Treatment of CAP – Adults
CID 2007:44(Suppl 2) S28-72
(Infectious Diseases Society of America/American Thoracic Society)
Can J Infect Dis 2000;11:237-48
(Canadian Infectious Disease Society/Canadian Thoracic Society)
Stanford Guide 2009
Outpatient / Most Common Pathogens / First Line Therapy / Alternate TherapyNo comorbid / Strep pneumonia,
Mycoplasma pneumonia,
Haemophilus influenza,
Chlamydophila pneumoniae / Azithromycin/clarithromycin / Doxycycline*
Comorbid
Abx in last 3 months
ñmacrolide resist strep pneumo (>25%) / Levofloxacin
OR
Ceftriaxone + azithromycin / Azithromycin + amox-clavulin
Inpatient
Ward / S. pneumonia, M. pneumonia, C. pneumoniae H. influenza, Legionella, ,Anaerobes / Levofloxacin
OR
Ceftriaxone + azithromycin
ICU§ / S. pneumoniae
Staphylococcus aureus
(MSSA, CA-MRSA)
Legionella species
Gram-negative bacilli
H. influenzae / Levofloxaxin + ceftriaxone
Levofloxacin + azithromycin / Levofloxacin + piptazo
ICU + suspect MRSA / ICU bugs +MRSA / Vancomycin + Levofloxacn / Linezolid + Levofloxacin
ICU + suspect pseudomonas / ICU bugs + p. aeruginosa / Antipneumococcal, antipseudomonal β-lactamase° PLUS
Ciprofloxacin or levofloxacin / β-lactamase° + aminoglycoside + azithromycin
OR
β-lactamase° + aminoglycoside + cipro/levoquin
*level III evidence
§This is the minimal regime, often will require coverage of MRSA or pseudomonas.
°pipercillin-tazobactam, cefepime, imipenem, meropenem
Etiology:
· In the patients managed as outpatients, M. pneumonia accounts for 15-37% of patients. It is likely strep pneumo is under diagnosed in this group.
· Strep pneumonia is accountable for about half of all cases requiring admission to hospital, followed by C. pneumonia and H influenza.
· Anaerobic gram negative bacilli like E-coli and Klebsiella are less common but are important to consider in patients who require ICU admission. They are also more common in a nursing home setting.
Risk Factors / Features of CA-MRSA pneumonia
· Resistant to fewer antimicrobials than are hospital-acquired MRSA strains.
· Most produce a toxin associated with the clinical features of
o necrotizing pneumonia
o shock
o respiratory failure F
o formation of abscesses and empyemas (in patients without RF’s for anaerobic aspiration pneumonia)
Risk Factors for Pseudomonas:
· Chronic oral steroid administration
· Severe underlying bronchopulmonary disease (ie COPD, asthma)
· Alcoholism
· Frequent antibiotic therapy
Drug Resistant S. pneumonia:
· Resistance to numerous classes of antibiotics: penicillins, cephalosporins, macrolides, fluoroquinolones, tetracyclines, sulfonamides.
