Table 5.
Intravenous antimicrobial treatment of intravenous catheter-related bloodstream infection in adults according to the specific pathogen isolated.
| Pathogen | Preferred antimicrobial agent | Example, dosagea | Alternative antimicrobial agent | Comment |
|---|---|---|---|---|
| Gram-positive cocci | ||||
| Staphylococcus aureus | ||||
| Meth susceptible | Penicillinase-resistant Penb | Naf or Oxa, 2 g q4h | Cfaz, 2 g q8h; or Vm, 15 mg/kg q12h | Penicillinase-resistant Pen or Csps are preferred to Vm.c For patients receiving hemodialysis, administer Cfaz 20 mg/kg (actual weight), round to nearest 500-mg increment, after dialysis |
| Meth resistante | Vm | Vm, 15 mg/kg q12h | Dapto, 6–8 mg/kg per day, or linezolid; or Vm plus (Rif or Gm); or TMP-SMZ alone (if susceptible) | Strains of S. aureus with reduced susceptibility or resistance to Vm have been reported; strains resistant to linezolid and strains resistant to Dapto have been reported |
| Coagulase-negative staphylococci | ||||
| Meth susceptible | Penicillinase-resistant Pen | Naf or Oxa, 2 g q4h | First-generation Csp or Vm or TMP-SMZ (if susceptible) | Vm has dosing advantages over Naf and Oxa, but the latter are preferred because of concerns about increasing Vm resistance |
| Meth resistant | Vm | Vm, 15 mg/kg iv q12h | Linezolid, Dapto 6 mg/kg per day, or Quin/Dalf | For adults <40 kg, linezolid dose should be 10 mg/kg; strains resistant to linezolid have been reported |
| Enterococcus faecalis/Enterococcus faecium | ||||
| Amp susceptible | Amp or (Amp or Pen) ± aminoglycoside | Amp, 2 g q4h or q6h; or Amp ± Gm, 1 mg/kg q8h | Vm | Vm may have dosing advantages over Amp, but there are concerns about Vm resistance |
| Amp resistant, Vm susceptible | Vm ± aminoglycoside | Vm, 15 mg/kg iv q12h ± Gm, 1 mg/kg q8h | Linezolid or Dapto 6 mg/kg per day | Quin/Dalf is not effective against E. faecalis |
| Amp resistant, Vm resistant | Linezolid or Dapto | Linezolid, 600 mg q12h; or Dapto 6 mg/kg per day | Quin/Dalf 7.5 mg/kg q8h | Susceptibility of Vm-resistant enterococci isolates varies; Quin/Dalf is not effective against E. faecalis |
| Gram-negative bacillid | ||||
| Escherichia coli and Klebsiella species | ||||
| ESBL negative | Third-generation Csp | Ctri, 12 g per day | Cipro or Atm | Susceptibility of strains varies |
| ESBL positive | Carbapenem | Erta, 1 g per day; Imi, 500 mg q6h; or Mero, 1 g 8 hr | Cipro or Atm | Susceptibility of strains varies |
| Enterobacter species and Serratia marcescens | Carbapenem | Erta, 1 g per day; Imi, 500 mg q6h; Mero, 1 g q8h | Cefepime or Cipro | Susceptibility of strains varies |
| Acinetobacter species | Amp/Sulb or carbapenem | Amp/Sulb, 3 g q6h; or Imi, 500 mg q6h; Mero, 1 g q8h | … | Susceptibility of strains varies |
| Stenotrophomonas maltophilia | TMP-SMZ | TMP-SMZ, 35 mg/kg q8h | Tic and Clv | … |
| Pseudomonas aeruginosa | Fourth-generation Csp or carbapenem or Pip and Tazo with or without aminoglycoside | Cefepime, 2 g q8h; or Imi, 500 mg q6h; or Mero, 1 g q8h; or Pip and Tazo, 4.5 g q6h, Amik, 15 mg/kg q24h or Tobra 5–7 mg/kg q24h | … | Susceptibility of strains varies |
| Burkholderia cepacia | TMP-SMZ or carbapenem | TMP-SMZ, 35 mg/kg q8h; or Imi, 500 mg q6h; or Mero, 1 g q8h | … | Other species, such as B. acidovorans and B. pickieii, may be susceptible to same antimicrobial agents |
| Fungi | ||||
| Candida albicans or other Candida species | Echinocandin or fluconazole (if organism is susceptible) | Caspo, 70 mg/kg loading dose, then 50 mg/kg per day; micafungin, 100 mg per day; anidulafungin, 200 mg loading dose followed by 100 mg per day; or fluconazole, 400–600 mg per day | Lipid AmB preparations | Echinocandin should be used to treat critically ill patients until fungal isolate is identified |
| Uncommon pathogens | ||||
| Corynebacterium jeikeium (group JK) | Vm | Vm, 15 mg/kg q12h | Linezolid (based on in vitro activity) | Check susceptibilities for other corynebacteria |
| Chryseobacterium (Flavobacterium) species | Fluoroquinolone, such as Lvfx | Lvfx 750 mg q24h | TMP-SMZ or Imi or Mero | Based on in vitro activity. |
| Ochrobacterium anthropi | TMP-SMZ or fluoroquinolone | TMP-SMZ, 35 mg/kg q8h; or Cpfx, 400 mg q12h | Imi or Mero plus aminoglycoside | … |
| Malassezia furfur | AmB | … | Voriconazole | Intravenous lipids should be discontinued; some experts recommend removal of catheter |
| Mycobacterium species | Susceptibility varies by species | … | … | Different species have wide spectra of susceptibility to antimicrobials [256, 257] |
NOTE. See S. aureus section of the text regarding important antibiotic management issues concerning linezolid. AmB, amphotericin B; Amp, ampicillin; Atm, aztreonam; Cfaz, cefazolin; cfur, cefuroxime; Clv, clavulanate; Cpfx, ciprofloxacin; Csp, cephalosporin; Ctri, ceftriaxone; Czid, ceftazidime; Erta, ertapenem; Gm, gentamicin; Imi, Imipenem; iv, intravenous; Ket, ketoconazole; Lvfx, levofloxacin; Mero, meropenem; Meth, methicillin; Mez, mezlocillin; Naf, nafcillin; Oxa, oxacillin; Pen, penicillin; PenG, penicillin G; po, by mouth; Pip, piperacillin; Quin/Dalf, quinupristin/dalfopristin; Rif, rifampin; Sulb, sulbactam; Tic, ticarcillin; Tm, tobramycin; TMP-SMZ, trimethoprim-sulfamethoxazole; Vm, vancomycin.
Initial antibiotic dosages for adult patients with normal renal and hepatic function and no known drug interactions. Fluoroquinolones should not be used for patients <18 years of age (see the section of the text devoted to treating pediatric infection [256, 257]).
Pen, if the strain is susceptible.
Some clinicians will add an aminoglycoside for the first 5 days of therapy.
Pending susceptibility results for the isolate.