Table 3.
Suggested targeted antibiotic therapy
| Microorganism | Antibiotica | Doseb | Route |
|---|---|---|---|
| Staphylococcus spp. | |||
| Oxacillin/methicillin susceptible | Flucloxacillinc | 4×2 g | i.v. |
| (+/−Fosfomycin)d for 2 weeks, followed by (according to susceptibility) | (3×5 g) | i.v. | |
| Rifampicine + | 2×450 mg | p.o. | |
| • Levofloxacin or | 2×500 mg | p.o. | |
| • Cotrimoxazole or | 3×960 mg | p.o. | |
| • Doxycycline or | 2×100 mg | p.o. | |
| • Fusidic acid | 3×500 mg | p.o. | |
| Oxacillin/methicillin resistant | Daptomycin or | 1×8 mg/kg | i.v. |
| Vancomycinf | 2×1 g | i.v. | |
| (+/−Fosfomycin)d for 2 weeks, followed by an oral rifampicin combination as above | (3×5 g) | i.v. | |
| Rifampicin resistant | Intravenous treatment according to susceptibility for 2 weeks (as above), followed by long-term suppression for ≥1 year | ||
| Streptococcus spp. | |||
| Penicillin Gc or | 4×5 million U | i.v. | |
| Ceftriaxon for 2–3 weeks, followed by | 1×2 g | i.v. | |
| Amoxicillin or | 3×1000 mg | p.o. | |
| Levofloxacin | 2×500 mg | p.o. | |
| Enterococcus spp. | |||
| Penicillin susceptible | Ampicillin + | 4×2 g | i.v. |
| Gentamicing for 2–3 weeks, followed by | 1×240 mg | i.v. | |
| Amoxicillin | 3×1000 mg | p.o. | |
| Penicillin resistant | Vancomycinf or | 2×1 g | i.v. |
| Daptomycin + | 1×10 mg/kg | i.v. | |
| Gentamicing for 2–4 weeks, followed by | 1×240 mg | i.v. | |
| (+/−Fosfomycin) | 3×5 g | i.v. | |
| Linezolid (max. 4 weeks) | 2×600 mg | p.o. | |
| Vancomycin resistant | Individual; removal of the implant or lifelong suppression necessary | ||
| Gram-negative | |||
| Enterobacteriaceae (Escherichia coli, Klebsiella, Enterobacter, etc.) | Ciprofloxacinh | 2×750 mg | p.o |
| Non-fermenters (Pseudomonas aeruginosa, Acinetobacter spp.) | Piperacillin/tazobactam or meropenem or | 4×4.5 g/3×1 g | i.v. |
| Ceftazidime+ | 3×2 g | i.v. | |
| Tobramycin | 1×300 mg | i.v. | |
| (or gentamicin) for 2–3 weeks, followed by | 1×240 mg | i.v. | |
| Ciprofloxacin | 2×750 mg | p.o. | |
| Ciprofloxacin resistant | Depending on susceptibility: meropenem 3×1 g, colistin 3× 3 million U, and/or fosfomycin 3×5 g i.v., followed by oral long-term suppression | ||
| Anaerobes | |||
| Gram-positive (Cutibacterium, Peptostreptococcus, Finegoldiamagna) | Penicillin Gc or | 4×5 million U | i.v. |
| Ceftriaxon for 2 weeks, followed by | 1×2 g | i.v. | |
| Rifampicine + | 2×450 mg | p.o. | |
| • Levofloxacin or | 2×500 mg | p.o. | |
| • Amoxicillin | 3×1000 mg | p.o. | |
| Gram-negative (Bacteroides) | Ampicillin/sulbactamc for 2 weeks, followed by | 3×3 g | i.v. |
| Metronidazol | 3×400 mg or 500 mg | p.o. | |
| Candida spp. | |||
| Fluconazole susceptible | Caspofungini | 1×70 mg | i.v. |
| Anidulafungin for 1–2 weeks, followed by | 1×100 mg (first day: 200 mg) | i.v. | |
| Fluconazole (suppression for ≥1 year) | 1×400 mg | p.o. | |
| Fluconazole resistant | Individual (e.g., with voriconazole 2×200 mg p.o.); removal of the implant or long-term suppression | ||
| Culture negative | Ampicillin/sulbactamc for 2 weeks, followed by | 3×3 g | i.v. |
| Rifampicine+ | 2×450 mg | p.o. | |
| Levofloxacin | 2×500 mg | p.o. | |
Notes:
Total duration of therapy: 6–12 weeks, usually 2 weeks intravenously, followed by oral route.
Laboratory testing 2× weekly: leukocytes, CRP, creatinine/eGFR, liver enzymes (AST/SGOT and ALT/SGPT). Dose adjustment according to renal function and body weight (<40/>100 kg).
Penicillin allergy of NON-type 1 (e.g., skin rash): cefazolin (3×2 g i.v.). In case of anaphylaxis (= type 1 allergy such as Quincke’s edema, bronchospasm, and anaphylactic shock) or cephalosporin allergy: vancomycin (2×1 g i.v.) or daptomycin (1×8 mg/kg i.v.) Ampicillin/sulbactam is equivalent to amoxicillin/clavulanic acid (3×2.2 g i.v.).
Fosfomycin can be added in treating Staphylococcal infection, especially MRSA, but it cannot replace rifampicin as an antibiofilm agent.58
Rifampicin is administered only if an implant is in situ. Add it to intravenous treatment as soon as wounds are dry and drains removed; in patients aged >75 years, rifampicin is reduced to 2×300 mg p.o.
Check vancomycin through concentration (take blood before next dose) at least 1×/week; therapeutic range: 15–20 µg/mL.
Give only, if gentamicin HL is tested susceptible (consult the microbiologist). In gentamicin HL-resistant Enterococcus faecalis, gentamicin is exchanged with ceftriaxone (1×2 g i.v.).
Add i.v. treatment (piperacillin/tazobactam 3×4.5 g or ceftriaxone 1×2 g or meropenem 3×1 g i.v.) in the first postoperative days (until wound is dry).
After a loading dose of 70 mg on day 1, reduce the dose to 50 mg in patients weighing <80 kg from day 2.
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CRP, C-reactive protein; eGFR, estimated glomerular filtration rate; HL, high level; i.v., intravenous; MRSA, methicillin-resistant S. aureus; p.o., per oral; SGOT, serum glutamic oxaloacetic transaminase; SGPT, serum glutamic pyruvic transaminase.