Immunocompromised antibiotics

Overview

The antibiotics listed are for common diseases in immunocompromised hosts

CMV Retinitis

====Severe Vision Threatening==== *Ganciclovir intraocular implant for 8 months AND

• • Valganciclovir 900mg PO q12hrs x 14 days then 900mg PO q24hrs x 7 days

====Peripheral lesions==== *Valganciclovir 900mg PO q12hrs x 21 days then 900mg PO q24hrs x 7 days

CMV esophagitis

• Ganciclovir 5mg/kg IV q12hrs x 21 days
• Foscarnet 90mg/kg IV q12hrs x 21 days

CMV colitis

• Ganciclovir 5mg/kg IV q12hrs x 21 days
• Foscarnet 90mg/kg IV q12hrs x 21 days

CMV neurologic disease

• Ganciclovir 5mg/kg IV q12hrs x 21 days then 5mg/kg IV q24hrs +
  • Foscarnet 90mg/kg IV q12hrs x 21 days then 90-120mg/kg IV q24hrs

CMV pneumonia

• Ganciclovir 5mg/kg IV q12hrs x 3 weeks

Cryptococcosis

Pulmonary (not AIDS associated)

• Fluconazole 400mg PO/IV q24hrs x 6-12 months OR
• Itraconazole 200mg PO q12hrs x 6-12 months OR
• Voriconazole 200mg PO q12hrs x 6-12 months

Pulmonary (with AIDS)

• Fluconazole 400mg PO q24hrs x 6-12 months

Meningitis (not AIDs associated)

• Amphotericin B 0.7-1mg/kg IV q24hrs AND Flucytosine 25mg/kg PO q6hrs x 4 weeks
  • Followed by Fluconazole 400mg PO q24hrs x 8 weeks

Meningitis (with AIDS)

• Amphotericin B 0.7-1mg/kg IV q24hrs AND Flucytosine 25mg/kg PO q6hrs x 2 weeks
  • Followed by Fluconazole 400mg PO q24hrs x 8 weeks
• Initiation of HAART is delayed by 2 to 10 weeks to minimize the risk of immune reconstitution syndrome

Pediatric Cryptococcal Meningitis

• Amphotericin B 0.7-1mg/kg IV daily x 2-4 weeks + Flucytosine 25mg/kg PO q6hrs
  • Followed by Fluconazole 6-12mg/kg PO daily x 8 weeks (max 400mg)

Neutropenic Fever

Therapy is aimed at treating multiple flora that include Gram Negatives, Gram Positive Bacteria, Pseudomonas and if there is an indwelling catheter or high risk, then MRSA.

Inpatient

• Monotherapy appears to be as good as dual-drug therapy
  • Cefepime 2g IV q8hrs or Ceftazidime 2g IV q8hrs OR
  • Imipenem/Cilastatin 1g IV q8hrs or Meropenem 1g IV q8hrs OR
  • Piperacillin/Tazobactam 4.5g IV q6hrs
• Consider adding Vancomycin to above regimen for:
  • Severe mucositis
  • Signs of catheter site infection
  • Fluoroquinolone prophylaxis was recently used against gram-negative bacteremia
  • Hypotension is present
  • Institutions with hospital-associated MRSA
  • Patient has known colonization with resistant gram-positive organisms

Outpatient

• Ciprofloxacin 750mg PO q12hrs AND Amoxicillin/Clavulanate 875mg PO q12hrs x 7 days OR
• Ciprofloxacin 750mg PO q12hrs AND Clindamycin 450mg PO q8hrs

Pediatric Inpatient

• Cefepime 50mg/kg IV q8hrs (max 2g) OR
• Meropenem 20mg/kg IV q8hrs (max 1g) OR
• Piperacillin/Tazobactam 80-100mg/kg IV q6-8hrs (max 4.5g)
• Add Vancomycin 15mg/kg IV q6hrs for same indications as adults

Pneumocystis Pneumonia (PCP)

