Sandbox g14

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Epidural abscess

  • Empiric antimicrobial therapy
  • Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks AND Ceftriaxone 2 g Iv q24h for 2–4 weeks, then PO to complete 6–8 weeks
Note (1): Decompressive laminectomy in conjunction with long-term antibiotic therapy tailored to culture results is required.
Note (2): For critically ill patients, a vancomycin loading dose of 20–25 mg/kg may be considered.
  • Culture-directed antimicrobial therapy
  • Penicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen: Penicillin G 4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • Methicillin-susceptible Staphylococcus aureus or Streptococcus
  • Preferred regimen: Cefazolin 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks OR Nafcillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Oxacillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • Alternative regimen: Clindamycin 600 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks
  • Methicillin-resistant Staphylococcus aureus
  • Preferred regimen: Vancomycin loading dose 25–30 mg/kg IV followed by 15–20 mg/kg IV q8–12h for 2–4 weeks, then PO to complete 6–8 weeks
  • Streptococcus
  • Preferred regimen: Penicillin G 3–4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Ampicillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • Enterococcus
  • Preferred regimen: Penicillin G 3–4 MU IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Ampicillin 2 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks
  • Enterobacteriaceae
  • Preferred regimen: Ceftriaxone 1–2 g IV q12h for 2–4 weeks, then PO to complete 6–8 weeks OR Cefotaxime 2 g IV q6–8h for 2–4 weeks, then PO to complete 6–8 weeks
  • Gram-negative bacteria
  • Preferred regimen:Ceftazidime 2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks OR Cefepime 2 g IV q12h for 2–4 weeks, then PO to complete 6–8 weeks
  • Alternative regimen: Ciprofloxacin 400 mg IV q12h for 2–4 weeks, then PO to complete 6–8 weeks OR Levofloxacin 750 mg IV q24h for 2–4 weeks, then PO to complete 6–8 weeks OR Moxifloxacin 400 mg IV q24h for 2–4 weeks, then PO to complete 6–8 weeks
  • Anaerobes
  • Preferred regimen: Metronidazole 500 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks
  • Staphylococcus, Gram-negative bacteria, and anaerobes (mixed infection)
  • Preferred regimen: Ampicillin-Sulbactam 3 g IV q6h for 2–4 weeks, then PO to complete 6–8 weeks OR Ticarcillin-Clavulanate 3.1 g IV q4h for 2–4 weeks, then PO to complete 6–8 weeks OR Piperacillin-Tazobactam 3.375 g IV q4–6h for 2–4 weeks, then PO to complete 6–8 weeks
  • Alternative regimen: Imipenem 500–1000 mg IV q6h for 2–4 weeks, then PO to complete 6–8 weeks OR Meropenem 1–2 g IV q8h for 2–4 weeks, then PO to complete 6–8 weeks

Brain abscess

  • Brain abscess, bacterial[4]
  • Empiric antimicrobial therapy (unknown source of infection)
  • Preferred regimen: Vancomycin 15–20 mg/kg IV q8–12h for 6–8 weeks, then orally for 2–3 months AND (Cefotaxime 2 g IV q4h for 6–8 weeks, then orally for 2–3 months OR Ceftriaxone 2 g IV q12h for 6–8 weeks, then orally for 2–3 months) AND Metronidazole 7.5 mg/kg IV q6h or 15 mg/kg IV q12h for 6–8 weeks, then orally for 2–3 months
  • Alternative regimen: Penicillin G 3–4 MU IV q4h for 6–8 weeks, then orally for 2–3 months AND (Cefotaxime 2 g IV q4h for 6–8 weeks, then orally for 2–3 months OR Ceftriaxone 2 g IV q12h for 6–8 weeks, then orally for 2–3 months) AND Metronidazole 7.5 mg/kg IV q6h or 15 mg/kg IV q12h for 6–8 weeks, then orally for 2–3 months
  • Specific considerations
  • Culture-directed antimicrobial therapy
  • Nocardia
  • Preferred regimen: (TMP-SMX 15 mg/kg/day of TMP component and 75 mg/kg/day of SMX component IV/PO q6–12h AND Imipenem 500 mg IV q6h) ± Amikacin 7.5 mg/kg IV q12h if multiple organ involvement
  • Alternative regimen: Linezolid 600 mg IV/PO q12h AND Meropenem 2 gm IV q8h
Note: IV antibiotics should be administered for 3–6 weeks, followed by oral antimicrobial therapy.
  • Brain abscess, tuberculous
  • Brain abscess, fungal

References

  1. ↑ Kasper, Dennis (2015). Harrison's principles of internal medicine. New York: McGraw Hill Education. ISBN 978-0071802154.
  2. ↑ Bartlett, John (2012). Johns Hopkins ABX guide : diagnosis and treatment of infectious diseases. Burlington, MA: Jones and Bartlett Learning. ISBN 978-1449625580.
  3. ↑ Darouiche, Rabih O. (2006-11-09). "Spinal epidural abscess". The New England Journal of Medicine. 355 (19): 2012–2020. doi:10.1056/NEJMra055111. ISSN 1533-4406. PMID 17093252.
  4. ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
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