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==[[Clostridium Difficile]]== | ==[[Clostridium Difficile]]== | ||
===Moderate Infection=== | ===Mild/Moderate Infection=== | ||
{{Moderate Cdiff Antibiotics}} | {{Moderate Cdiff Antibiotics}} | ||
===Serous Infection=== | ===Serous Infection=== | ||
Revision as of 16:56, 18 January 2019
Appendicitis
Coverage should extend to E. coli, Klebsiella, Proteus, and Bacteroides (an anaerobe)
Adult Simple Appendicitis
Antibiotic prophylaxis should be coordinated with surgical consult
Options:
- Cefoxitin 2g IV q6 hours OR
- Cefotetan 2g IV q12 hours OR
- Moxifloxacin 400mg IV once daily OR
- Ertapenem 1g IV once daily
Pediatric Simple Appendicitis
Options:
- Cefoxitin 40mg/kg IV q6 hours
- Cefotetan 40mg/kg IV q12 hours
- Gentamicin 2.5mg/kg IV q8hrs +
- Metronidazole 7.5mg/kg IV q6hrs OR
- Clindamycin 10mg/kg IV q8hrs
- Ertapenem 15mg/kg IV q12h (max 1g); >13 years: 1g IV daily
Adult Complicated Appendicitis
Defined as perforation, abscess, or phlegmon
Options:
- Metronidazole 500mg IV q8hrs +
- Cefepime 2g IV q12hrs OR
- Ciprofloxacin 400mg IV q12hrs OR
- Levofloxacin 750mg IV q24hrs OR
- Aztreonam 2g IV q8hrs
- Imipenem/Cilastatin 500mg IV q6hrs
- Meropenem 1g IV q8hrs
- Piperacillin/Tazobactam 4.5g IV q8hrs
Pediatric Complicated Appendicitis
Options:
- Metronidazole 7.5mg/kg IV q6hrs +
- Imipenem/Cilastatin 25mg/kg IV q6hrs (max 500mg)
- Meropenem 20mg/kg IV q8hrs (max 1g)
- Piperacillin/Tazobactam 100mg/kg IV q8hrs (max 4.5g)
Cautious use should be applied to use of fluoroquinolones in complicated pediatric appendicitis due to the risk of tendon injury
Cholecystitis
Most often isolated organisms are Escherichia coli, Klebsiella pneumonia, and anaerobes, especially Bacteroides fragilis
Uncomplicated
Pathogenicity of Enterococci remains unclear and specific coverage is not routinely suggested for community-acquired infections[1]
- Ertapenem 1g IV once daily OR
- Metronidazole 500mg IV q8hrs PLUS
- Ciprofloxacin 400mg IV q12 hrs OR
- Levofloxacin 750mg IV q24hrs OR
- Ceftriaxone 1g IV q24hrs
Complicated or Healthcare Associated
Examples of complication include severe sepsis or hemodynamic instability
- Vancomycin 15-20mg/kg PLUS any of the following options
Options:
- Metronidazole 500mg IV q8hrs PLUS Ciprofloxacin 400mg IV q12hrs
- Piperacillin/Tazobactam 4.5g IV q8hrs
- Imipenem/Cilastatin 500mg IV q6hrs
- Doripenem 500mg IV q8hrs
- Meropenem 1g IV q8hrs
Pediatric
- Ceftriaxone 50-75mg/kg IV daily (max 2g) + Metronidazole 7.5mg/kg IV q8hrs (max 500mg) OR
- Piperacillin/Tazobactam 80-100mg/kg IV q6-8hrs (max 4.5g) OR
- Meropenem 20mg/kg IV q8hrs (max 1g)
Clostridium Difficile
Mild/Moderate Infection
- Vancomycin 125 mg PO four times daily for 10 days
- Fidaxomicin 200 mg PO two times daily for 10 days
- Metronidazole 500mg PO or IV three times daily for 10 days (third line therapy)
Pediatric:
- Vancomycin 10mg/kg PO QID x 10 days (max 125mg/dose)
- Fidaxomicin 200mg PO BID x 10 days (>12yr and >40kg); weight-based for younger
- Metronidazole 7.5mg/kg PO/IV TID x 10 days (max 500mg/dose) (third line)
Serous Infection
- Vancomycin 125 mg PO four times daily for 10 days
- Fidaxomicin 200 mg PO two times daily for 10 days
Diverticulitis
Uncomplicated
First, consider whether antibiotics are needed:
- In immunocompetent patients with mild uncomplicated diverticulitis (no systemic signs, able to tolerate PO, reliable follow-up), a trial of supportive care alone (bowel rest, hydration, pain control) without antibiotics is reasonable[2][3]
- Antibiotics ARE indicated if: immunocompromised, significant comorbidities/frailty, CRP >140 mg/L, WBC >15 × 10⁹/L, refractory symptoms, vomiting, or CT showing fluid collection or longer segment of inflammation[2]
