SUGGESTED EMPIRIC ANTIMICROBIAL THERAPY BY SITE OF …

Northwestern Memorial Hospital SUGGESTED EMPIRIC ANTIMICROBIAL THERAPY BY SITE OF INFECTION

Empiric antimicrobial guidelines are based on the most likely organisms responsible for infection, NMH susceptibilities, and prevalence of resistant organisms. Therapy may need to be adjusted once identification and susceptibility are determined.

Previous antimicrobial therapy may affect the susceptibility of organisms that subsequently cause infection. Close attention should be given to courses of antimicrobial therapy administered to patients in the recent past. Alterations in empiric antimicrobial therapy may be required.

Anatomic site /diagnosis BONE

Acute osteomyelitis

Common Pathogens

Preferred therapy

S. aureus (MSSA and MRSA) vancomycin

Alternative**

Acute osteomyelitis in patient with hemoglobinopathy (Sickle cell disease or Thalassemia)

Salmonella species, other gram-negatives, S. aureus

ceftriaxone +/- vancomycin ciprofloxacin +/vancomycin

Long bone status post internal fixation of fracture Sternum, post-operative

S. aureus, S. epidermidis, gram-negatives S. aureus, S. epidermidis

vancomycin + cefepime vancomycin

Vertebral osteomyelitis +/epidural abscess

S. aureus most common, other vancomycin +/- ceftriaxone Gram-positives and Gram-negatives also possible

Comments

Bone biopsy and/or tissue biopsy is strongly recommended prior to starting antibiotics. Bone biopsy and/or tissue biopsy is strongly recommended. Fluoroquinolone resistance is increasingly reported among Salmonella.

Bone biopsy and/or tissue biopsy is strongly recommended. Bone biopsy and/or tissue biopsy is strongly recommended. Obtain blood cultures in non-surgeryassociated cases. Bone biopsy and/or tissue biopsy is strongly recommended.

Contiguous osteomyelitis with polymicrobial

vascular insufficiency

Chronic osteomyelitis

polymicrobial

CENTRAL NERVOUS SYSTEM

Empiric antibiotic therapy is not recommended; recommend bone biopsy for directed therapy.

Brain abscess--primary

Streptococci, Bacteroides spp., ceftriaxone + Enterobacteriaceae, S. aureus metronidazole; vancomycin

if concerned for MRSA

Biopsy is necessary for diagnosis. Consider Nocardia in both immunocompromised and immunocompetent patients.

** - Alternative column offers options for type-1 beta-lactam allergic patients where evidence exists, unless otherwise noted. If no alternative is listed, consultation with an ID specialist is recommended.

Brain abscess--post-surgical or Enterobacteriaceae, S. aureus vancomycin + ceftazidime post traumatic

Biopsy is recommended.

Anatomic site /diagnosis Encephalitis

Meningitis--acute bacterial

Common Pathogens HSV

Preferred therapy acyclovir

Alternative**

Comments

See IDSA guidelines for epidemiologic risk factors and diagnostic work-up for encephalitis,

delinesPatient_Care/PDF_Library/Encephalitis.pdf

S. pneumoniae, N. meningitidis vancomycin + ceftriaxone vancomycin + aztreonam Also recommended to administer

+/- ampicillin

+/-

before or with first dose of antibiotics:

trimethoprimsulfamethoxazole

dexamethasone 10mg IV q 6 hours x 4 days. See NEJM 2002; 347: 1549-56. See also IDSA guidelines for meningitis,



-

Patient_Care/PDF_Library/Bacterial%20Meningitis(1).p

df

Ampicillin or trimethoprim-

sulfamethoxizole is given to cover

Listeria monocytogenes, more common

in patients over age 50, alcoholics,

pregnant women, and patients with

impaired cellular immunity. Some

experts would add ampicillin or

trimethoprim-sulfamethoxizole

empirically to adults with suspected

bacterial meningitis during the first 2-3

days, until culture results become

available.

Meningitis--post neurosurgery or S. pneumoniae, S. aureus,

post head trauma

coliforms, P. aeruginosa

Menigitis/ventriculitis due to infected ventriculo-peritoneal shunt

S. aureus, S. epidermidis , diphtheroids, coliforms, P. acnes

vancomycin + ceftazidime vancomycin + aztreonam vancomycin + ceftazidime vancomycin + aztreonam Remove shunt

** - Alternative column offers options for type-1 beta-lactam allergic patients where evidence exists, unless otherwise noted. If no alternative is listed, consultation with an ID specialist is recommended.

