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| ==Clostridium difficile==
| | ==Mycobacterium terrae== |
| :*1.''' Initial episode''' <ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 |pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232 }} </ref><ref name="Planche2013">{{cite journal|last1=Planche|first1=Tim|title=Clostridium difficile|journal=Medicine|volume=41|issue=11|year=2013|pages=654–657|issn=13573039|doi=10.1016/j.mpmed.2013.08.003}}</ref><ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref><ref name="pmid20307191">{{cite journal|author=Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al.| title=Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). |journal=Infect Control Hosp Epidemiol | year= 2010 | volume= 31 | issue= 5 | pages= 431-55 | pmid=20307191 | doi=10.1086/651706 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20307191 }} </ref><ref name="pmid18971494">{{cite journal| author=Kelly CP, LaMont JT| title=Clostridium difficile--more difficult than ever. | journal=N Engl J Med |year= 2008 | volume= 359 | issue= 18 | pages= 1932-40 | pmid=18971494 | doi=10.1056/NEJMra0707500 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18971494 }} </ref>
| | * [[Mycobacterium terrae]] <ref>{{Cite journal| doi = 10.1164/rccm.200604-571ST| issn = 1073-449X| volume = 175| issue = 4| pages = 367–416| last1 = Griffith| first1 = David E.| last2 = Aksamit| first2 = Timothy| last3 = Brown-Elliott| first3 = Barbara A.| last4 = Catanzaro| first4 = Antonino| last5 = Daley| first5 = Charles| last6 = Gordin| first6 = Fred| last7 = Holland| first7 = Steven M.| last8 = Horsburgh| first8 = Robert| last9 = Huitt| first9 = Gwen| last10 = Iademarco| first10 = Michael F.| last11 = Iseman| first11 = Michael| last12 = Olivier| first12 = Kenneth| last13 = Ruoss| first13 = Stephen| last14 = von Reyn| first14 = C. Fordham| last15 = Wallace| first15 = Richard J.| last16 = Winthrop| first16 = Kevin| last17 = ATS Mycobacterial Diseases Subcommittee| last18 = American Thoracic Society| last19 = Infectious Disease Society of America| title = An official ATS/IDSA statement: diagnosis, treatment, and prevention of nontuberculous mycobacterial diseases| journal = American Journal of Respiratory and Critical Care Medicine| date = 2007-02-15| pmid = 17277290}}</ref> |
| ::*1.1 ''' Mild to moderate'''
| | :* 1. '''In vitro susceptibility''' |
| | | ::* All six of the isolates from a single center and 90% or more of an additional 22 isolates of M. terrae complex were susceptible to [[Ciprofloxacin]] and [[Sulfonamides]]. Recently, 11 isolates of M. terrae complex were also shown to be susceptible to [[Linezolid]] |
| :::* Preferred regimen: [[Metronidazole]] 500 mg orally q8h
| | :* 2. '''Antimicrobial therapy''' |
| :::* Alternative regimen(If no improvement in 5-7 days): [[Vancomycin]] 125 mg orally q6h
| | ::* Preferred regimen: [[Macrolide]] {{and}} [[Ethambutol]] or other agent based on in vitro susceptibility results |
| ::*1.2 '''Severe'''
| |
| :::* Preferred regimen: [[Vancomycin]] 125 mg orally q6h
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| ::*1.3 '''Severe complicated'''
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| :::* Preferred regimen: [[Vancomycin]] 500 mg orally q6h {{and}} [[Metronidazole]] 500 mg IV q8h
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| :::* NOTE: If ileus present, add [[Vancomycin]] 500 mg in 100 mL normal saline per rectum q6h as retention enema
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| :*2.'''Recurrence'''
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| ::*2.1 '''First recurrence'''
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| :::* preferred regimen: Same as first episode but stratified by severity
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| ::*2.2 '''Second recurrence'''
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| :::* preferred regimen: [[Vancomycin]] 125 mg 4 times daily for 14 days or 125 mg 2 times daily for 7 days or 125 mg once daily for 7 days or 125 mg once every 2 days for 8 days (4 doses) or 125 mg once every 3 days for 15 days (5 doses)
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| ==Clostridium perfringens==
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| | |
| ==Clostridium tetani==
| |
| *1. '''General measures''' <ref name=World Health Organization>{{cite web | title = Current recommendations for treatment of tetanus during humanitarian emergencies| url =http://www.who.int/diseasecontrol_emergencies/publications/who_hse_gar_dce_2010.2/en/ }}</ref>
