Sandbox ID Systemic

Anaplasmosis

SC

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Babesiosis

• Pathogen-directed antimicrobial therapy
• Preferred regimen (1): Combined therapy with Clindamycin and Quinine
• Preferred regimen (2): Both Atovaquone (a hydroxy-1,4-naphthoquinone) alone and Azithromycin (an azalide macrolide) alone appeared to be effective.

Note : Neither the regimen of Atovaquone and Azithromycin nor the regimen of Clindamycin and Quinine clears Babesiosis microti merozoites from the human blood as rapidly as might be desired.

Bartonella

• Bartonellosis or Carrion's disease

• The acute phase, or hematic phase, known as Oroya Fever

• Preferred regimen: Ciprofloxacin for 10 days- for patients younger than 7 years old, the scheme is 10 mg/kg divided into two doses, for patients between 7 and 14 years old the dose is 250 mg BID, and for patients older than 14 years old the dose is 500 mg BID
• Alternative regimen: Chloramphenicol 50mg/kg/day, divided into four doses during the first three days, and then 25 mg/kg/day until completing 14 days of treatment

Note (1): If a complication occurs during the acute phase, and the patient is not pregnant, then the treatment would be Ciprofloxacin AND (Ceftriaxone or Ceftazidime) during 10 days.

Note (2): If a pregnant patient has complicated acute Bartonellosis, the treatment is Chloramphenicol 50-100 mg/kg/day, divided into four doses, AND Penicillin G 50,000-100,000 IU/kg/day divided into 4 or 6 doses, for 14 days. (A complication should be suspected if there is no improvement within the first 72 hours of treatment.)

Note (3): The treatment schemes based on ciprofloxacin and chloramphenicol have the advantage of also covering the possibility of Salmonella species and Haemophilus influenzae in the pediatric population

Note (4): Patients with neurobartonellosis, respiratory distress syndrome, coagulopathy, and/or moderate to severe pericarditis may benefit from corticosteroids, such as Dexamethasone (0.5-1 mg/kg/day for three days).

Note (5): Red blood cell transfusions in the amount of 10-20mL/kg are given when the hematocrit is less than 20%.

Note (6): In case of severe pericardial tamponade, a pericardiectomy is done.

• The eruptive phase or tissue phase, known as Peruvian Wart

• Preferred regimen: Rifampin 10 mg/kg/day QID during 14 to 21 days.
• Alternative regimen: Azithromycin OR Erythromycin, OR Ciprofloxacin can be given for 7 to 14 days.

Note (1): In this phase, Chloramphenicol and Penicillin are not useful.

Note (2): In vitro analysis, Bacillus bacilliformis showed susceptibility to most beta-lactams, Rifampin, Erythromycin, Macrolides, Tetracycline, Quinolones, and Chloramphenicol.

Note (2): The bacterium is resistant to Vancomycin, Clindamycin, and Aminoglycosides.

Botulism

• Botulism

• Foodborne botulism

• Preferred regimen (adult): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.5 mL/min; incremental infusion rate if tolerated (every 30 minutes): double the rate; maximum infusion rate: 2 mL/min
• Preferred regimen (pediatric 1-17 years): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01 mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01 mL/kg/min ; maximum infusion rate: 0.03 mL/kg/min (20 – 100% of adult dose)
• Preferred regimen (pediatric < 1 year): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01 mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01 mL/kg/min ; maximum infusion rate: 0.03 mL/kg/min (10% of adult dose regardless of body weight)
• Note:Physicians may try to remove contaminated food still in the gut by inducing vomiting or by using enemas. A patient with severe botulism may require a ventilator as well as intensive medical and nursing care for several months.

• Infant botulism

• Preferred regimen: BabyBIG, Botulism Immune Globulin Intravenous (Human) (BIG-IV) is for the treatment of patients below one year of age.The recommended total dosage is 1mL/kg (50mg/kg), given as a single IV infusion as soon as the clinical diagnosis of infant botulism is made
• Note: infant with botulism must receive supportive care during their recovery. This includes ensuring proper nutrition,keeping the airway clear,watching for respiratory failure and if it develops,ventilator may be needed.

