Antimicrobial Therapy…

At 7:00 on a Monday morning, the day begins with a full line-up of ?to be seen.? A 35-year-old female with no past medical history presents to the ED complaining of cough and shortness of breath for 2 days that is progressively worsening. On physical examination, she is febrile with an oxygen saturation of 94% on room air and decreased breath sounds at the right base. You order a chest x-ray that shows right lower lobe consolidation.

The second patient on your tracking board is a 70-year-old female with fever, nausea, and back pain for 3 days. She is accompanied by her daughter, who states her mother hasn?t been herself today and that she had a similar presentation when she had a UTI 2 years ago. She is febrile to 38.3?C (101?F), oriented x2, with left costovertebral angle tenderness. Her urine dipstick is positive for leukocyte esterase and nitrites.

In the next bed, you are evaluating a 23-year-old male who has had a painful, swollen right forearm for 2 days. He reports a subjective fever earlier in the evening, but no other systemic symptoms. He denies any past medical history and has no IV drug abuse and no history of diabetes. He is afebrile with normal vital signs. A 6-cm area of erythema, induration, and tenderness is noted on his proximal forearm with a 2-cm central fluctuant, raised area. He has full range of motion at the elbow.

Just as you sit down for a cup of coffee, the triage nurse notifies you that she just received an 85-year-old male from a nursing home that was sent in for evaluation for fever. He has a history of insulin-dependent diabetes mellitus, hypertension, and dementia. On physical examination, he is febrile, with otherwise normal vital signs. His abdomen is slightly distended, soft, but diffusely tender to palpation.

Four infectious disease cases in a row ? it feels like an epidemic.?In the age of emerging pathogens — and when the right antibiotic?choice may be the difference between a good or bad outcome — which antibiotic(s) do you use?

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Last Updated on January 26, 2023

25 thoughts on “Antimicrobial Therapy…

  1. First patient: Co-amoxiclav IV
    second patient: co-amoxiclav/ bactrim IV + gentamicin
    Third patient: IV flucloxacillin
    Fourth patient: CoAmoxiclav + Metronidazole

  2. 1st pt: IV Rocephin and Zithromax
    2nd pt: IV Rocephin or Levaquin depending on allergies and Renal function
    3rd pt: PO Septra DS
    4th pt:IV Zosyn or Leva + Flagyl

  3. 1 community acquired pneumonia Vibramycin 200mg bid
    2. Pyelonephritis Administer ceftriaxone (1g intravenous/intramuscular [IV/IM]) or gentamicin (single 24h dose or divided every 8 hours) on day 1, followed by an oral fluoroquinolone from day 2 to days 10-14

    3 .Skin abscess, open and drain the abscess, Antibiotics are generally not necessary; however, they may be prescribed if the abscess is associated with a surrounding skin infection. clindamycin (Cleocin); 150 mg q6hr
    4. Abdominal infection Complete blood test, blood culture along with imaging procedures such as X-rays, ultrasound or CT scan are usually performed in order to identify the underlying cause of an infected abdomen. If tests reveal fluid buildup in the peritoneal cavity, the fluid would be tested in order to identify the pathogen responsible for causing an infection. If the presence of bacteria has been detected, antibiotic therapy should be initiated immediately. Antibiotics are given prior to the surgery, and should be continued after surgery as well. Broad spectrum antibiotics will be started after work-up for abdominal infection. amoxicillin 500mg q12hr

  4. 1.) Avelox 400 mg 1 po qday x 10 days
    2.) ceftriaxone 1 gram IV q24hours
    3.) no antibiotics are warranted at this time. I &d. If symptoms worsen or if cultures are positive for MRSA add Bactrim, Clindamycin or Doxycycline
    4.) Start sepsis work up including urinalysis, stool for hemoccult blood work, ct abdomen/pelvis, treat underlying infection based on source – in Invanz IV which will cover complicated UTI/Pyleonephritis, intra-abdominal infections, Community Acquired Pneumonia and can be used for prophylaxis of surgical sites – dosing depending on Cr and GFR

  5. patient 1- Community acquired pneumonia- augmentin and azithromycin
    patient 2- urosepsis. intravenous ceftriaxone
    patient 3- cellulitis/abscess- cloxacillin +- gentamycin if not responding with cloxa/flucloxacillin alone
    patient 4- intraabdominal sepsis? – iv cefobid and flagyl

  6. Patient 1: Ampicillin + macrolide (or monotherapy with levofloxacin or moxifoxacin if allergic to penicillin)
    Patient 2: Cefuroxime or Augmentin +/- aminoglycoside (or fluoroquinolone if allergic to penicillin)
    Patient 3: Drainage + flucloxacillin (or clindamycin if allergic to penicillin)
    Patient 4: Piperacillin with tazobactam (or clindamycin + aminoglycoside if allergic to penicillin)

  7. Case1- iv cefuroxime 1.5g stat and 750mg tds -+ zitromax 500mg od
    case2- iv augmentin1.2g bd
    case3- cap cloxacillin 500mg qid
    case4- iv cefobid -+ metronidazole 500mg tds

  8. .1.augmentin iv/po.
    2.augmentin iv.
    3.incision and drainage.culture,flucloxacillin po pro tem till culture results available.
    4.infection screen work up..

  9. ase 1
    iv augmentin 1.2mg stat and tds
    case 2
    iv ciprofloxacin 500mg stat and bd
    iv cloxacilline 1g stat and qid
    iv flagyl 500mg stat and bd
    acute abdomen workup

  10. – 1st patient has CAP: Outpatient, Azithro or Clarithro
    – 2nd patient has Acute Pyelonephritis: Hospitalization, blood and urine c\s, FQ (IV) or Ceftriaxone
    – 3rd patient has Localized Abscess: I&D, Culture, hot packs, +/- (if >5cm) TMP-SMX-DS or Clinda
    – 4th patient has Intra-abdominal infection: we have to r/o DKA, needs for emergency surgical intervention, full sepsis workup,
    PIP-TZ or AM-SB or MOXI (IV), if life threatining: IMP or MER

  11. first patient – should we think about community acquired penumonia – i would have given her – azythromycin

    second patient – suggests of uti , might be simple and not complicated , it would have been important for me to know her previous cultures – would give her – cefuroxime

    third patient – it is not clear that the erythema is infectious , if not just follow up and maybe i would have given an anti-histamine, if infectious – cefazolin

    forth patient – intraabdominal infection , i would have done a CT scan of the abdomen – given him a triade of ampicillin + garamycin+ metronidazole

  12. 1 – ceftriaxone 1g iv x 1+ Rx azithromycin (or other macrolide)

    2 – iv gentimicin or fluoroquinolone if inpt, fluoroquinolone x 14 days if outpt

    3 – TMP/SMX DS, 2 tabs BID to cover CA-MRSA, +\- I&D

    4 – cefepime 2g iv

  13. I m glad to answer you medical chalenge:
    here is my choice:
    1. first patient: amoxacilin/ ac.clavulanico + oseltamivir
    2. second patient cephalotin 2 gr iv tid
    3. third patient dicloxacilin + drainage
    4. fourth patient Sincerely I haven`t a clearly diagnosis for this patient so i wouldn`t start antibiotic without a clear diagnosis, because that could mask the clinical case., I ask for a abdominal Tomography with dye

  14. 1)azitromycin 500mg ud 1st day,250mg ud for other 4 days
    2)ciprofloxacin 250mg bid for 10-14 days
    3)doxacillin 2 *100mg for 3-4 days
    4)augmentin + flagyl after a CT scanner

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