BCPS 2013: Infectious Diseases

My infectious disease review.  I've already talked about pneumonia and may be revising these to go from the direction of the bugs and then the drugs again.  One thing I will say:  Invanz is not active against MRSA, ampicillin-resistant enterococci, Pseudomonas aeruginosa or Acinetobacter species.  Hear me?  :)

BCPS ID Review

Pneumonia	CAP	HAP
Organisms	M. pneumonia, S. pneumonia, H.flu, C. pneumonia, Legionella, Viruses	S. aureus, Pseudomonas, Enterobacter, Klebsiella pneumo, Candida, Acinetobacter, Serratia, E.coli, S.pneumonia
Treatment	Healthy no Abx in previous 3 months Macrolide (clarith or azith) OR doxycycline Cormorbidity or Abx in previous 3 months FQ (moxi, gemi, levo 750mg) Macrolide (or doxy) + [High-dose amox 1g tid OR amox/clav 2g bid OR ceph ] (ceftriaxone, cefuroxime, cefpodoxime)	Early onset (< 5 days) 3rd ceph (ceftriaxone, cefotaxime) FQ (levo, moxi, cipro) Amp/sulbactam Ertapenem Late onset (> 5 days or RF for MDR)    Ceftazidime OR cefepime + AG or FQ (cipro, levo) Imi, mero, or dori + AG or FQ (cipro, levo) Pip/taz + AG or FQ (cipro, levo)    + Vanco/linezolid only if MRSA risk factors
Duration	At least 5 days	7 days (14 days for Pseudomonas)

Influenza: Type A (Annual, H1N1, H1N2), Type B

Prophylaxis:  if outbreak and cannot receive vaccine

1. Amantadine, Rimantadine 5-7 weeks

2. Neuraminidase inhibitors: Oseltamivir 75-150mg daily x6wks; 75mg daily x7days within 2 days of contact

Zanamivir 10mg daily through inhalation x4wks

Treatment: only if severe symptoms or at risk for complications

1. Amantadine, Rimantadine- only against Type A, decreases symptoms 1 day  *do NOT use for at risk for complications

Dosing: 100mg bid x3-7 days [Elderly 100 daily]; ADJUST FOR RENAL DISEASE (amantadine> rimantadine)

AE: CNS, GI, peripheral edema, orthostatic hypotension

2. Oseltamivir- decreases symptoms 1-1.5 days

Dosing: 75mg bid x5days [CrCl <30 75mg daily]

AE: GI

3. Zanamivir- decreases symptoms 1-1.5 days

Dosing: 2 inhalations (5mg/inhalation) bid x5days

AE: bronchospasm, cough

UTIs	Treatment	Other	Comment
Uncomplicated cystitis	Nitrofurantoin 100mg bid      X 5 days TMP/SMX DS bid x 3 days Or Fosfomycin 3 gm once Duration: 3 days vs 5	Alternatives: Amox-clavulanate, cefdinir, cefaclor, or cefpodoxime x 3-7d or FQ x 3 d
Pregnancy	Amoxicillin Nitrofurantoin Cephalexin TMP/SMZ Duration: 7 days	AVOID: FQ Tetracyclines AG TMP/SMZ (esp 3rd trimester	Pregnant women should be screened for UTI even if asymptomatic
Recurrent cystitis	Relapse: treat 2-6 weeks	Reinfection <2/yr: pt initiated x3days 3+/yr: post-intercourse TMP/SMZ SS, cephalexin 250mg, nitro 50-100mg 3+/yr: daily or 3x/wk	3+/yr other can also use TMP 100mg, or Norfloxacin 200mg
Uncomplicated Pyelonephritis	Not requiring hospital: Cipro 500mg BID x 7d Cipro ER 1000mg daily x 7d OR Levo 750 mg daily x 5d OR TMP-SMX DS bid x 14d Hospitalized: IV FQ Aminoglycoside with or w/o ampicillin OR extended-spectrum cephalosporin or an extended-spectrum pcn with or without an aminoglycoside or carbapenem	Not requiring hospital: Or Oral beta-lactam (less effective) plus initial IV ceftriaxone 1gm OR IV 24-hour dose of aminoglycoside	For pts without N/V and not immunocompromised
Complicated UTIs	FQ levo x 5 days AG x 5-14 days	Extended spectrum Beta lactam
Catheter-related UTIs	Symptomatic pts x 7-10 days and cath removal	Assymptomatic pts should NOT be treated	E.coli, Candida, Enterococcus, Pseudo, Kleb pneumo, Enterobacter
Prostatitis	Acute: Duration 4 weeks TMP/SMZ Cephalosporins FQ	Chronic: 1-4 months TMP/SMZ FQ
Epididymitis	>35 yr: TMP/SMZ, FQ x 10 days- 4 weeks	< 35 yr: Ceftriaxone 250mg IM AND doxycycline 100mg bid x 10 days

