Editors: Susla, Gregory M.; Suffredini, Anthony F.; McAreavey, Dorothea; Solomon, Michael A.; Hoffman, William D.; Nyquist, Paul; Ognibene, Frederick P.; Shelhamer, James H.; Masur, Henry
Title: Handbook of Critical Care Drug Therapy, 3rd Edition
> Table of Contents > Chapter 10 - Infectious Diseases
Chapter 10
Infectious Diseases
 

TABLE 10.1. Parenteral Antimicrobial Agents of Choice for Specific Pathogens
(These recommendations for empiric therapy should be modified based on local susceptibility patterns. The susceptibility of clinically important pathogens must be substantiated by laboratory testing for most pathogens.)
Pathogen First Choices Alternatives
Acanthamoeba
   Encephalitis None definitely effective Pentamidine
Trimethoprim-sulfamethoxazole + rifampin
   Keratitis 0.1% propamidine (topical) + neomycin/gramicidin/polymyxin (topical) Polyhexamethylene biguanide 0.02% (topical)
Chlorhexidine 0.02% (topical)
Acinetobacter calcoaceticus— baumanni complex Imipenem or Meropenem or Tobramycin + ciprofloxacin Tobramycin + piperacillin
Colistin
Tigecycline
Ampicillin-sulbactam
Actinomyces israeli and others Penicillin G or Ampicillin Clindamycin
Doxycycline
Erythromycin
Ceftriaxone
Adenovirus None Cidofovir
Aeromonas hydrophila
   Bacteremia Ciprofloxacin Trimethoprim- sulfamethoxazole
Imipenem or Meropenem
Cefepime
   Diarrhea Trimethoprim- sulfamethoxazole Doxycycline
Ciprofloxacin
Alcaligenes xylosoxidans Imipenem or Meropenem or Piperacillin-tazobactam Trimethoprim- sulfamethoxazole
Ameba See Entameba histolytica or Naegleria
Anaplasma Doxycycline Ciprofloxacin
Aspergillus species Voriconazole Liposomal amphotericin B
(AmBisome) or ABLC
Amphotericin B
Itraconazole
Caspofungin
Micafungin
Babesia microti Atovaquone + azithromycin Clindamycin + quinine
Bacillus anthracis Inhalational or gastrointestinal Ciprofloxacin + clindamycin + rifampin ± penicillin G Doxycycline + clindamycin + rifampin
Bacillus anthracis cutaneous Ciprofloxacin Doxycycline
Bacillus cereus (invasive) Vancomycin or Clindamycin Imipenem or Meropenem
Levofloxacin
Bacillus subtilis Vancomycin or Clindamycin Imipenem or Meropenem
Levofloxacin
Bacteroides fragilis Metronidazole Imipenem or Meropenem
Piperacillin-tazobactam
Bacteroides melaninogenicus Metronidazole Piperacillin-tazobactam
Imipenem or Meropenem
Bartonella species (Cat scratch fever) Erythromycin or Azithromycin Clarithromycin
Doxycycline
Ciprofloxacin
Blastomyces dermatitidis Liposomal amphotericin B
(AmBisome) or ABLC
Itraconazole
Fluconazole
Amphotericin B
Bordetella pertussis Azithromycin Trimethoprim-sulfamethoxazole
Erythromycin
Clarithromycin
Borrelia burgdorferi
   Early
   Facial nerve palsy
   Arthritis
   Carditis
   Meningitis/Encephalitis
Doxycycline
Doxycycline
Doxycycline
Ceftriaxone
Ceftriaxone
Amoxicillin
Amoxicillin
Ceftriaxone
Doxycycline
Penicillin G
Burkholderia cepacia Imipenem or Meropenem Trimethoprim-sulfamethoxazole
Campylobacter fetus Imipenem or Meropenem Gentamicin
Erythromycin
Campylobacter jejuni Erythromycin or Azithromycin Doxycycline
Ciprofloxacin
Candida species (mucosal—not life-threatening) Fluconazole (IV/PO) or Caspofungin Itraconazole (IV/PO)
Amphotericin B
Liposomal amphotericin B
(AmBisome) or ABLC
Micafungin
Candida species (invasive) Liposomal amphotericin B
(AmBisome) or ABLC or Caspofungin
Fluconazole
Amphotericin B
Micafungin
Capnocytophaga ochracea (DF-1) Clindamycin Imipenem or Meropenem
Ceftriaxone
Ciprofloxacin
Doxycycline
Capnocytophaga canimorsus (DF-2) Ampicillin-sulbactam Ciprofloxacin
Ceftriaxone
Imipenem or Meropenem
Cardiobacterium Ceftriaxone Ampicillin + gentamicin
Chlamydia pneumoniae Doxycycline or Azithromycin Clarithromycin
Erythromycin
Levofloxacin or Gatifloxacin
Chlamydia psittaci Doxycycline Erythromycin
Azithromycin
Chlamydia trachomatis
   Pelvic inflammatory disease (PID) Doxycycline Azithromycin
Ofloxacin
Citrobacter diversus Imipenem or Meropenem Ciprofloxacin
Gentamicin
Citrobacter freundii Imipenem or Meropenem Ceftriaxone
Ciprofloxacin
Clostridium botulinum (botulism) Trivalent equine antitoxin (CDC)a (+ penicillin for wound botulism) Metronidazole + antitoxin
Clostridium difficile (diarrhea) Metronidazole (PO) Vancomycin (PO)
Bacitracin (PO)
Metronidazole (IV)
Clostridium species (non-tetanus) (non-botulinum) Penicillin G ± Clindamycin Piperacillin-tazobactam
Imipenem or Meropenem
Doxycycline
Clostridium tetani (tetanus) Penicillin G + human tetanus immune globulin (CDC)a Metronidazole
Doxycycline
Clindamycin
Imipenem or Meropenem (all with antitoxin)
Coccidioides immitis Liposomal amphotericin B
(AmBisome) or ABLC
Itraconazole (IV/PO)
Amphotericin B
Corynebacterium diphtheriae Penicillin + antitoxin (CDC)a Erythromycin + antitoxin
Clindamycin + antitoxin
Corynebacterium JK strain Vancomycin Penicillin G + gentamicin
Ciprofloxacin
Coxiella burnetii Doxycycline Ciprofloxacin
Cryptococcus neoformans Liposomal amphotericin B
(AmBisome) or ABLC ± flucytosine
Fluconazole
Amphotericin B
Cysticercosis Albendazole ± prednisone Praziquantel ± prednisone
Cytomegalovirus Ganciclovir ± IV immune globulin (IVIG) Foscarnet ± IV immune globulin (IVIG)
Ganciclovir + foscarnet ± IVIG
Cidofovir
DF-1 (Capnocytophaga) Clindamycin Imipenem or Meropenem
Cefoxitin
Ceftriaxone
DF-2 (Capnocytophaga) Ampicillin-sulbactam Ciprofloxacin
Ceftriaxone
Imipenem or Meropenem
Ehrlichia chaffeensis, phagocytophila, and other Ehrlichia Doxycycline Ciprofloxacin
Eikenella corrodens Ampicillin or Penicillin G Cefotaxime
