ANTIMICROBIAL STEWARDSHIP

Microbiology

Brokenshire College of Medicine

Group 6

Cresil Josol

Alec Jucar

Jamiel Kedtag

Leala Laguialam
 Table of Contents

 Typical Gram Stain Morphology of Selected Organisms

 Characteristics of Selected Organisms
 Laboratory
 Mechanism of Action of Antibacterial Agents
 Inhibition of Cell Wall Synthesis
 Inhibition of Protein Synthesis
 Inhibition of Synthesis of Nucleic Acid
 Guideline for Treatment of Pneumonia
 Guidelines for Treatment of Infective Endocarditis in Adults
 Guidelines for Treatment of Bone and Joint Infections in Adults
 Guidelines for Treatment of Urinary Tract Infections in Adults
 Guidelines for Treatment of Sexually Transmitted Infections
 Guidelines for Treatment of Bacterial Meningitis in Adults
 Guidelines for Management of Clostridium difficile Toxin-Positive Diarrhea
 Treatment of Skin and Skin Structure Infections
 Guidelines for ESBL
  Typical Gram Stain Morphology of Selected Organisms
Cocci
Gram Negative Gram Positive
> Diplococci > Clusters
 Neisseria meningitidis  Staphylococcus sp
 Neisseria gonorrheae
 Moraxella catarrhalis
> Other > Pairs, Chains
 Acinetobacter sp (coccobacilli)  Streptococcus sp.
 Enterococcus sp.
 Peptostreptococcus sp. (anaerobe)

Bacilli
Gram Negative Gram Positive
> Irregular > Enterobacteriaceae
- Diptheroid  Escherichia coli
 Corynebacterium sp.  Serratia sp
 Propionibacterium sp. (anaerobe)  Klebsiella sp
 Enterobacter sp
 Citrobacter sp
> Large, with spores > Nonfermentative
 Clostridium sp. (anaerobe)  Pseudomonas aeruginosa
 Bacillus sp.  Stenotrophomonas maltophilia
> Branching, beaded, rods > Haemophilus influenzae (coccobacilli)
 Nocardia sp.
 Actinomyces sp. (anaerobe)
> Other > Bacteroides fragilis group (anaerobe)
 Listeria monocytogenes (blood/ CSF)
 Lactobacillus sp. (vaginal/blood)
> Fusiform (long/ pointed)
 Fusobacterium sp (anaerobe)
 Capnocytophaga sp

 Characteristics of Selected Organisms

Cocci
Gram Positive Cocci (GPC) Gram Negative Cocci (GNC)
Catalase (+) Catalase (-) Coagulase(+) Coagulase (-)  Neisseria mengitidis
 Staphylococcus sp.  Enterococcus sp  Staphyloccus  Staphylococcus  Neisseria gonorrheae
 Streptococcus sp aureus epdermidis  Moraxella catarrhalis
 Staphylococcus  Acinetobacter sp
saprophyticus
 Staphylococcus
lugdunensis

Bacilli
Gram Positive Bacilli Gram Negative Bacilli
> Diphtheroids Lactose (+) Lactose (-)
- May be Corynebacterium sp  Escherichia coli Oxidase (-) Oxidase (+)
- Corynebacterium jeikeium,  Klebsiella  Proteus mirabilis  Pseudomonas aeruginosa
Corynebacterium striatum, pneumoniae  Proteus vulgaris  Aeromonas hydrophila
Corynebacterium amycolatum:  Enterobacter sp  Providencia sp.  Other pseudomonas sp
Resistant to many agents except  Citrobacter sp  Morganella morganii  Moraxella sp
Vancomycin  Serratia sp  Alcaligenes sp
> Anaerobic diphtheroids:  Salmonella sp  Burkholderia sp
Propionibacterium acnes  Shigella sp
> Bacillus sp:  Acinetobacter sp
- Bacillus anthracis: non-motile & non-  Stenotrophomonas
B-hemolytic maltoph
- Bacillus cereus: large “boxcar” rods
with spores
> Listeria monocytogenes: CSF, blood
> Lactobacillus sp: Vaginal flora
> Nocardia sp
> Rapidly growing mycobacteria
- Mycobacterium fortuitum
- Mycobacterium chelonae/abscessus
- Mycobacterium mycogenicum

