Nova Scotia Anglers Handbook On Injectable Drugs
. Pregnancy: see IWK spectrum app section Women’s Health- Genito-urinary PregnancyAsymptomatic Bacteriuria for treatment options, suggested duration and pregnancy consideration for antimicrobials. Invasive urological procedures in which mucosal trauma is likely:. Single antibiotic dose 1-2 hours pre-op. Antimicrobial choice should be based on urine culture and sensitivity results. Post renal transplant: limited evidence assessing routine treatment of ASB to prevent progression to symptomatic urinary tract infections or graft failure.
More evidence is needed to make a definitive recommendation. Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, et al. Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults. Clin Infect Dis; 2005;40:643-54. AMMI Canada. Symptom-Free Pee: Let It Be. Accessed on-line 07/2018.
Reproductive Care Program of Nova Scotia. Coussement J, et al. Scemla A, Abramowicz D, Nagler EV, Webster AC. Antibiotics for asymptomatic bacteriuria in kidney transplant recipients. Cochrane Database Syst Rev.
2018 Feb 1;2:CD011357. Beta-lactam Allergy Assessment and Management.Do not avoid all beta-lactams in patients reporting penicillin allergies.Penicillin allergy is over reported and cross-allergy between penicillins and cephalosporins is overestimated.
Beta-lactams include all penicillins (i.e. Table 1: Onset, symptoms, and management options for various beta-lactam associated reactions ReactionOnsetSymptomsManagement optionsHypersensitivity. IgE mediatedUsually 72 hoursNon-serious 2Contact dermatitis, pruritic maculopapular eruptionNot a contraindication to using a beta-lactam. Consider provocation challenge or an antibiotic with a different side chain.Serious or life-threatening 3AVOID all beta-lactamsNon-hypersensitivityAnytimeGastrointestinal symptoms, flushing during infusion, headache, yeast infection, isolated itchNot a contraindication to using a beta lactam1Skin testing has no role in the diagnosis of non-IgE mediated reactions.290% of rashes occurring after people take penicillin (amoxicillin) are mild non-IgE reactions. Rashes occur in up to 7% of people.3Serious or life-threatening non-IgE mediated hypersensitivity reactions are rare with beta-lactams.
They include Stevens-Johnson syndrome, topix epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis, hemolytic anemia, interstitial nephritis, hepatitis, and serum sickness. Cross-reactivity risk between penicillin and cephalosporins is low. For IgE-mediated allergies, the cross reaction between penicillin and cephalosporins is mediated by similarities of the specific chemical side chains of penicillin and cephalosporins, rather than the beta-lactam ring.
See cross-reaction chart. Beta-lactams with different side chains may be considered in those with a history of an IgE-mediated reaction. This consideration is based on theoretical risk and studies using this approach are not yet available. If unable to rule in or rule out an IgE-mediated allergy, referral to an allergist is recommended. Cefazolin for Surgical Prophylaxis in Patients with a Beta-lactam AllergyCefazolin is the drug of choice for surgical prophylaxis. Cefazolin is more effective than alternatives like clindamycin and vancomycin for reducing surgical site infections. Cefazolin is a safe medication with less toxicities than clindamycin and vancomycin.
Cefazolin can be administered quickly prior to incision.Can patients with a beta-lactam allergy receive cefazolin safely?. Cefazolin has a unique side chain. Since side chain similarities are responsible for IgE-mediated (anaphylaxis) cross-reactions, cefazolin does not cross-react with other beta-lactams. Cefazolin for surgical prophylaxis is given in a monitored preoperative setting. Cefazolin should be avoided if. History suggestive of a serious or life-threatening non-IgE-mediated reation to beta-lactams (e.g. Stevens-Johnson syndrome, toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis, hemolytic anemia, interstitial nephritis, hepatitis, serum sickness).
Anaphylaxis to cefazolin specifically. Febrile patients with hematologic malignancy recovering from neutropenia are at risk of chronic disseminated (hepatosplenic) candidiasis. Echinocandins do not achieve high urinary concentrations. Candida in respiratory secretions and catheter urine in asymptomatic patients is usually colonization and rarely requires therapy. Consider endocarditis if blood cultures consistently positive, persistent fever despite therapy, new heart murmur or embolic phenomena.
Microbiology report S-DD (susceptible-dose dependent):. Susceptibility depends on maximum blood levels. This requires a higher fluconazole dose than the standard dosing in adults with normal renal function. ID should be consulted if fluconazole is used in this situation. If CDI is suspected, send a stool sample for testing and initiate contact precautions. Empiric therapy for CDI should be started while awaiting diagnosis if:. Substantial delay in laboratory confirmation is expected.
