Malignant Otitis Externa Inflammation and damage at the base of the skull due to an untreated outer ear P. aeruginosa most common organism Yellow-green drainage from the ear Odor Fever Deep inner ear pain Spread of throughout the body Recurring Brain and/or nerve damage Osteomyelitis of temporal bone Cipro (Ciprofloxacin) 750 mg every 12 hours, oral OR 400 mg every 12 hours, (Piperacillin/Tazobacta m) 4g to 6 g every 4 to 6 Timentin (Ticarcillin/Clavulanate Potassium) 3 g every 4 hours, In severe cases, Primaxin (Imipenem/cilastin) may be used due to its pseudomonal coverage. In addition, aminoglycosides (i.e. gentamicin) in combination with antimicrobials with pseudomonal coverage may be used. Ciprofloxacin resistant strands of pseudomonas do not increase morbidity or mortality. (Ceftazidime) 2 g every 12 hours, Maxipime (Cefepime) 2 g every 12 hours,
Rhinocerebral Mucormycosis Initially presents itself as an acute sinus. Caused by the Inhalation of fungal spores which can move quickly to the brain if not treated promptly. Saprophytic aerobic fungi found in soil and bread mold. Headache, N/V, fever and lethargy Inflammation Facial: Weakness, numbness & pain Nasal: Pale or gray Necrotizing (black) areas in face Pus drainage Ocular: Fixed pupil Nystagmus Blindness Failure of prompt treatment may progress condition to a coma or stroke First-line therapy: Debridement Amphotericin B (weight based dose) Alternative therapy: Noxafil (Posaconazole) 400 mg twice daily, oral (suspension) Nephrotoxicity (associated with Amphotericin B; consider lipid based formulation) Achievement of steady state with posaconazole occurs in 1 week; should not be considered as initial therapy. While providing antifugal treatment, underlying cause of the compromised immune system must be addressed (i.e. hyperglycemia) Nerves: Altered mental status Dizziness & unsteady gait Duration of treatment is dependent on patient's response to therapy. Emphysematous Cholecystitis Discovery of gas in gallbladder lumen, wall or surrounding tissues Gallstones = ~50% of all cases : gram positive, gram negative, and anaerobes Negative effects of the following cranial nerves: II, III, IV, V, VI, & VII Cerebral edema Right upper quadrant pain not related to physical activity; may radiate Fever Absent bowel sounds Perforated gallbladder Septic shock Broad spectrum antibiotics: Example(s): Unasyn Primaxin combinations may be used and should possess gram positive, pseudomonal, and anaerobic coverage.
Urinary Tract Infection/ Pyelonephritis Bacteria in the urinary tract/ Upper urinary tract affecting the kidneys Gram-negative organisms E. Coli, P. mirabilis, P. aeruginosa, etc. Yeast In some cases, polymicrobial is present Dysuria Flank pain Abdominal discomfort Toxic fever Chills Dry mucous membranes Tachycardia Fluoroquinolones Cipro (Ciprofloxacin) 500 mg twice daily, oral Levaquin (Levofloxacin) 750 mg daily, oral If oral is intolerable, consider the following options of therapy: Longer duration of therapy (7-14 days) Levaquin = 5 days of therapy Second line therapy: (Ceftazidime) 500 mg every 8-12 hours, for 10 days Cipro or Levaquin IV (Piperacillin tazobactam) 3.375 mg every 6 Maxipime (Cefepime) 2 g every 12 hours, for 10 days Bactrim DS/Septra DS may be considered Primaxin (Imipenem-Cilastin) 500 mg every 6 hours, Merrem (Meropenem) 1 g every 8 hours, Ampicilin 1-2 g every 6 hours + Gentamicin 2mg/kg/dose every 8 Bullous Diabeticorum Unknown N/A Blisters Development of osteomyelitis N/A Spontaneous healing in 2-6 weeks
SSTI Inflammation or wounds Gram-positive MRSA Inflammation or wounds that fail to heal properly Development into more severe conditions such as osteomyelitis or necrotizing faciitis MSSA SSTIs: Nafcillin Oxacillin Dicloxacillin Cefazolin CA-MRSA SSTIs: Vancomycin Zyvox (Linezolid) 600 mg every 12 hours, intravenous or oral De-escalate antimicrobial when appropriate. Vancomycin trough ranges: 10-15 mg/l for minor s 15-20 mg/l for severe s Cleocin (Clindamycin) 600 mg/kg every 8 OR 300-450 mg three times daily, oral Cubicin (Daptomycin) 4 mg/kg every day, Doxycycline 100 mg twice daily, oral Bactrim (TMP-SMZ) 1-2 double strength tablets twice daily, oral
Diabetic Foot Infections Lack of blood flow due to chronic hyperglycemia, peripheral vascular disease, and neuropathy including S. aureus, Streptococci, & P. aeruginosa Tachycardia Hypotension Pain Fever Chills Purulent discharge Erythema Osetomyelitis Necrotizing faciitis Mild: Dicloxacillin Keflex (Cephalexin) Levaquin (Levofloxacin) Augmentin (Amoxicillin/ clavulanate) Doxycycline Bactrim DS (TMP-SMZ) Wound care & debridement play a major role in the healing process of these s. De-escalate antimicrobial therapy when appropriate. Vancomycin trough range: 15-20 mg/l Moderate- Severe: Levaquin (Levofloxacin) Rocephin (Ceftriaxone) Unasyn (Ampicillin-Sulbactam) Avelox (Moxifloxacin) Invanz (Ertapenem) Tygacil (Tygecycline) Levaquin or Cipro + Clindamycin Vancomycin (Piperacillintazobactam) Cubicin (Daptomycin) (Ceftazidime) Maxipime (Cefepime)
Osteomyelitis Untreated that has spread to the bone S. aureus Gram-negative bacill Localized pain Tenderness in infected area Swelling, fever Erythema Sepsis Augmentin 875 mg twice daily, oral 3.375 g every 6 hours, Wound care & debridement play a major role in the healing process of these s. should be a minimum of 6 weeks. Unasyn 3 g every 6 hours, Vancomycin trough range: 15-20 mg/l Timentin 3.1 g every 6 hours, Clindamycin600 mg every 6 hours, or oral + Cipro 750 mg oral OR 400 mg every 12 hours, OR Levaquin750 mg daily, oral + Vancomycin 15mg/kg every 12 hours, if MRSA is suspected or confirmed.
Necrotizing Faciitis Lethal due to untreated wound including anaerobes Skin necrosis Blisters Gas in soft tissue Spread of necrotic tissue in spite of antibiotics Sepsis Anti-pseudomonal fluoroquinolone i.e. Cipro 4.5 grams every 6 Wound care & debridement play a major role in the healing process of these s. Combination therapy may be used to effectively treat. Clindamycin 600-600 mg every 8 hours, Vancomycin trough range: 15-20 mg/l Vancomycin 15-20 mg/kg every 12 hours, Primaxin 1 g every 6-8 Merrem (Meropenem) 1g every 8 hours, 2 g every 6 hours, + Flagyl 500 mg every 6 OR Clindamycin (see dose above) Aminoglycosides