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Hospitalized patients

Infection Organisms First DOC Alternative
Osteomyelitis Presumed hematogenous source or contiguous without vascular insufficiency S. aureus Vancomycin Vanc
  • If S. aureus is methicillin-susceptible then cefazolin 2 g IV q8h or nafcillin 2 g IV q4h are the antibiotics of choice.
  • Obtain bone biopsy to determine microbiologic cause prior to initiation of antimicrobial therapy if blood cultures are negative and patient clinically stable.
With vascular insufficiency or diabetes mellitus (e.g. severe diabetic foot ulcer) S. aureus 

Enterobacteriaceae

Anaerobes

Vancomycin

PLUS ONE OF:

Piperacillin/Tazobactam 4.5 g IV q6-8h

OR

Ertapenem 1 g IV daily

For severe PCN allergy:

Vancomycin

PLUS ONE OF:

Ciprofloxacin400 mg IV q12h

OR

Levofloxacin 750 mg IV daily

OR

Aztreonam 2 g IV q8h

ALL WITH OR WITHOUT:

Metronidazole500 mg IV q8h (if patient critically ill)

  • Other organisms are possible, esp. with hardware microbiologic diagnosis and ID consultation recommended
  • Obtain bone biopsy to determine microbiologic cause prior to initiation of antimicrobial therapy if patient clinically stable
  • Once stable, switch to oral antibiotics based on susceptibility results.
Septic Arthritis S. aureus

Streptococci spp.

N. gonorrhoeae

Enterobacteriaceae (rarely)

Vancomycin

PLUS

Ceftriaxone1 g IV daily

For severe PCN allergy:

Vancomycin

PLUS ONE OF:

Ciprofloxacin 400 mg IV q12h

OR

Levofloxacin 500 mg IV daily

OR

Aztreonam g IV q8h if gonococcus is strongly suspected

Gram stain recommended to guide therapy.

Narrow coverage to microbiologically confirmed pathogens.

Brain abscess Streptococci (anaerobic or aerobic)

Bacteroides spp

Prevotella spp

Enterobacteriacea

Ceftriaxone

2 g IV q12h

PLUS

Metronidazole 500 mg PO/IV q8h

WITH OR WITHOUT*:

Vancomycin

Aztreonam

2 g IV q8h

PLUS

Vancomycin

PLUS

Metronidazole 500 mg PO/IV q8h

Consider expanded Gram-positive coverage if patient at risk for drug-resistant streptococci or MRSA
Meningitis

Community-onset

S. pneumoniae

Neisseria meningitidis

Listeria (especially in immuno-compromised, elderly patients, and alcoholics)

ceftriaxone

2 g IV q12h

PLUS

Vancomycin

WITH OR WITHOUT* one of:

TMP/SMX 15 mg/kg/day (in divided doses)

OR

'Ampicillin' 2 g IV q4h

For severe PCN allergy:

Vancomycin

PLUS

Aztreonam2 g IV q6h-q8h

WITH OR WITHOUT*:

TMP/SMX (if Listeria) 15 mg/kg/day (in divided doses)

  • Therapy should be guided by Gram stain.
  • If bacterial meningitis suspected, dexamethasone 10 mg PO/IV q6h x 4 days given before or with initial dose of antibiotics. 
  • Coverage for Listeria with TMP/SMX or ampicillin should be added for patients who are <2 or >50 years of age or immunocompromised.
Meningitis

Post-neurosurgical or device associated

S. aureus

Coagulase negative

Staphylococci

Gram negative rods

Cefepime

PLUS

'Vancomycin' 

For severe PCN allergy:

Aztreonam 2 g IV q6h-q8h

PLUS

Vancomycin

Native Valve S. aureus

Streptococci spp.

Enterococcus spp.