Fungi
Molds Yeast
Aseptate Septate Hyphae Thermally Candida sp
hyphae Dimorphic - Candida albicans if Germ
> Zygomycetes Brown Pigment Non Brown pigment  Histoplasma tube (+)
 Rhizopus Bipolaris sp  Aspergillus sp capsulatum Cryptococcus sp (no
 Mucor Exserohilum sp - Aspergillus fumigatus  Blastomyces pseuhohyphae)
Alternaria sp - Aspergillus flavus dermatidis Candida glabrata
Curvularia sp  Fusarium sp  Coccidioides Trichosporum
Sporothrix schenkii  Penicillium sp immitis Rhodotorula
(rose gardeners)  Paecilomyces sp
 Dermatophytes

Anaerobes
GNB GNC GPC GPB
 Bacteroides sp  Veilonella sp  Peptostreptococcus sp  Propionobacterium acnes
 Fusobacterium sp  Clostridium sp.
 Actinomyces sp
 Lactobacillus sp
 Eubacterium sp
 Bifidobacterium sp

 Laboratory and Specimen Collection

Collection of Upper Respiratory Tract Specimens

1. Oropharyngeal (OP) and nasopharyngeal (NP) swabs

a. Optimal timing. Specimens should be collected within 3 days of symptom

onset and no later than 7 days from all patients meeting the case definition
identified during the outbreak, ideally prior to the initiation of antimicrobial
chemoprophylaxis or therapy.

b. Swab types. Use only sterile dacron or rayon swabs with plastic shafts or if
available, flocked swabs. DO NOT use calcium alginate swabs or swabs with
wooden sticks, as they may contain substances that inactivate some viruses and
inhibit some molecular assays.

c. Collecting the OP swab. Insert swab into the posterior pharynx and
tonsillar areas. Rub swab over both tonsillar pillars and posterior oropharynx and
avoid touching the tongue, teeth, and gums.

d. Collecting the NP swab. Insert flexible wire shaft swab through the nares
parallel to the palate (not upwards) until resistance is encountered or the
distance is equivalent to that from the ear to the nostril of the patient indicating
contact with the nasopharnyx. Gently, rub and roll the swab. Leave the swab in
place for several seconds to absorb secretions before removing.

e. Specimen handling. Place NP and OP swabs immediately into a sterile vial

containing 2 ml of viral transport media without antibiotics. Both swabs can be 2
placed in the same vial, if desired. Aseptically, cut or break applicator sticks off
near the tip to permit tightening of the cap. Label the vial with the patient’s name,
ID number, specimen type, and date collected. If specimens will be examined
within 48 hours after collection, keep specimen at 4ºC and ship on wet ice or
refrigerant gel-packs, otherwise store frozen at ≤-70ºC and ship on dry ice. Avoid
freezing and thawing specimens. Viability of some pathogens from specimens
that were frozen and then thawed is greatly diminished and may result in
falsenegative test results.

2. Nasopharyngeal wash/aspirate. This specimen is commonly collected in

children <5 years old.

a. Optimal timing. Specimens should be collected within 3 days of symptom

onset and not later than 7 days from all patients meeting the case definition
identified during the outbreak, ideally prior to the initiation of antimicrobial
chemoprophylaxis or therapy.

b. Specimen collection. Have the patient sit with head tilted slightly backward.
Instill 1 ml-1.5 ml of nonbacteriostatic saline (pH 7.0) into one nostril. Flush a
plastic catheter or tubing with 2 ml-3 ml of saline. Insert the tubing into the nostril
parallel to the palate (not upwards). Aspirate nasopharyngeal secretions. If
permitted, repeat this procedure for the other nostril.

