Antibiotics 101 A review of common infections and their treatment For others, like me, who have a mental block against all things related to antibiotics

Antibiotic BINGO!! 0 Rules: 0 I will read a question for each “bingo ball,” if you have the corresponding phrase on your sheet, answer the question in the box 0 Complete a row, column or diagonal 0 All answers must be correct to win the game 0 Winner will receive a prize! Woohoo!!

Brief Micro Refresher 0 Gram positive cocci: 0 Catalase positive: 0 Coag positive: staph aureus 0 Coag negative: staph epi 0 Catalase negative: 0 Enterococcus 0 Streptococcus 0 Atypicals: 0 C.pneumo: intracellular gram neg 0 Mycoplasma: no cell wall 0 Legionella: intracellular gram neg 0 Gram negatives: 0 Lactase positive: 0 E.coli 0 Klebsiella 0 Enterobacter 0 Others: 0 Proteus 0 Acinetobacter 0 Morganella 0 Serratia 0 Pseudomonas aeruginosa 0 Moraxella 0 H. flu

Basic Antibiotic Coverage StrepStaphMRSAEnteroGram -PseudoAnaerobes (except bacteroides) Atypicals Penicillin Ampicillin++*-++/--+- Amox/clav Vancomycin++++/ st ceph nd ceph rd ceph++--+-*+- 4 th ceph Mero/imi++-+/-+++- Pip/tazo++-+*+++- Quinilones+*+-+/-++ + Azithromycin+/ Doxycyline+/- +/- *-+/--++ TMP-SMX+/

Community Acquired Pneumonia 0 Common pathogens: 0 S.pneumo, H.flu, moraxella, chlamydia, legionella, mycoplasma, viruses 0 Empiric treatment: 0 Outpatient: 0 Azithromycin 500mg x 1d then 250mg x 4d 0 Doxycycline 100mg BID x 7-10d 0 Moxifloxacin 400mg (or levo) x 7d for pts with co-morbidities 0 Inpatient: 0 Ceftriaxone 1g IV Q24hrs + azithromycin 500mg IV Q24hrs 0 Moxifloxacin 400mg or levofloxacin 750mg IV Q24hrs 0 Duration: 7-10d

Healthcare Associated Pneumonia 0 Criteria: 0 Hospitalization for two or more days within the past 90 days 0 Current hospitalization > 48hrs (*HAP) 0 Residence in skilled nursing facility or long term care facility within the last 30 days 0 Receiving outpatient IV therapy within the past 30 days 0 Attending a dialysis center in the last 30 days 0 Home wound care 0 Family member with known MDRP

HCAP Cont’d 0 Pathogens: 0 Pseudomonas 0 MRSA 0 Klebsiella, enterobacter, acinetobacter, serratia, E.Coli 0 Anaerobes (aspiration) 0 Empiric treatment: 0 Vitamin P and V 0 Piperacillin/tazo OR cefepime OR meropenem + vancomycin 0 Can also consider addition of gentamicin Pic 1: Pic 2:

COPD Exacerbation 0 Most common pathogens: 0 H.flu 0 Moraxella 0 Strep pneumo 0 Viruses: parainfluenza, flu, rhinovirus, RSV 0 Antibiotics: 0 Azithromycin (Z-pack) 0 Doxycycline 100mg BID x 10d 0 Amoxicillin mg TID x 10d 0 Other therapies: 0 Prednisone 0 Duonebs

Sinusitis 0 Common Pathogens: 0 Viruses: rhinovirus 0 S.pneumo 0 H.flu 0 Classification: 0 Acute: < 4wks 0 Subacute: 4-12 wks 0 Chronic: > 12wks

Sinusitis: Empiric Tx 0 When? 0 Persistent symptoms (>10d) or worsening symptoms at day 7 0 What? 0 Augmentin 875/125mg BID 0 Amoxicillin 500mg TID 0 Duration: 10-14d CBA/v126PDIjCZA/s1600/Neti+Pot+2.JPG

Cellulitis 0 Common pathogens: 0 Strepococcus 0 Staphylcoccus 0 Empiric treatment: 0 Outpatient: 0 Cephalexin 500mg QID or amoxicillin 500mg TID +/- doxycycline or TMP-SMX 0 Duration: 7-10d 0 Inpatient: 0 Vancomycin 0 Duration: 7-10d 0 Other therapies: elevation of affected area, +/- steroids

Cellulitis- Diabetics 0 Common pathogens: 0 Staph and strep 0 Enterobacter 0 Enterococcus 0 Pseudomonas 0 Anaerobes 0 Empiric treatment: 0 Augmentin 875mg BID 0 Clindamycin 300mg TID 0 Amp/sulbactam 3g IV Q6hrs 0 +/- vancomycin 0 Duration: 5-14d (resolution of symptoms) *Important note: bactrim and doxycycline have less strep activity so are not preferred agents

Urinary Tract Infection 0 Pathogens: 0 Pathogens: E.Coli, E.Coli, E.Coli, Staph saprophyticus, Proteus 0 Uncomplicated: 0 Women, no systemic symptoms (afebrile, no leukocytosis, etc) 0 Complicated: 0 Men, indwelling foley, systemic symptoms 0 Pyelonephritis: 0 Flank pain, fever, leukocytosis, +/- WBC casts

UTIs Empiric Treatment 0 Uncomplicated: 0 Check antiobiograms for resistance patterns 0 In Seattle: TMP-SMX = ciprofloxacin BUT nitrofurantoin is better than all! 0 Duration: 3-5d (5d for nitrofurantoin) 0 Complicated: 0 Cipro or TMP-SMX if mild to moderate illness 0 Pip/tazo, cefepime, ceftazidime, carbapenem for severe illness 0 Duration: 7-14 days in general (3-5 days after defervescence) 0 Pyelonephritis: 0 Ceftriaxone, ceftazidime, pip/tazo 0 Duration: 48hrs IV or until afebrile, then complete total 14d course

Osteomyelitis 0 Acute vs chronic: 0 Acute: first presentation, symptoms < 2 weeks, absence of necrotic bone 0 Chronic: necrotic bone, > 3 weeks of symptoms 0 Pathogens: 0 S. Aureus, coag negative staph, strep, enterococcus, pseudomonas, anaerobes 0 Diagnosis: 0 Blood culture, bone biopsy culture; wound culture is generally not helpful

Osteomyelitis 0 Chronic treatment: based on culture results 0 Empiric treatment for acute: need to cover anaerobes, MRSA, pseudomonas 0 Ampicillin/sulbactam OR pip/tazo OR carbopenem OR ceftriaxone 0 AND Vancomycin 0 Duration: 0 Acute: 4-6 weeks abx (usually minimum 2 weeks IV) 0 Chronic: 2-6 weeks IV abx then usually addition 6 weeks with oral therapy (until ESR and CPR normalize)

References 0 Sanford Guide to Antimicrobial Therapy: Sanford Guide Web Edition 2 0 Johns Hopkins Antibiotics Guide, Unbound Medicine iPhone App 0 Cleveland Clinic Guidelines for Antimicrobial Usage