ`ˆÃi>Ãi‡ÊvœÀÊÕÃiʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅Ê6œÀˆVœ˜>✏i]Ê
Posaconazole or AmBisome
®
for confirmed invasive aspergillosis.
UÊ1˜>VVi«Ì>LiÊÕÃiÃ
UÊʈV>vÕ˜}ˆ˜Ê>œ˜iÊœÀʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅ʜ̅iÀÊ>˜ÌˆvÕ˜}>Ê>}i˜ÌÃʈÃÊ
not recommended for empiric therapy in patients with CT findings
suggestive of aspergillosis (e.g., possible aspergillosis) without
plans for diagnostic studies.
UÊʈV>vÕ˜}ˆ˜Ê`œiÃʘœÌÊ…>ÛiÊ}œœ`Êin vitro activity against
zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
Candidiasis
UÊVVi«Ì>LiÊÕÃiÃ
UÊ/Ài>Ì“i˜ÌÊœvʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃÊ`ÕiÊÌœÊC. glabrata or C. krusei.
UÊÊ/Ài>Ì“i˜ÌÊœvʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃʈ˜Ê«>̈i˜ÌÃÊÜ…œÊ>ÀiÊ "/ÊVˆ˜ˆV>ÞÊ
stable due to candidemia or have received prior long-term azole
therapy.
UʏÌiÀ˜>̈ÛiÊÌÀi>Ì“i˜ÌÊœvÊÀiVÕÀÀi˜ÌÊiÃœ«…>}i>ÊV>˜`ˆ`ˆ>Èð
UʏÌiÀ˜>̈ÛiÊÌÀi>Ì“i˜ÌÊœvÊi˜`œV>À`ˆÌˆÃ°
UÊ1˜>VVi«Ì>LiÊÕÃiÃ
UÊʈV>vÕ˜}ˆ˜Ê…>ÃÊ«œœÀÊ«i˜iÌÀ>̈œ˜Êˆ˜ÌœÊÌ…iÊ -Ê>˜`ÊÕÀˆ˜>ÀÞÊÌÀ>VÌ°ÊÌÊ
should be avoided for infections involving those sites.
Neutropenic fever
UÊʈV>vÕ˜}ˆ˜ÊV>˜ÊLiÊÕÃi`ÊvœÀʘiÕÌÀœ«i˜ˆVÊviÛiÀʈ˜Ê«>̈i˜ÌÃÊÜ…œÊ>ÀiʘœÌÊ
suspected to have aspergillosis or zygomycosis.
Dose
UÊÊ>˜`ˆ`i“ˆ>]ʈ˜Û>ÈÛiÊV>˜`ˆ`ˆ>ÈÃ]ʘiÕÌÀœ«i˜ˆVÊviÛiÀ\Ê£ääÊ“}Ê6Ê
Q24H
UÊ>˜`ˆ`>Êi˜`œV>À`ˆÌˆÃ\Ê£xäÊ“}Ê6Ê+Ó{
UÊ,iVÕÀÀi˜ÌÊiÃœ«…>}i>ÊV>˜`ˆ`ˆ>ÈÃ\Ê£xäÊ“}Ê6Ê+Ó{
UʘÛ>ÈÛiÊ>ëiÀ}ˆœÃˆÃ\Ê£ääq£xäÊ“}Ê6Ê+Ó{
UÊ"LiÃiÊ«>̈i˜ÌÃ
UÊÊ£ääq£xäÊŽ}\Ê£xäÊ“}Ê6Ê+Ó{
UÊÊ> £xäÊŽ}\Êœ˜ÃՏÌÊÊ*…>À“>VˆÃÌ
Drug Interactions
UÊʏœÃiÊ“œ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊÜ…i˜ÊˆV>vÕ˜}ˆ˜ÊˆÃÊÕÃi`Ê܈̅ÊÌ…iÊ
vœœÜˆ˜}Ê>}i˜ÌÃÊVœ˜Vœ“ˆÌ>˜ÌÞ\
17
3.2 Agent-specific guidelines: Antifungals

20. 3.2 Agent-specific guidelines: Antifungals
18
UÊÊ-ˆÀœˆ“ÕÃÊqʏiÛiÃÊœvÊ-ˆÀœˆ“ÕÃÊ“>ÞÊLiʈ˜VÀi>Ãi`]Ê“œ˜ˆÌœÀÊvœÀÊ
Sirolimus toxicity
UÊÊ ˆvi`ˆ«ˆ˜iÊqʏiÛiÃÊœvÊ ˆvi`ˆ«ˆ˜iÊ“>ÞÊLiʈ˜VÀi>Ãi`]Ê“œ˜ˆÌœÀÊvœÀÊ
Nifedipine toxicity
UÊÊÌÀ>Vœ˜>✏iÊqʏiÛiÃÊœvÊÌÀ>Vœ˜>✏iÊ“>ÞÊLiʈ˜VÀi>Ãi`]Ê“œ˜ˆÌœÀÊvœÀÊ
Itraconazole toxicity
Toxicity
UÊʘvÕÈœ˜‡Ài>Ìi`ÊÀi>V̈œ˜ÃÊ­À>Ã…]Ê«ÀÕÀˆÌˆÃ®]Ê«…iLˆÌˆÃ]Ê…i>`>V…i]ʘ>ÕÃi>Ê
and vomiting, and elevations in hepatic enzymes.
UÊœ˜ˆÌœÀˆ˜}\Ê-/É/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ°
Posaconazole
Posaconazole is a broad spectrum azole anti-fungal agent. It has in vitro
activity against Candida, Aspergillus, Zygomycosis and Fusarium spp.
Acceptable uses
UÊ/Ài>Ì“i˜ÌÊœvʈ˜Û>ÈÛiÊâÞ}œ“ÞVœÃˆÃʈ˜ÊVœ“Lˆ˜>̈œ˜Ê܈̅ʓ«…œÌiÀˆVˆ˜Ê
UÊÊœ˜œÌ…iÀ>«ÞÊvœÀÊâÞ}œ“ÞVœÃˆÃÊ>vÌiÀÊÇÊ`>ÞÃÊœvÊVœ“Lˆ˜>̈œ˜ÊÌ…iÀ>«ÞÊ
with Amphotericin B
UÊ*Àœ«…ޏ>݈Ãʈ˜Ê«>̈i˜ÌÃÊ܈̅ʅi“>Ìœœ}ˆVÊ“>ˆ}˜>˜VÞ
UÊ/Ài>Ì“i˜ÌÊœvÊ>ëiÀ}ˆœÃˆÃʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê6œÀˆVœ˜>✏iʈ˜ÌœiÀ>˜Vi
Unacceptable uses
UÊ>˜`ˆ`ˆ>ÈÃÉ iÕÌÀœ«i˜ˆVÊviÛiÀ
UʈÀÃ̇ˆ˜iÊÌÀi>Ì“i˜ÌÊœvÊ>ëiÀ}ˆœÃˆÃ
Dose
"/-\Ê
UÊÊ>V…Ê`œÃiÊœvÊÃÕëi˜Ãˆœ˜ÊÃ…œÕ`ÊLiÊ}ˆÛi˜Ê܈̅Ê>ÊvՏÊ“i>ÊœÀÊ܈̅ʏˆµÕˆ`Ê
nutritional supplements if patients cannot tolerate full meals. Can also
be given with an acidic beverage (e.g. ginger ale).
UÊÊi>Þi`ÊÀii>ÃiÊÌ>LiÌÃÊ>˜`ÊœÀ>ÊÃÕëi˜Ãˆœ˜ÊV>˜˜œÌÊLiÊÕÃi`Ê
interchangeably due to differences in the dosing of each formulation.
Prophylaxis
UÊ"À>Ê-Õëi˜Ãˆœ˜\ÊÓääÊ“}Ê*"Ê+n
UÊÝÌi˜`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääÊ“}Ê*"Ê`>ˆÞ
Treatment
UÊÊ"À>Ê-Õëi˜Ãˆœ˜\ÊÓääÊ“}Ê*"Ê+ÈÊvœÀÊÇÊ`>ÞÃ]ÊÌ…i˜Ê{ääÊ“}Ê*"Ê
Q8-Q12H
UÊÊÝÌi˜`i`Ê,ii>ÃiÊ/>LiÌ\ÊÎääÊ“}Ê*"Ê+£ÓÊvœÀÊ£Ê`>Þ]ÊÌ…i˜ÊÎääÊ“}Ê
PO daily

21. Therapeutic monitoring:
UÊ*œÃ>Vœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊÜ…œÊ>Ài\
UÊ œÌÊÀi뜘`ˆ˜}ÊÌœÊÌ…iÀ>«ÞÊvœÀÊ>Ìʏi>ÃÌÊÇÊ`>ÞÃ
UÊ iˆ˜}ÊÌÀi>Ìi`ÊvœÀÊÕ˜Vœ““œ˜ÊœÀʏiÃÃÊÃÕÃVi«ÌˆLiÊœÀ}>˜ˆÃ“Ã
UÊÝ«iÀˆi˜Vˆ˜}Ê“ÕVœÃˆÌˆÃÊœÀÊ“>>LÃœÀ«Ìˆœ˜ÊÃÞ˜`Àœ“i
UÊ1˜>LiÊÌœÊVœ˜ÃÕ“iÊ…ˆ}…Êv>ÌÊ“i>ÃÊ­ˆvÊÀiViˆÛˆ˜}ÊÌ…iÊÃÕëi˜Ãˆœ˜®
Drug Interactions: See Table on p. 21
Toxicity
UÊÊÊÕ«ÃiÌÊ­H{䯮]Ê…i>`>V…iÃ]ÊiiÛ>̈œ˜Êˆ˜Ê…i«>̈VÊi˜âÞ“iðÊ,>ÀiÊLÕÌÊ
serious effects include QTc prolongation.
UÊÊœ˜ˆÌœÀˆ˜}\Ê-/É/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ
,iviÀi˜ViÃ\
ˆ˜ˆV>ÊivwV>VÞÊœvʘiÜÊ>˜ÌˆvÕ˜}>Ê>}i˜ÌÃ\ÊÕÀÀÊ"«ˆ˜ÊˆVÀœLˆœ°ÊÓääÈÆ™\{n·nn°
*œÃ>Vœ˜>✏i\Ê>ÊLÀœ>`ÊëiVÌÀÕ“ÊÌÀˆ>✏iÊ>˜ÌˆvÕ˜}>\Ê>˜ViÌʘviVÌʈðÊÓääxÆÊx\ÇÇx‡nx°
Voriconazole
NOTE: Voriconazole does not cover zygomycoses (Mucor,
Rhizopus, Cunninghamella, etc.).
Acceptable uses
UÊ Aspergillosis
UÊ Scedosporium apiospermum
UÊProphylaxis in patients with hematologic malignancy
Unacceptable uses
UÊÊCandidiasis / Neutropenic fever
Voriconazole should not be used as first-line therapy for the treatment
of candidiasis or for empiric therapy in patients with neutropenic fever.
Dose
UÊÊœ>`ˆ˜}Ê`œÃi\ÊÈÊ“}ÉŽ}Ê6É*"Ê+£ÓÊÝÊÓÊ`œÃiÃ
UÊ>ˆ˜Ìi˜>˜ViÊ`œÃi\Ê{Ê“}ÉŽ}Ê6É*"Ê+£Ó
UÊÊœÃiÊ>`ÕÃÌ“i˜ÌʈÃʘiViÃÃ>ÀÞÊvœÀÊ…i«>̈Vʈ˜ÃÕvwVˆi˜VÞ\
UÊ…ˆ`ʇÊ*Õ}…Ê­ÊœÀÊ ®\Ê↓ “>ˆ˜Ìi˜>˜ViÊ`œÃiÊLÞÊxä¯
UÊÊ…ˆ`ʇÊ*Õ}…Ê­®\Ê1ÃiÊœ˜ÞʈvÊLi˜iwÌÃÊœÕÌÜiˆ}…ÊÀˆÃŽÃ°Êœ˜ÃՏÌÊ
ID pharmacist for dose adjustment recommendations.
UÊÊœÃiÊiÃV>>̈œ˜Ê“>ÞÊLiʘiViÃÃ>ÀÞÊvœÀÊÃœ“iÊ«>̈i˜ÌÃÊ`ÕiÊÌœÊ
subtherapeutic levels.
UÊÊœÃiÊL>Ãi`Êœ˜Ê>VÌÕ>ÊLœ`ÞÊÜiˆ}…ÌÊÕ˜iÃÃÊ«>̈i˜ÌÊ€Îä¯ÊœÛiÀÊ 7ÆÊ
then use adjusted body weight. (Adj. BW).
`°Ê 7ÊrÊQ 7ʳÊä°{Ê­ 7Ê‡Ê 7®R
IBW - Ideal Body Weight
ABW - Actual Body Weight
19
3.2 Agent-specific guidelines: Antifungals

22. 3.2 Agent-specific guidelines: Antifungals
20
Therapeutic monitoring
UÊÊ6œÀˆVœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊÜ…œÊ>Ài\
UÊÊ œÌÊÀi뜘`ˆ˜}ÊÌœÊÌ…iÀ>«ÞÊ>vÌiÀÊ>Ìʏi>ÃÌÊxÊ`>ÞÃÊœvÊÌ…iÀ>«ÞÊÕȘ}Ê>Ê
mg/kg dosing strategy
UÊÊ,iViˆÛˆ˜}ÊVœ˜Vœ“ˆÌ>˜ÌÊ`ÀÕ}ÃÊÌ…>ÌÊ“>Þʈ˜VÀi>ÃiÊœÀÊ`iVÀi>ÃiÊ
Voriconazole levels
UÊÊÝ«iÀˆi˜Vˆ˜}Ê>`ÛiÀÃiÊiÛi˜ÌÃÊ`ÕiÊÌœÊ6œÀˆVœ˜>✏i
UÊÊÝ«iÀˆi˜Vˆ˜}ÊÊ`ÞÃvÕ˜V̈œ˜
UÊÊ6œÀˆVœ˜>✏iÊÌÀœÕ}…ʏiÛiÃÊÃ…œÕ`ÊLiÊœLÌ>ˆ˜i`ÊxqÇÊ`>ÞÃÊ>vÌiÀÊÃÌ>ÀÌÊœvÊ
Ì…iÀ>«ÞÊ­«iÀvœÀ“i`Êq®°
UÊÊœ>ÊÌÀœÕ}…\ÊÓqx°xÊ“V}É“°ÊiÛiÃʐʣʓV}É“Ê…>ÛiÊLii˜Ê
associated with clinical failures and levels >5.5 mcg/mL with toxicity.
Drug Interactions: See Table on p. 21
Toxicity
UÊÊ6ˆÃÕ>Ê`ˆÃÌÕÀL>˜ViÃÊ­HÎ䯮ÊÕÃÕ>ÞÊÃiv‡ˆ“ˆÌi`]ÊÀ>Ã…]ÊviÛiÀ]ÊiiÛ>̈œ˜ÃÊ
in hepatic enzymes.
UÊÊœ˜ˆÌœÀˆ˜}\Ê-/É/ÉLˆˆÀÕLˆ˜Ê>ÌÊL>Ãiˆ˜iÊ>˜`ÊiÛiÀÞÊ£qÓÊÜiiŽÃÊ>vÌiÀ
,iviÀi˜ViÃ\
6œÀˆVœ˜âœi\ʏˆ˜Ê˜viVÌʈÃÊÓääÎÆÊÎÈ\ÈÎä°
6œÀˆVœ˜>✏iʈ˜Ê˜iÕÌÀœ«i˜ˆVÊviÛiÀ\Ê Ê˜}ÊÊi`ÊÓääÓÆÎ{È­{®\ÓÓx°Ê
6œÀˆVœ˜>✏iÊ/\ʏˆ˜Ê˜viVÌʈÃÊÓäänÆÊ{È\Ó䣰
Azole drug interactions
The following list contains major drug interactions involving drug
metabolism and absorption. This list is not comprehensive and is
intended as a guide only. You must check for other drug interactions
when initiating azole therapy or starting new medication in patients
already receiving azole therapy.
Drug metabolism:
ÞÌœV…Àœ“iÊ­9*®Ê*{xäʈ˜…ˆLˆÌœÀÃ\Ê`iVÀi>ÃiÊÌ…iÊ“iÌ>LœˆÃ“ÊœvÊViÀÌ>ˆ˜Ê
drugs (CYP450 substrates) resulting in increased drug concentrations in
the body (occurs immediately)
ÞÌœV…Àœ“iÊ­9*®Ê*{xäʈ˜`ÕViÀÃ\ʈ˜VÀi>ÃiÊÌ…iÊ“iÌ>LœˆÃ“ÊœvÊViÀÌ>ˆ˜Ê
drugs (CYP450 substrates) resulting in decreased drug concentrations
in the body (may take up to 2 weeks for upregulation of enzymes to
occur)
Drug absorption/penetration:
*‡}ÞVœ«ÀœÌiˆ˜Ê­*‡}«®Êˆ˜…ˆLˆÌœÀ\Ê`iVÀi>ÃiÊÌ…iÊvÕ˜V̈œ˜ÊœvÊÌ…iÊivyÕÝÊ«Õ“«]Ê
resulting in increased absorption/penetration of P-gp substrates
*‡}ÞVœ«ÀœÌiˆ˜Êˆ˜`ÕViÀ\ʈ˜VÀi>ÃiÊÌ…iÊvÕ˜V̈œ˜ÊœvÊÌ…iÊivyÕÝÊ«Õ“«]Ê
resulting in decreased absorption/penetration of P-gp substrates
PotencyÊœvÊÞÌœV…Àœ“iÊ*{xäʈ˜…ˆLˆÌˆœ˜\Ê6œÀˆVœ˜>✏iÊ€ÊÌÀ>Vœ˜>✏iÊ€Ê
Posaconazole > Fluconazole

23. 21
3.2 Agent-specific guidelines: Antifungals
POSACONAZOLE (substrate and inhibitor for P-gp efflux, inhibitor of CYP3A4)
Drug Recommendations
Contraindicated œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ sirolimus Do not use
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cisapride, ergot alkaloids, pimozide,
quinidine, triazolam
Warning/precaution Cyclosporine ↓ cyclosporine dose to
3
⁄4
and monitor levels
Metoclopramide, proton pump inhibitors May ↓ posaconazole concentrations when using suspension
Midazolam Consider dose reducing
Tacrolimus ↓ tacrolimus dose to
1
⁄3
and monitor levels
Cimetidine, efavirenz, phenytoin, rifabutin, rifampin Avoid concomitant use unless benefit outweighs risk
If used together, monitor effects of drugs and consider decreasing dose
when posaconazole is added
Amiodarone, atazanavir, digoxin, erythromycin, all calcium channel blockers, Monitor effect of drugs and consider decreasing dose when
ritonavir, statins (avoid lovastatin and simvastatin), vinca alkaloids posaconazole is added
ITRACONAZOLE and major metabolite hydroxyitraconazole (substrate and inhibitor of CYP3A4 and P-gp efflux)
Drug Recommendations
Contraindicated œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ statins (lovastatin, simvastatin) Do not use
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cisapride, dofetilide, ergot alkaloids,
nisoldipine, oral midazolam, pimozide, quinidine, triazolam
Warning/precaution œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ atorvastatin, benzodiazepines, chemotherapy plasma concentration of the interacting drug, monitor levels when
(busulfan, docetaxel, vinca alkaloids), cyclosporine, digoxin, efavirenz, possible, monitor for drug toxicity and consider dose reduction
eletriptan, fentanyl, oral hypoglycemics, indinavir, IV midazolam,
nifedipine, ritonavir, saquinavir, sirolimus, tacrolimus, verapamil, steroids
(budesonide, dexamethasone, fluticasone, methylprednisolone), warfarin
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ alfentanil, buspirone, cilostazol, disopyramide,
felodipine, trimetrexate
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ carbamazepine, efavirenz, isoniazid, nevirapine, ↓ plasma concentration of itraconazole, if possible avoid concomitant
phenobarbital, phenytoin, rifabutin, rifampin, antacids, H2 receptor use or monitor itraconazole levels
antagonists, proton pump inhibitors
Clarithromycin, erythromycin, fosamprenavir, indinavir, ritonavir, saquinavir plasma concentration of itraconazole, monitor itraconazole levels and
monitor for toxicity
↓
↓

24. 3.2 Agent-specific guidelines: Antifungals
22
VORICONAZOLE (substrate and inhibitor of CYP2C19, CYP2C9, and CYP3A4)
Drug Recommendations
Contraindicated œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ carbamazepine, rifabutin, rifampin, Do not use
ritonavir 400 mg Q12H
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ long-acting barbiturates, cisapride,
ergot alkaloids, pimozide, quinidine, St. John’s Wort
Warning/precaution Cyclosporine ↓ cyclosporine dose to
1
⁄2
and monitor levels
Efavirenz
↓ voriconazole dose to 5 mg/kg IV/PO Q12H and ↓ efavirenz to 300 mg
PO daily
Tacrolimus ↓ tacrolimus dose to
1
⁄3
and monitor levels
Sirolimus ↓ÊÈÀœˆ“ÕÃÊ`œÃiÊLÞÊÇx¯Ê>˜`Ê“œ˜ˆÌœÀʏiÛiÃ
Omeprazole ↓ omeprazole dose to 1
⁄2

Maraviroc ↓ maraviroc dose to 150 mg twice daily
Methadone Monitor effect of the interacting drug and consider decreasing dose
Phenytoin
↓ voriconazole to 5 mg/kg IV/PO Q12H and monitor levels
Ritonavir low dose (100 mg Q12H) Avoid this combination unless benefits outweigh risks
Warfarin Monitor INR levels
œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ all benzodiazepines (avoid midazolam and triazolam), Monitor effect of drugs and consider decreasing dose when voriconazole
all calcium channel blockers, fentanyl, oxycodone & other long acting opioids, is added
NSAIDs, oral contraceptives, statins (avoid lovastatin and simvastatin),
sulfonylureas, vinca alkaloids, pomalidomide, simeprevir, boceprevir, telaprevir
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ alfentanil
FLUCONAZOLE (substrate of CYP3A4 and inhibitor of CYP3A4, CYP2C9, and CYP2C19, interactions are often dose dependent)
Drug Recommendations
Contraindicated Cisapride Do not use
Warning/precaution œ““œ˜ÞÊ«ÀiÃVÀˆLi`\ cyclosporine, glipizide, glyburide, phenytoin,
↓ plasma concentration of the interacting drug, monitor levels when
rifabutin, tacrolimus, warfarin possible, monitor for drug toxicity and consider dose reduction
iÃÃÊVœ““œ˜ÞÊ«ÀiÃVÀˆLi`\ oral midazolam, theophylline, tolbutamide
Rifampin ↓ plasma concentration of fluconazole, consider increasing fluconazole dose

25. 23
3.3 Agent-specific guidelines: Vaccines
Pneumococcal vaccination
There are two types of pneumococcal vaccines that are recommended
LÞÊ*Ê}Õˆ`iˆ˜iÃÊvœÀÊ>`ՏÌÊ«>̈i˜ÌÃ\Ê*˜iÕ“œVœVV>Ê«œÞÃ>VV…>Àˆ`iÊ
(Pneumovax 23
®
, PPV23) and Pneumococcal conjugate vaccine (Prevnar
13
®
, PCV13). Most patients should receive both vaccines in sequential
order, but NEVER together. See table below for indications for each vaccine.
Indications for pneumococcal vaccines for adults ≥ 19 years of age
Risk group Prevnar 13
®
Pneumovax 23
®
All adults ≥ 65 years of age Yes Yes
CSF leak or cochlear implants Yes Yes
Functional or anatomic aspleniaYes Yes, revaccinate 5
years after first dose
Immunocompetent persons with certain chronic medical conditions (e.g. heart disease*, lung disease
†
, liver disease,
DM), alcoholism, cigarette smoking
No Yes
““Õ˜œVœ“«Àœ“ˆÃi`Ê…œÃÌ\ÊVœ˜}i˜ˆÌ>É acquired immunodeficiencies, HIV, chronic renal failure, nephrotic syndrome, hematologic malignancies, organ transplant, long-term immunosuppressive therapy (e.g. steroids, active chemotherapy, radiation)Yes Yes, revaccinate 5
years after first dose
I˜VÕ`ˆ˜}Ê]ÊV>À`ˆœ“Þœ«>Ì…ˆiÃ]ÊiÝVÕ`ˆ˜}Ê…Þ«iÀÌi˜Ãˆœ˜ÆÊa˜VÕ`ˆ˜}Ê"*]Êi“«…ÞÃi“>]Ê
asthma
Timing and sequential administration of pneumococcal vaccines
UÊ œÊ…ˆÃÌœÀÞÊœÀÊÕ˜Ž˜œÜ˜Ê…ˆÃÌœÀÞÊœvÊ«˜iÕ“œVœVV>ÊÛ>VVˆ˜>̈œ˜Ê>˜`ÊLœÌ…Ê
vaccines are indicated, patient should receive Prevnar 13
®
first followed
by Pneumovax 23
®
at a minimum of 8 weeks later (ideally 6-12 months)
UÊvÊ«>̈i˜ÌÊ…>ÃÊÀiViˆÛi`Ê*˜iÕ“œÛ>ÝÊÓÎ
®
and both vaccines are indicated,
the patient should receive Prevnar 13
®
(minimum 1 year separation)
UÊvÊ«>̈i˜ÌÊ…>ÃÊÀiViˆÛi`Ê*ÀiÛ˜>ÀÊ£Î
®
≥ 8 weeks ago, and both vaccines
are indicated, the patient should receive Pneumovax 23
®
(minimum 8
weeks separation)
UÊvÊ«>̈i˜ÌÊ…>ÃÊÀiViˆÛi`ÊLœÌ…ÊÛ>VVˆ˜iÃÊ≥ 5 years ago and revaccination
is needed with Pneumovax 23
®
, a second dose should be administered
(minimum 5 years apart)
UÊ*>̈i˜ÌÃÊÜ…œÊ>ÀiÊÃiÛiÀiÞʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê­i°}°Ê /]ÊÃœˆ`ÊœÀ}>˜Ê
transplant) should follow institutional policy when available or consult ID
for optimal timing of vaccine administration
,iviÀi˜Vi\Ê
*Ê,iVœ““i˜`>̈œ˜Ã\Ê7,ÊÓä£{ÆÈέÎÇ®ÆnÓÓ‡nÓxÊ>˜`Ê7,ÊÓä£ÓÆÈ£­{ä®Æn£È‡n£™°Ê

26. 4.1 Organism-specific guidelines: Anaerobes
24
Organism-specific guidelines
Anaerobes
Although anaerobic bacteria dominate the human intestinal microbiome
only a few species seem to play an important role in human infections.
Infections caused by anaerobes are often polymicrobial.
UÊÊÀ>“‡˜i}>̈ÛiÊL>VˆˆÊ‡ÊBacteroides spp., Prevotella spp.,
Porphyromonas spp., Fusobacterium spp.
UÊÊÀ>“‡˜i}>̈ÛiÊVœVVˆÊ‡ÊVeillonella spp.
UÊÊÀ>“‡«œÃˆÌˆÛiÊL>VˆˆÊ‡ÊPropionibacterium spp., Lactobacillus spp.,
Actinomyces spp., Clostridium spp.
UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊ‡ÊPeptostreptococcus spp. and related genera
Clinical diagnosis of anaerobic infections should be suspected in the
presence of foul smelling discharge, infection in proximity to a muco sal
surface, gas in tissues or negative aerobic cultures. Proper spec i men
VœiV̈œ˜ÊˆÃÊVÀˆÌˆV>ÆÊÀiviÀÊÌœÊëiVˆ“i˜ÊVœiV̈œ˜Ê}Õˆ`iˆ˜iÃÊ>ÌÊ…ÌÌ«\ÉÉ
www.hopkinsmedicine.org/microbiology/specimen/index.html
Treatment Notes


.
UÊÊ-ÕÀ}ˆV>Ê`iLÀˆ`i“i˜ÌÊœvÊ>˜>iÀœLˆVʈ˜viV̈œ˜ÃʈÃʈ“«œÀÌ>˜ÌÊLiV>ÕÃiÊ
anaerobic organisms can cause severe tissue damage.
UÊÊ“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê>˜`ʏˆ˜`>“ÞVˆ˜Ê>ÀiÊVœ˜Ãˆ`iÀi`ÊÌœÊLiÊivviV̈ÛiÊ
empiric therapy against Gram-positive anaerobes seen in infections











Metronidazole
Clindamycin
Ertapenem
Cefotetan
Pip/Tazo
Amox/Clav
Penicillin
# Patients
Hidden Content
- JHH Internal use only

27. 25
4.1 Organism-specific guidelines: Anaerobes
above the diaphragm. Metronidazole is not active against
microaerophilic streptococci (e.g. S. anginosus group) and should not
be used for these infections.
UÊÊ6>˜Vœ“ÞVˆ˜ÊˆÃÊ>ÃœÊ>V̈ÛiÊ>}>ˆ˜ÃÌÊ“>˜ÞÊÀ>“‡«œÃˆÌˆÛiÊ>˜>iÀœLiÃÊ­i°}°Ê
Clostridium spp., Peptostreptococcus spp., P. acnes).
UÊÊ“«ˆÀˆVÊ`œÕLiÊVœÛiÀ>}iÊ܈̅ÊiÌÀœ˜ˆ`>✏iÊ ÊV>ÀL>«i˜i“ÃÊ
(Meropenem, Ertapenem) or beta-lactam/beta-lactamase inhibitors
(Ampicillin/Sulbactam, Piperacillin/Tazobactam, Amoxicillin/Clavulanic
acid) is NOT recommended given the excellent anaerobic activity of
these agents.
UÊÊB. fragilis group resistance to Clindamycin, Cefotetan, Cefoxitin, and
Moxifloxacin has increased and these agents should not be used
empirically for treatment of severe infections where B. fragilis is
suspected (e.g. intra-abdominal infections).
UÊÊœÃÌÊÀiÈÃÌ>˜Viʈ˜ÊÌ…iÊB. fragilis group is caused by beta-lactamase
production, which is screened for by the JHH micro lab.
UÊÊBacteroides thetaiotaomicron is less likely to be susceptible to
*ˆ«iÀ>Vˆˆ˜É/>âœL>VÌ>“ÆÊÌ…iÀivœÀi]ÊÜ…i˜ÊÌ…ˆÃÊœÀ}>˜ˆÃ“ʈÃʈ܏>Ìi`Ê
or strongly suspected (e.g. Gram negative rods in anaerobic blood
cultures in a patient on Piperacillin/tazobactam) alternative agents
with anaerobic coverage should be used until susceptibilities are
confirmed.
UÊÊ/ˆ}iVÞVˆ˜iʈÃÊ>V̈ÛiÊ>}>ˆ˜ÃÌÊ>Ê܈`iÊëiVÌÀÕ“ÊœvÊ}À>“‡«œÃˆÌˆÛiÊ>˜`Ê
gram-negative anaerobic bacteria in vitro but clinical experience with
this agent is limited.
Propionibacterium acnes
Indications for consideration of testing for P. acnes:
UÊ -ÊÃ…Õ˜Ìʈ˜viV̈œ˜Ã
UÊ*ÀœÃÌ…ïVÊÃ…œÕ`iÀʍœˆ˜Ìʈ˜viV̈œ˜ÃÊ
UÊ"Ì…iÀʈ“«>˜Ì>LiÊ`iÛˆViʈ˜viV̈œ˜Ã
Diagnosis
UÊÊՏÌÕÀiÃÊÃ…œÕ`ÊLiÊ…i`ÊvœÀʣ䇣{Ê`>ÞÃʈvÊ…ˆ}…ÊÃÕëˆVˆœ˜ÊvœÀÊP. acnes
as growth is slow
UÊÊœiV̈œ˜ÊœvÊ̈ÃÃÕiÊ>˜`ÊyÕˆ`ÊëiVˆ“i˜ÃÊvœÀÊVՏÌÕÀiʈÃÊ«ÀiviÀÀi`°ÊœÊ˜œÌÊ
send swabs for culture
UÊÊՏ̈«iÊÀi«ÀiÃi˜Ì>̈ÛiÊëiVˆ“i˜ÃÊ­«ÀiviÀ>LÞÊήÊÃ…œÕ`ÊLiÊÃi˜ÌÊ
for shoulder joint infections to assist in distinguishing contaminants
from pathogenic isolates — these could include synovial fluid, any
inflammatory tissue, and synovium
U Tissue specimens should also be sent for histopathology

28. 26
4.2 Organism-specific guidelines: P. acnes
Treatment
UÊÊ*i˜ˆVˆˆ˜ÊÊÓ‡ÎÊ“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{Ê­«ÀiviÀÀi`®
OR
UÊ* Ê>iÀ}ÞÊ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
NOTES
UÊÊÊVœ˜ÃՏÌÊÀiVœ““i˜`i`ÊvœÀÊ>ÃÈÃÌ>˜ViÊ܈̅ÊV…œˆViÊ>˜`Ê
duration of antibiotic therapy
UÊÊP. acnes is usually a contaminant in blood culture specimens. Draw
repeat cultures and consider clinical context before treatment
UÊÊ,>ÀiÊÀi«œÀÌÃÊœvÊ눘>Êˆ˜viV̈œ˜ÃÊ…>ÛiÊLii˜Ê˜œÌi`ÊvœÀÊP. acnes
UÊʏÊP. acnes isolutes at JHH are susceptible to Penicillin (see anaerobic
antibiogram p. 24)
UÊÊiÌÀœ˜ˆ`>✏iÊ`œiÃʘœÌÊ…>ÛiÊ>V̈ۈÌÞÊ>}>ˆ˜ÃÌÊP. acnes. Tetracyclines
are not routinely tested and resistance rates are variable.
UÊÊ Àœ>`iÀÊëiVÌÀÕ“Ê>}i˜ÌÃÊÃÕV…Ê>ÃÊiÀœ«i˜i“Ê>˜`Ê*ˆ«iÀ>Vˆˆ˜É
tazobactam would be expected to be active for Penicillin susceptible
isolates, but these are not first-line therapy
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊ`>Ì>ÊÃ…œÕ`ÊLiÊÕÃi`Ê̜ʅi«Ê}Õˆ`iÊÌ…iÀ>«iṎVÊ`iVˆÃˆœ˜Ã
U Consider removal of associated hardware

29. Streptococci
Viridans group Streptococci (alpha-hemolytic streptococci)
œÀ“>Ê“ˆVÀœLˆœÌ>ÊœvÊÌ…iÊœÀ>ÊV>ÛˆÌÞÊ>˜`ÊÊÌÀ>VÌÆÊȘ}iÊLœœ`ÊVՏÌÕÀiÃÊ
growing these organisms often represent contamination or transient
bacteremia
Five groups
UÊÊS. anginosus group (contains S. intermedius, anginosus, and
constellatus®\ÊÊVœ““œ˜ÞÊV>ÕÃiÊ>LÃViÃÃiÃÆÊ“>œÀˆÌÞÊ>ÀiÊ*i˜ˆVˆˆ˜Ê
susceptible
UÊÊS. bovisÊ}ÀœÕ«ÊQVœ˜Ì>ˆ˜ÃÊS. gallolyticus subspecies gallolyticus
(associated with colon cancer—colonoscopy mandatory, endocarditis
>ÃœÊ«ÀiÃi˜Ìʈ˜Ê€Êxä¯ÊœvÊV>ÃiîÊ>˜`ÊÃÕLëiVˆiÃÊpasteurinus
­>ÃÃœVˆ>Ìi`Ê܈̅ʅi«>ÌœLˆˆ>ÀÞÊ`ˆÃi>Ãi]Êi˜`œV>À`ˆÌˆÃʏiÃÃÊVœ““œ˜®RÆÊ
majority are Penicillin susceptible
UÊ S. mitis group (contains S. mitis, oralis, gordonii, and sanguinous®\Ê
Vœ““œ˜ÞÊV>ÕÃiÊL>VÌiÀi“ˆ>ʈ˜Ê˜iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ>˜`Êi˜`œV>À`ˆÌˆÃÆÊ
many have Penicillin resistance
UÊÊS. salivariusÊ}ÀœÕ«\ʏiÃÃÊVœ““œ˜ÊV>ÕÃiÊœvÊi˜`œV>À`ˆÌˆÃÆÊ“>œÀˆÌÞÊ>ÀiÊ
Penicillin susceptible
UÊÊS. mutansÊ}ÀœÕ«\ÊVœ““œ˜ÊV>ÕÃiÊœvÊ`i˜Ì>ÊV>ÀˆiÃÆÊÕ˜Vœ““œ˜ÊV>ÕÃiÊ
œvÊi˜`œV>À`ˆÌˆÃÆÊ“>œÀˆÌÞÊ>ÀiÊ*i˜ˆVˆˆ˜ÊÃÕÃVi«ÌˆLi
Beta-hemolytic Streptococci
All are susceptible to Penicillin
6>Àˆ>LiÊÀ>ÌiÃÊœvÊÀiÈÃÌ>˜ViÊ̜ʏˆ˜`>“ÞVˆ˜ÆÊ>ÃŽÊÌ…iÊ“ˆVÀœLˆœœ}ÞÊ
laboratory to perform susceptibility testing if you plan to use
Clindamycin or macrolides for moderate to severe infections.
While anti-staphylococcal penicillins (Oxacillin and Nafcillin) are the
agents of first choice for susceptible S. aureus infections, their activity
against streptococci is sub-optimal
ˆ}…ÊÀ>ÌiÃÊœvÊÀiÈÃÌ>˜ViÊÌœÊÌiÌÀ>VÞVˆ˜iÃÊ>˜`Ê/*É-8Ê«ÀiVÕ`iÊÌ…iˆÀÊ
empiric use for infections suspected to be caused by beta-hemolytic
streptococci
UÊÊS. pyogenesÊ­}ÀœÕ«ÊÊÃÌÀi«®\Ê«…>ÀÞ˜}ˆÌˆÃ]ÊÃŽˆ˜Ê>˜`ÊÃœvÌÊ̈ÃÃÕiÊ
ˆ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ÊiÀÞÈ«i>Ã]ÊViÕˆÌˆÃ]ʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃÆÊ
ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜Ê£°x‡x°Ó¯ÆÊ“>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜Ê{‡Ç¯°Ê
UÊÊS. agalactiaeÊ­}ÀœÕ«Ê ÊÃÌÀi«®\ʘiœ˜>Ì>Êˆ˜viV̈œ˜Ã]ʈ˜viV̈œ˜ÃÊœvÊÌ…iÊ
vi“>iÊ}i˜ˆÌ>ÊÌÀ>VÌ]ÊÃŽˆ˜Ê>˜`ÊÃœvÌÊ̈ÃÃÕiʈ˜viV̈œ˜Ã]ÊL>VÌiÀi“ˆ>ÆÊ
ˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜Ê£È‡ÓȯÆÊ“>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜ÊLJÎÓ¯°Ê
4.3 Organism-specific guidelines: Streptococci
27

30. 28
4.3 Organism specific guidelines: Multi-drug resistant Gram-negative rods
Antibiotic Susceptible Intermediate Resistant
Penicillin (oral) ≤ 0.06 0.12-1 ≥ 2
Penicillin (parenteral)
Non-CNS ≤ 2 4 ≥ 8
CNS ≤ 0.06 ≥ 0.12
Ceftriaxone
Non-CNS ≤ 1 2 ≥ 4
CNS ≤ 0.5 1 ≥ 2
UÊÊ``ˆÌˆœ˜ÊœvÊ6>˜Vœ“ÞVˆ˜ÊÌœÊivÌÀˆ>Ýœ˜iʈÃʘœÌʈ˜`ˆV>Ìi`ʈ˜ÊÌ…iÊi“«ˆÀˆVÊ
treatment of non-CNS infections caused by S. pneumoniae due to low
rates of resistance
Multi-drug resistant Gram-negative rods
Patients with infection or colonization with the resistant
organisms listed below should be placed on CONTACT
precautions (see isolation chart on p. 141)
Extended spectrum beta-lactamase (ESBL)-producing organisms
UÊÊ- ÃÊ>ÀiÊi˜âÞ“iÃÊÌ…>ÌÊVœ˜viÀÊÀiÈÃÌ>˜ViÊÌœÊ>Ê«i˜ˆVˆˆ˜Ã]Ê
cephalosporins, and Aztreonam.
UÊÊ/…iÞÊ>ÀiÊ“œÃÌÊVœ““œ˜ÞÊÃii˜Êˆ˜ÊK. pneumoniae and K. oxytoca,
E. coli, and P. mirabilis, and these organisms are automatically
screened by the JHH microbiology lab for the presence of ESBLs.
UÊÊÀœÕ«ÊÊ>˜`ÊÊÃÌÀi«ÌœVœVVˆ\ʈ˜viV̈œ˜ÃÊÈ“ˆ>ÀÊÌœÊS. pyogenes and
S. agalactiaeÆÊ>ÃÃœVˆ>Ìi`Ê܈̅ÊÕ˜`iÀÞˆ˜}Ê`ˆÃi>ÃiÃÊ­i°}°Ê`ˆ>LiÌiÃ]Ê
“>ˆ}˜>˜VÞ]ÊV>À`ˆœÛ>ÃVՏ>ÀÊ`ˆÃi>Ãi®Æʏˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜Viʈ˜ÊH£È¯Ê
œvÊ}ÀœÕ«ÊÊ>˜`ÊHÎίʜvÊ}ÀœÕ«Êʈ܏>ÌiÃÆÊ“>VÀœˆ`iÊÀiÈÃÌ>˜Viʈ˜Ê
HÓx¯ÊœvÊ}ÀœÕ«ÊÊ>˜`ÊHÓn¯ÊœvÊ}ÀœÕ«Êʈ܏>ÌiðÊ
Streptococcus pneumoniae
UÊÊœ““œ˜ÊV>ÕÃiÊœvÊÀiëˆÀ>ÌœÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ãʈ˜VÕ`ˆ˜}ʜ̈̈ÃÊ“i`ˆ>]Ê
ȘÕÈ̈Ã]Ê«˜iÕ“œ˜ˆ>ÊÛˆ>ʏœV>ÊëÀi>`ÊvÀœ“ÊÌ…iʘ>Ãœ«…>ÀÞ˜ÝÆʈ˜viV̈œ˜ÃÊ
involving the CNS, bones/joints and endocarditis via hematogenous
spread
UÊÊi˜ïV>Þ]ÊS. pneumoniae is in the S. mitis group of viridans group
ÃÌÀi«ÌœVœVVˆÆÊVœ˜ÃiµÕi˜ÌÞ]ÊÀ>«ˆ`Ê“œiVՏ>ÀÊÌiÃÌÃÊ“>ÞʘœÌÊLiÊ>LiÊÌœÊ
distinguish S. pneumoniae and streptococci in the S. mitis group.
UÊÊ*i˜ˆVˆˆ˜ÊˆÃÊÌ…iÊ>}i˜ÌÊœvÊwÀÃÌÊV…œˆViÊvœÀÊÃiÀˆœÕÃÊS. pneumoniae
infections when it is susceptible
UÊÊ*i˜ˆVˆˆ˜Ê>˜`ÊivÌÀˆ>Ýœ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊLÀi>Ž«œˆ˜ÌÃÊ>ÀiÊ`ˆvviÀi˜ÌÊvœÀÊ
CNS and non-CNS sites
MIC breakpoints for Penicillin and Ceftriaxone against
S. pneumoniae

31. UÊÊ,ˆÃŽÊv>VÌœÀÃÊvœÀʈ˜viV̈œ˜ÊœÀÊVœœ˜ˆâ>̈œ˜\ÊÀiVi˜ÌÊ…œÃ«ˆÌ>ˆâ>̈œ˜Ê>ÌÊ>˜Ê
institution with a high rate of ESBLs, residence in a long-term care
facility and prolonged use of broad spectrum antibiotics.
/Ài>Ì“i˜Ì\
UÊÊiÀœ«i˜i“Ê£Ê}Ê6Ê+nÊ­ÓÊ}Ê6Ê+nÊvœÀÊ -ʈ˜viV̈œ˜Ã®ÊÃ…œÕ`ÊLiÊ
used for ALL severe infections if the organism is susceptible.
UÊÊÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ÊV>˜ÊLiÊÕÃi`ÊvœÀÊÕ˜Vœ“«ˆV>Ìi`Ê1/ÊœÀÊÃœvÌÊ̈ÃÃÕiÊ
infection with adequate source control if the organism is susceptible.
UÊʈ«ÀœyœÝ>Vˆ˜ÊœÀÊ/*É-8ÊV>˜ÊLiÊÕÃi`Ê>ÃÊ>ÌiÀ˜>̈ÛiÃÊÌœÊÀÌ>«i˜i“Ê
for uncomplicated UTI or soft tissue infection with adequate source
control if the organism is susceptible. Nitrofurantoin may also be used
for uncomplicated UTI if the organism is susceptible.
Carbapenemase-producing Enterobacteriacae (CRE)
UÊ>ÀL>«i˜i“>ÃiÃÊ>ÀiÊi˜âÞ“iÃÊÌ…>ÌÊVœ˜viÀÊÀiÈÃÌ>˜ViÊÌœÊ>Ê«i˜ˆVˆˆ˜Ã]Ê
cephalosporins, carbapenems and Aztreonam.
UÊÊ“ˆVÀœLˆœœ}Þʏ>LʈÃʘœÊœ˜}iÀÊ«iÀvœÀ“ˆ˜}ÊÌ…iÊ“œ`ˆwi`Êœ`}iÊÌiÃÌ
UÊvÊV>ÀL>«i˜i“ʈÃÊÀiÈÃÌ>˜ÌÊÊ“ˆVÀœLˆœœ}Þʏ>LÊ܈ÊÀi«œÀÌÊœÀ}>˜ˆÃ“Ê
>ÃʺV>ÀL>«i˜i“ÊÀiÈÃÌ>˜Ì»ÆÊ…œÜiÛiÀ]ÊÌ…iÊiÝ>VÌÊ“iV…>˜ˆÃ“ÊœvÊ
resistance is not tested for at this time.
/Ài>Ì“i˜Ì\Ê
UÊiÀœ«i˜i“ÊÓÊ}Ê6Ê+nʈ˜vÕÃi`ÊœÛiÀÊÎÊ…œÕÀÃÊÃ…œÕ`ÊLiʈ˜VÕ`i`Ê
in most regimens based on data from small, retrospective studies
showing benefit even when the isolate is intermediate or resistant.
UÊÌʏi>ÃÌÊœ˜iÊ>``ˆÌˆœ˜>Ê>}i˜ÌÊÃ…œÕ`ÊLiÊ>``i`ÊL>Ãi`Êœ˜ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ
(e.g. Amikacin, Tigecycline, Colistin) except for UTI.
Multi-drug resistant (MDR) gram-negative organisms: defined as
organisms susceptible to NO MORE than ONE of the following antibiotic
V>ÃÃiÃ\ÊV>ÀL>«i˜i“Ã]Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]ÊyÕœÀœµÕˆ˜œœ˜iÃ]Ê«i˜ˆVˆˆ˜Ã]Ê
or cephalosporins. Note: susceptibility to sulfonamides, tetracyclines,
polymixins, and Sulbactam are NOT considered in this definition
Treatment
MDR Pseudomonas aeruginosa MDR Acinetobacter baumannii/calcoaceticus
complex
UÊÊivÌœœâ>˜iÉÌ>âœL>VÌ>“ÊÊ UÊ-lactam PLUS aminoglycoside if synergy expected
(if susceptible) OR
ORÊ UÊÊ œˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê
UÊʘ̈‡«ÃiÕ`œ“œ˜>Ê-lactam PLUS OR
ÊÊÊ>“ˆ˜œ}ÞVœÃˆ`iʈvÊÃÞ˜iÀ}ÞÊ«Ài`ˆVÌi`ÊÊ UÊÊ“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê­ˆvÊÃÕÃVi«ÌˆLi®ÊPLUS
or confirmed aminoglycoside (Sulbactam component has in vitro
OR activity against Acinetobacter spp.)
UÊÊœˆÃ̈˜Ê­ˆvÊÃÕÃVi«ÌˆLi®Ê ÊÊÊOR
Ê UÊÊ /ˆ}iVÞVˆ˜iÊ­ˆvÊÃÕÃVi«ÌˆLiÆÊvœÀʈ˜viV̈œ˜Ãʜ̅iÀÊÌ…>˜Ê
bacteremia)
*Combination therapy should be considered in severe infections.
4.4 Organism specific guidelines: Multi-drug resistant Gram-negative rods
29

32. 30
4.4 Organism specific guidelines: Multi-drug resistant Gram-negative rods
Synergy:
UÊvÊÌ…iÊœÀ}>˜ˆÃ“ʈÃʈ˜ÌiÀ“i`ˆ>ÌiÊÌœÊ>ÊLiÌ>‡>VÌ>“Ê>˜`ÊÃÕÃVi«ÌˆLiÊÌœÊ
aminoglycosides, synergy can be assumed.
UÊ/…iÊ“ˆVÀœLˆœœ}Þʏ>LÊ`œiÃʘœÌÊ«iÀvœÀ“ÊÃÞ˜iÀ}ÞÊÌiÃ̈˜}°Ê
Antibiotic doses for MDR and carbapenemase-producing
infections – normal renal and hepatic function
UÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n]ʈ˜vÕÃiÊœÛiÀÊÎÊ…œÕÀÃÊ
UÊivi«ˆ“i\ÊÓÊ}Ê6Ê+n]ʈ˜vÕÃiÊœÛiÀÊÎÊ…œÕÀÃ
UÊivÌ>âˆ`ˆ“iÉivi«ˆ“i\ÊÓÊ}Ê6ÊLœÕÃʏœ>`ˆ˜}Ê`œÃiÊœÛiÀÊÎäÊ“ˆ˜ÕÌiÃ]Ê
then 6 g IV as continuous infusion over 24 hours
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“\ÊΰÎÇxÊ}Ê6ÊLœÕÃʏœ>`ˆ˜}Ê`œÃiÊœÛiÀÊÎäÊ
minutes, then continuous infusion 3.375 g IV Q4H infused over 4
hours OR 4.5 g IV Q6H, infuse over 4 hours
UÊœˆÃ̈˜\ÊxÊ“}ÉŽ}Êœ˜Vi]ÊÌ…i˜ÊÓ°xÊ“}ÉŽ}Ê6Ê+£ÓÊ­vœÀÊ>``ˆÌˆœ˜>Ê
information, see p. 9)
UÊ“«ˆVˆˆ˜ÉÃՏL>VÌ>“\ÊÎÊ}Ê6Ê+{Ê­vœÀÊ,ÊA. baumannii only)
UÊ“ˆ˜œ}ÞVœÃˆ`iÃÊ­vœÀÊ`œÃˆ˜}]ÊÃiiÊ«°Ê£{È®
UÊ/ˆ}iVÞVˆ˜i\Ê£ä䇣xäÊ“}Ê6Ê+£ÓÊ
UÊivÌœœâ>˜iÉÌ>âœL>VÌ>“Ê£°x‡ÎÊ}Ê6Ê+n
,iviÀi˜ViÃ\Ê
- ÃÊ>˜`ÊVˆ˜ˆV>ÊœÕÌVœ“iðʏˆ˜Ê˜viVÌʈÃÊÓä£x\ÊÈä­™®\ʣΣ™\Óx°
Current therapies for P. aeruginosa°ÊÀˆÌÊ>Àiʏˆ˜ÊÓäänÆÓ{\ÓÈ£°Ê
œ“Lˆ˜>̈œ˜ÊÌ…iÀ>«ÞÊvœÀÊ,°Êˆ˜ÊˆVÀœLˆœÊ˜viVÊÓä£{ÆÓä\ÊnÈÓ‡ÇÓ°

33. Interpreting the microbiology report
Interpretation of preliminary microbiology data
Gram-positive cocci Gram-negative cocci
Aerobic
In clusters
UÊœ>}Տ>ÃiÊ­³®\ÊS. aureus
UÊÊœ>}Տ>ÃiÊ­q®\ÊS. epidermidis,
S. lugdunensis
In pairs/chains
UÊʈ«œVœVVÕÃ]Ê+ÕiÕ˜}Ê«œÃˆÌˆÛi\Ê
S. pneumoniae
UÊʏ«…>‡…i“œÞ̈V\Ê6ˆÀˆ`>˜ÃÊ}ÀœÕ«ÊÊ
Streptococci, Enterococcus
(faecalis and faecium)
UÊÊ iÌ>‡…i“œÞ̈V\Ê
Group A strep (S. pyogenes),
Group B strep (S. agalactiae),
Group C, D, G strep
Anaerobic: Peptostreptococcus spp. Anaerobic: Veillonella spp.
Gram-positive rods Gram-negative rods
Aerobic
>À}i\ Bacillus spp.
œVVœ‡L>VˆÕÃ\ÊListeria monocytogenes,
Lactobacillus spp.
-“>]Ê«iœ“œÀ«…ˆV\ Corynebacterium spp.
À>˜V…ˆ˜}Êw>“i˜ÌÃ\ Nocardia spp.,
Streptomyces spp.





Anaerobic
>À}i\ÊClostridium spp.
Small, pleomorphic: P. acnes, Actinomyces
spp.
* Serratia spp. can appear initially as non-lactose fermenting due to slow fermentation.
The Johns Hopkins microbiology laboratory utilizes standard reference
methods for determining susceptibility. The majority of isolates are
tested by the automated system.
The minimum inhibitory concentration (MIC) value represents the
concentration of the antimicrobial agent required at the site of infection
for inhibition of the organism.
The MIC of each antibiotic tested against the organism is reported
with one of three interpretations S (susceptible), I (intermediate), or
R (resistant). The highest MIC which is still considered susceptible
represents the breakpoint concentration. This is the highest MIC which
is usually associated with clinical efficacy. MICs which are
1
⁄2q
1
⁄8 the
Aerobic
ˆ«œVœVVÕÃ\ÊN. meningiditis, N.
gonorrhoeae, Moraxella catarrhalis
œVVœ‡L>VˆÕÃ\ H. flu, Acinetobacter spp.,
HACEK organisms
Aerobic Lactose fermenting: Citrobacter spp.,
Enterobacter spp., E. coli, Klebsiella
spp., Serratia spp.*
Non-lactose fermenting
UÊÊ"݈`>ÃiÊ­q®: Acinetobacter spp.,
Burkholderia spp., E. coli (rare), Proteus
spp., Salmonella spp., Shigella spp.,
Serratia spp.*, Stenotrophomonas
maltophilia
UÊÊ"݈`>ÃiÊ ­³®\ÊP. aeruginosa, Aeromonas
spp., Vibrio spp., Campylobacter spp.
(curved)
Anaerobic: Bacteroides spp.,
Fusobacterium spp., Prevotella spp.
5.1 Interpreting the microbiology report
31

34. 5.1 Interpreting the microbiology report
32
breakpoint MIC are more frequently utilized to treat infections where
antibiotic penetration is variable or poor (endocarditis, meningitis,
osteomyelitis, pneumonia, etc.). Similarly, organisms yielding antibiotic
MICs at the breakpoint frequently possess or have acquired a low-level
resistance determinant with the potential for selection of high-level
expression and resistance. This is most notable with cephalosporins
and Enterobacter spp., Serratia spp., Morganella spp., Providencia
spp., Citrobacter spp. and Pseudomonas aeruginosa. These organisms
all possess a chromosomal beta-lactamase which frequently will be
over-expressed during therapy despite initial in vitro susceptibility. The
intermediate (I) category includes isolates with MICs that approach
attainable blood and tissue levels, but response rates may be lower than
fully susceptible isolates. Clinical efficacy can potentially be expected in
body sites where the drug is concentrated (e.g., aminoglycosides and
beta-lactams in urine) or when a higher dose of the drug can be used
(e.g., beta-lactams). The resistant (R) category indicates the organism
will not be inhibited by usually achievable systemic concentrations of the
antibiotic of normal doses.
NOTE: MIC values vary from one drug to another and from one
bacterium to another, and thus MIC values are NOT comparable
between antibiotics or between organisms.
Spectrum of antibiotic activity
The spectrum of activity table is an approximate guide of the activity of
commonly used antibiotics against frequently isolated bacteria. It takes
into consideration JHH specific resistance rates, in vitro susceptibilities
and expert opinion on clinically appropriate use of agents. For antibiotic
recommendations for specific infections refer to relevant sections of the
JHH Antibiotic Guidelines.

35. 33
5.2 Spectrum of antibiotic activity
Penicillin G
Ampicillin
Ampicillin/sulbactam
Oxacillin/Nafcillin
Piperacillin/tazobactam
Cefazolin
Cefotetan
Ceftriaxone
Cefepime
Aztreonam
Ertapenem
Meropenem
Moxifloxacin
Ciprofloxacin
Azithromycin
Gent/Tobra/Amikacin
Vancomycin
Linezolid
Daptomycin
Ê /*É-8
Clindamycin
Doxycycline
Colistin
Metronidazole
GRAM-POSITIVE GRAM-NEGATIVE
Not active
Less active or potential resistance
Active
Atypicals
Abdominal anaerobes
Oral anaerobes
Pseudomonas spp.
Enterobacter spp.
Serratia spp.
Proteus spp.
Kebsiella spp.
E. coli
H. influenzae
Viridans strep.
S. pneumoniae
-hemolytic strep.
Coag. neg. staph
MSSA
MRSA
E. faecalis
VRE

36. 5.3 Interpretation of rapid diagnostic tests
34
Interpretation of rapid diagnostic tests
The JHH microbiology lab performs rapid nucleic acid microarray testing
on blood cultures growing Gram-positive organisms and peptide nucleic
acid fluorescence in situ hybridization (PNA-FISH) testing on blood
cultures growing yeast.
Nucleic acid microarray testing (Verigine
®
) for Gram-positive
cocci in blood cultures
UÊÊiÌiVÌÃÊ>˜`ʈ`i˜ÌˆwiÃÊÌ…iʘÕViˆVÊ>Vˆ`ÃÊœvÊ£ÓÊÀ>“‡«œÃˆÌˆÛiÊL>VÌiÀˆ>Ê
genera/species and 3 resistance markers.
UÊÊ >VÌiÀˆ>ÊëiVˆiÃ\ÊS. aureus, Coagulase-negative staphylococci, S.
lugdunensis, Staphylococcus spp. E. faecalis, E. faecium, S. pyogenes
(group A streptococci), S. agalactiae (group B streptococci), S.
pneumoniae, S. anginosus, Streptococcus spp. (e.g.,group C and G
streptococci, viridans group streptococci, etc.), Listeria spp.
UÊ,iÈÃÌ>˜ViÊ“>ÀŽiÀÃ\Ê“iV]ÊÛ>˜]ÊÛ>˜
Ê UÊÊvÊS. aureus is mecA positive the organism is resistant to Methicillin
and is reported as MRSA
Ê UÊÊvÊS. aureus is mecA negative the organism is susceptible to
Methicillin and is reported as MSSA
Ê UÊÊvÊ°Êfaecalis/faecium is vanA/B positive the organism is resistant
ÌœÊ6>˜Vœ“ÞVˆ˜ÊÊ>˜`ʈÃÊÀi«œÀÌi`Ê>ÃÊ6,ÆʘœÌiÊÌ…>ÌÊ>Ê6>˜Vœ“ÞVˆ˜‡
resistant E. faecalis are susceptible to Ampicillin at JHH
UÊÊ,iÃՏÌÃÊœvÊÌ…iÊÌiÃÌÊ>ÀiÊÀi«œÀÌi`Ê܈̅ˆ˜Ê·{Ê…œÕÀÃÊ>vÌiÀÊÌ…iÊLœœ`Ê
cultures turn positive
UÊ/iÃ̈˜}ʈÃÊ«iÀvœÀ“i`Êœ˜ÞÊœ˜ÊÌ…iÊwÀÃÌÊ«œÃˆÌˆÛiÊLœœ`ÊVՏÌÕÀiÊ
UÊÊ/iÃ̈˜}ʈÃÊ "/Ê«iÀvœÀ“i`Êœ˜ÊLœœ`ÊVՏÌÕÀiÃÊ}ÀœÜˆ˜}Ê“œÀiÊÌ…>˜Êœ˜iÊ
Gram positive organism but is performed on blood cultures growing
both Gram positive and negative organisms
UÊÊvÊÌ…iÊÌiÃÌʈÃʘi}>̈ÛiʈÌÊ܈ÊLiÊÀi«œÀÌi`Ê>Ãʘi}>̈ÛiÊvœÀÊÌ…iÊvœœÜˆ˜}Ê
œÀ}>˜ˆÃ“Ã\Ê-Ì>«…ޏœVœVVÕÃÊë«]ÊStreptococcus spp., E. faecalis, E.
faecium, Listeria spp.

37. 35
5.3 Interpretation of rapid diagnostic tests
Organism Preferred empiric therapy Alternative empiric therapy
(% susceptible in blood at JHH) if PCN allergic
MSSA Ê "Ý>Vˆˆ˜Ê­£ää¯®Ê œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êiv>✏ˆ˜Ê
Ê Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜
1
MRSAÊ 6>˜Vœ“ÞVˆ˜Ê­£ää¯®Ê >«Ìœ“ÞVˆ˜
Ê -ˆ˜}iÊ«œÃˆÌˆÛiÊVՏÌÕÀiÃÊ>ÀiÊœvÌi˜Ê>ÊVœ˜Ì>“ˆ˜>˜ÌÆʘœÊÌÀi>Ì“i˜ÌÊ
Coagulase-negative recommended. See p. 60 of the JHH Antibiotic Guidelines for
staphylococci information and indications for treatment. Call the microbiology lab for
more information and further work up if infection suspected (5-6510).
S. lugdunensisÊ 6>˜Vœ“ÞVˆ˜Ê­£ä䯮
2
Ê "Ý>Vˆˆ˜Ê­™È¯®ÊœÀÊ>«Ìœ“ÞVˆ˜Ê
E. faecalisÊ “«ˆVˆˆ˜Ê­™n¯®Ê 6>˜Vœ“ÞVˆ˜Ê­™x¯®
1
E. faecium (VRE)Ê ˆ˜i✏ˆ`Ê­nǯ®
3
Ê >«Ìœ“ÞVˆ˜Ê­™Ç¯®
E. faecium (not VRE)Ê 6>˜Vœ“ÞVˆ˜Ê­£ä䯮
3
Linezolid
Streptococcus spp.Ê œ˜‡œ˜Vœœ}ÞÊ«>̈i˜Ì\ÊivÌÀˆ>Ýœ˜i
4
-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜
1
Ê "˜Vœœ}ÞÊ«>̈i˜Ì\Ê6>˜Vœ“ÞVˆ˜
4
S. anginosus Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\ÊivÌÀˆ>Ýœ˜i
Ê Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜
1
S. pyogenes Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êiv>✏ˆ˜
(group A strep) -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜
1
S. agalactiae Ê *i˜ˆVˆˆ˜ÊÊ­£ää¯®Ê œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êiv>✏ˆ˜
(group B strep) Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜
1
S. pneumoniae Ê ivÌÀˆ>Ýœ˜iÊ­£ä䯮
4
Ê -iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜
1

(not meningitis)
S. pneumoniae Ê ivÌÀˆ>Ýœ˜iʳÊ6>˜Vœ“ÞVˆ˜ÊÊ -iÛiÀiÊ* Ê>iÀ}Þ\Ê
(meningitis) …œÀ>“«…i˜ˆVœÊ³Ê6>˜Vœ“ÞVˆ˜
1

Listeria spp. Ê “«ˆVˆˆ˜Ê­£ää¯®Ê /Àˆ“iÌ…œ«Àˆ“ÉÃՏv>“iÌ…œÝ>✏i
1
Consult allergy for skin testing /desensitization
2
Narrow to Oxacillin if found to be susceptible
3
Narrow to Ampicillin if found to be susceptible
4
Narrow to Penicillin G if found to be susceptible
PNA-FISH for yeast
UÊÊvÊ* ‡-ÊÃ…œÜÃÊC. albicans, most non-oncology patients without
prior azole exposure can be treated with fluconazole. For more
information see p. 117 and 134.
UÊÊvÊ* ‡-ÊÃ…œÜÃÊC. glabrata, treat with Micafungin until
susceptibilities available. For more information see p. 117 and 134.
UÊÊvÊ* ‡-ʘi}>̈ÛiÊvœÀÊC. albicans or C. glabrata, most cases can be
treated as unspeciated candidemia, unless cryptococcus is suspected
(send serum cryptococcal antigen). For more information see p. 117
and 134.

