Infectious Diseases: Curtis L. Smith, Pharm.D., BCPS

Infectious Diseases
Infectious Diseases
Curtis L. Smith, Pharm.D., BCPS
Ferris State University
Lansing, Michigan
ACCP Updates in Therapeutics® 2015: The Pharmacotherapy Preparatory Review and Recertification Course
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Infectious Diseases
Learning Objectives 3. A study is designed to assess the risk of pneumo-

coccal pneumonia in older adults 10 years or more
1. Describe appropriate treatment of patients with after their pneumococcal vaccination, compared
respiratory tract infections, urinary tract infec- with older adults who have never received the vac-
tions, central nervous system (CNS) infections, cination. Which study design is best?
skin and soft tissue infections, osteomyelitis, A. Case series.
intra-abdominal infections, and endocarditis.
B. Case-control study.
2. Identify appropriate preventive therapy for respira-
tory tract infections, CNS infections, endocarditis, C. Prospective cohort study.
and surgical wound infections. D. Randomized controlled trial.
4. S.C. is a 46-year-old woman who presents to the

Self-Assessment Questions clinic with purulent nasal discharge, nasal and
Answers and explanations to these questions can be facial congestion, headaches, fever, and dental
found at the end of this chapter. pain. Her symptoms began about 10 days ago,
improved after about 4 days, and then worsened
1. P.E. is a 56-year-old man who comes to the clinic again a few days later. Which is the best empiric
with a 3-day history of fever, chills, pleuritic chest therapy for S.C.?
pain, malaise, and cough productive of sputum. In A. Cefpodoxime 200 mg twice daily.
the clinic, his temperature is 102.1ºF (38.9ºC) (all
B. Clindamycin 300 mg orally four times daily.
other vital signs are normal). His chest radiograph
shows consolidation in the right lower lobe. His C. Amoxicillin/clavulanate 875 mg/125 mg
white blood cell count (WBC) is 14,400 cells/mm3, every 12 hours.
but all other laboratory values are normal. He is D. No antibiotic therapy needed because this is a
given a diagnosis of community-acquired pneumo- typical viral infection.
nia (CAP). He has not received any antibiotics in
5 years and has no chronic disease states. Which is 5. N.R. is a 28-year-old woman who presents to the
the best empiric therapy for P.E.? clinic with a 2-day history of dysuria, frequency,
A. Doxycycline 100 mg orally twice daily. and urgency. She has no significant medical his-
tory, and the only drug she takes is oral contracep-
B. Cefuroxime axetil 250 mg orally twice daily.
tives. Which is the best empiric therapy for N.R.?
C. Levofloxacin 750 mg/day orally.
A. Oral nitrofurantoin extended release (ER)
D. Trimethoprim/sulfamethoxazole double 100 mg twice daily for 3 days.
strength orally twice daily.
B. Oral ciprofloxacin 500 mg twice daily for
7 days.
2. H.W. is a 38-year-old woman who presents with
high temperature, malaise, dry cough, nasal con- C. Oral trimethoprim/sulfamethoxazole double
gestion, and severe headaches. Her symptoms strength twice daily for 3 days.
began suddenly 3 days ago, and she has been in D. Oral cephalexin 500 mg four times daily for
bed since then. She reports no other illness in her 3 days.
family, but several people have recently called in
sick at work. Which is best for H.W.? 6. B.Y. is an 85-year-old woman who is bedridden and
A. Azithromycin 500 mg, followed by 250 mg/ lives in a nursing home. She is chronically cathe-
day orally for 4 more days. terized, and her urinary catheter was last changed
3 weeks ago. Today, her urine is cloudy, and a uri-
B. Amoxicillin/clavulanic acid 875 mg orally
nalysis shows many bacteria. B.Y. is not noticing
twice daily.
any symptoms. A urine culture is obtained. Which
C. Oseltamivir 75 mg twice daily orally for 5 days. option is best for B.Y.?
D. Symptomatic treatment only.
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A. No therapy because she is chronically C. Administer ceftriaxone 2 g intravenously

catheterized and has no symptoms. every 12 hours and vancomycin 1000 mg
B. No antibiotic therapy, but the catheter should intravenously every 12 hours until the CSF
be changed. cultures are negative for bacteria.
C. Oral ciprofloxacin 500 mg twice daily for D. Administer acyclovir 500 mg intravenously
7 days and a new catheter. every 8 hours until the CSF culture results
are complete.
D. Oral ciprofloxacin 500 mg twice daily for
14–21 days without a change in catheter.
9.
L.G. is a 49-year-old woman with a history of
mitral valve prolapse. She presents to her physi-
7. V.E. is a 44-year-old man who presents to the emer-
cian’s office with malaise and a low-grade fever.
gency department with a warm, erythematous, and
Her physician notes that her murmur is louder than
painful right lower extremity. There is no raised
normal and orders blood cultures and an echocar-
border at the edge of the infection. Three days
diogram. A large vegetation is observed on L.G.’s
ago, he scratched his leg on a barbed wire fence on
mitral valve, and her blood cultures are growing
his property. His temperature has been as high as
Enterococcus faecalis (susceptible to all antibiot-
101.8°F (38°C) with chills. Doppler studies of his
ics). Which is the best therapy for L.G.?
lower extremity are negative. Blood cultures were
drawn, and they are negative to date. Which is the A. Penicillin G plus gentamicin for 2 weeks.
best empiric therapy for V.E.? B. Vancomycin plus gentamicin for 2 weeks.
A. Nafcillin 2 g intravenously every 6 hours. C. Ampicillin plus gentamicin for 4–6 weeks.
The infection may worsen, and necrotizing D. Cefazolin plus gentamicin for 4–6 weeks.
fasciitis must be ruled out.
B. Penicillin G, 2 million units intravenously 10. N.L. is a 28-year-old woman with no significant
every 4 hours. This is probably erysipelas. medical history. She reports to the emergency
C. Piperacillin/tazobactam 3.375 g intravenously department with fever and severe right lower quad-
every 6 hours. Surgical debridement is vitally rant pain. She has had a dull pain for the past few
important. days, but it suddenly became severe during the past
8 hours. Her temperature is 103.5°F (39.7°C), and
D. Enoxaparin 80 mg subcutaneously twice daily
she has rebound tenderness on abdominal exam-
and warfarin 5 mg/day orally.
ination. She is taken to surgery immediately, where
a perforated appendix is diagnosed and repaired.
8. R.K. is a 36-year-old woman who presents to the
Which is the best follow-up antibiotic regimen?
emergency department with a severe headache and
neck stiffness. Her temperature is 99.5°F (37.5°C). A. Vancomycin 1000 mg intravenously every
After a negative computed tomographic scan of the 12 hours plus metronidazole 500 mg
head, a lumbar puncture is performed, showing intravenously every 8 hours.
the following: glucose 54 mg/dL (peripheral, 104), B. Ceftriaxone 1 g/day intravenously plus
protein 88 mg/dL, and WBC 220 cells/mm3 (100% ciprofloxacin 400 mg intravenously every
lymphocytes). The Gram stain shows no organ- 12 hours.
isms. Which option describes the best therapy for C. Ertapenem 1 g/day intravenously.
R.K.?
D. No antibiotics needed after surgical repair
A. This is aseptic (probably viral) meningitis, of a perforated appendix.
and no antibiotics are necessary.
B. Administer ceftriaxone 2 g intravenously
every 12 hours until the cerebrospinal fluid
(CSF) cultures are negative for bacteria.
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I. RESPIRATORY TRACT INFECTIONS
A. Pneumonia
1. Pneumonia is the most common cause of death attributable to infectious diseases (very high rates in
older adults) and in the top 10 causes of death in the United States.
2. Hospital-acquired pneumonia is the second most common nosocomial infection (0.6%–1.1% of all
hospitalized patients). There is a higher incidence in patients in the intensive care unit recovering from
thoracic or upper abdominal surgery and in older adults.
3. Mortality rates
a. Community-acquired pneumonia (CAP) without hospitalization: less than 1%
b. CAP with hospitalization: about 14%
c. Nosocomial: about 33%–50%
B. Community-Acquired Pneumonia
1. Definition: Acute infection of the pulmonary parenchyma, accompanied by an acute infiltrate consis-
tent with pneumonia on chest radiograph or auscultatory findings. Patients must also not have any of the
following characteristics: hospitalization 2 days or more in the past 90 days; residence in a long-term
care facility; receipt of intravenous antibiotic therapy, chemotherapy, or wound care in the past 30 days;
or attendance at a hospital or hemodialysis clinic.
2. Symptoms of CAP are listed below. Older adults often have fewer and less severe findings (mental
status changes are common).
a. Fever or hypothermia
b. Rigors
c. Sweats
d. New cough with or without sputum (90%)
e. Chest discomfort (50%)
f. Onset of dyspnea (66%)
g. Fatigue, myalgias, abdominal pain, anorexia, and headache
3. Predictors of a complicated course of CAP are listed below. Hospitalization should be based on the
severity-of-illness scores (e.g., CURB-65, pneumonia severity index).
a. Age greater than 65 years
b. Comorbid illness (diabetes mellitus, congestive heart failure, lung disease, renal failure, liver
disease)
c. High temperature: more than 101°F (38°C)
d. Bacteremia
e. Altered mental status
f. Immunosuppression (e.g., steroid use, cancer)
g. High-risk etiology (Staphylococcus aureus, Legionella, gram-negative bacilli, anaerobic aspiration)
h. Multilobe involvement or pleural effusions
4. Severity-of-illness scoring systems in CAP
a. CURB-65
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Table 1. CURB-65 Scoring

CURB-65a
Symptom Points
Confusion 1
Urea >19 mg/dL 1
Respiratory rate ≥30 breaths/minute 1
SBP <90 mm Hg, DBP ≤60 mm Hg 1
Age ≥65 years 1
CRB-65 (without a blood urea nitrogen level) is useful in a primary practice setting.
a
DBP = diastolic blood pressure; SBP = systolic blood pressure.
Table 2. CURB-65 Location of Therapy

CURB-65
Score Risk of Death at 30 Days (%) Location of Therapy
0 0.7 Treat as outpatient
1 2.1 Treat as outpatient
2 9.2 Outpatient or inpatient
3 14.5 Inpatient (±ICU)
ICU = intensive care unit.
b. Pneumonia severity index (or Pneumonia Patient Outcomes Research Team score)
i. Evaluates 20 patient characteristics
ii. Assesses risk of mortality, similar to CURB-65
iii. Has predictive ability similar to that of CURB-65 but better in patients with lower mortality
risk
C. Nosocomial Pneumonia
1. Hospital-acquired pneumonia: Pneumonia that occurs 48 hours or more after admission and was not
incubating at the time of admission
2. Ventilator-associated pneumonia: Pneumonia that arises more than 48–72 hours after endotracheal
intubation
3. Health care–associated pneumonia: Pneumonia developing in a patient who was hospitalized 2 days
or more in the past 90 days; who resided in a nursing home or long-term care facility; who received
intravenous antibiotic therapy, intravenous chemotherapy, or wound care in the past 30 days; or who
attended a hospital or hemodialysis clinic
4. Risk factors for nosocomial pneumonia
a. Intubation and mechanical ventilation
b. Supine patient position
c. Enteral feeding
d. Oropharyngeal colonization
e. Stress bleeding prophylaxis
f. Blood transfusion
g. Hyperglycemia
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h. Immunosuppression or corticosteroids
i. Surgical procedures: thoracoabdominal, upper abdominal, thoracic
j. Immobilization
k. Nasogastric tubes
l. Previous antibiotic therapy
m. Admission to the intensive care unit
n. Advanced age
o. Underlying chronic lung disease
D. Microbiology (Table 3)
Table 3. Incidence of Pneumonia by Organism

