Pneumonia

For nonhospitalized patients with an established diagnosis of CAP who also have comorbidities, a history of recent
antibiotic use, or when the local rate of macrolide resistance is >25 percent (including all regions of the United States
and certain other countries), we suggest empiric monotherapy with a respiratory fluoroquinolone or combination
therapy with a beta-lactam plus either a macrolide or doxycycline.

For uncomplicated pneumonia in patients who have no significant comorbidities and/or risk factors for macrolide
resistance (use of antibiotics within the last three months, local rate of macrolide resistance >25 percent), we suggest
empiric treatment with an advanced macrolide.

Most outpatients with CAP should be treated for five days.

For hospitalized patients not requiring intensive care unit (ICU) admission, we suggest initial combination therapy with
an anti-pneumococcal beta-lactam (ceftriaxone, cefotaxime, ceftaroline, ertapenem, or ampicillin-sulbactam) plus a
macrolide (azithromycin or clarithromycin XL), or monotherapy with a respiratory fluoroquinolone (levofloxacin or
moxifloxacin) (Grade 1B)
Coverage for drug-resistant pathogens, such as Pseudomonas or MRSA, should be included in patients with risk
factors.

For hospitalized patients requiring ICU care, we suggest initial combination therapy with an anti-pneumococcal betalactam (ceftriaxone, cefotaxime, ceftaroline, or ampicillin-sulbactam) plus either intravenous (IV) therapy with
azithromycin or a respiratory fluoroquinolone (levofloxacin or moxifloxacin) plus, if MRSA is suspected, vancomycin or
linezolid (Grade 2B).
Coverage for other drug-resistant pathogens, such as Pseudomonas, should be included in patients with risk factors.
For most hospitalized patients who are at substantial risk of morbidity and mortality (eg, Pneumonia Severity Index
score IV or V; CURB-65 score 2), we suggest adjunctive glucocorticoids.
We suggest switching from intravenous to oral therapy when patients are hemodynamically stable, demonstrate some
clinical improvement (in fever, respiratory status, white blood count), and are able to take oral medications.

Meningitis
Initial therapy bacterial meningitis in adults: Same as table in QID 3245 (UW)

We recommend that antimicrobial therapy be initiated immediately after the performance of the lumbar puncture or, if a computed
tomography (CT) scan is to be performed before LP, immediately after blood cultures are obtained
For adults in the developed world with suspected bacterial meningitis in whom the organism is unknown or Streptococcus
pneumoniae is confirmed, we recommend administration of dexamethasone
No known immunodeficiency
S. pneumoniae, Neisseria meningitidis, and, less often, Haemophilus influenzae and group B Streptococcus are the most likely
causes of community-acquired bacterial meningitis in otherwise healthy adults up to the age of 60. Individuals aged over 50 years
are also at substantial risk of Listeria monocytogenes meningitis.
Ceftriaxone or Cefotaxime + Vancomycin
+ Ampicillin (In adults >50 years of age)
With the worldwide increase in the prevalence of penicillin-resistant pneumococci, vancomycin should be added to cefotaxime or
ceftriaxone as empiric treatment until culture and susceptibility results are available
Impaired cell-mediated immunity
(due, for example, to lymphoma, cytotoxic chemotherapy, or high-dose glucocorticoids), coverage must be directed against L.
monocytogenes and gram-negative bacilli (including Pseudomonas aeruginosa) as well as S. pneumoniae.
Vancomycin + Ampicillin + [Cefepime or Meropenem]
Healthcare-associated meningitis
Empiric therapy for healthcare-associated meningitis must cover both gram-positive and gram-negative (such as Klebsiella
pneumoniae and P. aeruginosa) pathogens
Vancomycin +[ Ceftazidime or Cefepime or Meropenem]
Allergy to beta-lactams
Vancomycin + Moxifloxacin + TMP/SFX (If Listeria coverage is required (in patients >50 years of age and/or in those with defects in
cell-mediated immunity)

The 4 regimens require normal renal function.

