542 Exam 2 dosing

What are (2) IV empiric / definitive options for MSSA associated bloodstream infections?(

Adult dosing, NO renal dysfunction)

(Drug, Dose, Route, Frequency

Cefazolin 2g IV Q8h

OR

Nafcillin 2g IV Q4h

What are (2) IV empiric / definitive options for MRSA associated bloodstream infections?

(Adult dosing, NO renal dysfunction)

(Drug, Dosing target / Dose, Frequency)

Vancomycin IV (trough 15-20 or AUC/MIC 400-600)

OR

Daptomycin 6mg/kg IV Q24h (some may use 8-10mg/kg per dose)

What are (2) empiric / definitive options for Staph. epidermidis associated bloodstream infections?

(Adult dosing, NO renal dysfunction)

(Drug, Dosing target / Dose, Frequency)

Same as MRSA:

Vancomycin IV (trough 15-20 or AUC/MIC 400-600)

OR

Daptomycin 6mg/kg IV Q24h (some may use 8-10mg/kg per dose)

What are the empiric / definitive treatment options (2) for Enterococcus faecalis associated bloodstream infections?

(Adult dosing, NO renal dysfunction)

(Drug, Dosing target / Dose, Frequency)

Ampicillin 2g IV Q4h

OR

Vancomycin IV (target trough 15-20 mg/L)

What are (3) empiric / definitive treatment options for (NON ESBL) E.coli associated bloodstream infections?

(Adult dosing, NO renal dysfunction)

(Drug, Dosing target / Dose, Frequency)

Same as Klebsiella spp. associated bacteremia:

• Ceftriaxone 2g IV Q24h

• Ciprofloxacin 400 mg IV Q12h OR 500 mg PO Q12h

• Levofloxacin 500 mg IV/PO Q24h

Definitive only & clinically stable: TMP/SMX PO 5mg/kg/dose Q8h-Q12h

What are (3) empiric / definitive treatment options for (NON ESBL) Klebsiella spp. associated bloodstream infections? Definitive & clinically stable patients?

(Adult dosing, NO renal dysfunction)

(Drug, Dose, Route, Frequency)

Same as E.Coli associated bacteremia:

• Ceftriaxone 2g IV Q24h

• Ciprofloxacin 400 mg IV Q12h OR 500 mg PO Q12h

• Levofloxacin 500 mg IV/PO Q24h

Definitive only & clinically stable: TMP/SMX PO 5mg/kg/dose Q8h-Q12h

What is the empiric treatment for ESBL-producing enterobacterales (E.Coli, Klebsiella spp.) associated bloodstream infections?

(Drug, Route, Dose, Frequency)

Ertapenem 1g IV Q24h

Critically ill: Meropenem 1g IV Q8h

What are (5) treatment options for Pseudomonas associated bloodstream infections?

(Drug, Route, Dose, Frequency)

•Cefepime 2g IV Q8h

•Ceftazidime 2g IV Q8h

•Ciprofloxacin 400mg IV Q8h OR 750mg PO Q12h

•Piperacillin/tazobactam:

—Intermittent infusion (30 min): 4.5g IV q6h

—Extended infusion (4 hrs): 3.375-4.5g IV Q8h

•Meropenem 1g IV Q8h

When using Piperacillin/tazobactam for the treatment of Pseudomonas associated bloodstream infections, what are the two infusion rates you can use?

(Duration, Dose, Route, Frequency)

Piperacillin/tazobactam:

• Intermittent infusion (30 min): 4.5g IV q6h

• Extended infusion (4 hrs): 3.375-4.5g IV Q8h

Typical final treatment duration for gram negative bloodstream infections?

7 days for gram negative

Typical final treatment duration for gram positive bloodstream infections?

14 days for gram positive

Exception: Complicated staph aureus

What are the (5) features of uncomplicated bacteremia?

NO endocarditis

NO implanted prostheses

NO evidence of metastatic sites of infection

Follow-up blood cultures 2-4 days after initial positive cultures are negative

Afebrile within 72 hours of starting effective treatment

What are the (2) recommended treatment durations for Staphylococcus aureus associated bacteremia?