Occasional gram negative rods

HACEK < 5%

Vancomycin

WITH or WITHOUT*

Ceftriaxone

2 g IV daily

For severe PCN allergy:

Vancomycin

WITH or WITHOUT*

CiprofloxacinID-R: VASF 400 mg IV q12h

  • Narrow coverage to microbiologically confirmed pathogens
  • Addition of Gram-negative coverage should be considered if the patient has a sub-acute presentation.
Prosthetic Valve S. aureus

S. epidermidis

Vancomycin

PLUS

Rifampin300 mg PO q8h

PLUS

Gentamicin 1 mg/kg/dose IV q8h for initial two weeks only

Single daily dose of gentamicin is not recommended

Rifampin has numerous clinically significant drug interactions.  Medication lists should be reviewed for potential drug-drug interactions with rifampin.
Spontaneous Bacterial Peritonitis (SBP) E. coli

Klebsiella spp.

'Streptococci. spp.

Ceftriaxone 1 g IV daily x 5 days For severe PCN allergy:

Vancomycin

PLUS

Aztreonam 2 g IV q8h

Secondary Peritonitis

Mild-Moderate intra-abdominal abscess

E. coli

Klebsiella 

B. fragilis

Streptococci spp

S. aureus

Ertapenem 1g IV daily

OR

Piperacillin/tazobactam 3.375 g IV q6h - 4.5g IV q6h

For severe PCN allergy:

Vancomycin

PLUS

Aztreonam 2 g IV q8h

PLUS

Metronidazole500 mg IV q8h

Secondary Peritonitis

Severe (major peritoneal soilage, large or multiple abscesses, patient hemodynamically unstable)

E. coli 

Klebsiella

B. fragilis 

P. aeruginosa

Enterococcus spp.

Streptococcus spp

S. aureus

Vancomycin

PLUS

Piperacillin/tazobactam 4.5 g IV q6h

For severe PCN allergy:

Vancomycin

PLUS

Aztreonam 2 g IV q8h

PLUS

Metronidazole500 mg IV q8h

For hemodynamically unstable health-care associated infection, consider meropenem.
Clostridium difficile-associated diarrhea Clostridium difficile Initial episode, mild to moderate disease

(WBC ≤15K and SCr less than 1.5 times premorbid level)

Vancomycin 125mg PO q6h x 10-14 days.  If unable to obtain at discharge, can complete course with Metronidazole500mg po q8h

Initial episode, severe disease

(WBC >15k and/or 50% increase in SCr)

Vancomycin 125mg PO q6h x 10-14 days.

Initial episode, severe disease with complications

(Severe disease with hypotension, shock, ilios, and/or megacolon)

Vancomycin 500mg PO/NG q6h x 10-14 days

PLUS

Metronidazole 500 mg IV q8h x 10-14 days

WITH OR WITHOUT

Vancomycin PR Rectal vancomycin should be considered in patients with ileus. It is given as 500 mg in 100 mL of 0.9% NaCl and instilled q6h (retain each dose for 1h)

  • First recurrence

Same therapy as initial episode, stratified by illness severity

  • First recurrence, special population (hematologic malignancy with >30 days expected neutropenia, recent HSCT, recent treatment for GVHD, solid organ transplant <3 months)

FidaxomicinID-R: UCSF SFGH  VASF 200mg PO BID x10 days

  • Second recurrence

Vancomycin with tapered or pulsed regimen

PLUS

Consult ID, GI

PLUS

Evaluate for fecal microbiota transplant

  • IV metronidazole alone is not indicated for treatment of C. difficile diarrhea.
  • IV metronidazole should only be used in combination with PO vancomycin in the ICU.
  • Recurrence in 5-30% of patients after first episode and 33-60% after second episode.
  • ID CONSULT recommended in patients with severe disease with complications or multiply recurrent disease, and for consideration of rectal vancomycin administration.
'Endometritis'  Bacteroides

Prevotella bivia

Group B & Astreptococci

Enterobacteriaceae

M. hominis

1st line:

Cefoxitin 2 g IV q6h 

2nd line:

Ertapenem 1 g IV daily

3rd line:

Ampicillin/sulbactam 3 g IV q6h

For severe PCN allergy:

Vancomycin

PLUS

Gentamicin

PLUS

Metronidazole 500 mg IV q12h

  • If test for chlamydia is positive add azithromycin or doxycycline.
  • Continue antibiotics until afebrile for 24-48 hours.
  • If still febrile > 48 hours and on cefoxitin or clindamycin/gentamicin postpartum, switch to ertapenem.
  • Wait 48 hours on an antibiotic regimen before considering regimen failed.
Peritonsillar abscess, deep neck infections Group A streptococci

Anaerobes

S. aureus

Ampicillin/sulbactam 3 g IV q6h

WITH OR WITHOUT*

Vancomycin 

Alternatively:

Ertapenem 1 g IV daily

WITH OR WITHOUT*

Vancomycin 

Alternatively:

Metronidazole 500 mg IV/PO q8h

PLUS

Ceftriaxone1 g IV q24h

WITH OR WITHOUT*

Vancomycin

For severe PCN allergy:

ClindamycinID-R: VASF 600 – 900 mg IV q8h

PLUS

CiprofloxacinID-R: VASF 400 mg IV q12h

OR

LevofloxacinID-R: VASF 500 mg IV daily

Often polymicrobial
  • Combinations of piperacillin/tazobactam, ampicillin/sulbactam, or ertapenem PLUS metronidazole should not be used.
  • Consider vancomycin use for patients at high risk for MRSA
Line-related bacteremia  S. epidermidis

S. aureus

Enterococci spp.

Gram-negative rods*

Yeast**

Vancomycin

WITH OR WITHOUT* one of:

Piperacillin/tazobactam

ID-R: SFGH

4.5 g IV q6h

OR

'CefepimeI' 2 g IV q8h

For severe PCN allergy:

Vancomycin

WITH OR WITHOUT* one of:

Aztreonam ID-R: SFGH 2 g q8h

  • Remove the offending intravascular device immediately, if possible.
  • Consider Gram-negative coverage for immunocompromised patients or those with prolonged hospitalization, recent antibiotic exposure or sepsis.
Community-Acquired Pneumonia  Immunocompetent patient – Medical Ward S. pneumoniae

Mycoplasma pneumoniae

Chlamydia pneumoniae

H. influenzae

Legionella pneumophilia

Klebsiella pneumoniae

(alcoholics)

No Recent antibiotic therapy:*

Ceftriaxone 1 g IV daily

PLUS

'Doxycycline'100 mg PO/IV q12h

For severe PCN allergy:

Levofloxacin 750 mg PO/IV daily

OR

MoxifloxacinID-R: SFGH 400 mg PO/IV daily

  • If patient has had recent antibiotic therapy, antibiotics from a different class should be selected (i.e. recent use of a fluoroquinolone should dictate selection of a non-fluoroquinolone regimen, and vice versa).
  • Consider influenza testing and treatment with oseltamivir.
Community-Acquired Pneumonia

Immunocompetent patient – ICU

S. pneumoniae

Mycoplasma pneumoniae

Chlamydia pneumoniae

H. influenzae

Legionella pneumophilia

Klebsiella pneumoniae

(alcoholics)

S. aureus

Ceftriaxone 1 g IV daily

PLUS

Azithromycin 500 mg IV daily

WITH OR WITHOUT*:

Vancomycin

For severe PCN allergy:

Vancomycin

PLUS one of:

Levofloxacin 750 mg IV daily

OR

Moxifloxacin 400 mg IV daily

  • MRSA risk factors: prior influenza, presence cavitary disease, empyema.
  • Consider influenza testing and treatment with oseltamivir.
  • If no microbiologic confirmation of MRSA then discontinue vancomycin.
  • See HCAP for risk factors for infection with Pseudomonas aeruginosa.
Healthcare –associated pneumonia (HCAP):

acquired in long-term care facility where antimicrobials used or Pseudomonas risk factors (see Comments)