· Macrolide resistance in some parts of the world (ie Asia) approaches 50%
· Risk Factors: Unlcear on predictive values for these
o Age <2 or >65
o Beta lactam therapy in last 3 months (most predictive)
o Alcoholism, Immunosuppressive therapies or illness
o Medical co-morbidities
o Exposure to a child in daycare
· Local S. Pneumoniae resistance Patterns 2010 from Calgary lab Services (% susceptible):
o Penicillin 95% (was 83-91% 2009)
o Ceftriaxone 95%
o Erythromycin 78%
o SXT 76%
o Levofloxacin 86%
o Tetracycline 87%
Treatment of CAP – Pediatrics
Paediatr Child Health. 2003:666-619
Alberta Clinical Practice Guideline 2008
Stanford guide 2009
Outpatient / Most Common Pathogens / First Line Therapy / Alternative Therapy1-3 month / C. trachomatis, S. pneumonia, parainfluenzae, RSV, bordatella / Erythromycin or
Azithromycin
4mo – 5 yrs / Streptococcus pneumoniae / Amoxicillin (80-90 mg/kg/day) / PCN allergy: azitho, clinda, or erythromycin
>5 yrs / Mycoplasma pneumoniae, Chlamydia pneumonia, S. pnemoniae / Azithromycin
Amoxicillin + Clarithromycin
Doxycycline if > 8 yrs old) / Amoxicillin + Doxycycline (if > 8 yrs old)
Amoxicillin + erythromycin
Inpatient / Most Common Pathogens / Non-ICU / ICU
1-3 month / C. trachomatis, S. pneumonia, parainfluenzae, RSV, bordatella / Erythromycin or azithromycin
Add cefuroxime or cefotaxime if febrile / Cefuroxime
OR
Cefotaxime + cloxacillin
<5 yrs / Streptococcus pneumoniae / Ampicillin
OR
Cefotaxime
OR
cefuroxime / cefotaxime + azithromycin +/-vancomycin
>5 yrs / Mycoplasma pneumoniae, Chlamydia pneumonia, S. pnemoniae* / Ceftriaxone + Azithro / Ceftriaxone + Azithro +/- Vanco (if evidence of lung necrosis)
Treatment of acute UTI and Pyelonephritis in Women
CID 2011;52:e103-120
(Infectious Diseases Society of America/European Society for Microbiology and Infectious Diseases)
Stanford Guide 2009
Uncomplicated UTI / Most Common Pathogens / First Line Therapy (TMP-SMX E-Coli resistance <20%) / Alternative Therapy(TMP-SMX E-Coli resistance <20%, sulfa allergy)
Outpatient management / E. coli (75%–95%), Klebsiella pneumonia, Staph saprophyticus. / TMP-SMX°
Nitrofurantoin*
Fosomycin / ciprofloxacin°
ciprofloxacin-ER, nitrofurantoin
Pyelonephritis / Most Common Pathogens / Outpatient / Inpatient/ HPTP
Uncomplicated pyelo / E.Coli>enterococcus, Klebsiella pneumonia, Staph saprophyticus. / Cipro / copro-ER PO
TMP-SMX PO
(treatment for 14days) / Gentamycin
Ciprofloxacin IV
Ceftriaxone
Pip-tazo
Ertapenem
Non-ICU
ICU
*for use only in acute uncomplicated cystitis, NOT to be used in pyelonepthritis. Poor suppression of pathogens in periurethral, vaginal and rectal flora.
°Know local resistance patterns
Cystitis:
· TMP-SMX is still a recommended first guideline in areas with E-Coli resisntance <20% (in Calgary it is 21% 2010)
· Fosomycin is not effective against staph saprophyticus.
o An anti-infective agent administered in a single 3g dose.
o In vitro activity against VRE, MRSA, ESBL – still require clinical data
o Not readily available, not often reported in routine susceptibilities.
· Β-lactms not recommended in treatment of acute uncomplicated cystitis.
· Local E-Coli susceptibility patterns:
o Amoxicillin 55%
o Cephalexin 73%
o Cefazolin 94%
o Ceftriaxone 97%
o TMP-SMX 79%
o Ciprofloxacin 94%
o Nitrofurantoin 98%
Pyelonephritis:
· These recommendations are for acute uncomplicated pyelo only.
· Local E-Coli susceptibility patterns:
o Pip/tazo 98%
o Ceftriaxone 97%
o TMP-SMX 79%
o Ciprofloxacin 94%
o Gentamycin 95%
· In Calgary, our ID experts have recommended that if we are going to treat a pyelonephritis we use gentamycin as a first line therapy.
o Higher resistance patterns of ceftriaxone to E-Coli are being seen
o Ceftriaxone excreted in bile (higher rate c. diff) compared to gentamycin excreted renally
o No need to monitor gent levels in short 1-4 day course therapy
o Toxicity very low with sort course, but a baseline creatinine is required.
