Parenteral agents for empiric treatment of moderate to severe diabetic foot infections*

AUC: area under the 24-hour time-concentration curve.
* These regimens do not have activity against carbapenem-resistant Enterobacteriaceae. Patients who have suspected or documented infection with a carbapenem-resistant organism should be managed in consultation with an expert in infectious diseases.
¶ Many of these agents require adjustment of the dose in the setting of renal dysfunction.
Δ Empiric coverage for Pseudomonas aeruginosa may not be necessary except in severe cases or when the patient has particular risk for involvement with this organism, such as a macerated wound or one with significant water exposure.
◊ These antibiotics can be given as a prolonged infusion over 3 to 4 hours. Patients who have a high risk of infection with drug-resistant pathogens or who are critically ill in the setting of a severe infection are most likely to benefit from prolonged infusion dosing. For additional information, refer to other UpToDate content on prolonged infusions of beta-lactams.
§ We aim to use the higher cefepime dose, particularly for severe infections or neutropenic patients, but dosing should take into account the condition treated, the minimum inhibitory concentration of the isolate, the potential for toxicity, and other patient-specific factors.
¥ In certain circumstances, such as prolonged outpatient antibiotic therapy, a dosing interval of every 12 hours may be considered; however, this dosing regimen has not been well-studied.
‡ These agents should be used in combination with an agent that has good gram-positive coverage, such as vancomycin, linezolid, or daptomycin.
† Variable activity against Pseudomonas. Consult local susceptibility data before use.
** For severely ill patients, a vancomycin loading dose (20 to 35 mg/kg) is appropriate; within this range, we use a higher dose for critically ill patients. The loading dose is based on actual body weight, rounded to the nearest 250 mg increment and not exceeding 3000 mg. The initial maintenance dose and interval are determined by nomogram (typically 15 to 20 mg/kg every 8 to 12 hours for most patients with normal renal function). Subsequent dose and interval adjustments are based on AUC-guided or trough-guided serum concentration monitoring. Refer to the UpToDate topic on vancomycin dosing for sample nomogram and discussion of vancomycin monitoring
¶¶ Because of the toxicity associated with long-term linezolid use, we do not recommend this agent for treatment of osteomyelitis.
ΔΔ Higher doses may be needed if there is concomitant osteomyelitis.