Antibiotic Guidelines 2015-2016 (DocToon - Page)

Antibiotic Guidelines
2015-2016
Treatment Recommendations
For Adult Inpatients
Also available online at
insidehopkinsmedicine.0rg/amp
Table of contents
1. Introduction ............................................................................................ 3
2. Johns Hopkins Hospital formulary and restriction status .................... 6
2.1 Obtaining ID approval ........................................................................6
2.2 Formulary .........................................................................................7
3. Agent-specic guidelines ...................................................................... 8
3.1 Antibiotics ........................................................................................8
Ceftaroline ......................................................................................8
Ceftolozane/tazobactam .................................................................8
Colistin ...........................................................................................9
Daptomycin ................................................................................. 10
Ertapenem................................................................................... 11
Fosfomycin .................................................................................. 11
Linezolid ...................................................................................... 12
Tigecycline .................................................................................. 13
Trimethoprim/sulfamethoxazole ................................................... 14
3.2 Antifungals..................................................................................... 16
AmBisome ................................................................................ 16
Micafungin ................................................................................... 17
Posaconazole .............................................................................. 18
Voriconazole ................................................................................ 19
Azole drug interactions................................................................. 20
3.3 Vaccines ....................................................................................... 23
Pneumococcal vaccines ............................................................... 23
4. Organism-specic guidelines .............................................................. 24
4.1 Anaerobes..................................................................................... 24
4.2 Propionibacterium acnes................................................................ 25
4.3 Streptococci.................................................................................. 27
4.4 Multi-drug resistant Gram-negative rods .......................................... 28
5. Microbiology information .................................................................... 31
5.1 Interpreting the microbiology report................................................ 31
5.2 Spectrum of antibiotic activity......................................................... 32
5.3 Interpretation of rapid diagnostic tests ............................................ 34
5.4 Johns Hopkins Hospital antibiogram ............................................... 36
6. Guidelines for the treatment of various infections...........................39
6.1 Abdominal infections .............................................................39
Biliary tract infections ................................................................... 39
Diverticulitis ................................................................................. 40
Pancreatitis ................................................................................. 41
Peritonitis (including SBP, GI perforation and peritonitis
related to peritoneal dialysis) ........................................................ 42
6.2 Clostridium difcile infection (CDI) ............................................ 47
6.3 Infectious diarrhea ..................................................................... 51
6.4 H. pylori infection ....................................................................... 54
6.5 Gynecologic and sexually transmitted infections ..................... 56
Pelvic inamatory disease ............................................................ 56
Endomyometritis .......................................................................... 56
Bacterial vaginosis ....................................................................... 57
Trichomoniasis ............................................................................ 57
Uncomplicated gonococcal urethritis, cervicitis, proctitis ............... 57
Syphilis........................................................................................ 58
6.6 Catheter-related bloodstream infections .................................. 60
(continued on next page)
Table of contents
6.7 Endocarditis ................................................................................ 65

6.8 Pacemaker/ICD infections......................................................... 71
6.9 Central nervous system (CNS) infections ................................. 73
Meningitis .................................................................................... 73
Encephalitis ................................................................................. 75
Brain abscess .............................................................................. 76
CNS shunt infection...................................................................... 76
Antimicrobial doses for CNS infections.......................................... 77
6.10 Acute bacterial rhinosinusitis (ABRS) .....................................78
6.11 Orbital cellulitis .....................................................................80
6.12 Pulmonary infections.................................................................. 82
COPD exacerbations .................................................................... 82
Community-acquired pneumonia ................................................... 83
Healthcare-acquired pneumonia. ................................................... 87
Ventilator-associated pneumonia ................................................... 88
Cystic brosis .............................................................................. 91
6.13 Respiratory virus diagnosis and management ......................... 93
6.14 Tuberculosis (TB) ........................................................................ 95
6.15 Sepsis with no clear source ....................................................... 99
6.16 Skin, soft-tissue, and bone infections......................................100
Cellulitis ..................................................................................... 100
Cutaneous abscess.................................................................... 101
Management of recurrent MRSA infections .................................. 102
Diabetic foot infections ............................................................... 103
Surgical-site infections................................................................ 105
Serious, deep soft-tissue infections (necrotizing fasciitis).............. 107
Vertebral osteomyelitis, diskitis, epidural abscess ....................... 108
6.17 Urinary tract infections (UTI)....................................................110
Bacterial UTI (including pyelonephritis and urosepsis) ................... 110
6.18 Candidiasis in the non-neutropenic patient ............................115
6.19 Guidelines for the use of prophylactic antimicrobials .................121
Pre-operative and pre-procedure antibiotic prophylaxis................. 121
Prophylaxis against bacterial endocarditis .................................. 125
Prophylactic antimicrobials for patients with
solid organ transplants ............................................................... 126
6.20 Guidelines for the use of antimicrobials in
neutropenic hosts. ....................................................................129
Treatment of neutropenic fever................................................... 129
expected prolonged neutropenia ................................................ 131
Use of antifungal agents in hematologic
malignancy patients ............................................................. 133
7. Informational guidelines .................................................................137
7.1 Approach to the patient with a history of penicillin allergy ................ 137
8. Infection control ..............................................................................139
8.1 Hospital Epidemiology & Infection Control .................................... 139
8.2 Infection control precautions ....................................................... 141
8.3 Disease-specic infection control recommendations ..................... 142
10. Appendix:
A. Aminoglycoside dosing and therapeutic monitoring ........................ 145
B. Vancomycin dosing and therapeutic monitoring.............................. 150
C. Antimicrobial therapy monitoring ................................................... 153
D. Oral antimicrobial use ................................................................... 154
E. Antimicrobial dosing in renal insufciency ....................................... 155
F. Cost of select antimicrobial agents ................................................ 159
1. Introduction
Introduction
Antibiotic resistance is now a major issue confronting healthcare
providers and their patients. Changing antibiotic resistance patterns,
rising antibiotic costs and the introduction of new antibiotics have
made selecting optimal antibiotic regimens more difcult now than
ever before. Furthermore, history has taught us that if we do not
use antibiotics carefully, they will lose their efcacy. As a response
to these challenges, the Johns Hopkins Antimicrobial Stewardship
Program was created in July 2001. Headed by an Infectious Disease
physician (Sara Cosgrove, M.D., M.S.) and an Infectious Disease
pharmacist (Edina Avdic, Pharm.D., M.B.A), the mission of the
program is to ensure that every patient at Hopkins on antibiotics
gets optimal therapy. These guidelines are a step in that direction.
The guidelines were initially developed by Arjun Srinivasan, M.D., and
Alpa Patel, Pharm.D., in 2002 and have been revised and expanded
annually.
These guidelines are based on current literature reviews, including
national guidelines and consensus statements, current microbiologic
data from the Hopkins lab, and Hopkins faculty expert opinion.
Faculty from various departments have reviewed and approved these
guidelines. As you will see, in addition to antibiotic recommendations,
the guidelines also contain information about diagnosis and other
useful management tips.
As the name implies, these are only guidelines, and we anticipate
that occasionally, departures from them will be necessary. When these
cases arise, we will be interested in knowing why the departure is
necessary. We want to learn about new approaches and new data as
they become available so that we may update the guidelines as needed.
You should also document the reasons for the departure in the patients
chart.
Sara E. Cosgrove, M.D., M.S.
Director, Antimicrobial Stewardship Program
Edina Avdic, Pharm.D., M.B.A

ID Pharmacist
Associate Director, Antimicrobial Stewardship Program
Kate Dzintars, Pharm.D.

ID Pharmacist
Janessa Smith, Pharm.D.

ID Pharmacist
1. Introduction
The following people served as section/topic reviewers

N. Franklin Adkinson, M.D. (Allergy/Immunology)
Paul Auwaerter, M.D. (Infectious Diseases)
Robin Avery, M.D. (Infectious Diseases)
John Bartlett, M.D. (Infectious Diseases)
Dina Benani, Pharm. D. (Pharmacy)
Michael Boyle, M.D. (Pulmonary)
Roy Brower, M.D. (Critical Care and Pulmonary)
Karen Carroll, M.D. (Pathology/Infectious Diseases)
Michael Choi, M.D. (Nephrology)
John Clarke, M.D. (Gastroenterology)
Todd Dorman, M.D. (Critical Care)
Christine Durand, M.D. (Infectious Diseases)
Khalil Ghanem, M.D. (Infectious Diseases)
James Hamilton, M.D. (Gastroenterology)
Carolyn Kramer, M.D. (Medicine)
Pam Lipsett, M.D. (Surgery and Critical Care)
Colin Massey, M.D. (Medicine)
Lisa Maragakis, M.D. (Infectious Diseases)
Kieren Marr, M.D. (Infectious Diseases)
Robin McKenzie, M.D. (Infectious Diseases)
Michael Melia, M.D. (Infectious Diseases)
George Nelson, M.D. (Infectious Diseases)
Eric Nuermberger, M.D. (Infectious Diseases)
Trish Perl, M.D., M.Sc. (Infectious Diseases)
Stuart Ray, M.D. (Infectious Diseases)
Anne Rompalo, M.D. (Infectious Diseases)
Annette Rowden, Pharm.D. (Pharmacy)
Paul Scheel, M.D. (Nephrology)
Cynthia Sears, M.D. (Infectious Diseases)
Maunank Shah, M.D. (Infectious Diseases)
Tiffeny Smith, Pharm.D. (Pharmacy)
Jennifer Townsend, M.D. (Infectious Diseases)
Robert Wise, M.D. (Pulmonary)
Frank Witter, M.D. (OB-GYN)
How to use this guide

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dose of antibiotics for the particular infection.
UALL DOSES IN THE TEXT ARE FOR ADULTS WITH NORMAL
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some important treatment notes that explain a bit about WHY the
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tips on diagnosis and management. PLEASE glance at these notes
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A word from our lawyers
The recommendations given in this guide are meant to serve as
treatment guidelines. They should NOT supplant clinical judgment or
Infectious Diseases consultation when indicated. The recommendations
were developed for use at The Johns Hopkins Hospital and thus may
not be appropriate for other settings. We have attempted to verify
that all information is correct but because of ongoing research, things
may change. If there is any doubt, please verify the information in the
}ìLV>}i>LV>}i}* i>V>LV
Infectious Diseases.
Also, please note that these guidelines contain cost information
that is condential. Copies of the book should not be distributed
outside of the institution without permission.
1. Introduction
when you are treating infections, as we think the information will prove
helpful. All references are on le in the ofce of the Antimicrobial
Stewardship Program (7-4570).
2.1 Obtaining ID approval
Obtaining ID approval
The use of restricted and non-formulary antimicrobials requires preapproval from Infectious Diseases. This approval can be obtained by any
of the following methods.
Approval method
* \>LV
Overnight Approval
Ordersets (e.g. neutropenic

fever, etc.)
Notes
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and 10 p.m. PING the ID consult pager
if you fail to get a response from the ID
approval pager within 10 minutes.
Restricted antibiotics ordered between
10 p.m. and 8 a.m. must be approved
by noon the following morning.
U*i>iiiLi}iii`
for approval if you go off shift before
8 a.m.
These forms are P&T-approved for
specic agents and specic indications.
The following list applies to ALL adult oors and includes the status of
both oral and injectable dosage forms, unless otherwise noted.
Unrestricted
Amoxicillin
Amoxicillin/clavulanate
Ampicillin/sulbactam
(Unasyn)
Ampicillin IV
Azithromycin
Cefazolin
Cefdinir
Cefotetan
Cefpodoxime
Ceftriaxone
Cefuroxime IV
Cephalexin
Clarithromycin
Clindamycin
Dicloxacillin
Doxycycline
Ertapenem
Erythromycin
Gentamicin
Metronidazole
Minocycline
Nitrofurantoin
Oxacillin
Penicillin V/G
Ribavirin oral
Rifampin
Streptomycin
Tobramycin
Trimethoprim/
sulfamethoxazole
Amphotericin B
deoxycholate
(Fungizone)
Flucytosine
Itraconazole oral solution
Restricted (requires ID
approval)
Amikacin
Aztreonam
Cefepime
Ceftaroline1
Ceftazidime
Ceftolozane/tazobactam1
Ciprooxacin
Colistin IV
Cytomegalovirus Immune
Globulin (Cytogam)2
Daptomycin1
Fosfomycin3
Linezolid
Meropenem
Moxioxacin
Nitazoxanide4
Palivizumab (Synagis)5
Piperacillin/tazobactam
<)
Quinupristin/
dalfopristin (Synercid)
Ribavirin inhaled5
Telavancin1
Tigecycline
Vancomycin
Liposomal amphotericin B
(AmBisome)
Micafungin
Fluconazole6
Posaconazole
Voriconazole
1Approval must be obtained from Antimicrobial Stewardship Program 24h/7 days a week
2Approval required, except for solid organ transplant patients
3Approval must be obtained 24h/7 days a week
4Approval must be obtained from Polk Service or ID Consult
5Approval must be obtained from ID attending physician 24h/7 days a week
6Oral Fluconazole, when used as a single-dose treatment for vulvovaginal candidiasis or when
used in compliance with the SICU/WICU protocol, does not require ID approval
Restricted antimicrobials that are ordered as part of a P&T-approved critical pathway or order
set do NOT require ID approval.
REMINDER: the use of non-formulary antimicrobials is strongly discouraged. ID
approval MUST be obtained for ALL non-formulary antimicrobials.
NOTE: Formulary antivirals (e.g. Acyclovir, Ganciclovir) do NOT require ID approval.
2.2 Antimicrobial formulary and restriction status
Selected formulary antimicrobials

and restriction status
3.1 Agent-specic guidelines: Antibiotics
Antibiotics
Ceftaroline
Ceftaroline is a cephalosporin with in vitro activity against staphylococci
(including MRSA), most streptococci, and many Gram-negative bacteria.
It does NOT have activity against Pseudomonas spp. or Acinetobacter
spp. or Gram negative anaerobes.
Acceptable uses (Cases must be discussed with Infectious Diseases
and Antimicrobial Stewardship Program)
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serious infections
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hemolytic anemia. However, if drug-induced hemolytic anemia is
suspected, discontinue Ceftaroline.
Ceftolozane/tazobactam
Ceftolozane/tazobactam is a novel cephalosporin and -lactamaseinhibitor combination. It has activity against Gram-negative organisms
and some strains of multi-resistant Pseudomonas spp. It does NOT have
activity against carbapenemase-producing Enterobacteriaceae. It also
has in vitro activity against some streptococci and some Gram-negative
anaerobes, but it does not have reliable Staphylococcus spp. activity.
8
Unacceptable uses
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or complicated urinary tract infections (cUTI) as current standard
regimens are sufcient for coverage of the typical pathogens involved
in these infections and less expensive options are available
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metronidazole for cIAI
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for dose adjustment recommendation).
Colistin (Colistimethate)
Colistin is a polymixin antibiotic. It has in vitro activity against
Acinetobacter spp. and Pseudomonas spp. but does NOT have activity
against Proteus, Serratia, Providentia, Burkholderia, Stenotrophomonas,
Gram-negative cocci, Gram-positive organisms, or anaerobes.
Acceptable uses
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and Pseudomonas on a case by case basis.
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renal function and dialysis (see p. 155 for dose adjustment
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Daptomycin
Daptomycin is a lipopeptide antibiotic. It has activity against most strains
of staphylococci and streptococci (including MRSA and VRE). It does
NOT have activity against Gram-negative organisms.
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coagulase-negative staphylococci in a patient with serious allergy to
Vancomycin
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Ertapenem
Ertapenem is a carbapenem antibiotic. It has in vitro activity against
many Gram-negative organisms including those that produce extended
spectrum beta-lactamases (ESBL), but it does not have activity against
Pseudomonas spp. or Acinetobacter spp. Its anaerobic and Grampositive activity is similar to that of other carbapenems, except it does
not have activity against Enteroccocus spp.
Acceptable uses
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diverticulitis, secondary peritonitis/GI perforation)
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dialysis (see p. 155 for dose adjustment recommendation)
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Fosfomycin
Fosfomycin is a synthetic, broad-spectrum, bactericidal antibiotic with in
vitro activity against large number of Gram-negative and Gram-positive
organisms including E. coli, Klebsiella spp., Proteus spp., Pseudomonas
spp., and VRE. It does not have activity against Acinetobacter spp.
Fosfomycin is available in an oral formulation only in the U.S. and its
pharmacokinetics allow for one-time dosing.
Acceptable uses
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allergies and/or when no other oral therapy options are available.
11
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10 times the upper limit of normal without
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organisms (e.g. Pseudomonas spp.) on case by case basis.
NOTE: Susceptibility to Fosfomycin should be conrmed prior to
initiation of therapy.
Unacceptable uses
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outside of the urinary tract because it does not achieve adequate
concentrations at other sites.
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treatment)
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dissolve and administered immediately.
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Linezolid
Acceptable uses
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or Vancomycin resistant Staphylococcus aureus (VRSA) infection
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staphylococcal infection in a patient with serious allergy to Vancomycin
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staphylococcal infection in a patient failing Vancomycin therapy (as
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used in combination with another agent
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with documented MRSA pneumonia after 2 to 3 days or if the
MIC of Vancomycin is 2 mcg/mL, or if achieving appropriate
vancomycin trough is unlikely (e.g., obesity)
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Antimicrobial stewardship
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Tigecycline
Tigecycline is a tetracycline derivative called a glycylcycline. It has in
vitro activity against most strains of staphylococci and streptococci
(including MRSA and VRE), anaerobes, and many Gram-negative
organisms with the exception of Proteus spp. and Pseudomonas
aeruginosa. It is FDA approved for skin and skin-structure infections and
intra-abdominal infections.
NOTE: Peak serum concentrations of Tigecycline do not exceed
1 mcg/mL which limits its use for treatment of bacteremia
Acceptable uses
U>>}iiv>>L`>viV>i
contraindications to both beta-lactams and uoroquinolones
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organisms including Acinetobacter spp. and Stenotrophomonas
maltophilia on a case by case basis
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transplant patient known to be colonized with VRE
Unacceptable uses
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Trimethoprim/sulfamethoxazole
(Bactrim, TMP/SMX)
Trimethoprim/sulfamethoxazole is a sulfonamide antibiotic. It has in vitro
activity against Enterobacteriaceae spp., B. cepacia, S. maltophilia,
Acinetobacter spp., Achromobacter spp., Nocardia spp., Listeria,
Pneumocystis jirovecii (PCP), staphylococci (including S. aureus and
Coagulase-negative staph), but does NOT cover Pseudomonas spp.
It has variable activity against streptococci and no activity against
anaerobes.
Acceptable uses
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US. aureus skin and soft-tissue infections (SSTI)
UPneumocystis jirovecii pneumonia (PCP) treatment and prophylaxis
US. maltophilia infections
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agent
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infections
Unacceptable uses
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Dose
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component
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procainamide, oral contraceptives
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doses (5-10 mg/kg/day) can be used after several weeks of therapy
or cutaneous infections
Ui}\}}`>`ì`ì]+
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for dose adjustment recommendation).
3.2 Agent-specic guidelines: Antifungals
Antifungals
Liposomal Amphotericin B (AmBisome)
NOTES:
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signicantly different. Do not use AmBisome doses when
ordering Amphotericin B deoxycholate and vice versa.
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stage renal disease on dialysis who are anuric.
AmBisome, like all Amphotericin B products, has broad spectrum
antifungal activity with in vitro activity against Candida, Aspergillus,
Zygomycosis and Fusarium.
Acceptable uses
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VVV>i}\q{}}`>
Toxicity
Uvi>iì>V\vii]V]}]i
U,i>>ii>Vi`>iVV>iV
drugs)
U iViL>>Vi
U*>VVi>]>]ì>]>i>]ii>
hepatic enzymes-rare
U}\ 1 Vi>i]]}]*>L>ii>``>
>i`>i-//>L>ii>ìiii
16
Aspergillosis
UVVi>Lii
UVL>6V>ivVwi`>i
aspergillosis (see p. 133)
U,iv>Vì>iviVL>6V>i]
Posaconazole or AmBisome for conrmed invasive aspergillosis.
U1>VVi>Lii
UV>v}>iVL>i>v}>>}i
not recommended for empiric therapy in patients with CT ndings
suggestive of aspergillosis (e.g., possible aspergillosis) without
plans for diagnostic studies.
UV>v}ì>i}ìn vitro activity against
zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).
Candidiasis
UVVi>Lii
U/i>iv>iV>``>ìC. glabrata or C. krusei.
U/i>iv>iV>``>>i>i "/VV>
stable due to candidemia or have received prior long-term azole
therapy.
Ui>ii>iviVii>}i>V>``>
Ui>ii>ivi`V>`
U1>VVi>Lii
UV>v}>ii>i
->`>>V
should be avoided for infections involving those sites.
Neutropenic fever
UV>v}V>Lii`viiVvii>i>i
suspected to have aspergillosis or zygomycosis.
Dose
U
>`ì>]>iV>``>]iiVvii\}6
Q24H
U
>``>i`V>`\x}6+{
U,iVii>}i>V>``>\x}6+{
U>i>i}\qx}6+{
U"Lii>i
Uqx}\x}6+{
U> x}\
*>>V
Drug Interactions
U
i}iViììV>v}iì
v}>}iVV>\
17
Micafungin
NOTE: Micafungin does not have activity against Cryptococcus.
U-qiiv->LiVi>i`]v
Sirolimus toxicity
U viìqiiv viì>LiVi>i`]v
Nifedipine toxicity
U>V>iqiiv>V>i>LiVi>i`]v
Itraconazole toxicity
Toxicity
Uvi>iì>V>]]iL]i>`>Vi]>i>
and vomiting, and elevations in hepatic enzymes.
U}\-//LL>L>ii>ìiqii>vi
Posaconazole
Posaconazole is a broad spectrum azole anti-fungal agent. It has in vitro
activity against Candida, Aspergillus, Zygomycosis and Fusarium spp.
Acceptable uses
U/i>iv>i}VVL>iV
Ui>v}V>vi`>vVL>i>
with Amphotericin B
U*>>ii>}V>}>V
U/i>iv>i}>i6V>ii>Vi
Unacceptable uses
U
>``> iiVvii
Uii>iv>i}
Dose
"/ -\
U >Vìvi`Li}i>vi>`
nutritional supplements if patients cannot tolerate full meals. Can also
be given with an acidic beverage (e.g. ginger ale).
Ui>iìi>i>Li>`>iV>Lii`
interchangeably due to differences in the dosing of each formulation.
Prophylaxis
U">-i\}*"+n
U iì`,ii>i/>Li\}*"`>
Treatment
U">-i\}*"+v`>]i{}*"
Q8-Q12H
U iì`,ii>i/>Li\}*"+v`>]i}
PO daily
18
Drug Interactions: See Table on p. 21

Toxicity
UiH{]i>`>Vi]ii>i>Vii,>iL
serious effects include QTc prolongation.
,iviiVi\
V>ivwV>Vvi>v}>>}i\
"VL\{nnn
*>V>i\>L>ìV>i>v}>\>ViviVxx\xnx
Voriconazole
NOTE: Voriconazole does not cover zygomycoses (Mucor,
Rhizopus, Cunninghamella, etc.).
Acceptable uses
UAspergillosis
UScedosporium apiospermum
UProphylaxis in patients with hematologic malignancy
Unacceptable uses
UCandidiasis / Neutropenic fever
Voriconazole should not be used as rst-line therapy for the treatment
of candidiasis or for empiric therapy in patients with neutropenic fever.
Dose
U>`}ì\}}6*"+ì
U>i>Viì\{}}6*"+
Ui>ìiVi>vi>VvwViV\
U
`*} \ >i>ViìLx
U
`*}
\1ivLiiwi}
ID pharmacist for dose adjustment recommendations.

UiiV>>>LiiVi>vi>iì
subtherapeutic levels.
UiL>i`>V>Lì}i>ii 7
then use adjusted body weight. (Adj. BW).
` 7rQ 7{ 7 7R
IBW - Ideal Body Weight
ABW - Actual Body Weight
19
Therapeutic monitoring:
U*>V>i}ii`LiVìi`>i>i\
U i`}i>v>i>`>
U i}i>i`vViViLi}>
U iiV}V>>Lì
U1>LiVi}v>i>viVi}ii
Therapeutic monitoring
U6V>i}ii`LiVìi`>i>i\
U i`}i>>vi>i>x`>vi>}>
mg/kg dosing strategy
U,iVi}VV>`}>>Vi>iìVi>i
Voriconazole levels
U iiV}>ìiiiì6V>i
U iiV}`vV
U6V>i}ii`LiL>i`xq`>>vi>v
i>ivi`q
U>}\qxxV}iiV}>iLii
associated with clinical failures and levels >5.5 mcg/mL with toxicity.
Drug Interactions: See Table on p. 21
Toxicity
U6>`L>ViH>ivi`]>]vii]ii>
in hepatic enzymes.
,iviiVi\
6Vi\
viV\
6V>iiiVvii\ }i`{{\x
6V>i/\
viVn{\
Azole drug interactions

The following list contains major drug interactions involving drug
metabolism and absorption. This list is not comprehensive and is
intended as a guide only. You must check for other drug interactions
when initiating azole therapy or starting new medication in patients
already receiving azole therapy.
Drug metabolism:
Vi
9**{xL\ìVi>iii>LvVi>
drugs (CYP450 substrates) resulting in increased drug concentrations in
the body (occurs immediately)
Vi
9**{x`Vi\Vi>iii>LvVi>
drugs (CYP450 substrates) resulting in decreased drug concentrations
in the body (may take up to 2 weeks for upregulation of enzymes to
occur)
Drug absorption/penetration:
*}Vi*}L\ìVi>iivVviivy]
resulting in increased absorption/penetration of P-gp substrates
*}Vi`Vi\Vi>iivVviivy]
resulting in decreased absorption/penetration of P-gp substrates
Potencyv
Vi*{xL\6V>i>V>i
Posaconazole > Fluconazole
20
Do not use
Recommendations
cyclosporine dose to 34 and monitor levels

May posaconazole concentrations when using suspension
Consider dose reducing
tacrolimus dose to 13 and monitor levels
Avoid concomitant use unless benet outweighs risk
If used together, monitor effects of drugs and consider decreasing dose
when posaconazole is added
Amiodarone, atazanavir, digoxin, erythromycin, all calcium channel blockers, Monitor effect of drugs and consider decreasing dose when
ritonavir, statins (avoid lovastatin and simvastatin), vinca alkaloids
posaconazole is added
Drug
iVLi`\ sirolimus
iViVLi`\ cisapride, ergot alkaloids, pimozide,
quinidine, triazolam
Cyclosporine
Metoclopramide, proton pump inhibitors
Midazolam
Tacrolimus
Cimetidine, efavirenz, phenytoin, rifabutin, rifampin
Warning/precaution
Drug
iVLi`\ statins (lovastatin, simvastatin)

iViVLi`\ cisapride, dofetilide, ergot alkaloids,
nisoldipine, oral midazolam, pimozide, quinidine, triazolam
iVLi`\ atorvastatin, benzodiazepines, chemotherapy

(busulfan, docetaxel, vinca alkaloids), cyclosporine, digoxin, efavirenz,
eletriptan, fentanyl, oral hypoglycemics, indinavir, IV midazolam,
nifedipine, ritonavir, saquinavir, sirolimus, tacrolimus, verapamil, steroids
(budesonide, dexamethasone, uticasone, methylprednisolone), warfarin
iViVLi`\ alfentanil, buspirone, cilostazol, disopyramide,
felodipine, trimetrexate
iVLi`\ carbamazepine, efavirenz, isoniazid, nevirapine,

phenobarbital, phenytoin, rifabutin, rifampin, antacids, H2 receptor
antagonists, proton pump inhibitors
Clarithromycin, erythromycin, fosamprenavir, indinavir, ritonavir, saquinavir
Do not use
Recommendations
plasma concentration of itraconazole, if possible avoid concomitant

use or monitor itraconazole levels
plasma concentration of the interacting drug, monitor levels when

possible, monitor for drug toxicity and consider dose reduction
plasma concentration of itraconazole, monitor itraconazole levels and

monitor for toxicity
Contraindicated
ITRACONAZOLE and major metabolite hydroxyitraconazole (substrate and inhibitor of CYP3A4 and P-gp efux)
Warning/precaution
Contraindicated
POSACONAZOLE (substrate and inhibitor for P-gp efux, inhibitor of CYP3A4)
21
Do not use
Recommendations
cyclosporine dose to 12 and monitor levels

voriconazole dose to 5 mg/kg IV/PO Q12H and efavirenz to 300 mg
PO daily
Tacrolimus
tacrolimus dose to 13 and monitor levels
Sirolimus
ìLx>ìi
Omeprazole
omeprazole dose to 12
Maraviroc
maraviroc dose to 150 mg twice daily
Methadone
Monitor effect of the interacting drug and consider decreasing dose
Phenytoin
voriconazole to 5 mg/kg IV/PO Q12H and monitor levels
Ritonavir low dose (100 mg Q12H)
Avoid this combination unless benets outweigh risks
Warfarin
Monitor INR levels
iVLi`\ all benzodiazepines (avoid midazolam and triazolam), Monitor effect of drugs and consider decreasing dose when voriconazole
all calcium channel blockers, fentanyl, oxycodone & other long acting opioids, is added
NSAIDs, oral contraceptives, statins (avoid lovastatin and simvastatin),
sulfonylureas, vinca alkaloids, pomalidomide, simeprevir, boceprevir, telaprevir
iViVLi`\ alfentanil
Drug
iVLi`\ carbamazepine, rifabutin, rifampin,

ritonavir 400 mg Q12H
iViVLi`\ long-acting barbiturates, cisapride,
ergot alkaloids, pimozide, quinidine, St. Johns Wort
Cyclosporine
Efavirenz
Contraindicated
Warning/precaution
Drug
Cisapride
iVLi`\ cyclosporine, glipizide, glyburide, phenytoin,

rifabutin, tacrolimus, warfarin
iViVLi`\ oral midazolam, theophylline, tolbutamide
Rifampin
Recommendations
plasma concentration of uconazole, consider increasing uconazole dose
Do not use
plasma concentration of the interacting drug, monitor levels when
possible, monitor for drug toxicity and consider dose reduction
FLUCONAZOLE (substrate of CYP3A4 and inhibitor of CYP3A4, CYP2C9, and CYP2C19, interactions are often dose dependent)
Warning/precaution
Contraindicated
VORICONAZOLE (substrate and inhibitor of CYP2C19, CYP2C9, and CYP3A4)
22
Indications for pneumococcal vaccines for adults 19 years of age

Risk group
All adults 65 years of age
CSF leak or cochlear implants
Functional or anatomic asplenia
Prevnar 13
Yes
Yes
Yes
Immunocompetent persons with certain No

chronic medical conditions (e.g. heart
disease*, lung disease, liver disease,
DM), alcoholism, cigarette smoking
Vi`\V}i> Yes
acquired immunodeciencies, HIV,
chronic renal failure, nephrotic
syndrome, hematologic malignancies,
organ transplant, long-term
immunosuppressive therapy (e.g.
steroids, active chemotherapy, radiation)
Pneumovax 23
Yes
Yes
Yes, revaccinate 5
years after rst dose
Yes
Yes, revaccinate 5
years after rst dose
IV`}
]V>`>i]iV`}iiaV`}
"*]ii>]
asthma
Timing and sequential administration of pneumococcal vaccines

