Antibiotic Susceptibility Chart (UW Medicine, 2015)

AntibioticSusceptibilityChart(UWMedicine,2015)

ClevelandClinic– GuidelinesforAntimicrobialUsage,2012-2013

*Examplesofdrugswithexcellentbioavailability(>90%)eligibleforIVtoPOswitchover*

*Examplesofdrugswithgoodbioavailability(60-90%)eligibleforIVtoPOswitchover*

JPharmacol Pharmacother.2014Apr-Jun;5(2):83–87.

Clostridiumdifficle Infection(IDSA/SHEA,2010)

Initialepisode

Mild/Moderate(WBC15orlower,SCr level<

1.5xpremorbidlevel)

Metronidazole500mgPO3timesadayfor10-14days

Severe,noileus(WBC15orhigher,ORaserum

creatinine≥1.5timespremorbidlevel)

Vancomycin125mgPO4timesdailyfor10-14days

PLUSMetronidazoleIV500mgq8h

Hypotensionorshock,ileus,megacolon

Vancomycin500mgPOqidPLUS

MetronidazoleIV500mgq8hPLUS

Mayaddrectalvancomycinifileus

RecurrentEpisodes• First:Sameasforan“initial”episode• Second:Vancomycininataperedand/orpulsedregiment

• Refertoliterature

Community-AcquiredInfection–Adults

Mild/ModerateSeverity(Appendixperforated/abscessed,other

infections)

Cefoxitin,ertapenem aloneOR(oneofthefollowing)

cefazolin,cefuroxime,ceftriaxone,ciprofloxacin,levofloxacin

COMBINEDWITHmetronidazole

HighRiskorseverity(severephysiologicdisturbance,advanced

age,immunocompromised)

Meropenem,piperacillin-tazobactam alone

OR(oneofthefollowing)cefepime,ceftazidime,

ciprofloxacin,levofloxacinCOMBINEDWITHmetronidazole

InitialEmpiricTreatmentofExtra-biliaryComplicatedIntra-abdominalInfection(IDSA,2010)

Antibiotics…shouldbeactiveagainst• EntericGram-negative

aerobicandfacultativebacilli

• EntericGram-positivestreptococci

Unasyn =notrecommended• HighE.coliresistance

RecommendationsforEmpiricAntimicrobialTherapyforHealth-CareAssociatedComplicatedIntra-abdominalInfection(IDSA,2010)

Organismsseen inhealth-careassociatedinfectioninlocal

institution

Carbapenem(Meropenem

only)

Piperacillin-tazobactam

Ceftazidime orcefepime,each

withmetronidazole

Aminoglycoside Vancomycin

<20%resistantP.aeruginosa,ESBL-producing Enterobacteriaceae,

Acinetobacter,orotherMDRGNB*

Yes Yes Yes No No

ESBL-producingEnterobacteriaceae

Yes Yes No Yes No

P.aeruginosa >20%resistanttoceftazidime*

Yes Yes No Yes No

MRSA No No No No Yes

ESBL:Extended-spectrumbeta-lactamaseGNB:Gram-negativebacilliMDR:Multi-drugresistant

*Refertoinstitutionantibiogram ifneeded*

Limittreatmentto4-7days

DiabeticFootInfection– MildSeverity(IDSA,2012)

Formild-moderateinfectionswithnorecentantibiotics:• TherapyjusttargetingaerobicGram+sissufficientFormostsevereinfections:• Startbroad-spectrumempirictherapyConsidercoveringforMRSAif:• localprevalenceishighorifpatienthasprevious

historyofMRSA

EmpirictherapydirectedatP.aeruginosaisusuallyunnecessaryEXCEPTforpatientswithriskfactorsfortrueinfection• “…IncountrieswhereP.aeruginosaisa

frequentisolate,orinpatientswhohavebeensoakingtheirfeet,whohavefailedtherapywithnonpseudomonal therapy,whohaveasevereinfection,empiricantipseudomonaltherapymaybeadvisable.”

