Template:ID-infections-by-organ-system

Cardiovascular

Endocarditis

Endocarditis, treatment ⇧ Return to Top ⇧

• Infective endocarditis

• Culture-negative endocarditis

• Culture-negative, native valve endocarditis

• Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks
• Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks AND Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 4–6 weeks
• Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q4–6h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h q8–12h; Ciprofloxacin 20–30 mg/kg/24h IV/PO q12h

• Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)

• Preferred regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks AND Cefepime 6 g/24h IV q8h for 6 weeks AND Rifampin 900 mg/24h PO/IV q8h for 6 weeks
• Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Gentamicin 3 mg/kg/24h IV/IM q8h; Cefepime 150 mg/kg/24h IV q8h; Rifampin 20 mg/kg/24h PO/IV q8h

• Culture-negative, prosthetic valve endocarditis (late, > 1 year)

• Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
• Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks AND Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 6 weeks
• Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q4h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h q8–12h; Ciprofloxacin 20–30 mg/kg/24h IV/PO q12h

• Culture-negative, prosthetic valve endocarditis (early, ≤ 1 year)

• Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks AND Rifampin 900 mg/24h PO/IV q8h for 6 weeks
• Alternative regimen: Vancomycin 30 mg/kg/24h IV q12h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6 weeks AND Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 4–6 weeks AND Rifampin 900 mg/24h PO/IV q8h for 6 weeks
• Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q4–6h; Gentamicin 3 mg/kg/24h IV/IM q8h; Vancomycin 40 mg/kg/24h IV q8–12h; Cefepime 150 mg/kg/24h IV q8h; Rifampin 20 mg/kg/24h PO/IV q8h

• Pathogen-directed antimicrobial therapy

• Bartonella

• Suspected Bartonella endocarditis

• Preferred regimen : Ceftriaxone sodium 2 g/24h IV/IM in 1 dose for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks ± Doxycycline 200 mg/kg/24h IV/PO q12h for 6 weeks
• Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Gentamicin 3 mg/kg/24h IV/IM q8h; Doxycycline 2–4 mg/kg/24h IV/PO q12h; Rifampin 20 mg/kg/24h PO/IV q12h

• Documented Bartonella endocarditis

• Preferred regimen: Doxycycline 200 mg/24h IV or PO q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 2 weeks
• Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Gentamicin 3 mg/kg/24h IV/IM q8h; Doxycycline 2–4 mg/kg/24h IV/PO q12h; Rifampin 20 mg/kg/24h PO/IV q12h

• Enterococcus

• Endocarditis caused by enterococcal strains susceptible to penicillin, gentamicin, and vancomycin

• Preferred regimen : Ampicillin 12 g/24h IV q4h for 4–6 weeks OR Penicillin G 18–30 million U/24h IV either continuously or q4h for 4–6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 4–6weeks
• Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
• Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Gentamicin 3 mg/kg/24h IV/IM q8h

• Endocarditis caused by enterococcal strains susceptible to penicillin, streptomycin, and vancomycin and resistant to gentamicin

• Preferred regimen : Ampicillin 12 g/24h IV q4h for 4–6 weeks OR Penicillin G 24 million U/24h IV continuously or q4h for 4–6 weeks AND Streptomycin 15 mg/kg/24h IV/IM q12h for 4–6 weeks
• Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Streptomycin 15 mg/kg/24h IV/IM q12h for 6 weeks
• Pediatric dose: Ampicillin 300 mg/kg/24h IV q4–6h; Penicillin 300 000 U/kg/24h IV q4–6h; Streptomycin 20–30 mg/kg/24h IV/IM q12h; Vancomycin 40 mg/kg/24h IV q8–12h; Streptomycin 20–30 mg/kg/24h IV/IM q12h

• Endocarditis caused by enterococcal strains resistant to penicillin and susceptible to aminoglycoside and vancomycin

• β-Lactamase–producing strain

• Preferred regimen: Ampicillin-sulbactam 12 g/24h IV q6h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
• Alternative regimen : Vancomycin 30 mg/kg/24h IV q12h for 6 weeks
• Pediatric dose: Ampicillin-sulbactam 300 mg/kg/24h IV q6h; Gentamicin 3 mg/kg/24h IV/IM q8h

• Intrinsic penicillin resistance

• Preferred regimen: Vancomycin 30 mg/kg/24h IV q12h for 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8h for 6 weeks
• Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Gentamicin 3 mg/kg/24h IV/IM q8h

• Endocarditis caused by enterococcal strains resistant to penicillin, gentamicin, and vancomycin

• Enterococcus faecium

• Preferred regimen : Linezolid 1200 mg/24h IV/PO q12h for ≥ 8 weeks OR Quinupristin-Dalfopristin 22.5 mg/kg/24h IV q8h for 8 weeks

• Enterococcus faecalis

• Preferred regimen : Imipenem/cilastatin 2 g/24h IV q6h for ≥ 8 weeks AND Ampicillin 12 g/24h IV q4h for ≥ 8 weeks OR Ceftriaxone sodium 4 g/24h IV/IM q12h for ≥ 8 weeks AND Ampicillin 12 g/24h IV q4h for ≥ 8 weeks
• Pediatric dose: Linezolid 30 mg/kg/24h IV/PO q8h; Quinupristin-Dalfopristin 22.5 mg/kg/24h IV q8h; Imipenem/cilastatin 60–100 mg/kg/24h IV q6h; Ampicillin 300 mg/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM q12h

• HACEK organisms

• Endocarditis caused by Haemophilus, Aggregatibacter (Actinobacillus), Cardiobacterium, Eikenella corrodens, or Kingella

