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: during neutropenia and at least 30 d after HSCT

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 greater than 10 days)

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

• Antifungal agent:

• ALL

• Preferred regimen:
• Alternative regimen:

• MDS ( neutropenic)- consider Posaconazole (category 1),Voriconazole ( category 2 B) until resolution of neutropenia
• AML ( neutropenic)-Fluconazole ( category 2 B), Amphotericin B Products ( category 2 B) until resolution of neutropenia
• Autologous HSCT with mucositis - Fluconazole (category 1), Micafungin (category 1) until resolution of neutropenia
• Allogenic HSCT- Fluconazole (category 1), Micafungin (category 1), Itraconazole (category 2B) Voriconazole ( category 2 B), Posaconazole (category 2 B), Amphotericin B (category 2 B) continue during neutropenia and for at least 75 days after transplant
• Significant GVHD - consider Posaconazole (category 1),Voriconazole ( category 2 B), Echinocandin (category 2 B), 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

Staphylococcal toxic shock syndrome

• Staphylococcal toxic shock syndrome

• (1) Meticillin sensitive Staphylococcus aureus

• Preferred regimen: Cloxacillin 250-500 mg q 6 hr PO (max dose: 4 g/24 hr) OR Nafcillin 4-12 g/24 hr divided q 4-6 hr IV (max dose: 12 g/24 hr) OR Cefazolin 0.5-2g q 8 hr IV or IM (max dose: 12 g/24 hr), AND Clindamycin 150-600 mg q 6-8 hr 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 q 12 hr PO (max dose: 1 g/24 hr) AND Clindamycin 150-600 mg q 6-8 hr 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 q 12 hr IV

• (2) Meticillin resistant Staphylococcus aureus

• Preferred regimen: Clindamycin 150-600 mg q 6-8 hr IV, IM, or PO (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO) OR Linezolid, AND Vancomycin or Teicoplanin
• 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 q 12 hr IV

• (3) Glycopeptide resistant or intermediate Staphylococcus aureus

• Preferred regimen: Linezolid 600 mg q 12 hr IV or PO AND Clindamycin 150-600 mg q 6-8 hr 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 q 12 hr 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 every 4–6 h IV AND Clindamycin 600–900 mg every 8 h 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 q 4-6 hr IV (max dose: 12 g/24 hr)), AND Clindamycin 150-600 mg q 6-8 hr 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 q 12 hr 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 q 4-6 hr IV or IM , AND (Vancomycin OR Teicoplanin)
• Alternative regimen (1): Vancomycin OR Teicoplanin
• Alternative regimen (2):Linezolid 600 mg q 12 hr 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

• 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

• 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
• 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 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