** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Northwestern Memorial Hospital SUGGESTED EMPIRIC ANTIMICROBIAL THERAPY BY SITE OF INFECTION

Empiric antimicrobial guidelines are based on the most likely organisms responsible for infection, NMH susceptibilities, and prevalence of

resistant organisms. Therapy may need to be adjusted once identification and susceptibility are determined.

Previous antimicrobial therapy may affect the susceptibility of organisms that subsequently cause infection. Close attention should be given to

courses of antimicrobial therapy administered to patients in the recent past. In many cases, obtaining the appropriate specimen(s) before antibiotics are started is critical to successful outcomes of an infectious disease. Alterations in empiric antimicrobial therapy may be required.

Anatomic site /diagnosis

Common Pathogens Preferred therapy Alternative** Comm ents

Bone Acute osteomyelitis Staphylococcus aureus

(MSSA and MRSA) vancomycin Bone biopsy and/or tissue biopsy

is strongly recommended prior to

starting antibiotics if patient is

hemodynamically stable. Acute osteomyelitis in patient with hemoglobinopathy (Sickle cell disease or Thalassemia)

Salmonella spp., other

Gram-negatives, S. aureus ceftriaxone +/- vancomycin ciprofloxacin +/-

vancomycin Bone biopsy and/or tissue biopsy is strongly recommended. Fluoroquinolone resistance is

increasingly reported among Salmonella spp.

Long bone status post internal

fixation of fracture

S. aureus, Staphylococcus epidermi dis,

Gram-negatives

vancomycin + cefepime Bone biopsy and/or tissue biopsy is strongly recommended.

Sternum, post-operative

S. aureus, S. epidermidis vancomycin Bone biopsy and/or tissue biopsy is strongly recommended.

Vertebral osteomyelitis +/-

epidural abscess

S. aureus most common (including MRSA), other

Gram-positives and

Gram-negatives also

possible

vancomycin + ceftriaxone, OR vancomycin + cefepime if risk factors for Pseudomonas aeruginosa

vancomycin +

fluoroquinolone OR daptomycin +/-

fluoroquinolone

Obtain blood cultures in non-surgery-associated cases. Bone biopsy and/or tissue biopsy is strongly recommended. In patient with acute neurologic

compromise, sepsis, or hemodynamic instability, ok to start empiric treatment prior to collecting bone or tissue cultures. IDSA Native Vertebral OM guidelines

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Contiguous osteomyelitis with

vascular insufficiency

polymicrobial Empiric antibiotic therapy is not

recommended; recommend

bone biopsy for directed

therapy CENTRAL NERVOUS SYSTEM

Meningitis—acute bacterial

Streptococcus pneumoniae, Neisseria meningitidis, Listeria monocytogenes

vancomycin + ceftriaxone +/- ampicillin†

vancomycin + aztreonam +/- trimethoprim- sulfamethoxazole†

Empiric antibiotics are indicated prior to LP if acute bacterial meningitis is suspected. Penicillin testing necessary with Beta-lactam allergy; contact infectious diseases and allergy services. If pneumococcal meningitis suspected, administer dexamethasone before or with first dose of antibiotics: Dexamethasone 10mg IV q 6 hours x 2-4 days.

If S. pneumoniae is ruled out as cause, discontinue dexamethasone. IDSA Bacterial Meningitis Guidelines † Ampicillin or trimethoprim- sulfamethoxizole is given to

cover Listeria monocytogenes, more common in patients over age 50, alcoholics, pregnant

women, and patients with impaired cellular immunity.

Meningitis--post-surgical or post traumatic

S. aureus, S. epidermi dis , Gram-n egati v es

vancomycin + cefepime (preferred)

For true PCN allergy:

vancomycin +

meropenem

Brain abscess--

primary S. pneumoniae, Streptococcus

spp., Bacteroides spp., Enterobacteriaceae, S. aureus

vancomycin +ceftriaxone +

metronidazole +/- ampicillin

Biopsy for microbiology and

pathology is necessary for diagnosis.