Mild Disease

• TMP/SMX 2 DS tablets PO q8hrs OR
  • High incidence of allergy in HIV
• Dapsone 100mg PO once daily + TMP 5mg/kg PO q8hrs OR
  • caution: dapsone can cause methemoglobinemia
• Atavaquone 750mg PO q12hrs OR
• Primaquine 30mg PO q24hrs + Clindamycin 450mg PO q8hrs

Severe Disease

• TMP/SMX 5mg/kg IV q8hrs x 21 days OR
• Pentamidine 4mg/kg IV daily over 60 min OR
  • Watch for side effects of hypoglycemia and hypotension
• Primaquine 30mg PO once daily + Clindamycin 900mg IV q8hrs

Prophylaxis

• TMP/SMX 1 DS tablet daily, but one single strength tablet daily or one double-strength three times weekly is acceptable.

Pediatric Treatment

• TMP/SMX 5mg/kg (TMP) IV/PO q6-8hrs x 21 days
• Pentamidine 4mg/kg IV daily x 21 days if TMP/SMX intolerant
• Dapsone 2mg/kg/day PO (max 100mg) + TMP 15mg/kg/day PO divided TID for mild disease

Pediatric Prophylaxis

• TMP/SMX 5mg/kg/day (TMP) PO divided BID 3 days/week (first line)
• Dapsone 2mg/kg/day PO daily (max 100mg) or Atovaquone as alternatives

Toxoplasmosis

Immunocompetent

Antibiotics only needed if patient has severe symptoms

• Pyrimethamine 200mg PO load then 50mg PO q24hrs x 4 weeks AND
  • Leucovorin 10mg PO q24hrs AND
  • Sulfadiazine 1g PO q6hrs

Immunosprepressed

• Pyrimethamine 200mg PO load then 75mg PO q24hrs x 4-8 weeks AND Leucovorin 25mg PO q24hrs PLUS
  • Sulfadiazine 1500mg PO q6hrs OR
  • Clindamycin 600mg PO or IV q6hrs OR
  • Azithromycin 1200mg PO q24hrs OR
  • Atovaquone 1500mg PO q12hrs

OR

• TMP/SMX 5mg/kg IV q12hrs

Pregnant

• Spiramycin 1g PO q8hrs
  • If amniotic fluid is positive treat with 3 weeks of pyrimethamine (50 mg/day orally) + sulfadiazine (3 g/day orally in 2-3 divided doses)
  • Alternate with a 3-week course of Spiramycin 1 g 3 times daily OR
• Pyrimethamine (25 mg/day orally) and sulfadiazine (4 g/day orally) divided 2 or 4 times daily until delivery AND
  • Leucovorin 10-25 mg/day orally to prevent bone marrow suppression
• Dapsone 50mg PO QD; Off label use

Congenital/Pediatric

• Pyrimethamine 2mg/kg/day PO x 2 days then 1mg/kg/day x 2-6 months, then 1mg/kg MWF AND
  • Sulfadiazine 50mg/kg PO BID AND
  • Leucovorin 10mg PO 3x/week
• Duration: 12 months for congenital toxoplasmosis
• Alternative: TMP/SMX 5mg/kg (TMP) PO/IV q12hrs
• Clindamycin 20-30mg/kg/day PO/IV divided q6hrs (max 2.4g/day) if sulfa allergic
• Spiramycin 50-100mg/kg/day PO divided q8hrs

See Also

Antibiotics by diagnosis

• Bone and joint antibiotics
• Cardiovascular antibiotics
• ENT antibiotics
• Eye antibiotics
• GI antibiotics
• GU antibiotics
• Neuro antibiotics
• OB/GYN antibiotics
• Pulmonary antibiotics
• Skin and soft tissue antibiotics
• Bioterrorism antibiotics
• Environmental exposure antibiotics
• Immunocompromised antibiotics
• Post exposure prophylaxis antibiotics
• Pediatric antibiotics
• Sepsis antibiotics
• Arthropod and parasitic antibiotics

For antibiotics by organism see Microbiology (Main)