Protocols in Orthopedic Antibiotics Therapy_2008

7/24/2019 Protocols in Orthopedic Antibiotics Therapy_2008

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ORTHOPAEDIC ANTIBIOTIC PROTOCOL

I. Prophylactic Antibiotic Therapy is mandatory in all MSF Surgical Missions.

II. Treatment Guideline or Early Inection ater O!teo!ynthe!i! (Acute Implant-relatedOsteitis): Available for all Ortopedic Surgery MSF Settings (e!-"a#ti$ %ort "arcourt)

III. Treatment Guideline or Late Inection (&ronic Osteomyelitis): Available for Speciali'edMSF Missions: econstructive Surgery$ Amman$ Meran$ and for all MSF Settings as a"elp uide

I" Prophylactic Antibiotic Therapy

#" Internal i$ation% clo!ed racture

*sual Organisms: ram-Positive bacteria (S. epidermidis, S. aureus)

Antimicrobialpropyla!is

&epa'oline+ g I, at induction of anaestesia plus additional dose of gintraoperatively$ en surgery is prolonged (/ 0 ours)

&" Type I and II open racture

*sual Organisms: ram-Positive and aerobic Gram-Negative bacteria

Antimicrobial

propyla!isfor 01 ours

&epa'oline2

+ g I, every + ours (3 0 g4day) immediately upon admission

entamicine 0 mg45g4day (give by slo I, pus over 67 minutes)

'" Type III open racture

*sual Organisms: Mixed aerobic and anaerobic Gram-Negative and Gram-Positive bacteria

Antimicrobialpropyla!isfor 8+ ours

&epa'oline2

+ g I, every + ours (3 0 g4day) immediately upon admission

entamicine2

0 mg45g4day (give by slo I, pus over 67 minutes)

Metronida'ole 977 mg I, every 1 ours

(ub!e)uently% dependin* on clinical cour!e+

Amo!icillin 4 clavulanic acid2

g I, 0 times daily (3 0 g4day) 6-9 days

entamicine mg45g I, every + ours (3 + mg45g4day) 6-9 days

&omments: ever substitute oral agent for intravenous terapy.

Guide to Antibiotic Therapy for MSF Orthopaedic Surgery Missions

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II" Treatment Guideline or Early Inection ater O!teo!ynthe!i!

;is guideline can be modified according to local resistances patterns. ;e treatment is surgicaland medical.

A" E,PIRICAL TREAT,ENT+ (TART I,,EDIATEL- PO(T.OP

;e patient ill re<uire Operati/e Inter/ention A(AP it e!ploration$ culture of deep tissue andfluid collections$ debridement and as-out. =uring te pending time aiting for antibiogrameresults$ empirical antibiotic therapy can begin promptly until organism identification andresistance testing are finali'ed. ;en treatment is ad>usted once microbiology is reported.

emoval O retention of device ill be determined by patient status$ e!tent of infection$ status of fi!ation device and ortopaedic surgeon advice. etention may be necessary$ assuming tefi!ation device is not loosened. Fracture stabili'ation is essential for infection control.

Most acute surgical infections are caused by Staphylococci (and occasionally by ram-egativeenterics) and terefore terapy directed against Staphylococcus aureus (and ram-egative

enterics) can begin as te result of culture and sensitivity test is aaited.

#" In conte$t! 0here ,ethicillin.(en!iti/e Staphylococcus aureus 1,((A2 i! mo!tpre/alent

&lo!acilline2

I, 97 mg45g4day (3 97 mg45g every 1 ours).&lo!acilline can be canged for &epa'oline 0 g4day if penicillin hypersensitivity

entamicine0 mg45g4day.

ive by slo I, pus over 67 minutes

&" In conte$t! 0here ,ethicillin.Re!i!tant Staphylococcus aureus 1,R(A2 repre!ent!

more than &34 o (taphylococci

,ancomycine2

I, +9 mg45g every + ours. I, over ?7 minutes

entamicine0 mg45g4day.

ive by slo I, pus over 67 minutes

&omment: @e aare tat you ill increase renal to!icity

B" LONG.TER, ANTIBIOTIC THERAP- 5ILL DEPEND 6PON THE 7INALORGANI(, IDENTI7ICATION AND THE ANTIBIOGRA,

#" (taphylococcu! aureu!