Uncomplicated and Complication: (Duration)

Uncomplicated: 14 days

Complicated: 4-6 weeks

Repeat blood cultures: Staph aureus & Candida BSI, (Repeat, Stop, when is Day 1 of tx?)

Repeat Q48h (surveillance) until negative

Day 1 of tx = 1st day of negative cultures

Repeat blood cultures: Gram-negatives BSI

Generally no added value to recheck

Day 1 of tx = 1st day of effective antibiotic

BSI treatment principles (4) (preferred: route, type, dosing, formulation)

• IV route preferred

• Bactericidal drugs preferred

• Dose at higher end of range (if dosing range available)

• Once stable, can consider PO switch w/ high bioavailability (e.g., IV ceftriaxone -> PO cipro for GNR)

*GNR, gram negative rods

What are the (3) potential complications of infective endocarditis?

• Valvular abscess

• Valve prolapse, aortic insufficiency -> heart failure (HF)

• Septic emboli -> (e.g. stroke, pulmonary embolism (PE))

What are the treatment options for MSSA associated Native Valve Infective Endocarditis?

(Drug, Dose, Route, Frequency, Duration)

Nafcillin 2g IV Q4h

OR

Cefazolin 2g IV Q8h

Duration: 6 weeks

What are (2) treatment options for MRSA associated Native Valve Infective Endocarditis?

(Drug, Route, Dose, Frequency, Duration)

Vancomycin IV (trough 15-20 or AUC/MIC 400-600)

OR

Daptomycin 8-10 mg/kg IV Q24h (total BW)

Duration: 6 weeks

What are the treatment options for MSSA associated Prosthetic Valve Infective Endocarditis?

(Drug, Dose, Route, Frequency)

Nafcillin 2g IV Q4h (or Cefazolin 2g IV Q8h) x ≥6 weeks

PLUS

Rifampin 300 mg PO Q8h x ≥6 weeks

PLUS

Gentamicin (1 mg/kg Q8h, IBW) (target peak 3-5 mg/L, target trough <1 mg/L) × 2 weeks

What are the treatment options for MRSA associated Prosthetic Valve Infective Endocarditis?

(Drug, Dose, Route, Frequency)

Vancomycin IV (trough 15-20 or AUC/MIC 400-600) × ≥6 weeks

PLUS

Rifampin 300 mg PO Q8h × ≥6 weeks

PLUS

Gentamicin (1 mg/kg Q8h, IBW) (target peak 3-5 mg/L, target trough <1 mg/L) × 2 weeks

What are the primary treatment regimens for Native Valve Streptococcal associated Infective endocarditis IF PCN MIC ≤0.12 µg/mL?

(Drug, Dose, Route, Frequency, DURATION)

Penicillin G 2-3 million units IV Q4h

OR

Ceftriaxone 2g IV Q24h

Duration: 4 weeks

Note, Beta-lactam allergy: Vancomycin IV (trough 15-20 or AUC/MIC 400-600)

What are the primary treatment regimens in Native Valve Streptococcal associated infective endocarditis IF you want to do a short course duration IF PCN MIC ≤0.12 µg/mL?

(Drug, Dose, Route, Frequency, Duration)

Short-course Duration: 2 weeks

Either, Penicillin G 2-3 million units IV Q4h IV

OR

Ceftriaxone 2g/ IV or IM Q24h

PLUS

Gentamicin 3 mg/kg once daily (Only target trough <1 µg/mL)

What are (2) treatment options for Native Valve, Streptococcal associated infective endocarditis IF PCN MIC >0.12 µg/mL to <0.5 µg/mL?

Penicillin G 4 MU IV Q4h × 4 week

OR

Ceftriaxone 2g/ IV or IM Q24h × 4 weeks

PLUS

Gentamicin 3 mg/kg once daily (target trough <1) × 2 weeks

Note, Beta-lactam allergy: Vancomycin IV (trough 15-20 or AUC/MIC 400-600) × 4 weeks

W hat are (2) treatment options for Streptococcal associated Prosthetic Valve Infective Endocarditis IF PCN MIC ≤0.12 µg/mL?