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Encephalitis HSV, arboviruses, enteroviruses, VZV, non-infectious causes.

IV acyclovir Obtain blood cultures. See IDSA guidelines for an extensive list of epidemiologic risk factors,

diagnostic work-up, and individualized empiric therapy for encephalitis:

IDSA Encephalitis Guidelines Prophylaxis for Neisseria

meningitidis contacts

ciprofloxacin or rifampin ceftriaxone 250

mg IM x 1 is

preferred agent

in pregnancy.

Contact Infection Control (pager 59196) for guidance.

Doses:

ciprofloxacin 500 mg po x 1

OR

rifampin 600 mg po q 12

hours x 4 doses

GASTROINTESTINAL GALLBLADDER

Cholecystitis (community- acquired) - Mild-moderate severity

Enterobacteriaceae ceftriaxone levofloxacin Community-acquired: symptoms

prior to admit or within 48h of

admit AND no hospitalization

within prior 90 days.

Cholangitis following biliary anastomosis – any severity

Enterobacteriaceae, anaerobes piperacillin/tazobactam aztreonam + metronidazole + vancomycin

Cholecystitis (community- acquired) – Severe physiologic

disturbance or high risk patient (advanced age or

immunocompromised),

Enterobacteriaceae, anaerobes piperacillin/tazobactam aztreonam +

metronidazole +

vancomycin

Cholecystitis (healthcare-

associated), biliary

sepsis or common

duct obstruction

Enterobacteriaceae, anaerobes

and the possibility of Gram-

negative resistance;

Enterococcus spp. in select

immunocompromised patients

piperacillin/tazobactam aztreonam +

metronidazo

le +/-

vancomycin

Healthcare-associated: prior

gallbladder instrumentation,

admitted longer than 48 hours,

hospitalized previously in the

past 90 days. See

IDSA Intra-abdominal Infection

Guidelines

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

C. difficile colitis Initial episode, any non-severe and severe: Oral vancomycin 125mg QID Initial episode, fulminant: Oral vancomycin 500mg QID plus metronidazole IV 500mg q8hours +/- vancomycin enema Recurrent episode: ID consult recommended

Vancomycin 125 mg PO QID is the drug of choice on formulary for initial episodes of CDI (non-

severe and severe). • For outpatients, fidaxomicin is an alternative recommended

oral therapy. • Fulminant CDI is defined as CDI with hypotension, shock,

ileus and/or toxic megacolon. Rectal administration of

vancomycin and IV metronidazole, and/or high dose vancomycin 500 mg PO may be

considered in fulminant cases of CDI. IDSA C. diff Guidelines

Diverticulitis, perirectal

abscess,

peritonitis

Community-acquired:

Enterobacteriaceae,

Bacteroides spp.

ceftriaxone +

metronidazole

levofloxacin +

metronidazole

Community-acquired: < 48h

of

admission, no hospitalization in past

90d.

High-risk: severe physiologic

disturbance, advanced age, or

immunocompromised state

IDSA Intra-abdominal Infections

Guidelines

Community-acquired, high-risk:

Enterobacteriaceae,

Bacteroides spp.,

Enterococcus spp., and the

possibility of Gram-negative

resistance

piperacillin-tazobactam aztreonam +

metronidazole + vancomycin

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Healthcare-associated or

severely ill: same as high-risk

community-acquired

piperacillin/tazobactam If patient has any of the following: post-op infections, recent cephalosporins use, immuncompromised, valvular heart disease or prosthetic intravascular material consider adding vancomycin

aztreonam +

metronidazole +

vancomycin

Both preferred and alternative therapies provide empiric Enterococcal coverage

(directed at E. faecali s ). E.

faecali s coverage is

recomm end ed, especially for

those with post-op infection,

those who have previously

received cephalosporins,

immunocompromised patients,

and those with prosthetic

intravascular material.

