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Emergency Department Empiric Antibiotic Recommendations:
 Uncomplicated urinary tract infections in women  Complicated urinary tract infections  Intra-abdominal infections
Restricted antimicrobials now stocked in the ED (but continue to require ID oversight):

Cefepime (Maxipime)
Ampicillin-Sulbactam (Unasyn)

 Daytime (9am- 6pm) call the Antimicrobial Assistance Program and request/notify of the need for either cefepime or ampicillin-sulbactam and order in IBEX.  Off-hours (6pm-9am) order cefepime or ampicillin-sulbactam in IBEX. The “night time request for restricted antimicrobials” form no longer needs to be sent to pharmacy. Pharmacy will track use via IBEX.  The IBEX chart must reflect the clinical indication for the restricted antimicrobial (see
Antimicrobial Assistance Program: (ID pharmacists and ID physicians available for approvals
and recommendations)
Pager 9407 (adult)
Pager 3737 (pediatrics)
NOTE !

If there is any delay in reaching an ID pharmacist or ID physician, call the pharmacy
directly. A first dose will be released STAT when a patient needs a restricted antimicrobial
emergently.

ED: Initial empiric therapy for suspected bacterial community-acquired pneumonia (CAP) and health-care associated
pneumonia (HCAP) in immunocompetent adults: outpatient and inpatient guidelines.

Condition
Preferred treatment options
Comments
Outpatient Previously healthy1
Doxycycline is active against 90%-95% of strains of S. pneumoniae, also active against H. influenzae, atypical agents, and category A bacterial agents of bioterrorism. Generally well tolerated and inexpensive. Macrolides active against most common pathogens, including atypical agents. Levaquin 750 mg orally once a day for 5 Macrolide resistance is reported for 20%-30% of Streptococcus pneumoniae. Z-Pack (Azithromycin 500 mg orally once on day 1 then 250 mg every day for day 2 to 5) Z-Pack + Amoxicillin-clavulanate 2 g
Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa. Compared with amoxicillin, amoxicillin-clavulanate spectrum in vitro includes B- Z-pack+ Amoxicillin 1 g orally three
lactamase producing bacteria, such as most H. influenzae, methicillin-susceptible Staphylococcus aureus, and anaerobes. Lacks activity against atypical agents, also is more expensive and has more gastrointestinal intolerance, when compared with amoxicillin. High dosages amoxicillin (3 g/day) required to achieve activity against >90% of Levaquin 750 mg orally once a day for 5 S. pneumoniae. Lacks activity against atypical agents and B-lactamase days Outpatient and comorbidities (malignancy, COPD, diabetes, renal, liver or CHF)1
Z-pack + Amoxicillin-clavulanate 2 g
Recent antibiotics: Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa. Amoxicillin-clavulanate 2 g orally twice Clindamycin 600 mg orally three times a day for 7 days Inpatient non-ICU1
Recent antibiotics: Antibiotic for treatment of any infection within the past 3 months. Recent use of a fluoroquinolone should dictate selection of a non- fluoroquinolone regimen, and vice versa. Z-pack + Ceftriaxone 1 g IV once daily
In obese patients use ceftriaxone 2g instead of 1g. Levaquin is active against >98% of S. pneumoniae strains in the United States, including penicillin-resistant strains. Concern for abuse with risk of increasing resistance by S. pneumoniae. Active against H. influenzae, atypical agents, methicillin-susceptible S. aureus. Expensive. If multi drug resistant gram negative
Ceftriaxone is active in vitro against 90%-95% of S. pneumoniae, also active suspected or previously isolated or if against H. influenzae and methicillin-susceptible S. aureus.
recently hospitalized: Cefepime 1
gram IV every 12 hours.
For patients with CAP in the ICU, always cover S. pneumoniae and Legionella. Legionella must be treated for 21 days. Patients hospitalized for pneumonia in the ICU should have 2 pretreatment blood cultures and endotracheal aspirate sent for Gram stain and culture. In obese patients use ceftriaxone 2g instead of 1g. Cefepime retains excellent activity against s. pneumoniae but also covers more resistant gram negatives. In obese patients use Cefepime 2g instead of 1g. Nursing Home Resident2
Elderly patients of long-term care facilities have been found to have a spectrum of pathogens that most closely resemble late-onset hospital acquired pneumonia and ventilator associated pneumonia. Coverage against More resistant gram negatives, including pseudomonas should be provided. 1. Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults. Mandell LA, Bartlett JG, Dowell SF, File TM, Musher D, and Whitney C. Clin Infect Dis 2003;37:1405-1433. 2. Guidelines for the Management of Adults with Hospital-acquired, Ventilator-associated, and Health-care-associated PneumoniaAmerican Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2005;171:388-416. ED: initial empiric therapy for treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis
in immunocompetent women: outpatient and inpatient guidelines.