38. Biliary tract infections – cholecystitis and
cholangitis
EMPIRIC TREATMENT
Community-acquired infections in patients without previous
biliary procedures AND who are not severely ill
UÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊÊÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʈ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+£Ó
Hospital-acquired infections OR patients with multiple therapeutic
biliary manipulations (e.g. stent placement/exchange, bilio-enteric
anastamosis of any severity) OR patients who are severely ill
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊPLUS Metronidazole 500
mg IV Q8H ≤ Vancomycin (see dosing section, p. 150)
In severely ill patients with cholangitis and complicated cholecystitis,
adequate biliary drainage is crucial as antibiotics will not enter bile in
the presence of obstruction.
Duration
UÊÊUncomplicated cholecystitis\ÊÌÀi>ÌÊœ˜ÞÊ՘̈ÊœLÃÌÀÕV̈œ˜ÊˆÃÊÀiˆiÛi`°Ê
NO post-procedure antibiotics are necessary if the obstruction is
successfully relieved.
UÊÊœ“«ˆV>Ìi`ÊV…œiVÞÃ̈̈Ã\Ê{Ê`>ÞÃ]ÊÕ˜iÃÃÊ>`iµÕ>ÌiÊÃœÕÀViÊVœ˜ÌÀœÊˆÃÊ
not achieved.
U Ê ˆˆ>ÀÞÊÃi«ÃˆÃ\Ê{‡ÇÊ`>ÞÃ]ÊÕ˜iÃÃÊ>`iµÕ>ÌiÊÃœÕÀViÊVœ˜ÌÀœÊˆÃʘœÌÊ
achieved.
TREATMENT NOTES
Microbiology
UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`ÃÊqÊE. coli, Klebsiella spp., Proteus spp.,
P. aeruginosa (mainly in patients already on broad-spectrum antibiotics
or those who have undergone prior procedures)
UÊʘ>iÀœLiÃÊqÊBacteroides spp., generally in more serious infections, or
ˆ˜Ê«>̈i˜ÌÃÊ܈̅Ê>Ê…ˆÃÌœÀÞÊœvÊLˆˆ>ÀÞÊ“>˜ˆ«Õ>̈œ˜ÃÆÊÀ>Àiʈ˜ÊÕ˜Vœ“«ˆV>Ìi`Ê
and community-acquired infections
UÊÊEnterococcus spp°ÊqÊÌÀi>Ì“i˜ÌʘœÌÊ>Ü>ÞÃʈ˜`ˆV>Ìi`ÆÊÕÃiÊVˆ˜ˆV>ÊÕ`}“i˜Ì
UÊÊ9i>ÃÌÊqÊÀ>Ài
39
6.1 Abdominal infections

39. 6.1 Abdominal infections
40
Management
UÊʘÊV>ÃiÃÊœvÊÕ˜Vœ“«ˆV>Ìi`Ê>VÕÌiÊV…œiVÞÃ̈̈Ã]Ê>˜ÌˆLˆœÌˆVÃÊÃ…œÕ`ÊLiÊ
given until the biliary obstruction is relieved (either by surgery, ERCP,
or percutaneous drain).
UÊÊ/Ài>Ì“i˜ÌÊœvÊi˜ÌiÀœVœVVˆÊˆÃÊÕÃÕ>ÞʘœÌʘii`i`ʈ˜Ê“ˆ`É“œ`iÀ>ÌiÊ
disease.
UÊÊ9i>ÃÌÊ}i˜iÀ>ÞÊÃ…œÕ`ÊLiÊÌÀi>Ìi`Êœ˜ÞʈvÊÌ…iÞÊ>ÀiÊÀiVœÛiÀi`ÊvÀœ“Ê
biliary cultures, not empirically.
,iviÀi˜ViÃ\
ˆˆ>ÀÞÊÌÀ>VÌʈ˜viV̈œ˜Ã\ÊÀÕ}ÃÊ£™™™ÆxÇ­£®\n£‡™£°
-ÊÕˆ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\ʏˆ˜Ê˜viVÌʈÃÊÓä£äÆxä\£ÎÎq£È{°
-…œÀÌÊVœÕÀÃiÊÌ…iÀ>«ÞÊvœÀÊ\Ê Ê˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°
Diverticulitis
EMPIRIC TREATMENT
NOTE: Patients with uncomplicated diverticulitis (defined as CT
Vœ˜wÀ“i`ʏiv̇È`i`Ê`ˆÃi>ÃiÊ܈̅œÕÌÊ>LÃViÃÃÆÊvÀiiÊ>ˆÀÊœÀÊwÃÌՏ>ʱ fever
and elevated inflammatory markers), can be treated conservatively
without antibiotics based on a RCT.
Mild/moderate infections – can be oral if patient can take PO
UÊÊ“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxÊ“}Ê*"Ê+£Ó
OR
UÊÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Metronidazole 500 mg IV/PO Q8H
OR
UÊÊÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+£ÓÊ",ʈ«ÀœyœÝ>Vˆ˜Ê
xääÊ“}Ê*"Ê+£ÓRÊPLUS Metronidazole 500 mg IV/PO Q8H
Severe infections
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+£ÓÊ",ÊâÌÀiœ˜>“Ê
£Ê}Ê6Ê+nRÊPLUS Metronidazole 500 mg IV Q8H
Duration
UÊ{Ê`>ÞÃ]ÊÕ˜iÃÃÊ>`iµÕ>ÌiÊÃœÕÀViÊVœ˜ÌÀœÊˆÃʘœÌÊ>V…ˆiÛi`°

40. TREATMENT NOTES
Microbiology
UÊʏ“œÃÌÊ>Êˆ˜viV̈œ˜ÃÊ>ÀiÊ«œÞ“ˆVÀœLˆ>
UÊÊœÃÌÊVœ““œ˜Þʈ܏>Ìi`Ê>iÀœLˆVÊœÀ}>˜ˆÃ“ÃÊqÊE. coli, K. pneumoniae,
Enterobacter spp., Proteus spp., Enterococcus spp.
UÊÊœÃÌÊVœ““œ˜Þʈ܏>Ìi`Ê>˜>iÀœLˆVÊœÀ}>˜ˆÃ“ÃÊqÊB. fragilis, Prevotella,
Peptostreptococci
Other considerations
UÊʘ̈“ˆVÀœLˆ>ÊÌÀi>Ì“i˜ÌÊvœÀÊ>VÕÌiÊÕ˜Vœ“«ˆV>Ìi`Ê`ˆÛiÀ̈VՏˆÌˆÃÊ“>ÞʘœÌÊ
accelerate recovery or prevent complications/recurrence.
UÊÊ/ÊÃV>˜ÊˆÃʈ“«œÀÌ>˜Ìʈ˜Ê>ÃÃiÃȘ}ʘii`ÊvœÀÊ`À>ˆ˜>}iʈ˜ÊÃiÛiÀiÊ`ˆÃi>Ãi°ÊÊ
,iviÀi˜Vi\
-ÊÕˆ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\ʏˆ˜Ê˜viVÌʈÃÊÓä£äÆxä\£ÎÎq£È{°
˜ÌˆLˆœÌˆVÃʈ˜Ê>VÕÌiÊÕ˜Vœ“«ˆV>Ìi`Ê`ˆÛiÀ̈VՏˆÌˆÃ°Ê ÀÊÊ-ÕÀ}ÊÓä£ÓÆ™™\xÎÓqxΙ°
-…œÀÌÊVœÕÀÃiÊÌ…iÀ>«ÞÊvœÀÊ\Ê Ê˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°
Pancreatitis
TREATMENT
UÊʘ̈LˆœÌˆVÊ«Àœ«…ޏ>݈ÃʈÃÊ "/ʈ˜`ˆV>Ìi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊÃiÛiÀiÊ>VÕÌiÊ
pancreatitis (SAP), including those with sterile pancreatic necrosis.
Uʘ̈“ˆVÀœLˆ>ÊÌ…iÀ>«ÞÊ…>ÃʘœÊivviVÌÊœ˜Ê“œÀLˆ`ˆÌÞÊ>˜`Ê“œÀÌ>ˆÌÞ]Ê>˜`Ê
prophylactic antibiotics have been associated with a change in the
spectrum of pancreatic isolates from enteric Gram-negatives to
Gram-positive organisms and fungi.
UÊʘviVÌi`Ê«>˜VÀi>̈VʘiVÀœÃˆÃʈÃÊ`iw˜i`ÊLÞÊ/ÊÃV>˜Ê܈̅Ê}>Ãʈ˜ÊÌ…iÊ
pancreas and/or percutaneous or surgical specimen with organisms
evident on gram stain or culture. Therapy should be directed based on
culture results.
UÊʘʫ>̈i˜ÌÃÊ«ÀiÃi˜Ìˆ˜}Ê܈̅ÊÃÕëiVÌi`Ê>L`œ“ˆ˜>ÊÃi«ÃˆÃ]ÊVœ˜Ãˆ`iÀÊ
i“«ˆÀˆVÊÌ…iÀ>«Þ\
UÊÊ*ˆ«iÀ>Vˆˆ˜‡Ì>âœL>VÌ>“Ê{°xÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʈ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+£ÓÊPLUS
Metronidazole 500 mg IV Q8H
41
6.1 Abdominal infections

41. 6.1 Abdominal infections
42
Pancreatic penetration of selected antibiotics
Good (>40%; MIC exceeded for most relevant organisms):
fluoroquinolones, carbapenems, Ceftazidime, Cefepime, Metronidazole,
Piperacillin-tazobactam
Poor (<40%): aminoglycosides, first-generation cephalosporins,
Ampicillin
Duration
For infected pancreatic necrosis, continue antibiotics for 14 days after
source control is obtained. Continuation of antibiotics beyond this time
places the patient at risk for colonization or infection with resistant
organisms and drug toxicity.
TREATMENT NOTES
UÊʘviV̈œ˜Ê`iÛiœ«Ãʈ˜ÊÎäqxä¯ÊœvÊ«>̈i˜ÌÃÊ܈̅ʘiVÀœÃˆÃÊ`œVÕ“i˜Ìi`ÊLÞÊ
CT scan or at the time of surgery.
UÊÊ*i>ŽÊˆ˜Vˆ`i˜ViÊœvʈ˜viV̈œ˜ÊœVVÕÀÃʈ˜ÊÌ…iÊÎÀ`ÊÜiiŽÊœvÊ`ˆÃi>Ãi
UÊÊ/…iÀiʈÃʈ˜ÃÕvwVˆi˜ÌÊiÛˆ`i˜ViÊÌœÊÀiVœ““i˜`ÊÃiiV̈ÛiÊ}ÕÌÊ
decontamination in management of pancreatitis.
,iviÀi˜ViÃ\
>VŽÊœvÊṎˆÌÞÊœvÊ«Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃ\ʘ˜Ê-ÕÀ}ÊÓääÇÆÓ{x\ÈÇ{°
Õˆ`iˆ˜iÃÊvœÀÊ“>˜>}i“i˜ÌÊœvÊ-*\ÊÀˆÌÊ>ÀiÊi`ÊÓää{ÆÎÓ\ÓxÓ{°
Peritonitis
DEFINITIONS
Primary peritonitis is spontaneous infection of the peritoneal cavity,
ÕÃÕ>ÞÊ>ÃÃœVˆ>Ìi`Ê܈̅ʏˆÛiÀÊ`ˆÃi>ÃiÊ>˜`Ê>ÃVˆÌiÃÊQ뜘Ì>˜iœÕÃÊL>VÌiÀˆ>Ê
«iÀˆÌœ˜ˆÌˆÃÊ­- *®R°Ê
Secondary peritonitis is infection of the peritoneal cavity due to
spillage of organisms into the peritoneum, usually associated with GI
perforation.
Tertiary peritonitis is a recurrent infection of the peritoneal cavity
following an episode of secondary peritonitis.
Primary peritonitis/Spontaneous bacterial
peritonitis (SBP)
EMPIRIC TREATMENT
UÊÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+£Ó
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê6É*"Ê+Ó{Ê­V>ÊÊœÀÊ
Antimicrobial Stewardship to discuss regimens for patients who have
been taking fluoroquinolones for SBP prophylaxis).

42. UÊÊ*>̈i˜ÌÃÊ܈̅ÊÃiÀÕ“ÊVÀi>̈˜ˆ˜iÊ€£Ê“}É`]Ê 1 Ê€ÎäÊ“}É`ÊœÀÊÌœÌ>Ê
LˆˆÀÕLˆ˜Ê€{Ê“}É`ÊÃ…œÕ`Ê>ÃœÊÀiViˆÛiʏLÕ“ˆ˜Ê­Óx¯®Ê£°xÊ}ÉŽ}Êœ˜Ê
day 1 and 1 g/kg on day 3 (round to the nearest 12.5 g).
Duration
UÊÊ/Ài>ÌÊvœÀÊ5 days
PROPHYLAXIS
Cirrhotic patients with gastrointestinal hemorrhage
UÊʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê ÊvœÀÊÇÊ`>ÞÃÊ
UÊÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{ÊV>˜ÊLiÊÕÃi`Êœ˜ÞʈvÊ«>̈i˜ÌʈÃÊ *"]ÊÌ…i˜Ê
switch to Ciprofloxacin 500 mg PO BID once bleeding is controlled
Non-bleeding cirrhotic patients with ascites
UÊÊ/*É-8Ê£Ê-Ê*"Êœ˜ViÊ`>ˆÞ
OR
UÊÊvÊÃՏv>Ê>iÀ}ˆV]ʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê`>ˆÞÊ
TREATMENT NOTES
Microbiology
UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`ÃÊ­˜ÌiÀœL>VÌiÀˆ>Vi>i]Êië°ÊE. coli and K.
pneumoniae), S. pneumoniae, enterococci, and other streptococci.
UÊÊ*œÞ“ˆVÀœLˆ>Êˆ˜viV̈œ˜ÊÃ…œÕ`Ê«Àœ“«ÌÊÃÕëˆVˆœ˜ÊœvÊÊ«iÀvœÀ>̈œ˜°
Diagnostic criteria
UÊÊÓxäÊ* Ê«iÀÊ““
3
of ascitic fluid.
UÊÊ*œÃˆÌˆÛiÊVՏÌÕÀiÊ܈̅ʐÊÓxäÊ* ÊÃ…œÕ`Ê«Àœ“«ÌÊÀi«i>ÌÊÌ>«°ÊvÊ* Ê€Ê
250 OR culture remains positive, patient should be treated.
Follow-up
UÊÊœ˜Ãˆ`iÀÊÀi«i>ÌÊ«>À>Vi˜ÌiÈÃÊ>vÌiÀÊ{nÊ…œÕÀÃÊœvÊÌ…iÀ>«Þ°
UÊÊœ˜Ãˆ`iÀÊV…>˜}ˆ˜}Ê>˜ÌˆLˆœÌˆVÃʈvÊ>ÃVˆÌiÃÊyÕˆ`Ê* Ê…>ÃʘœÌÊ`Àœ««i`ÊLÞÊ
Óx¯Ê>vÌiÀÊ{nÊ…œÕÀÃÊ>˜`ÉœÀÊ«>̈i˜ÌʈÃʘœÌÊVˆ˜ˆV>ÞÊÀi뜘`ˆ˜}°
Notes on prophylaxis against SBP
UÊʏÊ«>̈i˜ÌÃÊ܈̅ÊVˆÀÀ…œÃˆÃÊ>˜`ÊÕ««iÀÊÊLii`ÊÃ…œÕ`ÊÀiViˆÛiÊ
«Àœ«…ޏ>݈ÃÊvœÀÊÇÊ`>ÞÃÊ­xä¯Ê`iÛiœ«Ê- *Ê>vÌiÀÊLii`®°
UÊÊ*>̈i˜ÌÃÊÜ…œÊ}iÌÊ- *ÊÃ…œÕ`Ê}iÌʏˆviœ˜}Ê«Àœ«…ޏ>݈ÃÊ̜ʫÀiÛi˜ÌÊvÕÌÕÀiÊ
i«ˆÃœ`iÃÊ­{äqÇä¯ÊÀˆÃŽÊœvÊÀiVÕÀÀi˜Viʈ˜Ê£ÊÞi>À®°
UÊÊ*Àœ«…ޏ>݈ÃÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊvœÀÊÌ…œÃiÊ܈̅ʏœÜÊ«ÀœÌiˆ˜Ê
Vœ˜Vi˜ÌÀ>̈œ˜Ãʈ˜Ê>ÃVˆÌiÃÊ­Ê£äÊ}ɮʜÀʈ““Õ˜œÃÕ««ÀiÃÈœ˜ÊÜ…ˆiÊ
patient is in hospital.
,iviÀi˜ViÃ\
ˆ>}˜œÃˆÃ]ÊÌÀi>Ì“i˜ÌÊ>˜`Ê«Àœ«…ޏ>݈ÃÊœvÊ- *\ÊÊi«>ÌœÊÓäääÆÎÓ\£{Ó°
>˜>}i“i˜ÌÊœvÊÛ>ÀˆVi>Ê…i“œÀÀ…>}iʈ˜ÊVˆÀÀ…œÃˆÃ\Êi«>Ìœœ}ÞÊÓääÇÆ{È\™ÓÓqÎn°
43
6.1 Abdominal infections

43. 6.1 Abdominal infections
44
Secondary peritonitis/GI perforation
EMPIRIC TREATMENT
Perforation of esophagus, stomach, small bowel, colon, or
appendix
Patient mild to moderately ill
UÊÊÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʈ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+£ÓÊPLUS
Metronidazole 500 mg IV Q8H
Patient severely ill or immunosuppressed
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+È
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
500 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
QâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊORʈ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+nRÊPLUS
Metronidazole 500 mg IV Q8H
Empiric antifungal therapy is generally not indicated for GI
perforation unless patient has one of the following risk factors:
Esophageal perforation, immunosuppression, prolonged antacid or
antibiotic therapy, prolonged hospitalization, persistent GI leak.
Recommendations for patients who are clinically stable and have not
ÀiViˆÛi`Ê«ÀˆœÀʏœ˜}‡ÌiÀ“Ê>✏iÊÌ…iÀ>«Þ\
UÊʏÕVœ˜>✏iÊ{ää‡nääÊ“}Ê6É*"Ê+Ó{
Recommendations for patients who are NOT clinically stable or have
ÀiViˆÛi`Ê«ÀˆœÀʏœ˜}‡ÌiÀ“Ê>✏iÊÌ…iÀ>«Þ\
UÊʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{Ê
Duration of therapy for secondary peritonitis/GI perforation
Stomach Small Bowel Colon Appendix
Uncomplicated
Definition Operated on Operated on Operated on Non-necrotic or
within within within gangrenous
24 hours 12 hours 12 hours appendix
ÕÀ>̈œ˜Ê Ó{q{nÊ…œÕÀÃÊ Ó{q{nÊ…œÕÀÃÊ Ó{q{nÊ…œÕÀÃÊ Ó{Ê…œÕÀÃ
Complicated
iw˜ˆÌˆœ˜Ê >ÌiÊœ«iÀ>̈œ˜ÊœÀʘœÊœ«iÀ>̈œ˜ÆÊœÀʘiVÀœÌˆVÉ}>˜}Ài˜œÕÃÊ>««i˜`ˆÝ
Duration 4 days unless adequate source control is not achieved

44. TREATMENT NOTES
UÊÊ>ÕÃ>̈ÛiÊ>}i˜ÌÃÊvœÀÊÓ>ÊLœÜi]ÊVœœ˜]Ê>««i˜`ˆÝ\Ê>˜>iÀœLiÃÊ­ië°Ê
B. fragilis), Enterobacteriaceae (esp. E. coli, K. pneumoniae,
Enterobacter spp., Proteus spp.®Æʈ˜viV̈œ˜ÃÊÕÃÕ>ÞÊ«œÞ“ˆVÀœLˆ>°Ê
UÊÊ*>Ì…œ}i˜ÃÊV>ÕȘ}ÊÌiÀ̈>ÀÞÊ«iÀˆÌœ˜ˆÌˆÃÊ>ÀiÊÛ>Àˆ>LiÊ>˜`Ê>ÀiÊœvÌi˜Ê
ÀiÈÃÌ>˜ÌÊ̜ʜÀʘœÌÊVœÛiÀi`ÊLÞÊÌ…iʈ˜ˆÌˆ>Ê>˜Ìˆ“ˆVÀœLˆ>ÊÀi}ˆ“i˜ÆÊÌ…ÕÃ]Ê>Ê
change in antimicrobials is advised.
UÊÊÊV…>˜}iʈ˜Ê>˜Ìˆ“ˆVÀœLˆ>ÃÊÌ…iÀ>«ÞÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ
with hospital-acquired infections who are already on antimicrobials.
UÊÊ/Ài>Ì“i˜ÌÊœvÊi˜ÌiÀœVœVVˆÊÀi“>ˆ˜ÃÊVœ˜ÌÀœÛiÀÈ>ÊLÕÌÊÃ…œÕ`ÊLiÊ
considered in critically ill or immunocompromised patients or when
they are a dominant organism in the peritoneal culture.
UÊÊ/Ài>Ì“i˜ÌÊœvÊCandida spp. is generally indicated only when they are
recovered from blood or are a dominant organism in the peritoneal
culture in critically ill or immunocompromised patients.
UÊÊ*œÃÌœ«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÃÊvœÀÊ>««i˜`ˆVˆÌˆÃÊ>ÀiÊÕ˜˜iViÃÃ>ÀÞÊÕ˜iÃÃÊÌ…iÀiÊ
is clinical evidence of peritonitis, abscess, or gangrene.
UÊʘ̈LˆœÌˆVÃÊ>ÀiÊ>`Õ˜V̈ÛiÊÌœÊÃœÕÀViÊVœ˜ÌÀœ]ÊÜ…ˆV…ʈÃÊ>˜Ê>LÃœÕÌiÊ
necessity.
UÊÊ>VŽÊœvÊÃœÕÀViÊVœ˜ÌÀœÊˆÃÊ`iw˜i`Ê>ÃÊœ˜‡}œˆ˜}ÊVœ˜Ì>“ˆ˜>̈œ˜Ê>˜`ÉœÀÊ>˜Ê
undrained collection of infection.
,iviÀi˜Vi\
-ÊÕˆ`iˆ˜iÃÊvœÀʘÌÀ>‡>L`œ“ˆ˜>Ê˜viV̈œ˜Ã\ʏˆ˜Ê˜viVʈÃÊÓä£äÆxä\£ÎÎq£È{°
-…œÀÌÊVœÕÀÃiÊÌ…iÀ>«ÞÊvœÀÊ\Ê Ê˜}ÊÊi`ÊÓä£xÆÎÇÓ\£™™ÈqÓääx°
Peritonitis related to peritoneal dialysis
EMPIRIC TREATMENT
Mild to moderate illness: intraperitoneal therapy is preferred in
most cases.
Anuric patient
UÊÊiv>✏ˆ˜Ê£xÊ“}ÉŽ}ʈ˜Êœ˜iÊL>}Ê+Ó{Ê­£Ê}ʈvÊ«>̈i˜ÌʐÊÈxÊŽ}®ÊPLUS
UÊÊi˜Ì>“ˆVˆ˜ÊÓÊ“}ÉŽ}ʈ˜Êœ˜iÊL>}ʏœ>`ˆ˜}Ê`œÃi]ÊÌ…i˜Êi˜Ì>“ˆVˆ˜Êä°ÈÊ
mg/kg in one bag Q24H
Patient with urine output > 100 mL/day
UÊÊivÌ>âˆ`ˆ“iÊ£Ê}ʈ˜Êœ˜iÊL>}Ê+Ó{
Severe illness: systemic therapy is preferred.
UÊÊ,-/Ê"-\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê6ÊPLUS ONE
œvÊÌ…iÊvœœÜˆ˜}\
Qi˜Ì>“ˆVˆ˜ÊÓÊ“}ÉŽ}Ê6Ê",ÊivÌ>âˆ`ˆ“iÊ£Ê}Ê6Ê",ʈ«ÀœyœÝ>Vˆ˜Ê{ääÊ
“}Ê6R
45
6.1 Abdominal infections

45. 6.1 Abdominal infections
46
UÊÊ / Ê"-\ÊœÃiÊ«iÀÊ`ÀÕ}ʏiÛiÃÊ>˜`ÉœÀÊÀi˜>ÊvÕ˜V̈œ˜ÆÊ
consult pharmacy for recommendations for redosing and monitoring
Duration:Ê£äq£{Ê`>ÞÃ
TREATMENT NOTES
Microbiology
UÊÊœÃÌÊV>ÃiÃÊV>ÕÃi`ÊLÞÊVœ˜Ì>“ˆ˜>̈œ˜ÊœvÊÌ…iÊV>Ì…iÌiÀ
UÊÊՏÌÕÀiÃÊ“>ÞÊLiʘi}>̈Ûiʈ˜ÊxqÓä¯
UÊÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊ­S. aureus, coagulase-negative staphylococci,
Enterococcus spp.), Gram-negative rods, yeast (much less common)
Diagnosis
UÊʏÊ«>̈i˜ÌÃÊ܈̅ÊÃÕëiVÌi`Ê*‡Ài>Ìi`Ê«iÀˆÌœ˜ˆÌˆÃÊÃ…œÕ`Ê…>ÛiÊ*ÊyÕˆ`Ê
sampled for cell count, differential, gram stain, culture AND amylase.
WBC > 100/mm
3
Ê܈̅ʀÊxä¯Ê* ÊÃÕ}}iÃÌÃʈ˜viV̈œ˜°
UÊʏiÛ>Ìi`Ê>“ޏ>ÃiÊÃÕ}}iÃÌÃÊ«>˜VÀi>̈̈ÃÊœÀÊLœÜiÊ«iÀvœÀ>̈œ˜°
UÊʘÊÃÞ“«Ìœ“>̈VÊ«>̈i˜ÌÃÊ܈̅ÊVœÕ`ÞÊyÕˆ`Ê>VVœ“«>˜ˆi`ÊLÞÊ>L`œ“ˆ˜>Ê
pain and/or fever, empiric treatment should be started given the high
likelihood of infection.
UÊʘÊÃÞ“«Ìœ“>̈VÊ«>̈i˜ÌÃÊ܈̅ÊVi>ÀÊyÕˆ`]Ê>˜œÌ…iÀÊ*ÊyÕˆ`ÊiÝV…>˜}i]Ê
with a dwell time of at least 2 hours, should be sampled. The decision
to start empiric therapy in these cases will depend on how sick the
patient appears.
UÊʘÊ>ÃÞ“«Ìœ“>̈VÊ«>̈i˜ÌÃÊ܈̅ÊVœÕ`ÞÊyÕˆ`]ʈÌʈÃÊÀi>Ãœ˜>LiÊÌœÊ`i>ÞÊ
therapy pending the results of cell count, gram stain, and culture.
,iviÀi˜Vi\
-*ÊÕˆ`iˆ˜iÃÊvœÀÊ*iÀˆÌœ˜i>Êˆ>ÞÈÇÀi>Ìi`ʘviV̈œ˜Ã\Ê*iÀˆÌʈ>Ê˜ÌÊÓä£äÆÎä\
ΙÎÊq{Óΰ

46. Clostridium difficile infection (CDI)
Diagnosis and testing
UÊÊ>ÃiÊ`iw˜ˆÌˆœ˜ÊœvÊC. difficileÊ`ˆ>ÀÀ…i>\Ê«>ÃÃ>}iÊœvÊ≥ 3 unformed
stools in ≤ 24 hours AND either a positive stool test for C. difficile or
colonoscopic/histopathologic finding of pseudomembranous colitis.
UÊÊ/…iÊ“ˆVÀœLˆœœ}Þʏ>LÊÕÃiÃÊ>ÊÀi>‡Ìˆ“iÊ*,Ê>ÃÃ>ÞÊÌœÊ`iÌiVÌÊÌ…iÊ̜݈˜Ê Ê
gene, the toxin responsible for CDI. Thus, patients who are colonized
with toxigenic strains will test positive even if they do not have active
infection and clinical correlation with positive test results is important.
/…iÊÃi˜ÃˆÌˆÛˆÌÞÊœvÊÀi>Ê̈“iÊ*,ʈÃʀʙä¯ÊVœ“«>Ài`ÊÌœÊ̜݈}i˜ˆVÊ
culture.
UÊÊœÊ "/ÊÃi˜`ÊÃÌœœÊvœÀÊC. difficile testing if patients do not have
diarrhea or ileus. Hard stool, fluid obtained from colonoscopy and
rectal swabs will be rejected by the microbiology lab.
UÊʘʫ>̈i˜ÌÃÊÀiViˆÛˆ˜}ʏ>Ý>̈ÛiÃ]ʈÌʈÃÊÀiVœ““i˜`i`ÊÌœÊ`ˆÃVœ˜Ìˆ˜ÕiÊ
laxatives for 24-48 hours prior to C. difficile stool test to see if
diarrhea improves, unless the patient is clinically unstable.
UÊÊ iV>ÕÃiÊœvÊi˜…>˜Vi`ÊÃi˜ÃˆÌˆÛˆÌÞÊœvÊ*,]Ê`Õ«ˆV>ÌiÊÌiÃ̈˜}ʈÃʘœÌÊ
necessary or recommended. Testing is restricted to one specimen
within 7 days. Call the Laboratory Medicine resident or faculty member
on call for those rare instances when a second specimen is required.
UÊÊ-ÌœœÊvœÀÊC. difficile testing should be collected prior to starting
treatment for C. difficile.
UÊÊ-«iVˆ“i˜ÃÊÃ…œÕ`ÊLiÊ…>˜`ÊV>ÀÀˆi`ÊÌœÊÌ…iʏ>LÊ>ÃÊÃœœ˜Ê>ÃÊ«œÃÈLiÊ>vÌiÀÊ
collection. If they cannot be transported promptly, the samples should
be refrigerated.
UÊÊœÊ "/ÊÃi˜`ÊvœœÜ‡Õ«ÊC. difficile PCR during treatment or to
document resolution of disease, as utility of the results has not been
demonstrated.
TREATMENT
UÊÊ-/"*ÊÊ /," Ê /-Ê7 6,Ê*"-- °
UÊÊ"À>ÊÌ…iÀ>«ÞÊ“ÕÃÌÊLiÊÕÃi`ÊÜ…i˜iÛiÀÊ«œÃÈLiÊ>ÃÊÌ…iÊivwV>VÞÊœvÊ6Ê
Metronidazole is poorly established for CDI and there is no efficacy of
IV Vancomycin for CDI.
47
6.2 Clostridium difficile infection (CDI)

47. 6.2 Clostridium difficile infection (CDI)
48
Treatment depends on clinical severity
Infection severity Clinical manifestations
Asymptomatic C. difficile PCR positive without diarrhea,
carriage* ileus, or colitis
Mild or moderate C. difficile PCR positive with diarrhea but no
manifestations of severe disease
Severe C. difficile PCR positive with diarrhea and one or more
of the following attributable to CDI:
Ê UÊÊ 7 Ê≥ 15,000
Ê UÊÊ ˜VÀi>Ãiʈ˜ÊÃiÀÕ“ÊVÀi>̈˜ˆ˜iÊ> xä¯ÊvÀœ“ÊL>Ãiˆ˜i
Severe Complicated Criteria as above plus one or more of the following
attributable to CDI:
Ê UÊÞ«œÌi˜Ãˆœ˜
Ê UʏiÕÃÊ
Ê UÊ/œÝˆVÊ“i}>Vœœ˜ÊœÀÊ«>˜VœˆÌˆÃÊœ˜Ê/
Ê UÊ*iÀvœÀ>̈œ˜
Ê UÊ ii`ÊvœÀÊVœiVÌœ“Þ
Ê UÊ1Ê>`“ˆÃÈœ˜ÊvœÀÊÃiÛiÀiÊ`ˆÃi>Ãi
Infection severity Treatment
ÃÞ“«Ìœ“>̈VÊÊ ÊœÊ "/ÊÌÀi>ÌÆÊÌÀi>Ì“i˜ÌÊV>˜Ê«Àœ“œÌiÊÀi>«Ãˆ˜}Ê
carriage disease
ˆ`ÊœÀÊ“œ`iÀ>ÌiÊ UÊiÌÀœ˜ˆ`>✏iÊxääÊ“}Ê*"É /Ê+nÊ
Unable to tolerate oral therapy
Ê UÊÊ iÌÀœ˜ˆ`>✏iÊxääÊ“}Ê6Ê+nÊ­ÃÕLœ«Ìˆ“>ÆÊÃiiʘœÌiÊ
at start of CDI section above)
-iÛiÀiÊ UÊÊ6>˜Vœ“ÞVˆ˜ÊÃœṎœ˜Ê£ÓxÊ“}Ê*"É /Ê+ÈÊ
-iÛiÀiÊœ“«ˆV>Ìi`Ê UÊÊœ˜ÃՏÌÊÃÕÀ}iÀÞÊvœÀÊiÛ>Õ>̈œ˜ÊvœÀÊVœiVÌœ“ÞÊ>˜`ÊÊ
Ê UÊÊ 6>˜Vœ“ÞVˆ˜ÊÃœṎœ˜ÊxääÊ“}ÊLÞÊ /Ê+ÈÊPLUS
Metronidazole 500 mg IV Q8H
†

Unable to tolerate oral therapy or complete ileus
Ê UÊÊ 6>˜Vœ“ÞVˆ˜ÊxääÊ“}ʈ˜ÊxääÊ“Ê -Ê+ÈÊ>ÃÊÀiÌi˜Ìˆœ˜Ê
enema via Foley catheter in rectum + Metronidazole
500 mg IV Q8H
I£x‡Óx¯ÊœvÊ…œÃ«ˆÌ>ˆâi`Ê«>̈i˜ÌÃÊ>ÀiÊVœœ˜ˆâi`Ê܈̅ C. difficile.
†
Vancomycin dose can be decreased to 125 mg PO Q6H and Metronidazole can be stopped once
the patient has stabilized.
Other indications for oral Vancomycin use
UÊ œÊÀi뜘ÃiÊ̜ʜÀ>ÊiÌÀœ˜ˆ`>✏iÊ>vÌiÀÊxÊ`>ÞÃÊœvÊÌ…iÀ>«Þ
UÊ-iVœ˜`Êi«ˆÃœ`iÊœvÊÀiVÕÀÀi˜ÌÊ`ˆÃi>Ãi
UÊ*>̈i˜ÌÃÊ܈̅ÊÈ}˜ˆwV>˜ÌÊÈ`iÊivviVÌÃÊÌœÊiÌÀœ˜ˆ`>✏i
UÊ*>̈i˜ÌÃÊÜ…œÊ>ÀiÊ«Ài}˜>˜Ì
UÊÊœ˜Ãˆ`iÀʈ˜Ê«>̈i˜ÌÃÊ€ÊÈxÊÞi>ÀÃÊ}ˆÛi˜ÊÀi«œÀÌÃÊœvʈ˜VÀi>Ãi`Ê“œÀLˆ`ˆÌÞÊ
from CDI.

48. Duration
UÊ£äq£{Ê`>ÞÃ
Approach to patients who need to continue broad spectrum
antibiotic therapy
UÊiÌiÀ“ˆ˜iÊÌ…iÊÃ…œÀÌiÃÌÊ«œÃÈLiÊVœÕÀÃiÊœvÊ>˜ÌˆLˆœÌˆVÊÌ…iÀ>«Þ°Ê
UÊÊ,i«>ViÊÌ…iÊ>˜ÌˆLˆœÌˆVÊÌ…>Ìʈ˜`ÕVi`Ê]Ê«>À̈VՏ>ÀÞÊVi«…>œÃ«œÀˆ˜Ã]Ê
Clindamycin, and fluoroquinolones.
UÊÊvÊÌ…iʈ˜`ÕVˆ˜}Ê>}i˜ÌʈÃÊÀi«>Vi`Ê>˜`ÊÌ…iÊÊÀiÃœÛiÃ]ÊVœ“«iÌiÊ>Ê
ÃÌ>˜`>À`ʣ䇣{Ê`>ÞÊVœÕÀÃiÊœvÊÊÌ…iÀ>«ÞÆÊÌ…iÀiʈÃʘœÊ˜ii`ÊÌœÊiÝÌi˜`Ê
CDI therapy until the end of the course of antibiotic therapy.
UÊÊvÊÌ…iʈ˜`ÕVˆ˜}Ê>}i˜ÌÊV>˜˜œÌÊLiÊÃÌœ««i`ÊœÀÊÀi«>Vi`]ÊVœ˜Ãˆ`iÀÊ
continuing CDI therapy until the end of the course of antibiotic therapy
­`>Ì>Ê>Àiʏˆ“ˆÌi`®ÆÊÊÌ…iÀ>«ÞÊÃ…œÕ`ʘœÌÊLiÊVœ˜Ìˆ˜Õi`ÊLiÞœ˜`ÊÌ…iÊi˜`Ê
of antibiotic therapy if the patient remains asymptomatic.
Recurrent disease
UÊÊ,iÈÃÌ>˜ViÊÌœÊiÌÀœ˜ˆ`>✏iÊœÀÊ6>˜Vœ“ÞVˆ˜Ê…>ÃʘœÌÊLii˜Ê`œVÕ“i˜Ìi`Ê
conclusively.
UÊÊ,iVÕÀÀi˜ÌÊ`ˆÃi>ÃiÊ>vÌiÀÊ>ÊVœ“«iÌiÊVœÕÀÃiÊœvÊÌ…iÀ>«ÞÊœVVÕÀÃʈ˜ÊHÊ
Óx¯ÊœvÊ«>̈i˜ÌðÊ,i>«ÃiʈÃÊ`ÕiÊÌœÊv>ˆÕÀiÊÌœÊiÀ>`ˆV>ÌiÊëœÀiÃÊ­È䯮Ê
œÀÊ>VµÕˆÃˆÌˆœ˜ÊœvÊ>ʘiÜÊÃÌÀ>ˆ˜Ê­{䯮°ÊœVÕ“i˜ÌÊÀiVÕÀÀi˜ÌÊ`ˆÃi>ÃiÊ܈̅Ê
repeat stool testing.
UÊʈÀÃÌÊÀiVÕÀÀi˜ViÊÃ…œÕ`ÊLiÊÌÀi>Ìi`ÊÌ…iÊÃ>“iÊ>ÃÊÌ…iʈ˜ˆÌˆ>Êi«ˆÃœ`iÆÊ
severe disease should be treated with Vancomycin.
UÊÊ-iVœ˜`ÊÀiVÕÀÀi˜ViÊÃ…œÕ`ÊLiÊÌÀi>Ìi`Ê܈̅Ê6>˜Vœ“ÞVˆ˜ÊÌ>«iÀÊvœœÜi`Ê
by pulse dosing or fecal microbiota transplant (consult GI).
UÊvÊÃiÀˆœÕÃÊœÀʓՏ̈«iÊÀiVÕÀÀi˜ViÃ]ÊVœ˜ÃՏÌÊ°
Vancomycin taper regimen
125 mg 4 times daily ×Ê£äq£{Ê`>ÞÃ
125 mg BID × 7 days
125 mg daily × 7 days
£ÓxÊ“}ÊiÛiÀÞÊÓqÎÊ`>ÞÃÊvœÀÊÓqnÊÜiiŽÃÊ­«ÕÃiÊ`œÃˆ˜}®
NOTES
Management
UÊÊ-ÕÀ}ˆV>Êˆ˜ÌiÀÛi˜Ìˆœ˜ÊvœÀÊVœiVÌœ“ÞÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`Êi>ÀÞʈvÊÌ…iÊ
patient is clinically unstable secondary to CDI.
UÊÊ/Ài>Ì“i˜ÌÊœvÊÊÃ…œÕ`ÊLiÊVœ˜Ìˆ˜Õi`ʈ˜Ê«>̈i˜ÌÃÊÜ…œÊ…>ÛiÊ>ÊÃÕLÌœÌ>Ê
colectomy with preservation of the rectum.
UÊÊœÃÌÊ«>̈i˜ÌÃÊ܈̅ÊÃiÛiÀiÊÊÃ…œÕ`ÊÕ˜`iÀ}œÊ>L`œ“ˆ˜>Ê/ÊÌœÊÀՏiÊ
out toxic megacolon or pancolitis.
49
6.2 Clostridium difficile infection (CDI)

49. 6.2 Clostridium difficile infection (CDI)
50
UÊÊœÊ "/ÊÃi˜`ÊvœœÜ‡Õ«ÊC.difficile PCR to document resolution of
disease.
UÊʜʘœÌÊÕÃiÊ>˜Ìˆ“œÌˆˆÌÞÊ>}i˜Ìð
UÊÊ-Ìœ«Ê«ÀœÌœ˜Ê«Õ“«Êˆ˜…ˆLˆÌœÀÃÊ­**îÊÜ…i˜iÛiÀÊ«œÃÈLiÊ>ÃÊ`>Ì>ÊÃÕ}}iÃÌÊ
PPIs increase the risk of CDI.
UÊÊ/…iÊœvvi˜`ˆ˜}Ê>˜Ìˆ“ˆVÀœLˆ>Ê>}i˜ÌÃÊÃ…œÕ`ÊLiÊ`ˆÃVœ˜Ìˆ˜Õi`°ÊvÊ
antimicrobials are still required, it is best to avoid cephalosporins,
Clindamycin, and fluoroquinolones.
UÊÊ*Àœ«…ޏ>V̈VÊÕÃiÊœvÊœÀ>ÊiÌÀœ˜ˆ`>✏iÊœÀÊ6>˜Vœ“ÞVˆ˜Êˆ˜Ê«>̈i˜ÌÃÊ
receiving antimicrobial therapy for treatment of underlying infection
(other than CDI) is not recommended and may increase the patient’s
risk for CDI.
Infection control
UÊÊ*>̈i˜ÌÃÊ܈̅ÊÊÃ…œÕ`ÊLiÊ«>Vi`ʈ˜ÊVœ˜Ì>VÌÊ«ÀiV>Ṏœ˜ÃÊ>˜`ÊȘ}iÊ
rooms for the duration of hospitalization.
UÊÊ1ÃiÊÃœ>«Ê>˜`ÊÜ>ÌiÀÊÀ>Ì…iÀÊÌ…>˜Ê>Vœ…œ‡L>Ãi`Ê…>˜`Ê}iÊÕ«œ˜Êï݈˜}Ê
the room of a patient with CDI.
,iviÀi˜ViÃ\
-É-Êœ˜Ãi˜ÃÕÃÊÕˆ`iˆ˜iÃÊvœÀÊ\ʘviVÌÊœ˜ÌÀœÊœÃ«Ê«ˆ`i“ˆœÊÓä£äÆÊ
Σ\{Σq{x{°
>VŽÊœvÊṎˆÌÞÊœvÊÌÀi>̈˜}ÊÊV>ÀÀˆiÀÃ\ʘ˜Ê˜ÌiÀ˜Êi`Ê£™™ÓÆÊ££Ç\әLJÎäÓ°
œiVÌœ“Þʈ˜Ê\ʘ˜Ê-ÕÀ}ÊÓääÇÆÊÓ{x\ÓÈLJÇÓ°

50. 51
6.3 Infectious diarrhea
Infectious diarrhea
UÊFor treatment of C. difficile infection, see p. 47.
UÊ>ÀivՏÞÊ>ÃÃiÃÃÊÌ…iÊ«>̈i˜ÌÊLivœÀiÊ«ÀiÃVÀˆLˆ˜}Ê>˜Ìˆ“ˆVÀœLˆ>Ã°
UÊÊœÃÌʈ˜viV̈œÕÃÊ`ˆ>ÀÀ…i>ʈÃÊÃiv‡ˆ“ˆÌi`Ê>˜`Êœ˜ÞÊÀiµÕˆÀiÃÊÃÕ««œÀ̈ÛiÊ
management.
UÊÊ/Ài>Ì“i˜ÌÊ܈̅Ê>˜ÌˆLˆœÌˆVÃʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ“œÃÌÊ“ˆ`‡
“œ`iÀ>ÌiÊ`ˆÃi>ÃiÆÊÃiiÊëiVˆwVʈ˜`ˆV>̈œ˜Ãʈ˜ÊÌ>LiÊLiœÜ°
UÊÊ6ˆÀ>Ê«>Ì…œ}i˜Ã]ÊÃÕV…Ê>ÃÊ œÀœÛˆÀÕÃÊ>˜`Ê,œÌ>ÛˆÀÕÃÊVœ““œ˜ÞÊV>ÕÃiÊ
diarrhea and do not require antibiotics.
UÊʘ̈LˆœÌˆVÊÕÃiÊ“>Þʏi>`ÊÌœÊ>`ÛiÀÃiÊœÕÌVœ“iÃÊ­i°}°Ê…i“œÞ̈VÊÕÀi“ˆVÊ
syndrome with Shiga toxin-producing E. coli).
UÊʘ̈“œÌˆˆÌÞÊ>}i˜ÌÃÊÃ…œÕ`ʘœÌÊLiÊÕÃi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊLœœ`ÞÊ`ˆ>ÀÀ…i>]Ê
fever, or elevated WBC.
Microbiology
UÊÊœ““œ˜Ê˜œ˜‡ÛˆÀ>Ê«>Ì…œ}i˜Ãʈ˜Ê>VÕÌiÊVœ““Õ˜ˆÌÞ‡>VµÕˆÀi`Ê`ˆ>ÀÀ…i>\Ê
Salmonella, Shigella, Shiga toxin-producing E. coli, Campylobacter,
C. difficile (usually with antibiotic exposure).
UÊ œÃœVœ“ˆ>Ê`ˆ>ÀÀ…i>\ÊC. difficile
UÊÊ*iÀÈÃÌi˜ÌÊ`ˆ>ÀÀ…i>ʈvʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê­“œÃÌʏˆŽiÞÊV>ÕÃiÃÊÛ>ÀÞÊ
`i«i˜`ˆ˜}Êœ˜ÊÌÞ«iÊœvʈ““Õ˜œVœ“«Àœ“ˆÃi®\ÊGiardia, Cryptosporidium,
Cyclospora, Isospora, Microsporidia, Cytomegalovirus (CMV).
Diagnosis
UÊÊ œÌÊiÛiÀÞÊ`ˆ>ÀÀ…i>Êˆ˜iÃÃÊÀiµÕˆÀiÃÊÃÌœœÊVՏÌÕÀi°ÊiVˆÃˆœ˜ÊÌœÊÌiÃÌÊ
should be based on suspicion for specific pathogens and/or clinical
judgment of illness severity.
UÊÊ*>̈i˜ÌÃÊ܈̅ÊviLÀˆiÊ`ˆ>ÀÀ…i>Êˆ˜iÃÃiÃÊ܈̅ÊVˆ˜ˆV>Êvi>ÌÕÀiÃÊœvÊ
moderate to severe disease should receive empiric therapy only after
a fecal specimen is obtained for appropriate testing.
UÊÊiV>ÊëiVˆ“i˜ÃÊvÀœ“Ê«>̈i˜ÌÃÊ…œÃ«ˆÌ>ˆâi`ÊvœÀÊ€ÊÎÊ`>ÞÃÊÃ…œÕ`ʘœÌÊLiÊ
submitted for routine stool culture unless a high suspicion for specific
pathogen exists and/or if the patient is immunocompromised.
UÊÊՏ̈«iÊÃÌœœÊiÝ>“ˆ˜>̈œ˜ÃÊvœÀÊœÛ>Ê>˜`Ê«>À>ÈÌiÃÊ­"E*®Ê>ÀiÊœvʏœÜÊ
yield.
UÊÊiV>ÊiÕŽœVÞÌiɏ>VÌœviÀÀˆ˜Ê>ÃÃiÃÓi˜ÌÃÊÃ…œÕ`ʘœÌÊLiÊÕÃi`ÊÌœÊ
determine the therapeutic approach.

51. 6.3 Infectious diarrhea
52
Organism/Indications for treatment Treatment
Bacteria
Campylobacter spp.
/Ài>Ì“i˜ÌÊÀiVœ““i˜`i`ÊvœÀ\
UÊ-iÛiÀiʈ˜iÃÃ
UÊ}iʐÊÈÊ“œ˜Ì…ÃÊœÀÊ€ÊxäÊÞi>ÀÃ
UÊÀœÃÃÊLœœ`ʈ˜ÊÃÌœœ
Uʈ}…ÊviÛiÀ
UÊ7œÀÃi˜ˆ˜}ÊœÀÊÀi>«Ãˆ˜}ÊÃÞ“«Ìœ“Ã
UÊ*Ài}˜>˜VÞ
UÊ““Õ˜œVœ“«Àœ“ˆÃi`Ê…œÃÌ
E. coli (enterotoxigenic, enteropathogenic,
enteroinvasive) or empiric therapy of
traveler’s diarrhea
Shiga toxin producing E. coli (including
E. coliÊä£xÇ\Ç®
Non-typhoid Salmonella spp.
/Ài>Ì“i˜ÌÊÀiVœ““i˜`i`ÊvœÀ\
UÊ-iÛiÀiʈ˜iÃÃÊÀiµÕˆÀˆ˜}Ê…œÃ«ˆÌ>ˆâ>̈œ˜
UÊ}iʐÊÈÊ“œ˜Ì…ÃÊœÀÊ€ÊxäÊÞi>ÀÃ
UÊ >VÌiÀi“ˆ>
UÊ*ÀiÃi˜ViÊœvÊ«ÀœÃÌ…iÃiÃ
UÊ6>ÛՏ>ÀÊ…i>ÀÌÊ`ˆÃi>Ãi
UÊ-iÛiÀiÊ>Ì…iÀœÃViÀœÃˆÃ
UÊ>ˆ}˜>˜VÞÊœÀʜ̅iÀʈ““Õ˜œVœ“«Àœ“ˆÃi
Shigella spp.
Treatment always recommended even if result
returns when patient is asymptomatic.
Vibrio parahaemolyticus
œÌi\ÊÃÃœVˆ>Ìi`Ê܈̅ÊÃ…iwÃ…ÊVœ˜ÃÕ“«Ìˆœ˜
Treatment recommended for severe illness
Yersinia spp.
/Ài>Ì“i˜ÌÊÀiVœ“““i˜`i`ÊvœÀ\
UÊ““Õ˜œVœ“«Àœ“ˆÃi`Ê…œÃÌ
UÊ >VÌiÀi“ˆ>
UÊ*ÃiÕ`œ>««i˜`ˆVˆÌˆÃÊÃÞ˜`Àœ“i
UÊâˆÌ…Àœ“ÞVˆ˜ÊxääÊ“}Ê*"Ê`>ˆÞÊvœÀÊ£qÎÊ`>ÞÃ
Uʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê
Duration:Ê£qÎÊ`>ÞÃ
Treatment not recommended. Antibiotic
use associated with development of
hemolytic uremic syndrome.
Uʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê Ê
OR

UÊÊ/*É-8Ê£ÈäÉnääÊ“}Ê*"Ê Ê
(if susceptible)
OR

UÊÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{
Duration:ÊxqÇÊ`>ÞÃÆÊ£{Ê`>ÞÃÊvœÀÊ
immunocompromised host
UÊÊ/*É-8Ê£ÈäÉnääÊ“}ÊÊ*"Ê Ê
(if susceptible)
OR

Uʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê Ê
Duration:ÊÎÊ`>ÞÃÆÊÇÊ`>ÞÃÊvœÀʈ““Õ˜œ‡
compromised host
Uʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê ÊÝÊÎÊ`>ÞÃ
UÊÊ/*É-8Ê£ÈäÉnääÊ“}Ê*"Ê ÊÝÊÎqxÊ
days (if susceptible)
OR

Uʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê ÊÝÊÎÊ`>ÞÃ
OR

UÊÊœÝÞVÞVˆ˜iÊ£ääÊ“}Ê*"Ê ÊÝÊÎÊ`>ÞÃ
(not for bacteremia)
Treatment of infectious diarrhea

52. 53
6.3 Infectious diarrhea
Parasites
Entamoeba histolytica
Treat all (even asymptomatic)
E. dispar & E. moshkovskii infections do not
require treatment
Giardia spp.
UÊÊiÌÀœ˜ˆ`>✏iÊÇxäÊ“}Ê*"Ê/ÊÝÊxq£äÊ
days
OR

UÊÊ/ˆ˜ˆ`>✏iÊ£Ê}Ê*"Ê+£ÓÊÝÊÎÊ`>ÞÃ
UÊÊPLUS all patients should receive
Paromomycin 500 mg PO TID x 7 days
after the course of 1st agent complete
Asymptomatic patients
UÊÊ*>Àœ“œ“ÞVˆ˜ÊxääÊ“}Ê*"Ê/ÊÝÊÇÊ`>ÞÃ
UÊÊiÌÀœ˜ˆ`>✏iÊÓxä‡xääÊ“}Ê*"Ê/ÊÝÊ
Çq£äÊ`>ÞÃ
OR

U Tinidazole 2 g PO once
,iviÀi˜ViÃ\Ê
-ÊÕˆ`iˆ˜iÃÊvœÀÊ>˜>}i“i˜ÌÊœvʘviV̈œÕÃʈ>ÀÀ…i>Æʏˆ˜Ê˜viVÌʈÃÊÓää£ÆÎÓ\ÎΣqxä°
˜viV̈œÕÃÊ`ˆ>ÀÀ…i>ʈ˜Ê`iÛiœ«i`Ê>˜`Ê`iÛiœ«ˆ˜}ÊVœÕ˜ÌÀˆiÃ\Êʏˆ˜Ê>ÃÌÀœi˜ÌiÀœÊÓääx\Ι\ÇxÇqÇÇΰ

53. 6.4 Helicobacter pylori infection
54
Helicobacter pylori infection
NOTE: CONSIDER WITHHOLDING THERAPY INITIATION UNTIL PATIENT
DISCHARGED FROM HOSPITAL UNLESS ACUTE ULCER IS PRESENT
Established indications for testing for H. pylori and treating
positive patients
UÊÊV̈ÛiÊ«i«ÌˆVÊՏViÀÊ`ˆÃi>ÃiÊ­*1®ÊqÊ}>ÃÌÀˆVÊœÀÊ`Õœ`i˜>
UÊÊœ˜wÀ“i`Ê…ˆÃÌœÀÞÊœvÊ*1Ê­˜œÌÊ«ÀiÛˆœÕÏÞÊÌÀi>Ìi`ÊvœÀÊH. pylori)
UÊÊ>ÃÌÀˆVÊ/ʏޓ«…œ“>Ê­œÜÊ}À>`i®
UÊœœÜˆ˜}ÊÀiÃiV̈œ˜ÊœvÊ}>ÃÌÀˆVÊV>˜ViÀÊ
UÊ>“ˆÞÊ…ˆÃÌœÀÞÊœvÊ}>ÃÌÀˆVÊV>˜ViÀʈ˜Ê>Ê£ÃÌÊ`i}ÀiiÊÀi>̈Ûi
UÊÌÀœ«…ˆVÊ}>ÃÌÀˆÌˆÃ
Other indications where testing for H. pylori and treating positive
patients can be considered: nonulcer dyspepsia, long term PPI
use, persons using NSAID/ASA, unexplained iron deficiency anemia or
vitamin B12 deficiency, family members of patients with H. pylori with
mild dyspepsia.
First-line treatment
UÊÊ“œÝˆVˆˆ˜Ê£Ê}Ê*"Ê+£ÓÊPLUS Clarithromycin 500 mg PO Q12H
PLUS Pantoprazole 40 mg PO Q12H
OR
UÊ* Ê>iÀ}Þ
UÊʏ>ÀˆÌ…Àœ“ÞVˆ˜ÊxääÊ“}Ê*"Ê+£ÓÊPLUS Metronidazole 500 mg PO
Q12H PLUS Pantoprazole 40 mg PO Q12H
OR
UÊÊ/iÌÀ>VÞVˆ˜iÊxääÊ“}Ê*"Ê+ÈÊPLUS Metronidazole 500 mg
PO Q8H PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS
Pantoprazole 40 mg PO Q12H
UÊDuration:Ê£äq£{Ê`>ÞÃ
Documented recurrence of H. pylori disease
UÊvÊ«œÃÈLi]Ê>Ûœˆ`Ê>˜ÌˆLˆœÌˆVÃÊ«ÀiÛˆœÕÏÞÊÕÃi`ÊÌœÊÌÀi>ÌÊH. pylori
UÊÊ/iÌÀ>VÞVˆ˜iÊxääÊ“}Ê*"Ê+ÈÊPLUS Metronidazole 500 mg PO Q8H
PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS Pantoprazole 40
mg PO Q12H
UÊDuration: 14 days
TREATMENT NOTES
Diagnosis
UÊÊ**Ã]Ê
2
RA, Bismuth, and antibiotics with activity against H. pylori
should be withheld for at least 4 weeks prior to testing.

54. 55
6.4 Helicobacter pylori infection
UÊÊH. pylori stool antigen is the only FDA approved test (>™ä¯ÊÃi˜ÃˆÌˆÛˆÌÞÊ
and specificity).
UÊ1Ài>ÊLÀi>Ì…ÊÌiÃÌÊ“>ÞÊLiÊœ«Ìˆ“>ÊLÕÌʘœÌÊVœ““œ˜ÞÊ>Û>ˆ>Li°
UÊʘ`œÃVœ«ÞÊPLUSÊÀ>«ˆ`ÊÕÀi>ÃiÊÌiÃÌÊ­näq™x¯ÊÃi˜ÃˆÌˆÛˆÌÞÆÊ™Óq£ää¯Ê
specificity).
UÊÊH. pylori serology does not document current infection and should not
be used for clinical diagnosis.
Management
UÊʈÀÃÌʏˆ˜iÊÌÀi>Ì“i˜ÌÊiÀ>`ˆV>̈œ˜ÊÀ>ÌiÃÊiÃ̈“>Ìi`ÊLiÌÜii˜ÊxäqÇx¯°Ê
>ˆÕÀiÊ“œÃÌÊœvÌi˜Ê`ÕiÊ̜ʏ>ÀˆÌ…Àœ“ÞVˆ˜ÊÀiÈÃÌ>˜ViÊ­£äq£x¯®Ê>˜`ÉœÀÊ
non-adherence.
UÊÊÓ‡ÀiVi«ÌœÀÊ>˜Ì>}œ˜ˆÃÌÃÊ­i°}°Ê,>˜ˆÌˆ`ˆ˜i®ÊV>˜ÊLiÊÃÕLÃ̈ÌÕÌi`ÊvœÀÊÌ…iÊ
PPI if patients are unable to tolerate PPIs or if drug interactions are a
concern.
UÊÊ“œÝˆVˆˆ˜ÊPLUS Tetracycline can NOT be used together in treatment
due to low response rates.
UÊʜʘœÌÊÃÕLÃ̈ÌÕÌiÊœÝÞVÞVˆ˜iɈ˜œVÞVˆ˜iÊvœÀÊ/iÌÀ>VÞVˆ˜iÊœÀÊÊ
Azithromycin for Clarithromycin.
UÊʘʫ>̈i˜ÌÃÊ܈̅ʫœÃˆÌˆÛiÊÌiÃÌÊÀiÃՏÌÃÊi˜`œÃVœ«ÞʈÃÊ“>˜`>ÌœÀÞÊvœÀÊ>}iÊ
> 45-50 years, presence of mass GI bleeding, anemia, weight loss, or
family history of gastric cancer.
UÊÊ/iÃÌÊœvÊVÕÀiʈÃÊÀiVœ““i˜`i`Ê> {qnÊÜiiŽÃÊ«œÃÌÊÌÀi>Ì“i˜Ì°Ê
,iviÀi˜ViÃ\
Maastricht III Consensus Report. GutÊÓääÇÆxÈ\ÇÇÓ‡Çn£°
ACG Guidelines. Am J GastroenterolÊÓääÇÆ£äÓ\£nän‡£nÓx°

55. 6.5 Gynecologic and sexually transmitted infections
56
Pelvic inflammatory disease
UʘVÕ`iÃÊÃ>«ˆ˜}ˆÌˆÃ]ÊÌÕLœ‡œÛ>Àˆ>˜Ê>LÃViÃÃÊ>˜`Ê«iÛˆVÊ«iÀˆÌœ˜ˆÌˆÃ°Ê
UÊÊœÀÊÌÀi>Ì“i˜ÌÊœvÊ«œÃ̇œ«iÀ>̈ÛiÊ«iÀˆÌœ˜ˆÌˆÃÊœÀÊܜ՘`ʈ˜viV̈œ˜]Ê
see p. 44 and p. 105.
TREATMENT
NOTE: Avoid use of fluoroquinolones for N. gonorrhoeae due to
ÀiÈÃÌ>˜ViÊ­H£ä¯Êˆ˜Ê >Ìˆ“œÀiʈÌÞ®
UÊÊivœÌiÌ>˜ÊÓÊ}Ê6Ê+£ÓÊPLUS Doxycycline
* 100 mg PO BID for 14
days
OR
UÊÊÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{ÊPLUS Doxycycline* 100 mg PO BID for 14
days
OR
UÊÊ* Ê>iÀ}Þ\ʏˆ˜`>“ÞVˆ˜ÊÈä䇙ääÊ“}Ê6Ê+nÊPLUS Gentamicin (see
dosing section, p. 146)
Step-down therapy once patient is afebrile
UÊÊ*ÀiviÀÀi`\ÊœÝÞVÞVˆ˜iÊ£ääÊ“}Ê*"Ê Ê´ÊQˆ˜`>“ÞVˆ˜Ê{xäÊ“}Ê*"Ê
QID ORÊiÌÀœ˜ˆ`>✏iÊxääÊ“}Ê*"Ê RÊÌœÊVœ“«iÌiÊ£{Ê`>ÞÃÊÌœÌ>
*Azithromycin 1 g PO once weekly for 2 weeks can be used in the case of Doxycycline
contraindication or intolerance.
TREATMENT NOTES
Microbiology: N. gonorrhoeae, C. trachomatis, Gardnerella spp,
Ureaplasma urealyticum, anaerobes (Prevotella spp., B. fragilis), Gram-
negative rods, Streptococci
Treatment of partners
UʏÊÜœ“i˜Ê`ˆ>}˜œÃi`Ê܈̅Ê>VÕÌiÊ*ÊÃ…œÕ`ÊLiÊœvviÀi`Ê6ÊÌiÃ̈˜}°
UÊÊ>iÊ«>À̘iÀÃÊœvÊÜœ“i˜ÊÜ…œÊ…>ÛiÊ*ÊœvÌi˜Ê>ÀiÊ>ÃÞ“«Ìœ“>̈V°Ê
UÊÊ-iÝÊ«>À̘iÀÃÊ­“>iÊœÀÊvi“>i®ÊœvÊ«>̈i˜ÌÃÊÜ…œÊ…>ÛiÊ*ÊÃ…œÕ`Ê
be examined and treated empirically for C. trachomatis and
N. gonorrhoeae if they have had sexual contact with the patient during
the 60 days preceding onset of symptoms in the patient, regardless
of the pathogens isolated from the patient.
Endomyometritis
TREATMENT
UÊÊ->“iÊ>ÃÊvœÀÊ*ÊLÕÌʘœÊ˜ii`ÊvœÀÊ>``ˆÌˆœ˜ÊœvÊœÝÞVÞVˆ˜iÉâˆÌ…Àœ“ÞVˆ˜
Duration
UÊ/Ài>ÌÊ՘̈Ê«>̈i˜ÌÊ>viLÀˆiÊvœÀÊÓ{q{nÊ…œÕÀÃ

56. 57
6.5 Gynecologic and sexually transmitted infections
Bacterial vaginosis
TREATMENT
UÊÊiÌÀœ˜ˆ`>✏iÊ}iÊä°Çx¯]Êœ˜iÊvՏÊ>««ˆV>ÌœÀÊ­xÊ}®Êˆ˜ÌÀ>Û>}ˆ˜>Þ]Êœ˜ViÊ
daily for 5 days (preferred)
OR
UiÌÀœ˜ˆ`>✏iÊxääÊ“}Ê*"Ê ÊvœÀÊÇÊ`>ÞÃ
OR
Uˆ˜`>“ÞVˆ˜ÊÎääÊ“}Ê*"Ê ÊvœÀÊÇÊ`>ÞÃ
TREATMENT NOTES
Microbiology: anaerobic bacteria (Prevotella spp, Mobiluncus spp.),
G. vaginalis, Ureaplasma, Mycoplasma.
UÊÊ/Ài>Ì“i˜ÌʈÃÊÀiVœ““i˜`i`ʈ˜Ê>ÊÃÞ“«Ìœ“>̈VÊÜœ“i˜Ê>˜`Ê…ˆ}…ÊÀˆÃŽÊ
asymptomatic pregnant women.
Trichomoniasis (T.vaginalis)
NOTE: Treatment of partner recommended.
TREATMENT
UÊiÌÀœ˜ˆ`>✏iÊÓÊ}Ê*"Êœ˜ViÊ
OR
UÊiÌÀœ˜ˆ`>✏iÊxääÊ“}Ê*"Ê ÊvœÀÊÇÊ`>ÞÃ
Uncomplicated gonococcal urethritis, cervicitis,
proctitis
TREATMENT (includes treatment for C. trachomatis):
UÊivÌÀˆ>Ýœ˜iÊÓxäÊ“}ÊÊœ˜ViÊPLUS Azithromycin 1 g orally (preferred)
OR
UÊÊivÌÀˆ>Ýœ˜iÊÓxäÊ“}ÊÊœ˜ViÊPLUS Doxycycline 100 mg PO BID for
7 days
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊâˆÌ…Àœ“ÞVˆ˜ÊÓÊ}Ê*"Êœ˜ViÊ­«Ài“i`ˆV>ÌiÊ܈̅Ê
antiemetic or give snack before administration)
TREATMENT NOTES
UÊ6ÊÌiÃ̈˜}ÊÀiVœ““i˜`i`
UÊÊ/…iÊÕÃiÊœvÊivÌÀˆ>Ýœ˜iʈÃÊ«ÀiviÀÀi`ÊœÛiÀÊiw݈“iÊ>˜`Êiv«œ`œÝˆ“iÊ
due to increasing MICs for oral cephalosporins.

