Introduction

• Factors in selecting appropriate drugs to manage sepsis syndrome:

  • source of infection

  • gram stain

  • immune status

  • bacterial resistance patterns in the community and hospital

• Treatment:

  • gram-negative bacilli:

    • Third or fourth generation cephalosporins

      •  cefotaxime (Claforan)

      •  ceftizoxime (Cefizox)

      •  cefoperazone (Cefobid)

      •  ceftriaxone (Rocephin)

      •  cefepime (Maxipime)

      •  ceftazidime (plus activity against gram-positive cocci)

    • imipenem, meropenem (Merrem IV), aztreonam (Azactan)

  •  Cephalosporins (other than cefoperazone (Cefobid), cefepime (Maxipime), and ceftazidime (Fortax, Taxidime, Tazicef)): limited efficacy against Pseudomonas aeruginosa

  • Pseudomonas aeruginosa: effectively treated with imipenem, meropenem (Merrem IV), and aztreonam (Azactan).

  •  Aztreonam (Azactan): poor activity against gram-positive organisms and anaerobes

• Initial treatment:

  • Life-threatening sepsis and adults:

    • Third or fourth generation cephalosporin

      •  cefotaxime (Claforan)

      •  ceftizoxime (Cefizox)

      •  ceftriaxone (Rocephin)

      •  cefepime (Maxipime)

    • ticarcillin (Ticar)/clavulanic acid

    • piperacillin (Pipracil)/tazobactam

    • imipenem or meropenem (Merrem IV) {each together with aminoglycoside [gentamicin (Garamycin), tobramycin (Nebcin), or amikacin (Amikin)]}

  • If methicillin-resistant staphylococci is a consideration:

    • vancomycin (Vancocin) alone or

    • vancomycin (Vancocin) with gentamicin (Garamycin) and/or rifampin (Rimactane)

  • If bacterial endocarditisis is a consideration (prior to pathogen identification):

    • vancomycin (Vancocin) plus gentamicin (Garamycin)

  • Treatment of intra-abdominal or pelvic infection (likely to involve anaerobes):

    • ticarcillin (Ticar)/clavulanic acid

    • ampicillin (Principen, Omnipen)/sulbactam

    • piperacillin (Pipracil)/tazobactam

    • imipenem

    • meropenem

    • cefoxitin (Mefoxin) or cefotetan (Cefotan){each with or without an aminoglycoside, metronidazole (Flagyl) OR clindamycin (Cleocin) with an aminoglycoside}

Special Cases

• Neutropenic patients with suspected bacteremia

  • Treatment:

    • ceftazidime (Fortax, Taxidime, Tazicef)

    • imipenem

    • meropenem (Merrem IV)

    • cefepime (Maxipime) (in more seriously ill patients, add an aminoglycoside

    • amikacin (Amikin) and ceftriaxone (Rocephin) (single daily doses)

    • piperacillin (Pipracil)/tazobactam plus amikacin

    • Addition of vancomycin (Vancocin): in neutropenic cancer patients with bacteremia due to methicillin (Staphcillin)-resistant staphylococci were some strains of viridans.

• Resistant gram-negative bacilli

  •  Gram-negative bacilli resistant to:

    • aminoglycosides

    • third-generation cephalosporins

    • aztreonam (Azactan)

  • These bacilli susceptible to:

    • imipenem

    • meropenem (Merrem IV)

    • ciprofloxacin (Cipro)

  • Pseudomonas aeruginosa strains resistant gentamicin (Garamycin):

    • Susceptible to:

      • amikacin (Amikin)

      • ceftazidime (Fortax, Taxidime, Tazicef)

      • cefepime (Maxipime)

      • imipenem

      • meropenem (Merrem IV)

      • ciprofloxacin (Cipro)

      • trovafloxacin

      • aztreonam

      • possibly tobramycin (Nebcin) or netilmicin (Netromycin)

• Multiple antibiotic resistant enterococci

  •  Many strains resistant to:

    • penicillin

    • ampicillin (Principen, Omnipen)

    • gentamicin (Garamycin)

    • streptomycin

    • vancomycin (Vancocin)

  • Susceptible (in vitro, but with variable clinical results) to:

    • chloramphenicol (Chloromycetin)

    • doxycycline (Vibramycin, Doryx)

    • fluoroquinones

• Urinary tract infection (UTI)

  • Diagnosis

  • Acute, uncomplicated UTI: trimethoprim-sulfamethoxazole (Bactrim)(3-day course of treatment)

    • Alternative: fluoroquinone (three-day course of treatment)

    • Alternative (longer treatment):

      •  oral cephalosporin

      •  amoxicillin (Amoxil Polymox)(many urinary pathogens -- resistance to amoxicillin)

      •  fosfomycin (Monurol)(single dose)

  • Repeated UTIs or UTI occurring in the hospital or nursing-home setting:

    •  may be due to antibiotic-resistant gram-negative bacilli

    • Treatment:

      • fluoroquinone

      • oral amoxicillin (Amoxil Polymox)/clavulanic acid

      • oral third-generation cephalosporin (cefixime (Suprax), cefpodoxime (Vantin), ceftibuten) or idanyl ester of carbenicillin

    • in patients hospitalized with UTI:

      • third-generation cephalosporin

      • ticarcillin (Ticar)/clavulanic acid

      • piperacillin (Pipracil)/tazobactam

      • imipenem (occasionally in combination with aminoglycoside)