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Chapter 3. Antibiotic Susceptibility Profiles and Initial Therapy

203

Gram Stain Characteristics of Isolates

(by Morphology, Arrangement, Oxygen Requirements)

AEROBIC ISOLATES

GRAM-POSITIVE COCCI (CLUSTERS)			Listeria monocytogenes†bm	217
Staphylococcus aureus (MSSA/MRSA/			Nocardia asteroides, braziliensis†γ	217
	VISA/VRSA)†b	208	Rhodococcus equi†γ	217
Staphylococcus (coagulase negative)
	epidermidis (CoNS)†g	209	GRAM-NEGATIVE BACILLI
Staphylococcus saprophyticus†g		210	GRAM-NEGATIVE BACILLI
GRAM-POSITIVE COCCI (CHAINS)			Acinetobacter baumannii, lwoffi,
GRAM-POSITIVE COCCI (CHAINS)			calcoaceticus, haemolyticus*†v	218
Enterococcus faecalis (VSE)α/γ		210	Aeromonas hydrophila†m	218
Enterococcus faecium (VRE)α/γ		211	Aggregatibacter (Actinobacillus)
Group A streptococciβ		211	Aggregatibacter (Actinobacillus)
Group A streptococciβ		211	actinomycetemcomitans*	218
Group B streptococci (S. agalactiae)β		211	actinomycetemcomitans*	218
Group B streptococci (S. agalactiae)β		211	Alcaligenes (Achromobacter)
Group C, F, G streptococciβ		212	Alcaligenes (Achromobacter)	219
Streptococcus anginosus (S. milleri)			xylosoxidans†m	219
Streptococcus anginosus (S. milleri)			Bartonella henselae, quintana,
	group (S. intermedius, S. anginosus,		Bartonella henselae, quintana,
	group (S. intermedius, S. anginosus,		bacilliformis*	219
	S. constellatus)	213	bacilliformis*	219
Streptococcus (bovis) gallolyticusα/γ		213	Bordetella pertussis, parapertussis†	219
Viridans streptococci (S. mitior,			Brucella abortus, canis, suis, melitensis†	219
	mitis, mutans, oralis, sanguis,		Burkholderia (Pseudomonas)
	parasanguis, salivarius)α/γ	213	cepacia†m	220
GRAM-POSITIVE COCCI ß(PAIRS)			Burkholderia (Pseudomonas)
GRAM-POSITIVE COCCI ß(PAIRS)			pseudomallei†m	220
Group B streptococci (S. agalactiae)β		211	pseudomallei†m	220
Leuconostocα		213	Campylobacter fetus†m	220
Streptococcus pneumoniaeα		213	Campylobacter jejuni†m	221
GRAM-NEGATIVE COCCI (PAIRS)			Cardiobacterium hominis	221
GRAM-NEGATIVE COCCI (PAIRS)			Chromobacterium violaceum†m	221
Neisseria gonorrhoeae†		214	Chromobacterium violaceum†m	221
Neisseria meningitidis†		214	Chryseobacterium (Flavobacterium)	221
GRAM-POSITIVE BACILLI			meningosepticum†	221
GRAM-POSITIVE BACILLI			Citrobacter diversus, freundii,
Arcanobacterium (Corynebacterium)			Citrobacter diversus, freundii,	222
Arcanobacterium (Corynebacterium)		215	koseri†*m	222
	haemolyticumβ	215	Edwardsiella tarda*†m	222
Bacillus anthracis†γ		215	Edwardsiella tarda*†m	222
Bacillus cereus, subtilis,			Enterobacter agglomerans, aerogenes,
Bacillus cereus, subtilis,			cloacae*†m	223
	megaterium†βmv	215	cloacae*†m	223
Corynebacterium diphtheriae†β		216	Escherichia coli*†m	223
Corynebacterium jeikeium (JK)†γ		216	Francisella tularensis*†	223
Erysipelothrix rhusiopathiaeα		216	Hafnia alvei*†m	224

204	A n t i b i o t i c		E s s e n t i a l s
Helicobacter (Campylobacter)			Pseudomonas (Chryseomonas)
pylori†m		224	luteola (Ve-1)*†§m	229
Hemophilus influenzae, parainfluenzae,			Pseudomonas (Flavimonas)
aphrophilus, paraphrophilus*		225	oryzihabitans (Ve-2)*†§m	230
Kingella (Moraxella) kingae		225	Salmonella typhi, non-typhi*†m	230
Klebsiella pneumoniae, oxytoca*†		225	Serratia marcescens*†§m	230
Klebsiella ozaenae,			Shigella boydii, sonnei, flexneri,
rhinoscleromatis*†		226	dysenteriae*†§	231
Legionella sp†m.		226	Stenotrophomonas (Pseudomonas,
Leptospira interrogansm		226	Xanthomonas) maltophilia*†§m	231
Moraxella (Branhamella)			Streptobacillus moniliformis*	231
catarrhalis†§		227	Vibrio cholerae†§m	232
Morganella morganii*†§m		227	Vibrio parahaemolyticus†§m	232
Ochrobactrum anthropi (Vd)†§m		227	Vibrio vulnificus, alginolyticus†§m	232
Pasteurella multocida†§		227	Yersinia enterocolitica*†§	232
Plesiomonas shigelloides†§m		228	Yersinia pestis*†§	233
Proteus mirabilis, penneri,
vulgaris*†§m		228	SPIROCHETES
Providencia alcalifaciens, rettgeri,			Borrelia burgdorferim	233
stuartii*†§m		229	Borrelia recurrentism	234
Pseudomonas aeruginosa†§m		229	Spirillum minusm	234

* Oxidase negative. † Catalase positive. § Non-lactose fermenter.

(α) = α (alpha) hemolysis on BAP.	(m) = motile.
(β) = β (beta) hemolysis on BAP.	(v) = Gram variable bacilli.
(γ) = γ (gamma) hemolysis on BAP.

CAPNOPHILIC ISOLATES+

GRAM-NEGATIVE BACILLI		Capnocytophaga ochraceus
Capnocytophaga canimorsus/		(DF-1)m	235
cynodegni (DF-2 like)m	235	Eikenella corrodens	235
+ Capnophilic organisms grow best under increased CO2 tension. (m) = motile.

ANAEROBIC ISOLATES

GRAM-POSITIVE COCCI (CHAINS)		Bifidobacterium sp.	237
Peptococcus	236	Clostridium botulinumm	237
Peptostreptococcus	236	Clostridium difficilem	238
		Clostridium perfringens, septicum,
GRAM-POSITIVE BACILLI		novyimv	238
Actinomyces israelii, odontolyticus++	236	Clostridium tetanim	238
Arachnia propionica++	237	Eubacterium sp.	239

Lactobacillus sp.++ 239 Fusobacterium nucleatum 240 Propionibacterium acnes*† 239 Prevotella (Bacteroides) bivia 240

Prevotella (Bacteroides) melaninogenicus,

GRAM-NEGATIVE BACILLI intermedius 241 Bacteroides fragilis group (B. distasonis,

ovatus, thetaiotaomicron, vulgatus) . 240

++ Microaerophilic organisms. Grow best under decreased O2 concentration. * Oxidase negative. (m) = motile.

† Catalase positive. (v) = Gram variable bacilli.

YEASTS/FUNGI

Aspergillus fumigatus, flavus, niger† 242 Candida albicans 242 Candida (non-albicans): C. kruzei, Cryptococcus neoformans 243 lusitaniae, tropicalis, pseudotropicalis, Histoplasma capsulatum 244 glabrata, guilliermondii, dublinensis, Malassezia furfur 244 lipolytica 243 Penicillium marneffei 245

Alphabetical Index of Isolates

Acinetobacter baumannii, lwoffi, Borrelia recurrentis 234 calcoaceticus, haemolyticus 218 Brucella abortus, canis, suis, melitensis 219 Actinomyces israelii, odontolyticus 236 Burkholderia (Pseudomonas) cepacia 220

Aeromonas hydrophila 218 Burkholderia (Pseudomonas) Aggregatibacter (Actinobacillus) pseudomallei 220

actinomycetemcomitans 218 Campylobacter fetus 220 Alcaligenes (Achromobacter) Campylobacter jejuni 221 xylosoxidans 219 Candida albicans 242

Arachnia propionica 237 Candida (non-albicans): C. krusei, lusitaniae, Arcanobacterium (Corynebacterium) tropicalis, pseudotropicalis, glabrata,

haemolyticum 215 guilliermondii, dublinensis,

Aspergillus fumigatus, flavus, niger 242 lipolytica 243 Bacillus anthracis 215 Capnocytophaga canimorsus/

Bacillus cereus, subtilis, megaterium 215 cynodegni (DF-2 like) 235 Bacteroides fragilis group (B. distasonis, ovatus, Capnocytophaga ochraceus (DF-1) 235 thetaiotaomicron, vulgatus) 240 Cardiobacterium hominis 221 Bartonella henselae, quintana, Chromobacterium violaceum 221

bacilliformis 219 Chryseobacterium (Flavobacterium) Bifidobacterium sp 237 meningosepticum 221 Bordetella pertussis, parapertussis 219 Citrobacter diversus, freundii, koseri 222 Borrelia burgdorferi 233 Clostridium botulinum 237

Chapter 3. Antibiotic Susceptibility Profiles and Initial Therapy

205

206	A n t i b i o t i c		E s s e n t i a l s
Clostridium difficile		238	Pasteurella multocida		227
Clostridium perfringens, septicum, novyi		238	Penicillium marneffei		245
Clostridium tetani		238	Peptococcus		236
Corynebacterium diphtheriae		216	Peptostreptococcus		236
Corynebacterium jeikeium		216	Plesiomonas shigelloides		228
			Prevotella (Bacteroides) bivia		240
Cryptococcus neoformans		243
			Prevotella (Bacteroides)
Edwardsiella tarda		222
				melaninogenicus, intermedius	241
Eikenella corrodens		235
			Propionibacterium acnes		239
Enterobacter agglomerans, aerogenes,
			Proteus mirabilis, vulgaris		228
cloacae		223
			Providencia alcalifaciens, rettgeri,
Enterococcus faecalis (VSE)		210
				stuartii	229
Enterococcus faecium (VRE)		211	Pseudomonas aeruginosa		229
Erysipelothrix rhusiopathiae		216	Pseudomonas (Chryseomonas)
Escherichia coli		223		luteola (Ve-1)	229
Eubacterium sp		239	Pseudomonas (Flavimonas)
Francisella tularensis		223		oryzihabitans (Ve-2)	230
Fusobacterium nucleatum		240	Rhodococcus equi		217
Group A streptococci		211	Salmonella typhi, non-typhi		230
			Serratia marcescens		230
Group B streptococci (S. agalactiae)		211
			Shigella boydii, sonnei, flexneri,
Group C, F, G streptococci		212
				dysenteriae	231
Hafnia alvei		224
			Spirillum minus		234
Helicobacter (Campylobacter) pylori		224
			Staphylococcus aureus (MSSA/MRSA/
Hemophilus influenzae, parainfluenzae,
				VISA/VRSA)	208
aphrophilus, paraphrophilus		225
			Staphylococcus (coagulase negative)
Histoplasma capsulatum		244		epidermidis (CoNS)	209
Kingella kingae		225	Staphylococcus saprophyticus		210
Klebsiella ozaenae, rhinoscleromatis		226	Stenotrophomonas (Pseudomonas,
Klebsiella pneumoniae, oxytoca		225		Xanthomonas) maltophilia	231
Lactobacillus sp.		239	Streptobacillus moniliformis		231
Legionella sp.		226	Streptococcus (bovis) gallolyticus		213
Leptospira interrogans		226	Streptococcus pneumoniae		213
			Streptococcus anginosus (S. milleri) group
Leuconostoc		213
				(S. intermedius, S. anginosus,
Listeria monocytogenes		217
				S. constellatus)	213
Malassezia furfur		244
			Viridans streptococci (S. mitior, mitis,
Moraxella (Branhamella)
				mutans, oralis, sanguis,
catarrhalis		227
				parasanguis, salivarius)	213
Morganella morganii		227
			Vibrio cholerae		232
Neisseria gonorrhoeae		214	Vibrio parahaemolyticus		232
Neisseria meningitidis		214	Vibrio vulnificus, alginolyticus		232
Nocardia asteroides, brasiliensis		217	Yersinia enterocolitica		232
Ochrobactrum anthropi (Vd)		227	Yersinia pestis		233

Chapter 3. Antibiotic Susceptibility Profiles and Initial Therapy

207

Table 3.4. Key Factors in Antibiotic Selection (Isolate Known)

• Select an antibiotic with a high degree of activity against the known pathogen

(not colonizer).

• Dose appropriate for the target tissue to assure therapeutic/effective concentrations at site of infection. If necessary, adjust dose ↑for tissue targets that require higher doses, e.g., bacterial meningitis, endocarditis, etc., or ↓dose for sites with antibiotic concentrations that are above serum concentrations, e.g., skin, urine, etc.

• Select an empiric antibiotic with a “low resistance” potential avoid, if possible, antibiotics with a “high resistance” potential (also with a high degree of activity against the presumed

pathogen). Select a “low resistance” potential antibiotic for the same/different class with a high degree of activity.

• Select antibiotic with a good safety profile and minimal potential for drug-drug interactions.

• Select antibiotic that is relatively cost effective (first take into account the above principles).

Table 3.5. Antibiotic Selection Based on Resistance Potential

• Antibiotic resistance may be classified as natural (P. aeruginosa is naturally resistant to chloramphenicol, i.e., not in its spectrum). Acquired resistance may be relative or high level resistance (gentamicin resistant P. aeruginosa with extremely high MIC cannot be overcome by increased dosing). In contrast, relative resistance, e.g., meropenem relative resistance to

P.aeruginosa may be overcome, if antibiotic concentrations can be achieved with normal/high dosing that exceed the MIC of the organism at the site of infection.

• Therearemanymechanismsofantibioticresistance,butmechanismsdonotexplaindifferences in resistance potential within antibiotic classes. Mechanism of resistance does not explain why ciprofloxacin is responsible for nearly all fluoroquinolone resistance to S. pneumoniae and

P.aeruginosa. Similarly, among the five 3rd GC, only ceftazidime has been associated with

P.aeruginosa resistance problems.

• Clinically, antibiotics may be considered in terms of resistance potential, i.e., high, moderate, or low. "High resistance potential" antibiotics cause resistance even with minimal use, but with widespread use can cause (non-clonal) resistance problems when used in high volume or over time. While an occasional mutation may result sporadic resistance with any antibiotic, resistance to "low resistance potential" antibiotics is not related to antibiotic class, volume or duration of use. After decades of extensive worldwide use with "low resistance potential" antibiotics, there are no widespread resistance problems with "low resistance potential" antibiotics, e.g., nitrofurantoin, amikacin, ceftriaxone, doxycycline.

• If possible, always try to preferentially select a “low resistance potential”antibiotic with the appropriate spectrum and PK/PD characteristics for the pathogen/body site being treated. For each resistant problem pathogen in each antibiotic class, there are usually "low resistance potential" antibiotics alternatives within the class. In addition, other "low resistance potential" antibiotics may be found in different antibiotic classes. Try to use "low resistance potential" antibiotics in place of "high resistance potential" antibiotics, e.g., TMP-SMX (S. pneumoniae and MSSA resistance), tetracycline (S. pneumoniae and MSSA resistance), gentamicin (P. aeruginosa resistance), ceftazidime (S. pneumoniae and P. aeruginosa resistance), imipenem (P. aeruginosa resistance).