c. Specimen handling. Collect the specimens in sterile vials. Label each

specimen container with the patients name, ID number, specimen type, and the
date collected. If specimens will be examined within 48 hours after collection,
keep specimen at 4ºC and ship on wet ice or refrigerant gel-packs, otherwise
store frozen at ≤-70ºC and ship on dry ice. Avoid freezing and thawing
specimens. Viability of some pathogens (e.g. respiratory syncytial virus) from
specimens that are frozen and then thawed is greatly diminished and may result
in false-negative test results.

Collection of Lower Respitatory Tract Infections

1. Sputum, tracheal aspirate, broncheoalveolar lavage (BAL) fluid, pleural

fluid.
Due to the increased technical skill and equipment needs, collection of
specimens other than sputum from the lower respiratory tract may be limited to
patients presenting with more severe disease, including persons admitted to the
hospital and/or fatal cases.

a. Optimal timing. These specimens may be obtained at any time during the
clinical course, but ideally prior to initiation of antimicrobial therapy.

b. Specimen types. Acceptable lower respiratory tract specimens include

sputum, tracheal aspirate, BAL fluid, pleural fluid, or lung biopsy. Specimens with
less chance for upper airway contamination (i.e., BAL fluid, pleural fluid, lung
biopsy) are preferred.

c. Specimen collection.

i. BAL fluid, tracheal aspirate, pleural fluid Collect specimens in sterile

containers. Centrifuge half of the specimen, and fix the cell pellet in formalin.
Place the remaining uncentrifuged fluid into sterile vials with external caps and
internal O-ring seals. If there is no internal O-ring seal, then seal tightly with the
available cap and secure with Parafilm®. Label each specimen container with the
patient’s name, ID number, the specimen type, and the date the specimen was
collected.

ii. Sputum Educate the patient about the difference between sputum and oral
secretions. Have the patient rinse the mouth with water and then expectorate
deep cough sputum directly into a sterile screw-cap collection cup or sterile dry
container.

d. Specimen handling. Label the vial or container with the patient’s name, ID
number, specimen type, and date collected. Store fixed cells at room
temperature. If unfixed specimens will be examined within 48 hours after
collection, keep specimen at 4ºC and ship on wet ice or refrigerant gel-packs,
otherwise store frozen at ≤-70ºC and ship on dry ice. Avoid freezing and thawing
specimens. Viability of some pathogens from specimens that were frozen and
then thawed is greatly diminished and may result in false-negative test results.

Collection of Blood Components

1. Acute and convalescent serum specimens.

If possible, acute and convalescent sera should be obtained from all patients
identified during the outbreak. For most respiratory pathogens, both acute and
convalescent sera must be collected to permit a definitive diagnosis. Antibody
titers against suspected bacteria or viruses may be measured in sera and provide
an important adjunct to or confirmation of PCR and culture results. However,
these results are not timely enough to guide clinical care.

a. Optimal timing.
i. Acute. Acute serum specimens should be collected within one week of
symptom onset and submitted as soon as possible.
 ii. Convalescent. Convalescent specimens should be collected and submitted
at 3-6 weeks after the acute specimen was collected.

b. Collecting the sera. For each serum specimen, collect 5 ml of whole blood
into a serum separator tube (marble or tiger top SST). A minimum of 1 ml of
whole blood is needed for testing of pediatric patients.

c. Specimen handling. Allow whole blood to clot at room temperature for a 4

minimum of 30 minutes and centrifuge. Label the tube with the patient’s name, ID
number, specimen type, and date collected. Store refrigerated at 4ºC or frozen,
and ship on refrigerant gel packs or dry ice.

d. Aliquoting sera. If aliquoting is performed, divide the sera into 0.5 ml

aliquots in sterile containers. Label each vial with the patient’s name, ID number,
specimen type, and date collected. Store refrigerated at 4ºC or frozen, and ship
on refrigerant gel packs or dry ice.