o Dose: 5-7 mg/kg LBW IV per day
§ Lean Body Weight = (2.3 x height in inches over 5’ + 50kg M (45kg F))
o Exceptions, when to use ceftriaxone: (note that ceftriaxone does not cover enterococcus)
§ Pregnant
§ Renal impairment (GFR <60)
§ Cirrhosis or liver transplant
§ Previous aminoglycoside toxicity
Treatment of Acute Bacterial Meningitis
Clinical Microbiology Reviews;2010:467–492
(Infectious Diseases Society of America)
Paediatr Child Health;2008:309
(Canadian Paediatric Society)
Stanford guide
Patient Demographic / Most Common Pathogens / First Line Therapy / if Gram –ve bacilli on Gram stainNeonate (<1 mo) / L. monocytogenes, E-Coli, Group B streptococcus, gram negative bacilli / Ampicillin +gentamycin
OR
Ampicillin +cefotaxime / Ampicillin + gentamycin + cefotaxime
Healthy children >1 mo and Adults / H. Influenza*, Strep. pneumoniae , N. meningitides / Cefotaxime or ceftriaxone + Vancomycinξ
(+ Dexamethasone) / Meropenem + Vancomyin
(+ Dexamethasone)
Adults >50, immunocomprimised, alcoholic / All of above + Enterobacteriaceae + Listeria monocytogenes
(HIV +ve: staph aureus, salmonella) / Cefotaxime or ceftriaxone + Vancomycin
+ Ampicillin°
(+ Dexamethasone)
*Incidence of H. influenzus type b was dramatically reduced following vaccination.
°For coverage of L. Monocytogenes
ξThe addition of vancomycin is to provide double coverage of resistant S. pneumonia. Therapy can be narrowed based upon culture and sensitivity results
Treatment of Intra-abdominal sepsis
Can J Infect Dis Med Microbiol. 2010;21:11-37
(Canadian Surgical Society/Association of Medical Microbiology and Infectious Disease Canada)
CID 2010;50:133-164
(Guidelines from The Surgical Infection Society and the Infectious Diseases Society of America)
Outpatient / Most Common Pathogens / Monotherapy / CombinationCommunity Acquired with no recent antimicrobial use
(low to moderate severity)* / Core pathogens: Streptococcus sp, Enterobacteriaceae ( E-coli, Klebsiella sp, Proteus sp, Serratia marcescens) + anaerobes (B. fragilis, non-fragilis Bacteroides sp, Clostridium sp, Fusobacterium sp, Lactobacillus sp, Peptostreptococcus sp, and Veillonella sp) / Cefoxitin or
ertapenem, or moxifloxacin or tigecycline / 2nd / 3rd cephalosporin + metronidazole
ciprofloxacin + metronidazole
Community Acquired + recent antimicrobial use
AND
Health care associated +/- recent antibiotic use
AND
Severely ill patients° / Core pathogens + resistant G– bacilli, Enterococcus sp, P. aeruginosa, MRSA / Pip-tazo or
Meropenem or
imipenem / 3rd / 4th cephalosporin +metronidazole
ciprofloxacin + metronidazole
Tigecycline + ciprofoxacin
Pip-tazo + gent
Meropenem + gent
*APACHE II <15
°APACHE II 15
Notes:
· Up to 15 different specimens can be cultured from same infected peritoneal cavity, and it is not always clear which ones are the key pathogens and which are commensals.
· Classification:
o Uncomplicated (isolated organ system)
o Complicated (infection beyond organ source + peritonitis)
§ Community acquired
§ Health care associated
· Primary – obvious source ie SBP, peritoneal dialysis
· Secondary – Soiling from hollow viscus ie. Perfed DU
· Tertiary – recurrent infection
Treatment of Skin and Soft tissue Infections
CID 2005;41:1373-1406 (Infectious Diseases Society of America)
CID 2011:52:18-55 (Infectious Diseases Society of America)
Outpatient / Most Common Pathogens / First Line Therapy / Second Line TherapyCellulitis, non-purulent, no MRSA RF / β-hemolytic strep, strep B, C, G, staph aureus / Cephazolin/cephalexin / Clindamycin or
Clarithromycin, azithromycin or amox-clavulin, TMP-SMX
Cellulitis, purulent +MRSA RF’s / β-hemolytic strep, strep B, C, G, staph aureus (MRSA) / TMP-SMX
clindamycin
Doxycycline
Linezolid
Diabetic, immunocomprimised / β-hemolytic strep, strep B, C, G, staph aureus (MRSA), enterobacteriae, anaerobes / (mild-moderte)
Clindamycin + gentamycin
Or
Clindamycin + Ciprofloxacin / Severe)
Vancomycin +piptazo
Or
Vanco/cipro/metronidazole
Inpatient
Complicated cellulitis / β-hemolytic strep, strep B, C, G, staph aureus / Vancomycin / Linezolid
Daptomycin
Notes:
· Complicated Skin and soft tissue infection: patients with deeper soft-tissue infections, surgical or traumatic wound infection, major abscesses, cellulitis, and infected ulcers and burns.
