Sandbox ID Systemic

Anaplasmosis

SC

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Babesiosis

• Pathogen-directed antimicrobial therapy
• Preferred regimen (1): Combined therapy with Clindamycin and Quinine
• Preferred regimen (2): Both Atovaquone (a hydroxy-1,4-naphthoquinone) alone and Azithromycin (an azalide macrolide) alone appeared to be effective.

Note : Neither the regimen of Atovaquone and Azithromycin nor the regimen of Clindamycin and Quinine clears Babesiosis microti merozoites from the human blood as rapidly as might be desired.

Bartonella

• Bartonellosis or Carrion's disease

• The acute phase, or hematic phase, known as Oroya Fever

• Preferred regimen: Ciprofloxacin for 10 days- for patients younger than 7 years old, the scheme is 10 mg/kg divided into two doses, for patients between 7 and 14 years old the dose is 250 mg BID, and for patients older than 14 years old the dose is 500 mg BID
• Alternative regimen: Chloramphenicol 50mg/kg/day, divided into four doses during the first three days, and then 25 mg/kg/day until completing 14 days of treatment

Note (1): If a complication occurs during the acute phase, and the patient is not pregnant, then the treatment would be Ciprofloxacin AND (Ceftriaxone or Ceftazidime) during 10 days.

Note (2): If a pregnant patient has complicated acute Bartonellosis, the treatment is Chloramphenicol 50-100 mg/kg/day, divided into four doses, AND Penicillin G 50,000-100,000 IU/kg/day divided into 4 or 6 doses, for 14 days. (A complication should be suspected if there is no improvement within the first 72 hours of treatment.)

Note (3): The treatment schemes based on ciprofloxacin and chloramphenicol have the advantage of also covering the possibility of Salmonella species and Haemophilus influenzae in the pediatric population

Note (4): Patients with neurobartonellosis, respiratory distress syndrome, coagulopathy, and/or moderate to severe pericarditis may benefit from corticosteroids, such as Dexamethasone (0.5-1 mg/kg/day for three days).

Note (5): Red blood cell transfusions in the amount of 10-20mL/kg are given when the hematocrit is less than 20%.

Note (6): In case of severe pericardial tamponade, a pericardiectomy is done.

• The eruptive phase or tissue phase, known as Peruvian Wart

• Preferred regimen: Rifampin 10 mg/kg/day QID during 14 to 21 days.
• Alternative regimen: Azithromycin OR Erythromycin, OR Ciprofloxacin can be given for 7 to 14 days.

Note (1): In this phase, Chloramphenicol and Penicillin are not useful.

Note (2): In vitro analysis, Bacillus bacilliformis showed susceptibility to most beta-lactams, Rifampin, Erythromycin, Macrolides, Tetracycline, Quinolones, and Chloramphenicol.

Note (2): The bacterium is resistant to Vancomycin, Clindamycin, and Aminoglycosides.

Botulism

• Botulism

• Foodborne botulism

• Preferred regimen (adult): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.5 mL/min; incremental infusion rate if tolerated (every 30 minutes): double the rate; maximum infusion rate: 2 mL/min
• Preferred regimen (pediatric 1-17 years): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01 mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01 mL/kg/min ; maximum infusion rate: 0.03 mL/kg/min (20 – 100% of adult dose)
• Preferred regimen (pediatric < 1 year): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01 mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01 mL/kg/min ; maximum infusion rate: 0.03 mL/kg/min (10% of adult dose regardless of body weight)
• Note:Physicians may try to remove contaminated food still in the gut by inducing vomiting or by using enemas. A patient with severe botulism may require a ventilator as well as intensive medical and nursing care for several months.

• Infant botulism

• Preferred regimen: BabyBIG, Botulism Immune Globulin Intravenous (Human) (BIG-IV) is for the treatment of patients below one year of age.The recommended total dosage is 1mL/kg (50mg/kg), given as a single IV infusion as soon as the clinical diagnosis of infant botulism is made
• Note: infant with botulism must receive supportive care during their recovery. This includes ensuring proper nutrition,keeping the airway clear,watching for respiratory failure and if it develops,ventilator may be needed.