2. Whole blood for Culture. This specimen may be limited to patients with
more severe disease including persons admitted to the hospital.
a. Optimal timing. Whole blood should be collected as soon as possible after
illness onset and ideally before initiation of antimicrobial chemoprophylaxis or
therapy. For fatal cases, postmortem whole blood should always be obtained at
autopsy.
b. Collection. Collect whole blood in bottles according to clinical laboratory
guidelines.
c. Specimen handling. Label the bottle with the patient’s name, ID number,
specimen type, and date collected. Store and ship specimens with cold packs to
keep the specimen at 4ºC.

3. Whole blood plasma for PCR. For selected situations, whole blood may
be obtained for PCR.
a. Optimal timing. Whole blood should be collected as soon as possible after
illness onset and ideally before initiation of antimicrobial chemoprophylaxis or
therapy. For fatal cases, postmortem whole blood should always be obtained at
autopsy.
b. Collection. Collect 5-10 ml of whole blood in an EDTA (purple-top) tube.
c. Specimen handling. Label the tube with the patient’s name, ID number,
specimen type, and date collected. Store and ship specimens with cold packs to
keep the specimen at 4ºC.

Collection of Urine Specimen

1. Urine

a. Optimal timing. Urine may be collected within 7 days of symptom onset

from every patient identified during a respiratory disease outbreak for antigen
detection.
b. Specimen collection. Collect 10-20 ml of urine in a sterile container.
c. Specimen handling. Label the container(s) with the patient’s name, ID
 number, specimen type(s), and date collected. Store refrigerated at 4ºC and ship
on wet ice or refrigerant gel packs.

2. Collection of Stool Specimen

a. Optimal timing. Stool may be collected within 14 days of symptom onset

from patients hospitalized as part of a respiratory disease outbreak (e.g. from
SARS CoV suspect cases for RT-PCR).
b. Specimen collection. Collect 10-20 ml stool in a clean, dry, leak-proof
container.
c. Specimen handling. Label the container(s) with the patient’s name, ID
number, specimen type(s), and date collected. If specimens will be examined
within 48 hours after collection, they can be refrigerated at 4ºC; otherwise
store frozen at -70ºC and ship on dry ice.

 Mechanism of Action of Antibacterial Agents

 Inhibition of Protein Synthesis
 Inhibition of Cell Wall Synthesis
 Inhibition of Synthesis of Nucleic Acid

Inhibition of Protein Synthesis

Aminoglycosides Interfere with bacterial protein synthesis by binding to 30S and 50S ribosomal  Gentamicin
subunits.  Tobramycin
 Amikacin
Clindamycin Binds to the 50S ribosomal subunit (reversibly), preventing peptid-bond
formation and inhibiting protein synthesis
Macrolides Inhibit protein synthesis at the chain elongation step and binds to the 50S  Erythromycin
ribosomal subunit.  Azithromycin
 Clarithromyci
n
Tetracyclines Inhibit protein synthesis by binding to the 30S and possibly the 50S ribosomal  Doxycycline
subunits.  Tetracycline

Trimethoprim/su Trimethoprim inhibits dihydrofolic acid reduction to tetrahydrofolate,

l-famethoxazole resulting in sequential inhibition of the folic acid pathway. Sulfamethoxazole
interferes with bacterial folic acid synthesis and growth via inhibition of
dihydrofolic acid formation from PABA.