Condition and setting
Preferred treatment
Comments
Cystitis
E. coli is the causative pathogen in approximately 80 to 85 percent of episodes of acute uncomplicated cystitis. Staphylococcus saprophyticus is responsible for most TMP-SMX, in the past three months for any E. Coli resistance to TMP-SMX is about 10 % in the There is no apparent benefit in extending therapy with TMP-SMX or a fluoroquinolone past three days, and adverse reactions are more common in patients treated with longer regimens. This also appears to apply to women over the age of 65 years The antimicrobials currently recommended for cystitis, TMP-SMX, nitrofurantoin, and fluoroquinolones, have excellent activity in vitro against S. saprophyticus. The prevalence of resistance to nitrofurantoin among E. Women who might find it difficult to seek For patients with allergies to both TMP-SMX and/or additional care if their symptoms do not Fluroquinolones, another option is Keflex 250 mg po significantly improve over a short time: four times a day for 7 days, although compliance with
homelessness or lack of health insurance. release-XR-form of
nitrofurantoin) 100 mg twice
a day for 7 days can be
prescribed for outpatient
use only.
Pyelonephritis
Fever (>38ºC), flank pain, costovertebral In the Mount Sinai 2005 antibiogram for the ED, angle tenderness, and nausea or vomiting Ceftriaxone was effective against 97% of E.Coli Isolates. suggest upper tract infection and warrant E. Coli resistance to the fluoroquinolones remains well If outpatient therapy for mild pyelonephritis is a possibility in a patient tolerating oral medications/diet, would treat for 10 days with a fluroquinolone. Levaquin 500 mg orally once a day (or IV if unable to take po) Note: Patients with urethritis and vaginitis also may complain of dysuria, thereby presenting a diagnostic challenge. Urethritis caused by Neisseria gonorrheae or Chlamydia trachomatis is relatively more likely to be present if in the setting of a sexually transmitted disease (STD). Ref. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Infectious Diseases Society of America (IDSA). Warren JW; Abrutyn E; Hebel JR; Johnson JR; Schaeffer AJ; Stamm WE. Clin Infect Dis 1999 Oct;29(4):745-58. ED: Empiric antimicrobials for cystitis and pyelonephritis in men, pregnant women and nursing home
individuals.

Condition and setting
Preferred treatment options
Comments
Urethritis must be considered in sexually twice daily for 7 days.
examination for penile ulcerations and urine diagnostic tests for Neisseria gonorrhoeae For men <40 years of age it is usually and Chlamydia trachomatis (GC Probe) are daily for 7 days.
with cystitis or pyelonephritis, since they do not achieve reliable prostatic tissue concentrations and would be ineffective for occult prostatitis. twice daily for 4 weeks.
obstruction, and high fever: AVOID digital rectal exam as it could lead to sepsis, in daily for 4 weeks
All men with pyelonephritis should be evaluated daily 10-14 days
Ciprofloxacin 400 mg IV twice
daily for 10-14 days. (can switch
to po 500 mg po bid)
Pregnant women
Cystitis: treat as outpatients as long as TMP-SMX (160 mg/800 mg) Fluoroquinolones should be avoided in
orally twice a day for 7 days
pregnancy.
Pregnant women should have a follow-up urine culture performed one to two weeks after treatment to ensure that bacteriuria has been daily for 7 days. (FDA Category
B)
OR
Nitrofurantoin (Macrodantin)
100 mg four times a day for
7days (FDA Category B)
Macrobid (the extended release-
XR-form of nitrofurantoin) 100
mg twice a day for 7 days can
be prescribed for outpatient use
OR
250 mg orally four
times daily for 7 days. (FDA
Category B)
In the Mount Sinai 2005 antibiogram for the ED, Ceftriaxone was effective against 97% of E.Coli Isolates. Nursing Home patients
In the Mount Sinai 2005 antibiogram for the ED, Ceftriaxone was effective against 97% hospitalizations (>3) within the past If multi drug resistant gram
The choice of antibiotic should be based on year, recent hospitalization in an acute negative suspected or
the antimicrobial sensitivity if available. setting in the past 3 month, spinal cord previously isolated: Cefepime
Page the ID pharmacist (9407) or the ID
fellow on call for antimicrobial
assistance.
ED Initial Empiric Antibiotic Guidelines: diverticulitis, appendicitis, cholecystitis, spontaneous bacterial
peritonitis in cirrhotic patients.