Community Acquired (%) Hospital Acquired (%)
Unidentifiable 40–60 Unidentifiable 50
Mycoplasma pneumoniae 13–37 S. aureus 10
Streptococcus pneumoniae 9–20 Pseudomonas aeruginosa 8
Haemophilus influenzae 3–10 Enterobacter spp. 5
Chlamydia pneumoniae 1–17 K. pneumoniae 4
Legionella pneumophila 0.7–13 Candida spp. 3
Viruses Common Acinetobacter spp. 2
Others: Uncommon Serratia marcescens 2
Staphylococcus aureus Escherichia coli 2
Moraxella catarrhalis S. pneumoniae 1
Pneumocystis pneumonia
Anaerobes
Gram-negative bacilli
(e.g., Klebsiella pneumoniae)
Specific populations in community-acquired Issues in hospital-acquired pneumonia:
pneumonia: P. aeruginosa is transmitted by health care workers’
Alcoholics: S. pneumoniae, oral anaerobes, hands or respiratory equipment
gram-negative bacilli (e.g., Klebsiella) S. aureus is transmitted by health care workers’ hands
Nursing home: S. pneumoniae, H. influenzae, Enterobacteriaceae endogenously colonize
gram-negative bacilli, S. aureus hospitalized patients’ airways (healthy people seldom
COPD: S. pneumoniae, H. influenzae, M. catarrhalis have gram-negative upper airway colonization)
Postinfluenza: H. influenzae, S. aureus, S. pneumoniae Stress changes respiratory epithelial cells so that
Exposure to water: Legionella gram-negative organisms can adhere
Poor oral hygiene: oral anaerobes Up to 70% of patients in the intensive care unit have
gram-negative upper airway colonization, and 25% of
HIV infection: Pneumocystis jirovecii, S. pneumoniae, them will become infected through aspiration
M. pneumoniae, Mycobacterium
COPD = chronic obstructive pulmonary disease; HIV = human immunodeficiency virus.
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Patient Case
1. R.L. is a 68-year-old man who presents to the emergency department with coughing and shortness of
breath. His symptoms, which began 4 days ago, have worsened during the past 24 hours. He is coughing up
yellow-green sputum, and he has chills, with a temperature of 102.4°F (39°C). His medical history includes
coronary artery disease with a myocardial infarction 5 years ago, congestive heart failure, hypertension,
and osteoarthritis. He rarely drinks alcohol and has not smoked since his myocardial infarction. His med-
ications on admission include lisinopril 10 mg/day, hydrochlorothiazide 25 mg/day, and acetaminophen
650 mg four times/day. On physical examination, he is alert and oriented, with the following vital signs: tem-
perature 101.8°F (38°C), heart rate 100 beats/minute, respiratory rate 24 breaths/minute, and blood pressure
142/94 mm Hg. His laboratory results are normal except for blood urea nitrogen (BUN) 32 mg/dL (serum
creatinine 1.23 mg/dL). A sputum specimen is not available. If R.L. were hospitalized, which would be the
best empiric therapy for him?
A. Ampicillin/sulbactam 1.5 g intravenously every 6 hours.
B. Piperacillin/tazobactam 4.5 g intravenously every 6 hours plus gentamicin 180 mg intravenously
every 12 hours.
C. Ceftriaxone 1 g intravenously every 24 hours plus azithromycin 500 mg/day intravenously.
D. Doxycycline 100 mg intravenously every 12 hours.
E. Therapy: Pneumonia
1. CAP
a. Empiric treatment of nonhospitalized patients
i. Previously healthy and no antibiotic therapy in the past 3 months
(a) Macrolide (clarithromycin or azithromycin if Haemophilus influenzae is suspected)
(b) Doxycycline
ii. Comorbidities (chronic obstructive pulmonary disease [COPD], diabetes mellitus, chronic
renal or liver failure, congestive heart failure, malignancy, asplenia, or immunosuppression)
or recent antibiotic therapy (within the past 3 months)
(a) Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])
(b) Macrolide (or doxycycline) with high-dose amoxicillin (1 g three times/day) or amoxicillin/
clavulanate (2 g twice daily) or a cephalosporin (ceftriaxone, cefuroxime, or cefpodoxime)
b. Empiric treatment of hospitalized patients with moderately severe pneumonia
i. Respiratory fluoroquinolone (moxifloxacin, gemifloxacin [oral only], or levofloxacin [750 mg])
ii. Ampicillin, ceftriaxone, or cefotaxime (ertapenem in select patients) plus a macrolide (or
doxycycline)
c. Empiric treatment of hospitalized patients with severe pneumonia necessitating intensive care unit
treatment (may need to add other antibiotics if P. aeruginosa or methicillin-resistant S. aureus
[MRSA] is suspected)
i. Ampicillin/sulbactam plus either a respiratory fluoroquinolone or azithromycin
ii. Ceftriaxone plus either a respiratory fluoroquinolone or azithromycin
iii. Cefotaxime plus either a respiratory fluoroquinolone or azithromycin
d. Treatment duration: At least 5 days, with 48–72 hours afebrile and no more than one sign of clinical
instability (elevated temperature, heart rate, or respiratory rate; decreased systolic blood pressure;
or arterial oxygen saturation) before therapy discontinuation
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Patient Case
2. B.P. is a 66-year-old woman who underwent a two-vessel coronary artery bypass graft 8 days ago and has
been on a ventilator in the surgical intensive care unit since then. Her temperature is now rising, and a tra-
cheal aspirate shows many white blood cells and gram-negative rods. Her medical history includes coronary
artery disease with a myocardial infarction 2 years ago, COPD, and hypertension. Which is the best empiric
therapy for B.P.?
A. Ceftriaxone 1 g/day intravenously plus gentamicin 480 mg intravenously every 24 hours plus linezolid
600 mg intravenously every 12 hours.
B. Piperacillin/tazobactam 4.5 g intravenously every 6 hours.
C. Levofloxacin 750 mg/day intravenously plus linezolid 600 mg intravenously every 12 hours.
D. Cefepime 2 g intravenously every 12 hours plus tobramycin 480 mg intravenously every 24 hours plus
vancomycin 15 mg/kg intravenously every 12 hours.
2. Hospital-acquired pneumonia
a. Early onset (less than 5 days) and no risk factors for multidrug-resistant (MDR) organisms.
Common organisms include Streptococcus pneumoniae, H. influenzae, methicillin-sensitive
S. aureus (MSSA), Escherichia coli, Klebsiella pneumoniae, Enterobacter spp., and Proteus spp.
i. Third-generation cephalosporin (ceftriaxone)
ii. Fluoroquinolone (levofloxacin, moxifloxacin, ciprofloxacin)
iii. Ampicillin/sulbactam
iv. Ertapenem
b. Late onset (5 days or longer) or risk factors for MDR organisms. Common organisms include those
listed above for early onset plus Pseudomonas aeruginosa, K. pneumoniae (extended-spectrum
β-lactamase positive), Acinetobacter spp., MRSA, and Legionella pneumophila.
i. Ceftazidime or cefepime plus aminoglycoside or fluoroquinolone (ciprofloxacin, levofloxacin)
ii. Imipenem, meropenem, or doripenem plus aminoglycoside or fluoroquinolone (ciprofloxacin,
levofloxacin)
iii. Piperacillin/tazobactam plus aminoglycoside or fluoroquinolone (ciprofloxacin, levofloxacin)
iv. Vancomycin or linezolid should be added to the above regimens only if MRSA risk factors
(e.g., history of MRSA infection or colonization, recent hospitalization or antibiotic use, pres-
ence of invasive health care devices) are present or there is a high incidence locally (greater
than 10%–15%).
c. Treatment duration: Efforts should be made to decrease therapy duration to as short as 7 or 8 days
(14 days for pneumonia secondary to P. aeruginosa or Acinetobacter).
d. Risk factors for MDR organisms
i. Antibiotic therapy within the past 90 days
ii. Hospitalization of 5 days or more
iii. High resistance in community or hospital unit
iv. Risk factors for health care–associated pneumonia
(a) Hospitalization for 2 or more days in the preceding 90 days
(b) Residence in a nursing home or extended care facility
(c) Intravenous therapy (including antibiotics) or intravenous chemotherapy within 30 days
(d) Attendance at a hospital or hemodialysis clinic
(e) Home wound care within 30 days
v. Family member with MDR pathogen
vi. Immunosuppressive disease or therapy
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Patient Case
3. B.P., who eventually improves, is transferred to a regular floor. She cannot remember receiving any recent
vaccinations. Which is the best vaccination recommendation for this patient?
A. B.P. needs no vaccinations.
B. B.P. should receive the pneumococcal vaccine now and the influenza vaccine in the fall.
C. B.P. should receive the influenza vaccine in the fall, but because of her current infection, the pneumo-
coccal vaccine is unnecessary.
D. B.P. should receive the pneumococcal vaccine now, but she is not in a group in which the influenza
vaccine is recommended.
F. Influenza
1. Characteristics of influenza infection
a. Epidemic with significant mortality
b. Epidemics begin abruptly → peak in 2–3 weeks → resolve in 5–6 weeks
c. Occurs almost exclusively in the winter
d. Average overall attack rates of 10%–20%
e. Mortality greatest in those older than 65 years (especially with heart and lung disease): More than
80% of deaths caused by influenza are from this age group (20,000 deaths a year in the United
States).
2. Is it a cold or the flu? (Table 4)
Table 4. Differentiating the Symptoms of Cold and Influenza

Signs and Symptoms Influenza Cold
Onset Sudden Gradual
Temperature Characteristic, high (>101°F [38°C]) of 3–4 days’ duration Occasional
Cough Dry; can become severe Hacking
Headache Prominent Occasional
Myalgia (muscle aches and pains) Usual; often severe Slight
Tiredness and weakness Can last 2–3 weeks Very mild
Extreme exhaustion Early and prominent Never
Chest discomfort Common Mild to moderate
Stuffy nose Sometimes Common
Sneezing Sometimes Usual
Sore throat Sometimes Common
3. Pathophysiology
a. Type A
i. Influenza further grouped by variations in hemagglutinin and neuraminidase (e.g., H1N1,
H3N2)
ii. Changes through antigenic drift or shift
(a) Drift: Annual, gradual change caused by mutations, substitutions, and deletions
(b) Shift: Less common dramatic change leading to pandemics
iii. Causes epidemics every 1–3 years
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b. Type B
i. Type B influenza carries one form of hemagglutinin and one form of neuraminidase, both of
which are less likely to mutate than the hemagglutinin and neuraminidase of type A influenza.
ii. Changes through antigenic drift (minor mutations from year to year); when enough drifts
occur, an epidemic is likely.
iii. Causes epidemics every 5 years
4. Therapy
a. Treatment indicated in patients with confirmed or suspected influenza and the following conditions
(use only the neuraminidase inhibitors):
i. Hospitalized patients
ii. Severe, complicated, or progressive illness
iii. High risk of influenza complications:
(a) Patients younger than 2 years or 65 years and older
(b) Patients with chronic disease states: Pulmonary (including asthma), cardiovascular (except
hypertension alone), renal, hepatic, hematologic (including sickle cell disease), metabolic
disorders (including diabetes mellitus), or neurologic and neurodevelopment conditions
(c) Immunosuppressed patients
(d) Pregnant women
(e) Patients younger than 19 years who are receiving long-term aspirin therapy
(f) American Indians and Alaska Natives
(g) Patients who are morbidly obese
(h) Residents of nursing homes and other long-term care facilities
iv. Treatment may be considered for those without risk factors according to clinical judgment
(must initiate within 48 hours).
b. Adamantanes
i. Amantadine (Symmetrel), rimantadine (Flumadine)
ii. Inhibit viral uncoating and release of viral nucleic acid by inhibiting M2 protein
(a) Never effective against influenza B virus
(b) Not recommended for treatment because of current universal resistance in influenza A
c. Neuraminidase inhibitors
i. Oseltamivir (Tamiflu), Zanamivir (Relenza)
ii. Inhibit neuraminidase; symptoms resolve 1–1.5 days sooner.
iii. Adverse effects
(a) Oseltamivir: Gastrointestinal (nausea and vomiting)
(b) Zanamivir: Bronchospasm, cough (not recommended in patients with asthma or COPD)
iv. Dose
(a) Oseltamivir: 75 mg orally twice daily for 5 days; decrease dose to 75 mg/day orally in
patients with creatinine clearance less than 30 mL/minute.
(b) Zanamivir: Two inhalations (5 mg/inhalation) twice daily for 5 days
(c) Initiate within 48 hours of symptom onset.
5. Prevention
a. Chemoprophylaxis only for influenza-related complications in patients at very high risk (e.g.,
severely immunosuppressed patients) who cannot be protected by the vaccine when a high risk of
exposure exists
b. Amantadine, rimantadine: Not recommended for prevention because of current universal resistance
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c. Neuraminidase inhibitors
i. Oseltamivir (Tamiflu)
(a) Oseltamivir administered 75 mg/day orally for 6 weeks during peak influenza season
showed 74% protective efficacy (as prophylaxis in unvaccinated people).
(b) Begin oseltamivir 75 mg/day orally within 2 days of close contact with an infected person
and continue for no more than 10 days.
ii. Zanamivir (Relenza)
(a) Zanamivir 10 mg/day through inhalation for 4 weeks during peak influenza season showed
67% protective efficacy (as prophylaxis in unvaccinated people).
(b) Begin zanamivir 10 mg/day within 5 days of community outbreak and continue for
4 weeks during peak influenza season.
G. Immunizations Related to the Respiratory Tract

1. Pneumococcal vaccines
a. Characteristics: Pneumococcal polysaccharide vaccine (PPSV23)
i. PPSV contains 23 purified capsular polysaccharide antigens of S. pneumoniae.
ii. The 23 capsular types account for 85%–90% of invasive S. pneumoniae infection.
iii. Antibody levels remain elevated for at least 5 years.
b. Characteristics: Pneumococcal conjugate vaccine (PCV13)
i. PCV contains 13 purified capsular polysaccharide antigens of S. pneumoniae conjugated to a
carrier protein.
ii. The 13 capsular types are all in PPSV23 except for one.
iii. If both PCV13 and PPSV23 are required, PCV13 should be given first, followed by PPSV23 at
least 8 weeks later. If PPSV23 is given first, PCV13 should be given at least 6–12 months later.
c. Recommendations (Table 5)
Table 5. Pneumococcal Vaccine Recommendations (all recommendations are for PPSV23 except where noted)
Vaccination-Recommended Group Revaccination
Immunocompetent People
People ≥65 years of age Ideally give PCV13 first followed by
These people should receive PCV13 and PPSV23 PPSV23 in 8 weeks
Second dose of PPSV23 if patient received
vaccine ≥5 years previously and was
<65 years old at the time of vaccination
People 2–64 years of age with chronic cardiovascular disease, Not recommended
chronic pulmonary disease, diabetes mellitus, alcoholism, chronic
liver disease, cochlear implants or CSF leaks; adult asthmatics or
adult smokers
People with cochlear implants or CSF leaks should also receive
PCV13
People 2–64 years of age living in nursing homes or long-term care Not recommended
facilities
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Table 5. Pneumococcal Vaccine Recommendations (continued)

Vaccination-Recommended Group Revaccination
Immunocompromised People
Immunocompromised people ≥2 years old, including those Single revaccination recommended after
with HIV infection, leukemia, lymphoma, Hodgkin disease, 5 years (for anyone ≥2 years)
multiple myeloma, generalized malignancy, chronic renal failure,
or nephrotic syndrome; those receiving immunosuppressive
chemotherapy (including corticosteroids); and those who have
received an organ or bone marrow transplant
These people should also receive PCV13
People 2–64 years of age with functional or anatomic asplenia Single revaccination recommended after
These people should also receive PCV13 5 years (for anyone ≥2 years old)
CSF = cerebrospinal fluid; HIV = human immunodeficiency virus; PCV = pneumococcal conjugate vaccine; PPSV = pneumococcal polysac-
charide vaccine.
2. Influenza vaccine
a. Characteristics
i. Each year’s vaccine contains two strains of type A and one strain of type B, selected by world-
wide surveillance and antigenic characterization.
ii. Prevents illness in 70%–90% of healthy people younger than 65 years
iii. Prevents illness in 53%, hospitalization in 50%, and death in 68% of older adults
iv. Administer yearly in September or October.
b. Recommendations
i. Everyone older than 6 months should receive the vaccine annually.
ii. Children younger than 9 years should receive two doses, at least 1 month apart, the first season
they receive the vaccine. Intranasal live attenuated influenza vaccine recommended in chil-
dren 2–8 years old.
iii. In adults the Centers for Disease Control and Prevention (CDC) currently does not recommend
one vaccine over any other.
iv. Patients with egg allergies:
(a) O
nly hives after egg exposure: Administer recombinant inactivated influenza vaccine
(Flublok) or administer inactivated influenza vaccine but only by a health care provider
familiar with egg allergies.
(b) More severe symptoms after egg exposure: Administer recombinant inactivated influenza
vaccine (Flublok) or refer to an allergist for risk assessment.
c. Influenza vaccine products (Table 6)
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Table 6. Influenza Vaccine Products

