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Archive for the ‘Antibiotics’ Category

UTI resistance at Elmhurst

There has been increasing resistance to Cipro for urine cultures sent from Elmhurst ED. Cephalexin and Macrobid currently have lower resistance rate. Bactrim continues to have high resistance for treatment of UTI.

Sheree Givre, MD, FACEP
Associate Director
Department of Emergency Medicine
Queens SART, Medical Director

Written by phil

November 29th, 2012 at 7:53 pm

Posted in Antibiotics,Elmhurst

Winter 2010 Adult Emergency Department Initial Empiric Antibiotic Recommendations

The enclosed are recommendations and are not to substitute for clinical judgment for the following common infections:

Pneumonia
Meningitis
Neutropenic fever
Urinary tract infections
Intra-abdominal infections
Skin and soft-tissue infections
Clostridium difficile colitis

When possible draw 2 sets of blood cultures on patients admitted with a documented or suspected infection. This increases diagnostic yield and helps tailor antimicrobial therapy.

Previous culture data should guide empiric antimicrobial choices.
Community and institutional microbiology can change and checking prior culture data on patients with frequent healthcare and antibiotic exposures is strongly recommended.

Does antibiotic need approval? PAGER 9407
Piperacillin-tazobactam, imipenem-cilastatin, meropenem, ertapenem, oral vancomycin, and aztreonam require ID approval.
Initial doses of IV fluoroquinolones, cefepime, and ampicillin-sulbactam may not need ID approval for specific indications in the ED. Documentation in IBEX reflecting indication is required. TDS (inpatient) orders need ID approval.
Between 9am – 5pm, call Antimicrobial Stewardship Program for approval of these antibiotics.
During off hours (5pm – 9am), please fill out “night time request for restricted antimicrobials” form available in IBEX.
When ordering in IBEX, chart must reflect clinical indication for restricted antimicrobial.

Antimicrobial Stewardship Program:
(ID pharmacists and ID physicians available for approvals and recommendations)
Pager 9407 (adults)
Page Pediatric ID on call (pediatrics)

Other Infectious Disease pagers:
General ID consult – Pager 0649
Transplant ID consult – Pager 8678
Jeff Gumprecht – Pager 3043, Office 212-427-9550
Glenn Hammer – Pager 2562, Office 212-427-9550
Eric Neibart – Pager 2962, Office 212-427-9550
John Wolff – Pager 917-975-3175

NOTE: If there is delay in reaching an ID pharmacist/physician, call pharmacy or ED pharmacist directly. A first dose will be released STAT if restricted antimicrobial needed emergently. All subsequent doses will need approval.

C. diff
UTI
Pneumonia
Skin
Meningitis
Abdomen
Neutropenic fever

Written by reuben

December 14th, 2010 at 6:41 am

Posted in Antibiotics,ID

2009 Antibiogram

Written by reuben

August 17th, 2010 at 12:41 am

Posted in Antibiotics,ID

Correct Antibiotics for immunosuppressed patients going to ICU

(PNA core measure)

B-lactam (IV) + Macrolide (IV)

B-lactam (IV) + Antipneumococcal Quinolone (IV)

If documented B-lactam allergy: Antipneumoccal Quinlone(IV) + Aztreonam

B-lactam = Ceftriaxone, Cefotaxime, Ampicillin/ Sulbactam

Macrolide = Erythromycin, Clarithromycin, Azithromycin

Antipneumococcal Quinolones = Levofloxacin, Moxifloxaxin

B-lactam (IV + Macrolide (IV)
B-lactam (IV + Antipneumococcal Quinolone (IV)
If documented B-lactam allergy: Antipneumoccal Quinlone(IV) + Aztreonam
B-lactam = Ceftriaxone, Cefotaxime, Ampicillin/ Sulbactam
Macrolide = Erythromycin, Clarithromycin, Azithromycin
Antipneumococcal Quinolones = Levofloxacin, Moxifloxaxin

Written by reuben

April 28th, 2010 at 3:03 am

Antibiotic Restriction List

Written by phil

August 26th, 2009 at 10:41 pm

Posted in Antibiotics,ID,Pharmacy

CAP and HAP antibiotic recommendations

Written by reuben

October 10th, 2008 at 6:45 am

2006 MSH ED ANTIBIOGRAM

Some highlights from the ED Antibiogram:

MSSA: cefazolin 100% sensitive
MRSA: vancomycin 100% sensitive
Strep Pneumo: Ceftriaxone 100% sensitive
Strep Pneumo (meningitis): Vanco 100% sensitive
E Coli:
  macrobid 98% sensitive
  ceftriaxone 97% sensitive
  zosyn 97% sensitive
Pseudomonas:
  cefepime 100% sensitive
  zosyn 100% sensitive

Written by phil

February 6th, 2007 at 9:09 pm

Posted in Antibiotics

Time to First Antibiotics in Septic Shock

Kumar A et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006 Jun; 34:1589-96.
[Medline abstract]

Time to First Dose of Antibiotics Is Critical in Septic Shock

Early administration of effective agents saves lives.

