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ID EXAM 4 TREATMENTS
IAI, CDI, NON-C.DIFF DIARRHEA, SPESIS, ABSSI & BACTEREMIA
| DISEASE | TREATMENT | OTHER NOTES | PATHOGEN |
|---|---|---|---|
| IAI EMPIRIC TREATREAMENT (HIGH RISK) | - Cefepime + Metro - Imipenem, Cilastatin or Meropenem - Pip/Tazo X 4 days after adequate source control | RECOMMEND ECHINOCANDIN (micafungin) if severly ill w/ or suspect of Candida species LIMIT ABX TO 24 HOURS FOR: - pt with traumatic bowel perforation that has been operated on w/in 12 hours - Acute or gangrenous appendicitis/cholecysitis w/o perf | |
| IAI EMPIRIC TXT (LOW RISK) | - 3rd gen Cephas: Cefotaxime or Ceftriaxone + Metronidazole - Ertapenem (monotherapy) x 4 days after adequate source control | RECOMMEND Cipro + Metro for SERIOUS B-lactam allergies LIMIT ABX TO 24 HOURS FOR: - pt with traumatic bowel perforation that has been operated on w/in 12 hours - Acute or gangrenous appendicitis/cholecysitis w/o perf | |
| PO IAI TXT | - cipro + metro | ||
| INTIAL EPISODE C.DIFF TXT | - PREFERRED: Fidaxomicin x10 days | -ALT: Vanco x 10 days ALT for NON-SEVERE: if fida or vanco not available: Metro x 10-14 days | |
| FULMINANT C.DIFF TXT | - Vanco QID | IF ILEUS PRESENT: consider vanco rectally AND add metro Q8H | |
| FIRST RECURRENCE C.DIFF TXT | - PREFFERED: Fidaxomicin PO BID x 10 days or BID x 5 days followed by once every other day x 20 days | - ALT: PO Vanc taper with pulse therapy - ALT: Oral Vanc PO QID IF metro was used for inital episode | |
| SECOND OR SUBSEQUENT RECCURENCE | - Fidaxomicin PO BID x 10 day or 5 days followed by once every other day X 20 days | - ALT: PO Vanc Taper with pulse therapy - ALT: Vanc PO QID x 10 days FOLLOWED by rifaximin x 20 days - FECAL MICROBIOTA TRANSPLANT | |
| WATERY DIARRHEA TXT (adults) | E.coli: - Cipro Vibrio Cholerae: Doxy | E.coli ALT: rifaximin or Azithromycin Vibrio Cholerae: Azithromycin or Cipro | |
| DYSENTERIC DIARRHEA TXT (Adults) | Campylobacter species: Azithromycin Shigella: Cirpro or ceftriaxone Salmonealla: Azithromycin or cefrtriaxone or Cipro Yersinia: TMP-SMX | Campylobacter species: Cipro Shigella: Ampicillin or azithromycin or TMP-SMX Salmonealla: Ampicillin or TMP-SMX Yersinia: Cefotaxime IV or Cipro | |
| TRAVELERS DIARRHEA (ONLY TREAT IF SEVERE) | Azithromycin OR cipro OR Levo OR Ofloxacin OR rifamycin SV OR rifaximin | ||
| SEPSIS TXT STEPS | 1- Measure lactate 2- obtain blood cultures 3- admin broad spectrum ABX ( zoysn +tobra or Cefepime + tobra or levo) 4- rapid admin of crystalloid for hypotension or lactate 5- admin vasopressors if hypo or after fluid resuscitation; MAP ≥ 65 | ||
| EMPIRIC MILD NON-PURULENT SSTI TXT | ORAL! - PCN VK PO Q6H - Cephalexin PO Q6H - Dicloxacillin - Clinda | PATHOGEN: Strep | |
| EMPIRIC MOD NON-PURULENT SSTI TXT | IV!! - PCN Q4-6H - Ceftriaxone - Cefazolin Q8H - Clinda Q8H - Nafcillin Q4-6H | PATHOGEN: Strep + MSSA/MRSA | |
| EMPIRIC SEVERE NON-PURULENT SSTI TXT | - Vanco + Pip/Tazo | PATHOGEN: Strep + MRSA + Gram (-) + Anaerobes | |