Table 3.6. Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing

GRAM-POSITIVE COCCI (CLUSTERS)

Isolate

Isolate Significance

Therapy

Comments

Staphylococcus

• CSF = C*, P (CNS

MSSA: Nafcillin (IV), Cefazolin (IV),

MSSA: For oral treatment, 1st generation

aureus

shunts)

Clindamycin (IV/PO), a“respiratory

cephalosporins are better than oral anti-

(MSSA/MRSA)

• Blood = C*, P (from

quinolone”(IV/PO), Minocycline (IV/

staphylococcal penicillins (e.g., dicloxacillin)

soft tissue/bone

PO), Daptomycin (IV), any carbapenem

MRSA: in-vitro susceptibility testing is unreliable;

infection, abscess, IV

(IV), Linezolid (IV/PO), Tigecycline (IV),

treat MRSA infections empirically. Most effective

line infection, ABE,

Telavancin (IV)

drugs for MRSA are vancomycin, linezolid,

PVE)

ceftaroline fosamil (ABSSSI only), quinupristin/

• Sputum = C, P (S.

Hospital-acquired MRSA (HA-MRSA)/

aureus pneumonia is

dalfopristin, minocycline, daptomycin, tigecycline.

Community-onset MRSA (CO-MRSA):

rare; usually only after

Preferentially use minocycline instead of

Daptomycin (IV), Linezolid (IV/PO),

viral influenza)

doxycycline for MSSA/MRSA.

Tigecycline (IV), Vancomycin (IV),

• Urine = C, P

Community-acquired MRSA (CA-MRSA) SCC mec

Minocycline (IV/PO), Quinupristin/

(S. aureus in urine is

IV, V CA-MRSA has different susceptibilities than

usually due to skin

dalfopristin (IV), Telavancin (IV)

HA-MRSA/CO-MRSA (see p. 14). CA MRSA strains

contamination or

Community acquired MRSA (CA-MRSA):

with Panton-Valentin Leukocidin PVL+

rarely overwhelming

Doxycycline*, TMP–SMX, Clindamycin

gene cause two distinct clinical syndromes: severe

S. aureus bacteremia)

• Stool = C, P

VISA/VRSA: Linezolid (IV/PO), Daptomycin

necrotizing pneumonia (with viral influenza)

(enterocolitis)

and severe necrotizing fasciitis/pyomyositis. CA-

(IV), Telavancin (IV)

• Wound = C, P

MRSA is usually susceptible to doxycycline in

(cellulitis, abscess)

vitro, but minocycline more effective in vivo

than doxycycline, TMP–SMX, clindamycin. Drugs

effective against HA-MRSA/CO-MRSA are also effective

against CA-MRSA. However, drugs effective against

CA-MRSA are may not be effective against HA-MRSA/

CO-MRSA

MSSA/MRSA: Noncontinuous low-grade blood

culture positivity indicates skin contamination

during venipuncture. Continuous high-grade

blood culture positivity (3/4 or 4/4) indicates

intravascular infection or abscess

208

s l a i t n e s s E c i t o i b i t n A

				VISA/VRSA: MICs for vancomycin sensitive (VSSA),

				heteroresistant vancomycin intermediate (hVISA),
				intermediate (VISA), and resistant (VRSA) S. aureus
				are < 4 mcg/mL, < 4 mcg/mL (with subpopulations
				> 4 mcg/mL), 8–16 mcg/mL, and ≥ 32 mcg/mL,
				respectively.

Staphylococcus	• CSF = C*, P (CNS	MSSE: Linezolid (IV/PO), Daptomycin		Usually non-pathogenic in absence of prosthetic/
epidermidis	shunts)	(IV),	Vancomycin (IV), Telavancin (IV), any	implant materials. Common cause of PVE; rare
(MSSE/MRSE)	• Blood = C*, P (from IV	carbapenem (IV), a “respiratory quinolone”		cause of native valve SBE. Treat foreign body-
or coagulase-	lines, infected implants,	(IV/PO), Minocycline (IV/PO)		related infection until foreign body is removed.
negative	prosthetic valve
negative	endocarditis [PVE],	MRSE: Linezolid (IV/PO), Daptomycin (IV),		S. lugdunensis is a CoNS but is often misidentified
staphylococci	endocarditis [PVE],	MRSE: Linezolid (IV/PO), Daptomycin (IV),		S. lugdunensis is a CoNS but is often misidentified
	rarely from native valve
		Vancomycin (IV), Quinupristin/dalfopristin		as S. aureus since it produces “clumping factor”
(CoNS)		Vancomycin (IV), Quinupristin/dalfopristin		as S. aureus since it produces “clumping factor”
(CoNS)	subacute bacterial	(IV), Minocycline (IV/PO)		which gives a 1 rapid short tube coagulase test
Staphylococcus	endocarditis [SBE])			(long tube test —) although a CoNS resembles
lugdunensis	• Sputum = C			(long tube test —) although a CoNS resembles
lugdunensis	• Sputum = C			S. aureus in terms of invasiveness/virulence.
	• Urine = C (may			S. aureus in terms of invasiveness/virulence.
	• Urine = C (may			Unlike S. aureus, S. lugdensis is pan-sensitive to
	be reported as			Unlike S. aureus, S. lugdensis is pan-sensitive to
	be reported as			antibiotics which is another clue the isolate is not
	S. saprophyticus; request			antibiotics which is another clue the isolate is not
	novobiocin sensitivity			S. aureus. S. lugdensis bacteremia associated with
	to differentiate			community acquired (not nosocomial) SBE.
	S. epidermidis from
	other coagulase-
	negative staphylococci)

•Stool = NP

•Wound = C, P (infected foreign body drainage)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

*Minocycline (IV/PO) preferred.

Therapy Initial and Profiles Susceptibility Antibiotic .3 Chapter

209

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-POSITIVE COCCI (CLUSTERS)

		Preferred	Alternate Therapy
Isolate	Isolate Significance	Therapy	Comments

Staphylococcus	•	CSF = NP
saprophyticus	•	Blood = NP
(coagulase-	•	Sputum = NP
negative	• Urine = P (cystitis,
negative		pyelo)
staphylococci)	•	pyelo)
staphylococci)	•	Stool = NP
	•	Wound = NP

Preferred therapy			S. saprophyticus UTI is associated with a urinary
Amoxicillin (PO)			“fishy odor,” alkaline urine pH, and microscopic
TMP–SMX (PO)			hematuria. Novobiocin sensitivity differentiates
Nitrofurantoin (PO)			coagulase-negative staphylococci (sensitive) from
Alternate therapy			S. saprophyticus (resistant).
Any quinolone (PO)
Any 1st generation cephalosporin (PO)

GRAM-POSITIVE COCCI (CHAINS)

Enterococcus faecalis (VSE)

•CSF = NP (except from S. stercoralis hyperinfection or V-P shunt infection)

•Blood = C*, P (from GI/GU source, SBE)

•Sputum = NP

•Urine = C, P (cystitis, pyelonephritis)

•Stool = NP

•Wound = C, P (cellulitis)

Non-SBE		Non-SBE
	(IV)
Ampicillin			Cefoperazone (IV)
Amoxicillin (PO)		Chloramphenicol (IV)
Meropenem (IV)		Levofloxacin (IV/PO)
Piperacillin (IV)		Moxifloxacin (IV/PO)
Linezolid		Nitrofurantoin (PO)
(IV/PO)			(UTIs only)
Tigecycline (IV)		SBE
Daptomycin (IV)

		Any quinolone

SBE			(IV/PO)
Gentamicin +		Cefoperazone (IV)
ampicillin (IV) or
vancomycin (IV)
Meropenem (IV)
Piperacillin (IV)
Linezolid (IV/PO)

Sensitive to ampicillin, not penicillin. Cause of intermediate (severity between ABE and SBE) endocarditis, hepatobiliary infections, and UTIs. Enterococci (E. faecalis, E. faecium) are the only cause of SBE (below the waist) from GI/GU sources. Permissive pathogen (i.e., usually does not cause infection alone) in the abdomen/pelvis (except in gallbladder or urinary bladder/kidneys). Cefoperazone is the only cephalosporin with anti-E. faecalis (VSE) activity (MIC ~ 32 mcg/mL). Quinupristin/dalfopristin is not active against E. faecalis (VSE).

Treat vancomycin resistant E. faecalis as VRE (see E. faecium VRE p. 211).

210

s l a i t n e s s E c i t o i b i t n A

Enterococcus

•

CSF = NP (except

Non-SBE

Same spectrum of infection as E. faecalis.

faecium (VRE)

from S. stercoralis

Linezolid

(IV/PO), quinupristin/dalfopristin

Colonization common; infection uncommon.

hyperinfection or V-P

(IV), doxycycline (IV/PO),

Fecal carriage is intermittent but prolonged.

•

shunt infection)

tigecycline (IV), chloramphenicol

In vitro sensitivity = in vivo efficacy. Increased

Blood = C*, P (from

(IV/PO), nitrofurantoin (PO)

prevalence of E. faecalis (VRE) related to

GI/GU source, SBE)

•

(UTIs only)

vancomycin IV (not PO) use. Nitrofurantoin

Sputum = C

preferred for VRE lower UTIs/catheter-associated

• Urine = C, P (cystitis,

SBE

Chapter

pyelo)

bacteriuria.

•

Linezolid (IV/PO)

Stool = NP

Quinupristin/dalfopristin (IV)

•

Wound = C, P

(cellulitis)

Antibiotic

Group A

•

CSF = C*, P (rare cause

Amoxicillin (PO)

Penicillin (PO)

For Group A streptococcal pharyngitis, amoxicillin

streptococci

•

of ABM)

Any β-lactam (IV/

Clindamycin

is preferred over penicillin. Clindamycin is best

Susceptibility

Blood = P (from skin/

A streptococci. Nafcillin is the most active

PO)

(IV/PO)

for elimination of carrier states, and for penicillin-

soft tissue infection)

allergic patients with streptococcal pharyngitis.

• Sputum = P (rare

Any β-lactam is equally effective against Group

cause of CAP)

•

Urine = NP

anti-staphylococcal penicillin against Group A

Profiles

•

Stool = NP

• Wound = C, P

streptococci. Erythromycin is no longer reliable

(cellulitis)

against Group A streptococci due to increasing

and

• Throat = C, P (pharynx

resistance. Doxycycline has little/no activity

Initial

Group A streptococci

is colonized with

against Group A streptococci.

in ~ 30% of patients

Therapy

with EBV mono)

Group B

•

CSF = P

Non-SBE, non-CNS

Cause of UTIs and IV line infections in diabetics

streptococci

•

Blood = P (from IV

Clindamycin (IV/PO)

Vancomycin (IV)

and the elderly. Cause of neonatal meningitis.

(S. agalactiae)

line/urine source, SBE)

Amoxicillin (PO)

Infection is uncommon in the general population.

Rarely a cause of SBE in

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

211

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-POSITIVE COCCI (CHAINS)

Preferred

Alternate Therapy

Isolate

Isolate Significance

Therapy

Comments

•

Sputum = NP

Any 1st, 2nd, 3rd

SBE

Non-pregnant adults. On gram stain, GBS appear

•

Urine = P (CAB, UTIs,

generation

Meropenem (IV)

larger/rounder than S. pneumoniae. Colonies of

especially in diabetics,

cephalosporin

Ertapenem (IV)

GBS on BAP have a “sheen” (vs. S. pneumoniae).

•

elderly)

(IV/PO)

Linezolid (IV/PO)

Aminoglycosides and tetracyclines are ineffective.

Stool = NP

•

Wound = C, P

SBE

CNS

(diabetic foot

Ceftriaxone (IV)

Chloramphenicol

infections)

Penicillin (IV)

(IV)

Vancomycin (IV)

Linezolid (IV/PO)

CNS

Ceftriaxone (IV)

Penicillin (IV)

Group C, F, G

•

CSF = P (meningitis)

Ceftriaxone (IV)

Vancomycin (IV)

Group C, G streptococci may cause pharyngitis,

streptococci

•

Blood = P (from skin/

Penicillin (IV)

Amoxicillin (PO)

wound infections, and rarely SBE. Group G

soft tissue infection,

Ampicillin (IV)

Any 1st, 2nd, 3rd

streptococci associated with malignancies.

•

SBE)

Clindamycin

generation

Common pharyngeal colonizers in medical

Sputum = P (rare

(IV/PO)

cephalosporin (IV)

personnel.

cause of CAP)

Meropenem (IV)

• Throat = C (especially

Ertapenem (IV)

with viral pharyngitis),

P (pharyngitis in

•

medical personnel)

Urine = NP

•

Stool = NP

• Wound = P (cellulitis)

212

s l a i t n e s s E c i t o i b i t n A

			GRAM-POSITIVE COCCI (CHAINS)
Streptococcus	•	Blood = P (SBE from	Ceftriaxone (IV)	Vancomycin (IV)	Associated with GI malignancies. Non-
Streptococcus	•	Blood = P (SBE from	Ceftriaxone (IV)	Vancomycin (IV)	Associated with GI malignancies. Non-
(bovis)	•	GI source)	Ampicillin (IV)	Amoxicillin (PO)	enterococcal Group D streptococci (e.g.,
gallolyticus	•	Urine = NP	Clindamycin	Any cephalosporin	S. bovis) are sensitive to penicillin.
	•		(IV/PO)	(IV)
S. anginosus	•	CNS = P	Ceftriaxone (IV)	Amoxicillin (PO)	S. anginosus (S. milleri) group (S. intermedius,
(S. milleri) group	•	Blood = P	Vancomycin (IV)	Any cephalosporin	S. anginosus, S. constellatus) prone to invasive
(S. intermedius,	•	Wound = P (head/		(PO)	disease, bacteremia and abscess formation.
S. anginosus,		neck abscesses)
S. anginosus,
S. constellatus)	•
Viridans	•	CSF = NP (aseptic	Ceftriaxone (IV)	Amoxicillin (PO)	Low-grade blood culture positivity (1/4) indicates
streptococci	•	meningitis with SBE)	Penicillin (IV)	Any 1st, 2nd, 3rd	contamination during venipuncture. Continuous/
(S. mitior,	•	Blood = C*, P (1°		generation	high-grade blood culture positivity (3/4 or 4/4)
mitis, mutans,	•	bacteremia, SBE)		cephalosporin	indicates SBE until proven otherwise.
mitis, mutans,		Sputum = NP		cephalosporin	indicates SBE until proven otherwise.
oralis, sanguis,		Sputum = NP		(IV/PO)
oralis, sanguis,	•	Urine = NP		(IV/PO)
parasanguis,	•	Urine = NP		Meropenem (IV)
parasanguis,	•	Stool = NP		Meropenem (IV)
salivarius)	•	Stool = NP		Ertapenem (IV)
salivarius)	•	Wound = NP		Ertapenem (IV)
				Vancomycin (IV)
			GRAM-POSITIVE COCCI (PAIRS)
Leuconostoc	•	CSF = NP	Penicillin (IV)	Amoxicillin (PO)	Coccobacillary forms resemble streptococci/
Leuconostoc	•	CSF = NP	Penicillin (IV)	Amoxicillin (PO)	Coccobacillary forms resemble streptococci/
	•	Blood = P (PVE)	Ampicillin (IV)	Erythromycin (IV)	enterococci. Cause of infection in compromised
	•	Sputum = NP	Clindamycin	Minocycline (IV/PO)	hosts. Rare cause of IV line infection. Usually
	• Urine = P (UTIs)		(IV/PO)	Clarithromycin	vancomycin-resistant.
	•	Stool = NP	(IV/PO)	Clarithromycin	vancomycin-resistant.
	•	Stool = NP		XL (PO)
	•	Wound = NP		XL (PO)
	•	Wound = NP
Streptococcus	•	CSF = P (ABM)			Penicillin-resistant S. pneumoniae (PRSP) are
Streptococcus	•	CSF = P (ABM)	Multidrug Resistant S. pneumoniae		Penicillin-resistant S. pneumoniae (PRSP) are
pneumoniae	•	Blood = P (from	(MDRSP)		still sensitive to full-dose/high-dose β-lactams.
		respiratory tract			If possible, avoid macrolides, as > 30% of
		respiratory tract	A “respiratory quinolone” (IV/PO);		If possible, avoid macrolides, as > 30% of
	•	source)	telithromycin (PO); ertapenem (IV);		S. pneumoniae are macrolide resistant (MRSP).
		Sputum = C, P	telithromycin (PO); ertapenem (IV);		S. pneumoniae are macrolide resistant (MRSP).
		Sputum = C, P	meropenem (IV); cefepime (IV); linezolid		(~ 20–25% are naturally resistant and 10–15%
	•	Urine = NP	meropenem (IV); cefepime (IV); linezolid		(~ 20–25% are naturally resistant and 10–15%
	•	Urine = NP	(IV/PO); vancomycin (IV)		acquire macrolide resistance).
	•	Stool = NP	(IV/PO); vancomycin (IV)		acquire macrolide resistance).
	•	Stool = NP

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

Therapy Initial and Profiles Susceptibility Antibiotic .3 Chapter

213

(single dose).

meningococcal prophylaxis is an oral quinolone

for penicillin-allergic patients. Preferred

Chloramphenicol is an excellent choice

as meningeal inflammation decreases.