Patient symptoms are consistent with severe CDI. Assess patient for medications or interventions that are known to cause diarrhea, such as laxative therapy and enteral feeds, etc. Do not test stool of asymptomatic patients (3% - 14% carriage in adults admitted to hospital).
Test of cure is not recommended since testing can remain positive even after successful treatment. Discontinue antimicrobials if possible. Consider switching to an antimicrobial associated with a lower risk for CDI if antimicrobials are required. Consider discontinuing proton pump inhibitor therapy if appropriate.
Avoid opioids and antimotility agents (e.g. Loperamide). No antimicrobial treatment for CDI is required if diarrhea has resolved.Exception - cases where ileus may be possible (e.g. Severe and complicated disease). Infectious Diseases & Surgery consultation is recommended for severe and complicated CDI. Probiotics are not currently recommended for the treatment or prevention of CDI. CategorySeverity criteriaTreatment recommendationFirst recurrence, mild to moderate.
WBC ≤15 x 10 9 / L., and. Creatinine ≤1.5 x baseline, and. Age ≤ 65 years. Preferred: Vancomycin 125 mg PO QID for 14 days or. Alternative: Metronidazole 500 mg PO TID for 14 daysFirst recurrence, severe, uncomplicated. WBC 15 x 10 9 / L or.
Creatinine 1.5 x baseline or. Age 65 years or. Hypoalbuminemia. Vancomycin 125 mg PO QID for 14 daysSecond or subsequent recurrence. Consider consulting Infectious Diseases following one failed Vancomycin taper. Loo VG, Davis I, Embil J, Evans GA, et al.
Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. Journal of the Association of Medical Microbiology and Infectious Disease Canada. 2018; 3(2): 71-92. McDonald LC, Gerding DN, Johnson S, Bakken JS, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
Clin Infect Dis. 2018; 66(7):e1-e48.
Van Hise NW, Bryant AM, Hennessey EK, Crannage AJ, et al. Efficacy of Oral Vancomycin in Preventing Recurrent Clostridium difficile Infection in Patients Treated With Systemic Antimicrobial Agents. Clin Infect Dis. 2016 Sep 1;63(5):651-3. Appaneal HJ, Caffrey AR, LaPlante KL.
What is the role for metronidazole in the treatment of Clostridium difficile infection? Results from a national cohort study of Veterans with initial mild disease. Clin Infect Dis. 2018; Dec 18 Epub ahead of print. Fabre V, Dzintars K, Avdic E, Cosgrove SE. Role of Metronidazole in Mild Clostridium difficile Infections.
Clin Infect Dis. Signs and symptoms: dysuria, urgency, frequency, suprapubic pain/tenderness. No symptoms of upper urinary tract infection: fever, chills, flank pain, costovertebral angle tenderness. No risk factors for complicated infection:. Pregnancy.
Immunosuppression. Diabetes (especially if long term complications). Indwelling catheter. Anatomical abnormality. Voiding dysfunction.
Obstruction. Recent urogenital procedure. Cystitis in men is often, but not always, considered complicated. Ciprofloxacin is no longer recommended as fist line treatment due to high risk of adverse effects including tendinopathy, aortic dissection, peripheral neuropathy, central nervous system effects and C.
Difficile infection. Moxifloxacin should not be used as it does not attain sufficient concentration in the urine.
TMP-SMX. Associated with higher risk of renal injury, hyperkalemia, and sudden death if. Patients aged 65 years and older.
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Patients on medications that can increase potassium: angiotensin converting enzyme inhibitor (ACEi), angiotensin receptor blocker (ARB), or K+ sparing diuretic (e.g. Spironolactone). Regular monitoring of kidney function and electrolytes are recommended for patients with risk factors for hyperkalemia or prolonged duration of therapy. Nitrofurantoin should not be used in patients with:.
CrCl less than than 30 ml/min. Infections outside lower urinary tract due to poor distribution into serum and tissue. If Staphylococcus aureus is isolated in the urine, bacteremia may be present. The patient must be assessed for other sources of infection. Toronto Central Local Health Integration Network. Guidelines for Empiric Treatment of Urinary Tract Infections in Adults.
January 2015. Accessed online 09/2017. Www.antimicrobialstewardship.com. Gupta K, Hooton TM, Naber KG, Wullt B, et al. International Practice Guidelines for the Treatment of Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis.