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| | |
| :* Preferred regimen: Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
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| | |
| *2. '''Immunotherapy'''
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| | |
| :* Preferred regimen: Human TIG 500 units by intramuscular injection or intravenously as soon as possible {{and}} Age-appropriate TT-containing vaccine, 0.5 cc by intramuscular injection at a separate site
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| | |
| :* NOTE: patients without a history of primary TT vaccination should receive a second dose 1–2 months after the first dose and a third dose 6–12 months later
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| *3. '''Antibiotic treatment'''
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| | |
| :* Preferred regimen: [[Metronidazole]] 500 mg intravenously or orally every six hours {{or}} [[Penicillin G]] 100,000–200,000 IU/kg/day intravenously, given in 2–4 divided doses
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| | |
| :* Alternative regimen: [[Tetracyclines]] {{or}} [[Macrolides]] {{or}} [[Clindamycin]] {{or}} [[Cephalosporins]] {{or}} [[Chloramphenicol]]
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| *4. '''Muscle spasm control'''
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| :* Preferred regimen: [[Diazepam]] 5 mg intravenous {{or}} [[Lorazepam]] 2 mg titrating to achieve spasm control without excessive sedation and hypoventilation
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| | |
| :* Alternative regimen (1): [[Magnesium]] sulphate 5 gm (or 75mg/kg) intravenous loading dose, then 2–3 grams per hour until spasm control is achieved {{withorwithout}} [[Benzodiazepines]]
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| :* NOTE: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased
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| | |
| :* Alternative regimen (2): [[Baclofen]] {{or}} [[Dantrolene]] 1–2 mg/kg intravenous/orally every 4 hours
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| | |
| :* Alternative regimen (3): [[Barbiturates]] 100–150 mg every 1–4 hours by any route
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| | |
| :* Alternative regimen (4): [[Chlorpromazine]] 50–150 mg by intramuscular injection every 4–8 hours
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| :* Pediatric regimen: [[Lorazepam]] 0.1–0.2 mg/kg every 2–6 hours, titrating upward as needed; [[Barbiturates]] 6–10 mg/kg in children by any route; [[Chlorpromazine]] 4–12 mg every by intramuscular injection every 4–8 hours
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| :* NOTE: As for [[Benzodiazepines]], large amounts may be required (up to 600 mg/day); Oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest
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| *5. '''Autonomic dysfunction control'''
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| :* Preferred regimen: [[Magnesium]] sulphate {{or}} [[Morphine]] {{or}} [[Esmolol]]
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| ==Mycobacterium abscessus== | |
| *1.'''Limited, localized extrapulmonary disease ''' <ref>{{cite book | last = Bartlett | first = John | title = Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases | publisher = Jones and Bartlett Learning | location = Burlington, MA | year = 2012 | isbn = 978-1449625580 }}</ref> | |
| :* Preferred regimen: [[Clarithromycin]] 500 mg PO twice daily {{withorwithout}} [[Amikacin]] 10-15 mg/kg/day IV or 25 mg/kg three times weekly for 4 months
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| | |
| :* Alternative regimen (1): [[Amikacin]] {{and}} [[Cefoxitin]] 12 g/day typically for two weeks until clinical improvement in severe cases
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| :* Alternative regimen (2): [[Amikacin]] {{and}} [[Imipenem]] 500 mg IV q6-8h for two weeks until clinical improvement in severe cases
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| :* NOTE: Osteomyelitis should be treated for as least 6 months; Infected foreign bodies should be removed
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| *2.'''Pulmonary or serious extrapulmonary disease'''
| |