57. 6.5 Gynecologic and sexually transmitted infections
58
UÊÊÕ>ÊÌ…iÀ>«ÞÊÀiVœ““i˜`i`ÊvœÀÊN. gonorrhoeae even if C. trachomatis
is excluded.
UÊÊ-i˜`Ê}œ˜œÀÀ…i>ÊVՏÌÕÀiÊ­˜œÌʘÕViˆVÊ>Vˆ`Ê>“«ˆwV>̈œ˜ÊÌiÃ̮ʈvÊÞœÕÊ
suspect a treatment failure.
Syphilis
SCREENING
UÊÊ-VÀii˜ˆ˜}Ê>}œÀˆÌ…“Ê>ÌÊ\Ê>ÊÌÀi«œ˜i“>‡Ã«iVˆwVÊ>˜ÌˆLœ`ÞÊÌiÃÌÊ­®Ê
if positive, followed by RPR. A confirmatory FTA-ABS is provided if RPR
is negative.
UÊÊÊ«œÃˆÌˆÛiÊ]Ê>ʘi}>̈ÛiÊ,*,Ê>˜`Ê>Ê«œÃˆÌˆÛiÊ/Ê“>ÞÊLiÊ`ÕiÊÌœ\Ê­£®Ê
old treated syphilis (2) old untreated syphilis (3) early syphilis.
UÊÊiÌÊ…ˆÃÌœÀÞÊ>˜`ÊV>Ê >Ìˆ“œÀiʈÌÞÊi>Ì…Êi«>ÀÌ“i˜ÌÊ{£ä‡Î™È‡{{{nÊ
for prior history of syphilis treatment in Maryland
UÊÊvÊ«i˜ˆVˆˆ˜Ê>iÀ}ˆV]ÊÊVœ˜ÃՏÌÃʈÃÊÀiVœ““i˜`i`ÊÌœÊ}Õˆ`iÊÌ…iÀ>«Þ
Algorithm for reverse sequence syphilis screening
CIA
CIA positive CIA negative
RPR positive RPR negative
UÊÊœ˜ÃˆÃÌi˜ÌÊ܈̅Ê
syphilis infection
(past or present)
UÊÊ,iµÕˆÀiÃÊ…ˆÃÌœÀˆV>Ê
and clinical
evaluation to
determine prior
treatment history
Treponemal test that uses a different >˜Ìˆ}i˜Ê­/q -ÊœÀÊ/**®
FTA-ABS positive FTA-ABS negative ÊUÊ*œÃÈLiÊÃÞ«…ˆˆÃÊÊ UÊ-Þ«…ˆˆÃÊÕ˜ˆŽiÞ
ÊÊÊʈ˜viV̈œ˜Ê UÊvÊ«>̈i˜ÌÊ>ÌÊ…ˆ}…Ê
ÊUÊ,iµÕˆÀiÃÊÊ ÊÊÊÀˆÃŽÊvœÀÊÃÞ«…ˆˆÃ]
historical and retest in one
clinical month
evaluation
UÊÊvʈ˜VÕL>̈˜}ÊœÀÊ
primary syphilis
is suspected,
treat for early
syphilis
Neurosyphilis diagnosis
UÊÊ,iµÕˆÀiÃÊLœÌ…ÊVˆ˜ˆV>Ê­˜iÕÀœœ}ˆV>ÊÃÞ“«Ìœ“îÊ>˜`ʏ>LœÀ>ÌœÀÞÊVÀˆÌiÀˆ>°Ê
UÊÊ>LœÀ>ÌœÀÞÊVÀˆÌiÀˆ>Ê­>˜ÞÊVœ“Lˆ˜>̈œ˜Êœv®\ÊÃiÀœœ}ˆV>ÊiÛˆ`i˜ViÊœvÊ
ÃÞ«…ˆˆÃ]Ê«œÃˆÌˆÛiÊ-Ê6,Ê­xä¯ÊÃi˜ÃˆÌˆÛˆÌÞÆÊ…ˆ}…ÊëiVˆwVˆÌÞ®]Ê-Ê
«iœVÞ̜ÈÃÊ­€xÊ7 É“ÊˆvÊ6‡ÆÊ€£ä‡ÓäÊ7 É“ÊˆvÊ6³®]Ê-Ê
elevated protein concentration (>50 mg/dl)
UÊÊÕ“L>ÀÊ«Õ˜VÌÕÀiÊ­*®ÊÃ…œÕ`ÊLiÊœLÌ>ˆ˜i`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʫœÃˆÌˆÛiÊ
serological tests for syphilis plus neurological symptoms, serological
treatment failure (lack of four-fold decline in RPR titer), evidence of
tertiary syphilis
UÊÊœ˜Ãˆ`iÀÊ*ʈ˜Ê>ÃÞ“«Ìœ“>̈VÊ6³Ê«>̈i˜ÌÃÊ܈̅Ê>Ê{ÊVœÕ˜ÌÊ≤350
cells/ml or RPR titer ≥£\ÎÓ

58. 59
6.5 Gynecologic and sexually transmitted infections
TREATMENT
Early syphilis (primary, secondary, and early latent syphilis within one
year after infection)
UÊÊ*i˜ˆVˆˆ˜ÊÊ i˜â>Ì…ˆ˜iÊ­ ˆVˆˆ˜
® L-A) 2.4 million units IM once
UÊÊ-iÛiÀiÊ* Ê>iÀ}ˆiÃ\ÊœÝÞVÞVˆ˜iÊ£ääÊ“}Ê*"Ê ÊvœÀÊÓÊÜiiŽÃÊÊ
Note:Ê`ÕiÊ̜ʈ˜VÀi>Ãi`ÊÀiÈÃÌ>˜ViÊ­H{x¯ÊœvÊÃÌÀ>ˆ˜Ãʈ˜Ê >Ìˆ“œÀiÊ>ÀiÊ
resistant), Azithromycin is not recommended.
Late latent syphilis (asymptomatic infection with positive serology >1
year after infection or latent syphilis of unknown duration)
UÊÊ*i˜ˆVˆˆ˜ÊÊ i˜â>Ì…ˆ˜iÊ­ ˆVˆˆ˜
® L-A) 2.4 million units IM weekly for 3
weeks (total of 3 doses)
Neurosyphilis (can occur during any stage of syphilis)
UÊÊ*i˜ˆVˆˆ˜ÊÊÎq{Ê“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{ÊvœÀÊ£äq£{Ê`>ÞÃ
Syphilis in pregnancy
UÊÊ*i˜ˆVˆˆ˜ÊˆÃÊÌ…iÊœ˜ÞÊÀiVœ““i˜`i`ÊÌ…iÀ>«Þʈ˜Ê«Ài}˜>˜ÌÊ«>̈i˜ÌÃÊ܈̅Ê
any kind of syphilis. Allergy consult for penicillin desensitization is
recommended.
,iviÀi˜ViÃ\Ê
-iÝÕ>ÞÊÌÀ>˜Ã“ˆÌÌi`Ê`ˆÃi>ÃiÃÊÊÌÀi>Ì“i˜ÌÊ}Õˆ`iˆ˜iðÊ7,ÊÓä£äÉx™Ê­,,£Ó®ÆÊ
£q££ä°Ê
âˆÌ…Àœ“ÞVˆ˜ÊÛðʜÝÞVÞVˆ˜iÊvœÀÊ*°Ê"LÃÌiÌÊÞ˜iVœÊÓääÇÆÊ££ä­£®\xÎqÈä°
Discordant Results from Reverse Sequence Syphilis Screening. MMWR 2011/60
­äx®Æ£ÎÎq£ÎÇ

59. 60
6.6 Catheter-related bloodstream infections
Management of catheter-related
bloodstream infections (CR-BSI)
Diagnosis
UÊÊvÊÌ…iÀiʈÃÊ“œÀiÊÌ…>˜Ê“ˆ˜ˆ“>ÊiÀÞÌ…i“>ÊœÀÊ 9Ê«ÕÀՏi˜ViÊ>ÌÊÌ…iÊi݈ÌÊ
site, the catheter is likely infected. It should be removed and replaced
at a different site.
UÊÊ7…i˜Ê,‡ -ʈÃÊÃÕëiVÌi`]ÊÓqÎÊÃiÌÃÊœvÊLœœ`ÊVՏÌÕÀiÃÊÃ…œÕ`ÊLiÊ
drawn with AT LEAST one (and preferably > 1) from peripheral sites.
Blood cultures drawn through non-tunneled catheters are more likely
to yield contaminants.
UÊÊ/…iÊṎˆÌÞÊœvÊVՏÌÕÀiÃÊœvÊÌ…iÊV>Ì…iÌiÀÊ̈«ÊˆÌÃivʈÃʘœÌÊÜiÊ`iw˜i`]Ê>˜`Ê
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 cultures obtained as detailed above.
UÊÊ/iV…˜ˆµÕi\Ê/…iÊi݈ÌÊÈÌiÊÃ…œÕ`ÊLiÊVi>˜i`Ê܈̅Ê>Vœ…œ°Ê/…iÊ
catheter should be grasped a few centimeters proximal to the exit
site. A 5 cm segment of catheter including the tip should be cut off
with sterile scissors and placed in a sterile container.
UÊʘʈ˜ÃÌ>˜ViÃÊÜ…iÀiÊÌ…iÊLœœ`Ê>˜`ÊV>Ì…iÌiÀÊ̈«Ê>ÀiÊVՏÌÕÀi`Ê>ÌÊÌ…iÊÃ>“iÊ
time and the blood cultures are negative but the catheter tip culture is
positive, antibiotics are generally not recommended, even for patients
with valvular heart disease or immunosuppression.
UÊÊ/…iÊiÝVi«Ìˆœ˜ÊˆÃÊ«>̈i˜ÌÃÊÜ…œÃiÊV>Ì…iÌiÀÊ̈«ÃÊ}ÀœÜÊS. aureus and
…>Ûiʘi}>̈ÛiÊLœœ`ÊVՏÌÕÀiðÊ/…iÃiÊ«>̈i˜ÌÃÊÃ…œÕ`ÊÀiViˆÛiÊxqÇÊ
days of antibiotics.
UÊʏÊ«>̈i˜ÌÃÊÃ…œÕ`ÊLiÊvœœÜi`ÊVœÃiÞ]Ê>˜`ÊÀi«i>ÌÊVՏÌÕÀiÃÊÃ…œÕ`Ê
be sent if clinically indicated.
UÊÊ7…i˜Ê>ÊV>Ì…iÌiÀ‡Ài>Ìi`Ê -ʈÃÊ>ÃÃœVˆ>Ìi`Ê܈̅ÊV>Ì…iÌiÀÊ`ÞÃvÕ˜V̈œ˜]Ê
consider the possibility of suppurative thrombophlebitis.
EMPIRIC TREATMENT
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê±Êivi«ˆ“iÊ£qÓÊ}Ê6Ê+nÊ
(use higher dose if pseudomonas suspected)
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê
±ÊQˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRʱ
Tobramycin (see dosing section, p. 146)
Empiric treatment – Gram-positive cocci in clusters in 2 or more
sets of blood cultures
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®

60. 61
6.6 Catheter-related bloodstream infections
Coagulase-negative staphylococci (CoNS)
NOTE: Single positive cultures of CoNS should NOT be treated
unless they are confirmed by follow-up cultures, the patient is
immunosuppressed and/or critically ill, or the patient has implanted
hardware. In these cases, treatment can be started but repeat cultures
should be sent PRIOR to initiation of therapy to confirm the diagnosis.
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê
Change to
UÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ʈvÊÃÕÃVi«ÌˆLiÊ­«ÀiviÀÀi`ÊÌœÊ6>˜Vœ“ÞVˆ˜®
Duration:
UÊÎqÇÊ`>ÞÃʈvÊV>Ì…iÌiÀÊÀi“œÛi`Ê­«ÀiviÀÀi`®
UÊ£äq£{Ê`>ÞÃʈvÊV>Ì…iÌiÀÊÃ>Û>}iÊ>ÌÌi“«Ì
Methicillin-susceptible Staphylococcus aureus
UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ʈvÊÃÕÃVi«ÌˆLi
OR
UÊÊ œ˜‡>˜>«…ޏ>V̈VÊ* Ê>iÀ}Þ\Êiv>✏ˆ˜ÊÓÊ}Ê6Ê+n
OR
UÊʘ>«…ޏ>V̈VÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
Methicillin-resistant Staphylococcus aureus
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
UÊ6>˜Vœ“ÞVˆ˜Ê>iÀ}ÞÊœÀʈ˜ÌœiÀ>˜ViÊ­˜œÌÊÀi`Ê“>˜ÊÃÞ˜`Àœ“i®
Ê UÊ>«Ìœ“ÞVˆ˜Ên‡£äÊ“}ÉŽ}Ê6Ê+ÊÓ{
OR
Ê UÊivÌ>Àœˆ˜iÊÈääÊ“}Ê6Ê+Ên
UÊ6>˜Vœ“ÞVˆ˜Êv>ˆÕÀi\ÊVœ˜ÃՏÌÊ
TREATMENT NOTES
UÊ,i“œÛiÊV>Ì…iÌiÀ°Êˆ}…ÊÀi>«ÃiÊÀ>ÌiÃʈvÊV>Ì…iÌiÀʈÃʘœÌÊÀi“œÛi`°
UÊ6>˜Vœ“ÞVˆ˜ÊˆÃʈ˜viÀˆœÀÊÌœÊ"Ý>Vˆˆ˜ÊvœÀÊÌÀi>Ì“i˜ÌÊœvÊ--°
UÊÊ*>̈i˜ÌÃÊ܈̅ÊS. aureus bacteremia should have an echocardiogram to
rule out endocarditis. Transthoracic echo is acceptable only if the study
>`iµÕ>ÌiÞÊÛˆiÜÃÊÌ…iʏiv̇È`i`ÊÛ>ÛiÃÆÊ“œÃÌÊiÝ«iÀÌÃÊÀiVœ““i˜`Ê/°
UÊʈ˜i✏ˆ`ÊÃ…œÕ`ʘœÌÊLiÊÕÃi`ÊÀœṎ˜iÞÊvœÀÊÌÀi>Ì“i˜ÌÊœvÊS. aureus
bacteremia
UÊÀˆÌiÀˆ>ÊvœÀÊ>Ê£{Ê`>ÞÊVœÕÀÃiÊœvÊÌ…iÀ>«Þ
Ê UÊʘ`œV>À`ˆÌˆÃÊiÝVÕ`i`Ê܈̅Ê/Ê­«ÀiviÀÀi`®ÆÊ…ˆ}…ʵÕ>ˆÌÞÊ//Ê“>ÞÊLiÊ
adequate in select patients
Ê UÊ œÊˆ“«>˜Ìi`Ê«ÀœÃÌ…iÃiÃ
Ê UÊÊœœÜ‡Õ«ÊLœœ`ÊVՏÌÕÀiÃÊ`À>ܘÊÓ‡{Ê`>ÞÃÊ>vÌiÀÊÌ…iʈ˜ˆÌˆ>ÊVՏÌÕÀiÃÊ>ÀiÊ
negative for S. aureus

61. 62
6.6 Catheter-related bloodstream infections
Ê UÊÊ/…iÊ«>̈i˜ÌÊ`iviÀÛiÃViÃÊ܈̅ÊÇÓÊ…œÕÀÃÊœvʈ˜ˆÌˆ>̈œ˜ÊœvÊivviV̈ÛiÊ
antistaphylococcal therapy
Ê UÊÊ/…iÊ«>̈i˜ÌÊ…>ÃʘœÊœV>ˆâˆ˜}ÊÈ}˜ÃÊœÀÊÃÞ“«Ìœ“ÃÊœvÊ“iÌ>ÃÌ>̈VÊ
staphylococcal infection
Ê UÊ-œÕÀViÊVœ˜ÌÀœÊ…>ÃÊLii˜ÊœLÌ>ˆ˜i`
Ê UÊÊLÃi˜ViÊœvʜ̅iÀÊVœ˜`ˆÌˆœ˜ÃÊÌ…>ÌÊ“>ÞÊ>vviVÌÊ>LˆˆÌÞÊÌœÊVi>Àʈ˜viV̈œ˜Ê
based on clinical judgment (e.g. poorly controlled diabetes)
UÊʏÊœÌ…iÀÊ«>̈i˜ÌÃÊÃ…œÕ`ÊÀiViˆÛiÊ{‡ÈÊÜiiŽÃÊœvÊÌ…iÀ>«ÞÊL>Ãi`Êœ˜ÊiÝÌi˜ÌÊ
of infection
Enterococcus faecalis
NOTE: Can be contaminants. Draw repeat cultures to confirm before
ÃÌ>À̈˜}ÊÌÀi>Ì“i˜Ì°Ê£ää¯ÊœvÊE. faecalis blood isolates at JHH are
susceptible to Ampicillin, which should be used unless the patient has a
PCN allergy.
UÊÊ“«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê
OR
UÊÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£xä®Ê
Duration: Çq£{Ê`>ÞÃ
Enterococcus faecium
NOTE: Can be contaminants. Draw repeat cultures to confirm before
ÃÌ>À̈˜}ÊÌÀi>Ì“i˜Ì°Ê/…iÊ“>œÀˆÌÞÊ­Çn¯®ÊœvÊE. faecium blood isolates
at JHH are resistant to Vancomycin. If the isolate is susceptible to
Ampicillin or Vancomycin, these agents should be used preferentially at
the doses listed above for E. faecalis bacteremia.
UÊʈ˜i✏ˆ`ÊÈääÊ“}Ê6É*"Ê+£Ó
OR
UÊ>«Ìœ“ÞVˆ˜Ênq£ÓÊ“}ÉŽ}Ê6Ê+Ó{
TREATMENT NOTES
UÊÊœ˜Ãˆ`iÀÊiV…œV>À`ˆœ}À>“ʈvÊÌ…iÀiʈÃÊ«iÀÈÃÌi˜ÌÊL>VÌiÀi“ˆ>Ê­> 3 days)
on antibiotics.
UÊÊ/…iÊ>``ˆÌˆœ˜ÊœvÊi˜Ì>“ˆVˆ˜Ê`œiÃʘœÌÊ>««i>ÀÊÌœÊV…>˜}iÊœÕÌVœ“iÃʈ˜Ê
CR-BSI caused by Enterococcus in the absence of endocarditis.
Gram-negative bacilli
Antibiotic selection based on organism and susceptibilities.
Duration: Çq£äÊ`>ÞÃ

62. 63
6.6 Catheter-related bloodstream infections
TREATMENT NOTES
UÊÊ>Ì…iÌiÀÃÊ>ÀiʏiÃÃÊVœ““œ˜ÞÊÌ…iÊÃœÕÀViÊœvÊÌ…iʈ˜viV̈œ˜ÆÊ…œÜiÛiÀ]Ê
most advocate catheter removal if the catheter is the source.
Candida spp.
UÊ,iviÀÊ̜ʫ°Ê££ÇÊvœÀÊÌÀi>Ì“i˜ÌÊœvÊV>˜`ˆ`i“ˆ>
CATHETER SALVAGE
UÊÊCatheter removal is STRONGLY recommended for infections with
S. aureus, yeast and Pseudomonas, as the chance of catheter salvage
is low and the risk of recurrent infection is high.
UÊÊCatheters associated with tunnel infections CANNOT be salvaged and
should be removed.
UÊÊWhen catheter salvage is attempted, systemic antibiotics should be
given through the infected line.
UÊʘ̈LˆœÌˆVÊÕÃi`Ê>ÃʏœVŽÊÌ…iÀ>«ÞÊÃ…œÕ`Ê«ÀiviÀi˜Ìˆ>ÞÊ“>ÌV…Ê>˜ÌˆLˆœÌˆVÊ
used for systemic therapy.
Antibiotic Lock Therapy (ALT)
UÊʘ̈LˆœÌˆVʏœVŽÊÌ…iÀ>«ÞÊV>˜ÊLiÊÕÃi`ÊvœÀÊV>Ì…iÌiÀÊÃ>Û>}iÊin addition to
systemic antibiotics when feasible.
UÊÊ>Ì…iÌiÀÊÀi“œÛ>ÊÃ…œÕ`ÊLiÊ«iÀvœÀ“i`ʈvÊVՏÌÕÀiÃÊÀi“>ˆ˜Ê«œÃˆÌˆÛiÊ>vÌiÀÊ
72 hours of appropriate antibiotic lock therapy
Acceptable uses:
UÊÊ->Û>}iÊœvʏœ˜}‡ÌiÀ“ÊV>Ì…iÌiÀÃÊÌ…>ÌÊV>˜˜œÌÊLiÊÀi“œÛi`Ê­i°}°Ê`ˆ>ÞÈÃÊ
catheters, implantable permanent ports or central venous catheters
for chemotherapy) when there are NO systemic complications
(hemodynamic instability, tissue hypoperfusion, septic thrombosis,
infectious endocarditis or distant septic metastases) or signs of local
infection.
Unacceptable uses:
UÊÊ-…œÀ̇ÌiÀ“ÊÛi˜œÕÃÊV>Ì…iÌiÀÃ
UÊÊœ“«ˆV>Ìi`Ê, -Ê­i°}°ÊÌÕ˜˜iÊœÀÊ«œÀ̇«œVŽiÌʈ˜viV̈œ˜]ÊÃiÛiÀiÊ
sepsis, septic shock, endocarditis, osteomyelitis and hematogenous
seeding at other sites)
UÊ>Ì…iÌiÀÊÃ>Û>}iÊ܈̅ÊS. aureus infection.
Duration:ÊÇq£{Ê`>ÞÃÊ

63. 64
6.6 Catheter-related bloodstream infections
Standardized Concentrations of Antibiotics for ALT
Antibiotic Heparin (optional)
6>˜Vœ“ÞVˆ˜ÊxÊ“}ɓʈ˜Êä°™¯Ê -Ê äÊœÀÊxäääÊÕ˜ˆÌÃ
i˜Ì>“ˆVˆ˜ÊxÊ“}ɓʈ˜Êä°™¯Ê -Ê ÓxääÊÕ˜ˆÌÃÊ
UÊÊ/ÊÃ…œÕ`ÊLiʈ˜Ã̈i`ʈ˜ÊÌ…iʏՓi˜ÊœvÊÌ…iÊV>Ì…iÌiÀÊÜ…i˜Ê˜œÌʈ˜ÊÕÃi°
UÊÊÜiÊ̈“iÃÊÃ…œÕ`ÊLiÊ>ÌÊ“ˆ˜ˆ“Õ“ÊœvÊnq£ÓÊ…œÕÀÃÊ«iÀÊ`>ÞÊ­Õ«ÊÌœÊ
Ó{q{nÊ…®
UÊÊ/ÊÛœÕ“iʘii`i`Ê܈ÊÛ>ÀÞÊLÞÊÌÞ«iÊœvÊV>Ì…iÌiÀÊ>˜`Ê>Û>ˆ>LiʘՓLiÀÊ
œvʏՓi˜Ã°Ê˜Ê}i˜iÀ>]ÊÓqxÊ“ÊÃ…œÕ`ÊLiÊÃÕvwVˆi˜Ì°
,iviÀi˜ViÃ\
Stability and compatibility of antimicrobial lock solutions. Am J Health-Syst Pharm.
Óä£ÎÆÇä\Ó£nx‡Ó£™n°
IDSA Guidelines for the Diagnosis and Management of Intravascular Catheter-related
˜viV̈œ˜Ã\ÊClin Infect Dis Óää™Æ{™\£‡{x°

64. 65
6.7 Endocarditis
Treatment of native valve endocarditis
NOTES:
UÊÊ iÌ>‡>VÌ>“ÃÊ>ÀiÊhighly preferable to Vancomycin if the organism is
susceptible and if the patient is not severely allergic. Strongly consider
PCN desensitization for allergic patients.
UÊʘviV̈œÕÃʈÃi>ÃiÃÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊ>`ÛˆÃi`ÊvœÀÊV>ÃiÃÊœvʏiv̇È`i`Ê
infective endocarditis and prosthetic valve endocarditis, particularly in
those in which the preferred antibiotic cannot be used or in which the
organism is resistant to usual therapy.
UÊÊ/…iÀ>«iṎVÊ“œ˜ˆÌœÀˆ˜}\Ê
UÊÊ6>˜Vœ“ÞVˆ˜
UÊÊœ>ÊÌÀœÕ}…ʏiÛi\Ê£xqÓäÊ“V}É“
UÊÊi˜Ì>“ˆVˆ˜ÊvœÀÊÀ>“‡«œÃˆÌˆÛiÊÃÞ˜iÀ}Þ
UÊÊ>ˆÞÊ`œÃˆ˜}
UÊÊœ>ÊÌÀœÕ}…ʏiÛi\Ê1 mcg/mL
UÊÊ/À>`ˆÌˆœ˜>Ê`œÃˆ˜}Ê­+n®
UÊÊœ>Ê«i>ŽÊiÛi\ÊÎq{Ê“V}É“
UÊÊœ>ÊÌÀœÕ}…ʏiÛi\Ê1 mcg/mL
UÊÊ-iiÊ«°Ê£{nÊ>˜`Ê«°Ê£xäÊvœÀÊ`iÌ>ˆÃ
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
UÊÊ*i˜ˆVˆˆ˜ÊÊÎÊ“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{ÊvœÀÊ{ÊÜiiŽÃ
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\ÊivÌÀˆ>Ýœ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ{ÊÜiiŽÃ
OR
UÊÊQ*i˜ˆVˆˆ˜ÊÊÎÊ“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{Ê",ÊivÌÀˆ>Ýœ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊÓÊ
ÜiiŽÃRÊPLUS Gentamicin 3 mg/kg IV Q24H for 2 weeks
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ{Ê
weeks
ÀˆÌiÀˆ>ÊvœÀÊÓÊÜiiŽÊÌÀi>Ì“i˜Ì\
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ…>ÛiÊV>À`ˆ>VÊœÀÊiÝÌÀ>V>À`ˆ>VÊ>LÃViÃÃ
UÊÊÀÊ20 mL/min
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ…>Ûiʈ“«>ˆÀi`ÊnÌ…ÊVÀ>˜ˆ>Ê˜iÀÛiÊvÕ˜V̈œ˜Ê
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ…>ÛiÊAbiotrophia, Granulicatella, or Gemella spp.
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
and 0.5 mcg/mL
UÊÊQ*i˜ˆVˆˆ˜ÊÊ{Ê“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{Ê",ÊivÌÀˆ>Ýœ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ
{ÊÜiiŽÃRÊPLUS Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of
therapy

65. 66
6.7 Endocarditis
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ
4 weeks
Viridans streptococci or S. bovis with PCN MIC > 0.5 mcg/mL
and Abiotrophia defectiva, Granulicatella spp. and Gemella spp.
UÊÊœ˜ÃՏÌÊ
TREATMENT NOTES
UÊʏÊ«>̈i˜ÌÃÊ܈̅ÊS. bovis biotype I endocarditis should undergo GI
work-up to rule out underlying cancer.
Staphylococcus aureus – Methicillin susceptible, native valve,
right-sided involvement only
UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{
UÊÊ1ÃiÊ >vVˆˆ˜ÊvœÀÊ"Ý>Vˆˆ˜‡ˆ˜`ÕVi`Ê…i«>̈̈Ã
Criteria for 2-ÜiiŽÊÌÀi>Ì“i˜Ì\
UÊ*>̈i˜ÌʈÃÊ>˜Êˆ˜iV̈˜}Ê`ÀÕ}ÊÕÃiÀÊ܈̅ʓˆ˜ˆ“>ÊœÌ…iÀÊVœ“œÀLˆ`ˆÌˆiÃÊ
UÊÊiv̇È`i`Êi˜`œV>À`ˆÌˆÃʈÃÊÀՏi`ÊœÕÌÊ܈̅Ê/Ê­«ÀiviÀÀi`®ÊœÀÊ…ˆ}…Ê
quality TTE
UÊÊ/Ài>Ì“i˜ÌʈÃÊ܈̅Ê"Ý>Vˆˆ˜ÊœÀÊ >vVˆˆ˜Ê
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ…>ÛiÊ-Ê­{Ê< 200)
UÊÊ*>̈i˜ÌÊ`œiÃʘœÌÊ…>ÛiÊ>˜Êˆ“«>˜Ìi`Ê«ÀœÃÌ…iÈÃÊ­`ˆ>ÞÈÃÊ}À>vÌ]ÊiÌV®
UÊÊ œœ`ÊVՏÌÕÀiÃÊ>Àiʘi}>̈ÛiÊ܈̅ˆ˜Ê{Ê`>ÞÃÊ>vÌiÀÊÃÌ>À̈˜}ÊÌ…iÀ>«ÞÊ
UÊÊ/…iÀiʈÃʘœÊiÛˆ`i˜ViÊœvÊi“LœˆVÊ`ˆÃi>ÃiÊ"/,ÊÌ…>˜ÊÃi«ÌˆVÊ
pulmonary emboli
UÊÊ6i}iÌ>̈œ˜ÃÊ>ÀiÊ>Ê< 2 cm in size
UÊÊvÊ«>̈i˜ÌÊ`œiÃʘœÌÊ“iiÌÊVÀˆÌiÀˆ>ÊvœÀÊÓ‡ÜiiŽÊÌÀi>Ì“i˜Ì]ÊÌÀi>ÌÊvœÀÊ{Ê
weeks
Staphylococcus aureus – Methicillin susceptible, native valve,
left-sided involvement
UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{Ê
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êiv>✏ˆ˜ÊÓÊ}Ê6Ê+nÊ
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê-ÌÀœ˜}ÞÊVœ˜Ãˆ`iÀÊ* Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊœÀÊ
Vancomycin (see dosing section, p. 150)
UÊÊ/…iÊ>``ˆÌˆœ˜ÊœvÊi˜Ì>“ˆVˆ˜ÊÌœÊ>ÊLiÌ>‡>VÌ>“Ê“>ÞÊ…i«ÊVi>ÀÊLœœ`ÊVՏÌÕÀiÃÊ
faster but does not appear to affect mortality. It particularly should be
avoided in the elderly and in those with baseline renal impairment.
Staphylococcus aureus – Methicillin resistant, native valve
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®

66. 67
6.7 Endocarditis
Duration
UÊÊ1˜Vœ“«ˆV>Ìi`\ÊÈÊÜiiŽÃ
UÊÊœ“«ˆV>Ìi`Ê­«iÀˆÛ>ÛՏ>ÀÊ>LÃViÃÃÊvœÀ“>̈œ˜]Ê“iÌ>ÃÌ>̈VÊVœ“«ˆV>̈œ˜]Ê
«œœÀÊVœ˜ÌÀœi`Ê`ˆ>LiÌiÃÊ“iˆÌÕî\ÊÈÊœÀÊ“œÀiÊÜiiŽÃÊL>Ãi`Êœ˜ÊVˆ˜ˆV>ÊÊ
picture and response to therapy
UÊÊÊ>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i`ÊvœÀÊVœ“«ˆV>Ìi`Ê
diseases
S. pneumoniae, and Group A streptococci
UÊÊ*i˜ˆVˆˆ˜ÊÊÎÊ“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{ÊvœÀÊ{ÊÜiiŽÃ
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\ÊivÌÀˆ>Ýœ˜iÊÓÊ}Ê6Ê+Ó{ÊvœÀÊ{ÊÜiiŽÃÊ",Ê
Cefazolin 2 g IV Q8H for 4 weeks
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊ{Ê
weeks
UÊÊœÀÊS. pneumoniae, if PCN MIC ≥ 0.1, consult ID
Groups B, C and G streptococci
UÊÊ*i˜ˆVˆˆ˜ÊÊÎÊ“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{ÊvœÀÊ{qÈÊÜiiŽÃÊ´Êi˜Ì>“ˆVˆ˜Ê
3 mg/kg IV Q24H for the first 2 weeks of therapy
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êiv>✏ˆ˜ÊÓÊ}Ê6Ê+nÊvœÀÊ{qÈÊÜiiŽÃʱ
Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£{È®ÊvœÀÊ{qÈÊ
weeks ± Gentamicin 3 mg/kg IV Q24H for the first 2 weeks of therapy
UÊÊœ˜Ãˆ`iÀÊ>˜ÊÊœ˜ÃՏÌ
Enterococcus faecalis
UÊÊ“«ˆVˆˆ˜Ê>˜`Êi˜Ì>“ˆVˆ˜ÊÃÕÃVi«ÌˆLi\Ê“«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê",Ê
Penicillin G 4 million units IV Q4H PLUS Gentamicin 1 mg/kg IV Q8H
BOTH for 4-6 weeks
UÊÊ“«ˆVˆˆ˜ÊÃÕÃVi«ÌˆLiÊ܈̅ÊVœ˜ÌÀ>ˆ˜`ˆV>̈œ˜ÃÊvœÀÊ>“ˆ˜œ}ÞVœÃˆ`iÃÊœÀÊ
i˜Ì>“ˆVˆ˜ÊÀiÈÃÌ>˜Ì\Ê“«ˆVˆˆ˜ÊÓÊ}Ê6Ê+{Ê",Ê*i˜ˆVˆˆ˜ÊÊ{Ê“ˆˆœ˜Ê
units IV Q4H PLUS Ceftriaxone 2 g IV Q12H BOTH for 4-6 weeks

67. 68
6.7 Endocarditis
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê-ÌÀœ˜}ÞÊVœ˜Ãˆ`iÀÊ* Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊˆvÊ* Ê
allergy is anaphylactic or Vancomycin (see dosing section, p. 146)
PLUS Gentamicin 1 mg/kg IV Q8H BOTHÊvœÀÊ{qÈÊÜiiŽÃ
UÊÊ/Ài>ÌÊvœÀÊ{ÊÜiiŽÃÊœ˜ÞÊÜ…i˜ÊÃÞ“«Ìœ“ÃÊ…>ÛiÊLii˜Ê«ÀiÃi˜ÌÊvœÀÊ< 3
months AND there is a prompt response to therapy
Enterococcus faecium
UÊœ˜ÃՏÌÊ
,iviÀi˜Vi\
1ÃiÊœvÊivÌÀˆ>Ýœ˜iʈ˜Êi˜ÌiÀœVœVV>Êi˜`œV>À`ˆÌˆÃ\ʏˆ˜Ê˜viVÌʈÃÊÓä£ÎÆÊxÈ\£ÓÈ£‡n°
HACEK organisms (Haemophilus parainfluenzae, H. aphrophilus,
Actinobacillus actinomycetemcomitans, Cardiobacterium
hominus, Eikenella corrodens, Kingella kingae)
UÊÊivÌÀˆ>Ýœ˜iÊÓÊ}Ê6ÉÊ+Ó{ÊvœÀÊ{ÊÜiiŽÃ
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Êœ˜ÃՏÌÊ
Gram-negative organisms, culture negative endocarditis, or
fungal endocarditis
UÊÊœ˜ÃՏÌÊ
Treatment of prosthetic valve endocarditis
UÊÊi˜iÀ>ÞÊV>ÕÃi`ÊLÞÊÃÌ>«…ޏœVœVVˆÊˆ˜ÊÌ…iÊwÀÃÌÊ£qÓÊÞi>ÀÃÊvœœÜˆ˜}ÊÛ>ÛiÊ
replacement (both S. aureus and coagulase-negative staph). Etiologies
are similar to native valve infections 2 or more years post-op.
UÊi`ˆV>ÊÌÀi>Ì“i˜ÌÊ>œ˜iʈÃÊœvÌi˜Ê "/ÊivviV̈Ûi°
UʏÊ«>̈i˜ÌÃÊÃ…œÕ`Ê…>ÛiÊ>Ê/°
EMPIRIC TREATMENT
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Gentamicin 1 mg/kg
IV Q8H
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
UÊÊQ*i˜ˆVˆˆ˜ÊÊ{Ê“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{Ê",ÊivÌÀˆ>Ýœ˜iÊÓÊ}Ê6ÉÊ+Ó{RÊvœÀÊ
6 weeks ≤ Gentamicin 3 mg/kg IV Q24H for first 2 weeks of therapy
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊ
weeks

68. 69
6.7 Endocarditis
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
UÊÊQ*i˜ˆVˆˆ˜ÊÊ{Ê“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{Ê",ÊivÌÀˆ>Ýœ˜iÊÓÊ}Ê6ÉÊ+Ó{RÊ
PLUS Gentamicin 3 mg/kg IV Q24H for 6 weeks
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊ
weeks
Staphylococcus aureus—Methicillin susceptible
UÊÊ"Ý>Vˆˆ˜ÊÓÊ}Ê6Ê+{ÊvœÀÊÈÊÜiiŽÃÊPLUS Gentamicin 1 mg/kg IV Q8H for
first 2 weeks of therapy
AND
UÊÊ,ˆv>“«ˆ˜ÊÎääÊ“}Ê*"Ê+nÊvœÀÊÈÊÜiiŽÃÊafter blood cultures have
cleared
UÊÊÊ>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i`
Staphylococcus aureus—Methicillin resistant or Coagulase-
negative staphylococci
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊvœÀÊÈÊÜiiŽÃÊPLUS
Gentamicin 1 mg/kg IV Q8H for the first 2 weeks of therapy
AND
UÊÊ,ˆv>“«ˆ˜ÊÎääÊ“}Ê*"Ê+nÊvœÀÊÈÊÜiiŽÃÊafter blood cultures have
cleared
UÊÊvÊVœ>}Տ>Ãi‡˜i}>̈ÛiÊÃÌ>«…ޏœVœVVˆÊˆÃÊÃÕÃVi«ÌˆLiÊÌœÊ"Ý>Vˆˆ˜ÊÌ…i˜Ê
treat as S. aureusÊqÊiÌ…ˆVˆˆ˜ÊÃÕÃVi«ÌˆLi°
UÊÊÊ>˜`ÊV>À`ˆ>VÊÃÕÀ}iÀÞÊVœ˜ÃՏÌÃÊÀiVœ““i˜`i`
Gram-negative organisms or culture negative endocarditis
UÊÊœ˜ÃՏÌÊ
DUKE CRITERIA FOR INFECTIVE ENDOCARDITIS
Diagnostic criteria (Modified Duke criteria)
Definite endocarditis
UÊÊ*ÀiÃi˜ViÊœvÊÓÊ“>œÀÊVÀˆÌiÀˆ>Ê",ʣʓ>œÀÊ ÊÎÊ“ˆ˜œÀÊ",ÊxÊ“ˆ˜œÀ
Possible endocarditis
UÊÊ*ÀiÃi˜ViÊœvʣʓ>œÀÊ Ê£Ê“ˆ˜œÀÊ",ÊÎÊ“ˆ˜œÀÊVÀˆÌiÀˆ>
Rejected endocarditis
UÊʈÀ“Ê>ÌiÀ˜>ÌiÊ`ˆ>}˜œÃˆÃÊÌ…>ÌÊiÝ«>ˆ˜ÃÊÊ“>˜ˆviÃÌ>̈œ˜ÃÊœvÊ
(NOTE: simply having another infection does NOT exclude
endocarditis)

69. 70
6.7 Endocarditis
Major criteria
Microbiologic
UÊÊ/ÜœÊÃi«>À>ÌiÊLœœ`ÊVՏÌÕÀiÃÊ«œÃˆÌˆÛiÊvœÀÊ>ÊÌÞ«ˆV>ÊœÀ}>˜ˆÃ“\Ê
viridans streptococci, S. bovis, HACEK, S. aureus, Enterococcus
spp.
UÊÊ*iÀÈÃÌi˜ÌÊL>VÌiÀi“ˆ>Ê܈̅Ê>˜ÞÊœÀ}>˜ˆÃ“Ê>ÃÊiÛˆ`i˜Vi`ÊLÞ\ÊÓÊ
positive blood cultures drawn at least 12 hours apart OR 3/3
positive blood cultures with at least 1 hour between the first and
last OR the majority of more than 4 cultures positive from any time
period.
UÊÊ*œÃˆÌˆÛiÊCoxiella burnetti (Q fever) culture or serology.
Echocardiographic (TEE strongly recommended for prosthetic valve)
UÊÊ6i}iÌ>̈œ˜Ê­œ˜ÊÛ>ÛiÊœÀÊÃÕ««œÀ̈˜}ÊÃÌÀÕVÌÕÀiÊ",ʈ˜Ê«>Ì…ÊœvÊ
regurgitant jet)
UÊÊLÃViÃÃ
UÊÊ iÜÊ`i…ˆÃVi˜ViÊœvÊ«ÀœÃÌ…ïVÊÛ>Ûi
Physical exam
UÊÊ 7ÊÀi}ÕÀ}ˆÌ>˜ÌÊ“ÕÀ“ÕÀÊ­ÜœÀÃi˜ˆ˜}ÊœvÊœ`Ê“ÕÀ“ÕÀʈÃÊ "/Ê
sufficient)
Minor criteria
UÊÊ*Ài`ˆÃ«œÃˆ˜}ÊVœ˜`ˆÌˆœ˜\Ê«ÀiÛˆœÕÃÊi˜`œV>À`ˆÌˆÃ]ʈ˜iV̈œ˜Ê`ÀÕ}ÊÕÃi]Ê
prosthetic valve, ventricular septal defect, coarctation of the aorta,
calcified valve, patent ductus, mitral valve prolapse with regurgitation,
IHSS or other valvular heart disease
UÊÊiÛiÀÊ≥ 38.0°C (100.4°F)
UÊÊ“LœˆVÊiÛi˜ÌÃ\Ê>ÀÌiÀˆ>ÊœÀʫՏ“œ˜>ÀÞÊi“Lœˆ]ÊVœ˜Õ˜V̈Û>Ê
hemorrhage, retinal hemorrhage, splinter hemorrhage, intracranial
hemorrhage, mycotic aneurysm
UÊÊ““Õ˜œœ}ˆVÊ«…i˜œ“i˜œ˜\Ê"ÏiÀʘœ`iÃ]Ê}œ“iÀՏœ˜i«…ÀˆÌˆÃ]Ê«œÃˆÌˆÛiÊ
rheumatoid factor
UÊÊ*œÃˆÌˆÛiÊLœœ`ÊVՏÌÕÀiÃÊÌ…>ÌÊ`œ˜½ÌÊ“iiÌÊVÀˆÌiÀˆ>Ê>LœÛiÊ",ÊÃiÀœœ}ˆVÊ
evidence of active infection with an organism known to cause
endocarditis BUT single positive cultures for coagulase-negative
staphylococci are NOT considered even a minor criterion
,iviÀi˜ViÃ\
"À>ÊÌ…iÀ>«Þ\Ê“ÊÊi`Ê£™™ÈÆÊ£ä£\Èn‡ÇÈ°
-…œÀÌÊVœÕÀÃiÊÌ…iÀ>«Þ\ʘ˜Ê˜ÌiÀ˜Êi`Ê£™™{ÆÊ£Ó£\nÇ·Ȱ
ÕŽiÊVÀˆÌiÀˆ>\ʏˆ˜Ê˜viVÌʈÃÊÓäääÆÊÎä\Èηn°
Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜ÌÊœ˜Ê˜viV̈Ûiʘ`œV>À`ˆÌÃ\ʈÀVՏ>̈œ˜ÊÓääxÆÊ£££­Óή\iΙ{‡{Î{°
TEE in S. aureusÊL>VÌiÀi“ˆ>\ÊÊ“ÊœÊ>À`ˆœÊ£™™ÇÆÊÎä\Ê£äÇÓ‡n°
,-ÊL>VÌiÀi“ˆ>Éi˜`œV>À`ˆÌˆÃÊÀiVœ““i˜`>̈œ˜Ã\ʏˆ˜Ê˜viVÌʈÃÊÓ䣣ÆÊxÓ\i£n‡xx

70. 71
6.8 Pacemaker/ICD infections
Permanent pacemaker (PPM) and implantable
cardioverter-defibrillator (ICD) infections
NOTE: Obtain at least 2 sets of blood cultures before initiation of
antibiotic therapy
EMPIRIC TREATMENT
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®°Ê >ÀÀœÜÊÌ…iÀ>«ÞÊL>Ãi`Êœ˜Ê
culture results.
TREATMENT NOTES
MicrobiologypÃÌ>«…ޏœVœVVˆÊˆ˜ÊÇä‡nä¯ÊœvÊV>ÃiÃÊ­Hxä¯ÊVœ>}Տ>Ãi‡
˜i}>̈ÛiÊÃÌ>«…ޏœVœVVˆÊ>˜`ÊHxä¯ÊS. aureus)
Management
UÊvÊLœœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«œÃˆÌˆÛiÊœÀÊi˜`œV>À`ˆÌˆÃʈÃÊÃÕëiVÌi`Ê«>̈i˜ÌÃÊ
should undergo transesophageal echocardiography (TEE)
UÊœ“«iÌiÊiÝÌÀ>V̈œ˜ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅ʫœVŽiÌʈ˜viV̈œ˜Ê
and/or valvular or lead endocarditis
UÊÌÊÌ…iÊ̈“iÊœvÊiÝÌÀ>V̈œ˜]Ê̈ÃÃÕiÊ­À>Ì…iÀÊÌ…>˜ÊÃÜ>LîÊvÀœ“ÊÌ…iÊ}i˜iÀ>ÌœÀÊ
pocket should be sent for Gram-stain and culture and lead tips should
be sent for culture.
UÊ œÌiÊÌ…>ÌÊLiV>ÕÃiʏi>`ÃÊ>ÀiÊiÝÌÀ>VÌi`ÊÌ…ÀœÕ}…Ê>˜Êœ«i˜Ê}i˜iÀ>ÌœÀÊ
«œVŽiÌ]ÊÌ…iÞÊ“>ÞÊLiVœ“iÊVœ˜Ì>“ˆ˜>Ìi`ÊLÞÊÌ…iʈ˜viVÌi`Ê«œVŽiÌÆÊ
therefore, positive lead cultures are not always indicative of lead
endocarditis in patient with negative blood cultures.
UÊ œœ`ÊVՏÌÕÀiÃÊÃ…œÕ`ÊLiÊœLÌ>ˆ˜i`Ê>vÌiÀÊ`iÛˆViÊÀi“œÛ>°
UÊiÛˆViÊÀiˆ“«>˜Ì>̈œ˜ÊÃ…œÕ`ÊLiÊœ˜ÊÌ…iÊVœ˜ÌÀ>‡>ÌiÀ>ÊÈ`iÊÜ…i˜iÛiÀÊ
possible.
UÊœ“«iÌiÊiÝÌÀ>V̈œ˜ÊˆÃÊÃÌÀœ˜}ÞÊÀiVœ““i˜`i`ʈ˜Ê>Ê«>̈i˜ÌÃÊ
presenting with S. aureus bacteremia and no other source
UÊœ“«iÌiÊiÝÌÀ>V̈œ˜ÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʫiÀÈÃÌi˜ÌÊ
positive blood cultures with other organisms (e.g. coagulase-negative
staphylococci, enterococci, Gram-negative bacilli) on a case-by-case
basis.
UÊœ“«iÌiÊ`iÛˆViÊ>˜`ʏi>`ÊÀi“œÛ>ÊˆÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅Ê
valvular endocarditis.
Uʘ̈“ˆVÀœLˆ>Ê«Àœ«…ޏ>݈ÃʈÃÊ "/ÊÀiVœ““i˜`i`ÊvœÀÊ`i˜Ì>ÊœÀʜ̅iÀÊ
invasive procedures following placement
,iviÀi˜Vi\Ê
Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜ÌÊœ˜Ê**Ê>˜`Êʈ˜viV̈œ˜Ã\ʈÀVՏ>̈œ˜ÊÓä£äÆÊ£Ó£\{xnq{ÇÇ°

71. 72
6.8 Pacemaker/ICD infections
Reimplantation timing and duration of therapy
Diagnosis Timing of reimplantation Duration of therapy
Pocket site infection Blood cultures negative for 7-10 days if device erosion
72 hours and surgical site without inflammation
healing 10-14 days all others
Oral therapy can be
considered
Positive blood cultures Post-explantation blood Non-S. aureus\ÊÓÊÜiiŽÃÊ
with rapid clearance cultures negative for IV therapy
AND TEE with either 72 hours S. aureus\Ê{ÊÜiiŽÃÊ
no vegetation or IV therapy
uncomplicated lead
vegetation
Sustained positive blood Post-explantation blood 4 weeks IV therapy
cultures AND TEE with cultures negative for
no vegetation or 72 hours
uncomplicated lead
vegetation
Valve endocarditis Blood cultures negative for 4-6 weeks IV therapy
14 days (see Endocarditis p. 65)
,iviÀi˜Vi\
Ê-Vˆi˜ÌˆwVÊ-Ì>Ìi“i˜ÌÊœ˜Ê>À`ˆœÛ>ÃVՏ>ÀÊ“«>˜Ì>LiʏiVÌÀœ˜ˆVÊiÛˆViʘviV̈œ˜Ã\ʈÀVՏ>̈œ˜Ê
Óä£äÆÊ£Ó£\{xnqÇÇ°

72. 73
6.9 Central nervous system infections
Meningitis – Empiric treatment
TREATMENT
UÊÊANTIBIOTICS SHOULD BE STARTED AS SOON AS THE
POSSIBILITY OF BACTERIAL MENINGITIS BECOMES EVIDENT,
IDEALLY WITHIN 30 MINUTES.
UÊ DO NOT WAIT FOR CT SCAN OR LP RESULTS. IF LP MUST BE
DELAYED, GET BLOOD CULTURES AND START THERAPY.
UÊÊ`ÕÃÌÊÌ…iÀ>«ÞÊœ˜ViÊ«>Ì…œ}i˜Ê>˜`ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>ÀiÊŽ˜œÜ˜°
UÊÊ-œ“iÊ>`ÛœV>ÌiÊ«i˜ˆVˆˆ˜Ê`iÃi˜ÃˆÌˆâ>̈œ˜ÊvœÀÊ«>Ì…œ}i˜‡Ã«iVˆwVÊÌ…iÀ>«ÞÊ
in patients with severe allergies (p. 137).
UÊʘ̈LˆœÌˆVÊ`œÃiÃÊ>ÀiÊ…ˆ}…iÀÊvœÀÊ -ʈ˜viV̈œ˜ÃÊ­«°ÊÇÇ®°
UÊʘviV̈œÕÃʈÃi>ÃiÃÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊ>`ÛˆÃi`ÊvœÀÊ>Ê -ʈ˜viV̈œ˜Ã]Ê
particularly those in which the preferred antibiotic cannot be used or in
which the organism is resistant to usual therapy.
Empiric therapy
Host

Immuno competent*
>}iʐÊxä
Immunocompetent*
age > 50
Immuno-
compromised
†
Post neurosurgery or
penetrating head
trauma
Infected shunt
Pathogens

S. pneumo, N.
mening, H. influenzae
S. pneumo, Listeria,
H. influenzae,
N. mening, Group B
streptococci
S. pneumo, N.
mening, H. influenzae,
Listeria,
(Gram-negatives)
S. pneumo (if CSF
leak), H. influenzae,
Staphylococci,
Gram-negatives
S. aureus, coagulase-
negative staphylococci,
Gram-negatives (rare)
Preferred Abx

Vancomycin PLUS Ceftriaxone
Vancomycin PLUS
Ceftriaxone PLUS
Ampicillin
Vancomycin PLUS
Cefepime PLUS
Ampicillin
Vancomycin PLUS
Cefepime
Vancomycin PLUS
Cefepime
Alternative for
serious PCN
allergy (ID consult
recommended)
Moxifloxacin
‡
PLUS
Vancomycin
Moxifloxacin
‡
PLUS
Vancomycin PLUS
/*É-8
Vancomycin PLUS
/*É-8ÊPLUS
Ciprofloxacin
Vancomycin PLUS
Ciprofloxacin
Vancomycin PLUS
Ciprofloxacin
† Immunocompromised is defined as solid organ transplant, BMT in the past year, leukemia
undergoing treatment, or neutropenia
‡ Allergy consult for beta-lactam desensitization
* Use of Dexamethasone
UÊÊ``ˆÌˆœ˜ÊœvÊ`iÝ>“iÌ…>Ãœ˜iʈÃÊÀiVœ““i˜`i`ʈ˜Ê>Ê>`ՏÌÊ«>̈i˜ÌÃÊ܈̅Ê
suspected pneumococcal meningitis (note that this will be most adult
patients).
UÊÊœÃi\Êä°£xÊ“}ÉŽ}Ê6Ê+ÈÊvœÀÊÓq{Ê`>ÞÃ
UÊÊ/…iÊwÀÃÌÊ`œÃiÊ“ÕÃÌÊLiÊ>`“ˆ˜ˆÃÌiÀi`Ê£äqÓäÊ“ˆ˜ÕÌiÃÊLivœÀiÊœÀÊ
concomitant with the first dose of antibiotics.

73. 74
6.9 Central nervous system infections
UÊÊ`“ˆ˜ˆÃÌÀ>̈œ˜ÊœvÊ>˜ÌˆLˆœÌˆVÃÊÃ…œÕ`ʘœÌÊLiÊ`i>Þi`ÊÌœÊ}ˆÛiÊ
dexamethasone.
UÊÊiÝ>“iÌ…>Ãœ˜iÊÃ…œÕ`ʘœÌÊLiÊ}ˆÛi˜Ê̜ʫ>̈i˜ÌÃÊÜ…œÊ…>ÛiÊ>Ài>`ÞÊ
started antibiotics.
UÊÊœ˜Ìˆ˜ÕiÊ`iÝ>“iÌ…>Ãœ˜iÊœ˜ÞʈvÊÌ…iÊ-ÊÀ>“ÊÃÌ>ˆ˜ÊÃ…œÜÃÊÀ>“‡
positive diplococci or if blood or CSF grows S. pneumoniae
Pathogen-specific therapy (ID consult recommended)
Pathogens
S. pneumo PCN MIC ≤ 0.06
μg/ml AND/OR Ceftriaxone
MIC β0.5 μg/ml
S. pneumo PCN MIC ä°£q£Ê
μg/ml AND Ceftriaxone
MIC β1 μg/ml (ID consult
recommended)
S. pneumo PCN MIC 1
μg/ml AND Ceftriaxone
MIC ≥1 μg/ml (ID consult
recommended)
N. meningitidis PCN
susceptible (MIC β 0.1)
H. flu
Non ≥-lactamase producer
H. flu
≥-lactamase producer
Listeria
P. aeruginosa
E. coli
K. pneumoniae
Enterobacter spp.
S. aureusq--
-°Ê>ÕÀiÕÃq,-Ê
Coagulase-negative
staphylococci if Oxacillin MIC
≤ 0.25
Coagulase-negative
staphylococci Oxacillin MIC
0.25
Enterococcus
Candida species
Cryptococcus
Preferred
Penicillin OR Ceftriaxone
Ceftriaxone
Ceftriaxone PLUS
Vancomycin PLUS Rifampin
Penicillin OR Ceftriaxone
³
Ampicillin OR Ceftriaxone
Ceftriaxone
Ampicillin ± Gentamicin
‡
Cefepime OR Meropenem
Ceftriaxone
Meropenem
Oxacillin
Vancomycin
Oxacillin
Vancomycin
Ampicillin PLUS Gentamicin
‡
Amphotericin B
Amphotericin B PLUS
Flucytosine
Alternative for serious PCN allergy (Consult allergy for PCN skin testing ± desensitization)
Vancomycin OR
Moxifloxacin OR Linezolid
Moxifloxacin OR Linezolid
Moxifloxacin OR Linezolid
Consult ID
Ciprofloxacin*
Ciprofloxacin*
/*É-8Ê
Ciprofloxacin PLUS
Aztreonam
Aztreonam OR Ciprofloxacin
",Ê/*É-8
/*É-8ÊœÀʈ«ÀœyœÝ>Vˆ˜
Vancomycin
Vancomycin
Vancomycin PLUS Gentamicin
‡
* Consider beta-lactam desensitization
³ÊÕÃÌÊ}ˆÛiʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Êœ˜ViÊÌœÊiÀ>`ˆV>ÌiÊV>ÀÀˆiÀÊÃÌ>ÌiʈvÊ* ÊÕÃi`Ê>ÃÊÌÀi>Ì“i˜Ì
‡ Administer aminoglycosides systemically, not intrathecally

74. 75
6.9 Central nervous system infections
TREATMENT NOTES
Indications for head CT prior to LP
UʈÃÌœÀÞÊœvÊ -Ê`ˆÃi>ÃiÃÊ­“>ÃÃʏiÈœ˜]Ê6®
UÊ i܇œ˜ÃiÌÊÃiˆâÕÀiÊ­ 1 week)
UÊ*>«ˆi`i“>
UʏÌiÀi`ÊVœ˜ÃVˆœÕØiÃÃ
UÊœV>Ê˜iÕÀœœ}ˆVÊ`iwVˆÌ
Duration
UÊÊ-/"*ÊÌÀi>Ì“i˜ÌʈvÊ*ÊVՏÌÕÀiÊœLÌ>ˆ˜i`Ê«ÀˆœÀÊÌœÊ>˜ÌˆLˆœÌˆVÊÌ…iÀ>«ÞʈÃÊ
negative at 48 hours OR no PMNs on cell count
UÊS. pneumoniae\Ê£äq£{Ê`>ÞÃ
UÊN. meningitidis\ÊÇÊ`>ÞÃ
UÊListeria\ÊÓ£Ê`>ÞÃ
UÊH. influenzae\ÊÇÊ`>ÞÃ
UÊÀ>“‡˜i}>̈ÛiÊL>Vˆˆ\ÊÓ£Ê`>ÞÃ
Adjunctive therapy
UÊÊœ˜Ãˆ`iÀʈ˜ÌÀ>VÀ>˜ˆ>Ê«ÀiÃÃÕÀiÊ“œ˜ˆÌœÀˆ˜}ʈ˜Ê«>̈i˜ÌÃÊ܈̅ʈ“«>ˆÀi`Ê
mental status.
Encephalitis
UÊÊiÀ«iÃÊÛˆÀÕÃiÃÊ­-6]Ê6<6®ÊÀi“>ˆ˜ÊÌ…iÊ«Ài`œ“ˆ˜>˜ÌÊV>ÕÃiÃÊœvÊÌÀi>Ì>LiÊ
encephalitis.
UÊ-Ê*,ÃÊ>ÀiÊÀ>«ˆ`Ê`ˆ>}˜œÃ̈VÊÌiÃÌÃÊ>˜`Ê>««i>ÀʵՈÌiÊÃi˜ÃˆÌˆÛiÊ>˜`Ê
specific.
UÊ>ÛiʏœÜÊÌ…ÀiÃ…œ`ÊÌœÊÌÀi>ÌʈvÊÃÕëiVÌi`Ê>ÃÊÕ˜ÌÀi>Ìi`Ê“œÀÌ>ˆÌÞÊ
iÝVii`ÃÊÇ䯰
UÊ/Ài>Ì“i˜Ì\ÊVÞVœÛˆÀÊ£äÊ“}ÉŽ}Ê6Ê+nÊvœÀÊ£{qÓ£Ê`>ÞÃ

75. 76
6.9 Central nervous system infections
Brain abscess
UÊÊ“«ˆÀˆVÊÌÀi>Ì“i˜ÌʈÃÊ}Õˆ`i`ÊLÞÊÃÕëiVÌi`ÊÃœÕÀViÊ>˜`ÊÕ˜`iÀÞˆ˜}Ê
condition. While therapy should be adjusted based on culture results,
anaerobic coverage should ALWAYS continue even if none are grown.
Source/ Condition
Unknown
Sinusitis
Chronic otitis
Post neurosurgery
Cyanotic heart
disease
Pathogens
S. aureus,
Streptococci, Gram-
negatives, Anaerobes
Streptococci (incl.
S. pneumoniae),
Anaerobes
Gram-negatives,
Streptococci
Anaerobes
Staphylococci, Gram
negatives
Streptococci (esp.
S. viridans)
Preferred
Vancomycin PLUS
Ceftriaxone PLUS
Metronidazole
Q*i˜ˆVˆˆ˜Ê",Ê
ivÌÀˆ>Ýœ˜iRÊ*1-Ê
Metronidazole
Cefepime PLUS
Metronidazole
Vancomycin PLUS
Cefepime
Penicillin OR
Ceftriaxone
Alternative for
serious PCN allergy
(ID consult
recommended)
Vancomycin PLUS
Ciprofloxacin PLUS
Metronidazole
Vancomycin PLUS
Metronidazole
Aztreonam PLUS
Metronidazole PLUS
Vancomycin
Vancomycin PLUS
Ciprofloxacin
Vancomycin

,iviÀi˜ViÃ\
-ÊÕˆ`iˆ˜iÃÊvœÀÊ >VÌiÀˆ>Êi˜ˆ˜}ˆÌˆÃ\ʏˆ˜Ê˜viVÌʈÃÊÓää{ÆΙ\£ÓÈÇ°
iÝ>“iÌ…>Ãœ˜iʈ˜Ê>`ՏÌÃÊ܈̅ÊL>VÌiÀˆ>Ê“i˜ˆ˜}ˆÌˆÃ\Ê Ê˜}ÊÊi`ÊÓääÓÆÎ{Ç\£x{™°
CNS shunt infection
Diagnosis
UÊÊՏÌÕÀiÊœvÊViÀiLÀœÃ«ˆ˜>ÊyÕˆ`ÊÀi“>ˆ˜ÃÊÌ…iÊ“>ˆ˜ÃÌ>ÞÊœvÊ`ˆ>}˜œÃˆÃ°Ê
Clinical symptoms may be mild and/or non-specific, and CSF
chemistries and leukocyte counts may be normal.
Empiric Therapy
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Cefepime 2 g IV Q8H
OR
UÊÊ* ʏiÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Ciprofloxacin 400 mg IV Q8H
TREATMENT NOTES
UÊ ID consult recommended for assistance with timing of shunt
replacement and length of antibiotic therapy.
UÊÊ,i“œÛ>ÊœvÊ>ÊVœ“«œ˜i˜ÌÃÊœvÊÌ…iʈ˜viVÌi`ÊÃ…Õ˜ÌÊ܈̅ÊiÝÌiÀ˜>Ê
ventricular drainage or intermittent ventricular taps in combination
with the appropriate intravenous antibiotic therapy leads to the highest
effective cure rates. Success rates are substantially lower when the
infected shunt components are not removed.