2011 Mar 1;52(5):e103-20. Fralick M, Macdonald EM, Gomes T, Antoniou T, et al. Co-trimoxazole and sudden death in patients receiving inhibitors of reninangiotensin system: population based study. 2014 Oct 30;349:g6196. Crellin E, Mansfield KE, Leyrat C, Nitsch D, et al. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study.BMJ.
2018 Feb 9;360:k341. Collect 2 sets of blood cultures. Head CT prior to lumbar puncture if focal neurological signs, papilledema, altered mentation, new onset seizures, impaired cellular immunity. Lumbar puncture. Defer if high bleeding risk (INR 1.4, platelets.
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Dexamethasone 10 mg IV q6h should be started with or immediately before the FIRST dose of antibiotic and continued for 4 days if the causative agent is found to be S. Pneumoniae. Ceftriaxone 2 g IV q12h + vancomycin 25 mg/kg total body weight (TBW) IV loading dose followed by 15 mg/kg IV q8-12h (adjust for renal function). Vancomycin should be discontinued for S. Pneumoniae if susceptibility to ceftriaxone is confirmed (using CNS minimum inhibitory concentration (MIC) breakpoints). Add ampicillin 2 g IV q4h (adjust for renal function) for Listeria coverage if age 50 or risk factors (excessive alcohol consumption, immunocompromised, pregnant).
Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, Whitley RJ. Practice guidelines for the management of bacterial meningitis.
Clin Infect Dis. 2004;39(9):1267-84. Tunkel AR, van de Beek D, Scheld WM. Acute meningitis. edited by John E. Bennett, Raphael Dolin, Martin J.
Mandell, Douglas, And Bennett's Principles and Practice of Infectious Diseases. Philadelphia, PA:Elsevier/Saunders, 2015. Print. Straus SE, Thorpe KE, Holroyd-Leduc J.How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis? 2006 Oct 25;296(16):2012-22. Brouwer MC, McIntyre P, Prasad K, van de Beek D.
Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev. 2015 Sep 12;(9):CD004405. Dependent on presence or absence of complications. 14 days IV therapy minimum counting from first negative blood culture can be considered if ALL of the following criteria for uncomplicated S. Aureus bacteremia are met:. Infective endocarditis has been excluded, no implanted prostheses are present, follow-up cultures drawn 2-4 days after initial set are sterile, patient is afebrile within 72 hrs of antibiotic therapy, no evidence of metastatic infection present.
4-6 weeks IV therapy recommended for all complicated cases. Holland TL, Arnold C, Fowler VG Jr.
Clinical management of Staphylococcus aureus bacteremia: a review. 2014 Oct; 312(13):1330-41. Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011; 52(3):e18.
Van Hal SJ, Lodise TP, Paterson DL. The clinical significance of vancomycin minimum inhibitory concentration in Staphylococcus aureus infections: a systematic review and meta-analysis. Clin Infect Dis.
2012 Mar;54(6):755-71. Van Hal SJ, et al.
Predictors of Mortality in Staphylococcus aureus Bacteremia. Clin Microbiol Rev. 2012; 25 (2): 362-86. Local Antibiograms.
Serious infections due to beta-lactam resistant, Gram-positive microorganisms such as:. Methicillin resistant Staphylococcus aureus (MRSA). Ampicillin resistant Enterococcus spp. Methicillin resistant coagulase-negative staphylococci. Ceftriaxone resistant S. pneumoniae (meningitis). Infections due to Gram-positive microorganisms in patients with a history of severe delayed skin reactions/organ dysfunction to beta-lactam antimicrobials e.g. Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug rash with eosinophilia & systemic symptoms (DRESS).
Surgical prophylaxis. Vancomycin should be reserved for patients with a history of severe delayed skin reaction/organ dysfunction (ex: SJS, TEN, drug reaction with eosinophilia and systemic symptoms) to any beta-lactam antimicrobial OR a history of anaphylaxis to cefazolin (refer to NSHA beta-lactam allergy document). MRSA colonized patients. CrCl (mL/min)Target trough 10-15mg/LTarget trough 15-20 mg/L≥80q12hq8h (if.
Rybak et al. American Journal of Health-System Pharmacy January 2009, 66 (1) 82-98. Rybak et al. J Antimicrob Chemother.
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Crass RL et al. J Antimicrob Chemother. 2018 Nov 1;73(11):3081-3086.
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