Following appendectomy, no

perforation

none none Surgical prophylaxis only

Following appendectomy, with

perforation

Enterobacteriaceae,

Bacteroides spp.

ceftriaxone + metronidazole

aztreonam +

metronidazole

Hepatic abscess Enterobacteriaceae,

Bacteroides spp., Enterococcus spp.

ceftriaxone + metronidazole

Blood cultures are recommended. Diagnostic aspiration and/or drainage is

often indicated. Consider serologic testing for amoebiasis (Entamoeba histolytica antibody

IgG)

Pancreatitis--acute/non-

necrotizing

noninfectious No antibiotic therapy necessary

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Pancreatitis—acute/necrotizing

or infected pseudocyst, abscess

Enterobacteriaceae,

Enterococcus spp., S.

aureus, S. epidermidis ,

anaerobes, Candida spp.

piperacillin/tazobactam levofloxacin + metronidazole

Strongly recommend attemptingaspiration for microbiologic diagnosis and therapy.

Pip/tazo has adequate

penetration into pancreatic

necrosis, thus carbapenem

therapy is not indicated unless

patient has history of MDR

organisms.

Otto, W, et al. HPB (Oxford).

2006; 8(1): 43–48.

Peritonitis--spontaneous

bacterial peritonitis (SBP)

S. pneumoniae, K.

pneumoniae, E. coli

ceftriaxone aztreonam +

vancomycin

Peritonitis--Peritoneal Dialysis

related

S. aureus, S. epidermi di s,

Gram-negatives,

Candida spp.

vancomycin + cefepime Contact ID pharmacist on call (55955) for dosing recommendations. Obtain PD

fluid for microbiologic diagnosis. Often intraperitoneal therapy is ideal to treat these infections. ISPD PD-Dialysis Related Infection Guidelines

GENITAL

Endometritis-Acute postpartum

Group B Streptococcus,

anaerobes,

Enterobacteriaceae

ampicillin + clindamycin +

gentamicin

OR

ceftriaxone + metronidazole

clindamycin + gentamicin

Salpingitis/PID Neisseria gonorrhoeae, Chlamydia trachom ati s,

Bacteroides spp.,

Enterobacteriaceae, Group

B Streptococcus. .

ceftriaxone + metronidazole

+ doxycycline

Testing for GC and Chlamydia are strongly recommended. Discharge patient on oral doxycycline to complete a 14-day course.

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

For patients with documented

GC or Chlamydia, sexual

partners within prior 60 days need

medical evaluation and

treatment.

CDC STI Guidelines

HEART

Endocarditis Refer to guidelines or Optimizer

ID consult recommended. Refer to AHA guidelines: IDSA/ AHA Endocarditis

Management guidelines

JOINT

Septic joint/ at risk for

STI

At risk for sexually transmitted infection (STI): Neisseria gonorrhoeae, S. aureus, Streptococcus spp., rarely

enteric Gram-negative bacilli

ceftriaxone +/- vancomycin

aztreonam + vancomycin

Send blood cultures before antibiotics are started. Early joint aspiration is strongly recommended for cell count,

differential, gram stain, crystals, and culture to guide diagnosis. For type-1 penicillin allergy, consult Infectious Diseases and Allergy. If gonorrhea is suspected, cultures from the joint may or may not be positive.

Septic Joint- not at risk for STI

S. aureus (MSSA and MRSA), Streptococcus spp., Gram-negative bacilli

vancomycin + ceftriaxone vancomcyin + aztreonam

Prosthetic joint infection

S. aureus (MSSA and MRSA),

S. epidermi di s , Streptococcus spp., rarely Gram-negative

bacilli

vancomycin See 2013 IDSA Guideline for Prosthetic Joint Infections: IDSA Prosthetic Joint Guidelines