• CSF = P (ABM)

• Blood = P

(acute/chronic Any 3rd generation Meropenem (IV) CSF penetration/concentration decreases meningococcemia) cephalosporin

• Sputum = C, P (only (IV) in closed populations,

e.g., military recruits)

Comments

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-POSITIVE COCCI (PARIS)

Alternate

Isolate

Isolate Significance

Preferred Therapy

Therapy

•

Wound = P (cellulitis

Sensitive or relatively PCN-resistant

only in SLE)

Doxycycline (IV/PO); any cephalosporin

(IV/PO); clindamycin (IV/PO); amoxicillin/

clavulanic acid (PO)

GRAM-NEGATIVE COCCI (PARIS)

Neisseria

•

CSF = NP

Penicillin-sensitive

Cause of “culture negative” right-sided ABE. May be

gonorrhoeae (GC)

•

Blood = P (from

N. gonorrhoeae

cultured from synovial fluid/blood in disseminated

pharyngitis, proctitis,

GC infection (arthritis-dermatitis syndrome).

(PSNG)

ABE)

•

Ceftriaxone (IV/

Penicillin (IV/IM)

Spectinomycin is ineffective against pharyngeal

Sputum = NP

IM) Any quinolone

Amoxicillin (PO)

GC/incubating syphilis. PRNG are tetracycline-

•

Urine = P (urethritis)

(IV/PO)

Doxycycline (IV/PO)

resistant (TRNG). GC strains from Hawaii/California

•

Stool = NP

have increased quinolone resistance; use cefixime

•

Wound = NP

PRNG

PPNG

•

Rectal discharge = P

or ceftriaxone for such strains. Treat possible

Ceftriaxone

Spectinomycin (IM)

(GC proctitis)

Chlamydia trachomatis co-infection and sexual

(IV/IM)

Any quinolone (PO)

partners.

Any 1st, 2nd, 3rd gen.

cephalosporin

(IV/IM)

Neisseria

Penicillin (IV)

Chloramphenicol (IV)

In ABM, do not decrease meningeal dose of

meningitidis

Ampicillin (IV)

Cefepime (IV)

β-lactam antibiotics as patient improves, since

214

s l a i t n e s s E c i t o i b i t n A

	• Urine C, P (urethritis
	•	rarely)
	•	Stool = NP
	•	Wound = NP

			GRAM-	POSITIVE BACILLI

Arcanobacterium	•	CSF = NP	Doxycycline (PO)	Erythromycin (PO)	Causes membranous pharyngitis with scarlet
(Corynebacterium)	•	Blood = NP		Azithromycin (PO)	fever-like rash. Differentiate from C. diphtheriae by
haemolyticum	•	Sputum = P		Any 1st, 2nd, 3rd	culture. Penicillin and ampicillin are less effective	3Chapter
	•	Urine = NP		cephalosporin		3Chapter
		(oropharyngeal		generation	than erythromycin or doxycycline.
		secretions)		generation	than erythromycin or doxycycline.
		secretions)
	•	Stool/Wound = NP		(PO)		.
	•	Stool/Wound = NP		Clarithromycin		Antibiotic
				Clarithromycin		Antibiotic
				XL (PO)

Bacillus anthracis	•	CSF = P (ABM)	Penicillin (IV)	Amoxicillin (PO)	Doxycycline may be used for therapy/outbreak	Susceptibility
bioterrorist	•	Sputum = P	(IV/PO)		effective. Alert microbiology laboratory of	Susceptibility
(naturally	•	Blood = P (septicemia;	Doxycycline	Ampicillin (IV)	prophylaxis. Streptobacillary configuration in
acquired)		isolation required;	(IV/PO)		blood. Causes hemorrhagic meningitis, wound
(For potential		dangerous)	Any quinolone		infections, and bacteremia. Quinolones are
anthrax, see		(mediastinitis; anthrax			potentially biohazardous specimens.	Profiles
anthrax, see		pneumonia rare)			potentially biohazardous specimens.	Profiles
p. 173)	•	pneumonia rare)
p. 173)	•	Urine = NP
	•	Stool = NP				and
	•	Wound = P (ulcer;				and
	•	Wound = P (ulcer;				Initial
		isolation required;				Initial
		dangerous)				Therapy

Bacillus	•	CSF = NP	Vancomycin (IV)	Meropenem (IV)	Soil organisms not commonly pathogenic for
cereus, subtilis,	•	Blood = C*,	Clindamycin	Any quinolone	humans. Suspect pseudoinfection if isolated
megaterium		P (leukopenic	(IV/PO)	(IV/PO)	from clinical specimens. Look for soil/dust
		compromised hosts)			contamination of blood culture tube top/
					contamination of blood culture tube top/

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

215

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-POSITIVE BACILLI

			Preferred	Alternate
Isolate		Isolate Significance	Therapy	Therapy	Comments

	•	Sputum = NP			apparatus. Rare pathogen in leukopenic
	•	Urine = NP			compromised hosts.
	•	Stool = NP
	•	Wound = NP

Corynebacterium	•	CSF = NP	Penicillin (IV)	Doxycycline	Administer diphtheria antitoxin as soon as
diphtheriae	•	Blood = NP	Erythromycin (IV)	(IV/PO)	possible (p. 170). Antibiotic therapy is adjunctive,
	•	Sputum = P	Clindamycin	Clarithromycin	since diphtheria is a toxin-mediated disease.
		(oropharyngeal	(IV/PO)	XL (PO)	Patients may die unexpectedly from toxin-induced
		secretions)	(IV/PO)	XL (PO)	Patients may die unexpectedly from toxin-induced
	•	secretions)		Rifampin (PO)	myocarditis during recovery.
		Urine = NP		Rifampin (PO)	myocarditis during recovery.
		Urine = NP
	•	Stool = NP
	• Wound = P (wound
		diphtheria)

Corynebacterium	•	CSF = C*, P (CSF	Vancomycin (IV)	Quinupristin/	Cause of IV line/foreign body infections. In-vitro
jeikeium (JK)	•	shunts)	Linezolid (IV/PO)	dalfopristin (IV)	testing is not always reliable. Highly resistant to
	•	Blood = C*, P (from			most anti-gram positive antibiotics.
	•	IV lines)
	•	Sputum = NP
	•	Urine/Stool = NP
	•	Wound = C

Erysipelothrix	•	CSF = NP	Penicillin (IV)	Any 3rd generation	Cause of “culture-negative” SBE. Susceptible to
rhusiopathiae	•	Blood = P (from SBE)	Ampicillin (IV)	cephalosporin (IV)	clindamycin but resistant to vancomycin.
	•	Sputum = NP		Any quinolone
	•	Urine = NP		(IV/PO)
	•	Stool = NP		(IV/PO)
	•	Stool = NP
	• Wound = P (chronic
		erysipelas-like skin
		lesions)

216

s l a i t n e s s E c i t o i b i t n A

Listeria

•

CSF = P (ABM)

Ampicillin (IV)

Doxycycline (IV/PO)

Listeria ABM is common in T-cell deficiencies (e.g.,

monocytogenes

•

Blood = P (1°

Amoxicillin (PO)

Erythromycin (IV)

lymphoma, steroids, HIV). Causes SBE in normal

•

bacteremia, SBE)

Chloramphenicol

Meropenem (IV)

hosts, and is the commonest cause of

Sputum = NP

(IV)

bacteremia in non-neutropenic cancer patients.

•

Urine = NP

CNS

3rd generation cephalosporins are ineffective

•

Stool = NP

CNS

Meropenem (IV)

against Listeria.

•

Wound = NP

Ampicillin (IV)

(Meningeal

.3Chapter

(IV/PO)

dosed)

TMP–SMX (IV/PO)

Chloramphenicol

Linezolied (IV/PO)

SBE

Antibiotic

SBE

Meropenem (IV)

Ampicillin (IV)

Linezolied (IV/PO)

Nocardia

•

CSF = P (brain abscess)

TMP–SMX (IV/PO)

Imipenem (IV) plus

Branched, filamentous, beady hyphae are typical,

Susceptibility

asteroides,

•

(pneumonia, lung

Minocycline

either amikacin

but coccobacillary and bacillary forms are also

Blood = P (from lung/

brasiliensis

•

soft tissue source)

(IV/PO)

(IV) or any

common. Nocardia are gram-positive, aerobic, and

Sputum = P

3rd generation

acid fast. Linezolid is active against Nocardia and

abscess)

cephalosporin

may be effective if other agents cannot be used.

Profiles

•

(IV)

Quinolones and macrolides are usually ineffective.

Urine/Stool = NP

• Wound = P (skin

and

lesions from direct

inoculation or

Initial

dissemination)

Therapy

Rhodococcus

•

CSF = NP

Any quinolone

Erythromycin (IV)

Causes TB-like community-acquired pneumonia

equi

•

Blood = P (from

(IV/PO)

Imipenem (IV)

in AIDS patients. Filamentous bacteria break into

•

pneumonia, lung

Vancomycin (IV)

Meropenem (IV)

bacilli/cocci. Aminoglycosides and β-lactams are

•

abscess)

Doxycycline

relatively ineffective.

Sputum = P

(IV/PO)

(pneumonia with

TMP–SMX (IV/PO)

abscess/cavitation)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

217

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-POSITIVE BACILLI

				Alternate
Isolate		Isolate Significance	Preferred Therapy	Therapy	Comments

	•	Urine = NP
	•	Stool = NP
	•	Wound = NP

GRAM-NEGATIVE BACILLI

Acinetobacter	•	CSF = C*, P (ABM)	Any carbapenem	Any 3rd generation	Colonization common; infection uncommon. If
baumannii, lwoffi,	•	Blood = P (from IV	(IV)	cephalosporin	possible, avoid treating Acinetobacter
calcoaceticus,		line, lung, or urine	Ampicillin/	(IV) (except	colonization in respiratory secretions or
haemolyticus	•	source)	sulbactam (IV)	ceftazidime)	urine (CAB). Occurs in outbreaks of ventilator-
haemolyticus		Sputum = C, P (VAP)	sulbactam (IV)	ceftazidime)	urine (CAB). Occurs in outbreaks of ventilator-
		Sputum = C, P (VAP)	Colistin	Cefepime (IV)	associated pneumonia. Test susceptibility to each
	•	Urine = C, P (CAB)	Colistin	Cefepime (IV)	associated pneumonia. Test susceptibility to each
	•	Urine = C, P (CAB)	Polymyxin B	Fosfomycin (PO)	carbapenem (may be susceptible to one but not
	•	Stool = NP	Polymyxin B	Fosfomycin (PO)	carbapenem (may be susceptible to one but not
	•	Stool = NP	Minocycline		others). Use meropenem for MDR susceptible
	•	Wound = C	Minocycline		others). Use meropenem for MDR susceptible
		(common), P (rare)	(IV/PO)		isolates. For meropenem resistant MDR isolates,
					use colistin, polymyxin B, tigacycline, minocycline,
					or doripenem.

Aeromonas	•	CSF = NP	Gentamicin (IV)	Doxycycline (IV/PO)	Cause of wound infection, septic arthritis, diarrhea,
hydrophila	•	Blood = P (from	TMP–SMX (IV/PO)	Any 3rd generation	and necrotizing soft tissue infection resembling
		wound, urine, or GI	Any quinolone	cephalosporin	gas gangrene.
	•	source)	(IV/PO)	(IV/PO)
		Sputum = NP	(IV/PO)	(IV/PO)
		Sputum = NP		Any carbapenem (IV)
	•	Urine = C, P (CAB)		Any carbapenem (IV)
	•	Urine = C, P (CAB)		Aztreonam (IV)
	•	Stool = P (diarrhea)		Aztreonam (IV)
	•	Stool = P (diarrhea)
	• Wound = P (cellulitis)

Aggregatibacter	•	CSF = NP	Any quinolone	Penicillin (IV) +	Cause of “culture-negative” SBE. One of the HACEK
(Actinobacillus)	•	Blood = P (from	(IV/PO)	gentamicin (IV)	organisms. Found with Actinomyces in abscesses.
actinomycetem-	•	abscess, SBE)	Any 3rd generation	TMP–SMX (IV/PO)	Resistant to erythromycin and clindamycin.
comitans	•	Sputum = NP	cephalosporin
comitans	•	Urine/Stool = NP	cephalosporin
	•	Urine/Stool = NP	(IV/PO)
			(IV/PO)

218

s l a i t n e s s E c i t o i b i t n A

	• Wound = P (from
		abscess, draining
		fistulous tract)

Alcaligenes	•	CSF = P (rarely ABM)	Imipenem (IV)	Any quinolone	Water-borne pathogen resembling Acinetobacter
(Achromobacter)	•	Blood = P (from urine)	Meropenem (IV)	(IV/PO)	microbiologically. Resistant to aminoglycosides
xylosoxidans	•	Sputum = NP	Any 3rd generation	Cefepime (IV)	and 1st, 2nd generation cephalosporins.
	• Urine = P (CAB)		cephalosporin	Aztreonam (IV)		.3Chapter
	•	rare)	cephalosporin	Aztreonam (IV)		.3Chapter
	•	Stool = NP	(IV/PO)
	•	Wound = P (cellulitis	(IV/PO)
	•	Wound = P (cellulitis

						Antibiotic
quintana,	•	source, SBE)	Azithromycin (PO)	Any quinolone	(relapsing, trench fever, bacillary angiomatosis); B.	Antibiotic
Bartonella	•	CSF = NP	Doxycycline	Clarithromycin	B. henselae (bacteremia, endocarditis, peliosis
henselae,	•	Blood = P (from skin	(IV/PO)	XL (PO)	hepatis, bacillary angiomatosis); B. quintana
bacilliformis	•	Sputum = NP		(IV/PO)	are ineffective.	Susceptibility
bacilliformis		lesions)		(IV/PO)	are ineffective.	Susceptibility
	•	Urine = NP		Any aminoglycoside	present as FUO. Titers may cross react with
	•	Stool = NP		(IV)	C. burnetii (Q fever). TMP–SMX and cephalosporins
	•	Wound = P (skin		(IV)	C. burnetii (Q fever). TMP–SMX and cephalosporins
	•	Wound = P (skin
						Profiles
pertussis,	•	Blood = P (from	Clarithromycin	(IV/PO)	non-immunized adults. Macrolides remain	Profiles
Bordetella	•	CSF = NP	Erythromycin (IV)	Any quinolone	Causes pertussis in children and incompletely/
parapertussis		respiratory tract	XL (PO)	TMP–SMX	the preferred therapy. Resistant to penicillins,	and
		source)	Azithromycin	(IV/PO)	cephalosporins, and aminoglycosides.	and
	•	source)				Initial
		Sputum = C, P
		Sputum = C, P	(IV/PO)	Doxycycline (IV/PO)
		(pertussis)	(IV/PO)	Doxycycline (IV/PO)
	•	(pertussis)				Therapy
	•	Urine = NP				Therapy
	•	Stool = NP
	•	Wound = NP

Brucella abortus,	•	CSF = P (meningitis)	Doxycycline	TMP–SMX (IV/PO) +	Causes prolonged relapsing infection. Zoonotic
canis, suis,	•	Blood = P (from	(IV/PO) +	gentamicin (IV)	cause of brucellosis/Malta fever. Resistant to
melitensis		abscess, SBE)	gentamicin (IV)		penicillins.