Influenza Vaccine Indications Notes
Inactivated influenza vaccine 6 months and older Primary influenza vaccine; at this time, the
trivalent (IIV3, multiple brands) CDC has no preference for using any other
vaccine over this IIV3 vaccine
Intranasal live attenuated influenza 2–49 years without Pregnant women should receive the inactivated
vaccine quadrivalent (LAIV4, underlying illnesses vaccine
FluMist) (including health care Use of inactivated vaccine is preferred for
workers) vaccinating household members, health care
workers, and others who have close contact with
severely immunosuppressed people
High-dose trivalent influenza 65 years and older The CDC has no preference for using this
vaccine (high-dose Fluzone) vaccine over the regular influenza vaccine
Inactivated influenza vaccine 6 months and older The CDC has no preference for using this
quadrivalent (IIV4, Fluzone, and vaccine over the regular influenza vaccine
Fluarix)
Intradermal inactivated influenza 18–64 years Much smaller needle, but local reactions are
vaccine trivalent (IIV3, Fluzone significantly greater than with the IM vaccines
intradermal)
Inactivated influenza vaccine 18 years and older Grown in mammalian cell lines, but still
trivalent – cell culture based exposed to eggs early in production
(IIV3, Flucelvax) Same cautions for patients with egg allergies
Recombinant inactivated influenza 18 years and older Produced by recombinant technology; safe for
vaccine trivalent (RIV3, Flublok) patients with egg allergies
CDC = Centers for Disease Control and Prevention; IM = intramuscular.
H. Sinusitis
1. Definition and etiology
a. Inflammation of the mucosal lining of the nasal passage and paranasal sinuses lasting up to
4 weeks
b. Many different causes, including viruses, bacteria, and fungi
c. Viruses account for more than 90% of cases, whereas bacteria account for less than 10%.
2. Diagnosis
a. Presence of at least two major symptoms or one major and two or more minor symptoms (Table 7)
Table 7. Symptoms Associated with Diagnosis of Sinusitis

Major Symptoms Minor Symptoms
Purulent anterior nasal discharge Headache
Purulent or discolored posterior nasal discharge Ear pain, pressure, or fullness
Nasal congestion or obstruction Halitosis
Facial congestion or fullness Dental pain
Facial pain or pressure Cough
Hyposmia or anosmia Fever (for subacute or chronic sinusitis)
Fever (for acute sinusitis only) Fatigue
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b. Viral or bacterial? (Table 8)
Table 8. Differentiating Viral from Bacterial Sinusitis

Viral Bacterial
Symptoms Nasal discharge, congestion, and Nasal discharge, congestion, and scratchy throat
scratchy throat
Nasal discharge Clear to purulent to clear; purulence Persistent purulent discharge (>10 days) or
not present until days 4–5 early and severe (first 3–4 days) or increased
on days 5–6 after typical viral infection
(“double-sickening”)
Fever None (or early in course, resolving in High temperature (≥39ºC) and early
48 hours) (first 3–4 days)
Other symptoms Headache, facial pain, and myalgia Headache, facial pain, myalgia, daytime cough
(resolving in 48 hours)
Peak symptoms Days 3–6 Persistent >10 days or early and severe
(first 3–4 days) or improved symptoms that
worsen on days 5–6
Duration 5–10 days In general, >10 days
3. Treatment
a. Begin antibiotics as soon as bacterial sinusitis is diagnosed (see criteria in Table 8).
b. First-line therapy
i. Amoxicillin/clavulanate
ii. High-dose amoxicillin/clavulanate (2 g twice daily in adults or 90 mg/kg/day divided twice
daily) in:
(a) Geographic regions with high endemic rates (greater than 10%) of invasive penicillin-
nonsusceptible S. pneumoniae
(b) Those with a severe infection (e.g., evidence of systemic toxicity with a temperature of
39ºC or higher and a threat of suppurative complications)
(c) Attendance at day care
(d) Age younger than 2 years or older than 65 years
(e) Recent hospitalization
(f) Antibiotic use within the past month
(g) Those who are immunocompromised
c. Second-line therapy
i. Respiratory fluoroquinolone (including children with type I hypersensitivity to penicillin)
ii. Doxycycline
iii. Cefixime or cefpodoxime with clindamycin (for children with non–type I hypersensitivity to
penicillin)
iv. Intranasal saline irrigation as adjunctive therapy
v. Intranasal corticosteroids as adjunctive therapy in patients with allergic rhinitis
d. Therapy duration
i. Adults: 5–7 days
ii. Children: 10–14 days
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II. URINARY TRACT INFECTIONS
A. Introduction
1. Most common bacterial infection in humans: 7 million office visits per year; 1 million hospitalizations
2. Many women (15%–20%) will have a urinary tract infection (UTI) during their lifetime.
3. From 1–50 years of age, UTIs occur predominantly in women; after 50, men are affected because of
prostate problems.
B. Microbiology (Table 9)
Table 9. Incidence of Urinary Tract Infections by Organism

Community Acquired (%) Nosocomial (%)
Escherichia coli 73 E. coli 31
Staphylococcus saprophyticus 13 Pseudomonas aeruginosa 10
Proteus mirabilis 5 Other gram-negative bacilli 10
Klebsiella pneumoniae 4 K. pneumoniae 9
Enterococcus 2 Staphylococcus aureus 6
P. mirabilis 5
Enterococcus 2
Fungal 14
C. Predisposing Factors
1. Age
2. Female sex
3. Diabetes mellitus
4. Pregnancy
5. Immunosuppression
6. Urinary tract instrumentation
7. Urinary tract obstruction
8. Renal disease; renal transplantation
9. Neurologic dysfunction
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Patient Case
4. G.N. is a 62-year-old woman who presents to the clinic with a 3-day history of urinary frequency and dysuria.
During the past 24 hours, she has had nausea, vomiting, and flank pain. G.N. has a history of type 2 diabetes
mellitus, which is poorly controlled, with some diabetes-related complications. G.N. also has hypertension
and a history of several episodes of deep venous thrombosis. Her medications include glyburide 5 mg/day
orally, enalapril 10 mg orally twice daily, warfarin 3 mg/day orally, and metoclopramide 10 mg four times/
day. On physical examination, she is alert and oriented, with the following vital signs: temperature 102.8°F
(39°C), heart rate 120 beats/minute, respiratory rate 16 breaths/minute, supine blood pressure 140/75 mm Hg,
and standing blood pressure 110/60 mm Hg. Her laboratory values are within normal limits except for ele-
vated international normalized ratio 2.7, BUN 26 mg/dL, serum creatinine 1.88 mg/dL, and white blood cell
count (WBC) 12,000 cells/mm3 (78 polymorphonuclear leukocytes, 7 band neutrophils, 10 lymphocytes, and
5 monocytes). Her urinalysis shows turbidity, 2+ glucose, pH 7.0, protein 100 mg/dL, 50–100 WBC, positive
nitrites, 3–5 red blood cells, and many bacteria and positive casts. Which is the best empiric therapy for G.N.?
A. Trimethoprim/sulfamethoxazole double strength orally twice daily; duration of antibiotics 7 days.
B. Ciprofloxacin 400 mg intravenously twice daily and then 500 mg orally twice daily; duration of
antibiotics 10 days.
C. Gentamicin 140 mg intravenously every 24 hours; duration of antibiotics 3 days.
D. Tigecycline 100 mg once, then 50 mg every 12 hours and then doxycycline 100 mg twice daily;
duration of antibiotics 10 days.
D. Clinical Presentation
1. Lower UTI: Cystitis (older adults may have only nonspecific symptoms, such as mental status changes,
abdominal pain, and decreased eating or drinking)
a. Dysuria
b. Frequent urination
c. Urgency
d. Occasionally, gross hematuria
e. Occasionally, foul-smelling urine
2. Upper UTI: Pyelonephritis (older adults may have only nonspecific symptoms, such as mental status
changes, abdominal pain, and decreased eating or drinking)
a. Frequency, dysuria, hematuria
b. Suprapubic pain
c. Costovertebral angle tenderness; flank pain
d. Fever, chills
e. Elevated WBC
f. Nausea, vomiting
3. Factors associated with or used to define complicated UTI
a. Male sex
b. Hospital acquired
c. Pregnancy
d. Anatomic abnormality of the urinary tract
e. Childhood UTIs
f. Recent antimicrobial use
g. Indwelling urinary catheter
h. Recent urinary tract instrumentation
i. Immunosuppression
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4. Recurrent cystitis
a. Relapse: Infection with the same organism within 14 days of discontinuing antibiotics for the pre-
ceding UTI
b. Reinfection: Infection with a completely different organism; most common cause of recurrent
cystitis
E. Diagnosis: Urinalysis (blood cultures will be positive in 20% of patients with upper UTIs)
1. Pyuria (WBC greater than 5–10 cells/mm3)
2. Bacteriuria (more than 102 colony-forming units per milliliter is diagnostic)
3. Red blood cells
4. Cloudiness
5. Nitrite positive
6. Leukocyte esterase positive
7. Casts (if pyelonephritis)
F. Therapy
1. Uncomplicated cystitis
a. Recommended therapy
i. Trimethoprim/sulfamethoxazole 160 mg/800 mg twice daily for 3 days.
Avoid if resistance prevalence is known to exceed 20% or if used for UTI in previous 3 months.
ii. Nitrofurantoin 100 mg twice daily for 5 days
iii. Fosfomycin 3 g, one dose
b. Alternatives
i. Fluoroquinolones for 3 days
ii. β-Lactams for 3–7 days
2. Uncomplicated pyelonephritis
a. Outpatient therapy (if patient is not immunocompromised or does not have nausea and vomiting)
i. Trimethoprim/sulfamethoxazole for 14 days
ii. Fluoroquinolone for 5–7 days
iii. β-Lactam for 10–14 days (less effective than first two options)
b. Uropathogen resistance greater than 10%: Use initial dose of an intravenous, long-acting β-lactam
(e.g., ceftriaxone) or once-daily aminoglycoside.
3. Complicated UTIs
a. Inpatient therapy
i. Fluoroquinolone
ii. Aminoglycoside
iii. Extended-spectrum β-lactam
b. Therapy duration: 5–14 days (5 days with levofloxacin)
4. Pregnancy (pregnant women should be screened for bacteriuria and treated, even if asymptomatic)
a. 7-day treatment regimen
i. Amoxicillin
ii. Nitrofurantoin (avoid after 38 weeks’ gestation and during labor and delivery)
iii. Cephalexin
b. Antibiotics to avoid
i. Fluoroquinolones
ii. Tetracyclines
iii. Aminoglycosides
iv. Trimethoprim/sulfamethoxazole (used frequently but avoidance recommended, especially
during the late third trimester)
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5. Recurrent cystitis
a. Relapse
i. Assess for pharmacologic reason for treatment failure.
ii. Longer treatment (for 2–6 weeks, depending on length of initial course)
b. Reinfection (reassess need for continuous prophylactic antibiotics every 6–12 months)
i. If patient has two or fewer UTIs in 1 year, use patient-initiated therapy for symptomatic
episodes (3-day treatment regimens).
ii. If patient has three or more UTIs in 1 year and they are temporally related to sexual activity,
use postintercourse prophylaxis with trimethoprim/sulfamethoxazole single strength, cepha-
lexin 250 mg, or nitrofurantoin 50–100 mg.
iii. If patient has three or more UTIs in 1 year that are not related to sexual activity, use daily or
three times per week prophylaxis with trimethoprim 100 mg, trimethoprim/sulfamethoxazole
single strength, cephalexin 250 mg, or nitrofurantoin 50–100 mg.
6. Catheter-related UTIs
a. Short-term indwelling catheters
i. About 5% of patients develop a UTI per each day of catheterization; by 30 days, 75%–95% of
patients with an indwelling catheter will have bacteriuria.
ii. Preventive antimicrobial therapy is not recommended; it only increases the chance of selecting
out resistant organisms.
iii. Asymptomatic patients with bacteriuria should not be treated.
iv. Symptomatic patients with bacteriuria should be treated with 7 days of antibiotics if symptoms
resolve promptly and with 10–14 days of antibiotics if there is a delayed response (both dura-
tions whether or not catheter removed). Treat for 5 days with levofloxacin if the patient is not
severely ill; treat for 3 days in women 65 years and younger who have their catheters removed
and who do not have upper urinary tract symptoms.
v. The most common organisms are E. coli (21.4%), Candida spp. (21.0%), Enterococcus spp.
(14.9%), P. aeruginosa (10.0%), K. pneumoniae (7.7%), and Enterobacter spp. (4.1%).
b. Long-term indwelling catheters
i. Almost all patients will be bacteriuric with two to five organisms.
ii. Asymptomatic patients should not be treated.
iii. Symptomatic patients should be treated for a short period (7 days) to prevent resistance, and
catheter replacement may be indicated.
7. Prostatitis and epididymitis
a. Acute bacterial prostatitis
i. Primarily gram-negative organisms
ii. Therapy duration, 4 weeks
(a) Trimethoprim/sulfamethoxazole
(b) Fluoroquinolones
b. Chronic bacterial prostatitis
i. Difficult to treat
ii. Therapy duration, 1–4 months
(a) Trimethoprim/sulfamethoxazole
(b) Fluoroquinolones
8. Epididymitis
a. Older than 35 years, probably caused by enteric organisms
i. Therapy duration: 10 days to 4 weeks
ii. Antibiotics: trimethoprim/sulfamethoxazole or fluoroquinolones
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b. Younger than 35 years, probably gonococcal or chlamydial infection