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

KIDNEY, BLADDER AND PROSTATE Asymptomatic bacteriuria

E. coli , Enterobacteriaceae,

Should only be treated in pregnant women or patients

undergoing urologic procedures with anticipated mucosal bleeding --other patients should be evaluated on a case-by-case basis. See IDSA guidelines for asymptomatic bacteriuria: IDSA Asymptomatic Bacteriuria Guidelines

Cystitis E. coli , Enterobacteriaceae, S.

saprophyticus

nitrofurantoin (if estimated creatinine clearance >30 mL/min); cephalexin or IV cefazolin (reserved for

those who are unable to swallow pills

trimethoprim-

sulfamethoxaz

ole or

ciprofloxacin**

Consider testing urethritis for gonorrhea, chlamydia, and trichomonas. IDSA Uncomplicated Cystitis\Pyelo Guidelines

Complicated UTI/catheters

E. coli, Enterobacteriaceae,

cefazolin

May consider

alternative therapy based on patient’s history of urinary

pathogens

See IDSA guidelines for

catheter-related UTIs (recommended to d/c or change catheter)

IDSA Catheter Assoc UTI Guidelines

Asymptomatic Candiduria (Treat ONLY patients who are at high risk for dissemination, such as neutropenic patients, low birth weight infants <1500 g, and patients

who will undergo urologic manipulation)

Candida spp.

Remove catheter

Neutropenic patients and very low–birth-weight

infants should be treated as recommended for candidemia (see below)

Patients undergoing

urologic procedures should be treated with oral fluconazole, 400 mg (6

mg/kg) daily before and after the procedure

See IDSA guidelines for

candidiasis,

IDSA Candidiasis Guidelines

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Symptomatic Candiduria

C. albicans (and other fluconazole susceptible spp)

Remove catheter, fluconazole See IDSA guidelines for candidiasis, IDSA Candidiasis Guidelines Micafungin, liposomal Ampho and voriconazole have poor renal excretion and are NOT considered effective against fungal UTI

Fluconazole-resistant Candida spp

Page ID Pharmacist for alternatives

Pyelonephritis--acute,

uncomplicated

E. coli, Enterobacteriaceae Cefazolin Aztreonam (severe, confirmed beta-lactam allergy)

NMH urinary antibiogram shows similar (>90% susceptibility) of ceftriaxone and cefazolin.

Increasing rates of

ciprofloxacin- resistance among

Enterobacteriaceae have been

noted. See IDSA guidelines for

uncomplicated

UTIs/pyelonephritis,

IDSA Uncomplicated

Cystitis\Pyelo Guidelines

Pyelonephritis, with sepsis

Enterobacteriaceae,

cefepime +/- amikacin aztreonam + amikacin

+\- vancomycin

(severe, confirmed beta-lactam allergy)

Patients at increased risk of enterococcal infections: elderly, urinary obstruction and post

instrumentation; septic patients with these risks may benefit from empiric E. faecalis coverage

(i.e., piperacillin-tazobactam). Also, review prior urinary isolates for antibiotic resistance.

Perinephric abscess Enterobacteriaceae piperacillin/tazobactam Recommend drainage of larger abscesses, may need aspiration for microbiologic diagnosis.

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Prostatitis Enterobacteriaceae ceftriaxone trimethoprim-

sulfamethoxazole or doxycycline or

ciprofloxacin

Review antibiogram and susceptibilities. Note that there have been increasing rates of ciprofloxacin- resistance among Enterobacteriaceae.

LUNG

Pneumonia--community acquired

S. pneumoniae, H. influen z a e Mycoplasma, pneumoniae, Chlamydophila pneumoniae , Legionella pneumophila, viruses

ceftriaxone + azithromycin (Preferred for ICU) OR Levofloxacin (severe, confirmed beta-lactam allergy)

Levofloxacin (severe, confirmed beta-lactam allergy)

See NMH Community Onset Pneumoniae (CAP) Treatment for Non-ICU Patients

ATS/IDSA CAP Guidelines

If patient is critically ill, draw 2 sets of blood cultures.