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

219

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-NEGATIVE BACILLI

				Alternate
Isolate		Isolate Significance	Preferred Therapy	Therapy	Comments

	•	Sputum = NP	Doxycycline +	Doxycycline
	•	Urine = P	streptomycin	(IV/PO) + rifampin
	•	(pyelonephritis)	(IM)	(PO)
	•	Stool/Wound = NP		Any quinolone
				Any quinolone
				(IV/PO) + rifampin
				(PO)

Burkholderia	•	CSF = NP	TMP–SMX (IV/PO)	A “respiratory	Rare cause of urosepsis following urologic
(Pseudomonas)	•	Blood = P (usually	Minocycline (IV/PO)	quinolone”	instrumentation. Common water-borne colonizer
cepacia		from IV line/urinary		(IV/PO)	in intensive care units. Opportunistic pathogen
	•	tract infection)		Chloramphenicol	in cystic fibrosis/bronchiectasis. Resistant to
		Sputum = C (not a		Chloramphenicol	in cystic fibrosis/bronchiectasis. Resistant to
		Sputum = C (not a		(IV/PO)	aminoglycosides, colistin, and polymyxin B.
		cause of VAP)		(IV/PO)	aminoglycosides, colistin, and polymyxin B.
	•	cause of VAP)
	•	Urine = C
	•	Stool = NP
	•	Wound = NP

Burkholderia	•	CSF = NP	Imipenem (IV)	Chloramphenicol (IV)	Acute (septicemia)/chronic (cavitary CAP/abscesses)
(Pseudomonas)	•	Blood = P (from	Meropenem (IV)	TMP–SMX (IV/PO)	melioidosis endemic in S.E. Asia. Chronic melioidosis
pseudomallei		septicemic	Ceftazidime (IV)	Amoxicillin/clavulanic	resembles reactivation TB, but has lower lobe
	•	melioidosis)	Doxycycline (IV/PO)	acid (PO)	distribution. Prolonged latency until reactivation
		Sputum = P (chronic	Doxycycline (IV/PO)	acid (PO)	distribution. Prolonged latency until reactivation
		Sputum = P (chronic			years later. Slow response to effective therapy (1–2
		cavitary pneumonia)			years later. Slow response to effective therapy (1–2
	•	cavitary pneumonia)			weeks). Prolonged therapy needed to prevent
		Urine = NP			weeks). Prolonged therapy needed to prevent
		Urine = NP			relapse (≥3 months). Oxidase positive. Resistant to
	•	Stool = NP			relapse (≥3 months). Oxidase positive. Resistant to
	•	Wound = NP			penicillin, aminoglycosides, colistin.

Campylobacter	•	CSF = P (ABM)	Gentamicin (IV)	Chloramphenicol	Causes invasive infection with spread to CNS. CNS
fetus	•	Blood = P (from	Imipenem (IV)	(IV)	infection may be treated with meningeal doses of
		vascular source)	Meropenem (IV)	Ampicillin (IV)	chloramphenicol, ampicillin,

220

s l a i t n e s s E c i t o i b i t n A

	•	Sputum = NP		Any 3rd generation			or a 3rd generation cephalosporin. Resistant to
	•	Urine = NP			cephalosporin		erythromycin.
	•	Stool = NP			(IV)
	•	Wound = NP

Campylobacter	•	CSF = NP	Any quinolone	Azithromycin (PO)			Commonest cause of acute bacterial diarrhea.
jejuni	•	Blood = P (from GI	(IV/PO)	Clarithromycin			Resistant to TMP–SMX.
	•	source)	Erythromycin (PO)		XL (PO)
	•	Sputum = NP	Doxycycline
	•	Urine = NP	Doxycycline
	•	Urine = NP	(IV/PO)
	•	Stool = P (diarrhea)	(IV/PO)
	•	Stool = P (diarrhea)
	•	Wound = NP

Cardiobacterium	•	CSF = NP	Penicillin (IV) +	Any 3rd generation			Pleomorphic bacillus with bulbous ends. Often
hominis	•	Blood = P (from SBE)	gentamicin (IV)		cephalosporin		appears in clusters resembling rosettes. Indole
	•	Sputum = NP	Ampicillin (IV) +		(IV) + gentamicin		positive. Cause of “culture-negative” SBE (one of
	•	Urine = NP	gentamicin (IV)		(IV)		the HACEK organisms). Rare cause of abdominal
	•	Stool = NP	gentamicin (IV)		(IV)		the HACEK organisms). Rare cause of abdominal
	•	Stool = NP					abscess. Grows best with CO2 enhancement.
	•	Wound = NP					abscess. Grows best with CO2 enhancement.
							Resistant to macrolides and clindamycin.

Chromobacterium	•	CSF = NP	Gentamicin (IV)	Chloramphenicol			Cause of cutaneous lesions primarily in tropical/
violaceum	•	Blood = P (from	Doxycycline		(IV)		subtropical climates. Often mistaken for Vibrio or
	•	wound infection)	(IV/PO)				Alcaligenes. Resistant to β-lactams.
	•	Sputum = NP
	•	Urine = NP
	•	Stool = NP
	• Wound = P (drainage
		from deep soft tissue
		infection)

Chryseobacterium	•	CSF = P (ABM)	CNS	CNS			Rare cause of ABM in newborns and PVE in adults.
(Flavobacterium)	•	Blood = P (from IV line				Chloramphenicol	Only unencapsulated Flavobacterium species.
(Flavobacterium)	•	Blood = P (from IV line	TMP–SMX (IV/PO)			Chloramphenicol	Only unencapsulated Flavobacterium species.
meningosepticum	•	infection, PVE)			(IV)		Clindamycin, clarithromycin, and vancomycin are
meningosepticum	•	Sputum = NP			(IV)		Clindamycin, clarithromycin, and vancomycin are
							useful only in non-CNS

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

Therapy Initial and Profiles Susceptibility Antibiotic .3 Chapter

221

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-NEGATIVE BACILLI

			Preferred			Alternate
Isolate		Isolate Significance	Therapy			Therapy	Comments

	•	Urine = C, P	Non-CNS		Non-CNS		infections. Resistant to aztreonam and
		(from urologic		(IV) +			carbapenems.
		(from urologic	Vancomycin	(IV) +		Clarithromycin	carbapenems.
	•	instrumentation)	rifampin (PO)			XL (PO) +
	•	Stool = NP	Any quinolone			rifampin (PO)
	•	Wound = C, P	Any quinolone			rifampin (PO)
	•	Wound = C, P	(IV/PO)		Clindamycin
		(cellulitis)	(IV/PO)		Clindamycin
		(cellulitis)				(IV/PO)
						(IV/PO)

Citrobacter	•	CSF = C*, P (from NS	Any carbapenem		Aztreonam (IV)		Common wound/urine colonizer. Rare pathogen
diversus, freundii,	•	procedure)	(IV)		Piperacillin (IV)		in normal hosts. Often aminoglycoside resistant.
koseri	•	Blood = C*, P (from	Cefepime (IV)		Any 3rd generation		(C. freundii is usually more resistant than C. koseri).
		IV line/urinary tract	Any quinolone			cephalosporin (IV)
		infection)	Any quinolone			cephalosporin (IV)
	•	infection)	(IV/PO)
		Sputum = C (not	(IV/PO)
		Sputum = C (not
		pneumonia)
	• Urine = C, P
		(from urologic
	•	instrumentation)
	•	Stool = NP
	• Wound = C, P (rarely in
		compromised hosts)

Edwardsiella tarda	•	CSF = NP	Ampicillin (IV)		Doxycycline		Cause of bacteremia, usually from liver abscess or
	•	Blood = P (from liver	Amoxicillin (PO)			(IV/PO)	wound source.
	•	abscess)	Any quinolone		Any 3rd generation
	•	Sputum/Urine = NP	(IV/PO)			cephalosporin
	•	Stool = P	(IV/PO)			cephalosporin
	•	Stool = P				(IV/PO)
	• Wound C, P (wound					(IV/PO)
	• Wound C, P (wound
		infection)

222

s l a i t n e s s E c i t o i b i t n A

Enterobacter	•	CSF = C*, P (from NS	Any carbapenem	Any quinolone	Not a cause of community-acquired or
agglomerans,	•	procedure)	(IV)	(IV/PO)	nosocomial pneumonia. Common colonizer
aerogenes,	•	Blood = C*, P (from		Aztreonam (IV)	of respiratory secretions and wound/urine
cloacae		IV line/urinary tract		Piperacillin (IV)	specimens. Antibiotic resistance to E. cloacae
cloacae		infection)		Piperacillin (IV)	specimens. Antibiotic resistance to E. cloacae
		infection)		Cefepime (IV)	> E. aerogenes > E. agglomerans. Treatment
	• Sputum = C (not a			Cefepime (IV)	> E. aerogenes > E. agglomerans. Treatment
	• Sputum = C (not a				of Enterobacter colonizers with ceftazidime or
		cause of pneumonia)			of Enterobacter colonizers with ceftazidime or
		cause of pneumonia)			ciprofloxacin may result in MDR/ESBL Enterobacter
	• Urine = C, P				ciprofloxacin may result in MDR/ESBL Enterobacter	Chapter
		(post-urologic			sp.	Chapter
	•	instrumentation)			CRE usually susceptible only to tigacycline, colistin,	.3
	•	Stool = NP			CRE usually susceptible only to tigacycline, colistin,	.3
Escherichia coli	• Wound = C, P (rarely in		Any 1st, 2nd, 3rd	Aztreonam (IV)	polymyxin B, ceftazidime/avibactam, fosfomycin.	Antibiotic
Escherichia coli	•	CSF = P (ABM)	Any 1st, 2nd, 3rd	Aztreonam (IV)	Common pathogen, usually from GI/GU source.	Antibiotic
		compromised hosts)
	• Blood = P (from GI/		generation	Gentamicin (IV)	Many strains are resistant to ampicillin and some	Susceptibility
		GU source)	cephalosporin	TMP–SMX (IV/PO)	to 1st generation cephalosporins. ESBL-producing
	• Sputum = P (rarely		(IV/PO)		E. coli may be treated with a carbepenem.
		CAP from urinary	(IV/PO)		E. coli may be treated with a carbepenem.
		CAP from urinary	Amoxicillin (PO)
		source, VAP)	Amoxicillin (PO)		CRE usually susceptible only to tigacycline, colistin,
		source, VAP)	Any quinolone		CRE usually susceptible only to tigacycline, colistin,	Profiles
	• Urine = C, P		Any quinolone		polymyxin B, ceftazidime/avibactam, fosfomycin.
	• Urine = C, P		(IV/PO)
		(CAB, cystitis,
		(CAB, cystitis,
		pyelonephritis)	Ceftriaxone (IV)			and
	• Stool = C, P		Nitrofurantoin (PO)			and
	• Wound = P (cellulitis)					Initial
	•	(diarrhea)	(UTIs only)
						Therapy
Francisella	•	CSF = NP	Doxycycline	Chloramphenicol	Six clinical tularemia syndromes. Alert	Therapy
tularensis	•	Blood = P (isolation	(IV/PO)	(IV/PO)	microbiology laboratory of potentially
	•	dangerous)	Gentamicin	Any quinolone	biohazardous specimens. Do not culture.
	•	Sputum =	(IV/IM)	(IV/PO)	Resistant to penicillins and cephalosporins.
		P (tularemic	(IV/IM)	(IV/PO)	Resistant to penicillins and cephalosporins.
		P (tularemic	Streptomycin (IM)		Bioterrorist tularemia is treated the same as
		pneumonia; isolation	Streptomycin (IM)		Bioterrorist tularemia is treated the same as
		pneumonia; isolation			naturally-acquired tularemia.
		dangerous)			naturally-acquired tularemia.
		dangerous)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

223

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-NEGATIVE BACILLI

				Alternate
Isolate		Isolate Significance	Preferred Therapy	Therapy	Comments

	•	Urine/Stool = NP
	• Wound = P (isolation
		dangerous)

Hafnia alvei	•	CSF = C, P (from NS	Cefepime (IV)	Piperacillin (IV)	Formerly Enterobacter hafniae. Uncommon
	•	procedure)	Any quinolone	Imipenem (IV)	nosocomial pathogen. Rarely pathogenic in
	•	Blood = C*, P (from	(IV/PO)	Meropenem (IV)	normal hosts. Cause of UTIs in compromised
		IV line/urinary tract	Aztreonam (IV)		hosts.
		infection)	Aztreonam (IV)		hosts.
		infection)
	• Sputum = C (not
		pneumonia)
	• Urine = C, P
		(post-urologic
	•	instrumentation)
	•	Stool = NP
	• Wound = C, P (rarely
		in compromised
		hosts)

Helicobacter	•	CSF = NP	Omeprazole (PO) +	Doxycycline (PO)	Optimal therapy awaits definition. Treat until
(Campylobacter)	•	Blood = NP	clarithromycin	+ metronidazole	cured. Some strains of resistant H. pylori may
pylori	•	Sputum = NP	XL (PO)	(PO) + bismuth	respond to treatment with a quinolone.
	•	Urine = NP	Omeprazole (PO) +	subsalicylate (PO)	TMP–SMX is ineffective.
	•	Stool = P (from	Omeprazole (PO) +	subsalicylate (PO)	TMP–SMX is ineffective.
	•	Stool = P (from	amoxicillin (PO)
		upper GI tract biopsy	amoxicillin (PO)
		upper GI tract biopsy	Metronidazole (PO)
		specimens, not stool)	Metronidazole (PO)
	•	specimens, not stool)	+ amoxicillin
	•	Wound = NP	+ amoxicillin
			(PO) + bismuth
			subsalicylate (PO)

224

s l a i t n e s s E c i t o i b i t n A

Haemophilus

•

CSF = P (ABM)

For all Haemophilus

1st generation cephalosporins, erythromycin,

influenzae,

•

Blood = P (from

species

and clarithromycin have limited anti-H.

parainfluenzae,

respiratory tract or

influenzae activity; doxycycline and azithromycin

Any 2nd

, 3rd

Chloramphenicol

aphrophilus,

•

cardiac source)

generation

(IV)

are better. Hemophilus species are common

Sputum = C, P (CAP)

paraphrophilus

cephalosporin

TMP–SMX (IV/PO)

colonizers of the respiratory tract. Rarely a cause

•

Urine = NP

(IV/PO)

Azithromycin (PO)

of “culture-negative” SBE (H. parainfluenzae/

•

Stool = NP

Any quinolone

Aztreonam (IV)

aphrophilus are HACEK organisms). H.