• Preferred regimen : Ceftriaxone sodium 2 g/24h IV/IM in 1 dose for 4 weeks OR Ampicillin 12 g/24h IV q6h for 4 weeks OR Ciprofloxacin 1000 mg/24h PO or 800 mg/24h IV q12h for 4 weeks
• Pediatric dose: Ceftriaxone 100 mg/kg/24h IV/IM once daily; Ampicillin-sulbactam 300 mg/kg/24h IV divided into 4 or 6 equally divided doses; Ciprofloxacin 20–30 mg/kg/24h IV/PO q12h

• Staphylococcus

• Native valve endocarditis caused by oxacillin-susceptible staphylococci

• Preferred regimen (1): Nafcillin or Oxacillin 12 g/24h IV q4–6h for 6 weeks ± Gentamicin 3 mg/kg/24h IV/IM q8–12h for 3–5 days
• Preferred regimen (2): Cefazolin 6 g/24h IV q8h for 6 weeks ± Gentamicin 3 mg/kg/24h IV/IM q8–12h for 3–5 days
• Pediatric dose: Nafcillin or Oxacillin 200 mg/kg/24h IV q4–6h; Gentamicin 3 mg/kg/24h IV/IM q8h; Cefazolin 100 mg/kg/24h IV q8h; Gentamicin 3 mg/kg/24h IV/IM q8h

• Native valve endocarditis caused by oxacillin-resistant staphylococci

• Preferred regimen: Vancomycin 30 mg/kg/24h IV q12h for 6 weeks
• Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h

• Prosthetic valve endocarditis caused by oxacillin-susceptible staphylococci

• Preferred regimen: Nafcillin or Oxacillin 12 g/24h IV q4h for ≥ 6 weeks AND Rifampin 900 mg/24h IV/PO q8h for ≥ 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8–12h for 2 weeks
• Pediatric dose: Nafcillin or Oxacillin 200 mg/kg/24h IV q4–6h; Rifampin 20 mg/kg/24h IV/PO q8h; Gentamicin 3 mg/kg/24h IV/IM q8h

• Prosthetic valve endocarditis caused by oxacillin-resistant staphylococci

• Preferred regimen: Vancomycin 30 mg/kg 24 h q12h for ≥ 6 weeks AND Rifampin 900 mg/24h IV/PO q8h for ≥ 6 weeks AND Gentamicin 3 mg/kg/24h IV/IM q8–12h for 2 weeks
• Pediatric dose: Vancomycin 40 mg/kg/24h IV q8–12h; Rifampin 20 mg/kg/24h IV/PO q8h (up to adult dose); Gentamicin 3 mg/kg/24h IV or IM q8h

• Viridans group streptococci and Streptococcus bovis

• Native valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)

• Preferred regimen: Penicillin G 12–18 million U/24h IV either continuously or q4–6h for 4 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 4 weeks
• Alternative regimen (1): (Penicillin G 12–18 million U/24h IV either continuously or q4h for 2 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 2 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
• Alternative regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
• Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

• Native valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 to ≤ 0.5 μg/mL)

• Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 4 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 4 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
• Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 4 weeks
• Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

• Prosthetic valve endocarditis caused by highly penicillin-susceptible viridans group streptococci and Streptococcus bovis (MIC ≤ 0.12 μg/mL)

• Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 6 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 6 weeks) ± Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
• Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
• Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

• Prosthetic valve endocarditis caused by relatively penicillin-resistant viridans group streptococci and Streptococcus bovis (MIC > 0.12 μg/mL)

• Preferred regimen (1): (Penicillin G 24 million U/24h IV either continuously or q4–6h for 6 weeks OR Ceftriaxone 2 g/24h IV/IM in 1 dose for 6 weeks) AND Gentamicin 3 mg/kg/24h IV/IM in 1 dose for 2 weeks
• Preferred regimen (2): Vancomycin 30 mg/kg/24h IV q12h not to exceed 2 g/24h for 6 weeks
• Pediatric dose: Penicillin G 200,000 U/kg/24h IV q4–6h; Ceftriaxone 100 mg/kg/24h IV/IM in 1 dose; Gentamicin 3 mg/kg/24h IV/IM in 1 dose or q8h; Vancomycin 40 mg/kg/24h IV q8–12h

Mycotic aneurysm ⇧ Return to Top ⇧

• Empiric antimicrobial therapy

• Preferred regimen: Vancomycin 2 g/day IV divided q6-12h targeting trough concentration of 15-20 μg/mL for 6 weeks (for critically ill patient, start with a loading dose of 25 mg/kg followed by 15 mg/kg q12h) AND (Ceftriaxone 2 g IV q24h for 6 weeks OR Piperacillin-Tazobactam 3.375 g IV q6h for 6 weeks OR Ciprofloxacin 400 mg IV q12h for 6 weeks)
• Alternative regimen: Consider substituting Daptomycin for Vancomycin. Consider Cefepime, Imipenem-Cilastatin, Meropenem, or Ertapenem for Gram-negative bacteria.

Myocarditis

Lyme carditis ⇧ Return to Top ⇧

• Lyme carditis, adult

• Parenteral regimen

• Preferred regimen: Ceftriaxone 2 g IV q24h for 14 (14–21) days
• Alternative regimen: Cefotaxime 2 g IV q8h for 14 (14–21) days OR Penicillin G 18–24 million U/day IV q4h for 14 (14–21) days

• Oral regimen

• Preferred regimen: Amoxicillin 500 mg tid for 14 (14–21) days OR Doxycycline 100 mg bid for 14 (14–21) days OR Cefuroxime 500 mg bid for 14 (14–21) days
• Alternative regimen: Azithromycin 500 mg PO qd for 7–10 days OR Clarithromycin 500 mg PO bid for 14–21 days (if the patient is not pregnant) OR Erythromycin 500 mg PO qid for 14–21 days

Note (1): Parenteral regimen is recommended at the start of therapy for patients who have been hospitalized for cardiac monitoring; oral regimen may be substituted to complete a course of therapy or to treat ambulatory patients.