If gross hemoptysis, leukopenia, rapidly-progressing CXR, and/or lung necrosis or cavitation, add

empiric MRSA coverage with linezolid.

Antibiotic Therapy for Adults with CAP (Review). JAMA. Feb 2016

Pneumonia--community acquired

in ICU

as above ceftriaxone + azithromycin OR ceftriaxone + levofloxacin

Pneumonia--community acquired

in ICU

Pneumonia-community-acquired with identified increased risk for

resistant Gm Negative pathogens

Pseudomonas

spp.,

Enterobacteriaceae

cefepime + azithromycin

or

piperacillin-tazobactam +

azithromycin.

PNA

vancomycin +

aztreonam +/-

amikacin (severe, confirmed beta-lactam allergy)

"Hospital-acquired pneumonia"

refers to pneumonia that

develops >

48 hours after admission.

If MRSA is not isolated within 72

hours, MRSA coverage should

be stopped IDSA HAP/VAP guidelines

Pneumonia--hospital-

acquired

as above cefepime + vancomycin or

linezolid

Pneumonia--ventilator-

associated

as above Cefepime + vancomycin or linezolid

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Pneumonia—aspiration,

community acquired

Bacteroides spp., Peptostreptococcus spp,

Fusobacterium spp.,

viridians group

Streptococcusspp.

ampicillin/sulbactam or

ceftriaxone

+/-

metronidazole

clindamycin or levofloxacin + metronidazole (severe, confirmed beta-lactam allergy)

See review of aspiration pneumonia.\

Empyema Community-acquired

Streptococcus spp.,

Enterobacteriaceae, anaerobes

ceftriaxone + metronidazole Or ampicillin-sulbactam

ATS Empyema guidelines

Empyema Hospital-acquired

Streptococcus spp., S. aureus, Enterobacteriaceae, anaerobes

vancomycin + cefepime + metronidazole Or vancomycin + piperacillin-tazobactam

vancomycin + levofloxacin (severe, confirmed

beta-lactam allergy)

SEPSIS or ACUTE FEBRILE SYNDROME

Septic shock S. aureus (MSSA and MRSA), E. coli, Enterobacteriaceae vancomycin + cefepime + amikacin

vancomycin + aztreonam +

amikacin (severe, confirmed beta-lactam allergy)

See guidelines from Surviving Sepsis Campaign.

Surviving Sepsis Guidelines Consider adding empiric

doxycycline, particularly if recent exposure to woodlands, ticks, or developing countries.

Septic shock--post splenectomy

S. pneumoniae, N. meningitidis, H. influenz a e , Capnocytophaga spp.

ceftriaxone + vancomycin levofloxacin + vancomycin

(severe, confirmed beta-lactam allergy)

Toxic shock syndrome S. aureus (MSSA and MRSA), group A Streptococcus

vancomycin + clindamycin + penicillin G

Strongly recommend prompt

surgical evaluation for possible debridement and infectious diseases consultation.

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Not neutropenic, no hypotension, source unclear

S. aureus (MSSA and MRSA),

Streptococcus spp., E. coli vancomycin + ceftriaxone Consider adding empiric

doxycycline, particularly if recent exposure to woodlands, ticks, or

developing countries.

Not neutropenic, no hypotension,

suspect intra-abdominal source with

mild to moderate severity

Enterobacteriaceae Ceftriaxone + metronidazole

aztreonam +

metronidazole + vancomycin

(severe, confirmed beta-lactam allergy)

For patients with sepsis of high severity, see recommendations under Septic Shock.

Not neutropenic, no hypotension,

petechial rash

S. pneumoniae, N. meningitidis ceftriaxone + vancomycin Consider adding empiric

doxycycline, particularly if recent exposure to woodlands, ticks, or developing countries.