U viVVV>>VV>>`L
vaccines are indicated, patient should receive Prevnar 13 rst followed
by Pneumovax 23 at a minimum of 8 weeks later (ideally 6-12 months)
Uv>i>iVii`*i> and both vaccines are indicated,
the patient should receive Prevnar 13 (minimum 1 year separation)
Uv>i>iVii`*i> 8 weeks ago, and both vaccines
are indicated, the patient should receive Pneumovax 23 (minimum 8
weeks separation)
Uv>i>iVii`L>VVi 5 years ago and revaccination
is needed with Pneumovax 23, a second dose should be administered
(minimum 5 years apart)
U*>i>iiiiViì} /]`}>
transplant) should follow institutional policy when available or consult ID
for optimal timing of vaccine administration
,iviiVi\

*,iVi`>\7,{nnx>`7,{nn
23
3.3 Agent-specic guidelines: Vaccines
Pneumococcal vaccination
There are two types of pneumococcal vaccines that are recommended
L
*}ìiv>`>i\*iVVV>>VV>ì
(Pneumovax 23, PPV23) and Pneumococcal conjugate vaccine (Prevnar
13, PCV13). Most patients should receive both vaccines in sequential
order, but NEVER together. See table below for indications for each vaccine.
4.1 Organism-specic guidelines: Anaerobes
Organism-specic guidelines
Anaerobes
Although anaerobic bacteria dominate the human intestinal microbiome
only a few species seem to play an important role in human infections.
Infections caused by anaerobes are often polymicrobial.
U>i}>iL>VBacteroides spp., Prevotella spp.,
Porphyromonas spp., Fusobacterium spp.
U>i}>iVVVVeillonella spp.
U>iL>VPropionibacterium spp., Lactobacillus spp.,
Actinomyces spp., Clostridium spp.
U>iVVVPeptostreptococcus spp. and related genera
Clinical diagnosis of anaerobic infections should be suspected in the
presence of foul smelling discharge, infection in proximity to a mucosal
surface, gas in tissues or negative aerobic cultures. Proper specimen
ViVVV>iviiViViV}ìi>\
www.hopkinsmedicine.org/microbiology/specimen/index.html
Treatment Notes
Metronidazole
Clindamycin
Ertapenem
Cefotetan
Pip/Tazo
Amox/Clav
Penicillin
# Patients
Hidden Content
.
U-}V>ìLìiv>>iLVviV>LiV>i
anaerobic organisms can cause severe tissue damage.
UVL>V>>`
`>V>iVìi`LiivviVi
empiric therapy against Gram-positive anaerobes seen in infections
24
Propionibacterium acnes
Indications for consideration of testing for P. acnes:
U
-viV
U*iVìviV
U"i>>LiìViviV
Diagnosis
U
i`Lii`v{`>v}VvP. acnes
as growth is slow
U
iVvi>`yìVivViivii`
send swabs for culture
Uiiii>iiViivi>L`Lii
for shoulder joint infections to assist in distinguishing contaminants
from pathogenic isolates these could include synovial uid, any
inammatory tissue, and synovium
U Tissue specimens should also be sent for histopathology
25
4.1 Organism-specic guidelines: Anaerobes
above the diaphragm. Metronidazole is not active against

microaerophilic streptococci (e.g. S. anginosus group) and should not
be used for these infections.
U6>VV>>Vi>}>>>i>>iLii}
Clostridium spp., Peptostreptococcus spp., P. acnes).
U V`LiVi>}ii`>i V>L>ii
(Meropenem, Ertapenem) or beta-lactam/beta-lactamase inhibitors
(Ampicillin/Sulbactam, Piperacillin/Tazobactam, Amoxicillin/Clavulanic
acid) is NOT recommended given the excellent anaerobic activity of
these agents.
UB. fragilis group resistance to Clindamycin, Cefotetan, Cefoxitin, and
Moxioxacin has increased and these agents should not be used
empirically for treatment of severe infections where B. fragilis is
suspected (e.g. intra-abdominal infections).
Ui>ViiB. fragilis group is caused by beta-lactamase
production, which is screened for by the JHH micro lab.
UBacteroides thetaiotaomicron is less likely to be susceptible to
*i>V/>L>V>iivi]i}>>i`
or strongly suspected (e.g. Gram negative rods in anaerobic blood
cultures in a patient on Piperacillin/tazobactam) alternative agents
with anaerobic coverage should be used until susceptibilities are
conrmed.
U/}iVVi>Vi>}>>ìiVv}>i>`
gram-negative anaerobic bacteria in vitro but clinical experience with
this agent is limited.
4.2 Organism-specic guidelines: P. acnes
Treatment
U*iV6+{ivii`
OR
U*
>i}\6>VVii`}iV]x
NOTES
UViViì`v>>ViVVi>`
duration of antibiotic therapy
UP. acnes is usually a contaminant in blood culture specimens. Draw
repeat cultures and consider clinical context before treatment
U,>iiv>viV>iLiii`vP. acnes
UP. acnes isolutes at JHH are susceptible to Penicillin (see anaerobic
antibiogram p. 24)
Ui`>iì>i>V>}>P. acnes. Tetracyclines
are not routinely tested and resistance rates are variable.
U >ìiV>}iV>iii>`*i>V
tazobactam would be expected to be active for Penicillin susceptible
isolates, but these are not rst-line therapy
U-ViL`>>`Liiì}ìi>iVìV
U Consider removal of associated hardware
26
Viridans group Streptococci (alpha-hemolytic streptococci)

>VL>vi>V>>`>V}iL`Vi
growing these organisms often represent contamination or transient
bacteremia
Five groups
US. anginosus group (contains S. intermedius, anginosus, and
constellatus\VV>i>LVii>>i*iV
susceptible
US. bovis}QV>S. gallolyticus subspecies gallolyticus
(associated with colon cancercolonoscopy mandatory, endocarditis
>iixvV>i>`LiVipasteurinus
>V>iì>L>ì>i]i`V>ìVR
majority are Penicillin susceptible
US. mitis group (contains S. mitis, oralis, gordonii, and sanguinous\
VV>iL>Vii>iiV>i>ì`V>`
many have Penicillin resistance
US. salivarius}\iVV>ivi`V>`>>i
Penicillin susceptible
US. mutans}\VV>ivì>V>iVV>i
vi`V>`>>i*iVViLi
Beta-hemolytic Streptococci
All are susceptible to Penicillin
6>>Li>ivi>Vi
`>V>iVL}
laboratory to perform susceptibility testing if you plan to use
Clindamycin or macrolides for moderate to severe infections.
While anti-staphylococcal penicillins (Oxacillin and Nafcillin) are the
agents of rst choice for susceptible S. aureus infections, their activity
against streptococci is sub-optimal
}>ivi>Vii>VVi>`/*-8iVìi
empiric use for infections suspected to be caused by beta-hemolytic
streptococci
US. pyogenes}i\>}]>`vi
viVV`}ii>]Vi]iV}v>V
`>Vi>Vixx>Vìi>Vi{
US. agalactiae} i\i>>viV]viVvi
vi>i}i>>V]>`viviV]L>Vii>
`>Vi>Vi>Vìi>Vi
27
4.3 Organism-specic guidelines: Streptococci
Streptococci
4.3 Organism specic guidelines: Multi-drug resistant Gram-negative rods
U
>ìVVV\viV>S. pyogenes and
S. agalactiae>V>i`ì}ì>ii}`>Lii]
>}>V]V>`>V>ì>i
`>Vi>ViH
v}
>`Hv}>i>Vìi>Vi
Hxv}
>`Hnv}>i
Streptococcus pneumoniae
U
V>ivi>>VviVV`}i`>]
]i>>V>i>`vi>>viV
involving the CNS, bones/joints and endocarditis via hematogenous
spread
UiiV>]S. pneumoniae is in the S. mitis group of viridans group
iVVVVii]>ìV>i>Li>Li
distinguish S. pneumoniae and streptococci in the S. mitis group.
U*iVi>}ivwVViviS. pneumoniae
infections when it is susceptible
U*iV>`
iv>iViLLi>>i`vviiv
CNS and non-CNS sites
MIC breakpoints for Penicillin and Ceftriaxone against
S. pneumoniae
Antibiotic
Penicillin (oral)
Penicillin (parenteral)
Non-CNS
CNS
Ceftriaxone
Non-CNS
CNS
Susceptible
0.06
Intermediate
0.12-1
Resistant
2
2
0.06
8
0.12
1
0.5
2
1
4
2
U``v6>VV
iv>i`V>iìiV
treatment of non-CNS infections caused by S. pneumoniae due to low
rates of resistance
Multi-drug resistant Gram-negative rods

Patients with infection or colonization with the resistant
organisms listed below should be placed on CONTACT
precautions (see isolation chart on p. 141)
Extended spectrum beta-lactamase (ESBL)-producing organisms
U - >iii>Vvii>Vi>iV]
cephalosporins, and Aztreonam.
U/i>iViiK. pneumoniae and K. oxytoca,
E. coli, and P. mirabilis, and these organisms are automatically
screened by the JHH microbiology lab for the presence of ESBLs.
28
/i>i\
Uiii}6+n}6+nv
-viV`Li
used for ALL severe infections if the organism is susceptible.
U >ii}6+{V>Lii`vVV>i`1/vi
infection with adequate source control if the organism is susceptible.
U
y>V/*-8V>Lii`>>i>i >ii
for uncomplicated UTI or soft tissue infection with adequate source
control if the organism is susceptible. Nitrofurantoin may also be used
for uncomplicated UTI if the organism is susceptible.
Carbapenemase-producing Enterobacteriacae (CRE)
U
>L>ii>i>iii>Vvii>Vi>iV]
cephalosporins, carbapenems and Aztreonam.
UVL}>L}iiv}i`wi``}ii
UvV>L>iii>VL}>Li}>
>V>L>iii>ii]ii>ViV>v
resistance is not tested for at this time.
/i>i\
Uiii}6+nviì`LiVì`
in most regimens based on data from small, retrospective studies
showing benet even when the isolate is intermediate or resistant.
Ui>i>``>>}i`Li>`ì`L>i`ViLi
(e.g. Amikacin, Tigecycline, Colistin) except for UTI.
Multi-drug resistant (MDR) gram-negative organisms: dened as
organisms susceptible to NO MORE than ONE of the following antibiotic
V>i\V>L>ii]>}Vì]yi]iV]
or cephalosporins. Note: susceptibility to sulfonamides, tetracyclines,
polymixins, and Sulbactam are NOT considered in this denition
Treatment
MDR Pseudomonas aeruginosa
MDR Acinetobacter baumannii/calcoaceticus

complex
U
iv>i>L>V>
(if susceptible)
OR
Ui`>-lactam PLUS
>}Vìvi}i`Vi`
or conrmed
OR
U
vViLi
U-lactam PLUS aminoglycoside if synergy expected

OR
U
vViLi
OR
UVL>V>vViLiPLUS
aminoglycoside (Sulbactam component has in vitro
activity against Acinetobacter spp.)
OR
U/}iVVivViLivviVi>
bacteremia)
*Combination therapy should be considered in severe infections.
29
U,v>VvviVV>\iVi>>>>
institution with a high rate of ESBLs, residence in a long-term care
facility and prolonged use of broad spectrum antibiotics.
Synergy:
Uvi}>ii`>i>Li>>V>>`ViLi
aminoglycosides, synergy can be assumed.
U/iVL}>Lìivi}i}
Antibiotic doses for MDR and carbapenemase-producing
infections normal renal and hepatic function
Uiii\}6+n]vii
U
ivii\}6+n]vii
U
iv>ì
ivii\}6L>`}ìii]
then 6 g IV as continuous infusion over 24 hours
U*i>V>L>V>\x}6L>`}ìi
minutes, then continuous infusion 3.375 g IV Q4H infused over 4
hours OR 4.5 g IV Q6H, infuse over 4 hours
U
\x}}Vi]ix}}6+v>``>
information, see p. 9)
UVL>V>\}6+{v,A. baumannii only)
U}Vìv`}]ii{
U/}iVVi\x}6+
U
iv>i>L>V>x}6+n
,iviiVi\
- >`VV>Vi
viVx\\\x
Current therapies for P. aeruginosa
>i
n{\
L>i>v
,
VLviV{\n
30
Gram-positive cocci
Gram-negative cocci
Aerobic
In clusters
U
>}>i\S. aureus
U
>}>iq\S. epidermidis,
S. lugdunensis
In pairs/chains
UVVV]+i}i\
S. pneumoniae
U>iV\6`>}
Streptococci, Enterococcus
(faecalis and faecium)
U i>iV\
Group A strep (S. pyogenes),
Group B strep (S. agalactiae),
Group C, D, G strep
Aerobic
VVV\N. meningiditis, N.
gonorrhoeae, Moraxella catarrhalis
VVL>V\ H. u, Acinetobacter spp.,

HACEK organisms
Anaerobic: Peptostreptococcus spp.
Anaerobic: Veillonella spp.
Gram-positive rods
Gram-negative rods
Aerobic
>}i\ Bacillus spp.
VVL>V\Listeria monocytogenes,
Lactobacillus spp.
->]iV\ Corynebacterium spp.
>V}w>i\ Nocardia spp.,
Streptomyces spp.
Aerobic
Lactose fermenting: Citrobacter spp.,
Enterobacter spp., E. coli, Klebsiella
spp., Serratia spp.*
Non-lactose fermenting
U"`>iq: Acinetobacter spp.,
Burkholderia spp., E. coli (rare), Proteus
spp., Salmonella spp., Shigella spp.,
Serratia spp.*, Stenotrophomonas
maltophilia
U"`>i \ P. aeruginosa, Aeromonas
spp., Vibrio spp., Campylobacter spp.
(curved)
Anaerobic
>}i\Clostridium spp.
Small, pleomorphic: P. acnes, Actinomyces
spp.
Anaerobic: Bacteroides spp.,

Fusobacterium spp., Prevotella spp.
* Serratia spp. can appear initially as non-lactose fermenting due to slow fermentation.
The Johns Hopkins microbiology laboratory utilizes standard reference

methods for determining susceptibility. The majority of isolates are
tested by the automated system.
The minimum inhibitory concentration (MIC) value represents the
concentration of the antimicrobial agent required at the site of infection
for inhibition of the organism.
The MIC of each antibiotic tested against the organism is reported
with one of three interpretations S (susceptible), I (intermediate), or
R (resistant). The highest MIC which is still considered susceptible
represents the breakpoint concentration. This is the highest MIC which
is usually associated with clinical efcacy. MICs which are 1 2 q 1 8 the
31
5.1 Interpreting the microbiology report
Interpreting the microbiology report

Interpretation of preliminary microbiology data
5.1 Interpreting the microbiology report
breakpoint MIC are more frequently utilized to treat infections where

antibiotic penetration is variable or poor (endocarditis, meningitis,
osteomyelitis, pneumonia, etc.). Similarly, organisms yielding antibiotic
MICs at the breakpoint frequently possess or have acquired a low-level
resistance determinant with the potential for selection of high-level
expression and resistance. This is most notable with cephalosporins
and Enterobacter spp., Serratia spp., Morganella spp., Providencia
spp., Citrobacter spp. and Pseudomonas aeruginosa. These organisms
all possess a chromosomal beta-lactamase which frequently will be
over-expressed during therapy despite initial in vitro susceptibility. The
intermediate (I) category includes isolates with MICs that approach
attainable blood and tissue levels, but response rates may be lower than
fully susceptible isolates. Clinical efcacy can potentially be expected in
body sites where the drug is concentrated (e.g., aminoglycosides and
beta-lactams in urine) or when a higher dose of the drug can be used
(e.g., beta-lactams). The resistant (R) category indicates the organism
will not be inhibited by usually achievable systemic concentrations of the
antibiotic of normal doses.
NOTE: MIC values vary from one drug to another and from one
bacterium to another, and thus MIC values are NOT comparable
between antibiotics or between organisms.
Spectrum of antibiotic activity

The spectrum of activity table is an approximate guide of the activity of
commonly used antibiotics against frequently isolated bacteria. It takes
into consideration JHH specic resistance rates, in vitro susceptibilities
and expert opinion on clinically appropriate use of agents. For antibiotic
recommendations for specic infections refer to relevant sections of the
JHH Antibiotic Guidelines.
32
Penicillin G
Ampicillin
Ampicillin/sulbactam
Oxacillin/Nafcillin
Piperacillin/tazobactam
Cefazolin
Cefotetan
Ceftriaxone
Cefepime
Aztreonam
Ertapenem
Meropenem
Moxioxacin
Ciprooxacin
Azithromycin
Gent/Tobra/Amikacin
Vancomycin
Linezolid
Daptomycin
/*-8
Clindamycin
Doxycycline
Colistin
Metronidazole
E. faecalis
Not active
GRAM-POSITIVE
E. coli
H. inuenzae
Viridans strep.
S. pneumoniae
Less active or potential resistance
GRAM-NEGATIVE
Enterobacter spp.
Abdominal anaerobes
Oral anaerobes
Pseudomonas spp.
Serratia spp.
Proteus spp.
Kebsiella spp.
-hemolytic strep.
Coag. neg. staph
MSSA
MRSA
VRE
33
5.2 Spectrum of antibiotic activity
Active
Atypicals
5.3 Interpretation of rapid diagnostic tests
Interpretation of rapid diagnostic tests

The JHH microbiology lab performs rapid nucleic acid microarray testing
on blood cultures growing Gram-positive organisms and peptide nucleic
acid uorescence in situ hybridization (PNA-FISH) testing on blood
cultures growing yeast.
Nucleic acid microarray testing (Verigine) for Gram-positive
cocci in blood cultures
UiiV>`ìwiiViV>V`v>iL>Vi>
genera/species and 3 resistance markers.
U >Vi>iVi\S. aureus, Coagulase-negative staphylococci, S.
lugdunensis, Staphylococcus spp. E. faecalis, E. faecium, S. pyogenes
(group A streptococci), S. agalactiae (group B streptococci), S.
pneumoniae, S. anginosus, Streptococcus spp. (e.g.,group C and G
streptococci, viridans group streptococci, etc.), Listeria spp.
U,i>Vi>i\iV]>]>
UvS. aureus is mecA positive the organism is resistant to Methicillin
and is reported as MRSA
UvS. aureus is mecA negative the organism is susceptible to
Methicillin and is reported as MSSA
Uv faecalis/faecium is vanA/B positive the organism is resistant
6>VV>ìi`>6, i>>6>VV
resistant E. faecalis are susceptible to Ampicillin at JHH
U,ivii>iii`{>viiL`
cultures turn positive
U/i}iviìwiL`Vi
U/i} "/ivi`L`Vi}}i>i
Gram positive organism but is performed on blood cultures growing
both Gram positive and negative organisms
Uviii}>iLiii`>i}>iviv}
}>\->VVV]Streptococcus spp., E. faecalis, E.
faecium, Listeria spp.
34
Preferred empiric therapy

Alternative empiric therapy
(% susceptible in blood at JHH) if PCN allergic
MSSA
">V
iii*
>i}\
iv>
-iii*
>i}\6>VV1
MRSA
6>VV
>V
-}iiVi>ivi>V>>i>i
Coagulase-negative recommended. See p. 60 of the JHH Antibiotic Guidelines for
staphylococci
information and indications for treatment. Call the microbiology lab for
more information and further work up if infection suspected (5-6510).
">V>V
S. lugdunensis
6>VV2
E. faecalis
Vn
6>VVx1
3
E. faecium (VRE)
i`n
>V
E. faecium (not VRE)6>VV3
Linezolid
4
Streptococcus spp. V}>i\
iv>i -iii*
>i}\6>VV1
"V}>i\6>VV4
S. anginosus
*iV
iii*
>i}\
iv>i
-iii*
>i}\6>VV1
S. pyogenes
*iV
iii*
>i}\
iv>
(group A strep)
-iii*
>i}\6>VV1
S. agalactiae
*iV
iii*
>i}\
iv>
(group B strep)
-iii*
>i}\6>VV1
4
S. pneumoniae
iv>i
-iii*
>i}\6>VV1
(not meningitis)
S. pneumoniae
iv>i6>VV
-iii*
>i}\
(meningitis)
>iV6>VV1
Listeria spp.
V
/iv>i>i
1Consult
allergy for skin testing /desensitization

to Oxacillin if found to be susceptible
to Ampicillin if found to be susceptible
4Narrow to Penicillin G if found to be susceptible
2Narrow
3Narrow
PNA-FISH for yeast

Uv* -C. albicans, most non-oncology patients without
prior azole exposure can be treated with uconazole. For more
information see p. 117 and 134.
Uv* -C. glabrata, treat with Micafungin until
susceptibilities available. For more information see p. 117 and 134.
Uv* -i}>ivC. albicans or C. glabrata, most cases can be
treated as unspeciated candidemia, unless cryptococcus is suspected
(send serum cryptococcal antigen). For more information see p. 117
and 134.
35
5.3 Interpretation of rapid diagnostic tests
Organism
6.1 Abdominal infections
Biliary tract infections cholecystitis and

cholangitis
EMPIRIC TREATMENT
Community-acquired infections in patients without previous
biliary procedures AND who are not severely ill
U
iv>i}6+{
OR
U >ii}6+{
OR
U-iii*
>i}\
y>V{}6+
Hospital-acquired infections OR patients with multiple therapeutic
biliary manipulations (e.g. stent placement/exchange, bilio-enteric
anastamosis of any severity) OR patients who are severely ill
U*i>V>L>V>x}6+
OR
U iii*
>i}\
ivii}6+nPLUS Metronidazole
500 mg IV Q8H
OR
U-iii*
>i}\i>}6+nPLUS Metronidazole 500
mg IV Q8H Vancomycin (see dosing section, p. 150)
In severely ill patients with cholangitis and complicated cholecystitis,
adequate biliary drainage is crucial as antibiotics will not enter bile in
the presence of obstruction.
Duration
UUncomplicated cholecystitis\i>LViii`
NO post-procedure antibiotics are necessary if the obstruction is
successfully relieved.
U
V>i`ViV\{`>]i>ì>iViV
not achieved.
U >i\{`>]i>ì>iViV
achieved.
TREATMENT NOTES
Microbiology
U>i}>i`qE. coli, Klebsiella spp., Proteus spp.,
P. aeruginosa (mainly in patients already on broad-spectrum antibiotics
or those who have undergone prior procedures)
U>iLiqBacteroides spp., generally in more serious infections, or
>i>vL>>>>iVV>i`
and community-acquired infections
UEnterococcus sppqi>i>>`V>iìVV>`}i
U9i>q>i
39
Management
UV>ivVV>i`>ViViV]>LV`Li
given until the biliary obstruction is relieved (either by surgery, ERCP,
or percutaneous drain).
U/i>iviiVVV>iiì``ì>i
disease.
U9i>}ii>`Lii>i`vi>iiVii`v
biliary cultures, not empirically.
,iviiVi\
>>VviV\}x\n
-ìiv>>L`>viV\
viVx\q{
-Vii>v\ }i`x\qx
Diverticulitis
EMPIRIC TREATMENT
NOTE: Patients with uncomplicated diverticulitis (dened as CT
Vwiìvì`ì>i>LVivii>w> fever
and elevated inammatory markers), can be treated conservatively
without antibiotics based on a RCT.
Mild/moderate infections can be oral if patient can take PO
UVV>>>inx}*"+
OR
U
iv>i}6+{PLUS Metronidazole 500 mg IV/PO Q8H
OR
U >ii}6+{
OR
U-iii*
>i}\Q
y>V{}6+",
y>V
x}*"+RPLUS Metronidazole 500 mg IV/PO Q8H
Severe infections
U*i>V>L>V>x}6+
OR
U iii*
>i}\
500 mg IV Q8H
OR
U-iii*
>i}\Q
y>V{}6+",i>
}6+nRPLUS Metronidazole 500 mg IV Q8H
Duration
U{`>]i>ì>iViV>Vii`
40
Microbiology
U>viV>iVL>
UV>i`>iLV}>qE. coli, K. pneumoniae,
Enterobacter spp., Proteus spp., Enterococcus spp.
UV>i`>>iLV}>qB. fragilis, Prevotella,
Peptostreptococci
Other considerations
UVL>i>iv>ViVV>i`ìV>
accelerate recovery or prevent complications/recurrence.
U
/V>>>i}ii`v`>>}iiiiì>i
,iviiVi\
-ìiv>>L`>viV\
viVx\q{
LV>ViVV>i`ìV -}\xqx
-Vii>v\ }i`x\qx
Pancreatitis
TREATMENT
ULV> "/`V>i`>iiii>Vi
pancreatitis (SAP), including those with sterile pancreatic necrosis.
UVL>i>>ivviVL`>`>]>`
prophylactic antibiotics have been associated with a change in the
spectrum of pancreatic isolates from enteric Gram-negatives to
Gram-positive organisms and fungi.
UviVi`>Vi>ViVìwi`L
/V>}>i
pancreas and/or percutaneous or surgical specimen with organisms
evident on gram stain or culture. Therapy should be directed based on
culture results.
U>iii}iVi`>L`>i]Vì
iVi>\
U*i>V>L>V>{x}6+
OR
U iii*
>i}\
500 mg IV Q8H
OR
U-iii*
>i}\
y>V{}6+PLUS
Metronidazole 500 mg IV Q8H
41
TREATMENT NOTES
Pancreatic penetration of selected antibiotics

Good (>40%; MIC exceeded for most relevant organisms):
uoroquinolones, carbapenems, Ceftazidime, Cefepime, Metronidazole,
Piperacillin-tazobactam
Poor (<40%): aminoglycosides, rst-generation cephalosporins,
Ampicillin
Duration
For infected pancreatic necrosis, continue antibiotics for 14 days after
source control is obtained. Continuation of antibiotics beyond this time
places the patient at risk for colonization or infection with resistant
organisms and drug toxicity.
TREATMENT NOTES
UviVìiqxv>iiV`Vii`L
CT scan or at the time of surgery.
U*i>VìVivviVVViìivì>i
U/iivwViiìViiViìiVi}
decontamination in management of pancreatitis.
,iviiVi\
>Vvv>VV>LV\-}{x\{
ìiv>>}iiv-*\
>ii`{\x{
Peritonitis
DEFINITIONS
Primary peritonitis is spontaneous infection of the peritoneal cavity,
>>V>iìì>i>`>ViQ>iL>Vi>
i- *R
Secondary peritonitis is infection of the peritoneal cavity due to
spillage of organisms into the peritoneum, usually associated with GI
perforation.
Tertiary peritonitis is a recurrent infection of the peritoneal cavity
following an episode of secondary peritonitis.
Primary peritonitis/Spontaneous bacterial

peritonitis (SBP)
EMPIRIC TREATMENT
U
iv>i}6+
OR
U-iii*
>i}\y>V{}6*"+{V>
Antimicrobial Stewardship to discuss regimens for patients who have
been taking uoroquinolones for SBP prophylaxis).
42
Duration
U/i>v5 days
PROPHYLAXIS
Cirrhotic patients with gastrointestinal hemorrhage
U
y>Vx}*" v`>
U
iv>i}6+{V>Lii`v>i *"]i
switch to Ciprooxacin 500 mg PO BID once bleeding is controlled
Non-bleeding cirrhotic patients with ascites
U/*-8-*"Vi`>
OR
Uvv>>i}V]
y>Vx}*"`>
TREATMENT NOTES
Microbiology
U>i}>i` iL>Vi>Vi>i]iE. coli and K.
pneumoniae), S. pneumoniae, enterococci, and other streptococci.
U*VL>viV`Vviv>
Diagnostic criteria
Ux* i 3 of ascitic uid.
U*iVix* ìi>>v*
250 OR culture remains positive, patient should be treated.
Follow-up
U
ìii>>>Vii>vi{nvi>
U
ìV>}}>LVv>Viy`* >ì`L
x>vi{n>`>iVV>i`}
Notes on prophylaxis against SBP
U>iV>ìLii`ìVii
>v`>xìi- *>viLii`
U*>i}i- *`}ivi}>iivi
iì{qviViVii>
U*>`LiVìi`vii
VVi>>Vi}ii
patient is in hospital.
,iviiVi\
>}]i>i>`>v- *\i>\{
>>}iiv>Vi>i>}iV\i>}{\qn
43
U*>iiVi>i}`] 1 }`>
LL{}``>iViiLxx}}
day 1 and 1 g/kg on day 3 (round to the nearest 12.5 g).
Secondary peritonitis/GI perforation

EMPIRIC TREATMENT
Perforation of esophagus, stomach, small bowel, colon, or
appendix
Patient mild to moderately ill
U >ii}6+{
OR
U-iii*
>i}\
y>V{}6+PLUS
Patient severely ill or immunosuppressed
U*i>V>L>V>x}6+
OR
U iii*
>i}\
500 mg IV Q8H
OR
U-iii*
>i}\6>VVii`}iV]xPLUS
Qi>}6+nOR
y>V{}6+nRPLUS
Empiric antifungal therapy is generally not indicated for GI
perforation unless patient has one of the following risk factors:
Esophageal perforation, immunosuppression, prolonged antacid or
antibiotic therapy, prolonged hospitalization, persistent GI leak.
Recommendations for patients who are clinically stable and have not
iVii`}i>ii>\
UV>i{n}6*"+{
Recommendations for patients who are NOT clinically stable or have
iVii`}i>ii>\
UV>v}}6+{
Duration of therapy for secondary peritonitis/GI perforation

Uncomplicated
Denition
>
Complicated
iw
Duration
44
Stomach
Small Bowel
Colon
Appendix
Operated on
within
24 hours
{q{n
Operated on
within
12 hours
{q{n
Operated on
within
12 hours
{q{n
Non-necrotic or
gangrenous
appendix
{
>ii>i>iVV}>}i>i`
4 days unless adequate source control is not achieved
,iviiVi\
-ìiv>>L`>viV\
viVx\q{
-Vii>v\ }i`x\qx
Peritonitis related to peritoneal dialysis

EMPIRIC TREATMENT
Mild to moderate illness: intraperitoneal therapy is preferred in
most cases.
Anuric patient
U
iv>x}}iL>}+{}v>ix}PLUS
Ui>V}}iL>}>`}ì]ii>V
mg/kg in one bag Q24H
Patient with urine output > 100 mL/day
U
iv>ì}iL>}+{
Severe illness: systemic therapy is preferred.
U,-/"- \6>VVii`}iV]x6PLUS ONE
viv}\
Qi>V}}6",
iv>ì}6",
y>V{
}6R
45
TREATMENT NOTES
U
>>i>}iv>Li]V]>i`\>>iLii
B. fragilis), Enterobacteriaceae (esp. E. coli, K. pneumoniae,
Enterobacter spp., Proteus spp.viV>VL>
U*>}iV>}i>i>i>>Li>`>ivi
i>Vii`Li>>VL>i}i]>
change in antimicrobials is advised.
UV>}i>VL>i>`LiVìi`>i
with hospital-acquired infections who are already on antimicrobials.
U/i>iviiVVVi>Vi>L`Li
considered in critically ill or immunocompromised patients or when
they are a dominant organism in the peritoneal culture.
U/i>ivCandida spp. is generally indicated only when they are
recovered from blood or are a dominant organism in the peritoneal
culture in critically ill or immunocompromised patients.
U*i>i>LVv>i`V>iiVi>iii
is clinical evidence of peritonitis, abscess, or gangrene.
ULV>i>`ViViV]V>>Li
necessity.
U>VvViVìwi`>}}V>>>`>
undrained collection of infection.
U /
"- \ii`}ii>ì>vV
consult pharmacy for recommendations for redosing and monitoring
Duration:q{`>
TREATMENT NOTES
Microbiology
UV>iV>i`LV>>viV>ii
U
i>Lii}>ixq
U>iVVVS. aureus, coagulase-negative staphylococci,
Enterococcus spp.), Gram-negative rods, yeast (much less common)
Diagnosis
U>iiVi`*i>iì`>i*y`
sampled for cell count, differential, gram stain, culture AND amylase.
WBC > 100/mm 3x* }}iviV
U i>i`>>i}}i>Vi>Liiv>
U>V>iV`y`>VV>i`L>L`>
pain and/or fever, empiric treatment should be started given the high
likelihood of infection.
U>V>iVi>y`]>i*yìV>}i]
with a dwell time of at least 2 hours, should be sampled. The decision
to start empiric therapy in these cases will depend on how sick the
patient appears.
U>>V>iV`y`]i>>Liì>
therapy pending the results of cell count, gram stain, and culture.
,iviiVi\
-*ìiv*ii>>i>i`viV\*i>\
q{
46
Diagnosis and testing