Children with meningitis:

In special circumstances: Vanco + cefotax, and If G ve suspected or observed on gram stain, add aminoglycoside.
We recommend the use of dexamethasone for children with Hib meningitis (Grade 1A).
The agent of choice for empiric treatment of infections due to CoNS is
methicillin-resistant CoNS infections.

vancomycin; it is generally the mainstay of treatment for

Bacterial meningitis in the neonate: Treatment and outcome

Dont take it seriously

In neonates zero through three days of age, the most common bacterial pathogens are group B Streptococcus (GBS), Escherichia
coli, other enteric bacilli, and Listeria monocytogenes.
In neonates four days of age or older, other gram-negative organisms must be considered in addition to GBS, E. coli, and other
enterics
In continuously hospitalized neonates seven days of age or older, a wide range of potential gram-positive organisms must be
considered in addition to antimicrobial-resistant gram-negative organism
Early-onset
Initial empirical therapy for suspected bacterial meningitis within the first three to six days of age is ampicillin and an
aminoglycoside, usually gentamicin. OR Ampicillin + Cefotaxime.
Late-onset Initial empirical therapy for suspected bacterial meningitis after the first week of life depends upon the preliminary
CSF findings (particularly the Gram stain) and whether the neonate remains hospitalized or has been discharged from the
hospital.
In the non-hospitalized neonate who is strongly suspected to have bacterial meningitis), ampicillin plus an
aminoglycoside plus cefotaxime should be initiated.
Late-onset sepsis without meningitis in neonates who remain hospitalized is treated with vancomycin and an aminoglycoside.
In general, drugs between amp, vanc, aminog, cefotax

Brain abscess
For patients with a brain abscess arising from an oral, otogenic, or sinus source (eg, chronic otitis or mastoiditis, where the site of
abscess is usually the temporal lobe or cerebellum; or frontal or ethmoid sinusitis, where the site of abscess is usually the frontal
lobe), we recommend treatment with:
Metronidazole PLUS either penicillin G for a suspected oral focus, OR ceftriaxone or cefotaxime for a suspected sinus or
otogenic source.
For patients with a brain abscess from hematogenous spread (eg, bacteremia or endocarditis with multiple abscesses in middle
cerebral artery distribution), we recommend treatment with:
Vancomycin for empiric coverage of methicillin-resistant S. aureus. Metronidazole and ceftriaxone or cefotaxime, may be
added for initial empiric coverage if the bacteriology is uncertain.
For brain abscess in postoperative neurosurgical patients, we recommend treatment with: (= meningitis)
Vancomycin PLUS ceftazidime ,cefepime (2 g IV every eight hours), or meropenem .
For brain abscess following penetrating trauma, we recommend treatment with: (Not like meningitis)
Vancomycin PLUS either ceftriaxone or cefotaxime If the paranasal sinuses are involved, add metronidazole
For brain abscesses with an unknown source, we recommend treatment with (To cover all):
Vancomycin PLUS Either ceftriaxone or cefotaxime PLUS Metronidazole

PID
Pelvic inflammatory disease: Treatment

Acute PID is caused by cervical microorganisms (including Chlamydia trachomatis and Neisseria gonorrhoeae) as well as the
vaginal microflora, including enteric gram-negative rods, streptococci, genital mycoplasmas, and Gardnerella vaginalis.
Anaerobic coverage is warranted in patients with a history of recent endometrial instrumentation and women with severe or
complicated PID

For inpatient management of severe or complicated PID, we suggest use of a second generation cephalosporin (eg, cefoxitin IV or
cefotetan IV) combined with doxycycline .
Another option is clindamycin plus gentamicin (Both IV). (Which will kill which)
For outpatient therapy of mild or moderate PID, we suggest ceftriaxone (250 mg intramuscularly in a single dose)
plus doxycycline (orally for 14 days) (Grade 2B). We suggest the addition of metronidazole for those with a history of
gynecological instrumentation in the preceding two to three weeks.
The Antibiotic regimens for inpatient treatment of PID are also used for tuboovarian abscess treatment.