Skin and Soft Tissue Infections

Cellulitis	Nafcillin, Oxacillin, Dicloxacillin x5-10 days	Alternatives: Clinda, BL combos, 1st ceph	Vanco/Linezolid for MRSA PCN G if streptococcal
Erysipelas	Penicillin G, Clindamycin x 7-10 days
Necrotizing Fasciitis	B lactam combo + clinda  + cipro Carbapenems Cefotaxime + clinda OR metron	Streptococcal: High dose IV PCN + clindamycin	ABX not curative, surgical debridement necessary!
DM Foot Infection	Deep:  1-2 weeks Amp/sulbac, Ticar/clav, Pip/taz Ertapenem FQ + [clindamycin OR metron] Cefoxitin 3rd ceph + [clinda OR metron]	Shallow: treat like cellulitis PCN, 1st ceph, etc.	Topical: Becaplermin 0.01% Human platelet derived growth factor, improves healing from 35-50% Surgery also important

Osteomyelitis: treat for 4-6 weeks (chronic IV 6-8 weeks + 3-12 months PO)

1. Neonates: Nafcillin + [cefotaxime OR AQ]

2. Infants: Cefuroxime OR ceftriaxone OR [Nafcillin + cefotaxime]

3. Peds (>3yr): Nafcillin OR Cefazolin OR Clindamycin

4. Adults: Nafcillin OR Cefazolin OR Vancomycin

5. Pts with Sickle Cell Anemia: Nafcillin + Ampicillin

6. Prosthetic Joint Infections: Vancomycin + rifampin OR Nafcillin + rifampin

CNS Infections: Meningitis

Empiric: 7-14 days

1. Neonates: Ampicillin + AQ OR + cefotaxime

2. 1 month- 50 yrs: 3^rd ceph (cefotaxime, ceftriaxone) + Vanco

3. >50 yrs: 3^rd ceph +Vanco + ampicillin

4. penetrating head trauma: Vanco + cefepime, ceftazidime, meropenem

Pathogen Known: MOSTLY PCN G 4mill units IV q4h OR Ampicillin 2g q4h, alt: 3^rd ceph, vanco, mero, FQ

Corticosteriods: Dexamethasone 0.15 mg.kg q6h x2-4 days; give 10-20 mins before (or at time of ) Abx

Benefit in: Peds with H.flu and Adults with S. pneumo

Brain Abscess: Treat based on source: mostly metron + 3^rd Ceph                               Unknown source: Vanco + Metron+ 3^rd ceph

Endocarditis: Strep, Staph, Entero, HACEK    Duration: 4-6 weeks (8+ weeks with VRE)

Strep: PCN G ± gent, Ceftriaxone ± gent, Vanco

Staph: Oxa/nafcillin ± gent (+ rifampin if prosthetic valve), Cefazolin ± gent (+ rifampin if prosthetic)

MRSA: Vanco (+ rifampin if prosthetic); may also use Vanco in severe PCN allergy

Entero: [PCN G or ampicillin or vanco]  + [gent or streptomycin]                 VRE: linezolid, Quin/Dalf