76. 77
6.9 Central nervous system infections
UÊÊ/…iÊÀœiÊœvʈ˜ÌÀ>Ûi˜ÌÀˆVՏ>ÀÊ>˜ÌˆLˆœÌˆVÃʈÃÊVœ˜ÌÀœÛiÀÈ>]Ê>˜`Ê}i˜iÀ>ÞÊ
limited to refractory cases or cases in which shunt removal is not
possible. Intraventricular injection should be administered only by
experienced physicians.
,iviÀi˜ViÃ\
-ÊÕˆ`iˆ˜iÃÊvœÀÊÌ…iÊ>˜>}i“i˜ÌÊœvÊ >VÌiÀˆ>Êi˜ˆ˜}ˆÌˆÃ\ʏˆ˜Ê˜viVÌʈÃÊ
Óää{ÆΙ\£ÓÈÇ°Ê
/…iÀ>«Þʈ˜ÊViÀiLÀœÃ«ˆ˜>ÊyÕˆ`ÊÃ…Õ˜Ìʈ˜viV̈œ˜°Ê iÕÀœÃÕÀ}iÀÞÊ£™näÆÇ\{x™°
Antimicrobial doses for CNS infections – normal
renal function
Antibiotics
UÊÊ“ˆ˜œ}ÞVœÃˆ`iÃ\ÊÃiiÊ«°Ê£{x
UÊÊ“«ˆVˆˆ˜\ÊÓÊ}Ê6Ê+{Ê
UÊÊâÌÀiœ˜>“\ÊÓÊ}Ê6Ê+È
UÊÊivÌÀˆ>Ýœ˜i\ÊÓÊ}Ê6Ê+£Ó
UÊÊivi«ˆ“i\ÊÓÊ}Ê6Ê+n
UÊʈ«ÀœyœÝ>Vˆ˜\Ê{ääÊ“}Ê6Ê+nÊ­L>Ãi`Êœ˜Êˆ“ˆÌi`Ê`>Ì>®
UÊʜ݈yœÝ>Vˆ˜\Ê{ääÊ“}Ê6Ê+Ó{
UÊÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n
UÊÊiÌÀœ˜ˆ`>✏i\ÊxääÊ“}Ê6Ê+È
UÊÊ"Ý>Vˆˆ˜\ÊÓÊ}Ê6Ê+{
UÊÊ*i˜ˆVˆˆ˜\Ê{Ê“ˆˆœ˜ÊÕ˜ˆÌÃÊ6Ê+{Ê­Ó{Ê“ˆˆœ˜ÊÕ˜ˆÌÃÊ«iÀÊ`>Þ®
UÊÊ,ˆv>“«ˆ˜\ÊÈääÊ“}Ê6Ê+£ÓqÓ{
UÊÊ/*É-8\ÊxÊ“}ÉŽ}Ê­/*ÊVœ“«œ˜i˜Ì®Ê6Ê+È
UÊÊ6>˜Vœ“ÞVˆ˜\ʏœ>`Ê܈̅ÊÓxqÎxÊ“}ÉŽ}]ÊÌ…i˜Ê£xqÓäÊ“}ÉŽ}Ê+nq£ÓÊ
(minimum 1 g Q12H)
UÊÊ6>˜Vœ“ÞVˆ˜ÊÃ…œÕ`ÊLiÊ>`“ˆ˜ˆÃÌiÀi`Ê̜ʓ>ˆ˜Ì>ˆ˜ÊÃiÀÕ“ÊÌÀœÕ}…Ê
concentrations close to 20 mcg/mL.
Antifungals
UÊÊ“«…œÌiÀˆVˆ˜\Êä°Çq£Ê“}ÉŽ}Ê6Ê+Ó{
UÊ“ ˆÃœ“i
®
\Ê·{Ê“}ÉŽ}Ê6Ê+Ó{ÊvœÀÊÀÞ«ÌœVœVV>Ê“i˜ˆ˜}ˆÌˆÃ
UÊÊ“ ˆÃœ“i
®
\ÊxÊ“}ÉŽ}Ê6Ê+Ó{ÊvœÀÊ>˜`ˆ`>Ê“i˜ˆ˜}ˆÌˆÃ
UʏÕVœ˜>✏i\Ênääq£ÓääÊ“}Ê6É*"Ê+Ó{Ê­V>˜Ê}ˆÛiʈ˜Ê`ˆÛˆ`i`Ê`œÃiî
UÊʏÕVÞ̜Și\ÊÓxÊ“}ÉŽ}Ê*"Ê+È
Intraventricular antibiotics (ID consult recommended)
UÊÊ“ˆŽ>Vˆ˜\ÊÎäÊ“}Ê+Ó{Ê­Vœ˜Ì>ˆ˜ÃÊ«ÀiÃiÀÛ>̈Ûi®
UÊÊi˜Ì>“ˆVˆ˜\ÊxÊ“}Ê+Ó{
UÊÊ/œLÀ>“ÞVˆ˜\ÊxÊ“}Ê+Ó{
UÊÊ6>˜Vœ“ÞVˆ˜\ÊÓäÊ“}Ê+Ó{

77. 78
6.10 Acute bacterial rhinosinusitis
Acute bacterial rhinosinusitis (ABRS)
NOTE: Sinusitis in immunocompromised hosts can be caused by fungi
>˜`ʜ̅iÀʏiÃÇVœ““œ˜Ê«>Ì…œ}i˜ÃÆÊVœ˜ÃՏÌ>̈œ˜Ê܈̅ÊÊ>˜`Ê /ʈÃÊ
recommended to guide management and therapy.
œÃÌÊÀ…ˆ˜œÃˆ˜ÕÈ̈ÃÊ`œiÃʘœÌÊÀiµÕˆÀiÊ>˜ÌˆLˆœÌˆVÊÌÀi>Ì“i˜ÌÆÊÌÀi>Ì“i˜ÌÊ
Ã…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜ÊÌ…iÊvœœÜˆ˜}ÊÃVi˜>ÀˆœÃ\
UÊ*iÀÈÃÌi˜ÌÊÃÞ“«Ìœ“ÃÊœvÊ>VÕÌiÊÀ…ˆ˜œÃˆ˜ÕÈÌÕÃÊ≥ 10 days without
improvement
UÊiÛiÀÊ≥39°C and purulent nasal discharge or facial pain lasting >3-4
days from the beginning of illness
UÊ iÜÊœ˜ÃiÌÊœvÊviÛiÀ]Ê…i>`>V…iÊœÀʈ˜VÀi>Ãiʈ˜Ê˜>Ã>Ê`ˆÃV…>À}iÊvœœÜˆ˜}Ê
viral URI that lasted 5-6 days and was initially improving
EMPIRIC TREATMENT
Oral regimens
UÊ“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxÊ“}Ê*"Ê+£Ó
OR
UÊ“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊ8,ÊÓÊ}Ê*"Ê+£ÓÊÊvœÀÊ«>̈i˜ÌÃÊ܈̅ÊÃiÛiÀiÊ
infection (e.g. systemic toxicity with fever of 39°C), antibiotic use in
previous 30 days, immunocompromised
OR
UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êiv«œ`œÝˆ“iÊÓääÊ“}Ê*"Ê+£Ó
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê*"Ê`>ˆÞÊÊ
Parenteral regimens
UÊ“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+È
OR
UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\ÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+Ó{ÊÊ
Duration
UÊx‡ÇÊ`>ÞÃÊ
TREATMENT NOTES
Microbiology
UÊ*Ài`œ“ˆ˜>˜ÌÞÊS. pneumoniae, H. influenzae, M. catarrhalis
UÊÀ>“‡˜i}>̈ÛiÊi˜ÌiÀˆVÊL>VˆˆÊ>ÀiÊÀ>Ài
Management
UÊ ,-ʈÃÊÀ>ÀiÞÊ«ÀiÃi˜ÌÊ«ÀˆœÀÊÌœÊÇq£äÊ`>ÞÃÊœvÊÃÞ“«Ìœ“ÃÆÊÌÞ«ˆV>Ê
inciting etiologies of acute sinusitis include allergies and viral URI

78. 79
UÊՏÌÕÀiÃÊLÞÊ`ˆÀiVÌÊȘÕÃÊ>ëˆÀ>̈œ˜ÊœÀÊi˜`œÃVœ«ˆV>ÞÊ}Õˆ`i`ÊVՏÌÕÀiÊœvÊ
the middle meatus should only be obtained in patients who fail empiric
antibiotic therapy. Nasopharyngeal swab is NOT recommended for
obtaining culture data.
UÊœ˜wÀ“>̈œ˜ÊœvÊ`ˆ>}˜œÃˆÃÊ܈̅ʈ“>}ˆ˜}ʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ
uncomplicated ABRS. Consider CT in those with severe disease with
possible extension to the orbit or intracranial space.
UʘÌÀ>˜>Ã>ÊÃ>ˆ˜iʈÀÀˆ}>̈œ˜Ê­«…ÞÈœœ}ˆVÊœÀÊ…Þ«iÀÌœ˜ˆV®Ê>˜`ʈ˜ÌÀ>˜>Ã>Ê
corticosteroids are recommended as an adjuncts to antibiotic therapy
and can also provide symptomatic relief in patients in whom antibiotic
are not indicated
UÊ>VÀœˆ`iÃÊ­>ÀˆÌ…Àœ“ÞVˆ˜]ÊâˆÌ…Àœ“ÞVˆ˜®Ê>ÀiʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ
initial empiric therapy due to high rates of resistance of S. pneumoniae
­xx¯Ê>ÌÊ®
UÊiëˆÌiÊ-Ê}Õˆ`iˆ˜iÃÊÃÕ««œÀ̈˜}ÊÕÃiÊœvÊœÝÞVÞVˆ˜iÊ>ÃÊ>˜Ê
alternative agent for ABRS, Doxycycline is NOT recommended for
initial empiric therapy at JHH due to high rates of resistance of S.
pneumoniae ­Óǯ®Ê>˜` H. influenzae ­Îx¯®
UÊ,œṎ˜iÊVœÛiÀ>}iÊvœÀÊ,-ʈ˜Êˆ˜ˆÌˆ>Êi“«ˆÀˆVÊÌ…iÀ>«ÞÊvœÀÊ ,-ʈ˜Ê˜œÌÊ
recommended
,iviÀi˜Vi\Ê
-Ê}Õˆ`iˆ˜iÃÊvœÀÊ ,-°Êˆ˜Ê˜viVÌʈÃÊÓä£ÓÆÊx{­n®\iÇÓ‡i££Ó°Ê
6.10 Acute bacterial rhinosinusitis

79. 80
6.11 Orbital cellulitis
Orbital cellulitis
Preseptal cellulitisÊ­€™ä¯ÊœvÊV>Ãiî
UʘۜÛiÃÊ̈ÃÃÕiÃÊ>˜ÌiÀˆœÀÊÌœÊÌ…iÊœÀLˆÌ>ÊÃi«ÌÕ“Ê
UÊ*ÀiÃi˜ÌÃÊ܈̅ÊviÛiÀ]ÊiÞiˆ`ÊiÀÞÌ…i“>Ê>˜`ÊÃœvÌÊ̈ÃÃÕiÊÃÜiˆ˜}ÊLÕÌʘœÊ
orbital congestion
Postseptal cellultis
UÊ-ˆ}˜ÃÊœvÊ«iÀˆœÀLˆÌ>ÊViÕˆÌˆÃÊ>ÃÊÜiÊ>Ãʏˆ“ˆÌ>̈œ˜ÊœvÊœVՏ>ÀÊ“œÛi“i˜ÌÃ]Ê
pain with ocular movement, and/or proptosis
UÊ-iÛiÀiʈ˜viV̈œ˜ÊV>˜Ê>ÃœÊˆ˜ÛœÛiÊÛˆÃÕ>ÊœÃÃ]ÊÃÕL«iÀˆœÃÌi>Ê>LÃViÃÃ]Ê
globe displacement, abscess formation
UÊ"vÌi˜Ê>ÃÃœVˆ>Ìi`Ê܈̅ÊȘÕÈ̈ÃÊ
UÊ>˜ÊLiÊ>ÃÃœVˆ>Ìi`Ê܈̅ÊV>ÛiÀ˜œÕÃÊȘÕÃÊÌ…Àœ“LœÃˆÃ
EMPIRIC TREATMENT
UÊ“«ˆVˆˆ˜ÉÃՏL>VÌ>“ÊÎÊ}Ê6Ê+È
OR
UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\ÊivÌÀˆ>Ýœ˜iÊÓÊ}Ê6Ê`>ˆÞ
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê`>ˆÞ
Add Vancomycin (see dosing section, p. 150) in patients with history
of MRSA colonization or infection, evidence of abscess or bone
involvement, orbital trauma, recent ophthalmic surgery or severe
infection
Oral step down therapy (for patients without culture data to guide
therapy and without evidence of bony involvement or cavernous sinus
thrombosis)
UÊ“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxÊ“}Ê*"Ê+£Ó
OR
UÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êiv«œ`œÝˆ“iÊ{ääÊ“}Ê*"Ê+£Ó
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê*"Ê`>ˆÞ
Duration
UÊÇÊ`>ÞÃÊÕ«ÊÌœÊÈÊÜiiŽÃʈvÊiÛˆ`i˜ViÊœvÊLœ˜Þʈ˜ÛœÛi“i˜Ì
TREATMENT NOTES
Microbiology
UÊS. aureus, beta-hemolytic streptococci, S. pneumoniae, H. influenza,
M. catarrhalis (cultures are infrequently positive)
Management
UÊ“>}ˆ˜}ʈÃÊÀiVœ““i˜`i`ʈ˜Ê«œÃ̇Ãi«Ì>ÊViÕˆÌˆÃÊ­/ÊœÀÊ,®
UÊœ˜ÃՏÌ>̈œ˜Ê܈̅Ê]Ê /]Ê>˜`Êœ«…Ì…>“œœ}ÞÊÀiVœ““i˜`i`

80. 81
UÊ*œÃ̇Ãi«Ì>ÊViÕˆÌˆÃʈ˜Êˆ““Õ˜œVœ“«Àœ“ˆÃi`Ê…œÃÌÃÊV>˜ÊLiÊV>ÕÃiÊ
LÞÊvÕ˜}ˆÊ>˜`Ê“œ`ÃÆÊi“«ˆÀˆVÊ>˜ÌˆvÕ˜}>ÊÌ…iÀ>«ÞʈÃÊÀiVœ““i˜`i`ʈ˜Ê
consultation with ID
UÊ*œÃ̇Ãi«Ì>ÊViÕˆÌˆÃÊ܈̅Ê>LÃViÃÃÊvœÀ“>̈œ˜ÊÃ…œÕ`Ê«Àœ“«Ìʈ““i`ˆ>ÌiÊ
surgical intervention
UÊ,i뜘ÃiÊÌœÊ>««Àœ«Àˆ>ÌiÊ>˜ÌˆLˆœÌˆVÊÌ…iÀ>«ÞÊÃ…œÕ`ÊœVVÕÀʈ˜ÊÓ{ÊqÊ{nÊ
hours
UÊ*œœÀÊÀi뜘ÃiÊÌœÊ>˜ÌˆLˆœÌˆVÃ]ÊÜœÀÃi˜ˆ˜}ÊÛˆÃÕ>Ê>VÕˆÌÞÊœÀÊ«Õ«ˆ>ÀÞÊ
changes and/or evidence of an abscess are indications for surgery
6.11 Orbital cellulitis

81. 82
6.12 Pulmonary infections
COPD exacerbations
EMPIRIC TREATMENT
UÊÊÊ Doxycycline 100 mg PO BID for 5 days
OR
UÊÊâˆÌ…Àœ“ÞVˆ˜ÊxääÊ“}Ê*"É6Ê+Ó{ÊvœÀÊÎÊ`>ÞÃ
OR
UÊÊ“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxÊ“}Ê*"Ê ÊvœÀÊxÊ`>ÞÃ
OR
UÊÊiv«œ`œÝˆ“iÊÓääÊ“}Ê*"Ê ÊvœÀÊxÊ`>ÞÃ
OR
UÊiv`ˆ˜ˆÀÊÎääÊ“}Ê*"Ê ÊvœÀÊxÊ`>ÞÃ
TREATMENT NOTES
Microbiology
UÊÊ*Ài`œ“ˆ˜>˜ÌÞÊH. influenzae, M. catarrhalis, S. pneumoniae
UÊÊPseudomonas, Enterobacteriaceae are less common and seen in
patients with severe COPD and extensive antibiotic exposure.
Management
UÊÊ“«ˆÀˆVÊÕÃiÊœvÊyÕœÀœµÕˆ˜œœ˜iÃʈÃÊ`ˆÃVœÕÀ>}i`Ê>˜`ÊÃ…œÕ`Êœ˜ÞÊ
be considered if past or present microbiologic evidence indicates
infection with a pathogen(s) that is resistant to standard therapy (e.g.
Pseudomonas, Enterobacteriaceae).
UÊÊ6Ê>˜ÌˆLˆœÌˆVÃÊÃ…œÕ`Êœ˜ÞÊLiÊÕÃi`ʈvÊÌ…iÊ«>̈i˜ÌÊV>˜˜œÌÊÌœiÀ>ÌiÊ*"Ê
antibiotics.
UÊʘ̈LˆœÌˆVÃÊ>ÀiʘœÌʈ˜`ˆV>Ìi`ÊvœÀÊ>ÃÌ…“>Êy>ÀiÃʈ˜ÊÌ…iÊ>LÃi˜ViÊœvÊ
pneumonia.
Prophylactic antibiotics for the prevention of COPD exacerbations
UÊ*Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊ…>ÛiÊLii˜ÊÃ…œÜ˜ÊÌœÊÀi`ÕViÊÀ>ÌiÃÊœvÊ
exacerbations and improve reported quality of life but not to decrease
all-cause or respiratory-associated mortality
UÊ*Àœœ˜}i`ÊâˆÌ…Àœ“ÞVˆ˜ÊÕÃiÊ…>ÃÊLii˜Ê>ÃÃœVˆ>Ìi`Ê܈̅ʅi>Àˆ˜}ʏœÃÃÊ
>˜`Ê+/Ê«Àœœ˜}>̈œ˜ÆÊ«>̈i˜ÌÃÊ܈̅ÊL>Ãiˆ˜iÊ+/‡«Àœœ˜}>̈œ˜ÊÜiÀiʘœÌÊ
included in clinical trials
UÊ/…iÊ`iVˆÃˆœ˜Ê̜ʈ˜ˆÌˆ>ÌiÊ«Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊÃ…œÕ`ÊLiÊ“>`iÊœ˜Ê>Ê
case-by-case basis and should take in to account patient preferences,
financial constraints, risk factors for adverse events and input from the
patient’s pulmonologist
UÊ,iVœ““i˜`i`ÊÀi}ˆ“i˜\ÊâˆÌ…Àœ“ÞVˆ˜ÊÓxäÊ“}Ê*"Ê`>ˆÞ
UÊ >Ãiˆ˜iÊ>Õ`ˆœ“iÌÀÞÊ>˜`ÊʈÃÊÀiVœ““i˜`i`
,iviÀi˜ViÃ\
“iÀˆV>˜Êœi}iÊœvÊ*…ÞÈVˆ>˜ÃÊ*œÃˆÌˆœ˜Ê*>«iÀ\ʘ˜Ê˜ÌiÀ˜Êi`ÊÓää£ÆÊ£Î{\Èää°
ÕÀ>̈œ˜ÊœvÊÌ…iÀ>«Þ\Ê/…œÀ>ÝÊÓäänÆÊÈέx®\{£xqÓÓ°
âˆÌ…Àœ“ÞVˆ˜ÊvœÀÊ«ÀiÛi˜Ìˆœ˜\Ê °Ê˜}°ÊÊi`ÊÓ䣣ÆÊÎÈx\ÊÈn™ÆÊœV…À>˜iÊ>Ì>L>ÃiÊ-ÞÃÌÊ
Rev 2013 Nov 28.

82. 83
6.12 Pulmonary infections
Community-acquired pneumonia (CAP) in
hospitalized patients
NOTE: If patient is coming from a nursing home or long-term care
facility, see Healthcare-acquired pneumonia, p. 87.
EMPIRIC TREATMENT
Patient NOT in the ICU
UÊ“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+ÈÊPLUS Azithromycin 500 mg IV/PO
once daily
OR
UÊÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Azithromycin 500 mg IV/PO once daily
OR
Uʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê6É*"Ê+Ó{Ê
In non-critically ill patients, consider switch to oral agents as soon as patient
is clinically improving and eating (see next page for oral options and doses).
Patient in the ICU
Not at risk for infection with Pseudomonas (see risks below)
UÊÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{ÊPLUS Azithromycin 500 mg IV Q24H
OR
UÊÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+Ó{Ê
At risk for infection with Pseudomonas (see risks below)
UÊÊivi«ˆ“iÊ£‡ÓÊ}Ê6Ê+nÊPLUS Azithromycin 500 mg IV Q24H
OR
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+ÈÊPLUS Azithromycin 500 mg IV Q24H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+Ó{ÊPLUS Aztreonam
2 g IV Q8H
UÊÊ-«ÕÌÕ“Ê}À>“ÊÃÌ>ˆ˜Ê“>ÞÊ…i«Ê`iÌiÀ“ˆ˜iʈvÊPseudomonas is present.
UÊÊNarrow coverage if Pseudomonas is NOT present on culture at 48 hours.
Risks for PseudomonasÊ>˜`ʜ̅iÀÊÀiÈÃÌ>˜ÌÊÀ>“‡˜i}>̈ÛiÊœÀ}>˜ˆÃ“Ã\
LÀœ˜V…ˆiVÌ>ÈÃÆÊLÀœ>`‡Ã«iVÌÀÕ“Ê>˜ÌˆLˆœÌˆVÃÊvœÀÊ€ÊÇÊ`>ÞÃʈ˜ÊÌ…iÊ«>ÃÌÊ
“œ˜Ì…ÆÊ«Àœœ˜}i`Ê…œÃ«ˆÌ>ˆâ>̈œ˜Ê€ÊÇÊ`>ÞÃÆÊ`iLˆˆÌ>Ìi`ʘÕÀȘ}Ê…œ“iÊ
ÀiÈ`i˜ÌÆÊÀiVi˜ÌÊ“iV…>˜ˆV>ÊÛi˜Ìˆ>̈œ˜Ê€Ê{nÊÆʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê
due to solid organ transplant, hematologic malignancy, BMT, active
chemotherapy, prednisone > 20 mg daily for > 3 weeks.
DIAGNOSIS
UÊÊ““Õ˜œVœ“«iÌi˜ÌÊ«>̈i˜ÌÃÊ1-/Ê…>ÛiÊ>ÊV…iÃÌÊ8‡À>Þʈ˜wÌÀ>ÌiÊ̜ʓiiÌÊ
diagnostic criteria for pneumonia.
UÊÊ-«ÕÌÕ“Ê>˜`ÊLœœ`ÊVՏÌÕÀiÃÊÃ…œÕ`ÊLiÊÃi˜ÌÊœ˜Ê>Ê«>̈i˜ÌÃÊ>`“ˆÌÌi`ÊÌœÊ
the hospital BEFORE antibiotics are given.
UÊÊS. pneumoniae urine antigen should be obtained in all patients with CAP.
ÌÊ…>ÃÊëiVˆwVˆÌÞÊœvʙȯÊ>˜`Ê«œÃˆÌˆÛiÊ«Ài`ˆV̈ÛiÊÛ>ÕiÊœvÊnn°n‡™È°x¯°ÊÌÊ
is particularly useful if antibiotics have already been started or cultures
cannot be obtained.

83. 84
6.12 Pulmonary infections
UÊÊ/…iʏi}ˆœ˜i>ÊÕÀˆ˜iÊ>˜Ìˆ}i˜ÊˆÃÊÌ…iÊÌiÃÌÊœvÊV…œˆViÊvœÀÊ`ˆ>}˜œÃˆ˜}Ê
legionella infection. This test detects only L. pneumophila serogroup
£]ÊÜ…ˆV…ʈÃÊÀi뜘ÈLiÊvœÀÊÇäqnä¯Êœvʈ˜viV̈œ˜Ã°
DURATION
UÊ/…iÀ>«ÞÊV>˜ÊLiÊÃÌœ««i`Ê>vÌiÀÊÌ…iÊ«>̈i˜ÌʈÃ\
Ê UÊviLÀˆiÊvœÀÊ{nqÇÓÊ…œÕÀÃ
AND
Ê UÊÊ>ÃʘœÊ“œÀiÊÌ…>˜Êœ˜iÊœvÊÌ…iÊvœœÜˆ˜}ÊÈ}˜ÃÊ>˜`ÊÃÞ“«Ìœ“Ã\Ê,Ê
100 beats/min, RR 24 breaths/min, BP 90 mmHg, O
2
sat
Ê™ä¯]Ê>ÌiÀi`Ê“i˜Ì>ÊÃÌ>ÌÕðÊ
UÊÊ-Õ}}iÃÌi`Ê`ÕÀ>̈œ˜ÊœvÊÌ…iÀ>«ÞÊL>Ãi`Êœ˜Ê«>̈i˜ÌÊëiVˆwVÊv>VÌœÀÃ\
Ê UÊÊ3–5 days: Patient without immunocompromise or structural lung
disease
Ê UÊÊ7 days: Patients with moderate immunocompromise and/or
structural lung disease
Ê UÊÊ10–14 days: Patients with poor clinical response, who
received initial inappropriate therapy, or who are significantly
immunocompromised
UÊÊ1˜Vœ“«ˆV>Ìi`ÊL>VÌiÀi“ˆVÊ«˜iÕ“œVœVV>Ê«˜iÕ“œ˜ˆ>qÊ«Àœœ˜}i`Ê
course of antibiotic therapy not necessary, treat as pneumonia
UÊÊœÕ}…Ê>˜`ÊV…iÃÌÊ8‡À>ÞÊ>L˜œÀ“>ˆÌˆiÃÊ“>ÞÊÌ>ŽiÊ{qÈÊÜiiŽÃÊ̜ʈ“«ÀœÛi°Ê
There is NO need to extend antibiotics if the patient is doing well
otherwise (e.g. no fever).
Other causes of pneumonia
UÊÊ-ÕëiVÌi`Ê>ëˆÀ>̈œ˜\ Additional empiric coverage for aspiration is justified
only in classic aspiration syndromes suggested by loss of consciousness
(overdose, seizure) PLUS gingival disease or esophageal motility disorder.
Ceftriaxone, Cefepime, and Moxifloxacin have adequate activity against
most oral anaerobes. For classic aspiration, Clindamycin 600 mg IV Q8H
can be added to regimens not containing Piperacillin/tazobactam.
UÊÊœ““Õ˜ˆÌÞ‡>VµÕˆÀi`Ê,-\ Necrotizing pneumonia with cavitation in
absence of risk factors for aspiration listed above is concerning for
CA-MRSA pneumonia, particularly if associated with a preceding or
concomitant influenza-like illness. In these cases, Linezolid 600 mg IV/PO
Q12H can be added while awaiting culture data. Infectious Diseases
consult is strongly recommended. Use of Linezolid monotherapy for
MRSA bacteremia, even if associated with a pulmonary source, is not
recommended. In the absence of necrotizing pneumonia with cavitation,
empiric coverage for CA-MRSA can be deferred until sputum and blood
culture results return given their high diagnostic yield for CA-MRSA.
UÊÊ,iëˆÀ>ÌœÀÞÊÛˆÀÕÃiÃ\ Respiratory viruses can cause primary viral
pneumonia as well as lead to bacterial superinfection. Strongly consider
testing all patients with CAP during respiratory virus season (see p. 93).
,iviÀi˜ViÃ\
-É/-Êœ˜Ãi˜ÃÕÃÊÕˆ`iˆ˜iÃÊvœÀÊ*\ʏˆ˜Ê˜viVÌʈÃÊÓääÇÆ{{\-ÓÇ°
S. pneumo >˜Ìˆ}i˜\ÊÀV…ʘÌiÀ˜Êi`ÊÓ䣣ƣǣ­Ó®\£ÈÈqÇÓ
ÎÊ`>ÞÃÊœvÊÌ…iÀ>«ÞÊvœÀÊ*\Ê ÊÓääÈÆÎÎÓ\£Îxx°

84. 85
6.12 Pulmonary infections
Pathogen-specific and step-down therapy
Organism Preferred therapy PCN allergy Notes
S. pneumoniae PCN susceptible Penicillin G 1 million units IV Q6H Non-severe reaction:ÊÊ ™£¯ÊœvÊS. pneumoniae isolates at JHH
OR Cefpodoxime 200 mg PO BID (excluding oncology) are susceptible and
OR ™¯Ê>Àiʈ˜ÌiÀ“i`ˆ>ÌiÊÌœÊ* ]Ê{x¯Ê>Ài
Cefdinir 300 mg PO BID susceptible to Erythromycin (Erythromycin
Amoxicillin 500 mg PO TID Severe reaction: susceptibilities predict Azithromycin
Ê Ê âˆÌ…Àœ“ÞVˆ˜IQxääÊ“}Ê*"Ê`>ˆÞÊÊ8ÊÎÊ`>ÞÃÊÊ ÃÕÃVi«ÌˆLˆˆÌˆiÃÊvœÀÊS. pneumoniae), and
Ê Ê ",ÊxääÊ“}Êœ˜Vi]ÊÌ…i˜ÊÓxäÊ“}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃRÊ £ää¯Ê>ÀiÊÃÕÃVi«ÌˆLiÊ̜ʜ݈yœÝ>Vˆ˜
OR
Moxifloxacin 400 mg IV/PO daily
(if Erythromycin resistant)
S. pneumoniae PCN intermediate Penicillin G 1 million units IV Q6H Same as above
or urine antigen positive OR
Amoxicillin 1 g PO TID
S. pneumoniae PCN resistant, Ceftriaxone 1 g IV Q24 Moxifloxacin 400 mg IV/PO Q24H None of the S. pneumoniae isolates at
cephalosporin susceptible OR (excluding oncology) are resistant JHH
Cefpodoxime 200 mg PO BID to PCN
OR
Cefdinir 300 mg PO BID
H. influenzae ˜œ˜‡LiÌ>‡>VÌ>“>ÃiÊÊ “«ˆVˆˆ˜Ê£Ê}Ê6Ê+ÈÊ âˆÌ…Àœ“ÞVˆ˜IQxääÊ“}Ê *"Ê`>ˆÞÊ8ÊÎÊ`>ÞÃÊ",ÊÊ Çx¯ÊœvÊ H. influenzae isolates at JHH
producing (Ampicillin susceptible) OR xääÊ“}Êœ˜Vi]ÊÌ…i˜ÊÓxäÊ“}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃR (excluding oncology) are susceptible to
Amoxicillin 500 mg PO TID ORÊ “«ˆVˆˆ˜]Ê£ää¯ÊÌœÊivÌÀˆ>Ýœ˜i]ÊÈx¯ÊÌœÊ
Ê Ê iv«œ`œÝˆ“iÊÓääÊ“}Ê*"Ê ÊÊÊ /iÌÀ>VÞVˆ˜i]Ê>˜`Ê£ää¯Ê̜ʜ݈yœÝ>Vˆ˜Ê
OR
Cefdinir 300 mg PO BID
OR
Doxycycline† 100 mg PO BID
OR
Moxifloxacin 400 mg IV/PO daily
(if resistant to other options)

85. 86
6.12 Pulmonary infections
Pathogen-specific and step-down therapy
Organism Preferred therapy PCN allergy Notes
H. influenzae LiÌ>‡>VÌ>“>ÃiÊÊ “«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê+ÈÊ âˆÌ…Àœ“ÞVˆ˜IQxä äÊ“}Ê*"Ê`>ˆÞÊ8ÊÎÊ`>ÞÃÊ",Ê
producing (Ampicillin resistant) ORÊ xääÊ“}Êœ˜Vi]ÊÌ…i˜ÊÓxäÊ“}Ê*"Ê`>ˆÞÊ8Ê{Ê`>ÞÃR
Amoxicillin/clavulanate 875 mg PO BID OR
Cefpodoxime 200 mg PO BID
OR
Cefdinir 300 mg PO BID
OR
Doxycycline† 100 mg PO BID
OR
Moxifloxacin 400 mg IV/PO Q24H
(if resistant to other options)
L. pneumophilia Azithromycin 500 mg IV/PO Q24H Azithromycin 500 mg IV/PO Q24H x 7-10 days
OR OR
Ê œÝˆyœÝ>Vˆ˜Ê{ääÊ“}Ê6É*"Ê+Ó{Ê œÝˆyœÝ>Vˆ˜Ê{ääÊ“}Ê6É*"Ê+Ó{Ê8Ê £ä‡£{Ê`>ÞÃ
ՏÌÕÀiÊ>˜`ÊÕÀˆ˜iÊ>˜Ìˆ}i˜Ê˜i}>̈ÛiÊ iv«œ`œÝˆ“iÊÓääÊ“}Ê*"Ê ÊÊ œÝˆyœÝ>Vˆ˜Ê{ääÊ“}Ê6É*"Ê+Ó{Ê {x¯ÊœvÊ S. pneumoniae isolates at JHH
OR (excluding oncology) are susceptible to
Cefdinir 300 mg PO BID Erythromycin (Erythromycin susceptibilities
OR predict Azithromycin susceptibilities for
Ê “œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊ8,ÊÓÊ}Ê*"Ê Ê ÊS. pneumoniae®Ê>˜`ÊÇίÊ>ÀiÊÃÕÃVi«ÌˆLiÊ
Ê Ê Ê ÌœÊ/iÌÀ>VÞVˆ˜iÆÊÌ…iÀivœÀi]ÊÌ…iÃiÊ>}i˜ÌÃ
Ê œÌi\Ê1˜iÃÃÊÃÌÀœ˜}ÊÃÕëˆVˆœ˜ÊvœÀÊÊ Ê >ÀiÊÃÕLœ«Ìˆ“>ÊvœÀÊi“«ˆÀˆVÊÃÌi«‡`œÜ˜
L. pneumophilia, more than 3 days of therapy
Azithromycin for atypical coverage is not
needed due to very long half-life in lung tissue
IˆvÊÀÞÌ…Àœ“ÞVˆ˜ÊÃÕÃVi«ÌˆLiÆÊaʈvÊ/iÌÀ>VÞVˆ˜iÊÃÕÃVi«ÌˆLi

86. 87
6.12 Pulmonary infections
Healthcare-acquired pneumonia
(NOT ventilator-associated)
NOTE: If the patient is on antibiotic therapy or has recently been on
antibiotic therapy, choose an agent from a different class.
EMPIRIC TREATMENT
Patient with mild to moderate illness (e.g., not in or transferring to
the ICU/intermediate care unit, no or minimal oxygen requirement, no
hypotension)
UÊivÌÀˆ>Ýœ˜iIÊ£Ê}Ê6Ê+Ó{
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê6É*"Ê+Ó{
Patient with severe illness (e.g., in or transferring to the ICU/
intermediate care unit, concern for sepsis, significant oxygen
requirement, multi-lobar consolidation)
UÊivi«ˆ“iIÊÓÊ}Ê6Ê+nʱ Vancomycin
†
(see dosing section, p. 150)
OR
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“IÊ{°xÊ}Ê6Ê+Èʱ Vancomycin† (see dosing
section, p. 150)
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Ciprofloxacin 400 mg IV Q8H ± Gentamicin (see dosing section, p. 146)
*Consider adding Azithromycin 500 mg IV/PO Q24H if the patient is immunosuppressed
or coming from a nursing home or long term care facility to cover Legionella
†Add Vancomycin in patients with a history of MRSA colonization or infection,
necrotizing pneumonia, pneumonia after a respiratory viral illness, ill patients coming
from a nursing home or long term care facility, sepsis)
Patient with history of or risk factors for Pseudomonas and other
resistant Gram-negative organismsÊ­i°}°]ÊLÀœ˜V…ˆiVÌ>ÈÃÆÊLÀœ>`‡Ã«iVÌÀÕ“Ê
>˜ÌˆLˆœÌˆVÃÊvœÀÊ€ÊÇÊ`>ÞÃʈ˜ÊÌ…iÊ«>ÃÌÊ“œ˜Ì…ÆÊ«Àœœ˜}i`Ê…œÃ«ˆÌ>ˆâ>̈œ˜Ê€Ê
ÇÊ`>ÞÃÆÊ`iLˆˆÌ>Ìi`ʘÕÀȘ}Ê…œ“iÊÀiÈ`i˜ÌÆÊÀiVi˜ÌÊ“iV…>˜ˆV>ÊÛi˜Ìˆ>̈œ˜Ê
€Ê{nÊ…œÕÀÃÆʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê`ÕiÊÌœÊÃœˆ`ÊœÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê
hematologic malignancy, BMT, active chemotherapy, prednisone > 20
“}Ê`>ˆÞÊvœÀÊ€ÊÎÊÜiiŽÃ®\ÊÌÀi>ÌÊ>ÃÊÃiÛiÀiʈ˜iÃÃÊ܈̅ÊÌ>ˆœÀˆ˜}ÊœvÊ>˜ÌˆLˆœÌˆVÊ
based on past culture data
NOTE: Always narrow therapy based on cultures results
Oral step down therapy (if no sputum culture data to guide therapy)
UÊÊiv«œ`œÝˆ“iÊ{ääÊ“}Ê*"Ê Ê­ˆvÊœ˜ÊivÌÀˆ>Ýœ˜i®Ê",ʜ݈yœÝ>Vˆ˜Ê{ääÊ
mg PO daily
Duration:ʈvÊ«˜iÕ“œ˜ˆ>ÊVœ˜wÀ“i`Êx‡ÇÊ`>ÞÃÆʈvÊ«˜iÕ“œ˜ˆ>Ê`ˆ>}˜œÃˆÃʈÃÊ
questionable and patient improves, can considered stopping therapy
after 3 days
TREATMENT NOTES
Microbiology
UÊʘÌiÀœVœVVˆÊ>˜`ÊV>˜`ˆ`>ÊëiVˆiÃÊ>ÀiÊœvÌi˜ÊˆÃœ>Ìi`ÊvÀœ“ÊÌ…iÊëÕÌÕ“Ê
in hospitalized patients. In general, they should be considered to be
colonizing organisms and should not be treated with antimicrobials.

87. 88
6.12 Pulmonary infections
Antimicrobial management of “aspiration events”
UÊ*Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊ,Ê "/ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜ…œÊ>ÀiÊ
at increased risk for aspiration.
UÊ““i`ˆ>ÌiÊÌÀi>Ì“i˜ÌʈÃʈ˜`ˆV>Ìi`ÊvœÀÊ«>̈i˜ÌÃÊÜ…œÊ…>ÛiÊÓ>‡LœÜiÊ
obstructions or are on acid suppression therapy given the increased
risk of gastric colonization.
Uʘ̈LˆœÌˆVÊÌÀi>Ì“i˜ÌÊœvÊ«>̈i˜ÌÃÊÜ…œÊ`iÛiœ«ÊviÛiÀ]ʏiÕŽœVÞ̜ÈÃÊ>˜`Ê
infiltrates in the first 48 hours after an aspiration is likely unnecessary
since most aspiration pneumonias are chemical and antibiotic
treatment may only select for more resistant organisms.
UÊ/Ài>Ì“i˜ÌÊ-ÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜ…œÊ…>ÛiÊÃÞ“«Ìœ“ÃÊvœÀÊ
more than 48 hours or who are severely ill.
,iviÀi˜ViÃ\
ëˆÀ>̈œ˜Ê«˜iÕ“œ˜ˆÌˆÃÊ>˜`Ê>ëˆÀ>̈œ˜Ê«˜iÕ“œ˜ˆ>\Ê Ê˜}ÊÊi`ÊÓää£ÆÎ{{­™®\ÈÈx°
/-É-ÊÕˆ`iˆ˜iÃÊvœÀÊ*É6*\Ê,ÊÓääxƣǣ\Înn°
Ventilator-associated pneumonia (VAP)
UÊÊ-«ÕÌÕ“ÊVՏÌÕÀiÃÊÃ…œÕ`ÊLiÊœLÌ>ˆ˜i`Ê«ÀˆœÀÊÌœÊÃÌ>À̈˜}Ê>˜ÌˆLˆœÌˆVÃÊœÀÊ
if patient is failing therapy by endotracheal suction or invasive
techniques. ET suction appears just as sensitive but less specific
than invasive methods.
UÊÊEmpiric treatment MUST be narrowed as soon as sputum
culture results are known.
UÊÊvÊÌ…iÊ«>̈i˜ÌʈÃÊœ˜Ê>˜ÌˆLˆœÌˆVÊÌ…iÀ>«ÞÊœÀÊ…>ÃÊÀiVi˜ÌÞÊLii˜Êœ˜Ê>˜ÌˆLˆœÌˆVÊ
therapy, choose an agent from a different class.
Optimal treatment can likely be based on severity of illness as
determined by the Clinical Pulmonary Infection Score (CPIS).
Calculating the Clinical Pulmonary Infection Score (CPIS)
Temperature (°C)
Peripheral WBC
Tracheal
secretions
Chest X-ray
Progression
of infiltrate
from prior
radiographs
Culture of ET
suction
Oxygenation
(PaO2/FiO2)
0 points
36.5 to 38.4
{]äääÊqÊ££]äää
None
No infiltrate
None
No growth/light
growth
> 240 or ARDS
1 point
38.5 to 38.9
Ê{]äääÊœÀÊ
> 11,000
> 50% bands: add
1 extra point
Non-purulent
Diffuse or patchy
infiltrates
Heavy growth
Same bacteria on
gram stain: add 1
extra point
2 points
≤ 36.4 or ≥ 39
Purulent
Localized
infiltrate
Progression
(ARDS, CHF
thought unlikely)
≤ 240 and no
ARDS

88. 89
6.12 Pulmonary infections
EMPIRIC TREATMENT
If the CPIS is ≤ 6
UÊÊ6*ʈÃÊÕ˜ˆŽiÞ
UÊÊvÊ6*ÊÃÌÀœ˜}ÞÊÃÕëiVÌi`ÊÃiiÊÌÀi>Ì“i˜ÌÊÀiVœ““i˜`>̈œ˜ÃÊLiœÜ
UÊÊvÊ*-ÊÀi“>ˆ˜ÃÊ≤ 6 after 3 days, antibiotics can be stopped in most
cases
If the CPIS is > 6
Early-onset VAP (occurring within 72 hours of hospitalization and
patient has not been hospitalized or resided in a nursing home, long-
term care or rehabilitation facility in the past 3 months)
Etiology: S. pneumoniae, H. influenzea, S. aureus
UÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+Ó{
Late-onset VAP (all VAP that is not early-onset)
Etiology: S. aureus, P. aeruginosa, other Gram-negative bacilli
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUSÊQ*ˆ«iÀ>Vˆˆ˜É
tazobactam 4.5 g IV Q6H OR Cefepime 2 g IV OR +nRʱ Gentamicin
(see dosing section, p. 146)
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Qˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS
Gentamicin (see dosing section, p. 146)
Enterococci and candida species are often isolated from sputum in
hospitalized patients. In general, they should be considered to be
colonizing organisms and should not be treated with antimicrobials.
If the patient is immunocompromised, consider adding Azithromycin
500 mg Q24H to Piperacillin/tazobactam, Cefepime or Aztreonam to
cover Legionella
Duration
UÊÊ3 days if CPIS remains ≤ 6 in patients with initial CPIS ≤ ÈÆÊ6*ʈÃÊ
unlikely
UÊÊ7 days if the patient has clinical improvement
UÊÊvÊÃÞ“«Ìœ“ÃÊ«iÀÈÃÌÊ>ÌÊÇÊ`>ÞÃÊVœ˜Ãˆ`iÀÊ>ÌiÀ˜>̈ÛiÊÃœÕÀViÊ>˜`ÉœÀÊ
bronchoscopy with quantitative cultures
UÊÊ6*Ê>ÃÃœVˆ>Ìi`Ê܈̅ÊS. aureus bacteremia should be treated for at
least 14 days

89. 90
6.12 Pulmonary infections
TREATMENT NOTES
UÊÊTreatment MUST be narrowed based on culture results
UÊÊ/œLÀ>“ÞVˆ˜ÊˆÃÊÀiVœ““i˜`i`Ê>ÃÊ>ÊÃiVœ˜`Ê>}i˜ÌÊÌœÊLÀœ>`i˜Êi“«ˆÀˆVÊ
coverage rather than fluoroquinolones because of high rates of
resistance to fluoroquinolones in the institution.
UÊʘ̈“ˆVÀœLˆ>ÊÌ…iÀ>«ÞÊÃ…œÕ`ÊLiÊÌ>ˆœÀi`Êœ˜ViÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>ÀiÊ
known. Vancomycin should be stopped if resistant Gram-positive
organisms are not recovered. Gram-negative coverage can be
reduced to a single susceptible agent in most cases. The benefits of
combination therapy in the treatment of Pseudomonas are not well
`œVÕ“i˜Ìi`ÆʈvʈÌʈÃÊ`iÈÀi`]ÊÌ…i˜ÊVœ˜Ãˆ`iÀÊ}ˆÛˆ˜}ʈÌÊvœÀÊÌ…iÊwÀÃÌÊÇÓÊ
hours of therapy only.
Diagnosis
UÊÊ6*ʈÃÊ`ˆvwVՏÌÊÌœÊ`ˆ>}˜œÃi°
UÊÊ >VÌiÀˆ>ʈ˜Êi˜`œÌÀ>V…i>ÊÃÕV̈œ˜Ê“>ÞÊÀi«ÀiÃi˜ÌÊÌÀ>V…i>ÊVœœ˜ˆâ>̈œ˜Ê
and NOT infection.
UÊÊ+Õ>˜ÌˆÌ>̈ÛiÊVՏÌÕÀiÃÊœvÊ ÊyÕˆ`ÊV>˜Ê…i«Ê`ˆÃ̈˜}ՈÅÊLiÌÜii˜Ê
Vœœ˜ˆâ>̈œ˜Ê>˜`ʈ˜viV̈œ˜ÆÊ≥ 10
4
cfu/ml is considered significant
growth.
Other considerations
UÊÊ/À>V…i>ÊVœœ˜ˆâ>̈œ˜ÊœvÊÀ>“‡˜i}>̈ÛiÃÊ>˜`ÊS. aureus is not
eradicated even though lower airways are sterilized. Thus, post-
treatment cultures in the absence of clinical deterioration (fever,
rising WBC, new infiltrates, worsening ventilatory status) are not
recommended.
UÊʘ>`iµÕ>Ìiʈ˜ˆÌˆ>ÊÌÀi>Ì“i˜ÌÊœvÊ6*ʈÃÊ>ÃÃœVˆ>Ìi`Ê܈̅ʅˆ}…iÀÊ“œÀÌ>ˆÌÞÊ
(even if treatment is changed once culture results are known).
,iviÀi˜ViÃ\
/-É-ÊÕˆ`iˆ˜iÃÊvœÀÊ*É6\Ê,ÊÓääxƣǣ\Înn°
ˆ˜ˆV>ÊÀi뜘ÃiÊÌœÊ6*\Ê,ÊÓää£Æ£ÈÎ\£ÎÇ£‡£ÎÇx°Ê
6*\ÊÀV…ʘÌiÀ˜Êi`ÊÓäääÆ£Èä\£™ÓȇȰ
ˆ˜ˆ‡ \Ê…iÃÌÊ£™™nÆ££Î\{£Ó‡Óä°
*-ÊÃVœÀi\Ê“Ê,iÛÊ,iëˆÀʈÃÊ£™™£Æ£{Î\££Ó£q££Ó™°Ê
iÌiÀ“ˆ˜ˆ˜}ÊVœÕÀÃiÊœvÊÌ…iÀ>«ÞÊÕȘ}Ê*-Ê-VœÀi\Ê“ÊÊ,iëˆÀÊÀˆÌÊ>ÀiÊi`ÊÓäääÆÊ
£ÈÓ\xäxÊ>˜`ʘÌi˜ÃˆÛiÊ>ÀiÊi`ÊÓää{ÆÊÎä\ÊÇÎxqÇÎn°

90. 91
6.12 Pulmonary infections
Antibiotic selection and dosing for cystic
fibrosis patients
UÊÊ/…iÀ>«ÞÊÃ…œÕ`ÊLiÊL>Ãi`Êœ˜ÊVՏÌÕÀiÊ>˜`ÊÃÕÃVi«ÌˆLˆˆÌÞÊ`>Ì>ÊÜ…i˜Ê
>Û>ˆ>LiÆÊÌ…iÊ>}i˜ÌÊ܈̅ÊÌ…iʘ>ÀÀœÜiÃÌÊëiVÌÀÕ“ÊœvÊ>V̈ۈÌÞÊÃ…œÕ`ÊLiÊ
selected preferentially
UÊÊvÊ«œÃÈLi]ÊÃÌœ«Êv>ˆˆ˜}Ê>˜ÌˆLˆœÌˆVÃÊÜ…i˜Êˆ˜ˆÌˆ>̈˜}ʘiÜÊ>˜ÌˆLˆœÌˆVÃ
UÊʈ}…Ê`œÃiÃÊœvÊ>˜ÌˆLˆœÌˆVÃÊÃ…œÕ`ÊLiÊÕÃi`Ê̜ʓ>݈“ˆâiʏ՘}Ê«i˜iÌÀ>̈œ˜Ê
and reduce the risk of emergence of resistance (see below)
TREATMENT NOTES FOR SPECIFIC ORGANISMS
UÊPseudomonas aeruginosa
UÊÊ*ˆ«iÀ>Vˆˆ˜]Êivi«ˆ“i]Ê>˜`ÊivÌ>âˆ`ˆ“iÊÃ…œÕ`ÊLiÊÕÃi`Ê
preferentially to Meropenem to minimize the induction of
resistance to beta-lactams by Meropenem
UÊÊ/…iÃiÊ>}i˜ÌÃÊ>ÀiÊ}i˜iÀ>ÞÊVœ“Lˆ˜i`Ê܈̅ʅˆ}…‡`œÃiÊ
aminoglycosides based on in vitro evidence that there is synergy
against Pseudomonas
UÊÊœÀÊ«>̈i˜ÌÃÊ܈̅ʫi˜ˆVˆˆ˜Ê>iÀ}Þ]ʈ«ÀœyœÝ>Vˆ˜ÊœÀÊâÌÀiœ˜>“Ê
V>˜ÊLiÊVœ“Lˆ˜i`Ê܈̅Ê>˜Ê>“ˆ˜œ}ÞVœÃˆ`iÆÊ`iÃi˜ÃˆÌˆâ>̈œ˜ÊÌœÊLiÌ>‡
lactams or carbapenems should be strongly considered
UÊʘʫ>̈i˜ÌÃʈ˜ÌœiÀ>˜ÌÊœÀÊÀiÈÃÌ>˜ÌÊÌœÊ>“ˆ˜œ}ÞVœÃˆ`iÃ]ÊœˆÃ̈˜ÊV>˜Ê
be added
UÊÊœ˜Ìˆ˜ÕœÕÃʈ˜vÕÈœ˜ÊœvÊLiÌ>‡>VÌ>“ÃÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜ÊÃœ“iÊ
«>̈i˜ÌÃÆÊÃiiÊ«°ÊÓnÊvœÀÊ“œÀiʈ˜vœÀ“>̈œ˜°
UÊʘ…>i`Ê/œLÀ>“ÞVˆ˜Ê>˜`ÊœˆÃ̈˜ÊV>˜ÊLiÊÕÃi`Ê>ÃÊ>`Õ˜V̈ÛiÊÌ…iÀ>«Þ
UÊStenotrophomonas maltophilia
UÊÊS. maltophilia isolated from sputum usually represents colonization.
UÊÊvÊÃÕ«iÀˆ˜viV̈œ˜ÊˆÃÊÃÕëiVÌi`]Ê/*É-8ʈÃÊÌ…iÊwÀÃÌʏˆ˜iÊ>}i˜Ì°Ê
UÊÊ/ˆV>ÀVˆˆ˜ÉV>ÛՏ>˜>ÌiÊOR Minocycline may be used if susceptible in
«>̈i˜ÌÃÊÜ…œÊ>ÀiÊ>iÀ}ˆVÊœÀʈ˜ÌœiÀ>˜ÌÊœÀÊÀiÈÃÌ>˜ÌÊÌœÊ/*É-8°Ê
UÊStaphylococcus aureus
UÊÊS. aureus isolated from sputum can indicate colonization or
infection.
UÊÊ7…iÌ…iÀÊÌÀi>̈˜}ÊVœœ˜ˆâ>̈œ˜Ê܈̅ÊS. aureus in CF patients
improves outcomes is an area of active research, although
historically such colonization has not been successfully eradicated
with antimicrobial therapy. If this is attempted, possible agents
include Dicloxacillin, Cefazolin or Cephalexin for MSSA and
ˆ˜`>“ÞVˆ˜]Ê/*É-8]ÊœÝÞVÞVˆ˜i]Ê>˜`ʈ˜œVÞVˆ˜iÊvœÀÊ,-°ÊÊ
UÊÊ"Ý>Vˆˆ˜ÊˆÃÊÌ…iÊ`ÀÕ}ÊœvÊV…œˆViÊvœÀÊ--Ê«˜iÕ“œ˜ˆ>ÆÊ6>˜Vœ“ÞVˆ˜Ê
or Linezolid can be used for MRSA pneumonia.

91. 92
6.12 Pulmonary infections
Antibiotic doses for cystic fibrosis infections – normal renal
function
UÊivÌ>âˆ`ˆ“i\ÊÓÊ}Ê6Ê+nÊ
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“\ÊΰÎÇxÊ}Ê6Ê+{
UÊivi«ˆ“i\ÊÓÊ}Ê6Ê+n
UÊiÀœ«i˜i“\ÊÓÊ}Ê6Ê+n
Uʈ«ÀœyœÝ>Vˆ˜\ÊÇxäÊ“}Ê*"Ê+£ÓÊ",Ê{ääÊ“}Ê6Ê+n
UÊâÌÀiœ˜>“\ÊÓÊ}Ê6Ê+n
UÊ/ˆV>ÀVˆˆ˜ÉV>ÛՏ>˜>Ìi\Êΰ£Ê}Ê6Ê+{
UÊ/*É-8ÊvœÀÊS. maltophilia: 5 mg/kg IV/PO Q8H
UÊ/*É-8ÊvœÀÊS. aureus: 2 DS tablets PO BID
UÊœˆÃ̈˜\Ê·ÈÊ“}ÉŽ}É`>ÞÊ6Ê`ˆÛˆ`i`ʈ˜ÊÎÊ`œÃiÃÊ
Uʘ…>i`Ê/œLÀ>“ÞVˆ˜Ê­/"
®®\ÊÎääÊ“}Ê+£Ó
Uʘ…>i`ÊœˆÃ̈˜\ÊÇx‡£xäÊ“}Ê+£ÓÊ`i«i˜`ˆ˜}Êœ˜ÊÌ…iÊ`iˆÛiÀÞÊÃÞÃÌi“ÊÊ
Intravenous Tobramycin dosing and monitoring:
UÊœ>`ˆ˜}Ê`œÃi\Ê£äÊ“}ÉŽ}É`>ÞÊ}ˆÛi˜ÊœÛiÀʣʅœÕÀ°Ê
UÊÊ*i>ŽÊˆÃÊÀiVœ““i˜`i`Ê>vÌiÀÊwÀÃÌÊ`œÃi]ʣʅœÕÀÊ>vÌiÀÊÌ…iÊi˜`Êœvʈ˜vÕÈœ˜Ê
܈̅Ê}œ>ÊœvÊÓä‡ÎäÊ>˜`ÊÌÀœÕ}…Ê>ÌÊÓÎÊ…œÕÀÃÊ܈̅Ê}œ>ÊÊ£Ê“V}É“°Ê
UÊÊœÃiÃÊV>˜ÊLiʈ˜VÀi>Ãi`ÊÕ«Ê̜ʣÓÊ“}ÉŽ}É`>ÞʈvÊ>`iµÕ>ÌiÊ«i>ŽÃÊ
are not achieved. If trough is too low or too high, interval should be
changed.