S.aureus

S.pneumoniae

H.influenzae 

Antibiotic sensitive enteric gram negative bacilli:

E. coli

Enterobacter aerogenes

Klebsiella pneumoniae

Proteus mirabilis

Serratia marcesans

P. aeruginosa (if risk factors present)

Hemodynamically stable & no Pseudomonas risk factors

Vancomycin

PLUS one of:

Ertapenem 1 g IV daily

WITH OR WITHOUT one of*:

Doxycycline 100 mg IV/PO BID

OR

Levofloxacin 750 mg IV/PO daily

Hemodynamically unstable or Pseudomonas risk factors

Vancomycin

PLUS one of:

Piperacillin/tazobactamID-R: SFGH 4.5 g IV q6h

OR

CefepimeID-R: SFGH VASF 2 g IV q8h-q12h

WITH OR WITHOUT*:

Azithromycin 500 mg IV daily

For severe PCN allergy:

Vancomycin

PLUS one of:

AztreonamID-R: SFGH 2 g IV q8h

WITH OR WITHOUT one of*:

Doxycycline 100 mg IV/PO BID

OR

Azithromycin 500 mg IV daily

  • Pseudomonas risk factors include: structural lung disease, repeated exacerbations of severe COPD leading to frequent steroid and/or antibiotic use, recent mechanical ventilation, recent prior exposure to broad-spectrum antibiotics
  • Avoid using levofloxacin if the patient has recently been treated with a fluoroquinolone.
  • For patients admitted from the community with HCAP and not treated with levofloxacin, consider  adding atypical coverage with doxycycline (floor patients) or azithromycin (ICU patients).
Hospital-acquired pneumonia  EARLY ONSET

including ventilator-associated or less than 5 days of hospitalization, no risk factors for drug-resistant organisms*

S. aureus

S.pneumoniae

H.influenzae 

Antibiotic sensitive enteric gram negative bacilli:

E. coli

Enterobacter aerogenes

Klebsiella pneumoniae

Proteus mirabilis

Serratia marcesans

Vancomycin

PLUS one of

Levofloxacin 750 mg IV daily

OR

Ertapenem 1 g IV daily 

  • Risk factors include recent antibiotic exposure (within 30 days).
  • Consider influenza testing and treatment with oseltamivir when influenza is known to be circulating.
LATE ONSET

including ventilator-associated OR ≥ 5 days of hospitalization or risk factors for resistant organisms*

E. coli

Enterobacter aerogenes

P. aeruginosa

Klebsiella pneumoniae

'S. aureus' 

Vancomycin

PLUS one of:

Piperacillin/tazobactam 4.5 g IV q6h  

OR

Cefepime 2 g IV q8-12h

Alternatively:

Vancomycin

PLUS

Meropenem 1-2 g IV q8h**

For severe PCN allergy:

Vancomycin2

PLUS

Aztreonam 2 g IV q8h

WITH OR WITHOUT***:

Tobramycin

**Consider use in patients with current or recent use (< 7 days) of piperacillin/tazobactam or cefepime and in patients with recent infection with multidrug resistant gram-negative bacteria.

***Weigh risks and benefits of adding aminoglycoside for critical illness, immunocompromise, or history of infection or colonization with drug-resistant Gram-negative rods.

'Septic Shock'

Community onest, no recent healthcare exposure

Enterobacteriaceae

S. aureus

Streptococci spp.

Vancomycin

PLUS one of:

Piperacillin/

TazobactamID-R: SFGH 4.5 g IV q8h

OR

'Ertapenem' 1 g IV daily

For severe PCN allergy:

Vancomycin

PLUS

Metronidazole 500 mg IV/PO q8h

PLUS one of

AztreonamID-R: SFGH 2 g IV q8h

OR

Tobramycin

Healthcare-associated and/or previous antibiotic therapy Enterobacteriaceae

S. aureus

Streptococci spp.