• Wound botulism

• Preferred regimen (adult): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.5 mL/min; incremental infusion rate if tolerated (every 30 minutes): double the rate; maximum infusion rate: 2 mL/min
• Preferred regimen (pediatric 1-17 years): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01 mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01 mL/kg/min ; maximum infusion rate: 0.03 mL/kg/min (20 – 100% of adult dose)
• Preferred regimen (pediatric < 1 year): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01 mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01 mL/kg/min ; maximum infusion rate: 0.03 mL/kg/min (10% of adult dose regardless of body weight)

• Note (1): For wound botulism, antibiotics are used in addition to appropriate debridement.
• Note (2): Antibiotic therapy is recommended for wound botulism after antitoxin has been administered. Penicillin G 3 MU IV q4h in adults is frequently used. Metronidazole 500 mg IV q8h may be used as an alternative for penicillin-allergic patients.

Boutonneuese fever

• Boutonneuese fever

• Preferred Regimen ( adult)(1): Doxycycline 200 mg two oral doses in a single day

• Preferred Regimen ( adult)(2): Doxycycline 200 mg or 100 mg bid for 2-5 days
• Alternative regimen (adult)(1): josamycin 1g q8h for 7 days
• Alternative regimen (adult)(2):Ciprofloxacin
• Preferred Regimen ( Children <100 lbs): Doxycycline 2.2 mg/kg body weight PO q 12 h or( Children >100lbs ) 200 mg bid in one day and 200 mg bid qid or 100 mg bid for 2-5 days
• Alternative regimen (Children <8 y.o.)(1): josamycin 2.2mg/kg q12h for 5 days
• Alternative regimen (Children <8 y.o)(2): clarithromycin 15 mg/ kg in 2 divided doses for 7 days & azithromycin 10 mg per kg/day 1 dose for 3 days

Diphtheria

Diphtheria treatment

• Preferred Regimen Erythromycin 40 mg/kg/day; maximum, 2 gm/day) PO for 14 days OR Procaine penicillin G daily (300,000 U/day (for weight < 10 kg ) & 600,000 U/day (for weight >10 kg ) IM for 14 days
• Note: Since 1997, diphtheria antitoxin has been available only from CDC, through an Investigational New Drug (IND) protocol.

Fever of unknown origin

• Fever of unknown origin (FUO)

• Management should generally be withheld until the etiology of the fever has been ascertained, so that treatment can be directed against a specific pathology.
• Specific clinical considerations

• Neutropenic fever

• Exception may be made for neutropenic patients in which delayed treatment could lead to serious complications.
• After samples for cultures are obtained, patients with febrile neutropenia should be aggressively treated with broad-spectrum antibiotics covering Pseudomonas

• HIV/AIDS individuals

• HIV/AIDS individuals with pyrexia and hypoxia should be placed on empiric therapy for Pneumocystis jirovecii.

• Giant cell arteritis

• Empiric corticosteroids may be considered in patients with suspected giant cell arteritis to prevent vascular complications.
• Giant cell arteritis should be suspected in a patient over the age of 50 with the following symptoms:

• Newly onset headaches
• Abrupt onset of blurry vision
• Symptoms of polymyalgia rheumatica
• Jaw claudication
• Unexplained anemia
• Elevated ESR and/or CRP

Lymphangitis

• Preferred regimen: Dicloxacillin OR Cephalexin 500 mg PO qid for 1 week

• If Community-Associated Methicillin-Resistant Staphylococcus Aureus (CA-MRSA) suspected:

• Trimethoprim-sulfamethoxazole PO bid AND vancomycin 1 g IV every 12 hr

• If allergic to penicillin:

• Clindamycin 300 mg PO qid for 7 days OR Erythromycin 500 mg PO qid for 7 days OR Levofloxacin 500 mg PO daily OR Moxifloxacin 400 mg PO daily for 7 days.

Neutropenic fever, prophylaxis

• Neutropenic fever, prophylaxis

• Low risk ( Standard chemotherapy regimen for soild tumor, anticipated neutropenia <7 d)

• Antibacterial agent: none
• Antifungal agent: none
• Antiviral agent: none unless prior HSV episode

• Intermediate risk (Autologous HSCT (Hematopoietic stem cell transplant) , Lymphoma, multiple myeloma, CLL, Purine analog therapy [i.e Fludarabine,Clofarabine,nelarabine,cladribine], anticipated neutropenia 7- 10 days)

• Antibacterial agent: Consider fluroquinolone prophylaxis

• Antifungal agent: consider fluconozole during neutropenia and for anticipated mucositis

