RMH Antimicrobial Therapy

Question 1

Bacterial Meningitis: 16-50 yo

Answer 1

Ceftriaxone 2 g IV q12h
PLUS
Vancomycin 20 mg/kg IV x1 then pharmacy to close*
PLUS
Dexamethasone 0.15 mg/kg IV q6h (to be given before or with first antibiotic dose) x2-4 days

Question 2

Bacterial Meningitis: >50 yo

Answer 2

Ceftriaxone 2 g IV q12h
PLUS
Ampicillin 2g IV q4h
PLUS
Vancomycin 20 mg/kg IV x1 then pharmacy to close*
PLUS
Dexamethasone 0.15 mg/kg IV q6h (to be given before or with first antibiotic dose) x2-4 days

Question 3

CNS infections in post-NS or head trauma (includes pt with a shunt or ventriculitis)

Answer 3

Cefepime 1-2g IV q8h
PLUS
Vancomycin 20 mg/kg IV x1 then pharmacy to close*

Question 4

Open Ortho Fractures

Answer 4

Cefazolin 1-2g IV q8h +/- Genatmicin 5 mg/kg x1 then pharmacy to dose*

Question 5

Open Facial Fractures (without CSF leak)

Answer 5

Ampicillin/sulbactam 1.5-3g IV q8h

OR Cefazolin 1-2g IV q8h AND metronidazole 500mg IV q8h

Question 6

Neutropenic Fever

Answer 6

Cefepime 2g IV q8h

Question 7

Open Ortho Fractures

PCN or Cephalosporin allergy

Answer 7

Clindamycin 600-900 IV q8h +/- Gentamicin 5 mg/kgIV x1 then pharmacy to dose*

Question 8

Neutropenic Fever

PCN or Cephalosporin allergy

Answer 8

Aztreonam 2g IV q6-8h PLUS Vancomycin 20 mg/kg IV x1 then pharmacy to close*

Question 9

Diabetic Foot Infection/Decubitus Ulcer: Mild

Answer 9

clindamycin 600mg PO TID 
OR 
doxycycline 100 mg PO BID 
OR 
Bactrim DS 1-2 tablets PO BID
(chronic CM infections rq deep tissue culture prior to ab regimen if pt stable/not septic)

Question 10

Diabetic Foot Infection/Decubitus Ulcer: Moderate

Answer 10

cefotetan 2g IV q12h
OR
ciprofloxacin 400mg IV q8h AND clindamycin 600-900mg IV q8h

Question 11

Diabetic Foot Infection/Decubitus Ulcer: Severe

Answer 11

zosyn 3.375g IV q8h (over 4 hours)
AND
vancomycin 20mg/kg IV x 1 then pharmacy to dose*

Question 12

Diabetic Foot Infection/Decubitus Ulcer: Anaphylactic PCN allergy

Answer 12

ciprofloxacin 400mg IV q8h
AND
clindamycin 900mg IV q8h
—consider adding vancomycin 15mg/kg IV x1 then pharmacy to dose*

Question 13

necrotizing fasciitis/fourniers gangrene

Answer 13

vancomycin 20mg/kg IV x1 then pharmacy to dose*
AND
zosyn 3.375g IV q8h (over 4 hours) OR meropenem 1g IV q8h
AND
clindamycin 600-900mg IV q8h

Question 14

necrotizing fasciitis/fourniers gangren: Anaphylactic PCN allergy

Answer 14

vancomycin 20mg/kg IV x1 then pharmacy to dose*
AND
levofloxacin 750mg IV q24h
AND
metronidazole 500mg IV q6h OR clindamycin 600-900mg IV q8h

Question 15

purulent skin and soft tissue infections (furuncle/carbuncle/abscess): mild

Answer 15

irrigation and debridement (no abx rq)

Question 16

purulent skin and soft tissue infections (furuncle/carbuncle/abscess): moderate

Answer 16

Bactrim DS 1 tablet PO BID
OR
doxycycline 100 mg PO BID

Question 17

purulent skin and soft tissue infections (furuncle/carbuncle/abscess): severe

Answer 17

vancomycin 20mg/kg IV x1 then pharmacy to dose*

Question 18

non-purulent skin and soft tissue infections (cellulitis/erysipelas/necrotizing infection): mild

Answer 18

cephalexin 500mg PO QID
OR
clindamycin 450mg PO QID

Question 19

non-purulent skin and soft tissue infections (cellulitis/erysipelas/necrotizing infection): moderate

Answer 19

cefazolin IV q8h (<80 kg, then 1 g; >/=80 kg, then 2g)
OR
clindamycin 600mg IV q8h

Question 20

non-purulent skin and soft tissue infections (cellulitis/erysipelas/necrotizing infection): severe

Answer 20

vancomycin 20mg/kg IV x1 then pharmacy to dose*

Question 21

severe UTI (pyelonephritis rq. hospitalization, recent hospitalization, catheter-associated)
***Do not treat asymptomatic bacteriuria***

Answer 21

zosyn 3.37g IV q8h (over 4 hours)
OR
cefepime 1g IV q12h*

Question 22

community-acquired UTI: mild

Do not treat asymptomatic bacteriuria

Answer 22

nitrofurantoin 100mg PO q12h x 5 days
OR
Bactrim DS 1 tablet PO q12h x 3 days

Question 23

community-acquired UTI: moderateDo not treat asymptomatic bacteriuria

Answer 23

cefazolin 1g IV q12h

Question 24

community-acquired UTI: cephalosporin allergy

Do not treat asymptomatic bacteriuria

Answer 24

ciprofloxacin 200-400mg IV q12h

Question 25

community-acquired UTI: poor renal function

Answer 25

augmentin 500mg PO q12h x 3 days
OR
cephalexin 500mg PO q12h x 3 days

Question 26

Clostridium difficile, uncomplicated, initial episode

Answer 26

Vancomycin 125mg PO q6h x 10 days
discontinue all antibiotics if possible
—Fidoxomicin is an OhioHealth restricted antimicrobial agent

Question 27

Clostridium difficile, initial episode:

Complicated with hypotension, shock, ileus, or megacolon

Answer 27

Vancomycin 500mg PO/NG q6hr PLUS metronidazole 500mg IV q8hr

—add vancomycin 500mg/100mL 0.9% NaCl retention enema q6hr if complete ileus present

Question 28

Clostridium difficile, first recurrence

Answer 28

Vancomycin 125mg PO q6hr x 10 days

Prolonged taper if prior dz also tx with vancomycin

Question 29

Clostridium difficile, multiple recurrences

Answer 29

Fecal microbiota transplant (FMT)

Question 30

HAP/VAP

Answer 30

Cefepime 2g IV q8hr
OR
Zosyn 4.5g IV x 1 (over 30 minutes) followed by 3.375g IV q8hr (over 4 hours)
PLUS
vancomycin 20mg/kg IV x 1 then pharmacy to dose*
-consider tobramycin if pseudomonas risk