| :* Preferred regimen: [[Clarithromycin]] 500 mg PO twice daily {{and}} [[Amikacin]] 15 mg/kg/day IV {{and}} [[Cefoxitin]] 2g q4h IV {{or}} [[Imipenem]] 1g q6h IV for at least 2-4 months, if limited by adverse effects, then switch to[[Clarithromycin]] 500 mg PO BID or 1000 mg XR OD {{or}} [[Azithromycin]] 250 mg PO OD
| |
| :* Alternative regimen(1): [[Tigecycline]] 100 mg IV load then 50 mg IV q12h could be substituted as one of the injectables
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| :* Alternative regimen(2): [[Linezolid]] 600 mg PO q12h or 600 mg PO OD {{and}} [[Clarithromycin]] could replace parental tx if not tolerated or feasible
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| ==Tuberculous==
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| * Mycobacterium tuberculosis
| |
| :* '''First-line therapy''' (dosing information: <span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab3]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab4]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab5]</span>)
| |
| ::* [[Isoniazid]]
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| ::* [[Rifampin]]
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| ::* [[Rifabutin]]
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| ::* [[Pyrazinamide]]
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| ::* [[Ethambutol]]
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| | |
| :* '''Second-line therapy''' (dosing information: <span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab3]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab4]</span><span class="plainlinks">[http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm#tab5]</span>)
| |
| ::* [[Cycloserine]]
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| ::* [[Ethionamide]]
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| ::* [[Streptomycin]]
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| ::* [[Amikacin]]
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| ::* [[Kanamycin]]
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| ::* [[Capreomycin]]
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| ::* [[p-Aminosalicylic acid]]
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| ::* [[Levofloxacin]]
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| ::* [[Moxifloxacin]]
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| ::* [[Gatifloxacin]]
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| | |
| :* Susceptible Mycobacterium tuberculosis<ref>{{Cite journal| doi = 10.1164/rccm.167.4.603| issn = 1073-449X| volume = 167| issue = 4| pages = 603–662| last1 = Blumberg| first1 = Henry M.| last2 = Burman| first2 = William J.| last3 = Chaisson| first3 = Richard E.| last4 = Daley| first4 = Charles L.| last5 = Etkind| first5 = Sue C.| last6 = Friedman| first6 = Lloyd N.| last7 = Fujiwara| first7 = Paula| last8 = Grzemska| first8 = Malgosia| last9 = Hopewell| first9 = Philip C.| last10 = Iseman| first10 = Michael D.| last11 = Jasmer| first11 = Robert M.| last12 = Koppaka| first12 = Venkatarama| last13 = Menzies| first13 = Richard I.| last14 = O'Brien| first14 = Richard J.| last15 = Reves| first15 = Randall R.| last16 = Reichman| first16 = Lee B.| last17 = Simone| first17 = Patricia M.| last18 = Starke| first18 = Jeffrey R.| last19 = Vernon| first19 = Andrew A.| last20 = American Thoracic Society, Centers for Disease Control and Prevention and the Infectious Diseases Society| title = American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis| journal = American Journal of Respiratory and Critical Care Medicine| date = 2003-02-15| pmid = 12588714}}</ref><ref>{{Cite journal| doi = 10.1128/CMR.00042-07| issn = 1098-6618| volume = 21| issue = 2| pages = 243–261, table of contents| last1 = Rock| first1 = R. Bryan| last2 = Olin| first2 = Michael| last3 = Baker| first3 = Cristina A.| last4 = Molitor| first4 = Thomas W.| last5 = Peterson| first5 = Phillip K.| title = Central nervous system tuberculosis: pathogenesis and clinical aspects| journal = Clinical Microbiology Reviews| date = 2008-04| pmid = 18400795| pmc = PMC2292571}}</ref><ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref><ref>{{Cite journal| issn = 1057-5987| volume = 52| issue = RR-11| pages = 1–77| last1 = American Thoracic Society| last2 = CDC| last3 = Infectious Diseases Society of America| title = Treatment of tuberculosis| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2003-06-20| pmid = 12836625}}</ref>
