NOTES
1. Before initiating antibiotic therapy, make certain that all relevant cultures have been obtained (especially from the ER prior to first doses of antibiotics).
2. Due to the increasing prevalence of MRSA in the hospital and the community, Vancomycin should be part of initial regimen in all cases of sepsis; however, it is imperative that Vancomycin be discontinued at 48hr if neither MRSA or pathogenic MRSE are isolated in any cultures.
3. Vancomycin levels of 15-20mg/ml are optimal for MRSA pneumonia.
4. Linezolid (IV or po) may be the preferred alternative to Vancomycin for "true" MRSA pneumonia (not just simple colonization of the sputum) -- i.e. definite infiltrates on CXR, plus compatable gram-stain and/or clinical syndrome, especially in the presence of renal insufficiency.
5. Use of Cephalosporins in Patients with Penicillin Allergy: After taking a careful history, cephalosporins may be given safely to any patient without a history of an IgE-mediated (Type I) reaction to penicillin. (Pediatrics 2005;115:1048). Potential alternatives to penicillins and/or cephalosporins include combinations of Cipro or Aztreonam; PLUS, Clindamycin or [Vancomycin + Flagyl].
6. Streamlining: As noted throughout this Card, it is vital, in order to limit the emergence of resistant pathogens, to narrow the spectrum of antibiotic therapy based on culture data; i.e Ampicillin, not Cefepime or Zosyn, for Ampicillin-susceptible E. coli UTI.
7. Bioavailability: Avelox, Azithromycin, Cipro, Diflucan, and Flagyl are highly bioavailable (90-100% GI absorption). After the initial IV dose(s), they should generally be given po if the GI tract is functional.