92. 93
6.13 Respiratory virus diagnosis and management
Respiratory virus diagnosis and management
Diagnosis
UÊÊ,iëˆÀ>ÌœÀÞÊÛˆÀÕÃÊÌiÃ̈˜}ÊÃ…œÕ`ÊLiÊœLÌ>ˆ˜i`ÊÞi>ÀÊÀœÕ˜`Êœ˜Ê>˜ÞÊ«>̈i˜ÌÊ
for whom there is a clinical suspicion of respiratory virus infection. In
addition, during influenza and RSV season testing should be obtained
ˆ˜Ê«>̈i˜ÌÃÊ܈̅\
Ê UÊÊiÛiÀÊ>˜`ʈ˜yÕi˜â>‡ˆŽiÊÃÞ“«Ìœ“ÃÊ­ÃœÀiÊÌ…Àœ>Ì]Ê“Þ>}ˆ>]Ê>ÀÌ…À>}ˆ>]Ê
cough, runny nose and/or headache)
ÊU Suspected bronchiolitis or pneumonia
ÊU COPD/asthma exacerbation or respiratory failure
Ê UÊ1˜iÝ«>ˆ˜i`ÊÊiÝ>ViÀL>̈œ˜
Ê Uʏ`iÀÞÊ«>̈i˜ÌÃÊ܈̅ÊÕ˜iÝ«>ˆ˜i`ʘiÜÊœ˜ÃiÌÊ“>>ˆÃi
Ê UÊ*Ài}˜>˜ÌÊ«>̈i˜ÌÃÊ܈̅ÊÕ˜iÝ«>ˆ˜i`ÊÀiëˆÀ>ÌœÀÞÊÃÞ“«Ìœ˜Ã
Ê UÊÊ œ˜Ã«iVˆwVÊÃÞ“«Ìœ“ÃÊ>˜`Ê>Ê`œVÕ“i˜Ìi`ÊiÝ«œÃÕÀiÊÌœÊÃœ“iœ˜iÊ
with a respiratory illness
UÊÊ,iëˆÀ>ÌœÀÞÊÛˆÀÕÃÊÌiÃ̈˜}Ê>ÌÊÊ­œ˜iÊ *ÊyœVŽi`ÊÃÜ>LÊÃ…œÕ`ÊLiÊ
submitted for either panel)
Ê UÊÊ/iÃ̈˜}ÊvœÀʈ““Õ˜œVœ“«iÌi˜ÌÊ…œÃÌÃ\ÊÀ>«ˆ`ʘÕViˆVÊ>Vˆ`ÊÌiÃÌÊvœÀÊ,-6Ê
and influenza A/B
Ê UÊÊ/iÃ̈˜}ÊvœÀʈ““Õ˜œVœ“«Àœ“ˆÃi`Ê…œÃÌÃ]Ê«>̈i˜ÌÃÊLiˆ˜}Ê>`“ˆÌÌi`Ê
ÌœÊÌ…iÊ1]Ê>˜`Ê«>̈i˜ÌÃÊ܈̅ÊÃÌÀÕVÌÕÀ>ÊÕ˜}Ê`ˆÃi>Ãi\ÊiÝÌi˜`i`Ê
panel for RSV, influenza A/B, adenovirus, human metapneumovirus,
parainfluenza 1-3, and rhinovirus
Treatment of influenza in inpatients
UÊÊ“«ˆÀˆVÊÌÀi>Ì“i˜ÌÊœvÊ>`ՏÌʈ˜«>̈i˜ÌÃÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜ÊÌ…iÊ
vœœÜˆ˜}ÊÈÌÕ>̈œ˜ÃÊ`ÕÀˆ˜}ʈ˜yÕi˜â>ÊÃi>Ãœ˜\Ê
Ê UÊÊ*>̈i˜ÌÃÊ܈̅ÊviÛiÀÊ>˜`ʈ˜yÕi˜â>‡ˆŽiÊÃÞ“«Ìœ“Ã]ÊÕ˜iÝ«>ˆ˜i`Ê
interstitial pneumonia or new respiratory failure without an obvious
non-influenza cause
UÊÊ/Ài>Ì“i˜ÌÊÃ…œÕ`ÊLiʈ˜ˆÌˆ>Ìi`ʈ˜Ê>Ê«>̈i˜ÌÃÊÜ…œÊ>ÀiÊ>`“ˆÌÌi`ÊÌœÊÌ…iÊ
hospital and have influenza with symptom onset in the past 48-72 hours
UÊÊ/…iÊṎˆÌÞÊœvÊÌÀi>Ì“i˜ÌÊœvÊ«>̈i˜ÌÃÊÜ…œÊ«ÀiÃi˜Ìʏ>Ìiʈ˜ÊÌ…iÊVœÕÀÃiÊœvÊ
disease is uncertain and the decision to treat these patients can be
made on a case-by-case basis
UÊʘ̈ۈÀ>ÊV…œˆViʈÃÊ`i«i˜`i˜ÌÊœ˜ÊÌ…iÊÃÕÃVi«ÌˆLˆˆÌÞÊœvÊVˆÀVՏ>̈˜}ÊÃÌÀ>ˆ˜ÃÊ
which may vary from season to season (see
www.hopkinsmedicine.org/amp for current recommendations)
UÊÊÕÀ>̈œ˜\ÊxÊ`>ÞÃÊiÝVi«ÌÊvœÀÊ«>̈i˜ÌÃÊ܈̅ÊÃœˆ`ÊœÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê
hematologic malignancy, or BMT in whom 10 days can be given
because of prolonged viral shedding

93. 94
6.13 Respiratory virus diagnosis and management
Infection control
UÊʏÊˆ˜`ˆÛˆ`Õ>ÃÊ܈̅ÊÃÕëiVÌi`ÊÀiëˆÀ>ÌœÀÞÊÛˆÀÕÃʈ˜viV̈œ˜ÊÃ…œÕ`ÊLiÊ
placed on droplet precautions. A private room is required, unless
patients are cohorted. When outside of their room (i.e. during
transport) patients should wear a mask.
UÊʏÊ…i>Ì…ÊV>ÀiÊÜœÀŽiÀÃÊ“ÕÃÌÊÀiViˆÛiÊÌ…iʈ˜yÕi˜â>ÊÛ>VVˆ˜iÊÞi>ÀÞ°
UÊÊ*iÀÃœ˜˜iÊ܈̅Ê`ˆÀiVÌÊ«>̈i˜ÌÊV>ÀiÊœÀÊÜœÀŽˆ˜}ʈ˜ÊVˆ˜ˆV>Ê>Ài>ÃÊÜ…œÊ…>ÛiʘœÌÊ
received the influenza vaccine are required to wear a mask when within 6
feet of a patient. The dates of the mask requirement are determined by
HEIC and based on influenza activity in the local community.
U No one with fever may work until at least 24 hours after fever
has resolved (without antipyretics). All personnel with respiratory
symptoms and fever must call or report to their supervisor and must
call Occupational Health Services (OHS).
UÊ
Afebrile employees who have respiratory systems must wear a
surgical mask during patient contact (≤ 6 ft).
UÊÊvÊ>˜ÊÕ˜Û>VVˆ˜>Ìi`Ê7ʈÃÊiÝ«œÃi`ÊÌœÊ>Ê«>̈i˜ÌÊ܈̅Ê`œVÕ“i˜Ìi`Ê
influenza who was not on Droplet Precautions, notify HEIC and call
Occupational Health Services (OHS) immediately. OHS will decide
whether to recommend post-exposure prophylaxis.
Anti-influenza agents
Medication Adult dosing Side effects Notes
Oseltamivir Treatment:Ê œ““œ˜\ʘ>ÕÃi>]ÊÊ œÃiÊ>`ÕÃÌ“i˜ÌÊ
75 mg PO twice a day vomiting needed for GFR
Ê vœÀÊxÊ`>ÞÃÊ Ê ÈäÊ“É“ˆ˜Ê
Prophylaxis:Ê -iÛiÀi\
75 mg PO once a day hypersensitivity,
neuropsychiatric
<>˜>“ˆÛˆÀÊTreatment:Ê œ““œ˜\Ê`ˆ>ÀÀ…i>]ÊÊ -…œÕ`Ê "/ÊLiÊÕÃi`Ê
10 mg (2 oral inhalations) nausea, cough, in patients with
twice daily for 5 days headache, and chronic underlying
Prophylaxis: dizziness airway diseases
10 mg (2 oral inhalations)
Ê œ˜ViÊ>Ê`>ÞÊÊ Ê -iÛiÀi\ÊLÀœ˜V…œÃ«>Ó]Ê
hypersensitivity,
laryngeal edema,
facial swelling

94. 95
6.14 Tuberculosis (TB) infection
Tuberculosis (TB) infection
Latent TB infection (LTBI)
UÊÊ*ÀiÛˆœÕÃʈ˜viV̈œ˜Ê܈̅ÊM. tuberculosis (MTB) that has been contained by
the host immune response
UÊÊ*>̈i˜ÌÊ“>ÞÊ…>ÛiÊ>Ê«œÃˆÌˆÛiÊÌiÃÌÊ­ÃiiÊLiœÜ®ÊœÀÊÃÕ}}iÃ̈ÛiÊÀ>`ˆœ}À>«…ˆVÊ
findings such as calcified granulomata or minimal apical scarring, but do
not have symptoms of active TB disease
UÊÊ œÌʈ˜viV̈œÕÃÊ>˜`Ê`œiÃʘœÌÊÀiµÕˆÀiʈ܏>̈œ˜
Tests to diagnose latent LTBI
UÊÊ œÌ…Ê/ÕLiÀVՏˆ˜ÊÃŽˆ˜ÊÌiÃÌÊ­/-/®Ê>˜`ʘÌiÀviÀœ˜Ê}>““>ÊÀii>ÃiÊ>ÃÃ>ÞÊ­,®Ê
>Àiʈ“«iÀviVÌ]Ê>˜`Ê“>ÞÊœvviÀÊ`ˆÃVœÀ`>˜ÌÊÀiÃՏÌÃÊ­HÓ䯮°ÊÊ-i˜ÃˆÌˆÛˆÌÞÊœvÊ/-/Ê
and IGRA are similar.
UÊÊ œÌ…ÊÌiÃÌÃÊÃ…œÕ`ÊLiʈ˜ÌiÀ«ÀiÌi`ʈ˜ÊÌ…iÊVœ˜ÌiÝÌÊœvÊi«ˆ`i“ˆœœ}ˆVÊÀˆÃŽÊœvÊ/ Ê
exposure
UÊÊ/ ÊÌ…iÀ>«ÞÊÃ…œÕ`ʘœÌÊLiʈ˜ˆÌˆ>Ìi`Ê՘̈Ê>V̈ÛiÊ/ ʈÃÊiÝVÕ`i`Ê­LÞÊ
symptoms and radiography). Individuals with signs or symptoms of active
TB require further diagnostic workup before LTBI therapy.
UÊÊ/ ÊÌ…iÀ>«ÞÊÃ…œÕ`ʘœÌÊLiÊÃÌ>ÀÌi`ʈ˜ÊÌ…iÊ…œÃ«ˆÌ>Ê܈̅œÕÌÊ>ÊVi>ÀÊvœœÜ‡Õ«Ê
plan
Tuberculin skin test (TST)
UÊʘÌÀ>`iÀ“>Êˆ˜iV̈œ˜ÊœvÊ«ÕÀˆwi`Ê«ÀœÌiˆ˜Ê`iÀˆÛ>̈ÛiÊ­**®Ê>˜`Ê“i>ÃÕÀi“i˜ÌÊ
of induration diameter in 48-72
UÊÊÊ ÀˆÌiÀˆ>ÊvœÀÊ>Ê«œÃˆÌˆÛiÊÌiÃÌÊ>Ài
UÊÊÊxÊ““ÊqÊ…ˆ}…ÊÀˆÃŽÊœvÊ`iÛiœ«ˆ˜}Ê>V̈ÛiÊ/ Ê­i°}°]Ê6ʈ˜viV̈œ˜]ÊVœÃiÊ
contact of TB case, immunocompromised)
UÊÊÊ£äÊ““Êqʜ̅iÀÊÀˆÃŽÊv>VÌœÀÃÊvœÀÊ/ ʈ˜viV̈œ˜Ê­7]Ê1]Ê®
UÊÊÊ£xÊ““ÊqʘœÊÀˆÃŽÊv>VÌœÀÃÊvœÀÊ/
Interferon gamma release assay (IGRA)
UÊ,ÃÊ“i>ÃÕÀiʏޓ«…œVÞÌiÊÀii>ÃiÊœvʈ˜ÌiÀviÀœ˜Ê}>““>ʈ˜ÊÀi뜘ÃiÊÌœÊ
stimulation by MTB antigens.
UÊ,ÃÊ>ÀiʏiÃÃÊ>vviVÌi`ÊLÞÊ ÊÛ>VVˆ˜>̈œ˜ÊÃÌ>ÌÕÃÊœÀʈ˜viV̈œ˜Ê܈̅ʓœÃÌÊ
atypical mycobacteria (except M. marinum and M. kansasii) than TST
UÊ+Õ>˜ÌˆviÀœ˜‡œ`‡˜‡/ÕLiÊ­+/®ÊˆÃÊÕÃi`Ê>ÌÊ°Ê,iÃՏÌÃÊ>ÀiÊÀi«œÀÌi`Ê>ÃÊ
positive, negative, or indeterminate. An indeterminate result means that the
test result is not valid, which can be due to errors in specimen collection
(most common--insufficient/incorrect shaking of tubes after blood draw
or processing delays), or associated with certain conditions such as HIV
with a low CD4 count, steroid use or other immunosuppression, and
“>˜ÕÌÀˆÌˆœ˜ÊQ>LÕ“ˆ˜ÊΰxR°Ê˜`iÌiÀ“ˆ˜>ÌiÊÀiÃՏÌÃÊœvÌi˜ÊÀiµÕˆÀiÊ>ÊÀi«i>ÌÊ
test (ensure proper specimen collection).
UÊ7…i˜Ê«Ài‡ÌiÃÌÊ«ÀœL>LˆˆÌÞÊœÀÊ«ÀiÛ>i˜ViÊœvÊ/ ʈÃÊx¯Ê­i°}°]Ê1-‡LœÀ˜Ê
܈̅œÕÌÊvœÀiˆ}˜ÊÌÀ>Ûi®]Ê**6ÊœvÊ,ʈÃÊÀi`ÕVi`Ê­Ç䇙ä¯]ʈ°i°]Êv>Ãi‡«œÃˆÌˆÛiîÊ
Ü…ˆiÊ *6ʈÃÊ…ˆ}…Ê­™™¯®°ÊÊ
UÊ7…i˜Ê«Ài‡ÌiÃÌÊ«ÀœL>LˆˆÌÞÊvœÀʈ˜viV̈œ˜ÊˆÃÊ…ˆ}…Ê­i°}°]ÊvœÀiˆ}˜‡LœÀ˜]ÊHÎä¯Ê/ Ê
«ÀiÛ>i˜Vi®]Ê**6ÊœvÊ,ʈ˜VÀi>ÃiÃÊÌœÊH™x‡™™¯]ÊLÕÌÊ *6Ê`iVÀi>ÃiÃÊ
­n䇙ä¯]ʈ°i°]Êv>Ãi‡˜i}>̈Ûiî°ÊÊ

95. 96
6.14 Tuberculosis (TB) infection
UÊ+Õ>˜ÌˆÌ>̈ÛiÊÀiÃՏÌÃÊ“>ÞÊLiÊ…i«vՏÊÌœÊ}Õˆ`iʈ˜ÌiÀ«ÀiÌ>̈œ˜°Êœ˜Ãˆ`iÀÊÊ
Vœ˜ÃՏÌ>̈œ˜ÊvœÀÊÀiÃՏÌÃʘi>ÀÊÌ…iÊÌ…ÀiÃ…œ`ÊvœÀÊ+/Ê«œÃˆÌˆÛi\Ê>˜Ìˆ}i˜0.35.
Serial testing is not advised without ID consultation.
UÊ,ÃÊ`œÊ˜œÌÊ…>ÛiÊ}œœ`ÊÃi˜ÃˆÌˆÛˆÌÞÊœÀÊëiVˆwVˆÌÞÊvœÀÊ`ˆ>}˜œÃˆÃÊœvÊ>V̈ÛiÊ/
Active TB infection
UÊÊV̈ÛiÊÀi«ˆV>̈œ˜ÊœvÊ/ ÊV>ÕȘ}ʫՏ“œ˜>ÀÞÊœÀÊiÝÌÀ>«Õ“œ˜>ÀÞÊÈ}˜ÃÊœÀÊ
symptoms
UÊÊœ˜wÀ“i`ÊLÞÊ«œÃˆÌˆÛiÊ ÊÓi>À]Ê/ Ê`ˆÀiVÌÊÌiÃÌÊœÀÊVՏÌÕÀi
UÊÊ,iµÕˆÀiÃÊ>ˆÀLœÀ˜iʈ܏>̈œ˜
When to suspect active TB disease
High-risk individuals
UÊÊ,iVi˜ÌÊiÝ«œÃÕÀiÊÌœÊ>Ê«iÀÃœ˜Ê܈̅ʎ˜œÜ˜Ê/ ÆÊ…ˆÃÌœÀÞÊœvÊ>Ê«œÃˆÌˆÛiÊ/-/ÆÊ
6ʈ˜viV̈œ˜Æʈ˜iV̈œ˜ÊœÀʘœ˜‡ˆ˜iV̈œ˜Ê`ÀÕ}ÊÕÃiÆÊvœÀiˆ}˜ÊLˆÀÌ…ÊœÀÊÀiÈ`i˜ViÊ
ˆ˜Ê>ÊÀi}ˆœ˜Êˆ˜ÊÜ…ˆV…Ê/ ʈ˜Vˆ`i˜ViʈÃÊ…ˆ}…ÆÊÀiÈ`i˜ÌÃÊ>˜`Êi“«œÞiiÃÊœvÊ
…ˆ}…‡ÀˆÃŽÊVœ˜}Ài}>ÌiÊÃiÌ̈˜}ÃÊ­i°}°Ê«ÀˆÃœ˜Ã®ÆÊ“i“LiÀÃ…ˆ«Êˆ˜Ê>Ê“i`ˆV>ÞÊ
Õ˜`iÀÃiÀÛi`]ʏœÜ‡ˆ˜Vœ“iÊ«œ«Õ>̈œ˜ÆÊ>˜Ìˆ‡/ Ê>«…>ÊÌ…iÀ>«Þ
Clinical syndromes
UÊÊœÕ}…ÊœvÊ2 wk duration, with at least one additional symptom, including
fever, night sweats, weight loss, or hemoptysis
UÊʘÞÊÕ˜iÝ«>ˆ˜i`ÊÀiëˆÀ>ÌœÀÞʈ˜iÃÃÊœvÊ2 wk duration in a patient at high
risk for TB
UÊʘÞÊ«>̈i˜ÌÊ܈̅Ê6ʈ˜viV̈œ˜Ê>˜`ÊÕ˜iÝ«>ˆ˜i`ÊVœÕ}…Ê>˜`ÊviÛiÀÊ
UÊʘÞÊ«>̈i˜ÌÊœ˜Ê>˜Ìˆ‡/ Ê>«…>ÊÌ…iÀ>«ÞÊ܈̅ÊÕ˜iÝ«>ˆ˜i`ÊviÛiÀ
UÊÊœ““Õ˜ˆÌÞ‡>VµÕˆÀi`Ê«˜iÕ“œ˜ˆ>ÊÜ…ˆV…Ê…>ÃʘœÌʈ“«ÀœÛi`Ê>vÌiÀÊÇÊ`>ÞÃÊœvÊ
appropriate treatment
UÊʘVˆ`i˜Ì>Êw˜`ˆ˜}ÃÊœ˜ÊV…iÃÌÊÀ>`ˆœ}À>«…ÊÃÕ}}iÃ̈ÛiÊœvÊ/ Ê­iÛi˜ÊˆvÊÃÞ“«Ìœ“ÃÊ
are minimal or absent) in a patient at high risk for TB
Radiographic findings
UÊÊ*Àˆ“>ÀÞÊ/ Ê­œvÌi˜ÊÕ˜ÀiVœ}˜ˆâi`®\Ê>˜ÊÀiÃi“LiÊ*Ê>˜`ʈ˜ÛœÛiÊ>˜ÞʏœLiÃÆÊ
…ˆ>ÀÊ>`i˜œ«>Ì…Þ]Ê«iÕÀ>ÊivvÕÈœ˜ÃÊ>ÀiÊVœ““œ˜ÆÊV>ÛˆÌ>̈œ˜ÊˆÃÊÕ˜Vœ““œ˜°Ê
ˆ˜`ˆ˜}ÃÊœvÌi˜ÊÀiÃœÛiÊ>vÌiÀÊ£qÓÊ“œ˜Ì…ðÊ/…iÃiÊ>ÀiÊVœ““œ˜Êw˜`ˆ˜}Ãʈ˜Ê
patients with advanced HIV infection and TB.
UÊÊ,i>V̈Û>̈œ˜Ê/ \ʘwÌÀ>ÌiÃÊ܈̅ʜÀÊ܈̅œÕÌÊV>ÛˆÌ>̈œ˜Êˆ˜ÊÌ…iÊÕ««iÀʏœLiÃÊœÀÊ
Ì…iÊÃÕ«iÀˆœÀÊÃi}“i˜ÌÃÊœvÊÌ…iʏœÜiÀʏœLiÃÆÊ…ˆ>ÀÊ>`i˜œ«>Ì…ÞʈÃÊÛ>Àˆ>LiÆÊ/Ê
ÃV>˜Ê“>ÞÊ…>ÛiʺÌÀii‡ˆ˜‡LÕ`»Ê>««i>À>˜Vi°
Diagnosis
UÊÊ*>̈i˜ÌÃÊ܈̅ÊV…>À>VÌiÀˆÃ̈VÊÃÞ˜`Àœ“iÃÊ>˜`ÊÀ>`ˆœ}À>«…ˆVÊw˜`ˆ˜}ÃÊÃ…œÕ`Ê
have expectorated sputum obtained for AFB smear and culture.
UÊÊ-i˜ÃˆÌˆÛˆÌÞÊœvÊ ÊÓi>ÀÊœ˜ÊiÝ«iVÌœÀ>Ìi`ÊëÕÌՓʈÃÊxäqÇä¯ÆʈÌʈÃÊ
œÜiÀʈ˜Ê6³Ê«>̈i˜ÌðʜÀ˜ˆ˜}ÊiÝ«iVÌœÀ>Ìi`ÊëÕÌÕ“]ʈ˜`ÕVi`ÊëÕÌÕ“]Ê
bronchoscopy have higher sensitivity. AFB culture of lower respiratory tract
specimens is considered the gold standard.
UÊÊ ÊÓi>ÀÊ>˜`ÊVՏÌÕÀiÊÃ…œÕ`ÊLiÊœLÌ>ˆ˜i`ÊÀi}>À`iÃÃÊœvÊ8,Ê
findings in patients with high clinical suspicion, HIV infection or other
ˆ““Õ˜œVœ“«Àœ“ˆÃi`ÊÃÌ>ÌiðÊ8,ʈÃʘœÀ“>Êˆ˜Ê>««ÀœÝˆ“>ÌiÞÊ£ä¯ÊœvÊ6‡
infected patients with pulmonary TB.

96. 97
6.14 Tuberculosis (TB) infection
UÊÊ"LÌ>ˆ˜Ê>Ìʏi>ÃÌÊÎÊëÕÌÕ“ÊëiVˆ“i˜ÃÊ­ˆ˜`ÕVi`ÊœÀÊiÝ«iVÌœÀ>Ìi`®ÊÜ…i˜ÊÌÀÞˆ˜}Ê
to diagnose TB in patients who are smear negative so as to increase the
chance of isolating the organism for diagnosis and susceptibility testing.
Infection control
ˆÀLœÀ˜iÊ«ÀiV>Ṏœ˜ÃÊ>ÀiÊÀiµÕˆÀi`ʈ˜ÊÌ…iÊvœœÜˆ˜}ÊV>ÃiÃ\
UÊÊ-ÕëˆVˆœ˜ÊœvÊ`ˆÃi>ÃiÊÃÕvwVˆi˜ÌÞÊ…ˆ}…ÊÌœÊÜ>ÀÀ>˜ÌÊœLÌ>ˆ˜ˆ˜}ÊëÕÌÕ“Ê Ê
smear/culture as described above
UÊÊ*œÃˆÌˆÛiÊ ÊÓi>ÀÊœÀÊVՏÌÕÀiÊ՘̈Ê`ˆ>}˜œÃˆÃÊœvÊ/ ÊÛÃ°Ê /ʈÃÊVœ˜wÀ“i`
AIRBORNE PRECAUTIONS
IN NEGATIVE PRESSURE ROOM
Collect specimen(s) for AFB smear and culture
Expectorated sputum (3 required)* Induced sputum or bronchoscopy
Smear
positive
Smear
negative
MTD
positive
MTD
positive
MTD
negative
Smear
positive
Mycobacterium
Tuberculosis
Direct Test (MTD)
automatically
performed
If pt highly suspected
for TB, await culture
result and continue
isolation. Otherwise,
CALL HEIC 5-8384 to
DISCONTINUE ISOLATION
MTD
negative
Smear
negative
Obtain 2nd
and 3rd
specimen*
MTD test
performed
Continue isolation until at
least 14 days of therapy
AND clinical improvement
AND 3 consecutive negative
smears (Call HEIC for
approval to D/C isolation on
smear positive patient.)
*One expectorated sputum must be a first morning specimen; samples should
be collected at least 8 hours apart.
Smear
positive
CALL HEIC 5-8384 TO DISCONTINUE ISOLATION
Algorithm for isolation when active TB is suspected

97. 98
6.14 Tuberculosis (TB) infection
UÊʘœÜ˜Ê>V̈ÛiʫՏ“œ˜>ÀÞÊœÀʏ>ÀÞ˜}i>Ê/ Ê­ˆvÊ«>̈i˜ÌʈÃÊVÕÀÀi˜ÌÞÊœ˜Ê/ Ê
treatment, consult with HEIC and patient’s local health department to obtain
treatment history in order to determine if infectious at the time of current
…œÃ«ˆÌ>ˆâ>̈œ˜Æʈ˜Ê“i>˜Ìˆ“iÊ>ˆÀLœÀ˜iÊ«ÀiV>Ṏœ˜ÃÊ>ÀiÊÀiµÕˆÀi`®Ê
TREATMENT
Active TB
UÊÊVœ˜ÃՏÌʈÃÊÃÌÀœ˜}ÞÊÀiVœ““i˜`i`Ê
UÊÊ/…iÀ>«ÞÊÃ…œÕ`ÊLiʈ˜ˆÌˆ>Ìi`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅ʫœÃˆÌˆÛiÊ ÊÓi>ÀÊ>˜`ÊVˆ˜ˆV>Ê
findings consistent with active TB.
UÊÊ/…iÀ>«ÞÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅ʘi}>̈ÛiÊ ÊÓi>ÀÃÊ
when suspicion of TB is high and no alternate diagnosis exists. Multiple
specimens should be obtained for culture prior to treatment.
UÊœÕÀÊ`ÀÕ}ÃÊ>ÀiʘiViÃÃ>ÀÞÊvœÀʈ˜ˆÌˆ>Ê«…>ÃiÊ­ÓÊ“œ˜Ì…î°Ê
UÊÃœ˜ˆ>âˆ`Ê­ ®ÊÎääIÊ“}Ê­xÊ“}ÉŽ}®Ê*"Ê`>ˆÞÊ
UÊ,ˆv>“«ˆ˜Ê­,®ÊÈääIÊ“}Ê­£äÊ“}ÉŽ}®Ê*"Ê`>ˆÞ
UÊÊ*ÞÀ>∘>“ˆ`iÊ­*<®Ê£äääÊ“}Ê*"Ê`>ˆÞÊ­{äqxxÊŽ}®Ê",Ê£xääÊ“}Ê*"Ê
`>ˆÞÊ­xÈqÇxÊŽ}®Ê",ÊÓäääIÊ“}Ê*"Ê`>ˆÞÊ­ÇÈq™äÊŽ}®Ê
UÊÊÌ…>“LÕÌœÊ­ ®ÊnääÊ“}Ê*"Ê`>ˆÞÊ­{äqxxÊŽ}®Ê",Ê£ÓääÊ“}Ê*"Ê`>ˆÞÊ
­xÈqÇxÊŽ}®Ê",Ê£ÈääIÊ“}Ê*"Ê`>ˆÞÊ­ÇÈq™äÊŽ}®Ê
*Max dose regardless of weight.
UÊÊ*ÞÀˆ`œÝˆ˜iÊÓxÊ“}Ê*"Ê`>ˆÞʈÃÊÀiVœ““i˜`i`Ê̜ʫÀiÛi˜ÌÊ Ê>ÃÃœVˆ>Ìi`Ê
peripheral neuropathy in patients with HIV, malnutrition, alcohol abuse,
diabetes mellitus, renal failure or in pregnant or breastfeeding women.
Drug toxicity and monitoring
UÊÊÃœ˜ˆ>âˆ`\Ê>ÃÞ“«Ìœ“>̈VÊiiÛ>̈œ˜Êˆ˜Ê…i«>̈VÊi˜âÞ“iÃ]ÊÃiÀˆœÕÃÊ>˜`Êv>Ì>Ê
hepatitis, peripheral neurotoxicity
UÊÊ,ˆv>“«ˆ˜\ÊœÀ>˜}iÊ`ˆÃVœœÀ>̈œ˜ÊœvÊLœ`ÞÊyÕˆ`Ã]Ê…i«>̜̜݈VˆÌÞ]Ê«ÀÕÀˆÌˆÃÊ܈̅Ê
or without rash
UÊÊ*ÞÀ>∘>“ˆ`i\Ê…i«>̜̜݈VˆÌÞ]ʘœ˜}œÕÌÞÊ«œÞ>ÀÌ…À>}ˆ>]Ê>ÃÞ“«Ìœ“>̈VÊ
hyperuricemia, acute gouty arthritis
UÊÊÌ…>“LÕÌœ\ÊÀiÌÀœLՏL>ÀÊ>˜`Ê«iÀˆ«…iÀ>Ê˜iÕÀˆÌˆÃÊÊ
U œ˜ˆÌœÀˆ˜}\ÊL>Ãiˆ˜iÊ…i«>̈VÊÌÀ>˜Ã>“ˆ˜>ÃiÃ]ÊLˆˆÀÕLˆ˜]Ê>Ž>ˆ˜iÊ«…œÃ«…>Ì>Ãi]Ê
creatinine and CBC are recommended for all adults initiating TB treatment.
Monthly hepatic panel is recommended for patients with baseline
abnormalities, history of liver disease or viral hepatitis, chronic alcohol
consumption, HIV, IVDU, pregnancy or immediate post-partum state or
those taking other potentially hepatotoxic medications. Therapy should
be discontinued immediately if AST and ALT are 3 times the upper limit
of normal (ULN) in the presence of jaundice or hepatitis symptoms or 5
times the ULN in the absence of symptoms.
,iviÀi˜ViÃ\Ê
/-É-ÉÊÕˆ`iˆ˜iÃÊvœÀÊ`ˆ>}˜œÃˆÃÊœvÊ/ \Ê“ÊÊ,iëˆÀÊ>ÀiÊi`ÊÓäääƣȣ\£ÎÇÈ°
/-É-ÉÊÕˆ`iˆ˜iÃÊvœÀÊÌÀi>Ì“i˜ÌÊœvÊ/ \Ê7,ÆxÓ\,,‡££°Ê

98. 99
6.15 Sepsis with no clear source
Sepsis with no clear source
NOTE: Refer to specific sections of these guidelines for empiric
treatment recommendations for specific sources of infection
EMPIRIC TREATMENT
Cultures MUST be sent to help guide therapy.
UÊÊQ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“IÊ{°xÊ}Ê6Ê+ÈÊ",Êivi«ˆ“iIÊÓÊ}Ê6Ê+nRÊ
± Vancomycin (see dosing section, p. 150) (if at risk for MRSA) ±
Gentamicin (see dosing section, p. 146)
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\ÊQâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nÊ",ʈ«ÀœyœÝ>Vˆ˜Ê{ääÊ
“}Ê6Ê+nRÊPLUS Gentamicin (see dosing section, p. 146) PLUS
Vancomycin (see dosing section, p. 150)
*NOTE: If patient has history of ESBL-producing organism or has
suspected intra abdominal sepsis and recent prolonged exposure
(↓ 7 days) to Piperacillin/tazobactam or Cefepime, substitute with
Meropenem 1 g IV Q8H.
Risk factors for MRSA
UÊÊi˜ÌÀ>ÊÛi˜œÕÃÊV>Ì…iÌiÀʈ˜Ê«>Vi
UÊÊ"Ì…iÀʈ˜`Üiˆ˜}Ê…>À`Ü>ÀiÊ
UÊʘœÜ˜ÊVœœ˜ˆâ>̈œ˜Ê܈̅Ê,-
UÊÊ,iVi˜Ìʭ܈̅ˆ˜ÊÎÊ“œ˜Ì…îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`Ê…œÃ«ˆÌ>ˆâ>̈œ˜Ê>
2 weeks
UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}Ê…œ“iÊœÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ
UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi
TREATMENT NOTES
UÊÊœÀÊ«>̈i˜ÌÃÊ܈̅ÊÀi˜>Êˆ˜ÃÕvwVˆi˜VÞÊœÀÊ>“ˆ˜œ}ÞVœÃˆ`iʈ˜ÌœiÀ>˜Vi]Ê>Ê
beta-lactam may be combined with a fluoroquinolone IF 2 agents are
needed.
UÊÊ*œÌi˜Ìˆ>ÊÃœÕÀViÃÊ­i°}°]Ê«˜iÕ“œ˜ˆ>]Ê«iÀˆÌœ˜ˆÌˆÃ]ÊiÌV°®ÊÃ…œÕ`ÊLiÊ
considered when selecting therapy.
UÊÊ“«ˆÀˆVÊÌ…iÀ>«ÞʈÃÊ" 9Ê>««Àœ«Àˆ>ÌiÊÜ…ˆiÊVՏÌÕÀiÃÊ>ÀiÊ«i˜`ˆ˜}Ê
(72 hours max).
UÊÊ6>˜Vœ“ÞVˆ˜ÊÃ…œÕ`Ê>“œÃÌÊ>Ü>ÞÃÊLiÊÃÌœ««i`ʈvʘœÊÀiÈÃÌ>˜ÌÊÀ>“‡
positive organisms are recovered in cultures.

99. 100
6.16 Skin, soft-tissue, and bone infections
Skin, soft-tissue, and bone infections
Cellulitis
UÊʏÜ>ÞÃÊiiÛ>ÌiÊ>vviVÌi`ÊiÝÌÀi“ˆÌÞ°Ê/Ài>Ì“i˜ÌÊv>ˆÕÀiʈÃÊ“œÀiÊ
commonly due to failure to elevate than failure of antibiotics.
UÊÊ“«ÀœÛi“i˜ÌÊœvÊiÀÞÌ…i“>ÊV>˜ÊÌ>ŽiÊ`>ÞÃ]ÊiëiVˆ>Þʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê
lymphedema, because dead bacteria in the skin continue to induce
inflammation.
Non-suppurative cellulitis
Defined as cellulitis with intact skin and no evidence of purulent
drainage. Usually caused by beta-hemolytic streptococci (e.g. group A,
B, C, G streptococci) and MSSA.
TREATMENT
Oral (mild disease)
UÊ“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxÊ*"Ê+£Ó
OR
UÊi«…>i݈˜ÊxääÊ“}Ê*"Ê+È
OR
UÊ* Ê>iÀ}Þ\ʏˆ˜`>“ÞVˆ˜ÊÎääÊ“}Ê*"Ê+n
Parenteral (moderate to severe disease)
UÊ“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xÊ}Ê6Ê+È
OR
UÊiv>✏ˆ˜Ê£Ê}Ê6Ê+n
OR
UÊ* Ê>iÀ}Þ\ʏˆ˜`>“ÞVˆ˜ÊÈääÊ“}Ê6Ê+n
Duration: 5-7 days
TREATMENT NOTES
UʏÊLiÌ>‡…i“œÞ̈VÊÃÌÀi«ÌœVœVVˆÊ>ÀiÊÃÕÃVi«ÌˆLiÊ̜ʫi˜ˆVˆˆ˜
UÊʏˆ˜`>“ÞVˆ˜ÊÀiÈÃÌ>˜ViʈÃÊÃii˜Êˆ˜Ê£È‡ÎίʜvÊ}ÀœÕ«Ê ]Ê]Ê>˜`ÊÊÃÌÀi«Ê
LÕÌÊÀi“>ˆ˜ÃʏœÜʈ˜Ê}ÀœÕ«ÊÊÃÌÀi«Ê­{qǯ®
UÊÕÀ>̈œ˜\Êx‡ÇÊ`>ÞÃ
Suppurative cellulitis
Defined as cellulitis with purulent drainage or exudates in the absence of
a drainable abscess. Usually caused by S. aureus (MSSA and MRSA).
TREATMENT
Oral (mild disease)
UÊ/*É-8Ê£‡ÓÊ-ÊÌ>LÊ*"Ê
OR
UÊœÝÞVÞVˆ˜iÊ£ääÊ“}Ê*"Ê Ê",ʈ˜œVÞVˆ˜iÊ£ääÊ“}Ê*"Ê
OR
Uʏˆ˜`>“ÞVˆ˜ÊÎääÊ“}Ê*"Ê+n

100. 101
6.16 Skin, soft-tissue, and bone infections
OR
Uʏˆ˜`>“ÞVˆ˜ÊÈääÊ“}Ê6Ê+nÊ­ˆvÊ«>Ài˜ÌiÀ>ÊÌ…iÀ>«ÞʈÃʘii`i`®
Parenteral (moderate to severe disease)
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®
Duration: 5-7 days
TREATMENT NOTES
UÊÊ,iÈÃÌ>˜ViÊÌœÊyÕœÀœµÕˆ˜œœ˜iÃʈ˜ÊS. aureus is common and develops
µÕˆVŽÞÆÊÊ™x¯ÊœvÊ,-ʈ܏>ÌiÃÊ>ÀiÊÀiÈÃÌ>˜ÌÊÌœÊyÕœÀœµÕˆ˜œœ˜iðÊ
Monotherapy with fluoroquinolones for S. aureus infections is not
recommended.
UÊÊ,ˆv>“«ˆ˜ÊÃ…œÕ`Ê 6,ÊLiÊÕÃi`Ê>ÃÊ“œ˜œÌ…iÀ>«ÞÊLiV>ÕÃiÊÀiÈÃÌ>˜ViÊ
develops rapidly.
UÊÊ/…iÀiʈÃʘœÊiÛˆ`i˜ViÊÌ…>Ìʈ˜i✏ˆ`ʈÃÊÃÕ«iÀˆœÀÊÌœÊ/*É-8]Ê
Doxycycline, or Clindamycin in the management of skin infection or
osteomyelitis. Linezolid should only be considered when the S. aureus
isolate is resistant to or the patient is intolerant to these agents.
Less common causes of cellulitis
UÊÊ7ˆÌ…ÊLՏ>i]ÊÛiÈViÃ]Ê>˜`ÊՏViÀÃÊ>vÌiÀÊiÝ«œÃÕÀiÊÌœÊÃi>Ü>ÌiÀÊœÀÊÀ>ÜÊ
oysters, consider Vibrio vulnificus, especially in patients with liver
disease. Rare, but rapidly fatal if untreated. Treat with Ceftriaxone
1 g IV Q24H PLUS Doxycycline 100 mg PO BID.
UÊÊ iÕÌÀœ«i˜ˆV]ÊÃœˆ`ÊœÀ}>˜ÊÌÀ>˜Ã«>˜Ì]Ê>˜`ÊVˆÀÀ…œÌˆVÊ«>̈i˜ÌÃÊ“>ÞÊ
have cellulitis due to Gram-negative organisms. Consider expanding
coverage in these cases.
UÊÊvÊiÃV…>À]ÊVœ˜Ãˆ`iÀÊ>˜}ˆœˆ˜Û>ÈÛiÊœÀ}>˜ˆÃ“ÃÊ­ ,]Ê>ëiÀ}ˆœÃˆÃ]Ê“œ`®°Ê
ID consult is recommended.
UÊʘˆ“>Ê>˜`Ê…Õ“>˜ÊLˆÌiÃ\ÊPasteurella multocida should be covered in
cat and dog bites. Treat with Amoxicillin/clavulanate 875 mg PO BID
",Ê“«ˆVˆˆ˜ÉÃՏL>VÌ>“Ê£°xqÎÊ}Ê6Ê+È°ÊvÊ* Ê>iÀ}Þ\ʜ݈yœÝ>Vˆ˜Ê
400 mg PO/IV Q24H.
Cutaneous abscess

UÊʘVˆÃˆœ˜Ê>˜`Ê`À>ˆ˜>}iÊ­E®ÊˆÃÊÌ…iÊ«Àˆ“>ÀÞÊÌÀi>Ì“i˜ÌÊvœÀÊ>ÊVÕÌ>˜iœÕÃÊ
abscess.
UÊÊiÈœ˜ÃÊÌ…>ÌÊ>««i>ÀÊÃÕ«iÀwVˆ>ÊV>˜ÊœvÌi˜Ê…>ÛiÊ>ÃÃœVˆ>Ìi`Ê>LÃViÃÃÊ
formation that is not clearly appreciated without debridement of the
wound or, on occasion, additional imaging.
UÊÊÌÊÌ…iÊ̈“iÊœvÊE]Ê>ÊÃ>“«iÊÃ…œÕ`ÊLiÊœLÌ>ˆ˜i`ÊvœÀÊVՏÌÕÀiÊ>˜`Ê
sensitivity testing.
UÊÊœÃÌÊÃÌÕ`ˆiÃÊÌ…>ÌÊ…>ÛiÊLii˜Ê«ÕLˆÃ…i`ÊÌœÊ`>ÌiÊÃÕ}}iÃÌÊÌ…>ÌÊ>˜ÌˆLˆœÌˆVÃÊ
are adjunct to I&D in the management of uncomplicated skin
abscesses caused by CA-MRSA.

101. 102
6.16 Skin, soft-tissue, and bone infections
UÊʘ`ˆV>̈œ˜ÃÊvœÀÊ>˜Ìˆ“ˆVÀœLˆ>ÊÌ…iÀ>«Þʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊVÕÌ>˜iœÕÃÊ
>LÃViÃÃiÃ\
UÊÊ-iÛiÀiÊœÀÊÀ>«ˆ`ÞÊ«Àœ}ÀiÃÈÛiʈ˜viV̈œ˜Ã
UÊÊ/…iÊ«ÀiÃi˜ViÊœvÊiÝÌi˜ÃˆÛiÊ>ÃÃœVˆ>Ìi`ÊViÕˆÌˆÃ
UÊ-ˆ}˜ÃÊ>˜`ÊÃÞ“«Ìœ“ÃÊœvÊÃÞÃÌi“ˆVʈ˜iÃÃ
UÊÃÃœVˆ>Ìi`ÊÃi«ÌˆVÊ«…iLˆÌˆÃ
UÊʈ>LiÌiÃÊœÀʜ̅iÀʈ““Õ˜iÊÃÕ««ÀiÃÈœ˜
UÊ`Û>˜Vi`Ê>}i
UÊÊœV>̈œ˜ÊœvÊÌ…iÊ>LÃViÃÃʈ˜Ê>˜Ê>Ài>ÊÜ…iÀiÊVœ“«iÌiÊ`À>ˆ˜>}iʈÃÊ
difficult (e.g. face, genitalia)
UÊÊ>VŽÊœvÊÀi뜘ÃiÊ̜ʈ˜VˆÃˆœ˜Ê>˜`Ê`À>ˆ˜>}iÊ>œ˜i
UÊÊ/…iÀ>«ÞÊÃ…œÕ`ÊLiÊ}ˆÛi˜Êbefore incision and drainage in patients with
prosthetic heart valves or other conditions placing them at high risk
for endocarditis.
EMPIRIC TREATMENT
If antibiotic treatment is thought to be necessary, regimens are the
same as for suppurative cellulitis above.
Management of recurrent MRSA skin infections
1. Education regarding approaches to personal and hand
hygiene
UÊÊ*À>V̈ViÊvÀiµÕi˜ÌÊ…>˜`Ê…Þ}ˆi˜iÊ܈̅ÊÃœ>«Ê>˜`ÊÜ>ÌiÀÊ>˜`ÉœÀÊ
alcohol based hand gels, especially after touching infected skin or
wound bandages.
UÊÊœÛiÀÊ`À>ˆ˜ˆ˜}Êܜ՘`ÃÊ܈̅ÊVi>˜]Ê`ÀÞÊL>˜`>}iÃ
UÊʜʘœÌÊÃ…>ÀiÊ«iÀÃœ˜>ÊˆÌi“ÃÊ­i°}°ÊÀ>âœÀÃÆÊÕÃi`ÊÌœÜiÃÊ>˜`ÊVœÌ…ˆ˜}Ê
before washing)
UÊÊ,i}Տ>ÀÊL>Ì…ˆ˜}
UÊÊÛœˆ`Ê>ÊÃ…>Ûˆ˜}Ê
UÊÊ>Õ˜`iÀÊVœÌ…ˆ˜}]ÊÃ…iiÌÃ]ÊÌœÜiÃʈ˜Ê…œÌÌiÃÌÊÃÕˆÌ>LiÊÌi“«iÀ>ÌÕÀi
UÊʏi>˜Ê>Ê«iÀÃœ˜>ÊëœÀ̈˜}ÊVœÌ…ˆ˜}ÉiµÕˆ«“i˜ÌÊ
2. Decontamination of the environment
UÊʏi>˜Ê…ˆ}…ÊÌœÕV…Ê>Ài>Ãʈ˜ÊÌ…iÊL>Ì…Àœœ“Ê܈̅Ê>Ê`ˆÃˆ˜viVÌ>˜ÌÊ>V̈ÛiÊ
against S. aureusÊ`>ˆÞÊ­i°}°]Ê£ä¯Ê`ˆÕÌiÊLi>V…®°Ê
3. Topical decolonization (consider if a patient has ≥ 2 episodes
in 1 year or other household members develop infection)
UÊÊÕ«ˆÀœVˆ˜ÊÌ܈ViÊ`>ˆÞÊvœÀÊxÊ`>ÞÃÊ“>ÞÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ
܈̅Ê`œVÕ“i˜Ìi`ÊiÛˆ`i˜ViÊœvÊ,-ʘ>Ã>ÊVœœ˜ˆâ>̈œ˜ÆÊ
Mupirocin therapy should be initiated after resolution of acute
infection. Mupirocin should not be used in patients or patients’
family members who are not documented to have MRSA nasal
colonization.

102. 103
6.16 Skin, soft-tissue, and bone infections
UÊÊ >Ì…ˆ˜}ÊœÀÊÃ…œÜiÀˆ˜}Ê܈̅ÊV…œÀ…i݈`ˆ˜iÊœÀÊ…iÝ>V…œÀœ«…ˆ˜iÊ­œÀÊ
`ˆÕÌiÊLi>V…ÊL>̅îÊiÛiÀÞʜ̅iÀÊ`>ÞÊvœÀÊ£ÊÜiiŽÊÌ…i˜ÊÌ܈ViÊÜiiŽÞÆÊ
do not get these substances into ears or eyes
UÊÊ-ÞÃÌi“ˆVÊ>˜ÌˆLˆœÌˆVÃÊ>ÀiÊ "/ÊÀiVœ““i˜`i`ÊÃœiÞÊvœÀÊ`iVœœ˜ˆâ>̈œ˜
4. Evaluation of other family members
UÊʘÌÀ>‡v>“ˆÞÊÌÀ>˜Ã“ˆÃÈœ˜ÊÃ…œÕ`ÊLiÊ>ÃÃiÃÃi`Ê>˜`ʈvÊ«ÀiÃi˜Ì]Ê
all members should participate in hygiene and decolonization
strategies above, starting at that same time and after the acute
infection is controlled.
NOTE: Data on efficacy and durability of the decontamination and
decolonization strategies described above are limited.
,iviÀi˜ViÃ\
/*É-8ÊvœÀÊ,-\ʘ˜Ê˜ÌiÀ˜Êi`Ê£™™ÓÆ££Ç\Ιä‡n°
-ÊÕˆ`iˆ˜iÃÊvœÀÊÌÀi>Ì“i˜ÌÊœvÊ,-ʈ˜viV̈œ˜Ã\ʏˆ˜Ê˜viVÌʈÃÊÓ䣣ÆxÓ\£qÎn°Ê
̈œœ}ÞÊœvÊÃÕ««ÕÀ>̈ÛiÊViÕˆÌˆÃ\Êi`ˆVˆ˜iÊÓä£äÆn™\Ó£ÇqÓÓÈ°
Diabetic foot infections
EMPIRIC TREATMENT
Treatment depends on clinical severity
Infection Severity Clinical Manifestations
Uninfected No purulence or inflammation*
Mild Presence of purulence and 1 sign of inflammation*
and cellulitis (if present) 2 cm around ulcer limited to
skin or superficial subcutaneous tissue
Moderate Same as mild PLUSÊ>Ìʏi>ÃÌÊœ˜iÊœvÊÌ…iÊvœœÜˆ˜}\Ê 2
cm of cellulitis, lymphangitic streaking, spread beneath
the superficial fascia, deep tissue abscess, gangrene,
involvement of muscle, tendon, joint, or bone
Severe Any of above PLUS systemic toxicity or metabolic
instability
*erythema, pain, tenderness, warmth, induration
MILD INFECTIONS
Oral regimens
UÊÊ“œÝˆVˆˆ˜ÉV>ÛՏ>˜>ÌiÊnÇxÊ“}Ê*"Ê
OR
UÊÊi«…>i݈˜ÊxääÊ“}Ê*"Ê+
OR
UÊʏˆ˜`>“ÞVˆ˜ÊÎääÊ“}Ê*"Ê/Ê­VœÛiÀÃÊ,-®
Parenteral regimens
UÊʏˆ˜`>“ÞVˆ˜ÊÈääÊ“}Ê6Ê+nÊ­VœÛiÀÃÊ,-®
OR

103. 104
6.16 Skin, soft-tissue, and bone infections
UÊÊ"Ý>Vˆˆ˜Ê£‡ÓÊ}Ê6Ê+{
OR
UÊÊiv>✏ˆ˜Ê£Ê}Ê6Ê+n
MODERATE INFECTIONS
UÊÊÀÌ>«i˜i“Ê£Ê}Ê+Ó{
OR
UÊÊQˆ«ÀœyœÝ>Vˆ˜IÊxääÊ“}Ê*"Ê Ê",ʈ«ÀœyœÝ>Vˆ˜IÊ{ääÊ“}Ê6Ê+£ÓRÊ
PLUS ONEÊœvÊÌ…iÊvœœÜˆ˜}ÊQˆ˜`>“ÞVˆ˜ÊÈääÊ“}Ê6Ê+nÉÎääÊ“}Ê*"Ê
/Ê",ÊiÌÀœ˜ˆ`>✏iÊxääÊ“}Ê6É*"Ê/R
* BUT avoid fluoroquinolones in patients who were on them as
outpatients
If patient at risk for MRSA, add Vancomycin to regimens that do not
include Clindamycin.
Risk factors for MRSA
UÊʈÃÌœÀÞÊœvÊVœœ˜ˆâ>̈œ˜ÊœÀʈ˜viV̈œ˜Ê܈̅Ê,-
UÊÊ,iVi˜Ìʭ܈̅ˆ˜ÊÎÊ“œ˜Ì…îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`Ê…œÃ«ˆÌ>ˆâ>̈œ˜Ê€ÊÓÊ
weeks
UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}Ê…œ“iÊœÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ
UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi
SEVERE INFECTIONS
UÊÊ*ˆ«iÀVˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+È
OR
UÊÊQˆ«ÀœyœÝ>Vˆ˜IÊ{ääÊ“}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS
Clindamycin 600 mg IV Q8H
* Avoid fluoroquinolones in patients who were on them as outpatients.
If patient at risk for MRSA (see above)
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“Ê{°xÊ}Ê6Ê+ÈÊPLUS Vancomycin (see dosing
section, p. 150)
OR
UÊÊQˆ«ÀœyœÝ>Vˆ˜IÊ{ääÊ“}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS
Metronidazole 500 mg IV Q8H PLUS Vancomycin (see dosing section,
p. 150)
* Avoid fluoroquinolones in patients who were on them as outpatients
TREATMENT NOTES
Management
UÊÊʓՏ̈`ˆÃVˆ«ˆ˜>ÀÞÊ>««Àœ>V…Ê̜ʓ>˜>}i“i˜ÌÊÃ…œÕ`ʈ˜VÕ`iÊܜ՘`Ê
care consultation, assessment of vascular supply, vascular and/or
general surgery consultation and infectious diseases consultation.
UÊÊœ˜Ãˆ`iÀʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃʈ˜Ê«>̈i˜ÌÃÊÜ…œÊ>ÀiÊÃiÛiÀiÞʈ°
UÊʘ̈LˆœÌˆVÊÌ…iÀ>«ÞÊÃ…œÕ`ÊLiʘ>ÀÀœÜi`ÊL>Ãi`Êœ˜ÊVՏÌÕÀiÊÀiÃՏÌð

104. 105
6.16 Skin, soft-tissue, and bone infections
Microbiology
UÊÊiÕˆÌˆÃÊ܈̅œÕÌÊœ«i˜Êܜ՘`ÊœÀʈ˜viVÌi`ÊՏViÀ]Ê>˜ÌˆLˆœÌˆVʘ>‹Ûi\Ê
beta-hemolytic streptococci, S. aureus
UÊʘviVÌi`ÊՏViÀ]ÊV…Àœ˜ˆVÊœÀÊ«ÀiÛˆœÕÏÞÊÌÀi>Ìi`Ê܈̅Ê>˜ÌˆLˆœÌˆVÃ\ÊS. aureus,
beta-hemolytic streptococci, Enterobacteriaceae
UÊÊÝ«œÃÕÀiÊÌœÊÃœ>Žˆ˜}]ÊÜ…ˆÀ«œœ]Ê…œÌÊÌÕL\ÊÕÃÕ>ÞÊ«œÞ“ˆVÀœLˆ>]Ê“>ÞÊ
involve Pseudomonas
UÊÊ…Àœ˜ˆVÊܜ՘`ÃÊ܈̅ʫÀœœ˜}i`ÊiÝ«œÃÕÀiÊÌœÊ>˜ÌˆLˆœÌˆVÃ\Ê>iÀœLˆVÊÀ>“‡
positive cocci (GPC), Diphtheroids, Enterobacteriaceae, other Gram-
negative rods (GNR) including Pseudomonas
UÊÊ iVÀœÃˆÃÊœÀÊ}>˜}Ài˜i\Ê“ˆÝi`Ê>iÀœLˆVÊ*Ê>˜`Ê ,]Ê>˜>iÀœLiÃ
Diagnosis
UÊÊՏÌÕÀiÃÊœvÊÌ…iÊՏViÀÊL>ÃiÊ>vÌiÀÊ`iLÀˆ`i“i˜ÌÊV>˜Ê…i«Ê}Õˆ`iÊÌ…iÀ>«Þ°Ê
Biopsy of unexposed bone is NOT recommended. Avoid swabbing
non-debrided ulcers or wound drainage.
UÊÊ1ViÀÊyœœÀÊÃ…œÕ`ÊLiÊ«ÀœLi`ÊV>ÀivՏÞ°ÊvÊLœ˜iÊV>˜ÊLiÊÌœÕV…i`Ê܈̅Ê>Ê
metal probe then the patient should be treated for osteomyelitis with
antibiotics in addition to surgical debridement.
UÊÊ*>˜Ì>ÀÊv>ÃVˆˆÌˆÃÊ>˜`Ê>Ê`ii«ÊvœœÌ‡Ã«>Viʈ˜viV̈œ˜ÊV>˜ÊLiÊ«ÀiÃi˜Ì°Ê
Consider imaging to look for deep infections.
UÊÊ*ÕÌÀˆ`Ê`ˆÃV…>À}iʈÃÊ`ˆ>}˜œÃ̈VÊœvÊÌ…iÊ«ÀiÃi˜ViÊœvÊ>˜>iÀœLið
UÊÊÊ ,ʈÃÊ“œÀiÊÃi˜ÃˆÌˆÛiÊ>˜`ÊëiVˆwVÊÌ…>˜ÊœÌ…iÀÊ“œ`>ˆÌˆiÃÊvœÀÊ`iÌiV̈œ˜Ê
of soft-tissue lesions and osteomyelitis.
Duration
UÊÊÕÀ>̈œ˜ÊœvÊÌÀi>Ì“i˜ÌÊ܈Ê`i«i˜`Êœ˜ÊÀ>«ˆ`ˆÌÞÊœvÊÀi뜘ÃiÊ>˜`Ê
presence of adequate blood supply.
UÊʈŽiÞʘii`ÊÃ…œÀÌiÀÊÌÀi>Ì“i˜ÌÊ܈̅Ê>`iµÕ>ÌiÊÃÕÀ}ˆV>Êˆ˜ÌiÀÛi˜Ìˆœ˜Ê
­Çq£äÊ`>ÞÃÊ«œÃ̇œ«®Ê>˜`ʏœ˜}iÀÊvœÀÊœÃÌiœ“ÞiˆÌˆÃ°
UÊÊ…>˜}iÊ̜ʜÀ>ÊÀi}ˆ“i˜ÊÜ…i˜Ê«>̈i˜ÌʈÃÊÃÌ>Li°
,iviÀi˜Vi\
-ÊÕˆ`iˆ˜iÃÊvœÀÊ`ˆ>LïVÊvœœÌʈ˜viV̈œ˜°Êˆ˜Ê˜viVÌʈÃÊÓä£ÓÆx{\£ÎÓ‡£Çΰ
Surgical-site infections (SSI)
EMPIRIC TREATMENT
Infections following clean procedures (e.g. orthopedic joint
replacements, open reduction of closed fractures, vascular procedures,
median sternotomy, craniotomy, breast and hernia procedures)
UÊÊ"Ý>Vˆˆ˜Ê£qÓÊ}Ê6Ê+{
OR
UÊÊiv>✏ˆ˜Ê£Ê}Ê6Ê+n
OR

105. 106
6.16 Skin, soft-tissue, and bone infections
UÊÊ* Ê>iÀ}Þ\ʏˆ˜`>“ÞVˆ˜ÊÈääÊ“}Ê6Ê+n
OR
UÊʘۜÛi“i˜ÌÊœvÊ…>À`Ü>ÀiÊœÀÊ,-ÊÃÕëiVÌi`\Ê6>˜Vœ“ÞVˆ˜Ê
(see dosing section, p. 150)
Exception: Saphenous vein graft harvest site infections should be
treated with Ertapenem 1 g IV Q24H
Infections following contaminated procedures (GI/GU procedures,
oropharyngeal procedures, obstetrical and gynecology procedures)
Patients not on broad-spectrum antibiotics at time of surgery and
not severely ill
UÊÊÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊ* Ê>iÀ}Þ\ÊQˆ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê Ê",ʈ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê
6Ê+£ÓRÊPLUS Clindamycin 600 mg IV Q8H
Patients on broad-spectrum antibiotics at time of surgery or
severely ill
UÊÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+ÈÊ´Ê6>˜Vœ“ÞVˆ˜Ê
(see dosing section, p. 150) (if hardware present or MRSA suspected)
OR
UÊÊ œ˜‡ÃiÛiÀiÊ* Ê>iÀ}Þ\Êivi«ˆ“iÊ£Ê}Ê6Ê+nÊPLUS Metronidazole
xääÊ“}Ê6Ê+nÊ´Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}]Ê«°Ê£xä®Ê­ˆvÊ…>À`Ü>ÀiÊ
present or MRSA suspected)
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Qˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+nÊ",ÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nRÊPLUS
Metronidazole 500 mg IV/PO Q8H
Deep fascia involvement
UÊÊ/Ài>ÌÊ>ÃʘiVÀœÌˆâˆ˜}Êv>ÃVˆˆÌˆÃÊ­ÃiiÊÃÕLÃiµÕi˜ÌÊÃiV̈œ˜®
TREATMENT NOTES
Microbiology
UÊÊœœÜˆ˜}ÊVi>˜Ê«ÀœVi`ÕÀiÃÊ­˜œÊi˜ÌÀÞÊœvÊÉ1ÊÌÀ>VÌî
UÊÊStaphylococcus aureus
UÊÊ-ÌÀi«ÌœVœVVˆ]Ê}ÀœÕ«ÊÊ­iëiVˆ>ÞÊ܈̅Êi>ÀÞÊœ˜ÃiÌ]ʐÊÇÓÊ…œÕÀî
UÊÊœ>}Տ>Ãi‡˜i}>̈ÛiÊÃÌ>«…ޏœVœVVˆ
UÊÊœœÜˆ˜}ÊVi>˜‡Vœ˜Ì>“ˆ˜>Ìi`Ê>˜`ÊVœ˜Ì>“ˆ˜>Ìi`Ê«ÀœVi`ÕÀiÃÊ­i˜ÌÀÞÊœvÊ
GI/GU tracts with or without gross contamination)
UÊÊ"À}>˜ˆÃ“ÃÊ>LœÛi
UÊÊÀ>“‡˜i}>̈ÛiÊÀœ`Ã
UÊʘ>iÀœLiÃÊ­Vœ˜Ãˆ`iÀÊClostridiaÊ뫰ʈ˜Êi>ÀÞ‡œ˜ÃiÌʈ˜viV̈œ˜]Ê£qÓÊ
days)

106. 107
6.16 Skin, soft-tissue, and bone infections
UÊÊi˜iÀ>Þ]Êi“«ˆÀˆVÊÕÃiÊœvÊ6>˜Vœ“ÞVˆ˜ÊˆÃʘœÌʈ˜`ˆV>Ìi`ÊLiV>ÕÃiÊÌ…iÊ
percentage of SSIs caused by MRSA is low at Johns Hopkins Hospital
­£äqÓ䯮
Risk factors for MRSA
UʈÃÌœÀÞÊœvÊVœœ˜ˆâ>̈œ˜ÊœÀʈ˜viV̈œ˜Ê܈̅Ê,-
UÊÊ,iVi˜Ìʭ܈̅ˆ˜ÊÎÊ“œ˜Ì…îʜÀÊVÕÀÀi˜ÌÊ«Àœœ˜}i`Ê…œÃ«ˆÌ>ˆâ>̈œ˜Ê€ÓÊ
weeks
UÊÊ/À>˜ÃviÀÊvÀœ“Ê>ʘÕÀȘ}Ê…œ“iÊœÀÊÃÕL>VÕÌiÊv>VˆˆÌÞ
UÊʘiV̈œ˜Ê`ÀÕ}ÊÕÃi
Other management issues
UÊÊ>˜ÞÊ>`ÛœV>ÌiÊÌ…>ÌÊʈ˜viVÌi`Êܜ՘`ÃÊLiÊiÝ«œÀi`ÊLœÌ…ÊÌœÊ`iLÀˆ`iÊ
and to assess depth of involvement.
UÊÊ-Õ«iÀwVˆ>Êˆ˜viV̈œ˜ÃÊ“>ÞÊLiÊ>`iµÕ>ÌiÞÊÌÀi>Ìi`Ê܈̅Ê`iLÀˆ`i“i˜ÌÊ
alone.
UÊÊii«iÀʈ˜viV̈œ˜ÃÊ­ViÕˆÌˆÃ]Ê«>˜˜ˆVՏˆÌˆÃ®Ê˜ii`Ê>`Õ˜V̈ÛiÊ>˜ÌˆLˆœÌˆVð
UÊʘviV̈œ˜ÃÊÌ…>ÌÊiÝÌi˜`ÊÌœÊÌ…iÊv>ÃVˆ>ÊÃ…œÕ`ÊLiÊ“>˜>}i`Ê>ÃʘiVÀœÌˆâˆ˜}Ê
fasciitis.
UÊÊ*>̈i˜ÌÃÊ܈̅ʅޫœÌi˜Ãˆœ˜ÊÃ…œÕ`Ê…>ÛiÊÌ…iˆÀÊܜ՘`ÃÊiÝ«œÀi`ÊiÛi˜ÊˆvÊ
they are unremarkable on physical exam.
Serious, deep-tissue infections (necrotizing fasciitis)
THESE ARE SURGICAL EMERGENCIES!
ANTIBIOTICS ARE ONLY AN ADJUNCT TO PROMPT
DEBRIDEMENT!
ID should also be consulted
EMPIRIC TREATMENT (adjunct to surgery)
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUSÊQ*ˆ«iÀ>Vˆˆ˜ÉÊ
Ì>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+ÈÊ",Êivi«ˆ“iÊ£Ê}Ê6Ê+nRÊPLUS
Clindamycin 600-900 mg IV Q8H
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS
Qˆ«ÀœyœÝ>Vˆ˜Ê{ääÊ“}Ê6Ê+nÊ´Êi˜Ì>“ˆVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê
«°Ê£{È®RÊPLUS Clindamycin 600-900 mg IV Q8H
TREATMENT NOTES
Conventional nomenclature and microbiology
Pyomyositis
UÊÊS. aureus most commonly
UÊʏœÃÌÀˆ`ˆ>Ê“Þœ˜iVÀœÃˆÃÊqÊClostridia spp. (esp. C. perfringens)
UÊÊÀœÕ«ÊÊÃÌÀi«ÌœVœVV>Ê“Þœ˜iVÀœÃˆÃ

107. 108
6.16 Skin, soft-tissue, and bone infections
Fasciitis
UÊÊ/Þ«iÊ£ÊqÊ*œÞ“ˆVÀœLˆ>Êˆ˜viV̈œ˜ÃÊ܈̅Ê>˜>iÀœLiÃ]ÊÃÌÀi«ÌœVœVVˆÊ>˜`Ê
Gram-negative rods (Fournier’s gangrene is a type 1 necrotizing
fasciitis of the perineum)
UÊÊ/Þ«iÊÓÊqÊÀœÕ«ÊÊÃÌÀi«ÌœVœVVˆÊ«Ài`œ“ˆ˜>Ìi
UÊÊ>ÃiÃÊœvÊv>ÃVˆˆÌˆÃÊV>ÕÃi`ÊLÞÊVœ““Õ˜ˆÌÞ‡>ÃÃœVˆ>Ìi`Ê,-ÊÃÌÀ>ˆ˜ÃÊ…>ÛiÊ
been reported
Diagnosis
UÊÊ>˜ÊLiÊ`ˆvwVՏÌÊqÊ}>ÃÊ«Àœ`ÕV̈œ˜ÊˆÃʘœÌÊÕ˜ˆÛiÀÃ>Ê>˜`ʈÃÊ}i˜iÀ>ÞÊ
absent in streptococcal diseases.
UÊÊ>ˆ˜Ì>ˆ˜Ê…ˆ}…ʈ˜`iÝÊœvÊÃÕëˆVˆœ˜ÊÜ…i˜\
UÊÊ*>̈i˜ÌÃÊ>ÀiÊÛiÀÞʈÊvÀœ“ÊViÕˆÌˆÃÊ­…Þ«œÌi˜Ãˆœ˜]Ê̜݈VÊ>««i>À>˜Vi®
UÊÊ*>ˆ˜ÊœÕÌÊœvÊ«Àœ«œÀ̈œ˜Ê̜ʫ…ÞÈV>Êw˜`ˆ˜}Ã
UÊʘiÃÌ…iÈ>ÊœÛiÀÊ>vviVÌi`Ê>Ài>
UÊÊ,ˆÃŽÊv>VÌœÀÃÊÃÕV…Ê>ÃÊ`ˆ>LiÌiÃ]ÊÀiVi˜ÌÊÃÕÀ}iÀÞÊœÀÊœLiÈÌÞ
UÊʈ˜`ˆ˜}ÃÊÃÕV…Ê>ÃÊÃŽˆ˜Ê˜iVÀœÃˆÃÊœÀÊLՏ>i
UÊÊ*ÕÌÀˆ`Ê`ˆÃV…>À}iÊ܈̅ÊÌ…ˆ˜]ʺ`ˆÃ…Ü>ÌiÀ»Ê«ÕÃ
UÊÊ/ÊÃV>˜ÊV>˜Ê…i«Ê܈̅Ê`ˆ>}˜œÃˆÃÊLÕÌʈvÊÃÕëˆVˆœ˜ÊˆÃÊ“œ`iÀ>ÌiÊ̜ʅˆ}…]Ê
surgical exploration is the preferred diagnostic test. DO NOT delay
surgical intervention to obtain CT.
,iviÀi˜Vi\
-Ê}Õˆ`iˆ˜iÃÊvœÀÊ--/\ʏˆ˜Ê˜viVÌʈÃÊÓääxÆÊ{£\£ÎÇÎq{äÈ°
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 antibiotics until samples of abscess or bone can be
obtained for Gram-stain and culture.
EMPIRIC TREATMENT
UÊÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê±ÊQivÌÀˆ>Ýœ˜iÊÓÊ}Ê+£ÓÊOR
ivi«ˆ“iÊÓÊ}Ê6Ê+nRÊ
OR
UÊÊ-iÛiÀiÊ* Ê>iÀ}Þ\Ê6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®Ê±
Ciprofloxacin 400 mg IV Q8H
UÊ >ÀÀœÜÊÌ…iÀ>«ÞÊL>Ãi`Êœ˜ÊVՏÌÕÀiÊÀiÃՏÌð
TREATMENT NOTES
Microbiology
UÊÀ>“‡«œÃˆÌˆÛiÊVœVVˆÊˆ˜ÊÇx¯ÊœvÊV>ÃiÃÊ܈̅ʓ>œÀˆÌÞÊS. aureus
UÊÀ>“‡˜i}>̈ÛiÊÀœ`Ãʈ˜ÊH£ä¯

108. 109
6.16 Skin, soft-tissue, and bone infections
Management
UÊÊ"LÌ>ˆ˜ÊÌÜœÊÃiÌÃÊœvÊLœœ`ÊVՏÌÕÀiÃ]Ê-,]Ê>˜`Ê,*Ê«ÀˆœÀÊÌœÊÃÌ>À̈˜}Ê
antibiotic therapy.
UÊÊœÃÌʈ˜ÌÀ>Ûi˜œÕÃÊ`ÀÕ}ÊÕÃiÀÃÊ>˜`Ê«>̈i˜ÌÃÊ܈̅œÕÌÊÈ}˜ˆwV>˜ÌÊ
co-morbidities do not require empiric coverage for Gram-negative
rods.
UÊÊ“«ˆÀˆVÊÀ>“‡˜i}>̈ÛiÊVœÛiÀ>}iÊÃ…œÕ`ÊLiÊÕÃi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê`ˆ>LiÌiÃ]Ê
hard ware in place or recent surgery, and recurrent urinary tract infections.
UÊ,Ê܈̅ÊVœ˜ÌÀ>ÃÌʈÃÊÌ…iʈ“>}ˆ˜}Ê“iÌ…œ`ÊœvÊV…œˆVi°
UÊÊvÊLœœ`ÊVՏÌÕÀiÃÊ>Àiʘi}>̈ÛiÊ/Ê}Õˆ`i`ʘii`iÊLˆœ«ÃÞÉ>ëˆÀ>̈œ˜Ê
should be obtained for Gram stain and cultures.
UÊÊ“iÀ}i˜ÌÊÃÕÀ}ˆV>ÊVœ˜ÃՏÌ>̈œ˜ÊˆÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅Ê
signs and symptoms of spinal cord compromise.
UÊÊ-ÕÀ}ˆV>ÊÌ…iÀ>«ÞʈÃÊ«ÀiviÀÀi`ʈ˜Ê“>˜ÞÊV>ÃiÃÊœvÊi«ˆ`ÕÀ>Ê>LÃViÃÃÉÊ
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.
UÊÊ*>̈i˜ÌÃÊÃ…œÕ`Ê…>ÛiÊvÀiµÕi˜ÌÊ>ÃÃiÃÓi˜ÌÊœvʘiÕÀœœ}ˆVÊvÕ˜V̈œ˜]Ê
particularly at the time of initial presentation.
UÊʏÊ«>̈i˜ÌÃÊÀiµÕˆÀiÊ“œ˜ˆÌœÀˆ˜}ÊvœÀÊ>`iµÕ>ÌiÊÀi뜘ÃiÊÌ…ÀœÕ}…œÕÌÊÌ…iÊ
ÌÀi>Ì“i˜ÌÊVœÕÀÃiÆÊÊvœœÜÊÕ«Ê…ˆ}…ÞÊÀiVœ““i˜`i`°Ê
Duration
UÊ«ˆ`ÕÀ>Ê>LÃViÃÃÊ܈̅œÕÌÊœÃÌiœ“ÞiˆÌˆÃ\Ê{qÈÊÜiiŽÃÊ
UÊ6iÀÌiLÀ>ÊœÃÌiœ“ÞiˆÌˆÃʱÊi«ˆ`ÕÀ>Ê>LÃViÃÃ\ÊÈq£ÓÊÜiiŽÃÊ
UÊʘʫ>̈i˜ÌÃÊ܈̅ʅ>À`Ü>ÀiÊ«ÀiÃi˜ÌÊ«Àœœ˜}i`ÊœÀ>ÊÃÕ««ÀiÃÈÛiÊÌ…iÀ>«ÞÊ
ˆÃÊ}i˜iÀ>ÞÊÀiµÕˆÀi`Ê>vÌiÀÊVœ“«ïœ˜ÊœvÊ6Ê>˜ÌˆLˆœÌˆVÃÆÊÌ…iÃiÊ`iVˆÃˆœ˜ÃÊ
should be made in consultation with infectious diseases.
,iviÀi˜ViÃ\Ê
-«ˆ˜>Êi«ˆ`ÕÀ>Ê>LÃViÃÃ\Ê Ê˜}ÊÊi`ÊÓääÈÆÎxx\Óä£ÓqÓä°Ê
-«ˆ˜>Êi«ˆ`ÕÀ>Ê>LÃViÃÃ\Ê+ÊÊi`ÊÓäänÆ£ä£\£q£Ó°Ê