Data regarding the benefit of rapid time to first antibiotic dose in septic shock are limited and controversial. A common question is how the effect could be time-dependent when patients might have waited hours or days before presenting. In a retrospective study sponsored by a pharmaceutical company, researchers assessed the relation between time to first antibiotic dose and mortality in 2731 hypotensive septic shock patients at 14 intensive care units.

Research assistants reviewed charts and recorded data on a uniform data extraction sheet. Enrollment criteria were presumed or identified infection and sustained initial hypotension or recurrent hypotension after a fluid bolus. Forty-four percent of patients were admitted directly from the emergency department. The overall mortality rate was 56%.

Among 2154 patients who received effective antibiotic therapy, survival was 80% in those given antibiotics within the first hour of persistent or recurrent hypotension. However, for each hour of delay during the subsequent 6 hours, the chances of survival decreased by 7.6%. In multivariate analysis adjusted for illness severity, antibiotic effectiveness, single or multidrug coverage, early fluid resuscitation, number of failed organs, and time to vasopressor administration, the strongest predictor of outcome was time to effective antibiotic administration. Only half the patients received effective antibiotics within 6 hours of hypotension onset, and 30% had delays of more than 12 hours.

Comment: This retrospective study raises two critical concepts: First, prompt antibiotic administration in hypotensive septic shock is crucial, particularly if prospective observational studies validate that survival decreases with each hour of delay. Second, antibiotic delays are substantial, even in the sickest patients. Emergency physicians should consider antibiotic administration as part of resuscitation rather than as postresuscitation care. If we are to improve antibiotic administration in septic shock, a systematic process design will likely be needed for each ED.

Written by phil

November 14th, 2006 at 6:42 pm

Posted in Antibiotics

ABX – Empiric ABX for Severe Sepsis/Septic Shock

Written by phil

July 27th, 2006 at 3:11 am

Posted in Antibiotics

Antibiotic Recommendations

Emergency Department Empiric Antibiotic Recommendations:

Pneumonia
Uncomplicated urinary tract infections in women
Complicated urinary tract infections
Intra-abdominal infections
Skin and soft-tissue infections
Severe Sepsis & Septic Shock

Restricted antimicrobials now stocked in the ED (but continue to require ID oversight):

Cefepime (Maxipime)
Ampicillin-Sulbactam (Unasyn)

• Daytime (9am- 6pm) call the Antimicrobial Assistance Program and request/notify of the need for either cefepime or ampicillin-sulbactam and order in IBEX.

• Off-hours (6pm-9am) order cefepime or ampicillin-sulbactam in IBEX. The “night time request for restricted antimicrobials” form no longer needs to be sent to pharmacy. Pharmacy will track use via IBEX.

• The IBEX chart must reflect the clinical indication for the restricted antimicrobial (see recommendations).

Antimicrobial Assistance Program: (ID pharmacists and ID physicians available for approvals and recommendations)

Pager 9407 (adult)
Pager 3737 (pediatrics)

NOTE !
If there is any delay in reaching an ID pharmacist or ID physician, call the pharmacy directly. A first dose will be released STAT when a patient needs a restricted antimicrobial emergently.

—————————————————————————–
Recommendations provided thanks to Dr. Nassisi
—————————————————————————–

2006 Antibiogram Highlights

Written by phil

July 15th, 2006 at 3:39 pm

Posted in Antibiotics

ABX – Complicated UTI

Men – Cystitis.

Ciprofloxacin 500 mg orally twice daily for 7 days.

OR

Levaquin 500 mg orally once daily for 7 days.

For men <40 years of age it is usually an STD and >40 years of age it is usually E. Coli. Urethritis must be considered in sexually active men less than 40 years of age: examination for penile ulcerations and urine diagnostic tests for Neisseria gonorrhoeae and Chlamydia trachomatis (GC Probe) are warranted in this age group. Avoid Nitrofurantoin and beta-lactams in men with cystitis or pyelonephritis, since they do not achieve reliable prostatic tissue concentrations and would be ineffective for occult prostatitis.