DiabeticFootInfection– ModerateSeverity(IDSA,2012)

DiabeticFootInfection– ModerateSeverityCont’d(IDSA,2012)

“Wesuggestaninitialantibioticcourseforasofttissueinfectionofabout1–2weeksformildinfectionsand2–3weeksformoderateto

severeinfections”

ProstheticJointInfections(IDSA,2013)– Page1

ProstheticJointInfections(IDSA,2013)– Page2

Followingdebridement+retentionofprosthesis:• Staphylococcal:

• 2-6weeksofpathogen-specificIVtherapyPLUSrifampin300-450mgbid

• Non-staphyloccocal:• 2-6weeksofpathogen-specificIVorhighly

bioavailablePOtherapy

NEngl JMed.2009August20;361(8):787–794

COPD(GOLDGuidelines,2017)

Antibioticsshouldbegiventopatientswhohave3cardinalsymptoms:• Increaseindyspnea• Sputumvolume• Sputumpurulence

OR

Twoofthecardinalsymptoms• IFincreasedpurulenceis

oneofthose2• or[patientrequires]

mechanicalventilation

*Cultureifpatienthasfrequentexacerbations**Treatwithamoxicillin+clavulanicacidORazithromycinfor5-7days*

CommunityAcquiredPneumonia

Inpatient,non-ICU

Respiratoryfluoroquinolone(levofloxacin)OR

Β-lactamPLUSmacrolide(azithromycin)

Inpatient,ICU

B-lactam(cefotaxime,ceftriaxone,orampicillin-

sulbactam)PLUSEitherazithromycinOR a

respiratoryfluoroquinolone

IFPseudomonas isaconcern

Zosyn,cefepime,imipenem/meropenem PLUS

Levofloxacin(mayaddaminoglycosidealso)

IFCommunityAcquiredMRSA(rare,riskfactorincludeslung

abscess)AddvancomycinORlinezolid

*PatientswithCAPshouldbetreatedforaminimumof5days(levelIevidence),shouldbeafebrilefor48–72h,andshouldhavenomorethan1CAP-associatedsignofclinicalinstability(table10)beforediscontinuation

oftherapy

MostCommonPathogens

Inpatient(non-ICU)StreptococcuspneumoniaeMycoplasmapneumoniaeChlamydiapneumoniaeHaemophilus influenzae (unvaccinated)Legionellaspecies(rare)Stomach contents(aspiration)Respiratoryviruses

Inpatient(ICU)StreptococcuspneumoniaeStaphyloccocus aureusLegionellaspecies(rarely)Gram-negativebacilliH.influenzae (unvaccinated)

Community-AcquiredPneumonia(IDSA,2007)

Hospital-AcquiredPneumonia(HAP)(IDSA,2016)

Hospital-AcquiredPneumonia

MRSARisk?- Prior IVantibioticusewithin90days

- Hospitalizationinaunitwhere>20%ofS.aureusisolatesareMRSA

- Highriskofmortalityduetosepticshock,ventsupport(weakevidence)

Oneofthefollowing:Zosyn OR cefepime ORlevofloxacin

TheabovetherapyPLUS VancomycinORlinezolid(vancomycinfirst)

Highriskofmortality?- Sepsis

- Intubation

Twoofthefollowing(avoid2betalactams):Zosyn ORcefepime

OR levofloxacin/ciprofloxacinOR imipenem/meropenemOR anaminoglycosideOR

aztreonamPLUS vancomycinOR linezolid

No

Yes

MostCommon Pathogens• Pseudomonas aeroginosa• Staphylococcusaureus• Klebsiella pneumoniae• Escherichiacoli• Acinetobacter (lesscommon)

RiskFactorsformulti-drug resistantorganisms• PriorIVantibioticusewithin90days

Yes

PregnancyCategories– ClevelandClinicGuidelinesforAntibioticUsage,2012-2013

Antibiotic PregnancyCategory

Antibiotic PregnancyCategory

Amoxicillin B Clarithromycin C

Ampicillin(with/withoutsulbactam)

B Clindamycin B

Azithromycin B Daptomycin C

Aztreonam B Dicloxacillin B

Cefazolin B Ertapenem B

Cephalexin B Levofloxacin C

Cefdinir B Meropenem B

Cefepime B Metronidazole B(Butcontraindicatedin1st trimester

Cefotaxime B Nitrofurantoin B

Cefotetan B Penicillin G B

Ceftazidime B Piperacillin/Tazobactam B

Ceftriaxone B Sulfamethoxazole/Trimethoprim

D

Cefuroxime B Vancomycin C

Ciprofloxacin C

PregnancyCategories– CommonlyUsedAntibiotics

Source:Lexicomp,ClevelandClinic

SepsisEmpiricAntimicrobialTherapy(UWMedicine,2016)Page1

SkinandSkinStructureInfections(IDSA,2014)

