Urinary Tract Infections

Septic patients with a community-acquired urinary tract infection should be treated with a third-generation cephalosporin (ceftriaxone or cefotaxime) or a fluoro-quino-

lone (ciprofloxacin or levofloxacin). The causative pathogen is commonly an enteric gram-negative bacilli (i.e., Escherichia coli). Nosocomially-acquired urinary tract infections are often related to catheters and are caused by fermenting and nonfermenting (Pseudomonas) gramnegatives, and enterococci (see Table 82-3). ^-Lactam/^-lactamase inhibitors (i.e., piperacillin-tazobactam), an antipseudomonal cephalosporin (i.e., cefepime or ceftazidime), or an antipseudomonal carbapenem (imipenem, meropenem, or doripenem), plus an aminoglycoside are recommended

treatment options until susceptibilities are known (see Table 82-3). Community-Acquired Pneumonia

Septic patients with community-acquired pneumonia (CAP) are treated with a third-generation cephalosporin (ceftriaxone or cefotaxime) plus a macrolide (azithromycin or clarithromycin) or doxycycline, or a respiratory fluoroquinolone (levofloxacin, moxifloxacin, gemifloxacin) (see Table 82-3).32 The causative organisms for CAP are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and atypical organisms (Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella pneumophila). S. pneumoniae accounts for 60% of the deaths associated with CAP, and is resistant to penicillin and macrolides (multidrug resistant S. pneumoniae; MDRSP) 30% to 40% of the time.32,33 Controversy exists relating to the clinical significance of this resistance for nonmeningitis infections. Respiratory fluoroquinolones (levofloxacin, moxifloxacin, and gemifloxacin) may be utilized for MDRSP; however, clinical data have not shown them to be superior to cephalosporins plus a macrolide or doxycycline. The Centers for Disease Control and Prevention recommends reserving fluoroquinolones as last-line options in order to maintain their broad-spectrum anti-

bacterial activity. Treatment of methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas aeruginosa is a potential reason to modify the standard empirical regimen for CAP. Risk factors for the development of these pathogens are listed in Table 82-4.

Hospital-, Ventilator-, and Health Care—Associated Pneumonia

Treatment for septic patients with hospital-acquired, ventilator-acquired, and health care_associated pneumonia is dependent on risk factors for MDR organisms (Fig. 82-2). Recommended treatment for patients with no MDR risk factors are: third-generation cephalosporins (ceftriaxone or cefotaxime), fluoroquinolones (levofloxacin and moxifloxacin), ampicillin-sulbactam, or ertapenem (see Table 82_3).34 Recommended treatment for patients with MDR risk factors are: ^-lactam/^-lactamase inhibitors (piperacillin/tazobactam), antipseudomonal cephalosporin (cefepime or ceftazi-dime), or an antipseudomonal carbapenem (imipenem, meropenem, or dori3?enem), plus an aminoglycoside, plus vancomycin or linezolid (see Table 82_3). 4 If an aminoglycoside is undesirable, a antipseudomonal fluoroquinolone (ciprofloxacin or levofloxacin) may be utilized with a antipseudomonal ^-lactam (piperacillin/ tazobactam, cefepime, ceftazidime, imipenem, meropenem, or doripenem).

Table 82-4 Risk Factors for MRS A, Pseudomonas, and Gram-Negatives in CAP

Methicillin-Resistant Staphylococcus aureus End stage renal disease Injection drug abuse Prior influenza

Prior antibiotic therapy (especially fluoroquinolones) Pseudomonas aeruginosa Structural lung disease

Exacerbations of severe chronic obstructive pulmonary diseases leading to frequent steroid and/or antibiotic use, as well as prior antibiotic therapy Other Gram-negatives (Klebsiella pneumoniae or Acinetobacter species) Chronic alcoholism

Skin and Soft-Tissue Infections

Community-acquired skin and soft-tissue infections are caused by Streptococcus pyogenes and S. aureus. Treatment with nafcillin or cefazolin is recommended (see

Table 82_3).35 Soft-tissue infections caused by S. pyogenes can lead to streptococcal toxic shock syndrome. Although penicillins and cephalosporins are efficacious, exper-

imental models show clindamycin to be more effective than penicillin. Hospital-acquired skin and soft-tissue infections are caused by S. pyogenes, S. aureus, and enteric gram-negatives. Recommended treatment is a third-generation cephalosporin (ce-

fotaxime or ceftriaxone), ampicillin-sulbactam, or ertapenem, plus vancomycin (see Table 82-3).35

Intra-abdominal Infections

Intra-abdominal infections are polymicrobial, including enteric aerobes and anaerobes. Patients with community-acquired intra-abdominal infections of mild to moderate severity should be administered antibiotics with activity against enteric gram-negative bacilli, gram-negative anaerobes, and gram-positive cocci. Recommended treatment for mild to moderate community-acquired intra-abdominal infections are: ampici-llin/sulbactam; cephalosporins (ceftriaxone or cefotaxime) plus metronidazole; fluoroquinolones (levofloxacin, ciprofloxacin, or moxifloxacin) plus metronidazole; and ertapenem (see Table 82-3).36 Patients with nosocomial-acquired, high-severity intra-abdominal infections or immunosuppression should receive empiric treatment with broad-spectrum antibiotics. Broad-spectrum antibiotics such as anti-pseudomonal ^-lactam/^-lactamase in hibitors (piperacillin/tazobactam), carbapenems (imipenem, meropenem, or doripenem), antipseudomonal cephalosporins (cefepime or ceftazidime) plus metronidazole, or antipseudomonal fluoroquinolones (ciprofloxa-cin or levofloxacin) plus metronidazole are recommended (see Table 82-3). 6

Risk Factors for Multidrug Resistant (MDR) Pathogens

» Antimicrobial therapy in preceding 90 days

» Cu rrervt h c*s-p*tal«^tion Of & d ay* Or nn ore

* High frequency of antibiotic resistance rn Ihe community or specific hospital unit

• Immunosuppressive disease and/or therapy

■ Risk factors for healthcare associated pneumonia u Hospitalization for 2 days or more in the preceding 90 days o Residence in nursing home or extended care facility o Home infusion therapy o Chronic diaiysis within 30 days q Home wound cane □ Family member with MDR pathogen

Causative Pathogens: MOR Risk Factors

• Pseudomonas aeruginosa + Acinetobacter species

• Klebsiella pneumoniae - ESBL

• Legionella pneumophila

Causative Pathogens: No MDR Risk Factors

* Streptococcus pneumoniae

* Haemophilus Iinfluenzae

» Escherichia coli

* Klebsiella pneumoniae

* Enterobacter species

* Proteus species

* Serratia species

FIGURE 82-2. Risk factors for multidrug resistant pathogens and causative pathogens for hospital, ventilator, and health care-associated pneumonia.34 (ESBL, extended spectrum P-lactamase; MDR, multidrug resistant; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-sensit-

ive Staphylococcus aureus)

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