i. Therapy duration: 10 days
ii. Antibiotics: ceftriaxone 250 mg intramuscularly once plus doxycycline 100 mg twice daily
III. SKIN AND SKIN STRUCTURE INFECTIONS
A. Cellulitis
1. Description
a. Acute spreading skin infection that involves primarily the deep dermis and subcutaneous fat
b. Nonelevated, poorly defined margins
c. Warmth, pain, erythema and edema, and tender lymphadenopathy
d. Malaise, fever, and chills
e. Usually, patient has had previous minor trauma, abrasions, ulcers, or surgery (could be tinea infec-
tions, psoriasis, or eczema).
f. Often, patients have impaired lymphatic drainage.
2. Microorganism: usually S. pyogenes and occasionally S. aureus (rarely other organisms)
3. Treatment: 5–10 days (may extend therapy if infection has not improved)
a. Antistaphylococcal penicillin (nafcillin, oxacillin, or dicloxacillin)
b. Penicillin G if definitively streptococcal
c. Alternatives
i. Clindamycin
ii. β-Lactamase inhibitor combinations
iii. First-generation cephalosporin
d. Treat empirically for MRSA if associated with penetrating trauma, especially from illicit drug use,
purulent drainage, or with concurrent evidence of MRSA infection elsewhere
i. Outpatient: clindamycin, trimethoprim/sulfamethoxazole (add β-lactam for Streptococcus),
doxycycline (add β-lactam for Streptococcus),
ii. Inpatient: vancomycin, linezolid, daptomycin, or telavancin
B. Erysipelas
1. Description
a. Acute spreading skin infection that involves primarily the superficial dermis
b. Spreads rapidly through the lymphatic system in the skin (patients may have impaired lymphatic
drainage)
c. Usually occurs in infants and older adults
d. Usually occurs on the legs and feet (facial erysipelas can occur, but this is less common)
e. Warmth, erythema, and pain
f. Edge of infection is elevated and sharply demarcated from the surrounding tissue.
g. Systemic signs of infection are common, but blood cultures are positive only 5% of the time.
2. Microorganism: group A Streptococcus (S. pyogenes), but occasionally groups G, C, and B are seen
3. Treatment: 5 days (may extend therapy if infection has not improved)
a. Penicillin G
b. Clindamycin
C. Necrotizing Fasciitis
1. Description
a. Acute, necrotizing cellulites that involve the subcutaneous fat and superficial fascia
b. Infection extensively alters surrounding tissue, leading to cutaneous anesthesia or gangrene.
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c. Very painful (pain out of proportion to appearance)

d. Streptococcal infection: Either spontaneous or attributable to varicella, minor trauma (cuts, burns,
and splinters), surgical procedures, or muscle strain; mixed infection generally secondary to
abdominal surgery or trauma
e. Significant systemic symptoms, including shock and organ failure
2. Microorganisms
a. S. pyogenes
b. Mixed infection with facultative and anaerobic bacteria
3. Treatment
a. Surgical debridement: Most important therapy and often repeated debridement is necessary
b. Antibiotics are not curative; given in addition to surgery (if used early, may be effective alone)
c. Empiric therapy: Vancomycin or linezolid plus piperacillin/tazobactam or a carbapenem or ceftri-
axone with metronidazole
d. Streptococcal necrotizing fasciitis: High-dose intravenous penicillin plus clindamycin
D. Varicella-Zoster Virus Immunization: Shingles Vaccine (Zostavax)

1. Characteristics
a. Zoster vaccine is a live attenuated vaccine, identical to the chicken pox vaccine (Varivax) but with
significantly more plaque-forming units of virus per vaccination.
b. Significantly decreases the number of cases and the burden of illness in vaccinated patients
(50% effective, but decreases with age). In addition, significantly decreases the incidence and
persistence of post-herpetic neuralgia (40% effective)
2. Recommendations
a. One dose: Recommended for all adults 60 years and older (regardless of chickenpox or zoster
history); indicated in adults 50 years and older
b. Not indicated for treatment of active herpes zoster infections or post-herpetic neuralgia
Patient Case
5. G.N. returns to the clinic in 6 months with no urinary symptoms, but her chief concern is now an ulcer on her
right foot. She recently returned from a vacation in Florida and thinks she might have stepped on something
while walking barefoot on the beach. Her foot is not sore but is red and swollen around the ulcer. The ulcer is
deep, and the infection may involve the underlying bone. Her medications are the same as before. Vital signs
are stable, and there is nothing significant on physical examination except for the right foot ulcer. Laboratory
values are within normal limits (serum creatinine 0.86 mg/dL). Which best describes the organisms likely to
be responsible for G.N.’s foot ulcer?
A. Multiple anaerobic organisms.
P. aeruginosa.
B.
S. aureus.
C.
D. Polymicrobial with gram-positive, gram-negative, and anaerobic organisms.
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IV. DIABETIC FOOT INFECTIONS
A. Epidemiology
1. 25% of people with diabetes develop foot infections.
2. 1 in 15 requires amputation.
B. Etiology
1. Neuropathy: Motor and autonomic
a. Mechanical or thermal injuries lead to ulcerations without patient knowledge.
b. Gait disturbances and foot deformities; maldistribution of weight on the foot
c. Diminished sweating, causing dry, cracked skin
2. Vasculopathy: Decreased lower limb perfusion
3. Immunologic defects: Cellular and humoral
C. Causative Organisms: In general, polymicrobial (average, 2.1–5.8 microorganisms)

1. S. aureus
2. Streptococcus
3. Enterococcus
4. Proteus
5. E. coli
6. Klebsiella
7. Enterobacter
8. P. aeruginosa
9. Bacteroides fragilis
10. Peptococcus
D. Therapy
1. Preventive therapy
a. Examine feet daily for calluses, blisters, trauma, and so forth.
b. Wear properly fitting shoes.
c. No barefoot walking
d. Keep feet clean and dry.
e. Have toenails cut properly.
Patient Case
6. Which is the best empiric therapy for G.N.?
A. Nafcillin 2 g intravenously every 6 hours; duration of antibiotics 6–12 weeks.
B. Tobramycin 120 mg intravenously every 12 hours plus levofloxacin 750 mg/day intravenously; duration
of antibiotics 1–2 weeks.
C. Ampicillin/sulbactam 3 g intravenously every 6 hours; duration of antibiotics 2–3 weeks.
D. Below-the-knee amputation followed by ceftriaxone 1 g intravenously every 24 hours; duration of
antibiotics 1 week.
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2. Antimicrobial therapy
a. Mild infections (and no antibiotics in the past month)
i. No MRSA risk factors: penicillinase-resistant penicillin, first-generation cephalosporin, fluo-
roquinolone, or clindamycin
ii. MRSA risk factors: doxycycline or trimethoprim/sulfamethoxazole
b. Moderate to severe infections
i. Ampicillin/sulbactam
ii. Ertapenem
iii. Cefoxitin
iv. Third-generation cephalosporin
v. Moxifloxacin alone or ciprofloxacin/levofloxacin plus clindamycin
vi. Tigecycline
vii. If risk of P. aeruginosa (uncommon in diabetic foot infections and frequently a nonpathogenic
colonizer), use piperacillin/tazobactam, ceftazidime, cefepime, or carbapenem. Risk factors
for Pseudomonas include patients soaking their feet, lack of response to nonpseudomonal
therapy, or a severe infection.
viii. If risk of MRSA, use vancomycin, linezolid, or daptomycin. Risk factors for MRSA include
history of MRSA infection or colonization, high local prevalence of MRSA, or a severe
infection.
c. Treatment duration: 1–2 weeks for mild to moderate infections and 2–3 weeks for severe infections.
Four weeks or more is necessary for osteomyelitis; after amputation treatment, duration is 2–5 days
if there is no remaining infected tissue or 4 weeks or more if infected tissue remains.
E. Surgical Therapy
1. Drainage and debridement (appropriate wound care) are very important.
2. Amputation is often necessary; if infection is discovered early, can maintain structural integrity of
the foot.
Patient Case
7. W.A. is a 55-year-old man who presents with weight loss, malaise, and severe back pain and spasms that
have progressed during the past 2 months. He has also experienced loss of sensation in his lower extremities.
Four months before this admission, he had surgery for a fractured tibia, followed by an infection treated with
unknown antibiotics. W.A. has hypertension and diverticulitis. On physical examination, he is alert and ori-
ented, with the following vital signs: temperature 99.4°F (37.4°C), heart rate 88 beats/minute, respiratory rate
14 breaths/minute, and blood pressure 130/85 mm Hg. His laboratory values are within normal limits, except
for WBC 14,300 cells/mm3, erythrocyte sedimentation rate 89 mm/hour, and C-reactive protein 12 mg/dL.
Magnetic resonance imaging shows bony destruction of lumbar vertebrae 1 and 2, which is confirmed by a
bone scan. A computed tomography–guided bone biopsy shows gram-positive cocci in clusters. Which is the
best initial therapy for W.A.?
A. Vancomycin 15 mg/kg intravenously every 12 hours; duration of antibiotics 6 weeks.
B. Nafcillin 2 g intravenously every 6 hours; duration of antibiotics 2 weeks.
C. Levofloxacin 750 mg/day orally; duration of antibiotics 6 weeks.
D. Ampicillin/sulbactam 3 g intravenously every 6 hours; duration of antibiotics 2 weeks.
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V. OSTEOMYELITIS
A. Introduction
1. Infection of the bone with subsequent bone destruction
2. Around 20 cases per 100,000 people
B. Characteristics (Table 10)
Table 10. Characteristics of Osteomyelitis

Hematogenous Spread Contiguous Spread Vascular Insufficiency
Definition Spread of bacteria through the blood- Spread of bacteria from an Infection results from
stream from a distant site adjacent tissue infection or insufficient blood supply
by direct inoculation to fight the bacteria
Patient Children (<16 years): femur, tibia, Adults (25–50 years): Adults (>50 years)
population humerus femur, tibia, skull
Adult: vertebrae
Predisposing Bacteremia (e.g., IV catheters, IVDU, Open reduction of fractures Diabetes
factors skin infections, URI) Gunshot wound PVD
Sickle cell anemia Dental or sinus infections Post-CABG (sternum)
Soft tissue infections
Common Usually monomicrobial Usually mixed infection: Usually polymicrobial:
pathogens Children: Staphylococcus aureus S. aureus (60%), S. aureus, S. epidermidis,
(60%–90%), Staphylococcus epidermidis, S. epidermidis, Streptococcus
Streptococcus pyogenes, Streptococcus Streptococcus Gram-negative bacilli
pneumoniae, Haemophilus influenzae, Gram-negative bacilli: Anaerobic (Bacteroides
Pseudomonas aeruginosa, Enterobacter, P. aeruginosa fragilis group)
Escherichia coli (all <5%) (foot punctures), Proteus,
Klebsiella, E. coli Infected prosthesis:
Adults: S. aureus and gram-negative S. aureus, S. epidermidis
bacilli Anaerobic (human bites,
Sickle cell anemia: Salmonella (67%), decubitus ulcers)
S. aureus, S. pneumoniae
IV drug users: P. aeruginosa
CABG = coronary artery bypass graft; IV = intravenous; IVDU = intravenous drug use; PVD = pulmonary vascular disease; URI = upper
respiratory infection.
C. Clinical Presentation
1. Signs and symptoms
a. Fever and chills
b. Localized pain, tenderness, and swelling
c. Neurologic symptoms if spinal cord compression
2. Laboratory tests
a. Elevated WBC
b. Elevated erythrocyte sedimentation rate
c. Elevated C-reactive protein
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3. Diagnostic tests
a. Radiographic tests: Positive results lag behind infectious process.
b. Computed tomography and magnetic resonance imaging scans
c. Radionuclide imaging: Positive as soon as 24–48 hours after infectious process begins.
D. Empiric Therapy
1. Neonates younger than 1 month
a. Nafcillin plus cefotaxime or
b. Nafcillin plus an aminoglycoside
2. Infants (1–36 months)
a. Cefuroxime
b. Ceftriaxone
c. Nafcillin plus cefotaxime
3. Pediatrics (older than 3 years)
a. Nafcillin
b. Cefazolin
c. Clindamycin
4. Adults
a. Nafcillin, cefazolin, or vancomycin
b. Choose additional antibiotics according to patient-specific characteristics.
5. Patients with sickle cell anemia: Ceftriaxone/cefotaxime or ciprofloxacin/levofloxacin (no studies
assessing best empiric therapy)
6. Prosthetic joint infections
a. Debridement and retention of prosthesis or one-stage exchange of prosthesis
i. Staphylococcal: Pathogen-specific intravenous therapy plus rifampin 350–400 mg twice daily
for 2–6 weeks, followed by rifampin plus ciprofloxacin or levofloxacin for 3 months (hip,
elbow, shoulder, ankle prosthesis) or 6 months (knee prosthesis)
ii. Nonstaphylococcal: Pathogen-specific intravenous (or highly bioavailable oral) therapy for
4–6 weeks, followed by indefinite oral suppression therapy
b. Resection of prosthesis with or without planned reimplantation or amputation
i. Pathogen-specific intravenous (or highly bioavailable oral) therapy for 4–6 weeks
ii. Only 24–48 hours of antibiotic therapy after amputation if all infected tissue is removed
E. Therapy Length
1. Acute osteomyelitis: 4–6 weeks
2. Chronic osteomyelitis: 6–8 weeks of parenteral therapy and 3–12 months of oral therapy
F. Criteria for Effective Oral Therapy for Osteomyelitis

1. Adherence
2. Identified organism that is highly susceptible to the oral antibiotic used
3. C-reactive protein less than 2.0 mg/dL
4. Adequate surgical debridement
5. Resolving clinical course
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VI. CENTRAL NERVOUS SYSTEM (CNS) INFECTIONS
A. Meningitis: Introduction
1. Incidence: About 8.6 cases per 100,000 people
2. Occurs more often in male than in female patients
3. More common in children
B. Microbiology (Table 11)

1. Bacterial (septic meningitis)
Table 11. Bacterial Etiology of Meningitis, Based on Age

Age Most Likely Organisms Less Common Organisms
<1 month (newborns) Streptococcus agalactiae Escherichia coli
Listeria monocytogenes Klebsiella spp.
Streptococcus pneumoniae Herpes simplex type 2
Neisseria meningitidis
1–23 months S. pneumoniae Viruses
N. meningitidis E. coli
Haemophilus influenzae
Streptococcus agalactiae
2–50 years N. meningitidis H. influenzae
S. pneumoniae Viruses
>50 years S. pneumoniae L. monocytogenes, Streptococcus agalactiae,
N. meningitidis aerobic gram-negative bacilli, viruses
H. influenzae
2. Other causes (aseptic meningitis)

a. Viral
b. Fungal
c. Parasitic
d. Tubercular
e. Syphilis
f. Drugs (e.g., trimethoprim/sulfamethoxazole, ibuprofen)
C. Predisposing Factors
1. Head trauma
2. Immunosuppression
3. CNS shunts
4. Cerebrospinal fluid (CSF) fistula or leak
5. Neurosurgical patients
6. Alcoholism
7. Local infections
a. Sinusitis
b. Otitis media
c. Pharyngitis
d. Bacterial pneumonia
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8. Splenectomized patients
9. Sickle cell disease
10. Congenital defects
D. Clinical Presentation
1. Symptoms
a. Fever, chills
b. Headache, backache, nuchal rigidity, mental status changes, photophobia
c. Nausea, vomiting, anorexia, poor feeding habits (infants)
d. Petechiae or purpura (Neisseria meningitidis meningitis)
2. Physical signs
a. Brudzinski sign
b. Kernig sign
c. Bulging fontanel
E. Diagnosis
1. History and physical examination
2. Lumbar puncture
a. Elevated opening pressure
b. Composition in bacterial meningitis (Table 12)
Table 12. CSF Changes in Bacterial Meningitis