109. 110
6.17 Urinary tract infections
Bacterial urinary tract infections (UTI)
M
anagement of patients WITHOUT a urinary catheter
NOTE: Ciprofloxacin is not recommended for empiric treatment for in-patients with non-catheter associated UTI at JHH due to the low ra te of E. coli
ÃÕÃVi«ÌˆLˆˆÌÞÊ­Ç£¯®°Ê
Positive urine culture ↓ 100,000 CFU/mL
with no signs or symptoms
Signs and symptoms (e.g. dysuria, urgency
frequency, suprapubic pain)
AND pyuria (>10 WBC/hpf )
AND positive urine culture ↓100,000
CFU/mL
UÊÊ Uncomplicated: female, no urologic
abnormalities, no stones, no catheter
UÊÊ Complicated: male gender, possible
stones, urologic abnormalities, pregnancy





œÊÌÀi>Ì“i˜ÌÊÕ˜iÃÃÊÌ…iÊ«>̈i˜ÌʈÃ\
UÊ*Ài}˜>˜ÌÊ
UÊÊ LœÕÌÊÌœÊÕ˜`iÀ}œÊ>ÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÊ
UÊ*œÃÌÊÀi˜>ÊÌÀ>˜Ã«>˜Ì
UÊ iÕÌÀœ«i˜ˆV
1˜Vœ“«ˆV>Ìi`\
UÊÊ ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­>VÀœLˆ`
®
) 100 mg PO Q12H for
xÊ`>ÞÃÊ­ "/ʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊÀÊxäÊ“É“ˆ˜®
OR
UÊÊ i«…>i݈˜ÊxääÊ“}Ê*"Ê+ÈÊvœÀÊxÊ`>ÞÃÊ
OR
UÊÊ iv«œ`œÝˆ“iÊ£ääÊ“}Ê*"Ê+£ÓÊvœÀÊxÊ`>ÞÃÊ
OR
UÊÊ iv`ˆ˜ˆÀÊÎääÊ“}Ê*"Ê+£ÓÊvœÀÊxÊ`>ÞÃÊ
OR
UÊÊ Ê /*É-8Ê£Ê-ÊÌ>LÊ*"Ê+£ÓÊvœÀÊÎÊ`>ÞÃ
OR
UÊÊ 6Êœ«Ìˆœ˜\Êiv>✏ˆ˜Ê£Ê}Ê6Ê+nÊvœÀÊÎÊ`>ÞÃ
œ“«ˆV>Ìi`\
UÊÊ ->“iÊÀi}ˆ“i˜ÃÊ>ÃÊ>LœÛiÊiÝVi«ÌÊ`ÕÀ>̈œ˜ÊˆÃÊ
Çq£{Ê`>ÞÃ
UÊÊ "LÌ>ˆ˜ˆ˜}ÊÀœṎ˜iÊVՏÌÕÀiÃʈ˜Ê>ÃÞ“«Ìœ“>̈VÊ«>̈i˜ÌÃʈÃÊ
not recommended
UÊÊ ˜ÌˆLˆœÌˆVÃÊ`œÊ˜œÌÊ`iVÀi>ÃiÊ>ÃÞ“«Ìœ“>̈VÊL>VÌiÀˆÕÀˆ>ÊœÀÊ
prevent subsequent development of UTIs
UÊÊÊ/…iÊ«ÀiÛ>i˜ViÊœvÊ>ÃÞ“«Ìœ“>̈VÊL>VÌiÀˆÕÀˆ>ʈÃÊ
…ˆ}…\Ê£¯‡x¯Êˆ˜Ê«Ài“i˜œ«>ÕÃ>ÊÜœ“i˜]Êί‡™¯Êˆ˜Ê
«œÃÌ“i˜œ«>ÕÃ>ÊÜœ“i˜]Ê{䯇xä¯Êˆ˜Êœ˜}‡ÌiÀ“ÊV>ÀiÊ
ÀiÈ`i˜ÌÃÊ>˜`Ê™¯‡Óǯʈ˜ÊÜœ“i˜Ê܈̅Ê`ˆ>LiÌið
UÊÊ 1/Ãʈ˜Ê“i˜Ê>ÀiÊÌÀ>`ˆÌˆœ˜>ÞÊVœ˜Ãˆ`iÀi`ÊVœ“«ˆV>Ìi`°Ê
UTIs in men in the absence of obstructive pathology
(e.g. BPH, stones, strictures) are uncommon. Please
critically evaluate your diagnosis of UTI in male patients.
UÊÊ "À>ÊÌ…iÀ>«ÞʈÃÊ«ÀiviÀÀi`Ê>˜`ÊÃ…œÕ`ÊLiÊ}ˆÛi˜ÊÕ˜iÃÃÊ
patient is unable to tolerate oral therapy
UÊÊ vÊ6ÊLiÌ>‡>VÌ>“ÃÊ>ÀiÊÕÃi`Êi“«ˆÀˆV>ÞÊvœÀÊÎÊ`>ÞÃ]ʘœÊ
additional therapy is needed for uncomplicated cystitis
UÊÊ vÊ6ÊLiÌ>‡>VÌ>“ÃÊ>ÀiÊÕÃi`Êi“«ˆÀˆV>ÞÊvœÀʐÎÊ`>ÞÃÊ
or treating complicated cystitis, the patient can be
switched to an appropriate oral beta-lactam and duration
of IV therapy should be counted towards total duration
of therapy
UÊÊ "À>ÊœÃvœ“ÞVˆ˜ÊV>˜ÊLiÊÕÃi`ʈvÊÃÕÃVi«ÌˆLiÊvœÀÊÀ>“‡
negative MDR organisms (susceptibilities must be
requested)
Category Definition Empiric treatment Notes
Asymptomatic
bacteriuria

Acute cystitis

110. 111
6.17 Urinary tract infections
Signs and symptoms (e.g. fever, flank pain)
AND pyuria
AND positive urine culture 100,000
CFU/mL
Many patients will have other evidence of
upper tract disease (i.e. leukocytosis,
WBC casts, or abnormal i ties upon imaging)
SIRS with urinary source of infection
UÊÊ ivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊÊ ÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{Ê­ˆvÊ…ˆÃÌœÀÞÊœvÊ- ®
OR
UÊÊ * Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ",Ê
Gentamicin (see dosing section, p. 147)
UÊÊ ÕÀ>̈œ˜\ÊÇq£{Ê`>ÞÃ
Hospitalized > 48H
UÊÊ ivi«ˆ“iÊ£Ê}Ê6Ê+n
OR
UÊÊ * Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ",Ê
Gentamicin (see dosing section, p. 147)
UÊÕÀ>̈œ˜\ÊÇq£{Ê`>ÞÃ
UÊÊ ivi«ˆ“iÊ£Ê}Ê6Ê+n
OR
UÊÊ * Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+nÊ´Ê
Gentamicin (see dosing section, p. 147)
UÊÕÀ>̈œ˜\ÊÇq£äÊ`>ÞÃ
UÊÊ "À>ÊÃÌi«‡`œÜ˜ÊÌ…iÀ>«ÞÊÃ…œÕ`ÊLiÊÕÃi`ʈvÊœÀ}>˜ˆÃ“ʈÃÊ
susceptible
UÊÊ ÕÀ>̈œ˜ÊœvÊi“«ˆÀˆVÊ6ÊÌ…iÀ>«ÞÊÃ…œÕ`ÊLiÊVœÕ˜Ìi`Ê
towards total duration of therapy
"À>ÊÃÌi«‡`œÜ˜ÊÌ…iÀ>«ÞʈvÊœÀ}>˜ˆÃ“ʈÃÊÃÕÃVi«ÌˆLi\
Uʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê+£ÓÊvœÀÊÇÊ`>ÞÃÊ
UÊ/*É-8Ê£Ê-Ê*"Ê+£ÓÊvœÀÊLJ£äÊ`>ÞÃÊ
UÊiv«œ`œÝˆ“iÊ{ääÊ“}Ê*"Ê+£ÓÊvœÀÊ£{Ê`>ÞÃÊ
UÊÊ "À>ÊœÃvœ“ÞVˆ˜ÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈvÊÃÕÃVi«ÌˆLiÊvœÀÊ
Gram-negative MDR organisms (susceptibilities must be
requested). Consult ID Pharmacist for dosing.
UÊÊ "À>Êˆ«ÀœyœÝ>Vˆ˜ÊœÀÊ/*É-8Ê…>ÛiÊiÝVii˜ÌÊ
bioavailability and should be used as step-down therapy
if organism is susceptible
UÊÊ "À>ÊLiÌ>‡>VÌ>“ÃÊÃ…œÕ`ʘœÌÊLiÊÕÃi`ÊvœÀÊL>VÌiÀi“ˆ>Ê
due to inadequate blood concentrations
UÊÊ ÕÀ>̈œ˜ÊœvÊi“«ˆÀˆVÊ6ÊÌ…iÀ>«ÞÊÃ…œÕ`ÊLiÊVœÕ˜Ìi`Ê
towards total duration of therapy
Category Definition Empiric treatment Notes
Acute
pyelonephritis











Urosepsis

111. 112
6.17 Urinary tract infections
DIAGNOSIS
Specimen collection\Ê/…iÊÕÀiÌ…À>Ê>Ài>ÊÃ…œÕ`ÊLiÊVi>˜i`Ê܈̅Ê>˜Ê
antiseptic cloth and the urine sample should be collected midstream
or obtained by fresh catheterization. Specimens collected using
a drainage bag or taken from a collection hat are not reliable and
should not be sent.
Interpretation of the urinalysis (U/A) and urine culture
UÊÊ1Àˆ˜>ÞÈÃÊ>˜`ÊÕÀˆ˜iÊVՏÌÕÀiÃÊ“ÕÃÌÊLiʈ˜ÌiÀ«ÀiÌi`ÊÌœ}iÌ…iÀʈ˜Ê
context of symptoms
UÊUrinalysis/microscopy:
UÊʈ«Ã̈VŽ
UÊ ˆÌÀˆÌiÃʈ˜`ˆV>ÌiÊL>VÌiÀˆ>ʈ˜ÊÌ…iÊÕÀˆ˜i
UÊiÕŽœVÞÌiÊiÃÌiÀ>Ãiʈ˜`ˆV>ÌiÃÊÜ…ˆÌiÊLœœ`ÊViÃʈ˜ÊÌ…iÊÕÀˆ˜i
UÊÊ >VÌiÀˆ>\Ê«ÀiÃi˜ViÊœvÊL>VÌiÀˆ>Êœ˜ÊÕÀˆ˜>ÞÈÃÊÃ…œÕ`ÊLiÊ
interpreted with caution and is not generally useful
UÊÊ*ÞÕÀˆ>Ê­“œÀiÊÃi˜ÃˆÌˆÛiÊÌ…>˜ÊiÕŽœVÞÌiÊiÃÌiÀ>Ãi®\Ê€£äÊ7 É…«vÊœÀÊ
>27 WBC/microliter
UÊ1Àˆ˜iÊVՏÌÕÀiÃ\
UÊÊvÊ1ÉʈÃʘi}>̈ÛiÊvœÀÊ«ÞÕÀˆ>]Ê«œÃˆÌˆÛiÊVՏÌÕÀiÃÊ>ÀiʏˆŽiÞÊ
contamination
UÊÊœÃÌÊ«>̈i˜ÌÃÊ܈̅Ê1/Ê܈Ê…>ÛiÊ100,000 colonies of a
uropathogen. Situations in which lower colony counts may be
È}˜ˆwV>˜Ìʈ˜VÕ`i\Ê«>̈i˜ÌÃÊÜ…œÊ>ÀiÊ>Ài>`ÞÊœ˜Ê>˜ÌˆLˆœÌˆVÃÊ>ÌÊÌ…iÊ
time of culture, symptomatic young women, suprapubic aspiration,
and men with pyuria.
TREATMENT NOTES
UÊÊ*ÞÕÀˆ>ÊiˆÌ…iÀʈ˜ÊÌ…iÊÃiÌ̈˜}Êœvʘi}>̈ÛiÊÕÀˆ˜iÊVՏÌÕÀiÃÊœÀʈ˜Ê«>̈i˜ÌÃÊ
with asymptomatic bacteriuria usually requires no treatment. If
pyuria persists consider other causes (e.g. interstitial nephritis or
cystitis, fastidious organisms).
UÊÊœœÜ‡Õ«ÊÕÀˆ˜iÊVՏÌÕÀiÃÊœÀÊ1ÉÊ>ÀiÊœ˜ÞÊÜ>ÀÀ>˜Ìi`ÊvœÀÊœ˜}œˆ˜}Ê
symptoms. They should NOT be acquired routinely to monitor
response to therapy.
UÊÊ-iiÊ«°Ê££{ÊvœÀÊ`ˆÃVÕÃÈœ˜ÊœvÊÌÀi>Ì“i˜ÌÊœ«Ìˆœ˜ÃÊvœÀÊ6,Ê>˜`ÊÀi˜>Ê
concentrations of antibiotics.

112. 113
6.17 Urinary tract infections
Management of patients WITH a urinary catheter
Category Definition Empiric treatment
Asymptomatic
bacteriuria






Catheter-
associated UTI
(CA-UTI)














Urosepsis in a
patient with
nephrostomy
tubes
DIAGNOSIS
-«iVˆ“i˜ÊVœiV̈œ˜\ The urine sample should be drawn from the
catheter port using aseptic technique, NOT from the urine collection
bag. In patients with long term catheters (↓ 2 weeks), replace the
catheter before collecting a specimen. Urine should be collected before
antibiotics are started.
-Þ“«Ìœ“Ã\ Catheterized patients usually lack typical UTI symptoms.
-Þ“«Ìœ“ÃÊVœ“«>̈LiÊ܈̅ʇ1/ʈ˜VÕ`i\
UÊÊ iÜÊviÛiÀÊœÀÊÀˆ}œÀÃÊ܈̅ʘœÊœÌ…iÀÊÃœÕÀVi
UÊÊ iÜÊœ˜ÃiÌÊ`iˆÀˆÕ“]Ê“>>ˆÃi]ʏiÌ…>À}ÞÊ܈̅ʘœÊœÌ…iÀÊÃœÕÀVi
UÊÊ6ÊÌi˜`iÀ˜iÃÃ]Êy>˜ŽÊ«>ˆ˜]Ê«iÛˆVÊ`ˆÃVœ“vœÀÌ
UÊÊVÕÌiÊ…i“>ÌÕÀˆ>
Interpretation of the urinalysis (U/A) and urine culture
UÊÊ*ÞÕÀˆ>\ʘÊÌ…iÊ«ÀiÃi˜ViÊœvÊ>ÊV>Ì…iÌiÀ]Ê«ÞÕÀˆ>Ê`œiÃʘœÌÊVœÀÀi>ÌiÊ܈̅Ê
the presence of symptomatic CA-UTI and must be interpreted based
on the clinical scenario. The absence of pyuria suggests an alternative
diagnosis.
UÊÊ*œÃˆÌˆÛiÊÕÀˆ˜iÊVՏÌÕÀi\Ê↓ 1,000 colonies
Positive urine culture
↓ 100,000 CFU/mL
with no signs or
symptoms of infection
"/\ÊœLÌ>ˆ˜ˆ˜}Ê
routine cultures in
asymptomatic patients
is not recommended
Signs and symptoms
(fever with no other
source is the most
Vœ““œ˜ÆÊ«>̈i˜ÌÃÊ“>ÞÊ
also have suprapubic
or flank pain)
AND pyuria (10
WBC/hpf)
AND positive urine
culture ↓1,000
CFU/mL (see
information below
regarding significant
colony counts)





SIRS with urinary
source and
nephrostomy tubes
Remove the catheter
œÊÌÀi>Ì“i˜ÌÊÕ˜iÃÃÊÌ…iÊ«>̈i˜ÌʈÃ\
UÊ*Ài}˜>˜ÌÊ
UÊLœÕÌÊÌœÊÕ˜`iÀ}œÊ>ÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÊ
UÊ*œÃÌÊÀi˜>ÊÌÀ>˜Ã«>˜Ì
UÊ iÕÌÀœ«i˜ˆV
Antibiotics do not decrease asymptomatic
bacteriuria or prevent subsequent development
of UTI
UÊÊ,i“œÛiÊV>Ì…iÌiÀÊÜ…i˜Ê«œÃÈLi
Patient stable with no evidence of upper tract
`ˆÃi>Ãi\
UÊÊvÊV>Ì…iÌiÀÊÀi“œÛi`]ÊVœ˜Ãˆ`iÀÊœLÃiÀÛ>̈œ˜Ê>œ˜i
OR
UÊÊÀÌ>«i˜i“Ê£Ê}Ê6Ê+Ó{
OR
UÊÊivÌÀˆ>Ýœ˜iÊ£Ê}Ê6Ê+Ó{
OR
UÊʈ«ÀœyœÝ>Vˆ˜ÊxääÊ“}Ê*"Ê ÊœÀÊ{ääÊ“}Ê6Ê+£ÓÊ
(avoid in pregnancy and in patients with prior
exposure to quinolones)
UÊÕÀ>̈œ˜\ÊÃiiÊLiœÜ
Patient severely ill, with evidence of upper tract
disease, or hospitalized {nÊ\
UÊÊivi«ˆ“iÊ£Ê}Ê6Ê+nÊ
OR
UÊ* Ê>iÀ}Þ\ÊâÌÀiœ˜>“Ê£Ê}Ê6Ê+n
UÊÕÀ>̈œ˜\ÊÃiiÊLiœÜ
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ“}Ê6Ê+È
If prior urine culture data are available, tailor
therapy based on those results

113. 114
6.17 Urinary tract infections
DURATION
The duration of treatment has not been well studied for CA-UTI and
optimal duration is not known.
UÊÊÇÊ`>ÞÃʈvÊ«Àœ“«ÌÊÀiÃœṎœ˜ÊœvÊÃÞ“«Ìœ“Ã
UÊÊ£äq£{Ê`>ÞÃʈvÊ`i>Þi`ÊÀi뜘Ãi
UÊÊÎÊ`>ÞÃʈvÊV>Ì…iÌiÀÊÀi“œÛi`ʈ˜Êvi“>iÊ«>̈i˜ÌÊ 65 years with lower
tract infection.
TREATMENT NOTES
UÊÊ,i“œÛiÊÌ…iÊV>Ì…iÌiÀÊÜ…i˜iÛiÀÊ«œÃÈLi
UÊÊ,i«>ViÊV>Ì…iÌiÀÃÊÌ…>ÌÊ…>ÛiÊLii˜Êˆ˜Ê↓ 2 weeks if still indicated
UÊÊ*Àœ«…ޏ>V̈VÊ>˜ÌˆLˆœÌˆVÃÊ>ÌÊÌ…iÊ̈“iÊœvÊV>Ì…iÌiÀÊÀi“œÛ>ÊœÀÊÀi«>Vi“i˜ÌÊ
are NOT recommended due to low incidence of complications and
concern for development of resistance.
UÊÊ>Ì…iÌiÀʈÀÀˆ}>̈œ˜ÊÃ…œÕ`ʘœÌÊLiÊÕÃi`ÊÀœṎ˜iÞ
Treatment of Enterococci
UÊÊÊ “œÃÌÊ>ÊE. faecalis isolates are susceptible to Amoxicillin 500 mg
PO TID OR Ampicillin 1 g IV Q6H and should be treated with these
>}i˜ÌðʜÀÊ«>̈i˜ÌÃÊ܈̅Ê* Ê>iÀ}Þ\Ê ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­Ê>VÀœLˆ`
®
)
£ääÊ“}Ê*"Ê+£ÓÊ­`œÊ "/ÊÕÃiʈ˜Ê«>̈i˜ÌÃÊ܈̅ÊÀÊÊxäÊ“É“ˆ˜®°Ê
UÊE. faecium (often Vancomycin resistant)
UÊÊ ˆÌÀœvÕÀ>˜Ìœˆ˜Ê­>VÀœLˆ`
®
) 100 mg PO Q12H if susceptible (do NOT
use in patients with CrCl β 50 mL/min).
UÊ/iÌÀ>VÞVˆ˜iÊxääÊ“}Ê*"Ê+ÈʈvÊÃÕÃVi«ÌˆLi
UÊÊœÃvœ“ÞVˆ˜ÊÎÊ}Ê*"Êœ˜ViÊ­ˆvÊvi“>iÊ܈̅œÕÌÊV>Ì…iÌiÀÊœÀÊV>Ì…iÌiÀÊ
ˆÃÊÀi“œÛi`ÆÊ>ÃŽÊÌ…iÊ“ˆVÀœÊ>LÊvœÀÊÃÕÃVi«ÌˆLˆˆÌÞ®
UÊʈ˜i✏ˆ`ÊÈääÊ“}Ê*"Ê Ê",ÊœÃvœ“ÞVˆ˜ÊÎÊ}Ê*"ÊiÛiÀÞÊÓqÎÊ`>ÞÃÊ
(max 21 days) if complicated UTI or catheter can not be removed
Renal excretion/concentration of selected antibiotics
Good (≥60%): aminoglycosides, Amoxicillin, Amoxicillin/clavulanate,
Fosfomycin, Cefazolin, Cefepime, Cephelexin, Ciprofloxacin,
Colistin, Ertapenem, Trimethoprim/sulfamethoxazole, Vancomycin,
Amphotericin B, Fluconazole, Flucytosine
Variable (30-60%):Êiv«œ`œÝˆ“i]ʈ˜i✏ˆ`Ê­Î䯮]ÊœÝÞVÞVˆ˜iÊ
­Ó™qxx¯®]ÊivÌÀˆ>Ýœ˜i]Ê/iÌÀ>VÞVˆ˜iÊ­HÈ䯮ÊÊ
Poor (<30%): Azithromycin, Clindamycin, Moxifloxacin, Oxacillin,
Tigecycline, Micafungin, Posaconazole, Voriconazole
,iviÀi˜ViÃ\
*ÞÕÀˆ>Ê>˜`ÊÕÀˆ˜>ÀÞÊV>Ì…iÌiÀÃ\ÊÀV…ʘÌÊi`ÊÓäääÆ£Èä­x®\ÈÇ·ÇÇ°
IDSA Guidelines for treatment of uncomplicated acute bacterial cystitis and
«Þiœ˜i«…ÀˆÌˆÃʈ˜ÊÜœ“i˜\ʏˆ˜Ê˜viVÌʈÃÊ£™™™ÆÓ™\Ç{x°
-ÊÕˆ`iˆ˜iÃÊvœÀÊÌÀi>Ì“i˜ÌÊœvʇ1/\ʏˆ˜Ê˜viVÌʈÃÊÓä£äÆxä\ÈÓxqÈΰ

114. 115
6.18 Candidiasis in the non-neutropenic patient
Candidiasis in the non-neutropenic patient
Oropharyngeal disease (thrush)
Initial treatment
UÊʏœÌÀˆ“>✏iÊ£äÊ“}ÊÌÀœV…iÊxÊ̈“iÃÊ>Ê`>Þ
OR
UÊ ÞÃÌ>̈˜ÊÃÕëi˜Ãˆœ˜Êxää]äääÊÕ˜ˆÌÃÉx“Ê{Ê̈“iÃÊ>Ê`>Þ
Recurrent or intractable disease
UʏÕVœ˜>✏iÊ£ääqÓääÊ“}Ê*"Êœ˜ViÊ`>ˆÞ
Duration: xq£äÊ`>ÞÃ
NOTE: If refractory to Fluconazole consider fungal culture and
susceptibilities
Esophageal candidiasis
Initial treatment
UʏÕVœ˜>✏iÊÓääq{ääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
Duration: £{‡qÓ£Ê`>ÞÃ
Relapse
UÊʏÕVœ˜>✏iÊ{ääqnääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
Refractory to Fluconazole 800 mg daily (fungal culture and
susceptibilities are recommended)
UʈV>vÕ˜}ˆ˜Ê£xäÊ“}Ê6Êœ˜ViÊ`>ˆÞ
OR
UÊ“«…œÌiÀˆVˆ˜Ê Êä°Îqä°ÇÊ“}ÉŽ}Ê6Êœ˜ViÊ`>ˆÞ
OR
UÊ"À>ÊÌ…iÀ>«Þ\ÊÌÀ>Vœ˜>✏iÊœÀ>ÊÃœṎœ˜ÊÓääÊ“}Ê`>ˆÞ
Duration: £{qÓ£Ê`>ÞÃ
Candiduria
UÊ1Àˆ˜>ÀÞÊV>Ì…iÌiÀÊÀi“œÛ>Ê܈ÊÀiÃœÛiÊÌ…iÊV>˜`ˆ`ÕÀˆ>ʈ˜Ê{ä¯ÊœvÊV>Ãið
TREATMENT
Asymptomatic cystitis
UÊ/…iÀ>«ÞʘœÌÊÕÃÕ>Þʈ˜`ˆV>Ìi`
UÊÊœ˜Ãˆ`iÀʈ˜ÊÌ…iÊvœœÜˆ˜}ÊVœ˜`ˆÌˆœ˜ÃÊ­ÃiiÊÀi}ˆ“i˜ÃÊÕ˜`iÀÊ
ºÃÞ“«Ìœ“>̈VÊVÞÃ̈̈û®\
UÊ iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊ
UÊ,i˜>ÊÌÀ>˜Ã«>˜Ì
UÊ1Àˆ˜>ÀÞÊœLÃÌÀÕV̈œ˜ÊœÀÊ>L˜œÀ“>Ê1ÊÌÀ>VÌ
UÊ7…i˜ÊÀiVœÛiÀi`ʈ˜ÊÕÀˆ˜iÊ«ÀˆœÀÊÌœÊÕÀœœ}ˆVÊ«ÀœVi`ÕÀiÃ

115. 6.18 Candidiasis in the non-neutropenic patient
116
Symptomatic cystitis
Preferred therapy
UÊʏÕVœ˜>✏iÊÓääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞÊ
Duration:ÊÇq£{Ê`>ÞÃ
Fluconazole-resistant organism suspected or confirmed
UÊ“«…œÌiÀˆVˆ˜Ê Êä°Î‡ä°ÈÊ“}ÉŽ}Ê6Êœ˜ViÊ`>ˆÞÊ
Duration:Ê£qÇÊ`>ÞÃÊ
Pyelonephritis
NOTE: Candida pyelonephritis is usually secondary to hematogenous
spread except for patients with renal transplant or abnormalities of the
urogenital tract.
Preferred therapy
UʏÕVœ˜>✏iÊÓääq{ääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞÊ
Duration: 14 days
Fluconazole-resistant organism suspected or confirmed
UÊ“«…œÌiÀˆVˆ˜Ê Êä°xqä°ÇÊ“}ÉŽ}Ê6Êœ˜ViÊ`>ˆÞÊ
OR
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Êœ˜ViÊ`>ˆÞÊ
Duration: 14 days
TREATMENT NOTES
UÊ,i“œÛiÊÕÀˆ˜>ÀÞÊV>Ì…iÌiÀʈvÊ«œÃÈLi°
UÊÊ/…iÀ>«ÞÊœvÊV>˜`ˆ`ÕÀˆ>ʈ˜ÊÌ…iʘœ˜‡˜iÕÌÀœ«i˜ˆV]ʘœ˜‡1ÊV>Ì…iÌiÀˆâi`Ê
patient has not been shown to be beneficial and promotes resistance.
UÊÊ“ ˆÃœ“i
®
, Voriconazole, Itraconazole, and Posaconazole are not
recommended due to poor penetration into the urinary tract.
UÊʈV>vÕ˜}ˆ˜Ê«i˜iÌÀ>ÌiÃÊ«œœÀÞʈ˜ÊÌ…iÊÕÀˆ˜i]ÊLÕÌÊ`œiÃÊ«i˜iÌÀ>Ìiʈ˜ÌœÊ
renal tissue.
UÊ“«…œÌiÀˆVˆ˜Ê ÊL>``iÀÊÜ>Ã…iÃÊ>ÀiʘœÌÊÀiVœ““i˜`i`°
Candida vaginitis
Initial Therapy
UʏÕVœ˜>✏iÊ£xäÊ“}Ê*"Ê8Ê£Ê`œÃiÊ
OR
UʈVœ˜>✏iÊÓ¯ÊVÀi>“ÊxÊ}ʈ˜ÌÀ>Û>}ˆ˜>ÞÊœ˜ViÊ`>ˆÞÊ8ÊÇÊ`>ÞÃ
Recurrent (> 4 episodes/year of symptomatic infection)
UÊʏÕVœ˜>✏iÊ£xäÊ“}Ê*"Ê+ÇÓÊ8ÊÎÊ`œÃiÃ]ÊÌ…i˜Ê£xäÊ“}Ê>ÊÜiiŽÊ8Ê
6 months

116. 117
6.18 Candidiasis in the non-neutropenic patient
Candidemia
UÊÊ9-/Ê ÊÊ ""Ê1/1,Ê-"1Ê "/Ê Ê" -,ÊÊ
CONTAMINANT.
NOTE: Micafungin does not have activity against Cryptococcus
TREATMENT
Unspeciated candidemia
Patients who are clinically stable and have not received prior long-term
azole therapy
UʏÕVœ˜>✏iÊnääÊ“}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ…i˜Ê{ääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Êœ˜ViÊ`>ˆÞÊ
If the yeast is C. albicans or C. glabrata based on PNA FISH results,
follow the recommendations for C. albicans or C. glabrata noted below.
Otherwise, await speciation before modifying therapy as recommended
below, unless the patient becomes clinically unstable on Fluconazole.
Candida albicans
UʏÕVœ˜>✏iÊnääÊ“}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ…i˜Ê{ääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Êœ˜ViÊ`>ˆÞÊ
Patients should be transitioned to Fluconazole once stable.
Candida glabrata
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Êœ˜ViÊ`>ˆÞ
OR
UÊʏÕVœ˜>✏iÊnääÊ“}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ…i˜Ê{ääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞÊÊ
the isolate is susceptible with MIC 8 mcg/mL and the patient is stable.
If isolate is intermediate to Fluconazole and oral therapy is desired,
consult ID. Other azoles such as Voriconazole should not be used in
Fluconazole-resistant strains due to the same mechanism of resistance.
Candida krusei
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Êœ˜ViÊ`>ˆÞÊ
Fluconazole should NEVER be used to treat infections due to C. krusei
because the organism has intrinsic resistance to Fluconazole. This
“iV…>˜ˆÃ“ÊœvÊÀiÈÃÌ>˜ViʈÃʘœÌÊÃ…>Ài`Ê܈̅Ê6œÀˆVœ˜>✏iÆÊÌ…iÀivœÀi]Ê
oral Voriconazole can be used if isolate is susceptible (for dosing see
Voriconazole specific guidelines, p. 19).

117. 118
6.18 Candidiasis in the non-neutropenic patient
Candida lusitaniae
UʏÕVœ˜>✏iÊnääÊ“}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ…i˜Ê{ääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
C. lusitaniaeʈÃÊÀiÈÃÌ>˜ÌÊ̜ʓ«…œÌiÀˆVˆ˜Ê ʈ˜Ê>««ÀœÝˆ“>ÌiÞÊÓä¯ÊœvÊ
cases.
Candida parapsilosis
UʏÕVœ˜>✏iÊnääÊ“}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ…i˜Ê{ääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
Fluconazole-intermediate isolate
UʏÕVœ˜>✏iÊnääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
Fluconazole-resistant isolate
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Êœ˜ViÊ`>ˆÞ
If the patient is not responding to Micafungin then consider changing
to Amphotericin B. The minimum inhibitory concentrations (MICs) of
echinocandins are higher for C. parapsilosis than any other Candida
spp.ÆÊÌ…ˆÃÊ…>Ãʏi`ÊÌœÊVœ˜ViÀ˜ÊÌ…>ÌÊÃœ“iʈ˜viV̈œ˜ÃÊ܈̅ÊC. parapsilosis
may not respond well to echinocandins.
Candida tropicalis
UʏÕVœ˜>✏iÊnääÊ“}Ê6É*"Ê8Ê£Ê`œÃi]ÊÌ…i˜Ê{ääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
Fluconazole-intermediate isolate
UʏÕVœ˜>✏iÊnääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞ
Fluconazole-resistant isolate
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Êœ˜ViÊ`>ˆÞ
TREATMENT NOTES
Amphotericin B use in Candidemia
UÊÊ“«…œÌiÀˆVˆ˜Ê ʈÃÊ…ˆ}…ÞÊivviV̈ÛiÊ>}>ˆ˜ÃÌÊ>ÊCandida spp. except
for C. lusitaniaeÆÊ…œÜiÛiÀ]Ê>✏iÃÊ>˜`ÊiV…ˆ˜œV>˜`ˆ˜ÃÊ>ÀiÊv>ÛœÀi`ʈ˜Ê
susceptible strains over Amphotericin B products due to toxicity.
Doses for Candidemia
UÊ“«…œÌiÀˆVˆ˜Ê Êä°ÇÊ“}ÉŽ}Ê6Êœ˜ViÊ`>ˆÞ
OR
UÊÊ“ ˆÃœ“i
®
3 mg/kg IV once daily (if patient cannot tolerate
conventional Amphotericin B)
Duration
UÊÊ£{Ê`>ÞÃÊvœœÜˆ˜}Ê`œVÕ“i˜Ìi`ÊVi>À>˜ViÊœvÊLœœ`ÊVՏÌÕÀiÃÊ>˜`ÊVˆ˜ˆV>Ê
symptoms
UÊÊ*>̈i˜ÌÃÊ܈̅ʫiÀÈÃÌi˜ÌÊV>˜`ˆ`i“ˆ>Ê>˜`ÉœÀÊ“iÌ>ÃÌ>̈VÊVœ“«ˆV>̈œ˜ÃÊ
(e.g. endophthalmitis, endocarditis) need a longer duration of therapy
and evaluation by Ophthalmology and ID.

118. 119
6.18 Candidiasis in the non-neutropenic patient
Ê






Non-pharmacologic management
UÊÊ,i“œÛ>ÊœvÊ>Êi݈Ã̈˜}ÊVi˜ÌÀ>ÊÛi˜œÕÃÊV>Ì…iÌiÀÃʈÃÊ…ˆ}…ÞÊ
recommended.
UÊÊ*>̈i˜ÌÃÊÃ…œÕ`Ê…>ÛiÊLœœ`ÊVՏÌÕÀiÃÊ`>ˆÞÊœÀÊiÛiÀÞʜ̅iÀÊ`>ÞÊ՘̈Ê
candidemia is cleared.
UÊÊ*>̈i˜ÌÃÊÃ…œÕ`Ê…>ÛiÊ>˜Êœ«…Ì…>“œœ}ˆVÊiÝ>“ˆ˜>̈œ˜ÊÌœÊiÝVÕ`iÊ
candidal endophthalmitis prior to discharge, preferably once the
candidemia is controlled.
UÊÊV…œV>À`ˆœ}À>«…ÞÊV>˜ÊLiÊVœ˜Ãˆ`iÀi`ʈvÊÌ…iÊ«>̈i˜ÌÊ…>ÃÊ«iÀÈÃÌi˜ÌÊ
candidemia on appropriate therapy.
Endophthalmitis
UÊ>˜>}i“i˜Ìʈ˜ÊVœ˜Õ˜V̈œ˜Ê܈̅Ê"«…Ì…>“œœ}Þ
UÊÊÕiÊ̜ʫœœÀÊ -Ê>˜`ÊÛˆÌÀi>Ê«i˜iÌÀ>̈œ˜]ÊÌÀi>Ì“i˜ÌÊ܈̅ÊiV…ˆ˜œV>˜`ˆ˜ÃÊ
is NOT recommended.
Preferred therapy
UÊ
“«…œÌiÀˆVˆ˜Ê ʣʓ}ÉŽ}Ê6Êœ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxÊ“}ÉŽ}Ê*"Ê+È
OR
UÊ“ ˆÃœ“i
®
ÊxÊ“}ÉŽ}Ê6Êœ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxÊ“}ÉŽ}Ê*"Ê+È
Alternate therapy
UÊʏÕVœ˜>✏iÊ{ää‡nääÊ“}Ê6É*"Êœ˜ViÊ`>ˆÞʴʏÕVÞ̜ȘiÊÓxÊ“}ÉŽ}Ê
PO Q6H
Duration: {qÈÊÜiiŽÃ
Endocarditis
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.
Hidden Content
- JHH Internal use only

119. 120
6.18 Candidiasis in the non-neutropenic patient
Preferred therapy
UÊ“ ˆÃœ“iÁÊxÊ“}ÉŽ}Ê6Êœ˜ViÊ`>ˆÞ
Alternative therapy
UÊʈV>vÕ˜}ˆ˜Ê£xäÊ“}Ê6Êœ˜ViÊ`>ˆÞʴʏÕVœ˜>✏iÊ{ääqnääÊ“}Ê6É*"Ê
once daily
Duration: 6 weeks or longer
Notes on antifungal susceptibility testing
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀʏÕVœ˜>✏i]ÊÌÀ>Vœ˜>✏i]Ê6œÀˆVœ˜>✏i]Ê
Flucytosine, and Micafungin is performed routinely on the first yeast
isolate recovered from blood.
UÊʏÕVœ˜>✏iÊ>˜`ʈV>vÕ˜}ˆ˜ÊÃÕÃVi«ÌˆLˆˆÌÞÊ>ÀiÊÀi«œÀÌi`Êœ˜Ê>ÊˆÃœ>Ìið
UÊÊ"À}>˜ˆÃ“ÃÊÌ…>ÌÊ…>ÛiʈV>vÕ˜}ˆ˜ÊÃʈ˜ÊÌ…iÊÀ>˜}iÊœvÊ£qÓÊ“V}É“Ê
(reported as susceptible) may not respond to treatment. ID consult is
recommended in these cases.
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀÊVœ˜Ûi˜Ìˆœ˜>Ê“«…œÌiÀˆVˆ˜Ê ʈÃÊ`œ˜iÊÀœṎ˜iÞÊ
for C. lusitaniae and C. guillermondii, and for other organisms by
request.
UÊÊvÊÌ…iÊœÀ}>˜ˆÃ“ʈÃʈ˜ÌiÀ“i`ˆ>ÌiÊ­®Ê̜ʏÕVœ˜>✏i]ÊÌ…i˜ÊnääÊ“}Ê6É
PO once daily can be used. This choice is NOT recommended in an
immunocompromised patient, in a patient who is clinically unstable
due to candidemia, or in patients with endocarditis, meningitis or
endophthalmitis.
UÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊÜ…i˜\
UÊÕVœVÕÌ>˜iœÕÃÊV>˜`ˆ`ˆ>ÈÃʈÃÊÀivÀ>VÌœÀÞÊ̜ʏÕVœ˜>✏i
UÊÊ/Ài>̈˜}ÊœÃÌiœ“ÞiˆÌˆÃ]Ê“i˜ˆ˜}ˆÌˆÃ]ÊœÀÊi˜`œ«…Ì…>“ˆÌˆÃÊ܈̅Ê
Fluconazole
UÊ œœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«iÀÈÃÌi˜ÌÞÊ«œÃˆÌˆÛiÊœ˜ÊÕVœ˜>✏i
UÊÊ œ˜‡ÀœṎ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊV>˜ÊLiÊ>ÀÀ>˜}i`ÊLÞÊV>ˆ˜}ÊÌ…iÊ
mycology lab at 5-6148
Notes on Fluconazole prophylaxis
UÊʏÕVœ˜>✏iÊ«Àœ«…ޏ>݈ÃÊÃ…œÕ`ÊLiʏˆ“ˆÌi`ÊÌœÊÌ…iÊvœœÜˆ˜}ÊÃiÌ̈˜}Ã
UÊÊ*>̈i˜ÌÃÊiÝ«iVÌi`ÊÌœÊÀi“>ˆ˜Êˆ˜ÊÌ…iÊSICU or WICU for ≥ 72 hours
­ÀˆÌiÀˆ>ÊvÀœ“Êœ«Žˆ˜ÃÊ-1Ê«Àœ«…ޏ>݈ÃÊÃÌÕ`ÞÆÊ«Àœ«…ޏ>݈Ãʈ˜ÊœÌ…iÀÊ
ICUs has NOT been studied and is NOT recommended).
UÊÊ iÕÌÀœ«i˜ˆVÊ«>̈i˜ÌÃÊÕ˜`iÀ}œˆ˜}ÊLœ˜iÊ“>ÀÀœÜÊÌÀ>˜Ã«>˜Ì>̈œ˜ÊœÀÊ
treatment for leukemia/lymphoma
UÊÊ*>̈i˜ÌÃÊÜ…œÊ>ÀiÊ«œÃ̇œ«ÊvÀœ“ʏˆÛiÀÊœÀÊ«>˜VÀi>ÃÊÌÀ>˜Ã«>˜Ìð
UÊʏÕVœ˜>✏iÊ«Àœ«…ޏ>݈ÃÊÃ…œÕ`ÊLiÊÃÌœ««i`ÊÜ…i˜Ê-1ÊœÀÊ71Ê
patients are transferred to the floor
,iviÀi˜ViÃ\
-ÊÕˆ`iˆ˜iÃÊvœÀÊ/Ài>Ì“i˜ÌÊœvÊ>˜`ˆ`ˆ>ÈÃ\ʏˆ˜Ê˜viVÌʈÃÊÓää™Æ{n\xä·xÎx°
ÕVœ˜>✏iÊ«Àœ«…ޏ>݈Ãʈ˜ÊÃÕÀ}ˆV>Ê«>̈i˜ÌÃ\ʘ˜Ê-ÕÀ}ÊÓää£ÆÓÎÎ\x{Óqn°

120. 121
6.19 Guidelines for use of prophylactic antimicrobials
Pre-operative and pre-procedure antibiotic
prophylaxis
œÀÊëiVˆwVÊ«ÀœVi`ÕÀiÃÊ>˜`Ê>}i˜ÌÃÊÃiiʺ*iÀˆ‡œ«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÊ
«Àœ«…ޏ>݈ÃÊ`œVÕ“i˜Ì»Ê>ÌÊÜÜÜ°ˆ˜Ãˆ`i…œ«Žˆ˜Ã“i`ˆVˆ˜i°œÀ}É>“«
Drug Usual dose Redosing during procedure
iv>✏ˆ˜Ê Ê£ÓäÊŽ}\ÊÓÊ}Ê +{Ê­+ÓÊvœÀÊV>À`ˆ>VÊÃÕÀ}iÀÞ®
≥Ê£ÓäÊŽ}\ÊÎÊ}Ê +{Ê­+ÓÊvœÀÊV>À`ˆ>VÊÃÕÀ}iÀÞ®
ivœÌiÌ>˜Ê Ê£ÓäÊŽ}\ÊÓÊ}Ê +È
≥Ê£ÓäÊŽ}\ÊÎÊ}
Clindamycin 600 mg Q6H
Ciprofloxacin 400 mg None
Gentamicin 5 mg/kg None
Metronidazole 500 mg None
6>˜Vœ“ÞVˆ˜Ê ÊÇäÊŽ}\Ê£Ê}Ê +£Ó
Ê Ç£‡™™ÊŽ}\Ê£°ÓxÊ}
Ê €Ê£ääÊŽ}\Ê£°xÊ}
Important notes
UÊÊ/ˆ“ˆ˜}ʈÃÊVÀÕVˆ>°Ê˜ÌˆLˆœÌˆVÃÊ“ÕÃÌÊLiʈ˜ÊÌ…iÊÃŽˆ˜ÊÜ…i˜ÊÌ…iÊ
incision is made to be effective.
UÊÊi«…>œÃ«œÀˆ˜ÃÊV>˜ÊLiÊ>`“ˆ˜ˆÃÌiÀi`ÊœÛiÀÊÎqxÊ“ˆ˜Ê6Ê«ÕÅʍÕÃÌÊLivœÀiÊ
the procedure and will achieve appropriate skin levels in minutes.
Vancomycin and Ciprofloxacin must be given over 60 min. Clindamycin
Ã…œÕ`ÊLiʈ˜vÕÃi`ÊœÛiÀÊ£äqÓäÊ“ˆ˜°Ê
UÊÊœÀÊ>˜ÌˆLˆœÌˆVÃÊ܈̅ʏœ˜}iÀʈ˜vÕÈœ˜Ê̈“iÃÊ­i°}°Ê6>˜Vœ“ÞVˆ˜]Ê
Ciprofloxacin) the infusion should start 30 minutes prior to incision
UÊÊPost-procedure doses are NOT needed (exceptions are noted
in table). Single doses pre-procedure have been as effective as
post-procedure doses in all studies.
UÊÊ*>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê«Ài‡œ«iÀ>̈ÛiÊ>˜ÌˆLˆœÌˆVÃÊ}i˜iÀ>ÞÊ`œÊ "/ʘii`Ê
additional antibiotics for endocarditis prophylaxis.
UÊÊ*Àœ«…ޏ>݈ÃÊvœÀÊ«>̈i˜ÌÃÊ>Ài>`ÞÊœ˜Ê>˜ÌˆLˆœÌˆVÃ\
UÊÊœÀÊ>˜ÌˆLˆœÌˆVÃʜ̅iÀÊÌ…>˜Ê6>˜Vœ“ÞVˆ˜\Êœ`ÊÃÌ>˜`ˆ˜}Ê`œÃiÊ՘̈Ê
1 hour before incision
UÊÊœÀÊ6>˜Vœ“ÞVˆ˜\Ê,i`œÃiÊ>ÊvՏÊ`œÃiʈvÊnÊ…œÕÀÃÊ…>ÛiÊ«>ÃÃi`ÊȘViÊ
the last dose or a half dose if fewer than 8 hours have passed in
patient with normal renal function
UÊÊi˜Ì>“ˆVˆ˜ÊÃ…œÕ`ÊLiÊ}ˆÛi˜Ê>ÃÊ>ÊȘ}iÊ`œÃiÊœvÊxÊ“}ÉŽ}Ê̜ʓ>݈“ˆâiÊ
tissue penetration and minimize toxicity.
UÊÊvÊœ˜Ê`ˆ>ÞÈÃÊœÀÊÀÊÊÓäÊ“É“ˆ˜]ÊÕÃiÊÓÊ“}ÉŽ}
UʜʘœÌÊÀi`œÃi
UÊÊ1ÃiÊ>VÌÕ>ÊLœ`ÞÊÜiˆ}…ÌÊÕ˜iÃÃÊ«>̈i˜ÌʈÃÊ≥ÊÓä¯ÊœÛiÀʈ`i>ÊLœ`ÞÊ
weight (see p. 145)

121. 122
6.19 Guidelines for use of prophylactic antimicrobials
Procedure Prophylaxis PCN allergy
recommendations alternate prophylaxis
Urologic surgery/procedures
Transrectal prostate biopsy
1
Cefazolin Ciprofloxacin OR Gentamicin
2

Transurethral surgery (e.g. TURP, TURBT, Cefazolin Gentamicin
2

ureteroscopy, cystouretoscopy)
Lithotripsy Cefazolin Gentamicin
2

Nephrectomy or radical prostatectomy Cefazolin Clindamycin
Radical cystectomy, ileal conduit, Cefotetan Clindamycin PLUS
cystoprostatectomy or anterior exenteration Gentamicin
2
*i˜ˆiÊœÀʜ̅iÀÊ«ÀœÃÌ…iÃiÃÊ Qiv>✏ˆ˜Ê",Ê6>˜Vœ“ÞVˆ˜RÊÊQˆ˜`>“ÞVˆ˜Ê",Ê6>˜Vœ“ÞVˆ˜R
PLUS Gentamicin
2
PLUS Gentamicin
2
Cardiac surgery
Median sternotomy, heart transplant
3
Cefazolin Vancomycin
Median sternotomy, heart transplant with Cefazolin PLUS Vancomycin
previous VAD or MRSA colonization/infection
3
Vancomycin
Pacemaker or ICD insertion Cefazolin Clindamycin OR Vancomycin
Pacemaker or ICD insertion with MRSA Cefazolin PLUS Vancomycin
colonization/infection or generator exchange Vancomycin
VAD insertion Cefazolin Vancomycin
VAD insertion with MRSA colonization/infection Cefazolin PLUS Vancomycin
Vancomycin
VAD insertion with open chest
3
Cefazolin PLUS Vancomycin PLUS
Vancomycin Ciprofloxacin
Lung transplant
4
Cefepime Consult transplant ID
Vascular surgery
Carotid and brachiocephalic procedures Prophylaxis not Prophylaxis not
without prosthetic grafts recommended recommended
Upper extremity procedures with prosthetic Cefazolin Clindamycin OR Vancomycin
grafts and lower extremity procedures
L`œ“ˆ˜>Ê>œÀÌ>Ê«ÀœVi`ÕÀiÊœÀÊ}Àœˆ˜Êˆ˜VˆÃˆœ˜ÊÊ ivœÌiÌ>˜ÊÊ 6>˜Vœ“ÞVˆ˜Ê³Êi˜Ì>“ˆVˆ˜
2
Thoracic surgery
Lobectomy, pneumonectomy, lung resection, Cefazolin Clindamycin
thoracotomy, VATS
Esophageal cases Cefotetan Clindamycin
Neurosurgery
Craniotomy, cerebrospinal fluid-shunting Cefazolin Clindamycin
procedures, implantation of intrathecal pumps
Laminectomy Cefazolin Clindamycin
Spinal fusion Cefazolin Clindamycin OR Vancomycin
Spinal fusion with MRSA colonization/infection Cefazolin PLUS Vancomycin
Vancomycin
Transsphenoidal procedures Ceftriaxone Moxifloxacin 400 mg
Orthopedic surgery
Clean operations involving hand, knee, or Prophylaxis not Prophylaxis not
foot, arthroscopy recommended recommended
Total joint replacement Cefazolin Vancomycin
Total joint replacement with MRSA Cefazolin PLUS Vancomycin
colonization/infection Vancomycin
Open reduction of fracture/internal fixation Cefazolin Clindamycin OR Vancomycin
Lower limb amputation Cefotetan Clindamycin PLUS
Gentamicin
2
Spinal fusion Cefazolin Clindamycin OR Vancomycin
Spinal fusion with MRSA colonization/infection Cefazolin PLUS Vancomycin
Vancomycin
Laminectomy Cefazolin Clindamycin

122. 123
6.19 Guidelines for use of prophylactic antimicrobials
Procedure Prophylaxis PCN allergy
recommendations alternate prophylaxis
General surgery
*ÀœVi`ÕÀiÃʈ˜ÛœÛˆ˜}Êi˜ÌÀÞʈ˜ÌœÊÕ“i˜ÊœvÊÕ««iÀÊÊivœÌiÌ>˜Ê ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜
2

GI tract, gastric bypass procedures,
pancreaticoduodenectomy, highly selective
vagotomy, Nissen fundoplication
ˆˆ>ÀÞÊÌÀ>VÌÊ«ÀœVi`ÕÀiÃÊ­i°}°ÊV…œiVÞÃÌiVÌœ“Þ]ÊÊivœÌiÌ>˜Ê ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜
2

choledochoenterostomy)
i«>ÌiVÌœ“ÞÊ ivœÌiÌ>˜Ê ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜
2
Whipple procedure or pancreatectomy Cefotetan Clindamycin PLUS
Ciprofloxacin
Small bowel procedures Cefotetan Clindamycin PLUS
Gentamicin
2
*Ê iv>✏ˆ˜Ê",ÊivœÌiÌ>˜Ê ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜
2
Appendectomy (if complicated or perforated, Cefotetan Clindamycin PLUS
treat as secondary peritonitis) Gentamicin
2
Colorectal procedures, penetrating abdominal Cefotetan Clindamycin PLUS
trauma Gentamicin
2
Inguinal hernia repair Cefazolin Clindamycin
œ“«ˆV>Ìi`]Êi“iÀ}i˜ÌÊœÀÊÀi«i>Ìʈ˜}Õˆ˜>ÊÊ ivœÌiÌ>˜Ê ˆ˜`>“ÞVˆ˜Ê´Êi˜Ì>“ˆVˆ˜
2

hernia repair
Mastectomy Prophylaxis not Prophylaxis not
recommended recommended
Mastectomy with lymph node dissection Cefazolin Clindamycin PLUS
Gentamicin
2
Gynecologic surgery
Cesarean delivery procedures Cefazolin Clindamycin PLUS
Gentamicin
2
Hysterectomy (vaginal or abdominal) Cefazolin OR Cefotetan Clindamycin PLUS
Gentamicin
2
Oncology procedures Cefotetan Clindamycin PLUS
Gentamicin
2
Repair of cystocele or rectocele Cefazolin Clindamycin
Head and neck surgery
Parotidectomy, thyroidectomy, tonsillectomy Prophylaxis not Prophylaxis not
recommended recommended
Reconstructive procedure w/prosthesis Cefazolin Clindamycin
placement
Adenoidectomy, rhinoplasty, tumor-debulking, Cefotetan OR Clindamycin Clindamycin
or mandibular fracture repair
Major neck dissection Cefazolin Clindamycin
Plastic surgery
Clean with risk factors or clean-contaminated Cefazolin Clindamycin
Tissue expander insertion/implants/all flaps Cefazolin Clindamycin
Rhinoplasty No prophylaxis OR No prophylaxis OR
Cefazolin Clindamycin
Abdominal transplant surgery
Pancreas or pancreas/kidney transplant Cefotetan Clindamycin PLUS
Ciprofloxacin
Renal transplant/adult live donor Cefazolin Clindamycin
Liver transplant
4
Cefotetan Clindamycin PLUS
Ciprofloxacin
1
vÊ«Ài‡œ«ÊÀiVÌ>ÊÃVÀii˜Ê«iÀvœÀ“i`\ÊÃiiÊ«°Ê£Ó{Ê
2
Do not give additional doses of Gentamicin post-op for prophylaxis
3
For open chest, continue antibiotic prophylaxis until closure
4
Listed recommendations are for patients with no relevant microbiology data that would suggest
ÀiÈÃÌ>˜ÌÊœÀ}>˜ˆÃ“ÃÆÊ«Àœ«…ޏ>V̈VÊÀi}ˆ“i˜ÊÃ…œÕ`ÊLiÊÌ>ˆœÀi`ÊL>Ãi`Êœ˜ÊŽ˜œÜ˜Ê“ˆVÀœLˆœœ}ÞÊ`>Ì>Ê܈̅Ê
assistance of transplant ID (page in PING)

123. 124
6.19 Guidelines for use of prophylactic antimicrobials
Prophylaxis for Prostate Biopsy Based on Rectal Screen Results
Pre-op prophylaxis regimen
1
Post-op oral options
2
Ciprofloxacin Ciprofloxacin 750 mg PO 2 hours Ciprofloxacin 500 mg PO once
susceptible before procedure for any renal 12 hours after the procedure. If GFR
Ê vÕ˜V̈œ˜ÊÊÊ ÎäÊ“É“ˆ˜Ê˜œÊ˜ii`ÊvœÀÊ«œÃ̇œ«Ê`œÃi°Ê
ˆ«ÀœyœÝ>Vˆ˜ÊÊ /*É-8Ê£Ê-ʣʅœÕÀÊLivœÀiÊÊ /*É-8Ê£Ê-Ê*"Êœ˜ViÊ£ÓÊ…œÕÀÃÊ
ÀiÈÃÌ>˜Ì]Ê/*É-8Ê «ÀœVi`ÕÀi]Ê>˜`Ê£Ê-ÊÎÊ…œÕÀÃÊÊ >vÌiÀÊÌ…iÊ«ÀœVi`ÕÀi°ÊvÊ,ʐÎäÊ
susceptible before ml/min no need for post-op dose.
Ciprofloxacin and Cefazolin 2 g IV push (3-5 min) Cefpodoxime 100 mg PO once
/*É-8ÊÀiÈÃÌ>˜Ì]ÊÊ ÜˆÌ…ˆ˜Ê>˜Ê£Ê…œÕÀÊœvÊ«ÀœVi`ÕÀiÊOR
Cefazolin susceptible Cefdinir 300 mg PO once
Ciprofloxacin, Gentamicin 5 mg/kg IV once over No need for additional doses as
/*É-8]ÊÊ Îä‡ÈäÊ“ˆ˜ÊÊ i˜Ì>“ˆVˆ˜Ê>˜`ÊivÌÀˆ>Ýœ˜iÊÀiÌ>ˆ˜Ê
Cefazolin resistant OR therapeutic levels for 24 hours
Ceftriaxone 1 g IV over 30 min if
susceptible
Other resistance Call ID Pharmacist
patterns
1
All doses are for any renal function
2
Post-op antibiotics are not required by SCIP
Procedure Prophylaxis PCN allergy recommendations alternate prophylaxis
Interventional radiology procedures

ˆˆ>ÀÞÉÆÊV…i“œÊi“Lœˆâ>̈œ˜ÉÊÊ ivœÌiÌ>˜ÊÊ ˆ˜`>“ÞVˆ˜Ê
percutaneous liver ablation (hx. of PLUS Gentamicin
Lˆˆ>ÀÞÊÃÕÀ}iÀÞɈ˜ÃÌÀÕ“i˜Ì>̈œ˜®ÆÊ
cecostomy
…i“œÊi“Lœˆâ>̈œ˜ÆÊwLÀœˆ`ÉÕÀˆ˜iÊ *Àœ«…ޏ>݈ÃʘœÌÊ
>ÀÌiÀÞÊi“Lœˆâ>̈œ˜ÆÊ«iÀVÕÌ>˜iœÕÃÊÊ ÀiVœ““i˜`i`
ˆÛiÀÉÀi˜>ÉÕ˜}IÊ>L>̈œ˜ÆÊÛ>ÃVՏ>ÀÊ
vascular malformation embolization
†
Urologic procedure (not ablation) Cefazolin Gentamicin
Lymphangiogram/embolization Cefazolin Clindamycin
Placement of tunneled catheters Prophylaxis not
­i°}°ÊVi˜ÌÀ>Êˆ˜i®ÆÊÛi˜œÕÃÉ>ÀÌiÀˆ>ÊÊ ÀiVœ““i˜`i`
procedures.
Placement of implantable access Cefazolin Clindamycin
port (e.g. Mediport®)
*Pre-treatment w/ antibiotics can be considered for patients w/ COPD or h/o recurrent post-obstructive
pneumonia
†
Lymphatic or patients w/ necrotic skin undergoing vascular graft should receive prophylaxis
w/Cefazolin

124. 125
6.19 Guidelines for use of prophylactic antimicrobials
Prophylaxis against bacterial endocarditis
NOTES:
UÊÊ*>̈i˜ÌÃÊÜ…œÊ…>ÛiÊÀiViˆÛi`Ê>˜ÌˆLˆœÌˆVÃÊvœÀÊÃÕÀ}ˆV>Ê«Àœ«…ޏ>݈ÃÊ`œÊ˜œÌÊ
need additional prophylaxis for endocarditis.
Antibiotic prophylaxis solely to prevent endocarditis is not
recommended for GU or GI tract procedures.
Cardiac conditions associated with a high risk of endocarditis
for which prophylaxis is recommended prior to some dental and
respiratory tract procedures and procedures involving infected
skin or musculoskeletal tissue
UÊ*ÀœÃÌ…ïVÊV>À`ˆ>VÊÛ>Ûi
UÊ*ÀiÛˆœÕÃÊi«ˆÃœ`iÊœvʈ˜viV̈ÛiÊi˜`œV>À`ˆÌˆÃ
UÊœ˜}i˜ˆÌ>Ê…i>ÀÌÊ`ˆÃi>ÃiÊ­®
UÊÊÊ 1˜Ài«>ˆÀi`ÊVÞ>˜œÌˆVÊ]ʈ˜VÕ`ˆ˜}Ê«>ˆ>̈ÛiÊÃ…Õ˜ÌÃÊ>˜`ÊVœ˜`ÕˆÌÃ
UÊÊœ“«iÌiÞÊÀi«>ˆÀi`ÊVœ˜}i˜ˆÌ>Ê…i>ÀÌÊ`iviVÌÊ܈̅ʫÀœÃÌ…ïVÊ
material or device, whether placed by surgery or by catheter
intervention, during the first 6 months after the procedure
UÊÊ,i«>ˆÀi`ÊÊ܈̅ÊÀiÈ`Õ>Ê`iviVÌÃÊ>ÌÊÌ…iÊÈÌiÊœÀÊ>`>Vi˜ÌÊÌœÊÌ…iÊ
site of a prosthetic patch or prosthetic device
UÊÊ>À`ˆ>VÊÌÀ>˜Ã«>˜Ì>̈œ˜ÊÀiVˆ«ˆi˜ÌÃÊÜ…œÊ`iÛiœ«ÊV>À`ˆ>VÊÛ>ÛՏœ«>Ì…Þ
Antibiotic prophylaxis is recommended for the following dental
procedures ONLY:
UÊ>˜ˆ«Õ>̈œ˜ÊœvÊ}ˆ˜}ˆÛ>Ê̈ÃÃÕiÃÊœÀÊ«iÀˆ>«ˆV>ÊÀi}ˆœ˜ÊœvÊÌiiÌ…
UÊ*iÀvœÀ>̈œ˜ÊœvÊœÀ>Ê“ÕVœÃ>
Antibiotic prophylaxis is recommended for the following
respiratory tract procedures ONLY:
UʘVˆÃˆœ˜ÊœÀÊLˆœ«ÃÞÊœvÊÌ…iÊÀiëˆÀ>ÌœÀÞÊ“ÕVœÃ>
Antibiotic regimens
UÊ“œÝˆVˆˆ˜ÊÓÊ}Ê*"ʣʅœÕÀÊLivœÀiÊ«ÀœVi`ÕÀi
OR
UÊ* Ê>iÀ}Þ\ʏˆ˜`>“ÞVˆ˜ÊÈääÊ“}Ê*"ʣʅœÕÀÊLivœÀiÊ«ÀœVi`ÕÀi
OR
UÊ* Ê>iÀ}Þ\ÊâˆÌ…Àœ“ÞVˆ˜ÊxääÊ“}Ê*"ʣʅœÕÀÊLivœÀiÊ«ÀœVi`ÕÀi
OR
UÊÊ*>̈i˜ÌÊÕ˜>LiÊÌœÊÌ>ŽiÊœÀ>Ê“i`ˆV>̈œ˜\Ê“«ˆVˆˆ˜ÊÓÊ}ÊÉ6ʣʅœÕÀÊ
before procedure OR Cefazolin 1 g IM/IV 5 minute push prior to
procedure
,iviÀi˜Vi\
ÊÕˆ`iˆ˜iÃÊvœÀÊ*ÀiÛi˜Ìˆœ˜ÊœvʘviV̈Ûiʘ`œV>À`ˆÌˆÃ\ʈÀVՏ>̈œ˜ÊÓääÇÆÊ££È\£ÇÎÈqx{°