Postpartum endometritis
The infection is polymicrobial, usually involving a mixture of two to three aerobes and anaerobes from the lower genital tract.
Given the microbiology of these infections, we recommend broad spectrum antibiotics with coverage of beta-lactamase producing
anaerobes (Grade 1A). We suggest clindamycin (IV) plus gentamicin (IV) (Grade 2B). Ampicillin-sulbactam (1.5 g intravenously
every six hours) is a reasonable alternative in areas with significant clindamycin resistance in B. fragilis or if the patient is colonized
with group B streptococcus (GBS) [or in patients with renal insufficiency]
Metronidazole provides good activity against most anaerobes and can be useful with ampicillin and gentamicin, but is not the
preferred choice for breastfeeding women if a drug with a better safety profile is available.

Osteomyelitis
Osteomyelitis in adults:
The reference standard for diagnosis of osteomyelitis is isolation of bacteria from a bone biopsy sample obtained via sterile
technique, together with histologic findings of inflammation and osteonecrosis. Bone biopsy may not be needed for patients with
radiologic studies consistent with osteomyelitis in the setting of positive blood cultures. Cultures obtained from sinus tract drainage
are not reliable.
Treatment of osteomyelitis often requires both surgical debridement of necrotic material and antimicrobial therapy for eradication of
infection. The optimal duration of antibiotic therapy is not certain; we suggest continuing parenteral antimicrobial therapy at least six
weeks from the last debridement

Empiric therapy: Vancomycin PLUS an agent with activity against gram-negative organisms
MSSA: Oxacillin, Nafcillin, Cefazolin.
MRSA or Coagulase-negative staphylococci: Vancomycin
Gram-negative organisms (includingPseudomonas): Ciprofloxacin, Levofloxacin, Ceftazidime, Cefepime
Hematogenous osteomyelitis in children: Management

We recommend empiric antimicrobial therapy for most children with clinical features compatible with osteomyelitis, even if the
initial plain radiograph is normal.
Initial antimicrobial therapy for acute hematogenous osteomyelitis usually is administered parenterally. The empiric regimen is
determined by the most likely pathogens and antimicrobial susceptibilities based on epidemiologic factors including the child's
age (table 2), clinical features (table 3), and organisms prevalent in the community
For infants <3 months of age we use a third-generation cephalosporin (eg, cefotaxime), plus an antistaphylococcal
agent (vancomycin or nafcillin/oxacillin).
Empiric intravenous antimicrobial therapy for infants from birth to three months of age should be directed against S.
aureus, gram-negative bacilli, and group B Streptococcus, the most common causes of hematogenous osteomyelitis in

this age group.

Neonates who have been in an intensive care unit for more than one week should receive vancomycin, rather
than nafcillin/oxacillin. (increased risk for hospital acquired methicillin-resistant S. aureus or coagulase-negative
staphylococci).
For infants 3 months and children, we use cefazolin, nafcillin/oxacillin, clindamycin, or vancomycin, depending upon
the local prevalence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) and the
susceptibility of CA-MRSA to clindamycin.
These regimens are like regimens of septic arthritis in pediatrics.
Empiric intravenous antimicrobial therapy for children older than three months should be directed against S. aureus (the most
common cause of hematogenous osteomyelitis in this age group) and other gram-positive organisms (eg, group A
streptococci, S. pneumoniae). Broader empiric therapy may be necessary for special populations. ( see photo)

Bacterial arthritis
Bacterial arthritis: Treatment and outcome in infants and children
Bacterial arthritis requires prompt recognition and management; up to one-third of cases may be accompanied by
osteomyelitis. Delays in treatment are associated with long-term sequelae. This is especially true when the hip is involved.
The goals of treatment include sterilization and decompression of the joint space and removal of inflammatory debris to
relieve pain and prevent deformity or functional sequelae. Drainage of joint fluid and antimicrobial therapy are the
cornerstones of therapy.
Because delayed therapy is associated with long-term sequelae, treatment of infants and children with suspected bacterial
arthritis should begin immediately after blood and synovial fluid cultures are obtained
We recommend that empiric therapy include coverage for Staphylococcus aureus in all infants and children (Grade 1A). Depending
upon the child's age (table 1) (Not that important), Gram stain, and particular clinical circumstances (Same table of
hematogenous osteomyelitis), empiric coverage for additional pathogens may be necessary.