• Antiviral agent:

HSV , VZV- Acyclovir HSV - 400 - 800 mg PO bid ,VSZ in allogenic HSCT ( Hematopoietic stem cell transplant) recipent - 800 mg PO bid , Famciclovir- HSV or VZV 250 mg PO bid, Valacyclovir - HSV or VZV 500 mg bid or tid PO during neutropenia and at least 30 days after HSCT ( consider VZV prophylaxis given for 1 yr after HSCT)

• High risk cases (Acute Leukemia - induction , consolidation, Alemutuzumab Therapy, in allogenic HSCT including cord blood, GVHD treated with high dose steriods, Anticipated neutropenia >10 days)

• Antibacterial agent: levofloxacin 500- 750 mg PO/IV daily

• Antifungal agent:

• ALL

• Preferred regimen: Fluconazole in adult with bnormal renal function 400mg IV/ PO daily
• Alternative regimen: Amphotericin B Products

• MDS ( neutropenic)-

• Preferred regimen:Posaconazole EC 300 mg bid on day 1 and then 300 mg IV q day after or IV 300 mg q day after (category 1)
• Alternative regimen: Voriconazole ( category 2 B) until resolution of neutropenia

• AML ( neutropenic)-

• Alternative regimen: Fluconazole ( category 2 B),

::::* Alternative regimen: Amphotericin B Products ( category 2 B) until resolution of neutropenia

• Autologous HSCT with mucositis -

• Preferred regimen:Fluconazole (category 1),

::::* Preferred regimen:Micafungin (category 1) until resolution of neutropenia 
 

• Allogenic HSCT-

• Preferred regimen:Fluconazole (category 1),
• Preferred regimen: Micafungin (category 1),

• Alternative regimen: Itraconazole (category 2B) ,
• Alternative regimen: Voriconazole ( category 2 B),

::::* Alternative regimen: Posaconazole (category 2 B),

• Alternative regimen: Amphotericin B (category 2 B) continue during neutropenia and for at least 75 days after transplant

• Significant GVHD -

• Preferred regimen: Posaconazole (category 1),

::::* Alternative regimen: Voriconazole ( category 2 B),

• Alternative regimen: Echinocandin (category 2 B),

::::* Alternative regimen: Amphotericin B Products (category 2 B) until resolution of Significant GVHD

::*Antiviral agent

Acute Leukemia - induction , consolidation - HSV - Acyclovir 400 - 800 mg PO bid,Famciclovir , Valacyclovir - during neutropenia, Proteasome inhibitor - VZV- Acyclovir ,Famciclovir, Valacyclovir - during active therapy, Alemutuzumab Therapy- allogenic HSCT- Acyclovir ,Famciclovir 250 mg PO bid, or Valacyclovir 500 mg bid or tid as HSV Prophylaxis-- VZV prophylaxis- in allogenic transplant recipients, acyclovir prophylaxis should be considered for at least 1 yr after HSCT HSV prophylaxis - Minimum of 2 mo after alemtuzumab and until CD4 > 200 cell/ mcl During neutropenia and atleast 30 day after HSCT

• Antiviral agent

• Acyclovir-HSV - 400 - 800 mg PO bid ,VSZ in allogenic HSCT ( Hematopoietic stem cell transplant) recipent - 800 mg PO bid , CMV in allogenic HSCT recipent- 800 mg PO qid, unable to tolerate 250 mg/ m2 IV q 12 h
• Valacyclovir- HSV or VZV 500 mg bid or tid PO, CMV in allogenic HSCT recipent 2g qid PO
• Famciclovir HSV or VZV 250 mg PO bid
• Ganciclovir -CMV 5-6 mg/kg IV every day for 5 days/ week from engraftment until day 100 after HSCT
• Valganciclovir CMV 900 mg every day
• Foscarnet - CMV 60 mg/ kg tid or 60 mg /kg IV q 12 h for 7 days followed by 90 - 120 mg/ kg IV every day until day 100 after HSCT
• Ciclofovir- CMV - 5mg/ kg IV every other week with probenecid 2 gm PO 3 h before dose, followed by 1 gm PO 2 h after the dose and 1 gm PO 8 h after dose and IV hydration
• Oseltamivir Influenza A& B 75 mg PO every day