Inhibition of Cell Wall Synthesis

Beta- Penicillins and cephalosporins inhibit bacterial cell-wall Penicillins Cephalosporin Others
Lactams synthesis by binding to one or more penicillin-binding  Amoxicilli s  Meropene
proteins which in turn inhibits the final transpeptidation n  Cefazolin m
step of peptidoglycan synthesis in bacterial cell walls,  Ampicillin  Cefprozil  Aztreonam
thus inhibiting cell-wall biosynthesis. Bacteria  Dicloxacil  Cefepime
eventually lyse due to ongoing activity of organism lin  Cefrtiaxone
 autolytic enzymes (autolysins and murein hydrolases)  Oxacillin  Cefuroxime
while cell-wall assembly is arrested.  Piperacilli Cephalexin
n
Piperacillin/
tazobactam
Vancomycin Inhibits bacterial cell wall synthesis by blocking
glycopeptide polymerization through binding to the D-
alanyl-D-alanine portion of the cell wall precursor.

Daptomycin Acts at the cytoplasmic membrane and is hypothesized

to rapidly depolarize the cell membrane via an efflux of
potassium and possibly other ions. Cell death occurs as
a result of multiple failures in biosystems, including
DNA, RNA, and protein synthesis.

Inhibition of Nucleic Acid Synthesis

Ciprofloxacin Inhibits DNA-gyrase which does not allow the uncoiling of supercoiled DNA
and promotes breakdown of double-strand DNA.
Linezolid Binds to a site on the 23S ribosomal RNA of the 50S subunit, blocking formation
of the 70S initiation complex thus inhibiting translation.
Metronidazol Interacts with DNA causing a loss of helical DNA structure and strand breakage,
e resulting in inhibition of protein synthesis.

Tigecyclines Binds at the same site on the ribosome as tetracyclines, however binds 5-fold
more tightly. Also able to overcome the ribosomal protection mechanism of
tetracycline resistance.

 Guidelines for Treatment of Pneumonia

Guidelines for Treatment of Pneumonia in Adults
Source/ Empiric Empiric Therapy - Likely Pathogens Directed Therapy Usual
Setting Therapy Severe Penicillin Duration
Allergy1
Community2 Ceftriaxone + Levofloxacin Pneumococcus Penicillin G 7-14 d
azithromycin Legionella Azithromycin
Mycoplasma Haemophilus Doxycycline
influenzae Chlamydia Cefuroxime
pneumoniae Moraxella Doxycycline
catarrhalis Cefuroxime

Community/ Amp/Sulb Clindamycin Mouth flora Amp/Sulb or 14 d

Aspiration clindamycin
Hospital or Pip/Tazo ± Ciprofloxacin + Pseudomonas aeruginosa Pip/Tazo + gentamicin4 8 d5
hospital- vancomycin ± vancomycin Enterobacter sp Pip/Tazo6 ± gentamicin
3
aspiration gentamicin Serratia marcescens Pip/Tazo
or VAP Klebsiella sp Pip/Tazo
Acinetobacter sp Meropenem7
Staphylococcus aureus Oxacillin8
1 For severe pencillin allergy (ie, anaphylaxis). For delayed hypersensitivity reactions (eg, rash to a penicillin), a third/fourth -
generation cephalosporin (ie, ceftriaxone for CAP/cefepime for HAP) or carbapenem may be considered.
2 In immunocompromised hosts, consider adding TMP/SMX for Pneumocystis jirovecii (carinii) coverage.
3 Amikacin should be considered in intensive care units where gentamicin/tobramycin susceptibilities are lower.
4 Substitute tobramycin if resistant to gentamicin.
5 Consider a longer 14-day duration for Pseudomonas and Acinetobacter HAP.
6 For piperacillin/tazobactam-resistant isolates, TMP/SMX or meropenem may be appropriate alternative agents.
7 Carbapenem-resistant Acinetobacter have been detected. Consider ampicillin/sulbactam or ID consult for alternative therapies.
8 Note that 50% of S. aureus are resistant to oxacillin (or methicillin) and cefazolin. Vancomycin is appropriate in such patients.