Note (2): A temporary pacemaker may be required for patients with advanced heart block.

Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifestations.

• Lyme carditis, pediatric

• Parenteral regimen

• Preferred regimen: Ceftriaxone 50–75 mg/kg IV q24h (maximum, 2 g) for 14 (14–21) days
• Alternative regimen: Cefotaxime 150–200 mg/kg/day IV q6–8h (maximum, 6 g per day) for 14 (14–21) days OR Penicillin G 200,000–400,000 U/kg/day IV q4h (not to exceed 18–24 million U per day) for 14 (14–21) days

• Oral regimen

• Preferred regimen: Amoxicillin 50 mg/kg/day PO tid (maximum, 500 mg per dose) for 14 (14–21) days OR Doxycycline (for children aged ≥ 􏱢8 years) 4 mg/kg/day PO bid (maximum, 100 mg per dose) for 14 (14–21) days OR Cefuroxime 30 mg/kg/day PO bid (maximum, 500 mg per dose) for 14 (14–21) days
• Alternative regimen: Azithromycin 10 mg/kg/day (maximum of 500 mg per day) for 7–10 days OR Clarithromycin 7.5 mg/kg PO bid (maximum of 500 mg per dose) for 14–21 days OR Erythromycin 12.5 mg/kg PO qid (maximum of 500 mg per dose) for 14–21 days

Note (1): Parenteral regimen is recommended at the start of therapy for patients who have been hospitalized for cardiac monitoring; oral regimen may be substituted to complete a course of therapy or to treat ambulatory patients.

Note (2): A temporary pacemaker may be required for patients with advanced heart block.

Note (3): Patients treated with macrolides should be closely observed to ensure resolution of the clinical manifestations.

Pericarditis

Pericarditis, bacterial ⇧ Return to Top ⇧

• Bacterial pericarditis

• Empiric antimicrobial therapy

• Preferred regimen: Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 28 days AND Ciprofloxacin 400 mg IV q12h for 28 days
• Alternative regimen (1): Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 28 days AND Cefepime 2 g IV q12h for 28 days
• Alternative regimen (2): Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days AND Ceftriaxone 2 g IV q24h for 14–42 days

Note: Pericardiocentesis must be promptly performed. Pericardial drainage combined with effective systemic antibiotic therapy is mandatory (antistaphylococcal agent plus aminoglycoside, followed by tailored antibiotic therapy according to cultures). Frequent irrigation of the pericardial cavity with urokinase or streptokinase may be considered. Open surgical drainage through subxiphoid pericardiotomy is preferable. Pericardiectomy may be required in patients with dense adhesions, loculated and thick purulent effusion, recurrence of tamponade, persistent infection, and progression to constriction.

• Specific considerations

• Purulent pericarditis with contiguous pneumonia

• Preferred regimen: Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL AND (Ceftriaxone 1–2 g IV q12h OR Cefotaxime 2 g IV q6–8h) AND (Ciprofloxacin 400 mg IV q12h OR Levofloxacin 500–750 mg IV q24h)

• Purulent pericarditis with contiguous head and neck infection

• Preferred regimen: Imipenem 500 mg IV q6–8h OR Ampicillin-Sulbactam 3 g IV q6h

• Purulent pericarditis secondary to infective endocarditis

• Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h targeting trough levels of 15–20 μg/mL AND Gentamicin 3 mg/kg/day IV q8–12h

• Purulent pericarditis after cardiac surgery, pediatric

• Preferred regimen: Vancomycin 15 mg/kg IV q6h targeting trough levels of 15–20 μg/mL AND (Ceftriaxone 100 mg/kg/day IV q12–24h OR Cefotaxime 200–300 mg/kg/day IV q6–8h) AND Gentamicin 6–7.5 mg/kg/day IV q8h

• Purulent pericarditis with genitourinary infection, pediatric

• Preferred regimen: Vancomycin 15 mg/kg IV q6h targeting trough levels of 15–20 μg/mL AND (Ceftriaxone 100 mg/kg/day IV q12–24h OR Cefotaxime 200–300 mg/kg/day IV q6–8h) AND Gentamicin 6–7.5 mg/kg/day IV q8h

• Purulent pericarditis in immunocompromised host, pediatric

• Preferred regimen: Vancomycin 15 mg/kg IV q6h targeting trough levels of 15–20 μg/mL AND (Ceftriaxone 100 mg/kg/day IV q12–24h OR Cefotaxime 200–300 mg/kg/day IV q6–8h) AND Gentamicin 6–7.5 mg/kg/day IV q8h

• Pathogen-directed antimicrobial therapy

• Anaerobes

• Preferred regimen: Clindamycin 600–900 mg IV q8h for 14–42 days OR Metronidazole 7.5 mg/kg IV q6h for 14–42 days OR Ampicillin-Sulbactam 3 g IV q6h for 14–42 days

• Gram-negative bacilli

• Preferred regimen: Ciprofloxacin 400 mg IV q12h for 14–42 days OR Levofloxacin 500–750 mg IV q24h for 14–42 days OR Cefepime 2 g IV q12h for 14–42 days

• Legionella pneumophila

• Preferred regimen: Ciprofloxacin 400 mg IV q12h for 14–42 days OR Levofloxacin 500–750 mg IV q24h for 14–42 days OR Azithromycin 500 mg IV q24h for 14–42 days

• Mycoplasma pneumoniae

• Preferred regimen: Doxycycline 100 mg IV q12h for 14–42 days OR Azithromycin 500 mg IV q24h for 14–42 days