At minimum$ & 0ee8! o intra/enou! antibiotic! are recommended for sub-facial S. aureussurgical site infection before sitcing to an e!tended +-6 monts course of oral antibiotics.

=epending on resistance patterns$ potential oral combinations include:

. &iproflo!acin 897 mg ! + daily %O and ifampicine ?77 mg4day+. &otrimo!a'ole =S (double-strength) tablet every 1 ours and ifampicine ?77 mg4day6. &lindamycine ?77 mg ! 0 daily %O and ifampicine ?77 mg4day

&" Enterobacteriaceae (. coli, !lebsiella species$ and Proteus species)$ P!eudomona!

ou can rely on Chronic O!teomyeliti! Protocol and anticipate less drug resistance


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III" Treatment Guideline or Late Inection

;is protocol as been elaborated folloing MSF Amman Ortopaedic and econstructive SurgeryMissionB it results from te contributions of =r. Sopie Abgrall$ specialist in Infectiology at Avicenne"ospital (A%"%) in %aris$ i55i @lac5ell$ anaestesiologist and responsible for Infectology in

Amman and Meran and =elpine %oussin.

The oundation o treatment or Chronic O!teomyeliti! i! ade)uate (ur*ical Debridement .everteless antibiotic terapy plays an important ad>unctive role in acieving successfuloutcomes.

eneral rules:

• No antibiotic beore or*ani!m1!2 identiication$ culture and sensitivity testsB

• As large and toroug surgical debridement as necessary$ it strict cleaning of te oundB

• Fracture immobili'ation: almost alays it e!ternal fi!ationB

• Aerobic and anaerobic cultures of bone and4or soft tissue or li<uids:o On %ortagermC$ for solids

o On blood culture mediums$ for li<uids

Ideally$ culture sould be started itin 0 ours after surgery. If not$ samples sould be5ept in a fridge (0D&) for a ma!imum duration of 01 ours if a reliable result is e!pected.

Anaerobic cultures into anaerobic transport system$ transport time ≤ + $ room

temperature.

• o clinical$ biological or radiological e!am allos early interruption or alleviation of te

treatment: treatment duration is stated from te beginning. ;e only criteria for success isno infection after te end of te treatment and + years follo up.

;e folloing protocols are designed to guide antibiotic coice on te ard$ according to te

results of culture and sensitivity.

• If you are unsure about ic antibiotic regime to coose$ ASE FO "G%H

• If te Medical =irector can not assist you$ tey ill contact te egional Medical

&oordinator$ and if necessary$ te case can be discussed it =r. S. Abgrall in %aris.

(ummary

. Mandatory investigations and monitoring+. Stapylococcus aureus (MSSA)6. Stapylococcus aureus (OSA4MSA)

0. Streptococcus or nterococcus9. nterobacteriaceae i.e. . coli$ Elebsiella sp (non S@G)$ %roteus mirabilis?. nterobacteriaceae from S&%%M roup 3 nterobacter sp$ Serratia sp$ &itrobacter sp$

%roteus vulgaris$ %rovidencia sp$ Morganella sp.8. S@G producing organisms (eg$ . coli$ %roteus sp$ Elebsiella sp$ esistant to

&efta'idime$ &eftria!one)1. Acinetobacter baumaniiJ. %seudomonas aeruginosa7. Stenotropomonas maltopilia. Anaerobes

MSSA : Meticillin-sensitive Staphylococcus aureus

MSA : Meticillin-resistant Staphylococcus aureusOSA : O!acillin-resistant Staphylococcus aureusS@G : !tended spectrum beta-lactamases


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#" ,ANDATOR- IN9E(TIGATION( AND ,ONITORING

• ;e total course of treatment is ? + ee5s :

• *sually 0-? ee5s bi-antibioterapy folloed by ?-1 ee5s single agent antibioterapy)