Men – Prostatitis

Ciprofloxacin 500 mg orally twice daily for 4 weeks.

OR

Levaquin 500 mg orally once daily for 4 weeks

Acute prostatitis is manifested with frequency, dysuria, and difficulty urinating with fever and a tender prostate. In the presence of urinary retention or obstruction, and high fever: AVOID digital rectal exam as it could lead to sepsis, in these cases consult Urology.

Men – Acute pyelonephritis

Levaquin 500 mg IV/po once daily 10-14 days

OR

Ciprofloxacin 400 mg IV twice daily for 10-14 days. (can switch to po 500 mg po bid)

All men with pyelonephritis should be evaluated for causative factors.

Pregnant Women – Cystitis

TMP-SMX (160 mg/800 mg) orally twice a day for 7 days (FDA Category C: AVOID in first trimester)

OR

Amoxicillin 500 mg orally twice daily for 7 days. (FDA Category B)

OR

Nitrofurantoin (Macrodantin) 100 mg four times a day for 7days (FDA Category B)

OR

Macrobid (the extended release-XR-form of nitrofurantoin) 100 mg twice a day for 7 days can be prescribed for outpatient use
only. (FDA Category B)

OR

Cephalexin 250 mg orally four times daily for 7 days. (FDA Category B)

Fluoroquinolones should be avoided in pregnancy. Pregnant women should have a follow-up urine culture performed one to two weeks after treatment to ensure that bacteriuria has been eradicated. Treat as outpatients as long as they do not have symptoms suggestive of pyelonephritis. Have a low threshold for hospitalization.

Pregnant Women – Acute pyelonephritis

Ceftriaxone 1 gram IV every 24 hours for 10-14 days.

In the Mount Sinai 2005 antibiogram for the ED, Ceftriaxone was effective against 97% of E.Coli Isolates.

Nursing Home patients

Ceftriaxone 1 gram IV every 24 hours (preferred)

OR

If multi drug resistant gram negative suspected or previously isolated: Cefepime 1 gram IV every 12 hours.

Risk factors for multi-drug resistant resistant gram negative: frequent hospitalizations (>3) within the past year, recent hospitalization in an acute setting in the past 3 month, spinal cord injury individuals with intermittent catheterization, patients with suprapubic catheters or indwelling urinary catheters. In the Mount Sinai 2005 antibiogram for the ED, Ceftriaxone was effective against 97% of E.Coli Isolates.

——————————————————————————–
The choice of antibiotic should be based on the antimicrobial sensitivity if available. Page the ID pharmacist (9407) or the ID fellow on call for antimicrobial assistance.
——————————————————————————–

Ref: Patterson T. Detection, significance, and therapy of bacteriuria in pregnancy. Update in the managed health care era. Infect Dis Clin North Am 1997 Sep;11(3):593-608.
Nicolle, L. A practical guide to the management of complicated urinary tract infection. Drugs 1997; 53:583.

Written by phil

July 15th, 2006 at 3:37 pm

Posted in Antibiotics

ABX – Soft Tissue Infection

Cellulitis – Community acquired – Group A strep MSSA

Nafcillin 1–2 g every 4 h IV (Dicloxacillin 500 mg orally 4 times per day)

OR

Cefazolin 1 g every 8 h IV (Cephalexin 500 mg orally 4 times per day)

OR

Clindamycin 600 mg every 8 h IV (Clindamycin 300–450 mg orally 4 times per day).

Most cases of cellulitis are caused by Group A strep unless there is a portal of entry such as furuncles, carbuncles, abscesses or penetrating trauma in which case staph aureus is probably the cause. CDC data reveals that 99.5% of Group A strep strains remain susceptible to clindamycin, and 100% are susceptible to penicillin.

Cellulitis – Community acquired – MRSA suspected*

TMP-SMZ 2 double-strength tablets orally twice
per day.

OR

Clindamycin 600 mg every 8 h IV (Clindamycin 300–450 mg orally 4 times per day).

*Risk factors for Community acquired MRSA= Injection drug users, Homeless populations, Children, Jail and prison inmates, Military recruits, Native populations, Men who have sex with men, contact sports, HIV+ patients. Clindamycin has excellent antistaphylococcal activity, but there is the potential for emergence of inducible resistance to clindamycin if erythromycin resistance is present.

Cellulitis – Nosocomial – MRSA suspected*

Vancomycin 30 mg/kg/day IV every 12 hours.