•

Wound = P

Chapter

(IV/PO)

Ampicillin-resistant

influenzae and H. parainfluenzae (pathogens) may

Doxycycline

H. influenzae

be differentiated from the throat commensals

(IV/PO)

Meropenem (IV)

H. hemolyticus and H. parahemolyticus (non-

Antibiotic

Cefepime (IV)

pathogens) by hemolysis on sheep agar.

Imipenem (IV)

Ertapenem (IV)

Susceptibility

skeletal or cardiac

aminoglycoside

cephalosporin + any

osteomyelitis in children and endocarditis in

Aztreonam (IV)

Kingella

•

CSF = NP

Ampicillin (IV)

Any 3rd generation

Common colonizer of respiratory tract, but rarely

(Moraxella) kingae

•

Blood = P (from

+ any

(IV)

a respiratory pathogen. Causes septic arthritis/

•

source)

(IV)

Growth enhanced with CO2.

Profiles

Urine = NP

•

Sputum = C

aminoglycoside

adults (one of HACEK organisms). Oxidase positive.

•

Stool/wound = NP

Imipenem (IV)

and

Meropenem (IV)

Initial

Any quinolone

(IV/PO)

Therapy

Klebsiella

•

CSF = P (ABM)

Tigecycline (IV)

Any 3rd generation

TMP–SMX may be ineffective in systemic infection.

pneumoniae,

•

Blood = P (from

Any carbapenem

cephalosporin

Anti-pseudomonal penicillins have limited anti-

oxytoca

respiratory, GI, GU

(IV)

(IV, PO) except

Klebsiella activity. Klebsiella usually susceptible

source)

ceftazidine

to carbapenems. CRE usually susceptible only to

Any quinolone

tigecycline, colistin, polymyxin B, ceftazidime/

(IV/PO)

avibactam, fosfomycin.

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

225

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-NEGATIVE BACILLI

				Alternate
Isolate		Isolate Significance	Preferred Therapy	Therapy	Comments

	•	Sputum = C, P (CAP/		Aztreonam (IV)	NDM-1 metallo β-lactamase strains are
	•	VAP)		Cefepime (IV)	carbapenem resistant and usually susceptible only
	•	Urine = C (CAB), P			to colistin, tigacycline.
	•	Stool = NP
	• Wound = C, P

Klebsiella	•	CSF = NP	Any quinolone	TMP–SMX (PO) +	Skin infection usually requires prolonged
ozaenae,	•	Blood = NP	(PO)	rifampin (PO)	treatment for cure (weeks-to-months).
rhinoscleromatis	•	Sputum = NP
	•	Urine = NP
	•	Stool = NP
	•	Wound = P
		(rhinoscleromatis
		lesions)

Legionella sp.	•	CSF = NP	Any quinolone	Clarithromycin	Anti-Legionella activity: quinolones > doxycycline >
	•	Blood = NP	(IV/PO)	XL (PO)	erythromycin. Erythromycin failures are not
	•	Sputum = P (CAP	Doxycycline (IV/PO)	Erythromycin (IV)	uncommon. Rarely a cause of culture-negative
	•	or VAP)	Tigacycline (IV)	Telithromycin (PO)	SBE/PVE.
		Urine = NP	Tigacycline (IV)	Telithromycin (PO)	SBE/PVE.
		Urine = NP	Azithromycin
	•	Stool = NP	Azithromycin
	•	Stool = NP	(IV/PO)
	•	Wound = NP	(IV/PO)
	•	Wound = NP

Leptospira	•	CSF = P (ABM)	Doxycycline	Amoxicillin (PO)	Blood/urine cultures may be positive during
interrogans	•	Blood = P (1°	(IV/PO) Penicillin		initial/bacteremic phase, but are negative during
	•	bacteremia)	G (IV)		immune phase. Relapse is common. Resistant to
	•	Sputum = NP	Any 3rd generation		chloramphenicol.
	• Urine = P (excreted		cephalosporin
		in urine)	cephalosporin
	•	in urine)	(IV/PO)
		Stool = NP	(IV/PO)
		Stool = NP
	•	Wound = NP

226

s l a i t n e s s E c i t o i b i t n A

Moraxella	•	CSF = NP	Any 2nd, 3rd	Azithromycin (PO)	Almost all strains are β-lactamase positive and
(Branhamella)	•	Blood = P (rarely from	generation	Clarithromycin XL	resistant to penicillin/ampicillin. β-lactamase-
catarrhalis		CAP)	cephalosporin	(PO)	resistant β-lactams are effective. Resembles
	• Sputum = C, P (CAP)		(IV/PO)	TMP–SMX (IV/PO)	Acinetobacter on sputum gram stain.
	•	Urine = NP	(IV/PO)	TMP–SMX (IV/PO)	Acinetobacter on sputum gram stain.
	•	Urine = NP	Any quinolone	Amoxicillin/
	•	Stool = NP	Any quinolone	Amoxicillin/
	•	Stool = NP	(IV/PO)	clavulanic acid
	•	Wound = NP	(IV/PO)	clavulanic acid
	•	Wound = NP	Telithromycin (PO)	(PO)
			Telithromycin (PO)	(PO)
			Doxycycline
			(IV/PO)

Morganella	•	CSF = NP	Any quinolone	Any aminoglycoside	Common uropathogen. Causes bacteremia with
morganii	•	Blood = P (from GU	(IV/PO)	(IV)	urosepsis. Rare cause of wound infections.
	•	source)	Any 3rd generation	Aztreonam (IV)
	•	Sputum = NP	cephalosporin	Cefepime (IV)
	•	Urine = P	cephalosporin	Cefepime (IV)
	•	Urine = P	(IV)
		(CAB, cystitis,	(IV)
		(CAB, cystitis,	Any carbapenem
		pyelonephritis)	Any carbapenem
	•	pyelonephritis)	(IV)
	•	Stool = NP	(IV)
	• Wound = P (cellulitis
		rare)

Ochrobactrum	•	CSF = NP	Any quinolone	Any aminoglycoside	Pathogen in compromised hosts. Oxidase and
anthropi (CDC	•	Blood = P (from IV line	(IV/PO)	(IV)	catalase positive. Resistant to β-lactams.
group Vd)	•	infections)	TMP–SMX (IV/PO)	Imipenem (IV)
	•	Sputum = C		Meropenem (IV)
	•	Urine = C		Meropenem (IV)
	•	Urine = C
	•	Stool/Wound = C

Pasteurella	•	CSF = P (ABM)	Amoxicillin (PO)	Ampicillin/	Common cause of infection following dog/
multocida	•	Blood = P (from	Doxycycline	sulbactam	cat bites. Many antibiotics are effective,
		respiratory source,	(IV/PO)	(IV)	but erythromycin is ineffective. Resembles
	•	bite wound/abscess)	Penicillin G (IV)	Piperacillin (IV)	Hemophilus sp. on sputum gram stain.
		Sputum = C, P (CAP,	Penicillin G (IV)	Piperacillin (IV)	Hemophilus sp. on sputum gram stain.
		Sputum = C, P (CAP,		Any quinolone
		bronchiectasis)		Any quinolone
		bronchiectasis)		(IV/PO)
				(IV/PO)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

Therapy Initial and Profiles Susceptibility Antibiotic .3 Chapter

227

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-NEGATIVE BACILLI

Alternate

Isolate

Isolate Significance

Preferred Therapy

Therapy

Comments

• Urine = C, P

•

(pyelonephritis)

Stool = NP

• Wound = P (human/

animal bites)

Plesiomonas

•

CSF = NP

Any quinolone

Doxycycline (PO)

Infrequent cause of diarrhea, less commonly

shigelloides

•

Blood = P (from GU

(PO)

Aztreonam (PO)

dysentery. Oxidase positive. β-lactamase strains

•

source)

TMP–SMX (PO)

are increasing. Resistant to penicillins.

Sputum = NP

•

Urine = NP

• Stool = P (diarrhea)

•

Wound = NP

Proteus mirabilis,

•

CSF = NP

P. mirabilis, indole

P. mirabilis,

Usually a uropathogen. Most antibiotics are

vulgaris

•

Blood = P (from

effective against P. mirabilis (indole-negative);

(–)

indole (–)

urinary source)

(IV/PO)

P. penneri (indole-negative P. vulgaris) is resistant

•

Ampicillin (IV)

TMP–SMX

Sputum = C

Any 1st, 2nd, 3rd gen.

Amoxicillin (PO)

to ceftriaxone. Indole-positive Proteus sp. require

• Urine = C, P

cephalosporin

potent antibiotics to treat non-UTIs. P. penneri

(from urologic

P. vulgaris, indole (+)

(IV/PO)

(indole-negative P. vulgaris) resistant to 3rd gen.

instrumentation)

Aztreonam (IV) Any

•

cephalosporins; use cefepime, carbapenem, or

Stool = NP

P. vulgaris, indole

carbapenem (IV)

• Wound = C, P (wound

quinolone.

(+)

Any aminoglycoside

infection)

Any 3rd generation

(IV)

cephalosporin

(IV/PO)

Cefepime (IV)

Any quinolone

(IV/PO)

228

s l a i t n e s s E c i t o i b i t n A

Providencia	•	CSF = NP	Any quinolone	Any aminoglycoside	Almost always a uropathogen. Formerly classified
alcalifaciens,	•	Blood = C*, P (from	(IV/PO)	(IV)	as indole-positive Proteus.
rettgeri, stuartii	•	GU source)	Any 3rd generation	Aztreonam (IV)
	•	Sputum/Stool = NP	cephalosporin	Piperacillin (IV)
	•	Urine = C, P	cephalosporin	Piperacillin (IV)
	•	Urine = C, P	(IV/PO)	Imipenem (IV)
	•	Wound = C, P (rare)	(IV/PO)	Imipenem (IV)
	•	Wound = C, P (rare)	Cefepime (IV)
			Cefepime (IV)
			Meropenem (IV)			.3 Chapter
			Ertapenem (IV)

Pseudomonas	•	CSF = NP	Monotherapy	Doripenem (IV)	Colonization common; infection uncommon.
	•	Blood = P (from
aeruginosa	•	Blood = P (from	Meropenem (IV)	Colistin (IV)	If possible, avoid treating P. aeruginosa in	Antibiotic
	•	Sputum = C (usually),	Combination			Antibiotic
		respiratory, GU	Cefepime (IV)	Polymyxin B (IV)	respiratory secretions in ventilated patients (unless
		source)		Amikacin (IV)	tracheobronchitis) or urine cultures (CAB).
				Aztreonam (IV)	For serious systemic P. aeruginosa infection,
		P (rarely indicates	therapy	Aztreonam (IV)	For serious systemic P. aeruginosa infection,	Susceptibility
		P (rarely indicates	therapy		double-drug therapy preferred. All double anti-

		VAP)	either meropenem
	•	VAP)	either meropenem		P. aeruginosa regimens are equally effective.
	•	Urine = C, P	(IV) or cefepime		P. aeruginosa regimens are equally effective.
		(from urologic	(IV) plus amikacin		Individual differences in activity (MICs) are
	•	instrumentation)			unimportant if combination therapy is used.	Profiles
	•	Stool = NP			If MDR P. aeruginosa meropenem susceptible,	Profiles
	•	Wound = C (almost			treat with meropenem. If MDR P. aeruginosa
		always)			meropenem resistant, treat with colistin,	and
					meropenem resistant, treat with colistin,
					polymyxin B, or doripenem.
					polymyxin B, or doripenem.	Initial

Pseudomonas	•	CSF = NP	Imipenem (IV)	Piperacillin/	Opportunistic pathogen primarily in
(Chryseomonas)	•	Sputum = NP	Meropenem (IV)	tazobactam (IV)	compromised hosts.	Therapy
(Chryseomonas)	•	Blood = P (from IV line	Meropenem (IV)	tazobactam (IV)	compromised hosts.
luteola (CDC		infection)	Cefepime (IV)	Aztreonam (IV)
group Ve-1)	•	Urine = NP
	•	Urine = NP
	•	Stool = NP
	•	Wound = NP

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

229

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-NEGATIVE BACILLI

	Isolate		Isolate Significance	Preferred Therapy	Alternate Therapy	Comments
	Isolate		Isolate Significance			Comments

	Pseudomonas	•	CSF = P (NS	Imipenem (IV)	Any 3rd generation	Rare cause of central IV line infections
(Flavimonas)		•	procedures)	Meropenem (IV)	cephalosporin	in compromised hosts (usually in febrile
oryzihabitans		•	Blood = P (from IV line	Cefepime (IV)	(IV)	neutropenics). Rare cause of peritonitis in
(CDC group Ve-2)		•	infection)		Piperacillin (IV)	CAPD patients. Oxidase negative, unlike other
(CDC group Ve-2)		•	Sputum = NP		Piperacillin (IV)	CAPD patients. Oxidase negative, unlike other
		•	Urine = NP		Aztreonam (IV)	Pseudomonas species.
		•	Urine = NP
		•	Stool = NP
		• Wound = P (rare)

	Salmonella typhi,	•	CSF = NP	Any quinolone	Chloramphenicol	Carrier state is best eliminated by a quinolone or
non-typhi		•	Blood = P (from GI	(IV/PO)	(IV)	TMP–SMX. If drug therapy fails to eliminate carrier
		•	source)	Any 3rd generation	TMP–SMX (IV/PO)	state, look for hepatic/bladder calculi for persistent
		•	Sputum = NP	cephalosporin	Doxycycline	focus. Many strains are resistant to ampicillin/
		•	Urine = P (only with	cephalosporin	Doxycycline	focus. Many strains are resistant to ampicillin/
		•	Urine = P (only with	(IV)	(IV/PO)	amoxicillin.
			enteric fever)	(IV)	(IV/PO)	amoxicillin.
			enteric fever)
		• Stool = C (carrier),
			P (gastroenteritis,
		•	enteric fever)
		•	Wound = NP