| SEVERE NON-PUR SSTI POLYBACTERIAL | SAME AS EMPIRIC - Vanc + Pip/tazo | ||
| SEVERE NON-PUR SSTI S.PYOGENES | PCN + CLINDA | ||
| SEVERE NON-PUR SSTI CLOSTRIDIUM | PCN + CLINDA | ||
| SEVERE NON-PUR SSTI VIBRIO | DOXY + CEFTAZIDIME | ||
| SEVERE NON-PUR SSTI AEROMONAS | DOXY + CIPRO | ||
| EMPIRIC MILD PURULENT SSTI | ORAL!!! - I+D -TMP-SMX -CLINDA for 5 -7 days | PATHOGEN: STREP + S. AUREUS | |
| EMPIRIC MOD PURULENT SSTI | PO or IV!!! - I & D - TMP-SMX - DOXY for 5 - 7 days | PATHOGEN: S. AUREUS | |
| EMPIRIC SEVERE PURULENT SSTI | IV !!! - Vanco - Dapto - Linezolid - Televancin - Ceftaroline - Dalbavancin - Omadacycline - Tedizolid for 5 -7 days | PATHOGEN: MRSA if failed initial treatment or immunocompromised with SIRs with hypotension | |
| MSSA positive PURULENT SSTI | Dicloxacillin or Cephalexin for 5 - 7 days | ||
| MRSA positive PURULENT SSTI | IV! look at empiric treatment for severe infection for 5-7 days | ||
| EMPIRIC TXT MILD DFI | - NO RF: antistaph PCN or 1st gen cephalosporin - B-lactam allergy: Clinda or FQ (levo or moxi) or TMP-SMX or doxy - Recent ABX exposure: Amox/Clav or Amp/Sulbactam OR levo or Moxi OR TMP-SMX - HIGH RISK FOR MRSA: Linezolid, clinda, TMP-SMX or doxy | GPC, GNR, MRSA | |
| EMPIRIC TXT MOD OR SEVERE DFI NO COMPLICATIONS | - B lactam + B lactamase inhibitor: Amox/Clav or Amp/Sulbactam - @nd or #Wrd gen cephalosporin (cefuroxime, cefotaxime, ceftriaxone) | GPC, GNR | |
| EMPIRIC TXT MOD OR SEVERE DFI: RECENT ABX | - Pip/tazo - 2nd or 3rd gen cephalosporin (cefuroxime, cefotaxime or ceftriaxone) - Ertapenem | GPC, GNR | |
| EMPIRIC TXT MOD OR SEVERE DFI: MACERATED ULVER OR WARM CLIMATE | - Pip/tazo - Antistaph penicillin + Ceftazidime or ciprofloxacin - Mero or imipenem | GNR including Pseudomonas species | |
| EMPIRIC TXT MOD OR SEVERE DFI: ISCHEMIC LIMB/NECROSIS/GAS FORMING | - Amox clav OR Amp/Sulb OR pip/tazo - Carbapenems - 2nd or 3rd gen cepha + clinda or metro | GPC, GNR, Strict anaerobes | |
| EMPIRIC TXT MOD OR SEVERE DFI: MRSA RF | CONSIDER adding or subbing glycopeptides, linezolid, daptomycin, tmp-smx or doxy | MRSA | |
| EMPIRIC TXT MOD OR SEVERE DFI: RF for resistant GNR | Carbapenems or Cipro | ESBL | |
| CARDIAC SURGERY | Cefazolin or cefuroxime | ALT for B-lactam Allergy: Clina or Vanc | |
| THORACIC SURGERY | Cefazolin or Amp/sulbactam | ALT for B-lactam Allergy: Clina or Vanc | |
| ORTHOPEDIC SURGERY | Cefazolin | ALT for B-lactam Allergy: Clina or Vanc | |
| VASCULAR SURGERY | Cefazolin | ALT for B-lactam Allergy: Clina or Vanc | |
| Gram (-)Bacteremia Empiric therapy Considerations | - Infections characteristics - Patient Hx: culture HX, RFs - Resistance Risk: Hx of ESBL/MDRO w/in 1 y, prior ABX use - Pharmacologic considerations: drug allergies, organ function, SOA penetration, IV vs PO DOT=7-14 days | ||
| Steps to treatment for Gram (-) Bacteremia | - Clincal stat - Blood cultures - Imaging - Determine source + source control - Start empiric ABX therapy - De-escalate therapy based on susceptibility report - Determine DOT and F/U - DOT = 7-14 days | ||