*Risk Factors for Nosocomial MRSA= frequent hospitalization, nursing home resident, dialysis, immunocompromised.

NECROTIZING SKIN AND SOFT-TISSUE INFECTIONS

Clues: (1) pain disproportionate to physical findings, (2) violaceous bullae, (3) cutaneous hemorrhage, (4) skin sloughing, (5) skin anesthesia, (6) rapid progression, and (7) gas in tissue Surgical intervention is the major therapeutic
modality in cases of necrotizing fasciitis, also CT scanning and measurement of the serum creatine kinase (CK). The rationale for clindamycin is based on in vitro studies demonstrating both toxin suppression and modulation of cytokine (i.e., TNF) production.

Necrotizing Fasciitis

Ampicillin-sulbactam 1.5 g IV every 6 hours (3g if >100 Kg) + clindamycin 600–900 mg every 8 h iv

OR

Imipenem/cilastatin 1 g every 6–8 h iv

Monomicrobial infection caused by group A streptococcus (Streptococcus pyogenes) or clostridium. Predisposing factors: blunt trauma, varicella (chickenpox), injection drug use, a penetrating injury, surgical procedures, childbirth, burns, nonsteroidal antiinflammatory drugs.

OR

Mixed polymicrobial infection caused by aerobic and anaerobic bacteria. Predisposing risk Factors: immunocompromised, surgical procedures, diabetes, peripheral vascular disease, co-morbidities, decubitus ulcers, and spontaneous mucosal tears of the gastrointestinal or gastrourinary tract (i.e., Fournier gangrene).

Bites – Animal and Human

Ampicillin-sulbactam 1.5–3.0 g IV every 6h
(Amoxicillin/clavulanate 500/875 mg twice per day)

Bites – Animal and Human with PCN allergy

Clindamycin 600–900 mg IV every 8 h + Levaquin 500 mg IV once daily

Pasteurella species are isolated from 50% of dog bite wounds and 75% of cat bite wounds. Human bites reflect oral flora of the biter and tend to be more serious: strep viridans, Eikenella corrodens, Fusobacterium species, peptostreptococci, and Prevotella. Both Ampicillin-sulbactam and Fluroquinolones have activity against Pasteurella.

Diabetic Foot – Mild soft tissue infections AND no previous antibiotics

Nafcillin 1–2 g every 4 h IV
(Dicloxacillin 500 mg orally 4 times per day)

OR

Cefazolin 1 g every 8 h IV
(Cephalexin 500 mg orally 4 times per day)

OR

Clindamycin 600 mg every 8 h IV (Clindamycin 300–450 mg orally 4 times per day).

In mild diabetic soft tissue infections: therapy should be directed against aerobic gram positive organisms particularly, coagulase-negative staphylococci and S. aureus.

Diabetic Foot – Moderate soft tissue infections AND/OR previous antibiotic exposure

Ampicillin-sulbactam 1.5–3.0 g IV every 6h
(Amoxicillin/clavulanate 500/875 mg PO twice per day)

OR

Clindamycin 600–900 mg IV every 8 h + Levaquin 500 mg IV once daily

Initial oral broad-spectrum antimicrobial therapy should be directed at gram-positive, gram-negative, and anaerobic organisms.
——————————————————————————
Ref. Stevens DL, Bisno A, Chambers H et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections Clin Infect Dis 2005; 41:1373–406
IDSA guidelines for the diagnosis and treatment of diabetic foot infections: Clinical Infectious Diseases 2004; 39:885-910.

Written by phil

July 15th, 2006 at 3:36 pm

Posted in Antibiotics

ABX – Intra-Abdominal Infections

Cholangitis OR Cholecystitis

Unasyn 1.5 grams IV every 6 hours

In obese patients, use Unasyn 3g.

Acute cholecystitis is primarily an inflammatory process, however secondary infection of the gallbladder can occur as a result of cystic duct obstruction and bile stasis resulting in cholangitis.

Uncomplicated Diverticulitis – No Recent Hospitalization*

Cefazolin 1gm IV every 8 hours + Flagyl 500 mg IV every 8 hours (recommended as first line based on Mount Sinai antibiogram)

OR

Levaquin 500 mg po once every 24 hours + Flagyl 500 mg po every 8 hours

In obese patients use Cefazolin 2g.

Community isolates of E.Coli are 89% sens to Cefazolin, but only 81% sens to Fluroquinolones as per 2005 ED antibiogram. Agents that are used to treat nosocomial infections in the intensive care unit should not be routinely used to treat community-acquired infections which are principally Gram negative rods and anaerobes (particularly E. coli and B. fragilis), using broader-spectrum antibiotics would contribute to the development of resistance.