Imipenem or Meropenem
Ciprofloxacin
Entameba histolytica
   Severe intestinal Metronidazole (IV) or Tinidazole (PO) followed by Paromomycin (PO) Dehydroemetine followed by Iodoquinol (PO)
   Mild Metronidazole (IV/PO) or Tinidazole (PO) followed by Iodoquinol (PO) Paromomycin
   Asymptomatic Paromomycin (PO) Iodoquinol (PO)
Diloxanide (PO)
Enterobacter species Ciprofloxacin
Imipenem or Meropenem
Aztreonam
Cefepime
Piperacillin-tazobactam
Enterococcus (sensitive) Ampicillin ± gentamicin Vancomycin ± gentamicin
Daptomycin
Enterococcus (Vancomycin-resistant) Linezolid
Daptomycin
Synercid
Escherichia coli Ceftriaxone Gentamicin
Imipenem or Meropenem
Ciprofloxacin
Aztreonam
Piperacillin-tazobactam
Ampicillin (if sensitive)
Flavobacterium meningosepticum Vancomycin Trimethoprim-sulfamethoxazole
Erythromycin
Clindamycin
Imipenem or Meropenem
Francisella tularensis Streptomycin or Gentamicin Ciprofloxacin
Doxycycline
Fusobacterium Penicillin G or Metronidazole Cefoxitin or
Imipenem
Clindamycin
Gardnerella vaginalis Metronidazole Clindamycin (topical or PO)
Helicobacter pylori Amoxicillin + omeprazole (or rabeprazole) + clarithromycin Bismuth subsalicylate (PO) + metronidazole + tetracycline + omeprazole
Hemophilus influenzae Cefotaxime or Ceftriaxone Piperacillin-tazobactam
Imipenem or Meropenem
Levofloxacin, Gatifloxacin, or Moxifloxacin
Herpes simplex
   Keratoconjunctivitis Trifluridine (topical) + acyclovir Idoxuridine (topical)
Vidarabine (topical)
   Local Mucocutaneous Acyclovir Foscarnet
   Disseminated Acyclovir (high dose) Foscarnet
   Encephalitis Acyclovir (high dose) Foscarnet
Herpes zoster
   Local Famciclovir (PO) ± prednisone
Valacyclovir (PO) ± prednisone
Acyclovir ± prednisone
Foscarnet
   Disseminated Acyclovir (high dose) Foscarnet
Influenza A (H3N2) Oseltamivir Zanamivir (Inhal)
Influenza A Avian (H5N1) Oseltamivir Zanamivir (Inhal)
Influenza B Oseltamivir Zanamivir (Inhal)
Hantavirus None (No documented benefit from ribavirin)
Histoplasma capsulatum Liposomal amphotericin B
(AmBisome) or ABLC
Itraconazole (IV/PO)
Amphotericin B
Klebsiella species Ceftriaxone Gentamicin
Piperacillin
Imipenem or Meropenem
Piperacillin-tazobactam
Aztreonam
Ciprofloxacin or Levofloxacin
Legionella species Ciprofloxacin or
Levofloxacin or
Azithromycin or
Erythromycin ± rifampin
Trimethoprim-sulfamethoxazole + rifampin
Moxifloxacin
Leptospira Penicillin G or Ampicillin Doxycycline
Lice see Pediculosis
Listeria monocytogenes Ampicillin ± gentamicin or Penicillin ± gentamicin Trimethoprim-sulfamethoxazole
Erythromycin
Lyme disease See Borrelia burgdorferi
Malaria See Plasmodia
Moraxella catarrhalis (Branhamella catarrhalis) Ceftriaxone Levofloxacin, Gatifloxacin, Moxifloxacin
Telithromycin (PO)
Azithromycin
Trimethoprim-sulfamethoxazole
Morganella species Imipenem or Meropenem or Ceftriaxone Gentamicin
Ciprofloxacin or Levofloxacin
Mucormycosis Liposomal amphotericin B
(AmBisome) or ABLC
Amphotericin B
Posaconazole (investigational)
Mycobacterium avium intracellulare (Non-AIDS) Clarithromycin + ethambutol ± rifabutin Rifabutin (PO) + ciprofloxacin (or moxifloxacin) + amikacin
Mycobacterium avium-intracellulare (AIDS) Clarithromycin (PO) or Azithromycin (PO/IV) + ethambutol (PO) Rifabutin (PO) + moxifloxacin (or ciprofloxacin) + amikacin
Mycobacterium chelonae Clarithromycin or Azithromycin + amikacin Amikacin + cefoxitin
Mycobacterium fortuitum Amikacin + cefoxitin + probenecid Clarithromycin (PO)
Doxycycline
Imipenem
Mycobacterium kansasii Isoniazid (PO/IV) + rifampin (PO/IV) + ethambutol (PO) Trimethoprim-sulfamethoxazole
Amikacin (IV)
Ciprofloxacin (PO/IV)
Clarithromycin
Mycobacterium tuberculosis Isoniazid (PO/IM/IV) + rifampin (PO/IV) + pyrazinamide (PO) + ethambutol (PO) Cycloserine (PO)
Ethionamide (PO)
Streptomycin (IM/IV)
Amikacin (IV)
Linezolid (PO, IV)
Moxifloxacin (PO, IV)
Mycoplasma pneumoniae Clarithromycin
Azithromycin
Levofloxacin
Gatifloxacin
Moxifloxacin
Doxycycline
Naegleria fowleri Amphotericin B intraventricular + liposomal amphotericin
(AmBisome) or ABLC
Neisseria gonorrhea (uncomplicated) Ceftriaxone (IM) or Ofloxacin (PO/IV) or Doxycycline (PO) Cefotaxime
Ciprofloxacin
Neisseria gonorrhea Disseminated Ceftriaxone or Cefotaxime Ciprofloxacin
Levofloxacin
Neisseria meningitidis Penicillin G Ampicillin
Cefotaxime, or Ceftriaxone
Nocardia asteroides Trimethoprim-sulfamethoxazole ± amikacin Imipenem + amikacin
Ceftriaxone + amikacin
Nocardia brasiliensis Trimethoprim-sulfamethoxazole ± amikacin Ampicillin-sulbactam
Ceftriaxone + amikacin
Pasteurella multocida Penicillin G Cefazolin
Piperacillin-tazobactam
Doxycycline
Pediculosis (lice)
   Body, Head Permethrin 5% (topical) (Elimite) or Ivermectin (PO) Malathion 0.5% (topical)
Lindane 1% (Kwell) (topical)
Pyrethrin (RID) (topical)
Peptostreptococcus Penicillin G or Ampicillin Clindamycin
Metronidazole
Imipenem or Meropenem
Vancomycin
Plasmodia species potentially resistant
   Falciparum Quinidine gluconate (PO/IV) or Quinine (PO) + either Doxycycline, Clindamycin, or Fansidar (PO) Artesunate (PO) + mefloquine (PO)
Plasmodia species (not potentially resistant) Chloroquine (PO/IM) (followed by primaquine) Quinine (PO)
Quinidine (PO/IV)
Pneumocystis jiroveci (mild) Trimethoprim-sulfamethoxazole Atovaquone (PO)
Clindamycin + primaquine (PO)
Pentamidine (IV)
Trimetrexate (IV)
Pneumocystis jiroveci (severe) Trimethoprim-sulfamethoxazole + prednisone Pentamidine (IV) + prednisone or
Trimetrexate + prednisone
Propionibacterium acnes Penicillin Clindamycin