U
>iìwvC. difcile`>i>\>>}iv 3 unformed
stools in 24 hours AND either a positive stool test for C. difcile or
colonoscopic/histopathologic nding of pseudomembranous colitis.
U/iVL}>Li>i>i*
,>>ìiVi
gene, the toxin responsible for CDI. Thus, patients who are colonized
with toxigenic strains will test positive even if they do not have active
infection and clinical correlation with positive test results is important.
/iivi>i*
,V>i`}iV
culture.
U "/i`vC. difcile testing if patients do not have
diarrhea or ileus. Hard stool, uid obtained from colonoscopy and
rectal swabs will be rejected by the microbiology lab.
U>iiVi}>>i]iViì``Vi
laxatives for 24-48 hours prior to C. difcile stool test to see if
diarrhea improves, unless the patient is clinically unstable.
U iV>ivi>Viìv*
,]`V>ii}
necessary or recommended. Testing is restricted to one specimen
within 7 days. Call the Laboratory Medicine resident or faculty member
on call for those rare instances when a second specimen is required.
U-vC. difcile testing should be collected prior to starting
treatment for C. difcile.
U-iVi`Li>`V>iì>L>>Li>vi
collection. If they cannot be transported promptly, the samples should
be refrigerated.
U "/i`vC. difcile PCR during treatment or to
document resolution of disease, as utility of the results has not been
demonstrated.
TREATMENT
U-/"* /
," /-7 6 ,*"--
U">i>LiiìiiLi>iivwV>Vv6
Metronidazole is poorly established for CDI and there is no efcacy of
IV Vancomycin for CDI.
47
6.2 Clostridium difcile infection (CDI)
Clostridium difcile infection (CDI)
Treatment depends on clinical severity

Infection severity
Clinical manifestations
Asymptomatic
carriage*
C. difcile PCR positive without diarrhea,

ileus, or colitis
Mild or moderate
C. difcile PCR positive with diarrhea but no

manifestations of severe disease
Severe
C. difcile PCR positive with diarrhea and one or more

of the following attributable to CDI:
U7
15,000
UVi>iiVi>i> xvL>ii
Severe Complicated
Criteria as above plus one or more of the following

attributable to CDI:
Ui
Ui
U/Vi}>V>V
/
U*iv>
U ii`vViV
U
1>`viiiì>i
Infection severity
Treatment
>V
carriage
"/i>i>iV>ii>}

disease
`ì>i
Ui`>ix}*" /+n
Unable to tolerate oral therapy

Ui`>ix}6+nL>iii
at start of CDI section above)
-iii
U6>VVx}*" /+
-iii
V>i`
U
}ivi>>vViV>`
U6>VVx}L /+PLUS
Unable to tolerate oral therapy or complete ileus

U6>VVx}x -+>ii
enema via Foley catheter in rectum + Metronidazole
500 mg IV Q8H
Ixxv>i`>i>iVi` C. difcile.
Vancomycin dose can be decreased to 125 mg PO Q6H and Metronidazole can be stopped once
the patient has stabilized.
Other indications for oral Vancomycin use

U ii>i`>i>vix`>vi>
U-iVììviViì>i
U*>i}wV>ìivviVi`>i
U*>i>ii}>
U
ì>ixi>}iivVi>i`L`
from CDI.
48
Approach to patients who need to continue broad spectrum

antibiotic therapy
UiiiiiLiViv>LVi>
U,i>Vii>LV>`Vi`
]>V>Vi>]
Clindamycin, and uoroquinolones.
Uvi`V}>}ii>Vi`>ì
ii]Vii>
>`>`{`>Viv
i>iiiiìi`
CDI therapy until the end of the course of antibiotic therapy.
Uvi`V}>}iV>Liiì>Vi`]Vì
continuing CDI therapy until the end of the course of antibiotic therapy
`>>>ii`
i>`LiVi`Liìi`
of antibiotic therapy if the patient remains asymptomatic.
Recurrent disease
U,i>Vii`>i6>VV>Lii`Vii`
conclusively.
U,iViì>i>vi>ViiVivi>VVH
xv>i,i>iìv>ii>`V>ii
>Vv>i>{ViiViì>i
repeat stool testing.
UiViVi`Lii>iì>i>i>iì
severe disease should be treated with Vancomycin.
U-iVìViVi`Lii>i`6>VV>ivi`
by pulse dosing or fecal microbiota transplant (consult GI).
UviiiViVi]V
Vancomycin taper regimen
125 mg 4 times daily q{`>
125 mg BID 7 days
125 mg daily 7 days
x}iiq`>vqniii`}
NOTES
Management
U-}V>iivViV`LiVìiì>vi
patient is clinically unstable secondary to CDI.
U/i>iv
`LiVi`>i>i>L>
colectomy with preservation of the rectum.
U>iiii
`ì}>L`>
/i
out toxic megacolon or pancolitis.
49
Duration
Uq{`>
U "/i`vC.difcile PCR to document resolution of

disease.
Ui>>}i
U-L**iiiLi>`>>}}i
PPIs increase the risk of CDI.
U/ivvi`}>VL>>}i`Li`Vi`v
antimicrobials are still required, it is best to avoid cephalosporins,
Clindamycin, and uoroquinolones.
U*>VViv>i`>i6>VV>i
receiving antimicrobial therapy for treatment of underlying infection
(other than CDI) is not recommended and may increase the patients
risk for CDI.
Infection control
U*>i
`Li>Vi`V>ViV>>`}i
rooms for the duration of hospitalization.
U1i>>`>i>i>>VL>i`>`}ii}
the room of a patient with CDI.
,iviiVi\
- -
iìiv
\viV
ì
\{q{x{
>Vvvi>}
V>i\ii`\
iV
\-}{x\
50
UFor treatment of C. difcile infection, see p. 47.

U
>iv>ii>iLiviiVL}>VL>
UviV`>i>ivi`>ìii
management.
U/i>i>LViViì`v`
ì>iì>iiiiVwV`V>>LiLi
U6>>}i]V> >`,>VV>i
diarrhea and do not require antibiotics.
ULVi>i>`>ìiVii}iViV
syndrome with Shiga toxin-producing E. coli).
U>}i`Lii`>iL``>i>]
fever, or elevated WBC.
Microbiology
U
>>}i>ViV>Vi``>i>\
Salmonella, Shigella, Shiga toxin-producing E. coli, Campylobacter,
C. difcile (usually with antibiotic exposure).
U V>`>i>\C. difcile
U*ii`>i>vViìV>i>
ìi`}ivVi\Giardia, Cryptosporidium,
Cyclospora, Isospora, Microsporidia, Cytomegalovirus (CMV).
Diagnosis
U ii`>i>iiiViiVi
should be based on suspicion for specic pathogens and/or clinical
judgment of illness severity.
U*>iviLi`>i>iiVV>vi>iv
moderate to severe disease should receive empiric therapy only after
a fecal specimen is obtained for appropriate testing.
UiV>iViv>i>i`v`>`Li
submitted for routine stool culture unless a high suspicion for specic
pathogen exists and/or if the patient is immunocompromised.
Uii>>v>>`>>i"E*>iv
yield.
UiV>iVi>Vvi>ii`Lii`
determine the therapeutic approach.
51
6.3 Infectious diarrhea
Infectious diarrhea
Treatment of infectious diarrhea

Organism/Indications for treatment
Treatment
Bacteria
Campylobacter spp.
UVx}*"`>vq`>
/i>iiViì`v\
U-iiii
U}ixi>
UL`
U}vii
U7i}i>}
U*i}>V
UVi`
E. coli (enterotoxigenic, enteropathogenic,
enteroinvasive) or empiric therapy of
travelers diarrhea
U
y>Vx}*"
Duration:q`>
Shiga toxin producing E. coli (including

E. colix\
Treatment not recommended. Antibiotic

use associated with development of
hemolytic uremic syndrome.
Non-typhoid Salmonella spp.
U
y>Vx}*"
OR
U/*-8n}*"
(if susceptible)
OR
U
iv>i}6+{
/i>iiViì`v\
U-iiiii}>>
U}ixi>
U >Vii>
U*iiVivii
U6>>i>ì>i
U-iii>iVi
U>}>ViVi
Shigella spp.
Treatment always recommended even if result
returns when patient is asymptomatic.
Duration:xq`>{`>v
immunocompromised host
U/*-8n}*"
(if susceptible)
OR
U
y>Vx}*"
Duration:`>`>v
compromised host
Vibrio parahaemolyticus
U
y>Vx}*" `>
i\V>iìwV
Treatment recommended for severe illness
Yersinia spp.
/i>iiViì`v\
UVi`
U >Vii>
U*i`>i`Vì
52
U/*-8n}*" qx
days (if susceptible)
OR
U
y>Vx}*" `>
OR
UVVi}*" `>
(not for bacteremia)
Entamoeba histolytica
Treat all (even asymptomatic)
E. dispar & E. moshkovskii infections do not
require treatment
Ui`>ix}*"/xq
days
OR
U/`>i}*"+`>
UPLUS all patients should receive
Paromomycin 500 mg PO TID x 7 days
after the course of 1st agent complete
Asymptomatic patients
U*>Vx}*"/`>
Giardia spp.
Ui`>ixx}*"/
q`>
OR
U Tinidazole 2 g PO once
,iviiVi\
-ìiv>>}iivviV>i>
viV\qx
viV`>i>ìii`>`ìi}Vi\
>iix\\xq
53
Parasites
6.4 Helicobacter pylori infection
Helicobacter pylori infection

NOTE: CONSIDER WITHHOLDING THERAPY INITIATION UNTIL PATIENT
DISCHARGED FROM HOSPITAL UNLESS ACUTE ULCER IS PRESENT
Established indications for testing for H. pylori and treating

positive patients
UViiVViì>i*1q}>V`ì>
U
wi`v*1ii>i`vH. pylori)
U>V/>}>ì
U}iiVv}>VV>Vi
U>v}>VV>Vi>ì}iii>i
UV}>
Other indications where testing for H. pylori and treating positive
patients can be considered: nonulcer dyspepsia, long term PPI
use, persons using NSAID/ASA, unexplained iron deciency anemia or
vitamin B12 deciency, family members of patients with H. pylori with
mild dyspepsia.
First-line treatment
UV}*"+PLUS Clarithromycin 500 mg PO Q12H
PLUS Pantoprazole 40 mg PO Q12H
OR
U*
>i}
U
>Vx}*"+PLUS Metronidazole 500 mg PO
Q12H PLUS Pantoprazole 40 mg PO Q12H
OR
U/i>VVix}*"+PLUS Metronidazole 500 mg
PO Q8H PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS
Pantoprazole 40 mg PO Q12H
UDuration:q{`>
Documented recurrence of H. pylori disease
UvLi]>`>LViiì>H. pylori
U/i>VVix}*"+PLUS Metronidazole 500 mg PO Q8H
PLUS Bismuth subsalicylate 525 mg PO Q6H PLUS Pantoprazole 40
mg PO Q12H
UDuration: 14 days
TREATMENT NOTES
Diagnosis
U**]2RA, Bismuth, and antibiotics with activity against H. pylori
should be withheld for at least 4 weeks prior to testing.
54
Management
Uii>ii>`V>>ii>i`Liiixqx
>iviì
>Vi>Viqx>`
non-adherence.
UiVi>>}i},>ìV>LiLi`vi
PPI if patients are unable to tolerate PPIs or if drug interactions are a
concern.
UVPLUS Tetracycline can NOT be used together in treatment
due to low response rates.
ULiVViVViv/i>VVi
Azithromycin for Clarithromycin.
U>iiiii`V>`>v>}i
> 45-50 years, presence of mass GI bleeding, anemia, weight loss, or
family history of gastric cancer.
U/ivViiViì`> {qniii>i
,iviiVi\
Maastricht III Consensus Report. Gutx\n
ACG Guidelines. Am J Gastroenterol\nnnx
55
6.4 Helicobacter pylori infection
UH. pylori stool antigen is the only FDA approved test (>i
and specicity).
U1i>Li>i>Li>LV>>>Li
U `VPLUS>ì>iinqxiq
specicity).
UH. pylori serology does not document current infection and should not
be used for clinical diagnosis.
6.5 Gynecologic and sexually transmitted infections
Pelvic inammatory disease

UVì>}]L>>>LVi>ìVi
Ui>ivi>ii`viV]
see p. 44 and p. 105.
TREATMENT
NOTE: Avoid use of uoroquinolones for N. gonorrhoeae due to
i>ViH >i
U
ivi>}6+PLUS Doxycycline* 100 mg PO BID for 14
days
OR
U >ii}6+{PLUS Doxycycline* 100 mg PO BID for 14
days
OR
U*
>i}\
`>V}6+nPLUS Gentamicin (see
dosing section, p. 146)
Step-down therapy once patient is afebrile
U*ivii`\VVi}*" Q
`>V{x}*"
QID ORi`>ix}*" RVii{`>>
*Azithromycin 1 g PO once weekly for 2 weeks can be used in the case of Doxycycline
contraindication or intolerance.
TREATMENT NOTES
Microbiology: N. gonorrhoeae, C. trachomatis, Gardnerella spp,
Ureaplasma urealyticum, anaerobes (Prevotella spp., B. fragilis), Gramnegative rods, Streptococci
Treatment of partners
Ui`>}i`>Vi*`Livvii`6i}
U>i>ivi>i*vi>i>>V
U-i>i>ivi>iv>i>i*`
be examined and treated empirically for C. trachomatis and
N. gonorrhoeae if they have had sexual contact with the patient during
the 60 days preceding onset of symptoms in the patient, regardless
of the pathogens isolated from the patient.
Endomyometritis
TREATMENT
U->i>v*Lii`v>``vVViV
Duration
U/i>>i>viLiv{q{n
56
TREATMENT
Ui`>i}ix]iv>V>x}>>}>]Vi
daily for 5 days (preferred)
OR
Ui`>ix}*" v`>
OR
U
`>V}*" v`>
TREATMENT NOTES
Microbiology: anaerobic bacteria (Prevotella spp, Mobiluncus spp.),
G. vaginalis, Ureaplasma, Mycoplasma.
U/i>iiViì`>>Vi>`}
asymptomatic pregnant women.
Trichomoniasis (T.vaginalis)
NOTE: Treatment of partner recommended.
TREATMENT
Ui`>i}*"Vi
OR
Ui`>ix}*" v`>
Uncomplicated gonococcal urethritis, cervicitis,

proctitis
TREATMENT (includes treatment for C. trachomatis):
U
iv>ix}ViPLUS Azithromycin 1 g orally (preferred)
OR
U
iv>ix}ViPLUS Doxycycline 100 mg PO BID for
7 days
OR
U-iii*
>i}\V}*"Viii`V>i
antiemetic or give snack before administration)
TREATMENT NOTES
U6i}iViì`
U/iiv
iv>iiviiì
iwi>`
ivì
due to increasing MICs for oral cephalosporins.
57
Bacterial vaginosis
U>i>iViì`vN. gonorrhoeae even if C. trachomatis

is excluded.
U-i`}i>ViViV>V`>wV>iv
suspect a treatment failure.
Syphilis
SCREENING
U-Vii}>}>\>ii>iVwV>Lì

if positive, followed by RPR. A conrmatory FTA-ABS is provided if RPR
is negative.
Ui
]>i}>i,*,>`>i/>Liì\
old treated syphilis (2) old untreated syphilis (3) early syphilis.
Ui>`V> >i
i>i>i{{{{n
for prior history of syphilis treatment in Maryland
UviV>i}V]ViViì`}ìi>
Algorithm for reverse sequence syphilis screening
CIA
RPR positive
CIA positive
RPR negative
CIA negative
U
i
Treponemal test that uses a different
UvVL>}
syphilis infection
>}i/q -/**
primary syphilis
(past or present)
FTA-ABS positive FTA-ABS negative is suspected,
U,iiV> U*Li U-i
treat for early
and clinical
syphilis
viV
Uv>i>}
evaluation to
U,ii
v]
determine prior
historical and
retest in one
treatment history
clinical
month
evaluation
Neurosyphilis diagnosis
U,iiLVV>i}V>>`>L>Vi>
U>L>Vi>>VL>v\i}V>iìViv
]i
-6,xi}iVwV]
-
iVx7
v67
v6]
-
elevated protein concentration (>50 mg/dl)
UL>Vi*`LiL>i`>ii
serological tests for syphilis plus neurological symptoms, serological
treatment failure (lack of four-fold decline in RPR titer), evidence of
tertiary syphilis
U
ì*>>V6>i>
{V350
cells/ml or RPR titer \
58
Early syphilis (primary, secondary, and early latent syphilis within one
year after infection)
U*iV i>i V L-A) 2.4 million units IM once
U-iii*
>i}i\VVi}*" vii
Note:ìVi>iì>ViH{xv> >i>i
resistant), Azithromycin is not recommended.
Late latent syphilis (asymptomatic infection with positive serology >1
year after infection or latent syphilis of unknown duration)
U*iV i>i V L-A) 2.4 million units IM weekly for 3
weeks (total of 3 doses)
Neurosyphilis (can occur during any stage of syphilis)
U*iVq{6+{vq{`>
Syphilis in pregnancy
U*iViiViìì>i}>>i
any kind of syphilis. Allergy consult for penicillin desensitization is
recommended.
,iviiVi\
-i>>i`ì>i

i>i}ìi7,x,,
q
VVViv*"LiiV\xq
Discordant Results from Reverse Sequence Syphilis Screening. MMWR 2011/60
xq
59
TREATMENT
6.6 Catheter-related bloodstream infections
Management of catheter-related
bloodstream infections (CR-BSI)
Diagnosis
Uviii>>ii> 9iVi>ii
site, the catheter is likely infected. It should be removed and replaced
at a different site.
U7i
, -iVi`]qivL`Vi`Li
drawn with AT LEAST one (and preferably > 1) from peripheral sites.
Blood cultures drawn through non-tunneled catheters are more likely
to yield contaminants.
U/ivViviV>iiiviìwi`]>`
should ONLY be sent when there is a clinical suspicion of infection,
NOT routinely when lines are removed. They MUST be accompanied
by two sets of blood cultures obtained as detailed above.
U/iVi\/iii`LiVi>i`>V/i
catheter should be grasped a few centimeters proximal to the exit
site. A 5 cm segment of catheter including the tip should be cut off
with sterile scissors and placed in a sterile container.
U>ViiiiL`>`V>ii>iVi`>i>i
time and the blood cultures are negative but the catheter tip culture is
positive, antibiotics are generally not recommended, even for patients
with valvular heart disease or immunosuppression.
U/iiVi>iiV>ii}S. aureus and
>ii}>iL`Vi/ii>iìViixq
days of antibiotics.
U>i`Livi`Vi]>ìi>Vi`
be sent if clinically indicated.
U7i>V>iii>i` ->V>i`V>ii`vV]
consider the possibility of suppurative thrombophlebitis.
EMPIRIC TREATMENT
U6>VVii`}iV]x
iviiq}6+n
(use higher dose if pseudomonas suspected)
OR
U-iii*
>i}\6>VVii`}iV]x
Q
y>V{}6+n",i>}6+nR
Tobramycin (see dosing section, p. 146)
Empiric treatment Gram-positive cocci in clusters in 2 or more
sets of blood cultures
U6>VVii`}iV]x
60
U6>VVii`}iV]x
Change to
U">V}6+{vViLiivii`6>VV
Duration:
Uq`>vV>iiiiìvii`
Uq{`>vV>ii>>}i>i
Methicillin-susceptible Staphylococcus aureus
U">V}6+{vViLi
OR
U >>>VV*
>i}\
iv>}6+n
OR
U>>VV*
>i}\6>VVii`}iV]x
Methicillin-resistant Staphylococcus aureus
U6>VVii`}iV]x
U6>VV>i}i>Vii`>ì
U>Vn}}6+{
OR
U
iv>i}6+n
U6>VVv>i\V
TREATMENT NOTES
U,iiV>ii}i>i>ivV>iiii`
U6>VVvi">Vvi>iv--
U*>iS. aureus bacteremia should have an echocardiogram to
rule out endocarditis. Transthoracic echo is acceptable only if the study
>ì>iiiivì`>iiiiVi`/
Ui``Liiìvi>ivS. aureus
bacteremia
U
i>v>{`>Vivi>
U `V>ìVì`/ ivii`}>// >Li
adequate in select patients
U >iìi
UL`Vi`>{`>>vii>Vi>i
negative for S. aureus
61
Coagulase-negative staphylococci (CoNS)

NOTE: Single positive cultures of CoNS should NOT be treated
unless they are conrmed by follow-up cultures, the patient is
immunosuppressed and/or critically ill, or the patient has implanted
hardware. In these cases, treatment can be started but repeat cultures
should be sent PRIOR to initiation of therapy to conrm the diagnosis.
U/i>iìviiViv>vivviVi
antistaphylococcal therapy
U/i>i>V>}}vi>>V
staphylococcal infection
U-ViV>LiiL>i`
ULiViviV`>>>vviV>LVi>viV
based on clinical judgment (e.g. poorly controlled diabetes)
Ui>iìVii{iivi>L>iìi
of infection
Enterococcus faecalis
NOTE: Can be contaminants. Draw repeat cultures to conrm before
>}i>ivE. faecalis blood isolates at JHH are
susceptible to Ampicillin, which should be used unless the patient has a
PCN allergy.
UV}6+{
OR
U*
>i}\6>VVii`}iVx
Duration: q{`>
Enterococcus faecium
NOTE: Can be contaminants. Draw repeat cultures to conrm before
>}i>i/i>nvE. faecium blood isolates
at JHH are resistant to Vancomycin. If the isolate is susceptible to
Ampicillin or Vancomycin, these agents should be used preferentially at
the doses listed above for E. faecalis bacteremia.
Ui`}6*"+
OR
U>Vnq}}6+{
TREATMENT NOTES
U
ìiVV>`}>viiiiL>Vii>> 3 days)
on antibiotics.
U/i>``vi>Vì>i>V>}iVi
CR-BSI caused by Enterococcus in the absence of endocarditis.
Gram-negative bacilli
Antibiotic selection based on organism and susceptibilities.
Duration: q`>
62
Candida spp.
U,ivivi>ivV>`ì>
CATHETER SALVAGE
UCatheter removal is STRONGLY recommended for infections with
S. aureus, yeast and Pseudomonas, as the chance of catheter salvage
is low and the risk of recurrent infection is high.
UCatheters associated with tunnel infections CANNOT be salvaged and
should be removed.
UWhen catheter salvage is attempted, systemic antibiotics should be
given through the infected line.
ULVi`>Vi>ìvii>>V>LV
used for systemic therapy.
Antibiotic Lock Therapy (ALT)
ULVVi>V>Lii`vV>ii>>}iin addition to
systemic antibiotics when feasible.
U
>iii>`Liivi`vVii>i>vi
72 hours of appropriate antibiotic lock therapy
Acceptable uses:
U->>}iv}iV>ii>V>Liiiì}`>
catheters, implantable permanent ports or central venous catheters
for chemotherapy) when there are NO systemic complications
(hemodynamic instability, tissue hypoperfusion, septic thrombosis,
infectious endocarditis or distant septic metastases) or signs of local
infection.
Unacceptable uses:
U-iiV>ii
U
V>i`
, -i}iViviV]iii
sepsis, septic shock, endocarditis, osteomyelitis and hematogenous
seeding at other sites)
U
>ii>>}iS. aureus infection.
Duration:q{`>
63
TREATMENT NOTES
U
>ii>iiViViviviVii]
most advocate catheter removal if the catheter is the source.
Standardized Concentrations of Antibiotics for ALT

Antibiotic
Heparin (optional)
6>VVx} -
i>Vx} -
x
x
U/`LiiìiviV>iiii
Uii`Li>vnqi`>
{q{n
U/iiiì`>LivV>ii>`>>>LiLi
vi}ii>]qx`LivwVi
,iviiVi\
Stability and compatibility of antimicrobial lock solutions. Am J Health-Syst Pharm.
\nxn
IDSA Guidelines for the Diagnosis and Management of Intravascular Catheter-related
viV\Clin Infect Dis {\{x
64
NOTES:
U i>>V>>ihighly preferable to Vancomycin if the organism is
susceptible and if the patient is not severely allergic. Strongly consider
PCN desensitization for allergic patients.
UviVi>iV>>ì`vV>ivivì`
infective endocarditis and prosthetic valve endocarditis, particularly in
those in which the preferred antibiotic cannot be used or in which the
organism is resistant to usual therapy.
U/i>iV}\
U6>VV
U>}ii\xqV}
Ui>Vv>ii}
U>`}
U>}ii\1 mcg/mL
U/>`>`}+n
U>i>ii\q{V}
U>}ii\1 mcg/mL
U-ii{n>`xvì>
Viridans streptococci or S. bovis with PCN MIC 0.12 mcg/mL
U*iV6+{v{ii
OR
U iii*
>i}\
iv>i}6+{v{ii
OR
UQ*iV6+{",
iv>i}6+{v
iiRPLUS Gentamicin 3 mg/kg IV Q24H for 2 weeks
OR
U-iii*
>i}\6>VVii`}iV]xv{
weeks
i>viii>i\
U*>iì>iV>`>Vi>V>`>V>LVi
U
20 mL/min
U*>iì>i>i`nV>>iivV
U*>iì>iAbiotrophia, Granulicatella, or Gemella spp.
and 0.5 mcg/mL
UQ*iV{6+{",
iv>i}6+{v
{iiRPLUS Gentamicin 3 mg/kg IV Q24H for the rst 2 weeks of
therapy
65
6.7 Endocarditis
Treatment of native valve endocarditis
6.7 Endocarditis
OR
U-iii*
>i}\6>VVii`}iV]xv
4 weeks
Viridans streptococci or S. bovis with PCN MIC > 0.5 mcg/mL
and Abiotrophia defectiva, Granulicatella spp. and Gemella spp.
U

TREATMENT NOTES
U>iS. bovis biotype I endocarditis should undergo GI
work-up to rule out underlying cancer.
Staphylococcus aureus Methicillin susceptible, native valve,
right-sided involvement only
U">V}6+{
U1i >vVv">V`Viì>
Criteria for 2-iii>i\
U*>i>iV}`}i>iVLì
Uivìì`V>ì`/ ivii`}
quality TTE
U/i>i">V >vV
U*>iì>i-
{< 200)
U*>iì>i>>iì`>}>v]iV
U `Vi>ii}>i{`>>vi>}i>
U/iiiìViviLVì>i"/ ,>iV
pulmonary emboli
U6i}i>>i>< 2 cm in size
Uv>iìiiVi>viii>i]i>v{
weeks
Staphylococcus aureus Methicillin susceptible, native valve,
left-sided involvement
U">V}6+{
OR
U iii*
>i}\
iv>}6+n
OR
U-iii*
>i}\-}Vì*
ìi>
Vancomycin (see dosing section, p. 150)
U/i>``vi>V>Li>>V>>iVi>L`Vi
faster but does not appear to affect mortality. It particularly should be
avoided in the elderly and in those with baseline renal impairment.
Staphylococcus aureus Methicillin resistant, native valve
U6>VVii`}iV]x
66
S. pneumoniae, and Group A streptococci

U*iV6+{v{ii
OR
U iii*
>i}\
iv>i}6+{v{ii",
Cefazolin 2 g IV Q8H for 4 weeks
OR
U-iii*
>i}\6>VVii`}iV]xv{
weeks
US. pneumoniae, if PCN MIC 0.1, consult ID
Groups B, C and G streptococci
U*iV6+{v{qiii>V
3 mg/kg IV Q24H for the rst 2 weeks of therapy
OR
U iii*
>i}\
iv>}6+nv{qii
Gentamicin 3 mg/kg IV Q24H for the rst 2 weeks of therapy
OR
U-iii*
>i}\6>VVii`}iV]{v{q
weeks Gentamicin 3 mg/kg IV Q24H for the rst 2 weeks of therapy
U
ì>
Enterococcus faecalis
UV>ì>VViLi\V}6+{",
Penicillin G 4 million units IV Q4H PLUS Gentamicin 1 mg/kg IV Q8H
BOTH for 4-6 weeks
UVViLiV>`V>v>}Vì
i>Vi>\V}6+{",*iV{
units IV Q4H PLUS Ceftriaxone 2 g IV Q12H BOTH for 4-6 weeks
67
6.7 Endocarditis
Duration
U1VV>i`\ii
U
V>iì>>>LViv>]i>>VVV>]
Vi``>Liii\iiiL>i`VV>
picture and response to therapy
U>`V>`>V}iViViì`vVV>i`
diseases
6.7 Endocarditis
OR
U-iii*
>i}\-}Vì*
ìi>v*

allergy is anaphylactic or Vancomycin (see dosing section, p. 146)
PLUS Gentamicin 1 mg/kg IV Q8H BOTHv{qii
U/i>v{iii>iLiiiiv< 3
months AND there is a prompt response to therapy
Enterococcus faecium
U

,iviiVi\
1iv
iv>iiiVVV>i`V>`\
viVx\n
HACEK organisms (Haemophilus parainuenzae, H. aphrophilus,

Actinobacillus actinomycetemcomitans, Cardiobacterium
hominus, Eikenella corrodens, Kingella kingae)
U
iv>i}6+{v{ii
OR
U-iii*
>i}\

Gram-negative organisms, culture negative endocarditis, or
fungal endocarditis
U

Treatment of prosthetic valve endocarditis

Uii>V>i`L>VVViwqi>v}>i
replacement (both S. aureus and coagulase-negative staph). Etiologies
are similar to native valve infections 2 or more years post-op.
Ui`V>i>i>ivi "/ivviVi
U>i`>i>/
EMPIRIC TREATMENT
U6>VVii`}iV]xPLUS Gentamicin 1 mg/kg
IV Q8H
UQ*iV{6+{",
iv>i}6+{Rv
6 weeks Gentamicin 3 mg/kg IV Q24H for rst 2 weeks of therapy
OR
U-iii*
>i}\6>VVii`}iV]xv
weeks
68
Staphylococcus aureusMethicillin susceptible

U">V}6+{viiPLUS Gentamicin 1 mg/kg IV Q8H for
rst 2 weeks of therapy
AND
U,v>}*"+nviiafter blood cultures have
cleared
U>`V>`>V}iViViì`
Staphylococcus aureusMethicillin resistant or Coagulasenegative staphylococci
U6>VVii`}iV]xviiPLUS
Gentamicin 1 mg/kg IV Q8H for the rst 2 weeks of therapy
AND
U,v>}*"+nviiafter blood cultures have
cleared
UvV>}>ii}>i>VVVViLi">Vi
treat as S. aureusqiVViLi
U>`V>`>V}iViViì`
Gram-negative organisms or culture negative endocarditis
U