125. 126
6.19 Guidelines for use of prophylactic antimicrobials
Prophylactic antimicrobials for patients with
solid organ transplants
NOTE:ʏÊ`œÃiÃÊ>ÃÃÕ“iʘœÀ“>ÊÀi˜>ÊvÕ˜V̈œ˜ÆÊ`œÃiÊ“œ`ˆwV>̈œ˜ÃÊ“>ÞÊLiʈ˜`ˆV>Ìi`ÊvœÀÊ
reduced CrCI.
Kidney, kidney-pancreas, pancreas transplants
Indication Agent and dose Duration
Anti-viral prophylaxis (CMV, HSV, VZV)
CMV D-/R- Acyclovir 400 mg PO BID OR
Valacyclovir 500 mg PO BID 3 months
6ʳʜÀʇÉ,³Ê 6>}>˜VˆVœÛˆÀ
†
450 mg PO daily 3 months
6ʳÉ,‡Ê 6>}>˜VˆVœÛˆÀ
†
900 mg PO daily 6 months
Anti-fungal prophylaxis
Kidney Clotrimazole troches 10 mg PO QID OR
Nystatin suspension 500,000 units QID 1 month
‡
Pancreas and kidney Fluconazole 400 mg PO daily 1 month
PCP prophylaxisÊ ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ ÈÊ“œ˜Ì…Ã
Ê -iVœ˜`ʏˆ˜i\ÊÌœÛ>µÕœ˜iÊ£xääÊ“}Ê*"Ê`>ˆÞ
Ê /…ˆÀ`ʏˆ˜i\Ê>«Ãœ˜iIÊ£ääÊ“}Ê*"Ê`>ˆÞÊ",Ê
aerosolized Pentamidine
Acute rejection treated with Thymoglobulin or Muromonab (OKT3)
Anti-viral prophylaxis (CMV, HSV, VZV)
CMV D-/R- Acyclovir 400 mg PO BID OR 3 months
Valacyclovir 500 mg PO BID
6ʳʜÀʇÉ,³Ê 6>}>˜VˆVœÛˆÀ
†
450 mg PO daily 3 months
6ʳÉ,‡Ê 6>}>˜VˆVœÛˆÀ
†
900 mg PO daily 3 months
Anti-fungal prophylaxis Clotrimazole troches 10 mg PO QID 1 month
PCP prophylaxis ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ ÈÊ“œ˜Ì…Ã
Ê -iVœ˜`ʏˆ˜i\ÊÌœÛ>µÕœ˜iÊ£xääÊ“}Ê*"Ê`>ˆÞ
Ê /…ˆÀ`ʏˆ˜i\Ê>«Ãœ˜iIÊ£ääÊ“}Ê*"Ê`>ˆÞÊ",
aerosolized Pentamadine
Liver transplants
Indication Agent and dose Duration
Anti-viral prophylaxis (CMV, HSV, VZV)
CMV D-/R- Acyclovir 400 mg PO BID OR 3 months
Valacyclovir 500 mg PO BID
6ʳʜÀʇÉ,³Ê 6>}>˜VˆVœÛˆÀ
†
450 mg PO daily 3 months
6ʳÉ,‡Ê 6>}>˜VˆVœÛˆÀ
†
900 mg PO daily, 6 months
followed by PCR monitoring
Anti-fungal prophylaxis Fluconazole 400 mg PO daily 6 weeks
PCP prophylaxisÊ ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊÊ £ÓÊ“œ˜Ì…Ã
Ê ÌiÀ˜>̈ÛiÃ\ÊÌœÛ>µÕœ˜iÊ£xääÊ“}Ê*"Ê`>ˆÞÊ
or Dapsone 100 mg PO daily

126. 127
6.19 Guidelines for use of prophylactic antimicrobials
Heart transplants
Indication Agent and dose Duration
Anti-viral prophylaxis (CMV, HSV, VZV)
6ʇÉ,‡Ê œÊ«Àœ«…ޏ>݈ÃÊÕ˜iÃÃÊ-6Ê}ÊœÀÊ6<6Ê}ÊÊ ÎÊ“œ˜Ì…Ã
positive. If positive serology, Valacyclovir
500 mg PO BID
6ʳʜÀʇÉ,³Ê 6>}>˜VˆVœÛˆÀ
†
900 mg PO daily 3 months
6ʳÉ,‡Ê 6>}>˜VˆVœÛˆÀ
†
900 mg PO daily 6 months
Anti-fungal prophylaxis Nystatin suspension 500,000 units QID Until
prednisone
dose ≤ 10
mg/d x 3
months
PCP prophylaxisÊ ˆÀÃÌʏˆ˜i\Ê/*É-8Ê--Êœ˜iÊÌ>LiÌÊ*"Ê`>ˆÞÊ",Ê £ÓÊ“œ˜Ì…Ã
Ê Ê Ê /*É-8Êœ˜iÊ-ÊÌ>LiÌÊ*"ÊÌ…ÀiiÊ̈“iÃÉÜiiŽÊ
Ê -iVœ˜`ʏˆ˜i\Ê>«Ãœ˜iIÊ£ääÊ“}Ê*"Ê`>ˆÞ
Ê /…ˆÀ`ʏˆ˜i\ÊÌœÛ>µÕœ˜iÊ£xääÊ“}Ê*"Ê`>ˆÞÊ
Toxoplasmosis prophylaxis
/œÝœÊ,³Ê ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊÊ£ÓÊ“œ˜Ì…Ã
Ê -iVœ˜`ʏˆ˜i\Ê>«Ãœ˜iIÊ£ääÊ“}Ê*"Ê`>ˆÞÊPLUS
Pyrimethamine and Leucovorin
/œÝœÊ³ÊœÀÊÕ˜Ž˜œÜ˜‡Ê ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ--ÊÌ>LiÌÊ*"Ê`>ˆÞÊ£ÓÊ“œ˜Ì…ÇÊ
ÊÊ`œ˜œÀÊÃÌ>ÌÕÃÊ -iVœ˜`ʏˆ˜i\Ê>«Ãœ˜iIÊ£ääÊ“}Ê*"Ê`>ˆÞÊPLUS Lifelong
Pyrimethamine and Leucovorin
Lung transplants
Indication Agent and dose Duration
Anti-viral prophylaxis
CMV D-/R- Ganciclovir 5 mg/kg IV Q12H x Lifelong
Received 14 days, then Ganciclovir 5 mg/kg IV
non-leukoreduced Q24H x 16 days, then Valacyclovir 500 mg
or CMV unscreened PO BID or Acyclovir 800 mg PO TID x 1 year
PRBCs followed by Acyclovir 200 mg PO TID
CMV D-/R- Valacyclovir 500 mg PO BID or Acyclovir Lifelong
Received leukoreduced 800 mg PO TID x 1 year followed by Acyclovir
or CMV() PRBCs 200 mg PO TID
6ʳʜÀʇÉ,³Ê >˜VˆVœÛˆÀÊxÊ“}ÉŽ}Ê6Ê+£ÓÊÝÊ£{Ê`>ÞÃ]ÊÌ…i˜ÊÊ ˆviœ˜}
Valganciclovir 900 mg PO daily x 3 months
(until CMV shell vial negative from 3 month
surveillance bronchoscopy), then Valacyclovir
500 mg po BID or Acyclovir 800 mg PO TID x
1 year, then Acyclovir 200 mg PO TID lifelong.
6ʳÉ,‡ÊÊÊ >˜VˆVœÛˆÀÊxÊ“}ÉŽ}Ê6Ê+£Ó…ÊÝÊ£{Ê`>ÞÃ]ÊÌ…i˜Êʈviœ˜}
Ganciclovir 5 mg/kg IV daily x 3 months, then
Valganciclovir 900 mg PO daily (until CMV shell

127. 128
6.19 Guidelines for use of prophylactic antimicrobials
vial negative from 6 month surveillance BAL),
then Valacyclovir 500 mg PO BID or Acyclovir
800 mg PO TID x 1 year, then Acyclovir 200 mg
PO TID lifelong.
Anti-fungal prophylaxis
No Aspergillus Inhaled Amphotericin B per protocol During initial
colonization hospitalization
stay
Ê ÞÃÌ>̈˜Êxää]äääÊÕ˜ˆÌÃÊ Ê+ÈÊ՘̈ÊÊÊ ÎqÈÊ“œ˜Ì…ÃÊ
extubated, then Clotrimazole troches
10 mg PO Q6H until prednisone dose

10 mg daily
AspergillusÊVœœ˜ˆâ>̈œ˜Ê 6œÀˆVœ˜>✏iÊ­`œÃi`ÊLÞÊÜiˆ}…Ì®ÊÊÊ ÎqÈÊ“œ˜Ì…ÃÊ

Êșʎ}\Ê6œÀˆVœ˜>✏iÊÓääÊ“}Ê*"Ê

69 kg to Ê™{ÊŽ}\Ê6œÀˆVœ˜>✏i
300 mg PO BID

Ê™{ÊŽ}\Ê6œÀˆVœ˜>✏iÊ{ääÊ“}Ê*"Ê
PCP prophylaxisÊ ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ-ÊÌ>LiÌÊ*"ÊÊ ˆviœ˜}
ÊÊ ÊÌ…ÀiiÊ̈“iÃÉÜiiŽÊ",Ê/*É-8Êœ˜iÊ
SS tablet PO daily
Ê -iVœ˜`ʏˆ˜i\Ê>«Ãœ˜iIÊ£ääÊ“}Ê*"Ê`>ˆÞÊÊ
Ê /…ˆÀ`ʏˆ˜i\ÊÌœÛ>µÕœ˜iÊ£xääÊ“}Ê*"Ê`>ˆÞÊ
ÊrÊ`œ˜œÀ]Ê,ÊrÊÀiVˆ«ˆi˜Ì]Ê­q®ÊrÊÃiÀœ˜i}>̈Ûi]Ê­³®ÊrÊÃiÀœ«œÃˆÌˆÛi
NOTES:
/*É-8ÊÌ…iÀ>«ÞÊÀi`ÕViÃÊÀˆÃŽÊœvʈ˜viV̈œ˜Ê܈̅ÊListeria spp., Nocardia spp., and
Toxoplasmosis, but does not eliminate risk.
For splenectomized patients, antibacterial prophylaxis with Amoxicillin 500 mg PO BID
(or Doxycycline if PCN allergy) is recommended for 1 year.
*Recommended screening for G6PD deficiency prior to initiation of Dapsone.
†
If Valgancylovir is stopped prior to recommended duration of therapy due to intolerance,
recommend initiation of Acylovir or Valacyclovir for antiviral prophylaxis.
‡
/*qÎÊ“œ˜Ì…Ã

128. 129
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Neutropenic fever
NOTE: These guidelines were developed for use in BMT and leukemia
patients and may not be fully applicable in other instances.
Definitions
UÊ iÕÌÀœ«i˜ˆ>\Ê ÊÊxääÉ““
3
UÊÊiÛiÀ\ÊÊ/i“«Ê€ÊÎn°äcÊÊ̈“iÃÊÌÜœÊ>Ìʏi>ÃÌÊÓÊ…œÕÀÃÊ>«>ÀÌÊ",Ê
Temp > 38.3° C times one
TREATMENT
Always tailor antibiotics based on susceptibility profiles
vÊÌ…iÊ«>̈i˜ÌʈÃÊ…Þ«œÌi˜ÃˆÛiÊœÀʜ̅iÀ܈ÃiÊÕ˜ÃÌ>Li]ÊÃiiʺ/Ài>Ì“i˜ÌÊœvÊ
Vˆ˜ˆV>ÞÊÕ˜ÃÌ>LiÊ«>̈i˜Ìûʭœ««œÃˆÌi®°
Initial fever
UÊÊivi«ˆ“iÊÓÊ}Ê6Ê+nÊ´Ê6>˜Vœ“ÞVˆ˜IÊ­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£xä®
OR
UÊ*ˆ«iÀ>Vˆˆ˜ÉÌ>âœL>VÌ>“ÊΰÎÇxÊ}Ê6Ê+{Ê´Ê6>˜Vœ“ÞVˆ˜IÊ­ÃiiÊ`œÃˆ˜}Ê
section p. 150)
I˜`ˆV>̈œ˜ÃÊvœÀÊ6>˜Vœ“ÞVˆ˜\ÊÃÕëiVÌi`Ê,‡ -]ÊÃŽˆ˜Ê>˜`ÊÃœv̇̈ÃÃÕiʈ˜viV̈œ˜Ã]Ê
pneumonia, severe oral or pharyngeal mucositis, history of MRSA infection or
colonization.
OR
UÊ-iÛiÀiÊ* Ê>iÀ}ÞÊ­>˜>«…ޏ>݈ÃÊœÀÊ-ÌiÛi˜Ã‡œ…˜Ãœ˜Ê-Þ˜`Àœ“i®\Ê
Strongly consider allergy consult to verify allergy in patients with
unclear histories (see section on Penicillin allergy, p. 137)
UÊâÌÀiœ˜>“ÊÓÊ}Ê6Ê+nÊPLUS Gentamicin
†
(see dosing section, p. 146)
PLUS Vancomycin (see dosing section, p. 150)
†
If strong concern for nephrotoxicity and no prior fluoroquinolone use, can substitute
Ciprofloxacin 400 mg IV Q8H for Gentamicin.
Step-down therapy for discharge
UÊÊCiprofloxacin 750 mg PO BID PLUS Amoxicillin/clavulanate 875 mg
PO BID
OR
Uʜ݈yœÝ>Vˆ˜Ê{ääÊ“}Ê*"Ê`>ˆÞ

129. 130
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Persistent fever or new fever after 4-7 days in clinically
stable patients without established bacterial infection
UÊœ˜Ìˆ˜ÕiÊ>˜ÌˆLˆœÌˆVÃÊ>LœÛiÊ>˜`ÊÊ>˜ÌˆvÕ˜}>ÊVœÛiÀ>}iÊ
vÊÀiViˆÛˆ˜}ʏÕVœ˜>✏iÊ«Àœ«…ޏ>݈ÃÊœÀʘœÊvÕ˜}>Ê«Àœ«…ޏ>݈Ã\
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{ʈvÊȘÕÃÊ>˜`ÉœÀÊV…iÃÌÊ/ʘœÌÊÃÕ}}iÃ̈ÛiÊ
of fungal infection
OR
UÊ6œÀˆVœ˜>✏iÊÈÊ“}ÉŽ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌÜœÊ`œÃiÃÊÌ…i˜Ê{Ê“}ÉŽ}Ê6É
PO Q12H if chest CT suggestive of fungal infection
If receiving Voriconazole or Posaconazole prophylaxis or sinus CT
ÃÕ}}iÃ̈ÛiÊœvÊvÕ˜}>Êˆ˜viV̈œ˜\
UÊ“ ˆÃœ“iÁÊxÊ“}ÉŽ}Ê6Ê+Ó{Ê
Clinically unstable patient and/or persistent fever despite
appropriate antibacterial and antifungal coverage
UÊœ˜ÃՏÌÊ"˜Vœœ}ÞÉ/À>˜Ã«>˜ÌÊÊ
UÊ6>˜Vœ“ÞVˆ˜Ê­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜]Ê«°Ê£xä®ÊPLUS Meropenem 1 g IV
+nÊ´Ê“ˆŽ>Vˆ˜ÊˆvÊ«>̈i˜ÌÊÕ˜ÃÌ>LiÊ­ÃiiÊ`œÃˆ˜}ÊÃiV̈œ˜Ê«°Ê£{È®Ê
OR
UÊ-iÛiÀiÊ* Ê>iÀ}Þ\Êœ˜ÃՏÌÊ"˜Vœœ}ÞÉ/À>˜Ã«>˜ÌÊÊ

130. 131
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Prophylactic antimicrobials for patients with
expected prolonged neutropenia
NOTE:ʏÊ`œÃiÃÊ>ÃÃÕ“iʘœÀ“>ÊÀi˜>ÊvÕ˜V̈œ˜ÆÊ`œÃiÊ“œ`ˆwV>̈œ˜ÃÊ“>ÞÊLiʈ˜`ˆV>Ìi`ÊvœÀÊ
reduced CrCI.
1. Leukemia patients
Indication Agent and dose Duration
Antibacterial prophylaxis Moxifloxacin 400 mg PO daily PLUS Day 1 until
Amoxicillin 500 mg PO TID (start on day 5) ANC
100/mm
3
OR
initiation of
ºˆÀÃÌÊiÛiÀ»Ê
antibiotics
˜ÌˆvÕ˜}>Ê«Àœ«…ޏ>݈ÃÊ ˆÀÃÌʏˆ˜i\Ê6œÀˆVœ˜>✏iÊ­ÃiiÊ`œÃˆ˜}ʈ˜Ê /ÊÃiV̈œ˜®Ê >ÞÊ£Ê՘̈ÊÊ
Ê -iVœ˜`ʏˆ˜i\Ê*œÃ>Vœ˜>✏iÊÃÕëi˜Ãˆœ˜ÊÓääÊ“}ÊÊ Ê
PO TID OR 300 mg tablet daily 100/mm
3

Ê ÌiÀ˜>̈ÛiÃ\ʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{Ê",ÊÊ Ê
Fluconazole 400 mg PO daily
Antiviral prophylaxis Valacyclovir 500 mg PO BID OR Acyclovir Day 1 until
800 mg PO BID ANC
Ê vÊÛœ“ˆÌˆ˜}ÊœÀÊ`ˆ>ÀÀ…i>\ÊVÞVœÛˆÀÊÓxäÊ“}É“
2
100/mm
3

IV Q12H
†
**Ê«Àœ«…ޏ>݈ÃÊÊ ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊÊ >ÞÊ£Ê՘̈ÊÊ
in high risk patients
‡
Ê -iVœ˜`ʏˆ˜i\Ê>«Ãœ˜iÊ£ääÊ“}Ê*"Ê`>ˆÞÊ ˆ““Õ˜œ‡ÊÊ
Ê /…ˆÀ`ʏˆ˜i\ÊÌœÛ>µÕœ˜iÊÇxäÊ“}Ê*"Ê Ê ÃÕ«ÀiÃÈœ˜Ê
resolves
2. Lymphoma, myeloma patients
Indication Agent and dose Duration
Antibacterial prophylaxis Moxifloxacin 400 mg PO daily Day 7 of
(lymphoma only) chemo until
ANC
500/mm
3
Antifungal prophylaxis Fluconazole 200 mg PO daily Day 1
through all
cycles of
chemo-
therapy in
high risk
patients.
Antiviral prophylaxis Valacyclovir 500 mg PO BID OR Acyclovir Day 7 through
800 mg PO BID all cycles of
Ê vÊÛœ“ˆÌˆ˜}ÊœÀÊ`ˆ>ÀÀ…i>\ÊVÞVœÛˆÀÊÓxäÊ“}É“
2
chemo-
IV Q12H
†
therapy
**Ê«Àœ«…ޏ>݈ÃÊÊ ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊÊ >ÞÊÇÊÌ…ÀœÕ}…Ê
in high risk patients
‡
Ê -iVœ˜`ʏˆ˜i\Ê>«Ãœ˜iÊ£ääÊ“}Ê*"Ê`>ˆÞÊ >ÊVÞViÃÊœvÊÊ
Ê /…ˆÀ`ʏˆ˜i\ÊÌœÛ>µÕœ˜iÊÇxäÊ“}Ê*"Ê Ê V…i“œ‡ÊÊ
therapy

131. 132
6.20 Guidelines for use of antimicrobials in neutropenic hosts
3. Bone marrow transplant patients/peripheral blood stem cell transplant patients
Indication Agent and dose Duration
Antibacterial prophylaxis* Moxifloxacin 400 mg PO daily Day zero until
engraftment
Antifungal prophylaxis Fluconazole 400 mg PO daily Day zero until
ANC
500/mm
3
˜ÌˆvÕ˜}>Ê«Àœ«…ޏ>݈Ãʈ˜ÊÊ ˆÀÃÌʏˆ˜i\Ê*œÃ>Vœ˜>✏iÊÃÕëi˜Ãˆœ˜ÊÓääÊ“}Ê*"
patients with GVHD
¶
TID OR 300 mg tablets daily
Ê -iVœ˜`ʏˆ˜i\Ê6œÀˆVœ˜>✏iÊ­`œÃi`ÊLÞÊÜiˆ}…Ì®
69 kg Voriconazole 200 mg PO BID
69 kg to 94 kg Voriconazole 300 mg PO BID
94 kg Voriconazole 400 mg PO BID
Antiviral prophylaxis Valacyclovir 500 mg PO BID OR Day zero
Acyclovir 800 mg PO BID until 1 yr
Ê vÊÛœ“ˆÌˆ˜}ÊœÀÊ`ˆ>ÀÀ…i>\ÊVÞVœÛˆÀÊÓxäÊ“}É“
2
(allogeneic
IV Q12H
†
transplants)
or 6 months
(autologous
transplants)
PCP prophylaxis
†
Ê ˆÀÃÌʏˆ˜i\Ê/*É-8Êœ˜iÊ--ÊÌ>LÊ*"Ê`>ˆÞÊ œ}i˜iˆVÊ
Ê -iVœ˜`ʏˆ˜i\/*É-8Ê-ÊÌ>LÊÓÊ̈“iÃÊÜiiŽÞÊÊ ÌÀ>˜Ã«>˜Ì\Ê
OR Dapsone 100 mg PO daily Day 21 or
Ê /…ˆÀ`ʏˆ˜i\ÊÌœÛ>µÕœ˜iÊÇxäÊ“}Ê*"Ê Ê i˜}À>vÌ“i˜ÌÊ
Ê œÕÀ̅ʏˆ˜i\Ê*i˜Ì>“ˆ`ˆ˜iÊÎääÊ“}Ê Ê+ÓnÊ`>ÞÃÊ ­Ü…ˆV…iÛiÀÊ
is later)
until at least
1 year
(longer if
steroids or
ongoing risk)
Autologous
ÊÊ Ê ÌÀ>˜Ã«>˜Ì\Ê
Engraftment
until 6 months
NOTES:
/*É-8ÊÌ…iÀ>«ÞÊÀi`ÕViÃÊÀˆÃŽÊœvʈ˜viV̈œ˜Ê܈̅Êi˜V>«ÃՏ>Ìi`ÊL>VÌiÀˆ>]ÊListeria spp., Nocardia
spp., and Toxoplasmosis, but does not eliminate risk. It is the preferred antibiotic regimen for
PCP prophylaxis.
*In patients with fluoroquinolone allergy or who cannot tolerate a fluoroquinolone due to QTc
prolongation, consider Cefpodoxime 400 mg PO BID.
†
Acyclovir should be dosed by ideal body weight
‡
Þiœ“>Ê«>̈i˜ÌÃʈvÊœ˜ÊÃÌiÀœˆ`ÃÆÊÞ“«…œ“>Ê«>̈i˜ÌÃʈvÊ6³]Êœ˜ÊV…Àœ˜ˆVÊÃÌiÀœˆ`Ã]ÊyÕ`>À>Lˆ˜i°
iÕŽi“ˆ>Ê«>̈i˜ÌÃ\Ê]ÊV…Àœ˜ˆVÊÃÌiÀœˆ`Ã]ÊÃÉ«Ê /Ê՘̈Ê£ÊÞi>ÀÊ>vÌiÀÊÌÀ>˜Ã«>˜Ì]ÊœÀÊ«>̈i˜ÌÊÜ…œÊ
received cladribine, fludarabine, or alemtuzumab.
¬"Ì…iÀÊ«Àœ«…ޏ>݈Ãʈ˜Ê>VÕÌiÊ6\ʜ݈yœÝ>Vˆ˜]Ê/*É-8°

132. 133
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Guidelines for the use of antifungal agents in
hematologic malignancy patients
Filamentous fungi
ID consult recommended for assistance with antifungal selection
TREATMENT
Aspergillus spp.
Initial therapy
UÊÊ6œÀˆVœ˜>✏iÊÈÊ“}ÉŽ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌÜœÊ`œÃiÃÊÌ…i˜Ê{Ê“}ÉŽ}Ê6É
PO Q12H (see Voriconazole guidelines, p. 19, for more information).
OR
UÊ“ ˆÃœ“i
® 5
mg/kg IV Q24H
NOTES:
UÊÊ6œÀˆVœ˜>✏iʈÃÊVœ˜Ãˆ`iÀi`ÊLÞÊ“>˜ÞÊÌœÊLiÊÌ…iÊwÀÃ̇ˆ˜iÊÌÀi>Ì“i˜ÌÊœvÊ
suspected filamentous fungal infections in the immunocompromised
host as most of these infections are caused by Aspergillus species.
Although the data are limited, Voriconazole appears more effective
than Amphotericin for this very serious infection.
UÊÊœ“Lˆ˜>̈œ˜Ê>˜ÌˆvÕ˜}>ÊÌ…iÀ>«ÞÊVœ˜ÃˆÃ̈˜}ÊœvÊ6œÀˆVœ˜>✏iÊPLUS
Micafungin should be considered for the treatment of confirmed
invasive aspergillosis that is documented by culture, positive
galuctomannan assay, or histopathology for the first two weeks
of therapy. Longer duration of combination therapy has not been
evaluated.
Fusarium spp.
UÊÊÊVœ˜ÃՏÌÊÃ…œÕ`ÊLiʈ˜ÛœÛi`ʈ˜ÊÌ…iÃiÊV>Ãið
UÊÊ6œÀˆVœ˜>✏iÊÈÊ“}ÉŽ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌÜœÊ`œÃiÃÊÌ…i˜Ê{Ê“}ÉŽ}Ê
IV/PO Q12H PLUS Ambisome 5 mg/kg IV Q24H (see Voriconazole
guidelines, p. 19, for more information). Dose escalation may be
necessary for some patients.
Scedosporium apiospermum
UÊÊ6œÀˆVœ˜>✏iÊÈÊ“}ÉŽ}Ê6É*"Ê+£ÓÊ̈“iÃÊÌÜœÊ`œÃiÃÊÌ…i˜Ê{Ê“}ÉŽ}Ê
IV/PO Q12H PLUS Micafungin 100 mg IV Q24H (see Voriconazole
guidelines, p. 19, for more information).
NOTE:
UÊÊ/Ài>Ì“i˜ÌÊ܈̅ʜ̅iÀÊ>}i˜ÌÃÊ…>ÃÊÞˆi`i`Ê`ˆÃ>««œˆ˜Ìˆ˜}ÊÀiÃՏÌðÊ
Voriconazole appears to be the best option but the data are limited.

133. 6.20 Guidelines for use of antimicrobials in neutropenic hosts
134
Zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
UÊ“ ˆÃœ“i
®
5 mg/kg IV once daily PLUS a second antifungal agent
UÊÊÊVœ˜ÃՏÌÊÀiµÕˆÀi`°
UÊÊ-ÕÀ}ˆV>Ê`iLÀˆ`i“i˜ÌÊ>˜`ÊVœÀÀiV̈œ˜ÊœvÊÕ˜`iÀÞˆ˜}ÊÀˆÃŽÊv>VÌœÀÃÊ­i°}°Ê
acidosis, hyperglycemia) are critical.
Candida
TREATMENT
UÊÊ9-/Ê ÊÊ ""Ê1/1,Ê-"1Ê 6,Ê Ê" -,ÊÊ
CONTAMINANT.
UÊÊ-iiÊÃiV̈œ˜ÃÊLiœÜÊœ˜Êi“«ˆÀˆVÊÌ…iÀ>«ÞÊ>˜`Êœ˜Ê«>Ì…œ}i˜‡Ã«iVˆwVÊ
therapy.
Unspeciated candidemia
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{
OR
UÊ“ ˆÃœ“i
®
5 mg/kg IV Q24H
If the yeast is C. albicans or C. glabrata, the recommendations for C.
albicans noted below can be followed. If the yeast is not C. albicans,
await speciation before modifying therapy as recommended below.
NOTE: Micafungin does not cover Cryptococcus
Candida albicans
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{
OR
UÊÊ“ ˆÃœ“i
®
ÊÎqxÊ“}ÉŽ}Ê6Ê+Ó{
NOTE: Patients who are clinically stable and no longer neutropenic can
be switched to Fluconazole if the organism is susceptible.
Candida glabrata
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{
OR
UÊÊ“ ˆÃœ“i
®
5 mg/kg IV Q24H
Candida krusei
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{
OR
UÊÊ“ ˆÃœ“i
®
5 mg/kg IV Q24H

134. 135
A
135
6.20 Guidelines for use of antimicrobials in neutropenic hosts
NOTE: C. krusei is intrinsically resistant to Fluconazole and these
infections can be difficult to treat. In stable patients, Voriconazole can be
used if susceptible and oral therapy is desired. (See p. 19 for dosing).
Candida parapsilosis
UÊ“ ˆÃœ“i
®
ÊÎqxÊ“}ÉŽ}Ê6Ê+Ó{Ê
NOTES:
UÊÊœÃÌÊC. parapsilosis isolates remain susceptible to Fluconazole, which
can be used in stable and non-neutropenic patients.
UÊÊ/…iÀiÊ>Àiʏˆ“ˆÌi`Ê`>Ì>ÊÌ…>ÌÊÃÕ}}iÃÌÊÌ…>ÌʈV>vÕ˜}ˆ˜Ê“>ÞÊLiʈ˜viÀˆœÀÊÌœÊ
Amphotericin B in these infections.
Candida tropicalis
UʈV>vÕ˜}ˆ˜Ê£ääÊ“}Ê6Ê+Ó{
OR
UÊÊ“ ˆÃœ“i
®
ÊÎqxÊ“}ÉŽ}Ê6Ê+Ó{
TREATMENT NOTES










Notes on antifungal susceptibility testing
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊvœÀʏÕVœ˜>✏i]ÊÌÀ>Vœ˜>✏i]Ê6œÀˆVœ˜>✏i]Ê
Flucytosine (5-FC), and Micafungin is performed routinely on the first
yeast isolate recovered from blood.
Hidden Content
- JHH Internal use only

135. A
136136
6.20 Guidelines for use of antimicrobials in neutropenic hosts
UÊʏÕVœ˜>✏iÊ>˜`ʈV>vÕ˜}ˆ˜ÊÃÕÃVi«ÌˆLˆˆÌˆiÃÊ>ÀiÊÀi«œÀÌi`Êœ˜Ê>ÊLœœ`Ê
isolates.
UÊÊ"À}>˜ˆÃ“ÃÊÌ…>ÌÊ…>ÛiʈV>vÕ˜}ˆ˜ÊÃʈ˜ÊÌ…iÊÀ>˜}iÊœvÊ£qÓÊ“V}É“Ê
(reported as susceptible) may not respond to treatment. ID consult is
recommended in these cases.
UÊÊSusceptibility testing for conventional Amphotericin B is done routinely
for C. lusitaniae and C. guillemondii and for other organisms by
request.
UÊÊ-ÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ÊÜ…i˜\Ê
UÊÊÕVœVÕÌ>˜iœÕÃÊV>˜`ˆ`ˆ>ÈÃʈÃÊÀivÀ>VÌœÀÞÊ̜ʏÕVœ˜>✏i
UÊÊ/Ài>̈˜}ÊœÃÌiœ“ÞiˆÌˆÃ]Ê“i˜ˆ˜}ˆÌˆÃ]ÊœÀÊi˜`œ«…Ì…>“ˆÌˆÃÊ܈̅Ê
Fluconazole
UÊÊ œœ`ÊVՏÌÕÀiÃÊ>ÀiÊ«iÀÈÃÌi˜ÌÞÊ«œÃˆÌˆÛiÊœ˜ÊÕVœ˜>✏i
UÊÊ œ˜‡ÀœṎ˜iÊÃÕÃVi«ÌˆLˆˆÌÞÊÌiÃ̈˜}ÊV>˜ÊLiÊ>ÀÀ>˜}i`ÊLÞÊV>ˆ˜}ÊÌ…iÊ
mycology lab at 5-6148
,iviÀi˜Vi\
-ÊÕˆ`iˆ˜iÃÊvœÀÊ/Ài>Ì“i˜ÌÊœvÊ>˜`ˆ`ˆ>ÈÃ\ʏˆ˜Ê˜viVÌʈÃÊÓää™Æ{n\xäΰ

136. 137
7.1 Approach to the patient with a history of penicillin allergy
137
Approach to the patient with a history
of penicillin allergy
Penicillin reactions – Incidence
UÊÊÊ n䇙ä¯ÊœvÊ«>̈i˜ÌÃÊÜ…œÊÀi«œÀÌÊÌ…iÞÊ>Àiʺ>iÀ}ˆV»ÊÌœÊ* Ê>VÌÕ>ÞÊ…>ÛiÊ
negative skin tests and are not at increased risk of an allergic reaction.
UÊÊ*i˜ˆVˆˆ˜ÊÀi>V̈œ˜ÃÊœvÊÃœ“iÊÌÞ«iÊœVVÕÀʈ˜Êä°ÇÊ̜ʣä¯ÊœvÊ>Ê«>̈i˜ÌÃÊ
who get the drug.
UÊÊ 1/\Ê/…iʈ˜Vˆ`i˜ViÊœvÊ>˜>«…ޏ>V̈VÊÀi>V̈œ˜ÃʈÃÊä°ää{¯ÊÌœÊä°ä£x¯°
UÊÊ,>ÌiÃÊœvÊVÀœÃÇÀi>V̈œ˜Ê>iÀ}ˆiÃÊÌœÊVi«…>œÃ«œÀˆ˜ÃÊ>ÀiÊÕ˜Ž˜œÜ˜ÊLÕÌÊ
thought to be low.
UÊÊ,>ÌiÃÊœvÊ* Ê>˜`ÊV>ÀL>«i˜i“ÊÃŽˆ˜ÊÌiÃÌÊVÀœÃÃÊÀi>V̈ۈÌÞÊ>ÀiÊ{ǯ]Ê
although clinical rates of hypersensitivity reactions in patients with
Ài«œÀÌi`Ê* Ê>iÀ}ÞÊÜ…œÊÀiViˆÛiÊV>ÀL>«i˜i“ÃÊ>ÀiÊ™q££¯°
UÊÊÀœÃÃÊÀi>V̈œ˜ÃÊ̜ʓœ˜œL>VÌ>“ÃÊ­âÌÀiœ˜>“®Ê`œÊ "/Ê>««i>ÀÊ̜ʜVVÕÀ°
Penicillin skin testing
UÊÊ7…i˜Ê`œ˜iÊVœÀÀiV̏Þ]ʈÃÊ…ˆ}…ÞÊ«Ài`ˆV̈ÛiÊœvÊÃiÀˆœÕÃ]Ê>˜>«…ޏ>V̈VÊÀi>V̈œ˜Ã°
UÊÊ*>̈i˜ÌÃÊ܈̅Ê>ʘi}>̈ÛiÊÃŽˆ˜ÊÌiÃÌÊ>ÀiÊNOT at risk for anaphylactic reactions.
UÊÊ,>ÀiÞ]ÊÃŽˆ˜ÊÌiÃÌʘi}>̈ÛiÊ«>̈i˜ÌÃÊ“>ÞÊ}iÌÊ“ˆ`Ê…ˆÛiÃÊ>˜`ʈÌV…ˆ˜}Ê
following penicillin administration but these RESOLVE with continued
treatment.
UÊÊ-Žˆ˜ÊÌiÃÌÃÊV>˜˜œÌÊ«Ài`ˆVÌÊ`iÀ“>Ìœœ}ˆVÊœÀÊÊÀi>V̈œ˜ÃÊœÀÊ`ÀÕ}ÊviÛiÀð
UÊÊ-Žˆ˜ÊÌiÃ̈˜}ʈÃʘœÜÊ>Û>ˆ>LiÊ>ÌÊ°Ê*i>ÃiÊVœ˜ÃՏÌʏiÀ}ÞÊ>˜`Ê
Immunology.
Penicillin reactions—Types
UÊ ImmediateÊ­ÌÞ«iÊ£®Êqʘ>«…ޏ>݈Ã]Ê…Þ«œÌi˜Ãˆœ˜]ʏ>ÀÞ˜}i>Êi`i“>]Ê
wheezing, angioedema, urticaria
UÊʏ“œÃÌÊ>Ü>ÞÃÊœVVÕÀÊwithin 1 hour of administration. Hypotension
always occurs soon after administration
UÊÊ>˜ÊLiÊ«Ài`ˆVÌi`ÊLÞÊÃŽˆ˜ÊÌiÃÌÃ
UÊ AcceleratedÊqÊ>ÀÞ˜}i>Êi`i“>]ÊÜ…ii∘}]Ê>˜}ˆœi`i“>]ÊÕÀ̈V>Àˆ>Ê
(NOT hypotension)
UÊÊ"VVÕÀÊ܈̅ˆ˜Ê£‡ÇÓÊ…œÕÀÃÊœvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜
UÊÊ>˜ÊLiÊ«Ài`ˆVÌi`ÊLÞÊÃŽˆ˜ÊÌiÃÌÃ
UÊ LateÊqÊ,>Ã…Ê­“>VՏœ«>«Õ>ÀÊœÀÊ“œÀLˆˆvœÀ“ÊœÀÊVœ˜Ì>VÌÊ`iÀ“>̈̈î]Ê
destruction of RBC, WBC, platelets, serum sickness
UÊʏ“œÃÌÊ>Ü>ÞÃÊœVVÕÀÊ>vÌiÀÊÇÓÊ…œÕÀÃÊœvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜
UÊÊ,>Ã…iÃÊÃœ“ï“iÃÊ}œÊ>Ü>ÞÊ`iëˆÌiÊVœ˜Ìˆ˜Õi`ÊÌÀi>Ì“i˜Ì
UÊÊ>VՏœ«>«Õ>ÀÊ>˜`Ê“œÀLˆˆvœÀ“ÊÀ>Ã…iÃÊ"Ê "/Ê«Àœ}ÀiÃÃÊÌœÊ
Stevens-Johnson syndrome
UÊÊ>ÌiÊÀi>V̈œ˜ÃÊ>ÀiÊ "/Ê«Ài`ˆVÌi`ÊLÞÊÃŽˆ˜ÊÌiÃÌÃ
UÊ Stevens-Johnson SyndromeÊqÊiÝvœˆ>̈ÛiÊ`iÀ“>̈̈ÃÊ܈̅ʓÕVœÕÃÊ
membrane involvement

137. 138138
7.1 Approach to the patient with a history of penicillin allergy
UÊʏ“œÃÌÊ>Ü>ÞÃÊœVVÕÀÊ>vÌiÀÊÇÓÊ…œÕÀÃÊœvÊ>`“ˆ˜ˆÃÌÀ>̈œ˜
UÊÊ "/Ê«Ài`ˆVÌi`ÊLÞÊ>Ê…ˆÃÌœÀÞÊœvÊÀ>Ã…Ê",ÊLÞÊÃŽˆ˜ÊÌiÃÌÃ
Approach to the patient with reported penicillin allergy
UÊÊ Àˆiv]ÊvœVÕÃi`Ê…ˆÃÌœÀÞÊV>˜ÊLiÊ6,9Ê…i«vՏ°
UÊÊ+ÕiÃ̈œ˜ÃÊÌœÊ>ÃŽ\
1. How long after beginning penicillin did the reaction occur?
2. Was there any wheezing, throat or mouth swelling, urticaria?
3. If a rash occurred, what was the nature of the rash? Where was it
and what did it look like?
4. Was the patient on other medications at the time of the reaction?
5. Since then, has the patient ever received another penicillin or
Vi«…>œÃ«œÀˆ˜Ê­>ÃŽÊ>LœÕÌÊÌÀ>`iʘ>“iÃʏˆŽi\ÊÕ}“i˜Ìˆ˜]ÊiyiÝ]Ê
Trimox, Ceftin, Vantin)?
6. If the patient received a beta-lactam, what happened?
Interpreting the history of the patient reporting penicillin allergy
UÊÊANY patient who has a history consistent with an immediate
reaction (laryngeal edema, wheezing, angioedema, urticaria)
SHOULD NOT receive beta-lactams without undergoing skin
testing first EVEN IF they have received beta-lactams with no
problems after the serious reaction.
UÊÊ*>̈i˜ÌÃÊÜ…œÊÀi«œÀÌʘœ˜‡>˜>«…ޏ>V̈VÊÀi>V̈œ˜ÃÊ>˜`Ê…>ÛiÊÀiViˆÛi`Ê
other penicillins without problems DO NOT have penicillin allergy
and are not at increased risk for an allergic reaction compared to
the general population.
UÊÊ*>̈i˜ÌÃÊÜ…œÊÀi«œÀÌʘœ˜‡>˜>«…ޏ>V̈VÊÀi>V̈œ˜ÃÊ>˜`Ê…>ÛiÊÀiViˆÛi`Ê
cephalosporins can get cephalosporins but not necessarily PCNs.
UÊÊ*>̈i˜ÌÃÊÜ…œÊÀi«œÀÌÊ>Ê…ˆÃÌœÀÞÊœvÊ>ʘœ˜‡ÕÀ̈V>Àˆ>ÊÀ>Ã…ÊÌ…>ÌʈÃÊ "/Ê
consistent with Stevens-Johnson syndrome (target lesions with
mucous membrane inflammation) and developed after ≥ 72 hours
of penicillin are not at increased risk for an adverse reaction. They
should, however, be watched closely for development of rashes.
UÊÊ*>̈i˜ÌÃÊÜ…œÊÀi«œÀÌÊÀi>V̈œ˜ÃÊVœ˜ÃˆÃÌi˜ÌÊ܈̅ÊÃiÀÕ“ÊÈVŽ˜iÃÃÊ
(rare) can receive either penicillins or cephalosporins with careful
monitoring for recurrence.
UÊÊ*>̈i˜ÌÃÊÜ…œÊÀi«œÀÌÊÊÃÞ“«Ìœ“ÃÊ­`ˆ>ÀÀ…i>]ʘ>ÕÃi>®Ê«ÀœL>LÞÊ`œÊ
not have penicillin allergy and do not appear to be at increased
risk for an adverse reaction. They should be closely observed for
recurrent symptoms and be given supportive therapy if they occur.
,iviÀi˜ViÃ\Ê
ÊÓää£ÆÓnx\Ó{™n°
1ÃiÊœvÊV>ÀL>«i˜i“Ãʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê* Ê>iÀ}Þ\Êʘ̈“ˆVÀœL°Ê…i“œÌ…iÀÊÓää{Æx{\Ê
££xxqÇ°Ê
˜˜Ê˜ÌiÀ˜Êi`ÊÓääÇÆ£{È\ÓÈÈq™°

138. 139
A
139
8.1 Hospital Epidemiology & Infection Control
Hospital Epidemiology and Infection Control
(HEIC)
UÊÊœ˜ÃՏÌÊÌ…iÊÊÜiLÈÌiÊœÀÊÊ«œˆVˆiÃÊœ˜ˆ˜iÊ­*"®Ê­ÜÜÜ°
hopkinsmedicine.org/heic) for detailed isolation charts, HEIC policies,
and surveillance information
Hand hygiene
UÊÊvÊ…>˜`ÃÊ>ÀiʘœÌÊۈÈLÞÊÃœˆi`]ÊÌ…i˜Ê>Vœ…œ‡L>Ãi`Ê…>˜`ÊÃ>˜ˆÌˆâiÀÃÊ>ÀiÊ
recommended for cleaning. If hands are visibly soiled, wash hands
with soap and water for at least 15 seconds.
UÊÊ>˜`Ê…Þ}ˆi˜iʈÃÊÀiµÕˆÀi`ÊÕ«œ˜Êi˜ÌiÀˆ˜}Ê>Ê«>̈i˜ÌÊÀœœ“]ÊÕ«œ˜Êï݈˜}]Ê
between patients in a semi-private room, and other times per hospital
policy.
UÊÊ1ÃiÊÃœ>«Ê>˜`ÊÜ>ÌiÀÊÕ«œ˜Êexiting the room of a patient with
C. difficile infection.
UÊÊ œÊ>À̈wVˆ>Êw˜}iÀ˜>ˆÃÊ>ÀiÊ«iÀ“ˆÌÌi`ÊvœÀÊ>˜ÞÊÃÌ>vvÊ“i“LiÀÊÜ…œÊ…>ÃÊ
patient contact or handles sterile supplies.
Bloodborne pathogen exposures (needlestick or other exposure)
The prompt treatment of injuries and exposures is vital to prevent the
transmission of disease. Whatever the exposure, IMMEDIATE cleaning of
the exposure site is the first priority.
UÊÊ-Žˆ˜Êܜ՘`ÃÊÃ…œÕ`ÊLiÊVi>˜i`Ê܈̅ÊÃœ>«Ê>˜`ÊÜ>ÌiÀ
UÊÊÕVœÕÃÊ“i“LÀ>˜iÃÊÃ…œÕ`ÊLiÊyÕÃ…i`ÊÌ…œÀœÕ}…ÞÊ܈̅ÊÜ>ÌiÀ
UÊÊÞiÃÊÃ…œÕ`ÊLiʈÀÀˆ}>Ìi`Ê܈̅Ê>ʏˆÌiÀÊœvʘœÀ“>ÊÃ>ˆ˜i
vÌiÀÊVi>˜ˆ˜}ÊÌ…iÊiÝ«œÃÕÀiÊÈÌi]ÊV>Êx‡-/8Ê­x‡Çn{™®Ê>˜`ÊvœœÜÊ
instructions to contact the ID physician. Workplace injuries should be
Ài«œÀÌi`ʈ““i`ˆ>ÌiÞÊœ˜ÊÌ…iʺ“«œÞiiÊ,i«œÀÌÊœvʘVˆ`i˜ÌÊœÀ“»Ê>˜`Ê
to the Occupational Injury ClinicÊ­ >œVŽÊ£Î™]Êœ˜`>ÞqÀˆ`>Þ]ÊÇ\ÎäÊ
a.m. to 4 p.m., 5-6433), and to your supervisor.
Standard Precautions
UÊÊ,œṎ˜iÊ…>˜`Ê…Þ}ˆi˜iÊ UÊÊ >}ÊVœ˜Ì>“ˆ˜>Ìi`ʏˆ˜i˜Ê>ÌÊ«œˆ˜ÌÊœvÊÕÃi
UÊÊœ˜ÃˆÃÌi˜ÌÊ>˜`ÊVœÀÀiVÌÊ}œÛiÊÕÃiÊÊ UÊÊ,i}Տ>ÀÊVi>˜ˆ˜}ÊœvÊi˜ÛˆÀœ˜“i˜Ì>Ê
surfaces
UÊ««Àœ«Àˆ>ÌiÊÕÃiÊœvÊ}œÜ˜ÃÊ̜ʫÀiÛi˜ÌÊÊ UÊ,œṎ˜iÊVi>˜ˆ˜}ÊœÀÊ`ˆÃ«œÃ>Êœv
contamination of uniform/clothing patient-care equipment
UÊ««Àœ«Àˆ>ÌiÊÕÃiÊœvÊ“>ÃŽÃ]ÊiÞiÊÊ UÊ-ÌÀˆVÌÊ>`…iÀi˜ViÊÌœ
protection and face shields (i.e., when occupational safety requirements
suctioning, or when splash likely)

139. A
140
8.1 Hospital Epidemiology & Infection Control
140
Communicable diseases—exposures and reporting
ÊÃ…œÕ`ÊLiʘœÌˆwi`\
UÊÊvÊ«>̈i˜ÌÃÊœÀÊ7ÃÊ>ÀiÊiÝ«œÃi`ÊÌœÊ>ÊVœ““Õ˜ˆV>LiÊ`ˆÃi>ÃiÊ­ˆ°i°Ê
meningococcal disease, varicella, TB etc.)
UÊÊLœÕÌÊ7ÃÊ܈̅Ê>VÕÌiÊ…i«>̈̈ÃÊ]Ê ÊœÀÊ]Ê->“œ˜i>]Ê-…ˆ}i>]Ê
Campylobacter, or pneumonia requiring hospital admission
UÊÊLœÕÌÊ>˜ÞÊÕ˜ÕÃÕ>ÊœVVÕÀÀi˜ViÊœvÊ`ˆÃi>ÃiÊœÀÊVÕÃÌiÀ]Ê«>À̈VՏ>ÀÞÊ
diseases that have the potential to expose many susceptible
individuals
UÊÊ-ÕëˆVˆœ˜ÊœÀÊ`ˆ>}˜œÃiÃÊœvÊÌ…iÊvœœÜˆ˜}Ê`ˆÃi>ÃiÃÊ­`ˆÃi>ÃiÃÊ܈̅Ê
require immediate notification by phone or pager). If disease is
in a HCW, notify HEIC and Occupational Health (98 N. Broadway,
-ÕˆÌiÊ{Ó£]Êœ˜`>ÞqÀˆ`>Þ]ÊÇ\ÎäÊ>°“°ÊÌœÊ{\ääÊ«°“°]Êx‡ÈÓ££®Ê
immediately
Anthrax
Avian Influenza
Botulism
Brucellosis
Creutzfeldt-Jakob disease (CJD)

Diphtheria

Glanders
Highly resistant organisms (i.e. VISA,
VRSA)

Legionellosis
Measles (rubeola)

Meningococcal disease
Monkeypox
Mumps
Pertussis

Plague
Poliomyelitis
Q Fever
Rabies
Ricin toxin
Rubella (German measles) Salmonellosis SARS

Scabies Shigellosis Smallpox (orthopox viruses)

Streptococcal Group A or B invasive disease

Tuberculosis
Tularemia
Varicella (chickenpox or disseminated zoster)

Viral hemorrhagic fever
Yellow Fever
Physicians are required to report communicable disease to the
>Ìˆ“œÀiʈÌÞÊi>Ì…Êi«>ÀÌ“i˜ÌÊ­{£ä‡Î™È‡{{ÎÈ]Êv>Ý\Ê{£ä‡ÈÓx‡äÈnn®°Ê
For a complete list of communicable diseases, see the HEIC Web site,
Ì…iÊÊ7iLÊÈÌi]Ê…ÌÌ«\ÉɈ`i…>°`…“…°“>Àޏ>˜`°}œÛÉ-ˆÌi*>}iÃÉÜ…>̇
to-report.aspx or the BCHD Web site, www.baltimorehealth.org/acd.
html.

140. 141141
8.2 Infection control precautions
JHH Precautions Categories
These precaution categories must be used in addition to Standard Precautions. The following table includes general requirements for precaution
categories. The complete table and the type of isolation required for each organism can be found on the HEIC website. If reco mmendations on this table
cannot be followed, please contact HEIC.
Contact Droplet Airborne
Precautions Precautions Precautions
(sign color) (pink) (orange) (blue) ¶
Private room Required unless Required unless Required
cohorted cohorted*
Door closed No No Yes
Mask/Eye Protection No If within 6 feet PAPR or N95
†
to
of patient enter room‡
Gown and Gloves To enter room To enter room No
Examples MRSA, C.diff, zoster§ Influenza, bacterial TB, disseminated
meningitis zoster§
* Required for pertussis and diphtheria
†
Fit-testing is required to use an N95 mask for airborne precautions
‡ HCWs who are Varicella-immune do not have to wear a PAPR or N95 if patient is in isolation for zoster or chickenpox
§ Disseminated zoster, zoster in an immunocompromised host, and chickenpox require both Contact and Airborne Precautions

141. 142142
8.3 Disease-specific infection control recommendations
Disease-specific infection control
recommendations
Carbapenem-resistant Enterobacteriaceae (CRE)
Routine active surveillance cultures for CRE are performed in patients
who have been hospitalized in a country other than the U.S. in the past
6 months. Patients are placed on Contact Precautions pending cullture
results. The results are to be used for isolation purposes, not to guide
therapy or clinical care. The overwhelming majority of positive
surveillance cultures represents colonization, not infection, and
should not prompt any antimicrobial therapy.
Creutzfeldt-Jakob disease (CJD)
CJD, variant CJD and other diseases caused by prions are resistant to a
number of standard sterilization and disinfection procedures. Iatrogenic
transmission of CJD has been associated with percutaneous exposure
to medical instruments contaminated with prion/central nervous system
(CNS) tissue residues, transplantation of CNS and corneal tissues and
recipients of human growth hormone and gonadotropin. Transmission of
CJD has not been associated with environmental contamination or from
person-to-person via skin contact. The following additional precautions
must be made when processing equipment that could be contaminated
܈̅ʫÀˆœ˜ÊÀi>Ìi`Ê“>ÌiÀˆ>\
UÊÊ œÌˆvÞÊÊ>˜`ÊÌ…iÊÕ˜ˆÌÊ“>˜>}iÀÉV…>À}iʘÕÀÃiʈ““i`ˆ>ÌiÞÊœvÊ>˜ÞÊ
suspected or confirmed CJD case and refer to the CJD policy on the
HEIC Web site.
UÊÊ1ÃiÊ`ˆÃ«œÃ>LiÊiµÕˆ«“i˜ÌÊÜ…i˜iÛiÀÊ«œÃÈLi°Êvʘœ˜‡`ˆÃ«œÃ>LiÊ
equipment is used, Central Sterile Department shall be notified prior to
the start of the procedure.
UÊÊ>LiÊ>Ê>LœÀ>ÌœÀÞÊ>˜`Ê«>Ì…œœ}ÞÊÀiµÕˆÃˆÌˆœ˜ÃÊ>ÃÊÃÕëiVÌi`ÊÊ>˜`Ê
notify the lab before sending specimens.
UÊÊ/…iÊvœœÜˆ˜}Ê>ÀiÊVœ˜Ãˆ`iÀi`Ê…ˆ}…Þʈ˜viV̈ÛiÊ>˜`ÊÃ…œÕ`ÊLiÊ…>˜`i`Ê
܈̅ÊiÝÌÀi“iÊV>Ṏœ˜\ÊLÀ>ˆ˜]Ê눘>ÊVœÀ`]Êœ«ÌˆVÊ̈ÃÃÕiÃÊ>˜`Ê«ˆÌÕˆÌ>ÀÞÊ
gland
UÊÊ/…iÊvœœÜˆ˜}Ê>ÀiÊVœ˜Ãˆ`iÀi`ÊÌœÊLiÊœvʏœÜiÀʈ˜viV̈ۈÌÞ\Ê-]ÊŽˆ`˜iÞ]Ê
liver, lung, lymph nodes, spleen, placenta, tonsillar tissue and olfactory
tissue.
Methicillin-resistant Staphylococcus aureus (MRSA)
Routine active surveillance cultures for MRSA are performed on select
units to identify patients with MRSA. When a culture is positive for
MRSA the patient is placed on Contact Precautions. The results are
to be used for isolation purposes, not to guide therapy or clinical care.
The overwhelming majority of positive surveillance cultures

142. 143143
8.3 Disease-specific infection control recommendations
represents colonization, not infection, and should not prompt
any antimicrobial therapy.
Surveillance cultures should be obtained upon admission and weekly
ˆ˜ÊÌ…iÊvœœÜˆ˜}ÊÕ˜ˆÌÃ\Ê1]Ê71]Ê6-1]Ê-1]Ê/1Ê­™7®]Ê 1]Ê
CCU/PCCU, PICU, NICU, oncology units, Nelson 4.
To remove a patient from MRSA precautions, cultures from the original
site of infection and 2 nares cultures taken ≥ 72 hours apart must be
negative. Nares cultures should not be sent if the patient has received
antibiotics active against MRSA in the previous 48 hours. Once this is
accomplished, call HEIC to review culture data and initiate deflagging.
Pertussis
All patients with pertussis should be placed on Droplet Precautions
for five days from the start of therapy. If the patient is not on therapy,
Droplet Precautions should be continued for three weeks from the onset
of cough. Private room is required.
/Ài>Ì“i˜Ì\
UÊÊâˆÌ…Àœ“ÞVˆ˜ÊxääÊ“}Ê*"Êœ˜ViÊœ˜Ê`>ÞÊ£]ÊÌ…i˜ÊÓxäÊ“}Ê*"Ê`>ˆÞÊœ˜Ê
`>ÞÃÊÓqx
OR
UÊÊ>VÀœˆ`iÊ>iÀ}Þ\Ê/*É-8Ê£Ê-ÊÌ>LiÌÊ*"Ê ÊvœÀÊ£{Ê`>ÞÃ
Prophylaxis with the above regimens is required for all household
contacts within three weeks of exposure. Use the same antibiotic as
for treatment. All household contacts and HCWs with exposure to
the patient should also have up-to-date immunizations for Bordetella
pertussis.
Scabies
All patients with conventional or Norwegian scabies should be placed on
Contact Precautions. Norwegian scabies is a severe form of heavy
mite infestation.
UÊÊ*ÀˆÛ>ÌiÊÀœœ“ÊÀiµÕˆÀi`°
UÊÊ*>̈i˜ÌÃÊ܈̅ÊVœ˜Ûi˜Ìˆœ˜>ÊÃV>LˆiÃÊ“ÕÃÌÊLiÊÌÀi>Ìi`Ê܈̅Ê>ÊÃV>LˆVˆ`iÊ
once, and the precautions may be discontinued 24 hours after the
treatment is completed.
UÊÊ*>̈i˜ÌÃÊÜˆÌ…Ê œÀÜi}ˆ>˜ÊÃV>LˆiÃÊÀiµÕˆÀiÊÓÊÌÀi>Ì“i˜ÌÃÊ܈̅Ê>ÊÃV>LˆVˆ`iÊ
1 week apart. Contact precautions may be discontinued 24 hours
after the second treatment is completed.
UÊʘviÃÌi`ÊVœÌ…ˆ˜}Ê>˜`ʏˆ˜i˜ÊÃ…œÕ`ÊLiÊÃi>i`ʈ˜Ê>Ê«>Ã̈VÊL>}ÊvœÀÊ{nÊ
hours. The mite will not survive off a human host for more than 48
hours. Clothing/patient belongings should be sent home with the
patient’s family/caretaker. Linens and clothing should be washed in
the washing machine on the hot cycle.