• Wound botulism

• Preferred regimen (adult): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.5 mL/min; incremental infusion rate if tolerated (every 30 minutes): double the rate; maximum infusion rate: 2 mL/min
• Preferred regimen (pediatric 1-17 years): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01 mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01 mL/kg/min ; maximum infusion rate: 0.03 mL/kg/min (20 – 100% of adult dose)
• Preferred regimen (pediatric < 1 year): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01 mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01 mL/kg/min ; maximum infusion rate: 0.03 mL/kg/min (10% of adult dose regardless of body weight)

• Note (1): For wound botulism, antibiotics are used in addition to appropriate debridement.
• Note (2): Antibiotic therapy is recommended for wound botulism after antitoxin has been administered. Penicillin G 3 MU IV q4h in adults is frequently used. Metronidazole 500 mg IV q8h may be used as an alternative for penicillin-allergic patients.

Boutonneuese fever

• Boutonneuese fever

• Preferred Regimen ( adult)(1): Doxycycline 200 mg two oral doses in a single day

• Preferred Regimen ( adult)(2): Doxycycline 200 mg or 100 mg bid for 2-5 days
• Alternative regimen (adult)(1): josamycin 1g q8h for 7 days
• Alternative regimen (adult)(2):Ciprofloxacin
• Preferred Regimen ( Children <100 lbs): Doxycycline 2.2 mg/kg body weight PO q 12 h or( Children >100lbs ) 200 mg bid in one day and 200 mg bid qid or 100 mg bid for 2-5 days
• Alternative regimen (Children <8 y.o.)(1): josamycin 2.2mg/kg q12h for 5 days
• Alternative regimen (Children <8 y.o)(2): clarithromycin 15 mg/ kg in 2 divided doses for 7 days & azithromycin 10 mg per kg/day 1 dose for 3 days

Diphtheria

Diphtheria treatment

• Preferred Regimen Erythromycin 40 mg/kg/day; maximum, 2 gm/day) PO for 14 days OR Procaine penicillin G daily (300,000 U/day (for weight < 10 kg ) & 600,000 U/day (for weight >10 kg ) IM for 14 days
• Note: Since 1997, diphtheria antitoxin has been available only from CDC, through an Investigational New Drug (IND) protocol.

Fever of unknown origin

• Fever of unknown origin (FUO)

• Management should generally be withheld until the etiology of the fever has been ascertained, so that treatment can be directed against a specific pathology.
• Specific clinical considerations

• Neutropenic fever

• Exception may be made for neutropenic patients in which delayed treatment could lead to serious complications.
• After samples for cultures are obtained, patients with febrile neutropenia should be aggressively treated with broad-spectrum antibiotics covering Pseudomonas

• HIV/AIDS individuals

• HIV/AIDS individuals with pyrexia and hypoxia should be placed on empiric therapy for Pneumocystis jirovecii.

• Giant cell arteritis

• Empiric corticosteroids may be considered in patients with suspected giant cell arteritis to prevent vascular complications.
• Giant cell arteritis should be suspected in a patient over the age of 50 with the following symptoms:

• Newly onset headaches
• Abrupt onset of blurry vision
• Symptoms of polymyalgia rheumatica
• Jaw claudication
• Unexplained anemia
• Elevated ESR and/or CRP

Lymphangitis

• Preferred regimen: Dicloxacillin OR Cephalexin 500 mg PO qid for 1 week

• If Community-Associated Methicillin-Resistant Staphylococcus Aureus (CA-MRSA) suspected:

Neutropenic fever, prophylaxis

      Neutropenic fever, prophylaxis

Salmonella bacteremia

• Preferred regimen: Ciprofloxacin 400 mg every 12 hours IV AND Ceftriaxone 1 to 2 g every 12 to 24 hrs IV.

• When the salmonellae are known to be susceptible:

• Preferred regimen: Ampicillin 1 to 2 g IV every 4 to 6 hrs OR Trimethoprim-sulfamethoxazole 8 mg/kg/day