P. aeruginosa

Vancomycin

PLUS

Piperacillin/

Tazobactam 4.5 g IV q6h

OR

Cefepime 2 g IV q8h

For severe PCN allergy:

Vancomycin

PLUS

Metronidazole 500 mg IV q8h

AND

Aztreonam 2 g IV q8h

WITH OR WITHOUT:

Tobramycin

For patients with neutropenia, organ transplant, severe hepatic failure, or current/recent (<7 days) piperacillin/tazobactam or cefepime:

Vancomycin

Plus

Meropenem 1-2 g IV q8h

'Abscess' 'S.aureus' Vancomycin Empirical Gram-negative and/or anaerobic coverage is not routinely indicated.

Incision and drainage is primary therapy for abscesses. After incision and drainage and once patient is stable, switch to oral antibiotics based on culture and susceptibility results.

'Cellulitis' Group A streptococci

Other beta-hemolytic streptococci

S.aureus

Vancomycin

Alternatively:

Cefazolin 1 g IV q8h if patient is stable and cellulitis is not associated with an abscess or other purulent focus of infection

Empirical Gram-negative and/or anaerobic coverage is not routinely indicated.
Necrotizing fasciitis or suspected deep tissue extension Group A streptococci

S. aureus

Anaerobes

Gram-negative rods

Vancomycin

PLUS ONE OF:

Piperacillin/tazobactam 4.5 g IV q6-8h

OR

Ertapenem 1 g IV daily

ALL WITH:

Clindamycin600 – 900 mg IV q8h 

Alternatively if infection is health-care associated:

Vancomycin

PLUS

Meropenem1-2 g IV q8h

PLUS

Clindamycin600-900 mg IV q8h

For severe PCN allergy:

Vancomycin

PLUS

AztreonamID-R: SFGH 2 g IV q8h

PLUS

Clindamycin ID-R: VASF 600-900 mg IV q8h

Clindamycin added for anti-toxin properties. Limited data support use for infections caused by Group A streptococci and Clostridium perfringens. Discontinue clindamycin once adequate surgical debridement is achieved.  

Asymptomatic bacteriuria Enterobacteriaceae

Enterococcusspecies

No treatment required Exceptions: pregnant women, patients having traumatic urologic procedures, recent kidney transplant .
Catheter-associated candiduria Candida species No treatment required Pyuria alone is not an indication for treatment.
Community-acquired Pyelonephritis  Enterobacteriaceae (E. coli) Ceftriaxone

1 g IV q24h

OR

Cefazolin 1g IV q8h (VASF only)

OR

Ertapenem 1g IV daily

For severe PCN allergy:

Vancomycin

PLUS ONE OF EITHER:

Gentamicin

OR

Aztreonam ID-R: SFGH

2 g IV q8h

 Duration of therapy 7-14 days based on clinical response.

Healthcare-associated UTI Enterobacteriaceae (e.g. E. coli)

P. aeruginosa (less common)

Ceftriaxone

1 g IV q24h

OR

Ertapenem 1g IV daily

OR

Piperacillin/tazobactamID-R: SFGH 4.5g IV q8h

For severe PCN allergy:

ONE OF:Criteria: signs and symptoms compatible with a UTI, no other identified source of infection, & ≥ 1000 cfu of ≥ 1 bacterial species on urine culture

Gentamicin

OR

Aztreonam ID-R: SFGH

2 g IV q8h

BOTH WITH OR WITHOUT:

Vancomycin

  • Pyuria alone is not an indication for treatment.
  • A negative urinalysis suggests an alternative source of infection.
  • Remove catheter if possible.
  • Switch to oral therapy when susceptibilities known and patient stable.
  • 7 days of therapy is recommend if patient has prompt resolution of symptoms
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