Neurosyphilis

penicillin G

Penicillin testing necessary with Beta-lactam allergy; contact infectious diseases and allergy services. Dose: penicillin G (23-4 million units IV q 4 hr) for 10-14 days, then benzathine penicillin 2.4 MU IM weekly x 3.

Anatomic site /diagnosis Prophylaxis for Neisseria meningitidis contacts

Common Pathogens

Preferred therapy Rifampin or ciprofloxacin

Alternative**

Comments

Ceftriaxone 250 mg IM Contact infection control for guidance.

is preferred agent in Doses:

pregnancy.

rifampin 600 mg po q 12 hours x 4

doses

OR

ciprofloxacin 500 mg po x 1.

GALLBLADDER Cholecystitis (communityacquired*) - Mild-moderate severity

Cholangitis following biliary anastamosis ? any severity

Enterobacteriaceae

ceftriaxone

Enterobacteriaceae, anaerobes piperacillin/tazobactam

Cholecystitis (communityacquired) ? Severe physiologic disturbance or high risk patient (advanced age or immunocompromised),

Enterobacteriaceae, anaerobes piperacillin/tazobactam

levofloxacin

aztreonam + metronidazole + vancomycin aztreonam + metronidazole + vancomycin

*Community-acquired: symptoms prior to admitor within 48h of admit AND no hospitalization within prior 90 days.

** - Alternative column offers options for type-1 beta-lactam allergic patients where evidence exists, unless otherwise noted. If no alternative is listed, consultation with an ID specialist is recommended.

Cholecystitis (healthcareassociated), biliary sepsis or common duct obstruction

Enterobacteriaceae, anaerobes piperacillin/tazobactam and the possibility of gramnegative resistance; enterococcus in select immunocompromised patients

aztreonam + metronidazole +/vancomycin

Healthcare-associated: prior gallbladder instrumentation, admitted longer than 48 hours, hospitalized previously in the past 90 days. See IDSA guidelines for intraabdominal infections,

es-Patient_Care/PDF_Library/Intraabdominal%20Infectin.pdf

Anatomic site /diagnosis GASTROINTESTINAL C. difficile colitis

Common Pathogens

Preferred therapy

oral metronidazole or oral vancomycin

Alternative**

Diverticulitis, perirectal abscess, Community-acquired:

peritonitis

Enterobacteriaceae,

Bacteroides

ceftriaxone + metronidazole levofloxacin + metronidazole

Community-acquired, high-risk: piperacillin-tazobactam Enterobacteriaceae, bacteroides, enterococcus, and the possibility of gram-negative resistance

levofloxacin + metronidazole

Comments

Metronidazole PO is the drug of choice for initial episode of mild-to-moderate CDI. Vancomycin 125 mg PO QID is drug of choice for severe C. difficile (WBC> 15 and/or creatinine > 1.5 times the premorbid value). Rectal administration and/or high dose vancomycin 500 mg PO may be considered in severe, complicated cases of C. difficile infection (above plus hypotension, shock, ileus or toxic megacolon). See IDSA guidelines for C. difficile colitis,

delines-Patient_Care/PDF_Library/cdiff2010a.pdf

Community-acquired: < 48h of admission, no hospitalization in past 90d. High-risk: severe physiologic disturbance, advanced age, or immunocompromised state. See IDSA guidelines for intra-abdominal infections,

delines-Patient_Care/PDF_Library/Intraabdominal%20Infectin.pdf

** - Alternative column offers options for type-1 beta-lactam allergic patients where evidence exists, unless otherwise noted. If no alternative is listed, consultation with an ID specialist is recommended.

Healthcare-associated or

piperacillin/tazobactam +

severely ill: same as high-risk vancomycin

community-acquired

levofloxacin + metronidazole + vancomycin

Following appendectomy, no perforation

none

none

Empiric enterococcal coverage (directed at E. faecalis ) is recommended, especially for those with post-op infection, those who have previously received cephalosporins, immunocompromised patients, and those with prosthetic intravascular material. Surgical prophylaxis only

** - Alternative column offers options for type-1 beta-lactam allergic patients where evidence exists, unless otherwise noted. If no alternative is listed, consultation with an ID specialist is recommended.

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