DUKE CRITERIA FOR INFECTIVE ENDOCARDITIS
Diagnostic criteria (Modied Duke criteria)
Denite endocarditis
U*iiViv>Vi>",> ",x
Possible endocarditis
U*iiViv> ",Vi>
Rejected endocarditis
U>i>i`>}>i>>vi>v
(NOTE: simply having another infection does NOT exclude
endocarditis)
69
6.7 Endocarditis

UQ*iV{6+{",
iv>i}6+{R
PLUS Gentamicin 3 mg/kg IV Q24H for 6 weeks
OR
U-iii*
>i}\6>VVii`}iV]xv
weeks
6.7 Endocarditis
Major criteria
Microbiologic
U/i>>iL`Viiv>V>}>\
viridans streptococci, S. bovis, HACEK, S. aureus, Enterococcus
spp.
U*iiL>Vii>>}>>iìVi`L\
positive blood cultures drawn at least 12 hours apart OR 3/3
positive blood cultures with at least 1 hour between the rst and
last OR the majority of more than 4 cultures positive from any time
period.
U*iCoxiella burnetti (Q fever) culture or serology.
Echocardiographic (TEE strongly recommended for prosthetic valve)
U6i}i>>i}Vi",>v
regurgitant jet)
ULVi
U iìViViviV>i
Physical exam
U 7i}}>i}v` "/
sufcient)
Minor criteria
U*i`}V`\ii`V>`]iV`}i]
prosthetic valve, ventricular septal defect, coarctation of the aorta,
calcied valve, patent ductus, mitral valve prolapse with regurgitation,
IHSS or other valvular heart disease
Uii 38.0C (100.4F)
U LVii\>i>>iL]VV>
hemorrhage, retinal hemorrhage, splinter hemorrhage, intracranial
hemorrhage, mycotic aneurysm
U}Vii\"iì]}ii]i
rheumatoid factor
U*iL`Vi>ìiVi>>Li",i}V
evidence of active infection with an organism known to cause
endocarditis BUT single positive cultures for coagulase-negative
staphylococci are NOT considered even a minor criterion
,iviiVi\
">i>\i`\n
-Vii>\ii`{\n
iVi>\
viV\n
-ViwV->iiviVi `V>`\
V>x\i{{{
TEE in S. aureusL>Vii>\
>`\n
,-L>Vii>i`V>ìVi`>\
viVx\inxx
70
NOTE: Obtain at least 2 sets of blood cultures before initiation of

antibiotic therapy
EMPIRIC TREATMENT
U6>VVii`}iV]x >i>L>i`
culture results.
TREATMENT NOTES
Microbiologyp>VVVnvV>iHxV>}>i
i}>i>VVV>`HxS. aureus)
Management
UvL`Vi>iii`V>ìVi`>i
should undergo transesophageal echocardiography (TEE)
U
iii>ViViì`v>iViviV
and/or valvular or lead endocarditis
Uiivi>V]i>i>>Lvi}ii>
pocket should be sent for Gram-stain and culture and lead tips should
be sent for culture.
U i>LiV>ii>`>ii>Vi`}>i}ii>
Vi]i>LiViV>>i`LiviVi`Vi
therefore, positive lead cultures are not always indicative of lead
endocarditis in patient with negative blood cultures.
U `Vi`LiL>i`>viìVii>
UiVii>>`LiiV>>i>ìiii
possible.
U
iii>V}iViì`>>i
presenting with S. aureus bacteremia and no other source
U
iii>V`LiVìi`>iii
positive blood cultures with other organisms (e.g. coagulase-negative
staphylococci, enterococci, Gram-negative bacilli) on a case-by-case
basis.
U
iiìVi>ì>ì>iViì`v>i
valvular endocarditis.
UVL>> "/iViì`vì>i
invasive procedures following placement
,iviiVi\
-ViwV->ii**>`
viV\
V>\{xnq{
71
6.8 Pacemaker/ICD infections
Permanent pacemaker (PPM) and implantable

cardioverter-debrillator (ICD) infections
6.8 Pacemaker/ICD infections
Reimplantation timing and duration of therapy

Diagnosis
Pocket site infection
Timing of reimplantation
Blood cultures negative for
72 hours and surgical site
healing
Positive blood cultures

with rapid clearance
AND TEE with either
no vegetation or
uncomplicated lead
vegetation
Sustained positive blood
cultures AND TEE with
no vegetation or
uncomplicated lead
vegetation
Valve endocarditis
Post-explantation blood
cultures negative for
72 hours
Duration of therapy
7-10 days if device erosion
without inammation
10-14 days all others
Oral therapy can be
considered
Non-S. aureus\ii
IV therapy
S. aureus\{ii
IV therapy
Post-explantation blood
cultures negative for
72 hours
4 weeks IV therapy
Blood cultures negative for

14 days
4-6 weeks IV therapy

(see Endocarditis p. 65)
,iviiVi\
-ViwV->ii
>`>V>>>Li iVViViviV\
V>
\{xnq
72
TREATMENT
UANTIBIOTICS SHOULD BE STARTED AS SOON AS THE
POSSIBILITY OF BACTERIAL MENINGITIS BECOMES EVIDENT,
IDEALLY WITHIN 30 MINUTES.
UDO NOT WAIT FOR CT SCAN OR LP RESULTS. IF LP MUST BE
DELAYED, GET BLOOD CULTURES AND START THERAPY.
Uì>Vi>}i>`ViLi>i
U-i>`V>iiVìi>v>}iiVwVi>
in patients with severe allergies (p. 137).
ULVì>i}iv
-viV
UviVi>iV>>ì`v>
-viV]
particularly those in which the preferred antibiotic cannot be used or in
which the organism is resistant to usual therapy.
Empiric therapy
Host
Pathogens
Preferred Abx
Immunocompetent*
>}ix
Immunocompetent*
age > 50
S. pneumo, N.
mening, H. inuenzae
S. pneumo, Listeria,
H. inuenzae,
N. mening, Group B
streptococci
S. pneumo, N.
mening, H. inuenzae,
Listeria,
(Gram-negatives)
S. pneumo (if CSF
leak), H. inuenzae,
Staphylococci,
Gram-negatives
S. aureus, coagulasenegative staphylococci,
Gram-negatives (rare)
Vancomycin PLUS
Ceftriaxone
Vancomycin PLUS
Ceftriaxone PLUS
Ampicillin
Alternative for
serious PCN
allergy (ID consult
recommended)
Moxioxacin PLUS
Vancomycin
Moxioxacin PLUS
Vancomycin PLUS
/*-8
Vancomycin PLUS
Cefepime PLUS
Ampicillin
Vancomycin PLUS
/*-8PLUS
Ciprooxacin
Vancomycin PLUS
Cefepime
Vancomycin PLUS
Ciprooxacin
Vancomycin PLUS
Cefepime
Vancomycin PLUS
Ciprooxacin
Immunocompromised
Post neurosurgery or
penetrating head
trauma
Infected shunt
Immunocompromised is dened as solid organ transplant, BMT in the past year, leukemia
undergoing treatment, or neutropenia
Allergy consult for beta-lactam desensitization
* Use of Dexamethasone
U``vì>i>iiViì`>>`>i
suspected pneumococcal meningitis (note that this will be most adult
patients).
Ui\x}}6+vq{`>
U/iwìLi>ìi`qiLivi
concomitant with the rst dose of antibiotics.
73
6.9 Central nervous system infections
Meningitis Empiric treatment
U`>v>LV`Liì>i`}i
dexamethasone.
Ui>i>i`Li}i>i>i>i>`
started antibiotics.
U
iì>i>ivi
->>>
positive diplococci or if blood or CSF grows S. pneumoniae
Pathogen-specic therapy (ID consult recommended)
Pathogens
Preferred
S. pneumo PCN MIC 0.06

g/ml AND/OR Ceftriaxone
MIC 0.5 g/ml
S. pneumo PCN MIC q
g/ml AND Ceftriaxone
MIC 1 g/ml (ID consult
recommended)
S. pneumo PCN MIC 1
g/ml AND Ceftriaxone
MIC 1 g/ml (ID consult
recommended)
N. meningitidis PCN
susceptible (MIC 0.1)
H. u
Non -lactamase producer
H. u
-lactamase producer
Listeria
P. aeruginosa
Penicillin OR Ceftriaxone
E. coli
K. pneumoniae
Enterobacter spp.
S. aureusq--
->iq,-
Coagulase-negative
staphylococci if Oxacillin MIC
0.25
Coagulase-negative
staphylococci Oxacillin MIC
0.25
Enterococcus
Candida species
Cryptococcus
Ceftriaxone
Alternative for serious

PCN allergy (Consult
allergy for PCN skin
testing desensitization)
Vancomycin OR
Moxioxacin OR Linezolid
Ceftriaxone
Ceftriaxone PLUS
Vancomycin PLUS Rifampin
Penicillin OR Ceftriaxone
Consult ID
Ampicillin OR Ceftriaxone
Ciprooxacin*
Ceftriaxone
Ciprooxacin*
Ampicillin
Cefepime OR Meropenem
Gentamicin
Meropenem
Oxacillin
Vancomycin
Oxacillin
/*-8
Ciprooxacin PLUS
Aztreonam
Aztreonam OR Ciprooxacin
",/*-8
/*-8
y>V
Vancomycin
Vancomycin
Vancomycin
Ampicillin PLUS Gentamicin

Amphotericin B
Amphotericin B PLUS
Flucytosine
Vancomycin PLUS Gentamicin
* Consider beta-lactam desensitization

}i
y>Vx}Vii>`V>iV>i>iv*
i`>i>i
Administer aminoglycosides systemically, not intrathecally
74
TREATMENT NOTES
Indications for head CT prior to LP
Uv
-ì>i>i]
6
U iiii 1 week)
U*>iì>
Uii`VVi
UV>i}VìwV
Duration
U-/"*i>iv*ViL>i`>LVi>
negative at 48 hours OR no PMNs on cell count
US. pneumoniae\q{`>
UN. meningitidis\`>
UListeria\`>
UH. inuenzae\`>
U>i}>iL>V\`>
Adjunctive therapy
U
ì>V>>ii}>i>i`
mental status.
Encephalitis
Uiii-6]6<6i>ii`>V>ivi>>Li
encephalitis.
U
-*
,>i>``>}Vi>`>i>iii>`
specic.
U>iiì>viVi`>i>i`>
iVii`
U/i>i\VV}}6+nv{q`>
75
Brain abscess
U Vi>i}ì`LiVi`Vi>`ì}
condition. While therapy should be adjusted based on culture results,
anaerobic coverage should ALWAYS continue even if none are grown.
Source/ Condition
Pathogens
Preferred
Unknown
S. aureus,
Streptococci, Gramnegatives, Anaerobes
Streptococci (incl.
S. pneumoniae),
Anaerobes
Gram-negatives,
Streptococci
Anaerobes
Staphylococci, Gram
negatives
Streptococci (esp.
S. viridans)
Vancomycin PLUS
Ceftriaxone PLUS
Metronidazole
Q*iV",
iv>iR*1-
Metronidazole
Cefepime PLUS
Metronidazole
Sinusitis
Chronic otitis
Post neurosurgery
Cyanotic heart
disease
Vancomycin PLUS
Cefepime
Penicillin OR
Ceftriaxone
Alternative for
serious PCN allergy
(ID consult
recommended)
Vancomycin PLUS
Ciprooxacin PLUS
Metronidazole
Vancomycin PLUS
Metronidazole
Aztreonam PLUS
Metronidazole PLUS
Vancomycin
Vancomycin PLUS
Ciprooxacin
Vancomycin
,iviiVi\
-ìiv >Vi>i}\
viV{\
i>i>i>`L>Vi>i}\ }i`{\x{
CNS shunt infection

Diagnosis
U
ivViiL>yì>i>>v`>}
Clinical symptoms may be mild and/or non-specic, and CSF
chemistries and leukocyte counts may be normal.
Empiric Therapy
U6>VVii`}iV]xPLUS Cefepime 2 g IV Q8H
OR
U*
i}\6>VVii`}iV]xPLUS
Ciprooxacin 400 mg IV Q8H
TREATMENT NOTES
UID consult recommended for assistance with timing of shunt
replacement and length of antibiotic therapy.
U,i>v>ViviviViìi>
ventricular drainage or intermittent ventricular taps in combination
with the appropriate intravenous antibiotic therapy leads to the highest
effective cure rates. Success rates are substantially lower when the
infected shunt components are not removed.
76
,iviiVi\
-ìivi>>}iiv >Vi>i}\
viV
{\
/i>ViiL>y`viV i}in\{x
Antimicrobial doses for CNS infections normal

renal function
Antibiotics
U}Vì\ii{x
UV\}6+{
Ui>\}6+
U
iv>i\}6+
U
ivii\}6+n
U
y>V\{}6+nL>iì``>>
Uy>V\{}6+{
Uiii\}6+n
Ui`>i\x}6+
U">V\}6+{
U*iV\{6+{{i`>
U,v>\}6+q{
U/*-8\x}}/*Vi6+
U6>VV\>`xqx}}]ixq}}+nq
(minimum 1 g Q12H)
U6>VV`Li>ìi`>>i}
concentrations close to 20 mcg/mL.
Antifungals
UiV\q}}6+{
U i\{}}6+{v
VVV>i}
U i\x}}6+{v
>``>i}
UV>i\nq}6*"+{V>}i`ì`ì
UVi\x}}*"+
Intraventricular antibiotics (ID consult recommended)
U>V\}+{V>ii>i
Ui>V\x}+{
U/L>V\x}+{
U6>VV\}+{
77
U/iiv>iV>>LVVi>]>`}ii>
limited to refractory cases or cases in which shunt removal is not
possible. Intraventricular injection should be administered only by
experienced physicians.
6.10 Acute bacterial rhinosinusitis
Acute bacterial rhinosinusitis (ABRS)

NOTE: Sinusitis in immunocompromised hosts can be caused by fungi
>ìiV>}iV>>` /
recommended to guide management and therapy.
ìii>LVi>ii>i
`LiVìiìv}Vi>\
U*iiv>Vi 10 days without
improvement
Uii39C and purulent nasal discharge or facial pain lasting >3-4
days from the beginning of illness
U iivvii]i>`>ViVi>i>>`V>}iv}
viral URI that lasted 5-6 days and was initially improving
EMPIRIC TREATMENT
Oral regimens
UVV>>>inx}*"+
OR
UVV>>>i8,}*"+v>iiii
infection (e.g. systemic toxicity with fever of 39C), antibiotic use in
previous 30 days, immunocompromised
OR
U iii*
>i}\
ivì}*"+
OR
U-iii*
>i}\y>V{}*"`>
Parenteral regimens
UVL>V>x}6+
OR
U iii*
>i}\
iv>i}6+{
OR
U-iii*
>i}\y>V{}6+{
Duration
Ux`>
TREATMENT NOTES
Microbiology
U*i`>S. pneumoniae, H. inuenzae, M. catarrhalis
U>i}>iiiVL>V>i>i
Management
U ,->iiiq`>vV>
inciting etiologies of acute sinusitis include allergies and viral URI
78
,iviiVi\
-}ìiv ,-
viVx{n\ii
79
6.10 Acute bacterial rhinosinusitis
U
iLìV>>i`VV>}ì`Viv
the middle meatus should only be obtained in patients who fail empiric
antibiotic therapy. Nasopharyngeal swab is NOT recommended for
obtaining culture data.
U
w>v`>}>}}iViì`v
uncomplicated ABRS. Consider CT in those with severe disease with
possible extension to the orbit or intracranial space.
U>>>>i}>}ViV>`>>>
corticosteroids are recommended as an adjuncts to antibiotic therapy
and can also provide symptomatic relief in patients in whom antibiotic
are not indicated
U>Vì
>V]V>iiViì`v
initial empiric therapy due to high rates of resistance of S. pneumoniae
xx>
Uii-}ìi}ivVVi>>
alternative agent for ABRS, Doxycycline is NOT recommended for
initial empiric therapy at JHH due to high rates of resistance of S.
pneumoniae >` H. inuenzae x
U,iVi>}iv,->iVi>v ,-
recommended
6.11 Orbital cellulitis
Orbital cellulitis
Preseptal cellulitisvV>i
Uii>iiL>i
U*iivii]iiìi>>`vii}L
orbital congestion
Postseptal cellultis
U-}viL>Vi>i>>vV>ii]
pain with ocular movement, and/or proptosis
U-iiiviVV>>i>]Lii>>LVi]
globe displacement, abscess formation
U"vi>V>i`
U
>Li>V>i`V>iL
EMPIRIC TREATMENT
UVL>V>}6+
OR
U iii*
>i}\
iv>i}6`>
OR
U-iii*
>i}\y>V{}6`>
Add Vancomycin (see dosing section, p. 150) in patients with history
of MRSA colonization or infection, evidence of abscess or bone
involvement, orbital trauma, recent ophthalmic surgery or severe
infection
Oral step down therapy (for patients without culture data to guide
therapy and without evidence of bony involvement or cavernous sinus
thrombosis)
UVV>>>inx}*"+
OR
U iii*
>i}\
ivì{}*"+
OR
U-iii*
>i}\y>V{}*"`>
Duration
U`>iiviìVivLii
TREATMENT NOTES
Microbiology
US. aureus, beta-hemolytic streptococci, S. pneumoniae, H. inuenza,
M. catarrhalis (cultures are infrequently positive)
Management
U>}}iViìì>Vi
/,
U
>] /]>`>}iViì`
80
81
6.11 Orbital cellulitis
U*i>ViVi`V>LiV>i
Lv}>`ìV>v}>i>iViì`
consultation with ID
U*i>Vi>LViv>ì`>i
surgical intervention
U,ii>>i>LVi>`VV{q{n
hours
U*ii>LV]i}>>V>
changes and/or evidence of an abscess are indications for surgery
6.12 Pulmonary infections
COPD exacerbations
EMPIRIC TREATMENT
UDoxycycline 100 mg PO BID for 5 days
OR
UVx}*"6+{v`>
OR
UVV>>>inx}*" vx`>
OR
U
ivì}*" vx`>
OR
U
iv`}*" vx`>
TREATMENT NOTES
Microbiology
U*i`>H. inuenzae, M. catarrhalis, S. pneumoniae
UPseudomonas, Enterobacteriaceae are less common and seen in
patients with severe COPD and extensive antibiotic exposure.
Management
U Vivyi`V>}i`>``
be considered if past or present microbiologic evidence indicates
infection with a pathogen(s) that is resistant to standard therapy (e.g.
Pseudomonas, Enterobacteriaceae).
U6>LV`Lii`vi>iV>i>i*"
antibiotics.
ULV>i`V>i`v>>y>ii>LiViv
pneumonia.
Prophylactic antibiotics for the prevention of COPD exacerbations
U*>VV>LV>iLiii`Vi>iv
exacerbations and improve reported quality of life but not to decrease
all-cause or respiratory-associated mortality
U*}i`Vi>Lii>V>iì>}
>`+/}>>iL>ii+/}>ii
included in clinical trials
U/iìV>i>VV>LV`Li>ì>
case-by-case basis and should take in to account patient preferences,
nancial constraints, risk factors for adverse events and input from the
patients pulmonologist
U,iViìì}i\Vx}*"`>
U >ii>ì>` iViì`
,iviiVi\
iV>
i}iv*V>**>i\ii`{\
>vi>\/>nx\{xq
Vvii\ }i`x\n
V>i>>L>i-
Rev 2013 Nov 28.
82
NOTE: If patient is coming from a nursing home or long-term care

facility, see Healthcare-acquired pneumonia, p. 87.
EMPIRIC TREATMENT
Patient NOT in the ICU
UVL>V>x}6+PLUS Azithromycin 500 mg IV/PO
once daily
OR
U
iv>i}6+{PLUS Azithromycin 500 mg IV/PO once daily
OR
Uy>V{}6*"+{
In non-critically ill patients, consider switch to oral agents as soon as patient
is clinically improving and eating (see next page for oral options and doses).
Patient in the ICU
Not at risk for infection with Pseudomonas (see risks below)
U
iv>i}6+{PLUS Azithromycin 500 mg IV Q24H
OR
U*
>i}\y>V{}6+{
At risk for infection with Pseudomonas (see risks below)
U
ivii}6+nPLUS Azithromycin 500 mg IV Q24H
OR
U*i>V>L>V>{x}6+PLUS Azithromycin 500 mg IV Q24H
OR
U-iii*
>i}\y>V{}6+{PLUS Aztreonam
2 g IV Q8H
U-}>>>iìiivPseudomonas is present.
UNarrow coverage if Pseudomonas is NOT present on culture at 48 hours.
Risks for Pseudomonas>ìi>>i}>i}>\
LViV>L>ìV>LVv`>i>
}i`>>`>ìL>i`}i
iìiViiV>V>i>{nVi`
due to solid organ transplant, hematologic malignancy, BMT, active
chemotherapy, prednisone > 20 mg daily for > 3 weeks.
DIAGNOSIS
UVii>i1-/>i>Vi8>w>iii
diagnostic criteria for pneumonia.
U->`L`Vi`Lii>>i>ì`
the hospital BEFORE antibiotics are given.
US. pneumoniae urine antigen should be obtained in all patients with CAP.
>iVwVv>ìi`Vi>ivnnnx
is particularly useful if antibiotics have already been started or cultures
cannot be obtained.
83
Community-acquired pneumonia (CAP) in

hospitalized patients
U/ii}i>i>}iiivVViv`>}}
legionella infection. This test detects only L. pneumophila serogroup
]ViLivqnvviV
DURATION
U/i>V>Lii`>vii>i\
UviLiv{nq
AND
U>i>iviv}}>`\,
100 beats/min, RR 24 breaths/min, BP 90 mmHg, O2 sat
]>iiì>>
U-}}ii``>vi>L>i`>iiVwVv>V\
U35 days: Patient without immunocompromise or structural lung
disease
U7 days: Patients with moderate immunocompromise and/or
structural lung disease
U1014 days: Patients with poor clinical response, who
received initial inappropriate therapy, or who are signicantly
immunocompromised
U1VV>i`L>ViiViVVV>i>q}i`
course of antibiotic therapy not necessary, treat as pneumonia
U
}>`Vi8>>L>i>>i{qiii
There is NO need to extend antibiotics if the patient is doing well
otherwise (e.g. no fever).
Other causes of pneumonia
U-iVi`>>\ Additional empiric coverage for aspiration is justied
only in classic aspiration syndromes suggested by loss of consciousness
(overdose, seizure) PLUS gingival disease or esophageal motility disorder.
Ceftriaxone, Cefepime, and Moxioxacin have adequate activity against
most oral anaerobes. For classic aspiration, Clindamycin 600 mg IV Q8H
can be added to regimens not containing Piperacillin/tazobactam.
U
>Vi`,-\ Necrotizing pneumonia with cavitation in
absence of risk factors for aspiration listed above is concerning for
CA-MRSA pneumonia, particularly if associated with a preceding or
concomitant inuenza-like illness. In these cases, Linezolid 600 mg IV/PO
Q12H can be added while awaiting culture data. Infectious Diseases
consult is strongly recommended. Use of Linezolid monotherapy for
MRSA bacteremia, even if associated with a pulmonary source, is not
recommended. In the absence of necrotizing pneumonia with cavitation,
empiric coverage for CA-MRSA can be deferred until sputum and blood
culture results return given their high diagnostic yield for CA-MRSA.
U,i>i\ Respiratory viruses can cause primary viral
pneumonia as well as lead to bacterial superinfection. Strongly consider
testing all patients with CAP during respiratory virus season (see p. 93).
,iviiVi\
-/-
iìiv
*\
viV{{\-
S. pneumo >}i\Vii`\q
`>vi>v
*\ \xx
84
85
Ceftriaxone 1 g IV Q24
OR
Cefpodoxime 200 mg PO BID
OR
Cefdinir 300 mg PO BID
V}6+
OR
Amoxicillin 500 mg PO TID
S. pneumoniae PCN resistant,

cephalosporin susceptible
H. inuenzae Li>>V>>i
producing (Ampicillin susceptible)
Penicillin G 1 million units IV Q6H

OR
Amoxicillin 1 g PO TID
S. pneumoniae PCN intermediate

or urine antigen positive
Amoxicillin 500 mg PO TID
Penicillin G 1 million units IV Q6H

OR
Preferred therapy
S. pneumoniae PCN susceptible
Pathogen-specic and step-down therapy
Organism
PCN allergy
VIQx}*"`>8`>",
x}Vi]ix}*"`>8{`>R
OR
ivì}*"
OR
OR
Doxycycline 100 mg PO BID
OR
Moxioxacin 400 mg IV/PO daily
(if resistant to other options)
Moxioxacin 400 mg IV/PO Q24H
Same as above
Non-severe reaction:
OR
Severe reaction:
VIQx}*"`>8`>
",x}Vi]ix}*"`>8{`>R
OR
Moxioxacin 400 mg IV/PO daily
(if Erythromycin resistant)
Notes
xvH. inuenzae isolates at JHH

(excluding oncology) are susceptible to
V]
iv>i]x
/i>VVi]>`y>V
None of the S. pneumoniae isolates at

(excluding oncology) are resistant JHH
to PCN
vS. pneumoniae isolates at JHH

(excluding oncology) are susceptible and
>iii`>i*
]{x>i
susceptible to Erythromycin (Erythromycin
susceptibilities predict Azithromycin
ViLivS. pneumoniae), and
>iViLiy>V
86
ivì}*"
y>V{}6*"+{
OR
OR
VV>>>i8,}*"
i\1i}Vv
L. pneumophilia, more than 3 days of

Azithromycin for atypical coverage is not
needed due to very long half-life in lung tissue
i>ì>}ii}>i
Iv VViLiav/i>VViViLi
Azithromycin 500 mg IV/PO Q24H

OR
y>V{}6*"+{
L. pneumophilia
PCN allergy
Azithromycin 500 mg IV/PO Q24H x 7-10 days

OR
y>V{}6*"+{8{`>
VIQx}*"`>8`>",
x}Vi]ix}*"`>8{`>R
OR
OR
OR
Doxycycline 100 mg PO BID
OR
Moxioxacin 400 mg IV/PO Q24H
(if resistant to other options)
Preferred therapy
VL>V>x}+
OR
Amoxicillin/clavulanate 875 mg PO BID
H. inuenzae Li>>V>>i
producing (Ampicillin resistant)
Pathogen-specic and step-down therapy
Organism
{xvS. pneumoniae isolates at JHH

(excluding oncology) are susceptible to
Erythromycin (Erythromycin susceptibilities
predict Azithromycin susceptibilities for
S. pneumoniae>`>iViLi
/i>VViiivi]ii>}i
>iL>viVi`
therapy
Notes
NOTE: If the patient is on antibiotic therapy or has recently been on

antibiotic therapy, choose an agent from a different class.
EMPIRIC TREATMENT
Patient with mild to moderate illness (e.g., not in or transferring to
the ICU/intermediate care unit, no or minimal oxygen requirement, no
hypotension)
U
iv>iI}6+{
OR
U-iii*
>i}\y>V{}6*"+{
Patient with severe illness (e.g., in or transferring to the ICU/
intermediate care unit, concern for sepsis, signicant oxygen
requirement, multi-lobar consolidation)
U
iviiI}6+n Vancomycin (see dosing section, p. 150)
OR
U*i>V>L>V>I{x}6+ Vancomycin (see dosing
section, p. 150)
OR
U-iii*
Ciprooxacin 400 mg IV Q8H Gentamicin (see dosing section, p. 146)
*Consider adding Azithromycin 500 mg IV/PO Q24H if the patient is immunosuppressed
or coming from a nursing home or long term care facility to cover Legionella
Add Vancomycin in patients with a history of MRSA colonization or infection,
necrotizing pneumonia, pneumonia after a respiratory viral illness, ill patients coming
from a nursing home or long term care facility, sepsis)
Patient with history of or risk factors for Pseudomonas and other

resistant Gram-negative organismsi}]LViV>L>ìV
>LVv`>i>}i`>>
`>ìL>i`}iiìiViiV>V>i>
{nVi`ì`}>>>]
hematologic malignancy, BMT, active chemotherapy, prednisone > 20
}`>vii\i>>iiii>}v>LV
based on past culture data
NOTE: Always narrow therapy based on cultures results
Oral step down therapy (if no sputum culture data to guide therapy)
U
ivì{}*" v
iv>i",y>V{
mg PO daily
Duration:vi>Vwi`x`>vi>`>}
questionable and patient improves, can considered stopping therapy
after 3 days
TREATMENT NOTES
Microbiology
U iVVV>`V>``>iVi>ivi>i`vi
in hospitalized patients. In general, they should be considered to be
colonizing organisms and should not be treated with antimicrobials.
87
Healthcare-acquired pneumonia
(NOT ventilator-associated)
Antimicrobial management of aspiration events

U*>VV>LV, "/iViì`v>i>i
at increased risk for aspiration.
Ui`>ii>i`V>i`v>i>i>Li
obstructions or are on acid suppression therapy given the increased
risk of gastric colonization.
ULVi>iv>iìivii]iV>`
inltrates in the rst 48 hours after an aspiration is likely unnecessary
since most aspiration pneumonias are chemical and antibiotic
treatment may only select for more resistant organisms.
U/i>i-iViì`v>i>iv
more than 48 hours or who are severely ill.
,iviiVi\
>i>`>>i>\ }i`{{\x
/--ìiv*6*\,
x\nn
Ventilator-associated pneumonia (VAP)