 Guidelines for Treatment of Infective Endocarditis in Adults

Guidelines for Treatment of Infective Endocarditis in Adults
IE Setting Empiric Therapy1 Alternate Empiric Likely Pathogens Directed Therapy
Therapy
Native valve Penicillin G + Vancomycin Viridans streptococci Penicillin G2 or ceftriaxone3
gentamicin Streptococcus bovis Penicillin G2 or ceftriaxone3
OR Enterococcus Ampicillin4 + gentamicin5
ceftriaxone HACEK group Ceftriaxone3
Staphylococcus aureus Oxacillin ± gentamicin5.6
PVE Vancomycin + Same Staphylococcus aureus Oxacillin + gentamicin + rifampin5,6
gentamicin + Coagulase-negative Oxacillin + gentamicin + rifampin5,6
rifampin staphylococci Penicillin G7 or ceftriaxone3
Viridans streptococci ± gentamicin5
Enterococcus Ampicillin4 + gentamicin5
1 Antimicrobial therapy should be initiated AFTER blood cultures are drawn.
2 Penicillin MIC 0.12 mcg/mL and 0.5 mcg/mL should be treated with enterococci regimen.
3 Ceftriaxone 2 g IV q24h.
4 Ampicillin 12 g/day in 6 divided doses (renal dose adjustment necessary). Vancomycin should be substituted for ampicillin
resistant isolates.
5 Low-dose gentamicin; 1 mg/kg IV q8h with interval adjusted for renal insufficiency.
6 Oxacillin 2 g IV q4h. Vancomycin should be substituted if the isolate is oxacillin-resistant.
7 Penicillin 24 million units/day in 4 or 6 divided doses (renal dose adjustment necessary).

 Guidelines for Treatment of Bone and Joint Infections in Adults

Guidelines for Treatment of Bone and Joint Infections in Adults
Clinical Empiric Therapy Likely Directed Usual
Setting Pathogens Therapy Duration1
Osteomyelitis:
Healthy adult Vancomycin Staphylococcus aureus Oxacillin or cefazolin2 4-6 wk

Posttraumatic Piperacillin/ Staphylococcus aureus Oxacillin or cefazolin2 4-6

tazobactam+ Streptococcus Penicillin G or ampicillin
vancomycin Gram-negative bacili Ceftriaxone
Pseudomonas aeruginosa Piperacillin/tazobactam
Ampicillin/
Diabetic foot sulbactam Usually polymicrobial Ampicillin/sulbactam 4-6 wk followed
by PO
Septic arthritis Vancomycin Staphylococcus aureus Oxacillin or cefazolin2 4 wk
Gonococcus3 Ceftriaxone 2 wk4

Total joint Vancomycin Staphylococcus aureus Oxacillin or cefazolin2 4 wk

replacement Staphylococcus epidermidis Vancomycin5
Streptococcus Penicillin G or ampicillin
1 May require prolonged therapy, depending on clinical situation.
2 Substitute vancomycin if oxacillin-resistant.
3 Young adults.
4 May switch to oral therapy when clinically indicated.
5 Substitute oxacillin or cefazolin if susceptible.

 Guidelines for Treatment of Urinary Tract Infections in Adults

Guidelines for Treatment of Urinary Tract Infections 1 in Adults
Clinical Setting Likely Pathogens Empiric Therapy Alternatives Usual Duration
Acute uncomplicated Escherichia coli, TMP/SMX2 Ciprofloxacin2 3d
cystitis other
Enterobacteriace

Mild-moderate Escherichia coli, TMP/SMX2 Ciprofloxacin2 10-14 d

pyelonephritis3 other
Enterobacteriace

Severe Escherichia coli, Piperacillin/tazobactam Ciprofloxacin5,6 10-14 d

pyelonephritis4 other 5,6

Enterobacteriace

1 UTI defined as symptoms plus pyuria (ie, >10 WBC).

2 Oral therapy preferred.
3 Limited nausea and vomiting; able to tolerate oral medication.
4 Nausea and vomiting; NPO.
5 May switch to oral therapy when appropriate.
6 Narrow therapy when culture and susceptibility results are available.

