Microsoft word - sicu_hcuv. empirical antibiotic therapy.doc

Table 1. By type of infection, microorganisms to be suspected in relation to the presence or not of risk factors for multidrug resistance and
suggested empirical treatments [VAP: ventilador-associated pneumonia; MDR: multidrug resistance; ESBL: extended-spectrum β-lactamase;
ESCPM group (Enterobacter cloacae, Enterobacter aerogenes, Serratia marcescens, Citrobacter freundii, Providencia rettgeri and Morganella
morganii); MRSA: methicillin-resistant S. aureus; HACEK (Haemophilus spp., Aggregatibacter -formerly Actinobacillus-
actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella spp)]
INFECTION TYPE
SUSPECTED PATHOGENS
EMPIRICAL TREATMENT
COMMENTS
Pneumonia or
No risk factors for MDR bacteria
Cefotaxime or ertapenem IV antibiotic treatment should not exceed >7 days S. pneumoniae H. influenzae Addition of macrolides/azalides improves the prognosis of S. aureus (methicillin-susceptible) Azithromycin or levofloxacin pneumococcal pneumonia Legionella Presence of risk factors for first-
Piperacillin/tazobactam or cefepime or ESBL-producing isolates are involved in ≈10% level of resistancea
meropenem or doripenem pneumonia caused by enterobacteria. When confirmed, Above microorganisms plus: monotherapy with carbapenems (meropenem, imipenem, Levofloxacin or amikacin ertapenem) is indicated ESBL-producing enterobacteria Penicillin-resistant S. pneumoniae Suspiction of infection by P. aeruginosa: It is P. aeruginosa recommended the association of two antipseudomonal compounds In bacteremic infections by MRSA, consider the association of linezolid + daptomycin Presence of risk factors for second-
Antipseudomonal betalactam different Treatment election should consider previous antibiotic level of resistanceb
from those previously used, with treatments and susceptibility of isolates in surveillance Above microorganisms plus: preference for carbapenems cultures of colonizing flora Non-fermenter gramnegative bacilli Levofloxacin or amikacin Consider administration of an inhalated antibiotic AmpC and/or carbapenemase- producing enterobacteria Consider associations with colimycin, fosfomycin and Multidrug-resistant P.aeruginosa aRisk factors for first-level of resistance: Significant comorbidities and/or antibiotic treatment for >3-5 days bRisk factors for second-level of resistance: Hospital admission and/or prolonged antibiotic treatment (>7 days) Bloodstream infections: Coagulase-negative staphylococci
Daptomycin or vancomycin Gram-negative bacteria should always be suspected in the primary bacteremia/
S. aureus (including MRSA) critically ill patient regardless site of central venous Enterococcus spp. Cefepime or piperacillin/tazobactam or bacteremia
meropenem or doripenem Klebsiella spp. If methicillin-susceptibility in staphylococci is confirmed, change to cloxacillin P. aeruginosa Acinetobacter spp. In persistent (>5-7 days) or recurrent (without endovascular foci) bacteremia by S. aureus, a second anti- staphylococcal drug (with or without rifampicin) should be If the patient is under cloxacillin treatment, add daptomycin with or without rifampicin. If the patient is under daptomycin treatment, add linezolid or fosfomycin or cloxacillin, with or without If the patient is under vancomycin treatment, change to daptomycin + cloxacillin, with or without Candida spp. Echinocandin or fluconazol An antifungal drug with activity against Candida spp. should be considered in critically ill patients with central venous catheter in the femoral vein and/or parenteral nutrition, severe sepsis or recent abdominal surgery Urinary tract infections With criteria for severe sepsis or
Meropenem or doripenem Due to its high frequency, ESBL-producing enterobacteria presence of risk factors for first-
should be covered in patients with severe sepsis or septic level of resistancea
ESBL-producing enterobacteria Presence of risk factors for
Meropenem or Doripenem + Amikacin Treatment election should consider previous antibiotic second-level of resistanceb
treatments and susceptibility of isolates in surveillance Above microorganisms plus: cultures of colonizing flora Use of colimycin or tigecyclin may be necessary. Although Multidrug-resistant P.aeruginosa, tigecycline concentrations in urine are not high, it may be Enterococcus spp. useful in case of pyelonephritis Acinetobacter spp. Candida spp. aRisk factors for first-level of resistance: Significant comorbidities and/or antibiotic treatment for >3-5 days bRisk factors for second-level of resistance: Hospital admission and/or prolonged antibiotic treatment (>7 days) No risk factors for MDR bacteria
