Sandbox/Alejandro

Neutropenic Patients Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005

• Patients with neutropenia require an antimicrobial therapy with a broader coverage.
• The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.

Recommended Duration of Antimicrobial Therapy Based on the Microorganism.

Microorganism	Duration of Therapy
▸ Gram-negative Bacteria	7-14 days
▸ Gram-positive Bacteria	7-10 days
▸ Fungi	Until clinical resolution

▸ Click on the following categories to expand treatment regimens.

Neutropenia   ▸  Gram-Negative Bacteria   ▸  Gram-Positive Bacteria   ▸  Fungi

Gram-Negative Bacteria Preferred Regimen ▸ Meropenem 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min) OR ▸ Imipenem/cilastatin 0.5–1 g IV q6–8h(max: 50mg/kg/day) OR ▸ Ertapenem 1 g IV/IM q24h OR ▸ Cefepime 2g IV q8h OR ▸ Ceftazidime 2g IV q8h OR ▸ Piperacillin/tazobactam 3.375 g IV q6–8h Alternative Regimen 1 ▸ Amikacin 15 mg/kg/day IV/IM divided q8-12h (max: 15 mg/kg/day) OR ▸ Gentamicin 3-5 mg/kg/day IV/IM divided q6-8h OR ▸ Gentamicin 4-7 mg/kg/day IV q24h (adjust dosage based on serum concentrations) PLUS ▸ Cefepime 2g IV q8h OR ▸ Piperacillin/tazobactam 3.375 g IV q6–8h (max 24 g/day) Alternative Regimen 2 ▸ Piperacillin/tazobactam 3.375 g IV q6–8h (max 24 g/day) PLUS ▸ Ciprofloxacin 400mg IV q8h Gram-Positive Bacteria Preferred Regimen ▸ Vancomycin† 15-20 mg/kg IV q8-12h Alternative Regimen ▸ Linezolid 600 mg IV/PO q12h OR ▸ Daptomycin 4mg/kg IV q24h † Vancomycin should be discontinued if culture results remain negative after 72-96 hrs Fungi Preferred Regimen ▸ Liposomal Amphotericin B 3 mg/kg/day IV × 1-2 weeks OR ▸ Amphotericin B deoxycholate 0.7-1 mg/kg/day IV × 1-2 weeks OR ▸ Amphotericin B lipid complex 5 mg/kg/day IV × 1-2 weeks Alternative Regimen ▸ Voriconazole 6 mg/kg IV q12h x 1 day, then 3 mg/kg IV q12h OR ▸ Voriconazole 200 mg PO q12h OR ▸ Caspofungin 70 mg IV once, then 50 mg IV q24h x ≥ 14 days

Cellular Immune Deficient Patients Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005

• Patients with cellular immunodeficiency require a pathogen-specific antimicrobial therapy.
• The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.

Recommended Duration of Antimicrobial Therapy Based on the Microorganism.

Microorganism	Duration of Therapy
▸ Nocardia spp	3-12 months
▸ Atypical mycobacteria	6-12 months
▸ Cryptococcus spp	8-12 weeks
▸ Histoplasma spp	≥ 12 months
▸ Varicella-zoster virus	7-10 days
▸ Herpes simplex virus	7 days
▸ Cytomegalovirus	21 days

Bacteria   ▸  Nocardia spp   ▸  Atypical mycobacteria Fungi   ▸  Cryptococcus spp   ▸  Histoplasma spp Viruses   ▸  Varicella-zoster virus   ▸  Herpes simplex virus   ▸  Cytomegalovirus

Nocardia spp Preferred Regimen ▸ TMP-SMX x 3-12 months Alternative Regimen 1 ▸ Sulfadiazine 2-4 g PO 1 dose FOLLOWED BY ▸ Sulfadiazine 2-4 g/day PO q4-8h x 3-12 months Alternative Regimen 1 ▸ Imipenem 250-500 mg IV q6-8h x 3-12 months Atypical mycobacteria† Preferred Regimen ▸ Clarithromycin 500 mg PO q12h PLUS ▸ Ethambutol 15 mg/kg PO q24h WITH OR WITHOUT ▸ Rifabutin 300 mg PO q24h Alternative Regimen ▸ Azithromycin 500 mg PO q24h PLUS ▸ Ethambutol 15 mg/kg PO q24h WITH OR WITHOUT ▸ Rifabutin 300-450 mg PO q24h † Adapted from Am J Respir Crit Care Med Vol 175. pp 367–416, 2007 Cryptococcus spp Preferred Regimen Moderate Severe to Severe Disease ▸ Liposomal Amphotericin B 3 mg/kg/day IV × 1-2 weeks OR ▸ Amphotericin B deoxycholate 0.7-1 mg/kg/day IV × 1-2 weeks OR ▸ Amphotericin B lipid complex 5 mg/kg/day IV × 1-2 weeks FOLLOWED BY ▸ Itraconazole 200 mg PO q12h x ≥12 months Mild to Moderate Disease ▸ Itraconazole 200 mg PO q12h x ≥12 months Adapted from Clin Infect Dis. 2007;45(7):807-25. Histoplasma spp Preferred Regimen ▸ Liposomal Amphotericin B 3 mg/kg/day x 1- 2 weeks OR ▸ Amphotericin B lipid complex 5 mg/kg/day x 1- 2 weeks FOLLOWED BY ▸ Itraconazole 200mg q8h x 3 days FOLLOWED BY ▸ Itraconazole 200mg q12h x 6-12 months Varicella-zoster virus Preferred Regimen ▸ Acyclovir 10-12 mg/kg IV (infusion over 1 hour) q8h x 7-10 days Alternative Regimen ▸ Famciclovir 500 mg PO x 7-10 days OR ▸ Valacyclovir 500 mg PO x 7-10 days Herpes simplex virus Preferred Regimen ▸ Acyclovir 10 mg/kg IV (infusion over 1 hour) q8h x 7-10 days Alternative Regimen ▸ Famciclovir 500 mg PO x 7 days OR ▸ Valacyclovir 500 mg PO x 7 days Cytomegalovirus Preferred Regimen ▸ Ganciclovir 5 mg/kg IV q12h x 21 days Alternative Regimen ▸ Valganciclovir 900 mg PO q12h x 21 days