U-Vi`LiL>i`>}>LV
if patient is failing therapy by endotracheal suction or invasive
techniques. ET suction appears just as sensitive but less specic
than invasive methods.
UEmpiric treatment MUST be narrowed as soon as sputum
culture results are known.
Uvi>i>LVi>>iViLii>LV
therapy, choose an agent from a different class.
Optimal treatment can likely be based on severity of illness as
determined by the Clinical Pulmonary Infection Score (CPIS).
Calculating the Clinical Pulmonary Infection Score (CPIS)
Temperature (C)
Peripheral WBC
0 points
36.5 to 38.4
{]q]
Tracheal
secretions
Chest X-ray
None
Progression
of inltrate
from prior
radiographs
Culture of ET
suction
None
Oxygenation
(PaO2/FiO2)
> 240 or ARDS
88
No inltrate
No growth/light
growth
2 points
1 point
36.4 or 39
38.5 to 38.9
{]
> 11,000
> 50% bands: add
1 extra point
Purulent
Non-purulent
Diffuse or patchy
inltrates
Localized
inltrate
Progression
(ARDS, CHF
thought unlikely)
Heavy growth
Same bacteria on
gram stain: add 1
extra point
240 and no
ARDS
If the CPIS is 6
U6*i
Uv6*}iViìii>iiVi`>Li
Uv
*-i> 6 after 3 days, antibiotics can be stopped in most
cases
If the CPIS is > 6
Early-onset VAP (occurring within 72 hours of hospitalization and
patient has not been hospitalized or resided in a nursing home, longterm care or rehabilitation facility in the past 3 months)
Etiology: S. pneumoniae, H. inuenzea, S. aureus
U
iv>i}6+{
OR
U-iii*
>i}\y>V{}6+{
Late-onset VAP (all VAP that is not early-onset)
Etiology: S. aureus, P. aeruginosa, other Gram-negative bacilli
U6>VVii`}iV]xPLUSQ*i>V
tazobactam 4.5 g IV Q6H OR Cefepime 2 g IV OR +nR Gentamicin
(see dosing section, p. 146)
OR
U-iii*
Q
y>V{}6+n",i>}6+nRPLUS
Gentamicin (see dosing section, p. 146)
Enterococci and candida species are often isolated from sputum in
hospitalized patients. In general, they should be considered to be
colonizing organisms and should not be treated with antimicrobials.
If the patient is immunocompromised, consider adding Azithromycin
500 mg Q24H to Piperacillin/tazobactam, Cefepime or Aztreonam to
cover Legionella
Duration
U3 days if CPIS remains 6 in patients with initial CPIS 6*
unlikely
U7 days if the patient has clinical improvement
Uvi>`>Vì>i>iVi>`
bronchoscopy with quantitative cultures
U6*>V>i`S. aureus bacteremia should be treated for at
least 14 days
89
EMPIRIC TREATMENT
TREATMENT NOTES
UTreatment MUST be narrowed based on culture results
U/L>ViViì`>>iV`>}iL>ìiV
coverage rather than uoroquinolones because of high rates of
resistance to uoroquinolones in the institution.
UVL>i>`Li>i`ViViLi>i
known. Vancomycin should be stopped if resistant Gram-positive
organisms are not recovered. Gram-negative coverage can be
reduced to a single susceptible agent in most cases. The benets of
combination therapy in the treatment of Pseudomonas are not well
`Vii`vìi`]iVì}}viw
hours of therapy only.
Diagnosis
U6*`vwV`>}i
U >Vi>i`>Vi>V>iii>Vi>V>
and NOT infection.
U+>>iViv y`V>i`}Liii
V>>`viV 104 cfu/ml is considered signicant
growth.
Other considerations
U/>Vi>V>v>i}>i>`S. aureus is not
eradicated even though lower airways are sterilized. Thus, posttreatment cultures in the absence of clinical deterioration (fever,
rising WBC, new inltrates, worsening ventilatory status) are not
recommended.
U>ì>i>i>iv6*>V>i`}i>
(even if treatment is changed once culture results are known).
,iviiVi\
/--ìiv*6\,
x\nn
V>ii6*\,
\x
6*\Vii`\
\
in\{
*-Vi\,i,i{\q
ii}Vivi>}
*--Vi\,i
>ii`
\xx>ìi
>ii`{\xqn
90
U/i>`LiL>i`Vi>`ViL`>>i
>>>Lii>}ii>iiVv>V`Li
selected preferentially
UvLi]v>}>LVi>}i>LV
U}ìv>LV`Lii`>i}ii>
and reduce the risk of emergence of resistance (see below)
TREATMENT NOTES FOR SPECIFIC ORGANISMS
UPseudomonas aeruginosa
U*i>V]
ivii]>`
iv>ì`Lii`
preferentially to Meropenem to minimize the induction of
resistance to beta-lactams by Meropenem
U/ii>}i>i}ii>VLi`}ì
aminoglycosides based on in vitro evidence that there is synergy
against Pseudomonas
U>iiV>i}]
y>Vi>
V>LiVLi`>>}Vììi>Li>
lactams or carbapenems should be strongly considered
U>ii>i>>}Vì]
V>
be added
U
vvLi>>V>V>LiVìiì
>iiinviv>
U>i`/L>V>`
V>Lii`>>`Vii>
UStenotrophomonas maltophilia
US. maltophilia isolated from sputum usually represents colonization.
UviviViVi`]/*-8iwi>}i
U/V>VV>>>iOR Minocycline may be used if susceptible in
>i>i>i}Vi>i>/*-8
UStaphylococcus aureus
US. aureus isolated from sputum can indicate colonization or
infection.
U7iii>}V>S. aureus in CF patients
improves outcomes is an area of active research, although
historically such colonization has not been successfully eradicated
with antimicrobial therapy. If this is attempted, possible agents
include Dicloxacillin, Cefazolin or Cephalexin for MSSA and
`>V]/*-8]VVi]>`VViv,-
U">Vi`}vVViv--i>6>VV
or Linezolid can be used for MRSA pneumonia.
91
Antibiotic selection and dosing for cystic

brosis patients
Antibiotic doses for cystic brosis infections normal renal

function
U
iv>ì\}6+n
U*i>V>L>V>\x}6+{
U
ivii\}6+n
Uiii\}6+n
U
y>V\x}*"+",{}6+n
Ui>\}6+n
U/V>VV>>>i\}6+{
U/*-8vS. maltophilia: 5 mg/kg IV/PO Q8H
U/*-8vS. aureus: 2 DS tablets PO BID
U
\}}`>6`ì`ì
U>i`/L>V/" \}+
U>i`
\xx}+ìi`}iìii
Intravenous Tobramycin dosing and monitoring:
U>`}ì\}}`>}ii
U*i>iViì`>viwì]>viii`vv
}>v>`}>}>V}
UiV>LiVi>i`}}`>v>ì>ii>
are not achieved. If trough is too low or too high, interval should be
changed.
92
Diagnosis
U,i>i}`LiL>iì>`>>i
for whom there is a clinical suspicion of respiratory virus infection. In
addition, during inuenza and RSV season testing should be obtained
>i\
Uii>`yi>ii>]>}>]>>}>]
cough, runny nose and/or headache)
U Suspected bronchiolitis or pneumonia
U COPD/asthma exacerbation or respiratory failure
U1i>i`
i>ViL>
U ì>ii>iìi>>i
U*i}>>ii>iì>
U iVwV>`>`Viiìiii
with a respiratory illness
U,i>i}>i *yVi`>L`Li
submitted for either panel)
U/i}vVii\>`ViV>Vìv,-6
and inuenza A/B
U/i}vVi`]>iLi}>ì`
i
1]>`>iV>}ì>i\iiì`
panel for RSV, inuenza A/B, adenovirus, human metapneumovirus,
parainuenza 1-3, and rhinovirus
Treatment of inuenza in inpatients
U Vi>iv>`>i`LiVìiì
v}>`}yi>i>\
U*>ivii>`yi>i]i>i`
interstitial pneumonia or new respiratory failure without an obvious
non-inuenza cause
U/i>i`Li>i`>>i>i>ìì
hospital and have inuenza with symptom onset in the past 48-72 hours
U/ivi>iv>iii>iiViv
disease is uncertain and the decision to treat these patients can be
made on a case-by-case basis
U>VViìiìiViLvVV>}>
which may vary from season to season (see
www.hopkinsmedicine.org/amp for current recommendations)
U>\x`>iViv>i`}>>>]
hematologic malignancy, or BMT in whom 10 days can be given
because of prolonged viral shedding
93
6.13 Respiratory virus diagnosis and management
Respiratory virus diagnosis and management
6.13 Respiratory virus diagnosis and management
Infection control
U``>iViì>viV`Li
placed on droplet precautions. A private room is required, unless
patients are cohorted. When outside of their room (i.e. during
transport) patients should wear a mask.
Ui>V>iiiViiiyi>>VVii>
U*iiìV>iV>i}VV>>i>>i
received the inuenza vaccine are required to wear a mask when within 6
feet of a patient. The dates of the mask requirement are determined by
HEIC and based on inuenza activity in the local community.
U No one with fever may work until at least 24 hours after fever
has resolved (without antipyretics). All personnel with respiratory
symptoms and fever must call or report to their supervisor and must
call Occupational Health Services (OHS).
UAfebrile employees who have respiratory systems must wear a
surgical mask during patient contact ( 6 ft).
Uv>>VV>i`
7ii`>>i`Vii`
inuenza who was not on Droplet Precautions, notify HEIC and call
Occupational Health Services (OHS) immediately. OHS will decide
whether to recommend post-exposure prophylaxis.
Anti-inuenza agents
Medication
Adult dosing
Side effects
Notes
Oseltamivir
Treatment:
75 mg PO twice a day
vx`>
Prophylaxis:
75 mg PO once a day
\>i>]
vomiting
-iii\
hypersensitivity,
neuropsychiatric
i>ì
needed for GFR

Treatment:
10 mg (2 oral inhalations)
twice daily for 5 days
Prophylaxis:
10 mg (2 oral inhalations)
Vi>`>
\`>i>]
nausea, cough,
headache, and
dizziness
-` "/Lii`
in patients with
chronic underlying
airway diseases
<>>
94
-iii\LV>]
hypersensitivity,
laryngeal edema,
facial swelling
Latent TB infection (LTBI)

U*iviVM. tuberculosis (MTB) that has been contained by
the host immune response
U*>i>>i>iiiiLi}}ii>`}>V
ndings such as calcied granulomata or minimal apical scarring, but do
not have symptoms of active TB disease
U viV>`ìii>
Tests to diagnose latent LTBI
U /LiVi/-/>ìvi}>>ii>i>>,
>iiviV]>`>vvi`V`>iH-iv/-/
and IGRA are similar.
U i`LiiiiìViviì}Vv/
exposure
U/ i>`Li>i`>Vi/ iVì`L
symptoms and radiography). Individuals with signs or symptoms of active
TB require further diagnostic workup before LTBI therapy.
U/ i>`Li>iì>>Vi>v
plan
Tuberculin skin test (TST)
U>ì>iVvwiìì>i**>ì>ii
of induration diameter in 48-72
U
i>v>ii>i
Uxq}vìi}>Vi/ i}]6viV]Vi
contact of TB case, immunocompromised)
Uqiv>Vv/ viV
7]1]
Uxqv>Vv/
Interferon gamma release assay (IGRA)
U,i>iViii>ivivi}>>ii
stimulation by MTB antigens.
U,>ii>vviVi`L
>VV>>viV
atypical mycobacteria (except M. marinum and M. kansasii) than TST
U+>vi`/Li+/i`>,i>iii`>
positive, negative, or indeterminate. An indeterminate result means that the
test result is not valid, which can be due to errors in specimen collection
(most common--insufcient/incorrect shaking of tubes after blood draw
or processing delays), or associated with certain conditions such as HIV
with a low CD4 count, steroid use or other immunosuppression, and
>Q>LxRìi>iiviii>ii>
test (ensure proper specimen collection).
U7iiiL>Li>iViv/ xi}]1-L
vi}>i]**6v,i`Vi`]i]v>ii
i *6}
U7iiiL>LvviV}i}]vi}L]H/
i>iVi]**6v,Vi>iHx]L *6ìVi>i
n]i]v>ii}>i
95
6.14 Tuberculosis (TB) infection
Tuberculosis (TB) infection
U+>>ii>Liiv}ìii>
ì
V>vii>ii`v+/i\>}i0.35.
Serial testing is not advised without ID consultation.
U,`>i}ìiVwVv`>}v>Vi/
Active TB infection
UViiV>v/ V>}>i>>}
symptoms
U
wi`Li i>]/ ìViVi
U,ii>Li>
When to suspect active TB disease
High-risk individuals
U,iViii>i/ v>i/-/
6viViViV`}ivi}LiìVi
>i}V/ VìVi}iì>ìiiv
}V}i}>ii}i}iLi>i`V>
ìii`]Vi>>/ >>i>
Clinical syndromes
U
}v2 wk duration, with at least one additional symptom, including
fever, night sweats, weight loss, or hemoptysis
Ui>iì>iv2 wk duration in a patient at high
risk for TB
U>i6viV>ì>i`V}>`vii
U>i>/ >>i>i>i`vii
U
>Viì>V>i`>vi`>v
appropriate treatment
UVì>w`}Vi>`}>}}iiv/ iiv
are minimal or absent) in a patient at high risk for TB
Radiographic ndings
U*>/ viiV}i`\
>iiLi
*>ì>Li
>>ì>]i>ivv>iVV>>V
`}viii>viq/ii>iVw`}
patients with advanced HIV infection and TB.
U,i>V>/ \w>iV>>iiLi
iii}iviiLi>>ì>>>Li
/
V>>>iiiL`>i>>Vi
Diagnosis
U*>iV>>ViVì>`>`}>Vw`}`
have expectorated sputum obtained for AFB smear and culture.
U-iv i>iiV>i`xq
i6>i}iiV>i`]`Vi`]
bronchoscopy have higher sensitivity. AFB culture of lower respiratory tract
specimens is considered the gold standard.
U i>>`Vi`LiL>iì}>ìv
8,
ndings in patients with high clinical suspicion, HIV infection or other
Vi`>i
8,>>>iv6
infected patients with pulmonary TB.
96
Infection control
LiiV>>iiiìv}V>i\
U-Vvì>ivwVi}>>L>}
smear/culture as described above
U*i i>Vi`>}v/ /Vwi`
Algorithm for isolation when active TB is suspected

AIRBORNE PRECAUTIONS
IN NEGATIVE PRESSURE ROOM
Collect specimen(s) for AFB smear and culture
Expectorated sputum (3 required)*
Smear
positive
Mycobacterium
Tuberculosis
Direct Test (MTD)
automatically
performed
Induced sputum or bronchoscopy
Smear
negative
MTD
negative
Smear
positive
Obtain 2nd
and 3rd
specimen*
Smear
positive
MTD test
performed
MTD
positive
MTD
positive
Continue isolation until at

least 14 days of therapy
AND clinical improvement
AND 3 consecutive negative
smears (Call HEIC for
approval to D/C isolation on
smear positive patient.)
Smear
negative
If pt highly suspected
for TB, await culture
result and continue
isolation. Otherwise,
CALL HEIC 5-8384 to
DISCONTINUE ISOLATION
MTD
negative
CALL HEIC
5-8384 TO
DISCONTINUE
ISOLATION
*One expectorated sputum must be a first morning specimen; samples should

be collected at least 8 hours apart.
97
U"L>>i>iVi`ViìiV>iì}
to diagnose TB in patients who are smear negative so as to increase the
chance of isolating the organism for diagnosis and susceptibility testing.
U>Vi>>}i>/ v>iVi/
treatment, consult with HEIC and patients local health department to obtain
treatment history in order to determine if infectious at the time of current
>>i>i>LiiV>>iii`
TREATMENT
Active TB
UV}iViì`
U/i>`Li>i`v>ii i>>`VV>
ndings consistent with active TB.
U/i>`LiVìi`v>ii}>i i>
when suspicion of TB is high and no alternate diagnosis exists. Multiple
specimens should be obtained for culture prior to treatment.
U`}>iiVi>v>>i
U>` I}x}}*"`>
U,v>,I}}}*"`>
U*>>ì*<}*"`>{qxx}",x}*"
`>xqx}",I}*"`>q}
U >L n}*"`>{qxx}",}*"`>
xqx}",I}*"`>q}
*Max dose regardless of weight.
U*ìx}*"`>iViììi >V>i`
peripheral neuropathy in patients with HIV, malnutrition, alcohol abuse,
diabetes mellitus, renal failure or in pregnant or breastfeeding women.
Drug toxicity and monitoring
U>`\>>Vii>i>Vii]i>`v>>
hepatitis, peripheral neurotoxicity
U,v>\>}i`V>vL`y`]i>V]
or without rash
U*>>ì\i>V]}>>}>]>>V
hyperuricemia, acute gouty arthritis
U >L\iLL>>ìi>i
U }\L>iii>V>>>i]LL]>>i>>i]
creatinine and CBC are recommended for all adults initiating TB treatment.
Monthly hepatic panel is recommended for patients with baseline
abnormalities, history of liver disease or viral hepatitis, chronic alcohol
consumption, HIV, IVDU, pregnancy or immediate post-partum state or
those taking other potentially hepatotoxic medications. Therapy should
be discontinued immediately if AST and ALT are 3 times the upper limit
of normal (ULN) in the presence of jaundice or hepatitis symptoms or 5
times the ULN in the absence of symptoms.
,iviiVi\
/--

ìiv`>}v/ \,i
>ii`\
/--

ìivi>iv/ \7,x\,,
98
6.15 Sepsis with no clear source
Sepsis with no clear source

NOTE: Refer to specic sections of these guidelines for empiric
treatment recommendations for specic sources of infection
EMPIRIC TREATMENT
Cultures MUST be sent to help guide therapy.
UQ*i>V>L>V>I{x}6+",
iviiI}6+nR
Vancomycin (see dosing section, p. 150) (if at risk for MRSA)
OR
U-iii*
>i}\Qi>}6+n",
y>V{
}6+nRPLUS Gentamicin (see dosing section, p. 146) PLUS
Vancomycin (see dosing section, p. 150)
*NOTE: If patient has history of ESBL-producing organism or has
suspected intra abdominal sepsis and recent prolonged exposure
( 7 days) to Piperacillin/tazobactam or Cefepime, substitute with
Meropenem 1 g IV Q8H.
Risk factors for MRSA
U
i>iV>ii>Vi
U"iì}>`>i
UV>,-
U,iViVi}i`>>>
2 weeks
U/>viv>}iL>Viv>V
UiV`}i
TREATMENT NOTES
U>ii>vwViV>}Vìi>Vi]>
beta-lactam may be combined with a uoroquinolone IF 2 agents are
needed.
U*i>Vii}]i>]i]iV`Li
considered when selecting therapy.
U Vi>" 9>>iiVi>ii`}
(72 hours max).
U6>VV`>>>Lii`vi>>
positive organisms are recovered in cultures.
99
6.16 Skin, soft-tissue, and bone infections
Skin, soft-tissue, and bone infections

Cellulitis
U>ii>i>vviViìi/i>iv>ii
commonly due to failure to elevate than failure of antibiotics.
Uiivii>V>>i`>]iiV>>i
lymphedema, because dead bacteria in the skin continue to induce
inammation.
Non-suppurative cellulitis
Dened as cellulitis with intact skin and no evidence of purulent
drainage. Usually caused by beta-hemolytic streptococci (e.g. group A,
B, C, G streptococci) and MSSA.
TREATMENT
Oral (mild disease)
UVV>>>inx*"+
OR
U
i>ix}*"+
OR
U*
>i}\
`>V}*"+n
Parenteral (moderate to severe disease)
UVL>V>x}6+
OR
U
iv>}6+n
OR
U*
>i}\
`>V}6+n
Duration: 5-7 days
TREATMENT NOTES
ULi>iViVVV>iViLiiV
U
`>Vi>Viiiv} ]
]>ì
Li>}i{q
U>\x`>
Suppurative cellulitis
Dened as cellulitis with purulent drainage or exudates in the absence of
a drainable abscess. Usually caused by S. aureus (MSSA and MRSA).
TREATMENT
Oral (mild disease)
U/*-8->L*"
OR
UVVi}*" ",VVi}*"
OR
U
`>V}*"+n
100
Parenteral (moderate to severe disease)

U6>VVii`}iV]x
Duration: 5-7 days
TREATMENT NOTES
U,i>ViyiS. aureus is common and develops
Vxv,->i>ii>yi
Monotherapy with uoroquinolones for S. aureus infections is not
recommended.
U,v>` 6 ,Lii`>i>LiV>ii>Vi
develops rapidly.
U/iiiìVi>iì/*-8]
Doxycycline, or Clindamycin in the management of skin infection or
osteomyelitis. Linezolid should only be considered when the S. aureus
isolate is resistant to or the patient is intolerant to these agents.
Less common causes of cellulitis
U7L>i]iVi]>`Vi>viiii>>i>
oysters, consider Vibrio vulnicus, especially in patients with liver
disease. Rare, but rapidly fatal if untreated. Treat with Ceftriaxone
1 g IV Q24H PLUS Doxycycline 100 mg PO BID.
U iiV]`}>>>]>`VV>i>
have cellulitis due to Gram-negative organisms. Consider expanding
coverage in these cases.
UviV>]Vì>}>i}> ,]>i}]`
ID consult is recommended.
U>>`>Li\Pasteurella multocida should be covered in
cat and dog bites. Treat with Amoxicillin/clavulanate 875 mg PO BID
",VL>V>xq}6+v*
>i}\y>V
400 mg PO/IV Q24H.
Cutaneous abscess
UV>``>>}iEi>i>iv>V>i
abscess.
Ui>>i>iwV>V>vi>i>V>i`>LVi
formation that is not clearly appreciated without debridement of the
wound or, on occasion, additional imaging.
UiivE]>>i`LiL>i`vVi>`
sensitivity testing.
Uì>>iLiiLi``>i}}i>>LV
are adjunct to I&D in the management of uncomplicated skin
abscesses caused by CA-MRSA.
101
OR
U
`>V}6+nv>ii>i>iiì`
U`V>v>VL>i>>iV>i
>LVii\
U-iii>`}iiviV
U/iiiViviii>V>i`Vi
U-}>`viVi
UV>iìViL
U>Liiiii
U`>Vi`>}i
UV>vi>LVi>>i>iiVii`>>}i
difcult (e.g. face, genitalia)
U>VviiV>``>>}i>i
U/i>`Li}ibefore incision and drainage in patients with
prosthetic heart valves or other conditions placing them at high risk
for endocarditis.
EMPIRIC TREATMENT
If antibiotic treatment is thought to be necessary, regimens are the
same as for suppurative cellulitis above.
Management of recurrent MRSA skin infections
1. Education regarding approaches to personal and hand
hygiene
U*>VVivii>`}ii>>`>i>`
alcohol based hand gels, especially after touching infected skin or
wound bandages.
U
i`>}`Vi>]`L>`>}i
U>ii>ii}>iì>`V}
before washing)
U,i}>L>}
U`>>}
U>ìV}]ii]ii>Liii>i
U
i>>i>}V}ii
2. Decontamination of the environment
U
i>}V>i>iL>>`viV>>Vi
against S. aureus`>i}]ìLi>V
3. Topical decolonization (consider if a patient has 2 episodes
in 1 year or other household members develop infection)
UVVi`>vx`>>LiVìi`>i
`ViiììViv,->>V>
Mupirocin therapy should be initiated after resolution of acute
infection. Mupirocin should not be used in patients or patients
family members who are not documented to have MRSA nasal
colonization.
102
NOTE: Data on efcacy and durability of the decontamination and

decolonization strategies described above are limited.
,iviiVi\
/*-8v,-\ii`\n
-ìivi>iv,-viV\
viVx\qn
}v>iVi\i`Vin\q
Diabetic foot infections

EMPIRIC TREATMENT
Treatment depends on clinical severity
Infection Severity
Uninfected
Mild
Clinical Manifestations
No purulence or inammation*
Presence of purulence and 1 sign of inammation*
and cellulitis (if present) 2 cm around ulcer limited to
skin or supercial subcutaneous tissue
Moderate
Same as mild PLUS>i>iviv}\ 2
cm of cellulitis, lymphangitic streaking, spread beneath
the supercial fascia, deep tissue abscess, gangrene,
involvement of muscle, tendon, joint, or bone
Severe
Any of above PLUS systemic toxicity or metabolic
instability
*erythema, pain, tenderness, warmth, induration
MILD INFECTIONS
Oral regimens
UVV>>>inx}*"
OR
U
i>ix}*"+
OR
U
`>V}*"/Vi,-
Parenteral regimens
U
`>V}6+nVi,-
OR
103
U >}i}Viìi>Vi
ìLi>VL>iii`>viiiViii
do not get these substances into ears or eyes
U-iV>LV>i "/iViììvìV>
4. Evaluation of other family members
U>v>>`Li>ii`>`vii]
all members should participate in hygiene and decolonization
strategies above, starting at that same time and after the acute
infection is controlled.
U">V}6+{
OR
U
iv>}6+n
MODERATE INFECTIONS
U >ii}+{
OR
UQ
y>VIx}*" ",
y>VI{}6+R
PLUS ONEviv}Q
`>V}6+n}*"
/",i`>ix}6*"/R
* BUT avoid uoroquinolones in patients who were on them as
outpatients
If patient at risk for MRSA, add Vancomycin to regimens that do not
include Clindamycin.
UvV>viV,-
U,iViVi}i`>>
weeks
U/>viv>}iL>Viv>V
UiV`}i
SEVERE INFECTIONS
U*iV>L>V>{x}6+
OR
UQ
y>VI{}6+n",i>}6+nRPLUS
Clindamycin 600 mg IV Q8H
* Avoid uoroquinolones in patients who were on them as outpatients.
If patient at risk for MRSA (see above)
U*i>V>L>V>{x}6+PLUS Vancomycin (see dosing
section, p. 150)
OR
UQ
y>VI{}6+n",i>}6+nRPLUS
Metronidazole 500 mg IV Q8H PLUS Vancomycin (see dosing section,
p. 150)
* Avoid uoroquinolones in patients who were on them as outpatients
TREATMENT NOTES
Management
U`V>>>V>>}ii`Vì`
care consultation, assessment of vascular supply, vascular and/or
general surgery consultation and infectious diseases consultation.
U
ìiV}v>V>i>iiii
ULVi>`Li>i`L>i`Vii
104
Diagnosis
U
iviViL>i>viìLìiV>i}ìi>
Biopsy of unexposed bone is NOT recommended. Avoid swabbing
non-debrided ulcers or wound drainage.
U1Viy`LiLi`V>ivvLiV>LiVi`>
metal probe then the patient should be treated for osteomyelitis with
antibiotics in addition to surgical debridement.
U*>>v>V>`>ìiv>ViviVV>Liii
Consider imaging to look for deep infections.
U*``V>}i`>}VviiiViv>>iLi
U,iii>ìVwV>i`>ivìiV
of soft-tissue lesions and osteomyelitis.
Duration
U>vi>iìi`>`vii>`
presence of adequate blood supply.
Uiiiìi>i>ì>i}V>ii
q`>>`}ivii
U
>}i>i}ii>i>Li
,iviiVi\
-ìiv`>LiVvviV
viVx{\
Surgical-site infections (SSI)

EMPIRIC TREATMENT
Infections following clean procedures (e.g. orthopedic joint
replacements, open reduction of closed fractures, vascular procedures,
median sternotomy, craniotomy, breast and hernia procedures)
U">Vq}6+{
OR
U
iv>}6+n
OR
105
Microbiology
U
ii`viVi`Vi]>LV>i\
beta-hemolytic streptococci, S. aureus
UviVi`Vi]VVii>i`>LV\S. aureus,
beta-hemolytic streptococci, Enterobacteriaceae
U i>}]]L\>VL>]>
involve Pseudomonas
U
V`}iìi>LV\>iLV>
positive cocci (GPC), Diphtheroids, Enterobacteriaceae, other Gramnegative rods (GNR) including Pseudomonas
U iV}>}ii\i`>iLV*
>` ,]>>iLi
U*
>i}\
`>V}6+n
OR
Uiiv>`>i,-iVi`\6>VV
(see dosing section, p. 150)
Exception: Saphenous vein graft harvest site infections should be
treated with Ertapenem 1 g IV Q24H
Infections following contaminated procedures (GI/GU procedures,
oropharyngeal procedures, obstetrical and gynecology procedures)
Patients not on broad-spectrum antibiotics at time of surgery and
not severely ill
U >ii}6+{
OR
U*
>i}\Q
y>Vx}*" ",
y>V{}
6+RPLUS Clindamycin 600 mg IV Q8H
Patients on broad-spectrum antibiotics at time of surgery or
severely ill
U*i>V>L>V>x}6+6>VV
(see dosing section, p. 150) (if hardware present or MRSA suspected)
OR
U iii*
>i}\
x}6+n6>VVii`}]xv>`>i
present or MRSA suspected)
OR
U-iii*
Q
y>V{}6+n",i>}6+nRPLUS
Metronidazole 500 mg IV/PO Q8H
Deep fascia involvement
U/i>>iV}v>ViiLiiiV
TREATMENT NOTES
Microbiology
U}Vi>Viìiv1>V
UStaphylococcus aureus
U-iVVV]}iiV>i>i]
U
>}>ii}>i>VVV
U}Vi>V>>i`>`V>>i`Viìiv
GI/GU tracts with or without gross contamination)
U"}>>Li
U>i}>i`
U>iLiVìClostridiai>iviV]q
days)
106
Other management issues

U>>`V>i>viVi``Liii`LìLì
and to assess depth of involvement.
U-iwV>viV>Li>ì>ii>i`ìLìi
alone.
UiiiviVVi]>Vii`>`Vi>LV
UviV>iiìv>V>`Li>>}i`>iV}
fasciitis.
U*>ii`>iiìiìiv
they are unremarkable on physical exam.
Serious, deep-tissue infections (necrotizing fasciitis)
THESE ARE SURGICAL EMERGENCIES!
ANTIBIOTICS ARE ONLY AN ADJUNCT TO PROMPT
DEBRIDEMENT!
ID should also be consulted
EMPIRIC TREATMENT (adjunct to surgery)
U6>VVii`}iV]xPLUSQ*i>V
>L>V>x}6+",
ivii}6+nRPLUS
Clindamycin 600-900 mg IV Q8H
OR
U-iii*
Q
y>V{}6+ni>Vii`}iV]
{RPLUS Clindamycin 600-900 mg IV Q8H
TREATMENT NOTES
Conventional nomenclature and microbiology
Pyomyositis
US. aureus most commonly
U
`>iVqClostridia spp. (esp. C. perfringens)
UiVVV>iV
107
Uii>]iViv6>VV`V>i`LiV>ii
percentage of SSIs caused by MRSA is low at Johns Hopkins Hospital
q
UvV>viV,-
U,iViVi}i`>>
weeks
U/>viv>}iL>Viv>V
UiV`}i
Fasciitis
U/iq*VL>viV>>iLi]iVVV>`
Gram-negative rods (Fourniers gangrene is a type 1 necrotizing
fasciitis of the perineum)
U/iqiVVVi`>i
U
>ivv>VV>i`LV>V>i`,->>i
been reported
Diagnosis
U
>Li`vwVq}>`Vi>>`}ii>
absent in streptococcal diseases.
U>>}ìvVi\
U*>i>iivVii]V>i>>Vi
U*>vV>w`}
Uii>i>vviVi`>i>
U,v>VV>`>Lii]iVi}iLi
U`}V>iVL>i
U*``V>}i]`>i
U
/V>V>i`>}LvVì>i}]
surgical exploration is the preferred diagnostic test. DO NOT delay
surgical intervention to obtain CT.
,iviiVi\
-}ìiv--/\
viVx{\q{
Vertebral osteomyelitis, diskitis, epidural abscess