Proteus Ceftriaxone Gentamicin
Piperacillin-tazobactam
Aztreonam
Imipenem or Meropenem
Providencia species Ceftriaxone or Ciprofloxacin Piperacillin-tazobactam
Imipenem or Meropenem
Aztreonam
Pseudomonas aeruginosa Imipenem ± Gentamicin or Ciprofloxacin Piperacillin-tazobactam
Cefepime
Levofloxacin
Ceftazidime
Aztreonam
Respiratory Syncytial Virus (RSV) Ribavirin (aerosol) Palivizumab
Rhizopus species Liposomal amphotericin B
(AmBisome) or ABLC
Amphotericin B
Posaconazole (investigational)
Rhodococcus equi Vancomycin + ciprofloxacin Vancomycin + amikacin
Imipenem or Meropenem
Erythromycin or Azithromycin
Ciprofloxacin
Rickettsia species Doxycycline Levofloxacin
Salmonella typhi Ceftriaxone Trimethoprim-sulfamethoxazole
Ciprofloxacin
Cefotaxime or Ceftizoxime
Salmonella species (nontyphi) Cefotaxime Piperacillin-tazobactam
Trimethoprim-sulfamethoxazole
Cefotaxime
Ciprofloxacin
Scabies Permethrin 5% cream (topical) Ivermectin (PO)
Crotamiton 10% (topical)
Serratia marcescens Ceftriaxone ± gentamicin Either Gentamicin or Amikacin ± either Piperacillin- tazobactam or Ceftriaxone
Cefepime
Imipenem or Meropenem
Ciprofloxacin
Aztreonam
Shigella species Ciprofloxacin Trimethoprim-sulfamethoxazole
Staphylococcus aureus (methicillin-sensitive) Oxacillin ± gentamicin Vancomycin
Cefazolin
Imipenem or Meropenem
Daptomycin
Linezolid
Staphylococcus aureus (methicillin-resistant) Vancomycin ± either Rifampin or Gentamicin Linezolid
Daptomycin
Staphylococcus epidermidis Vancomycin ± rifampin Linezolid
Daptomycin
Staphylococcus haemolyticus Trimethoprim-sulfamethoxazole Ciprofloxacin
Staphylococcus lugdunensis Oxacillin Daptomycin
Vancomycin
Cefazolin
Staphylococcus saprophyticus Ampicillin-sulbactam Cefazolin
Levofloxacin
Trimethoprim-sulfamethoxazole
Stenotrophomonas maltophilia Trimethoprim-sulfamethoxazole Ciprofloxacin
Streptococcus groups A, B, C, G; bovis; milleri; viridans Penicillin G ± gentamicin Cephazolin
Vancomycin
Cefepime
Streptococcus pneumoniae (penicillin sens.) Penicillin G ± gentamicin Levofloxacin, Moxifloxacin
Imipenem or Meropenem
Ceftriaxone
Streptococcus pneumoniae (moderate penicillin resistance) Cefotaxime or Ceftriaxone Vancomycin
Levofloxacin, Moxifloxacin
Linezolid
Streptococcus pneumoniae (high level penicillin- resistant; MIC > 1.0 µg/ml) Levofloxacin Vancomycin ± rifampin
Moxifloxacin
Gatifloxacin
Linezolid
Strongyloides stercoralis Ivermectin (PO) Albendazole (PO)
Toxoplasma gondii Sulfadiazine (PO) + pyrimethamine (PO) + folinic acid (PO/IV) Clindamycin (IV) + pyrimethamine (PO) + folinic acid (PO/IV)
Trimethoprim-sulfamethoxazole
Atovaquone (PO) + pyrimethamine (PO) + folinic acid (PO/IV)
Trimethoprim-sulfamethoxazole (IV) + pyrimethamine (PO) or Trimetrexate (IV) + folinic acid (PO/IV)
Treponema pallidum Penicillin G
(Neuro: 12–24M U/d IV)
(Late latent, cardiac, or other tertiary: Benzathine 2.4M U IM q7d × 3)
Doxycycline
Ceftriaxone
Variola virus Cidofovir
Vibrio cholerae Doxycycline Trimethoprim-sulfamethoxazole
Ciprofloxacin
Vibrio vulnificus Doxycycline ± ceftazidime Cefotaxime
Ciprofloxacin
Yersinia enterocolitica Trimethoprim-sulfamethoxazole Ceftriaxone
Ciprofloxacin
Tobramycin
Amikacin
Yersinia pestis Streptomycin or Gentamicin ± doxycycline Doxycycline
Ciprofloxacin
*Primaquine indicated for P. vivax and P. ovale
IM, intramuscular; IV, intravenous; PO, by mouth
aCDC: obtain from Centers for Disease Control (404) 639–2206 (days) or (404) 639–2888 (nights, weekends, holidays)
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TABLE 10.2. Empiric Therapy for Common Infectious Syndromes in the ICU
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TABLE 10.3. Antimicrobial Drugs—Doses, Toxicities
Agent Usual Adult Dosage Adverse Effects/Comments
Penicillins
β-Lactamase Susceptible, Nonantipseudomonal Penicillins
Penicillin G IV low dose: 600,000–1,200,000 U/d
IV high dose: 4M U load, then 1M U q1h
Hypersensitivity: drug fever, rash
Anaphylactic reactions (approximately 1 in 10,000)
Blood: positive Coombs, hemolytic anemia, cytopenia, nephrotoxicity, seizures, phlebitis at IV site
Use pump for infusion to avoid inadvertent bolus
2 mEq Na+/MU of penicillin G sodium
Benzathine penicillin IM: 600,000–1,200,000 U qd As with penicillin G, plus local reactions at injection site; not for IV administration
Ampicillin IV: 1–3 g q4–6h Rash
Urticarial rash, often not true penicillin allergy: especially patients with infectious mononucleosis, lymphocytic leukemia, or those on allopurinol
Fever, low WBC, high SGOT (rare), anaphylactic reactions; convulsions (with excessively rapid infusions)
Interstitial nephritis
2.9 mEq Na+/g
β-Lactamase Susceptible, Antipseudomonal Penicillins
Piperacillin IV: 2–4 g q4–6h
Urinary tract: IV: 2 g q6h
Similar to other penicillins
1.85 mEq Na+/g
Combination β-Lactamase Inhibitors and β-Lactam Agents
Ticarcillin-clavulanic acid IV: 3.1 g q4–6h Similar to ticarcillin alone
4.75 mEq Na+/g
Ampicillin-sulbactam IV: 1.5–3 g q6h Similar to ampicillin alone
5 mEq Na+/1.5g
Piperacillin-tazobactam IV: 3.375 g q4–6h Similar to piperacillin alone
2.35 mEq Na+/g piperacillin
For pseudomonas; use q4h regimen
β-Lactamase Resistant Penicillins
Nafcillin Moderate infection: IV/IM: 1 g q4h
Severe infection: IV: 2 g q4h
Phlebitis, rash, drug fever, eosinophilia, hemolytic anemia, neutropenia, interstitial nephritis, elevated SGOT, nausea, diarrhea
2.9 mEq Na+/g
Oxacillin Moderate infection: IV/IM: 1 g q4h
Severe infection: IV: 2 g q4h
Similar to nafcillin (neutropenia less frequent)