Uncomplicated Diverticulitis – Recent Hospitalization*

Ceftriaxone 1 gm IV every 24 hours + Flagyl 500 mg IV every 6 hours (recommended as first line based on Mount Sinai antibiogram)

OR

Unasyn 1.5 grams IV every 6h.

In obese patients use ceftriaxone 2g instead of 1g or Unasyn 3g.

*Recent Hospitalization: Within the past three months or frequent hospitalizations (>3) within the past year.

Appendicitis – No Recent Hospitalization*

Cefazolin 1gm IV every 8 hours + Flagyl 500 mg IV every 8 hours

Community isolates of E.Coli are 89% sens to Cefazolin, but only 81% sens to fluroquinolones as per 2005 ED antibiogram.

Appendicitis – Recent Hospitalization*

Ceftriaxone 1 gm IV every 24 hours + Flagyl 500 mg IV every 6 hours (recommended as first line based on Mount Sinai antibiogram)

OR

Unasyn 1.5 grams IV every 6 hours.

*Recent Hospitalization: Within the past three months or frequent hospitalizations (>3) within the past year.

SBP in Cirrhotic Patients – Not on Furoquinolone Prophylaxis

Cefotaxime 2 g IV every 8 hours

Most cases of SBP are due to gut bacteria, such as Escherichia coli and Klebsiella. Dosing of cefotaxime 2 g intravenously every eight hours produces excellent ascitic fluid levels.

Written by phil

July 15th, 2006 at 3:36 pm

Posted in Antibiotics

ABX – Uncomplicated UTI in Women

Cystitis – with the following:

  • Has no history of allergy to Sulfa drug
  • Has not been on antibiotics, especially TMP-SMX, in the past three months for any reason.
  • Has not been hospitalized recently

TMP-SMX (160 mg/800 mg) orally twice a day for 3 days

E. coli is the causative pathogen in approximately 80 to 85 percent of episodes of acute uncomplicated cystitis. Staphylococcus saprophyticus is responsible for most other episodes. E. Coli resistance to TMP-SMX is about 10 % in the northeast US.
There is no apparent benefit in extending therapy with TMP-SMX or a fluoroquinolone past three days, and adverse reactions are more common in patients treated with longer regimens. This also appears to apply to women over the age of 65 years
Allergy to TMP-SMX

Cystitis with Risk factors for TMP-SMX resistance including:

  • Moderate to severe symptoms
  • Women who might find it difficult to seek additional care if their symptoms do not significantly improve over a short time: homelessness or lack of health insurance.

Ciprofloxacin 250 mg orally twice a day for 3 days

OR

Nitrofurantoin (Macrodantin) 100 mg four times a day for 7days

OR

Macrobid (the extended release-XR-form of nitrofurantoin) 100 mg twice a day for 7 days can be prescribed for outpatient use only.

The antimicrobials currently recommended for cystitis, TMP-SMX, nitrofurantoin, and fluoroquinolones, have excellent activity in vitro against S. saprophyticus.
The prevalence of resistance to nitrofurantoin among E. coli is less than 5 percent.
For patients with allergies to both TMP-SMX and/or Fluroquinolones, another option is Keflex 250 mg po four times a day for 7 days, although compliance with such a regimen might be an issue.

Pyelonephritis

Fever (>38ºC), flank pain, costovertebral angle tenderness, and nausea or vomiting suggest upper tract infection and warrant more aggressive diagnostic and therapeutic measures.

If outpatient therapy for mild pyelonephritis is a possibility in a patient tolerating oral medications/diet, would treat for 10 days with a fluroquinolone.

Ceftriaxone 1 g IV once a day

OR

Ciprofloxacin 500 mg po twice a day (or 400 mg IV twice a day if unable to take oral)
OR

Levaquin 500 mg orally once a day (or IV if unable to take po)

In the Mount Sinai 2005 antibiogram for the ED, Ceftriaxone was effective against 97% of E.Coli Isolates. E. Coli resistance to the fluoroquinolones remains well below 5 percent in most studies.

——————————————————————————
Note: Patients with urethritis and vaginitis also may complain of dysuria, thereby presenting a diagnostic challenge. Urethritis caused by Neisseria gonorrheae or Chlamydia trachomatis is relatively more likely to be present if in the
setting of a sexually transmitted disease (STD).