 Guidelines for Treatment of Sexually Transmitted Infections

Disease Recommended treatment Comment
Pathogens Primary Alternates
Chancroid: Erythromycin 500mg PO Ceftriaxone 250mg
Haemophilus ducreyi tid x 7d IM x 1 or
Azithromycin 1g x
1dose
Uncomplicated Azithromycin 1g x
Gonorrhea Ceftriaxone 250mg IM x 1 1dose
Neisseria gonorrhea dose
Disseminated Ceftriaxone 1 g IV q24h x 1-
Gonorrhea: 2 d or until improved,
Neisseria gonorrhea followed by cefexime 400mg
PO bid to complete total
therapy of 7-10 d
Epididymis (sexually Ceftriaxone 250mg IM + Levofloxacin Levofloxacin should only be used if
acquired): doxycycline 100mg PO bid x 500mg PO x 10d nonsexually acquired epididymis, due
Chlamydia trachomatis 10d to FQ- resistant N gonorrhea
Neisseria gonorrhea
Genital herpes: First episode genital:
Herpes simplex virus Acyclovir 400mg PO tid x 7-
10 d
First episode proctitis:
Acyclovir 400mg PO 5x/d x
7-10 d
Severe herpes infection:
Acyclovir 5mg/kg IV q8h x
5-7 d
Pelvic inflammatory Inpatient: Ceftriaxone 2g IV
disease (PID): q24h + doxycycline 100mg
Chlamydia trachomatis IV q12h metronidazole
Neisseria gonorrhea 500mg IV q12h until
Mycoplasma hominis improved, then doxycycline
Streptococci 100mg PO bid x 14d
Enterobacteriacae
Anaerobes Outpatient: Ceftriaxone
2g50mg IM x 1 +
doxycycline 100mg PO bid
metronidazole 500mg PO bid
x 14d
Syphilis: Primary, secondary or latent
Treponema pallidum < 1 year:
Penicillin G benzathine 2.4
million units IM x 1
Late latent > 1 year:
Penicillin G benzathine 2.4
million units IM q wk x 3 wk
Neurosyphilis:
Penicillin G 3-4 million units
IV q4h x 10-14d
Urethritis or Ceftriaxone 250mg IM x 1 +
cervicitis: doxycycline 100mg PO bid
Chlamydia trachomatis x7d
Ureaplasma
urealyticum
Neisseria gonorrhea
 Guidelines for Treatment of Bacterial Meningitis in Adults
Recurrent:
Acyclovir 400mg PO tid or 800mg PO
bid x 5d or 2d
Prevention of recurrence:
Acyclovir 400mg PO bid
Clindamycin 900mg Evaluate and treat sexual partners.
IV q8h + Test for syphilis and HIV.
gentamicin, Erythromycin stearate 500mg PO qid
followed by instead of doxycycline if pregnant.
doxycycline 100mg For PID unrelated to sexual activity,
PO bid to complete treat as for intra-abdominal sepsis
total therapy of 14d
Doxycycline 100mg All stages of syphilis require follow-
PO bid x 14d up for possible relapse. Evaluate and
treat sexual partners. Test for HIV.
Pregnant women allergic to penicillin
Doxycycline 100mg should be desensitized
PO bid x 28d
Procaine penicillin Patient allergic to penicillin should be
2.4 million units IM desensitized
q24h + Probenecid
500mg PO bid x 10-
14d
Azithromycin 2 g Quinolones do not eradicate
PO x 1 incubating syphilis. Evaluation and
treat sexual partners. Test for syphilis
and HIV. Due to increased prevalence
of fluoroquinolone- resistant N
gonorrhea the CDC no longer
remommends fluoroquinilone the
CDC no longer recommends
fluoroquinilones for the treatment of
gonorrhea
 Clinical Setting Empiric Likely Pathogens Directed Usual Duration
Therapy Therapy
Community Vancomycin Pneumococcus Penicillin G 2 wk
Cetftriaxone Meningcoococous Penicillin G 1-2 wk
Haemophilis influenza ceftriaxone 1-3 wk
Immunocompromised Ceftriaxone + Listeria sp Ampicillin 1-2 wk
or age > 50 years vancomycin + GNB(Pseudomonas +gentamicin
ampicillin aeroginosa) Cefepime +
pneumococcus gentamicin
Penicillin G
Postneurosurgical/ Vancomycin + Staphylococcus epidermidis Vancomycin
posttraumatic cefepime Staphylococcus aureus oxacillin
GNB (Pseudomonas Cefepime +
aeruginosa gentamicin
Pneumococcus Penicillin 9

