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:

• Trimethoprim-sulfamethoxazole PO bid AND vancomycin 1 g IV every 12 hr

• If allergic to penicillin:

• Clindamycin 300 mg PO qid for 7 days OR Erythromycin 500 mg PO qid for 7 days OR Levofloxacin 500 mg PO daily or Moxifloxacin 400 mg PO daily for 7 days.

Neutropenic fever, prophylaxis

      Neutropenic fever, prophylaxis
    
   ::*Recommendation A-2a rests primarily on meta-analyses from a Cochrane review,which showed that systemically absorbed oral fluoroquinolones are the most tolerable choice for prophylaxis in neutropenic oncology patients and are equally protective whether used alone or combined with other antibacterials active against Gram-positive organisms.

• Evidence from other meta-analyses77,79–81,105,106 supported Recommendation A-2b for use of an orally administered triazole antifungal drug (eg, fluconazole) to prevent invasive Candida infections in patients with > 10% risk or a mold-active triazole (eg, itraconazole oral solution) if aspergillosis risk is > 6%.
• A systematic review and meta-analysis of RCTs87,107 supported Recommendation A-2c on use of trimethoprim-sulfamethoxazole to prevent Pneumocystis pneumonia in immunocompromised patients not infected by HIV. The Panel recommends use of lamivudine for HBV prophylaxis (Recommendation A-2d); systematic reviews,suggested it is the only drug available to treat active HBV infection that also has been studied in an RCT to prevent HBV reactivation in oncology patients at risk. A Cochrane review91 reported that acyclovir was the only nucleoside analog tested in placebo-controlled trials as prophylaxis against reactivation of herpesviruses in oncology patients at risk (Recommendation A-2e); meta-analyses showed acyclovir decreased both oral lesions and viral isolates. Recommendation A-2f on use of inactivated trivalent influenza vaccine is based on a Cochrane review of RCTs of viral vaccines for patients with hematologic malignancies103 and agrees with other guidelines.

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