| Steps to treat Gram (+) Bacteremia | Same as Gram (-) but you repeat cultures for gram (+) | - staphylococcus spp (stickiest of all the bugs = s.aureus) - streptococcus spp -enterococcus spp | |
| Gram (-) Bacteremia step down from IV to PO | URINARY SOURCE: Amox/Clauv, cephalexin, TMP/SMX, FQs NON-URINARY SOURCE: FQs or TMP/SMX | Consider when: - Pt has clinically improved w/in 24-48 hrs - has an uncomplicated bacteremia - "easy to kill" pathogens (e.coli, P.mirabilis or K.pneumo) | |
| Gram (+) Empiric therapy considerations | - Infection characteristics - Pt HX - Resistance Risk: HX of VRE or MRSA w/in 1 year, prior ABX use - Pharma considerations: Drug allergies, organ function, SOA penetration, IV vs PO | ||
| Empiric therapy for Gram (+) Bacteremia: Staph- S. Aureus | MRSA: Vanc, Daptomycin, Linezolid MSSA: Cefazolin, Oxacillin or Nafcillin | DOT: empiric therapy (uncomplicated) = 2 weeks Tailored therapy (complicated) = 4-6 weeks | |
| Empiric Therapy for Gram (+) Bacteremia: Steptococcus | S.pneumo - IV ceftriaxone S. pyogenes (group A strep) - IV PCN + IV Clinda or Linezoilid All other streps: IV B-Lactams | S.PYOGENES IS A TOXIN PRODUCING ORGANISM: Can DC clinda or Linezolid after 48 hours DOT: 7-10 days | |
| Definitive (Narrow) therapy for Gram (+) Bacteremia: Strep | Commonly IV PCN or Ceftriaxone | S.PYOGENES IS A TOXIN PRODUCING ORGANISM: Can DC clinda or Linezolid after 48 hours DOT 7-10 days | |
| Empiric Therapy for Gram (+) Bacteremia: Enterococcus Spp | - Enterococcus Faecalis- Ampicillin or Vanc - Enterococcus faecium - Linezolid, Daptomycin | DOT: 10-14 days | |
| IE Dental Prophylaxis | Admin x1 30-60 min prior to procedure - 1st line: Amox 2 gPO - 2nd: Azithromycin 500mg or Doxycyline 100 mg PO IV only: cefazolin or ceftriaxone | When to give prophylaxis: - Prosthetic <3 valve or <3 valve with artifical material - Hx of endocarditis - Heart transplant - Congential heart defects, such as a heart valve disease | |
| IE treatment Viridans Group Step | Penicillin or ceftriaxone (+/- gentamicin) | F/U : - Blood cultures 24-48 hrs until negative - Repeat TTE/TEE after completion of ABX therapy DOT: 4-6 weeks of IV therapy | |
| IE Treatment MSSA | Nafcillin or Cefazolin (+ genta AND rifampin if prosthetic valve) | F/U : - Blood cultures 24-48 hrs until negative - Repeat TTE/TEE after completion of ABX therapy DOT: 4-6 weeks of IV therapy | |
| IE Treatment MRSA | vanco or dapto (+ genta and rifampin if valve) | F/U : - Blood cultures 24-48 hrs until negative - Repeat TTE/TEE after completion of ABX therapy DOT: 4-6 weeks of IV therapy | |
| IE Treatment Enterococci | PCN OR Ampicillin + Gentamicin OR Ampicillin + High Dose Ceftriaxone. IF VRE use = dapto or linezolid | F/U : - Blood cultures 24-48 hrs until negative - Repeat TTE/TEE after completion of ABX therapy DOT: 4-6 weeks of IV therapy |
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texantaco