• Antiviral agent prophylaxis

Intermediate risk cases Autologous HSCT, Lymphoma, multiple myeloma, CLL, Purine analog therapy ( i.e Fludarabine) - HSV , VZV- Acyclovir HSV - 400 - 800 mg PO bid ,VSZ in allogenic HSCT ( Hematopoietic stem cell transplant) recipent - 800 mg PO bid,Famciclovir- HSV or VZV 250 mg PO bid,Valacyclovir - HSV or VZV 500 mg bid or tid PO during neutropenia and at least 30 days after HSCT ( consider VZV prophylaxis given for 1 yr after HSCT)

high risk cases

Acute Leukemia - induction , consolidation - HSV - Acyclovir - 400 - 800 mg PO bid,Famciclovir- 250 mg PO bidValacyclovir - 500 mg bid or tid PO during neutropenia, Proteasome inhibitor -VZV- Acyclovir-800 mg PO bid ,Famciclovir-250 mg PO bid ,Valacyclovir-500 mg bid or tid PO- during active therapy,

Alemutuzumab Therapy, allogenic HSCT ,GVDH requiring steriod treatment- Acyclovir-400 - 800 mg PO bid ,Famciclovir- HSV or VZV 250 mg PO bid

, orValacyclovir-500 mg bid or tid Note (1) VZV prophylaxis- in allogenic transplant recipients, acyclovir prophylaxis should be considered for at least 1 yr after HSCT Note (2) HSV prophylaxis - Minimum of 2 mo after alemtuzumab and until CD4 > 200 cell/ mcl During active therapy including periods of neutropenia and atleast 30 day after HSCT

P.jirovecii - single or double  strength 3 times/ week

• Antifungal agent:

Salmonella bacteremia

• Preferred regimen: Ciprofloxacin 400 mg every 12 hours IV AND Ceftriaxone 1 to 2 g every 12 to 24 hrs IV.

• When the salmonellae are known to be susceptible:

• Preferred regimen: Ampicillin 1 to 2 g IV every 4 to 6 hrs OR Trimethoprim-sulfamethoxazole 8 mg/kg/day

Clostridial toxic shock syndrome

• Clostridium sordelli toxic shock syndrome

• Pathogen-directed antimicrobial therapy

• Preferred regimen: Ampicillin 250-500 mg q4-8h IV or IM OR Amoxicillin-clavulanate 250-500 mg q8-12h PO OR Piperacillin-tazobactam 4.5 g IV q8h OR Ticarcillin 3.1 g IV q8h OR Clindamycin 600 to 900 mg IV q8h OR Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per dose OR Imipenem 500 mg IV q6h OR Linezolid 600 mg q12h IV or PO OR Metronidazole 30 mg/kg/24 hr divided q6h PO or IV (max dose: 4 g/24 hr)

Note (1): Clostridium sordellii is a cause of toxic shock syndrome (CSTS) associated with gynecologic procedures, childbirth, and abortion (including spontaneous, surgical, and medical abortion). Gastrointestinal and vaginal colonization of Clostridium sordellii can occur in healthy individuals.

Note (2): Treatment of Clostridium sordellii toxic shock syndrome consists of antibiotic therapy, surgical debridement, and aggressive resuscitation

Staphylococcal toxic shock syndrome

• Staphylococcal toxic shock syndrome

• (1) Methicillin sensitive Staphylococcus aureus

• Preferred regimen: Cloxacillin 250-500 mg q6h PO (max dose: 4 g/24 hr) OR Nafcillin 4-12 g/24 hr divided q4-6hr IV (max dose: 12 g/24 hr) OR Cefazolin 0.5-2g q8h IV or IM (max dose: 12 g/24 hr), AND Clindamycin 150-600 mg q6-8h IV, IM, or PO (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
• Alternative regimen (1):Clarithromycin 250-500 mg q12h PO (max dose: 1 g/24 hr) AND Clindamycin 150-600 mg q6-8h IV, IM, or PO (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
• Alternative regimen (1):Rifampicin, AND Linezolid 600 mg q 12 hr IV or PO OR Daptomycin OR Tigecycline 100 mg loading dose followed by 50 mg q12h IV

• (2) Methicillin resistant Staphylococcus aureus

• Preferred regimen: Clindamycin 150-600 mg q6-8h IV, IM, or PO (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO) OR Linezolid 600 mg q12h IV or PO , AND Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per dose or Teicoplanin
• Alternative regimen (1):Rifampicin, AND Linezolid 600 mg q12h IV or PO OR Daptomycin OR Tigecycline 100 mg loading dose followed by 50 mg q12h IV

