Chapter 115. Approach to the Acutely Ill Infected Febrile Patient (Part 2)

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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...

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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 Possible Treatment Comme S Syndrome Etiologies nts ee Chap. Sepsis without a Clear Focus Septic Pseudom Vancomycin Adjust 1 shock onas spp., (1 g q12h) plus treatment when 29, 130, gram-negative culture data 143,
fludrocortisoneb or may improve outcome in Cefepime (2 g patients with q12h) septic shock. Overwhel Streptoc Ceftriaxone (2 If a β- 2 ming post- occus g q12h) plus lactam– 65 splenectomy pneumoniae, sensitive strain sepsis Haemophilus Vancomycin is identified, influenzae, (1 g q12h) vancomycin can Neisseria be discontinued. meningitidis Babesiosis Babesia Either: Atovaqu 2 microti (U.S.), one and 01, 204
with fewer side or effects. Atovaquone Treatmen (750 mg q12h) plus t with doxycycline c Azithromycin (100 mg bid ) (500-mg loading for potential dose, then 250 mg/d) coinfection with Borrelia burgdorferi or Ehrlichia spp. may be prudent. Sepsis with Skin Findings Meningoco N. Penicillin (4 Consider 1 ccemia meningitidis mU q4h) protein C 36, 167 replacement in or fulminant meningococcem Ceftriaxone (2
g q12h) ia. Rocky Rickettsi Doxycycline If both Mountain spotted a rickettsii (100 mg bid) meningococcem fever (RMSF) 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 bidc) If RMSF is diagnosed, doxycycline is the proven
superior agent. Purpura S. Ceftriaxone (2 If a β- 1 fulminans pneumoniae, H. g q12h) plus lactam– 36, 265 influenzae, N. sensitive strain meningitidis Vancomycin is identified, (1 g q12h) vancomycin can be discontinued. Erythroder Group A Vancomycin If a 1 ma: toxic shock Streptococcus, (1 g q12h) plus penicillin- or 29, 130 syndrome Staphylococcus oxacillin-
toxigenic bacteria should be debrided; IV immunoglobuli n can be used in severe cases.d Sepsis with Soft Tissue Findings Necrotizin Group A Penicillin (2 Urgent 1 g fasciitis Streptococcus, mU q4h) plus surgical 19, 130 mixed evaluation is
substituted for penicillin while culture data are pending. Clostridial Clostridi Penicillin (2 Urgent 1 myonecrosis um perfringens mU q4h) plus surgical 35 evaluation is Clindamycin critical. (600 mg q8h) Neurologic Infections Bacterial S. Ceftriaxone (2 If a β- 3 meningitis pneumoniae, N. g q12h) plus lactam– 76 meningitidis sensitive strain is identified, vancomycin can be discontinued. If the patient is >50 years old or
has comorbid disease, add ampicillin (2 g q4h) for Listeria coverage. Vancomycin Dexamet (1 g q12h) 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.
Brain Streptoc Vancomycin Urgent 3 abscess, occus spp., (1 g q12h) plus surgical 76 suppurative Staphylococcus evaluation is intracranial spp., anaerobes, Metronidazole critical. If a infections gram-negative (500 mg q8h) plus penicillin- or bacilli oxacillin- Ceftriaxone (2 sensitive strain g q12h) is isolated, those agents are superior to vancomycin (penicillin, 4 mU q4h; or oxacillin, 2 g q4h). Cerebral Plasmod Quinine (650 Do not 2 malaria ium falciparum mg tid) plus use 01, 203 glucocorticoids. Tetracycline
(250 mg tid) Spinal Staphylo Vancomycin Surgical 3 epidural abscess coccus spp., (1 g q12h) plus evaluation is 72 gram-negative essential. If a bacilli Ceftriaxone (2 penicillin- or g q24h) oxacillin- sensitive strain is isolated, those agents are superior to vancomycin (penicillin, 4 mU q4h; or oxacillin, 2 g q4h). Focal Infections Acute S. Ceftriaxone (2 Adjust 1 bacterial aureus, β- g q12h) plus treatment when 18 endocarditis hemolytic culture data
endocarditis hemolytic culture data Vancomycin streptococci, become (1 g q12h) HACEK available. group,e Surgical Neisseria spp., evaluation is S. pneumoniae essential. a Drotrecogin alfa (activated) is administered at a dose of 24 µg/kg per 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. 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, Eikenella corrodens, and Kingella kingae.