HACEK: ceftriaxone, Amp/sulbactam, FQ

PPx: dental and resp tract procedures: Amoxicillin 2g PO 1 hr prior                          PCN Allergy: Clinda, azith/clarith

Perotonitis/ Intra-Abdominal Infections

Mild-Mod: cefoxitin, Ticar/clav, ertapenem, moxifloxain,tigecycline;  [cipro/levo +metronidazole],

[cefazolin/ cefuroxime/ceftriaxone/cefotaxime + metronidazole]

Severe, healthcare acquired, High-risk: Pip/Taz, [ceftazidime/cefepime +metronidazole], imi/cil, mero, dori, [cipo/levo +

metronidazole (not for healthcare acquired)]

Duration: 4-7 days, [injuries repaired in 12hr can be treated for only 24 hr]

C. difficile: diagnose by presence of endotoxins

Initial Therapy:  Mild to moderate initial episode:  Metronidazole 500mg PO/IV tid x 10-14days OR Vanco 125mg PO QID x 10-14days

Severe initial episode:  Vancomycin 125 mg PO QID for 10-14 days

Severe complicated CDI: Vancomycin 500mg PO plus Metronidazole IV 500mg Q8H

Recurrences:  First recurrence:  Same as for initial episode

Second recurrence: Vancomycin tapered/pulsed

Medical/Surgical PPX

Procedure	Treatment	Comment
Gastric/duodenal	Cefazolin 1-2g	Indicated: morbid obesity, esophe obstruction, decreased gastric pH or motility
Biliary	Cefazolin 1-2g	Indicated with (without?): acute cholecystitis, obstr. jaundice, common duct stones, >70yr
Appendectomy	Cefoxitin 1-2g Cefazolin 1-2g  + metronidazole OR amp/sulbactam	If perforated treat x 3-7 days
Colorectal	Cefoxitin 1-2g Cefazolin + metronidazole OR amp/sulbacam Gent/tobra 1.5mg/kg + clinda 600mg/metron 0.5-1g ± neomycin +erythromycin/ metronidazole	PO/IV may be better bc PO only may cause Cdiff Mechanical bowel prep is not recommended
Obstetrics/GYN	Hysterectomy: Cefazolin/cefoxitin 1-2g Caesarian: cefazolin 1-2g	Caesarian: administer AFTER cord clamped
Cardiothoracic	Cardiac surg/Pulm resection: cefazolin/cefur oxime 1-2g Vascular surg: cefazolin 1g q8h x3doses	For all: Use Vanco if MRSA risk
Orthopedic	Cefazolin 1-2g (or cefur or vanco)	Indicated: surgery involves prosthetics
Head/Neck	Cefazolin 1-2g Amp/sul 1.5-3g Gent 1.5mg/kg + clinda 600-900mg	Indicated: major surgery when incision through oral or pharyngeal mucosa
Urologic	NOT recommended	If (+) urine culture, treat then operate

And because pseudomonas is always mentioned:

Pseudomonas aeruginosa

Drugs of Choice:  Piperacillin-tazobactam, Imipenem, Meropenem, Ceftazidime, Cefepime, Amikacin, Gentamycin, Tobramycin, Ciprofloxacin

Alternatives:  Timentin, Aztreonam, Levofloxacin

Third-Line agents:

Comments:  (Gram-negative bacilli).   Consider using two agents from two different classes as empiric treatment in critically ill patients if P. aeruginosa is suspected. Once susceptibilities known, narrow to one drug according to susceptibility report.

