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Microsoft word - sicu_hcuv. empirical antibiotic therapy.doc

Table 1. By type of infection, microorganisms to be suspected in relation to the presence or not of risk factors for multidrug resistance and
suggested empirical treatments [VAP: ventilador-associated pneumonia; MDR: multidrug resistance; ESBL: extended-spectrum β-lactamase;
ESCPM group (Enterobacter cloacae, Enterobacter aerogenes, Serratia marcescens, Citrobacter freundii, Providencia rettgeri and Morganella
morganii); MRSA: methicillin-resistant S. aureus; HACEK (Haemophilus spp., Aggregatibacter -formerly Actinobacillus-
actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella spp)]
INFECTION TYPE
SUSPECTED PATHOGENS
EMPIRICAL TREATMENT
COMMENTS
Pneumonia or
No risk factors for MDR bacteria
IV antibiotic treatment should not exceed >7 days Tracheobronchitis
Addition of macrolides/azalides improves the prognosis of S. aureus (methicillin-susceptible) Presence of risk factors for first-
ESBL-producing isolates are involved in ≈10% level of resistancea
pneumonia caused by enterobacteria. When confirmed, monotherapy with carbapenems (meropenem, imipenem, Penicillin-resistant S. pneumoniae Suspiction of infection by P. aeruginosa: It is recommended the association of two antipseudomonal compounds In bacteremic infections by MRSA, consider the association of linezolid + daptomycin Presence of risk factors for second-
Treatment election should consider previous antibiotic level of resistanceb
treatments and susceptibility of isolates in surveillance Consider administration of an inhalated antibiotic Consider associations with colimycin, fosfomycin and aRisk factors for first-level of resistance: Significant comorbidities and/or antibiotic treatment for >3-5 days bRisk factors for second-level of resistance: Hospital admission and/or prolonged antibiotic treatment (>7 days) Bloodstream infections: Coagulase-negative staphylococci
Gram-negative bacteria should always be suspected in the primary bacteremia/
critically ill patient regardless site of central venous catheter-associated
bacteremia
If methicillin-susceptibility in staphylococci is confirmed, In persistent (>5-7 days) or recurrent (without endovascular foci) bacteremia by S. aureus, a second anti- staphylococcal drug (with or without rifampicin) should be If the patient is under cloxacillin treatment, add If the patient is under daptomycin treatment, add linezolid or fosfomycin or cloxacillin, with or without If the patient is under vancomycin treatment, change to daptomycin + cloxacillin, with or without An antifungal drug with activity against Candida spp. should be considered in critically ill patients with central venous catheter in the femoral vein and/or parenteral nutrition, severe sepsis or recent abdominal surgery Urinary tract infections With criteria for severe sepsis or
Due to its high frequency, ESBL-producing enterobacteria presence of risk factors for first-
should be covered in patients with severe sepsis or septic level of resistancea
Presence of risk factors for
Treatment election should consider previous antibiotic second-level of resistanceb
treatments and susceptibility of isolates in surveillance Use of colimycin or tigecyclin may be necessary. Although Multidrug-resistant P.aeruginosa, tigecycline concentrations in urine are not high, it may be Acinetobacter spp. Candida spp. aRisk factors for first-level of resistance: Significant comorbidities and/or antibiotic treatment for >3-5 days bRisk factors for second-level of resistance: Hospital admission and/or prolonged antibiotic treatment (>7 days) Intraabdominal
No risk factors for MDR bacteria
In case of lack of control of the infectious foci, follow infections
treatment recommendations in the presence of risk factors Presence of risk factors for first-
In case of lack of control of the infectious foci, follow level of resistancea
treatment recommendations in the presence of risk factors
Presence of risk factors for second-
Treatment election should consider previous antibiotic level of resistanceb
treatments and susceptibility of isolates in surveillance Tigecycline + piperacillin/tazobactam or In critically ill patients, echinocandins are the elective treatment for Candida antifungal therapy aRisk factors for first-level of resistance: Significant comorbidities and/or antibiotic treatment for >3-5 days bRisk factors for second-level of resistance: Hospital admission and/or prolonged antibiotic treatment (>7 days)
Endocarditis
If glomerular filtrate is <40 ml/min or concomitant treatment with potentially neurotoxic drugs, change Risk for MRSA (including
If vancomycin MIC ≥1 mg/l, severe sepsis or bacteremia intravenous drug users and
for >5 days, consider heteroresistance or tolerance and healthcare facilities)
Addition of gentamin should be avoided if glomerular filtrate is <40 ml/min. Consider change to cotrimoxazole. Addition of fosfomycin should be avoided if MIC ≥32 Initiate rifampicin from the 3rd-5th day on. Viridans group streptococci Vancomycin could be considered when MIC≤1 mg/l for Addition of gentamin should be avoided if glomerular filtrate is <40 ml/min. Consider change to cotrimoxazole. Addition of fosfomycin should be avoided if MIC ≥32 Considerar gentamicin if Enterococcus spp. is isolated Skin and Soft tissue
In infections by S. aureus producing panton valentine infections
Clostridium perfringes
leukocidin or superantigens, the antibiotic regimen should Clostridium septicum
Necrotizing fasciitis
Staphylococcus aureus
Mixed polymicrobial infection:
Consider high doses of tigecycline in moderately severe polymicrobial infections involving MRSA and in patients Peptostreptococcus spp. Bacteroides spp. Table 2. Doses of common antibiotics for the treatment of infections in the critically ill patient
Drug
Dose (iv)
Comments
1-2 g as initial dose followed by 8g in 24h continuous infusion 1-2 g as initial dose followed by 6g in 24h continuous infusion 1-2 g as initial dose followed by 6g in 24h continuous infusion 1-2 g as initial dose followed by 6g in 24h continuous infusion 1-2 g as initial dose followed by 12g in 24h continuous infusion 9 × 106 U followed by 4.5 × 106 U / 12 h Administered as intermittent slow infusion (4 h) Administered as intermittent slow infusion (4 h) or continuous infusion referred to adjusted body weigth; body weight = ideal body weight + 0.4 × (total weight – 2 g as initial dose followed by 16g in 24h continuous infusion 100- 200 mg followed by 50- 100 mg / 12 h 35 mg / kg followed by 35 mg / kg / day in

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