2.5 mEq Na+/g
Cephalosporins/Cephamycins/Carbacephem
Parenteral
Cefazolin IV/IM: 0.5–3 g q6–8h Rash, elevated SGOT, elevated alkaline phosphatase, phlebitis (less than with cephalothin), positive Coombs
2 mEq Na+/g
Cefepime IV/IM: 2 g q12h Rash
Cefepime is sodium free
Cefotaxime Moderate infection: IV/IM: 1 g q8–12h
Life-threatening infection: IV/IM: 2 g q4h
Phlebitis, rash, eosinophilia, positive Coombs, neutropenia
Elevated SGOT, diarrhea
2.2 mEq Na+/g
Cefoxitin IV/IM: 1–2 g q4–6h Phlebitis, pruritus, rash, fever, eosinophilia, positive Coombs (without hemolysis), leukopenia, mildly elevated BUN
Falsely elevated serum creatinine
Transiently elevated SGOT, SGPT, LDH, alkaline phosphatase
2.3 mEq Na+/g
Ceftazidime IV/IM: 0.5–2 g q8–12h Phlebitis
Hypersensitivity: rash, eosinophilia, fever
Positive Coombs, neutropenia, thrombocytosis
Elevated SGOT
Diarrhea, elevated BUN
2.3 mEq Na+/g
Ceftriaxone IV/IM: 0.5–2 g q12–24h Phlebitis
Hypersensitivity: rash, eosinophilia, fever
Neutropenia, thrombocytosis
Elevated SGOT
“Pseudocholelithiasis” secondary to sludge in gallbladder
3.6 mEq Na+/g
Cefuroxime IV/IM: 0.75–1.5 g q8h Phlebitis, rash, positive Coombs, lowered hematocrit, eosinophilia, neutropenia
Elevated SGOT, alkaline phosphatase, LDH, bilirubin
Diarrhea, nausea
2.4 mEq Na+/g
Carbapenems
Ertapenem IV: 1 g q24h Similar to meropenem, imipenem
6.0 mEq Na+/g
Imipenem-cilastatin IV: 0.5–1 g q6–8h Phlebitis
Hypersensitivity: rash, pruritus, eosinophilia
Positive Coombs, neutropenia
Oliguria
Elevated SGOT, SGPT, alkaline phosphatase
Confusion, seizures, myoclonus
Nausea, vomiting (especially with too rapid IV infusion), diarrhea, pseudomembranous colitis
In elderly patients with poor renal function, cerebrovascular disease, or seizure disorders, consider avoiding this agent because of high risk of neurological side effects
1.6 mEq Na+/500 mg
Meropenem IV: 1–2 g q8h Similar to imipenem but less contraindicated for patients with renal, cerebrovascular, or seizure disorders
3.92 mEq Na+/500 mg
Monobactams
Aztreonam Moderately severe infection: IV: 1 g q8h
Life-threatening infection: IV: 2 g q6h
Phlebitis
Hypersensitivity, rash (no cross-reactivity with penicillin G), eosinophilia
Elevated SGOT
Diarrhea, nausea, vomiting
Seizures
Aztreonam is sodium-free
Aminoglycosides and Related Antibiotics (See Table 10.4)
Amikacin IV: 15 mg/kg/d divided q8h
IV: for extended interval (i.e., q24h) see Table 10.4
Nephrotoxicity (proteinuria, elevated BUN), ototoxicity
Eosinophilia, arthralgia, fever, skin rash, probable neuromuscular blockade
q24h regimen not as well studied, but can be given at high doses at extended intervals, i.e., 20–32 mg/kg q24h if renal function is normal (see Table 10.4)
Gentamicin IV: For extended interval (i.e., q24h) see Table 10.4
IV: 3–5 mg/kg/d divided q8h or given q24h
Intrathecal: 4 mg q12h (Preservative free)
Nephrotoxicity (proteinuria, elevated BUN), ototoxicity (especially vestibular), fever, rash, neuromuscular blockade
q24h regimen not well studied for life-threatening disease; but can be given as high doses at extended intervals, i.e., 5–8 mg/kg q24h (see Table 10.4)
Neomycin sulfate Hepatic coma: PO 4–12 g/d
Enteropathogenic E. coli: PO 100 mg/kg/d
Nausea, vomiting, diarrhea, “malabsorption”
Ototoxicity, nephrotoxicity, neuromuscular blockade if sufficiently absorbed
Streptomycin IM/IV: 0.5–2 g/d Ototoxicity (vestibular, auditory) nephrotoxicity, drug fever, neuromuscular blockade, rash, circumoral paresthesias
Often in short supply
Tobramycin IV: 3–5 mg/kg/d divided q8h Nephrotoxicity, ototoxicity, (dizziness, hearing loss) neuromuscular blockade, rash
Macrolides, Cloramphenicol Glycopeptides, and Others
Azithromycin IV: 500 mg qd × 1–2 d Diarrhea, nausea, abdominal pain, pain at infusion site
If unable to convert to PO therapy, reduce IV dose to 100 mg IV qd; provides approximately same systemic expose as 250 mg PO daily, with oral bioavailability equal to 37%
Chloramphenicol IV: 50 mg/kg/d Rarely used except in unusual circumstances because of risk of aplasia or litigation or both
Decreased RBC in approximately one-third of patients; aplastic anemia incidence of 1 of 21,000 courses
Fever, skin rash, anaphylactoid reactions, optic atrophy or neuropathy, digital paresthesias, minor disulfiramlike reactions
2.3 mEq Na+/g
Clindamycin IV: 150–900 mg q8h Diarrhea, pseudomem-branous colitis with toxic megacolon
Rash, neutropenia, eosinophilia
Occasional elevated SGOT and alkaline phosphatase
Neuromuscular blockade
Erythromycin IV: 500 mg–1 g q6h Nausea, vomiting, abdominal cramps (both PO and IV), diarrhea, phlebitis at infusion site
Rare rash, elevated SGOT, cholestatic jaundice (especially with erythromycin estolate; rare with erythromycin ethyl succinate)
Reversible deafness (high dose), PVCs, torsade de pointes
For legionellosis, 1g IV q6h is preferred over lower doses
Spectinomycin IM: 2 g once Rash, drug fever, local pain on injection
Anaphylaxis
Synercid (Quinupristin-Dalfopristin) IV: 7.5 mg/kg q8–12h Myalgias
Vancomycin IV: 1 g q12h
PO: 125–500 mg q6h
Intrathecal: 5–10 mg q48–72h
Phlebitis, fever, rash, nausea, ototoxicity
Neutropenia, eosinophilia, anaphylactoid reactions
“Red man syndrome” (flushing over upper chest)—rate dependent
Hypotension with rapid IV push
Oral doses not absorbed systemically; oral therapy limited to treatment of antibiotic associated diarrhea due to C. difficile
Tetracyclines