BCPS 2013: Infectious Disease (Pneumonia)

Infectious Disease.  The topic that I like but loathe.  At the same time. Pneumonia

1. Community Acquired Pneumonia (CAP) - not hospitalized 2 days or more within the past 90 days, not in a LTC facility/residence, no IV antibiotic therapy, IV chemo, or wound care in the past 30 days, or attendance at a hospital or dialysis clinic.  Must have at least two of the following symptoms:  fever or hypothermia, rigors, sweats, new cough (with or without sputum), chest discomfort, onset of dyspnea, or fatigue, pain, headache, myalgias, anorexia.CURB-65 - predictor of complicated course and whether to admit to the hospital.  Give a point for each of the following:  age > 65, comorbid illnes (DM, CHF, lung dz, renal dz, liver dz), high temp > 101F, Bacteremia, altered mental status (think elderly), immunosuppression (cancer, steroid use), High-risk etiology (S. aureus, legionella, G- bacilli, anaerobic aspiration), multilobe involvement or pleural effusion.
2. Nosocomial Pneumonia:  Hospital Acquired Pneumonia (HAP) (48 hours or more after admission), Ventilator Assoc Pneumo (more than 48–72 hours after intubation), Health care Assoc Pneumo (2 or more days within 90 days of the infection) - know risk factors of nosocomial pneumonia.  Pretty common sense.
3. CAP Organisms:  Unidentifiable (40-60%), M.pneumo, S. pneumo, H.flu, C.pneumo, viruses, S. aureus, Moraxella cat,
4. Alcoholics - S. pneumoniae, oral anaerobes, gram negative bacilli
5. Nursing Home - S. pneumoniae, H. influenzae, gram negative bacilli, S. aureus
6. COPD - S. pneumoniae, H. influenzae, M. catarrhalis
7. Postinfluenza: H. influenzae, S. aureus, S. pneumoniae
8. Exposure to water: Legionella
9. Poor oral hygiene: oral anaerobes
10. HIV infection: P. jiroveci, S. pneumoniae, M. pneumoniae, Mycobacterium

HAP Organisms:  S. aureus, Pseudomonas aeruginosa, Enterobacter spp., Klebsiella pneumoniae, Candida, Acinetobacter spp., Serratia marcescens, Escherichia coli, S. pneumoniae

P. aeruginosa is transmitted by health care workers’ hands or respiratory equipment S. aureus is transmitted by health care workers’ hands Enterobacteriaceae endogenously colonize hospitalized patients’ airways (healthy people seldom have gram negative upper airway colonization) Stress changes respiratory epithelial cells so that gram-negative organisms can adhere Up to 70% of patients in the intensive care unit have gram-negative upper airway colonization, and 25% of them will become infected through aspiration

TREATMENT

CAP - duration of treatment at least five days:

Empiric nonhospitalized - prev healthy and no abx in past 3 mos - macrolide or doxy (macrolide if H.flu suspected) and if comorbidities present or recent antibiotics in past 3 months - Respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin [750 mg])

-- OR -- Macrolide (or doxycycline) with high-dose amoxicillin (1 g 3 times/day) or amoxicillin/clavulanate (2 g 2 times/day) or with a cephalosporin (ceftriaxone, cefuroxime, or with cefpodoxime)

Empiric treatment of hospitalized patients with moderately severe pneumonia - Respiratory fluoroquinolone

--OR-- Ampicillin, ceftriaxone, or cefotaxime (ertapenem in select patients) plus a macrolide (or doxycycline)

Empiric treatment of hospitalized patients with severe pneumonia requiring intensive care unit treatment (may need to add other antibiotics if P. aeruginosa or MRSA is suspected)

• Ampicillin/sulbactam plus either a respiratory fluoroquinolone or azithromycin
• Ceftriaxone plus either a respiratory fluoroquinolone or azithromycin
• Cefotaxime plus either a respiratory fluoroquinolone or azithromycin

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 d/c

Hospital Acquired Pneumonia - 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).

1. Early onset (less than 5 days) and no risk factors for multidrug-resistant organisms -  Common organisms include S. pneumoniae, Haemophilus influenzae, (MSSA), Escherichia coli, Klebsiella pneumoniae, Enterobacter spp., and Proteus spp. -- Treatment -- Third-generation cephalosporin (cefotaxime or ceftriaxone), Fluoroquinolone (levofloxacin, moxifloxacin, ciprofloxacin), Ampicillin/sulbactam, OR Ertapenem
2. 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. -- Treatment -- a.  Ceftazidime or cefepime plus aminoglycoside or fluoroquinolone (cipro-, levo-)  b.  Imipenem, meropenem, or doripenem plus aminoglycoside or fluoroquinolone (ciprofloxacin, levofloxacin), OR c.  Piperacillin/tazobactam plus aminoglycoside or fluoroquinolone (ciprofloxacin, levofloxacin)  ***Vancomycin or linezolid should be used only if MRSA risk factors (e.g., history of MRSA infection/colonization, recent hospitalization or antibiotic use, presence of invasive health care devices) are present or there is a high incidence locally (greater than 10%–15%).