| |
| ::* '''Intensive phase (adult)'''
| |
| :::* Preferred regimen: [[Isoniazid]] 5 mg/kg (max: 300 mg) for 2 months {{and}} [[Rifampin]] 10 mg/kg (max: 600 mg) for 2 months {{and}} [[Pyrazinamide]] 15–30 mg/kg (max: 2 g) for 2 months {{and}} [[Ethambutol]] 15–20 mg/kg (max: 1 g) for 2 months
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| ::* '''Continuation phase (adult)'''
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| :::* Preferred regimen: [[Isoniazid]] 5 mg/kg (max: 300 mg) for 4 months {{and}} [[Rifampin]] 10 mg/kg (max: 600 mg) for 4 months
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| ::* '''Intensive phase (pediatric)'''
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| :::* Preferred regimen: [[Isoniazid]] 10–15 mg/kg (max: 300 mg) for 2 months {{and}} [[Rifampin]] 10–20 mg/kg (max: 600 mg) for 2 months {{and}} [[Pyrazinamide]] 15–30 mg/kg (max: 2 g) for 2 months {{and}} [[Ethambutol]] 15–20 mg/kg (max: 1 g) for 2 months
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| ::* '''Continuation phase (pediatric)'''
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| :::* Preferred regimen: [[Isoniazid]] 10–15 mg/kg (max: 300 mg) for 7–10 months {{and}} [[Rifampin]] 10–20 mg/kg (max: 600 mg) for 7–10 months
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| :::: Note (1): World Health Organization guidelines recommend that Ethambutol should be replaced by Streptomycin (contraindicated in pregnancy) in tuberculous meningitis.<ref>{{Cite book| edition = 4th| publisher = World Health Organization| isbn = 9789241547833| title = Treatment of Tuberculosis: Guidelines| location = Geneva| series = WHO Guidelines Approved by the Guidelines Review Committee| date = 2010| url = http://www.ncbi.nlm.nih.gov/books/NBK138748/| pmid = 23741786}}</ref>
| |
| :::: Note (2): A 9– to 12–month course of treatment is recommended for tuberculous meningitis.<ref>{{Cite book| edition = 4th| publisher = World Health Organization| isbn = 9789241547833| title = Treatment of Tuberculosis: Guidelines| location = Geneva| series = WHO Guidelines Approved by the Guidelines Review Committee| date = 2010| url = http://www.ncbi.nlm.nih.gov/books/NBK138748/| pmid = 23741786}}</ref><ref>{{Cite journal| issn = 1057-5987| volume = 52| issue = RR-11| pages = 1–77| last1 = American Thoracic Society| last2 = CDC| last3 = Infectious Diseases Society of America| title = Treatment of tuberculosis| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2003-06-20| pmid = 12836625}}</ref>
| |
| :::: Note (3): Adjuvant [[Dexamethasone]] 0.3–0.4 mg/kg/day (max: 24 mg) is recommended unless drug resistance is suspected.<ref>{{Cite journal| doi = 10.1056/NEJMoa040573| issn = 1533-4406| volume = 351| issue = 17| pages = 1741–1751| last1 = Thwaites| first1 = Guy E.| last2 = Nguyen| first2 = Duc Bang| last3 = Nguyen| first3 = Huy Dung| last4 = Hoang| first4 = Thi Quy| last5 = Do| first5 = Thi Tuong Oanh| last6 = Nguyen| first6 = Thi Cam Thoa| last7 = Nguyen| first7 = Quang Hien| last8 = Nguyen| first8 = Tri Thuc| last9 = Nguyen| first9 = Ngoc Hai| last10 = Nguyen| first10 = Thi Ngoc Lan| last11 = Nguyen| first11 = Ngoc Lan| last12 = Nguyen| first12 = Hong Duc| last13 = Vu| first13 = Ngoc Tuan| last14 = Cao| first14 = Huu Hiep| last15 = Tran| first15 = Thi Hong Chau| last16 = Pham| first16 = Phuong Mai| last17 = Nguyen| first17 = Thi Dung| last18 = Stepniewska| first18 = Kasia| last19 = White| first19 = Nicholas J.| last20 = Tran| first20 = Tinh Hien| last21 = Farrar| first21 = Jeremy J.| title = Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults| journal = The New England Journal of Medicine| date = 2004-10-21| pmid = 15496623}}</ref><ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref>
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| :::: Note (4): Liaise with microbiology laboratory about genotype testing for drug resistance if there is high risk for MDR-TB.<ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref>
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| :* Tuberculous meningitis caused by Mycobacterium tuberculosis resistant to isoniazid or rifampin
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| ::* '''Isoniazid monoresistance'''<ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref>
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| :::* Substitute fluoroquinolone for isoniazid in intensive phase regimen.