Doxycycline IV: 100 mg q12h on 1st day then 100–200 mg/d Hepatotoxicity, negative nitrogen balance, pseudotumor cerebri; phlebitis (central line preferred)
Tigecycline IV: 100 mg × 1 then 50 mg q12h Nausea, vomiting
Avoid in pregnancy
Fluoroquinolones
Ciprofloxacin IV: 400 mg q8–12h Nausea, diarrhea, vomiting, abdominal pain
Headache, insomnia, nightmares, toxic psychosis, confusion, seizures
Rash, angioedema
Elevated SGOT, alkaline phosphatase, WBC, creatinine
Gatifloxacin IV: 200–400 mg qd Similar to ciprofloxacin
Levofloxacin IV: 500–750 mg qd Similar to ciprofloxacin
Use higher dose for most ICU settings
Moxifloxacin IV: 400 mg qd Similar to ciprofloxacin
Ofloxacin IV: 200–400 mg q12h Similar to ciprofloxacin
Miscellaneous Antibacterial Agents
Colistin IV: 1.25–2.5 mg/kg q12h Nephrotoxicity, abnormal vision, paresthesias, confusion
Daptomycin IV: 4–6 mg/kg qd Myalgias
Linezolid IV/PO: 600 mg q12h Thrombocytopenia
Neuropathies (prolonged use)
Serotonin syndrome
Metronidazole IV: 500 mg q6h Nausea, vomiting, diarrhea, metallic taste, headache, rare paresthesias, ataxia, seizures, urticaria, phlebitis at injection site
14 mEq Na+/500 mg
Tinidazole PO: 2 g once or qd Similar to metronidazole
Trimethoprim (TMP)-sulfamethoxazole (SMX) IV: TMP 320 mg/SMX 1,600 mg q8h Urticaria, maculopapular and morbilliform rashes, nausea, vomiting, diarrhea
Glossitis, rare jaundice
Headache, depression, rare hallucinations, pseudotumor cerebri
Renal: falsely elevated creatinine, renal failure, hyperkalemia
Neutropenia, thrombocytopenia, agranulocytosis
May trigger asthma in sulfite-sensitive individuals
Antifungals
Amphotericin B IV: 0.5–1.5 mg/kg qd Premeds: diphenhydramine 50 mg IV, meperidine 50 mg IV, acetaminophen 650 mg PO
Hydration: ≥500 ml 0.9% NaCl pre- and postinfusion
Administer in D5W, not in electrolyte solutions
Administer over 1–4 h (1 h may be as well tolerated as 4 h)
Hydrocortisone: 25–100 mg IV if fever, chills not controlled by other premeds
Toxicity: renal (dose related elevation of creatinine), renal tubular wasting, lowered K, lowered Mg, fever, chills, nausea, vomiting, phlebitis, anemia, headache
Initiating doses in stepwise fashion (1 mg, 5 mg, 10 mg, etc.) is probably unnecessary
Bladder irrigation: 50 mg/ 1,000 cc sterile water
ABLC (Abelcet) IV: 5 mg/kg qd Same as amphotericin B but less frequent
ABLC (amphotericin B lipid complex)
Liposomal ampho B (AmBisome) IV: 5–7.5 mg/kg qd Same as amphotericin B but less common
Higher doses have been used
Anidulafungin IV: 35 mg qd Minimal to date
Caspofungin IV: 70 mg × 1 d then 50 mg qd Elevated transaminase
Fluconazole IV/PO: 400 mg q24h Histamine release
Nausea, vomiting, diarrhea
Elevated ALT/AST, confusion, rash, eosinophilia
Flucytosine PO: 37.5 mg/kg q6h Nausea, vomiting, diarrhea, leukopenia, thrombocytopenia
Elevated ALT/AST
Rash
Falsely elevated creatinine if EKTACHEM analysis used
Itraconazole PO: 200 mg bid
IV: 200 mg PO bid × 4 doses then 200 mg qd
Nausea, abdominal pain, rash, edema, hypokalemia, hepatitis
Administer capsule with meals, administer oral solution on an empty stomach
Micafungin IV: 150 mg qd (acute therapy) Leukopenia
Histamine release
Posaconazole (Investigational) PO: 400 mg q12h Elevated ALT/AST
Voriconazole IV: 6 mg/kg q12h × 24 h then 4 mg/kg q12h
PO: 400 mg q12h × 1 d then 200 mg q12h (if >40 kg body weight)
Elevated transaminase
Visual disturbances
Rash
Thrombocytopenia
Antiretroviral Should discontinue all antiretrovirals if adherence or gastrointestinal absorption not ensured
No intravenous preparations are available
Anti-HIV nucleosides/nucleotides All drugs in this class can cause hepatic steatosis and lactic acidosis
Abacavir PO: 300 mg bid/600 mg qd Rash, myalgia, fever: never rechallenge after stopping for rash, fever, or myalgias
Didanosine (ddl) PO: 400 mg qd Pancreatitis, peripheral neuropathy
Emtricitabine (FTC) PO: 200 mg qd Few
Lamivudine (3TC) PO: 150 mg bid Toxicities are rare
Stavudine (d4T) PO: 30–40 mg bid Pancreatitis, peripheral neuropathy
Tenofovir PO: 300 mg qd Renal tubular dysfunction
If stopped, beware hepatitis B flare
Anti-HIV Nonnucleosides
Efavirenz PO: 600 mg qd CNS effects (e.g., insomnia, vivid dreams), rash, drug interactions
Anti-HIV Proteases Drug interactions with agents metabolized by cytochrome P450 system can be significant
Lopinavir-Ritonavir PO: 3 capsules bid or 2 tablets bid or 6 capsules qd or 4 tablets qd Diarrhea, nausea, hypertriglyceridemia, elevated transaminase
Antivirals (Nonantiretrovirals)
Acyclovir PO (HSV): 200 mg 5 doses/day
PO (VZV): 800 mg 5 doses/day
IV (most HSV): 5 mg/kg q8h
IV (HSV encephalitis or disseminated VZV): 10–12 mg/kg IV q8h
Phlebitis (IV)
Lethargy
Tremors/seizures
Confusion
Crystalluria
Elevated ALT/AST
4.2 mEq Na+/g
Adefovir PO: 10 mg PO qd Few
Cidofovir IV: 5 mg/kg qw × 2, then qow Nephrotoxicity, neutropenia, hypotony
Given with oral probenecid 2 g at 2 h predose infusion, and administer 1 g orally at 2 and 8 h postinfusion
Given with 1 liter 0.9% NaCl preinfusion
Foscarnet IV: 60 mg/kg q8h or 90 mg/kg q12h (acute) 90–120 mg/kg q24h (chronic) Infuse over 2 h after 1 L 0.9% NaCl load
Nephrotoxicity
Nausea, vomiting
Headache, seizures
Leukopenia, anemia
Elevated SGOT
Penile ulcers
Ganciclovir IV: 5 mg/kg q12h (acute) 5 mg/kg q24h (chronic) Leukopenia
Thrombocytopenia
Fever
Rash
Elevated ALT/AST
46 mEq Na+/500 mg vial
Palivizumab IV: 15 mg/kg IM (pediatric) Elevated ALT/AST
Allergic response to Ig
Ribavirin Aerosol: 6g over 12–18 h per day
IV: Investigational
Bronchospasm, environmental hazard precautions