• Ken validity of bacteriology results is uncertain$ initial I, treatment during +-6 ee5s is

preferable• ;e antibiotics used to treat Osteomyelitis ave significant side-effects and regular laboratory

monitoring is essential

• AGG %A;I;S S"O*G= "A,:

o S$ &%$ F@&: %re-operatively

o enal L Giver function: %rior to starting Antibiotic ;erapy

• The ollo0in* in/e!ti*ation! !hould be perormed 0ee8ly ile te patient is on antibiotics

(regardless of eter tey are an Inpatient$ Outpatient or ave returned ome to Ira< tocomplete teir course of antibiotics): S$ &%$ F@&$ enal Giver function

S%&IAG &ASS

• %atients receiving Gine'olid treatment are at ris5 of trombocytopenia and sould ave a full

blood count performed ee5ly for te duration of teir treatment. ;ey are also at ris5 of periperal neuropaty and sould ave regular clinical e!amination. Ma!imal duration of treatment: +1 days.

• %atients receiving &olistin terapy are at ris5 of renal impairment and sould ave teir renal

function monitored tice a ee5.

• %atients being treated it entamicine or Ami5acin sould ave te troug drug level

measured after te tird day of treatment and ee5ly tereafter if te level is itin teacceptable range. ;ey sould also ave renal function monitored tice a ee5

Gine'olid 3/ F@& Kee5ly

&olistin 3/ enal Function ;ice Kee5ly

entamicine or Ami5acin

3/ enal Function ;ice Kee5ly

3/ entamicine 4 Ami5acin;roug medication level

After ;ird =ay$ tenKee5ly if Gevel Satisfactory

AGG =OSS S"O*G= @ A=N*S;= ;O A mg45g4dose @ASIS FO &"IG=

&" Staphylococcus aureus, sen!iti/e to O$acillin or ,ethicillin 1,((A2

PHA(E #+

KES to ? ;o Antibiotics.

Ideally recommended for te first to ee5s$ but if tere are no clinical sign of sepsis$ ten oralantibiotics can be started as soon as possible$ according to te antibiogram. =o not useentamicine for more tan 9 days.

&lo!acilline:

I, + g ! 0 (1 g total). &ildren: 97 mg45g4day in 6 to 0 infusions

entamicine I, 0 mg45g ! (67 minute infusion)


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;" ;KO from te list belo (depending on te organism sensitivity results)

ifampicin %O ?77 mg ! + Sould , be used alone. &ildren: 7 mg45g ! +

&ec5 liver function tests @efore starting treatment ten ee5lyB revie antibiotic coice if rising

&lindamycine %O?77 mg ! 0 (if rytromycin and &lindamycine sensitive). &ildren: 67mg45g4day

&an cause severe diarroea due to an overgrot of "lostridium di##icileB revie and consider stopping te antibiotic if tis developsB send a stool specimen for a ". di##icile to!in test if tere isany doubt

Oflo!acin %O +77 mg ! 6. &ildren: 9 mg45g4day

If Oflo!acin can not be obtained or if polymicrobial infection$ &I%OFGOA&I oral 897 mg ! +(cildren: +7 mg45g4day) can be used but sould usually be reserved for P. aeruginosa infection

&otrimo!a'ole %O 177 mg sulfameto!a'ole4 ?7 mg trimetoprim ! 6$&onsider if polymicrobial infection. &ildren: ?7 mg45g4day SM 4 +mg45g4day ;M%.

Fusidic acid %O 977 mg ! 6. Sould , be used alone. &ildren: 97 mg45g4day

Fosfomycin I,0 g ! 0. Sould , be used alone. &onsider if polymicrobialinfection. &ildren: +77 mg45g4day

&lo!acillin I,+ g ! 0 (1 g total). , as oral antibiotic. &ildren: 97 mg45g4dayin 6 to 0 infusions.