• Neisseria meningitidis

• Preferred regimen: Penicillin G 5–24 MU/day IM/IV q4–6h for 14–42 days OR Cefotaxime 2 g IV q6–8h for 14–42 days OR Ceftriaxone 2 g IV q24h for 14–42 days

• Staphylococcus aureus, methicillin-susceptible

• Preferred regimen: Nafcillin 1–2 g IV q4h for 14–42 days OR Oxacillin 1–2 g IV q4h for 14–42 days OR Cefazolin 1–2 g IV q48h for 14–42 days OR Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days OR Clindamycin 600–900 mg IV q8h for 14–42 days

• Staphylococcus aureus, methicillin-resistant

• Preferred regimen: Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days OR Linezolid 600 mg IV q12h for 14–42 days

• Streptococcus pneumoniae, penicillin-susceptible

• Preferred regimen: Penicillin G 5–24 MU/day IM/IV q4–6h for 14–42 days OR Cefotaxime 2 g IV q6–8h for 14–42 days OR Ciprofloxacin 400 mg IV q12h for 14–42 days OR Levofloxacin 500–750 mg IV q24h for 14–42 days

• Streptococcus pneumoniae, penicillin-resistant

• Preferred regimen: Ciprofloxacin 400 mg IV q12h for 14–42 days OR Levofloxacin 500–750 mg IV q24h for 14–42 days OR Vancomycin 1 g IV q12h targeting trough levels of 15–20 μg/mL for 14–42 days

Central Nervous System

Brain abscess ⇧ Return to Top ⇧

• Empiric antimicrobial therapy

• Brain abscess in otherwise healthy patients

• Preferred regimen: (Cefotaxime 8–12 g/day IV q4–6h OR Ceftriaxone 4 g/day IV q12h) AND Metronidazole 30 mg/kg/day IV q6h
• Alternative regimen: Meropenem 6 g/day IV q8h

• Brain abscess with comorbidities

• Otitis media, mastoiditis, or sinusitis

• Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h

• Dental infection

• Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h

• Penetrating trauma or post-neurosurgy

• Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h OR Cefepime 2 g IV q12h) AND Vancomycin 30–45 mg/kg/day q8–12h

• Lung abscess, empyema, or bronchiectasis

• Preferred regimen: Penicillin G 4 MU IV q4h AND Metronidazole 30 mg/kg/day q6h AND TMP-SMZ 10–20 mg/kg/day q6–12h

• Bacterial endocarditis

• Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h AND Gentamicin 5 mg/kg/day IV q8h

• Congenital heart disease

• Preferred regimen: Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h

• Transplant recipients

• Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Metronidazole 30 mg/kg/day q6h AND Voriconazole 8 mg/kg/day q12h AND (TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h)

• Patients with HIV/AIDS

• Preferred regimen: (Cefotaxime 8–12 g/day q4–6h OR Ceftriaxone 4 g/day q12h) AND Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd

• Staphylococcus aureus coverage

• Preferred regimen: Vancomycin 30–45 mg/kg/day q8–12h

• Mycobacterium tuberculosis coverage

• Preferred regimen: Isoniazid 300 mg qd AND Rifampin 600 mg qd AND Pyrazinamide 15–30 mg qd AND Ethambutol 15 mg/kg/day qd

• Pathogen-directed antimicrobial therapy

• Bacteria

• Actinomyces

• Preferred regimen: Penicillin G 4 MU IV q4h
• Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h

• Bacteroides fragilis

• Preferred regimen: Metronidazole 30 mg/kg/day IV q6h
• Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h

• Enterobacteriaceae

• Preferred regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h
• Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR TMP-SMZ 10–20 mg/kg/day q6–12h OR Ciprofloxacin 800–1200 mg/day IV q8–12h OR Meropenem 2 g IV q8h

• Fusobacterium

• Preferred regimen: Metronidazole 30 mg/kg/day q6h
• Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h OR Meropenem 2 g IV q8h

• Haemophilus

• Preferred regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h
• Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR TMP-SMZ 10–20 mg/kg/day q6–12h

• Listeria monocytogenes

• Preferred regimen: Ampicillin 12 g/day q4h OR Penicillin G 4 MU IV q4h
• Alternative regimen: TMP-SMZ 10–20 mg/kg/day q6–12h

• Nocardia

• Preferred regimen: TMP-SMZ 10–20 mg/kg/day q6–12h OR Sulfadiazine 4–6 g/day q6h
• Alternative regimen: Meropenem 2 g IV q8h OR Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Amikacin 15 mg/kg/day IV q8h

• Prevotella melaninogenica

• Preferred regimen: Metronidazole 30 mg/kg/day q6h
• Alternative regimen: Clindamycin 2400–4800 mg/day IV q6h OR Meropenem 2 g IV q8h

• Pseudomonas aeruginosa

• Preferred regimen: Ceftazidime 6 g/day q8h OR Cefepime 6 g/day q8h
• Alternative regimen: Aztreonam 6–8 g/day IV q6–8h OR Ciprofloxacin 800–1200 mg/day IV q8–12h OR Meropenem 2 g IV q8h

• Staphylococcus aureus, methicillin-susceptible

• Preferred regimen: Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h
• Alternative regimen: Vancomycin 30–45 mg/kg/day IV q8–12h

• Staphylococcus aureus, methicillin-resistant

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h
• Alternative regimen: TMP-SMZ 10–20 mg/kg/day q6–12h

• Streptococcus

• Preferred regimen: Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h
• Alternative regimen: Cefotaxime 2 g IV q4-6h OR Ceftriaxone 2 g IV q12h OR Vancomycin 30–45 mg/kg/day IV q8–12h