Risk factors for MDR organisms -- Antibiotic therapy within the past 90 days, Hospitalization of 5 days or more, High resistance in community or hospital unit, Risk factors for health care–associated pneumonia, Immunosuppressive disease and/or therapy

A wonderful article published just last November that I love.  (Pharmacy Times)  Only thing is it doesn't go into the detail of the different antibiotics with Late vs Early Onset of Hospital Acquired.  Just CAP.  That's OK

And because guidelines haven't changed, my quizlet from last year.  Hope you enjoy:

BCPS 2013: Pediatrics Otitis Media

Such a fun topic!  Who loves it when the kid says his/her ear hurts?  I cringe just thinking about this one: Otitis Media:  The Bane of all Daycare and all School-aged Youngsters

Common Pathogens

• Viral
• S. pneumoniae
• Nontypeable H. influenzae
• Moraxella catarrhalis

Treatment

• Watch and wait if > 2 yo and pain/fever less than 48-72 hours
• Bulging tympanic membrane/perforation = antibiotics
• Always antibiotics if < 6 months old 4. Middle ear fluid does not indicate repeated treatment unless persists > 3 months
• Corticosteroids, antihistamines, and decongestants are not recommended

Antibiotic regimens a. Amoxicillin (high dose: 80–90 mg/kg/day): Recommended by AAP as the first-line therapy for acute otitis media b. Amoxicillin/clavulanate c. Cefuroxime d. Other antibiotic options (e.g., cefdinir, cefpodoxime) may be effective. e. Duration i. The most appropriate duration is unclear. ii. In general, 7–10 days, but a shorter course (5 days) has been used in children older than 2 years iii. For confirmed cases of acute otitis media not responding to the initial antimicrobial regimen within 48–72 hours, a change in antibiotic regimen is warranted. Failure of the the above warrants ceftriaxone IM for 3 days or tubes i. Intramuscular ceftriaxone may also be considered if adherence is a concern. ii. Tympanostomy with tube placement may be most beneficial for children with persistent otitis media with effusions and significant hearing loss (e.g., greater than 25-dB hearing loss in both ears for more than 12 weeks).

Prophylaxis 1. Reserved for patients with recurrent acute otitis media 2. Reduces occurrence by about one episode per year 3. The risk of promoting bacterial resistance may outweigh the slight benefit

All Things Vancomycin

Believe it or not, vancomycin was first isolated in the fifties from an isolate of dirt in the jungles of Borneo by a missionary. It is a naturally occurring antibiotic made by the soil bacterium Actinobacteria. The name vancomycin comes from the word vanquish.  Initially it was used as a sort-of last resort for penicillinase-producing strains of Staphylococcus aureus.  Today, vancomycin is one of the most widely used antibiotics for the treatment of serious gram positive infections involving methicillin-resistant S. aureus (MRSA). Years ago, early use of vancomycin was associated with several different types of toxicities including infusion related effects (Red Man Syndrome), nephrotoxicity (kidney), and possible ototoxicity (damage to ears).  It was determined later that the majority of these adverse effects were due to the early formulations that contained impurities; however, by that time, its use was decreased with the development of other penicillin-type medicines like methicillin, oxacillin, and nafcillin).  Thanks to MRSA, Vancomycin is making a huge comeback, or has been since the early 1980s.

On a side note, Red Man Syndrome is not an allergic reaction.  This can be managed with a histamine blocker or slowing down the infusion.  Can't tell you how many times I have seen this listed as an allergy to vancomycin on someone's profile.

