Antimicrobial treatment of intravascular catheter-related bloodstream infection (CRBSI) according to the pathogen isolated (with antibiotic susceptibilities reported)

Pathogen	Preferred antimicrobial agents and dosing (adult)	Alternative antimicrobial agents and dosing (adult)
Staphylococci
Methicillin susceptible	Nafcillin 2 g IV every 4 hours Oxacillin 2 g IV every 4 hours Cefazolin 2 g IV every 8 hours Flucloxacillin* 2 g IV every 6 hours	Vancomycin (dosing as summarized below)
Methicillin resistant	Vancomycin:^¶ Loading dose: 20 to 35 mg/kg IV once Initial maintenance dose and interval: determined by nomogram; typically 15 to 20 mg/kg IV every 8 to 12 hours for most patients with normal kidney function Subsequent dose and interval adjustments based on AUC-guided (preferred) or trough-guided serum concentration monitoring	Daptomycin^Δ 6 to 10 mg/kg IV every 24 hours
Enterococci^◊
Ampicillin susceptible	Ampicillin 2 g IV every 4 hours	Vancomycin (dosing as summarized above)
Ampicillin resistant, vancomycin susceptible	Vancomycin (dosing as summarized above)	Daptomycin^Δ 6 to 10 mg/kg IV every 24 hours Linezolid 600 mg IV (or orally) every 12 hours
Ampicillin resistant, vancomycin resistant	Daptomycin^Δ 6 to 10 mg/kg IV every 24 hours	Linezolid 600 mg IV (or orally) every 12 hours
Enterobacteriaceae (examples include E. coli, Klebsiella spp, Enterobacter spp)
ESBL negative	Ceftriaxone 2 g IV every 24 hours	Ciprofloxacin 400 mg IV every 12 hours
ESBL positive	Imipenem 500 mg IV every 6 hours Meropenem 1 g IV every 8 hours Ertapenem 1 g IV every 24 hours	Ciprofloxacin 400 mg IV every 12 hours
Pseudomonas spp^§
	Ceftazidime 2 g IV every 8 hours Cefepime 2 g IV every 8 hours Piperacillin-tazobactam 4.5 g IV every 6 hours^¥	Imipenem 500 mg IV every 6 hours Meropenem 1 g IV every 8 hours Ciprofloxacin 400 mg IV every 8 hours

Dosing recommendations are for adult patients with normal organ function. For more detail, including duration of treatment and dosage adjustments (eg, for organ impairment), refer to the clinical topic review of intravascular non-hemodialysis CRBSI and individual drug information monographs included within UpToDate.

ESBL: extended-spectrum beta-lactamase.
* Flucloxacillin is not available in the United States and Canada.
¶ Refer to UpToDate topic on vancomycin dosing for further discussion.
Δ Standard daptomycin dosing (as approved by the US Food and Drug Administration) for bloodstream infection is 6 mg/kg IV every 24 hours. Because daptomycin exhibits concentration-dependent killing, some experts recommend doses of up to 8 to 10 mg/kg IV once daily, which appear safe; further study is needed.
◊ Refer to the UpToDate topic on treatment of catheter infections for further discussion of issues related to treatment of infection due to Enterococcus spp.
§ Combination therapy for empiric treatment of CRBSI due to Pseudomonas spp is warranted for patients with sepsis, neutropenia, or severe burns. In such cases, an aminoglycoside (such as gentamicin or tobramycin) may be administered in combination with one the agents listed above. In the setting of renal insufficiency or in institutions with high frequency of aminoglycoside resistance, a fluoroquinolone may be used as a second agent. Once susceptibility data are available, directed therapy with a single active agent is appropriate.
¥ Dosing is expressed as the combined amount of piperacillin and tazobactam and is intended for administration by the traditional infusion method over 30 minutes. Extended infusion administration may be considered; refer to the UpToDate clinical topic review of prolonged infusions of beta-lactam antibiotics.

Reference:

Safdar N, Handelsman J, Maki DG. Does combination antimicrobial therapy reduce mortality in Gram-negative bacteraemia? A meta-analysis. Lancet Infect Dis 2004; 4:519.

Graphic 79387 Version 15.0

خرید پکیج

Antimicrobial treatment of intravascular catheter-related bloodstream infection (CRBSI) according to the pathogen isolated (with antibiotic susceptibilities reported)