• Fungi

• Aspergillus

• Preferred regimen: Voriconazole 8 mg/kg/day q12h
• Alternative regimen: Amphotericin B deoxycholate 0.6–1.0 mg/kg/day IV q24h OR Amphotericin B lipid complex 5 mg/kg/day IV q24h OR Itraconazole 400–600 mg/day IV q12h OR Posaconazole 800 mg/kg/day IV q6–12h

• Candida

• Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
• Alternative regimen: Fluconazole 400–800 mg/day IV q24h

• Cryptococcus neoformans

• Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
• Alternative regimen: Fluconazole 400–800 mg/day IV q24h

• Mucorales

• Preferred regimen: Amphotericin B lipid complex 5 mg/kd/day q24h OR Amphotericin B deoxycholate 15 mg/kg/day q8h
• Alternative regimen: Posaconazole 800 mg/kg/day IV q6–12h

• Pseudallescheria boydii (Scedosporium apiospermum)

• Preferred regimen: Voriconazole 8 mg/kg/day q12h
• Alternative regimen: Itraconazole 400–600 mg/day IV q12h OR Posaconazole 800 mg/kg/day IV q6–12h

• Protozoa

• Toxoplasma gondii

• Preferred regimen: Sulfadiazine 4–6 g/day q6h AND Pyrimethamine 25–100 mg/day qd
• Alternative regimen (1): Pyrimethamine 25–100 mg/day qd AND Clindamycin 2400–4800 mg/day IV q6h
• Alternative regimen (2): Pyrimethamine 25–100 mg/day qd AND (Azithromycin 1200–1500 mg/day IV q24h OR Atovaquone 750 mg IV q6h OR Dapsone 100 mg PO q24h)
• Alternative regimen (3): TMP-SMZ 10–20 mg/kg/day q6–12h

Cerebrospinal fluid shunt infection ⇧ Return to Top ⇧

• Empiric antimicrobial therapy

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Cefepime 2 g IV q8h OR Ceftazidime 2 g IV q8h OR Meropenem 2 g IV q8h)

• Pathogen-directed antimicrobial therapy

• Enterococcus

• Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) AND Gentamicin 1–1.7 mg/kg IV q8h

• Gram-negative bacilli

• Preferred regimen: Ceftriaxone 2 g IV q12h OR Cefepime 2 g IV q12h OR Meropenem 2 g IV q8h OR Aztreonam 2 g IV q6h

• Propionibacterium acnes

• Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) ± Gentamicin 1–1.7 mg/kg IV q8h

• Staphylococcus, coagulase-negative

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h ± Rifampin 600 mg IV/PO q24h

• Staphylococcus aureus, methicillin-resistant

• Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h ± Rifampin 600 mg IV/PO q24h

• Staphylococcus aureus, methicillin-susceptible

• Preferred regimen: (Nafcillin 2 g IV q4h OR Oxacillin 2 g IV q4h) ± Rifampin 600 mg IV/PO q24h

• Streptococcus agalactiae

• Preferred regimen: (Penicillin G 4 MU IV q4h OR Ampicillin 2 g IV q4h) AND Gentamicin 1–1.7 mg/kg IV q8h

• Fungi

• Preferred regimen: Amphotericin B 0.6–1.0 mg/kg IV q24h OR Amphotericin B liposomal 5 mg/kg/day IV q24h

Encephalitis ⇧ Return to Top ⇧

• Empiric antimicrobial therapy

• Preferred regimen: Acyclovir 10 mg/kg IV q8h for 14–21 days

Note (1): Acyclovir should be initiated in all patients with suspected encephalitis, pending results of diagnostic studies.

Note (2): Other empiric antimicrobial agents should be administered on the basis of specific epidemiologic or clinical clues.

• Specific epidemiologic considerations

• Agammaglobulinemia — Enteroviruses, Mycoplasma pneumoniae
• Age

• Neonates — Herpes simplex virus type 2, cytomegalovirus, rubella virus, Listeria monocytogenes, Treponema pallidum, Toxoplasma gondii
• Infants and children — Eastern equine encephalitis virus, Japanese encephalitis virus, Murray Valley encephalitis virus, influenza virus, La Crosse virus
• Elderly persons — Eastern equine encephalitis virus, St. Louis encephalitis virus, West Nile virus, sporadic CJD, L. monocytogenes

• Animal contact

• Bats — Rabies virus, Nipah virus
• Birds — West Nile virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, Cryptococcus neoformans (bird droppings)
• Cats — Rabies virus, Coxiella burnetii, Bartonella henselae, T. gondii
• Dogs — Rabies virus
• Horses — Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, Hendra virus
• Old World primates — B virus
• Raccoons — Rabies virus, Baylisascaris procyonis
• Rodents — Eastern equine encephalitis virus (South America), Venezuelan equine encephalitis virus, tickborne encephalitis virus, Powassan virus (woodchucks), La Crosse virus (chipmunks and squirrels), Bartonella quintana
• Sheep and goats — C. burnetii
• Skunks — Rabies virus
• Swine — Japanese encephalitis virus, Nipah virus
• White-tailed deer — Borrelia burgdorferi

• Immunocompromised persons — Varicella zoster virus, cytomegalovirus, human herpesvirus 6, West Nile virus, HIV, JC virus, L. monocytogenes, Mycobacterium tuberculosis, C. neoformans, Coccidioides species, Histoplasma capsulatum, T. gondii

• Ingestion

• Raw or partially cooked meat — T. gondii
• Raw meat, fish, or reptiles — Gnanthostoma species
• Unpasteurized milk — Tickborne encephalitis virus, L. monocytogenes, C. burnetii

