Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 2) The Acutely Ill Patient: Treatment In the acutely ill patient, empirical antibiotic therapy is critical and should be administered without undue delay. Increased prevalence of antibiotic resistance in community-acquired bacteria must be considered when antibiotics are selected. Table 115-1 lists first-line treatments for infections considered in this chapter. In addition to the rapid initiation of antibiotic therapy, several of these infections require urgent surgical attention. Neurosurgical evaluation for subdural empyema or spinal epidural abscess, otolaryngologic surgery for possible mucormycosis, and cardiothoracic surgery for critically ill patients with acute endocarditis are as important as antibiotic therapy. For infections such as necrotizing fasciitis and clostridial myonecrosis, rapid surgical intervention supersedes other diagnostic or therapeutic maneuvers. Table 115- 1 Empirical Treatment for Common Infectious Disease Emergencies Clinical Syndrome Possible Etiologies Treatment Comme nts S ee Chap. Sepsis without a Clear Focus Septic shock Pseudom onas spp., gram - negative Vancomycin (1 g q12h) plus Adjust treatm ent when culture data 1 29, 130, 143, or Cefepime (2 g q12h) fludrocortisone b may improve outcome in patients with septic shock. Ceftriaxone (2 g q12h) plus Overwhel ming post- splenectomy sepsis Streptoc occus pneumoniae , Haemophilus influenzae, Neisseria meningitidis Vancomycin (1 g q12h) If a β- lactam– sensitive strain is identified, vancom ycin can be discontinued. 2 65 Babesiosis Babesia microti (U.S.), Either: Atovaqu one and 2 01, 204 or Atovaquone (750 mg q12h) plus Azithromycin (500-mg l oading dose, then 250 mg/d) with fewer side effects. Treatmen t with doxycycline (100 mg bid c ) for potential coinfection with Borrelia burgdorferi or Ehrlichia spp. may be prudent. Sepsis with Skin Findings Penicillin (4 mU q4h) or Meningoco ccemia N. meningitidis Ceftriaxone (2 Consider protein C replacement in fulminant meningococcem 1 36, 167 g q12h) ia. Rocky Mountain spotted fever (RMSF) Rickettsi a rickettsii Doxycycline (100 mg bid) If both meningococcem ia and RMSF are being considered, use chloramphenico l alone (50– 75 mg/kg per day in four divided doses) or ceftriaxone (2 g q12h) plus doxycyclin e (100 mg bid c ) If RMSF is diagnosed, do xycycline is the proven superior agent. Ceftriaxone (2 g q12h) plus Purpura fulminans S. pneumoniae , H. influenzae, N. meningitidis Vancomycin (1 g q12h) If a β- lactam– sensitive strain is identified, vancomycin can be discontinued. 1 36, 265 Erythroder ma: toxic shock syndrome Group A Streptococcus, Staphylococcus Vancomycin (1 g q12h) plus If a penicillin- or oxacillin - 1 29, 130 toxigenic bacteria should be debrided; IV immunoglobuli n can be used in severe cases. d Sepsis with Soft Tissue Findings Necrotizin g fasciitis Group A Streptococcus, mixed Penicillin (2 mU q4h) plus Urgent surgical evaluation is 1 19, 130 substituted for penicillin while culture data are pending. Penicillin (2 mU q4h) plus Clostridial myonecrosis Clostridi um perfringens Clindamycin (600 mg q8h) Urgent surgical evaluation is critical. 1 35 Neurologic Infections Bacterial meningitis S. pneumoniae , N. meningitidis Ceftriaxone (2 g q12h) plus If a β- lactam– sensitive strain is identified, vancomycin can be discontinued. If the patient is >50 years old or 3 76 has comorbid disease, add ampicillin (2 g q4h) for Listeria coverage. Vancomycin (1 g q12h) Dexamet hasone (10 mg q6h x 4 days) improves outcome in adult patients with meningitis (especially pneumococcal) and cloudy CSF, positive CSF Gram's stain, or a CSF leukocyte count >1000/µL. Vancomycin (1 g q12h) plus Metronidazole (500 mg q8h) plus Brain abscess, suppurative intracranial infections Streptoc occus spp., Staphylococcus spp., anaerobes, gram-negative bacilli Ceftriaxone (2 g q12h) Urgent surgical evaluation is critical. If a penicillin- or oxacillin- sensitive strain is isolated, those agents are superior to vancomycin (penicillin, 4 mU q4h; or oxacillin, 2 g q4h). 3 76 Quinine (650 mg tid) plus Cerebral malaria Plasmod ium falciparum Tetracycline Do not use glucocorticoids. 2 01, 203 [...]... bacilli Surgical evaluation 3 is 72 essential If a Ceftriaxone (2 penicilling q24h) or oxacillinsensitive strain is isolated, those agents are superior to vancomycin (penicillin, mU 4 q4h; or oxacillin, 2 g q4h) Focal Infections Acute S bacterial aureus, endocarditis hemolytic Ceftriaxone (2 β- g q12h) plus Adjust treatment when 18 culture data 1 endocarditis hemolytic culture data Vancomycin streptococci,... insufficiency c Tetracyclines can be antagonistic in action to β-lactam agents Adjust treatment as soon as the diagnosis is confirmed d The optimal dose of IV immunoglobulin has not been determined, but the median dose in observational studies is 2 g/kg (total dose administered over 1–5 days) e Haemophilus aphrophilus, H paraphrophilus, H parainfluenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis,... hour for 96 h It has been approved for use in patients with severe sepsis and a high risk of death as defined by an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of ≥25 and/or multiorgan failure b Hydrocortisone (50-mg IV bolus q6h) with fludrocortisone (50-µg tablet daily for 7 days) may improve outcomes of severe sepsis, particularly in the setting of relative adrenal insufficiency . Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 2) The Acutely Ill Patient: Treatment In the acutely ill patient, empirical antibiotic therapy is critical. are selected. Table 115- 1 lists first-line treatments for infections considered in this chapter. In addition to the rapid initiation of antibiotic therapy, several of these infections require. 1 36, 265 Erythroder ma: toxic shock syndrome Group A Streptococcus, Staphylococcus Vancomycin (1 g q12h) plus If a penicillin- or oxacillin - 1 29, 130 toxigenic bacteria should