In monitoring Vancomycin, trough serum concentrations are the most accurate method.  Typically draw the trough level prior to the fourth dose (steady-state).  Keep trough levels above at least 10 mg/L to avoid development of resistance.  For a pathogen with an MIC of 1 mg/L, the minimum trough concentration would have to be at least 15 mg/L.  For complicated infections, the optimal trough concentrations are 15-20 mg/L to improve penetration, increase optimal serum concentrations, and improve clinical outcomes.

How to dose?  Dosing vancomycin is a bit of an art, but start at 15-20 mg/kg using actual body weight.  Many hospitals encourage a maximum dose of 2 grams.  Definitely adjust dose in renal dysfunction.

Creatinine Clearance(based on Cockcroft and Gault and not eGRF)	Dose*
>60 ml/min	Uncomplicated Infections: 10-15 mg/kg q12h1  Serious Infections: Consider loading dose of 25mg/kg IV x1, followed by 15-20 mg/kg q8-12h (45-60mg/kg/day divided q12h or q8h)2
40-60 ml/min	10-15 mg/kg q12h-q24h
20-40 ml/min	5-10 mg/kg q24h
10-20 ml/min	5-10 mg/kg q24h-q48h
<10 ml/min	10 - 15 mg/kg IV loading dose x1; redose according to serum levels
Hemodialysis	15-20 mg/kg load, then 500 mg IV post HD only
CVVH	10-15 mg/kg q24h

* round dose to 250mg, 500mg, 750mg, 1g, 1.25g, 1.5g, 1.75g or 2g (maximum: 2gm/dose)

Higher total daily doses of vancomycin have been associated with nephrotoxicity

¹ For patients with uncomplicated infections requiring vancomycin, trough levels of 10-15 mcg/ml are recommended.

² For patients with serious infections due to MRSA (central nervous system infections, endocarditis, ventilator-associated pneumonia, bacteremia or osteomyelitis) , trough levels of 15-20 mcg/ml are recommended.

Vancomycin troughs are not recommended in patients in whom anticipated duration of therapy is short (≤ 3 days)

Trough levels are recommended for routine monitoring (for intermittent hemodialysis, a pre-dialysis level should be drawn). Trough levels should be obtained within 30 minutes before 4^th dose of a new regimen or dosage change.

Once weekly monitoring is reasonable in patients with stable renal function and clinical status. (Data supporting safety or prolonged troughs of 15-20 mcg/ml is limited.)

There is a great app out there I recommend called Vancomycin ClinCalc Full.  The author also has a website called ClinCalc you can check out to see if the dosing matches how your particular program wants you to do it.

I don't earn a dime for that link either, I just enjoy finding quality programs to work more efficiently.

I love Dr. Walter Crittenden, PharmD MD "An Infections Disease Compendium:  A Persiflagers Guide" on the iPad as well.

One of my biggest pet-peeves is when I hear someone say, "Oh I have blown their kidneys!" in regards to one serum creatinine level coming back higher.  Hey, let's wait until 2-3 consecutive high serum creatinine concentrations (increase of 0.5 mg/dL or 150% increase from baseline, whichever is greater) after several days before making such a claim.  Seriously.

And the "Rants and Screeds" of Dr. Crittenden, "Vancomycin is a shitty drug; mostly static, toxic, lousy pharmacokinetics, penetrates poorly into all tissues.  When compared to beta lactams, it is always worse."

Gotta love that!

Meet Mr. MRSA

I thought I would introduce you to an infectious organism every week!  Today, the lucky "bug" as they are referred to in the medical community is methicillin resistant staphylococcus aureus (MRSA). If I was a common layperson in the field of medicine, I would view this microorganism as a very nasty flesh eating entity.  I thought I would shed some light about MRSA.  Whether you are dealing with a soft tissue infection, pneumonia, central nervous system infection, endocarditis (heart), or bone and joint, the treatment differs.

Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body. It's tougher to treat than most strains of staphylococcus aureus -- or staph -- because it's resistant to some commonly used antibiotics.