If antibiotics are prescribed (4-7 day course preferred):[2]
Preferred:
- Amoxicillin/Clavulanate 875/125mg PO Q8hrs x 5 days (or Augmentin XR 2 tablets BID [each tablet 1gm amoxicillin 62.5mg clavulanate])[4][5]
- Equally effective as fluoroquinolone + metronidazole with lower C. difficile risk (especially in patients ≥65 years)[5]
- Avoids FDA black box fluoroquinolone risks (tendinopathy, neuropathy, aortic dissection, CNS effects)[6]
Alternatives (penicillin allergy or intolerance):
- Trimethoprim/Sulfamethoxazole one double-strength tablet BID PLUS Metronidazole 500mg PO Q8h x 5 days
- Metronidazole 500mg PO Q8hrs PLUS Ciprofloxacin 500mg PO BID x 5 days (reserve for patients without non-fluoroquinolone options)[6]
- Moxifloxacin 400mg PO QDaily (same fluoroquinolone cautions apply)[7]
Complicated
Options:
- Ticarcillin/Clavulanate 3.1 g IV Q6h or
- Piperacillin/Tazobactam 3.375 g IV q6 hours x 7-10 days
- Ciprofloxacin 400 mg IV q12h and Metronidazole 1 g IV Q12h
- Ampicillin 2 g IV Q6h and Metronidazole 500 mg IV q6h Plus (Gentamicin 7 mg/kg Q24h or Ciprofloxacin 400 mg IV Q12h)
- Imipenem/Cilastatin 500 mg IV Q6h
General Sick
Intra-Abdominal Sepsis/Peritonitis
| Harbor-UCLA | Santa Monica-UCLA | Other | |
| Primary |
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| Allergy or prior exposure |
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Pediatric
- Metronidazole 7.5mg/kg IV q8hrs (max 500mg) + one of:
- Ceftriaxone 50-75mg/kg IV daily (max 2g) OR
- Cefotaxime 50mg/kg IV q8hrs (max 2g/dose)
- Piperacillin/Tazobactam 80-100mg/kg IV q6-8hrs (max 4.5g) OR
- Meropenem 20mg/kg IV q8hrs (max 1g)
Infectious Diarrhea
Campylobacter jejuni
- Erythromycin 500mg PO BID x 5 days
- Ciprofloxacin 500mg PO BID x 5 days OR
- Azithromycin 500mg PO once daily x 5 days
Pediatric:
- Azithromycin 10mg/kg PO daily x 3 days (max 500mg)
- Erythromycin 10mg/kg PO QID x 5 days (max 500mg/dose)
Entamoeba Histolytica
- Metronidazole 750mg PO three times daily for 5-10 days PLUS
- Paromomycin 500mg q8hrs for 7 days OR
- Iodoquinol 650mg q 8hrs daily 20 days
Giardia lamblia
- Metronidazole 250mg PO q8hrs for 7-10days
- Tinidazole 2g PO once
Microsporidium
- Albendazole 400mg PO BID x 21 days + HAART therapy if HIV positive
Cryptosporidium
- Paromomycin 500mg PO q8hrs x 14-28days +HAART therapy if HIV positive
Salmonella (non typhoid)
- Treatment is not recommended routinely but should be considered if:
- Immunocompromised
- Age<6 mo or >50yo
- Has any prostheses
- Valvular heart disease
- Severe Atherosclerosis
- Active Malignancy
- Uremic
Options: Immunocompromised patients should have 14 days of therapy
- TMP/SMX 1 DS tab PO BID x 5 days
- Ceftriaxone 2g IV once daily x 5 days
- Levofloxacin 500mg PO once daily x 5 days
- Ciprofloxacin 500mg PO BID x 5 days
Pediatric:
- Treatment recommended if age <6 months, immunocompromised, or bacteremia
- Ceftriaxone 50-75mg/kg IV daily x 5 days (max 2g)
- TMP/SMX 8mg/kg/day (TMP) PO divided BID x 5 days
- Azithromycin 10mg/kg PO day 1, then 5mg/kg/day x 4 days
Shigella
Treatment extended for 10 days if immunocompromised'
- Ciprofloxacin 500mg PO BID x 5 days
- TMP/SMX 1 DS tab PO BID x 5 days
- Levofloxacin 500mg PO once daily x 5 days
- Azithromycin 500mg PO daily x 5 days
Pediatric:
- Azithromycin 10mg/kg PO day 1 (max 500mg), then 5mg/kg/day x 4 days
- Ceftriaxone 50mg/kg IM/IV daily x 5 days (max 2g)
- TMP/SMX 8mg/kg/day (TMP) PO divided BID x 5 days (if susceptible)
Vibrio Cholerae
- Doxycycline 300mg PO as single dose
- TMP/SMX 1 tablet (5mg/kg) PO BID daily x 3 daily
- Azithromycin 20mg/kg (1g) PO once
Yersinia enterocolitica
Antibiotics are not required unless patient is immunocompromised or systemically ill
- Ciprofloxacin 500mg PO BID daily
- Levofloxacin 500mg PO once daily