MostCommonPathogens:StreptococcusspeciesStaphylococus aureusAerobicGram-negativebacilli(diabeticfoot)Anaerobes(diabeticfoot)

Abscess:5- to10-daycourseofanantibioticactiveagainstthepathogenisolatedErysipelasandcellulitis:5days,canextendifinfectionstillpresent

BacterialVaginosis(CDC2015Guidelines)

Superscript:1.Therecommendedregimensareequallyefficacious.2.Thesecreamsareoil-basedandmayweakenlatexcondomsanddiaphragms

*Treatmentisrecommendedforallsymptomaticpregnantwomen

GramNegative GramVariable Other

Prevotella species Gardnerellavaginalis

Ureaplasmaurealyticum

Poryphromonasspecies

Mobiluncusspecies

Bacteroidesspecies

Peptostreptococcus species

Somecommonlyseenpathogens:

Sources:UpToDate,CDC2015STDGuidelines

ChlamydiatrachomatisInfections(CDC2015Guidelines)

Superscriptnumbersintableabove:3.Forpregnantwomen:seecompleteCDCguidelines4.Doxycyclineshouldnotbeadministeredduringpregnancy,lactation,ortochildren<8yearsofage.5.Ifpatientcannottoleratehigh-doseerythromycinbaseschedules,changeto250mg4x/dayfor14days.6.Ifpatientcannottoleratehigh-doseerythromycinethylsuccinate schedules,changeto400mgorally4timesadayfor14days.7. Levofloxaciniscontraindicatedforpregnantorlactatingwomen8.Azithromycinsafeandeffectiveperclinicalexperienceandpublishedstudies9.Erythromycinestolate iscontraindicatedduringpregnancy10.Effectivenessoferythromycintreatmentisapproximately80%;asecondcourseoftherapymayberequired.

GonococcalInfections(CDC2015Guidelines)

Mostcommonpathogen:Neisseriagonorrhoeae(Gram-negative)

Superscriptnumbersintableabove:8.Clinicalexperienceandpublishedstudiessuggestthatazithromycinissafeandeffective10.Effectivenessoferythromycintreatmentisapproximately80%; asecondcourseoftherapymayberequired.

PelvicInflammatoryDisease(CDC2015Guidelines)

GramNegatives:NeisseriagonorrhoeaeChlamydiatrachomatisHaemophilus influenzae

GramPositive:Streptococcusagalactiae

GramVariableGardnerella vaginalis

Ureaplasma urealyticumMycoplasmagenitalium

Somecommonlyseenpathogens:

Syphilis(CDC2015Guidelines)

Superscriptnumbersintableabove:3.Forpregnantwomen:seecompleteCDCguidelines7.Doxycycline,tetracyclinecontraindicatedforpregnantwomen24.Pregnantpatientsallergictopenicillinshouldbetreatedwithpenicillinafterdesensitization.

AsymptomaticBacteriuria(IDSA,2005)

MostCommonPathogens:• Escherichiacoli(moresoinwomen)• Proteusmirabilis(moresoinmen)• Enterococcus species• Klebsiella pneumoniae

Cathetersareariskfactorforpolymicrobial bacteriuriainmenandwomen.Culturesmaygrow:• Pseudomonasaeruginosa• Providenciastuartii• Morganella morgannii

Doesthepatienthavealong-term,indwellingcatheter?• Considerifthisiscolonizationvsacuteinfection

• Pyruria =notindicationfortreatmentIFaccompaniedbyasymptomaticbacteriuria

UncomplicatedCystitisandPyelonephritisinWomen(IDSA,2010)

Nitrofurantoin:avoidin65orgreaterandthosewithCrCl <30mls/min

Pivmecillinam:notapprovedinUSA

Fluoroquinolones:RarechanceofCNSsideeffectsinelderly

TreatUTIsfor3-7daysdependingondrugchosen

IDSA,Lexicomp

Antibiotic Susceptibility Chart (UW Medicine, 2015)

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