Antibiotic Choices - Handbook of Lower Extremity Infections

Report
Warren S. Joseph, DPM, FIDSA
Roxborough Memorial Hospital, Phila., PA
www.leinfections.com
 Deep
soft tissue & Bone cultures grew
MSSA & Group B Streptococcus
 Patient initially on Vanco + pip/tazo
 Given these bugs…what drug do you
choose?
 Cephalexin
A
marked decrease in patients
presenting with MRSA
 An increase in ESBL/KPC caused DFI
 The approval and release of ceftaroline
 The revised IDSA DFI Guidelines
“Aerobic gram-positive cocci (especially
Staphylococcus aureus) are the
predominant pathogens in diabetic foot
infections. Patients who have chronic
wounds or who have recently received
antibiotic therapy may also be infected
with gram-negative rods, and those with
ischemia or gangrene may have obligate
anaerobes.” CID Oct 1, 2004
Anti-Staph and Strep
antibiotic
 May
be true in mild infection but no
definitive data
 Polymicrobial flora may worsen
Staphylococcus
Enterobacteriaceae
prognosis
aureus
Anaerobes
 Caution in severe infection and in
Beta-haemolytic
Commensal gram-positive cocci
Strep
osteomyelitis
Slide Courtesy of A. Berendt, MD
IDSA Mild (po)




ASOC
Amoxicillin/clavulanic acid
Clindamycin
Oral PRP
Moderate/Severe





Β-lactam/β-lactamase inhibitor compound
Ertapenem
Cefazolin
Clindamycin (IV/PO)
Vancomycin
THE ROLE OF HANDWASHING IN THE SPREAD of MRSA
NEJM Jan 2009
Mild



Later generation tetracycline (PO)
• Minocycline
• Doxycycline
TMP/SMX
Clindamycin (+/-)
Moderate/Severe





Linezolid (IV/PO)
Vancomycin (IV)
Daptomycin (IV)
Tigecycline (IV)
Ceftaroline (IV)
 An
increasing clinical problem
 “Staph aureus with reduced
susceptibility to vancomycin”
 aka “MIC Creep”
• Difficult to detect
• MIC on the rise from 0.5 » 1.0 » 2.0 µg
• Have been associated with Tx failures
 PLEASE
– Look at your vancomycin MIC if
considering its use against MRSA!
90
80
80.9
79.9
70.4
% of Isolates
70
64.6
60.1
60
50
40
39.7
35.1
28.8
30
20
19.9
18.9
10
0
0.2
0.2
2000
2001
MIC ≤0.5
MIC=minimum inhibitory concentration.
Wang G et al. J Clin Microbiol. 2006;44:3883-3886.
0.3
2002
MIC=1
0.2
2003
MIC ≥2
0.8
2004
“If you show a vancomycin MIC against
MRSA of >1µg/ml you can not achieve a
level of vancomycin that is high enough
to be both safe and effective. You should
use an alternative agent”
paraphrasing Robert Moellering, MD, ICAAC 2009
Courtesy of Lee Rogers, DPM
 This
one is easy…pretty much anything
you use for Staphylococcus will be active
against Group B Streptococcus
 Extended Spectrum β-lactamases (ESBL)
• Increasing in E. coli, Proteus mirablis & Kleb pneumo
along with other gnr
• Resistant to most penicillins, cephalosporins and β
lactamase inhibitor compounds
• Still susceptible to most carbapenems and tigecycline
 Carbapenemase producing gnr (KPC)
• Not yet as common as ESBL
• As name implies, resistant to carbapenems
 NDM-1
 Do
we need to concern ourselves??
 Do
we really need to treat it?
Options
 Ciprofloxacin (PO/IV)
 Ceftazidime (IV)
 Cefepime (IV)
 Aztreonam (IV)
+/- Aminoglycoside
 Other
quinolone
 Piperacillin/tazobactam *
 “Head
of the Snake” principle
 Consider empiric “De-escalation”
therapy depending on local MRSA
prevalence
 Watch your vancomycin MICs for “creep”
 Be aware of ESBLs and KPCs in your
hospital (speak with your IC specialist)
 Be alert for “Pseudomonophobia”

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