NOTE: In absence of bacteremia, clinical instability, or signs and
symptoms of spinal cord compromise strong consideration should be
given to withholding antibiotics until samples of abscess or bone can be
obtained for Gram-stain and culture.
EMPIRIC TREATMENT
U6>VVii`}iV]xQ
iv>i}+OR
ivii}6+nR
OR
U-iii*
>i}\6>VVii`}iV]x
Ciprooxacin 400 mg IV Q8H
U >i>L>i`Vii
TREATMENT NOTES
Microbiology
U>iVVVxvV>i>S. aureus
U>i}>i`H
108
Duration
U `>>LViii\{qii
U6iiL>iii`>>LVi\qii
U>i>`>iii}i`>iii>
}ii>ii`>viViv6>LViiìV
should be made in consultation with infectious diseases.
,iviiVi\
->i`>>LVi\ }i`xx\q
->i`>>LVi\+i`n\q
109
Management
U"L>ivL`Vi] -,]>`
,*>}
antibiotic therapy.
U>i`}i>`>i}wV>
co-morbidities do not require empiric coverage for Gram-negative
rods.
U V>i}>iVi>}i`Lii`>i`>Lii]
hardware in place or recent surgery, and recurrent urinary tract infections.
U,V>i>}}i`vVVi
UvL`Vi>ii}>i
/}ììiìL>>
should be obtained for Gram stain and cultures.
U i}i}V>V>iViì`v>i
signs and symptoms of spinal cord compromise.
U-}V>i>ivii`>V>ivi`>>LVi
osteomyelitis (e.g. extensive infection, pre-vertebral abscess, spine
instability, hardware involvement). CT-guided aspiration and/or
antibiotic therapy alone may be considered in some circumstances.
Discussion with infectious diseases and surgery is recommended to
optimize management.
U*>i`>ivii>iivi}VvV]
particularly at the time of initial presentation.
U>iii}v>ì>iii}i
i>iViv}iViì`
110
Bacterial urinary tract infections (UTI)
Empiric treatment
i>iii>i\
U*i}>
ULì}>}VViì
U*i>>>
U iiV
1VV>i`\
U v>>VL`) 100 mg PO Q12H for
x`> "/>i
x
OR
U
i>ix}*"+vx`>
OR
U
ivì}*"+vx`>
OR
U
iv`}*"+vx`>
OR
U/*-8->L*"+v`>
OR
U6\
iv>}6+nv`>
V>i`\
U->ii}i>>LiiVi`>
q{`>
Denition
Positive urine culture 100,000 CFU/mL
with no signs or symptoms
Signs and symptoms (e.g. dysuria, urgency

frequency, suprapubic pain)
AND pyuria (>10 WBC/hpf )
AND positive urine culture 100,000
CFU/mL
UUncomplicated: female, no urologic
abnormalities, no stones, no catheter
UComplicated: male gender, possible
stones, urologic abnormalities, pregnancy
Category
Asymptomatic
bacteriuria
Acute cystitis
U1/i>i>`>Vìi`VV>i`
UTIs in men in the absence of obstructive pathology
(e.g. BPH, stones, strictures) are uncommon. Please
critically evaluate your diagnosis of UTI in male patients.
U">i>ivii`>``Li}ii
patient is unable to tolerate oral therapy
Uv6Li>>V>>iiìV>v`>]
additional therapy is needed for uncomplicated cystitis
Uv6Li>>V>>iiìV>v`>
or treating complicated cystitis, the patient can be
switched to an appropriate oral beta-lactam and duration
of IV therapy should be counted towards total duration
of therapy
U">vVV>Lii`vViLiv>
negative MDR organisms (susceptibilities must be
requested)
Notes
U"L>}iVi>>V>i
not recommended
ULV`ìVi>i>>VL>Vi>
prevent subsequent development of UTIs
U/ii>iViv>>VL>Vi>
}\xii>>i]
i>>i]{x}iV>i
iì>ì`>Lii
NOTE: Ciprooxacin is not recommended for empiric treatment for in-patients with non-catheter associated UTI at JHH due to the low rate of E. coli
ViL
Management of patients WITHOUT a urinary catheter
6.17 Urinary tract infections
111
Denition
Signs and symptoms (e.g. fever, ank pain)
AND pyuria
AND positive urine culture 100,000
CFU/mL
Many patients will have other evidence of
upper tract disease (i.e. leukocytosis,
WBC casts, or abnormalities upon imaging)
SIRS with urinary source of infection
Category
Acute
pyelonephritis
Urosepsis
Empiric treatment
U
iv>i}6+{
OR
U >ii}6+{vv -
OR
U*
>i}\i>}6+n",
U>\q{`>
Hospitalized > 48H
U
ivii}6+n
OR
U*
>i}\i>}6+n",
U>\q{`>
U
ivii}6+n
OR
U*
>i}\i>}6+n
U>\q`>
U">
y>V/*-8>iiVii
bioavailability and should be used as step-down therapy
if organism is susceptible
U">Li>>V>`Lii`vL>Vii>
due to inadequate blood concentrations
U>viV6i>`LiVi`
towards total duration of therapy
Notes
U">iì>`Lii`v}>
susceptible
U>viV6i>`LiVi`
towards total duration of therapy
">iì>v}>ViLi\
U
y>Vx}*"+v`>
U/*-8-*"+v`>
U
ivì{}*"+v{`>
U">vVV>LiVìi`vViLiv
Gram-negative MDR organisms (susceptibilities must be
requested). Consult ID Pharmacist for dosing.
DIAGNOSIS
Specimen collection\/ii>>i>`LiVi>i`>
antiseptic cloth and the urine sample should be collected midstream
or obtained by fresh catheterization. Specimens collected using
a drainage bag or taken from a collection hat are not reliable and
should not be sent.
Interpretation of the urinalysis (U/A) and urine culture
U1>>ìViLiiii`}ii
context of symptoms
UUrinalysis/microscopy:
UV
U i`V>iL>Vi>ii
UiViii>i`V>iiL`Viii
U >Vi>\iiVivL>Vi>>`Li
interpreted with caution and is not generally useful
U*>iii>iViii>i\7
v
>27 WBC/microliter
U1iVi\
Uv1i}>iv>]iVi>ii
contamination
U>i1/>i100,000 colonies of a
uropathogen. Situations in which lower colony counts may be
}wV>Vì\>i>i>i>`>LV>i
time of culture, symptomatic young women, suprapubic aspiration,
and men with pyuria.
TREATMENT NOTES
U*>iiii}vi}>iiVi>i
with asymptomatic bacteriuria usually requires no treatment. If
pyuria persists consider other causes (e.g. interstitial nephritis or
cystitis, fastidious organisms).
UiVi1>i>>i`v}}
symptoms. They should NOT be acquired routinely to monitor
response to therapy.
U-ii{v`Vvi>iv6, >ì>
concentrations of antibiotics.
112
Category
Asymptomatic
bacteriuria
Denition
Positive urine culture
100,000 CFU/mL
with no signs or
symptoms of infection
Empiric treatment
Remove the catheter
i>iii>i\
U*i}>
ULì}>}VViì
U*i>>>
"/ \L>}
U iiV
routine cultures in
Antibiotics do not decrease asymptomatic
asymptomatic patients bacteriuria or prevent subsequent development
is not recommended
of UTI
Signs and symptoms
CatheterU,iiV>iiiLi
associated UTI (fever with no other
Patient stable with no evidence of upper tract
source is the most
(CA-UTI)
ì>i\
V>i> UvV>iiii`]VìLi>>i
also have suprapubic
OR
or ank pain)
U >ii}6+{
AND pyuria (10
OR
WBC/hpf)
U
iv>i}6+{
AND positive urine
OR
culture 1,000
U
y>Vx}*" {}6+
CFU/mL (see
(avoid in pregnancy and in patients with prior
information below
exposure to quinolones)
regarding signicant
U>\iiLi
colony counts)
Patient severely ill, with evidence of upper tract
disease, or hospitalized {n\
U
ivii}6+n
OR
U*
>i}\i>}6+n
U>\iiLi
Urosepsis in a SIRS with urinary
U*i>V>L>V>x}6+
source and
patient with
If prior urine culture data are available, tailor
nephrostomy tubes
nephrostomy
therapy based on those results
tubes
DIAGNOSIS
-iViViV\ The urine sample should be drawn from the
catheter port using aseptic technique, NOT from the urine collection
bag. In patients with long term catheters ( 2 weeks), replace the
catheter before collecting a specimen. Urine should be collected before
antibiotics are started.
-\ Catheterized patients usually lack typical UTI symptoms.
-V>Li
1/Vì\
U ivii}iVi
U iiì]>>i]i>}iVi
U
6iìi]y>>]iV`Vv
UVii>>
Interpretation of the urinalysis (U/A) and urine culture
U*>\iiiViv>V>ii]>ìVi>i
the presence of symptomatic CA-UTI and must be interpreted based
on the clinical scenario. The absence of pyuria suggests an alternative
diagnosis.
U*iiVi\ 1,000 colonies
113
Management of patients WITH a urinary catheter
DURATION
The duration of treatment has not been well studied for CA-UTI and
optimal duration is not known.
U`>viv
Uq{`>vì>iìi
U`>vV>iiii`vi>i>i 65 years with lower
tract infection.
TREATMENT NOTES
U,iiiV>iiiiiLi
U,i>ViV>ii>>iLii 2 weeks if still indicated
U*>VV>LV>iivV>iii>i>Vii
are NOT recommended due to low incidence of complications and
concern for development of resistance.
U
>ii}>`Liiì
Treatment of Enterococci
U>E. faecalis isolates are susceptible to Amoxicillin 500 mg
PO TID OR Ampicillin 1 g IV Q6H and should be treated with these
>}i>i*
>i}\ v>>VL`)
}*"+` "/i>i
x
UE. faecium (often Vancomycin resistant)
U v>>VL`) 100 mg PO Q12H if susceptible (do NOT
use in patients with CrCl 50 mL/min).
U/i>VVix}*"+vViLi
UvV}*"Vivvi>iV>iiV>ii
ii`>iV>LvViL
Ui`}*" ",vV}*"iiq`>
(max 21 days) if complicated UTI or catheter can not be removed
Renal excretion/concentration of selected antibiotics
Good (60%): aminoglycosides, Amoxicillin, Amoxicillin/clavulanate,
Fosfomycin, Cefazolin, Cefepime, Cephelexin, Ciprooxacin,
Colistin, Ertapenem, Trimethoprim/sulfamethoxazole, Vancomycin,
Amphotericin B, Fluconazole, Flucytosine
Variable (30-60%):
ivì]i`]VVi
qxx]
iv>i]/i>VViH
Poor (<30%): Azithromycin, Clindamycin, Moxioxacin, Oxacillin,
Tigecycline, Micafungin, Posaconazole, Voriconazole
,iviiVi\
*>>`>V>ii\Vi`x\
IDSA Guidelines for treatment of uncomplicated acute bacterial cystitis and
iii\
viV\{x
-ìivi>iv
1/\
viVx\xq
114
Oropharyngeal disease (thrush)

Initial treatment
U
>i}Vixi>`>
OR
U >ix]x{i>`>
Recurrent or intractable disease
UV>iq}*"Vi`>
Duration: xq`>
NOTE: If refractory to Fluconazole consider fungal culture and
susceptibilities
Esophageal candidiasis
Initial treatment
UV>iq{}6*"Vi`>
Duration: {q`>
Relapse
UV>i{qn}6*"Vi`>
Refractory to Fluconazole 800 mg daily (fungal culture and
susceptibilities are recommended)
UV>v}x}6Vi`>
OR
UiV q}}6Vi`>
OR
U">i>\>V>i>}`>
Duration: {q`>
Candiduria
U1>V>iii>iiiV>``>{vV>i
TREATMENT
Asymptomatic cystitis
U/i>>`V>i`
U
ìiv}Vìii}iì
>VV\
U iiV>i
U,i>>>
U1>LV>L>1>V
U7iiViiì}VViì
115
6.18 Candidiasis in the non-neutropenic patient
Candidiasis in the non-neutropenic patient
Symptomatic cystitis
Preferred therapy
UV>i}6*"Vi`>
Duration:q{`>
Fluconazole-resistant organism suspected or conrmed
UiV }}6Vi`>
Duration:q`>
Pyelonephritis
NOTE: Candida pyelonephritis is usually secondary to hematogenous
spread except for patients with renal transplant or abnormalities of the
urogenital tract.
Preferred therapy
UV>iq{}6*"Vi`>
Duration: 14 days
Fluconazole-resistant organism suspected or conrmed
UiV xq}}6Vi`>
OR
UV>v}}6Vi`>
Duration: 14 days
TREATMENT NOTES
U,ii>V>iivLi
U/i>vV>``>iiiV]
1V>iii`
patient has not been shown to be benecial and promotes resistance.
U i, Voriconazole, Itraconazole, and Posaconazole are not
recommended due to poor penetration into the urinary tract.
UV>v}ii>iii]Lìii>i
renal tissue.
UiV L>`ì>i>iiViì`
Candida vaginitis
Initial Therapy
UV>ix}*"8ì
OR
UV>iVi>x}>>}>Vi`>8`>
Recurrent (> 4 episodes/year of symptomatic infection)
UV>ix}*"+8ì]ix}>ii8
6 months
116
U9 -/ ""
1/1, -"1 "/
" - ,
CONTAMINANT.
NOTE: Micafungin does not have activity against Cryptococcus
TREATMENT
Unspeciated candidemia
Patients who are clinically stable and have not received prior long-term
azole therapy
UV>in}6*"8ì]i{}6*"Vi`>
Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy
UV>v}}6Vi`>
If the yeast is C. albicans or C. glabrata based on PNA FISH results,
follow the recommendations for C. albicans or C. glabrata noted below.
Otherwise, await speciation before modifying therapy as recommended
below, unless the patient becomes clinically unstable on Fluconazole.
Candida albicans
UV>in}6*"8ì]i{}6*"Vi`>
Patients who are NOT clinically stable due to Candidemia or have
received prior long-term azole therapy
UV>v}}6Vi`>
Patients should be transitioned to Fluconazole once stable.
Candida glabrata
UV>v}}6Vi`>
OR
UV>in}6*"8ì]i{}6*"Vi`>
the isolate is susceptible with MIC 8 mcg/mL and the patient is stable.
If isolate is intermediate to Fluconazole and oral therapy is desired,
consult ID. Other azoles such as Voriconazole should not be used in
Fluconazole-resistant strains due to the same mechanism of resistance.
Candida krusei
UV>v}}6Vi`>
Fluconazole should NEVER be used to treat infections due to C. krusei
because the organism has intrinsic resistance to Fluconazole. This
iV>vi>Vi>i`6V>iiivi]
oral Voriconazole can be used if isolate is susceptible (for dosing see
Voriconazole specic guidelines, p. 19).
117
Candidemia
Candida lusitaniae
UV>in}6*"8ì]i{}6*"Vi`>
C. lusitaniaei>iV >>iv
cases.
Candida parapsilosis
UV>in}6*"8ì]i{}6*"Vi`>
Fluconazole-intermediate isolate
UV>in}6*"Vi`>
Fluconazole-resistant isolate
UV>v}}6Vi`>
If the patient is not responding to Micafungin then consider changing
to Amphotericin B. The minimum inhibitory concentrations (MICs) of
echinocandins are higher for C. parapsilosis than any other Candida
spp.>i`VVi>iviVC. parapsilosis
may not respond well to echinocandins.
Candida tropicalis
UV>in}6*"8ì]i{}6*"Vi`>
Fluconazole-intermediate isolate
UV>in}6*"Vi`>
Fluconazole-resistant isolate
UV>v}}6Vi`>
TREATMENT NOTES
Amphotericin B use in Candidemia
UiV }ivviVi>}>>Candida spp. except
for C. lusitaniaeii]>i>ìVV>`>iv>i`
susceptible strains over Amphotericin B products due to toxicity.
Doses for Candidemia
UiV }}6Vi`>
OR
U i 3 mg/kg IV once daily (if patient cannot tolerate
conventional Amphotericin B)
Duration
U{`>v}`Vii`Vi>>VivL`Vi>`VV>
symptoms
U*>iiiV>`ì>>ì>>VVV>
(e.g. endophthalmitis, endocarditis) need a longer duration of therapy
and evaluation by Ophthalmology and ID.
118
Hidden Content
Non-pharmacologic management
U,i>v>i}Vi>iV>ii}
recommended.
U*>i`>iL`Vi`>iii`>
candidemia is cleared.
U*>i`>i>>}Vi>>iVì
candidal endophthalmitis prior to discharge, preferably once the
candidemia is controlled.
U VV>`}>V>LiVìi`vi>i>ii
candidemia on appropriate therapy.
Endophthalmitis
U>>}iiVV">}
Ui
->ì>ii>]i>iiVV>`
is NOT recommended.
Preferred therapy
UiV }}6Vi`>Vix}}*"+
OR
U ix}}6Vi`>Vix}}*"+
Alternate therapy
UV>i{n}6*"Vi`>Vix}}
PO Q6H
Duration: {qii
Endocarditis
Consultation with ID and Cardiac Surgery is recommended. Surgical
valve replacement is considered a critical component for cure. If
the patient is not a candidate for surgery then life-long Fluconazole
suppression is likely required.
119
Preferred therapy
U ix}}6Vi`>
Alternative therapy
UV>v}x}6Vi`>V>i{qn}6*"
once daily
Duration: 6 weeks or longer
Notes on antifungal susceptibility testing
U-ViLi}vV>i]>V>i]6V>i]
Flucytosine, and Micafungin is performed routinely on the rst yeast
isolate recovered from blood.
UV>i>`V>v}ViL>iii`>>i
U"}>>>iV>v}
i>}ivqV}
(reported as susceptible) may not respond to treatment. ID consult is
recommended in these cases.
U-ViLi}vVi>iV ìi
for C. lusitaniae and C. guillermondii, and for other organisms by
request.
Uvi}>ii`>iV>i]in}6
PO once daily can be used. This choice is NOT recommended in an
immunocompromised patient, in a patient who is clinically unstable
due to candidemia, or in patients with endocarditis, meningitis or
endophthalmitis.
U-ViLi}`LiVìiì\
UVV>iV>``>iv>VV>i
U/i>}ii]i}]i`>
Fluconazole
U `Vi>iiiiV>i
U iViLi}V>Li>>}i`LV>}i
mycology lab at 5-6148
Notes on Fluconazole prophylaxis
UV>i>`Liiìv}i}
U*>iiiViì>iSICU or WICU for 72 hours
i>v-
1>`>i
ICUs has NOT been studied and is NOT recommended).
U iiV>iì}}Li>>>>
treatment for leukemia/lymphoma
U*>i>ivi>Vi>>>
UV>i>`Liiì-
17
1
patients are transferred to the oor
,iviiVi\
-ìiv/i>iv
>``>\
viV{n\xxx
V>i>}V>>i\-}\x{qn
120
iVwVViì>`>}iii*ii>i>LV
>`Vi>ìi`Vi}>
Drug
iv>
ivi>
Clindamycin
Ciprooxacin
Gentamicin
Metronidazole
6>VV
Usual dose
}\}
}\}
}\}
}\}
600 mg
400 mg
5 mg/kg
500 mg
}\}
}\x}
}\x}
Redosing during procedure

+{+vV>`>V}i
+{+vV>`>V}i
+
Q6H
None
None
None
+
Important notes
U/}VV>LVLiiii
incision is made to be effective.
U
i>V>Li>ìiìqx6Livi
the procedure and will achieve appropriate skin levels in minutes.
Vancomycin and Ciprooxacin must be given over 60 min. Clindamycin
`Liviìq
U>LV}ivii}6>VV]
Ciprooxacin) the infusion should start 30 minutes prior to incision
UPost-procedure doses are NOT needed (exceptions are noted
in table). Single doses pre-procedure have been as effective as
post-procedure doses in all studies.
U*>iiVi}ii>i>LV}ii>` "/ii`
additional antibiotics for endocarditis prophylaxis.
U*>v>i>i>`>LV\
U>LVi>6>VV\`>`}ì
1 hour before incision
U6>VV\,iì>vìvn>i>i`Vi
the last dose or a half dose if fewer than 8 hours have passed in
patient with normal renal function
Ui>V`Li}i>>}iìvx}}>i
tissue penetration and minimize toxicity.
Uv`>
]i}}
Uiì
U1i>V>Lì}i>iiì>L`
weight (see p. 145)
121
6.19 Guidelines for use of prophylactic antimicrobials
Pre-operative and pre-procedure antibiotic

prophylaxis
Procedure
Urologic surgery/procedures
Transrectal prostate biopsy1
Transurethral surgery (e.g. TURP, TURBT,
ureteroscopy, cystouretoscopy)
Lithotripsy
Nephrectomy or radical prostatectomy
Radical cystectomy, ileal conduit,
cystoprostatectomy or anterior exenteration
*iiiii
Cardiac surgery
Median sternotomy, heart transplant3
Median sternotomy, heart transplant with
previous VAD or MRSA colonization/infection3
Pacemaker or ICD insertion
Pacemaker or ICD insertion with MRSA
colonization/infection or generator exchange
VAD insertion
VAD insertion with MRSA colonization/infection
VAD insertion with open chest3
Lung transplant4
Vascular surgery
Carotid and brachiocephalic procedures
without prosthetic grafts
Upper extremity procedures with prosthetic
grafts and lower extremity procedures
L`>>>Viì}V
Prophylaxis
recommendations
PCN allergy
alternate prophylaxis
Cefazolin
Cefazolin
Ciprooxacin OR Gentamicin2
Gentamicin2
Gentamicin2
Clindamycin
Clindamycin PLUS
Gentamicin2
Q
iv>",6>VVRQ
`>V",6>VVR
PLUS Gentamicin2
PLUS Gentamicin2
Cefazolin
Cefazolin
Cefotetan
Cefazolin
Cefazolin PLUS
Vancomycin
Cefazolin
Cefazolin PLUS
Vancomycin
Cefazolin
Cefazolin PLUS
Vancomycin
Cefazolin PLUS
Vancomycin
Cefepime
Vancomycin PLUS
Ciprooxacin
Consult transplant ID
Prophylaxis not
recommended
Cefazolin
Prophylaxis not
recommended
Clindamycin OR Vancomycin
ivi>
6>VVi>V2
Thoracic surgery
Lobectomy, pneumonectomy, lung resection, Cefazolin
thoracotomy, VATS
Esophageal cases
Cefotetan
Neurosurgery
Craniotomy, cerebrospinal uid-shunting
procedures, implantation of intrathecal pumps
Laminectomy
Spinal fusion
Spinal fusion with MRSA colonization/infection
Vancomycin
Vancomycin
Vancomycin
Vancomycin
Vancomycin
Clindamycin
Clindamycin
Cefazolin
Clindamycin
Clindamycin
Vancomycin
Transsphenoidal procedures
Cefazolin
Cefazolin
Cefazolin PLUS
Vancomycin
Ceftriaxone
Orthopedic surgery
Clean operations involving hand, knee, or
foot, arthroscopy
Total joint replacement
Total joint replacement with MRSA
colonization/infection
Open reduction of fracture/internal xation
Lower limb amputation
Prophylaxis not
recommended
Cefazolin
Cefazolin PLUS
Vancomycin
Cefazolin
Cefotetan
Prophylaxis not
recommended
Vancomycin
Vancomycin
Spinal fusion
Cefazolin
Spinal fusion with MRSA colonization/infection Cefazolin PLUS
Vancomycin
Laminectomy
Cefazolin
122
Moxioxacin 400 mg
Clindamycin PLUS
Gentamicin2
Vancomycin
Clindamycin
Prophylaxis
recommendations
General surgery
*Viì}iivi
ivi>
GI tract, gastric bypass procedures,
pancreaticoduodenectomy, highly selective
vagotomy, Nissen fundoplication
>>VViìi}ViViV]
ivi>
choledochoenterostomy)
i>iV
ivi>
Whipple procedure or pancreatectomy
Cefotetan
Small bowel procedures
Cefotetan
*
Appendectomy (if complicated or perforated,
treat as secondary peritonitis)
Colorectal procedures, penetrating abdominal
trauma
Inguinal hernia repair
V>i`]ii}iii>}>
hernia repair
Mastectomy
iv>",
ivi>
Cefotetan
Cefotetan
Cefazolin
ivi>
PCN allergy
`>Vi>V2
`>Vi>V2
`>Vi>V2
Clindamycin PLUS
Ciprooxacin
Clindamycin PLUS
Gentamicin2
`>Vi>V2
Clindamycin PLUS
Gentamicin2
Clindamycin PLUS
Gentamicin2
Clindamycin
`>Vi>V2
Mastectomy with lymph node dissection
Prophylaxis not
recommended
Cefazolin
Prophylaxis not
recommended
Clindamycin PLUS
Gentamicin2
Gynecologic surgery
Cesarean delivery procedures
Cefazolin
Clindamycin PLUS
Gentamicin2
Clindamycin PLUS
Gentamicin2
Clindamycin PLUS
Gentamicin2
Clindamycin
Hysterectomy (vaginal or abdominal)
Cefazolin OR Cefotetan
Oncology procedures
Cefotetan
Repair of cystocele or rectocele
Cefazolin
Head and neck surgery

Parotidectomy, thyroidectomy, tonsillectomy
Prophylaxis not
recommended
Reconstructive procedure w/prosthesis
Cefazolin
placement
Adenoidectomy, rhinoplasty, tumor-debulking, Cefotetan OR Clindamycin
or mandibular fracture repair
Major neck dissection
Cefazolin
Plastic surgery
Clean with risk factors or clean-contaminated
Tissue expander insertion/implants/all aps
Rhinoplasty
Prophylaxis not
recommended
Clindamycin
Clindamycin
Clindamycin
Cefazolin
Cefazolin
No prophylaxis OR
Cefazolin
Clindamycin
Clindamycin
No prophylaxis OR
Clindamycin
Abdominal transplant surgery

Pancreas or pancreas/kidney transplant
Cefotetan
Renal transplant/adult live donor

Liver transplant4
Cefazolin
Cefotetan
Clindamycin PLUS
Ciprooxacin
Clindamycin
Clindamycin PLUS
Ciprooxacin
1viiV>Viiivi`\ii{
2Do
not give additional doses of Gentamicin post-op for prophylaxis

open chest, continue antibiotic prophylaxis until closure
recommendations are for patients with no relevant microbiology data that would suggest
i>}>>VVi}i`Li>i`L>i`VL}`>>
assistance of transplant ID (page in PING)
3For
4Listed
123
Procedure
Procedure
Prophylaxis
recommendations
PCN allergy
Interventional radiology procedures

>ViiL>
ivi>
`>V
percutaneous liver ablation (hx. of
PLUS Gentamicin
L>}ii>
cecostomy
iiL>wLì
*>
>iiL>iV>i
iViì`
ii>}I>L>>V>
vascular malformation embolization
Urologic procedure (not ablation)
Cefazolin
Gentamicin
Lymphangiogram/embolization
Cefazolin
Clindamycin
Placement of tunneled catheters
Prophylaxis not
i}Vi>ii>i>
iViì`
procedures.
Placement of implantable access
Cefazolin
Clindamycin
port (e.g. Mediport)
*Pre-treatment w/ antibiotics can be considered for patients w/ COPD or h/o recurrent post-obstructive
pneumonia
Lymphatic or patients w/ necrotic skin undergoing vascular graft should receive prophylaxis
w/Cefazolin
Prophylaxis for Prostate Biopsy Based on Rectal Screen Results
Pre-op prophylaxis regimen1
Post-op oral options2
Ciprooxacin
susceptible
Ciprooxacin 750 mg PO 2 hours

before procedure for any renal
vV
Ciprooxacin 500 mg PO once

12 hours after the procedure. If GFR
ii`vì
y>V
i>]/*-8
susceptible
/*-8-Livi
Viì]>`-
before
/*-8-*"Vi
>viiViìv,
ml/min no need for post-op dose.
Ciprooxacin and
/*-8i>]
Cefazolin susceptible
Cefazolin 2 g IV push (3-5 min)

>vViì
Cefpodoxime 100 mg PO once

OR
Cefdinir 300 mg PO once
Ciprooxacin,
/*-8]
Cefazolin resistant
Gentamicin 5 mg/kg IV once over
OR
Ceftriaxone 1 g IV over 30 min if
susceptible
No need for additional doses as

i>V>`
iv>ii>
therapeutic levels for 24 hours
Other resistance
Call ID Pharmacist
patterns
1 All doses are for any renal function 2 Post-op antibiotics are not required by SCIP
124
NOTES:
U*>i>iiVii`>LVv}V>>`
need additional prophylaxis for endocarditis.
Antibiotic prophylaxis solely to prevent endocarditis is not
recommended for GU or GI tract procedures.
Cardiac conditions associated with a high risk of endocarditis
for which prophylaxis is recommended prior to some dental and
respiratory tract procedures and procedures involving infected
skin or musculoskeletal tissue
U*iVV>`>V>i
U*iiìvviVii`V>`
U
}i>i>ì>i

U1i>i`V>V
]V`}>>i>`V`
U
iii>i`V}i>i>ìviViV
material or device, whether placed by surgery or by catheter
intervention, during the rst 6 months after the procedure
U,i>i`
i`>ìviV>ii>`>Vii
site of a prosthetic patch or prosthetic device
U
>`>V>>>iViìiV>`>V>>
Antibiotic prophylaxis is recommended for the following dental
procedures ONLY:
U>>v}}>ii>V>i}vii
U*iv>v>V>
Antibiotic prophylaxis is recommended for the following
respiratory tract procedures ONLY:
UVLvii>V>
Antibiotic regimens
UV}*"LiviViì
OR
U*
>i}\
`>V}*"LiviViì
OR
U*
>i}\Vx}*"LiviViì
OR
U*>i>Li>i>i`V>\V}6
before procedure OR Cefazolin 1 g IM/IV 5 minute push prior to
procedure
,iviiVi\
ìiv*iivviVi `V>`\
V>\qx{
125
Prophylaxis against bacterial endocarditis

solid organ transplants
NOTE:ì>i>i>vVì`wV>>Li`V>i`v
reduced CrCI.
Kidney, kidney-pancreas, pancreas transplants
Indication
Agent and dose
Duration
Anti-viral prophylaxis (CMV, HSV, VZV)

CMV D-/RAcyclovir 400 mg PO BID OR
Valacyclovir 500 mg PO BID
6,
6>}>VV 450 mg PO daily
6,
3 months
3 months
6 months
Anti-fungal prophylaxis
Kidney
Clotrimazole troches 10 mg PO QID OR
Nystatin suspension 500,000 units QID
Pancreas and kidney
Fluconazole 400 mg PO daily
1 month
1 month
PCP prophylaxis
i\/*-8i-->Li*"`>
-iVì\>ix}*"`>
/ì\>iI}*"`>",
aerosolized Pentamidine
Acute rejection treated with Thymoglobulin or Muromonab (OKT3)

3 months
3 months
6,
3 months
6,
Anti-fungal prophylaxis Clotrimazole troches 10 mg PO QID
1 month
PCP prophylaxis
i\/*-8i-->Li*"`>
-iVì\>ix}*"`>
/ì\>iI}*"`>",
aerosolized Pentamadine
Agent and dose
Duration
Liver transplants
Indication

6,
6,
6>}>VV 900 mg PO daily,
followed by PCR monitoring
Anti-fungal prophylaxis Fluconazole 400 mg PO daily
PCP prophylaxis
i\/*-8i-->Li*"`>
i>i\>ix}*"`>
or Dapsone 100 mg PO daily
126
3 months
3 months
6 months
6 weeks
Indication
Agent and dose
6,
>i-6}6<6}
positive. If positive serology, Valacyclovir
500 mg PO BID
6,
6,
Anti-fungal prophylaxis Nystatin suspension 500,000 units QID
PCP prophylaxis
Duration
3 months
6 months
Until
prednisone
dose 10
mg/d x 3
months
i\/*-8--i>Li*"`>",
/*-8i->Li*"iiiii
-iVì\>iI}*"`>
/ì\>ix}*"`>
Toxoplasmosis prophylaxis
i\/*-8i-->Li*"`>
/,
-iVì\>iI}*"`>PLUS
Pyrimethamine and Leucovorin
/
i\/*-8i-->Li*"`>
`>
-iVì\>iI}*"`>PLUS Lifelong
Pyrimethamine and Leucovorin
Lung transplants
Indication
Agent and dose
Duration
Anti-viral prophylaxis
CMV D-/RReceived
non-leukoreduced
or CMV unscreened
PRBCs
Ganciclovir 5 mg/kg IV Q12H x