• Insect contact

• Mosquitoes — Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, Murray Valley encephalitis virus, Japanese encephalitis virus, West Nile virus, La Crosse virus, Plasmodium falciparum
• Sandflies — Bartonella bacilliformis
• Ticks — Tickborne encephalitis virus, Powassan virus, Rickettsia rickettsii, Ehrlichia chaffeensis, Anaplasma phagocytophilum, C. burnetii (rare), B. burgdorferi
• Tsetse flies — Trypanosoma brucei gambiense, Trypanosoma brucei rhodesiense

• Occupation

• Exposure to animals — Rabies virus, C. burnetii, Bartonella species
• Exposure to horses — Hendra virus
• Exposure to Old World primates — B virus
• Laboratory workers — West Nile virus, HIV, C. burnetii, Coccidioides species
• Physicians and health care workers — Varicella zoster virus, HIV, influenza virus, measles virus, M. tuberculosis
• Veterinarians — Rabies virus, Bartonella species, C. burnetii

• Person-to-person transmission — Herpes simplex virus (neonatal), varicella zoster virus, Venezuelan equine encephalitis virus (rare), poliovirus, nonpolio enteroviruses, measles virus, Nipah virus, mumps virus, rubella virus, Epstein-Barr virus, human herpesvirus 6, B virus, West Nile virus (transfusion, transplantation, breast feeding), HIV, rabies virus (transplantation), influenza virus, M. pneumoniae, M. tuberculosis, T. pallidum

• Recent vaccination — Acute disseminated encephalomyelitis

• Recreational activities

• Camping/hunting — Agents transmitted by mosquitoes and ticks
• Sexual contact — HIV, T. pallidum
• Spelunking — Rabies virus, H. capsulatum
• Swimming — Enteroviruses, Naegleria fowleri

• Season

• Late summer/early fall — Agents transmitted by mosquitoes and ticks, enteroviruses
• Winter — Influenza virus

• Transfusion and transplantation — Cytomegalovirus, Epstein-Barr virus, West Nile virus, HIV, tickborne encephalitis virus, rabies virus, iatrogenic CJD, T. pallidum, A. phagocytophilum, R. rickettsii, C. neoformans, Coccidioides species, H. capsulatum, T. gondii

• Travel

• Africa — Rabies virus, West Nile virus, P. falciparum, T. brucei gambiense, T. brucei rhodesiense
• Australia — Murray Valley encephalitis virus, Japanese encephalitis virus, Hendra virus
• Central America — Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, P. falciparum, Taenia solium
• Europe — West Nile virus, tickborne encephalitis virus, A. phagocytophilum, B. burgdorferi
• India, Nepal — Rabies virus, Japanese encephalitis virus, P. falciparum
• Middle East — West Nile virus, P. falciparum
• Russia — Tickborne encephalitis virus
• South America — Rabies virus, Eastern equine encephalitis virus, Western equine encephalitis virus, Venezuelan equine encephalitis virus, St. Louis encephalitis virus, R. rickettsii, B. bacilliformis (Andes mountains), P. falciparum, T. solium
• Southeast Asia, China, Pacific Rim — Japanese encephalitis virus, tickborne encephalitis virus, Nipah virus, P. falciparum, Gnanthostoma species, T. solium
• Unvaccinated status — Varicella zoster virus, Japanese encephalitis virus, poliovirus, measles virus, mumps virus, rubella virus

• Specific clinical considerations

• General findings

• Hepatitis — Coxiella burnetii
• Lymphadenopathy — HIV, Epstein-Barr virus, cytomegalovirus, measles virus, rubella virus, West Nile virus, Treponema pallidum, Bartonella henselae and other Bartonella species, Mycobacterium tuberculosis, Toxoplasma gondii, Trypanosoma brucei gambiense
• Parotitis — Mumps virus
• Rash — Varicella zoster virus, B virus, human herpesvirus 6, West Nile virus, rubella virus, some enteroviruses, HIV, Rickettsia rickettsii, Mycoplasma pneumoniae, Borrelia burgdorferi, T. pallidum, Ehrlichia chaffeensis, Anaplasma phagocytophilum
• Respiratory tract findings — Venezuelan equine encephalitis virus, Nipah virus, Hendra virus, influenza virus, adenovirus, M. pneumoniae, C. burnetii, M. tuberculosis, Histoplasma capsulatum
• Retinitis — Cytomegalovirus, West Nile virus, B. henselae, T. pallidum
• Urinary symptoms — St. Louis encephalitis virus

• Neurologic findings

• Cerebellar ataxia — Varicella zoster virus (children), Epstein-Barr virus, mumps virus, St. Louis encephalitis virus, Tropheryma whipplei, T. brucei gambiense
• Cranial nerve abnormalities — Herpes simplex virus, Epstein-Barr virus, Listeria monocytogenes, M. tuberculosis, T. pallidum, B. burgdorferi, T. whipplei, Cryptococcus neoformans, Coccidioides species, H. capsulatum
• Dementia — HIV, human transmissible spongiform encephalopathies (sCJD and vCJD), measles virus (SSPE), T. pallidum, T. whipplei
• Myorhythmia — T. whipplei (oculomasticatory)
• Parkinsonism — Japanese encephalitis virus, St. Louis encephalitis virus, West Nile virus, Nipah virus, T. gondii, T. brucei gambiense
• Poliomyelitis-like flaccid paralysis — Japanese encephalitis virus, West Nile virus, tickborne encephalitis virus; enteroviruses (enterovirus-71, coxsackieviruses), poliovirus
• Rhombencephalitis — Herpes simplex virus, West Nile virus, enterovirus 71, L. monocytogenes

• Pathogen-directed antimicrobial therapy

• Viruses

• Adenovirus

• Preferred regimen: supportive

• B virus (herpes B virus)