143. 144144
8.3 Disease-specific infection control recommendations
UÊÊvÊ«Àœœ˜}i`ÊÃŽˆ˜‡Ìœ‡ÃŽˆ˜ÊVœ˜Ì>VÌÊœVVÕÀÃÊ܈̅Ê>ÊÃV>LˆiÃÊ«>̈i˜Ì]Ê
prophylactic treatment is required. Healthcare workers should contact
HEIC if an exposure is suspected.
Vancomycin-resistant enterocci (VRE)
Routine active surveillance cultures for VRE are performed on select
units to identify patients with VRE. Surveillance culture results are found
ˆ˜ÊÌ…iÊiiVÌÀœ˜ˆVÊ«>̈i˜ÌÊÀiVœÀ`Ê܈̅ÊÌ…iÊÌiÃÌʘ>“iʺ >VÌiÀˆœœ}Þ‡-Ìœœ‡
6,Ê-ÌœœÊ-ÕÀÛ°ÊՏ̰»Ê7…i˜Ê>ÊVՏÌÕÀiÊ}ÀœÜÃÊ6,]ÊÌ…iÊ«>̈i˜ÌʈÃÊy>}}i`Ê
for Contact Precautions. The results are to be used for isolation
purposes, not to guide therapy or clinical care. The overwhelming
majority of positive surveillance cultures represents colonization,
not infection, and should not prompt any antimicrobial therapy.
Surveillance cultures should be obtained upon admission and weekly
ˆ˜ÊÌ…iÊvœœÜˆ˜}ÊÕ˜ˆÌÃ\Ê1]Ê71]Ê6-1]Ê-1]Ê/1Ê­™7®]Ê /Ê>˜`Ê
Leukemia units, NCCU, PICU.
The patient must be off antibiotics for ≥ 48 hours and cultures from
original site of infection AND 3 stool or perirectal cultures taken ≥ 1
week apart must be negative. Once this is accomplished, call HEIC to
review culture data and initiate deflagging.
Varicella-Zoster
Immunocompetent patients with disseminated zoster and all
immunosuppressed patients with zoster need Contact AND Airborne
Precautions°Ê/…iÊvœœÜˆ˜}Ê`iw˜ˆÌˆœ˜ÃÊ>««ÞÊ̜ʫ>̈i˜ÌÃÊ܈̅ÊâœÃÌiÀ\
UÊÊImmunosuppressed:ÊLœ˜iÊ“>ÀÀœÜÊÌÀ>˜Ã«>˜ÌÊ܈̅ˆ˜ÊÌ…iÊ«>ÃÌÊÞi>ÀÆÊ
>VÕÌiʏiÕŽi“ˆ>ÆÊÃœˆ`ÊœÀ}>˜ÊÌÀ>˜Ã«>˜ÌÊÀiVˆ«ˆi˜ÌÃÆÊ«>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê
cytotoxic or immunosuppressive treatments, including steroid
treatment for ≥ ÎäÊ`>ÞÃÊ܈̅ÊÌ…iÊvœœÜˆ˜}Ê`œÃiÃ\Ê`iÝ>“iÌ…>Ãœ˜iÊ
3 mg daily, cortisone 100 mg daily, hydrocortisone 80 mg daily,
«Ài`˜ˆÃœ˜iÊÓäÊ“}Ê`>ˆÞ]Ê“i̅ޏ«Ài`˜ˆÃœ˜iÊ£ÈÊ“}Ê`>ˆÞÆÊ6³Ê«>̈i˜ÌÃÊ
with CD4 < 200
UÊÊDisseminated: lesions outside of 2 contiguous dermatomes

144. 145
A
145
A. Aminoglycoside dosing and monitoring
Aminoglycoside dosing and monitoring
Aminoglycosides enhance the efficacy of some antibiotics. Except for
urinary tract infections, aminoglycosides should seldom be used alone
to treat infections.
Aminoglycoside dosing weight:
Calculate Ideal Body Weight (IBW)
IBW female (kg)ÊrÊ(2.3 x inches over 5’)ʳÊ45.5
IBW male (kg) r (2.3 x inches over 5’)ʳÊ50
For patients < 20% over IBW, use Actual Body Weight
(ABW)
For patients ≥ 20% over IBW, use Dosing Body Weight
(DBW)
­ 7®ÊrÊQ 7ʳÊä°{Ê­ 7ÊqÊ 7®RÊ
Estimation of creatinine clearance (CrCl) by Cockcroft-Gault
equation:
(If a patient’s renal function is declining, this equation may overestimate CrCl)
Ê ÀÊr
­£{äÊqÊ>}i®Ê­Üiˆ}…Ìʈ˜ÊŽ}I®
x 0.85 (if female)
72 (serum creatinine)
* Use Actual Body Weight (ABW) unless patient ≥ÊÓä¯ÊœÛiÀÊ 7]ÊÕÃiÊ 7Ê>ÃÊ`iÃVÀˆLi`Ê
above

Extended-interval dosing, also sometimes referred to as “once-
daily” administration, utilizes higher dose and less frequent
aminoglycoside administration, whereas patient-specific dosing,
previous referred to as “traditional dosing”, typically utilizes smaller
doses with more frequent administration. See table below for dosing
recommendation based on indication and patient’s renal function. For
mycobacterial infections, urinary tract infections, SICU/WICU
protocol and gram-positive synergy (e.g. endocarditis), please
see separate sections below. For cystic fibrosis patients, see the
Cystic Fibrosis section (p.92)

145. A
146
A. Aminoglycoside dosing and monitoring
146
Patient-specific dosing Extended-interval dosing
IndicationsÊ ,i˜>Êv>ˆÕÀi]Êœ˜ÊÉ66]Êi˜`œV>À`ˆÌˆÃ]ÊÊ UÊÊ œÀ“>ÊÀi˜>ÊvÕ˜V̈œ˜Ê­ÀÊ
Gram-negative infections (in combination with >60 mL/min) and all other
beta-lactams), CNS infections, septic shock, indications not listed under
burn patients, patients with altered volume patient specific dosing
status (e.g. ascites, anasarca, trauma)
DosingÊÊœÃiÊ­“}®ÊrÊ`iÈÀi`Ê«i>ŽÊÝÊQ7iˆ}…ÌÊ­Ž}®ÊÝÊ6`ÊÊ i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\
Ê ­ÉŽ}®RÊ x‡ÇÊ“}ÉŽ}Ê6Ê+Ó{
ÊUÊÊ iÈÀi`Ê«i>Ž\ choose from below “ˆŽ>Vˆ˜\
ÊUÊÊ 7iˆ}…Ì\ ABW or DBW 15-20 mg/kg IV Q24H
ÊUÊÊ Volume of distribution (Vd) typically ranges
LiÌÜii˜Êä°ÓxÊqÊä°xÊÉŽ}ʈ˜Ê“œÃÌÊ«>̈i˜ÌðÊ
Higher Vd should be used in critically ill and
volume overloaded
patients.
Ê œÃˆ˜}ʈ˜ÌiÀÛ>ÊL>Ãi`Êœ˜ÊÀ\
Ê ÀÊ€Èä\Ê+nI
Ê ÀÊÎä‡Èä\Ê+£Ó
Ê ÀÊÎäÉ66É\Ê`œÃiÊLÞʏiÛi
*If targeting high peaks, use maintenance dose
frequency of Q12-24H.
Desired Peak Gentamicin/ Amikacin This dosing strategy is designed
Peaks and Tobramycin ÌœÊÌ>À}iÌÊÌ…iÊvœœÜˆ˜}\
Troughs Pneumonia 10 mcg/mL 25-35 mcg/mL Peak
Septic shock i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\ʣȇÓä
Endocarditis 8-10 mcg/mL 20-30 mcg/mL mcg/mL
Osteomyelitis “ˆŽ>Vˆ˜\Ê{ä‡ÈäÊ“V}É“
MDR 10-20 mcg/mL 45-50 mcg/mL Trough
organismsÊ L>Ãi`Êœ˜ÊÊ L>Ãi`Êœ˜ÊÊ i˜Ì>“ˆVˆ˜É/œLÀ>“ÞVˆ˜\Ê
Trough Gentamicin/ Amikacin £Ê“V}É“
Tobramycin “ˆŽ>Vˆ˜\ʐ{Ê“V}É“
All IndicationsÊ £‡ÓÊ“V}É“Ê £äÊ“V}É“
Therapeutic Trough: draw 30 minutes prior to the 3rd dose
Drug
Monitoring Peak: obtain 1 hour after end of infusion, after
the 3rd dose.
Frequency of monitoring
Ê UÊÊ "˜ViÊ>ÊÜiiŽÊ>vÌiÀÊ`iÈÀi`Ê«i>ŽÉÌÀœÕ}…ʈÃÊ
established in patients with normal renal
function
Ê UÊÊ œÀiÊÌ…>˜Êœ˜ViÊÜiiŽÞ\Ê

After changes in dosing regimen
Patient is on dialysis
Patient in acute renal failure, SCr increased
LÞÊä°xÊ“}É`ÊœÀÊÎä¯vÀœ“ÊL>Ãiˆ˜iÊ
Major changes in the patient’s volume status
If the patient meets ANY of the criteria below, a trough level is recommended prior to the Ó˜`Ê`œÃi\ UÊÊœ˜Vœ“ˆÌ>˜Ìʘi«…ÀœÌœÝˆVÊ
medications
UÊÊœ˜ÌÀ>ÃÌÊiÝ«œÃÕÀiÊ
UÊ}iÊ
≥ 60 years
UÊÊ*>̈i˜ÌʈÃʈ˜ÊÌ…iÊ1
UÊÊ"Ì…iÀÊÀˆÃŽÃÊvœÀʘi«…ÀœÌœÝˆVˆÌÞÊ
­i°}°Ê`ˆ>LiÌiÃ]ÊŽˆ`˜iÞÊ/8®
If trough higher than desired
troughs, use patient specific
dosing to adjust dose.
Aminoglycoside dosing for Gram-negative
infections

146. 147
A
147
A. Aminoglycoside dosing and monitoring
Aminoglycoside dosing in mycobacterial
infections
Amikacin is the preferred agent to treat all mycobacterial infections,
except Mycobacterium chelonae. For M. chelonae infections,
Tobramycin is the recommended aminoglycoside. Streptomycin
is another aminoglycoside sometimes used to treat mycobacterial
infections such as M. tuberculosis. Please contact the Antimicrobial
Stewardship Program pharmacist for Tobramycin/Streptomycin dosing
recommendation for this indication.
Amikacin:
œÀ“>ÊÀi˜>ÊvÕ˜V̈œ˜\
"˜ViÊ`>ˆÞ\Ê£xÊ“}ÉŽ}Ê6Ê+Ó{Ê­œÀÊ£äÊ“}ÉŽ}Ê6Ê+Ó{ʈvÊ€xäÊÞi>ÀÃÊœvÊ
age)
/…ÀˆViÊÜiiŽÞ\ÊÓxÊ“}ÉŽ}Ê6ÊÌ…ÀiiÊ̈“iÃÊ>ÊÜiiŽÊ­“>ÞÊLiÊ“œÀiÊ`ˆvwVՏÌÊ
to tolerate)
L˜œÀ“>ÊÀi˜>ÊvÕ˜V̈œ˜\ Discuss with pharmacy clinical specialist
Therapeutic drug monitoring: Peak and trough not generally
˜iViÃÃ>ÀÞ]ÊiÝVi«Ìʈ˜ÊÌ…œÃiÊ܈̅ÊÀi˜>Êˆ˜ÃÕvwVˆi˜VÞÊ­,ʐÈäÊ“É“ˆ˜®Ê
>˜`ʈvÊ-Àʈ˜VÀi>ÃiÃÊLÞÊä°xÊ“}É`ÊœÀÊ€Îä¯ÊvÀœ“ÊL>Ãiˆ˜iÊÜ…ˆiÊ«>̈i˜ÌÊ
on aminoglycoside therapy. Check a trough concentration to monitor for
toxicity. Peaks in the low 20 mcg/mL range are acceptable, and trough
Vœ˜Vi˜ÌÀ>̈œ˜ÃÊ>ÀiÊ«ÀiviÀ>LÞʐ{Ê“VÉ“ÊœÀÊÕ˜`iÌiVÌ>Li°
Aminoglycoside dosing in urinary tract infections
CrCl (mL/min) Gentamicin/Tobramycin Amikacin
≥60 3 mg/kg IV Q24H or 10 mg/kg IV Q24H or
1 mg/kg IV Q8H 3 mg/kg IV Q8H
40-59 1 mg/kg Q12H 3 mg/kg IV Q12H
20-39 1 mg/kg Q24H 3 mg/kg IV Q24H
ÓäÊ £Ê“}ÉŽ}Ê" IÊ ÎÊ“}ÉŽ}Ê6Ê" I
*Give one dose, check level in 24 hours, redose when Gentamicin/Tobramycin level
£Ê“V}É“ÊœÀÊ“ˆŽ>Vˆ˜Ê{Ê“V}É“
“ˆ˜œ}ÞVœÃˆ`iÃÊ>ÀiÊ…ˆ}…ÞÊVœ˜Vi˜ÌÀ>Ìi`ʈ˜ÊÕÀˆ˜iÆÊÌ…iÀivœÀi]ÊÌ…iÀ>«iṎVÊ
drug monitoring is not necessary in patients with normal renal function.
Suggested doses in the above table will likely provide adequate urine
concentrations for highly susceptible organisms. Trough should be
checked to monitor for toxicity in patients with renal insufficiency
­,ʐÈäÊ“É“ˆ˜®Ê>˜`ʈvÊ-Àʈ˜VÀi>ÃiÃÊLÞÊä°xÊ“}É`ÊœÀÊ€Îä¯ÊvÀœ“Ê
baseline while patient on aminoglycoside therapy.
UÊÊGentamicin/Tobramycin:Ê`iÈÀi`ÊÌÀœÕ}…ʐ£Ê“V}É“ÊœÀÊÕ˜`iÌiVÌ>Li°Ê
UÊÊAmikacin:Ê`iÈÀi`ÊÌÀœÕ}…ʐ{Ê“V}É“ÊœÀÊÕ˜`iÌiVÌ>Li°

147. A
148
A. Aminoglycoside dosing and monitoring
148
Aminoglycoside dosing in the SICU/WICU
Gentamicin/Tobramycin
Loading dose 4 mg/kg using actual body weight, followed by a
patient-specific maintenance dose.
Amikacin
Loading dose 16 mg/kg using actual body weight, followed by a
patient-specific maintenance dose.
Therapeutic Drug Monitoring
vÌiÀʏœ>`ˆ˜}Ê`œÃi\ʣʅœÕÀÊ«i>ŽÊ>˜`ÊnÊ…œÕÀʏiÛiÊ>vÌiÀÊÌ…iÊi˜`ÊœvÊÌ…iÊ
infusion to facilitate calculating patient specific kinetic parameters.
Aminoglycoside dosing for Gram-positive synergy
Dosing for patients with normal renal function:
UÊ Gentamicin\ÊÎÊ“}ÉŽ}Ê6Êœ˜ViÊ`>ˆÞʈÃÊÀiVœ““i˜`i`ÊvœÀÊÌÀi>Ì“i˜ÌÊ
of endocarditis with Viridans streptococci or S. bovis in patients with
normal renal function (CrCl 60 ml/min).
UÊÊGentamicin: 1 mg/kg IV Q8H is recommended for treatment
Enterococcal and other Gram-positive endocarditis infections in
patients with normal renal function (CrCl 60 ml/min). Patients >65
years old should be started on Q12H if normal renal function.
Dosing adjustment for renal insufficiency
CrCl (mL/min) Dosing
{äqx™ÊÊ £Ê“}ÉŽ}Ê+£Ó
ÓäqΙÊÊ £Ê“}ÉŽ}Ê+Ó{
ÓäÊ £Ê“}ÉŽ}Ê" I
IÊʈÛiÊœ˜iÊ`œÃi]ÊV…iVŽÊiÛiÊˆ˜ÊÓ{Ê…œÕÀÃ]ÊÀi`œÃiÊÜ…i˜ÊiÛiÊ£Ê“}É
NOTE: See infective endocarditis guidelines (p. 65) for duration.
THERAPEUTIC DRUG MONITORING
UÊÊ*i>ŽÊ>˜`ÊÌÀœÕ}…Ê>ÀiÊÀiVœ““i˜`i`Ê>ÀœÕ˜`ÊÌ…iÊÌ…ˆÀ`Ê`œÃiÊÌœÊ>ÃÃÕÀiÊ
appropriate dosing.
UÊÊiÈÀi`ÊÃiÀÕ“ÊVœ˜Vi˜ÌÀ>̈œ˜ÃÊœvÊGentamicin

Peak levels:ÊÎqxÊ“V}É“
Trough levels:ʐʣʓV}ɓ

148. 149
A
149
A. Aminoglycoside dosing and monitoring
Monitoring for toxicity for inpatients
NEPHROTOXICITY
UÊÊSerum creatinine should be measured at least every other day. If
VÀi>̈˜ˆ˜iʈ˜VÀi>ÃiÃÊLÞÊä°xÊ“}É`ÊœÀÊ€Îä¯ÊvÀœ“ÊL>Ãiˆ˜i]ÊÕÃiÊ«>̈i˜ÌÊ
specific dosing.
UÊÊi>ÃÕÀiÊserum aminoglycoside levels as needed. See each dosing
section above for frequency.
UÊÊ-œ“iÊ`>Ì>ÊÃÕ}}iÃÌÊÌ…>ÌʏœÜiÃÌʏiÛiÊœvʘi«…ÀœÌœÝˆVˆÌÞÊœVVÕÀÃÊÜ…i˜Ê
aminoglycosides are administered during the activity period (e.g.
£Î\Îä®]ÊÌ…iÀivœÀiÊ>vÌiÀ˜œœ˜Ê>`“ˆ˜ˆÃÌÀ>̈œ˜ÊˆÃÊ«ÀiviÀÀi`°Ê
OTOTOXICITY
UÊÊœ˜Ãˆ`iÀÊLˆÜiiŽÞÊVˆ˜ˆV>ÊÃVÀii˜ˆ˜}ÊvœÀʜ̜̜݈VˆÌÞ
Ê UÊÊ…iVŽÊL>Ãiˆ˜iÊÛˆÃÕ>Ê>VÕˆÌÞÊÕȘ}Ê>Ê-˜ii˜Ê«œVŽiÌÊV>À`
Ê UÊÊ/œÊÃVÀii˜ÊvœÀʜ̜̜݈VˆÌÞ]Ê…>ÛiÊ«>̈i˜ÌÊÃ…>ŽiÊ…i>`Ê>˜`ÊÌ…i˜ÊÀi‡Ài>`Ê
card.
Ê UÊÊœ˜ViÀ˜ÊÃ…œÕ`ÊLiÊÀ>ˆÃi`ʈvÊ«>̈i˜ÌʏœÃiÃÊÓʏˆ˜iÃÊœvÊÛˆÃÕ>Ê>VÕˆÌÞ°Ê
Consider formal audiology testing.
Ê UÊÊœ˜Ì>VÌÊÕ`ˆœœ}ÞÊ­x‡È£xήÊvœÀÊ…i«Ê܈̅ÊÌiÃ̈˜}ÊvœÀʜ̜̜݈VˆÌÞ
,iviÀi˜ViÃ\
*É*Ê«>À>“iÌiÀ\ÊʘviVÌʈÃÊ£™nÇÆÊ£xx\™Îq™™
"˜ViÊ`>ˆÞʘœ“œ}À>“ÃÊÀiÛˆiÜ\ÊPharmacotherapy ÓääÓÆÊÓÓ­™®\£äÇÇq£änΰ
*>̈i˜Ì‡Ã«iVˆwVÊ`œÃˆ˜}\ÊCrit Care MedÊ£™™£ÆÊ£™\£{näq£{nx°
-1É71Ê`œÃˆ˜}\ÊSurgeryÊ£™™nÆÊ£Ó{\Ç·n°
i«…ÀœÌœÝˆVˆÌÞ\ÊAntimicrob Agents and ChemotherÊÓääÎÆÊ{Ç\£ä£ä°
/-É-ÊÞVœL>VÌiÀˆÕ“ÊÕˆ`iˆ˜iÃ\ÊAm J Respir Crit Care MedÊÓääÇÆÊ£Çx\ÎÈÇq{£È°
À>“‡«œÃˆÌˆÛiÊ-Þ˜iÀ}Þ\ÊCirculationÊÓääxÆÊ£££­Óή\ÊiΙ{Êq{Î{°

149. A
150
B. Vancomycin dosing and monitoring
150
Vancomycin dosing and monitoring
DOSING
£°ÊÃ̈“>ÌiÊVÀi>̈˜ˆ˜iÊVi>À>˜ViÊ­À®ÊÕȘ}ÊœVŽVÀœv̇>ՏÌÊiµÕ>̈œ˜\

ÀÊr
­£{äÊqÊ>}i®Ê­Üiˆ}…Ìʈ˜ÊŽ}®Ê
x 0.85 (if female)
72 (serum creatinine*)
* For patients with low muscle mass (i.e. many patients > 65 yrs), some advocate using
a minimum value of 1 to avoid overestimation of CrCl
2. Patients who are seriously ill with complicated infections such as
meningitis, pneumonia, osteomyelitis, endocarditis, and
bacteremia and normal renal function should receive initial loading
dose of 20-25 mg/kg, followed by 15-20 mg/kg Q8-12H using
Actual Body Weight (ABW). For other indications see nomogram
dosing below.
3. Calculate maintenance dose (using ABW) based on estimated or
actual CrCl. See suggested nomogram dosing below.
Note: Younger patients with normal renal function may need higher or
more frequent dosing than suggested below.
Weight CrCl (mL/min)
(kg) >60 30–59 15–29 <15
{äÊConsult Pharmacy
{äqÈäÊ ÇxäÊ“}Ê ÇxäÊ“}ÊÊ ÇxäÊ“}Ê £äääÊ“}]ÊÌ…i˜ÊÀi`œÃiÊLÞʏiÛi
†

Q12H Q24H Q48H
ÈäqÇxÊ £äääÊ“}Ê £äääÊ“}ÊÊ £äääÊ“}Ê £äääÊ“}]ÊÌ…i˜ÊÀi`œÃiÊLÞʏiÛi
†

Q12H Q24H Q48H
Çxq™äÊ £ÓxäÊ“}Ê £ÓxäÊ“}ÊÊ £ÓxäÊ“}Ê £ÓxäÊ“}]ÊÌ…i˜ÊÀi`œÃiÊLÞʏiÛi
†

Q12H Q24H Q48H
™äq££äÊ £xääÊ“}Ê £xääÊ“}ÊÊ £xääÊ“}Ê £xääÊ“}]ÊÌ…i˜ÊÀi`œÃiÊLÞʏiÛi
†

Q12H Q24H Q48H
££äq£ÓxÊ £ÇxäÊ“}Ê £ÇxäÊ“}ÊÊ £ÇxäÊ“}Ê £ÇxäÊ“}]ÊÌ…i˜ÊÀi`œÃiÊLÞʏiÛi
†

Q12H Q24H Q48H
£Óxq£{äÊ ÓäääÊ“}Ê ÓäääÊ“}ÊÊ ÓäääÊ“}Ê ÓäääÊ“}]ÊÌ…i˜ÊÀi`œÃiÊLÞʏiÛi
†

Q12H Q24H Q48H
>140 Consult Pharmacy
†
œÀÊ«>̈i˜ÌÃÊ܈̅ÊÀÊ£xÊ“É“ˆ˜Ê>˜`ʘœÌÊÀiViˆÛˆ˜}Ê…i“œ`ˆ>ÞÈÃÊÀi`œÃiÊÜ…i˜ÊÀ>˜`œ“Ê
iÛiÊ£xqÓäÊ“V}É“°Ê
DOSING IN RENAL REPLACEMENT THERAPY
Dosing is dependent on type of renal replacement therapy.
Intermittent Hemodialysis (iHD)
UÊInitial dose: 15-20 mg/kg once
UÊÊ*>̈i˜ÌÃÊÃ…œÕ`ÊLiÊÀi‡`œÃi`ÊL>Ãi`Êœ˜ÊÃiÀՓʏiÛiÃÊ`À>ܘÊ>ÀœÕ˜`ÊÌ…iÊ
dialysis session. Consider redosing at 5-10 mg/kg.

150. 151
A
151
B. Vancomycin dosing and monitoring
Ê UÊÊÊ *Ài‡`ˆ>ÞÈÃʏiÛiÊ(preferred)\ʐÓxÊ“V}É“Ê­vœÀÊ“i˜ˆ˜}ˆÌˆÃÊVœ˜Ãˆ`iÀÊ
Ài‡`œÃˆ˜}ʈvʐÎäÊ“V}É“®
Ê UÊ*œÃ̇`ˆ>ÞÈÃʏiÛi\ʐÓäÊ“V}É“®
Note:Ê“ÕÃÌÊÜ>ˆÌÊÎqÈÊ…œÕÀÃÊ>vÌiÀÊÌ…iÊi˜`ÊœvÊÌ…iÊ`ˆ>ÞÈÃÊÌœÊ>VVœÕ˜ÌÊvœÀÊ
redistribution of tissue and plasma levels
UÊÊœÀÊ«>̈i˜ÌÃÊ܈̅Ê-,Êœ˜Ê>ÊÃÌ>LiÊÊÃV…i`Տi]Ê>ÊÀi}ˆ“i˜ÊÃ…œÕ`ÊLiÊ
established that coincides with HD (e.g. 500 mg qHD). Once weekly
serum levels can be drawn to monitor for accumulation.
Continuous Renal Replacement Therapy (e.g. CVVHD)
UÊ Loading dose: 25-30 mg/kg once
UÊÊMaintenance: 15-20 mg/kg q24h (assuming no interruption in CRRT,
e.g. line clotting)
Ê UÊ œÌi\ʈ>ÞÈÃÊyœÜÊÀ>ÌiÃÊ€Ó°xÊɅʇÊVœ˜ÃՏÌÊ«…>À“>VÞ
UÊMonitoring:
Ê UÊÊ*>̈i˜ÌÃÊ܈̅ÊV…>˜}ˆ˜}Ê`ˆ>ÞÈÃÊyœÜÊÀ>ÌiÃÊœÀÊ`ˆ>ÞÈÃÊ…i`ÊvœÀÊ€{Ê
hours may need more frequent monitoring (consult pharmacy)
Ê UÊÊ*>̈i˜ÌÃÊœ˜ÊÃÌ>LiÊ`ˆ>ÞÈÃÊyœÜÊÀ>ÌiÃÊÃ…œÕ`Ê…>ÛiÊÌÀœÕ}…ʏiÛiÊ
checked prior to 4th dose
Peritoneal Dialysis (PD)
UÊInitial dose: 15-20 mg/kg once
UÊÊÊ œ˜ÃՏÌÊ«…>À“>VÞÊvœÀÊÀiVœ““i˜`>̈œ˜ÃÊvœÀÊÀi‡`œÃˆ˜}Ê>˜`Ê“œ˜ˆÌœÀˆ˜}Ê
serum levels.
THERAPEUTIC DRUG MONITORING (LEVELS)
UÊTrough levels are the most accurate and practical method for
monitoring Vancomycin effectiveness and toxicity.
UÊPeak levels should NOT be obtained.
Measuring serum Vancomycin levels
UÊÊ/ÀœÕ}…ʏiÛiÃÊÃ…œÕ`ÊLiÊœLÌ>ˆ˜i`Ê܈̅ˆ˜ÊÎäÊ“ˆ˜ÕÌiÃÊœvÊÌ…iʘiÝÌÊ`œÃiÊ>ÌÊ
steady-state conditions (approximately before the 4th dose).
UÊʘʫ>̈i˜ÌÃÊ܈̅Ê-,Êœ˜Ê…i“œ`ˆ>ÞÈÃ]ʈÌʈÃÊ«ÀiviÀ>LiÊ̜ʜLÌ>ˆ˜Ê>Ê
pre-hemodialysis level with the routine laboratory venipuncture on the
morning of hemodialysis. In the event a pre-hemodialysis level is not
obtained, a post-hemodialysis level may be drawn at least six hours
after the dialysis session.
UÊÊ/ÀœÕ}…ʏiÛiÃÊÃ…œÕ`ÊLiÊVœ˜Ãˆ`iÀi`ʈ˜Ê«>̈i˜ÌÃÊ܈̅Ê>˜ÞÊÌ…iÊvœœÜˆ˜}Ê
VˆÀVÕ“ÃÌ>˜ViÃ\
UÊÊ,iViˆÛˆ˜}Ê>}}ÀiÃÈÛiÊ`œÃˆ˜}Ê­€£xääÊ“}Ê+£Ó®ÊœÀÊ+nʈ˜ÌiÀÛ>
U
Serious infections such as meningitis, endocarditis, osteomyelitis,
and MRSA pneumonia.
UÊÊ1˜ÃÌ>LiÊÀi˜>ÊvÕ˜V̈œ˜Ê­V…>˜}iʈ˜Ê-ÀÊœvÊä°xÊ“}É`ÊœÀÊxä¯ÊvÀœ“Ê
baseline) or dialysis

151. A
152152
B. Vancomycin dosing and monitoring
UÊÊœ˜VÕÀÀi˜ÌÊÌ…iÀ>«ÞÊ܈̅ʘi«…ÀœÌœÝˆVÊ>}i˜ÌÃÊ­i°}°Ê>“ˆ˜œ}ÞVœÃˆ`iÃ]Ê
Colistin, Amphotericin B)
UÊ*Àœœ˜}i`ÊVœÕÀÃiÃÊ­≥ 5 days) of therapy.
UÊÀiµÕi˜VÞÊœvÊ“œ˜ˆÌœÀˆ˜}Ê6>˜Vœ“ÞVˆ˜ÊÌÀœÕ}…ʏiÛiÃ\Ê
UÊÊ"˜Vi‡ÜiiŽÞÊ“œ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊ܈̅ÊÃÌ>LiÊ
renal function who have achieved desired trough levels.
UÊÊœÀiÊvÀiµÕi˜ÌÊ“œ˜ˆÌœÀˆ˜}ʈÃÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÜ…œÊ>ÀiÊ
hemodynamically unstable and/or with changing renal function.
Desired Vancomycin trough levels
UÊÊ*˜iÕ“œ˜ˆ>]ÊœÃÌiœ“ÞiˆÌˆÃ]Êi˜`œV>À`ˆÌˆÃ]ÊL>VÌiÀi“ˆ>\Ê£x‡ÓäÊ“V}É“
UÊÊ -ʈ˜viV̈œ˜Ã\ÊÓäÊ“V}É“
UÊÊ iÕÌÀœ«i˜ˆVÊviÛiÀ]ÊÃŽˆ˜Ê>˜`ÊÃŽˆ˜‡ÃÌÀÕVÌÕÀiʈ˜viV̈œ˜Ã\ʣ䇣xÊ“V}É“
UÊʈ˜ˆ“Õ“ÊÃiÀÕ“ÊÌÀœÕ}…ÊVœ˜Vi˜ÌÀ>̈œ˜ÃÊ€£äÊ“V}É“ÊÃ…œÕ`Ê>Ü>ÞÃÊ
be maintained to avoid development of resistance.
Monitoring for Toxicity
UÊÊ-iÀÕ“ÊVÀi>̈˜ˆ˜iÊÃ…œÕ`ÊLiÊ“i>ÃÕÀi`Ê>Ìʏi>ÃÌÊiÛiÀÞʜ̅iÀÊ`>Þʈ˜ˆÌˆ>Þ]Ê
then weekly if patient’s renal function remains stable.
UÊʈ“ˆÌi`Ê`>Ì>ÊÃÕ}}iÃÌÊ>Ê`ˆÀiVÌÊV>ÕÃ>ÊÀi>̈œ˜Ã…ˆ«ÊLiÌÜii˜Ê
nephrotoxicity and higher serum trough concentrations (>15-20 mcg/
mL). Monitor Vancomycin trough levels (see above for frequency and
indications).
UÊÊœÀ“>Ê>Õ`ˆœœ}ÞÊÌiÃ̈˜}ʈÃʘœÌÊÀiVœ““i˜`i`ÊvœÀÊ«>̈i˜ÌÃÊÀiViˆÛˆ˜}Ê
Vancomycin, unless signs and symptoms of ototoxicity became
apparent.
,iviÀi˜ViÃ\
-É-*É-*ÊÕˆ`iˆ˜iÃÊÌ…iÀ>«iṎVÊ“œ˜ˆÌœÀˆ˜}ÊœvÊ6>˜Vœ“ÞVˆ˜\Ê“ÊÊi>Ì…‡-ÞÃÌÊ
*…>À“°ÊÓää™ÆÊÈÈÆÊnÓ°Ê
œÀÃiÊiÌÊ>°Ê˜Ìˆ“ˆVÀœLˆ>Ê}i˜ÌÃÊ…i“œÌ…iÀÊ£™nÇÆÊΣ\£Ç·ǰ
6>˜`iV>ÃÌiiiÊiÌÊ>°Êˆ˜Ê˜viVÌʈÃÊÓ䣣ÆÊxÎ\£Ó{q™°
>ÀÌ…ÊiÌÊ>°Êˆ`˜iÞʘÌÊ£™™ÈÆÊxä\™Ó™qÎÈ°

152. 153
A
153
C. Antimicrobial therapy monitoring
UÊÊ œ˜}ÊÌiÀ“Ê`iw˜i`Ê>ÃÊ ≥ 1 week, except for aminoglycosides and Amphotericin B (see below)
UÊÊ œÀÊÕÃiÊœ˜Viʈ˜ˆÌˆ>Ê`œÃˆ˜}Ê>˜`ÊÃiÀՓʏiÛiÃÊ…>ÛiÊLii˜ÊiÃÌ>LˆÃ …i`
UÊÊ /…iÃiÊ“œ˜ˆÌœÀˆ˜}ÊÀiVœ““i˜`>̈œ˜ÃÊ>˜`Ê“œ˜ˆÌœÀˆ˜}ÊvœÀÊ>}i˜ÌÃʘœÌÊ ˆÃÌi`ÊÃ…œÕ`ÊLiʈ˜`ˆÛˆ`Õ>ˆâi`]ÊL>Ãi`Êœ˜Êi>V…Ê«>̈i˜Ì½ÃÊVˆ˜ˆV >Êvi>ÌÕÀiÃ]ʈ˜VÕ`ˆ˜}Ê}i˜iÀ>Ê…i>Ì…ÊÃÌ>ÌÕÃ]Ê>}i]Ê
underlying conditions and organ dysfunction, concomitant medications, drug treatment history, type of infection, and type and d ose of antibiotic
Recommendations for monitoring patients receiving long-term antimicrobial therapy
,iviÀi˜Vi\Ê*À>V̈ViÊÕˆ`iˆ˜iÃÊvœÀÊ"ÕÌ«>̈i˜ÌÊ*>Ài˜ÌiÀ>Ê˜Ìˆ“ˆ VÀœLˆ>Ê/…iÀ>«Þ\ʏˆ˜Ê˜viVÌʈÃÊÓää{ÆÊÎn\£Èx£°
Frequency
Weekly
Twice weekly
Weekly
(twice weekly, if increased risk)
Twice weekly
£qÓÊÜiiŽÃÊ
Weekly
Weekly
Weekly
Weekly
Weekly
(twice weekly, if increased risk)
Weekly
Weekly
Weekly
£ÊqÊÓÊÜiiŽÃ
Weekly
Weekly, unless change in creatinine
(
°xä¯ÊvÀœ“ÊL>Ãiˆ˜i®]ÊÌ…i˜ÊÌ܈ViÊÜiiŽÞÊ
At each dialysis session
Other
Clinical monitoring and patient education
for hearing/vestibular dysfunction at
each visit (see p. 149 for vestibular
screening method)
Clinical monitoring for neurotoxicity
(dizziness, paresthesia, vertigo,
confusion, visual disturbances, ataxia)
Clinical monitoring for myopathy
Clinical monitoring for peripheral
neuropathy and optic neuritis
Drug interactions (monitor start of any
new medications)
Drug interactions (monitor start of any
new medication), visual changes
Antimicrobial agent(s)
Aminoglycosides (Amikacin, Gentamicin,
Tobramycin, Streptomycin)
Amphotericin B, AmBisome
®
≥-lactams (Aztreonam, carbapenems,
cephalosporins, penicillins)
Oxacillin, Nafcillin, carbapenems
Penicillin G potassium
Micafungin
Colistin
Daptomycin
Linezolid
Rifampin
Voriconazole /Posaconazole
Vancomycin
Test
CBC
BUN, Creatinine
“ˆ˜œ}ÞVœÃˆ`iʏiÛiÊqÊ trough
(see dosing section p. 145)
BUN, Creatinine, K, Mg, Phos
CBC, AST, ALT
CBC, BUN, Creatinine
add AST/ALT/bilirubin
add K
AST/ALT/bilirubin
BUN, Creatinine
CBC, BUN, Creatinine , CPK
CBC
CBC, AST/ALT/bilirubin
CBC, AST/ALT/ bilirubin
œÀ“>ÊÀi˜>ÊvÕ˜V̈œ˜\
CBC, BUN, Creatinine
ÊÊÊÊ6>˜Vœ“ÞVˆ˜ÊiÛiÊqÊ trough
(see dosing section p. 150)
ˆ>ÞÈÃ\
Vancomycin level
(see dosing section p. 150)

153. A
154
D. Oral antimicrobial use
154
Oral antimicrobial use in hospitalized patients
When using an agent that is considered to be bioequivalent (no
significant difference in rate and extent of absorption of the therapeutic
ingredient) via the parenteral and oral route, the oral formulation is
preferred if the patient does not have the contraindications listed below.
Contraindications to oral therapy
UÊ *"Ê­ˆ˜VÕ`ˆ˜}Ê“i`ˆV>̈œ˜Ã®Ê
UÊʘ>LˆˆÌÞÊÌœÊÌ>Žiʜ̅iÀÊœÀ>Ê“i`ˆV>̈œ˜ÃÊ",ʘœÌÊÌœiÀ>̈˜}Ê>ʏˆµÕˆ`Ê
diet/tube feeds
UÊi“œ`Þ˜>“ˆVʈ˜ÃÌ>LˆˆÌÞÊ
UÊ,iViˆÛˆ˜}ÊVœ˜Ìˆ˜ÕœÕÃÊ ÊÃÕV̈œ˜ˆ˜}Ê
UÊÊ-iÛiÀiʘ>ÕÃi>]ÊÛœ“ˆÌˆ˜}]Ê`ˆ>ÀÀ…i>]ÊÊœLÃÌÀÕV̈œ˜]Ê`ÞӜ̈ˆÌÞ]Ê
mucositis
UÊÊ“>>LÃœÀ«Ìˆœ˜ÊÃÞ˜`Àœ“iÊ
U A concomitant disease state that contraindicates the use of oral
medications
NOTE: There are only a limited number of agents that can be
used orally for bacteremia or fungemia; these are noted in
the table below.
Bioavailability of oral antimicrobials
Antimicrobial % Oral absorption
Should NOT be used orally for bacteremia
“œÝˆVˆˆ˜Ê Ç{ÊqÊ™ä¯
Amoxicillin/Clavulanate (Augmentin
®®ÊÊÊ Ç{ÊqÊ™ä¯
Azithromycin
*Ê ÎnÊqÊnί
i«…>i݈˜ÊÊ ™ä¯
Cefpodoxime
*ÊÊ {£ÊqÊxä¯
ˆ˜`>“ÞVˆ˜ÊÊ ™ä¯
œÝÞVÞVˆ˜iÊ ™äÊqÊ£ää¯
/iÌÀ>VÞVˆ˜iÊÊ ÇxÊqÊnä¯
Can be used orally for bacteremia or fungemia
Ciprofloxacin


Ê ÈxÊqÊnx¯
Fluconazole >™ä¯
Linezolid
†Ê £ää¯
iÌÀœ˜ˆ`>✏iÊ £ää¯
Moxifloxacin


Ê ™ä¯
Trimethoprim/sulfamethoxazole
†Ê £ää¯
Voriconazole
‡¶Ê ÈäÊqʙȯ
* Oral absorption is enhanced in presence of food
†
Should not be used for S. aureus bacteremia
‡
Oral absorption is decreased in presence of food
¶
Inter-patient variability
œÊ˜œÌÊÕÃiÊ܈̅ÊVœ˜Ìˆ˜ÕœÕÃÊÌÕLiÊvii`ÃÊ­6Ê«ÀiviÀÀi`®°Ê*>̈i˜ÌÃÊ܈̅ÊVÞVˆVÊÌÕLiÊvii`Ã\Ê
separate oral fluoroquinolone by 2 hours before and 6 hours after tube feeds.

154. 155
A
155
E. Antimicrobial dosing in renal failure insufficiency
Antimicrobial dosing in renal insufficiency
Dosing recommendations can vary according to indication and patient-
specific parameters. All dosage adjustments are based on creatinine
clearance calculated by Cockcroft-Gault equation.

CrCl =
(140 – age) (weight in kg)
x 0.85 (if female)
72 (serum creatinine*)
*
For patients with low muscle, some advocate using a minimum of 1 to avoid
overestimation of CrCl.
†
If patient is on hemodialysis (HD) schedule administration so that patient
receives daily dose immediately AFTER dialysis. For assistance with dosage
adjustments for patients receiving CVVHD or CVVHDF, please call pharmacy.
Drug Typical dose CrCl Dose adjustment for
(may vary) (mL/min) renal insufficiency
VÞVœÛˆÀÊ6ÊÊÊ xq£äÊ“}ÉŽ}Ê+nÊ €xäÊ xq£äÊ“}ÉŽ}Ê+n
Ê Ê ÓxqxäÊ xq£äÊ“}ÉŽ}Ê+£Ó
Ê Ê £äqÓ{Ê xq£äÊ“}ÉŽ}Ê+Ó{
Ê Ê £äÊœÀÊ
†
Ê Ó°xqxÊ“}ÉŽ}Ê+Ó{
Acyclovir PO 200 mg 5x daily >10 200 mg 5x daily
­i˜ˆÌ>Ê…iÀ«iÃ®Ê Ê £äÊ ÓääÊ“}Ê+£ÓÊ
Acyclovir PO 800 mg 5x daily >25 800 mg 5x daily
­iÀ«iÃÊ<œÃÌiÀ®ÊÊ Ê £äqÓxÊ nääÊ“}Ê+n
Ê Ê £äÊœÀÊ
†
800 mg Q12H
Amikacin See section on
aminoglycoside dosing
“œÝˆVˆˆ˜Ê xääq£äääÊ“}Ê+£ÓÊ €ÎäÊ xääq£äääÊ“}Ê+£Ó
Ê Ê £äqÎäÊ ÓxäqnÇxÊ“}Ê+£Ó
Ê Ê £äÊœÀÊ
†
Ê ÓxäqnÇxÊ“}Ê+Ó{
Amoxicillin 1 g Q8H >30 1g Q8H
­«˜iÕ“œ˜ˆ>®Ê Ê £äqÎäÊ £}Ê+£Ó
Ê Ê £äÊœÀÊ
†
1g Q24H
“œÝˆVˆˆ˜ÉÊ xääq£äääÊ“}Ê+£ÓÊ €ÎäÊ xääq£äääÊ“}Ê+£Ó
V>ÛՏ>˜>ÌiÊ Ê £äqÎäÊ ÓxäqxääÊ“}Ê+£Ó
Ê Ê £äÊœÀÊ
†

ÓxäqxääÊ“}Ê+Ó{
“«…œÌiÀˆVˆ˜Ê Ê ä°Çq£Ê“}ÉŽ}Ê+Ó{Ê qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
AmBisome
®
Ê ÎqxÊ“}ÉŽ}Ê+Ó{Ê qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
“«ˆVˆˆ˜Ê £qÓÊ}Ê+{qÈÊÊ €xäÊ £qÓÊ}Ê+{qÈ
Ê Ê £äqxäÊ £qÓÊ}Ê+Èqn
Ê Ê £äÊœÀÊ
†
Ê £qÓÊ}Ê+n
“«ˆVˆˆ˜ÉÊ £°xqÎÊ}Ê+ÈÊ≥ÎäÊ £°xqÎÊ}Ê+È
ÃՏL>VÌ>“Ê Ê £xqÓ™Ê £°xqÎÊ}Ê+£Ó
≤14 or HD
†
Ê £°xqÎÊ}Ê+Ó{
Ampicillin/ 3 g Q4H ≥50 3 g Q4H
ÃՏL>VÌ>“Ê­vœÀÊ Ê £äqxäÊ ÎÊ}Ê+È
Acinetobacter, HD
†
3 g Q8H
E. faecalis)
âˆÌ…Àœ“ÞVˆ˜Ê ÓxäqxääÊ“}Ê+Ó{Ê qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
âÌÀiœ˜>“ÊÊ £qÓÊ}Ê+nÊÊ≥ÎäÊ £qÓÊ}Ê+nÊ
Ê Ê £äqÓ™Ê £qÓÊ}Ê+£ÓÊ
Ê Ê £äÊœÀÊ
†
Ê £qÓÊ}Ê+Ó{
iv>✏ˆ˜Ê £qÓÊ}Ê+nÊ≥ÎxÊ £qÓÊ}Ê+n
Ê Ê ££qÎ{Ê £Ê}Ê+£Ó
Ê Ê £äÊœÀÊ £Ê}Ê+Ó{
intermittent HD
†

HD
†
2 g Q HD, if HD in 2 days
OR 3g Q HD, if HD in 3 days

155. A
156
E. Antimicrobial dosing in renal failure insufficiency
156
Cefdinir 300 mg Q12H ≥30 300 mg Q12H
Ê Ê ÎäÊ Ê ÎääÊ“}Ê+Ó{
HD
†
300 mg QHD
Cefepime 1 g Q8H >60 1 g Q8H
Ê Ê ÎäqÈäÊ Ê £Ê}Ê+£Ó
Ê Ê Ó™ÊœÀÊ
†
1 g Q24H
Cefepime 2 g Q8H >60 2 g Q8H
­i˜ÌÀ>Ê˜iÀÛœÕÃÊÊ Ê ÎäqÈäÊ £Ê}Ê+nÊ
ÃÞÃÌi“ʈ˜viV̈œ˜ÃÊœÀÊÊ Ê ££qÓ™Ê £Ê}Ê+£Ó
Pseudomonas®Ê Ê ££ÊœÀÊ
†
1 g Q24H
ivœÌiÌ>˜Ê £qÓÊ}Ê+£ÓÊÊ≥ÎäÊ £qÓÊ}Ê+£Ó
Ê Ê £äqÓ™Ê £qÓÊ}Ê+Ó{
Ê Ê £äÊœÀÊ
†
500 mg Q24H
iv«œ`œÝˆ“iÊ £ääq{ääÊ“}Ê+£ÓÊ≥ÎäÊ £ääq{ääÊ“}Ê+£Ó
Ê Ê ÎäÊ £ääq{ääÊ“}Ê+Ó{
HD
†
ÊÊ £ääq{ääÊ“}ÊÌ…ÀiiÊ̈“iÃÉ
week
Ceftaroline 600 mg Q12H >50 600 mg Q12H
Ê Ê ÎäqxäÊ {ääÊ“}Ê+£Ó
Ê Ê £xqÓ™Ê ÎääÊ“}Ê+£Ó
Ê Ê £xÊœÀÊ
†
200 mg Q12H
Ceftaroline for 600 mg Q8H >50 600 mg Q8H
,-Ê Ê ÎäqxäÊ {ääÊ“}Ê+n
Ê Ê £xqÓ™Ê ÎääÊ“}Ê+n
Ê Ê £xÊœÀÊ
†
400 mg Q12H
ivÌ>âˆ`ˆ“iÊ £qÓÊ}Ê+nÊ €xäÊ £qÓÊ}Ê+n
For PseudomonasÊ ÎäqxäÊ £qÓÊ}Ê+£Ó
Ê ÓÊ}Ê+nÊ £xqÓ™Ê £qÓÊ}Ê+Ó{
Ê Ê £xÊœÀÊ
†
1 g Q24H
Ceftolozane/ 1.5 g Q8H >50 1.5 g Q8H
Ì>âœL>VÌ>“Ê Ê ÎäqxäÊ ÇxäÊ“}Ê+n
Ê Ê £xqÓ™Ê ÎÇxÊ“}Ê+n
Ê Ê Ó™ÊœÀÊ
†
Load with 750 mg, then
150 mg Q8H
Ceftolozane/ 3 g Q8H >50 3 g Q8H
Ì>âœL>VÌ>“Ê Ê ÎäqxäÊ £°xÊ}Ê+n
­-iÀˆœÕÃʘviV̈œ˜Ã®Ê Ê £xqÓ™Ê ÇxäÊ“}Ê+n
Ê Ê ÉәʜÀÊ
†
Load with 1.5 g, then
375 mg Q8H
ivÌÀˆ>Ýœ˜iÊ £qÓÊ}Ê+Ó{Ê qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
ivÌÀˆ>Ýœ˜iÊÊ ÓÊ}Ê+£ÓÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
(Central nervous
system infections)
Cephalexin 500 mg PO Q6H >50 500 mg Q6H
Ê Ê £äqxäÊ xääÊ“}Ê+n
Ê Ê £äÊœÀÊ
†
500 mg Q12H
Cidofovir 5 mg/kg Q week for ≤55 or Cr>1.5 Not recommended
2 weeks, then every
other week
ˆ«ÀœyœÝ>Vˆ˜Ê6Ê {ääÊ“}Ê+nq£ÓÊÊ≥ÎäÊ {ääÊ“}Ê+nq£ÓÊ
Ê Ê ÎäÊœÀÊ
†
400 mg Q24H
ˆ«ÀœyœÝ>Vˆ˜Ê*"Ê ÓxäqÇxäÊ“}Ê+£ÓÊ≥ÎäÊ ÓxäqÇxäÊ“}Ê+£Ó
Ê Ê ÎäÊœÀÊ
†
Ê ÓxäqxääÊ“}Ê+Ó{
>ÀˆÌ…Àœ“ÞVˆ˜Ê ÓxäqxääÊ“}Ê+£ÓÊ≥ÎäÊ ÓxäqxääÊ“}Ê+£Ó
Ê Ê ÎäÊ ÓxäqxääÊ“}Ê+Ó{
ˆ˜`>“ÞVˆ˜Ê *"\ÊÎääÊ“}Ê+nÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
Ê 6\ÊÈääÊ“}Ê+nÊ Ê
Colistin 2.5 mg/kg Q12H ≥50 2.5 mg/kg Q12H
­œˆÃ̈“iÌ…>Ìi®Ê Ê ÓäqxäÊ Ó°xÊ“}ÉŽ}Ê+Ó{
≤20 or HD
†
1.25 mg/kg Q24H
Drug Typical dose CrCl Dose adjustment for
(may vary) (mL/min) renal insufficiency

156. 157
A
157
E. Antimicrobial dosing in renal failure insufficiency
>«Ìœ“ÞVˆ˜ÊÊ Èq£äÊ“}ÉŽ}Ê+Ó{ÊÊ≥ÎäÊ Èq£äÊ“}ÉŽ}Ê+Ó{
vœÀÊi˜`œV>À`ˆÌˆÃÉÊ Ê ÎäÊ Èq£äÊ“}ÉŽ}Ê+{n
bacteremia HD
†
Ê Èq£äÊ“}ÉŽ}Ê+{n
ˆVœÝ>Vˆˆ˜Ê ÓxäqxääÊ“}Ê+ÈÊÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
œÝÞVÞVˆ˜iÊ £ääÊ“}Ê+£ÓÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
Ertapenem 1 g Q24H ≥30 1 g Q24H
Ê Ê ÎäÊœÀÊ
†
500 mg Q24H
Ì…>“LÕÌœÊ £xqÓxÊ“}ÉŽ}Ê+Ó{ÊÊ≥10 Normal dose Q24H
Ê Ê £äÊ œÀ“>Ê`œÃiÊ+{n
HD
†
Normal dose QHD session
ÕVœ˜>✏iÊ ÓääqnääÊ“}Ê+Ó{Ê≥50 Normal dose (e.g. 100, 400,
800 mg) Q24H
Ê Ê xäÊœÀÊ
†
Load w/normal dose, then
Ê Ê ÊÊ xä¯ÊœvʘœÀ“>Ê`œÃiÊ+Ó{
ÕVÞ̜ȘiÊ­xq®Ê £Ó°xqÓxÊ“}ÉŽ}Ê+ÈÊ €{äÊ £Ó°xqÓxÊ“}ÉŽ}Ê+È
Ê Ê Óäq{äÊ £Ó°xqÓxÊ“}ÉŽ}Ê+£Ó
Ê Ê £äq£™Ê £Ó°xqÓxÊ“}ÉŽ}Ê+Ó{
Ê Ê £äÊœÀÊ
†
Ê £Ó°xqÓxÊ“}ÉŽ}Ê+Ó{q{n
Ganciclovir 5 mg/kg Q12H ≥70 5 mg/kg Q12H
­˜`ÕV̈œ˜Ê`œÃi®Ê Ê xäqÈ™Ê Ó°xÊ“}ÉŽ}Ê+£Ó
Ê Ê Óxq{™Ê Ó°xÊ“}ÉŽ}Ê+Ó{
Ê Ê £äqÓ{Ê £°ÓxÊ“}ÉŽ}Ê+Ó{
Ê Ê £äÊœÀÊ
†
1.25 mg/kg three times/week,
administer after HD
Ganciclovir 5 mg/kg Q24H ≥70 5 mg/kg Q24H
­>ˆ˜Ìi˜>˜ViÊÊ Ê xäqÈ™Ê Ó°xÊ“}ÉŽ}Ê+Ó{
`œÃi®Ê Ê Óxq{™Ê £°ÓxÊ“}ÉŽ}Ê+Ó{
Ê Ê £äqÓ{Ê ä°ÈÓxÊ“}ÉŽ}Ê+Ó{
Ê Ê £äÊœÀÊ
†
0.625 mg/kg three times/
week, administer after HD
i˜Ì>“ˆVˆ˜Ê qÊ qÊ Ê -iiÊÃiV̈œ˜Êœ˜Ê>“ˆ˜œ}ÞVœÃˆ`iÊ
dosing
Ãœ˜ˆ>âˆ`Ê ÎääÊ“}Ê+Ó{Ê qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜ÌÊ
ˆ˜i✏ˆ`Ê ÈääÊ“}Ê+£ÓÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜ÌÊ
Meropenem 1 g Q8H >51 1 g Q8H
Ê Ê ÓÈqxäÊ £Ê}Ê+£Ó
Ê Ê £äqÓxÊ xääÊ“}Ê+£Ó
Ê Ê £äÊœÀÊ
†
500 mg Q24H
Meropenem 2 g Q8H >51 2 g Q8H
­i˜ˆ˜}ˆÌˆÃ]Ê,ÊÊ Ê ÓÈqxäÊ £Ê}Ê+nÊ
ˆ˜viV̈œ˜Ã®ÊÊ Ê £äqÓxÊ £Ê}Ê+£Ó
Ê Ê £äÊœÀÊ
†
1 g Q24H
iÌÀœ˜ˆ`>✏iÊ xääÊ“}Ê+nÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
ˆV>vÕ˜}ˆ˜Ê £ääq£xäÊ“}Ê+Ó{Ê qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
œÝˆyœÝ>Vˆ˜Ê {ääÊ“}Ê+Ó{ÊÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
Nitrofurantoin 100 mg Q12H ≥50 100 mg Q12H
(Macrobid
®
®Ê Ê xäÊ œÌÊÀiVœ““i˜`i`
Oseltamivir 75 mg Q12H >60 75 mg Q12H
­/Ài>Ì“i˜Ì®Ê Ê ÎäqÈäÊ ÇxÊ“}Ê+Ó{
Ê Ê £äqÓ™Ê ÎäÊ“}Ê+Ó{
Ê Ê £äÊœÀÊ
†
30 mg QHD session
Oseltamivir 75 mg Q24H >60 75 mg Q24H
­*Àœ«…ޏ>ÝˆÃ®Ê Ê ÎäqÈäÊ ÎäÊ“}Ê+Ó{
Ê Ê £äqÓ™Ê ÎäÊ“}Ê+{n
Ê Ê £äÊœÀÊ
†
30 mg every other HD session
"Ý>Vˆˆ˜Ê £qÓÊ}Ê+{qÈÊÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
*i˜ˆVˆˆ˜ÊÊÊ Îq{Ê“ˆˆœ˜ÊÕ˜ˆÌÃÊ+{Ê≥xäÊ Îq{Ê“ˆˆœ˜ÊÕ˜ˆÌÃÊ+{
Ê Ê £äq{™Ê £°xÊ“ˆˆœ˜ÊÕ˜ˆÌÃÊ+{
Ê Ê £äÊœÀÊ
†
1.5 million units Q6H
Drug Typical dose CrCl (mL/min) Dose adjustment for
(may vary) renal insufficiency

157. A
158
E. Antimicrobial dosing in renal failure insufficiency
158
*ˆ«iÀ>Vˆˆ˜ÉÊ Î°ÎÇxq{°xÊ}Ê+ÈÊ €{äÊ ÊΰÎÇxÊ}Ê+ÈÊ­{°xÊ}Ê+È
tazobactam for Pseudomonas)
Ê ÊÊ Óäq{äÊ Ê Ó°ÓxÊ}Ê+ÈʭΰÎÇxÊ}Ê+ÈÊvœÀÊ
Pseudomonas)
Ê Ê ÓäÊÊ Ê Ó°ÓxÊ}Ê+nÊ­Ó°ÓxÊ}Ê+ÈÊvœÀÊ
Pseudomonas)
HD
†
2.25 g Q12H (2.25 g Q8H for
Pseudomonas)
*œÃ>Vœ˜>✏iÊ -iiÊ*œÃ>Vœ˜>✏iÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
guidelines p. 18
*ÞÀ>∘>“ˆ`iÊ £xqÎäÊ“}ÉŽ}Ê+Ó{Ê≥£äÊ £xqÎäÊ“}ÉŽ}Ê+Ó{
Ê Ê £äÊ £ÓqÓäÊ“}ÉŽ}Ê+Ó{
HD
†
Ê ÓxqÎäÊ“}ÉŽ}Ê+ÊÃiÃÈœ˜
+Õˆ˜Õ«ÀˆÃ̈˜ÉÊ Ç°xÊ“}ÉŽ}Ê+nÊÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
dalfopristin
,ˆv>“«ˆ˜Ê­/ ®Ê ÈääÊ“}Ê+Ó{Ê qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
,ˆv>“«ˆ˜Ê ÎääÊ“}Ê+nq£ÓÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
/ˆ}iVÞVˆ˜iÊ £ääÊ“}Êœ˜Vi]ÊÌ…i˜ÊÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜Ì
50 mg Q12H
/*É-8ÊÊ*"\Ê£qÓÊ-ÊÌ>LÊ+£ÓÊ≥ÎäÊ £qÓÊ-ÊÌ>LÊ+£ÓÊœÀÊ
­1/ÃÊœÀÊViÕˆÌˆÃ®Ê6\Ê£ÈäqÎÓäÊ“}Ê+£ÓÊ Ê£ÈäqÎÓäÊ“}Ê6Ê+£ÓÊÊ
Ê ­œÃˆ˜}ʈÃÊL>Ãi`Êœ˜ÊÊ ÎäÊœÀÊ
†
Ê £qÓÊ-ÊÌ>LÊ+Ó{ÊœÀ
Ê /*ÊVœ“«œ˜i˜Ì®Ê Ê £ÈäqÎÓäÊ“}Ê6Ê+Ó{
/*É-8ÊÊÊ xÊ“}ÉŽ}Ê+ÈqnÊ≥ÎäÊ xÊ“}ÉŽ}Ê+ÈqnÊ
­**ÊœÀÊÃiÀˆœÕÃÊÊ Ê ÎäÊ Ó°xÊ“}ÉŽ}Ê+Èqn
systemic infections) HD
†
2.5 mg/kg Q8H
6>>VÞVœÛˆÀÊ xääq£äääÊ“}Ê+£ÓÊ≥ÎäÊ xääq£äääÊ“}Ê+£Ó
­i˜ˆÌ>Ê…iÀ«iÃ®Ê Ê £äqÓ™Ê xääq£äääÊ“}Ê+Ó{
Ê Ê £äÊœÀÊ
†

500 mg Q24H
Valacyclovir 1 g Q8H ≥50 1 g Q8H
­iÀ«iÃÊ<œÃÌiÀ®Ê Ê Îäq{™Ê £Ê}Ê+£Ó
Ê Ê £äqÓ™Ê £Ê}Ê+Ó{
Ê Ê £äÊœÀÊ
†

500 mg Q24H
Valganciclovir 900 mg Q12H ≥60 900 mg Q12H
­˜`ÕV̈œ˜Ê`œÃi®Ê Ê {äqx™Ê {xäÊ“}Ê+£Ó
Ê Ê ÓxqÎ™Ê {xäÊ“}Ê+Ó{
Ê Ê £äqÓ{

450 mg Q48H
Ê Ê £äÊœÀÊ
†

Not recommended
Valganciclovir 900 mg Q24H ≥60 900 mg Q24H
­>ˆ˜Ìi˜>˜ViÊ`œÃi®Ê Ê{äqx™Ê {xäÊ“}Ê+Ó{
Ê Ê ÓxqÎ™Ê {xäÊ“}Ê+{n
Ê Ê £äqÓ{

450 mg twice weekly
Ê Ê £äÊœÀÊ
†

Not recommended
6>˜Vœ“ÞVˆ˜Ê qÊ qÊ Ê -iiÊÃiV̈œ˜Êœ˜ÊÛ>˜Vœ“ÞVˆ˜Ê
dosing
6œÀˆVœ˜>✏iÊ -iiÊ6œÀˆVœ˜>✏iÊÊ qÊ œÊ`œÃ>}iÊ>`ÕÃÌ“i˜ÌʈÃ
guidelines p. 19 necessary for PO. IV should
not be administered to patients
with CrCl ≤50 mL/min due to
accumulation of the vehicle.
†
If patient is on hemodialysis (HD) schedule administration so that patient receives
daily dose immediately AFTER dialysis. For assistance with dosage adjustments for
patients receiving CVVHD or CVVHDF, please call pharmacy.
Drug Typical dose CrCl (mL/min) Dose adjustment for (may vary) renal insufficiency

158. 161
A
161
10. Index
Index
HH
Abdominal infections
Biliary tract infections ..... 39-40
Diverticulitis ......................... 40
Pancreatitis .................... 41-42
Peritonitis, peritoneal
dialysis-related .................. 45
Peritonitis/GI perforation . 42-45
SBP .............................. 42-43
Acute bacterial
rhinosinusitis ................... 78-79
Allergy, penicillin ................... 137
Anaerobes ......................... 24-25
Amikacin
See Aminoglycosides
Aminoglycosides
Gram-negative infection
dosing ...............................146
Gram-positive synergy
dosing ............................ 148
Mycobacterial infection
dosing ............................ 147
SICU/WICU dosing ............. 148
UTI dosing ......................... 147
Amphotericin B, lipid ............... 16
Antibiotic lock therapy ............. 63
Antibiogram ....................... 37-38
Antimicrobial dosing
Aminoglycosides
See Aminoglycosides
CNS infections ..................... 73
Renal insufficiency....... 155-158
Surgical prophylaxis .... 121-124
Vancomycin
See Vancomycin
Aspergillosis ......................... 133
Aspiration pneumonia........ 84, 88
Azole drug interactions ...... 21-22
H H
Bacterial vaginosis .................. 57
Biliary tract infections ......... 39-40
Bloodstream infections
Catheter-related .............. 60-64
Candida ..................117, 134
Enterococcus spp. ............ 62
Gram-negative rods ........... 62
S. aureus .......................... 61
Staph, coagulase-negative . 61
Brain abscess ........................ 76
HH
Candidemia ....................117-118
Candidiasis
Hematologic patient .....134-136
Non-neutropenic host ...115-120
Candiduria ......................115-116
Catheter-related
bloodstream infections .....60-64
Cellulitis..........................100-101
Ceftaroline.................................8
Ceftolozane/tazobactam ......... 8-9
Central nervous system (CNS)
infections
Antibiotic dosing ...................77
Brain abscess ..................76-77
Encephalitis ..........................75
Meningitis ........................73-75
Shunt infection .................76-77
Cholangitis .........................39-40
Cholecystitis .......................39-40
Clostridium difficile
infections.........................47-50
Colistin .................................9-10
Communicable diseases,
reporting ............................140
Community-acquired pneumonia
Empiric therapy ...............83-84
Pathogen-specific therapy .85-86
COPD exacerbations ................82
Cost of antimicrobials .....159-160
Cystic fibrosis .....................91-92
HH
Daptomycin ....................... 10-11

159. 162
10. Index
Diarrhea ............................ 51-53
Diabetic foot
infections.................... 103-105
Diverticulitis ............................ 40
Dosing, antimicrobials
See Antimicrobial dosing
HH
Encephalitis ............................ 75
Endocarditis ...................... 65-70
Treatment
Culture-negative ................ 68
Diagnosis .................... 69-70
Fungal ..................... 119-120
Pathogen-specific
therapy ..................... 65-69
Prosthetic valve ........... 68-69
Prophylaxis ........................ 125
Endomyometritis .................... 56
Epidural abscess ........... 108-109
Ertapenem ............................. 11
HH
Febrile neutropenia ........ 129-130
Formulary ................................. 7
Fosfomycin ....................... 11-12
Fungal infections
Candida spp
................115-120, 134-136
Filamentous fungi ........ 133-134
Prophylaxis, SICU/WICU ..... 120
Fusarium .............................. 133
HH
Gentamicin
See Aminoglycosides
GI perforation ......................... 45
Gonococcal urethritis,
cervicitis, proctitis ........... 57-58
Gynecologic infections
Endomyometritis .................. 56
Pelvic inflammatory
disease ............................ 56
HH
Healthcare-acquired pneumonia
(not VAP) .........................87-88
H. pylori infection ................54-55
HH
ICD infection ...................... 71-72
ID approval
Antimicrobials ........................ 7
Pager .................................... 6
Infection control ............. 139-144
Infectious diarrhea ............. 51-53
Influenza............................ 93-94
Isolation precautions ............. 141
HH
Linezolid .............................12-13
Long-term antimicrobial
therapy ...............................153
HH
Meningitis, bacterial ............73-75
Antimicrobial dosing ..............77
Empiric therapy ....................73
Pathogen-specific therapy .....74
MDR Gram-negative
organisms .......................28-30
Micafungin ..........................17-18
Microbiology.......................31-35
MRSA
Decolonization .............102-103
Soft-tissue infections ....100-101
Surveillance .................142-143
H H
Necrotizing fasciitis ....... 107-108
Neutropenic fever .......... 129-130
Nosocomial pneumonia ...... 87-88
H"H
Oncology
Neutropenic fever ........129-130

160. 163
10. Index
Oral antimicrobials .................154
Orbital cellulitis ...................80-81
H*H
P. acnes infection ...............25-26
Pacemaker infection ...........71-72
Pancreatitis ........................41-42
Parasites .................................53
Pelvic inflammatory disease .....56
Penicillin allergy .....................137
Peritonitis/GI perforation .....42-45
Peritoneal dialysis-related ......45
Spontaneous bacterial .....42-43
Post-op / post-procedure
infections ..................105-107
Pneumonia
Community-acquired ........83-84
Healthcare-acquired .........87-88
Ventilator-associated ........88-90
Pneumococcal vaccine ............23
Posaconazole .....................18-19
Pre-operative prophlyaxis .121-124
Price of antimicrobials ....159-160
Prophylactic use of antimicrobials
Endocarditis .......................125
Fluconazole in ICUs .............120
Hematologic
malignancy ................ 131-132
Pre-op / pre-procedure 121-124
Solid organ ..................126-128
H,H
Renal insufficiency
Antimicrobial dosing .....155-158
Reported diseases .................140
Resistant Gram-negative
infections.........................28-30
Respiratory viruses .............93-94
Restricted antimicrobials ............7
H-H
SBP ...................................42-43
Sepsis .....................................99
Sexually transmitted
diseases ..........................57-59
Shunt infection ....................76-77
Sinusitis .............................78-79
Skin, soft-tissue and
bone infections
Cellulitis .......................100-101
Cutaneous abscess .....101-102
Diabetic foot
infection ...................103-105
Necrotizing fasciitis ......107-108
Post-op infections ........105-107
Recurrent MRSA ..........102-103
Surgical-site
infections ..................105-107
Vertebral osteomyelitis,
diskitis, epidural
abscess ....................108-109
Streptococci ......................24-25
Surgical prophylaxis ........121-124
Surgical-site infections ....105-107
Surveillance
CRE ...................................142
MRSA ..........................142-143
VRE ....................................144
Susceptibility testing ...........31-32
Syphilis ..............................58-59
H/H
Therapeutic monitoring
Aminoglycosides ..........145-149
Vancomycin .................150-152
Outpatient long-term
antimicrobial therapy ........153
Tigecycline ..............................13
Tobramycin
See Aminoglycosides
Transplant
Antimicrobial prophylaxis
Hematologic
malignancy ............. 131-132
Solid organ................ 126-128

161. 164
10. Index
Trichomoniasis ......................... 57
Trimethoprim/
sulfamethoxazole ..............14-15
Tuberculosis ........................95-98
H1H
Urinary tract infections
Bacterial
Cystitis ........................... 110
Pyelonephritis ................. 111
Urosepsis ....................... 111
Catheter-related .......... 113-114
Fungal ........................ 115-116
H6H
Vancomycin
Dosing ....................... 150-152
Monitoring .................. 151-152
Ventilator-associated
pneumonia (VAP) ............. 88-90
Vertebral osteomyelitis, diskitis,
epidural abscess ........ 108-109
Voriconazole ..................... 19-20
VRE Surveillance ................... 144
H7H
Wound infections,
post-op ........................105-107

163. Important Phone Numbers
THE JOHNS HOPKINS HOSPITAL
Antibiotic Approval: .... PING “JHH Antibiotic Approval Pager”
Antimicrobial Stewardship Program: ...................... 7-4570
Infectious Diseases Consults:.... PING “JHH Infectious Diseases”
Oncology/Transplant Service (Transplant ID) .... PING “Transplant/
Oncology Infectious Diseases”
Adult Inpatient Pharmacy (Zayed 7000): ................... 5-6150
Critical Care and Surgery Pharmacy (Zayed 3121):........... 5-6505
Weinberg Pharmacy:................................... 5-8998
Microbiology Lab: ..................................... 5-6510
Hospital Epidemiology & Infection Control: ................ 5-8384
HEIC Emergency Beeper:............................... 3-3855
JOHNS HOPKINS BAYVIEW MEDICAL CENTER
Antibiotic Approval: .......PING “Bayview Antibiotic Approval”
Infectious Disease Consults:. .PING “Bayview Infectious Diseases”
Bayview Inpatient Pharmacy: .............................0-0958
Microbiology Lab: ......................................5-6510
Hospital Epidemiology & Infection Control: .................0-0515
The Johns Hopkins Hospital
Antimicrobial Stewardship Program
Intranet: insidehopkinsmedicine.org/amp Internet: hopkinsmedicine.org/amp
Osler 425 [phone] (7-4570)
© Copyright 2015 by The Johns Hopkins Hospital Antimicrobial Stewardship Program. All rights reserved. No part of this publication may be reproduced without permission in writing from The Johns Hopkins Hospital Antimicrobial Stewardship Program.
Cover art: Charlotte Ford Cosgrove, Line Drawing II 33, 2008.