Not neutropenic, no hypotension,

suspect urinary source

Enterobacteriaceae,

Enterococcus spp.

piperacillin/tazobactam

aztreonam

Fever & neutropenia (no hypotension, no apparent source) in a cancer patient receiving chemotherapy

Enterobacteriaceae,

Pseudomonas aeruginosa.

cefepime vancomycin +

aztreonam (severe, confirmed

beta-lactam allergy)

Empiric vancomycin is unnecessary unless patient is hemodynamically unstable, has pneumonia or PCN allergy, severe mucositis, or there is evidence of catheter-related infection on exam. Discontinue vancomycin after 72

hours if started for suspected or

confirmed gram-positive

bacteremia that was

later identified as non-MRSA or

as a single isolate of coagulase

negative staphylococcus. See

IDSA guidelines for neutropenic

fever:

IDSA Neutropenic Fever

Guidelines

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Fever & neutropenia -- febrile longer than 96 hours

as above (fever & neutropenia) + fungal infection

add micafungin Micafungin has broad coverage for Candida spp. It is not the preferred antifungal agent for all cancer patients, however, as this drug does not treat Aspergillus spp. or Mucor spp. High risk cancer patients are considered at increased risk of mold infections. For more information, see:

IDSA Neutropenic Fever Guidelines

SKIN

Bite--animal Pasteurella multocida, Fusobacterium spp,

Capnocytophaga spp. (dog bite)

amoxicillin-clavulanate or ampicillin-sulbactam

ciprofloxacin + clindamycin **

More specific therapy depends upon animal involved Evaluate the need for tetanus

and/or rabies vaccination

Bite--human viridans group Streptococcus spp., S.epidermi di s , Corynebacterium spp., S.

aureus , Eikenella spp., Bacteroides spp., Peptostreptococcus spp.,

Fusobacterium spp., Prevotella spp.

amoxicillin-clavulanate or ampicillin-sulbactam

ciprofloxacin + clindamycin **

Boils (furunculosis) or cutaneous abscesses

S. aureus (MSSA and

MRSA)

Incision and drainage is the primary treatment. Antibiotic therapy is needed only if associated fever or systemic infection or if extensive surrounding cellulitis is present: trimethoprim- sulfamethoxazole or

doxycycline

clindamycin Hot packs, incision and drainage serves as primary therapy. If incision and drainage is performed, sampling for culture and sensitivity is beneficial. Note: clindamycin resistance is present in > 50% of MRSA isolates. See IDSA SSTI

Guidelines Cellulitis Non-purulent: Group A

Streptococcus spp., Group

B, C, G Streptococcus

spp

(S. aureus i s uncommon in

absence of abscess, necrosis,

or purulent drainage.)

cefazolin clindamycin See Antibiotic Resources for

NMH guidelines (Skin and Soft tissue Infection Treatment Algorithm)

IDSA SSTI Guidelines.

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Purulent: Cellulitis with purulent exudates or at risk for MRSA (Cellulitis associated

with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization

with MRSA, injection drug use, purulent drainage, or SIRS)

Mild: incision and drainage Moderate: incision and drainage + trimethoprim- sulfamethoxazole OR doxycycline Severe: incision and drainage +

vancomycin

Culture and sensitivities

are indicated for de-

escalation.

See IDSA guidelines for

MRSA infections,

IDSA MRSA Guidelines

Cellulitis--IV catheter-related

Coagulase-negative Staphylococcus spp., S. aureus (MSSA and MRSA),

Remove catheter + vancomycin

IDSA SSTI Guidelines

Decubitus ulcer Streptococcus spp., Enterococcus spp,

Enterobacteriaceae,

Pseudomonas spp.,

Bacteroides spp., S. aureus

(MSSA and MRSA),

polymicrobial

Wound care; vancomycin +

piperacillin/tazobactam

Consider wound care alone (no

antibiotic therapy) with no signs

of systemic illness, soft tissue

abscess, or local cellulitis. With

exposed bone, obtain bone

biopsy prior to administering

antimicrobials to guide therapy.