Hemolytic anemia
Concentration 20 mg/ml (6 g in 300 ml sterile H2O without preservatives)
Trifluridine topical 1 drop of 1% q2h (max 9 drops/d) Burning, edema, hypersensitivity
Interferon alpha SC/IM (hepatitis B): 5M U qd
SC/IM (hepatitis C): 3M U qd
Fever
Myalgia, fatigue
Headache
Anorexia
Rash
Leukopenia, thrombocytopenia
Antiparasitics
Chloroquine PO: 600 mg base at T = 0, then 300 mg base at 6 h, 24 h, 48 h for malaria Nausea, vomiting, pruritus, rash, hemolytic anemia, leukopenia, thrombocytopenia
Ivermectin PO: 12 mg PO qd × 2 d Headache, fever, abdominal pain
Pentamidine IV: 4 mg/kg q24h Infuse over 1 h
Nephrotoxicity
Hyperglycemia followed by hypoglycemia
Torsades de pointes
Can be given IM but causes sterile abscesses
Pyrimethamine PO: 100 mg/d × 1 then 25–100 mg qd Leukopenia, rash, ataxia, tremors, seizures
Quinine PO: 600 mg tid Tinnitus, headache, nausea, hemolysis
Quinidine IV: 10 mg/kg load (maximum 600 mg) in 0.9% NaCl over 1 h followed by 0.02 mg/kg/min × 72 h, then oral quinine 600 mg tid to complete 7 d for malaria More available than quinine
IV: hypotension
Sulfadiazine PO: 1–2 g PO q6h
IV: none (consider using TMP/SMX)
Rash, fever, nephritis, nausea, hemolysis
Antimycobacterials
Capreomycin IV: 1 g qd Nephrotoxicity
Isoniazid PO/IM/IV: 300 mg qd Administer with pyridoxine
Hepatitis, neuropathy, rash, fever, headache, psychosis, seizures
Rifabutin PO: 300 mg qd Myalgias, arthralgias, leukopenia, neuritis
Rifampin PO/IV: 600 mg qd Orange urine and secretions, hepatitis, fever, nausea
Ethambutol PO: 15–25 mg/kg qd Rash, optic neuritis, confusion, gout
Pyrazinamide PO: 15–30 mg/kg qd GI intolerance, rash, arthralgia, hepatotoxicity, hyperuricemia
Streptomycin IM/IV: 15 mg/kg (adult <40 y), qd
10 mg/kg (>40 y) qd
Ototoxicity, nephrotoxicity
Call (800) 254–4445 to obtain from Pfizer
ALT, aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; CNS, central nervous system; ICU, intensive care unit; IM, intramuscular; IV, intravenous; HSV, herpes simplex virus; LDH, lactate dehydrogenase; PO, by mouth; PVC, premature ventricular contractions; RBC, red blood cells; SGOT, serum glutamic-oxaloacetic transaminase; SGPT, serum glutamic-pyruvic transaminase; VZV, varicella zoster virus; WBC, white blood cells
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TABLE 10.4. Aminoglycoside Dosing Protocols
I. Multiple Daily Dosage Regimen
Aminoglycoside Condition Dosage Comments
A. Loading Doses—To be given once initially— See Section C for determining when to use actual body weight (ABW) and lean body weight (LBW)
Gentamicin/Tobramycin Non–head injured
Head injured
Uncomplicated urinary tract infection
2.5–3 mg/kg ABW
2–2.5 mg/kg ABW
2 mg/kg LBW
Expected peak concentrations: 6–8 mg/L
Amikacin Non–head injured
Head injured
Uncomplicated urinary tract infection
10–12 mg/kg ABW
8–10 mg/kg ABW
8 mg/kg LBW
Expected peak concentration: 25–35 mg/L
B. Maintenance Doses— See Section C for determining when to use actual body weight (ABW) and lean body weight (LBW) and how to determine dosing interval
Gentamicin/Tobramycin Non–head injured 1.8–2 mg/kg ABW at selected interval Expected peak concentrations: 6–8 mg/L
Head injured 1.5–1.8 mg/kg ABW at selected interval
Uncomplicated urinary tract infection 1 mg/kg LBW at selected interval Due to the high concentrations of drug excreted into the urine, allowing lower dose therapy, routine monitoring of serum concentrations in uncomplicated urinary tract infections may not be required
Amikacin Non–head injured 7.5–8 mg/kg ABW at selected interval Expected peak concentration: 25–35 mg/L
Head injured 6–7.5 mg/kg ABW at selected interval
Uncomplicated urinary tract infection 4 mg/kg LBW at selected interval Due to the high concentration of drug excreted into the urine, routine monitoring of serum concentrations in uncomplicated urinary tract infections may not be required
C. Determining Aminoglycoside Dosing Weights and Dosing Intervals Calculating Aminoglycoside Dose
  1. Use actual body weight to determine the dose for infections in critically ill patients.
  2. Use lean body weight to determine the dose for treating urinary tract infections.
Calculating Lean Body Weight (kg)
Males: 50 kg + [(2.3 kg) × (inches >5 feet)]
Females: 45.5 kg + [(2.3 kg) × (inches >5 feet)]
  1. Determine or estimate creatinine clearance (CrCl).
  2. Measured creatinine clearance can be determined from 4-, 12-, or 24-hour urine collections.
  3. Estimating creatinine clearance (ml/min) using the Cockcroft and Gault formula (note: the Cockcroft and Gault formula as well as other formulas used to estimate creatinine clearance tend to overestimate creatinine clearance in critically ill patients):
image Females: 0.85 × male CrCl
Selecting Appropriate Dosing Interval for Multiple Daily Dose Regimen
Intervals for Maintenance Doses
Creatinine Clearance (ml/min) Dosing Interval
>160 q8h
100–159 q8–12h
60–99 q12–18h
40–59 q18–24h
<40 q24–48h
II. Single Daily Dose or High Dose Extended Interval Regimens
Some clinicians prefer to give larger gentamicin doses once daily to patients with normal renal function on the presumption that these regimens are equally effective, less toxic, and less expensive. Peak gentamicin level measurements are usually unnecessary but trough levels should be drawn and should be undetectable at the end of the selected dosing interval in order to take advantage of the postantibiotic effect and minimize toxicity. Appropriateness in ICU of this approach is controversial.