In case of lack of control of the infectious foci, follow infections
Cefotaxime + metronidazole treatment recommendations in the presence of risk factors K. pneumoniae for first-level resistance B. fragilis Presence of risk factors for first-
Meropenem or imipenem or ertapenem In case of lack of control of the infectious foci, follow level of resistancea
treatment recommendations in the presence of risk factors Above microorganisms plus: Daptomycin or linezolid or vancomycin for second-level resistance ESBL-producing enterobacteria P. aeruginosa Enterococcus spp. Piperacillin/tazobactam or cefepime or
Presence of risk factors for second-
Meropenem or doripenem + daptomycin Treatment election should consider previous antibiotic level of resistanceb
or linezolid or vancomycin treatments and susceptibility of isolates in surveillance All the above microorganisms plus: cultures of colonizing flora Tigecycline + piperacillin/tazobactam or Non-fermenter gramnegative bacilli AmpC and/or carbapenemase- producing enterobacteria Multidrug-resistant P.aeruginosa Candida spp. In critically ill patients, echinocandins are the elective treatment for Candida antifungal therapy aRisk factors for first-level of resistance: Significant comorbidities and/or antibiotic treatment for >3-5 days bRisk factors for second-level of resistance: Hospital admission and/or prolonged antibiotic treatment (>7 days)
Endocarditis
S. aureus Ampicillin + cloxacillin If glomerular filtrate is <40 ml/min or concomitant Coagulase-negative staphylococci treatment with potentially neurotoxic drugs, change Prosthetic valve >12 Viridans group streptococci Gentamicin (3-5 days) gentamicin by daptomycin months post-surgery Enterococcus spp. Streptococcus bovis Risk for MRSA (including
Ampicillin + daptomycin + fosfomycin If vancomycin MIC ≥1 mg/l, severe sepsis or bacteremia intravenous drug users and
for >5 days, consider heteroresistance or tolerance and healthcare facilities)
Gentamicin (3-5 days) change to daptomycin Addition of gentamin should be avoided if glomerular filtrate is <40 ml/min. Consider change to cotrimoxazole. Ampicillin + vancomycin Addition of fosfomycin should be avoided if MIC ≥32 mg/l. Consider change to cotrimoxazole Prosthetic valve <12 Daptomycin + fosfomycin + gentamicin or Initiate rifampicin from the 3rd-5th day on. months post-surgery Coagulase-negative staphylococci Viridans group streptococci Vancomycin could be considered when MIC≤1 mg/l for Enterococcus spp. the MRSA and normal renal function Streptococcus bovis Addition of gentamin should be avoided if glomerular filtrate is <40 ml/min. Consider change to cotrimoxazole. K. pneumoniae Addition of fosfomycin should be avoided if MIC ≥32 Salmonella enteritidis mg/l. Consider change to cotrimoxazole P. aeruginosa Considerar gentamicin if Enterococcus spp. is isolated Skin and Soft tissue
Group A streptococci Piperacillin/tazobactam or meropenem In infections by S. aureus producing panton valentine infections
Clostridium perfringes
leukocidin or superantigens, the antibiotic regimen should Clostridium septicum
include linezolid or clindamicin Necrotizing fasciitis
Staphylococcus aureus
(Fournier's gangrene, Mixed polymicrobial infection:
Daptomycin or linezolid or clindamycin early surgical wound Enterococcus spp. infection 24-48 h post- Bacillus cereus P. aeruginosa Consider high doses of tigecycline in moderately severe Klebsiella spp. polymicrobial infections involving MRSA and in patients Proteus spp. with allergy to β-lactams Peptostreptococcus spp. Bacteroides spp. Table 2. Doses of common antibiotics for the treatment of infections in the critically ill patient
Drug
Dose (iv)
Comments
1-2 g as initial dose followed by 8g in 24h continuous infusion 1-2 g as initial dose followed by 6g in 24h continuous infusion 1-2 g as initial dose followed by 6g in 24h continuous infusion 1-2 g as initial dose followed by 6g in 24h continuous infusion 1-2 g as initial dose followed by 12g in 24h continuous infusion May be administered as bolus Administered as intermittent slow infusion (4 h) Administered as intermittent slow infusion (4 h) or continuous infusion 7-9 mg /kg/d (1 dose) referred to adjusted body weigth; body weight = ideal body weight + 0.4 × (total weight – Intermittent slow infusion (2 h) 1200 mg in 24 h continuous infusion Intermittent slow infusion (3 h) Piperacillin-tazobactam 2 g as initial dose followed by 16g in 24h continuous infusion 100- 200 mg followed by 50- 100 mg / 12 h Kg referred to total body weight continuous infusion

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