PHA(E &+

KES 8 to + O Antibiotic

&lindamycine %O?77 mg ! 0 (if rytromycin and &lindamycine sensitive). &ildren: 67mg45g4day

&an cause severe diarroea due to an overgrot of "lostridium di##icileB revie and consider stopping te antibiotic if tis developsB send a stool specimen for a ". di##icile to!in test if tere isany doubt

or


If Oflo!acin can not be obtained or if polymicrobial infection$ &I%OFGOA&I oral 897 mg ! +(cildren: +7 mg45g4day) can be used but sould usually be reserved for P. aeruginosa infection

or

&otrimo!a'ole %O177 mg sulfameto!a'ole4 ?7 mg trimetoprim ! 6$&onsider if polymicrobial infection. &ildren: ?7 mg45g4day SM 4 +mg45g4day ;M%.

or


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&lo!acilline %O+ g ! 0 Oral &lo!acillin is not ell absorbed$ so coose tis only en&lindamycin$ &otrimo!a'ol or Oflo!acin can not be used.&ildren: 97 mg45g4day

Sould usually not be used orally$ but if no oter oral antibiotic is available and if intravenousinfusion is not possible$ &GOA&IGGI can only be used orally for long-term suppressant treatmentof osteomyelitis.

Giver function tests must be monitored regularly to loo5 for drug induced epatitis$ F@& also. If liver function tests are rising$ revie coice of antibiotic.

'" Staphylococcus aureus re!i!tant to O$acillin or ,ethicillin 1OR(A;,R(A2

PHA(E #+

KES to ? ;o Antibiotics

Ideally recommended for te first to ee5s$ but if tere are no clinical sign of sepsis$ ten oralantibiotics can be started as soon as possible$ according to te antibiogram. =o not use

entamicine for more tan 9 days.

;eicoplanin$ or S& + mg45g every + ours for te first 9 doses$ ten + mg45g4day

,ancomycin I,Goading dose 9mg45g folloed by 07mg45g4+0s given continuouslyor$ if not possible$ in 0 divided doses (infused over + ours)

%lus (2)

entamicine I, 0 mg45g ! (67 minute infusion)


ifampicin %O?77 mg ! + (if sensitive). Sould , be used alone$ &ildren: 7mg45g ! +

Fusidic acid %O977 mg ! 6 (if sensitive). Sould , be used alone$ &ildren: 97mg45g4day

&otrimo!a'ole %O177 mg Sulfameto!a'ole4 ?7 mg ;rimetoprim ! 6 (if sensitive)&onsider if polymicrobial infection$ &ildren: ?7 mg45g4day SM 4 +mg45g4day ;M%

&lindamycin %O?77 mg ! 0 (if rytromycin and &lindamycin-sensitive)$ &ildren: 67mg45g4day

Gine'olid %O?77 mg ! +. o longer tan 0 ee5s. ot it lycopeptides (i.e.,ancomycin4;eicoplanin). &ildren: 67 mg45g4day

;eicoplanin or S& + mg45g every + ours for te first 9 doses$ ten + mg45g4day

,ancomycin I,Goading dose 9 mg45g folloed by 07mg45g4+0 s given continuouslyor$ if not possible$ in 0 divided doses (infused over + ours)

Forsfomycin I,0 g ! 0. Sould , be used alone. &onsider if polymicrobial

infection. &ildren: +77 mg45g4day


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&omment: MSA is usually resistant to Oflo!acine and &iproflo!acin$ so tese sould not be usedfor treatment

PHA(E &+

KES 8 to + (7 ee5s)

e$cept LINE<OLID durin* = 0ee8!% then cea!e.

%referably a !in*le oral antibiotic from te list belo$ according to te sensitivities of teorganism$ &%; IFAM%I&I and F*SI=I& A&I= ic must alays be given togeter or itanoter antibiotic.