Component Normal CSF Bacterial Meningitis
Glucose 30–70 mg/dL <50 mg/dL
(2/3 peripheral) (≤0.4 CSF/blood)
Protein <50 mg/dL >150 mg/dL
WBC <5 cells/mm3 >1200 cells/mm3
pH 7.3 7.1
Lactic acid <14 mg/dL >35 mg/dL
CSF = cerebrospinal fluid; WBC = white blood cell count.
c. CSF stains and studies

i. Gram stain (microorganisms): Helps identify organism in 60%–90% of cases
ii. Latex agglutination: High sensitivity, 50%–100%, for common organisms
(a) Not recommended routinely
(b) Most useful in patients pretreated with antibiotics with subsequent negative CSF Gram
stains and cultures
iii. Acid-fast staining (tubercular meningitis)
iv. India ink test (Cryptococcus)
v. Cryptococcal antigen
vi. Herpes simplex virus polymerase chain reaction
3. Laboratory findings
a. Elevated WBC with a left shift
b. CSF Gram stain
c. CSF cultures (positive in 75%–80% of bacterial meningitis cases)
d. Blood cultures (±)
e. C-reactive protein concentrations: High negative predictive value
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Patient Case
8. D.M. is a 21-year-old university student who presents to the emergency department with the worst headache
of his life. During the past few days, he has felt slightly ill but has been able to go to class regularly and eat
and drink adequately. This morning, he awoke with a terrible headache and pain whenever he moved his
neck. He has no significant medical history and takes no medications. He cannot remember the last time he
received a vaccination. On physical examination, he is in extreme pain (10/10) with the following vital signs:
temperature 102.4°F (39.1°C), heart rate 110 beats/minute, respiratory rate 18 breaths/minute, and blood pres-
sure 130/75 mm Hg. His laboratory values are within normal limits, except for WBC 22,500 cells/mm3
(82 polymorphonuclear leukocytes, 11 band neutrophils, 5 lymphocytes, and 2 monocytes). A computed
tomography scan of the head is normal, so a lumbar puncture is performed with the following results: glucose
44 mg/dL (peripheral, 110), protein 220 mg/dL, and WBC 800 cells/mm3 (85% neutrophils, 15% lympho-
cytes). Gram staining shows abundant gram-negative cocci. Which is the best empiric therapy for D.M.?
A. Penicillin G 4 million units intravenously every 4 hours plus dexamethasone 4 mg intravenously every
6 hours.
B. Ceftriaxone 2 g intravenously every 12 hours.
C. Ceftriaxone 2 g intravenously every 12 hours plus dexamethasone 4 mg intravenously every 6 hours.
D. Ceftriaxone 2 g intravenously every 12 hours plus vancomycin 1000 mg intravenously every 12 hours.
F. Empiric Therapy
1. Neonates younger than 1 month
a. Ampicillin plus aminoglycoside or
b. Ampicillin plus cefotaxime
2. Infants (1–23 months): Third-generation cephalosporin (cefotaxime or ceftriaxone) plus vancomycin
3. Children and adults (2–50 years): Third-generation cephalosporin (cefotaxime or ceftriaxone) plus
vancomycin
4. Older adults (50 years and older): Third-generation cephalosporin (cefotaxime or ceftriaxone) plus
vancomycin plus ampicillin
5. Penetrating head trauma, neurosurgery, or CSF shunt: Vancomycin plus cefepime, ceftazidime, or
meropenem
G. Therapy for Common Pathogens

1. S. pneumoniae
a. A minimum inhibitory concentration (MIC) of 0.1 mcg/mL or less
i. Penicillin G 4 million units intravenously every 4 hours
ii. Ampicillin 2 g intravenously every 4 hours
iii. Alternative: Third-generation cephalosporin or chloramphenicol
b. An MIC 0.1–1.0 mcg/mL
i. Third-generation cephalosporin
ii. Alternative: cefepime or meropenem
c. An MIC 2.0 mcg/mL or greater
i. Vancomycin plus a third-generation cephalosporin
ii. Alternative: moxifloxacin
2. N. meningitidis
a. An MIC less than 0.1 mcg/mL
i. Penicillin G 4 million units intravenously every 4 hours
ii. Ampicillin 2 g intravenously every 4 hours
iii. Alternative: third-generation cephalosporin or chloramphenicol
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b. An MIC 0.1–1.0 mcg/mL

ii. Alternative: chloramphenicol, fluoroquinolone, or meropenem
3. H. influenzae
a. β-Lactamase negative
i. Ampicillin 2 g intravenously every 4 hours
ii. Alternative: third-generation cephalosporin, cefepime, chloramphenicol, or fluoroquinolone
b. β-Lactamase positive
ii. Alternative: cefepime, chloramphenicol, or fluoroquinolone
4. Streptococcus agalactiae
a. Penicillin G 4 million units intravenously every 4 hours
b. Ampicillin 2 g intravenously every 4 hours
c. Alternative: third-generation cephalosporin
5. Listeria monocytogenes
a. Penicillin G 4 million units intravenously every 4 hours
b. Ampicillin 2 g intravenously every 4 hours
c. Alternative: trimethoprim/sulfamethoxazole or meropenem
H. Therapy Length: Based on clinical experience, not on clinical data

1. N. meningitidis: 7 days
2. H. influenzae: 7 days
3. S. pneumoniae: 10–14 days
I. Adjunctive Corticosteroid Therapy

1. Risks and benefits
a. Significantly less hearing loss and other neurologic sequelae in children receiving dexamethasone
for H. influenzae meningitis
b. Significantly improved outcomes, including decreased mortality, in adults receiving dexametha-
sone for S. pneumoniae meningitis
c. May decrease antibiotic penetration (decreased penetration of vancomycin in animals after
dexamethasone)
2. Dose and administration
a. Give corticosteroids 10–20 minutes before or at same time as antibiotics.
b. Dexamethasone 0.15 mg/kg every 6 hours for 2–4 days
c. Use in children with H. influenzae meningitis or in adults with pneumococcal meningitis; however,
may need to initiate before knowing specific causative bacteria
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Patient Case
9. After D.M.’s diagnosis, there is concern about prophylaxis. Which is the best recommendation for meningitis
prophylaxis?
A. The health care providers in close contact with D.M. should receive rifampin 600 mg every 12 hours
for four doses.
B. Everyone in D.M.’s dormitory and in all of his classes should receive rifampin 600 mg/day for 4 days.
C. Everyone in the emergency department at the time of D.M.’s presentation should receive the
meningococcal conjugate vaccine.
D. Everyone in the emergency department at the time of D.M.’s presentation should receive rifampin
600 mg every 12 hours for four doses.
J. Prophylaxis
1. S. pneumoniae
a. PCV: 13 valent
i. All children younger than 23 months
ii. Children 24–59 months with high-risk status
(a) Certain chronic diseases
(b) Alaska Native or American Indian
(c) African American
(d) Day care attendees
iii. Adults 65 years or older
iv. Adults with asplenia or who are immunocompromised
b. PPSV23 valent: Give to those at risk (see patient groups in Pneumonia section above).
2. N. meningitidis
a. Chemoprophylaxis: For close contacts (household or day care) and exposure to oral secretions of
index case
i. Rifampin
(a) Adults: 600 mg every 12 hours × 4 doses
(b) Children: 10 mg/kg every 12 hours × 4 doses
(c) Infants (younger than 1 month): 5 mg/kg every 12 hours × 4 doses
ii. Ciprofloxacin 500 mg orally × 1 (adults only)
iii. Ceftriaxone 125–250 mg intramuscularly × 1
b. Meningococcal polysaccharide vaccine (Menomune) and meningococcal conjugate vaccine
(Menactra, Menveo) (both lack serogroup B)
i. Indications (use Menactra or Menveo unless patient is older than 55 years)
(a) Young adolescents (11–12 years)
(b) College freshmen living in dormitories (4 cases per 100,000 per year, especially freshmen
living in dormitories)
(c) Military recruits
(d) Travel to “meningitis belt” of Africa and Asia, Saudi Arabia for Islamic Hajj pilgrimage
(e) People with asplenia (anatomic or functional)
(f) People with terminal complement component deficiencies
(g) Outbreaks of meningococcal disease
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ii. Booster dose

(a) Adolescents: Recommended at 16 years of age if they received a first dose at age 11–12
years or at 5 years after the first dose, up to age 21 years, to those who first received the
vaccine at age 13–15 years
(b) Asplenic or immunocompromised patients: Recommended in 2 months and then every
5 years
3. H. influenzae
a. Chemoprophylaxis: For everyone in households with unvaccinated children
i. Adults: Rifampin 600 mg/day for 4 days
ii. Children (1 month to 12 years): Rifampin 20 mg/kg/day for 4 days
iii. Infants younger than 1 month: Rifampin 10 mg/kg/day for 4 days
b. H. influenzae type B polysaccharide vaccine
i. All children
ii. Indications regardless of age
(a) Asplenia (anatomic or functional)
(b) Sickle cell disease
(c) Hodgkin disease
(d) Hematologic neoplasms
(e) Solid organ transplantation
(f) Severely immunocompromised (non–HIV related)
iii. Consider for people with HIV infection.
K. Brain Abscess
1. Pathophysiology
a. Direct extension or retrograde septic phlebitis from otitis media, mastoiditis, sinusitis, and facial
cellulitis
b. Hematogenous: Particularly lung abscess or infective endocarditis: 3%–20% have no detectable
focus.
a. Expanding intracranial mass lesion: Focal neurologic deficits
b. Headache
c. Fever
d. Seizures
e. Mortality is about 50%.
3. Microbiology
a. Usually polymicrobial
b. Streptococcus spp. in 50%–60%
c. Anaerobes in about 40%
4. Therapy
a. Incision and drainage: By craniotomy or stereotaxic needle aspiration
b. Suggested empiric regimens based on source of infection
i. Otitis media or mastoiditis: metronidazole plus third-generation cephalosporin
ii. Sinusitis: metronidazole plus third-generation cephalosporin
iii. Dental sepsis: penicillin plus metronidazole
iv. Trauma or neurosurgery: vancomycin plus third-generation cephalosporin
v. Lung abscess, empyema: penicillin plus metronidazole plus sulfonamide
vi. Unknown: vancomycin plus metronidazole plus third-generation cephalosporin
c. Corticosteroids if elevated intracranial pressure
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Patient Case
10. T.S. is a 48-year-old man who presents to the emergency department with fever, chills, nausea and vomiting,
anorexia, lymphangitis in his right hand, and lower back pain. He has no significant medical history except
for kidney stones 4 years ago. He has no known drug allergies. He is homeless and was an intravenous drug
abuser (heroin) for the past year but quit 2 weeks ago. On physical examination, he is alert and oriented, with
the following vital signs: temperature 100.8°F (38°C), heart rate 114 beats/minute, respiratory rate 12 breaths/
minute, and blood pressure 127/78 mm Hg. He has a faint systolic ejection murmur, and his right hand is
erythematous and swollen. His laboratory values are all within normal limits. He had an HIV test 1 year ago,
which was negative. One blood culture was obtained that later grew MSSA. Two more cultures were obtained
that are now growing gram-positive cocci in clusters. A transesophageal echocardiogram shows vegetation
on the mitral valve. Which is the best therapeutic regimen for T.S.?
A. Nafcillin intravenous therapy; antibiotic duration 2 weeks.
B. Nafcillin intravenously plus rifampin therapy; antibiotic duration 6 weeks or longer.
C. Nafcillin intravenously plus gentamicin intravenous therapy; antibiotic duration 2 weeks of both
antibiotics.
D. Nafcillin intravenously plus gentamicin; antibiotic duration 6 weeks (nafcillin) with gentamicin for the
first 3–5 days.
VII. ENDOCARDITIS
A. Introduction
1. Infection of the heart valves or other endocardial tissue
2. Platelet-fibrin complex becomes infected with microorganisms: vegetation
3. Main risk factors include mitral valve prolapse, prosthetic valves, and intravenous drug abuse.
4. Three or four cases per 100,000 people per year
B. Presentation and Clinical Findings

a. Fever: Low grade and remittent
b. Cutaneous manifestations (50% of patients): petechiae (including conjunctival), Janeway lesions,
splinter hemorrhage
c. Cardiac murmur (90% of patients)
d. Arthralgias, myalgias, low back pain, arthritis
e. Fatigue, anorexia, weight loss, night sweats
2. Laboratory findings
a. Anemia: normochromic, normocytic
b. Leukocytosis
c. Elevated erythrocyte sedimentation rate and C-reactive protein
d. Positive blood culture in 78%–95% of patients
3. Complications
a. Congestive heart failure: 38%–60% of patients
b. Emboli: 22%–43% of patients
c. Mycotic aneurysm: 5%–10% of patients
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C. Microbiology (Table 13)

1. Three to five blood cultures of at least 10 mL each should be drawn during the first 24–48 hours.
2. Empiric therapy should be initiated only in acutely ill patients. In these patients, three blood samples
should be drawn during a 15- to 20-minute period before antibiotics are initiated.
Table 13. Incidence of Microorganisms in Endocarditis

Organism Incidence (%)
Streptococcus 50
Staphylococcus aureus 25
Enterococcus 8
Coagulase-negative Staphylococcus 7
Gram-negative bacilli 6
Candida albicans 2
D. Treatment (Table 14)
Table 14. Treatment Recommendation for Endocarditis