(Drug, Dose, Route, Frequency, Duration)

Penicillin G 4 million U IV Q4h × 6 week

OR

Ceftriaxone 2g IV Q24h × 6 week

+/-

Gentamicin 3 mg/kg once daily (target trough <1) × 2 week

Note, Beta-lactam allergy: Vancomycin IV (trough 15-20 or AUC/MIC 400-600) × 6 weeks

What are (2) treatment options for Streptococcal associated Prosthetic Valve Infective Endocarditis? (PCN-Resistant strain)

(Drug, Dose, Route, Frequency, Duration)

Penicillin G 4 million U IV Q4h

OR

Ceftriaxone 2g IV Q24h

PLUS

Gentamicin synergy (3mg/kg/24hr, one dose, target trough: <1)

Duration: 6 weeks

Note, Beta-lactam allergy: Vancomycin IV (trough 15-20 or AUC/MIC 400-600) × 6 weeks

What is the primary treatment option for Enterococcal Native or Prosthetic Valve associated Infective Endocarditis? (Susceptible to PCN/Amp + Gent)

(Drug, Dose, Route, Frequency, Duration)

Ampicillin 2g IV Q4h

PLUS

Gentamicin IV (1 mg/kg Q8h, IBW) (target peak 3-5 mg/L, target trough <1 mg/L)

Duration: 4-6 weeks

* 4 weeks: NVE, symptoms <3 months

* 6 weeks: NVE, symptoms >3 months, or any prosthetic valve/material

What is the primary treatment option for Enterococcal Native or Prosthetic Valve associated Infective Endocarditis? (Susceptible to PCN/Amp, RESISTANT to Gent)

(Drug, Dose, Route, Frequency, Duration)

(Dual beta-lactam synergy)

Double B-lactam Ampicillin 2g IV Q4h

PLUS

Ceftriaxone 2g IV Q12h (Note: different from typical Q24h)

Duration: 6 weeks

What are (2) treatment options for Native or Prosthetic Valve Vancomycin Resistant Enterococcal (VRE) associated Infective Endocarditis?

(Drug, Dose, Route, Frequency, Duration)

Daptomycin 10-12 mg/kg IV Q24h (total BW)

OR

Linezolid 600mg IV/PO Q12h

Duration: At least 6 weeks

What is the mechanism of gentamicin synergy with beta-lactams, and what are the two dosing strategies with their respective pharmacokinetic targets?

Beta-lactam disrupts cell wall -> aminoglycoside penetrates to 30S ribosome

1. IF dose: 1 mg/kg, target peak 3-5 mg/L, 2. IF dose: 3mg/kg, target trough <1 mg/L

What are (4) treatment options for Infective Endocarditis Prophylaxis (dental procedures) in patients WITH a penicillin allergy?

Cephalexin 2g PO

OR

Azithromycin 500mg PO

OR

Clarithromycin 500mg PO

OR

Doxycycline 100mg PO (Note: Added in 2021 AHA Guideline Update)

Regimen: Single Dose 30 to 60 min before procedure

What is the preferred PO treatment option for Infective Endocarditis Prophylaxis (dental procedures)?

Amoxicillin 2g PO

Regimen: Single Dose 30 to 60 min before procedure

What is a "TTE"?

TransThoracic Echocardiogram (TTE), used for diagnosis of infective endocarditis

What is "TEE"

TransEsophageal Echocardiogram (TEE), used for diagnosis of infective endocarditis

Pneumonia outpt w/o comorbidities

Amoxi 1 g TID x 5 d

OR

Doxycycline 100 mg BID x 10 d

OR

Azithro 500 mg QD x 3 d or 500 mg on D1 —> 250 mg for 5 days

OR

Claritho 500 mg IR q12h or 1g ER QD x 5 d

Pneumonia w/ comorbidities monotherapy

Levo 750 mg QD

or

Moxi 400 mg PO QD (no pseudomonas coverage)

Pneumonia w/comorbidities double therapy

Augmentin

• 500 mg IR TID

• 875 mg IR BID

• 2 g ER BID

OR

Cefepodoxime or cefuroxime

+

Doxycycline 100 mg BID x 10 d

Azithro 500 mg QD x 3 d

Claritho 500 mg IR q12h or 1 g ER QD x 5 days

Pneumonia inpt w/o comorbidities monotherapy

Levo 750 mg IV or PO QD

OR

Moxi 400 mg QD

Pneumonia inpt w/o comorbidities double therapy

Ceftriaxone 1-2 g IV QD

OR

Cefotaxime 1-2 g IV q8h

OR

Unasyn 1.5-3g IV q6h

OR

Ceftaroline 600 mg IV q12h (x 7d if MRSA)