For critically ill patients with reduced creatinine clearances, the dosing interval may have to be adjusted to greater than 24 hours with the help of trough serum concentration monitoring.
Drug Dosage Comments
Gentamicin 5–8 mg/kg ABW Infuse over 60 min
Expected peak concentration: 20–25 mg/L
Desired trough level before next dose: 0 mg/L
Amikacin 20–32 mg/kg ABW Infuse over 60 min
Expected peak concentration: 80–100 mg/L
Desired trough level before next dose: 0 mg/L
Selecting Appropriate Dosing Interval for High Dose Extended Interval Regimen
Intervals for Maintenance Doses
Creatinine Clearance (ml/min) Dosing Interval
>110 q24h
81–110 q36h
60–80 q48h
<60 per levels
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TABLE 10.5. Cardiac Lesions That Warrant Antibiotic Prophylaxis Against Endocarditis
Prophylaxis should be administered only if the patient has appropriate cardiac pathology and a procedure warranting prophylaxis.
Prophylaxis Recommended Prophylaxis Not Recommended
High-risk category
Prosthetic cardiac valves (including bioprosthetic and homograft valves)
Previous bacterial endocarditis
Complex cyanotic congenital heart disease (i.e., single ventricle states, transposition of the great arteries, tetralogy of Fallot)
Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk category
Most other congenital cardiac malformations (other than above and below)
Acquired valvular dysfunction (i.e., rheumatic heart disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvular regurgitation and/or thickened leaflets
Negligible-risk category (no greater risk than the general population)
Isolated secundum atrial septal defect
Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua, beyond 6 mo)
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvular regurgitation
Physiologic, functional, or innocent heart murmurs
Previous Kawasaki disease without valvular dysfunction
Previous rheumatic fever without valvular dysfunction
Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
(Adapted from Dajani AS, et al. Prevention of bacterial endocarditis; recommendations by the American Heart Association. JAMA 1997;277;1794–1801.)
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TABLE 10.6. Bacterial Endocarditis—Procedures that Require Prophylaxis
Prophylaxis should be administered only if the patient has appropriate cardiac pathology and a procedure warranting prophylaxis.
Procedures that Warrant Prophylaxis* Procedures that Do Not Warrant Prophylaxis
Dental extractions
Periodontal procedures including surgery, scaling and root planning, probing, and recall maintenance
Dental implant placement and reimplantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Subgingival placement of antibiotic fibers or strips
Initial placement of orthodontic bands but not brackets
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants where bleeding is anticipated
Respiratory Tract
Tonsillectomy and/or a adenoidectomy
Surgical operations that involve respiratory mucosa
Bronchoscopy with a rigid bronchoscope
Gastrointestinal Tract**
Sclerotherapy for esophageal varices
Esophageal stricture dilatation
Endoscopic retrograde cholangiography with biliary obstruction
Biliary tract surgery
Surgical operations that involve intestinal mucosa
Genitourinary Tract
Prostatic surgery
Cystoscopy
Urethral dilation
Restorative dentistry (operative and prosthodontic) with or without retraction cord††
Local anesthetic injections (nonintraligamentary)
Intracanal endodontic treatment; postplacement and buildup
Placement of rubber dams
Postoperative suture removal
Placement of removable prosthodontic or orthodontic appliances
Taking of oral impressions
Fluoride treatments
Taking of oral radiographs
Orthodontic appliance adjustment
Shedding of primary teeth
Respiratory Tract
Endotracheal intubation
Bronchoscopy with a flexible bronchoscope, with or without biopsy†††
Tympanostomy tube insertion
Gastrointestinal Tract
Transesophageal echocardiography†††
Endoscopy with or without gastrointestinal biopsy†††
Genitourinary Tract
Vaginal hysterectomy†††
Vaginal delivery†††
Caesarean section
In uninfected tissue:
   Urethral catheterization
   Uterine dilatation and curettage
   Therapeutic abortion
   Sterilization procedures
Insertion or removal of intrauterine devices
Other
Cardiac catheterization, including balloon angioplasty
Implanted cardiac pacemakers, implanted defibrillators, and coronary stents
Incision or biopsy of surgically scrubbed skin
Circumcision
*Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions.
**Prophylaxis is recommended for high-risk patients; optional for medium-risk patients.
This includes restoration of decayed teeth (filling cavities) and replacement of missing teeth.
††Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding.
†††Prophylaxis is optional for high-risk patients.
(Adapted from Dajani AS, et al. Prevention of bacterial endocarditis; recommendations by the American Heart Association. JAMA 1997;277:1794–1801.)
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TABLE 10.7. Bacterial Endocarditis Prophylaxis—Drugs of Choice
Patient Category Drug/Dosage Time in Relation to Procedure
Dental/Oral/Respiratory Tract or Esophageal Procedures
Oral
Penicillin tolerant Amoxicillin 2 g PO 1 h preprocedure
Penicillin allergic Azithromycin or Clarithromycin 500 mg PO or
Clindamycin 600 mg PO or
Cephalexin or Cefadroxil 2.0 g
1 h preprocedure
1 h preprocedure
1 h preprocedure
Parenteral
Penicillin tolerant Ampicillin 2.0 g IV/IM Within 30 min preprocedure
Penicillin allergic Vancomycin 1.0 g or
Clindamycin 600 mg IV or
Cefazolin 1.0 g
Slowly over 1 h starting preprocedure
Within 30 min preprocedure
Within 30 min preprocedure
Genitourinary or Gastrointestinal (Excluding Esophageal) Procedures
Parenteral High Riska
Penicillin tolerant Ampicillin 2 g IV/IM + gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg) followed 6 h later by Ampicillin 1 g IV/IM or Amoxicillin 1 g PO Within 30 min preprocedure and follow-up 6 h post 1st dose
Penicillin allergic Vancomycin 1 g IV over 1–2 h + gentamicin 1.5 mg/kg IV (not to exceed 120 mg)—complete infusions within 30 min of starting procedure Complete within 30 min preprocedure
Parenteral Moderate Risk
Penicillin tolerant Ampicillin 2 g IV/IM Within 30 min preprocedure
Penicillin allergic Vancomycin 1 g IV over 1–2 h Within 30 min preprocedure
Oral Moderate Risk Amoxicillin 2 g PO 1 h preprocedure
IM, intramuscular, IV, intravenous; PO, by mouth
aHigh risk: prosthetic valve, history of endocarditis, surgically constructed systemic/pulmonary shunts or conduits
(Adapted from Dajani AS et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277:1794–1801.)