14 days, then Ganciclovir 5 mg/kg IV
Q24H x 16 days, then Valacyclovir 500 mg
PO BID or Acyclovir 800 mg PO TID x 1 year
followed by Acyclovir 200 mg PO TID
Lifelong
CMV D-/RReceived leukoreduced

or CMV() PRBCs
Valacyclovir 500 mg PO BID or Acyclovir

Lifelong
800 mg PO TID x 1 year followed by Acyclovir
200 mg PO TID
6,
>VVx}}6+{`>]i vi}
Valganciclovir 900 mg PO daily x 3 months
(until CMV shell vial negative from 3 month
surveillance bronchoscopy), then Valacyclovir
500 mg po BID or Acyclovir 800 mg PO TID x
1 year, then Acyclovir 200 mg PO TID lifelong.
6,
>VVx}}6+{`>]i vi}
Ganciclovir 5 mg/kg IV daily x 3 months, then
Valganciclovir 900 mg PO daily (until CMV shell
127
Heart transplants
vial negative from 6 month surveillance BAL),

then Valacyclovir 500 mg PO BID or Acyclovir
800 mg PO TID x 1 year, then Acyclovir 200 mg
PO TID lifelong.
Anti-fungal prophylaxis
No Aspergillus
Inhaled Amphotericin B per protocol
colonization
AspergillusV>
PCP prophylaxis
>x] +
extubated, then Clotrimazole troches
10 mg PO Q6H until prednisone dose
10 mg daily
6V>iì`Li}
}\6V>i}*"
69 kg to {}\6V>i
300 mg PO BID
{}\6V>i{}*"
i\/*-8i->Li*"
iiiii",/*-8i
SS tablet PO daily
-iVì\>iI}*"`>
/ì\>ix}*"`>
During initial
hospitalization
stay
q
vi}
r`],riVi]qrii}>i]rii
NOTES:
/*-8i>i`VivviVListeria spp., Nocardia spp., and
Toxoplasmosis, but does not eliminate risk.
For splenectomized patients, antibacterial prophylaxis with Amoxicillin 500 mg PO BID
(or Doxycycline if PCN allergy) is recommended for 1 year.
*Recommended screening for G6PD deciency prior to initiation of Dapsone.
If Valgancylovir is stopped prior to recommended duration of therapy due to intolerance,
recommend initiation of Acylovir or Valacyclovir for antiviral prophylaxis.
/*q
128
NOTE: These guidelines were developed for use in BMT and leukemia
patients and may not be fully applicable in other instances.
Denitions
U ii>\
x3
Uii\/inc
i>i>>>",
Temp > 38.3 C times one
TREATMENT
Always tailor antibiotics based on susceptibility proles
vi>iiiii>Li]ii/i>iv
VV>>Li>ii
Initial fever
U
ivii}6+n6>VVIii`}iVx
OR
U*i>V>L>V>x}6+{6>VVIii`}
section p. 150)
I`V>v6>VV\iVi`
, -]>`viviV]
pneumonia, severe oral or pharyngeal mucositis, history of MRSA infection or
colonization.
OR
U-iii*
>i}>>>-ii-ì\
Strongly consider allergy consult to verify allergy in patients with
unclear histories (see section on Penicillin allergy, p. 137)
Ui>}6+nPLUS Gentamicin (see dosing section, p. 146)
PLUS Vancomycin (see dosing section, p. 150)
If strong concern for nephrotoxicity and no prior uoroquinolone use, can substitute
Ciprooxacin 400 mg IV Q8H for Gentamicin.
Step-down therapy for discharge

UCiprooxacin 750 mg PO BID PLUS Amoxicillin/clavulanate 875 mg
PO BID
OR
Uy>V{}*"`>
129
6.20 Guidelines for use of antimicrobials in neutropenic hosts
Neutropenic fever
Persistent fever or new fever after 4-7 days in clinically

stable patients without established bacterial infection
U
i>LV>Li>`>v}>Vi>}i
viVi}V>i>v}>>\
UV>v}}6+{v>`Vi
/}}ii
of fungal infection
OR
U6V>i}}6*"+iìi{}}6
PO Q12H if chest CT suggestive of fungal infection
If receiving Voriconazole or Posaconazole prophylaxis or sinus CT
}}iivv}>viV\
U ix}}6+{
Clinically unstable patient and/or persistent fever despite
appropriate antibacterial and antifungal coverage
U
"V}/>>
U6>VVii`}iV]xPLUS Meropenem 1 g IV
+n>Vv>i>Liii`}iV{
OR
U-iii*
>i}\
"V}/>>
130
NOTE:ì>i>i>vVì`wV>>Li`V>i`v
reduced CrCI.
1. Leukemia patients
Indication
Agent and dose
Duration
Antibacterial prophylaxis
Moxioxacin 400 mg PO daily PLUS

Amoxicillin 500 mg PO TID (start on day 5)
Day 1 until
ANC
100/mm3 OR
initiation of
ii
antibiotics
v}>>
i\6V>iii`} /iV
-iVì\*>V>ii}
PO TID OR 300 mg tablet daily
i>i\V>v}}6+{",
>

100/mm3

Antiviral prophylaxis
*
*>
in high risk patients
Valacyclovir 500 mg PO BID OR Acyclovir

800 mg PO BID
v}`>i>\VVx}2
IV Q12H
Day 1 until
ANC
100/mm3
i\/*-8i-->L*"`>
-iVì\>i}*"`>
/ì\>ix}*"
>
i
resolves
2. Lymphoma, myeloma patients
Indication
Agent and dose
Duration
Antibacterial prophylaxis
(lymphoma only)
Moxioxacin 400 mg PO daily
Antifungal prophylaxis
Day 7 of
chemo until
ANC
500/mm3
Day 1
through all
cycles of
chemotherapy in
high risk
patients.
Valacyclovir 500 mg PO BID OR Acyclovir

800 mg PO BID
v}`>i>\VVx}2
IV Q12H
Day 7 through
all cycles of
chemotherapy
i\/*-8i-->L*"`>
-iVì\>i}*"`>
/ì\>ix}*"
>}
>VViv
Vi
therapy
*
*>
in high risk patients
131

expected prolonged neutropenia
3. Bone marrow transplant patients/peripheral blood stem cell transplant patients
Indication
Agent and dose
Duration
Antibacterial prophylaxis*
Moxioxacin 400 mg PO daily
Day zero until

engraftment
Antifungal prophylaxis
Day zero until

ANC
500/mm3
v}>>
patients with GVHD
i\*>V>ii}*"
TID OR 300 mg tablets daily
-iVì\6V>iì`Li}
69 kg Voriconazole 200 mg PO BID
69 kg to 94 kg Voriconazole 300 mg PO BID
94 kg Voriconazole 400 mg PO BID
Valacyclovir 500 mg PO BID OR

Acyclovir 800 mg PO BID
v}`>i>\VVx}2
IV Q12H
Day zero
until 1 yr
(allogeneic
transplants)
or 6 months
(autologous
transplants)
i\/*-8i-->L*"`>
-iVì\/*-8->Liii
OR Dapsone 100 mg PO daily
/ì\>ix}*"
i\*i>ì} +n`>
}iiV
>>\
Day 21 or
i}>vi
Vii
is later)
until at least
1 year
(longer if
steroids or
ongoing risk)
Autologous
>>\
Engraftment
until 6 months
PCP prophylaxis
NOTES:
/*-8i>i`VivviViV>>i`L>Vi>]Listeria spp., Nocardia
spp., and Toxoplasmosis, but does not eliminate risk. It is the preferred antibiotic regimen for
PCP prophylaxis.
*In patients with uoroquinolone allergy or who cannot tolerate a uoroquinolone due to QTc
prolongation, consider Cefpodoxime 400 mg PO BID.
Acyclovir should be dosed by ideal body weight
i>>ivi`>>iv6]VVi`]y`>>Li
ii>>i\]VVi`] /i>>vi>>]>i
received cladribine, udarabine, or alemtuzumab.
"i>>Vi6\y>V]/*-8
132
Filamentous fungi
ID consult recommended for assistance with antifungal selection
TREATMENT
Aspergillus spp.
Initial therapy
U6V>i}}6*"+iìi{}}6
PO Q12H (see Voriconazole guidelines, p. 19, for more information).
OR
U i 5 mg/kg IV Q24H
NOTES:
U6V>iVìi`L>Liiwii>iv
suspected lamentous fungal infections in the immunocompromised
host as most of these infections are caused by Aspergillus species.
Although the data are limited, Voriconazole appears more effective
than Amphotericin for this very serious infection.
U
L>>v}>i>V}v6V>iPLUS
Micafungin should be considered for the treatment of conrmed
invasive aspergillosis that is documented by culture, positive
galuctomannan assay, or histopathology for the rst two weeks
of therapy. Longer duration of combination therapy has not been
evaluated.
Fusarium spp.
UV`LiiìiV>i
U6V>i}}6*"+iìi{}}
IV/PO Q12H PLUS Ambisome 5 mg/kg IV Q24H (see Voriconazole
guidelines, p. 19, for more information). Dose escalation may be
necessary for some patients.
Scedosporium apiospermum
U6V>i}}6*"+iìi{}}
IV/PO Q12H PLUS Micafungin 100 mg IV Q24H (see Voriconazole
guidelines, p. 19, for more information).
NOTE:
U/i>ii>}i>iì``>}i
Voriconazole appears to be the best option but the data are limited.
133
Guidelines for the use of antifungal agents in

hematologic malignancy patients
Zygomycoses (Mucor, Rhizopus, Cunninghamella, etc.).

U i 5 mg/kg IV once daily PLUS a second antifungal agent
UVii`
U-}V>ìLìi>`ViVvì}v>Vi}
acidosis, hyperglycemia) are critical.
Candida
TREATMENT
U9 -/ ""
1/1, -"1 6 ,
" - ,
CONTAMINANT.
U-iiiVLiiVi>>`>}iiVwV
therapy.
Unspeciated candidemia
UV>v}}6+{
OR
U i 5 mg/kg IV Q24H
If the yeast is C. albicans or C. glabrata, the recommendations for C.
albicans noted below can be followed. If the yeast is not C. albicans,
await speciation before modifying therapy as recommended below.
NOTE: Micafungin does not cover Cryptococcus
Candida albicans
UV>v}}6+{
OR
U iqx}}6+{
NOTE: Patients who are clinically stable and no longer neutropenic can
be switched to Fluconazole if the organism is susceptible.
Candida glabrata
UV>v}}6+{
OR
U i 5 mg/kg IV Q24H
Candida krusei
UV>v}}6+{
OR
U i 5 mg/kg IV Q24H
134
Candida parapsilosis
U iqx}}6+{
NOTES:
UC. parapsilosis isolates remain susceptible to Fluconazole, which
can be used in stable and non-neutropenic patients.
U/ii>ii``>>>}}i>V>v}>Livi
Amphotericin B in these infections.
Candida tropicalis
UV>v}}6+{
OR
U iqx}}6+{
TREATMENT NOTES
Hidden Content
Notes on antifungal susceptibility testing

U-ViLi}vV>i]>V>i]6V>i]
Flucytosine (5-FC), and Micafungin is performed routinely on the rst
yeast isolate recovered from blood.
135

A
NOTE: C. krusei is intrinsically resistant to Fluconazole and these

infections can be difcult to treat. In stable patients, Voriconazole can be
used if susceptible and oral therapy is desired. (See p. 19 for dosing).
A
UV>i>`V>v}ViLi>iii`>L`
isolates.
U"}>>>iV>v}
i>}ivqV}
(reported as susceptible) may not respond to treatment. ID consult is
recommended in these cases.
USusceptibility testing for conventional Amphotericin B is done routinely
for C. lusitaniae and C. guillemondii and for other organisms by
request.
U-ViLi}`LiVìiì\
UVV>iV>``>iv>VV>i
U/i>}ii]i}]i`>
Fluconazole
U `Vi>iiiiV>i
U iViLi}V>Li>>}i`LV>}i
mycology lab at 5-6148
,iviiVi\
-ìiv/i>iv
>``>\
viV{n\x
136
Penicillin reactions Incidence

Unv>iii>i>i}V*
>V>>i
negative skin tests and are not at increased risk of an allergic reaction.
U*iVi>VviiVVv>>i
who get the drug.
U 1/\/iVìViv>>>VVi>V{x
U,>ivVi>V>i}iVi>>iL
thought to be low.
U,>iv*
>`V>L>iiiVi>V>i{]
although clinical rates of hypersensitivity reactions in patients with
ii`*
>i}iViiV>L>ii>iq
U
i>VL>V>i>` "/>i>VV
Penicillin skin testing
U7iìViV]}i`Vivi]>>>VVi>V
U*>i>i}>ii>iNOT at risk for anaphylactic reactions.
U,>i]ii}>i>i>}iì>`V}
following penicillin administration but these RESOLVE with continued
treatment.
U-iV>i`Vì>}Vi>V`}vii
U-i}>>>Li>*i>iVi}>`
Immunology.
Penicillin reactionsTypes
UImmediateiq>>]i]>}i>iì>]
wheezing, angioedema, urticaria
U>>VVwithin 1 hour of administration. Hypotension
always occurs soon after administration
U
>Lii`Vi`Li
UAcceleratedq>}i>iì>]ii}]>}iì>]V>>
(NOT hypotension)
U"VVv>`>
U
>Lii`Vi`Li
ULateq,>>V>>LvV>Vì>]
destruction of RBC, WBC, platelets, serum sickness
U>>VV>viv>`>
U,>iii}>>ìiViì>i
U>V>>>`Lv>i" "/}i
Stevens-Johnson syndrome
U>ii>V>i "/i`Vi`Li
UStevens-Johnson Syndromeqiv>iì>V
membrane involvement
137
7.1 Approach to the patient with a history of penicillin allergy
Approach to the patient with a history

of penicillin allergy
7.1 Approach to the patient with a history of penicillin allergy
U>>VV>viv>`>
U "/i`Vi`L>v>",Li
Approach to the patient with reported penicillin allergy
U iv]vVi`V>Li6 ,9iv
U+i>\
1. How long after beginning penicillin did the reaction occur?
2. Was there any wheezing, throat or mouth swelling, urticaria?
3. If a rash occurred, what was the nature of the rash? Where was it
and what did it look like?
4. Was the patient on other medications at the time of the reaction?
5. Since then, has the patient ever received another penicillin or
Vi>>>L>ì>ii\}i]iyi]
Trimox, Ceftin, Vantin)?
6. If the patient received a beta-lactam, what happened?
Interpreting the history of the patient reporting penicillin allergy
UANY patient who has a history consistent with an immediate
reaction (laryngeal edema, wheezing, angioedema, urticaria)
SHOULD NOT receive beta-lactams without undergoing skin
testing rst EVEN IF they have received beta-lactams with no
problems after the serious reaction.
U*>ii>>>VVi>V>`>iiVii`
other penicillins without problems DO NOT have penicillin allergy
and are not at increased risk for an allergic reaction compared to
the general population.
U*>ii>>>VVi>V>`>iiVii`
cephalosporins can get cephalosporins but not necessarily PCNs.
U*>ii>v>V>>>> "/
consistent with Stevens-Johnson syndrome (target lesions with
mucous membrane inammation) and developed after 72 hours
of penicillin are not at increased risk for an adverse reaction. They
should, however, be watched closely for development of rashes.
U*>iii>VViiVi
(rare) can receive either penicillins or cephalosporins with careful
monitoring for recurrence.
U*>ii`>i>]>i>L>L`
not have penicillin allergy and do not appear to be at increased
risk for an adverse reaction. They should be closely observed for
recurrent symptoms and be given supportive therapy if they occur.
,iviiVi\
nx\{n
1ivV>L>ii>i*
>i}\VL
ii{x{\
xxq
ii`{\q
138
U
i
iLiVii*"
hopkinsmedicine.org/heic) for detailed isolation charts, HEIC policies,
and surveillance information
Hand hygiene
Uv>`>iLi`]i>VL>i`>`>i>i
recommended for cleaning. If hands are visibly soiled, wash hands
with soap and water for at least 15 seconds.
U>`}iiiiìi}>>i]i}]
between patients in a semi-private room, and other times per hospital
policy.
U1i>>`>iexiting the room of a patient with
C. difcile infection.
U >wV>w}i>>iii`v>>vviLi>
patient contact or handles sterile supplies.
Bloodborne pathogen exposures (needlestick or other exposure)
The prompt treatment of injuries and exposures is vital to prevent the
transmission of disease. Whatever the exposure, IMMEDIATE cleaning of
the exposure site is the rst priority.
U-``LiVi>i`>>`>i
UViL>i`Liyi`}>i
U i`Li}>i`>iv>>i
viVi>}iiii]V>x-/8xn{>`v
instructions to contact the ID physician. Workplace injuries should be
iiì`>ii ii,ivVì>`
to the Occupational Injury Clinic >V]`>q`>]\
a.m. to 4 p.m., 5-6433), and to your supervisor.
Standard Precautions
U,i>`}ii
U
i>`ViV}ii
U >}V>>iì>vi
U,i}>Vi>}vii>
surfaces
U>iiv}ii U,iVi>}`>v
contamination of uniform/clothing
patient-care equipment
U>iiv>]ii
U-V>ìiVi
protection and face shields (i.e., when
occupational safety requirements
suctioning, or when splash likely)
139
8.1 Hospital Epidemiology & Infection Control

A
Hospital Epidemiology and Infection Control

(HEIC)
8.1 Hospital Epidemiology & Infection Control

A
Communicable diseasesexposures and reporting

`Liwi`\
Uv>i
7>iii`>VV>Liì>ii
meningococcal disease, varicella, TB etc.)
UL
7>Vii>]
]->i>]-}i>]
Campylobacter, or pneumonia requiring hospital admission
UL>>VViVivì>iVi]>V>
diseases that have the potential to expose many susceptible
individuals
U-V`>}iviv}ì>iì>i
require immediate notication by phone or pager). If disease is
in a HCW, notify HEIC and Occupational Health (98 N. Broadway,
-i{]`>q`>]\>{\]x
immediately
Anthrax
Avian Inuenza
Botulism
Brucellosis
Creutzfeldt-Jakob disease (CJD)
Diphtheria
Glanders
Highly resistant organisms (i.e. VISA,
VRSA)
Legionellosis
Measles (rubeola)
Meningococcal disease
Monkeypox
Mumps
Pertussis
Plague
Poliomyelitis
Q Fever
Rabies
Ricin toxin
Rubella (German measles)
Salmonellosis
SARS
Scabies
Shigellosis
Smallpox (orthopox viruses)
Streptococcal Group A or B invasive
disease
Tuberculosis
Tularemia
Varicella (chickenpox or disseminated
zoster)
Viral hemorrhagic fever
Yellow Fever
Physicians are required to report communicable disease to the

>i
i>i>i{{{]v>\{xnn
For a complete list of communicable diseases, see the HEIC Web site,
i7iLi]\ì>`>>`}-i*>}i>
to-report.aspx or the BCHD Web site, www.baltimorehealth.org/acd.
html.
140
141
To enter room
MRSA, C.diff, zoster
Door closed
Mask/Eye Protection
Gown and Gloves

Examples
Droplet
Precautions
(orange)
Required unless
cohorted*
No
If within 6 feet
of patient
To enter room
Inuenza, bacterial
meningitis
Yes
PAPR or N95 to
enter room
No
TB, disseminated
zoster
Airborne
Precautions
(blue)
Required
8.2 Infection control precautions
* Required for pertussis and diphtheria

Fit-testing is required to use an N95 mask for airborne precautions
HCWs who are Varicella-immune do not have to wear a PAPR or N95 if patient is in isolation for zoster or chickenpox
Disseminated zoster, zoster in an immunocompromised host, and chickenpox require both Contact and Airborne Precautions
(sign color)
Private room
Contact
Precautions
(pink)
Required unless
cohorted
No
No
JHH Precautions Categories

These precaution categories must be used in addition to Standard Precautions. The following table includes general requirements for precaution
categories. The complete table and the type of isolation required for each organism can be found on the HEIC website. If recommendations on this table
cannot be followed, please contact HEIC.
8.3 Disease-specic infection control recommendations
Disease-specic infection control

recommendations
Carbapenem-resistant Enterobacteriaceae (CRE)
Routine active surveillance cultures for CRE are performed in patients
who have been hospitalized in a country other than the U.S. in the past
6 months. Patients are placed on Contact Precautions pending cullture
results. The results are to be used for isolation purposes, not to guide
therapy or clinical care. The overwhelming majority of positive
surveillance cultures represents colonization, not infection, and
should not prompt any antimicrobial therapy.
Creutzfeldt-Jakob disease (CJD)
CJD, variant CJD and other diseases caused by prions are resistant to a
number of standard sterilization and disinfection procedures. Iatrogenic
transmission of CJD has been associated with percutaneous exposure
to medical instruments contaminated with prion/central nervous system
(CNS) tissue residues, transplantation of CNS and corneal tissues and
recipients of human growth hormone and gonadotropin. Transmission of
CJD has not been associated with environmental contamination or from
person-to-person via skin contact. The following additional precautions
must be made when processing equipment that could be contaminated
i>i`>i>\
U v
>ì>>}iV>}iii`>iv>
suspected or conrmed CJD case and refer to the CJD policy on the
HEIC Web site.
U1i`>LiiiiiiLiv`>Li
equipment is used, Central Sterile Department shall be notied prior to
the start of the procedure.
U>Li>>L>>`>}i>iVi`
>`
notify the lab before sending specimens.
U/iv}>iVìi`}viVi>``Li>ì`
iiiV>\L>]>V`]Vi>`>
gland
U/iv}>iVìi`LiviviV\
-]ì]
liver, lung, lymph nodes, spleen, placenta, tonsillar tissue and olfactory
tissue.
Methicillin-resistant Staphylococcus aureus (MRSA)
Routine active surveillance cultures for MRSA are performed on select
units to identify patients with MRSA. When a culture is positive for
MRSA the patient is placed on Contact Precautions. The results are
to be used for isolation purposes, not to guide therapy or clinical care.
The overwhelming majority of positive surveillance cultures
142
Surveillance cultures should be obtained upon admission and weekly

iv}\
1]7
1]
6-
1]-
1]
/17]
1]
CCU/PCCU, PICU, NICU, oncology units, Nelson 4.
To remove a patient from MRSA precautions, cultures from the original
site of infection and 2 nares cultures taken 72 hours apart must be
negative. Nares cultures should not be sent if the patient has received
antibiotics active against MRSA in the previous 48 hours. Once this is
accomplished, call HEIC to review culture data and initiate deagging.
Pertussis
All patients with pertussis should be placed on Droplet Precautions
for ve days from the start of therapy. If the patient is not on therapy,
Droplet Precautions should be continued for three weeks from the onset
of cough. Private room is required.
/i>i\
UVx}*"Vi`>]ix}*"`>
`>qx
OR
U>Vì>i}\/*-8->Li*" v{`>
Prophylaxis with the above regimens is required for all household
contacts within three weeks of exposure. Use the same antibiotic as
for treatment. All household contacts and HCWs with exposure to
the patient should also have up-to-date immunizations for Bordetella
pertussis.
Scabies
All patients with conventional or Norwegian scabies should be placed on
Contact Precautions. Norwegian scabies is a severe form of heavy
mite infestation.
U*>iii`
U*>iVi>V>LiLii>i`>V>LVì
once, and the precautions may be discontinued 24 hours after the
treatment is completed.
U*>i i}>V>Liiii>i>V>LVì
1 week apart. Contact precautions may be discontinued 24 hours
after the second treatment is completed.
Uvii`V}>ì`Lii>i`>>VL>}v{n
hours. The mite will not survive off a human host for more than 48
hours. Clothing/patient belongings should be sent home with the
patients family/caretaker. Linens and clothing should be washed in
the washing machine on the hot cycle.
143
represents colonization, not infection, and should not prompt

any antimicrobial therapy.
Uv}i`V>VVV>V>Li>i]
prophylactic treatment is required. Healthcare workers should contact
HEIC if an exposure is suspected.
Vancomycin-resistant enterocci (VRE)
Routine active surveillance cultures for VRE are performed on select
units to identify patients with VRE. Surveillance culture results are found
iiiVV>iiVìi>i >Vi}-
6, --
7i>Vi}6, ]i>iy>}}i`
for Contact Precautions. The results are to be used for isolation
purposes, not to guide therapy or clinical care. The overwhelming
majority of positive surveillance cultures represents colonization,
not infection, and should not prompt any antimicrobial therapy.
Surveillance cultures should be obtained upon admission and weekly
iv}\
1]7
1]
6-
1]-
1]
/17] />`
Leukemia units, NCCU, PICU.
The patient must be off antibiotics for 48 hours and cultures from
original site of infection AND 3 stool or perirectal cultures taken 1
week apart must be negative. Once this is accomplished, call HEIC to
review culture data and initiate deagging.
Varicella-Zoster
Immunocompetent patients with disseminated zoster and all
immunosuppressed patients with zoster need Contact AND Airborne
Precautions/iv}ìw>>ii\
UImmunosuppressed:Li>>>i>i>
>Viii>`}>>>iVi>iiVi}
cytotoxic or immunosuppressive treatments, including steroid
treatment for `>iv}ì\ì>i>i
3 mg daily, cortisone 100 mg daily, hydrocortisone 80 mg daily,
iì}`>]iiì}`>6>i
with CD4 < 200
UDisseminated: lesions outside of 2 contiguous dermatomes
144
Aminoglycoside dosing weight:

Calculate Ideal Body Weight (IBW)
IBW female (kg)r(2.3 x inches over 5)45.5
IBW male (kg) r (2.3 x inches over 5)50
For patients < 20% over IBW, use Actual Body Weight
(ABW)
For patients 20% over IBW, use Dosing Body Weight
(DBW)
7rQ 7{ 7q 7R
Estimation of creatinine clearance (CrCl) by Cockcroft-Gault
equation:
(If a patients renal function is declining, this equation may overestimate CrCl)
r {q>}ii}}I x 0.85 (if female)

72 (serum creatinine)
* Use Actual Body Weight (ABW) unless patient i 7]i 7>ìVLi`

above
Extended-interval dosing, also sometimes referred to as oncedaily administration, utilizes higher dose and less frequent
aminoglycoside administration, whereas patient-specic dosing,
previous referred to as traditional dosing, typically utilizes smaller
doses with more frequent administration. See table below for dosing
recommendation based on indication and patients renal function. For
mycobacterial infections, urinary tract infections, SICU/WICU
protocol and gram-positive synergy (e.g. endocarditis), please
see separate sections below. For cystic brosis patients, see the
Cystic Fibrosis section (p.92)
145
A. Aminoglycoside dosing and monitoring

A
Aminoglycoside dosing and monitoring

Aminoglycosides enhance the efcacy of some antibiotics. Except for
urinary tract infections, aminoglycosides should seldom be used alone
to treat infections.

A
Aminoglycoside dosing for Gram-negative

infections
Indications
Dosing
Patient-specic dosing
,i>v>i]
66]i`V>`]
Gram-negative infections (in combination with
beta-lactams), CNS infections, septic shock,
burn patients, patients with altered volume
status (e.g. ascites, anasarca, trauma)

i}rìiì>Q7i}}6`
}R
Uiiì>\ choose from below

U7i}\ ABW or DBW
UVolume of distribution (Vd) typically ranges
Liiixqx}>i
Higher Vd should be used in critically ill and
volume overloaded
patients.
}i>L>i`
\+nI
\+
66\ìLii
Extended-interval dosing
U >i>vV
>60 mL/min) and all other

indications not listed under
patient specic dosing
i>V/L>V\
x}}6+{
>V\
15-20 mg/kg IV Q24H
*If targeting high peaks, use maintenance dose

frequency of Q12-24H.
Desired
Peaks and
Troughs
Peak
Pneumonia
Septic shock
Endocarditis
Osteomyelitis
MDR
organisms
Trough
Gentamicin/
Tobramycin
10 mcg/mL
Amikacin
8-10 mcg/mL
20-30 mcg/mL
25-35 mcg/mL
This dosing strategy is designed

>}iiv}\
Peak
i>V/L>V\
mcg/mL
>V\{V}
Trough
i>V/L>V\
V}
>V\{V}
10-20 mcg/mL 45-50 mcg/mL

L>i`
L>i`
Gentamicin/ Amikacin
Tobramycin
All Indications V} V}
Therapeutic Trough: draw 30 minutes prior to the 3rd dose If the patient meets ANY of the
Drug
criteria below, a trough level
Monitoring Peak: obtain 1 hour after end of infusion, after is recommended prior to the
the 3rd dose.
`ì\
U
V>iV
Frequency of monitoring
medications
U"Vi>ii>viìiì>}
U
>ii
established in patients with normal renal
U}i 60 years
function
U*>ii
1
Ui>Viii\
U"iviV
After changes in dosing regimen
i}`>Lii]ì/8
Patient is on dialysis
If trough higher than desired
Patient in acute renal failure, SCr increased troughs, use patient specic
Lx}`vL>ii
dosing to adjust dose.
Major changes in the patients volume status
146
Amikacin is the preferred agent to treat all mycobacterial infections,

except Mycobacterium chelonae. For M. chelonae infections,
Tobramycin is the recommended aminoglycoside. Streptomycin
is another aminoglycoside sometimes used to treat mycobacterial
infections such as M. tuberculosis. Please contact the Antimicrobial
Stewardship Program pharmacist for Tobramycin/Streptomycin dosing
recommendation for this indication.
Amikacin:
>i>vV\
"Vi`>\x}}6+{}}6+{vxi>v
age)
/Viii\x}}6iii>ii>Lii`vwV
to tolerate)
L>i>vV\ Discuss with pharmacy clinical specialist
Therapeutic drug monitoring: Peak and trough not generally
iVi>]iViii>vwViV,
>`v-
Vi>iLx}`vL>iii>i
on aminoglycoside therapy. Check a trough concentration to monitor for
toxicity. Peaks in the low 20 mcg/mL range are acceptable, and trough
VVi>>iivi>L{VìiV>Li
Aminoglycoside dosing in urinary tract infections

CrCl (mL/min)
60
40-59
20-39
Gentamicin/Tobramycin
3 mg/kg IV Q24H or
1 mg/kg IV Q8H
1 mg/kg Q12H
1 mg/kg Q24H
}}"
I
Amikacin
10 mg/kg IV Q24H or
3 mg/kg IV Q8H
3 mg/kg IV Q12H
3 mg/kg IV Q24H
}}6"
I
*Give one dose, check level in 24 hours, redose when Gentamicin/Tobramycin level
V}>V{V}
}Vì>i}VVi>iìiivi]i>iV
drug monitoring is not necessary in patients with normal renal function.
Suggested doses in the above table will likely provide adequate urine
concentrations for highly susceptible organisms. Trough should be
checked to monitor for toxicity in patients with renal insufciency
,>`v-
Vi>iLx}`v
baseline while patient on aminoglycoside therapy.
UGentamicin/Tobramycin:ìi`}V}ìiV>Li
UAmikacin:ìi`}{V}ìiV>Li
147

A
Aminoglycoside dosing in mycobacterial

infections

A
Aminoglycoside dosing in the SICU/WICU

Gentamicin/Tobramycin
Loading dose 4 mg/kg using actual body weight, followed by a
patient-specic maintenance dose.
Amikacin
Loading dose 16 mg/kg using actual body weight, followed by a
patient-specic maintenance dose.
Therapeutic Drug Monitoring
vi>`}ì\i>>`nii>viii`vi
infusion to facilitate calculating patient specic kinetic parameters.
Aminoglycoside dosing for Gram-positive synergy

Dosing for patients with normal renal function:
UGentamicin\}}6Vi`>iViì`vi>i
of endocarditis with Viridans streptococci or S. bovis in patients with
normal renal function (CrCl 60 ml/min).
UGentamicin: 1 mg/kg IV Q8H is recommended for treatment
Enterococcal and other Gram-positive endocarditis infections in
patients with normal renal function (CrCl 60 ml/min). Patients >65
years old should be started on Q12H if normal renal function.
Dosing adjustment for renal insufciency
CrCl (mL/min)
{qx
q
Dosing
}}+
}}+{
}}"
I
Iiiì]ViVii{]iìiii}
NOTE: See infective endocarditis guidelines (p. 65) for duration.