- TMP/SMX 1 DS tab (5mg/kg) PO BID
Traveler's Diarrhea
Options for Adults:
- Ciprofloxacin 750mg PO once daily x 1-3 days[8]
- First choice for use except in South and Southeast Asia[9]
- Azithromycin 500mg PO q24h x 3 days OR 1000mg PO x 1[10]
- Rifaximin 200mg PO TID x 3 days[13]
- Ineffective against mucosally invasive pathogens (Shigella, Salmonella, Campylobacter)
- Considered very safe as it is not absorbed
Typhoid Fever
Oral therapy with Quinolone Susceptibility
- Ciprofloxacin 500-750 mg PO q 12 hrs x 14 days
Parenteral Therapy with Quinolone Susceptibility
- Ciprofloxacin 400 mg IV q 12 hrs x 10 days
Parenteral Therapy with Quinolone Resistance
- if nalidixic acid resistant, assume fluoroquinolone resistant
- Ceftriaxone 2g IV q 24 hrs x 14 days
- OR
- Cefixime 10-15 mg/kg IV q 12 hrs x 8 days
Oral Therapy with Quinolone Resistance
- Azithromycin 1 g PO daily x 5 days
- Amoxicillin Not 1st line treatment; 50-100mg/kg/day PO divided q6-8h x 14 days; First Dose: 12.5mg-33.3mg/kg PO x 1
- Amoxicillin Not 1st line treatment; 50-100mg/kg/day PO divided q6-8h x 14 days
Pediatric
- Ceftriaxone 50-80mg/kg IV daily x 10-14 days (max 2g)
- Azithromycin 10-20mg/kg PO daily x 5-7 days (max 1g)
- Cefixime 15-20mg/kg/day PO divided BID x 7-14 days (max 400mg/dose)
See Also
Antibiotics by diagnosis
- Bone and joint antibiotics
- Cardiovascular antibiotics
- ENT antibiotics
- Eye antibiotics
- GI antibiotics
- GU antibiotics
- Neuro antibiotics
- OB/GYN antibiotics
- Pulmonary antibiotics
- Skin and soft tissue antibiotics
- Bioterrorism antibiotics
- Environmental exposure antibiotics
- Immunocompromised antibiotics
- Post exposure prophylaxis antibiotics
- Pediatric antibiotics
- Sepsis antibiotics
- Arthropod and parasitic antibiotics
For antibiotics by organism see Microbiology (Main)
References
- ↑ Ansaloni L, et al. 2016 WSES guidelines on acute calculous cholecystitis. World Journal of Surgery. (2016) 11:25. DOI 10.1186/s13017-016-0082-5
- ↑ 2.0 2.1 2.2 Peery AF, Shaukat A, Strate LL. AGA Clinical Practice Update on Medical Management of Colonic Diverticulitis: Expert Review. Gastroenterology. 2021;160(3):906-911.e1. doi:10.1053/j.gastro.2020.09.059
- ↑ Qaseem A, et al. Diagnosis and Management of Acute Left-Sided Colonic Diverticulitis: A Clinical Guideline From the American College of Physicians. Ann Intern Med. 2022;175(3):399-415.
- ↑ Balasubramanian I et al. Out-Patient Management of Mild or Uncomplicated Diverticulitis: A Systematic Review. Dig Surg. 2017;34(2):151-160.
- ↑ 5.0 5.1 Gaber CE, Kinlaw AC, Edwards JK, et al. Comparative Effectiveness and Harms of Antibiotics for Outpatient Diverticulitis: Two Nationwide Cohort Studies. Ann Intern Med. 2021;174(6):737-746. doi:10.7326/M20-6315
- ↑ 6.0 6.1 FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. July 26, 2016.
- ↑ Wilkins T et al. Diagnosis and Management of Acute Diverticulitis. Am Fam Physician. 2013 May 1;87(9):612-620.
- ↑ Hoge CW. et al. Trends in antibiotic resistance among diarrheal pathogens isolated in Thailand over 15 years. Clin Infect Dis. 1998;26:341–5
- ↑ Steffen R, et al. Traveler's Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ Sanders JW. et al. An observational clinic-based study of diarrheal illness in deployed United States military personnel in Thailand: presentation and outcome of Campylobacter infection. Am J Trop Med Hyg. 2002;67:533–8
- ↑ Steffen R, et al. Traveler's Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ Steffen R, et al. Traveler's Diarrhea: A Clinical Review. JAMA. 2015;313(1):71-80. doi:10.1001/jama.2014.17006
- ↑ DuPont HL. et al. Rifaximin versus ciprofloxacin for the treatment of traveler's diarrhea: a randomized, double-blind clinical trial. Clin Infect Dis. 2001;33:1807–15