Written by phil

July 15th, 2006 at 3:35 pm

Posted in Antibiotics

ABX – Pneumonia

Outpatient Previously healthy – No Recent Antibiotic Therapy

Doxycycline 100 mg orally twice a day for 7 days

OR

Levaquin 750 mg orally once a day for 5 days

OR

Z-Pack (Azithromycin 500 mg orally once on day 1 then 250 mg every day for day 2 to 5)

Doxycycline is active against 90%-95% of strains of S. pneumoniae, also active against H. influenzae, atypical agents, and category A bacterial agents of bioterrorism. Generally well tolerated and inexpensive. Macrolides active against most common pathogens, including atypical agents. Macrolide resistance is reported for 20%-30% of Streptococcus pneumoniae.

Outpatient Previously Healthy – Recent Antibiotic Therapy

Z-Pack + Amoxicillin-clavulanate 2 g orally twice a day for 7 days.

OR

Z-pack+ Amoxicillin 1 g orally three times a day for 7 days

OR

Levaquin 750 mg orally once a day for 5 days

Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa. Compared with amoxicillin, amoxicillin-clavulanate spectrum in vitro includes B-lactamase producing bacteria, such as most H. influenzae, methicillin-susceptible Staphylococcus aureus, and anaerobes. Lacks activity against atypical agents, also is more expensive and has more gastrointestinal intolerance, when compared with amoxicillin. High dosages amoxicillin (3 g/day) required to achieve activity against >90% of S. pneumoniae. Lacks activity against atypical agents and B-lactamase producing bacteria.

Outpatient with Comorbidities* – No Recent Antibiotic Therapy**

Levaquin 750 mg orally once a day for 5 days

Outpatient with Comorbidities* – Recent Antibiotic Therapy**

Z-pack + Amoxicillin-clavulanate 2 g orally twice a day for 7 days.

OR

Levaquin 750 mg once a day for 5 days

* Comorbities = Malignancy, COPD, Diabetes, CHF, Renal or Liver Disease

** Recent Antibiotics = Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa.

Suspected Aspiration with Infection

Amoxicillin-clavulanate 2 g orally twice a day for 7 days

OR

Clindamycin 600 mg orally three times a day for 7 days Coverage of oral flora.

Inpatient Non-ICU

Community acquired Levaquin 750 mg orally once daily

OR

Z-pack + Ceftriaxone 1 g IV once daily

If multi drug resistant gram negative suspected or previously isolated or if recently hospitalized: Cefepime 1 gram IV every 12 hours.

Recent antibiotics: Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa. In obese patients use ceftriaxone 2g instead of 1g. Levaquin is active against >98% of S. pneumoniae strains in the United States, including penicillin-resistant strains. Concern for abuse with risk of increasing resistance by S. pneumoniae. Active against H. influenzae, atypical agents, methicillin-susceptible S. aureus. Expensive. Ceftriaxone is active in vitro against 90%-95% of S. pneumoniae, also active against H. influenzae and methicillin-susceptible S. aureus.

Aspiration with infection
Clindamycin 600 mg orally every 8 hours + Levaquin 750 mg orally once daily Coverage of oral flora.

ICU – Not recently hospitalized

Ceftriaxone 1g IV once daily + Azithromycin 500 mg po or IV once daily

For patients with CAP in the ICU, always cover S. pneumoniae and Legionella. Legionella must be treated for 21 days. Patients hospitalized for pneumonia in the ICU should have 2 pretreatment blood cultures and endotracheal aspirate sent for Gram stain and culture. In obese patients use ceftriaxone 2g instead of 1g.

ICU – Recently hospitalized

Cefepime 1g IV every 12 hours + Azithromycin 500 mg po or IV once daily

Cefepime retains excellent activity against s. pneumoniae but also covers more resistant gram negatives. In obese patients use Cefepime 2g instead of 1g.

Nursing Home Resident2

ICU – Hospitalized or ICU bound

Cefepime 1 g IV every 12 hours + Azithromycin 500 mg po or IV once daily

Elderly patients of long-term care facilities have been found to have a spectrum of pathogens that most closely resemble late-onset hospital acquired pneumonia and ventilator associated pneumonia. Coverage against More resistant gram negatives, including pseudomonas should be provided.

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1. Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults. Mandell LA, Bartlett JG, Dowell SF, File TM, Musher D, and Whitney C. Clin Infect Dis 2003;37:1405-1433.
2. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Health-care-associated Pneumonia?American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2005;171:388-416.

Written by phil

July 15th, 2006 at 3:33 pm

Posted in Antibiotics