• Established disease

• Preferred regimen: Valacyclovir 1,000 mg PO tid OR Ganciclovir 5 mg/kg IV q12h for ≥ 14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily indefinitely OR Valacyclovir 1 g PO tid indefinitely
• Alternative regimen: Acyclovir 15 mg/kg IV q8h for ≥ 14 days until resolution of neurologic symptoms, then Acyclovir 800 mg PO 5 times daily OR Valacyclovir 1 g PO tid indefinitely

• Prophylaxis after bite or scratch

• Preferred regimen: Valacyclovir 1,000 mg PO tid

• Cytomegalovirus (CMV)

• Preferred regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance AND Foscarnet 90 mg/kg IV q12h for 14–21 days, followed by 90-120 mg/kg IV qd for maintenance

• Eastern equine encephalitis virus

• Preferred regimen: supportive

• Epstein-Barr virus (EBV)

• Preferred regimen: supportive ± Corticosteroids

Note: Acyclovir is not recommended.

• Hendra virus

• Preferred regimen: supportive

• HSV-1 and HSV-2

• Preferred regimen: Acyclovir 10 mg/kg IV q8h for 14–21 days
• Preferred regimen (neonates): Acyclovir 20 mg/kg IV q8h for 21 days

• Human herpesvirus 6 (HHV-6)

• Preferred regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance OR Foscarnet 90 mg/kg IV q12h for 14–21 days, followed by 90-120 mg/kg IV qd for maintenance

• Human immunodeficiency virus (HIV)

• Preferred regimen: HAART

• Influenza virus

• Preferred regimen: Oseltamivir 75 mg PO bid

• Japanese encephalitis virus

• Preferred regimen: supportive

Note: Interferon alpha is not recommended.

• JC virus

• Preferred regimen: Reversal or control of immunosuppression OR HAART in patients with AIDS

• La Crosse virus

• Preferred regimen: supportive

• Measles virus

• Life-threatening disease

• Preferred regimen: Ribavirin

• SSPE

• Preferred regimen: Ribavirin intrathecal

• Mumps virus

• Preferred regimen: supportive

• Murray Valley encephalitis virus

• Preferred regimen: supportive

• Nipah virus

• Preferred regimen: supportive

• Alternative regimen: Ribavirin

• Nonpolio enteroviruses

• Preferred regimen: supportive

Note: Consider intraventricular γ-globulin for chronic and/or severe disease.

• Poliovirus

• Preferred regimen: supportive

• Powassan virus

• Preferred regimen: supportive

• Rabies virus

• Preferred regimen: supportive

Note: Administer rabies immunoglobulin and vaccination for postxposure prophylaxis.

• Rubella virus

• Preferred regimen: supportive

• St. Louis encephalitis virus

• Preferred regimen: supportive
• Alternative regimen: IFN-α-2b

• Tickborne encephalitis virus

• Preferred regimen: supportive

• Vaccinia

• Preferred regimen: supportive ± Corticosteroids (if suggestive of post-immunization)

• Venezuelan equine encephalitis virus

• Preferred regimen: supportive

• Varicella zoster virus (VZV)

• Preferred regimen: Acyclovir 10–15 mg/kg IV q8h for 10–14 days ± Corticosteroids
• Alternative regimen: Ganciclovir 5 mg/kg IV q12h for 14–21 days, followed by 5 mg/kg IV qd for maintenance ± Corticosteroids

• West Nile virus

• Preferred regimen: supportive

• Western equine encephalitis virus

• Preferred regimen: supportive

• Bacteria

• Anaplasma phagocytophilum (human granulocytotrophic ehrlichiosis)

• Preferred regimen: Doxycycline

• Bartonella bacilliformis (Oroya fever, Carrion's disease)

• Preferred regimen: Chloramphenicol OR Ciprofloxacin] OR Doxycycline OR Ampicillin OR Trimethoprim-Sulfamethoxazole

• Bartonella henselae (cat scratch disease)

• Preferred regimen: Doxycycline OR Azithromycin ± Rifampin

• Borrelia burgdorferi (Lyme disease)

• Preferred regimen: Ceftriaxone OR Cefotaxime OR Penicillin G

• Coxiella burnetii (Q fever)

• Preferred regimen: Doxycycline AND Fluoroquinolone AND Rifampin

• Ehrlichia chaffeensis (human monocytotrophic ehrlichiosis)

• Preferred regimen: Doxycycline

• Listeria monocytogenes

• Preferred regimen: Ampicillin AND Gentamicin
• Alternative regimen: Trimethoprim-Sulfamethoxazole

• Mycobacterium tuberculosis

• Preferred regimen: (Isoniazid AND Rifampin AND Pyrazinamide AND Ethambutol) ± Dexamethasone (if suggestive of meningitis)

• Mycoplasma pneumoniae

• Preferred regimen: Azithromycin OR Doxycycline OR Fluoroquinolone

• Rickettsia rickettsii (Rocky Mountain spotted fever)

• Preferred regimen: Doxycycline
• Alternative regimen: Chloramphenicol (for pregnant patients)

• Treponema pallidum (syphilis)

• Preferred regimen: Penicillin G
• Alternative regimen: Ceftriaxone

• Tropheryma whipplei (Whipple's disease)

• Preferred regimen: Ceftriaxone for 2–4 weeks, followed by Trimethoprim-Sulfamethoxazole for 1–2 years OR Cefixime for 1–2 years

• Fungi

• Coccidioides

• Preferred regimen: Fluconazole
• Alternative regimen: Itraconazole OR Voriconazole OR Amphotericin B (intravenous and intrathecal)

• Cryptococcus neoformans

• Preferred regimen (1): Amphotericin B deoxycholate AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
• Preferred regimen (2): Amphotericin B lipid complex AND Flucytosine for 2 weeks, followed by Fluconazole for 8 weeks
• Preferred regimen (3): Amphotericin B deoxycholate AND Flucytosine for 6–10 weeks, followed by Fluconazole for 8 weeks

Note: Consider placement of lumbar drain or VP shunt.