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TABLE 10.8. Antimicrobial Prophylaxis in Surgery
Procedure Prophylactic Drug(s) Drug Regimen (Usually Given During Hour Prior to Surgery;a One Dose Preoperative is Adequate in Most Situations; Vancomycin Should be Substituted for Cephalosporin to Cover MRSA)
Cardiothoracic
Median sternotomy Cefazolin or 1–2 g IV preoperatively (± q4–8h × 1–3 d)
Cefuroxime or 1.5 g IV preoperatively (± q8h × 1–3 d)
Vancomycin 1 g IV preoperatively (q12h × 1–3 d)
Pacemaker insertion None or Cefazolin or Vancomycin 1–2 g IV preoperatively (± q8h × 24 h)
Pneumonectomy or lobectomy Cefazolin or 1–2 g IV preoperatively (± q8h × 24 h postoperatively)
Vancomycin 1 g IV preoperatively (± q12h × 24 h postoperatively)
Peripheral vascular Cefazolin or 1–2 g IV preoperatively (± q8h × 24 h postoperatively)
Vancomycin 1 g IV preoperatively (± q12h postoperatively)
General Surgery
Cholecystectomy None or
Cefazolin or 1–2 g IV preoperatively ± q12h × 1–3 d
Clindamycin + gentamicin 600 mg IV preoperatively (± q8h × 24 h)
1.5 mg/kg IV preoperatively (± q8h × 24 h)
Cholangitis Treat for infection per Table 10.2
Herniorrhaphy None
Colon surgery Oral (alone or with IV)
Neomycin + erythromycin + laxative
1 g PO of each antibiotic at 1 PM, 2 PM, 11 PM preoperatively; 4L polyethylene glycol electrolyte solution PO over 2h at 10 AM preoperatively
IV
Cefoxitin or
Cefazolin +
   metronidazole
1–2 g IV preoperatively (± q4h × 3)
1–2 g IV preoperatively plus
0.5–1.0 g IV
Clindamycin + gentamicin or Ciprofloxacin 600 mg IV × 1
1.5 mg/kg IV × 1
400 mg IV × 1
Gastrectomy Cefazolin or
Gentamicin + clindamycin or
Ciprofloxacin
1 g IV preoperatively if high risk
120 mg IV preoperatively
600 mg IV preoperatively
400 mg IV preoperatively
Appendectomy Cefoxitin or 2 g IV preoperatively (± q6h × 3 doses if nonperforated) and for 3–5 d if perforated
Cefazolin + metronidazole 1–2 g IV and q8h × 3 doses if nonperforated, and for 3–5 d if perforated
500 mg IV preoperatively once if nonperforated or preoperatively and q8h IV × 3–5 d if perforated
Alternative: Ciprofloxacin +
   clindamycin
400 mg preoperatively q6h × 3 doses if nonperforated, or for 3–5 d if perforated
900 mg IV preoperatively once if nonperforated or preoperatively and q8h IV if perforated
Mastectomy None
Penetrating abdominal trauma Cefoxitin 2 g IV upon hospital admission, and 2 g IV q6h × 2–5 d if GI perforation found
Ruptured viscus Cefoxitin + gentamicin or
Clindamycin + gentamicin
2 g IV pre-op 1 g IV q8h ≥5 d
1.5 mg/kg IV q8h ≥5 d
900 mg IV q8h ≥5 d
1.5 mg/kg IV q8h ≥5 d
Gynecologic
Caesarean section (esp high risk) Cefazolin or 1–2 g IV after clamping cord (± 6 and 12 h later)
Cefoxitin or
Metronidazole or Clindamycin + gentamicin or levofloxacin
2 g IV after clamping cord
500 mg IV after clamping cord
600 mg IV after clamping cord
1.5 mg/kg IV
750 mg IV
Dilatation and curettage None
Instillation abortion, 2nd trimester Cefazolin or
Metronidazole
1–2 g IV preprocedure and 6 and 12 h postprocedure
500 mg PO preprocedure (± q4h for 2 doses postprocedure)
Induced abortion, 1st trimester Penicillin or
Doxycycline
2 MU IV before (± 3 h postprocedure)
100 mg PO pre- and 200 mg 30 min postprocedure
Hysterectomy, abdominal or vaginal Cefazolin or
Cefoxitin or
Metronidazole or Clindamycin + gentamicin or levofloxacin
1 g preoperatively and 6 and 12 h later
2 g IV preoperatively
500 mg IV
600 mg preoperatively
1.5 mg/kg preoperatively or 750 mg IV
Head and Neck
Tonsillectomy None
Radical resection Cefazolin or 2 g IV preoperatively (± q8h × 2 doses)
Clindamycin + gentamicin 600 mg IV preoperatively (± q8h × 2 doses)
1.5 mg/kg IV preoperatively (± q8h × 2 doses)
Neurosurgical
CSF Shunts None or
   Cefazolin or
   Vancomycin
1–2 g IV preoperatively
1 g IV preoperatively
Craniotomy Clindamycin or 600 mg IV preoperatively (± 4 h × 1–3 d postoperatively if high risk)
Vancomycin + gentamicin 500 mg IV preoperatively
1.5 mg/kg IV preoperatively
Orthopedic
Arthroplasty and replacement Cefazolin or 1–2 g IV preoperatively (± q8h × 3–4 doses)
Vancomycin or
Clindamycin
1 g IV preoperatively (± q12h × 3–6 doses)
600 mg IV preoperatively (± q6h × 3–4 doses
Open reduction of closed fracture Cefazolin or
Vancomycin
1–2 g IV preoperatively (± q8h × 3 doses)
1g IV ± 1 g IV q12h × 2 doses
Reduction of open fracture Cefazolin or
Vancomycin
1–2 g upon admission (± q8h × 10 d)
1 g IV ± 1 g IV q12h × doses
Laminectomy or spinal fusion None or
Cefazolin or
Vancomycin
1–2 g IV preoperatively (± q8h × 3 d)
1 g IV preoperatively (± q12h × 3 d)
Urology
Prostatectomy None
Ciprofloxacin
400 mg IV if documented organism
GI, gastrointestinal; IV, intravenous; MRSA, methicillin resistant staphylococcus aureus; PO, by mouth
Antimicrobial prophylaxis for surgery: (An advisory statement from the National Surgical Infections Prevention Project, Clinical Infectious Diseases 2004;38:1706–15.)
aProphylactic drugs should ideally be given during the 1 hour period prior to surgery. (Vancomycin or quinolones can be given 2 hours prior to surgery.) For prolonged procedures or when blood loss is extensive, subsequent doses may be necessary at intervals 1–2 times the half-life of the drug. Postoperative antibiotics are rarely documented to be necessary, although two or more postoperative doses are FDA approved for many regimens. Thus many experts try to avoid continuing antibiotic prophylaxis postoperatively unless the surgical field is contaminated, e.g., a perforated viscus. The one exception is cardiothoracic surgery: continuation for 72 hours postoperatively is recommended.