· RF’s for CA-MRSA: prison and jail inmates, injection drug users, Native American populations, gay men, participants in contact sports, and children
Treatment of postpartum endometritis
Stanford Guide
Population / Most Common Pathogens / First Line Therapy / Second Line Therapy(includes both post C/S and post vaginal delivery)° / G+: Group B streptococci,strep viridans, enterococci,
G-: E. coli, P. bivia,
anaer: bacteroides, aerobic streptococci, G. vaginalis, peptostreptococci
other: C. trachomonatis, M. hominis / (Cefoxitin or piptazo )+ doxycycline* / Clindamycin + gentamycin
Clindamycin + ceftriaxone
°48hrs – 6 days MUST cover for C. trachomonatis
*doxycycline cannot be administered during breastfeeding
Pregnancy
A) Controlled studies in women fail to demonstrate a risk to the fetus.
B) Animal studies have not revealed toxicity but there are no adequate human studies, or animal studies have shown toxicity that was not confirmed in human studies.
C) Animal studies have revealed toxicity and there are no adequate human studies, or studies in humans and animals are not available. Drug should only be given if potential benefit justifies the potential risk to the fetus.
D) Positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk. X. Human and/or animal studies have shown a risk to the fetus, and risks outweigh benefits. Contraindicated in pregnancy.
Lactation
· L1 = SAFEST: Drug used in a large number of breastfeeding women without affecting infant, or studies indicate that the possibility of harm to infant is remote, or the drug is not orally bioavailable in infants. L2 = SAFER: Drug used in a limited number of breastfeeding women without affecting infant, and/or risk to infant by using drug is remote.
· L3 = MODERATELY SAFE: There are no controlled studies. The risk of adverse effects in the infant is possible, or studies show only minimal non-threatening adverse reactions. Benefit versus risk to the infant must be considered.
· L4 = POSSIBLY HAZARDOUS: There is evidence of risk to the breastfed infant or breast milk production, but the benefits to the mother may outweigh the risk to the infant (e.g. in life-threatening situations or when safer drugs cannot be used).
· L5 = CONTRAINDICATED: Studies show a significant and documented risk to infants, or it is a drug that has a high risk of causing significant infant harm. The drug is contraindicated in breastfeeding, as the possible harm to the infant outweighs any potential benefits from breastfeeding. AAP ratings: Recommendations from American Academy of Pediatrics (AAP), published in Pediatrics 2001;108:776-89.
AAP ratings: Recommendations from American Academy of Pediatrics (AAP), published in Pediatrics 2001;108:776-89. ✓= approved - drug is usually compatible with breastfeeding.
Breastfeeding and Lactation Guidelines
Briggs GG, et al. Drugs in pregnancy and lactation. 7th ed. 2005/FDA
Antibiotic / Safe Pregnancy / Safe Lactation / NotesPenicillins / B / L1 ✓
Pipercillin-Tazobactam / B / L2
Cephaolsporins / B / L1/2 ✓
Meropenem / B / L3
Aminoglycosides / C / L2 / (small amount excreted into milk, clinically not significant levels in infant)
Azithromycin / B / L2 / (small amount excreted, clinically not significant levels in infant)
Clarithromycin / C / L2
Fluoroquinolones / C / L3 (Do not use) / Greenish discoloration of teeth
CLindamycin / B / L3 ✓ / (infant may develop diarrhea)
Metronidazole / B (NOT in 1st trimester) / L2
Nitrofurantoin / B (NOT in 3rd trimester) / L2 ✓ / -G6PD and term fetuses may develop hemolytic anemia
Sulfonamides / C / D 3rd trimester / L3 / -G6PD and term fetuses may develop hemolytic anemia
Tetracyclines / D / L3/L4 (DO NOT use)
Vancomycin / B / L1 ✓
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