THERAPEUTIC DRUG MONITORING
U*i>>`}>iiViì`>ì`ì>i
appropriate dosing.
UiiìVVi>vGentamicin
Peak levels:qxV}
Trough levels:V}
148
NEPHROTOXICITY
USerum creatinine should be measured at least every other day. If
Vi>iVi>iLx}`vL>ii]i>i
specic dosing.
Ui>iserum aminoglycoside levels as needed. See each dosing
section above for frequency.
U-i`>>}}i>iiiviVVVi
aminoglycosides are administered during the activity period (e.g.
\]iivi>vi>`>ivii`
OTOTOXICITY
U
ìLiiVV>Vii}vV
U
iVL>ii>>V}>-iiViV>`
U/ViivV]>i>i>ii>`>ìii>`
card.
U
Vi`Li>i`v>iiiv>>V
Consider formal audiology testing.
U
>V`}xxvii}vV
,iviiVi\
**>>ii\viVnxx\q
"Vi`>}>ii\Pharmacotherapy \qn
*>iiVwV`}\Crit Care Med\{nq{nx
-
17
1`}\Surgeryn{\n
iV\Antimicrob Agents and Chemother{\
/--VL>Viìi\Am J Respir Crit Care Medx\q{
>i-i}\Circulationx\i{q{{
149

A
Monitoring for toxicity for inpatients
B. Vancomycin dosing and monitoring

A
Vancomycin dosing and monitoring

DOSING
>iVi>iVi>>Vi
}
VVv>i>\
{q>}ii}}
72 (serum creatinine*)
x 0.85 (if female)
* For patients with low muscle mass (i.e. many patients > 65 yrs), some advocate using
a minimum value of 1 to avoid overestimation of CrCl
2. Patients who are seriously ill with complicated infections such as

meningitis, pneumonia, osteomyelitis, endocarditis, and
bacteremia and normal renal function should receive initial loading
dose of 20-25 mg/kg, followed by 15-20 mg/kg Q8-12H using
Actual Body Weight (ABW). For other indications see nomogram
dosing below.
3. Calculate maintenance dose (using ABW) based on estimated or
actual CrCl. See suggested nomogram dosing below.
Note: Younger patients with normal renal function may need higher or
more frequent dosing than suggested below.
Weight
(kg)
{
{q
>60
3059
Consult Pharmacy
x}
x}
Q12H
Q24H
qx } }
Q12H
Q24H
xq x} x}
Q12H
Q24H
q x} x}
Q12H
Q24H
qx x} x}
Q12H
Q24H
xq{ } }
Q12H
Q24H
>140
Consult Pharmacy
CrCl (mL/min)
1529
<15
x}
Q48H
}
Q48H
x}
Q48H
x}
Q48H
x}
Q48H
}
Q48H
}]iiìLii
}]iiìLii
x}]iiìLii
x}]iiìLii
x}]iiìLii
}]iiìLii
>i
x>ìVi}i`>iìi>`
iixqV}
DOSING IN RENAL REPLACEMENT THERAPY

Dosing is dependent on type of renal replacement therapy.
Intermittent Hemodialysis (iHD)
UInitial dose: 15-20 mg/kg once
U*>i`Liiì`L>iìii`>>ì
dialysis session. Consider redosing at 5-10 mg/kg.
150
Continuous Renal Replacement Therapy (e.g. CVVHD)

ULoading dose: 25-30 mg/kg once
UMaintenance: 15-20 mg/kg q24h (assuming no interruption in CRRT,
e.g. line clotting)
U i\>y>ixV>>V
UMonitoring:
U*>iV>}}`>y>i`>i`v{
hours may need more frequent monitoring (consult pharmacy)
U*>i>Li`>y>i`>i}ii
checked prior to 4th dose
Peritoneal Dialysis (PD)
UInitial dose: 15-20 mg/kg once
U
>>VviVi`>vi`}>`}
serum levels.
THERAPEUTIC DRUG MONITORING (LEVELS)
UTrough levels are the most accurate and practical method for
monitoring Vancomycin effectiveness and toxicity.
UPeak levels should NOT be obtained.
Measuring serum Vancomycin levels
U/}ii`LiL>iìviiì>
steady-state conditions (approximately before the 4th dose).
U>i -,i`>]ivi>LiL>>
pre-hemodialysis level with the routine laboratory venipuncture on the
morning of hemodialysis. In the event a pre-hemodialysis level is not
obtained, a post-hemodialysis level may be drawn at least six hours
after the dialysis session.
U/}ii`LiVìi`>i>iv}
VV>Vi\
U,iVi}>}}ii`}x}++ni>
U Serious infections such as meningitis, endocarditis, osteomyelitis,
and MRSA pneumonia.
U1>Lii>vVV>}i-
vx}`xv
baseline) or dialysis
151
A
U*i`>ii(preferred)\xV}vi}Vì
i`}vV}
U*`>ii\V}
Note:>q>viii`vi`>>VVv
redistribution of tissue and plasma levels
U>i -,>>LiViì]>i}i`Li
established that coincides with HD (e.g. 500 mg qHD). Once weekly
serum levels can be drawn to monitor for accumulation.

A
U
Vii>iV>}ii}>}Vì]
Colistin, Amphotericin B)
U*}i`Vi 5 days) of therapy.
UiiVv}6>VV}ii\
U"Viii}iViì`v>i>Li
renal function who have achieved desired trough levels.
Uivii}iViì`v>i>i
hemodynamically unstable and/or with changing renal function.
Desired Vancomycin trough levels
U*i>]ii]i`V>`]L>Vii>\xV}
U
-viV\V}
U iiVvii]>`ViviV\xV}
Ui}VVi>V}`>>
be maintained to avoid development of resistance.
Monitoring for Toxicity
U-iVi>i`Lii>i`>i>iii`>>]
then weekly if patients renal function remains stable.
Ui``>>}}i>ìVV>>i>Liii
nephrotoxicity and higher serum trough concentrations (>15-20 mcg/
mL). Monitor Vancomycin trough levels (see above for frequency and
indications).
U>>`}i}iViì`v>iiVi}
Vancomycin, unless signs and symptoms of ototoxicity became
apparent.
,iviiVi\
--*-*ìii>iV}v6>VV\i>-
*>n
ii>VL>}i
iin\
6>ìV>iiii>
viVx\{q
>i>ìx\q
152
153
>i>vV\
CBC, BUN, Creatinine
6>VViiqtrough
(see dosing section p. 150)
>\
Vancomycin level
At each dialysis session
C. Antimicrobial therapy monitoring

A
Weekly
Weekly, unless change in creatinine
( xvL>ii]iViii
,iviiVi\*>VViìiv">i*>ii>VL>/i>\
viV{n\x
Vancomycin
U}iìwi`> 1 week, except for aminoglycosides and Amphotericin B (see below)

UiVi>`}>ìii>iLiii>Li`
U/ii}iVi`>>`}v>}ii``Li``>i`]L>iì>V>iVV>vi>i]V`}}ii>i>>]>}i]
underlying conditions and organ dysfunction, concomitant medications, drug treatment history, type of infection, and type and dose of antibiotic
Test
Frequency
Antimicrobial agent(s)
Other
CBC
Weekly
Aminoglycosides (Amikacin, Gentamicin,
Clinical monitoring and patient education
BUN, Creatinine
Twice weekly
Tobramycin, Streptomycin)
for hearing/vestibular dysfunction at
}Vìiiqtrough
Weekly
each visit (see p. 149 for vestibular
(twice weekly, if increased risk)
screening method)
BUN, Creatinine, K, Mg, Phos
Twice weekly
Amphotericin B, AmBisome
CBC, AST, ALT
qii
CBC, BUN, Creatinine
Weekly
-lactams (Aztreonam, carbapenems,
cephalosporins, penicillins)
add AST/ALT/bilirubin
Weekly
Oxacillin, Nafcillin, carbapenems
add K
Weekly
Penicillin G potassium
AST/ALT/bilirubin
Weekly
Micafungin
BUN, Creatinine
Weekly
Colistin
Clinical monitoring for neurotoxicity
(twice weekly, if increased risk)
(dizziness, paresthesia, vertigo,
confusion, visual disturbances, ataxia)
CBC, BUN, Creatinine , CPK
Weekly
Daptomycin
Clinical monitoring for myopathy
CBC
Weekly
Linezolid
Clinical monitoring for peripheral
neuropathy and optic neuritis
CBC, AST/ALT/bilirubin
Weekly
Rifampin
Drug interactions (monitor start of any
new medications)
CBC, AST/ALT/ bilirubin
qii
Voriconazole /Posaconazole
Drug interactions (monitor start of any
new medication), visual changes
Recommendations for monitoring patients receiving long-term antimicrobial therapy
When using an agent that is considered to be bioequivalent (no

signicant difference in rate and extent of absorption of the therapeutic
ingredient) via the parenteral and oral route, the oral formulation is
preferred if the patient does not have the contraindications listed below.
Contraindications to oral therapy
U *"V`}i`V>
U>L>ii>i`V>",i>}>`
diet/tube feeds
Ui`>V>L
U,iVi}V V}
U-iii>i>]}]`>i>]LV]`]
mucositis
U>>Lì
U A concomitant disease state that contraindicates the use of oral
medications
NOTE: There are only a limited number of agents that can be
used orally for bacteremia or fungemia; these are noted in
the table below.
Bioavailability of oral antimicrobials
Antimicrobial
% Oral absorption
Should NOT be used orally for bacteremia
V
{q
Amoxicillin/Clavulanate (Augmentin
{q
Azithromycin*
nqn
i>i
Cefpodoxime*
{qx
`>V
VVi
q
/i>VVi
xqn
Can be used orally for bacteremia or fungemia
Ciprooxacin
xqnx
Fluconazole
>
Linezolid
i`>i
Moxioxacin
Trimethoprim/sulfamethoxazole
Voriconazole
q
* Oral absorption is enhanced in presence of food
Should not be used for S. aureus bacteremia
Oral absorption is decreased in presence of food
Inter-patient variability
iVLivii`6ivii`*>iVVVLivii`\
separate oral uoroquinolone by 2 hours before and 6 hours after tube feeds.
D. Oral antimicrobial use

A
Oral antimicrobial use in hospitalized patients
154
Dosing recommendations can vary according to indication and patientspecic parameters. All dosage adjustments are based on creatinine
clearance calculated by Cockcroft-Gault equation.
CrCl =
(140 age) (weight in kg) x 0.85 (if female)

72 (serum creatinine*)
For patients with low muscle, some advocate using a minimum of 1 to avoid
overestimation of CrCl.
If patient is on hemodialysis (HD) schedule administration so that patient

receives daily dose immediately AFTER dialysis. For assistance with dosage
adjustments for patients receiving CVVHD or CVVHDF, please call pharmacy.
Drug
Typical dose
(may vary)
CrCl
(mL/min)
Dose adjustment for

renal insufciency
VV6
Acyclovir PO
i>ii
Acyclovir PO
ii<i
Amikacin
xq}}+n
200 mg 5x daily
800 mg 5x daily
x
xqx
q{

>10
>25
qx
V
Amoxicillin
i>
V
V>>>i
iV
AmBisome
V
V
L>V>
xq}+
1 g Q8H
xq}+
q}}+{
qx}}+{
q}+{q
xq}+
Ampicillin/
L>V>v
Acinetobacter,
E. faecalis)
V
i>
iv>
3 g Q4H

>30
q

q
q
x
qx
xq
14 or HD
50
qx
HD
xq}}+n
xq}}+
xq}}+{
xqx}}+{
200 mg 5x daily
}+
800 mg 5x daily
n}+n
800 mg Q12H
See section on
aminoglycoside dosing
xq}+
xqnx}+
xqnx}+{
1g Q8H
}+
1g Q24H
xq}+
xqx}+
xqx}+{
`>}i>ì
`>}i>ì
q}+{q
q}+qn
q}+n
xq}+
xq}+
xq}+{
3 g Q4H
}+
3 g Q8H
xqx}+{
q}+n
q}+n

x
q{
intermittent HD
HD
`>}i>ì
q}+n
q}+
q}+{
q}+n
}+
}+{
2 g Q HD, if HD in 2 days
OR 3g Q HD, if HD in 3 days
155
E. Antimicrobial dosing in renal failure insufciency

A
Antimicrobial dosing in renal insufciency

A
Drug
Typical dose
(may vary)
CrCl
(mL/min)
Dose adjustment for

renal insufciency
Cefdinir
300 mg Q12H
30
HD
>60
q

>60
q
q

q

HD
Ceftolozane/
>L>V>
600 mg Q12H
600 mg Q8H
q}+n
For Pseudomonas
}+n
1.5 g Q8H
>50
qx
xq
x
>50
qx
xq
x
x
qx
xq
x
>50
qx
xq
Ceftolozane/
>L>V>
-iviV
3 g Q8H
>50
qx
xq
iv>i
iv>i
(Central nervous
system infections)
Cephalexin
Cidofovir
q}+{
}+
q
q
300 mg Q12H
}+{
300 mg QHD
1 g Q8H
}+
1 g Q24H
2 g Q8H
}+n
}+
1 g Q24H
q}+
q}+{
500 mg Q24H
q{}+
q{}+{
q{}iii
week
600 mg Q12H
{}+
}+
200 mg Q12H
600 mg Q8H
{}+n
}+n
400 mg Q12H
q}+n
q}+
q}+{
1 g Q24H
1.5 g Q8H
x}+n
x}+n
Load with 750 mg, then
150 mg Q8H
3 g Q8H
x}+n
x}+n
Load with 1.5 g, then
375 mg Q8H
`>}i>ì
`>}i>ì
500 mg PO Q6H
5 mg/kg Q week for

2 weeks, then every
other week
{}+nq
xqx}+
xqx}+
*"\}+n
6\}+n
2.5 mg/kg Q12H
>50
qx

55 or Cr>1.5
500 mg Q6H
x}+n
500 mg Q12H
Not recommended
50
qx
20 or HD
{}+nq
400 mg Q24H
xqx}+
xqx}+{
xqx}+
xqx}+{
`>}i>ì
Cefepime
1 g Q8H
Cefepime
2 g Q8H
i>i
iviV
Pseudomonas
ivi>
q}+
ivì
q{}+
Ceftaroline
Ceftaroline for
,-
iv>ì
y>V6
y>V*"
>V
`>V
Colistin
i>i
156
2.5 mg/kg Q12H

x}}+{
1.25 mg/kg Q24H
Typical dose
(may vary)
CrCl (mL/min)
Dose adjustment for

renal insufciency
>V
vi`V>`
bacteremia
V>V
VVi
Ertapenem
>L
q}}+{
V>i
qn}+{
HD
q
q
30

10
HD
50
Vixq
Ganciclovir
`Vì
xqx}}+
5 mg/kg Q12H
x
{
q{
q

70
xq
xq{
q{

Ganciclovir
>i>Vi
ì
5 mg/kg Q24H
70
xq
xq{
q{

i>V
>`
i`
Meropenem
Meropenem
i}]
,
viV
i`>i
V>v}
y>V
Nitrofurantoin
(Macrobid
Oseltamivir
/i>i
Oseltamivir
*>
">V
*iV
}+{
}+
1 g Q8H
2 g Q8H
x}+n
qx}+{
{}+{
100 mg Q12H
75 mg Q12H
75 mg Q24H
q}+{q
q{+{
q
q
>51
qx
qx

>51
qx
qx

q
q
q
50
x
>60
q
q

>60
q
q

q
x
q{

q}}+{
q}}+{n
q}}+{n
`>}i>ì
`>}i>ì
1 g Q24H
500 mg Q24H
Normal dose Q24H
>ì+{n
Normal dose QHD session
Normal dose (e.g. 100, 400,
800 mg) Q24H
Load w/normal dose, then
xv>ì+{
xqx}}+
xqx}}+
xqx}}+{
xqx}}+{q{n
5 mg/kg Q12H
x}}+
x}}+{
x}}+{
1.25 mg/kg three times/week,
administer after HD
5 mg/kg Q24H
x}}+{
x}}+{
x}}+{
0.625 mg/kg three times/
week, administer after HD
iiiV>}Vì
dosing
`>}i>ì
`>}i>ì
1 g Q8H
}+
x}+
500 mg Q24H
2 g Q8H
}+n
}+
1 g Q24H
`>}i>ì
`>}i>ì
`>}i>ì
100 mg Q12H
iViì`
75 mg Q12H
x}+{
}+{
30 mg QHD session
75 mg Q24H
}+{
}+{n
30 mg every other HD session
`>}i>ì
q{+{
x+{
1.5 million units Q6H
xqx}+
}+
1 g Q24H
xqx}}+{
157

A
Drug

A
Drug
Typical dose
(may vary)
CrCl (mL/min)
Dose adjustment for

renal insufciency
*i>V
tazobactam
xq{x}+
q{
x}+{x}+
for Pseudomonas)
x}+x}+v
Pseudomonas)
x}+nx}+v
Pseudomonas)
2.25 g Q12H (2.25 g Q8H for
Pseudomonas)
`>}i>ì
HD
q
xq}}+{
q}}+{
xq}}+i
`>}i>ì
HD
*>V>i
*>>ì
+
dalfopristin
,v>/
,v>
/}iVVi
/*-8
1/Vi
/*-8
*
*i
systemic infections)
6>>VV
i>ii
Valacyclovir
ii<i
Valganciclovir
`Vì
Valganciclovir
>i>Viì
6>VV
6V>i
-ii*>V>i
guidelines p. 18
xq}}+{
x}}+n
}+{
}+nq
}Vi]i
50 mg Q12H
*"\q->L+
6\q}+
}L>i`
/*Vi
x}}+qn
xq}+
1 g Q8H
900 mg Q12H
900 mg Q24H
q
-ii6V>i
guidelines p. 19
q
q
q
HD
q

50
q{
q

60
{qx
xq
q{

60
{qx
xq
q{

q
q
`>}i>ì
`>}i>ì
`>}i>ì
q->L+
q}6+
q->L+{
q}6+{
x}}+qn
x}}+qn
2.5 mg/kg Q8H
xq}+
xq}+{
500 mg Q24H
1 g Q8H
}+
}+{
500 mg Q24H
900 mg Q12H
{x}+
{x}+{
450 mg Q48H
Not recommended
900 mg Q24H
{x}+{
{x}+{n
450 mg twice weekly
Not recommended
-iiiV>VV
dosing
`>}i>ì
necessary for PO. IV should
not be administered to patients
with CrCl 50 mL/min due to
accumulation of the vehicle.
If patient is on hemodialysis (HD) schedule administration so that patient receives

daily dose immediately AFTER dialysis. For assistance with dosage adjustments for
patients receiving CVVHD or CVVHDF, please call pharmacy.
158
HH
Abdominal infections
Biliary tract infections ..... 39-40
Diverticulitis ......................... 40
Pancreatitis .................... 41-42
Peritonitis, peritoneal
dialysis-related .................. 45
Peritonitis/GI perforation . 42-45
SBP .............................. 42-43
Acute bacterial
rhinosinusitis................... 78-79
Allergy, penicillin ................... 137
Anaerobes......................... 24-25
Amikacin
See Aminoglycosides
Aminoglycosides
Gram-negative infection
dosing ...............................146
Gram-positive synergy
dosing ............................ 148
Mycobacterial infection
dosing ............................ 147
SICU/WICU dosing ............. 148
UTI dosing ......................... 147
Amphotericin B, lipid ............... 16
Antibiotic lock therapy............. 63
Antibiogram....................... 37-38
Antimicrobial dosing
Aminoglycosides
See Aminoglycosides
CNS infections ..................... 73
Renal insufciency....... 155-158
Surgical prophylaxis .... 121-124
Vancomycin
See Vancomycin
Aspergillosis ......................... 133
Aspiration pneumonia........ 84, 88
Azole drug interactions ...... 21-22
Biliary tract infections......... 39-40

Bloodstream infections
Catheter-related .............. 60-64
Candida ..................117, 134
Enterococcus spp. ............ 62
Gram-negative rods ........... 62
S. aureus.......................... 61
Staph, coagulase-negative . 61
Brain abscess ........................ 76
H
H
Candidemia ....................117-118
Candidiasis
Hematologic patient .....134-136
Non-neutropenic host ...115-120
Candiduria ......................115-116
Catheter-related
bloodstream infections.....60-64
Cellulitis..........................100-101
Ceftaroline.................................8
Ceftolozane/tazobactam.........8-9
Central nervous system (CNS)
infections
Antibiotic dosing ...................77
Brain abscess..................76-77
Encephalitis ..........................75
Meningitis ........................73-75
Shunt infection .................76-77
Cholangitis .........................39-40
Cholecystitis .......................39-40
Clostridium difcile
infections.........................47-50
Colistin .................................9-10
Communicable diseases,
reporting ............................140
Community-acquired pneumonia
Empiric therapy ...............83-84
Pathogen-specic therapy . 85-86
COPD exacerbations................82
Cost of antimicrobials .....159-160
Cystic brosis.....................91-92
H H
HH
Bacterial vaginosis.................. 57
Daptomycin ....................... 10-11

161
10. Index
A
Index
10. Index
Diarrhea ............................ 51-53

Diabetic foot
infections.................... 103-105
Diverticulitis ............................ 40
Dosing, antimicrobials
See Antimicrobial dosing
H H
Encephalitis ............................ 75
Endocarditis ...................... 65-70
Treatment
Culture-negative ................ 68
Diagnosis .................... 69-70
Fungal ..................... 119-120
Pathogen-specic
therapy ..................... 65-69
Prosthetic valve ........... 68-69
Prophylaxis ........................ 125
Endomyometritis .................... 56
Epidural abscess ........... 108-109
Ertapenem ............................. 11
HH
Febrile neutropenia ........ 129-130
Formulary................................. 7
Fosfomycin ....................... 11-12
Fungal infections
Candida spp
................ 115-120, 134-136
Filamentous fungi ........ 133-134
Prophylaxis, SICU/WICU ..... 120
Fusarium .............................. 133
HH
Gentamicin
See Aminoglycosides
GI perforation ......................... 45
Gonococcal urethritis,
cervicitis, proctitis........... 57-58
Gynecologic infections
Endomyometritis.................. 56
Pelvic inammatory
disease ............................ 56
162
HH
Healthcare-acquired pneumonia
(not VAP) .........................87-88
H. pylori infection ................54-55
HH
ICD infection ...................... 71-72
ID approval
Antimicrobials ........................ 7
Pager .................................... 6
Infection control............. 139-144
Infectious diarrhea ............. 51-53
Inuenza............................ 93-94
Isolation precautions ............. 141
HH
Linezolid.............................12-13
Long-term antimicrobial
therapy...............................153
HH
Meningitis, bacterial ............73-75
Antimicrobial dosing..............77
Empiric therapy ....................73
Pathogen-specic therapy .....74
MDR Gram-negative
organisms .......................28-30
Micafungin..........................17-18
Microbiology.......................31-35
MRSA
Decolonization .............102-103
Soft-tissue infections ....100-101
Surveillance .................142-143
H H
Necrotizing fasciitis ....... 107-108
Neutropenic fever .......... 129-130
Nosocomial pneumonia...... 87-88
H"H
Oncology
Neutropenic fever ........129-130
H*H
P. acnes infection ...............25-26
Pacemaker infection ...........71-72
Pancreatitis ........................41-42
Parasites.................................53
Pelvic inammatory disease .....56
Penicillin allergy .....................137
Peritonitis/GI perforation .....42-45
Peritoneal dialysis-related ......45
Spontaneous bacterial .....42-43
Post-op / post-procedure
infections ..................105-107
Pneumonia
Community-acquired ........83-84
Healthcare-acquired .........87-88
Ventilator-associated ........88-90
Pneumococcal vaccine ............23
Posaconazole .....................18-19
Pre-operative prophlyaxis.121-124
Price of antimicrobials ....159-160
Prophylactic use of antimicrobials
Endocarditis .......................125
Fluconazole in ICUs .............120
Hematologic
malignancy................ 131-132
Pre-op / pre-procedure 121-124
Solid organ ..................126-128
H,H
Renal insufciency
Antimicrobial dosing.....155-158
Reported diseases.................140
Resistant Gram-negative
infections.........................28-30
Respiratory viruses .............93-94
Restricted antimicrobials ............7
H-H
SBP ...................................42-43
Sepsis.....................................99
Sexually transmitted
diseases..........................57-59
Shunt infection....................76-77
Sinusitis .............................78-79
Skin, soft-tissue and
bone infections
Cellulitis .......................100-101
Cutaneous abscess .....101-102
Diabetic foot
infection ...................103-105
Necrotizing fasciitis......107-108
Post-op infections ........105-107
Recurrent MRSA ..........102-103
Surgical-site
infections ..................105-107
Vertebral osteomyelitis,
diskitis, epidural
abscess....................108-109
Streptococci ......................24-25
Surgical prophylaxis........121-124
Surgical-site infections ....105-107
Surveillance
CRE ...................................142
MRSA ..........................142-143
VRE ....................................144
Susceptibility testing ...........31-32
Syphilis ..............................58-59
H/H
Therapeutic monitoring
Aminoglycosides..........145-149
Vancomycin .................150-152
Outpatient long-term
antimicrobial therapy ........153
Tigecycline ..............................13
Tobramycin
See Aminoglycosides
Transplant
Antimicrobial prophylaxis
Hematologic
malignancy ............. 131-132
Solid organ................ 126-128
163
10. Index
Oral antimicrobials .................154

Orbital cellulitis ...................80-81
10. Index
Trichomoniasis......................... 57
Trimethoprim/
sulfamethoxazole ..............14-15
Tuberculosis ........................95-98
H1H
Urinary tract infections
Bacterial
Cystitis ........................... 110
Pyelonephritis ................. 111
Urosepsis ....................... 111
Catheter-related .......... 113-114
Fungal ........................ 115-116
H6H
Vancomycin
164
Dosing ....................... 150-152

Monitoring .................. 151-152
Ventilator-associated
pneumonia (VAP) ............. 88-90
Vertebral osteomyelitis, diskitis,
epidural abscess ........ 108-109
Voriconazole ..................... 19-20
VRE Surveillance ................... 144
H7H
Wound infections,
post-op........................105-107
Important Phone Numbers

THE JOHNS HOPKINS HOSPITAL
Antibiotic Approval: . . . . PING JHH Antibiotic Approval Pager

Antimicrobial Stewardship Program: . . . . . . . . . . . . . . . . . . . . . . 7-4570
Infectious Diseases Consults: . . . . PING JHH Infectious Diseases
Oncology/Transplant Service (Transplant ID) . . . . PING Transplant/
Oncology Infectious Diseases
Adult Inpatient Pharmacy (Zayed 7000): . . . . . . . . . . . . . . . . . . . 5-6150
Critical Care and Surgery Pharmacy (Zayed 3121):. . . . . . . . . . . 5-6505
Weinberg Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-8998
Microbiology Lab: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6510
Hospital Epidemiology & Infection Control: . . . . . . . . . . . . . . . . 5-8384
HEIC Emergency Beeper: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3-3855
JOHNS HOPKINS BAYVIEW MEDICAL CENTER
Antibiotic Approval: . . . . . . . PING Bayview Antibiotic Approval

Infectious Disease Consults:. . PING Bayview Infectious Diseases
Bayview Inpatient Pharmacy: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0-0958
Microbiology Lab: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5-6510
Hospital Epidemiology & Infection Control: . . . . . . . . . . . . . . . . . 0-0515
The Johns Hopkins Hospital

Antimicrobial Stewardship Program
Intranet: insidehopkinsmedicine.org/amp
Internet: hopkinsmedicine.org/amp
Osler 425
(443) 287-4570 (7-4570)
Copyright 2015 by The Johns Hopkins Hospital Antimicrobial
Stewardship Program. All rights reserved. No part of this publication
may be reproduced without permission in writing from The Johns
Hopkins Hospital Antimicrobial Stewardship Program.
Cover art: Charlotte Ford Cosgrove, Line Drawing II 33, 2008.

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Antibiotic Guidelines

6.7 Endocarditis ................................................................................ 65

Edina Avdic, Pharm.D., M.B.A

Kate Dzintars, Pharm.D.

Janessa Smith, Pharm.D.

The following people served as section/topic reviewers

How to use this guide

2.1 Obtaining ID approval

Ordersets (e.g. neutropenic

2.2 Antimicrobial formulary and restriction status

Selected formulary antimicrobials

3.1 Agent-specic guidelines: Antibiotics

3.1 Agent-specic guidelines: Antibiotics

Acceptable uses (Cases must be discussed with Infectious Diseases

3.1 Agent-specic guidelines: Antibiotics

30 ml/min (see p. 155 for

3.1 Agent-specic guidelines: Antibiotics

3.1 Agent-specic guidelines: Antibiotics

3.1 Agent-specic guidelines: Antibiotics

3.1 Agent-specic guidelines: Antibiotics

3.1 Agent-specic guidelines: Antibiotics

3.2 Agent-specic guidelines: Antifungals

3.2 Agent-specic guidelines: Antifungals

3.2 Agent-specic guidelines: Antifungals

Drug Interactions: See Table on p. 21

ID pharmacist for dose adjustment recommendations.

3.2 Agent-specic guidelines: Antifungals

3.2 Agent-specic guidelines: Antifungals

Azole drug interactions

cyclosporine dose to 34 and monitor levels

iVLi`\ statins (lovastatin, simvastatin)

iVLi`\ atorvastatin, benzodiazepines, chemotherapy

iVLi`\ carbamazepine, efavirenz, isoniazid, nevirapine,

plasma concentration of itraconazole, if possible avoid concomitant

plasma concentration of the interacting drug, monitor levels when

3.2 Agent-specic guidelines: Antifungals

plasma concentration of itraconazole, monitor itraconazole levels and

POSACONAZOLE (substrate and inhibitor for P-gp efux, inhibitor of CYP3A4)

3.2 Agent-specic guidelines: Antifungals

cyclosporine dose to 12 and monitor levels

iVLi`\ carbamazepine, rifabutin, rifampin,

iVLi`\ cyclosporine, glipizide, glyburide, phenytoin,

plasma concentration of uconazole, consider increasing uconazole dose

VORICONAZOLE (substrate and inhibitor of CYP2C19, CYP2C9, and CYP3A4)

Indications for pneumococcal vaccines for adults 19 years of age

Immunocompetent persons with certain No

Timing and sequential administration of pneumococcal vaccines

3.3 Agent-specic guidelines: Vaccines

4.1 Organism-specic guidelines: Anaerobes

4.1 Organism-specic guidelines: Anaerobes

above the diaphragm. Metronidazole is not active against

4.2 Organism-specic guidelines: P. acnes

Viridans group Streptococci (alpha-hemolytic streptococci)

4.3 Organism-specic guidelines: Streptococci

4.3 Organism specic guidelines: Multi-drug resistant Gram-negative rods

Multi-drug resistant Gram-negative rods

MDR Acinetobacter baumannii/calcoaceticus

U-lactam PLUS aminoglycoside if synergy expected

*Combination therapy should be considered in severe infections.

4.4 Organism specic guidelines: Multi-drug resistant Gram-negative rods

4.4 Organism specic guidelines: Multi-drug resistant Gram-negative rods

VVL>V\ H. u, Acinetobacter spp.,

Anaerobic: Peptostreptococcus spp.

U>i>iVi`i`vN. gonorrhoeae even if C. trachomatis