Sandbox g32
Meningitis, bacteria
- Bacterial meningitis[1]
- Empiric antimicrobial therapy based on specific predisposing factors
- Age
- Age < 1 month
- Common causative pathogens: Streptococcus agalactiae, Escherichia coli, Listeria monocytogenes, Klebsiella species
- Preferred regimen: Ampicillin 12 g/day IV q4h AND (Cefotaxime 8–12 g/day q4–6h OR Amikacin 15 mg/kg/day IV q8h OR Gentamicin 5 mg/kg/day IV q8h OR Tobramycin 5 mg/kg/day IV q8h)
- Age 1–23 months
- Common causative pathogens: Streptococcus pneumoniae, Neisseria meningitidis, S. agalactiae, Haemophilus influenzae, E. coli
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
- Age 2–50 years
- Common causative pathogens: N . meningitidis, S. pneumoniae
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
- Age > 50 years
- Common causative pathogens: S. pneumoniae, N. meningitidis, L. monocytogenes, aerobic Gram-negative bacilli
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND Ampicillin 12 g/day IV q4h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
- Head trauma
- Basilar skull fracture
- Common causative pathogens: S. pneumoniae, H. influenzae, group A β-hemolytic streptococci
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
- Penetrating trauma
- Common causative pathogens: Staphylococcus aureus, coagulase-negative staphylococci (especially Staphylococcus epidermidis), aerobic Gram-negative bacilli (including Pseudomonas aeruginosa)
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND Cefepime 6 g/day IV q8h OR Ceftazidime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h
- Postneurosurgery
- Common causative pathogens: Aerobic Gram-negative bacilli (including P. aeruginosa), S. aureus, coagulase-negative staphylococci (especially S. epidermidis)
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND Cefepime 6 g/day IV q8h OR Ceftazidime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h
- CSF shunt
- Common causative pathogens: Coagulase-negative staphylococci (especially S. epidermidis), S. aureus, aerobic Gram-negative bacilli (including P. aeruginosa), Propionibacterium acnes
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND Cefepime 6 g/day IV q8h OR Ceftazidime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h
- CSF Gram stain-directed antimicrobial therapy
- Gram positive, lancet-shaped diplococci suggestive of Streptococcus pneumoniae
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
- Alternative regimen: Meropenem 6 g/day IV q8h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h
- Gram negative diplococci suggestive of Neisseria meningitidis
- Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
- Alternative regimen: Penicillin G 24 MU/day IV q4h OR Ampicillin 12 g/day IV q4h OR Chloramphenicol 4–6 g/day IV q6h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h OR Aztreonam 6–8 g/day IV q6–8h
- Gram positive, short bacilli suggestive of Listeria monocytogenes
- Preferred regimen: (Ampicillin 12 g/day IV q4h OR Penicillin G 24 MU/day IV q4h) ± (Amikacin 15 mg/kg/day IV q8h OR Gentamicin 5 mg/kg/day IV q8h OR Tobramycin 5 mg/kg/day IV q8h)
- Alternative regimen: Trimethoprim-Sulfamethoxazole 10–20 mg/kg/day q6–12h OR Meropenem 6 g/day IV q8h
- Gram positive cocci in short chains suggestive of Streptococcus agalactiae
- Preferred regimen: (Ampicillin 12 g/day IV q4h OR Penicillin G 24 MU/day IV q4h) ± (Amikacin 15 mg/kg/day IV q8h OR Gentamicin 5 mg/kg/day IV q8h OR Tobramycin 5 mg/kg/day IV q8h)
- Alternative regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
- Gram negative coccobacilli suggestive of Haemophilus influenzae
- Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
- Alternative regimen: Chloramphenicol 4–6 g/day IV q6h OR Cefepime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h
- Gram negative bacilli suggestive of Escherichia coli
- Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
- Alternative regimen: Cefepime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h OR Aztreonam 6–8 g/day IV q6–8h OR Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h OR Trimethoprim-Sulfamethoxazole 10–20 mg/kg/day q6–12h
- Pathogen-directed antimicrobial therapy