Length of Therapy (weeks)
Organism Recommended Therapy Native Valve Prosthetic Valve
Viridans streptococci PCN G 4 —
(with PCN MIC PCN G + gentamicin 2 6a
≤0.12 mcg/mL) Ceftriaxone 4 —
Ceftriaxone + gentamicin 2 6a
Vancomycin 4 6
Viridans streptococci PCN G + gentamicin 4b 6
(with PCN MIC Ceftriaxone + gentamicin 4b
6
>0.12 mcg/mL) Vancomycin 4 6
Staphylococcus, Oxacillin or nafcillin 6 ≥6b
methicillin sensitive ± Gentamicin for 3–5 days
Plus rifampin in prosthetic valves
Cefazolin 6 ≥6b
± Gentamicin for 3–5 days
Vancomycin (only if severe PCN allergy) 6 ≥6b
Staphylococcus, Vancomycin 6 ≥6b
methicillin resistant Plus rifampin and gentamicin in prosthetic
valves
Daptomycin (not for prosthetic valves)
Enterococcus PCN G or ampicillin + gentamicin or 4–6 6
streptomycin
Vancomycin + gentamicin or streptomycin 6 6
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Table 14. Treatment Recommendation for Endocarditis (continued)

Length of Therapy (weeks)
Organism Recommended Therapy Native Valve Prosthetic Valve
Enterococcus, PCN resistant Ampicillin/sulbactam or vancomycin + 6 6
gentamicin
Enterococcus faecium, Linezolid ≥8 ≥8
PCN, aminoglycoside, and Quinupristin/dalfopristin ≥8 ≥8
vancomycin resistant
Enterococcus faecalis, Imipenem/cilastatin + ampicillin ≥8 ≥8
PCN, aminoglycoside, and Ceftriaxone + ampicillin ≥8 ≥8
vancomycin resistant
HACEK group Ceftriaxone 4 6
Ampicillin/sulbactam 4 6
Fluoroquinolone (ciprofloxacin, levofloxacin, 4 6
moxifloxacin)
Gentamicin can be added for 2 weeks if creatinine clearance is greater than 30 mL/minute.
a
Gentamicin for 2 weeks.

b
HACEK = Haemophilus, Actinobacillus Cardiobacterium, Eikenella, Kingella; MIC = minimum inhibitory concentration; PCN = penicillin.
E. Prophylaxis (Table 15)
Table 15. Endocarditis Prophylaxis

Conditions in Which Prophylaxis Is Necessary Dental Procedures That Require Prophylaxis
Prosthetic cardiac valves including bioprosthetic and Any dental procedure that involves the gingival
homograft valves tissues or periapical region of a tooth and for
Previous bacterial endocarditis procedures that perforate the oral mucosa
Congenital heart disease

Unrepaired cyanotic congenital heart disease Other Procedures That Require Prophylaxis
Respiratory tract
Completely repaired congenital heart defect with
prosthetic material or device, during the first 6 months Tonsillectomy or adenoidectomy
after the procedure Surgical operations that involve an incision or
Repaired congenital heart disease with residual defects biopsy of the respiratory mucosa
adjacent to or at the site of a prosthetic patch or device
Cardiac transplant recipients who develop cardiac
valvulopathy
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F. Recommended Prophylaxis for Dental or Respiratory Tract Procedures (Table 16)
Table 16. Prophylaxis for Dental or Respiratory Tract Procedures

Situation Agent Regimen
Standard general prophylaxis Amoxicillin Adults: 2 g; children: 50 mg/kg 1 hour before procedure
Unable to take oral medications Ampicillin Adults: 2 g IM/IV; children: 50 mg/kg IM/IV within
30 minutes before procedure
Cefazolin or Adults: 1 g IM/IV; children: 50 mg/kg IM/IV within
ceftriaxone 30 minutes before procedure
Allergic to penicillin Clindamycin Adults: 600 mg; children: 20 mg/kg 1 hour before
procedure
Cephalexin Adults: 2 g; children: 50 mg/kg 1 hour before procedure
Azithromycin or Adults: 500 mg; children: 15 mg/kg 1 hour before
clarithromycin procedure
Allergic to penicillin and unable Clindamycin Adults: 600 mg; children: 20 mg/kg IV within 30 minutes
to take oral medications before procedure
Cefazolin or Adults: 1 g IM/IV; children: 50 mg/kg IM/IV within
ceftriaxone 30 minutes before procedure
IM = intramuscularly; IV = intravenously.
Patient Case
11. Six months after treatment of his endocarditis, T.S. is visiting his dentist for a tooth extraction. Which anti-
biotic is best for prophylaxis?
A. Tooth extractions do not require endocarditis prophylaxis.
B. Administer amoxicillin 2 g 1 hour before the extraction.
C. Administer amoxicillin 3 g 1 hour before the extraction and 1.5 g 6 hours for four doses after the
extraction.
D. T.S. is not at increased risk of endocarditis and does not need prophylactic antibiotics.
VIII. PERITONITIS AND INTRA-ABDOMINAL INFECTIONS
A. Introduction
1. Definition: Inflammation of the peritoneum (serous membrane lining the abdominal cavity)
2. Types
a. Primary: Spontaneous or idiopathic, no primary focus of infection
b. Secondary: Occurs secondary to an abdominal process
B. Primary Peritonitis
1. Etiology
a. Alcoholic cirrhosis and ascites (peritonitis occurs in 10% of these patients)
b. Other: postnecrotic cirrhosis, chronic active hepatitis, acute viral hepatitis, congestive heart fail-
ure, systemic lupus erythematous, metastatic malignancy (common underlying problem is ascites)
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2. Microbiology
a. E. coli
b. K. pneumoniae
c. S. pneumoniae
d. Group A Streptococcus
3. Pathogenesis
a. Hematogenous: Portosystemic shunting increases bacteria in the blood, infecting ascitic collection.
b. Lymphogenous
c. Transmural through the intact gut wall from the lumen
d. Vaginally through the fallopian tubes
4. Clinical manifestations and diagnosis
a. Fever
b. Abdominal pain
c. Nausea, vomiting, diarrhea
d. Diffuse abdominal tenderness, rebound tenderness, hypoactive or no bowel sounds
e. Ascitic fluid
i. Protein: Low because of hypoalbuminemia or dilution with transudate fluid from the portal
system
ii. WBC more than 300 cells/mm3 (85% have more than 1000 cells/mm3), primarily granulocytes
iii. pH: Less than 7.35
iv. Lactic dehydrogenase: More than 25 mg/dL
v. Gram stain: 60%–80% are negative, but diagnostic if it is positive
C. Secondary Peritonitis
1. Etiology
a. Injuries to the gastrointestinal tract, including
i. Peptic ulcer perforation
ii. Perforation of a gastrointestinal organ
iii. Appendicitis
iv. Endometritis secondary to intrauterine device
v. Bile peritonitis
vi. Pancreatitis
vii. Operative contamination
viii. Diverticulitis
ix. Intestinal neoplasms
x. Secondary to peritoneal dialysis
2. Microbiology of intra-abdominal infections
a. Stomach and proximal small intestine: aerobic and facultative gram-positive and gram-negative
organisms
b. Ileum: E. coli, Enterococcus, anaerobes
c. Large intestine: obligate anaerobes (i.e., Bacteroides, Clostridium perfringens), aerobic and fac-
ultative gram-positive and gram-negative organisms (i.e., E. coli, Streptococcus, Enterococcus,
Klebsiella, Proteus, Enterobacter)
3. Clinical manifestations and diagnosis
a. Fever, tachycardia
b. Elevated WBC
c. Abdominal pain aggravated by motion, rebound tenderness
d. Bowel paralysis
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e. Pain with breathing

f. Decreased renal perfusion
g. Ascitic fluid
i. Protein: High (more than 3 g/dL); exudate fluid
ii. WBCs: Many, primarily granulocytes
D. Therapy
1. Therapy or prophylaxis should be limited in:
a. Bowel injuries caused by trauma that are repaired within 12 hours (treat for less than 24 hours)
b. Intraoperative contamination by enteric contents (treat for less than 24 hours)
c. Perforations of the stomach, duodenum, and proximal jejunum (unless patient is on antacid therapy
or has malignancy) (prophylactic antibiotics for less than 24 hours)
d. Acute appendicitis without evidence of perforation, abscess, or peritonitis (treat for less than 24 hours)
2. Mild to moderate community-acquired infection
a. Cefoxitin
b. Cefazolin, cefuroxime, ceftriaxone, or cefotaxime plus metronidazole
c. Ticarcillin/clavulanate
d. Ertapenem
e. Moxifloxacin
f. Ciprofloxacin or levofloxacin plus metronidazole
g. Tigecycline
3. High-risk or severe community-acquired or health care–acquired infection
a. Piperacillin/tazobactam
b. Ceftazidime or cefepime plus metronidazole
c. Imipenem/cilastatin, meropenem, or doripenem
d. Ciprofloxacin or levofloxacin plus metronidazole (not for health care–acquired infections)
e. Aminoglycoside when extended-spectrum β-lactamase–producing Enterobacteriaceae or P. aeru-
ginosa is of concern (health care–acquired infections only)
f. Vancomycin for MRSA (health care–acquired infections only)
4. Therapy duration: 4–7 days (unless source control is difficult)
IX. CLOSTRIDIUM DIFFICILE INFECTION
A. Introduction
1. Clostridium difficile is transmitted by the fecal-oral route.
2. Overgrowth in the gastrointestinal tract occurs after antibiotic therapy.
3. Risk factors: hospital stays, medical comorbidities, extremes of age, immunodeficiency states, advanc-
ing age, use of broad-spectrum antibiotics for extended periods
4. Production of endotoxins A and B causes pathogenesis.
5. Symptoms: watery diarrhea, abdominal pain, leukocytosis, gastrointestinal tract complications
6. New strain (BI/NAP1) produces more enterotoxin, produces binary toxin, has increased sporulation
capacity, and is resistant to fluoroquinolones. Increased risk of metronidazole failure, morbidity, and
mortality
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B. Therapy
1. Initial episode and first recurrence
a. Metronidazole 500 mg orally (or intravenously) three times a day for 10–14 days
i. For mild to moderate episodes
ii. Oral is the preferred route.
b. Vancomycin 125 mg orally four times a day for 10–14 days, for severe episodes.
c. Fidaxomicin 200 mg orally twice daily for 10 days: No difference in clinical cure rates compared
with vancomycin but lower incidence of recurrence
2. Second and third recurrences
a. Consider fidaxomicin if not already given.
b. Can consider higher doses of vancomycin (500 mg orally four times a day)
c. Taper therapy: Vancomycin 125 mg orally four times a day for 14 days, twice daily for 7 days, and
daily for 7 days
d. Pulse therapy: Recommended vancomycin course of therapy for initial episode (for 10–14 days),
followed by vancomycin every other day for 8 days, and then every 3 days for 15 days
e. Consider rifaximin 400 mg twice daily for 14 days or nitazoxanide 500 mg twice daily for 10 days.
Patient Case
12. You are a pharmacist who works closely with the surgery department to optimize therapy for patients under-
going surgical procedures at your institution. The surgeons provide you with principles of surgical prophy-
laxis that they believe are appropriate. Which is the best practice for optimizing surgical prophylaxis?
A. Antibiotics should be redosed for extended surgical procedures; redose if the surgery lasts longer than
4 hours or involves considerable blood loss.
B. All patients should be given antibiotics for 24 hours after the procedure; this will optimize prophylaxis.
C. Preoperative antibiotics can be given up to 4 hours before the incision; this will make giving the
antibiotics logistically easier.
D. Vancomycin should be the antibiotic of choice for surgical wound prophylaxis because of its long
half-life and activity against MRSA.
X. MEDICAL AND SURGICAL PROPHYLAXIS
A. Introduction
1. Prophylaxis: Administering the putative agent before bacterial contamination occurs
2. Early therapy: Immediate or prompt institution of therapy as soon as the patient presents; usually,
contamination or infection will have preceded the initiation of therapy (e.g., dirty wounds).
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B. Classification of Surgical Procedures (Table 17)
Table 17. Classification of Surgical Procedures

Surgical Procedure Infection Rate (%)
Clean: No entry is made in the respiratory, gastrointestinal, or genitourinary tracts or in 1–4
the oropharyngeal cavity
In general, it is elective with no break in technique and no inflammation encountered
Clean contaminated: Entry in the respiratory, gastrointestinal, genitourinary, or biliary 5–15
tracts or oropharyngeal cavity without unusual contamination
Includes clean procedures with a minor break in technique
Contaminated: Includes fresh traumatic wounds, gross spillage from the gastrointestinal 16–25
tract (without a mechanical bowel preparation), a major break in technique, or incisions
encountering acute, nonpurulent inflammation
Dirty: Includes procedures involving old traumatic wounds, perforated viscera, or 30–100
clinically evident infection
C. Risk Factors for Postoperative Wound Infections

1. Bacterial contamination
a. Exogenous sources: Flaw in aseptic technique
b. Endogenous sources
i. Most important except in clean procedures
ii. Patient flora causes infection.
2. Host resistance
a. Extremes of age
b. Nutrition (i.e., malnourished patients)
c. Obesity
d. Diabetes mellitus (decreased wound healing and increased risk of infection)
e. Immunocompromised
f. Hypoxemia
g. Remote infection
h. Presence of foreign body
i. Healthy person tolerates inoculum of 105.
ii. In presence of foreign body, need only 102
D. Indications for Surgical Prophylaxis

1. Common postoperative infection with low morbidity
2. Uncommon postoperative infection with significant morbidity and mortality
E. Principles of Prophylaxis (Figure 1; Tables 18 and 19)

1. Timing: Antibiotics must be present in the tissues at the time of bacterial contamination (incision) and
throughout the operative period; “on-call” dosing is not acceptable.
a. Administering antibiotics earlier than immediately preoperatively (within 60 minutes before inci-
sion or 60–120 minutes if using vancomycin or a fluoroquinolone) is unnecessary.
b. Initiating antibiotics postoperatively is no more effective than administering no prophylaxis.
c. Antibiotics should be redosed for extended surgical procedures.
d. Redose if the surgery lasts longer than 4 hours (or more than 2 half-lives of the antibiotic) or
involves considerable blood loss.
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Figure 1. Principles of prophylaxis.