Septic arthritis in adults

Endocarditis
Antimicrobial therapy of native valve endocarditis

In general, empiric therapy should cover staphylococci (methicillin susceptible and resistant), streptococci, and
enterococci. Vancomycin is an appropriate choice for initial therapy in most patients.
Virtually all of HACEK organisms, even strains that produce beta-lactamase, are highly susceptible to third-generation
cephalosporins, such as ceftriaxone
Infective endocarditis in injection drug users
Staphylococcus aureus accounts for more than one-half of cases of IE among IDUs. Streptococci and enterococci are the next
most common pathogens. Less commonly, fungi and gram-negative bacilli can also cause IE in IDUs.
Suggested regimens for therapy of prosthetic valve endocarditis due to Staphylococcus:
Nafcillin or oxacillin OR Cefazolin OR Vancomycin (a must in Oxacllin resistant)
PLUS Rifampin PLUS Gentamicin

Suggested regimens for therapy of prosthetic valve endocarditis due to enterococci

Aqueous penicillin G OR Ampicillin OR Vancomycin (best as some strains resistant to penicillin)
PLUS Gentamycin

Bactericidal activity against enterococci requires the synergistic interaction of a cell wall active agent (penicillin, ampicillin,
or vancomycin) and an aminoglycoside (gentamicin or streptomycin)

Suggested regimens for therapy of prosthetic valve endocarditis due to strains of viridans streptococci
and Streptococcus bovis relatively or fully resistant to penicillin G
Aqueous penicillin G OR Ceftriaxone PLUS Gentamycin.
OR Single drug treatment Vancomycin

Cystitis & Pyelonephritis

Parenteral regimens for empiric treatment of complicated pyelonephritis

The microbial spectrum of complicated cystitis and pyelonephritis includes organisms associated with uncomplicated UTIs (mainly
Escherichia coli, with occasional other species of Enterobacteriaceae, such as Proteus mirabilis and Klebsiella pneumoniae) as
well as Pseudomonas, Serratia, Providencia, enterococci, staphylococci, and fungi. In addition, organisms causing complicated
cystitis are more likely to be resistant to commonly used oral antimicrobials recommended for uncomplicated cystitis.
For patients with complicated cystitis who can tolerate oral therapy we suggest empiric treatment with an oral fluoroquinolone such
as ciprofloxacin or levofloxacin (Grade 2B). The duration range is generally 5 to 10 days. Parenteral therapy may be warranted for
treatment of patients who cannot tolerate oral therapy or for patients with infection that is suspected to be due to resistant
organisms; reasonable regimens that may be administered once daily include levofloxacin, ceftriaxone , ertapenem (drug of choice
for known or suspected infection with an extended-spectrum beta-lactamase producing organism), or an aminoglycoside.

Antimicrobial agent
Mild to moderate pyelonephritis
Ceftriaxone
Cefepime
Ciprofloxacin
Levofloxacin
Aztreonam*
Severe pyelonephritis with incomplete urinary drainage and/or in an
immunocompromised patient
Ampicillin-sulbactam
Ticarcillin-clavulanate
Piperacillin-tazobactam
Ceftolozane-tazobactam
Ceftazidime-avibactam
Meropenem
Imipenem
Doripenem

Previous antimicrobial use and results of any recent urine cultures should inform the choice of an empiric regimen.
Doses are for patients with normal renal function.
In the setting of pregnancy, the above agents are acceptable with the exceptions of ciprofloxacin, levofloxacin, and
imipenem.

After clinical improvement is observed, parenteral therapy can be switched to oral therapy.
For outpatient treatment of uncomplicated pyelonephritis we suggest ciprofloxacin (500 mg orally twice daily for seven days or 1000
mg extended release once daily for seven days) or levofloxacin (750 mg orally once daily for five to seven days)
----------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------Most cases of acute bacterial prostatitis are caused by gram-negative organisms, and empiric antibiotic therapy should be
directed against this class. We suggest empiric treatment with trimethoprim-sulfamethoxazole or a fluoroquinolone

Q: vanco effective for group b strept?

Diverticulitis, appendicitis

sepsis

Collected by: Khaled Elfert