	Serratia	•	CSF = P (from NS	Any 3rd generation	Any carbapenem	Enterobacteriaceae. Associated with water
marcescens		•	procedures)	cephalosporin	(IV)	sources. Common colonizer of respiratory
		•	Blood = P (from IV line	(IV/PO) (except	Gentamicin (IV)	secretions/urine in ICU. Serratia nosocomial
		•	or urinary source)	ceftazidime)	Aztreonam (IV)	pneumonia and PVE are rare. Cause of septic
			Sputum = C, P (rarely	ceftazidime)	Aztreonam (IV)	pneumonia and PVE are rare. Cause of septic
			Sputum = C, P (rarely	Any quinolone	Piperacillin (IV)	arthritis, osteomyelitis, and SBE (IV drug abusers).
			in VAP)	Any quinolone	Piperacillin (IV)	arthritis, osteomyelitis, and SBE (IV drug abusers).
		•	in VAP)	(IV/PO)		Among the aminoglycosides, gentamicin has the
			Urine = C, P	(IV/PO)		Among the aminoglycosides, gentamicin has the
			Urine = C, P	Cefepime (IV)		greatest anti-Serratia activity.
			(post-urologic	Cefepime (IV)		greatest anti-Serratia activity.
		•	instrumentation)
		•	Stool = NP
		• Wound = C, P (rare)

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Shigella boydii,	•	CSF = NP	Any quinolone (IV/	TMP–SMX (IV/PO)	No carrier state. Severity of dysentery varies with
sonnei, flexneri,	•	Blood = P (from GI	PO)	Azithromycin	the species: S. dysenteriae (most severe) >
dysenteriae	•	source)		(IV/PO)	S. flexneri > S. sonnei/boydii (least severe).
	•	Sputum = NP
	•	Urine = NP
	• Stool = P (Shigella
	•	dysentery)
	•	Wound = NP				3 Chapter

Steno-	•	CSF = C, P (from NS	TMP–SMX (IV/PO)	Cefepime (IV)	Potential pulmonary pathogen only in
trophomonas	•	procedures)	Minocycline	Any respiratory	bronchiectasis/cystic fibrosis. Resistant to
(Pseudomonas,		Blood = C*, P (from	Minocycline	Any respiratory	bronchiectasis/cystic fibrosis. Resistant to	.
			(IV/PO)	quinolone	aminoglycosides and carbapenems. Although
			(IV/PO)	quinolone	aminoglycosides and carbapenems. Although	Antibiotic
Xanthomonas)	•	Sputum = C (not VAP)		(IV/PO)	usually carbapenem resistant, ~60% of strains	Antibiotic
Xanthomonas)		IV line infection, GU		(IV/PO)	usually carbapenem resistant, ~60% of strains
maltophilia		source)			demonstrate synergy with meropenem +
	•	Urine = C, P			levofloxacin. Susceptible to chloramphenicol,	Susceptibility
	•	Urine = C, P			rifampin, colistin, polymyxin B.
	•	Wound = C, P (rarely in
		(from urologic
	•	instrumentation)
	•	Stool = NP				Profiles
Streptobacillus	•	CSF = P (brain abscess)	Penicillin (IV)	Oxycycline	Cause of Haverhill fever and rat-bite fever, with	Profiles
		compromised hosts)
moniliformis	•	Blood = P (from	Ampicillin (IV)	(IV/PO)	abrupt onset of severe headache/arthralgias after	and
		wound)	Amoxicillin (PO)	Erythromycin (IV)	bite wound has healed. No regional adenopathy.	and
	•	wound)	Amoxicillin (PO)	Erythromycin (IV)	bite wound has healed. No regional adenopathy.	Initial
	•	Sputum = P (lung		Clindamycin	Morbilliform/petechial rash. Arthritis in 50%. May	Initial
		abscess)		Clindamycin	Morbilliform/petechial rash. Arthritis in 50%. May
	•	abscess)		(IV/PO)	cause SBE.	Therapy
		Urine = NP		(IV/PO)	cause SBE.
		Urine = NP
	•	Stool = NP
	• Wound = P (from rat
		bite)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

231

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

			GRAM-NEGATIVE BACILLI

			Preferred Therapy	Alternate
Isolate		Isolate Significance	Preferred Therapy	Therapy	Comments
Isolate		Isolate Significance		Therapy	Comments

Vibrio cholerae	•	CSF = NP	Doxycycline	TMP–SMX (IV/PO)	No carrier state. Treat for 3 days. Single-dose
	•	Blood = P (from GI	(IV/PO)		therapy is often effective. Resistant to ampicillin.
	•	source)	Any quinolone
	•	Sputum = NP	(IV/PO)
	•	Urine = NP	(IV/PO)
	•	Urine = NP
	• Stool = P (cholera)
	•	Wound = NP

Vibrio	•	CSF = NP	Doxycycline	Any quinolone	Most cases of gastroenteritis caused by
parahaemolyticus	•	Blood = P (from GI	(IV/PO)	(IV/PO)	V. parahaemolyticus are self-limited and require
	•	source)			no treatment.
	•	Sputum = NP
	•	Urine = NP
	• Stool = P (diarrhea)
	•	Wound = P

Vibrio vulnificus,	•	CSF = NP	Doxycycline	Piperacillin (IV)	Causes necrotizing soft tissue infection resembling
alginolyticus	•	Blood = P (from GI/	(IV/PO)	Ampicillin/	gas gangrene. Patients are critically ill with fever,
	•	wound source)	Any quinolone	sulbactam (IV)	bullous lesions, diarrhea, and hypotension. Treat
	•	Sputum = NP	(IV/PO)		wound infection, bacteremia. Aminoglycoside
	•	Urine = NP	(IV/PO)		wound infection, bacteremia. Aminoglycoside
	•	Urine = NP			susceptibilities are unpredictable.
	•	Stool = P (diarrhea)			susceptibilities are unpredictable.
	•	Stool = P (diarrhea)
	• Wound = P (water-
		contaminated wound
		raw oysters, other
		shell fish ingestion)

Yersinia	•	CSF = NP	Any quinolone	TMP–SMX (IV/PO)	Cause of diarrhea with abdominal pain. If pain in
enterocolitica	•	Blood = P (from GI	(IV/PO)	Any 3rd generation	is right lower quadrant, may be mistaken for acute
		source)		cephalosporin	appendicitis.
				(IV/PO)

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	•	Sputum = NP	Gentamicin (IV)
	•	Urine = NP	Doxycycline
	•	Stool = P (diarrhea)	(IV/PO)
	•	Wound = NP

Yersinia pestis	•	CSF = NP	Doxycycline	Chloramphenicol	Cause of bubonic, septicemic, and pneumonic
	•	Blood = P (septicemic	(IV/PO)	(IV/PO)	plague. Doxycycline or any quinolone may
		plague; isolation	Streptomycin (IM)		be used for prophylaxis. Alert microbiology
	•	required; dangerous)	Gentamicin		laboratory of potentially biohazardous specimens.
		Sputum = P	Gentamicin		laboratory of potentially biohazardous specimens.
		Sputum = P	(IV/IM)		Do not culture. Bioterrorist plague is treated the
		(pneumonic plague;	(IV/IM)		Do not culture. Bioterrorist plague is treated the
		(pneumonic plague;	Any quinolone		same as naturally-acquired plague.
		isolation required;	Any quinolone		same as naturally-acquired plague.
		isolation required;	(IV/PO)
	•	dangerous)	(IV/PO)
	•	Urine = NP
	•	Stool = NP
	• Wound = P (lymph
		nodes, lymph node
		drainage; bubonic
		plague; isolation
		required; dangerous)

			SPIROCHETES

Borrelia	•	CSF = P	Doxycycline (PO)	Any cephalosporin	Cause of Lyme disease. β-lactams and doxycycline
burgdorferi	•	(neuroborreliosis)	Amoxicillin (PO)	(PO)	are effective. Erythromycin least effective for
	•	Blood = P (rarely		Azithromycin (PO)	erythema migrans. Minocycline may be preferred
		isolated; requires		Erythromycin (PO)	to doxycycline for neuroborreliosis.
		special media)		Erythromycin (PO)	to doxycycline for neuroborreliosis.
	•	special media)
	•	Sputum = NP
	•	Urine = NP
	•	Stool = NP
	• Wound = P (rarely
		isolated from
		erythema migrans
		lesions)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

Therapy Initial and Profiles Susceptibility Antibiotic .3 Chapter

233

Table 3.6. Usual Clinical Significance of AEROBIC Isolates Pending Susceptibility Testing (cont'd)

SPIROCHETES

			Preferred Therapy	Alternate
Isolate		Isolate Significance	Preferred Therapy	Therapy	Comments
Isolate		Isolate Significance		Therapy	Comments

Borrelia	•	CSF = P (ABM)	Doxycycline	Erythromycin (IV)	Cause of relapsing fever. May be recovered from
recurrentis	•	Blood = P (1°	(IV/PO)	Penicillin (IV)	septic metastatic foci. Septic emboli may
	•	bacteremia)	Azithromycin	Ampicillin (IV)	cause sacroiliitis, SBE, myositis, orchitis, or
	•	Sputum = NP	(IV/PO)	Any 1st, 2nd, 3rd	osteomyelitis.
	•	Urine = NP		generation
	•	Stool = NP		generation
	•	Stool = NP		cephalosporin
	•	Wound = NP		cephalosporin
	•	Wound = NP		(IV/PO)
				(IV/PO)

Spirillum minus	•	CSF = NP	Penicillin (IV)	Doxycycline	Cause of rat-bite fever. Bite wound heals promptly,
	•	Blood = P (from	Amoxicillin (PO)	(IV/PO)	but 1–4 weeks later becomes painful, purple and
	•	wound source, SBE)		Any quinolone	swollen, and progresses to ulceration and eschar
	•	Sputum = NP		(IV/PO)	formation. Painful regional adenopathy. Central
	•	Urine = NP		(IV/PO)	formation. Painful regional adenopathy. Central
	•	Urine = NP			maculopapular rash is common (rarely urticarial).
	•	Stool = NP			maculopapular rash is common (rarely urticarial).
	•	Stool = NP			Arthralgias/arthritis is rare compared to rat-bite
	•	Wound = P (from			Arthralgias/arthritis is rare compared to rat-bite
	•	Wound = P (from			fever from Streptobacillus moniliformis. Rarely
		rat bite)			fever from Streptobacillus moniliformis. Rarely
					causes SBE.

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

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s l a i t n e s s E c i t o i b i t n A

Table 3.7. Clinical Significance of CAPNOPHILIC Isolates Pending Susceptibility Testing

GRAM-NEGATIVE BACILLI

			Preferred	Alternate
Isolate	Isolate Significance		Therapy	Therapy	Comments

Capnocytophaga	•	CSF = NP	Ampicillin/	Clindamycin	Associated with animal bites or cancer. May cause
canimorsus/	•	Blood = P (from	sulbactam (IV)	(IV/PO)	fatal septicemia in cirrhotics/asplenics. Resistant to
cynodegni		GI source, bite	Piperacillin/	Any quinolone	aminoglycosides, metronidazole, TMP–SMX, and
(DF-2 like)	•	wound)	tazobactam (IV)	(IV/PO)	aztreonam.
(DF-2 like)		Sputum = NP	tazobactam (IV)	(IV/PO)	aztreonam.
		Sputum = NP	Imipenem (IV)	Doxycycline
	•	Urine = NP	Imipenem (IV)	Doxycycline
	•	Urine = NP	Meropenem (IV)	(IV/PO)
	•	Stool = NP	Meropenem (IV)	(IV/PO)
	•	Stool = NP	Ertapenem (IV)
	•	Wound = P (from	Ertapenem (IV)
		dog/cat bite)

Capnocytophaga	•	CSF = NP	Ampicillin/	Clindamycin	Thin, spindle-shaped bacilli resemble Fusobacteria
ochraceus (DF-1)	•	Blood = P (from GI,	sulbactam (IV)	(IV/PO)	morphologically.“Gliding motility” seen in hanging
		wound, abscess	Piperacillin/	Any quinolone	drop preparations. Cause of septicemia, abscesses,
	•	source)	tazobactam (IV)	(IV/PO)	and wound infections. Resistant to aminoglycosides,
		Sputum = NP	tazobactam (IV)	(IV/PO)	and wound infections. Resistant to aminoglycosides,
		Sputum = NP	Imipenem (IV)	Doxycycline	metronidazole, TMP–SMX, and aztreonam.
	•	Urine = NP	Imipenem (IV)	Doxycycline	metronidazole, TMP–SMX, and aztreonam.
	•	Urine = NP	Meropenem (IV)	(IV/PO)
	•	Stool = NP	Meropenem (IV)	(IV/PO)
	•	Stool = NP	Ertapenem (IV)
	•	Wound = P	Ertapenem (IV)

Eikenella	•	CSF = NP	Penicillin (IV)	Piperacillin (IV)	Cause of “culture-negative” SBE (one of the
corrodens	•	Blood = P (SBE in IV	Ampicillin (IV)	Ampicillin/	HACEK organisms). Resistant to clindamycin and
	•	drug abusers)	Imipenem (IV)	sulbactam (IV)	metronidazole.
	•	Sputum = NP	Meropenem (IV)	Doxycycline
	•	Urine = NP	Meropenem (IV)	Doxycycline
	•	Urine = NP	Ertapenem (IV)	(IV/PO)
	•	Stool = NP	Ertapenem (IV)	(IV/PO)
	•	Stool = NP		Amoxicillin (PO)
	•	Wound = P (IV drug		Amoxicillin (PO)
	•	Wound = P (IV drug
		abusers)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

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235

Table 3.8. Usual Clinical Significance of ANAEROBIC Isolates Pending Susceptibility Testing

GRAM-POSITIVE BACILLI

			Preferred	Alternate
Isolate		Isolate Significance	Therapy	Therapy	Comments

Peptococcus	•	CSF = P (brain abscess)	Penicillin (IV)	Chloramphenicol (IV)	Normal flora of mouth, GI tract, and
	• Blood = P (from		Ampicillin (IV)	Erythromycin (IV)	pelvis. Associated with mixed aerobic/
		GI/pelvic source)	Amoxicillin (PO)	Any carbapenem (IV)	anaerobic dental, abdominal, and pelvic
	• Sputum = C, P		Clindamycin	Moxifloxacin (IV/PO)	infections, especially abscesses.
		(aspiration pneumonia,	Clindamycin	Moxifloxacin (IV/PO)	infections, especially abscesses.
		(aspiration pneumonia,	(IV/PO)
		lung abscess)	(IV/PO)
	•	lung abscess)
	•	Urine/Stool = NP
	• Wound = P (rarely a
		sole pathogen)

Peptostreptococcus	•	CSF = P (brain abscess)	Penicillin (IV)	Chloramphenicol (IV)	Normal flora of mouth, GI tract, and
	• Blood = P (GI/pelvic		Ampicillin (IV)	Erythromycin (IV)	pelvis. Associated with mixed aerobic/
		source)	Amoxicillin (PO)	Any carbapenem (IV)	anaerobic dental, abdominal, and pelvic
	• Sputum = C, P		Clindamycin	Moxifloxacin (IV/PO)	infections, especially abscesses.
		(aspiration pneumonia,	Clindamycin	Moxifloxacin (IV/PO)	infections, especially abscesses.
		(aspiration pneumonia,	(IV/PO)
		lung abscess)	(IV/PO)
	•	lung abscess)
	•	Urine/Stool = NP
	• Wound = P (rarely a
		sole pathogen)

GRAM-POSITIVE BACILLI

Actinomyces israelii,	•	CSF = P (brain abscess)	Amoxicillin (PO)	Erythromycin (PO)	Anaerobic and non-acid fast. Usually
odontolyticus	•	Blood = NP	Doxycycline (PO)	Clindamycin (PO)	presents as cervical, facial, thoracic, or
					abdominal masses/fistulas. Prolonged

236

s l a i t n e s s E c i t o i b i t n A

	•	Sputum = C, P (lung			(6–12 month) treatment is needed for
	•	abscess)			cure. Unlike Nocardia, Actinomyces
	•	Urine = NP			rarely causes CNS infections. May be
	•	Stool = NP			cultured from polymicrobial brain
	•	Wound = P (fistulas/			cultured from polymicrobial brain
	•	Wound = P (fistulas/			abscess of pulmonary origin. Quinolones,
		underlying abscess)			abscess of pulmonary origin. Quinolones,
		underlying abscess)			aminoglycosides, metronidazole, and
					aminoglycosides, metronidazole, and
					TMP–SMX have little activity.