 Guidelines for Management of Clostridium difficile Toxin-Positive

Diarrhea
Clinically stable piperacillin/ tazobactam 3.375g IV q6h
Penicillin allergy history of:
Rash Cefepime 2g IV q8h
Anaphylaxis Aztreonam 2g IV q6h + vancomycin + gentamicin
Severe mucositis or suspected catheter in blood Add vancomycin to regimen
cultures or Gram – positive organism in blood
cultures
Clinically unstable ( based on BP, RR, and mental Add gentamicin and vancomycin to regimen
status
Fever >/= 72 hours on broad-spectrum Considering adding voriconazole
antimicrobials
Fever > 72 hours and hemodynamic instability Consider change in antibacterial regimen (eg. Change to
and/or respiratory meropenem)

 Treatment of Skin and Skin Structure Infections

Treatment of Skin and Skin Structure Infections1
Clinical Setting Likely Pathogens Empiric Therapy Alternatives Usual Duration
Uncomplicated S aureus Oxacillin or cefazolin3 Vancomycin3,4 7 days
cellulitus2 Streptococci

Diabetic foot S aureus Ampicillin/sulbactam Ciprofloxacin + Guided by patient response to

Streptococci clindamycin treatments
Aerobic GNBs
Anaerobes

Necrotizing fasciitis Group A streptococc STAT Surgery Consult Guided by patient response to
Polymicrobial Vancomycin + clindamycin treatments

1 If abscess present, incision and drainage (I&D) is imperative for cure. I&D may be sufficient if isolated abscess <5 cm
2 Complicating risk factors: chronic ulcer; including diabetic, vascular insufficiency; including chronic venous stasis and peripheral
arterial disease, surgical wound, residence in health care facility within 90 days, recurrent cellulitis > twice in the preceding year,
animal or human bite, indwelling medical device, perirectal infection, periorbital infection, salt or fresh water exposure, and
immunocompromised state.
3 If culture negative or unavailable, change to oral doxycycline 100 mg PO bid, TMP/SMX DS 1-2 tabs PO bid, or clindamycin
300- 450 mg PO tid when able.
4 Use first-line empiric if MRSA risk factors present. Risk factors include: injection drug use, diabetes mellitus, end-stage renal
disease, human immunodeficiency virus infection, contact sports, prisoners, soldiers, men who have sex with men, Native
Americans, recent antimicrobial exposure, known colonization with MRSA, contact with person diagnosed with MRSA infection,
and report of spider bite

 Algorithm for Patient Antimicrobial Therapy

References
 http://icamr.doh.gov.ph/images/PDF/Antimicrobial-Stewardship-Manual-of-
Procedures-for-Hospitals-2016-v2.pdf
 https://www.slideshare.net/phicna2005/doh-antimicrobial-stewardship-
program-in-hospitals-manual-of-procedures-mop-2016
 http://www.clevelandclinicmeded.com/medicalpubs/antimicrobial-guidelines/
 http://www.clevelandclinicmeded.com/medicalpubs/antimicrobial-
guidelines/pdf/Antimicrobial-2013.pdf#page=14
 https://www.cdc.gov/antibiotic-use/healthcare/programs.html
 https://www.cdc.gov/urdo/downloads/speccollectionguidelines.pdf