Information from Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgi-
cal-wound infection. N Engl J Med 1992;326:281-6.
Table 18. Temporal Relation Between the Administration of Prophylactic Antibiotics and Rates of Surgical Wound
Infection
Time of No. of No. (%) of Relative Risk (95% CI) Odds Ratio (95% CI)
Administrationa Patients Infections
Early 369 14 (3.8) 6.7 (2.9–14.7) 4.3 (1.8–10.4)
Preoperative 1708 10 (0.59) 1.0
Perioperative 282 4 (1.4) 2.4 (0.9–7.9) 2.1 (0.6–7.4)
Postoperative 488 16 (3.3) 5.8 (2.6–12.3) 5.8 (2.4–13.8)
All 2847 44 (1.5) — —
For administering antibiotics; “early” denotes 2–24 hours before the incision, “preoperative” 0–2 hours before the incision, “perioperative”
a
within 3 hours after the incision, and “postoperative” more than 3 hours after the incision.
CI = confidence interval.
Table 19. Duration of Surgical Procedure and Risk of Infection

Duration of Surgical Infections/Standard Infections/Cefoxitin
Procedure Infections/Total Patients (%) Regimen Patients (%) Regimen Patients (%)
<3 hours 0/46 0/29 0/17
≥3 hours to ≤4 hours 4/46 (8.7) 2/21 (9.5) 2/25 (8.0)
>4 hours 5/27 (18.5) 0/13 5/14 (35.7)
Information from Kaiser AB, Herrington JL Jr, Jacobs JK, et al. Cefoxitin versus erythromycin, neomycin, and cefazolin in colorectal opera-
tions. Importance of the duration of the surgical procedure. Ann Surg 1983;98:525-30.
2. Duration
a. Most procedures, including gastrointestinal, orthopedic, and gynecologic procedures, require anti-
biotics only as long as the patient is in the operating room; administration beyond surgical closure
is not necessary.
b. Cardiac procedures may require 24 hours of antibiotics after surgery.
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3. Spectrum
a. Need only activity against skin flora unless the operation violates a hollow viscus mucosa
b. Gastrointestinal, genitourinary, hepatobiliary, and some pulmonary operations require additional
antibiotics.
c. Colorectal surgery is one procedure in which broad-spectrum aerobic and anaerobic coverage is
most effective.
d. Attempt to avoid a drug that may be needed for therapy if infection occurs.
4. Adverse reactions and bacterial resistance
a. Antibiotic prophylaxis should not cause greater morbidity than the infection it prevents.
b. Overuse may lead to resistance, which could prevent further use of the antibiotic for surgical pro-
phylaxis or other infections (duration of administration is an important factor).
5. Cost
a. Prophylaxis can account for a substantial portion of the antibiotic budget.
b. Must be weighed against the cost of treating one person with a postoperative infection
F. Antibiotic Prophylaxis in Specific Surgical Procedures

1. Gastrointestinal
a. Gastric or duodenal
i. Because of acidity, little normal flora
ii. Rates of intragastric organisms and postoperative infections increase with increasing pH.
iii. Indicated for morbid obesity, esophageal obstruction, decreased gastric acidity, or decreased
gastrointestinal motility
iv. Recommendation: Cefazolin 2 g before induction
b. Biliary
i. Biliary tract normally has no organisms.
ii. Indicated for high-risk patients. (Often, intraoperative cholangiography shows unexpected
common duct stones, so some studies recommend using antibiotics in all biliary surgery.
In addition, studies have shown an increase in infection rates without risk factors.)
(a) Acute cholecystitis
(b) Obstructive jaundice
(c) Common duct stones
(d) Age older than 70 years
iii. Recommendation: Cefazolin, cefoxitin, cefotetan, or ceftriaxone 2 g or ampicillin/sulbactam
3 g before induction
c. Appendectomy
i. Acutely inflamed or normal appendix: Less than 10% risk
ii. Evidence of perforation: More than 50% risk (treatment necessary)
iii. If perforated appendix, treat for 3–7 days
iv. Recommendation: Cefoxitin or cefotetan 2 g (or cefazolin plus metronidazole) before induction
d. Colorectal
i. A 30%–77% infection rate without antibiotics
ii. One of the few surgical procedures in which coverage for aerobes and anaerobes has proved
most effective
iii. Preoperative antibiotics
(a) Combined oral and parenteral regimens may be better than parenteral regimens alone.
(b) Oral regimens are inexpensive; however, some data suggest they are less effective when
used alone (without parenteral agents), have greater toxicity, and may increase the risk of
C. difficile infections.
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Infectious Diseases
(c) Recommendation: Cefoxitin or cefotetan 2 g (or cefazolin or ceftriaxone plus metronida-

zole or ampicillin/sulbactam or ertapenem) before induction or gentamicin/tobramycin
5 mg/kg and clindamycin 900 mg–metronidazole 500 mg preinduction with or without
neomycin 1 g and erythromycin 1 g at 19, 18, and 9 hours before surgery or neomycin 2 g
and metronidazole 2 g at 13 and 9 hours before surgery
(d) Mechanical bowel preparation is not recommended and may be harmful.
2. Obstetrics and gynecology
a. Vaginal or abdominal hysterectomy
i. Antibiotics are most effective in vaginal hysterectomies but generally are given for both
procedures.
ii. Recommendation: Cefazolin or cefoxitin or cefotetan 2 g (or ampicillin/sulbactam) before
induction
b. Cesarean section. Recommendation: Cefazolin 2 g after the cord is clamped
3. Cardiothoracic
a. Cardiac surgery
i. Antibiotics decrease the risk of mediastinitis.
ii. Recommendation: Cefazolin or cefuroxime 2 g preinduction (plus intraoperative doses), if
MRSA is probable or patient has been hospitalized, and then vancomycin
b. Pulmonary resection (i.e., lobectomy and pneumonectomy). Recommendation: Cefazolin 2 g
before induction (or ampicillin/sulbactam or vancomycin)
c. Vascular surgery
i. High mortality with infected grafts
ii. Recommendation: Cefazolin 2 g before induction and every 8 hours for three doses; if MRSA
is probable, then use vancomycin
4. Orthopedic
a. Prophylaxis is indicated when surgery involves prosthetic materials (i.e., total hip or knee, nail, or
plate).
b. Recommendation: Cefazolin 2 g before induction (or vancomycin)
5. Head and neck
a. Indicated for major surgical procedures when an incision is made through the oral or pharyngeal
mucosa
b. Recommendation: Cefazolin or cefuroxime 2 g plus metronidazole or ampicillin/sulbactam 3 g or
clindamycin 900 mg before induction
6. Urologic
a. In general, not recommended
b. Indicated if patient has a positive urine culture before surgery (should treat and then operate)
c. If therapy is unsuccessful, cover for the infecting organism and operate.
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Infectious Diseases
REFERENCES
Respiratory Tract Infections Skin and Soft Tissue Infections
1. Mandell LA, Wunderink RG, Anzueto A, et al. 1.

Stevens DL, Bisno AL, Chambers HF, et al.
Infectious Diseases Society of America/American Practice guidelines for the diagnosis and manage-
Thoracic Society consensus guidelines on the man- ment of skin and soft tissue infections: 2014 update
agement of community-acquired pneumonia in by the Infectious Diseases Society of America.
adults. Clin Infect Dis 2007;44(suppl 2):S27-S72. Clin Infect Dis 2014;XX:1-43.
2. American Thoracic Society; Infectious Diseases 2.
Lipsky BA, Berendt AR, Cornia PB, et al.;
Society of America. Guidelines for the manage- Infectious Diseases Society of America. 2012
ment of adults with hospital-acquired, ventilator- Infectious Diseases Society of America clinical
associated, and healthcare-associated pneumonia. practice guideline for the diagnosis and treat-
Am J Respir Crit Care Med 2005;171:388-416. ment of diabetic foot infections. Clin Infect Dis
3. Centers for Disease Control and Prevention (CDC). 2012;54:e132-73.
Antiviral agents for the treatment and chemopro- 3. Liu C, Bayer A, Cosgrove SE, et al.; Infectious
phylaxis of influenza: Recommendations of the Diseases Society of America. Clinical practice
Advisory Committee on Immunization Practices guidelines by the Infectious Diseases Society of
(ACIP). MMWR 2011;60:1-28. America for the treatment of methicillin-resistant
4.
Grohskopf LA, Olsen SJ, Sokolow LZ, et Staphylococcus aureus infections in adults and
al.; Influenza Division, National Center for children. Clin Infect Dis 2011;52:e18-55.
Immunization and Respiratory Diseases, CDC. 4.
Stevens DL, Bisno AL, Chambers HF, et al.
Prevention and control of seasonal influenza Practice guidelines for the diagnosis and manage-
with vaccines: recommendations of the Advisory ment of skin and soft-tissue infections. Clin Infect
Committee on Immunization Practices (ACIP)— Dis 2005;41:1373-406.
United States, 2014–15 influenza season. MMWR
Morb Mortal Wkly Rep 2014;63(32):691-7.
5.
Chow AW, Benninger MS, Brook I, et al.; Osteomyelitis
Infectious Diseases Society of America. IDSA
1.
Osmon DR, Berbari EF, Berendt AR, et al.;
clinical practice guideline for acute bacterial rhi-
Infectious Diseases Society of America. Diagnosis
nosinusitis in children and adults. Clin Infect Dis
and management of prosthetic joint infection: clin-
2012;54:e72-e112.
ical practice guidelines by the Infectious Diseases
Society of America. Clin Infect Dis 2013;56:e1-e25.
Urinary Tract Infections
1. Gupta K, Hooton TM, Naber KG, et al.; Infectious Central Nervous System Infections
Diseases Society of America; European Society
1. Tunkel AR, Hartman BJ, Kaplan SL, et al. Practice
for Microbiology and Infectious Diseases.
guidelines for the management of bacterial menin-
International clinical practice guidelines for the
gitis. Clin Infect Dis 2004;39:1267-84.
treatment of acute uncomplicated cystitis and
pyelonephritis in women: a 2010 update by the
Infectious Diseases Society of America and the
Endocarditis
European Society for Microbiology and Infectious
Diseases. Clin Infect Dis 2011;52:e103-20. 1.
Baddour LM, Wilson WR, Bayer AS, et al.
Infective endocarditis: diagnosis, antimicro-
bial therapy, and management of complications.
Circulation 2005;111:3167-84.
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Infectious Diseases
2. Wilson W, Taubert KA, Gewitz M, et al.

Prevention of infective endocarditis. Guidelines
from the American Heart Association. Circulation
2007;115:1656-8.
Intra-abdominal Infections
1. Solomkin JS, Mazuski JE, Bradley JS, et al.;

Infectious Diseases Society of America. Diagnosis
and management of complicated intra-abdominal
infection in adults and children: guidelines by
the Surgical Infection Society and the Infectious
Diseases Society of America. Clin Infect Dis
2010;50:133-64.
Clostridium difficile Infections
1.
Cohen SH, Gerding DN, Johnson S, et al.;
Society for Healthcare Epidemiology of America;
Infectious Diseases Society of America. Clinical
practice guidelines for Clostridium difficile infec-
tion in adults: 2010 update by the Society for
Healthcare Epidemiology of America (SHEA) and
the Infectious Diseases Society of America (IDSA).
Infect Control Hosp Epidemiol 2010;31:431-55.
2. Surawicz CM, Brandt LJ, Binion DG, et al.
Guidelines for diagnosis, treatment, and pre-
vention of Clostridium difficile infections. Am J
Gastroenterol 2013;108(4):478-98.
Medical and Surgical Prophylaxis
1. Bratzler DW, Dellinger EP, Olsen KM, et al.