Arachnia propionica	•	CSF = P (brain abscess)	Clindamycin	Erythromycin (IV)	Polymicrobial pathogen in dental, lung,
	•	Blood = P (from dental,	(IV/PO)		and brain abscesses.
		GI, lung source)	Ampicillin (IV) +
	• Sputum = C, P (lung		gentamicin (IV)
		abscess)	gentamicin (IV)
	•	abscess)
	•	Urine = NP
	•	Stool = NP
	•	Wound = NP

Bifidobacterium sp.	•	CSF = P (brain abscess)	Clindamycin	Erythromycin (IV)	Usually part of polymicrobial infection.
	•	Blood = NP	(IV/PO)
	•	Sputum = C, P (lung	Ampicillin (IV) +
	•	abscess)	gentamicin (IV)
		Urine/Stool = NP	gentamicin (IV)
		Urine/Stool = NP
	•	Wound = NP

Clostridium botulinum	•	CSF = NP	Penicillin (IV)	Clindamycin (IV/PO)	Give trivalent equine antitoxin (p. 170)
	•	Blood = NP		Imipenem (IV)	as soon as possible. Antibiotic therapy is
	•	Sputum = NP		Meropenem (IV)	adjunctive.
	•	Urine/Stool = NP
	• Wound = P (wound
		botulism)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

Therapy Initial and Profiles Susceptibility Antibiotic .3 Chapter

237

Table 3.8. Usual Clinical Significance of ANAEROBIC Isolates Pending Susceptibility Testing (Cont’d)

GRAM-POSITIVE BACILLI

			Preferred		Alternate
Isolate		Isolate Significance	Therapy		Therapy	Comments

Clostridium difficile	•	CSF = NP	C. difficle diarrhea	C. difficile diarrhea		C. difficile diarrhea PO vancomycin
	• Blood = P (rarely from					preferred. PO vancomycin more reliably
	• Blood = P (rarely from		Vancomycin (PO)		Metronidazole (PO)	preferred. PO vancomycin more reliably
	•	GI source)	Nitazoxanide (PO)	C. difficle colitis		effective than PO metronidazole.
		Sputum = NP		C. difficle colitis		Nitazoxanide also highly effective. PO
		Sputum = NP
	•	Urine = NP	C. difficle colitis	Tigacycline (IV)
	•	Urine = NP	C. difficle colitis	Tigacycline (IV)		metronidazole, not PO vancomycin,
	• Stool = C (normal fecal		Metronidazole			metronidazole, not PO vancomycin,
	• Stool = C (normal fecal		Metronidazole			increases prevalence of VRE. C. difficile
		flora),	(IV/PO)			increases prevalence of VRE. C. difficile
		flora),	(IV/PO)			colitis, use IV or PO metronidazole
		P (antibiotic-associated	Nitazoxanide (PO)			colitis, use IV or PO metronidazole
		P (antibiotic-associated	Nitazoxanide (PO)			(IV vancomycin ineffective). Nitazoxanide
	•	diarrhea/colitis)				(IV vancomycin ineffective). Nitazoxanide
	•	Wound = NP				(PO) or tigacycline (IV) also highly
						effective. Diagnose C. difficile diarrhea
						by stool C. difficile toxin assay/PCR.
						Diagnose C. difficile colitis by C. difficile +
						toxin assay/PCR plus colitis on abdominal
						CT scan/colonoscopy.

Clostridium perfringens,	•	CSF = NP	Penicillin (IV)	Clindamycin (IV)		Usual cause of myonecrosis (gas
septicum, novyi	•	Blood = P (from GI	Piperacillin/	Chloramphenicol (IV)		gangrene). Surgical debridement is
	•	source/malignancy)	tazobactam (IV)	Imipenem (IV)		crucial; antibiotic therapy is adjunctive.
	•	Sputum = NP	Meropenem (IV)			Also causes emphysematous
	•	Urine = NP	Meropenem (IV)			Also causes emphysematous
	•	Urine = NP	Ertapenem (IV)			cholecystitis/cystitis. Does not form
	•	Stool = NP	Ertapenem (IV)			cholecystitis/cystitis. Does not form
	•	Stool = NP				spores in blood cultures as does C.
	• Wound = P (gas					spores in blood cultures as does C.
	• Wound = P (gas					sordelli.
		gangrene)				sordelli.

Clostridium tetani	•	CSF = NP	Penicillin (IV)	Imipenem (IV)		Prompt administration of tetanus immune
	•	Blood = NP	Clindamycin (IV)	Meropenem (IV)		globulin is crucial (p. 170). Antibiotic
						therapy is adjunctive.

238

s l a i t n e s s E c i t o i b i t n A

	•	Sputum = NP
	•	Urine/Stool = NP
	• Wound = P (wound
		tetanus)

Eubacterium sp.	•	CSF = P (brain abscess)	Clindamycin	Erythromycin (IV)	Pathogen in lung/pelvic/brain abscesses,
	•	Blood = P (from dental,	(IV/PO)		and chronic periodontal disease.
	•	GI, GU, lung source)	Ampicillin (IV) +		Eubacterium bacteremias are associated	.3Chapter
	•	Urine/Stool = NP				.3Chapter
	•	Sputum = P (lung	gentamicin (IV)		with malignancies.
		abscess)	gentamicin (IV)		with malignancies.
		abscess)
	•	Wound = NP
	•	Wound = NP				Antibiotic

Lactobacillus sp.	•	CSF = P (ABM)	Ampicillin (IV) +	Erythromycin (IV)	Uncommon pathogen in normal/
	•	Blood = P (1°	gentamicin (IV)		compromised hosts. Rare cause of SBE.
		bacteremia, SBE, or	Clindamycin		Variably resistant to cephalosporins and	Susceptibility
	•	from endometritis)	(IV/PO)		quinolones. Some clindamycin-resistant	Susceptibility
		Sputum = NP	(IV/PO)		quinolones. Some clindamycin-resistant
		Sputum = NP			strains. Resistant to metronidazole and
	•	Urine = P (rare)			strains. Resistant to metronidazole and
	•	Urine = P (rare)			vancomycin.
	•	Stool = NP			vancomycin.
	•	Stool = NP
	•	Wound = NP				Profiles

Propionibacterium	•	CSF = C*, P (meningitis	Penicillin (IV)	Doxycycline (IV/PO)	Common skin colonizer/blood culture
acnes	•	from NS shunts)	Clindamycin		contaminant. Rarely causes prosthetic	and
		Blood = C*, P (from IV	(IV/PO)		joint infection, endocarditis, or CNS shunt	and
		Blood = C*, P (from IV	(IV/PO)		joint infection, endocarditis, or CNS shunt	Initial
	•	Sputum = NP				Initial
		line infection, SBE)			infection. Resistant to metronidazole.
					infection. Resistant to metronidazole.	Therapy
	•	Urine = NP				Therapy
	•	Stool = NP
	•	Wound = C

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

239

Table 3.8. Usual Clinical Significance of ANAEROBIC Isolates Pending Susceptibility Testing (cont'd)

GRAM-NEGATIVE BACILLI

			Preferred	Alternate
Isolate		Isolate Significance	Therapy	Therapy	Comments

Bacteroides fragilis	•	CSF = P (meningitis	Tigecycline (IV)	Moxifloxacin (IV/PO)	Major anaerobe below the diaphragm.
group (B. distasonis,		from Strongyloides	Piperacillin/	Ampicillin/sulbactam	Usually part of polymicrobial lower
ovatus, thetaiotao-		hyperinfection)	tazobactam	(IV)	intra-abdominal and pelvic infections.
micron, vulgatus)	• Blood = P (from GI/		(IV)	Clindamycin (IV/PO)	Cefotetan is less effective against
micron, vulgatus)		pelvic source)	(IV)	Clindamycin (IV/PO)	Cefotetan is less effective against
	•	pelvic source)	Any carbapenem	or combination	B. fragilis DOT strains (B. distasonis,
		Sputum = NP	Any carbapenem	or combination	B. fragilis DOT strains (B. distasonis,
		Sputum = NP	(IV)	of Metronidazole	B. ovatus, B. thetaiotaomicron). Resistant
	•	Urine = NP, P (only from	(IV)	of Metronidazole	B. ovatus, B. thetaiotaomicron). Resistant
	•	Urine = NP, P (only from		(IV/PO) plus either	to penicillin.
		colonic fistula)		(IV/PO) plus either	to penicillin.
	•	Stool = NP		ceftriaxone (IV) or
	•	Wound = NP		levofloxacin (IV/PO)

Fusobacterium	•	CSF = P (brain abscess)	Clindamycin	Chloramphenicol (IV)	Mouth flora associated with dental
nucleatum	•	Blood = P (from lung,	(IV/PO)	Metronidazole	infections and anaerobic lung infections.
		GI source)	Piperacillin/	(IV/PO)	F. nucleatum is associated with jugular
	• Sputum = P (aspiration		tazobactam		vein septic phlebitis and GI cancer.
		pneumonia, lung	tazobactam		vein septic phlebitis and GI cancer.
		pneumonia, lung	(IV)		Resembles Capnophagia sp. on sputum
		abscess)	(IV)		Resembles Capnophagia sp. on sputum
	•	abscess)	Ampicillin/		gram stain.
		Urine = NP	Ampicillin/		gram stain.
		Urine = NP	sulbactam (IV)
	•	Stool = NP	sulbactam (IV)
	• Wound = P (rarely)

Prevotella (Bacteroides)	•	CSF = NP	Penicillin (IV/PO)	Any quinolone	Cause of dental, oropharyngeal, and
bivia	•	Blood = P (from dental,	Any β-lactam	(IV/PO)	female genital tract infections.
		lung, pelvic source)	(IV/PO)	Doxycycline (IV/PO)
	• Sputum = P (lung			Clindamycin (IV/PO)
		abscess)		Clindamycin (IV/PO)
		abscess)

240

s l a i t n e s s E c i t o i b i t n A

•

Urine = NP

•

Stool = NP

•

Wound = NP

Prevotella (Bacteroides)

•

CSF = P (brain abscess)

Aspiration

Aspiration pneumonia/

Predominant anaerobic flora of mouth.

melaninogenicus,

•

Blood = P (from oral/

Known as “oral pigmented” Bacteroides

pneumonia/lung

lung abscess

intermedius

pulmonary source)

(IV/PO)

(e.g., B. melanogenicus). Antibiotics used

abscess

Doxycycline

• Sputum = P (from

Any β-lactam (IV/

to treat community-acquired pneumonia

aspiration pneumonia,

Brain abscess

PO)

are effective against oral anaerobes (e.g.,

lung abscess)

Chloramphenicol (IV)

•

Any quinolone

Prevotella) in aspiration pneumonia;

Urine = NP

(IV/PO)

does not require anti-B. fragilis coverage

•

Stool = NP

•

Wound = NP

Brain abscess

with clindamycin, metronidazole, or

moxifloxacin.

Penicillin (IV)

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

Therapy Initial and Profiles Susceptibility Antibiotic .3 Chapter

241

Table 3.9. Clinical Significance of YEAST/FUNGI Pending Susceptibility Testing

YEAST/FUNGI

		**Usual Isolate	Preferred	Alternate
Isolate		Significance	Therapy	Therapy	Comments

Aspergillus species	•	CSF = P (only from	See p. 55:	See p. 55:	A. fumigatus is the usual cause of invasive
		disseminated	Voriconazole	Posaconazole (PO);	aspergillosis. Growth of Aspergillus sp.
		infection)	(IV/PO)	Amphotericin B	from a specimen can represent airborne
	• Blood = C, P		Amphotericin B	deoxycholate (IV)	contamination. Aspergillus pneumonia and
		(1° fungemia or from	Amphotericin B	deoxycholate (IV)	contamination. Aspergillus pneumonia and
		(1° fungemia or from	lipid formulation		disseminated aspergillosis are not uncommon
		pulmonary source)	lipid formulation		disseminated aspergillosis are not uncommon
		pulmonary source)	(IV)		in patients on chronic steroids or immuno-
	• Sputum = C, P		(IV)		in patients on chronic steroids or immuno-
	• Sputum = C, P				suppressives (esp. organ transplants).
		(pneumonia)			suppressives (esp. organ transplants).
	•	Urine = NP			Recovery of Aspergillus from sputum or BAL
	•	Stool = NP			is not diagnostic of Aspergillus pneumonia.
	• Wound = NP, P (rarely,				Definative Dx is by lung biopsy demonstrating
		but possible with			vessel/tissue invasion. b 1,3 D-glucan (BG)+,
		extensive wounds, e.g.,			aspergillus galactomannan (AG)+.
		burns)			aspergillus galactomannan (AG)+.
		burns)

Candida albicans	•	CSF = P (only from	Fluconazole	Amphotericin B	Common colonizer of GI/GU tracts.
		disseminated	(IV/PO)	deoxycholate	Colonization common in diabetics, alcoholics,
	•	infection)	Micafungin (IV)	(IV/PO)	patients receiving steroids/antibiotics.
	•	Blood = P	Caspofungin (IV)	Amphotericin B lipid	Commonest cause of fungemia in hospitalized
		(1° candidemia or from	Caspofungin (IV)	Amphotericin B lipid	Commonest cause of fungemia in hospitalized
		(1° candidemia or from	Anidulafungin (IV)	formulation (IV)	patients. Candidemia secondary to central
		IV line infection)	Anidulafungin (IV)	formulation (IV)	patients. Candidemia secondary to central
		IV line infection)	Posaconazole (PO)	Itraconazole	IV lines should always be treated as possible
	• Sputum = C, P (only		Posaconazole (PO)	Itraconazole	IV lines should always be treated as possible
	• Sputum = C, P (only			(IV/PO)	disseminated disease even though this is not
		from disseminated		(IV/PO)	disseminated disease even though this is not
		infection)		Voriconazole	invariably the case. Repeated blood cultures
				(IV/PO)	and careful follow-up (including

242

s l a i t n e s s E c i t o i b i t n A

• Urine = C, P (from

ophthalmoscopy) should be undertaken to

cystitis, pyelonephritis)

exclude possible occult dissemination following

• Stool = C (source of

even a single positive blood culture. Primary

•

candiduria)

candidal pneumonia is rare.

Wound = NP

Candida non-

•

CSF = P (only from

Micafungin (IV)

Fluconazole (IV/PO)

Non-albicans Candida cause the same

Chapter

albicans

•

disseminated infection)

Caspofungin (IV)

Amphotericin B

spectrum of invasive disease as C. albicans.

Blood = P

Anidulafungin (IV)

deoxycholate

Fluconazole-susceptibility varies predictably

(1° candidemia or from

Posaconazole (PO)

(IV/PO)

by species. C. glabrata (usually) and C. krusei

IV line infection)

•

Voriconazole

Amphotericin B lipid

(almost always) are resistant to fluconazole.