Gine'olid %O?77 mg ! +. o longer tan 0 ee5s. ot it lycopeptides (i.e.,ancomycin4;eicoplanin). &ildren: 67 mg45g4day

or

&otrimo!a'ole %O

177 mg sulfameto!a'ole4 ?7 mg trimetoprim ! 6. &onsider if

polymicrobial infection. &ildren: ?7 mg45g4day SM 4 + mg45g4day;M%

or$ if tere is no alternative available ten use ;eicoplanin as follos:

;eicoplanin S& + mg45g every + ours for te first 9 doses$ ten + mg45g4day

or

ifampicin %O?77 mg ! + (if sensitive). Sould , be used alone. &ildren: 7mg45g ! +

plus (2)

Fursidic acid %O977 mg ! 6 (if sensitive). Sould , be used alone. &ildren: 97mg45g4day

=" STREPTOCOCCUS or ENTEROCOCCUS

PHA(E #+


Ideally recommended for te ir!t t0o 0ee8!$ but if tere are no clinical !i*n o !ep!i!$ tenoral antibiotic! can be started as soon as possible$ according to te antibiogram. =o not useentamicin for more tan 9 days.

Amo!icillin I, 6 g ! 0. &ildren: +77 mg45g4day

plus (2)

entamicin I, 0 mg45g ! (67 minute infusion)

It is only necessary to give ;AMI&I for te first 8 days or less if no clinical sepsis$ ten

continue it furter ee5 of I, AMOI&IGGI before moving to oral single agent treatment

;" ;KO from te list belo (depending on te organism sensitivity results)Guide to Antibiotic Therapy for MSF Orthopaedic Surgery Missions

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Amo!icillin I,6 g ! 0. O; FO N$%&"&""'S "*'M. &ildren: +77mg45g4day

ifampicin %O?77 mg ! + (if sensitive) Sould , be used alone. &ildren: 7mg45g ! +

&otrimo!a'ole %O177 mg Sulfameto!a'ole4 ?7 mg ;rimetoprim ! 6 if sensitive., FO N$%&"&""'S. &onsider if polymicrobial infection.&ildren: ?7 mg45g4day SM 4 + mg45g4day ;M%

&lindamycin %O?77 mg ! 0 (if ;"OM&I and &GI=AM&I-sensitive), FO N$%&"&""'S. &ildren: 67 mg45g4day

;eicoplanin S&+ mg45g every + ours for te first 9 doses$ ten + mg45g4dayFO N$%&"&""'S "*'M

Piperacillin% Piperacillin;Ta>obactam% Imipenem are sensitive (in case of polymicrobial infectionit gram-negative organisms). "oever$ be very cautious about Enterococcus faecium tat ismostly resistant to Ampicillin and ill also be resistant to %iperacillin4;a'obactam and sould betreated it a Glycopeptide. SE "G% IF O* A *S*.See belo for dosages

PHA(E &+


Amo!icillin %O + g ! 6 (3 ? g total)

or

&lindamycin %O?77 mg ! 0 (if rytromycin and &lindamycin-sensitive) , FON$%&"&""'S. &ildren: 67 mg45g4day

or

&otrimo!a'ole %O177 mg Sulfameto!a'ole4 ?7 mg ;rimetoprim ! 6 (if sensitive), FO N$%&"&""'S. &onsider if polymicrobial infection.&ildren: ?7 mg45g4day SM 4 + mg45g4day ;M%

or

;eicoplanin S&+ mg45g every + ours for te first 9 doses$ ten + mg45g4dayFO N$%&"&""'S "*'M. &onsider if polymicrobial infectionit MSA.

or

If ram-egative resistant organisms are associated$ Streptococcus and nterococcus ill usuallybe sensitive to %iperacillin4;a'obactam$ in te case of very resistant ram-egative organisms toImipenem. "oever$ be very cautious about nterococcus #aecium tat is mostly resistant to Ampicillin and ill also be resistant to %iperacillin4;a'obactam and sould be treated it alycopeptide suc as ,ancomycin.


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SE "G% IF O* A *S*.

?" Enterobacteriaceae i"e" E. coli, lebsiella !p 1non E(BL2% Proteus mirabilis

PHA(E #+


Ideally recommended for te first to ee5s$ but if tere are no clinical sign of sepsis$ ten oralantibiotics can be started as soon as possible$ according to te antibiogram. =o not use Ami5acinfor more tan 9 days.

&eftria'one I, + g ! +. &ildren: 97 mg45g.