• (3) Glycopeptide resistant or intermediate Staphylococcus aureus

• Preferred regimen: Linezolid 600 mg q12h IV or PO AND Clindamycin 150-600 mg q6-8h IV, IM, or PO (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO) (if sensitive)
• Alternative regimen (1):Daptomycin OR Tigecycline 100 mg loading dose followed by 50 mg q12 IV

Note: Incidence increasing. Geographical patterns highly variable

Streptococcal toxic shock syndrome

• Streptococcal toxic shock syndrome

• (1) Group A streptococcus

• Preferred regimen: Penicillin G, 2–4 million units q4–6h IV AND Clindamycin 600–900 mg q8h IV, (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
• Alternative regimen (1): (Macrolide Azithromycin 500 mg PO day 1 followed by 250 mg for 4 days OR Fluoroquinolone Oxacillin 2-12 g/24 hr divided q4-6h IV (max dose: 12 g/24 hr)), AND Clindamycin 150-600 mg q6-8h IV, IM, or PO (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
• Alternative regimen (2): Linezolid 600 mg q 12 hr IV or PO OR Daptomycin OR Tigecycline 100 mg loading dose followed by 50 mg q12h IV

Note : Macrolide and Fluoroquinolone resistance increasing

• (2) Macrolide, lincosamide, and streptogramin B (MLS) resistant group A streptococcus

• Preferred regimen: Penicillin G 2-24 million units/24 hr divided q4-6h IV or IM , AND (Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per doseOR Teicoplanin)
• Alternative regimen (1): Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per doseOR Teicoplanin
• Alternative regimen (2): Linezolid 600 mg q12h IV or PO OR Daptomycin OR Tigecycline 100 mg loading dose followed by 50 mg q 12 hr IV

Note : Macrolide resistance associated with Clindamycin resistance

Typhus, louse-borne

• Louse born typhus, Rickettsia prowazekii (epidemic typhus, sylvatic typhus and Brill–Zinsser typhus

• Pathogen-directed antimicrobial therapy

• In adults

• Preferred regimen (1): Doxycycline 200 mg PO for 5 days or 2-3 days after defervescence
• Preferred regimen (2): Doxycycline 100-200 mg PO single dose in outbreak situation
• Alternative regimen: Chloramphenicol 60 to 75 mg/kg/day PO in four divided doses

• In childern

• Preferred regimen (1): Doxycycline 100-200 mg PO single dose

• In pregnant women

• Preferred regimen: Doxycycline 100-200 mg PO single dose

Typhus, murine

• Murine typhus,Rickettsia typhi (flea-borne infection)

• Pathogen-directed antimicrobial therapy

• In adults

• Preferred regimen : Doxycycline 100 mg bid PO continued for 3 days after the symptoms have resolved, Doxycycline 100-200 mg, PO single dose
• Alternative regimen (1): Fluoroquinolones Oxacillin 2-12 g/24 hr divided q4-6h IV (max dose: 12 g/24
• Alternative regimen (2): Chloramphenicol 60 to 75 mg/kg/day PO in four divided doses

• In childern

• Preferred regimen: Doxycycline 100-200 mg, PO for 3-7 days
• Alternative regimen: Chloramphenicol 50-75 mg/kg/24 hr divided q 6-8 hr IV or PO

• In pregnant women

• Preferred regimen: Doxycycline 100-200 mg, PO single dose late trimester
• Alternative regimen (1): Erythromycin Base: 333 mg PO q 8 hr; estolate/stearate/ base: 250-500 mg q 6 hr PO
• Alternative regimen (2): Chloramphenicol 50 mg/kg/24 hr divided q 6 hr IV or PO (max dose: 4 g/24 hr) (early trimester: first and second trimesters)

Typhus, scrub

• Scrub typhus, Orientia tsutsugamushi (previously called Rickettsia tsutsugamushi- mite-borne infectious disease)

• Pathogen-directed antimicrobial therapy

• Preferred regimen: Doxycycline (100 mg PO or IV bd) for 3 days OR Chloramphenicol 500 mg PO or IV q6h
• Alternative regimen: Azithromycin 500 mg PO day 1 followed by 250 mg for 4 days