Dr. Cutrell gave the second half of his introductory lecture on antibiotics today. It provides a great framework for understanding antibiotic principles and approaching clinical questions on the wards or in the ICU. Remember, vanc/zosyn isn’t always the answer!
At noon conference today, Dr. James Cutrell kicked off our “Back to Basics” series with a great introduction to antibiotics and the concept of antibiotic stewardship. Check out the slides below & stay tuned for the sequel later this month!
Also, click below to read the perspective piece from NEJM by Drs. Nathan & Cars regarding antibiotic resistance.
- GI or GU infections in patients with prior abx
- Bacteremia, endocarditis in those with extensive HC exposure
- E. faecalis: Often remains sensitive to ampicillin, beta-lactams
- E. faecium: Often multi-drug resistant
- Consider Nitrofurantoin or Fosfomycin
Invasive infections Rx
- Amp-sens VRE faecalis: Amp, Amp/Sulb, Pip/Tazo, Imi/Meropenem active
- Linezolid, High dose Daptomycin (8-12 mg/kg daily), Tigecycline à Consult ID for assistance
- Must meet all of following: No IE (by TEE); No prostheses; Negative f/u blood cultures at 2-4 days; Defervescence within 72 h of effective therapy; No metastatic infection
- Vancomycin or Daptomycin for minimum 2 weeks
Complicated Bacteremia or Endocarditis
- 4-6 weeks at minimum
- No benefit to adding gentamicin or rifampin for native valve IE
- Generally defined as persistent bacteremia around day 7 of therapy (median time to clearance of MRSA bacteremia is 7-9 days)
- May also define failure as patient getting worse on current tx
- Remember SOURCE CONTROL!!!
- PO options acceptable for SSTI or completion of osteo Rx; IV preferred for invasive disease
- Vancomycin is the empiric drug of choice in most serious infections (duh!)
- Vanc MIC ≥ 2 associated with higher rates of Rx failure so consider alternative agents
- If vancomycin intolerance or failure:
- PNA: Linezolid, Ceftaroline
- Bacteremia/Endocarditis: Daptomycin, Ceftaroline
- CNS: Linezolid
- Osteo: Dapto, Ceftaroline
- Goal is “the administration of effective IV abx within 1st hour of recognition of septic shock or severe sepsis.” — (grade 1B and 1C, respectively)
- Initial empiric Rx should include “one or more drugs active against all likely pathogens with adequate penetration into tissues presumed to be source of sepsis.” — (grade 1B)
- Abx should be “reassessed daily for potential de-escalation.” — (grade 1B)
- “Combination therapy, when used empirically for severe sepsis, should not be continued more than 3-5 days” but de-escalate to single-agent therapy as soon as susceptibilities are known.” — (grade 2B)
- Source control in first 12 hours if feasible. — (grade 1C)
- Empiric Rx depends on host factors, recent abx exposure, allergies, clinical syndrome and likely site of infection, local antibiogram and pt’s prior infections or colonization
- Combination therapy recommended in neutropenics with severe sepsis, those with prior MDR pathogens, and respiratory failure or septic shock patients. — (grade 2B)
- Practically, this usually means vancomycin + anti-Pseudomonal beta-lactam + either aminoglycoside or anti-Pseudomonal FQ
Sometimes it’s hard to remember all the dosing of those antibiotics and their indications for infections, particularly CNS and abscesses. Click on the links below to open a quick reference guide in how to treat these infections!
Special thanks to Ramu, MariAlison, and Parker for creating this blog post!