If &F;IAO can not be obtained$ &FO;AIM I, + g !0 (cildren: 97 mg45g) can be

used

plus (2)

Ami5acin I, 9 mg45g ! (67 minute infusion)

If ram-%ositive infection associated and if sensitive$ use ;AMI&I I, 0 mg45g ! (67minute infusion)


Oflo!acin %O +77 mg ! 6. &ildren: 9 mg45g4dayIf OFGOA&I can not be obtained or if polymicrobial infection$ &I%OFGOA&I oral 897 mg ! +(cildren: +7 mg45g4day) can be used but sould usually be reserved for Pseudomonas aeruginosainfection

&otrimo!a'ole %O177 mg Sulfameto!a'ole4 ?7 mg ;rimetoprim ! 6 if sensitive.&onsider if polymicrobial infection. &ildren: ?7 mg45g4day SM 4 +mg45g4day ;M%


&olistin I,6 millions units ! 6 (if sensitive). Proteus, Providencia, Serratia alaysresistant. &onsider if polymicrobial infection. &ildren: 77 777units45g4day

If ram-%ositive organisms or resistant ram-egative organisms are associated$ %I%A&IGGI(0g ! 0)$ %I%A&IGGI4 ;APO@A&;AM (0g 0)$ or IMI%M in case of very resistant ram-egative organisms can be used. See belo for dosages

PHA(E &+




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If OFGOA&I can not be obtained or if polymicrobial infection$ &I%OFGOA&I oral 897 mg ! +(cildren: +7 mg45g4day) can be used but sould usually be reserved for Pseudomonas aeruginosainfection

&otrimo!a'ole %O177 mg Sulfameto!a'ole4 ?7 mg ;rimetoprim ! 6 if sensitive.&onsider if polymicrobial infection. &ildren: ?7 mg45g4day SM 4 +

mg45g4day ;M%

@" Enterobacteriaceae rom E(CPP, Group+ Enterobacter !p% Serratia !p%Citrobacter !p% Proteus !ulgaris, Pro!i"encia !p, #organella !p

E(CPP, or*ani!m! are ALL automatically re!i!tant to cephalo!porin! 1i"e" cea>olin%cetria$one2 e/en i they are reported a! bein* !en!iti/e on the laboratory report" It i! /eryimportant not to all into thi! trap"

PHA(E #+


Ideally recommended for te ir!t t0o 0ee8!$ but if tere are no clinical !i*n o !ep!i!$ tenoral antibiotic! can be started as soon as possible$ according to te antibiogram. =o not use Ami5acin for more tan 9 days.

&efepime I, + g ! 6 (67 minute infusion). &ildren: 77 mg45g4day

plus (2)

Ami5acin I, 9 mg45g ! (67 minute infusion)If ram-%ositive infection associated and if sensitive$ use ;AMI&I I, 0 mg45g ! (67minute infusion)







If ram-%ositive organisms or resistant ram-egative organisms are associated$ %I%A&IGGI4;APO@A&;AM (0g 0)$ or IMI%M in case of very resistant ram-egative organisms can beused. See belo for dosages


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PHA(E &+




or


SE A=,I& if te organism you are treating is not sensitive to any of tese combinations of antibiotics

" E(BL producin* or*ani!m! 1e*% E. coli, Proteus !p, lebsiella !p Re!i!tantto Ceta>idime% Cetria$one2

PHA(E #+


Ideally recommended for te ir!t t0o 0ee8!$ but if tere are no clinical !i*n o !ep!i!$ tenoral antibiotic! can be started as soon as possible$ according to te antibiogram. =o not use Ami5acin for more tan 9 days.