Condition
Preferred treatment options
Comments
Cholangitis OR Cholecystitis
Acute cholecystitis is primarily an inflammatory process, however secondary infection of the gallbladder can occur as a result of cystic duct obstruction and Uncomplicated Diverticulitis
Community isolates of E.Coli are 89% sens to Cefazolin, but only 81% sens to fluroquinolones as per 2005 ED antibiogram. (recommended as first line based on Mount Agents that are used to treat nosocomial infections in the intensive care unit should not be routinely used to treat community-acquired infections which are principally Gram negative rods and anaerobes (particularly E. coli and B. fragilis), using broader-spectrum antibiotics would contribute to the Ceftriaxone 1 gm IV every 24 hours Recent Hospitalization: Within the past three months or frequent hospitalizations (>3) within the past year. (recommended as first line based on Mount In obese patients use ceftriaxone 2g instead of 1g or Unasyn 3g. Appendicitis
Community isolates of E.Coli are 89% sens to Cefazolin, but only 81% sens to fluroquinolones as per 2005 ED antibiogram. Recent Hospitalization: Within the past three months or frequent hospitalizations (recommended as first line based on Mount Spontaneous bacterial peritonitis in cirrhotic patients.
Most cases of SBP are due to gut bacteria, such as Escherichia coli and Dosing o2 g intravenously every eight hours produces excellent ascitic fluid levels Ref: Solomkin J, Mazuski J, Baron E et al, Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections. Clin Inf Dis 2003,37:997-1005. ED: Empiric antimicrobials for Management of Skin and Soft-Tissue Infections
Condition and setting
Preferred treatment
Comments
CELLULITIS
Most cases of cellulitis are caused by Group A strep Community acquired
(Dicloxacillin 500 mg orally 4 unless there is a portal of entry such as furuncles, carbuncles, abscesses or penetrating trauma in which case staph aureus is probably the cause. CDC data reveals that 99.5% of Group A strep strains Cefazolin 1 g every 8 h IV (Cephalexin 500 mg orally 4 remain susceptible to clindamycin, and 100% are susceptible to penicillin. times per day)
OR
mg orally 4 times per day). TMP-SMZ 2 double- Community acquired
Risk factors for Community acquired MRSA: Injection drug users, Homeless populations, Children, Jail and prison inmates, Military recruits, Native populations, Men who have sex with men, contact sports, HIV+ patients. Clindamycin 600 mg every 8 h IV (Clindamycin 300–450 Clindamycin has excellent antistaphylococcal activity, but there is the potential for emergence of inducible resistance to clindamycin if erythromycin resistance is present. Nosocomial
Risk Factors for Nosocomial MRSA : frequent hospitalization, nursing home resident, dialysis, NECROTIZING SKIN AND SOFT-TISSUE
INFECTIONS
Surgical intervention is the major therapeutic (1) pain disproportionate to physical findings, (2) modality in cases of necrotizing fasciitis, also CT violaceous bullae, (3) cutaneous hemorrhage, (4) skin scanning and measurement of the serum creatine sloughing, (5) skin anesthesia, (6) rapid progression, kinase (CK). The rationale for clindamycin is based
on in vitro studies demonstrating both toxin
suppression and modulation of cytokine (i.e., TNF)
production.

Necrotizing fasciitis
Monomicrobial infection caused by group A streptococcus (Streptococcus pyogenes) or clostridium. Predisposing factors: blunt trauma, varicella Kg) + clindamycin 600–900
(chickenpox), injection drug use, a penetrating injury, surgical procedures, childbirth, burns, nonsteroidal antiinflammatory drugs. OR Mixed polymicrobial
infection caused by aerobic and anaerobic bacteria. Predisposing risk Factors: immunocompromised, surgical procedures, diabetes, peripheral vascular disease, co-morbidities, decubitus ulcers, and spontaneous mucosal tears of the gastrointestinal or gastrourinary tract (i.e., Fournier gangrene). Animal and Human
Ampicillin-sulbactam 1.5–3.0 Pasteurella species are isolated from 50% of dog bite wounds and 75% of cat bite wounds. Human bites reflect oral flora of the biter and tend to be more serious: strep viridans, Eikenella corrodens, Fusobacterium species, peptostreptococci, and Prevotella. Both Ampicillin-sulbactam and Fluroquinolones have DIABETIC FOOT INFECTIONS

Mild soft tissue infections AND no

In mild diabetic soft tissue infections: therapy should be previous antibiotics
(Dicloxacillin 500 mg orally 4 directed against aerobic gram positive organisms particularly, coagulase-negative staphylococci and S.
Moderate soft tissue infections AND/OR

Ampicillin-sulbactam 1.5–3.0 Initial oral broad-spectrum antimicrobial therapy should previous antibiotic exposure
be directed at gram-positive, gram-negative, and (Amoxicillin/clavulanate
500/875 mg twice per day)
OR
Clindamycin 600–900 mg
IV every 8 h
+
Ref. Stevens DL, Bisno A, Chambers H et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections Clin Infect Dis 2005; 41:1373–406 IDSA guidelines for the diagnosis and treatment of diabetic foot infections: Clinical Infectious Diseases 2004; 39:885-910.

Source: http://sinaiem.org/clinical/mssm_ed_abx_2006.pdf

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