The symptoms of MRSA depend on where you're infected. Most often, it causes mild infections on the skin, causing sores or boils. But it can also cause more serious skin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract.

Though most MRSA infections aren't serious, some can be life-threatening. Many public health experts are alarmed by the spread of tough strains of MRSA. Because it's hard to treat, MRSA is sometimes called a "super bug."  Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that causes infections in different parts of the body. It's tougher to treat than most strains of staphylococcus aureus -- or staph -- because it's resistant to some commonly used antibiotics.

The symptoms of MRSA depend on where you're infected. Most often, it causes mild infections on the skin, causing sores or boils. But it can also cause more serious skin infections or infect surgical wounds, the bloodstream, the lungs, or the urinary tract.

Though most MRSA infections aren't serious, some can be life-threatening.  Many public health experts are alarmed by the spread of tough strains of MRSA.  Because it's hard to treat, MRSA is sometimes called a "super bug." 

Also just news today... an almost instant test in detecting MRSA.

Skin and soft-tissue infections

1.  Abscess  - incision and drainage
2. Purulent cellulitis
   • Clindamycin 300-450 mg PO TID (C diff)
   • Bactrim 1-2 DS tablets BID (pregnancy category C/D)
   • Doxycycline 100 mg BID (pg category D and not recommend for children under 8)
   • Minocycline 200 mg x 1, then 100 mg PO BID
   • Linezolid 600 mg BID (expensive)
3.  Nonpurulent cellultis
   • Beta lactam (cephalexin and dicloxacillin) 500 mg QID
   • Clindamycin 300-450 mg TID
   • Beta lactam and/or Bactrim or a tetracycline – amoxicillin 500 mg TID
   • Linezolid 600 mg BID
4. Complicated SSTI
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
   • Linezolid 600 mg PO/IV BID
   • Daptomycin (cubicin) 4 mg/kg/dse IV QD
   • Telavancin 10 mg/kg/dose IV QD
   • Clindamycin 600 mg PO/IV TID
5. Bacteremia
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
   • Daptomycin 6 mg/kg/dose IV QD
6. Infective endocarditis, native valve – same as bacteremia
7. Infective endocarditis prosthetic valve
   • Vancomycin and gentamicin and rifampin – 15-20 mg/kg/dose IV every 8-12 hrs,                                          i.      1 mg/kg/dose IV every 8 h,  300 mg PO/IV every 8 h
8.  Persistant bacteremia
9. Pneumonia
   • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours        
   • Linezolid 600 mg PO/IV BID
   • Clindamycin 600 mg PO/IV TID
10. Osteomyelitis (Bone and Joint Infections)
    • Vancomycin 15-20 mg/kig/dose IV every 8-12 hours
    • Daptomycin 6 mg/kg/day IV QD
    • Linezolid 600 mg PO/IV BID
    • Clindamycin 600 mg PO/IV TID
    • TMP-SMX and rifampin – 3.5-4.0 mg/kg/dose PO/IV every 8-12 h
11. Septic arthritis
    • Vancomycin 15-20 mg/kg every 8-12 hours
    • Daptomycin 6 mg/kg/day IV QD
    • Linezolid 600 mg PO/IV BID
    • Clindamycin 600 mg PO/IV TID
    • Bactrim 3.5-4.0 mg/kg/dose PO/IV every 8-12 hours
12. Meningitis
    • Vancomycin 15-20 mg/kg/dose IV every 8-12 hours
    • Linezolid 600 mg PO/IV BID
    • Bactrim 5 mg/kg/dose PO/IV every 8-12 hours
13. Brain abscess, subdural empyema, spinal epidural abcess
    • Vancomycin 15-20 mg/kg/dose every 8-12 hours
    • Linezolid 600 mg po/iv BID
    • Bactrim 5 mg/kg/dose PO/IV every 8-12 hours
14. Septic thrombosis of cavernous or dural venous sinus
    • Vanc same
    • Zyvox
    • Bactrim same