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| :::* Continue treatment with rifampin, pyrazinamide, and fluoroquinolone for 12 months.
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| ::* '''Rifampin monoresistance'''<ref>{{Cite journal| doi = 10.1016/j.jinf.2009.06.011| issn = 1532-2742| volume = 59| issue = 3| pages = 167–187| last1 = Thwaites| first1 = Guy| last2 = Fisher| first2 = Martin| last3 = Hemingway| first3 = Cheryl| last4 = Scott| first4 = Geoff| last5 = Solomon| first5 = Tom| last6 = Innes| first6 = John| last7 = British Infection Society| title = British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children| journal = The Journal of Infection| date = 2009-09| pmid = 19643501}}</ref>
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| :::* Substitute Fluoroquinolones for Rifampin in intensive phase regimen.
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| :::* Continue treatment with isoniazid, pyrazinamide, and fluoroquinolone for 18 months.
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| ::* '''MDR-TB (resistant to Isoniazid and Rifampin)'''<ref>{{Cite journal| doi = 10.1128/CMR.00042-07| issn = 1098-6618| volume = 21| issue = 2| pages = 243–261, table of contents| last1 = Rock| first1 = R. Bryan| last2 = Olin| first2 = Michael| last3 = Baker| first3 = Cristina A.| last4 = Molitor| first4 = Thomas W.| last5 = Peterson| first5 = Phillip K.| title = Central nervous system tuberculosis: pathogenesis and clinical aspects| journal = Clinical Microbiology Reviews| date = 2008-04| pmid = 18400795| pmc = PMC2292571}}</ref>
| |
| :::* MDR tuberculosis therapy should be considered if there is a history of prior tuberculosis treatment, contact with a patient with MDR tuberculosis, or a poor clinical response to first-line TB therapy within 2 weeks despite a firm diagnosis and an adequate adherence to treatment.
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| :::* Second-line agents such as Aminoglycosides penetrate the BBB only in the presence of inflamed meninges, and Fluoroquinolones, while able to penetrate into the CNS, have lower CSF levels than in the serum or brain parenchyma.
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| :::* Consult infectious disease specialist.
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| ::* '''XDR-TB (resistant to Isoniazid, Rifampin, Fluoroquinolones, and either Capreomycin, Kanamycin, or Amikacin)'''<ref>{{Cite journal| doi = 10.1128/CMR.00042-07| issn = 1098-6618| volume = 21| issue = 2| pages = 243–261, table of contents| last1 = Rock| first1 = R. Bryan| last2 = Olin| first2 = Michael| last3 = Baker| first3 = Cristina A.| last4 = Molitor| first4 = Thomas W.| last5 = Peterson| first5 = Phillip K.| title = Central nervous system tuberculosis: pathogenesis and clinical aspects| journal = Clinical Microbiology Reviews| date = 2008-04| pmid = 18400795| pmc = PMC2292571}}</ref>
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| :::* Consider Ethionamide or Cycloserine to build the treatment regimen.
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| :::* Consult infectious disease specialist.
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| ==References==
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| {{reflist|2}}
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