- Streptococcus pneumoniae (adult)
- Penicillin MIC < 0.1 μg/mL
- Preferred regimen: Penicillin G 24 MU/day IV q4h OR Ampicillin 12 g/day IV q4h
- Alternative regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h OR Chloramphenicol 4–6 g/day IV q6h
xx
- Penicillin MIC 0.1–1.0 μg/mL
- Preferred regimen: Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h
- Alternative regimen: Cefepime 6 g/day IV q8h OR Meropenem 6 g/day IV q8h
- Penicillin MIC ≥ 2.0 μg/mL
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
- Alternative regimen: Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h
- Cefotaxime or ceftriaxone MIC ≥ 1.0 μg/mL
- Preferred regimen: Vancomycin 30–45 mg/kg/day IV q8–12h AND (Ceftriaxone 4 g IV q12–24h OR Cefotaxime 8–12 g/day q4–6h)
- Alternative regimen: Gatifloxacin 400 mg/day IV q24h OR Moxifloxacin 400 mg/day IV q24h
- Streptococcus pneumoniae (pediatric)
- Penicillin MIC
- <0.1 μg/mL
- Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
- Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children
- 0.1–1.0 μg/mL
- Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
- Alternative regimen: Cefepime 150 mg/kg tid for children OR meropenem 120 mg/kg tid for children
- ≥2.0 μg/mL
- Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND Ceftriaxone 80–100 mg/kg bid/OD for children OR Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
- Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
- Cefotaxime or ceftriaxone MIC ≥1.0 μg/mL
- Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND Ceftriaxone 80–100 mg/kg bid/OD for children OR Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
- Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
- Neisseria meningitidis (adult)
- Penicillin MIC
- <0.1 μg/mL
- Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
- Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day OR chloramphenicol 4-6g qid
- 0.1–1.0 μg/mL
- Preferred regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day
- Alternative regimen: chloramphenicol 4-6g qid OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 6g tid
- Neisseria meningitidis (pediatric)
- Penicillin MIC
- <0.1 μg/mL
- Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
- Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
- 0.1–1.0 μg/mL
- Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
- Alternative regimen: chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 120 mg/kg tid for children
- Listeria monocytogenes (adult)
- Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
- Alternative regimen: Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid {{or]} meropenem 6g tid
- Listeria monocytogenes (pediatric)
- Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
- Alternative regimen: Trimethoprim-sulfamethoxazole10–20 mg/kg bid-qid for children {{or]} meropenem 120 mg/kg tid for children
- Streptococcus agalactiae (adult)
- Preferred regimen: Penicillin G 24 mU 6 times per day OR ampicillin 12g 6 times per day
- Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day
- Streptococcus agalactiae (pediatric)
- Preferred regimen: Penicillin G 0.15 mU/kg tid/bid for 0-7 days neonates; 0.2 mU/kg tid/qid for 8-28 days neonates; 0.3 mU/kg 4-6 times per day for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
- Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
- Escherichia coli and other Enterobacteriaceae (adult)
- Preferred regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day
- Alternative regimen: Aztreonam 6–8 g tid/qid OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 6g tid OR Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid {{or]} ampicillin 12g 6 times per day
- Escherichia coli and other Enterobacteriaceae (pediatric)
- Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
- Alternative regimen: Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD OR meropenem 120 mg/kg tid for children OR Trimethoprim-sulfamethoxazole10–20 mg/kg bid-qid for children OR ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
- Pseudomonas aeruginosa (adult)
- Preferred regimen: Cefepime 6g tid OR ceftazidime 6g tid
- Alternative regimen: Aztreonam 6–8 g tid/qid OR ciprofloxacin 800–1200 mg bid/tid {or}} meropenem 6g tid