• Histoplasma capsulatum

• Preferred regimen: Amphotericin B liposomal for 4–6 weeks, followed by Itraconazole for at least 1 year and until resolution of CSF abnormalities

• Protozoa

• Acanthamoeba

• Preferred regimen (1): Trimethoprim-Sulfamethoxazole AND Rifampin AND Ketoconazole
• Preferred regimen (2): Fluconazole AND Sulfadiazine AND Pyrimethamine

• Balamuthia mandrillaris

• Preferred regimen: (Azithromycin OR Clarithromycin) AND Pentamidine AND Flucytosine AND Fluconazole AND Sulfadiazine AND (Thioridazine OR Trifluoperazine)

• Naegleria fowleri

• Preferred regimen: Amphotericin B (intravenous and intrathecal) AND Rifampin AND (Azithromycin OR Sulfisoxazole OR Miconazole)

• Plasmodium falciparum

• Preferred regimen: Quinine OR Quinidine OR Artesunate OR Artemether
• Alternative regimen (1): Atovaquone-Proguanil
• Alternative regimen (2): Exchange transfusion (for > 10% parasitemia or cerebral malaria)

• Toxoplasma gondii

• Preferred regimen: Pyrimethamine AND Sulfadiazine OR Clindamycin
• Alternative regimen (1): Trimethoprim-sulfamethoxazole
• Alternative regimen (2): Pyrimethamine AND (Atovaquone OR Clarithromycin OR Azithromycin OR Dapsone

• Trypanosoma brucei gambiense (West African trypanosomiasis)

• Preferred regimen: Eflornithine OR Melarsoprol

• Trypanosoma brucei rhodesiense (East African trypanosomiasis)

• Preferred regimen: Melarsoprol

• Helminths

• Baylisascaris procyonis

• Preferred regimen: Albendazole AND Diethylcarbamazine AND Corticosteroids

• Gnathostoma

• Preferred regimen: Albendazole OR Ivermectin

• Taenia solium (cysticercosis)

• Preferred regimen: Albendazole AND Corticosteroids
• Alternative regimen: Praziquantel AND Corticosteroids

• Prion

• Human transmissible spongiform encephalopathy

• Preferred regimen: supportive

Epidural abscess ⇧ Return to Top ⇧

• Spinal epidural abscess

• Empiric antimicrobial therapy

• Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks AND Ceftriaxone 2 g Iv q24h for 2–4 weeks, then PO to complete 6–8 weeks

Note (1): Decompressive laminectomy in conjunction with long-term antibiotic therapy tailored to culture results is required.

Note (2): For critically ill patients, a vancomycin loading dose of 20–25 mg/kg may be considered.

• Pathogen-directed antimicrobial therapy

• Penicillin-susceptible Staphylococcus aureus or Streptococcus

• Preferred regimen: Penicillin G 4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks

• Methicillin-susceptible Staphylococcus aureus or Streptococcus

• Preferred regimen: Cefazolin 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks OR Nafcillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Oxacillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
• Alternative regimen: Clindamycin 600 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks

• Methicillin-resistant Staphylococcus aureus

• Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks

• Streptococcus

• Preferred regimen: Penicillin G 3–4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Ampicillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks

• Enterococcus

• Preferred regimen: Penicillin G 3–4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Ampicillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks

• Enterobacteriaceae

• Preferred regimen: Ceftriaxone 1–2 g IV q12h for 2–4 weeks, then PO to complete 6–8 weeks OR Cefotaxime 2 g IV q6–8h for 2–4 weeks, then PO to complete 6–8 weeks

• Gram-negative bacteria

• Preferred regimen:Ceftazidime 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks OR Cefepime 2 g IV q12h for 2–4 weeks, then PO to complete 6–8 weeks
• Alternative regimen: Ciprofloxacin 400 mg IV q12h for 2–4 weeks, then PO to complete 6–8 weeks {{or]] Levofloxacin 750 mg IV q24h for 2–4 weeks, then PO to complete 6–8 weeks OR Moxifloxacin 400 mg IV q24h for 2–4 weeks, then PO to complete 6–8 weeks

• Anaerobes

• Preferred regimen: Metronidazole 500 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks

• Staphylococcus, Gram-negative bacteria, and anaerobes (mixed infection)

• Preferred regimen: Ampicillin-Sulbactam 3 g IV q6h for 2–4 weeks, then PO to complete 6–8 weeks OR Ticarcillin-Clavulanate 3.1 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Piperacillin-Tazobactam 3.375 g IV q4–6h for 2–4 weeks, then PO to complete 6–8 weeks
• Alternative regimen: Imipenem 500–1000 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks OR Meropenem 1–2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks

Gastrointestinal and Intraabdominal

Tropical sprue ⇧ Return to Top ⇧

• Tropical sprue

• Preferred regimen: Folic acid 5 mg PO bid for 2 weeks, followed by 1 mg PO tid AND (Tetracycline 250 mg PO qid OR Doxycycline 100 mg PO qd for 4–6 weeks, up to 6 months in residents of the tropics who have had long-term disease)
• Alternative regimen: Folic acid 5 mg PO bid for 2 weeks, followed by 1 mg PO tid AND Ampicillin 500 mg bid for ≥ 4 weeks

Note: Vitamin B12 deficiency may be corrected with Vitamin B12 1000 mcg IM weekly for 4 weeks, followed by monthly for 3 to 6 months.