Imipenem I, + g ! 6. &ildren: 77 mg45g4day

plus (2)


If ram-%ositive infection associated and if sensitive$ use ;AMI&I I, 0 mg45g ! (67minute infusion)





Fosfomycin I, 0 g ! 0. Sould , be used alone. &onsider if polymicrobialinfection. &ildren: +77 mg45g4day


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If ram-%ositive organisms or resistant ram-egative organisms are associated$ %I%A&IGGI4;APO@A&;AM (0g 0)$ or IMI%M in case of very resistant ram-egative organisms can be

used. See belo for dosages

PHA(E &+




or


SE A=,I& if te organism you are treating is not sensitive to any of tese combinations of antibiotics

" $C%NETO&$CTER &$U#$N%%

Automatically re!i!tant to cephalo!porin! 1i"e" cea>olin% cetria$one2 e/en i they arereported a! bein* !en!iti/e on the lab report" It i! /ery important not to all into thi! trap"

PHA(E #+



%iperacillin4;a'obactam

I, Goading dose of 0 g in ?7 minute infusion folloed by ? g 4+0 oursgiven continuously or$ if not possible$ in 0 divided doses. &ildren: +07mg 67 mg45g4day

or

Imipenem I, + g ! 6 if resistant cinetobacter. &ildren: +77 mg45g4day

plus (2)




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I,Goading dose of 0 g in ?7 minute infusion folloed by ? g 4+0 oursgiven continuously or$ if not possible$ in 0 divided doses. &ildren: +07mg 67 mg45g4day





ifampicin %O?77 mg ! + (if sensitive). Sould , be used alone. &ildren: 7

mg45g ! +

PHA(E &+



I,Goading dose of 0 g in ?7 minute infusion folloed by ? g 4+0 oursgiven continuously or$ if not possible$ in 0 divided doses. &ildren: +07mg 67 mg45g4day





SE A=,I& if te organism you are treating is not sensitive to any of tese combinations of

antibiotics.

" PSEU'O#ON$S $ERU(%NOS$

PHA(E #+



&efta'idime I, Goading dose of + g in ?7 minute infusion folloed by ? g 4+0 oursgiven continuously or$ if not possible$ in 6 divided doses. &ildren: +9


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mg45g ten 77 mg45g4day

or

Imipenem I, + g ! 6 if resistant Pseudomonas. &ildren: +77 mg45g4day

plus (2)


;" ;KO for at least 0 ee5s (depending on te organism sensitivity results) ;" O

&efta'idime I,Goading dose of + g in ?7 minute infusion folloed by ? g 4+0 oursgiven continuously or$ if not possible$ in 6 divided doses. &ildren: +9mg45g ten 77 mg45g4day

Imipenem I, + g ! 6 if resistant Pseudomonas. &ildren: +77 mg45g4day

&iproflo!acin %O 897 mg ! + after cec5ing for te sensitivity. &ildren: +7 mg45g4day


&olistin I,6 millions units ! 6 (if sensitive). Proteus, Providencia, Serratia alaysresistant. &onsider if polymicrobial infection. &ildren: 77 777

units45g4day

I needed 1polymicrobial inection or re!i!tance2+

• %iperacillin4;a'obactam$ &efepime$ Imipenem

• Fosfomycin$ &olistin

@ut tese are comple! infections and you sould see5 advice from te Medical =irector.

O; tat ;A%M is ineffective against Pseudomonas aeruginosa so is not a cause for concern if it is reported as beeing resistant on te laboratory report.

#3" Stenotrophomonas maltophilia

See Antibiogram only three antibiotic! are potentially active

&ombination treatment it ;KO antibiotics sould be used for at least 6 to 0 ee5s ;" Oantibiotic

;icarcillin4&lavulanic acid :

I, 9 g ! 6. &ildren: +97 mg45g4day

&otrimo!a'ole %O177 mg Sulfameto!a'ol4 ?7 mg ;rimetoprim ! 6 . &onsider if polymicrobial infection. &ildren: ?7 mg45g4day SM 4 + mg45g4day

;M%

or


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;icarcillin4&lavulanic acid :

I, 9 g ! 6. &ildren: +97 mg45g4day

&iproflo!acin %O 897 mg ! + after cec5ing for te sensitivity. &ildren: +7 mg45g4day

##" ANAEROBE(

Metronida'ole %O 977 mg ! 6 4day. &ildren: 97 mg45g4day

&lindamycin %O ?77 mg ! 0 4day. &ildren: 67 mg45g4day


MSF-OCP

11 July !!"

9

Documents

Protocols in Orthopedic Antibiotics Therapy_2008