- Pseudomonas aeruginosa (pediatric)
- Preferred regimen: Cefepime 150 mg/kg tid for children OR ceftazidime 100–150 mg/kg tid/bid for 0-7 days neonates; 150 mg/kg tid for 8-28 days neonates; 150 mg/kg tid for children
- Alternative regimen: meropenem 120 mg/kg tid for children
- Haemophilus influenzae (adult)
- β-Lactamase negative
- Preferred regimen: ampicillin 12g 6 times per day
- Alternative regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day OR Cefepime 6g tid OR chloramphenicol 4-6g qid OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
- β-Lactamase positive
- Preferred regimen: Ceftriaxone 4g bid/OD OR cefotaxime 8-12g 4-6 times per day
- Alternative regimen: Cefepime 6g tid OR chloramphenicol 4-6g qid OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
- Haemophilus influenzae (pediatric)
- β-Lactamase negative
- Preferred regimen:ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children
- Alternative regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children OR Cefepime 150 mg/kg tid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
- β-Lactamase positive
- Preferred regimen: Ceftriaxone 80–100 mg/kg bid/OD for children OR cefotaxime 100–150 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 225–300 mg/kg tid/qid for children
- Alternative regimen: Cefepime 150 mg/kg tid for children OR chloramphenicol 25 mg/kg OD for 0-7 days neonates; 50 mg/kg bid/OD for 8-28 days neonates; 75–100 mg/kg qid for children OR Gatifloxacin 400 mg OD OR moxifloxacin 400 mg OD
- Staphylococcus aureus (adult)
- Methicillin susceptible
- Preferred regimen: Nafcillin 9–12 g 6 times per day OR oxacillin 9–12 g 6 times per day
- Alternative regimen: Vancomycin 30–45 mg/kg tid/bid OR meropenem 6g tid
- Methicillin resistant
- Preferred regimen: Vancomycin 30–45 mg/kg tid/bid
- Alternative regimen: Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid OR linezolid
- Staphylococcus aureus (pediatric)
- Methicillin susceptible
- Preferred regimen: Nafcillin 75 mg/kg bid/tid for 0-7 days neonates; 100–150 mg/kg tid/qid for 8-28 days neonates; 200 mg/kg qid for children OR oxacillin 75 mg/kg bid/tid for 0-7 days neonates; 150–200 mg/kg tid/qid for 8-28 days neonates; 200 mg/kg qid for children
- Alternative regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children OR meropenem 120 mg/kg tid for children
- Methicillin resistant
- Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children
- Alternative regimen: Trimethoprim-sulfamethoxazole 10–20 mg/kg bid-qid for children OR linezolid
- Staphylococcus epidermidis (adult)
- Preferred regimen: Vancomycin 30–45 mg/kg tid/bid
- Alternative regimen: Linezolid
- Staphylococcus epidermidis (pediatric)
- Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children
- Alternative regimen: Linezolid
- Enterococcus species (adult)
- Ampicillin susceptible
- Preferred regimen: ampicillin 12g 6 times per day AND gentamicin 5 mg/kg tid
- Ampicillin resistant
- Preferred regimen: Vancomycin 30–45 mg/kg tid/bid AND gentamicin 5 mg/kg tid
- Ampicillin and vancomycin resistant
- Preferred regimen: Linezolid
- Enterococcus species (pediatric)
- Ampicillin susceptible
- Preferred regimen: ampicillin 150 mg/kg tid for 0-7 days neonates; 200 mg/kg tid/qid for 8-28 days neonates; 300 mg/kg qid for children AND gentamicin 5 mg/kg bid for 0-7 days neonates; 7.5 mg/kg tid for 8-28 days neonates; 7.5 mg/kg tid for children
- Ampicillin resistant
- Preferred regimen: Vancomycin 20–30 mg/kg bid/tid for 0-7 days neonates; 30–45 mg/kg tid/qid for 8-28 days neonates; 60 mg/kg qid for children AND gentamicin 5 mg/kg bid for 0-7 days neonates; 7.5 mg/kg tid for 8-28 days neonates; 7.5 mg/kg tid for children
- Ampicillin and vancomycin resistant
- Preferred regimen: Linezolid
References
- ↑ Tunkel, Allan R.; Hartman, Barry J.; Kaplan, Sheldon L.; Kaufman, Bruce A.; Roos, Karen L.; Scheld, W. Michael; Whitley, Richard J. (2004-11-01). "Practice guidelines for the management of bacterial meningitis". Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 39 (9): 1267–1284. doi:10.1086/425368. ISSN 1537-6591. PMID 15494903.