Diabetic foot ulcer

(superficial) without

evidence of surrounding cellulitis or exposed bone

skin flora No antibiotic therapy necessary

Diabetic foot ulcer--mild; small,

only skin with

minimal

surrounding

inflammation,

pulses present

Polymicrobial: S. aureus

(MSSA and MRSA),

streptococcus spp,

amoxicillin-clavulanate or cephalexin

trimethoprim-

sulfamethoxazole

or doxycycline

See IDSA guidelines for diabetic foot Infections,

IDSA Diabetic Foot Guidelines

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Diabetic foot ulcer--severe; limb-

threatening, skin,

subcutaneous,

possibly bone,

inflammation, fever,

neutrophilia

Polymicrobial: S. aureus

(MSSA and MRSA),

streptococcus spp, coliforms,

anaerobes, Pseudomonas

aeruginosa

piperacillin/tazobactam +/-

vancomycin

clindamycin +

ciprofloxacin

Send tissue specimen (bone

preferable) for culture prior to starting empiric therapy. See

IDSA guidelines for diabetic foot infections,

IDSA Diabetic Foot Guidelines

Infected wound--post-operative

Surgery not involving GI tract:

S. aureus (MSSA and MRSA),

Group A, B, C, or G

Streptococcus spp.

vancomycin + piperacillin/tazobactam

vancomycin + ceftriaxone + metronidazole

IDSA SSTI Guidelines.

Surgery involving GI tract: S.

aureus (MSSA and MRSA),

coliforms, Bacteroides spp.

vancomycin + piperacillin-

tazobactam

VASCULAR Necrotizing fasciitis Streptococci (group A, C, G),

Clostridium spp.,

polymicrobial, including

S. aureus

vancomycin + clindamycin

+ piperacillin/tazobactam

For confirmed

severe PCN allergy: Aztreonam + vancomycin

Prompt surgical consult for immediate surgical debridement is indicated.

If streptococcal necrotizing

fasciitis, consider management for toxic shock syndrome.

Recommend infectious diseases consult. See IDSA SSTI Guidelines.

Catheter-associated bloodstream infection

Coagulase-negative

staphylococci, S. aureus

(MSSA and MRSA);

Enterococcus spp.

Remove line Vancomycin If high suspicion for Gram-

negative: + cefepime

May be able to salvage a long-term line if infection is due to S. epidermidis AND no evidence of tunnel infection or complicated

blood stream infection.

IDSA Cath Related Bloodstream Infection Guidelines

** Severe allergy to Preferred Therapy only Version Approved by Antimicrobial Subcommittee 7/2/2018

Impaired host catheter-associated bloodstream infection

S. epidermi di s , other

coagulase-negative

staphylococci, S. aureus

(MSSA and MRSA),

Enterobacteriaceae,

Pseudomonas

aeruginosa, Candida

species, VRE

vancomycin + cefepime +/- amikacin

Consider short course of amikacin in addition to other antibiotics if patient is clinically unstable. Consider coverage for

vancomycin-resistant Enterococcus (VRE) if patient is colonized with this organism

(replace vancomycin with linezolid or daptomycin). If hemodynamically unstable,

consider adding fungal coverage (micafungin or fluconazole).

IDSA Cath Related Bloodstream Infection Guidelines

Hyperalimentation-associated line infection

As with impaired host line

infection, Candida spp.

is more common

+micafungin or fluconazole in addition to

above recommendations based on anatomic

site/diagnosis

Consider micafungin rather than

fluconazole if patient has

been receiving fluconazole

in the month prior to

fungemia.

Documented candidemia

micafungin if neutropenic, critically ill, or prior exposure to fluconazole in past month

fluconazole Consider micafungin rather than

fluconazole if patient has

been receiving fluconazole

in the month prior to

fungemia or if the patient is

critically ill. Review patient’s

recent microbiology for any

recent history of resistant

Candida spp.

IDSA Candidasis Guidelines