+

Azithro 500 mg IV/PO QD x min 3 d

OR

Clarithro 500 mg PO BID x min 5 d

OR

Dorxy 100 mg PO BID x 10 d

Pneumonia inpt w/ pseudomonas risk monotherapy

Levo 750 mg IV/PO QD

Pneumonia inpt w/pseudomonas risk double therapy

Zosyn 4.5 g IV q6h

OR

Cefepime 2 g IV q8h

OR

Ceftaroline 2 g IV q8h

OR

Meropenem 1 g IV q8h

OR

Imi/cila 500 mg IV q6h

OR

Aztreonam.

+

Azithro 500 mg IV/PO QD x min 3 d

OR

Clarithro 500 mg PO BID x min 5 d

OR

Dorxy 100 mg PO BID x 10 d (if macrolide CI)

Pneumonia HAP/VAP inpt low risk (at least 7 d)

Zosyn 4.5 g IV q6h

OR

Cefepime 2 g IV q8h

OR

Meropenem 1 g IV q8h

OR

Imi/cila 500 mg IV q6h

OR

Levo 750 mg PO QD

Pneumonia HAP/VAP inpt low risk + high MRSA risk

add vanco 15 mg/kg q12h

OR

Line 600 mg q12h

OR

Cipro 400 mg IV q8h

OR

aztreonam 2 g IV q8h

Pneumonia HAP/VAP inpt high risk

Zosyn 4.5 g IV q6h

OR

Cefepime 2 g IV q8h

OR

Meropenem 1 g IV q8h

OR

Imi/cila 500 mg IV q6h

+

Levo 750 mg PO QD

OR

Cipro 400 mg IV TID or 750 mg PO BID

OR

Aztreonam 2 g IV q8h

OR

Genta or tobra or amika

+

Vanco 15 mg/kg q12 h

OR

Line 600 mg q12h

CNS comm onset bacterial s.pneumoniae or n.meningitidis

Ceftria 2 g IV q12h

+

Vanco 15-20 mg/kg IV q8-12h

+

Dexamethasone 0.15 mg/kg IV q6h x 4 d

CNS comm onset bacterial L. monocytogenes

Also add if immunocomp or > 50 y/o

Ampi 2g IV q4h

CNS comm onset aseptic

Acyclovir 10 mg/kg IV q8h

Bacterial meningitis - L.monocytogenes

Ampi or PCN G

Bacterial meningitis - s.pneumoniae

Ceftria 2 g IV q12h + vanco 15/20 mg/kg IV q8-12h

THEN DE-ESC TO

Ampi or PCN G

Bacterial meningitis - n.meningitidis

Ceftri 2 g IV q12h

THEN DE-ESC TO

Ampi or PCN G

Septic arthritis gram pos

Vanco or cefazolin x 4 wks

Septic arthritis gram neg

3rd or 4th cephalo x 4 wks

Prosthetic joint infxt

Vanco IV + 3rd or 4th cephalo

+

Rifampin 300-450 mg PO BID if susceptivle, staph, and retained hardware or one stage

Duration: months

Osteomyelitis

Vanco or ceftri x 6 wks

SSTI mild PO

Dicloxacilin

OR

Cephalexin

OR

Clinda, moxi, or levo if beta lactam allergy

SSTI Mild w/ MRSA PO

Clinda

OR

Line

OR

Amox/cepha + doryx

OR

Amox/cepha + bactrim

SSTI moderate IV

Ceftriaxone

OR
Unasyn

OR

Moxi

OR
Levo

SSTI pseudomonas risk IV

Cefepime

OR

Zosyn

OR

Levo

OR

Imi/meropenem

SSTI MRSA risk IV

Vanco

OR

Line

OR

Dapto

SSTI severe IV

Cefepime + metro

OR

Levo + metro

OR

Zosyn

OR

Imi

OR

Mero

SSTI Nectrotizing

Zosyn + clinda

OR

Imi/mero + clinda