Antibiotic

Sputum = NP

(IV/PO)

formulation (IV)

C. lusitaniae is often resistant to amphotericin

•

Urine = C (indwelling

Itraconazole

B (deoxycholate and lipid-associated

catheters), P (from

cystitis, pyelonephritis)

(IV/PO)

formulations). Other species are generally

Susceptibility

• Stool = C (source of

susceptible to all agents.

•

candiduria)

Wound = NP

Profiles

Cryptococcus

•

CSF = P (meningitis,

CNS

C. neoformans meningitis may occur with

neoformans

brain abscess)

or without dissemination. Cryptococcal

•

Amphotericin B

Fluconazole (IV/PO)

Blood = P (from

deoxycholate

pneumonia frequently disseminates to CNS.

and

•

pulmonary source)

(IV) ± flucytosine

Non-CNS

C. neoformans in blood cultures occurs in

Sputum = P

(PO)

Itraconazole (IV/PO)

compromised hosts (e.g., HIV) and indicates

Initial

(pneumonia)

Fluconazole (IV/PO)

•

disseminated infection.

Urine = NP

Non-CNS

Therapy

•

Stool = NP

Amphotericin B

•

Wound = NP*

deoxycholate

(IV)

C = colonizer;

C* = skin contaminant; NP = non-pathogen at site; P =

pathogen at site; (IV/PO)

= IV or PO. See p. xi for all other abbreviations.

* Cutaneous cryptococcus represents disseminated infection. ** Fungi can produce disseminated infections that involve essentially any organ. Isolation of a

fungus from any normal sterile site should be cause for a careful review of the patient's epidemiology, risk factors, and clinical presentation.

243

Table 3.9. Usual Clinical Significance of YEAST/FUNGI Pending Susceptibility Testing (cont'd)

YEAST/FUNGI

		**Usual Isolate	Preferred	Alternate
Isolate		Significance	Therapy	Therapy	Comments

			Amphotericin B
			lipid formulation
			(IV)

Histoplasma	•	CSF = P (from	Itraconazole	Fluconazole (IV/PO)	Histoplasma recovered from CSF/blood
capsulatum		disseminated	(IV/PO)	Amphotericin B lipid	cultures indicates dissemination. Disseminated
	•	infection, pneumonia)	Amphotericin B	formulation (IV)	(reactivated latent) histoplasmosis is most
	•	Blood = P	deoxycholate		common in compromised hosts (e.g., HIV).
		(1° fungemia, rarely	deoxycholate		common in compromised hosts (e.g., HIV).
		(1° fungemia, rarely	(IV)		Itraconazole is ineffective for meningeal
		SBE)	(IV)		Itraconazole is ineffective for meningeal
	•	SBE)			histoplasmosis, but is preferred for chronic
		Sputum = P			histoplasmosis, but is preferred for chronic
		Sputum = P			suppressive therapy.
		(pneumonia,			suppressive therapy.
	•	mediastinitis)
	•	Urine = P
	•	Stool = P
	•	Wound = P

Malassezia furfur	•	CSF = NP	Itraconazole	Fluconazole	M. furfur IV line infections are associated
	•	Blood = P (from IV line	(IV/PO)	(IV/PO)	with IV lipid hyperalimentation emulsions.
	•	infection)	Ketoconazole (PO)		Fungemia usually resolves with IV line removal.
	•	Sputum = NP			Morphology in blood is blunt buds on a broad
	•	Urine = NP			Morphology in blood is blunt buds on a broad
	•	Urine = NP			base yeast. M. furfur requires long chain fatty
	•	Stool = NP			base yeast. M. furfur requires long chain fatty
	•	Stool = NP			acids for growth (overlay agar with thin layer of
	•	Wound = P			acids for growth (overlay agar with thin layer of
	•	Wound = P			olive oil, Tween 80, or oleic acid).
		(eosinophilic folliculitis)			olive oil, Tween 80, or oleic acid).
		(eosinophilic folliculitis)

244

s l a i t n e s s E c i t o i b i t n A

Penicillium	•	CSF = NP	Amphotericin B	Amphotericin	Histoplasma-like yeast forms seen in lymph
marneffei	•	Blood = P (usually from	deoxycholate	B lipid	nodes, liver, skin, bone marrow, blood.
		dissemination)	(IV)	formulation (IV)	Characteristic red pigment diffuses into
	• Sputum = P (pneumonia)		Itraconazole		agar. Closely resembles histoplasmosis
	•	Urine = NP	Itraconazole		agar. Closely resembles histoplasmosis
	•	Urine = NP	(IV/PO)		yeast forms (H. capsulatum has narrow
	•	Stool = NP	(IV/PO)		yeast forms (H. capsulatum has narrow
	•	Stool = NP			based budding yeast forms, but P. marneffei
	•	Wound = NP*			based budding yeast forms, but P. marneffei
	•	Wound = NP*			has transverse septa). Skin lesions indicate
					has transverse septa). Skin lesions indicate
					dissemination. May resemble molluscum
					contagiosum. Hepatosplenomegaly is
					common.

C = colonizer; C* = skin contaminant; NP = non-pathogen at site; P = pathogen at site; (IV/PO) = IV or PO. See p. xi for all other abbreviations.

*Cutaneous lesions represents disseminated infection.

**Fungi can produce disseminated infections that involve essentially any organ. Isolation of a fungus from any normal sterile site should be cause for a careful review of the patient's epidemiology, risk factors, and clinical presentation.

Therapy Initial and Profiles Susceptibility Antibiotic .3 Chapter

245

246 A n t i b i o t i c E s s e n t i a l s

Table 3.10. Technique for Gram Stain and Giemsa Stain

GRAM STAIN

Clinical applications: CSF, sputum, urine

Technique:

1. Place specimen on slide.

2. Heat fix smear on slide by passing it quickly over a flame. 3. Place crystal violet solution on slide for 20 seconds.

4. Wash gently with water.

5. Apply Gram iodine solution to slide for 20 seconds.

6. Decolorize the slide quickly in solution of acetone/ethanol. 7. Wash slide gently with water.

8. Counterstain slide with safranin for 10 seconds.

9. Wash gently with water; air dry or blot dry with bibulous paper.

Interpretation: Gram-negative organisms stain red; gram-positive organisms stain blue. B fragilis stains weakly pink. Fungi stain deep blue. For interpretation of Gram stain findings in CSF, urine, sputum, and feces see Tables 3.6–3.9.

GIEMSA STAIN

Clinical applications: Blood buffy coat, bone marrow

Technique:

1. Place specimen on slide.

2. Fix smear by placing slide in 100% methanol for 1 minute. 3. Drain methanol off slide.

4. Flood slide with Giemsa stain (freshly diluted 1:10 with distilled water) for 5 minutes. 5. Wash slide gently with water; air dry.

Interpretation: Fungi/parasites stain light/dark blue.

Table 3.11. Clinical Use of CSF Gram Stain, WBC Type, Glucose (see Color Atlas of CSF Gram stains)

Gram Stain	Organism/Condition

Gram-positive bacilli	Pseudomeningitis (Bacillus,	Listeria
	Corynebacteria)

Gram-negative bacilli	H. influenzae (small, encapsulated,	Non-enteric/enteric aerobic
	pleomorphic)	bacilli (larger, unencapsulated)

Gram-positive cocci	Gp A, B, D, streptococci (pairs/chains)	S. aureus (pairs/clusters)
	S. pneumoniae (pairs)	S. epidermidis (pairs/clusters)

Gram-negative diplococci	Neisseria meningitidis

Chapter 3. Antibiotic Susceptibility Profiles and Initial Therapy			247
Table 3.11. Clinical Use of CSF Gram Stain, WBC Type, Glucose (cont'd)

Gram Stain	Organism/Condition

Mixed organisms	Pseudomeningitis	Neonatal meningitis Meningitis
(polymicrobial)	Anaerobic organisms (brain abscess	2° to penetrating head trauma
	with meningeal leak)

WBC Type/Glucose	Organism/Condition

Purulent CSF, no	Neisseria meningitidis	Listeria
organisms

Clear CSF, no organisms	Viral meningitis	Lymphocytic choriomeningitis
	Viral encephalitis	(LCM)
	TB/fungal meningitis	Drug induced aseptic meningitis
	Sarcoidosis meningitis	Listeria
	Meningeal carcinomatosis	HIV
	Brain abscess	Syphilis
	Parameningeal infection	Leptospirosis
	Septic emboli 2° to SBE	Bacterial meningitis (very early/
	SLE cerebritis	partially-treated)
	Lyme’s disease	Meningitis (leukopenic host)
		Rocky Mountain Spotted Fever

Cloudy CSF, no WBCs	S. pneumoniae

Predominantly PMNs,	Bacterial meningitis (partially-treated)	Parameningeal infection
decreased glucose	Listeria	Septic emboli 2° to SBE
	HSV-1/2 encephalitis	Amebic meningoencephalitis
	TB (early/beginning therapy)	Syphilis (early)
	Sarcoidosis	Posterior-fossa syndrome

Predominantly	Bacterial meningitis (partially-treated)	Viral meningitis
lymphocytes, normal	Sarcoidosis	Viral encephalitis
glucose	Lyme’s disease	Parameningeal infection
	HIV	TB/fungal meningitis
	Leptospirosis	Parasitic meningitis
	Rocky Mountain Spotted Fever	Meningeal carcinomatosis

Predominantly	Bacterial meningitis (partially-treated)	Enteroviral meningitis
lymphocytes, decreased	TB/fungal meningitis	Listeria
glucose	Sarcoidosis	Leptospirosis
	Lymphocytic choriomeningitis (LCM)	Syphilis
	Mumps	Meningeal carcinomatosis

Red blood cells	Traumatic tap	TB meningitis
	CNS bleed/tumor	Amebic (Naegeleria)
	Listeria	meningoencephalitis
	Leptospirosis	Anthrax
	Herpes (HSV-1) encephalitis

248	A n t i b i o t i c E s s e n t i a l s

Table 3.12. Clinical Use of the Sputum Gram Stain (see Color Atlas of Sputum Gram stains)

Gram Stain	Organism	Comments

Gram-positive diplococci	S. pneumoniae	Lancet-shaped encapsulated diplococci (not
		streptococci)

Gram-positive cocci	S. aureus	Clusters predominant. Short chains or pairs
(grape-like clusters)		may also be present

Gram-positive cocci	Group A streptococci	Virulence inversely proportional to length of
(short chains or pairs)		streptococci. Clusters not present

Gram-positive beaded/	Nocardia	Coccobacillary forms common
filamentous branching
organisms

Gram-negative cocco-	H. influenzae	Pleomorphic may be encapsulated.
bacillary organisms		Gram negative cocci/bacilli. Lightly
		stained

Gram-negative bacilli	Klebsiella	Plump and encapsulated
	P. aeruginosa	Thin and often arranged in end-to-end pairs

Gram-negative diplococci	Moraxella (Branhamella)	Kidney bean-shaped diplococci
	catarrhalis
	Neisseria meningitidis

Table 3.13. Clinical Use of the Urine Gram Stain (see Color Atlas of Urine Gram stains)

Gram Stain	Organism	Comments

Gram-positive cocci (clusters)*	S. aureus	Skin flora contaminant
	S. epidermidis	Skin flora contaminant
	S. saprophyticus	Uropathogen

Gram-positive cocci (chains)	Group B streptococci	Uropathogen
	Group D streptococci	Uropathogen
	E. faecalis	May represent colonization or infection
	E. faecium	May represent colonization or infection

Gram-negative bacilli*	Coliform bacilli	Uropathogen; may represent
		colonization or infection

Gram-negative diplococci*	N. gonorrhoeae	Gonococcal urethritis
	N. meningitidis	Rare cause of urethritis

*Staphylococci (except S. saprophyticus), S. pneumoniae, and B. fragilis are not uropathogens.

Chapter 3. Antibiotic Susceptibility Profiles and Initial Therapy			249
Table 3.14. Clinical Use of the Fecal Gram Stain

Gram Stain	Possible Organisms

Fecal leukocytes present	Enteropathogenic E. coli	Aeromonas hydrophila
	(EPEC)	Chlamydia trachomatis
	Enteroinvasive E. coil (EIEC)	Plesiomonas shigelloides
	Shigella	Neisseria gonorrhoeae (proctitis)
	Yersinia	Herpes simplex virus (HSV-1)
	Campylobacter	Noninfectious: Ulcerative colitis
	Salmonella
	Vibrio parahaemolyticus
	Vibrio vulnificus

No fecal leukocytes	Enterovirus	Norwalk virus
	Rotavirus	Vibrio cholerae
	Coronavirus	Bacillus cereus (food poisoning)
	Enterotoxigenic E. coli (ETEC)	Giardia lamblia
	S. aureus	Isospora belli
	Clostridium perfringens	Cryptosporidia
	Adenovirus	Strongyloides stercoralis

Fecal leukocytes variable	Clostridium difficile	Cytomegalovirus (CMV)
	Enterohemorrhagic E. coli	Herpes simplex virus (HSV-1)
	(EHEC)

Red blood cells present	Shigella	Clostridium difficile
	Salmonella	Cytomegalovirus (CMV)
	Campylobacter	Yersinia
	EPEC	Plesiomonas shigelloides
	EHEC	Noninfectious: Ulcerative colitis
	Enteroinvasive E. coli (EIEC)
	Enterohemorrhagic E. coli
	(EHEC)

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Bottone EJ (ed). An Atlas of the Clinical Microbiology of Infectious Diseases, Volume 2. Viral, fungal, and parasitic agents. Taylor and Francis, 2006.

Bowden RA, Ljungman P, Snydman DR (eds). Transplant Infections (3rd Ed), Lippincott Williams & Wilkins, Philadelphia, PA, 2010.

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Cohen J, Powderly WG, Opal S (Eds). Infectious Diseases (4th Ed). Elsevier, Philadelphia 2015.

de la Maza LM, Pezzlo MT, Shigei JT, et al. (eds). Color Atlas of Medical Bacteriology. ASM Press, Washington, D.C., 2004.

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Janda JM, Abbott SL (eds). The Enterobacteria (2nd Ed), ASM Press, Washington, D.C., 2006.

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Lorian V (ed). Antibiotics in Laboratory Medicine (5th Ed), Lippincott Williams & Wilkins, Philadelphia, 2005.

Madigan MT, Martinko JM, Parker J (eds). Brock Biology of Microorganisms (10th Ed), Prentice Hall, Upper Saddle River, NJ, 2003.

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Versalovic J, Carroll KC, Funke G, et al. (eds). Manual of Clinical Microbiology (10th Ed), Washington, DC, ASM Press, 2011.

Chapter 4. Parasites, Fungi, Unusual Organisms

253

Chapter 4

Parasites, Fungi, Unusual Organisms*

Kenneth F. Wagner, DO, James H. McGuire, MD

Burke A. Cunha, MD, Jean E. Hage, MD

John H. Rex, MD, Edward J. Bottone, PhD

Parasites, Fungi, Unusual Organisms in Blood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Parasites, Fungi, Unusual Organisms in CSF/Brain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261. . . . .

Parasites, Fungi, Unusual Organisms in Lungs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265 Parasites, Fungi, Unusual Organisms in Heart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273. . . . . . . . . .

Parasites, Fungi, Unusual Organisms in the Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273. . . . . .

Parasites, Fungi, Unusual Organisms in Stool/Intestines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .276. . Parasites, Fungi, Unusual Organisms in Skin/Muscle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .283 References and Suggested Readings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298. . . . . . . . .

Treatment of Malaria in Adults in the US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721

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