Surgical Infection Prevention Guidelines Writers
Workgroup. Clinical practice guidelines for anti-
microbial prophylaxis in surgery. Am J Health Syst
Pharm 2013;70:195-283.
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Infectious Diseases
ANSWERS AND EXPLANATIONS TO PATIENT CASES
1. Answer: C 3. Answer: B
Although ampicillin/sulbactam has good activity This patient should receive vaccinations now. There are
against H. influenzae, Moraxella catarrhalis, and S. no contraindications to receiving either pneumococcal
pneumoniae (but not drug-resistant S. pneumoniae or influenza vaccine immediately after an episode of
[DRSP]), it has no activity against atypical organisms pneumonia. It is best to vaccinate whenever patients
(L. pneumophila, Mycoplasma pneumoniae, Chlamydia are available. This patient’s age and medical history put
pneumoniae). Current recommendations are to include her at risk of both pneumococcal disease and influenza.
a macrolide with a β-lactam antibiotic for hospitalized Therefore, administration of pneumococcal and influ-
patients with community-acquired pneumonia (CAP). enza vaccines is indicated (if it is during the middle of
Piperacillin/tazobactam has good activity against H. influenza season and she was not vaccinated in the fall,
influenzae, M. catarrhalis, and S. pneumoniae (but not she can receive the influenza vaccine now). The patient’s
DRSP) and, with gentamicin, is excellent for pneumo- age places her in a group needing the pneumococcal
nia caused by most gram-negative organisms. However, vaccine, and everyone should receive the influenza vac-
this increased activity is not necessary for CAP, and the cine. The causative agent for her current infection does
combination has no activity against atypical organisms. not affect the recommendation for vaccination.
Ceftriaxone plus azithromycin is the best initial choice.
It has excellent activity against atypical organisms 4. Answer: B
(because of azithromycin), H. influenzae, M. catarrhalis, Although the treatment duration is correct for this
and S. pneumoniae (even intermediate DRSP). Although patient’s diagnosis (7 days), oral trimethoprim/sulfa-
doxycycline has activity against atypical organisms and methoxazole is inappropriate for complicated pyelone-
most of the typical organisms that cause CAP, it is not phritis. It will also interact with warfarin, increasing the
recommended as monotherapy in hospitalized patients. risk of bleeding. Ciprofloxacin 400 mg intravenously
In addition, its activity against S. pneumoniae may be twice daily and then 500 mg orally twice daily for
limited (if the patient lives in an area with extensive 10 days is an appropriate choice and duration (7–14
DRSP). Doxycycline would not be the best initial choice. days) for this complicated pyelonephritis (it may also
interact with warfarin but to a lesser extent than tri-
2. Answer: D methoprim/sulfamethoxazole). It would be expected
Ceftriaxone plus gentamicin plus linezolid is not good to have activity against the common organisms caus-
empiric therapy because ceftriaxone has limited activ- ing complicated pyelonephritis. Gentamicin for 3 days
ity against P. aeruginosa, and gentamicin has variable is too short a treatment duration, and tigecycline, fol-
activity against P. aeruginosa, depending on the insti- lowed by doxycycline, is not recommended for com-
tution. Because the patient has been on a ventilator and plicated pyelonephritis (although tigecycline is found
in an intensive care unit for 8 days, she is at increased unchanged in the urine).
risk of nosocomial pneumonia, specifically caused by
P. aeruginosa (and possibly MRSA, depending on the 5. Answer: D
institution). Although piperacillin/tazobactam has good Diabetic foot infections are generally polymicrobial
activity against most common causes of nosocomial (average organisms, 2.5–5.8).
pneumonia (including P. aeruginosa), the most recent
guidelines recommend two antibiotics with activity 6. Answer: C
against P. aeruginosa for patients with severe noso- Nafcillin has excellent activity against gram-positive
comial pneumonia, and she may require an antibiotic organisms, but it would miss the gram-negative organ-
with MRSA activity. Levofloxacin has only moderate isms and anaerobes often involved in moderate to
activity against P. aeruginosa, and two drugs should severe diabetic foot infections. Tobramycin and levo-
be used. Cefepime plus tobramycin plus vancomycin is floxacin would be good against aerobic organisms,
the best empiric therapy because it includes two antibi- but levofloxacin has only limited activity against
otics with excellent activity against P. aeruginosa and anaerobes. Tobramycin may also not be a good choice
another agent for MRSA. for a patient with diabetes mellitus with long-term
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Infectious Diseases
complications (because of the increased risk of nephro- risk of acquiring this infection (e.g., college students
toxicity). β-Lactamase inhibitor combinations are good living in dormitories), its use during an outbreak is very
agents because they have activity against the organ- limited.
isms that are often involved. At this time, a regimen
active against P. aeruginosa is probably not necessary. 10. Answer: D
Treatment duration may need to be extended if the bone The treatment duration in Answer A is too short (naf-
is involved. Aggressive antibiotic treatment often pre- cillin intravenously × 2 weeks) for S. aureus endocar-
vents the need for an amputation. ditis. Only streptococcal endocarditis can be treated for
2 weeks. Although nafcillin intravenously plus rifampin
7. Answer: A therapy for 6 weeks or longer is an appropriate duration
Because sensitivities of the gram-positive organism for MSSA, the rifampin does not need to be added in
are still unknown, vancomycin is the best choice. patients with native valve endocarditis. Nafcillin intra-
In addition, the therapy duration for osteomyelitis is venously plus gentamicin intravenously × 2 weeks is
4–6 weeks. Therefore, the 2-week duration with naf- too short for S. aureus endocarditis. Nafcillin intrave-
cillin is too short. Although levofloxacin is advanta- nously × 6 weeks with gentamicin for the first 3–5 days
geous because it can be given orally, it will probably is the recommended treatment for MSSA endocarditis.
not achieve adequate bone concentrations to eradicate Gentamicin should be added for 3–5 days to decrease
S. aureus (the most likely organism). Ampicillin/ the duration of bacteremia.
sulbactam is effective against S. aureus (except for
MRSA); its broad spectrum of activity is not necessary 11. Answer: B
in this situation, and the duration is too short. This patient is at increased risk of endocarditis because
of his history of the disease. Tooth extractions require
8. Answer: B prophylaxis for those at risk. Amoxicillin 2 g, 1 hour
From his presentation and laboratory values, this patient before the tooth extraction, is the current recommended
has bacterial meningitis. The gram-negative cocci on dose. The 2-g dose is adequate for protection, and a
Gram stain are probably N. meningitidis. Penicillin is follow-up dose is not needed. Amoxicillin 3 g, 1 hour
effective against N. meningitidis; however, some strains before the extraction, and 1.5 g, 6 hours for four doses
are resistant, and until culture results are received, it after the extraction, is the older recommended dose.
is unwise to use this agent alone. Ceftriaxone alone is A follow-up dose is not needed.
effective for meningococcal meningitis, and this is the
best answer (although some may continue to use van- 12. Answer: A
comycin until the cultures actually grow N. meningit- Redosing antibiotics for surgical prophylaxis is very
idis). Dexamethasone is beneficial only in adults with important, especially for antibiotics with short half-
pneumococcal meningitis (not meningococcal menin- lives, for extended surgical procedures, or for when
gitis). Ceftriaxone is the appropriate empiric antibiotic there is extensive blood loss. Antibiotics given beyond
therapy in this situation. Vancomycin is generally used the surgical procedure are generally unnecessary and
empirically because of its activity against highly pen- only increase the potential for adverse drug reactions
icillin-resistant S. pneumoniae. Because this is proba- and resistant bacteria. Although preoperative antibiot-
bly not pneumococcal meningitis, vancomycin can be ics given up to 4 hours before the incision may improve
discontinued. the logistics of administering surgical prophylaxis,
study results show that antibiotics must be given as
9. Answer: A close to the time of the incision as possible (definitely
Only people in close contact to a patient with menin- within 2 hours). Vancomycin should not be used rou-
gococcal meningitis require prophylaxis (primarily tinely for surgical prophylaxis. The Centers for Disease
those who live closely with the patient and those who Control and Prevention does not recommend the use
are exposed to oral secretions). The correct regimen of vancomycin for “routine surgical prophylaxis other
is rifampin 600 mg every 12 hours for four doses. than in a patient with life-threatening allergy to β-lac-
Although the vaccine is a good idea for those at future tam antibiotics.”
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Infectious Diseases
ANSWERS AND EXPLANATIONS TO SELF-ASSESSMENT QUESTIONS
1. Answer: A 4. Answer: C
The patient has CAP that does not require hospitaliza- This patient has symptoms suggestive of bacterial
tion (CURB-65 score is 1 at most [no mention of mental sinusitis, including two major symptoms and a few
status]). Because he has not received any antibiotics in minor symptoms. The fact that the symptoms improved
the past 3 months and has no comorbidities, he is at low and then worsened suggests a bacterial sinusitis that
risk of DRSP. Therefore, the drug of choice is either followed a viral infection. Although the combination of
a macrolide or doxycycline. Cefuroxime is not recom- cefpodoxime and clindamycin is an option for sinusitis
mended for treatment of CAP. Fluoroquinolones are in penicillin-allergic patients, it is not recommended to
recommended only if the patient has had recent anti- give either of these alone for treatment. The best option
biotics or has comorbidities. Trimethoprim/sulfa- is amoxicillin/clavulanate, which has activity against
methoxazole is not used for CAP. organisms commonly seen in bacterial sinusitis and is
considered a first-line agent.
2. Answer: D
The symptoms of this patient (high temperature, mal- 5. Answer: C
aise, dry cough, nasal congestion, and severe headaches) Although nitrofurantoin is a recommended first-line
are most consistent with influenza; therefore, an anti- agent, the therapy duration is too short for its use.
bacterial agent would not affect recovery. Oseltamivir Because this patient has no contraindications to the
should be initiated within 48 hours of symptom onset, use of trimethoprim/sulfamethoxazole or nitrofuran-
so because this patient is more than 3 days out from toin, and trimethoprim/sulfamethoxazole resistance
symptom onset, oseltamivir will not affect recovery. rates are not mentioned as being high, fluoroquinolones
Because of the viral etiology and time since symptom would not be considered appropriate as first-line ther-
onset, symptomatic treatment is all that is indicated. apy in this particular case. In addition, 7 days of ther-
apy is not necessary. The best choice for this patient is
3. Answer: B trimethoprim/sulfamethoxazole double strength twice
A case-control study would be the most appropri- daily orally for 3 days. The patient should be counseled
ate study design because it is the most ethical, cost- about the potential interaction between antibiotics and
effective, timely method. A stronger study design—for oral contraceptives. β-Lactams are not as effective as
instance, a prospective cohort study or a randomized trimethoprim/sulfamethoxazole, and data are limited
controlled trial—has many disadvantages if used to on their use for 3 days.
answer this question. In a prospective cohort study, too
many patients would need to be observed because of 6. Answer: A
the low incidence of confirmed pneumococcal pneu- For the asymptomatic patient who is bedridden and
monia. This study would therefore be too costly and chronically catheterized, with cloudy urine and bac-
take too long to complete. Randomized controlled trials teria shown by urinalysis, no therapy is indicated. All
also have many disadvantages in this situation. First, patients with chronic urinary catheters will be bacteri-
patients would need to be vaccinated and then observed uric. Because this patient is asymptomatic, the catheter
for at least 10 years. Second, too many patients would does not need to be replaced. If she were symptomatic,
need to be observed because of the low incidence of catheter replacement might be indicated. Antibiotics
confirmed pneumococcal pneumonia. Third, it would are not indicated; however, a 7-day course would be
be unethical to randomly assign half the patients to no appropriate if treatment were instituted. A long course
vaccination. This study would therefore be too costly, of treatment only increases the risk of acquiring resis-
unethical, and time-consuming. A case series would tant organisms.
evaluate only a few patients given a diagnosis of pneu-
mococcal pneumonia 10 or more years after vaccina- 7. Answer: A
tion. It would not provide comparative data, nor would Because cellulitis (which the patient appears to have)
it provide a strong study design. is usually caused by Streptococcus or Staphylococcus,
nafcillin is the drug of choice (vancomycin could be
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Infectious Diseases
initiated empirically if MRSA were a concern in this

patient). Necrotizing fasciitis must be ruled out because
other organisms may be involved, and surgery would be
crucial. Although penicillin is the treatment of choice
for erysipelas, the patient probably has acute cellulitis
(there is no raised border at the edge of the infection,
which is indicative of erysipelas). Although piperacillin/
tazobactam has activity against both Streptococcus and
Staphylococcus, this treatment is too broad spectrum
for an acute cellulitis. Because Doppler studies are neg-
ative, the likelihood of a deep venous thrombosis is low.
8. Answer: C
Even if a patient is believed to have aseptic meningi-
tis after analysis of the CSF, antibiotics must be given
until CSF cultures are negative. In empiric therapy
for bacterial meningitis in adults (i.e., when the CSF
Gram stain is negative), ceftriaxone should be used
in combination with vancomycin. The vancomycin is
necessary for activity against resistant S. pneumoniae.
Although the symptoms and CSF results are similar to
what is expected for herpes simplex encephalitis, the
use of acyclovir alone in this patient is inappropriate.
Antibacterials must be used as well. Viral meningitis
is generally caused by coxsackie virus, echovirus, and
enterovirus, which are not treated with acyclovir.
9. Answer: C
Enterococcal endocarditis should be treated for 4–6
weeks. The 2-week treatment regimen is indicated
only for streptococcal endocarditis. There is also no
indication that the patient is penicillin allergic; thus,
vancomycin should not be used as first-line treatment.
Ampicillin plus gentamicin for 4–6 weeks is the reg-
imen of choice for penicillin-susceptible enterococcal
endocarditis. Cephalosporins have no activity against
Enterococcus; therefore, the regimen with cefazolin is
inappropriate.
10. Answer: C
A perforated appendix requires antibiotics after surgery
for an intra-abdominal infection. The combination of
vancomycin and metronidazole does not have adequate
activity against aerobic, gram-negative organisms (e.g.,
E. coli). The combination of ceftriaxone and ciproflox-
acin does not have adequate activity against anaerobic
organisms (e.g., B. fragilis group). Ertapenem is a good
choice for intra-abdominal infections, although it has
limited activity against Enterococcus.
1-359

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What are some common infections discussed in the document?

What are some common infections discussed in the document?

What are some appropriate treatment options discussed for different types of infections?

What are some appropriate treatment options discussed for different types of infections?

Infectious Diseases

Learning Objectives 3. A study is designed to assess the risk of pneumo-

4. S.C. is a 46-year-old woman who presents to the

A. No therapy because she is chronically C. Administer ceftriaxone 2 g intravenously

I. RESPIRATORY TRACT INFECTIONS

Table 1. CURB-65 Scoring

DBP = diastolic blood pressure; SBP = systolic blood pressure.

Table 2. CURB-65 Location of Therapy

Table 3. Incidence of Pneumonia by Organism

Table 4. Differentiating the Symptoms of Cold and Influenza

G. Immunizations Related to the Respiratory Tract

Table 5. Pneumococcal Vaccine Recommendations (continued)

Table 6. Influenza Vaccine Products

Table 7. Symptoms Associated with Diagnosis of Sinusitis

b. Viral or bacterial? (Table 8)

Table 8. Differentiating Viral from Bacterial Sinusitis

II. URINARY TRACT INFECTIONS

Table 9. Incidence of Urinary Tract Infections by Organism

b. Younger than 35 years, probably gonococcal or chlamydial infection

III. SKIN AND SKIN STRUCTURE INFECTIONS

c. Very painful (pain out of proportion to appearance)

D. Varicella-Zoster Virus Immunization: Shingles Vaccine (Zostavax)

IV. DIABETIC FOOT INFECTIONS

C. Causative Organisms: In general, polymicrobial (average, 2.1–5.8 microorganisms)

B. Characteristics (Table 10)

Table 10. Characteristics of Osteomyelitis

F. Criteria for Effective Oral Therapy for Osteomyelitis

VI. CENTRAL NERVOUS SYSTEM (CNS) INFECTIONS

B. Microbiology (Table 11)

Table 11. Bacterial Etiology of Meningitis, Based on Age

2. Other causes (aseptic meningitis)

Table 12. CSF Changes in Bacterial Meningitis

c. CSF stains and studies

G. Therapy for Common Pathogens

b. An MIC 0.1–1.0 mcg/mL

H. Therapy Length: Based on clinical experience, not on clinical data

I. Adjunctive Corticosteroid Therapy

ii. Booster dose

B. Presentation and Clinical Findings

C. Microbiology (Table 13)

Table 13. Incidence of Microorganisms in Endocarditis

D. Treatment (Table 14)

Table 14. Treatment Recommendation for Endocarditis

Table 14. Treatment Recommendation for Endocarditis (continued)

Gentamicin for 2 weeks.

E. Prophylaxis (Table 15)

Table 15. Endocarditis Prophylaxis

Congenital heart disease

F. Recommended Prophylaxis for Dental or Respiratory Tract Procedures (Table 16)

Table 16. Prophylaxis for Dental or Respiratory Tract Procedures

VIII. PERITONITIS AND INTRA-ABDOMINAL INFECTIONS

e. Pain with breathing

IX. CLOSTRIDIUM DIFFICILE INFECTION

X. MEDICAL AND SURGICAL PROPHYLAXIS

B. Classification of Surgical Procedures (Table 17)

Learning Objectives 3. A study is designed to assess the risk of pneumo-

4. S.C. is a 46-year-old woman who presents to the

A. No therapy because she is chronically C. Administer ceftriaxone 2 g intravenously

(c) Recommendation: Cefoxitin or cefotetan 2 g (or cefazolin or ceftriaxone plus metronida-

1. Mandell LA, Wunderink RG, Anzueto A, et al. 1.

2. Wilson W, Taubert KA, Gewitz M, et al.

1. Solomkin JS, Mazuski JE, Bradley JS, et al.;

1. Bratzler DW, Dellinger EP, Olsen KM, et al.